Indiana Veterans Home

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 2 residents reviewed for resident rights. (Resident B and 73)Findings include:1. A facility witness statement, dated 9/22/25, indicated LPN 4 told CNA 6 she needed to give Resident B a suppository and advised CNA 6 when she provided resident care, LPN 4 would give it to him. When CNA 6 provided care, LPN 4 came into the room. As the resident was facing the wall, LPN 4 put on her gloves, gave the suppository, and the resident immediately yelled out. Resident B said the nurse was supposed to ask him before she gave him the suppository and Resident B did not want the suppository. LPN 4 told the resident he had not had a bowel movement in days and he needed it. Resident B again told the nurse he did not want it. LPN 4 told him he could push it out, like if he had a bowel movement, and left the room.
A facility incident report, dated 9/23/25, indicated LPN 4 administered Resident B a suppository and did not inform or get permission from the resident first. The resident was displeased he was not informed and received the suppository.
The clinical record for Resident B was reviewed on 12/3/25 at 1:13 p.m. The diagnoses included, but were not limited to, bradycardia, hypotension, congestive heart failure, and obstructive hypertrophic cardiomyopathy.
A physician's order, dated 7/17/24, indicated to administer a bisacodyl 10 milligram (mg) suppository per the rectum every three (3) days as needed (prn) for no bowel movement.
A care plan, dated 2/9/23, indicated the resident displayed paranoia and inappropriate sexual behaviors. Interventions included, but were not limited to, when providing care, such as hygiene or changing, allow the resident to complete as many tasks independently as he can to minimize touching or opportunities for inappropriateness, prior to providing care, remind the resident he needed to keep his hands away from staff members and provide cues to the resident as needed.
A care plan, dated 9/17/25, indicated Resident B was at risk of constipation. Interventions included, but were not limited to, administer medication when needed.
During an interview, on 12/3/25 at 2:02 p.m., the Director of Nursing (DON) indicated LPN 4 gave Resident B a suppository without permission and did not tell him what she was going to do. The nurse should always inform the resident when doing any type of care.
During an interview, on 12/3/25 at 3:04 p.m., CNA 6 indicated LPN 4 informed her Resident B needed a suppository and when she provided the resident care to find her. CNA 6 was in the resident's room, and the resident was lying on his left side facing the wall. LPN 4 entered the resident's room and without saying a word, LPN 4 put on gloves, approached the resident facing the wall and gave the resident the suppository. The resident did not see LPN 4 and was extremely upset when he received the suppository. LPN 4 did not notify the resident he was getting a suppository or of the option to refuse the suppository. LPN 4 turned around without saying a word to the resident, removed her gloves, and walked out of the room.
During an interview, on 12/8/25 at 11:42 a.m., LPN 3 indicated a nurse should explain to a resident what was going to happen and the option to refuse.
2. a. A facility witness statement, dated 10/17/25, indicated CNA 7 told Resident 73 he needed to stop hitting his call light and she wasn't dealing with his crap today. During lunch, CNA 7 yelled at Resident 73 when she dropped a plate and told him it was his fault, she dropped the plate and stated, look what you made me do.
A facility incident report, dated 10/17/25, indicated CNA 7 made rude and inappropriate statements to Resident 73 about the use of his call light.
b. A facility witness statement, dated 11/25/25, indicated CNA 7 told Resident 73 she wasn't going to lay him down after lunch and he was not allowed to sit there and press his call light repeatedly. CNA 7 was informed she had to lay the resident down as it was his right to do so.
A facility incident report, dated 11/25/25, indicated CNA 7 talked inappropriately to Resident 73.
A facility witness statement, dated 11/25/25, indicated CNA 9 helped CNA 7 lay Resident 73 down in bed. While care was being provided, CNA 7 talked over Resident 73 when he was trying to say something and told him, We are laying you in bed like you wanted, you got your way.
The clinical record for Resident 73 was reviewed on 12/5/25 at 11:53 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, cardiomegaly, dementia, depression, cerebrovascular accident (stroke), and hemiplegia and hemiparesis affecting the left side.
A care plan, dated 10/28/25, indicated the resident needed assistance with care tasks due to weakness, decreased mobility, and decreased cognition related to a history of a stroke with left side contractures. Interventions included, but were not limited to, the resident needed assistance with sitting and lying and chair to bed transfers, transfer with mechanical lift and 2 staff assist, and to encourage the use of the call light as needed.
During an interview, on 12/3/25 at 2:05 p.m., the Director of Nursing (DON) indicated CNA 7 would get irritated with Resident 73. Staff should not talk to the residents in a negative way.
A current facility policy, titled Liberalized medication pass, dated as revised 10/2025 and received by the Superintendent on 12/5/25 at 12:42 p.m., indicated .to administer medications in a safe manner while honoring the resident's wishes in their daily activity .provide an environment as close to homelike as possible for all the residents residing in this population and give as many choices as possible to its residents .follow 6 rights when passing medication
A current facility policy, titled Implementation of resident rights, dated as revised 8/2013 and received by the Superintendent on 12/5/25 at 12:42 p.m., indicated .annual in-services and ongoing training will be performed with the protection of Resident rights promoted in all applicable aspects of the staffs' performance of duties .Contract service providers shall also be provided training as indicated .Facility staff and contract health care providers will inform Residents in advance, in language and terms the Resident understands, of any changes in care and treatment. Information will be provided whenever the Resident asks, when an assessment is performed, during treatments, medication administration . in order to assure the Resident is able to give informed consent .dignity and respect of each resident.staff are trained to assure this quality of life is maintained by .residents will be included in conversations being held in their presence and spoken to when being provided care or assistance with activities of daily living .residents will be supported in their desire to choose activities, schedules and health care consistent with their own interests and needs
This citation relates to Intake 2624760.
3.1-3(t)

Based on interview and record review, the facility failed to ensure a physician's order to hold a medication was followed according to the parameters for 2 of 7 residents reviewed for quality of care. (Resident 60 and 87)Findings Include:1. The clinical record for Resident 60 was reviewed on 12/4/25 at 2:08 p.m. The diagnoses included, but were not limited to, combined systolic and diastolic heart failure, fistula of the intestine, and cellulitis of the left toe.A care plan, dated 9/11/25, indicated the resident had a diagnosis of congestive heart failure, nonrheumatic mitral valve insufficiency, nonrheumatic tricuspid valve insufficiency and A-Fib. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 9/4/25, indicated administer metoprolol extended release (a blood pressure medication) 25 milligrams (mg) once a day with instructions to hold for a heart rate less than 60 or a systolic blood pressure less than 105.A medication administration record (MAR), dated 10/1/25 through 10/31/25, indicated metoprolol was administered outside of the hold parameters on the following dates:On 10/9/25, the medication was administered with a heart rate of 53.On 10/12/25, the medication was administered with a systolic blood pressure of 104.On 10/19/25, the medication was administered with a heart rate of 50. On 10/20/25, the medication was administered with a heart rate of 51.On 10/22/25, the medication was administered with a systolic blood pressure of 103.On 10/27/25, the medication was administered with a heart rate of 59.A MAR, dated 11/1/25 through 11/30/25, indicated metoprolol was administered outside of the hold parameters on the following dates: On 11/3/25, the medication was administered with a heart rate of 58.On 11/6/25, the medication was administered with a heart rate of 52.On 11/15/25, the medication was administered with a heart rate of 57.On 11/19/25, the medication was administered with a heart rate of 58.On 11/20/25, the medication was administered with a heart rate of 57.On 11/27/25, the medication was administered with a heart rate of 58.2. The clinical record for Resident 87 was reviewed on 12/4/25 at 11:48 a.m. The diagnoses included, but were not limited to, hypertension, cognitive communication deficit, dementia, alcohol dependence with alcohol-induced persisting dementia, and bipolar disorder. A care plan, dated 6/3/24, indicated the resident was at risk for fluid volume excess. Interventions included, but were not limited to, to provide medication as prescribed and to monitor and document the blood pressure and heart rate.A physician's order, dated 7/16/25, indicated administer metoprolol 25 mg three (3) tablets twice daily with special instructions to hold for a heart rate less than 55.A MAR, dated 9/1/25 through 9/30/25, indicated metoprolol was administered outside of the hold parameters, on 9/9/25, when the morning dose was administered with a heart rate of 54. A MAR, dated 11/1/24 through 11/30/24, indicated metoprolol was administered outside of the hold parameters, on 11/16/25, when the morning dose was administered with a heart rate of 53. During an interview, on 12/8/25 at 10:29 a.m., RN 2 indicated a resident's vital signs should be obtained before administering a medication with parameters. The heart rate and blood pressure would be documented on the MAR. If the results were outside of the parameters, she would hold the medication, and make a note on the MAR. If a medication was held, the nurse's initials would have parenthesis around them on the MAR to indicate it was not given.During an interview, on 12/8/25 at 10:57 a.m., the Director of Nursing (DON) indicated a medication should not be given if a resident's vital signs were outside the physician's parameters.During an interview, on 12/8/25 at 11:07 a.m., the Assistant Superintendent indicated the facility did not have a specific medication administration policy. They followed Lippencott's Nursing Procedures.The Lippencott's Nursing Procedures, 9th edition, indicated .follow a written or typed order or an order entered into a computer order-entry system.verify that other essential elements of the medication order are present.specific instructions for use.3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident was kept safe during a transfer for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a 3 cm laceration to his posterior scalp. The deficient practice was corrected on 6/13/25, prior to the start of the survey and was therefore past noncompliance.
Findings include:
A facility reported incident (FRI), dated 6/8/25, indicated Resident B had a change of plane from a Hoyer lift. Resident B received a 3 cm laceration to the posterior scalp, was sent to the emergency room (ER) for evaluation and returned with 3 staples to his posterior head.
The clinical record for Resident B was reviewed on 6/18/25 at 1:10 p.m. The diagnoses included, but were not limited to, obsessive compulsive disorder, anemia, restlessness and agitation, and abnormal posture.
A hospital report, dated 6/8/25, indicated the resident was seen for a scalp laceration and a closed head injury from a fall at a nursing home at 1:07 p.m. The wound was closed with 3 staples, and the resident was returned to the nursing home.
A facility statement, dated 6/8/25, CNA 4 indicated the Hoyer swing was placed under the resident and hooked to the machine for the transfer. The Hoyer lift was turning the resident towards his chair, the swing was crooked, and the left corner of the lift went loose, and the resident went down on his left side. The resident hit his head on the floor.
A facility statement, dated 6/8/25, CNA 5 indicated the resident was being transferred by herself and CNA 4 to his Broda chair. She and CNA 4 attached the Hoyer lift straps to the machine. She did not verify that all the straps were secure with CNA 4 before attempting to move the resident in the Hoyer lift. The strap on the resident's left side closest to his head fell off and therefore was not securely strapped. Resident B fell out of the lift with his feet in the air and his head on the ground. Resident B's head was bleeding.
A nursing progress note, dated 6/9/25, indicated Resident B had a fall from a Hoyer transfer on 6/8/25. The strap on the resident's upper side became dislodged, the resident had a change of plane and struck the back of his head. A 3 cm laceration to the back of his head was noted and the resident was sent to the ER for evaluation and treatment. Resident B returned to the facility with 3 staples to the back of his head. The root cause for the fall was determined to be equipment malfunction. The lift was assessed for proper operability. The transfer process and safety were reviewed.
During an observation, on 6/17/2025 at 1:44 p.m., Resident B was transferred from his bed to the Broda chair using the Hoyer lift. The machine did not have a malfunction. Resident B did not move during the transfer. QMA 6 and QMA 7 ensured the Hoyer sling was secured and rechecked prior to utilization of the equipment.
During an interview, on 6/18/25 at 11:36 a.m., CNA 4 indicated she and CNA 5 secured the Hoyer straps to the Hoyer lift prior to the resident being transported from his bed to the Broda chair. During the resident transfer, one of the straps became unhooked and the resident fell to the floor. The resident hit his head and had a laceration. He was sent to the hospital. She indicated she did not know how or why the strap came off the hook on the Hoyer lift.
During an interview, on 6/17/25 at 1:50 p.m., QMA 6 indicated the Hoyer machine did work. The 4 straps for the machine must be secured and rechecked prior to using the lift. If the straps were secured, the lift would not allow the resident to fall. Two staff members must assist with the transfer.
During an interview, on 6/17/25 at 1:58 p.m., QMA 7 indicated the Hoyer machine did work. Two staff members must assist with the Hoyer lift transfer. The 4 straps for the machine must be secured and rechecked prior to using the machine for a lift. If the straps were secured, the lift would not allow the resident to fall.
During an interview, on 6/17/25 at 4:10 p.m., the interim Director of Nursing (DON) indicated the Hoyer equipment was checked. The Hoyer sling had no cuts or tears, and the mechanical functioning of the equipment was not in disrepair and was not malfunctioning.
An electronic total lift competency check list, not dated and received from the Superintendent on 6/18/25 at 2:15 p.m., indicated .Attaches straps to lift on first or second pair of hooks. 8. Ensures all straps are secure
The deficient practice was corrected by 6/13/25 after the facility educated staff on transfers, return demonstrations were performed, skill check offs were competed for all staff who utilize the Hoyer lift for transfers. Audits were initiated and on-going.
This citation relates to Complaint IN00461086.
3.1-45(a)(1)
3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of dementia was free from a physical restraint used to inhibit freedom of movement for 1 of 2 residents reviewed for restraints. (Resident B) The deficient practice was corrected on 3/31/25, prior to the start of the survey, and therefore was past noncompliance.
Findings include:
A facility reported incident (FRI) indicated, on 3/29/25 at 9:25 a.m., Resident B was found to have the foot of his bed elevated to prevent him from getting out of his bed during the night. Resident B was on a locked memory care unit. It was discovered Resident B's bed was elevated and a pillow was placed under his mattress. The night shift indicated the resident was restless and had attempted to get out of his bed multiple times during the shift.
The clinical record for Resident B was reviewed on 4/11/25 at 10:30 a.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, major depressive disorder, and unsteadiness on feet.
A Brief Interview for Mental Status (BIMS) assessment indicated the resident was severely cognitively impaired.
A nursing progress note, dated 3/29/25, indicated Resident B was trying to get out of bed. A pillow had been placed under the edge of the mattress and the foot of his bed was significantly elevated upon entering the resident's room this morning. Shift-to-shift report indicated the resident had been restless and attempted to get out of his bed multiple times throughout the night shift.
During a facility documented interview, on 3/29/25, LPN 10 indicated she was summoned to Resident B's room by CNA 11 and 12 at 8:30 a.m. Upon entering the resident's room, she observed a pillow had been placed under the edge of the resident's mattress and the bed frame which propped the center of the mattress up. The foot of his bed was elevated significantly. LPN 10 indicated during shift change report she was told the resident had made several attempts to get out of bed.
During a facility documented interview, on 3/29/25, CNA 11 indicated she went into Resident B's room with another staff member, at 8:30 a.m., to get the resident up for his shower. When she pulled down his blanket, she noticed a pillow under his mattress and reported it to the nurse. During shift change report, it was indicated Resident B had tried to get up a lot during the night. The foot of the bed was also elevated quite a bit.
During a facility documented interview, on 3/29/25, CNA 12 indicated she went with another staff member to transfer Resident B to his wheelchair. When his blankets were lifted, she noticed a pillow under the mattress and the foot of the bed was elevated. She indicated during shift change a comment had been made regarding the resident having made several attempts to get out of bed last night.
During a facility documented interview, on 4/1/25, CNA 13 indicated she worked the evening shift, on 3/28/25. She did notice a pillow was placed at the foot of Resident B's bed as she assisted the resident to get up. She did not think anything about the situation at the time.
During an interview, on 4/10/25 at 3:50 p.m., the Assistant Director of Nursing (ADON) 4 indicated he had interviewed staff regarding the incident with Resident B. The night shift staff reported that the resident was restless and had attempted to get out of bed multiple times during the night. The staff did not admit to elevating the resident's bed or placing a pillow under his mattress. He indicated those actions were considered a restraint and abuse. All staff members on the memory care unit received an in-service on abuse and the unit was monitored for restraints.
During an interview, on 4/10/25 at 4:30 p.m., the Superintendent indicated the resident should not have had the foot of his bed elevated to prevent him from exiting his bed. The staff did not admit to elevating the resident's bed. The residents were being monitored for restraints and staff were in-serviced on abuse.
A current facility policy, titled ABUSE; IDENTIFICATION, PREVENTION, AND REPORTING, dated as revised 4/1/24 and received from the Superintendent on 4/10/25 at 4:50 p.m., indicated .Abuse: the willful infliction of injury, unreasonable confinement intimidation or punishment .Involuntary Seclusion: Involuntary seclusion is defined as separation from other residents or from the resident's room or confinement to resident's room (with or without roommates) against the resident's will
The deficient practice was corrected by 3/31/25, after the facility implemented a systemic plan which included a thorough investigation, an in-service of staff regarding abuse, a room sweep for restraints of residents and rooms, and on-going audits.
This citation relates to Complaint IN00456532.
3.1-3(w)

Based on observation, interview and record review, the facility failed to wear PPE (personal protective equipment) into an enhanced barrier precaution (EBP) room for 1 of 4 residents reviewed for transmission-based precautions. (Resident 39)
Finding includes:
During an observation, on 12/4/24 at 2:04 p.m., Register Nurse (RN) 13 entered Resident 39's room to administer medication. The resident had a gastrostomy tube (a tube surgically inserted into the stomach to provide medication and nutrition) and was in isolation for enhanced barrier precautions. RN 13 did not put on an isolation gown to give the medication via gastrostomy tube.
The clinical record for Resident 39 was reviewed on 12/4/24 at 11:28 a.m. The diagnoses included, but were not limited to, Huntington's disease (a disorder which damages brain cells), dysphagia (difficulty swallowing) and abnormal weight loss.
A physician's order, dated 12/1/24, indicated the resident was in Enhanced Barrier Precautions.
During an interview, on 12/4/24 at 2:39 p.m., RN 13 indicated the resident was not in isolation. The nurse then read the sign on the resident's door and indicated she should have worn a gown.
During an interview, on 12/4/24 at 2:40 p.m., the Nursing Supervisor 12 indicated when a resident was in EBP the staff were supposed to a wear a gown and gloves. They needed to wear both when giving gastrostomy tube medications.
A current facility policy, titled Enhanced Barrier Precaution, dated 6/24 and provided by the Assistant Director of Nursing (ADON) on 12/6/24 at 3:00 p.m., indicated .Enhanced Barrier Precautions: All residents with any of the following: Wounds .feeding tube, regardless of MDRO colonization status .Required PPE .Gloves and gown prior to the high contact care activity
3.1-18(b)
3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure the correct amount of oxygen was administered to 1 of 2 residents reviewed for respiratory care. (Resident 64)
Finding includes:
During an observation, on 12/2/24 at 12:35 p.m., Resident 64 was sitting at a table in the common area in his reclining wheelchair. He was wearing oxygen administered via a portable oxygen tank hanging on the back of his wheelchair at a rate of 3 liters per minute (L).
During an observation, on 12/3/24 at 4:19 p.m., the resident was sitting in his wheelchair with the portable oxygen tank turned off and hanging on the back of his wheelchair. There was no oxygen tubing present. The resident was not receiving any supplemental oxygen.
During an observation, on 12/4/24 at 11:53 a.m., the resident was coloring with the staff in the common area with the portable oxygen tank on the back of his wheelchair delivering oxygen at 1.5 liters per minute. At 12:05 p.m., CNA 8 pushed Resident 64 in his wheelchair to another table for lunch with the portable tank hanging on the back of the wheelchair still set at 1.5 liters per minute.
The clinical record for Resident 64 was reviewed on 12/4/24 at 1:11 p.m. The diagnoses included, but were not limited to, cardiac arrhythmia (problem with the heart's rhythm or rate), essential primary hypertension, pain, anoxic brain damage, dementia, anemia, mood disorder with depressive features, other seizures, and psychotic disorder with delusions.
A physician's order, dated 6/14/24, indicated to administer oxygen at 2 liters per minute during the day.
A current care plan, dated as last reviewed on 11/27/24, included a problem of being at risk for shortness of breath, dyspnea (difficulty breathing), and respiratory distress related to a disorder of the diaphragm. An approach, with a start date of 9/3/24, indicated to administer oxygen as ordered.
A recent Minimum Data Set (MDS) quarterly assessment, dated 9/2/24, indicated the resident received supplemental oxygen with shortness of breath or trouble breathing with exertion, at rest, and when lying flat.
During an interview, on 12/4/24 at 12:42 p.m., LPN 11 indicated the portable tank was delivering 1.5 liters per minute of oxygen and the resident should be on 2 liters per minute. LPN 11 turned the portable tank dial to deliver 2 liters per minute of oxygen to the resident.
A current policy, titled Oxygen Therapy, with no review date and received from the Administrator on 12/5/24 at 12:30 p.m., indicated .Physician's order is necessary for the administration of oxygen .set flow rate as ordered by the physician
3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure staff did not leave a resident unsupervised in a multi-sensory room for longer than 30 minutes per the facility policy, to ensure the resident had a call light or a way to summon staff while in the multi-sensory room, and failed to ensure staff did not leave the resident lying on a fall mat on the floor for an extended period of time for 1 of 6 residents reviewed for supervision. (Resident J)
Finding includes:
The clinical record for Resident J was reviewed on 12/5/24 at 11:32 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, violent behavior, primary insomnia, Alzheimer's disease, anxiety disorder, malignant neoplasm of prostate, frequency of micturition, history of falling, pain, and dementia with psychotic disturbance, mood disturbance, anxiety, and agitation.
A significant change Minimum Data Set (MDS) assessment, dated 10/21/24, indicated the resident required moderate assistance to move from lying to sitting on the side of his bed, to come to a standing position from sitting in a chair, and to transfer from his wheelchair to bed.
1a. During an observation, on 12/3/24 at 11:01 a.m., the Snoezelin Room door was locked and only accessible by a staff member key. The window on the door was covered and the room inside could not be viewed. The blinds on the side window next to the door were open. The rough outline of the bean bag chair could be seen when placing your face right up against the window. The white blanket could be seen with the blue light on. Other items in the room could not be viewed. No sounds could be heard from outside of the room. Once the door was opened, the sound machine which had been playing could easily be heard. The room was dim and lit with only the blue light. Large objects could be seen but smaller items were still difficult to view. There was a messaging recliner in the room which could not be seen from the window. No call light could be seen.
A comprehensive care plan, with a start date of 7/23/24, indicated the resident was to be offered the opportunity to spend time in the sensory room in the bean bag chair.
A comprehensive care plan, with a start date of 9/4/24, indicated to assist the resident to the Snoezelen room as needed for calming and redirection.
A comprehensive care plan, with a start date of 10/21/24, indicated the resident was to be monitored while in the sensory room by a staff member.
A 15-minute checks document, dated 11/11/24, indicated the resident was in the Snoezelin room from 2:30 p.m. until 5:30 p.m.
A 15-minute checks document, dated 11/12/24, indicated the resident was in the Snoezelin room from 12:15 p.m. until 4:30 p.m.
A 15-minute checks document, dated 11/14/24, indicated the resident was in the Snoezelin room from 1:15 p.m. until 4:30 p.m.
A 15-minute checks document, dated 11/15/24, indicated the resident was not in the Snoezelin room at all the entire day. However, a nursing progress note at 1:18 p.m. indicated the resident was taken to the Snoezelin room where he attempted to hit the staff and stayed in the room for a short time.
A 15-minute checks document, dated 11/22/24, indicated the resident was in the Snoezelin room from 2:15 p.m. until 9:30 p.m. However, a nursing progress note indicated the resident was sleeping in the Snoezelin room at the beginning of the midnight shift until the nurse woke the resident up at about 11:00 p.m., to administer his bedtime medications. Then, the resident was taken to his room.
A 15-minute checks document, dated 11/23/24, indicated the resident was in the Snoezelin room from 12:45 p.m. until 4:00 p.m.
A 15-minute checks document, dated 11/30/24, indicated the resident was in the Snoezelin room from 2:15 p.m. until 5:00 p.m. A nursing progress note, at 6:47 p.m., indicated the resident opted to relax in the Snoezelin room.
During an interview, on 12/3/24 at 11:01 a.m., CNA 8 indicated the facility did not like doors to be propped open, so the door was shut when a resident was in the Snoezelin room. It was difficult to hear sounds inside the room when the door was shut, and you were outside of the room. She tried to stay in the room with the resident when she could but not everyone stayed in the room and sometimes, they were busy and could not stay the entire time. There was no call light in the room. She indicated it was hard to hear when you were out in the hallway, but you could look in the window to check on things. She did not think the resident could get out of the bean bag chair on his own.
During an interview, on 12/3/24 at 4:24 p.m., CNA 9 indicated Resident J was on every 15-minute checks which were recorded on papers in a binder at the nurse's station. When the resident was in the Snoezelin room, the staff took turns staying in or near the room as much as they could and recorded his location on the paper in the binder.
During an interview, on 12/6/24 at 11:22 a.m., CNA 10 indicated Resident J was currently the only resident which used the Snoezelin room, and he was on every 15-minute checks. There was no call light, but staff could look in through the observation window to check on him. They tried to leave him alone if he was sleeping and not fidgeting. She did not stay with the resident. Sometimes, he slept in there during the day for a few hours. She did not think he could get out of the bean bag chair on his own.
During an interview, on 12/9/24 at 1:38 p.m., QMA 6 indicated the staff had supervised Resident J more closely the first few times the resident was in the room by propping the door open for the 15-minute checks, but now someone was just checking on him by looking through the window as they walked by the room for the 15-minute checks. She did not think he could get out of the bean bag chair on his own.
During an interview, on 12/9/24 at 1:52 p.m., the Dementia Care Director 3 indicated the term supervision meant watching and being present with a resident.
During an interview, on 12/9/24 at 2:44 p.m., the Administrator indicated the staff were not following the current policy for the Snoezelin room or the care plan for the resident. There was not a call light, but there was a bell in the Snoezelin room.
During all interviews with the nursing staff who provided care to the resident, no staff member indicated there was a bell or any way for the resident to call for staff while he was in the Snoezelin room. Every staff member indicated the resident did not have a means to call for help other than when the staff checked on him.
A current facility policy, titled Multi-Sensory Room, dated as revised on 2/2018 and received from the Administrator on 12/6/24 at 1:45 p.m., indicated .The Multi-Sensory Room (MSR) (also referred to as a Snoezelen room) is a therapeutic environment created for the express purpose of delivering high levels of stimuli to patients in the memory care units .Residents must be supervised when visiting the MSR .the resident's time in the MSR should be limited to thirty (30) minutes
1b. During an observation, on 12/3/24 at 2:05 p.m., Resident J's room had a regular mattress on a low bed frame with a large red mat on the floor right next to the bed.
A comprehensive care plan, with a start date of 7/23/24, indicated the resident was at risk for falls. The interventions included, but were not limited to, 8/23/24, resident was to have a raised edge mattress.
Resident J's bed was observed to have a regular mattress and not a raised edge mattress.
A comprehensive care plan, with a start date of 10/21/24, indicated the resident had a history of aggressive behaviors and would slide himself out of his Broda chair. He had a large red mat at his bedside. The interventions included, but were not limited to, 10/21/24, ensure the resident was checked on frequently while having mat time and to offer to get him up when checking on him.
The care plan did not clarify what mat time meant or if the resident was too be left to sleep on the red fall mat beside his bed for long periods.
A 15-minute checks document, dated 11/11/24, indicated the resident was lying on the red mat from 12:15 a.m. until 4:45 a.m. The documentation indicated the resident had been on the mat since 8:00 p.m.
A nursing progress note, dated 11/12/24 at 2:13 a.m., indicated the resident had napped in his chair periodically at the beginning of the shift before bedtime. He attempted to slide out of the chair at different times. The resident was taken to bed per his usual bedtime, slept briefly, tried to get out of bed, and yelled for help as usual.
A 15-minute checks document, dated 11/12/24, indicated the resident was on the red mat from 9:45 p.m. until 12:00 a.m. According to the 15-minute checks document, dated 11/13/24, the resident remained on the mat until 3:45 a.m.
A 15-minute checks document, dated 12/3/24, indicated the resident was on the red fall mat next to his bed from 12:15 a.m. until 6:45 a.m. and again from 9:15 p.m. until 12:00 a.m.
A nursing progress note, dated 12/3/24 at 3:08 a.m., indicated the resident had been restless and calling out to staff for most of the night. After making several attempts to get out of bed by himself, he rolled onto the mat and kept attempting to pull himself under the low bed frame.
A 15-minute checks document, dated 12/4/24, indicated the resident was on the red fall mat from 12:15 a.m. until 6:00 a.m.
A nursing progress note, dated 12/4/24 at 3:56 a.m., indicated the resident slept on and off through the night and had been cooperative with care.
The progress note did not include the reason the resident was on the mat instead of in the bed from 9:15 p.m. on 12/3/24 until 6:00 a.m. on 12/4/24.
During an interview on 12/6/24 at 11:22 a.m., CNA 10 indicated the staff tried to leave Resident J alone if he was sleeping and not fidgeting.
During an interview, on 12/9/24 at 2:44 p.m., the Administrator indicated the resident should not be sleeping long hours on the fall mat on his floor instead of his pressure relieving mattress.
A current facility policy, titled Fall Prevention and Investigation, dated as last revied 12/2021 and provided by the Administrator on 12/9/24 and 2:57 p.m., indicated .unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred
A current facility policy, titled Resident Rights, not dated and provided by the Administrator on 12/9/24 and 2:57 p.m., indicated .The resident has a right to a dignified existence .facility must protect and promote the rights of each resident .facility must care for its residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality
This citation relates to Complaint IN00448381.
3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure the physician was notified when blood sugar readings were in the call parameter range and to hold medications per the physician ordered parameters for 3 of 3 residents reviewed for quality of care. (Resident 93, 35 and 108)
Findings include:
1. The clinical record for Resident 93 was reviewed on 12/4/24 at 9:43 a.m. The diagnoses included, but were not limited to, diabetes mellitus, atrophy of the kidney, and hypothyroidism.
A current care plan, with a start date of 8/1/24, indicated the resident was at risk of complications related to diabetes and to notify the physician or Nurse Practitioner (NP) as needed.
A physician's order, with a start date of 10/2/24, indicated to check blood sugars in the morning and at night and to call the physician if the blood sugar was below 60 or above 350.
The electronic medical record indicated, on 10/7/24, the morning blood sugar was 57.
A progress note, dated 10/7/24 at 6:08 a.m., indicated the blood sugar this morning was 57. The resident was given chocolate milk and a Nutri grain bar. When the resident was rechecked the blood sugar was 67 and the resident was working on another chocolate milk.
There was no documentation to indicate the physician was notified of the low blood sugar reading.
During an interview, on 12/5/24 at 3:30 p.m., Nursing Supervisor 4 indicated she could not find the low blood sugar notification in the chart. There should be an event opened when they notify the physician of an out-of-range blood sugar.
During an interview, on 12/5/24 at 3:33 p.m., Dementia Care Director 3 indicated the low blood sugar notification was not in the resident's chart.
During an interview, on 12/9/24 at 10:16 a.m., the Director of Nursing (DON) indicated they did not have a policy for following physician's orders.
3. The clinical record for Resident 108 was reviewed on 12/4/24 at 12:12 p.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease stage 2, type 2 diabetes mellitus with hypoglycemia without coma and hyperglycemia, anxiety disorder, Alzheimer's disease, depression, irritability, and anger.
A physician's order, dated 5/28/24, indicated special instructions were if the blood sugar reading was greater than 340 to give Novolog U-100 insulin 12 units and call the MD.
The electronic medical record indicated the following blood sugars were elevated and the physician needed notified:
On 10/17/24 at 11:32 a.m., the blood sugar reading was 350.
On 10/18/24 at 3:37 p.m., the blood sugar reading was 362.
The clinical record did not include any documentation of physician notifications for the blood sugars greater than 340 on 10/17/24 or 10/18/24.
During an interview, on 12/5/24 at 3:32 p.m., the Dementia Care Director 3 indicated he could not find any documentation the physician was notified of the elevated blood sugar readings on the dates of 10/17/24 or 10/18/24.
During an interview, on 12/9/24 at 1:44 p.m., LPN 7 indicated the nurse should notify the nurse practitioner for any blood sugar which was above or below the the ordered parameters if it occurred during normal daytime hours. They would call the telemedicine physician if it was during off hours, weekends, or a holiday. The nurse should document the call and the physician's response in the electronic medical record.
A current facility policy, titled Physician Contact, dated as reviewed on 9/2023 and received from the Administrator on 12/9/24 at 10:15 a.m., indicated .The following symptoms/signs .that require immediate notification are .blood sugars .that are outside or exceed the specific call orders for care
A current facility policy, titled Liberalized Medication Pass, and received from the Director of Nursing on 12/9/24 at 10:15 a.m., indicated .The policy of this facility is to administer medications in a safe manner
3.1-37(a)
2. The clinical record for Resident 35 was reviewed on 12/5/24 at 2:55 p.m. The diagnoses included, but were not limited to, congestive heart failure, hypertension, and atrial fibrillation.
a. A physician's order indicated to give Digoxin (a medication used to treat heart failure) 125 mcg (microgram) and to hold the medication if the apical pulse was less than 60.
A review of the MAR (Medication Administration Record) indicated Digoxin was administered when the apical pulse was below the hold parameters per the physician's order on the following dates:
1. On 4/21/24, with a heart rate of 59.
2. On 4/29/24, with a heart rate of 58.
3. On 5/14/24, with a heart rate of 56
b. A physician's order indicated to give Lisinopril (a medication used to treat high blood pressure) 2.5 mg (milligrams) and to hold the medication if the systolic blood pressure was less than 105.
A review of the MAR indicated Lisinopril was administered when the systolic blood pressure was below the hold parameters per the physician's order on the following dates:
1. On 1/8/24, with a systolic blood pressure of 101.
2. On 1/16/24, with a systolic blood pressure of 102.
3. On 3/21/24, with a systolic blood pressure of 91.
4. On 4/20/24, with a systolic blood pressure of 99.
5. On 4/24/24, with a systolic blood pressure of 98.
6. On 6/20/24, with a systolic blood pressure of 97.
7. On 6/30/24, with a systolic blood pressure of 102.
8. On 7/3/24, with a systolic blood pressure of 94.
9. On 7/9/24, with a systolic blood pressure of 101.
10. On 7/27/24, with a systolic blood pressure of 81.
11. On 7/31/24, with a systolic blood pressure of 103.
12. On 10/25/24, with a systolic blood pressure of 100.
13. On 11/3/24, with a systolic blood pressure of 103.
14. On 11/14/24, with a systolic blood pressure of 104.
During an interview, on 12/9/24 at 10:39 a.m., LPN 2 indicated medications would be held if the resident's vital signs were below the physician ordered hold parameters.
During an interview, on 12/9/24 at 9:51 a.m., the DON (Director of Nursing) indicated a medication should not be given below a physician's hold parameter. The medications were administered below the hold parameters on the dates listed above.
During an interview, on 12/9/24 at 10:36 a.m., the DON indicated the facility did not have a policy about following physician's orders.

Based on observation, interview and record review, the facility failed to ensure a moderately impaired resident was free from restraints for 1 of 6 residents reviewed for abuse. (Resident B)
Finding includes:
An incident report sent to the Indiana Department of Health indicated, on 1/26/24, Resident B was found during morning rounds to have the foot of his recliner elevated with a dining room chair to prevent him from lowering the legs of his recliner during the night. It was reported CNA 9 had elevated the resident's recliner legs during the night to prevent the resident from lowering his legs. Resident B was allowed out of his recliner after discovery and was monitored for any signs and symptoms of distress.
The clinical record for Resident B was reviewed on 2/12/24 at 12:15 p.m. Diagnoses included, but were not limited to, hypertensive heart disease, major depressive disorder, dementia, osteoporosis, and hyperlipidemia.
The resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident's cognition was moderately impaired.
A nursing note, dated 1/26/24 at 3:34 p.m., indicated CNA 8 reported to Assistant Director of Nursing (ADON) 10 when she was making her rounds with CNA 9, a chair was noted to be under the foot of the recliner for Resident B. She indicated she asked CNA 9 if the resident had requested the chair and leg elevation. CNA 9 indicated the resident kept putting his feet down while he was in the chair. CNA 9 indicated Resident B had swelling in his legs and feet and he needed his chair legs elevated. CNA 9 indicated she did not know if it was a restraint, but she did it to keep his feet elevated.
A facility conducted interview, on 1/26/24, noted CNA 8 indicated she observed during her morning rounds with CNA 9 Resident B had a dining room chair under the foot area of his resident recliner. CNA 9 indicated the resident needed his legs elevated when he was in his recliner and the resident did not keep his legs elevated. CNA 9 indicated she did not know if it was a restraint, but it did keep the resident's feet elevated. CNA 8 told CNA 9 it was a restraint, and she removed the chair. CNA 8 reported the incident.
A nursing progress note, dated 1/30/24, indicated the resident was interviewed. He indicated he did not use a chair to elevate his feet when he was in the recliner. He demonstrated he could lower his recliner footrest without a chair underneath. The resident could not move a chair and put it in place to elevate the recliner. The resident did not show any distress when the chair placement and incident, on 1/26/24, was discussed.
A facility conducted interview, on 2/2/24, noted CNA 9 indicated when she came to work, on 1/25/2024, the chair was under the footrest of the resident's recliner. She told the resident it was not safe to have the chair in that position and she removed the chair. She reported during the shift, she saw the resident place the chair under his recliner. She told the resident it was not safe, and the resident told her to go away. She told the supervisor the resident had a chair under his footrest, and it was an unsafe situation with the chair placement. CNA 9 indicated she did not know the supervisor's name.
During an interview, on 2/9/24 at 1:45 p.m., CNA 8 indicated she observed during her morning rounds on 1/26/24 with CNA 9, Resident B had a dining room chair under the footrest of his recliner. CNA 9 indicated the resident needed his legs elevated when he was in his recliner, and he did not keep his feet up while sitting in his chair. She indicated he had edema in his feet. She asked CNA 9 if she knew the chair was a restraint. CNA 9 said she did not know. She told CNA 9 it was a restraint, and she removed the chair. She assisted the resident to lower his footrest and reported the incident to her supervisor.
During an interview, on 2/9/24 at 1:50 p.m., ADON 5 indicated she was aware of the situation with CNA 9. The staff member was sent home while the investigation was ongoing. The resident could not have moved the chair by himself or placed it under the footrest of his recliner. The resident needed stand by assist to self-transfer, walked with a shuffling gait, and he needed an assist of one staff for support and transfer. She indicated the chair placement was considered a restraint.
During an interview, on 2/9/24 at 1:54 p.m., RN 6 indicated Resident B was not able to lift one of the dining room chairs, place the object under his recliner, and then climb into the recliner. The resident had mobility and cognitive issues. The chair placement was considered a restraint.
During an interview, on 2/9/24 at 1:58 p.m., the Director of Nursing (DON) indicated Resident B had a care plan for dementia and cognitive loss, for walker utilization for mobility and a wheelchair for long distance, and for falls. She indicated CNA 9 was an agency staff member and she was asked not to return to the facility for employment after the investigation of the incident was completed. Resident B was not able to place the dining room chair under his recliner footrest and then climb into his recliner. The chair placement was considered a restraint.
During an interview, on 2/9/24 at 1:22 p.m., Resident B indicated he did not need a chair to elevate his feet while in his recliner. He demonstrated he could elevate the footrest of the recliner. There was no dining room chair in his room. The resident did not want to discuss the incident when a chair was used to keep his footrest elevated. The resident was observed to be unsteady in his gait and his ability to move without assistance from a staff member. The resident had difficulty with speech and cognition when answering questions.
A current facility policy, titled ABUSE; IDENTIFICATION, PREVENTION, AND REPORTING, dated as revised 5/7/20 and received from the DON on 2/9/2024 at 4:50 p.m., indicated .Abuse: the willful infliction of injury, unreasonable confinement intimidation or punishment .Involuntary Seclusion/ abandonment: Action or inaction that leaves the resident without ability to obtain food, clothing, shelter or care .or confinement to his/her room against the resident's will
This citation relates to Complaint IN00427195.
3.1-3(w)

2. During an observation, on 10/19/23 at 1:50 p.m., Resident 23 was resting in bed and had oxygen on. The oxygen tubing was not dated.
The record for Resident 23 was reviewed on 10/23/23 at 3:27 p.m. Diagnoses included, but were not limited to, dementia, insomnia, and hypertension.
A physician's order, date 8/17/23, indicated the resident was to wear oxygen at 1 liter continuously.
During an interview, on 10/19/23 at 2:57 p.m., the Respiratory Therapy Supervisor indicated the oxygen tubing was not dated. The oxygen tubing should be dated.
During an interview, on 10/19/23 at 2:58 p.m., the Respiratory Therapy Supervisor indicated the facility did not have a policy for labeling or dating oxygen tubing. The oxygen tubing should be changed and dated once a week.
3.1-47(a)(6)
Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated and initialed for 2 of 2 residents reviewed for oxygen. (Resident C and 23)
Findings include:
1. During an observation, on 10/19/23 at 12:40 p.m., Resident C was wearing a nasal cannula with oxygen at 2 LPM (liters per minute). The oxygen tubing was not dated or initialed.
The record for Resident C was reviewed on 10/23/23 at 10:24 a.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, heart failure, dependence on supplemental oxygen, chronic obstructive pulmonary disease, and emphysema.
A care plan, revised on 7/11/22, indicated the resident was at risk for shortness of breath, dyspnea, and respiratory distress. The interventions included, but were not limited to, encourage resident to wear oxygen as ordered and to administer oxygen as ordered.
A physician's order, dated 9/22/23, indicated oxygen by nasal cannula set at 4 LPM (liters per minute)
at night and when napping.
A physician's order, dated 9/22/23, indicated oxygen at 2 LPM per nasal cannula when needed.
During an interview, on 10/19/23 at 12:45 p.m., RN 11 indicated there was not a date on the oxygen tubing. The oxygen tubing should be dated and initialed when the tubing was changed.
During an interview, on 10/19/23 at 1:05 p.m., RN 11 indicated the Respiratory Therapy (RT) staff was responsible for changing oxygen tubing.
During an interview, on 10/19/23 at 2:50 p.m., the Respiratory Therapy Supervisor 12 indicated oxygen tubing was changed once a week by the RT department and the oxygen tubing was dated and initialed by the RT staff. The nurses could also change the tubing when needed. The nursing staff could have changed the tubing and not dated or initialed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include a resident's family/healthcare representative (HCR) in decisions about a staff who made visits outside of work hours to a resident with dementia, delusions, and aggressive behaviors and to include the resident's negative interactions with male staff on his plan of care for 1 of 2 residents reviewed for dementia care. (Resident J)
Finding includes:
During a telephone interview, on 10/4/23, an anonymous complainant indicated RN 14 was causing emotional distress to Resident J and continued to visit the resident even though he was no longer on the unit RN 14 worked. The resident had pictures of RN 14's children and she was emotionally attached to the resident.
During an interview, on 10/23/23 at 2:31 p.m., Social Services 9 indicated Resident J had early onset dementia and was agitated at times. He was moved to another building because he was struggling with the male staff and always wanted to oversee the staff and residents. The resident was young and could intimidate staff. RN 14 looked like the resident's ex-wife, and he thought she was his ex-wife. Some other staff had complained RN 14 spent too much time with Resident J and it was keeping her from doing her job and paying attention to the other residents. Resident J's family was involved, they helped with interventions, and took the resident on outings.
The record for Resident J was reviewed on 10/23/23 at 2:08 p.m. Diagnoses included, but were not limited to, dementia with mood disturbance and psychotic disturbance, restlessness and agitation, history of traumatic brain injury, and type 2 diabetes mellitus.
A physician's order, dated 9/29/23, indicated the resident's behaviors to monitor for were intrusive invasion of privacy, disrobing, insufficient clothing in public areas, pacing, wandering, sexual aggression, delusions, hallucinations, rummaging, restlessness, verbal agitation, irritability, and short temperedness. Note any of the behaviors and the interventions attempted and notify the Nurse Practitioner and Social Services as needed.
The physician's order did not include the resident's negative interactions with males.
A care plan, dated 12/15/22, indicated the resident had a diagnosis of dementia with mood disturbance, agitation, trouble sleeping, and little interest in activities. The interventions included, but were not limited to, administer medications as appropriate, report significant changes in mood and/or behavior to the nurse practitioner and physician, refer to psychiatry as needed, assist the resident with communicating with family members and friends, help with phone calls, encourage the resident to attend activities, encourage socialization with peers and refer to social services as needed.
The care plan did not include getting RN 14 involved with care or the need for female staff to assist instead of male staff.
A care plan, dated 9/21/23, indicated the resident was at a risk for mood distress related to a recent room and unit change. The resident needed time to adjust to the new setting. The goal was for the resident to display positive adjustment to the new room and unit by a positive affect and participation in the daily routine. The interventions included, but were not limited to, allow the resident time to express thoughts and feelings, encourage daily activities of interest, help the resident to maintain a consistent routine, introduce the resident to the new surroundings and peers, to provide cues as needed, report adjustment concerns to social services, and report signs of increased mood distress to the nurse practitioner and physician.
The care plan did not include having staff from the previous unit to visit or to have female staff help the resident adjust to the new surroundings.
A care plan, dated 10/3/23, indicated the resident declined care at times including clothing change, showers, and meals. The goal was for the resident to accept care necessary for overall health and well-being. The interventions included, but were not limited to, allow the resident time to process information and to express thoughts and feelings, assess for hunger, thirst, toileting and pain, notify the nurse practitioner, physician and social services of concerns related to care, notify the resident of what to expect before providing care, offer cues and guidance as needed, offer verbal reassurance as needed, re-approach at a later time or with alternate staff and to use simple terms and phrases.
The care plan did not include the resident had negative interactions with male staff and did not include to get a female staff to provide care.
A facility pharmacy review note, dated 10/17/23, indicated the resident had delusions about re-deployment and was moved to another building after a verbal aggression against another resident.
During an interview, on 10/23/23 at 2:52 p.m., Certified Nursing Assistant (CNA) 8 indicated quite a few of the resident's family visited last week. RN 14 also visited the resident on the days she worked and would go to his building on her breaks and her lunch time. Resident J would get irate when RN 14 left and then wouldn't take his medications for the male nurse.
During an interview, on 10/23/23 at 3:07 p.m., Social Services 10 indicated RN 14 knew Resident J well when he resided in his previous building. RN 14 would visit the resident in his new building and provided one on one. Social Service 10 was not sure how often RN 14 visited.
During an observation with Social Services 10, on 10/23/23 at 3:14 p.m., Resident J had pictures of RN 14's three children in his room along with his family's photographs. Social Services 10 was not aware the pictures of RN 14's children were in the resident's room.
During an interview, on 10/23/23 at 3:44 p.m., Social Services 10 indicated the resident talked about kids at times and the facility tried to promote a homelike environment. She did not know if Resident J had asked for the photographs of RN 14's children.
During an interview, on 10/24/23 at 2:28 p.m., the [NAME] building Unit Manager (UM) indicated the resident had fast moving, early onset dementia. He was paranoid, did a lot of pacing. The UM limited his presence with Resident J since the resident was agitated by males. He knew RN 14 came to visit Resident J although he did not know the frequency of the visits.
During an interview, on 10/24/23 at 2:44 p.m., Social Services 10 indicated she did not know if the resident's HCR was aware of the continued visits from RN 14. She tried to call Resident J's family today to ask if they were aware of the visits and frequency of the visits from RN 14. The Health Care Representative did not answer, and a message was left to ask her to return the call.
During an interview, on 10/24/23 at 3:25 p.m., the Superintendent indicated she was not aware of how frequently RN 14 visited Resident J. It was not an expectation for all staff to bring in pictures of their families and give them to the residents. RN 14 had been helping Resident J adjust and she could spend time with the residents during her break if she chose to do so. The family had not been notified of RN 14 spending her break time with the resident and the facility should notify the family of the visits and would need to include the visits in the care plan so everyone would understand.
A social services progress note, dated 10/25/23 at 9:30 a.m., indicated the resident's Health Care Representative (HCR) called back and was notified RN 14 who worked on the resident's previous unit was making visits with the resident since he was moved to the [NAME] building. The HCR indicated the resident seemed very obsessed with RN 14. The RN was appropriate with the resident although the HCR worried for RN 14's safety since the resident had misconceptions and thought they had a romantic relationship. The HCR also had a concern about Resident J's negative perception of a male peer on his unit.
During an interview, on 10/25/23 at 10:29 a.m., RN 14 indicated Resident J was very funny and would talk to her at the nurse's station when he was in the [NAME] building. RN 14 would visit the resident at the [NAME] building and he smiled when he would see her. She usually went to visit the resident on one or two of her breaks when working and she enjoyed visiting him. She had asked Social Services 10 if she could continue to visit the resident. Resident J had a lot of abandonment issues and she wanted to make sure he did not feel abandoned. She was aware the resident had thought he had a romantic relationship with a female staff. When she visited the resident, it was as friends, and she would keep the door open. She had brought in pictures of her children and Resident J and another resident had the pictures.
During an interview, on 10/25/23 at 10:45 a.m., the Superintendent indicated the facility did not have any specific training about relationships with resident who had dementia. There was no documentation in Resident J's record about RN 14 asking Social Services 10 if she could still visit Resident J when he moved to the different unit.
During an interview, on 10/25/23 at 3:32 p.m., the facility psychiatrist indicated the resident had Wernicke-Korsakoff syndrome (alcohol related dementia). He was young, delusional, at risk of hurting others, and had poor impulse control. He did not know the resident was not cooperative with male staff and was only aware of negative interactions with male residents. He had observed RN 14 and Resident J talking at the nurses' station. He did not know about any pictures of RN 14's children being at the facility. The facility had implemented behavioral interventions for the resident. There was a boundary between being professional and talking about personal family with residents. There would be concerns about clinicians referring to residents as friends.
A current policy, titled Behavioral Health Policy, revised on 2/18 and received from the Director of Nursing on 10/25/23 at 12:55 p.m., indicated .It is the policy of IVH [Indiana Veterans' Home] to ensure all resident receive timely, effective interventions and treatment for mental, behavioral or social dysfunction and/or difficulties. The behavior health policy exists to promote the residents optimal functioning level including emotional, behavioral, and social components in the least restrictive environment. The behavior health committee's functions to provide a holistic comprehensive review of the issue[s] and establish a comprehensive recommendation for the resident's plan of care
This Federal Tag relates to Complaint IN00418944.
3.1-37(a)

Based on interview and record review, the facility failed to schedule follow-up care on recommendations from the dentist for 1 of 1 resident reviewed for dental services. (Resident G)
Finding includes:
During an interview, dated 10/20/23 at 11:45 a.m., Resident G indicated he lost his uppers when he was here the last time and was trying to get new ones.
The record for Resident G was reviewed on 10/23/23 at 10:06 a.m. Diagnoses included, but were not limited to, dysphagia, pain, type 2 diabetes, and cerebral infarction.
A dental visit note, dated 1/17/23, indicated the resident needed a tooth extraction. The son was contacted and agreed with the extraction.
A dental visit note, dated 10/2/23, indicated the dentist discussed with the resident the need to have his remaining teeth extracted and have dentures fabricated. No acute infections were noted, and he ate puree food well.
During an interview, on 10/26/23 at 2:49 p.m., the Assistant Superintendent indicated the resident had not been scheduled for a dental extraction.
A current policy, titled Dental Services, dated as reviewed 9/2023 and received from the Assistant Superintendent on 10/30/23 at 10:37 a.m., indicated .It is the intent .to ensure residents have access to routine and 24 - hour emergency dental care .If there is a dental emergency the dentist should be contacted immediately
3.1-24(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure an ice machine was clean and room tray drinks were covered for 1 of 5 units reviewed for dining. ([NAME] 2).
Findings include:
1. During an observation, on 10/23/23 at 9:59 p.m., the ice machine on [NAME] 4 appeared dirty. The piece where the ice came out had a lot of crusted white hard water areas with unidentified brown areas stuck to both the inside and outside of the plastic piece.
During an interview, on 10/24/23 at 3:10 p.m., the Maintenance Manager indicated the ice machines were cleaned once a month by maintenance. He was unsure what the brown areas around the plastic piece of the ice machine were. It might have been soda which had crusted over.
2. During an observation, on 10/23/23 at 12:14 p.m., Residents 1, 16, and 77 were observed to have trays delivered with drinks not covered.
During an interview, on 10/23/23 at 12:15 p.m., CNA 17 indicated the drinks did not have covers.
During an interview, on 10/23/23 at 12:16 p.m., RN 18 indicated the drinks should have been covered.
A current policy, titled POLICY/PROCEDURE: FOOD SERVICES, dated as last revised in May 2009 and received from the Infection Preventionist on 10/26/23 at 5:04 p.m., indicated .Tray service to the resident's floor shall be provided in accordance with the resident's plan of care. Each tray shall be appropriately covered .All trays, set up in advance of serving, shall be appropriate covered
There was no policy received for cleaning the ice machines by exit conference.
3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident in a wheelchair was assisted to get off the facility vehicle safely for 1 of 5 residents reviewed for falls. (Resident O) Resident O sustained a subdural hematoma and was hospitalized for 2 days. The deficient practice was corrected on 8/27/23, prior to the start of the survey and was therefore past noncompliance.
Findings include:
A Facility Reported Incident (FRI), dated 8/25/23 at 8:33 a.m., indicated Facility Driver 7 reported an accident while he was transporting Resident O. The driver was getting Resident O off the van at the hospital when he lost control of the resident's wheelchair while moving it toward the back of the van. The lift was down, and the resident fell backwards off the van and hit his head. Driver 7 fell on top of the resident. The facility had maintenance assess the van and lift, reviewed their transportation policies, and provided education and skills checks to staff. The follow up included the resident had a subdural hematoma and was admitted to the hospital. All staff received education on proper procedures for transferring residents on and off the facility buses. Driver 7 was no longer employed by the facility.
During an interview, on 10/20/23 at 11:30 a.m., Resident O indicated he fell out of the back of the facility van during a trip to a doctor's appointment. He spent three days in the hospital for a brain bleed. The facility terminated the staff who was driving the van. The staff did not raise the lift in the back. He thought the staff lost his balance, grabbed the resident to hold onto, fell, and pulled them both off the van.
The record for Resident O was reviewed on 10/23/23 at 4:34 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, acquired absence of the right leg below the knee, age related nuclear bilateral cataracts, difficulty in walking, generalized anxiety disorder, and major depressive disorder.
A witness statement by Driver 7, dated 8/25/23, indicated Driver 7 lost control of Resident 0's wheelchair while removing him from the bus. The wheelchair lift had not been raised and both the resident and Driver 7 fell off the bus.
A hospital Discharge summary, dated [DATE], indicated the resident presented to the hospital for trauma care after sustaining a fall from a vehicle. He fell backwards in a wheelchair and hit the back of his head. He sustained a subdural hematoma.
A Passenger Transportation Safety In-Service, not dated and received from the Superintendent on 10/23/23 at 4:15 p.m., indicated .Off-loading your Passenger .Make sure that the vehicle is in the parked position .Make sure that the parking brake is engaged .Make sure the passenger restraints are still fastened prior to checking the lift for proper usage .Make sure the lift is in the up position
During an interview, on 10/24/23 at 3:08 p.m., the Superintendent indicated she received a phone call, on 8/25/23 at 8:33 a.m., from Driver 7. Driver 7 reported he was trying to get Resident O to the back of the bus, lost control of the resident's wheelchair, and fell off the back of the bus. The wheelchair ramp/lift was on the ground. When getting a resident off the bus, the lift/ramp should be in the up position. The Driver 7 did not have the lift in the up position prior to moving the resident. Resident O was in a regular wheelchair and Driver 7 lost control of the wheelchair, fell back, and tried to catch the resident and the wheelchair. Both Driver 7 and Resident O fell out of the bus onto the ground. The resident was admitted to the hospital for a subdural hematoma and right shoulder pain. A current policy, titled Transportation Drivers' Safety, indicated .safety precautions regarding residents should be always followed . residents must be securely fastened in the vans .safety precautions should be followed for pushing wheelchairs, the residents should be forward facing at all times .in the event of an accident the driver should first make sure the residents are safe
The deficient practice was corrected by 8/27/23 after the facility terminated Driver 7, maintenance assessed the van and lift, the facility reviewed their transportation policies, and all staff received education on proper procedures for transferring residents on and off the facility buses.
3.1-45(a)(1)

Based on interview and record review, the facility failed to notify the provider when blood sugars were out of call parameters for 1 of 1 resident reviewed for insulin. (Resident 62)
Findings include:
The record for Resident 62 was reviewed on 10/23/23 at 11:19 a.m. Diagnoses included, but were not limited to, dementia with mood disturbance, Alzheimer's disease, and type 2 diabetes.
A physician's order, with a start date of 7/9/23 and an end date of 1/16/23, indicated to call the provider for a blood sugar above 351.
A current physician's order, dated 1/30/2023, indicated if a blood sugar was greater than 351, call the NP (Nurse Practitioner) or PA (Pysician's Asistant).
The following blood sugars were noted:
a. On 10/20/22 at 4:54 p.m., the resident's blood sugar was 381.
b. On 12/8/22 at 11:45 a.m., the resident's blood sugar was 375.
c. On 4/26/23 at 8:00 p.m., the resident's blood sugar read high (above 400).
d. On 5/17/23 at 8:00 p.m., the resident's blood sugar was 361.
There were no notes indicating the facility notified the provider for these blood sugars.
During an interview, on 10/25/23 at 9:10 a.m., the IP (Infection Preventionist) indicated a high blood sugar was over 400.
During an interview, on 10/25/23 at 2:07 p.m., RN 15 indicated blood sugars over 351 should be called into the provider.
During an interview, on 10/26/23 at 10:18 a.m., the IP indicated a blood sugar should be called to the provider if the monitor was saying high. The resident had call orders to notify the provider for blood sugars greater than 351. There was no documentation for the provider being notified for the blood sugars out of range. The nurse should always call the provider if the meter read high or the resident had call orders parameters.
A current policy, titled POLICY AND PROCEDURE: PHYSICIAN CONTACT, dated as reviewed in September 2023 and received from the Social Service Director on 10/26/23 at 9:45 a.m., indicated .The following symptoms/signs and examples of situations that require immediate notification are not to be all-inclusive .Change in vital signs outside ordered parameters or general guidelines .diabetics that are outside or exceed the specific call orders for care
3.1-37(a)

Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for PASARR (Preadmission Screening and Resident Review). (Resident 101)
Finding includes:
The record for Resident 101 was reviewed on 10/23/23 at 9:48 a.m. Diagnoses included, but were not limited to, unspecified mood disorder with paranoia and behaviors, vascular dementia with psychotic disturbance, cerebrovascular disease, and post-traumatic stress disorder (PTSD).
A PASRR level 1 screening, dated 9/14/23, indicated the resident had a diagnosis of bipolar disorder added from a MDS assessment.
The resident did not have a diagnosis of bipolar disorder.
A MDS assessment, dated 8/16/23, indicated the resident was marked to have a diagnosis of bipolar disorder.
During an interview, on 10/25/23 at 4:13 p.m., the Social Service Director indicated the MDS assessment was coded incorrectly by the previous MDS Coordinator by mistake. The resident did not have bipolar disorder.
The MDS assessment incorrectly coded the resident had a diagnosis of bipolar disorder and incorrectly led the facility to screen the resident for a level 2 PASARR.
During an interview, on 10/26/23 at 5:04 p.m., the Assistant Superintendent indicated the facility used the RAI (Resident Assessment Instrument) manual for their policy.
A RAI manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, indicated .nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment
3.1-31(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a cognitively impaired resident who received hospice services was free from abuse for 1 of 3 residents reviewed for abuse. (Resident B)
Finding includes:
The record for Resident B was reviewed on 10/23/23 at 11:27 a.m. Diagnoses included, but were not limited to, encounter for palliative care, pain of the left hip, dementia with anxiety, hearing loss, and cognitive communication deficit.
A physician's order, dated 7/14/23, indicated to discontinue weights and labs due to hospice and end stage dementia.
A care plan, dated 7/12/23, indicated the resident was receiving hospice services due to Alzheimer's disease. The goal was for the resident to be kept comfortable, to have her pain managed throughout the progression of the disease, and to have psychosocial support through the end-of-life care.
A facility reported incident (FRI), dated 8/8/23, indicated an incident occurred at 7:34 a.m., when QMA 2 was observed to pull Resident B's face towards her to administer medication when the resident was being resistive to taking the medications. An investigation was initiated.
A statement of witness dated 8/8/23 at 7:15 a.m., from QMA 2 indicated she was attempting to give Resident B her morning medications. The resident was hard of hearing, was distracted, and looking away. QMA 2 touched/gently tapped the resident's arm and then touched her face to get her attention.
A statement of witness dated 8/8/23 at 7:35 a.m., from CNA 3 indicated she witnessed QMA 2 talk in an aggressive manner towards Resident B. QMA 2 was repeating look at me then pushed the resident's food away from her and said Jesus Christ. Then QMA 2 grabbed the resident's face and pulled it towards her to give the resident the medications.
A statement of witness dated 8/8/23 at 7:38 a.m., from LPN 4 indicated CNA 3 told her QMA 2 was attempting to administer medications to Resident B who was seated at a dining room table for breakfast. QMA 2 verbally prompted the resident several times without success since the resident was preoccupied with her meal and fidgeting with her napkin. QMA 2 then pushed the resident's food and other items away from her and continued to attempt to administer the medications. QMA 2 then grabbed the resident's chin to turn the resident's face towards her and administered the medication.
A statement of witness dated 8/8/23 at 7:35 a.m., from CNA 5 indicated during breakfast QMA 2 approached Resident B with her medications and asked the resident several times to open her mouth. The resident seemed to be zoned out. QMA 2 stated for the resident to look at her. Then she grabbed the resident's face and the resident groaned. QMA 2 gave the resident her medication and stated, if I wait until after she is done eating, she will be too full to take her medicine.
A statement of witness dated 8/8/23 at 7:30 a.m., from Staff 6 indicated on the morning of 8/8/23, the residents were in the dining room having breakfast. Resident B was eating her breakfast and QMA 2 came in the room to give the resident her medication. The resident was resistant and QMA 2 kept telling the resident to open her mouth. Then QMA 2 took her hand and pulled the resident's face towards her to give the resident the medication.
During an interview, on 10/24/23 at 2:22 p.m., the [NAME] Building Unit Manager indicated the resident's dementia had progressed and she was strictly on comfort care. On 8/8/23, QMA 2 was attempting to give the resident her medications. The resident was fiddling with her food and ignoring the QMA. The QMA pushed the resident's food away and grabbed the resident's face towards her and gave the medications. An investigation was completed and the QMA 2 was terminated. The UM did not know the exact reason QMA 2 was terminated.
During an interview, on 10/24/23 at 3:19 p.m., the Superintendent indicated, on 8/8/23, the [NAME] Building Unit Manager called her to let her know about the medication administration interaction with QMA 2 and Resident B. She watched the facility video, interviewed staff, and got their statements. After the investigation was completed, it was determined it was in the best interest to not have QMA 2 work at the facility any longer. QMA 2's actions were considered verbal abuse according to the facility policy.
A current policy, titled Abuse: Identification, Prevention, and Reporting, revised on 5/7/20 and received from the Superintendent upon entrance, indicated .It is the intent of the Indiana Veteran's Home to assure that all residents of their facility are free from physical, sexual, verbal and/or mental abuse, corporal punishment and involuntary seclusion .Abuse .Physical Abuse .Includes but is not limited to hitting, slapping, pinching, or corporal punishment .Staff or contractor to resident abuse with or without injury .Verbal Abuse .The use of oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability .Examples of verbal abuse include but are not limited to .threats of harm, statements to frighten a resident, or belittling a resident .Mistreatment .Inappropriate treatment or exploitation of a resident
3.2-27(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident had a door to the bathroom in his room for 1 of 1 resident reviewed for dignity. (Resident J)
Finding includes:
During an observation, on 10/19/23 at 2:54 p.m., Resident J did not have a door for the bathroom in his room. The sink and toilet were visible when entering the resident's room.
The record for Resident J was reviewed on 10/23/23 at 2:08 p.m. Diagnoses included, but were not limited to, dementia with mood disturbance, restlessness and agitation, type 2 diabetes mellitus, and history of a traumatic brain injury.
During an interview, on 10/23/23 at 2:31 p.m., Social Services 9 indicated she did not know the reason the resident did not have a door to his bathroom.
During an interview, on 10/23/23 at 2:52 p.m., CNA 8 indicated the resident was getting a sliding door for his bathroom. She thought the door might have been taken off since the resident would slam the door at times.
During an observation and interview, on 10/23/23 at 3:03 p.m., CNA 8 observed Resident J's bathroom and indicated she did not know the reason he did not have a door for his bathroom. The other residents' rooms had sliding doors for the bathroom.
During an interview, on 10/23/23 at 3:44 p.m., Social Services 10 indicated the door for Resident J's bathroom was in the process of being replaced. She did not know the reason there was no bathroom door.
During an interview, on 10/23/23 at 4:07 p.m., Social Services 10 indicated she checked with the facility Superintendent and no one knew what happened to the previous bathroom door for Resident J.
A current policy, titled Indiana Veteran's Home Resident Rights, dated April 1, 2006 and received from the Superintendent at entrance, indicated .The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility, including those specified in this section. The facility [NAME] provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. A facility must protect and promote the rights of each resident .The resident has the right to personal privacy .Personal privacy includes accommodations
3.1-3(p)(1)
3.1-3(t)

Based on interview and record review, the facility failed to ensure a resident was free from restraints for 1 of 6 residents reviewed for abuse allegations. (Resident C)
Findings include:
An incident report sent to the Indiana Department of Health indicated on 7/8/2023 at 6:30 a.m., Resident C was found during morning rounds to have the foot of his bed elevated to prevent him from getting out of his bed during the night. Resident C was on a locked memory unit. It was reported CNA 2 had elevated the resident's bed during the night to prevent the resident from exiting the bed. Resident C was allowed out of his bed after discovery and was monitored for any signs and symptoms of distress.
The record for Resident C was reviewed on 7/18/2023 at 12:15 p.m. Diagnoses included, but were not limited to,
hypertension, cognitive communication deficit, dementia, insomnia, violent behavior, and muscle weakness.
The resident had a BIMS (Brief Interview for Mental Status) of 00 which indicated the resident was severely impaired cognitively.
A nursing note, dated 7/8/2023, indicated CNA 2 gave report to the oncoming morning staff. She indicated she had elevated Resident C's foot of his bed to prevent him from getting out of bed throughout the night. She indicated the resident had been out of bed twice that night.
A facility conducted interview, on 7/8/2023, noted CNA 7 indicated during report CNA 2 reported the resident had been up a couple of times during the night and she then raised the foot of his bed all the way up so he could not get out of bed.
A facility conducted interview, on 7/9/2023, noted LPN 3 indicated the CNA staff on duty in the a.m. shift of 7/8/2023 informed her CNA 2 reported she had elevated the resident' bed to keep him from getting up on the night shift. The CNA staff found the resident with his legs elevated and head lowered so he could not get out of bed.
A facility interview with CNA 2 conducted by ADON 5 (Assistant Director of Nursing), on 7/10/2023 at 10:45 a.m , indicated she did elevate the bed of Resident C. She elevated the foot of the bed high enough so he could not get out of bed. She indicated she did not think it was a restraint.
A facility conducted interview, on 7/10/2023, noted Social Service staff 9 indicated the resident was not able to recall the incident, and had no concerns with the staff member involved in the incident. His conversation was non-sensical. The resident was in no distress and there were no psychosocial concerns at the time of her visit.
A facility conducted interview, on 7/11/2023, noted CNA 8 indicated during report when they got to the resident's room CNA 2 reported the resident had been up a couple of times during the night and she then raised the foot of his bed all the way up so he could not get out of bed. The resident's bed was legs high and head low.
During an interview, on 7/17/2023 at 1:50 p.m., ADON 5 indicated he interviewed CNA 2, on 7/10/2023, and she admitted to raising the resident's bed to keep him from getting out of bed during the night shift. She indicated the resident had been up twice during the night and he needed to stay in bed so to prevent him from getting out of the bed, she elevated the leg section of his bed. CNA 2 did not think elevating the bed and keeping the resident from getting out of bed was a restraint. CNA 2 was an agency staff member, and the agency was notified of the incident. The action by CNA 2 was a restraint and was considered abuse.
During an interview, on 7/17/2023 at 1:50 p.m., Resident C indicated the foot of his bed had been put up by a staff member one time. When asked if he could get out of bed when the foot part of his bed was in the up position, the resident answered yes. The resident did not exhibit any violet behavior or signs or symptoms of distress during the interview. The resident did have a speech problem which made it difficult to understand some of his conversation, which was non-sensical.
During an interview, on 7/17/2023 at 2:20 p.m., LPN 3 indicated she was made aware of the situation, and immediately assessed the resident. The resident had no signs or symptoms of distress. The resident was allowed to get out of bed, the foot of the bed was lowered, and an investigation was started.
During an interview, on 7/18/2023 at 3:30 p.m., the Superintendent indicated CNA 2 was suspended from the facility indefinitely. CNA 2 did restrain the resident. The resident did not show any signs or symptoms of distress from the restraint. CNA 2 willfully restrained Resident C to prevent him from getting out of his bed. CNA 2 was reported to the Attorney General for abuse.
During an observation and interview, on 7/18/2023 at 4:00 p.m., with the Superintendent a visual tape for the night of 7/8/2023 showed the resident was last up at 4:04 a.m. The tape did not show the resident up after 4:04 a.m.
A current facility policy, titled ABUSE; IDENTIFICATION, PREVENTION, AND REPORTING, revised 5/7/20 and received from the Superintendent on 7/17/2023 at 4:50 p.m., indicated .Abuse: the willful infliction of injury, unreasonable confinement intimidation or punishment .4. Involuntary Seclusion/ abandonment: Action or inaction that leaves the resident without ability to obtain food, clothing, shelter or care .or confinement to his/ her room against the resident's will
This Federal tag relates to Complaint IN00412481
3.1-3(w)