Orchard Pointe Health Campus

Based on interview and record review the facility failed to follow physician orders for 1 of 23 residents reviewed. (Resident 8)Findings include: Resident 8's record review, began on 03/09/2026 at 11:04 AM diagnosis included diabetes, Alzheimer's, and epilepsy. A physician order, dated 1/13/26 indicated Resident 8 was at risk for malnutrition related to comorbidities. Nursing was to monitor weight and intakes as ordered, monitor dental status to ensure ability to chew was adequate, follow up with dietitian as recommended, monitor meds for adverse effects nausea/vomiting/diarrhea, decreased appetite, monitor for any negative outcomes such as decreased oral intakes or weight loss and notify the physician every shift. Resident 8's weights documentation indicated on 2/9/26 Resident 8 weighed 175lbs and on 03/04/26 she weighed 168.8. This was a loss of 3.54% in 23 days. Resident 8's progress notes, dated March 2026, indicated there was no documentation the physician was notified of Resident 8's weight loss. In an interview, on 03/11/2026 at 8:42 AM, the Director of Nursing (DON) indicated the nursing staff fax or call the medical provider regarding resident changes or needs or place concerns in an internal communication book for the following day. The DON indicated the facility nursing staff document physician notification in a progress note. The physician communication book, dated 3/4/26 through 3/10/26, contained no documentation of physician notification for Resident 8's weight loss. In an interview, on 03/11/2026 at 10:12 AM, Qualified Medication Assistant (QMA) 7, indicated Resident 8 ate in the restorative dining room so the staff could assist him when needed and monitor his intakes. QMA 7 indicated the staff documents intakes in the medical record under intakes and outputs. QMA 7 indicated if she were to notice a change in resident eating, she would inform a nurse. In an interview, on 3/11/2026 at 10:16AM, Licensed Practical Nurse (LPN) 9 indicated when staff enter weights into the computer, nursing gets an alert in red when nursing needs to notify the dietician. LPN 9 indicated staff become concerned when residents lose 5% of body weight in 30 days and 10% of body weight in 6 months. Resident 8's intakes were reviewed between 2/9/26 and 03/04/26. The following intakes were documented as 50% or less: 3/4 lunch 26-50%2/24 breakfast zero2/20 dinner 26-50%2/19 lunch 1-25%2/18 breakfast and lunch 1-25%2/13 dinner 1-25%There was no documentation to indicate the resident was offered alternatives or supplements. In an interview, on 03/11/2026 at 10:52 AM, the DON indicated there was no documentation regarding a physician had been notified regarding Resident 8's weight loss in the communication book or in his medical record. A policy titled, Provider Notification Guidelines dated 9/12/17 last updated 12/8/25, was provided by the Executive Director on 3/11/25 at 11:31AM. The policy indicated 11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record. This policy did not include to follow physician orders. 410 IAC 16.2 3.1-37

Based on observation, interview, and record review, the facility failed to ensure choices for dining and dressing were upheld for 1 of 6 residents reviewed (Resident 60).Findings include:In an observation, on 03/09/2026 at 1:04 PM, Resident 60 was observed seated in the Restorative Dining room, fully dressed, awaiting lunch service. In an observation, on 03/10/2026 at 1:06 PM, Resident 60 was observed sitting in her bed leaning to the right with her lunch tray positioned on a tray table in front of her. In an interview, on 03/10/2026 at 1:07 PM, Resident 60 indicated she was very upset. Resident 60 indicated staff told her she could not get out of bed. Resident 60 asked if she had a terrible disease that confined her to bed she had not been told about. Resident 60 indicated she preferred to eat in the dining room, but she was not allowed to get out of bed. Resident 60 indicated she was not in a comfortable position to eat and kept falling to the right side. Resident 60's record was reviewed om 03/09/2026 at 11:08 AM. Diagnoses included displaced intertrochanteric fracture of the left femur. A Basic Interview for Mental Status (BIMS) assessment, dated 3/7/2026 at 10:07 AM, indicated Resident 60 had a BIMS score of 13 (cognitively intact). Resident 60's Inventory of Personal Items, dated 3/6/2026 at 3:34 PM, had no marks or notations recording any clothing or personal items had been inventoried for Resident 60. In an interview, on 03/10/2026 at 1:08 PM, Licensed Practical Nurse (LPN) 5 indicated Resident 60 could not get out of bed because Resident 60's family had not brought in enough clothes. LPN 5 indicated the facility has no clothing to offer to assist her to get up, only a hospital gown. In an interview, on 03/10/2026 1:11 PM, the Social Services Director (SSD) indicated staff should reach out to family to see if someone had anything they could bring when a resident did not have enough clothes. The SSD indicated the facility had donated items of all sizes that were kept on hand for occasions of clothing shortages. The SSD indicated Resident 60 had a family member who visited daily, so she did not know why Resident 60 did not have adequate clothing. The SSD indicated staff should come to the SSD office to obtain clothes when shortages occurred, but no staff had notified her of a shortage. She indicated she would notify the staff of the clothing supply in case they were not aware. In an interview, on 03/11/2026 11:44 AM, Certified Nurse Aide (CNA) 6 indicated on the morning of 3/10/2026, no pants were available in Resident 60's closet. CNA 6 indicated she checked the lost and found supply and was unable to find any pants for Resident 60. CNA 6 indicated she did not contact the SSD for additional assistance in finding clothes. CNA 6 indicated Resident 60 was positioned upright in the bed to eat her lunch, but needed frequent repositioning due to falling to the right side. A current policy, titled Resident Rights Guidelines, dated 12/08/2025, provided by the Administrator on 3/11/2026 at 11:27 AM, indicated residents had a right to enjoy full use of all areas of the campus, including dining rooms. The policy indicated residents have the right to exercise choice in daily activities. 410 IAC 16.2- 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to provide dignified, timely meal service for 1 of 8 residents observed (Resident 60).Findings include:In a continuous observation, beginning on 03/09/2026 at 1:04 PM, Resident 60 was assisted to her table in the restorative dining room. Another resident was eating her lunch at the table. On 03/09/2026 at 1:17 PM, Certified Nurse Aide (CNA) 2 indicated to Resident 60 staff members were looking for her lunch tray. Resident 60 indicated she did not want to be a bother and would go back to her room without eating. CNA 2 indicated Resident 60's lunch tray would arrive soon and encouraged Resident 60 to stay. On 03/09/2026 at 1:24 PM, CNA 3 offered Resident 60 a cup of watermelon indicating Resident 60 could eat the watermelon while waiting for the meal tray to be delivered. Resident 60 again indicated she did not want to be a bother and could return to her room. CNA 6 then assisted Resident 60 to fill out a lunch order on a menu form. On 3/9/2026 at 1:33 PM, Resident 60's lunch tray was delivered. In an interview on, 03/09/2026 at 1:33 PM, Registered Nurse (RN) 4 indicated residents should be served promptly at mealtime. RN 4 indicated Resident 60 should not have had to wait so long to be served. In an interview on, 03/09/2026 1:35 PM, CNA 3 indicated she did not know what went wrong with Resident 60's meal service, CNA 3 indicated 2 staff members were asked to look for the tray on the hall tray cart or the kitchen and no one returned with the tray or any update on when the tray could be expected. CNA 3 indicated Resident 60 waited an excessive amount of time to receive her tray. Resident 60's record was reviewed on 03/09/2026 at 11:08 AM. Diagnoses included displaced intertrochanteric fracture of the left femur. A Basic Interview for Mental Status (BIMS) assessment, dated 03/07/2026 at 10:07 AM, indicated Resident 60 had a BIMS score of 13 (cognitively intact). A current care plan, titled Profile Care guide, with a goal date of 6/6/2026 indicated Resident 60 required set up assistance with meals. In an interview on, 3/11/2026 at 11:40 AM, the Director of Nursing indicated the facility did not have a policy addressing timely meal service. A current policy, titled Resident Rights Guidelines, dated 12/08/2025, provided by the Administrator on 03/11/2026 at 11:47 AM, indicated residents have a right to be treated with dignity and respect. 410 IAC 16.2- 3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure showering was completed for 1 of 6 residents reviewed (Resident 65). During an interview, on 3/9/26 at 10:32 AM, Resident 65 indicated she had not had a shower since before her admission.A review of an admission BIMS (Basic Interview for Mental Status) Assessment for Resident 65 dated 3/5/26, indicated her BIMS score was 15 (cognitively intact).A review of bathing notes, dated 3/5/26-3/10/26, indicated Resident 65 had not received a shower on Saturday, 3/7/26. A partial bed bath was completed on 3/6/26, 3/7/26, 3/8/26, 3/9/26, and 3/10/26. In an interview, on 3/10/26 at 2:30 PM, Resident 65 indicated she had not showered yet and needed a shower badly.In an interview, on 3/10/26 at 2:40 PM, QMA 12 indicated Resident 65 needed 1 staff member to assist her with a shower. QMA 12 indicated they did not know when Resident 65 was due for a shower. In an interview, on 3/10/26 at 2:44 PM, RN 10 indicated they did not know when Resident 65 was due for a shower. RN 10 indicated they reviewed the electronic record, but scheduled shower days had not been assigned.A review of the Shower Schedule Binder on 3/10/26 at 2:50 PM, indicated Resident 65 was scheduled to shower on Saturdays and Wednesdays, during the day shift.A review of Resident 65's current Care plan titled Profile Care Guide, indicated the resident was to have showers twice a week, per schedule. In an interview, on 3/12/2026 at 11:22 AM, the Director of Nursing indicated showers are ordered two days a week for every resident, unless contraindicated. The Executive Director indicated in an interview on 3/12/26 at 11:28 AM, the facility did not have a policy about shower frequency.A current admission agreement indicated residents had a right to receive services in the facility with reasonable accommodation of resident needs and preferences. 410 IAC 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure food that was at proper temperature in 2 of 2 observations. Food prepared in the kitchen was consumed by 57 of 57 residents who resided in the facility.
Findings include:
During a continuous observation on 1/6/25 from 09:24 AM to 10:00 AM the following observation was made:
The temperature of the alcohol cooler was 62 deg. Several bottles of various types of alcohol, one case of bottled water, and a cheese tray were found to be inside. Employee 2, indicated the cheese tray would be thrown away.
In an interview on 01/06/25 at 02:17 PM, a resident's family member indicated the resident had complained her food was served cold sometimes.
During an observation on 1/8/25 from 10:47 AM - 11:00 AM, the following observation was made:
Two of three plates of pureed food, sitting on a shelf above steam table under warming lights, had a temperature measurement of 89 degrees.
Resident Counsel minutes, dated 10/28/24, indicated menu changes hadn't improved much since the before month. Food was coming out cold during meal services. Dietary Aids were reaching across other plates to drop off other resident food.
Resident Counsel minutes, dated 11/25/24, indicated food was coming out cold during meal services. Dietary Aides were continuing to reach across other plates to drop off resident food.
Resident Counsel minutes, dated 12/30/24, indicated cold food was being served and vegetables were not being cooked all the way.
A current policy, dated 1/2024, titled Hot and Cold Food Temperature Holding Guideline was provided by an administrator on 1/8/15 at 1:28 PM. The policy indicated hot food in the steam table should be at least 135 or higher degrees Fahrenheit and arrive approximately at greater than or equal to 120 degrees Fahrenheit when the resident is served.
3.1-21 (a)(1)(2)

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and serving practices for 3 of 3 observations. Food prepared in the kitchen was consumed by 57 of 57 residents who resided in the facility.
Findings include:
During a continuous observation on 1/6/25 from 09:24 AM - 10:00 AM the following observations were made:
The drying rack had clear, round, lids stacked with moisture in between lids.
The floor in the dishwashing area and dry pantry had dry, brown, particles in sizes from grains of sand to grains of rice. ,
Observations of the dry pantry included the following:
An opened bottle of molasses had must a use by date of 3/11/24.
There were 2 onions sprouting green leaves, one with 4 inches of green growth. One onion was brown, black, and was soft.
A yellow cake mix had an expired date of 12/22/24.
Observations in the walk-in refrigerator included the following:
Six bowls of cottage cheese were uncovered and undated.
There were quarter-sized areas of a white, fuzzy substance, on top of 2 strawberries. The received on date was 1/2/25.
There was a broken eggshell, whites, and yolk spread to a softball sized area on the floor.
Observations in the walk-in freezer included the following:
A frozen leftover turkey with a use by date of 12/21/24, was not sealed.
A bag with 2 pork patties was not labeled or sealed.
In an interview on 1/6/25 at 09:40 AM, the Director of Food Service indicated a deep floor clean was completed at the end of each day, the egg was broken during the delivery.
In an interview, on 01/07/25 02:53 PM, the facility administrator indicated 57 residents of 57 residents residing in the facility consumed food that was prepared in the kitchen.
A current policy, dated 1/2024, titled Food Labeling and Dating Policy was provided by an administrator on 1/7/15 at 3:24 PM. The policy indicated any product removed from its original container, has a broken seal, has been processed in any way must have a label . that contains the following: . Date and Time the food was labeled . Use by date .Securely cover the food item.
A current policy, dated 1/2024, titled Storage Procedures was provided by an administrator on 1/7/15 at 3:24 PM. The policy indicated open packages are labeled, dated, and stored in closed containers. Refrigerated storage temperature will be at 41 degrees F or below. Prepared perishables such as salads, puddings, milk, etc., are stored in a refrigerator and covered, labeled, and dated until used. All foods in the freezer are wrapped in a moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated.
3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sanitary handling of personal protective gowns for 2 of 8 residents reviewed (Resident 34 and Resident 45) and proper hand hygiene in meal service in the assisted dining room. This practice affected 7 of 10 residents who ate their meals in the assisted dining room.
Findings include:
1. During an observation, on 1/7/24 at 10:32 AM, upon opening the door to Resident 45's room a yellow, disposable gown drifted into the doorway of Resident 45's door touching the doorframe, handle and door. The gown was hanging on the wall on Resident 45's roommate's side of the room near his belongings. Resident 45's bed was empty. Water was heard running in the shower of the attached bathroom. Certified Nurse Aide (CNA) 19 opened the bathroom door, and indicated Resident 45 was in the shower. CNA 19 was not wearing a gown.
Resident 45s record was reviewed on 1/7/24 at 1:50 PM. Diagnoses included presence of urogenital implants, and neuromuscular dysfunction of the bladder.
Resident 45's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 45 used an indwelling catheter.
A physician's order dated 1/7/25 indicated Resident 45 should receive levofloxacin (an antibiotic) 750 mg daily for 7 days for a urinary tract infection.
Resident 45's current care plan titled: Resident requires enhanced barrier precautions, indicated the resident had a problem of suprapubic catheter use, with a goal date of 4/2/25. Interventions included don/doff and dispose of PPE systematically and appropriately utilize gown and gloves per EPB policy during high contact ADL care.
In an interview, on 1/7/25 at 10:32 AM, Licensed Practical Nurse (LPN) 20 indicated used gowns should not hang in the doorway of the room due to contamination risk.
During an interview, on 1/7/25 at 10:35 AM, the Assistant Director of Nursing (ADON) indicated staff should be wearing gloves and a gown when performing showers for Resident 45. She indicated disposable gowns are stored in a closet in the hallway and should not be stored hanging in the doorway after use.
2. During an observation, on 1/7/24 at 10:33 AM, upon opening the door to Resident 34's room a yellow, disposable gown was observed wadded up and stuffed into the inside door handle.
Resident 34's record was reviewed on 1/7/24 at 1:50 PM. Diagnoses included neuromuscular dysfunction of the bladder and gastrostomy status.
Resident 34's current annual Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 34 used an indwelling catheter and a gastric tube.
Resident 34's current care plan titled, Resident requires enhanced barrier precautions, indicated the resident had a problem of feeding tube and indwelling catheter use, with a goal date of 4/1/25. Interventions included don/doff and dispose of PPE systematically and utilize gown and gloves during high contact ADL care.
A physician's order dated 1/7/25 indicated Resident 34 should receive cephalexin (an antibiotic) 500 mg three times daily for 7 days for a urinary tract infection.
In an interview, on 1/7/25 at 10:33 AM, LPN 20 indicated used gowns should not be placed on the inside of the door handle due to contamination risk.
During an interview, on 1/7/25 at 10:35 AM, the ADON indicated disposable gowns are stored in a closet in the hallway and should not be stored after use in the door handle. She indicated disposable gowns should be discarded after use.
A current policy, titled Standard Precautions Guidelines, dated 5/11/16 provided by the Administrator on 1/8/24 at 12:07 PM indicated equipment or items in the resident's environment likely to have been contaminated with potentially infectious matter should be handled in such a manner to prevent transmission of infectious agents.
3. During an observation, on 1/9/25 at 9:06 AM, Qualified Medicine Aide (QMA) 21 passed trays to 6 residents seated in the assisted dining room. As she passed the trays she touched each resident's silverware, cut up and prepared residents' food and handed utensils to the residents, frequently contacting their hands, clothing and belongings. No hand hygiene was performed. Certified Nurse Aide (CNA) 22 assisted an unidentified male resident to apply a sweater and then washed her hands with 12 seconds of scrubbing. QMA 21 washed her hands with a 5- second hand scrub and returned to resident care. QMA 21 washed her hands two additional times during observation with durations of 5 and 7 seconds of scrubbing.
During an interview, on 1/9/25 at 9:47 AM, CNA 22 indicated staff should sanitize their hands between each tray and perform handwashing after every third tray or when they touch a resident or contaminate their hands. She indicated scrubbing should last 20 seconds. She indicated she was in a hurry and should have washed her hands correctly.
During an interview, on 1/9/25 at 9:48, QMA 21 indicated staff should scrub their hands for 60 seconds each time they washed their hands. She indicated she should have washed her hands while passing the trays but was in a hurry to get all the food out and forgot.
A current policy titled Guidelines for Handwashing/Hand Hygiene, dated 5/11/16, provided by the ADON on 1/9/25 at 11:07 AM indicated hand hygiene should be performed before and after serving meals and before and after having direct contact with residents. The policy indicated handwashing should include 20 seconds of friction.
3.1-18(l)

Based on interview and record review the facility failed to ensure freedom from verbal and physical abuse for 2 of 24 residents reviewed (Resident A, and Resident B).
Findings include:
In a review of a written complaint on 1/6/25 at 9:24 AM, a Complainant indicated Qualified Medicine Aide (QMA) 7 had been verbally abusive to Resident A in Complaint IN00450607. The Complainant indicated a facility vendor had witnessed and reported the abuse to the Administrator. The Complainant indicated the Administrator and Assistant Director of Nursing (ADON) were aware of the abuse and did not report it to Resident A's family or the State Department of Health. The Complainant indicated QMA 7 had previous occurrences of witnessed abuse and was eligible to be rehired.
During an interview on 1/7/25 at 11:27 AM, Facility Vendor 6 indicated they were present in the assisted dining room on 11/15/24 during breakfast. Vendor 6 indicated QMA 7 came into the assisted dining room with an agitated demeanor, verbally indicating displeasure about being assigned to assist in feeding residents. Vendor 6 indicated Resident A made a statement she was unable to hear to QMA 7, who was seated next to Resident A assisting him with his meal. Vendor 6 indicated QMA 7 became upset and raised her voice to Resident A. She told the resident she only disrespected him because he had disrespected her. QMA 7 then abruptly stood up, grabbed Resident A's meal tray and slammed it on the tray cart. Vendor 6 indicated QMA 7's body language appeared angry and escalated as she went over to Resident B. Resident B had been seated at a table with her clothing protector in her mouth. QMA 7 forcibly pulled the clothing protector out of Resident B's mouth verbally indicating she should not be eating laundry detergent. Vendor 6 indicated an unidentified employee came in the room and asked QMA 7 to leave the dining room and finish her medication pass. Vendor 6 indicated they had emailed the Administrator requesting a phone call since she was not present in the building at the time. Vendor 6 indicated they verbally reported the incident as described to the Administrator over the phone on 11/19/24.
1. During an interview on 1/7/25 at 3:52 PM, Resident A's Power of Attorney (POA) indicated they were not aware of any occurrences of disrespectful, rude or abusive conduct toward Resident A. The POA indicated Resident A would not have the ability to recall any abusive event that may have occurred.
Resident A's record was reviewed on 1/8/24 at 11:52 AM. Diagnoses included diffuse traumatic brain injury with loss of consciousness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression.
Progress notes between 11/15/24 and 11/19/24 did not include any assessments or interviews with Resident A pertaining to recollection or psychosocial effects from verbal abuse.
2. Resident B's record was reviewed on 1/8/25 at 12:59 PM. Diagnoses included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, personal history of traumatic brain injury, and mild intellectual disabilities. Resident B was unable to be interviewed about abuse.
Progress notes between 11/15/24 and 11/19/24 did not include any assessments or interviews with Resident B pertaining to recollection or psychosocial effects from abuse.
In an interview, on 1/8/25 at 1:51PM, Certified Nurse Aide (CNA) 11 indicated rude or inappropriate speech toward a resident should be reported to the person in charge of the shift, or the nurse management.
In an interview, on 1/8/24 at 1:53 PM, Licensed Practical Nurse (LPN)12 indicated verbal abuse could include derogatory or disrespectful speech and physical abuse could include rough physical touch during care. She indicated a nurse's first action upon witnessing abuse was to call the corporate compliance hotline posted on the wall near the front office. LPN 12 walked to the sign and pointed at the phone number.
In an interview, on 1/8/24 at 1:56 PM, Life Enrichment Aide (LEA) 13 indicated rough handling of a resident during care, yelling and using downgrading or derogatory speech toward residents were examples of abuse. LEA 13 indicated any witnessed abuse should be reported to the ADON or the Administrator.
In an interview, on 1/8/24 at 2:01 PM, CNA 14 indicated any staff member witnessing abuse should make sure the resident was safe and then immediately report the abuse directly to the Administrator. If the Administrator was not available, staff should report to the nurse manager in charge.
In a confidential interview, on 1/9/24 at 9:58 AM, Employee 18 indicated QMA 7 had contacted them and indicated she had been terminated for being verbally inappropriate with a resident and roughly pulling a clothing protector out of a resident's mouth. Employee 18 indicated they were on duty the day of the incident and no person from management had requested a statement from them about any knowledge of the incident.
In an interview, on 1/9/25 at 2:49 PM, The Administrator indicated QMA 7 was disciplined on 11/19/24 because she had reportedly slammed a breakfast tray down in front of a student. She indicated this incident had been the final incident for this employee concerning conduct. She indicated she had received a report over the phone from the instructor of the CNA class, who performed clinical work in the building, QMA 7 had slammed a tray down in front of a student. She indicated the instructor did not mention anything to indicate any verbal or physical abuse had occurred. She indicated she had no reason to suspect abuse, so she did not conduct an abuse investigation. She indicated she had no statements or notes describing the incident or behavior regarding rough treatment of residents.
A witness statement given by the Administrator, dated 11/19/24, presented by the ADON on 1/10/25 at 8:53 AM, indicated the CNA instructor had reported QMA 7 having negative interactions in front of residents in the dining room. The note further indicated she would have jumped in if the situation had gotten physical or abusive.
A witness statement given by the ADON, dated 11/19/24, presented by the ADON on 1/10/25 at 8:53 AM indicated she interviewed QMA 7 had asked Resident A to show her respect because she showed him respect. She indicated QMA 7 denied slamming a tray down.
During an interview, on 1/10/25 at 11:30 AM, Registered Nurse (RN) 19 indicated she was not aware of any inappropriate behavior at any time in the assisted dining room by any staff member. She indicated when a student or instructor noticed any inappropriate behavior, they should report it to her or an administrative staff member immediately.
A current policy dated 7/2/24, titled Abuse and Neglect Procedural Guidelines, provided by the Administrator on 1/6/24 at 9:29 AM indicated physical abuse can include corporal punishment, involving physical punishment to control behavior. Mental abuse involves the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. The policy indicated occurrences of suspected abuse should be reported to the Administrator or the Administrator's designee immediately after resident safety was secured. The policy indicated physicians, consultants, volunteers and other contracted employees and providers should be provided with the Abuse and Neglect Procedural Guidelines for awareness of protocols. The policy indicated the Administrator should identify and interview all involved persons including the alleged victim, perpetrator, witnesses and all others who may have knowledge of the allegation. The Administrator should provide complete, thorough documentation of the investigations.
This citation is related to complaint IN00450607.
3.1-27(b)

Based on interview and record review the facility failed to ensure an allegation of abuse was reported to the Department of Health for 2 of 24 residents reviewed (Resident A, and Resident B).
Findings include:
In a complaint review, on 1/6/25 at 9:24 AM, a Complainant indicated Qualified Medicine Aide (QMA) 7 had been verbally abusive to Resident A in Complaint IN00450607. The Complainant indicated a facility vendor had witnessed and reported the abuse to the Administrator. The Complainant indicated the Administrator and Assistant Director of Nursing (ADON) were aware of the abuse and did not report it to Resident A's family or the State Department of Health.
During an interview, on 1/7/25 at 11:27 AM, Facility Vendor 6 indicated they were present in the assisted dining room on 11/15/24 during breakfast. Vendor 6 indicated QMA 7 came into the assisted dining room with an agitated demeanor, verbally indicating displeasure about being assigned to assist in feeding residents. Vendor 6 indicated Resident A made a statement she was unable to hear to QMA 7, seated next to Resident A assisting him with his meal. Vendor 6 indicated QMA 7 became upset and raised her voice to Resident A. She told Resident A she only disrespected him because he had disrespected her. QMA 7 then abruptly stood up, grabbed Resident A's meal tray and slammed it on the tray cart. Vendor 6 indicated QMA 7's body language appeared angry and escalated as she went over to Resident B. Resident B had been seated at a table with her clothing protector in her mouth. QMA 7 forcibly pulled the clothing protector out of Resident B's mouth. She told Resident B she should not be eating laundry detergent. Vendor 6 indicated an unidentified employee came in the room and asked QMA 7 to leave the dining room and finish her medication pass. Vendor 6 indicated they had emailed the Administrator requesting a phone call since she was not present in the building at the time. Vendor 6 indicated they verbally reported the incident to the Administrator over the phone on 11/19/24.
1. During an interview on 1/7/25 at 3:52 PM, Resident A's Power of Attorney (POA) indicated they were not aware of any occurrences of disrespectful, rude or abusive conduct toward Resident A. The POA indicated Resident A would not have the ability to recall any abusive event that may have occurred.
Resident A's record was reviewed on 1/8/24 at 11:52 AM. Diagnoses included diffuse traumatic brain injury with loss of consciousness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression.
2. Resident B's record was reviewed on 1/8/25 at 12:59 PM. Diagnoses included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, personal history of traumatic brain injury, and mild intellectual disabilities. Resident B was unable to be interviewed about abuse.
In an interview, on 1/9/25 at 2:49 PM, The Administrator indicated QMA 7 was disciplined on 11/19/24 because she had reportedly slammed a breakfast tray down in front of a student. She indicated this incident had been the final incident for this employee concerning conduct. She indicated she had received a report over the phone from the instructor of the CNA class, who performed clinical work in the building, QMA 7 had slammed a tray down in front of a student. She indicated the instructor did not mention anything to indicate any verbal or physical abuse. She indicated she had no reason to suspect abuse, so she did not conduct an abuse investigation, or report the incident. She indicated she had no statements or notes describing the incident or QMA 7's behavior.
A current policy dated 7/2/24, titled Abuse and Neglect Procedural Guidelines, provided by the Administrator on 1/6/24 at 9:29 AM indicated the Administrator was accountable for investigating and reporting. The policy indicated the Administrator should identify and interview all involved persons including the alleged victim, perpetrator, witnesses and all others who may have knowledge of the allegation. The Administrator should provide complete, thorough documentation of the investigations. All alleged violations should be reported to the Department of Health within 24 hours of the report.
This citation is related to complaint IN00450607.
3.1-28 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure a resident's ted hose were on every morning per physician's order for 1 of 2 reviewed. (Resident 1).
Findings include:
During an observation on 1/22/24 at 11:25 AM Resident 1 was not wearing her TED hose on either leg.
During an observation on 1/25/24 at 10:53 AM Resident 1 was not wearing her TED hose on either leg.
During an observation on 1/26/24 at 9:26 AM Resident was not wearing her TED hose on either leg.
During an observation on 1/26/24 at 11:45 AM Resident was not wearing her TED hose on either leg.
Resident 1's record was reviewed on 01/22/24 1:30 PM, diagnoses included a history of traumatic brain injury, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, and a history of venous thrombosis and embolism.
Resident 1's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was a 9 (moderate cognitive impairment). The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) when lower body dressing and putting on and taking off footwear (socks, shoes, and other footwear).
A Physician order dated 3/6/19 indicated bilateral TED hose were to be applied to the Resident 1's lower extremities (legs) every morning between 6:00 AM and 10:00 AM. There was no indication what time the TED hose were to be removed.
Resident 1's current care plan titled pertinent ADLs (Activities of Daily Living) indicated the resident required staff assistance to complete ADL tasks completely and safely. The care plan indicated Resident 1 would complete ADL tasks completely and safely with a goal date 3/24/24. Interventions did not include applying bilateral TED hose to the resident's lower legs every morning.
Resident 1's current care plan titled pertinent ADLs (Activities of Daily Living) indicated the resident had a potential for decline in ADL's related to chronic pain, dementia, a traumatic brain injury, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, osteoporosis, seizures, a history of venous thrombosis and embolism, constipation, rash, cough, and dermatitis. The care plan indicated Resident 1 would be free of an ADL decline with a goal date 3/24/24. Interventions did not include applying bilateral TED hose to the resident's lower legs every morning.
The Medication Administration Record (MAR) dated 1/1/24 - 1/26/24, indicated no documentation by nursing staff Resident 1's TED hose being applied or refusal by the resident every morning between 6:00 AM - 10:00 AM.
The Treatment Administration Record (TAR) dated 1/1/24 - 1/26/24, indicated no documentation of Resident 1's TED hose being applied or refusal by the resident every morning between 6:00 AM - 10:00 AM.
Progress notes dated 1/1/24 to 1/26/24, received 1/26/24 at 10:30 AM, indicated no documentation by nursing staff of Resident 1's TED hose being applied or refusal by the resident every morning between 6:00 AM - 10:00 AM.
In an interview on 1/26/24 at 9:26 AM, QMA 1 indicated Resident 1 was not wearing TED hose.
In an interview on 1/26/24 at 9:32 AM, RN 2 indicated the night shift puts on Resident 1's TED hose.
A current policy, reviewed 12/31/23, titled Guidelines for Physician Services, provided by the Clinical Support Nurse on 1/26/24 at 10:30 AM, indicated physician orders should be maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act - federal act setting standards of how care should be provided to nursing home residents) and campus policy.
3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure documentation requirements for transfer or discharge were met for 1 of 5 residents reviewed (Resident 26).
Findings include:
Resident 26's record was reviewed on 1/22/24 at 1:43 PM. Diagnoses included diffuse large B-cell lymphoma, unspecified site, neoplasm of uncertain behavior of the parotid salivary glands and acquired hemolytic anemia, unspecified.
A review of Resident 26's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact).
An MDS dated [DATE] indicated Resident 26 had been discharged from the facility with a return anticipated.
A review of progress notes dated 9/19/23 at 11:20 AM indicated Resident 26 went to a physician's office for an appointment. The next chronological progress note entry dated 9/23/23 at 9:23 PM indicated Resident 26 had returned from a hospital stay. No documentation of Resident 26's condition, documents sent, or report given was available for review.
A review of a Notice of Transfer and Discharge form dated 9/19/23 indicated Resident 26 had been discharged to another health facility because her health had improved sufficiently, and she no longer needed the services provided by the facility. There was no indication on the transfer form the residnet had been transferred to the hospital.
An MDS dated [DATE] indicated Resident 26 had been discharged from the facility with a return anticipated.
A review of progress notes dated 10/11/23 at 3:52 PM indicated Resident 26 had a large BM that day. There was no indication the residnet had been sent to the hospital. The next chronological progress note entry dated 10/19/23 at 9:40 PM indicated Resident 26 had returned from a hospital stay. No documentation of Resident 26's condition, documents sent, or report given was available for review.
A review of a Notice of Transfer and Discharge form dated 10/12/23 indicated Resident 26 had been discharged to another health facility because her health had improved sufficiently, and she no longer needed the services provided by the facility. There was no indication in the form the residnet had been sent to the hospital.
In an interview on 1/24/24 at 1:43 PM, the Clinical Support Nurse (CSN) indicated nursing staff should document transfers from the facility in the medical record. She indicated documentation should include notification of family, assessment of current condition, report given to receiving facility staff, and any other pertinent information. She indicated the information should be found in progress notes, observations, or the event section of the medical record.
During a record review conducted with the CSN on 1/24/23 at 1:50 PM, she indicated she was unable to find any discharge documentation in the progress notes, observations, or event section of the EMR for Resident 26 on 9/19/23 or 10/12/23.
A current policy dated 7/11/23 provided by the CSN on 1/26/24 at 9:11 AM indicated nursing staff should document information regarding the transfer in the medical record. The policy indicated a discharge summary should be completed with a copy printed, signed, and scanned into the medical record.
3.1-12(a) 3