Albany Health Care & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to follow physician's wound treatment orders to promote healing of an arterial ulcer for 1 of 3 residents reviewed for skin conditions. (Resident 2)Finding includes:During an observation on 2/16/26 at 3:38 p.m., Resident 2 was in bed with a dressing on the right foot. The dressing included an orange bordered gauze, rolled gauze, and a net stocking.Resident 2's clinical record was reviewed on 2/20/26 at 1:50 p.m. Diagnoses included heart failure, type 2 diabetes mellitus, and reduced mobility.A wound treatment order, dated 12/23/25, included the following: Cleanse the pressure injury to the right dorsum foot with povidone iodine (antiseptic for wound), air dry, apply skin preparation, and place a foam dressing on day shift every day for wound healing. This order was discontinued on 2/18/26.A current wound treatment order, dated 2/12/26, included the following: Apply horseshoe pad to the right medial foot, paint area with povidone iodine (antiseptic for wound), and apply Alginate (wound dressing) between toes. Cover with ABD (absorbent wound dressing) pad, soft roll, and rolled gauze. Secure with stretch net. Change dressing three times weekly every 72 hours. A Treatment Administration Record (TAR) for February 2026 indicated the following:On 2/5/25 - the wound treatment was not completedOn 2/11/26 - the wound treatment was not completedOn 2/12/26 - both wound treatment orders were marked as completedOn 2/13/26 - the old wound treatment order was marked as completedOn 2/14/26 - the old wound treatment order was marked as completedOn 2/15/26 - both wound treatment orders were marked as completedOn 2/16/26 - the old wound treatment order was marked as completedOn 2/17/26 - the old wound treatment order was marked as completedOn 2/18/26 - both wound treatment orders were marked as completedA 12/30/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. She required maximal staff assistance with lower body dressing, repositioning, and footwear. The resident was dependent on staff assistance for transfers. Resident 2 was at risk for pressure ulcers and had one unstageable pressure ulcer. A current care plan, dated 12/22/25, indicated the resident had an unstageable pressure ulcer on the right dorsum foot. Interventions included resident wound treatments as ordered (12/22/25).A wound center progress note, dated 2/11/26, indicated the right foot wound was an arterial ulcer. A provider progress note, dated 2/12/26, indicated the resident was evaluated at the wound clinic for the right medial foot wound and had a non-pressure chronic ulcer of the right foot which was managed with wound care. Circulation was worsened and is expected to improve with bilateral lower extremity stent placement. The treatment ordered included a horseshoe pad to the right medial foot, apply Betadine (wound antiseptic) and cover with an ABD pad three times weekly. Continue the current wound care regimen. During an interview on 2/19/26 at 4:49 p.m., Unit Manager 11 indicated the resident had weekly visits to the wound clinic. Wound treatment orders were provided by the wound clinic. The facility performed the treatments based on those orders. The facility updated the wound treatment orders when the resident returned from the wound clinic. The facility had received new orders to change the resident's dressing from every day to every three days, but she did not catch the duplicate order until 2/18/26 when she completed the resident's dressing change. On 2/20/26 at 2:20 p.m., Unit Manager 11 indicated it appeared the facility continued to do daily dressing changes rather than following the new order. On 2/18/26, during wound care, she was unable to get the horseshoe pad removed so she cleansed around it and left it in place. The resident had an appointment scheduled for next week, so she intended to leave the horseshoe pad in place until the resident attended her appointment. She did not contact the wound clinic for further instructions regarding the inability to remove the horseshoe pad. On 2/20/26 at 4:43 p.m., the DON indicated staff should always follow the physician's orders. Previous wound care orders should have been discontinued when the facility received new wound care orders. Wound care performed more frequently than ordered had the potential to increase the resident's risk of infection. The provider must be notified when wound care cannot be completed according to the order to obtain clarification for further instructions.A current facility policy, dated 11/29/23, titled Wound Treatment Management, provided by the Administrator on 2/20/26 at 5:07 p.m., indicated the following: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 3.1-37(a)

Based on observation and interview, the facility failed to ensure medications were dated when opened and medication was discarded when expired for 1 of 3 medication carts reviewed for medication storage. (100 hall) Finding includes:During a medication storage observation of the 100 hall medication cart, accompanied by QMA 10 on 2/18/26 at 3:11p.m., the following was observed: Six bottles of eye drops were open and undated. Two metered dose inhalers were open and undated. One bottle of Robitussin DM (cough medicine) was open, undated, and had an expiration date of 9/2024. One bottle of Black Seed herbal supplement was open and undated. Nine bottles of Miralax (laxative) were open and undated. Two bottles of liquid Docusate Sodium were open and undated. One bottle of cough medication liquid was open and undated. One bottle of Lactulose (laxative) was open and undated. Five bottles of Milk of Magnesia (laxative) were open and undated. One bottle of saline nasal spray was open and undated. Two bottles of Flonase (steroid) nasal spray was open and undated. During an interview at the time of the observation, QMA 10 indicated he was unsure if opened items needed labeled and dated at the time the product was opened and thought the facility went by the product expiration dates. During an interview at the time of the observation, RN 12 indicated he found the bottle of Robitussin DM in a resident's room. The resident's family had brought it to the facility. He removed the medication from the resident's room and placed it in the medication cart. He was aware the resident did not have an order for the Robitussin when he placed it in the medication cart. He did not notify the physician or request an order for the medication. He was not aware it had expired. During an interview, on 2/18/26 at 3:48 p.m., LPN 11 indicated all medications were to be labeled with an open date and all medications in the medication cart were to have a physician order. Any expired item was to be removed. During an interview, on 2/18/26 at 4:06 p.m., the DON indicated that medication items were to be dated when opened. All medications were to have a physician order and there were not to be any expired medications in the medication cart. A current facility policy, revised 4/16/24, titled Labeling of Medications and Biological's, provided by the Corporate Nurse Consultant, on 2/18/26 at 4:40 p.m., indicated the following: Policy: All medications and biological's used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 3.1-25(j)3.1-25(k)3.1-25(o)

Based on observation, record review, and interview, the facility failed to provide grooming assistance for 1 of 2 residents reviewed for activities of daily living. (Resident 16) Findings include:During an observation, on 2/16/26 at 10:33 a.m., Resident 16 sat in a wheelchair in the dining room. He was unshaven. During an observation, on 2/17/26 at 10:11 a.m., Resident 16 sat in a wheelchair in his room. He was unshaven. During an observation, on 2/18/26 at 10:55 a.m., the resident sat in a wheelchair in the dining room. He was unshaven. Resident 16's clinical record was reviewed on 2/18/26 at 3:48 p.m. Diagnoses included altered mental status, dementia, other lack of coordination, other reduced mobility, and need for assistance with personal care. A quarterly Minimum Data Set (MDS) assessment, dated 1/19/26, indicated the resident was severely cognitively impaired. He required substantial/maximal staff assistance with personal hygiene. A current care plan, created 12/17/24, indicated the resident needed assistance with his activities of daily living (ADLs) related to activity intolerance. An intervention, revised 9/12/25, indicated the resident was dependent on staff assistance for his morning and evening care. A point of care response history indicated the resident had received a shower on 2/11/26 and bed baths on 2/15/26 and 2/18/26. During an observation, on 2/19/26 at 4:50 p.m., the resident propelled himself in his wheelchair out of the dining room. He was unshaven and had facial hair the length of the diameter of a pea. At the same time, during an interview, the Corporate Nurse Consultant indicated the resident did not appear he had been shaved recently. The residents were generally shaved twice weekly with showers. CNA 8 was offering and shaving residents this week. She wondered if CNA 8 had offered to shave Resident 16. During an interview, on 2/19/26 at 4:52 p.m., CNA 8 indicated she had not shaved, nor offered to shave, Resident 16 this week. During an interview, on 2/20/26 at 2:17 p.m., CNA 6 indicated the residents were shaved on shower days and as needed. Resident 16 normally requested to have his shaving done or performed the shaving himself with set up. He did not refuse to be shaved or showered as far as she knew. During an interview, on 2/20/26 at 2:18 p.m., CNA 5 indicated she set up the resident with his electric razor yesterday to shave. She wondered if the razor was not working properly. He had a couple of electric razors and shaved himself with set up. She usually shaved men when she got them up in or when they got a shower. The resident received showers on second shift. During an interview, on 2/20/26 at 2:59 p.m., the DON indicated the residents should be shaved at least twice a week on shower days. A facility document, provided by the Administrator on 2/20/26 at 3:09 p.m., titled Resident Care Procedure #39: RCP-Electric Razor, did not include when or how often a resident should be shaved. 3.1-38(a)(3)(D)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to utilize proper hand hygiene and avoid touching food with bare hands during meal tray distribution for 4 of 9 opportunities during room meal tray deliveries on the 200 hall. Findings include:During an observation on 2/16/26 at 12:11 p.m., CNA 8 entered room [ROOM NUMBER]-D with a meal tray. She rearranged a book and cup on the overbed table prior to setting up the meal tray. Hand hygiene was not performed. CNA 8 then removed the dinner roll bare handed and set the dinner roll on top of the wrap it came in. On 2/16/26 at 12:19 p.m., CNA 8 entered room [ROOM NUMBER]-W with a meal tray. She took the dinner roll out of a plastic bag with her bare hands and placed it in front of the resident. During an interview on 2/16/26 at 3:03 p.m., CNA 8 indicated she probably should have washed her hands before touching residents' food. She used hand sanitizer after handing out lunch trays to avoid cross contamination. Hand hygiene was utilized for infection prevention.During an observation on 2/19/26 at 4:56 p.m., CNA 9 retrieved a meal tray from the cart, and delivered the meal tray to room [ROOM NUMBER]-D. CNA 9 assisted the resident with meal set up and touched personal items on the beside table. She exited room [ROOM NUMBER]-D, poured a yellow drink from the drink cart, and placed the cup on a tray in the food cart. Then CNA 9 delivered a meal tray to room [ROOM NUMBER]-D and exited the room. Hand hygiene was not observed at any time throughout the observation. During an interview on 2/19/26 at 5:16 p.m., CNA 9 indicated she probably should have performed hand hygiene after she passed out each tray. Hand hygiene was done to prevent cross contamination.On 2/20/26 at 2:32 p.m., the Infection Preventionist indicated hand hygiene was required before picking up any meal trays.On 2/20/26 at 2:33 p.m., the DON indicated hand hygiene must be completed every time staff enter and exit resident rooms, after touching themselves, and after touching objects. Food should not be touched bare handed.A current policy, revised 10/2017, titled Hand Antiseptic for Food Service, provided by the Corporate Nurse Consultant on 2/20/26 at 2:48 p.m., indicated the following: Policy. Hand antiseptic or antimicrobial gel used by staff as a hand dip or wash will be limited to situations that involve no direct contact with food by the bare hands. Hand antiseptic may be applied between washing hands twice before full hand washing must be completed.3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate catheter maintenance and services to prevent potential urinary tract infections for 1 of 2 residents reviewed for indwelling catheters. (Resident 16) Finding includes: During an observation, on 2/16/26 at 3:34 p.m., Resident 16 sat in his wheelchair in his room. His urinary catheter tubing, with cloudy, yellow urine, came from the resident's waistband and went down under the resident's wheelchair into a privacy bag. The catheter tubing under the wheelchair hung within the diameter of a pencil eraser from the floor. During an observation, on 2/17/26 at 10:11 a.m., the resident sat in his wheelchair in his room. His urinary catheter tubing was coiled on his lap. During an observation, on 2/18/26 at 11:51 a.m., the resident sat in his wheelchair in the dining room. His urinary catheter tubing hung down and rested on the floor, then went into a privacy bag. During an observation, on 2/18/26 at 12:07 p.m., the resident propelled himself in his wheelchair out of the dining room. The urinary catheter tubing drug on the floor underneath his wheelchair. During an observation, on 2/18/26 at 3:28 p.m., the resident propelled himself away from the dining room. The urinary catheter tubing drug on the floor as he propelled himself out of the dining room. Resident 16's clinical record was reviewed on 2/18/26 at 3:48 p.m. Diagnoses included benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, retention or urine, neuromuscular dysfunction of bladder, altered mental status, dementia, and the need for assistance with personal care. Physician orders included doxycycline (antibiotic) 50 mg daily for chronic urinary tract infections (started 2/8/25, discontinued 2/17/26), methenamine hippurate (urinary anti-infective) 1 g (gram) twice a day for urinary tract infection prophylaxis (2/17/26), tamsulosin (for BPH) 0.4 mg daily (6/28/25), suprapubic catheter 16 French with 10 cc bulb (8/6/25), clean suprapubic site with normal saline, pat dry, and apply T sponge every shift (11/4/25), irrigate suprapubic catheter with 50 mL sterile water every day and evening shift (8/15/25), and maintain enhanced barrier precautions due to indwelling device (2/11/25). A quarterly Minimum Data Set (MDS) assessment, dated 1/19/26, indicated the resident was severely cognitively impaired. He was dependent on staff for toileting hygiene and transfers. He required substantial/maximal staff assistance with showering/bathing, upper and lower body dressing, donning and doffing footwear, personal hygiene, and wheeling 150 feet in a manual wheelchair. He required partial/moderate staff assistance with wheeling 50 feet in a manual wheelchair. A current care plan, revised 1/7/25, indicated the resident had chronic and recurring urinary tract infections. An intervention, initiated 12/24/24, indicated to administer prophylactic medications as ordered. A current care plan, revised 7/1/25, indicated the resident had a suprapubic catheter related to neurogenic bladder. Interventions included change catheter system when clinically indicated or ordered (initiated 1/8/25), give catheter care every shift (initiated 1/8/25), observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen (initiated 1/8/25), and maintain enhanced barrier precautions (initiated 2/9/25). During an observation, on 2/18/26 at 4:01 p.m., the resident sat in his room in the doorway of his room. The urinary catheter tubing lay on the floor under his wheelchair. At 4:04 p.m., the ADON paused as she passed the resident's room. She smiled and waved at the resident. During an observation, on 2/18/26 at 4:05 p.m., the resident sat in his room in his wheelchair. His left heel rested on the urinary catheter tubing. He moved and the tubing became twisted around his left front wheelchair wheel. During an interview, on 2/18/26 at 4:06 p.m., the ADON indicated the resident's urinary tubing was currently on the floor. The resident's urinary catheter was usually placed on the back of the resident's wheelchair to keep the tubing off the floor. During an interview, on 2/18/26 at 4:09 p.m., CNA 5 indicated the resident's catheter tubing should not be on the floor. To prevent the urinary catheter tubing from dragging on the floor, she clipped the tubing to the resident's clothes. She tried to watch for when the tubing became unclipped and reclipped it to his clothes because the resident was very mobile in his wheelchair. During an interview, on 2/18/26 at 4:11 p.m., CNA 6 indicated the urinary catheter tubing should not be on the floor. She usually clipped the resident's tubing to his pants. The resident moved all over the place, and that was why the urinary catheter tubing was sometimes on the floor. During an observation, on 2/19/26 at 11:44 a.m., the resident sat in his wheelchair at the dining room table. His urinary catheter tubing was laying over his leg and went into a privacy bag under his wheelchair. The drainage spout from the urinary drainage bag was unsecured and hung from the privacy bag onto the floor. During an observation, on 2/19/26 at 11:52 a.m., the resident was assisted out of the dining room while sitting in his wheelchair. The urinary catheter bag spout drug on the floor. The DON secured the drainage spout so that it no longer drug on the floor. During an interview, on 2/19/26 at 3:48 p.m., the DON indicated neither the resident's urinary catheter tubing nor the urinary drainage bag spout should be dragging on the floor. A current facility policy, revised 7/1/24, titled Catheter Care, provided by the Administrator on 2/19/26 at 3:56 p.m., indicated the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care.Ensure tubing and catheter bag does not touch the floor.

Based on observation, record review, and interview, the facility failed to provide meal assistance to maintain nutritional status for 1 of 4 residents reviewed for nutrition. (Residents 21) Finding includes:During a dining observation, on 2/18/26 at 12:04 p.m., Resident 21's meal assistance was provided by her visitor who sat on the right side of Resident 21and offered the resident several bites. The resident accepted one bite. The visitor switched seats and moved to a chair located on Resident 21's left side. After moving to Resident 21's left side, the resident consistently accepted every bite of food offered for the rest of the observation. Resident 21 drank fluids from a cup with a straw.During a continuous dining observation, on 2/19/26 at 8:20 a.m., a staff member sat on the right side of Resident 21. Resident 21's neck was bent forward, and her head was hanging downwards. The staff member offered two additional bites, which the resident did not accept. The staff member indicated Resident 21 did not eat well for breakfast and walked over to a kiosk and started charting. At 8:26 a.m., the resident allowed food and fluids to fall from her mouth. The staff member approached Resident 21 from the left side and asked her if she was okay. Resident 21 indicated she was okay. The staff member asked if she had anything else in her mouth. Resident 21 opened her mouth to show the staff member her mouth was empty. The staff member removed Resident 21 from the dining room.During a meal observation, on 2/19/26 at 11:42 a.m., Resident 21's lunch was placed in front of her. A cup of ice cream and a supplement were present. Resident 21 was not served a drink. At 11:48 a.m., a staff member sat down between Resident 21 and another resident. The staff member was on Resident 21's right side. The staff member did not acknowledge Resident 21. The staff member offered the other resident several bites of food and encouragement. At 11:50 a.m., the staff member acknowledged Resident 21. Resident 21 had her head turned to the left. The staff member, while seated on resident 21's right side, attempted to reach around the front of Resident 21and tried to angle her wrist enough to give Resident 21 a bite of food. Resident 21 did not accept the offered spoonful of food. This was the only bite of food offered at that time. At 11:52 a.m., the staff member got up and assisted another resident out of the dining room. At 11:55 a.m. the staff member returned to the dining room and sat down in her previous location between the residents. The staff reached around Resident 21 and offered a bite of food to the resident. Resident 21 attempted to accept the bite but only received the tip of the spoonful. Two bites of food were offered between 11:42 am and 11:56 a.m. Resident 21's visitor arrived at 11:56 a.m. and offered to assist the resident with her meal. The resident and her meal were moved to a different table. The resident was not provided a drink. Initially the family sat down on Resident 21's right side and then promptly moved to her left side and offered Resident 21 a bite of food. Resident 21 accepted the first bite offered. The resident occasionally held the food in her mouth for a couple of seconds before swallowing. The visitor left the dining room and returned with a foam cup in which she poured a soda, placed a lid on the cup, and placed a straw in the lid. Resident 21 immediately drank from the straw when fluids offered. Resident 21 accepted a variety of foods when offered. The resident was observed to have taken an additional 10 bites and continued eating until the end of the observation.During an observation, on 2/19/26 at 4:56 p.m., Resident 21 was lying in a low bed with the head of bed elevated approximately 30 degrees and the left side of the bed against the wall. The resident's meal sat in an opened foam container on her bedside table. The bedside table was not within reach of the resident. An applesauce container was opened about a quarter of the way and there was one spoonful divot in the pureed pizza. There were no supplements present. Resident 21 was awake and looking around. No staff member was present in the room. At 5:09 p.m., CNA 9 entered Resident 21's room with a foam cup and placed it on the bedside table. CNA 9 greeted the resident, indicated she would be back, and departed Resident 21's room. No drink or bite of food was offered while CNA 9 was in the room. At 5:12 p.m., CNA 9 and CNA 13 entered Resident 21's room and shut the door. No bites of food or fluids were offered during the observation from 4:56 p.m. to 5:12 p.m.During an observation, on 2/19/26 at 5:16 p.m. CNA 13 exited Resident 21's room, carrying a microwaveable cup of chicken noodle soup. CNA 9 remained in the room, standing in front of Resident 21. Resident 21 sat in her wheelchair with the bedside table in front of her. During an interview, at the time of the observation, CNA 9 indicated Resident 21 was dependent for all care. Resident 21 had dementia and a history of a right hip injury. Resident 21 would not accept food from her when offered earlier in the week but the CNA was able to get her to drink a homemade milkshake. Resident 21's supper remained sitting on the bedside table in front of the resident, the food appearance was unchanged from the prior observation (one spoonful divot). CNA 13 entered the room and removed the foam container and placed it in the food cart in the hall. CNA 9 indicated the resident liked chicken noodle soup and CNA 13 was warming it up at that time. Resident 21 looked at staff and stated no mashed potatoes. At 5:20 p.m., CNA 13 placed a bowl of chicken noodle soup on Resident 21's bedside table. CNA 13 indicated Resident 21 had a major stroke years ago and had steadily been declining since her admission to the facility. She did not feel that Resident 21 had right sided neglect (did not acknowledge their right side). No offer of fluids or food had been given. CNA 9 indicated the soup was hot and CNA 13 departed room. At 5:24 p.m., Resident 21 was observed reaching across the bedside table towards the soup. Resident 21 indicated she was hungry. CNA 9 handed Resident 21 a foam cup. Resident 21 immediately grasped the cup with both hands and began drinking from the straw. CNA 9 indicated Resident 21 did well if you handed her the cup to hold. She did not feel Resident 21 had right sided neglect. The resident continued to steadily drink from the cup. At 5:27 p.m. CNA 9 indicated the soup was still too hot to eat and she would give the resident a bite once it cooled down. No bites of food were offered throughout observation.Resident 21's clinical record was reviewed on 2/20/26 at 3:00 p.m. Diagnoses included dementia, age-related physical debility, cerebral infarction, cognitive communication deficit, and need for assistance with personal care.Current physician orders included regular diet with pureed texture, thin consistency, (2/10/26), 206 (supplement) juice, preferably orange, at breakfast and dinner, and ice cream with all meals and for bedtime snack.A quarterly MDS (Minimum Data Set) assessment, dated 2/6/26, indicated the resident was severely cognitively impaired. The resident required partial/moderate assistance with eating and oral hygiene. The resident did not have a loss of liquids or solids from mouth when eating or drinking. She did not hold food in her mouth or have residual food in mouth after meals. No coughing or choking occurred during meals or when swallowing medication. No complaints of difficulty or pain when swallowing. Resident 21's weight was 99 pounds and a loss of five percent or more in the last month or a loss of 10 percent or more in the last six months was identified and noted that the resident was not on a prescribed weight loss regimen. She received a mechanically altered diet that required a change in the texture of food or liquids.A current care plan, revised on 12/20/25, indicated Resident 21 was at risk for malnutrition due to dementia, reduced mobility, and a recent illness. Interventions included the following: meal intakes were to be reviewed (7/23/25), weights were to be reviewed (7/23/25), and extra food or beverage was to be received with meals or between meals to provide calories and/or protein (7/23/25).A current care plan, dated 12/20/25, indicated Resident 21 had an unplanned weight loss due to recent illness and family unable to visit as family brings in additional food items for the resident. Interventions included the following: assist the resident with eating (12/20/25).A current care plan, revised on 8/5/25, indicated Resident 21 had a communication deficit as evidenced by a cerebral vascular accident, history of transient ischemic attacks (mini-strokes), and a cognitive communication deficit related to dementia. Interventions included the following: You will ensure having my attention, face me from the front and not on the side, before speaking with me (8/5/25).A weight history in Resident 21's electronic record, indicated on 08/05/2025, the resident weighed 134 pounds. On 2/8/26, the resident weighed 93.6 pounds, which is a 30.15% loss.During an interview, on 2/20/26 at 4:38 p.m., LPN 9 indicated Resident 21 was a picky eater. Family had announced a lot of food dislikes for the resident. Resident 21's dementia was progressing. Resident 21's diet had recently changed to pureed. Varying meal intakes were noted. She was not aware if Resident 21 had one-sided neglect. Staff were to sit at her level, eye to eye, while assisting Resident 21 with her meals. Resident 21 would often eat ice cream when offered.During an interview, on 2/20/26 at 4:43 p.m., the DON indicated staff was to ensure Resident 21 sat upright for her meals. Staff were to offer the resident foods based on her preferences, alternate bites of food with drinks with fluids. Staff were to sit down beside her when meal assistance was offered. She was unaware if Resident 21 had neglect on one side or not.During an interview, on 2/20/26 at 4:49 p.m., the ADON indicated Resident 21 had one-sided neglect but was unsure which side.During an interview, on 2/20/26 at 4:51 p.m., CNA 15 was sitting across the table from Resident 21. A nursing aide in training sat on Resident 21's right side and was assisting Resident 21 with her meal. CNA 15 indicated Resident 21 would feed self at times and encouragement was needed. Resident 21 was able to drink from a cup without assistance. CNA 15 did not feel Resident 21 had one-sided neglect and did not feel sitting on one side versus another affected her eating. Staff were aware that Resident ate better for lunch when her representative was present. Resident 21 was not eating well for this meal.A current facility policy, dated 11/29/23, titled Serving a Meal, provided by the Nurse Consultant, on 2/20/26 at 6 p.m., indicated the following: .3. Remove dome lid from the tray, and check to be sure everything is included on the meal tray that is required by the diet card, and the residence preference. 4. Arrange the dishes in silverware so the resident can reach them easily.12. Remember that some residents take a long time to eat. Provide adequate time for the resident to consume the meal and offer to reheat foods as needed. 13. Offer additional fluids and water with the meal when there are no fluid restrictions.A current facility policy, dated 11/27/23, titled Assisted Nutrition and Hydration, , provided by the Nurse Consultant, on 2/20/26 at 6 p.m., indicated the following: Policy: Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being.Policy Explanation and Compliance Guidelines: 1. The Facility will: a. Provide nutritional and hydration care and services to each resident, consistent with the residents comprehensive assessment; b. Recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration.2.the facility will ensure each resident: a. Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residence clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; . 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure implementation of care plan interventions to prevent falls for 1 of 3 residents reviewed for falls (Resident C). Finding includes: During an observation, on 1/14/26 at 11:28 a.m., Resident C sat in her wheelchair at a table in the dining room as CNA 3 assisted her with eating. The resident wore nonskid socks and a brace on her right foot/leg. Resident C's clinical record was reviewed on 1/14/26 at 2:39 p.m. Diagnoses included age related physical disability, syncope (fainting) and collapse, difficulty walking, and vascular dementia. The current orders included melatonin 10 mg daily at bedtime for insomnia (4/10/25), metoprolol tartrate 25 mg twice a day for hypertension - hold for systolic blood pressure less than 100 or heart rate less than 60 (7/9/25), and silent pressure alarm to bed (6/2/25). A modification of the quarterly Minimum Data Set (MDS) assessment, dated 11/10/25, indicated the resident was severely cognitively impaired. She used a walker and a wheelchair for mobility. She required partial to moderate staff assistance with walking and supervision to touching staff assistance with wheelchair mobility. She had two or more falls without injury since the prior assessment. A bed alarm was used daily. A current care plan, indicating the resident was at risk for falls related to impaired balance, was initiated 9/29/23. The care plan interventions included the following: A bed alarm will be used to remind staff the resident required assistance with bed mobility and transfers (revised 6/2/25), the resident preferred her bed to be up against the wall to make her feel safe (initiated 4/10/2025), Dycem (a non-slip material used for grip and stability) in recliner to prevent sliding (initiated 12/11/25), Dycem in wheelchair (initiated 9/20/25), and a low bed with a mat on the floor to decrease the risk of injuring herself when the resident rolled out of bed (initiated 4/18/25). Fall risk assessments completed on 7/11/25, 10/11/25, and 1/11/26 each indicated the resident was a high fall risk. A progress note, dated 10/17/25 at 6:09 p.m., indicated the resident was found lying on her side on the floor in front of her wheelchair. The resident's roommate indicated the resident was trying to get up from her wheelchair. No injuries were noted. A fall interdisciplinary team (IDT) progress note, dated 10/20/25 at 11:19 a.m., indicated the resident's fall on 10/17/25 was reviewed. Interventions included continuing the restorative therapy with walking and dressing/grooming, blood work to be obtained and follow up with any abnormal results to rule out acute illness. The immediate intervention after the fall was to lay the resident down, as she requested, in a low bed with a mat in place. A progress note, dated 11/10/25 at 6:30 a.m., indicated the resident was found sitting on her buttocks on the floor in her room. No injuries were noted. A fall IDT note, dated 11/11/25 at 11:17 a.m., indicated the 11/10/25 fall was reviewed. Interventions included the resident was to be an early riser as she allowed. An interview with the resident's family had indicated the resident was an early riser. A progress note, dated 12/11/25 at 12:30 p.m., indicated the resident was found lying on her side on the floor in her room with her legs stretched out. A laceration with bleeding to her right eyebrow was sustained from hitting her head during the fall. A fall IDT note, dated 12/12/25 at 12:15 p.m., indicated the 12/11/25 fall was reviewed. Interventions included shoes or proper footwear in place when resident was up for the day, and the resident's recliner was to have a non-slip mat placed in it to prevent sliding. A progress note, dated 12/29/25 at 1:58 p.m., indicated the resident moved to the secured unit. A progress note, dated 1/9/26 at 11:01 p.m., indicated the staff witnessed the resident slide off her bed. No injuries were noted. A fall IDT note, dated 1/12/26, indicated the 1/9/26 fall was reviewed. Interventions included the Social Services Director calling the family and requesting cotton pajama bottoms which would not be slick and to remove other slick bottoms from the resident's room. During an observation, on 1/15/26 at 12:05 p.m., the resident sat in her wheelchair at a table in the dining room as CNA 3 assisted her with eating. The resident wore nonskid socks and a brace on her right foot/leg. During an observation, on 1/15/26 at 12:06 p.m., the resident's bed was not against the wall as per care plan, no non-slip mat was found in the recliner, and no fall mat was visible in the room. During an observation, on 1/15/26 at 12:28 p.m., the resident was lying in a low bed without a mat beside it. The bed was not up against the wall. The wheelchair and recliner lacked a non-slip mat. No fall mat was visible in the room. During an interview, on 1/15/26 at 12:36 p.m., CNA 3 indicated each resident's fall interventions were listed on the Kardex on the electronic chart. The specific fall interventions for Resident C was a bed alarm, increased supervision, and assistance with toileting. The resident did not have a fall mat since she moved from the other unit. Fall mats were not permitted on the secured unit because they were considered a fall hazard. She thought the resident did have a non-slip mat, but it was not in her room, her wheelchair, or her recliner. CNA 3 indicated the bed was not against the wall. During an interview, on 1/15/26 at 12:41 p.m., QMA 4 indicated the residents' fall interventions were listed in the Kardex. Sometimes, when a new intervention was initiated, Unit Manager 5 would tell the staff and have them sign a paper. She pulled up the Kardex on the computer screen. The Kardex indicated the resident was to have a mat beside her bed, non-slip mat in her wheelchair and her recliner, and her bed was to be up against the wall. During an interview, on 1/15/26 at 1:11 p.m., Unit Manager 6 indicated she monitored and supervised the secured unit when a QMA, and not a nurse, was on duty. The residents' specific fall interventions were listed in the care plan and in the Kardex. Resident C had been moved back to the secured unit recently. She had a fall mat on the other unit, but the fall mats were not utilized on the secured unit because they were a fall risk with the residents who wandered in and out of resident rooms. Resident C's care plan was not revised yet. She had seen a non-slip mat in the resident's room last week and was uncertain what had happened to it. During an interview, on 1/15/26 at 1:18 p.m., the DON indicated Resident C's care plan should have been updated and the appropriate interventions such as the bed against the wall and the non-slip mat placed in the wheelchair and recliner should have been in place. She indicated fall mats were not used on the secured unit as they were a trip hazard. A current facility policy, revised 8/2024, provided by the DON on 1/15/26 at 2:23 p.m., titled Fall Investigation and Risk Evaluation, indicated the following: . 'Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. 'Avoidable Accident' means the an accident occurred because the facility failed to:.implement interventions, including adequate supervision and assistive devices . This citation relates to Intake 2705971.3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to protect a resident's right to be free from sexual abuse by another resident for 1 of 3 residents reviewed for abuse (Residents B and C) when a cognitively impaired male resident (Resident B) with a history of sexually charged behavior was observed in the lounge with his hand underneath the cognitively impaired female (Resident C) resident's shirt fondling her breast. Findings include:During an observation on 12/15/25 at 10:09 a.m., Resident B was seated in a recliner in the North Lounge with his feet elevated and his eyes closed. During an observation on 12/15/25 at 10:46 a.m., Resident C was seated in a Broda chair (high-backed wheelchair) in the hallway near the entrance to the North Lounge by the 300 Unit Nurses' station. She was awake, tracked with her eyes, but was unable to respond verbally when spoken to. Resident B's clinical record was reviewed on 12/15/25 at 1:35 p.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, unspecified dementia, sexual aversion disorder, and difficulty in walking. A 10/17/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. Resident B used a wheelchair and walker for mobility. He required partial assistance from staff for upper body dressing, substantial assistance from staff for bathing, lower body dressing, transfers, and donning footwear, partial assistance for personal hygiene, and was dependent on staff assistance for toileting. A current care plan, dated 9/10/23, for a cognitive deficit related to dementia, cognitive communication deficit, exhibited fluctuating confusion, poor safety awareness, poor judgement and poor decision making. Interventions included you will provide me with cues, prompts, and reminders as necessary (12/25/23). A current care plan, dated 12/14/23, for behavioral symptoms such as touching female staff inappropriately, removing clothes, and touching and grabbing female peers inappropriately. Interventions included explain to be that by behavior is inappropriate (12/14/23),allow me to express my feelings (12/14/23), approach me from the front and make sure you have my attention (12/14/23), facility staff will follow me with 15 minute checks until 11/21/25 (initiated 6/7/24 and revised on 11/18/25), I will refrain from saying inappropriate comments to staff and residents (12/5/25), I will report and you will observe for changes in my behaviors and determine if any alterations in care plan is needed (12/14/23), medications as ordered (11/24/25), staff will offer to place me in the recliner or bed after meals or activities (11/18/25), staff will direct me away from female residents as necessary (11/18/25), you will follow me on the Behavioral Management Program (11/18/25), and you will remove me to a quiet area away from females as necessary (11/18/25). Resident B's Behavior Sheets included sexually charged behaviors on the following dates:On 6/7/24, while in the North Lounge, Resident B attempted to grab Resident C's breast. Both residents were removed and Resident B was placed on 15-minute checks. The behavior improved after staff talked with the resident. On 7/3/25, Resident B touched a female staff member from her thigh up to her crotch during resident care. Resident B's behavior improved when he was told that inappropriate touching was not allowed. He confirmed understanding. On 8/16/25, after Resident B was placed on the toilet, he grabbed and squeezed a female CNA's breast. Behavior ceased when the CNA reminded the resident it was inappropriate behavior. On 11/17/25, following the evening meal, Resident B and Resident C were placed in the North Lounge while assisting another resident to bed. Resident B was found touching Resident C's breast. The residents were separated. Resident B was placed on 15 minutes checks. Resident B will be offered to sit in the recliner in his room or the North Lounge following meals as tolerated. The provider was considering hormone therapy for Resident B. On 11/20/25, while in the dining room, Resident B told the QMA She had something nice sticking out the front of her shirt. No further comments were made when the QMA instructed the resident it was an inappropriate statement to make. Resident C's clinical record was reviewed on 12/15/25 at 3:09 p.m. Diagnosis included dementia, need for assistance with personal care, major depressive disorder, and cognitive communication deficit. An 8/18/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Cognitive skills for daily decision making were severely impaired. Resident C used a wheelchair for mobility. She required substantial assistance from staff for eating, oral hygiene, upper and lower body dressing, turning, footwear, and personal hygiene. She was dependent on staff assistance for toileting, bathing, and transfers.A current care plan, dated 11/17/25, indicated the resident was at risk for psychosocial concerns related to a male peer touching me inappropriately and may exhibit signs of the following: trembling, flinching, tearfulness, change in appetite, change in cooperation with care, change in sleep, anxious facial expressions, rapid breathing, or restlessness. Interventions include the following: staff will ensure Resident C is not near Resident B (11/18/25), staff will provide reassurance to the resident that she is safe by talking to her and with gentle smiling (11/18/25), and you will observe for psychosocial and mental status changes and document and report as indicated (11/17/25). A progress note, dated 11/18/25 at 6:46 p.m., indicated the resident's chest was inspected while on the bed. No bruises, abrasions, or wounds noted in both breasts. The resident remained calm, no reaction, facial grimacing, guarding, or complaint of pain upon examination. Review of a facility investigation file included a handwritten statement from CNA 3 indicating Resident B was witnessed with his hand inside Resident C's shirt touching her breast. A behavior note indicated the incident occurred on 11/17/25 at 6:00 p.m. A handwritten statement by the Administrator indicated the Administrator and DON were notified of the incident between Resident B and Resident C on 11/17/25 at 8:25 p.m. The residents' representatives were notified by the Administrator and the DON beginning on 11/18/25 at 9:45 a.m.A facility reported incident submitted to Indiana Department of Health (IDOH), dated 11/17/25 at 6:01 p.m. and submitted on 11/18/25, indicated staff were removing residents from the dining room following evening meal and placing them in the North Lounge. Staff assisted a resident to bed and returned to the North Lounge and found Resident B touching Resident C's breast. The residents were separated. They were unable to determine consent from Resident C because the resident was non-verbal. Resident C was assessed with no physical or behavior changes. Resident B was immediately placed on 15-minute checks. Notifications were made to the providers, resident representatives, Administrator, and the DON. Preventative Measures Taken 11/18/25: Resident B was to be offered the chance to sit in the recliner in his room following meals as he tolerated. A medication review was requested for Resident B and he would be added to rounding for the counselor and psychiatric provider. Resident C would be monitored for changes in her daily habits and behaviors that could indicate distress. Care plans were reviewed and updated. During a telephone interview on 12/15/25 at 12:28 p.m., CNA 3 indicated Resident B had been sexually inappropriate with residents and staff for two years. He had been known to attempt to touch female residents and female staff members inappropriately, as well as say sexually inappropriate things. When left in his wheelchair, Resident B was able to unlock the wheels and approach female residents. As a result, staff were aware that Resident B was to be assisted into the recliner in the lounge or in his room so that he was not close enough to touch female residents. On 11/17/25, between 5:30 p.m. and 6:00 p.m., CNA 4 assisted Resident B in the North Lounge in his wheelchair rather than the recliner where Resident C was after their evening meal, while CNA 4 assisted CNA 3 to put another resident in bed. When CNA 3 returned to the North Lounge, Resident B had rolled up in his wheelchair next to Resident C in her Broda chair, with his hand inside the front of Resident C's gown against her skin, while fondling her breast. This was sexual abuse. Resident C was non-verbal, dependent on staff for everything, and could not defend herself. CNA 3 asked CNA 4 to separate them since her hands were full. CNA 3 and CNA 4 took Resident C to her room and Resident B was assisted into the recliner in the North Lounge. The new intervention since the incident on 11/17/25 was that Resident B was required to have constant supervision when he was in an area with female residents. On 12/15/25 at 1:22 p.m., RN 5 indicated he was working on 11/17/25, and after dinner at approximately 6:00 p.m., an unidentified CNA reported to him that Resident B was seen touching Resident C's breast in the North Lounge across from the 300 Unit nurse station. The residents were immediately separated. RN 5 asked the aides to take Resident C to her room and assist Resident B to the recliner. RN 5 initiated 15 minutes checks for Resident B. He instructed the CNAs to have their eyes on Resident B every time they passed by the resident, even if it was more frequent than 15-minute intervals. RN 5 assessed both breasts of Resident C since he was uncertain which breast Resident B touched. No skin impairments were found. During shift report when he left at 7:00 p.m. on 11/17/25, RN 5 told RN 6 to inform the Administrator, DON, SSD, and unit manager of the abuse that happened between Resident B and Resident C on his shift because he forgot to report it. It was not new for Resident B to be sexually inappropriate as he was known to say sexually inappropriate comments to females prior to the incident on 11/17/25. He denied any concerns with adequate staff for monitoring and preventing abuse. During an interview on 12/15/25 at 2:10 p.m., CNA 4 indicated, on 11/17/25, she had assisted Resident B to the entryway to the North Lounge in his wheelchair after supper and locked the wheels. RN 5 was at the nurses' station across from the North Lounge. There were a few other male residents seated in the chairs in the North Lounge. Resident C and another female resident were in the North Lounge seated in their wheelchairs near the middle of the North Lounge. She did not notify RN 5 that she was leaving the resident in his wheelchair with other female residents in the room before she went to assist CNA 3 to put a different resident in bed. CNA 4 was aware Resident B had previously been sexually in appropriate with females and she should have ensured Resident B was in the recliner prior to leaving Resident B in a room with female residents. She did not think it would be a problem since the nurse was at the nurses' station, but thought about it after she was in the other resident's room. When CNA 3 exited another resident's room, CNA 3 found Resident B touching Resident C's breast and told CNA 4. CNA 4 reported the incident immediately to RN 5. During a telephone interview on 12/15/25 at 4:38 p.m., RN 6 indicated she was not on duty on 11/17/25 when Resident B touched Resident C's breast. She had arrived at 7:00 p.m. that day for her shift and received report from RN 5. RN 5 had not reported anything to her about the incident between Resident B and Resident C, nor was she aware until approximately 8:00 p.m. on 11/17/25, when she heard CNAs talking in the hallway and inquired about more details. CNA 3 explained that she had witnessed Resident B touching Resident C's breast earlier that evening. She immediately told CNA 3 it must be reported immediately and instructed her to report. RN 6 then called the DON and reported what CNA 3 had reported to her. During an interview, on 12/15/25 at 4:55 p.m., the DON indicated she was first notified on 11/17/25 just prior to 8:30 p.m. by RN 6 that Resident B had touched Resident C's breast. She believed it occurred on 11/17/25 at approximately 6:01 p.m. Resident B had previously known inappropriate sexual behaviors. The facility should have prevented Resident C from experiencing sexual abuse. A current facility policy, revised 7/10/24, titled Abuse, Neglect and Exploitation, provided by the Administrator on 12/15/25 at 11:11 a.m., indicated the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies that prohibit abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. III. Prevention of Abuse, Neglect and Exploitation. The facility will implement policies and procedure to prevent and prohibit all types of abuse. B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms. G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. This citation relates to Intake 2672438. 3.1-27(a)(1)

Based on record review and interview, the facility failed to immediately report an allegation of sexual abuse to the Administrator for 1 of 3 residents reviewed for abuse. (Resident C) Finding includes:A facility reported incident submitted to Indiana Department of Health (IDOH), dated 11/17/25 at 6:01 p.m. and submitted on 11/18/25, indicated staff were removing residents from the dining room following evening meal and placing them in the North Lounge. Staff assisted a resident to bed and returned to the North Lounge and found Resident B touching Resident C's breast. Review of the facility investigation file included a handwritten statement of the Administrator that indicated the Administrator and DON were notified of the incident between Resident B and Resident C on 11/17/25 at 8:25 p.m. During a telephone interview on 12/15/25 at 12:28 p.m., CNA 3 indicated she found Resident B in the North Lounge with his hand inside the front of Resident C's gown fondling her breast. The residents were separated then CNA 4 reported everything to RN 5. CNA 3 was talking to RN 6 later in the shift when she learned that RN 5 had not reported the incident between Resident B and Resident C to RN 6 during shift change report. RN 6 recommended CNA 3 to report the incident to the DON. CNA 3 had not reported the incident herself to anyone prior to 11/17/25 around 8:20 p.m. when she sent a text to the DON. The alleged abuse should have been reported immediately to the nurse, Administrator, and the DON. She knew CNA 4 had reported it immediately to RN 5 when CNA 3 and CNA 4 were separating Resident B and Resident C. During an interview on 12/15/25 at 1:22 p.m., RN 5 indicated he was working on 11/17/25 and after dinner at approximately 6:00 p.m. an unidentified CNA reported to him that Resident B was seen touching Resident C's breast in the North Lounge across from the 300 Unit nurse station. It was sexual abuse when Resident B touched Resident C's breast as Resident C could not consent to sexual contact due to her severe cognitive impairment. During shift report, when RN 5 left at 7:00 p.m. on 11/17/25, RN 5 told RN 6 to inform the Administrator, DON, Social Service Director (SSD), and the Unit Manager of the abuse that happened between Resident B and Resident C on his shift because he forgot to report it. The CNAs were required to report any abuse to the nurse on the specific unit. He should have reported any abuse immediately to the Administrator, DON, SSD, Unit Supervisor, family representatives and the physician. During an interview on 12/15/25 at 2:10 p.m., CNA 4 indicated on 11/17/25 after supper CNA 3 told CNA 4 she found Resident B touching Resident C's breast in the North Lounge. CNA 4 reported the incident immediately to RN 5. Sexual abusive behavior should have been reported to the nurse and the DON immediately when it happened. Staff had access to contact the DON and Administrator after regular business hours. During a telephone interview on 12/15/25 at 4:38 p.m., RN 6 indicated she had reported the incident of sexual abuse between Resident B and Resident C to the DON on 11/17/25 after she was made aware at approximately 8:00 p.m. by CNA 3. The abuse allegation should have been reported immediately to the DON and the Administrator. During an interview 12/15/25 at 4:55 p.m., the DON indicated she was first notified on 11/17/25 just prior to 8:30 p.m. by RN 6 that Resident B had touched Resident C's breast. She believed it occurred on 11/17/25 at approximately 6:01 p.m. The DON reported this information to the Administrator on 11/17/25 at 8:30 p.m. The abuse allegation should have been reported immediately to the Administrator when the incident occurred. On 12/15/25 at 5:07 p.m., the Administrator indicated she was notified of the above incident between Resident B and Resident C on 11/17/25 at 8:25 p.m. when the DON called her. No other staff member had reported the incident to her prior. Staff, regardless of position, should have reported abuse to the Administrator immediately when it occurred. A current facility policy, revised 7/10/24, titled Abuse, Neglect and Exploitation, provided by the Administrator on 12/15/25 at 11:11 a.m., indicated the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies that prohibit abuse, neglect, exploitation and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or report of abuse, neglect or exploitation occur. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator. a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.Cross reference F600. This citation relates to Intake 2672438.3.1-28(c)

Based on record review and interview, the facility failed to identify and immediately report alleged abuse to the administrator for 1 of 3 residents reviewed for resident abuse. (Resident B) This deficient practice had the potential to affect 19 out of 77 residents in the facility who resided on the 300 Unit. The deficient practice was corrected on 6/27/25, prior to the start of survey, and was therefore past noncompliance.
Findings include:
Review of a facility reported incident, dated 6/22/25 at 2:35 p.m., indicated Resident B's daughter had reported Resident B had bruising to her bilateral hands as a result of a staff member holding onto her arms last night. It was noted Resident B had bruises on her left hand and wrist and to her right wrist. CNA 3 was suspended pending an investigation.
During a review of the facility abuse investigation, on 7/1/25 at 11:04 a.m., 13 resident interviews were held with no identified concerns and six non-interviewable residents had skin assessments completed. Statements from Resident B, the perpetrator, and four additional staff members were included. No additional abuse concerns were identified by other residents or staff during the investigation. A skin assessment was completed on 6/23/25 at 3:20 PM on Resident B. The skin assessment indicated Resident B had bruising to her bilateral hands and right wrist. Staff statements indicated Resident B had reported alleged abuse by CNA 3 to several staff members, who all failed to immediately report the alleged abuse to the Administrator. A facility-wide investigation was carried out and abuse inservicing was completed. The education included Resident Care Expectations and Abuse and Protecting your Profession. Four inservicing signature sheets, dated 6/22/25, contained 74 staff signatures. An employee roster indicated 45 staff members were called and were given the inservicing information via phone. The Ombudsman was notified regarding an abuse allegation, the investigation findings, and outcome via email on 6/24/25 at 3:52 p.m. Resident B's daughter was provided with Ombudsman information on 6/24/25 at 4:45 p.m. The local police department was notified on 6/25/25 at 10:14 a.m. CNA 3 was terminated on 6/25/25. Adult Protective Services (APS) was notified via email 6/27/25 at 11:21 a.m.
During an interview on 7/1/25 at 1:56 p.m., the DON indicated on 6/22/25 at approximately 2:30 p.m., RN 8 notified her Resident B told the resident's daughter that she received bruises to her hands and both wrists due to a staff member on night shift having grabbed her hands and held her down. The DON was not notified by any other staff members regarding the alleged abuse prior to the notification she received from RN 8. The DON immediately notified the Administrator of the abuse allegation and began the investigation. CNA 3 was suspended pending the investigation. The investigation did not identify any further instances of abuse or any adverse effects by staff members' actions. During the investigation interviews LPN 4, CNA 6, CNA 7, were educated regarding abuse and any suspicion, reported or observed abuse was to be reported immediately to the administrator.
During a phone interview on 7/1/25 at 4:14 p.m., CNA 3 indicated on 6/22/25, sometime after midnight and in the early morning hours, Resident B had accused CNA 3 of being abusive and she was going to report it to her daughter. CNA 3 reported Resident B's statement to LPN 4 the night it occurred. She did not report the allegation to anyone else.
During a phone interview on 7/1/25 at 4:45 p.m., LPN 4 indicated on 6/22/25 at approximately 3:00 a.m., Resident B told him that CNA 3 had bruised her all up. CNA 3 continued to work her shift after the allegation was made. Her shift ended at 6:00 a.m. LPN 4 did not report the alleged abuse to anyone until the DON called him the next day and questioned him about abuse concerns. The DON provided him with education regarding abuse and timely reporting.
During a phone interview on 7/2/25 at 9:48 a.m., CNA 6 indicated that on the night of 6/22/25 she had heard CNA 3 tell LPN 4 that she had to get stern with Resident B because CNA 3 had to tell Resident B six times that she needed to go to bed and stop waking up other residents. On 6/22/25, between 2:30 and 3:30 a.m., Resident B held up her hands and showed CNA 6 the bruising on them. Resident B commented she could not wait to tell her daughter that she did this to me. CNA 6 had thought the daughter had caused the bruising. CNA 6 did not report the bruising or Resident B's allegation that someone had caused the bruising to her. The DON provided her with education regarding abuse and timely reporting via phone.
During a phone interview on 7/2/25 at 10:32 a.m., RN 8 indicated on 6/22/25 Resident B's daughter informed her that the resident had accused a staff member of holding her down last night and caused bruising to her wrist and hands. RN 8 immediately notified the DON.
During a phone interview on 7/2/25 at 10:46 a.m., CNA 7 indicated during the 6/22/25 shift report, CNA 3 did not report any allegations of abuse or bruising to him. On 6/22/25, at approximately 6:45 a.m., he observed bruising on Resident B's wrists and hand. Resident B accused a staff member of grabbing her by the hands during the night shift. CNA 7 failed to report the allegation of abuse at that time. On 6/22/25, between 10:00 and 10:30 a.m., Resident B continued to mention the allegation. CNA 7 reported the allegation to RN 9 who was assisting as a CNA that day. CNA 7 did not report the allegation or bruising to management until he was called into the DON's office later that day. The DON provided him with education regarding abuse and timely reporting.
On 7/2/25 at 11:51 a.m., the Administrator indicated the DON notified her on 6/22/25 at 2:25 p.m. of an Abuse allegation. She arrived at the facility one and a half hours later. She was not notified of the alleged abuse by anyone else prior to the DON's call. She should have been notified immediately when it happened on night shift.
An auditing tool, titled Systemic Actions to Prevent Reoccurrence, provided by the Corporate Nurse Consultant on 7/2/25 at 12:14 p.m., indicated the following: Staff Education and Retraining: All direct care staff have received re-education .Employee Monitoring and Engagement: The Director of Nursing or designee will interview 5 employees weekly for four weeks, then monthly for five months, to assess their understanding of behavioral management, reporting requirements, and comfort and escalating concerns to leadership .QAPI: The team will review trends monthly .and modify interventions as needed.
A current policy, last revised on 9/17, titled Incident Investigating and Reporting, provided by the DON on 7/2/25 at 8:49 a.m., indicated the following: Policy: It is the policy of this facility to ensure that reportable incidents are investigated, recorded, and reported in accordance with the state and federal laws . Facility Reporting and Investigation Instructions: 1. The facility will ensure that all allegations of mistreatment, neglect or abuse, including injuries of unknown source, are reported immediately to the Administrator of the facility and to other officials in accordance with state law through established procedures (including to the State survey and certification agency)
Cross reference F600.
This citation relates to Complaint IN00462025.
3.1-28(c)

Based on record review and interview, the facility failed to ensure a cognitively impaired resident was free from staff-to-resident abuse as a result of physical retaliation to a combative resident for 1 of 3 residents reviewed for abuse. (Resident B) This deficient practice had the potential to affect 19 of 77 residents in the facility who resided on the 300 Unit. The deficient practice was corrected on 6/27/25, prior to the start of survey, and was therefore past noncompliance.
Finding includes:
Review of a facility reported incident, dated 6/22/25 at 4:27 p.m., indicated the following: Description added On 6/22/25 the facility was notified Resident B reported to her daughter that she had bruising to bilateral hands due to a staff member holding onto her arms last night. CNA 3 was the staff member involved. Type of Injury included dark purple bruises to bilateral wrists and the left hand. The resident denied pain to the areas. Immediate Action Taken included notifications to the physician, family, DON, and the Administrator. The staff member involved was suspended pending an investigation. Follow up indicated the investigation was completed. Residents and staff interviews were conducted with no new concerns identified. The employee was terminated due to her failure to meet the facility's expectations and standards when handling the situation. The family, physician, Adult Protective Services (APS), Ombudsman, and local law enforcement were notified of the findings. All staff were re-educated on abuse prevention and the mandatory reporting protocol. Nursing staff were re-educated on de-escalation and safe handling of combative behaviors.
Resident B's clinical record was reviewed on 7/1/25 at 11:52 a.m. Diagnoses included the need for assistance with personal care, dementia, reduced mobility, and insomnia.
A 6/13/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident B had moderate cognitive impairment. She had trouble falling or staying asleep, or she slept too much. Behaviors included verbal behavioral symptoms directed at others, other behavioral symptoms not directed towards others, and rejection of care. The resident used a walker and wheelchair for mobility. The resident required substantial/maximal staff assistance for all self-care tasks and mobility tasks, other than she needed supervision when walking ten feet and partial/moderate assistance with wheeling wheelchair 50 feet with two turns. The resident was frequently incontinent of bowel and bladder. There were no identified skin issues. She received a scheduled pain medication regimen, and her pain occasionally affected her sleep and day-to-day activities.
Resident B's current care plans included the following:
A 12/6/24 problem of behavioral symptoms presented as: combative with care, refusing care, yelling and cursing at staff, repetitively yelling out and name calling of staff. Interventions included the following: Social Services staff will intervene as necessary (12/6/24), You will encourage activities of interest (12/6/24), You will leave me alone and reapproach as necessary (12/6/24), Gently remind resident that her behavior/comments are inappropriate (12/8/24), You will assist me, as needed, with calling family when I am upset (4/26/25), I will be followed on the Behavioral Management Program (5/19/25)
A 1/6/25 problem of difficulty sleeping related to insomnia. Interventions included the following: staff is to offer non-pharmacological interventions such as back rub, warm drinks, soft music or tones, re-positioning, decreased stimuli, and a comfortable environment.
A 6/22/25 problem of distrusting her caregivers by displaying emotional distress, fearfulness, and anxiety, related to being handled roughly during care on 6/22/25. Interventions included the following: Staff is to approach resident from the front, avoid sudden movements or waking her up abruptly, describe steps to be taken before providing her personal care, if the resident is choosing not to have personal care, reapproach at a later time, and social services to follow up with her daily until she is seen by the mental health counselor.
A 6/24/25 problem of a bruise to her left hand related to trauma. Interventions included the following: the resident will have two staff members in her room and staff members will take a break if the resident is experiencing behaviors.
A 6/24/25 problem of a bruise to her left wrist related to trauma. Interventions included the following: the resident will have two staff members in her room and staff members will take a break if the resident is experiencing behaviors.
A 6/24/25 problem of a bruise to her right wrist related to trauma. Interventions included the following: the resident will have two staff members in her room and staff members will take a break if the resident is experiencing behaviors.
A skin assessment, dated 6/20/25 at 9:55 a.m., indicated the resident did not have any skin concerns.
A skin assessment, dated 6/23/25 at 3:20 p.m. indicated the resident had a dark purple bruise on the left wrist and measured 3 centimeters (cm) by 3.5 cm. The area was closed and dry. A dark purple bruise was on the right wrist and measured 2.5 cm by 2.5 cm. The area was closed and dry. A dark purple bruise was on the left hand and measured 3 cm by 3 cm. The area was closed and dry. No other skin concerns were identified.
The clinical record lacked documentation of maladaptive behavior expressions for Resident B from 6/21/25 through 7/2/25. The last behavior expression documented in the clinical record was on 6/12/25.
A Nurse's note, dated 6/22/25 at 2:30 p.m., indicated the provider was notified of an allegation and bruising.
A Social Services note, dated 6/23/25 at 9:00 a.m., indicated the resident denied any distress and reported she felt safe. She was unable to recall the incident.
A Nurse's note, dated 6/24/25 at 1:59 p.m., indicated the resident and daughter were spoken to. Bruising was assessed on Resident B's bilateral wrists and left hand on 6/22 and again on 6/24/25. The bruises were not tender to touch and the resident denied any pain related to the bruises.
A Social Services note, dated 6/24/25 at 3:23 p.m., indicated during a follow up with the Resident B, she indicated she had a good day. When the resident was asked about the bruises on her arms, she was able to recall the incident. The resident explained that when she saw other people going out, she wanted to go too. The fat girl grabbed her arms right there and said she could not go. The resident denied any fear or anxiety related to the incident. The resident was informed CNA 3 would no longer provide her care.
A review of the facility investigation file, provided by the DON on 7/1/25 at 11:04 a.m., contained the following information:
A hand written statement from RN 8, dated 6/22/25 at 2:00 p.m., indicated the resident's family member asked RN 8 if there were any incident reports from last night. The resident told the family member the CNA held her down and she had bruises to both wrists. The resident had purple bruising to bilateral wrists and to the left hand. The resident stated, a short fat CNA with dark hair came in during the middle of the night, started to do something and grabbed both arms. The resident was unable to give an exact time. She shook her head and repeated middle of night. The resident was unable to provide any further details. RN 8 notified the DON at 2:17 p.m.
A typed statement from the Administrator, dated 6/22/25 at 2:29 p.m., indicated the Administrator was informed of an allegation between a CNA and a resident. Staff explained a resident's family member reported bruising on a resident's wrists. When the resident was asked by the family member what happened, the resident explained that a short fat staff grabbed her wrists. An investigation was immediately initiated. The Administrator attempted to reach CNA 3, the perpetrator, and left a voicemail. On 6/22/25 at 3:03 p.m., the resident representative was notified and made aware an investigation was underway. The Administrator called the family member who reported the concern. She explained Resident B pointed out bruises on her arms during the visit and told the family member, the Nurse Aide grabbed my arms and there is bruising. Another attempt to reach CNA 3 was made from a different number, and left another voicemail. On 6/22/25 at 4:20 p.m., the Administrator and DON was able to reach CNA 3 via telephone for a statement. CNA 3 was notified an investigation was underway and she was suspended pending the investigation. When asked to explain what happened on 6/22/25, CNA 3 explained the resident was upset and up all night. The resident started swinging when CNA 3 tried to care for her. CNA 3 used a shirt to wrap the resident's hands to keep her from hitting. When asked to explain, CNA 3 would not elaborate. CNA 3 denied grabbing the resident's wrists or holding the resident down. She was informed the facility would notify her of the investigation outcome.
A STAFF TO RESIDENT ABUSE form indicated Resident B was assessed for injury on 6/22/25 at 2:45 p.m. Dark purple bruises were present to the back of the left hand and on bilateral wrists.
Typed statements obtained by the DON, on 6/22/25 from 3:30 p.m. - 4:00 p.m., indicated the following:
LPN 4 stated that CNA 3 got Resident B up, into her wheelchair, and brought her to the North television lounge next to LPN 4. Resident B told LPN 4, She's not nice! She's a b****! She bruised me all over! I am covered in bruises! LPN 4 had assisted the resident with her blanket and did not notice any discoloration on her hands and wrists at that time. He was educated that Resident B's comments should have been reported immediately to the Administrator as suspicious in nature for initiation of an investigation. He verbalized understanding.
CNA 6 stated she noticed bruising to the resident's hands when she was providing care at approximately 2:00 a.m. on 6/22/25. Regarding the bruises, Resident B stated, She did it to me! The resident told CNA 6 she could not wait to tell her daughter what had been done to her. CNA 6 also heard a conversation between CNA 3 and LPN 4 during which CNA 3 told LPN 4 she had to be stern with Resident B and told her to stop her yelling. CNA 6 was educated that the information should have been reported immediately as an allegation of abuse. CNA 6 verbalized understanding.
CNA 7 stated he started his shift after CNA 3. On his first interaction with Resident B, he noticed the resident had bruises. The resident told him, This fat a** girl grabbed me. The resident demonstrated to CNA 7 how the perpetrator treated her by taking two hands and holding onto CNA 7's hands/wrists. CNA 7 was educated that this should have been immediately reported as an allegation of abuse. CNA 7 verbalized understanding.
Resident B was interviewed with her family member present. When asked about the bruising on her hands and wrists, the resident stated That girl grabbed my hands and held them last night. The resident was unable to identify the specific time but indicated it was the short fat girl with long dark hair. The resident denied any pain from the bruising and her range of motion was per usual. The chart revealed the resident was on aspirin daily.
Four Abuse in-service attendance logs, dated 6/22/25, contained 74 signatures. The education included information about identifying types of abuse to include questionable actions or statements, stress and burnout related to abuse, and protection of the residents from staff involved in an abuse allegation.
On 6/23/25, thirteen alert and oriented residents were interviewed with no identified concerns of abuse.
On 6/23/25, six non-interviewable residents received full skin assessments, with no other suspicious skin impairments found other than the bruising to Resident B's wrists and hand.
Review of an email, dated 6/24/25 at 3:52 p.m., indicated the facility notified the Ombudsman of an abuse allegation, the investigation findings, and the outcome.
On 6/24/25 at 4:45 p.m., the facility provided the resident's representative with the Ombudsman contact information.
A Handling difficult behaviors in-service attendance log, dated 6/25/25, contained 10 signatures.
A Corrective Action Form, dated 6/25/25, indicated CNA 3 was terminated from employment due to violations of facility policies regarding appropriate resident care, abuse prevention, and the management of challenging behaviors.
The local police department was notified on 6/25/25 at 10:14 a.m. The police report indicated Resident B reported a CNA, with a description of the CNA, pushed her back into her wheelchair, held her by her wrists, and told her she was not to get up. The report indicated light bruising remained to the resident's left wrist. The resident did not want to file charges.
On 6/27/25 at 11:21 a.m., the facility notified the Adult Protective Services (APS) of the abuse investigation.
During an interview on 7/1/25 at 1:56 p.m., the DON indicated on 6/22/25 at approximately 2:30 p.m., RN 8 notified her Resident B told the resident's daughter that she received bruises to her hand and both wrists due to a staff member on night shift having grabbed her hands and held her down. The resident had given a physical description of CNA 3. This was reported to RN 8 by the resident's daughter when she inquired about the bruises. The DON immediately notified the Administrator of the abuse allegation and began the investigation. The resident was in the dining room with her daughter when the DON approached the resident and noticed the bruises on her wrists and hand. Upon asking the resident what happened regarding the bruises, her allegations remained unchanged. As the DON obtained statements from RN 8, Resident B, LPN 4, CNA 6, and CNA 7, the allegations of abuse remained consistent. The physical description of the perpetrator matched CNA 3 who was assigned to provide the resident's care when the alleged event occurred during night shift sometime before 6:00 a.m. on 6/22/25. When the DON and the Administrator reached CNA 3 via telephone for a statement, CNA 3 reported the resident had been combative during care that night. The resident was swinging at CNA 3. In response, CNA 3 wrapped a shirt around the resident's hands. The DON educated CNA 3 you can't do that when residents display behaviors. CNA 3 was suspended pending the investigation. The investigation did not identify any further instances of abuse or any adverse effects by staff members' actions. During the investigation interviews, LPN 4, CNA 6, CNA 7, were educated regarding observed abuse, reported abuse, and/or any suspicion of abuse and the importance of an immediate investigation for the resident safety. They were educated on their role of identifying and reporting while administrations role of investigating the allegations and determining if it was abuse. The facility determined that CNA 3 had been abusive to the resident because she admitted to wrapping the resident's hands in a shirt when the resident was combative and the resident had bruises following the event. The resident was known to be verbally and physically aggressive with staff at times. This made the resident at higher risk for being abused.
During a phone interview on 7/1/25 at 4:14 p.m., CNA 3 indicated on 6/22/25, sometime after midnight and in the early morning hours, Resident B was screaming all night and wanted her family. CNA 3 was in the resident's room without any other staff. She sat in her room for a minute but that did not calm the resident. CNA 3 assisted the resident into the wheelchair and the resident became combative and started swinging at CNA 3. Before she took the resident to the lounge, CNA 3 pulled the residents shirt around her arms in a manner to restrict the residents arms from hitting. The resident accused CNA 3 of being abusive to her and she was going to report it to her daughter. CNA 3 did not see any bruising on the resident and she did not know why the resident had bruises that morning after the interaction between CNA 3 and Resident B. CNA 3 should have gone to get someone else to provide Resident B's care rather than restricting the resident's arms. CNA 3 reported Resident B's statement of abuse to LPN 4 the night it occurred on 6/22/25.
During a phone interview on 7/1/25 at 4:45 p.m., LPN 4 indicated on 6/22/25 Resident B had been awake throughout the night shift and LPN 4 and other staff had been in and out of the resident's room. The resident kept saying she wanted to get up. At approximately 2:00 a.m., after his break he noticed CNA 3 was sitting in a wheelchair outside of Resident B's room. He thought it was weird, but CNA 3 told him she thought it might help the resident relax if she was out of the room. LPN 4 instructed CNA 3 to get the resident up, since she had requested to get up and bring her down to the lounge. At approximately 3:00 a.m., when CNA 3 brought the resident to the lounge, Resident B told LPN 4 that CNA 3 had bruised her all up. LPN 4 did not complete a head to toe assessment nor report the alleged abuse to anyone until the DON called him during the day after his shift and questioned him about any abuse concerns on the night shift. The resident had been pleasant during interactions with LPN 4. Resident B was known to be challenging at times due to her behaviors. He had not documented any behaviors on 6/22/25, because her behaviors were not as bad as they had been on other days. CNA 3 continued to work her shift after the allegation was made. CNA 3's shift ended at 6:00 a.m. The DON provided LPN 4 with education regarding abuse,timely reporting, and protecting the residents by sending involved staff home.
During a phone interview on 7/2/25 at 9:48 a.m., CNA 6 indicated she came in early at 6:00 p.m. on 6/21/25 and worked until 10:00 p.m. on the 300 Unit, where she provided care for Resident B. She had not seen any skin impairments to the residents skin when she was assigned to the resident during those four hours. At 10:00 p.m., CNA 3 came in and was assigned to the 300 Unit. CNA 6 began the CNA float position at that time and covered the different units for their breaks. Some time between approximately 2:30 a.m. and 3:30 a.m., she relieved CNA 3 for a break. When CNA 3 gave report to CNA 6, CNA 3 reported that Resident B was up in the lounge watching television. CNA 3 did not mention in report the resident was combative with her. Resident B started yelling out after CNA 6 was floating on her unit so CNA 6 asked the resident what she was wanted to do. The resident requested to go back to bed, so she took her to her room and assisted her into her bed. The resident was cooperative with care when CNA 6 assisted her. Resident B held up her hands and showed CNA 6 the bruising. Resident B commented she could not wait to tell her daughter that she did this to me. CNA 6 thought the daughter had caused the bruising. CNA 6 had gone down to the 300 Unit at another time on the night of 6/22/25 and she heard CNA 3 tell LPN 4 that she had to get stern with Resident B because Resident B had to be told six times that she needed to go to bed and stop waking up other residents. CNA 6 did not report the bruising or Resident B's allegation that someone had caused the bruising to her. The DON provided CNA 6 with education regarding abuse and timely reporting via phone.
During a phone interview on 7/2/25 at 10:32 a.m., RN 8 indicated on 6/22/25 Resident B's daughter approached RN 8 and asked if there were any incidents reported last night. The resident's daughter noticed bruising on the resident's wrists and hand. Resident B had informed her daughter the aide that held her down last night caused the bruising. RN 8 then asked Resident B what happened. The resident explained that sometime in the night last night the short, fat, CNA, with long dark hair held her down. As a result, her wrists and her hand was bruised.
During a phone interview on 7/2/25 at 10:46 a.m., CNA 7 indicated during the 6/22/25 morning shift report, CNA 3 did not report any allegations of abuse or bruising to him that occurred on night shift. On 6/22/25, at approximately 6:45 a.m., he observed bruising on Resident B's wrists and hand. Resident B accused a staff member of grabbing her by the hands during the night shift. CNA 7 failed to report the allegation of abuse at that time. On 6/22/25, between 10:00 and 10:30 a.m., Resident B mention the allegation of abuse to CNA 7 again. CNA 7 indicated it was unusual for Resident B to remember vivid details. The DON provided him with education regarding abuse and protecting the resident. RN 8 provided education to CNA 7 regarding behavior responses.
On 7/2/25 at 11:51 a.m., the Administrator indicated the DON notified her on 6/22/25 at 2:25 p.m. of an abuse allegation by CNA 3 to Resident B. Restraining of the resident's arms was considered abusive. The facility should have protected Resident B from abuse. The facility in-serviced on behavior techniques. They have in-servicing scheduled for the second Thursday of every month to include re-education on abuse and reporting with examples to review.
An auditing tool, titled Systemic Actions to Prevent Reoccurrence, provided by the Corporate Nurse Consultant on 7/2/25 at 12:14 p.m., indicated the following: Staff Education and Retraining: All direct care staff have received re-education on trauma-informed care, de-escalation techniques, safe physical care methods . Resident Monitoring - Interviewable Residents: The Social Service Director (or designee) will interview four alert and oriented residents weekly for four weeks, then monthly for five months, to assess perceptions of care, concerns about rough handling, or unreported injuries. Interviews will be documented and reviewed during QAPI. Resident monitoring - Non-Interviewable Residents: The nursing team will conduct weekly head-to-toe skin assessments on all non-interviewable residents for 6 months to monitor for unexplained bruising or injury. Any findings will immediately be reviewed by the DON and HFA for investigation and follow-up. Employee Monitoring and Engagement: The Director of Nursing or designee will interview 5 employees weekly for four weeks, then monthly for five months, to assess their understanding of behavioral management . and comfort and escalating concerns to leadership. Behavioral Care Oversight: The IDT (Interdisciplinary Team) will review the care plans for residents with the history of combative behaviors to ensure: Appropriate interventions and de-escalation strategies are included. Staff assignments consider training and experience .QAPI: An ad hoc QAPI project will be initiated to monitor patterns of injuries . and training efficiency. The team will review trends monthly, evaluate the effectiveness of interviews and skin assessments, and modify interventions as needed. A Staff Interview and Education Validation Tool, Resident Interview Audit Tool, and Compliance with Reporting Allegations of Abuse/Neglect/Exploitation Validation Checklist were tools used for ongoing monitoring.
A current facility policy, revised 10/17/22, titled Freedom from Abuse, Neglect, Exploitation and Misappropriation of Property, provided by the DON on 7/1/25 at 10:30 a.m., indicated the following: Policy Statement . The resident has the right to be free from abuse . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Policy Interpretation and Implementation . Each resident has the right to be free from abuse, neglect, and corporal punishment or any type by anyone . ABUSE: .The facility must provide a safe resident environment and protect residents from abuse . Staff to Resident Abuse of Any Type .When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident . It is the facility's responsibility to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to resident behavior . All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population . Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited
The deficient practice was corrected by 6/27/25 after the facility implemented a systemic plan that included a thorough investigation, facility in-service regarding abuse/reporting/protecting, responses to staff burnout, and an in-service regarding handling challenging behaviors.
This citation relates to Complaint IN00462025.
3.1-27(a)

Based on interview and record review, the facility failed to ensure mail was distributed to residents on Saturdays. This deficiency had the potential to affect 79 of 79 residents who resided in the facility.
Finding includes:
During a Resident Council group interview, on 1/10/25 beginning at 1:38 p.m., Resident 3 indicated the facility did not deliver mail to the residents on Saturdays. There was no one at the facility to deliver mail because the administrative offices were closed on the weekends. Residents 45, 67, 30, 53, and 62 indicated they did not receive mail on Saturdays.
During an interview, on 1/10/25 at 4:00 p.m., QMA 4 indicated he was uncertain if mail was delivered to the facility residents on Saturdays.
During an interview, on 1/10/25 at 4:06 p.m., CNA 6 indicated she did not think the residents received mail on Saturdays. If the facility did receive mail, it went to the business office.
During an interview, on 1/10/25 at 4:07 p.m., the Dementia Care Director indicated the residents did not get mail on Saturdays because the business office was closed.
During an interview, on 1/14/25 at 10:34 a.m., the Activity Director indicated the activity assistants had not been passing mail to the residents on Saturday until this past Saturday, 1/11/24. They had thought the business office was required to gather the mail from the mailbox since the business office sorted the mail.
During an interview, on 1/14/24 10:41 a.m., the Administrator indicated when they had hired new activities assistants, the information had not been passed to them to get the mail and deliver it to the residents on Saturdays.
A current facility policy, revised 5/2017 and titled Mail Distribution, provided by the Administrator on 1/14/25 at 11:24 a.m., indicated the following: .Distribute all mail promptly to the addressed resident unopened .Deliver the mail to the residents within 24 hours of delivery by the postal service
3.1-3(s)(1)

Based on observation, interview, and record review, the facility failed to ensure the most recent Indiana Department of Health (IDOH) survey reports were readily available for review. This deficiency had the potential to affect 79 of 79 residents who resided in the facility.
Finding includes:
During a Resident Council group interview, on 1/10/25 beginning at 1:38 p.m., Residents 3, 30, 45, 53, 62, and 67 indicated they did not know where the State Department of Health survey reports were located.
During an observation, on 1/10/25 at 3:35 p.m., the State Department of Health survey report was located in a binder placed in a wall pocket on the wall beside the Human Resources office. The most recent survey in the binder was from the Annual Recertification and State Licensure Survey completed on 1/22/24. The report lacked the plan of correction.
Review of the facility's IDOH survey history indicated Complaint Investigation Surveys were completed on 5/3/24, 9/13/24, and 10/18/24.
During an interview, on 1/14/25 at 10:39 a.m., the Human Resources Director indicated she believed the Administrator was responsible for maintaining the State Department of Health survey report binder that was located in the wall pocket near her office door.
During an interview, on 1/14/25 at 10:43 a.m., the Administrator indicated he was responsible for updating and maintaining the survey results binder. He remembered printing out survey reports for this past year, but was uncertain what had happened to the papers as they were not in the binder.
A current facility policy, dated 11/1/23, titled Availability of Survey Results, provided by the DON on 1/14/25 at 12:21 p.m., indicated the following: .A readable copy of our company's most recent federal and/or state survey report and plan of correction for any identified deficiencies is maintained in a 3-ring loose-leaf binder titled Results of the Most Recent Survey .The facility will maintain reports of any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility
3.1-3(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis and psychotropic medication for 1 of 1 residents reviewed for PASRR. (Resident 59)
Findings include:
Resident 59's clinical record was reviewed on 1/9/25 at 3:55 p.m. The most current PASRR was completed on 6/20/23. The application submitted indicated that the resident had no known or suspected mental health diagnoses. No mental health medications were listed.
Resident 59's diagnoses included psychotic disorder with delusions due to know physiological condition (9/18/23), unspecified mood (affective) disorder (8/28/23), generalized anxiety disorder (6/29/23), other recurrent depressive disorders (6/29/23), and dementia in other diseases classified elsewhere, mild, with agitation (6/29/23).
Physician's orders included escitalopram oxalate (antidepressant) 10 milligrams (mg) daily at bedtime (7/24/24), olanzapine (antipsychotic) 5 mg daily in the morning (4/16/24), and olanzapine 7.5 mg daily in the evening (10/15/24).
A current care plan for behavioral symptoms included being easily agitated with others, choosing not to have care provided, verbal aggression, refusing medications, repetitive movements of rubbing arms and legs, yelling at staff, rocking, picking at face and arms, delusions, hallucinations, paranoia, name calling, cursing at staff, refusing care, refusing to change clothes, refusing staff assistance to brush hair and perform oral hygiene, repetitive movement of coming in and out of the dining-room, cursing under breath, appearing anxious for unknown reasons, grabbing and shoving peers, cursing and threatening peers, and wanting more food due to forgetting she just ate was initiated on 7/22/23 and revised on 1/3/24. Interventions included the following: administer medications as ordered (9/21/23), provide mental health services as indicated (8/6/23), and remove known triggers (7/22/23).
A Nurse's Note, dated 10/9/23 at 3:58 p.m., indicated a new order was received from the psychiatric nurse practitioner (NP) for the resident to be sent to a neuropsychiatric hospital. The resident was transferred via facility van to the neuropsychiatric hospital.
A Physician Narrative Progress Note, dated 10/9/23 at 11:14 p.m., indicated the resident was assessed for continued mood swings and behaviors which included agitation, aggression, wandering, anxiety, and confusional states. The resident had been seen by the NP on 10/9/23. The resident was initially calm but showed some signs of paranoia as she walked into the dining room and started looking around. The facility was providing one-on-one care which the resident did not like and said someone kept following her around. The resident was on one-on-one care with staff due to increased physical and verbal aggression as well as increased mood swings. The resident had been found standing over another resident with a pillow over that's resident's face. The resident had multiple incidences of physical aggression over the past several weeks. Her behaviors worsened over the last several weeks. As the resident sat in the dining room, the noise level increased. The resident yelled a profane statement. The NP's plan indicated it was concerning to adjust any medications as it was believed the resident should be sent out to a psychiatric hospital where she could get more one-on-one aggressive treatment, and her medications could be adjusted.
A Physician Narrative Progress Note, dated 10/30/23 at 11:28 p.m., indicated the resident was assessed by the psychiatric NP. Her recent hospital stay was reviewed. The resident had been transferred to a neuropsychiatric hospital due to worsening behaviors, agitation, and severe aggression. While at the hospital, the resident's risperidone (antipsychotic) was increased then discontinued. She started on olanzapine 5 mg twice a day which was increased to 10 mg twice a day on 10/23/24. The resident reported that she thought her mood was okay. She said she kept her necklace hidden, which was a string of pearls because she believed people would steal them. She exhibited paranoia and restlessness while wandering. The staff had reported that the resident was very on edge since return from the neuropsychiatric hospital.
During an interview, on 1/14/25 at 4:30 p.m., the Social Services Designee (SSD), who was responsible for PASRR submissions, indicated the PASRR completed on 6/20/23 was the only PASRR completed she had for the resident. The resident should have had a new PASRR submitted when the resident received the mental illness diagnoses.
According to the Indiana PASRR Level I & Level of Care Screening Procedures for Long Term Care Services Provider Manual, retrieved from maximusclinicalservices.com on 1/14/24, last revised 4/20/20, .If a NF [nursing facility] resident's behavioral or mental status significantly changes, the NF must submit a new Level I to report the change through the PASRR process. This applies to people who have a known Level II condition and to people with a previous negative Level I . Examples of a mental status change event include: A new mental health diagnosis that is not listed on previous [NAME] or Level II. A new psychotropic medication for mental illness
A current facility policy, dated 11/1/23, titled Specialized Rehabilitative Services, provided by the SSD on 1/14/25 at 5:03 p.m., indicated the following: .The facility shall provide or obtain services from an outside resource for specialized rehabilitation services .as well as ensure that residents with Mental Disorder (MD), Intellectual Disability (ID) or related conditions receive services as determined by their Preadmission Screening and Resident Review (PASARR)

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan with individualized interventions to maintain the resident's highest practicable mental, physical, and psychosocial outcome for 1 of 1 resident reviewed for a limited range of motion. (Resident 73)
Finding includes:
During an interview on 1/7/25 at 12:10 p.m., Resident 73 was laying in bed in his room with his door closed. He indicated he was paralyzed from his chest down. He had received therapy when he admitted a few months ago, but therapy ended. He was waiting for insurance to get more therapy. He had not received any restorative care or passive range of motion on his lower extremities to ensure he did not have a decline while he waited on insurance. He had spoken to two different therapy staff members quite some time ago and requested restorative care, but had not received any. He was concerned about losing the progress he had made in therapy.
Resident 73's clinical record was reviewed on 1/9/25 at 5:08 p.m. Diagnoses included paralytic syndrome, constipation, complete paraplegia, other reduced mobility, generalized muscle weakness, and need for assistance with personal care.
The resident's clinical record lacked a care plan related to being at risk for a decrease in range of motion and/or development of contractures related to the resident's diagnosis of paraplegia.
During an interview on 1/13/25 at 5:14 p.m., the MDS Coordinator indicated a care plan for restorative care should have been developed and implemented, but it had not been and was not in the resident's clinical record.
A current facility policy, revised 9/18/24, titled Comprehensive Care Plan, provided by the DON on 1/14/25 at 12:05 p.m., indicated the following: .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment
Cross Reference F688.
3.1-35 (a)
3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure the resident's representative was invited to participate in the ongoing care planning process for 1 of 1 residents reviewed for care planning. (Resident 34)
Findings include:
During an interview, on 1/8/25 at 11:19 a.m., Resident 34's representative indicated she had been invited one time to a care plan meeting. She had not been invited since that first meeting. She did not know when the meetings were held.
Resident 34's clinical record was reviewed on 1/9/25 at 11:54 a.m. Diagnoses included anxiety disorder, delusional disorder, Alzheimer's disease, and unspecified dementia, moderate, with agitation.
An annual Minimum Data Set (MDS) assessment, dated 10/29/24, indicated the resident was severely cognitively impaired. An interview about preferences with the resident indicated having her family or a close friend involved in discussions about her care was very important to her.
A current care plan indicated Resident 34 did not plan to return to the community and wished to be asked about returning to the community on comprehensive assessments only (initiated 2/11/22 and revised 9/20/23). Interventions included the following: Encourage the resident's family to be involved in the resident's plan of care (initiated 2/11/22).
A progress note, dated 4/26/23 at 2:00 p.m., indicated a phone call was placed to the resident's representative to set up a care plan conference. The resident's representative was not reached, and a message could not be left as the voice mail had not been set up.
The clinical record lacked more recent documentation of attempts to invite the resident's representative to participate in the resident's care plan conferences.
During an interview, on 1/10/25 at 3:32 p.m., the Social Services Designee (SSD) indicated she invited the short term stay residents' representatives by phone. She invited the long-term stay residents' representatives by mail.
During an interview, on 1/14/25 at 10:51 a.m., the SSD indicated if the invitation to the care plan conference was not in the progress notes, then she did not have documentation that the resident's representative had been invited. The resident's representative visited the resident two to three times a week, and the resident's care was often discussed. She had invited the resident representative verbally to care plan conferences, but she did not have documentation of those discussions.
A facility policy, revised 2/2019, titled Care Plan Meeting and Invitations, provided by the DON on 1/14/25 at 3:29 p.m., indicated the following: .SSD/Designee will send a standard letter to the Resident Representative or place a call to schedule the care plan meeting .The SSD/Designee will document that the letter was sent or the phone call was made and the response received from the resident or the resident representative
3.1-35(d)(2)(B)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate restorative care services as recommended by therapy for a resident with limited range of motion for 1 of 1 resident reviewed for restorative care. (Resident 73)
Finding includes:
During an interview on 1/7/25 at 12:10 p.m., Resident 73 was laying in bed. He indicated he was paralyzed from his chest down. He had received therapy when he admitted a few months ago, but therapy ended. He was waiting for insurance to get more therapy. He had not received any restorative care or passive range of motion on his lower extremities to ensure he did not have a decline while he waited on insurance. He had spoken to two different therapy staff members quite some time ago and requested restorative care, but had not received any. He was concerned about losing the progress he had made in therapy.
The resident's clinical record was reviewed on 1/9/25 at 5:08 p.m. The resident admitted to the facility on [DATE]. Diagnoses included, paralytic syndrome, constipation, complete paraplegia, other reduced mobility, generalized muscle weakness, and need for assistance with personal care.
A physician's medication order, dated 9/26/24, included baclofen 10 mg tablet- give 20 mg by mouth three times a day for muscle spasms, and was discontinued on 10/21/24.
Current physician's medication orders included the following: gabapentin (neuropathy pain reliever) 600 milligrams (mg) oral capsule by mouth three times a day for ascending paralysis, dated 9/13/24; baclofen (muscle relaxer) 20 mg tablet by mouth every six hours for spasms, dated 10/21/24; Senna-Plus (stool softener) 8.6-50 mg oral tablet by mouth twice daily for constipation, dated 9/13/24; Dulcolax (laxative) rectal suppository 10 mg rectally at bedtime every three days for constipation, dated 10/7/24
Review of the Medication Administration Record from October 2024 through January 2025 indicated the resident's baclofen was increased to four times daily after therapy ended due to increased spasms. An additional medication was added to treat constipation.
A current order, dated 9/12/24, indicated the resident's rehabilitation potential was fair.
The clinical record lacked current orders for speech therapy, occupational therapy, physical therapy, or restorative care services.
A quarterly Minimum Data Set (MDS) assessment, dated 12/21/24, indicated Resident 73 was cognitively intact. Rejection of care behaviors were not exhibited during the assessment period. The resident had a functional limitation in range of motion in the lower extremities with impairment on both sides. He was dependent on staff for assistance with toileting, bathing, lower body dressing, footwear, rolling left and right, and transfers. He required substantial staff assistance for personal hygiene. Walking was not attempted. A manual wheelchair was used for mobility. No days of Therapy Services or Restorative Nursing was received during the assessment period.
The resident's clinical record lacked a care plan for restorative care or services to maintain or improve range of motion.
A Physical Therapy Discharge summary, dated [DATE], indicated Resident 73 was discharged from physical therapy as he had reached maximum potential with skilled services. Discharge recommendations included the Restorative Nursing Program for passive range of motion and was set up with Restorative Aide 10, who was trained to perform these services.
A Therapy Discharge Recommendation form, dated 10/4/24, indicated Resident 73's restorative nursing recommendations included passive range of motion. This included one set of 20 repetitions of slow motion secondary to spasticity.
A Physiatry progress note, dated 10/8/24 at 3:44 p.m., indicated the resident's current functional status as of 10/8/24 was minimal staff assistance for bed mobility tasks, minimal to moderate assistance from staff was needed for both transfers and toileting using a slide board, minimal assistance from staff was needed for upper body dressing, and maximal assistance was needed for lower body dressing.
A Nurse's Note, dated 10/21/24 at 1:27 p.m., indicated the nurse received a new order to increase the baclofen for muscle spasms.
A Nurse's Note, dated 11/11/24 at 2:22 p.m., indicated the resident complained of an increase in spasms that were painful. The resident's spouse was aware of the clinical situation because the resident was not wanting to get up to get weighed.
The clinical record lacked indication of restorative services being provided to the resident.
During an interview on 1/13/25 at 11:52 a.m., Restorative Aide 15 indicated she and Restorative Aide 10 were assigned to all the residents who were required to receive Restorative Nursing Services. They typically worked with each resident in 15 minute increments each day. Depending on the order, they may be worked with twice daily. This was documented in the clinical record under restorative each time it was completed. These were the Restorative Aides' primary duties each day. Restorative Aide 15 indicated she had never been assigned to provide Resident 73 restorative care.
During an interview on 1/13/25 at 5:05 p.m., the Physical Therapist indicated she was familiar with Resident 73. The resident had spoken with her when he was discharged from physical therapy regarding a desire to get restorative care/passive range of motion for his lower extremities. She had completed the Therapy Discharge Recommendation form and gave it to the Rehabilitation Director at that time. The form was dated 10/4/24.
During an interview on 1/13/25 at 5:09 p.m., the Rehabilitation Director indicated a copy of the resident's Therapy Discharge Recommendation form was given to the previous MDS Coordinator (who was no longer employed at the facility) on the date she received it from the therapy staff. The MDS Coordinator was responsible for the assignment of the residents to a Restorative Aide for initiation of the recommendations. A new MDS Coordinator had started since that time.
During an interview on 1/13/25 at 5:14 p.m., the MDS Coordinator indicated Resident 73 was not on her list of residents assigned to receive restorative care. She indicated the resident's chart lacked any tabs for restorative care where the care should have been documented. She had not been provided a copy of the resident's Therapy Discharge Recommendation form, as this occurred prior to her employment.
During an interview on 1/13/25 at 5:22 p.m., the DON indicated the resident had not received restorative care. Therapy recommendations should have been initiated by the previous MDS Coordinator, but was not done.
During an interview on 1/14/25 at 12:00 p.m., Restorative Aide 10 indicated she had never provided Resident 73 restorative care because he was not assigned by the MDS Coordinator. The resident was at risk for a decrease in range of motion and contractures due to his paraplegia.
A current facility policy, revised 3/2022, titled RESTORATIVE/ADL NURSING, provided by the DON on 1/13/25 at 5:29 p.m., indicated the following: .It is the policy of this facility to ensure that a resident without limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates it is unavoidable; A resident with limited range of motion receives appropriate treatment and services to prevent further decline; and A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a decline is unavoidable
3.1-42(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision for a cognitively impaired resident with a history of falls to prevent repeated falls for 1 of 2 residents reviewed for accidents. (Resident 129)
Findings include:
During an observation, on 1/7/25 at 1:19 p.m., Resident 129 was lying in a bed in the low position with a tall mat beside his bed. The resident was awake and watching television.
During an observation, on 1/8/24 at 11:53 a.m., Resident 129 was assisted in his wheelchair to his room. He declined to get into bed. He had a brace on his right wrist.
During an observation, on 1/9/24 at 2:48 p.m., Resident 129 was lying in bed, turned onto his left side. A tall mat was beside his bed.
During an observation, on 1/10/24 at 3:50 p.m., Resident 129 was lying in bed holding and looking at his remote control. The tall mat was beside his bed. He was had his oxygen on per nasal cannula.
During an observation, on 1/13/24 at 3:07 p.m., Resident 129 self-propelled his wheelchair out of the dining/activity area. He wore nonskid socks and an oxygen cannula. He held a package of candy bars, a package of chips, and a can of soda he had won at BINGO.
Resident 129's clinical record was reviewed on 1/9/25 at 8:53 a.m. Diagnoses included repeated falls, syncope (fainting) and collapse, hypoxemia (low concentration of oxygen in blood), muscle weakness (generalized), difficulty in walking, other lack of coordination, history of falling, unspecified mood (affective) disorder, and altered mental status.
Current physician orders included the following: divalproex 125 milligrams (mg) twice a day for mood stabilization (12/23/24), hydrocodone-acetaminophen 10-325 mg every six hours as needed for pain (12/12/24), check function and placement of silent pressure alarm to bed and chair/wheelchair every shift for safety (12/17/24), and keep splint clean and dry until follow up with orthopedic physician and check skin each shift to monitor for break down for radial fracture (12/23/24).
An admission Minimum Data Set (MDS) assessment, dated 12/14/24, indicated Resident 129 was severely cognitively impaired. He had hallucinations and rejected care one to three days of the assessment period. He had limitations of his functional range of motion to his upper and lower extremities on both sides. He required substantial to maximal assistance with toileting, bathing, dressing, putting on and taking off footwear, rolling left and right in bed, moving from sitting to lying, moving from lying to sitting, moving from sitting to standing, transferring from chair to bed and bed to chair, and transferring to the toilet. He was short of breath with exertion and when lying flat. He had fallen the month prior to admission. He had fallen two or more times with no injuries and one time with injury since he was admitted . A bed alarm was used daily.
A current care plan for falls indicated the resident was at risk for falls related to history of falls, syncope, and decrease in safety awareness (initiated 12/17/24 and revised on 1/8/24). Interventions included the following: A silent pressure chair/bed alarm was to be used to alert staff that the resident needed staff assistance with transfers (initiated 12/17/24 and revised 1/8/25); The resident was to wear proper footwear or non-slip footwear when he is up (initiated 12/17/24); The resident will have a non-slip mat in his wheelchair to decrease the resident from sliding out of his wheelchair (initiated 12/17/24); The resident will sleep/rest in a floor bed that is low to the floor with a mat on the floor to assist in decreasing the risk of the resident injuring himself when he rolls out of bed (initiated 12/17/24); The resident will be toileted at 7:00 p.m. as he allows (initiated 12/18/24); and The resident will be reminded to change position slowly (initiated 12/22/24).
An admission evaluation, dated 12/12/24 at 7:34 p.m., indicated the resident had fallen in the last month and two to six months prior to admission. He had a fracture related to a fall in the six months prior to admission.
A fall risk assessment, dated 12/12/24 at 7:37 p.m., indicated the resident had intermittent confusion. He had three or more falls in the past three months. He was chair bound and/or required assistance with elimination. He received three to four medications which increased the risk of falling. He had three or more predisposing conditions which increased the risk of falling. He was a high fall risk.
A Hospital Emergency Department Progress Note, dated 12/22/24 at 6:58 a.m., indicated the resident presented to the emergency department by ambulance. The resident reported he was sitting in a chair and was asleep. He was unsure what had happened. The staff reported he fell forward out of his chair and hit his head. He sustained a large laceration to his forehead. His right forearm had tenderness with flexion and extension of the wrist. On the right side of the forehead just below the hairline was an approximately 2.5 centimeter (cm) irregular laceration that was y-shaped with an additional linear portion extending from the center gaping, bleeding controlled. The laceration was repaired with five sutures. The x-ray showed a distal radius (bone in the forearm) fracture and possible scaphoid (small bone in the wrist) fracture. The orthopedic physician was consulted about the x-ray findings and a follow-up was advised. A splint was applied to the right upper extremity. The resident was discharged back to the facility.
An x-ray of the right wrist, dated 12/22/24 at 8:48 a.m., indicated an avulsion (a break in a small piece of bone in the wrist that's attached to a ligament or tendon) fracture arising from the volar (palm side) aspect of the wrist and a lucency (darker area on the X-ray) through the scaphoid which may represent a nondisplaced fracture.
The resident's fall events and immediate interventions were as follows:
A Nurses Note and Fall Investigation Worksheet, dated 12/13/24 for the fall at 5:40 a.m., indicated the resident was found lying on his right side on the floor next to his bed with his head near the foot of the bed. The resident's feet were bare. The call light was not sounding. The resident complained of some soreness to back and leg. No obvious injuries were noted. The immediate intervention was the placement of a bed alarm.
A Nurses Note and Fall Investigation Worksheet, dated 12/13/24 for the fall at 8:00 p.m., indicated the resident was found on both knees on the floor in his room. The resident had appeared to attempt to self-transfer from wheelchair. He wore gripper socks. His call light was sounding. An alarm was being used at the time of the fall and was working properly. No new injuries were noted. The immediate intervention was the placement of a chair alarm pad underneath the resident. The resident was assisted into the wheelchair, and the call light was clipped to his shirt. He was reminded to use the call light if he wished to move.
A Nurses Note and Fall Investigation Worksheet, dated 12/14/24 at 7:00 a.m., indicated the resident was found sitting on the floor at the side of the bed with his back resting against the bed and his legs extended in front of him. The resident indicated he was sitting on the bed at the time of the fall. The bed was in low position. The resident had one gripper sock on and one was off on the floor beside him. The bed alarm was in place and sounded. The call light was not sounding. No new injuries were noted. The immediate intervention was the placement of the bed in a low position with a mat at the side of the bed. The resident was also assisted back to bed, and his gripper socks were reapplied.
A Nurses Note and Fall Investigation Worksheet, dated 12/14/24 at 9:00 p.m., indicated the resident was sitting in a wheelchair at the nurses station. The resident leaned forward and grabbed at the floor. He fell out of the chair onto his side. The wheelchair brakes were locked. The resident had gripper socks on both feet. The chair alarm was in place and sounded after the fall. A skin tear to the resident's right hand was measured at 1.8 cm by 0.2 cm. The immediate intervention was the placement of the nonslip mat in the wheelchair under the cushion. The skin tear was cleansed and dressed.
A Nurses Note and Fall Investigation Worksheet, dated 12/18/24 for the fall at 7:30 p.m., indicated the resident attempted to stand up and fell onto his left side in front of the nurses station. An alarm was in place and working. The immediate intervention was the toileting of the resident and assisting him to bed.
A Nurses Note and Fall Investigation Worksheet, dated 12/22/24 at 5:50 a.m., indicated the nurse was standing at the medication cart when the resident fell forward without warning and hit his head on the floor. Pressure was applied to his wound, and his neck was stabilized. He transferred to the hospital. He had a one-inch laceration on his forehead. The resident wore gripper socks. The chair alarm was in place and working properly.
A Nurses Note, dated 12/22/24 at 3:15 p.m., indicated the resident returned from the hospital with a laceration to his forehead, an abrasion of his right arm, a distal radius fracture, and lumbar radiculopathy (condition where a nerve in the spine is damaged or irritated). Sutures were intact to his forehead and open to air.
A Fall IDT (interdisciplinary team) Note, dated 12/24/24 at 1:16 p.m., indicated Resident 129 was seated in a wheelchair at the nurses station when staff witnessed the resident falling forward from the wheelchair. Staff was unable to intervene. The immediate intervention for the fall on 12/22/24 at 5:50 a.m., was to remind the resident to change positions slowly.
During an interview, on 1/14/25 at 11:52 a.m., QMA 13 indicated the interventions to prevent falls for the resident were his chair alarm, a bed alarm, a mat beside his bed, and he was taken to the bathroom every two hours even though he had a catheter. The resident was generally up and about in the sight of staff.
During an interview, on 1/14/25 at 12:28 p.m., LPN 19 indicated interventions to prevent falls for the resident included his bedside mat. She indicated she needed to access his care plan. Then, she indicated bed and chair pads that alarmed at the nurses station were used. He also did not stand well and required nonskid footwear. He had a nonslip mat in his wheelchair. He was to be toileted at 7:00 p.m. The staff also monitored him. She indicated whenever she went up and down the hall she looked in every room.
During an interview, on 1/14/25 at 12:41 p.m., CNA 20 indicated interventions to prevent falls for the resident included a tall mat beside his bed, a bed alarm, a chair alarm in his wheelchair, gripper socks or shoes on, and his call light should be in reach. She could look at the [NAME] (list of care strategies in the clinical record) if she needed more information.
During an interview, on 1/14/25 at 3:08 p.m., the DON indicated they tried to do all kinds of things to prevent the resident from falling like bringing him to the nurses station. Since one of his resident representatives had returned to town and visited frequently, he had been doing much better.
During an interview, on 1/14/25 at 4:17 p.m., the DON indicated the pressure alarms should not be used in place of supervision for the residents. She did not have documentation of increased supervision or additional interventions that would show increased supervision for the resident.
A current facility policy, revised 10/8/24, titled Accidents and Supervision, provided by the DON on 1/13/25 at 4:28 p.m., indicated the following: Policy: The resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary
3.1-45(a)(2)

Based on interview and record review, facility failed to ensure the physician was notified of a resident's significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 72)
Findings include:
Resident 72's clinical record was reviewed on 1/10/25 at 8:56 a.m. Diagnoses included Alzheimer's disease, dysphagia, oropharyngeal phase (swallowing difficulty that occurs in the mouth and throat), and other recurrent depressive disorders.
Current physician's orders included regular diet, mechanical soft texture with ground meat and thin consistency liquids (7/31/24), super cereal (fortified food supplement) at breakfast (8/13/24), and magic cup (vitamin and mineral rich food supplement) at lunch (9/3/24).
A Minimum Data Set (MDS) assessment on 12/14/24 indicated the resident was severely cognitively impaired. The staff assessment of her mood indicated the resident had poor appetite or overeating for two to six days of the assessment period. She required partial to moderate assistance with eating.
The resident's weights were as follows:
7/30/24 - 107.4 pounds
11/25/24 - 99.2 pounds
12/16/24 - 101.6 pounds
12/23/24 - 101.3 pounds
12/30/24 - 92.5 pounds
1/6/25 - 95.7 pounds
1/13/25 - 96.3 pounds
The resident experienced an 8.69% weight loss in one week from 12/23/24 to 12/30/24. She experienced a 6.75% weight loss in one month from 11/25/24 to 12/30/24. From 7/30/24 to 1/13/25, nearly a six-month span, she experienced a 10.24% weight loss.
The clinical record lacked notification of the physician or the resident representative of the resident's significant weight loss.
During an interview, on 1/14/25 at 11:20 a.m., LPN 17, the charge nurse on the resident's unit, indicated when a resident had a significant weight loss or gain, the physician and family were notified. Notifications were documented in the progress notes. The staff, typically, reweighed a resident when a significant change in weight occurs to ensure the weight was correct. The aides reported to the nurses when they obtained the residents' weights. She thought the resident might have been followed by the nutritional at risk (NAR) team. The aides had not told LPN 17 of the resident's weight loss, and she indicated they most likely told the NAR team. She had been unaware of the resident's weight loss.
During an interview, on 1/14/25 at 11:29 a.m., RN 18 who was the unit manager and part of the NAR team, indicated the resident was not currently on the NAR list. She did not know the resident had experienced significant weight loss. She indicated the dietician should have notified the NAR team when the weight was put into the electronic medical record as the software triggered an alert with a significant weight loss or gain. She found where the weight loss had triggered the alert. She was unable to find where the physician had been notified.
During an interview, on 1/14/25 at 12:00 p.m., the DON indicated the physician should have been notified of the resident's significant weight loss.
A current facility policy, revised on 2/2022, titled PHYSICIAN/CLINICAN/FAMILY/RESPONSIBLE PARTY NOTIFICATION FOR CHANGE IN CONDITION, provided by the DON on 1/14/25 at 12:08 p.m., indicated the following: .The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident representative when there is .a significant change in the resident's physical, mental, or psychosocial status
3.1-22(b)(1)

Based upon observation, record review, and interview, the facility failed to ensure accurate records were kept of the administration of controlled medications for 6 of 14 residents reviewed (Residents 22, 47, 56, 58, 66, and 67).
Findings include:
During an observation of the secured unit medication cart, accompanied by LPN 4, on 1/22/24 at 9:46 a.m., the narcotic reconciliation log was reviewed. A reconciliation of controlled medications was performed at this time by LPN 4, with the following concerns observed:
Resident 56 had 23 tablets of hydrocodone (a narcotic pain medication) 5-325 tablets. The medication log indicated 24 tablets.
Resident 56 had 28 tablets of alprazolam 0.25 mg (anxiolytic). The medication log indicated 29 tablets.
Resident 58 had 18 tablets of hydrocodone-acetaminophen 5-325 mg tablets. The medication log indicated 19 tablets.
Resident 67 had 27 tablets of pregabalin (anticonvulsant) 100 mg tablets. The medication log indicated 28 tablets.
Resident 47 had 26 tablets of diphenoxylate (used to treat diarrhea). The medication log indicated 27 tablets.
Resident 66 had 24 tablets of lacosamide (anticonvulsant) 100 mg. The medication log indicated 25 tablets.
Resident 22 had 11 tablets of hydrocodone-acetaminophen 10-325 mg. The medication log indicated 12 tablets.
Resident 22 had 14 tablets of clonazepam (benzodiazepine) 1 mg. The medication log indicated 16 tablets.
During an interview with LPN 4, on 1/22/24 at 9:50 a.m., she indicated she did not sign out the medications prior to administering them. Her practice was to document on the controlled medication logs at the end of the day.
During an interview with the Director of Nursing, on 1/22/24 at 9:59 a.m., she indicated the controlled medications should have been logged off after each administration.
Review of a current facility policy titled Preparing Controlled Substances for Administration, dated 5/17, and provided by the DON on 1/22/24 at 10:28 a.m., indicated the following: .General Guidelines: 1) Schedule I, II, III, and IV medications must be counted at the beginning and the end of each shift. 2) The count is normally conducted with one 'off-going' staff member and one 'on-coming' staff member .3) These medications must be signed out for each administration with the amount remaining accurately documented .15) Obtain the controlled substance sign out log. 16) Compare the amount in the container with the amount listed on the sign-out log. If incorrect, notify the charge nurse, unit manager, or director of nursing. If correct, proceed .19) Record the amount of medication removed on the sign-out log
3.1-25(e)(2)(3)

Based on interview, and record review, the facility failed to remove CNA students from CNA duties when they failed to become certified within four months of their hire date (CNA Student 5 and 6).
Finding includes:
Review of employee records on 1/19/23 at 2:49 p.m. indicated CNA Student 5 and CNA Student 6 were hired on 8/9/23.
Review of the nursing employee schedules from 12/10/23 through 1/15/23, provided by the Nurse Consultant on 1/19/23 at 4:10 p.m., indicated the following:
CNA 5 had worked on 12/11/23, 12/13/23, 12/14/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/22/23, 12/24/23, 12/27/23, 12/28/23, 1/3/24, 1/5/24, 1/7/24, 1/8/24, 1/10/24, 1/11/24, 1/12/24, 1/14/24, and 1/15/24.
CNA 6 worked on 12/11/23, 12/12/23, 12/26/23, 12/30/23, 12/31/23, 1/1/24, 1/3/24, 1/5/24, 1/8/24, 1/13/24, and 1/14/23.
During an interview on 1/22/24 at 12:00 p.m., the DON indicated CNA 5 had not yet passed her test. She was uncertain of the status of CNA 6. She was unaware the students had been hired more than 4 months ago.
During an interview on 1/22/24 at 12:03 p.m., the Administrator indicated he was uncertain about the status of CNA 5 and CNA 6. He needed to contact the corporate person who managed the CNA students.
During an interview on 1/22/24 at 12:20 p.m., the Administrator indicated CNA 5 and CNA 6 were both past the 120 days from their hire dates. He planned to immediately terminate, then rehire the students.
A facility policy, revised 2/19/20, provided by the Nurse Consultant on 1/22/24 at 4:22 p.m., titled Certified Nursing Assistant (CNA), indicated .Must possess specific educational and experience requirements such as .Certified by the State as a C.N.A. in good standing. (CNAs transferring from another state or graduating CNA students not yet certified, may work for 120 days while awaiting their certification.)
3.1-14(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls for 1 of 5 residents reviewed for falls (Resident 22).
Finding includes:
During an observation, on 1/16/23 at 11:46 a.m., Resident 22 ambulated with a rolling walker in the hallway. She was bent over at the waist and pushed the walker in front of her. Another resident had her hand on Resident 22's hip area and encouraged Resident 22 to walk to the dining area.
During an observation, on 1/18/24 at 10:28 a.m., the resident ambulated in her room using the footboard of the bed to steady herself.
During an observation, on 1/22/24 at 9:40 a.m., the resident ambulated with the rolling walker in the hall wearing purple foam clogs.
Resident 22's clinical record was reviewed on 1/18/24 at 3:23 p.m. Diagnoses included dystonia, vascular dementia, anxiety, heart failure, unspecified, low back pain, muscle weakness (generalized), abnormalities of gait and mobility, pain in right knee, delusional disorders, and major depressive disorder, recurrent, severe with psychotic symptoms.
Current physician orders included divalproex sodium 125 mg (for mood stabilization) every evening, donepezil 10 mg (for dementia) at bedtime, clonazepam (for dystonia - movement disorder that causes muscles to contract involuntarily) 2 mg two times a day, quetiapine 25 mg (antipsychotic for delusional disorder) two times a day, and hydrocodone-acetaminophen 10-325 mg (opioid for pain) every six hours.
An 11/20/23 annual Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She required substantial/maximal assistance with bed-to-chair/chair-to-bed transfers, toilet transfers, and tub/shower transfers. She was frequently incontinent of bladder and bowel.
A current care plan for falls related to confusion and weakness (7/3/23) included the following interventions: I will be provided non-slip socks instead of foam clogs until my family can provide proper fitting shoes (1/5/24) and silent alarms when in bed and/or chair (11/16/23).
Quarterly fall risk assessments completed on 10/4/23 and 1/4/24 indicated the resident was a high fall risk.
A nurses note, on 10/28/23 at 12:45 a.m., indicated the resident had a witnessed fall. She was in the lounge when she backed out of the corner with her walker. Her walker got caught on the corner of the end table. She fell back into the door and hit her head. A small bump was noted to the back of her head. She stated her bottom hurt.
A fall interdisciplinary team (IDT) note, on 10/31/23 at 10:45 a.m., indicated the 10/28/23 fall was reviewed. The initial intervention was to redirect or assist the resident when wandering in the late-night hours. The IDT agreed the lounge door was to be closed during sleep hours to provide safety to residents who may be wandering in late hours.
A nurses note, on 11/10/23 at 3:10 p.m., indicated the resident was found on the floor in another resident's room. The resident attempted to lie down in the bed by the window. The bed moved. The resident fell to the floor. The resident was found sitting on her buttocks with her legs and feet out in front of her. Bruising was noted to her left upper arm. An immediate intervention was to ensure all the beds were locked.
A fall IDT note, on 11/13/23 at 12:58 p.m., indicated the fall on 11/10/23 was reviewed. Staff was to ensure all the beds on the special unit were locked while stationary.
A nurses note, on 11/16/23 at 5:31 a.m., indicated the resident sat on the floor in the hall with her shoes on. She leaned on the wall with her walker in front of her. No injuries were identified. An immediate intervention was to have a bed alarm placed until the resident was evaluated by the IDT.
A fall IDT note, on 11/16/23 at 3:41 p.m., indicated the fall on 11/16/23 was reviewed. The resident was unable to state what had happened during her fall. She had labs drawn and a urinalysis with a culture and sensitivity completed.
A nurses note on 12/8/23 at 11:09 p.m., indicated the resident ambulated with her rolling walker down the hall and fell backwards onto her buttocks. No injuries were identified. An immediate intervention was to offer the resident a snack at 10:00 a.m.
A fall IDT note, on 12/11/23 at 10:13 p.m., indicated the fall on 12/8/23 was reviewed. The resident stated she wanted some crackers after her fall. The resident's falls on 11/10/23 and 11/15/23 were reviewed for a pattern. An intervention for the resident to receive a snack at 10:00 a.m. was added.
A nurses note, on 1/5/24 at 2:40 p.m., indicated the resident was found in her room next to her bed with her walker in reach. The resident stated she was going to the dining room.
A nurses note, on 1/5/24 at 5:33 p.m., indicated the immediate intervention for the fall was to provide the resident with non-slip socks instead of her foam clogs until the family could provide proper fitting shoes.
A fall IDT note, on 1/8/24 at 2:11 p.m., indicated the fall on 1/5/23 was reviewed. The resident received a skin tear to her right elbow. An intervention for the staff to offer the resident a snack when she appeared restless was added.
The resident's Bedside [NAME] Report, provided by the Nurse Consultant on 1/19/24 at 3:19 p.m., indicated the resident was to be provided with non-slip sock instead of foam clogs until the family could provide proper fitting shoes. Silent alarms to be used when in bed and/or chair.
During an interview, on 1/22/24 at 10:49 a.m., CNA 9 indicated she did not usually work on the secured unit. She utilized the [NAME] to tell her what interventions were required for falls and behaviors.
During an interview, on 1/22/24 at 10:58 a.m., CNA 10 indicated the resident usually wore her foam clogs and walked well in them. The resident did not walk well in nonslip socks. Silent alarms were not used for the resident.
During an interview, on 1/22/24 at 11:04 a.m., the Dementia Care Director indicated the use of the nonskid socks was up to the family whether they wanted the resident to wear them or not. The resident did not have silent alarms utilized for her bed or chair. Interventions for falls were listed in the [NAME].
During an interview, on 1/22/24 at 11:48 p.m., LPN 4 indicated she believed the resident was permitted to wear foam clogs until the family found a new pair of better fitting shoes. Silent alarms for the bed and chair were not used for the resident.
During an interview, on 1/22/24 at 12:00 p.m., the DON indicated she was uncertain about the intervention for non-slip sock instead of foam clogs for the resident. According to the care plan, the resident should have been wearing nonskid socks and should have silent alarms. The ADON managed the resident falls and may have more information.
During an interview, on 1/22/24 at 12:23 p.m., the ADON indicated the interventions added to the care plan were probably added by a nurse as an immediate intervention after a fall. She was unaware of the resident's intervention to have a silent alarm or to wear non-slip socks instead of foam clogs.
A facility policy, dated 11/1/23, provided by the DON at 1/22/24 at 12:19 p.m., titled Fall Prevention Program, indicated .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed
3.1-45(a)(2)

Based on record review and interview, the facility failed to notify the Long-Term Care Ombudsman of transfers out of the facility for 2 of 3 residents reviewed for hospitalizations (Residents 37 and 66).
Findings include:
1. Resident 37's clinical record was reviewed on 1/18/24 at 9:44 a.m.
A nurses note, dated 12/25/23 at 9:56 a.m., indicated the resident was sent to the hospital for altered level of consciousness.
A nurses note, dated 12/26/23 at 2:50 p.m., indicated the resident had been admitted to the hospital with altered mental status and lethargy.
A nurses note, dated 12/28/23 at 1:05 p.m., indicated the resident returned from the hospital.
The facility ombudsman notification binder, provided by the Social Services Designee (SSD) on 1/22/24 at 11:28 a.m., lacked ombudsman notification for the resident's transfer to the hospital.
2. Resident 66's clinical record was reviewed on 1/18/24 at 3:24 p.m.
A nurses note, dated 12/15/23 at 1:10 p.m., indicated the resident was sent to the hospital for altered level of consciousness, hallucinations, and to prevent self-harm.
A nurses note, dated 12/16/23 at 4:45 p.m., indicated the resident was admitted to the hospital for altered mental status.
A nurses note, dated 12/19/23 at 5:05 p.m., indicated the resident returned from the hospital.
The facility ombudsman notification binder, provided by the Social Services Designee (SSD) on 1/22/24 at 11:28 a.m., lacked ombudsman notification for the resident's transfer to the hospital.
During an interview, on 1/22/24 at 3:42 p.m., the SSD indicated the ombudsman had not been notified of Resident 37's and Resident 66's transfers to the hospital. The residents had been placed on hospital leave. The electronic medical record report she utilized to notify the ombudsman did not include the residents on hospital leave.
A facility policy, provided by the Nurse Consultant on 1/22/24 at 4:22 p.m., titled Admission, Transfer, Discharge Policy and dated 10/31/22, indicated .Emergency Transfer to Acute Care .A copy of the notification given/sent to the resident and/or resident representative should also be sent to the ombudsman as required, and the facility must maintain evidence that the notice was sent.
3.1-12(a)(6)(A)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a significant medication error when QMA1 administered the wrong medications to Resident B and Resident C. This deficient practice resulted in Resident B being sent to the hospital where she was diagnosed with accidental drug ingestion and received treatment for lack of adequate oxygen to the body tissues (acute hypoxia), low blood pressure (hypotension), and slow heart rate (bradycardia).
Findings include:
Review of a 8/14/23 facility-reported incident to the Indiana Department of Health indicated Residents B and C had been administered each other's medications on 8/12/23. Resident B required transfer to the hospital for treatment.
The clinical record for Resident B was reviewed on 8/16/2023 at 10:00 a.m. Diagnoses included, hypertension, presence of cardiac pacemaker, cognitive communication deficit, chronic obstructive pulmonary disease, and dementia. The resident was allergic to morphine.
The resident's photograph had not been added to the electronic health record.
Review of admission Minimum Data Set (MDS) assessment, dated 8/15/2023, indicated the resident had severe cognitive impairment.
Resident B had current physician's orders for sertraline HCL(antidepressant) oral concentrated 20 mg/ml. Give one (1) ml by mouth in the morning for depression/anxiety.
These medications, intended for Resident B, were administered to Resident C.
The clinical record for Resident C was reviewed on 8/16/2023 at 10:47 a.m. Diagnoses included atrial fibrillation, congestive heart failure, hypertension, chronic kidney disease stage 4, and bradycardia.
The resident's photograph had not been added to the electronic health record.
Review of admission Minimum Data Set (MDS) assessment, dated 8/15/2023, indicated the resident had severe cognitive impairment.
Review of the resident's physician orders indicated Resident C had the following current morning medication orders:
a. Furosemide (loop diuretic) oral tablet 20 mg. Give 1 tablet by mouth on time a day for diuretic.
b. Isosorbide Monoitrate (nitrate) ER tablet extended release 24 hour 30 mg. Give 1 tablet by mouth one time a day for chest pain.
c. Lisinopril (anti-hypertensive) oral table 5 mg. Give 1 tablet by mouth one time a day for hypertension.
d. Risperdal (anti-anxiety) oral tablet 0.25 mg. Give 1 tablet by mouth one time a day for anxiety.
e. Spironolactone (potassium sparring diuretic) oral tablet 25 mg. Give 1 tablet by mouth one time a day for diuretic for congestive heart failure.
f. Doxycycline Hyclate (antibiotic) oral tablet 100 mg. Give 1 tablet by mouth two times a day for pneumonia for 10 days.
g. Metoprolol Tartrate (anti-hypertensive) oral tablet 25 mg. Give 0.5 tablet by mouth two times a day for hypertension.
h. Morphine Sulfate ER (opioid analgesic) oral tablet extended release 15 mg. Give 1 tablet by mouth every 12 hours for pain
j. Hydroxyzine Pamoate (antihistamine) oral capsule 25 mg. Give 1 capsule by mouth every 8 hours for anxiety and itching.
These medications, intended for Resident C, were administered to Resident B.
Review of a Change in Condition note, dated 8/12/2023 at 2:00 p.m., indicated Resident B was sitting up in a chair. The resident was found non-responsive with respirations at six breaths per minute. The resident's oxygen saturation was 92%, and dropped to 84%. Oxygen was applied and titrated to 4 liters, and brought the oxygen saturation to 90%. Narcan was administered and the resident's respirations increased to 10 breaths per minute. The resident became more responsive, but was confused and lethargic. The resident was sent to the hospital for evaluation and treatment.
During an interview on 8/16/2023 at 10:06 a.m., the Director of Nursing indicated during the morning medication pass on 8/12/2023, QMA1 entered Resident B and Resident C's room. The two residents were admitted on the same day and were placed in the same room. The residents were new admits and QMA1 was not familiar with them. The QMA asked Resident B if they were [name] and the resident responded yes. QMA1 prepared the medication and administered it to the resident. Then QMA1 repeated the steps for Resident C. QMA1 returned to the room shortly after administering the medications and a family member was present and called Resident B by the correct name. QMA1 asked the family member to clarify who Resident B and Resident C were. The family member identified the residents correctly. QMA1 realized she had administered the wrong medications to the wrong resident and informed the nurse. Due to having an allergy to morphine, and having been administered morphine, Resident B was assessed and monitored closely. The physician and families were notified. At around 2:00 p.m., Resident B became difficult to arouse. The NP was called and an order for Narcan (opioid antagonist)) was received. The Narcan was administered and the resident was sent to the hospital for evaluation and treatment.
During an interview on 8/16/2023 at 10:33 a.m., QMA1 indicated on 8/12/2023, during the morning medication pass, she entered the room of Resident B and Resident C. QMA1 indicated that was the first time she had seen the two new residents. The QMA asked Resident B if she was (says name) and the resident answered yes. The QMA administered the medications. The QMA returned to the room later to get a blood pressure for Resident B and a family member was present. The QMA heard the family member call Resident B's correct name and immediately realized she had administered the wrong medications to Resident B and Resident C. The medication error was reported to the nurse.
Review of the Medication Skill Competency: Oral Medication Pass Procedure, dated 3/2015 and last revised 4/20, was provided by the DON on 8/16/2023 at 11:13 a.m. This procedure was to re-educate nursing staff and indicated the following: .Procedure Steps .Demonstrates appropriate identification of residents by name, birthdate, photo on chart. Proper use of 5 rights of medication administration demonstrated
This Federal tag relates to complaint IN00415086.
3.1-48(c)(2)