Brickyard Healthcare -Sycamore Village Care Center

Based on observation, interview and record review, the facility failed to ensure medications were dated when opened in 1 of 3 medication carts reviewed for medication storage. (East Hall)Findings include:During an observation, on 1/8/26 at 11:01 a.m., with the Infection Preventionist Nurse, the East Hall medication cart had the following:a. One multi-use tube of Triad Wound paste was not labeled with an open date.b. One multi-use tube of Diclofenac gel 1% was not labeled with an open date.During an interview, on 1/8/26 at 11:06 a.m., the Infection Preventionist Nurse indicated the medications should have been labeled with a date when they were opened.During an interview, on 1/9/26 at 10:52 a.m., RN 3 indicated if a new tube of medication was opened, it would be dated with the date opened and placed in the treatment cart with the residents' other medications.During an interview, on 1/9/26 at 12:46 p.m., Pharmacist 8 indicated she was unsure of the shelf life of Diclofenac gel and Triad Wound paste once opened, but they should be dated when they were opened.A current facility policy, titled Labeling of Medications and Biologicals, dated as revised 2025 and provided by the Executive Director on 1/8/26 at 2:00 p.m., indicated .Labels for multi-use vials must include: a. The date the vial was initially opened. 3.1-25(j)

Based on observation, interview and record review, the facility failed to ensure privacy was provided for a resident during care for 1 of 1 resident randomly reviewed for privacy. (Resident 5)Findings include: During a random observation, on 1/7/26 at 11:21 a.m., RN 9 and QMA 15 entered Resident 5's room to administer medication through the resident's gastrostomy tube (a tube placed through the abdomen directly into the stomach for long-term feeding, hydration, and medication delivery). RN 9 placed the medication on the bedside table and asked QMA 15 to watch the medication while she washed her hands. RN 9 returned and QMA 15 exited the room. RN 9 did not have water to flush the medication and asked the Executive Director (ED) to get a cup of water off the medication cart. The ED brought the water to RN 9 and left the room. Resident 5's door and privacy curtain remained open. RN 9 pulled the resident's covers back, lifted his gown, and exposed his abdomen. The privacy curtain and the door remained open. A visitor in the facility walked by the resident's room and looked inside. The clinical record for Resident 5 was reviewed on 1/6/26 at 3:11 p.m. The diagnoses included, but were not limited to, cerebral infarction, diabetes mellitus, atrial fibrillation, acute kidney failure, and gastrostomy tube.A care plan, dated 4/21/25, indicated the resident required enteral feeding.During an interview, on 1/7/26 at 11:21 a.m., RN 9 indicated she did not close the door or the curtain to provide privacy for Resident 5. During an interview, on 1/7/26 11:41 a.m., QMA 15 indicated the privacy curtain, or door should always be closed when completing any kind of care with the resident. A current facility policy, titled Resident Rights, undated and received from the ED on 1/9/25 at 11:30 a.m., indicated .The resident has a right to a dignified existence, self-determination and communication with, and access to, persons and services inside and outside the Facility .Information about resident rights and responsibilities will be given to the resident both orally and in writing 3.1-3(p)(4)

Based on interview and record review, the facility failed to ensure staff obtained another weight after a documented weight gain for 1 of 3 residents reviewed for quality of care. (Resident 23) Findings include:The clinical record for Resident 23 was reviewed on 1/7/26 at 9:53 a.m. The diagnoses included, but were not limited to, cerebral palsy, conversion disorder with seizure or convulsions, anxiety disorder, hypertension, cognitive communication deficit, and intellectual disabilities. A care plan, dated 6/23/25, indicated Resident 23 triggered for obesity and a body mass index (BMI) greater than 30. Interventions included, but were not limited to, weights according to the physician's order.A clinical record indicated Resident 23 had the following weight:On 7/1/25, the resident's weight was 244.0 pounds. On 8/5/25, the resident's weight was 270.0 pounds. Resident 23 had a significant weight gain of 10.66% in 36 days. There was no documentation located in the medical record to indicate another weight had been obtained to determine if the weight was correct or the physician was notified.During an interview, on 1/9/26 at 10:55 a.m., LPN 2 indicated if the resident had a significant weight gain or loss the physician should be called. If the resident had a weight gain and a diagnosis of congestive heart failure, the physician could order a diuretic. During an interview, on 1/9/26 at 10:58 a.m., RN 3 indicated it was very important to notify the physician if there was a significant weight change. The resident could need additional orders, or the physician could want to see the resident. RN 3 indicated she would also complete an assessment to determine if the resident had edema. During an interview, on 1/9/26 at 11:25 a.m., the Registered Dietician (RD) indicated nursing staff should complete another weight on a resident if there was a significant weight loss or gain. There was no documentation in the clinical record to indicate the resident was reweighed.During an interview, on 1/9/25 at 11:27 a.m., the Executive Director (ED) indicated there was no documentation the physician was notified of the weight gain. A current facility policy, titled Weight Monitoring, undated and received from the ED on 1/9/26 at 11:47 a.m., indicated .A significant change in weight is defined as: 5% change in weight in 1 month (30 days) .The physician should be informed of a significant change in weight and may order nutritional interventions 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident was kept safe during care and transfers for 1 of 4 residents reviewed for accidents. (Resident C)Findings include:During an interview, on 1/7/26 at 10:39 a.m., Resident C's daughter indicated the resident had fallen twice. The first was from her bed. The resident's bed was smaller than her current bed, she rolled out and fell on the floor during incontinence care. There was only one CNA in the room, and the CNA pushed the resident too hard, and she fell out of her bed. The second was from the mechanical lift. The facility did not call her when the resident's lift strap on the pad broke. The resident called from the ambulance. When the resident was in the emergency room, the Executive Director called but it was at least 30 minutes after the resident was in the emergency room. The Executive Director had asked if she wanted to see the broken pad and then when she asked to see the pad the Executive Director indicated it was no longer available. The clinical record for Resident C was reviewed on 1/6/26 at 10:34 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, congestive heart failure, hypertension, morbid obesity, and osteoarthritis of the right and left knee.An annual Minimal Data Set (MDS) assessment, dated 10/23/25, indicated Resident C was dependent on staff with transfers.A care plan, dated 12/18/24, indicated Resident C had a self-care performance deficit. Interventions included, but were not limited to, 1/28/25, trapeze bar above the bed to assist with repositioning. 12/18/24, Resident C required substantial assistance to complete bed mobility, was dependent on toileting, and totally dependent on transfers. Encourage Resident C to participate, when possible, with each interaction.A care plan, dated 12/18/24, indicated Resident C was at risk of falls. Interventions included, but were not limited to, 12/18/24, assistance with transfers, ensure resident wore appropriate non-skid footwear, and the environment remained safe.1. A facility's change of condition note, dated 11/26/25 at 11:50 a.m., indicated Resident C was receiving incontinence care. While the resident turned towards the window on her left side, the resident fell out of the bed. The resident held herself with the trapeze, her hand slipped off, and she fell out. The resident received a small scratch on the back of her right lower leg. The new intervention was for two (2) people to assist with care. A fall risk evaluation, dated 11/26/25, indicated Resident C had a low risk for falls.A physician's progress note, dated 11/28/25 at 8:00 a.m., indicated Resident C was seen for follow-up of right ankle pain experienced post fall. Her x-ray did not show acute fracture. She had right ankle pain with no acute fracture or dislocation seen.An interdisciplinary team note, dated 12/4/25 at 11:11 a.m., indicated Resident C had a fall and slid off the edge of the bed during care, on 11/26/25. The new intervention was two (2) caregivers when providing peri care.During an interview, on 1/4/26 at 2:51p.m., Resident C indicated she had fallen when she was too close to the edge of the bed while staff were providing incontinence care, and she rolled off the bed. The bed was too small. During an interview, on 1/7/25 at 1:00 p.m., the Executive Director indicated Resident C did fall out of bed during incontinence care. Resident C did not get hurt.During an interview, on 1/7/26 at 5:04 p.m., CNA 17 indicated she was completing peri care on the resident. Resident C helped with turning from her back towards the window. She grabbed the overhead trapeze and rolled to the left. The bed was close to the window, Resident C slid off the bed, and her left foot went to the floor, and her right leg went up in the air. She landed on the floor and was in a split position between the bed and the window. CNA 17 yelled for the nurse, and they used the mechanical lift to help Resident C off the floor.2. An interdisciplinary team note, dated 12/4/25 at 12:45 p.m., indicated Resident C returned from the emergency room after a recent fall. Resident C had complaints of pain related to the fall.A facility's change of condition note, dated 12/4/25 at 3:00 p.m., indicated Resident C was being transferred with the Hoyer lift. Resident C was approximately an inch off the bed when the Hoyer sling snapped and the resident fell to floor. Three (3) staff members were present at the transfer. Resident C had significant pain in her lumbar area and was sent to the emergency room for evaluation.A fall risk evaluation, dated 12/4/25 at 3:30 p.m., indicated Resident C had 1-2 falls in the past 3 months. Resident C was chairbound and incontinent.An interdisciplinary team note, dated 12/5/25 at 10:01 a.m., indicated Resident C fell from Hoyer sling. The Hoyer sling broke and the resident was sent to the emergency room for evaluation.A nursing progress note, dated 12/5/25 at 12:40 p.m., indicated Resident C returned from the hospital. She reported new back pain. New physician's orders were received for as needed Norco (a pain medication), Robaxin (a muscle relaxing medication), and routine Lidoderm patches (a topical patch used for pain) to her back.A nursing progress note, dated 12/5/25 at 2:53 p.m., indicated Resident C was assessed for side rails and passed the assessment.A post fall evaluation, dated 12/8/25 at 4:24 p.m., indicated Resident C was being transferred with the Hoyer lift when the Hoyer sling strap broke. The resident had a bruise on her hand and lower back pain.A hospital document, dated 12/26/25, indicated an x-ray of the spine was completed with no fractures detected. The hospital was unable to obtain a CT (computed tomography) scan due to patient's weight. The resident had a fall from a height of less than 3 feet and reported experiencing pain localized to the thoracic (middle section of the spine), right shoulder, and noted discomfort associated with positional changes in bed.A fall risk evaluation, dated 1/2/25, indicated Resident C was at moderate risk for falls. During an observation, on 1/6/26 at 11:11 a.m., Certified Nursing Assistant (CNA) 13 and CNA 14 were transferring Resident C into her recliner. Resident C was lying flat in her bariatric bed. Resident C grabbed the trapeze handle and assisted in rolling herself over onto her left side. CNA 13 placed the large blue Hoyer pad underneath the resident and instructed the resident to roll onto her right side. Once the pad was under the resident; CNA 14 pushed the mechanical lift to the right side of the bed. The CNAs attached the straps of the pad onto the hooks and began to lift Resident C off the bed. Resident C asked the CNAs to stop and to cross the straps at her feet. CNA 13 informed Resident C they could not cross the straps. CNA 13 indicated the pad was the correct pad for Resident C and the nurse had told her which pad to use. During an interview, on 1/6/26 at 11:19 a.m., Unit Manager 16 indicated the mechanical lift pads were based on the resident's weight and were normally stored in each resident's room. During an observation and interview, on 1/6/26 at 11:25 a.m., Unit Manager 16 indicated the lift pads were normally kept in the clean storage room or the resident's room. Unit Manager 16 pulled a lift pad out from a large blue barrel to look at the tag with the weight. The pad did not have a weight limit on tag and Unit Manager 16 indicated she was not sure why. The Patient Lift Safety Guide indicated assess the patient's size, weight, and hip measurement and choose the size of the sling based on the manufacturer's recommendation for the patient's measurements. Choosing the correct sling size was critical for safe patient transfer. If the sling was too large, the patient could slip out. If the sling was too small, the patient could fall out. If the sling was between sizes, the smaller size could keep the patient more secure. Using the wrong sling or attaching the sling incorrectly could cause an accident which could result in serious injury or death.During an interview, on 1/6/26 at 11:30 a.m., Resident C indicated the staff had crossed the straps down by her feet on more than one occasion. When staff used the large pad, she felt like she would slide out. The CNAs not normally assigned to her would use the incorrect pad. Resident C indicated the pad the staff used the day of the incident felt smaller. She told the CNAs and they said it would be okay then shortly after was when the strap broke and she fell. She hit her right shoulder and back on the mechanical lift legs. She felt like she broke her back. During an interview, on 1/7/25 at 4:22 p.m., CNA 10 indicated on the day of the incident, CNA 11, CNA 12, and herself hooked the straps to the lift. She could not remember how they attached the straps. CNA 12 raised the resident up about 2 inches off the bed and pulled the lift out. CNA 11 was guiding the resident when the stitching on the strap came loose, the resident fell and landed on the mechanical lift legs. Resident C hit her left lower back on the mechanical lift. CNA 10 was not sure which pad they used or if the pad was the correct weight limit for Resident C. During an interview, on 1/9/26 at 10:30 a.m., the Ombudsman indicated Resident C's family member had called him with concern. Resident C had fallen from a mechanical lift and had also fallen from the bed during peri care. During an interview, on 1/9/26 at 10:39 a.m., LPN 2 indicated Resident C required a mechanical lift. During an interview, on 1/9/26 at 10:42 a.m., RN 3 indicated to use the mechanical lift, you should know the weight of the resident. The pads were labeled with the weights. She believed the resident used a pad for 500 pounds. The CNAs should know which pad Resident C used. During an interview, on 1/9/26 at 12:50 p.m., CNA 11 indicated on the day of the incident, she helped CNA 10 and 12 with Resident C. They used the bigger pad which crossed under the resident at the legs. CNA 12 began to raise the resident up while she guided the resident off the bed. Resident C had just cleared the bed when the right strap unraveled and broke. The resident fell to the ground and hit her back on the mechanical lift legs. 3. During an interview, on 1/9/25 at 1:22 p.m., Resident C indicated earlier this morning two (2) guys, and a girl (unable to recall their names) came in with the mechanical lift to transfer her back to bed. The resident had an overhead trapeze at the head of bed. During the transfer, the mechanical lift hit her overhead trapeze bar and knocked the trapeze bar down. The trapeze bar bumped the back of her head. The resident indicated her head was a little sore but did not bleed. During an interview, on 1/9/25 at 9:45 a.m., the Executive Director (ED) indicated Resident C did have an incident with the mechanical lift today. The trapeze bar dropped and hit the back of her head. She had a small bump on her head, but it was not open. She spoke to the resident who stated she was fine.At the exit conference, the ED indicated she had no additional information provided related to the incidents. The facility did not have a policy on the use of mechanical lifts.A current facility policy, titled Accidents and Supervision, dated 12/4/25 and received from the ED on 1/9/25 at 11:30 a.m., indicated .The residents' environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.All staff.are to be involved in observing and identifying potential hazards in the environment.This citation relates to Intake 2680656.3.1-45(a)(1)3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a safe and sanitary condition in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 95 of 95 residents who received food from the kitchen.Findings include:During the kitchen observation, on 1/4/26 at 10:58 a.m., with the Dietary Manager (DM), the following were observed:a. The walk-in refrigerator contained two 16-ounce cans of Pepsi open, two cans of Pepsi not open, one 16-ounce bottle of water opened, a thirty-two-ounce bottle of Coffee Mate French Vanilla liquid creamer with no sugar and a Gordons choice whipped topping. All without a date or label.b. Four empty cardboard boxes were not broken down and stacked on the floor by the back exit door. c. The floor under the serving station had dried unknown food and unopened condiment packets. d. The floor under and around the oven had unknown food substances and grease.e. The floor in the refrigerator had small particles of unknown food, pieces of carboard, pieces of clear tape, and lids to unknown containers.f. The floor in the dry food area had dried sticky liquid of unknown substance, small particles of dried food, plastic white fork and spoon, and small pieces of paper.g. The floor in the dishwashing station had food, pieces of paper, aluminum foil, and grimy scuffing.h. Eight rolling carts had dried food products and dried liquid.i. The chemical storage closet had a pint [NAME] jar with clear orange liquid with no date or label.j. The juice dispenser station next to the hand-washing station had an open can of coke and a can of glass cleaner.k. The microwave had dried unknown food particles on the exterior and interior.l. The stove top had dried food product on it with a pan of butter uncovered with a brush in pan.During an interview, on 1/4/26 at 11:20 a.m., the Dietary Manager indicated the employees were not supposed to store their drinks in the refrigerator.During an interview, on 1/4/26 at 11:24 a.m., the Dietary Manager indicated cardboard boxes should not be stored on the floor.During an interview, on 1/4/26 at 11:28 p.m., the Dietary Manager indicated the flooring through the kitchen, refrigerator, freezer, and dry food pantry should be clean and free of debris.During an interview, on 1/4/26 at 11:29 p.m., the Dietary Manager indicated rolling carts should be clean.During an interview, on 1/4/26 at 11:30 a.m., the Dietary Manager indicated chemicals in storage area should be labeled.During an interview, on 1/4/26 at 11:34 a.m., the Dietary Manager indicated the juice station shelf should not have employee drinks or cleaning products on it.During an interview, on 1/4/26 at 11:40 a.m., the Dietary Manager indicated cooking appliances should be clean.During an interview, on 1/09/26 at 10:10 a.m., the Registered Dietician (RD) indicated no liquid substances should be stored in a [NAME] jar and kept in the chemical storage closet anywhere in the facility.A current facility policy, titled Sanitation Inspection, with no revision dated and received from the Executive Director (ED) on 1/9/26 at 11:45 a.m., indicated .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.All food service areas shall be kept clean, sanitary, free from litter, rubbish.A policy for chemical storage was not provided.3.1-21(i)(3)

2. During observations, on 12/12/24, 12/13/24, and 12/17/24, no enhanced barrier precautions (EBP) sign was noted outside Resident 61's room per the physician's order.
During observations, on 12/18/24 and 12/19/24, both an enhanced barrier precautions and Contact Precaution signs were noted in the hallway outside the resident's door.
The clinical record for Resident 61 was reviewed on 12/16/24 at 10:09 a.m. The diagnoses included, but were not limited to, enterocolitis due to clostridium difficile (C-diff), urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms.
A current physician's order, dated 8/20/24, indicated enhanced barrier precautions were to be in place and a sign was to be outside the resident's room.
A physician's order, initiated on 11/7/24 and completed on 12/7/24, indicated the resident was to be on contact precautions for enterocolitis due to clostridium difficile.
A care plan, initiated 8/20/24, indicated Resident 61 required enhanced barrier precautions. Interventions included, but were not limited to, follow enhanced barrier precaution guidelines as ordered.
During an interview, on 12/17/24 at 11:25 a.m., Licensed Practical Nurse (LPN) 2 indicated Resident 61 should be on contact precautions and a sign should be up outside the resident's door.
During an interview, on 12/18/24 at 1:25 p.m., the Director of Nursing (DON) indicated both contact precaution and enhanced barrier precautions signs were in place outside of Resident 61's door. The enhanced barrier precautions sign was placed to the left of the door and the contact precaution sign was placed to the right over a personal protective equipment (PPE) cart. She indicated staff were to follow the contact precautions.
During an interview, on 12/19/24 at 9:42 a.m., CNA 2 indicated Resident 61 was on contact precautions and staff were to wear gowns and gloves every time they entered the room.
During an interview, on 12/19/24 at 9:45 a.m., LPN 3 indicated there was a current physician's order for enhanced barrier precautions. The order for contact precautions was completed on 12/7/24 and the contact precaution sign should not be outside the resident's door.
A current facility policy, titled Enhanced Barrier Precautions, dated 3/20/24 and received from the Executive Director (ED) on 12/17/2024 at 4:04 p.m., indicated .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following .wounds .feeding tubes .Implementation of Enhanced Barrier Precautions .PPE for enhanced barrier precautions .when performing high-contact care activities .High-contact resident care activities include .Device care or use .feeding tubes .Wound care
A current facility policy, titled Transmission-Based (Isolation) Precautions, dated May 2024 and received from the DON on 12/19/24 at 12:02 p.m., indicated .contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .Initiation of Transmission-Based Precautions .signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room
3.1-18(b)
Based on observation, interview and record review, the facility failed to ensure staff wore PPE (personal protective equipment) and to ensure the correct isolation signs were posted for 2 of 3 residents reviewed for transmission-based precautions. (Resident 67 and 61)
Finding includes:
1. During an observation, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 entered Resident 67's room to administer medication. The resident was in enhanced barrier precautions. RN 5 did not put on a gown when entering the room.
The clinical record for Resident 67 was reviewed on 12/13/24 at 11:35 a.m. The diagnoses included, but were not limited to, hypoxia, cardiomegaly, anxiety disorder, pressure ulcers, gastrostomy tube (g-tube), and dysphagia (difficulty swallowing).
A physician's order, dated 8/20/24, indicated enhanced barrier precaution with a sign outside the resident's room and to wear a gown and gloves for high contact resident care.
A care plan, dated as revised on 10/25/24, indicated Resident 67 required enhanced barrier precautions. Interventions included, but were not limited to, follow enhanced barrier precaution guidelines as ordered, PPE for high-contact resident care and for residents with urinary catheters and feeding tubes.
During an interview, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 indicated she should have put on an isolation gown.
During an interview, on 12/17/24 at 2:35 a.m., Licensed Practical Nurse (LPN) 4 indicated a gown and gloves were required when providing care to Resident 67. Staff providing direct care to the resident was responsible to wear the proper PPE.

Based on interview and record review, the facility failed to ensure the SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) forms were accurately completed for 2 of 3 residents discharged from Medicare services and remained in the facility. (Resident 45 and 91)
Findings include:
1. The Advance Beneficiary Notice of Non-coverage (ABN) form for Resident 45 was reviewed on 12/13/24 at 2:03 p.m.
On 10/8/24, the facility provided Resident 45 the ABN form which indicated their coverage was ending on 10/10/24. The form was blank in response to the options of coverage for physical therapy and occupational therapy.
The blank section of the ABN form read as follows:
Read this notice to make an informed decision about your care, ask any questions and choose an option below about whether to receive therapy. Check only one box. We cannot do this for you.
There were no options chosen for this section of the form.
2. The ABN form for Resident 91 was reviewed on 12/13/24 at 2:03 p.m.
On 12/4/24, the facility provided Resident 91 the ABN form which indicated their coverage was ending on 12/2/24. The form was blank in response to the options for remaining in the facility.
The blank section of the SNF ABN form read as follows:
Read this notice to make an informed decision about your care, ask any questions and choose an option below. Check only one box. We cannot do this for you.
There were no options chosen for this section of the form.
During an interview, on 12/16/24 at 10:48 a.m., the Business Office Manager (BOM) indicated the Social Service department was responsible for assisting the residents to complete the forms. The Business Office would only assist with completion of the forms if Social Services was not present at the time the forms were to be completed. She indicated if one form had an option chosen, then she would assume all the forms would have an option chosen.
During an interview, on 12/16/24 at 10:53 a.m., the Social Service Director indicated one of the three options for coverage should have been chosen and should not have been blank.
A current facility policy, titled Advance Beneficiary Notices, dated 2024 and received from the Executive Director on 12/19/24 at 12:15 p.m., indicated .Contents of the form shall comply with related instructions and regulations regarding the use of the form .The Business Office Manager, or designee, is responsible for issuing notices .Documentation shall comply with form instructions .A notice must be completed before delivery
3.1-4(f)(3)

2. The clinical record for Resident 52 was reviewed on 12/16/24 at 2:44 p.m. The diagnoses included, but were not limited to, anxiety disorder, post-traumatic distress disorder, depression, and adjustment disorder.
A notice of PASARR level 1 screen outcome, dated 10/24/24, indicated no level 2 was required and no mental illness was suspected. The current mental health medications included aripiprazole (an antipsychotic medication) and duloxetine (an antidepressant medication). If changes occur or new information refuted these findings, a new screen must be submitted.
Physician's orders, with a start date of 11/18/24, indicated clonazepam and buspirone (antianxiety medications) and zolpidem tartrate (a hypnotic medication for sleep).
Clonazepam, buspirone and zolpidem were not included on the PASARR mental health medication section.
During an interview, on 12/17/24 at 10:24 a.m., the Social Service Director indicated another PASARR would be completed if new psychotropic medications were added and another PASARR was not completed.
A current facility policy, titled Resident Assessment - Coordination with PASARR Program, dated 2024 and received from the Executive Director on 12/17/24 at 10:35 a.m., indicated .All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a positive serious mental disorder or intellectual disability arises later .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review
3.1-16(d)(1)(A)
3.1-16(d)(1)(B)
Based on interview and record review, the facility failed to ensure Preadmission Screening and Record Review (PASARR) evaluations were updated and accurate for 2 of 4 residents reviewed for PASARR. (Resident 95 and 52)
Findings include:
1. The clinical record for Resident 95 was reviewed on 12/16/24 at 8:56 a.m. The diagnoses included, but were not limited to, major depressive disorder, post-traumatic distress disorder, insomnia, and anxiety disorder.
A PASARR notice of level I screen outcome, dated 10/23/24, indicated a Level II screen was not required. The rational for the determination indicated there was no evidence of a serious mental health condition.
The PASARR level I screen indicated major depressive disorder was listed as a current mental health condition and the current mental health medications prescribed were duloxetine and bupropion for depression.
The PASARR did not include the diagnoses of anxiety disorder, post-traumatic stress disorder, or insomnia.
Physician's orders, dated 11/12/24, indicated Resident 95 was taking Buspirone 5 mg (milligrams) for anxiety disorder and trazadone 50 mg for insomnia.
During an interview, on 12/18/24 at 11:57 a.m., the Social Service Director indicated the PASARR did not include the diagnoses of anxiety, post-traumatic stress disorder, or insomnia and was missing the medications buspirone and trazadone.

Based on interview and record review, the facility failed to ensure the physician ordered parameters to hold blood pressure medications were followed for 1 of 1 resident reviewed for quality of care. (Resident 87)
Finding includes:
The clinical record for Resident 87 was reviewed on 12/16/24 at 8:35 a.m. The diagnoses included, but were not limited to, essential primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and dementia.
A physician's order, dated 5/9/24 and discontinued 12/5/24 at 5:15 p.m., indicated to give diltiazem (a blood pressure medication) by mouth two times a day and to hold the medication for a systolic blood pressure less than 120.
A physician's order, dated 12/6/24, indicated to give lisinopril (a blood pressure medication) by mouth one time a day and to hold the medication for a systolic blood pressure less than 120.
A Medication Administration Record (MAR), dated October 2024, indicated diltiazem was given on 10/23/24 with a systolic blood pressure of 117.
A Medication Administration Record (MAR), dated November 2024, indicated diltiazem was given on 11/22/24 with a systolic blood pressure of 109.
A MAR, dated December 2024, indicated diltiazem was given, on 12/4/24, with a diltiazem was given on 12/4/24 with a systolic blood pressure of 105, on 12/5/24 with a systolic blood pressure of 115, and lisinopril was given on 12/15/24 with a systolic blood pressure of 118.
During an interview, on 12/19/24 at 9:39 a.m., the Dementia Unit Manager 8 and LPN 9 indicated a check mark on the MAR indicated the medication had been given. If the blood pressure was below the ordered parameter, then the medication should have been held and marked with a code 3 or 7 to show it had not been given.
A current facility policy, titled Medication Administration, received from the Director of Nursing (DON) on 12/19/24 at 12:02 p.m., indicated .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 interview and record review, the facility failed to ensure an admission weight was obtained for 2 of 5 residents reviewed for nutrition. (Resident D and H)
Finding includes:
1. The clinical record for Resident D was reviewed on 12/16/24 at 9:10 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, muscle wasting and atrophy, and chronic heart failure.
A weight summary indicated Resident D weighed 284 pounds on 11/11/24. This was the first weight the facility recorded in the electronic medical record (EMR).
Resident D was admitted on [DATE]. The resident was not weighed until 5 days after admission.
The facility's clinical admission assessment, dated 11/6/24, included a spot to enter the weight. There was no weight entered.
2. The clinical record for Resident H was reviewed on 12/16/24 at 10:45 a.m. The diagnoses included, but were not limited to, muscle wasting and atrophy, essential hypertension, and morbid obesity.
A weight summary indicated Resident H weighed 306 pounds on 12/13/24. This was the first weight the facility recorded in the EMR.
Resident H was admitted on [DATE]. The resident was not weighed until 6 days after admission.
The facility's clinical admission assessment, dated 12/9/24, included a spot to enter the weight. There was no weight entered.
During an interview, on 12/19/24 at 9:56 a.m., Licensed Practical Nurse (LPN) 6 indicated the first day a resident was admitted an admission weight would be obtained.
During an interview, on 12/19/24 at 10:16 a.m., Regional Dietician 11 indicated if the resident had a history of heart failure an admission weight would be obtained the day they were admitted .
During an interview, on 12/19/24 at 11:25 a.m., LPN 7 indicated the day a resident was admitted , the facility would obtain an admission weight.
The facility did not have a policy which addressed admission weights.
3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure policy and procedures were followed for medications administered through a gastrostomy tube (g-tube) for 1 of 1 resident reviewed for a gastrostomy tube. (Resident 67)
Finding includes:
During an observation, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 opened a medication capsule and poured the medicine into an unmeasured cup of water. RN 5 entered Resident 67's room and placed the cup with the medication, a piston (used to delivery medication into the g-tube) and a 10 milliliter (ml) syringe of normal saline solution on the bedside table. She removed the cap of the prefilled normal saline syringe and placed the end of the syringe to the g-tube port. RN 5 pushed the normal saline into the residents g-tube port, then took the larger piston and filled the piston with the medication. She then quickly pushed the medication into the g-tube.
The clinical record for Resident 67 was reviewed on 12/13/24 at 11:35 a.m. The diagnoses included, but were not limited to, gastrostomy tube (g-tube) and dysphagia (difficulty swallowing).
A physician's order, dated 8/20/24, indicated to check placement of the g-tube prior to medication administration and to flush the g-tube with 30 ml of water before and after the medication administration.
A physician's order, dated 9/26/24, indicated to give gabapentin (a medication used for nerve pain) 400 milligram (mg) capsule via g-tube three times a day.
During an interview, on 12/17/24 at 1:58 p.m., RN 5 indicated she flushed the g-tube with the prefilled normal saline solution syringe to make sure the tube was not clogged. She forgot to check placement or residual prior to the giving the medication.
During an interview, on 12/17/24 at 2:14 p.m., the Director of Nursing (DON) indicated a prefilled normal saline solution syringe should not be used on a g-tube. The nurse should use water before and after the medication was given through a g-tube and not use normal saline.
A current facility policy, titled Medication Administration via Enteral Tube, dated 2024 and received from the DON indicated .Verify physician orders for medication and enteral tube flush amount .Enteral tube placement must be verified prior to administering any fluids or medication .Flush enteral tube with at least 15 ml of water prior to administering medication unless otherwise ordered by prescriber. Dilute the solid or liquid medication .Flush tube again with at least 15 ml water taking into account resident's volume status .Flush the tube with a final flush of at least 15 ml of water to ensure drug delivery and clear the tube
3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to ensure a physician's order, a care plan, a signed consent, and an assessment was obtained prior to the use of side rails for 1 of 7 residents reviewed for accidents. (Resident 95)
Finding includes:
During an observation and interview, on 12/12/24 at 10:07 a.m., Resident 95 was in his room lying in bed with bilateral side rails attached to the bed. He indicated the side rails were on the bed when he moved in, and he believed the side rails were to keep him from rolling out of the bed. The facility did not have him sign a consent for the use of the side rails.
During an observation, on 12/13/24 10:14 a.m., Resident 95 was lying in bed with bilateral side rails attached to the bed.
During an observation, on 12/16/24 at 11:31 a.m., Resident 95 was sitting up on the side of his bed with bilateral side rails attached to the bed.
The clinical record for Resident 95 was reviewed on 12/16/24 at 8:56 a.m. The diagnoses included, but were not limited to, muscle wasting and atrophy, cellulitis of left lower limb, acquired absence of left great toe, and impaired balance.
A physician's order, an informed consent, and an assessment for the use of the side rails were not found in the resident's medical record.
A care plan, dated 11/17/24 and last revised 11/22/24, indicated Resident 95 had a self-care performance deficit. Interventions included, but were not limited to, providing limited assistance with bathing, dressing, toileting, personal hygiene, transfers, and bed mobility.
Resident 95's care plans did not include the current use of the side rails.
During an interview, on 12/16/24 at 2:19 p.m., the Director of Nursing (DON) indicated an assessment, and consent should be completed before side rails are attached to a resident's bed. Resident 95 was placed into a bed which already had the side rails attached and the facility did not obtain the consent and assessment.
A current facility policy, titled Proper Use of Bed Rails, dated 2024 and received by the Executive Director (ED) on 12/17/24 at 12:16 p.m., indicated .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. If bed rails are used, the facility ensures correct installation use and maintenance of the rails .Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars
3.1-45(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services were obtained and maintained timely to support a resident's healthcare needs for 1 of 5 residents reviewed for pain management. (Resident E)
Finding includes:
An Indiana Department of Health intake form indicated Resident E was made to detox from his medications. There was no physician's order to stop the medication, and the resident was discharged from the facility without his Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves) medication.
The clinical record for Resident E was reviewed on 12/17/24 at 9:15 a.m. The diagnoses included, but were not limited to, Multiple Sclerosis, anxiety disorder, and muscle spasms of back.
A Preadmission Screening and Resident Review (PASRR), dated 6/7/24, indicated Resident E would need support from staff to take his medications safely and correctly.
A hospital history and physical, dated 6/13/24, indicated Buprenorphine (an opioid medication used to treat opioid use disorder, acute pain, and chronic pain) was on Resident E's current medication list.
The resident was admitted to the facility from the hospital on 6/14/24.
The hospital discharge orders, dated 6/14/24, indicated to continue to administer Buprenorphine 8 milligram (mg), 0.5 tablet three times a day.
A physician's order, dated 6/17/24, indicated Resident E was to receive Buprenorphine 8 mg, 0.5 tablet three times a day for Multiple Sclerosis.
The Medication Administration Record (MAR) indicated the Buprenorphine 0.5 tablet three times a day was not administered in the afternoon or evening of 6/27/24.
A physician's order, dated 6/28/24, indicated Resident E was to take Buprenorphine 8 mg, 1.5 tablets one time a day.
A physician's order, dated 7/8/24, indicated Resident E was to take Buprenorphine 8 mg and to give 4 mg three times a day.
A nursing progress note, dated 7/9/24, indicated the medication had been held due to the administration instructions had been changed.
A nursing progress note, dated 7/14/24 at 3:40 p.m., indicated the facility was out of the Buprenorphine.
A nursing progress note, dated 7/16/24, indicated Resident E had asked about being out of his medication. The facility contacted the pharmacy and was informed a new prescription was needed before the pharmacy could fill the order.
A nursing progress note, dated 7/17/24, indicated the Nurse Practitioner (NP) 10 agreed to send a new order of Buprenorphine with enough doses to last until 7/31/24. NP 10 was seeing other patients and would not send the order until the evening. The medication would not be available until 7/18/24.
A nursing progress note, dated 7/21/24, indicated the facility received a fax from the pharmacy and the order for the medication needed clarified.
A nursing progress note, dated 7/24/24, indicated the medication was unavailable and could not be administered.
A nursing progress note, dated 7/25/24, indicated Resident E requested to be discharged early. The resident was discharged from the facility on 7/25/24.
The medical record for Resident E indicated the resident missed 19 days of Buprenorphine.
A facility Discharge summary, dated [DATE], indicated medications were sent home with Resident E. The facility was to print and attach a copy of discharge medications to Resident E's discharge packet. A copy of the discharge medication list was not found in the discharge packet provided by the facility for review and no appointment for the pain clinic had been made.
During an interview, on 12/17/24 at 11:47 a.m., the Director of Nursing (DON) indicated she was unaware the medication order of Buprenorphine was to be given for the resident's Multiple Sclerosis.
During an interview, on 12/19/24 at 1:33 p.m., the Executive Director (ED) indicated the facility did not have any further information to submit regarding Resident E's medication or the facility being unable to obtain the medication from the pharmacy.
A current facility policy, titled Pharmacy Services, dated 2024 and received from the DON on 12/19/24 at 8:35 a.m., indicated .It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with the state and federal requirements, and reflect current standards of practice .The process (including documentation, as applicable) of receiving and interpreting prescriber's orders; acquiring, receiving .reconciling .distributing, administering .of all medications .The facility will provide pharmaceutical services to include procedures that ensure accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice .The licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care, medication care, or quality of life .The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements. The pharmacist, in collaboration with the facility and medication director, should include within its services to .Develop mechanisms or communicating, addressing, and resolving issues related to pharmaceutical services .Strive to assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescriber (in accordance with state requirements), including physicians, advanced practice nurses, pharmacists, and physician assistants .The pharmacist, in collaboration with the facility and medical director, may include other aspects of pharmaceutical services such as .Development of procedures and guidance in relation to medication issues
This citation relates to Complaint IN00439869.
3.1-25(a)
3.1-25(g)(1)
3.1-25(g)(2)
3.1-25(g)(3)

Based on observation, interview and record review, the facility failed to ensure compromised controlled substance medications were not stored in the medication cart for 2 of 4 medication carts observed for medication storage. (North cart and South cart)
Findings include:
1. During an observation, on 12/18/24 at 10:45 a.m., the North medication cart had five compromised controlled substance cards.
a. The clinical record for Resident 14 was reviewed on 12/18/24 at 11:35 a.m. The diagnoses included, but were not limited to, insomnia and anxiety disorder
A card of quviviq (for insomnia) 25 milligram (mg) tablet for Resident 14 had clear tape covering the back of the number 6 slot.
b. The clinical record for Resident 42 was reviewed on 12/18/24 at 11:40 a.m. The diagnoses included, but were not limited to, pain and anxiety.
A card of oxycodone (for pain) 10 mg tablet for Resident 42 had a slit on the back of the card in the number 22 slot.
A card of alprazolam (for anxiety) 1 mg tablet for Resident 42 had a slit on the back of the card in the number 23 slot.
c. The clinical record for Resident 51 was reviewed on 12/18/24 at 11:47 a.m. The diagnoses included, but were not limited to, pain.
A card of Norco (for pain) 10-325 mg tablet had a slit on the back of the card in the number 8 slot.
d. The clinical record for Resident 23 was reviewed on 12/18/24 at 11:55 a.m. The diagnoses included, but were not limited to, pain.
A card of tramadol (for pain) 50 mg tablet had a slit on the back of the card in the number 30 slot.
During an interview, on 12/18/24 at 12:00 p.m., LPN 13 indicated there should not be tape or slits on the back of the cards. She did not look at the back of the cards when counting the narcotics.
2. During an observation, on 12/18/24 at 12:15 p.m., the South medication cart had one compromised controlled substance card.
The clinical record for Resident 75 was reviewed on 12/18/24 at 12:35 p.m. The diagnoses included, but were not limited to, insomnia and anxiety disorder
A card of Clonazepam (for anxiety) 0.5 mg had a slit on the back of the card in the number 29 slot.
During an interview, on 12/18/24 at 12:00 p.m., Licensed Practical Nurse (LPN) 12 indicated the pills should not be taped or opened on the back of the cards. The pills should be destroyed by two nurses.
During an interview, on 12/18/24 at 12:30 p.m., the Director of Nursing (DON) indicated the staff should not tape the backs of the narcotics cards. The pills needed to be destroyed.
A current policy, titled Controlled Substance Administration & Accountability, dated 2024 and received from the DON on 12/19/24 at 9:43 a.m., indicated .Obtaining/Removing/Destroying Medication .The entire amount of controlled substances obtained or dispensed is accounted for. Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Control Drug Record, or via the automated dispensing system
3.1-25(n)
3.1-25(o)

Based on interview and record review, the facility failed to ensure staff were being supervised when a staff member physically kicked a resident in his back for 1 of 3 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 10/15/2023, prior to the start of the survey, and was therefore past noncompliance.
Finding includes:
An incident report to the Indiana Department of Health indicated a staff member struck Resident B in the back while he was standing next to the medication cart in the facility. The resident complained of back pain, on 10/3/2023, after the kick to his back. The resident was sent to the hospital for evaluation per physician's order, on 10/3/2023. The staff member was suspended when the hospital staff indicated the resident alleged abuse by the staff member. Family was notified and the investigation continued. The resident returned to the facility with no new orders from the hospital and was not admitted to the hospital. The local police department was notified of the abuse allegation.
The record for Resident B was reviewed on 10/25/2023 at 10:31 a.m. Diagnoses included, but were not limited to, discitis (an infection of the intervertebral disc space) of the lumbosacral region, osteomyelitis (inflammation of the bone) of the vertebra and lumbar region, electrocution, chronic pain, and acquired absence of the left and right upper limbs.
An emergency room (ER) report from the hospital, dated 10/3/2023, indicated no acute fracture or traumatic subluxation was identified. Vertebral body heights were preserved. Sacral joints were congruent. The impression was no evidence of acute fracture or traumatic subluxation of the lumbar. The police were notified and spoke with the resident. The resident spoke with the facility, and he returned to the facility with no new orders.
In a facility investigation note, dated 10/3/2023, Staff Member 3 indicated the resident came to her around 8:00 p.m., and indicated Staff Member 2 ran up to him jokingly and kicked him in the back while he was at the medication cart earlier in the day. He did not report it until now because Staff Member 2 asked him not to report the incident. The resident said he had called his lawyer and his lawyer wanted him to have an x-ray. Staff Member 3 notified the Director of Nursing (DON) and began an investigation.
In a facility investigation note, dated 10/3/2023, Staff Member 2 indicated she did jokingly kick the resident in his back, on 10/3/2023 at 5:00 p.m., while he was standing near the nurses medication cart on the south hall. She meant to kick the medication cart but missed and kicked the resident instead. She indicated the resident was in some pain but was not eligible for pain medication for another hour. The resident was okay with the incident and knew it was not intentional and she was just playing around. She did not report the incident.
In a facility investigation note, dated 10/4/2023, Staff Member 4 indicated she was at the nursing medication cart with the resident at 5:00 p.m., on 10/3/2023, when Staff Member 2 came walking by and playfully kicked her foot up and her foot made contact with the residents lower back area. The resident was not upset nor in pain. The resident signed himself out of the facility to go and play with his dog outside. Later in the evening, around 7:30 p.m., the resident complained of pain in the lower back area. The area was red, no bleeding was noted, and medication was given to the resident for pain. The staff member did not report the incident.
A facility investigation note, dated 10/3/2023 at 11:25 p.m., indicated during an interview with the Executive Director (ED) and the resident, the resident indicated he did feel the staff member intended to kick him but not to cause him any harm. It was a lack of professionalism from Staff Member 2. She was just playing around and made a bone head move. He was not afraid of Staff Member 2 and was not afraid to be at the facility.
A facility investigation note, dated 10/3/2023 at 11:30 p.m., indicated during an interview with the DON and the resident while the resident was in the hospital ER, the resident indicated he felt a jolt on his back while he was standing at the medication cart. The resident indicated he was kicked by Staff Member 2 with her boot to his back. The resident indicated it could have been unintentional. The resident indicated he was not afraid of Staff Member 2. She meant him no harm. The x-rays of his back were okay, and the police had been notified. He felt safe to return to the facility.
A facility investigation note, dated 10/4/2023 at 8:30 a.m., indicated during an interview with the ED and the resident, the resident indicated he did not want to talk without his lawyer present. The resident did indicate he and Staff Member 2 were friends and he felt bad he got her into trouble. He indicated he felt safe at the facility and wanted to stay until he was discharged .
A staff member notification, dated 10/3/2023, indicated Staff Member 2 was suspended pending investigation of an alleged abuse allegation. Staff member 2 made contact with a resident's back potentially causing injury and did not report the unusual occurrence immediately.
A staff member notification, dated 10/5/2023, indicated Staff Member 2 was terminated. Staff Member 2 made contact with a resident's back potentially causing injury and did not report the unusual occurrence immediately.
A staff member notification, dated 10/4/2023, indicated Staff Member 4 was given disciplinary action for not reporting an unusual occurrence which involved a violation of safety rules.
During an interview, on 10/25/2023 at 1:19 p.m., the ED indicated Staff Member 2 kicked Resident B in his back. Resident B was sent to the ER for evaluation after complaining of pain 3 hours after the incident occurred. His x-rays were negative for trauma or a fracture. Staff Member 2 was suspended immediately and then terminated after the investigation. Staff Member 4 received disciplinary action for not immediately starting an investigation when the incident occurred.
During an interview, on 10/25/2023 at 2:47 p.m., the DON indicated she was not notified of the abuse allegation until 3 hours after the incident occurred. The staff thought Staff Member 2 was horseplaying with the resident and he had no pain nor was upset about the incident. The resident complained of pain and requested an x-ray of his back which was when they notified her of the incident.
The deficient practice was corrected, by 10/15/23, after the facility implemented a systemic plan that included the following actions: The facility investigated the incident involving Resident B and the abuse allegation, terminated Staff Member 2, educated the staff on abuse, residents rights and professionalism and the facility began audits on residents which included skin assessments and interviews.
This Federal tag relates to Complaint IN00418925.
3.1-45(a)(2)

2. The record for Resident J was reviewed on 9/27/23 at 4:19 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, anxiety disorder, cognitive communication deficit, insomnia, anxiety, dementia in other diseases, and psychosis related to dementia and depression.
A physician's order, dated 8/23/23, indicated Risperdal (a medication for schizophrenia) 0.5 mg daily for psychosis with dementia.
An IDT (interdisciplinary team) note, dated 3/1/23 at 5:55p.m., indicated a new order for Risperdal 0.25 mg (milligrams) was given by the psychiatric nurse practitioner. The resident's husband and hospice were made aware of the new order. The resident would be observed routinely for signs and symptoms of side effects to the medication. AIMs (Abnormal Involuntary Movement scale) assessment completed and would be completed routinely while taking antipsychotic medication.
An IDT note, dated 3/29/23 at 2:44 p.m., indicated a new order was given by the psychiatric nurse practitioner to increase the dosage of Risperdal to 0.5 mg at bedtime. Hospice and the resident's husband made aware of the new order.
The IDT notes did not include documentation on education provided to the husband regarding the antipsychotic medications, risks/benefits, or medication side effects.
A care plan, dated 2/11/22, indicated a potential for drug related complications associated with the use of psychotropic medications related to anti-anxiety, anti-depressant, and anti-psychotic medications. Interventions included, but were not limited to, observe for side effects of antipsychotic medication, and report them to the physician: sedation (sleepiness), drowsiness, dry mouth, constipation, blurred vision, extra pyramidal symptoms (muscle dysfunction), weight gain, edema (swelling), postural hypotension (low blood pressure), sweating, loss of appetite, and urinary retention.
During an interview, on 10/3/23 at 11:00 a.m., the DNS indicated she did not have documentation of education for the husband regarding the use of the Risperdal, side effects, or the risks and benefits of the medication.
A current publication, titled Mobile PDR (physician's desk reference), indicated .Abilify [aripiprazole] is an antipsychotic .used in adults for schizophrenia, bipolar 1 disorder and as an adjunct for major depression . antipsychotics are not a recommended treatment of dementia-related psychosis in geriatric adults and the use of Abilify should be avoided if possible due to an increase in morbidity and mortality in elderly adults with dementia receiving antipsychotics .deaths have typically resulted from heart failure, sudden death or infections (primarily pneumonia) .an increased incidence of cerebrovascular adverse events, including fatal events, has been reported
A current publication, titled Mobile PDR (physician's desk reference), indicated .Risperdal (risperidone) is an antipsychotic .used for schizophrenia and bipolar disorder in adults .antipsychotics are not a recommended treatment of dementia-related psychosis in geriatric adults and the use of risperidone should be avoided if possible due to an increase in morbidity and mortality in elderly adults with dementia receiving antipsychotics .deaths have typically resulted from heart failure, sudden death or infections (primarily pneumonia) .an increased incidence of cerebrovascular adverse events, including fatal events, has been reported
A current policy, titled Use of Psychotropic Medication, not dated and received from the DNS on 10/3/23 at 1:00 p.m., indicated .the indications for initiating, withdrawing or withholding medications as well as the use of non-pharmacological approaches will be determined by: assessing the residents underlying condition, current signs, symptoms expressions, and preferences and goals for treatment .identification of underlying causes (when possible) .the attending physician will assume leadership in medication management by developing, monitoring, and modifying medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team .the indications for use of any psychotropic drug will be documented in the medical record .residents who use psychotropic drugs shall receive a gradual dose reduction, unless clinically contraindicated, in an effort to discontinue these drugs .the effects of psychotropic medications on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis, such as: upon physician evaluation (routine and as needed), during the pharmacist's monthly medication regimen review, during MDS (minimum data set) review (quarterly, annually, significant change), and in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturers specifications, and the resident's comprehensive plan of care .the residents response to the medication(s), including progress towards goals and presence/ absence of adverse consequences, shall be documented in the resident's medical record .the facility shall identify the medication for use, as possible, using pre-admission screening and other pre-admission data .the physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission
3.1-48(a)(6)
3.1-48(b)(2)
Based on observation, interview and record review, the facility failed to ensure residents and resident's representatives were informed of the risks of antipsychotic medications and a gradual dose reduction was considered for 2 of 5 residents reviewed for unnecessary medications. (Resident 73 and J)
Findings include:
1. During an observation, on 9/27/23 at 12:00 p.m., Resident 73 was in her room with staff assisting her to eat lunch and the resident was making some grunting sounds.
During an observation, on 9/28/23 at 3:07 p.m., the resident responded yes to the knock on her door.
During an observation, on 9/29/23 at 3:25 p.m., the resident was in the shower room with staff and making repetitive sounds.
The record for Resident 73 was reviewed on 9/28/23 at 1:23 p.m. Diagnoses included, but were not limited to, traumatic subdural (between the skull and the brain) hemorrhage, dementia with other behavioral disturbance, aphasia (difficulty speaking), senile degeneration of the brain, anxiety disorder, major depressive disorder, and repeated falls.
a. A care plan, dated 12/19/22, indicated the resident was at a risk for adverse effects related to psychotropic drug use. The interventions included, but were not limited to, observe for side effects and report to the physician, a pharmacist review of the medications as needed, provide medication as ordered by the physician, and evaluate for effectiveness and to refer to mental health services for medication and behavior intervention recommendations.
A care plan, dated 4/11/23, indicated the resident occasionally had disruptive behaviors during activities such as yelling out which was related to the diagnosis of dementia. The interventions included, but were not limited to, the resident didn't like to sit still for long so please bring to activities just before the program begins, provide shorter duration activities, call the resident's name or gently touch her arm to help maintain awareness of the activity, offer soothing activities and understand if the resident wants to stay in her room.
A physician's order, dated 12/9/22, indicated to give aripiprazole (an antipsychotic medication) 2 milligram (mg) one time a day related to severe dementia with behavioral disturbance.
A care plan meeting minutes, dated 12/9/22, indicated the team members in attendance included nursing and the resident's family member. The areas discussed included, discharge plans, advanced directives, acute medical conditions, chronic medical conditions, skin/wound conditions, nutrition/hydration, cognition, bowel/bladder, rehabilitation services, physical function, and behavior health activities.
The care plan meeting minutes did not include anything about medications, medications side effects, or medication risks and benefits.
During an interview, on 10/2/23 at 2:13 p.m., the Director of Nursing Services (DNS) indicated the facility talked about the resident's medications during the care plan meeting although they did not have any specifics about what was discussed listed in the care plan meeting minutes. The facility did not have any documentation of a review of the medication risks and benefits.
b. A Treatment Administration Record (TAR), for the month of March 2023, with behavior monitoring for psychosis/delusions, agitation and repetitive calling out, indicated the resident had none of those behaviors for the month.
A TAR, for the month of April 2023, with behavior monitoring for psychosis/delusions, agitation and repetitive calling out, indicated the resident had one behavior on April 7 for the day shift. The resident remained the same after the interventions of fluids, food, redirection, and one to one.
The TAR did not indicate which one of the listed behaviors occurred.
A pharmacy physician recommendation, dated 4/3/23, indicated the resident had a current order for aripiprazole 2 mg daily for dementia with behaviors since 12/22. Please consider discontinuing.
The physician/prescriber response, dated 4/14/23, indicated the gradual dose reduction (GDR) was contraindicated due to the resident continued to exhibit behaviors and the behaviors were expected to worsen with a change of medication.
The physician/prescribed response did not include the type of behaviors exhibited by the resident.
A progress note, dated 6/2/23 at 12:23 p.m., indicated the resident was being assisted with lunch. The resident often had behaviors of yelling out related to the diagnosis of dementia and difficulty making herself understood. The resident's behavior was not distressing to herself or to others. The resident was generally easily redirected. The resident's care plan reflected she would yell at at times.
During an interview, on 10/3/23 at 10:05 a.m., CNA 3 indicated the resident would repeat words, really didn't have any behaviors, and did not try to hurt herself or anyone else. Sometimes she would try to get out of bed by herself.
During an interview, on 10/3/23 at 11:29 a.m., the DNS indicated the resident's behaviors included some calling out and some refusals of care. The resident's daughter in law had indicated the resident was rude and blunt. The DNS was not able to report any psychosis, delusions, or distressing resident behaviors.

Based on observation, interview and record review, the facility failed to ensure a resident who requested dental services had the paperwork completed and was scheduled for the dentist for 1 of 2 residents reviewed for dental. (Resident H)
Finding includes:
During an observation, on 9/26/23 at 2:23 p.m., Resident H was watching television in her room. She had some missing bottom teeth and no top teeth. Her front bottom teeth were noted to have some yellowish substance from the gums extending up to the teeth.
The record for Resident H was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, unspecified dementia, chronic obstructive pulmonary disease, cerebral infarction, hemiplegia (paralysis of one side of the body) affecting the right dominant side, dysphagia (difficulty swallowing), and osteoarthritis.
A physician's order, dated 4/27/23, indicated the resident may see the podiatrist, dentist, audiologist, ophthalmologist, and optometrist.
An application for limited benefit in-facility dental policy was signed by the resident's responsible party on 4/27/23 to consent to the facility dental services.
A care plan, dated 4/27/23, indicated the resident was at a risk for dental problems related to full upper dentures, partial bottom dentures, and being dependent for oral care. The resident did not want to wear the dentures. The interventions included, but were not limited to, assist with oral care as needed and to observe and notify the physician of any changes in dental status.
A care plan, dated 6/30/23, indicated the resident would have the following ancillary services made available to her including dental, optical, podiatry, and audiology. The goal included the resident would have the desired ancillary services through the next review on 8/4/23. The interventions included, but were not limited to, the resident had elected to have dental, optical, audiology, and behavioral health services.
During an interview, on 10/2/23 at 2:19 p.m., the Director of Nursing Services (DNS) indicated she did not take care of scheduling and putting residents on the dental list. She did not know the reason Resident H had not been seen by the dentist yet.
A dental schedule, for 10/18/23, did not include Resident H as being scheduled for dental services.
A progress note, dated 10/2/23 at 3:11 p.m., indicated the resident's Designated Power of Attorney (DPOA) was called and informed of paperwork which needed signed for the resident to be seen for dental care.
During an interview, on 10/3/23 at 10:56 a.m., the Social Services Director indicated it would take 3 to 4 days for a dental referral to be sent and then it would take one (1) month to three (3) months before the resident would be seen for dental services. The SSD did not know the reason Resident H's dental visit had been delayed.
During an interview, on 10/3/23 at 11:06 a.m., the Alzheimer's Unit Director indicated the resident needed additional paperwork signed before she could be put on the dentist's list and she was not aware of the needed paperwork. The SSD just gave her the paperwork yesterday.
A current policy, titled Dental Services, dated 2023 and received from the DNS on 10/3/23 at 1:20 p.m., indicated .It is the policy of this facility to assist in obtaining routine [to the extent covered under the State plan] and emergency dental care .'Routine dental services' means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings [new and repairs] minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures .The dental needs of each resident are identified through the physical assessment .and are addressed in each resident's plan of care .Residents and /or resident representatives, during the admission process, are notified of dental services available under the State plan .The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location .All actions and information regarding dental services, including any delays related to obtaining dental services will be documented in the resident's medical record
3.1-24(a)(1)

Based on observation, interview and record review, the facility failed to ensure staff sanitized their hands during dining service, staff used gloves to touch medications and a resident's Foley (indwelling urinary) catheter was off the floor for 1 of 2 dining rooms observed, 1 of 7 residents observed for medication administration and 1 of 1 resident reviewed for urinary catheters. (Activity Staff 2, Resident M, and Resident 35)
Findings include:
1. During a dining observation of the memory care unit, on 9/27/23 at 11: 48 a.m., Activity Staff 2 was observed to assist a resident to cut up the food on her plate and spread her napkin out. Activity Staff 2 then took a clean tray from the food cart and walked into another resident room to assist her to set up her tray. Then Activity Staff 2 picked up the dirty tray from outside the memory care isolation room and put the dirty tray on the dining table which had drinks with some type of red liquid. The drinks had not been used yet. There were also unused condiment packets and a coffee carafe for serving on the same table. Activity Staff 2 did not sanitize her hands after touching any of the trays including the dirty tray from the isolation room.
During an interview, on 9/27/23 at 12:10 p.m., the Executive Director (ED) indicated she would do an in-service on the use of hand sanitizer with the staff.
2. During an observation, on 9/26/23 at 2:38 p.m., Resident M was lying in bed with the catheter bag on the floor. The Social Service Director (SSD) went into the resident's room, hooked the catheter bag on the wheelchair, and indicated the catheter bag should not be on the floor.
The record for Resident M was reviewed on 9/27/23 at 4:57 p.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder (the nerves and muscles do not work well together in the bladder), presence of urogenital implants (way to help treat stress incontinence caused by a weak sphincter) and urinary tract infection.
A care plan, dated 11/3/22, indicated the resident had alterations in elimination of bowel and bladder, indwelling urinary catheter. Interventions included, but were not limited to, keep the drainage bag of the catheter below the level of the bladder and off the floor.
During an interview, on 9/26/23 at 2:38 p.m., the Social Service Director indicated the catheter bag should not be on the floor.
During an interview, on 10/2/23 at 9:23 a.m., the Executive Director (ED) was aware the catheter bag on the floor.
3. During an ongoing observation of medication administration, on 9/27/23 starting at 9:57 a.m., LPN 8 did not sanitize her hands. The nurse took a pill out of the package using her bare hands and placed the pill in a medication cup for Resident 35.
The record for Resident 35 was reviewed on 9/27/23 at 2:57 p.m. Diagnoses included, but were not limited to, congestive heart failure, hypertension, and diabetes mellitus.
During an interview, on 9/27/23 at 10:07 a.m., LPN 8 indicated she should have sanitized her hands and not touched the pill with her bare hands.
During an interview, on 9/27/23 at 11:17 a.m., the Director of Nursing Services (DNS) indicated pills should not be touched with bare hands.
A current policy, titled Hand Hygiene, dated 2023 and received from the DNS on 10/3/23 at 1:20 p.m., indicated .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of proactive
A current policy, titled Medication Administration, dated 2023 and received from the DNS on 10/2/23 at 1:20 p.m., indicated .Wash hands prior to administering medication per facility protocol and products
3.1-18(b)(1)
3.1-18(l)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were dressed in regular clothing like other residents unless their preferences were identified for alternative clothing for 1 of 1 resident reviewed for dignity. (Resident 75)
Finding includes:
During an observation, on 9/28/23 at 1:15 p.m., Resident 75 was in her room, sitting in her wheelchair. She was wearing a hospital gown and had a blanket covering her legs.
During an observation, on 9/28/23 at 3:44 p.m., the resident was in a wheelchair propelling herself in the hallway and common area wearing a hospital gown. The other residents in the facility were observed wearing regular clothing.
The record for Resident 75 was reviewed on 9/27/23 at 4:39 p.m. Diagnoses included, but were not limited to, fracture of the right femur (thigh bone), chronic obstructive pulmonary disease, and post-traumatic stress disorder.
A resident personal belongings inventory sheet, dated 9/13/23 and signed by the resident, indicated one black sleeveless top, one brownish colored pair of slippers, one white [NAME] sweater, one pair of black biker shorts, two brushes, one black cell phone, one charger and extra black box, two (2) word search books, and one coloring book.
A care plan for wearing a hospital gown in the hallway and common areas was not located.
During an interview, on 9/29/23 at 3:11 p.m., the resident indicated she preferred to wear her clothes and did not like to wear a gown in the halls. The resident was admitted with one pair of yellow pants, one red shirt, and a pair of white socks. There were no clothes in her room and the staff told her they were down in the laundry being washed. She indicated they had not washed her clothes since she had been there.
During an interview, on 9/29/23 at 3:13 p.m., the Executive Director (ED) and the Director of Nursing (DNS) indicated last Friday they had a conversation with the resident about calling her loved one to bring clothes in. They both indicated her family brought clothes into her. On 9/28/23, there was a late note put in, for 9/27/23, indicating the resident's clothes were being labeled and in the laundry.
During an interview, on 9/29/23 at 3:20 p.m., the ED and DNS asked the resident if she remembered talking to them. The ED and DNS asked if they could get clothes for her. The DNS and ED asked the resident if she called her loved one to bring her clothes as was mentioned in their conversation.
During an interview, on 9/29/23 at 3:21 p.m., the resident indicated she remembered talking to them. The resident did not call her loved one to bring in the clothes and her boyfriend never brought her clothes. The resident indicated she wanted to wear something other than a hospital gown.
During an interview, on 9/29/23 at 3:35 p.m., the resident indicated she only had the outfit she was admitted to the facility. She came with one pair of yellow pants, one red shirt, and one pair of white socks. Her boyfriend did not bring her clothes. She was wearing a Colts short sleeved shirt, a white pair of pants, and a pair of short white socks given to her by staff.
During an interview, 9/29/23 at 3:09 p.m., the Clinical Support Nurse indicated there was no care plan or documentation to indicate the resident's preference was to wear a hospital gown.
A current policy, titled Resident Rights, not dated and received from the ED at the entrance conference, indicated .The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility
3.1-3(t)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify residents' family representatives prior to staff spending the residents' personal funds for 4 of 4 residents reviewed for protection of resident funds. (Residents B, E, F and D)
Findings include:
A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents.
1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, cognitive communication disorder, and depressive disorder.
During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager (BOM) indicated the Social Service Director (SSD) and Unit Manager 10 were able to shop for the residents. They would go to the BOM and request money. They would ask for $1,000.00 or more to shop for the residents' personal items. The families were not notified of the funds being removed from the personal accounts.
2. The record for Resident E was reviewed on 9/27/23 at 3:59 p.m. Diagnoses included, but were not limited to, dementia, anxiety disorder, and depressive disorder.
During an interview, on 10/02/23 at 9:09 a.m., the Executive Director (ED) indicated the families were not notified of the money taken out of the resident's funds.
3. The record for Resident F was reviewed on 9/27/23 at 4:0 p.m. Diagnoses included, but were not limited to, dementia with agitation, anxiety disorder, and delusional disorders.
An email, dated 8/2/22 at 2:52 p.m., indicated the family representative asked to be informed of all purchases made on the resident's behalf.
During an interview, on 9/28/23 at 11:49 a.m., the BOM indicated the former Activity Director was the one mainly shopping for the resident. Unit Manager 10 would shop for the residents on the dementia unit. The staff would request money for the residents. They would provide receipts and bring in the purchased item.
4. During an interview, on 9/27/23 at 4:07 p.m., Resident D's family member indicated the BOM gave permission to Unit Manager 10 to use the resident's money to buy clothes for the resident. The facility did not get her consent to spend the money. Unit Manager 10 had spent some of the money for herself.
The record for Resident D was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, dementia, generalized anxiety disorder, down syndrome, and a communication deficit.
During an interview, on 10/2/23 at 9:09 a.m., the ED indicated Unit Manager 10 only admitted to using 360 dollars of [NAME] cash and she was aware there was a lot more than Unit Manager 10 admitted to. The Power of Attorney (POA) was not notified prior to shopping.
A current policy, titled Resident Personal Funds, dated 2023 and received from the ED on 9/28/23 at 10:56 a.m., indicated .The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds .The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's person funds entrusted to the facility on the resident's behalf .The individual financial record must be available to the resident through quarterly statements and upon request
This Federal Tag relates to Complaint IN00418241.
3.1-6(e)

Based on interview and record review, the facility failed to notify the physician of a blood glucose level greater than the physician's call orders for 1 of 1 resident reviewed for notification. (Resident B)
Finding includes:
The record for Resident B was reviewed on 9/27/23 at 5:02 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dependence on renal dialysis.
A care plan, dated 11/27/20, indicated the resident was at risk for alteration in blood glucose due to diabetes mellitus. The interventions included, but were not limited to, give insulin per order, report abnormal results per parameters/guidelines.
A physician's order, dated 9/17/22, indicated to give Lispro (insulin for blood glucose levels) solution 100 unit/ml(milliliter). Inject the insulin as per sliding scale if the blood glucose levels were as follows:
a. 150-200 = 1 units.
b. 201-250 = 2 units.
c. 251-300 = 3 units.
d. 301-350 = 4 units.
e. 351-400 = 5 units. Call the physician if the blood glucose levels were less than 70 or more than 400.
A facility vital sign document indicated the following blood glucose levels:
a. The blood glucose level, on 4/10/23, was 446. The physician was not notified.
b. The blood glucose level, on 4/14/23, was 475. The physician was not notified.
c. The blood glucose level, on 4/21/23, was 423. The physician was not notified.
d. The blood glucose level, on 9/24/23, was 447. The physician was notified 3 days later, on 9/29/23.
There was no documentation to indicate the physician was notified of the blood glucose levels out of the call parameter.
During an interview, on 10/3/23 at 11:16 a.m., the Nurse Manager indicated if a blood glucose level was out of range, they would call their endocrinologist. The nurses would sometimes take a second blood glucose level when they received a high reading. It was preferred, the nurses not chart a high blood glucose level until they have tested it twice. The facility policy indicated when a resident had a blood glucose level out of the physician's call orders, the nurse should call the physician if it was out of the range.
During an interview, on 10/3/23 at 4:14 p.m., the Director Nursing Services (DNS) indicated the facility did not contact the physician with the blood glucose levels above 400.
A current policy, titled Blood Glucose Monitoring, revised 2022 and received from the Director of Nursing on 10/3/23 at 9:00 a.m., indicated .The facility will perform blood glucose monitoring as per physician's orders .Verify the physician's orders .Report critical test results to physician timely .Document the procedure
3.1-5(a)(2)
3.1-5(a)(3)

Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C)
Finding includes:
During an interview, on 9/26/23 at 10:07 a.m., Resident C indicated someone had sworn at her and was unsure of who or when.
The record for Resident C was reviewed on 9/28/23 at 11:53 a.m. Diagnoses included, but were not limited to, major depressive disorder, heart failure, and vascular dementia.
The facility did an investigation on 7/12/23. The investigation included:
a. During an interview, on 7/12/23, CNA 4 indicated he was asked for help by 2 other CNAs to assist with care for Resident C.
b. During an interview, on 7/12/23, CNA 5 indicated she and CNA 6 got the help of CNA 4 to help provide care for Resident C. She indicated the resident was resistant to care and she heard CNA 4 say shut your old a** up. The roommate was not in the room.
c. During an interview, on 7/12/23, CNA 6 indicated she asked CNA 4 to help provide care to Resident C. She indicated while providing care she heard CNA 4 say yeah you know what time it is, come on, get your old a** up.
The facility investigation indicated they did not substantiate the allegation. During the investigation, the facility identified customer service issues with CNA 4 and made the decision to no longer employ him.
During an interview, on 9/29/23 at 3:44 p.m., CNA 5 indicated CNA 4 said shut your old a** up to the resident.
During an interview, on 9/29/23 at 3:44 p.m., CNA 6 indicated CNA 4 said yeah you know what time it is, come on, get your old a** up to the resident.
During an interview, on 10/2/23 at 11:35 a.m., the Clinical Support Nurse indicated she did not deny the incident happened, but the facility did abuse training and an investigation so what else could the facility have done.
During an interview, on 10/03/23 at 12:45 p.m., the DNS (Director of Nursing Services) indicated the resident used to work in a factory and was a truck driver, so she was used to foul language. What seemed like inappropriate language to one person might not be inappropriate language to the resident. She was not sure if the resident was care planned for being ok with inappropriate language.
A current care plan, dated 3/13/23, indicated to allow for a calm and unhurried environment and to encourage communication.
The resident did not have a care plan for being ok with the use of inappropriate language.
A current policy, titled Abuse, Neglect and Exploitation, dated 2023 and received upon entrance from the Executive Director indicated .Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability
3.1-27(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an interview, on 9/27/23 at 4:07 p.m., Resident D's family member indicated the BOM gave permission for Unit Manager 10 to use the resident's money to buy clothes for the resident. The facility did not get her consent to spend the money. Unit Manager 10 had spent some of the money for herself.
The record for Resident D was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, dementia, generalized anxiety disorder, down syndrome, and a communication deficit.
An investigation report, dated 9/25/23, indicated Unit Manager 10 made the following purchase, on 8/8/22 at 7:12 p.m.:
a. The receipt total was $1,122.32.
b. Unit Manager 10's charge card ending in 4201 was charged $300.
c. The rest of the bill was paid with the resident's funds totaling $900 in cash. $77.68 was issued in change.
d. A total of $200 in Kohl's cash was issued.
The $200 [NAME] cash was not returned to the resident.
An investigation report, dated 9/25/23, indicated Unit Manager 10 made a purchase which used $900 from the resident's funds. $160 in Kohl's cash was issued.
The $160 in Kohl's cash was not returned to the resident.
During an interview, on 10/2/23 at 9:09 a.m., the ED indicated Unit Manager 10 only admitted to using $360 of [NAME] cash and she was aware there was a lot more than Unit Manager 10 admitted to. The Power of Attorney (POA) was not notified prior to shopping.
During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager indicated the former Activity Director was the one mainly shopping for the residents. Unit Manager 10 would shop for the residents on the dementia unit. The staff would request money for the residents. They would provide receipts and bring in the purchased items. They would ask for 1000's of dollars before. The families were not called to notify them of the funds being removed from the resident's account.
A current policy, titled Abuse, Neglect and Exploitation, dated 2023 and received from the ED on 9/29/23 at 4:46 p.m., indicated .by developing and implementing written policies and procedures that prohibit an prevent abuse, neglect, exploitation and misappropriation of resident property .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent
This Federal Tag relates to Complaint IN00418241.
3.1-28(a)
Based on interview and record review, the facility failed to ensure residents' personal property was not used by staff for 4 of 4 residents reviewed for misappropriation of property. (Residents B, E, F and D)
Findings include:
A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents.
1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, cognitive communication disorder, and depressive disorder.
A Withdrawal Transaction Report for a Kohl's receipt, dated 10/8/22, indicated Unit Manager 10 was using her personal account and receiving Kohl's cash and Kohl's rewards. The amount Unit Manager 10 received was Kohl's cash of $400.00 and Kohl's rewards of $106.73.
During an interview, on 9/29/23 at 3:32 p.m., the Executive Director (ED) indicated she took the Kohl's receipts and verified the receipts with the items in the resident's room. The item on the receipt indicated a bottle of Juicy [NAME] cologne was purchased for $119.00. The items purchased did not get put on the resident's inventory sheet, however the ED indicated the facility took the receipts and matched the items on the receipt with what was in the residents room. The Juicy [NAME] cologne was not verified.
During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager indicated the former Activity Director was the one mainly shopping for the resident. Unit Manager 10 would shop for the residents on the dementia unit. The staff would come to her and request money. The residents had to spend down their money so nothing was really said. They would provide receipts and bring in the purchased items. They would ask for 1000's of dollars before and now anything over $300 must be approved by the ED. The families were not called to notify them of the funds being removed from the resident's account.
2. The record for Resident E was reviewed on 9/27/23 at 3:59 p.m. Diagnoses included, but were not limited to, dementia, anxiety disorder, and depressive disorder.
A Withdrawal Transaction Report for a Kohl's receipt, dated 8/26/23, indicated Unit Manager 10 was using her personal account and receiving Kohl's cash and Kohl's rewards. The amount Unit Manager 10 received was Kohl's cash of $360.00 and Kohl's rewards of $91.88.
3. The record for Resident F was reviewed on 9/27/23 at 4:0 p.m. Diagnoses included, but were not limited to, dementia with agitation, anxiety disorder, and delusional disorders.
A Withdrawal Transaction Report for a Kohl's receipt, dated 8/26/23, indicated Unit Manager 10 was using her personal account and receiving Kohl's cash and Kohl's rewards. The amount Unit Manager 10 received was Kohl's cash of $400.00 and Kohl's rewards of $11.68.

Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was implemented to address a resident's preferences for 1 of 1 resident reviewed for dignity. (Resident 75)
Finding includes:
During an observation, on 9/28/23 at 3:44 p.m., Resident 75 was in a wheelchair in the common area wearing a hospital gown.
The record for Resident 75 was reviewed on 9/27/23 at 4:39 p.m. Diagnoses included, but were not limited to, fracture of the right femur (thigh bone), chronic obstructive pulmonary disease, and post-traumatic stress disorder.
A care plan for wearing a hospital gown in the common areas was not located.
During an interview, on 9/29/23 at 3:11 p.m., the resident indicated she preferred to wear her own clothes and did not like to wear a gown in the halls. The resident was admitted with one pair of yellow pants, one red shirt, and a pair of white socks. There were no clothes in her room and the staff told her they were down in the laundry being washed. She indicated they had not washed her clothes since she had been there.
During an interview, on 9/29/23 at 3:09 p.m., the Clinical Support Nurse indicated there was no care plan or documentation to indicate the resident's preference was to wear a hospital gown.
A current policy, titled Care Plan Revisions Upon Status Change, dated 2/2023 and received from the Director of Nursing Services on 10/13/22 at 1:20 p.m., indicated .The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .Upon identification of a change in status, the nurse will notify the Minimum Data Set (MDS) Coordinator, the physician, and the resident representative .The care plan will be updated with the new or modified interventions
3.1-31(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure activities were offered daily for 5 of 5 residents reviewed for activities. (Resident 18, 23, 29, 43 and 85)
Findings include:
1. During an interview, on 9/28/23 at 1:34 p.m., Resident 18 indicated there had been a volunteer coming in twice a week for bingo. They had not had an Activity Director for months.
The record for Resident 18 was reviewed on 9/29/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, hypertension, and heart failure.
A care plan, dated 12/24/19, indicated the resident made their activity interests known. Interventions included, but were not limited to, enjoyed attending group functions such as bingo, trivia, and parties/socials at her discretion.
A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 3 activities marked for evening shift.
2. During an interview, on 9/28/23 at 1:35 p.m., Resident 23 indicated she was so bored and depressed because she had nothing to do.
The record for Resident 23 was reviewed on 9/2/23 at 4:16 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, and hypertension.
A care plan, dated 11/17/21, indicated the resident made their activity interests known. Interventions included, but were not limited to, enjoyed attending group functions such as socials, spiritual programs, resident council, bingo/other games, and exercise at her discretion and parties/socials at her discretion.
A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 1activity marked for evening shift.
3. During an interview, on 9/28/23 at 1:37 p.m., Resident 29 indicated all the facility had to do was bingo twice a week.
The record for Resident 29 was reviewed on 10/2/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, bipolar disorder, and schizophrenia.
A care plan, dated 3/27/23, indicated the resident had personal preferences and activities of interest. Interventions included, but were not limited to, it was important for the resident to make her own decisions related to group activities and her level of participation.
A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 2 activities marked for evening shift.
4. During an observation, on 9/29/23 at 9:23 a.m., the resident was lying in her bed. She indicated no activities were offered to her yesterday or today and she was bored.
During an interview, on 9/26/23 at 12:10 p.m., Resident 43 indicated she enjoyed doing activities and had not participated in them for a while. The Activity staff quit and had been gone for a few months. The only activity they had was bingo once or twice a week and a volunteer came in for bingo.
The record for Resident 43 was reviewed on 9/2/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, hypertension, and heart failure.
A care plan, dated 12/24/19, indicated the resident made their activities of interest known. Interventions included, but were not limited to, enjoyed attending group functions such as bingo, trivia, and parties/socials at her discretion.
A documentation survey report, for 8/24/23 to 9/14/23, indicated the resident participated in 3 activities marked for dayshift.
During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager indicated the previous Activity Director was no longer employed and it had been several months since there had been an Activity Director for the skilled side of the building.
During an interview, on 9/29/23 at 8:40 a.m., the Director of Nursing Services (DNS) indicated they hired two different people for activities and they both quit. The old Activities Director quit without notice a few months ago. The facility had a volunteer coming in twice a week for bingo and a lady once a month played a [NAME] during meals. The skilled side did not have activities and the dementia unit did. She could not pull activities from the dementia unit. The dementia unit went to Indiana beach on an outing and the skilled side had not been on any outings.
During an interview, on 9/29/23 at 9:12 a.m., the DNS indicated they offered the residents coloring pages and bingo twice a week.
During an interview, on 10/02/23 at 10:00 a.m., the Executive Director (ED) indicated she was aware activities was an issue.
5. During an observation, on 9/27/23 at 10:52 a.m., Resident 85 was lying in bed in his room.
During an observation, on 9/28/23 at 1:41 p.m., the resident was lying in bed in his room with his eyes closed. The television was on.
During an observation, on 9/29/23 at 12:32 p.m., the resident was lying in bed in his room with his eyes closed. The television was on.
During an observation, on 10/3/23 at 9:59 a.m., the resident was lying in bed with his eyes closed. The room was darkened, the television was not on and there was no reading material on his bedside table, nightstand, or dresser.
The record for Resident 85 was reviewed on 9/29/23 at 3:52 p.m. Diagnoses included, but were not limited to, bipolar disorder with current episode depressed, type 2 diabetes mellitus with diabetic neuropathy, generalized anxiety disorder, weakness, and mild cognitive impairment of an unknown cause.
A care plan, dated 6/26/23, indicated the resident had impaired cognitive function as evidenced by a diagnosis of mild cognitive impairment of an unknown cause. The interventions included, but were not limited to, involve in activities not dependent on the resident's ability to communicate, music, parties, games and involve in enjoyable activities which orient to reality.
An activity assessment, dated 6/17/23, indicated the resident's leisure preferences included reading, television, music, and visiting with family.
An activity report, dated August 2023, indicated the resident had activities on 8/5, 8/6, 8/12, 8/13, 8/19, 8/26 and 8/27/23. This was a total of 7 days out of 31.
An activity report, dated September 2023, indicated the resident had activities on 9/1, 9/2, 9/3, 9/9, 9/10, 9/11, 9/16, 9/17, 9/24 and 9/25. This was 10 days out of 30 days.
During an observation and interview, on 10/3/23 at 10:50 a.m., an anonymous staff indicated the resident did not have any reading material in his room currently. He did like the daily handout provided by the facility although for some reason he did not have one in his room. There was no reading material on his dresser, nightstand or on his bedside table. He would play bingo sometimes.
During an interview, on 10/3/23 at 11:27 a.m., the Director of Nursing Services (DNS) indicated the resident's son was very active and would bring stuff in and out of the resident's room. The resident would go to bingo sometimes.
During an interview, on 10/3/23 at 11:39 a.m., the DNS indicated the facility had not had a full-time staff for activities since June 2023. The Executive Director (ED) indicated they had volunteers twice a week for bingo. There was music entertainment once monthly and therapy animals every 2 weeks.
A current policy, titled Activities, dated 2023 and received from the Medical Record staff on 10/2/23 at 10:00 a.m., indicated .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Activities will encourage both independence and interaction with the community .'Activities' refer to any endeavor, other than routine ADLs [activities of daily living], in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical cognitive, and emotional health. These include, but are not limited to activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence .Each resident's interest and needs will be assessed on a routine basis .Activities will be designed with the intent to .Enhance the resident's sense of well-being, belonging, and usefulness .Create opportunities for each resident to have a meaningful life .Promote or enhance physical activity .Promote or enhance cognition .promote or enhance emotional health .Reflect resident's interests and age .Reflect choices of the resident .Activities will include individual, small and large group activities as well as .Indoor and Outdoor Activities .Activities away from the facility .Religious Programs .Exercise Programs .Community Activities .Social Activities .In-Room Activities .Individualized Activities .Educational Programs
3.1-33(a)
3.1-33(b)(1)
3.1-33(b)(2)
3.1-33(b)(3)
3.1-33(b)(4)
3.1-33(b)(5)
3.1-33(c)

Based on interview and record review, the facility failed to ensure there was communication between the hospice company and the facility for care provided by the hospice staff for 1 of 1 resident reviewed for hospice. (Resident 73)
Findings include:
The record for Resident 73 was reviewed on 9/28/23 at 1:23 p.m. Diagnoses included, but were not limited to, traumatic subdural (between the skull and the brain) hemorrhage, dementia with other behavioral disturbance, aphasia (difficulty speaking), senile degeneration of the brain, anxiety disorder, major depressive disorder, and repeated falls.
A care plan, dated 12/18/22, indicated the resident was on hospice care related to end of life care. The interventions included, but were not limited to, coordinate care with hospice, keep the family informed of changes in condition, and to notify hospice of any changes in condition or medication changes.
A physician's order, dated 3/8/23, indicated hospice.
The hospice binder had a CNA visit listed, on 9/22/23.
The hospice Certified Nursing Assistant (CNA) care plan, dated 7/27/23, indicated the CNA was to complete a shower at each visit, assist to get dressed, comb hair, shampoo hair, complete oral hygiene, and provide nail care.
The hospice care plan did not include the frequency of hospice CNA visits.
During an interview, on 9/28/23 at 3:21 p.m., the Dementia Unit Manager (UM) did not know if the hospice CNA had been at the facility this week for the resident.
During an interview, on 9/29/23 at 3:20 p.m., LPN 12 indicated she would call hospice to find out why the hospice CNA had not been to the facility this week or why there was no documentation of the CNA visit. The hospice supervisor was not sure if the hospice CNA had been to see the resident this week and would find out and call the facility back. The hospice CNA was to visit the resident at the facility twice weekly.
During an interview, on 10/2/23 at 2:13 p.m., the Director of Nursing Services (DNS) indicated the resident admitted to the facility on hospice.
During an interview, on 10/3/23 at 10:05 a.m., CNA 7 indicated the hospice CNA was supposed to be at the facility twice weekly for the resident although the CNA only came once weekly.
A current policy, titled, Hospice Services Facility Agreement, dated 2023 and received from the DNS on 10/3/23 at 1:20 p.m., indicated, .It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility .The Administrator maintains agreements with one or more Medicare-certified hospices .If hospice care is furnished in the facility through an agreement, the facility will .Ensure the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services .Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC [long term care] facility before hospice care is furnished to any resident .The written agreement[s] will set out at least the following .The services hospice will provide .the hospice's responsibilities for determining the appropriate hospice plan of care .The services the facility will continue to provide based on each resident's plan of care .A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day .The facility has a designated [the Assistant Director of Nursing, or specify the member from the interdisciplinary team] to be responsible for working with hospice representatives to coordinate care to the resident provided by the facility and hospice staff .The designated member of the facility working with the hospice representative is responsible for .Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family
3.1-37(a)

Based on interview and record review, the facility failed to provide enough staff to prevent low weekend staffing reported in the third quarter to the Pay-Roll Based Journal (PBJ) staffing report and to provide staff to have activities for the residents on the 100 and 200 halls.
Findings include:
1. A PBJ staffing report, for the third quarter of 2023, indicated the facility had reported low weekend staffing for the months of April, May, and June.
During a resident council meeting, on 9/28/23 at 1:34 p.m., the resident council reported the staff were slow to answer call lights or they would come into the room, turn off the call light, and not come back. The day shift and the evening shift were the worst for getting call lights answered.
During an interview, on 10/3/23 at 12:35 p.m., the Executive Director (ED) indicated she did not start working until July 2023 and was not able to address the low weekend staffing as reported on the PBJ report.
During an interview, on 10/03/23 at 12:57 p.m., the Director of Nursing Services (DNS) indicated the third quarter staffing was excessively low on the weekend. They had several staff quit and leave. The month of April had lots of staff off for spring break. They were working short, one Unit Manager and 10 CNAs (Certified Nursing Assistants) over all the shifts. The facility management staff had worked to cover the CNA shortages. She was not able to show the schedules for the third quarter when management covered the shortages for the CNAs and would provide the schedules on 10/4/23 by email.
The facility had not provided schedules to show how the management staff covered the shortages for the CNAs during the third quarter.
2. During a resident council meeting, on 9/28/23 at 1:34 p.m., the resident council representative indicated the facility had not had activities for months now. There was a volunteer who came in twice a week for bingo. The facility would only allow the volunteer to work two days a week. They indicated it was boring and depressing since there was nothing to do.
During an interview, on 10/3/23 at 11:39 a.m., the DNS indicated the facility had not had full time staff for activities since June 2023. The Executive Director (ED) indicated contracted services were being used and providing activity staff as needed. They also had volunteers twice a week for bingo. There was music entertainment once monthly and therapy animals every 2 weeks.
A current policy, titled Activities, dated 2023 and received from the Medical Record staff on 10/2/23 at 10:00 a.m., indicated .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction with the community
3.1-17(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's contracted fingers/hands were assessed and to provide services for the contractures for 1 of 2 residents reviewed for limited range of motion. (Resident 73)
Finding includes:
During an observation, on 9/29/23 at 12:18 p.m., Resident 73 was sitting up in bed, with a food tray in front of her and was eating using her hands. The resident's fingers were all pointed to the palms of her hands.
The record for Resident 73 was reviewed on 9/28/23 at 1:23 p.m. Diagnoses included, but were not limited to, traumatic subdural (between the skull and the brain) hemorrhage, dementia with other behavioral disturbance, aphasia (difficulty speaking), senile degeneration of the brain, anxiety disorder, major depressive disorder, and repeated falls.
A care plan, dated 12/20/22, indicated the resident had difficulty chewing related to her diagnosis of dementia. The resident used assistive devices to aid in feeding herself and still needed staff assistance. The interventions included, but were not limited to, use a divided plate as ordered, monitor meal consumption, and to provide assistance at meals.
The care plan did not include anything about finger/hand contractures.
A wound care progress note, dated 4/11/23, indicated the resident had moisture and odor noted on the palmar surface of her bilateral hands related to contractures. The resident had generalized dry, thin, and fragile skin. The plan included, the resident's fingernails needed trimmed and to ensure the hands were dried completely to prevent yeast and skin breakdown.
The wound note did not include if the contractures were new or had been there previously.
A Minimum Data Set (MDS) assessment, dated 7/6/23, indicated the resident had no impairment in functional limitation with her hands.
During an observation, on 10/2/23 at 12:21 p.m., with the Clinical Support Nurse, the resident was sitting up in a Broda chair (chair for positioning). The resident's fingers were contracted towards the palms of her hand.
During an interview, on 10/2/23 at 12:22 p.m., the Dementia Unit Manager indicated the resident could only barely open her hands and could grasp some items.
During an interview, on 10/2/23 at 12:23 p.m., CNA 7 indicated the resident could only partially open her fingers and most of the time her fingers were closed towards the palms of her hands.
During an interview, on 10/2/23 at 2:13 p.m., the Director of Nursing Services (DNS) indicated the resident did not have a previous therapy evaluation of her hands since she was on hospice.
During an interview, on 10/2/23 at 2:28 p.m., Occupational Therapist (OT) 11 indicated today was the first therapy screening for the resident. She was asked to look at the resident's hands. The resident had trouble opening her hands. Both hands had contractures. All the resident's fingers except her thumbs had contractures. She was not able to determine the cause of the contractures. The resident's wrists had limited range of motion although no contracture.
During an interview, on 10/2/23 at 2:42 p.m., the Executive Director (ED) indicated she did not know the resident's condition of her fingers/hands at admission and did not know if the contractures were the same, better, or worse.
During an interview, on 10/3/23 at 10:05 a.m., CNA 7 indicated the resident's [NAME] on the computer kiosk did not have anything listed about the resident's hand contractures or range of motion (ROM) for the fingers/hands.
During an interview, on 10/3/23 at 11:47 a.m., the DNS indicated there was no documentation to show if the resident's contractures were present upon admission or if they had improved or worsened. The documentation she could provide was the wound note, dated 4/11/23.
During an interview, on 10/3/23 at 3:54 p.m., the DNS indicated the resident did not have a care plan for the finger/hand contractures.
A current policy, titled Skin Assessment, dated 2022 and received from the DNS on 10/3/23 at 1:20 p.m., indicated .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury
The facility did not provide a policy on contractures by time of exit.
3.1-42(a)(1)
3.1-42(a)(2)