Brickyard Healthcare - Brookview Care Center

Based on observation, interview and record review, the facility failed to ensure staff maintained infection control by touching pill medications with their bare hands for 1 of 1 random observations of a medication administration. (Resident 53) Findings include:An observation was made of Qualified Medication Aide (QMA) 5 at a medication cart on 1/23/26 at 9:44 a.m. QMA 5 was observed to touching the medication drawers and multiple medication cards. The QMA pulled a medication card out of her medication cart and popped the resident's medication tablet into her bare hand. She placed the tablet into a medication cup full of other medications. The QMA indicated, at that time, the medication was for Resident 53. No hand washing or hand sanitizer was used by QMA 5, prior to popping the resident's medication into her hand or during the observation. An interview was conducted with the Nurse Consultant and the Director of Nursing (DON) on 1/23/26 at 2:00 p.m. The DON indicated staff should not touch medication tablets with their bare hands. The clinical record for Resident 53 was reviewed on 1/22/26 at 1:30 p.m. The residents diagnoses included, but were not limited to type II diabetes mellitus. A medication administration policy was provided by the Executive Director on 1/23/26 at 2:54 p.m. It indicated, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines:.14. Remove medication from source, taking care not to touch medication with bare hand. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure residents' rooms were homelike and in good repair for 2 of 4 resident rooms observed during an environmental tour. (Resident 10 and Resident 24) Findings include: 1.An observation was made of Resident 10's room on 1/21/26 at 11:22 a.m. The resident's closet door was observed to be broken. During an environmental tour, with Housekeeping Staff 1, Housekeeping Staff 2, and the Senior District Operations Manager on 1/28/26 at 11:51 a.m., Resident 10's room was observed. The sliding closet door was observed not attached inside the medal track causing the closet door to freely move out instead of glide back-n-forth in the track. Housekeeper Staff 1 indicated the closet door had been broken for a while. The Senior District Operations Manager indicated the medal track was bent and needed replaced. 2. An observation was made of Resident 24's room on 1/21/26 at 11:39 a.m. The bottom brown baseboard was observed pulled away from the wall under the heat and air unit. An interview was conducted with Resident 24 on 1/21/26 at 11:40 a.m. The resident indicated the baseboard had been like that for a long time. During an environmental tour, with Housekeeping Staff 1, Housekeeping Staff 2, and the Senior District Operations Manager on 1/28/26 at 11:51 a.m., Resident 24's room was observed. The bottom brown baseboard was observed pulled away from the wall under the heat and air unit. They indicated the maintenance department would address repairs that were needed in the resident rooms. The Facility Maintenance Guidelines and Procedure was provided by the Executive Director on 1/28/26 at 12:17 p.m. It indicated, It is our intent to provide a clean, comfortable environment. The maintenance of the facility will be conducted as follows:.Staff should place items they find in the normal course of their day in the TELS Work Order System when found as well as placing items in the system when residents make requests. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program for 2 of 4 residents reviewed for activities (Resident C and Resident B). Findings include:1.During an observation, on 1/21/26 at 11:38 a.m., Resident C was lying in bed with his eyes open. There was no music or television on in the resident's room. During an observation, on 1/22/26 at 11:56 a.m., Resident C was lying in bed with his eyes open. There was no music or television on in the resident's room.During an observation, on 1/23/26 at 11:18 a.m., Resident C was sitting in his room in a high back wheelchair with his eyes open. There was no music or television on in his room. Review of the clinical record of Resident C, on 1/23/26 at 2:09 p.m., indicated the resident's diagnoses included, but were not limited to, anoxic brain damage (the brain was completely deprived of oxygen, leading to severe physical, cognitive, and emotional issues), persistent vegetative state (consciousness resulting from sever brain damage where awake but showing no signs of awareness), muscle weakness, and sleep disorder (conditions that impair the amount of sleep resulting in daytime distress).The care plan for Resident C, dated 7/24/25, indicated the resident was in a persistent vegetative state and was unable to communicate. The resident was dependent on staff to anticipate his needs. The resident's family indicated the resident enjoyed music and being read to. The interventions included, but were not limited to, leave music and television on for the resident to hear during the day. During an interview with the Activity Director, on 1/23/26 at 1:34 p.m., she indicated she thought the CNA's were responsible to ensure Resident C's television or radio was on. 2.During an observation and interview with Resident B on 1/21/26 at 11:59 a.m., Resident B was sitting in her room with no self initiated activities occurring. The resident indicated the facility did not have enough activities and there was no variety of activities offered. The resident indicated she stayed in her room most of the time because there was no activities occurring. The resident indicated the facility did have bingo.During an observation and interview with Resident B on 1/23/26 at 10:50 a.m., Resident B was sitting in her room watching the television. The resident indicated she would like the facility to offer arts and crafts, play cards, have music and go outside when the weather was nice. Review of the clinical record of Resident B on 1/22/26 at 10:51 a.m., indicated the resident's diagnoses included, but were not limited to, end stage renal disease (irreversible phase of kidney failure), heart failure (chronic, progressive condition where the hear muscle was too weak) and weakness. The annual Minimum Data Set (MDS) for Resident B, dated 11/4/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. It was somewhat important to the resident to read the newspaper, books, magazines, be around animals, listen to music and keep up with the news. The care plan for Resident B, dated 11/13/25, indicated the resident enjoyed group programs such as bingo, cards, outings, resident council, going outdoors and attending church. The preference evaluation for Resident B, dated 1/21/26, indicated the resident enjoyed spending time with her family member, jigsaw puzzles, watching television, going to church and socializing with other residents. The resident indicated it was very important to have books, magazines, newspapers, keep up with the news, listen to music, do activities in groups, go outside when the weather was good and participate in religious services. During an interview with the Activity Director, on 1/23/26 at 1:34 p.m., she indicated she started working at the facility in November 2025. The facility had not had an activity assistant for the long term care part of the facility, but had one start work yesterday. The facility did have an activity assistant that worked on the two memory care units and when she had time she attempted to help the Activity Director on the long term care side of the facility. The Activity Director indicated she was required to attend meetings daily, from 9:00 a.m. to 10:00 a.m., and then had care plan meetings every Wednesday, from 10:00 a.m. to 1:00 p.m., it depended on how many care plan meetings were scheduled that day. The Activity Director indicated Resident B enjoyed going to bingo and had not reported to her that she would like to do other activities. The activity policy provided by the Director Of Nursing (DON) on 1/23/26 at 2:00 p.m., indicated the facility would provide an ongoing activity program to support residents in their choices. Activities were to promote self-esteem, pleasure, comfort, education, creativity, success, and independence. This citation relates to Intake 2713078. 3.1-33(a)

Based on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 11) Findings include: 1.The clinical record for Resident 11 was reviewed on 1/21/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus (chronic metabolic disorder characterized by high blood sugar). A care plan, dated 1/10/25, indicated Resident 11 had diabetes mellitus. The interventions included, but were not limited to, the staff were to administer the diabetic medications as ordered. A physician's order, dated 9/11/25, indicated Resident 11 was to receive 5 units of aspart insulin before meals. The insulin was not to be given if the resident's blood sugar was less than 100. The order was discontinued on 1/21/26. The January 2026 Medication Administration Record indicated on the following dates and shifts Resident 11 had received 5 units of aspart insulin when her blood sugar reading was less than 100: -On 1/8/26 in the morning, the resident's blood sugar reading was 94. The resident was administered 5 units of insulin. -On 1/13/26 in the morning, the resident's blood sugar reading was 92. The resident was administered 5 units of insulin. -On 1/17/26 in the morning, the resident's blood sugar reading was 89. The resident was administered 5 units of insulin. A physician's order, dated 11/19/25, indicated the staff were to administer 20 units of glargine insulin to Resident 11 in the mornings. The insulin was to be held if the resident's blood sugar was less than 110. The January 2026 Medication Administration Record indicated on the following dates and shifts Resident 11had received 20 units of glargine insulin when her blood sugar reading was less than 110: -On 1/8/26, the resident's blood sugar reading was 94. The resident was administered 20 units of glargine insulin. -On 1/9/26, the resident's blood sugar reading was 80. The resident was administered 20 units of glargine insulin. -On 1/13/26, the resident's blood sugar reading was 92. The resident was administered 20 units of glargine insulin. -On 1/16/26, the resident's blood sugar reading was 83. The resident was administered 20 units of glargine insulin. -On 1/17/26, the resident's blood sugar reading was 89. The resident was administered 20 units of glargine insulin. -On 1/20/26, the resident's blood sugar reading was 91. The resident was administered 20 units of glargine insulin. -On 1/21/26, the resident's blood sugar reading was 106. The resident was administered 20 units of glargine insulin. -On 1/22/26, the resident's blood sugar reading was 90. The resident was administered 20 units of glargine insulin. -On 1/25/26, the resident's blood sugar reading was 71. The resident was administered 20 units of glargine insulin. -On 1/26/26, the resident's blood sugar reading was 93. The resident was administered 20 units of glargine insulin.-On 1/27/26, the resident's blood sugar reading was 102. The resident was administered 20 units of glargine insulin. A physician's order, dated 1/21/26, indicated the staff was to administer 3 units of aspart insulin to Resident 11 before meals. If the resident's blood sugar was less than 110, the insulin was not to be given. The January 2026 Medication Administration Record indicated on the following dates and shifts Resident 11had received 3 units of aspart insulin before meals when the resident's blood sugar reading was less than 110: -On 1/25/26 in the morning, the resident's blood sugar reading was 71 and in the afternoon, the resident's blood sugar reading was 84. The resident was administered 3 units of insulin in the morning and in the afternoon. -On 1/26/26 in the morning, the resident's blood sugar reading was 93. The resident was administered 3 units of insulin. -On 1/27/26 in the morning, the resident's blood sugar reading was 102. The resident was administered 3 units of insulin. An interview was conducted with the Director of Nursing on 1/27/26 at 3:22 p.m. She indicated the staff had administered the resident's insulins when they should have been held, per the prescribed parameters as ordered by the physician. 2.The clinical record for Resident 11 was reviewed on 1/21/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, congested heart failure (chronic condition where the heart muscle weakens and can't pump enough oxygen-rich blood to meet the body's needs). A care plan, dated 1/22/25, indicated Resident 11 had swelling in her legs due to heart valve replacement, hypertension (high blood pressure), congestive heart failure and chronic kidney disease. The interventions included, but were not limited to, the staff were to monitor vital signs and notify medical provider of abnormalities and give medications as ordered. A physician's order, dated 9/23/25, indicated the staff were to administer 2 tablets of 20 milligrams of torsemide (water pill, used to treat excess fluid retention) daily to Resident 11. The medication was not to be given if the resident's systolic blood pressure (the top number in a blood pressure reading) was less than 100. The January 2026 MAR indicated Resident 11 had received 40 milligrams of torsemide every morning from 1/1/26 through 1/27/26. There were no blood pressures obtained prior to the administrations as ordered. An interview was conducted with the Director of Nursing on 1/27/26 at 3:22 p.m. She indicated she was unable to find blood pressure readings that had been obtained prior to the administration of the resident's 40 milligrams of torsemide medication. The order was not set up correctly in the electronic medication system in error. A medication administration policy was provided by the Executive Director on 1/23/26 at 2:54 p.m. It indicated, Policy.Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely develop and update behavior plans of care and to document behaviors on behavior tracking logs for 3 of 3 residents reviewed for behaviors (Resident 12, Resident 50, and Resident 1). Findings include:
1. The clinical record for Resident 50 was reviewed on 1/23/26 at 10:20 a.m. The resident's diagnosis included, but were not limited to, schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels, ranging from manic highs to depressive lows).
A Quarterly Minimum Data Set (MDS) Assessment, completed 8/11/25, indicated the resident was able to make herself understood and understand others. She had severely impaired decision making and was independent with transfers and ambulation.
A Change of Condition Situation progress note, dated 9/1/25 at 3:12 p.m., indicated Resident 50 had told staff that a male resident (Resident 1) went inside her room, touched her breast and private parts, and slapped her face. However, the male resident (Resident 1) was on his bed when staff checked his room. Resident 50 had repeated the same story to the writer (of the progress note). The male resident was on his bed asleep. A head-to-toe assessment was done and no redness or swelling noted on the resident's face. Resident 50 had no reports of discomfort or pain.
A physician's progress note, dated 9/2/25, indicated Resident 50 was seen due to reports/allegations of inappropriate contact by another resident on 9/1/25. Resident 50 had alleged male resident came to her room, touched her inappropriately and slapped her face. Staff reports that male resident was resident in his bed in his own room at the time of the report/allegation. Resident 50 had no apparent evidence of acute injury noted at the time. The assessment and plans indicated Resident 50 had paranoid schizophrenia chronic fluctuating psychosis with labile mood as well as delusions and apparent hallucinations, acutely anxious and paranoid with recent allegations against another resident. No physical evidence of assault as resident reported to staff over weekend.
A Behavior Charting note, dated 9/25/2025 at 1:39 p.m., indicated Resident 50 reported a false interaction with another resident. Resident 50 with noted delusional thinking. Prior to behavior, Resident 50 was walking in the hallway and up in communal space. The intervention attempted by staff was to return the resident to her room. Effectiveness of intervention indicated Resident 50 was able to be redirected at that time.
A Physician's Progress note, dated 11/6/25, indicated Resident 50 had poor judgement and poor insight in her medical condition due to her diagnosis of paranoid schizophrenia. She had delusional symptoms and was unable to make firm and consistent decisions for herself.
A General Note created by Registered Nurse (RN) 20 on 12/15/25 at 11:44 a.m. as a late entry for 12/13/25 at 10:45 a.m., indicated Resident 50 approached RN 20 with a video of another resident (Resident 1) exposing himself to Resident 50. When Resident 50 was asked why Resident 1 was in her room and Resident 50 indicated she invited him but did not state why. RN 20 educated Resident 50 about recording someone without permission and nursing staff would monitor both parties for 72 hours following event.
Resident 50's clinical record contained a Capacity to Consent assessment, dated 12/13/25, that indicated Resident 50 could tell you what it means to engage in sexual activity. She had the ability to avoid exploitation, the ability to say yes or no to sexual activities at any time, understood that they could change their mind about engaging in sexual activity at any time. Resident 50 had the ability to identify who they are having a relationship with. Resident 50's sexual behaviors were consistent with her formally held beliefs and understood that sexual activity can have physician, emotional, and health consequences.
Resident 50's clinical record did not include a physician's assessment of her cognitive ability and insight to engage in a sexual relationship.
Resident 50's clinical record contained a General Note, dated 12/29/2025 at 10:30 a.m., that indicated the nurse was alerted to Resident 50's room. When the room was entered, Resident 50 was sitting on the floor on her knees, with her feet behind her and was undressed from the waist down. Male resident (Resident 1) was noted to be on the floor, fully dressed. Resident 50 then became agitated and started yelling at staff to leave her room.
A General Note, dated 12/29/2025 at 10:30 a.m., indicated Resident 50 was in the hallway partially dressed in her bra but had removed her shirt. Resident 50 was gesturing to a male resident (Resident 1) who was also in the hallway.
Resident 50's clinical record contained a Physician Note written by NP 21, dated 12/29/2025 5:13p.m., that indicated when provider walked into room, Resident 50 was sitting on the floor with bra on and unknown if undergarments were present. NP 21 and Licensed Practical Nurse (LPN) 22 attempted to educate Resident 50 on sexual behavior, STDs, and possible pregnancy. Offered Resident 50 birth control, however Resident 50 became verbally abusive to NP 21 and repeatedly stated to get the F*** out of her room. To prevent Resident 50 further distress, NP 21 left room. Staff reported that Resident 50's guardian had returned call and agreed to placing Resident 50 on Depo Provera birth control shots. The physician has ordered labs and Depo Provera would not be started until lab results are obtained. Resident 50 had a previous episode of sexual behavior noted by staff on 12/13/2025 and per staff note resident had recorded another resident (Resident 1) exposing himself to her.
Resident 50's clinical record contained a Progress Note from the physician, dated 1/1/26 at 8:00 a.m., indicated Resident 50 was being evaluated due to her request she and a male resident at the facility wish to participate in intimate sexual activities. Resident 50 was not cooperative during interaction and was rather very agitated and yelling and grabbing the physician's document and apparatus and threw them away. This was after we had been communicating by writing for approximately 45 minutes. Some of the things Resident 50 had said were that she did not initiate this and that it was the male resident who had approached her about the relationship. Resident 50 eventually told the physician that she would like to engage in intimate sexual relationship with a male, but she does not want any birth control. Resident 50 indicated she does not want to have any birth control treatments. Resident 50 was educated in writing that a serum pregnancy test, hepatitis b and c test, and HIV test were ordered. She was informed at this time that birth control was a must have if she wanted to have any intimate sexual relationship with a male. The impression the physician got was that she had an acute flareup of her manic episode with her bipolar disorder. Resident 50 does not have any decision-making capability to engage in sexual activity with a male as requested. The physician's conclusion was that Resident 50 did not have the decision-making capability to have any sexual relationship with a male resident at this facility because she had no insight in her decision.
Resident 50's clinical record did not contain a care plan that indicated she was unable to consent to sexual activity.
During an interview on 1/23/26 at 2:06 p.m., Certified Nursing Assistant (CNA) 23 and CNA 24 indicated they worked with Resident 1 and Resident 50 often. The nurse had informed them, sometime around New Years, to try to keep them out of each other's rooms.
During an interview on 1/23/26 at 2:29 p.m., Social Worker (SW) 1 indicated she had not been made aware that Resident 50 had video tapped Resident 1 exposing himself. SW 1 should have been made aware of these incidents.
During an interview on 1/23/2026 at 2:50 p.m., the Staff Development Coordinator (SDC) indicated on 12/13/25 she had been made aware that Resident 50 had videotaped Resident 1 with his hands down his pants. The ED had been made aware. SDC had not seen the video. The SDC could not recall if any specific interventions were set up for either resident after the incident. The staff did look in on them often to ensure they were not together.
During an interview on 1/27/25 at 10:03 a.m., the DON indicated that she had updated Resident 50's history of behaviors care plan on 1/5/26.
During an interview on 1/27/26 at 11:10 a.m., Qualified Medication Aide (QMA) 25 indicated he had not been informed to try to keep Resident 1 out of Resident 50's room. Resident 1 often went to Resident 50's room and Resident 50 would come to Resident 1's room.
During an interview on 1/23/26 at 3:22 p.m., RN 20 indicated the staff were told to keep Resident 1 and Resident 50 separated and to keep an eye on them. Resident 50 often went to Resident 1's room and asked Resident 1 to come with her. The facility had done an Inservice about respecting the resident's right to be sexual and to provide privacy for resident's who were being sexual.
During an interview on 1/27/26 at 12:27 p.m., SW 1 indicated Resident 50 did not have a care plan about redirecting others from her room or what to do if a resident may want to visit with her privately.
Resident 50's clinical record did not include a care plan related to Resident 50 identifying herself as different people.
2.The clinical record for Resident 1 was reviewed on 1/21/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to, vascular dementia (losing touch with reality, characterized by hallucinations and delusions caused by brain damage) with behavior disturbance, schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and chronic hepatitis C (a long-term, contagious liver infection caused by the hepatitis C virus).
A care plan, initiated 5/20/25, indicated Resident 1 had impaired cognition function/dementia and communications deficits related to dementia and a history of stroke (blood flow to the brain was interrupted or blood vessels burst causing brain cells to die). The goal was for him to maintain current level of cognitive function. The interventions was for staff to reorient and supervise as needed; keep his routine consistent and try to provide consistent care givers as much as possible to decrease confusion; use task segmentation to support short term memory deficits; break tasks into one step at a time as needed to promote understanding.
A care plan, initiated 6/24/25, indicated Resident 1 had a behavior problem of intrusive wandering or exit seeking related to his vascular dementia with behavior disturbance. He was known to propel his wheelchair backwards with potential to bump into objects or people. The goal was for him to have no evidence of behavior problems, and he would have no injury to self or others. The intervention was for staff to redirect Resident 1 from others resident's rooms as needed, initiated 6/24/25.
A Quarterly MDS Assessment, completed 9/27/25, indicated Resident 1 was able to make himself understood and to understand others. He was severely cognitively impaired. The resident required set-up assistance and supervision for transfers from his bed to his wheelchair.
A Psychiatric Subsequent Assessment, dated 10/15/25, indicated Resident 1 was seen to manage a chronic condition. Resident reported that his mood was okay. Resident 1 believed the year was 2002 and the month was March.
A General Note, created by RN 20 on 12/15/25 at 11:45 a.m. as a late entry for 12/13/2025 at 10:45 a.m., indicated Resident 1 was in another resident's [Resident 50] room exposing himself when asked what he was doing in the other resident's room Resident 1 indicated she told me to come in there. Resident 1 was removed from Resident 50's room and will be monitored for 72 hours.
Resident 1's clinical record contained a Capacity to Consent assessment, dated 12/13/25, that indicated Resident 1 was able to tell you what it means to engage in sexual activity. He was able to avoid exploitation and had the ability to say yes or no to sexual activity at any time. He understood that they could change their mind about engaging in sexual activity at any time and had the ability to identify who they are having a relationship with. Resident 1's sexual behaviors were consistent with his formally held beliefs, and he understood that sexual activity can have physical, emotional, and health consequences.
The clinical record did not contain a physician's assessment of Resident 1's cognitive ability to consent to a sexual relationship
Resident 1's clinical record contained a General Note, dated 12/28/2025 at 6:30 p.m., that indicated Resident 1 was found in another resident's room. Both residents appeared calm. Resident 1 had his clothes and shoes on and was sitting in his wheelchair. Resident 1 was redirected back to his own room and provided education about the importance of asking consent prior to going into another resident's room.
Resident 1's clinical record did not contain a care plan related to Resident 1's wishes to be in a sexual relationship with another resident at the facility.
Resident 1's clinical record contained a Progress note from the physician, dated 1/1/2026 at 8:00 a.m., that indicated the provider was asked to evaluate Resident 1, who wishes to engage in intimate sexual relationship with a female resident (Resident 50) at the same facility. Resident 1 was unable to provide detailed treatments that he had for hepatitis C. He was informed he was at risk of passing this sexually to the female resident. The physician did not approve that Resident 1 engage in any sexual activities with this female because she did not have the mental capacity to consent to sexual relationship. Resident 1 was told that the female partner he was trying to engage in sexual activity with did not have decision-making capability to engage in sex. She does not have good insight and the consequences of what she was trying to get into, so it was up to him not to engage in any sexual activity with this female resident. Resident 1's mental capacity was also impaired as he could not tell the physician what he had in mind to prevent a pregnancy or STD.
Resident 1's clinical record did not contain a care plan that indicated he was unable to consent to sexual activity.
A General Progress Note, dated 1/4/2026 at 3:30 p.m., indicated Resident 1 continued to go into another resident's room after being redirected back to his own room. Management was made aware. Staff would continue to monitor.
A General Progress Note, dated 1/5/25 at 6:00 p.m., indicated family and unit manager made aware that Resident 1 was transferred to another room.
During an interview on 1/23/26 at 2:06 p.m., Certified Nursing Assistant (CNA) 23 and CNA 24 indicated they worked with Resident 1 and Resident 50 often. The nurse had informed them, sometime around New Years, to try to keep them out of each other's rooms.
During an interview on 1/23/26 at 2:29 p.m., Social Worker (SW) 1 indicated she had not been made aware that Resident 1 had exposed himself to Resident 50. SW 1 should have been made aware of these incidents.
During an interview on 1/23/2026 at 2:50 p.m., the Staff Development Coordinator (SDC) indicated on 12/13/25 she had been made aware that Resident 50 had videotaped Resident 1 with his hands down his pants. The ED had been made aware. SDC had not seen the video. The SDC could not recall if any specific interventions were set up for either resident after the incident. The staff did look in on them often to ensure they were not together. Resident 1 had impaired cognitive ability and did not make rational decisions.
During an interview on 1/27/26 at 11:47 a.m., SW 1 indicated Resident behaviors are tracked by behavior notes and charting by the CNAs in Point Click Care (PCC). The Behavior Note Report and the behavior notes were reviewed in morning meeting. The behavior notes were used more for new behaviors. The PCC behavior charting was more for behaviors that had already been identified. Behavior care plans were made by social services and with an IDT team.
On 1/27/26 at 10:03 a.m., the DON provided the current Behavioral Health Services Policy that read .It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being.3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.5. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being.7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person0centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will.b. Obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health. c. Monitor the residents closely for expressions or indications of distress. d. Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable.f. Assess and develop a person-centered care plan for concerns, identified in the resident's assessment. g. Share concerns with the interdisciplinary [IDT] to determine underlying causes of mood and behavior changes, including differential diagnosis. h. Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record. i. Ensure appropriate follow-up assessment, if needed. j. Discuss potential modifications to the care plan. k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the residents.8. The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: a. Have interventions that are person-centered, evidenced-based, culturally competent, trauma-informed, and in accordance with professional standards of practice.c. Reflects the resident's goals for care.e. maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety.h. Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition.12. The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside r=sources such as physician psychiatrists, or neurologists
On 1/27/26 at 9:13 a.m., the ED provided the Sexual Expression of Residents policy, that read .1. The staff will document observations of residents engaging in intimacy and/ or sexual activity and notify social services and the Director of Nursing. 2. The social services staff will notify the interdisciplinary team. 3. The social services staff will educate the residents about any disease processes and the residents' rights. a. Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/ or sexual expression. b. Resident with decisional capacity have a right to privacy, including private space for sexual expression. c. Resident with decisional capacity have a right to confidentiality. 4. The physician will be notified regarding all residents participating in se for a clinical and cognitive evaluation to determine intact cognitive decision-making-capacity and capacity to give consent.6. Care plan meeting with the interdisciplinary team shall be scheduled as soon as possible from the initial notification of the social services staff. a. The interdisciplinary team shall conduct a review of situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of and protects those involved. B. Outcomes of the interdisciplinary team review will be shared with the residents involved and documented in the plan of care.
On 1/30/26 at 2:30 p.m., the Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists ©American Bar Association Commission on Law and Aging - American Psychological Association from the American Psychological Association web site which read .There are no generally accepted approaches or criteria for the assessment of consent to sexual activity. [NAME] et al., [1999] suggest that the following be considered by the examining clinician, with the understanding that some individuals with capacity to consent would not meet all of these criteria: Is an adult, as defined by state law; demonstrates an awareness of person, time, place, and event; possesses a basic knowledge of sexual activities; possesses the skills to participate safely in sexual activities; i.e., whether the person understands how and why to effectively use an appropriate method of birth control, and whether the person chooses to do so; understands the physical and legal responsibilities of pregnancy; is aware of sexually transmittable diseases and how to avoid them; demonstrates an awareness of legal implications concerning wrongful sexual behaviors [e.g., sexual assault, inappropriateness of sex with minors, exploitation, etc.]; can identify when others' rights are infringed; learns that 'no' from another person means to stop [i.e., understands that it is always inappropriate to have sex or engage in other activities with someone who says no or otherwise objects by words or action]s; knows when sexual advances are appropriate as to time and place [e.g., different places and times may apply to dancing, touching, sexual intercourse]; does not allow his or her own disability to be exploited by a partner; knows when both parties are agreeing to the same sexual activity; does not exploit another person with a lower functioning who might not be able to say no or defend oneself; expresses understandable responses to life experiences [i.e., can accurately report events]; can describe the decision-making process used to make the choice to engage in sexual activity; demonstrates the ability to differentiate truth from fantasy and lies; possesses a reasoning process that includes an expression of individual values; can reasonably execute choices associated with a judgmental process; is able to identify and recognize the feelings expressed by others, both verbally and nonverbally; expresses emotions consistent with the actual or proposed sexual situation; rejects unwanted advances or intrusions to protect oneself from sexual exploitation; identifies and uses private areas for intimate behavior; is able to call for help or report unwanted advances or abuse [[NAME] et al., 1999, p. 63-64]. [NAME] Lichtenberg offers the following suggestions for assessing sexual consent capacity: 1. Patient's awareness of the relationship: a. Is the patient aware of who is initiating sexual contact? b. Does the patient believe that the other person is a spouse and, thus, acquiesces out of a delusional belief, or [is he/she] cognizant of the other's identity and intent? c. Can the patient state what level of sexual intimacy [he/she] would be comfortable with? 2. Patient's ability to avoid exploitation: a. Is the behavior consistent with formerly held beliefs/values? b. Does the patient have the capacity to say no to any uninvited sexual contact? 3. Patient's awareness of potential risks: a. Does the patient realize that this relationship may be time limited [placement on unit is temporary]? b. Can the patient describe how [he/she] will react when the relationship ends?' These authors note that while being able to state the level of sexual activity or intimacy is wanted is an important consideration, one must also assess the ability to refuse or resist sexual advances. Lichtenberg et al., also emphasized Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists ©American Bar Association Commission on Law and Aging - American Psychological Association 67 the importance of residents understanding that the ending of a relationship might be one of the potential risks of entering into a sexual relationship. Residents can leave facilities for a variety of reasons [e.g., transfer due to illness], thereby terminating the relationship .
3.The clinical record for Resident 12 was reviewed on 1/21/26 at 1:30 p.m. The resident's diagnosis included, but was not limited to, metabolic encephalopathy (change in how brain works. Fluctuating confusion and attention issues).
The Quarterly Minimum Data Set (MDS) Assessment, dated 10/3/25, indicated Resident 12 was moderately cognitively impaired.
The Quarterly MDS Assessment, dated 12/30/25, indicated Resident 12 was cognitively intact.
A discharge care plan for Resident 12, initiated date of 4/16/25 and revised on 12/16/25, indicated the resident required 24 hour supervision and care. Plans of discharging was uncertain at this time.
A care plan, dated 4/16/25, indicated Resident 12 had diagnoses of depression and anxiety. The interventions in place, dated 4/16/25 and revised on 12/16/25, indicated the staff were to administer medications as ordered, provide psychiatric services, and discuss any concerns the resident had.
A care plan, revision date of 1/9/26, indicated Resident 12 had a diagnosis of cognitive communication deficit evidence by becoming forgetful and needed reminders or verbal cues for daily decision-making. The following interventions, with an initiated date 4/14/25, indicated, but were not limited to: staff were to Cue, reorient and supervise as needed, encourage resident to go to dialysis as scheduled, and report suspected worsening of cognition or memory to the Medical Doctor. A intervention with a revision date of 12/15/25, indicated to discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers.
An elopement assessment, dated 12/9/25, indicated Resident 12 was not an elopement risk.
A nursing note, dated 12/27/25 at 4:24 p.m., indicated Resident 12 attempted to leave the building. The resident appeared to be agitated and verbalized I am leaving. The resident was redirected back in the building by another staff member.
A behavior note for Resident 12, dated 12/27/26, indicated around 2:45 p.m., the resident was taling and happy then at 4:30 p.m., the resident was found to be attempting to leave the facility unaccompanied. The physician assistant (PA) on call was notified and ordered alprazolam (used for short-term relief of anxiety and panic disorders by slowing down the central nervous system) 0.5 mg (milligrams) every 8 hours for anxiety and agitation x 3 days.
A medical provider note, dated 12/27/25, indicated Resident 12 had exhibited exit-seeking behavior this afternoon. He was redirected without incident. Will continue to monitor.
A medical provider visit note, dated 12/29/25, indicated Resident 12 was being seen that day for making attempts to get out of the facility by himself over the weekend. The resident had reported to the medical provider he would like to leave and go back to (another State). The resident was unable to provide who he would be staying with, other than friends nor how he would continue with his dialysis treatments in the other State. The resident did not have family that resided in the other State. The resident had poor judgment, and poor insight in his medical condition. He suffered from some cognitive challenges which was likely related to his previous polysubstance use disorder causing encephalopathy (a diagnosable mental health condition where a person compulsively uses three or more different classes of substances, leading to significant impairment in their life).
A physician's order, dated 12/30/25, indicated Resident 12 was to receive 0.5 milligrams of Xanax every 8 hours as needed (PRN) for agitation and anxiety.
A care plan for elopement was not developed with interventions for Resident 12.
A behavior note, dated 12/30/25, indicated, the resident was found near the employee log-in area. The resident was .pressing [a keyless digital lock] keypad near the employee log-in area. Staff had attempted to redirect the resident and the resident started cursing and refusing to be redirected. The unit manager was able to intervien.
A behavior note, dated 12/31/25, indicated, the resident was agitated, yelling in the dining room, calling staff names and was screaming loudly in the dining room. The staff tried to redirect the resident and the resident screamed louder calling staff more names and threw self on the floor out of wheelchair in the dining room.
Resident 12's behavior care plans were not updated with new interventions to address behaviors.
An elopement evaluation, dated 1/4/26, indicated Resident 12 did not have a history of elopement and wandering. He was not an elopement risk.
A social services note, dated 1/7/26, indicated the resident reported that he did not plan to be in this State. He stated he was traveling when he experienced a medical emergency, was taken to a hospital in this State.
An elopement evaluation, dated 1/9/26, indicated Resident 12 did have a history of elopement and wandering. The resident scored a five on the assessment indicating he was an elopement risk.
A nursing note, dated 1/9/26, indicated the resident called 911 (emergency services) without informing the nurse at 2:45 p.m. The emergency service team (911) arrived at the facility since the resident indicated he wanted to kill himself to the 911 caller.
Hospital discharge report, dated 1/9/26, indicated, the resident arrived at the emergency department related to suicidal ideation. The resident was trying to leave his facility and had threatened to kill himself if he was not able to leave.
A nursing note, dated 1/10/26, indicated the resident returned from hospital with no new orders. The hospital noted indicated they had conversations with him about different coping mechanisms while feeling angry about things. The resident indicated he was just mad and was not really going to do anything. The resident was to be checked on every 30 minutes for 72 hours

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident, who was assessed by the facility as an elopement risk, did not exit the facility unsupervised, for 1 of 3 residents reviewed for elopement and elopement risk (Resident B). The resident was able to exit the secured memory care unit through a bathroom window without the knowledge of staff. The resident was found at a local gas station, located in a busy intersection, and later sent to a local hospital after involvement with local police and emergency medical services (EMS).The Immediate Jeopardy began on October 1, 2025, when a cognitively impaired resident with dementia exited the secured memory care unit through a bathroom window unsupervised into a potentially dangerous area, including a multiple lane, busy intersection, that the resident had to cross to get to the local gas station located approximately 0.3 miles away from the facility. The Executive Director, Director of Nursing, and the Corporate Nurse were notified of the Immediate Jeopardy on 10/6/25 at 4:27 p.m.Findings include:The clinical record for Resident B was reviewed on 10/6/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia with agitation and behavioral disturbances, sleep disorder, and diabetes. He was admitted to the facility's secured memory care unit on 8/7/25. An admission Minimum Data Set (MDS) assessment, completed 8/14/25, indicated Resident B had severely impaired cognition. He displayed wandering behaviors for one to three days during the assessment period. The wandering behaviors placed him at a significant risk for potential danger. An elopement risk assessment, dated 8/15/25, indicated Resident B had a history of elopement and/or attempted elopement while at home. He had a history of attempted leaving the facility without informing staff. He had verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. He had wandered with a goal-directed specific destination. His wandering behavior was likely to affect the safety and well-being of himself or others. He had been recently admitted or re-admitted (within the past 30 days) and was not accepting of the situation.A care plan, dated 8/15/25, indicated he was at risk for elopement from the facility related to attempts to leave the facility unattended and impaired safety awareness. The goal was for his safety to be maintained, and he would not leave the facility unattended. The interventions included distracting him from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Identify patterns of wandering and intervene as appropriate. Leave of absences with supervision. Place his picture in the elopement binder. Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Resident resided on a secured unit. A care plan, dated 8/26/25, indicated he had the potential to be verbally or physically aggressive related to dementia with agitation, with recent episodes observed. The goal was for him to have no new episodes of physical aggression toward peers. The interventions included administering medications as ordered, assessing and anticipating his needs, provide physical and verbal cues to alleviate anxiety; give positive feedback, assisting with verbalization of source of agitation, assisting to set goals formore pleasant behavior, encourage seeking out of staff member when agitated, and psychiatric/psychogeriatric consult as indicated.A care plan, dated 8/26/25, indicated he was at risk for sleep pattern disturbance. The resident had an order or had used sleep medication and had periods of staying awake at night due to being a truck driver in the past. The goal was for him to exhibit no sleep related behavioral symptoms, such as restlessness, irritability, lethargy, or disorientation. The interventions included administering sleep medications as ordered by the physician, assessing for adverse side effects, and assisting him in establishing a daily routine with periods of rest and activity. Also, to maintain an environment conducive to sleep (quiet, comfortable temperature, dimmed lights). A Behavioral Health Diagnostic Assessment, dated 9/2/25, indicated the reason for Resident B's referral for treatment was anxiety disorders, agitation, neurocognitive disorders, feeding/eating or sleep/wake disorders. The clinical assessment indicated Resident B was alert and conversational but not oriented. He was only oriented to person. He thought [NAME] was the president and stated he was in his older 20s when asked about his age. Resident B reported some anxiety. He can be physically aggressive with others on the Memory Care Unit. A General Note, dated 10/1/25 at 2:15 a.m., indicated at the start of the shift, at 10:00 p.m., Resident B was in his bedroom in bed sleeping. At around 2:15 a.m., during rounding, Resident B was awake in his bedroom with no noted anxiety at that time. Resident B walked out of his bedroom and into the hallway, and then went back into the bedroom and closed the door. At 4:15 a.m., writer (writer of the General Note) was notified by CNA (Certified Nurse Aide) that resident was not in the room. A search was initiated at that time, and a chair was in place under the window in the resident's bathroom and the window was open. At 4:15 a.m., the writer called code silver, and a search of the premises inside and outside was initiated. The Executive Director (ED), physician, and family were notified. The writer was notified that resident was at an acute care hospital at 4:45 a.m. The physician, ED, and family were notified.An SBAR (Situation, Background, Assessment, and Recommendation) Change of Condition note, dated 10/1/25 at 11:02 a.m., indicated Resident B had reported to the acute care hospital that he had fallen during the time he had left the building. An observation was conducted of the male memory care unit with the Maintenance Supervisor (MS) on 10/6/25 at 10:06 a.m. Resident B's room was observed with windows in the bed area and bathroom. The MS indicated the resident had moved a chair to the bathroom and climbed out of the bathroom window. The bathroom was observed with a wood block screwed inside the window. The MS indicated the wood block was placed after the resident had eloped out of the window. He indicated the two plastic pieces that were on the window, that were to prevent the window from opening all the way, were broken off. He believed it was the resident that night who had broken the two plastic pieces on the window but was unsure. He indicated he had put a wood block in other residents' bathroom windows prior to the incident but had not gotten to Resident B's bathroom window yet. All the resident rooms regardless of whether a resident resides in memory care have a wood block placed in the bedroom area windows for prevention of the windows from opening all the way. The male memory care unit ,since the incident, now had all the residents' bathroom windows with wood blocks applied as well. During an interview on 10/6/25 at 10:25 a.m., the ED indicated the male memory care unit was opened in July of 2025. She received a call from the facility staff that reported Resident B had eloped out the bathroom window. The resident was appropriately dressed in a hooded sweatshirt, pants, socks, and shoes. She was aware he did have a history of attempting to elope out of the doors but was not aware he could climb out of windows. During the silver alert, the facility staff had contacted hospitals, and they were able to find the resident at an acute care hospital. The ED drove to the hospital to speak with Resident B. He reported to her he moved a chair in the bathroom and climbed out the window. He had fallen climbing out of the window to the ground. The resident was observed with an abrasion on his arm. After he hit the ground, he couldn't recall what happened, but he stated, I ran the h*** out of there. He did end up at the gas station across the street from a local fast-food place. He had taken a candy bar and some gum from the gas station. The gas station staff had contacted the emergency medical services (EMS), and he was taken to an acute care hospital. The resident's cognitive baseline fluctuates; at times he was more cognitively intact than other times. The resident had reported the purpose of the elopement was that he needed to get to the bank. After the incident, the ED spoke to the resident's Power of Attorney (POA), and she reported the resident does get anxious about his money after a certain family member visits.An interview was conducted with Family Member (FM) 2 on 10/6/25 at 10:58 a.m. FM 2 indicated Resident B had a history of attempting to escape through windows. FM 2 had visited the facility, in the past, and had seen the bathroom window open. FM 2 had told a staff member that if Resident B realized the windows were opened, he would try to use the window to get out. FM 2 did not see any alarms or safety devices on the windows to keep them from opening. An interview was conducted with FM 3 on 10/6/25 at 12:33 p.m. FM 3 indicated she had seen the bathroom window open and expressed concern about Resident B eloping through the window. FM 3 had been told by the staff that there was nothing to worry about. FM 3 had informed the staff that Resident B would try to get out of the facility any way he could. FM 3 had told a staff member of the facility that Resident B would try to get out of the window. An interview was conducted with CNA 4 on 10/6/25 at 12:50 p.m. CNA 4 indicated she worked the 6:00 p.m. to 6:00 a.m. shift. She had worked the night of Resident B's elopement. She worked often on the memory care unit. Resident B had been pacing that night and appeared to be anxious. He normally would be sleeping. She had checked on him at 10:00 p.m., 12:00 a.m., and 2:00 a.m. At approximately 4:00 a.m.- 4:15 a.m., she had checked on the resident. The resident's bathroom door was locked. After opening the door, a chair was found in the bathroom with the window opened. Resident B was not in the bathroom. CNA 4 then alerted the nurse that Resident B was unable to be found. She had never opened nor seen the bathroom window open prior to the incident. CNA 4 didn't even know the residents' windows in the bathrooms were able to be opened.An interview was conducted with CNA 5, Unit Manager (UM) 6, Qualified Medication Aide (QMA) 7, and Licensed Practical Nurse (LPN) 8 on 10/6/25 at 2:08 p.m. They indicated Resident B was pleasant and easily redirected when he was agitated. The resident had been attempting to exit through the door for about 48-72 hours after he was admitted to the facility. He did adjust and had not been attempting since. The resident's family had attempted to care for him at home but had to admit him to the facility. He had become more aggressive towards the family. They have not observed the residents' windows open on the memory care unit nor do they open the residents' windows. QMA 7 indicated she had gone out to an appointment with Resident B, on the morning of 9/30/25, and he was not observed to be having any behaviors during that appointment and did not mind having to return back to the unit that day. An interview was conducted with LPN 8 on 10/6/25 at 2:55 p.m. She indicated she worked night shift approximately two to three times a month on the male memory care unit. LPN 8 had worked the night of 10/1/25, when Resident B eloped. Resident B can be agitated at times. He will voice about family stealing his money and needing to go to the bank. The resident did not appear to be anxious to her that night nor did she receive report he had been anxious that day. The resident was dressed that night but normally went to bed that way. If he was not sleeping, he normally would come into the dining room and talk with her at night. That night, he had walked in the hallway but had not come into the dining room to speak with her. From approximately 4:00 a.m. to 4:15 a.m., CNA 4 had reported Resident B was unable to be located. LPN 8 had gone into the resident's room and found a chair in the bathroom with the screen and window open. A silver alert was immediately called. LPN 8 had never observed the residents' bathroom windows opened by staff nor residents.An interview was conducted with the ED on 10/6/25 at 4:23 p.m. She indicated she had not had any conversations with Resident B's Power of Attorney (POA) regarding the elopement risk of the windows in the residents' bathrooms. The ED had spoken with the facility's admission staff member and case manager. They also had no conversations with the POA about the elopement risks involving the windows in the residents' bathrooms.On 10/6/25 at 4:01 p.m., an interview was conducted with the Memory Care Director (MCD). The MCD indicated she had spoken with Resident B's family when he was admitted to the facility. The family had informed the MCD that Resident B was an elopement risk but had not told her that Resident B had a history of trying to leave through windows. When Resident B was first admitted to the facility, he displayed exit seeking behaviors. The exit seeking behaviors had subsided after he had been at the facility for a while. Resident B could become agitated and was not always easily redirected. His cognition varied from day to day. The MCD indicated she believed the bathroom windows should have been locked and had not noticed they were not. FM 3 had informed the MCD of the family's concerns about the windows after Resident B had eloped on 10/1/25. The MCD had not seen any of the bathroom windows on the secured unit open. On 10/6/25 at 2:46 p.m., the Executive Director provided the current Elopement and Wandering Residents policy that indicated .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/ alarms to help avoid elopement . 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .The past noncompliance Immediate Jeopardy began on October 1, 2025. The immediate jeopardy was removed and the deficient practice corrected, on October 1, 2025, after the facility implemented a systemic plan that included the following actions: an audit of all residents was completed and elopement assessments were updated, education was given to all staff on elopement protocol, elopement drills were conducted on every shift, and all windows in the facility were audited to ensure safety blocks were in place. All identified windows missing safety blocks were installed. This citation is related to Intake 2633368 and Intake 2632780.3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy (feeding) tube received flushes per the physician's orders for 1 of 3 residents reviewed for feeding tubes. (Resident D)Findings include:The clinical record for Resident D was reviewed on 8/27/25 at 3:10 p.m. The diagnoses included, but were not limited to, muscle weakness, dysphagia, diabetes mellitus, and gastrostomy status. A Quarterly Minimum Data Set (MDS) assessment, dated 6/27/25, indicated Resident D had a feeding tube and received greater than 51% of their nutrition via the feeding tube. A care plan for tube feeding, initiated 4/14/25, indicated Resident D required tube feeding related to dysphagia. The interventions included, but were not limited to, see physician orders for current feeding orders and indicated Resident D was dependent with receiving tube feeding and water flushes. A current physician's order, dated 6/23/25, indicated the use of tube feeding to run at 65 milliliters (mLs) per hour and water flushes of 50 mL per hour. An observation was conducted of Resident D, on 8/27/25 at 1:50 p.m., with Registered Nurse (RN) 2. RN 2 pushed a button on the feeding pump to display the amount of water flushes Resident D was receiving. The pump was set to administer 60 mL per hour of water flushes and was confirmed by RN 2. An observation was conducted of Resident D, on 8/27/25 at 4:13 p.m., with Nurse 3. Nurse 3 pushed a button of the feeding pump to display the amount of water flushes Resident D was receiving. The pump was set to administer 60 mL per hour of water flushes and was confirmed by Nurse 3. A policy entitled Care and Treatment of Feeding Tubes, revised August 2024, was provided by the Director of Nursing on 8/27/25 at 5:00 p.m. The policy indicated feeding tubes would be utilized according to physician orders and direction for staff to provide care to the feeding tube that included, but were not limited to, frequency of and volume for flushing. This citation is related to Intake 2572707. 3.1-46(a)(2)

Based on interview and record review, the facility failed to ensure a resident was transported to appointments regarding a tunneled catheter removal for 1 of 3 residents reviewed for appointments. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 5/27/25 at 10:30 a.m. The diagnoses included, but were not limited to, anoxic brain damage (brain being deprived of oxygen), tracheostomy status ((surgically created hole in the neck that connects to the trachea (windpipe) to help a person breathe)), gastrostomy status (tube inserted through the abdomen and into the stomach), and osteomyelitis of vertebra (infection of the bone).
A care plan, dated 4/15/25, indicated Resident B was on intravenous (IV) antibiotics related to an infection. The interventions included, but were not limited to, observing the IV dressing, changing the IV dressing and IV tubing as directed, monitor for signs and symptoms of infection, and monitor for signs of leaking at the IV side, edema at the IV insertion site, and/or any leaking of IV fluid out of the insertion site.
A physician note, dated 4/29/25, indicated Resident B was scheduled for a tunneled catheter removal on 5/6/25 in the interventional radiology department at a local hospital.
A progress note, dated 5/6/25 at 1:44 p.m., indicated Resident B's appointment was rescheduled due to a transportation issue.
A progress note, dated 5/12/25 at 11:13 a.m., indicated Resident B's appointment was missed due to the transportation company arriving at the facility early. The transportation company left and never returned to take Resident B to his scheduled appointment.
An interview was conducted with Registered Nurse (RN) 1 on 5/27/25 at 11:54 a.m. She indicated, on 5/6/25, she realized the transportation company didn't arrive at the facility to transport Resident B to his appointment and it was getting close to his appointment time. RN 1 contacted the transportation company, and they indicated Resident B was not on the list to be transported on 5/6/25. On 5/12/25, the transportation company arrived but it was around 11:00 a.m. and the appointment was for 1:00 p.m. RN 1 was under the impression Family Member 2 wanted to accompany Resident B to his appointments. Since Family Member 2 was not there, RN 1 instructed the transportation company to return later to pick up Resident B. The transportation company never returned to pick up Resident B for his appointment on 5/12/25. RN 1 indicated she did not call Family Member 2 to confirm if they were accompanying Resident B to his appointment.
An interview was conducted with Family Member 2 on 5/27/25 at 11:39 a.m. She indicated Resident B had experienced missed appointments for the removal of his IV access on 5/6/25 and 5/12/25. On 5/12/25, she was told the transportation company arrived early and the facility staff didn't have Resident B go to the appointment because it was too early. So, the appointment was cancelled due to Family Member 2 not being there. Family Member 2 indicated she did not need to be there. Resident B was just to undergo the removal of his IV access.
An appointment was scheduled, on 5/29/25, for Resident B's tunneled catheter removal.
An interview conducted with the Director of Nursing (DON), on 5/27/25 at 2:22 p.m., indicated there was no facility policy regarding resident appointments.
This citation is related to Complaint IN00459452.
3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with an intravenous (IV) access had orders for continued care for the IV access for 1 of 1 resident reviewed for IV access. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 5/27/25 at 10:30 a.m. The diagnoses included, but were not limited to, anoxic brain damage (brain being deprived of oxygen), tracheostomy status ((surgically created hole in the neck that connects to the trachea (windpipe) to help a person breathe)), gastrostomy status (tube inserted through the abdomen and into the stomach), and osteomyelitis of vertebra (infection of the bone).
A physician order, dated 4/3/25, indicated the administration of Ertapenem Sodium Solution Reconstituted (broad spectrum antibiotic); administer one gram IV in the evening for an infection for six weeks.
An IV care plan, dated 4/15/25, indicated Resident B was on IV antibiotics related to an infection. The interventions included, but were not limited to, observing the IV dressing, changing the IV dressing and IV tubing as directed, monitor for signs and symptoms of infection, and monitor for signs of leaking at the IV side, edema at the IV insertion site, and/or any leaking of IV fluid out of the insertion site.
The April 2025 electronic medication administration record (EMAR) indicated Resident B's left chest single lumen PICC (peripherally inserted central catheter; form of IV access that can be used for an extended period) dressing was to be changed on a routine basis while in use. The order start date was 4/4/25 and discontinued on 5/2/25.
The April 2025 EMAR indicated Resident B's left chest singe lumen PICC was to be observed every shift for signs and symptoms of infection. The order start date was 4/4/25 and discontinued on 5/2/25.
A physician note, dated 4/29/25, indicated Resident B was scheduled for a tunneled catheter removal on 5/6/25 in the interventional radiology department at a local hospital.
A progress note, dated 5/2/25, indicated Resident B's left chest singe lumen PICC was not a PICC. An appointment for the removal of the tunneled catheter line was scheduled for 5/6/25.
The electronic health record indicated the following appointments were scheduled for Resident B's removal of the tunneled catheter, but the procedure was not able to be completed on 5/6/25 and 5/12/25.
An appointment was scheduled for Resident B's tunneled catheter removal on 5/29/25.
An observation was conducted of Resident B, on 5/27/25 at 11:25 a.m., with the Director of Nursing (DON). An IV access was still noted on Resident B's left chest. There was a dressing observed to the IV access with a written date of 5/21/25. The DON indicated the residents with an IV access should have monitoring and dressing changes conducted.
There were no current orders reflective of the care and maintenance of the IV site to include any dressing changes, flushes to the IV access, and/or monitoring for any complications of the IV site.
An interview conducted with the DON, on 5/27/25 at 2:24 p.m., indicated there was no documentation to reflect the dressing changes and/or monitoring of the IV access currently in the electronic health record for Resident B.
A policy entitled Intravenous Therapy, undated, was provided by the DON on 5/27/25 at 2:22 p.m. The policy indicated the following, .12. A doctor's order is obtained before starting IV therapy . 13. IV sites are checked every four (4) hours or as per facility protocol and PRN [as needed] for signs and symptoms of infection or inflammation . 15. IV documentation is recorded in the nurses' notes and/or Medication Administration Record . 16. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medications and will discontinue as per the practitioner's order
This citation is related to Complaint IN00459452.
3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure a resident's call light was responded to in a timely manner, resulting in the resident experiencing anxiety, related to concerns regarding her health for 1 of 3 resident reviewed for staffing to meet resident needs. (Resident C)
Findings include:
In an interview with Resident C on 3-4-25 at 10:10 a.m., she indicated she has resided at the facility for about 6 years and typically was treated very well by staff and staff typically were very attentive to her, including with call light response. About two or so weeks ago, [I] had been sent to ER [emergency room] for a nosebleed. After I got back here, around 4:00 a.m., my heart started thumping real hard and I turned on my call light to have the nurse come and check on me and get my vital signs. Not a soul showed up until after the day shift got here, somewhere around 7:00 a.m. It kind of scared me and my roommate. Who knows what could have happened to me? And it worries me that this type of thing could happen to someone else, too, that might be worse off than me. She indicated in the over five years she has been here, nothing like this has occurred before or since. She shared she had spoken to several people in management, including the new Director of Nursing (DON) who assured her things will be better.
On 3-4-25 at 11:58 a.m., the Corporate Nurse provided a copy of a Grievance Form, dated 2-20-25, which indicated the Social Services Designee received a grievance from Resident C, on 2-20-25, regarding her call light not being responded to by facility staff, from when she activated it at 4:00 a.m., until 7:00 a.m., on 2-20-25. This concern was shared with the DON. The form documented the DON resolved the concern on 2-21-25, with an explanation provided of, Employees were written up after complete thorough investigation was done.
In an interview with the DON on 3-4-25 at 12:15 p.m., she indicated she had spoken with Resident C on 2-20-25, about her call light not being answered for several hours. She indicated both Resident C and her roommate were both very alert and oriented and did not have a history of telling lies about the staff. I met with the nurse and aide that worked the night before [2-19-25 into 2-20-25]. Both of them said they didn't think her call light was on. The nurse wrote a statement on the write-up, but refused to sign it. I explained to both of them this type of thing is considered neglect and it is taken very seriously. They understand they are at the point where if anything else happens, they will be terminated. I decided not to terminate them, but to give them an opportunity for improvement.
On 3-4-25 at 12:37 p.m., the DON provided copies of documents entitled, 3 Step Employee Memorandum, for Licensed Practical Nurse (LPN) 4 and Certified Nurse Aide (CNA) 5. The documents indicated, Describe the incident in detail .Failed to answer call light in a timely manner, and indicated this was a failure to perform assigned duties in an appropriate manner or at assigned times. In the section identified as Corrective Action To Be Taken (State corrective action you feel the employee may take to eliminate the problem.), it indicated for both employees, You must do purposely [sic] rounding on shift. All call lights must be answered in a timely manner. All assigned job duties must be completed on shift. Notify work colleague when taking scheduled break.
LPN 4 handwrote a comment of, Resident's light was not on. Call light sounds on East Wing. East Wing nurse stated she did not see light. I also have two halls at night so am not on hall at all times. The signature line for LPN 4 was unsigned by LPN 4, but had a handwritten notation of, Refused to Sign. CNA 5's document did not have any employee comment, but in the employee signature area of the document, it indicated the counseling was conducted by phone. Both documents were signed by two facility supervisors.
In an interview on 3-4-25 at 2:20 p.m., with the Corporate Nurse, she indicated education was conducted on responding to call lights with the nurse and aide at the time of their counseling. The remainder of the staff were receiving education on this topic from the Executive Director and the new DON on a one-on-one basis, to be able to set goals individually with each employee. She indicated the Executive Director and DON are about half-way through the employee list at this point and there will be an all-staff meeting on 3-6-25, which was planned prior to this survey, to address a number of issues, including but not limited to, responding to call lights in a timely manner.
The clinical record of Resident C was reviewed on 3-3-25 at 3:38 p.m. Her diagnoses included, but were not limited to congestive heart failure, diabetes with neuropathy, morbid obesity and end stage renal with dialysis. Her most recent Minimum Data Set assessment, dated 12-30-24, indicated she was cognitively intact.
This citation is related to Complaint IN00454054.
3.1-3(t)

Based on interview and record review, the facility failed to provide 1 of 3 residents, reviewed for transfers, a copy of the facility's bed hold policy prior to transferring to an area hospital. (Resident D)
Findings include:
The clinical record of Resident D was reviewed on 3-4-25 at 10:57 a.m. Her diagnoses included, but were not limited to, Wernicke's encephalopathy, CVA (cardiovascular accident or stroke) with left sided hemiparesis and hemiplegia, dysphagia (difficulty swallowing), gastrostomy (gastric feeding tube), and moderate protein-calorie malnutrition.
A review of Resident D's progress notes indicated she had pulled out her gastric feeding tube, on 3-2-25, and was sent to an area hospital to have it replaced. A document, identified as a nursing home to hospital transfer form, was completed on 3-2-25 at 5:50 a.m. It indicated the reason for the transfer as Resident pulled out G-tube. The clinical record failed to have a copy of the bed hold policy in place and was unable to be provided by the facility prior to the exit of the survey.
In an interview on 3-4-25 at 10:25 a.m., with Registered Nurse (RN) 3, she indicated when a resident was sent out to the emergency room, the nursing staff were to complete and send with the resident a copy of the bed hold policy and the state transfer paperwork.
In an interview with the Corporate Nurse on 3-4-25 at 2:17 p.m., she indicated the facility does not have a specific policy regarding the use of the transfer-discharge paperwork, but follows the state and federal regulations and utilizes the state paperwork, including the bed hold documentation. We are to send that with the resident to the hospital and keep a copy for the chart.
This citation is related to Complaint IN00454054.
3.1-12(a)(25)(A)
3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 3 residents reviewed for abuse. (Resident D)
Findings include:
The clinical record for Resident D was reviewed on 1/21/25 at 1:00 p.m. The diagnoses included, but were not limited to, dementia.
A Facility Reported Incident [FRI] was reported to the Indiana Department of Health, dated 12/30/24, indicating an incident had occurred, on 12/30/24, with Resident D. A brief description of the allegation indicated Resident D reported his wallet, credit card, and insurance card was taken. The follow up to the incident indicated Staff and resident interviews completed with no concerns. Credit card has been canceled and new [insurance] card ordered. Facility to replace wallet .
The investigation to the reported incident was provided by the Administrator on 1/21/25 at 2:00 p.m. The investigation included resident interviews that were conducted during the investigation. The resident interview questions were the following:
1. Has staff, a resident, or anyone else here, abused you - this includes verbal, physical, or sexual abuse? If yes ask who the abuser was, what happened, when it occurred, where it happened, and how often .Did you tell staff? If yes, ask who the resident told. Report immediately to the administrator .
2. Have you seen any resident here being abused? If yes ask who the abuser was, what happened, when it occurred, where it happened, and how often .a. Did you tell staff? If yes, ask who the resident told. Report immediately to the administrator .
The investigation did not include interviews that were conducted with the residents related to misappropriation of property.
An interview was conducted with the Administrator on 1/21/25 at 3:08 p.m. She indicated the investigation for Resident D was completed. There were two allegations reported on 12/30/24. An allegation of abuse and an allegation of misappropriation of property. The staff that conducted interviews with the residents must have been asking only the abuse questions.
An abuse policy was provided by the Executive Director on 1/21/25 at 11:40 a.m. It indicated the following, .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .V. Investigation of alleged abuse, neglect and exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation . 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation .
This citation is related to Complaint IN00451414.
3.1-28(d)

Based on interview and record review, the facility failed to ensure that a narcotic pain medication was placed in a controlled substance lock box upon being delivered to the facility and to ensure the oncoming and off going licensed personnel signed the controlled drug shift audit form when completing the controlled drug audit each shift for 1 of 3 residents reviewed for pain medications (Resident E).
Findings include:
The clinical record for Resident E was reviewed on 1/21/25 at 11:15 a.m. The diagnoses included, but were not limited to, diabetes and chronic non-pressure skin ulcers of the left leg.
An admission Minimum Data Set (MDS) assessment, completed 10/14/24, indicated she was cognitively intact and received scheduled pain medications.
A care plan, last revised on 11/1/24, indicated Resident E was at risk for pain related to wounds on legs and toes and diabetes. The goal was for her to not have interruptions in normal activities due to pain. The interventions included, but were not limited to, administer analgesics (pain medication) as ordered by the physician.
A physician's order, dated 1/14/25, indicated she was to receive fentanyl (narcotic pain medication) transdermal patch 25 micrograms (mcg) per hour. One patch was to be applied transdermal (on the skin) every three days. This order was discontinued on 1/16/25.
A physician's order, dated 1/16/25, indicated she was to receive fentanyl transdermal patch 25 micrograms (mcg) per hour. One patch was to be applied transdermal every three days.
An electronic medication administration record (EMAR) note, dated 1/15/25 at 12:56 p.m., indicated the fentanyl transdermal patch was not administered due to it being on order from the pharmacy.
A Physician's Assistant Follow Up Visit note, dated 1/15/25, indicated resident E was evaluated for follow up of pain management. Fentanyl patches were not yet available from pharmacy, so she would continue the previous regimen until fentanyl patches are obtained. Resident E had no acute complaints at that time. Staff reported no other acute care concerns. Resident E appeared comfortable and in no acute distress.
On 1/21/25 at 1:25 p.m., the Administrator provided the investigation file for Indiana State Reportable, dated 1/15/25, which indicated while counting narcotics during shift change, it was noted there were four fentanyl patches 25 mcg missing for one resident. The count was re-conducted with no change in the outcome. The Director of Nursing Services and the Administrator were notified of the missing medication.
The investigation file contained a packing slip from the facility pharmacy, dated 1/14/25, which indicated that four fentanyl transdermal patches, 25 mcg, were sent to the facility from the pharmacy.
During an interview on 1/21/25 at 1:50 p.m., the Administrator indicated Resident E's fentanyl patches, and the narcotic count sheet were missing. The fentanyl patches were left on the nursing station unattended. The facility was investigating to determine what happened to the fentanyl patches. The nurses' who had access to the medications when they were delivered had been drug tested with negative results.
During an interview on 1/21/25 at 2:03 p.m., Pharmacy Technician 10 indicated that four fentanyl 25 mcg patches were sent to the facility and signed for by Registered Nurse (RN) 2.
On 1/21/25 at 2:35 p.m., the [NAME] Hall narcotic book was observed with RN 3. The Emergency Kit and Controlled Drug- Shift Audit form for January 2025 was observed. There were no signatures present for the oncoming nurse, on 1/14/25 night shift, the oncoming nurse on 1/15/25 day shift, the oncoming nurse on 1/16/24 day shift, and 1/16/25 off going nurse on evening shift.
During an interview on 1/21/25 at 2:35 p.m., RN 3 indicated the blanks on the Emergency Kit and Controlled Drug- Shift Audit form was because the staff had not signed the form.
During an interview on 1/21/25 at 2:41 p.m., RN 2 indicated she had received the pharmacy delivery on the night shift of 1/14/25. The delivery was very large that night because there had been a new admission on the [NAME] Hall. RN 2 could not specifically recall if she had received Resident E's fentanyl patches due to the amount of medication she had received that night. RN 2 had left all the delivered medication on the nurses' station so that the other nurses could come pick up the medications for their halls. Since there were so many medications delivered for the [NAME] Hall, RN 2 had placed all the [NAME] Hall medications in a bag and taken them to the [NAME] Hall nurses' station. There had not been anyone at the [NAME] Hall nurses' station when she dropped off the bag of medications. RN 2 had told the [NAME] Hall nurse she put the medications that had been delivered at the [NAME] nurses' station when they passed in the hallway. RN 2 was not sure what happened to Resident E's fentanyl patches after she took them to the [NAME] Hall nurses' station. The controlled medications were counted between each shift. After the controlled medication count, the oncoming and off going nurse should sign the Emergency Kit and Controlled Drug Shift Audit form at the front the narcotic book.
During an interview on 1/21/25 at 3:15 p.m., Unit Manager (UM) 4 indicated the facility staff had searched the facility thoroughly and had not been able to find Resident E's fentanyl patches. There had been a lot of medications delivered on the night shift, of 1/14/25, including multiple other narcotics. All the other narcotics were accounted for. UM 4 was unsure where the fentanyl patches could have gone. She questioned if they may have been thrown away because the fentanyl patches are normally delivered in a small plastic sleeve, which may have gotten stuck on something. UM 4 had educated the nursing staff about double checking and ensuring that all medications they sign for are present prior to signing the delivery forms.
On 1/21/25 at 11:40 a.m., the Corporate Support Health Care Administrator provided the Narcotic Pain Patch Policy, last revised February 2023, which read .It is the policy of this facility to maintain records of all Narcotic patches at the time of receiving in the facility until destruction .Narcotic patches will be kept in a controlled substance lock box and reconciled at the end of each shift between the charge nurse responsible and the charge nurse taking responsibility of the medications . Both nurses will sign the shift change log verifying the count is accurate at the time of the reconciliation .
This citation is related to Complaint IN00451414.
3.1-25(e)(2)
3.1-25(e)(3)

Based on observation, interview, and record review, the facility failed to have a functional call light in a resident's room and timely replace cove base at the base of a toilet for 2 of 7 residents observed for environment. (Resident 13 and 48)
Findings include:
1. On 12/17/24 at 1:46 p.m., Resident 13's bathroom was observed. The elevated concrete base of the toilet was exposed and missing the cove base. Resident 13 indicated that it looked dirty and had been that way for a while.
On 12/20/24 at 11:06 a.m., an environmental tour was conducted with the Maintenance Supervisor (MS). Resident 13's bathroom was observed, the elevated concrete toilet base was missing the cove base.
During an interview on 12/20/24 at 11:45 a.m., the MS indicated the concrete base had been painted in November 2024 and then repainted again recently. Replacement of the cove base must have been missed. He did not believe there was a work order to replace the cove base.
2. On 12/16/24 at 3:40 p.m. an observation of Resident 48's room revealed their call light was missing its button cover.
An observation conducted on 12/17/24 at 2:35 p.m., revealed Resident 48's call light was still missing its button cover.
An interview was conducted, on 12/18/24 at 1:57 p.m., with Certified Nurse Aide (CNA) 1. CNA 1 pushed Resident 48's call light and indicated the call light was broken and would be getting a new one.
On 12/20/24 at 1:50 p.m. the [NAME] President of Risk and Regulatory (VPRR) indicated there was not a specific call light policy and it would fall under standards of care.
On 12/20/24 at 1:50 p.m., the Executive Director provided the current Facility Maintenance Guidelines and Procedure which read, .Staff should place items they find in the normal course of their day in the TELS [sic] Work Order System when found as well as placing items in the system when residents make requests .
3.1-19(u)(1)

Based on observation, interview, and record review the facility failed to label refrigerated food with date opened, appropriately store frozen food, appropriately restrain facial hair of dietary staff with the use of a beard restraint, and store personal belongings away from drying rack of clean dishes. This had the potential to affect 67 of 74 residents in the facility.
Findings include:
A tour of the kitchen was conducted, on 12/16/24 on 10:20 a.m., with the Dietary Manager (DM). Inspection of the walk-in freezer revealed packaging of frozen corn dogs left open to air. The DM indicated that the packaging should not be open to air. Inspection of refrigerated foods revealed three bags of undated bags of lettuce, visible discoloration of lettuce was present in one of three bags. The DM indicated the date must have rubbed off the bags of lettuce and discarded them. [NAME] 2 had a full goatee and was not wearing a beard restraint while in the kitchen. A jacket was observed hanging on a chair adjacent to a drying rack of clean dishes. The DM indicated that the jacket belonged to one of the facility's cooks and it should not be there.
On 12/17/24 at 11:40 a.m., the kitchen was entered for a second tour and [NAME] 2 was observed with a full goatee without a beard restraint.
On 12/19/24 at 10:20 a.m., the kitchen was entered and [NAME] 2 was observed wearing a beard restraint covering his goatee.
An interview was conducted with the DM, on 12/19/24 at 10:22 a.m., regarding the use of beard restraints. The DM indicated their policy states facial hair was to be a quarter of an inch to require the use of a beard restraint.
A policy for Dietary Employee Personal Hygiene, dated 2022, was provided by the Director of Nursing on 12/19/24 at 10:38 a.m. The policy states, .Hair restraints . a. All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. b. Head coverings must be clean .
A policy for Food Safety Requirements, dated 2024, was provided by the Director of Nursing on 12/19/24 at 10:38 a.m. The policy states, Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers .
3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a medication was administered as ordered for 1 of 1 resident reviewed for dialysis. (Resident 71)
Findings include:
The clinical record for Resident 71 was reviewed on 12/20/24 at 2:00 p.m. The diagnoses included, but were not limited to, amputation of right leg and renal dialysis.
A hospital discharge, dated 9/17/24, indicated the resident was to receive one tablet of 500/125 milligrams of amoxicillin clavulanate at bedtime in the evening after dialysis, and one tablet of 500 milligrams of amoxicillin one hour prior to appointment.
A physician order, dated 12/6/24, indicated the resident was to receive four tablets of 500 milligrams of amoxicillin one hour prior to dialysis every Tuesday, Thursday, and Saturday.
The December 2024 Medication Administration Record indicated the resident had received the 500 milligrams of amoxicillin one hour prior to dialysis every Tuesday, Thursday and Saturday.
An interview was conducted with the Director of Nursing on 12/19/24 at 2:36 p.m. She indicated the resident had a recent hospitalization, and the staff activated the wrong amoxicillin order. The resident should be receiving one tablet of 500/125 milligrams of amoxicillin clavulanate at bedtime in the evening after dialysis.
3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's right to be treated with respect and dignity by a staff member who forcefully attempted to get a resident with a decreased ability to perform activities of daily living (ADLs) to perform her own incontinent care for 1 of 3 residents reviewed for abuse. (Resident D)
Findings include:
The clinical record for Resident D was reviewed on 9/20/24 at 1:55 p.m. Her diagnoses included, but were not limited to, asthma, morbid obesity, and hypertensive urgency.
A minimum data set assessment, dated 8/11/24, indicated Resident D was moderately cognitively impaired and was dependent on assistance for bathing/showering, dressing, and toileting. She required partial to moderate assistance with personal hygiene.
An interview with Resident D was conducted on 9/20/24 at 2:27 p.m. She indicated, on 8/20/24, she required assistance with incontinent care and requested for two people to help her. When her nurse came in to assist, she grabbed her arm and placed a cold, wet towel in her hand and forcefully took her arm down to her pelvic area. She indicated the nurse said if her arm can reach down there then she can clean herself up and she didn't have any aliments with her arms. She indicated this interaction made her feel very upset, degraded, and humiliated. She indicated that she still feels sad about the incident and it was uncalled for.
An interview with the Executive Director (ED) was conducted on 9/20/24 at 2:00 p.m. She indicated the incident was about a resident who needed assistance with incontinent care and stated she needed two people to assist her. According to her, she believed the physician's assistant and a certified nursing assistant were in the resident's room when the nurse came in to assist her. She indicated the nurse grabbed the resident's arm and guided her arm to her pelvic area to assist her with her rehabilitation efforts and for her to wipe herself. She indicated when she spoke with Resident D, she indicated the nurse was forceful.
This citation is related to Complaint IN00442213.
3.1-3(a)
3.1-3(t)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D)
Findings include:
The clinical record for Resident D was reviewed on 9/20/24 at 1:55 p.m. Her diagnoses included, but were not limited to, asthma, morbid obesity, and hypertensive urgency.
A minimum data set assessment, dated 8/11/24, indicated Resident D was moderately cognitively impaired and was dependent on assistance for bathing/showering, dressing, and toileting. She required partial to moderate assistance with personal hygiene.
An interview with Resident D was conducted on 9/20/24 at 2:27 p.m. She indicated, on 8/20/24, she required assistance with incontinent care and requested for two people to help her. When her nurse came in to assist, she grabbed her arm and placed a cold, wet towel in her hand and forcefully took her arm down to her pelvic area. She indicated the nurse said if her arm can reach down there then she can clean herself up and she didn't have any aliments with her arms. She indicated this interaction made her feel very upset, degraded, and humiliated. She indicated she still felt sad about the incident and it was uncalled for.
An interview with the Executive Director (ED) was conducted on 9/20/24 at 2:00 p.m. She indicated the incident was about a resident who needed assistance with incontinent care and stated she needed two people to assist her. According to her, she believed the physician's assistant (PA) and a certified nursing assistant (CNA) were in the resident's room when the nurse came in to assist her. She indicated the nurse grabbed the resident's arm and guided her arm to her pelvic area to assist her with her rehabilitation efforts and for her to wipe herself. She indicated when she spoke with Resident D, she indicated the nurse was forceful.
An incident report, dated 8/20/24, was received on 9/20/24 at 3:41 p.m. It indicated, on 8/20/24 at 1:30 p.m., a CNA stated another employee was utilizing inappropriate language and made contact with Resident D's arm. The immediate action taken was the initiation of an investigation and a full skin assessment was completed. Preventive measures taken indicated the investigation was initiated, social services notified to follow for signs and symptoms of psychosocial distress, and care plans were reviewed and updated. The follow-up, dated 8/26/24, indicated all staff was educated on abuse prohibition. All interview able residents were interviewed, psychosocial wellbeing was completed with no signs of distress, and care plans were reviewed and updated as needed.
The investigation file for the incident was received on 9/20/24 at 10:03 a.m. from the ED. The file did not contain a statement from the PA even though she was a witness to the incident. It did not contain a written statement from Resident D. The ED indicated she had spoken with the resident but did not get her statement in writing. There was no statement from the CNA that reported the incident.
An Abuse, Neglect and Exploitation policy was received on 9/19/24 at 11:08 a.m., from the Director of Nursing Services. The policy indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation .Investigation of Alleged Abuse, Neglect and Exploitation .an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Written procedures for investigations include .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation.
This citation is related to Complaint IN00442213.
3.1-28(a)
3.1-28(d)

Based on interview and record review, the facility failed to identify individualized approaches of care for a resident with a diagnosis of dementia with agitation and to prevent a resident's distress for 1 of 3 residents reviewed for abuse. (Resident C)
Findings include:
The clinical record for Resident C was reviewed on 9/20/24 at 10:00 a.m. His diagnoses included, but were not limited to, dementia with moderate agitation, cerebral amyloid angiopathy (a condition that causes bleeding inside the brain and damages brain tissue leading to the loss of the ability to think), and reactive emotional distress. He was admitted to the facility, on 7/18/24, and moved to the locked memory unit, on 7/24/24, per a physician's note.
A physician's order to give one 25 mg (milligrams) tablet of quetiapine (medication used to treat psychosis, schizophrenia, bipolar disorder and depression) as needed every 12 hours for delirium was placed on 7/18/24.
A physician's assistant (PA) progress note, dated 7/19/24 at midnight, indicated Resident C was admitted to the facility following a recent hospitalization for placement to an extended care facility. Neurological testing revealed moderate dementia with agitation and reactive emotional distress as well as REM (rapid eye movement) behavior disorder (a sleep disorder that involves abnormal movements, behaviors, emotions, perceptions and dreams that occur while falling asleep, sleeping, between sleep stages or during arousal from sleep). He had increased behavioral disturbances at home with agitation and aggression which was noted on his outpatient psychiatry appointment on 6/4/24.
On 7/23/24, the order for Resident C's 25 mg of quetiapine, as needed every 12 hours, was discontinued.
The PA progress note, dated 7/24/24 at midnight, indicated the reason for the acute visit was per staff's request as Resident C exhibited increased anxiety and was moved to the locked memory care unit.
The clinical record did not contain any behavior notes until 7/26/24.
A behavior note, dated 7/26/24 at 2:26 p.m., indicated Resident C was seen in the hall walking completely naked. When he was approached, he was visibly upset and started to swing at staff with closed fists.
Resident C's baseline care plan did not reference his behaviors (swinging closed fists at staff), nor did it contain interventions to the behaviors.
The PA progress note, dated 7/30/24 at midnight, indicated Resident C was evaluated for intermittent behavior issues. Staff noted the resident was sometimes agitated and aggressive with staff and had displayed intermittent erratic behaviors throughout the day. He responded with some verbal antagonism to the instructions by staff and his aggression is concerning. No changes to his medication regime were attempted at the time but may consider the potential for an as needed medication for agitation/aggression if the behaviors persisted or worsened.
On 8/2/24, a physician's order for 25 mg of quetiapine to be given at bedtime for depression and agitation was placed.
The PA progress note, dated 8/2/24 at midnight, indicated per the family's request, Resident C's buspirone (used to treat anxiety) was discontinued, but resident will likely need another medication in its place to help manage mood/behaviors given continued breakthrough agitation and behavior issues per staff.
On 8/11/24, Resident C's order for 25 mg of quetiapine at bedtime was discontinued.
On 8/13/24, a physician's order was placed for Resident C. It indicated to give 25 mg of quetiapine every 12 hours as needed. The order was discontinued on 8/14/24.
On 8/15/24, a physician's order was placed for Resident C to receive one 25 mg tablet of quetiapine at bedtime. The order was discontinued on 8/23/24.
Resident C's care plan, dated 8/19/24, indicated he had a history of behaviors which included removing his cardiac monitor related to having dementia. The interventions included, but were not limited to, attempt interventions before the behavior begins, offer him something he liked as a diversion, and to speak to him in an unhurried, calm voice. The care plan did not indicate what he liked to be used as a diversion, nor did it indicate he was physically aggressive (swinging closed fists) or what made him agitated.
A physician's progress note, effective date of 8/19/24 at midnight, indicated Patient has advanced dementia. He has associated psychotic symptoms with intermittent hallucinations. He also has episodes of agitation. There is also associated general anxiety and insomnia.
A self-reported incident, dated 8/29/24, indicated at approximately 2:30 p.m., Resident C who had a severe cognitive deficit was in the common dining room on the reflections unit. Resident C was being re-directed from a behavior and made contact with Resident B's head with a closed hand. The residents were immediately separated. Resident C was placed on one-on-one observation until he was sent to the hospital for evaluation. Resident B was assessed, and no injuries were noted.
An interview with QMA 3 (qualified medication assistant 3), conducted on 9/20/24 at 9:38 a.m., indicated she was the only staff member present when Resident C hit Resident B on 8/29/24. She indicated a group of female residents and Resident C (who is male) were in the common dining room talking and listening to music. She indicated she was tending to a resident just outside of the common dining room when she heard Resident C yell out SHHH really loud. She indicated the sound alerted her that something was wrong. She indicated she had told Resident C to come out of the dining room as to re-direct him and when she did Resident C banged his hand on table making a loud noise which startled the female residents. He proceeded to ask the female residents for their cups so he could throw it at QMA 3. QMA 3 indicated, Resident C had said something to the effect of 'someone give me something to throw at this b****'. She indicated he was all worked up and needed to call for help, so she had turned from Resident B (whom she had been assisting) and was just heading to the nursing office when she heard Resident B say 'OW, stop that! When she turned around, Resident C had grabbed both of Resident B's arms with his one hand and she saw him hit her. She stated, he hit her three times. She indicated she did not see the first hit but assumed that was why Resident B had yelled out ow. She did witness the second hit, and he had a closed fist and when he went to hit her, he drew his arm back to strike her and made contact. He hit her in the face/head. She indicated she ran over trying to get him to release her arms and that was when he hit her for the third time. She stated she finally got him off of her and told Resident B to go down the hallway and away from him. He then turned to the other ladies in the room, so she told them to get on other side of table. She wanted to let him focus on her so he wouldn't target the other residents. He was screaming and hollering. She managed to call for help and when help arrived, he was still physically aggressive. She indicated the loudness of the noise from them talking just triggered him. She knew this from a prior experience with Resident C. She indicated when he moved in, she was in Resident C's room talking to his wife when he did the shhh thing and his wife had stated he does that when things are too loud for him.
Resident C's treatment administration record (TAR), for August 2024, indicated for behavior monitoring related to the use of psychotropic medications. There weren't any behaviors noted for the month nor were there any intervention attempts noted.
An interview with the Director of Nursing Services (DNS) was conducted on 9/20/24 at 11:39 a.m. She indicated Resident C was seen by neurology at the Veterans Administration but did not know what/if any recommendations were indicated as his wife took him to those appointments. She indicated his care plan should have addressed his behaviors upon admission given he was admitted with dementia with agitation.
A Behavioral Health Services policy was received on 9/20/24 at 11:53 a.m. It indicated, It is the policy of this facility to ensure all resident receive necessary behavioral health services to assist them in reaching and maintain their highest level of mental and psychosocial functioning .The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .The assessment and care plan will include goals that are person-centered and individualized .Staff will .obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health .Monitor the resident closely for expressions or indications of distress .Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record .Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident .The care plan shall .have interventions that are person-centered, evidence-based, trauma informed, and in accordance with professional standards of practice .be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition
3.1-37(a)
3.1-43(a)(2)

Based on interview and record review, the facility failed to ensure follow up to a resident that was unable to be located in the facility during the night for 1 of 4 residents reviewed for accidents. (Resident B)
Findings include:
The clinical record of Resident B was reviewed on 6/4/24 at 1:28 p.m. The diagnoses included, but were not limited to, hypertension, muscle weakness, alcohol abuse, and diabetes mellitus.
A significant change minimum data set (MDS) assessment, dated 3/28/24, indicated Resident B was cognitively intact, utilized a wheelchair, received daily injections of insulin, administration of a diuretic, administration of a hypoglycemic medication, and administration of an opioid medication.
A release of responsibility for therapeutic home visits form, dated for March, April, and May of 2024, indicated Resident B signed out of the facility on a leave of absence for 9 days in March, 7 days in April, and one day in May. There were no leave of absence forms for Resident B dated June of 2024.
A progress note, dated 6/2/24 at 10:42 p.m., indicated Resident B left the facility and would not be redirected per policy or sign out that he was taking a leave of absence.
A progress note, dated 6/2/24 at 11:37 p.m., indicated Resident B returned to the facility.
A progress note, dated 6/3/24 at 10:30 p.m., indicated the following, . Resident B was not in his room when writer did rounds to check residents. Per CNA [certified nursing aide] resident was not here since Sunday [6/2/24]. Writer checked the sign in/out book and no sign out under the resident's name .
There was no indication that staff knew of Resident B's whereabouts as to when he left the facility, if medications were retrieved for Resident B to take while he was out of the facility, and where Resident B was in case of any emergency.
An interview conducted with Resident B, on 6/4/24 at 11:10 a.m., indicated he was in the process of moving to a different facility. He indicated he was allowed to have a certain number of days out of the year to utilize as a leave of absence. He would let the facility staff know when he was planning to take a leave of absence. He would sign in and out of the leave of absence book. He commented on how he left the facility last night but did not have any medications to take while he was on a leave of absence. He was planning to return to the facility sometime on 6/4/24.
An interview conducted with the Director of Nursing (DON), on 6/4/24 at 11:29 a.m., indicated she was concerned when she read the progress note about staff not being able to find Resident B in his room. She was concerned about where he could be regarding his medications, care for himself, etc. Resident B does like to go on a leave of absence quite often and it's not uncommon for him to do so.
An interview conducted with the DON, on 6/4/24 at 2:58 p.m., indicated the receptionist did see the resident leave the facility on 6/3/24 in the evening time. The receptionist did not let the staff know Resident B had left and she was educated about the policy and procedure for when a resident leaves the facility.
A policy titled Therapeutic Leave, undated, was provided by the DON on 6/4/24 at 2:54 p.m. The policy indicated the following, .2. The facility will coordinate with the resident and/or representative the length of time the resident will be gone to ensure that adequate amounts and appropriate medication is ready for administration while on the leave .4. The facility will document in the medical record the resident's leave of absence and any education given to the resident and/or representative prior to the leave .6. If a resident has not returned from therapeutic leave as expected, the facility will attempt to contact the resident and resident representative and document attempts in the medical record
3.1-45(a)(2)

Based on interview and record review, the facility failed to follow up with a resident's representative regarding their care plan meeting for 1 of 1 resident reviewed for care planning. (Resident H)
Findings include:
The clinical record for Resident H was reviewed on 11/14/23 at 11:00 a.m. Her diagnoses included, but were not limited to, dementia. She resided on the memory care unit of the facility.
The 8/17/23 care plan meeting minutes indicated Resident H's plan of care was reviewed in detail with Family Member 12 by phone.
The 11/2/23 care plan meeting minutes indicated the plan of care was reviewed in detail per the IDT (interdisciplinary team.) Resident H's guardian was invited, but did not attend.
An interview was conducted with Family Member 12 on 11/14/23 at 11:45 a.m. He indicated the facility sent him a care plan invitation informing him of the date of Resident H's most recent care plan and for him to call the facility for a specific time slot. He called the facility, left a message, and they never returned his call. This was a couple of weeks ago, and the care plan had come and gone without his participation.
An interview was conducted with the DON (Director of Nursing) on 11/14/23 at 3:24 p.m. She indicated their previous Business Office Assistant sent out care plan invitations, but she stopped working at the facility a couple of months ago, and it had been a group effort since. The MDSC (Minimum Data Set Assessment Coordinator) usually stayed on top of it.
An interview was conducted with the MDSC on 11/16/23 at 2:33 p.m. She indicated she did not send out care plan invitations, but she did put the dates on the calendar for the Business Office Manager to review and mail out invitations to family. They wanted the family to call to schedule a care plan meeting. Once they did, they usually spoke with social services, and if social services was unavailable, the call would go to her. She was not made aware Family Member 12 called to schedule. She thought their social services director left around the time of Resident H's care plan meeting, so she was unsure who would have taken Family Member 12's message.
On 11/15/23 at 2:40 p.m., the MDSC provided the 10/23/23 care plan invitation mailed to Family Member 12. It indicated the meeting was scheduled for 11/2/23 and to please contact social services at the facility's phone number for Resident H's scheduled time.
The Care Planning-Resident Participation policy was provided by the DON on 11/16/23 at 9:28 a.m. It read, The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative.

Based on observation, interview and record review, the facility failed to ensure a resident's catheter was flushed as ordered; the catheter tubing not touching the ground or kinked and good hygiene practices during catheter care with the removal of a soiled brief for 1 of 1 residents reviewed for catheter. (Resident 56)
Findings include:
The clinical record for Resident 56 was reviewed on 11/13/23 at 1:39 p.m. The diagnoses included, but were not limited to: urogenital implants and obstructive and reflux uropathy (structural or functional/blockage of urinary tract).
A Quarterly 10/11/23 Minimum Data Set (MDS) Assessment, indicated Resident 56's cognition was intact.
A bladder care plan dated 12/8/23 indicated the resident had an indwelling catheter. The staff was to provide catheter care every shift.
A physician order dated 5/18/23 indicated the resident had 20 french Foley catheter.
A physician order dated 5/18/23 indicated the resident was to receive Foley catheter care every shift.
A physician order dated 10/20/23 indicated the resident's catheter was to be irrigated with 60 milliliters of acetic acid at night.
The November 2023 Medication/Treatment Record (MAR/TAR) indicated the resident's catheter had not been irrigated with 60 milliliters of acetic acid on 11/14/23 and 11/15/23.
A random observation was made of Resident 56 on 11/13/23 at 11:50 a.m. The resident was in his wheelchair in the hallway with his catheter tubing observed dragging on the ground.
An observation was made of Resident 56 on 11/13/23 at 1:39 p.m. The resident was in his wheelchair with shorts on. The resident's tubing was curled up and strapped to his leg. The tubing was observed with reddish-orange urine puddled and trapped through the looped tubing.
An interview was conducted with Resident 56 on 11/13/23 at 1:40 p.m. He indicated he did not like the catheter tubing to be looped on his leg, and he would need to request for someone to flush the catheter.
An observation was made of catheter care on Resident 56 with License Practical Nurse (LPN) 7 on 11/15/23 at 10:19 a.m. The resident was in bed at that time. The catheter tubing had yellow urine running through it. LPN 7 was observed removing the tape and pulling the resident's brief down away from the resident's body. The brief was observed with a brown liquid substance on the inside of the brief. LPN 7 had indicated the brown substance was not stool; it was discharge. She then was observed providing catheter care and infection control was maintained through out the care. She then placed the soiled brief back on the resident and retaped it. At that time, LPN 7 had reported to the resident she would have a Certified Nursing Assistant (CNA) come back in and change the resident's soiled brief.
An interview was conducted with LPN 7 on 11/15/23 at 10:56 a.m. She indicated the resident's acetic acid irrigation medication to irrigate the catheter was not available on 11/14/23 and 11/15/23 to provide irrigation to Resident 56's catheter. The medical provider had not been made aware, but has been notified that day. The medical provider has placed a hold on the irrigation until the medication arrives.
A catheter policy was provided by the Director of Nursing on 11/16/23 at 9:32 a.m. It indicated .Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintained their dignity and privacy when indwelling catheters are in use.
3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents on the memory care unit with a consistent activity program that considered their cognitive status; update a resident's dementia care plan to include specific interventions used to address her crying out during group settings; attempt non-pharmacological interventions prior to increasing a psychotropic medication; and timely update the plan of care for a resident with wandering behaviors for 2 of 3 residents reviewed for dementia care and 24 of 24 residents on the memory care unit. (Residents H, 10, 40, 60, 52, 126)
Findings include:
1. The Memory Care Unit activity calendar, posted on the wall of the unit, was provided by the DON (Director of Nursing) on 11/17/23 at 12:47 p.m. It indicated the activity on 11/13/23 at 2:00 p.m. was creative art.
An observation was made on 11/13/23 at 2:01 p.m. Resident 10 was walking up the hallway from her room. She passed by 3 people, including 2 residents and one staff member. She asked each of them why it was so boring here. There was no creative art activity occurring on the unit at this time.
The Memory Care Unit activity calendar indicated the activities scheduled for 11/14/23 were: chair exercise at 9:00 a.m., coffee & chat at 10:00 a.m., and trivia at 11:00 a.m.
An interview with the AIT (Administrator in Training) and observation was made on 11/14/23 at 9:44 a.m. There were 10 residents sitting in the activity room. I Love [NAME] was playing on the television. The AIT was sitting with the residents. The AIT indicated they were watching a little t.v. until the next activity at 10:00 a.m. The AIT indicated she did not normally work on this unit and normally worked at the front of the facility. She made rounds regularly, but did not normally sit on this unit and watch television with the residents. She was unsure who some of the residents were in the room with her. Resident 60 was sitting in a black vegan leather chair in the corner, with her head down and eyes closed.
On 11/14/23 at 10:00 a.m., the AIT stood up and announced that I Love [NAME] was over; that chair exercises were done; and it was now time for the next activity. She walked out of the activity room for about 30 seconds, came back, and sat back down in activity room. Resident H and Resident 10 were present in the room, not watching television. As of 11/14/23 at 10:07 a.m., residents were still in the activity room with the television on, as coffee & chat had not yet began.
An interview was conducted with Family Member 14 on 11/14/23 at 10:12 a.m. in Resident 126's room after leaving the activity room. She indicated Resident 126 had only been at the facility for 10 days and she'd visited about 4 times thus far. She never saw any activities on the unit during her 4 visits. He was either sleeping in bed or sitting in the t.v. room.
On 11/14/23 at 10:17 a.m., residents were still sitting in the activity/t.v. room, as coffee & chat had not yet begun.
An observation of trivia in the dining room was made on 11/14/23 between 10:40 a.m. and 10:55 a.m. The residents who were previously in the activity room were now in the dining room across the hall having coffee. The AIT was sitting at the front of the dining room asking trivia questions aloud. The following trivia questions were asked to the residents with the following responses:
What is the smallest unit of memory? None of the residents knew the answer. The AIT informed them the answer was helobite. One resident asked what a helobite was. The AIT answered, I don't know.
What is the hottest planet in the solar system? Two residents answered the sun. The AIT reminded them since the question asked planet, the answer could not be sun, and informed them the answer was [NAME].
How many Lord of the Rings films are there? None of the residents knew the answer. The AIT informed them the answer was three.
Which animal is on the Porsche logo? One of the residents answered two. Another resident answered [NAME]. The AIT informed them the answer was a horse.
What does BMW stand for? None of the residents knew the answer. The AIT informed them the answer was Bavarian Motor Works.
Which country invented tea? One of the residents knew the answer was China. This was the only trivia questioned answered correctly by a resident during the trivia observation.
Which bone are babies born without? None of the residents knew the answer. The AIT informed them the answer was knee cap.
Which planet has the most gravity? None of the residents knew the answer. The AIT informed them the answer was [NAME].
Which American state is the largest? One resident answered Texas, and one resident answered California. The AIT informed them the answer was Alaska.
What is the smallest country in the world? None of the residents knew the answer. The AIT informed them the answer was Vatican City.
What is the world's longest river? One of the residents answered Amazon. The MCD (Memory Care Director) answered Nile, which was correct.
How many Pyramids of [NAME] were made? The MCD immediately responded 3, which was correct.
What is the national dish of Spain? One resident guessed lasagna. None of the residents knew the answer. The AIT informed them the answer was paella.
Who wrote [NAME] Holmes? None of the residents knew the answer. The AIT informed them the answer was [NAME].
When was Nike founded? None of the residents knew the answer. The AIT informed them the answer was 1971.
What is the tallest building in the world? None of the residents knew the answer. The AIT informed them the answer was Burj [NAME].
Which mammal has no vocal cords? None of the residents knew the answer. The AIT informed them the answer was a giraffe.
An observation of 4 residents, including Resident 10, in the activity room was made on 11/15/23 at 9:24 a.m. The AIT (Administrator in Training) was also present. There was an exercise program playing on the television. Only one resident was participating with the AIT in the exercises. Two of the residents, including Resident 10, were sitting with their eyes closed. No one was actively encouraging the 3 nonparticpating residents to participate. Resident H and Resident 126 both entered the activity room at 9:26 a.m. Resident 40 was not present during this observation.
On 11/15/23 at 9:33 a.m. an interview and observation was conducted with Resident 40 in her room. She was sitting in her wheel chair. She indicated she had a shower earlier this morning, did not know chair exercises were occurring in the activity room, and that no one asked her if she'd like to participate.
During an interview with CNA (Certified Nursing Assistant) 13 on 11/15/23 at 9:42 a.m., she indicated she assisted Resident 40 with her shower after coming into work, then took her to breakfast.
On 11/15/23 at 9:35 a.m., Resident 40 asked where the exercises were occurring and if she could participate. This information was immediately relayed to QMA (Qualified Medication Aide) 4. QMA 4 assisted Resident 40 into the activity room near the television. Resident 40 began participating by moving her feet up and down to the beat, crossing her arms over her chest, and bopping her head in her wheel chair, mimicking the exercise instructor on the television.
An interview was conducted with QMA 4 in the presence of CNA 13 on 11/15/23 at 10:40 a.m. QMA 4 indicated she worked on the memory care unit 3-4 days a week and worked a lot of double shifts. CNA 13 and CNA 3 were the primary CNAs who worked on the unit. It was usually her, 2 CNAs, and the MCD who worked on the unit during the day. As far as activities on the unit, coffee was usually served around this time, the 10:00 a.m. hour, and it was hit or miss once that was over. CNA 3 and CNA 13 were good at getting residents bathed, toileted, and dressed. They could do activities with the residents sometimes, but not morning chair exercises, because the CNAs were still busy with ADLs and her with administering medications. A lot of residents went to therapy and didn't want to do chair exercises upon return. They had a variation of residents on the unit, but most of those activities are too high functioning for these residents, like the trivia game yesterday. Residents needed more sensory type activities. They had maybe a half hour available in the morning to actually sit with residents. Normally, residents were either in their rooms by themselves or in the activity room with the television on. The MCD didn't return to the unit from morning meeting until around 10:00 a.m., when she did the coffee activity with them. The MCD would do another group activity with residents in the afternoon, like puzzles or coloring. There was no structured, ongoing activity program on the unit. The chair exercise activity that occurred earlier today was not a normal thing on the unit. They needed an actual staff member, designated for activities on the unit, if regular, consistent activities were to occur.
An interview was conducted with CNA 13 on 11/15/23 at 10:40 a.m. in the presence of QMA 4. She indicated she worked on the memory care unit of the facility 3 to 4 days a week. She and the other CNA tried to help with activities, but they did not have time to do anything regularly. The chair exercise activity that occurred earlier today was not a normal thing on the unit. Normally, after assisting residents with getting up and dressed for the day, after breakfast, they would take them back to their room or into the activity room to watch television. She didn't think the activities on the unit were at their level, like bowling. There was no activity aide for the memory care unit. She told the MCD they needed someone to activities on the unit, because she did not have time to do activities and provide care to residents.
An observation was made on the way into the MCD's office to conduct an interview with her on 11/15/23 at 1:43 p.m. There were 10 residents sitting in the activity room with the television on. No staff were present in the room with them.
An interview was conducted with the MCD on 11/15/23 at 1:43 p.m. She indicated she normally conducted the activity program on the unit. When she began working at the facility in May, 2023, there was an activity assistant on the unit who only did activities, but they hadn't worked at the facility for a couple of months now. They hadn't had anyone designated for activities since then. They tried to chip in and do it. The residents enjoyed trivia and she thought the questions being asked during trivia were for seniors, but not necessarily cognitively impaired residents. The hour of 1:00 p.m. to 2:00 p.m. was down time. They just had Westerns playing on the television, because that was a time to provide toileting to residents after lunch. She stated, I can't be 10 different places at once. I need a 9:00 a.m. activity person and someone to do room visits.
2. The clinical record for Resident 52 was reviewed on 11/14/23 at 11:00 a.m. Her diagnoses included, but were not limited to: dementia, mood disorder, and major depressive disorder.
Her impaired cognition care plan, revised 9/15/23, indicated she had difficulty making herself understood. Interventions were to anticipate her care needs and help her as needed. There was no intervention to provide soothing touch or to provide one on one attention.
Her dementia with incidents of rejecting or resisting care care plan, revised 9/15/23, indicated she may cry out or yell while receiving care such as changing soiled clothing, trying to hit or kick staff. an intervention was to provide soothing touch and reassurance while assisting with care. It did not reference crying or yelling out during group activities/settings.
An observation of a group trivia activity was made in the dining room of the memory care unit on 11/14/23 at 10:40 a.m. Resident 52 began yelling out at the table at which she was sitting with other residents.
An observation of Resident 52 was made on 11/14/23 at 11:12 a.m. She was no longer in the group trivia activity in the dining room with the other residents. She was sitting by herself in her wheel chair in the hallway outside of the dining room. She was crying and yelling out for her mother. The AIT (Administrator in Training) came out of the dining room, into the hallway and attempted to calm her. After a few minutes of the AIT attempting to calm her, the AIT returned to the dining room, and Resident 52 continued to cry and yell out for her mother. Shortly thereafter, QMA 4 approached Resident 52 in the hallway, began rubbing her back, and attempting to calm her. QMA 4 then assisted Resident 52 down the hall near the nurse's station and provided her more direct attention. Resident 52 began calming down when QMA 4 rubbed her back.
An interview was conducted with QMA 4 on 11/15/23 at 10:40 a.m. QMA 4 indicated she worked on the memory care unit 3-4 days a week and worked a lot of double shifts. She indicated she was unsure how Resident 52 got from the dining room into the hallway during trivia yesterday and left by herself. She stated, That hurt me. It wasn't right to leave her in the hallway. Someone could have come to her and asked her to watch Resident 52 instead of leaving her alone in the hallway. Some of the other staff would leave Resident 52 in an a group environment that was upsetting to her. When Resident 52 yelled out in group settings, it upset the other residents in the group, and then Resident 52 would just get louder. She tried to deescalate those situations by removing Resident 52 from the upsetting environment and providing her one on one attention, like she did yesterday.
An interview was conducted with CNA 13 on 11/15/23 at 10:40 a.m. She indicated she worked on the memory care unit of the facility 3 to 4 days a week. When she removed Resident 52 from a group activity for yelling out, she didn't leave her alone. On Monday, 11/13/23, Resident 52 was screaming and hollering, during a group setting, so QMA 4 asked her if she'd bring Resident 52 to her near the nurse's station to provide her one on one attention. The MCD stopped CNA 13 from removing her from the room and informed her she was going to redirect her instead.
An interview was conducted with the MCD on 11/15/23 at 1:43 p.m. She indicated Resident 52's yelling out was part of her disease process. She didn't want staff to remove her from the group setting right away. She liked to redirect her 3 times before removing her. She knew the other residents get upset and everything, but she didn't want to isolate her. Yesterday during trivia, the MCD asked one of the CNAs to come and get Resident 52 from the group, but she wasn't sure what they were going to do with her. She assumed they would take her to her room. She didn't know why Resident 52 was left alone in the hallway to cry out.
The 11/1/23 psychiatry note read, Staff Report: Staff report the patient has been speaking with more word salad since she last returned from the hospital, just over a month ago. Over the last couple of weeks she has been getting gradually louder and louder. She begins to yell words that do not make sense. This occurs in all areas of the unit and at anytime. Very unpredictable. Today she got so loud that it began to agitate the residents around her and some felt she was yelling at them. She had to be removed from the dining room as staff was not able to settle her down. Frequently they are able to encourage her to stop yelling and she may take the volume down but most often she does not. They utilize many distraction techniques. [NAME] does this even when laying in her bed with the lights dimmed. She does it at night as well. Her roommate handles this very well at present.
3. The clinical record for Resident 60 was reviewed on 11/14/23 at 9:44 a.m. The Resident's diagnosis included, but were not limited to, Dementia with agitation.
An admission MDS (Minimum Data Set) Assessment, completed 8/8/23, indicated Resident 60 had severely impaired cognition, wandered without a purpose 4 to 6 days during the 7-day observation period, required supervision with walking 10 feet, and needed set up assist with eating.
A physician's order, dated 8/1/23, indicated she was to receive divalproex Sodium (seizure medication used to stabilize mood) 125 mg each morning and 250 mg each bedtime for dementia and psychotic disturbance.
A care plan, initiated 8/4/23, indicated Resident 60 was at risk for elopement related to stating she was leaving and going home and wandering. The goal was for her to remain safe during her placement at the facility. The interventions, initiated 8/4/23, were to access for secure unit, involve her in preferred activities, redirect her from the doors, and take picture of her and update the elopement book. An intervention, initiated 8/7/23, was to place a Roam Alert.
A behavior charting progress note, dated 8/10/23 at 7:46 p.m., read .Describe Behavior/Mood: Resident [60] in another resident room. [Other] Resident stated yelling get out. Writer responded immediately and resident [60] was holding one of [other]resident stuffed animals. Writer attempted to ask resident [60] for animal when resident [60] swung toy at writer knocking off my glasses. Resident [60] then lost balance hitting her upper back on dresser in room. Resident [60] continue to try and swing animal at writer. Writer called for assist and left room. Resident [60] then picked up my glasses and putting them in her pocket and came out into hallway. Staff asked resident [60] for glasses, and she stated no they are mine. Staff walked with resident [60] up and down hallway several times. Staff able to remove glasses from pocket and take resident to her room. Resident was then assisted into bed
There were no new interventions added to the at risk for elopement/ wandering care plan after the behavior incident on 8/10/23.
A care plan, initiated 8/12/23, indicated Resident 60 has a potential for drug related complications due to the use of psychotropic medication, anti- depressant medication, anti-psychotic medication, and mood stabilizer. The goal was for her to be free of psychotropic drug related complications. The intervention, initiated 8/12/23, included but were not limited to, observe for side effects of and report to the physician. provide medications as ordered by physician and evaluate for effectiveness.
A care plan, initiated 8/12/23, indicated that Resident 60 had a physical functioning deficit related to her self-care. The goal was for her to improve her level of physical functioning. The interventions included, but were not limited to, eating assistance of set up and supervision.
A care plan, initiated 8/12/23, indicated Resident 60 had cognitive loss/ dementia and impaired cognitive function related to dementia. The goal was for her to communicate her basic needs daily. The interventions, initiated 8/12/23, included but were not limited to, administer medications as ordered, assist with ADL (Activities of Daily Living), involve in enjoyable activities which orient to reality and don't depend on orientation, and to offer reminders which assist her in orientation.
A Change of Condition note, dated 9/26/2023 at 2:20 p.m., indicated Resident 60 had wandered into another resident's room. The other resident was calling for someone to come and remove Resident 60. Upon entering the room, it was noted that Resident 60 was crying. The staff indicated the other resident had made contact with Resident 60 on her left hand and buttocks. No injuries were noted, and Resident 60 was placed on 15-minute checks.
A physician's order, dated 9/26/23, indicated Resident 60 was to receive divalproex sodium oral capsules delayed release sprinkles 250 mg each morning for dementia.
There were no new nonpharmacological interventions added to the elopement/ wandering care plan after the behavior incident on 9/26/23.
A counseling and psychiatric consent, dated 10/2/23, indicated Resident 60 could receive psychiatric consults and counselling.
A Physician's progress note, dated 10/2/23, indicated Resident 60 had increased agitation and restlessness over the last few weeks. Her mood was stable at the time. Depakote (divalproex sodium) dose was recently increased to 250 mg twice daily. Psychiatry services following and assisting with management.
The behavior monitoring documentation for September, October, and November 2023 were reviewed. Behaviors of wandering had been documented on the following days:
behaviors of wandering, crying, repeated movements have been documented on 9/4, 9/5, 9/6, 9/7, 9/11, 9/12, 9/15, 9/20, 9/21, 9/23, 9/24, 9/26, 9/27, 10/2, 10/4, 10/5, 10/10, 10/11, 10/17, 10/18, 10/24, 10/25, 10/26, 10/28, and 10/29/23. The interventions used to assist with managing wandering behavior were to redirect or toilet.
On 11/14/23 at 9:44 a.m., Resident 60 was observed sitting in the activity room with her head down and her eyes closed. She was not watching the television program.
On 11/15/23 at 10:09 a.m., Resident 60 was observed sleeping in her bed.
On 11/15/23 at 2:30 p.m., Resident 60 was observed sleeping in her bed.
During an interview on 11/15/23 at 2:44 p.m., QMA (Qualified Medication Aide) 4 and CNA (Certified Nursing Assistant) 5 indicated that Resident 60 wandered around the memory care unit often when she was first admitted . The wandering had gotten better recently. They had tried to label her room with bright flowers, but she did not recognize them. Normally, when Resident 60 wandered into another resident's room, the other resident would just call out to have her removed.
On 11/16/23 at 10:24 a.m., Resident 60 was laying in her bed with her eyes closed. A staff member was cutting her fingernails and indicated that Resident 60 was sleepy today.
During an interview on 11/16/23 at 10:32 a.m., CNA 3 indicated that Resident 60 had been having a decline in her ability to feed herself for the past couple of weeks and now needed the staff to feed her. Resident 60's wandering had improved recently. When Resident 60 wandered, CNA would redirect her at time by walking with her around the unit to see if Resident 60 needed something. At times CNA 3 would sit and talk with Resident 60 for a while, which seemed to calm her. Resident 60 would also sit and watch the television for a short while. CNA 3 did not recall stop signs or door signs being used to keep Resident 60 from entering rooms.
During an interview on 11/16/23 at 2:26 p.m., the Memory Care Coordinator and the DON indicated that Resident 60 had been increasingly lethargic for the last couple of days and the Nurse Practitioner had been informed. The DON indicated that she was unaware of why new non-pharmacological interventions had not been done prior to the increase of the divalproex sodium. Resident 60 had not been seen by the psychiatry provider since the consent had been signed on 10/2/23.
On 11/16/23 at 2:00 p.m., the DON provided the current Dementia Care Policy which read, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being .1. The facility will assess, develop, and implement care plans through an interdisciplinary tem (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia .4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .5. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being .8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status .
3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a residents' grievances were addressed and timely complete a grievance form for 1 of 1 resident reviewed for missing property and 1 of 3 residents reviewed for dignity. (Residents B and G)
Findings include:
1. The clinical record for Resident B was reviewed on 11/13/23 at 1:39 p.m. The diagnosis included, but was not limited to: anxiety disorder. The resident was admitted to the facility on [DATE].
A 10/19/23 admission Minimum Data Set (MDS) Assessment, indicated Resident B's cognition was intact.
An interview was conducted with Resident B on 11/13/23 at 2:21 p.m. He indicated he had reported to the Administrator In Training (AIT) shortly after he was admitted , License Practical Nurse (LPN) 10 was rude to him, and she continues to be rude.
An interview was conducted with the AIT on 11/15/23 at 2:36 p.m. She indicated Resident B had reported to her LPN 10 had been rude to him shortly after he was admitted . She had not filled out a grievance for the concern. She believed, he was just aggravated about being in the facility.
2. The clinical record for Resident G was reviewed on 11/13/23 at 2:03 p.m. The Resident's diagnosis included, but were not limited to, hypertension and diabetes.
An admission MDS (Minimum Data Set) Assessment, completed 9/9/23, indicated Resident G was cognitively intact.
During an interview on 11/13/23 at 1:55 p.m., Resident G indicated he was missing a prayer book. He had told a staff member at the nurses' station that it was missing about 2 weeks ago.
During an interview on 11/13/23 at 1:55 p.m., Visitor 6 indicated that he had brought the prayer book to Resident G and was surprised it had not been found yet.
During an interview on 11/14/23 at 3:25 p.m., the DON (Director of Nursing) indicated there were no grievance forms on file in the last month for Resident G.
During an interview on 11/17/23 at 11:41 a.m., LPN (Licensed Practical Nurse) 2 indicated she had not been made aware that Resident G was missing a prayer book and If Resident G had informed a staff member, a grievance form should have been completed at that time.
A grievance policy was provided by the Director of Nursing on 11/16/23 at 9:32 a.m. It indicated .Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .Procedure: .The staff member receiving receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Take any immediate actions needed to prevent further potential violations of any resident right .Forward the grievance form to the Grievance Official as soon as practicable. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions on the grievance form .
3.1-7(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' dignity was maintained by staff not being respectful for 6 of 69 residents reviewed for dignity. (Residents' B, C, D, E, G, and H)
Findings include:
1. The clinical record for Resident G was reviewed on 11/13/23 at 2:03 p.m. The Resident's diagnosis included, but were not limited to, hypertension and diabetes.
An admission MDS (Minimum Data Set) Assessment, completed 9/9/23, indicated Resident G was cognitively intact.
During an interview on 11/13/23 at 2:03 p.m., Resident G indicated that he had overheard the staff of the facility yelling at each other in the hallways. He had heard the staff being disrespectful of each other in the hallways.
2. The clinical record for Resident E was reviewed on 11/13/23 at 2:39 p.m. The diagnosis included, but was not limited to: falls.
An interview was conducted with Resident E on 11/13/23 at 2:17 p.m. She indicated the staff are rude in the facility. She had pushed her call light and ask a staff member for a writing pen. After the staff member left the room, the resident had overheard another staff member that was standing in the hallway; state to the staff member that just left her room, What does that woman want now? She felt that was disrespectful the the staff member making that comment about her. It made her feel uncomfortable to ask for anything from the staff.
3. The clinical record for Resident B was reviewed on 11/13/23 at 1:39 p.m. The diagnosis included, but was not limited to: anxiety disorder. The resident was admitted to the facility on [DATE].
A 10/19/23 admission Minimum Data Set (MDS) Assessment, indicated Resident B's cognition was intact.
An interview was conducted with Resident B on 11/13/23 at 2:21 p.m. He indicated he had reported to the Administrator In Training (AIT) shortly after he was admitted , License Practical Nurse (LPN) 10 was rude to him, and she continues to be rude. During care recently, LPN 10 had stated to him don't talk to me while she was providing care. After speaking with other staff about her rudeness, he was told by the staff that was just how she is.
An interview was conducted with Resident C on 11/13/23 at 2:30 p.m. He indicated he had witnessed LPN 10 stating to Resident B, not to speak to her while she was providing care.
During a resident council meeting on 11/13/23 at 2:34 p.m., the council indicated some staff are respectful and some staff are not.
5. The clinical record for Resident D was reviewed on 11/14/23 at 8:39 a.m. The diagnosis included, but was not limited to: stroke.
An interview was conducted with Resident D on 11/14/23 at 10:44 a.m. She indicated some staff are disrespectful and unpleasant. You never know what mood they will be in.
6. An interview was conducted with Family Member 12 on 11/14/23 at 11:39 a.m. He indicated some of the staff treated residents with dignity and respect, but some did not. Maybe once a week, he heard staff use vulgar, unprofessional language, including cursing, within earshot of Resident H and other residents.
An interview was conducted with the Director of Nursing (DON) and Executive Director (ED) on 11/17/23 at 12:08 p.m. The ED indicated the staff morale has been good in the facility, but they have had to let go a couple of staff members that were not good fit for the facility. The facility was currently working on team building and has started a committee to boost staff morale. The staff have been educated on good customer service and abuse, and it will continue.
A Promoting/Maintaining Resident Dignity policy was provided by the DON on 11/16/23 at 9:32 a.m. It indicated Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .When interacting with a resident, pay attention to the resident as an individual. Respond to requests for assistance in a timely manner. Explain care of procedures to the resident before initiating the activity. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered .Speak respectfully to residents; avoid discussions about residents that may be overheard .
The resident rights policy was provided by the DON on 11/16/23 at 9:23 a.m. It indicated .Respect and dignity. The resident has a right to be treated with respect and dignity .
This citation relates to complaint IN00418192.
3.1-3(t)