Every finding on record at Adams Heritage

Based on interview and record review the facility failed to ensure a care plan was initiated for 1 of 1 residents reviewed. (Resident 3)Findings include:Resident 3's record was reviewed on 05/26/2026 at 10:10 AM. Diagnoses included major depressive disorder, obesity, and history of falling.A review of Resident 3's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact).There was no care plan related or interventions for major depressive disorder.In an interview, on 05/29/2026 at 12:51 PM, the Administrator indicated Resident 3's care plan was personalized, and they are monitoring behaviors related to depression.In an interview, on 05/29/2026 at 1:33 PM, the DON stated they did not have any care plans specific to major depressive disorder.A current policy, dated 05/29/2026, provided by the DON indicated the care plan would include measurable objectives and time frames for meeting the resident's medical, nursing, and mental/psychosocial needs.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observation, interview and record review the facility failed to ensure food items were labeled and dated in the kitchen. 37 of 37 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation, on 5/21/25 at 9:10 AM, about 20 salad dressing packets were observed in a cooler in the dining room. No expiration dates were observed on the packets. Two open boxes of assorted cheesecake slices, an open box of carrot cake, a plastic container of cupcakes and an open box of cookie dough were observed in the walk-in cooler with no labels or dates. An open bag of shredded cheese had an open date of 4/13/25 with instructions marked on the package to discard on 4/20/25. An open box in the reach in freezer contained an open plastic bag containing hamburger patties with the meat exposed to the air. An open box contained an open plastic bag of hot dogs. The hot dogs were open to air and covered with about 1/2 inch of frost in most places. Neither the hamburgers nor hot dogs were labeled and dated. 9 eggs were observed in a container in the reach-in salad cooler with no label or date. In an interview, on 5/21/25 at 9:12 AM, the Dietary Manager (DM) indicated the dressing packets came from boxes in the dry storage area, but she had no written record of rotation of product to verify each packet coming from the existing boxes in dry storage. She indicated the packets needed to be discarded since the expiration date was unknown. The dietary manager indicated the boxes of cheesecake, carrot cake, cookie dough and container of cupcakes should have been labeled and dated. She indicated the expired cheese should have been discarded. In an interview, on 5/23/25 at 10:53 AM, the Director of Nursing (DON) indicated all 37 residents residing in the facility were served food prepared in the kitchen. A current policy, dated 9/24, provided by the Administrator on 5/21/25 at 2:20 PM indicated all food should be labeled, dated and discarded appropriately. The policy indicated food should be labeled and dated as soon as the original packaging is broken. Any food manufactured in house and served in individual portions will be labeled with a name and expiration date. 3.1-21(i)(2)

Based on observation, interview, and record review; the facility failed to separate oral medications from external medications for 1 of 1 cart reviewed affecting 1 resident. (100 hall, Resident 28). On 07/24/24, at 09:45 AM, during an observation and interview with RN 2; Resident 28's oral medications were obsered stored in locked medication cart (100 Hall) alongside his external medication Triad hydrophilic wound dressing paste and Bengay. RN 2 denied any problem mixing orals with externals. RN 2 explained all the medications were for Resident 28. RN 2 explained one of the creams was Bengay and the other was a topical for a wound. RN 2 offered to move external medications to the treatment cart. In an interview on 7/25/24 at 7:51AM, the DON (Director of Nursing) indicated RN 2 was from the hospital and was not up to date on nursing home requirements. The DON further indicated after speaking with RN 2 she had just completed the dressing change and put the cream there due to being called away. The medication cart and treatment cart were within 10 feet of each other. Resident 28's record review began on 7/29/24 at 9:36AM. Diagnoses included parplegia, pain, and heart disease. A medication administration audit report dated July 2024, indicated Resident 28's dressing change was completed on 7/24/24 at 6AM and at 1:41PM by RN 2. The 100 Hall cart was observed 7/24/24 at 09:45AM, approximately 3 hours later. Resident 28's physician orders included Triad hydrophilic external paste, apply to buttocks/thighs topically every day and evening shift for excoriation apply to areas around wound vac; dated 5/24/24. Additionally, an order for Bengay lidocaine external cream 4%, apply to joints topically every 12 hours as needed for pain, ok for unsupervised self-administration was dated 4/10/24. A current facility policy, titled Storing Medications, dated 2/1/94 was provided by DON on 7/29/24 at 11:10AM. The policy indicated .all drugs intended for internal use should be stored together in a medication cart. No other policies were provided at time of exit. 3.1- 25(j)

Based on observation, interview, and record review, the facility failed to ensure medications were administered without errors for 2 of 12 residents reviewed; during 2 of 30 medications observed. (Resident 15 and Resident 7) Findings include: During an observation, on 10/27/22 at 11:22 AM, observed Resident 15's medication was dropped on the floor by QMA 3 (Qualified Medical Assistance). QMA 3 picked the pills up off the floor near the entry and bathroom of Resident 15's shared room. QMA 3 put the pills back into the paper cup and administered them to Resident 15. During an observation, on 10/27/22 at 11:28AM, QMA 3 was observed checking Resident 7's blood sugar and subsequent administration of insulin. QMA 3 did not wipe off the pen with alcohol prior to putting on a new needle. QMA 3 dialed in 10 units and took the pen into Resident 7's room. QMA 3 cleaned the area prior to putting the pen flush with the skin then pushed the button at the opposite end of pen. QMA 3 waited 8 seconds before removing the pen from contact with skin. QMA 3 did not prime the needle to ensure it was functioning properly. 1) Resident 15's record review, began on 10/27/22 at 1:26PM, indicated his diagnosis included vitamin D deficiency. Resident 15's physician orders included Cholecalciferol tabled 125mcg, 2 tablets by mouth once daily for vitamin D deficiency. 2) Resident 7's record review, began on 10/27/22 at 1:16pm, indicated his diagnosis included unspecified dementia, moderate intellectual disabilities, and type 2 diabetes (insulin dependent). Resident 7 had a physician's order for NovoLog solution, inject 10 units before meals. In an interview, QMA 2 on 10/28/22 at 1:10PM indicated she would work with the nurse to determine how to destroy dropped medications. QMA 2 indicated she would replace the pill with one from Resident 15's emergency box, each resident at facility had a box with a day of emergency medications to be used when needed and then replaced. QMA 2 indicated the correct steps in administering insulin with pen. In an interview, the DON (Director of Nursing), on 10/31/22 at 9:02 AM, indicated both QMA 2 and QMA 3 were agency staff not directly hired by facility. The DON indicated the agencies were required to send licensed staff and the facility also checked their licenses. The facility had a contract with both agencies suppling the QMAs without any specific training outlined. A policy titled, Use of Insulin Pen dated 7/2022, was provided by DON on 10/27/22 at 1:42PM. The policy indicated .Purpose: to improve the accuracy of insulin dosing, to provide increased resident comfort .Wipe rubber seal with an alcohol pad. Priming the insulin pen. a. dial 2 units by turning the dose selector clockwise. b. with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat this procedure until at least one drop of insulin appears . 3.1-48(C)(2)

Based on observation, interview, and record review, the facility failed to ensure sanitary practices were followed in the kitchen. 39 of 39 residents residing in the facility ate their meals from the facility kitchen. Findings include: On 8/30/2021 between 10:45 a.m. and 1:05 p.m. in a continuous observation, lunch meal tray preparation and service was observed. At 11:05 a.m., Dietary Aide 1 moved a 3 tiered cart from the dish room to the area where paper products were stored. then sprayed the shelves of the cart. Dietary Aide 1 indicated the spray was a disinfectant used to clean the carts, but needed to be used away from food. Dietary Aide 1 was observed to spray the top shelf of the cart, then wiped immediately with a cloth. She proceeded to spray the middle and lower shelves with the disinfectant and wipe off immediately. Dietary Aide 1 moved the 3 tiered cart to the end of the meal tray prep line. Dietary Aide 1 was interviewed and indicated the facility used the three tray carts rather than the enclosed metal food carts to deliver the room meal trays to the residents. Dietary Aide 1 indicated the CNAs (Certified Nursing Assistants) serve the meal trays faster from the open carts then they did from the enclosed metal carts becasue the open carts carried 6 meal trays and were taken to the residents quicker than when the trays were in the enclosed carts waiting for all the meal trays to be served on the hall. At 11:15 a.m., Dietary Aide 1 was observed to wash her hands, proceeded to put meal tickets on 6 meal trays, then silverware wrapped in a paper napkin. The top of the knife, fork and spoon were not covered with the napkin. Cook 6 was interviewed and indicated the silverware should be covered. Between 11:23 a.m. through 11:43 a.m. , Cook 6, washed their hands, then plated the lunch meal. Dietary Aide 1 was obwas observed to use her bare hand to open the kitchen door with the lever handle, then went towards the beverage station. Dietary Aide 1 opened the door with 1 hand, entered the kitchen carrying 2 beverages in her hand, placed the beverages on the meal trays, used both hands to retrieve plastic lids and put them on top of the beverages. Dietary Aide 1 was not observed to perform hand hygiene after touching the door, before retrieving beverages, touching the plastic lids, nor the meal trays. Dietary Aide 1 was observed to go in and out of the kitchen door to retrieve beverages for the 6 meal trays, putting lids on the beverages and did not perform hand hygiene. Dietary Aide 1 loaded the 6 meal trays onto the 3 tiered cart. At 11:34 a.m., Dietary Aide 1 opened the kitchen door, then pulled the open meal cart through the door to deliver it to the hall. Dietary Aide 1 was not observed to perform hand hygiene after touching the kitchen door and before pushing the meal cart to the hall. From 11:37 a.m., to 11:55 a.m., Dietary Aide 1 returned to the kitchen through the kitchen door and was observed to wash their hands. Dietary Aide 1 reviewed the meal tickets on the meal trays. Dietary Aide 1 was observed to go out of the kitchen door touching the lever handle to retrieve beverages for the meal trays. Dietary Aide 1 was not observed to perform hand hygiene after touching the kitchen door, retrieving beverages, putting beverages on the meal trays and putting lids on the beverages for the 6 meal trays. At 11:55 a.m., Dietary Aide 1 opened the kitchen door and pulled the open meal cart through the door to deliver it to the hall. Dietary Aide 1 was not observed to perform hand hygiene after touching the kitchen door before pushing the meal cart to the hall. From 12:00 p.m., to 12:28 p.m., Dietary Aide 1 returned to the kitchen through the kitchen door and was observed to wash their hands. Dietary Aide 1 reviewed the meal tickets on the meal trays. Dietary Aide 1 was observed to go out of the kitchen door touching the lever handle to retrieve beverages for the meal trays. Dietary Aide 1 was not observed to perform hand hygiene after touching the kitchen door, retrieving beverages, putting beverages on the meal trays and putting lids on the beverages for the 6 meal trays. At 12:28 p.m., Dietary Aide 1 opened the kitchen door and pulled the open meal cart through the door to deliver it to the hall. Dietary Aide 1 was not observed to perform hand hygiene after touching the kitchen door before pushing the meal cart to the hall. At 12:30 p.m., Dietary Aide 1 was observed to return to the kitchen through the door to the dishwashing area, held the door open and pushed the 3 tiered cart with dirty meal trays and dishes. Dietary Aide 1 was observed to unload the 3 tiered cart and put the dirty trays in the dishwashing area. Dietary Aide 1 proceeded to retrieve a spray bottle of disinfectant and a cloth. Dietary Aide 1 was observed to spray and wipe the tray with the cloth immediately for each of the 3 shelves on the cart. Dietary Aide 1 was interviewed about the disinfectant used and indicated they were not aware how long the disinfectant needed to remain on the surface before wiping off. Dietary Aide viewed the directions on the TB Quat Disinfectant spray bottle. The instructions indicated to spray evenly over surface, be sure to wet all surfaces thoroughly and leave the product on the surface for a 3 minute contact time to kill bacteria and viruses and 10 minutes for [CONDITION(S)] A. The label further indicated all food contact surfaces should be rinsed thoroughly with potable water after disinfecting. At 12:35 p.m., Dietary Aide 1 indicated she had not waited 3 minutes before wiping of the carts shelves. Dietary Aide 1 proceeded to push the 3 tiered cart to the end of the meal tray line and not re-disinfect the 3 tiered cart. Dietary Aide 1 was observed to wash her hands and proceed to prep 6 more meal trays. At 12:40 p.m., Dietary Aide 1 used her hand to open the kitchen door lever handle and leave the dining room to retrieve beverages. Dietary Aide 1 was interviewed and indicated they had not done hand hygiene nor hand washing after touching the kitchen door or handle. Dietary Aide 1 proceeded to retrieve beverages for the beverage center in the dining room. Dietary Aide 1 indicated they were not sure how they were going to get the beverages without touching the kitchen door. Dietary Aide 1 was observed to put the poured beverages in the window to the kitchen and then enter the kitchen, wash her hands, then retrieve the poured beverages from the window, put them on the meal trays and covered them with the lids. Dietary Aide 1 was not observed to perform hand hygiene before touching the drinking glasses, before dispensing beverages in the drinking glasses, nor placing them in the kitchen/dining room window. The poured beverages drinking glasses were then placed on the meal trays. Dietary Aide 1 was not observed to wash he hands after putting the beverages on the meal trays or when putting plastic lids on the beverages. Dietary Aide 1 retrieved a handled mug from the shelf near the kitchen door, then used her elbow to push the door lever handle down and used her back to open the door to retrieve a beverage for the meal tray. Dietary Aide 1 returned to the kitchen, touched the door handle with their hands, used both hands to put the mug on the meal tray, retrieved a spouted lid for the mug and put it on the handled mug. Dietary Aide 1 was not observed to perform hand hygiene after touching the kitchen door handle. Dietary Aide 1 was observed to retrieve 2 handled mugs, leave through the kitchen door, touching the door handle to open it. The Dietary Aide was not observed to perform hand hygiene after touching the door, after she dispensed beverages and after she put them in the kitchen window. Dietary Aide 1 opened the kitchen door, held it with their foot as they washed their hands in the dining room sink by the door, entered the kitchen, retrieved the handled mugs in the window, and placed them on the meal trays. Dietary Aide 1 put plastic anti-splash lids on the mugs. Dietary Aide proceeded to put the meal trays on the 3 tiered cart which was not disinfected for the appropriate amount of time. At 12:44 p.m., Cook 6 was observed to go through the kitchen door, touched the door lever handle to open the door when going out and coming back into the kitchen. Cook 6 was observed to put beverage glass on the meal tray using both hands to put it on the meal tray. Cook 6 then washed their hands. Cook 6 did not perform hand hygiene between touching the door handle and putting the beverage glasses on the trays. At 12:45 p.m., Dietary Aide 1 was observed to exit the kitchen door touching the door handle. They indicated they were looking for plastic utensils for a meal tray. Dietary Aide was not observed to wash their hands before retrieving the plastic utensils from the dining room nor after returning to the dining room, wrapping the plastic utensils in a paper napkin, then wrapping in plastic wrap and putting them on a meal tray on the 3 tiered cart. Dietary Aide 1 was leaving the kitchen when Cook 6 was interviewed and indicated all beverages should be covered with lids or plastic wrap. At 12:47 a.m., Cook 6 was observed to remove a tray with plates of pie from a 3 tiered cart below the kitchen window. Cook 6 pulled the 3 tiered cart to the end of the meal tray line. The cart left the kitchen with 3 meal trays on the cart. At 12:50 p.m., Dietary Aide 1 returned with an empty 3 tiered cart, brought it through the kitchen door touching the door handle to open the door and push the cart to the end of the meal tray line. Dietary Aide 1 was observed to wash her hands. The 3 tiered meal cart was not observed to be cleaned with a disinfectant. At 1:00 p.m., the last meal cart with 6 meals left the kitchen for delivery to residents. The meal cart was not disinfected prior to putting meal trays on it. At 1:05 p.m. the dietary staff was interviewed and indicated the Dietary Manager had been off ill for several weeks and dietary staff who were students had returned to school. They also indicated they had trouble getting paper products. They were using beverage napkins instead of dinner napkins, were short on lids and needed to cover with plastic wrap. They indicated the door would be considered dirty and they needed to find away to get the beverages without touching the kitchen doors. They indicated they needed to remember to wash hands after touching the door going in and out of the kitchen. On 8/30/21 at 2:45 p.m., in annterview with the Associate Clinical Director indicated they would follow the Indiana Food Code for hand washing in the kitchen. On 8/30/21 at 3:05 p.m., the current facility policy was reviewed. The Administrator provided the policy on 8/30/21 at 3:03 p.m., from Indiana Food Code, Section 128 through 131, titled, Hand Washing, which was not dated. The Indiana Food Code 410 IAC 7-24-129 When to wash hands .indicated, .Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapping single-services and single-use articles and the following .(6) After handling soiled surfaces, equipment, or utensils .(7) During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks .(9) Before touching food or food-contact surfaces .(11) After engaging in other activities that contaminated the hands .(b) For purposes of this section, a violation of subsection (a) is a critical item On 8/30/21 at 3:05 p.m., the current facility policy was reviewed. The Administrator provided the current facility policy on 8/30/21 at 2:55 p.m., was titled, CLEANING AND SANITIZING PUSH CARTS AND ROOM SERVICE TABLES, with a revision date of 4-2012. The facility policy indicated, .In compliance with our safe food handling practices, optimum cleaning and sanitizing of the push carts and room service tables will be assured .Cleaning and sanitizing is done as needed .PROCEDURE: A. Prepare a sanitizing solution according to standard procedure .D. Using a cleaning cloth and sanitizing solution, clean and sanitize carts and tables On 8/30/21 at 3:05 p.m., there current facility policy was reviewed. The Administrator provided the EPA (United States Environmental Protection Agency). The list indicated, .the disinfectants used against [CONDITION(S)]-CoV-2 (virus that can lead to COVID-19). The EPA Registration Number -2 Quaternary ammonium Disinfectant by [Manufacturer], Ready to use had a contact time of 2 minutes On 9/1/21 at 2:49 p.m., The Administrator provided a copy of the [Brand] TB Quat Disinfectant, information on the spray bottle. The manufacturer's directions indicated, .TB Quat Disinfectant is designed specifically as a general non-acid cleaner and disinfectant for use in hospitals, nursing homes, schools and hotels .Directions for Use As A Cleaner/Disinfectant: Spray evenly over surface. Be sure to wet all surfaces thoroughly. Let product remain on surface for 3 minutes. for [CONDITION(S)] A, let surface remain wet for 10 minutes. Wipe with clean cloth, sponge or paper towel .Note: All food contact surfaces such as kitchen counters, and tables used for food preparation, appliances and sinks must be rinsed thoroughly with potable water after disinfecting. This product must not be used to clean the following surfaces: utensils, glassware and dishes . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to implement and maintain infection control practice to properly prevent COVID-19 for 6 of 39 residents. (Resident 17, Resident 13, Resident 26, Resident 21, Resident 89 and Resident 84) Findings include:Based on [observations/interviews/record review], the facility failed to [properly prevent and/or contain - or other appropriate statement] . 1.During an observation of the lunch meal service on [DATE] at 11:44 a.m., CNA 7 was wearing an N95 mask and goggles. CNA 7 preformed hand hygiene, then retrieved a meal tray from the cart. CNA 7 was observed to walk down the hallway to a room with Transmission Based Precautions (TBP). The room door was identified with a Yellow Zone TBP sign. The sign inidicated Contact Droplet precautions were in order. The PPE required included an N95 mask, faceshield or goggles, single gown with each encounter, gloves, hand hygiene when donning (putting on PPE) and doffing (taking off PPE.) CNA 7 was observed to put the meal tray on top of the PPE caddy, removed a gown from the drawer of the PPE caddy, donned it, and tied the gown in the back. CNA 7 proceeded to pick up the meal tray, informed the resident their lunch was ready, entered the room and put the meal tray on the over-the-bed table in front of the seated resident. CNA7 was not observed to don gloves before entering the TBP room to deliver the meal tray. CNA 7 removed the domed plate cover, and assisted the resident with the meal tray. CNA 7 then removed the disposable gown, entered the bathroom, came out to look for the TBP trash disposal and indicated there was none in the room. CNA 7 discarded the gown in the bathroom trash, washed their hands and exited the room. CNA 7 was interviewed and indicated they had not put on gloves when delivering the meal tray in the TBP room, and indicated a gown and gloves should have been worn in the TBP room when entering the room. CNA 7 also indicated hand hygiene should be done before and after using PPE. 2. On [DATE] at 11:03 a.m., Nurse 3 was observed to obtain a green cloth from the shower room and placed it on the medication cart. The nurse indicated the cloth was saturated with Oxycide (a disinfectant). Nurse 3 was observed to gather a glucometer and supplies and entered Resident 17's room on [DATE] at 11:05 a.m. to obtain a blood sugar. The nurse did not find any tissues in the room. Nurse 3 was observed to remove her gloves, return the supplies to the med cart, and obtained a box of tissues from the supply room down the hall. Nurse 3 returned to Resident 17's room, dropped off the tissues, then returned to the medication cart for the glucometer and supplies. Without using hand sanitizer, Nurse 3 donned gloves and obtained the resident's blood sugar. The nurse returned to the medication cart, then used the green cloth to wipe the glucometer with the Oxycide for less than 5 seconds. During an observation of a glucometer blood sugar test on [DATE] at 4:22 p.m., Nurse 4 was observed to obtain the blood sugar for Resident 26. Nurse 4 was observed to clean the glucometer with a Dispatch wipe, then wrapped the Dispatch wipe around the glucometer along with a tissue. The nurse placed the glucometer in the medication cart. During an observation of a glucometer blood sugar test on [DATE] at 4:32 p.m., Nurse 4 was observed to use a second glucometer to obtain the blood sugar for Resident 13. The nurse returned to the medication cart and cleaned the glucometer with the Dispatch wipe and then wrapped the wipe around the glucometer along with a tissue and placed it inside the medication cart. An interview with Nurse 4 on [DATE] at 4:47 p.m., indicated after using the glucometer, it was cleaned with the Dispatch wipe and the wipe was wrapped around the glucometer for 3 to 5 minutes. During observation of a glucometer blood sugar test with QMA 5 (Qualified Medication Aide) on [DATE] at 3:25 p.m., the QMA donned gloves and obtained a blood sugar for Resident 21. After the blood sugar test, QMA 5 was observed to obtain a Dispatch wipe from the container and wiped off the glucometer and disposed of the wipe. An interview with QMA 5 on [DATE] at 3:35 p.m., indicated the glucometer was to be cleaned with a Dispatch wipe for 30 seconds and then allowed to air dry. 3. An observation of Nurse 3 on [DATE] at 11:15 a.m., indicated she was to prepare an insulin injection for Resident 13. The nurse found the Novolog insulin expired and went to the medication room down the hall to obtain a new insulin. The nurse returned with a Novolog Flex Pen and indicated Resident 13 would get 10 units. The nurse was not observed to use hand sanitizer after returning from the medication room. On [DATE] at 11:19 a.m., Nurse 3 was observed to don gloves and administered the insulin to Resident 13. During an observation of an insulin injection, Nurse 4 was observed to administer 50 units of Novolog insulin to Resident 13 on [DATE] at 4:39 p.m. Nurse 4 was not observed to wear gloves for the administration of the insulin. During an observation of insulin administration on [DATE] at 4:48 p.m., Nurse 4 was observed to administer 13 units of insulin to Resident 26 with a [MEDICATION(S)] Kwik pen without the use of gloves. An interview with the DON (Director of Nursing) on [DATE] at 5:25 p.m., indicated nursing staff were expected to wear gloves when administering the insulin injections. 4. During a review of the facility's COVID-19 infection control processes on [DATE] at 9:00 a.m., screenings for COVID-19 signs and symptoms were lacking for Resident 89 and for Resident 24. Resident 89 was tested for COVID-19 on [DATE] and was positive. The resident had signs and symptoms of a sore throat, tiredness and weakness. Resident 89 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The resident was quarantined and in TBP (Transmission Based Precautions) through [DATE]. A review of the [DATE] MAR/TAR (Medication Administration Record/Treatment Administration Record) indicated the resident had orders for monitoring for signs and symptoms of COVID-19 dated [DATE]. The monitoring was discontinued on [DATE]. Resident 89 was not monitored for signs and symptoms of COVID-19 upon her return to the facility after [DATE]. Resident 24 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 24 was placed in TBP upon her return to the facility due to hospitalization and her unvaccinated status. A review of the [DATE] MAR/TAR indicated Resident 24 was not monitored for signs and symptoms of COVID-19 upon her return to the facility after [DATE]. An interview with the Associate Clinical Director of Senior Services on [DATE] at 10:54 a.m., indicated residents should still be monitored for COVID-19 signs and symptoms. A current policy, Coronavirus Pandemic, dated [DATE], was provided by the DON on [DATE] at 12:28 p.m. The policy indicated, .Residents will be assessed for symptoms of COVID 19 infection upon admission to the facility, and daily during this pandemic and implement appropriate infection prevention practices for incoming symptomatic residents A current policy, Disinfecting Glucometers, last revised on [DATE], was provided by the DON on [DATE] at 3:20 p.m. The policy indicated, .To outline and maintain the facility's procedure as it relates to the disinfection process to ensure adequate cleansing and reduce possibility of patient-to-patient transmission of disease .gather equipment .wipes with EPA-registered detergent/germicide with tuberculocidal or HBV/HIV label claim .if gloves are soiled with blood/body fluids after using the glucometer, change gloves before proceeding .remove test strip from glucometer prior to disinfecting .remove one wipe from container and snap lid snugly to prevent drying out the remaining wipes .squeeze or wring out excessive solution from wipe into a tissue or waste receptacle .wipe glucometer front, back, and sides .use gentle scrubbing to remove any visible blood or body fluids .allow glucometer to remain wet for one (1) minute .place glucometer on clean tissue to air dry before using on another resident A current policy, Hand Hygiene, last reviewed ,d+[DATE], was provided by the DON on [DATE] at 11:20 a.m. The policy indicated, .Decontaminate hands before having direct contact with patients even if wearing gloves .decontaminate hands after removing gloves A current policy, Medication Administration: Injection Insulin Prepared and Administration, last reviewed ,d+[DATE], was provided by the DON on [DATE] at 3:20 p.m. The policy indicated, .Aftercare of equipment .place used disposable articles and gloves in plastic bag and discard 3.,d+[DATE](a)

Based on observation, interview and record review, the facility failed to document intake amounts for a resident on fluid restrictions. For 1 of 1 resident. ( Resident 24) Findings include, The clinical record for Resident 24 was reviewed on 8-31-21 at 2:27 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 240 cc diet coke with each meal, 120 cc orange juice with [MEDICATION(S)] administration, 120 cc fluid with medication pass twice daily, and 180 cc as needed/free fluid. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No total amount of fluid intakes were noted. A current care plan indicated Resident 24 had an activities daily living (ADL) self-care performance deficit related to new left above the knee [CONDITION(S)], chronic pain, [CONDITION(S)], [CONDITION(S)]. The interventions included: eating- the resident required set up assistance by staff to eat. The resident preferred to eat meals in room and was safe to do so. Give Regular diet-Fluid restrictions: 1500 ml ( see orders). During an observation on 8-31-21 at 1:45 p.m., of Resident 24's room, on the bedside table next to Resident 24, was a lunch tray. There were also three white foam (about 8 ounces) disposable cups. Two of them were empty and one was filled with liquid to the top. There were two clear disposable plastic cups (about 16 ounces), one was empty. The other cup was half full of liquid. On the dresser next to the resident's bed, there was a water pitcher that was filled to top with liquid. Resident 24 was interviewed on 8-31-21 at 1:46 p.m. The resident indicated, the staff provide her with her drinks, or anything she needs. Registered Nurse 2 (RN) was interviewed on 8-31-21 at 11:52 a.m. She indicated when they have anyone with fluid restrictions, they will monitor the fluid intake each shift. Third shift nurse would calculate and document the total amount. Also the kitchen would document the total amount to make sure the resident was getting what they were ordered. The certified nursing aides (CNA) would not document the total. Dietary Aide 1 ( DA), was interviewed on 8-31-21 at 2:07 p.m. She indicated the white foam disposable cups would hold between 240-250 ml. The kitchen followed the nurse slips that were filled out, for any restrictions. The Director Of Nursing (DON) was interviewed on 8-31-21 at 12:37 p.m. She indicated Resident 24's total amount of fluids to be received was on the physician order. The nurses would check it off on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . They would follow whatever the order indicated. A current facility policy, Fluid Restrictions, dated 8-1-2008, was provided by DON on 8-31-21 at 3:12 p.m. The policy indicated . The fluid restriction for a specific amount is included in the orders section of the medical record. Fluid restrictions patterns have been established for most fluid restriction amounts. These patterns are consistent throughout the facility. If a fluid restriction is ordered for an amount not already established, the Dietary Manager will communicate with the nurse of that resident as soon as possible and they will agree on a pattern. This will be documented in the electronic medical record (EMR) and in Nutritional Services until the resident is discharged or the fluid restriction is discontinued 3.1-37

Based on interview and record review the facility failed to monitor side effects of Antidepressant, and Antianxiety medications for 3 of 5 residents reviewed. ( Resident 15, Resident 23, and Resident 37) Findings include: 1. The record for Resident 15 was reviewed on 9-1-21 at 10:45 a.m. Diagnoses included, but were not limited to, anxiety disorder, unspecified, major depressive disorder, single episode, unspecified. The physician orders indicated Resident 15 had been prescribed [MEDICATION(S)] tablet 10 milligrams (mg) antidepressant, by mouth, 1 tablet, one time a day, everyday at 8: 00 a.m., start date 1-12-21 for depression. The Medication Administration Record (MAR) dated July and August 2021 indicated the medication [MEDICATION(S)] had been given at 8:00 a.m. each day. A current care plan, indicated the resident used antidepressant medication related to depression, [MEDICATION(S)] dated 12-2020. The interventions were, administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. There was no documentation to indicate monitoring for side effects and effectiveness had occurred. 2. The record for Resident 23 was reviewed on 9-1-21 at 12:00 p.m. Diagnoses included, but were not limited to, unspecified dementia with behaviors disturbance, generalized anxiety disorder, other recurrent depressive disorders. The physician orders indicated Resident 23 was to receive [MEDICATION(S)] tablet 10 mg antianxiety, by mouth, 10 mg three times a day, 8:00 a.m., 1:00 p.m., and 8:00 p.m. start date 3-11-21 for anxiety. Also, the resident was to receive [MEDICATION(S)] tablet 10 mg antidepressant, by mouth, 1 tablet, one time a day at 8:00 a.m. Start date 11-10-2020 for generalized anxiety disorder. A review of the MAR dated June and July 2021, indicated the medication [MEDICATION(S)] 10 mg tablet was given each day at 8:00 a.m. A review of the MAR dated June and July 2021, indicated the medication [MEDICATION(S)] tablet 10 mg was given each day at 8:00 a.m.1:00 p.m., and 8:00 p.m. A review of the current care plan indicated the resident received an antidepressant. There was potential for adverse side effects. The staff were to be aware the antidepressant could increase Resident 23's risk for falls. Interventions were to administer medication as ordered, monitor for effectiveness and adverse reactions to the medication, and notifiy the MD as needed. There was no documentation to indicate monitoring for side effects and effectiveness had occurred. 3. The record for Resident 37 was reviewed on 9-1-21 at 1:00 p.m. Diagnoses included, but were not limited to, mild cognitive impairment, adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder, recurrent, unspecified. The physician order indicated Resident 37 was to receive the medication [MEDICATION(S)] 20 tablet mg, an antidepressant, by mouth, 20 mg, one time a day, every day at 8:00 a.m. Start date was 6-15-21 for major depressive disorder. A review of the MAR dated July and August 2021 indicated the medication [MEDICATION(S)] 10 mg tablet was given at 8: 00 a.m. each day. A review of the current care plan indicated the resident had depression. The interventions were to administer medications as ordered, monitor and document for side effects and effectiveness. There was no documentation to indicate monitoring for side effects and effectiveness had occurred. The Director of Nursing was interviewed on 9-1-21 at 10:28 a.m. she indicated there should be a physician's order to monitor for side effects, the monitoring could be daily or per shift. The Associate Clinical Director was interviewed on 9-1-21 at 10:46 a.m. She indicated the facility did not monitor for side effects, since they have a Psych NP who sees the residents monthly. A current facility policy, Behavioral Management Program, dated 2-9-2000, was provided by the DON on 9-1-21 at 12:27 p.m. The policy indicated . the facility's policy is to observed mood and behavior symptoms of residents, in accordance with State and Federal regulations A current facility policy, Monitoring Antipsychotic Meds for Tardive Dyskinesia, dated 2-9-2000, was provided by the DON on 9-1-21 at 12:27 p.m. The policy indicated .In order to ensure proper monitoring of side effects from the use of antipsychotic medications, this facility will implement formal monitoring for evidence of tardive dyskinsia 3.1-48 (b)(1)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled as required in 1 of 2 medication carts observed (Prairie Path Medication Cart). Findings include: An observation of the Prairie Path Medication Cart with QMA 5 (Qualified Medication Aide) on 8-31-2021 at 4:45 p.m., indicated there were four bottles of unopened over-the-counter medications in the bottom left drawer without labels to identify the residents who were to receive these medications. The four bottles of medications observed included a bottle of Complete Multivitamin 450 tablets, a bottle of [MEDICATION(S)] [MEDICATION(S)] 90 softgels, a bottle of Osteo Bi Flex 120 tablets, and a bottle of Stool Softener 100 mg (milligrams) 400 softgels. An interview with QMA 5 on 8-31-2021 at 4:53 p.m., indicated she was not able to say to which resident these bottles of medications beloonged. She indicated a resident's family probably brought the medications to the facility for the resident. She indicated the bottles should have had the resident's name, at least the first initial and last name, physician name, and opened date printed on the medication bottle. A facility resident listing by room was provided by the Administrator on 8-26-2021 at 11:00 a.m. The listing indicated 18 residents resided on the Prairie Path 200 hall. A current policy, Labeling of Medication, last revised 8/2021, was provided by the DON (Director of Nursing) on 9-1-2021 at 10:00 a.m. The policy indicated, .All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations .1. Medication labels must be legible at all times .6. Labels for over-the-counter drugs shall include all necessary information, such as: a. the resident name b. the prescribing physician's name c. name of drug/strength 3.1-25(l)

Based on record review, and interview, the facility failed to ensure all residents were free from verbal abuse for 1 of 3 residents reviewed. (Resident B) Findings include The facility's policy titled Abuse, Neglect and Exploitation, Staff treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Definitions: 1. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. It includes verbal abuse On 4/30/21, the facility self-reported an incident to the Indiana Department of Health (IDOH) dated 4/27/21, it involved Certified Nursing Assistant (CNA) 5 and a CNA student mocking Resident B. The report indicated the Administrator began an investigation immediately. Upon review of the conference room camera, the Administrator was able to see the allegations had been true. Resident B's family was notified, then the rest of the residents on that hall way were interviewed for any allegations, concerns, and safety. Employee 5 was terminated, and the CNA student's instructor was notified that the student could no longer return to the facility. The clinical record for Resident B was reviewed on 5/13/21. The resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 4/23/21 at 3:56 P.M., indicated Resident B appeared to be in a more cheerful mood and was having full conversations with staff, in place of the usual one word answers and she indicated to Licensed Practical Nurse (LPN) 1 that she was feeling better. A progress note dated 4/27/21 at 9:35 P.M., indicated a CNA found her on the floor beside her bad and resident had told the CNA she was trying to get into my W/C [wheelchair]. A progress note dated 4/29/21 at 2:30 P.M., indicated the resident was sitting on the floor and told the staff I wanted in my W/C. A progress note dated 4/30/21 at 4:08 P.M., indicated the Director of Nursing (DON) received allegations of abuse to the resident and the investigation was completed on 4/30/21. The Minimum Data Set (MDS) note dated 4/30-5/6/21 indicated Resident B engaged in conversation some and answers were usually short, on or two words, and occasionally a full sentence, and the resident had a Brief Interview for Mental Status (BIMS) score of 8. The Psychiatric NP progress notes dated 5/5/21 at 4:28 P.M., indicated the resident was seen to follow up on the recent allegation of abuse reported by staff. The note indicated the staff reported the resident had been moaning more the last few days mostly intermittently and sometimes constant during the night. Staff also noted the resident's affect has been flat and her mood sad. The NP note indicated Resident B was engaging very little, mood was sad, and at times became frustrated and fearful of what's going on around her. The NP had asked the resident if she was fearful or scared and the resident moaned a little and did not give any response. The NP noted the resident did not recall the staff making fun of her, and the NP documented She is clearly sad today. The progress note dated 5/8/21 at 7:03 P.M., indicated Resident B complained of hip pain using just Pain. pain. Hip. A written statement from LPN 1, dated 4/30/21, indicated that she had noticed Resident B seemed to be withdrawn and that she had felt like the resident had finally started to open up after starting medication. LPN 2 then indicated she heard there had been some mimicking of the resident right in front of her. The LPNs went to speak with Resident B at that time and found out the allegations were corroborated by the resident and she had stated they make fun of me. Resident B then began to cry. LPN 1 then notified the DON and Administrator. A written statement from CNA 4, dated 5/10/21, indicated she had gone out on 4/28/21 with [previous employee 5] when he told her that he had been mocking the resident (B) the night before around 9:30 P.M. the night before. The statement indicated he put his head on the table and began acting like the resident and that Resident B had lifted her head up and said stop mocking me. He indicated he then told her if she did not stop that she was going to end up in the psycho ward like all her other friends. During an interview on 5/13/21 at 11:20 A.M., the Administrator indicated [previous employee 5] and the student CNA had taken Resident B into the conference room on 4/27/21 to monitor her after her fall; she had just a gown on and they could have monitored her in her room. During an interview on 5/13/21 at 11:56 A.M., CNA 4 indicated [previous employee 5] seemed to be in the I don't care mode and had told her he wanted to quit many times before the incident. This Federal tag relates to complaint IN 831. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to properly implement infection prevention and control practices to prevent potential development and transmission of COVID-19. The deficit practice had the potential to affect 41 of 41 residents who resided at the facility. Findings include: 1. On 10/28/2020 at 12:20 p.m., the facility was entered. The Employee Pre shift Medical Screening log was observed at the front desk. The from indicated All employees with direct patient contact must undergo medical screening prior to the start of their shift each day. The form was observed to have the following: space to document temperature and check if yes for the following: body aches, cough, sore throat, nasal congestion, runny nose and initials. At the bottom of the form was observed If fever is equal to or over 100.4 degrees F (Fahrenheit) is present, staff may not work. If symptomatic but no fever, staff may work but must strictly follow hand hygiene and respiratory precautions . On 10/28/2020 at 12:24 p.m. a sign on the front desk indicated EFFECTIVE IMMEDIATELY .every employee must log in and complete pre-screening form for COVID temp(temperature)/symptoms! We are no longer able to write our names/initials, temp, and check symptoms on paper! See Directions below! Check temp with thermometer. Regardless of temp, you must continue with below steps. If your temp is 100.4 or greater sit down, take a drink of water, fan yourself for a minute, etc. Re-check temp after a few minutes. After re-checking, if temp does not go down, please notify nurse and continue with below steps. One of the questions asks about temp, it will tell you if you are ok to work or not; log into email .open and read email from .click on Employee Pre-shift Medical Screen Form .Answer yes/no questions as prompted .click submit at end. It will notify you if you are ok to continue to work or if you should notify supervisor/return home . On 10/28/2020 at 12:30 p.m., the DON/IP (Director of Nursing/Infection Preventions) was interviewed. She indicated the acceptable range for a temperature obtained from a thermometer would be 96 F to 100.4 F. On 10/28/2020 at 2:16 p.m., the Charge Nurse was interviewed. She indicated when visitors/vendors came to the front door, they rang the doorbell because the front door was locked. She indicated usually the BOM (Business Office Manager) would let the visitor/vendor in. If she was not available, whoever heard the doorbell would let the vendor/visitor in. She indicated the staff were to check the visitor/vendors temperature. On 10/28/2020 at 2:00 p.m., the Employee Pre Shift Medical Screening log was reviewed from the visitor entrance at the main entrance to the facility. The following was observed: On 10/8/20 a temperature of 91.7 was documented with no initials for the entry. An entry on 10/22/20 had a signature with the same initials documented on the entry. The information in the temperature column was 106 A and documentation was lacking of a temperature entered for this visitor/vendor. On 10/26/20 a visitor/vendor signed in, documented they had body aches and runny nose and was initialed by visitor/vendor who signed in. Documentation was lacking on these entries which indicated the supervisor had been notified of temperature, signs and/or symptoms. Documentation further lacked to indicate any follow up and/or restrictions had been provided. On 10/29/2020 at 3:30 p.m., the Adm and DON were interviewed. They indicated for the entry of 10/22 with no temperature documented but the information for temperature was 106 A this was the room number the vendor was visiting. 2. On 10/28/2020 at 2:17 p.m. the Charge Nurse was interviewed. She indicated when staff enter the facility they come in through the back door and they screen themselves. She indicated they check and record their own temperatures. She indicated they began doing the screening electronically but sometimes staff did not check in. She indicated when they check in electronically, they have to log into the system and it takes more time. She indicated more staff documented their screenings on paper than in the computer. The Charge Nurse provided copies of the employee Pre shift Medical Screening from 10/5/2020 to 10/26/2020. The following was observed documented: On 10/5 Employee 4 temp of 90.8; 10/6 Employee 5 had cough/nasal congestion; 10/7 Employee 6 had sore throat, nasal congestion; two temperatures on two separate lines were documented with no date and no name, only one initial in the area to document initials, these entries were made between two other entries dated 10/7; 10/8 Employee 7 had nasal congestion and runny nose; 10/8 Employee 8 had cough and nasal congestion; Employee 9 on 10/8 had a temp of 99.1 and body aches; 10/8 Employee 3 documented a temperature of 100.3 and initialed the entry; Employee 11 had nasal congestion and runny nose on 10/9; on 10/14 Employee 12 documented cough, nasal congestion, runny nose and initialed the entry; on 10/15 Employee 12 documented body aches, cough, nasal congestion; on 10/16 Employee 13 documented sore throat; 10/18 Employee 14 cough; Employee 14, 10/20 body aches, 10/22 Employee 14 body aches and nasal congestion; 10/20 and 10/21 Employee 13 body aches and nasal congestion; 10/21 Employee 15 cough and nasal congestion; 10/21 Employee 16 cough; 10/21 Employee 17 runny nose; 10/24 Employee 18 temp of 95.5; 10/24 Employee 19 temp documented of 92.4; 10/25 Employee 20 documented temp 95.8; on 10/27 Employee 21 documented a temp of 92.2. Documentation was lacking on these entries to indicate supervisor had been notified of signs and/or symptoms, and/or documentation and/or lack of and any follow up and/or guidance and/or restrictions had been provided. Documentation was lacking the employees had been reviewed. No employee tested positive for COVID during this time frame. On 10/28/2020 at 2:00 p.m., the time sheet for Employee 3 was reviewed for 10/8/2020. The Pre shift medical screening dated 10/8 indicated she documented a temp of 100.3. The time sheet indicated Employee 3 worked on 10/8 from 4:02 p.m. to 6:50 p.m. Documentation was lacking the supervisor had been notified of sign/symptoms and/or documented temperature and of the temperature having been rechecked. Documentation was lacking the employee had been reviewed and approved to work. Employee 3 tested negative for COVD during this time frame. On 10/28/2020 at 3:40 p.m. the time sheet for Employee 2 was reviewed for 10/22/20. She worked on 10/22, 10/23 and 10/24. The Pre shift medical screening dated 10/22 indicated she indicated she had a cough. The list of staff members who tested positive for COVID 19 was reviewed at 3:40 p.m. The list indicated Employee 2 had a cough on 10/22 when she signed in before her shift. Employee 2 tested negative for COVD during this time frame. On 10/28/2020 at 3:50 p.m. the ADM provided a copy of the policy and procedure Coronaries Pandemic . dated 3/15/2020. The policy included but was not limited to, the following: .Purpose: To minimize the impact of thee COVID-19 pandemic in senior living . The Procedure included but was not limited to,, the following: .Visitors and Staff: .All staff is screened on arrive to shift and verified .N-95 masks and eye protection have been provided to all employees to be utilized . On 10/29/2020 at 9:40 a.m. the DON/IP was interviewed. She indicated the screening process for visitors was the BOM let visitors/vendors in the building during normal business hours. She would take their temp before they were permitted into the building. The DON/IP indicated if visitors had signs and symptoms she assumed the BOM would have notified her. The DON indicated if she was made aware of an issue with the information obtained by the BOM, she would have reviewed it, and would have noted so on the Employee Pre-Shift Medical Screening sheet. The DON/IP indicated she reviewed the Employee PreShift Medical Screening logs daily to ensure the the visitors/vendors and employee logs were complete. She indicated she reviewed them to make sure all staff working have been screened prior to working, for the temperature reading and that no yes answers were checked for the screening questions. She indicated the acceptable temperature reading range would be 96 F to below 100.4 F. She indicated for the temperature logged of 100.3 F on 10/8/20 should have been rechecked and documented as such on the screening form. On 10/29/2020 at 9:45 a.m., the DON/IP indicated the staff entered the facility through the back door and screened themselves, taking their temps and answering the screening questions. She indicated this was done online on the screening tool and if any answers to questions were yes this information would go to Employee Health at the Hospital. The DON/IP indicated she thought the staff had to complete both the online and the paper copies of the screening questions, when they checked themselves in. The DON/IP indicated the employee who had answered the screening question and/or temp in a manner that was out of the acceptable guidelines, she though Employee Health were quick to get the employee an answer. The DON indicated if a staff member was instructed by Employee Health they were not permitted to work, she, the DON would get an email indicating such. On 10/29/2020 at 3:30 p.m. the ADM provided a copy of Adams Health Network Employee Health COVID-19 Work Exclusion Guide dated 3/7/2020. The following was observed on the form: Symptoms: Fever (temp over 100.4) AND no other symptoms, work restrictions stay home Duration at least 24 hours of no fever without the use of fever-reducing medications .Symptoms: No fever AND one of more of the following: cough, sore throat, nasal congestion, runny nose, body aches; Work Restriction: high-risk units (OB or ICU) able to work in an alternate department with restrictions, may not enter high-risk departments; All other departments: able to work AND must report symptoms to supervisor or nursing supervisor AND must strictly follow hand hygiene and respiratory protection/cough etiquette policies .duration: For high risk units (OB or ICU) 24 hours have passed since the start of symptoms AND symptoms have significantly improved; Duration for All other departments: symptoms improve. The bottom of the form had documented high risk units include obestrics and intensive care units. For high risk units, there is zero-tolerance for working while ill . On 10/29/2020 at 3:30 p.m., the Administrator (ADM) and DON/IP were interviewed. They indicated the Employee Pre-Shift Medical Screening form should be completed thoroughly for vendors/visitors and/or staff. They indicated any yes answers on the screening form and/or temperatures out of range, should have been brought to the attention of a nurse for evaluation. 3. On 10/28/2020 at 12:30 p.m., the Director of Nursing/Infection Preventions (DON/IP) was interviewed. She indicated she had only been at the facility approximately 9 days. She indicated the following: of the current 41 residents in the facility, 18 of the residents were on the COVID unit in the red zone. She indicated the resident COVID cases began on 10/19/20. She indicated they had a church service at the facility on 10/15/20. Vendor 1 tested positive on 10/19/20. She indicated during the service, Vendor 1 wore a mask and the residents were socially distanced. She indicated they passed communion in separate cups. The DON/IP indicated of the 17 residents who went to that church service, 12 tested positive for COVID between 10/18 and 10/24/2020. On 10/28/2020 at 3:40 p.m. the ADM provided a copy of the sign in form Vendor 1 used to sign in on for the 10/15/2020 service he provided. The form was titled (name of facility) and had the following statements followed by a place to sign and date the form: I have read and agree to the guidelines in this policy, I understand non-compliance with this policy will result in denial of outdoor visitation . This form had the date 10/15 written in along with the signature of Vendor 1 and a written temperature. Documentation of lacking of screening questions being completed. On 10/29/2020 at 10:35 a.m. the BOM was interviewed. She indicated during the church service on 10/15/2020, Vendor 1 was observed to have a cloth mask on. She indicated the following for the church service on 10/15/20. She was observed to go to the large room where the church service was held. She indicated she sanitized her hands and then prepared the communion elements. She indicated the wine was poured into small individual type cups (no more than 1/2 wide rim at the top and 3/4 inch deep) and placed in a circular type plate with holders for the cups, which were under 1/2 in spaced apart. She indicated she then placed the wafers on the round dish in the center of the circular plate. She indicated she did not have gloves on and did not sanitize hands between passing the wafers and/or wine to each resident. She indicated she then took the plate around from table to table dispensing to the residents. She indicated she gave the resident a wafer. She indicated she tried to not touch the resident's hand but tried to drop the wafer in their hand. She indicated she either handed the resident a cup of wine and/or placed it on the table. Again, she did not sanitize her hands between passing the elements to each resident. On 10/29/2020 at 3:30 p.m., the ADM and DON/IP were interviewed. They were made aware of the incomplete screening of Vendor 1 on 10/15/2020 and indicated he should have been thoroughly screened. They indicated they understood areas of revision for infection control practices during the church service. 4. On 10/28/2020 at 12:35 p.m., the DON/IP indicated Vendor 2 was at the facility on 10/20/20 and tested positive for COVID on 10/22/20. She indicated of the 10 residents who had their hair done on 10/20/2020, 3 tested positive for COVID 19 between 10/22 and 10/26/2020. On 10/29/2020 at 11:50 a.m. Vendooor 2 was interviewed. She indicated she last worked on 10/20/2020. She indicated she wore a KN95 mask but no goggles and/or shield when she was working with the residents. She indicated she wears eyeglasses. 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during meal service potentially affecting 49 of 49 residents residing in the facility. Findings include: 1. An observation of the lunch meal hall service on 8/24/17 indicated the following: At 12:17 p.m., the meal cart was delivered to the Prairie Path Hall. CNA 10 was observed to push the meal cart down the hallway next to a hand sanitizer dispenser. CNA 10 was observed to use the hand sanitizer foam on her hands before she opened the meal cart door. She retrieved the meal tray from the meal cart and delivered it to a resident in their room. The CNA placed the meal tray on the overbed table and used both hands to move the overbed table in front of a resident seated in a recliner chair. The resident asked CNA 10 to open a package of crackers. CNA 10 was observed to go into the bathroom and wash her hands with soap and water for 10 seconds before she dried her hands with a clean, dry paper towel. CNA 10 then returned and was observed to open the package of crackers for the resident and put the crackers on the resident's plate. CNA 10 left the room and used hand sanitizer foam from the hall dispenser for hand hygiene. In an interview, the DON on 8/30/17 at 10:45 a.m., indicated during hand washing with soap and water, the staff should lather their hands for at least 20 seconds. She indicated hand foam sanitizer could be used for hand hygiene if the hands were not visibly soiled. She also indicated hand washing with soap and water should be done before meals. 2. An observation of lunch meal service, in the main dining room on 8/24/2017 indicated the following: At 11:20 a.m., CNA 8 was observed taking a residents plate from a Food Service Worker (FSW) with their thumb over the rim of the plate. At 11:25 a.m., FSW 1 was observed serving two plates of food to spearate residents in the dining room. FSW 1's thumbs were over the rims of the plates. At 11:29 a.m., FSW 1 was observed serving two plates of food to two different residents in the dining room. FSW 1's thumbs were over the rim of the plates. At 12:06 p.m., FSW 1 was observed serving two plates of food two additional residents in the dining room. FSW 1's thumbs were over the rim of the plates. During lunch meal service on 8/24/2017 between 11:19 a.m. and 12:12 p.m., several Food Service Workers had been observed opening the door with their bare hands to enter the kitchen, they picked up plates to be served. No hand hygiene was performed. The FSWs were also observed opening the door with their bare hands to serve plated meals without hand hygiene performed. The practice was observed several times during the meal service. 3. An observation of lunch meal service, in the main dining room on 8/28/2017 indicated the following: At 11:15 a.m., FSW 4 was observed serving two plates of food to residents in the dining room. FSW 4's thumbs were over the rim of the plates. During this same time, FSW 2 was observed serving two plates of food to residents in the dining room. FSW 2's thumbs were over the rim of the plates. Cook 6 was observed opening the kitchen door with their bare hand and serving a plate of food to a resident in the dining room with thumb over the rim of the plate. At 11:22 a.m., FSW 4 was observed serving two plates of food to residents in the dining room. FSW 4's thumbs were over the rim of the plates. During this time it was observed FSW 5 had served food onto a plate. FSW 5's thumb was over the rim of plate. They then placed it on the heat table. At 11:26 a.m., FSW 1 was observed serving two plates of food to residents in the dining room. FSW 1's thumbs were over the rim of the plates. During this time, FSW 2 was observed to have touched their face twice, before they opened the refrigerator, removed three plates of pastries and three dishes of applesauce. FSW 2, then opened the kitchen door with their bare hand and served residents the items off the tray. FSW 2 opened the kitchen door with their bare hands, then washed their hands at the sink inside the kitchen door. FSW 2 then picked up two plates of food to serve the residents in the dining room. FSW 2's thumbs were over the rim of the plates. During lunch meal service on 8/28/2017, several Food Service Workers had been observed opening the door with their bare hands, entered the kitchen, and picked up plates to be served with no hand hygiene performed. It was also observed the Food Sevice Workers opened the door with their bare hands to serve plated meals with no hand hygiene performed. The practice was observed several times during the meal service. During an interview on 8/28/2017 at 12:20 p.m., the Maintenance Supervisor indicated the kitchen door that opened into the dining room was a fire door and was not allowed to be propped open. During an interview on 8/29/2017 at 10:32 a.m., Lead Cook 9 indicated the plates should be carried without thumbs being over the rim of the plates. They indicated the door between the kitchen and dining room was a problem during meal service because of hands touching the handles to open the door. A policy titled Food Safety Program, dated 6/2017 and provided by Lead Cook 9 on 8/29/2017 at 11:56 a.m., indicated .H Handwashing 1. The most important aspect of personal cleanliness is frequent and thorough handwashing. Most oftern it will be dirty hands that transmit contaminants to the food product. 2.These activities, among others, should always be followed by handwashing: a. contact with infected or unsanitary areas of the body .c. hand contact with unclean equipment, surfaces, soiled clothing, and rags .3. Proper handwashing procedures: a. Turn on water to a temperature as warm as the hands can comfortably stand. b. Moisten the hands and apply a disinfectant soap to them lathering well beyond the wrists and as far up the arm as necessary. c. Pay particular attention to the areas between the fingers and around the nails. d. Rub one hand against the other using friction for 20 seconds. e. Rinse thoroughly under running water allowing the water to flow from above, down to the fingertips-this will rinse away contaminants. f. Dry hands thoroughly with sanitary single-service towels, turn off faucet with the hand towels and discard into a trash receptacle. NOTE: Be careful not to touch anything that contaminates the hands before returning to work. Wash hands as often as necessary to keep hands clean and sanitary at all times A current policy titled Infection Control in Nutritional Services, dated 8/3/2006, provided by Lead Cook 9 on 8/29/2017 at 11:56 a.m., indicated .Nutritional Services will maintain efficient, safe, and sanitary methods of food preparation and will provide patients, personnel, and the public with food free from contamination and spoliage. D. Food Service 1. Food should be served with clean utensils or other suitable implements to avoid direct hand contact with food A current form with no title, dated 2010 by the DHCC Inservice Manual, provided by the Lead Cook 9 on 8/30/2017 at 10:47 a.m., indicated, .Proper Tableware Techniques and included diagrams as to how bowls, plates, cups, glasses and utensils should be handled the diagrams indicated to carry plated food with no part of the hand or fingers over the rim of the plate. 3.1-21(i)(2)

Based on observation, interview and record review, the facility failed to ensure the kitchen floor and ceiling vents were maintained in a clean and sanitary manner. The facility further failed to ensure the dishwasher rinse temperatures were maintained at the manufacture's recommended temperature for dishware sanitation. The facility further failed to ensure all milk temperatures were checked prior to meal service and foods were dated as to when they were opened. This deficient practice had the potential to affect all 46 residents in the facility. Findings include: 1. On 7/5/16 at 10:10 a.m., the dishwasher was observed being used. Several loads of dishes had been observed to be processed through the dishwasher. At this time, Dishwasher Staff #1 was interviewed. She indicated her job was the Dishwasher and cook. She indicated the current wash temperature of the dishwasher was 164 degrees Fahrenheit (F), as she read the dial on the machine. As the dishes progressed to the rinse stage in the dishwasher, Dishwasher Staff #1 read the temperature of the rinse cycle as 175 degrees. At this time, Dishwasher Staff #1 was interviewed as to what the temperature of the rinse cycle should be. Dishwasher Staff #1 indicated it's just shy. A label on the dishwasher indicated wash temp (temperature) 160 degrees and rinse temp 180 degrees. Dishwasher #1 indicated the dishwasher sanitized the dishes by heat. At 10:43 a.m., the Food Service Manager (FSM) was asked to run the dishwasher and check the temperatures. She ran the dishwasher and read the wash temp at 158 degrees F. She said she wanted the dishwasher temp to be 160 F and she wanted the rinse temp (temperature) to be 180 F. At this time, the FSM ran 3 loads through the dishwasher and the highest rinse temp was 176 F. The 4th load of dishes was read at 184 degrees by the FSM. The FSM indicated the morning cook was the staff who runs the dishwasher and logs these temps. At this time, the dishwasher temp log for July 2016 was reviewed and all of the temps documented were 160 F for wash and 180 F for rinse. On 7/5/16 at 10:45 a.m., Cook #1 was interviewed. She indicated she ran the dishwasher when she arrived in the morning to ensure the temperatures are within normal limits. She indicated the desired temperature for the rinse cycle was 180 F. She indicated if the temps are off, she would then run another load through the dishwasher until the temps were up to what they were supposed to be. On 7/5/16 at 10:46 a.m., the FSM was interviewed. She indicated the dishwasher sanitized the dishes by heat. On 7/5/16 at 10:50 a.m., the FSM provided a copy of the Appliance Temp (Temperature) Log. This form was dated July 2016 and had the following temperatures documented for the dishwasher from 7/1/16 to 7/5/16. The dishwasher's wash temperature was documented daily as 160 degree F and the rinse temperature was 180 degrees F. On 7/5/16 at 10:55 a.m., the FSM was made aware of the prior dishwasher temps lower than 180 F on the rinse cycle. The FSM indicated she was not aware of the temp not being up to 180 F until this time. The FSM indicated the dishes had already been put away otherwise she would have run them through again. On 7/5/16 at 11:30 a.m., the FSM indicated the Maintenance Supervisor had adjusted the temperature on the dishwasher. At this time, the dishwasher was observed to have a rinse temperature of 184 degrees. On 7/12/16 at 12:25 p.m., the Food Service Manager (FSM) indicated when the Maintenance Man was made aware of the temperature of the rinse cycle on the dishwasher on 7/8/16 he adjusted the temperature so it would reach at least 180 degrees for the rinse cycle. On 7/12/15 at 12:55 p.m., the FSM provided a copy of the policy for Dishwasher Temperature Check with a date of 5/3/91. The policy included, but was not limited to, the following: .If the .rinse (temperature) is not at least 180 degrees, Maintenance will be notified immediately. 2. On 7/5/16 at 10:20 a.m., a gallon of 2% milk that was observed opened in the refrigerator. The container was 3/4 empty and there was no date as to when the gallon of milk had been opened. On 7/8/16 at 11 a.m., Cook #1 was observed to have three separate, gallon containers of milk. Cook #1 indicated she was checking the temperature of the milk prior to service. One of the gallons of milk was full and the other two were at least 1/2 empty. Cook #1 checked the temperature of the one gallon of milk that was full, by removing the lid and placing the thermometer into the gallon of milk. She read the temperature of the milk at 47.3 degrees Fahrenheit. She did not check the temperature of the remaining two, gallon containers of milk. On 7/8/16 at 11:10 a.m., the FSM was made aware of the temperature of the full gallon of milk and the two other gallons of milk, which had not had the temperature checked. At this time the FSM took the full gallon of milk, shook it up and rechecked the temperature. The FSM read the temperature of the milk at 44 degrees Fahrenheit. This gallon of milk was not served. At this time, the FSM checked the temperature of the two partial gallons of milk and the FSM read the temperature at 39 degrees F. The FSM then went to the dining room to check the temperature of the gallon of milk which had been placed on a slab of ice in a pan. The FSM read the temperature of the partial gallon of milk at 45 degrees F. She indicated she would replace this gallon of milk with another after verifying the temperature was within normal range. She indicated she wanted the temperature of the milk to be below 41 degrees. On 7/12/16 at 12:55 p.m., the FSM was interviewed. She indicated each gallon of milk should have had the temperature checked prior to service and also each gallon of milk should be labeled as to when it was opened. On 7/12/16 at 3:34 p.m., the FSM (Food Service Manager) provided a current policy and procedure for Cooling Foods. The policy and procedure was dated 4/20/09, and included but was not limited to, the following: .Once food is at proper temperature, it is labeled, dated and stored appropriately 3. On 7/5/16 at 10:40 a.m., two metal pans were observed on the floor underneath of the ice machine in the kitchen. The large oblong pan was observed to be entirely underneath the ice machine and was only visible from the floor. The other pan was positioned with 1/2 of the pan underneath the ice machine and the other 1/2 visible when standing at one of the two handwashing sinks, which was beside the ice machine. There was at least 4 inches of cloudy, water in the pan with a moth observed floating in the water. Also observed in the pan, was an unidentifiable substance, which appeared to be of food substance. On 7/8/16 at 8:35 a.m., the FSM was interviewed. She indicated the pans below the ice machine were just drip pans for leaking water. On 7/8/16 at 8:40 a.m., the Maintenance Supervisor was interviewed. He indicated the pans were placed on the floor to catch the condensation from the pipes underneath the ice machine. At this time, the floor between the back of the ice machine and the wall behind were observed. The ice machine was positioned at least 3-5 inches away from the wall. The floor was covered with dark debris, in some areas with the floor surface not visible due to the amount of dark material on the floor. The dark debris on the floor was observed along the entire width of the ice machine. On 7/8/16 at 9:10 a.m., Housekeeper #1 was interviewed. She indicated the floor beneath and around the ice machine should be cleaned every other night after supper. She indicated usually housekeeping cleaned the floors in the kitchen and the dietary department does the walls. Housekeeper #1 indicated there used to be a log for cleaning but that they don't have one now. At this time, Housekeeper #1 was mopping the floor behind the ice machine. She indicated she observed dust and black stuff behind the ice machine. The floor behind the ice machine appeared to be clean at this time. On 7/8/16 at 9:12 a.m., the FSM was interviewed. She indicated the items in the kitchen are to be pulled out away from the wall every night and cleaned behind and underneath them. She also indicated it doesn't look like the appliances have been pulled out as there were scattered crumbs and debris throughout the edge of the floor, especially up against the wall. She indicated the debris and crumbs on the floor appeared to be from more than 1 meal service/preparation. On 7/8/16 at 9:50 a.m., a multi tiered shelf was observed in the kitchen in the food prep area. This shelf was moved when pulled with one hand. The outline of the base of the shelf was visible on the floor where dark debris residue had accumulated around the base. On 7/8/16 at 10:05 a.m., there was scattered debris observed under the multi shelf which housed the paper products. This was located between the walk in freezer and the walk in refrigerator. Scattered debris was also observed underneath the food prep tables in the center island area of the kitchen. On 7/8/16 at 10:18 a.m., the FSM indicated the main traffic area in the dining room floor was clean but not underneath the appliances and the food prep tables. There were crumbs and bits of food and debris scattered along the edge of the wall around the perimeter of the kitchen. On 7/8/16 at 10:06 a.m., the Maintenance Supervisor, provided a copy of the current policy for Dietary Main Kitchen Area Cleaning. The policy was dated 3/1/00 and included, but was not limited to, the following: .Purpose: To ensure monthly cleaning of the moveable and stationary cooking equipment and fire wall .Procedure: .sweep under all kitchen equipment to remove any debris .wet mop the floor under and in front of the cooking equipment . At this time, the Maintenance Supervisor was interviewed. He indicated the floors were to be cleaned nightly and this included between and underneath equipment and food preparation tables and stations. On 7/8/16 at 10:20 a.m., the Maintenance Supervisor was made aware of the scattered dirt and debris observed on the floors, between and underneath the food preparation tables and appliances. The Maintenance Supervisor indicated at this time, It's obvious they didn't clean under things. On 7/8/16 at 11:00 a.m., two ceiling vents were observed over the door to the walk in refrigerator and the walk in freezer in the kitchen. The vent over the freezer door was observed to have a thick accumulation of grayish matter on the grates in an area of at least 6 inches in circumference. On 7/8/16 at 11:15 a.m., the FSM was made aware of of the piece of broccoli which was at least 1 inch in length, observed on the floor underneath a food prep table. At the time, the FSM reviewed the weekly menu and indicated the last time broccoli was served from the kitchen was on 7/4/16. On 7/8/16 at 11:27 a.m., the Maintenance Supervisor was made aware of the grayish matter on the ceiling vent over the walk in freezer. At this time, he brushed his hand over the vent and the grayish matter fell from the vent. The Maintenance Supervisor was interviewed at this time and indicated the vents had been cleaned not long ago but these vents must have been missed. 3.1-21(i)(3)

Based on observation, interview and record review, the facility's QA/PI (Quality Assurance /Performance Improvement) Committee failed to identify, implement and/or revise action plans for the identified concerns to ensure the facility's kitchen floors and vents were clean and sanitary, the dishwasher hot water temperature reached 180 degrees Fahrenheit to sanitize dishes, the temperature of the milk was measured prior to serving to the residents, and the foods and beverages were appropriately labeled with opened dates. The QA/PI Committee also failed to identify and ensure accurate documentation on the clinical records of the controlled substances administered to the residents were on the MAR (Medication Administration Record) and on the Controlled Substance sign out record. They also failed to ensure the effectiveness of the administered controlled medications were documented in the resident's clinical record. The Committee further failed to identify and ensure the controlled substance counts were correct and the controlled medications were sign out by the nurse when administered. These practices had the potential to affect 46 of 46 who reside in the facility. Findings include: The QA/PI Committee consisted of the facility's Administrator, all Department Managers, the Medical Director and Therapy. An interview with the DON (Director of Nursing) on 7/12/16 at 4:25 p.m., indicated the QA/PI Committee met monthly. The DON indicated she was the contact person and leader of the QA/PI Committee. She indicated all of the facility's Department Managers were on the committee and attended monthly. She also indicated the Medical Director attended the meeting monthly. She indicated the Pharmacy, Laboratory, Radiology were invited to the meeting quarterly or as needs arose. The DON indicated every Department Manager monitored and reported on concerns and action plans for their department. She indicated the committee had developed action plans for fall prevention and skin excoriations. She indicated several audits statistics were reviewed monthly, which included catheters, psychoactive medications, pressure ulcers, weight loss and weight gain and infections. She indicated Social Service informed the Committee of the Concern Reports which included resident and family concerns. She indicated she worked with the Resident Council President closely on identified concerns of the Council. She also indicated the Resident Council President, the Residents and staff could attend the QA/PI meetings. She indicated the facility had a Guardian Angle Rounds and the assigned staff talk with their assigned residents monthly and tried to resolve any problems or concerns right away. She indicated the Committee developed action plans for identified ongoing concerns. She indicated approaches were developed, implemented and then monitored for 6 months to 1 year after the goals were met. The DON indicated the QA/PI Committee had not identified the concerns found during the survey. She indicated they would develop action plans for accurate documentation of administration of narcotics and controlled substances. An action plan would be developed to provide sanitary kitchen, equipment and dishes, the food temperatures would be taken and labeled correctly. She further indicated the QA/PI Committee would develop action plan approaches to resolve the identified concerns and indicated it would take all departments and staff to work together to meet goals. On 7/12/16 at 4:00 p.m., a review of the facility's current policy, titled Performance Improvement, with revised dated of 05/11/16 was provided by the DON on 7/6/16 at 3:00 p.m., which indicated, .The quality Assurance Committee is responsible for identifying and monitoring areas that require preventive and corrective actions, particularly issues which negatively affect quality of care and services provided to residents. The Committee also develops and initiates plans of action to correct any identified quality of care problems, and evaluates results of corrective actions for implementation of problem resolutions ' 3.1-52(a)(2)

Based on observation, interview and record review, the facility failed to ensure personal care products, personal hand sanitizer and odor control chemicals were stored securely. This deficient practice had the potential to affect 25 confused and independently mobile residents of the 46 residents who resided in the facility. Findings include: On 7/6/16 at 1:13 p.m., the 100 hall medication (med) cart was observed positioned by the nurses station. In the left side of the med cart was observed to be an open type storage area. In this unsecured, open storage area was a spray can, labeled Odor Control and a bottle of hand sanitizer. At 1:15 p.m., a bottle of hand sanitizer was observed on the unattended med cart for the 200 hall. No nurses were observed at the nurses station and residents were observed walking and self propelling in wheelchairs around the nurses station area. On 7/6/16 at 2:18 p.m., the bathroom in Room # 215 was observed. On the back of the toilet, a 16.9 ounce (brand name) Cream Lotion was observed. On the bedside table, the following personal care products were observed; 2 ounce (Brand Name) lotion and 20 ounce (Brand Name) Lotion. All of the above personal care products had printed on the label Keep out of reach of children. On 7/6/16 at 2:29 p.m., in Room 212, a 24.5 oz bottle of (Brand Name) Lotion was observed in the bathroom on the back of the toilet. The label indicated Keep out of reach of children. Two residents shared this bathroom. On 7/6/16 at 2:32 p.m., in Room 211, a tube of (Brand name) Lotion was observed at the bedside with the following observed on the label: Keep out of reach of children. A shelf in the bathroom, which was at least 4 feet high, was observed to have the following on it: 6 ounce aerosol can of antiperspirant and an 8 ounce bottle of (Brand Name) of Peroxide mouth sore cleanser. Both products had Keep out of reach of children on the label. On 7/6/16 at 2:48 p.m. in Room 210, a 7 ounce bottle of (Brand Name) Lotion was observed on a table. The label indicated to Keep out of reach of children. On 7/7/17 at 9:05 a.m., the can of Odor Control and bottle of hand sanitizer remained in the opened storage area on the side of the 100 hall medication cart. On 7/12/16 at 11:00 a.m., the bathroom in Room # 215 was observed. On the back of the toilet a 16.9 ounce (brand name) Cream Lotion was observed. On the bedside table, the following personal care products were observed; 2 ounce (Brand Name) lotion and 20 ounce (Brand Name) Lotion. All of the above personal care products had printed on the label Keep out of reach of children. On 7/12/16 at 11:05 a.m., in Room 212, a 24.5 oz bottle of (Brand Name) Lotion was observed in the bathroom on the back of the toilet. The label indicated Keep out of reach of children. Two of the residents reviewed were observed to share this bathroom. On 7/12/16 at 11:10 a.m., in Room 211, a tube of (Brand name) Lotion was observed at the bedside with the following observed on the label: Keep out of reach of children. A shelf in the bathroom, which was at least 4 feet high, was observed to have the following on it: 6 ounce aerosol can of antiperspirant and an 8 ounce bottle of (Brand Name) of Peroxide mouth sore cleanser. Both products had Keep out of reach of children on the label. On 7/12/16 at 11:15 a.m. in Room 210, a 7 ounce bottle of (Brand Name) Lotion was observed on a table. The label indicated to Keep out of reach of children. 2. During the initial observation of the Residents' rooms the following was observed: An observation in room 102 on 7/5/16 at 3:10 p.m., in the bathroom, indicated two - 1.5 ounce (oz.) cans of shave cream, the label indicated .Keep out of reach of children One - 3 oz. (Brand) pre-electric shave lotion, product information indicated, .May cause eye irritation .skin irritation .harmful if swallowed in large quantities .respiratory tract irritation An observation in room 112 on 7/5/16 at 3:50 p.m., in the bathroom, indicated a 2.6 oz. (Brand) solid antiperspirant and a 16 fluid oz. bottle of (Brand) dry skin lotion were sitting on an open shelf by the sink near the door. The shelf was about 4' from the floor. Both products were labeled with .Keep out of reach of children An observation in room 106 on 7/6/16 at 3:36 p.m., in the bathroom, indicated one - 2.4 oz. tube of (Brand) denture adhesive was sitting on an open shelf by the sink near the door. The shelf was about 4' from the floor. The product information indicated, .This paste may produce transient eye irritation. Ingestion of large amounts my cause nausea or vomiting. Esophageal blockage could occur in rare cases An observation in room 108 on 7/6/16 at 4:40 p.m., in the bathroom, indicated a 3 ounce (oz.) shaker bottle of antifungal powder, three - 1.5 oz. of antiperspirant and one, 2 oz. spray bottle of (Brand) odor remover were sitting on an open shelf by the sink near the doorway. The shelf was about 4 feet off the floor. Each product was labeled with keep out of reach of children. Additional personal care products were in the bathroom and stored on tall free standing open shelving unit with 4 shelves, the following were products were observed on the open shelves: One -24 oz. bottle of (Brand) mouthwash, the label indicated, .Keep out of reach of children One - 1.5 oz. roll on antiperspirant, the label indicated, .Keep out of reach of children One - 1 fluid oz. bottle of (Brand) baby shampoo, the label indicated, .Keep out of reach of children One - 14 oz. bottle of (Brand) cocoa butter lotion, the label indicated, .Keep out of reach of children One box of (Brand) denture cleanser tablets, the label indicated, Keep out of reach of children . One can of aerosol hairspray, the label indicated, .Keep out of reach of children Additional products were observed to be stored on the open shelving unit. An observation in room 103 on 7/7/16 at 9:36 a.m., in the bathroom, a 1.5 oz. roll-on antiperspirant was sitting on an open shelf by the sink near the doorway. The shelf was about 4 feet off the floor. The product label indicated, .Keep out of reach of children 3. Observation of Resident's rooms on 7/12/16 from 10:15 a.m. to 10:45 a.m., indicated the following: An observation of room 102 at 11:15 a.m., in the bathroom, indicated, one - 1.5 oz. can of shave cream, the label indicated .Keep out of reach of children One - 4 oz. bottle of (Brand) smooth and cool fresh moisturizing body lotion with aloe, the label indicated, .for external use only An observation of room 103 at 11:20 a.m., in the bathroom, a 1.5 oz. can of shave cream was sitting on an open shelf by the sink near the doorway. The shelf was about 4 feet off the floor. The product label indicated, .Keep out of reach of children On the bedside table was sitting one - 10 fluid oz. bottle of (Brand) dry skin lotion, the label indicated, .External use only .Do not get in eyes .Keep out of reach of children On the window sill was sitting one 22 oz. (Brand) baby powder, the label indicated, .avoid inhalation .Avoid contact with eyes An observation of room 106 at 11:25 a.m., in the bathroom, a 2 oz. tube of (Brand) moisturizing body cream was sitting on an open shelf by the sink near the doorway. The shelf was about 4 feet off the floor. The product label indicated, .Keep out of reach of children In case of accidental ingestion seek professional assistance or Contact Poison Control Center An observation in room 108 on 7/12/16 at 11:30 a.m., in the bathroom, indicated a 4 oz. tube of (Brand) Callazime skin protective paste, a 3 ounce (oz.) shaker bottle of antifungal powder, three - 1.5 oz. antiperspirant and one - 2 oz. spray bottle of (Brand) odor remover were sitting on an open shelf next the doorway close to the sink. The shelf was about 4 feet off the floor. Each product was labeled with keep out of reach of children. On the back of the toilet sat a 24.5 oz. bottle of (Brand) Cocoa butter body lotion, the label indicated, .Keep out of reach of children Additional products in the bathroom were stored on a 5' (foot) free standing open shelving unit with 4 shelves. The following were products were observed on the open shelves: One -24 oz. bottle of (Brand) mouthwash, the label indicated, .Keep out of reach of children One 0.85 oz. tube of toothpaste, the label indicated, .Keep out of reach of children under 6 years old .Do not swallow One - 1 fluid oz. bottle of (Brand) baby shampoo, the label indicated, .Keep out of reach of children One box of (Brand) denture cleanser tablets, the label indicated, Keep out of reach of children . One 20 oz. bottle of (Brand) shampoo and conditioner, the label indicated, .for external use only . One - 2 oz. tube of Once a Day moisturizer body cream, the label indicated, .Keep out of reach of children One 2.2 oz. tube of (Brand) denture adhesive cream, The product information indicated, .This paste may produce transient eye irritation. Ingestion of large amounts my cause nausea or vomiting. Esophageal blockage could occur in rare cases One -12 oz. bottle (Brand) fragrance free daily moisturizing lotion, the label indicated, .Keep out of reach of children One - 13.5 oz. bottle of (Brand) in-shower lotion, the label indicated, Keep out of reach of children . One - 8.4 oz. bottle of (Brand) mouthwash, the label indicated, .Keep out of reach of children An observation in room 112 on 7/12/16 at 11:45 a.m., in the bathroom, indicated a 2.6 oz. (Brand) solid antiperspirant and a 16 fluid oz. bottle of (Brand) dry skin lotion were sitting on an open shelf by the sink near the door. The shelf was about 4' from the floor. The products were labeled with .Keep out of reach of children On 7/12/16 at 10:50 a.m., the Social Service Director provided a current list of residents, who the facility indicated, were alert, confused and independently mobile. The list indicated of the 46 residents in the facility, 25 of them were considered alert, confused and mobile. After further review of the list provided, 6 of the residents, who the facility identified as confused and independently mobile, were observed to have personal care products unsecured in their rooms. On 7/12/16 at 12:49 p.m., the DON (Director of Nursing) provided the following Safety Data Sheets for the following products: (product name) Odor Eliminator and Quick Care Foam Hand Sanitizer. The Safety Data Sheet for the Odor Eliminator included, but was not limited to, the following: Hazards Identification .may cause an allergic skin reaction .may cause respiratory irritation .avoid spraying in eyes .Precautions for Safe Storage: .Keep out of reach of children .Do not inhale vapors, Avoid contact with eyes, do not ingest, observe all label precautions The Safety Data Sheet for the Foam Hand Sanitizer, included but was not limited to, the following: Flammable liquid and vapor and causes serious eye irritation . On 7/12/16 at 12:49 p.m., the DON (Director of Nursing) provided the following policy, which was dated 10/2011: Resident Rights. The policy included, but was not limited to, the following: .A resident has the right to .A safe, clean .homelike environment . 3.1-45(a)(1)

Based on interview and record review, the facility failed to identify inaccuracies and missing doses on controlled drug use records for 2 of 41 controlled drug use records reviewed. Further, the facility failed to identify discrepancies in the administration of narcotic medications for 2 residents (Resident #29, Resident #13). Findings include: 1. On 7/8/16 at 11:00 a.m., the clinical record of Resident #29 was reviewed. [DIAGNOSES REDACTED]. The record indicated a current physician's orders [REDACTED]. Resident #29 had two controlled drug use records for morphine 2.5 mg by mouth every 4 hours as needed for pain/SOB. Record #1 had a starting quantity of 20 doses which were signed out between 2/14/16 and 6/27/16. Record #2 had starting quantity of 8 doses which were signed out between 6/28/16 and 6/8/16 (sic). On 5/9, 5/15, and 5/29/16, documentation on the Medication Administration Record (MAR) indicated a morphine dose was given but did not indicate the reason for morphine use (pain/shortness of breath) nor the effectiveness of the medication after administered. Documentation was lacking in the NN (nurses notes) of the receipt and/or response to the prn (as needed) medication. On 5/22 and 5/28/16, Resident #29 's controlled drug use record #1 indicated morphine 2.5 mg was signed out. Documentation was lacking on the MAR of times the morphine had been administered. Documentation was lacking in the NN (nurses notes) of the receipt and/or response to the prn medication. On 6/26 and 6/27/16 at 12:00 p.m. and 11:00 p.m., Resident #29 ' s controlled drug use record #1 indicated morphine 2.5 mg was signed out. Documentation was lacking on the MAR of times the morphine had been administered. Documentation was lacking in the NN (nurses notes) of the receipt and/or response to the prn medication. On 6/28/16 at 4:00 a.m., Resident #29 ' s controlled drug use record #2 indicated morphine 2.5 mg was signed out. Documentation on the MAR indicated a morphine dose given but did not indicate reason for morphine use (pain/shortness of breath) nor effectiveness of medication after administered. Documentation was lacking in the NN (nurses notes) of the receipt and/or response to the prn medication. On 7/3 at 4:46 a.m. and 11:07 p.m. and 7/4/16 at 4:00 a.m. and 8:26 p.m., documentation on the MAR indicated a morphine dose given but did not indicate reason for morphine use (pain/shortness of breath) nor effectiveness of medication after administered. Documentation was lacking in the NN (nurses notes) of the receipt and/or response to the prn medication. Further review of Resident #29 ' s controlled drug use record #2 indicated starting quantity of 8 doses of morphine 2.5 mg with the following sign out dates, times, amount on hand, amount given and amount remaining signed out by the nurse: On 6/28/16 at 4:00 a.m., 8 doses were on hand, one dose was given, and 7 doses remained. On 6/2/16 at 8:00 p.m., 7 doses were on hand, one dose was given, and 6 doses remained. On 6/3/16 at 4:00 a.m., 6 doses were on hand, one dose was given, and 5 doses remained. On 6/3/16 at 8:00 p.m., 5 doses were on hand, one dose was given, and 4 doses remained. On 6/4/16 at 4:00 a.m., 3 doses were on hand, one dose was given, and 2 doses remained. Crossed out with a line through the notation indicated that on 6/4/16 at 8:00 a.m., 2 doses were on hand, one dose was given, and 1 dose remained. On 6/7/16 at 11:00 p.m., 2 doses were on hand, one dose was given and 1 with a 0 written over it, was written at dose remained. On 6/8/16 at 4:00 a.m., 1 dose was on hand, one dose was given, and 0 doses remained. On 6/2, 6/3, 6/4, 6/7, and 6/8/16, Resident #29 ' s controlled drug use record #2 indicated morphine 2.5 mg was signed out. Documentation was lacking on the MAR of time/dates the morphine had been administered. Documentation was lacking in the NN (nurses notes) of the receipt and/or response to the prn medication. On 7/8/16 at 12:35 p.m., during an interview, the Director of Nursing (DON) indicated she had not been aware of any discrepancies with controlled drug use records or missing doses for residents in the facility until this day. Daily shift count sheets for controlled drug use records did not indicate any discrepancies with controlled substances from 4/25/16 through the present date. On 7/12/16 at 11:35 a.m., the DON indicated the facilities pharmacy does not manage or monitor controlled medications provided by hospice agencies providing care and services to residents of the facility. Manifest forms for controlled medications are provided to the DON when they are delivered to the facility from the pharmacy supplying these medications for the hospice agency. Upon receipt of controlled medications, generic controlled drug use records are initiated by nursing staff and used to reconcile controlled medications at each shift. 2. On 7/8/16 at 12:05 p.m., RN #2 was observed trying to reconcile Resident #13 ' s controlled drug use record for Norco 5/325 mg tablets. She indicated there were 14 doses of Norco 5/325 mg tablets present which did not match the controlled drug use record indicating 15 doses remained. RN #2 indicated the discrepancy would be reported to the Director of Nursing (DON) per facility policy. On 7/8/16 at 12:15 p.m., the clinical record of Resident #13 was reviewed and indicated diagnoses, included but were not limited to, cancer. The record indicated an order dated 4/5/16 for Norco 5/325 mg tablets, take 1 tablet by mouth every 6 hours as needed for pain. On 4/20/16, Resident #13 ' s controlled drug use record indicated Norco 5/325 mg tablet was signed out. Documentation was lacking on the MAR and NN of time the Norco 5/325 mg tablet was administered and/or response to the prn medication. On 4/25/16 at 10:00 a.m., Resident #13 ' s controlled drug use record indicated Norco 5/325 mg was signed out and 15 tablets remained. On 7/8/16 at 12:35 p.m., during an interview, DON indicated she had not been aware of any discrepancies with controlled drug use records or missing doses for residents in the facility until this day. Daily shift count sheets for controlled drug use records did not indicate any discrepancies with controlled substances from 4/25/16 through the present date. Further, she agreed the controlled drug use record for Resident #13 indicated 15 tablets remained but only 14 tablets were present when counted. On 7/8/16 at 12:54 p.m., RN #1 indicated nurses counted controlled substances at the beginning and end of their shift. If discrepancies were found, nurses would attempt to determine cause of the discrepancy and if unable to determine, would notify the DON. On 7/8/16 at 1:45 p.m., RN #3 indicated it was the facilities policy to conduct a physical inventory of controlled substances at the beginning and end of each shift worked. Any discrepancies were reported immediately to the DON. On 7/11/16 at 9:44 a.m., the DON provided a current policy titled CONTROLLED SUBSTANCE STORAGE indicated the following: . Procedures .F. At each shift change or when keys are transferred, a physical inventory of all controlled substances, including the emergency supply is conducted by two licensed nurses and is documented .G. Any discrepancy in controlled substance counts is reported to the director of nursing immediately .K. The consultant pharmacist or designee routinely monitors controlled substance storage, records (i.e.individual controlled substance accountability sheets, MARS .during (monthly) medication storage inspection 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure staff washed their hands for the recommended amount of time, after touching residents and soiled objects, and before assisting residents with their meals and feeding residents their meals. The facility also failed to protect clean clothing protectors from potential contamination. The facility further failed to ensure foods kept in the pantry freezer/refrigerator were properly labeled and dated and the refrigerator was clean and free of spills. This deficient practice had the potential to affect 46 of 47 residents who received food and beverages prepared, served, and stored by the facility. Findings include: 1. During an observation of the lunch meal in the dining room on 8/17/15, the following was observed: At 11:11 a.m., Certified Nursing Assistant (CNA) #1 was observed to lather her hands for 14 seconds prior to rinsing. She was then observed to sit down next to residents seated at a dining room table. At 11:13 a.m., CNA #2 was observed to lather her hands for 9 seconds prior to rinsing. She was then observed to assist with meal service. At 11:15 a.m., CNA #2 was observed to lather her hands for 4 seconds prior to rinsing. She was observed to move a resident seated in a geri-chair closer to a dining room table and also move a small stool on wheels with her bare hands next to a resident seated at a dining room table. She was then observed to leave the dining room. At 11:16 a.m., CNA #1 was observed to get up from the table where she was seated, move to the handwashing sink, and lather her hands for 11 seconds prior to rinsing. She was then observed to sit down next to residents seated at a dining room table. At 11:18 a.m., CNA #2 was observed to re-enter the dining room. She was observed to lather her hands for 6 seconds prior to rinsing. She was then observed to sit down next to a resident seated at a dining room table. At 11:20 a.m., CNA #2 was observed to leave the dining room. At 11:23 a.m., CNA #2 was observed to push a resident seated in a wheelchair into the dining room and up to a dining room table. She was observed to pick up a clean clothing protector and place it on the resident without washing her hands. At 11:24 a.m., CNA #2 was observed to lather her hands for 7 seconds prior to rinsing. She was then observed to sit down next to a resident seated at a dining room table. At 11:25 a.m., CNA #2 was observed to get up from the dining room table where she was seated and close the window blinds. She was then observed to lather her hands for 12 seconds prior to rinsing and return to the same dining room table. At 11:26 a.m., CNA #1, who was still seated next to a resident at a dining room table, picked up the resident's eating utensils and prepared the food for her to eat. She was not observed to wash her hands prior to handling the eating utensils. At 11:27 a.m., CNA #1 was observed to get up from the dining room table where she had been seated, move to the handwashing sink, and lather her hands for 11 seconds prior to rinsing. She was then observed to return to the dining room table, pick up the eating utensils for a resident, feed the resident the lunch meal, and move glasses of beverages around the table by touching the rims of the glasses. At 11:31 a.m., CNA #2 was observed to leave the dining room At 11:37 a.m., CNA #2 was observed to re-enter the dining room. She was observed to lather her hands for 14 seconds prior to rinsing. She was then observed to sit at a table next to a resident, pick up the resident's eating utensils, and begin to feed the resident the lunch meal. At 11:39 a.m., CNA #2 was observed to remove a resident from the dining room. At 11:43 a.m., CNA #2 was observed to re-enter the dining room. She was observed to lather her hands for 11 seconds prior to rinsing. She was then observed to sit at a table next to a resident seated at a dining room table and assist the resident with the lunch meal. At 11:45 a.m., CNA #1 was observed to get up from the dining room table where she had been seated. She was observed to move to the handwashing sink and lather her hands for 7 seconds prior to rinsing. She then returned to the dining room table, picked up the resident's knife and fork, and cut up her food for her to eat. At 11:47 a.m., CNA #2 was observed to stand up from the table where she had been seated. She was observed to rest her right hand on the back of a resident's geri-chair. She was then observed to sit down by pulling her slacks up with her hands and continued assisting residents with their lunch meal. She was not observed to wash her hands after touching soiled objects. At 11:48 a.m., CNA #1 was observed to get up from the table where she had been seated, move to the handwashing sink, and lather her hands for 8 seconds prior to rinsing. She was observed to return to the same dining room table, assist a resident with the lunch meal and feed another resident the lunch meal. At 11:50 a.m., CNA #2 was observed to remove menus from several dining room tables and clear dirty dishes from a place setting at a dining room table. She was then observed to leave the dining room. At 11:51 a.m., CNA #2 was observed to re-enter the dining room. She was observed to lather her hands for 15 seconds prior to rinsing. She was then observed to sit at a dining room table and feed a resident the lunch meal. 2. During an observation of the facility pantry on 8/17/15 at 12:03 p.m., the following was observed: In the freezer section of the refrigerator in the facility pantry, there were 3 microwaveable meals not labeled or dated and a paper sack containing homemade ice cream sandwiches not labeled or dated. In the refrigerator in the facility pantry, there was a large spill of a dried sticky substance underneath the vegetable bins. The floor of the pantry was sticky. 3. During an observation of the lunch meal in the dining room on 8/19/15, the following was observed: At 11:41 a.m., CNA #3 was observed to lather her hands for 16 seconds prior to rinsing. She was then observed to move a small stool on wheels over to a dining room table with her bare hands. She then was observed to re-wash her hands, lathering her hands for 13 seconds prior to rinsing. She was then observed to sit down next to a resident seated at a dining room table to assist the resident with the lunch meal. At 11:46 a.m., CNA #3 was observed to get up from the table to assist a resident in a wheelchair. She was observed to move to the handwashing sink and lather her hands for 11 seconds prior to rinsing. She was then observed to return to the dining room table where she had been seated to assist residents with the lunch meal. At 11:53 a.m., CNA #2 was observed to enter the dining room and pick up clean clothing protectors for residents without washing her hands. She was observed to place clean clothing protectors on residents while holding the other clothing protectors between her arm and her uniform. She was then observed to move to the handwashing sink and lather her hands for 16 seconds prior to rinsing. She then sat down at a dining room table to assist residents with their lunch meal. At 11:59 a.m., CNA #2 was observed to stand up from the table where she had been seated by pulling her chair back from the dining room table with her right hand so a dietary person could deliver a resident's food. She was observed to butter the resident's dinner roll without washing her hands. The dinner roll was left on top of the tablecloth and not placed back on the resident's plate. The resident was observed to eat the dinner roll. CNA #2 was then observed to leave the dining room table ,move to the handwashing sink, and lather her hands for 15 seconds prior to rinsing. She was observed to return to the dining room table to feed a resident and assist another resident with the lunch meal. At 12:10 p.m., CNA #2 was observed to push a resident seated in a wheelchair from the dining room into the hallway. She was observed to re-enter the dining room and lather her hands for 11 seconds prior to rinsing. She was then observed to sit down next to a resident seated at a dining room table by pulling her slacks up with her hands. She then handled a glass of juice for a resident, and picked up the resident's eating utensils to prepare the food for her to eat. At 12:14 p.m., CNA #2 received bowls of food for a resident and began to feed her. She was not observed to wash her hands At 12:23 p.m., CNA #4 was observed to push a resident seated in a wheelchair into the dining room. She was then observed to place a clean clothing protector on the resident without washing her hands. At 12:27 p.m., CNA #3 was observed to enter the dining room and lather her hands for 10 seconds prior to rinsing. She was then observed to to sit next to a resident seated at a dining room table and handle the resident's clean clothing protector. At 12:30 p.m., CNA #3 was observed to assist the same resident to eat by handling her eating utensils. The Director of Nursing (DON) was interviewed on 8/20/15 at 2:50 p.m. During the interview she indicated clean clothing protectors should not be held up against a staff's uniform, but questioned why staff should have to wash their hands prior to putting a clean clothing protector on a resident. She also indicated she had instructed the CNAs to wash their hands to a quick rendition of the Happy Birthday song, approximately 10-12 seconds. When queried, she indicated staff did not have enough time to stand at the sink and wash their hands for 20 seconds. She further indicated food items in the pantry refrigerator/freezer and the cleanliness of the refrigerator/freezer and the pantry were the responsibility of the Dietary Department. The Certified Dietary Manager (CDM) was interviewed on 8/20/15 at 4:00 p.m. During the interview she indicated the Dietary Department was responsible for stocking the pantry, throwing un-dated and un-labeled items away, and keeping it clean. The CDM was interviewed on 8/21/15 at 1:30 p.m. During the interview she indicated the 3rd shift in the Dietary Department were to clean the pantry everyday. A current facility policy Handwashing, revised on 9/06 and provided the CDM on 8/20/15 at 3:03 p.m., indicated .To minimize the risk of infection to the patient and caregiver. To prevent direct and indirect transfer of micro-organisms from care provider to patient .Moisten hands and apply soap .Wash hands for 20 seconds to one minute as indicated .Hands should be washed .After contact with patient .before handling food A current facility policy Village Pantry, with a revision date of 07/13 and provided by the CDM on 8/20/15 at 3:03 p.m., indicated .Food items stocked in Village Pantry will be kept safe and sanitary .All foods will be labeled by identification and dated at which date the items are to be thrown out .Refrigerators will be checked for outdated items A current facility policy Handling/Transport/Storage of Clean Linen. with a review date of June 26, 2015 and provided by the DON on 8/21/15 at 10:46 a.m., indicated .Hand hygiene must be performed immediately before handling clean linen .Always handles clean linen in a sanitary manner by keeping linen away from clothing & off of possible contaminated surfaces 3.1-21(i)(2)

Based on interview and record review, the facility failed to attempt a gradual dose reduction for a [MEDICAL CONDITION] medication for 1 resident (Resident #37) of 5 residents reviewed for unnecessary medication. Findings include: Review of the clinical record for Resident #37 on 8/18/15 at 2:28 p.m., indicated the following: [DIAGNOSES REDACTED]. A Psychiatry Note for Resident #37, dated 6/11/14, indicated she had been diagnosed with [REDACTED]. The note also indicated there was no depression, no euphoria, no emotional lability, no hostility, not suicidal, no compulsive behavior, no impulsive behavior, no unusual behavior, no violent behavior, no disturbing or unusual thoughts, feelings, or sensation, no unreasonable or irrational fears, no magical thinking, not having fantasies, no interpersonal relationship problems, no emotional problem/concerns, no sleep disturbances, normal functioning ability, and no character deficiency. The note further indicated she exhibited hallucinations, but exhibited no delusions. The note indicated the plan to start [MEDICATION NAME] (anti-psychotic medication) 0.25 mg (milligrams) daily at HS (hour of sleep). A Psychiatric Follow-up Note for Resident #37, dated 6/25/14, indicated the current [DIAGNOSES REDACTED]. The note recommended to continue [MEDICATION NAME] 0.25 mg HS. A [MEDICAL CONDITION] Medication Meeting note for Resident #37, dated 6/17/15, indicated her behaviors and moods were stable. The note also indicated to not adjust her medication. A physician's orders [REDACTED]. A Social Service Note for Resident #37, dated 9/12/14, indicated her [DIAGNOSES REDACTED]. The note also indicated her medications included [MEDICATION NAME]. The note further indicated there were no negative behaviors cited by staff. An Adverse Behaviors/Moods/Interventions note for Resident #37, dated 9/17/14, indicated she was stable, her behaviors had decreased substantially, and not to adjust her medications. A Social Service Note for Resident #37, dated 12/4/14, indicated she continued to receive [MEDICATION NAME]. The note also indicated there were no behaviors noted. An Adverse Behaviors/Moods/Interventions for Resident #37, dated 12/17/14, indicated she displayed disorganized speech, inattention, and trouble concentrating on 12/17/14. The Recommendations/Notes indicated to not adjust her medications (contraindicated statement from MD and family/POA). There was no documentation in the clinical record of a physician contraindication statement. A Note to Attending Physician/Prescriber from the Pharmacy for Resident #37, dated for the month of December 2014, indicated she was receiving [MEDICATION NAME] 25 mg HS and the [MEDICATION NAME] was due for a GDR (gradual dose reduction). The note also indicated per discussion with the behavior management team, the resident continued to exhibit behaviors and a reduction did not seem to be in her best interest. The note further indicated Resident #37's physician agreed. There was no additional documentation or tracking of behaviors or symptoms in the clinical record, and no documentation in the clinical record of a physician contraindication statement. A Physician visit note for Resident #37, dated 2/20/15, indicated the [MEDICATION NAME] would not be changed per pharmacy recommendation. A Social Service Note for Resident #37, dated 5/20/15, indicated she continued to receive [MEDICATION NAME]. The note also indicated there were no negative behaviors noted. A [MEDICAL CONDITION] Medication Meeting note for Resident #37, dated 6/17/15, indicated her behaviors and mood were stable and to not adjust her medications. A physician's orders [REDACTED]. A Nursing Note for Resident #37, dated 7/2/15, indicated to change [DIAGNOSES REDACTED]. A Note to Attending Physician/Prescriber from the Pharmacy for Resident #37, dated 7/15/15, indicated she was receiving [MEDICATION NAME] 0.25 mg for dementia with behaviors and the [MEDICATION NAME] was due for a GDR. A handwritten note from the Director of Nursing on the GDR request from the pharmacy, dated 7/20/15, indicated she was under the care of a Psychiatrist and the facility had a contraindication statement for the resident. There was no documentation the resident had seen a psychiatrist since 6/11/14, no documentation or tracking of behaviors or symptoms in the clinical record, and no documentation in the clinical record of a physician contraindication statement. Review of the Nursing Notes for Resident #37, dated 7/31/15 through 8/20/15, only indicated 1 episode of delusional thinking on 8/11/15. Review of Resident Care Meeting Notes, dated from 8/22/14 through 8/3/15, did not indicate Resident #37 displayed any adverse behaviors or moods. A Resident Care Guide for Resident #37, with a start date of 5/8/14, indicated she could become confused, lost, agitated at times, combative, and argumentative. The guide also indicated she could be redirected. The guide did not include the symptom of delusions. A statement from Resident #37's physician, dated 8/20/15, indicated It is has been in the past and is now also clinically contraindicated to attempt reduction of this medication. Resident is on the lowest possible dose to address her condition (recommended dose for geriatric patients is 0.5 mg daily - bid (twice a day); patient is only on 0.25 mg Q (every) HS daily. Reducing or discontinuing this medication would severely impair the resident's function and increase distressed behavior. Reducing this medication would also likely increase the instability of her known psychiatric diagnosis. A copied page from Mosby's 2014 Nursing Drug Reference, provided by the Director of Nursing (DON) on 8/20/15 at 11:45 a.m., indicated a Black Box Warning for [MEDICATION NAME] with increased mortality in elderly patients with dementia-related [MEDICAL CONDITION]. A facility care plan for Resident #37, with a review date of 5/27/15, indicated the problem area of [DIAGNOSES REDACTED]. Approaches to the problem included, but were not limited to, administer medications as ordered, keep physician updated, observe for adverse moods and/or behaviors and document, attempt to identify environmental triggers, medical condition, or other factors that may be causing adverse issues and attempt to resolve, and provide guidance, supervision, and cues as needed to maintain health and safety. The Director of Social Service was interviewed on 8/19/15 at 1:45 p.m. During the interview she indicated any behaviors a resident may exhibit were to be documented in the nursing notes. She also indicated during each morning meeting, the DON would print off any nursing notes of the residents who had exhibited behaviors for discussion. She further indicated the nursing notes printed off by the DON were how she received the information concerning behaviors of residents. She also indicated Resident #37 was not seen by the Psychiatrist on a regular basis, but only once per year. A family member of Resident #37 was interviewed with the DON on 8/20/15 at 9:15 a.m. During the interview he indicated when Resident #37 was admitted to the facility she would yell, pace, and cry. He also indicated her physician tried her on numerous medications and the Psychiatrist had placed her on [MEDICATION NAME]. He further indicated after she was started on the [MEDICATION NAME], a nurse from the facility contacted him telling him the medication was not appropriate for individuals diagnosed with [REDACTED]. The DON and Administrator were interviewed on 8/20/15 at 3:00 p.m. During the interview they indicated Resident #37 had done well on the [MEDICATION NAME] and they would work hard to keep her on it. They also indicated she had continued to have behaviors, but they were not documented. They did not indicate she had displayed any delusional behaviors. A current facility policy Anti-Psychotic Drugs, with a revision dated of 10/11 and provided by the Director of Social Services on 8/20/15 at 11:55 a.m., indicated .The physician in coordination with the Behavior Management team will continually re-evaluate the need for the drug and suggest drug holidays or reduction of dosage to the lowest possible dose to control symptoms 3.1-48(a)(2)

Based on observation, interview and record review, the facility failed to ensure the glucometers were cleaned with a disinfectant after each use which had the potential to affect 1 of 6 residents reviewed who required glucometer checks. (Resident #44) Findings include: An observation, on 7-16-2014 at 11:23 a.m., indicated Nurse #1 used a glucometer to check Resident #44's blood sugar. Nurse #1 was observed to clean the glucometer after the procedure with a Hygea antiseptic wipe. Nurse #1 indicated the wipe was left surrounding the glucometer for 2 minutes, then removed. An interview with Nurse #2, on 7-16-2014 at 4:05 p.m., indicated the Hygea antiseptic wipe was used to clean the glucometers after use for the Residents' blood sugar checks. An interview with Nurse #3, on 7-16-2014 at 4:15 p.m., indicated there were 2 glucometers, one for each medication cart. Further interview with Nurse #3, indicated the facility began using the Hygea antiseptic wipes a couple months ago. An interview with the Director of Nursing (DON), on 7-17-2014 at 10:10 a.m., indicated the DON was not aware the Hygea antiseptic wipe was being used for cleaning the glucometers. The DON indicated the Hygea had been in use in the facility around 2 months and the DON indicated the Hygea was not the correct product for cleaning the glucometers. An undated copy of the manufacturer's cleaning instructions for the "ACCU-CHEK [MEDICATION NAME] meter" (the type of glucometer used by the facility) provided by the DON on 7-17-2014 at 10:22 a.m., indicated "to...disinfect...with one of these cleaning solutions: Super Sani-Cloth, 70% rubbing alcohol...10% household bleach solution...." A policy "Infection Control Policy for Glucometers", dated 7-8-2014, and provided by the DON on 7-17-2014 at 10:22 a.m., indicated "the hand held glucose meters should be disinfected after each use...supplies...cleaning solution: Clorox Germicidal wipes or Super Sani-Cloth disposable germicidal wipes are acceptable for use in cleaning the ACCU-Check...system...." 3.1-18(b)(1) 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure weight records were accurate for 3 residents (Resident #24, Resident #20, and Resident #5) and failed to document the reason for a difference in weight for 1 resident(Resident #65) which had an affect for 4 of 5 residents reviewed for weight loss. Findings include: 1. The clinical record of Resident #24 was reviewed. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) Assessment, dated 5/29/14, included, but was not limited to, the following: cognition was independent; height 58 inches; weight 99 pounds (lbs.); independent in eating status; and had been taking a diuretic for the last 7 days. A "Weight Tracking System Report" was received from the DON (Director of Nursing) on 7/15/14 at 11 a.m. The report included, but was not limited to, the following weights for 2014: 4/7=98.8 lb.; 5/2=86.8 reweigh; 6/3=87 lb reweigh; 7/3= 99.1 lb reweigh. On 7/17/14 at 3:24 p.m., the Medical Records (MR) LPN was interviewed. She indicated if there was a 2 1/2 lb. weight difference from the previous weekly weight, and more than a 5 lb difference from the previous monthly weight, the resident was to be reweighed. She indicated this "reweight" was the weight documented in the Weight Tracking System Report. She indicated the reweights were done the same day as the most recent weight that prompted the need to verify the weight. On 7/18/14 at 10:46 a.m. the Medical Records LPN and DON were interviewed regarding Resident #24. She indicated the following: regarding the physician order [REDACTED]." At the time, the DON looked in the computer system to see if the physician had been notified of the weight 8.3 lb weight gain in 1 day and she was unable to find documentation the physician had been notified of this. She indicated the first time the physician was notified was on 4/15/14. They indicated the nurse who documented the weight on 4/8/14 of 97.1 lb would have compared it to the weight of 88.8 lbs on 4/7/14. They indicated the nurse who took the weights would then have looked back to the resident's admission weight on 4/7/14, which the Medical Records LPN indicated was 99 lbs, which was documented on another form. The MR LPN indicated the weight of 88.8 lb on 4/7/14 was probably an "entry error" from the nurse who performed the daily weights. The MR LPN indicated the weight of 88.8 lb, could have been corrected to reflect the "actual" admission weight of 99 lbs. but had not been. 2. On 7/18/14 at 9:25 a.m., the MR LPN provided a copy of the "Monthly Weights" for July 2014. This form indicated to "re-weigh of (sic) greater than a 5 lb difference." The form included, but was not limited to, the following: For Resident #20, the June Weight was documented as 209.5 lb, July weight as 190.8 lb and the reweight was 197.5 lb. The MR LPN indicated this resident had been monitored with daily weights. 3. The "Monthly Weights" form also indicated Resident #5 had the following weights documented: June weight was 97.1 lb; July weight was 86.3 lb and the reweight was 100.4 lbs. The MR LPN indicated the days shift staff always weighed the residents and they try to weigh them in the morning before breakfast. She indicated if the monthly weight "is off" they reweigh the resident again, soon, at least the same day if not immediately. On 7/18/14 at 9:25 a.m., the MR LPN was interviewed regarding Resident #5 and the 14.1 lb increase from the July weight of 86.3 lb to the reweight of 100.4 lb. She indicated this resident was weighed in her wheelchair (WC) and the 100.4 lb weight was probably the weight of the resident and her wc. She indicated the 100.4 lb weight was the correct weight because "it was closest to the June weight." She indicated when the weights were obtained sometimes, there was a subtraction error on the weight records when the CNAs subtract the weight of the wc from the combined weight of the resident and the wc, when the weight was obtained. The MR LPN indicated this resident was on weekly weights. The Medical Records LPN indicated the Registered Dietician (RD) looked at the weights on the "Weight Tracking System" on the computer and if she had a concern, would look at the daily and/or weekly weights which were documented on the TAR (Treatment Administration Record). The Medical Records LPN indicated nursing monitored the daily weights. On 7/18/14 at 10:07 a.m., CNA #10 was interviewed. She indicated she worked the day shift and did weigh residents. She indicated for residents who are usually in their wc, staff weighed the resident in their wc. After the resident was put back to bed, the staff weighed the resident's wc and whatever else they had with them when they were weighed, for example blankets. She indicated they then subtract the empty weight of the wc from the weight of the resident in the wc to obtain the resident's actual weight. She indicated the actual resident weight was the only one they documented on the weight record. 4. Review of the clinical record for Resident #65, on 7/17/14 at 2:31 p.m., indicated the following: [DIAGNOSES REDACTED]. An Admission Nursing Assessment for Resident #65, dated 3/13/14, indicated an admission weight of 208 pounds with a usual weight of 210 pounds. The assessment also indicated usual food intakes of 100%. Facility weights for Resident #65 indicated the following: 208.20 pounds on 3/13/14, a re-weigh of 180.80 pounds on 3/18/14, 178.60 pounds on 3/21/14, and 176.40 pounds on 3/24/14. A Nutritional Risk Assessment for Resident #65, dated 3/18/14, indicated she received a No Concentrated Sweets diet. The assessment also indicated a height of 67 inches and a weight of 208 pounds with a BMI (body mass index) of 32. A Dietary Progress Note for Resident #65, dated 3/20/14 and written by the Certified Dietary Manager (CDM), indicated she received a No Concentrated Sweets diet which she fed herself. The note further indicated her admission weight was recorded as 208 pounds and her 5 day weight was 180 pounds, resulting in a 13% weight loss in 5 days. The note also indicated the resident was not sure what she weighed when she came to the facility but knows she did not lose that much weight. A Dietary Progress Note for Resident #65, dated 3/21/14 at 1:43 p.m. and written by the Registered Dietitian, indicated nursing weighed the resident and her weight was 179 pounds. The note did not provide a reason for the difference between her admission weight of 208 pounds on 3/14/14 and the weight of 179 ponds on 3/21/14. There were no additional notes from the CDM or the Registered Dietitian available in the clinical record of Resident #65. The Administrator, the Director of Nursing, and Medical Records were interviewed on 7/18/14 at 11:31 a.m. During the interview they indicated a reason should have been documented for the weight loss after the re-weigh of Resident #65. Medical Records was interviewed on 7/18/14 at 11:59 a.m. During the interview she indicated she spoke with the Registered Dietitian. The Registered Dietitian indicated she had not documented the reason for the weight loss. On 7/18/14 at 11:44 a.m. a current copy of the policy and procedure for "Guidelines for Pertinent Charting", dated 5/2010, were received from the DON. This policy included, but was not limited to, the following: "All significant changes in resident status are thoroughly assessed and documented in the resident record based on assessment findings...The nurse is responsible to identify and accurately chart assessment findings in a concise manner...." 3.1-50(a)(1) 3.1-50(a)(2)