Every finding on record at Envive of Hartford City

Based on record review and interview, the facility failed to report an allegation of abuse to the State Agency within the required time frame. (Resident B) Findings include A facility reported incident, dated 10/27/25 at 4:19 p.m., submitted to the Indiana Department of Health indicated an incident occurred on 10/27/25 at 3:01 p.m. The reported incident indicated the following: On 10/27/25 Resident B reported to the Administrator that CNAs yelled at her on 10/26/25. On 10/27/25 an investigation was initiated, and the CNAs were suspended pending the investigation outcome. Review of the facility's abuse investigation file, provided on 11/6/25 at 11:49 a.m., included the following: RN 9's statement indicated Resident B's representative approached the nurses station on 10/26/25 at approximately 1:00 p.m. and asked to talk to someone about a concern she had regarding the resident. Resident B had reported to her that Resident B had overheard, at lunch, the CNAs say from around a corner that she was old enough and should not be peeing herself, and that they were not going to continue to get her up and down like a yo-yo. During an interview, on 11/7/25 at 2:13 p.m., RN 9 indicated on 10/26/25, after lunch, the CNAs were taking residents from the dining room to their rooms. Resident B's representative asked to speak to the Administrator. The resident's representative indicated Resident B had told her the CNAs had said Resident B was old enough to hold her urine, and they had to keep getting her up and down like a yo-yo to go to the bathroom. During an interview, on 11/7/25 at 2:24 p.m., RN 9 indicated she had let the Administrator know about the incident on 10/26/25 at 1:26 p.m., according to the date and time on her phone. During an interview, on 11/7/25 at 3:30 p.m., the Administrator indicated she had received a text from RN 9 about the incident with Resident B on 10/26/25. She had spoken to RN 9 and the Resident B's representative on 10/26/25. RN 9 indicated Resident B was not overly upset. The Administrator had not believed this was abuse, but more of a customer service issue since Resident B had overheard something. Once she spoke to Resident B on 10/27/25 at 3:00 p.m., and Resident B indicated the CNAs yelled at her, cried, and indicated she did not want the CNAs to be fired, the Administrator decided the situation was possible abuse. She began the investigation and notified the State Agency at that time. A current facility policy, dated 8/2024, titled Abuse, Neglect, Exploitation and Misappropriate, Reporting, and Investigating, provided by the Administrator on 11/6/25 at 4:23 p.m., indicated the following: .All reports of resident abuse (including injuries of unknow origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigation by facility management. Findings of all investigation are documented and reported.If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 'Immediately' is defined as: h. within two hours of an allegation involving abuse. Cross Reference F610. This citation relates to Intake 2657526. 3.1-28(c)

Based on record review and interview, the facility failed to conduct a thorough investigation of an allegation of abuse and failed to implement immediate interventions to prevent potential abuse while the investigation was in progress. (Resident B) Findings include: A facility reported incident, dated 10/27/25 at 4:19 p.m., submitted to the Indiana Department of Health indicated an incident occurred on 10/27/25 at 3:01 p.m. The reported incident indicated the following: On 10/27/25 Resident B reported to the Administrator that CNAs yelled at her on 10/26/25. On 10/27/25 an investigation was initiated, and the CNAs were suspended pending the investigation outcome. CNA 3 and CNA 5 were the CNAs mentioned in the report. The clinical record for Resident B was reviewed on 11/6/25 at 10:30 a.m. Diagnoses included fracture of lower end of left femur, chronic kidney disease, stage 4, type 2 diabetes mellitus with diabetic polyneuropathy, morbid obesity due to excess calories, anxiety disorder, and muscle weakness. Current orders included torsemide (diuretic) 20 mg daily and resident uses a mechanical lift with the assistance of two staff members. An admission Minimum Data Set (MDS) assessment, dated 9/2/25, indicated the resident was cognitively intact. She was dependent on staff assistance for toileting. She required substantial/maximal staff assistance with bathing and lower body dressing. She was frequently incontinent of bowel and bladder. A care plan, initiated 8/27/25 and revised 9/3/25, indicated that the resident had an ADL (activities of daily living) self-care performance deficit related to impaired mobility, recent femur fracture, and extensive medical history. Interventions included the following: The resident required a mechanical lift for transfers with two staff assistance (8/27/25) and the resident required extensive assistance of one or two staff assistance with toileting (9/3/25). A care plan, initiated 8/27/25 and revised 9/3/25, indicated the resident had bladder incontinence related to impaired mobility and diuretics. Interventions included the following: Clean the resident's perineal area with each incontinence episode (8/27/25) and supply the resident with toileting devices as appropriate (8/27/25). A care plan, initiated on 10/3/25 and revised on 10/29/25, indicated the resident had made false statements and accusations. She had stated she had to stay in bed all weekend because there were no clean mechanical lift pads when she had in reality stated she did not want to get up when the aides attempted to assist her. She said no one wanted to lay her down and put her on the bedpan because they cannot ever find a bedpan when in reality her bedpan was sitting right beside her bed. She said she did not receive a dessert when she had taken hers off her tray and put in her pocket prior to asking for another dessert. Interventions included the following: Care in pairs (10/3/25). A progress note, dated 10/27/25 at 4:21 p.m., indicated the physician and family were aware of the resident's concern. The resident's clinical record lacked additional information on the resident's allegation of abuse and subsequent actions by the facility. Review of the facility's grievance log for September 2025 and October 2025, provided by the Administrator on 11/6/25 at 10:12 a.m., indicated one grievance was filed on 10/26/25 at 3:00 p.m. The grievance indicated Resident B's resident representative wanted to be notified about the resident's medication changes and upcoming appointments. She was concerned about resident's heel wound progression with the resident's future discharge home. Review of the facility's abuse investigation file, provided on 11/6/25 at 11:49 a.m., included the following: CNA 5's statement on 10/28/25 indicated Resident B was in the dining room for lunch on 10/26/25. CNA 5 was informed by CNA 3 that Resident B needed changed. CNA 5 and CNA 3 laid the resident down and performed care. The nurse called the CNAs into the doorway of Resident B's room and asked if CNA 5 and CNA 3 were the two. Resident B said they were not, and the situation had not even happened that day. CNA 5 explained to the resident's representative that CNA 5 and CNA 3 had assisted the resident to lay down and performed care. RN 9's statement indicated Resident B's representative approached the nurses station on 10/26/25 at approximately 1:00 p.m. and asked to talk to someone about a concern she had regarding the resident. Resident B had reported to her that Resident B had overheard, at lunch, the CNAs say from around a corner that she was old enough and should not be peeing herself, and that they were not going to continue to get her up and down like a yo-yo. The nurse went down to the resident's room with the representative to talk to Resident B. The resident could not or would not say who the staff were that had said those things. RN 9 called the two CNAs into the resident's room and asked Resident B if they were the ones who said those things about her. She said it was not them, it was something she overheard as the aides were walking away from her on a different day. CNA 5 explained to the resident representative that the aides had laid Resident B down, provided care, and left. The Social Services soft file notes indicated the resident had been checked on 10/28/25 and 10/29/25 for any continuing concerns. The abuse investigation file lacked a statement from CNA 3 and additional staff and resident interviews regarding resident abuse. The facility provided additional investigation documents 11/6/25 at 4:20 p.m. which included abuse allegations of staff and resident interviews. One staff interview was not dated by the staff member, and one staff interview appeared to have the date of 11/6/25 written over as 10/28/25. The documents did not include a statement from CNA 3. Confidential interviews were conducted during the course of the survey and indicated the following: A staff and resident abuse allegation questionnaire was completed on 11/6/25 and not on 10/28/25 as the questionnaire was dated. A staff and resident abuse allegation questionnaire was filled out by the Administrator that did not accurately reflect if abuse had been seen by the interviewee or the correct date of 11/6/25. CNA 5 had referred to Resident B as a crybaby to staff members in the hall. She had muttered, under her breath, for another resident to put their f***ing feet up when she pushed the resident's wheelchair. It was unknown if the resident heard CNA 5. The incidents had been reported to the Administrator. Resident B had indicated CNA 5 told her to pee in her brief. Resident B had indicated she was going to tell the Administrator of that interaction. After lunch on 10/26/25, RN 9 had told CNA 3 and CNA 5 that Resident B needed toileted. The CNAs finished up with another resident, then immediately went into Resident B's room and provided care. After Resident B's care was provided, RN 9 told CNA 3 and CNA 5 that Resident B indicated the CNAs had called her a baby. RN 9 went with the CNAs into Resident B's room. RN 9 asked Resident B if the CNAs in the room were the CNAs that had said the statements she had reported. Resident B indicated it could have been them, but she did not remember. Both CNAs provided care as usual until the end of the shift, and then RN 9 questioned both the CNAs about the incident. During an interview, on 11/6/25 at 4:02 p.m., Resident B indicated some staff treat her really well, but some not so much. One girl was put on vacation because she was making fun of the resident. She couldn't remember the girl's name except it started with a K. She had been written up according to the administrator and was off for a while. The CNA got mad because she had to clean the resident up when the resident's water pills took effect. The aide told another person that the resident should act like an adult and not a baby because the resident knew when she had to go to the bathroom. The aides came into the room when the resident's representatives were in the room, and the one CNA said, You quit lying. After the CNA left, the nurse talked to the resident for a little longer, but the resident indicated she would not give a name on who talked badly about her because the facility needed help. She did not think the residents should be treated rudely, but she did not want to get anyone in trouble. During an interview, on 11/7/25 at 10:32 a.m., the resident's representative indicated she believed it was a Sunday when she had called the facility. Resident B had called her and was upset. She had run out of the appropriate size briefs. She had been incontinent, her clothes were wet, and she was afraid the incontinence would go onto the floor. She was upset because she had heard someone around the corner say that a grown woman shouldn't wet herself. The resident representative came to the facility and told the nurse she wanted to talk to the on-call person. The nurse indicated she would text the Administrator. The resident representative along with another family member went to the resident's room. Resident B was in bed. She was very upset. The nurse brought down the two CNAs who were on the unit. One CNAs indicated she was tired of being lied on. The resident was visibly upset, had tears in her eyes, and looked fearful. The resident indicated when the CNAs left that now they would be mean to her. The resident indicated she did not see who said she shouldn't wet herself, but she thought it was the one who was not always nice to other residents either. The resident representative talked to the Administrator later that day. During an interview, on 11/7/25 at 1:37 p.m., CNA 5 indicated she believed on 10/26/25 after lunch she and CNA 3 were told that Resident B needed changed. Resident B wouldn't tell the CNAs she was incontinent but told the nurse she was incontinent. The CNAs changed the resident, then were told a little later they needed to go to Resident B's room. The resident's representative was in the room with a family member when the CNAs and the nurse entered the room. Resident B said it was not them. The CNAs checked on the resident again and finished their shift. The CNAs did not write out a statement that day (10/26/25). CNA 5 told the Administrator her statement, the Administrator wrote it out, then CNA 5 signed it on 10/27/25. CNA 5 indicated Resident B knows when she goes to the bathroom. Resident B was supposed to be transferring with the walker, but she would not. Resident B did stuff to trap the CNAs in her room. When Resident B had a concern, she would not tell the staff but called her sister to report them. CNA 5 had no disciplinary actions against her while working at the facility. During an interview, on 11/7/25 at 2:13 p.m., RN 9 indicated on 10/26/25, after lunch, the CNAs were taking residents from the dining room to their rooms. Resident B's representative asked to speak to the Administrator. The resident's representative indicated Resident B had told her the CNAs had said Resident B was old enough to hold her urine, and they had to keep getting her up and down like a yo-yo to go to the bathroom. When the resident representative and RN 9 went down to Resident B's room, Resident B indicated she had overheard the conversation, and it had not happened that day. The CNAs came down to the room. She indicated she was not accusing them. Resident B did not act intimidated, but she was crying without any visible tears. After the CNAs left the room, RN 9 spoke with the resident representative for a while longer. She then called the Administrator. She did not send anyone home; the CNAs finished their shift. During an interview, on 11/7/25 at 2:24 p.m., RN 9 indicated she had let the Administrator know of the incident on 10/26/25 at 1:26 p.m. according to the date and time on her phone. During an interview, on 11/7/25 at 3:30 p.m., the Administrator indicated on 10/27/25 at 3:00 p.m., Resident B told her that the CNAs yelled at her on 10/26/25. Prior to that she had received a text from RN 9 about the situation on 10/26/25. She talked to RN 9 on the phone around 4:00 pm on 10/26/25. The resident's representative had told RN 9 that 2 CNAs said that adults don't pee their pants. RN 9 talked to Resident B who had a different story. Resident B said different times and was not sure of anything. RN 9 had said she saw the CNAs on the floor that day passing by the room and pulled them into the room for Resident B to identify as the alleged perpetrators. When Resident B was asked if the CNAs were the ones who spoke about her in the hall, she said no. RN 9 indicated Resident B was not overly upset. RN 9 told her the resident did not know if it happened that day or another time. RN 9 told the Administrator that Resident B never really got out what she meant. The Administrator called the resident's representative after she hung up with RN 9 and did not reach her. The resident's representative called the Administrator back approximately 20 minutes later and discussed the situation. The resident representative agreed Resident B kept changing her story. On 10/27/25 at 3:00 p.m., she talked to Resident B. The resident cried and indicated she did not want the CNAs to be fired or get in trouble. The Administrator began the investigation and reported the incident at that time to the State agency. The Administrator had believed this was not abuse, but more of a customer service issue since Resident B had overheard something. However, once she talked to Resident B, she felt like this was an abuse thing. The CNAs were suspended after the Administrator talked to Resident B. She had one previous report of CNA 5 swearing in the hall. The person who reported the swearing indicated no resident had been around when the swearing happened. The Administrator spoke with CNA 5 and told her swearing was not acceptable in the facility. She indicated it could be intimidating to bring alleged perpetrators into the resident's room for the resident to identify them. She was uncertain why CNA 3's statement was not included in the investigation. She indicated all parties involved should be included to ensure a thorough investigation. The staff and resident interviews regarding the abuse allegation were completed on the dates that were on the papers. A facility document, provided by the Administrator on 11/7/25 at 3:54 p.m., was notes on an interview with CNA 3. The document indicated CNA 3 said she got up Resident B and put her to bed. The resident had said no, it was not the CNAs that said the statements about her incontinence. The CNAs always go into the resident's room and take care of her. A current facility policy, dated 8/2024, titled Abuse, Neglect, Exploitation and Misappropriate, Reporting, and Investigating, provided by the Administrator on 11/6/25 at 4:23 p.m., indicated the following: .All reports of resident abuse (including injuries of unknow origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigation by facility management. Findings of all investigation are documented and reported.All allegations are thoroughly investigated.Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. This citation relates to Intake 2657526. 3.1-28(d)

Based on interview, observation, and record review, the facility failed to protect a resident's dignity by failing to provide necessary assistive mechanical lift slings for the transfer process resulting in a resident having to remain in bed despite her preferences for daily activities for 1 of 3 residents reviewed for dignity. (Resident 26)Finding includes: During an interview, on 9/22/25 at 10:34 a.m., Resident 26 indicated she required a mechanical lift for transferring from bed to her wheelchair and back to the bed. She was informed by facility staff there was a limited supply of mechanical lift slings, and she had to stay in bed over the previous weekend due to a mechanical lift sling not being available. She had soiled her sling due to incontinence and then had to wait for two days for the sling to be washed, air dried, and returned to the floor. Resident 26's clinical record was reviewed on 9/25/25 at 4:02 p.m. Diagnoses included muscle wasting and atrophy (shrink), fracture of the lower end of the femur (thigh bone that extends from hip to knee), morbid obesity, muscle weakness, and anxiety.A 9/2/25, admission, Minimum Data Set (MDS) assessment indicated Resident 26' was cognitively intact. She was dependent for toileting, hygiene, and needed substantial/maximal assistance for lower body dressing. Mobility activities were not attempted due to medical condition or safety concerns.A 9/2/25, state optional, MDS assessment indicated Resident 26 was totally dependent on two plus persons' physical assistance for transfers.A current care plan, revised on 9/3/25, indicated Resident 26 had an activity of daily living (ADL) self-care performance deficit related to impaired mobility, a recent femur fracture, and an extensive medical history. Interventions included Resident 26 required a mechanical lift with two staff assistance for transfers (08/27/25), she was dependent for toileting hygiene (9/3/25), and she did not walk (8/27/25).A current care plan, revised on 9/3/25, indicated that Resident 26 had bladder incontinence related to impaired mobility and diuretics. Interventions included Resident 26 was to be supplied with toileting devices, including bedpan, as appropriate (8/27/25).A current care plan, revised on 8/29/25, indicated Resident 26 had personal preferences in regard to her care that were important to her. She really enjoyed arts and crafts and was extremely social and liked being around other people. The goals indicated Resident 26 would attend the activities of her choice throughout her stay and her desires and personal preferences would be honored within the parameters of safe care through the next review. Interventions included to ensure Resident 26's dignity was maintained.During an interview, on 9/25/25 at 11:48 a.m., CNA 11 indicated the facility had a limited supply of full body slings for the mechanical lift. Residents had to be left in bed due to the lack of mechanical lift slings available due to quantity or slings being laundered.During an interview, on 9/26/25 at 1:26 p.m., CNA 5 indicated residents had informed her they had to stay in bed due to mechanical lift slings being unavailable. Soiled mechanical lift slings were sent to laundry to get washed and air dried. The turnaround time after a mechanical sling was sent to laundry was usually the next day.During an interview, on 9/26/25 at 2:13 p.m., the DON indicated mechanical lift slings were overseen by housekeeping, and they maintained a list of facility slings. She was unsure if the list contained the types and sizes of the slings. Slings were numbered when purchased. Slings were replaced if one was disposed of. Once slings were sent to laundry, the turnaround time was the same day or the next day. During an interview, on 9/26/25 at 2:35 p.m., the Administrator indicated that the mechanical lift sling list could not be located. The slings were numbered on their tags once received at the facility. She thought the facility had 21 slings in total. She was not aware that mechanical lift slings were not available. She purchased three new slings earlier this year. During an observation, on 9/26/25 at 2:45 p.m., the Administrator opened the linen closet. The linen closet contained three split slings and one shower sling. One of the four slings was numbered.During an interview, on 9/26/25 at 2:58 p.m., the DON indicated she was not aware of residents being left in bed due to lack of mechanical lift slings. She expected staff to notify her if residents were unable to get out of bed. She was not aware of any concerns regarding the lack of slings.During an interview, on 9/26/25 at 3:55 p.m., RN 12 indicated she was not aware Resident 26 was left in bed between 9/20/25 and 9/21/25 due to a mechanical lift sling being unavailable. She recalled Resident 26 had remained in bed one of the days over the past weekend, but was unable to recall which day. During a phone interview, on 9/26/25 at 3:56 p.m., CNA 13, indicated Resident 26 had to stay in bed after supper on 9/21/25 due to the lift sling being soiled. Another sling that would fit her properly and without digging into her skin was unavailable. Resident 26 did not want to use the split sling due to it going underneath her knees and she had knee pain. Resident 26 did not like the type of sling that had straps which crisscrossed under the legs. During a phone interview, on 9/26/25 at 4:00 p.m., CNA 11 indicated Resident 26 was left in bed on Saturday 9/20/25. Staff provided personal care to Resident 26 and had gotten her dressed. Staff went to the linen closet to obtain a lift sling, and a full body sling was unavailable. Resident 26 stayed in bed due to the full body sling being laundered. Resident 26 did not get out of bed until 9/21/25.During a phone interview, on 9/26/25 at 4:09 p.m., CNA 3 indicated Resident 26 was left in bed on 9/20/25 due to the lack of availability of a full body sling. Resident 26 preferred full body slings due to split slings not being comfortable for her and because she has knee pain. Resident 26 was informed of a full body sling being unavailable and the inability to get her out of bed. CNA 3 initially checked laundry, and the sling was in the wash and again a couple hours later and it was hanging and air-drying. CNA 3 informed the weekend nurse that slings were not available. This was not the first incident that a resident had to be left in bed due to lack of lift slings. Previously, staff had informed the prior housekeeping supervisor. During an interview, on 9/2625 at 4:18 p.m., Resident 26 indicated that staff were unable to get her out of bed the previous weekend due to the lack of mechanical lift slings. She became very stiff due to being in bed for a prolonged period of time. This was not the first time this had occurred. A previous time caused her to miss playing BINGO, which was one of her favorite activities that she participated in. This past weekend, staff had gotten her dressed and ready for the day and then informed her they couldn't get her up due to the mechanical lift sling being in the laundry. Slings were usually in laundry for 24-48 hours. Most days, it had come to feel like first come first serve for lift slings. Sling shortage appeared to be on all shifts, all days of the week. She preferred full body slings due to safety and anxiety. Due to her size and physical problems, she felt she would fall out of a split sling. The CNAs were aware she preferred full body slings.A current facility policy, dated 8/2024 and titled SUBJECT: Dignity, provided by the Administrator on 9/26/25 at 3:51 p.m., indicated the following: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals choices preferences values and beliefs.5. When assisting with care residents are supported in exercising their rights for example residents are: b. encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities;.d. allowed to choose when to sleep, eat, and conduct activities of daily living .12. Demeaning practices and standards of care that compromise dignity or prohibited. Staff are expected to promote dignity and assist residents; for example: f. promptly responding to a residence request for toileting assistance.A current facility policy, dated 8/2024, titled SUBJECT: Activities of Daily Living (ADLs), Supporting, provided by the Administrator on 9/26/25 at 4:43 p.m., indicated the following: Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: b. mobility (transfer and ambulation, including walking); c. elimination (toileting);.7. The resident's response to interventions will be monitored evaluated and revised as appropriate.3.1-3(t)3.1-3(u)(1)3.1-3(v)(1)

Based on observation, record review, and interview, the facility failed to ensure ordered adaptive equipment for eating was provided for 1 of 3 residents reviewed for activities of daily living (ADLs) (Resident 29). Finding includes: During an observation, on 9/22/25 at 11:40 a.m., Resident 29 was served lunch. His meal was served on a regular plate, regular bowl, and regular utensils. No adaptive utensils, plateware, or cups were observed in the dining room. During an observation, on 9/23/25 at 11:44 a.m., Resident 29 used regular utensils, cups, and plates during lunch. Resident 29's clinical record was reviewed on 9/24/25 at 3:04 p.m. Diagnoses included unspecified intellectual disabilities, vascular dementia, muscle weakness (generalized), and dysphagia (difficulty/discomfort swallowing) oropharyngeal phase. Current orders included resident to use built up handled utensils, one handled cup with spout, scoop bowl, and plate with suction base at all meals (9/27/24). An annual Minimum Data Set (MDS) assessment, dated 7/11/25, indicated the resident was severely cognitively impaired. He was independent with eating. A current nutritional care plan indicated the resident was at risk for malnutrition related to body mass index greater than 25 and chronic disease (9/14/14). Interventions included built up handled utensils (7/21/25), handled cup with spout (7/21/25), plate with suction base (7/21/25), provide built up utensils, one handled cup with spout, scoop bowl and plate with base at all meals (11/5/24), and scoop bowl with suction cup (7/21/25). During an interview, on 9/25/25 at 11:48 a.m., CNA 11 indicated the resident fed himself and did not use specialty items during dining service. She looked around the dining room and indicated everyone in the main dining room utilized regular cups, plates, and bowls. Adaptive dining equipment needs were communicated verbally or on the Kardex (care needs summary) in the resident's electronic chart. During an interview, on 9/25/25 at 12:08 p.m., CNA 11 accessed the resident's information on an electronic tablet and indicated the adaptive dining equipment was listed. She did not recall the resident ever using the listed adaptive dining equipment and was unaware he was supposed to use it. The resident managed well without the listed adaptive equipment, though he experienced minimal difficulty at times. During an interview, on 9/25/25 at 3:44 p.m., the DON indicated the adaptive dining equipment was listed on the resident's Kardex in the resident's clinical record. Once an order was received, the nursing staff completed a dietary communication slip. The dietary staff was responsible for the provision of the adaptive dining equipment at meals. The resident's care plan and orders should be followed. During an interview, on 9/25/25 at 3:59 p.m., the Administrator reviewed the resident's dietary slip for dinner. She indicated that adaptive dining equipment was not listed on the slip, although it should have been. A current facility policy, dated 12/2022, titled SUBJECT: Kitchen Operations: Meal Service and Distribution, provided by the DON on 9/26/25 at 3:06 p.m., indicated the following: POLICY .Effective equipment will be provided .PROCEDURE: 2. All residents will be orivided with the proper assistive devices as identified by the care plan A current facility policy, dated 8/2024, titled SUBJECT: Assistance with Meals, provided by the DON on 9/26/25 at 4:05 p.m., indicated the following: .Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipement and utensils) will be provided for residents who need or request them. Thes may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups 3.1-38(a)(2)(D)

Based on interview, observation, and record review, the facility failed to provide transfer assistance to a dependent resident for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident 26)Finding includes:During an interview, on 9/22/25 at 10:34 a.m., Resident 26 indicated she required a mechanical lift for transferring from bed to her wheelchair and back to the bed. She was informed by facility staff there was a limited supply of mechanical lift slings, and she had to stay in bed over the previous weekend due to a mechanical lift sling not being available. She had soiled her sling due to incontinence and then had to wait for two days for the sling to be washed, air dried, and returned to the floor. Resident 26's clinical record was reviewed on 9/25/25 at 4:02 p.m. Diagnoses included muscle wasting and atrophy (shrink), fracture of the lower end of the femur (thigh bone that extends from hip to knee), morbid obesity, muscle weakness, and anxiety.A 9/2/25, admission, Minimum Data Set (MDS) assessment indicated Resident 26' was cognitively intact. She was dependent for toileting, hygiene, and needed substantial/maximal assistance for lower body dressing. Mobility activities were not attempted due to medical condition or safety concerns.A 9/2/25, state optional, MDS assessment indicated Resident 26 was totally dependent on two plus persons' physical assistance for transfers.A current care plan, revised on 9/3/25, indicated Resident 26 had an activity of daily living (ADL) self-care performance deficit related to impaired mobility, a recent femur fracture, and an extensive medical history. Interventions included Resident 26 required a mechanical lift with two staff assistance for transfers (08/27/25), she was dependent for toileting hygiene (9/3/25), and she did not walk (8/27/25).A current care plan, revised on 9/3/25, indicated that Resident 26 had bladder incontinence related to impaired mobility and diuretics. Interventions included Resident 26 was to be supplied with toileting devices, including bedpan, as appropriate (8/27/25).During an interview, on 9/25/25 at 11:48 a.m., CNA 11 indicated the facility had a limited supply of full body slings for the mechanical lift. Residents had to be left in bed due to the lack of mechanical lift slings available due to quantity or slings being laundered.During an interview, on 9/26/25 at 1:26 p.m., CNA 5 indicated residents had informed her they had to stay in bed due to mechanical lift slings being unavailable. Soiled mechanical lift slings were sent to laundry to get washed and air dried. The turnaround time after a mechanical sling was sent to laundry was usually the next day.During an interview, on 9/26/25 at 2:13 p.m., the DON indicated mechanical lift slings were overseen by housekeeping, and they maintained a list of facility slings. She was unsure if the list contained the types and sizes of the slings. Slings were numbered when purchased. Slings were replaced if one was disposed of. Once slings were sent to laundry, the turnaround time was the same day or the next day.During an interview, on 9/26/25 at 2:35 p.m., the Administrator indicated that the mechanical lift sling list could not be located. The slings were numbered on their tags once received at the facility. She thought the facility had 21 slings in total. She was not aware that mechanical lift slings were not available. She purchased three new slings earlier this year.During an observation, on 9/26/25 at 2:45 p.m., the Administrator opened the linen closet. The linen closet contained three split slings and one shower sling. One of the four slings was numbered.During an interview, on 9/26/25 at 2:58 p.m., the DON indicated she was not aware of residents being left in bed due to lack of mechanical lift slings. She expected staff to notify her if residents were unable to get out of bed. She was not aware of any concerns regarding the lack of slings.During an interview, on 9/26/25 at 3:55 p.m., RN 12 indicated she was not aware Resident 26 was left in bed between 9/20/25 and 9/21/25 due to a mechanical lift sling being unavailable. She recalled Resident 26 had remained in bed one of the days over the past weekend, but was unable to recall which day.During a phone interview, on 9/26/25 at 3:56 p.m., CNA 13, indicated Resident 26 had to stay in bed after supper on 9/21/25 due to the lift sling being soiled. Another sling that would fit her properly and without digging into her skin was unavailable. Resident 26 did not want to use the split sling due to it going underneath her knees and she had knee pain. Resident 26 did not like the type of sling that had straps which crisscrossed under the legs. During a phone interview, on 9/26/25 at 4:00 p.m., CNA 11 indicated Resident 26 was left in bed on Saturday 9/20/25. Staff provided personal care to Resident 26 and had gotten her dressed. Staff went to the linen closet to obtain a lift sling, and a full body sling was unavailable. Resident 26 stayed in bed due to the full body sling being laundered. Resident 26 did not get out of bed until 9/21/25.During a phone interview, on 9/26/25 at 4:09 p.m., CNA 3 indicated Resident 26 was left in bed on 9/20/25 due to the lack of availability of a full body sling. Resident 26 preferred full body slings due to split slings not being comfortable for her and because she has knee pain. Resident 26 was informed of a full body sling being unavailable and the inability to get her out of bed. CNA 3 initially checked laundry, and the sling was in the wash and again a couple hours later and it was hanging and air-drying. CNA 3 informed the weekend nurse that slings were not available. This was not the first incident that a resident had to be left in bed due to lack of lift slings. Previously, staff had informed the prior housekeeping supervisor.During an interview, on 9/2625 at 4:18 p.m., Resident 26 indicated that staff were unable to get her out of bed the previous weekend due to the lack of mechanical lift slings. She became very stiff due to being in bed for a prolonged period of time. This was not the first time this had occurred. A previous time caused her to miss playing BINGO, which was one of her favorite activities that she participated in. This past weekend, staff had gotten her dressed and ready for the day and then informed her they couldn't get her up due to the mechanical lift sling being in the laundry. Slings were usually in laundry for 24-48 hours. Most days, it had come to feel like first come first serve for lift slings. Sling shortage appeared to be on all shifts, all days of the week. She preferred full body slings due to safety and anxiety. Due to her size and physical problems, she felt she would fall out of a split sling. The CNAs were aware she preferred full body slings.A current facility policy, dated 8/2024, titled SUBJECT: Activities of Daily Living (ADLs), Supporting, provided by the Administrator on 9/26/25 at 4:43 p.m., indicated the following: Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: b. mobility (transfer and ambulation, including walking); c. elimination (toileting);.7. The resident's response to interventions will be monitored evaluated and revised as appropriate.3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure the physician ordered diet was followed for 1 of 3 residents reviewed for nutrition (Resident 16). Finding includes:Resident 16's clinical record was reviewed on 9/24/25 at 3:47 p.m. Diagnoses included type 2 diabetes mellitus without complications, vitamin B12 deficiency anemia, and dementia.Current orders included regular diet with mechanical soft texture, no mashed potatoes, straws with liquids and given on right side of mouth, small sips (5/2/25), sitagliptin phosphate (for diabetes) 50 mg daily (9/24/25), and insulin glargine 100 units/mL - inject 15 units twice a day (5/10/25). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/25, indicated the resident was severely cognitively impaired. He required supervision and cueing with eating. A current nutritional care plan (revised on 5/21/25) indicated the resident was at risk for malnutrition related to chronic disease, a body mass index greater than 25, and altered carbohydrate metabolism from diabetes. Interventions included provide and serve diet as ordered (2/10/25) and registered dietitian (RD) to evaluate and make diet change recommendations as needed (2/10/25). A nutritional risk assessment, completed by the dietitian, dated 7/16/25, indicated the resident received a regular diet with mechanical soft textures, thin liquids, no mashed potatoes, and straws with liquids and given in small sips on right side of mouth. During a dining observation on 9/25/25 at 11:34 a.m., the resident fed himself bites of meatloaf, mashed potatoes and gravy, carrots, and vanilla ice cream. He indicated that he was eating bananas and pointed to the carrots. During a dining observation on 9/25/25 at 12:09 p.m., CNA 3 assisted the resident with eating all his mashed potatoes and meat loaf. Resident 16's 9/25/25 lunch meal ticket, provided by CNA 3, listed mashed potatoes for the resident's starch for the meal. During an interview, on 9/25/25 at 12:20 p.m., CNA 3 indicated she assisted Resident 16 to eat his mashed potatoes, and he seemed to do okay with them. He had received mashed potatoes on his meal trays other times she had worked. During an interview, on 9/26/25 at 11:40 a.m., the Dietary Manager indicated when a resident's diet order changed, she was supposed to get a form with the diet change. She was not always given the form with diet changes. She had been unaware of Resident 16's order for no mashed potatoes. The diet card had listed mashed potatoes for serving. During an interview, on 9/26/25 at 1:14 p.m., the Speech Therapist (ST) indicated she did not know how the no mashed potatoes got put on the order she had put in for the resident on 5/21/25. She had not limited mashed potatoes in the past as there would not be a reason to do so. n The dietary manager had asked her if she knew about the resident having an order for no mashed potatoes about a month ago. She thought it might have been a dislike put in by the nursing department, but she did not know. The resident had not been on her caseload at that time, so she did not investigate it any further. During an interview, on 9/26/25 at 2:14 p.m., RN 7 indicated she had only put in a diet order one time. The ST put the order into the resident's electronic record, then the nurse filled out a form with the diet change and gave the form to dietary. During an interview, on 9/26/25 at 2:56 p.m., the DON indicated when the ST recommended a diet, the ST put the order in the resident's electronic record, the nurse confirmed the order, then a form was given to dietary with the diet change. The resident's diet orders should have been followed, and the resident should not have received mashed potatoes. A current facility policy, revised 8/2024, provided by the DON on 9/26/25 at 3:45 p.m., titled Medication, Diet, and Treatment Orders, indicated the following: .Dietary orders will be communicated to the dietary department using the dietary communication form and will be added to the meal ticket. 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to ensure carpeting in resident rooms, hallways and common areas were clean and free from stains for 2 of 2 units in the facility (100 hall and 200 hall). This deficient practice had the potential to impact 25 of 25 residents who resided in the facility. Findings include:Confidential interviews were conducted during the survey. During a confidential interview, it was indicated the hallways had spots or stains. The facility said they would have the carpet cleaned. It was at least five months since they shampooed it. It needed a good scrub. During a confidential interview, it was indicated the facility shampooed the carpet once in a while, but not often.During a confidential interview, it was indicated there had been spots on hallway carpets for quite a while.During a confidential interview, it was indicated there was heavy staining on the carpet in empty resident rooms.During a confidential interview, it was indicated the facility did not have a way to shampoo carpets.During a confidential interview, it was indicated dark spots on the carpet had been present for over a year and a half. Review of Resident Council meeting minutes for May, June, and July 2025 indicated concerns regarding the frequency and thoroughness of room cleaning and/or floor cleaning. During an environmental tour of the facility on 8/6/25 from 11:36 a.m. to 12:12 p.m., the following concerns regarding clean and stain-free carpets were observed: The Theater Room common activity room carpeting had approximately 11 dark brown quarter-sized marks in the center of the room.The 200 hallway had brown carpeting over the entire hall. The hallway had grayish discoloration to carpeting at the threshold area of the majority of the resident room doorways.The hallway carpeting outside of room [ROOM NUMBER] had a white- yellowish mark approximately the 1/2 inch by 1/2 inch in size. The hallway carpet outside room [ROOM NUMBER] had a dark brown smudgy mark approximately 3 inches by 2 inches.Unoccupied resident room [ROOM NUMBER]'s carpet located outside the bathroom door had a brownish gray discolored area about 2 feet by 2 feet .Unoccupied resident room [ROOM NUMBER]'s carpet in front of the armoire had a dark brown spot with a spill-like pattern approximately 1 foot by 2 foot. In the middle of the room, there was another dark brown spot about 4 inches by 4 inches in size.In the center of the 200 hallway between rooms [ROOM NUMBERS], the carpet had a dark brown spot approximately 3 inches by 3 feet.Throughout the 200 hallway the carpet had random dark brown colored quarter-sized spots. The hallway carpet outside room [ROOM NUMBER] had a one foot by one foot splatter-like dark brown mark.The hallway carpet outside room [ROOM NUMBER] had a one foot by one foot dark mark. The hallway carpet outside the 200 shower room threshold area had a gray discolored area which extended from the door to about two feet out.The hallway outside room [ROOM NUMBER] had a 1 foot by two-foot spill-like dark mark.Unoccupied resident room [ROOM NUMBER]'s carpeting had 3 feet by 6 feet splotchy discoloration in the center of the room. Unoccupied resident room [ROOM NUMBER]'s carpeting had a one foot by two feet dark spot in the center of the room and beside the bed had a dark brown smudge-looking three feet by one foot mark.The hallway carpet in the middle of hall between room [ROOM NUMBER] and 202 had one foot by 2 feet oily-looking dark mark. Unoccupied resident room [ROOM NUMBER]'s carpeting had a three feet by five feet dark mark, just inside door. The rest of the carpet had splotchy discoloration throughout the room. Resident room [ROOM NUMBER]'s carpeting in front of recliner had a two foot by one foot dark mark.Unoccupied resident room [ROOM NUMBER]'s carpeting had a four foot by three foot dark mark in center of room and small spots throughout.The Entrance Lobby/Lounge, 200 Nursing Station, and hallway leading from these areas to the 100 Hall/Secured Unit, Main Dining Room and Therapy room also had brown carpet with random discoloration. The Entrance Lobby/Lounge had a one foot by one foot dark brown mark on the carpet in front of the TV and there were multiple small dark spots in front of the chair.The hallway carpet outside the Administrator's office had a one foot by two foot dark brown spill like mark.The 200 Hall Nursing Station carpet had a two foot by three foot dark brown spot.The hallway carpet outside the Employee Entrance Service Corridor door had a two foot by one foot dark brown mark and three inch by one inch dark mark.The Therapy room carpet had a two foot by two foot dark brown mark in the center of the room.The 100 Hall/Secured Dementia Unit had a lighter brown flecked carpet throughout the hallway and in resident rooms.The hallway carpet outside room [ROOM NUMBER] had a one foot by two foot discolored area.The hallway carpet outside the Treatment Room had a one foot by one foot dark brown spot.Unoccupied resident room [ROOM NUMBER]'s carpet had a two foot by three-foot light gray mark in the center of the room.The hallway carpeting outside room [ROOM NUMBER] had a four inch by three inch yellow/off white mark.The hallway carpet prior to rooms [ROOM NUMBERS] had an eight inches by two inch dark brown spilled pattern mark.The hallway carpet prior to rooms [ROOM NUMBERS] had a two foot by one foot dark brown mark.The hallway carpet in front of the exit door by room [ROOM NUMBER] had a white ring like a leak stain which extended from the door approximately one foot and was about five feet in length.The combination Lounge and Dining room's carpet had a one foot by two foot yellowish stain by the table.The small lounge by the 100 hall nursing station's carpet had a three inch by five inch dark mark and a four inch by three inch dark mark. During an interview on 8/6/25 at 10:42 a.m., the DON indicated the facility had borrowed a carpet shampooer from a sister facility and shampooed carpets near the end of June 2025. A professional carpet cleaning statement, provided by the Administrator on 8/6/25 at 10:43 a.m., indicated the carpeting in the 3three halls, lobby, Nurses Station, Office, and a spot in the Therapy Room was last professionally cleaned on 11/5/24. This citation relates to Intake 2578686.

Based on observation, interview, and record review, the facility failed to ensure resident medications were properly labeled and disposed of for 1 of 3 medication carts observed. (200 Front Hall Cart) Finding includes: During an observation, on 3/13/25 beginning at 11:04 a.m., the top drawer in the left section of the 200 Front Hall Medication Cart contained an uncovered paper medication cup containing a green capsule, two cream-colored capsules, two round white tablets, and one oblong oval shaped white tablet. The paper cup had Resident N's last name and the words evening meds written in pen on it. During an interview, at the same time of the observation above, LPN 3 indicated she had not noticed the paper cup of medications in the cart when she passed medications earlier. Resident N had probably refused the medications, and the evening shift nurse had forgotten to destroy them. When a resident refused his/her medication, the medication should be destroyed right away. During an interview, on 3/13/25 at 11:06 a.m., the Director of Nursing indicated medications should be destroyed immediately after a resident refused them, and medications found in medication cups in the medication cart should be destroyed upon finding them. A current facility policy, dated 8/2024, titled Discarding and Destroying Medications, provided by the Administrator on 3/13/25 at 1:57 p.m., indicated the following: .Medications that cannot be returned to the dispensing pharmacy (e.g., non unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances This citation relates to Complaint IN00453004. 3.1-25(k) 3.1-25(o)

A. Based on observation, interview, and record review the facility failed to follow physician's orders for 1 of 16 residents reviewed for resident choices. (Resident C) B. Based on interview and record review, the facility failed to follow up on reported resident's concerns for 1 of 16 residents reviewed for resident choices. (Resident B) Findings include: A. During an interview on 11/1/24 at 1:51 p.m., Resident C's representative indicated the resident had problems with swelling in his lower extremities. The resident had requested compression wraps for his bilateral lower legs some time back, but the facility had not provided the compression wraps. The resident's representative indicated he had asked the nurse again on 11/1/24 for compression wraps for the resident's bilateral lower legs to help with the ongoing swelling in the resident's lower legs and feet. During an observation at the time of interview, the resident's bilateral legs and feet were elevated in his recliner, moderately swollen, and without compression wraps. During an observation on 11/6/24 at 4:20 p.m., the resident was seated on the side of his bed. His feet were bare, and his pant legs were pulled up as the resident looked at his legs and feet. Compression wraps were not in place. Moderate swelling was noted with tight skin in the resident's bilateral lower legs and feet. The resident's bilateral shins were cracked. He indicated his resident representative had asked the facility about getting an order for the compression wraps for his legs and feet, but so far no one had used any compression wraps on his legs and feet since he had been at the facility. Review of the Treatment Administration Record indicated the compression wraps were applied on 11/6/24 and 11/7/24. Resident C's clinical record was reviewed on 11/6/24 at 4:58 p.m. Diagnoses included chronic peripheral venous insufficiency, stage 3 chronic kidney disease, and retention of urine. Current physician orders included application of compression wraps to the bilateral legs every day shift for prevention and removal of ace wraps daily at bedtime, dated 11/5/24. A quarterly Minimum Data Set (MDS) assessment, dated 9/10/24, indicated the resident was cognitively intact. He required substantial assistance from staff for toileting, showering, and lower body dressing. A current care plan, dated 5/21/24, included a risk for fluid imbalance related to stage 3 chronic kidney disease and diuretic use. Interventions included to observe for and notify the provider of observed signs and symptoms of fluid overload (5/21/24). The interventions lacked compression wraps to the bilateral lower extremities. A Nurse's Note, dated 11/1/24 at 2:56 p.m., indicated the resident requested compressions wraps for his bilateral legs. A Nurse's Note, dated 11/4/24 at 9:43 a.m., indicated the resident requested compression wraps for his legs. A Nurse's Note, dated 11/5/24 at 9:07 a.m., indicated orders were received for compression wraps to the resident's legs. During an observation at the time of interview on 11/7/24 at 12:35 p.m., the resident was in bed and indicated no one had applied compression wraps to his legs and feet even though they were requested several days ago. The resident's legs and feet were without compression wraps in place during the observation and remained moderately swollen. During an interview at the time of observation on 11/7/24 at 1:05 p.m., CNA 9 indicated she had provided the resident's care on 11/6/24 and 11/7/24 and the resident did not have compression wraps on him during those dates on her shift. He did not have compression wraps on his lower extremities during the interview. She was very familiar with the resident's care and had never seen any compression wraps anywhere in his room. The resident always had swelling in his lower extremities. He was cooperative and compliant when care was provided. She looked through the resident's drawers and his room with no compression wraps found during the observation. She was not aware the resident had an order to wear compression wraps. During an interview on 11/7/24 at 1:13 p.m., the DON indicated orders should not have been signed off by the nurse before the treatment had been completed. During an interview on 11/7/24 at 3:02 p.m., the [NAME] President of Clinical Services indicated the facility lacked a policy regarding following physician orders. The facility followed nursing standards of practice. 45122 B. During an interview, on 11/4/24 at 8:54 a.m., Resident B indicated her pain patch was no longer working. She was glad LPN 11 was working that day as LPN 11 had notified the physician about the resident's increased pain and was waiting to hear what the physician decided. Resident B's clinical record was reviewed on 11/6/24 at 3:21 p.m. Diagnoses included radiculopathy lumbar region (a painful condition that occurs when the nerve roots in the lower back are compressed or irritated), chronic kidney disease stage 3, and adult failure to thrive. Physician's orders included buprenorphine (narcotic pain medication) transdermal patch 5 micrograms per hour (mcg/hr) apply weekly (started 10/17/24), acetaminophen (for pain) 8 hour arthritis extended release 650 milligrams (mg) daily (started 10/23/24), naproxen (for pain) 500 mg twice a day (started 12/13/23), tramadol (for pain) 100 mg twice a day (started 4/20/24), acetaminophen 650 mg every 4 hours as needed (PRN) for pain (started 4/19/24), and tramadol 50 mg every 24 hours as needed for pain (started 4/20/24). The Minimum Data Set (MDS) assessment, dated 10/25/24, indicated the resident was cognitively intact. She received scheduled and PRN pain medications. A care plan for pain was initiated on 5/22/24 and revised on 4/18/23. Interventions included the following: Administer analgesics as per orders (initiated 5/6/22 and revised 5/6/22). Evaluate the effectiveness of pain interventions. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition (initiated 5/6/22). Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain (initiated 5/6/22). A Nurse's Note, dated 11/4/24 at 9:21 a.m., indicated the resident had increased leg pain and had requested to try gabapentin (used for pain for certain nervous conditions). The medication administration record for November 2024 indicated the resident had a pain level of 7 of 10 when her buprenorphine transdermal patch was applied on 11/7/24. The resident's clinical record was reviewed on 11/8/24 at 9:30 a.m. for a follow-up to the resident's request about gabapentin. No documentation of a new order or a response from the physician was found. During an interview, on 11/8/24 at 10:10 a.m., Licensed Practical Nurse (LPN) 7 indicated if the family or resident requested anything from the physician, she would fax the physician, put it in the doctor's book on what was requested, and document the request in the progress notes. After 24 hours if nothing was done, she would check on it again. If she was waiting for a response from the physician, she would place the request on the 24-hour report sheet and ask the oncoming nurse to follow up on the request to the physician. During an interview, on 11/8/24 at 10:24 a.m., Registered Nurse (RN) 8 indicated she would document in the nurses notes about the resident's complaint and about the physician's notification. She would place it on the 24-hour sheet. If she was not there the next day, someone else should follow up on the physician's response. During an interview, on 11/8/24 at 3:41 p.m., the Director of Nursing indicated how soon a request should be followed-up on depended on the request. She indicated the resident had several medications for pain, and the resident's physician had changed this past week due to a change in the medical director. The resident's prior physician was sometimes slow to respond to the facility's requests. No one had followed up on the resident's request to try gabapentin as far as she knew. A current facility policy, dated 8/2022, titled Resident Change of Condition, provided by the DON on 11/8/24 at 4:43 p.m., indicated the following: POLICY . It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place. PROCEDURE . 3. Non-Urgent Medical Change . c. If unable to reach the physician or family/responsible party, all calls to physicians or exchanges and family/responsible party requesting callbacks will be documented in the medical record. d. If the physician has not returned the call by the end of the shift, the oncoming nurse will be notified for follow-up. e. If unable to contact attending physician or alternate timely, the Medical Director will be notified for response and intervention for the resident change of condition . g. The licensed nurse responsible for the resident will continue assessment and documentation in the medical record every shift until the resident's condition has stabilized. This citation relates to complaint IN00444162. 3.1-37(a)

Based on interview and record review, the facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications (Resident 16 and Resident 18). Findings include: 1. Resident 16's clinical record was reviewed on 11/7/24 at 11:52 a.m. Diagnoses included aphasia following cerebral infarction, depression, disorientation, and anxiety disorder. Physician's orders included lorazepam (antianxiety) 0.5 mg (milligrams) two tablets every 4 hours as needed (PRN) for anxiety/agitation (started 10/27/24) and lorazepam 0.5 mg every 6 hours PRN anxiety/agitation (started 8/5/24 and discontinued 10/27/24). A significant change Minimum Data Set (MDS) assessment, dated 8/28/24, indicated the resident was severely cognitively impaired. A medication administration record for August 2024 indicated the resident was given lorazepam 0.5 mg on 8/5/24 at 5:04 p.m. and 11:05 p.m., 8/7/24 at 11:24 a.m., and 8/12/24 at 9:03 p.m. A medication regimen review, completed on 8/19/24, indicated lorazepam 0.5 mg give every 6 hours PRN anxiety/agitation started on 8/5/24 was a PRN order for a psychotropic drug and was limited to 14 days, except if the prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days. Rationale and duration of the PRN order was to be documented by the prescriber in the resident's medical record. A medication administration record for September 2024 indicated the resident was given lorazepam 0.5 mg on 9/11/24 at 1:56 p.m. and 10:18 p.m., 9/14/24 at 10:57 p.m., 9/17/24 at 9:09 p.m., 9/18/24 at 6:12 a.m., 9/20/24 at 10:32 p.m., 9/21/24 at 7:11 p.m., and 9/28/24 at 1:57 a.m. A medication administration record for October 2024 indicated the resident was given 0.5 mg lorazepam on 10/18/24 at 10:35 p.m., 10/26/24 at 7:28 p.m., and 10/27/24 at 1:46 p.m. A medication regimen review, completed on 10/21/24, indicated lorazepam 0.5 mg give every 6 hours PRN anxiety/agitation started on 8/5/24 was a PRN order for a psychotropic drug and was limited to 14 days except if the prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days. Rationale and duration of the PRN order was to be documented by the prescriber in the resident's medical record. The nurses notes lacked documentation of physician notification and response to the 8/19/24 and 10/21/24 medication regimen reviews. A Nurse's Note, dated 10/27/24 at 3:27 p.m., indicated the PRN lorazepam order for 0.5 mg started on 8/5/24 was discontinued. A new order for lorazepam 1 mg every 4 hours PRN anxiety/agitation was started and lacked a stop date. 2. Resident 28's clinical record was reviewed on 11/7/24 at 9:27 a.m. Diagnoses included anxiety disorder and congestive heart failure. Physician's orders included lorazepam 0.5 mg every 6 hours PRN for anxiety/agitation (started 7/30/24) and lorazepam 0.5 mg two times a day (started 11/4/24). A significant change MDS assessment, dated 8/9/24, indicated the resident was moderately cognitively impaired. A medication administration record for August 2024 indicated the resident was given lorazepam 0.5 mg on 8/13/24 at 7:05 p.m. and 8/15/24 at 6:00 p.m. A medication regimen review, completed on 8/19/24, indicated lorazepam 0.5 mg give every 6 hours PRN anxiety/agitation started on 7/30/24 required a 14 day stop date or for longer duration if clinically appropriate. A medication administration record for October 2024 indicated the resident was given lorazepam 0.5 mg on 10/4/24 at 3:54 p.m. The Nurse's Notes lacked documentation of the physician notification and response of the 8/19/24 medication regimen review. During an interview, on 11/8/24 at 3:38 p.m., the DON indicated the pharmacy's medication regimen review would have been sent to the resident's physician for review. She usually kept the reviews clipped until she received a response. She had missed this review and did not have a physician response. A current facility policy, dated 2020, provided by the DON on 11/8/24 at 4:43 p.m., titled Drug Regimen Review, indicated the following: .A written report is provided to the physician within seven working days or according to facility policy, with a copy to the facility .The physician's response is documented in the Consultant Pharmacist review record or elsewhere in the resident's medical record .The physician provides a written response of the report to the facility within one month after the report is sent. A copy of the report is kept by the facility until the physicians signed response is returned 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an as needed (PRN) psychoactive medication for 2 of 5 residents reviewed for unnecessary medications. (Resident 16 and Resident 28) Findings include: 1. During an observation, on 11/4/24 at 9:20 a.m., Resident 16 rested in bed with his eyes closed. On 11/6/24 at 3:59 p.m., the resident rested in bed in bed with his eyes closed and leaned right. On 11/7/24 at 12:43 p.m., the resident rested in bed with his eyes gazing at the television. Resident 16's clinical record was reviewed on 11/7/24 at 11:52 a.m. Diagnoses included aphasia following cerebral infarction, depression, disorientation, and anxiety disorder. Physician's orders included lorazepam (antianxiety) 0.5 mg (milligrams) two tablets every 4 hours PRN for anxiety/agitation (started 10/27/24), lorazepam 0.5 mg every 6 hours PRN anxiety/agitation (started 8/5/24 and discontinued 10/27/24), and duloxetine (antidepressant) delayed release 90 mg daily (started 10/22/24). A significant change Minimum Data Set (MDS) assessment, dated 8/28/24, indicated the resident was severely cognitively impaired. He was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, showering/bathing, upper and lower body dressing, rolling left and right, moving from sitting to lying and lying to sitting, and transfers. A care plan for the behavior of calling 911 for basic needs instead of pressing his call light was initiated 5/31/24 and revised on 9/18/24. The interventions included the following: Care givers to provide positive interaction and attention and to stop and talk to the resident when passing by him (initiated 5/31/24 and revised on 9/18/24). Discuss the resident's behavior with him and explain/reinforce why the behavior is inappropriate and/or unacceptable (initiated 5/21/24 and revised 9/18/24). Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (initiated 5/31/24). A care plan for the use of antianxiety medication to treat symptoms of anxiety disorder was initiated on 7/10/24 and revised on 7/10/24. The goals included the resident will show decreased number of episodes of anxiety though the next review date of 12/5/24 (initiated 7/10/24 and revised 8/29/24). The interventions included the following: Administer antianxiety medications as ordered by the physician. Monitor for side effects and effectiveness every shift (initiated 7/10/24). A medication administration record for August 2024 indicated the resident was given lorazepam 0.5 mg on 8/5/24 at 5:04 p.m. and 11:05 p.m., 8/7/24 at 11:24 a.m., and 8/12/24 at 9:03 p.m. A Nurse's Note, dated 8/5/24 at 5:01 p.m., indicated the resident was having anxiety. The physician ordered PRN lorazepam 0.5 mg every 6 hours. A Nurse's Note, dated 8/5/24 at 5:04 p.m., indicated the resident was having a lot of anxiety/agitation and a PRN lorazepam was given. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. A Nurse's Note, dated 8/5/24 at 11:05 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. The behavior monitoring and interventions report on 8/5/24 indicated no resident behaviors were observed. No interventions were marked. A Nurse's Note, dated 8/6/24 at 8:58 a.m., indicated the resident was sleeping soundly and would not awaken to take medications. A Nurse's Note, dated 8/7/24 at 11:24 a.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 8/7/24. A nurses note, dated 8/12/24 at 9:03 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. The behavior monitoring and interventions report on 8/12/24 indicated no resident behaviors were observed and no interventions attempted. A medication administration record for September 2024 indicated the resident was given lorazepam 0.5 mg on 9/11/24 at 1:56 p.m. and 10:18 p.m., 9/14/24 at 10:57 p.m., 9/17/24 at 9:09 p.m., 9/18/24 at 6:12 a.m., 9/20/24 at 10:32 p.m., 9/21/24 at 7:11 p.m., and 9/28/24 at 1:57 a.m. A Nurse's Note, dated 9/11/24 at 1:56 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 9/11/24. A Nurse's Note, date 9/14/24 at 10:57 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. The behavior monitoring and interventions report on 9/14/24 indicated no resident behaviors were observed. No interventions were marked. A Nurse's Note, dated 9/17/24 at 9:09 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 9/17/24. A nurses note, dated 9/18/24 at 6:12 a.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 9/18/24. A Nurse's Note, dated 9/20/24 at 10:32 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 9/20/24. A nurses note, dated 9/21/24 at 7:11 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 9/21/24. A Nurse's Note, dated 9/28/24 at 1:57 a.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. The behavior monitoring and interventions report on 9/28/24 indicated no resident behaviors were observed. No interventions were marked. A medication administration record for October 2024 indicated the resident was given 0.5 mg lorazepam on 10/18/24 at 10:35 p.m., 10/26/24 at 7:28 p.m., and 10/27/24 at 1:46 p.m. A Nurse's Note, dated 10/18/24 at 10:35 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. The behavior monitoring and interventions report on 10/18/24 indicated no resident behaviors were observed. No interventions were marked. A Nurse's Note, dated 10/26/24 at 7:28 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. The behavior monitoring and interventions report on 10/26/24 indicated no resident behaviors were observed. No interventions were marked. 2. During an observation on 11/4/24 at 10:14 a.m., Resident 28 was sitting up in a wheelchair in her room with her eyes open. During an observation on 11/6/24 at 3:57 p.m., the resident was lying in bed with her eyes closed. During an observation on 11/7/24 at 8:30 a.m., the resident was lying in bed in with her eyes closed. Resident 28's clinical record was reviewed on 11/7/24 at 9:27 a.m. Diagnoses included anxiety disorder and congestive heart failure. Physician's orders included lorazepam 0.5 mg every 6 hours PRN for anxiety/agitation (started 7/30/24), lorazepam 0.5 mg two times a day (started 11/4/24), and hydroxyzine pamoate (used for anxiety) 25 mg twice a day (started 2/15/24 and discontinued 11/4/24). A significant change MDS assessment, dated 8/9/24, indicated the resident was moderately cognitively impaired. She required partial/moderate assistance with toileting hygiene, showering and bathing, upper body dressing, and moving from sitting to lying and lying to sitting. She was dependent on the staff for transfers. A care plan with a focus on the resident's restlessness, nervousness, and other anxiety symptoms due to anxiety disorder was initiated on 1/8/24 and revised on 8/28/24. The interventions included the following: Encourage the resident to participate in activities of choice (initiated 1/15/24 and revised 8/28/24). Give meds as ordered (initiated 1/8/24 and revised 1/15/24). A medication administration record for October 2024 indicated the resident was given lorazepam 0.5 mg on 10/4/24 at 3:54 p.m. A Nurse's Note, dated 10/4/24 at 3:54 p.m., indicated the resident was given a PRN lorazepam for anxiety/agitation. The resident's clinical record lacked interventions attempted prior to administration of the PRN medication. No behaviors or interventions were marked on the behavior monitoring and interventions report on 10/4/24. During an interview, on 11/8/24 at 10:10 a.m., Licensed Practical Nurse (LPN) 7 indicated prior to giving any PRN medications, interventions should be attempted. The nurse should always put in a progress note of the behavior and the interventions. During an interview, on 11/8/24 at 10:24 a.m., Registered Nurse (RN) 8 indicated before giving PRN medications, the order should be checked, the expiration date should be checked, check what interventions are appropriate and do those, and document the behavior and interventions. During an interview, on 11/8/24 at 3:48 p.m., the Director of Nursing (DON) indicated interventions should be attempted prior to giving PRN psychoactive medications. She was unable to supply documentation of interventions attempted prior to the administration of the PRN medications for the residents. A current facility policy, dated 8/2024, provided by the DON on 11/8/24 at 4:43 p.m., titled Psychotropic Medication Use, indicated the following: .Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control procedures during insulin administration for 2 of 4 residents reviewed for medication administration. (Residents 16 and 7) Findings include: 1. During a random medication administration observation on 11/6/24 at 10:56 a.m., RN 5 removed Resident 16's insulin aspart Flexpen 100 units/milliliter(mL) from the compartment in the top drawer of the medication cart where the insulin pens for the residents on the 200 unit were stored. She removed the unsealed pen cap, did not cleanse the rubber stopper of the multi-dose pen, and attached the pen needle to the insulin pen. The pen was primed and dialed to 11 units for scheduled and sliding scale insulin. The skin was cleansed with an alcohol pad, and the insulin was administered subcutaneously in the resident's right lower abdomen. Resident 16's clinical record was reviewed on 11/8/24 at 12:35 p.m. Diagnoses included, type 2 diabetes mellitus with diabetic neuropathy. Current physician's orders, dated 5/8/24, included insulin aspart injection solution 100 units/mL - inject 7 units subcutaneously with meals and insulin aspart injection solution 100 units/mL - inject as per sliding scale subcutaneously with meals. 2. During a random medication administration observation on 11/6/24 at 11:20 a.m., RN 5 removed Resident 7's Humalog KwikPen (insulin) solution pen-injector 100 units/mL from the compartment in the top drawer of the medication cart where the insulin pens for the residents on the 200 unit were stored. She removed the unsealed pen cap, did not cleanse the rubber stopper of the multi-dose pen, and attached the pen needle to the insulin pen. The pen was primed and dialed to a total of 7 units for scheduled and sliding scale insulin. The skin was cleansed with an alcohol pad, and the insulin was administered subcutaneously in the resident's left upper arm. Resident 7's clinical record was reviewed on 11/8/24 at 12:49 p.m. Diagnoses included, type 2 diabetes mellitus with other circulatory complications. A current physician's order, dated 11/27/23, included Humalog injection solution 100 units/mL - inject 5 units subcutaneously with meals. A current physician's order, dated 12/13/23, included Humalog KwikPen solution pen-injector 100 units/mL - inject as per sliding scale subcutaneously before meals and at bedtime. During an interview on 11/6/24 at 11:30 a.m., RN 5 indicated she should have cleansed the rubber stoppers for the insulin pen injectors prior to attachment of the needles during the medication administration observations, because they were pierced multiple times since they were opened for administration of the medication. This should have been done for infection prevention. During an interview on 11/7/24 at 3:04 p.m., the [NAME] President of Clinical Operations indicated the insulin pens should have been cleansed prior to attachment of the needle according to the manufacturers' guidelines. A current document, last revised on 2/2023, titled Insulin Aspart FlexPen INSTRUCTIONS FOR USE, provided by the Administrator on 11/7/24 at 3:03 p.m., indicated the following: .Preparing your Insulin Aspart FlexPen . A. Pull off the pen cap . Wipe the rubber stopper with an alcohol swab A current document, last revised on 7/2023, titled INSTRUCTIONS FOR USE HUMALOG . KwikPen . injection, for subcutaneous use 3 mL single-patient-use pen (100 units per mL), provided by the Administrator on 11/7/24 at 3:03 p.m., indicated the following: .Preparing your Pen . Step 1: .Pull the Pen Cap straight off . Wipe the Rubber Seal with an alcohol swab A current document, titled Insulin Pens, last reviewed 2/24/24 and retrieved on 11/12/24 from the Cleveland Clinic website: https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections. The guidance included the following: Step-by-step instructions for preparing your insulin pen include: 1. Wash your hands. 2. Remove the cap of the insulin pen . 4. Wipe the rubber stopper with an alcohol wipe. 5. Attach a new pen needle to the insulin pen 3.1-18(a)

Based on interview and record review, the facility failed to ensure an abuse allegation was reported to the Indiana Department of Health for 1 of 4 residents reviewed for abuse. (Resident D and Resident B) Findings include: During an interview with Resident D, on 6/14/24 at 1:07 p.m., she indicated when she was in her previous room, Resident B had pushed her into her room from behind and told her to stay in her room, and she didn't need to be coming out of her room. Resident D reported this to the Administrator and the Social Service Director and completed a grievance form. Resident D's clinical record was reviewed on 6/14/24 at 12:50 p.m. A significant change Minimum Data Set (MDS) assessment indicated she was cognitively intact. She had a care plan for making false statements/accusations towards staff and other residents, i.e. making statements that she was hit or pushed by another resident when it was impossible for that to have happened (Revised 4/23/24). Her interventions included allow her to vent feelings (1/8/24), allow her to express her concerns (revised 4/19/24), provide comfort/support (revised 4/19/24), and redirect her and offer alternative options (revised 4/19/24). A Resident Concern Form for Resident D, dated 5/17/24 at 8:30 a.m. and completed by the Housekeeping Supervisor, indicated Resident D stated Resident B came to her door and grabbed her door handle and told her to stay in her d--n room. She told him not to say that and walked past him. An addendum to Resident D's concern/grievance, dated 5/17/24 at 9:00 a.m., written by the Administrator, indicated the initial story reported was that Resident B pushed Resident D back into her room as she was trying to get out of her room. Resident D told the Housekeeping Supervisor that Resident B told Resident D that he was going to kick her a--. The Administrator spoke with Resident D after this was reported and Resident D explained that Resident B followed her to her room, put his hand on her door and told her to get in there and stay. The Housekeeping Supervisor received two different stories than what the Administrator received. The Administrator spoke with each staff member, and no one saw it happen as well as no one saw Resident B on that end of the hall that morning. A handwritten statement by RN 4, dated 5/17/24, indicated RN 4 was standing at the blood sugar medication cart and Resident D told her Resident B had pushed her into her room and she was going to move to another room. A handwritten statement by the Housekeeping Supervisor, dated 5/17/24 at 8:35 a.m., indicated Resident D came up to her in the hall and told her Resident B shoved her into her room and told her he was going to knock her on her a--. When the Housekeeping Supervisor came out of room [ROOM NUMBER], Resident B was outside of a nearby room, nowhere close to her room, walking towards her. A social service note, dated 5/20/24 at 2:56 p.m., indicated the Social Service Director checked with Resident D regarding her room change. She stated she was comfortable in the room, and she had no further issues with her peer. If she saw him in the hallway, she just didn't talk to him or went in the other direction. During an interview with the Administrator, on 6/17/24 at 12:20 p.m., she indicated Resident D initially reported to the Housekeeping Supervisor that Resident B pushed her in her room and told her to stay in her room. When the Administrator went to Resident D's room to interview her, she indicated to her Resident B followed her to her room, put his hand on her door, and told her to get in there and stay. The allegation was not reported to the state agency because when she went to talk to Resident D, she changed her story and said that he followed her to her room and put his hand on her door and told her to get in there and stay. A current facility policy, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines, provided by the Administrator on 6/17/24 at 1:59 p.m., indicated the following: .Procedures .4.d. Identification .ii. The Executive Director is responsible for: 1. Notification to the State Department of Health (per State Guidelines) .g. Reporting/response .ii. Ensure that all alleged violations involving abuse .are reported immediately .and to other officials (including to the State Survey Agency) This citation relates to Complaint IN00432995. 3.1-28(c)

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 30 of 30 residents who resided in the facility. Findings include: A Payroll Based Journal (PBJ) report, compiled on 12/7/23 for Fiscal Year 2023's 3rd quarter (April 1 - June 30), indicated four or more days within the quarter with no RN hours. The report indicated the dates without RN coverage included April 1, April 2, April 15, April 29, May 13, and May 14. A review of the facility's Daily Nursing Assignment Sheets indicated the following: On April 1, there had not been an RN for eight consecutive hours at the facility. On April 2, there had not been an RN for eight consecutive hours at the facility. On April 15, there had not been an RN for eight consecutive hours at the facility. On April 29, the DON was included as having been at the facility for eight consecutive hours for RN coverage. On May 13, there had not been an RN for eight consecutive hours at the facility. On May 14, there had not been an RN for eight consecutive hours at the facility. During an interview, on 12/19/23 at 11:02 a.m., the DON indicated there had been dates when an RN was not at the facility for eight consecutive hours. There had been times that she was in the facility as RN coverage, but did not work eight consecutive hours. During an interview, on 12/19/23 at 11:28 a.m., the Business Office Manager indicated when the DON or MDS (Minimum Data Set) Nurse were in the facility for RN coverage, she coded their hours to reflect the hours were counted as RN coverage. Review of a current facility policy, titled RN Coverage, with a last revision date of 6/1/2023 and provided by the Regional Administrator on 12/19/23 at 4:33 p.m., indicated .Registered Nurse (RN): Registered nurses (RNs) are responsible for the overall delivery of care to the residents .Nursing homes must have at least one RN for at least 8 straight hours a day, 7 days a week 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure the appropriate storage of refrigerated foods by the use of a refrigerator unable to maintain refrigeration at safe levels. This deficiency had the potential to affect 30 of 30 residents residing in the facility who received meals from the kitchen. Finding includes: During an observation, on 12/13/23 at 10:07 a.m., the kitchen refrigerator temperature was 46 degrees Fahrenheit (F). The refrigerator contained various items including cheese and other dairy products. The Dietary Manager, at the same time, indicated the staff had been in and out of the refrigerator recently. She thought this was why the refrigerator temperature was reading 46 degrees F. Review of a facility Resource: Refrigerator/Freezer Temperature Log, document, provided by the Administrator on 12/13/23 at 11:02 a.m., indicated the refrigerator temperatures for December 2023 were as follows: 12/1/23 morning 41 degrees, evening 46 degrees 12/2/23 morning 44 degrees, evening 45 degrees 12/3/23 morning 42 degrees, evening 43 degrees 12/4/23 morning 46 degrees, evening 49 degrees 12/5/23 morning 48 degrees, evening 49 degrees 12/6/23 morning 48 degrees, evening 49 degrees 12/7/23 morning 46 degrees, evening 47 degrees 12/8/23 morning 47 degrees, evening 46 degrees 12/9/23 morning 46 degrees, evening 46 degrees 12/10/23 morning 46 degrees, evening 47 degrees 12/11/23 morning 45 degrees, evening 47 degrees 12/12/23 morning 45 degrees, evening 46 degrees 12/13/23 morning 47 degrees. During an interview, on 12/14/23 at 3:20 p.m., the Dietary Manager indicated the facility had received and installed a new refrigerator that afternoon. All of the food stored in the previous refrigerator had been thrown away. She had no where else to store the refrigerated foods while waiting for the new refrigerator, as there were no other refrigerators in the kitchen. She had let maintenance know about the increased refrigerator temperatures on 12/1/23. During an interview, on 12/15/23 at 1:44 p.m., the Administrator indicated during morning meeting on 12/8/23, she learned about the refrigerator not staying cold. She reported the refrigerator's malfunctioning to her corporate managers. No other refrigerators were used in the kitchen. On 12/13/23, about midday, all the food in the refrigerator had been thrown away. The food thrown away included cottage cheese, cream cheese, other cheeses, and milk. During an interview, on 12/15/23 at 1:52 p.m., the Dietary Manager indicated she had placed frozen eggs in the old refrigerator to thaw and used them. The refrigerator had contained butter and tomatoes. She had purchased small amounts of milk at a time, so it was not in the refrigerator too long. She thought maintenance thawed the refrigerator on 12/13/23. An invoice for the new refrigerator, provided by the Administrator on 12/15/23 at 2:01 p.m., was dated 12/13/23. During an interview, on 12/15/23 at 2:22 p.m., the Maintenance Director indicated he learned about the malfunctioning refrigerator on 12/8/23. He unthawed the refrigerator on 12/8/23\, as it had a brick of ice on the coils. The refrigerator was working when he left the faciity on [DATE]. He told the administrator about the malfunctioning refrigerator. He unthawed the refrigerator again on 12/14/23, but it began accumulating ice on the coils within a very short time. The facility only had the one refrigerator. A current facility policy for Kitchen Operations: Food Storage, dated 1/2023, provided by the Dietary Manager on 12/18/23 at 10:50 a.m., indicated .Food is stored at an appropriate temperature .Temperatures for refrigerators should be <41 [degrees] Fahrenheit .If temperature of refrigerator is above 40 [degrees] F, take food temperatures of item(s) stored within. If items remain at 41 [degrees] F or less, move items to working refrigeration unit. If items are above 41 [degrees] F, discard and log items discarded 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure residents' right to receive mail on Saturdays was maintained for 9 of 9 residents interviewed during a resident council meeting. Findings include: During a resident council interview, on 12/15/23 at 2:00 p.m., the residents present indicated mail was not delivered on Saturdays. During an interview, on 12/15/23 at 3:13 p.m., the Administrator indicated the mail was sorted and delivered to residents Monday through Friday, but they did not pass mail on Saturdays. Review of an undated, current facility policy, titled INDIANA RESIDENT RIGHTS & FACILITY RESPONSIBILITIES, provided by the DON on 12/19/23 at 3:58 p.m., indicated it is the facility's policy to abide by all resident rights, and to communicate these rights to residents and their designated representatives in a language that they can understand .(s) The resident has the right to privacy in written communications, including the right to: (1) send and promptly receive mail that is unopened. 3.1-3(s)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident with PTSD (Post Traumatic Stress Disorder) received care to mitigate triggers that may cause re-traumatization for 1 of 1 residents reviewed for trauma informed care (Resident 26). Findings include: During an observation, on 12/15/23 at 10:34 a.m., Resident 26 was outside for a smoke break with a staff member and four other residents. Her clinical record was reviewed on 12/15/23 at 11:00 a.m. Diagnoses included PTSD. Current physician orders included Seroquel (anti-psychotic) 25 mg, give two tablets (50 mg) at bedtime for PTSD, ordered 10/6/23. A 10/17/23 admission MDS (Minimum Data Set) assessment indicated she was cognitively intact. She had no mood or behaviors. She received an anti-psychotic medication on a routine basis. A current care plan, dated 10/19/23, indicated she used anti-psychotic medications related to traumatic stress disorder. The goal, with a target date of 1/23/23, indicated she would remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. The interventions, dated 10/19/23, indicated psychotropic medications would be administered as ordered and side effects and effectiveness would be monitored, ongoing need for medication discussed with physician and family, reviewed behaviors/interventions and alternate therapies attempted and their effectiveness, and monitor, document, and report as needed any adverse reactions of psychotropic medications. A current care plan, dated 12/7/23, indicated she had a behavior problem related to she got unnecessarily agitated/angry with staff. The goal, with a target date of 1/23/24, indicated she would have no evidence of behavior problems by review date. The interventions, dated 12/7/23, indicated medications would be administered as ordered and side effects and effectiveness would be monitored and documented, and if reasonable, resident's behavior would be discussed with her and an explanation for why behavior was inappropriate and/or unacceptable. The care plans lacked information of what triggered a re-traumatization for the resident and interventions/strategies to mitigate this risk. A Psychosocial Assessment, dated 10/30/23 at 9:45 a.m., indicated the resident had a verbal altercation with another resident. The diagnosis that may have contributed to the problem was PTSD. Triggers that may have caused behavioral outbursts included fighting or angry outbursts. She was re-directed to an area with less stimulation. A Psychosocial Note, dated 10/30/23 at 9:49 a.m., indicated no mood or behavior changes noted. A facility form, titled Behavior Monthly Flow Sheet, indicated the following behaviors were monitored, agitated/angry and uncooperative/refusal of care. In October the following behaviors had been observed: agitated/angry on 10/7/23 and uncooperative/refused care on 10/26/23. In November the following behaviors had been observed: she had been uncooperative/refused care on 11/4/23. A Mood and Behavior Communication Memo, dated 12/17/23 at 10:00 p.m., indicated the resident and her roommate had argued about the television and lights. The interventions included, provided one on one and conversation of interest. The clinical record lacked information of what triggered a re-traumatization for the resident and interventions/strategies to mitigate this risk. During an interview, on 12/19/23 at 9:53 a.m., LPN 7 indicated not being able to take a smoke break triggered behaviors from the resident. The interventions used included activities were offered and she played games on her phone. During an interview, on 12/19/23 at 10:33 a.m., the Social Service Director indicated her triggers were being around abusive men. Her behaviors were not something that medication would improve. She gathered information from behavior memos and reviewed progress notes to log behaviors, what interventions had been attempted, and effectiveness of interventions. During an interview, on 12/19/23 at 11:06 a.m., the DON indicated the resident's triggers included not being able to go out to smoke because of weather, when someone disagreed with her, and when she wasn't first at something. Review of a current facility policy, titled Trauma Informed Care (TIC) Policy, dated 2019 and provided by the DON on 12/19/23 at 3:58 p.m., indicated .The facility will ensure that residents who are survivors receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident .Trauma informed activities of the facility include, but are not limited to: .Care planning person centered approaches and interventions in response to the universal screening and/or periodic assessment of resident survivor needs including but not limited to honoring individual preferences and routines and responding to the emotional and psychosocial needs of resident survivors .Implementation of monitoring the staff implementation of interventions and performing quality improvement measures in response to identified needs and/or as problems are identified

Based on observation, interview, and record review, the facility failed to ensure a resident received individualized, non-pharmacological interventions for dementia-type behaviors before increasing psychoactive medications for 2 of 5 residents reviewed for dementia care (Resident 18 and 25). Finding includes: 1. During an observation, on 12/15/23 at 9:53 a.m., Resident 18 was conversing with her roommate in her room. During an observation, on 12/19/23 at 10:34 a.m., Resident 18 was sitting in her wheelchair in her room crocheting. Resident 18's clinical record was reviewed on 12/15/23 at 9:15 a.m. She was admitted on [DATE]. Her diagnoses included anxiety disorder, unspecified, unspecified dementia, unspecified severity with anxiety, unspecified dementia, unspecified severity, with mood disturbance, major depressive disorder, single episode, moderate, and unspecified dementia, unspecified severity, with agitation. Her physician's orders included donepezil (for Alzheimer's disease)10 mg at bedtime (12/5/22), quetiapine fumarate (antipsychotic) 50 mg daily (8/26/23), quetiapine fumarate 50 mg - 2 tablets at bedtime (8/26/23), sertraline (antidepressant) 100 mg daily - take with 1.5 tablets of 50 mg to equal 175 mg (12/21/22), and sertraline 50 mg 1.5 tablets daily - take with 100 mg tablet to equal 175 mg (12/21/22). An 11/15/23 quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. She had no mood indicators for depression. She had no behaviors. She took antidepressant and antipsychotic medications. A care plan, initiated on 12/5/22, indicated the resident was at risk for elopement related to cognitive impairment and/or impaired safety awareness. Interventions, initiated on 12/5/22, included offer distractions when resident is wandering such as activities of choice, pleasant diversion, food, conversation, television, music, etc., offer resident baby doll or stuffed animal to care for, offer resident the restroom, and redirect the resident to appropriate areas. A care plan, initiated on 12/8/22 and revised on 6/22/23, indicated the resident had impaired cognitive function related to dementia, long-term memory loss, and short-term memory loss. Interventions, initiated 12/8/22, included administer medications as ordered. Monitor/document for side effects and effectiveness. Communication: use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions - turn off television, radio, close door, etc. The resident understands consistent simple directive sentences. Provide the resident with necessary cues - stop and return if agitated. Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Monitor/document/report as needed any changes in cognitive function, specifically expressing self, difficulty understanding others, level of consciousness, mental status. Provide a program of activities that accommodates the resident's abilities. Provide the resident with a homelike environment. A care plan, initiated on 12/8/22 and revised on 8/18/23, indicated the resident may exhibit restlessness, nervousness, and/or other anxiety symptoms related to anxiety. Interventions, initiated on 12/8/22, included: The resident was on a behavior monitoring program. Give medications as ordered. Medication review as indicated. A care plan, initiated and revised on 12/8/23, indicated the resident was at risk for exhibiting crying, tearfulness and/or expressions of sadness related to depression. Interventions included: Behavior monitoring as indicated (12/8/22). Medication review as indicated (12/8/22). Provide comfort and one on one as needed (11/28/23). A care plan, initiated and revised on 9/10/23, indicated the resident has delusions related to the resident telling staff her son had been in and he would be back to take her home. Interventions, initiated on 9/10/23, included: Behavior Monitoring Program as indicated. Medication review as indicated. Delusions: Assist resident to an area with less stimulation; Assure resident that the delusion is not real and that she is safe; Explain task to the resident. A Social Services note, on 8/17/23 at 2:15 p.m., indicated the resident had been seen by the psych NP. Her quetiapine had been reduced from 50 mg twice a day to 50 mg daily at bedtime. A Progress note, on 8/25/23 at 8:00 p.m., indicated the resident's representative voiced concerns that the resident was having increased confusion and agitation. The resident had insisted that her family was coming to take her home and refused to go to bed several evenings in a row. According to the resident's representative, when the resident lived with the resident's representative, the quetiapine dose had been reduced and she had worsening behaviors. The physician was notified. A Nurses note, on 8/26/23 at 6:01 p.m., indicated the resident was at the nurse's station stating her family was coming to pick her up like he picked up last evening. The nurse told the resident she had not left the previous evening. The resident's representative was called and indicated the family was not coming to get her that evening. A Nurses note, on 8/26/23 at 8:28 p.m., indicated the on-call physician was notified and gave the order to restart the resident at the original dose of quetiapine. The order for quetiapine was to take 50 mg every morning and 100 mg every bedtime. The recent gradual dose reduction had failed due to increased delusions. A Nurses note, on 8/27/23 at 6:10 p.m., indicated the resident was slightly agitated and anxious. She packed her belongings and indicated her son was coming to get her. The progress notes lacked additional documentation of behaviors or interventions provided from 8/27/23 through 12/13/23. No behaviors or interventions were documented in the tasks list from 11/18/23 through 12/18/23. During an interview, on 12/19/23 at 2:16 p.m., LPN 52 indicated the resident did not have behaviors except when she had a bladder infection several months ago. During an interview, on 12/19/23 at 2:18 p.m., the Social Services Designee (SSD) indicated she had questioned the increase in the quetiapine when she reviewed the behaviors. There was one behavior documented on 8/25/23 on the behavior monthly flow sheet of delusions with the interventions being ineffective. The on-call physician had increased the resident's quetiapine dosage, not the psych NP. She was uncertain why the psych NP had not addressed the increase in the medication. 40461 2. During an observation, on 12/14/23 at 3:28 p.m., Resident 25 was sitting in a wheel-chair in the doorway of her room. On 12/15/23 at 10:37 a.m., she was sitting in a wheel-chair in her room. On 12/15/23 at 1:45 p.m., she was sitting in a wheel-chair in her room with a blanket draped over her. On 12/18/23 at 9:33 a.m., she was in a wheel-chair propelling herself around the facility. On 12/18/23 at 9:38 a.m., she had propelled the wheel-chair in front of the nurses' station and asked if she could leave. A QMA dialed the phone for her and she spoke with her daughter. On 12/18/23 at 9:43 a.m., she was in wheel-chair near the nurses station writing checks with her purse on her lap. On 12/19/23 at 8:28 a.m., she was sitting in her room in a wheel-chair. On 12/19/23 at 8:45 a.m., she was sitting in her room in a wheel-chair. Resident 25's clinical record was reviewed on 12/15/23 at 9:36 a.m. Diagnoses included, anxiety disorder and dementia, unspecified severity, with anxiety that had been added to her list of diagnoses on 11/27/23. Current physician orders included Xanax (anti-anxiety) 0.25 mg, give two tablets (0.5 mg) every 24 hours PRN (as needed) for breakthrough anxiety (order date 12/16/23), Xanax 0.25 mg, one tablet three times a day for anxiety (order date 12/18/23), Xanax 0.25 mg, give two tablets (0.5 mg) in the afternoon for anxiety (order date 12/19/23), and target behaviors: anxiety: self-reported nervousness, restlessness, sleeplessness, at the end of each shift mark how often behavior occurred, intensity, and how she responded to redirection (order date 12/13/23). An 10/5/23 admission MDS assessment indicated she had severe cognitive impairment. Her preferences indicated it was somewhat important to her to have snacks between meals, to have books, newspaper, and magazines, to listen to music, to do things with groups of people, and to participate in religious activities. It was very important to her to keep up with the news, to do her favorite activities, and go outside when the weather permitted. A current care plan, dated 11/27/23, indicated she exhibited restlessness, nervousness and/or other anxiety/confusion symptoms related to she thought her daughter had left her here and was confused as to why she was at the facility and wanted to go home. The goal, initiated on 11/27/23 and with a target date of 1/11/24, indicated she would have decreased anxiety symptoms through next review. Interventions dated 11/27/23 included, behavior monitoring program as indicated, and give medications as ordered. Interventions dated 12/5/23 included, resident assured her family knew she was at facility and didn't forget her, redirected to her room to see that her personal items were there, offered food or drink of her choice, and provided comfort and emotional support. A Mood and Behavior Communication Memo, dated 11/15/23, indicated she had hollered out, got up, and walked in the hallway. Interventions that had been attempted without effectiveness included, toileting, change position, provided fluids, provided quiet environment, placed in chair and/or bed, provided one on one, allowed her to vent her feelings, provided reassurance and comfort, allowed time to calm/re-approach, and re-direction. A Mood and Behavior Communication Memo, dated 11/23/23 at 6:00 p.m., indicated she had been restless and rejected care. Interventions that had been attempted without effectiveness included toileting, provided fluids, provided quiet environment, provided one on one, allowed her to vent her feelings, provided reassurance and comfort, allowed time to calm/re-approach, and re-direction. A progress note, dated 11/27/23 at 4:04 a.m., indicated she had been anxious, restless, and confused all evening. She was assisted to bed and had rested well. A progress note, dated 11/27/23 at 11:56 a.m., indicated she continued to be anxious while self propelling in hallway. A progress note, dated 11/27/23 at 1:39 p.m., indicated a new order to add a diagnosis of dementia. A progress note, dated 11/29/23 at 5:30 p.m., indicated she had increased anxiety, PRN medication for anxiety had been given with little effectiveness. She had been tearful, shaky, and stated she was scared. Staff had provided one on one time with re-direction that had been somewhat effective, wanted to be with someone at all times, and physician was notified. A Mood and Behavior Communication Memo, dated 11/29/23, indicated she had been restless through the night. Interventions that had been attempted without effectiveness included toileting, changed position, provided fluids, provided quiet environment, mental health services, and validation of feelings and words. A progress note, dated 11/30/23 at 1:13 p.m., indicated the physician had ordered an increase in her anti-anxiety medication. A facility form, titled Behavior Monthly Flow Sheet, indicated the following behaviors were monitored, restlessness/nervous, hallucinations/paranoia/delusion, refusal of care, and wandering. In November the following behaviors had been observed, she had been restless/nervous on 11/15, 11/23, 11/29, and 11/30/23, and she had a refusal of care on 11/23/23. A progress note, dated 12/2/23 at 7:52 a.m., indicated she had increased anxiety, the PRN anti-anxiety medication had been given. She had been shaky and stated she was scared. Staff had provided one on one with re-direction that had been somewhat effective. She had a hallucination of a little boy and girl in her room that had told her she had to leave. Staff continued to assure her she was safe. A progress note, dated 12/4/23 at 12:20 p.m., indicated a new order had been received to discontinue the PRN anti-anxiety medication and start Xanax 0.5 mg tablet four times a day. A progress note, dated 12/8/23 at 8:16 a.m., indicated the Xanax was decreased to 0.25 mg three times a day. A progress note, dated 12/9/23 at 8:16 a.m., indicated Resident 25 had been anxious, followed the nurse around the facility, and was not easily re-directed. Scheduled medication had been given but had not been effective. Call placed to physician for an order for a PRN dose of Xanax for breakthrough anxiety. A progress note, dated 12/12/23 at 12:08 p.m., indicated an order for Xanax 0.25 mg one tablet every 24 hours PRN had been received. A progress note, dated 12/16/23 at 9:57 a.m., indicated she had been anxious, followed nurse around the facility, and was not easily re-directed. Scheduled medication given as ordered but was not effective. She had called her son three times and her daughter twice that morning. A progress note, dated 12/16/23 at 12:06 p.m., indicated the physician was notified of her behavior, and an order to had been received to increase the PRN Xanax to 0.5 mg for breakthrough anxiety. A progress note, dated 12/17/23 at 2:51 a.m., indicated she was awake and sitting on the side of her bed yelling and trying to get up. Staff explained it was too early to get up and assisted her back into the bed. A progress note, dated 12/18/23 at 1:50 p.m., indicated order had been received to adjust the routine Xanax order to 0.25 mg three times a day and 0.5 mg in the afternoon. A Mood and Behavior Communication Memo, dated 12/12/23 at 2:45 a.m., indicated restlessness, she had gotten herself up in the wheelchair and was going down the hallway. She indicated she didn't want to go to bed. Interventions: provided snack, provided one on one, allowed her to vent her feelings. The outcome, she her eventually allowed staff to put back to bed. A Mood and Behavior Communication Memo, dated 12/16/23 at 11:58 a.m., indicated she had been verbally aggressive and exit seeking, and tried to open front door to leave. She had been told she could not leave because she lived here, and she turned around and screamed that she did not live there. Interventions: allowed time to calm/re-approach, re-direction, PRN medication administered. The outcome, she continued to exit seek. A Mood and Behavior Communication Memo, dated 12/17/23 at 1:30 a.m. and 3:00 a.m., indicated she had walked around her room without staff assistance, she was assisted back into bed but she continued to get up. Interventions: provided snack, provided one on one, allowed her to vent her feelings, and re-direction. The outcome, she continued to try to get up. During an interview, on 12/19/23 at 9:53 a.m., LPN 7 indicated Resident 25 had a short attention span, liked interactions with others, and felt most comfortable when her daughter was there. The interventions she used included, encouraged her to attend activities, assisted her with calling her son or daughter, and the PRN Xanax. Her dementia was the cause of her behaviors. If a behavior was noted, it got documented in Risk Management section of the electronic clinical record and the SSD (Social Service Director) reviewed those notes. During an interview, on 12/19/23 at 10:45 a.m., the SSD indicated the resident had a short attention span and her behaviors were related to dementia. Staff had attempted to re-direct her, offer her snacks, and assist her to call her family. It was sometimes hard to distract her and better to give her the anti-anxiety medication instead. She reviewed the Mood and Behavior Communication Memos and checked progress notes daily for the behavior monitoring and tracking. During an interview, on 12/19/23 at 11:15 a.m., the DON indicated staff were expected to fill out the behavior communication paper and give to the SSD when a resident had a behavior. It would include interventions that would have been tried and if they had been effective. Her behaviors were related to dementia. Non-pharmacological interventions were expected to be attempted before administering the PRN Xanax. Review of a current facility policy, titled Personalized Care, dated 6/1/2023 and provided by the DON on 12/19/23 at 3:58 p.m., indicated .1. All staff will be involved in life enrichment programming during the residents' waking hours. The life enrichment programming in the facilities is designed to engage the residents and facilitate the highest level of function .2. Although residents with memory impairment do better when a basic routine is followed, individualized, center focused care provides flexibility and facilitates honoring personal interests and preferences 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure non-pharmacological interventions were employed prior to increasing an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident 18). Finding includes: During an observation, on 12/15/23 at 9:53 a.m., Resident 18 was conversing with her roommate in her room. During an observation, on 12/19/23 at 10:34 a.m., Resident 18 was sitting in her wheelchair in her room crocheting. Resident 18's clinical record was reviewed on 12/15/23 at 9:15 a.m. She was admitted on [DATE]. Her diagnoses included anxiety disorder, unspecified, unspecified dementia, unspecified severity with anxiety, unspecified dementia, unspecified severity, with mood disturbance, major depressive disorder, single episode, moderate, and unspecified dementia, unspecified severity, with agitation. Her physician's orders included donepezil (for Alzheimer's disease)10 mg at bedtime (12/5/22), quetiapine fumarate (antipsychotic) 50 mg daily (8/26/23), quetiapine fumarate 50 mg - 2 tablets at bedtime (8/26/23), sertraline (antidepressant) 100 mg daily - take with 1.5 tablets of 50 mg to equal 175 mg (12/21/22), and sertraline 50 mg 1.5 tablets daily - take with 100 mg tablet to equal 175 mg (12/21/22). An 11/15/23 quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. She had no mood indicators for depression. She had no behaviors. A care plan, initiated and revised on 12/8/22, indicated the resident used antipsychotic medications and was at risk for complications. Interventions included administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness every shift, discus with physician, family about ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. A medication regimen review by the pharmacist was completed on 6/26/23. A reduction in the dose of quetiapine from 100 mg at bedtime and 50 mg daily to quetiapine 75 mg at bedtime and 50 mg daily (a reduction of 175 mg to 125 mg total daily) was recommended. The physician agreed on 6/27/23 and the order was changed on 6/30/23. A NP progress note, on 7/20/23 at 9:39 a.m., indicated the resident had a gradual dose reduction of quetiapine on 6/30/23. Psychotropic medications and behaviors were reviewed. No behaviors had been reported over the review period. The plan for the resident was to decrease the quetiapine to 50 mg twice a day as a gradual dose reduction attempt. A NP progress note, on 8/17/23 at 4:14 p.m., indicated the NP attended a behavior management meeting and reviewed the psychotropic medications and behaviors. No behaviors had been reported over the review period. The plan for the resident was to decrease the quetiapine to 50 mg at bedtime as a gradual dose reduction attempt. A Progress note, on 8/25/23 at 8:00 p.m., indicated the resident's representative voiced concerns that the resident was having increased confusion and agitation. The resident had insisted that her family was coming to take her home and refused to go to bed several evenings in a row. According to the resident's representative, when the resident lived with the resident's representative, the quetiapine dose had been reduced and she had worsening behaviors. The physician was notified. A Nurses note, on 8/26/23 at 6:01 p.m., indicated the resident was at the nurse's station stating her family was coming to pick her up like he picked up last evening. The resident had not left the previous evening. The resident's representative was called and indicated the family was not coming to get her that evening. A Nurses note, on 8/26/23 at 8:28 p.m., indicated the on-call physician was notified and gave the order to restart the resident at the original dose of quetiapine. The order for quetiapine was to take 50 mg every morning and 100 mg every bedtime. The recent gradual dose reduction had failed due to increased delusions. A Nurses note, on 8/27/23 at 6:10 p.m., indicated the resident was slightly agitated and anxious. She packed her belongings and indicated her son was coming to get her. Behavior Monthly Flow Sheets for June, July, and August 2023, provided by the Social Service Director on 12/19/23 at 2:15 p.m., indicated the resident had one behavior of delusions on 8/26/23 with no additional behaviors documented for other months or days. During an interview, on 12/19/23 at 2:16 p.m., LPN 52 indicated the resident did not have behaviors except when she had a bladder infection several months ago. During an interview, on 12/19/23 at 2:18 18 p.m., the Social Services Designee indicated the resident had been admitted with the quetiapine order and other psychotropic medications. The psych NP had been working on reducing the quetiapine and did not order the increases. The son did not think the reduction in the quetiapine would be successful, but it was. The increase in the dose was ordered by the on-call doctor over a weekend. Generally, if a dose reduction had failed, the medication would not immediately be increased to the original dose before the two previous reductions. The resident had not had behaviors until the last gradual dose reduction. A current facility policy, dated 2020, provided by the DON on 12/19/23 at 3:58 p.m., titled Monitoring of Anti-Psychotics, indicated .Gradual dose reduction is attempted with all residents who receive antipsychotic medications, unless clinically contraindicated. Contraindication to dose reduction must be documented in the resident's medical record by the responsible physician .During the last seven days of each month in which the dose is reduce an assessment of the behavior is completed by the nursing staff, to guide the physician in making dose reductions 3.1-48(b)(2)

A. Based on observation, interview, and record review, the facility failed to ensure biologicals requiring refrigeration were monitored per CDC guidelines for 1 of 1 refrigerators reviewed for medication/biological storage. B. Based on observation, interview, and record review, the facility failed to ensure residents' medications were properly disposed of or sent back to the pharmacy for credit for 1 of 1 medication storage rooms observed. Findings include: A. During an observation of the medication storage room beginning on [DATE] at 8:49 a.m., with RN 51, the medication refrigerator contained 10 vials/doses of influenza vaccines and had a standard thermometer. The refrigerator log indicated the refrigerator temperature was monitored daily. A facility document, provided by the DON on [DATE] at 10:08 a.m., titled Daily Freezer/Refrigerator Temperature Log, indicated the location was the medication room for [DATE]. Temperatures for the refrigerator were taken daily. During an interview, on [DATE] at 10:08 a.m., the DON indicated the refrigerator containing the vaccines had always been monitored daily not twice a day. During an interview, on [DATE] at 11:12 a.m., the DON indicated the facility did not have a policy on the storage of vaccines. The article Vaccine Storage and Handling Toolkit - [DATE], was retrieved on [DATE] from the Centers of Disease Control and Prevention website at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdfhttps://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. The guidance indicated if the temperature monitoring device did not read maximum/minimum temperatures then the temperature must be checked and recorded a minimum of two times a day as a minimal action to protect the vaccine supply. B. During an observation of the medication storage room beginning on [DATE] at 8:49 a.m. with RN 51, a tub filled with multiple medications for multiple residents was on a bottom shelf. During an interview, at the same time, RN 51 indicated the medications were to be returned to the pharmacy. She was uncertain of the paperwork to be filled out or the process as she had not sent back medications herself. During an observation beginning on [DATE] at 10:08 a.m., the tub filled with medications was reviewed with the DON. The medications included Entresto (for heart failure), Xarelto (blood thinner), doxycycline (antibiotic), amoxicillin and clavulanic acid (antibiotic), cefuroxime (antibiotic), glucagon injection (for very low blood sugars), a discharged resident's insulin injectable pens (for diabetes), a deceased resident's Tresiba Flex touch injectable pens (for diabetes), a discharged resident's Prevnar 20 vaccine (vaccine), an unmarked used fluticasone propionate salmeterol inhaler (for difficulty breathing), and loose, unmarked albuterol/ipratropium vials for nebulizer (for difficulty breathing). A stack of six medication cards was near the bottom of the tub with return paperwork dated [DATE]. During an interview, at the same time, the DON indicated one of the nurses periodically went through the medication carts and refrigerator to check for and remove expired/discharged residents' medications and discontinued medications. The medications had not been sorted yet, so no paperwork had been filled out. A current policy, dated 2020, titled Medication Storage in the Facility, provided by the DON on [DATE] at 11:12 a.m., indicated .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists A current policy, dated 2020, titled Returning of Prescription Medications to the Pharmacy, provided by the DON on [DATE] at 11:12 a.m., indicated POLICY: Each state has specific rules and regulations as it relates to returning medications- Each facility and pharmacy will adhere to their individual State's Rules and Regulations as it pertains to returns 3XXX,d+[DATE](o) 3XXX,d+[DATE](q) 3XXX,d+[DATE](r)