Every finding on record at Golden Years Homestead

Based on interview and record review, the facility failed to monitor for adverse side effects of opioid medications with and increased dose for 1 of 3 residents reviewed for pain management. Findings include:A list of recent deaths was provided by the Director of Nursing on [DATE] at 10 AM. The list indicated Resident B passed away on [DATE] at 5:08 AM at the facility.Resident B's record was reviewed on [DATE] at 10:29 AM. Diagnoses included post right hip fracture, Parkinson's, diabetes mellitus, depression and stage 3 chronic kidney disease.Resident B was admitted to the facility on [DATE] for rehab due to a right hip fracture.Active orders included the following for pain:admission order, [DATE] included Hydrocodone- Acetaminophen (Norco) Oral Tablet 5-325 MG - give 1 tablet by mouth every 4 hours as needed for pain.admission order, dated [DATE], indicated give Naproxen Oral Tablet 500 mg - 1 tablet every 12 hours as needed for pain.An order, dated [DATE], indicated to give Oxycodone - Acetaminophen Oral Tablet 5- 325 mg - 1 tablet by mouth every 4 hours as needed for pain/discomfort in right hip.An order, dated [DATE], indicated to give Morphine Sulfate Contin Oral Tablet Extended Release 15 MG - 1 tablet by mouth every 12 hours for pain for 7 Days. There were no orders to monitor the side effects of pain medications.The Mediation Administration Record (MAR), dated [DATE] - [DATE], indicated the following medications were given for pain:[DATE]: Norco at 1:20AM, Norco at 10:04 AM and Oxycodone at 2:41 PM[DATE]: Norco at 9:23AM, Oxycodone at 1:02PM, Norco at 5:22 PM and Oxycodone at 9:43 PM[DATE]: Naproxen at 3:39 AM, Norco at 6:32 AM, Oxycodone at 10:42 AM, Norco at 1:51 PM, Oxycodone at 4:46 PM[DATE]: Norco at 6:20 AM, Oxycodone at 9:53 AM, Norco at 1:04 PM, Oxycodone at 2:12 PM, Oxycodone at 5:10 PM and Morphine at 9:00 PMA nursing note, dated 11/1, indicated Resident B requested to go to the hospital due to increased pain. The note indicated Resident B returned the same day with a new order of Oxycodone - Acetaminophen Oral Tablet 5- 325 mg - 1 tablet by mouth every 4 hours as needed for pain/discomfort in right hip.An admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident B had a BIMS of 9/15 (moderate cognitive impairment).A social service note, dated [DATE], indicated a care plan meeting was held with Resident B, Resident B's power of attorney (POA) and family. There was no documentation of doctor visits or communication requests.A nursing note, dated [DATE], indicated the doctor discontinued as needed Hydrocodone- Acetaminophen (Norco) Oral Tablet 5-325 MG - give 1 tablet by mouth every 4 hours and added an order of Morphine 15 mg every 12 hours twice a day for 7 days. The note indicated Resident B was notified of the orders. The note did not indicate Resident B's POA, nor family were notified of the medication changes.A pain assessment dated [DATE] at 2:37 AM indicated Resident B's morphine medication was effective and pain was at a 3/10.A nursing note, dated [DATE] at 5:20 AM, indicated Resident B was found deceased in her bed.There are no notes or assessments between 2:37 and 5:20 AM.During an interview on [DATE] at 10:05 AM, Resident B's POA indicated Resident B admitted to the facility post right hip surgery for rehabilitation. Resident B's POA indicated she had had a care plan meeting on [DATE], was told the doctor planned to visit the resident on [DATE]. Resident B's POA indicated she was unable to attend but requested a phone call during the visit. Resident B's POA indicated she did not receive a call from the doctor nor the facility regarding medication changes for Resident B. Resident B's POA indicated on [DATE] evening she visited Resident B, indicated she seemed spicy. Resident B's POA indicated when Resident B seemed spicy, this meant her medications were off. Resident B's POA indicated she requested a printed medication list from the nurse and upon review, she observed a new order of morphine 15 mg to be given every 12 hours, twice a day. Resident B's POA indicated she was not aware of the new order, requested the nurse hold the medication for the evening so she could talk to the doctor in the morning. Resident B's POA indicated she did not want Resident B to receive morphine. Resident B's POA indicated on [DATE] morning, she received a call from the facility indicating Resident B had passed away. Resident B's POA indicated the nurse had indicated Resident B did receive the ordered morphine the night before.During an interview on [DATE] at 11:25AM. The DON, Physical Therapist 4 and Social Service Director (SSD) indicated a care plan meeting was held on [DATE] with Resident B, Resident B's POA and family. The SSD and BOM indicated they did not recall discussion regarding the doctor visit on [DATE]. The SSD indicated if a Resident had BIMS less than 12 the POA would be updated with any changes regarding medications or care. SSD indicated the Doctor or Nurse Practitioner visit new admission residents daily for the first week. The SSD indicated Resident B's POA should have been notified of medication changes. The DON indicated residents are monitored every 2 hours by staff. The DON indicated the staff did not document monitoring completion.During an interview on [DATE] at 1:56 PM, Registered Nurse (RN) 3 indicated she had worked on [DATE] evening shift into [DATE] morning. RN 3 indicated she was not told to hold any orders in report. RN 3 indicated on [DATE] was the first time she had cared for Resident B, but she was alert and orientated. RN 3 indicated she administered morphine as ordered at 9 PM, then checked on the resident around 12 AM and again at 2: 30 AM. RN 3 indicated Resident B's vital signs were within normal range at 12 AM. RN 3 indicated around 5 AM the aide notified the nurse of Resident B's death. RN 3 indicated when family requested medication to be held, she documented the request and notified the doctor. RN 3 indicated after administering pain medications she followed up on the effectiveness within the hour and monitored for adverse side effects.During an interview on [DATE] at 1:35 PM, RN 5 indicated staff monitored for adverse side effects of pain medications. RN 5 indicated new medications, such as morphine, required additional monitoring. RN 5 indicated she completed a vital assessment 30 minutes to 1 hour after the administration of morphine and continued to frequently check on the residents to ensure no adverse side effects occurred. RN 5 indicated resident's POA were notified of medication changes and when a hold request was made, the nurse documented the request. RN 5 indicated she notified the doctor of hold request as well.A policy, last revised [DATE], titled Medication Administration, was provided by the Administrator on [DATE] at 10 AM. The policy indicated to monitor adverse side effects.According to the World Health organization article, dated [DATE], titled opioid overdose, opioids have a long half-life and can build up in the system over time or with concurrent use in combination doses. Risk factors for opioid overdose include using opioids in combination with each other or other substances, and chronic conditions such as liver or kidney disease.This finding relates to Intake 2652223.3.1 - 37 (a)

Based on observation, interview, and record review the facility failed to assess mobility for 1 of 4 residents reviewed. (Resident 35) Findings include:During an observation, on 07/30/2025 at 9:59 AM, Resident 35 was in a wheelchair. [NAME] her feet were not resting on foot rest and her chin was tucked with her head tucked sharply to the right and her fists were clenched. During an observation, on 07/31/2025 at 9:50 AM, Resident 35 was sitting in a specialized chair in front of a fireplace with her chin tucked and feet on a footrest. Resident 35's head was all the way to her right and out of the head rest. Resident 35's record was reviewed on 7/31/25 at 11:52am. Her diagnoses included Parkinson's, type 2 diabetes, and unspecified dementia. The record indicated a Minimum Data Set (MDS) assessment (section GG) was completed on 7/11/25 with no impairment to upper extremities.The care plan, dated 7/11/25, was without a specific plan for contractions of upper or lower body. In an interview, on 08/01/2025 at12:56 PM, the MDS coordinator indicated she should have coded hands and shoulder impairment on the assessment. The MDS Coordinator indicated she would do a modification to that assessment. The MDS Coordinator indicated she would also ensure the contractures were in Resident 35's care plan. A policy titled, Accurate Reporting of Functional Performance-MDS Section GG was provided by the Administrator on 8/4/25 at 10:36AM. The policy indicated, .4. The resident's self-care and mobility performance will be based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care team members, or family and documented in the resident's medical record during the assessment period. 7. Functional goals will be incorporated into each resident's care plan.Not in state rules.

Based on interview and record review, the facility failed to ensure allegations of verbal abuse and mistreatment were reported to the Administrator and state agency within required timeframes for 3 of 5 residents reviewed (Resident B, Resident D, and Resident H).Findings include:A report, dated 6/29/25, alleged Resident B and Resident H were involved when Certified Nurse Aid (CNA) 5 had yelled at the residents and not provided care according to their individual care plans. The report alleged the incidents had been reported to management, but nothing had been done. The report indicated Resident D had alleged physical abuse, reported to Human Resource staff instead of the Administrator or Director of Nursing (DON) per facility policy, and no investigation had allegedly been done.1.The report, dated 6/29/25, alleged on 5/26/25, Resident B had wanted to have his brief changed and had been trying to get staff's attention. He had been seated in his wheelchair next to his bed. His call light was on the other side of the bed and out of his reach. Employee 2 indicated they had observed the call light out of the resident's reach, had turned the call light on and placed it on his overbed table in front of him. Approximately, 1 and 1/2 hours later, Employee 2 returned to check on the resident. He indicated staff had not come to help him although his call light was turned off. Employee 2 turned the call light on again, verified it was on and working correctly, and told the resident they would be back to check on him. A half hour later, Employee 2 returned, observed the call light off and the call light moved out of the resident's reach. Resident B indicated staff had not yet assisted him to change his brief. Employee 2 summoned their supervisor (Employee 3) who went to the resident's room and waited for staff to provide the resident assistance. Employee 3 indicated they would report the incident.On 7/16/25 at 12:43 P.M., Resident B's record was reviewed. Diagnoses included Parkinson's disease and dementia.A quarterly Minimum Data Set (MDS) assessment, dated 5/23/25, indicated the resident had no cognitive impairment. He had no behaviors or indicators of delirium. He required partial to maximal assistance with his activities of daily living (ADL) due to his Parkinson's disease symptoms.Care Plans indicated:5/26/25-Resident B required assistance with his ADL's and was able to make his needs known without difficulty. Interventions included: assist with dressing, toileting and transfers; and encourage the resident to use the call light to ask for assistance.5/26/25-The resident was incontinent of bowel and bladder and required assistance with incontinent care; he could usually recognize the urge to toilet but required assistance with toileting. Interventions included: change incontinent briefs frequently and assist to toilet frequently.On 7/16/25 at 11:05 A.M., Resident B's spouse was interviewed. She indicated she came to the facility every other day for long periods of time. When asked about staff, she indicated Resident B had multiple issues with CNA 5 for some time and had reported her last fall. She believed care from CNA 5 had improved but remained concerned with the call light placement and it not being placed within the resident's reach. She had witnessed this several times when CNA 5 cared for him. She indicated the resident was becoming more fearful due to increasing dependency from Parkinson's disease and he needed to have access to the call light to summon help from staff. On 7/16/25 at 1:56 P.M., the Clinical Nurse Leader (CNL), for the unit where all 3 residents resided, was interviewed. She indicated she had been made aware of resident's complaints about CNA 5. She spoke with CNA 5 about resident care but hadn't reported the complaints to the DON. When asked, the CNL indicated putting a resident's call light out of their reach or yelling at resident's could be considered abuse and she should have reported it.On 7/16/25 at 3:50 P.M., Employee 2 was interviewed. The employee indicated they had reported the concerns to the CNL due to the seriousness of resident's complaints and alleged lack of follow up. The employee indicated Resident B and his spouse had reported, CNA 5 had a rectangular shaped device in her pocket, pulled partly out and shown to the resident. CNA 5 allegedly told Resident B, they were recording him so he couldn't say anything about the CNA. On 7/17/25 at 10:45 A.M., Resident B was interviewed. He indicated having issues with CNA 5. The CNA was temperamental and never knew what kind of mood she would be in. He indicated approximately 1 month ago, CNA 5 had gotten really angry with him, had pulled his call light out from the socket and threw it against the wall. Around the same time, the CNA had shown him a device in her pocket and said she was recording him so he couldn't say things about her. He indicated there were times when CNA 5 would turn off his call light and leave the room without helping him or would place his call light out of his reach so he couldn't call for help. When questioned, he indicated he had not reported the incident with the recording device as he hadn't wanted the CNA to get mad at him.On 7/17/25 at 11:06 A.M., in an interview, Employee 3 indicated on 5/26/25, Employee 2 had reported Resident B had his call light turned off, placed out of his reach, and was not provided care as requested. Employee 3 went to the resident's room and turned on the call light. Employee 3 stayed in the room with Resident B until staff came in and assisted him to change. They indicated they had notified the CNL of the incident but hadn't been made aware of follow up. When asked, Employee 3 indicated, in the past, allegations of abuse were reported to the DON however, a new Administrator was employed at the facility and she had instructed all employees to notify her immediately of any allegations of abuse, neglect, mistreatment or any grievance which could be potential abuse.2. A report, dated 6/29/25, indicated Employee 2 had been told on 5/26/25, by Qualified Nurse Aid (QMA) 7, Resident D had been very agitated and reported CNA 5 had hit him. QMA 7 had allegedly reported Resident H's allegation to the Human Resource's (HR) office.On 7/17/25 at 1:55 P.M., Resident D's record was reviewed. Diagnoses included Parkinson's disease and dementia.A quarterly MDS Assessment, dated 4/30/25, indicated Resident D had severely impaired cognition. Most days he felt down and depressed. He had no behaviors but was prescribed an antipsychotic medication to treat hallucinations caused by Parkinson's. He required partial to moderate assistance with his activities of daily living. Care Plans indicated Resident D had severely impaired cognition/memory due to dementia and required assistance with his ADL's. He was care planned for trauma care due to serving in the armed forces during war time. He had behaviors of yelling and wanting to get out of the facility.On 7/17/25 at 12:45 P.M., the DON was interviewed. She indicated neither HR staff nor any other staff had reported an allegation of abuse by Resident D. She had no knowledge of QMA 7 having concerns with the resident nor why the QMA would report an allegation to the HR department. QMA 7 was unavailable for interview.3. A report, dated 6/29/25, indicated Resident H alleged CNA 5 always yelled at her. CNA 5 was overheard telling the resident she (CNA 5) was done with their shit.On 7/17/25 at 2:19 P.M., Resident H's record was reviewed. Diagnoses included dementia, major depressive disorder, anxiety disorder, and mixed incontinence of bladder.A quarterly MDS assessment, dated 5/1/25, indicated a Brief Interview Mental Status score of 10-moderate cognitive impairment. Resident H had refused to answer all the BIMS questions to calculate her score nor would she answer questions regarding her mood. She had no indicators of delirium or behaviors. The resident required maximal assistance with transfers and toileting and was always incontinent of bowel and bladder.Care plans indicated:-5/2/25: Resident H had a diagnosis of dementia with short and long term memory deficits. She recently scored a 10 out 15 on her BIMS assessment due to refusing to participate in interviews.-5/2/25: Resident H had psychosocial well-being problems related to anxiety, depression and dementia. She was able to effectively make her needs known however tended to be easily annoyed with others and become agitated. She could be condescending during conversations and tended to keep to herself. Interventions included: provide encouragement; provide 1:1 visits frequently; continue sessions with counselor and monitor for symptoms of distress.-5/2/25: The resident was incontinent of bowel and bladder and required assistance with toileting. Resident H was able to recognize urges however would delay notifying staff of her need to transfer to the commode. Interventions included: assist her to toilet frequently.On 7/16/25 at 3:50 P.M., Employee 2 was interviewed. Employee 2 indicated Resident H could be antagonistic with staff but staff were trained to deal with behaviors and shouldn't yell or curse at residents. On 7/17/25 at 10:10 A.M., Resident H was interviewed. She appeared guarded and initially, annoyed at being asked questions. She indicated CNA 5 always yelled at her and told her not to put her call light on. On 7/16/25 at 11:05 A.M., Resident M, identified as interviewable without cognitive impairment by the facility, was interviewed. The resident resided in the room next to Resident H. Resident M identified herself as a nurse for many years. She expressed much empathy for the staff due to work required to care for residents. When asked, she indicated regret at having to say she had overheard CNA 5 yell several times at Resident H.On 7/17/25 at 3:30 P.M., the Administrator and Director of Nursing were interviewed. The Administrator was new and hadn't been employed by the facility at the time the incidents allegedly occurred so was unable to provide further information. The Administrator indicated all staff had been educated on the abuse policy and chain of command for reporting. She was to be notified of any grievance which could indicate abuse or allegations of actual abuse immediately. The Director of Nursing indicated she was not notified of the incidents reported regarding Resident B, Resident D, or Resident H but should have been.A current facility policy, titled Abuse, Neglect, Exploitation Policy, was provided by the Administrator on 7/16/25 at 12:00 P.M., and indicated the following: Mistreatment means inappropriate treatment of resident .Verbal Abuse means the use of oral .communication or sounds that willfully includes disparaging and derogatory terms to residents .Prevention of Abuse .The campus will implement policies and procedures to identify, correct, and intervene in situations in which abuse could occur .5. Verbal abuse overheard .7. Psychological abuse overheard 8. Failure to provide care needs such as comfort, safety .An immediate investigation is warranted when suspicion of abuse, neglect, or reports of abuse or neglect occur .Reporting of all alleged violations will be made to the Administrator and required agencies .a. Immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in body injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury This Citation relates to Complaint 1229505.3.1-28(c)

Based on interview and record review, the facility failed to ensure a resident was administered medication as ordered by the physician for 1 of 3 residents reviewed (Resident Q). Findings include: On 5/7/25 at 10:45 A.M., Resident Q's record was reviewed. Diagnoses included epilepsy with partial seizures and dementia. A physician order, dated 11/14/25, indicated to give Levetiracetam (anti-seizure medication) 750 milligrams (mg); take 1 tablet by mouth every 12 hours for seizures. A physician order, dated 4/30/25, was to discontinue Levetiracetam 750 mg; take 1 tablet by mouth every 12 hours and start Lacosamide 100 mg tablets; take 1 tablet by mouth 2 times per day for seizures. An Interdisciplinary (ID) note, dated 4/30/25 at 2:05 p.m., indicated Resident Q had gone out for an appointment with the Neurologist. She returned to the facility with new orders to discontinue Levetiracetam and begin Lacosamide 100 mg tablets; take 1 tablet by mouth 2 times per day for seizures. The pharmacy was notified of the change in orders. A Medication Administration Record (MAR), dated May 2025, indicated Lacosamide 100 mg; 1 tablet by mouth 2 times per day was not administered on 5/1, 5/2, 5/3, and 5/4/25. The order was put on the MAR on 5/5/25. Resident Q received the first dose of Lacosamide on 5/5/25 at 9:00 p.m. The MAR, dated May 2025, indicated the resident received Levetiracetam 750 mg 1 tablet by mouth every 12 hours at 9:00 a.m. and 9:00 p.m. on 5/1, 5/2, 5/3, 5/4, 5/5 and 5/6/25 and 9:00 a.m. on 5/7/25. Levetiracetam was not discontinued on 4/30/25 as ordered and was administered without a physician order from 5/1/25 until 5/7/25 after the 9:00 a.m. dose when the error was identified and the medication discontinued as ordered. On 5/7/25 at 11:17 A.M., Registered Nurse (RN) 9 was interviewed. She indicated when a resident goes out to see a specialist, they should return with a progress note. The note may contain physician orders. When a resident returned from an appointment, the nurse on duty was responsible for reviewing the progress note, noting any new physician orders, transcribing the order onto a physician order form, MAR and notifying the pharmacy of the new medication order. RN 9 had been aware of the new order for Lacosamide and had administered the medication as ordered. She had not been aware the Levetiracetam was to have been discontinued on 4/30/25 and administered the medication as scheduled on the MAR. On 5/7/25 at 12:15 P.M., the Director of Nursing (DON) was interviewed. She indicated the order for Lacosamide was noted and put in place on 5/5/25 when it was discovered the order had not been transcribed onto the MAR nor administered as ordered. She had not been aware of the order to discontinue the Levetiracetam. The Levetiracetam was discontinued and the physician notified as soon as the error was discovered. The facility had no written policy for following physician orders but the DON indicated nurses were expected to follow physician orders as part of the nursing practice. This Citation relates to Complaint IN00457512. 3.1-37

Based on interview and record review, the facility failed to ensure a resident's inappropriate touching behavior was identified, prevention interventions implemented and the behavior trended for 2 of 3 residents reviewed for behaviors (Resident D and Resident E). Findings include: Reports, dated 4/12/25 and 4/13/25, alleged Resident D had inappropriately touched a female resident (Resident E) on her legs and chest. Both reports indicated there had been no documented interventions put in place to protect the residents and ensure no further inappropriate touching occurred. The reports alleged there was no documentation in either resident's record regarding the behaviors on 4/7/25. 1. On 5/5/25 at 1:44 P.M., Resident D's record was reviewed. Diagnoses included, Parkinson's, dementia, anxiety, and depression. A quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated a Brief Interview Mental Status (BIMS) assessment indicated Resident D had no cognitive impairment. He had several mood indicators as follows: little interest or pleasure in doing things, feeling down, depressed, hopeless, and feeling tired with little energy. He ambulated short distances without aids and was independent in mobility when using his wheelchair. He was receiving hospice services for end stage Parkinson's disease. A care plan, dated 4/7/25, indicated the resident had socially inappropriate behavior. Interventions included to monitor Resident D's behavior, assist him to determine the cause, intervene as needed to ensure safety of self and others, divert attention, assist to quiet location, modify environment, discuss behavior with him and observe behavioral clues to help understand the behavior. A care plan, dated 2/10/25, indicated Resident D was at risk for adverse effects related to use of a hypnotic for insomnia and anti-depressant medications for depression and anxiety. Interventions were to administer medications as ordered and monitor for adverse effects. The care plan hadn't indicated type of behaviors staff were to monitor for, how often Resident D was to be monitored, nor the type of behavioral clues to help understand the behavior. The care plan hadn't indicated the resident had depression. The care plan hadn't indicated behaviors the resident expressed when feeling depressed or anxious such as fatigue, appetite changes, agitation, expressions of guilt, apathy, anger or acting out towards self or others. Interdisciplinary Notes (ID) indicated the following: -4/3/25 at 11:53 a.m., Resident D was observed sitting in the fireplace room talking with other residents who were not responsive. He held one the resident's hands. -4/7/25 at 11:28 a.m., staff reported to the unit manager, over the weekend, Resident D had been feeding his tablemate at meal times. He was observed in his tablemates (Resident F) room, sitting in her recliner, rubbing her shoulders and neck. He had been observed in her room off and on during the morning. -11:42 a.m., Resident D was observed in Resident F's room, standing behind the resident and attempting to lift her up in her wheelchair. Staff spoke with him about not doing this as he or Resident F could hurt themselves. -11:47 p.m., the nurse indicated she had been notified by staff, Resident D had engaged in inappropriate behavior (not documented type of inappropriate behavior) throughout the day. The nurse notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON). -4/8/25 at 3:26 p.m., the hospice case manager was in to visit and reported to the hospice physician, Resident D was having behaviors out of character for him. New orders were given to decrease Resident D's Carbidopa (treats Parkinsons) from every 4 hours to every 6 hours. The physician explained to the hospice case manager, the amount of Carbidopa prescribed may have overstimulated his brain causing a type of psychosis (disconnection from reality). The resident indicated he was feeling down and having family issues at the time. New order given for anti-depressant medication to be given for increased depression and anxiety. -4/9/25 at 3:26 p.m., Resident D had no changes in his condition and remained in his room for the duration of the shift. -10:54 p.m., Resident D had spent a lot of time in his room and hadn't socialized with anyone. -4/14/25 at 1:57 p.m., Resident D had some confusion during the day. At lunch, he spoke of someone coming for lunch but had no visitors. He told the Certified Nurse Aid (CNA) he doesn't know what is wrong with him today. -4/16/25 at 11:22 a.m., the ID team met to review the resident's use of psychotropic medications. Resident D was prescribed Zoloft (anti-depressant), Restoril (for sleep), and Cymbalta (anti-depressant). His dose of Restoril was decreased. There was no documentation of the residents behaviors. A Hospice Plan of Care, updated on 4/14/25, indicated Resident D had been involved in an inappropriate incident at the facility the incident had involved other residents. Support was being provided to the residents family as they dealt with the consequences of the incidents. The resident was on 15 minute watches. The resident had been started on Zoloft on 4/8/25 for inappropriate sexual behavior. His Carbidopa was decreased due to inability to tolerate increased dose for leg pain, stiffness, and spasms. There was no documentation to indicate Resident D had been on 15 minute watches or time frames in which the 15 minute watches had been active. A psychiatric Nurse Practitioner (NP) progress note, dated 4/16/25, indicated Resident D was seen for follow-up psychiatric medication management to assess mood, behavior and efficacy of psychotropic medications prescribed for depression and insomnia. The resident reported his mood was pretty good. He had no signs or symptoms of depression or anxiety and had no reported changes in mood, sleep or appetite. Staff denied any acute concerns. Medication review indicated he was prescribed Carbidopa 5 times per day (every 4 hours). The resident was alert and awake; oriented to person, place and situation; had impaired judgement and insight; flat affect; and no delusions or hallucinations were verbalized. The resident was to continue on his medications for depression and Parkinsons. His medication for insomnia would be decreased. The psychiatric NP progress note hadn't indicated the NP was aware of hand holding observed on 4/3/26 or Resident D's inappropriate touching of female residents on 4/7/25. The progress note hadn't indicated the resident's dose of Carbidopa had been decreased from 5 times per day to 4 times due to psychosis like behaviors observed on 4/7/25. 2. On 5/5/25 at 3:12 P.M., Resident E's record was reviewed. Diagnoses included Lewy body dementia with psychotic disturbance, recurrent major depressive disorder and anxiety. A quarterly MDS assesment, dated 4/11/25, indicated Resident E had severely impaired cognition. She was verbal with clear speech but was rarely understood or able to understand others. She had no mood indicators or behaviors. Resident E was dependent on staff for all activities of daily living (ADL's), was non-ambulatory, had contractures to her legs, and sat in a Broda chair where placed by staff. She was receiving hospice services for end stage dementia. Care plans, with start dates of 4/12/25, indicated the following: -Resident E had periods of restlessness with a recent decline in condition. She was receiving hospice services to aid with care and pain management. She had periods of calling out and being easily distracted. Interventions were to administer her medications as ordered. -Resident E had signs of depression, had multiple losses over the past year and a half including death of husband, decline in health and admission to a nursing home. Interventions included to provide psychiatric services. -Resident E tended to be resistive to care and had behaviors of calling out without a known reason for doing so. She was prescribed anti-depressant medication for depression and anxiety and anti-psychotic medications for Parkinsons psychosis. Interventions included dependent care, hospice care, and inclusion of family with care. ID notes indicated: -4/3/25 at 11:56 a.m., Resident E was seated by the fireplace and was fidgeting with her clothes and blanket. -4/7/25 at 2:45 a.m., hospice services continued. Residnet E had no change of condition observed or reported. -11:33 a.m., Resident E was resting quietly in her broda chair sitting by the fireplace. No changes noted; no verbal/non-verbal signs of pain or discomfort. No changes made to her care plan. -4/8/25 at 4:22 p.m., Resident E had been stable; slept off and on throughout the day; and had no verbal/non-verbal signs of pain or discomfort. -4/9/25 at 3:05 a.m., Resident E continued with hospice services. She had no change in condition and rested comfortably. -10:56 p.m., Resident E was resting quietly in her broda chair sitting by the fireplace. No changes noted; no verbal/non-verbal signs of pain or discomfort. No changes made to her care plan. -4/10/25 at 1:23 p.m., Resident E had no significant changes. She had no verbal/non-verbal signs of pain or discomfort. -4/11/25 at 10:55 a.m., Resident E was seated by the fireplace and was fidgeting with her clothes. She's had no noted changes and no changes to her care plan. -4/15/25 at 12:17 p.m., Resident E and her belongings were moved to a room on another wing. A hospice visit note, dated 4/8/25 at 8:30 a.m., indicated the hospice nurse had been notified by the Unit Manager, another resident had been observed to touch Resident E inappropriately. The other resident was observed to hold Resident E's hand, rub her leg, and was observed putting his hand up her pant leg. There had been no sexual contact made due to presence of resident's incontinence brief and her positioning in the broda chair. The incident was discussed with the DON who reported she and the Unit Manager viewed the camera footage of the incident and there was no sexual contact observed. Resident D was no longer able to go into other resident's rooms and would be closely monitored in common areas. The hospice nurse visited Resident E observed resting comfortably in bed without signs of distress. Resident E was provided a bedbath by the hospice aide. Her skin was observed to be without discoloration or edema. Resident E denied pain and had no signs of increased anxiety. She was unable to recall anything inappropriate or uncomfortable over the past week. On 5/5/25 at 2:54 P.M., Qualified Medication Aid (QMA) 2 was interviewed. She indicated on 4/7/25, she was giving report to the on-coming nurse (Licensed Practical Nurse-LPN 3) at approximately 7:00 p.m. when Certified Nurse Aid (CNA) 4 reported to her and LPN 3, she had just observed Resident D and Resident E in the fireplace room. Resident D had his hand up Resident E's pant leg. CNA 4 reported she moved Resident E to her room and Resident D to his room. QMA 2 left for the evening and on her next scheduled day to work, Resident E had been moved to another wing. QMA 2 indicated she tried to keep Resident D away from the ladies. On 5/5/25 at 3:15 P.M., CNA 4 was interviewed. She indicated on 4/7/25, she had been picking up supper trays when she observed Resident D seated in his wheelchair next to Resident E, seated in her broda chair in the fireplace room. She contined to pick up trays from resident's rooms when she observed Resident D with his hand up Resident E's pant leg. She removed Resident E, took her to her room and left Resident D by the fireplace. She indicated Resident D asked if CNA 4 was going to tell his wife and if what he'd done would be put in the paper. CNA 4 then reported what she had seen to QMA 2 and LPN 3. CNA 4 indicated she had assisted Resident E with putting on her pajamas and hadn't observed any skin issues. A written statement by CNA 5, dated 4/7/25 at 6:47 p.m., indicated she had observed Resident D propel himself into Resident E's room. She went to the room and observed Resident D with his hand on Resident E's chest. Resident D was removed from Resident E's room. There was no cdocumentation of Resident D having his hand on Resident E's chest. On 5/6/25 at 9:45 A.M., CNA 6 was interviewed. She indicated she worked with Resident D daily and had worked with Resident E until she was moved to another wing. She indicated she had never observed him with behaviors of inappropriately touching his peers and it was very surprising. She indicated she had observed Resident D on 4/7/25, in Resident F's room rubbing her shoulders. Resident F was alert and oriented and able to make decisions for herself. She appreciated the shoulder rubbing and indicated liking the attention. CNA 6 reported her observations to the Unit Manager but had not believed it to have been inappropriate. CNA 6 indicated Resident D liked to visit a resident on another wing and would get all spiffed up before going to visit. She was not aware of who the resident was, only he had a friend he liked to visit. Resident D was independent in mobility in his wheelchair and was able to visit other wings of the facility as desired. A CNA work sheet, dated 4/29/25, had not indicated any behavior interventions were in place to monitor Resident D's visits with other female residents. On 5/6/25 at 10:22 A.M., CNA 7 was interviewed. He indicated Resident D used to come over on his wing to visit with Resident X in her room but hadn't done so recently due to Resident D's spouse's wishes. He indicated Resident E resided on the wing but Resident D had not been observed visiting her room. On 5/6/25 at 11:32 A.M., the DON was interviewed. She provided a copy of her investigation of the 4/7/25 incident between Resident D and Resident E. She indicated Resident D had resided in the facility for over a year and she had not been informed of behaviors related to inappropriately touching female residents. He had been having odd behaviors described as inattention, difficulty focusing, looking above her when speaking to him, not making eye contact, and seeming out of touch with reality. She had been notified of the incident and the Unit Manager had come to the building to investigate. LPN 3 had been instructed to put the resident on 15 minute checks and keep a close eye on Resident D. The DON indicated on 4/8/25, she and the Unit Manager viewed the camera footage of the incident and observed the resident holding Resident E's hand and then rubbing her arm and knee and placing his hand under her pant leg where he rubbed her leg. Resident E's family was notified of the incident. She indicated Resident E was moved to another wing per family request. On 5/7/25 at 10:15 A.M., the Social Services Director (SSD) was interviewed. She indicated she and her assistant managed behaviors in conjunction with the ID team and psychiatric NP. She indicated she gets notified of a new behavior through an alert documented on a paper form and given to her or her assistant. The care plan and behaviors were then reviewed and changes made as required. She had no precise knowledge of the incident between Resident D and Resident E, had been unable to find documentation her assistant had been made aware of and followed up on the incident. The care plan had not been updated with specific behavioral interventions related to the incident, how to prevent further recurrence and protect residents involved or other residents with the potential to be affected. The SSD provided a copy of Resident D's monthly behavior monitoring flowsheet for April. She indicated the flowsheets were used for psychotropic medication reviews. Targeted behaviors being monitored for Resident D was insomnia and depression. The flowsheet had not indicated how Resident D expressed depression such as sad face, decreased appetite, anger with spouse, verbalizing hopelessness, changes in sleep, inappropriate touching, etc. On 5/7/25 at 12:57 P.M., the DON provided a current copy of the facility policy, titled Behaviorial Health Services-Social Services, which stated: It is the policy of this community to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .The community utilizes the comprehensive assessment process .The assessment and care plan will include goals that are person centered and individualized .Monitor the resident closely for expressions or indications of distress. Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate the change in behavior was unavoidable .Share concerns with the ID team to determine underlying causes of mood and behavior changes .Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record. Ensure appropriate follow-up assessment This Citation relates to Complaints IN00457494 and IN00457512. 3.1-37

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 of 3 residents reviewed (Resident D and Resident E). Findings include: Reports, dated 4/12/25 and 4/13/25, alleged Resident D had inappropriately touched a female resident (Resident E) on her legs and chest. Both reports indicated there had been no documented interventions put in place, following the alleged incident, to protect the residents and ensure no further inappropriate touching occurred. The reports alleged there was no documentation in either resident's record regarding the incidents on 4/7/25. 1. On 5/5/25 at 1:44 P.M., Resident D's record was reviewed. Diagnoses included, Parkinson's, dementia, anxiety, and depression. An Interdisciplinary (ID) note, dated 4/7/25 at 11:47 p.m., indicated the nurse had been notified by staff, Resident D had engaged in inappropriate behavior throughout the day. The nurse notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON). An ID note, dated 4/8/25 at 3:26 p.m., indicated the hospice case manager had spoken with the hospice physician and reported the resident was having behaviors out of character for him. The ID notes, dated 4/7 through 4/8/25, hadn't indicated what inappropriate behaviors the resident was having, who was affected by the behaviors and interventions taken by the facility to address the behaviors. A Hospice Plan of Care, updated on 4/14/25, indicated Resident D had been involved in an inappropriate incident at the facility which involved other residents. The resident was on 15 minute checks. There was no documentation of the resident being on 15 minute checks when inappropriate behaviors were observed on 4/7/25. There was no documentation of 15 minute checks being completed when the hospice plan of care was updated on 4/14/25. A psychiatric Nurse Practitioner (NP) progress note, dated 4/16/25, indicated Resident D was seen for follow-up psychiatric medication management to assess mood, behavior and efficacy of psychotropic medications prescribed for depression and insomnia. Staff denied any acute concerns. Medication review indicated he was prescribed Carbidopa 5 times per day (every 4 hours). The psychiatric NP progress note hadn't indicated the NP was aware of the incidents of inappropriate touching on 4/7/25. The progress note hadn't indicated the resident's dose of Carbidopa had been decreased from 5 times per day to 4 times due to psychosis like behaviors observed on 4/7/25. 2. On 5/5/25 at 3:12 P.M., Resident E's record was reviewed. Diagnoses included Lewy body dementia with psychotic disturbance, recurrent major depressive disorder and anxiety. An ID note, dated, 4/7/25 at 2:45 a.m., indicated hospice services continued for Resident E and she had no change of condition observed or reported. The ID note hadn't indicated the resident had been observed to be touched inappropriately by Resident D. There was no documented notification to the physician or family. There was no skin assessment completed immediately to check for injury due to the contact nor documentation of how the resident was being kept safe through the night until further assessment could be completed and the care plan updated. A hospice visit note, dated 4/8/25 at 8:30 a.m., indicated the hospice nurse had been notified by the Unit Manager, another resident had been observed to touch Resident E inappropriately. The other resident was observed to hold Resident E's hand, rub her leg, and was observed putting his hand up her pant leg. There had been no sexual contact made due to presence of resident's incontinence brief and her positioning in the broda chair. The incident was discussed with the DON who reported she and the Unit Manager viewed the camera footage of the incident and there was no sexual contact observed. The other resident was no longer able to go into other resident's rooms and would be closely monitored in common areas. The hospice nurse visited Resident E who was observed resting comfortably in bed without signs of distress. Resident E was provided a bedbath by the hospice aid and her skin observed without discoloration or edema. Resident E denied pain and had no signs of increased anxiety. She was unable to recall anything inappropriate or uncomfortable over the past week. The hospice visit note hadn't indicated how Resident D was no longer able to go into other resident's rooms. There was no documentation in the clinical record for either Resident D or Resident E to indicate the DON and Unit Manager had conducted to rule out no sexual contact had occurred. Neither resident's record indicated families were notified of the incident nor interventions put into place to keep each resident safe. On 5/6/25 at 11:32 A.M., the DON was interviewed. She provided a copy of her investigation of the 4/7/25 incident between Resident D and Resident E. She had been notified of the incident and the Unit Manager had come to the building to investigate on 4/7/25. The nurse in charge, who reported the incident, had been instructed to put the resident on 15 minute checks and keep a close eye on Resident D. There was no documentation to indicate this had been implemented. On 5/7/25 at 4:34 P.M., the DON provided a current copy of the facility policy, titled Documentation in the Medical Records which stated: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .Licensed team members and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record at the time of service, but no later than the shift in which the assessment, observation, or care service occurred This Citation relates to Complaints IN00457494 and IN00457512. 3.1-50(a)

Based on observation, interview and record review, the facility failed to ensure medications were dated when opened, and destroyed when expired in 2 of 4 medication carts. Findings include: During an observation, on [DATE] at 1:36 PM, with License Practical Nurse (LPN) 4 on the D hall medication cart, Trelegy 100/ 62.5, inhaler was without a box and no open date for Resident 47. LPN 4 indicated medication should not be in the cart without the date. During an observation on [DATE] at 1:50 PM, with Qualified Medication Aide (QMA) 5 on C hall medication cart, there was an open bottle of Nystatin [NAME] 100 mg with no open date for Resident 27. On the second medication Cart on C hall with QMA 5, was a bottle of Lidoncaine Sol 2% oral with no open date for Resident 25. In the same medication cart, was the medication Insulin Lispro INJ 100 U with an open date of [DATE] and an expiration date of [DATE] for Resident 37. In the same drawer there was a medication of Lantus INJ 100 U with an open date of [DATE] and expiration date of [DATE] for Resident 13. 1. A record review for Resident 47 on [DATE] at 9:05 AM. Diagnoses included, Chronic Pulmonary Disease unspecified. A review of the Physician orders indicated to give Trelegy Ellipta 100 mcg (microgram)-62.5 mcg- 25 mcg powder for inhalation ( Fluticasone-umecclidin-vilanter) inhale 1 puff daily at noon, rinse mouth with water after use- 1 puff inhalation every day for chronic pulmonary disease with a start date of [DATE]. A review of the medication administration record (MAR), dated [DATE], indicated Trelegy Ellipta was given on the following dates: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17. There was no open date for this medication. 2. A record review of Resident 27, on [DATE] at 9:35 AM. Diagnoses included, Alzheimer's disease with late onset. A review of the physician orders indicated there were no active orders for the Nystatin [NAME] 100. 3. A record review of Resident 25, on [DATE] at 9:45 AM. Diagnoses included, Chronic Obstructive pulmonary disease. A review of the physician ordersindicated to give Lidocaine 2% mucosal solution (generic) 15 milliliter (ml). Swish and spit every 8 hours before meals. A review of the MAR, dated [DATE], indicated Lidocaine 2% solution was given on the following dates: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17. There was no open date for this medication. 4. A record review of Resident 37, at [DATE] at 10:05 AM. Diagnoses included, Type 2 diabetes mellitus. A review of the physician orders indicated to give Humalog U-100 insulin 100 units/ml-subcutaneous solution (insulin lispro)- 2 units subcutaneous three times a day for diabetes with each meal, and Insulin lispro ( U-100) 100 unit/ml subcutaneous solution (generic)-100 unit/ml: give 2 units- 201 through 250 4 units- 251 through 350 6 units- 351 through 400 A review of the MAR, dated [DATE], indicated Insulin lispro was given on the following dates: 17. The medication had expiration date of [DATE]. 5. A record review of Resident 13 at [DATE] at 10:25 AM. Diagnoses included, Type 2 diabetes mellitus. A review of the physician orders indicated to give Lantus INJ 100/ml-inject 50 units subcutaneous daily. A review of the MAR, dated [DATE], indicated Lanuts INJ 100 units was given on the following dates: 15, 16, and 17. This medication had a expiration date of [DATE]. A current facility policy, Medication storage Policy, dated [DATE], was provided by the Director of Nursing on [DATE] at 8:51 AM. The policy indicated . it is the policy of this facility to ensure all medications housed on out premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security 3XXX,d+[DATE](j)(m) and (n)

Based on observation, interview, and record review the facility failed to ensure 1 of 5 residents reviewed were free of abuse. (Resident 26). Findings include. Resident 26's record was reviewed 9/17/24 at 2:18PM. Resident 26's diagnoses included dementia, depression, and muscle weakness. A Minimal Data Set (MDS) assessment, dated 8/21/24, indicated Resident 26's Brief Interview for Mental Status score (BIMS ) was 3. A score of 3 indicated severe cognitive decline. Section E of MDS indicated Resident 26 had no behavioral symptoms of aggression. Resident 26 was continent of bowel and used a catheter due to urine retention. Resident 26's care plan, dated 9/17/24, indicated he had cognitive loss. Interventions were to allow plenty of time for care, do not rush or push, do not show impatience. Resident 26's care plan, dated 9/17/24, had a problem of argumentative behavior and becoming agitated easily by others. Interventions were to please intervene as needed to ensure safety and the safety of others, please talk with resident in calm manner; do not give directions, do not argue. Resident 26's September 2024 behavior sheet was reviewed. There were 48 documentations missing. There were 3 behaviors being monitored. Anxiety, aggression, and sleep disturbance per shift. Of the 108 documented there were 4 behaviors noted. 2 on 9/16/24 aggression and anxiety and 2 on 9/18/24 aggression and anxiety. The behavior on 9/16/24 was documented as 1st shift. The intervention was documented as redirection and as effective. The behaviors on 9/18/24 were also recorded as 1st shift. The intervention was redirection. The outcome was zero. Resident 26 was observed on 9/17/24 at approximately 10AM, playing bingo in the main activity room. He was sitting at a table with others calmly. Resident 26 was observed on 9/18/24 at approximately noon eating a meal at table with peers talking quietly, no distress noted. During an observation, on 9/19/24 at 12:17 PM, the video taped footage of an incident between Resident 26 and Qualified Medication Assistant (QMA) 6 on 9/16/24 at 6:18AM was viewed. The video tape showed Resident 26 and QMA 6 at a med cart near the corner of a hall. Talking for several minutes. The resident had no hand gestures, pacing, or other signs of agitation noted. QMA 6 had a relaxed posture. QMA 6 pushed Resident 26 against the wall. Resident 26 walks away and comes back with something in his hand. He approaches QMA 6, they again have a brief discussion. Resident 26 reaches towards her and begins to walk away. QMA 6 then perused Resident 26 reaching around his body and grabbed his glasses from his face while he was in motion. Resident 26 immediately turns back around and begins another discussion. The video then goes to another view of the hall and shows Resident 26 with an arm on QMA 6 and another reaching for something. At the time QMA 6 was up against the wall. QMA 6 then pushes Resident 26 across the entire width of the hall into the opposite wall. Resident 26 falls down the wall onto the ground. Resident 26 loses his shoe during this interaction. QMA then walks away leaving Resident 26 on the ground alone, she looks back states something and walks around the corner. The incident took place on a secured memory care unit. Throughout the video there was another staff member going in and out of rooms on the unit. The other staff member never showed any alarm. There was another resident present who was not interviewable and was unharmed. In an interview, on 9/19/24 at 12:17 PM, the Director of Nursing (DON ), indicated her reaction as disbelief and shock. The DON described the footage as QMA 6 pushed Resident 26 against the wall. The DON presented statements from QMA 6 and other staff as part of her investigation of incident. In an interview, on 9/20/24 at 10:06AM, HR (Human Resources) indicated there was a 3.5 min gap missing in the recordings. The view of cameras changed from Hickory Dining to Hickory Living cameras. There was no visualization of QMA 6 or Resident 26 from 6:14:25AM to 6:18:12AM on 6/16/24. The cameras were meant to pick up any motion and record. The HR director indicated the Memory Care Manager (MCM) came to her around 9:30AM and asked to see the videos. Notification was then made to the DON, the Administrator, family, and the Physician An observation of the Hickory Living video, on 9/20/24 at 10:06AM, indicated after the incident, Resident 26 laid on the floor for 5 seconds before gathering his shoe and getting himself up from the floor. A fall statement, dated 9/16/24, indicated Resident 26 was pulling QMA 6's hair and grabbing her. She tripped over own shoes and fell up against wall down to floor while being abused by the resident A statement from QMA 6, dated 9/16/24 at 3:10PM, indicated Resident 26 indicated he was going to walk with her. Resident 26 accused QMA 6 of waking him up. She reminded him when she came to him room, he was on the toilet soiled. He then reminded her she said she would come back, and she did not. He called her an idiot and then spelled it out IDOT (sic). QMA 6 then explained that idiot had 2 I's. He asked for her name. she told him. He returned with a pad of paper and asked her to write it down. He was going to report her. QMA 6 explained she already told him . QMA 6 refused to write her name. Resident 26 grabbed QMA 6's badge. QMA 6 attempted to grab it back. QMA 6 then quickly slid Resident 26's glasses off. He demanded his glasses back. QMA said for the badge. Resident 26 had QMA 6 up against the wall. QMA 6 asked Resident 26 to let her go. Resident 26 refused. An unidentified resident came closer, QMA 6 wrote in her statement a distraction was possible and she pushed Resident 26. An MCM statement indicated upon arriving for work on 9/16/24, she was met by QMA 6 who requested her to get the badge from Resident 26. The MCM went to Resident 26, he indicated he turned it in downtown. After he felt around for it, he gave it easily to the MCM who gave Resident 26 his glasses. Resident 26 stated, oh there those are. The DON's statement indicated Resident 26 complained of back pain and was given an Xray to rule out any injuries. He also fell a few days prior to the incident, during an activity and had minor complaints then as well. DON indicated disciplinary action was taken for QMA 6. In an interview, , the Maintenance Supervisor indicated the cameras were set to record on movement to allow for longer saving time. Less recording increased ability to save for more days. Maintenance measured the width of the hallway where incident occurred at 7ft. 8 inches. There were no other signs of struggle. No holes in the wall, and no scratches at time of incident to Maintenances knowledge. During an observation, on 9/20/24 at 12:24PM, there were no pictures, fire extinguishers, doors, or other items attached to the walls during observation. In an interview, on 9/23/24 at 9:38A , the Restorative Aid indicated facility training related to abuse indicated staff was never to put hands on a resident.The abuse training module was on the computer. The Restorative Aid indicated the facility did not do any simulated trainings to her knowledge. A policy and procedure titled, Abuse, Neglect, Exploitation Policy dated 9/20/22 last updated 4/23/24 was obtained from DON on 9/23/24 at 9:40AM. The policy indicated . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish It can include verbal abuse, sexual abuse, physical abuse, and mental abuse This Federal Citation is realted to complaint IN00443361. 3.1-27(a)

Based on observation, interview, and record review the facility failed to ensure interventions were implemented to prevent feelings of fear for 1 of 2 residents reviewed. (Resident 3) Findings include: In an interview, on 9/17/24 at 11:09AM, She indicated she had been overwhelmed since her husband's passing in May 2024. Resident 3 pointed to several boxes against the wall across from her bed of memorabilia she felt responsible to sort and disperse to family members. Resident 3 explained her diagnosis of PTSD realted to sexual, verbal, and physical abuse as a child. Resident 3 indicated the only times she was triggered in the facility was when a peer (Resident 85) was coming into her room uninvited especially at night. Resident 3 described a male peer coming into her room sometimes making it to the foot of her bed before she would see him or feel him looking at her. Resident 3 reported she would be the one to alert staff to his continued unwanted presence in her room, and he would be redirected back to his room. After several incidents, more than 5 times of redirecting peer back to his room, the Resident 85 was moved to another room and the visits stopped. Resident 3 indicated no other solution was given to her or offered. The facility placed no stop signs on her door, no net was placed to deter the peer. Resident 3 requested to be able to lock her door and was told that was not allowed for safety concerns. Resident 3 indicated she felt safe at this time. Resident 3 indicated Resident 85 never got far enough to do anything physically to her but she felt very anxious and extremely uncomfortable in the situation. During an observation, on 9/17/24 at 11:09AM, Resident 3 was observed to be tearful. Resident 3's record was reviewed on 9/18/24 at 10:59AM. Diagnoses included anxiety, depression, and post traumatic stress disorder. A Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Brief Interview of Mental Status (BIMS ) score was 15. A score of 15 indicated no cognitive decline. Section D for mood indicated Resident 3 had difficult falling, staying, or sleeping too much nearly every day. Section E for behaviors indicated Resident 3 had no behaviors. Monthly Behavior Monitoring Flowsheets were reviewed, dated August 2024. No incidents of behaviors were recorded. The behaviors being monitored were mood disorders, depression, and insomnia. August 23 was without documentation. Monthly Behavior Monitoring Flowsheets were reviewed, dated September 2024. No incidents of behaviors were recorded. The behaviors being monitored were mood disorders, depression, and insomnia. Resident 3's Brief Trauma Questionaire was not dated. The DON dated it for the date of admission. The DON indicated no other trauma assessment was performed. In the questionnaire it was identified Resident 3 had trauma related to the following: Accident were she was seriously injured, a life threatening illness and cancer, before age 18 was physically punished and would feel threatened or in danger. and was pressured into having unwanted sexual contact and would feel in danger. A Care Plan, dated 6/3/24, indicated a problem of mood state, signs of depression, diagnoses of anxiety, depression, personality disorder, PTSD (post traumatic stress disorder). The goal was the resident would like her mood to improve. Interventions were as follows: administer medications as ordered, schedule psych eval and follow any treatment recommendations, and provide an opportunity to vent issues. There was no trauma specific problem in the care plan. No goal made for trauma needs. There were no interventions or triggers identified. A care plan, dated 9/20/24, included a problem of trauma. The problem indicated a potential for mood disturbance related to history of childhood trauma- moved on and healed from traumatic events in their life and denies having any triggers for remininscing. The goal indicated the resident would be able to verbalize if they become triggered and remembering past events through next review. The interventions were as follows: Observe for non verbal cues regarding traumatic events Offer resident safe place to vent feelings Encourage resident to participate in activities of enjoyments such as Offer psych services if willing to participate A physician note, dated 8/26/24, indicated Resident 3 had an acute complaint of a male peer coming into her room. Resident 3 was given PRN hydroxyzine every 8hrs and details were discussed with social services. A policy and procedure titled, Trauma Informed Care dated 11/2019, last updated 8/21/2024 was provided by DON on 9/19/24 at 2:16PM. The policy indicated .provide care and services account for experiences and preferences, and address the needs of trauma survivors by minimizing triggors and/or retraumatization .d. physical, sexual, mental, and/or emotional abuse (past or present). i. Traumatic life events (death of a loved one, personal illness, etc) a. safety. Ensuring residents have a sense of emotional and physical safety. d. empowerment. voice. and choice. 7. Trauma specific care plan will interventions will recognize the interrelationship between trauma and symptoms of trauma.

Based on observation, interview and record review the facility failed to ensure infection control measures were maintained for oxygen tank tubing for 2 of 3 residents reviewed. (Resident 16 and Resident 247) During an observation, on 9/17/24 at 12:20 PM, there were 2 oxygen tanks in the hallway on the floor. The tubing for both tanks were observed to be wrapped around the hand rail outside of the beauty shop. There were no covers, any bags, or dates observable for the tubing to be placed into. In an interview, on 9/17/24 at 12:25 PM, the Director of Nursing (DON), indicated the resident would wear their oxygen to the beauty shop and leave the tank outside. 1. A record review of Resident 16 was completed on 9/17/24 at 1:05 PM. Diagnosis included, chronic obstructive pulmonary disease. A physician order for Oxygen 2 liter (L)/ min, indicated to give nasal oxygen every shift for chronic obstructive pulmonary disease with (acute) exacerbation. 2. A record review of Resident 247 was completed on 9/17/24 at 1:05 PM . Diagnosis included, dependence on supplemental oxygen. A physician order of Oxygen- 2L/min indicated to give nasal oxygen every shift for chronic obstructive pulmonary disease. In an interview, on 9/19/24 at 9:00 AM, DON indicated the facility did not have a current facility policy. 3.1-18(a)

Based on interview and record review, the facility failed to enure an injury of unknown origin was reported for 1 of 3 residents reviewed (Resident D). Findings include: On 4/4/24 at 1:27 P.M., Resident D's record was reviewed. Diagnoses included dementia with behavioral disturbance. An IDT (Interdisciplinary Team) note, dated 2/26/24 at 11:00 a.m., indicated the resident was observed with swelling and discoloration of the right side of her face. She was not wearing her dentures becasue they were broken. The resident's family was notified of the swelling and broken dentures. The family member indicated too the IDT they were aware of the injury to her face and had taken her to theER on [DATE] to be evaluated and treated. A late entry progress note dated 2/23/24 at 4:00 p.m., indicated the resident's right cheek and side of her face had been swollen without bruising. An IDT note, dated 3/23/24 at 12:27 p.m., indicated Resident D had swelling near and blue bruising below her right eye. She had no signs of discomfort or pain. Staff were interviewed by the facility about the swelling and bruising, but no one knew what had occurred. There was no further documentation in progress or event notes regarding the resident's injuries documentated on 2/23/24 and 3/23/24. There was no investigation into the cause, affect of injury on the resident or follow up for resolution of the injury. In an interview on 4/24/24 at 2:35 P.M., the Director of Nursing (DON) indicated staff had assumed the resident had fallen and had gotten herself back up in both incidents. Staff removed the resident's enabler bars to her bed and her nightstand to prevent fall with injury however, it was unknown whether her injuries were due to falls. She indicated neither she nor the Administrator reported the injuries observed on 2/23/24 or 3/22/24 but should have as the resident was unable to tell staff how they occurred, had no witnessed or reported falls, wasn't prescribed blood thinners, and the injuries had occurred to her face/head. A current policy, titled Compliance with Reporting Abuse, Neglect, Exploitation Policy was provided at 2:37 P.M. by the DON which stated: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources .immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed times .d. Injuries of unknown source: Includes circumstances when both the following conditions are met; The source of the injury was not observed by any person or could not be explained by the resident. The injury is suspicious because of the extent of the injury, location of the injury This tag relates to Complaint IN00431247. 3.1-28(c)

Based on interview and record review, the facility failed to notify the physician and family timely of a significant change in condition for 1 of 1 residents reviewed (Resident D). Findings include: On 3/11/24 at 10:57 A.M., Resident D's family member/POA (Power of Attorney) was interviewed. The family member indicated the resident had been admitted to the facility following hospitalization for C. Diff colitis (Clostridium Difficile infection of colon). She had completed her therapy and family was waiting until her C. Diff infection was completely resolved to take her home due to home health refusing to provide care at home with an active C. Diff infection. The POA alleged on 12/25/23, another family member had been in to visit the resident. Reidnet D complained of right sided pain in her midsection. The family indicated they did not inform the facility. On 12/27/23, 2 other family members visited and the resident was observed to grab at her right side and stated oh that hurts. Family asked staff to assess the resident and inform the doctor or NP (Nurse Practitioner) of the pain. The staff member was alleged to have put the resident's name on the NP list to be seen at the next scheduled visit. On 12/29/23, a family member contacted the DON (Director of Nursing). The DON indicated she hadn't been aware of the right sided pain Resident D had been having and she was unable to find documentation of the NP visiting her to assess the pain. On 12/31/23, family members came in to visit. Resident D was observed lying in bed, on her right side, in a fetal position. She was lethargic and only responded with mumbles. The family members observed an isolation cart outside the resident's room and asked a CNA (Certified Nurse Aide) why the cart was outside the room. They indicated the CNA hadn't known why the cart was there but thought it was due to the resident having diarrhea. The family asked to speak with the nurse. QMA 2 (Qualified Medication Aid) indicated to the family there was nothing wrong with Resident D. The QMA indicated the resident was having diarrhea and at some point, she was put into isolation. LPN 3 was informed by the family about the concerns with the Resident D's right sided pain, lethargy and diarrhea. The family requested the resident be sent to the hospital for evaluation. The POA indicated the facility hadn't notified the family Resident D was having diarrhea, had been placed in isolation and indicated niether the physician nor the NP were notified of her symptoms until family came in and asked for her to be sent to the hospital. The POA indicated the resident was hospitalized [DATE] until 1/8/24 and hadn't returned to the facility per family's wishes. On 3/12/24 at 10:22 A.M., Resident D's record was reviewed. Diagnoses included Alzheimer's dementia and C. Diff colitis. An admission MDS (Minimum Data Set) assessment, dated 11/16/23, indicated the resident had severely impaired cognition. A Discharge Summary, dated 11/27/23, indicated Resident D's expected date of discharge would be 11/30/23 following discharge from therapies. Her diarrhea had improved however, staff reported Resident D had loose, malodorous stools containing mucous, occurring over 11/25/23 through 11/26/23. An order to check for C. Diff was given and a sample was obtained on 11/28/23. The stool culture was positive for C. Diff. Resident D was prescribed a 10 day course of antibiotics beginning 12/4/23. An NP progress note, dated 12/14/23, indicated Resident D had been seen for a post acute care visit. The resident had a history of C. Diff and had been taking Vancomycin (antibiotic) with the last dose scheduled for 12/15/23. She was waiting to go home until her C. Diff infection was resolved as home healthcare wouldn't accept her with an active C. Diff infection. Assessment and Plan indicated C. Diff: resident had a known history of C. Diff and had been on a course of Vancomycin. She would likely undergo testing to assess resolution of the infection. Her return home had been delayed due to concerns from home healthcare about C. Diff infection so ensuring resolution of the infection would be crucial for her transition back home. Staff were to notify the NP of any acute changes in conditions, concerns, or needs. An NP progress note, dated 12/27/23 indicated the resident was seen for chronic care follow up. Resident D's C. Diff infection had resolved on 12/19/23, she had formed stools and was awaiting discharge. Both the resident and staff denied any acute concerns or needs at the time of the visit. The note indicated the resident should continue to be monitored for signs of C. Diff recurrence following completion of antibiotics on 12/15/23. The NP progress note, dated 12/27/23, hadn't indicated the NP was aware of the resident's complaint of right sided flank pain or the family's voiced concerns. Nurse notes, dated 12/31/23 indicated the following: -10:10 a.m., the resident was having mucous like stools which had an odd odor. -2:37 p.m., the resident was resting in bed. She'd had very loose stools with mucous and unusual odor. -3:05 p.m., the family was in and wanted the resident sent to the hospital. The on-call NP was notified and orders given to transport to the hospital for evaluation. Family all came in her room even though was aware of possible C. Diff. On 3/12/24 at 1:25 P.M., QMA 2 was interviewed. She indicated she recalled the resident had complained of back pain but she hadn't observed any obvious injury. She couldn't recall details but indicated if concerns had been reported to her, she would've told the nurse and either she or the nurse would put the request to be seen by the NP in the NP folder for the next visit. She indicated QMA's don't place isolation carts outside resident's rooms as nurses make determinations about isolation. On 3/12/24 at 1:49 P.M., LPN 3 was interviewed. She indicated she was the weekend supervisor who was in charge on 12/31/23. She hadn't put the resident into isolation and assumed Resident D had been placed in isolation the week. She indicated she had been going to notify the family of the resident's loose stools but hadn't had a chance to call either the family or the NP prior to the family's visit. LPN 3 indicated she had not been told Resident D had loose stools or she was in isolation for suspected C. Diff infection. She hadn't recalled the resident complaining of pain however, she had complained of being tired and she had adamantly refused to eat her lunch. On 3/12/24 at 2:30 P.M., the Director of Nursing (DON) was interviewed. She was able to review Resident D's bowel movement chart. The chart indicated the resident had loose stools on day shift on 12/30/23. There was no documentation to indicate the NP or family had been notified. The DON indicated if the resident had been having loose stools and put back into isolation, the doctor or NP and family should've been notified. A current policy, provided by the Assistant Director of Nursing on 3/12/24 at 3:06 P.M. and titled Notification of Changes, stated the following: The purpose of the policy is to ensure the campus promptly informs the residents, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .clinical complications This tag relates to Complaint IN00429037. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a resident was effectively secured in the wheelchair following manufacturer recommendations during a van transport. This deficient practice resulted in the resident falling out of the wheelchair when a van driver applied the brakes and incurring a spinal injury. (Resident Z) The Immediate Jeopardy began on 1/3/24 when Resident Z slid out of his wheelchair during transport when the facility van made a sudden stop. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on January 29, 2024 at 4:06 P.M. The immediate jeopardy was removed on 1/30/2024 Findings include: On 1/29/24 at 10:25 A.M., Resident Z's record was reviewed. Diagnoses included lumbar stenosis (narrowing of open spaces in lower spine which puts pressure on spinal cord and nerves traveling through the spine). The resident admitted to the facility 12/19/23 for short-term rehabilitation following reconstructive surgery to his spine. On 1/3/24, the resident was seen at the emergency room and diagnosed with a new acute compression fracture to his 4th lumbar vertebrae following a fall from his wheelchair while being transported in the facility van. He discharged from the facility on 1/4/24. An Admission MDS (Minimum Data Set) assessment, dated 12/26/24, indicated the resident experienced mild cognitive impairment and no impairment to upper or lower body range of motion. A written statement by Resident Z, dated 1/3/24, indicated Van Driver 3 was transporting him back to the facility when the driver slammed on his brakes causing the resident to slide forward and out of the wheelchair. His legs went 2 different directions and he was stuck and in pain and couldn't get up. Van Driver 3 grabbed me and lifted him back into the chair. The resident alleged the van driver commented we need to replace those referring to the safety belts. The van driver asked if he wanted to go to the hospital but he hadn't seen any obvious injuries so he told the driver it was okay to take him back to the facility. When he returned to the facility, staff came to his room to assess and talk with him about the incident. He told them his back and leg hurt and requested an x-ray be done. Staff indicated they would get an order for the x-ray but weren't sure if it would be completed and read that evening. The resident called his daughter who then transported him to the hospital where he was diagnosed with a compression fracture to his spine. An investigation of the incident was provided by the Administrator on 1/29/24 at 9:52 A.M. He indicated he had interviewed the van driver about how he secured the resident in the van. Van Driver 3 indicated, after loading the resident and his wheelchair into the van, he secured the frame of the wheelchair with 4 straps-one for each corner of the wheelchair. He then secured the harness seatbelt and made sure it fit him snuggly, however the lap belt had not been utilized. The van driver indicated there were 2 additional straps which could be used for the wheelchair frame to keep the wheelchair in place but he didn't normally use those. Van Driver 3 secured the resident in the van the way he had been trainedby the Maintenace Director to secure residents. The Administrator indicated Van Driver 3 had been terminated for unrelated issues but had the drivers written statement of the incident. the Administrator indicated there was not a facility policy regarding safety in the van nor was there a safety assessment to ensure resident safety while riding in the van. A written statement by Van Driver 3, indicated on 1/3/24 at approximately 4:30 p.m., he was transporting Resident Z back to the facility following an appointment. He came to a busy intersection of the road and had to hit his brakes hard to avoid a collision. The resident slid out of his wheelchair and onto the floor of the van. Van Driver 3 stopped at a nearby gas station where he was able to assist the resident back up into the chair by putting his arms under the resident's armpits and pulling him back up and resecuring him again in the wheelchair. The resident complained of some pain but when asked, denied need to call ambulance. Van Driver 3 returned to the facility at 4:48 p.m. and told the charge nurse and Assistant Director of Nursing (ADON) about the incident. There was no documentation in the statement of the shoulder harness or lap belt being utilized. On 1/29/24 at 1:12 P.M., the Maintenance Director, who was responsible for training and management of the van drivers, was interviewed in the van where the incident occurred. He indicated he trained Van Driver 3 as per training provided to him by the company the van was purchased from 3 years earlier. He indicated use of both the shoulder and lap belt together to secure the resident in the wheelchair was optional but not required according to his training. In the vehicle, an empty wheelchair was observed positioned in the front portion of the van, secured by 4 straps, attached at one end to the metal portion of the wheelchair with J hooks. The other ends of the straps were attached to 4 floor retractors which secured the wheelchair in place. The Maintenance Director demonstrated use of the combination lap/shoulder belt system used to secure residents in the wheelchair. The combination belt could be used as a shoulder belt only or used as a combination lap and shoulder belt. He indicated during his training, he was told use of a lap restraint was optional when securing residents in wheelchairs and only shoulder belts were required. He provided an instruction manual for installation of the 4-point wheelchair securement system and brief user manual for their installed system-Q-5000 series by Qstraint. He indicated he had contacted someone at the company who verbally indicated use of both the lap and shoulder belts were optional. Since the incident with Resident Z occurred, the Maintenance Director indicated staff would use the combination lap and shoulder belt for transporting residents. The Qstraint manual indicated manufacturer's recommendations were to use both the lap and shoulder restraint when securing a resident in the wheelchair for transport. The training given to the van drivers did not include securing the lap belts. The New Hire checklist for transportation for new van drivers included a section for how to lock in the wheelchair for transport, but did not indicate shoulder or body belts for security were necessary. A Use and Care Manual-Vehicle Anchorages and Accessories for 4-Point Wheelchair Securement Systems: Q-5000 Series was retrieved from www.qstraint.com on 1/29/24 at 1:46 P.M. which indicated the following: Important Safeguards and Warnings .Compliant shoulder and pelvic belt restraint must go across occupant's shoulder and pelvis (lap), and not be worn twisted or held away from the occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance of the system Under IC 9-19-10-2 safety belt instruction indicates (sic) each occupant shall have a safety belt properly fastened about the occupant's body at all times when the vehicle is in forward motion. The Immediate Jeopardy that began on 1/3/24 was removed and the deficient practice corrected on 1/30/2024 when the facility completed training of van drivers to use both shoulder and lap belt restraints for securing residents in wheelchairs during transportation, but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This tag relates to Complaints IN00425478 and IN00426117. 3.1-45(a)

Based on observation, interview and record review, the facility failed to implement a comprehensive QAPI program to ensure residents were provided with safe transportation provided by the facility. 43 of 90 residents residing in the facility utilized van transportation. Findings include: During a complaint survey, dated 1/29/24 to 1/30/24, a deficiency was cited at Immediate Jeopardy-F689 when the facility failed to ensure a resident was secured in the wheelchair following manufacturer recommendations during transport. The resident slid out of the wheelchair and onto the floor when the transportation van made an abrupt stop causing the resident to sustain a spinal injury. Cross reference F689. On 1/29/24 at 9:52 A.M., the Administrator was interviewed. He indicated the facility conducted an investigation of the incident occurring on 1/3/24 which resulted in a resident's injury. During interviews, he determined staff had secured the resident with the harness belt as trained per manufacturer's recommendations. According to staff, use of a lap belt along with the harness belt was recommended for use, but not required. The Administrator indicated to prevent reoccurrence, facility staff would begin to use the lap belt in addition to the standard wheelchair security system. All transport staff would be trained in the updated procedure however, the facility had not yet developed a written policy/procedure. The facility did not have a policy regarding safety in the van nor was there a safety assessment used to ensure resident safety while riding in the van. The facility had no QAPI plan in place to ensure the updated procedure for securing resident's in wheelchairs during transport was followed accurately and consistently and was being monitored. On 1/30/24 at 1:14 P.M., the Administrator provided a current copy of the facility policy titled Quality Assurance and Performance Improvement (QAPI) which stated: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides .'Adverse Event' is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or risk thereof .The QA program will develop and implement appropriate plans of action to correct identified quality deficiencies .The QAPI plan will address the following elements .b. Policies and procedures for feedback, data collection systems, and monitoring .d. A prioritization of program activities that focus on resident safety, health outcomes, autonomy, choice and quality of care, as well as, high-risk, or problem prone areas as identified in the facility assessment that reflects the specific units, programs, departments, and unique population the facility serves .f. A process to ensure care and services delivered meet accepted standards of quality .The facility will maintain documentation and demonstrate evidence of it's ongoing QAPI program. Documentation may include, but is not limited to .Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events .2. The governing body will .ensure that corrective actions address gaps in systems, and are evaluated for effectiveness This tag relates to Complaints IN00425478 and IN00426117.

Based on interview and record review, the facility failed to ensure preferences and options for showers and meals were offered and observed for 1 of 2 residents reviewed. (Resident 40) Findings include: During an interview on 9/8/23 at 11:26 AM, Resident 40 indicated the inability to have meal options or to choose shower times and days was concerning. Resident 40 indicated they only got whatever meal that was available to them. They did not get to choose other options. Resident 40 further indicated she did not get her showers on Wednesday and Saturdays as she was told she would. When she gripes loud and hard enough she may get a shower on Thursdays when it was conveient for the staff. She preferred shower times to be in the afternoon. Resident 40's record review began on 9/8/23 at 2:19 PM. Diagnoses included, chronic obstructive pulmonary disease with acute exacerbation. Resident 40's BIMS (brief interview mental status) was a 13 out of 15 (cognitively intact). A physician order dated 5/18/23, indicated a diet order of regular with mechanical soft textures. During an interview on 9/8/23 at 1:27 PM, Dietary Cook 6 indicated the facility did not offer a menu or substitutes to residents with therapeutic diets (mechanical soft). They also did not give residents with low BIMS or diagnoses of Dementia/Alzheimer's any choice of meal options. Resident 40's bathing detail from 8/1/23 through 9/8/23 indicated the following: 8/2/23( Wednesday) on 1st shift, a bed bath was given. 8/5/23( Saturday) on 1st shift, a shower was given. There was no indication a shower or bed bath was offered or given on the following dates in August 2023: 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15. 8/16/23( Wednesday) 1st shift, a bed bath was given. 8/19/23( Saturday) 1st shift, a shower was given. There was no indication a shower or bed bath was offered or given on the following dates in August 2023: 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and September 1, 2023. 9/2/23( Saturday) 1st shift, a shower was given. 9/6/23 (Wednesday) 1st shift a shower was given. During an interview on 9/11/23 at 11:51 AM, the Director of Nursing indicated Resident 40's shower times were changed and staff was informed. She indicated the facility did not have a policy for resident choices and the closest thing would be resident rights. A review of facility's Admission Agreement, was provided by the Director of Nursing. The facility's admission agreement indicated . self-determination .you have the right to and the facility must promote and facilitate self-determination through support of resident choices, including: The right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with your interests, assessments, plan of care and other applicable provisions of this part .You have the right to make choices about aspects of your life in the facility that significant to you 3.1-3(u)

Based on interview and record review the facility failed to ensure physician orders were followed for 2 of 2 residents reviewed. (Resident 9 and Resident 198) Findings include: 1 In an interview on 9/6/23 at 1:04 PM, Resident 9 and her daughter indicated she was confused. Resident 9 indicated the bandage on her leg was from a fall she had at a named facility. Resident 9 was unable to idientify her current facility. Resident 9 was unable to recall why she fell or when. Resident 9 complained of being tired but denied any other complaints. Resident 9's daughter indicated there were times her mother's pain medication was not available when it was to be given. The daughter had no other complaints. In an interview, on 9/11/23 at 1:31PM, RN 4 indicated she removed (2) 25mcg Fentanyl patches and a 100mcg Fentanyl patch from Resident 9 and replaced them with a 100mcg Fentanyl patch. RN 4 indicated there was a onetime order for the (2) 25mcg patches until the 100mcg patches were received from the facility pharmacy. Residents 9's record review began on 9/11/23 at 2:22PM, her diagnoses included chronic pain, osteoarthritis, and polyneuropathy. Resident 9's Current Quarterly MDS (Minimum Data Set) assessment on 8/24/23, Section C for Cognitive Patterns indicated her BIMS (Brief Interview of Mental Status) was a 12 showing mild cognitive decline. Section N of Resident 9's MDS indicated she received Opioid medication for 7 of the 7 days reviewed. Resident 9's history and physical dated September 6, 2023, listing current medications did not include Fentanyl patch. Subsequent history and physicals did include Fentanyl patch. The current order for the Fentanyl patch was dated January of 2023. Resident 9's MAR (Medication Administration Record), narcotic count sheets, and physician orders indicated medications were not given as ordered. The last 3 months of physician orders were reviewed. Orders for narcotic medications were as follows: Norco 5-325mg tablet four times a day start date 8/8/23 stopped 9/10/23. Fentanyl Patch check placement every shift start date 1/28/23. Fentanyl 100mcg/hr. transdermal path apply 1 patch topically every 72 hours start date 1/28/23. From September 1 through September 10th the MARs documented Fentanyl patch was administered and placement was checked as indicated by staff initials as follows: 9/1/23 11am Fentanyl 100mcg patch med not available supervisor called pharmacy to resolve the issue. The note indicated the facility had not heard from the pharmacy that day 9/4/23 11am Fentanyl 100mcg patch med not available. The patches had been delivered. The staff member removed the old patch, and the ADON (Assistant Director of Nursing) was notified. 9/10/23 11am Fentanyl 100mcg patch med not available supervisor notified. 9/10/23 11am Norco 5-325mg med not available 9/10/23 4pm Norco 5-325mg med not available 9/10/23 9pm Norco 5-325mg med not available Resident 9's controlled substance count sheet indicated no Norco was removed for the 9/6/23 bedtime dose. The missed dose was not documented in Resident 9's chart. Resident 9's controlled substance count sheets for Fentanyl patches indicated there were gaps from 8/23/23 to 8/29/23 and from 8/29/23 to 9/5/23. There was documentation on the September 2023 MAR and count sheet to support the Fentanyl patch administration was on 9/5/23 and 9/7/23; 48 hours not 72 hours as prescribed. On 9/12/23 at 9:18AM the DON provided a onetime order for (2) 25mcg Fentanyl patches for Resident 9 due to the medication available in emergency medication supply. The DON further provided a hand written note from a facility staff to indicate she placed them on Resident 9 on 9/10/23 at 12:05AM there was no physician's order, no MAR, no progress note, and no narcotic sign off sheet to indicate Resident 9 received the medication. In an interview on 9/12/23 at 9:18AM the DON indicated the problem was the QMAs (Qualified Medication Assistant) were prohibited from documenting. The DON indicated they had a backup local pharmacy. The DON indicated the facility stopped their contract with the current facility pharmacy with a required 90 days' notice. The DON indicated in this case the problem was not the just the pharmacy lack of timeliness but also the doctor was on vacation. 2) Resident 198's Record review began on 9/11/23 at 2:33 PM. His diagnoses included dementia and end of life care. Resident 198's orders for the last 60 days were reviewed. The orders included Oxycodone 20mg/ml give 0.5ml by mouth every 2 hours as needed for break through pain start date 8/23/23; Fentanyl 25mcg 1 patch every 3 days start date 8/20/23; Oxycodone 20mg/ml give 0.5ml by mouth every 12 hours start date 8/13/23; Apply Fentanyl patch to area of hairless, clean skin out of reach of resident and cover with transparent dressing start date 8/19/23. The orders did not match the documented count sheet orders nor the MAR. Resident 198's MARs dated August 2023 indicated to apply Fentanyl patch to area of hairless clean skin out of resident reach was documented on 8/3/23, 8/6/23; 8/9/23; 8/12/23; 8/15/23; 8/18/23; and 8/21/23. The application did not match the administration record or the controlled count record sheet. Resident 198's controlled substance record dated August 2023 documented the Fentanyl patch was signed out on 8/5/23; 8/6/23; 8/8/23; 8/11/23; 8/11/23; 8/15/23; 8/18/23; 8/20/23; and 8/23/23. The controlled substance sign out sheet did not indicate the patch was administered or removed from stock every 3 days as ordered. Resident 198's MARs dated August 2023 indicated Fentanyl 25mcg/hr. transdermal patch was administered on 8/5/23; 8/8/23; and 8/20/23. The period of 8/8/23 to 8/20/23 was not 72 hours as ordered. At the end of the August 2023 MAR documentation there was one documentation of Fentanyl patch on 8/6/23 placed on the right back shoulder. One Fentanyl patch on 8/21/23 1:04 PM was a new patch administered 8/20/23, due to the one admiinistered on 8/18/23 was missing. In an interview on 9/12/23 at 11:18AM, the DON indicated Resident 9's last 60 days of medication requisitions was retrieved from trash cans. Resident 198's medication requisitions were unavailable. The DON indicated she was unaware others were discarding the requisitions after receiving the supply from pharmacy. No policy or further information was available by time of exit. This Federal Citation is related to Complaint IN00415824 and IN00417181. 3.1-37

Based on observation, interview, and record review the facility failed to ensure safety for 1 of 5 people reviewed. (Resident 9) During an observation and interview with Resident 9 on 9/6/23 at 1:04 PM she appeared with a white criss cross bandage wrapped around leg. She indicated she fell at a facility and referred to it as some place else. She was unable to indicate when or how she fell . She was unable to tell what she had for breakfast or lunch. During an interview on 9/11/23 at 1:08PM, Resident 9 did not remember going outside at all. Resident 9 indicated she blacks out at times. She was further able to indicate the memory loss was off and on. Resident 9 complained of being tired. During an interview on 9/11/23 at 1:11PM, Resident 9's daughter indicated Resident 9 had began to wander and more confused in the last two months. The daughter was unable to indicate where the Resident 9 was found or how long she was missing. The daughter indicated she got a phone call to explain Resident 9 eloped and refused to come in for a period but was safe. Resident 9's daughter further indicated she was glad they did find her mother as she would not have been able to get back into the building because of the needed code. During an interview on 9/11/23 at 1:31PM, RN (Registered Nurse) 4 indicated Resident 9 was looking out the door near room [ROOM NUMBER] on 9/7/23 around lunch time, when RN 4 went to another unit to give meds. RN 4 indicated a CNA (Certified Nursing Assistant) saw Resident 9 through the window near room [ROOM NUMBER] outside by herself. RN 4 immediately sent the CNA out to be with Resident 9 and alerted social services to go out and assess. RN 4 indicated Resident 9 refused to return to the facility. She was upset, wanted to leave, and she was going home. Resident 9 consented to returning to the building with RN 4 after a stroll. Upon returning, RN 4 alerted staff, filled out a social service report (on paper), and started 15min checks. RN 4 indicated she told everyone. RN 4 admitted to forgetting to put in a progress note or to update the CNA assignment sheet with the information. RN 4 indicated Resident 9 had attempted to elope a couple of times in the past but would always come right back without hesitation. RN 4 indicated Resident 9 had increased confusion and looking for her husband who has passed. Resident 9's record review began on 9/11/23 at 2:22PM, indicated diagnoses included history of falls, major depression, glaucoma, and dementia. Resident 9's current Quarterly MDS (Minimum Data Set) assessment on 8/24/23, Section C for Cognitive Patterns indicated her BIMS (Brief Interview of Mental Status) was a 12 showing some moderate cognitive decline. Resident 9's history and physical from 8/15/23 indicated she has been becoming more confused and had an increase in wandering than she usually had despite medication reductions. On the 8/22/23 note, the doctor indicated the confusion continued. Resident 9's most recent elopement risk completed 7/13/23 indicated the facility assumed no elopement risk potential. The assessment had not been updated to indicate the changes in Resident 9. The mental stability assessment was marked as alert and oriented, but the resident was not alert and oriented as evidenced by an inablility to indicate where she was or what she had eaten. The elopement attempts section was not marked, but there were recent attemps with success. The emotional status assessment indicated the resident was happy, but Resident 9 was not happy with placement as evidenced by wanting to leave and not wanting to come back in. The dementia or mental disorders portion was marked as 1, no dementia or mental disorders. The elopement number of days without attempts assessment was marked as greater than 120, but there were attempts with in 30 days. Resident 9 was not care planned for elopement or wandering. Resident 9's most recent care plan 9/5/23 did not address her elopment attempts or give the staff any interventions to attempt to prevent elopement. No policy or further information was provided by time of exit. 3.1-45(a)

Based on observation, interview, and record review the facility failed to provide adequate pain management for 1 of 3 residents reviewed. (Resident 13). Findings include: During an observation and interview on 9/6/23 at 9:52AM, Resident 13 was lying in bed clutching one hand inside of the other. Resident 13 indicated he was always in pain. Resident was aware of his diagnoses and medications. Resident 13 indicated he did not receive any non-pharmaceutical interventions for his pain prior to as needed narcotic pain medication. Resident 13 indicated he tried not to take the medication on days he did not have therapy. Resident13 rated his pain during this interview a 7 with the majority being in his hands and back. Resident 13 indicated when he was home and able to care for himself running his hands under warm water helped loosen up the joints and greatly improved the pain and mobility. During an observation and interview with Resident 13, on 9/7/23 at 11:18 AM, in his room sitting in a wheelchair next to his bed. During this interview he rated his pain an 8. He described the pain as crunching and stabbing. Resident 13 indicated he last had pain medication at 6am. Resident 13 indicated the lifts were not made for people with curved spines. Resident 13 indicated getting in and out of bed were the worst part of his day. Resident 13 indicated his back spasms most times. Resident 13's record review, began on 9/7/23 at 12:01PM, his diagnoses included polyosteoarthritis, hypertrophic osteoarthropathy, anxiety, and chronic pain. Resident 13's current MDS (Minimum Data Set) section C: BIMS (Brief Interview of Mental Status) assessment score was a 15. A score of 15 indicated no cognitive decline. Section N: Medications indicated Resident 13 received an opioid medication 7 of 7 days in review period. Resident 13 had an order for hydrocodone-Acetaminophen 5-325mg by mouth twice daily start date 5/25/23 and hydrocodone-Acetaminophen 5-325mg 1 tablet every 6 hours as needed for chronic pain. From September 1st through September 7th Resident 13 received hydrocodone-Acetaminophen 5-325mg as needed three times. On 9/3/23 at 11:27AM, on 9/4/24 at 12:00PM, and 9/7/23 at 12:04PM. There was no documented assessments of pain intensity, type, place, or effectiveness of the medication. There was no documentation of non-pharmacological interventions attempted prior to as needed pain medication being administered. Resident 13's care plan did not indicate any non-pharmacological interventions. The care plan indicated an assessment regarding the cause of his pain and the effectiveness of the medication was yet to be performed. A policy titled, Pain Management first effect date 5/2019 with most recent revision date 10/24/22, was provided by the DON (Director of Nursing) on 9/8/23 at 2:06PM. The policy indicated, Pain assessment .2. e. Identify key characteristics of the pain. Duration. Frequency. Location. Timing. Pattern. Radiation. F. obtaining descriptors of the pain (stabbing, aching, pressure, spasms). G. identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or relieve pain. H. impact of pain on quality of life. I. current prescribed medications. J. Resident's goals for pain management. Pain Management and Treatment. 1. Based upon evaluation, the facility in collaboration with the attending physician/prescriber, the resident will develop, implement, monitor, and revise as necessary interventions to prevent or manage individual resident's pain. 6. non-pharmacological interventions will include but are not limited to: a. environmental comfort measure b. loosening any constrictive bandage c. applying splint/pillows . 3.1-37(a)

Based on interview and record review the facility failed to ensure residents receive culturally competent, trauma-informed care for 1 of 1 residents reviewed (Resident 49). Findings include: Resident 49's record was reviewed on 09/06/23 at 11:44 AM. Diagnoses included cognitive communication deficit, major depressive disorder, and history of falling. There was no PTSD (Post Traumatic Stress Disorder) diagnosis present at time of review. A review of Resident 49's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). There were no care plans for PTSD. A review of progress notes dated 08/01/2023 at 2:40 PM indicated Resident 49 informed the Nurse Practitioner (NP) of recent PTSD flare ups caused by loud noises, scaring Resident 49. In an interview on 09/08/23 at 11:53 AM, Resident 49 indicated they had not been depressed recently, but loud noises have been more irritating, upsetting and recalling PTSD situations. Resident 49 indicated they had spoken to the NP regarding these concerns. A current policy dated 03/01/2023 provided by the Director of Nursing indicated the facility should provide care and services delivered using multiple approaches to address the needs of trauma survivors.

Based on interview, observation, and record review the facility failed to ensure to maintain a sanitary kitchen for 3 of 3 observations. Findings include: 1. In an interview on 9/6/23 at 9:47 AM, the Dietary Manager (DM) indicated the kitchen had a low temperature dishwasher. During an observation on 9/6/23 at 9:47 AM, the dishwasher wash was 80 F and the rinse was 85 F. During an observation on 9/6/23 at 1:06 PM, the dishwasher wash was 82 F and the rinse was 82 F. In an interview on 9/6/23 at 1:06 PM, the DM indicated this was a normal temperature for the dishwasher. An email, dated 9/6/23, by the dishwasher servicing company was provided by the DM at 1:06 PM. The email indicated the wash temperature should be 120 F and the rinse should be 50-100 parts per million for chlorine to properly sanitize. A policy was requested from the Director of Nursing (DON) on 9/6/23 at 1:28 PM. The facility did not provide a policy by the survey exit. 3.1-21(i)(3)