Every finding on record at Morgantown Woods of Journey

Based on interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed 92 days after the previous MDS assessment for 2 of 3 residents reviewed for Resident Assessment. (Resident 2, Resident 24)Findings include: 1. On 3/10/26 at 11:43 a.m., Resident 2's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and hypertension. The quarterly MDS assessment was dated 10/3/25. The clinical record lacked documentation of another assessment since 10/3/25. 2. On 3/10/26 at 11:50 a.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder and anxiety. The quarterly MDS assessment was dated 10/3/25. The clinical record lacked documentation of another assessment since 10/3/25. During an interview on 3/11/26 at 12:04 p.m., the Corporate MDS nurse indicated Resident 2 and Resident 24's clinical record lacked documentation of a quarterly MDS assessment since 10/3/25. On 3/11/26 at 2:49 p.m., the Administrator provided the facility policy, Assessment Frequency/Timeliness, dated 2/1/24, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .4. A quarterly review assessment will be completed no less than once every 3 months. It must be completed within 92 days of the ARD [assessment reference date] of the most recent OBRA [Omnibus Budget Reconciliation Act] assessment. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)(3)

Based on record review and interview, the facility failed to ensure Minimum Data Set Assessments were accurate for 2 of 14 residents reviewed for comprehensive assessment. (Resident 5, Resident 29) Findings include:1. On 3/10/26 at 11:05 a.m., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder and anxiety disorder. The Preadmission Screening and Resident Review (PASARR), dated 9/14/19, indicated the resident had serious mental illness. Current physician's orders indicated the resident was taking Torsemide (a diuretic) beginning on 7/12/25 and Depakote (an anticonvulsant) beginning on 7/11/25. The annual Minimum Data Set (MDS) Assessment, dated 8/11/25, indicated the resident did not have a serious mental illness and was not taking diuretic or anticonvulsant medications. During an interview on 3/11/26 at 1:50 p.m., the Director of Nursing indicated the 8/11/25 annual MDS assessment was incorrectly coded. 2. On 3/10/26 at 11:53 a.m., Resident 29's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder, depression, and anxiety. The Preadmission Screening and Resident Review (PASARR), dated 2/12/20, indicated Resident 29 had a Level 2 related to serious mental illness. The annual Minimum Data Set (MDS) assessment, dated 8/21/25, indicated no Level 2 was completed. During an interview on 3/11/26 at 12:04 p.m., the Corporate MDS nurse indicated Resident 29's annual MDS was incorrect. On 3/11/26 at 2:49 p.m., the Administrator provided the facility policy, Conducting an Accurate Resident Assessment Policy, dated 2/1/24, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status . 410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)

Based on record review and interview, the facility failed to ensure a resident had an accurate Level I Preadmission Screening and Resident Review (PASARR) for 1 of 3 residents reviewed for PASARR. (Resident 24)Findings include: On 3/10/26 at 10:08 a.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia and anxiety. Resident 24's PASARR, dated 3/3/25, indicated no Level II required due to no serious mental illness, no mental health symptoms, and no antidepressants or any other mental health medication were prescribed. There was no evidence of a PASARR condition of a serious mental health condition. If changes occur or new information refutes these findings, a new screen must be submitted. Resident 24's admission date was 3/31/25 with the diagnosis of schizophrenia and a diagnosis date of anxiety was 4/17/25. The Order Summary Report dated 3/11/26 indicated the following:- Buspirone (antianxiety medication) 15 milligrams (mg) give a 0.5 tablet twice a day for anxiety, start date 1/9/26. - Paroxetine (antidepressant medication) 30 mg give one table one time a day, start date 3/6/26. During an interview on 3/11/26 at 10:45 a.m., the DON (Director of Nursing) indicated Resident 24's Level 1 was completed prior to his admission to the facility and no new Level 1 had been completed since his admission. On 3/11/26 at 2:49 p.m., the Administrator provided the facility policy, Preadmission Screening and Resident Review Policy, revised date 3/11/26, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .9. The Administrator and Director of Nursing will monitor compliance with PASARR requirements through periodic audits of admissions and resident records .

Based on interview and record review, the facility failed to develop a comprehensive care plan related to noncompliance for 1 of 14 residents reviewed for care plans. (Resident 39)Findings include:On 3/9/26 at 2:58 p.m., Resident 39's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), hypertension, dementia, diabetes mellitus with circulatory complications, and heart failure. A Physician's Order, dated 6/2/24, indicated the resident was prescribed a 2,000 cc (cubic centimeters; equivalent to 1 milliliter) fluid target goal, with 480 cc at breakfast, 480 cc at lunch, 480 cc at dinner, 120 cc each shift, and 120 cc at bedtime. The resident's progress notes indicated the following: - On 12/8/25 at 2:42 p.m., the resident had frothy sputum and asked for 8-10 mugs of ice in one shift. He was educated he was not to have more than 2 mugs of ice per shift. - A Dietitian Evaluation, dated 12/29/25, indicated the resident did not adhere to his prescribed fluid restriction diet and occasionally consumed in excess of the fluid goal. - On 1/13/26 at 9:10 p.m., the resident refused to follow his fluid restriction. - On 1/21/26 at 11:14 a.m., the resident had coffee and less than 15 minutes later he asked for ice. When he was reminded of his fluid restriction, he became angry and shook his walker at staff. - On 1/26/26 at 11:52 a.m., the resident refused to adhere to his fluid restriction goals regardless of repeated education on extra fluid and respiratory status. - On 1/30/26 at 11:30 a.m., the resident was educated on his fluid target goal. He denied an understanding and demanded water and drinks. His roommate gave him water. He was provided education to the possible side effected of CHF (heart failure) exacerbation, he stated he understood, but he wanted the water anyway. The clinical record lacked a comprehensive person-centered care plan related to Resident 39's noncompliance with the prescribed fluid restriction. During an interview on 3/10/26 at 3:25 p.m., QMA 2 indicated the resident was noncompliant with the ordered fluid restriction. They offered him ice chips to slow him down, but he was constantly begging staff for water, saying he was always thirsty, and his roommate would give him water. They educated him each time, but it did not work. On 3/11/26 at 3:15 p.m., the Director of Nursing (DON) was asked to provide a care plan which addressed the resident's fluid restriction noncompliance, and she provided two care plans titled, [Resident's name] has coronary artery disease (CAD) related to atherosclerosis. He was recently in the ER for mild pulmonary congestion and fluid overload, initiated on 5/7/24, and [Resident's name] has behavior problems of using attention seeking behaviors of pressing that (sic) call light continuously just to pick something up off of the floor, or to grab some that (sic) is in reach for him, he also will yell very loudly HELP instead of pressing the call light, when he doesn't need anything but a cup of ice or the television changed. When resident is redirected or reeducated he will get agitated, initiated on 3/21/25. During an interview at that time, the DON indicated the care plans did not directly address his fluid restriction noncompliance.410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(2)

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse when a male resident punched another male resident in the face for 1 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include:On 12/17/25 at 8:14 a.m., the Administrator provided a copy of a facility reportable incident, dated 12/1/25 at 6:05 p.m. A review of the facility reportable incident indicated Resident B had been agitated the entire day and displayed verbal and physical aggression toward staff. Resident C had been experiencing an episode of psychosis, had not been easily redirected, and had displayed numerous psychotic behaviors over the previous several days. Staff observed Resident B make contact with Resident C's face with a closed fist.During an interview on 12/17/25 at 8:23 a.m., Qualified Medication Aide (QMA) 1 indicated, on 12/1/25 at approximately 6:00 p.m., she walked to the front of the facility near the kitchen and heard a loud noise. When she looked in the direction of the noise, QMA 1 witnessed Resident C sitting on a bench in the front lobby area. Resident B was standing in front of Resident C punching Resident C in his face with a right closed fist. QMA 1 was not able to count the number of times Resident C was punched by Resident B, but that it was multiple times. The two residents were immediately separated. A small, bluish-purple, swollen area was observed under Resident C's right eye. Resident C indicated his eye hurt and QMA 1 got ice to apply to Resident C's right eye. Resident B had been aggressive toward residents in the past.The clinical record for Resident C was reviewed on 12/17/25 at 9:00 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, schizophrenia, and anxiety.A quarterly Minimum Data Set (MDS) assessment, dated 11/28/25, indicated Resident C was cognitively intact.A progress note, dated 12/1/25 at 6:05 p.m., indicated Resident C had a small bruise under his right eye that measured 1 centimeter (cm) by 0.6 cm with a small cut and was the result of Resident B punching Resident C. The clinical record for Resident B was reviewed on 12/17/25 at 9:30 a.m. The diagnoses included, but were not limited to, dementia, anxiety, and depression.A quarterly MDS assessment, dated 9/3/25, indicated Resident B was severely cognitively impaired.A progress note, dated 12/1/25 at 6:10 p.m., indicated Resident B was physically and verbally aggressive and punched Resident C in the face multiple times.On 12/17/25 at 9:45 a.m., the Administrator provided a copy of a facility policy, dated 3/5/24, and indicated this was the policy currently used by the facility. A review of the policy indicated it was the policy of the facility to prevent abuse.This citation relates to Intake 2681931.3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the sanitation bucket in the kitchen was at the correct level required for 1 of 1 sanitation bucket reviewed during the kitchen initial tour. This has the potential to affect 35 of 35 residents served from the kitchen. Findings include: During the initial kitchen tour on 4/7/25 at 10:15 a.m., the Assistant Dietary Manager tested the sanitizing solution in the sanitation bucket on the three compartment sink. She used the test strip and dipped the strip in the sanitizing solution. She read the test strip color to the color chart on the bottle which indicated it was 170. She was unsure what color on the test strip bottle, the test strip should of been. On 4/7/25 at 10:36 a.m., the Assistant Dietary Manager indicated the sanitizing solution was low. It should of been 272-700. On 4/9/25 at 4:15 p.m., the Regional Registered Dietician provided the facility's policy, The Sanitizing Buckets, revised 3/31/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. Cleaning and sanitizing buckets will be prepared at the start of each shift and replaced as needed in order to maintain proper concentration of cleaning/sanitizing solution . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set assessment for 4 of 12 residents reviewed. The admission from location, daily use of limb restraints, anticoagulant medications, and prognosis were coded incorrectly. (Resident 35, Resident 27, Resident 18, Resident 1). Findings include: 1. Resident 35's clinical record was reviewed on 4/8/25 at 11:24 a.m. The diagnosis included, but was not limited to, Alzheimer's Disease. Resident 35's admitted was 1/15/25. A review of nursing progress notes indicated Resident 35 had been staying with his sister in another state but had recently moved back to this area to be closer to where his brother lived. Resident 35's Admission Minimum Data Set (MDS) assessment, dated 1/28/25, indicated the resident had admitted from a nursing home. During an interview on 4/8/25 at 11:32 a.m., the Administrator indicated the resident had been living out of state with his sister prior to being admitted to the facility. During an interview on 4/8/25 at 1:58 p.m., the MDS Coordinator indicated the Admission MDS assessment for Resident 35 was incorrect because the resident had admitted from home after living with his sister. A review of the RAI,Version 3.0 User's Manual, on 4/9/25 at 3:30 p.m., indicated . A1805 Code 01: Home/Community: if the resident was admitted from a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly . 50647 2. Resident 27's clinical record was reviewed on 4/8/25 at 1:39 p.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), anxiety, and psychosis (when people lose some contact with reality). A physician order, dated 5/31/24, indicated .Broda Chair with straps while up for safety and positioning, unable to maintain erect torso. Paces to the point of exhaustion and unaware of her environment. Release and reposition every 2 hours and as needed. Review quarterly and as needed for continued use of Broda Chair requirements . The Quarterly MDS assessment, dated 3/15/25, lacked documentation for daily use of limb restraints. During an interview with the Assistant Director of Nursing Services (ADNS)/ MDS Coordinator on 4/9/25 at 2:00 p.m., she indicated that the resident used limb restraints daily while in the Broda chair and the MDS assessment should have been coded to reflect that. A review of the RAI,Version 3.0 User's Manual, on 4/9/25 at 3:00 p.m., indicated .P0100: Physical Restraints .Review the resident's medical record .to determine if physical restraints were used during the 7-day look-back period . 3. Resident 18's clinical record was reviewed on 4/8/25 at 12:02 p.m. The diagnoses included, but were not limited to, COPD, dementia and schizophrenia (affects a person's ability to think, feel, and behave clearly). A physicians order, dated 8/17/24, indicated Eliquis Oral Tablet 2.5 MG (a medication to prevent and treat blood clots), give 1 tablet by mouth two times a day. The order was discontinued on 2/19/25. The Quarterly MDS assessment, dated 3/8/25, indicated resident's medication included an anticoagulant (a medication that reduce the blood's ability to clot, preventing or slowing down the formation of blood clots). During an interview with the Assistant Director of Nursing Services (ADNS)/ MDS Coordinator on 4/9/25 at 2:00 p.m., she indicated that the resident was not taking an anticoagulant at the time of the Quarterly MDS assessment and it should have been coded no. A review of the RAI,Version 3.0 User's Manual, on 4/9/25 at 3:00 p.m., indicated .Item N0415, High-Risk Drug Classes: Use .Review the resident's medical record for documentation that any of these medications were received by the resident .during the 7-day lookback period . 34848 4. Resident 1's clinical record was reviewed on 4/6/25 at 10:34 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, Parkinson's disease, and dementia. A 12/27/24 quarterly MDS assessment, indicated the resident did not have a life expectancy of less than 6 months for section J1400: Prognosis. A 3/15/24 physician's order indicated the resident was admitted to hospice care on 3/15/24. During an interview on 4/9/25 at 2:35 p.m., the MDS coordinator indicated she normally coded the MDS assessments as 'no' because she was taught to do so. She further indicated the Resident Assessment Instrument (RAI) manual was accessible to her when she completed the MDS assessments. During an interview on 4/9/25 at 3:52 p.m., the DNS indicated the facility did not have a policy related to MDS coding and the facility followed the RAI manual for coding purposes. On 4/10/25 at 11:56 a.m., a review of the Center for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument, dated October 2024, indicated, . J1400: Prognosis . Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to maintain resident's dignity while assisting residents with the meal for 2 of 2 dining observations. Staff stood while assisting the resident. (Resident 27) Findings include: During a dining room observation on 4/7/25 at 12:23 p.m. until 12:40 p.m., CNA 1 was observed to stand to the left of Resident 27 to assist the resident with the meal. CNA 1 then placed her hand on the forehead of Resident 27 to hold her head up while she placed a spoon in the resident's mouth. CNA 1 did not talk with Resident 27, she was observed to talk with other staff members while they assisted residents during the noon meal. During an observation on 4/8/25 at 12:20 p.m., Resident 27 was observed eating with assistance of the Activity Director (AD). The AD was observed to be standing in front of the resident while assisting with the meal. On 4/8/25 at 1:39 p.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and psychosis (when people lose some contact with reality). The Quarterly Minimum Data Set (MDS) assessment, dated 3/15/25, indicated no BIMS (Brief Interview for Mental Status) score. An ADL (Activities of Daily Living) care plan (revised on 12/23/24), indicated the resident had an ADL self-care performance deficit related to dementia. The care plan indicated that the resident was dependent on staff for assistance with meals. During an interview on 4/9/25 at 1:55 p.m., CNA 3 indicated Resident 27 required total assistance with meals. CNA 3 indicated that while assisting residents with meals, staff should not stand while assisting with meals, and should engage residents not other staff. On 4/9/25 at 3:52 p.m., the DNS (Director of Nursing Services) provided a copy of Resident Rights (undated), she indicated this was a policy currently being used in the facility. A review of the Resident's Rights indicated . Right of dignified existence: Be treated with consideration, respect and dignity, recognizing each resident's individuality, .A home-like environment . 3.1-3(t)

Based on observation, interview, and record review, the facility failed to communicate the resident's choice of advance directive to the staff responsible for the resident's care for 1 of 1 residents reviewed for Advance Directive. (Resident 186) Findings include: On [DATE] at 2:28 p.m., Resident 186's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), left side hemiplegia (paralysis on one side), and schizophrenia. Resident 186's admitted was [DATE]. The clinical record lacked documentation of the Indiana Physician Orders for Scope of Treatment (POST) form. During an interview on [DATE] at 10:55 a.m., the Director of Nursing (DNS) indicated Social Services would complete the POST form on admission, the nurse practitioner would review and sign, and then scan the POST form into the electronic health record (EHR) with a copy going in a binder at the nurse's station. The DNS could not locate the POST form in the EHR. With the DNS, the binder at the nursing station was observed to lack Resident 186's POST form. On [DATE] at 11:14 a.m., the DNS presented the POST form, dated [DATE]. The POST form indicated Resident 186 requested Cardiopulmonary Resuscitation (CPR) and full medical attention. At that time, she indicated it was in the scanned pile which was not at the nursing station. On [DATE] at 3:53 p.m., the DNS provided the facility's policy, Residents' Rights Regarding Treatment and Advance Directives, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . 3XXX,d+[DATE](f)(5)

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from physical restraints for 1 of 3 residents reviewed for restraints. Documentation of re-evaluation of the need for restraints was not completed. (Resident 27) Findings include: On 4/7/25 at 11:35 a.m., Resident 27 was observed sitting in a Broda chair awake in the hallway with leg straps over both legs to prevent her from getting out of the chair. On 4/7/25 at 2:40 p.m., Resident 27 was observed sitting in a Broda chair asleep in her room with leg straps over both legs to prevent her from getting out the chair. On 4/8/25 at 9:32 a.m., Resident 27 was observed sitting in a Broda chair asleep in her room with leg straps over both legs to prevent her from getting out of the chair On 4/8/25 at 10:00 a.m., Resident 27 observed sitting in a Broda chair in her room. Two patient care staff members released and repositioned the leg straps at that time. On 4/9/25 at 11:08 a.m., Resident 27 observed sitting in a Broda chair asleep in her room with leg straps over both legs to prevent her from getting out of the chair. On 4/9/25 at 11:40 a.m., two patient care staff were observed in Resident 27's room with the resident, they released and repositioned leg straps. Resident 27's clinical record was reviewed on 4/8/25 at 1:39 p.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), anxiety, and psychosis (when people lose some contact with reality). A physician order, dated 5/31/24, indicated .Broda Chair with straps while up for safety and positioning, unable to maintain erect torso. Paces to the point of exhaustion and unaware of her environment. Release and reposition every 2 hours and as needed. Review quarterly and as needed for continued use of Broda Chair requirements . The Quarterly Minimum Data Set (MDS) assessment, dated 3/15/25, lacked documentation for daily use of limb restraints. A Care Plan, revised 3/26/25, indicated, Broda chair with straps while up for safety and positioning. The Informed Consent for Use of Restraints, dated on 5/9/24 for Resident 27 indicated, .Broda Chair with leg straps to prevent resident from falling out of chair . The document lacked recommended duration and release and reposition schedule. The Quarterly Adaptive Device Review, dated 1/31/25 for Resident 27 indicated, .device initiated on 5/31/24, .Medical reason for use: unable to maintain erect torso .Rationale for continued use of restrictive device: positioning . The clinical record lacked any previous quarterly reviews. During an interview with the DNS (Director of Nursing Services) on 4/9/25 at 3:20 p.m., the DNS indicated there were no further evaluations completed on Resident 27. She indicated evaluations should be completed quarterly for re-evaluation of continued need of restraint use. On 4/9/25 at 3:52 p.m., the DNS provided the facility's policy, Restraint Free Environment dated 7/15/24, and indicated it was a policy currently being used by the facility. A review of the policy indicated .6 .The resident's record needs to include documentation .ongoing re-evaluation of the need for the restraint . 3.1-26(r) 3.1-26(s)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident and resident's representative for 2 of 2 residents reviewed for hospitalization. (Resident 8, Resident 19). Findings include: 1. On 4/8/25 at 2:00 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension, and heart failure. Resident 8's progress notes, dated 1/17/25 at 7:50 a.m., indicated Resident 8 was to go to the emergency room due to resident chest x-ray results indicated possible pneumonia. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer form, dated 1/17/25 at 7:30 a.m., indicated Resident 8 was transferred to the hospital. The progress notes and transfer form lacked documentation of a written notification of the transfer and discharge was given the resident or the resident's representative. 2. On 4/8/25 at 2:19 p.m., Resident 19's clinical record was reviewed. The diagnoses included, but were not limited to, epilepsy, diabetes mellitus, and gastro-esophageal reflux disease. Resident 19's progress notes, dated 2/3/25 at 3:49 p.m., indicated he was sent to the emergency room for a possible blood transfusion. The SNF/NF to Hospital Transfer form, dated 2/3/25 at 9:00 a.m., indicated Resident 19 was transferred to the hospital. Resident 19's progress notes, dated 2/11/25 at 1:49 a.m., indicated he was sent to the emergency room for bloody stools. The SNF/NF to hospital Transfer form, dated 2/11/25 at 2:40 a.m., indicated Resident 19 was transferred to the hospital. The progress notes and transfer form lacked documentation of a written notification of the transfer and discharge was given the resident or the resident's representative. During an interview on 4/9/25 at 12:05 p.m., the Director of Nursing Services (DNS) indicated they were unaware of needing to provide the resident or the resident's representative a written notification when the residents transfers or discharges. On 4/9/25 at 3:53 p.m., the DNS provided the facility policy, Transfer and Discharge (including AMA [against medical advice]), revised date 3/20/25 and indicated this was the policy currently being used by the facility. A review of the policy indicated .g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from physical restraints for 3 of 5 residents reviewed for restraints. Documentation of releasing the restraint and repositioning was not completed and informed consent for the use of restraints was not completed prior to placing the resident in restraints. (Resident 3, Resident 16, Resident 27) Findings include: 1. On 6/26/24 at 2:11 p.m., Resident 16 was observed sitting in a broda chair asleep in the hallway with lap straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 9:10 a.m., Resident 16 was observed sitting in the broda chair asleep in the hallway with leg straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 10:24 a.m., Resident 16 was observed sitting in the broda chair asleep in her room with leg straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 11:29 a.m., Resident 16 was observed sitting in the broda chair asleep in her room with leg straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 12:28 p.m., Resident 16 was observed sitting in the broda chair awake in the hallway with leg straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 2:00 p.m., Resident 16 was observed sitting in the broda chair awake in the hallway with leg straps around her legs to prevent her from getting out of the chair. On 7/1/24 at 10:19 a.m., Resident 16 was observed sitting in the broda chair awake in the hallway with leg straps around her legs to prevent her from getting out of the chair. On 7/1/24 at 12:12 p.m., Resident 16 was observed sitting in the broda chair awake in her room with leg straps around her legs to prevent her from getting out of the chair. On 7/1/24 at 2:56 p.m., Resident 16 was observed sitting in the broda chair awake in her room with leg straps around her legs to prevent her from getting out of the chair. Resident 16's clinical record was reviewed on 6/28/24 at 9:30 a.m. The diagnoses included, but were not limited to, progressive supranuclear ophthalmoplegia (slow and difficult muscle movements) and anxiety disorder. Physician orders, dated 7/2/24, for Resident 16 indicated, . broda/geri chair with tray while up due to leaning to sides and forward, unable to maintain direct torso . The physician orders did not indicate using leg restraints when resident was sitting in the broda chair. The Quarterly Minimum Data Set (MDS) assessment, dated 5/8/24, assessed Resident 16 as using limb restraints daily. A care plan, initiated on 8/9/23, and current through target date 6/12/24, for Resident 16 indicated, . Problem: Resident requires use of broda chair with straps while up due to inability to maintain erect torso . Goal: Resident will be free from negative outcomes or decline in functioning relative to restraint use . Interventions: 9. Release every 2 hours and prn [as needed] to reposition and toilet . The Informed Consent for Use of Restraints form, dated 5/8/24, for Resident 16 indicated, . broda chair with leg straps . release and reposition every 2 hours and when toileting . A review of the clinical record for Resident 16 lacked documentation of where the resident was released and repositioned every 2 hours while up in the broda chair with leg straps. 2. On 6/27/24 at 10:43 a.m., Resident 3 was observed sitting in a broda chair awake in his room with lap straps around his legs to prevent him from getting out of the chair. On 6/28/24 at 9:12 a.m., Resident 3 was observed sitting in a broda chair asleep in his room with lap straps around his legs to prevent him from getting out of the chair. On 6/28/24 at 10:25 a.m., Resident 3 was observed sitting in a broda chair asleep in his room with lap straps around his legs to prevent him from getting out of the chair. On 6/28/24 at 11:28 a.m., Resident 3 was observed sitting in a broda chair asleep in his room with lap straps around his legs to prevent him from getting out of the chair. On 6/28/24 at 1:59 p.m., Resident 3 was observed sitting in a broda chair awake in his room with lap straps around his legs to prevent him from getting out of the chair. On 7/1/24 at 10:20 a.m., Resident 3 was observed sitting in a broda chair awake in his room with lap straps around his legs to prevent him from getting out of the chair. On 7/1/24 at 2:59 p.m., Resident 3 was observed sitting in a broda chair asleep in his room with lap straps around his legs to prevent him from getting out of the chair. Resident 3's clinical record was reviewed on 7/1/24 at 10:25 a.m. The diagnoses included, but were not limited to, Alzheimer's disease and traumatic brain injury. Physician orders, dated 7/2/24, for Resident 3 indicated, . broda chair with straps to be utilized while up due to inability to maintain erect torso, leans to side and forward . The Annual Minimum Data Set (MDS) assessment, dated 6/5/24, assessed Resident 3 as using limb restraints daily. A care plan, initiated on 9/1/23, and current through target date 5/13/24, for Resident 3 indicated, . Problem: Resident requires use of broda chair while up due to inability to recall he is unable to bear his own weight . Goal: Resident will be free from negative outcomes or decline in functioning relative to restraint use . Interventions: 9. Release resident every 2 hours and prn for toileting and repositioning . The Informed Consent for Use of Restraints form, dated 6/29/24, for Resident 3 indicated, . broda chair with straps . release and reposition every 2 hours and when toileting . The consent form was dated after the resident was observed to be in a broda chair with leg restraints. A review of the clinical record for Resident 3 lacked documentation of where the resident was released and repositioned every 2 hours while up in the broda chair with leg straps. During an interview on 7/2/24 at 11:48 a.m., the Director of Nursing indicated the facility did not have a consent prior to the 6/29/24 date for Resident 3's use of restraints. 3. On the following dates, times, and locations, Resident 27 was observed sitting in a Broda wheelchair (a chaired designed to provide supportive positioning, decrease postural deviations, and enhance patient safety while facilitating safe, frequent repositioning) with restraining straps secured across the resident's upper legs. The straps were unable to be removed by the resident: - On 6/26/24 from 9:40 a.m. to 11:55 a.m., Resident 27 was observed to be straining against the restraints and emitting a high pitched vocal sound in her room. - On 6/26/24 from 1:20 p.m. to 3:30 p.m., in her room. - On 6/27/24 from 9:30 a.m. to 12:15 p.m., Resident 27 was observed to be straining against the restraints in her room. - On 6/28/24 from 10:00 a.m. to 12:35 p.m., in her room. - On 6/28/24 from 2:05 p.m. to 3:25 p.m., Resident 27 was observed to be straining against the restraints and emitting a high pitched vocal sound in her room. - On 7/1/24 from 9:31 a.m. to 11:47 a.m., in her room. - On 7/1/24 from 1:00 p.m. to 3:15 p.m., in her room. - On 7/2/24 at 9:05 a.m., in the dining room. - On 7/2/24 at 11:40 a.m., Resident 27 was observed to be straining against the restraints and emitting a high pitched vocal sound in her room. There were no observations of the resident being removed from restraints or pacing during the survey time period. On 7/1/24 at 11:50 a.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, unspecified mood disorder and dementia. Physician's orders with a start date of 5/31/24 through the current date indicated, Broda chair with straps while up for safety and positioning, unable to maintain erect torso. Paces to the point of exhaustion and unaware of her environment. Release and reposition every two hours and as needed. There was no documentation indicating the resident was released from the restraint every 2 hours and there was no documentation identifying any type of specific direct monitoring and supervision provided during the use of the restraint. A care plan with a review start date of 6/14/24 and a target date of 7/6/24 indicated the resident was to be released from the restraint and repositioned every 2 hours. During an interview on 7/2/24 at 9:00 a.m., CNA 1 indicated she was not certain how often the resident was to be out of the restraint but believed it was fairly frequently. During an interview on 7/2/24 at 9:30 a.m., CNA 2 indicated she was not certain how often the resident was to be out of the restraint, and on evening shift staff released the restraint and walked with the resident, as the resident enjoyed walking. During an interview on 7/2/24 at 1:16 p.m., the DON indicated the clinical record did not indicate Resident 3, Resident 16, and Resident 27 were released from their restraints and repositioned every 2 hours. On 7/1/24 at 1:15 p.m., the Administrator provided the facility's policy,Restraint Free Environment dated 3/1/24, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate to complete documentation of where the resident was repositioned or released every 2 hours while in restraints nor having an Informed Consent for Use of Restraint formed signed prior to placing the resident in restraints. 3.1-26(h)

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed. As needed antipsychotic medications were prescribed for longer than 14 days, gradual dose reductions (GDR) were not completed, and antipsychotic medications did not have an adequate diagnosis. (Resident 3) Findings include: During an observation on 6/27/24 at 9:49 a.m., Resident 3 was observed sitting upright in a broda chair with lower limb restrains in place. The resident repeatedly shouted, Come here!, in a loud and intelligible voice. On 6/27/24 at 10:17 a.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, personal history of traumatic brain injury, insomnia, and anxiety. A 5/9/24 physician's order indicated the resident was prescribed olanzapine (antipsychotic medication) 2.5 milligrams, two times a day, related to Alzheimer's disease and prochlorperazine maleate (antiemetic and antipsychotic medication) 1 tablet by mouth every six hours as needed for nausea and vomiting. An Annual Minimum Data Set (MDS) assessment, dated 6/5/24, indicated the resident had a diagnosis of Alzheimer's disease and used antipsychotic medication. The MDS assessment also indicated a GDR was not attempted and was not clinically documented as contraindicated. A Psychotropic and Sedative/Hypnotic Utilization by Resident, for records updated between 2/1/24 and 2/8/24, included, but was not limited to: - Zyprexa (olanzapine) 2.5 mg twice a day for dementia diagnosis ordered 4/18/22, next evaluation 2/2024. - Prochlorperazine maleate 10 mg every six hours as needed for nausea and vomiting, ordered 10/4/23, next evaluation 1/2024. The clinical record lacked an evaluation for the continued use of as needed antipsychotics, adequate diagnosis for antipsychotics, and attempted GDR for psychotropic medications. During an interview on 7/2/24 at 2:30 p.m., the Clinical Support Nurse indicated resident should not have a antipsychotic medication for dementia without behaviors. She further indicated she believed the resident's hospice care would be an indicator for not attempting a GDR for as needed antipsychotics. On 7/2/24 at 3:30 p.m., the Administrator provided the facility policy, Gradual Dose Reduction of Psychotropic Drugs, revised on 2/14/24, and indicated it was the policy currently being used. A review of the policy indicated, . GDR is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. Psychotropic Drug is defined as any drug that affects brain activities associated with mental process and behavior . 4. The timeframes and duration of attempts to taper any medication . c. Opportunities during the care process to consider whether the medications should be continued, reduced, discontinued, or otherwise modified include: i. During the monthly medication regime review by the pharmacist. ii. When the physician or prescribing practitioner evaluated the resident's progress . 3.1-48(a)(3) 3.1-48(b)(2)

Based on observation and interview, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff for 5 of 5 days of daily posted nurse staffing reviewed. Findings include: On 6/26/24 at 11:42 a.m., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 6/27/24 at 10:26 a.m., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 6/28/24 at 9:28 a.m., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 7/1/24 at 10:49 a.m., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 7/2/24 at 10:20 a.m., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. During an interview on 7/2/24 at 11:37 a.m., the Clinical Support Nurse indicated the facility should be including actual hours worked on the staffing sheet and be updated the following day to reflect the actual hours worked by licensed staff. They indicated the facility did not have a policy in regard to specific requirements on the nurse staffing sheets.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident with a history of elopement from walking out the same emergency exit door on 3 consecutive days for 1 of 3 residents reviewed for elopement. Resident B was found 1.1 miles in an empty commercial lot by the police. (Resident B) The Immediate Jeopardy began on March 23, 2024, when Resident B exited the facility without staff supervision. The Administrator and the [NAME] President of Clinical Operations were notified of the Immediate Jeopardy, on March 27, 2024 at 10:45 a.m. The Immediate Jeopardy was removed, on 3/28/24 at 4:45 p.m., 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 3/26/24 at 7:02 a.m., Resident B was observed lying in bed resting. Resident B was not on 1-on-1 (continuous) supervision. During an interview on 3/26/24 at 7:05 a.m., CNA 1 (Certified Nursing Aide) indicated CNA 1 knew Resident B had left the faciity on [DATE] (Saturday) on evening shift. Resident B left the facility again, on 3/25/24 (Monday) on evening shift. Resident B was not on 1-on-1 supervision when CNA 1 arrived at the facility, on 3/25/24 at approximately 11:00 p.m., nor was Resident B on 1-on-1 supervision during night shift, from 3/25/24 at approximately 11:00 p.m. until 3/26/24 at approximately 7:00 a.m., when CNA 1 left work. On 3/26/24 at 7:07 a.m., the emergency exit door in the dining room was observed. The emergency exit door was shut and had a keypad to the right of the door. The small, battery operated, door alarm was not observed on the door nor the door frame. The door led out to a front porch that was not secured. The porch was approximately 15 feet from a busy main street. There were cars parked on each side of the street which caused poor visibility to see oncoming traffic. During an interview on 3/26/24 at 7:35 a.m., the VPCO (Vice President of Clinical Operations) indicated, on 3/23/24 at an unknown time, Resident B walked out the emergency exit door in the dining room, at the front of the facility. The alarms did not sound because that door was not connected to the internal alarm system, but did have a small, battery operated, generic alarm that would sound like a doorbell if the door was opened. The staff received a call from the county police department, on 3/23/24 at approximately 10:27 p.m., and asked if Resident B was a resident at this facility. Resident B returned to the facility accompanied by police, on 3/23/24 at approximately 10:35 p.m. The officer reported to the nurse that Resident B said he was just getting fresh air and wanted to go to Indianapolis to visit his mother. When Resident B returned to the facility with the police, Resident B was placed on 15-minute checks. The VPCO had just been informed that Resident B walked out the same emergency exit door, on 3/24/24 (one day after the initial elopement), and again, on 3/25/24 (two days after the initial elopement). Resident B eloped in July of 2023 as well. The staff should have notified the VPCO when Resident B left the facility each time. The information regarding the elopements on 3/24/24 should have been documented by the DON (Director of Nursing) and the elopement on 3/25/24 should have been documented by the agency nurse. Resident B should have been on 1-on-1 supervision to prevent the elopements. During an interview on 3/26/24 at 8:35 a.m., Resident B indicated he went outside over the past few days to get fresh air and walk. During an interview on 3/26/24 at 9:49 a.m., LPN 1 (Licensed Practical Nurse) indicated LPN 1 was the nurse that worked evening shift, on 3/23/24 from 7:00 p.m. until 7:00 a.m. LPN 1 received a call from the county police dispatch, on 3/23/24 at approximately 10:25 p.m. The police dispatcher asked if Resident B lived at this facility. The police dispatcher indicated Resident B was found by police approximately 1.1 miles from the facility walking in an empty commercial lot on Highway 135. LPN 1 verified Resident B was returned to the facility by police, on 3/23/24 at approximately 10:35 p.m. Resident B indicated to LPN 1 and the police officer that Resident B just wanted to walk, get fresh air, and go see his mother in Indianapolis. Resident B was wearing pajama pants, a long sleeve dark green shirt, and non-skid socks. Resident B was not wearing shoes. Resident B had a small abrasion on the right side of his ankle, but Resident B could not remember how the abrasion happened. Resident B was immediately placed on 15 minute checks. When LPN 1 checked the emergency exit door in the dining room, LPN 1 found a small battery-operated doorbell alarm with corroded batteries inside. LPN 1 changed the batteries and resecured the emergency exit. On 3/26/24 from 11:05 a.m. until 11:17 a.m., the location where the police officer found Resident B, on 3/23/24 at approximately 10:25 p.m., was observed. The empty commercial parking lot was approximately 1.1 miles from the facility, located on State Highway 135. From the facility, Resident B walked approximately 0.3 miles and crossed over train tracks. After the train tracks, the sidewalks ended. At 0.4 miles from the facility, the speed limit increased to 55 miles an hour, there were no street lights, and the terrain from approximately 0.4 miles to the empty commercial parking lot was rough gravel approximately 1.5 feet wide next to the highway and tall grass and weeds. During an interview on 3/26/24 at 12:38 p.m., CNA 2 indicated CNA 2 worked evening shift, on 3/25/24 (2 days after the initial elopement). Resident B left the facility at an unknown time and returned on his own by walking to the employee entrance, on 3/25/24 at approximately 9:00 p.m. CNA 2 knew Resident B was at the employee entrance because the wander guard alarm sounded, so CNA 2 turned off the alarm, and walked Resident B to his room. Resident B was wearing sweatpants, a t-shirt, and non-skid socks. Resident B was not wearing shoes. The agency nurse told Resident B that he could not pace on the front hall near the dining room because the staff could not supervise him. After dinner, CNA 2 saw Resident B pacing up and down the front hallway near the dining room and emergency exit door. CNA 2 and an agency nurse were the only clinical staff working during evening shift, on 3/25/24. CNA 2 knew Resident B should have been on 1-on-1 with a staff member, but CNA 2 could not provide 1-on-1 supervision as other residents needed care as well. The historical weather report for the facility was reviewed, on 3/26/24 at 2:30 p.m. The AccuWeather indicated: On 3/23/24 from 8:00 p.m. until 10:30 p.m., the temperature was approximately 36 to 38 degrees Fahrenheit. On 3/24/24 from 5:00 p.m. until 5:45 p.m., the temperature was approximately 53 to 55 degrees Fahrenheit. On 3/25/24 from 7:00 p.m. until 9:00 p.m., the temperature was approximately 64 to 66 degrees Fahrenheit. During an interview on 3/27/24 at 8:04 a.m., the VPCO indicated Resident B walked out the same emergency exit door in the dining room, on 3/24/24 (1 day after the initial elopement). There were staff in the dining room, but the staff were assisting other residents. The clinical record for Resident B was reviewed on 3/27/24 at 8:40 a.m. The diagnoses included, but were not limited to, non-traumatic brain dysfunction, schizophrenia, psychotic disorder, and bilateral hand amputation. A Court Order Appointing Guardian Over Incapacitated Person, dated 8/16/23, indicated Resident B was an incapacitated person and was not unable to make health care decisions due to schizophrenia. A guardian was granted for Resident B. An Outpatient Burn Hospital Physical Therapy Note, dated 3/1/23, indicated Resident B sustained frostbite to bilateral hands, face, and heels. Resident B left his group home in the night and was exposed to extreme cold for an unknown amount of time. Resident B required bilateral wrist amputations in January 2023. A Quarterly MDS (Minimum Data Set) assessment, dated 2/6/24, indicated Resident B was cognitively intact. A care plan, dated 7/19/23 and current through 5/6/24, indicated Resident B was at risk to wander from the facility secondary to a long history of homelessness and Resident B expressed his wish to leave. The care plan was reviewed on 8/9/23, 11/7/23, 2/6/24, and 3/26/24. The care plan also indicated, on 7/24/23, elopement and, on 3/26/24, care plan reviewed no changes made. Undated interventions included, but were not limited to, monitor placement of bracelet alarm and document presence and check function of bracelet alarm at the front and back doors. An Elopement Risk Assessment, dated 7/17/23, indicated Resident B was not an elopement risk. Resident B was alert and had not had an elopement. A hand written note at the bottom of the assessment, dated 7/17/23, indicated a wander guard was to be utilized because Resident B was ambulatory and expressed a wish to return to street life. A Psychiatric Hospital Note, dated 7/26/23, indicated per facility nursing staff Resident B bolted out of the dining room during dinner and ran into the street. Resident B was threatening staff. Resident B was found later by a police canine unit and Resident B reported he was walking back to his home in Indianapolis. Resident B threatened staff prior to eloping from the secure facility and Resident B reported no one wanted him to be there so he left. Resident B had a history of substance abuse and cocaine use. An Elopement Risk Assessment, dated 8/8/23, indicated Resident B was an elopement risk. Resident B had intermittent confusion and had 1 to 2 elopements. An Elopement Risk Assessment, dated 2/3/24, indicated Resident B was an elopement risk. Resident B had intermittent confusion and had 1 to 2 elopement. A progress note, dated 3/23/24 at 10:55 p.m., indicated LPN 1 received a call from police dispatch. The dispatcher indicated Resident B was found walking down State Highway 135 at 10:27 p.m. Resident B returned to the facility with a police officer. Resident B indicated he needed fresh air. The police officer indicated while in transport, Resident B indicated he wanted to go to Indianapolis to see his mother. An abrasion was noted to the front of Resident B's right ankle. Resident B couldn't remember how the abrasion happened. Resident B was placed on 15-minute checks. Resident B indicated that he ran and pushed the emergency exit door in the dining room open with his body. The emergency exit door was secured when the alarm batteries were replaced. An Elopement Risk Assessment, dated 3/23/24, indicated Resident B was an elopement risk. Physician's orders initiated, on 3/24/24 at 6:30 p.m., (after the second elopement) were as follows: 1. Increase Haloperidol (a prescription medication used to treat psychosis) tablet to 15 mg (milligrams) orally at bedtime for psychosis; 2. Increase Haloperidol decanoate (a prescription injectable medication used to treat psychosis) to 150 mg, give 1 dose when available then every 28 days for psychosis and agitation; 3. 1-on-1 direct care for the next 24 hours from 3/24/24 at 6:30 p.m. until 3/25/24 at 6:30 p.m., then re-evaluate. The March 2024 behavior monitoring documentation indicated Resident B had auditory hallucinations every day from 7:00 a.m., until 3:00 p.m., except on 3/17/24 and 3/24/24. Resident B was not observed to have any auditory hallucinations on any other shifts. On 3/23/24 from 3:00 p.m. until 11:00 p.m. Resident B had exit seeking behaviors. A progress note, dated 3/27/24, indicated the elopement event from Monday, 3/25/24, was investigated. Resident B returned to facility at approximately 8:00 p.m. The clinical record did not include sufficient documentation to determine the specific details regarding elopement 1, on 3/23/24, elopement 2, on 3/24/24, nor elopement 3, on 3/25/24. During an interview on 3/28/24 at 10:50 a.m., CNA 3 indicated on 3/24/24 at approximately 5:00 p.m. CNA 3 was passing dinner trays to the residents who wanted to have dinner in their rooms. CNA 3 saw Resident B walk out to the hallway then Resident B turned and walked back into his room. Approximately 10 minutes later, Resident B wasn't in his room. CNA 3 immediately went outside and looked around the facility. CNA 3 located Resident B approximately 3 blocks from the facility walking away from the facility. When CNA 3 caught up with Resident B, Resident B indicated Resident B did not want to go back to the facility. Resident B was wearing sweat pants, long sleeve shirt, and non-skid socks. Resident B was not wearing shoes. CNA 3 brought Resident B back to the facility at approximately 5:45 p.m. The alarm did not sound when he left the facility. On 3/26/24 at 8:57 a.m., the VPCO provided a copy of a facility policy, titled Elopements and Wandering Residents, dated 2/16/24, and indicated this was the current policy used by the facility. A review of the policy indicated alarms are not a replacement for necessary supervision. This facility ensures residents at risk for elopement and or wandering behaviors receive adequate supervision to prevent accidents. The Immediate Jeopardy, that began on 3/23/24, was removed on 3/28/24 when the facility inserviced the staff 1-on-1 supervision and ensured the unsecured door was under supervision until it could be replaced, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This citation relates to Complaint IN00431134. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical restraints for 4 of 5 residents reviewed for physical restraints. (Resident 28, Resident 3, Resident 15, Resident 23) Findings include: 1. On the following dates, times, and locations, Resident 28 was observed sitting in a Broda wheelchair (a chaired designed to provide supportive positioning, decrease postural deviations, and enhance patient safety while facilitating safe, frequent repositioning) with restraining straps secured across the resident's upper legs. The straps were unable to be removed by the resident: - On 8/6/23 at 11:00 a.m. and 2:00 p.m. in her room. - On 8/7/23 at 10:54 a.m. and 2:20 p.m. in her room. - On 8/8/23 at 10:10 a.m. and 11:30 a.m. in her room, at 1:38 p.m. in the dining room, and at 2:45 p.m. in the hallway near the nurse's station. - On 8/9/23 at 9:17 a.m. in the dining room, at 10:28 a.m., 11:05 a.m., and 3:21 p.m. in her room. - On 8/10/23 at 9:45 a.m. in her room. There were no observations of the resident pacing during the survey time period. On 8/8/23 at 11:35 a.m., Resident 28's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety disorder and dementia. Physician's orders with a start date of 4/1/23 through the current date indicated, Broda chair with straps at meals to remain on task, Broda chair with straps as needed related to pacing to the point of exhaustion. No documentation was identified that specified the length of time or frequency the resident was to be in the broda chair with straps. There was no documentation indicating if or when the resident was released from the restraints, and there was no documentation identifying any type of specific direct monitoring and supervision provided during the use of the restraint. During an interview on 8/9/23 at 11:45 a.m., the Assistant Director of Nursing indicated the resident leaned forward when she paced, and she paced quickly and to the point of physical exhaustion, therefore, the broda chair and restraint straps were for her safety. Staff removed the straps at times to walk with her. The physician order did not indicate a specific length of time or frequency the resident was to be in or out of the broda straps. 35318 2. On 8/8/23 at 10:46 a.m., Resident 3 was sitting in the hallway in the broda (for positioning) chair with lap strap restraints on. On 8/8/23 at 1:37 p.m., Resident 3 was sitting in his room in the broda chair with lap strap restraints on. On 8/8/23 at 2:09 p.m., Resident 3 was sitting in his room in the broda chair with lap strap restraints on. On 8/8/23 at 3:07 p.m., Resident 3 was sitting in his room in the broda chair with lap strap restraints on. On 8/9/23 at 10:42 a.m., Resident 3 was sitting in his room in the broda chair with lap strap restraints on. Resident 3's clinical record was reviewed on 8/9/23 at 11:00 a.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance and seizures. Resident 3's Quarterly Minimum Data Set (MDS) assessment, dated 5/16/23, indicated the resident used a chair that prevents rising which is considered to be a restraint. Current physician orders, dated 8/1/23 through 8/31/23, indicated Resident 3's orders included, but were not limited to: - Broda straps to maintain trunk control. The order lacked documentation for the length of time Resident 3 should be in the broda chair, how often, the type of monitoring and ongoing evaluation while resident was sitting in the broda chair. During an interview on 8/9/23 at 11:45 a.m., the Assistant Director of Nursing indicated the physician order did not indicate a specific length of time or frequency the resident was to be in or out of the broda straps. 3. On 8/7/23 at 10:33 a.m., Resident 15 was sitting in the hallway in the broda chair with lap strap restraints on. On 8/8/23 at 10:47 a.m., Resident 15 was sitting in her room in the broda chair with lap strap restraints on. On 8/8/23 at 1:37 p.m., Resident 15 was sitting in her room in the broda chair with lap strap restraints on. On 8/8/23 at 3:08 p.m., Resident 15 was sitting in her room in the broda chair with lap strap restraints on. On 8/10/23 at 10:32 a.m., Resident 15 was sitting in her room in the broda chair with lap strap restraints on. Resident 15's clinical record was reviewed on 8/10/23 at 10:48 a.m. The diagnoses included, but were not limited to, ataxia (impaired balance or coordination) following unspecified cerebrovascular accident and supra nuclear palsy. Resident 15's Quarterly Minimum Data Set (MDS) assessment, dated 5/23/23, indicated the resident used a chair that prevents rising which is considered to be a restraint. Current physician orders, dated 8/1/23 through 8/31/23, indicated Resident 15's orders included, but were not limited to, may use broda chair in evenings to maintain support. An updated physician order, dated 8/7/23, indicated to update current broda chair order to, broda chair while up due to inability to maintain erect torso related to palsy. The order lacked documentation of having restraints or straps for Resident 15. During an interview on 8/10/23 at 11:00 a.m., the Assistant Director of Nursing indicated there was no order for Resident 15 which indicated the resident should be in restraints or straps while in the broda chair. 38312 4. On 8/6/23 at 11:04 a.m., Resident 23 was observed to be lying in his bed with his bed positioned against the wall on his right side and with a half side rail positioned in the middle of his left side of the bed. On 8/7/23 at 10:59 a.m., Resident 23 was observed to be lying in his bed with his bed positioned against the wall on his right side and with a half side rail positioned in the middle of his left side of the bed. On 8/7/23 at 11:49 a.m., Resident 23 was observed to be sitting at the foot of his bed with his bed positioned against the wall on his right side and with a half side rail positioned in the middle of his bed left side of his bed. On 8/8/23 at 11:27 a.m., Resident 23 was observed to be ambulating in his room. On 8/9/23 at 11:48 a.m., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with behaviors, agitation, and muscle weakness. A Quarterly Minimum Data Set (MDS) assessment, dated 7/15/23, indicated Resident 23 had moderate impaired cognition and required limited assistance of one with bed mobility, and no restraint use. A Side Rail Assessment, dated 7/15/23, Resident 23 was ambulatory; demonstrated poor bed mobility; had history of falls; used the side rail for rising, positioning, or support; had cognitive impairment; one side rail was indicated to assist resident with positioning or turning. A Physical Restraint Elimination Evaluation, dated 7/15/23, indicated Resident 23 utilized a half side rail times one to enhance his ability to turn, reposition, and transfer. A care plan, dated 7/18/23 and current through target date 10/18/23, indicated Resident 23 utilized a half side rail to enhance his ability to turn and reposition. The interventions lacked documentation of where the side rail was to be placed on the side of the bed. During an interview on 8/9/23 at 11:10 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident 23 had been utilizing a half side rail on his bed since his decline in activities of daily living. Once he was steady on his feet, he was able to ambulate in his room. During an interview on 8/10/23 at 1:20 p.m., the Director of Nursing (DON) indicated Resident 23 was able to ambulate in his room and utilized his half side rail for turning and repositioning in bed. With the DON in Resident 23's room, she observed his half side rail and indicated the side rail was not placed in the proper position. The half side rail needed to be placed higher up towards the head of the bed. During an interview on 8/9/23 at 2:27 p.m., the DON indicated Resident 23 could not get out of his bed freely and ambulate with the half side rail placed in the middle of the bed. On 8/10/23 at 1:15 p.m., the Director of Nursing provided the policy, Use of Restraints, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy . 2. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather that climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . 8. Treatment restraints shall be applied for no longer than the time required to complete the treatment . 9. Restraints shall only be used upon the written order of a physician . c. The type of restraint and period of time for the use of the restraint . 12. b. The restraints that are used will be the least restrictive and applied for the least amount of time . d. A resident placed in a restraint will be observed at least every thirty minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record . e. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each two hours in which restraints are employed . f. Restrained residents must be repositioned at least every two hours on all shifts . 19. Documentation regarding the use of restraints shall include: . e. The length of effectiveness of the restraint time . 3.1-26(b) 3.1-26(f) 3.1-26(g) 3.1-26(h)

Based on interview and record review, the facility failed to ensure that written notification required for facility-initiated transfers were given to the residents or resident representatives for 3 of 3 residents reviewed. (Resident 9, Resident 32, Resident 18) Findings include: 1. On 8/9/23 at 10:00 a.m., Resident 9's clinical record was reviewed. The diagnosis included, but was not limited to, schizophrenia. A review of his discharge Minimum Data Set Assessment, dated 7/25/23, indicated he was sent out to the psychiatric hospital. A 8/3/23 readmission progress note, indicated Resident 9 was sent to the psychiatric inpatient hospital after an elopement and threatening to kill staff. There was no documentation the resident or resident's representative had been notified of his transfer in writing and provided the appeal rights information in writing and the contact information of the Office of the State LTC (Long-Term Care) Ombudsman after the resident was sent out to the hospital. During an interview on 8/10/23 at 9:25 a.m., the Assistant Director of Nursing (ADON) indicated the notice of transfer requirements had been likely been provided to the resident and resident representative when the resident was sent to the hospital. However, staff did not make a copy of the notice for the record. There was no other documentation or policy available for review. 2. On 8/9/23 at 10:12 a.m., Resident 18's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder, alcohol use disorder, insomnia, and Lewy body dementia with severe behavioral and psychotic disturbance. A review of his discharge Minimum Data Set Assessment, dated 5/2/23, indicated he was sent out to the psychiatric hospital, and on 5/28/23, he was sent to an acute care hospital. On 4/25/23, Resident 18's psychiatric progress note, indicated the resident was being seen following an admission to psychiatric inpatient hospital. There was no documentation the resident or resident's representative had been notified of her transfer in writing and provided the appeal rights information in writing and the contact information of the Office of the State LTC (Long-Term Care) Ombudsman after the resident was sent out to the hospital. During an interview on 8/10/23 at 9:25 a.m., the Assistant Director of Nursing (ADON) indicated the notice of transfer requirements had been likely been provided to the resident and resident representative when the resident was sent to the hospital. However, staff did not make a copy of the notice for the record. There was no other documentation or policy available for review. 3. On 8/9/23 at 10:32 a.m., Resident 32's clinical record was reviewed. The diagnoses included, but were not limited to, depression, anxiety, alcohol use disorder, insomnia, and dementia. A review of his discharge Minimum Data Set Assessment, dated 7/5/23, indicated he was discharged to another nursing home. During an interview on 8/10/23 at 9:25 a.m., the Assistant Director of Nursing (ADON) indicated the notice of transfer requirements had likely been provided to the resident and resident representative when the resident was discharged . However, staff did not make a copy of the notice for the record. There was no other documentation or policy available for review. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to ensure staff provided notifications of bed hold policy required for residents that transferred to the hospital for 2 of 2 residents reviewed for hospitalization . (Resident 9, Resident 18) Findings include: 1. On 8/9/23 at 10:00 a.m., Resident 9's clinical record was reviewed. The diagnosis included, but was not limited to, schizophrenia. A review of his discharge Minimum Data Set Assessment, dated 7/25/23, indicated he was sent out to the psychiatric hospital. Review of the resident's clinical record revealed no documentation that a written notice that specified the facility's bed-hold policy permitting the resident to return and resume resident in the facility was provided to the resident or resident's representative. During an interview on 8/10/23 at 9:25 a.m., the Assistant Director of Nursing (ADON) indicated the bed-hold policy had been likely been provided to the resident and resident representative when the resident was sent to the hospital. However, staff did not make a copy for the clinical record. There was no other documentation or policy available for review. 2. On 8/9/23 at 10:12 a.m., Resident 18's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder, alcohol use disorder, insomnia, and Lewy body dementia with severe behavioral and psychotic disturbance. A review of his discharge Minimum Data Set Assessment, dated 5/2/23, indicated he was sent out to the psychiatric hospital, and on 5/28/23, he was sent to an acute care hospital. Review of the resident's clinical record revealed no documentation that a written notice that specified the facility's bed-hold policy permitting the resident to return and resume resident in the facility was provided to the resident or resident's representative. During an interview on 8/10/23 at 9:25 a.m., the Assistant Director of Nursing (ADON) indicated the bed-hold policy had been likely been provided to the resident and resident representative when the resident was sent to the hospital. However, staff did not make a copy for the clinical record. There was no other documentation or policy available for review. 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for quarter 2 (January, February, March) of fiscal year 2023. Findings include: On 8/8/23 at 10:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN hours for 1/18/23, 1/26/23, 2/8/23, 2/9/23, 2/14/23, and 2/20/23. The report further indicated the facility failed to have Licensed Nursing Coverage 24 hours/Day on 2/8/23 2/9/23, 2/17/23, and 2/10/23. Lastly, the facility received a 1 star staffing rating during the 2 quarter. A review of the staffing sheets the Business Office Manager submitted indicated there was not RN coverage on 1/18/23, 2/14/23, and 2/20/23, but the facility did have 24 hours of licensed nurse coverage. During an interview at that time, she indicated that the website to submit PBJ information was not user friendly and will often time out, erasing all of the information she had entered. She further indicated that she has been a month behind on submitting data.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services) for Quarter 2 (January, February, March) of fiscal year 2023. Findings include: On 8/8/23 at 10:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN hours for 1/18/23, 1/26/23, 2/8/23, 2/9/23, 2/14/23, and 2/20/23. A review of the staffing sheets with the Business Office Manager (BOM) submitted indicated there was not RN coverage on 1/18/23, 2/14/23, and 2/20/23. The BOM did not know why there was no RN coverage for those days. 3.1-17(a)(3)