Every finding on record at Alexandria Care Center

Based on observation, interview, and record review, the facility failed to provide supervision to mitigate the risk of repeated falls and failed to ensure individualized fall interventions were developed, added to the plan of care, and implemented to prevent repeated falls for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident suffering a left hip fracture requiring surgical repair. Finding includes: Resident B' s clinical record was reviewed on 4/27/26 at 11:41 a.m. Diagnoses included Alzheimer's disease, displaced intertrochanteric fracture of the left femur, insomnia, trigeminal neuralgia, and anxiety. Current orders included memantine (treats dementia) 10 mg twice daily (11/14/25), carbamazepine (anticonvulsant) extended release 100 mg twice daily for trigeminal neuralgia (1/14/26), bed alarm to alert staff to unassisted transfers (9/12/25), and chair alarm on at all times for fall prevention (3/2/26). A 1/29/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. Resident B required partial assistance from staff for toileting, bathing, dressing, footwear donning and doffing, and personal hygiene. She required supervision from staff for chair/bed transfers, toilet transfer, and to move from sitting position to standing position. She required set-up assistance to walk 10 feet. The resident had two or more falls with no injury since admission or the prior assessment. She used a wheelchair for mobility. The resident was taking anticonvulsant medication. Resident B had a current, 6/25/25, care plan problem of falls related to a history of falls, unsteadiness, and poor safety awareness. Interventions included non-skid footwear at all times (8/19/25), non-skid strips at bedside (8/19/25), ensure pathways are clutter free (8/19/25), visual checks every hour (11/20/25), staff to assist resident to restroom at 4:00 a.m. (12/29/25), provide night light for adequate lighting (2/26/26), keep bed in low position while in bed (3/10/26), motion detector at bedside (3/27/26), ensure pathways are clear of unused walkers (4/14/26), staff to assist resident out of the dining room while adjusting to new glasses (4/15/26), and resident to remain in day room/dining room after meals until staff offers assistance to bed (4/27/26). The care plan was last reviewed on 4/27/26. The care plan lacked interventions for the bed alarm and chair alarm. An 11/3/25 care plan problem indicated the resident was dependent on others for all activities of daily living and required 24-hour supervision. Interventions included provision of one-to-one service as needed. The care plan was last reviewed on 2/13/26. An 11/3/25 care plan problem indicated the resident wandered and was at risk of getting into potentially dangerous places. Interventions included ensure all basic needs are met (11/3/25). The care plan was last reviewed on 2/13/26. Resident B's progress notes and assessments indicated the following fall history: On 11/20/25 at 7:00 p.m., the resident had an unwitnessed fall and was found by family on the floor at the end of her bed near the closet. She had a 3-centimeter (cm) abrasion to her left lower back. Cognitive factors included resident wandering without regard to fatigue or hunger. Neurological checks were completed. The immediate intervention implemented was resident education to go back to bed and to use her wheelchair. An 11/21/25, Interdisciplinary Team (IDT) progress note indicated the root cause of the fall on 11/20/25 included weakness and poor safety awareness. The new intervention was visual checks every hour. On 12/1/25 at 4:00 a.m., the resident had an unwitnessed fall in front of her restroom and was laying on her back. No injuries were found. Cognitive factors included resident wandering without regard to fatigue or hunger. The immediate intervention implemented was that she was assisted to the toilet. A 12/2/25, IDT progress note indicated the root cause of the fall on 12/1/25 included resident fell. The new intervention was staff providing assistance to the bathroom at 4:00 a.m. On 12/11/25 at 12:00 p.m., the resident had a witnessed fall in the dining room when she tripped over another resident's foot and fell on her left side. No injuries were found. The immediate intervention was to assist the resident to meals/table while adjusting to her new glasses. A 12/12/25, IDT progress note indicated the root cause of the fall on 12/11/25 included the resident adjustment to new glasses. The new interventions included provision of resident assistance from the table while adjusting to new glasses. On 1/17/26 at 1:55 p.m., the resident had an unwitnessed fall in the dining room. No injuries were found. Cognitive factors included resident wandering without regard to fatigue or hunger. The immediate intervention was to ensure paths were clear. An undated IDT progress note indicated the root cause of the fall on 1/17/26 indicated the resident attempted to pick up a puzzle piece from the floor. The new intervention included clear pathways. On 1/20/26 at 2:20 p.m., the resident had an unwitnessed fall on the floor in front of her recliner on her left side. No injury was found. The immediate interventions were resident laid down for a nap and a family member sat with her. A 1/22/26, IDT progress note indicated the root cause of the fall on 1/20/26 included resident fell in front of recliner in the room. The new intervention was provider evaluation. The clinical record lacked an individualized intervention related to falls prevention. On 1/24/26 at 7:07 a.m., the resident had an unwitnessed fall, landing on her right knee. The roommate's walker was tipped over. No injuries were found. Non-skid footwear was not in place. A 2/5/26 fall risk assessment indicated Resident B was at high risk for falls. On 2/25/26 at 3:35 a.m., the resident had an unwitnessed fall on the floor at the doorway with bare feet and complained of left hip/leg pain. The resident was found to have a left hip fracture. Immediate interventions included neurological checks, and the resident was transferred to emergency care for evaluation and treatment. A 3/2/26 care plan indicated a problem of a recent left hip fracture. Interventions included monitoring for signs and symptoms of infection at the surgical site (3/2/26). A 3/6/26, significant change, MDS assessment indicated the resident was severely cognitively impaired. The resident was dependent on staff for toileting hygiene bathing, lower body dressing, and donning and doffing footwear. She required substantial assistance from staff for upper body dressing and transfers. Resident B was dependent on staff to walk 10 feet and used a wheelchair for mobility. She had major surgery to repair a fracture prior to this admission. On 3/9/26 at 11:45 p.m., the resident had an unwitnessed fall on the floor on the left side beside the bed. No injuries were found. Cognitive factors included resident wandering without regard to fatigue or hunger. Neurological checks were completed. Immediate interventions included the resident's assistance with getting dressed and assisted back to bed with the bed alarm. A 3/10/26, IDT progress note indicated the root cause of the fall on 3/9/26 included the resident was trying to get out of bed to get dressed. The new intervention was a low bed. On 3/21/26 at 2:30 p.m., the resident had an unwitnessed fall on the floor in front of a glider/rocker chair without injuries. Cognitive factors included resident wandering without regard to fatigue or hunger. The immediate intervention included increased supervision. A 3/23/26, IDT progress note indicated the root cause of the fall on 3/21/26 included resident incontinence and attempting to clean self. The new intervention was a motion detector at the bedside at night. On 4/24/26 at 7:00 p.m., the resident had an unwitnessed fall on the floor in the restroom, with her buttocks against the bathtub. The resident had an abrasion to the middle right side of her back. Cognitive factors included resident wandering without regard to fatigue or hunger. The immediate interventions included assisting her to the toilet and keeping her in the common areas until offered to lay down. A 4/27/26, IDT progress note indicated the root cause of the fall on 4/24/26 was wandering. The new intervention included the resident was to remain in the dining room after meals until staff offered to put her to bed. The clinical record lacked any hourly checks according to care plan interventions prior to the resident's left hip fracture on 3/25/26. During an observation, on 4/27/26 at 4:17 p.m., Resident B self-propelled in her wheelchair wandering down the hallway and into another resident's room. On 4/27/26 at 4:30 p.m., an observation of Resident B's room indicated a lack of non-skid strips beside her bed. During an interview, on 4/27/26 at 11:11 p.m., CNA 6 indicated she was the only staff member on the Memory Care Unit on night shift when Resident B had an unwitnessed fall resulting in a hip fracture. CNA 6 was washing wheelchairs in the shower room early that morning. When she came out of the memory care shower room, Resident 6 was sitting on the floor, wearing a shirt and brief, with her back against the door frame to her room. The Memory Care Unit was typically staffed with one or two aides for night shift. There were 14 residents on the Memory Care Unit when Resident B fractured her hip. The nurse was scheduled on the other units when the resident fell. Occasionally, Resident B wandered out of her room at night and wanted coffee. The resident was at high risk for falls because of multiple falls. Prior to her hip fracture on 2/25/26, the resident was rounded on every two hours per protocol. Resident B's fall interventions prior to her hip fracture included non-skid footwear, a bed alarm, toileting, and snacks for redirection. On 4/27/26 at 11:25 p.m., RN 7 indicated she was the only nurse in the building on night shift on 2/25/26 when Resident B fell. She was at the 100 Unit nurses' station when CNA 6 opened the Memory Care Unit doors and yelled out for RN 7's assistance. Upon arrival to the Memory Care Unit, the resident was sitting in the doorway of her room, bare buttocks against the floor, pants around her ankles, and the bed alarm was activated. The resident expressed pain and was unable to tolerate weight bearing activity on her left leg during the assessment. Resident B was sent out of the facility for further evaluation. Resident B was known to wander at night and attempted to use the bathroom unassisted prior to her hip fracture on 2/25/26. On 4/28/26 at 10:51 a.m., CNA 8 indicated Resident B and three other residents on the Memory Care Unit were known to wander. She was not aware of any interventions for Resident B on her shift that required frequent monitoring. The CNA had an assignment sheet they followed for interventions. The 300 Hall CNA Assignment Sheet indicated Resident B's interventions included hourly visual checks, non-skid footwear at all times, and non-skid strips at bedside. On 4/28/26 at 11:02 a.m., CNA 9 indicated she was familiar with the Memory Care Unit residents on various shifts. Prior to Resident B's hip fracture on 2/25/26, the resident required some standby assistance with donning footwear and toileting hygiene. The resident walked without staff assistance and was able to get her pants and shirt on by herself. She was known to get up during night shift hours. CNA 9 was not aware of any frequent monitoring requirements for Resident B prior to the hip fracture. Since the resident's hip fracture, the resident wandered about in a wheelchair and required one person assistance for transfers to the wheelchair. The resident was more incontinent and required assistance with all dressing since the hip fracture.On 4/28/26 at 11:28 a.m., the Corporate Nurse Consultant reviewed Resident 6's room and indicated the room lacked non-skid strips on either side of the resident's bed for fall prevention. She reviewed the CNA Assignment sheet for the 300 Hall (Memory Care Unit) and indicated non-skid strips should have been in place on the floor beside the resident's bed. On 4/28/26 at 11:35 a.m., LPN 10 indicated fall interventions should have been implemented immediately when they were placed on the care plan. Non-skid strips should have been implemented for Resident B on 3/23/25. Failure to implement fall interventions placed the residents at risk for further falls. On 4/28/26 at 12:00 p.m., the Administrator indicated unit managers were supposed to complete rounding to ensure non-skid strips were in place and not peeling up. Over time, the non-skid strips would peel up from the floor. During an interview, on 4/28/26 at 12:08 p.m., the Administrator indicated Resident B's family had a timeframe, prior to the resident's hip fracture, when someone sat with the resident for one-on-one supervision. The resident did not have any falls during the time the family had someone with Resident B. Resident B was impulsive and would get up without assistance. The Administrator did not know what else the facility could do to prevent falls for Resident B. The resident's representative had voiced concerns after the resident's hip fracture regarding a need for more staff on the Memory Care Unit at night. There were times the Memory Care Unit was staffed at night with only one aide. She was uncertain how many staff were on the Memory Care Unit when Resident B fell on 2/25/26 and fractured her hip. On 4/28/26 at 2:10 p.m., the Regional [NAME] President of Operations indicated the facility did not have a fall preventions policy related to the provision of adequate supervision to prevent falls. On 4/28/26 at 2:23 p.m., the DON indicated the facility should have been able to identify a lack of supervision related to falls during root cause analysis of resident falls. On 4/28/26 at 2:49 p.m., the Administrator indicated the facility had an obligation to provide services to meet the residents' needs. The facility did not provide one-on-one care services, and the family signed acknowledgement of that information. The facility followed CMS guidelines regarding provision of safe care for the residents. A current facility policy, dated 10/2014, titled FALL PREVENTION PROGRAM, provided by the Administrator on 4/27/26 10:49 a.m., indicated the following: PURPOSE: To identify residents who are at risk for falls and subsequently implement appropriate, individualized fall prevention interventions. POLICY: It is the policy of this facility to identify any resident who is at increased risk for falls. Identified resident shall be monitored by the Interdisciplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing resident risk of injury. This deficiency relates to Intake 2977460. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure residents prescribed antipsychotic medications received appropriate Gradual Dose Reductions (GDR) attempts and had indication for continued use when GDRs were attempted and were deemed unsuccessful without clinical justification for 2 of 5 residents reviewed for unnecessary medications (Residents 8 and 12).Findings include:1. During an observation, on 8/11/25 at 11:21 a.m., Resident 8 ambulated up behind another resident and spoke with the other resident. During an observation, on 8/11/25 at 3:04 p.m., Resident 8 sat in a chair in the dining/activity area and participated in an activity. During an observation, on 8/12/25 at 10:06 a.m., Resident 8 ambulated around the tables in the dining area and observed the Activity Director setting up a bucket activity. During an observation, on 8/12/25 at 3:49 p.m., Resident 8 stood at the dining table and worked on a puzzle. During an observation, on 8/13/25 at 8:22 a.m., Resident 8 ambulated down the hall to the dining room. During an observation, on 8/14/25 at 10:09 a.m., Resident 8 smiled and tapped a balloon during a balloon activity. During an observation, on 8/14/25 at 3:53 p.m., Resident 8 stood at a table in the dining area and put together puzzle pieces. Resident 8's clinical record was reviewed on 8/13/25 at 8:49 a.m. Diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. Current orders included quetiapine (antipsychotic) 12.5 milligrams (mg) at bedtime (1/29/25) and mirtazapine (antidepressant) 7.5 mg at bedtime. A 7/29/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She had no mood indicators or behaviors marked for the assessment period. She required supervision/cueing with eating, upper body and lower body dressing, and putting on/taking off footwear. She required supervision/ touching staff assistance with personal hygiene. She required partial/moderate staff assistance with oral hygiene, toileting hygiene, and showering/bathing. For mobility, she required supervision/touch assistance of staff for rolling left to right in bed, moving from sitting to lying on bed, and ambulating 10 feet. She required partial/moderate staff assistance with lying to sitting on edge of bed, coming from sitting to standing position, chair to bed/ bed to chair transfers, tub/shower transfers, and walking 50 with two turns and 150 feet down a corridor. She received an antipsychotic with a gradual dose reduction attempted on 1/22/25. A current care plan for behavior symptoms indicated the resident presented with primary diagnoses of psychosis, other dissociative and conversion disorders and may exhibit mood and behavior challenges. The long-term goal indicated the episodes of mood and behaviors will be redirected and/or diffused daily through the next review. Approaches included the following: psychiatric care as ordered, ensure all needs are met, assess for pain/discomfort as needed, encourage the resident to vent their feelings and provide reassurance, be a good listener, encourage activities of interest and pleasure, redirect any inappropriate behavior and comments, and assist the resident in problem solving any issues. The care plan was last reviewed/revised 6/24/25. A current care plan for behavior symptoms indicated the resident presented with a diagnosis of anxiety disorder and may exhibit mood and behavior challenges. The long-term goal indicated episodes of mood and behaviors will be redirected and/or diffused daily through next review. Approaches included the following: psychiatric care as ordered, ensure all needs are met, assess for pain/discomfort as needed, encourage the resident to vent their feelings and provide reassurance, be a good listener, encourage activities of interest and pleasure, redirect any inappropriate behavior and comments, and assist the resident in problem solving any issues. The care plan was last reviewed/revised 6/24/25. A current care plan for major depressive disorder had a long-term goal of episodes of depressed moods will be redirected and diffused daily through the next review as evident by documented efficacy of interventions on the Behavior Memos. Interventions will be effective as evidenced by fewer episodes through next review as evident by review of documented Behavior Memos denoting number of episodes exhibited. Resident may exhibit signs and symptoms of tearfulness, negative statements, decreased appetite, and sad expressions. Approaches included the following: Observe for depressive symptoms such as crying, change in sleeping and eating patterns, restlessness and negative statements, assess for pain/discomfort as needed, medications as ordered, if applicable, complete depression assessment as needed, provide mental health services as needed, encourage activities of choice and interest, notify physician and resident representative of any significant change in condition, provide Social Services One to One programming as needed. Provided reassurance and comfort as needed, validate the resident's feelings and emotions as needed, ensure all basic needs are met, and quetiapine as ordered. The care plan was last reviewed/revised on 6/24/25. A current care plan for medications indicated the resident required the use of an antipsychotic medication and was at risk for adverse side effects. Approaches included the following: administer the medication as ordered, monitor for adverse side effects such as : drowsiness, sedation, agitation, somnolence, insomnia, headache, nervousness, and hostility, observe for change in mood or behavior, notify the nurse of noted problems for further evaluation and possible physician and resident representative notification, refer for psychological evaluation, attempt gradual dose reduction per policy, monitor for extrapyramidal symptoms per policy, refer to consultant pharmacist as needed, and medication is quetiapine. A facility pharmacy recommendation, dated 1/22/25, indicated a gradual dose reduction of quetiapine was recommended. The recommendation to discontinue quetiapine 12.5 mg daily was accepted by the provider. A Mood and Behavior Communication Memo, dated 1/23/25 at 1:00 p.m. and provided by the Administrator on 8/15/25 at 2:48 p.m., indicated the resident approached the nurse's station and said she was looking for her children. The staff member told the resident her son had been in earlier. The resident said that was not true and became verbally aggressive. She raised her voice and asked why the staff member lied to her. The resident was assisted to call her son and calmed down. A Mood and Behavior Communication Memo, dated 1/23/25 at 2:00 p.m. and provided by the Administrator on 8/15/25 at 2:48 p.m., indicated the resident was tearful, anxious and wanted to see her family. The resident was provided one on one attention, allowed to vent feelings, and provided conversation of interest. The behavior remained unchanged. A Mood and Behavior Communication Memo, dated 1/26/25 at 10:00 a.m. and provided by the Administrator on 8/15/25 at 2:48 p.m., indicated the resident was restless and kept asking to leave. She said her parents were coming to get her soon. The resident was provided with a snack, one on one, time to calm and reapproached, and redirection. The staff member attempted to calm resident and was pushed away. The behavior remained unchanged. A Mood and Behavior Communication Memo, dated 1/27/25 at 6:30 p.m. and provided by the Administrator on 8/15/25 at 2:48 p.m., indicated the resident repeatedly asked where her parents were and why she could not leave and go home. The staff walked with the resident. The resident was provided with fluids, allowed to vent feelings, and family was called for assistance. The behavior was unchanged. A Mood and Behavior Communication Memo, dated 1/29/25 at 4:40 p.m. and provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident demonstrated confusion. The son requested a behavior memo be completed. The resident was provided with a snack, conversation of interest, and reassurance and comfort. The resident's increased confusion remained unchanged. A nursing progress note, dated 1/29/25 at 4:42 p.m., indicated the resident's representative came to facility to visit and was upset about the recent medication changes and wanted the staff to document the resident's confusion. The resident was pleasant and cooperative. She came down to the dining room for meals with a decrease noted in her appetite. She had no falls. She had no distress and denied pain/discomfort A nursing progress note, dated 1/29/25 at 4:56 p.m., indicated the nurse contacted the Psychiatric Nurse Practitioner (NP) about the family's concern of a failed GDR. The NP gave orders to restart quetiapine 12.5 mg daily. A Mood and Behavior Communication Memo, dated 1/31/25 at 9:00 p.m. and provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident repeatedly called her son saying her granddaughter had run away with the kids. The resident was provided with fluids, a quiet environment, redirection, reassurance and comfort, and pleasant pictures or photo album. The staff walked with her and used humor. The behavior remained unchanged. A nursing progress note, dated 2/2/25 at 3:25 p.m., indicated the resident had needed increased assistance performing activities of daily living. She had a decline in memory and needed redirection and reassurance more frequently. Family reported a change in the resident and said she was tearful at times. The psychiatric NP was notified. A nursing progress note, dated 2/8/25 at 8:46 p.m., indicated the resident's representative came in and demanded the resident's urine be collected and sent out to assess due to her having hallucinations and increased confusion. Urine was checked. The urine showed positive for leukocytes (white blood cells) and hemoglobin (blood cells). The physician was notified and received new orders to send urine to lab for urinalysis and culture and sensitivity. A Mood and Behavior Communication, dated 2/14/25 at 2:50 p.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident thought her son was her husband. She repeatedly referred to him as her husband during the conversation. The resident was allowed to vent feelings and provided a conversation of interest. The behavior improved, and she recognized her son as her son. A Mood and Behavior Communication, dated 2/26/25 at 3:30 p.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident requested the staff to let her out to get her kids from school. Later, at supper time, she repeatedly asked where her food was, and it was in front of her. She called her son. The behavior improved. A nursing progress note, dated 3/2/25 at 4:30 p.m., indicated the resident repeatedly asked where her grandchildren were and needed the nurse to find them. The resident was easily redirected for a short time. A Mood and Behavior Communication, dated 3/21/25 at 4:00 p.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident was very confused and thought her parents and sons were coming in to pick her up. Son attempted to redirect the resident. The resident was provided with fluids, a quiet environment, and one on one. The behavior remained unchanged. A Mood and Behavior Communication, dated 3/30/25 at 12:00 p.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident repeatedly asked where the kids were and if they were safe. She went out with her son and was confused. She asked where the kids were and did not believe the answers he gave her. The resident was provided with relaxation techniques, a quiet environment, fluids, a snack, one on one, and time to calm. She was allowed to vent her feelings. The behavior improved. A Mood and Behavior Communication, dated 4/15/25 at 9:00 p.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident was more confused and restless according to family. The resident was provided with fluids and toilet. The behavior remained unchanged. The nurse indicated she was going to request labs and check the resident's urine. A nursing progress note, dated 4/25/25 at 9:54 a.m., indicated urinalysis results were normal and negative for an infection. During an interview, on 8/14/25 at 3:54 p.m., CNA 8 indicated she had not seen the resident have behaviors. She sometimes would pace around the doors and look for her kids. She told the resident her kids had been picked up from school. During an interview, on 8/15/25 at 11:52 p.m., CNA 9 indicated the resident became a lot more confused when she had a urinary tract infection, and when she had to have help with walking after she fell. During an interview, on 8/15/25 at 12:14 p.m., RN 7 indicated the resident became very confused. She called the nurse her daughter and did not recognize her son. She seemed to be getting better lately. When she had a urinary tract infection and fell, she became very hateful. During an interview, on 8/15/25 at 2:06 p.m., the DON and Administrator indicated the resident's representative became very upset when a GDR was done. During an interview, on 8/15/25 at 3:34 p.m., the DON indicated the behaviors documented could be related to dementia. However, she wondered if the resident hallucinated. The resident often would influence her roommate when she was upset, and the roommate would also become upset. The resident's representative insisted the resident needed antipsychotic medication. The black box warning for quetiapine, accessed from the FDA website on 8/15/25 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/020639s069lbl.pdf, indicated the following: .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHTS AND BEHAVIORS. The indications for usage were schizophrenia, bipolar I disorder manic episodes, and bipolar disorder, depressive episodes. 2. During an observation, on 8/11/25 at 12:27 p.m., Resident 12 sat in a wheelchair and conversed nonsensically with other residents. During an observation, on 8/11/25 at 3:12 p.m., Resident 12 sat in her wheelchair and talked to another resident. During an observation, on 8/12/25 at 10:04 a.m., Resident 12 in her wheelchair at a table and colored a picture as she talked to other residents. During an observation, on 8/13/25 at 9:13 a.m., Resident 12 sat in her wheelchair in the TV lounge and participated in a current events activity. During an observation, on 8/13/25 at 10:54 a.m., Resident 12 was tearful. The Activity Director sat down beside resident at a table and talked with her. The Activity Director read the resident a book. The resident was no longer tearful. During an observation, on 8/14/25 at 10:12 a.m., Resident 12 sat in her wheelchair and actively watched a balloon activity. Her eyes followed the balloon. During an observation, on 8/14/25 at 3:51 p.m., Resident 12 sat in her wheelchair in the hall watching other doing activities. Resident 12's clinical record was reviewed on 8/13/25 at 12:01 p.m. Diagnoses included dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, major depressive disorder, single episode, mild, Alzheimer's disease with late onset, unspecified psychosis not due to a substance or known physiological condition, and depression. Current orders included divalproex (anticonvulsant for mood disorder) 250 mg twice a day, risperidone (antipsychotic) 0.125 mg twice a day, and sertraline (antidepressant) 100 mg daily. A 7/15/25, quarterly, MDS indicated the resident sometimes understood others and was sometimes understood. The resident was unable to complete the interview for mental status. The staff assessment of the resident's mental status indicated the resident's cognitive skills for daily decision making were moderately impaired, and decisions were poor. She had disorganized thinking and inattention which fluctuated. No mood indicators or behaviors were marked. She required supervision/touching assistance with eating. She required partial/moderate staff assistance with oral hygiene. She required substantial/maximal staff assistance with upper body dressing. She was dependent on staff for toileting, showering/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. She was dependent on staff for rolling left to right, moving from sitting to lying, moving from lying to sitting, chair to bed and bed to chair transfers, toilet transfers, tub/shower transfers. She required partial/moderate staff assistance with walking 10 feet and 50 feet with two turns. She required partial/moderate staff assistance in wheelchair for 50 feet and was dependent on staff for 150 feet. A current care plan for delirium indicated the resident was at risk for delirium or acute confused episodes related to diagnoses of Alzheimer's dementia and psychosis as evidenced by disorganized thinking and inattention. The long-term goal was that the resident will have no complication associated with signs or symptoms of delirium through next review. Approaches included the following: administer medications, as ordered: divalproex and risperidone, ensure resident's safety, give reassurance to resident, manipulate resident's environment as needed, monitor for change in resident's mood and behaviors, monitor for signs or symptoms of delirium such as inattention, disorganized thinking, altered level consciousness, psychomotor retardation, and acute confusion, monitor for underlying signs or symptoms of medical condition that could cause delirium such as : UTI or other type of infection, hypoxia or signs or symptoms of dehydration, monitor lab results as ordered, monitor resident for ADL (activities of daily living) needs, oxygen saturation levels as needed and oxygen as needed, refer to psych services, speak calmly, slowly, and call resident by name, update physician as needed of resident's condition, and vital signs as needed. A current care plan for medications indicated the resident required the use of an antipsychotic medication and was at risk for adverse side effects. The long-term goal was that the resident will have no signs or symptoms of adverse reaction associated with the use of anti-psychotic medication through the next review. Approaches included the following: administer medication as ordered, monitor for adverse side effects such as drowsiness, sedation, agitation, somnolence, insomnia, headache, nervousness, hostility, observe for change in mood or behavior, notify the nurse of noted problems for further evaluation and possible physician and resident representative notification, refer for psychological evaluation as indicated, attempt gradual dose reduction per policy, monitor for extrapyramidal symptoms per policy, refer to consultant pharmacist as needed, and medications used is risperidone to treat dementia with agitation. A current care plan for the diagnosis of anxiety indicated symptoms may include fatigue, restlessness, sweating, irritability, racing thought, excessive worry, fear, poor concentration, sensation of abnormal heartbeat, or trembling. The long-term goal was that the episodes of increased anxiety will be successfully addressed, and resident will be calmed as evident by documented efficacy of interventions listed in the Behavior Memo. Interventions will be effective as evidenced by fewer episodes of anxiety as evident by review of documented Behavior Memos denoting number of episodes of anxiety exhibited. Approaches included: ensure calm environment, ensure all basic needs have been met, encourage activities of preference, provide mental health services as ordered, encourage resident to express thoughts and feelings, provide reassurance and comfort as needed, provide relaxation techniques as needed such as visualization, relaxing music, and massage, administer medication as ordered, and medication hydroxyzine as ordered. A current care plan for behavioral symptoms indicated the resident presented with primary diagnosis of psychosis and may exhibit mood and behavior challenges. The long-term goal was that episodes of mood and behaviors will be redirected and/or diffused daily through the next review. Approaches included the following: psychiatric care as ordered, ensure all needs are met, assess for pain/discomfort, encourage the resident to vent their feelings and provide reassurance, be a good listener, encourage activities of interest and pleasure, redirect any inappropriate behavior and comments, assist the resident in problem solving, and monitor for changes, notify the physician if warranted. The care plan lacked indication of how the resident's psychosis presented, nor how the resident expressed behaviors. A current care plan for cognitive loss/dementia indicated the resident has the progressive cognitive and communicative deficits associated with Alzheimer's disease. Approaches included the following: administer medications as ordered, approach the resident from the front, change the topic if the resident becomes upset/agitated, divalproex as ordered, encourage family and friends to visit and bring familiar objects from home, ensure you have been seen before initiating therapeutic touch, explain the purpose for your visit in terms the resident can understand, monitor for changes in status and notify the physician and responsible party as indicated, risperidone as ordered, speak in a clear, low calm tone of voice at a volume that is easily heard by the resident, and use nonverbal gestures to supplement verbal communication where appropriate. A current care plan for medication indicated the resident required the use of divalproex and risperidone to treat dementia and is at risk for experiencing adverse side effects. The long-term goal indicated that the resident would have no signs or symptoms of an adverse reaction associated with the medications used to treat dementia through the next review. Approaches included the following: administer medications as ordered, give no more than two choices to avoid confusion and over stimulation, monitor for changes in mood or behavior, monitor for signs and symptoms of adverse reaction such as diarrhea, insomnia, headache, nausea, dizziness, monitor labs as ordered, notify nurse of change for further evaluation and possible physician and resident representative notification, and try to use short simple sentences and ask questions that require a yes or no type answer. A Mood and Behavior Communication Memo, dated 1/31/25 at 7:00 p.m. and provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident became upset when the staff member was unable to get to her right away to be toileted. The behavior improved when the resident was toileted. A Mood and Behavior Communication Memo, dated 2/3/25 at 8:15 p.m. and provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident was assisted out of her wheelchair to go to the bathroom, and she began crying. She cursed at the staff member and then sat in her chair. The resident was provided toileting, position was changed, and time to calm/reapproach. The behavior worsened. The resident became more agitated. A nursing progress note, dated 2/25/25 at 1:52 p.m., indicated the resident had a couple of tearful episodes. A Mood and Behavior Communication Memo, dated 2/26/25 all day 2:00 p.m. to 10:00 p.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident was emotional after she had been toileted. She became tearful and scooted around in her wheelchair for a few hours. The resident was provided toileting, a quiet environment, and reassurance and comfort. The behavior improved after she ate dinner. A facility pharmacy recommendation, dated 2/26/25, indicated a gradual dose reduction of risperidone was recommended. The recommendation to decrease the risperidone 0.25 mg daily to 0.125 mg daily was ordered 2/28/25 by the provider. A nursing progress note, dated 2/27/25 at 11:04 a.m., indicated the resident was cooperative until the water was turned on for her shower. The resident called the CNA names during the shower. She took the shower hose and sprayed the CNA. She hit the CNA in the arm during the shower. A Mood and Behavior Communication Memo, dated 2/28/25 for 2:00 - 10:00 p.m., provided by the Administrator on 8/15/25 at 2:48 p.m., indicated the resident was rolling her wheelchair too close to other residents. She saw her mom and dad. She told the staff they were not listening to her and cried over not getting attention all the time. The resident was provided toileting, a snack, one on one, and time to calm. The behavior remained unchanged. A nursing progress note, dated 3/5/25 at 9:15 a.m., indicated the resident was anxious and tearful for an unknown reason. She was reassured numerous times, but the reassurance was not helpful. She was given a snack, and a male peer sat next to her. She ate her breakfast, patted the male sitting next to her on the head and shoulder and smiled. She had no further tearfulness. A Mood and Behavior Communication Memo, dated 3/7/25 at 4:30 p.m., provided by the Administrator on 8/15/25 at 2:48 p.m., indicated the resident was hallucinating repeatedly that another resident was her husband. The resident was provided toileting, venting of feelings, and redirection. The behavior was unchanged. A Mood and Behavior Communication Memo, dated 4/15/25 at 6:10 a.m., provided by the Administrator on 8/15/25 at 1:30 p.m., indicated the resident was crying. She was upset and paced in her wheelchair. The resident ran over the staff member's feet with wheelchair twice while going back and forth on the unit. The resident was provided with a drink, toileting, and one on one. The behavior was unchanged. During an interview, on 8/14/25 at 3:54 p.m., CNA 8 indicated she had seen Resident 12 have behaviors only a few times. She cried and sometimes she kicked when the behaviors were bad. During an interview, on 8/15/25 at 11:52 p.m., CNA 9 indicated the resident would sometimes become very tearful. She did not have many problems with her. During an interview, on 8/15/25 at 12:16 p.m., RN 6, RN 7, and CNA 9 indicated behavior sheets were supposed to be filled out for things like agitation and aggression, but not for regular confusion. During an interview, on 8/15/25 at 2:06 p.m., the Administrator and DON indicated they would look for additional behavior sheets completed on the resident. During an interview, on 8/15/25 at 3:36 p.m., the DON indicated the behaviors exhibited by the resident could be dementia associated behaviors, or they could be hallucinations. She was uncertain that she was qualified to determine if the resident's behaviors were hallucinations or dementia associated behaviors. A black box warning for risperidone, accessed from the FDA website https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020272s056,020588s044,021346s033,021444s03lbl.pdf on 8/15/25 indicated the following: .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS. The indications for use indicated treatment of schizophrenia, short-term treatment of acute manic or mixed episodes associated with bipolar I disorder in adults, and the treatment of irritability associated with autistic disorder in children and adolescents aged 5-16 years. A current facility policy, dated 4/2025 and provided by the DON on 8/15/25 at 3:02 p.m., titled PSYCHOTROPIC MEDICATION CONSENT, USE AND GRADUAL DOSE REDUCTION, indicated the following .Antipsychotic medications are generally used only for the following diagnoses as documented in the resident's record, consistent with the definitions(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions) . The use of these diagnoses only to support the use of anti-psychotic medication is strictly prohibited. Use of these diagnoses must be verifiable according to accepted standards of practice. A. Schizophrenia b. Schizo-affective Disorder c. Schizophreniform Disorder d. Delusional disorder e. Mood Disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression) f. Psychosis g. Medical illness with psychotic symptoms and/or treatment-related psychosis or mania h. Tourette's Syndrome i. Huntington's Disease.The facility will, in consultation with the facility's consulting pharmacist and the prescribing provider, consider gradual dose reduction.in order to find the lowest effective dose of psychotropic medications. Observation will be performed in order to identify symptoms of failed dose reduction, and the same shall be documented if observed. 3.1-48(a)(4)3.1-48(b)(2)

Based on record review and interview, the facility failed to ensure the resident's representative was notified in writing of transfer/discharge appeal rights and the facility bed hold policy for 4 of 7 residents reviewed for hospitalizations (Resident 6, 7, 22, and 57) and failed to provide communication to the receiving health care facility for 1 of 7 residents reviewed for hospitalizations. (Resident 22)Findings include: 1.Resident 7's clinical record was reviewed on 8/14/25 at 9:04 a.m. Diagnoses included Alzheimer's disease, vascular dementia, unspecified severity, with agitation, dementia, moderate, with agitation, unspecified dementia, unspecified severity, with other behavior disturbance, and major depressive disorder, recurrent, severe with psychotic symptoms. A nursing progress note, dated 6/3/25 at 7:22 p.m., indicated the resident became physically aggressive and threw clothing items, hangers, and a television out of the resident's room. She tried to slam her walker into the staff members. A referral was sent to a psychiatric facility. The resident's emergency contact and power of attorney were notified of the occurrence. A nursing progress note, dated 6/3/25 at 11:30 p.m., indicated the resident was awakened to transfer to the psychiatric facility. The emergency medical technicians (EMT) were given all transfer paperwork and clothing for three days. The resident left the building at 11:30 p.m. The clinical record lacked indication the resident's representative was notified of the notice of transfer/discharge appeal rights and bed hold policy in writing for the resident's transfer to the hospital A Nursing Home to Hospital Transfer Form, left on the conference table on 8/15/25 at 1:30 p.m., indicated the resident transferred to the psychiatric facility on 6/3/25. In the Additional Relevant Information section was written Family aware. During an interview, on 8/15/25 at 12:03 p.m., RN 6 indicated when a resident was transferred the following paperwork is sent: SBAR (form which included situation, background, assessment, and recommendation, the CCD (continuity of care document which included diagnoses, medications, next of kin contact information, vaccinations, and resident goals), and a face sheet. The packet also included a bed hold in it. The paperwork was sent with the EMTs. During an interview, on 8/15/25 at 12:09 p.m., RN 7 indicated when a resident was transferred, she printed off the CCD, the resident face sheet, and some additional paperwork which included a transfer/discharge notice, and a bed hold for resident transfers. The notice of transfer was given to the DON, the bed hold was given to the EMTs. During an interview, on 8/15/25 at 3:16 p.m., the Social Services Director (SSD) indicated she filled out transfer paperwork including the bed hold and transfer/discharge appeal rights for planned discharges. She did not manage any of the paperwork for the emergent transfers except for the ombudsman notification of the resident's transfer/discharge. During an interview, on 8/15/25 at 3:40 p.m., the DON indicated the nursing units had packets to fill out for emergent transfers, which included a bed hold. The nurse would hand the documents to the family if they came to the facility, otherwise the nurse gave the papers to the EMTs. If the resident was out of the facility for an extended period, the transfer/discharge forms and bed hold policy would be mailed to them. The facility did not keep a log of transfer/discharge and bed hold notifications that were sent to the resident representatives. 2.Resident 6's clinical record was reviewed on 8/14/25 at 10:21 a.m. Diagnoses included chronic respiratory failure with hypoxia (low oxygen level), congestive heart failure, and disorientation. A progress note, dated 1/28/25 at 6:09 p.m., indicated Resident 6 had a high heart rate, high blood pressure, confusion, and incontinence. The on-call provider was notified, and staff were instructed to send Resident 6 to the emergency department. Bed hold paperwork was filled out and faxed to the hospital emergency department. Resident 6's emergency contact and ADON were made aware of the transfer. Resident 6's clinical record included an incomplete Nursing Home to Hospital Transfer Form dated 1/28/25. The first page of the form did not include the resident's date of birth , admission date, contact person information or transfer notification, who to call at nursing home, primary care physician name and telephone number, resident risk alerts, and personal belongings that were sent with the resident at the time of the transfer. The second page of the form was blank other than the resident's name, date of birth , and the hospital transfer date. The form completed by section was signed by the nurse with a time entered of 6:20 p.m. A Notice of Transfer or Discharge form dated 1/28/25, and a copy of the bed hold policy was present. The Notice of Transfer or Discharge Request for Hearing form in the record was blank and lacked any information on the form. A progress note, dated 3/01/25 at 6:30 p.m., indicated Resident 6 requested to go to the emergency room. The facility provider was made aware and transfer order received. A progress note, dated 3/01/25 at 7:40 p.m., indicated report was given to a staff member at the hospital. Emergency services provided Resident 6 transportation to the hospital emergency department. Resident 6's clinical record included a Nursing Home to Hospital Transfer Form, Notice of Transfer or Discharge form, a copy of the bed hold policy, and a Notice of Transfer or Discharge Request for Hearing. All the forms were dated 3/1/25. The second page of the Nursing Home to Hospital Transfer Form was not located in the resident's clinical record. A progress note, dated 6/8/25 at 3:39 p.m., indicated Resident 6 had shortness of breath, wheezing, an elevated heart rate, and whistling sounds noted on respiration. The facility provider was notified and gave an order to send Resident 6 to the emergency room. The resident's daughter was notified and the [NAME] Fire Department transported Resident 6 to the emergency room. The facility CCD report and the bed hold policy were sent with the [NAME] Fire Department at the time of the transfer. Resident 6's clinical record included an incomplete Nursing Home to Hospital Transfer Form. The form did not include the name of the hospital the resident was transferred to, the date of the transfer, physician's name and telephone number, or the primary care clinician at the nursing facility. The second page was left blank. The Notice of Transfer or Discharge form, a copy of the bed hold policy, and a Notice of Transfer or Discharge Request for Hearing were in the record and dated 6/8/25. Resident 6's clinical record lacked documentation indicating her representative was notified in writing of the transfer/discharge appeal rights and the bed hold policy at the time of all three hospitalizations. 3.Resident 57's clinical record was reviewed on 8/13/25 at 11:45 a.m. Diagnoses included displaced intertrochanteric fracture of right femur (a break in the upper thigh bone), chronic kidney disease, and hypertension (high blood pressure). A progress note, dated 6/28/25 at 9:01 p.m., indicated that Resident 57's family was notified of Resident 57's medical status and it was determined to send her to the emergency room (ER). The DON and ED were notified, and report was called to the hospital ER. Resident 57's clinical record included a Nursing Home to Hospital Transfer Form, Notice of Transfer or Discharge form, a copy of the bed hold policy, and a Notice of Transfer or Discharge Request for Hearing. All the forms were dated 6/28/25. The Notice of Transfer or Discharge Request for Hearing form did not indicate Resident 57's name, telephone number, or address. Resident 57's clinical record lacked documentation indicating her representative was notified in writing of the transfer/discharge appeal rights and the bed hold policy. During an interview, on 8/14/2025 at 2:05 p.m., the Social Services Director (SSD) indicated she did not have anything to do with the bed hold policies and notifications, other than making sure the completed forms were in resident's discharge files. Due to the nursing staff being responsible for completing paperwork at the time of a resident's facility transfer, she was unsure if the nursing staff provided families with copies of the bed hold paperwork. During an interview, on 8/14/2025 at 2:21 p.m., the Administrator indicated there was a packet, located at the nurse's station, that consisted of the paperwork that was to be filled out by the nurses at the time of resident transfers or discharges. Bed hold policy was given to residents who were alert and oriented, as long as they are awake. If not given to the resident, and a family member was at the bedside they would be provided with paperwork, and if no one is present, copies were mailed. She was unsure if there was a log indicating if paperwork was mailed to families. During an interview, on 8/15/2025 at 3:12 p.m., the SSD indicated she was responsible for making sure residents who had planned facility discharges had their discharge instructions and paperwork. In emergent situations the nursing department were responsible for completing the necessary paperwork. She had never mailed a bed hold policy or a copy of the Notice of Transfer or Discharge paperwork to a family member. During an interview, on 8/15/2025 at 3:39 p.m., the DON indicated nurses were to fill out transfer paperwork at the time of a resident's facility transfer. The paperwork was located in a prepared emergent packet at the nurse's station. The completed paperwork was sent with the EMT's to be taken to the receiving provider. If the paperwork was not able to be completed prior to EMT arrival, paperwork was faxed to receiving provider. The packet was able to be given to an oriented resident or a family member if present, and they were able to give the packet to the receiving provider. Staff verbally informed families when a bed hold policy had been sent to a facility. Facility staff may possibly mail transfer paperwork if a resident is out for an extended leave. She was unsure if any had been mailed out, as there is not a log indicating this. 4.Resident 22's clinical record was reviewed on 8/15/25 at 10:28 a.m. Diagnoses included unspecified dementia, type 2 diabetes mellitus, stage 4 chronic kidney disease, and gastro-esophageal reflux disease (GERD). The facility census report indicated Resident 22 was hospitalized on the following dates: 1/17/25, 3/1/25, 3/3/25, 4/11/25, and 7/22/25. The clinical record lacked progress notes for hospitalizations on 3/3/25, 4/11/25, and 7/22/25. A Notice of Transfer or Discharge, dated 1/17/25, provided by the DON on 8/15/25 at 1:30 p.m., was completed and signed by the DON. The clinical record lacked indication of the resident and/or their representative being notified of transfer/discharge rights. The clinical record lacked documentation of a report of Resident 22's condition being given to the receiving facility. A Notice of Transfer or Discharge, dated 3/1/25, provided by the DON on 8/15/25 at 1:30 p.m., was completed and signed by the DON. The clinical record lacked indication of the resident and/or their representative being notified of transfer/discharge rights. A Notice of Transfer or Discharge, dated 3/3/25, provided by the DON on 8/15/25 at 1:30 p.m., was completed and signed by the DON. The clinical record lacked indication of the resident and/or their representative being notified of transfer/discharge rights. The clinical record lacked documentation of a report of Resident 22's condition given to the receiving facility. A Notice of Transfer or Discharge, dated 4/11/25, provided by the DON on 8/15/25 at 1:30 p.m., was completed and signed by the DON. The clinical record lacked indication of the resident and/or their representative being notified of transfer/discharge rights. A Notice of Transfer or Discharge, dated 7/22/25, provided by the DON on 8/15/25 at 1:30 p.m., was completed and signed by the Administrator. The clinical record lacked indication of the resident and/or their representative being notified of transfer/discharge rights. During an interview with the DON, on 8/15/25 at 11:55 a.m., she indicated family was usually notified by phone to let them know when their family was transferred (to the hospital). All paperwork would be printed and given to the emergency medical technicians (EMTs) who picked up the residents to transfer them to the hospital. EMTs got report from the nurse and would then pass the information on to the receiving facility. A current facility document, titled Transfer Discharge and Discharge Planning, provided by the Administrator on 8/14/25 at 2:50 p.m., indicated the following: .The facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless.A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs A through F, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.Documentation in the resident's medical record must include: A) The basis for the transfer, B) In the case of 'the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility', facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).The documentation required must be made by the resident's physician when transfer or discharge is necessary under paragraph A). A current facility document, titled Bed Hold, provided by the Regional Nurse Consultant (RNC) on 8/15/25 at 1:47 p.m., indicated the following: .Before a resident is transferred to a hospital or goes on a therapeutic leave, facility personnel will provide written information to the resident or resident representative that specifies the facility bed hold policy. In case of emergency transfer, every effort will be made to notify the resident or resident representative at the time of transfer as to the bed hold policy. Should this not occur, effort will be made to provide written notice to the resident or resident representative within 24 hours of transfer. 3.1-12(3) 3.1-12(5) 3.1-12(6)(A)

Based on record review and interview, the facility failed to administer a PRN (as needed) medication per physician orders for 2 of 16 residents reviewed for physician orders. (Resident 35 and Resident 5)1.Resident 35's clinical record was reviewed on 8/13/25 at 1:56 p.m. Diagnoses included Alzheimer's disease, essential hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat).Current orders included hydralazine 10 milligrams four times a day as needed for high blood pressure [to lower blood pressure]. Special instructions included: administer the medication when Resident 35's blood pressure was above 165 [systolic (top number)].The clinical record indicated the following:On 7/1/25 the resident's blood pressure was 170/83. Hydralazine was not administered.On 7/6/25 the resident's blood pressure was 198/87. Hydralazine was not administered.On 7/14/25 the resident's blood pressure was 181/77. Hydralazine was not administered.On 7/15/25 the resident's blood pressure was 169/73. Hydralazine was not administered.On 7/17/25 the resident's blood pressure was 170/72. Hydralazine was not administered.On 7/24/25 the resident's blood pressure was 183/77. Hydralazine was not administered.On 7/25/25 the resident's blood pressure was 170/88. Hydralazine was not administered.On 7/29/25 the resident's blood pressure was 182/92. Hydralazine was not administered.On 7/30/25 the resident's blood pressure was 175/83. Hydralazine was not administered.On 8/14/25 the resident's blood pressure was 181/86. Hydralazine was not administered.A quarterly Minimum Data Set (MDS) assessment, dated 7/30/25, indicated Resident 35's cognitive status was severely impaired.A current care plan, dated 5/15/25, indicated Resident 35 had a diagnosis of hypertension and was at risk for associated complications. Interventions included administer medications as ordered, hydralazine as ordered, amlodipine as ordered, metoprolol as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters, and monitor for signs of hypertension. 2.Resident 5's clinical record was reviewed on 8/15/25 at 1:36 p.m. Diagnoses included dementia, essential hypertension, and anxiety.Current orders included hydralazine 25 milligrams every 6 hours as needed for high blood pressure. Special instructions included: administer the medication when Resident 5's blood pressure was above 165 [systolic].The clinical record indicated the following:On 7/3/25 the resident's blood pressure was 170/78. Hydralazine was not administered.On 7/19/25 the resident's blood pressure was 172/84. Hydralazine was not administered.On 7/28/25 the resident's blood pressure was 169/85. Hydralazine was not administered.On 7/29/25 the resident's blood pressure was 168/93. Hydralazine was not administered.On 7/31/25 the resident's blood pressure was 168/67. Hydralazine was not administered.On 8/3/25 the resident's blood pressure was 181/86. Hydralazine was not administered.A quarterly Minimum Data Set (MDS) assessment, dated 5/6/25, indicated Resident 5's cognitive status was severely impaired.A current care plan, dated 5/21/25, indicated Resident 5 had a diagnosis of hypertension and was at risk for associated complications. Interventions included administer medications as ordered, hydralazine as ordered, clonidine as ordered, lisinopril as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters, and monitor for signs of hypertension. During an interview, on 8/15/25 at 3:39 p.m., the DON indicated the facility's nurse practitioner had given parameters to recheck blood pressures an hour after medication administration and prior to hydralazine administration. Blood pressure rechecks should be documented by the nurses in the residents' progress notes. She was unsure if parameter instructions were being followed or documented. She confirmed Resident 5 and 35's hydralazine was not administered per orders. If administered as ordered, it should have helped in managing their blood pressure.A current policy, revised April 2017, titled MEDICATION ADMINISTRATION, provided by the DON on 8/15/25 at 3:02 p.m., indicated the following: PURPOSE: To safely administer medications as per physicians' orders.A current facility policy, revised September 2017, titled PRN MEDICATIONS, provided by the Regional Consultant on 8/15/25 at 4:15 p.m., indicated the following: .POLICY: It is the policy of this facility to monitor the administration of all PRN medications.PROCEDURE: 1. Each resident should have a PRN Flow Sheet housed with the applicable resident Medication Administration Record.4. Should a PRN be necessary to treat another symptom (e.g. constipation, fever, etc.) the same should be listed on the flow sheet.6. The nurse/QMA must re-visit the resident follow PRN medication administration to evaluate medication efficacy.the nurse must further assess and determine the need to contact the physician relative to the resident's unresolved complaint/concern/symptom.3.1-37(a)

Based on observation, interview, and record review, the facility failed to follow the dietitian's recommendations and follow a physician's order for a resident with significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 8) Finding includes:During an observation, on 8/13/25 at 7:48 a.m., Resident 8 was eating her biscuits and gravy. She had white milk on her tray. Resident 8's clinical record was reviewed on 8/13/25 at 8:49 a.m. Diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, mild, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, Vitamin D deficiency, vomiting, and underweight. Current orders included the following: regular diet, chocolate milk with meals, cottage cheese with meals, vanilla ice cream with lunch and dinner, yogurt with breakfast, Boost (supplement) high protein - give 350 ml (milliliters) three times a day, Boost breeze daily, Boost plus high protein - twice a day, quetiapine(antipsychotic) 12.5 milligrams (mg) at bedtime (1/29/25), and mirtazapine (antidepressant) 7.5 mg at bedtime. A 7/29/25 quarterly Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She had no mood indicators or behaviors marked. She required supervision/cueing with eating. She had significant weight loss and was on a therapeutic diet. A current care plan indicated the resident had incurred significant weight loss. Approaches included the following: mirtazapine as ordered, determine potential causal factor of decreased consumption/weight loss and involve appropriate disciplines to provide intervention - food preferences - depression/isolation - need for increased assistance - dining seating/atmosphere. Review of the resident's weights indicated on 2/2/25 the resident weighed 94.8 pounds and on 8/1/25 the resident weighed 82.8 pounds, which was a 12.66 % weight loss over six months. The resident was seen on 6/24/25 for weight loss by the nurse practitioner (NP). She requested a dietitian consultation. A dietitian consult note, dated 7/11/25 indicated the resident had greater than 10% weight loss in six months. The dietitian indicated the resident had triggered a significant weight loss and had trending weight loss. She received a regular diet with yogurt at breakfast, chocolate milk with meals, Boost with meals, and Boost three times a day. The resident's acceptance of the supplements varied. Mirtazapine was started on 7/9/25. The dietitian recommended discontinue the Boost at meals to promote oral intake at meals., change Boost plus high protein to twice a day and add Boost breeze daily. During an observation, on 8/14/25 at 12:03 p.m., the resident received white milk on her tray. During an observation, on 8/14/25 at 12:11 p.m., LPN 13 brought a Boost high protein supplement to the resident while the resident was eating her meal. During an interview, on 8/14/25 at 12:19 p.m., LPN 13 indicated chocolate milk was not on the dietary slip. The resident should have chocolate milk. The chocolate milk was signed off for each meal on the medication administration record (MAR). She indicated she gave the resident chocolate Boost at meals and wondered if that counted as chocolate milk. A review of the resident's lunch ticket for 8/14/25, provided by LPN 13 on 8/14/25 at 12:19 p.m., indicated chocolate milk was not listed. During an interview, on 8/15/25 at 1:53 p.m., RN 10 indicated the DON reviewed the dietitian's recommendations and notified the NP for new orders. During an interview, on 8/15/25 at 1:57 p.m., the DON indicated the when the dietitian made recommendations, the DON discussed them with the NP. The DON indicated the resident's representative had indicated the resident seemed to do better drinking than eating. The DON was unable to provide documentation of the reasoning for not following the dietitian's recommendation to not give the Boost at meals. A current facility policy, dated 10/2014, provided by the DON on 8/15/25 at 3:02 p.m., titled DIETITIAN RECOMMENDATION, indicated the following: .Administrative nursing staff shall be responsible to ensure said recommendations are communicated to the resident's physician as soon as possible, but no later than three (3) days from receiving said recommendation. Physician response shall be documented and implemented accordingly. 3.1-46(a)(2)

Based on observation and interview, the facility failed to ensure medications were stored in a secure manner when one medication cart was left unlocked and unattended. This deficiency had the potential to allow access to medications belonging to 19 residents. Findings include:During an observation on 8/12/25 at 11:03 a.m., the 100-hallway medication cart was unattended and unlocked. The hallway was empty until 11:10 a.m. when two (unidentified) Certified Nursing Assistants (CNAs) approached and entered a nearby resident room. At approximately 11:15 a.m., LPN 5 approached and locked the medication cart. She indicated she was the nurse responsible for the medication cart. She had inadvertently left the cart unlocked. Keys to the cart were in her pocket. The cart contained medications for 19 residents.During an interview with the Director of Nursing (DON) on 8/15/25 at 3:53 p.m., she indicated all medication carts should be locked when not in use.A current facility document, titled Storing Drugs, provided by the DON on 8/15/25 at 3:02 p.m., indicated the following: .Drugs and biologicals will be stored in a safe, secure, and orderly manner at appropriate temperatures and accessible only to licensed nursing and pharmacy personnel or staff members lawfully authorized to administer medications .2) When a permitted person is not in a drug storage area, the drug storage areas and devices must be kept locked 3.1-25(m)

Based on observation and interview, the facility failed to ensure hygienic food handling practices were followed during dining services for 1 of 19 residents observed in the main dining room. (Resident 35)Findings include:During an observation, on 8/11/2025 at 12:06 p.m., CNA 4 offered to cut Resident 35's hamburger sandwich. Using her left hand, CNA 4 placed all five of her fingertips on the top bun and pushed the top bun in a downward motion to secure the bun in place as she used a knife, in her right hand, to cut the sandwich in half. During an interview, on 8/11/2025 at 12:43 p.m., CNA 4 indicated she should not have touched Resident 35's food with her bare hands. Food was not to be touched barehanded and a fork and knife was to be used to cut a sandwich. During an interview, on 8/15/25 at 3:39 p.m., the DON indicated staff were not to touch resident's food with bare hands. All staff were previously educated on hand hygiene, food handling, and other specifics of food service(s). A facility policy, dated August 2024, provided by the DON on 8/15/25 at 3:02 p.m., titled Glove Use & Meal Service, indicated the following: Policy: In an effort to protect food products from contamination, all products should be used serving utensils. Procedure: 4. Employees may not touch ready-to-eat food with bare hands; gloves must be worn. 3.1-18(a)

Based on interview and record review, the facility failed to prevent a significant medication error, resulting in the hospitalization of a resident for altered mental status. (Resident B) Findings include: Resident B's closed clinical record was reviewed on 7/2/25 at 11:08 a.m. Diagnoses included displaced fracture of right femur, atrial fibrillation (irregular heartbeat), heart disease. The resident admitted to the facility from the hospital on 6/27/25. Current physician orders include buprenorphine-naloxone (treats narcotic dependence) 8-2 milligram (mg) sublingual twice a day, tramadol (opiate pain medication) 50 mg every six hours, ciprofloxacin (antibiotic) 500 mg one tablet twice a day for three days for urinary tract infection (UTI), iron 325 mg one tablet daily for anemia, and potassium gluconate 595 mg daily for hypokalemia. A current care plan, dated 6/27/25, indicated Resident B was at risk for atrial fibrillation. Interventions included administering medication as ordered, aspirin as ordered, Eliquis as ordered, monitor vital signs as needed, notify physician if any concerns, and obtain her pulse as indicated. A current care plan, dated 6/27/25, indicated Resident B had a recent history of a fracture and was at risk for pain and infection due to right femur fracture. Interventions included assess pain location, duration, intensity, and frequency, assess the residents level of pain as needed, monitor of signs and symptoms of infection/complications such as: elevated temperature, redness, swelling, and or warmth. Notify the nurse of any problems for further evaluation and possible physician and resident representative notification, offer pain medication as ordered and monitor effectiveness. Review of a pharmacy consolidated delivery sheet dated 6/27/25 indicated naloxone (Narcan) hcl 4 mg nasal spray was administered and checked off as being received by LPN 8 on 6/27/25. On 6/28/25 at 10:58 a.m., Resident B was alert and oriented. Resident B's speech was clear and she was able to make her needs known. Resident B's pulse was strong and regular. Resident B denied any chest pain, feeling of her heart racing, or being fatigued. Resident B complained of right hip pain that was relieved with prescribed medications. A June 2025 Medication Administration Report (MAR) indicated buprenorphine-naloxone 8-2 mg was administered by LPN 4 on 6/27/25 between 6:30 p.m. and 10:30 p.m. A progress note, dated 6/28/25 at 9:01 p.m., indicated Resident B had complaints of being hot and yawning. Resident B's blood pressure was 180/100 millimeters of mercury (mmHg). Staff were unable to obtain her oxygen saturation. A new order was received to send Resident B to the hospital for evaluation and treatment. A call was placed to 911. Emergency Medical Technicians (EMTs) arrived and transported Resident B to the hospital. Hospital Records, dated 6/28/25 and 6/29/25, indicated Resident B admitted with complaints of altered mental status after receiving 4 mg of intranasal Narcan. Resident B had a history of atrial fibrillation (abnormal heart rhythm) and had been off her Eliquis (blood thinner) due to an upcoming surgery. Resident B was cardioverted (shocked) back into normal sinus rhythm after the third attempt. Resident B continued to be agitated after the cardioversion, but her blood pressure had initially been stable afterward. A hospital physician note indicated Resident B was in shock with a blood pressure of 79/31 mmhg. Resident B was admitted to the ICU due to cardiogenic shock (heart cannot pump well) with acute cystitis (kidney infection) without hematuria with shock. During an interview, on 7/2/25 at 12:06 p.m., the facility's Pharmacist indicated naloxone (Narcan) nasal spray was sent to the nursing facility. If naloxone was administered, a residents blood pressure would need to be monitored. Side effects from the naloxone include sweating or flushing, hot flashes, abdominal cramping, vomiting, disorientation or dizziness. Side effects could also affect the heart rate. When someone is in pain, symptoms include body sweats and increased heart rate. The resident's symptoms could have been from pain, withdrawal, or the medication. On 7/2/25 at 12:54 p.m., LPN 4 indicated Resident B was playing cards at the time of the medication administration. The naloxone nasal spray was in the bottom of the medication cart. Resident B received tramadol then administered the naloxone instead of the ordered buprenorphine- naloxone. LPN 4 helped Resident B administer the naloxone nasal spray. The nurse indicated she normally checked the label against the medication. She had noticed the buprenorphine- naloxone was ordered as a film and the naloxone was a nasal spray, but was unable to recall when she noticed that. Roughly 10 minutes later, another nurse advised LPN 4 to assess Resident B, as she was experiencing symptoms. Resident B was displaying trembling, complaint of being hot. She was oriented and able to state she was shaking and trembling. Her blood pressure was low. On 7/2/25 at 1:30 p.m., the facility's Medical Director indicated Resident B was discharged from the hospital on 6/27/25 following hip surgery with an order for buprenorphine- naloxone, but the hospital did not send in a prescription to the pharmacy. If buprenorphine- naloxone was stopped abruptly, one would start experiencing withdrawal symptoms. Withdrawal symptoms would not happen several hours after her hospital discharge. Naloxone's effect would not be long lasting in a person's system, which is why the medication can be administered every few minutes. The two most common causes of cardiogenic shock were heart attack or sepsis. A person's age, along with other commodities including anemia, which Resident B could have experienced due to her surgery, would affect her heart. Within the first 90 days following hip surgery, those resident become very bedridden, not wanting to move around. Age, anemia, and dehydration increased the risk of developing deep vein thrombosis (DVT) or pulmonary embolism (PE). From his medical standpoint, he felt Resident B likely suffered from sepsis, heart attack, or maybe even a PE. Any of these three conditions could put someone into cardiogenic shock. On 7/2/25 at 3:09 p.m., RN 7 indicated the Nurse Practitioner (NP) discontinued the naloxone order upon the resident's admission to the facility. RN 6 was unaware the naloxone was ordered through the pharmacy. The naloxone was never ordered through the facility. It only existed on Resident B's hospital discharge medication summary. On 7/2/25 at 3:34 p.m., LPN 8 indicated she did not recall receiving naloxone from the pharmacy. She placed medication in the resident's drawer; any medication overflow would be placed in the bottom drawer of the mediation cart. A current facility policy, dated 4/2017, titled Medication Administration, provided by the Administrator, on 7/3/25 at 3:37 p.m., indicate the following: Guidelines for medication administration: 1. Medications are administered to residents only as prescribed and only by person licensed or qualified to do so. 10. Always observe the six rights of giving each medication: right resident, right medicine, right time, right dose, right route, right documentation. 11. Read the label and MAR three times when preparing the medication This citation relates to Complaints IN00462642 and IN00462522. 3.1-25(b)(9)

Based on interview and record review, the facility failed to monitor vital signs per physician orders prior to giving medications for 3 of 3 residents reviewed. (Resident 24, 31, and 35) Findings include: 1. Resident 24's clinical record was reviewed on 8/27/24 at 9:45 a.m. Diagnoses included dementia, old myocardial infarction (heart attack), unspecified atrial fibrillation (rapid and irregular heart rate), and hypertension (high blood pressure). Resident orders included metoprolol tartrate (high blood pressure) 25 milligram (mg) tablet twice daily, hold if heart rate is below 60 and/or systolic blood pressure (top number) is below 120. A Consultant Pharmacist's Medication Regimen Review for May 2024, provided by the DON on 8/28/24 at 2:09 p.m., indicated the Medication Administration Report (MAR) showed that in the last couple of weeks, this dose was administered eight times when the residents systolic blood pressure was less than 120. Please make sure to hold when indicated. A Medication Administration Report (MAR), for June 2024, indicated the resident received metoprolol tartrate as follows: On June 4th a.m., with a systolic blood pressure of 80. On June 4th p.m., with a systolic blood pressure of 119. On June 7th p.m., with a systolic blood pressure of 104. On June 9th p.m., with a systolic blood pressure of 107. On June 13th a.m., with a systolic blood pressure of 87. On June 14th p.m., with a systolic blood pressure of 107. On June 15th a.m., with a systolic blood pressure of 106. On June 16th a.m., with a systolic blood pressure of 115. On June 19th a.m., with a systolic blood pressure of 114. On June 27th a.m., with a systolic blood pressure of 118. On June 29th a.m., with a systolic blood pressure of 104. On June 29th p.m., with a systolic blood pressure of 110. On June 30th a.m., with a systolic blood pressure of 100. A Medication Administration Report (MAR), for August 2024, indicated the resident received metoprolol tartrate as follows: On August 7th p.m., with a systolic blood pressure of 116. On August 11th p.m., with a systolic blood pressure of 113. On August 12th a.m., with a systolic blood pressure of 113. On August 13th a.m., with a systolic blood pressure of 112. On August 13th a.m., with a systolic blood pressure of 105. On August 16th p.m., with a systolic blood pressure of 118. On August 24th p.m., with a systolic blood pressure of 116. On August 25th a.m., with a systolic blood pressure of 93. Resident 24's comprehensive care plan, revised on 7/24/24, indicated she had a diagnosis of hypertension and is at risk for associated complication. Interventions included administering medications as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters, metoprolol per doctor order, monitor blood pressure and heart rate per order. 2. Resident 31's clinical record was reviewed on 8/27/24 at 11:08 a.m. Diagnoses included essential (primary) hypertension, unsteadiness on feet, unspecified atrial fibrillation (rapid and irregular heart rate), and unspecified tachycardia (rapid heartbeat). Resident orders included metoprolol tartrate (high blood pressure) 25 mg tablet twice daily, hold if heart rate is below 70. Cozaar (high blood pressure) 25 mg tablet once daily, hold for systolic blood pressure below 120. A Medication Administration Report (MAR), for June 2024, indicated the resident received losartan as follows: On June 1st, with a systolic blood pressure of 114. On June 22nd, with a systolic blood pressure of 118. A Medication Administration Report (MAR), for July 2024, indicated the resident received losartan as follows: On July 9th, with a systolic blood pressure of 115. On July 21st, with a systolic blood pressure of 118. On July 21st, with a systolic blood pressure of 118. A Medication Administration Report (MAR), for August 2024, indicated the resident received losartan as follows: On August 14th, with a systolic blood pressure of 119. On August 22nd, with a systolic blood pressure of 107. Resident 31's comprehensive care plan, revised on 7/30/24, indicated he had a diagnosis of hypertension and is at risk for associated complication. Interventions included administering medications as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters, administer losartan, and check blood pressure and heart rate. 3. Resident 35's clinical record was reviewed on 8/26/24 at 3:54 p.m. Diagnoses included dementia, heart failure, edema, essential (primary) hypertension, repeated falls, and multiple rib fractures. Resident orders included metoprolol succinate (high blood pressure) extended release 75 mg tablet once daily, hold if heart rate is below 60. A Medication Administration Report (MAR), for July 2024, indicated the resident received metoprolol succinate daily July 23rd through July 31st even though her heart rate was not recorded on the MAR. A Medication Administration Report (MAR), for August 2024, indicated the resident received metoprolol succinate daily August 7th through August 14th even though her heart rate was not recorded on the MAR. No vitals were recorded under vital signs from July 23rd through August 8th. Resident 35's comprehensive care plan, revised on 7/23/24, indicated she had a diagnosis of hypertension and is at risk for associated complication. Interventions included administering medications as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters. During an interview, on 8/29/24 at 12:02 p.m., LPN 5 indicated for the medications that are ordered with parameters, the computer requires the user to put in those parameters before being able to proceed to administer the medication. If a number is put in outside of the parameter, it will notify the user that it is out of range. The user would need to hit the okay button or cancel the administration altogether. When the user hits the cancel button, then she can put in that the medication was not administered due to condition. When the users clicks on the medication she wants to give it will pop up a box for vital signs if those are needed before administering the medication. Once those have been entered, the user would then click prep. You would then hit complete to indicate the medication was administered. It would be very difficult to accidentally administer the medication when the user has three steps to go through to finalize that the medication was given. On medications that require a blood pressure or heart rate, there is a red star where you must enter the vitals before it lets you proceed to the next step. During an interview, on 8/28/24 at 12:18 p.m., LPN 8 indicated the physician put parameters on certain medications like blood pressure or heart rate. The medication would be held if the vitals were not within the parameter range. She would click that the medication was not given and give a reason why it was held. During an interview, on 8/28/24 at 12:19 p.m., LPN 9 indicated she takes vitals on medications with parameters. If the vitals are not within the parameter range, she would hold the medication and indicate why the medication was not given. During an interview, on 8/29/24 at 3:36 p.m., the DON indicated an in-service on parameters was just completed for the nurses and the Qualified Medication Aides (QMA). They all verbalized they understood and will check vitals prior to administering medications. If they don't give a mediation, they will document a reason why it wasn't given. A current facility policy, revised 4/2017, titled Medication Administration, provided by the DON, on 8/29/24 at 2:04 p.m., indicated the following: .Purpose: To safely administer medications as per physicians' orders. 20. Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for 1 of 14 residents observed during dining on the secured unit. (Resident 35) Finding includes: During an observation, on 8/26/24 at 12:32 p.m., Resident 35 sat in her wheelchair at the dining table. Her chair was low in comparison to the table height and put the resident at chin level to the table. She took a bowl of food off her tray on the table and put the bowl in her lap to eat. During an observation, on 8/27/24 at 12:17 p.m., CNA 6 assisted the resident in her wheelchair to the dining table. The resident's chin was at the level of the table and close to the table edge. She reached up to the tray on the table to get some potato chips. During an observation, on 8/28/24 at 12:14 p.m., the resident sat at the dining table. Her chin was at table height. She reached up to get a food bowl from her tray and held it while eating. Resident 35's clinical record was reviewed on 8/26/24 at 3:54 p.m. Her diagnoses included Alzheimer's disease with late onset, dementia, visual hallucinations, depression, anxiety disorder, and abnormal weight loss. The current physician's orders included mirtazapine (for appetite stimulant) 7.5 mg daily at bedtime (started 5/7/24) and resident is to have all foods served in bowls at every meal (started 3/13/24). A significant change Minimum Data Set (MDS) assessment, completed on 6/28/24, indicated the resident was moderately cognitively impaired. She required supervision to touching assistance with eating and partial to moderate assistance with transfers. She had experienced a significant weight loss. A care plan for eating, initiated on 3/20/24 and last revised on 7/2/24, indicated the resident required staff assistance for meal consumption. The interventions included ensure resident is seated in an environment which will provide staff assistance and encourage meal consumption. During an interview, on 8/29/24 at 4:01 p.m., the DON indicated she was aware the resident sat a little low in her chair to the table. She thought they had tried a bedside table for dining but was uncertain if any other interventions had been attempted. During an interview, on 8/30/24 at 8:46 a.m., CNA 7 indicated the resident almost always sat at the regular dining table until today. A lower table had been brought into the dining room for her. The resident may have used a bedside table as her dining table at some time, but CNA 7 did not remember much about it. During an interview, on 8/30/24 at 8:47 a.m., LPN 5 indicated the resident had an order for her food to be placed in bowls so she could put in her lap because she sat low at the table. She had placed her plate in her lap prior to getting the bowls which made it difficult for her to eat. They had briefly tried to have her sit in a regular chair, but she stood up as soon as she was done with her meal and tried to leave. She was a fall risk, so the wheelchair was used to prevent falls. During an interview, on 8/30/24 at 11:16 a.m., the DON indicated she had spoken to the Administrator about the resident's seat height to the table height. They had not thought about it being an issue. During an interview, on 8/30/24 at 11:24 a.m., the Administrator indicated the facility did not have a policy on dining. 3.1-3(t) 3.1-3(v)(1)

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis. (Resident 12) Finding includes: Resident 12's clinical record was reviewed on 8/27/24 at 1:49 p.m. Diagnoses included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (1/20/23), schizophrenia (1/20/23), major depressive disorder (1/20/23), generalized anxiety disorder (4/28/23), psychotic disorder with delusions due to known physiological condition (5/31/23), and restlessness and agitation (5/31/23). Physician's orders included buspirone (antianxiety) 10 mg twice a day (started 8/13/24), lamotrigine (for schizophrenia) 25 mg twice a day (started 8/18/23), and olanzapine (antipsychotic) 15 mg twice a day (started 8/13/24). A care plan for physical behavior symptoms directed towards others, initiated on 5/11/23 and last revised on 8/8/24, indicated the resident exhibited physical behavioral symptoms directed towards others such as hitting and throwing things. Interventions included psychoactive medications as ordered which included lamotrigine and olanzapine. A care plan for delusions, initiated on 4/25/23 and last revised on 8/8/24, indicated the resident suffered from delusions due to schizophrenia as he believed there was a horse in his room that was trying to hurt him and his roommate, believed people are going to cut off his toes, and thought staff was out to get him. Interventions included notify nurse and social services for further evaluation and possible physician and resident representative notification and administer medications as ordered which included lamotrigine and olanzapine. A mood and behavior communication memo, dated 5/6/24 no time, indicated the resident thought people were out to get him and kill him. He thought someone was going to shoot him and isolated in his room due to those beliefs. A mood and behavior communication memo, dated 5/15/24 at 3:00 p.m., indicated the resident said the dietary personnel had poisoned his dinner the night before. A mood and behavior communication memo, dated 6/20/24 at lunch time, indicated the resident refused to come out of his room from lunch. He said someone one would kill him if he came out of his room with his work shirt on. A PASRR completed on 7/1/23 did not indicate the resident's current mental health diagnoses. During an interview, on 8/28/24 at 4:00 p.m., the DON indicated she would look for the most recent PASRR completed for the resident, including the application. Review of the PASRR Level 1 Screen Outcome, dated 8/29/24, provided by the Social Services Director on 8/29/24 at 10:38 a.m., indicated the Level 1 had been submitted on 8/28/24. The PASRR Level I Determination indicated a Level II evaluation must be conducted. During an interview, on 8/29/24 at 2:02 p.m., the Corporate Social Services Consultant indicated the facility did not have a policy for PASRR Level l. They followed the PASARR provider guidelines. During an interview, on 8/29/24 at 3:04 p.m., the Social Services Director indicated a new Level I had been submitted on 8/28/24 for the resident because she had noticed he had new psychological diagnoses that required an updated Level l. Review of the Indiana PASRR FAQs for providers [frequently asked questions], revised 2022, accessed on 9/3/24 at 9:48 a.m. at maximusclincalservices.com, indicated the following: .If a significant change in mental health status has occurred since the last approval, a new Level I screening is required When is Status Change review required? Whenever there is a change in the mental status of an individual, since the prior Level 1 review

Based on observation, record review, and interview, the facility failed to develop and implement individualized interventions to reduce physical aggression toward a resident (Resident 29) by a resident with dementia (Resident 23). Findings include: During an observation, on 9/29/23 at 8:50 a.m., Resident 23 was sitting in a wheelchair in the lounge with six other residents. Her clinical record was reviewed on 9/29/23 at 2:06 p.m. Diagnoses included, dementia, unspecified severity, with agitation, anxiety, depression, and psychotic disorder with delusions due to known physiological condition. Current physician orders included Rexulti (anti-psychotic), 1 mg (milligram) tablet once a day, with an order date of 6/21/23, Remeron (antidepressant), 15 mg tablet once a day at bedtime, with an order date of 8/22/23, and Zoloft (antidepressant), 100 mg tablet, take one and one-half tablets to equal 150 mg once a day, with an order date of 8/22/23. A 7/15/23 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment. She required supervision with bed mobility and transfers, and was independent with locomotion on and off the unit A current mental health service care plan, dated 11/20/20 with last revision date of 9/6/23, indicated she received mental health services due to depression, anxiety, delusions, hallucinations, and psychotic disorder with delusions. The goal indicated she would accept mental health services as ordered through next review. Interventions included, mental health services provided as ordered, continue to observe for significant change in mood/behavior such as crying, negative statements, isolation, change in daily routine, changes in eating or sleeping habits, etc., and notify physician and resident representative upon any significant change. A current physical behavioral symptoms directed towards others care plan, dated 8/14/22 with last revision date of 9/6/23, indicated she exhibited physical behavioral symptoms directed towards others such as hitting, kicking, pushing, and grabbing due to dementia with delusions. The goals indicated her behavior would not have a significant impact on self or others daily and interventions would be effective as evidenced by fewer episodes through next review. Interventions included, upon any signs and/or symptoms of agitation, don't begin care, if care had started and she became combative, stop care, ensure safety, and allow her to calm down, allow the resident time to calm and then re-approach, try to identify the immediate cause for the behavior, and limit distractions. A progress note, dated 6/9/23 at 7:49 p.m., indicated Resident 23 had been violent with staff and another resident, and had been difficult to redirect. She was taken to a nearby hospital by her family. A progress note, dated 6/10/23 at 1:37 a.m., indicated the hospital had noted her heart rate to be elevated in the 120s, had received intravenous medication, and was monitored. The resident was expected to return to the facility when her heart rate was stabilized. A progress note, dated 6/10/23 at 3:19 a.m., indicated a nurse from the hospital had called the facility to report the resident had become agitated when she had been told she would be returned to the facility. She hit and spat on staff and attempted to exit seek. The hospital delayed discharging her back to the facility and planned to have a psychological evaluation completed. A progress note, dated 6/21/23 at 2:43 p.m., indicated she had returned to the facility from a behavioral unit. A Mood and Behavior Communication Memo, dated 6/22/23 at 11:30 p.m., indicated she had the following behaviors: made negative statements, verbally and physically aggressive, socially inappropriate, and had delusions. She had been going into other resident's rooms going through their things, slamming doors, and fighting when she had been told she needed to leave the room. The interventions attempted included one on one provided with her, conversation of interest, and redirection. All were unsuccessful. A Mood and Behavior Communication Memo, dated 7/5/23 at 4:30 p.m., indicated she had the following behaviors: made negative statements, agitation, restlessness, and had been physically aggressive. She had grabbed a nurse's wrist and tried to twist it, and hit the nurse with a closed fist. The interventions attempted included one on one provided with her, conversation of interest, and redirection. All indicated they had all been unsuccessful. A progress note, dated 7/5/23 at 9:32 p.m., indicated she had tried to get out of the secure unit multiple times, argued and threatened to get physical with other residents, and hit a staff member. A Psychiatry NP (Nurse Practitioner) Progress Note, dated 7/13/23, indicated her delusional disorder was stable. Rexulti 1 mg daily was continued. Her dementia was severe, and appropriate behavioral interventions and psychotherapeutic communication were continued. A Mood and Behavior Communication Memo, dated 9/6/23 at 5:00 p.m., indicated she had the following behaviors: made negative statements, agitation, and physically and verbally aggressive. Staff assisted her with donning a clothing protector and she hit them in the face. The interventions attempted included toileting, changed position, provided fluids, provided relaxation techniques, walked with her, massage hand, shoulders and back, provided quiet environment, placed in chair and/or bed, provided an object to hold/manipulate, engaged in physical activity, provided snack, provided one on one with her, allowed her to vent her feelings, conversation of interest, activity of choice and interest, provided reassurance and comfort, called family for assistance, used humor, television and/or radio, provided pleasant pictures or photo album, time to calm/re-approach, redirection, as needed medication administered, managed pain, called physician, mental health services, hospitalized , repetitive activities of folding, sorting, stacking and rocking, validation of feelings and words, and report of concern completed. All interventions had been unsuccessful. A progress note, dated 9/19/23 at 11:35 p.m., indicated around 7:30 p.m., she had gotten angry because she had seen another resident with a stuffed dog, and yelled there were not supposed to dogs/animals here. She made her way towards resident's room while a CNA assisted him to bed. She was heard yelling and had become more angry, nurse attempted to talk with her, and the resident hit her twice when she attempted to remove her via the wheelchair from the other room. Ten minutes later, as the CNA assisted another resident for bed, Resident 23 approached them in her wheelchair. She was mean and yelling, and the nurse looked down the hall and saw the resident grab the other resident's right arm (Resident 29). The nurse ran to help the CNA, and the resident tried to bite and hit the nurse. The CNA got the other resident in the room and closed the door. The nurse tried to talk with her, but she was agitated and mean, and was following residents up and down the hall. Resident 23's family was notified and they took the resident to a nearby hospital. A progress note, dated 9/20/23 at 12:15 a.m., indicated she had returned to facility from the emergency room . No new orders had been received. During an interview, on 10/2/23 at 8:47 a.m., CNA 7 indicated Resident 23 got agitated easily, and had entered other resident's rooms and tried taking things from them. During an interview, on 10/2/23 at 8:49 a.m., CNA 5 indicated the resident was not always easily redirected when she had behaviors. During an interview, on 10/3/23 at 9:58 a.m., the Nurse Consultant indicated the resident had been to a behavioral unit a couple of times recently. During an observation, on 10/3/23 at 1:40 p.m., Resident 29 was lying in bed. Her clinical record was reviewed on 10/3/23 at 1:41 p.m. Diagnoses included age-related physical debility, dementia without behavioral disturbance, anxiety, and depression. Current physician orders included Zoloft 50 mg tablet, give with 100 mg tablet to equal 150 mg, daily for depression. A 7/15/23 significant change MDS assessment indicated she had severe cognitive impairment. She required supervision to transfer, walk in room, and with locomotion on the unit. She required limited assistance to walk in corridor and with locomotion off the unit. A current secure unit care plan, dated 10/15/21 with last revision date of 9/13/23, indicated she required placement on a secured unit due to Alzheimer's. The goal indicated she would continue to reside on the secured unit providing therapeutic environment as evidenced by the resident not wandering from the facility through next review. Interventions included, resident allowed to move about freely in the secured unit as long as the resident's safety is ensured. Her clinical record did not include information about her right arm having been grabbed by another resident, or any follow up related to possible psych-social harm resulting from the incident. During an interview, on 10/3/23 at 10:00 a.m., the Administrator indicated Resident 23 had not been involved in any resident to resident altercations. He considered any willful contact from one resident to another resident to be abuse, and since no residents had been harmed in any of the events, he didn't feel he needed to report them. Regarding the incident on 6/9/23, Resident 23 had been sent to the hospital because she had been difficult to re-direct and had normally been easy to re-direct. Regarding the incident on 7/5/23, the facility investigation determined there was no immediate threat and she had been easily re-directed. The investigation into the incident on 9/19/23 determined Resident 23 was trying to protect Resident 29. Review of 2023 online Alzheimer's Association education titled Treatments for Behavior, retrieved from https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior, indicated the following: .Non-drug approaches .Non-drug approaches to managing behavior symptoms promote physical and emotional comfort. Many of these strategies aim to identify and address needs that the person with Alzheimer's may have difficulty expressing as the disease progresses. Non-drug approaches should always be tried first. Steps to developing successful non-drug treatments include: Recognizing that the person is not just acting mean or ornery, but is having further symptoms of the disease. Identifying the cause and how the symptom may relate to the experience of the person with Alzheimer's 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure medication was secured after medication administration for 1 of 4 residents observed during medication administration (Resident 11). Finding includes: During an observation, on 10/3/23 at 9:55 a.m., Resident 11 was given his medications crushed in pudding, followed by sips of nectar thick liquid containing polyethylene glycol (laxative). The resident became fatigued while swallowing his medications and LPN 51 placed the cup of the remaining liquid containing the polyethylene glycol on the resident's bedside table, left the room, and pushed the medication cart down the hallway. During an interview, at the time of the observation, LPN 51 indicated she was leaving the cup containing the liquid and polyethylene glycol for the CNAs (certified nurse aides) to help the resident to drink later. During an interview, on 10/3/23 at 1:50 p.m., the DON indicated LPN 51 should have taken the cup of liquid with medication with her when she left the room. A current facility policy, revised 4/2017, titled Medication Administration, provided by the Corporate Clinical Nurse on 10/3/23 at 2:04 p.m., indicated the following: .Always observe the resident taking their medication(s). Never permit medication to remain in the resident's room. 3.1-25(m)

Based on record review and interview, the facility failed to ensure 1 of 7 residents reviewed for immunizations received a pneumococcal vaccination to remain up to date with pneumococcal vaccination (Resident 24). Finding includes: Resident 24's clinical record was reviewed on 9/29/23 at 3:40 p.m. His diagnoses included chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease of the coronary artery, and chronic kidney disease. An Informed Consent for Pneumococcal Vaccine form was signed by the resident's legal representative on 1/25/22. An Immunization/Mantoux Record, provided by the Administrator on 10/2/23 at 3:44 p.m., indicated the resident had received the pneumococcal 13-valent conjugate vaccine on 3/25/22. The form lacked documentation of a refusal or a medical contraindication for an additional pneumococcal vaccination. During an interview, on 10/2/23 at 4:08 p.m., the Administrator indicated the immunization records had been removed from the paper charts. Medical records staff had been entering the information in the electronic charts. The facility was having difficulty retrieving some of the information that had been entered into the electronic record. During an interview, on 10/3/23 at 9:40 a.m., the Administrator indicated he tracked the COVID-19 immunizations, and the DON tracked the other immunizations. During an interview, on 10/3/23 at 2:00 p.m., the DON indicated she utilized a spreadsheet to track the residents' immunizations. Resident 24 had received one pneumococcal vaccination and was due for another one. The facility had administered several pneumococcal 20-valent conjugate vaccines this past July. She was uncertain if Resident 24 had received the vaccine at that time. During an interview, on 10/3/23 at 2:25 p.m., the DON indicated the resident had been missed when the facility administered the pneumococcal 20-valent conjugate vaccines to the residents in July. An online reference titled Pneumococcal Vaccine Timing for Adults (3/15/23), retrieved on 10/3/23 from the Centers of Disease Control (CDC) website, indicated for adults [AGE] years old and older - if the pneumococcal 13-valent was the only prior pneumococcal vaccine received, then the pneumococcal 20-valent conjugate vaccine or the pneumococcal polysaccharide vaccine should be received at one year or greater after the prior vaccine to be up to date with pneumococcal vaccination. A current facility policy, dated 10/2015, provided by the Administrator on 9/27/23 at 11:00 a.m. during the facility entrance conference, titled Pneumococcal Disease Immunization, indicated .offer and vaccinate all residents against pneumococcal disease according to the guidelines set forth by state and federal regulations, unless medically contraindicated .If the vaccine is medically contraindicated or refused, this information must appear on the Immunization Record 3.1-13(a)

Based on record review and interview the facility failed to prevent physical abuse of a cognitively impaired resident resulting in bruising and skin tears for 1 of 3 residents reviewed for abuse. (Resident B). Finding include: The clinical record for Resident B was reviewed on 8/19/2022 at 9:49 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change Minimum Data Set (MDS) assessment, dated 7/21/22, was reviewed on 8/19/22 at 9:49 a.m. The MDS indicated Resident B was severely cognitively impaired. Review of the clinical record indicated the resident had a care plan for physical behavioral symptoms directed towards others. Interventions included upon any signs and/or symptoms of agitation, don't begin care. Review of the clinical record indicated the resident had a care plan for rejection of care. Interventions included upon signs/symptoms of agitation, do not begin or continue with care. Review of the clinical record indicated the resident had a care plan for bed mobility. The care plan indicated one to two staff members needed to provide care. During an observation on 8/19/22 at 10:55 a.m., Resident B was observed sitting in his wheelchair. The resident had bilateral bruising on the tops of his forearms and a bruise on the underside of his left forearm. The resident was unable to verbalize how he had gotten the bruises. During an interview on 8/19/22 at 11:40 a.m., CNA (Certified Nursing Assistant) 12 indicated Resident B had been known to have behaviors. When he is in pain he is kind of feisty. He calms down after he has his medicine. We always have 2 people to do his care. During an interview on 8/19/22 at 12:00 p.m., CNA 8 indicated she over heard a co-worker (CNA 11) mention something about a resident that she took as abuse. CNA 11 stated while providing care for Resident B alone, the resident had been fighting with him and the resident ended up with skin tears. CNA 11 stated That's what he gets. CNA 8 reported the concern to the Administrator immediately. During 2 separate interviews on 8/19/22 at 12:27 p.m. and 12:44 p.m., CNA 11 indicated on the evening of 8/16/22, he had been providing care to the resident alone. The resident was combative and had caused himself to get skin tears when he made contact with the side rails. CNA 11 indicated he was dodging blows and working quickly. CNA 11 indicated he could have walked away but he did not want to leave the resident half dressed. CNA 11 did not seek out help from another staff member and indicated the resident may have been calmer after his medication. During an interview on 8/19/22 at 1:02 p.m., LPN 17 indicated on the evening of 8/16/22 she heard Resident B yelling. She went to investigate and found CNA 11 leaving the resident's room. She asked CNA 11 what was going on and CNA 11 stated, I don't know. He is crazy. and walked away. LPN 17 indicated when she spoke with the resident he was too upset to tell her why he was upset. LPN 17 indicated she looked at the resident and did not see any injury. She indicated the resident calmed down after he had his evening medication. During an interview on 8/19/22 at 1:58 p.m., CNA 19 indicated at the end of the shift she heard CNA 11 tell the nurse Resident B had skin tears and had been fighting him while he was putting the resident to bed. This Federal tag relates to Complaint IN 182. 3.1-27(a)(1)

Based on record review and interview, the facility failed to complete Preadmission Screening and Resident Review (PASRR) for residents newly diagnosed with mental illness for 4 of 7 residents reviewed for PASRR (Residents 19, 5, 31, and 33). Findings include: 1. Resident 19's clinical record was reviewed on 8/8/22 at 10:22 a.m. Diagnoses included, but were not limited to, depression, dementia, delusional disorder, [CONDITION(S)] disorder. She had a current, 7/29/21, care plan problem of delusions and hallucinations of things being wet such as her bed, blanket, briefs, or pants and the belief she was dying. Review of a PASRR level 1 assessment, dated 11/10/19, did not indicate mental health diagnoses were present. The assessment was not repeated after she was diagnosed with schizoaffecitve disorder on 7/29/21. 2. Resident 5's clinical record was reviewed on 8/9/22 at 10:37 a.m. Diagnoses included, but were not limited to, chronic systolic heart failure, dementia with behaviors, major depressive disorder, expressive language disorder, [CONDITION(S)] disorder, and mood disorder. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an 8/24/21 PASRR Level 1 assessment indicated he had depression and dementia. He was prescribed [MEDICATION(S)] and [MEDICATION(S)] for depression. He had no diagnoses related to [CONDITION(S)] disorder. During an interview, on 8/12/22 at 10:16 a.m., the Social Service Director indicated the residents had not had a new Level 1 PASRR assessment completed when they had been diagnosed with mental illness. 3. During an observation, on 8/9/22 at 1:56 p.m., Resident 31 was lying in bed. On 8/10/22 at 9:51 a.m., she was lying in bed. On 8/11/22 at 8:58 a.m., she was sitting in a wheel-chair in the dining room. Her clinical record was reviewed on 8/9/22 at 11:16 a.m. She had admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety, delusional disorder, psychotic disorder with hallucinations and [CONDITION(S)] disorder. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (anti-anxiety) 5 mg, one tablet three times a day for anxiety, the order date was 2/16/22. b. [MEDICATION(S)] (anti-psychotic) 0.5 mg (milligram), one tablet at bedtime for psychotic disorder with hallucinations, the order date was 2/22/2. A 7/1/22 quarterly MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and had not had any behaviors during the assessment period. She had received an anti-psychotic and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR (Gradual Dose Reduction). A current care plan, with a revised date of 8/8/22, indicated she exhibited verbal behavioral symptoms directed towards others such as, threatening others, screaming at others, cursing at others and name calling. Interventions included, but were not limited to, attempt to use diversion, distraction and reorientation to calm her, such as singing and talking with staff. A current care plan, with a revised date of 8/8/22, indicated she suffered from delusions (fixed false beliefs) due to dementia as evidenced by false beliefs building was on fire, a gas leak and son was her spouse. Interventions included, but were not limited to, gently explain that belief was false and introduce evidence to prove why it was not true and administer medications as ordered. A Social Service Assessment, dated 6/10/22, indicated psychotic disorder with hallucinations, anxiety, recurrent depressive episodes, Alzheimer's disease and attention/concentration deficit. Behavioral symptoms and and care plan implementation to address behaviors: delusional disorders and confusion. Care plans reviewed and updated. A progress note, dated 6/15/22 at 4:00 p.m., indicated a new order to add a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Psychiatry Progress Note, dated 6/28/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Behavioral and psychological symptoms of dementia: history of visual hallucinations and delusional thoughts that cause fear, tearfulness and anxiety, none recently reported, symptoms appeared stable and continue [MEDICATION(S)] 0.5 mg every bedtime. A mood and behavior communication memo, dated 7/19/22 at 2:00 p.m., indicated crying/tearfulness and wanted to go home. One on one was provided with her as well as reassurance and comfort, the interventions did not change the mood or behavior. A Psychiatry Progress Note, dated 7/20/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. [CONDITION(S)] disorder: GDR- after reviewing current medication therapy as well as recent behaviors and discussion with DON (Director of Nursing), pharmacy, Administration, and Social Services, contraindicating any dose reduction of [MEDICATION(S)] as a reduction would likely increase symptoms of [CONDITION(S)] and anxiety, continued to have delusional thoughts about rats getting her that caused hear and anxiety. Delusional thoughts were less frequent. A mood and behavior communication memo, dated 7/20/22 from 6:00 to 10:00 p.m., indicated she had disturbed other residents by yelling out about seeing rats and worried about children playing in the street. Had been provided snacks and water, toileted, relaxation techniques, quiet environment, one on one, conversation of interest, time to calm then re-approach and redirection. Possible trigger: urinalysis results indicated an urinary tract infection, physician to be notified on 7/21/22. A Psychiatry Progress Note, dated 7/26/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Anxiety: symptoms appear stable, continue [MEDICATION(S)] 5 mg three times a day. [CONDITION(S)] disorder: symptoms appeared stable, continue [MEDICATION(S)] 0.5 mg every bedtime. During an interview, on 8/12/22 at 8:46 a.m., RN 14 indicated the resident usually sang and made happy noises, had yelled out that the building was on fire, re-directing and distracting her usually helped. During an interview on 8/12/22 at 9:09 a.m., the Social Service Director indicted a PASRR (Preadmission Screening and Resident Review) referral for an evaluation and determination related to the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4. During an observation, on 8/9/22 at 3:16 p.m., Resident 33 was sitting in a chair in the lounge across from the nurses' station. On 8/11/22 at 8:56 a.m., he was assisted out of the shower room and into the lounge area. His clinical record was reviewed on 8/9/22 at 10:43 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, physical aggression, depression, anxiety and [CONDITION(S)] disorder. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 10 mg, one tablet three times a day for anxiety, the order date was 8/24/21. b. [MEDICATION(S)] 1 mg, one tablet twice a day for dementia with behavioral disturbance, the order date was 9/28/21. c. [MEDICATION(S)] (anti-depressant) 25 mg, one tablet daily along with a [MEDICATION(S)] 50 mg tablet to equal 75 mg daily for depression, the order date was 6/15/22. A 7/1/22 quarterly MDS assessment indicated he had severe cognitive impairment. He had not had any hallucinations or delusions during the assessment period. Physical behavioral symptoms directed towards others and rejection of care had occurred 1 to 3 days during the assessment period. He had received an anti-psychotic, anti-depressant and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR. A current care plan, with a revised date of 7/13/22, indicated he was at risk for [CONDITION(S)] or acute confusion related to dementia and [CONDITION(S)] disorder as evidenced by inattention, disorganized thinking and altered level of consciousness. The interventions included, but were not limited to, monitor for signs or symptoms of [CONDITION(S)] such as: inattention, disorganized thinking, altered level of consciousness, psycho-motor [CONDITION(S)] and acute confusion and administer medications as ordered. A current care plan, with a revised date of 714/22, indicated he required the use of an anti-psychotic medication, [MEDICATION(S)], to treat dementia with behaviors and [CONDITION(S)] disorder. Interventions included, but were not limited to, observe for change in mood or behavior. A current care plan, with a revised date of 8/8/22, indicated he presented with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, encourage activities of interest such as: (List). The care plan did not list activities of interest. A current care plan, with a revised date of 8/8/22, indicated he exhibited physical behavioral symptoms directed towards others such as: pushing, grabbing and hitting others. Interventions included, but were not limited to, [CONDITION(S)] medications as ordered. A progress note, dated 6/15/22 at 4:00 p.m., indicated a new order to add a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Social Service Assessment, dated 6/15/22, indicated [CONDITION(S)] disorder, dementia with behavioral disturbance, physical aggression, depression and anxiety. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A Psychiatry Progress Note, dated 6/15/22, indicated no behaviors or [CONDITION(S)] reported since last visit, no new concerns had been reported and appeared stable from a psychiatric standpoint. [CONDITION(S)] disorder: symptoms appear stable, continue [MEDICATION(S)] 1 mg twice a day. During an interview, on 8/12/22 at 8:47 a.m., RN 14 indicated his behaviors were rejection of care, especially with incontinent care. During an interview, on 8/12/22 at 9:30 a.m., the Social Service Director indicated he did not have delusions, he did have aggression with care and rejection of care. A PASRR referral for an evaluation and determination related to the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of frequently asked questions related to Indiana PASRR for providers, located on website https://maximusclinicalservices.com/sites/default/files/pasrr/documents/IN%20PASRR%20FAQ_S% 1%20-%204.21.21.pdf and dated 2020, indicated .22. When is a new Level I needed for a NF resident who admitted with a negative Level I PASRR approval? A negative Level I review is valid indefinitely, as long as there has been no change in mental health status

Based on observation, interview and record review, the facility failed to ensure residents had access to call lights for 3 of 3 residents reviewed for accommodation of needs (Residents 189, 2 and 35). Findings include: 1. During and observation, on 8/9/22 at 8:39 a.m., Resident 139 was lying in a low bed, the call light was under the low bed. On 8/9/22 at 1:39 p.m., she was lying in bed against the assist rail, the call light was in the waste-basket and not within her reach. The resident's clinical record was reviewed on 8/9/22 at 10:36 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 7/19/22 admission MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and was totally dependent with bed mobility and toilet use. During an interview, on 8/10/22 at 8:48 a.m., LPN 7 indicated the resident was able to use the call light to ask for assistance. 2. During an interview, on 8/8/22 at 1:37 p.m., Resident 2 was in his room in his wheelchair. He indicated he was waiting for his therapy session. His call light was secured to the bed behind him, out of his reach. He indicated he would have called to see when the therapist was coming, but he could not reach the call light. He couldn't transfer himself or propel the wheelchair due to weakness. On 8/8/22 at 1:42 p.m., COTA 34 entered the room and assisted the resident to the therapy room. Review of Resident 2's clinical record was completed on 8/8/22 at 2:10 p.m. A 4/15/22, quarterly, Minimum Data Set (MDS) assessment indicated he was cognitively intact and was dependent for transfers and locomotion. 3. During a care observation, on 8/10/22 at 11:03 a.m., Resident 35 was in bed. His call light was secured to the right side of his bed, while the resident was propped with pillows on his left side. During an interview, at the time of the observation, RN 35 indicated the resident was capable of using his call light, and it should have been kept in reach. Resident 35's clinical record was reviewed on 8/9/22 at 11:25 a.m. A 7/4/22, quarterly, MDS assessment indicated he was moderately cognitively impaired and required extensive assistance with bed mobility. Review of a current facility policy titled CALL LIGHT, dated 10/2014 and provided by the Administrator on 8/12/22 at 8:45 a.m., indicated the following: .Resident will have a call light to summon facility personnel to ensure the resident's needs will be met .Resident's call light is to be within reach 3.1-3(v)(1)

Based on record review and interview, the facility failed to ensure a resident's advance directive was reviewed and signed by the resident or representative for 1 of 16 reviewed for advance directives in the initial pool (Resident 23). Findings include: Resident 23's clinical record was reviewed on 8/8/22 at 10:27 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a current, signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 8/12/22 at 9:29 a.m., the Admission Coordinator indicated Advance Directives were kept in the resident charts. During an interview, on 8/12/22 at 1:30 p.m., the Administrator indicated the resident's representative had filled out the information on the form for 1st and 2nd choice contacts, but had apparently forgotten to sign the form. Review of a current facility policy titled Advance Directive, dated 1/2015 and provided by the Administrator on 8/12/22 at 1:05 p.m. indicated the following: .When presented with an Advance Directive document, the facility shall verify the attending physician has a copy of the document and shall place a copy .as well as on the resident's clinical record in the nurses station 3.1-4(l)(4)(A)(ii)

Based on interview and record review, the facility failed to accurately screen for mental disorders prior to admission for 1 of 7 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Resident 40) Findings include: Resident 40's clinical record was reviewed on 8/11/22 at 11:06 a.m. Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A social history and psychosocial assessment dated [DATE] lacked documentation of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current psychoactive medication section was blank. Progress notes dated 6/2/2022 from the Nurse Practitioner (NP) indicated [MEDICATION(S)] 50 mg daily was ordered. A social service assessment dated [DATE] lacked documentation of the [MEDICATION(S)] order. The PASARR with a review date of 6/3/22 listed a medication order for [MEDICATION(S)] (antianxiety) oral liquid 0.5 mg as discontinued under the mental health medications and lacked an entry for [MEDICATION(S)]. An interdisciplinary care plan conference record dated 6/6/22 listed [MEDICATION(S)] under psychoactive medications and lacked documentation of the [MEDICATION(S)] order. During an interview, on 8/11/22 at 2:11 p.m., the Social Services Director indicated she vaguely remembered Resident 40. She indicated she did not remember the resident's [MEDICATION(S)] order. The PASARR lacked documentation of the physician's [MEDICATION(S)] order. During an interview, on 8/12/22 at 10:38 a.m., the Nurse Consultant indicated the facility did not have a facility PASARR policy and used the state guidelines. 3.1-16(d)

Based on observation, record review and interview, the facility failed to identify and implement individualized, non-pharmacological interventions for residents with expressions of behavior for 3 of 4 residents reviewed for dementia care (Residents 31, 33 and 5). Findings include: 1. During an observation, on 8/9/22 at 1:56 p.m., Resident 31 was lying in bed. On 8/10/22 at 9:51 a.m., she was lying in bed. On 8/11/22 at 8:58 a.m., she was sitting in a wheel-chair in the dining room. Her clinical record was reviewed on 8/9/22 at 11:16 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (anti-anxiety) 5 mg, one tablet three times a day for anxiety, the order date was 2/16/22. b. [MEDICATION(S)] (anti-psychotic) 0.5 mg (milligram), one tablet at bedtime for psychotic disorder with hallucinations, the order date was 2/22/22. A 7/1/22 quarterly MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and had not had any behaviors during the assessment period. She had received an anti-psychotic and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR (Gradual Dose Reduction). A current care plan, with a revised date of 8/8/22, indicated she exhibited verbal behavioral symptoms directed towards others such as, threatening others, screaming at others, cursing at others and name calling. Interventions included, but were not limited to, attempt to use diversion, distraction and reorientation to calm her, such as singing and talking with staff. A current care plan, with a revised date of 8/8/22, indicated she suffered from delusions (fixed false beliefs) due to dementia as evidenced by false beliefs building was on fire, a gas leak and son was her spouse. Interventions included, but were not limited to, gently explain that belief was false and introduce evidence to prove why it was not true and administer medications as ordered. A mood and behavior communication memo, dated 4/24/22 at 1:00 a.m., indicated she had made repetitive verbalizations and hallucinations, thought there was a dog and kept yelling for the dog. Interventions attempted included toileting, provided liquids, quiet environment, snack, allowed her to vent her feelings and provided her reassurance and comfort, the behavior was unchanged. A mood and behavior communication memo, dated 5/9/22 at 4:00 a.m., indicated she had made negative statements, repetitive verbalizations and hallucinations she was getting bit by rats. Interventions attempted included toileting, placed in chair or bed and given time to calm and then re-approached, the behavior was unchanged. A mood and behavior communication memo, dated 5/19/22 at 3:00 a.m., indicted she had made negative statements, restlessness, repetitive verbalizations, repetitive concerns, verbally aggressive, rejection of care, socially inappropriate, hallucinations and delusions. She had refused to go to the bathroom, interventions attempted included provided relaxation technique and quiet environment, one on one, allowed her to vent feelings and redirection, the behavior was unchanged. A Social Service Assessment, dated 6/10/22, indicated psychotic disorder with hallucinations, anxiety, recurrent depressive episodes, Alzheimer's disease and attention/concentration deficit. Behavioral symptoms and and care plan implementation to address behaviors: delusional disorders and confusion. Care plans reviewed and updated. A Psychiatry Progress Note, dated 6/28/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Behavioral and psychological symptoms of dementia: history of visual hallucinations and delusional thoughts that cause fear, tearfulness and anxiety, none recently reported, symptoms appeared stable and continue [MEDICATION(S)] 0.5 mg every bedtime. A mood and behavior communication memo, dated 7/19/22 at 2:00 p.m., indicated crying/tearfulness and wanted to go home. One on one was provided with her as well as reassurance and comfort, the interventions did not change the mood or behavior. A Psychiatry Progress Note, dated 7/20/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. [CONDITION(S)] disorder: GDR- after reviewing current medication therapy as well as recent behaviors and discussion with DON (Director of Nursing), pharmacy, Administration, and Social Services, contraindicating any dose reduction of [MEDICATION(S)] as a reduction would likely increase symptoms of [CONDITION(S)] and anxiety, continued to have delusional thoughts about rats getting her that caused hear and anxiety. Delusional thoughts were less frequent. A mood and behavior communication memo, dated 7/20/22 from 6:00 to 10:00 p.m., indicated she had disturbed other residents by yelling out about seeing rats and worried about children playing in the street. Had been provided snacks and water, toileted, relaxation techniques, quiet environment, one on one, conversation of interest, time to calm then re-approach and redirection. Possible trigger: urinalysis results indicated an urinary tract infection, physician to be notified on 7/21/22. A Psychiatry Progress Note, dated 7/26/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Anxiety: symptoms appear stable, continue [MEDICATION(S)] 5 mg three times a day. [CONDITION(S)] disorder: symptoms appeared stable, continue [MEDICATION(S)] 0.5 mg every bedtime. During an interview, on 8/12/22 at 8:46 a.m., RN 14 indicated the resident usually sang and made happy noises, had yelled out that the building was on fire, re-directing and distracting her usually helped. Cross Reference F644 2. During an observation, on 8/9/22 at 3:16 p.m., Resident 33 was sitting in a chair in the lounge across from the nurses' station. On 8/11/22 at 8:56 a.m., he was assisted out of the shower room and into the lounge area. His clinical record was reviewed on 8/9/22 at 10:43 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 10 mg, one tablet three times a day for anxiety, the order date was 8/24/21. b. [MEDICATION(S)] 1 mg, one tablet twice a day for dementia with behavioral disturbance, the order date was 9/28/21. c. [MEDICATION(S)] (anti-depressant) 25 mg, one tablet daily along with a [MEDICATION(S)] 50 mg tablet to equal 75 mg daily for depression, the order date was 6/15/22. A 7/1/22 quarterly MDS assessment indicated he had severe cognitive impairment. He had not had any hallucinations or delusions during the assessment period. Physical behavioral symptoms directed towards others and rejection of care had occurred 1 to 3 days during the assessment period. He had received an anti-psychotic, anti-depressant and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR. A current care plan, with a revised date of 7/13/22, indicated he was at risk for [CONDITION(S)] or acute confusion related to dementia and [CONDITION(S)] disorder as evidenced by inattention, disorganized thinking and altered level of consciousness. The interventions included, but were not limited to, monitor for signs or symptoms of [CONDITION(S)] such as: inattention, disorganized thinking, altered level of consciousness, psycho-motor [CONDITION(S)] and acute confusion and administer medications as ordered. A current care plan, with a revised date of 7/14/22, indicated he required the use of an anti-psychotic medication, [MEDICATION(S)], to treat dementia with behaviors and [CONDITION(S)] disorder. Interventions included, but were not limited to, observe for change in mood or behavior. A current care plan, with a revised date of 8/8/22, indicated he presented with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, encourage activities of interest such as: (List). The care plan did not list activities of interest. A current care plan, with a revised date of 8/8/22, indicated he exhibited physical behavioral symptoms directed towards others such as: pushing, grabbing and hitting others. Interventions included, but were not limited to, [CONDITION(S)] medications as ordered. A Social Service Assessment, dated 6/15/22, indicated [CONDITION(S)] disorder, dementia with behavioral disturbance, physical aggression, depression and anxiety. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A Psychiatry Progress Note, dated 6/15/22, indicated no behaviors or [CONDITION(S)] reported since last visit, no new concerns had been reported and appeared stable from a psychiatric standpoint. [CONDITION(S)] disorder: symptoms appear stable, continue [MEDICATION(S)] 1 mg twice a day. A mood and behavior communication memo, dated 7/25/22 at 7:40 p.m., indicated he had been found in another resident's room and had been incontinent of bowel movement, uncooperative with care, was combative hitting staff and resisting shower, it took two CNA's to complete the shower and assist him to bed. A mood and behavior communication memo, dated 7/28/22 at 9:20 p.m., indicated he had removed his brief, staff attempted to put it back on him, and he punched staff in the arm, behavior unchanged after interventions attempted. A mood and behavior communication memo, dated 8/6/22 at 10:00 p.m., indicated he had been sleeping in a chair, staff woke him to offer toileting and he became physically aggressive, tried to assist him to bed, he refused to sit anywhere, had a bowel movement and refused to be changed, there had only been one staff member on the secure unit, interventions had been attempted but behavior was unchanged. During an interview, on 8/12/22 at 8:47 a.m., RN 14 indicated his behaviors were rejection of care, especially with incontinent care, give him time to calm the re-approach or change staff member typically was effective. During an interview, on 8/12/22 at 9:30 a.m., the Social Service Director indicated he did not have delusions, he did have aggression with care and rejection of care. Cross Reference F644 3. On 8/9/22 at 11:26 a.m., Resident 5 was in his wheelchair in room, chin to chest. On 8/10/22 at 8:43 a.m., he was in his recliner in his room with his eyes closed, holding a cup in his left hand halfway to his mouth and a spoon in his right hand. On 8/10/22 at 1:45 p.m., he was in his recliner, asleep. On 8/11/22 at 10:15 a.m. he was asleep in bed with the room dark. On 8/12/22 at 8:07 a.m., he was up in his wheelchair in the dining area, eating breakfast. Resident 5's clinical record was reviewed on 8/9/22 at 10:37 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/20/22, quarterly, MDS assessment indicated he was severely cognitively impaired and had a fluctuating behavior of disorganized thinking. He had no [CONDITION(S)], but had verbal and physical behaviors 1-3 days of the assessment period. He required extensive assistance for mobility, transfers and hygiene. He had a current care plan problem, reviewed 8/8/22, of rejection of care such as medication, treatments, ADL assistance, and bathing. Interventions included, but were not limited to, approach from the front in a calm manner, call the resident by his name, explain the purpose of the visit, allow time to calm down and reapproach as needed, praise efforts, attempt to determine the reason for rejection and seek solutions if able, and limit distractions. The care plan lacked individualized interventions for the resident. A current care plan problem, reviewed 8/8/22, indicated he had agitation and aggression. Interventions included, but were not limited to, talk about vintage cars he has restored. A current care plan problem, reviewed 8/8/22, indicated he had physical behaviors of hitting. Interventions included, but were not limited to, allow to calm down, music, massage or exercise to calm, praise compliance, and psychiatric medications as ordered. The care plan lacked individualized interventions for the resident. A current care plan problem, reviewed 8/4/22, indicated he required the use of antipsychotic medication to treat dementia with behaviors and agitation/PBSD (psychological and behavioral symptoms of dementia). He had a failed dose reduction on 7/20/22. A current 8/8/22 care plan for daily preferences indicated it was somewhat important to the resident to have his daily preferences honored. He preferred to sleep in and go to bed at 11:00 p.m. A review of nurses notes and behavior memos indicated the following: On 5/3/22, he refused his medications. On 5/4/22, he spit out his medications. On 5/7/22, he struck staff in the face when they were removing his foot pedals. They went to get other staff to help lay him down and he tried hitting them as well. On 5/8/22 at 5:30 p.m., he started swinging at an aide while getting him ready for bed and was inches from hitting aide in the face. On 5/9/22, he was swinging at an aide, and kicking at her as well, during care. On 5/18/22, an order was received to decrease the desvenlafax to 50 mg daily. On 5/24/22, he was using expletives and hitting and kicking while staff was putting him to bed at 6:45 p.m. He eventually calmed down and allowed assist to bed and fell asleep. On 5/26/22 at 8:20 p.m., he refused his medications, and was balling up his fists and lunging forward. He attempted to knock the spoon of medications out of the nurses hand. A CNA took him to his room to put him to bed per his request, but he hit staff in the chest. A call was placed to the psychiatric nurse practitioner and a discussion was held regarding an inpatient psychiatric stay versus sending him to the emergency department. As of 9:30 p.m., he had been sitting in his room and had calmed down. When asked if he wanted to lay down, he yelled no. The behavior memo indicated the [MEDICATION(S)] was increased following a failed dose reduction. On 5/26/22 at 8:30 p.m., he had a behavior of hitting a staff member, refusing medications, and being verbally and physically aggressive. He refused to be assisted to bed. On 6/2/22, he refused his morning medications and raised his hand in a threatening manner and refused his bedtime medications. On 6/7/22, he hit a CNA in the stomach multiple times, squeezed a CNA's wrist and told the CNAs he was going to kill them. A 6/15/22 pharmacist note to the prescriber indicated the resident had dementia and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The document was signed by the NP with the notation he had psychological and behavioral symptoms of dementia. On 6/15/22, the [MEDICATION(S)] was changed to 25 mg twice daily and the [MEDICATION(S)] was increased to 500 mg three times daily. On 6/18/22, he threw a water cup on staff during medication pass and refused his medications except the one for pain. On 7/13/22, he refused his bedtime medications and was agitated. On 7/7/22, he refused a shower or to get up. He swung on staff and hit her in face when gotten up for lunch. When the same staff member went to put him in his room after lunch, he tried to hit her again. On 7/13/22, he refused his bedtime medications. On 7/14/22, he refused a shower and ADL care; he indicated he was tired and in pain. A 7/20/22 psychiatric NP note indicated an acute visit for increased physical aggression since the reduction of [MEDICATION(S)] (on 6/15/22). He had no delusions or hallucinations. His symptoms of depression benefited from the [MEDICATION(S)], and was increased to 25 mg in a.m. and 50 mg at bedtime and he was to continue the [MEDICATION(S)]. His current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/22, he refused his bedtime medications. On 7/23/22, he was kicking and punching staff during cares. On 7/24/22, he hit a CNA in the chest during cares. A 7/26/22 psychiatric NP note indicated he had been combative and refused to eat or take his medications over the past week. He had no delusions or hallucinations. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/22, he refused restorative exercises. An 8/4/22 wound assessment indicated he had a 2.5 centimeter (cm) long (L) x 2.3 cm width (W) x 0.1 cm depth (D) abrasion to his right foot with a small serous exudate with slough and irregular edges. An 8/4/22 wound assessment indicated he had a 1.2 cm L x 1.3 cm W x 0.3 cm D skin tear to his right lateral foot with serous exudate and a yellow wound bed. On 8/9/22, he became physical during a shower and bit a CNA. The note indicated three CNAs were present during the shower. During an interview, on 8/12/22 at 9:02 a.m., CNA 31 indicated Resident 5 did not have any delusions or hallucinations, but did have lots of behaviors. He did not want to do things because of pain, but the nurses say they're managing his pain. Sometimes if you told him his family was coming to visit, he would allow care to be done. Other times, he just needed re-approached. During an interview, on 8/12/22 at 9:07 a.m., CNA 32 indicated the resident was confused. When he was approached about getting dressed, he would initially be okay with it, then he would change his mind. His foot wounds would upset him, and then he would become resistant to care. A lot of it was just his personality. During an interview, on 8/12/22 at 9:10 a.m., LPN 33 indicated the resident could sometimes is resistant to care and he may be grumpy and not get along with others. She was not aware of him seeing or hearing things. He may cuss you one minute, then smile and love you the next. During an interview, on 8/12/22 at 9:30 a.m., the SSD indicated the resident would cry at times, or think he was still in his old times. He would think his family was at the facility when they weren't or he had done things he shouldn't have. She was not aware of what the resident's signs of dementia were versus what his signs and symptoms of [CONDITION(S)] disorder were. He received the anti-psychotic medication for [CONDITION(S)] disorder. Review of a current facility policy titled ANTIPSYCHOTIC MEDICATION/GRADUAL DOSE REDUCTION, dated September 2017 and provided by the Nurse Consultant on 8/12/22 at 10:38 a.m., indicated the following: .Since diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .The symptoms are identified as being due to [CONDITION(S)] or [CONDITION(S)] .delusions .The behavioral symptoms present a danger to the resident or to others .The symptoms are significant enough that the resident is experiencing one or more of the following: inconsolable or persistent distress .a significant decline in function; and/or substantial difficulty receiving needed care 3.1-37(a)

Based on observation, record review and interview, the facility failed to provide adequate supervision and appropriate interventions to prevent falls for residents with a history of falls for 2 of 3 residents reviewed for falls (Residents B and D). This deficient practice resulted in Resident B sustaining a fracture of the fibular neck. Findings include: 1. On 9/22/21 at 1:42 p.m. Resident B was observed sitting in her wheelchair in her room watching television. On 9/23/21 at 1:40 p.m. a staff member from the therapy department was talking to her while she sat in her wheelchair in her room. Resident B's clinical record was reviewed on 9/22/21 at 9:46 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, [CONDITION(S)], [CONDITION(S)] disease, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), major depressive disorder, hypertension, anxiety disorder, [CONDITION(S)], dementia and mood disorder. Her medications included, but were not limited to, [MEDICATION(S)] (cognition enhancement) 5 milligram (mg) daily, lorazepam (anti-anxiety) 0.5 mg daily in the evening, [MEDICATION(S)] 240 mg daily, [MEDICATION(S)] (blood pressure) 10 mg daily, [MEDICATION(S)] (sleep) 3 mg daily, [MEDICATION(S)] (cognition enhancement) 14 mg daily, [MEDICATION(S)] (steroid)10 mg daily, [MEDICATION(S)] (anti-depressant) 125 mg daily , [MEDICATION(S)] (nerve pain) 300 mg three times daily, [MEDICATION(S)] (blood pressure) 10 mg three times daily, [MEDICATION(S)] 50 mg three times daily, lorazepam 0.25 mg daily in the morning. She had an order for two half siderails up for bed mobility. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was moderately cognitively impaired. She required extensive assistance for bed mobility and locomotion on and off the unit. She required extensive assistance with two staff members for transfers and toileting. She had an impairment to her bilateral lower extremities. She used a wheelchair. She had no falls since admission or the prior assessment, which ever was most recent. A chair alarm was used daily. The fall risk assessments, dated 4/7/21, 6/11/21, 6/22/21 and 7/23/21, indicated she was at risk for falls. She had a fall care plan, revised on 8/26/21. Her goal was her risk factors would be identified and appropriate interventions implemented and revised as necessary in an attempt to avoid significant injury related to falls through the next review. Her individualized interventions included, but were not limited to, change bed, chair alarm, dycem to wheelchair, tilt wheelchair seat and staff to assist with tidying up her room. Her nurses notes indicated she had, but was not limited to, the following falls and care plan interventions: On 6/10/21 at 11:00 p.m., she was noted to be on the floor of the right side of her bed laying on her back. The bed was in the lowest position. She stated she was trying to find the crinkles in her bed, staff was to ensure bedding was at residents liking at each bed check. The intervention was mats to be placed at beside bed bilaterally. On 6/21/21 at 3:00 p.m., she was found on the floor on the bedside mat, no injuries were noted. She complained of bilateral knee pain. The intervention was to place a table by her bed for her phone. On 7/21/21 at 7:00 p.m., she had shower. Staff notified nurse that an incident occurred before shower causing bruising and hematoma. Area measuring 7 centimeter (cm) x 13 cm. Resident denied pain at this time. An Accident and Incident report and investigation, dated 7/21/21 at 4:10 p.m. indicated a walker had fell on to top of the resident's right leg/foot while she was taken from her room in her wheelchair to dinner, no redness/swelling was noted to top area at this time. The walker was removed from the room and taken back to the therapy department. Her leg was elevated and an ice pack applied to the area. A golfball sized hematoma was noted by the evening shift nurse. On 7/22/21 at 10:40 a.m., she was found on the floor in her room. She had a skin tear to her right knee. The intervention was toileting every two hours. On 7/23/21 at 3:00 p.m., she continued to complain of pain to her left lower extremity and x-rays were completed. A new order was received to send her to the hospital for evaluation and treatment due to the left lower extremity after accidental trauma and fall, pain and unwilling/unable to bear weight. The emergency room notes, dated 7/23/21, indicated x-rays were completed of the left tibia-fibia and left ankle, the impression was an acute minimally displaced fibular head and neck fracture. Smooth cortical irregularity in the distal fibula consistent with healed prior fracture. An x-ray of the left knee was completed, the impression was acute nondisplaced fracture of the fibular neck. During an interview with the DON, on 9/23/21 at 1:49 p.m., she indicated Resident B was working on standing and strengthening with therapy and her health had gone back and forth. She knew from experience when she worked night shift and she would turn on her call light on and when she entered into the resident's room, she had already flipped her covers back and was ready to get up. 2. During the initial tour of the facility, on 9/22/21 at 8:50 a.m., Resident D was observed sitting in a broda chair in the common area on the 200 hall, he had yellow/green bruising to the right side of his face. On 9/23/21 at 8:39 a.m., he was observed in bed with his head elevated. The bed was at waist height, a fall mat was on the floor next to his bed and no staff members were in the resident's room. CNA 26 walked up to the nurses station and indicated he was getting ready to feed the resident, he had just put his bed up but needed to get spoons and straws and if he was not with the resident the bed should be all the way to the floor. On 9/23/21 at 1:43 p.m., he was lying in bed with bed in low position, a fall mat was beside the bed on the floor, two visitors sat in chairs at his bedside. Resident D's clinical record was reviewed on 9/22/21 at 9:17 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, [CONDITION(S)], dementia, weakness and hypertension. His medications included, but were not limited to, [MEDICATION(S)] (blood pressure) 25 mg daily, tamsulosin ([CONDITION(S)]) 0.4 mg daily, [MEDICATION(S)] (anti-psychotic) 4 mg three times daily, lorazepam (anti-anxiety) 0.5 mg three times daily, [MEDICATION(S)] (pain) 7.5-325 mg - 15 milliliters (ml) four times daily. The fall risk assessments, dated 2/3/21 and 4/16/21 indicated he was at a risk for falls. A significant change MDS, dated [DATE], indicated the resident was rarely or never understood. He was totally dependent on two staff members for bed mobility and transfers. He was totally dependent with one staff member for locomotion on and off the unit. He had an impairment to his bilateral lower extremities. He had a condition or chronic disease that may result in a life expectancy of less than six months. He had a fall with fracture within six months prior to admission. He had one fall with no injury since admission or prior assessment, whichever was most recent. A nurses note, dated 7/28/21 at 10:30 p.m., indicated the resident was on a leave of absence to a psychiatric facility. A Patient Summary Report from a local hospital, dated 8/11/21, indicated while the resident was at the psychiatric facility he had a fall. An impression of an x-ray of his pelvis indicated fracture of the right femoral neck with shortening, favored to be subacute or old. An impression of the CT of his pelvis without contrast indicated subcapital fracture of the right femoral neck with displacement and shortening. Nondisplaced fractures extend to the greater trochanter. His nurses notes indicated he had, but was not limited to, the following falls and care plan interventions: On 8/20/21 at 5:00 p.m., he was found on the floor and no injuries were noted. He complained of general discomfort. The intervention was dycem between the sheet and mattress. On 9/5/21 at 11:00 a.m., QMA found the resident on the floor in front of his bed on his right side, his head was at the head of his bed and his feet at the foot of his bed, a small amount of blood was on the floor under his head, a small less than 1 cm abrasion on his right lateral eyebrow. Unable to check an eye assessment to his right eye due to complaints of pain. He was assisted back into bed by the assistance of four staff members and lift blanket. Ice and pressure was applied to his right brow and ice to right eye. The intervention was a bed alarm. On 9/6/21 at 6:00 p.m., he was in the dining room when a CNA addressed another resident. Resident D leaned forward and fell out of chair face first onto the floor. A new order was received if family wanted to send resident to ER then send. Son was in agreement with sending the resident to ER. The intervention was to keep broda chair in a reclined position except when eating. On 9/6/21 at 9:30 p.m., ER nurse indicated he would return to the facility with a fractured right orbital and broken nose and stated there was nothing they could do for him. The impression of the CT of orbits without contrast, dated 9/6/21, from the emergency room , indicated a nondisplaced fracture of the right orbital roof. The small amount of extraconal hemorrhage causes minimal asymmetric proptosis without stretching of the optic nerve. There was extensive preseptal swelling on the right. Comminuted fracture of the right nasal bone and right maxillary nasal process. During an interview with CNA 6, on 9/22/21 at 1:46 p.m., she indicated she was feeding Resident D breakfast and had his bed up at care height, she was the only one on the front hall and was doing the best she could do, she left the resident to give him a break and attended to another resident, she had sat down to fill out a shower sheet at the nurses station and another CNA had found him lying on the floor. She had left his breakfast tray in the room because he was not done eating, his bed was supposed to be lowered and she had forgotten to go back to him. During an interview with RN 9, on 9/23/21 at 9:01 a.m., he indicated he had never witnessed Resident D fall and he was proactive, when the resident was squirmy, he could possibly be in pain and would give him pain medication. If he saw him that way, he would assess him at that time. During an interview with the DON, on 9/23/21 at 1:49 p.m., she indicated Resident D had a low bed and a mat at bedside and kept his broda chair in a reclined position. He had not been trying to get up for the past couple days and his health had declined since the return from the hospital after his psychiatric stay. A current policy, titled Fall Prevention Program, provided by the Administrator, on 9/23/21 at 1:13 p.m., indicated the following: . Policy: It is the policy of this facility to identify any resident who is increased risk for falls. Identified residents shall be monitored by the Interdisplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing resident risk of injury. The IDT shall review those residents identified as being at risk for falls or those residents who have sustained fall and are at risk for recurrent falls This Federal tag relates to Complaint IN 261. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to provide adequate supervision for a resident at risk for falling for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident 44 falling and sustaining a left [MEDICAL CONDITION] requiring surgical intervention (Resident 44). Findings include: During an observation of Resident 44's room, on 1/15/20 at 2:06 p.m., the bathroom door had a picture of a toilet on the outside of it. Resident 44's clinical record was reviewed on 1/15/20 at 1:45 p.m. [DIAGNOSES REDACTED]. She had current orders for, but not limited to, [MEDICATION NAME] (antidepressant) 20 mg at bedtime, [MEDICATION NAME] (water pill) 40 mg daily, [MEDICATION NAME] (blood pressure) 5 mg daily, [MEDICATION NAME] (antipsychotic) 25 mg one-half tablet in the morning and one tablet in the evening, Fast Freeze pain relief topically to bilateral lower extremities/knees twice daily, [MEDICATION NAME] (anxiety) 0.5 mg three times daily, and up with assistance of a rolling walker. A 1/1/2020, quarterly, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. She had two or more falls since her prior assessment without injury, and one with injury (except major). She required limited assistance with bed mobility and transfers, and supervision to walk in her room and in the corridor, and with locomotion on and off the unit. She required extensive assistance with dressing, toilet use, and personal hygiene. She had a current, 2/5/19, care plan problem for risk for falls, reviewed on 1/11/20. Interventions included, but were not limited to, toilet every 2 hours (8/31/19) and a bed alarm in place (9/15/19 and 1/8/20). Review of a 10/26/19 Fall Risk Assessments indicated she was at high risk for falls. Review of a 12/27/19 progress note indicated she had been found on the floor at 1:45 a.m., next to her bed, with no injuries noted. A 12/27/19 Accident and Incident Report and Investigation document indicated she didn't know what happened, but needed to get up to urinate. A corresponding Post Fall Investigation document indicated she toileted independently. A bed alarm was in place under her sheet, but did not function properly at the time of the fall. A 12/27/19 at 10:00 a.m., a progress note indicated the bed alarm was discontinued. A 1/5/20 progress note indicated she had been found on the floor of her bathroom, at 10:09 p.m., with a small abrasion to her left ear. She told staff she had been urinating. A 1/5/20 physician order [REDACTED]. A 1/7/20 progress note indicated bruising was noted to her left shoulder and left cheek bone, below her eye, and was associated with her fall on 1/5/20. A 1/8/20 progress note indicated she was found on the floor at 11:30 p.m., with a black and blue hematoma to her right forehead, above her eye, after she had tripped over oxygen tubing while attempting to walk to the bathroom. She was transferred to the emergency department for evaluation, and an order was received for a bed alarm. A 1/11/20 progress note indicated she was found on the floor in the bathroom at 10:30 p.m., sitting under the sink with her pants down, yelling for help. She had a large red/blue lump on her left forehead, and told staff she had struck her head on the trashcan. She was transferred to the emergency department due to left hip pain. A 1/11/20 Accident and Incident Report and Investigation document indicated her bed alarm was unplugged from the unit, and did not sound when she got up to go the bathroom. A 1/12/20 progress note indicated she had been admitted to the hospital due to a fracture of her left hip. A 1/12/20 hospital History and Physical indicated she would require surgery to repair the [MEDICAL CONDITION], and she had a closed head injury due to a right frontal scalp hematoma. A 1/15/20 hospital discharge instruction sheet, a urinary catheter had been placed on 1/15/20 for [MEDICAL CONDITION]. During an interview, on 1/15/20 at 2:12 p.m., RN 14 indicated on the night of the resident's last fall, she had been getting shift report and had just completed rounds. Resident 44 had been fairly independent, but had started to decline in the previous couple of weeks. She had fallen, and they started a bed alarm, but during the day she was independent. She had a prolapsed uterus and was toileted frequently. She was more groggy at night and would try to turn the alarm off, but couldn't figure it out. The alarm did not stop her from falling, and she would be up every few hours. Her interventions included, being seen by therapies, she had a bed alarm, and staff was keeping up with toileting her. She had a bed alarm previously, but it was removed when she changed rooms. During an interview, on 1/15/20 at 3:34 p.m., CNA 20 indicated the resident was able to toilet herself, and would go upon rising, after breakfast, and sometimes before meals and then after meals. During an interview, on 1/16/20 at 9:29 a.m., the DON indicated the resident's uterine prolapse was chronic for her, and she had no adverse effects from it, and it was monitored as a chronic condition. 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify the physician when a resident had a fall with a head injury for 1 of 3 residents reviewed for accidents. This deficient practice resulted a delay in treatment after a fall with head injury and death four days after the fall.(Resident B). The immediate jeopardy began on [DATE] when the resident fell in the shower, hitting her head on the floor. The resident had an initial assessment that indicated an abnormal pupil response. The physician was not notified until the following morning. The resident was then sent to the hospital and died on [DATE]. The Executive Director was notified of the immediate jeopardy on [DATE] at 3:29 p.m. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings included: The clinical record for Resident B was reviewed on [DATE] at 10:00 a.m. [DIAGNOSES REDACTED]. An 30-day Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. She required two-person assistance for transfers and toileting. On [DATE], a new order was received for Xarelto (blood thinner) 10 mg daily for [MEDICAL CONDITION] prevention. A previous fall assessment indicated the following blood pressures: On [DATE] the blood pressures were ,[DATE], ,[DATE], ,[DATE] On [DATE] the blood pressures were ,[DATE], ,[DATE], ,[DATE] On [DATE] the blood pressures were ,[DATE], ,[DATE], ,[DATE] On [DATE] the blood pressure was ,[DATE]. A progress note, dated [DATE], indicated the resident had been yelling most of the morning. On [DATE], a progress note indicated the resident was yelling out most of the night. A progress note, dated [DATE], indicated the resident was up in her wheelchair trying to speak, but difficult to understand. An occurrence initial assessment, dated [DATE] at 10:00 p.m., indicated the resident climbed out of her bed and was taken to the bathroom to be toileted. While seated in her wheelchair, she slid out after she became restless and agitated. She then began to bang her head on the shower room floor. She was given a shower to remove the feces and then three staff members put her back to bed. The resident had pink and blue bruising around her right eye. The investigation indicated the physician was notified on [DATE] at 9:45 a.m. and the family was notified at 10:00 a.m. During the fall the resident hit her head and neurological checks were initiated. She was on a medication that thinned her blood. The form indicated the Director of Nursing (DON) or designee had been notified on [DATE] at 11:40 p.m. The form was signed by LPN 9. The post fall investigation indicated the resident had a witnessed fall in the shower room and had a history of [REDACTED]. The initial neurological assessment was dated [DATE] at 10:00 p.m. The vital signs included a blood pressure of ,[DATE], temperature 96.8, pulse 89, respirations 18 and oxygen saturation 92%. The right and left pupil response was sluggish. The neurological assessments continued to be noted as sluggish through the night until the resident was sent to the hospital on [DATE]. A progress note, dated [DATE] at 11:40 p.m., indicated the resident had pink and blue bruising to the right eye. The pupils were equal and reactive to light. The incident took place at 10:00 p.m. The Assistant Director of Nursing (ADON) was notified per Qualified Medication Aide (QMA) 11. A progress note, dated [DATE] at 10:00 a.m., indicated the resident's daughter was notified they were sending the resident to the hospital for evaluation. The resident's daughter was upset she was not notified of the fall the prior night when it occurred. A late entry progress note, dated [DATE] at 11:00 p.m., indicated on [DATE] at 9:45 a.m., the ADON went to Resident B's room to assess the resident from the fall. The resident was found to be non-verbal and having difficulty keeping her eyes focused. The Nurse Practitioner (NP) was rounding in the facility and was notified of the residents condition. A hospital admission and physical, dated [DATE], indicated the resident had a witnessed fall in the bathroom at the nursing facility. The resident went to bed and upon evaluation this morning, the resident was noted to have altered mental status with bruising around her eye. The POA was at the bedside and indicated she was notified of the fall this morning. The resident was brought to the emergency room where she was found to have evidence of [MEDICAL CONDITION] on the imaging. The resident was a Do Not Resuscitate (DNR) and the POA was not interested in extraordinary heroic measures. The resident was admitted to the hospital for comfort measures. A review of the symptoms indicated the resident was unable to provide a review of symptoms due to unresponsiveness. On examination, the resident was found to appear to be uncomfortable, not alert and in no acute distress. Her pupils were equally round and reactive to light and accommodation. The Computed [NAME]ography (CT) scan showed acute intraparenchymal hemorrhage involving the left [DIAGNOSES REDACTED]. The assessment and plan indicted the options were limited and the prognosis was poor. The resident may to be considered for hospice care depending on the outcome overnight. The hospital record indicated the resident died on [DATE] at 2:45 a.m.with family at her side. The discharge [DIAGNOSES REDACTED]. During a telephone interview on [DATE] at 8:43 a.m., LPN 9 indicated both herself and LPN 10 went to assess the resident in the shower room and her pupils were sluggish. She indicated sluggish was usually a concern, but a lot of the residents had a slower pupil response. She did not notify the physician of the fall because she thought the 3rd shift nurse would notify the physician. She stayed late to fill out the incident report. Review of LPN 9's time card for [DATE], she arrived to work at 1:53 p.m. and left at 12:27 a.m. on [DATE]. An employee written warning, signed and dated [DATE], indicated LPN 9 received a warning for failing to contact the physician and legal representative. The incident occurred on [DATE] at 10:00 p.m. and the physician and family were not notified until 9:45 a.m. on [DATE]. LPN 10 received the same written warning that was signed [DATE]. Review of a current policy, titled NOTIFICATION OF CHANGE, dated ,[DATE], was provided by the DON on [DATE] at 11:55 a.m., indicated the following: PURPOSE: To keep resident, legal representative .physician (when applicable) aware of changes which directly affect the care and welfare of the resident. POLICY: Facility personnel shall immediately inform resident, consult with resident's physician; and, if known, notify the resident's legal representative or interested family member when there is: an accident involving the resident that results in injury and has the potential for requiring physician intervention; a significant change . a need to alter treatment . a decision to transfer Review of another facility policy, titled NEUROLOGICAL ASSESSMENT, dated ,[DATE] and revised ,[DATE], was provided by the Administrator [DATE] at 11:50 a.m., indicated the following: PURPOSE: To determine the level of neurological function of a resident. .PR[NAME]EDURE: 1. Notify physician whenever head injury or suspected head injury occurs 9. Notify physician of any abnormalities Reaction to Light ABNORMAL RESP: Pupil fixed; reacts sluggishly The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: education and monitoring of physician notification. This Federal tag relates to complaint IN 745. 3XXX,[DATE](a)(1)

Based on interview and record review, the facility failed to use a gait belt during a transfer and failed to do a nursing assessment prior to moving the resident after falling for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident B falling and sustaining an acute [MEDICAL CONDITION] which resulted in death (Resident B). The immediate jeopardy began on [DATE] when the resident fell in the shower due to improper transfer, hitting her head on the floor. The resident had an initial assessment that indicated an abnormal pupil response. The resident was sent to the hospital the following day and died on [DATE]. The Executive Director was notified of the immediate jeopardy on [DATE] at 3:29 p.m. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings included: The clinical record for Resident B was reviewed on [DATE] at 10:00 a.m. [DIAGNOSES REDACTED]. An 30-day Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. She required two-person assistance for transfers and toileting. A health care plan, dated [DATE] and revised [DATE], indicated the resident had multiple risk factors for falls. Interventions included, but were not limited to, staff re-educated on use of gait belt with ambulation and transfers ([DATE]) and check alarm for proper functioning. An occurrence initial assessment, dated [DATE] at 10:00 p.m., indicated the resident climbed out of her bed and was taken to the bathroom to be toileted. While seated in her wheelchair, she slid out after she became restless and agitated. She then began to bang her head on the shower room floor. She was given a shower to remove the feces and then 3 staff members put her back to bed. The resident had pink and blue bruising around her right eye. The investigation indicated the physician was notified on [DATE] at 9:45 a.m. and the family was notified at 10:00 a.m. The fall was known the resident hit her head and neurological checks were initiated. She was on a medication that thinned her blood. The form indicated the Director of Nursing (DON) or designee had been notified on [DATE] at 11:40 p.m. The form was signed by LPN 9. The post fall investigation indicated the resident had a witnessed fall in the shower room and had a history of [REDACTED]. The initial neurological assessment was dated [DATE] at 10:00 p.m. The vital signs included a blood pressure of ,[DATE], temperature 96.8, pulse 89, respirations 18 and oxygen saturation 92%. The right and left pupil response was sluggish. The neurological assessments continued to be noted as sluggish throughout the night until the resident was sent to the hospital on [DATE]. A progress note, dated [DATE] at 11:40 p.m., indicated the resident had pink and blue bruising to the right eye. The pupils were equal and reactive to light. The incident took place at 10:00 p.m. The Assistant Director of Nursing (ADON) was notified per Qualified Medication Aide (QMA) 11. A progress note, dated [DATE] at 10:00 a.m., indicated the resident's daughter was notified they were sending the resident to the hospital for evaluation. The resident's daughter was upset she was not notified of the fall the prior night when it occurred. A late entry progress note, dated [DATE] at 11:00 p.m., indicated on [DATE] at 9:45 a.m., the ADON went to Resident B's room to assess the resident from the fall. The resident was found to be non-verbal and having difficulty keeping her eyes focused. The Nurse Practitioner (NP) was rounding in the facility and was notified of the residents condition. A hospital admission and physical, dated [DATE], indicated the resident had a witnessed fall in the bathroom at the nursing facility. The resident went to bed and upon evaluation this morning, the resident was noted to have altered mental status with bruising around her eye. The POA was at the bedside and indicated she was notified of the fall this morning. The resident was brought to the emergency room where she was found to have evidence of [MEDICAL CONDITION] on the imaging. The resident was a Do Not Resuscitate (DNR) and the POA was not interested in extraordinary heroic measures. The resident was admitted to the hospital for comfort measures. A review of the symptoms indicated the resident was unable to provide a review of symptoms due to unresponsiveness. On examination, the resident was found to appear to be uncomfortable, not alert and in no acute distress. Her pupils were equally round and reactive to light and accommodation. The Computed [NAME]ography (CT) scan showed acute intraparenchymal hemorrhage involving the left [DIAGNOSES REDACTED]. The assessment and plan indicted the options were limited and the prognosis was poor. The resident may to be considered for hospice care depending on the outcome overnight. The hospital record indicated the resident died on [DATE] at 2:45 a.m.with family at her side. The discharge [DIAGNOSES REDACTED]. During a telephone interview on [DATE] at 3:01 p.m., CNA 1 indicated she moved the resident from the bed to the wheelchair without gait belt. She took her to the shower room and was transferring her from the chair to the shower chair in the shower room without a gait belt and the resident fell to the floor. She indicated the nurse was called down, but did not do anything to help and told them to get her showered and back to bed. The resident was not acting any different. During an interview on [DATE] at 3:09 p.m., CNA 2 indicated herself and CNA 3 were at the nurses' station and another CNA was doing rounds and told CNA 1 that Resident B was a crappy mess. She was still a student at that time, but could tell CNA 1 was mad that she had to take care of the resident right before her shift ended. CNA 1 transferred the resident by herself and they went to do the spray out of the bedding. Her and CNA 3 were in the spray out room when another CNA was walking by and asked us if we could hear CNA 1 asking for help from the shower room. CNA 1 asked her to help get the resident up she said she could not because she was a student and told her to call the nurse to check on the resident. LPN 9 came in and said to get the resident upand shower her. During a telephone interview on ,[DATE] 8:43 a.m., LPN 9 indicated she heard yelling and two CNA's were yelling at each other. She indicated Resident B was on the floor, naked and covered in feces. CNA 1 indicated the resident had pounded her head, but she did not observe that. She had problems with the CNA before. The resident did not appear to be in pain. She was not aware the aides put her back to bed. Both herself and LPN 10 went to the resident's room to check on her and her neurological assessment was fine and her pupils were sluggish. She indicated sluggish was a concern, but the room was dark. During a telephone interview on ,[DATE] at 9:11 a.m., CNA 5 indicated it was her first or second day of orientation and she was working with CNA 4 on 300 Hall. Someone came and asked them to come up front because someone had fallen in the shower. They ran up to the shower room and CNA 1 and CNA 2 were already in the shower room. She asked what happened and was told the resident fell , slid out of the chair. She said the way the room was positioned, it did not look like she slid out of the chair. Someone went and told the nurses the resident fell and the nurse told them to get her back to bed. She knew the nurses' needed to assess her before they moved her. Someone got a blanket and CNA 2 told the nurses again and the CNA's were told to put her back in bed. CNA 2 tried to call the ADON at least twice and he did not answer. CNA 4 got the resident into her wheelchair and then herself and CNA 4 went back to the locked unit. They got called back up to the shower room because CNA 1 could not get the resident up into the wheelchair. CNA 4 alone got the resident in her chair and as they were walking past the nurses' station again, she told them the resident had a goose egg on her head. The nurses were not in the shower room at any time when she was in there with the resident. During a telephone interview on [DATE] at 9:25 a.m., QMA 11 indicated she was told the resident fell in the shower room. One CNA came and told her the nurses were not going to do an incident and she did not believe they were not going to do an incident report so she went to look at the resident and saw she had a goose egg above her right eye. She was told the nurses did assess her in the shower room, but she was not there. The nurses' were still doing shift change report when she went and told them the resident had a goose egg above her eye. She indicated they did go down and thought that was when the first neuro checks were done after they were told of goose egg. The nurses had initially said she was ok and was back in bed. During a telephone interview on [DATE] at 11:11 a.m., LPN 10 indicated she got to work around 10:00 p.m. She went behind the nurses' station and her and LPN 9 began shift report and heard a commotion. One aide was in the shower doorway and CNA 2 was yelling back at her. They thought they were going to break up an argument and no one mentioned a fall. They were then told the resident had a fall. LPN 9 went in the shower room and she stood back because it was crowded. The resident did not appear to be in pain and she had feces all over her. LPN 9 checked her out and then stepped out. LPN 9 said she would stay and do the incident report and instruct the aide to get the resident cleaned up and put into bed. She indicated she did document her pupils were sluggish and that may have not been the best word, but they were not brisk. A lot of the residents do not have brisk pupil response. She did not see any change through the night with the resident. During a telephone interview on [DATE] at 1:56 p.m., CNA 4 indicated she had just arrived to work when she got a call in the back to help with the resident. The nurses' were giving report. No nurse was present during the time she was in the shower room. She got a second call to help get the resident into bed. The resident was stood up and she still has feces on her so CNA 1 cleaned her up again and then they put her into bed. She did not see the nurses' in the room either. She had a bruise on her eye so she told QMA 11 that the resident had a goose egg. The resident was very out of it. The resident was dazed and odd and she knew something was wrong with her. An employee warning, dated [DATE], indicated LPN 10 received a 2nd written warning related to failure to notify the physician following an incident and completing and accident and incident report. An employee warming, dated [DATE], indicated CNA was given a 2nd warning related to failure to follow proper procedures for incidents and accidents. She also failed to use a gait belt per facility policy. An employee warning, dated [DATE], indicated LPN 9 received a 2nd written warning related to failure to notify the physician following an incident completing and accident and incident report. Review of a current facility policy, titled GAIT BELT, dated ,[DATE], was provided by the DON on [DATE] at 11:55 a.m., indicated the following: PURPOSE: Gait belts provide caregivers with a secure hold point while assisting residents during supervised ambulation and transfers. Gait belts may also help prevent back injuries to the caregiver. ,,,PR[NAME]EDURE: .4. Assist resident to stand on count of three. 5. Allow resident to gain balance. Ask the resident if dizzy. 6. Stand to side and slightly behind resident while continuing to hold onto belt A INTERNAL FALL INVESTIGATION PR[NAME]ESS, was provided by the Administrator on [DATE] at 2:11 p.m., indicated the following: .Resident is left as found (not moved) until licensed nurse assessment is conducted. .Following assessment, physician is contacted and resident is either transported Physician contact must include information if the resident is on an anticoagulant The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included monitoring of the transferring of residents by staff. This Federal tag relates to complaint IN 745. 3XXX,[DATE](a)(2)

Based on interview and record review the facility failed to protect a female resident from verbal abuse by a male resident for 1 of 3 residents reviewed for abuse (Resident M). Findings include: B. Resident M's clinical record was reviewed on 8/30/2017 at 8:55 a.m., indicated her [DIAGNOSES REDACTED]. A review of the INTERDISCPLINARY CARE PLAN CONFERENCE RECORD, dated 5/25/2017, indicated Resident M had documented behaviors of crying and tearfulness. She had a health care plan ABUSE-SUSPECTED PAST, which indicated the following, The resident/family reports a history of abuse. Husband/ roommate often become verbally loud, resident becomes tearful and defends husband interventions included, but were not limited to, assure the resident that she is safe and mental health services as ordered. A review of the behavioral memos, provided by the SSD on 8/30/2017, indicated the following: On 3/11/2017 Called to room by Resident M from down the hall, upon entering room noted res (resident, roomate) sitting on edge of recliner foot still extended holding on to wc (wheelchair) telling Resident M to get him up out of recliner aggressively telling her to do it, she isn't trying. Wife crying saying she couldn't. This was marked as verbally aggressive. On 4/13/2017, .Call light came . on (Resident M) was in the recliner and (Resident H) was in the bathroom .he said where is (Resident M)- I (staff member) said in the recliner in your room he then stated that he had been yelling for her to get him help (when I walked in when the call light first went off Resident M. was crying) (assuming from him yelling at her to do things and she isn't feeling well) (Resident H) stated she isn't in as bad shape as I am she is fine This was marked as verbally aggressive. On 4/14/2017, yelling cussing name calling res .(Resident M) w/c was caught on another residents wheel .calling him an a----le This was marked as verbally aggressive. On 4/15/2017, (Resident H) began yelling at (Resident M) demanding she get out of the restroom so he could get in . On 4/16/2017, Resident had put on call light .when I got to RM (room) I could hear him yelling at (Resident M) for her to get off her a-- and walk to get him some help roomate asked me What the he-- use is she she won't even help with my pants or socks. I said she is not supposed to be doing things like this for you He acted upset and said yeah that's how good wives treat their husbands. On 4/17/2017, Resident yelling at (Resident M) am I hard to get along with? This was marked as verbally aggressive. On 4/26/2017 Had pushed resident back to room after breakfast. We got to room and asked if wanted to go to the restroom (not knowing (Resident M) was already in there. When he found (Resident M) in restroom he immediately began complaining at her (Resident M) to hurry get out she takes to long. I told him to leave her be and and we could go to another restroom no problem. He refused and said he would just wait on her to get out. This was marked as verbally aggressive. On 4/26/2017 Husband was being rude and acting out when he found out it wasn't his shower night. He went ballistic on (Resident M), (name of employee), (name of employee) and myself. It was bad enough (Resident M) was in tears! We even offered to give him a shower and that did not help. He got even ruder with his comments! This was marked as verbally aggressive behavior On 4/23/2017 Res put his light on as the student and I went to go see what he needed we could hear resident yelling at his wife (Resident M) telling her to get his walker now and that he needed up This was marked as verbally aggressive. On 5/1/2017, I heard husband screaming in his room when I went in, (Resident M) was walking toward the bed. He was yelling at her. I asked what was wrong, resident said well I'm wondering why (Resident M) is sleepy all day she needs to get up. I said it is only 2:30 a.m (Resident M) got back in bed and went back to sleep. This was marked as verbally aggressive. On 8/2/2017, .pulled the call light cord out of the wall .he began yelling that they don't ever fix anything and then began (in a sturn tone also) telling (Resident M) that she needs to get up out of the chair and get ready for breakfast . On 8/2/2017, Walked into residents room he was already in his bathroom, standing up yelling at (Resident M) saying come in here and pull my d--n pants down On 8/9/2017, Heard husband yelling at (Resident M) to hurry up and get the F--k out of the bathroom he began questioning her why she didn't answer and she just told him he has to share. I asked (Resident M) if she was okay she said yes he just acts like an ass sometimes. On 8/18/2017, Husband and (Resident M) where (SIC) returning to their room after supper. Reident was yelling at (Resident M) to push him, he was saying push me you son of a b---- you are a useless and worthless piece of sh-- all you do is sleep. (Resident M) was trying to help him and he continued yelling at her The Social Service Progress Notes were reviewed on 8/30/2017 at 7:35 a.m., indicated the following: 4/17/2017- multiple behavior memos about verbal aggression toward Resident M. 4/29/2017- met with resident and family discussed recent behavior and effect the yelling / demands are having on Resident M. Resident M denied any issues, Resident H often unaware Resident M is upset or tearful. 6/16/2017- Resident yelling at Resident M because she was not following instructions for making a phone call. In a confidential interview, an employee 1 indicated Resident M husband and roomate was like this to Resident M and she cried and got very upset. The employee indicated this behavior toward Resident M happened everyday and they considered this behavior to be verbal abuse. The employee indicated they tried to calm the husband down when he got angry, they talked to him and tried to reason with him. The employee indicated that when he got verbally abusive with Resident M the staff do not separate them and this behavior has directly affected Resident M emotionally as evidenced by her crying while the yelling was taking place. In a confiential interview, an employee 2 indicated the staff had abuse training about 2 weeks ago. The employee indicated the husband yelled and screamed at everyone including Resident M. She indicated Resident M often cried when and after being yelled at by her husband, who was also her roomate. Employee 2 indicated staff do not separate the couple when this happens. The employee indicated they do not offer support for Resident M, only [MEDICATION NAME] (antianxiety medication) at night. The employee indicated the staff just has to deal with the husband. During an interview with the SSD on 9/1/2017 at 9:28 a.m., she indicated the husband was a stubborn old man who liked to joke and that his joking was often confused as aggression. She indicated he needed to have his needs met immediately. She indicated when the couple first moved in she tried to interfere during the yelling and screaming, but that was not what they wanted. She indicated the couples relationship was like this prior to living here. The SSD indicated that when left alone Resident M takes the brunt of he husband's frustrations. The SSD indicated that the husband's yelling at Resident M was verbal abuse, but what can I do about it? She indicated Resident M makes excuses for his behavior. She indicated staff made a behavior memo after each episode and those were reviewed at the morning meetings with the Administrator. During an interview with the Administrator on 9/1/2017 at 10:07 a.m., she indicated she was aware of the husband's behaviors toward Resident M. She indicated they discussed them at the morning meetings and they were seen by psych services. She indicated the following, is it abuse or family dynamics? The ISDH reportable incidents were provided and reviewed, there were no incidents reported involving the husband and Resident M. RESIDENT RIGHTS were provided by the Administrator on 8/30/2017 at 5:19 a.m., and indicated .RESIDENT BEHAVIOR AND FACILITY PRACTICES .(b) Abuse. The resident has the right to be free from verbal .mental abuse This Federal Tag relates to complaint IN 107 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to prevent the neglect of a resident in regard to providing timely services to prevent incontinent episodes for 2 of 3 residents reviewed for neglect. (Resident B and D, CNA #9, CNA #1) Findings include: 1. During an observation and interview on 8/1/16 at 8:25 a.m., Resident B indicated she was not doing very well today. She indicated she told a third shift CNA that she needed to use the bathroom and the CNA told her she did not have time to take her, causing her to soil herself. Resident B was visibly upset and angry. During record review on 8/1/16 at 2:30 p.m., [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) annual assessment, dated 6/25/16, indicated Resident B was cognitively intact. During an interview on 8/1/16 at 8:30 a.m., CNA #10 indicated she came to work at 6:00 a.m. today. She indicated CNA #9 was Resident B's CNA during the night. She indicated when she came to work, Resident B was still in her chair and was soaked through her pad. She indicated the resident also told her the third shift CNA did not take her to the bathroom when asked. During an interview on 8/1/16 at 11:18 a.m., the Director of Nursing (DON) was asked if she had received any reported concern about 3rd shift. She indicated CNA #10 did state a concern, but did not mention any specific resident. During an interview on 8/1/16 at 11:20 a.m., the DON and Corporate Nurse #6, spoke to CNA #10 at the 100 Hall nurse's station. CNA #10 indicated she told the DON about the concern, but had not filled out a report. She indicated she was currently on break and would complete the report when she clocked back in. Corporate Nurse #6 instructed her to report the concern now. A care plan, dated 7/8/16, indicated a problem with performing Activities of Daily Living (ADL) related to weakness, incontinence and impaired balance for Resident B. Interventions included, but were not limited to, shower and/or baths per schedule, assist with ADL care and monitor for changes in ADL .notify charge nurse .further evaluation. 2. The clinical record of Resident D was reviewed on 8/2/16 at 2:14 p.m. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment, dated 6/25/16, indicated Resident D was cognitively intact. Resident D received total assist with two-person assist for bathing. During an interview on 8/2/16 at 1:50 p.m., Resident D indicated she was currently wet with urine and had mentioned to staff earlier that she needed to use the bathroom. She indicated she had waited up to 3 hours before being changed. She indicated she told CNA #1 that she needed to use the bathroom. Resident D was wearing black pants and not visibly wet. During an interview on 8/2/16 at 2:00 p.m. CNA #1 indicated she was told by Resident D that she needed to use the bathroom, but she was in another resident's room. She indicated she just reported to second shift that Resident D needed to be changed and she would follow-up prior to leaving. A care plan, dated 6/30/16, indicated a problem with performing Activities of Daily Living (ADL) related to weakness, incontinence and impaired balance. Resident D required one or two to assist in ADL care. Interventions included, but were not limited to, shower and/or baths per schedule, assist with ADL care and monitor for changes in ADL .notify charge nurse .further evaluation. During an interview on 8/2/16 at 3:10 p.m., Regional Director #8 indicated the incident for Resident B had since been report to the State Agency. He indicated several concerns had since been identified and additional reports had been filed. He indicated the Administrator was currently on vacation. Review of a facility policy, dated 10/2014, titled, ABUSE, provided by Corporate Nurse #6 on 8/1/15 at 9:30 a.m., indicated: POLICY: It is the policy of this facility allegations of abuse will be communicated to, and thoroughly investigated by, the correct authorities. .2. This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source .immediately to the administrator of the facility. .4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, anguish or deprivation of an individual of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. .Neglect-Failure to provide goods and services necessary to avoid physical harm, mental and/or physical anguish or mental illness. .6. All employees, .whom to report abuse and when .their responsibility upon witnessing abuse .8. The facility Administrator is designated .absence, this responsibility is delegated to the Director of Nursing Services. This Federal tag relates to Complaint IN 725 and IN 0. 3.1-27(a)

Based on observation, interview and record review, the facility failed to report an alleged neglectful incident between a resident and a staff member in a timely manner to the appropriate agency for 1 of 3 residents interviewed for neglect in a sample of 3. (Resident B and CNA #9) Findings include: During an observation and interview on 8/1/16 at 8:25 a.m., Resident B indicated she was not doing very well today. She indicated she told a third shift CNA that she needed to use the bathroom and the CNA told her she did not have time to take her, causing her to soil herself. During record review on 8/1/16 at 2:30 p.m., [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) annual assessment, dated 6/25/16, indicated Resident B was cognitively intact. During an interview on 8/1/16 at 8:30 a.m., CNA #10 indicated she came to work at 6:00 a.m. today. She indicated CNA #9 was Resident B's CNA during the night. She indicated when she came to work, Resident B was still in her chair and was soaked through her pad. She indicated the resident also told her the third shift CNA did not take her to the bathroom when asked. During an interview on 8/1/16 at 11:18 a.m., the Director of Nursing (DON) was asked if she had received any reported concern about third shift. She indicated CNA #10 did state a concern, but did not mention any specific resident. During an interview on 8/1/16 at 11:20 a.m., the DON and Corporate Nurse #6, spoke to CNA #10 at the 100 Hall nurse's station. CNA #10 indicated she told the DON about the concern, but had not filled out a report. She indicated she was currently on break and would complete the report when she clocked back in. Corporate Nurse #6 instructed her to report the concern now. A care plan, dated 7/8/16, indicated a problem with performing Activities of Daily Living (ADL) related to weakness, incontinence and impaired balance. Interventions included, but were not limited to, shower and/or baths per schedule, assist with ADL care and monitor for changes in ADL .notify charge nurse .further evaluation. During an interview on 8/2/16 at 3:10 p.m., Regional Director #8 indicated the incident for Resident B had since been report to the State Agency. He indicated several concerns had since been identified and additional reports had been filed. He indicated the Administrator was currently on vacation Review of a facility policy, dated 10/2014, titled, ABUSE, provided by Corporate Nurse #6 on 8/1/15 at 9:30 a.m., indicated: POLICY: It is the policy of this facility allegations of abuse will be communicated to, and thoroughly investigated by, the correct authorities. .2. This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source .immediately to the administrator of the facility. .4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, anguish or deprivation of an individual of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. .Neglect-Failure to provide goods and services necessary to avoid physical harm, mental and/or physical anguish or mental illness. .6. All employees, .whom to report abuse and when .their responsibility upon witnessing abuse .8. The facility Administrator is designated .absence, this responsibility is delegated to the Director of Nursing Services. This Federal tag relates to Complaint IN 725 and IN 0. 3.1-28(c)

Based on observation, interview and record review, the facility failed to implement their facility policy related to reporting immediately to the administrator any allegation of neglect of a resident for 2 of 3 residents reviewed for neglect. (Resident B and D) Findings include: 1. During an observation and interview on 8/1/16 at 8:25 a.m., when asked, Resident B indicated she was not doing very well today. She indicated she told a third shift CNA that she needed to use the bathroom and the CNA told her she did not have time to take her, causing her to soil herself. During record review on 8/1/16 at 2:30 p.m., [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) annual assessment dated [DATE], indicated Resident B was cognitively intact. During an interview on 8/1/16 at 8:30 a.m., CNA #10 indicated she came to work at 6:00 a.m. today. She indicated CNA #1 was Resident B's CNA during the night. She indicated when she came to work, Resident B was still in her chair and was soaked through her pad. She indicated the resident also told her the third shift CNA did not take her to the bathroom when asked. During an interview on 8/1/16 at 11:18 a.m., the Director of Nursing (DON) was asked if she had received any reported concern about third shift. She indicated CNA #10 did state a concern, but did not mention any specific resident. During an interview on 8/1/16 at 11:20 a.m., the DON and Corporate Nurse #6, spoke to CNA #10 at the 100 Hall nurse's station. CNA #10 indicated she told the DON about the concern, but had not filled out a report. She indicated she was currently on break and would do so when she clocked back in. Corporate Nurse #6 instructed her to report the concern now. A care plan, dated 7/8/16, indicated a problem with performing Activities of Daily Living (ADL) related to weakness, incontinence and impaired balance. Interventions included, but were not limited to, shower and/or baths per schedule, assist with ADL care and monitor for changes in ADL .notify charge nurse .further evaluation. 2. The clinical record of Resident D was reviewed on 8/2/16 at 2:14 p.m. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment, dated 6/25/16, indicated Resident D was cognitively intact. Resident D received total assist with two-person assist for bathing. During an interview on 8/2/16 at 1:50 p.m., Resident D indicated she was currently wet with urine and had mentioned to staff earlier that she needed to use the bathroom. She indicated she had waited up to 3 hours before being changed. She indicated she told CNA #1 that she needed to use the bathroom. During an interview on 8/2/16 at 2:00 p.m. CNA #1 did indicate she was told by Resident D that she needed to use the bathroom, but she was in another resident's room. She indicated she just reported to second shift that Resident D needed to be changed and she would follow-up prior to leaving. A care plan, dated 6/30/16, indicated a problem with performing Activities of Daily Living (ADL) related to weakness, incontinence and impaired balance. Resident D required on or two to assist in ADL care. Interventions included, but were not limited to, shower and/or baths per schedule, assist with ADL care and monitor for changes in ADL .notify charge nurse .further evaluation. During an interview on 8/2/16 at 3:10 p.m., Regional Director #8 indicated the incident for Resident B had since been reported to the State Agency. He indicated several concerns had since been identified and additional reports had been filed. He indicated the Administrator was currently on vacation Review of a facility policy dated 10/2014, titled, ABUSE, provided by Corporate Nurse #6 on 8/1/15 at 9:30 a.m., indicated; POLICY: It is the policy of this facility allegations of abuse will be communicated to, and thoroughly investigated by, the correct authorities. .2. This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source .immediately to the administrator of the facility. .4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, anguish or deprivation of an individual of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. .Neglect-Failure to provide goods and services necessary to avoid physical harm, mental and/or physical anguish or mental illness. .6. All employees, .whom to report abuse and when .their responsibility upon witnessing abuse .8. The facility Administrator is designated .absence, this responsibility is delegated to the Director of Nursing Services. This Federal tag relates to Complaint IN 725 and IN 0. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a roommate disagreement resulting in verbal abuse by a family member and causing tearfulness and isolation for 1 of 15 residents interviewed for roommate concerns. (Resident #77) Findings include: On 11/30/15 at 3:28 p.m., during an interview, Resident #77 indicated Resident #25's daughter had yelled at her and had pointed her finger at her about having her television too loud. Resident # 25 was interviewed and indicated she did not like the television volume loud. She also indicated she did not particularly like watching television. She also indicated she did not have any issues with other residents. She indicated she had a sensitivity to light and developed migraines as a result. Resident #77's clinical record was reviewed on 12/03/15 at 3:42 p.m. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment, dated 9/9/15, indicated the resident was cognitively intact. No information about the incident was indicated in the nurse's notes. The POSSIBLE OR POTENTIAL MENTAL ANGUISH ASSESSMENT,dated 11/3/15, indicated the purpose of the interview as Verbal Abuse. The resident indicated she refused breakfast and was tearful and/or crying with fearfulness described as Voiced being in trouble with increased agitation. The observations by the staff indicated the resident ate in her room with encouragement and stayed in her new room throughout the day. She was observed tearful and crying in the morning with increased agitation. The EVALUATION OF NEW OR WORSENING MOOD OR BEHAVIOR, dated 11/3/15, indicated the resident was verbally abused by her roommate's family member. The resident was sobbing and stated I will leave this building if treated like that again. The additional comments indicated Resident #77 was emotionally distraught this a.m. due to the roommate's daughter's accusation of causing trouble for roommate. The Social Service (SS) progress notes indicated the following: On 10/30/15 Resident #77 indicated she was not allowed to turn up the television or open the blinds in the room as this bothered the roommate. On 11/3/15 (no time Insert-Update-) the Social Service Director indicated she found Resident #77 in her dark room shaking and crying. The resident indicated the roommate's daughter had cornered her the evening prior and yelled and accused her of causing problems for her roommate. Resident was taken to the SS's office where she continued to cry and was visibly upset. A review of the Visitor to Resident Abuse form, dated 11/3/15, indicated the resident was moved to another room to keep her safe. It also indicated the daughter of Resident # 15 would be supervised during visits due to volatile outbursts. The form also indicated the daughter had been interviewed by the SSD regarding the incident on 11/2/15 with Resident # 77. The daughter was recorded as becoming verbally aggressive with the SSD. The INTRA-FACILITY TRANSFER, dated 11/3/15, indicated the resident requested a room change, waived the relocation plan, and was moved to a different room. 3.1-27(a)(1)