Every finding on record at Aspen Trace Health & Living Community

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 22 residents reviewed for resident call light access. (Resident 12) Finding includes: On 4/22/25 at 9:18 a.m., Resident 12 was observed sitting up in bed. The over-the-bed table was in front of the resident. Resident 12's call light was observed hanging from the headboard behind the resident's left shoulder. The call light was out of sight and out of reach of Resident 12. During an interview at that time, Resident 12 indicated she did not know where her call light was. Resident 12 indicated the call light was not always accessible to her when she was in bed. During an interview on 4/22/25 at 9:25 a.m., Qualified Medication Aide (QMA) 3 indicated call lights were to be within the resident's reach. During an interview on 4/22/25 at 9:45 a.m., the Assistant Director of Nursing indicated call lights were to be kept within the resident's reach. On 4/22/25 at 9:55 a.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, repeated falls, diabetes, and chronic kidney disease. The Annual Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident 12 was moderately cognitively impaired, required substantial assistance with transfers, and had a history of falls. Resident 12's care plan, revised on 3/25/25, indicated the resident was at risk of falls. The interventions, included but was not limited to, keep call light within reach. On 4/24/25 at 9:45 a.m., the Director of Nursing provided a copy of the Resident Rights policy, dated June 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .communities are committed to protecting and promoting the rights of the residents .equal access to quality care .receive care in accordance with personal preference . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled with an open date for 1 of 4 medication carts observed. An insulin pen was not labeled with an open date. (Renaissance 2 Medication Cart) Finding includes: On 4/22/25 at 8:30 a.m., the Renaissance 2 Medication Cart was observed. An opened Insulin Flex Pen 100 units/ml (milliliter) lacked labeling indicating the date the insulin pen was opened or to whom it was prescribed. LPN 2 indicated there was no label on the insulin and confirmed at that time that the 300-unit flex pen had 100 units remaining. During an interview on 4/22/25 at 9:48 a.m., the Corporate Nurse indicated the open date should have been on the insulin pen. On 4/22/25 at 1:10 p.m., the Corporate Nurse provided a policy titled, Section D, Drug Storage from Life Span Policy and procedure [NAME], undated, and indicated it was the current policy being used by the facility. A review of the policy indicated .Refrigerator Storage, 7, Insulin and PPD (TB) vaccine and other multi-dose vials requiring refrigeration need to be dated when opened. All vials should be discarded 28 days of the open date . 3.1-25(j)

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 2 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Cook 2, Dietary Manager) Findings include: 1. During a follow-up kitchen observation on 7/5/23 from 11:30 a.m. to 11:50 a.m., the following was observed: a. Cook 2 was observed walking through out the kitchen area where the noon meal was being prepared and was observed near the steam table and near the food carts where the noon meal was being held. Cook 2 was observed to have multiple hairs in front of both ears, approximately 2 inches in length, and multiple hairs, approximately one inch in length above and below the neckline, that were observed to not be covered. b. The DM (Dietary Manager) was observed walking through out the kitchen area where the noon meal was being prepared and was observed near the steam table and near the food carts where the noon meal was being held. The DM was observed to have multiple hairs, approximately 2 inches in length at and above the neckline, that were observed to not be covered. 2. During a follow-up kitchen observation on 7/5/23 from 12:50 p.m. to 12:55 p.m., the following was observed: a. Cook 2 was observed walking through out the kitchen area near the steam table where the noon meal was being held. Cook 2 was observed to have multiple hairs in front of both ears, approximately 2 inches in length, and multiple hairs, approximately one inch in length, above and below the neckline, that were observed to not be covered. b. The DM was observed walking through out the kitchen and near the steam table where the noon meal was being held. The DM was observed to have multiple hairs, approximately 2 inches in length, at and above the neckline, that were observed to not be covered. On 7/7/23 at 8:00 a.m., the Activity Director provided a copy of the 4/27/23 Resident Council Minutes. A review of the minutes indicated, .New business .Dietary - staff not wearing hairnets . On 7/7/23 at 3:50 p.m., the Kitchen Corporate Consultant provided a copy of the Resident/Family Concern/Grievance Form, dated 4/27/23. A review of the document indicated, .Person receiving concern: Activity Director; Department responsible for concern: Dietary. Section 1: nature of concern .hairnets. During an interview on 7/5/23 at 1:00 p.m., the Kitchen Corporate Consultant indicated all staff hair was to be totally covered while in the kitchen. On 7/5/23 at 1:13 p.m., the Kitchen Corporate Consultant provided a copy of the Environmental Sanitation/Infection Control policy, dated 2012, and indicated it was the current policy in use by the facility. A review of the policy indicated, .staff involved in storing, preparing, distributing and serving food to residents practice habits of good personal hygiene to protect residents from contamination and food borne illness. Standards of personal hygiene reflect federal, state and local requirements .hair restraint that effectively covers head .is worn in food preparation areas .hair is arranged to prevent contamination of food, equipment, and utensils . On 7/7/23 at 3:30 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints, such as hats, hair coverings or nets .that are designed and worn to effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to follow the plan of care for 1 of 4 residents reviewed for medication administration. Physician's orders were not followed. (Resident B) Finding includes: During an observation on 7/6/23 at 8:55 a.m., Registered Nurse (RN) 3 was observed preparing Resident B's medications with the DON present. When RN 3 got to the order for the dabigatran etexilate (Pradaxa) medication, RN 3 indicated that the medication was not available and that it had been reordered from the pharmacy. Neither staff member knew the generic name for the medication. During an interview on 7/6/23 at 1:57 p.m., the Administrator and the DON indicated that the medication had not been recognized by the generic name by staff administering medications and staff were unaware it was in the medication cart. They indicated Resident B had received it intermittently and should have received it twice daily as ordered. During an observation with the Administrator on 7/6/23 at 3:15 p.m., Resident B's dabigatran etexilate (Pradaxa) medication was observed in the bottom drawer of the medication cart containing Resident B's other medications. The label indicated that the pharmacy had sent the medication to the facility on [DATE]. On 7/7/23 at 9:15 a.m., Resident B's clinical record was reviewed. Resident B's diagnoses included, but were not limited to, paroxysmal atrial fibrillation (a rapid, erratic heart rate that starts and stops on its own), chronic diastolic congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), chronic kidney disease, and the presence of a cardiac pacemaker. Physician orders included, and were not limited to: - Dabigatran etexilate (Pradaxa, a blood thinner or anticoagulant medication) capsule; 75 mg (milligrams) 1 capsule, oral twice a day for paroxysmal atrial fibrillation with a start date of 6/26/23 and no stop date noted. Resident B's electronic medication administration record (eMAR) from 6/26/23 through 7/6/23 was reviewed and indicated that the following: - On 6/27/23 for the Upon Rising (7:00 a.m. - 11:00 a.m.) dose, the medication was marked as not administered; the reason was On Hold and the comment was awaiting pharmacy. - On 6/27/23 for the Before Bedtime (6:00 p.m. - 10:00 p.m.) dose, the medication was marked as not administered; the reason was Other, and the comment was pending pharm. - On 6/28/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Other, and the comment was waiting on rx [prescription]. - On 6/29/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable, and the comment was pharmacy notified, waiting on delivery. - On 6/30/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable, and the comment was pharmacy has been notified. - On 7/1/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable. The entry lacked an associated comment. - On 7/2/23 for the Upon Rising dose, the medication was marked as not administered; the reason was On Hold and the comment was awaiting arrival. - On 7/3/23 for the Upon Rising dose, the medication was marked as not administered; the reason was On Hold and the comment was awaiting pharmacy. - On 7/5/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable, and the reason was medication reordered. - On 7/5/23 for the Before Bedtime dose, the medication was marked as not administered; the reason was Drug/Item Unavailable. The entry lacked an associated comment. On 7/10/23 at 8:50 a.m., the DON provided a copy of the Protocol for Following Physician Orders, dated for 4/3/17, and indicated it was the policy currently in use by the facility. A review of the policy indicated under the procedure portion, All licensed staff will verify and follow physician orders as written. If for any reason, the physician order cannot be followed, the professional will contact the physician for further instructions. This Federal tag relates to Complaint IN00412739. 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure a medical record were complete for 1 of 3 residents reviewed for medical records. (Resident B) Finding includes: During an interview on 12/29/22 at 2:07 p.m., Resident B indicated she was sent to the hospital a few weeks ago but she didn't remember why. The clinical record for Resident B was reviewed on 12/30/22 at 8:31 a.m. The diagnosis included, but was not limited to, anxiety disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 9/22/22, indicated Resident B was cognitively intact. A hospital discharge summary, dated 10/7/22, indicated Resident B was sent to the emergency department and diagnosed with aspiration and pneumonia. The clinical record lacked information related to Resident B's transfer to the hospital. During an interview on 12/30/22 at 12:19 p.m., the DON (Director of Nursing) indicated Resident B was sent to the emergency department on 10/7/22. The staff should have documented when Resident B was sent to the hospital. On 12/30/22 at 10:00 a.m., the DON provided a copy of a facility policy, titled Change in a Resident's Condition or Status, dated 10/2010, and indicated this was the current policy used by the facility. A review of the policy indicated the nurse supervisor/charge nurse with record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This Federal tag relates to Complaint IN00397556. 3.1-50(a)(1)

Based on interview and record review, the facility failed to ensure a resident's code status preference was documented accurately in the clinical record for 1 of 32 residents reviewed for advanced directives. (Resident 12) Findings include: On 6/25/19 at 2:13 p.m., the clinical record for Resident 12 was reviewed. [DIAGNOSES REDACTED]. Resident 12's face sheet indicated the resident was a full code (meaning a desire for all life sustaining measures to be implemented). The annual MDS (Minimum Data Set) assessment, dated 3/13/19, indicated Resident 12 was severely cognitively impaired. Resident 12's care plan, initiated on 9/8/14 and current through 9/8/19, indicated Resident 12 had chosen all life sustaining measures. The POST (Indiana Physician order [REDACTED]. Resident 12's POA (Power of Attorney) signed the form on 9/25/18 and the Physician signed the form on 9/26/18. No other POST form was located in Resident 12's medical file. Resident 12's progress notes, dated 6/5/19 at 3:46 p.m., indicated .remain full code . The Physician Orders, dated 6/25/19, indicated, .Code status: DNR, special instructions: see POST . Interviewed, on 6/26/19 at 9:12 a.m., the DON (Director of Nursing) indicated Resident 12's POST form was completed on 9/26/18 and it showed the resident's code status preference was DNR. The physician's orders [REDACTED]. The SSD (Social Service Director) contacted Resident 12's POA and confirmed the resident was to have had a DNR code status. Interview on 6/26/19 at 11:00 a.m., the Cherish Memory Unit Manager indicated if a resident became unresponsive, staff were to verify the Resident's face sheet to determine the code status and appropriate actions to be implemented. On 6/26/19 at 2:00 p.m., the DON provided a copy of the CarDon Code Status Policy, dated 3/14/14, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Upon admission to a CarDon community the facility designee (preferably a licensed nurse and/or social services) will determine the resuscitative wishes of the resident Each resident will choose either a full code status or a do not resuscitate status (DNR) .The attending physician will be notified of each resident's resuscitative status and the nurse will write a doctor's order in the chart .each CarDon community to honor the Indiana Physician order [REDACTED].The nurse will write a doctor's order for a full code or DNR even when a completed POST form is present .It is CarDon's policy to routinely review the code status of each resident with the resident and/or responsible party when the plan of care is reviewed . 3.1-4(f)(4)(A)(ii) 3.1-4(f)(5)

Based on record review and interview, the facility failed to develop a care plan for a resident receiving oxygen, for 1 of 2 residents reviewed for respiratory care. (Resident 38) Findings include: On 6/28/19 at 9:33 a.m., the clinical record of Resident 38 was reviewed. A physician's orders [REDACTED]. The clinical record lacked a care plan for oxygen. Interview, on 6/27/2019 at 2:03 p.m., the Director of Nursing indicated a care plan for oxygen had not been created for Resident 38. On 6/27/19 at 2:06 p.m., the Director of Nursing provided a policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), and indicated it was the current policy being used by the facility. A review of the policy indicated .8. The comprehensive, person-centered care plan will: l. Identify the professional services that are responsible for each element of care. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was provided assistance while walking which resulted in a cognitively impaired and high risk fall resident having fallen and sustained facial injuries for 1 of 7 residents reviewed for falls (Resident 53) and the facility failed to ensure the beauty shop that contained hazardous chemicals was locked when left unattended potentially affecting 20 of 102 self mobile cognitively impaired residents. Findings included: 1. On 6/24/19 at 1:58 p.m., Resident 53 was in the Cherished Memories Unit, sitting in the lounge area during a group activity. Resident 53 was observed to have a faded blue-gray colored bruise above her left eye, both eyes were reddened around the eye sockets, and had two small bumps in the middle of her forehead. On 6/26/19 at 2:26 p.m., Resident 53's clinical record was reviewed. [DIAGNOSES REDACTED]. The most current nursing fall risk assessment, dated 2/4/19, indicated Resident 53 had a cognitive deficit; [MEDICAL CONDITION]; and a history of falling. The quarterly MDS (Minimum Data Set) assessment, dated 4/5/19, indicated Resident 53 was severely cognitively impaired; was not steady during balance transitions and walking; required physical assistance with ambulation; and indicated resident 53 .was not steady, only able to stabilize with staff assistance . Resident 53's care plan, dated 1/28/15 and current through 7/19/19, indicated resident at risk for falling and fall related injuries related to decreased safety awareness .muscle weakness .impaired balance .history of falls .Alzheimer's dementia .goal: will minimize risk for falls and fall related injuries .interventions: provide non-skid footwear; assist with ADL's (activity of daily living); bed against wall; keep call light within reach; keep personal items and frequently used items within reach; observe for and report any noted functional changes. The care plan lacked interventions for staff to assist during ambulation based on assessed dated 4/5/19. On 6/21/19 at 4:55 a.m., progress notes indicated, CNA (certified nursing aide) was in resident's room. Instructed to go toilet to get changed. Observed resident for steadiness. Resident stood up and took two steps and was steady. CNA turned to closet and grabbed shirt and turned around and saw resident going down to the floor. Resident was seen by CNA hitting forehead on floor. Complete physical assessment done with raised area above left eyebrow. Ice applied immediately. Sticky area found on floor and resident's socks were halfway off . On 6/21/19 at 5:12 a.m., an event report titled, Safety Events - Post Fall Assessment, indicated on 6/21/19 at 4:47 a.m., Resident 53 had a staff witnessed fall in her room. Resident 53 fell next to her bed. The environmental factors that may have contributed to the fall .sticky floor. Check any physical assessment that are abnormal after the resident fell .knot on forehead. The assessment lacked evaluation for CNA not having assisted the resident after standing and starting to walk. Interview, on 6/27/19 at 10:35 a.m., Cherish Memories Unit Manager indicated Resident 53 ambulated independently, but was unsteady on her feet. Staff were to be sure Resident 53 was steady on her feet before leaving her side. She fell on [DATE]. On 6/27/19 at 12:01 p.m., the DON provided a copy of the Clinical Fall Prevention Policy and Procedure, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. A review of the policy indicated, .The purpose of this policy is to provide CarDon communities with best practices and evidence based approaches to prevent falls and protect residents who are at risk for falling .components of this fall program include .fall risk assessment; fall event assessment; strategies of prevention; strategies of intervention .root cause analysis will be performed utilizing the '5 whys' . 2. On 6/24/19 from 11:35 a.m. to 11:42 a.m., during a random observation, the beauty shop door was unlocked and unsupervised. There were no other staff or residents in the area during the observation. The following was observed: a. Four 16 ounce cans of aerosol hairspray sitting on the counter. All cans were approximately half full. b. One pair of hair shears found in an unlocked drawer. c. One 24 ounce spray bottle of Tile Plus. The Material Data Sheet indicated this product was corrosive. The handling and storage information indicated, Any non-intended or non-authorized use of this product may result in severe personal injuries including [MEDICAL CONDITION] damage to equipment and severe corrosion .may cause tissue damage in the mouth, throat, and stomach. (MONTH) be fatal if swallowed. During an observation, on 6/25/19 from 10:58 a.m. to 11:05 a.m., the beauty shop was unlocked and unsupervised. It was observed that one resident from the assisted living side of the facility was sitting in a beauty shop chair with no staff in the room. The beautician had returned to the beauty shop at 11:05 a.m. Interview, on 6/24/19 at 11:45 a.m., the beautician indicated she was unaware of the facilities policy regarding the beauty shop door being locked when unsupervised. She often left the door unlocked for brief periods of time when she would go and get residents for their appointments and when needed to assist the residents with their care while at the beauty shop. Interview, on 6/25/19 at 2:05 p.m., the Director of Nursing (DON) indicated the beauty shop should be locked when left unsupervised. Interview, on 6/26/19 at 9:15 a.m., the DON indicated they did not have a policy specifically for the beauty shop. On 6/26/19 at 9:15 a.m., the DON provided a copy of their chemical hazards policy, dated (MONTH) (YEAR), titled: Safety Policies Chemical Hazards, and indicated it was the current policy being used by the facility. A review of the policy indicated, Chemicals must be locked up at all times and out of reach of residents. Interview, on 6/26/19 at 10:30 a.m., the DON indicated there were 20 residents residing in the facility that were cognitively impaired and self-mobile. On 6/26/19 at 9:15 a.m., the DON indicated they did not have a policy specifically for the beauty shop. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a documentation for the disposition of a discharged residents' medications, for 2 of 3 residents reviewed for medication disposition. (Resident 101 and 102) Findings: 1. On 6/28/19 at 10:42 a.m., Resident 102's closed clinical record was reviewed. Resident 102 was admitted to the facility on [DATE] and passed away on 5/29/19. At the time of discharge, Resident 102's Physicians Orders included, but were not limited to, [MEDICATION NAME] 125mg, [MEDICATION NAME] 2mg, and [MEDICATION NAME] 50mg. The clinical record lacked documentation that indicated the disposition of Resident 102's medications. Interview, on 6/28/19 at 11:20 a.m., the Director of Nursing (DON) indicated she was unable to located Resident 102's drug disposition record. She indicated based on facility policy, Resident 102 should have had a drug disposition and a waste record for the controlled substances. On 7/1/19 at 10:40 a.m., the DON provided a copy of their discharge medication policy, dated (MONTH) (YEAR), titled: Discharge Medications, and indicated it was the current policy being used by the facility. A review of the policy indicated, during discharge .6. The nurse shall complete the medication disposition record. 2. The closed clinical record for Resident 101 was reviewed on 6/28/19 at 9:34 a.m. Resident 101 was admitted to the facility on [DATE] and discharged to an assisted living facility on 5/24/19. Progress notes, dated 5/24/19 at 1:20 p.m., indicated Resident 101 was discharged , with his medications, to an assisted living facility on 5/24/19. Physician Orders, dated (MONTH) 2019, at the time of discharge from the facility included, but were not limited to: [MEDICATION NAME] 10 mg. Atorvastatin 20 mg. Vitamin D3 5000 units [MEDICATION NAME] oxalate 10 mg. [MEDICATION NAME] 100 mcg. [MEDICATION NAME] 10 mg. [MEDICATION NAME] 25 mg. Xarelto 10 mg. Senna 8.6 mg. The clinical record lacked documentation regarding the disposition of the above medications. Interview, on 6/28/19 at 11:25 a.m., the DON (Director of Nursing) indicated the facility lacked a drug disposition record indicating which medications and how many were given to Resident 101 upon his discharge from the facility. On 7/1/19 at 10:46 a.m., the DON provided an updated copy of the Discharge Medications policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .the nurse will reconcile pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented .the nurse shall complete the medication disposition record, including: the resident's name; the name of the person who will be assisting or administering the medication after discharge; the date of discharge the name of each medication .the quantity or amount of each medication .the signature of the person receiving the medications .the signature of the nurse releasing the medications .the nursing staff shall forward completed drug disposition records to medical records .the complete list of the resident's medications shall also be provided to the resident upon discharge . 3.1-25(s)

Based on record review and interview, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was coded to accurately reflect a resident's discharge status for 1 of 3 residents reviewed for discharge status. (Resident 87) Findings include: The closed clinical record of Resident 87 was reviewed on 5/3/18 at 2:46 p.m. [DIAGNOSES REDACTED]. A care plan for the resident, dated 1/4/18 and current through 3/31/18, indicated the resident had established goals of returning home after her rehabilitation at the facility. A nursing progress note, dated 1/31/18 at 1:57 p.m., indicated Resident 87 was discharging facility at this time .to return to apartment at (name of assisted living facility). A discharge Minimum Data Set assessment, dated 1/31/18, indicated Resident 87 was discharged to an acute care hospital. Interview, on 5/2/18 at 3:03 p.m., the Executive Director indicated this was an MDS documentation error. 3.1-31(d)

Based on observation, record review, and interview, the facility failed to ensure an activity care plan with personalized interventions was developed for 1 of 1 resident reviewed for activities. (Resident 32) Findings include: The clinical record of Resident 32 was reviewed on 4/30/18 at 2:19 p.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. An admission Minimum Data Set assessment, dated 1/15/18, indicated the resident was independent in her ability to make decisions. On 4/30/18 at 2:19 p.m., Resident 32 was observed lying in her bed, talking to herself. An interview with the resident, at that time indicated, How can I go to activities? I'm blind, can't see to play bingo or anything. Nothing good on the TV. An Activity Assessment, dated 1/11/18, indicated it was very important to Resident 32 to participate in religious services, somewhat important to listen to music, and important but no longer able to keep up with the news and have books, newspapers and magazines to read. Resident 32's preference was to have independent leisure time. Her leisure interests included current events, music, radio, and spiritual activities. A care plan, dated 1/11/18 through 7/11/18, indicated, Resident prefers to engage in independent activities. The goal was, Resident will engage in independent activities of interests including but not limited to visiting with family/friends, listening to the TV/music/news and/or spiritual activities on a daily basis through next review. Approaches towards achieving the goal were, Provide activity calendar (resident legally blind), Provide resident with independent leisure supplies as needed, Respect resident's right to refuse activities, Thank and praise resident for all participation efforts. No resident specific approaches which addressed her preferences as indicated in the Activity assessment dated [DATE], such as religion, music, books, newspapers, magazines, current events, and radio, were found in the resident's activity careplan. Interview, on 5/9/18 at 2:30 p.m., the Director of Nursing indicated she, could see how the approaches in Resident 32's activity care plan were not resident specific. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident at risk for sexual abuse for 1 of 5 residents reviewed for abuse. (Resident 110) Findings include: The clinical record for Resident 110 was reviewed on [DATE] at 11:00 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 6 (severely impaired cognitive status). The Significant change Minimum Data Set (MDS) Assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). The assessment also indicated no behaviors. An Observation report, dated [DATE], indicated a BIMS score of 4 (severely impaired cognitive status). A Care Plan, dated [DATE], indicated Resident 110 is not to spend time in her male friend's room (Resident 10); who is also a resident at facility. She has times of going in his room and sitting outside of his door. Goal: Resident will not spend time in her male friend's room or sit outside of his room. Interventions included, but were not limited to: offer an activity to Resident 110 when she needs redirected away from male resident's room. Staff to remind resident and redirect her if she is in or around his room. Staff to spend 1:1 time with resident when she becomes upset about not being able to spend time in his room. The clinical record for Resident 10 was reviewed on [DATE] at 2:45 p.m. [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 - Cognitively Intact. A Care plan, dated [DATE], indicated Resident 10 has times of inappropriately touching a female resident. Goal: Resident will not inappropriately touch female residents. Interventions included, but not limited to: continuous monitoring. A Care plan, dated [DATE], indicated Resident 10 expressed to staff that he wants to continue his relationship with a female resident. He prefers to meet outside of his room due to her making negative comments about his deceased wife and family which causes him to become upset and tearful. Goal: Resident will comply with resident's wishes. Interventions included but not limited to Spend 1:1 time with resident during times of sadness. On [DATE] at 1:53 p.m., the Executive Director provided a copy of an incident dated [DATE]. Brief Description of Incident: The two residents (Resident 10 and Resident 110) have had a relationship for awhile now. Previously they were both cognitively intact, as they were both scoring a 15 on BIMS. Resident 110 recently had a hospital stay and her BIMS score has been lower since that occurrence. Staff reported seeing the two residents kissing today. The Social worker approached the two residents and got them to visit in common areas. Residents are upset because they feel like the facility is impeding on their right to privacy. The facility attempted to get the residents BIMS score, Resident 110 refused, as she was too upset today. She did agree to allow staff to get her BIMS tomorrow morning. Type of injury: None. Immediate action taken: [DATE], Action taken: Residents were separated. The Executive Director immediately notified MD (Medical Director) and Family and made them aware of the situation. Both residents were placed on behavior monitoring. Psychosocial monitoring initiated for (Resident 110). Both families are aware of the relationship and have no concerns. Type of preventative measures added [DATE] Residents separated to ensure safety. Will re-do BIMS tomorrow morning. On [DATE] at 2:30 p.m., documentation of behavior monitoring, as indicated, was requested from the Executive Director. No behavior monitoring documentation provided for incident dated [DATE], by the end of the survey. On [DATE] at 10:00 a.m., the Executive Director provided a copy of an incident dated [DATE]. A Brief Description of Incident: The two residents (Resident 10 and Resident 110) had a relationship for a while now. Previously they were both cognitively intact, as they were both scoring a 15 on the BIMS. Resident 110's BIMS had been lower. The residents have previously agreed to meet in a common space for supervision. Nurse reported that she observed Resident 10 with his hand up Resident 110's skirt and it appeared to be resting on her leg. Nurse immediately intervened and separated the two residents for safety. Social Services spoke with Resident 10 and he admitted to having is hand up her skirt and acknowledged that this was not appropriate. Residents, especially Resident 110, have voiced displeasure with the facility intervening. Type of Injury: no injury. Preventative measures: The residents have visiting time in the common area. Residents separated to ensure safety. During an interview, on [DATE] at 11:25 a.m., the Executive Director indicated Resident 110 and Resident 10 have been in a relationship for quite some time. They are like a couple. They even have disagreements like a couple would. Resident 110 is very fond of resident 10 and enjoys his company. Resident 110 gets upset when the issue of touching is brought up. On ,[DATE] at 9:37 a.m., the Executive Director provided a copy of a statement made by Certified Nursing Assistant (CNA) 1 dated [DATE] (incident [DATE]). The statement indicated, On the night of concern I looked out the window of the office to check on (Resident 110 and Resident 10). I seen (Resident 10) had his hand under Resident (110's skirt). I told the nurse and we went out there to stop them. (Resident 10) stopped and came in the building (Resident 110) stayed outside. Not one time did I hear (Resident 110) say stop. The window in the office was opened, and she wasn't saying stop when we went outside to stop them. On [DATE] at 9:37 a.m., the Executive Director provided a copy of a statement made by Licensed Practical Nurse (LPN) 2 dated [DATE] (incident [DATE]). The statement indicated, On [DATE] @ around 9 pm, I approached nurse's station and noticed that (Resident 10 and Resident 110) were sitting out on front patio. I noted (Resident 10) to be leaning over towards (Resident 110). Upon further investigation noted that (Resident 10) had his left hand between )Resident 110's) legs. I immediately went outside and intervened. (Resident 110) had her skirt pulled up to above the middle of her thigh. I immediately told them that this was not an appropriate at to be doing. they immediately stopped. Resident 10 said 'it's 9 O'clock and all is well.' (Resident 110) was not in any distress during my presence. (Resident 10) came inside and went to his room and proceeded to get ready for bed. On [DATE] at 9:37 a.m., the Executive Director provided a copy of a statement made by the Social Services Director (SSD) dated [DATE] (incident [DATE]). The statement indicated Resident 10 said that he touched Resident 110 under her skirt on top of her clothes. He said that she never told him to stop. When asked what she was saying while he was doing that he said that she said that it felt good. During an interview on [DATE] 1:27 p.m., the Renaissance Nurse Manager indicated Resident 110's cognitive status varies. Some days she (Resident 110) is very confused and it depends on the time of day. She remembers some things just fine. During an interview, on [DATE] at 2:30 p.m., the Social Services Director (SSD) indicated Resident 110 and Resident 10 have been in a relationship and were like a couple. Resident 110's cognitive status varies. She is upset because she loves Resident 10 and wants to be with him, however she did not approve of him touching her on the patio. The Psych Doctor was in today, and I can give you a full report tomorrow. During an interview on [DATE] at 3:15 p.m., Licensed Practical Nurse (LPN) 2 indicated she was working her shift and stopped at the nurses station and witnessed Resident 110 and Resident 10 outside on the patio without supervision. Resident 10 was leaning toward Resident 110. LPN went outside to observe the interaction. Resident 110's skirt was raised above her thigh. Resident 10 had his hand resting on Resident 110's upper thigh. I immediately intervened and asked the residents to come inside the building. Resident 110 was not in any distress and no injury was noted. Resident 110 was compliant with coming into the building. Resident 10 stated, 'It is 9 O'clock and all is well.' LPN also indicated Resident 110 has been upset since the incident and will not talk to her. During an interview on [DATE] at 2:01 p.m., Resident 110 became teary eyed. Resident 110 indicated she was in love with Resident 10. I just hope he is not gone now. Resident 110 also indicated Resident 10 touched her on the leg when they were outside on the patio. She had asked him not to and I told him Let's just go in now. Resident 110 indicated she did not want to talk about it anymore. On [DATE] at 2:35 p.m., the patio was observed. The patio exit/entrance door is located next to the Renaissance nurse's station. Three alert residents were sitting outside in their wheelchairs. Not all areas of the patio could be viewed from the nurse's station. On [DATE] at 9:35 a.m., the Executive Director provided a policy titled: Abuse Policy, dated [DATE] and revised on ,[DATE], and also indicated the policy was the one currently being used by the facility. The Policy indicated Policy Statement: It is the policy of CarDon & associates to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The following guidelines outline the components of our Abuse Prevention Program: .Policy Interpretation and Implementation: .2. Our facility's resident rights abuse prevention in-service programs consist of the following information: .d. A review of the resident's responsibilities and rules of conduct as developed by our facility. e. What constitutes abuse, neglect, and misappropriation of resident property. III. Preventing Resident Abuse Policy Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Policy Interpretation and Implementation: 1. Preventing resident abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: .j. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. Policy Interpretation and Implementation .7. To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: .c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. 3XXX,[DATE](a)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident who preferred to stay in her wheelchair received frequent repositioning to prevent the development and worsening of a pressure ulcer for 1 of 1 resident who met the criteria for pressure ulcer review. (Resident 77) Findings include: The clinical record of Resident 77 was reviewed on 6/5/17 at 11:16 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 2/22/17, indicated Resident 77 was severely cognitively impaired, not ambulatory, needed extensive assistance of 2 plus staff for bed and chair mobility, and was at risk for developing a pressure ulcer. A care plan, dated 1/9/17 and current through 8/9/17, indicated Resident 77 was at risk for skin breakdown related to decreased bed mobility and generalized weakness. Approaches included, Turn and reposition per resident individual need. The care plan did not indicate the frequency in which the resident needed to be repositioned. A care plan, dated 4/6/17 and current through 8/9/17, indicated Resident 77 refused offers of personal care. Approaches included encouraging resident to lie down when she fell asleep in her wheelchair. On 4/7/17, Resident 77's family was contacted requesting permission to provide some Occupational Therapy for wheelchair positioning because the resident kept leaning to the right. The family did not wish the resident to receive this positioning therapy. On 4/27/17, Resident 77 developed a Stage 2 pressure ulcer (a partial thickness loss of skin presenting as a shallow open ulcer) on her right buttock. A care plan, dated 4/28/17 and current through 8/9/17, indicated the resident had a pressure ulcer on her right buttock. Approaches included, Turn and reposition per resident need. The careplan did not indicate the frequency in which the resident needed to be repositioned. On 5/4/17, a Skin Condition Assessment Tool indicated the pressure ulcer had progressed to a Stage 4 (full thickness tissue loss with exposed bone or muscle). On 5/25/17, the Nurse Practitioner indicated, in a progress note, Resident 77 was non ambulatory, spent much time in her wheelchair prior to the wound development, had mild malnutrition and little supportive skin structure, all factors which increased the resident's risk for developing a pressure ulcer. On 6/1/17, the Nurse Practitioner documented in a progress note the formation of Resident 77's pressure ulcer may have been unavoidable due to her many risk factors. During an observation, on 6/5/17 from 12:45 p.m. to 1:20 p.m., Resident 77 was positioned in her wheelchair and did not appear to have been repositioned. An observation, on 6/5/17 at 1:35 p.m., indicated a pressure ulcer on Resident 77's right buttock, covered with a clear dressing, surrounding skin slightly reddened. The resident indicated it hurt sometimes. During on observation, on 6/7/17 from 9:40 a.m. to 10:10 a.m., Resident 77 was positioned in her wheelchair and did not appear to have been repositioned. On 6/7/17 at 10:15 a.m., CNA 8 who was taking care of Resident 77 that day and frequently cared for her, indicated Resident 77 did not usually want to go back to bed during the day. The CNA would assist the resident to the bathroom once or twice during her 8 hour shift, but indicated she did not know of anything else she was supposed to do to assist the resident to reposition herself in the wheelchair. Review of a CNA (Certified Nursing Assistant) Daily Assignment sheet indicated an intervention for Resident 77 was to offer to lay her down after meals. No other interventions were on the assignment sheet which would alert the CNA to assist the resident with repositioning while she was in her wheelchair. Mayo Clinic Bedsores (pressure ulcers) (April 25, 2017) was retrieved on 6/8/17 at 8:30 p.m. from the Mayo Clinic website. This guidance included advising their patients who use wheelchairs to shift their weight frequently, about every 15 minutes, and ask for help repositioning about once an hour. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's environment was maintained in good repair for 1 of 13 residents reviewed (Resident 83). Findings include: On 5/31/17 at 2:31 p.m., during an observation, Resident 83's pocket door (restroom entry door) was marred with black markings and the door was very difficult to slide open. On 6/1/17 at 3:05 p.m., during an interview, Resident 83 indicated the bathroom door does not work properly and never has. The staff has not been able to fix the door; there have been times when she was unable to open the bathroom door causing her to ask the nursing staff to open the bathroom door so she could use the toilet. Resident was unable to state how many times that had happened. On 6/1/17 at 4:17 p.m., during an environmental tour conducted with the Senior Executive Director (SED) and Maintenance Supervisor (MS), Resident 83's pocket door was observed with multiple black marks on the door and it was very difficult to slide the door open. On 6/2/17 at 9:11 a.m., during an interview, the SED indicated Resident 83's bathroom pocket door rollers were repaired in 2014, 2015, and 2016. There were no recent work orders submitted for Resident 83's bathroom door. If environmental issues were identified by staff and residents, they were to submit a work request form to the front desk staff person who would then enter the data into the Direct Supply TELS electronic system. The system would then trigger the appropriate department for resolution. On 6/1/17 at 3:00 p.m., Resident 83's clinical record was reviewed. Resident 83 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated 3/21/17, indicated a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). On 6/2/17 at 9:00 a.m., the SED provided Resident 83's Work Orders List for Aspen Trace, specifically the bathroom door maintenance work orders. Documentation indicated the following: a ticket was generated on 12/2/14 and resolved on 12/5/14; a ticket was generated on 10/7/15 and resolved on 10/12/15; and a ticket was generated on 5/31/16 and resolved on 6/2/16. The MS generated a ticket on 6/2/17 and the status is listed as in-progress. Each ticket identified issues with the bathroom door being difficult to open. On 6/2/17 at 9:00 a.m., the SED provided an undated Aspen Trace Doors, Locks & Alarms: Test operation of doors and locks policy, and indicated the policy was the one currently being used by the facility. The policy stated, test doors and hardware for proper operation and condition. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure careplans were developed with person-centered interventions based on the comprehensive and ongoing assessments for a resident who developed a pressure ulcer ( Resident 77) and a cognitively impaired resident who required supervision during interaction with a male peer (Resident 110) for 2 of 24 residents reviewed for care plans. Findings include: 1. The clinical record of Resident 77 was reviewed on 6/5/17 at 11:16 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 2/22/17, indicated Resident 77 was severely cognitively impaired, not ambulatory, needed extensive assistance of 2 plus staff for bed and chair mobility, and was at risk for developing a pressure ulcer. A care plan, dated 1/9/17 and current through 8/9/17, indicated Resident 77 was at risk for skin breakdown related to decreased bed mobility and generalized weakness. Approaches included, Turn and reposition per resident individual need. The care plan did not indicate the frequency in which the resident needed to be repositioned. A care plan, dated 4/6/17 and current through 8/9/17, indicated Resident 77 refused offers of personal care. Approaches included encouraging resident to lie down when she fell asleep in her wheelchair. On 4/7/17 Resident 77's family was contacted requesting permission to provide some Occupational Therapy for wheelchair positioning because the resident kept leaning to the right. The family did not wish the resident to receive this positioning therapy. On 4/27/17, Resident 77 developed a Stage 2 pressure ulcer (a partial thickness loss of skin presenting as a shallow open ulcer) on her right buttock. A care plan, dated 4/28/17 and current through 8/9/17, indicated the resident had a pressure ulcer on her right buttock. Approaches included, Turn and reposition per resident need. The careplan did not indicate the frequency in which the resident needed to be repositioned. On 5/4/17 a Skin Condition Assessment Tool indicated the pressure ulcer had progressed to a Stage 4 (full thickness tissue loss with exposed bone or muscle). On 5/25/17 the Nurse Practitioner indicated, in a progress note, Resident 77 was non ambulatory, spent much time in her wheelchair prior to the wound development, had mild malnutrition and little supportive skin structure, all factors which increased the resident's risk for developing a pressure ulcer. On 6/1/17, the Nurse Practitioner documented in a progress note the formation of Resident 77's pressure ulcer may have been unavoidable due to her many risk factors. An observation, on 6/5/17 at 1:35 p.m., indicated a pressure ulcer on Resident 77's right buttock, covered with a clear dressing, surrounding skin slightly reddened. The resident indicated it hurt sometimes. On 6/7/17 at 10:15 a.m., CNA 8, who was taking care of Resident 77 that day and frequently cared for her, indicated Resident 77 did not usually want to go back to bed during the day. The CNA would assist the resident to the bathroom once or twice during her 8 hour shift, but indicated she did not know of anything else she was supposed to do to assist the resident to reposition the resident in the wheelchair. Review of a CNA (Certified Nursing Assistant) Daily Assignment sheet indicated an intervention for Resident 77 was to offer to lay her down after meals. No other interventions were on the assignment sheet which would alert the CNA of the resident's need to be assisted to reposition while she was in her wheelchair to help relieve pressure on her buttocks. Mayo Clinic Bedsores (pressure ulcers) (April 25, 2017) was retrieved on 6/8/17 at 8:30 p.m. from the Mayo Clinic website. This guidance included advising their patients who use wheelchairs to shift their weight frequently, about every 15 minutes, and ask for help repositioning about once an hour. Skin Risk Assessments, dated 11/15/16 and 5/1/17, indicated Resident 77 needed assistance to reposition and sat up for more than 2 hour periods of time. On 6/7/17 at 10:45 a.m., the Executive Director provided a policy dated 2/17/15, titled, Wound Management, and indicated it was the policy currently used by the facility. The policy indicated if a resident is assessed to be at risk for developing a pressure ulcer, interventions will be added to the individual resident's care plan to ensure care is provided to 1. Prevent the development of a new wound/open area 2. Promote the healing of an existing wound/open area . 2. The clinical record for Resident 110 was reviewed on 06/02/2017 at 11:00 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated 02/05/2017, indicated a Brief Interview for Mental Status (BIMS) score of 6 (severely impaired cognitive status). The Significant change Minimum Data Set (MDS) Assessment, dated 05/02/2017, indicated a Brief Interview for Mental Status (BIMS) score of 9 (moderately impaired cognitive status). An Observation report dated 06/01/2017, indicated a BIMS score of 4 (severely impaired cognitive status). On 06/01/2017 at 1:53 p.m., the Executive Director provided a copy of an Incident dated: 04/05/2017 at 4:01 p.m. Brief Description of Incident: The two residents (Resident 10 and Resident 110) have had a relationship for awhile now. Previously they were both cognitively intact, as they were both scoring a 15 on BIMS. Resident 110 recently had a hospital stay and her BIMS score has been lower since that occurrence. Staff reported seeing the two residents kissing today. Type of preventative measures added 04/05/2017, residents separated to ensure safety. Resident #110's clinical record lacked documentation of a care plan in regard to implement interventions of provide supervision of resident when interacting with male peers. On 6/1/2017 at 10:00 a.m., the Executive Director provided a copy of an incident dated, 05/31/2017, A brief Description of Incident: The two residents (Resident 10 and Resident 110) had a relationship for a while now. Previously they were both cognitively intact, as they were both scoring a 15 on the BIMS. Resident 110's BIMS had been lower. The residents have previously agreed to meet in a common space for supervision. Nurse reported that she observed Resident 10 with his hand up Resident 110's skirt and it appeared to be resting on her leg. Nurse immediately intervened and separated the two residents for safety. During an interview on 06/06/2017 at 3:15 p.m., Licensed Practical Nurse (LPN) 2 indicated she was working her shift and stopped at the nurses station and witnessed Resident 110 and Resident 10 outside on the patio without supervision. Resident 10 was leaning toward Resident 110. LPN went outside to observe the interaction. Resident 110's skirt was raised above her thigh. Resident 10 had his hand resting on Resident 110's upper thigh. I immediately intervened and asked the residents to come inside the building. Resident 110 was not in any distress and no injury was noted. Resident 110 was compliant with coming into the building. Resident 10 stated, 'It is 9 O'clock and all is well.' LPN also indicated Resident 110 has been upset since the incident and will not talk to her. On 06/01/2017 at 2:30 p.m., documentation of behavior monitoring and/or care plan was requested from the Executive Director. Documentation provided indicated no development of a care plan until after the second incident dated 6/01/2017. 3.1-35(a) 3.1-35(b)(1)

Based on record review and interview, the facility failed to ensure a resident's medications were administered according to physician's orders for 1 of 3 residents reviewed for physician orders in a sample of 3 (Resident B). Findings include: Resident B was admitted to the facility, on 7/11/15, with [DIAGNOSES REDACTED]. Recapitulation of the physician's orders for January 2017, indicated the Resident was originally prescribed [MEDICATION NAME] (sleep supplement) 4 milligrams (mg) daily on 10/14/16 and was originally prescribed [MEDICATION NAME] (antipsychotic) 2.5 mg upon rising and 2.5 mg before bedtime on 2/3/16. Review of the Medication Administration Record [REDACTED]. The record lacked documentation the facility notified the family the [MEDICATION NAME] and [MEDICATION NAME] needed refilled or the physician was notified the medications were not administered. During an interview with the Administrator and Director of Nursing (DON) on 1/31/17 at 11:50 a.m., they indicated the family would be providing the resident's medications ([MEDICATION NAME] and [MEDICATION NAME]), but did not deliver them until the next day (12/31/16). They also indicated, the family signed an Alternate Pharmacy Agreement on 7/9/15. The agreement indicated staff could and would, utilize the facility pharmacy to deliver medications in the event the family does not provide them. Additionally, the Administrator and DON indicated, the nurse did not request the unavailable medications from the facility's pharmacy. The record lacked documentation staff obtained the [MEDICATION NAME] and [MEDICATION NAME] from the facility pharmacy. This Federal tag relates to Complaint IN 231. 3.1-37(a)

Based on record review and interview, the facility failed to ensure contact precaution protocols were in place for 1 of 3 residents reviewed for contact precautions in a sample of 3 (Resident #B). Findings include: The record for Resident #B was reviewed on 8/3/16 at 9:50 a.m. [DIAGNOSES REDACTED]. Review of the clinical record for Resident #B for July 2016, lacked documentation of contact precaution for suspected Clostridium difficile (c-diff). A progress note dated 7/14/16 at 8:34 p.m., indicated Resident #B had several episodes of diarrhea. Staff indicated he had 5 episodes of diarrhea on the previous shift and he was refusing to eat but would drink fluids. The physician was notified and orders for laboratory tests (BMP-basic metabolic panel blood work and stool sample for[DIAGNOSES REDACTED]) were received. An Outpatient Doctor Summary Report dated 7/15/16, indicated the BMP had been drawn, results received and the physician had been informed. The record lacked any documentation regarding results for the laboratory test for[DIAGNOSES REDACTED]. A progress note dated 7/18/16, indicated the resident had dark brown emesis and diarrhea and was sent out to the hospital emergency room for evaluation and treatment. A hospital Emergency Department (ED) note dated 7/18/16, indicated the resident had a [DIAGNOSES REDACTED]. During an interview on 8/4/16 at 9:05 a.m., with the Administrator and Director of Nursing (DON), they indicated there were no laboratory test results for the[DIAGNOSES REDACTED] test, because it had not been picked up by the lab when they came in to draw the resident's blood. During an interview with the DON on 8/4/16 at 10:00 a.m., she indicated they had inserviced staff on a new procedure to be sure all lab tests were completed in a timely manner and as ordered. According to the Centers for Disease Control at www.cdc.com, a document titled How can Clostridium difficile infection be prevented in . healthcare settings (retrieved 8/4/16), indicated: Use Contact Precautions for patients with known or suspected[DIAGNOSES REDACTED] infection . This Federal tag relates to Complaint IN 916.

Based on record review and interview, the facility failed to ensure laboratory tests were completed timely for 1 of 3 residents reviewed for laboratory tests in a sample of 3 (Resident #B). Findings include: The record for Resident #B was reviewed on 8/3/16 at 9:50 a.m. [DIAGNOSES REDACTED]. A progress note dated 7/14/16 at 8:34 p.m., indicated Resident #B had several episodes of diarrhea. Staff indicated he had 5 episodes of diarrhea on the previous shift and he was refusing to eat but would drink fluids. The physician was notified and orders for laboratory tests (BMP-basic metabolic panel blood work and stool sample for [MEDICAL CONDITION]/[MEDICAL CONDITION]) were received. An Outpatient Doctor Summary Report dated 7/15/16, indicated the BMP had been drawn, results received and the physician had been informed. The record lacked any documentation regarding results for the laboratory test for [MEDICAL CONDITION]. A progress note dated 7/18/16, indicated the resident had dark brown emesis and diarrhea and was sent out to the hospital emergency room for evaluation and treatment. A hospital Emergency Department (ED) note dated 7/18/16, indicated the resident had a [DIAGNOSES REDACTED]. During an interview on 8/4/16 at 9:05 a.m., with the Administrator and Director of Nursing (DON), they indicated there were no laboratory test results for the [MEDICAL CONDITION] test because it had not been picked up by the lab when they came in to draw the resident's blood (7/14/16). During an interview with the DON on 8/4/16 at 10:00 a.m., she indicated they had inserviced staff on a new procedure to be sure all lab tests were completed in a timely manner and as ordered. This Federal tag relates to Complaint IN 916.

Based on record review and interview, the facility failed to ensure a careplan was developed for a resident who experienced a significant weight loss, for 1 of 1 resident reviewed for significant weight loss. (Resident #82) Findings include: The clinical record of Resident #82 was reviewed on 4/12/16 at 10:00 a.m. [DIAGNOSES REDACTED]. Review of the resident's weight record indicated: 11/1/15 weight was 102.8. 2/11/16 weight was 92. (a significant weight loss of 10% from 11/1/15) A nutrition note, dated 2/19/16, indicated the resident had experienced significant weight loss and the Registered Dietician (RD) recommended the resident receive a nutritional supplement of a house shake daily. The note indicated Resident #82 had agreed to receiving this supplement. No order was found in the resident's record for this nutritional supplement nor any documentation the resident received the house shake. 3/1/16 weight was 87. (a significant weight loss of 5% from 2/11/16 and a significant weight loss of 15% from 11/1/15) A care plan for the Resident #82 was created on 3/14/16, for being nutritionally at risk after the resident had a documented weight loss 2/11/16, 2/19/16, and 3/1/16. On 3/17/16, an RD note indicated Resident #82 had agreed to receive the house shake supplement 2 times per day, and a physician order [REDACTED]. On 4/3/16, the resident's weight was 88.6, a 1.6 pound gain from the previous month. A care plan for Resident #82 was created on 4/17/16 for the identification of a significant weight loss between 11/1/15 and 2/11/16. On 4/13/16 at 11:15 a.m., the Administrator provided an undated policy, titled, Weight Management Policy, and indicated it was the policy currently used by the facility. The policy indicated the Interdisciplinary Team (IDT) would meet, weekly on residents with significant weight changes to evaluate current interventions and make changes as necessary to stabilize the resident and attain the care plan goal .Review any assessment information provided by other disciplines outside of nursing such as .Dietary .Implement additional interventions . 3.1-35(a)

Based on record review and interview, the facility failed to ensure a care plan was updated for a resident who developed pressure ulcers for 1 of 3 residents who met the criteria for review of updated pressure ulcer care plans. (Resident #77) Findings include: The clinical record of Resident #77 was reviewed on 4/12/16 at 3:07 p.m. [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment, dated 2/10/16, indicated the resident did not have a pressure ulcer, needed extensive assistance for bed mobility, and was at risk for developing a pressure ulcer. A care plan, initiated 2/8/16, and current through 5/19/16, indicated the resident was at risk for skin breakdown related to decreased mobility. Interventions, including offloading of heels while in bed, were put in place and documented as done. The record indicated on 2/19/16, the resident developed unstageable pressure ulcers on her left and right heels, suspected due to deep tissue injury. An updated care plan for the resident having actual skin breakdown was not found in the resident's record. On 4/15/1 at 11:30 a.m., Licensed Practical Nurse (LPN) #1 indicated the resident's care plan had not been updated for for developing pressure ulcers on her heels bilaterally. On 4/14/16 at 3:00 p.m., LPN #1 provided an undated policy, titled, Wound Management, and indicated it was the policy currently used by the facility. The policy indicated, .Each wound will be visualized by the wound team to provide oversight of the care plan interventions .Skin conditioned worsened .Review of care plan .Any changes made to care plan . 3.1-35(d)(2)(B)