Every finding on record at Majestic Care of New Haven

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 3 resident's reviewed (Resident B). Findings include:On 4/1/26 at 12:50 P.M., Resident B's record was reviewed. Diagnoses included dementia. A quarterly Minimum Data Set (MDS) assessment, dated 1/15/26, indicated Resident B had moderately impaired cognition with no behaviors. He used a wheelchair for mobility, was able to propel himself short distances, but required moderate assistance for long distances. A care plan, dated 8/8/25, indicated Resident B had episodes of physical and verbal aggression towards others, trying to get their attention. He might hit, push, yell at, or antagonize others and block their way from getting past him in the hallway. Interventions included: approach the resident in a calm and friendly manner; explain to resident what you are doing prior to initiating a task; offer distraction or activity such as snack or watching a movie; remove him from the situation; and if he becomes combative or resistive, postpone care/activity, allow him to regain his composure and re-approach as needed. A nurse note, dated 3/12/2026 at 4:27 p.m., indicated Resident B was interviewed about an incident on 3/11/26. He could not recall anything out of the ordinary happening. He had no signs of psychosocial distress and continued with his normal day-to-day routine. A Nurse Practitioner (NP) note, dated 3/13/26 at an unknown time, indicated the resident was seen for exposure to wound cleanser. Resident B had allegedly been sprayed with wound cleanser to his face. He had no recollection of this and had no acute concerns. He had no breathing issues and his mentation remained at baseline. Review of a facility investigation, dated 3/12/26, indicated Housekeeper 1 had reported an incident to the Administrator. On 3/11/26, the staff member observed Resident B being sprayed with a liquid by Registered Nurse (RN) 4 while attempting to remove an item from his hands. On 4/1/26 at 1:15 P.M., Licensed Practical Nurse (LPN) 2 was interviewed. She indicated on 3/11/26, between 1:30-2:00 p.m., Resident B had been observed to take 2 packets of adhesive wipes off the counter of the nurse's station. LPN 2 asked for them back and the resident refused. She then offered him a snack in exchange for the packets, but he yelled at her and said No. RN 4, who was observing the exchange from behind the nurse station, came up to Resident B and sprayed something near his face causing him to drop the packets and look at RN 4. LPN 2 indicated RN 4 hadn't said a word to the resident, sprayed a wound cleanser near his face and then walked away. LPN 2 hadn't reported the incident because she hadn't thought of it as abuse. On 4/1/26 at 1:22 P.M., Housekeeper 1 was interviewed. She indicated she had been in the hallway in front of the nurse station and observed LPN 2 talking to Resident B who held something in his hands. LPN 2 was heard talking calmly to the resident, trying to coax the item from him but the resident refused and kept yelling at the nurse. She then observed RN 4 walk around the nurse station, approach the resident from behind and beside him and spray something towards his face. Resident B startled, looked at the nurse, and started wiping his face and rubbing his eye. RN 4 looked down the hall, saw the housekeeper looking at her and walked away. The housekeeper indicated initially, she hadn't thought it was considered abuse but felt uncomfortable with the incident. The following day, she reported it to her supervisor and the Administrator. On 4/1/26 at 1:52 P.M., the Administrator and Director of Nursing (DON) were interviewed. The DON indicated, as soon as the incident was reported on 3/12/26, RN 4 was suspended pending investigation. LPN 2 and Housekeeper 1 were suspended for not reporting the incident immediately to the Administrator. The Administrator and DON reviewed video footage of the incident and investigation completed resulting in RN 4's termination of employment. A current facility policy, titled Abuse, was provided by the Administrator on 4/1/26 at 3:56 P.M. The policy indicated Residents had the right to be free from abuse defined as willful infliction of injury including disciplinary action taken for the purpose of penalizing or punishing a resident. Allegations of abuse were to be reported to the Administrator immediately and investigation started. The past non-compliance deficiency began on 3/11/26 and deficient practice corrected on 3/14/26 after the facility suspended the 2 employees for not reporting the abuse immediately, terminated employment of the employee involved in the incident, and reported to local law authorities and Indiana Department of Health as required. Resident B was observed for injury and monitored for psychosocial distress related to the incident. On 3/12/26, the facility took steps to identify other residents with the potential to be affected by completing interviews on all alert/oriented residents and performing skin assessments on all non-alert and oriented residents. There were no issues found. All staff were educated on the facility abuse and abuse reporting policies which were completed on 3/14/26. To ensure ongoing compliance, the facility would conduct 4 resident interviews and/or skin assessments weekly to assess for abuse and conduct 5 employee interviews weekly to ensure staff knew how to correctly report abuse for the next 6 months. This Citation relates to Intake 2803402. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)

Based on observation, interview, and record review, the facility failed to ensure puree meals were consistently temperature-tested for 4 of 4 residents observed.Finding include:During an observation on 01/04/2026 at 11:38 AM, dietary staff was temping the food, and the puree broccoli temped at 130 F.In a interview, on 01/04/2026 at 11:38 AM, [NAME] 11 indicated the food was below temperature, then asked if she should place food back to be reheated. [NAME] 11 indicated, she would be placing food on the burner to cook. A record review of food temperature logs, dated December 2025 indicated the following:On 12/31/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/27/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/25/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/18/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/14/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/13/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/12/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/11/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/8/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/4/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.In a interview, on 1/9/26 at 8:52 AM, the Director of Nursing indicated on these dates there were 4 residents ordered puree diets.A current facility policy, Safe food handling, dated 3/1/25, was provided by the Director of Nursing on 1/8/26 at 10:06 AM. The policy indicated .Will follow safe food handling to significantly reduced the risk for foodborne illness, thus strengthening the safety of the food provided to our residents/patients 1.3-21 (a)(1)(2)

Based on record review, observation, and interview; the facility failed to ensure an effective process was in place to prevent recurrent medication storage concerns for 1 of 3 carts reviewed.Findings include: During an observation, on 01/04/2026 at 11:08 AM, a bottle of liquid medication was observed with the liquid level approximately 1.5 inches from the top if the bottle. The medication label had NOT OPEN in capital letters with black marker. There was no open date on the bottle. Licensed Practical Nurse (LPN) 2 opened the lid. A puncture to the inner seal was observed with red liquid on the puncture and around inner part of lid. The multiple dose bottle was opened and used. Resident 47's record was reviewed on 1/4/26 at 11:22AM. The medication was discontinued and did not have an active order. The open bottle of a multiple dose container without an open date prompted a citation of F0761. The [NAME] Report for the facility was reviewed on 1/4/26 at 8:52AM. The report indicated the facility was cited for F0761 Labeling/Store Drugs and Biologicals on the following dates 07/2022, 05/2023, 03/2024 and 1/2025. In an interview, on 1/9/26 at 10:04AM, the Director of Nursing (DON) indicated the facility did not have a current improvement plan for medication storage. The DON indicated the facility did cart audits Monday through Friday for expired medications, medications without an open date, and for any loose pills in the cart. The DON indicated they did cart to Medication Administration Record (MAR) audits weekly to ensure there were no medications in the cart that did not belong. The DON indicated the facility did audits and reported the results in their Quality Assurance Performance Improvement (QAPI) meetings.

Based on observation, record review and interview the facility failed to ensure, dinning staff were following menu tickets for 4 of 4 residents reviewed. (Resident 46, Resident 49, Resident 63 and Resident 67)Findings include:During a dining observation on 01/04/2026 at 11:45 AM, it was observed Resident 63 and Resident 67 were not served broccoli salad on their lunch trays. A review of the residents' food tickets confirmed both individuals were scheduled to receive the broccoli salad as part of their meal.During a dining observation on 01/05/2026 at 12:02 PM, Resident 67 indicated he did not receive any garlic bread. He further stated that he frequently does not receive items listed on his meal ticket and that no substitutions are provided.A review of the food meal posting, dated 01/05/26, on 01/05/2026 12:08 PM, indicated garlic bread was listed. The sign was not modified to include a substitute if needed.A review of grievances on 1/8/26 at 12:20 PM indicated the following:A grievance related to Resident 46, dated 12/6/25, indicated she was having trouble with the lunch/dinning staff. The follow up indicated the dinning staff were not looking at her meal ticket and left food off of her meal tray.A grievance related to Resident 49, dated 10/27/25, indicated the resident was having issues with her meal trays (lunch and dinner). The findings indicated, dinning staff were not following the meal ticket. In a interview, on 1/6/26 at 1:25 PM, the Regional Nurse Consultant and Regional Dietary Manager, indicated dinning staff should look over the resident's diet and meal tickets to make sure they did not receive an item they should not get. A current facility policy, titled Menus, dated 1/2/24, was provided by the Director of Nursing on 1/8/26 at 10:06 AM. The policy indicated . Menus will be followed .Menus will consider the preferences of the resident population .the facility will determine an alternate menu/choices to accommodate resident choices/preference as possible 1.3-20(i)(1)

Based on interview and record review, the facility failed to ensure collaboration with the off-site dialysis center for 1 of 1 resident reviewed (Resident 7).Findings included:Resident 7's record was reviewed on 01/04/2026 at 10:34 AM. Diagnoses included end stage renal disease and dependence on renal dialysis.A review of Resident 7's dialysis communication record indicated the pre-dialysis section did not include vital signs and was incomplete on 01/05/2026, 12/30/2025, 12/28/2025, 12/26/2025, 12/23/2025, 12/21/2025, 12/19/2025, 12/17/2025, and 12/10/2025.During an interview, on 01/07/2026 at 10:10 AM, Resident 7 indicated he took a folder to dialysis and inside it contained his medications and the dialysis communication form. Resident 7 indicated the facility did not always complete the form.During an interview, on 01/07/2026, the Director of Nursing (DON) indicated the facility did not complete the pre-dialysis section on the communication form as the facility had its own assessments. The DON indicated the assessment contained the same information and was sent with the resident to dialysis. The DON indicated the facility did not have a dialysis folder and instead sent a packet with the resident to each appointment. The DON indicated she did not have a way to demonstrate the facility sent the assessment, as the facility did not maintain a folder and sent the information in a packet.During an interview, on 01/08/2026 at 9:33 AM, the Dialysis Center Registered Nurse (RN) indicated Resident 7 routinely came to dialysis with a folder. The Dialysis Center RN indicated the facility often sent the dialysis communication sheet blank. The Dialysis Center RN indicated the section the facility was supposed to complete was often not filled out. The Dialysis Center RN indicated the facility did not send a separate facility assessment with the resident.A current policy dated July 2020, provided by the DON, indicated, Continued assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at an off-site dialysis center. Collaboration with the dialysis facility's plan of care. Appropriate paperwork as required by the off-site dialysis center will be sent with the resident.3.1-37(a)

Based on interview and record review, the facility failed to ensure pain management was provided for 1 of 3 residents reviewed (Resident 11). Findings included:Resident 11's record was reviewed on 1/4/2026. Diagnoses included pain in the right leg, other specified arthritis (unspecified site), primary osteoarthritis of the left elbow, primary osteoarthritis of the left shoulder, lumbago with sciatica, and systemic lupus erythematosus (unspecified).A review of physician orders, dated 11/10/2025 at 11:15 AM, indicated to give oxycodone-Acetaminophen Oral Tablet 7.5-325 MG 1 tablet by mouth every 8 hours as needed for severe pain greater then 7 on the pain scale. The order had a discontinued date of 12/18/2025.A review of physician orders dated 12/18/2025 at 12:30 PM indicated to give oxycodone-Acetaminophen Oral Tablet 7.5-325 MG 1 tablet by mouth every 8 hours as needed for severe pain greater than 7 on the pain scale.A review of Resident 11's current Care Plan indicated the resident was at risk of pain due to arthritis, lupus, and sciatica, with a goal date of 2/16/2026. Interventions included offering nonpharmacological interventions such as position changes, relaxation, a quiet environment, back rubs, and diversional activities.A review of Resident 11's Medication Administration Record (MAR), dated December 2025, indicated oxycodone-Acetaminophen Oral Tablet 7.5-325 MG was administered when the resident's pain level was less than 7 on the following dates: on 12/5/2025, Resident 11 reported a pain level of 4; on 12/7/2025, Resident 11 reported a pain level of 6; on 12/16/2025, Resident 11 reported a pain level of 6; and on 12/27/2025, Resident 11 reported a pain level of 6.A review of Resident 11's progress notes dated 12/5/2025, 12/7/2025, 12/16/2025, and 12/27/2025 was completed. No documentation of nonpharmacological interventions being provided was located in the notes.During an interview, on 1/7/2026 at 12:00 PM, the Director of Nursing (DON) indicated she could not find a reason why the oxycodone was administered for pain less than 7. The DON indicated the medication should not have been administered.A review of a current policy provided by the DON on 1/8/2026 at 10:06 AM indicated, Pharmacological interventions will follow a systematic approach for selecting medication and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain.3.1-37(a)

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 2 residents reviewed (Resident 67).Findings included:During an interview on 01/07/2026 at 9:46 AM, Resident 67 indicated facility staff spoke with him inappropriately. Resident 67 indicated Licensed Practical Nurse (LPN) 9, Qualified Medication Aide (QMA) 10, and the Rehabilitation Director (RD) were present in his room that morning while discussing the condition of his room walls being half painted. Resident 67 indicated the RD stated she would submit a maintenance request. Resident 67 indicated he stated he had never lived in a place where the walls were half painted. Resident 67 indicated the RD stated how were the walls in prison. Resident 67 indicated prison was no place for a black educated man such as himself and indicated he had never been to prison. Resident 67 indicated the RD stated she was going to leave because she was outnumbered. Resident 67 indicated he interpreted this statement to mean the RD was leaving because she was the only white person in the room, as he, the LPN, and the QMA were black. During the interview, Resident 67's voice was raised and his eyes were glassy as he discussed the incident.During an interview on 01/07/2026 at 10:25 AM, the Director of Nursing (DON) indicated LPN 9 and QMA 10 informed her of comments made by the RD. The DON indicated the RD had been suspended pending investigation of the incident.During an interview on 01/08/2026 at 8:51 AM, LPN 10 indicated she was present in the room with Resident 67 and QMA 9. LPN 10 indicated the RD entered the room while she was completing rounds. LPN 10 indicated Resident 67 discussed his walls being half painted and that the RD stated she would submit a work order. LPN 10 indicated Resident 67 stated he had never been in a place where his room was not fully painted. LPN 10 indicated the RD stated you have been to prison. LPN 10 indicated Resident 67 stated prison was no place for an educated black man. LPN 10 indicated the RD stated well I am outnumbered I am going to go. LPN 10 indicated she interpreted this statement to mean the RD was leaving because she was the only white person in the room, as all others present were black.On 01/08/2026 at 1:30 PM, the DON provided a copy of the facility's investigation into the incident. The investigation file included the following statements:In a statement dated 1/7/2025 LPN 10 indicated while in the residents room, the RD from therapy entered the room and stated she need to complete room rounds for another manager. After she completed inspecting room she stated that she was going to write a maintenance request for residents room to be painted. The Resident stated that he has never been anywhere where his room hadn't been painted. The RD stated you have been to jail before. The Resident stated prison is no place for an educated black man. The RD continued to say I have to get out of here, I'm outnumbered. The RD then exited the room. The Resident stated he was very upset about the comments she made. In a statement, dated 1/7/2025, the RD indicated While covering room rounds this morning, Resident 67 was vocal about the condition of the walls in his room. When asked if maintenance request forms were filled out, she was told 3 requests were already completed and given to the Executive Director (ED) and maintenance. The resident made reference to being in prison. At which point she was uncomfortable with the conversation and excused herself from the room. She felt outnumbered being in the room as LPN 10 and QMA 9 were also in the room with the resident.In a statement, dated 1/7/2025, the Social Services Director (SSD) indicated on 1/7/26 around 9:00 a.m. she met with Resident 67. She asked him if anything had happened today to upset or bother him, and he stated that it did not. He stated that he was doing fine. He was laughing and smiling as we spoke. He said that someone made a comment that was racist. When I asked him to explain, he told me about how he had told staff member RD how much he did not like the fact his room is not fully painted. When he said this to the RD, she made a comment about something how he should see what it looks like in prison. He stated that staff member LPN 10 and QMA 9 were also in the room. RD made a comment that she was outnumbered. I asked him if she made the comment in a sarcastic or joking manner, and he said that she did.A review of Resident 67's current quarterly assessment indicated a Basic Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.A review of the facility's policy dated February 2018, provided by the DON, indicated Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability.This citation is related to Intake 2710550.3.1-27(b)

Based on record review and interview the facility failed to notify a family of transfer for 1 of 4 residents reviewed. (Resident 2)Findings include: Resident 2's record review began on 1/4/26 at 10:14 AM. Resident 2's diagnosis included history of myocardial infraction (heart attack), chronic obstructive pulmonary disease, and heart disease.A progress note, dated 10/26/25 at 10:15PM, indicated the resident was sent to ER for chest pain not relieved by Nitroglycerin tablet sublingual and per resident request. EMS was called.There were no progress notes to indicate Resident 2's emergency contact was notified of their trip to the Emergency Room. There was no note in the record to indicate Resident 2 did not want his emergency contact notified. Resident 2 was his own responsible party with his brother named as emergency contact.Resident 2's care plan indicated family was involved with the resident in the last 14 days yet did not indicate Resident 2 did not want brother involved in care or contacted in case of an emergency:Resident 2 indicated it was very important to choose what clothes he wore, to take care of his belongings, to choose the way he bathes, to have snacks available, to choose his own bedtime, and to have family or friends involved in his care plan. A review of Resident 2's care plans indicated there was no entries to address Resident 2 not wanting his emergency contact notified in case of an emergency. In an interview, on 1/7/26 at 10:24AM, the DON indicated Resident 2 did not wish for his brother to be notified. The DON indicated the wishes were in his care plan. In an interview, on 1/7/26 at 2:15PM, the Regional Nurse Consultant indicated Resident 2's brother was not notified due to Resident 2 being his own responsible party. A current policy and procedure were provided by DON on 1/8/26 at 11:31AM. The policy was titled Use and Disclosure of PHI for Facility Directories, Care Involvement, and Notification purposes dated 8/27/25 last revision date of 10/1/25. Involvement in Care and Notification a. We may disclose PHI directly relevant to a person's involvement in resident's/patient's care or payment, or to notify individuals of the patient's location, condition, or death. 3.1-5(a)

Based on observation and record review the facility failed to ensure only current medications and medications with an open date were present in medication carts for 1 of 3 carts reviewed. Findings include: During an observation on 01/04/2026 at 11:08 AM, a bottle of medication was observed with the liquid level approximately 1.5 inches from the top of the bottle. The medication label had NOT OPEN in capital letters written in black marker. There was no open date on the bottle. Licensed Practical Nurse (LPN) 2 opened the lid. The inner seal was punctured with red liquid on the puncture and around inner part of lid. The multiple dose bottle was opened and some of the medication used. The medication was labeled with Resident 47's information. The medication was Guaifenesin liquid 100mg/5ml. The medication pharmacy label was dated 5/25/25 as being dispensed.Resident 47's record was reviewed on 1/4/26 at 11:22AM. Resident 47 did not have an active order for Guaifenesin liquid 100mg/5ml. In an interview, on 1/4/26 at 11:30 AM, the Director of Nursing (DON) indicated Resident 47 should have had an order for the medication but did not have one currently. A policy and procedure titled, Medication Storage provided by DON on 1/8/26 at 1:49PM, did not indicate what labeling practices should be.A policy and procedure titled, Labeling of Medication, review date 1/27/2025, was provided by the DON on 1/8/26 at 2:12PM. The policy indicated. 3) Multidose vials/devises should be labeled with date opened and or accessed. 3.1-25(j)(m)and(n)

Based on observation, interview, and record review the facility failed to ensure labeling of opened medications on 1 of 2 medication carts reviewed. ( Resident 55, Resident 9, and Resident 49) Findings include: During an observation on [DATE] at 10:27 AM, with Qualified Medical Assistant 4, in the 200 Hall medication cart, in the top drawer was the following: an inhaler of Trelegy Ellipta labeled for Resident 55 had an expiration date of [DATE] no open date. Resident 9's inhaler of Flucticsalme AER, had an open date of [DATE] and an expiration date of [DATE]. Resident 49's inhaler of Fluticsame Spr, had no open date and a expiration date of [DATE]. In an interview, on [DATE] at 10:32 AM, QMA 4 indicated the staff would usually go through the cart to make sure everything was labeled, then discard the medication that was not labeled or was expired. In an interview, on [DATE] at 11:30 AM, the Director of Nursing indicated she spoke to the pharmacy and the 3 inhalers should have been removed from the cart. 1. Resident 55's record review began on [DATE] at 11:13 AM. Resident 55's diagnoses included chronic obstructive pulmonary disease. Resident 55 had a physician order for Trelegy Ellipta Inhalation Aerosol Powder breath activate ,d+[DATE]XXX,d+[DATE] microgram (mcg), directions were: 1 puff inhale orally one time a day related chronic obstructive pulmonary disease. Rinse mouth with water after use spit back into cup after use, with a start date of [DATE]. Resident 55's Medication Administration Record (MAR) for Trelegy Ellipta Inhalation Aerosol indicated resident received the medication on [DATE]. 2. Resident 9's record review began on [DATE] at 11:33 AM. Resident 9's diagnoses included asthma. Resident 9 had a physician order for Advair Diskus inhalation Aerosol powder breath activated ,d+[DATE] mcg (fluticasone-Salmeterol), to be given 1 puff inhale orally two times a day related to acute and chronic respiratory failure. The resident was to rinse theri mouth with water after use. Start date was [DATE]. Resident 9's MAR for Advair Diskus inhalation Aerosol powder breath activated ,d+[DATE] mcg (fluticasone-Salmeterol) received the inhaler two times a day on [DATE], 14, 15, 16, 17, 18, 19, 20, and 21. 3. Resident 49's record review began on [DATE] at 12:13 PM. Resident 49's diagnoses included chronic obstructive pulmonary disease. Resident 49 had a physician order for Proventil HFA inhalation Aerosol Solution 108 (90 base) mcg. Directions were to take 2 puffs inhale orally every 4 hours as needed for short of breath. The residnet may keep the medication at bedside. Start date was [DATE]. Resident 49's MAR for Proventil HFA inhalation Aerosol Solution 108 (90 base) mcg, indicated the medication had not been used. A policy titled, Medication Administration, dated [DATE] was received by the Regional Nurse Consultant on [DATE] at 11:13 AM. The policy indicated . Disposal of medication(s) should be completed for medication(s) that are without secure closure, outdate, contaminated and/or deteriorated .disposal needs to be timely .remove medication(s) immediately from stock . 3XXX,d+[DATE](j)(m)(n)

Based on interview and record review, the facility failed to ensure residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place for 2 of 3 residents reviewed for unnecessary psychotropic medications (Resident D and Resident J). Findings include: 1. On 6/12/24 at 11:43 A.M., Resident D's record was reviewed. Diagnoses included dementia, chronic pain, generalized anxiety disorder, sleep disorder and major depressive disorder. Resident D was currently hospitalized for a change in condition. A quarterly MDS (Minimum Data Set) assessment, dated 3/4/24, indicated the resident had no cognitive impairment and no behaviors. She had several mood indicators including feeling hopeless; trouble sleeping/sleeping too much; having little energy; moving slowly/fidgety or restless; and trouble concentrating; indicating moderate depression. She was prescribed antidepressant and opioid medications but the MDS did not note any prescribed antipsychotic medications. Care Plans and dates initiated/revised indicated the following: -Initiated 3/8/24: Resident D was at risk for alterations in mood due to verbalization of mood indicators including little interest in doing things, feeling down, depressed and hopeless; trouble falling and staying asleep, feeling tired and having little energy; trouble concentrating and moving slowly. The goal was for her mood to improve as evidenced by a decrease in the frequency of mood symptoms. Interventions included: Notify behavioral health specialist of changes or no improvement in her mood; encourage her to express her feelings; administer medications as ordered and observe for adverse side effects; assist the resident and family to identify strengths, positive coping skills and reinforce these; labs as indicated; and pharmacist to review medication regimen. -Revised 7/29/21: The resident had difficulty sleeping due to sleep disturbance. The goal was for her to wake up refreshed and not be fatigued during the day. Interventions were to administer medications as ordered; assess for pain and treat as indicated; and assess for symptoms of depression or anxiety and treat as indicated. -Revised 12/23/23: The resident had behavior symptoms of seeing/talking to people not present, making false statements and agitation. Interventions were non-pharmacologic and included postponing care when agitated; listening to her needs; maintain safe environment; and provide personal space. -Revised 6/4/23: The resident exhibited behavior symptoms of shortness of breath, repetitive movements, and panic attacks when feeling unwell or during bad weather. Interventions were non-pharmacologic and included: assess resident's needs; allow her to vent her feelings; and document her behaviors. -Revised 5/18/23: The resident received psychotropic medications and was at risk for side effects of antidepressant medication and sleep aid. Interventions included to administer medications as ordered and observe for adverse reactions. A change in condition note, dated 5/28/24 at 9:17 p.m., indicated the resident had altered mental status, was being sent to the hospital for evaluation and treatment. She remained at the hospital for 2 days with a diagnosis of sepsis related to a urinary tract infection. She returned to the facility on [DATE] with orders for the following psychotropic medications: Cymbalta (antidepressant), and Trazodone (sleeping pill). An Admission assessment, dated 5/30/24 at an unknown time, indicated the resident had returned to the facility per ambulance, had been yelling and screaming upon arrival. She was placed in bed and positioned for comfort. She was alert and oriented to self and had no signs or symptoms of pain/discomfort. Delusions and hallucinations were present. The family and NP were notified of her return to the facility. A MAR (Medication Administration Record), dated May 2024, indicated on 5/30/24 at 10:43 p.m., Resident D was administered Haloperidol Lactate (anti-psychotic) injection solution-inject 5 mg intramuscularly (IM) one time only for anxiety/agitation. The order for Haloperidol was given by the medical NP. A behavior symptom monitoring form, dated 5/30/24 at 9:59 p.m. and 5/31/24 at 5:59 a.m., 7:49 a.m., and 9:26 p.m., indicated the resident had no behaviors observed. There were no other entries for those dates on the monitoring form. There was no documentation in the nurse progress notes regarding the resident's re-admission to the facility, her condition, behaviors exhibited requiring use of an anti-psychotic, notification to the provider, notification of family prior to use of IM Haldol, or follow up documentation after administration of the medication. A medical NP progress note, dated 5/31/24 at an unknown time, indicated the resident was visited following readmission to the facility from the hospital. The resident had gone out for confusion and had been diagnosed with a urinary tract infection with sepsis. She remained confused and delusional. Her mentation had been significantly declining, she had become confused/disoriented and continuously yelled out in pain. Several of the resident's medications had been discontinued while hospitalized . Her pain medication and anti-anxiety medication would be restarted due to her yelling out. The progress note hadn't indicated the resident had been ordered Haldol IM on 5/30/24. There was no indication the psyc provider had been contacted regarding behavior or as a consult prior to Haldol being ordered or administered. 2. On 6/13/24 at 2:39 P.M., Resident J's record was reviewed. Diagnoses included chronic obstructive pulmonary disease (COPD) and major depressive disorder. A quarterly MDS (Minimum Data Set) assessment, dated 4/18/24, indicated Resident J had no cognitive impairment and no behaviors. She had several mood indicators which included feeling hopeless; trouble sleeping/sleeping too much; having little energy; moving slowly/fidgety or restless; and trouble concentrating which indicated moderate depression. A care plan, revised on 4/14/24, indicated the resident was at risk for alterations in mood due to verbalization of mood indicators including little interest in doing things, feeling down, depressed and hopeless; trouble sleeping, feeling tired and having little energy; trouble concentrating and moving slowly. The goal was for her mood to improve as evidenced by a decrease in the frequency of mood symptoms. Interventions were: Notify behavioral health specialist of changes or no improvement in her mood; encourage her to express her feelings; administer medications as ordered and observe for adverse side effects. An NP (Nurse Practitioner) progress note, dated 5/7/24, indicated the following: Resident J was seen following re-admission to the facility from the hospital for UTI (Urinary Tract Infection). The resident had been seen on previous visits on 3/13/24 for respiratory symptoms; 3/28/24 for increased nerve pain; 4/18/24 for refill of pain medication which had recently been decreased due to the resident having intermittent confusion; and 4/23/24 for complaints of right shoulder pain and resident's request for referral to ortho. None of the previous visits nor current visit indicated the resident had symptoms of anxiety which required use of Xanax. An NP progress note, dated 6/4/24, indicated the resident had been seen for congestion. During the visit, the resident requested the Xanax be refilled and orders given to re-order the medication. The progress note hadn't indicated the reason why the resident was taking Xanax or the need for intermittent use of the medication. An NP progress note, dated 6/11/24, indicated the resident had a fall on this day and had landed on her right forearm and knee. The resident indicated she'd had intermittent dizziness the past couple of days. Resident J was on several sedating medications including Percocet (narcotic pain medication), Ropinirole (for restless leg syndrome), Cyclobenzaprine (muscle relaxant), and Xanax (anti-anxiety). The plan was to decrease the dosage of her muscle relaxant. The progress note hadn't indicated the reason for the resident being prescribed Xanax nor need for intermittent use of the medication. A psychiatric NP progress note, dated 5/8/24, indicated the resident was being seen for a history of anxiety and depression. The resident had no behaviors charted since admission to the facility. The resident was alert and a good historian. She admitted to increased depressive symptoms and was agreeable to increasing the dose of her anti-depressant. Her past use of psychotropic medication included Xanax. Assessment and plan was to discontinue 1 of her prescribed anti-depressants and increase the dose of her other antidepressant medication (Cymbalta) for recurrent moderate major depressive disorder and generalized anxiety. The resident's medication, used to help her sleep, was increased to 100 mg of Trazodone by mouth at bedtime for sleep disorder. The progress note hadn't indicated the resident recently was prescribed Xanax, reason for use, or associated behaviors. On 6/14/24 at 11:37 A.M., LPN 2 (Licensed Practical Nurse) was interviewed. She indicated Resident J had no behaviors or indicators of anxiety but would request Xanax when she felt anxious. Resident J had no plan of care nor diagnosis of anxiety prior to being seen by the psychiatric NP on 5/8/24, who documented the resident had depressive symptoms and generalized anxiety which would be treated with Cymbalta (anti-depressant). There was no documentation of behaviors associated with the resident feeling anxious, no non-pharmacological interventions to be tried prior to administering Xanax, nor was there documentation of potential for adverse effects due to intermittent use of Xanax in addition to simultaneous use of other sedating medications which the resident was prescribed. On 6/13/24 at 10:33 A.M., the SSD-Social Services Director was interviewed. She indicated staff were to document behaviors in the resident's chart every shift. She would review behaviors on the 24 hour report sheet and review the number of behaviors daily and monthly. She indicated residents who have mood and/or behaviors symptoms requiring use of psychotropic medications either routinely or on as needed basis, were to have a care plan and behavior monitoring to assist with assessing if interventions and medication use was effective. On 6/13/24, information for Alprazolam (Xanax), was retrieved from PDR.net (Prescribers Digital Reference), which indicated Xanax was a benzodiazepine medication prescribed for panic disorder and generalized anxiety disorder. It had a black box warning for risk for fatal respiratory depression in those with COPD or pulmonary disease and when used with other sedating medications. Xanax should be used cautiously in debilitated adults who were more sensitive to the effects of benzodiazepines. There's a higher risk of falls in the elderly due to drowsiness and decreased level of consciousness. All benzodiazepines increase the risk of cognitive impairment, delirium, falls, and fractures. On 6/13/24 at 12:30 P.M., the SSD provided a current copy of the facility policies titled Mood and Behavior Management and Psychotropic Management indicated: Mood and Behavior Management: Residents are provided with a supportive environment that is aimed at prevention, relief and/or accommodation of their behavior and/or mood in addition to interventions that are specific to the resident's individualized needs .A care plan should be initiated for any behavioral symptom that affects, or can affect, the resident or others. All residents who are taking antipsychotic, anxiolytic, sedative/hypnotic, or anticonvulsant medication routinely or as needed are to have corresponding plans of care and to be included in the mood and behavior monitoring program to assist with assessing the efficacy of interventions and medication use .All mood and/or behavioral symptoms are reported to nursing .Any new or worsening mood and/or behavioral symptoms are documented in a progress note completed by nursing or social services Psychotropic Management: Psychotropic medications are managed in collaboration .Each resident receiving psychotropic medication will have a supporting diagnoses .appropriate indication for use .and Gradual Dose Reduction .Residents receiving an order for a PRN psychotropic medication will have a 14 day stop date entered in the orders with re-evaluation of medication documented in the clinical record. All residents who are taking antipsychotic, anxiolytic, sedative/hypnotic medications are required to have a behavior monitoring program in place identifying targeted behavioral symptoms being monitored as well as personalized non-pharmacological interventions .Resident who are on the behavior program will be reviewed monthly for a quantification of behaviors and evaluation of interventions This tag relates to Complaints IN00434551, IN00436439, and IN00436524. 3.1-48(a)(6) 3.1-48(b)(1)

Based on observation, interview, and record review the facility failed to ensure a resident with a known contagious condition was assessed and care planned for 1 of 3 residents reviewed (Resident E). Findings include: During an interview on 6/13/24 at 2:15 P.M., the Director of Nursing (DON) indicated Resident E had recurrent episodes of head lice after returning from leave of absences (LOA) where she visited with family. She indicated Resident E was to be checked for lice upon return to the facility and if found, staff were to obtain treatment orders. Treatment orders would be put in the physician's orders and communicated to staff in the plan of care. Resident E's record was reviewed on 6/14/24 at 10:14 AM. Diagnoses included adult neglect or abandonment confirmed or suspected, delusional disorder, and major depressive disorder. Resident E's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Brief Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident required substantial to maximal assistance with bathing, including haircare and personal hygiene. Resident E's current care plan did not address lice infestation, past or present, risk factors or staff protocols. Facility census records indicated Resident E left the facility for a LOA on 4/25/24 and returned on 5/1/24. In an interview, on 6/14/24 at 11:00 A.M., Licensed Practical Nurse (LPN) 2 indicated Resident E had returned from LOA with head lice. She indicated a treatment had been completed and she was isolated. She did not recall any special assessments or protocols being done during the isolation period. Progress notes, dated 5/15/24, indicated Resident E was seen by Nurse Practitioner (NP) 3 for pediculosis capitis (head lice), noticed by the resident 2 days earlier. The note indicated Resident E had tried over the counter permethrin shampoo one day earlier and lice were actively visible in Resident E's hair. Progress notes dated 5/21/24 indicated NP 4 visited Resident E for examination of head and scalp. The note indicated Resident E presented with greasy hair contained in a shower cap, and Resident E had indicated her hair was soaked in olive oil. The note indicated Resident E had been brushing her hair and using a nit comb herself, had a dime sized open, draining wound on her left forehead and indicated staff should assist with use of nit brushing. The note indicated small white areas were present on the scalp that may have been dry skin or nits. Dicloxacillin ( an antibiotic) was ordered for cellulitis of the scalp. Progress notes dated 5/23/24 indicated NP 4 examined Resident E with no nits or lice observed. The note indicated nursing should continue nit comb use and monitor for lice. A progress note dated 5/31/24 at 1:00 pm indicated during a visit with her therapist, Resident E indicated she was isolated in her room due to recently having lice. The note indicated Resident E found it hard to stay in her room and wished to leave her room to attend group activities. A progress note dated 6/12/24 at 1:00 PM indicated NP 5 visited Resident E and she was isolated to her room for a lice infestation. Physician orders dated 5/15/24 at 3:49 PM indicated Ivermectin external lotion 0.5% was ordered to be applied to resident E's scalp, left on for 10 minutes and rinsed, as a one-time dose for pediculosis capitis (head lice). No additional orders for head lice treatment were available for review. A current Kardex document (nurse aid assignment sheet) did not include use of any medicated shampoo or special considerations for hair and scalp care. Staff education pertaining to care of a resident with pediculosis was not available for review. Weekly nursing summaries dated 5/1/24, 5/8/24, 5/15/24, 5/24/24, 5/31/24, and 6/7/24 did not indicate the presence of lice, or any entries under other pertinent information. During an interview on 6/14/24 at 12:15 P.M., Resident E indicated NP 3 visited her the previous day, did not see any nits or lice and released her from isolation. Resident E indicated she was in isolation for about 4 weeks, and she was happy to be able to shower. She indicated she had been washing her hair in the bathroom sink because she couldn't leave her room and the woman she shared a bathroom with didn't like it. She indicated a staff member had brought her olive oil and a shower cap at one point to attempt to treat her condition. In an interview on 6/14/24 at 11:32 AM, the DON indicated she could not find an order for isolation and did not know when Resident E's isolation began or ended. She indicated formal assessments of Resident E's lice were not conducted and she could not find documentation of residents sharing her bathroom, or otherwise in proximity, being checked for lice. She indicated she did not find any additional provider orders for treatments, a plan of care for infestation with lice, or staff education on lice protocols. A current policy, undated, titled head Lice and Scabies exposure and treatment, provided by the Regional Nurse Consultant (RNC) indicated the nurse should assess the resident with signs such as itching, scratching, rash, nits or lice, report findings to the practitioner and obtain a treatment regimen. The policy indicated treatment should be conducted as ordered and the infested resident should be placed on transmission-based precautions and placed in a single occupancy room away from other residents to avoid transmission. The policy indicated personal clothing, bedding and linens should be decontaminated by washing in hot water. Items unable to be laundered should be dry cleaned or sealed in a plastic bag for 2 weeks. Combs and brushes should be soaked in hot water, at least 130 degrees, for at least 5-10 minutes. A current policy, undated, titled Isolation- Categories of Transmission-Based Precautions provided by the RNC indicated isolation precautions should be used when caring for residents who are diagnosed with or suspected to have communicable diseases. The policy indicated contact isolation precautions should be used in residents with a diagnosis of pediculosis. This citation is related to complaint IN00436491. 3.1-37(a)

Based on Interview, and Record review, the facility failed to ensure the immunization for the COVID-19 vaccine was provided to 4 of 5 residents reviewed. (Resident 15, Resident 18, Resident 64, and Resident 69) Findings include: A record review began on 3/6/24 at 12:34 PM, Resident 15 diagnosis include, anemia and autistic disorder. A review of Resident 15's immunizations. There were no updated consents/declination for the COVID-19 vaccine. A consent form was provided by the Director of Nursing (DON) on 3/7/24 at 8:40 AM, indicated Resident 15 gave consent to receive vaccine dated 11/29/23. A record review on 3/6/24 at 12:45 PM for Resident 18, diagnosis include, acute and chronic respiratory failure with hypoxia. A review of Resident 18's immunizations. There were no updated consents/declination for the COVID-19 vaccine. A consent form was provided by the DON on 3/7/24 at 8:40 AM, indicated Resident 18 gave consent to receive vaccine dated 11/29/23. A record review on 3/6/24 at 12:55 PM for Resident 64, diagnosis include, age-related osteoporosis without current pathological fracture. A review of Resident 64's immunizations. There were no updated consents/declination for the COVID-19 vaccine. A consent form was provided by the DON on 3/7/24 at 8:40 AM, indicated Resident 64 gave consent to receive vaccine dated 11/29/23. A record review on 3/6/24 at 1:10 PM for Resident 69, diagnosis include, chronic obstructive pulmonary disease, unspecified. A review of Resident 68's immunizations. There were no updated consents/declination for the COVID-19 vaccine. A consent form was provided by the DON on 3/7/24 at 8:40 AM, indicated Resident 68 gave consent to receive vaccine dated 12/1/23. An interview on 3/7/24 at 8:40 AM, the DON, indicated, in December there was a miscommunication with the pharmacy that was given the clinic at the facility. So only 12 residents got the vaccine, there was going to be another clinic but that got canceled. The 4 residents were missed and never received the vaccine. A current facility policy, SARS-CoV-2 resident vaccine, was provided by the DON on 3/7/24 at 8:40 AM. The policy indicated . All residents who have no medical contraindications to the vaccine will be offered the SARS-CoV-2 vaccine and eligible booster doses to encourage and promote the benefits associated with vaccination .Upon approval and distribution, the SARS-CoV-2 vaccine shall be offered to residents, unless the vaccine is medically contraindicated or the resident is already up to date vaccinated .Administration of the SARS-CoV-2 vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination

Based on observation, and interview, the facility failed to ensure masking, hand hygiene, and equipment disinfection practices were implemented and maintained. 41 residetns resided on the 300/ 400 hall. Findings include: 1. During an observation on 3/3/24 at 8:50A M, on the front door of the facility a sign indicated face masks were required. Two unidentified employees walking past the front desk were not wearing face masks. During an observation on 3/3/24 at 9:00 A M, on the 300 hall an unidentified employee was observed to not be wearing a face mask. During an interview on 3/3/24 at 9:22 AM, the Director of Nursing (DON) indicated the facility had 2 staff members test positive for COVID-19, so everyone was to wear a mask as a precaution. An observation on 3/3/24 at 9:29 AM, an unidentified staff member was observed coming out room [ROOM NUMBER], bringing out a meal tray wearing blue gloves. The staff member placed the meal tray into a metal cart, then entered room [ROOM NUMBER] wearing the same blue gloves and without performing hand hygiene. The staff member came out of room [ROOM NUMBER] with the same gloves on and placed the meal tray into a metal cart. The staff member was observed to push the metal cart down the hall and entered the kitchen using a code without changing gloves or having performed hand hygiene. The staff member did not change gloves after each room or use hand hygiene. During an observation on 3/3/24 at 10:12 AM at the 300/ 400 hall nurses station, an unidentified employee was observed walking out of a resident's room with a mask below their chin. The employee continued to speak to another employee. In an interview on 3/3/24 at 11:00 AM, the Regional Nurse, indicated since the facility was not considered to be in outbreak, the staff would not have to wear a mask. In an interview on 3/8/24 at 9:14 AM, the Administrator, DON and Regional Nuse, indicated staff should be wearing face masks properly. Even after staff were told they did not have to wear masks, there were still employees wearing masks below chins, and walking through out hallways. 45243 2. During an observation on 03/03/24 at 09:45 AM, Registered Nurse (RN) 3 was observed popping two pills from medication cards into her ungloved hand, then putting them into a small medication cup. During an observation on 03/03/24 at 11:56 AM, RN 3 was observed with one gloved and one ungloved hand. RN 3 was pushing pills from medication cards into her hand, then put them into a cup During an observation on 03/03/24 at 11:19 AM, Qualified Medication Aide (QMA) 5, took Resident 136's blood sugar with a glucometer. QMA 5 used an alcohol wipe to clean the resident's finger, waited for it to dry, took the samle, then with a gloved hand, took the glucometer out to the cart, placed the glucometer on the medication cart and removed the gloves. QMA 5 obtained new gloves, another strip, another alcohol wipe and walked into Resident 15's room. QMA 5 did not perform hand hygiene, and did not disinfect the glucometer between uses. In an interview on 03/03/24 at 11:24 AM, QMA 5 indicated she was unsure what the procedure for glucometer disinfection was. QMA 5 indicated she did not have anything to clean the glucometer with. A current facility policy, Glucometer Disinfection, dated February 2023, was provided by the Director of Nursing on 3/4/24 at 10:06 AM. The policy indicated . The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to resident and employees .cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic's products .disinfection is the process that eliminates many or all pathogenic microorganisms, excepts bacterial spores, on inanimate objects .the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use A current facility policy, Policies and Practices-Infection Control, dated 2/2018, was provided by the 3/3/24 at 11:15 AM. The policy indicated . The facility's infection prevention and control program (ICPC) is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections .All personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degrees of direct resident contact and responsibilities 3.1-18(a)

Based on observation, interview and record review the facility failed to implement a compliance program to ensure prior identified medications labeling was complaint. This affected 4 of 4 residents reviewed (Resident 50, Resident 64, Resident 37, and Resident 25) Findings include: The facility annual survey completed on 5/5/23 identified noncompliance with medication labeling and storage. During an observation on 03/03/24 at 11:02 A.M., 4 injectable medications (insulin) were observed to be opened, but without an opened date. In an interview on 3/3/24 at 11:02 A.M., Registered Nurse (RN) 3 indicated Resident 50's insulin Glargine solution, Resident 64's Lispro insulin, Resident 25's Humalog insulin, and Resident 37's Lispro insulin were opened without open dates. RN 3 indicated she did not know when they were opened or if they were any good. In an interview on 3/3/24 at 2:46 P.M., the Director of Musing (DON) indicated the facility completed a mock survey on 2/29/24, but the facility did not waste the insulins that were not properly labeled. In an interview on 3/8/24 at 9:14 AM, the Administrator, DON, and Regional Nurse indicated the facility completed a mock survey on 2/29/24. The survey incuded an audit of the medications cart. Between the date they audited to the day the annual survey started, someone had opened the insulins, but not dated them. The observation of the undated, opened insulins was on 3/3/24 at 11:02 AM. The facility did not audit the medication cart for 4 days . A current facility policy, Quality Assurance and Performance Improvement (QAPI), dated February 2023, was provided by the Regional Nurse on 3/8/24 at 9:57 AM. The policy indicated . 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 of the facility provides .problem-prone areas refers to care or service areas that have historically had repeated problems 3.1-52(a)

Based on observation and interview the facility failed to ensure 2 out of 2 garbage receptacles in kitchen were covered. 81 of 83 residents residing in the facility ate meals prepared in the kitchen Findings include: During an observation on 03/03/2024 at 9:00 A.M. two garbage receptacles were observed open, without a lid in the kitchen; one was located in the main kitchen next to handwashing station, the other in the dishwashing area. The receptacles were 80 percent full with plastic material, carboard, and food scraps. During an observation on 03/03/2024 at 10:33 A.M. two garbage receptacles were observed open, without lids in the kitchen. The receptacles were 95 percent full with no changes to contents. In an interview on 03/03/2024 at 10:45 A.M., the Dietary Manager indicated the garbage receptacles needed to be covered and instructed a dietary employee to cover them with lids. The Ditary Manager indicated 81 residents ate food prepared in the kitchen. A current policy dated 08/2017 provided by the Administrator on 03/04/2024 at 10:30 A.M. indicated appropriate lids should be provided for all containers. Staff should be responsible for ensuring the lid is placed on garbage receptacles after each use. 3.1-21(i)(5)

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was onsite for an 8 hour shift 5 days of 90 reviewed. Findings include: A record review began on 3/6/24 at 10:04 AM, of staffing data report for quarter 4 2023 ( July 1-September 30). This staffing data report identified areas of concern. No RN hours were recorded for the following dates: 7/1/23, 7/2/23, 7/30/23, 8/5/23, and 9/10/23. A review of the schedule dated July 1, 2023, indicated there were no RN hours documented for day shift 6 AM- 2 PM., evening shift 2 PM - 10 PM., or night shift 10 PM -6 AM. A review of the schedule dated July 2, 2023, indicated there were no RN hours documented for day shift 6 AM- 2 PM., evening shift 2 PM - 10 PM., or night shift 10 PM -6 AM. A review of the schedule dated July 30, 2023, indicated there were no RN hours documented for day shift 6 AM- 2 PM., evening shift 2 PM - 10 PM., or night shift 10 PM -6 AM. A review of the schedule dated August 5, 2023, indicated there were no RN hours documented for day shift 6 AM- 2 PM., evening shift 2 PM - 10 PM., or night shift 10 PM -6 AM. A review of the schedule dated September 1, 2023, indicated there were no RN hours documented for day shift 6 AM- 2 PM., evening shift 2 PM - 10 PM., or night shift 10 PM -6 AM. A review of the schedule dated September 10, 2023, indicated there were no RN hours documented for day shift 6 AM- 2 PM., evening shift 2 PM - 10 PM., or night shift 10 PM -6 AM. An interview on 3/7/24 at 9:58 A.M. the Director of Nursing indicated there were no RNs on those dates. A current facility policy, Nursing services and sufficient staff, dated February 2023, was provided by the Regional Nurse on 3/8/24 at 9:16 AM. The policy indicated . Expect when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week 3.1-17(b)(3)

Based on observation, and interview, the facility failed to ensure medications were dated when opened for 4 of 21 residents residing on the 100 hall. (Resident 50, Resident 64, Resident 25, and Resident 37) Findings include: During an observation on 03/03/24 at 11:02 A.M., 4 injectable medications were observed to be opened, but without an opened date. In an interview on 3/3/24 at 11:02 A.M., RN 3 indicated Resident 50's insulin Glargine solution, Resident 64's Lispro insulin, Resident 25's Humalog insulin, and Resident 37's Lispro insulin were opened without open dates. RN 3 indicated she did not know when they were opened or if they were any good. 1. Resident 50's record was reviewed 3/4/24 at 12:19 P.M. Diagnoses included ischemic heart disease, and diabetes, A physician's order, dated 12/15/23 indicated to give Resident 50 Glargine, 35 units, subcutaneously, 2 times daily. A Medication Administration Record (MAR) dated March 2024 indicated Resident 50 had been given Glargine, 35 units, subcutaneously on 3/4/24 at 7:00 A.M. 2. Resident 64's record was reviewed on 3/3/24 at 11:06 A.M. Diagnoses included respiratory failure and diabetes. A physician's order, dated 12/18/24, indicated to give Resident 64 Lispro 15 units subcutaneously before meals. An MAR, dated March 2024, indicated Resident 64 was given Lispro, 15 units, subcutaneously on 3/4/24 at 7:00 A.M. and at 11:00 A.M. 3. Resident 25's record was reviewed 3/4/24 at 11:25 A.M. Diagnoses included atrial fibrillation and diabetes. A physician's order, dated 10/5/22, indicated to give Resident 25 Humalog insulin in a sliding scale according to his blood sugar result before meals and at bedtime. An MAR, dated March 2024, indicated Resident 25 had received 4 units of Humalog insulin in response to blood sugar results at 7:00 A.M. and 4 units at 11:00 A.M. 4. Resident 37's record was reviewed 3/5/24 at 11:34 A.M. Diagnoses included hypertension and diabetes. A physician's order, dated 6/19/23, indicated to give Resident 37 Lispro insulin in a sliding scale according to his blood sugar result before meals and at bedtime. An MAR, dated March 2024, indicated Resident 37 received Lispro insulin 2 units at 7:00 A.M. and 4 units at 11:00 A.M. In an interview on 3/3/23 at 2:46 P.M., the DON indicated they did a mock survey on 2/29/24, therefore they did not waste the insulins that were not properly labeled. A policy, dated February 2023, indicated medications must be labeled with an opened, date, discarded within 28 days of opening, and discarded according to manufacturer's recommendations. 3.1-25 (m)

Based on interview and record review, the facility failed to ensure monies available to the resident were accessed and paid to the resident for 2 of 3 residents reviewed. (Resident 67 and Resident 66) Findings include: 1. In an interview on 3/6/24 at 1:00 P.M., Resident 67 indicated she had received a lump sum payment from Social Security on 11/20/23 related to underpayment. She indicated on 12/29/23, the facility levied a care cost of $4600.00 without warning or explanation. Resident 67's record was reviewed 3/6/24 at 3:00 P.M. Resident 67's diagnoses included: diabetes, morbid obesity, and hypertension. A most recent quarterly MDS dated [DATE] indicated Resident 67 had no cognitive impairment. A Resident Fund Management Service form, dated 8/10/22, indicated Resident 67 agreed to a Resident Fund account. This would allow her $52.00 each month from her Medicaid account. An Authorized Representative for Health Coverage Form dated 6/20/23 indicated Resident 67 agreed to have the facility manage her monies. Resident Statement dated 5/23/23 indicated care cost was $248.00 monthly. A review of the statement indicated no care costs had been taken out of the account for the months 6/23, 7/23, 8/23, 9/23, 10/23, or 11/23. This would amount to a cost of $1,488.00. The form indicated on 12/29/23, an amount of $4,600 had been debited from Resident 67's account. The statement indicated Resident 67 had no insurance costs. In an interview on 3/7/24 at 1:23 P.M., the Business Office Manager (BOM) indicated she was unsure why the amount of $4600.00 was taken except the facility had to spend that amount to keep Resident 67's insurance. 2. Resident 66 was interviewed 3/6/24 at 1:23 P.M. He indicated in the interview he was not receiving his VA Nursing Home Benefit. He indicated he was admitted to the facility with VA benefit in March, 2022. His VA benefit should have increased $90 per month due to an additional nursing home benefit. Resident 66's record was reviewed 3/6/24 at 2:45 P.M. Diagnoses included Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes. A most current quarterly MDS dated [DATE] indicated Resident 66 had no cognitive impairment. A Resident Fund Management Service form dated 5/25/22 indicated Resident 66 agreed to have his funds direct deposited into a facility account. A review of the Resident Statement, dated 11/1/23 through 2-1-24, indicated VA benefits of $1336.00 were paid on 11/1/23, 12/1/23, 12/29/23, and 2/1/24. The statement indicated the facility withdrew $1035.00, leaving $301.00 in the resident's account. insurance premiums were paid each month, but the VA Nursing Home premium had not been received. In an interview on 3/7/24 at 9:05 A.M., the Business Office Manager (BOM) indicated VA increased the benefit for residents residing in a Nursing Facility when VA was notified of admission. She indicated she was unsure why Resident 66's admission had not been communicated to the VA, but would file the form on his behalf. A Request for Nursing Home Information in Connection with Claim for Aid and Attendance form, dated 3/8/24, provided by the BOM on 3/8/24 at 9:17 A.M., indicated the BOM had completed the form for additional assistance. A policy dated 2023 titled Resident Personal Funds indicated the facility would ensure resident's choosing direct deposit would have their monies managed, held and safeguarded. 3.1-6 (b)

Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed. (Resident 10) Findings include: Resident 10's record was reviewed on 03/05/24 at 01:23 P.M. Diagnoses included paraplegia, COPD, diabetes, morbid obesity, and arteriosclerotic heart disease. A physician's order, dated 2/6/24 indicated to obtain daily weights; and notify the physician if weight gain was greater than 3 pounds in a day or 5 pounds in a week. A care plan, dated 2/20/24, indicated to obtain weights as ordered and to notify the physician of weight changes. A review of Vital Signs indicated only the admission weight had been documented. Progress notes dated 2/6/24 through 3/7/24 indicated Resident 10 had no refusals of care. The Medication Administration Record (MAR), dated 2/24, indicated no weights had been documented. In an interview on 3/5/24 at 1:46 P.M., the DON indicated the staff did not check the box for the weight to be entered in the MAR, so it was not recorded. A policy titled Provision of Physician Ordered Services, dated February 2023, indicated care and services should be provided according to physician's orders and accepted standards of practice. 3.1-37

Based on observation, interview and record review, the facility failed to develop and implement an effective behavioral management plan for 1 of 1 residents reviewed. This resulted in a resident to resident altercation (Resident Q, and Resident S) and 3 residents fearing for their safety (Resident U, Resident T, and Resident V). Findings include: On 4/4/23 at 12:04 P.M., Resident Q was observed in the hallway in his wheelchair. He was yelling loudly, wanted to go outside and smoke immediately. At the time, the facility was under a severe weather threat. Going outside was not safe. He continued to yell and [NAME] insults at staff who tried to explain the danger and he could go out after the storm. He yelled angrily he'd been out in storms before and he was going outside to smoke. He continued to yell and scream profanities at anyone around him including residents and staff. Several staff members stood around him from a distance in the hall across from the dining room where residents were seated for lunch. His behaviors were continuous until 12:23 P.M. when he abruptly stopped yelling. -At 12:25 P.M., the resident was yelling, screaming, and threatening anyone around him. He threatened bodily harm to anyone if they came near him. He talked to himself and others not present. -From 12:26 P.M. until 1:00 P.M., the resident continued moving about the hallways with staff always present to remove other residents out of his way and keep them safe. He went up to the front desk where he threw items from a table in front of the desk. He continued to scream, yell and threatened others as he moved through the hallway. He eventually turned and went back down the hallway near the dining room where he continued screaming, yelling profanities, threatening anyone who would come near him and hitting the wall. The police were called, he was removed from the facility at 1:10 P.M. and taken to the hospital for evaluation. On 4/4/23 at 1:10 P.M., Resident Q's record was reviewed. Diagnoses included paranoid schizophrenia, vascular dementia with behavioral disturbance, generalized anxiety disorder, depression, nicotine dependence, and bilateral (both) below knee amputations. The resident admitted to the facility following hospitalization for gangrene of the foot. Prior to hospitalization , the resident had been homeless. He had gone to shelters but had been non-compliant with the rules and asked to leave. He was not taking his medications for his mental disorder and indicated he hadn't needed them. Hospital notes indicated he was gravely disabled due to schizophrenia. A quarterly MDS (Minimum Data Set) assessment, dated 3/15/23, indicated the resident had moderately impaired cognition. He indicated moods of feeling down, difficulty sleeping, feeling tired, difficulty concentrating and feelings of moving slowly. He had physical and verbal behaviors towards others 1-3 days and had no rejection of care during the assessment period. He required extensive assistance of 1 staff for activities of daily living (ADL). Once up in his wheelchair, he required supervision as he propelled himself throughout the facility. Care plans were as follows: -Initiated 12/22/22: the resident exhibited behavior symptoms of paranoid schizophrenia such as believing he was being poisoned by gas in the vents, throwing items and destroying silverware. He had medication in place to treat the symptoms. The goal was for the resident to demonstrate effective coping skills related to his behaviors. Interventions included: administer medications as ordered and provide the resident with plastic utensils with meals. There was no indication the facilit had attempted identify triggers for his behavior. -Initiated 12/22/22: the resident received psychotropic medication and was at risk for side effects of antipsychotic medication. Interventions included: administer medications as ordered by physician. There was no indication the facility had a plan should the resident refuse medications. -Initiated 12/23/22: the resident had behavior symptoms of refusing care, medications and treatments at times. The goal was for the resident to demonstrate effective coping skills related to his behaviors. Interventions included: administer medications as ordered. there was no indication the facility had tracked possible triggers for his refusal behavior, -Initiated 12/27/22: the resident had behavior symptoms of aggression/agitation by slamming doors, pushing chairs/tables and throwing small objects at the ground. The goal was for the resident to demonstrate effective coping skills related to his behaviors. Interventions included: Identify behavior triggers (room needing swept, trash needing taken out, tables needing to be washed) and reduce exposure to triggers; offer therapeutic activities such as wiping down tables, cleaning hand rails, changing trash liners/picking up trashbags. There was no indication the facility identified interventions aimed at preventing the behavior. A psychiatric NP (Nurse Practitioner) progress note, dated 1/4/23, indicated Resident Q was prescribed Chlorpromazine (anti-psychotic medication for schizophrenia symptoms of aggression and desire to hurt self or others) 100 mg (milligrams) by mouth at bed time. During the visit, resident was being moved to another room because his roommate complained the resident was messy and left messes everywhere. Once in his new room, the resident was observed going through drawers and dumping stuff on the floor. Staff reported he had agitation with aggression at times due to not being able to go outside and smoke when temperatures were too low. The resident destroyed silverware at meals so was given plastic utensils only. Staff reported the resident had behaviors of yelling, screaming, kicking, pushing, grabbing, abusive language, threatening behavior and rejection of care. He was prescribed an anti-anxiety medication for 14 days to assist him with anxiety and fragile mood as he adjusted to the nursing home. Care plans had not been updated with this information to assist staff in providing behavioral care. A licensed counselor progress note, dated 1/13/23, indicated the resident was seen for a diagnostic evaluation. He was described as very moody and not cooperative with care. He used tobacco, got upset when he could not go outside to smoke when he wanted, didn't like to take showers, called staff derogatory names, threw things when upset, tried to get up on his own (had amputations), tipped his wheelchair, argued with staff, and had been having delusions. He had taken apart a bed because he believed he could fix it, had torn things apart in his room and believed they were broken. He had a long criminal history and history of drug abuse in the past. He'd had multiple stays at homeless shelters but would not follow the rules, would become belligerent, threatening, and wouldn't be allowed back. Additionally, he had stays in multiple nursing homes. The recommendation was to follow up with the resident. The care plan did not address the trigger realted to smoking, calling staff degrogatoty names, argueing, or the resident's delusions. There were no psychiatric services provided in February 2023. A review of Resident Q's MAR (Medication Administration Record) dated February, March, and April 2023 indicated the resident had multiple refusals of medication including Chlorpromazine, prescribed to treat his mental illness. In February and March 2023, the resident refused his medications and accepted only 5 doses of Chlorpromazine each month. For April, he'd accepted 1 dose, given on 4/3/23. A (Late Entry) progress note, dated 2/27/23 at 7:34 p.m., indicated the resident had refused all his medications for 1st and 2nd shift. When the resident was asked if he was ready for his medications, he yelled at the nurse and stated to leave him alone. He helped himself to coffee at the nurse's station. The coffee was was cold, so he threw the coffee all over the floor. A (Late Entry) progress note, dated 2/28/23 at 10:26 a.m., indicated the NP was notified of the resident refusing medication. There were no new orders. A progress note, dated 3/1/23 at 9:40 p.m., indicated the resident had refused all his medications and stated there was nothing wrong with him. No moods or behaviors were observed according to the documentation. A psychiatric NP progress note, dated 3/8/23, indicated the resident had no change in his mood from prior visits. He appeared comfortable, isolating self in his room. The plan was to start him on an anti-depressant medication for depression and anxiety. The progress note had not indicated the resident was refusing his medications. A behavior monitoring record, dated 3/6 through 4/4/23, indicated the following behaviors: -3/12/23 at 3:14 a.m., the resident had behaviors of yelling, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, abusive language, threatening, and being sexually inappropriate. These physical behaviors were not addressed on the care plan, and had no interventions to calm or prevent recurrance. There was no indication of interventions attempted to calm the behavior. -3/16/23 at multiple times during the day/evening, he had behaviors of yelling, wandering, abusive language and refusing care. There was no indication of interventions attempted to calm the behavior. -3/23/23 at 1:16 p.m., he was yelling.There was no indication of interventions attempted to calm the behavior. -4/4/23 at 8:21 a.m., the resident had behaviors of yelling, pushing, abusive language, and was threatening. There was no indication of interventions attempted to calm the behavior. An Incident note, dated 3/12/23 at 3:00 a.m., indicated a CNA (Certified Nurse Aide) heard shouting down the hall. When the CNA arrived to the room where the yelling was occurring at, they had been unable to open the room door and gained entry from the adjoining bathroom. The resident was observed sitting in his bed, shouting obscenities at his roommate (Resident S) and threatening to do bodily harm to him. The roommate was on the floor in front of the bathroom door. The resident was told to stop his behavior, but he refused and continued to yell and threaten his roommate. The roommate was moved to another room for his protection. An IDT (Interdisciplinary Team) progress note, dated 3/13/23 at 12:36 p.m., indicated a meeting was held to discuss the resident's interaction with his roommate. The residents were separated and safety ensured. The IDT discussed having psychiatric services assess the resident as he had been refusing medications. Staff were to continue to monitor and observe the resident for behaviors. A progress note, dated 3/13/23 at 3:49 p.m., indicated the psychiatric NP was notified of the resident's recent behaviors and medication refusals. There were no new orders given. Behaviors that occurred on 3/16/23 throughout the day and evening had no further documentation completed as to cause or interventions used to stop the behaviors. A psychiatric NP progress note, dated 3/23/23 at 1:00 p.m., indicated the NP was notified by the nurse of resident's continued refusal of his psychotropic medications over an extended period of time. Review of progress notes had not indicated any behaviors or expressions of aggression in the time frame of 3/16 to 3/23/23. Staff were to continue to monitor him until her next visit. A licensed counselor progress note, dated 3/24/23, indicated the resident had been refusing all of his medications recently. The therapist met with him to offer support. The plan was to continue with ongoing behavioral health services to offer support and affect regulation. There was no documentation in the progress note to indicate the counselor was aware of the incident on 3/12/23 between the resident and his roommate or the threatening behaviors he had displayed. A progress note, dated 4/4/23 at 8:37 a.m., indicated Resident Q had wheeled himself down the hallway, grabbed a clean linen cart and shoved it down the hallway. The Therapy Director was present and reminded the resident not to shove things. He started yelling, cursing, and was verbally aggressive to her. He continued to propel himself down the hall while staff stayed nearby until he calmed down. On 4/4/23 at 1:48 P.M., Resident T and Resident U, identified as interviewable by the facility, were interviewed. Both indicated they were afraid of Resident Q due to outbursts occurring over several weeks. Two weeks ago, the resident had the same behaviors of yelling obscenities and throwing things. Resident T and Resident U had rooms in the same hallway as Resident Q. Both indicated they no longer felt safe in the facility. Resident T indicated she had been in the activity room across from the dining room when the resident had acted out. She indicated he had come into the room, had thrown an open bottle of Coke at her and got her clothes wet. She indicated the resident always had behaviors related to wanting to go out and smoke. They indicated they had told the Social Services about their fear, but nothing had been done. On 4/4/23 at 2:00 P.M., Resident V, not identified as interviewable but who had been observed near the front desk when Resident Q had been acting out, indicated they hadn't felt safe in the facility over the last month and wanted to leave. The resident indicated residents had to be moved out of Resident Q's way when he was yelling and screaming. The resident indicated this wasn't fair. He was allowed to disrupt everyone else's plans because he had behaviors when he didn't get his way. Resident V indicated she had told staff about her fears, but someone just came and made sure she was OK after each behavior. On 4/4/23 at 2:08 P.M., the Social Services Director (SSD) was interviewed. She indicated she had been aware the resident had been refusing his medications but wasn't sure what the facility was allowed to do about it because resident's had the right to refuse medications. The resident's history, prior to admission, indicated he was non-compliant with medications. When questioned, she indicated she wasn't sure what the resident's triggers were for his behaviors. The resident liked to clean so an intervention had been put into place to give him a spray bottle and rag and encourage him to clean when he's frustrated. She did not know if the psychiatric NP or medical doctor had been notified of his refusal to take his medications to treat his mental disorder. She indicated she was going to talk with staff and gather names of resident's who had witnessed Resident Q's mental crisis and removal by police from the facility and follow up to monitor for any psychosocial distress. During a confidential staff interview, Staff 5 indicated several residents were afraid of Resident Q and his many outbursts. Staff tried to shield other residents from his angry outbursts but residents saw, heard them and it was upsetting for them. On 4/4/23 at 4:10 P.M., the Administrator provided a current copy of the facility policies titled Mood and Behavior Management and Psychotropic Management which stated the following: -Mood and Behavior Management: It is the policy of the facility to provide interventions for all residents with behavioral and/or mood indicators that may be problematic or distressing. Residents are provided a supportive environment that is aimed at prevention, relief and/or accommodation of their behavior and/or mood in addition to interventions that are specific to the resident's individualized needs .If the resident is being monitored for the symptom(s), the nursing assistant or designee will document the symptom(s) exhibited, interventions attempted and whether they were effective in POC on TASKS. Any new or worsening mood/and/or behavioral symptoms are documented in a progress note completed by nursing or social services. The IDT reviews all new or worsening moods and/or behaviors, evaluates the interventions, presents any new interventions that may be applicable, and attempts to determine the underlying cause of the symptoms -Psychotropic Management .All residents who are taking antipsychotic medication (used for behavioral indication) are required to have a behavior monitoring program in place identifying targeted behavioral symptoms being monitored as well as personalized non pharmacologic interventions 3.1-43(a)(1)

Based on interview and record review, the facility failed to send a resident to the hospital when their condition worsened and as resident/family requested, which resulted in a rapid deterioration of condition and resident death for 1 of 3 residents reviewed (Resident B). The Immediate Jeopardy began on [DATE] when Resident B complained of abdominal pain which worsened over 2 days. The facility failed to assess and monitor the progression of abdominal pain and failed to send the resident to the hospital, as requested, when her condition deteriorated. The Administrator, Director of Nursing (DON), and Regional Consultant Nurse were notified of the Immediate Jeopardy on [DATE] at 5:00 P.M. The immediate jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE] at 12:14 P.M., Resident B's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated a BIMS (Brief Interview Mental Status) score of 15-no cognitive impairment. Resident B had no behaviors or rejection of care. She had an indwelling catheter and was always incontinent of bowel. A care plan, dated [DATE], indicated the resident was at risk for constipation due to decreased mobility, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, administer medications and treatments as ordered, observe for signs or symptoms of complications related to constipation such as change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, slow/low pulse, abdominal distention, vomiting, small loose stools, fecal smearing, bowel sounds, sweating, abdominal tenderness, guarding, rigidity, fecal impaction, document abnormal findings and notify the physician. On [DATE], during a routine physician visit, Resident B complained of dull right lower abdominal pain which she'd had in the past when constipation had been an issue. A physical exam indicated bowel sounds were decreased but her abdomen was not distended and was soft. She complained of abdominal tenderness when deeply palpated but had no guarding or rebound. Her abdominal exam suggested constipation. The physician spoke with the house Nurse Practitioner (NP). She indicated she was going to obtain an abdominal x-ray. The physician indicated if the x-ray showed there was significant stool present, he would consider a trial of enemas. The resident had an as needed (PRN) order for [MEDICATION(S)] (medication for constipation) but he ordered this to be given daily for 3 days until the x-ray was obtained. Resident B's bowel movement (BM) records, indicated on [DATE], she'd had 2 medium and 1 small BM, on ,d+[DATE] and [DATE], she had large BM's each day. She was given [MEDICATION(S)] as ordered on ,d+[DATE] and [DATE]. The resident had 2 small and 3 medium BM's. There were no abdominal assessments or nurse progress notes completed from ,d+[DATE]-[DATE]. On [DATE] at 8:00 a.m., a nurse progress note indicated the resident complained of sharp abdominal pain and her belly was distended. She indicated she had vomited earlier in the day and was having BM's. Resident B's abdomen was distended, hard to the touch and she complained of pain at a level of 10 (on scale of ,d+[DATE] with 10 being the worst pain). The on-call NP was notified and gave orders to either send resident to the hospital for treatment or get an abdominal x-ray to be done at the facility. The DON was notified and the abdominal x-ray ordered. A KUB (Kidneys/Ureters/Bladder) abdominal x-ray, completed on [DATE] at 10:52 a.m. and reported on [DATE] at 12:24 p.m., indicated the resident had a large bowel obstruction, possibly volvulus (an obstruction due to twisting or knotting of the gastrointestinal tract), with a maximal colonic distension of 19.5 centimeters (normal colon diameter: ,d+[DATE] centimeters). There was a large amount of rectal stool present. A nurse progress note, dated [DATE] at 1:00 p.m., indicated the resident complained of difficulty breathing, had an abdominal pain level of 10 and had vomited. There was brown emesis observed in a basin, and on a towel. Her blood pressure was low at ,d+[DATE], pulse was high at 128, respirations 24 and oxygen saturation was very low at 75% (normal above 90%). Oxygen at 3 liters was placed on the resident. The NP was notified of the resident's vitals, abdominal x-ray results and requested the resident be sent to the hospital. The DON was notified and approved. The EMS was called for transport to the hospital. A hospital emergency room (ER) note, provided by the facility on [DATE] at 2:44 P.M., indicated on [DATE] at 2:08 p.m., the resident presented to the ER in [CONDITION(S)]. The EMS had been called out to the facility for a resident with complaints of abdominal pain initially. Upon EMS arrival at the nursing home, the resident had been awake, alert and had abdominal pain for the past 2 days. While being transferred into the ambulance, the resident became unresponsive and CPR (Cardiopulmonary Resuscitation) was started. The resident had coffee-ground emesis and her abdomen was markedly distended. She was unable to be resuscitated and died at the hospital. The ER doctor indicated he suspected the resident had gone into [CONDITION(S)] from internal hemorrhage. The Coroner's cause of death indicated the resident had a cardiac arrhythmia due to internal hemorrhage and [CONDITION(S)]. On [DATE] at 1:56 P.M., the DON was interviewed. During the interview, she indicated the RN (Registered Nurse) on duty (RN 5), on [DATE] Resident B had complaints of abdominal discomfort and abdominal distention. RN 5 had called the on-call NP who had ordered to send the resident to the hospital for evaluation or obtain an abdominal x-ray at the facility. The DON indicated she instructed RN 5 to try and irrigate the resident's foley catheter and see if that relieved the abdominal distention. She indicated she had wanted RN 5 to get the abdominal x-ray and try other interventions at the facility prior to sending the resident to the hospital. The DON indicated she hadn't known that the resident complained of severe abdominal pain. On [DATE] at 2:02 P.M., RN 5 was interviewed. She indicated, on [DATE], she had gotten report from 3rd shift, but the report did not indicate Resident B had been ill. She had gone into the resident's room at approximately 7:15 a.m. to complete her wound treatment but the resident had refused. At 8:00 a.m., QMA 3 (Qualified Medication Aide) informed her Resident B had reported she had vomited earlier and had abdominal pain. QMA 3 had not seen the emesis. RN 5 assessed the resident. She had a distended abdomen and was complaining of sharp pain. The resident indicated she hadn't eaten for 2 days. RN 5 called the on-call NP. The NP indicated the resident could be sent to the hospital or if the resident refused hospitalization , an abdominal x-ray could be done at the facility. After speaking with the NP, she went back to the resident's room and informed her what the NP ordered. The resident called her mother and had RN 5 talk with her on the phone in her room. The mother agreed and the resident agreed the resident should go to the ER for evaluation and treatment as they could do more for her there depending on what the problem was. RN 5 called the DON. RN 5 indicated the DON told her to cancel the ER order and just order the abdominal x-ray. The DON wanted RN 5 to try other interventions to relieve the resident's abdominal distention like irrigating her foley catheter. RN 5 irrigated the residents catheter, but the cather irrigation did not help. She called the DON back and reported irrigating the catheter had not helped, the resident's abdomen was hard, continuing to distend, and the resident wanted to go to the hospital. The DON would not give approval to send the resident to the hospital. RN 5 and the CNA's (Certified Nurse Assistant) tried to make the resident comfortable by positioning her in her chair and then putting her back into bed without success. RN 5 indicated she contacted the DON, by phone, 4 times trying get her approval to send the resident to the hospital. She indicated she informed the DON the resident's abdominal distention was slowly worsening, she had severe pain but was told she could not send the resident to the hospital. During a confidential interview, Employee 7 indicated they had worked on [DATE], had heard Resident B yelling throughout the day she was in pain and wanted to go to the hospital. This was not like the resident. She indicated Resident B smoked and was always the first person waiting in line to go outside for smoke breaks and she hadn't wanted to get up to smoke on that day. During a confidential interview, Employee 8, indicated on [DATE], the resident had complained of abdominal pain and hadn't wanted to eat anything. They indicated on [DATE], the resident had been heard yelling that she was hurting and wanted to go to the hospital. On [DATE] at 3:07 P.M., the house NP was interviewed. She indicated she had been in the facility on [DATE] when Resident B's physician had visited. The physician asked her about the resident's complaints of abdominal pain. The NP shared that the resident had similar complaints on [DATE] of being constipated although staff had indicated she had BM's. The resident had complained of mild pelvic pressure and lower abdominal pain. She generally had a lot of diarrhea at baseline. An order was given to change the foley catheter and irrigate it every shift for 5 days and give [MEDICATION(S)] (medication for constipation) 1 time per day for 5 days. She indicated she was going to look further into the resident's recurrent abdominal pain, wanted to get a CT scan and would plan to see the resident on the following Monday for further evaluation. She indicated she was going to look further into the resident's recurrent abdominal pain, wanted to speak with the resident about getting a CT scan and would plan to see the resident on the following Monday for further evaluation. She did not order a CT scan or abdominal x-ray on [DATE]. When asked, she indicated the facility wanted to try to provide treatments in-house if appropriate and safe to do so rather than always sending residents out to the hospital. Resident B had a long history of non-compliance and refusing hospitalization s in the past, however, if the resident requested to go to the hospital and had complaints of severe pain with abdominal distention, she should have been sent to the hospital for evaluation and treatment. On [DATE] at 2:13 P.M., Resident B's mother was interviewed by phone. She indicated she had a phone call around 8:00 a.m. on Sunday, [DATE] from her daughter. Resident B was having severe abdominal pain and she didn't know if she should go to the hospital. The nurse (RN 5) got on the phone and explained the NP had been notified of the residents abdominal distention and severe pain. The NP gave the option of the resident going to the hospital for treatment or having an x-ray done at the facility. The nurse indicated she thought the resident should go to the hospital. She and her daughter agreed going to the hospital was appropriate. She indicated her daughter was in pain and she wanted her sent to the hospital right away. She was angry the facility had not sent her daughter to the hospital immediately as she was in severe pain and thought she should go. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility inserviced nurses on changes in resident condition and licensed nurse autonomy to send residents to the hospital if warranted by assessments, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because all licensed nurses had not been inserviced. This Federal tag relates to Complaint IN 346. 3.,d+[DATE]

Based on interview and record review, the facility failed to provide treatment and care to address a resident's pain for 1 of 3 residents reviewed (Resident J). The deficient practice resulted in Resident J's hospitalization for unrelieved pain. Findings include: 1. On 2/9/20 at 12:56 P.M., Resident J's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 1/3/20, indicated she had a BI[CONDITION] (Brief Interview Mental Status) score of 10 which signified she had moderately impaired cognition. The resident was non-ambulatory and required extensive assistance from 2 staff members for bed mobility and transfers. She denied pain during the assessment. A CAA (Care Area Assessment), dated 7/26/19, indicated the resident had mild, occasional pain related to [MEDICAL CONDITION]. A Care Plan, dated 10/4/18, indicated the resident was at risk for pain. The goal was that she would verbalize adequate relief of pain. Interventions included, but were not limited to, administer medication as ordered, notify physician of unrelieved or worsening pain, observe and report changes in usual routine, sleep patterns, withdrawal or resistance to care, and observe for symptoms of non-verbal pain. Hospital ER records, dated [DATE] at 5:20 p.m., indicated the resident was seen for a possible injury to her right leg. The resident stated she had fallen sometime the past weekend and had pain in her right leg but was unable to say what had occurred. The right knee was ecchmotic (bruised) and she could bend the knee but had pain with palpitation of the knee and lower femur. X-rays were completed and showed an acute spiral type fracture to the mid femoral shaft. She was administered 0.5 mg [MEDICATION NAME] (narcotic pain medication) per IV (intravenous) for pain control. The resident underwent [REDACTED]. On 2/10/20 at 11:58 A.M., Resident J's family member contacted the [ENTITY] by telephone and reported concerns that the resident had sustained a fall as the cause of her pain and finding of right leg fracture upon hospitalization . The family member indicated the resident told her that her leg hurt and that she had fallen the day before. The POA (Power of Attorney) was not notified of the resident's complaints of pain. The family member alleged staff members, who had worked the past weekend and were questioned by the family member and POA, indicated the resident had complained of leg pain on Saturday evening-1/25/20, Sunday-1/26/20, and Monday morning-[DATE]. An NP (Nurse Practitioner) progress note, dated [DATE] at unknown time, indicated the NP was notified by Resident J's family member, that something was wrong with the resident. The resident complained of right leg pain. She was assisted into bed, examined, and found to have swelling along the right femur and knee. The resident was in obvious pain and would not bear weight. The NP was unable to determine if the resident's right leg was shortened or rotated because the resident couldn't tolerate the right leg to be straightened. The note indicated Resident J had obvious pain to palpitation of the right femur and knee and grimaced slightly to palpitation of the right hip. Orders were given to send to the ER for evaluation and treatment per family request. Staff were to administer [MEDICATION NAME] (pain medication) 5-325 mg (milligram) 1 tablet by mouth every 6 hours as needed for pain. Review of nurse progress notes indicated there were none written between 1/20/20 through 1/26/20. On [DATE] at 2:57 p.m., a nurse note indicated new orders had been received for STAT x-ray's to the residents right femur and right knee due to leg pain. On [DATE] at 3:33 p.m., a nurse note indicated the resident's POA wanted the resident sent to the ER for evaluation and treatment due to right leg pain and [MEDICAL CONDITION]. The resident was sent at 3:54 p.m. There was no note in the resident record regarding assessment or follow up to the resident's fall. Neither nurse progress notes nor the MAR (Medication Administration Record) for 1/2020 indicated the resident had received any pain medication prior to being discharged to the hospital on [DATE] at 3:54 p.m. The resident was prescribed a routine daily dose of anti-[MEDICAL CONDITION] medication which was used to treat inflammation and joint discomfort from [MEDICAL CONDITION]. She was prescribed [MEDICATION NAME] 325 mg tablets-give 2 tablets by mouth every 4 hours as needed for mild pain-ordered 7/19/19. The resident was not administered any [MEDICATION NAME] during the month of January 2020. During a confidential interview, Staff Member 7 alleged that the resident had been found on the floor next to her bed on 1/25/20, between 7-8 p.m., by the nurse. Staff Member 7 indicated they were asked by the nurse to help transfer the resident off of the floor and into her Broda chair. The resident was on the floor with her back slightly against the bed and one leg bent under her. Staff Member 7 and the nurse transferred the resident into her chair and while doing so, the resident complained of pain in her right leg, but the nurse did not look at the residents legs. Staff member 7 indicated she did not witness any further assessment by the nurse, then had reported the fall to the oncoming nurse about 10 p.m. During a confidential interview, Staff Member 3 alleged the nurse stated the resident had been trying to crawl out of bed and was found on the floor, next to her bed, the evening of 1/25/20 and had been assisted from the floor and into her Broda chair. When assisted back into bed, Resident J complained that her right leg hurt which was reported to the nurse. Staff member 3 indicated the resident continued to complain of pain to her right leg when assisted with hands on care on Sunday-1/26/20 and Monday-[DATE]. The staff member indicated the nurse on duty was notified of the resident's pain each time she complained that her leg hurt, but there was no assessment or follow up from the nurse. During a confidential interview, Staff Member 5 indicated after the resident was put to bed on 1/25/20, she was found about an hour later, sitting in her Broda chair at the nurse's station with the nurse. When asked, Resident J indicated she had fallen out of bed which was confirmed by the nurse. Staff Member 5 indicated disbelief that the resident could've been on the floor because she required 2 staff members to move around in bed and hadn't tried to get out of bed before. Resident J was assisted back to bed with 2 staff members. When moved, the resident yelled out ouch ouch and indicated her right leg hurt. The staff member reported the resident's complaint of pain to the nurse, but the nuirse did not follow up with the resident to determine the cause of her pain. Staff Member 5 indicated the resident continued to complain of right leg pain with hands on care on Sunday-1/26/20 and Monday-[DATE]. She indicated she told the nurse each time the resident complained of pain, but the nurse did not give the resident pain medication or go into the room to check on her. The morning of [DATE], the resident indicated she didn't want to get up out of bed because her right leg hurt. The staff member notified the nurse who allegedly indicated the resident had pain at times due to [MEDICAL CONDITION] and she should be encouraged to get up so as not to get stiff. The resident agreed to get up and was transferred with 2 staff members but would not bear weight. She yelled out ouch-my leg hurts! and used her right hand to grab her right leg. The nurse was again notified of the resident's unusual pain, but no follow up was completed by the nurse. In a confidential interview, an interested party indicated the nurse had not assessed the resident or completed an incident report after being informed of the fall. On 2/12/20 at 2:45 P.M., a copy of the facility's policy for pain recognition and management was requested. The DNS (Director of Nursing Services) indicated she wasn't sure if the facility had such a policy but would look for one. There was no facility policy provided by time of exit 4:30 P.M. This Federal tag relates to Complaint IN 430. 3.1-37(a)