Every finding on record at Summit Health and Living

Based on observation, interview, and record review, the facility failed to ensure a resident did not receive an antipsychotic medication without indication when the facility failed to identify targeted behaviors and individualized interventions to support the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 12)Findings include:During an interview with Resident 12's representative on 4/30/26 at 11:08 a.m., she indicated she felt Resident 12 received quetiapine (an antipsychotic) as a babysitter for the facility. The resident just sat around, and the representative felt like he got tired of doing nothing. During an observation on 4/30/26 at 12:24 p.m., staff assisted Resident 12 with lunch. His eyes were closed much of the time, and he would occasionally open them when staff said his name. During an observation on 5/1/26 at 10:49 a.m., Resident 12 sat near the nurse's station. He held a soft activity book with tactile sensory objects and ran his fingers over the objects. During an observation on 5/1/26 at 2:36 p.m., Resident 12 sat quietly near the nurse's station. Resident 12's clinical record was reviewed on 5/4/26 at 11:22 a.m. Diagnoses included hypersomnia (excessive daytime sleepiness or excessive nighttime sleep), Parkinson's disease, macular degeneration (eye disease affecting vision), generalized anxiety disorder, dementia (unspecified) with other behavioral disturbance, and psychotic disorder with delusions due to known physiological condition. Current physician's orders included quetiapine fumarate 25 mg one half tablet (12.5 mg) by mouth at bedtime (2/19/26) and buspirone (antianxiety) 5 mg one tablet by mouth three times a day (9/16/25). The following quarterly MDS assessments indicated the resident did not exhibit delusions, hallucinations, or behaviors: 5/9/25, 8/5/25, 1/29/26, and 4/28/26. A quarterly MDS assessment, dated 11/4/25, indicated the resident did not exhibit delusions or hallucinations but did exhibit a behavior of swatting or hitting.A current care plan, initiated on 7/24/24, indicated Resident 12 had an alteration in neurological status related to Parkinson's disease progression. Interventions included cueing and reorienting the resident as needed, give medications as ordered, monitor for signs and symptoms of tremors, rigidity, dizziness, changes in level of consciousness, and slurred speech, and reposition/ambulate every two hours as tolerated. A current care plan, initiated 7/24/24, indicated Resident 12 had a communication problem related to a hearing deficit. Interventions included anticipating and meeting the resident's needs, promoting proper communication with others, communicating face to face with television off, observing confounding problems related to a decline in the resident's cognitive status and mood, use communication techniques which enhance interaction, allowing adequate time to respond. Repeat as necessary, do not rush, request feedback from resident for clarification, face the resident when speaking and make eye contact. Turn off television or radio as needed to reduce environmental noise, ask yes/no questions when appropriate, use simple, brief, consistent words and cues, use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures, use effective strategies such as touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, and use a quiet setting for communicating with the resident. A current care plan, initiated on 7/24/24, indicated Resident 12 had impaired cognitive functioning/dementia or impaired thought processes related to dementia and Parkinson's disease. Interventions included to use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions, and use consistent, simple, directive sentences. If the resident would become agitated, stop the interaction and return later. A current care plan, initiated on 7/24/24, indicated Resident 12 was visually impaired related to macular degeneration. He was legally blind in the left eye and the right eye was severely impaired. Interventions included keeping the resident's room and belongings in a specific order to promote independence. A current care plan, initiated on 8/13/24, indicated Resident 12 received psychotropic medications related to behavior management. Interventions included administering medications as ordered, observe and record occurrences of behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others), and document per facility policy, observe/record/report to MD, as needed, side effects and adverse reactions of psychoactive medications such as unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, and behavioral symptoms not usual to the person. A current care plan, initiated on 8/12/24, indicated Resident 12 had a behavior problem related to severely limited vision, decline in cognition, and Parkinson's disease. He might become resistive to care, and yell and swing at staff. Interventions included 1:1 supervision at nurse's station (11/6/24), administer medications as ordered (8/23/24), anticipate and meet resident's needs, provide opportunities for positive interactions, stop and talk to resident when passing him, approach and speak in a calm manner, divert his attention, remove him from the situation and take to an alternate location as needed, attempt to determine underlying cause of behavior(s), considering the location, time of day, persons involved, and the situation, offer snacks and drinks (11/6/24), provide a program of activities that is of interest and accommodates resident's status, and turn on music and give him time to calm down (1/8/26). A current care plan, initiated 8/30/24, indicated Resident 12 received antianxiety medications related to anxiety disorder. Interventions included giving medications as ordered, and monitor for side effects such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision, mania, hostility, and rage, aggressive or impulsive behaviors, hallucinations, observe for safety related to the use of antianxiety medications which were associated with increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia (falls, broken hips, and broken legs), and observe for target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.). A current care plan, initiated on 10/29/24 and revised on 11/5/24, indicated Resident 12 had delusions related to acute disease progress with Parkinson's. He saw things that he needed to do and attempted to self-transfer often. He had poor safety awareness and was legally blind, putting him at high risk for falls. Interventions included giving medications as ordered, psychological services as needed, and the use of a pull-tab alarm. A current care plan, initiated 1/13/25, indicated Resident 12 might demonstrate physical behaviors, such as hitting or kicking at staff, related to dementia. Interventions included analyzing key times, places, circumstances, triggers, and what helped de-escalate behaviors, assess for contributing sensory deficits, and assess/anticipate the resident's needs (food, thirst, toileting needs, comfort level, positioning, pain), provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, document observed behavior(s) and attempted interventions in behavior log, consult psychiatric services when needed. When the resident becomes agitated, intervene before agitation escalates, guide the resident away from source of distress, engage him calmly in conversation; if response is aggressive, staff should walk away calmly and approach later. A current care plan, initiated 1/29/25, indicated Resident 12 liked to stand and walk. His memory impairment did not allow him to remember that he was unsafe to stand and walk unassisted. Being able to move about in his environment enriched his senses and helped him maintain his range of motion. It allowed him to feel independent and purposeful. He was unsafe to walk alone but he would still attempt to do so. He was not to be restricted in any way that did not allow him to stand, even when unassisted. Interventions included inviting the resident to activities that promoted exercise (2/26/25), use of a pull-tab alarm (4/29/25), fall assessments with each fall, and staff would follow all safety precautions in place (2/26/25). A current care plan, initiated 4/24/25, indicated Resident 12 took medications that had a blackbox warning (used when clinical data shows the drug can cause severe harm, hospitalization, or death). Interventions included educating the resident and his family about black box warnings, give medications per order, notify the MD of signs and symptoms of black box warning signs observed, and notify the MD about abnormal labs. A current care plan, initiated 5/12/25, indicated Resident 12 took a high-risk antipsychotic medication related to delusions and a mood disorder. Interventions included administering medications as ordered at the lowest dose possible to achieve the desired results, verify medication was swallowed, document AIMS (Abnormal Involuntary Movement Scale) at least quarterly, and observe for potential side effects (pseudoparkinsonism, acute dystonia, akathisia, tardive dyskinesia, anticholinergic effects, hypotension, blood cell disorders, orthostatic hypotension, lethargy, drowsiness, destabilized blood sugar, dizziness), report severe mental status or mood changes, falls, seizures, cardiac arrhythmias, suicidal ideation, new or worsening involuntary movements, implement non-pharmacological interventions per mood/behavior care plan, obtain labs, and report new or worsening symptoms. Resident 12's care plans lacked identification of specific delusions or hallucinations and lacked individualized non-pharmacological interventions to manage or support the resident experiencing delusions or hallucinations.During an observation on 5/4/26 at 10:40 a.m., Resident 12 sat in his wheelchair in the activity area. He was looking in the direction of other residents participating in a group activity. On 5/4/26 at 1:47 p.m., Resident 12 sat outside in his wheelchair with his eyes closed, with a contented look on his face. On 5/4/26 at 3:17 p.m., Resident 12 sat in his wheelchair in his room. His representative talked to him quietly. On 5/6/26 at 9:23 a.m., Resident 12 lay in his bed with eyes closed. On 5/6/26 at 9:58 a.m., Resident 12 sat in his wheelchair near the nurse's station. A staff member asked how he was doing and he responded okay. On 5/6/26 at 10:09 a.m., Resident 12 sat in his wheelchair in the dining room with his eyes closed, while a pastor spoke to the residents. On 5/6/26 at 12:17 p.m., Resident 12 sat in his wheelchair in the dining room. Staff assisted him with eating. On 5/6/26 at 3:21 p.m., Resident 12 sat in his wheelchair, speaking with his representative. On 5/7/26 at 12:11 p.m., Resident 12 sat in his wheelchair in the dining room with his eyes closed. An occurrence note, dated 6/1/2025 at 2:45 p.m., indicated the resident stood, causing his wheelchair to flip, and he landed on his coccyx before staff could reach him. The resident had no safety awareness and tried to stand, unassisted. An IDT note, dated 6/2/2025 at 11:41 a.m., indicated the resident stood from his wheelchair, was observed to fall, landing on his coccyx, and the chair flipped sideways. Two staff members ran towards him, but he fell before they could reach him. The team spoke with hospice regarding frequent falls related to the progression of Resident 12's Parkinson's disease. A behavior note, dated 6/20/2025 at 10:30 p.m., indicated the resident was grabbing at another resident's wheelchair. He attempted to stand several times. Staff intervened with verbal cues, physical assist, toileting, and an activity tool board. An occurrence note, dated 6/30/2025 at 6:00 p.m., indicated the resident was found sitting on the floor with his back to the wall in front of the nurse's station. After a physical assessment, staff put the resident to bed. Confusion was noted to be the root cause of the fall. A progress note, dated 8/2/2025 at 9:57 a.m., indicated the resident did, at times, get anxious and would stand up without assistance or resist care. He was pleasant and cooperative on that shift, with no standing up without assistance. He slept at night and napped during the day. A progress note, dated 8/24/2025 at 10:00 a.m., indicated the resident was found crawling on the floor in his room. A progress note dated 8/25/2025 at 3:48 p.m., indicated the resident continued to attempt to crawl from bed despite mats, alarms, and low bed position. The Interdisciplinary team (IDT) decided to put Resident 12's bed against the wall to limit possible exit routes from the bed. A psychiatric NP note, dated 10/8/2025 at 10:23 a.m., indicated the resident continued to be extremely restless when awake, constantly moving around in bed to the point of sliding out onto the floor. His mouth moved constantly and he verbalized his racing thoughts, although they made no sense. His anxiety appeared to be stable, and he was due for a review of his antianxiety medication, buspirone. He had been on quetiapine immediate release (IR) 25 mg twice a day at 2:00 p.m., and 9:00 p.m., to target his most struggle-some times of the day. The family preferred he no longer receive the quetiapine in the afternoon, only at bedtime. The family requested psychological services be discontinued. He had been on quetiapine since 2/2025 with fewer falls and fewer behaviors noted. A progress note, dated 10/15/2025 1:22 p.m., indicated the resident was alert and talkative and his appetite was good. He attempted to stand from his wheelchair and was successfully redirected. A progress note, dated 10/29/2025 at 3:06 p.m., indicated the resident displayed increased restlessness since a GDR of his antianxiety medication, buspirone. He attempted to get out of his chair more often, pushed and pulled the dining room table when eating, and was not eating his full meal. He attempted to get up twice that day and the alarm sounded. Staff reported he would ball up his fist but did not swing. Resident 12 displayed impulsivity in the past. Staff provided 1:1 care to settle him down. Staff talked to him, gave him a back rub, and reminded him not to get up. Non-pharmacological interventions were successful. A progress note, dated 12/3/25 at 8:18 a.m., indicated the resident was receiving care from a CNA. He started punching the CNA and said, I'm going to beat the shit out of you. The resident appeared agitated, was offered reassurance, and a new caregiver was provided, resulting in compliance from the resident. A progress note, dated 12/8/2025 7:31 p.m., indicated the resident was resistive during care and kicked a CNA in the chest. He frowned but resistance stopped when care was completed. A progress note, dated 12/9/2025 1:20 p.m., indicated the resident was hitting, agitated and kicking during care, and when assisted getting up or being put to bed. A progress note, dated 1/29/2026 at 1:00 a.m., indicated the resident was calm and cooperative, at times resistive to care. A progress note, dated 2/19/2026 11:00 a.m., indicated the resident was sitting up in bed, confused and slow to engage in conversation. He was calm and when asked a question, he was able to respond after a delay. Resident 12 had a visual deficit that might cause him to react/resist because he was startled, on occasion, with care. He did not know who was there, but when staff explained to him what they were doing, he would comply with care. A progress note, dated 2/25/26 at 6:11 p.m., indicated the resident appeared more awake, was talking out loud, and grabbing on to the handrail while sitting at the nurse's station. A progress note, dated2/28/2026 at 2:33 p.m., indicated staff noticed resident being more playful and attentive since the decrease in quetiapine from 25 mg to 12.5 mg. A progress note, dated 3/4/2026 1:10 a.m., indicated no changes in appetite, behavior, or sleep patterns. A progress note, dated 3/5/2026 at 12:00 p.m., indicated the resident was found on the floor after climbing out of bed. No injuries were noted. A progress note, dated 3/5/26 at 6:06 p.m., indicated the resident was resistive to vital signs assessment. He balled up his fist but did not strike the nurse. His eyes were unreactive to light. A progress note, dated 3/5/26 at 6:41 p.m., indicated the resident attempted to climb out of bed. While in the dining room, waiting for dinner, he picked up the table and staff intervened. When a nurse tried to get vital signs, he balled up his fist but did not strike out. He was more awake and more fidgety. A progress note, dated 3/6/26 at 4:45 p.m., indicated the resident was moving his arms and hands as though he was working.A progress note, dated 3/10/26 at 9:09 p.m., indicated while two CNAs were putting the resident to bed, he punched a male CNA in the arm, lifted his knees and put them into a CNA's rib cage, and tried to kick. One staff held his hands or legs and the other performed peri-care. That behavior was suspected to be triggered by a recent dose reduction in quetiapine. The resident could not be reasoned with, grimaced, and wanted to be left alone. A progress note, dated 3/19/26 at 6:01 p.m., indicated the resident was calm and cooperative at dinner. There were no changes in mood or behavior. A CNA behavior note, dated 3/19/26, indicated Resident 12 was pointing at the ceiling. She asked him what he was pointing at and he replied, Those airplanes. The resident was not distressed, and the CNA described his mood as calm.A progress note, dated 4/28/26 at 8:39 a.m., indicated the resident was quiet, without behaviors, slept at night and napped during the day. A progress note, dated 4/27/26 at 5:41 p.m., indicated the resident was calm, pleasant, and exhibited no behavior. A progress note, dated 4/28/26 at 4:11 p.m., indicated Resident 12 verbalized phrases and words with mumbled speech. He was unable to make his wants and needs known. He was quiet and exhibited no behavior. He was resting in bed and usually slept throughout the night except for care times. A progress noted, dated 4/28/26 at 8:39 a.m., indicated Resident 12 was quiet with no behaviors noted. A progress note, dated 4/28/26 at 3:29 p.m., indicated Resident 12 appeared calm and no distress was noted. A CNA behavior note, dated 4/28/26, indicated the resident was observed grabbing something in the air and talking to himself. The CNA did not offer non-pharmacological interventions and the behavior note lacked documentation of the resident's mood at the time. The clinical record lacked documentation of Resident 12 experiencing delusions or hallucinations resulting in stress or discomfort to the resident. A quarterly Minimum Data Set assessment, dated 4/28/26, indicated Resident 12 was severely cognitively impaired, had no indications of psychosis (hallucinations/delusions) and no behaviors. He used a wheelchair for mobility, and was dependent on staff for eating, oral hygiene, toileting, personal hygiene, rolling left to right in bed, sitting to lying, and sitting to standing. He was dependent on staff for all transfers. He received an antipsychotic and antianxiety medication on a routine basis. The last gradual dose reduction (GDR) was attempted on 2/17/26. A bed alarm and a chair alarm were used daily. During an interview with CNA 5 on 5/7/26 at 10:21 a.m., she indicated Resident 12 tried to hit and kick another CNA during peri-care. He did the same type of thing to CNA 5 another time. She was not sure Resident 12 understood what was taking place when care was provided. He would mumble, but was hard to understand. When staff helped him eat, he would sometimes try to say something. Some days, before eating, he would pray. Sometimes, he would reach for things that were not there or while dining, he might pull on the tablecloth. She did not think he was delusional or experiencing hallucinations. Generally, he was just aggressive or combative during care activities. During an interview with Nurse Practitioner (NP) 4 on 5/7/26 at 10:57 a.m., she indicated Resident 12's family no longer wanted her to treat the resident. The family felt like she treated the resident like a [NAME] pig and did not approve of the changes to his medications. Resident 12 was receiving the quetiapine due to delusions related to his Parkinson's disease. Before he was admitted to the facility, he had been very physically active and was an avid kick boxer. Then, he had a fall at home and after his hospitalization, he was never the same again. Upon admission in July of 2024, he was able to ambulate but since that time, his coordination had declined and he could no longer walk. The delusions he had were causing him to get up out of bed frequently, causing multiple falls. NP 4 started the resident on quetiapine at that time (2024). When they tried to decrease the dosage of the quetiapine, his falls increased. She was afraid he was going to fall and break something. Delusions were reported to her by staff. She did not have documentation of specific delusions or hallucinations. The most recent GDR was initiated by hospice. The last time she saw Resident 12 was on 10/14/25 and at that point, he was on 25 mg quetiapine at 2:00 p.m. and 9:00 p.m. During an interview with LPN 6 on 5/7/26 at 11:44 a.m., she indicated Resident 12 would kick-box during care. His movements were controlled. He would talk randomly and called out to people who were not in the room. He did not use full sentences. He reached out with his hands as if doing something, even trying to eat when nothing was in his hand. She considered those behaviors to be delusions or hallucinations. He was trying to do something with his hands that was not there to do. He would sometimes instruct staff on how to help him with his task. During an interview with the MDS Coordinator on 5/7/26 at 2:59 p.m., she indicated Resident 12 had delusions where he would pull himself up to the wall and fidget with something unseen. His wife brought in a busy board so he could fidget with something. She thought he believed whatever was on the wall was real. The resident's ability to speak waxed and waned from day to day. Some days, he could talk and respond appropriately. Other days, his speech was nonsensical. She questioned if the antipsychotic (not quetiapine) he was given during his hospitalization, prior to his admittance to the facility, might have caused some of his initial problems. During an interview with the DON on 5/7/26 at 2:59 p.m., she indicated Resident 12 would sometimes end up on the floor during his delusions. If staff tried to redirect him, or get him off the floor, he would become agitated because he was working on his job. Resident 12's family wanted him to stay as independent as possible. The facility tried to find common ground with the family and tried different medications. One medication they put him on completely snowed the resident (unresponsive, drooling). The goal was to help him remain active, not snowed. He was currently on the quetiapine because of his restlessness and agitation. The restlessness and agitation resulted in falls, typically at nighttime. She thought the delusions were what caused him to try to get up. Resident 12 did not say things like, Did you see that man over there? Rather, when he would fidget with an unseen object, he would say I need to fix this. Because he was (previously) very active, he liked to propel himself in his wheelchair, but he would fall out of the chair. His restlessness in bed caused multiple falls. A current facility policy, titled Use of Psychotropic Medications, provided by the Administrator on 5/7/26 at 4:30 p.m., indicated the following: .It is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.Adequate Indications for Use - refers to identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for us is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals.Chemical Restraint - refers to any drug used for discipline or that makes it more convenient (less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety. 410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(w)

Based on interview and record review, the facility failed to ensure staff (QMA 2) intervened to protect a resident (Resident B), who was verbally abused by another staff member (CNA 1). The facility also failed to ensure staff reported the allegation of verbal abuse of a resident (Resident B) by another staff member (CNA 1) in a timely manner to the Administrator, resulting in the facility failing to report the suspicion/actual verbal abuse to the appropriate regulation agencies in a timely manner. Findings include:Resident B's clinical record was reviewed on 1/14/26 at 11:31 a.m. Diagnoses included vascular dementia without behavioral disturbance, anxiety, and cerebral infarction due to thrombosis of right posterior cerebral artery.The most current quarterly Minimal Data Set assessment (MDS), dated [DATE], indicated Resident B was moderately cognitively impaired. The resident had impaired function to the left side upper and lower extremities and dependent for toilet hygiene, shower/bathe, dressing of the lower body, footwear, personal hygiene, and all transfers.A current care plan, dated 1/18/21, indicated Resident B had impaired cognitive functioning or impaired thought process related to vascular dementia. Interventions included keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion.A current care plan, dated 8/3/22, indicated Resident B could be verbally abusive with staff. Interventions included caregivers were to provide opportunities for positive interactions. A current care plan, dated 1/18/21, indicated Resident B had impaired cognitive functioning or impaired thought process related to vascular dementia. Interventions included keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion.A current care plan for ADLs (Activities of Daily Living), dated 11/12/25, indicated interventions included staff to encourage the resident to participate to the fullest extent possible with each interaction.A facility self-reported incident, dated 12/30/25 at 5:23 p.m., indicated QMA 2 reported on 12/29/25 at 6:01 p.m., an uncomfortable situation occurred between CNA 1 and Resident B. During a shower, CNA 1 pushed the resident into the corner of the shower furthest away from the showerhead. The resident grabbed for the showerhead and started to bathe themselves. CNA 1 took it away and refused to let the resident have it and stated staff were not supposed to let the resident have the showerhead. CNA 1 continued to wash the resident's upper body and QMA 2 washed the resident's legs. CNA 1, then gave the resident a washcloth and told them to wash their junk. QMA 2 assisted the resident in washing the lower body. The resident stated they had to urinate. After they finished, the resident grabbed the showerhead and CNA 1 tried to take it away. They continued a tug-of-war with the showerhead. CNA 1 demanded the resident return the showerhead because they were not allowed to have it. The resident became upset and stated other staff members allow him to have the showerhead. CNA 1 resumed the shower. After the shower, the resident thanked both staff members sincerely. CNA 1 used a sarcastic tone while saying You're welcome. The facility asked QMA 2 why the incident was not reported immediately. QMA 2 indicated she did not feel it needed to be reported because the resident as not harmed, in distress and QMA 2's focus was to avoid further conflict by continuing to assist with resident care. QMA 2 reported that CNA 1's was pleasant and cooperative prior to and after the encounter. However, during the encounter CNA 1's attitude changed as evidenced by a change in the tone change when care was being provided to Resident B. The Resident was interviewed and their story corroborated with QMA 2's. The resident further alleged that CNA 1 had jerked the showerhead away from him. The resident also stated that CNA 1 dumped shampoo on his head and wouldn't put it in his hand. The resident said other care givers allow him to complete what he can and then provide assistance. The resident stated CNA 1 threw a washcloth at him and told him to wash his junk.During an interview on 1/14/26 at 10:50 a.m., QMA 2 indicated, on 12/29/25, CNA 1 asked for assistance showering Resident B. During the shower, CNA 1 was rude and demanding with the resident. CNA 1 moved the resident to the corner of the shower, away from the showerhead. During the shower, the resident reached for the showerhead. CNA 1 told the resident he (Resident B) was not allowed to have the showerhead and staff had been told so. QMA 2 indicated she had never been told the resident could not have the showerhead. During the shower, the resident indicated they needed to urinate. When the resident was finished, they continued with the shower. CNA 1 threw a washcloth at the resident and told him to wash his junk. QMA 2 assisted the resident in cleaning his private area. The resident reached for the showerhead again. CNA 1 told the resident he was not allowed to have the showerhead, and they began a tug-of-war for the showerhead and CNA 1 jerked it away from the resident. QMA 2 attempted to keep the resident from becoming more upset, by continuing care, but did not stop CNA 1 nor ask her to leave the area. CNA 1 and QMA 2 got the resident back to his room and the resident thanked QMA 2. The resident then thanked CNA 1, but she did not respond. The resident had to thank her twice before she responded with a sarcastic you're welcome. QMA 2 did not know if CNA 1 and Resident B had any other interactions for the rest of the shift (2:00 p.m. - 10:00 p.m.). QMA 2 indicated the shower encounter started between 3:00 p.m. and 3:30 p.m. QMA 2 indicated she considered the encounter abusive. QMA 2 indicated the resident was upset and didn't think he had done anything wrong. He had never been told he was not allowed to have the showerhead. At one point the resident told QMA 2 this was bull shit. During an interview on 1/14/26 at 12:00 p.m., the Administrator indicated the CNA's used assignment sheet for resident care information. Review of the facility's CNA assignment sheets lacked indication that Resident B was not able to use the showerhead himself. During an interview on 1/14/26 at 12:44 p.m., Resident B indicated he was satisfied with his care at the facility. There was one staff person who was not nice and would not give him the showerhead during his showers. He identified that staff member as CNA 1. The resident indicated the incident had upset him but he was not harmed physically. The resident indicated he liked to do whatever he could for himself and staff were good about helping him.During an interview on 1/14/26 at 12:54 p.m., CNA 3 indicated she was unaware of anyone being told Resident B was not allowed to have the showerhead. The resident had been known to spray staff while in the shower, but this did not happen consistently. The resident should be able to have the showerhead if he asked for it. CNA 3 indicated that the resident usually asked her to put shampoo in his hand and he washed his hair himself.During an interview on 1/14/26 at 1:09 p.m., CNA 4 indicated he worked with CNA 1 in the past while she provided care for Resident B. During that time CNA 1 was not nice to the resident. CNA 4 never reported the concerns.During an interview on 1/14/26 at 3:08 p.m., the DON indicated it was the expectation of the facility that staff protect the resident first then immediately report suspected or actual abuse to the Administrator. If the Administrator was not available, staff would report to the DON. QMA 2 should have reported the concern immediately. CNA 1 should not have remained in the facility. If the incident had been handled appropriately, CNA 1 and the resident would have been separated and CNA 1would have been sent home pending investigation. The DON indicated Resident B was allowed to have the showerhead. The facility saw this as a resident's rights violation. It came up in the investigation that some of the aides had not allowed Resident B to have the showerhead because he sprayed them. CNA 1 was not professional when she told the resident he could not have the showerhead and to wash his junk. The DON also indicated all staff should report any concerns of abuse, mistreatment, or neglect immediately.CNA 1 was not available for interview during the survey.CNA 1's timecard was reviewed on 1/14/26 at 3:00 p.m. CNA 1 worked from 1:57 p.m. to 10:10 p.m. on 12/29/25.A current policy, dated 10/2017, titled Reporting of Reasonable Suspicion of a Crime, Reporting, Investigate/Prevent/Correct Any Alleged Violations was provided by the Administrator on 1/14/26 at 3:49 p.m. The policy indicated the following: . VII Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should:Respond to the needs of the resident and protect them from further incident (document)Notify the Administrator immediately, Administrator will notify others as applicable.Cross reference F600. This citation relates to Intake 2704766.3.1-28 (c)

Based on interview and record review, the facility failed to protect a resident's right to make choices and to promote independent activities of daily living. (Resident B and CNA 1)Findings include:During an interview on 1/14/26 at 10:50 a.m., QMA 2 indicated on 12/29/25, CNA 1 asked the QMA for assistance showering Resident B. During the shower, CNA 1 was rude and demanding with the resident. CNA 1 moved the resident to the corner, away from the showerhead. During the shower, the resident reached for the showerhead. CNA 1 indicated to the resident that he (Resident B) was not allowed to have the showerhead, and staff were told he wasn't to have it. QMA 2 indicated she had never been told the resident could not have the showerhead, nor was it in his plan of care. The resident reached for the showerhead again. CNA 1 told the resident he was not allowed to have the showerhead, and they began a tug-of-war for the showerhead.During an interview on 1/14/26 at 12:44 p.m., Resident B indicated he was satisfied with his care at the facility. There was one staff person who was not nice and would not give him the showerhead during his shower. The staff member was CNA 1. The resident indicated the incident had upset him, but he was not harmed physically. The resident indicated he likes to do whatever he could for himself and staff were good about helping him.During an interview on 1/14/26 at 12:54 p.m., CNA 3 indicated she was unaware of anyone being told Resident B was not allowed to have the showerhead. The resident had been known to spray staff while in the shower, but not consistently. The resident should be able to have the showerhead if he asked for it.During an interview on 1/14/26 at 2:20 p.m., the MDS Coordinator indicated Resident B should have been allowed to have the showerhead. During an interview on 1/14/26 at 3:08 p.m., the DON indicated Resident B was allowed to have the showerhead. The resident had never been restricted from having the showerhead. The facility saw this as a resident right violation. It came up in the investigation that some of the aides had not allowed Resident B to have the showerhead because he sprayed them. CNA 1 was not available for interview during the survey.Resident B's clinical record was reviewed on 1/14/26 at 11:31 a.m. Diagnoses included vascular dementia without behavioral disturbance, anxiety, and cerebral infarction due to thrombosis of right posterior cerebral artery.The most current quarterly Minimal Data Set assessment (MDS), dated [DATE], indicated Resident B was moderately cognitively impaired. The resident had impaired function to the left side upper and lower extremities and was dependent for toilet hygiene, shower/bathe, dressing of the lower body, footwear, personal hygiene, and all transfers.A current care plan for ADLs (Activities of Daily Living) was dated 11/12/25. Interventions included staff to encourage the resident to participate to the fullest extent possible with each interaction. The care plan lacked an intervention to restrict the resident from using the showerhead.A CNA assignment sheet, dated 12/29/25, lacked indication the resident should not be allowed to hold the showerhead during bathing. Behavior progress notes, dated October 2025 through 1/14/26 indicated four times that the resident was not allowed to have the showerhead after asking for it: 10/30/25 at 3:55 p.m., 11/14/25 at 4:58 p.m., 11/24/25 at 8:12 p.m., and 12/8/25 at 7:53 p.m.An undated staff education form, titled Know Your Rights under Federal Nursing Home Regulations was provided by the Administrator on 1/14/26 at 3:49 p.m. The form indicated the following: Resident RightsYou have the right do a dignified existence, self-determination, and communication access to persons and services inside and outside the facilityRespect and DignityYou have the right to be free from abuse, neglect, misappropriation of your property, exploitation, corporal punishment or involuntary seclusion.The right to reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger the health or safety of you or other residents.Self-determinationYou have the right to and the facility must promote and facilitate self-determination through support of resident choice, including: .You have the right to make choices about aspects of your life in the facility that are significant to you.This citation relates to Intake 2704766.3.1-3 (a) (1)

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member (Resident B and CNA 1).Findings include:During an interview on 1/14/26 at 10:50 a.m., QMA 2 indicated, on 12/29/25, CNA 1 asked for assistance showering Resident B. During the shower, CNA 1 was rude and demanding with the resident. CNA 1 moved the resident to the corner of the shower, away from the showerhead. During the shower, the resident reached for the showerhead. CNA 1 told the resident he (Resident B) was not allowed to have the showerhead and staff had been told so. QMA 2 indicated she had never been told the resident could not have the showerhead. During the shower, the resident indicated they needed to urinate. When the resident was finished, they continued with the shower. CNA 1 threw a washcloth at the resident and told him to wash his junk. QMA 2 assisted the resident in cleaning his private area. The resident reached for the showerhead again. CNA 1 told the resident he was not allowed to have the showerhead, and they began a tug-of-war for the showerhead and CNA 1 jerked it away from the resident. QMA 2 attempted to keep the resident from becoming more upset, by continuing care, but did not stop CNA 1 nor ask her to leave the area. CNA 1 and QMA 2 got the resident back to his room and the resident thanked QMA 2. The resident then thanked CNA 1, but she did not respond. The resident had to thank her twice before she responded with a sarcastic you're welcome. QMA 2 did not know if CNA 1 and Resident B had any other interactions for the rest of the shift (2:00 p.m. - 10:00 p.m.). QMA 2 indicated the shower encounter started between 3:00 p.m. and 3:30 p.m. QMA 2 indicated she considered the encounter abusive. QMA 2 indicated the resident was upset and didn't think he had done anything wrong. He had never been told he was not allowed to have the showerhead. At one point the resident told QMA 2 this was bull shit. During an interview on 1/14/26 at 12:44 p.m., Resident B indicated he was satisfied with his care at the facility. There was one staff person who was not nice and would not give him the showerhead during his showers. He identified that staff member as CNA 1. The resident indicated the incident had upset him but he was not harmed physically. The resident indicated he liked to do whatever he could for himself and staff were good about helping him.Resident B's clinical record was reviewed on 1/14/26 at 11:31 a.m. Diagnoses included vascular dementia without behavioral disturbance, anxiety, and cerebral infarction due to thrombosis of right posterior cerebral artery.The most current quarterly Minimal Data Set assessment (MDS), dated [DATE], indicated Resident B was moderately cognitively impaired. The resident had impaired function to the left side upper and lower extremities and dependent for toilet hygiene, shower/bathe, dressing of the lower body, footwear, personal hygiene, and all transfers.A current care plan, dated 1/18/21, indicated Resident B had impaired cognitive functioning or impaired thought process related to vascular dementia. Interventions included keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion.A facility self-reported incident, dated 12/30/25 at 5:23 p.m., indicated QMA 2 reported on 12/29/25 at 6:01 p.m., an uncomfortable situation occurred between CNA 1 and Resident B. During a shower, CNA 1 pushed the resident into the corner of the shower furthest away from the showerhead. The resident grabbed for the showerhead and started to bathe themselves. CNA 1 took it away and refused to let the resident have it and stated staff were not supposed to let the resident have the showerhead. CNA 1 continued to wash the resident's upper body and QMA 2 washed the resident's legs. CNA 1, then gave the resident a washcloth and told them to wash their junk. QMA 2 assisted the resident in washing the lower body. The resident stated they had to urinate. After they finished, the resident grabbed the showerhead and CNA 1 tried to take it away. They continued a tug-of-war with the showerhead. CNA 1 demanded the resident return the showerhead because they were not allowed to have it. The resident became upset and stated other staff members allow him to have the showerhead. CNA 1 resumed the shower. After the shower, the resident thanked both staff members sincerely. CNA 1 used a sarcastic tone while saying You're welcome. The facility asked QMA 2 why the incident was not reported immediately. QMA 2 indicated she did not feel it needed to be reported because the resident as not harmed, in distress and QMA 2's focus was to avoid further conflict by continuing to assist with resident care. QMA 2 reported that CNA 1's was pleasant and cooperative prior to and after the encounter. However, during the encounter CNA 1's attitude changed as evidenced by a change in the tone change when care was being provided to Resident B. The Resident was interviewed and their story corroborated with QMA 2's. The resident further alleged that CNA 1 had jerked the showerhead away from him. The resident also stated that CNA 1 dumped shampoo on his head and wouldn't put it in his hand. The resident said other care givers allow him to complete what he can and then provide assistance. The resident stated CNA 1 threw a washcloth at him and told him to wash his junk.CNA 1 was not available for interview during the survey.A current facility policy, dated 10/2017, titled Reporting of Reasonable Suspicion of a Crime, Reporting, Investigate/Prevent/Correct Any Alleged Violations was provided by the Administrator on 1/14/26 at 3:49 p.m. The policy indicated the following: Policy: It is the policy of the Community Long Term Care that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, exploitation, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies service the resident, family members, legal guardians, friends, or other individuals.This citation relates to Intake 2704766.3.1-27(b)

Based on interview and record review, the facility failed to prevent the neglect of a dependent resident when CNA 1 did not implement the resident's care plan interventions nor follow manufacture's guidelines for the operation of a mechanical lift, resulting in a resident fall when the mechanical lift tipped over during a transfer for 1 of 3 residents reviewed for mobility transfers utilizing a mechanical lift. (Resident B)Findings include:Resident B's clinical record was reviewed on 8/20/25 at 10:10 a.m. Diagnoses included cerebral infarction, vascular dementia, hemiplegia and hemiparesis affecting left non-dominate side, type 2 diabetes, chronic kidney disease, hypertension, anticoagulant use, depressive disorder, and chronic pain syndrome. A current care plan, dated 1/18/21, indicated the resident had an activity of daily living deficit. Interventions included two staff member participation for mobility transfers. The most current quarterly MDS (Minimum Data Set) Assessment, dated 7/10/25, indicated the resident was dependent for transfers to and from a bed to a chair or wheelchair. An undated facility CNA Assignment Sheet indicated Resident B required two-person assist for transfers. A facility self-reportable, dated 7/26/25, indicated, at approximately 4:05 p.m. on 7/26/25, CNA 2 entered Resident B's room. Resident B was in the mechanical lift and lifted high in the air. The only other person in the room was CNA 1. CNA 2 indicated CNA 1 had been transferring the resident from the bed to a high-backed, reclining wheelchair chair alone. CNA 2 called for assistance from the nurses. When LPN 3 entered the room, they observed Resident B on the floor, the mechanical lift tipped over on its side, and CNA 1 and CNA 2 standing nearby. The resident was assessed and sent to the hospital for evaluation and treatment.A written interview between the DON and CNA 1, dated 7/26/25, indicated CNA 1 started the mechanical lifting process without assistance from another staff member. In a written statement, dated 7/26/25, CNA 2 indicated she was searching for the mechanical lift. She entered Resident B's room and saw the resident lifted into the air via the mechanical lift with only one operator present. CNA 1 pushed the machine forward, and the resident fell to the floor. CNA 2 indicated CNA 1 never asked for assistance with the transfer.In a written statement, dated 7/26/25, LPN 3 indicated she heard staff yelling for RN 4. She went to the room and found Resident B on the floor with CNA 1 and CNA 2 standing nearby. The resident was assessed and returned to bed. LPN 3 indicated she had never seen CNA 1 attempt to use the mechanical lift without assistance. However, after the incident, she became aware CNA 1 had attempted the transfer without assistance. In a written statement, dated 7/26/25, RN 4 indicated she heard staff calling her name. When she arrived at Resident B's room, she observed the resident on the floor and was told he fell from the mechanical lift. CNA 2 told her when she entered the room, the resident was already in the mechanical lift sling, and it was elevated to the highest position. The machine tipped over, causing the resident to fall to the floor. During an interview on 8/20/25 at 10:54 a.m., the DON indicated CNA 1 was no longer an employee of the facility. CNA 1was not available for interview during this survey.During an interview on 8/20/25 at 11:02 a.m., Resident B indicated he was dropped from the mechanical lift. The resident was unable to remember who was involved or specifics about the incident. The resident indicated he had a bad headache and was sent to the hospital. TDuring an interview on 8/20/25 at 11:14 a.m., CNA 5 indicated staff have always been required to use two people to operate mechanical lifts.During an interview on 8/20/25 at 11:23 a.m., the Maintenance Supervisor indicated the mechanical lift was checked after the incident and they were unable to find anything wrong with the function of the lift. During an interview on 8/20/25 at 11:25 a.m., CNA 6 indicated staff always used two staff members to operate a mechanical lift. She denied any problems finding someone to help. Staff used CNA assignment sheets to see what type of care the residents needed.During an interview on 8/20/25 at 11:40 a.m., RN 4 indicated she heard staff yelling for her. When she arrived at the resident's room, she observed the resident on the floor with the lift pad under him. Staff used the lift pad to move the resident closer to the bed and lift him back onto the bed. The resident was assessed for injuries and sent to the hospital. After the incident, RN 4 was informed that the resident was already in the mechanical lift and elevated when the CNA 2 arrived at the room. To operate a mechanical lift in this facility, there must be two people present.During an interview on 8/20/25 at 12:03 p.m., CNA 2 indicated she entered the resident's room and observed Resident B up in the air. The resident was positioned over a high-backed, reclining wheelchair. The chair was not positioned in a laid-back position appropriate for transfers. The resident started to fall, and the machine tipped over. CNA 2 indicated she tried to reach the resident but was unsuccessful. The resident complained of a headache. He was sent to the hospital. There should always be two people present to operate the mechanical lift.During an interview on 8/20/25 at 1:00 p.m., the Administrator indicated the facility recently amended their transfer policy to indicate the use of two staff members when using a mechanical lift. The Administrator indicated prior to the policy amendment; the facility used the manufacturer's recommendation which indicated the use of two staff members. Review of the manufacture's guidelines indicated the following: . Invacare recommends that two (2) assistants be used for ALL lifting preparation, transferring from and transferring to procedures. The use of one (2) assistant is totally based on the evaluation of the heath care professional for each individual case. Review of a current facility policy, last revised 7/28/25, titled Safe Resident Handling/Transfers and provided by the DON on 8/20/2025 at 11:58 a.m. indicated the following: . Compliance Guidelines .15. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. This citation is related to complaint 2572653.3.1-27(a)(3)

Based on interview and record review, the facility failed to ensure mail was distributed on Saturdays. This deficiency had the potential to affect 32 of 32 residents who resided in the facility. Finding includes: During a Resident Council group interview, beginning on 6/25/25 at 9:40 AM, the Resident Council President indicated residents never got mail on Saturdays because no one worked in the facility's business office on Saturdays. Residents 16, 21, and 31 indicated they did not think they received mail on Saturdays, but were uncertain. During an interview, on 6/27/25 at 9:34 a.m., LPN 3 indicated she worked on the weekends, but she was uncertain if residents received mail on Saturdays. During an interview, on 6/27/25 at 2:13 p.m., the Administrator indicated the facility's mail was delivered to a post office box, and they did not pick up the facility's mail on Saturdays. She did not have anyone to get the mail on Saturdays, so mail was not delivered on Saturdays to the residents. According to the United States Post Office website, accessed on 6/27/25 at 4:39 p.m. at https://tools.usps.com/locations/details/1383938, the Summitville post office was open from 9:00 a.m. to 11:00 a.m. on Saturdays. A QSO (Quality, Safety, & Oversight) memo (QSO-24-21-NH) provided by the Administrator on 6/27/25 at 4:58 p.m. as the facility policy, indicated the following: .The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service; and 'Promptly' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service 3.1-3(s)(1)

Based on observation, interview, and record review the facility failed to ensure nursing staff had competencies for the administration of medications, flushes, and feedings though a gastrostomy tube (feeding tube) for 1 of 6 residents reviewed for medication administration. (Resident 1) Finding includes: During an observation on 6/26/25 at 8:13 p.m., RN 13 performed hand hygiene, then crushed a phenobarbital (for seizures) 60 milligram (mg) tab and placed in approximately 10 milliliters (mg) of water in medication cup, poured out 7.5 ml of levetiracetam (for seizures) solution 100 mg/ml in a medication cup, and opened a 30 ml packet of ProStat (supplement) and placed in a cup and added 120 ml water. Upon entering Resident 1's room, she raised the head of the bed up. She washed her hands, applied gloves, drew up the phenobarbital/water mix in the syringe, attached the syringe to the gastrostomy tube (g-tube), used the syringe plunger and pushed the medication through the g-tube. She drew up water in the syringe, attached the syringe to the g-tube, pushed the syringe plunger to administer the water flush. She repeated the same steps with the levetiracetam administration. She drew up the ProStat mixture in the syringe, attached the syringe to the g-tube, then pushed the ProStat mixture through the syringe into the g-tube using the plunger. She repeated the steps with the ProStat solution until the solution was completely administered. She administered the water flush utilizing the syringe and plunger through the g-tube. Then, she drew up the Nutren 2.0 (feeding) into the syringe, attached to the g-tube, pushed the plunger, and administered the feeding. She repeated the administration of the feeding through the g-tube as before until all the feeding was administered. She administered a water flush, utilizing the syringe plunger to administer the flush through the g-tube. During the observation, she indicated the g-tube only had lock type connectors for the syringes, so she pushed the medications, flushes, and feedings through the g-tube. She indicated the g-tube almost pulled the liquid from the syringe on its own. She did not use gravity to administer the medications, flushes, or the feedings. During an interview, on 6/26/25 at 8:39 a.m., RN 13 indicated she did not check for placement prior to initiating the medication administration. She normally checked for residual gastric contents by aspiration prior to administering medications and feeding through a g-tube. Resident 1's clinical record was reviewed on 6/26/25 at 3:00 p.m. Diagnoses included epilepsy, unspecified, not intractable, without status epilepticus, dysphagia oropharyngeal phase, and profound intellectual disabilities. Current orders included phenobarbital 60 mg via g-tube twice a day, levetiracetam 100mg/ml - 7.5 ml daily flush with 30 ml water before and after administration, ProStat30 ml mixed with 120 ml water daily, Nutren 2.0 - 250 ml with 60 ml water before and 60 ml flush after feeding twice a day, and check for g-tube residual prior to formula/medication administration. During an interview, on 6/26/25 at 3:24 p.m., LPN 7 indicated g-tube placement was checked by aspirating the stomach contents prior to the administration of medications and feeding through a g-tube. Resident 1 had a piston syringe, but she (LPN 7) took the plunger out of the syringe prior to hooking the syringe up to the g-tube for medication administration and allowed the medications and feedings to flow into the stomach by gravity. During an interview, on 6/26/25 at 3:57 p.m., the DON indicated typically g-tube placement was checked by aspiration of stomach contents prior to medication and feeding administration. Medication and feedings were typically administered per gravity; they were not pushed through the g-tube. A current facility policy, last revised 1/27/25, provided by the Administrator on 6/27/25 at 10:18 a.m., titled Enteral Tube Medication Administration, indicated the following: .Prepare medication(s) for enteral tube administration .Verify enteral tube placement a. Observe gastric contents and check pH of aspirated gastric contents .Assess for gastric residual volume a. not recommended for resident(s) who are alert and able to report symptoms indicating enteral feeding is not being tolerated well. B. Check prior to medication(s) administration .Administer each medication by gravity 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to implement interventions to promote the healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 29) Finding includes: During an observation, on 6/24/25 at 11:28 a.m., Resident 29 sat in his recliner with his feet elevated and wore socks and shoes. He did not wear heel protection boots. During an observation, on 6/25/25 at 9:21 a.m., the resident sat in his recliner with his feet elevated. He did not wear heel protection boots. During an observation, on 6/25/25 at 11:19 a.m., Resident 29 sat in his recliner with his feet elevated. His feet were off the edge of the recliner with the backs of his heels touching the edge of the recliner. He did not wear heel protection boots. During an observation, on 6/25/25 at 4:26 p.m., the resident lay in his bed with his feet covered. His legs and ankles were bare. He did not wear heel protection boots. During an observation, on 6/26/25 at 9:14 a.m., Resident 29 lay in bed with socks on, and his heels were lying on the bed. He did not wear heel protection boots. During an observation, on 6/26/25 at 10:29 a.m., Resident 29 sat in his recliner with his feet elevated, and his heels were positioned against the recliner edge. He did not wear heel protection boots. Resident 29's clinical record was reviewed on 6/26/25 at 10:43 a.m. Diagnoses included heart failure, peripheral vascular disease, presence of aortocoronary bypass graft, type 2 diabetes mellitus without complications, and muscle weakness. Current orders included the following: Clean left heel with normal saline. Apply nickel thick layer of Santyl (medication for removal of dead tissue of wound) to wound bed. Cover with saline moistened gauze and foam dressing daily and as needed for soilage/displacement. Prevalon boots (heel protection boots for pressure relief) to right and lower extremities at all times. May remove for therapy and hygiene. Every shift for protection. A Medication Administration record for June 2025 indicated the resident's order for the Prevalon boots was signed off as completed every shift from 6/1/25 through 6/25/25. An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was cognitively intact. He had no maladaptive behaviors. He was dependent on staff for lower body dressing and putting on/taking off footwear. He required substantial/maximal assistance with toileting hygiene, showering/bathing, toilet transfers, and tub/shower transfers. He required partial/moderate assistance with rolling left and right in bed. He had a stage 2 pressure injury (partial-thickness skin loss with exposed dermis) upon admission and was at risk for pressure injuries. A current care plan, initiated on 3/26/25, last revised on 6/24/25, indicated the resident had deep tissue injuries (persistent non-blanchable deep red, maroon or purple discoloration) to right and left heels. Interventions included elevate heels when in bed (4/9/25), Notify physician if wound not healing or signs/symptoms of infection (4/9/25), Prevalon boots as ordered (4/9/25), and Treatment as ordered (4/9/25) A Nursing admission Assessment on 3/27/25 indicated the resident's heels were reddened and cracked. A Wound Assessment, dated 4/2/25, indicated the resident's left heel had a stage 2 pressure injury that measured 5 centimeters (cm) long by 5 cm wide by zero cm deep. The left heel presented with a fluid filled blister with a reddened periwound (the area of skin immediately surrounding a wound.) The wound margins were dark in color. A Wound Assessment, dated 4/16/25, indicated the resident's left heel had an unstageable pressure injury (obscured full-thickness skin and tissue loss) measuring 3.5 cm long by 3.0 cm wide by less than 0.1 cm deep. The wound bed had 50 % brown eschar (dead tissue) and 50 % pink granulation (temporary, living tissue that acts as a foundation for new skin to grow over). The wound had a moderate amount of light brown drainage. The resident indicated he had a lot of pain to the left heel. A Wound Assessment, dated 5/14/25, indicated the resident's left heel had an unstageable pressure injury measuring 2.3 cm long by 2.2 cm wide by 0.1 cm deep. The wound was unstageable for 50 % of the wound bed, and 50 % of the wound bed was granulated tissue. The pressure injury had a moderate amount of light pink/brown drainage. A Wound Assessment, dated 6/10/25, indicated the resident's left heel had an unstageable pressure injury measuring 3 cm long by 1.5 cm wide by less than 0.1 cm deep. The wound had greater than 50 % slough (a type of non-viable tissue, often appearing as yellow or white, moist, and stringy substance) and less than 50 percent pink tissue. The pressure injury had a small amount of light pink drainage. A Wound Assessment, dated 6/25/25, indicated the resident's left heel had an unstageable pressure injury measuring 2.4 cm long by 01.5 cm wide by less than 0.1 cm deep. The pressure injury had a moderate amount of serosanguineous (thin, watery, and pinkish in color) drainage. Wound margins and the periwound were macerated (the softening and breakdown of skin due to prolonged exposure to moisture). During an observation, on 6/26/25 at 12:13 p.m., CNA 4 entered the resident's room and asked if he had completed his lunch. He sat in his recliner with his feet resting on the floor. He did not wear heel protection boots. During an interview, on 6/26/25 at 12:40 p.m., CNA 4 indicated for special interventions for someone with wounds she could look at a paper, the guide sheet, they had for the CNAs that listed residents' special needs. During a wound observation, on 6/26/25 at 12:51 p.m., RN 13 performed wound care on the resident's left heel. The resident's wound to the left medial heel was approximately quarter size with a pink wound bed and white, macerated wound edges. She did not attempt to apply the resident's heel protection boots following the treatment. During an observation, on 6/26/25 at 12:59 p.m., RN 13 left the resident's room. The resident lay in bed with his heels on the bed, and his heel protection boots were in his roommate's recliner. During an observation, on 6/26/25 at 4:25 p.m., the resident rested on his back in his bed. His feet lay on the bed. His heel protection boots were laying in his roommate's recliner. QMA 5 entered the resident's room and came back out. During an observation, on 6/26/25 at 4:26 p.m., the resident's heel protection boots remained on his roommate's recliner. During an interview, on 4/26/25 at 4:35 p.m., CNA 6 indicated they had a lot of interventions listed on the guide sheet for the residents which included pressure injury interventions. He asked the nurse when something may have changed and was not on the guide sheet During an interview, on 6/26/25 at 4:37 p.m., QMA 5 went into the resident's room and saw the heel protection boots on his roommate's recliner. He was not wearing his heel protection boots. She indicated he only wore his heel protection boots at night, as far as she knew. Review of the guide sheet, provided by LPN 7 on 6/26/25 at 4:40 p.m., indicated Resident 29 liked to sit in his recliner and had problems with his feet. The guide sheet lacked mention of the resident's heel protection boots. Review of the resident's clinical record for 6/24/25 through 6/26/25 indicated a lack of documented resident refusals to wear his heel protection boots. During an observation, on 6/27/25 at 11:10 a.m., the resident sat in his recliner with his feet resting on his recliner. He wore socks and did not have his heel protection boots on. During an interview, on 6/27/25 at 11:36 a.m., RN 8 and CNA 9 indicated they turned the resident frequently and put heel boots on him when he was in bed. RN 8 indicated the resident told her he wanted a break from the boots today while he was up. CNA 9 indicated the guide sheet usually told them if a resident required heel boots. If the resident refused to wear his boots, they told the nurse, and she documented it since they were unable to document refusals in their charting. During an interview, on 6/27/25 at 3:06 p.m., LPN 7 indicated the resident often refused his heel protection boots. He wore them at night. She had not documented when he refused to wear them during the day. During an interview, on 6/27/25 at 3:44 p.m., the DON indicated the resident often refused his heel protection boots. She expected the staff to apply the heel protection boots as ordered and document any refusals to wear the boots. During an interview, on 6/27/25 at 4:23 p.m., the MDS Coordinator indicated the resident had a care plan for refusing treatments. The care plan reviewed on 6/26/25 did not contain the care plan with a focus of noncompliance. The resident's current care plan, provided by the MDS Coordinator, on 6/27/25 at 4:23 p.m., indicated the resident was noncompliant with treatments with an initiation date of 4/17/25 and a revision date of 6/26/25. Review of the resident's care plan with revisions, on 6/27/25 at 4:50 p.m., indicated the following: .I am non compliant with Treatments Date Initiated: 04/17/2025 Revision on: 06/26/2025 Revision by: . [LPN 14] . - I am non compliant with Treatments Date Initiated: 06/26/2025 . I will have no complications r/t my non compliance through next review date. Date Initiated: 04/17/2025 Revision on: 06/26/2025 Revision by: . [LPN 14] Target Date: 07/03/2025 - I will have no complications r/t my non compliance through next review date. Date Initiated: 06/26/2025. A current policy, last revised 7/26/21, provided by the DON on 6/27/25 at 4:56 p.m., titled Wound Program Policy and Procedures, indicated the following: .Nursing staff will employ preventative measures successfully manage skin integrity of those residents who are identified to be at risk 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure the activity director completed the required education to meet the qualifications for an activity director. Finding includes: Employee records were reviewed on 6/26/25 at 3:30 p.m. The records lacked documentation of the required training for the Activity Director (AD). During an interview on 6/27/25 at 4:53 p.m., the Administrator indicated that the AD began her position approximately 90 days ago. The AD was not currently certified and was registered for an Activity Director course with a requested date of 7/7/25. Confirmation of the training had not yet been received. The Activity Director consulted with other AD's at sister facilities by zoom meetings or by going to their facilities. There had not been any activities onsite supervision since the previous AD, who departed early April 2025. 3.1 -33(e)

A. Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care for 1 of 2 resident reviewed for wound care. (Resident 29) B. Based on observation, interview, and record review, the facility failed to utilize infection control and prevention strategies during handwashing with g-tube medication and feeding administration, hand hygiene with glove use, and insulin administration. Findings include: A. Resident 29's clinical record was reviewed on 6/26/25 at 10:43 a.m. Diagnoses included heart failure, peripheral vascular disease, presence of aortocoronary bypass graft, type 2 diabetes mellitus without complications, and muscle weakness. Current orders included the following: Clean left heel with normal saline. Apply nickel thick layer of Santyl (medication for removal of dead tissue of wound) to wound bed. Cover with saline moistened gauze and foam dressing daily and as needed for soilage/displacement. During an observation, on 6/26/25 at 12:51 p.m., the door of Resident 29's room had an Enhanced Barrier Precautions sign. The sign indicated providers and staff must wear gloves and a gown for high-contact resident care activities including wound care. A cart containing personal protective equipment (PPE) was outside the door. RN 13 walked into the room with wound supplies, performed hand hygiene, applied gloves, and performed wound care on the resident's left heel. She did not apply a gown. During an interview, on 6/26/25 at 1:01 p.m., RN 13 indicated she had not noticed the EBP sign on the resident's door. She should have worn a gown. During an interview, on 6/26/25 at 3:24 p.m., LPN 7 indicated residents on EBP included those with catheters, ostomies, and wounds. Signs for EBP were placed on the residents' doors who required EBP. If she did anything where she touched the resident at all on EBP then she always put on a gown and gloves. During an interview, on 6/26/25 at 3:57 p.m., the DON indicated when wound care was performed, she would expect the nurse to wear a gown, gloves, and possibly a mask or splash guard if the resident was on EBP. A current policy, last revised 2/2025, provided by the Administrator on 6/27/25 at 10:18 a.m., titled Enhanced Barrier Precautions, indicated the following: . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms B1. During a medication administration observation for Resident 1, on 6/26/25 at 8:13 p.m., RN 13 performed hand hygiene, applied gloves, administered medications and a bolus feeding through a gastrostomy tube to the resident. Upon completion of the medication and feeding administration, she removed her gloves, then washed her hands. She applied soap, lathered her hands, rinsed her hands, then turned off the water faucet with the back of her hand. She dried her hands with paper towel. At the same time as the observation, she indicated she should have used a paper towel to turn off the water faucet. During an interview, on 6/26/25 at 3:24 p.m., LPN 7 indicated the procedure to wash hands was to turn on the water, wet hands, get soap, wash all areas of the hands, sing the Happy Birthday song, rinse hands, use a paper towel to dry hands, then turn off the water faucet with a paper towel. During an interview, on 6/26/25 at 3:57 p.m., the DON indicated when handwashing is performed the water faucet should be turned off with a paper towel. According to the CDC website, https://www.cdc.gov/museum/pdf/cdcm-[NAME]-stem-hand-hygiene-lesson.pdf, accessed on 6/30/25 at 3:30 p.m., the procedure for handwashing included the following steps : Wet hands with water; 1. Apply enough soap to cover all hand surfaces; 2. Rub hands palm to palm; 3. Right palm over left dorsum with interlaced fingers and vice versa; 4. Palm to palm with fingers interlaced; 5. Backs of fingers to opposing with fingers interlocked; 6. Rotational rubbing of left thumb clasped in right palm and vice versa; 7. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa; 8. Rinse hands with water; 9. Dry hands thoroughly. 10. Use towel to turn off faucet; 11. Your hands are now safe. A current facility policy, last revised on 10/2017, provided by the Administrator on 6/27/25 at 10:18 a.m., titled STANDARD PRECAUTIONS INFECTION CONTROL, indicated the following: .Perform hand hygiene .After removing gloves B2. During a medication administration observation, on 6/26/25 at 11:28 a.m., RN 13 recapped an insulin safety syringe that she had used to administer insulin to Resident 8. She held the used syringe in her right hand and grasped the needle cap with her left hand and brought them together until the needle cap secured to the syringe. RN 13 indicated that she did not like recapping needles. During an interview, on 6/26/25 at 11:38 a.m., RN 13 indicated that she was unsure if the needle she recapped was a safety needle or not. RN 13 retrieved an unopened insulin syringe from medication cart. The syringe was identified as an insulin safety syringe. RN 13 was unaware that the plastic sliding sheath was a safety feature. During an interview, on 6/26/25 at 4:06 p.m., the DON indicated staff was not to recap needles and the facility used safety needles. A current policy with a review date of 2/5/2025, titled Syringe and Needle Disposal, indicated the following: Policy: to ensure used syringes, needles, and sharps are immediately disposed of safely, or as soon as feasible after use, according to the State and Federal regulations, CDC and OSHA guidelines. Procedure: 2) Do Not recap needles after use to avoid needle-stick injury. a. If MUST recap needle, a one-handed scoop technique using the needle itself to pick up the cap and then the cap is pushed against a hard surface (i.e. counter, wall) to ensure tight fit on device . 8. Activate any safety features of the device used (i.e. sheath, retractable needles) A current policy, titled STANDARD PRECAUTIONS INFECTION CONTROL, provided by the Administrator on 6/24/25 at 2:10 p.m., indicated the following: .e. Perform hand hygiene: v. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. vi. After removing gloves A current policy, titled Infection Control Program, indicated the following: Policy: .All staff engaged in direct patient care should be instructed in correct techniques and be familiar with our facilities established infection control policies and procedures 3.1-18(a) 3.1-18(j) 3.1-18(l)

Based on interview and record review, the facility failed to ensure the resident's advance directives were completed by the resident with decisional capacity for 1 of 16 residents reviewed for advance directives. (Resident 4) Finding includes: Resident 4's clinical record was reviewed on [DATE] at 9:04 a.m. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (thickening and hardening of the artery without chest pain) and paroxysmal atrial fibrillation (irregular heartbeat that lasts a short time and usually returns to normal). Current physician's orders included no CPR (cardiopulmonary resuscitation), dated [DATE]. An Indiana Physician Orders for Scope of Treatment (POST) form was completed on [DATE]. In the instructions, the form indicated if the patient lacked decisional capacity, the legal representative or a proxy may complete the POST on behalf of the patient. Section E indicated in order for the POST form to be effective the patient, legally appointed representative, or proxy must sign and date the form. The resident representative had signed the form on [DATE]. Section F indicated the relationship of the representative or proxy identified in Section E and indicated if the patient does not have capacity. The form was signed by the nurse practitioner on [DATE]. An admission Minimum Data Set (MDS) assessment completed on [DATE] indicated the resident was cognitively intact. A care plan, initiated on [DATE] and revised on [DATE], indicated the resident was a no code (do not resuscitate) per her desire. A Social Service progress note, dated [DATE] at 12:09 p.m., indicated the resident was her own responsible person. During an interview, on [DATE] at 2:14 p.m., RN 3 and LPN 4 indicated the nurses went over advance directives with the residents or their representatives on admission. If a resident was mentally competent, he/she should sign the advance directives. During an interview, on [DATE] at 2:16 p.m., QMA (qualified medication aide) 5 indicated the resident was alert and oriented. During an interview, on [DATE] at 2:22 p.m., LPN 6 indicated the resident knew the staff by name and seemed oriented. If a resident was oriented, then advance directives would be signed by the resident. She thought the resident had wanted her representative to sign the advance directives. During an interview, on [DATE] at 3:09 p.m., the DON indicated the resident's daughter had signed the POST as the resident had refused to sign her admission paperwork. The daughter had signed everything. She was uncertain if the resident had been reapproached to sign advance directives or if the resident's record contained documentation of the resident's refusal to sign paperwork. During an interview, on [DATE] at 3:55 p.m., the DON had been unable to locate the resident's refusal to sign paperwork during the admission process or attempts to reapproach the resident later. She provided a statement signed by the Office Manager on [DATE] that indicated the resident refused to sign paperwork on her own and insisted the representative sign for her due to not being in a well enough state. During an interview, on [DATE] at 4:52 p.m., the Administrator indicated she had been unable to locate the facility policy on advance directives. She had reached out to her corporate consultant and was still waiting for the policy. 3XXX,d+[DATE](f)(7)

Based on observation, record review, and interview, the facility failed to ensure a resident was not started on a routine antipsychotic medication without indication for 1 of 5 residents reviewed for dementia care (Resident 82). Finding includes: During an observation, on 9/4/24 at 11:00, Resident 82 sat in a wheelchair in his room while his representative shaved him. He kept his eyes closed throughout the procedure and had to be roused for questions. During an observation, on 9/5/24 at 1:18 p.m., the resident sat outside the facility in a wheelchair with a visitor sitting at his side. During an observation, on 9/9/24 at 8:34 a.m., the resident sat in a wheelchair in his room and spoke about his wife. During an observation, on 9/9/24 at 1:54 p.m., the resident propelled himself in a wheelchair down the hallway using the siderails to pull himself and smiled as other residents, staff, and visitors talked to him. Resident 82's clinical record was reviewed on 9/6/24 at 8:23 a.m. He was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, and unspecified symptoms and signs involving cognitive functions and awareness. Current physician's orders included donepezil (for Alzheimer's disease) 10 mg daily, memantine (for Alzheimer's disease) 10 mg daily, and quetiapine (antipsychotic) 50 mg daily at bedtime. An admission Minimum Data Set (MDS) assessment completed on 8/19/24 indicated the resident was severely cognitively impaired. He exhibited physical symptoms not directed toward others for one to three days during the assessment period. The symptoms did not significantly interfere with the resident's care and did not put others at significant risk of physical injury. He did not exhibit wandering or rejection of care behaviors. A current care plan, initiated on 8/20/24 and revised on 8/26/24, indicated the resident had a behavior problem related to: He refused care, yelled, threatened staff, and wanted to find wife. His cognitive ability was worse in the evening and night where he became more confused and acted out. His interventions included the following: Administer medications as ordered. Monitor/document for side effect and effectiveness (8/20/24); Caregivers to provide opportunity for positive interaction and attention. Stop and talk with the resident as passing by (8/20/24); Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert his attention. Remove the resident from the situation and take to an alternate location as needed (8/20/24); Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention such as a busy box, snack, or talking about his family (8/20/24) and Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (8/20/24). A Nurses Note, dated 8/15/24 at 2:00 a.m., indicated the resident yelled out repeatedly. He wanted to know where he was, where his wife was, and what happened to his leg. His questions were answered. He was given reassurance. Five minutes later, the resident continued to yell and awakened others. The resident exhibited the yelling behavior several times. A Nurses Note, dated 8/22/24 at 3:17 a.m., indicated the resident yelled out and demanded to go home. The resident threatened staff with physical harm. His confusion triggered the behavior. The resident was clean and dry with no sign or symptoms of distress. He was agitated. Interventions attempted included the following: Fluids and snacks were offered; Assistance to the wheelchair to sit up for a while was offered; and Assistance to turn on and watch television was offered. The interventions were refused. The resident was reminded he was at the facility for therapy, and it was the middle of the night. The resident indicated he did not care. The resident was given incontinence care and was quiet. A Nurse Note, dated 8/23/24 at 6:17 a.m., indicated the resident yelled out most of the night wanting to know where his wife was, why he was at the facility and where his leg was. Staff attempted to redirect and were not very successful. His confusion and dementia triggered the behavior. The staff assisted the resident up into his wheelchair. He sat at the nurses' station, was given a snack, and interacted with the staff. The resident began to fall asleep and was assisted back to his bed. The resident slept for about an hour and a half and began to yell out again. A Nurse Note, dated 8/26/24 at 11:59 p.m., indicated the resident yelled out and wanted the police called. The resident indicated he was at his home. The resident was reminded he was at the nursing home. He wanted the police called and wanted his wife to be with him. Staff reminded him of his location, situation, time of night and that his wife had been there earlier and was currently sleeping. He did not accept the staff's reminders. A Nurse Note, dated 8/27/24 at 12:07 a.m., indicated the triggers for the above behaviors was the resident saw or heard staff pass by his room. He indicated it was too noisy. He was confused and unaware of the situation, location, time, and date. Reassurance was not effective. He became argumentative and agitated. The resident was reminded of the location and his situation. He was offered food and fluids. The staff attempted to reposition him in bed. The television was turned off. A light at bedside was turned on. A Nurses Note, dated 8/27/24 at 11:05 a.m., indicated the resident's representative had spoken to the resident's neurologist about the resident's yelling and behaviors at night. A prescription was sent for quetiapine 50 mg daily at bedtime related to moderate dementia with behavioral disturbance. The Nurse Practitioner (NP) was updated. The resident's representative brought the medication to the facility. The physician's orders lacked orders for psychoactive medications upon admission and prior to the initiation of the quetiapine order. A Nurses Note, dated 8/31/24 at 1:16 p.m., indicated the resident's representative reported the resident had been having increased evening and daytime sleepiness the last few days. The resident had napped on and off throughout the shift but was easily awakened. A Nurse Note, date 9/2/24 at 11:03 p.m., indicated the resident had started quetiapine and it was not effective. He yelled out, argued with staff, and wanted the police called. During an interview, on 9/9/24 at 1:58 p.m., CNA 10 indicated the resident had urinated on the floor today. He had yelled out for assistance after he urinated on the floor. She had not been told any special interventions for the resident for any behaviors. During an interview, on 9/9/24 at 2:02 p.m., CNA 9 indicated the resident liked to call out. His behaviors got worse after supper when his wife left because he was sundowning (his confusion increased late in the afternoon into the night). The staff gave the resident snacks, took him to the bathroom often, because he liked to use the bathroom a lot and that helped a little. He also enjoyed talking to other residents. She thought the resident was lonely at times. During an interview, on 9/9/24 at 2:09 p.m., CNA 11 indicated the resident became anxious at night when his wife was gone. He tried to redirect the resident by talking about his wife. Later in the night, he got worse. Usually, the staff could talk to him and give him ice cream and that helped. For the most part, he was sweet. During an interview, on 9/9/24 at 2:17 p.m., QMA 5 indicated she met the resident in the moment for his behaviors and that seemed to work. During an interview, on 9/9/24 at 2:18 p.m., LPN 6 indicated the staff had to get the resident out of bed sometimes. The resident believed the facility was his house and often asked why the staff were in his house. Sometimes he would sleep for several hours in bed. She thought the resident's representative had reached out to the resident's dementia doctor. She had attempted to call the resident's representative, but the resident's representative did not answer her calls, so she called another member of the resident's family. That was when the resident's representative contacted the resident's neurologist. She was uncertain if the facility had contacted the neurologist to discuss the resident's recent order for quetiapine. During an interview, on 9/9/24 at 3:04 p.m., the DON indicated she had not spoken with the neurologist or his office. The facility did not typically start with antipsychotic medication for behaviors. They worked with the doctor and the psychological services NP. She knew the resident was having behaviors. The resident's representative had called the neurologist and already had the bottle of the medication when she told the facility. The NP had been notified, and had said it was okay. A description of the interactions between the neurologist's office and the resident's representative from the neurologist's office, provided by the Administrator on 9/9/24 at 4:20 p.m., indicated the neurologist had been contacted by the resident's representative on 8/26/24 at 8:49 a.m. The resident's representative indicated the resident was residing at the facility for rehabilitation and physical therapy. He had been in the hospital for a week for Respiratory Syncytial Virus (RSV) and a urinary tract infection. He was getting worse. His sundowning had worsened. He was not sleeping at night. The neurologist ordered quetiapine 50 mg daily at bedtime on 8/26/24 at 9:41 a.m. The resident representative was notified, on 8/26/24 at 9:50 a.m., of the new order and requested the order to be sent to a nearby pharmacy. An NP progress note, dated 8/27/24, provided by the Administrator on 9/9/24 at 4:20 p.m., indicated the resident had been seen for an admission follow up. He had been sundowning and at night, had not been sleeping well, and had become agitated. The resident's representative had reached out to the resident's neurologist. The resident had a history of dementia now with increasing behavioral disturbance. The neurologist prescribed the resident quetiapine 50 mg at bedtime to help with the insomnia and behaviors. Otherwise, the resident had been adjusting better during the daytime hours. A facility policy, dated 10/2022, provided by the Administrator on 9/9/24 at 4:20 p.m., titled Psychotropic Medication Policy, indicated the following: .Based on a comprehensive assessment of a resident, the facility must ensure: Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .Facility will use extreme caution in utilizing antipsychotic medications in the elderly. The following will be considered prior to initiation of antipsychotic medication. 1. Behavioral symptoms present a danger to the resident or others. 2. Expression or indications of distress that are significant distress to the resident. 3. If not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which are presenting a danger or significant distress 3.1-37(a) 4.1-48(b)(1)

Based on interview and record review, facility failed to ensure residents received offered vaccinations available for 1 of 5 residents reviewed for immunizations (Resident 8). Findings include: Resident 8's clinical record was reviewed on 9/6/24 at 9:24 a.m. Diagnoses included dementia without behavioral disturbance, psychotic disturbance, anxiety, post- traumatic stress disorder, major depressive disorder and pneumonia. Resident 8 had received pneumococcal polysaccharide vaccine (PPSV) 23 on 7/12/16, and pneumococcal conjugate vaccine (PCV) 13 on 7/16/15. CDC recommendations indicated to give one dose of PCV 20 at least 5 years after the last pneumococcal vaccine dose. Resident 8 was educated on PCV 20 and consented for the vaccine on 5/18/24. A written interdisciplinary team (IDT) note on the vaccination consent form, dated 5/19/24, received from the DON on 9/9/24 at 10:00 a.m., indicated the resident was currently ill and he had a past reaction to the vaccine. At this time, Prevnar 20 was not required, and they would reassess in the future. During an interview, on 9/9/24 at 11:51 a.m., the DON indicated she would check with the resident to see if he still wanted the Prevnar 20 vaccination. A current facility policy, titled Infection Control; Influenza and Pneumococcal Vaccinations, last revised on 7/28/21 and provided by the DON on 9/9/24 at 4:15 p.m., indicated Policy: Essential Senior Health and Living must develop policies and procedures to ensure that all residents in the facility receive the Influenza Vaccination between October 1 thru March 31 annually and the Pneumococcal Vaccination at least once or is either medically contraindicated or has previously been immunized. All residents admitted to the facility will have physician's order for influenza and pneumococcal vaccinations from their physicians, if not current and not medically contraindicated. 3.1-13(a)

Based on record review and interview, the facility failed to ensure Schedule II narcotics were not diverted by the Director of Nursing for 5 of 8 residents reviewed for misappropriation of property (Residents B, C, D, E and F). Findings include: Review of a Facility Reported Incident, dated 2/15/23 at 10:52 a.m., indicated the narcotic count was not accurate for Resident B because the DON (Director of Nursing) had taken two cards of hydrocodone that contained 30 tablets on each card. The Administrator-in-Training had entered the DON's office and found one card of hydrocodone tablets, but not the other card. The investigation revealed additional Level 2 narcotics had been unaccounted for. A review of Schedule II narcotics, provided by the Consultant Administrator on 3/2/23, indicated the following: 1. Resident B's hydrocodone 7.5 mg (milligram) with 325 mg acetaminophen had 35 tablets unaccounted for and 26 tablets of hydrocodone 10 mg with 325 mg acetaminophen unaccounted for. 2. Resident C's Percocet 5 mg with 325 mg acetaminophen had 83 tablets unaccounted for and Percocet 7.5 mg with 325 mg acetaminophen had 62 tablets unaccounted for. 3. Resident D's hydrocodone 5 mg with 325 mg acetaminophen had 33 tablets unaccounted for. 4. Resident E's hydrocodone 5 mg with 325 mg acetaminophen had 28 tablets unaccounted for. 5. Resident F's hydrocodone 5 mg with 325 mg acetaminophen had 25 tablets unaccounted for. During an interview, on 3/2/23 at 10:00 a.m., the Administrator indicated the DON had been terminated. The investigation concluded the DON had been removing the medications from the cart on the premise of destroying them, after new medication orders were received. The staff didn't question her actions. During an interview on 3/2/23 at 11:00 a.m., the Infection Prevention Nurse indicated two nurses were required to destroy Schedule II medications. Review of a current facility policy, titled DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, dated January 2007 and provided by the Infection Prevention Nurse on 3/2/23 at 11:02 a.m., indicated .Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations .C. Schedule II medications remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of by two licensed nurses as directed by state laws, regulations, and/or the DEA This Federal tag relates to complaint IN00401812. 3.1-28(a)

Based on record review and interview, the facility failed to accurately code medications on the Minimum Data Set (MDS) assessment for 2 of 16 sampled residents (Residents 11 and 24). Findings include: 1. Resident 11's clinical record was reviewed on 11/3/22 at 9:43 a.m. Diagnoses, included but were not limited to, major depressive disorder. A 10/3/22 quarterly MDS assessment indicated the resident received an antipsychotic medication. A gradual does reduction (GDR) was attempted on 6/28/22. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 11/3/22 at 2:40 p.m., the MDS coordinator indicated the resident did not take antipsychotic medications. She indicated the MDS was coded incorrectly; the resident received an antidepressant medication and not an antipsychotic medication. The GDR date was for the reduction in the antidepressant medication. 2. Resident 24's clinical record was reviewed on 11/2/22 at 12:58 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 10/24/22 quarterly MDS assessment indicated the resident did not receive antipsychotic medications. Current physician's medication orders included, [MEDICATION(S)] (antipsychotic) 100 mg daily ordered on 9/28/22. During an interview, on 11/3/22 at 2:35 p.m., the MDS Coordinator indicated the coding in the MDS was an input error. The resident received an antipsychotic medication during the MDS assessment period. During an interview, on 11/3/22 at 3:32 p.m., the MDS Coordinator indicated the Resident Assessment Instrument (RAI) manual was used as the facility's policy for the MDS assessments. The current RAI manual indicated, .Review the resident's medication administration records to determine if the resident received an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, whichever is more recent. Code 1, yes: if antipsychotics were received on a routine basis only .

Based on record review and interview, the facility failed to ensure an allegation of abuse had been reported timely for 2 of 2 residents reviewed (Resident 15 and Resident 8). Findings include: 1. During an interview, on 11/1/22 at 1:37 p.m., Resident 15 indicated he had come from a family of 10 brothers and he wasn't bothered by the other residents. During an observation, on 11/1/22 at 3:41 p.m., he was sitting in a wheel-chair in the library with a staff member and two other male residents. His clinical record was reviewed on 11/2/22 at 9:55 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 9/29/22 admission MDS (Minimum Data Set) assessment indicated he had moderate cognitive impairment. A current care plan, initiated 9/23/22, indicated he had the potential to demonstrate verbally abusive behaviors related to dementia, poor impulse control, adjustment disorder and trouble adjusting to the facility. The goal, with a target date of 12/21/22, indicated he demonstrated effective coping skills through the review date. Interventions included assessed resident's understanding of a situation and allowed time for him to express himself and his feelings about the situation. A progress note, dated 10/28/22 at 9:00 a.m., indicated Resident 15 was in the library yelling for help, he told a staff member another resident (Resident 8) told him he was going to blow his head off. The resident was removed from the library, assisted to the nurses station and was able to repeat what had been said to him. 2. During an interview, on 10/31/22 at 10:58 a.m., Resident 8 indicated he attended some activities and had been treated well. During an observation, on 11/1/22 at 3:40 p.m., he was sitting in a wheel-chair in his room talking with his wife. Resident 8's clinical record was reviewed on 111/1/22 at 2:33 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 8/8/22 quarterly MDS assessment indicated he had moderate cognitive impairment. A current care plan, initiated 8/4/22, indicated he was seen by psych services for [CONDITION(S)] in Vietnam, certain things triggered him to have homicidal ideation. The goal, with a target date of 1/10/23, indicated he would continue to speak with psych services for the benefit of his mental health through the review. Interventions included, allowed to discuss his feelings, medication per physician recommendation and provided reassurance when he felt down. A progress note, dated 10/28/22 at 9:10 a.m., indicated another resident (Resident 15) had alleged he was going to blow that resident's head off. He had shook his head no, and indicated he may have implied it or said something about a pistol, the other resident bumped into him with his wheel-chair and it made him mad. Resident 8 was reminded that it was not appropriate to have said that and he needed to ask for staff assist with his needs. Residents had been separated and 15 minute safety checks had been started. During an interview, on 11/1/22 at 12:45 p.m., the Administrator indicated she did not report the allegation and didn't feel it needed to be reported. Review of a current facility policy, titled ABUSE, NEGLECT, AND EXPLOITATION, with a revised date of 10/2022 and provided by the Director of Nursing on 11/3/22 at 10:23 a.m., indicated .1. The Abuse Coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures 3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure a resident did not receive an antipsychotic medication without indication, failed to identify targeted behaviors to support the use of antipsychotic medication, and failed to initiate person-centered care plan interventions, for 2 of 3 residents reviewed for dementia care (Residents 16 and 8). Findings include: 1. During an observation, on 11/9/21 at 1:20 p.m., Resident 16 was lying in bed. On 11/10/21 at she was lying in bed. On 11/12/21 at 9:59 a.m., she was lying in bed. Her clinical record was reviewed on 11/9/21 at 1:24 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (Alzheimer's disease therapy) 10 MG (milligram), one tablet one time a day for dementia, order date 1/11/21. b. [MEDICATION(S)] (antidepressant) 50 MG, one tablet one time a day related to anxiety disorder due to known physiological condition, order date 5/25/21. c. [MEDICATION(S)] (antipsychotic) 2.5 MG, give 2.5 MG two times a day related to mood (affective) disorder and dementia with behavioral disturbance, order date 8/5/21. d. Behavior/intervention/side effect progress note every shift for medications [MEDICATION(S)] and [MEDICATION(S)], order date 8/17/21. An 10/11/21 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment. No moods or behaviors had been identified. She had received an antipsychotic and antidepressent everyday during the assessment period. The antipsychotic had been received on a routine basis and a GDR (gradual dose reduction) had not been attempted. A current care plan, initiated on 1/14/21 and revised on 8/24/21, indicated she used [CONDITION(S)] medications related to behavior management and delusional disorder. Interventions included, but were not limited to, observe and record occurrence of for target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others), and document per facility protocol, initiated 1/19/21. A current care plan, initiated 1/18/21 and revised on 2/27/21, indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, provide 1:1 with resident for a short time until she has calmed and provided assurance that she was safe and staff would remain in the building at all times, both revised on 1/27/21. A current care plan, initiated on 1/18/21, indicated the resident had [CONDITION(S)] or an acute confusional episode related to acute disease process Alzheimer's disease and delusional disorder. Interventions included, but were not limited to, staff would use the resident's preferred name, identify themselves at each interaction, face the resident when speaking and make eye contact, reduce distractions - turn off television, radio, close door, provide her with necessary cues - stop and return if agitated, revised on 1/27/21. A Behavior Charting note, dated 9/13/21 at 3:31 p.m., indicated she had refused to allow oxygen saturation to be obtained and wouldn't allow the nurse to administer an intradermal injection to test for [CONDITION(S)]. Prior to the behavior she had been sitting in a chair or lying in bed. Staff attempted to talk her into allowing the nurse and another staff member to obtain vital signs. Intervention was not effective. A Behavior Charting note, dated 9/14/21 at 11:09 a.m., indicated she had refused to allow blood draw, listening to her lung sounds, and treatment to her head. Prior to the behavior she had been sitting in wheelchair after breakfast. Staff attempted talking to her to reassure that it doesn't hurt different people. The intervention was not effective. A Behavior Charting note, dated 9/22/21 at 7:44 p.m., indicated the resident had yelled at staff trying to obtain oxygen saturation and listen to her lung sounds. Staff attempted to redirect one on one. The intervention was not effective. A Behavior Charting note, dated 9/26/21 at 4:41 p.m., indicated resident had hit staff during care. Prior to the behavior she was awake after napping. Staff attempted one on one and redirecting. The behaviors had stopped once she was up. An IDT (Interdisciplinary Team) progress note, dated 9/29/21 at 10:00 a.m., indicated the DON (Director of Nursing), SSD (Social Service Director), Psych NP (Nurse Practitioner), Consultant Pharmacist, and the Administrator had met to discuss the resident's psychoactive medications. Resident was taking [MEDICATION(S)] 50 MG daily, which is due for review in November, and [MEDICATION(S)] 2.5 MG twice a day for behavioral and psychological symptoms of dementia, which is due for review in January. Resident had improved since initiation of [MEDICATION(S)] on 8/6/21. She had allowed blood to be drawn on two occasions, and participated more willingly in activities. Resident was followed by Psych NP. Team made no new recommendations. A Behavior Charting note, dated 10/2/21 at 12:06 a.m., indicated the resident had refused to allow vital signs to be obtained. Prior to the behavior she had been lying in bed. Staff reapproached several times. The intervention was not effective. A Behavior Charting note, dated 10/2/21 at 3:49 p.m., indicated the resident had been resistant to allowing the nurse to obtain her oxygen saturation level, but was able to obtain her temperature and listen to her lungs. Prior to the behavior she had been sitting in her room. A Behavior Assessment, dated 10/24/21, indicated no behaviors. An IDT progress note, dated 10/26/21 at 10:15 a.m., indicated the DON, MDS Coordinator, consultant pharmacist, Psych NP, social service/activity staff, and Administrator met to discuss residents [CONDITION(S)] medications. Resident was taking [MEDICATION(S)] 50 MG, due for GDR in November, and [MEDICATION(S)] 2.5 MG twice a day, due for review in January She had been more pleasant and participatory in activities since [MEDICATION(S)] had started. If she didn't recognize someone because of a mask she would yell I don't know you, but overall more pleasant. Team made no new recommendations. Is followed by Psych NP. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior Charting note, dated 10/27/21 at 12:14 p.m., indicated she had refused to allow vital signs to be obtained. Prior to the behavior she had been lying in bed. Staff attempted to reapproach her. The intervention was not effective. A Behavior Assessment, dated 10/29/21, indicated no behaviors, mood pleasant and cooperative with care. A Behavior Charting note, dated 11/9/21 at 3:06 p.m., indicated she would not allow the nurse to obtain her blood pressure, oxygen saturation, or pulse. Prior to the behavior she had been in her room, sitting in her wheelchair. Staff attempted to ask her how she was feeling and if her arm hurt, and tried to explain why it was important for her vital signs to be obtained. The interventions were not effective. A Behavior Charting note, dated 11/11/21 at 10:56 a.m., indicated the resident had refused shower and washing her face that morning. Staff attempted one on one and redirecting. The interventions were not effective. During an interview, on 11/12/21 at 10:01 a.m., QMA (Qualified Medication Aide) 7 indicated the resident sometimes had behaviors, didn't like to have her blood pressure taken and refused care. The intervention used was to reapproach to see if her mood had changed. She was not aware of a list of targeted behaviors or behaviors that would support the use of [CONDITION(S)] medications that needed to be monitored. They just report any behavior a resident had. During an interview, on 11/12/21 at 10:11 a.m., QMA 12 indicated the resident sometimes refused to allow her blood pressure to be checked and if other residents were around her she would tell them to get away. Intervention of talking to her usually worked. Charge Nurse was notified about any behaviors that had occurred, she was not aware of any specific behaviors related to the use of [CONDITION(S)] medications that needed to be monitored. During an interview, on 11/12/21 at 10:19 a.m., LPN 5 indicated the resident frequently refused showers and having vital signs taken. Intervention that worked was to reapproach. Behaviors are documented under Behavior Charting note in the clinical record. No specific or target behaviors to monitor related to [CONDITION(S)] medication use, they monitor all behaviors. 2. During an observation, on 11/8/21 at 10:37 a.m., Resident 8 was sitting in her room. On 11/10/21 at 10:33 a.m., she was sitting in a recliner. On 11/12/21 at 10:00 a.m., she was lying in bed under the covers. Her clinical record was reviewed on 11/10/21 at 2:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Refer to psych services, order date 6/29/21. b. [MEDICATION(S)] 50 MG tablet, one tablet one time a day related to major depressive disorder, order date 8/24/21. c. [MEDICATION(S)] (antipsychotic) 50 MG tablet, one tablet at bedtime for agitation, order date 10/26/21. d. [MEDICATION(S)] (mood stabilizer) delayed release 125 MG tablet, one tablet two times a day related to violent behavior and restlessness and agitation, order date 10/26/21. e. [MEDICATION(S)] delayed release 250 MG tablet, one tablet two times a day related to violent behavior and restlessness and agitation, order date 10/26/21. f. Behavior/intervention/side effect progress note every shift for medications [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], order date 10/29/21. A 9/13/21 quarterly MDS assessment indicated she had severe cognitive impairment. Moods related to little interest or pleasure in doing things and trouble falling asleep or staying asleep, or sleeping too [NAME] had occurred nearly everyday. No behaviors had been exhibited. She had received an antipsychotic and antidepressent everyday during the assessment period. The antipsychotic had been received on a routine basis and a GDR had not been attempted. A current care plan, initiated on 1/19/21 and revised on 2/23/21, indicated she used [CONDITION(S)] medications related to behavior management, potential for injury to self or others, and dementia with behavioral disturbance. Interventions included, but were not limited to, observe and record occurrence of for target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others),and document per facility protocol, initiated 1/19/21. A current care plan, initiated on 1/19/21 and revised on 11/8/21, indicated she was resistive to care related to mood disorder, may refuse showers or incontinence care, and would allow care when she decided she wanted it. The goal, with a 12/30/21 target date, indicated she would cooperate with care through next review date. Interventions initiated on 1/19/21 included, but were not limited to, clear explanation of all care activities to have been given as they occurred during each contact, if she resisted ADL's (activities of daily living), reassure her, leave and return 5-10 minutes later and try again, provide consistency in care to promote comfort with ADL's, maintain consistency in timing of ADL's, caregivers and routine, as much as possible. A current care plan, initiated on 2/23/21 and revised on 8/24/21, indicated she used [CONDITION(S)] medications related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was GDR on 8/24/21, [MEDICATION(S)] GDR contraindicated on 9/22/20, and [MEDICATION(S)] started on 7/15/21 and increased on 8/24/21. Interventions, initiated on 2/23/21, included, administer medications as ordered, observe and document for side effects and effectiveness, consult with pharmacy and medical doctor to consider dosage reduction when clinically appropriate, and observe, record, and report to medical doctor as needed, side effects and adverse reactions of psychoactive medications. An IDT (Interdisciplinary Team) progress note, dated 9/30/21 at 10:00 a.m., indicated the DON, SSD, Psych NP, Consultant Pharmacist, and the Administrator had met to discuss the residents psychoactive medications. She was taking [MEDICATION(S)] 250 MG twice a day., [MEDICATION(S)] 25 MG at bedtime, due for review in February, and [MEDICATION(S)] 50 MG daily, due for review in January for depression. Resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Team discussed resident's behaviors at length included biting and hitting. Psych NP recommended increasing resident's [MEDICATION(S)] to 375 MG twice a day. New order by NP for [MEDICATION(S)] increase. A Behavior Charting note, dated 10/3/21 at 12:07 a.m., indicated she had behavior of combative with care, prior to the behavior she had been lying in bed, staff attempted to reapproach and talking resident through what staff wanted to do and why. The interventions were not effective. A Behavior Charting note, dated 10/3/21 at 9:18 p.m., indicated behavior that she attempted to bite and scratch with bedtime care, staff attempted to redirect the resident one on one. The intervention was not effective. A Behavior Charting note, dated 10/4/21 at 9:30 p.m., indicated behavior that she yelled and cursed during a shower, scratched and attempted to bite staff. Prior to the behavior in the shower, she had been sitting in her room. Staff attempted to calmly talk with the resident. The intervention was not effective. A Behavior Charting note, dated 10/5/21 at 5:26 a.m., indicated behavior that she hit and cursed during care. Prior to the behavior she had been resting quietly in bed. Staff tried to talk with her during care to distract her and turned music on. The interventions were not effective. A Behavior Charting note, dated 10/5/21 at 9:51 p.m., indicated behavior that she was uncooperative with bedtime care and hit at CNA (Certified Nursing Assistant). Staff attempted to redirect her one on one. The intervention was not effective. A Behavior Charting note, dated 10/7/21 at 3:44 p.m., indicated behavior that she had been hitting, biting, scratching and cursing during her shower. Staff attempted to talk to her and reassure they would be done soon. The intervention was not effective. A Behavior Charting note, dated 10/8/21 at 9:28 p.m., indicated behavior that she had been hitting, cursing and scratched staff during bedtime care. Prior to the behavior she had been resting quietly in bed. Staff attempted to turn music on, tried different staff members, tried to talk and distract her during care. The interventions were not effective. A Behavior Charting note, dated 10/9/21 at 10:48 a.m., indicated behavior that she had been aggressive with staff during ADL care. Staff attempted one on one and redirecting, the interventions were not effective. A Behavior Charting note, dated 10/9/21 at 8:06 p.m., indicated behavior of swinging her arms and attempted to hit staff during bedtime care. Prior to the behavior she had been resting quietly in in her recliner watching television. Staff attempted talking with her to distract her and turned Christian music on. The interventions were not effective. A Behavior Charting note, dated 10/15/21 at 8:26 p.m., indicated behavior of hitting, scratching, pinching, and trying to bite during bedtime care. Staff attempted to redirect her with one on one. The intervention was not effective. A Behavior Charting note, dated 10/17/21 at 9:40 p.m., indicated behavior of digging her fingernails into a CNA's arms during bedtime care. Prior to the behavior she had been listening to [NAME] Jackson sing. Staff attempted to redirect her with one on one and signing along with her. The interventions were not effective. A Behavior Charting note, dated 10/18/21 at 6:48 p.m., indicated behaviors during a shower included screaming and digging fingernails into CNA's arm. Staff attempted redirection and one on one. The interventions were not effective. A Behavior Charting note, dated 10/21/21 at 9:23 p.m., indicated behaviors during a shower included scratching and trying to bite and hit CNA's. Staff attempted to redirection and one on one. The interventions were not effective. A Behavior Charting note, dated 10/22/21 at 9:42 p.m., indicated behavior during care of hitting and trying to bite staff. Prior to the behavior she had been resting quietly in her chair. The staff attempted to talk with her to distract her and turned Christian music on. The interventions were not effective. A Behavior Charting note, dated 10/23/21 at 9:50 p.m., indicated she had been combative during care. Prior to the behavior she had been sitting in her recliner listening to music. Staff attempted to talk with her and distract her, music was already playing, different staff tried to reapproach the resident. The interventions were not effective. A Behavior Charting note, dated 10/24/21 at 9:28 p.m., indicated the resident had been resting in bed, during bed check she required incontinence care, was scratching, biting, cursing, kicking, and yelling during care. Staff attempted to talk with her and distract her, she was given her baby doll to hold, and Christian music was turned on. The interventions were not effective. A Behavior Charting note, dated 10/25/21 at 11:07 p.m., indicated behavior of refusing shower and kicking and cursing staff during bedtime care. Prior to the behavior she had been resting in her room. Staff attempted different staff members to approach her about taking a shower and she continued to refuse. A nurse progress note, dated 10/28/21 at 2:14 p.m., indicated the resident had been seen by the NP on 10/26/21. A new order had been received to increase [MEDICATION(S)] to 50 MG due to increased agitation and aggression. A Behavior Charting note, dated 10/31/21 at 11:10 p.m., indicated behavior of hitting and scratching staff during bedtime care. Staff attempted to redirect resident one on one. The intervention was not effective. A Behavior Charting note, dated 11/4/21 at 7:43 p.m., indicated behavior of hitting and scratching staff during a shower. Staff attempted to resident and one on one. The interventions were not effective. During an interview, on 11/12/21 at 10:01 a.m., QMA 7 indicated the resident has behaviors some days of hitting and screaming if she didn't want incontinent care provided, interventions to coax her with coffee, she also liked bananas and talking about her dog. The nurse asked CNA's and QMA's if the resident had any behaviors and put information in the computer. She was not aware of a list of targeted behaviors or behaviors that would support the use of [CONDITION(S)] medications that needed to be monitored. They just report any behavior a resident had. During an interview, on 11/12/21 at 10:11 a.m., QMA 12 indicated the resident would once in a while scratch or curse staff, they leave her alone and try again, that usually works, she likes to listen to [NAME] Jackson and they turn that on for her. Charge Nurse was notified about any behaviors that had occurred, she was not aware of any specific behaviors related to the use of [CONDITION(S)] medications that needed to be monitored. During an interview, on 11/12/21 at 10:19 a.m., LPN 5 indicated the resident had behaviors of smacking, digging her fingernails in staff's arms, and name calling. Interventions included trying to redirect her or one on one, if those weren't effective, then approach later. Behaviors are documented under Behavior Charting note in the clinical record. No specific or target behaviors to monitor related to [CONDITION(S)] medication use, they monitor all behaviors. During an interview, on 11/12/21 at 2:03 p.m., the Administrator indicated behaviors were reviewed in monthly behavior meeting, IDT progress notes, and sometimes in other progress notes. Staff were trained to leave then reapproach or try another caregiver if behaviors occurred. The facility did not have a policy related to behaviors or dementia care. During an interview, on 11/12/21 at 2:04 p.m., the DON indicated the medication order included the behavior being monitored. Review of a current facility policy, titled COMPREHENSIVE CARE PLANS, with a revised date of 10/2017 and provided by the Administrator on 11/12/21 at 3:51 p.m., indicated Policy: The Facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights and that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment .1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being 3.1-37(a)

Based on observation, interview and record review, the facility failed to prevent development of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers (Resident 10). Findings include: During an interview with Resident 10, on 11/8/21 at 1:41 p.m., she indicated she had just lost the scab on her right heel last week and it was tender and still hurt. They rubbed something on it but she didn't know what it was. She had a walking boot and doctor thought the pressure area was from the walking boot and that her foot may not had gotten back far enough in the boot. On 11/9/21 at 1:23 p.m., she sat across from the nurses station in her wheelchair, she had a pressure reducing boot on her right foot and a shoe on her left foot. During an observation of the resident's right heel, with the Wound Nurse, on 11/10/21 at 11:10 a.m., the area was the approximately size of a nickel it was partially yellow with the bottom of the wound darker in color (brown/gray). Inside the wound at the top was pink/red tissue (granulation tissue approximately the size of a pencil eraser. The Wound Nurse indicated, last week on 11/4/21, the scab or cap had come off of her heel and there was granulation tissue in the area. She also indicated the area was yellow and hard/calloused, and inside the wound at the top was granulation tissue. The pressure ulcer measured 2 centimeters (cm) x 2 cm. The granulation tissue measured 0.4 cm x 0.7 cm. She considered it to still be a Deep Tissue Injury (DTI). The Nurse Consultant then observed the area and indicated it was unstageable, the treatment needed to be changed and to switch to heel protector boots. Resident 10's clinical record was reviewed on 11/9/21 at 1:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her orders included, but were not limited to, skin prep to bilateral heels every shift with the start date of 9/15/21, range of motion (ROM) to right ankle every shift start 8/5/21, weekly skin assessment revised on 2/5/21. Heel protector to bilateral heels when in chair with the start date of 8/7/21. She had discontinued order that was started on 6/25/21 and discontinued on 7/7/21 that indicated standard of care (SOC) charting every shift for right ankle fracture. Check splint condition, neurovascular status of right lower extremity and pain control, etc. She had a discontinued order that was started on 7/2/21 and discontinued on 7/16/21 that indicated Controlled Ankle Motion (CAM) boot to right lower leg. May remove for ADL's and sleep if no pain. She had a discontinued order that was started on 7/7/21 and discontinued on 8/19/21, SOC charting every shift for right ankle fracture. Check boot condition, remove boot and inspect skin (unless resident has pain, then need to notify MD) neurovascular status of right lower extremity and pain control, etc. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was cognitively intact. She required limited assistance of one staff member for bed mobility, transfers, walking in her room and corridor. She required extensive assistance with one staff member for locomotion on and off the unit, dressing, toilet use and personal hygiene. She used a walker and a wheelchair. She was at risk for developing pressure ulcers. Her care plans included, but were not limited to the following: She had an actual fall with major injury, on 6/24/21, due to poor balance, unsteady gait while ambulating unassisted, initiated on 7/6/21. Her interventions included, but were not limited to, CAM boot to right lower extremity, remove for Activity for Daily Living (ADL's) and for sleep if no pain. [NAME] muscular assessment for left lower extremity every shift. Toe down weight bearing no more than 25%. She had a potential for pressure ulcer development related to DTI on her left heel from wearing her CAM boot following fracture. She was hesitant to get out of bed after her fracture so she stayed in bed most of the time which made her a high risk for pressure injuries, initiated on 7/12/21. Her goal was she would have intact skin, free of redness, blisters or discoloration by/through review date. Her interventions included, but were not limited to, assess/record/observe wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Her nurses notes included, but were not limited to, and indicated the following: On 6/24/21 at 4:05 a.m., she was sitting on her bottom with head against bathroom door and her feet facing toilet, she indicated her knee gave out. Her outer right ankle started to swell and she had a knot on back of her head. On 6/25/21 at 12:45 a.m., she returned from a local emergency room . She had a closed bimalleolar fracture of right ankle and she had a leg splint to her right leg. Her right leg was elevated on a pillow. A risk for pressure ulcer assessment, dated 6/30/21 at 11:12 p.m., indicated she was at moderate risk for developing a pressure ulcer. The comment section indicated her skin was warm and dry and intact. Skin turgor was poor. Lotion and creams were applied by staff. On 7/1/21 at 2:29 p.m., she returned from orthopedic appointment. She had a new order to wear CAM boot, remove boot for ADL's and to sleep if she is having no pain. On 7/2/21 at 1:07 a.m., her pedal pulse was present, resident was able to wiggle toes. She rested comfortably in bed with boot on. On 7/2/21 at 2:53 p.m., CAM boot was on, she had good sensation to her foot and minimal swelling. She denied tingling or numbness. On 7/2/21 at 5:46 p.m., CAM boot was being worn. She could wiggle her toes and temperature was normal. On 7/3/21 at 1:16 a.m., her pedal pulse was present, she was able to wiggle toes. She rested comfortably in bed with boot on. On 7/3/21 at 10:26 a.m., CAM boot intact. Her foot was elevated on pillow. She was able to wiggle toes, extremity was warm to touch with positive pedal pulses. She denied any numbness or tingling. On 7/3/21 at 4:25 p.m., CAM boot intact. Her foot was elevated on pillow. She was able to wiggle toes, extremity was warm to touch with positive pedal pulses. She denied any numbness or tingling. On 7/4/21 at 2:36 a.m., the boot was in place to her right ankle and elevated on a pillow at that time. Pedal pulse were present. She was able to wiggle toes. She had minimal discomfort was noted and repositioning was effective. On 7/4/2021 at 10:24 a.m., CAM boot intact. Her foot was elevated on pillow. She was able to wiggle toes, extremity was warm to touch with positive pedal pulses. She denied any numbness or tingling. On 7/4/21 at 6:45 p.m., skin to right foot/leg was warm and dry. No skin irritation related to splint. She was able to move toes at will. Pedal pulse were palpable. Right lower extremity was elevated. On 7/5/21 at 12:18 a.m., skin to right foot/leg was warm and dry. CAM boot was in place, no related skin irritation noted. She was able to move toes at will. Pedal pulse palpable. Right lower extremity was elevated. On 7/5/21 at 3:44 p.m., CAM boot had been on all day, except while she received her shower. She had a hard time transferring and not putting weight on her right foot. It was explained to her that she could put weight on the toe of her boot to support during transfers. Her toes moved easily and were warm to touch. No complaints of numbness or tingling. She took pain medication to control pain. On 7/5/21 at 6:23 p.m., CAM boot was on right foot on a pillow. She was able to wiggle toes and normal temperature. On 7/6/21 at 1:41 a.m., she complained of right foot aching. CAM boot on but loosened, which seemed to help. Pedal pulses were present and resident could move toes. On 7/6/21 at 3:43 p.m., CAM Boot was on, resident had [MEDICATION(S)] patch for pain control. She stayed in bed and didn't want to move much except to be changed. She slept a lot. She was able to move toes, they were warm to touch with no complaints of numbness or tingling. On 7/6/21 at 9:20 p.m., CAM boot worn. She was able to wiggle her toes. She had normal skin temperature. On 7/7/21 at 12:52 a.m., She complained of her right foot aching. CAM boot on but loosened, which seemed to help. Pedal pulses were present and resident could move toes. On 7/7/21 at 1:41 p.m., CAM boot intact, her foot was elevated on a pillow. She was able to wiggle her toes, extremity was warm to touch with positive pedal pulses. She denied any numbness or tingling. skin surfaces were intact. On 7/7/21 at 6:16 p.m., CAM boot intact, her foot was elevated on a pillow, she was able to wiggle toes, extremity was warm to touch with positive pedal pulses. She denied any numbness or tingling. Skin surfaces are intact. Lotion was applied to dry areas. Bruising to right lateral foot and ankle. On 7/8/21 at 12:56 a.m., she complained of her right foot aching like a tooth ache. CAM boot on, her pedal pulses were present and she could move her toes. A risk for pressure ulcer assessment, dated 7/8/21 at 12:42 a.m., indicated she was at mild risk for developing pressure ulcers. Comments section indicated her skin was warm and dry to touch with no tenting. On 7/8/21 at 11:19 a.m., CAM boot intact, her foot was elevated on a pillow, she was able to wiggle toes, extremity was warm to touch with positive pedal pulses. She denied any numbness or tingling. Skin surfaces were intact. Skin care was given with skin surfaces intact. Lotion applied to dry areas. Bruising to right lateral foot and ankle remained. On 7/8/21 at 11:19 a.m., bruising to medial foot and ankle as well. Noted 2 cm x 2.5 cm DTI post heel. New order received for skin prep every shift. The back of CAM boot padded. 7/8/21 at 6:14 p.m., CAM boot intact. She complained frequently for boot to be loosened and readjusted. No [CONDITION(S)] noted and pedal pulse were present. Skin prep applied to heel. During an interview with the Wound Nurse, on 11/12/21 at 10:35 a.m. she indicated they ordered new boots for her. They would document on the nurses notes for monitoring her skin each shift. During an interview with the Wound Nurse, on 11/12/21 at 1:30 p.m., she indicated the resident did not have an injury per the Preventative Skin Care Measures with Braden Scale, dated 6/30/21 and the orthopedic office visit on 7/1/21, indicated no injury. She returned with the CAM boot 7/1/21. On 7/8/21 there was no injury on the skin assessment in the morning and in the evening with removal, the pressure ulcer was there on 7/8/21. They removed the boot each shift with care. The order that indicated CAM boot to right lower leg may remove for ADLs and sleep if no pain. Touch Down Weight Bearing (TDWB) which meant no more than 25% just to maintain balance every shift for fractured right ankle was what they used to check her heel, took off the boot and did a skin assessment. The CNA would take it off and clean her foot and she would do the assessment. She completed the treatment daily but measured the pressure ulcer on Wednesdays. A 7/26/21 revised policy titled, Wound Program Policy and Procedures, provided by the Administrator, on 11/12/21 at 3:51 p.m. indicated the following: Policy: Wound Care Program: It is the practice of Essential Senior Health and Living to provide a comprehensive approach to preservation and protection of each resident's skin integrity while under out care .Identification of Risk for Pressure Injury: The Braden Scale will be used as one tool to assist in identification of each resident's risk for pressure injury . With the purpose being to identify causative/contributing factors to develop pressure injuries . Because anyone over the age of [AGE] years should be considered at some degree of risk, it is important to note that anyone [AGE] years or older should be upgraded to next level of overall risk, per Braden Scale guidelines 3.1-40(1)

Based on record review and interview, the facility failed to ensure infection prevention and control strategies were followed during a global pandemic of COVID-19 when an employee was allowed to work without completing a health screening prior to the start of their shift, for 1 of 3 Healthcare Personnel (HCP) reviewed for health screenings (Cook 5). Findings include: During entrance conference, on 10/13/20 at 11:05 a.m., the DON indicated a dietary staff member tested positive for COVID-19 on 10/12/20. She had last worked on October 8, 2020 and complained of not feeling well after her shift had ended. A review of the dietary staffing schedule, provided by the MDS Coordinator on 10/13/20 at 12:20 p.m., indicated Cook 5 had worked on October 3, 4, 5, 6, 7, and 8, 2020. Review of Visitor/Employee/Vendor Screening indicated Cook 5 had not been screened for symptoms related to COVID-19 on October 3, 4, 5, 6, or 7. On October 13, 2020 at 2:54 p.m., the MDS Coordinator was not able to find that screenings had been done. During an interview, on October 13, 2020 at 2:56 p.m., the DON indicated she spot checked the health screening forms daily, but did not check that each employee scheduled to work had been screened. A Facility form, titled TRAINING FOR THE SCREENERS FOR COVID-19, provided by the DON on October 13, 2020 at 4:15 p.m., indicated 1. ALL PEOPLE WHO WALK IN THE DOOR MUST BE SCREENED Guidance from the CDC titled, Preparing for COVID-19 in Nursing Homes, updated June 25, 2020, indicated .Core Practices .Evaluate and Manage Healthcare Personnel .Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure cold drinks were served in a sanitary manner to 18 of 22 residents that received cold drinks in the dining room. During a dining observation, beginning on 4/10/19 at 11:55 a.m., Cook 7 was picking up glasses by the rim to serve cold drinks to 18 residents in the dining room. She passed all cold drinks in this manner, except for the four residents that required the use of the two-handled, lidded cups. A follow up dining observation, beginning on 4/11/19 at 11:54 a.m., Cook 7 served cold drinks to several residents in the dining room. She was observed to have picked up and served 13 of 31 glasses by the rim. During an interview, on 4/11/19 at 2:30 p.m., the Dietary Manager indicated the employees were taught to not touch the rims of the glasses, they were instructed to avoid touching the area that a resident's mouth would touch when drinking. Review of a current, 1/2017, facility policy titled Dining Service Policy, provided by the Dietary Manager, on 4/12/19 at 2:51 p.m., indicated glass and cups are to be handled by the bottom or the sides of the glass. 3.1-21(i) (3)