**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 4 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely these deficient practices would lead to chronic or recurrent fear and anxiety. Findings include: During the initial tour of the AACU (Advanced Alzheimer's Care Unit) accompanied by LPN 27, on 8/2/23 at 9:45 a.m., Resident B was observed lying in her bed. LPN 27 indicated Resident B liked to take morning naps and wandered the unit in the afternoon. During an interview with LPN 27, on 8/2/23 at 11:28 a.m., she indicated Resident B was not aggressive but did have a tongue on her. It was typical to find her in someone else's room. On 8/2/23 at 2:13 p.m., Resident B was observed ambulating independently in the hallway. On 8/3/23 at 11:01 a.m., Resident B was observed sitting in a dining room chair at a table, with another resident across the table from her. Resident B's clinical record was reviewed on 8/2/23 at 1:47 p.m. Diagnoses included hallucinations, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, delusional disorders, cognitive communication deficit, Alzheimer's disease with early onset, major depressive disorder, recurrent, in remission, anxiety disorder due to known physiological condition and psychotic disorder with hallucinations due to known physiological condition. Her current medications included buspirone (anxiety) 5 mg (milligram), donepezil (memory loss) 10 mg daily, sertraline (depression) 75 mg daily and divalproex sodium (mood disorder) 125 mg twice daily. A quarterly MDS (Minimum Data Set), dated 7/13/23, indicated she was severely cognitively impaired. She had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days during the assessment period. She wandered four to six days during the assessment period. She required extensive assistance of one staff member for bed mobility, transfers, walking in room/corridor, locomotion on/off unit, dressing, toilet use and personal hygiene. She had a current care plan problem of sometimes having behaviors that included wandering in the halls with no pants on, wandering into others rooms and laying in their bed and looking for her dad (3/2/23). Her interventions included staff would redirect her to her own bed as needed (3/3/23) and allow her time to fully wake up before redirecting her out of another resident's bed (7/30/23). She had a current care plan for a history of trauma that affected her negatively due to growing up in poverty and another stressful event that occurred in her life since being in the nursing facility. The triggers that have the potential to re-traumatize her included staff not talking to me in a slow calm manner (7/31/23). Her interventions included encourage her to be as independent as possible (7/31/23), her triggers were staff talking to her in a hurried tone (7/31/23), respect her personal space (7/31/23), staff would assist her with recovery and help avoid re-traumatization (7/31/23) and staff would know what her triggers were (7/31/23). A change of condition note, dated 7/29/23 at 1:09 p.m., indicated she had hit her head during a possible fall incident. She had a small bump on the top of the right side of her head and she reported she had neck pain with range of motion. She was sent to the ER (Emergency Room). The ER physician progress note, dated 7/29/23 at 1:21 p.m., indicated she was being seen for complaint of neck pain. Her history of present illness included she was [AGE] years old with a history of dementia and was assaulted at the nursing home. She stated she was at the of the bed, when an aide came in and threw her on the ground. She denied any loss of consciousness but that she hit the back of her head. She appeared at baseline mentally. She denied any chest pain, shortness of breath, stomach pain or back pain. Reportedly, there was a fellow staff member that witnessed her being thrown on the ground. She had no external signs of trauma. Her vitals were within normal limits. She complained of a headache. A CT (Computerized Tomography) scan of her head and cervical spine were ordered and were unremarkable. A nurses note, dated 7/29/23 at 4:45 p.m., indicated Resident B's brother was notified of her being transported to the ER and of the staff member allegedly getting rough with her. A nurses note, dated 7/31/23 at 11:40 a.m., indicated a skin assessment was completed. There was bruising to her right upper extremity, her right hand (6 cm x 5.8 cm), and her left wrist (6.5 cm x 5.2 cm). The bruises were purple in color. She denied any pain or discomfort and stated that she bumped into things all day. A nurses note, dated 8/2/23 at 9:59 a.m., indicated a follow up call was made to Resident B's brother regarding the incident that occurred with a CNA. He was informed the CNA was no longer employed at the facility as she failed to follow the resident care and treatment protocol which resulted in a negative outcome. During an interview with Housekeeper 12, with the Assistant [NAME] President of Operations present, on 8/2/23 at 2:48 p.m., she indicated when she was in the AACU dining room, she could see Resident B laying on the floor in another resident's room. She observed CNA 6 pick the top of Resident B's head up and slam her head onto the floor while Resident B laid on the floor. Housekeeper 12 just stood there stunned. She told her co-worker what happened, and later told her boss. During an interview with CNA 7, on 8/2/23 at 3:18 p.m., she indicated she and CNA 6 were taking a male resident to his room to lay him down after lunch. Resident B was in the male resident's bed when they walked into his room. CNA 6 walked over to Resident B and began shaking her arm aggressively to get her out of his bed. Resident B screamed Stop it! multiple times. CNA 6 then picked Resident B up by her left arm and left leg and lifted her off the bed (approximately waist high). Resident B kicked CNA 6 pretty hard and knocked CNA 6's glasses off her face and a piercing from her nose. CNA 6 then dropped Resident B on the floor. Resident B landed on her bottom and hit her head on the foot board of the bed. She felt CNA 6 intentionally dropped Resident B to the floor. She yelled at CNA 6 to leave the room and yelled at Housekeeper 12, who was standing in the dining room, to go get a nurse. Resident B yelled Yeah, bit--h get out of here! CNA 6 took a step out of the room and then stepped back into the room with her fist clenched like she was going to hurt Resident B. She left the room. LPN 23 entered the room to check on Resident B. CNA 6 then came back into the room with Housekeeper 12 and QMA 8 to look for her nose ring. CNA 6 indicated she wouldn't touch Resident B the rest of the day. Later, CNA 6 asked CNA 7 if she believed that she meant to hurt Resident B, and CNA 7 told her that she could had handled the situation better than she had. Earlier, Resident D had indicated to her that CNA 6 grabbed her by her wrists and slammed her down onto the shower chair and it hurt. CNA 6 was sent home around 2:00 p.m. During an interview with LPN 23, on 8/2/23 at 4:11 p.m., she indicated QMA 8 came to her while she was on the ACU (Alzheimer's Care Unit). She told her CNA 6 was crying from having her glasses and nose piercing ripped off of her face and that she was so pis--d off that the situation had gotten to that point. CNA 6 had gone in to the male resident's room and Resident B was in his bed, so she picked Resident B up in a cradle position to sit her up on the side of the bed. Resident B was kicking at her, so she lowered her to the ground. CNA 6 requested to go outside for a smoke break but wanted to get her nose ring from the room first. When LPN 23 entered the male resident's room, Resident B was standing up and did not appear in any distress. Housekeeper 12, CNA 7, and QMA 8 were in the room looking for CNA 6's nose piercing and it was located within a minute or two. CNA 6 indicated she needed to go to the other unit to have her friend help her put her nose piercing in and she would not touch Resident B the rest of the day if that's what she had to do. LPN 23 and CNA 7 walked Resident B to her room. CNA 7 indicated to LPN 23 she wanted to talk to her privately about what really happened. CNA 7 was visibly upset and indicated to her CNA 6 was roughly shaking Resident B to wake her up and to get her out of the male resident's bed. CNA 6 picked Resident B up by her one arm and one leg and dropped her and that she was rough with another resident earlier but had reported it to LPN 19 already. While they were talking privately, CNA 6 entered the room crying. She indicated she was sorry this had happened. LPN 23 indicated she worked with CNA 6 the previous weekend for the last four hours of CNA 6's sixteen hour shift. LPN 23 felt CNA 6 was kind of hateful and disrespectful to the residents in the way she spoke to them. She yelled at them rather than talking to them. She had an attitude towards the residents. There was a male resident who tried to follow her into a female resident's room,and rather than redirecting him calmly, CNA 6 said to the male resident You can't come in here, this is a female resident's room and I have to change her! LPN 23 indicated she didn't think too much of it and thought CNA 6 was just over-stimulated or irritated. LPN 23 went to report what was told to her by CNA 7 to LPN 19, who had worked at the facility longer than she had. As she walked to the break room to talk with LPN 19, CNA 7, Housekeeper 12, and a Laundry Aide were talking in the hall. Housekeeper 12 informed her CNA 6 shoved Resident B's head on the ground. LPN 23 spoke with LPN 19, and went back to the unit to assess Resident B. Resident B told LPN 23 she was shoved to the ground. She was pushed on her chest and hit her head. LPN 19 walked CNA 6 out of the building. During an interview with LPN 19, on 8/2/23 at 4:39 p.m., she indicated she was on lunch break when LPN 23 came to get her and indicated there was a mess in AACU. CNA 6 was already outside. CNA 7 reported she had witnessed CNA 6 roughly try to get Resident B up. Resident B started fighting CNA 6 and knocked out her nose ring and knocked her glasses off of her face, and CNA 6 just dropped Resident B on the floor. LPN 19 felt CNA 6 should had left Resident B where she was and let her go back to sleep. CNA 7 had reported to her that Resident D was grabbed by CNA 6 during her shower. LPN 19 was in the process of handling other things and was passing medication at the time CNA 7 reported this to her (between 8:00 a.m. and 9:00 a.m.). She called the DON and sent Resident B to the hospital because she complained of neck pain. When CNA 6 came back in from smoking she indicated this was [NAME]--t and she didn't do anything, she was just trying to get Resident B up out of bed and she started kicking and fighting and she went to the ground. During a phone interview with CNA 6, on 8/3/23 at 9:36 a.m., she indicated Resident B was laying in another resident's bed. She woke her up by tapping on her shoulder and removed the blanket and informed her she was in the wrong room. Resident B didn't want to get up, but she needed to take care of the resident of the bed she was in. She assisted her to sit up and moved her to the head of the bed by putting her arm under Resident B's shoulder blades and thigh. She did not pick her up. Resident B was upset and confused, and thought she was in the correct room. She assisted her to stand up from the bed. Resident B was upset, and she hit her (the CNA's) glasses off her face and her facial piercing from her nose. As Resident B walked, the CNA lowered her to the ground. She did not drop her. After the resident was on the ground, CNA 7 had asked her to leave the room. She felt it was because the resident needed another person to assist her. She did not believe she touched Resident B while she was on the floor. She left the room. She was in pain due to her piercing was ripped out of her face. It was a tense situation, she was not mad at Resident B. Resident D had repeated verbalizations, such as can she go to her room when she was already in her room. During her shower, she tried to stand up and she would tap her on the shoulder to cue her and told her that the tile was slippery. She felt that she managed her stress well and when she felt stressed out, she asked to take a 15 minute break. During an interview with QMA 8, on 8/3/23 at 2:31 p.m., she indicated she was sitting at the desk charting. CNA 6 walked down the hall crying, and indicated she tried to get Resident B out of a male resident's bed, and Resident B ripped her nose ring out of her nose and knocked her glasses off her face. QMA 8 reported to LPN 23 what CNA 6 told her. She went back to the male resident's room with CNA 6 to find CNA 6's nose ring and then CNA 6 left the unit. Resident B was [NAME] and smart-mouthed, but she had never seen her be aggressive. CNA 7 reported to her, about 30 minutes prior to the incident with Resident B, that Resident D tried to stand up during the shower and CNA 6 shoved her back into the shower chair. A current facility policy, titled Abuse, Neglect and Exploitation, copyrighted 2023 and provided by the DON, on 8/2/23 at 2:45 p.m., indicated the following: Policy: It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse The deficient practice was corrected by August 1, 2023, prior to the start of the survey, and was therefore past noncompliance. The facility had completed resident assessments, staff and resident interviews, and education related to abuse. This Federal tag relates to complaint IN00414267. 3.1-27(a)(1)

Based on interviews and record review, the facility failed to report to the Administrator or designee allegations of abuse for 1 of 3 allegations of abuse reviewed (CNA 6 to Resident D). This failure to report the allegation immediately resulted in CNA 6's abuse of a cognitively impaired resident later in the day. Findings include: During an interview with LPN 19, on 8/2/23 at 4:39 p.m., she indicated CNA 7 had reported to her Resident D was grabbed roughly by CNA 6 during her shower on 7/29/23. LPN 19 was in the process of handling other things and was passing medication at the time CNA 7 reported this to her (between 8:00 a.m. and 9:00 a.m.). She did not report the allegation to the Administrator or their designee. An Incident Submission email confirmed an incident report was submitted to the Indiana Department of Health on 8/3/23 at 2:51 p.m. The actual or identified date and time of the incident was 7/31/23 at 1:39 p.m. The report indicated the following: The description added, on 8/3/23, indicated during another investigation, CNA 7 reported that Resident D alleged CNA 6 was rough during her shower and verbalized CNA 6 held her wrist and pushed her into the shower chair. Resident D was moderately cognitively impaired. During an interview with the DON, on 8/3/23 at 2:10 p.m., she indicated she thought they had 24 hours to report abuse and had always reported abuse within 24 hours to the State Agency. The information in the reportable related to staff to resident abuse was what she was told during interviews and they were still completing interviews. The housekeeper was not interviewed until on Monday 7/31/23. The allegation of abuse for Resident D, they were not aware of until Monday 7/31/23. They had investigated the allegation with Resident D along with the allegation of abuse for Resident B and was located in the investigation in the binder, it was not reported to the State Agency. LPN 19 was suspended for not reporting the allegation of abuse to Resident D, she knew about the allegation in the morning but she was busy with other things. Review of the current IDOH Long-Term Care Abuse and Incident Reporting Policy, effective 12/8/22 and retrieved from https://www.in.gov/health/files/IDOH-LTC-Abuse-and-Incident-Reporting-policy_policy-SIGNED.pdf indicated the following: .Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or other health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property .Immediately means as soon as possible, in the absence of a shorter state time frame requirement, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse .All allegations of staff to resident abuse must be reported. Staff may receive allegations from any source, including other staff, residents, family members, or other health care providers. Also, each occurrence must be reported. If staff are aware of or witnessed any abuse that occurs, it must be reported Cross reference F600 and F609. This Federal tag relates to complaint IN00414267. 3.1-28(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the physical abuse of a cognitively impaired resident (Resident G) by a staff member (CNA [Certified Nursing Aide] 17). The facility also failed to prevent sexually inappropriate behaviors when a cognitively intact resident (Resident F) touched a severely cognitively impaired resident (Resident E) inappropriately. Using the reasonable person concept, it is likely these deficient practices would lead to chronic or recurrent fear and anxiety. The deficient practice was corrected by February 15, 2023, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, audits, and education related to abuse. Findings include: 1. Review of a facility reportable, dated 2/14/2023, indicated the ED (Executive Director) was escorting a terminated employee from the facility. The terminated employee became vocal and stated whoever punched [Resident G] in the face needed to be next. The facility had previously investigated a bruise under the resident's right eye, and determined it was from a previous fall. Once the allegation was made by the terminated employee the facility re-opened an investigation. The clinical record for Resident G was reviewed on 2/24/2023 at 2:30 p.m Diagnoses included, type 2 diabetes, encephalopathy, anxiety disorder, hypertension, vascular dementia with behaviors and chronic pain. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 2/15/2023, indicated the resident was severely cognitively impaired. Review of a care plan, dated 8/30/2022, indicated I sometimes have behaviors which include Rejection of care such as yelling and being combative with care. Interventions included, but were not limited to, please tell me what you are going to do before you begin; Speak to me unhurriedly and in a calm voice. Review of a risk management report, dated 1/27/2023, indicated staff noted a purple bruise to the resident's right eye right measuring 4.8 centimeters (cm) long x 2.4 cm wide. Staff noted the bruise was observed on 1/27/2023 at 6:00 a.m., when the day shift began. In a written statement, dated 2/15/2023, Employee 18 indicated CNA 4 and CNA 17 had provided care to the resident, and when they exited the room CNA 17 indicated the resident had elbowed her in the private area. A written statement by the DON (Director of Nursing) indicated on 2/15/2023, CNA 17 was notified of suspension, pending investigation. CNA 17 had indicated the resident sustained a fall a few days prior, and then he had the bruise. CNA 17 indicated the resident was combative at times, but care was always completed with two staff members and it wasn't that bad. A written statement, dated 2/15/2023, by the ED and DON, indicated CNA 4 was re- interviewed regarding any incident on 1/25/2023. During the interview, CNA 4 stated She did it. She hit him. I am sorry I haven't said anything sooner, but I was afraid that I would lose my job. CNA 4 and CNA 17 had been providing care to the resident. CNA 4 was holding the resident's hands and CNA 17 was standing behind the resident. The resident's hand slipped from CNA 4 and the resident's elbow hit CNA 17 in the private area. From behind the resident, CNA 17 swung out and hit the resident in the eye. CNA 4 indicated they were shocked and it happened so quickly. During an interview, on 2/27/2023 at 11:13 a.m., CNA 4 indicated on 1/25/2023 while providing care for Resident G with CNA 17,the following had occurred: Dinner had just finished between 5:00 and 5:30 p.m. Usually they got people ready for bed, changed them, toileted them. She (CNA 17) asked for help with Resident G. CNA 4 was holding his hands and at first, the resident was ok. When CNA 17 started to pull the resident's pants down, he had started to shake. He had then pulled his hands free and hit her. CNA 4 didn't see where, but knew he had hit her. She was standing behind him, and just shot out and hit him on his face with a closed hand. When CNA 4 asked her why she did that, she said I am sorry he just hit me in my (slang term for female private area). CNA 4 was shocked and did not know how to react, so he just stayed away from her. He didn't tell anyone. He realized now he should have told someone. When the ED and DON asked him the previous week what had happened, he told them what had actually happened. He had never seen CNA 17 do anything like that before. She was one of the kinder aides, so he was really shocked. During the survey, the facility attempted to contact CNA 17 for an interview, but were unsuccessful. 2. The clinical record for Resident E was reviewed on, 2/24/2023 at 1:47 p.m Diagnoses included, dementia, anxiety, visual hallucinations, and delusional disorder. Review of the most recent admission Minimum Data Set (MDS) assessment, dated 2/2/2023, indicated the resident was severely cognitively impaired. The resident was admitted to the facility's memory care secured unit on 1/27/2023. Resident behaviors included wandering four to six days out of the assessment period. A current care plan, dated 1/27/2023, indicated I have a diagnosis of Alzheimer's or related dementia. Due to cognitive loss, diminished decision making capabilities and safety and security issues, placement in the secure Alzheimer's Care unit with programs designed for this population is needed as evidenced by: dx [diagnosis] of dementia. Review of a facility reportable incident, dated 2/7/2023, indicated on 2/6/2023 at 9:30 a.m., Housekeeper 2 observed Resident F with his hands down the back of Resident E's pants. The residents were in Resident E's room. The clinical record for Resident F was reviewed on 2/24/2023 at 2:00 p.m. Diagnoses included, end stage renal disease with dependence on renal dialysis, obstructive sleep apnea, depressive disorder, vascular dementia, anxiety, and sexual dysfunction. Review of the most recent quarterly MDS, dated [DATE], indicated the resident was cognitively intact. Behaviors included, but were not limited to the following: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)- occurred one to three days during the assessment period. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)-occurred one to three days during the assessment period. A current care plan, dated 4/1/2022, indicated I sometimes have behaviors which include kissing other residents, holding others [sic] resident's hands; inappropriate touching Dx: other sexual dysfunction not due to a sustance o [sic] know [sic] physiological condition. Review of a Psychiatry Progress Note, dated 12/29/2022, indicated there were no sexually in appropriate behaviors during the visit. The gradual dose reduction for Paxil was declined since there had been a decrease in sexually inappropriate behaviors since receiving Paxil (antidepressant/antianxiety) 20 mg once a day. Review of a Psychiatry Progress Note, dated 1/19/2023 indicated the resident was being seen for psychiatric follow up and medication management for dementia, depression, mood disorder, and sexual inappropriate behaviors. The noted indicated the resident had multiple noted behaviors of inappropriate gestures and touching of staff and other residents, but was stable. An order for Depo-Provera (hormone-suppressant) 150 mg/ml weekly-on Monday after dialysis and to monitor closely as written at this visit. Review of a Psychiatry Progress Note, dated 2/2/2023 indicated the resident was being seen for acute increased sexually inappropriate behaviors towards staff and other residents. The resident had a new order for Depo-Provera 150 mg/ml intramuscular suspension one a day on Fridays. One dose had been administered at the time of the visit. The order was changed to Mondays after dialysis on 2/2/2023. During an interview, on 2/24/2023 at 2:24 p.m., Housekeeper 2 indicated on 2/6/2023 she had entered Resident F's room, and observed him with his hands down the back of Resident E's pants. The housekeeper reported Resident E did not seem to know what was happening. She just looked at me dumbfounded. It was like she was saying 'I don't know what to do'. She didn't seem to be on board with it. During an interview, on 2/24/2023 at 3:17 p.m., the DON indicated Resident F was no longer on the secured unit. He had been placed there because of his confusion and exit-seeking behaviors. After the incident, the resident was reassessed and moved off the unit. Resident E was new to the facility, and wandered in and out of other residents' rooms. During an interview, on 2/27/2023 at 10:28 a.m., the DON indicated Resident F had a history of sexually inappropriate behaviors and had not moved from the secured unit due to his fluctuations in his cognitive state and exit-seeking behaviors. The facility felt he was safe to move off the unit, after the incident, because his BIMS (cognitive assessment) was 15 out of 15. During an interview, on 2/27/2023 at 1:32 p.m., QMA (Qualified Medication Aide) 8 indicated she had never had any experience with Resident F's behaviors. But, she knew he could be head strong and had heard about his sexually inappropriate behaviors. During an interview, on 2/27/2023 at 1:25 p.m. LPN 7 indicated Resident F was made a care in pairs (two-person ) because he would fondle the staff during care. Review of a current, undated facility policy, titled Abuse, Neglect and Exploitation was provided by the Assistant Director of Nursing on 2/24/2023 at 10:19 a.m. The policy indicated the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Definitions: . Abuse means the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by any individual including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through use of technology .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm This Federal tag relates to complaints IN00401123 and IN00401809. 3.1-27(a)(1)