Every finding on record at Woodlands the

Based on record review and interview, the facility failed to implement their facility abuse policy when a staff member failed to report a suspicion of abuse of a cognitively impaired resident, which delayed the initiation of the facility investigation and reporting to the appropriate agencies, for 1 of 3 residents reviewed for abuse. (Resident B, RN 3 and QMA 1) Findings include: Resident B's clinical record was reviewed on 5/6/25 at 10:00 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease-stage 4, type 2 diabetes, obstructive and reflux uropathy, and depression. The most recent significant change Minimum Data Set (MDS) assessment, dated 4/9/25, indicated the resident was severely cognitively impaired. During an interview on, 5/7/25 at 1:08 p.m., LPN 2 indicated, on 4/8/25, she was having difficulty administering medications to Resident B. The resident was combative and repeatedly refused medication. RN 3 arrived and was appraised of the situation. RN 3 indicated the resident had to take the mediation due to terminal restlessness. LPN 2 told her she refused to make the resident take the medication and handed her the keys to the medication cart. RN 3 and QMA 1 took the medication cart keys. QMA 1 prepared the medication and entered the resident's room with RN 3 and shut the door. LPN 2 did not see staff interaction with the resident, but heard the resident yelling that she did not want the medication. QMA 1 came out of the resident's room and indicated they were able to get what they could inside her and the resident had been fighting and spitting out the medication. LPN 2 indicated the incident occurred approximately one month ago and she had not reported it to anyone. The Regional [NAME] President, Regional Clinical Director, and DON were present during the interview and indicated they had not been made aware of this incident. During an interview on 5/7/25 at 1:13 p.m., the Regional [NAME] President indicated anyone with a suspicion of abuse or mistreatment should report it to the Executive Director immediately. A current policy, dated 6/27/24, titled Abuse-Reporting and Response- Suspicion of a Crime was provided by Regional Clinical Director on 5/7/25 at 10:44 a.m. The policy indicated the following: Reporting Procedures 1. Once an associate or other covered individual at the facility (e.g., medical director) forms a reasonable suspicion that a crime has been committed against a resident or other individual receiving services at the facility, he or she must immediately notify the Executive Director of their suspicion. This citation relates to complaint IN00457345. 3.1-28(c)

Based on observation, record review, and interview, the facility failed to allow residents to continue to gather around the nurses' station, as was their preference and common practice, for 4 of 4 residents reviewed for resident preferences. (Residents C, D, E, & F) Findings include: During an interview on 4/1/24 at 11:33 a.m., the Memory Care Activities Director indicated the Divisional Director of Clinical Services (DDCS) had insisted on moving furniture around and taking furniture away in the common areas of the secured unit. Specifically, a table that was in the dining room that was used during activities and meals by staff was removed. The residents enjoyed gathering around the nurses' station to talk with staff and each other. The DDCS indicated to staff they were to return the residents to their rooms following an activity or meals. On occasion, the residents had to be re-directed when they attempted to move a chair from the dining room or down the hall to the nurses' station area. The DDCS also removed tables and chairs from the activities room and the TV lounge. The TV lounge now had no seating and the activities area had only two chairs for residents to sit at a counter, facing the wall to do a puzzle or any other activity. The Memory Care Activities Director felt these changes had caused stress on the unit for the residents and staff and to provide a comfortable environment that they have been accustomed to in the past. There was a lot of confusion. During an interview on 4/1/25 at 11:53 a.m., CNA 3 indicated she felt the residents thought of the area around the nurses' station as a sort of living room area. They would gather there and talk, or rest when walking from the dining room to their rooms down the hallway. She felt the removal of the seating around the nurse's station had caused the residents stress and confusion, as they had nowhere to sit per their usual, and were confused as to what they should be doing and where to go. During an interview on 4/1/25 at 1:47 p.m., CNA 4 indicated the staff had been instructed to move residents to their rooms from the dining room and discourage them from gathering at the nurses's station. The TV lounge was observed with CNA 4 during the interview. There were two chairs placed against the wall facing the TV. A resident was observed seated in one of the chairs watching TV. CNA 4 indicated the staff were aware that the chairs would need to be removed when the DDCS visited again to avoid her becoming upset. The CNA indicated she felt the falls had increased and the changes have contributed to this. 1. Resident C's clinical record was reviewed on 4/1/25 at 3:01 p.m. Diagnoses included schizophrenia, difficulty walking, convulsions, history of falling, and dementia. A current care plan, revised on 8/13/25, indicated the resident had impaired cognitive ability/impaired thought processes related to the diagnoses of dementia. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. An Event Note, dated 3/7/25 at 5:17 a.m., indicated the resident had a fall in her room. She indicated to staff she was getting up to go to the bathroom. The resident's call light was in reach but had not been activated. 2. Resident D's clinical record was reviewed on 4/1/25 at 3:08 p.m. Diagnoses included dementia, protein-calorie malnutrition, gastro-esophageal reflux disease (GERD), convulsions, and history of falls. A current care plan, revised on 5/2/23, indicated the resident had GERD. Interventions included, to avoid lying down for at least one hour after eating. Encourage resident to stand/sit upright after meals An Event Note, dated 3/8/25 at 7:00 a.m., indicated the resident had a fall in her room. She was observed in her room, sitting on her bottom with her back against the foot of the bed with her legs extended out. Resident was complaining about her head and the nurse observed a laceration and hematoma to the back of the resident's head. 3. Resident E's clinical record was reviewed on 4/1/25 at 3:11 p.m. Diagnoses included dementia, moderate protein-calorie malnutrition, muscle weakness, heart failure, and dysphagia. A current care plan, revised 1-8/15/24, indicated the resident had specific preferences. Interventions included, that most of the time, the resident chooses not to participate in group activities and prefers to eat her meals in her room. to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. An Event Note, dated 3/8/25 at 2:55 p.m., indicated the resident had a fall in her room and was observed sitting on her bottom on the floor with her back against the bathroom door. Her walker was tipped over in front of her. 4. Resident F's clinical record was reviewed on 4/1/25 at 3:19 p.m. Diagnoses included Alzheimer's disease, muscle weakness, dysphagia, major depressive disorder, and history of falls. The resident admitted to the facility 5/15/24. A current care plan, created 5/17/24, indicated the resident was independent/dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included, to introduce the resident to residents with similar background, interests and encourage/facilitate interaction. An Event Note, dated 3/8/25 at 11:45 p.m., indicated the resident had a fall in her room. She was found lying on the floor approximately five feet from her bed, lying on her back, arms bent at elbows with hands resting on upper abdomen. Her legs were bent at the knees with the soles of her shoes on the floor. Resident's walker was observed between resident's feet and the bathroom door. A review of the falls on the memory care unit for a Friday, Saturday or Sunday in January, February and March were as follows: In January 2025 there were two falls; in February 2025, there were seven falls on the weekends; and in March there were a total of eight weekend falls on or following 3/7/25, following the changes on the memory care unit. Anonymous interviews were completed during the survey. During an anonymous interview on 4/1/25 at 1:56 p.m., it was indicated the removal of the chairs around the nurses' station caused a lot of confusion for the residents. The DDCS had directed the staff to take the residents from the dining room following an activity or meal to their rooms to watch TV or into the TV lounge which now had no seating. During a telephone interview on 4/1/25 at 2:36 p.m., the facility's previous DON who resigned recently due to the stress caused by the DDCS, indicated falls had increased on the memory care unit following the rapid changes. She knew of four falls that occurred the weekend following the removal of the seating around the nurses' station and the seating in the activities and TV lounges. The staff had verbalized concerns regarding the changes and the effect they would have on the residents. The DDCS ignored the staff concerns. The residents who fell over that weekend, were know to sit at the nurses' station when leaving the dining room before continuing to their rooms. She felt the residents routine and continuity had been affected by the multiple rapid changes. The residents were confused and upset. During an interview on 4/1/25 at 3:12 p.m., an anonymous resident representative indicated they visited routinely. They felt changes like the ones that had been made were difficult for memory care residents to manage. The residents loved sitting together around the nurses' station, and they were very surprised and dismayed that the facility removed the chairs. They asked the staff why the chairs had been removed and they responded that corporate said they could not have them there anymore. There's a little room that they normally used to visit their relative, and it was nice because they didn't have to squeeze into the resident's room and disturb their roommate. The TV room had seating and was mostly private for their visit. They came in for a visit, and suddenly all the furniture and seating was gone. They could not have visits in that room any longer unless they all stood, including their relative. They felt it was very inconvenient and uncaring to do this without any notice or explanation. During an interview on 4/1/25 at 3: 24 p.m., the Regional Director of Clinical Services (RDCS) indicated his goal had been to improve the memory care unit and get residents more involved with activities such as using the life stations (i.e.,baby station, work bench, games, puzzles, etc.) His thought was by removing the chairs around the nurses' station, and the table and chairs out of the TV room, it might encourage the residents to use the physical objects. He now felt that removing the table and chairs from the TV room was premature when considering the residents would need a place to sit to watch the television. He and the Divisional Director of Clinical Services (DDCS) were using this facility as a pilot for memory care units in the state and were trying new things to engage the residents. They planned to ask the staff at some point for suggestions, but wanted to try some things first. He had not followed up with the memory care staff since making the changes, to see if the changes had been positive or negative, or if the changes had been effective at engaging the residents at the life stations. During a telephone interview on 4/1/25 at 3:53 p.m., the DDCS indicated her goal was to improve the quality of the day-to-day activities for the residents. She felt these changes would enhance the memory care unit. She felt having chairs at the nurses' station was not something she wanted to see. The residents could fall when trying to sit down. She would expect the staff to toilet the residents and encourage a nap following group activities and meals. The tables were removed from the activities room due to them being circular, and people with dementia do not do well with circular tables. The table in the activity room was square, but taller than she felt was safe, and the corners could cause injury. She also felt it was a fall hazard. Her plan was to replace the tables and chairs in time. The plan was to starting with this facility and make unit a premier memory care unit. She had not reached out to the staff, the Administrator, nor the DON to obtain feedback on the current changes that had been made. She would have liked the staff to embrace these changes better. She felt she had included the staff and asked for suggestions, but none of the staff provided any feedback. A current facility policy, reviewed 11/19/24, titled, Resident Rights, provided by the Administrator on 4/1/25 at 4:32 p.m., included the following: .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section .Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. This citation relates to complaint IN00456358. 3.1-3(u)(3)

Based on record review and interview, the facility failed to prevent a resident's involuntary seclusion by placing her in an activity room, alone and without explanation as to the reason for the deviation from her normal preferred activity and routine, for 1 of 1 residents reviewed for involuntary seclusion. (Resident B) Finding include: During an interview on 4/1/25 at 11:23 a.m., the Administrator indicated the Divisional Director of Clinical Services (DDCS) had been visiting the facility about once a month. She had been in the building Tuesday through Friday during the recent Annual Survey, which completed on 3/7/25. The facility's memory care unit was currently being focused on as a pilot unit for the corporation, so her main focus during her visits had been on the memory care unit. During an interview on 4/1/25 at 11:53 a.m., CNA 3 indicated Resident B enjoyed sitting outside the nurse's station. Resident B felt she was the Executive Director of the unit and liked to make sure things were running smoothly. During a recent visit, the DDCS moved the resident from the nurse's station area and directed her into the activities room. She had the resident sit at the counter in the room and then turned and walked away, leaving the resident alone. CNA 3 indicated she went into the activities room as Resident B appeared confused. Resident B indicated to her, What did I do wrong? Why have they put me in here by myself? Am I in trouble? CNA 3 indicated it had been upsetting seeing the resident's distress and wondered why the DDCS moved Resident B to sit in a room by herself, when her normal routine was to supervise the nurse's station. During an interview on 4/1/25 at 1:47 p.m., CNA 4 indicated she overheard Resident B talking with CNA 3. The resident sounded sad and confused as to why she had to sit in that room and could not understand what she had done wrong. CNA 3 removed the resident from the activities room and assisted her to the dining room with other residents. During an telephone interview on 4/1/25 at 3:53 p.m., the DDCS indicated having chairs around the nurses station was not something she personally wanted to see. The residents could fall when trying to sit down. She would have liked the staff to better embrace the changes being made. Resident B's clinical record was reviewed on 4/1/25 at 10:21 a.m. Diagnoses included Alzheimer's disease, severe protein-calorie malnutrition, and history of stroke. She admitted to the facility on [DATE]. A significant change minimum data set (MDS) assessment, dated 3/19/25, indicated the resident had moderate cognitive impairment, used a walker for mobility, self transferred, and had no behaviors or rejection of care during the assessment period. A current care plan, revised on 9/16/24, indicated the resident had impaired cognitive ability and impaired thought processes related to the diagnoses of dementia. Interventions included to keep the resident's routine consistent. A current facility policy, reviewed 11/19/24, titled, Area of Focus: Abuse & Neglect, provided by the Administrator on 4/1/25 at 4:32 p.m., included: What Each resident has the right to be free from abuse, neglect, .This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This citation relates to complaint IN00456358. 3.1-27(a)(4)

Based on observation, interview and record review, the facility failed to ensure food was prepared and served using safe sanitary food preparation and handling methods. This deficient practice has the potential to impact 69 of 69 residents who received their meals from the kitchen. Findings include: During the lunch meal preparation and service on 3/6/25 from 11:48 a.m. to 12:10 p.m., the following concerns were observed: At 11:51 a.m.,Cook 6 touched the refrigerator door with her gloved hands. Using the same contaminated gloves, she removed two hot dogs from a plastic bag and placed them on plates to put them in the microwave. At 11:52 a.m., she used her same gloved hands to pull up her pants. She then removed her hotdogs from the microwave. At 11:53 a.m., she washed her hands and put on new clean gloves. She then went to the food service area where she began to serve food. Wearing the same gloves, she touched meal tickets, counter tops, trays, lids, end utensil handles. At 12:00 p.m., [NAME] 6 left the meal service area wearing her soiled gloves. She went into the dry storage area where she obtained a bag of hot dog buns. She opened the hot dog buns touching the exterior of the bag with her same soiled gloves. She then touched a hot dog and buns with the same soiled gloves she had been completing her other work. At 12:02 p.m., she touched a second hot dog and bun placing them on a plate, using her soiled gloves. She then touched tarter sauce packets with the same gloved hands. At 12:03 p.m., she moved a hot dog on the plate using her same gloved hands. At 12:05 p.m., she then touched a hamburger bun with her soiled gloved hands. At 12:08 p.m., she carried a hamburger bun on the flat palm of her soiled gloved hands over to the grill where a hamburger was being prepared. During an interview on 3/06/25 at 12:08 p.m., [NAME] 6 indicated she was not supposed to handle or serve food with her gloved hands. A current 9/8/22, facility policy titled Safe Food Handling, provided by the Dietary Manager on 3/6/25 at 3:15 p.m., indicated the following: .Cross-contamination-means to transfer of harmful substances or disease-causing organisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned All food is handled carefully to avoid contamination with potentially harmful debris . 3.1-21(i)(1)

Based on observation, interview, and record review, the facility failed to ensure residents who received psychoactive medications had gradual dose reductions or statements of clinical contraindication and/or had identified and documented targeted behavioral systems for the use of psychotropic medications for 2 of 5 residents reviewed for unnecessary mediation (Residents 19 and 54) and 2 of 2 residents reviewed for side effect monitoring of psychoactive medications and/or opioids (Residents 32 and 48). Findings include: 1. Resident 19's clinical record was reviewed on 3/4/25 at 1:51 p.m. Current diagnoses included dementia, anxiety, and delusional disorder. Current medication orders included olanzapine 5 mg (antipsychotic medication) give 1 tablet daily at bedtime (11/20/24), alprazolam 0.25 mg (antianxiety medication) give 1 tablet preceding showers on every Wednesday and Saturday (12/12/24), and sertraline HCl 25 mg (antidepressant medication) 1 tablet once daily (9/20/24). A 1/6/25 pharmacy Consultant Report indicated to please consider discontinuing olanzapine. Rationale for recommendation: CMS requires that antipsychotics, being used to treat expressions of distress associated with dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. The physician response to this recommendation was marked as I decline. The justification for the declination indicated the resident was irritable, slammed doors, had violent behaviors, and on-going agitation. The form lacked a statement of contraindication that included a risk-benefit analysis. An 11/6/24 pharmacy Consultant Report indicated the resident received alprazolam 0.25 mg two times weekly for showers. The physician response to this recommendation was marked as I decline. The justification for declination indicated no change, patient doing well on this regimen. The form lacked a statement of contraindication that included a risk-benefit analysis. A 12/24/24, quarterly, Minimum Data Set assessment (MDS) indicated the resident was severely cognitively impaired, received antipsychotic medication, antianxiety medication, antidepressant medication, had no delusions or hallucinations during the assessment, and displayed no maladaptive behaviors during the assessment period. The resident's clinical record lacked identified targeted behavioral indicators/identified behavioral symptoms for the use of the antipsychotic medication, antianxiety medication, and antidepressant medication. The resident's clinical record lacked care plans related to identified targeted behaviors for the use of an antianxiety medication, antidepressant medication, or antipsychotic medication. Review of the resident's clinical record for December 1, 2024 to March 7, 2025 lacked the documentation of maladaptive behaviors which negatively impacted quality of life or quality of care or documentation of any delusions or hallucinations. A 2/26/25, Psychiatry Progress Note indicated the resident had a generalized anxiety disorder and would exhibit agitation associated with personal care. She had a history of a single episode of a depressive disorder and depression was mild and stabilized. She had a diagnosis of psychotic disorder with delusions due to unknown physical condition. She exhibited agitation, but no recent or overt psychosis, paranoia or disorganized thoughts. She was on olanzapine and the primary care provider declined discontinuation. On 3/3/25 at 11:24 a.m., Resident 19 was observed sitting calmly in the activity/dining area on the dementia unit. On 3/4/25 at 9:48 a.m., Resident 19 was observed sitting calmly in the activity/dining area on the dementia unit. On 3/6/25 at 12:21 p.m., Resident 19 was observed sitting calmly in the activity/dining area on the dementia unit. During an interview on 3/6/25 at 11:30 a.m., the Dementia Unit Director indicated Resident 19 did not display either hallucinations or delusions. She did at times become agitated with care. She mostly displayed signs and symptoms of dementia. During an interview on 3/7/25 at 9:52 a.m., LPN 7 indicated Resident 19 did not appear to see or hear things that were not present. She did display dementia behaviors such as confusion. During an interview on 3/7/25 at 11:39 a.m. Activity Assistant 4 indicated Resident 19 did not appear to see or hear things that were not present. She did have dementia and was confused at times. 2. Resident 54's clinical record was reviewed on 3/04/25 at 1:59 p.m. Current diagnoses included dementia with psychotic disturbances, anxiety, and depression. Current orders included olanzapine 5 mg (antipsychotic medication) give 1 tablet daily at bed time (1/17/25) [on admission]. A 1/20/25 pharmacy Consultant Report indicated the resident received an antipsychotic, olanzapine, without documentation of diagnosis and adequate indication for use, in the medical record . If the antipsychotic is to continue, please update the medical record to include: 1. the specific diagnosis/indication requiring treatment that is based upon an assessment of the resident's condition and therapeutic goals. 2. a list of the symptoms or targeted behaviors . including their impact on the resident . 3. documentation that other causes .have been considered .and that ongoing monitoring has been ordered . The physician response to this recommendation indicated to add a diagnosis of dementia with delusional disorders. The clinical record lacked indication of symptomology related to the delusional disorder. A 1/23/25, admission MDS assessment indicated the resident was severely cognitively impaired, received antipsychotic medication, received antidepressant medication, had no delusions or hallucinations during the assessment, and displayed no maladaptive behaviors during the assessment period. The resident's clinical record lacked identified targeted behavioral indicators/identified behavioral symptoms for the use of the antipsychotic medication. The resident's clinical record lacked care plans related to identified targeted behaviors for the use of an antipsychotic medication. Review of the resident's clinical record for January 17, 2025 to March 7, 2025 lacked documentation of maladaptive behaviors which negatively impacted quality of life or quality of care or delusions and hallucinations. A 2/13/25, psychiatric Initial Consult indicated the resident's hallucinations were within normal limits, delusions-none. On 3/3/25 at 11:23 a.m., Resident 54 was seated calmly in the dining/activity area. On 3/4/25 at 9:56 a.m., the resident was napping in her room. On 3/6/25 at 12:26 p.m., the resident was walking calmly in her room. On 3/7/25 at 9:57 a.m., the resident was sitting in her room. During an interview on 3/6/25 at 11:30 a.m., the Dementia Unit Director indicated Resident 54 did not display either hallucinations or delusions. She did at times become agitated or upset. She mostly displayed signs and symptoms of dementia. During an interview on 3/7/25 at 9:52 a.m., LPN 7 indicated the resident did not appear to see or hear things that were not present. She did display dementia behaviors such as lack of understanding or confusion. During an interview on 3/7/25 at 11:39 a.m. Activity Assistant 4 (AA 4) indicated the resident did not appear to see or hear things that were not present. She did have dementia and was confused at times. During an interview on 3/06/25 at 11:09 a.m., the Administrator indicated the facility would review Resident 19 and 54's record for specific behavioral indicators for the use of psychoactive medications, documented behaviors, care plans related to said behavioral symptoms and/or statements of contraindications which included risk benefit analysis. As of the exit conference on 3/8/25 at 3:00 p.m., the facility had not provided resident specific behavioral indicators for the use of antipsychotic medications, documented symptoms, care planed regarding said symptoms and/or contraindications for use that included a risk benefit analysis. 3. Resident 32's clinical record was reviewed on 3/5/25 at 9:26 a.m. Diagnoses included Alzheimer's disease with late onset, unspecified schizophrenia, unspecified mood disorder due to known physiological condition with depressive features, and psychosis not due to a substance or known physiological condition. Current orders included risperdone ER (extended release) (antipsychotic medication) 37.5 milligrams (mg) intramuscular (IM) suspension, inject one time a day every 2 weeks on Wednesday for delusions and hallucinations (10/18/24) and sertaline (antidepressant medication) 50 mg give one tablet by mouth daily for depression (10/17/24). A 10/18/24 pharmacy Consultant Report indicated Resident 32 had a diagnosis of dementia and received risperidone ER. Antipsychotics have a BOXED WARNING for increased risk of morality in older adults with psychosis related to dementia .Please attempt a gradual dose reduction of Risperidone ER, with the end goal of discontinuation. The physician response to this recommendation was marked as I accept. The clinical record lacked a dose reduction to the Risperidone ER medication order. A 2/1/25 pharmacy Consultant Report indicated Resident 32 had received risperidone ER 37.5 mg IM every 14 days for delusions since 5/23 and sertraline 50 mg by mouth daily for depression since 8/24. Please consider decreasing the risperidone ER to 25 mg IM every 14 days for delusions. Document that a Gradual Dose Reduction (GDR) is a clinically contraindicated for the sertraline. The physician response to this recommendation was marked as I decline. The response indicated re-evaluate at next GDR, patient is impulsive and has behaviors, delusions. Patient has ongoing visual hallucinations. The form did not contain a statement of contraindication that included a risk-benefit analysis. A behavior progress note, dated 1/20/25, indicated the resident was yelling out and reported a baby being burnt in the oven. The resident was unable to recall the behavior. The care plan was reviewed and revised. A 1/23/25, quarterly, MDS assessment indicated the resident was cognitively intact and received antipsychotic and antidepressant medications, had no delirium, delusions, or hallucinations during the assessment period, did not reject care or wander and displayed no maladaptive behaviors during the assessment period. The resident's clinical record lacked care plans related to the specific delusions, hallucinations, or behaviors for the use of antipsychotic and antidepressant medications. The care plans specified side effects for staff to report. A 2/13/25, psychiatry progress note indicated the resident was discussed at an interdisciplinary (IDT) GDR/Behavioral meeting. At this meeting, the appropriateness of this patient's medications/diagnoses were reviewed. Any pertinent behavioral or mood changes were also discussed. After discussion, it was decided that a GDR of Risperadal was not appropriate for today. GDR was contraindicated due to patient remaining in need of this med for stability and psychotic clinical signs and/or symptoms. Staff reported it was variable .The resident's schizophrenia diagnosis was reviewed by the collaborating physician on 1/14/25 who indicated they did not have adequate historical information to justify diagnosis. The previous GDR was a failed attempt on 10/31/24. During an observation, on 3/3/25 at 1:45 p.m., Resident 32 was sleeping in a low bed. She did not awaken after multiple knocks on the door and verbal calls. On 3/4/25 at 9:46 a.m., Resident 32 was quietly lying in bed, awake. She indicated she liked the nursing staff. They assisted her with bathing and took good care of her. On 3/5/25 at 10:21 a.m., Resident 32 was reclined in a specialty wheelchair by the nurse station. The resident was asleep. The nurse station was loud and the resident did not awaken at the noise level. On 3/6/25 at 10:16 a.m., Resident 32 was being propelled to the dining room in her specialty wheelchair. She was awake and smiling as people passed by. During an interview, on 3/7/25 at 9:57 a.m., CNA 23 indicated Resident 32 was very nice and did not get aggressive. The resident would call out hey to people as they knocked on her door or passed by her room. During an interview, on 3/7/25 at 10:30 a.m., LPN 14 indicated the only behavior Resident 32 had was when she yelled out right at each meal time, probably when she was hungry. This resident had never been aggressive with her. During an interview, on 3/7/25 at 10:34 a.m., CNA 18 indicated Resident 32 had not talked about seeing things or hearing things that were not there. She was known to yell out hey a lot when she saw people pass her room or when someone made noises close by. During an interview, on 3/7/25 at 10:40 a.m., the DON indicated the facility had no further documentation to provide related to Resident 32's delusions, hallucinations, or behaviors. 4. Resident 48's clinical record was reviewed on 3/4/25 at 2:11 p.m. Diagnoses included delusional disorder, unspecified depression, unspecified anxiety, and failure to thrive. Current orders included risperidone 0.25 mg tablet, give one time a day for delusional disorder (8/1/24), risperidone 0.50 mg tablet, give one time at bedtime for delusions and hallucinations ( 8/1/24), and sertraline 50 mg tablet, give one time a day for depression (8/21/24). A 1/6/25 pharmacy Consultant Report indicated Resident 48 had received an antidpressant, sertraline 50 mg by mouth once a day for management of depressive symptoms since 7/24. For the initial attempt at a GDR, please document that a GDR is clinically contraindicated. The physician response to this recommendation was marked as I decline. The response area was left blank. The form did not contain a statement of contraindication that included a risk-benefit analysis. A 2/1/25 pharmacy Consultant Report indicated Resident 48 received an antipsychotic, risperidone 0.25 mg by mouth once a day and 0.50 mg by mouth at bedtime for delusions since 7/24. Please consider decreasing to risperidone 0.25 mg twice daily for delusions. The physician response to this recommendation was marked as I decline. The response area was left blank. The form did not contain a statement of contraindication that included a risk-benefit analysis. A nursing progress note, dated 2/10/25 indicated the resident's representative was informed of the GDR recommendation and did not want the medications changed. The facility continued with current medication dosages. The GDR was refused. A 2/23/25, quarterly, MDS assessment indicated the resident was cognitively intact and received antipsychotic and antidepressant medications, had no delirium, delusions, or hallucinations during the assessment period, did not reject care or wander and displayed no maladaptive behaviors during the assessment period. The clinical record lacked identified delusions, hallucinations, or behavioral symptoms for the use of the antipsychotic and antidepressant medications. The clinical record lacked care plans related to the specific delusions, hallucinations, or behaviors for the use of antipsychotic and antidepressant medications. The care plans specified side effects for staff to report. During an observation, on 3/3/25 at 10:57 a.m., Resident 48 was sleeping in a high bed with her oxygen in place. She was easy to awaken and indicated the staff were kind. On 3/4/25 at 10:02 a.m., Resident 48 was lying flat on her back in bed. She indicated she did not get out of bed much due to pain in her knees and she didn't like the lift device. On 3/5/25 at 10:34 a.m., Resident 48 was lying in bed with her head slightly elevated. She indicated she was doing fine today. During an interview, on 3/7/25 at 9:57 a.m., CNA 23 indicated she had never heard Resident 48 yelling out or talking about seeing things no one else could see, or hearing voices no one else could hear. She was never mean or violent during care. During an interview, on 3/7/25 at 10:30 a.m., LPN 14 indicated it had been several months since the resident last talked about seeing children or men in her room that were not there. During an interview, on 3/7/25 at 10:34 a.m., CNA 18 indicated Resident 48 sometimes talked without making much sense and it was hard to follow her train of thought. She used to mention seeing children in her room, but that was months ago. During an interview, on 3/7/25 at 10:40 a.m., the DON indicated she had spoken with the Medical Director and he explained per the current regulations, if the GDR was refused by the family this superceded any pharmacy recommendations or physician orders. Resident 48's family refused any medication changes. The DON indicated she had no further documentation to provided related to Resident 48's hallucinations or delusions. A current 11/19/24, facility policy titled Areas of Focus: Psychotropic Medication Management, which was provided by the DON on 3/7/25 at 10:00 a.m., indicated the following: .giving psychotropic medication only when necessary to treat a specific diagnosed and documented condition. 2. Implementing GDR and other non-pharmacological interventions for residents who receive psychotropic medications, unless contraindicated . The resident's medical record must show documentation of adequate indications for a medication's use . 3.1-48 (a)(1)

Based on observation, record review, and interview, the facility failed to ensure preventative interventions were implemented for 1 of 3 residents reviewed for pressure ulcers. (Resident 5) Finding includes: During an observation on 3/3/25 at 9:42 a.m., Resident 5 was seated in a wheelchair in her room. The resident indicated she had pain to her buttocks. The facility put cream on her buttocks, but she thought it needed more than that. This had been going on for the last couple of months. Staff used a mechanical lift when they assisted her in and out of bed. The resident's bed had a standard healthcare mattress. Resident 5's clinical record was reviewed on 3/4/25 at 3:49 p.m. Diagnoses included unilateral primary osteoarthritis of the right knee, difficulty in walking, unspecified lack of coordination, unsteadiness on feet, and pain. Current orders included an airflow mattress (1/10/23) and hydrocolloid dressing (wound treatment) (3/4/25) to the left guteal fold every three days and as needed for friction. An annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated the resident was cognitively intact. Rejection of care behaviors were not exhibited during the assessment period. She was dependent on staff assistance for toileting, bathing, lower body dressing, personal hygiene, rolling left and right, and transfers. The resident used a wheelchair for mobility. She was at risk for pressure ulcers. The resident did not have any pressure ulcers. Skin interventions included a pressure reducing device for the bed. A current care plan, initiated on 6/3/19, indicated the resident was at risk for a break in skin integrity/pressure ulcers related to decreased mobility, incontinence, and obesity. The resident had friction and shearing to the left buttocks. Interventions included the following: apply an air mattress to the bed and a cushion to the chair (1/15/23), clean and dry the skin after each incontinent episode (6/3/19), apply the treatment as ordered (4/10/24), and apply a cushion to the wheelchair (1/10/24). During an observation on 3/5/25 at 4:45 p.m., Resident 5 was in bed, turned slightly to her left side. The bed lacked a low air loss mattress. During an interview on 3/6/25 at 11:15 a.m., LPN 14 indicated Resident 5 had a skin impairment to the left gluteal fold that healed, then reopened on 3/3/25 due to friction and shear. During a wound observation on 3/6/25 at 3:00 p.m., Resident 5 was turned to her right side on a standard mattress. An intact hydrocolloid dressing was on her left lower buttock, where the unsecured brief rested against the skin. A low air loss mattress was not in place to the bed. During an interview on 3/7/25 at 12:20 p.m., CNA 12 indicated the resident did not have a low air loss mattress in place. During an interview on 3/7/25 at 1:53 p.m., Corporate Nurse Consultant 8 indicated the resident's low air loss mattress was not in place as ordered and care planned. The clinical record lacked documentation for a reason the low air loss mattress was not in place. During an interview on 3/7/25 at 1:58 p.m., LPN 10 indicated Resident 5 was at risk for skin impairment due to incontinence, skin moisture, and her lack of self mobility. The order for a low air loss mattress should have been followed. The clinical record typically contained an order to ensure the low air loss mattress was in place and working properly. The resident's clinical record lacked an order to check the low air loss mattress. A current facility policy, revised 8/25/21, titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, provided by the Regional Clinical Support on 3/7/25 at 2:12 p.m., indicated the following: POLICY .Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP [National Pressure Injury Advisory Panel] and WOCN [Wound, Ostomy, Continent Nurses Society] 3.1-35(g)(2)

A. Based on observation and interview, and record review, the facility failed to utilize infection prevention and control practices related to hand hygiene during medication administration for 2 of 3 random residents reviewed during medication administration. (Residents 26 and 6) B. Based on observation, interview, and record review, the facility failed to implement and follow enhanced barrier precautions (EBP) for a resident at higher risk for infection with a wound and indwelling urinary catheter for 1 of 3 residents reviewed for pressure ulcers. (Residents 22) Findings include: A. During a medication administration observation on 3/5/25 from 8:46 a.m. to 8:48 a.m., LPN 13 performed hand hygiene after she prepared Resident 26's medications and entered the resident's room. She administered one spray of saline nasal solution 0.65% in each of the resident's nostrils. Without performing hand hygiene, she cleansed the resident's left upper arm with an alcohol wipe using her right hand, and administered the resident's Humalog using her right hand. She removed the needle from the insulin pen with her left hand and placed it in the sharps container. She did not don gloves during the nasal spray administration, nor when she removed the used needle. LPN 13 administered oral medications to the resident. After LPN 13 disposed of the medication cup into the trash, she administered fluticasone nasal spray with her ungloved hand and administered one spray to each nostril. During an interview on 3/5/25 at 4:48 p.m., LPN 13 indicated she should have washed her hands prior to the administration of the resident's insulin during the medication administration observation and after she administered the resident's nasal sprays. Gloves should have been used for nasal spray administration and insulin administration. During an interview on 3/6/25 at 2:44 p.m., the DON indicated gloves were required when nasal sprays and insulins were administered. Hand hygiene was required after medication administration and prior to touching other surfaces. A current facility policy, last revised 11/15/24, titled Medication Administration through certain Routes of Administration, provided by the DON on 3/6/25 at 3:00 p.m., indicated the following: Applicability . establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care [LTC] facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations . Subcutaenous [sic] Injections . Procedure . 7. Perform hand hygiene and don gloves . 11. Cleanse site with alcohol swab beginning at center of site and rotating outward approximately 2 inches. Allow skin to dry completely; do not fan or blow on site . 14. Inform resident he/she will feel a slight pinch, pressure or stinging sensation as the medication is injected . 16. After injection, remove needle quickly and gently . 19. Remove gloves and perform hand hygiene . Nasal Medications . 4. Perform hand hygiene and put on gloves . 6. Shake the suspension well . 11. Atomizer (Nasal Spray) . Occlude one nostril . Insert atomizer tip into open nostril. Instruct resident to inhale and squeeze atomizer once, quickly, and firmly. Repeat if ordered, then repeat on other side, if appropriate . 13. Replace cap/cover; discard barrier. 14. Remove and dispose of gloves and perform hand hygiene B.1. During a random observation on 3/3/25 at 3:00 p.m., Resident 22 rested in her bed. A urinary catheter was hung on the bed frame. Resident 22's clinical record was reviewed on 3/4/25 at 3:47 p.m. Diagnoses included unspecified dementia, flaccid neuropathic bladder, need for assistance with personal care, and stage four pressure ulcer of the sacral region. A current physician's order, dated 2/28/25, indicated to cleanse the left buttock/coccyx area with normal saline and pat dry. Place a small amount of Medihoney (wound treatment) on the wound on day shift every 3 days and as needed for soilage or dislodgement. The clinical record lacked an order for enhanced barrier precautions. A quarterly Minimum Data Set (MDS) assessment, dated 1/29/25, indicated the resident had severe cognitive impairment. She was dependent on staff assistance for eating, toileting, dressing, bathing, repositioning, and personal hygiene. She utilized an indwelling urinary catheter and always had bowel incontinence. She was at risk for pressure ulcers and had one stage three pressure ulcer that was present on admission. Skin interventions included a pressure reducing device for the bed, a pressure reducing device for the chair, and pressure ulcer care. A current care plan, dated 12/20/24, indicated the resident had a stage two pressure area to the left buttocks/coccyx, unavoidable, related to the end of life. Interventions included the following: pressure reducing mattress (12/20/24), treatment as ordered (12/20/24), and Prosource and Med Pass (supplements) as ordered (12/23/24). The care plan lacked interventions for enhanced barrier precautions. A left buttock pressure wound assessment, dated 2/28/25, indicated the wound was present on admission. It was a partial thickness loss wound with exposed dermis. The wound to the left buttock was healing well and measured 0.9 centimeters (cm) length by 0.8 cm width by 0.1 cm depth. There was no drainage, wound edges were clean, and the surrounding skin was pink. There were no signs of infection. During an observation on 3/5/25 at 4:05 p.m., Resident 22 was lying in bed turned slightly to her left side on a low air loss mattress. The urinary catheter was hung on the right side bed frame. During a wound care observation for Resident 22 on 3/6/25 from 9:45 a.m. to 9:49 a.m., a urinary catheter drainage bag was hung on the frame of the bed. LPN 7, CNA 11, and the Staff Development Coordinator (SDC) entered the room. The SDC stood at the foot of the bed. CNA 11 donned gloves and leaned in, with her clothing directly against the resident's bed linens and catheter tubing, and she rolled the resident onto her left side. LPN 7 washed her hands in the sink after placing wound care supplies on the overbed table. LPN 7 donned gloves, removed the old dressing from the resident's sacral area, doffed her gloves, and washed her hands. LPN 7 donned clean gloves, performed cleansing of the wound, doffed her gloves, and washed her hands. With clean gloves, she measured the open wound which was slightly smaller than a dime coin with no discernable depth. LPN 7 doffed her gloves, washed her hands, donned clean gloves, and applied the Medihoney to the wound bed with a cotton tipped applicator. The wound was covered with the new dated dressing. CNA 11 assisted the resident to her back. Both CNA 11 and LPN 7 leaned in with their clothing directly against the bed linens and repositioned the resident. CNA 11 and LPN 7 did not wear gowns during the wound care observation. During an interview on 3/6/25 at 10:01 a.m., LPN 7 indicated Resident 22's room lacked indication that enhanced barrier precautions in place. Residents who required enhanced barrier precautions typically had a yellow PPE canister on the door and an enhanced barrier precaution sign similar to a room just down the Southern Pines Unit. She believed residents were in enhanced barrier precautions if they had specific bacteria in their urine. LPN 7 was uncertain what other reasons a resident required enhanced barrier precautions. She was not aware she should have followed enhanced barrier precautions and worn additional PPE when a resident had wounds or a urinary catheter. During an interview on 3/6/25 at 10:14 a.m., the SDC indicated the resident's room lacked indication of enhanced barrier precautions being in place. Neither LPN 7 nor CNA 11 wore gowns during high contact care during the wound care observation. The SDC was responsible for staff education. During an interview on 3/6/25 at 10:28 a.m., CNA 12 indicated residents who had central lines, feeding tubes, respiratory devices, and catheters required enhanced barrier precautions. Staff were required to wear gowns, masks, gloves, and potentially goggles to provide care for enhanced barrier precautions. When enhanced barrier precautions were implemented, the resident's door had an EBP sign and a PPE canister on the outside of the resident's door. Staff were required to clarify what PPE had to be worn in the room prior to entering the room for resident care in the event a resident had a urinary catheter without an EBP sign on their door, During an interview on 3/6/25 at 10:35 a.m., CNA 11 indicated she had not followed EBP during the wound care observation because an EBP sign and PPE canister was not on the resident's door. Residents with an open wound, catheter, tracheostomy, central lines, and dialysis access devices were required to have EBP. She regularly provided Resident 22's care since she admitted to the facility and she had never seen an EBP sign nor a PPE canister on the resident's door. The resident had an open wound and a urinary catheter since admission. To her knowledge, the resident had not been in EBP prior to the wound care observation on 3/6/25. A current facility policy, last revised 3/21/24, titled Enhanced Barrier Precautions, provided by the Administrator on 3/6/24 at 11:00 a.m., indicated the following: Policy . The facility should use Enhanced Barrier Precautions [EBP] as an additional MDRO [Multi-drug Resistant Organism] mitigation strategy for residents that meet the following criteria, during high-contact resident care activities; EBP are indicated for resident with any of the following: . 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO 3.1-18(l) 3.1-18(b)(2)

Based on observation and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) pens were dated when opened and disposed of when expired for 1 of 4 carts reviewed for medication storage. (Hickory Hall 2 cart) Finding includes: During a medication storage observation of the Hickory Hall 2 cart, accompanied by LPN 14 on [DATE] at 9:55 a.m., the following was observed: One undated NovoLog (aspart insulin) Flexpen with 10 units remaining and one lispro (insulin) KwikPen, dated [DATE], with 185 units remaining. During an interview, at the time of the observation, LPN 14 indicated insulin was good for 28 days and all insulin pens and vials should be dated when opened. The lispro insulin was expired and should not be given to the resident. LPN 14 indicated there were 9 diabetic residents who received medication from the Hickory Hall 2 medication cart. During an interview, on [DATE] at 2:21 p.m., the Director of Nursing (DON) indicated the expectation for staff was to date all insulin pens and vials on the day they were opened. Staff should be checking this date each time the medication was utilized to ensure it was not expired. A current facility policy, revised [DATE], titled, Storage and Expirations Dating of Medications and Biological's, provided by the Administrator on [DATE] at 1:30 p.m., indicated the following: .11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e.,vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened .11.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g. needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . 3XXX,d+[DATE](j)

Based on observation, interview, and record review, the facility failed to manage resident funds using acceptable accounting principles for 2 of 3 residents reviewed for personal funds. (Residents 34 and 27) Findings include: During a medication storage and labeling observation accompanied by LPN 14 on 3/6/25 at 9:49 a.m., in the Hickory medication room, small labeled and dated envelopes were on a storage shelf open with dollar bills in plain view. The envelopes were labeled November 2024 and October 2024, and included the names of Resident 34 and 27. During an observation of Hickory Medication Cart 1 accompanied LPN 15 on 3/6/25 at 10:04 a.m., hand-written money logs for Residents 34 and 27 were in the narcotic reconciliation book, dating back to December 2024. During an interview on 3/6/25 at 11:00 a.m., LPN 15 indicated the logs were kept for Residents 34 and 27, who were roommates, because they had a history of stealing each other's money when it was kept in their room. Resident 34's clinical record was reviewed on 3/6/25 at 11:15 a.m Diagnoses included unspecified dementia, bipolar disorder, and schizoaffective disorder. The current care plan indicated the resident had specific preferences and had misplaced personal items. She had ordered fast food on her own and required money during offsite hours and weekends. Due to her frequent misplacement of money, her funds were placed in the medication storage room. A facility Resident Fund Management Service agreement, dated 4/21/22, was signed by the resident. Resident 27's clinical record was reviewed on 3/6/25 at 11:10 a.m Diagnoses included unspecified schizophrenia and bipolar disorder manic without psychotic features. The current care plan indicated the resident had behaviors related to anxiety and would misplace personal items. She frequently ordered fast food on her own and required funds during offsite hours and weekends. Due to her repeated misplacement of money, her funds were kept in the medication storage room. A progress note, dated 5/17/24 at 6:28 a.m., indicated the resident requested money from her envelope. A facility Resident Fund Management Service agreement, dated 4/21/22, was signed by Resident 27's representative. During an interview on 3/6/25 at 12:11 p.m., the Director of Nursing indicated Residents 34 and 27 often misplaced money, as opposed to stealing from each other. The money logs and envelopes were interventions put in place by the business office. During an interview on 3/7/25 at 11:50 a.m , the Business Office Manager (BOM) indicated when a resident requested a deposit or withdrawal from their account, a receipt/deposit slip was created and signed by the resident and a witness. The BOM was unaware of the money logs controlled by nursing. During an interview on 3/7/25 at 11:53 a.m. , the Administrator indicated the facility lacked a policy regarding keeping of resident funds outside the trust, but noted, on admission, the facility offered residents and family a lockbox to be kept in the resident's room. If staff noticed the resident had valuables in plain view, they again offered a lockbox. A current facility policy titled Resident Trust Policy and Procedures, provided by the Regional Clinical Support on 3/7/25 at 11:15 a.m., indicated the following: .The facility will follow all regulations regarding resident trust funds .Resident Access to Funds: The facility shall maintain a petty cash-on-hand fund. This fund shall be made from operating funds. As such, disbursements to residents serve as an advance to the resident. The cash-on-hand is then replenished with withdrawals made from the resident accounts of those resident to whom the cash was advanced A disbursement of cash to a resident should be documented with a signed receipt in triplicate. a. One copy of the signed receipt shall be provided to the resident. b. One copy of the signed receipt shall be kept with the petty cash-on-hand until the next replenishment reconciliation. At that point, the receipt shall be kept with the reconciliation as backup. c. The final copy of the receipt shall remain in the receipt book as a chronological archive 3.1-6(e)

Based on observation, record review, and interview, the facility failed to post the daily facility census number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily during random observations. Finding includes: During an observation and record review, on 3/3/25 at 9:25 a.m., the two Nursing Staff Directly Responsible for Resident Care boards were posted from 2/27/25- 2/28/25 on the wall outside the Admissions Office and indicated the following: On 2/27/25, the total number of licensed and unlicensed staff was 3 Registered Nurses (RN), 7 Licensed Practical Nurses (LPN), 1 Qualified Medication Aide (QMA), and 19 Certified Nursing Assistants (CNA). The census was 68. On 2/28/25, the total number of licensed and unlicensed staff was 3 RN's, 7 LPN's, 1 QMA, and 17 CNA's. The census number was 68. During an observation and record review, on 3/3/25 at 11:00 a.m., the two Nursing Staff Directly Responsible for Resident Care boards were updated and indicated the following: On 3/2/25, the total number of licensed and unlicensed staff was 3 RN's, 7 LPN's, 1 QMA, and 17 CNA's. The census was 69. On 3/3/25, the total number of licensed and unlicensed staff was 3 RN's, 8 LPN's, 1 QMA, and 19 CNA's. The census was 69. During an observation and record review, on 3/4/25 at 9:44 a.m., the two Nursing Staff Directly Responsible for Resident Care boards were unchanged and had not been updated. During an observation and record review, on 3/4/25 at 2:07 p.m., the two Nursing Staff Directly Responsible for Resident Care boards were unchanged and had not been updated. During an observation and record review, on 3/5/25 at 9:20 a.m., the two Nursing Staff Directly Responsible for Resident Care boards were unchanged and had not been updated. During an observation and record review, on 3/5/25 at 10:40 a.m., the two Nursing Staff Directly Responsible for Resident Care boards were updated and indicated the following: On 3/4/25, the total number of licensed and unlicensed staff was 2 RN's, 10 LPN's, 2 QMA's, and 21 CNA's. The census was 72. On 3/5/25, the total number of licensed and unlicensed staff was 3 RN's, 7 LPN's, 2 QMA's, and 24 CNA's. The census was 72. During an interview, on 3/7/25 at 10:45 a.m., the Administrator indicated the Director of Nursing (DON) was responsible for updating the staffing information daily. During an interview, on 3/7/25 at 10:57 a.m., the DON indicated this was a task recently added to her responsibilities as the facility did not have a scheduler. She tried to ensure this was updated daily. She was aware the staff posting on Monday, at the beginning of the annual survey, was incorrect and showed the previous Thursday and Friday information. She worked Monday through Friday and tried to remember to change the staff posting before she left work on Friday nights to reflect the weekend information. She also missed updating the staff posting on Tuesday of this week. A current facility policy, last reviewed on 11/26/24 and titled, Area of Focus: Facility Staffing Posting, was provided by the Regional Clinical Support on 3/7/25 at 11:04 a.m., and indicated the following: .The facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current . The nurse staffing data needs to be posted on a daily basis at the beginning of each shift .

Based on interview and record review, the facility failed to employ a qualified Food Services Director. This deficient practice had the potential to impact 70 of 70 facility residents. Finding includes: Review of the employee record form, completed by the facility following the entrance conference on 2/4/25, indicated the Food Services Director had been employed by the facility since 8/6/20. During an interview on 2/5/25 at 10:58 a.m., the Administrator indicated the Food Services Director had been enrolled in a dietary manager program, but failed to obtain the certification. The Food Services Director had since re-enrolled in the program. The Administrator believed the Food Service Director was ServSafe Management (a national certification for food service management) certified. The Food Services Director was not available during the survey from February 4 through February 6, 2025. During an interview on 2/6/25 at 12:08 p.m., the Assistant Dietary Manager indicated she was not ServSafe Management certified. The Registered Dietician came to the facility on ce a week on Thursdays. During an interview on 2/6/25 at 12:15 p.m., the Administrator indicated the Food Services Director began in that position on 5/16/22. She worked in a different position for the facility prior to that date. She was not a Certified Dietary Manager nor ServSafe Management certified, and lacked the required qualifications for the Food Services Director. During an interview on 12/6/25 at 12:27 p.m., the Administrator indicated all residents received meals from the facility kitchen. The census was currently 70. A current facility policy, revised on 4/16/24 and titled Departmental Leadership Requirements, provided by the Administrator on 2/6/25 at 12:20 p.m., indicated the following: Policy . The Food and Nutrition Services department operates under the direction of a qualified individual who has appropriate competencies and skills necessary to oversee the functions of the food and nutrition services. If a full-time dietician is not employed, the Executive Director designates a qualified person to serve as full-time Director of Food and Nutrition Services with frequently scheduled consultations from a qualified dietician or other clinically qualified nutrition professional This citation relates to complaint IN00452465. 3.1-20(c)

Based on record review and interview, the facility failed to prevent misappropriation of a resident's medication for 1 of 3 residents reviewed for misappropriation. (Resident C). The deficient practice was corrected on 1/15/25, prior to the start of survey, and was therefore past noncompliance. Finding includes: Review of a facility reported incident, dated 1/10/25 at 6:30 a.m., indicated the following: Brief Description of Incident: Upon shift change on 1/10/25, during medication count, Resident C's morphine sulfate IR (narcotic pain reliever) 15 milligram (mg) tablets were short by 2 tablets. LPN 5 returned to the facility and requested to speak with the Administrator and DON at 10:00 a.m. LPN 5 admitted she had taken the medication. There were no injuries. The immediate actions taken were as follows: On 1/10/25 an investigation was started immediately, the medication count was re-verified by 2 additional nurses, Resident C was assessed for any sign or symptoms of distress or pain, Resident C denied pain or missing his pain medication, the local police department was notified, and LPN 5 was placed on a suspension pending the investigation. Preventative measures taken included: interviews by Social Services of all the residents on the same unit with no complaints related to missing medications, initiation of the drug diversion protocol, initiation of abuse re-education, and the facility replacement of Resident C's morphine tablets. Resident C's clinical record was reviewed on 2/4/25 at 4:30 p.m. The resident discharged from the facility on 1/10/25. Diagnoses included intervertebral disc degeneration, pain, and malignant neoplasm of the liver. A physician's order, dated 12/30/24, included morphine sulfate 15 mg - one tablet by mouth every six hours as needed for pain. The order was discontinued on 1/10/25. A physician's order, dated 1/10/25, indicated the resident was able to be discharged home with all of his morphine tablets. Review of the resident's morphine narcotic sheet indicated the resident should have had 30 pills left during shift change on 1/10/25, and the card contained 28 pills. A quarterly Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had mild cognitive impairment. A care plan, dated 11/24/24, indicated the resident expressed pain and discomfort related to liver cancer and neuropathy. Interventions included, administer pain medications as ordered (11/24/24) and evaluate the effectiveness of pain interventions (11/24/24). A Nurse's note, dated 1/10/25 at 7:40 a.m., indicated during shift change narcotic count the resident's morphine 15 mg tablet card was short two pills. The medication count was verified by the (unidentified)QMA and the (unidentified) LPN and the pharmacy verified the amount of pills that were sent to the facility. The DON, Administrator, and provider were notified. The resident was evaluated for pain and denied any concerns. During an interview on 2/4/25 at 4:47 p.m., the Administrator indicated LPN 5 returned to the building and requested to speak with him and the DON on 1/10/25. The Administrator and DON spoke with LPN 5 on 1/10/25 at the facility regarding the missing medication during narcotic count at the end of her shift. LPN 5 admitted she had taken the two pills from Resident C's medications stored by the facility, and later ingested them at home rather than having a drink. She was initially suspended during the investigation and then terminated after completion of the investigation. A review of the facility investigation file, provided by the Administrator on 2/4/25 at 5:00 p.m., contained the following information: A hand-written statement from QMA 6, dated 1/10/25, indicated after she received report from the nurse, they began narcotic count. When they got to Resident C's morphine, it was two tablets short. They reviewed the Medication Administration Record (MAR) and recounted. It was unclear what happened to the missing medication. A second nurse was consulted and counted the medication again with the same result. Next, they contacted the DON. A hand-written statement from LPN 7, dated 1/10/25, indicated she was called by two nurses regarding Resident C's medication count being off. LPN 7 counted the chart and found it to be short by two. She reviewed the MAR and called the pharmacy to verify the amount of medication that was sent to the facility. The DON was notified. The off-going nurse was drug tested and sent home pending an investigation. LPN 7 assessed Resident C for pain concerns and he denied any concerns or pain during the night. The Social Services and Administrator were notified. The emergency drug kits were verified as well as the discontinued medications. A typed statement from the Administrator, dated 1/10/25, indicated he was requested by LPN 5 to meet, along with the DON, on 1/10/25 at 10:10 a.m. LPN 5 reported she had popped out two morphine tablets as few nights ago to keep the count from being off and she stuck the two morphine tablets in her pocket and forgot about it. On Wednesday, 1/8/25, she was doing laundry at home when she found the two morphine tablets in her pocket. LPN 5 went on to state that she had been under a lot of stress. She would usually have a drink, but she took the pills instead. LPN 5 was informed of her suspension pending further investigation on 1/10/25 at 10:20 p.m. Review of a shift to shift Controlled Substance Inventory Count Sheet from 1/8/25 to 1/10/25 indicated both on-coming and off-going medication cart attendees had verified count on each exchange of the Southern Pines medication cart and included the date of the discrepancy on the morning of 1/10/25 at 6:00 a.m. Review of LPN 5's urine drug screen results, dated 1/10/25 at 6:45 a.m., indicated the urine drug screen was positive for opiates (codeine/morphine) and opiates codeine/morphine/or hydrocodone. Review of LPN 5's employee file, provided by the Administrator on 2/5/25, indicated the nurse had an active nursing license. The nurse completed abuse and resident rights training upon hire. During an interview on 2/5/25 at 12:43 p.m., QMA 6 indicated, approximately three weeks ago around 6:00 a.m., she received shift report from LPN 5. They proceeded to do the narcotic count on the Southern Pines Unit, when they found two pills missing for Resident C. She called LPN 7 to check the cart and there was still a discrepancy. LPN 7 called the pharmacy while LPN 5 and QMA 6 finished counting the remainder of the cart to check for any further discrepancies. LPN 5 called the DON at home to report it. LPN 7 and QMA 6 re-counted the cart verifying the doses with the MAR to ensure no one had miscounted. The discrepancy remained. The DON arrived soon after that and took over. During an interview on 2/5/25 at 1:13 p.m., LPN 7 indicated, earlier in January, QMA 6 and LPN 5 notified her at shift change in the morning of a narcotic discrepancy. She was asked to do a count and found that two pills of morphine missing. She called the pharmacy to attempt to find the error but the two pills remained unaccounted for. She instructed LPN 5 to call the DON. The DON then instructed LPN 7 to complete a urine drug screen on LPN 5 and then she sent LPN 5 home. LPN 7 then assessed Resident C for any pain or missing medications, which he denied. During an interview on 2/5/25 at 3:08 p.m., the DON indicated she was notified at home of a medication discrepancy on 1/10/25 by LPN 5, QMA 6, and LPN 7 and gave them direction. Upon arrival to the facility, she counted all the carts and the two missing morphine pills on the Southern Pines cart remained missing. LPN 5 later returned to the building and admitted she had taken the two morphine pills from the medication cart a few nights ago, was stressed out, and later ingested the pills. No discrepancies were found prior to 1/10/25, until the shift-to-shift narcotic count after LPN 5's night shift. It was not acceptable for staff to take the residents' medications. This was considered misappropriation of the resident's medications. LPN 5 was not available for interview during the survey from February 4 through February 6, 2025. A current facility policy, last reviewed 6/17/24 and titled Abuse - Identification of Types, provided by the Administrator on 2/5/25 at 3:47 p.m., indicated the following: Policy . It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators . Federal Regulations . The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Definition . Misappropriation of resident property - is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent The deficient practice was corrected by 1/15/25 after the facility implemented a systemic plan that included a facility in-service regarding abuse/misappropriation, report of misappropriation, an investigation, and quality assurance activities. This citation relates to complaint IN00451056. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure anti-depressant medication and mood stabilizer medication was not started without indication for use for 1 of 3 residents reviewed for abuse (Resident D). Findings include: A Facility Reported Incident indicated, on 5/4/24 at 8:01 p.m., a female resident was discovered on the floor near the area of Resident D. Resident D indicated he had pushed her. They were immediately separated and the female resident was sent to the emergency room due to complaints of pain. On 5/15/24 at 10:40 a.m., Resident D was being propelled in a wheelchair by a staff member to an activity in the main dining room. On 5/15/24 at 1:57 p.m., Resident D was lying in bed and indicated concerns about the pain in his shoulder and how his right hand had not worked right in four years. On 5/16/24 at 1:15 p.m., Resident D was lying in bed. Resident D's clinical record was reviewed on 5/15/24 at 10:14 a.m. Diagnoses included unspecified dementia, unspecified severity, with agitation, anxiety disorder, insomnia, and depression. Resident D's medications included depakote (mood stabilizer) 125 mg (milligram) twice daily for unspecified dementia with unspecified severity with agitation (started on 5/6/24) and Celexa (antidepressant) 10 mg daily for depression (started on 5/7/24). A 4/25/24, quarterly, Minimum Data Set (MDS) indicated Resident D was severely cognitively impaired. He had verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others). This behavior occurred one to three days during the assessment period. Resident D's care plan indicated he was in the vicinity where another resident fell on [DATE] (initiated on 5/4/24). His goal was to have no further episodes of verbal and physical aggression (5/4/24). His interventions included he was immediately placed on one on one supervision, psychiatric services was contacted to see him and the table was removed from the lounge area as well (5/4/24), the social worker was to provide psychosocial support (5/4/24). Resident D's care plan indicated he exhibited a tendency to become territorial with his surroundings. He liked to sit in a specific spot in the hall in his wheelchair. He liked to people watch. He may exhibit feelings of being threatened with others close to his vicinity (initiated on 5/6/24). His goal was he would have fewer episodes of voicing out displeasure towards other when he felt another person maybe in the area, daily through next review (5/6/24). His interventions included keep the side of the room he sits in free from any items such as desks, chairs, or tables, let him sit completely alone on his side of the room, always encourage him to join others in group activities, he enjoyed Bingo (5/6/24). Review of Resident D's progress notes indicated the following: A behavior note, dated 2/24/24 at 2:52 p.m., indicated the resident kept yelling at other residents over a table at the front of the unit. He stated the table was his. Resident D kept trying to tell other residents they couldn't sit in the chairs up front, because someone was stealing from him. The table was moved into the lounge and it was explained to Resident D that it was not appropriate to yell and curse at others. Resident D calmed down after the table was removed. A behavior note, dated 2/22/24 at 2:26 p.m., indicated Resident D was agitated and yelled that someone took his four coffee cups from his stand. He was reassured that the cups were picked up and taken to be washed. He calmed down after the explanation. On 5/4/24 at 7:00 p.m., a call was placed to Resident D's family regarding the incident this evening. His family was informed Resident D would be on one on one observations for the next few days. The clinical record lacked indication of what the incident was or what had occurred on 5/4/24. On 5/5/24 at 5:38 a.m., he was on one on one observations due to the incident. He rested throughout the night. He had no worsening aggression or behaviors noted. He would continue to be monitored closely by staff and any changes would be noted. A behavior note, dated 5/5/24 at 1:27 p.m., indicated Resident D was interviewed, and he appeared to be calm with no signs or symptoms of anger. When he was asked what happened he said nothing, she fell on her own and refused to discuss anything else. He was a little agitated by the questions being asked and the writer of the note backed off. A care management note, dated 5/5/24 at 1:47 p.m., indicated his Brief Interview for Mental Status (BIMS) score demonstrated he was severely cognitively impaired. Another BIMS assessment would be administered the next day. The resident was on an antibiotic for an infection. A behavior note, dated 5/5/24 at 7:21 p.m., indicated Resident D had been on one on ones. He had no behavior such as verbal or physical aggression. He stated he was remorseful about the incident that occurred and had stated in several ways that the incident occurred. The table was removed from the lounge and Resident D had no concerns regarding this at this time. Psychiatric services would see him tomorrow and psychosocial support would continue to be offered. A care management note, dated 5/5/24 at 7:27 p.m., indicated the Interdisciplinary Team (IDT) discussed the event and Resident D was immediately placed on one on one supervision. Psychiatric services was contacted to see Resident D, the table was removed from the lounge area, and the social worker would provide psychosocial support. A behavior note, dated 5/6/24 at 12:52 a.m., indicated Resident D continued on one on one supervision. He had not shown any aggression or disruptive behavior today. He had been engaged and conversated with staff. He would continue to be monitored. On 5/6/24 at 10:22 a.m., his family was made aware of a new order for depakote. A behavior note, dated 5/6/24 at 4:02 p.m., indicated Resident D remained on one on ones. He had been polite and agreeable today. He appeared to enjoy the special attention. On 5/6/24 at 6:30 p.m., the psychiatric nurse practitioner saw Resident D and ordered Celexa 10 mg daily. The family was made aware. An Initial Psychiatry Consult note, dated 5/6/24, indicated Resident D was being seen at the request of the facility and primary care provider for dementia with mood disturbance and agitation, depression, anxiety and insomnia. Staff reported the resident was territorial, with increased paranoia that someone will take his things. He was verbally aggressive towards other residents. He pushed a resident down and the resident had fractures from the fall. He reported he was doing well, and could do better if he had his teeth. He felt like people were going to take his belongings. He was pleasant, and not reporting depression. He had anxiety and was aggressive when others were near his belongings. On 5/6/24 at 11:34 p.m., Resident D remained on observations from the resident-to-resident altercation. No adverse effects were noted. He had no emotional distress or mental anguish. He remained on one on one observations from the altercation. On 5/6/24 at 11:39 p.m., Resident D tolerated the start of Celexa and Depakote with no adverse effects thus far. A care management note, dated 5/7/24 at 11:57 a.m., indicated IDT reviewed Resident D's behavior. His current status, diagnoses, and medications were reviewed. His care plan was reviewed and revised as necessary. A communication note with family, dated 5/8/24 at 7:18 a.m., indicated Resident D's family was spoken to regarding moving him off the memory care unit. He was taken to the room by the one on one staff and he was shown the room. He liked it and liked his new roommate because he recalled him being on the unit before. He thought he used to work with him. Resident D had shown little patience with others who were demented. The move would be better for him emotionally and behavior-wise. The resident's family agreed. A behavior note, dated 5/8/24 at 7:44 a.m., indicated Resident D continued on one on one observations with no behaviors at that time. On 5/8/24 at 7:46 a.m., he was moved off the memory care unit. During an interview with the Social Service Director, on 5/15/24 at 10:46 a.m., she indicated Resident D was on the memory care unit and would get very territorial. There was a table by the exit door that he sat at in his wheelchair. He was territorial over the drawer in the table, so it was removed. He then became territorial over a chair. He had one altercation on the memory care unit where he shoved a female resident down. When the Social Service Director asked Resident D about the incident, he told her that the female resident reached down for the drawer and went to pull it out and she lost her balance and fell backward. He was just a grumpy old man, and he guarded his snacks in that drawer. No one witnessed the incident between Resident D and the female resident. He was not alert and oriented, and she thought he was severely cognitively impaired. During an interview with CNA 7, on 5/15/24 at 11:12 a.m., she indicated Resident D did not normally get up until after breakfast. He used a wheelchair and normally sat by the door to the memory care unit. He could be grumpy at times, and he didn't like people messing with his stuff. There was a little table at the entrance to the unit he would wheel up to and he kept his snacks in the drawer. He was territorial over the table. She hadn't seen him have an altercation with another resident. If anyone walked up to him and the table, he would say stay away from my stuff. She had never seen him be violent. During an interview with LPN 5, on 5/16/24 at 9:28 a.m., she indicated Resident D was a little grumpy and didn't want his things touched. Behaviors were documented in the nurses' notes. During an interview with the SSD, on 5/16/24 at 9:45 a.m., she indicated Resident D was put on depakote because he kept messing with his suprapubic catheter and he kept pulling it out. He liked to wear the catheter on the outside of his pants and indicated that's what the doctor had told him to do. The medication was also started because the resident was being territorial with the desk. If anyone got close to his desk he would yell Get them away. There was a resident who couldn't hear and would come near him, and he would tell her to get away. She would get away and sit in a chair. Then he would take out a cracker out of his drawer and take a bite, as if to taunt her. She would yell at him and tell him not to eat that. The SSD would sit in her office and just laugh at them. The worst thing the facility did was give him that table. During an interview with CNA 13, on 5/16/24 at 9:53 a.m., she indicated Resident D would growl if anyone got close to his coffee/table. She had never seen him be aggressive. During an interview with the DON, on 5/16/24 at 10:15 a.m., she indicated they took the table away from Resident D. He had no physical aggression towards others. They were not 100% sure he pushed the female resident down, but he was territorial with his surroundings. She reached for his coffee, and he tried to prevent her from getting it, and she stepped back and fell . His initial response was that he did push her, but they were not sure if he really did. He was seen by psychiatric services on the Monday afterward the incident and his medications were adjusted. He had not had prior physical aggression. He was on one-on-one observations for seven days. He didn't like his stuff messed with, they moved him off the memory care unit because he had no elopements, and the boundaries of other residents were different outside the unit. The Medical Director ordered the depakote on 5/6/24. The DON could not locate notes regarding why the doctor put Resident D on the medication and the psychiatric NP ordered the Celexa. The DON was not sure what the NP's notes indicated as the reason to prescribe the Celexa. Resident D had a diagnosis of depression. During an interview with the Medical Director, 5/16/24 at 10:44 a.m., he indicated he had been in the facility and staff reported Resident D had frequent behaviors. He had an altercation this one time with another resident, when they were trying to get the same item. Resident D grabbed her, pushed her, and she had received broken bones. The Medical Director treated the resident's aggressiveness and prevented him from injuring another resident. If they didn't do anything, they would receive a citation and if they do something like medicate a resident, they would receive a citation, so either way, it would be the same conversation. During an interview with the Psychiatric NP, on 5/16/24 at 11:23 a.m., she indicated this had been the first time she had seen Resident D. There were mixed reports about whether the incident was witnessed or unwitnessed. Resident D said he pushed the female resident and said he felt like people were taking his things. Basically, the resident said to her that he going to do what he could to keep other residents from getting his things. She tried to talk to him about what he would do, and he would change the conversation and she tried to redirect the conversation back. He did not present with agitation and was with a staff member for one on one observation. She had no justification to put him on an antipsychotic or to send him out to psychiatric hospital. She felt she needed to initiate Celexa to keep him from hurting somebody else and felt that was the best course of action to create more of an antianxiety effect. Celexa and Lexapro (antidepressant) were her go-to medications for a resident to be more restful. A current facility policy, titled Unnecessary Medication, provided by the DON on 5/16/24 at 1:42 p.m., indicated the following: . Procedure . 2. The facility will assess the resident's underlying condition, current signs, symptoms, and expressions and preferences and goals for treatment. This will assist the facility in determining if there are any indications for initiating, or withholding medication(s), as well as the use of non-pharmacological approaches. a. A diagnosis alone may not warrant treatment with medication . 3. e. The use of non-pharmacological approaches, unless contraindicated, to minimize the need for medications . 4. The resident's medical record should show documentation of adequate indications for a medication's use and the diagnosed condition for which a medication is prescribed This citation relates to Complaint IN00433954. 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure cogntively impaired residents were offered services during dining to promote dignity and a homelike, comfortable atmosphere for 6 of 23 resident observed during dining observation. (Residents 9, 13, 23, 25, 31, and 66) Findings include: During a dining observation on the Ivy Court Memory Care Unit on 2/22/24 10:56 a.m. to 12:06 p.m., residents were observed seated around the dining room. Some residents had been served beverages. The activity assistant (AA 12) was observed seated at a table, alone, off in a small area in the dining room. She had a song playing on her cell phone with low volume. At 11:00 a.m., the song playing on AA 12's cell phone ended. No activity was occurring, no music was playing, and the TV in the dining room was off. Residents remained seated at the tables and two left the dining room. AA 12 remained seated in the area to the side of the dining room. At 11:18 a.m., AA 12 played a song on her cellphone with low volume. A few residents seated close to her table began to clap and move in their chairs. The song finished. At 11:23 a.m., Resident 31 indicated to Resident 9, I think I'll just lay my head down and take a nap. Resident 9 replied, yeah and sighed. The dining room remained quiet with no music, activity or TV. AA 12 could be heard having a conversation with Resident 23 who had sat at the side table with them. At 11:26 a.m., AA 12 indicated to Resident 23, I'll see you in a bit, I'm going to lunch. I'll show you those pictures when I get back. She had not addressed any other residents prior to exiting the dining room. At 11:28 a.m., Resident 19 indicated to no one in particular, I think I'll go to sleep and placed her head in her hands for a few seconds, then turned her wheelchair around and left the dining room. At 11:35 a.m., the room remained quiet with no music, activities or TV. Two residents were observed leaving the dining room. At 11:48 a.m., the drink cart had been delivered. Residents asked CNA 11, as she entered the dining room, when beverages would be served. Resident 25 approached the drink cart and CNA 11 asked her to go to a table please, and assisted Resident 25 to a table facing a window. At 11:50 a.m., Resident 23 began to sing God Bless America, joined by Resident 25 and Resident 66 and other residents began to clap. Following the song, the room remained quiet without music, activity or TV. At 11:57 a.m., several residents began entering or being escorted to the dining room. A nurse entered the dining room and turned on the TV. Residents watched a talk show. The first lunch tray was served at 12:06 p.m. A clinical record review for Resident 9 was completed on 2/23/24 at 10:30 a.m. Diagnoses included dementia, history of traumatic brain injury, and depression. A quarterly Minimum Data Set (MDS) assessment, dated 12/18/23, indicated the resident had severe cognitive impairment. An admission MDS assessment, dated 6/30/23, indicated she indicated having books, newspapers, and magazines to read as very important, and having music and doing things with groups of people as somewhat important. A clinical record review for Resident 13 was completed on 2/23/24 at 1:40 p.m. Diagnoses included dementia and cognitive communication deficit. An annual MDS assessment, dated 10/6/23, indicated she had severe cognitive impairment and found doing things with groups of people and music were somewhat important. A clinical record review for Resident 14 was completed on 2/23/24 at 1:45 p.m. Diagnoses included dementia and anxiety disorder. An annual MDS assessment, dates 5/18/23, indicated resident had severe cognitive impairment and found doing things with groups of people were somewhat important. A clinical record review for Resident 23 was completed on 2/23/24 at 1:48 p.m. Diagnoses included dementia and anxiety disorder. An annual MDS assessment, dated 5/8/23, indicated she had severe cognitive impairment and found doing things with groups of people were somewhat important. A clinical record review for Resident 25 was completed on 2/21/24 at 10:48 a.m. Diagnoses dementia, major depressive disorder, cognitive communication deficit. An annual MDS assessment, 4/7/23, indicated she had severe cognitive impairment and found doing things with groups of people and music were somewhat important. A clinical record review for Resident 31 was completed on 2/23/24 at 1:51 p.m. Diagnoses included dementia, schizophrenia, and cognitive communication deficit. An annual MDS assessment, dated 2/13/24, indicated she had severe cognitive impairment and found doing things with groups of people and music were somewhat important. A clinical record review for Resident 66 was completed on 2/23/24 at 1:34 p.m. Diagnoses included dementia and protein-calorie malnutrition. An annual MDS assessment, dated 1/25/24, indicated she had severed cognitive impairment, and found doing things with groups of people, music and news were somewhat important. During an interview on 2/23/24 at 1:57 a.m., the Activity Director indicated there should be a planned activity on the Memory Care unit during the wait for lunch service to engage residents. She was unsure why AA 12 had not engaged the residents. During review of the February 2024 Activity Calendar for Ivy Court, provided by the Activity Director on 2/23/24 at 2:37 p.m., indicated an activity scheduled at 11:30 a.m. as Daily Chronicles. A current facility policy, revised 11/2/21, titled, Therapeutic Activities Program, provided by the Administrator on 2/23/24 at 1:31 p.m., indicated, Policy, The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program Definition, Activities - Refers to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense off well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. 3.1-3(t)

Based on interview and record review, the facility failed to resolve Resident Council concerns and provide a response to the group regarding their concerns. Findings include: Review of facility Resident Council minutes, on 2/21/24 at 2:30 p.m., indicated the following concerns were reported during the meetings: On 1/10/24, concerns with call lights, showers, and linen on the floor were reported. On 2/7/24, concerns with call lights, linen on floor, and care issues were reported. The minutes lacked specific details regarding these concerns. The minutes lacked a response to the resident council group or action taken to resolve any concerns from the previous meetings. Review of resident council concerns in the grievance binder was completed on 2/21/24 at 4:30 p.m. The reported resident council concerns/grievances from the resident council meeting held on 1/10/24 were not included. In response to the 2/7/24 resident council concerns, which did not include water temperature complaints, undated inservice materials indicated water temperature concerns were to be reported to the nurse immediately so it could then be reported to the Administrator or Maintenance Director. During an interview on 2/21/24 at 4:35 p.m., the Administrator indicated all of the grievances and responses were provided in the binder. During an interview on 2/21/24 at 4:49 p.m., the SSD indicated all grievances and resident council concerns were current and provided in the grievance binder. Any concerns brought up in the resident council meetings should have been placed on a blue card (grievance form). The appropriate manager who addressed the concerns completed the responses to the group or person who submitted the concerns. The Administrator signed off on the concern/grievance after it was addressed and feedback was provided to those who voiced the concerns. During a Resident Council group interview on 2/22/24 at 11:00 a.m., the following concerns were expressed: Two out of five residents in attendance indicated concerns/grievances were not addressed promptly. Four out of seven residents indicated no one provided feedback on their resident council concerns to inform them what or if anything was done to correct their concerns. The Activity Director (AD) attended the meetings and took minutes, but she did not discuss any action taken on the concerns reported from the previous meetings. Concerns reported during the resident council meeting in January were still unresolved and brought up again in February. A response/action taken was not provided to the resident council group on 2/7/24 regarding the unresolved concerns about call lights, showers, and linens on the floor. Seven out of seven residents indicated no one responded to them regarding how grievances/concerns were addressed. They discussed a lack of hot water in the residents' rooms, from approximately 12:00 a.m. to 4:00 a.m., during at least the last four months. The lack of hot water in resident rooms had not been corrected, nor a response provided to the resident council group regarding this concern. Three of seven residents indicated cold water was used during incontinence care and/or to wash their hands after toileting in the night. The water felt cold and was not a pleasant temperature for bathing or personal hygiene. This was not a water temperature they would select for bathing or personal hygiene at home. None of them received a response to the unresolved water concerns. During an interview on 2/22/24 at 11:32 a.m., the AD indicated she attended the Resident Council group monthly meetings and took minutes regarding their current month concerns mentioned during the meeting. Resident Council group concerns were placed on a blue card to be addressed by the proper department. Responses to the residents' concerns were not discussed from the previous meeting. The Resident Council group voiced a concern regarding cold water in the night during the 2/7/24 resident council meeting. The grievance/concern forms were to be filled out by the next morning. This concern was not documented in the resident council minutes, the grievance binder, nor the maintenance request forms provided. During an interview on 2/23/24 at 2:20 p.m., the AD indicated everything reviewed in the Resident Council group meeting was included in the minutes. She thought the concerns from the meeting on 1/10/24 were placed on a grievance form to be addressed, but they were not in the grievance binder. The same concerns again reported during the meeting on 2/7/24, were unresolved concerns from the 1/10/24 meeting. These concerns were not placed in the grievance process until mentioned again on 2/7/24. During an interview on 2/23/24 at 2:43 p.m., the Administrator indicated concerns brought to the resident council meeting should be placed on a grievance form. Follow up should be completed with the person or group who filed the concerns within 24 hours, and resolved within 48 hours. A current facility policy, revised on 9/27/23, titled Resident Council, and provided by the Administrator on 2/23/24 at 2:41 p.m., indicated the following: .Federal Regulations . The resident has a right to organize and participate in resident groups in the facility . (iv). The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. a. The facility must be able to demonstrate their response and rationale for such response . Procedure . 3. The Activities Director or Social Services Director will facilitate follow-up on all complaints, suggestions and ideas presented at the council meeting and will report results at the next meeting for the resident's information. This information will be included in the minutes. 4. Each department director will be responsible for filling out a comment and concern form, prior to the next meeting to provide his or her input . 3.1-3(l)

Based on observation, interview and record review, the facility failed to maintain proper hot water temperatures for personal hygiene in a comfortable and homelike manner for 3 of 5 residents reviewed for environment. (Residents B, D, and C) Findings include: 1. During an interview on 2/20/24 at 3:14 p.m., Resident B indicated the water in the resident's restroom was cold and very uncomfortable when staff provided incontinence care during the day and night shifts. It was difficult to get back to sleep when cold water was used on the resident's buttocks in the middle of the night. This was reported to all of the aides who provided care to the resident on multiple shifts weekly since December. This concern was also reported to LPN 4, RN 5, and RN 6 on various occasions. Over a month ago, the resident reported the concerns to the DON and ADON. The water temperature remained unchanged. During a continuous observation on 2/20/24 from 3:21 p.m. to 3:26 p.m., the resident's hot water faucet was turned on and ran continuously. The water was cold to the touch throughout the observation. During a continuous observation on 2/21/24 from 11:00 a.m. to 11:05 a.m., the resident's hot water faucet was turned on and ran continuously. The water was lukewarm to touch throughout the observation. 2. During an interview on 2/20/24 at 3:17 p.m., Resident D indicated the water in her restroom had been very cold since approximately September 2023. The resident reported this to multiple aides at least weekly and also reported it to LPN 4 and other unidentified nurses. The shower water was warm in the shower room, but when the residents' decided to get a bed bath or needed incontinence care, the water was cold. They had to wash their hands with cold water after toileting. The resident previously let the water run for up to 20 minutes, and it only got to room temperature. During a continuous observation on 2/20/24 from 3:21 p.m. to 3:26 p.m., the resident's hot water faucet was turned on and left running. The water was cold to the touch throughout the observation. During a continuous observation on 2/21/24 from 11:00 a.m. to 11:05 a.m., the resident's hot water faucet was turned on and ran continuously. The water was lukewarm to touch throughout the observation. 3. During an interview on 2/19/24 at 2:37 p.m., Resident C indicated the water was too cold for her bed baths. Since the water was cold, they marked her bed bath as a refusal. During an interview at the time of observation on 2/21/24 at 11:13 a.m., the resident's hair had an oily appearance. She indicated she preferred bed baths on Tuesdays. She refused bed baths on some days because the water was really cold in the resident's restroom. She tolerated incontinence care with the cold water so her skin would not break down, but it was really uncomfortable to have cold water used all over her body. The water temperature in the restroom had been cold since approximately November. She had reported the cold water to multiple aides, on a regular basis when they have provided incontinence care since November. The resident also reported the water temperature concerns to the Marketing Director and LPN 4 on unknown dates. The only response she received from LPN 4 was, Well it is winter, what do you expect? Otherwise, no one got back with her to indicate what, if anything, was done to resolve the water temperature problems. During a continuous observation on 2/21/24 from 11:32 a.m. to 11:38 a.m., the resident's hot water faucet was turned on and ran continuously. The water was lukewarm to touch throughout the observation. During an interview at the time of observation on 2/22/24 from 10:17 a.m. to 10:19 a.m., the Maintenance Director indicated Resident C's restroom hot water was 66.5 degrees Fahrenheit when he turned it on. The water was 89.1 degrees Fahrenheit after it ran continuously for two minutes. This was not an acceptable hot water temperature. He had not attempted to use a different thermometer to check for thermometer accuracy and no mechanical changes were made since August 2023. The two water heaters on the Hickory Unit also supplied hot water to the kitchen and laundry rooms. Hickory Unit was the only unit that reported water temperature concerns. The other units had their own independent water heaters. During a continuous observation at the time of interview on 2/22/24 from 1:44 p.m. to 1:47 p.m., Resident C's hot water faucet in her restroom was turned on by LPN 4 to complete hand hygiene. She indicated the water was cold and the water ran continuously for 3 minutes. The water was only tepid after it ran 3 minutes. Tepid water remained too cold to be used for personal hygiene and she understood why the residents would not want to be bathed with water that cold. During an interview on 2/22/24 at 9:04 a.m., CNA 7 indicated she was familiar with residents on all of the units. Several unnamed residents on the Hickory Unit had mentioned the water in the resident's restrooms was cold when she assisted them with incontinence care. She noticed it was cold in the mornings and had been cold between 1:00 a.m. and 3:00 a.m. as well. The warm water in the resident's room was not a temperature she would find comfortable for bathing. Although the water temperature concerns were ongoing for several residents, she had not reported the water temperature concerns to anyone for further review because she knew the Maintenance Director was aware of the water temperature concerns. During an interview on 2/22/24 at 9:16 a.m., LPN 4 indicated Residents B, D, and C had reported the cold water temperatures in the resident's restrooms since it got cold out. The hot water had to run approximately 11 minutes in the Hickory Unit before the residents got any warm water. Sometimes, it still remained cold. The water was not a temperature that was pleasant or homelike for bathing. The Maintenance Director had been notified of the water temperature concerns on several occasions, but it remained a problem. During an interview on 2/22/24 at 9:43 a.m., the Maintenance Director indicated the resident's hot water temperatures should be maintained between 100 - 120 degrees Fahrenheit. The water temperatures were logged weekly in an electronic system. During an interview on 2/22/24 at 9:57 a.m., the Maintenance Director indicated around November a resident complained about a lack of hot water in his restroom. He checked the water temperature, but the resident continued to complain weekly about cold water. The resident tells anyone who will listen to him. Different staff members have also mentioned water temperature concerns. Additionally, they have called him into the facility at midnight due to cold water. The water temperatures had been checked and were within acceptable guidelines. The Maintenance Request Forms from 11/1/23 to 2/22/24 were reviewed on 2/22/24 at 10:39 a.m. One request, dated 1/7/24, indicated there was no hot water on the halls and the shower was only lukewarm. Only one temperature of 113.4 degrees Fahrenheit was logged without a defined location. The request was marked completed on 1/8/24. During an interview on 2/23/24 at 2:43 p.m., the Administrator indicated he was aware of one unknown resident who reported room temperature water in the resident's restroom the first week of February. These concerns should have been placed through the grievance process to ensure they were followed through and resolved. He was unable to provide the hot water temperature monitoring logs for residents' rooms that should have been completed weekly. Instead, the Maintenance Director told him he had checked the shower room temperatures since the resident rooms ran on the same water heater. A review of the facility water temperature logs was completed on 2/23/24 at 3:18 p.m. Water temperature logs lacked weekly monitoring of the water temperatures in resident rooms from 11/10/23 to 2/22/24. The last resident room temperature monitoring occurred on 12/8/23. Further water temperature monitoring information was not provided prior to the survey exit. A current facility document, dated 2022, titled RESIDENT ADMISSION AGREEMENT, provided by the Administrator on 2/19/24 at 10:00 a.m., indicated the following: . Section 11: Resident Rights . 48. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely A current facility policy, dated 1/15/24, titled Water Temperature Inspection, provided by the Administrator on 2/23/24 at 2:59 p.m., indicated the following: Policy . The facility monitors all water temperatures on a weekly basis or more often if needed . Procedure . Shower/Faucet Temperatures: 1. Temperatures will be taken weekly from one resident's room on each wing on a rotating basis . 2. Satisfactory temperature range is maintained per state regulations. 3. All temperatures will be recorded on a temperature log sheet This tag relates to complaint IN00428872. 3.1-19(r)(1) 3.1-19(r)(2)

Based on observation, interview, and record review, the facility staff failed to utilize the grievance process to address and resolve resident grievances/concerns/complaints, to ensure follow up with a corrective action for 3 of 3 residents reviewed for grievances about lack of hot water availability. (Residents B, D, and C) Findings include: 1. During an interview on 2/20/24 at 3:14 p.m., Resident B indicated the water in the resident's restroom was cold and very uncomfortable when staff provided incontinence care during the day and night shifts. This was reported to all of the aides who provided care to the resident on multiple shifts weekly since December. This concern was also reported to LPN 4, RN 5, and RN 6 on various occasions. Over a month ago, the resident reported the concerns to the DON and ADON. Although the concerns were reported to multiple staff, no one has responded to the resident with any plan of correction to resolve the water temperature. The water temperature remained unchanged. 2. During an interview on 2/20/24 at 3:17 p.m., Resident D indicated the water in her restroom has been very cold since approximately September 2023. The resident reported this to multiple aides at least weekly and also reported it to LPN 4 and other unidentified nurses. No one responded to her to let her know if the facility had any plans to fix the water problem. She was uncertain if anyone even cared about the residents' using cold water for personal hygiene. The shower water was warm in the shower room, but when the residents' decided to get a bed bath or needed incontinence care, the water was cold. The water was even cold to wash their hands in the restroom after toileting. The resident previously let the water run for up to 20 minutes and it was only room temperature. 3. During an interview on 2/19/24 at 2:37 p.m., Resident C indicated the water was too cold for her bed baths. Since the water was cold, staff marked her bed bath as a refusal. During an interview on 2/21/24 at 11:13 a.m., Resident C's hair had an oily appearance. The resident indicated she preferred bed baths on Tuesdays. The resident had refused bed baths on some days because the water was really cold in the resident's restroom. She tolerated incontinence care with the cold water so her skin would not break down, but it was really uncomfortable to have cold water used all over her body. The water temperature in the restroom had been cold since approximately November. She had reported the cold water to multiple aides on a regular basis when they have provided incontinence care. The resident also reported the water temperature concerns to the Marketing Director and LPN 4 on unknown dates. The only response she received from LPN 4 was, Well it is winter, what do you expect? Otherwise, no one got back with her to indicated what, if anything, was being done to resolve the water temperature problems. Review of the facility's grievances from 11/1/23 to 2/21/24 (in a binder provided by the Administrator) was completed on 2/21/24 at 4:30 p.m. It lacked concerns/grievances regarding water temperatures reported by staff or residents B, D, or C. During an interview on 2/22/24 at 9:04 a.m., CNA 7 indicated she was familiar with residents on all of the units. Several unnamed residents on the Hickory Unit had mentioned the water in the resident's restrooms was cold when she assisted them with incontinence care. She noticed it was cold in the mornings and has been cold between 1:00 a.m. and 3:00 a.m. as well. The warm water in the resident's room was not a temperature she would want to use for bathing. Even though the water temperature was ongoing for several residents, she had not reported the water temperature concerns to anyone for further review because she knew the Maintenance Director was aware of the water temperature concerns. During an interview on 2/22/24 at 9:16 a.m., LPN 4 indicated Residents B, D, and C had reported the cold water temperatures in the resident's restrooms since it got cold out. The facility had grievance forms, but none were completed for the water temperature concerns because the residents never told her to specifically make it a complaint. The hot water had to run over 10 minutes in the Hickory Unit for them to get any warm water. Sometimes, it remained cold. The water was not a temperature that was pleasant or homelike for bathing. The Maintenance Director had been notified of the water temperature concerns on several occasions, but it remained a problem. During an interview on 2/22/24 at 9:34 a.m., the Marketing Director indicated water temperature concerns in the residents' rooms was a concern that should be reported via a grievance form. Any staff member, resident, or visitor could complete a grievance form. The grievance forms were readily available for concerns. During an interview on 2/23/24 at 2:43 p.m., the Administrator indicated he was aware of one unknown resident who reported room temperature water in the restroom the first week of February. He was unaware of any further concerns regarding cold water in the residents' restrooms. These concerns should have been placed through the grievance process to ensure they were followed through. Grievances should have been responded to in 24 hours, and resolved in 48 hours. A current facility policy, dated 9/25/23, titled Grievance Program (Concern and Comment), provided by the Administrator on 2/23/24 at 2:52 p.m., indicated the following: Policy .1. Residents and their families have the right to file a complaint . 2. Residents' rights should be protected when voicing complaints to maximize the quality of life for each individual and to promote customer satisfaction with facility care and services. 3. The Concern & Comment Program is utilized to address the concerns of residents, family members and visitors . Federal Regulations . The resident has the right to voice grievances to the facility or other agency or entity that hears grievances . Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished . and other concerns regarding the LTC facility stay . The resident has the right to, and facility must make prompt efforts by the facility to resolve grievances the resident may have . Definitions . Prompt effort to resolve - This refers to a facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . Procedure . 3. Any associate can assist in the completion of a Concern & Comment Form if a resident, family member, or guest expresses a concern or comment. Concern & Comment Forms can be found in centralized locations throughout the facility. a. Resolve the concern, if possible. If resolution is not possible at that time, explain to the individual that another staff member will be assigned to investigate the concern and will contact them in a timely manner. B. All concerns are reported to the Supervisor on duty who will then contact the Executive Director, Director of Nursing, and/or other personnel as needed . 8. Following up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction . Executive Director and/or Designee is responsible for the following: 1. Overseeing the facility's overall grievance program, including the Concern & Comment program. 2. Ensuring that all grievances and Concern & Comment Reports have been reviewed and addressed in a timely and appropriate manner and that concerned individuals feel that some type of resolution has been communicated, achieved, and maintained This tag relates to complaint IN00428872. Cross reference F584. 3.1-7(a)(1) 3.1-7(a)(2)

Based on observation and interview, the facility failed to ensure medications were labeled with resident identifiers and directions for 1 of 2 medications storage rooms reviewed (Hickory) and for 2 of 4 medication carts reviewed (Hickory 2 and South carts). Findings include: 1. During a medication storage observation of the Hickory hall unit medication room, accompanied by LPN 4 on 2/22/24 at 3:22 p.m., five unlabeled 650 mg (milligram) acetaminophen (to treat fevers or mild pain) suppositories were in the refrigerator. During an interview, at the time of the observation, LPN 4 indicated there was not a label present on the medications. 2. During a medication storage observation of the Hickory 2 medication cart, accompanied by LPN 4 on 2/22/24 at 3:30 p.m., an open and unlabeled bottle of Copper (a supplement) 2 mg tablets was observed. During an interview, at the time of the observation, LPN 4 indicated there was not a label present on this medication. 3. During a medication storage observation of the South unit medication cart, accompanied by LPN 10 on 2/22/24 at 3:46 p.m., the following medications were observed without resident identifiers and directions: One bottle [NAME] aspirin (a pain reliever) 81 mg tablets, One bottle loperamide hydrochloride (to treat diarrhea) 2 mg tablets, One bottle St. [NAME] aspirin (a pain reliever) 81 mg tablets, and One bottle B-12 (a vitamin) 5000 mcg (micrograms) capsules. During an interview, at the time of the observation, LPN 10 indicated these medications did not have any resident identifier labels or markings on the bottles. During an interview, on 2/23/24 at 11:45 a.m., the DON indicated all medications stored in the medication rooms or carts should have a label with resident identifiers, or at least a name written on the containers. During an interview, on 2/23/24 at 2:33 p.m., the DON indicated the facility did not have a specific policy related to medication labeling but followed the Indiana State regulations as listed in the operations manual. 3.1-25(j) 3.1-25(k)

Based on interview and record review, the facility failed to ensure a communication process was utilized between the facility and dialysis center to maintain complete and accurate records for continuity of care for 1 of 1 resident reviewed for dialysis. (Resident 4) Finding includes: During an interview on 2/22/24 at 3:53 p.m., LPN 4 indicated Resident 4's dialysis binder contained the communication held between the dialysis center and the facility for continuity of care. The Pre/Post Dialysis Communication forms were sent with the resident, after the facility nurse documented her assessment, and prior to the departure from the facility. Often, the dialysis center returned the communication form back to the facility without completing their assessment of the resident on the communication form. The nurses from the facility did not call the dialysis center for a report or to request the resident assessment information for continuity of care. If the dialysis center had any concerns, they called the facility. The facility completed the post dialysis section of the communication form when the resident returned and placed the incomplete communication in the dialysis binder. Resident 4's clinical record was reviewed on 2/22/24 at 3:54 p.m. Diagnoses included, stage 5 chronic kidney disease and dependence on renal dialysis. The resident's clinical record lacked communication between the facility and dialysis center for each day the resident received dialysis services at the dialysis center. A quarterly Minimum Data Set (MDS) assessment, dated 1/24/24, indicated the resident had severe cognitive impairment. He received dialysis while he was a resident. A care plan indicated the resident was non-compliant with his fluid restriction. Interventions included the following: monitor the resident's fluid intake (10/3/23), educate him as needed to stay within the parameter of his allotted fluids for the day, and explain the risks. (1/5/24) The Pre/Post Dialysis Communication log lacked the entire dialysis assessment on the following dates: 2/12/24, 2/14/24, 2/16/24, 2/19/24, and 2/21/24. The information lacked vitals, pre-dialysis weight, post-dialysis weight, bruit presence, thrill presence, type of vascular access site, the amount of lunch consumed if the resident at lunch at the dialysis center, medication given, and instructions for the skilled nursing facility. During an interview on 2/22/24 at 5:00 p.m., the DON indicated the dialysis provider often failed to completed their portion of the resident Pre-Post Dialysis Communication log when the resident returned to the facility from the dialysis center. They did not have any other location for dialysis communication. When the dialysis center did not complete the form, it was assumed nothing went wrong. She felt the dialysis center would call if they had had any concerns. The facility did not have anyone appointed as a liaison between the facility and the dialysis center to monitor the communication to ensure the facility maintained thorough communication for continuity of care. The nurse on the resident's unit was not expected to obtain the missing communication when they returned to the facility. Any additional communication via telephone was charted in the progress notes. During an interview on 2/23/24 at 9:32 a.m., the Administrator indicated the facility should have followed the facility's contract with the dialysis center regarding the maintenance of completed and thorough communication, between the facility and the dialysis center, in the resident's record. A current facility document, dated 1/1/2017, titled AGREEMENT FOR DIALYSIS SERVICES, provided by the Administrator on 2/19/24 at 12:00 p.m., indicated the following: .4. Record Maintenance. a. By Facility. Facility . have primary responsibility for maintaining all resident records . b.Facility shall be entitled to receive copies of medical records of Provider specific to the Services rendered to resident to facilitate and support the resident's treatment, plan of care 3.1-37(a)

Based on record review and interview, the facility failed to follow the pharmacy services and procedures manual during pharmacy delivery to ensure medication deliveries were accepted according to facility protocol, resulting in a missed dose of pain medication. (Resident 48) Findings include: A 2/16/24 facility reported incident record indicated Resident 48 was missing a card of medication containing 30 tablets of hydrocodone-acetaminophen (a narcotic pain reliever) 5-325 mg (milligram). The facility staff was not able to locate the medication card needed for a requested pain relief intervention. An undated written statement in the incident record, indicated LPN 13 called the pharmacy to request an update for delivery of Resident 48's hydrocodone-acetaminophen 5-325 mg medication and was advised the delivery was completed on 2/13/24. Review of a 2/16/24 written statement in the facility investigation indicated LPN 10 was called over to the Hickory hall nurse's station on 2/13/24 and signed the pharmacy delivery papers, took possession of the kits, and proceeded back to her assigned location on the Ivy Court unit. Review of a 2/19/24 written statement in the facility investigation indicated RN 6 was approached by hospice staff on 2/16/23 to provide Resident 48 with one dose of hydrocodone-acetaminophen pain relief medication. RN 6 was not able to provide this medication as it was not able to be found. Resident 48's clinical record was reviewed on 2/23/24 at 1:55 p.m. Diagnosis included chronic obstructive pulmonary disease and stage four chronic kidney disease. Resident 48 was admitted to hospice services on 10/16/23 with a terminal illness. A current physician order, dated 1/21/24, indicated one hydrocodone-acetaminophen 5-325 mg tablet to be given every 4 hours as needed for pain. During an interview, on 2/22/24 at 3:30 p.m., LPN 4 indicated pharmacy deliveries were done at the Hickory hall nurse's station only and two nurses were required to check that the correct medications were delivered and sign for acceptance of the delivery. She indicated the facility got a copy which was filed in the pharmacy review folders on each unit. The narcotic medication arrived in a different colored bag than the rest of the medications. The nurses assigned to each area would be contacted to come and retrieve the medications for that unit. A review of the pharmacy Proof of Delivery receipt for 2/13/24 indicated only one staff member signed for the delivery. During an interview, on 2/23/24 at 3:18 p.m., the DON indicated the pharmacy deliveries were made at the Hickory hall nurse's station and the policy states for two nurses to review the delivered medications before signing on the delivery drivers electronic tablet. The facility received the delivery receipt attached to the delivery bag. The DON indicated, during the course of the investigation, it was discovered LPN 10 failed to examine the contents received at the facility on 2/13/24. A current facility policy, revised 1/1/22, titled, LTC Facility's Pharmacy Services and Procedures Manual, provided by the Administrator on 2/23/24 at 2:34 p.m., indicated the following: . 1. Upon delivery by Pharmacy, Facility nurse or other authorized designee on behalf of Facility should: 1.1 Sign the delivery manifest (may be electronic signature if permitted by Applicable law), note the time of arrival, and take responsibility for the receipt, proper storage, and distribution of the delivered medications 2. A Facility nurse should inspect the package(s) for damage or errors and notify Pharmacy as soon as possible but within twenty-four hours of any damage or other discrepancies 3.1-25(a)

Based on observation, interview and record review, the facility failed to prevent staff to resident abuse for 2 of 2 residents reviewed for abuse (Resident G and C). Using the reasonable person concept, it is likely this deficient practice would lead to anxiety and fearfulness (Resident G). Findings include: 1. Resident G's clinical record was reviewed on 12/1/22 at 11:49 a.m. Diagnoses included, but were not limited to, communication deficit, unspecified focal traumatic brain injury without loss of consciousness, sequela, need for assistance with personal care, and major depressive disorder, single episode. Physician orders included citalopram hydrobromide (antidepressant) 20 mg (milligram) daily. A quarterly MDS (Minimum Data Set), dated 10/14/22, indicated he was severely cognitively impaired. He had a current care plan, initiated on 11/11/22, for having been traumatized by a staff member and he was trying to cope. He felt bad about himself and felt maybe he was to blame for her dislike for him and maybe he needed to change. His goal was he would find a way to feel good about himself again as evidenced by smiling and getting out of bed more and attending some activities with others. His interventions included to visit and encourage him to be up and out of bed, arrange for him to see the psychiatric nurse practitioner and continue with his weekly routine of seeing the mental health counseling services. A psychosocial note, dated 11/8/22 at 12:26 p.m., indicated he had an incident with a staff member which had upset him the prior morning. The occurrence had been addressed and would not happen again. Resident G was spoken to again this morning, he was still a little worried that the staff member may do something to him, but he was relieved when he was informed that the person was no longer at the facility. No injuries happened as a result of the incident, but it left him with some anxiety which had since been resolved. He exhibited no signs or symptoms of mental or emotional anguish. He would continue to be monitored to ensure no lasting concerns. A psychosocial note, dated 11/9/22 at 4:22 p.m., indicated he was doing well this day. He exhibited no sign or symptoms of mental or emotional anguish this day. He was smiling and stated that he felt good. A psychosocial note, dated 11/10/22 at 5:40 p.m., indicated he asked if CNA 6 was going to come back. He stated he was afraid of her and did not want to see her again. He was afraid she was mad at him and might do something. He was assured that he was safe, and no harm would come to him. He was relieved. He exhibited just a little sign of emotional distress. He had apparently been thinking about the whole thing and just wanted to make sure she would not be able to retaliate against him. He was afraid of her. He was seen by the mental health counseling services and she noted that he exhibited moderate depression. She tried to get him to identify a positive about himself and he was unable to. He may have just needed time to get back to his emotional baseline. A cognitive patterns/BIMS (Brief Interview for Mental Status) note, dated 11/11/22 at 9:54 a.m., indicated his BIMS score was 11 (moderately cognitively impaired) this day and stated he felt better and was not so afraid now. He had started to forget about the CNA who didn't like him, but he didn't know what he did that made her not like him. He was assured it was not him and to not take it personally. A mood/PHQ-9 (Patient Questionnaire-9) note, dated 11/11/22 at 1:20 p.m., indicated he had some depression, he felt bad about himself at least 7 out of 14 days. He thought others didn't like him but did not know why. It made him feel bad. He talked with the therapist from the mental health counseling service and stated it made him feel better. Review of CNA 6's employee file, on 12/2/22 at 10:00 a.m., indicated the following: On 8/24/22, she was reprimanded for poor job performance, staff members complained she was rude to residents, was not a team player, and was constantly on her cellphone. On 9/28/22, she was reprimanded for using her cellphone during resident care, poor job performance and not being a team player, and not attending to resident's needs in a timely fashion. The supervisor comments indicated multiple residents had complained she did not attend to needs in timely manner and multiple reports she took excessive breaks. On 10/6/22, she was reprimanded for cellphone use during resident care, not attending to resident needs in timely fashion and being a poor team player. Supervisor comments were multiple residents complained she did not attend to the resident needs in timely manner. She had made comments she was not charting and was not doing showers. During an interview, on 12/1/22 at 12:48 p.m., Dietary Aide 7 indicated CNA 6 was serving meals in the dining room. Resident G was heard to ask for something he didn't have. CNA 6 told him to stop complaining and eat his food. It was alarming to see her say that to him. Dietary Aide 7 had gone with Dietary Aide 10 to report another incident about a week later to the Admissions/Marketing staff member and the Administrator. They had them write statements. CNA 6 was always very short and rude to the residents. While assisting the residents with meals, she would be on her cellphone. A facility investigation was reviewed on 12/1/22 at 12:49 p.m. Other residents had indicated CNA 6 was very rude during care and had yelled at times. She used inappropriate language and behavior when providing care. She had told a resident to sit down now and asked what do you want now, she had just been in the room and she was busy. During an interview, with Dietary Aide 10 on 12/1/22 at 3:30 p.m., she indicated about a week or so prior to what Dietary Aide 7 had witnessed, a resident had been standing with her walker near the service window in the dining room. She looked like she was urinating and CNA 6 had indicated to the resident it was nasty, she was a grown woman and she needed to go to the bathroom. There were other resident's present in the dining room at the time. The dietary aide reported it to the Dietary Supervisor and then went with Dietary Aide 7 to the Administrator's office to report the incidents they both had witnessed with CNA 6. She was asked to write a statement and to slip it under the Administrator's door. CNA 6 seemed like she had an attitude towards the residents when they asked for help. During an interview with Resident G, on 12/2/22 at 9:35 a.m., he knew he had an incident with a staff member but couldn't remember what had happened at the time. During an interview with the Social Service Director, on 12/2/22 at 1:21 p.m., she indicated Resident G was afraid that CNA 6 was going to retaliate against him. He was reassured that would not happen. He was actually afraid of her for two to three days and was visibly upset about it. He was frightened to death. He was bullied in the past and was beat with a baseball bat for trying to defend a girl and had suffered a traumatic brain injury. He had told her he didn't know why she didn't like him. He had indicated to her CNA 6 would get down to his ear and tell him to stop asking for anything else. It was scary for him. At times, even she was afraid of some of the staff. 2. Resident B's clinical record was reviewed on 11/30/22 at 2:07 p.m. Diagnosis included, but were not limited to, depression, bipolar disorder, current episode depressed, severe, without psychotic features, agoraphobia without panic disorder, anxiety disorder and altered mental status. Her orders included alprazolam (antianxiety) 0.25 mg daily, divalproex sodium (treat bipolar disorder) 500 mg daily, paroxetine (antidepressant) HCL (hydrochloride) 20 mg daily and risperidone (antipsychotic) 0.5 mg daily. An admission MDS assessment, dated 10/24/22, indicated she was moderately cognitively impaired. She had a current care plan, dated 11/17/22, for an event with a staff member which had greatly upset her. Her goal was she would not let the event stop her from living her best life in the facility, as evidenced by going out of her room, socializing with others, attending and participating in activities of her choice. Her interventions were to arrange for her to be evaluated by psychiatric nurse practitioner and weekly visits from the local mental health counseling therapist, monitor her for any negative changes in her moods and report to her physician. As she was a fairly new resident, get her acquainted with others in the facility and have her down for morning coffee and invite her to activities. An event note, dated 11/16/22 at 7:00 a.m., indicated she stated an incident occurred the evening prior with a staff member, resulting in a tiny skin tear between her right thumb and index finger. The small area was cleaned and a band aid was placed on it. She had no complaints of pain or discomfort. The Administrator, DON, medical doctor, and family was made aware. A psychosocial note, dated 11/16/22 at 10:30 a.m., indicated an event the evening prior had left her upset, and was being investigated by administration. She felt bad about the situation and initially had not wanted to report it. She was in a wheelchair and required assistance from staff for her daily care needs. A cognitive patterns/BIMS note, dated 11/16/22 at 10:37 a.m., indicated she was cognitively intact. She talked about her experience the prior evening with the two staff members and stated how it made her feel. A psychosocial note, dated 11/17/22 at 4:25 p.m., indicated she was very happy, relaxed and glad things were back to normal. She was no longer afraid and was thankful to Social Services and the Administrator for taking care of everything for her. A facility investigation was reviewed on 12/1/22 at 10:49 a.m. It indicated staff had reported CNA 16 could be rude, she cursed in the hall because they were short staffed, and residents needed to be interviewed about her. A resident indicated CNA 16 was not allowed in her room because she had told her to do something now. During an interview with LPN 4, on 12/1/22 at 3:23 p.m., she indicated Resident C was moved to a new room while her roommate was receiving end of life care. Resident C had been expecting a phone call from her son and was sitting in the doorway to her old room because her phone was in the room. She had tried to remove Resident C from the doorway and she wouldn't move, so she went back to passing medications down the hall. She told CNA 16 about Resident C, so she had tried to remove Resident C from the doorway of the room. Resident C locked her wheelchair and wouldn't move. CNA 16 tried to pull Resident C from the doorway of the room in her wheelchair and Resident C received a skin tear to her right hand between her thumb and index finger. She did not ask CNA 16 to remove her from the room. During an interview with Resident C, on 12/2/22 at 9:00 a.m., she indicated she had moved rooms while her roommate was in the process of dying, but all her belongings were still in the room with her roommate. She was waiting on a phone call from her son in the doorway to the room. The nurse tried to pull her out of the room and then went back down the hall. The nurse then asked CNA 16 to get her out of the room. CNA 16 came to her and tried to pull her backwards out of the room. She locked her brakes and CNA 16 still tried to pull her out. When she grabbed her wheels, she hurt both her hands but she had a cut on her right hand. She believed CNA 16 no longer worked at the facility. A current facility policy titled, Abuse - Identification of Types, found on the table on 12/1/22 at 2:00 p.m., indicated the following: .Policy: It is policy of the facility to identify abuse . This includes but is not limited to, identifying, and understanding the different types of abuse and possible indicators This Federal tag relates to complaint IN00394806. 3.1-27(a) 3.1-27(b)

Based on interview and record review, the facility failed to ensure a resident received required notification for an involuntarily transferred, a resident was not involuntarily transferred without medical necessity. This deficient practice resulted in a resident being involuntarily moved 77 miles from the facility and a decline in the residents mobility level for 1 of 3 residents reviewed for transfer service. (Resident C) Findings include: During an interview on 6/8/2021 at 11:27 a.m., Resident C indicated 3 different aides entered her room (at the Woodlands) on the morning of 5-21-2021 and told the resident to get up and get dressed because she was leaving the facility. The resident indicated she told the staff she was not going anywhere. The resident indicated she had not asked to transfer from the facility. A nurse came in her room and stated if the resident did not get in the wheelchair, she would give her a shot. The resident told the nurse I haven't done anything. I never told them I wanted to go to another facility. The resident indicated the nurse told her she was going to (name of facility located in Ft. [NAME]). The resident indicated three staff members forced her to lay down on her left side while the nurse administered an injection. The resident indicated after 30 minutes a nurse and another staff member (male who helped hold her down) entered her room and told her to get in the wheelchair. The resident told them No. She said the staff started pulling on her and she had cried out in pain. The male staff member pulled her legs and laughed at the resident stating she was putting on. The resident got into the wheelchair and on her way out of the facility she requested to use the phone so she could call the State to report the facility. The facility refused to allow her to use the phone. The resident stated before the transfer she had been able to walk using a walker. Since she had been in the new facility, she was unable to walk. She indicated she did not know what medication they had administered to her via the injection, but felt it was the reason she was no longer able to walk. The resident stated her inability to walk made her very depressed. During an interview on 6/8/2021 at 2:11 p.m., QMA (Qualified Medication Aide) 8 indicated on 5/21/2021 he entered the resident's room to administer eye medication. The resident became upset and threw water on him. He left to get assistance from LPN 7 due the resident's behaviors per behavioral protocol. He indicated LPN 7 stated the resident was getting ready for transfer to another facility at 10:30 a.m. During an interview on 6/8/2021 at 10:27 a.m., LPN 7 indicated she was called to the resident's room by QMA 8. She indicated the resident was upset because she thought they were trying to steal her eyes. The resident had never said that to her before. LPN 7 called the physician and received an one time order for [MEDICATION(S)] (antipsychotic medication), which she administered. Review of an Admission noted by the (Name of receiving facility Nurse Practitioner), dated 5/21/2021, indicated the following: . patient is a new admission from a local skilled nursing facility. She states she had turned the facility into state and placement here was revenge. She is confused to time and situation and appears slightly delusional. States pain at time of visit is a 10 out of 10 because she was held captive at previous nursing home. During an interview on 6/8/2021 at 11:17 a.m., Nurse 9 from the (Name of receiving facility) indicated the following: She has not had any behaviors for us. She is depressed but she is cooperative. She lets the CNAs (Certified Nursing Assistant) know that she is depressed. She has not said why she is depressed. She eats but she stays in her room in her bed. She is still cooperative but does not participates in any activity with other residents. She is a total assist. During an interview on 6/8/2021 at 11:05 a.m., the Social Services Director (SSD) from the (name of receiving facility) indicated the following: She was very friendly and pleasant. She has not had any behaviors since she has been here. Review of the (name of receiving facility) Admission Agreement, dated 5/21/2021, indicated the resident was able to sign her own admission paperwork. During a 6/7/21, 12:15 p.m. interview, the Woodland's Social Services Director (SSD) indicated Resident C was moved to a (name of receiving facility) because the resident had delusions about her eyes and was fearful in the facility. She indicated the resident did not request the transfer herself. The facility had initiated the transfer and the resident was in agreement with it. The SSD also indicated the Area Ombudsman had been involved in management of the resident's delusions and the need for transfer. At this time, the SSD was requested to provide documentation of the delusions, care plan for delusions, the plan for transfer, Ombudsman involvement, and paperwork regarding the residents desire and consent for transfer and/or a 30 day notice of involuntary transfer. Resident C's closed clinical record was reviewed on 6/7/21 at 10:45 a.m. The resident's discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated the resident was her own responsible party, no one had guardianship or Power of Attorney for the resident. The resident desired to make her own choices. She had resided in [NAME] prior to her admission to the Woodlands. The resident was admitted to the facility on [DATE] and involuntarily transferred from the facility on 5/21/21. The resident had no listed family or contacts in the receiving facility's city. A 3/9/21, quarterly, Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment. required limited assistance from one individual for walking in her room and transferring from one surface to another and used a walker as a mobility device. At the time of her, 5/21/21, discharge, the resident had a care plan in place regarding fall prevention. Approaches to this care plan included using an walker to ambulate and stand by assistance while ambulating. At the time of her, 5/21/21, discharge the resident had a current care plan need as follows; Discharge Plan reveals [resident's name] wanting to remain in the facility. The target date for this care plan was 6/8/21. The resident's closed clinical record documentation on the day of her involuntary transfer on 5/21/21, included but was not limited to the following: A 5/21/21, 9:06 a.m., Discharge Summary, authored by the Social Services Director, indicated [resident C's name] has been accepted at [facility name] behavior facility. She wants to be where no one here can look in her eyes and she is fearful they will try to take her eyes out in this facility. We have tried diligently to assure her that no one wants to harm her but has been to no avail. Hopefully she will feel more secure with a new place that has not had delusions pertaining to staff there. She is leaving today around 10:30 a.m. A Late Entry (no indication when entry was made) Progress Note with a effective date 5/21/2021, 10:00 a.m., indicated the resident became agitated because staff were looking at her eyes because they wanted to take them. The doctor and family were notified. The resident was given [MEDICATION(S)] to calm her for her transfer to the receiving facility. A 5/21/21, 1:17 p.m. Behavioral Progress Note indicated the following,, [resident's name] had started cursing everyone this morning and accused this writer of looking into her eyes. She was becoming agitated and does not like being by the window in her room where people can look through the window to see her eyes. She is becoming OCD about eyes and people trying to take them. She was finally given some [MEDICATION(S)] [an anti-psychotic medication] to calm her while she is transported to (name of receiving facility) [77 miles from [NAME]] She stated, 'I hate it here.' Resident C had a 5/21/21, one day, physician's telephone order for [MEDICATION(S)] Solution [an anti-psychotic medication] 5 MG/ML inject 2.5 mg intramuscularly one time only related to restlessness and agitation. The resident's record indicated the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to her 5/21/21, involuntary discharge, the resident's closed clinical records included, but was not limited to, the following documentation regarding her psychosocial well being, physical well being, and/or the need to transfer from the facility: A 5/10/21, 12:55 p.m., Communication Progress Note, indicated This writer contacted [resident's name] niece [who the record indicated was not guardian or POA] to let her know that we are looking for alternated placement for [resident's name]. She needs somewhere that can handle her behaviors better than we can. She said she understood . A 5/11/21, 1:35 a.m., Progress Note indicated the resident had a urinary tract infection and would require antibiotics for 10 days. The resident had a, 5/12/21, (nine days prior to her involuntary discharge) Physician's Progress Notes which did not mention the resident having any current delusions, being fearful, wanting to leave the facility, was a danger to herself or others, and/or having a need to relocate to a behavioral facility. A 5/13/21, 11:35 a.m., Discharge Summary Progress Note, indicated [resident's name] has been accepted to [facility name] in Ft. [NAME] where she will have more assist for her behaviors hopefully with better outcomes. A 5/14/21, 10:30 a.m., Psychosocial Progress Note, which indicated the writer had spoken to the resident about the possibility of moving to a different place that does not have the people there that she does not like. This entry did not indicated the resident was notified she would be relocated. The entry indicated she was notified of the possibility of a move. The closed record lacked any documentation that this conversation was followed up by the notification of the resident that she had been accepted to the new facility and the resident was in agreement to the relocation. The clinical record indicated the resident last saw her psychiatrist on 3/18/21. The note from this visit did not contain documentation of the resident having delusions about her eyes or being fearful of staff, wanting to leave the facility, being a danger to herself or others, and/or having the need to relocate the a behavioral facility. Progress Note For Individual Therapy dated 2/24/21, 3/3/21, 3/10/21, 3/18/21, 3/24/21, 4/21/21, 5/11/21, and 5/18/21 indicated the resident had periodic delusions. However, the notes did not indicate these thought were negatively impacting the facility's ability to provide care, or any identified unmet need due to the delusions. The notes did not identify the resident being fearful to stay at the Woodlands, a need for the resident to relocate to a behavioral facility, the resident being a danger to herself or others, and/or the resident's desire to relocate. The resident's closed clinical record lacked the following: a. Documentation of the resident requesting to be moved to another facility, b. Any form of involuntary discharge notice or supporting documentation for said discharge, c. A notice of involuntary discharge signed by the resident, d. For three months prior to her involuntary discharge (3/1/21 to 5/20/21) the record lacked any documentation of the resident having delusions about her eyes or being fearful of staff. In addition, the record for this 3 month period lacked documentation of any maladaptive behaviors that had negatively impacted the residents quality of life or quality of care or put her or others at risk for harm. e. A care plan regarding delusional thoughts about her eyes and/or delusions which caused her to be fearful. f. A care plan regarding the resident need to transfer to another facility. g. A care plan related to services which were offered to allow the resident to remain at the Woodlands or the success or failure of said plan. h. Communication with the Ombudsman for her involvement in the resident's involuntary transfer or assistance to prevent a transfer, i. Involvement of the resident's ongoing counselor in the relocation of the resident or services needed for her to remain in the facility, j. Involvement of the resident's Psychiatrist in the relocation of the resident or services needed for her to remain in the facility. Review of a 31 page packet of documents the Administrator provided on 6/8/21 at 11:10 a.m., and indicated had been faxed to the receiving facility as part of the pre-admission process, indicated the documentation contained no information about the resident having delusions and being afraid in the facility. The documents indicated the resident refused care at times, yelled, called staff racial slurs, and cursed. During a 6/7/21, 12:40 p.m., interview, the Area Ombudsman indicated she had not been contact by the facility to assist with Resident C's behaviors and/or delusions nor had to assisted with the need for the resident to be transferred from the facility. During a 6/7/21, 3:35 p.m., interview, the Administrator was asked to provide any information or documentation the facility had regarding Resident C requesting to move from the facility, documentation of displayed delusions or fears, a care plan regarding delusions and or fears, a care plan regarding the need to relocate, documentation of services offered to prevent discharge, a 30 day discharge notice, documentation of any evaluation or assessment that indicated an involuntary transfer was necessary to met the residents medical needs, documentation of Area Ombudsman involvement, and any information indicating the resident's Psychiatrist or Counselor assisted in the decision making and transition. During a 6/7/21, 5:03 p.m., interview LCSW (Licensed Clinical Social Worker), who had been providing individual therapy for Resident C, indicated she had not recommended the resident be moved to a behavioral facility nor had the facility consulted her about this matter. She additionally indicated that although the resident did have delusions, they had not been at a level that prevented the resident from residing at the Woodlands. The delusions did not significantly impact the facilities ability to provide care and services. The resident had not been identified as a danger to herself or others. The resident had not verbalized to the counselor that she desired to move from the facility. She had not been asked to be involved in the transition process. During an 6/8/21, 11:15 a.m., interview, the DON indicated the facility did not have any documentation of discharge notice given to the resident, paperwork sent with the resident at the time or discharge, discharge planning or services to prevent discharge. A review of Google Maps on 6/8/21 at 2:50 p.m., indicated the distance from [NAME] Indiana to the receiving facility was 77.4 miles. At the time of the 6/8/21, 3:16 p.m., exit conference the facility had not provided information or documentation regarding Resident C requesting to move from the facility, documentation of displayed delusions or fears, a care plan regarding delusions and or fears, a care plan regarding the need to relocate, documentation of services offered to prevent discharge, a 30 day discharge notice, documentation of any evaluation or assessment that indicated an involuntary transfer was necessary to met the residents medical needs, documentation of Area Ombudsman involvement, and any information indicating the resident's Psychiatrist or Counselor assisted in the decision making and transition. During an interview at this time, the Administrator indicated they had no additional information to provide. A current, undated, facility policy, provided by the DON on 6/8/21 at 9:41 a.m., titled Admission/Transfer/Discharge Procedures and Nursing Documentation indicated the following: Definitions 'Facility-initiated transfer or discharge' : A transfer or discharge which the resident objects to, did not originate through the resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences . Facility- Initiated Transfers A copy of the notice of transfer/discharge will be sent to a representative of the Office of the State Long-term Care Ombudsman for all facility initiated transfers or discharges . For any other types of facility- initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the noticed to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. This Federal tag relates to complaint IN 888. 3.1-12(a)(4)

Based on interview and record review the facility failed to transfer a dependant resident according to the plan of care for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted on the resident sustaining a [MEDICAL CONDITION] humerus and a fracture to the left tibia. Findings include: The clinical record for Resident B was reviewed on 6/14/2018 at 9:51 AM. [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of a current care plan, dated 5/23/2018, indicated the following: [MEDICAL CONDITION]. Resident has a dx (diagnosis) of [MEDICAL CONDITION] and is at risk for fractures. Interventions indicated the resident required the assistance of two staff members for transfers. The Admission Minimum Data Set (MDS) assessment, dated 5/23/2018, indicated Resident B was severely cognitively impaired. The resident required extensive assistance of two staff members for transfer, dressing, bathing personal hygiene and toileting. Review of the facility reportable investigation indicated the night shift nurse reported the resident was moaning with pain in her sleep during the night of 5/31/2018. The family member of the resident reported a pop noise was heard on the evening of 5/31/2018 during a transfer to the wheelchair. The nursing notes lacked any documentation of the incident on 5/31/2018. Review of the nursing note, dated 6/1/2018 at 10:39 AM., indicated Resident c/o (complained of) pain in left shoulder with movement. Left shoulder x/ray ordered (5 hours after the incident). Resident and daughter made aware . Review of the nursing note, dated 6/1/2018 at 12:17 PM, indicated the facility informed the physician of the results of the shoulder x ray (approximately 6 hours after the incident). The resident was sent to the emergency room for evaluation and treatment. Review of the nursing note, dated 6/1/2018, at 12:18 PM, indicated the family member stated during the transfer the resident hit the wheelchair arm rest with the elbow and they heard a popping sound. The resident did not complain of pain at the time, but did complain of pain during the night. The x-ray showed possible [MEDICAL CONDITION] humerus. Movement of the left arm was limited due to the pain. The physician was notified. New order to send the resident to the emergency room for evaluation and treatment was obtained. The resident was diagnosed with [REDACTED]. Review the x- ray report, dated 6/1/2018, indicated the following: Conclusion: [MEDICAL CONDITION] humerus. A step-off at the scapula. During an interview on 6/14/2018 at 6:35 AM, Resident B's family member indicated on 5/31/2018, between 5:30 PM and 6:00 PM, CNA (Certified Nursing Assistant) 1 transferred the resident by himself from the bed to the wheelchair without using a gait belt. The family member informed CNA 1 the resident was usually transferred with a standup lift. CNA 1 indicated they did not like using stand up lifts because they hurt the resident. During the transfer a loud popping was heard coming from the resident's shoulder. The family member indicate they felt CNA 1 had refused to use the stand up lift. After diner CNA 1 and CNA 3 transferred the resident from the wheelchair to the bed without using a stand up lift or gait belts. During an interview on 6/14/2018, the Director of Nursing (DON) indicated all transfers should be done with a gait belt. The DON also indicated the nursing staff did not document the incident in the resident's clinical record. At 7:00 PM the physician should not have been faxed with a request for the x-ray. The nursing staff should have called the physician or the physician on call to get an order for [REDACTED]. During an interview on 6/14/2018 at 7:48 AM, Resident B's family member indicated the resident exhibited pain during both transfers. During an interview on 6/14/2018 at 7:50 AM, LPN 2 indicated on 5/31/2018 just prior to the shift change at 6:00 PM, the private Home Health Aide stated the resident was exhibiting pain during the transfer. When the night shift nurse arrived she was informed of the residents report of pain. During the narcotic count, the family member approached and indicated the resident was in pain. The LPN denied ever being told by the family member or CNA 1 of the incident. During an interview on 6/15/2018 at 8:25 AM, LPN 4 indicated she was working on 5/31/2018 and was not told about any popping sound during any transfer of Resident B. She was told in report the resident was transferred and then her arm started hurting. The resident's family member approached her after diner around 7:00 PM and told her the resident's arm was hurting, she gave the resident her pain medication at that time. She spoke with the family member who agreed it could wait until the morning to call the MD. She didn't think it was emergent. She indicated she Faxed the MD a request for X-ray. During an interview on 6/15/2018 at 9:55 AM, CNA 3 indicated she assisted CNA 1 during a transfer, of Resident B, the evening of 5/31/2018. CNA 3 indicated the resident was showing signs of pain and she reported this to the nurse. The CNA indicated the resident was held under her arms and picked up and placed in the bed. The family member stated the resident was usually transferred with a stand up lift. We didn't use the lift because she (resident) wouldn't have been able to tolerate the lift straps under her arms. This Federal tag relates to Complaint IN 279. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to provide services to prevent the development of and promote the healing of pressure ulcers in 1 of 4 residents reviewed for pressure ulcers. This deficient practice resulted in the decline in healing of a pressure ulcer (Resident #35) having an increase in stage from 3 cm x 3 cm x 0.1 cm to size 1.2 cm x 2 cm, unstageable. Findings include: 1. Resident #35's clinical record was reviewed on 9/15/14 at 2:37 p.m. The resident's [DIAGNOSES REDACTED]. During an observation on 9/15/14 at 8:33 p.m., LPN #14 removed the old dressing on the lower back of Resident #35. The area had a small amount of drainage noted. The peri wound area was dark and uneven. The wound bed was white with small amounts of pink noted. Review of physician orders [REDACTED]. The dressing was to be changed daily. During an interview on 9/15/14 at 8:25 p.m., LPN #14 indicated there was no Santyl available to complete the dressing change as the physician had ordered. During an interview on 9/15/14 at 1:33 p.m., the Assistant Director of Nursing (ADON) indicated the facility had 3 pressure ulcers which had developed in house and one community acquired pressure ulcer. She indicated all but one of the in-house pressure ulcers were healing. Resident #35's pressure ulcer had declined and become unstageable. The Nursing Wound note, dated 8/29/14, indicated the resident was found to have an area of concern to her lower back. The area was red in color and measured 3 cm x 3 cm x <0.1 cm. Review of the Nursing Wound note, dated 9/5/14, indicated the resident was found to have a stage 1 to her lower back red in color and measured 3 cm x 3 cm x 0 depth. The Nursing Wound note, dated 9/12/14, indicated the stage 1 pressure ulcer had declined in healing and had become unstageable with black eschar noted around the peri wound area and white eschar noted in the wound bed. Review of the Weekly Pressure Ulcer Tracking Report for September 2014 indicated the wound was discovered on 8/29/14. The resident had a, 9/4/14, care plan problem for Wound type/location Unstageable to lower back. The care plan indicated the nursing staff should observe for signs and symptoms of infection or delayed healing and report to physician; inspect skin during bathing, especially over bony prominences. The resident had a 4/4/14, care plan problem for Activities of Daily Living (ADL's): "Resident requires assist in completing ADL's related to decreased mobility, generalized weakness, incontinence, impaired cognition and behaviors." The care plan indicated the nursing staff should check the resident every 2 hours and as needed, provide prompt peri care and chart all incontinent episodes. Review of Quarterly Minimum Data Set assessment, dated 7/4/14, indicated Resident #35's functional status was as follows: Bed mobility extensive assistance with one person physical assist. Transfers: extensive assist with one person physical assist Locomotion on unit: extensive assist with one person physical assist Locomotion off unit: extensive assist with one person physical assist Toilet use: extensive assist with one person physical assist Mobility device: wheelchair. Review of the Monthly Flow Report for August and September 2014, indicated Resident #35 was totally dependent, full staff performance, with one person physical assist for the activities of bed mobility,transfer, toilet use, personal hygiene and bathing. No further information was provided for the decline in Resident # 35's pressure ulcer. 3.1-40(a)(1)

Based on observation, record review and interview, the facility failed to ensure residents who required the assistance of the staff for personal hygiene needs received that care in accordance with facility policy and plan of care. This affected 2 of 3 residents reviewed for assistance with personal hygiene in a Stage 2 Sample of 34. (Resident # 96 and #18) This resulted in the development of inflamed soft oral tissues for 1 resident ( #96) who needed assistance with oral/dental care. Findings: 1.) The clinical record for resident #96 was reviewed on 7/13/11 at 10:30 a.m. The clinical record indicated Resident #96 was admitted on [DATE]. [DIAGNOSES REDACTED]. An admission Minimum Data Assessment, dated 6/2/11, indicated Resident #96 had no problems with memory or recall and was not cognitively impaired. The assessment indicated she had no oral or dental problems and required extensive assistance from one staff member for personal hygiene needs. An Oral Assessment Form, dated 5/26/11, indicated Resident #96 had upper dentures and lower natural teeth with two teeth missing. The form indicated the resident's mucous membranes and gums were pale and slightly dry. A health care plan problem, dated 6/13/11, indicated Resident #96 required assistance from the staff for completing all activities of daily living related to weakness, right [MEDICAL CONDITIONS]. One of the approaches for this problem was for staff to set up supplies and assist resident with oral care. The approach did not indicate how often oral care was to be given. During an interview on 7/12/2011 at 9:48 a.m., Resident #96 indicated her dentures had only been cleaned once in the last week. She indicated her natural teeth had not been brushed since she was admitted . She indicated she needed the assistance of the staff to set up supplies and assist her with brushing her teeth due to paralysis of one arm/hand. During an observation with CNA #2 (the CNA who provided care to the Resident #96 on the 7-3 shift) on 7/13/11 at 3 p.m., she located a tube of toothpaste (appeared full or almost full), a box of denture cleaning tablets, a dental cup, and two dry toothbrushes in the resident's drawer. During an interview at this time, CNA #2 indicated she had not assisted Resident #96 with any type of dental care during her shift. The "Daily care" monthly flow reports for May, June, and July, 2011 were blank for the category of "dentures cleaned" for all three months. A dental exam report, dated 7/11/11, indicated the resident wore upper dentures, but her lower teeth were natural. The report indicated her oral hygiene was poor and her soft tissues were red and inflamed. The report indicated the dentist spoke about taking the resident's dentures out at night so the soft tissue could "breathe". The report indicated "Clean denture for pt (patient)." A nursing note entry, dated 7/11/11 at 2:00 p.m., indicated the dentist had visited and cleaned the resident's teeth. The note lacked any information related to the need to take the resident's teeth out at night. During an interview with the Director of Nursing and Resident #96 on 7/13/11 at 3:55 p.m., Resident #96 indicated she had only been given oral/dental care once since admission which was done once by the dentist when she was seen by him earlier in the week. 2.) The clinical record for Resident #18 was reviewed on 7/13/11 at 2:50 p.m. [DIAGNOSES REDACTED]., debility, [MEDICAL CONDITIONS], and circulatory disease. On 7/12/11 at 9:45 a.m., Resident #18 was observed with facial hair on her chin and a large soiled area on the front of her shirt. A health care plan problem, dated 7/23/08, indicated Resident #18 required assistance from the staff for completing all ADL's (Activities of Daily Living) related to dementia, decline in cognition, decline in mobility, [MEDICAL CONDITIONS]. One of the approaches for this problem was for the staff to dress the resident in clothes that are clean and in good repair. A Quarterly Review Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #18 had a Brief Interview for Mental Status (BIMS) score of 3 (which indicates the resident has severe cognitive impairment). The assessment indicated she required extensive assistance from one staff member for dressing and personal hygiene needs. Activities of Daily Living (ADL) documentation indicated Resident #18 had been shaved once during July, twice in June, and 3 times in May. 3.) Review of the current facility policy, titled "Oral Hygiene: Cleaning Dentures," provided by the DoN on 7/14/11, at 2:00 p.m., included, but was not limited to, the following: "Policy The purpose of the procedure is: To cleanse and freshen the resident's mouth. To clean the resident's teeth. To lessen the potential of infections in the mouth.... 1. Provide dental care before breakfast and at bedtime. Instruct the resident to rinse his/her mouth out after each meal.... ...9. As you provide denture care, examine the resident's mouth and gums for any paleness of the gums, mouth sores, any bleeding and areas of discoloration.... ...Reporting Procedures: The nursing assistant must report the following information to the staff/charge nurse: 1. That denture care has been given.... ...Plan of Care: The resident's plan of care must address: 1. The type of dental care to be provided. 2. The frequency of the care. 3. Special devices necessary, if any. 4. Who is responsible for providing the care.... 4.) Review of the current facility policy, titled "Oral Hygiene: Conscious Resident," provided by the DoN on 7/14/11, at 2:00 p.m., included, but was not limited to, the following: "Policy The purpose of the policy is to: Cleanse and freshen the resident's mouth. Clean the resident's teeth. Decrease the risk of infections within the mouth.... ...Key Procedural Points 1. Provide dental care before breakfast and at bedtime. Instruct the resident to rinse his/her mouth after each meal.... ...Reporting Procedures: The nursing assistant must report the following information to the staff/charge nurse: 1. That special mouth care has been given.... ...Plan of Care: The resident's plan of care must address: 1. The type of dental care to be provided. 2. The frequency of the care. 3. Special devices necessary, if any. 4. Who is responsible for providing the care? 5. Other information as necessary or appropriate...." 3.1-38(a)(3)(C) 3.1-38(a)(3)(D)

Based on observation, record review and interview, the facility failed to ensure the Quality Assessment and Assurance Committee identified deficient practices and developed plans of action related to the oral hygiene needs for 1 resident resulting in red and inflamed soft gum tissues (Resident # 96); failed to identify discrepancies in documentation of administration of narcotic and hypnotic medications (Residents #81 and # 95 ); failed to identify the lack of or incorrect dosage of sliding scale insulin (Residents # 96, #39, # 27); failed to identify the need for incontinence care (Resident # 27) and failed to identify the need to develop health care plans for pain management and oral care for (Residents #81 and #96). These practices actually affected 5 residents in the Stage 2 sample of 34 with the potential to affect all residents in the facility. Findings include: 1.) During an interview on 7/12/2011 at 9:48 a.m., Resident #96 indicated her dentures had only been cleaned once in the last week. She indicated her natural teeth had not been brushed since she was admitted . She indicated she needed the assistance of the staff to set up supplies and assist her with brushing her teeth due to paralysis of one arm/hand. The clinical record for resident #96 was reviewed on 7/13/11 at 10:30 a.m. The clinical record indicated Resident #96 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED].. An Oral Assessment Form, dated 5/26/11, indicated Resident #96 had upper dentures and lower natural teeth with two teeth missing. The form indicated the resident's mucous membranes and gums were pale and slightly dry. A health care plan problem, dated 6/13/11, indicated Resident #96 required assistance from the staff for completing all activities of daily living related to weakness, right [MEDICAL CONDITIONS]. One of the approaches for this problem was for staff to set up supplies and assist resident with oral care. The approach did not indicate how often oral care was to be given. A dental exam report, dated 7/11/11, indicated the resident wore upper dentures, but her lower teeth were natural. The report indicated her oral hygiene was poor and her soft tissues were red and inflamed. The report indicated the dentist spoke with the staff about taking the resident's dentures out at night so the soft tissue could "breathe". The report indicated "Clean denture for pt (patient)." During an observation with CNA #2 (the CNA who provided care to the Resident #96 on the 7-3 shift) on 7/13/11 at 3 p.m., she located a tube of toothpaste (appeared full or almost full), a box of denture cleaning tablets, a dental cup, and two dry toothbrushes in the resident's drawer. During an interview at this time, CNA #2 indicated she had not assisted Resident #96 with any type of dental care during her shift. During an interview with the Director of Nursing and Resident #96 on 7/13/11 at 3:55 p.m., Resident #96 indicated she had only been given oral/dental care once since admission which was done once by the dentist when she was seen by him earlier in the week. The facility failed to identify the resident's need for assistance with oral hygiene and ensure care was provided resulting in the resident having poor dental hygiene with red and inflamed soft tissues (gums). Refer to F312 for detailed information related to failure to provide oral hygiene care resulting in actual harm identified during dental exam. 2. The clinical record for Resident #81 was reviewed on 7/13/11 at 9:30 a.m. [DIAGNOSES REDACTED]. A pain assessment, dated 6/25/11 and updated on 7/14/11, indicated Resident #81 was at risk for pain and had experienced pain in the past. During an interview on 7/11/11 at 3:09 p.m., Resident #81 indicated she had a history of [REDACTED]. physician's orders [REDACTED]. The orders also indicated the resident could have [MEDICATION NAME] with [MEDICATION NAME] ([MEDICATION NAME]-a narcotic pain medication) 5/325 mg (milligrams) one tablet, two times a day as needed for moderate to severe pain and Zolpidiem [MEDICATION NAME] (Ambien-a hypnotic) 5 mgs at bedtime as needed for [MEDICAL CONDITION]. The "narcotic sign out sheets" for Resident #81 listed the dates and times the "as needed" [MEDICATION NAME] pain medication was signed out for the resident. Included, but were not limited to, were the following dates and times: 7/2/11 at 8 a.m., and 7/8/11 at 8:30 a.m.,-the narcotic sign out sheets did not indicate what type of pain the medication was given for or if the medication relieved the resident's pain. The Medication Administration Records for Resident #81, lacked any information related to the [MEDICATION NAME] medication having been given on the two dates and times noted above. The nursing notes for the dates and times noted above lacked any information related to the pain medication having been given as signed out on the narcotic record. The "hypnotic sign out sheets" for Resident #81 indicated [MEDICATION NAME] was signed out for the resident at bedtime on July 1, 2, 3, 4, 7, and 8, 2011. [MEDICATION NAME] was only recorded on the MAR as having been given on 7/1, 7/4, and 7/7/11. No information was recorded on the MAR for 7/2, 7/3, and 7/8/11. The nursing notes lacked any information related to [MEDICATION NAME] having been given on those three dates or if the medication was effective. b. Resident #95's Clinical Record review was completed on 7/13/11 at 2:12 p.m. The resident's [DIAGNOSES REDACTED]. The resident's current physician's orders [REDACTED]. The orders included an order for [REDACTED]. The resident also had an order for [REDACTED]. Review of the resident's MAR (Medication Administration Record) for July, 2011 indicated the resident had received [MEDICATION NAME]-apap 5/325 mg on the following dates: 7/3 - one time 7/4 - three times 7/6 - three times 7/7 - one time 7/8 - one time 7/9 - one time 7/11 - four times 7/12 - three times 7/13 - one time 7/14 - two times Review of the [MEDICATION NAME]/apap 5/325 mg Controlled Substance Record for July, 2011, indicated the medication had been signed out on the following dates and times: 7/1 at 12:15 a.m., 5:30 a.m., 10:30 a.m., and 7:00 p.m. 7/2 at 12:30 a.m., 5:00 a.m., 9:00 a.m., and 5:00 p.m. 7/3 at 12:45 a.m., 4:30 a.m., 10:00 a.m., 3:00 p.m., and 8:00 p.m. 7/4 at 12:00 a.m., 4:00 a.m., 3:45 p.m., and 8:20 p.m. 7/5 at 1:30 a.m., 5:30 a.m., 2:45 p.m., 7:15 p.m., and 11:30 p.m. 7/6 at 4:00 a.m., 9:30 a.m., 1:30 p.m., 5:30 p.m., and 9:30 p.m. 7/7 at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. 7/8 at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 4:00 p.m., and 9:00 p.m. 7/9 at 5:00 a.m., 9:00 a.m., 5:00 p.m., and 9:00 p.m. 7/10 at 1:00 a.m., 5:00 a.m., 10:30 a.m., 5:00 p.m., 9:30 and p.m. 7/11 at 1:30 a.m., 9:00 a.m., 1:30 p.m., 5:45 p.m., and 10:20 p.m. 7/12 at 2:45 a.m., 9:00 a.m., 1:30 p.m., 5:45 p.m., and 10:15 p.m. 7/13 at 3:05 a.m., 7:45 a.m., 12:30 p.m., 5:00 p.m., and 9:20 p.m. 7/14 at 3:15 a.m. and 9:30 a.m. The Controlled Substance Record indicated the pain medication was signed out for the resident a total of 63 times in July, but was only recorded on the front of the MAR as having been given 20 times. The resident received the medication 43 times without documentation of the medication being given on the MAR. Review of the July, 2011, MAR for [MEDICATION NAME] 5 mg as needed at bedtime indicated the resident received the medication on 7/3, 7/4, and 7/8. Review of the July, 2011, Controlled Substance Record for the [MEDICATION NAME] 5 mg indicated the medication was signed out for the resident on 7/1, 7/3, 7/4, 7/5, 7/6, 7/8, 7/9, 7/10, 7/11, 7/12, and 7/13. This indicated the medication was signed out on 8 occasions that were not documented as having been given on the MAR. The facility failed to identify discrepancies between the narcotic sign out sheets and the MAR. Refer to F329 and F428 for detailed information related to discrepancies between records of controlled substance medications. 3.a The clinical record for resident #96 was reviewed on 7/13/11 at 10:30 a.m. [DIAGNOSES REDACTED]. A recapitulation of physician's orders [REDACTED]. The orders also indicated Resident #96 was to receive [MEDICATION NAME]per sliding scale based on glucose results taken before meals and at bedtime. The sliding scale insulin orders included, but were not limited to, the following: Blood sugar 181-250=give 4 units of [MEDICATION NAME] insulin Blood sugar 251-300=give 6 units of [MEDICATION NAME] The June and July Medication Administration Records (MAR) lacked documentation of sliding scale insulin having been given based on the glucometer results on the following dates and times: 6/2/11 at 6 a.m.-blood sugar 204-no insulin documented as having been given 6/2/11 at 11 a.m. -blood sugar 188-no insulin documented as having been given 6/3/11 at 11 a.m. -blood sugar 238-no insulin documented as having been given 6/10/11 at 4 p.m. -blood sugar 218-no insulin documented as having been given 6/11/11 at 4 p.m.-blood sugar 205-no insulin documented as having been given 6/11/11 at 8 p.m.-blood sugar 217-the MAR indicated a "zero" for no insulin having been given 6/20/11 at 4 p.m.-blood sugar 197-no insulin documented as having been given 6/21/11 at 4 p.m.-blood sugar 199-no insulin documented as having been given 6/22/11 at 8 p.m.-blood sugar 197-no insulin documented as having been given 6/25/11 at 4 p.m.-blood sugar 274-no insulin documented as having been given 6/26/11 at 4 p.m.-blood sugar 190-no insulin documented as having been given 6/29/11 at 6 a.m.-blood sugar 210-no insulin documented as having been given 6/30/11 at 11 a.m.-blood sugar 188-no insulin documented as having been given 7/7/11 at 6 a.m.-blood sugar 202-no insulin documented as having been given b. Resident #39's clinical record review was completed on 7/14/11 at 9:42 a.m. The resident's current physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. Resident #39 had a sliding scale insulin coverage order for Humalog 100 units per milliliter to be given subcutaneously for the following blood sugar ranges: 141 - 180 give 1 unit 181 - 220 give 2 units 221 - 260 give 4 units 261 - 300 give 6 units 301 - 340 give 7 units 341 - 380 give 8 units 381 - 420 give 9 units 421 - 460 give 10 units greater than 460 give 12 units. Review of the July, 2011, MAR (Medication Administration Record) indicated Resident #39 had a blood sugar of 146 at 6:00 a.m., on 7/7/11. The clinical record lacked an indication of 1 unit of Humalog insulin coverage being given. The resident had a 6:00 a.m., blood sugar of 159 on 7/9/11. The clinical record lacked an indication of 1 unit of Humalog insulin coverage being given. The resident had a 6:00 a.m., blood sugar of 171 on 7/13/11. The clinical record lacked an indication of 1 unit of Humalog insulin coverage being given. c. The clinical record for Resident #27 was reviewed on 7/12/11 at 9:00 a.m. Resident #27's current [DIAGNOSES REDACTED]. The resident had current physician's orders [REDACTED]. Resident #27 had a health care plan, dated 6/11, which indicated the resident had a problem listed as, resident has a [DIAGNOSES REDACTED]. Approaches for this problem included: Monitor blood sugars as ordered, administer medications per order, administer insulin per order and oversee available labs. A. Monitor blood sugars two times daily at 6 a.m. and 4 p.m. B. Inject [MEDICATION NAME] 70 units at bedtime. C. Inject [MEDICATION NAME]according to blood sugar results use sliding scale as follows 200-250 = 4 units 251-300 = 6 units 301-350 = 8 units greater than 350 call the physician. Review of the May, and June 2011 Medication Administration Records indicated on the following dates and times Resident #27 did not have her blood sugar monitored as ordered and or received the incorrect sliding scale insulin dose, May May 19 at 6 a.m., no blood sugar result was documented as having been completed May 19, blood sugar was 209 at 4 p.m., no sliding scale insulin was given. The resident should have received 4 units May 29, at 6 a.m., no blood sugar result was documented as having been completed. May 29, blood sugar at 4 p.m., was 380. No sliding scale insulin was documented as having been given. The resident's physician should have been called and insulin orders received for a blood sugar result greater than 350. June June 4th, 6 a.m., blood sugar was 235. No sliding scale insulin was given. The resident should have received 4 units. June 6th, 6 a.m., blood sugar was 215. No sliding scale insulin was given. The resident should have received 4 units. June 15, 6 a.m., No blood sugar result was documented. June 29, 6 a.m., blood sugar result was 205. No insulin was documented as given. The resident should have received 4 units. Refer to F309 for detailed information related to failure to identify inconsistencies in administration or lack of administration of insulin. 4. The clinical record for Resident #27 was reviewed on 7/12/11 at 9:00 a.m. Resident #27's current [DIAGNOSES REDACTED]. During observation on 7/11/11 at 11:30 a.m., Resident #27 was sitting on her bed in her room. A strong odor was immediately noted. The odor was body odor and/or urine odor. During observation on 7/11/11 at 2:30 p.m., Resident #27 was in her room in her bed. A slight urine odor was noted in the room. During observation on 7/12/11 at 9:00 a.m., a strong urine odor and body odor was noted in the resident's room. A Health care plan, dated 5/1/11, indicated the resident had a problem listed as, requires assist in completing ADL's due to weakness and episodes of incontinence. The goal for the health care plan was the resident will assist with dressing self daily thru next review. Approaches for this problem included: set up clothing and assist resident with dressing and undressing, set up personal hygiene products and assist with oral care, hair care, nail care, a.m. and p.m. care, perineal care, and assist with showers 2 times a week with partials on non-shower days, observe for changes in level of participation with ADL's (activities of daily living) and refer to therapy screening if needed. During an interview on 7/13/11 at 1:20 p.m., with LPN #4, the nurse assigned to care for Resident #27, she indicated the resident was able to take herself to the bathroom and she completed her own peri care. She further indicated the resident did not always "do a good job" with her peri care. LPN #4 indicated she had "occasionally" noted a urine odor in the resident's room. She indicated the CNAs who were assigned to the resident would have to monitor the resident's bathing and toileting needs more closely. Refer to F272 and F315 for detailed information related to the facility's failure to identify the resident's incontinence needs. 5. The clinical record for Resident #81 was reviewed on 7/13/11 at 9:30 a.m. [DIAGNOSES REDACTED]. During an interview on 7/11/11 at 3:09 p.m., Resident #81 indicated she had a history of [REDACTED]. She indicated she was receiving routine pain medications, but they were not "holding her pain." She was observed during the interview to be making a rocking motion back and forth in her chair. She indicated this movement sometimes helped to relieve her back pain. She indicated it was not yet time for any more pain medication. physician's orders [REDACTED]. The orders also indicated the resident could have [MEDICATION NAME] with [MEDICATION NAME] ([MEDICATION NAME]-a narcotic pain medication) 5/325 mg (milligrams), one tablet, two times a day as needed for moderate to severe pain. An "Interim Care Plan" for Resident #81, dated 6/25/11, indicated she "has pain". The care plan lacked any information related to the type of pain and/or frequency of the pain. The care plan listed one intervention for the pain which was "[MEDICATION NAME] (a narcotic pain patch) every 3 days". The care plan lacked any information of the resident having an order for [REDACTED]. The Interim Care Plan was the only care plan noted in the clinical record. Refer to F279 for detailed information related to the facility's failure to identify the need to develop care plans. 6. During an interview on 7/15/11 at 10:00 a.m., the Administrator indicated the facility's quality assurance program had not identified: The failure of the staff to provide oral care as needed for Resident # 96,. sliding scale insulin coverage not being given as ordered by physician for Residents # 96, #39, #27,, narcotics being signed out on narcotics count sheet but not documented as being given on medication administration record (MAR) for Residents # 81 and # 95,.incontinence care not performed as needed for Resident # 27 or the failure to develop a pain management care plan for Resident # 81. During an interview with the Unit Manager on 7/15/11 at 10:40 a.m., she indicated the nursing staff had not identified the concerns as noted above. 3.1-52(b)(2)

Based on observation, record review and interview, the facility failed to assure supervision and use of a gait belt during ambulation for 1 (Resident A) of 3 residents among the sample of 4 reviewed for the application of braces or splints. This failure resulted in a fall with a fracture of the hip requiring hospitalization and a surgical repair. Findings include: The record of Resident (A) was reviewed 6/15/11, at 3:20 P.M., and indicated a 9/2/04, admission with [DIAGNOSES REDACTED]. The 3/20/11, quarterly review of the minimum data set (MDS) indicated Resident (A) required extensive assist with transfers, ambulation, and toileting. Resident (A) was assessed as unsteady and as requiring assistance for standing, turning, and with surface to surface transfers. The 3/20/11, MDS assessment indicated Resident (A) was cognitively alert. Documentation did not indicate a physician's orders [REDACTED]. The current 3/30/11, plan of care indicated a risk for falls related to a decline in mobility. Interventions indicated assist with transfers and ambulation with the use of a walker, and application of braces to the right and left ankles. The 6/14/11, 4:45 P.M., (late) nursing note, documented by Registered Nurse (RN #1) indicated at 6:30 this A.M., the 11-7 certified nursing assistant (CNA #1) called this nurse to the room. CNA #1 stated Resident (A) had fallen. RN #1 documented Resident (A) was observed lying on the floor on the left side with the head resting against the recliner. The legs were extended outward. The left leg was bent at the knee. Resident (A) complained of pain to the left hip, radiating down the leg. Resident (A) said the pain was a 9 on a scale of 1-10. Documentation indicated CNA #1 said she was walking behind Resident (A) from the bath room toward the bed when (Resident A) fell suddenly to the left onto the floor. Documentation indicated Resident (A) was using a walker, had the bilateral leg braces on, and shoes with the laces tied. Documentation also indicated the floor was not wet. CNA #1 stated she tried to stop the fall but was unable to support Resident (A). CNA #1 indicated Resident (A) pulled her (CNA #1) down during the fall. Documentation indicated CNA #1 said she did not land on Resident (A). CNA #1 reported one of her hands was on the floor and the other about the shoulder of Resident (A). Documentation indicated a complete body assessment with slight swelling to the left hip. The family and physician were notified and Resident (A) was transferred to the local hospital by ambulance at 7:15 A.M. An (undated) addendum indicated when Resident (A) was lying on the floor, it was noted the right shoe was slipping off the foot. A 6/15/11, 5:30 P.M., nursing note indicated the interdisciplinary team (IDT) met to review the 6/14/11, fall. The IDT team determined Resident (A) was being ambulated to bed from the bath room and fell to the left side. The IDT team assessment indicated Resident (A) was using a walker and was assisted by 1 person. The team noted the shoes and braces had been applied prior to ambulation. The team indicated Resident (A) had been admitted for a surgical repair of the hip and questioned if the fracture could be pathological. New interventions were to be addressed on re-admission. RN #1 was interviewed at 2:40 P.M., 6/15/11, and indicated Resident (A) had rheumatoid arthritis and wore tennis shoes with leg braces due to the inward turning of one foot. RN #1 indicated CNA #1 had said her hand was on the back of Resident (A) when she (Resident A) fell to the left. RN #1 indicated she had checked the leg braces during the 6/14/11, assessment and each was on the correct foot. RN #1 indicated the bottom of the braces were labeled (R) right and (L) left. CNA #1 was interviewed by telephone at 9:40 A.M., 6/16/11, and indicated the morning of the 6/14/11, fall Resident (A) had used the walker and started leaning sideways . CNA #1 indicated she was unable to catch Resident (A) and prevent the fall. CNA #1 indicated she had put one hand out to prevent falling on top of the resident. CNA #1 indicated she had gone down to the floor with Resident (A). CNA #1 indicated Resident (A) was a 1 person assist for ambulation with the leg braces,shoes, and walker. At 1:10 P.M., 6/16/11, a visit was made to the local hospital. Resident (A), who was on the orthopedic floor, was observed seated in a recliner with the feet elevated straight outward. During interview at this time, Resident (A) indicated CNA #1 (first name of CNA #1) fell on her 6/14/11. Resident (A) indicated CNA #1 had a hand on her (Resident A's) back and pushed against her during the fall. Resident (A) indicated CNA #1 had not used a gait belt. Resident (A) indicated the CNAs were supposed to use gait belts. Resident (A) indicated she believed CNA #1 could have caught her if a gait belt had been used. The 6/14/11, hospital history/physical, documented by the orthopedic surgeon, indicated a recommendation for the surgical repair of the hip. The surgeon documented (Resident A) had minimal ambulatory ability prior to the fall and hopefully could be restored to this level of activity post op (operation). After a return to the facility, at 2:00 P.M., 6/16/11, a second interview was conducted by telephone with CNA #1. CNA #1 indicated she had not fallen on Resident (A). CNA #1 indicated she had caught herself on the floor as Resident (A) pulled her down during the fall. CNA #1 indicated she had one arm wrapped around the waist of Resident (A) and her left hand was outward to break her (CNA #1) fall. CNA #1 indicated she had tried to catch Resident (A), could not, and fell with her. CNA #1 indicated she had a gait belt with her. CNA #1 indicated she had not used the gait belt because Resident (A) ambulated with a walker and was a 1 person assist. CNA #1 indicated gait belts were used for 2 person assists or if indicated on the Daily Care Guide (CNA assignment sheet). CNA #1 indicated she was not sure how long Resident (A) had been on the toilet prior to the transfer. CNA #1 indicated she had assisted (Resident A) to the toilet, then started checking on other residents. CNA #1 indicated if she had used the gait belt it might have helped in supporting Resident (A) and breaking the fall. CNA #2 was interviewed at 2:15 P.M., 6/16/11, and indicated she used a gait belt for transfers with all residents. CNA #2 indicated it was safer to use a gait belt because it provided something to hold onto to secure the resident. Qualified Medication Aide (QMA #1) was interviewed at 2:20 P.M., 6/16/11, and indicated she used a gait belt if a 2 person assist was required for transfer, or if a resident used a walker. QMA #1 indicated the Daily Care Guide was also a reference for assist devices. Licensed Practical Nurse (LPN #1) was interviewed at 2:40 P.M., 6/16/11, and indicated everyone carried a gait belt. LPN #1 indicated gait belts were to be used with all transfers as a safety measure. The Director of Nursing (DoN) was interviewed at 2:45 P.M., 6/16/11, and indicated the facility policy was to use a gait belt with all transfers. The DoN indicated use of a gait belt might not be included on the Daily Care Guide because it was an understood policy. The DoN provided the facility's 11/04, Gait Belts for Transfer Policy on 6/16/11. The standard indicated gait belts were provided to assist staff to safely transfer or ambulate a resident. Procedure #5/ambulation, indicated the resident was to be assisted to stand by grasping the belt at the waist from underneath; standing on the weaker side and wrapping an arm around the waist of the resident, then grasping the belt from underneath. A firm grasp was to be maintained on the belt as ambulation proceeded. 3.1-45(a)(2)

BASED ON OBSERVATION, RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO ENSURE A RESIDENT'S RIGHT TO REFUSE AN ORDERED DIET CONSISTENCY WAS HONORED FOR 1 OF 18 RESIDENTS REVIEWED FOR RESIDENT RIGHTS IN THE SAMPLE OF 18, WHICH RESULTED IN RESIDENT IRRITABILITY, ANXIOUS BEHAVIOR, FRUSTRATION, UNHAPPINESS, AND VERBAL AGGRESSION. (RESIDENT B) FINDINGS INCLUDE: 1. REVIEW OF THE CURRENT, UNDATED, FACILITY POLICY, TITLED "RESIDENT RIGHTS", PROVIDED BY THE DIRECTOR OF NURSING ON 6/8/10 AT 12:45 P.M., INDICATED THE FOLLOWING, "RESIDENT RIGHTS THE RESIDENT HAS A RIGHT TO A DIGNIFIED EXISTENCE, SELF-DETERMINATION,, AND COMMUNICATION WITH AND ACCESS TO PERSONS AND SERVICES INSIDE AND OUTSIDE THE FACILITY. A FACILITY MUST PROTECT AND PROMOTE THE RIGHTS OF EACH RESIDENT, INCLUDING EACH OF THE FOLLOWING RIGHTS: (a) EXERCISE OF RIGHTS (1) THE RESIDENT HAS THE RIGHT TO EXERCISE HIS OR HER RIGHTS AS A RESIDENT OF THE FACILITY AND AS A CITIZEN OR RESIDENT OF THE UNITED STATES... (2) THE RESIDENT HAS THE RIGHT TO BE FREE OF INTERFERENCE, COERCION, DISCRIMINATION, AND REPRISAL FROM THE FACILITY IN EXERCISING HIS OR HER RIGHTS... (d) FREE CHOICE. THE RESIDENT HAS THE RIGHT TO... (3) UNLESS ADJUDGED INCOMPETENT OR OTHERWISE FOUND TO BE INCAPACITATED UNDER THE LAWS OF THE STATE, PARTICIPATE IN PLANNING CARE AND TREATMENT OR CHANGES IN CARE AND TREATMENT..." 2. THE RECORD OF RESIDENT B WAS REVIEWED ON 6/7/10 AT 10:25 A.M., AND INDICATED THE RESIDENT'S [DIAGNOSES REDACTED]. THE RESIDENT WAS admitted on [DATE], AND RE-admitted on [DATE]. THE RESIDENT WAS discharged FROM THE FACILITY ON 5/10/10. THE RECORD INDICATED THE RESIDENT'S WIFE WAS THE POWER OF ATTORNEY AND HEALTH CARE REPRESENTATIVE EFFECTIVE 1/8/03. THE "SPEECH THERAPY WEEKLY SUMMARY," DATED 3/10/10, INDICATED "...PATIENT REQUIRED A DIET DOWNGRADE TO PUREED SOLIDS THIS PAST WEEK DUE TO THE SEVERE ORAL PHASE DYSPHASIA AND DEFICITS THAT WERE EXHIBITED CONSISTENTLY WITH EACH MEAL AND SNACK...." THE SPEECH THERAPY PROGRESS NOTE INDICATED THE FOLLOWING: ON 4/1/10, "...PATIENT ALSO CONTINUED TO MAKE COMPLAINTS ABOUT CURRENT DIET OF PUREED AND STATED WANTS "REGULAR FOOD."...." ON 4/5/10, "...PATIENT CONTINUED TO MAKE COMPLAINTS ABOUT PUREED DIET...." ON 4/8/10, "...NEW DIET UPGRADE TO MECHANICAL SOFT SOLIDS...OVERALL, PATIENT IS DOING EXCELLENT WITH CURRENT DIET UPGRADE...." ON 4/9/10 ,"...PATIENT REPORTED HE LIKES THIS DIET LEVEL MUCH BETTER..." ON 4/21/10, "...DOWNGRADED BACK TO PUREED SOLIDS AGAIN DUE TO INCREASED CHOKING RISK INVOLVED...EXPLAINED TO DOCTOR PATIENT WOULD NOT CONSUME PUREED IF DIET WAS DOWNGRADED. PATIENT HAS VOICED HE IS NEVER GOING TO EAT ANYMORE IF THEY SERVE HIM 'THAT NASTY STUFF, I DO NOT CARE IF I GET CHOKED, IT WILL NOT HAPPEN.' ...DOCTOR AWARE OF CURRENT CONCERNS/STATED WOULD LIKE TO SEE PATIENT REMAIN ON CURRENT DIET IF AT ALL POSSIBLE. WIFE ALSO AWARE/STATED SHE IS WORRIED HE WILL STOP EATING IF PLACED BACK ON PUREED...." ON 4/23/10, "...IT WAS DETERMINED PATIENT WOULD REQUIRE DOWNAGRED (SIC) TO PUREED SOLDIS (SIC) DUE TO CHOKGN (SIC) RISK INVOLVED. (SIC). WIFE EXPRESSED SHE WANTED PATIEN (SIC) TO REMAIN ON MECHACUL (SIC) SOFT, BUT EDUCTED (SIC) WIFE THIS IS NTO (SIC) SAEF (SIC) FOR PATIENT AND TAHT (SIC) DOCTYRO (SIC) WOULD NEED TO ORDER.... (SIC)." ON 4/28/10, "...THIS INTERVENTION IS MEDICALLY NECESSARY TO ENSURE PATIENT IS SAFELY TOLERATING CURRENT DIET OF PUREED SOLIDS. PATIENT CONSUMED 100% OF PUREED, BUT CONTINUED TO REPORT HE 'DOES NOT LIKE IT,' AND WANTS TO BE PUT BACK ON MECHANICAL SOFT SOLIDS. THIS HAS BEEN EDUCATED TO PATIENT AT LENGTH WITH WIFE AS WELL. WIFE FULLY AWARE PATIENT IS AT INCREASED RISK FOR CHOKING AND IT IS MEDICALLY NECESSARY AT THIS TIME TO GIVE PUREED. HAD LEFT NOTE FOR DOCTOR AFTER DISCUSSED WITH HIM ON MONDAY PATIENT MAKES COMPLAINTS ABOUT PUREED, BUT IT IS NOT FELT IT IS SAFE FOR ANY OTHER SOLID DIET LEVEL. DOCTOR STATED AT THIS TIME THAT HE WOULD HAVE TO THINK ABOUT WRITING ORDER FOR MECHANICAL SOFT DESPITE PATIENTS/WIFE'S WISHES. PATIENT REMAINS UNSAFE AND IMPULSIVE WITH EATING HABITS AND CONTINUES TO TAKE LARGE BITES/SIPS WITHOUT ALTERNATING SOLIDS/LIQUIDS TO HELP CLEAR ORAL RESIDUE. WIFE AWARE OF THIS AS WELL....LEFT ANOTHER NOTE FOR DOCTOR ABOUT REQUEST FOR MECHANICAL SOFT DESPITE RISK. WILL ATTEMPT TO TALK TO DOCTOR TO DETERMINE IF HE WOULD AGREE TO WIFE/PATIENT REQUEST, EVEN THOUGH PATIENT MAY BECOME CHOKED/DEVELOP COMPLICATIONS FROM SWALLOWING DIFFICULTY AND IMPULSIVE EATING HABITS...." ON 4/29/10, "...PATIENT CONSUMED GOOD INTAKES OF PUREED, BUT WIFE CONTINUES TO MAKE COMPLAINTS OF THE CURRENT PUREED DIET AND STILL WOULD LIKE DOCTOR TO UPGRADE PATIENT TO MECHANICAL SOFT...EXPLAINED TO WIFE AND PATIENT THAT ST (SPEECH THERAPY) IS UNABLE TO UPGRADE DIET AND THAT DOCTOR WILL HAVE TO ADDRESS, BUT MAIN CONCERN IS THE SAFETY OF THE PATIENT AND TO KEEP PATIENT FROM CHOKING AND DEVELOPING COMPLICATIONS. THIS HAS BEEN DISCUSSED WITH DOCTOR AT LENGTH AND DOCTOR HAS NOT YET AGREED TO DO ABOVE. RECOMMEND PATIENT TO REMAIN ON CURRENT DIET...." ON 4/30/10, "...PATIENT HAS STARTED TO REFUSE TO EAT ANY PUREED MEAL THIS DATE AND REPORTED HE IS NOT GOING TO KEEP EATING IF IT IS PUREED. HAVE ATTEMPTED TO SPEAK WITH DOCTOR FURTHER THIS WEEK REGARDING PATIENT AND WIFE REQUEST TO UPGRADE TO MECHANICAL SOFT DESPITE INCREASED CHOKING RISK. WIFE HAS VERBALIZED UNDERSTANDING ON THE SEVERE CHOKING RISK, BUT STILL WANTS PATIENT TO BE ABLE TO EAT WHAT HE WANTS, EVEN THOUGH SHE IS AWARE OF ABOVE, AS SHE IS IN THE ROOM AT MEALS MOST OF THE TIME AND WILL BE "ABLE TO HELP HIM WITH IMPULSIVE/UNSAFE EATING HABITS." PHONED DOCTOR AND HE STATED HE WANTED NURSES TO WRITE ORDER FOR VERBAL ORDER FOR MECHANICAL SOFT DESPITE RISK INVOLVED, WIFE AWARE...WIFE SIGNED OFF ON ABOVE. IN ADDITION TO ABOVE, HAD EDUCATED WIFE FURTHER ON RATIONALE FOR CURRENT DIET OF PUREED AS OF THIS MORNING AND WIFE SIGNED THAT SHE UNDERSTOOD REASONING AND IMPORTANCE OF PUREED. HOWEVER, AS STATED ABOVE, WIFE THEN CONTINUED TO COMPLAIN AND REQUESTED MECHANICAL SOFT AND DOCTOR WAS CALLED. PATIENT TO CONTINUE ON MECHANICAL SOFT DIET ORDER AT THIS TIME, DESPITE RISK FOR CHOKING...." ON 5/3/10, "PATIENT UNABLE TO REMAIN ON DIET DOCTOR GAVE VERBALLY ON FRIDAY AFTER ST PHONED TO INFORM WIFE/PATIENT EXTREMELY UPSET ABOUT PATIENT RECEIVING PUREED. DOCTOR WROTE UPGRADE TO MECHANICAL SOFT DESPITE SEVERE RISK OF CHOKING, BUT ALSO GAVE ORDER FOR PUREED IF WIFE WAS NOT PRESENT. WIFE/2 VISITORS BECAME EXTREMELY UPSET, YELLING AT THIS WRITER/STAFF, VERBALLY ABUSIVE. 1 VISITOR SAID, "WOULD YOU LIKE TO EAT THIS "@#@ EVERY DAY?" WIFE EXTREMELY COMBATIVE/VERBALLY ABUSIVE/DEMANDED PATIENT BE PLACED BACK ON MECHANICAL SOFT. WIFE STATED, "I KNOW HE GETS CHOKED, HE GOT CHOKED ALL TIME AT HOME...IF HE GETS CHOKED, HE GETS CHOKED." WIFE EDUCATED ONCE AGAIN EXTENSIVELY ON RISKS INVOLVED DUE TO ORAL DYSPHASIA//IMPULSIVE/UNSAFE EATING HABITS, EXPLAINED PATIENT UNABLE TO SENSE WHAT HE IS DOING WHEN FEEDING SELF, UNABLE TO MONITOR BITE SIZES/HAS MOUTHFUL OF SOLIDS IN MOUTH/CONTINUES TO SHOVEL LARGE BITES. EDUCATED WIFE THIS IS DUE TO MULTIPLE EPISODES/EXTENSIVE DAMAGE TO BRAIN DUE TO MULTIPLE [MEDICAL CONDITION]'S ([MEDICAL CONDITION])/MULTIPLE TIA'S ([MEDICAL CONDITION]) STILL OCCURRING. WIFE STATED SHE IS AWARE OF CHOKING RISKS, BUT HAS DONE FINE WHEN SHE HAS GIVEN HIM MECHANICAL SOFT/REGULAR. NOTED WIFE HAS GIVEN PATIENT HER REGULAR LUNCH TRAY/MECHANICAL SOFT FROM OUTSIDE FACILITY AT DINNER. WIFE STATED PATIENT WILL NOT EAT PUREED IF WE DO NOT CHANGE IT....WIFE EDUCATED ON RISK OF CHOKING/COMPLICATIONS, EVEN DEATH IF HE WERE TO BECOME CHOKED/WE ARE TRYING TO KEEP PATIENT AS SAFE AS POSSIBLE WIFE DID NOT AGREE...WHEN WIFE PRESENT, PATIENT BECOMES UPSET/AGITATED/RAISES VOICE HE 'HATES PUREED.' WIFE STATED IN FRONT OF PATIENT SHE DOES NOT WANT PATIENT TO EAT BABY FOOD/WILL TAKE PATIENT OUT OF FACILITY IF WE DO NOT MEET HER REQUESTS. FACILITY AWARE/ADMINISTRATOR, STAFF AWARE...." ON 5/4/10, "PATIENT HAS MADE COMPLAINTS ABOUT PUREED DIET LEVEL.... WIFE REMAINS UPSET ABOUT ST REFUSAL/DOCTORS REFUSAL TO UPGRADE PATIENT BACK TO MECHANICAL SOFT SOLIDS....SPOKE TO ADMINISTRATOR REGARDING SITUATION LAST NIGHT WITH FAMILY/WIFE/PATIENT COMPLAINTS ABOUT PUREED/DOCTOR REFUSAL TO UPGRADE TO MECHANICAL SOFT. EXPLAINED TO ADMINISTRATOR/REHAB MANAGER FAMILY IS UPSET THERE IS NO DIET WAIVER AT THIS FACILITY AT THIS TIME TO ALLOW PATIENT TO RECEIVE MECHANICAL SOFT/HAVE THREATENED TO MOVE PATIENT OUT OF FACILITY IF WE DO NOT AGREE TO HER REQUEST. INFORMED STAFF WIFE HAS STATED PATIENT WILL BE FINE IF HE HAS MECHANICAL SOFT, AS SHE IS PRESENT AT MOST ALL MEALS TO MONITOR HIM/ENSURE HE DOES NOT GET CHOKED...." ON 5/6/10, "PATIENT REMAINS "UPSET" WITH THIS WRITER, AS PATIENT IS VERY UPSET WITH CURRENT DIET LEVEL OF PUREED AND REPORTED TO THIS WRITER THAT HE DID NOT FEEL LIKE DOING ANYTHING OR TALKING TO THIS WRITER UNTIL THIS WRITER CHANGES DIET TO MECHANICAL SOFT SOLIDS...CARE PLAN HELD TO DISCUSS PATIENT/WIFE COMPLAINTS REGARDING DIET RECOMMENDATIONS/CURRENT ORDER FOR PUREED...PATIENT STATED TO THIS WRITER, 'I AM SO PISSED AT YOU, I USED TO LIKE YOU, BUT I AM STILL PISSED, I WAS TOLD IT IS ALL YOUR FAULT, DOCTOR SAID I COULD EAT WHATEVER I WANT.' HOWEVER, DOCTOR STILL DID NOT WRITE ORDER FOR MECHANICAL SOFT, DESPITE CHOKING RISK AT THIS TIME. EXPLAINED TO PATIENT IT IS OKAY IF HE IS UPSET WITH ST/DIET RECOMMENDATIONS/ EXPLAINED WE ARE TRYING TO KEEP HIM AS SAFE AS POSSIBLE....ST CONTINUES TO RECOMMEND PUREED/THIN LIQUIDS, WIFE STILL STATING SHE IS TRYING TO GET DOCTOR TO WRITE ORDER FOR MECHANICAL SOFT." ON 5/7/10, "...PATIENT REMAINS UPSET WITH ST DUE TO NOT LIKING CURRENT SOLID DIET OF PUREED, AND HAS BEEN EVEN IGNORING THIS WRITER WHEN TASKS HAVE BEEN ATTEMPTED...PATIENT HAS EVEN REPLIED TO THIS WRITER WHEN ENCOURAGED HE DID NOT FEEL LIKE DOING ANYTHING BUT SLEEPING AND CONTINUES TO STATE HE WILL NOT EAT ANYMORE IF THIS WRITER DOES NOT CHANGE DIET TO MECHANICAL SOFT. PATIENT/WIFE HAVE BEEN EDUCATED AT LENGTH WITH REGARD TO RATIONALE FOR CURRENT DIET/HAVE EXPLAINED ST IS UNABLE TO UPGRADE PATIENT DUE TO ORAL DYSPHASIA DEFICITS AND ALSO DISPLAYS IMPULSIVE EATING HABITS...WHEN ASKED QUESTIONS PATIENT WILL STATE, 'I DON'T KNOW OR CARE RIGHT NOW...PLEASE LET ME GO BACK TO BED.'...PATIENT TRIALED AGAIN WITH MECHANICAL SOFT, WIFE KEEPS INSISTING ON DIET CHANGES, BUT REPORTS NOW AWARE ST UNABLE TO WRITE ORDER FOR UPGRADE DUE TO EATING HABITS/SIGNIFICANT ORAL DYSPHASIA/CHOKING RISK. WIFE REPORTED STILL WANTS PATIENT ON PUREED MEATS, HOWEVER, AS UNABLE TO CHEW WELL, BUT OVERALL IS JUST LOOKING OUT FOR HIS QUALITY OF LIFE, DESPITE PATIENT GETTING CHOKED REPEATEDLY AT HOME/STATED IF HE GETS CHOKED HERE, SOMETHING HAPPENS, IT HAPPENS, BUT PATIENT IS UNHAPPY/ANXIOUS/FRUSTRATED WITH CURRENT DIET OF PUREED...WIFE CONTINUES TO DISCUSS ABOVE WITH VARIOUS STAFF/EVEN STAFF THAT DO NOT CARE FOR PATIENT. PATIENT REMAINS UPSET/TELLS THIS WRITER REPEATEDLY HE IS MAD AT THIS WRITER...." ON 5/10/10, "PATIENT/WIFE STILL EXTREMELY UPSET ABOUT DIET RECOMMENDATION. PER WIFE/STAFF, WIFE IS MOVING PATIENT TO ANOTHER FACILITY. PER NURSE, DOCTOR WAS SUPPOSED TO/HAD TOLD HER HE WAS GOING TO UPGRADE PATIENT TO MECHANICAL SOFT ON FRIDAY. HOWEVER, ORDER HAD NOT BEEN WRITTEN. PATIENT WOULD NOT EVEN ACKNOWLEDGE THIS WRITER/RESPOND TO ST WHEN ATTEMPTS WERE MADE. PATIENT WOULD NOT ANSWER ST'S QUESTIONS WHEN THIS WRITER ASKED HIM QUESTIONS, IF HE WANTED SOMETHING TO DRINK/EAT/WOULD NOT COMPLY WITH ORAL MECHANISM EXERCISES...PATIENT CONTINUED TO MAKE COMPLAINTS TO OTHER STAFF/OTHER RESIDENTS....EXPLAINED TO WIFE/FAMILY/PATIENT DOCTOR HAD NOT WRITTEN NEW DIET ORDER. DOCTOR STATED HE HAD, AS DOCTOR PRESENT AS NURSES STATION. NURSE FOUND NOTE IN DOCTOR'S NOTES, BUT HAD NOT WRITTEN ORDER. DOCTOR THEN WROTE ORDER FOR MECHANICAL SOFT/THIN LIQUIDS...WIFE/FAMILY STILL UPSET/STATED THEY WERE STILL MOVING PATIENT. WIFE STATED SHE KNEW SHE WAS DOING HER JOB, BUT THIS WRITER WOULD WANT TO DO SAME THING IF IT WAS HER HUSBAND. WIFE STATED, "I KNOW HE GETS CHOKED, BUT THIS IS ALL HE HAS."...FAMILY/PATIENT STILL EXTREMELY UPSET...." THE NURSE NOTE, DATED 5/5/10 AT 6:30 P.M., INDICATED "EXPLAINED TO WIFE ABOUT SPEECH THERAPY RECOMMENDATIONS TO HAVE RES (RESIDENT) CONT (CONTINUE) WITH PUREED FOOD CONSISTENCY AND THINK LIQ (LIQUIDS). RES WIFE HAS BEEN FEEDING HIM MECH (MECHANICAL) SOFT FOODS AND STATED YOU SEE WHAT I'M DOING. I ADVISED MRS. (LAST NAME) THAT HE IS AT RISK FOR CHOKING AND ASPIRATION. RES WIFE STATED TO GET OUT OF ROOM. I TOLD WIFE I WOULD INFORM ED (EXECUTIVE DIRECTOR) OF CONCERNS." THE NURSE NOTE, DATED 5/5/10 AT 7:30 P.M., INDICATED ...RES OFTEN REFUSED MEALS ON TRAY ET (AND) WIFE FEEDS HIM OTHER FOOD...." THE NURSE NOTE, DATED 5/7/10 AT 10:15 A.M., INDICATED "...SEVERAL COMPLAINTS THRU-OUT (SIC) MEAL R/T (RELATED TO) PUREED DIET...." ON 5/8/10 AT 11:20 A.M., "...WIFE CONTINUES TO BRING ITEMS OF FOOD INTO THE FACILITY TO FEED RES...." THE physician progress notes [REDACTED]. ONLY WAY HE CAN HAVE MECH SOFT DIET IS FOR MD (MEDICAL DOCTOR) TO "OVER-RIDE" FACILITY RECOMMENDATIONS AND AFTER CONVERSATION WITH PT AND WIFE THEY UNDERSTAND RISKS OF ADVANCE TO MECH SOFT DIET WITH THIN LIQUIDS SO I'M WILLING TO WRITE FOR THIS AS LONG AS HE IS MONITORED CLOSELY...." THE SOCIAL SERVICE NOTE, DATED 5/6/10 (UNTIMED), INDICATED "(RESIDENT NAME) SAID 'DON'T' TAKE ANY LIP FROM THEM.' MRS. (LAST NAME) WAS UPSET AND CURSING. IN THE CARE PLAN MRS. (NAME) WAS VERY ANGRY ABOUT (RESIDENT'S) DIET. SHE STATED "IF HE CHOKES HE CHOKES!!" SHE LEFT THE CARE PLAN CURSING AND ANGRY. SHE STATED UNDERSTANDING THE NEED TO FOLLOW DOCTOR'S ORDERS, BUT "THAT AIN'T GOING TO HAPPEN!" SHE THEN STORMED OUT." THE SOCIAL SERVICE NOTE, DATED 5/10/10 (UNTIMED), INDICATED "THIS WRITER INFORMED TODAY THAT (RESIDENT NAME) WAS BEING TRANSFERRED TO (FACILITY NAME)...SHE (WIFE) SAID SHE WAS TAKING (RESIDENT) TO WHERE HE CAN EAT WHAT EVER HE WANTS...." THE ADMINISTRATOR WAS INTERVIEWED ON 6/7/10 AT 12:00 P.M., AND INDICATED THE CORPORATION DID NOT SUPPORT THE SIGNING OF DIET WAIVERS, AND WAS ACTING IN THE BEST INTEREST OF THE RESIDENT. THE ADMINISTRATOR INDICATED RESIDENT RIGHTS WERE NOT CONSIDERED WHEN THE RESIDENT/WIFE CONTINUALLY REQUESTED NOT TO COMPLY WITH DIET ORDERS. THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER 2010-1042/IN 353. 3.1-4(d)3.1-38(f)