Every finding on record at Chase Center

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician and the physician was notified when the medications were not administered for 1 of 5 residents reviewed for quality of care. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 11/17/25 at 4:18 p.m. The diagnoses included, but were not limited to, traumatic brain injury, influenza A virus with pneumonia, dementia, borderline personality disorder, and anxiety disorder. 1. A physician's order, dated 11/2/25, indicated to administer oseltamivir phosphate (an antiviral medication) 12.5 milliliters through the gastrostomy tube (a flexible tube surgically inserted through the abdomen wall to deliver nutrition, fluids and medication directly in the stomach) every 12 hours for 5 days.The Medication Administration Record (MAR), for November, indicated the oseltamivir phosphate was not administered on 11/3/25 at 6:00 p.m., on 11/5/25 at 6:00 p.m., and on 11/6/25 at 6:00 p.m.2. A physician's order, dated 11/7/25, indicated to administer oseltamivir phosphate 12.5 milliliters through the gastrostomy tube every 12 hours until 11/10/25.The MAR, for November, indicated the oseltamivir phosphate was not administered on 11/8/25 at 6:00 a.m.3. A physician's order, dated 11/7/25, indicated to administer amoxicillin and potassium clavulanate (an antibiotic medication) 875-125 milligrams through the gastrostomy tube every 12 hours for 2 days.The MAR, for November, indicated the amoxicillin and potassium clavulanate was not administered on 11/3/25 at 6:00 p.m., and on 11/6/25 at 6:00 p.m.There was no documentation the physician was notified of the missed medication doses.During an interview, on 11/19/25 at 10:33 a.m., Registered Nurse (RN) 2 indicated missing medications or newly ordered medications could be pulled from the emergency drug kit (EDK). If the medication was not in the EDK, the nurse would call the pharmacy and get the medication sent STAT (immediately). The physician would be notified of the missed medication. During an interview, on 11/18/25 at 12:56 p.m., the Director of Nursing (DON) indicated the nurse on duty had indicated she administered the antibiotic. The nurse did not mark the medication off on the MAR and there was no way to know for sure if the medication was given. The nurses should document when medications are administered. A current facility policy, titled Medication Administration General Guidelines, received from the DON on 11/18/25 at 2:15 p.m., indicated .Medication(s) prepared or administered only by.personnel authorized by state laws and regulations to prepare or administer medications .Follow the six rights of medication administration .Right medication .Right dose .Right patient .Right route .Right time .Right documentation . Documentation is completed on the MAR/eMAR immediately after medication(s) ingested by resident and completed by the licensed personnel administer the medication(s) .Document any scheduled medication(s) that is withheld, refused, or given at a different time than scheduled .MAR/eMAR should have the licensed personnel initials circled for the medication(s) with an explanation written in the proper area on the backside of MAR/eMAR page designated .3.1-37(a)

Based on interview and record review, the facility failed to ensure pneumococcal vaccines were provided when requested with a signed consent form for 1 of 5 residents reviewed for immunizations. (Resident 3)Findings include: The clinical record for Resident 3 was reviewed on 11/17/25 at 4:18 p.m. The diagnoses included, but were not limited to, traumatic brain injury, influenza A virus with pneumonia, seizures, dementia, borderline personality disorder, and anxiety disorder.A vaccination summary form indicated Resident 3 received a pneumococcal vaccine, on 8/4/18, and the vaccination was now past due.An informed consent form for a pneumococcal vaccine, dated 7/29/25, indicated the resident consented to receiving the vaccination.The electronic medical record did not include documentation Resident 3 received a pneumococcal vaccination after the signed consent form on 7/29/25.During an interview, on 11/18/25 at 2:59 p.m., the Director of Nursing (DON) indicated Resident 3 did not receive the pneumococcal vaccine. The immunization should have been provided soon after the consent was signed. A current facility policy, titled Pneumococcal Vaccines, dated as revised on 4/28/25 and received from the Administrator on entrance, indicated .Under these standing orders residents who meet criteria for Pneumococcal vaccination may receive the vaccine by the nurse or by any appropriately qualified personnel who follow facility policy .Obtain consents from the resident or responsible party and document in the resident's medical record .Document vaccine administration in resident's medical record .If the vaccine was not given, record the reason(s) for non-receipt of the vaccine (e.g. medical contraindication, resident rights, given prior to admission) in the resident's record 3.1-18(b)(5)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for 1 of 1 resident reviewed for MDS accuracy. (Resident 28) Finding includes: The clinical record for Resident 28 was reviewed on 10/30/24 at 3:28 p.m. The diagnoses included, but were not limited to bipolar disorder, vascular dementia, intermittent explosive disorder, conduct disorder, and visual hallucinations. An annual MDS assessment, dated 12/14/23, indicated the resident had a diagnosis of bipolar disorder. A quarterly MDS assessment, dated 5/30/24, indicated the resident had a diagnosis of bipolar disorder. A quarterly MDS assessment, dated 8/20/24, indicated the resident had a diagnosis of bipolar disorder. The psychiatry nurse practitioner notes, dated 9/5/24 and 10/3/24, indicated the resident had a diagnosis of bipolar disorder. The assessment and plan indicated no changes to the current plan of care. A psychiatry nurse practitioner late entry note, dated 10/31/24, indicated incorrect documentation was struck out of the resident's Electronic Health Record (EHR) notes for 9/5/24 and 10/3/24. During an interview, on 10/31/24 at 9:16 a.m., the Administrator indicated Resident 28 did not have a diagnosis of bipolar disorder. The diagnosis was added in error to the MDS assessment and to the resident's EHR. During an interview, on 11/4/24 at 3:30 p.m., the MDS Coordinator indicated she coded the resident's MDS assessment incorrectly. The bipolar diagnosis was added to the resident's record in error. The MDS Coordinator could not find any documentation Resident 28 had a diagnosis of bipolar disorder. A current policy, titled MDS Supportive Documentation Policy, dated as revised 10/10/23 and received from the Administrator on 11/4/24 at 3:57 p.m., indicated .To accurately record the needs of our residents through MDS assessments, as required by federal regulations .Supportive Documentation in the medical record must be dated during the assessment reference period to support the MDS Responses .The Assessment Reference Date (ARD) is the last date for collecting MDS data .The Social Services Director will be responsible for the following CAA's and Care Plans: a. Delirium, b. Cognitive Loss/Dementia, c. Psychosocial Well Being, d. Mood State, e. Behaviors, f. Return to the Community/Referral 3.1-31(d)(3)

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for a resident identified as a high risk for elopement for 1 of 6 residents reviewed for accidents. (Resident 4) Finding includes: The clinical record for Resident 4 was reviewed on 10/29/24 at 4:10 p.m. The diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (a type of dementia), anxiety, dementia without behavioral, psychotic or mood disturbance, and visual hallucinations. A wander risk evaluation, dated 10/8/24 at 4:13 p.m., indicated the resident had forgetfulness and/or a short attention span, had diagnoses of Alzheimer's and dementia with psychosis, was taking antipsychotics, and had a history of wandering. Her score was 11 which indicated she was at high risk for elopement. There was no comprehensive person-centered care plan in place for high-risk elopement. During an interview, on 11/4/24 at 4:00 p.m., LPN 5 indicated a care plan should have been developed. A current policy, titled Elopement, with a revision date of 8/10/22 and received from the Administrator on 11/4/24 at 3:30 p.m., indicated .a care plan will be developed with appropriate interventions implemented to provide for the resident's safety .an elopement binder will be kept and maintained on each unit and the front office 3.1-35(a) 3.1-35(d)(1)

Based on observation, interview and record review, the facility failed to ensure medication carts were free of loose pills and to ensure staff labeled eye drops with an opened date in 2 of 3 medication carts reviewed for medication storage. (200-unit and 300-unit) Findings include: 1. During a medication cart observation with Registered Nurse (RN) 2, on 10/30/24 at 11:34 a.m., the 200-hall medication cart was observed to have the following: a. The bottom of the second drawer had one and a half loose white pills. b. The bottom of the third drawer had one loose white pill. During an interview, on 10/30/24 at 11:41 a.m., RN 2 indicated the loose pills should be destroyed when found in the bottom of the medication cart. During an interview, on 10/30/24 at 11:44 a.m., LPN 3 indicated when pills were found in the bottom of the carts, they should be removed and put in the container located in the medication room. During an interview, on 10/30/24 at 12:30 p.m., the Director of Nursing indicated loose pills should not be in the bottom of the medication cart. There should be no loose pills in the cart. 46961 2. During an observation of the medication cart on the 300-unit, on 10/30/24 at 11:09 a.m., the eye drops for Residents 4, 56 and 61 had no open dates on the outside container or the bottle containing the eye drops. a. The clinical record for Resident 4 was reviewed on 10/29/24 at 4:10 p.m. The diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (a type of dementia), diabetic kidney disease, and long-term use of insulin. A physician's order, dated 10/3/24, indicated to instill Systane ophthalmic solution (for dry eyes) into both eyes. b. The clinical record for Resident 56 was reviewed on 10/29/24 at 4:27 p.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), cachexia (weakness or wasting of the body), anorexia, Alzheimer's disease, and dementia without behavioral psychotic or mood disturbance. A physician's order, dated 8/22/24, indicated to instill Latanoprost (used for glaucoma) in both eyes at bedtime. c. The clinical record for Resident 61 was reviewed on 10/30/24 at 11:30 a.m. The diagnoses included, but were not limited to, generalized anxiety disorder, nutritional anemia, essential hypertension, cachexia, and obsessive-compulsive disorder. A physician's order, dated 10/1/24, indicated to instill Atropine sulfate ophthalmic solution every 2 hours as needed. During an interview, on 11/10/24 at 11:10 a.m., RN 4 indicated the eye drops would need to be reordered due to not having an open date. The manufacturers guidelines for Systane eye drops indicated to dispose of the drops 1 month after opening. The manufacturers guidelines for atropine sulfate indicated to dispose of the drops 28 days after opening. The manufacturers guidelines for Latanoprost indicated to dispose of the eye drops 6 weeks after opening. 3.1-25(j) 3.1-25(o)

Based on interview and record review, the facility failed to notify the physician of a blood glucose level greater than the physician's call orders and to notify the physician of a significant weight loss for 3 of 3 residents reviewed for notification. (Resident 38, 45 and 20) Findings include: 1. The record for Resident 38 was reviewed on 9/11/23 at 11:50 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, Alzheimer's, hypertension, and depressive disorder. A physician's order, dated 3/2/23, indicated to check blood glucose levels at 6:00 a.m., 12:00 p.m., 5:00 p.m., and 8:00 p.m. Notify the physician if blood glucose levels were greater than 400 or less than 60. A physician's order, dated 5/12/23, indicated to give Humalog Kwik pen insulin (used for high blood glucose levels) 12 units for a blood glucose level of 401-450 and notify the physician. A facility record for the resident's blood glucose levels indicated, on 7/6/23 at 5:15 p.m., the resident's blood glucose level was 407. There was no documentation the physician was notified of the blood glucose greater than 400. A care plan, dated 9/7/23, indicated the resident had a potential for fluctuating blood glucose levels related to insulin dependent diabetes. The interventions included, but were not limited to, treat the blood glucose levels according to physician orders and the facility policy. During an interview, on 9/12/23 at 3:01 p.m., LPN 3 indicated the resident's blood glucose level usually was high and had insulin for coverage. During an interview, on 9/12/23 at 3:16 p.m., LPN 3 indicated if the resident's blood glucose level was 400 or above the physician needed to be called. The nurse needed to find out if the physician had any additional orders. During an interview, on 9/12/23 at 3:49 p.m., the Director of Nursing (DON) indicated there were no notes notifying the physician. The physician needed to be notified of the blood glucose level greater than 400. During an interview, on 9/12/23 at 4:05 p.m., the DON indicated they called the physician to verify the call orders and the physician indicated he wanted to be called if the resident's blood glucose level was greater than 400. 2. The record for Resident 45 was reviewed on 9/13/23 at 3:55 p.m. Diagnoses included, but were not limited to, Alzheimer's, Crohn's disease (a chronic long-term disease which causes inflammation in your gastrointestinal (GI) tract), ileostomy (a surgically created opening in the abdominal wall through which digested food passes), and pressure ulcer stage 3. The resident had the following weights: 1. On 8/10/23, the weight was 126.6 pounds (lbs). 2. On 9/11/23, the weight was 115.7 lbs. The resident had an 8.61% weight loss in 1 month. A Nutritional at Risk (NAR) progress note, dated 8/16/23 at 9:39 a.m., indicated the resident was on weekly weights. The resident had a 12.3% weight gain in 180 days. There was no documentation of a significant weight loss of 8.61% in 1 month. The physician was notified, on 9/8/23, of a 12.6% weight gain in 6 months. The physician was not notified of the 8.61% weight loss from 8/10/23 to 9/11/23. A facility intake document, dated 7/1/23 to 8/28/23, indicated the resident's average meal intakes were 50 to 75%. The resident was offered alternate food choices and 0% intake was documented. A care plan, revised on 8/28/23, indicated the resident was at nutritional risk related to congestive heart failure, and Crohn's disease of large intestine. The interventions included, but were not limited to, provide ordered diet, and offer food substitutions, determine resident's preferences regarding additional nutritional support. During an interview, on 9/11/23 at 3:25 p.m., LPN 3 indicated the resident was a hit or miss when it came to eating. The staff encouraged the resident to eat meals and the resident ate approximately 50%. During an interview, on 9/13/23 at 3:00 p.m., the DON indicated the resident's weight did not trigger for a significant weight loss yet and it was not time to notify the physician of a weight loss. The resident was on NAR and was weighed weekly. The facility notified of physician, on 9/8/23, of a 12.6% weight gain in 6 months and not the significant weight loss. 48525 3. The record for Resident 20 was reviewed on 9/11/23 at 10:40 a.m. Diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes, Alzheimer's disease, and dementia. The residents weight log indicated the following weights: 1. On 4/3/23, the weight was 190.3 lbs. 2. On 4/10/23, the weight was 188.0 lbs. 3. On 4/17/23, the weight was 170.4 lbs. The resident had a 9.36% weight loss in 1 week. A care plan, dated 5/18/23, indicated the facility will weigh the resident each Monday. A care plan, dated 8/17/23, indicated to notify the MD (medical doctor) of any condition changes. During an interview, on 9/12/23 at 11:48 a.m., the DON (Director of Nursing) indicated the facility had not contacted the MD about the resident's weight changes until 4/26/23. The MD was not notified about the weight loss until 9 days later. A current policy, titled Weight Policy, revised on 10/12/22 and received from the DON on 9/11/23 at 10:54 a.m., indicated .Significant weight changes will be defined as: 5% in 30 days .Resident Representative and physician will be notified of significant weight changes A current policy, titled MD and Resident and/or Resident Representative Notification, revised on 7/1/22 and received from the Director of Nursing on 9/12/23 at 4:49 p.m., indicated .Inform the Resident, consult with the Resident's physician and notify the Resident's Representative when: A significant change in the Resident's physical, mental or psychosocial status .Even if a Resident is mentally competent, the Resident Representative will be notified of significant changes, unless otherwise specified according to the Resident's preference. Such preference will be included in the Resident's care plan A current policy, titled Medication Administration Schedule, revised on 5/23/23 and received from the Director of Nursing on 9/12/23 at 4:49 p.m., indicated .Administer right after resident eats. Do NOT give insulin if resident does not eat per medical director. If resident's blood sugar is 300 or greater then insulin may be administered prior to resident eating and if resident does not eat the meal. The employee must know this does not apply to medication prescribed for administration in accordance with meals or for medications such as insulin .Communicate with the physician to request orders be changed or discontinued as needed. 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set) quarterly review was correctly filled out regarding the PASARR (Preadmission Screening and Resident Review) for 1 of 1 resident reviewed for resident assessment. (Resident 7) Finding includes: The record for Resident 7 was reviewed on 9/11/23 at 11:10 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, major depression, psychotic disorder, delusional disorder, and anxiety disorder. A PASARR level 1 screening outcome, dated 2/10/23, indicated there was no status change. An MDS assessment, dated 4/25/23, indicated the resident had not been evaluated by a PASARR level 2 and determined to have a serious mental illness or related illness. During an interview, on 9/7/23 at 11:14 a.m., the Administrator indicated a PASARR level 2 was done at the resident's previous facility, and they were never sent the PASARR level 2. The MDS was not marked for having a PASARR level 2 completed. During an interview, on 9/13/23 at 3:17 p.m., the DON indicated the facility did not have a MDS policy and followed the RAI (Resident Assessment Instrument) Manual. A current manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, indicated .Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASARR determination 3.1-31(a) 3.1-31(d)

Based on interview and record review, the facility failed to recognize a significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 45) Finding includes: The record for Resident 45 was reviewed on 9/13/23 at 3:55 p.m. Diagnoses included, but were not limited to, Alzheimer's, Crohn's disease (a chronic long-term disease-causing inflammation in your gastrointestinal (GI) tract) and ileostomy (a surgically created opening in the abdominal wall through which digested food passes). A physician's order, dated 2/2/23, indicated the resident was on a regular diet and double portions or protein. A physician's order, dated 2/21/23, indicated the resident was to be given fortified food (foods with nutrients added to them to help boost their nutritional value) with supper. A physician's order, dated 4/13/23, indicated the resident was to be given fortified food with breakfast. A physician's order, dated 4/26/23, indicated the resident was to be given fortified food with lunch. The resident had the following weights: 1. On 8/10/23, the weight was 126.6 pounds (lbs). 2. On 9/11/23, the weight was 115.7 lbs. The resident had a 8.61% weight loss in 1 month. A Nutritional at Risk (NAR) progress note, dated 8/16/23 at 9:39 a.m., indicated the resident was on weekly weights. The resident had a 12.3% weight gain in 180 days. There was no documentation for the significant weight loss of 8.61% in 1 month. A facility intake document, dated 7/1/23 to 8/28/23, indicated the resident's average meal intakes were 50 to 75%. The resident was offered alternate food choices and 0% intake was documented. A care plan, revised on 8/28/23, indicated the resident was at nutritional risk related to congestive heart failure and Crohn's disease of large intestine. The interventions included, but were not limited to, provide ordered diet, and offer food substitutions, determine resident's preferences regarding additional nutritional support. During an interview, on 9/11/23 at 3:25 p.m., LPN 3 indicated the resident was a hit or miss when it came to eating. The resident ate approximately 50-75% of the meals. During an interview, on 9/13/23 at 3:00 p.m., the Director of Nursing (DON) indicated the resident's weight did not trigger for a significant weight loss and it was not time to notify the physician of a weight loss. The resident was on NAR and was weighed weekly. The facility notified the physician, on 9/8/23, of a 12.6% weight gain in 6 months and did not notify the physician of the significant weight loss. A current policy, titled Weight Policy, revised on 10/12/22 and received from the DON on 9/11/23 at 10:54 a.m., indicated .It is the policy of [name of facility] to identify residents who may be at nutritional risk due to weight change .Significant weight changes will be defined as: 5% in 30 days, 7.5% in 90 days and 10% in 180 days .Resident Representative and physician will be notified of significant weight changes 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called for a Full Code status resident found unresponsive and without vital signs for 1 of 2 residents reviewed for death. (Resident B) The immediate jeopardy began on [DATE], when staff entered Resident B's room at 8:30 a.m., to get her up for breakfast. She was found unresponsive with no blood pressure, no apical or radial pulse, and no respirations. The resident was a Full Code. Registered Nurse (RN) 2 did not initiate CPR or call 911. She stated the resident was beyond resuscitating. The facility policy and procedures indicated staff should perform CPR and call 911 for all unresponsive Full Code residents. At 8:44 a.m., RN 2 notified the facility physician via text of the resident's death. The on call physician was called at 9:25 a.m. At 10:32 a.m., the on call physician gave the order to release the body to the funeral home. The Administrator and Director of Nursing were notified of the immediate jeopardy at 12:14 p.m., on [DATE]. The Immediate Jeopardy was removed on [DATE] and the deficient practice corrected on [DATE] prior to the start of the survey and was therefore Past Noncompliance. Findings include: The record for Resident B was reviewed on [DATE] at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Indiana Physicians Orders for Scope of Treatment (POST), dated [DATE], indicated the resident wished to have Cardiopulmonary Resuscitation (CPR) performed and full interventions including life support measures in the intensive care unit. The resident wished to use intubation, advanced airway interventions, and mechanical ventilation as indicated. The document indicated a preference to transfer to the hospital and/or intensive care unit if indicated to meet medical needs. A Care Plan, dated [DATE], indicated the resident was a Full Code status. The goal was to honor the resident's choice and wishes. The interventions included, but were not limited to, monitor for complaints of pain and discomfort, honor the residents wishes and initiate CPR, if needed and dial 911. A progress note, dated [DATE] at 8:48 a.m., indicated Certified Nursing Assistant (CNA) 7 walked into Resident B's room and immediately summoned Registered Nurse (RN) 2. RN 2 was unable to get the resident's blood pressure, respiration rate, an apical or radial pulse. RN 2 sent Physician 5 a text message to inform him the resident appeared to be beyond the point of resuscitation and was a full code. A facility copy of the text messages to the Physician 5, dated [DATE] at 8:44 a.m., indicated RN 2 could not obtain vital signs on Resident B. The resident was too far beyond point of resuscitating and was a full code. An order to release the body was requested. Physician 5 responded to the text at 1:48 p.m., and asked who the message was from. A progress note, dated [DATE], indicated at 9:25 a.m., Physician 6 was called to request a release of body. A progress note, dated [DATE], indicated at 10:32 a.m., an order was received from Physician 6 to release the body. A facility investigation report, dated [DATE], indicated RN 2 was passing medication when CNA 7 requested assistance in Resident B's room. CNA 7 reported the resident did not look right. RN 2 went into the resident's room and found the resident on her side with her leg hanging over the bed. RN 2 verified the code status immediately after assessing the resident. RN 2 apologized for her poor judgement but denied making the decision to withhold CPR. The Director of Nursing (DON) indicated RN 2's lack of action was her decision. A Certificate of Death form, dated [DATE], indicated the resident's cause of death was cardiac arrhythmia, [CONDITION(S)] and coronary artery disease. During an interview, on [DATE] at 3:38 p.m., the Administer indicated the staff went into the resident's room to get her up for breakfast and they found the resident unresponsive. Staff immediately summoned RN 2 to check the resident. RN 2 was unable to get a blood pressure, an apical or radial pulse, respirations or an oxygen saturation. Physician 5 was sent a text message and informed the resident appeared beyond the point of resuscitating and was a full code. RN 2 did not initiate CPR. The facility policy indicated for residents with a full code to start CPR and call 911. The staff should have started CPR and called 911. During an interview, on [DATE] at 11:32 a.m., Housekeeping Staff 3 indicated on [DATE] at 6:45 a.m., or 7:00 a.m., she knocked on Resident B's door and there was no response. Resident B appeared to be sleeping. Housekeeping Staff 3 proceeded to clean the resident's bedside table and her bathroom. The resident's color was normal, she was not gray. During an interview, on [DATE] at 1:47 p.m., Licensed Practical Nurse (LPN) 4 indicated she was working the morning shift on [DATE]. She was passing medication when she went to get something from the kitchen. CNA 7 asked for LPN 4 to come help RN 2 because they found Resident B unresponsive. RN 2 was doing vital signs and asked LPN 4 to phone the physician. She paged Physician 6 who was on call although she did not know the exact time of the page. The on call physician answered and RN 2 indicated she had tried to contact the facility Physician 5 and he was not returning the call. She told the on call Physician 6 the resident did not have a pulse or breath sounds. LPN 4 asked if the physician wanted CPR and the on call Physician 6 said to hold CPR since it would not do any good to start at this point. For residents who have a full code status, CPR should be started immediately, 911 called and staff should bring the crash cart into the room. The physician should be notified after these steps. During an interview, on [DATE] at 4:45 p.m., CNA 7 indicated on [DATE] she was working the morning shift. The staff was running late, and breakfast was already on the unit, and they were trying to wake up residents. Resident B did not respond to verbal conversation, looked very pale and gray, had no color at all, and her legs were hanging off the bed. RN 2 was notified and asked to check the resident. Then CNA 7 went to the kitchen to get LPN 4 to assist RN 2. A current policy, titled Advance Directives, dated as revised on [DATE] and received from the Administrator on [DATE] at 4:35 p.m., indicated .Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Code Status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops .If a resident is found unresponsive, experiencing cardiac or respiratory arrest, call [DATE] and initiate CPR. Have another staff member dial 564 to page overhead and announce, 'All available nursing staff to room .STAT' .A crash cart is located on each unit in the 'Solid/Clean Utility Room' The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed on [DATE] and the deficient practice corrected on [DATE] when the facility implemented a systemic plan which included the following actions: the facility completed a house wide audit of code status', validated the nursing staffs CPR, reviewed Advanced Directives and Code Status policy, revised the Code Status policy, reviewed and updated the Notification of Change in Condition policy and re-educated licensed nurses with any changes, terminated the nurse after the investigation was completed, schedule CPR class, educated staff on overhead paging, labeled all phones providing directions for emergency overhead paging, re-educated all licensed nurses on code status and appropriate response. This Federal tag relates to Complaint IN 462. 3.,d+[DATE](a)

Based on interview and record review, the facility failed to ensure the diagnoses were appropriate for the use of [CONDITION(S)] medications for 5 of 5 residents reviewed for unnecessary medications (Residents 7, 12, 38, 24 and 40). Findings include: 1. The record for Resident 7 was reviewed on 9/23/22 at 10:34 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, impulse disorder, depressive disorder and dementia in other disease with behavioral disturbance and psychotic disorder with delusions. A physician's order, dated 7/28/21, indicated [MEDICATION(S)] (an antipsychotic) 0.5 mg (milligram) by mouth twice a day for psychotic disorder with delusions (typically a symptom of mental disorder). A physician's order, dated 7/28/21, indicated [MEDICATION(S)] (an antipsychotic) 0.25 mg (milligram) by mouth in the morning for psychotic disorder with delusions. A care plan, dated 9/19/22, indicated the resident had delusions, Alzheimer's disease and the resident received an antipsychotic medication. The resident was prescribed an antipsychotic medication to help manage behavior symptoms. Approaches included, but were not limited to, rule out [CONDITION(S)], assist the resident to call his wife and offer a snack. 2. The record for Resident 12 was reviewed on 9/21/22 at 3:18 p.m. Diagnoses included, but were not limited to, [CONDITION(S)] disease, hypertension, dementia with Lewy bodies, psychotic disorder with delusions. A physician's order, dated 7/7/22, indicated [MEDICATION(S)] (an antipsychotic) 50 mg tablet by mouth daily for psychotic disorder with delusions due to know physiological condition. A care plan, dated 9/14/22, indicated the resident was at a potential risk for side effect for antipsychotic medications. 3. The record for Resident 38 was reviewed on 9/23/22 at 2:15 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder with delusions, hypertension, depressive disorder and chronic pain. A physician's order, dated 8/28/22, indicated [MEDICATION(S)] (an antipsychotic) 2.5 mg tablet by mouth daily for psychotic disorder with delusions. A care plan, dated 8/20/22, indicated the resident had dementia with behavioral disturbance, a psychotic disorder with delusions. The resident was prescribed an antipsychotic medication to help manage behavior symptoms. Approaches included, but were not limited to, provide medication and avoid overstimulation. 4. The record for Resident 24 was reviewed on 9/21/22 at 4:30 p.m. Diagnoses included, but were not limited to, Fahr's disease ([CONDITION(S)] disease of the basil ganglia), dyskinesia (a movement disorder), and polyneuropathy (a malfunction of many peripheral nerves through out the body). A physician's order, dated 5/5/21, indicated to administer [MEDICATION(S)] (an antipsychotic medication for [CONDITION(S)]) 0.5 milligrams twice daily for Fahr's syndrome. A physician's order, dated 5/18/21, indicated to reduce [MEDICATION(S)] to 0.25 milligrams in the a.m., and 0.5 milligrams in the p.m., for 2 weeks, then re-evaluate verified medication usage for tremors. A physician's order, dated 12/31/21, indicated [MEDICATION(S)] 0.25 milligrams twice daily for dyskinesia due to Fahr's disease. A fax, dated 5/25/22, was sent to the physician from the facility indicating the resident was having an increase in tremors. The response was to continue gradual dose reduction and the resident would be seen in 2 weeks. A fax, dated 6/8/21, sent to the physician from the facility indicated the resident was having worsening tremors and rolling of the right shoulder since the [MEDICATION(S)] was stopped. The response from the physician was to continue to observe the worsening tremors. The physician indicated the symptoms were not prominent at a visit earlier in the day. A physician's note, dated 8/11/21 at 10:40 a.m., indicated the use of [MEDICATION(S)] was for movement disorder in her right arm and shoulder. The [MEDICATION(S)] was discontinued upon admission to the facility due to an unclear reason for the use of the medication. The physician also indicated the lack of familiarity with treating the movement disorder with [MEDICATION(S)]. The use of [MEDICATION(S)] seemed to be counterintuitive. A neurologist's progress note, dated 9/8/21 at 2:18 p.m., indicated the resident was referred due to right dyskinesia [MEDICATION(S)] for more than a year. [MEDICATION(S)] (an anti-Parkinson medication) 25/100 milligrams was started as a trial. A neurologist's note, dated 12/3/21 at 12:44 p.m., indicated the arm movement had worsened and increased. No symptom relief was noted from the use of [MEDICATION(S)]. The [MEDICATION(S)] was restarted at a low dose of 0.25 milligrams twice daily. A physician's note, dated 12/14/22, indicated the risk versus benefits of [MEDICATION(S)] were discussed with staff at the facility. He agreed with the restart of [MEDICATION(S)]. During an interview, on 9/23/22 at 3:17 p.m., the Resident Care Manager indicated the resident was on [MEDICATION(S)] and the medication was gradually decreased on admission due to an unclear diagnosis. The symptoms returned and she had an unsuccessful trial of [MEDICATION(S)]. During an interview, on 9/27/22 at 3:30 p.m., the pharmacist indicated the use of the [MEDICATION(S)] for Fahr's disease was an off label use. 5. The record for Resident 40 was reviewed on 09/22/22 1:39 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, (mental confusion) impulse control disorder (failure to resist a temptation, urge or an impulse or having inability not to speak on a thought) and chronic kidney disease. A behavior note, dated 4/18/22, indicated the resident wandered into peers' rooms 5 times. The peers' did not seem affected by the wandering. The interventions included, but were not limited to, allowed resident to voice concerns, offered snack, provided 1:1, and walk with the resident. The outcome indicated the resident did not appear distressed. A behavior note, dated 5/20/22 10:24 a.m., indicated the resident had wandered into the doorway of 2 other residents rooms. She was offered snacks, provided 1:1 and assisted to walk around the facility. The interventions were effective. A psychiatric note, dated 7/7/22, indicated the staff reported increased wandering, reports she was waiting to go home, taking items from others rooms and reports of verbal aggression with staff. A failed dose reduction was noted due to the above behaviors. A physician's order, dated 7/7/22, indicated [MEDICATION(S)] ([MEDICATION(S)]) 250 milligrams twice daily for impulse control disorder. A care plan, dated 8/22/22, indicated history of being sexually inappropriate related to dementia. Interventions included, but were not limited to, have 2 staff members when she was provided a bath, 1:1 visits to provide education regarding procedure and necessity. A care plan, dated 9/2/22, indicated refusals of care related to Alzheimer's disease. A care plan, dated 9/2/22, indicated disruptive behavior related to dementia, resident would urinate in the trash can, on plate covers, the floor or her meal tray rather than using the restroom. A care plan, dated 9/6/22, indicated impulse control disorder related to impulsiveness, manifested by yelling at staff and family and repeatedly calling son. During an interview, on 9/27/22 at 3:30 p.m., the pharmacist indicated the [MEDICATION(S)] was being used off label. A recent publication of PDR.net (physicians desk reference) indicated .the approved use of [MEDICATION(S)] was to treat [CONDITION(S)], [CONDITION(S)] disorder, including acute [CONDITION(S)] or mixed episodes associated with [CONDITION(S)] 1 disorder in adults .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .[MEDICATION(S)] ([MEDICATION(S)]) was indicated for the treatment of [CONDITION(S)] disorder, including [CONDITION(S)], [CONDITION(S)] depression and major depressive disorder .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .[MEDICATION(S)] ([MEDICATION(S)]) was indicated for the treatment of [CONDITION(S)] .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .[MEDICATION(S)] was indicated for the treatment of [CONDITION(S)] disorder including [CONDITION(S)] .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A current policy, titled Resident management of behavioral changes/concerns/modifications of behavior management plans/use of [CONDITION(S)] medications/prn use of [CONDITION(S)] medications, with a revision date of 12/7/21 and received from the Director of Nursing on 9/27/22 at 11:30 a.m., indicated .a [CONDITION(S)] drug affecting brain activity associated with mental processes and behaviors .these drugs include, but are not limited to .antipsychotics, antidepressants, antianxiety and hypnotics .necessary to treat a specific condition as diagnosed and documented in the clinical record 3.1-48(a)(4)

Based on interview and record review, the facility failed to submit a revised Preadmission Screen and Resident Review (PASARR) Level I after new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. The record for Resident 12 was reviewed on 9/21/22 at 3:18 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR Level I, completed on 4/13/22, indicated no mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If changes occurred or new information refuted these findings then a new screen must be submitted. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The record for Resident 38 was reviewed on 9/23/22 at 2:15 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR Level I, completed on 10/8/18, indicated no mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If changes occurred or new information refuted these findings then a new screen must be submitted. A Behavior Management Evaluation, dated 8/4/22, indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 9/27/22 at 9:48 a.m., the Administrator and Director of Nursing indicated a PASARR Level II needed to be done if they were put on a [CONDITION(S)] medication. During an interview, on 9/27/22 at 11:30 a.m., the Administrator indicated a new PASARR should have been completed when the antipsychotic medication was added. During an interview, on 9/27/22 at 12:53 p.m., the Director of Nursing indicated the facility did not have a policy on PASARR. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a resident needing assistance with ADL's (activity of daily living) was provided the scheduled daily showers for 1 of 5 residents reviewed for showers. (Resident 12) Finding includes: During an observation, on 9/19/22 at 2:34 p.m., Resident 12 was sitting in a recliner. The resident was covered with a blanket and his hair was greasy and not combed. During an observation, on 9/23/22 at 9:53 a.m., RN 8 was putting the resident's shirt back on. She indicated the resident could be difficult to provide care at times. The record for Resident 12 was reviewed on 9/21/22 at 3:18 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 9/14/22, indicated the resident needed assistance with activities of daily living. The goal included the resident would be clean, fed and well groomed with assistance of staff. The MDS (Minimum Data Set) assessment, dated 4/20/22, indicated the resident needed one person physical assist with showers and bathing. A facility report, received from the Resident Care Manager (RCM) 9 on 9/27/22 at 3:15 p.m., indicated Resident 12 was missing 21 showers from 4/20/22 through 9/25/22. The report was marked did not occur on the missed showers. The resident's hair was shampooed 4 times between 9/4/22 through 9/25/22. During an interview, on 9/20/22 at 10:59 a.m., the resident's family member indicated the staff were short handed and they take a long time to get to him. He was supposed to get a shower two times a week and was not sure when he had one. During an interview, on 9/26/22 at 3:08 p.m., RCM 9 indicated, on 8/15/22, the facility started offering 3 showers a week. They had a care plan meeting and discussed the showers. The resident was receiving 2 showers per week on Wednesday and Saturday. It was very hard to give him a shower because of his Lewy body. A current policy, titled Activities of Daily Living (ADL's), dated as revised 5/15/17 and received from the Director of Nursing on 9/27/22 at 11:30 a.m., indicated .Assisting in activities of daily living are skills required in nursing as well as other professions such as nursing assistants. This include assisting in resident with personal hygiene, oral care, nail care, or toileting etc. (This list is not intended to be all inclusive) .Grooming/Personal Hygiene: Always allow residents to do as much as possible for themselves 3.1-38(a)(3)(B)

Based on interview and record review, the facility failed to recognize and notify the physician of a significant weight loss for 1 of 6 residents reviewed for nutrition. (Resident 29) Finding includes: The record for Resident 29 was reviewed on 9/24/22 at 2:42 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 7/27/22, indicated the resident had a potential for fluid volume deficit. The interventions included, but were not limited to, encourage fluid intake, provide assist with fluids and monitor indicators of hydration. The care plan did not include monitoring the resident's weights. A care plan, dated 7/27/22, indicated the resident was at a nutritional risk related to [CONDITION(S)], dependent on hemodialysis, therapeutic diet related to [CONDITION(S)] had a potential for fluid volume deficit. The interventions included, but were not limited to, obtain weight as ordered and offer substitutions as needed. The resident had the following weights: 1. On 8/1/22, the weight was 193.2 pounds (lbs.). 2. On 9/5/22, the weight was 174 lbs. The resident had a 9.95% weight loss in 1 month. A progress note, dated 9/21/22 at 12:07 p.m., indicated Physician 5 was notified of a 10.9% eight loss in 30 days. The physician was notified 17 days after the significant weight loss occurred. A current policy, titled Weight Assessment and Intervention, dated as revised on 7/08/22 and received from the Director of Nursing (DON) on 9/26/22 at 11:30 p.m., indicated .It is the policy of [name of facility] multidisciplinary team to prevent, monitor, and intervene for undesirable weight loss or gain for our residents .Any weight change of 5% in one month, 7.5% in 3 months, or 10% in 6 months or more since the last weight will be reweighed within 3 days to verify the weight .If a resident is on a fluid restriction due to excessive fluid intake the MD and Resident Representative will be notified of weight changes +/- 5lbs. [CONDITION(S)] patients will be weighed daily or per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A current policy, titled Dining Services Policy and Procedure, dated 9/2022 and received from the DON on 9/26/22 at 11:30 p.m., indicated .To communicate nutritional monitoring tools used by dietary and IDT team .Nutrition Assessment will be completed upon admission and documented in the medical record .Resident weights will be monitored for significant unexpected change. (5% in 1 month, 7.5% in 3 months, 10% in 6 months). Appropriate intervention will be planned, implemented, reviewed and changed as needed until weight is stable . 3.1-46(a)(1)

Based on interview and record review, the facility failed to notify the physician of a new skin condition for 1 of 3 residents reviewed for bruising (Resident B). Finding includes: The record for Resident B was reviewed on 4/6/2021 at 11:53 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A shower sheet, dated 3/13/2021, indicated the resident had a small cut on a toe on her left foot. The shower sheet was signed by LPN 2. There was no documentation in the electronic record to include an assessment or notification to the physician of the cut on the left foot. A skin problem note, dated 3/23/2021 at 12:32 p.m., indicated the resident had purple bruises on her left foot and toes. A skin problem note, dated 3/24/2021 at 12:22 a.m., indicated the resident had purple bruising on the left foot and toes which was located between, on top and on the underside of the toes. The documentation did not include a notification to the physician of the bruising of the left foot and toes. During an interview, on 4/6/2021 at 2:24 p.m., the Unit Manager (UM) indicated she did not know what had happened to the resident's left foot or toes to cause the bruising. The documentation did not include notification to the physician of the bruising. A current facility policy, titled Skin Impairment, dated as revised on 1/15/16 and received from the Executive Director on 4/6/2021 at 3:00 p.m., indicated .It is the policy of [name of facility] that residents will be thoroughly assessed upon admission, when new open areas are identified .and weekly by licensed nurse, in an attempt to maintain the skin integrity of all resident .Nursing assistants will observe the resident's skin daily during repositioning, toileting, bathing or showering, and promptly report new areas or changes to the charge nurse .During any skin assessment, the nurse will inspect for any skin abnormalities, such as redness, swelling, rash, bruising, skin tears, blisters .The nurse discovering the area will describe the impaired skin, place pertinent charting in the resident's file and notify the physician, wound nurse or designee, resident, and family/responsible party A current facility policy, titled MD and Resident and/or Resident Representative Notification, dated as revised on 7/22/2019 and received from the Executive Director on 4/6/2021 at 3:45 p.m., indicated .All pertinent information in regards to residents will be communicated to the family/responsible party in a manner according to the urgency of the matter .To provide quality of care by notifying the family/responsible party when there is a change in condition, clinical complications, need to alter treatment, commerce a new fort of treatment, an accident/incident, development/change of pressure or statis ulcer etc. [This list is not intended to be all inclusive] .Any change in condition that the nurse feels is not an emergency, but family notification is needed within 24 hours .Faxing messages to the physician will only occur if the condition does not require immediate attention. These conditions might include, but are not limited to .request for skin care This Federal Tag relates to Complaint IN 160. 3.1-5(a)(2)

Based on interview and record review, the facility failed to thoroughly assess and document a new skin condition for 1 of 3 residents reviewed for falls (Resident B). Finding includes: During an interview, on 4/6/2021 at 3:21 p.m., Resident B's family member indicated the resident had complained of pain in her feet, ankles and knees during a visit. The family member removed the resident's shoes and socks and noted bruising on three of the toes on the left foot. The family notified the office staff who was assisting with visitation and the staff indicated the resident was having pain from her physical therapy. The family was concerned and called the facility the next day to make sure the nursing staff were aware of the bruising. The record for Resident B was reviewed on 4/6/2021 at 11:53 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 3/12/2021 at 7:03 a.m., indicated the resident had a fall in her room. She had stood up from the toilet, started taking steps and slid on urine on the floor. The injuries included a bump on the upper right head and left knee pain. A shower sheet, dated 3/13/2021, indicated the resident had a small cut on a toe on her left foot. The shower sheet was signed by LPN 2. There was no documentation in the electronic record to include an assessment of the left foot or the small cut noted on the shower sheet on 3/13/2021. A communication to the physician, dated 3/15/2021 at 2:05 p.m., indicated the resident would not walk or stand to transfer and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment of the residents foot included in the electronic documentation. A skin problem note, dated 3/23/2021 at 12:32 p.m., indicated the resident had purple bruises on her left foot and toes. The documentation did not include the size of the bruising, the exact location of the bruising or notification to the physician. A skin problem note, dated 3/23/2021 at 3:28 p.m., indicated the resident had bruising on the left foot digits 2, 3 and 4 which were purple in color. The documentation did not include the size of the bruising or the exact location on the toes. A skin problem note, dated 3/24/2021 at 12:22 a.m., indicated the resident had purple bruising on the left foot and toes located between, on top and the underside of the toes. The documentation did not include the measurements of the bruising or notification to the physician of the bruising. During an interview, on 4/6/2021 at 2:24 p.m., the Unit Manager (UM) indicated she did not know what had happened to the resident's left foot or toes to cause the bruising. There was not an incident report initiated when the bruising on the toes was identified and there should have been one completed. The documentation did not include notification to the physician of the bruising. During an interview, on 4/6/2021 at 2:28 p.m., LPN 2 indicated she was told by another staff the resident's family member had been at the facility to visit and took the resident's shoes off and noticed the bruising on the resident's toes and reported it to the staff. A current policy, titled Skin Impairment, dated as revised on 1/15/16 and received from the Executive Director on 4/6/2021 at 3:00 p.m., indicated .It is the policy of [name of facility] that residents will be thoroughly assessed upon admission, when new open areas are identified .and weekly by licensed nurse, in an attempt to maintain the skin integrity of all resident .Nursing assistants will observe the resident's skin daily during repositioning, toileting, bathing or showering, and promptly report new areas or changes to the charge nurse .During any skin assessment, the nurse will inspect for any skin abnormalities, such as redness, swelling, rash, bruising, skin tears, blisters .The nurse discovering the area will describe the impaired skin, place pertinent charting in the resident's file and notify the physician, wound nurse or designee, resident, and family/responsible party This Federal Tag relates to Complaint IN 160. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident's medication was free from theft by facility staff for 1 of 3 residents reviewed for misappropriation of property (Resident B). Finding includes: A facility incident report, dated 09/21/2020, indicated on 09/17/2020 Resident B's controlled medication count for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligram) was zero and there should have been one remaining tablet. RN 2 indicated she had given an extra dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg prior to leaving for lunch at about 11:50 a.m. and documented it was given at 5:30 p.m. The record for Resident B was reviewed on 01/25/2021 at 11:30 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Physician order, dated 09/16/2020, indicated [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, to give one tablet by mouth twice per day in the a.m. and p.m. A narcotic count sheet, dated 09/10/2020, indicated Resident B was given [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on 09/17/2020 at 5:50 p.m. During an interview, on 01/25/2021 at 3:30 p.m., the Administrator indicated RN 2 stated she had given the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg earlier than the prescribed time due to the resident's complaints of pain. RN 2 had a probationary license, was sent for a drug and the screen was positive for [MEDICATION NAME]. The facility could not determine if Resident B ever received the medication since there was no witness and the resident was unable to be interviewed. A current policy, titled Abuse, Neglect and Exploitation of Residents Property and Reportable Unusual Occurrences, dated 11/01/2017 and received from the Administrator on 01/26/2021 at 4:00 p.m., indicated .It is the policy of (name of facility) to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property .Misappropriation of Resident's Funds or Property .Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's property or money without the resident's consent .Residents' property includes all residents' possessions, regardless of their apparent value since it may hold [MEDICATION NAME] value to the resident .Includes any medication dispensed in the name of a resident A current policy, titled Inventory of Schedule II Controlled Substances and Other Medications with a Risk of Abuse, dated 09/12/2018 and received from the Administrator on 01/26/2021 at 4:00 p.m., indicated .it is the policy of (name of facility) to separate individual controlled substance records on all Schedule II controlled substances and medications with a potential for abuse in the form of a declining inventory using the Controlled Substance Count Verification .The facility should routinely reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet, to the Medication Administration Record [REDACTED].An investigation will be completed to determine: Whether a dose was in fact administered This Federal Tag relates to Complaint IN 776 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure staff removed their gloves between tasks and failed to ensure staff performed hand hygiene between tasks for 3 of 3 staff members observed during random observations. (Activity Assistant 1, CNA 2 and Housekeeper 3) Findings include: 1. Upon entrance to the facility, on October 31, 2020 at 10:00 a.m., Activity Assistant 1 was observed coming from an area of the facility, wearing gloves. She unlocked and opened the entrance to the facility while wearing the gloves. During an interview, at this time, Activity Assistant 1 indicated she had been sorting silverware prior to answering the door and should not have been wearing gloves to answer the door. The employee, still wearing the gloves, returned to the area she had come out of prior to answering the door. She had not been observed to have removed her gloves. During an interview, on October 31, 2020 at 1:15 p.m., the Executive Director indicated Activity Assistant 1 should have removed her gloves and performed hand hygiene prior to answering the door. 2. During a random observation of the Monticello Unit, on October 31, 2020, CNA 2 entered the room of Resident 1, she was not observed to perform hand hygiene or don gloves upon her entrance into the room. While in the room, CNA 2 made contact with items in the residents environment. Upon exiting the room, CNA 2 was not observed to have performed hand hygiene prior to assisting Resident 2. 3. During a random observation, on the Burlington Unit on October 31, 2020 at 11:01 a.m., Housekeeper 3 was observed wearing gloves, cleaning and arranging clear window barriers set on common area tables. Housekeeper 3 then went to her cleaning cart, removed her gloves, donned new gloves and returned to another table to rearrange the table cloth and clean the window barrier. During an interview, on October 31, 2020 at 11:02 a.m., Housekeeper 3 indicated she was not sure if she needed to perform hand hygiene after glove removal. She then returned to her supply cart, removed her gloves and left the area. She was not observed to have performed hand hygiene after removing her gloves. A current facility policy, titled Infection Control-Hand Hygiene, dated as revised on December 01, 2016 and provided by the Executive Director on October 31, 2020 at 1:30 p.m., indicated .It is the policy .that hand hygiene must be performed .whether, or not, gloves are worn; immediately after their removal of gloves and when otherwise indicated to avoid transfer of microorganisms to other residents, visitors, employees, equipment, and/or the environment .Specific examples of hand hygiene .include, but are not limited to: .After touching any item or surface that may have been contaminated .before and after removing gloves 3.1-18(a) 3.1-18(l)

Based on observation, interview and record review, the facility failed to prepare pureed foods according to standard recipes to maintain nutritional value and taste for 7 of 7 residents who received pureed food. (Residents 13, 26, 31, 33, 34, 49, 52). Findings include: During an observation of the kitchen, on 7/10/19 at 3:42 p.m., Cook 2 was preparing to puree chicken and indicated he did not have a recipe and was told to add water to the chicken to puree. The Dining Manger (DM) was present and indicated they usually used water to puree the meats and the staff were aware pureed foods should be pudding consistency although there was not a recipe book for preparing pureed foods. Cook 2 then put green beans and water in a clean container to puree and the DM indicated there was not a recipe and she was not aware if a stabilizer was needed for the green beans. During an interview, on 7/11/19 at 2:58 p.m., the DM indicated she had contacted her company and the facility should have procedures and recipes in place for pureeing foods. She indicated the Registered Dietician 3, who usually worked at a different facility stated her facility used thickeners for some foods and also broth and gravies during the puree process and was surprised this facility was not doing the same. She indicated when just water was added to the puree process there was less calories for the same amount of food. Residents 13, 26, 31, 33, 34, 49, and 52 received pureed food from the kitchen. A procedure, not dated, received from the DM on 7/12/19 at 2:50 p.m., indicated, .All meals should follow (name of company) recipes, including [MEDICATION NAME] diet. Surveyors will want to know the exact amounts of thickening agent and fluid and also what type of fluid used for the item, such (as) broth for meat item, milk for potatoes, fruit juice for fruit .texture of [MEDICATION NAME] food item needs to be firm, not watery or running loosely on the plate .[MEDICATION NAME] diet should be served as attractively as the regular diet, and should be flavorful and palatable . 3.1-21(a)(1)

Based on observation, interview and record review, the facility failed to ensure a resident's body was properly covered while she was in the dining and lounge areas of the unit for 1 of 1 resident reviewed for dignity (Resident 51). Findings include: During an observation, on 7/8/19 at 12:28 p.m., Resident 51 was sitting up, in a chair, in the dining area of the unit and her buttocks were visible from the back of the chair, her pants were not pulled up and her top was not long enough to cover her buttocks. During an observation, on 7/8/19 at 1:18 p.m., the resident was standing up in the lounge area of the unit and her obese abdomen was hanging out and was not covered by her shirt. The resident tried to pull up her pants and to cover her abdomen although she could not get the pants to cover the exposed skin. She then ambulated on the unit with her abdomen hanging out from under her shirt. During an observation, on 7/11/19 at 1:41 p.m., the resident was sitting up in a recliner, in the common lounge area on the unit, she tried to pull her shirt down to cover her abdomen and part of her abdomen was still sticking out under her shirt. The record for Resident 51 was reviewed on 7/11/19 at 9:29 a.m. [DIAGNOSES REDACTED]. During an interview, on 7/11/19 at 2:45 p.m., the Monticello Unit Manager (UM) indicated the resident would get aggressive at times when staff tried to assist her to pull up her pants or pull her shirt down to cover her exposed skin. The UM indicated there was not a care plan for the resident having difficulty with exposed skin or not allowing staff to help cover her skin. The UM indicated it was an ongoing issue with the resident however no documentation could be located. A current policy, not dated, titled Your Rights As A Resident, received from the Director or Nursing, on 7/12/19 at 12:50 p.m., indicated, .A facility must care for its residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality 3.1-3(t)

Based on interview and record review, the facility failed to notify the physician of an 8 pound weight gain in one week for a resident who was on a fluid restriction for 1 of 1 residents reviewed for physician notification (Resident 51). Finding includes: The record for Resident 51 was reviewed on 7/11/19 at 9:29 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The resident had the following weights: a. On 6/17/19 260.4 pounds. b. On 6/24/19 268.4 pounds. The resident had an 8 pound weight gain in one week and the facility did not notify the physician of the weight gain. During an interview, on 7/12/19 at 4:03 p.m., the DON indicated the physician was not notified of the weight gain as it was not considered a significant weight gain. A current policy titled MD and Resident and/or Resident Representative Notification revised on 11/1/17 and received from the DON on 7/11/19 at 9:15 a.m., indicated, .All pertinent information in regards to residents will be communicated to the family/responsible party in a manner according to the urgency of the matter .Contact Procedure for Physician or Designee .Faxing messages to the physician will only occur if the condition does not require immediate attention .Conditions that require immediate attention will be addressed by contacting the physician on the phone 3.1-5(a)(3)

Based on observation, record review and interview, the facility failed to ensure baseboard heating was not too hot to prevent injury for 1 of 3 residents reviewed with falls and/or found on floor in a total sample of 3 residents. This had the potential to affect all 88 residents of the facility. This resulted in third degree (full thickness) burns to one resident. (Resident #B) Findings include: Resident #B's record was reviewed on 12/15/10 at 10:55 a.m. The record indicated Resident #B's [DIAGNOSES REDACTED]. During the initial tour of the facility with LPN #2 on 12/15/10 at 10:45 a.m., indicated Resident #B was currently in the hospital for a burn to her right shin (leg) due to an unknown origin. The quarterly "Minimum Data Set (MDS) assessment, dated 10/4/10, indicated Resident #B was independent for bed mobility, required one person physical assist for transfers, and required supervision (set-up) with in room ambulation. The MDS further listed the resident as having both short and long term memory problems and moderately impaired cognitive skills for daily decision-making. An "Incident Report," dated 12/10/10, indicated Resident #B was observed laying on her left side under the bed of her roommate at 11:55 a.m. The resident was stating "...I'm scared...I'm scared...Am I dead....?" The report indicated there were no witnesses to the incident and that the resident was noted to have burns and blisters to her right arm, right thigh, and right knee. The measurements of the wounds listed were: 15 cm (centimeters) x (by) 9.5 cm 2 cm x 4 cm" 24 cm x 7.6 cm 17 cm x 15 cm 2.5 cm x 1.4 cm 0.4 cm x 0.6 cm Safety device in place was listed as an "Alarmed Mattress Pad" which was not working and was replaced. Recommendations to prevent similar incidents included "other...Alarms were changed...." The report was not signed by the nurse performing the initial assessment, there was no documentation to indicate who first observed the burns and where the resident was at the time of discovery, there was no documentation from the staff members caring for the resident for the 24 hours prior to incident, no documentation of the condition of the clothing over the burned area or that the pants were cut off, no documentation that she was laying close to an electric heating unit nor the temperature of the heating element. The "Follow-up Investigation for Injury of Unknown Etiology," dated 12/10/10, indicated the following: "...type of injury...burn...date observed 12/10/10...." The timeline listed on the report included: - 9:30 a.m., CNA #3 took Resident #B from the breakfast table, to the bathroom, and then to bed. The alarm was checked on the bed and was functioning. - 10:00 a.m., CNA #3 entered Resident #B's room to obtain the mechanical lift left in the room. The CNA indicated the resident was in bed asleep. There was also a statement from CNA #6 stating she entered the residents room and checked on her. She adjusted the resident's blankets an checked the bed alarm. - CNA #7 documented that he helped put Resident #B back into bed, but before doing so, checked the bed alarm and determined that it was not working. He then proceeded to switch out the alarm with one that worked. There was no documentation to indicate when this happened nor that she was on the floor. - LPN #5 documented she walked into the resident's room to draw her blood sugar when she saw the resident's leg under the bed by the window. On 12/15/10 at 2:15 p.m., observations were made with the Health Facility Administrator of the resident heating units in random rooms throughout the facility. Room 301's heater registered 151 degrees, Room 220 registered 166 degrees, Room 105 registered 165 degrees, and Room 103 registered 162 degrees. The Administrator indicated the facility was in the process of replacing the old heaters with newer ones that don't get as hot during their current remodeling phase. The facility had been replacing heaters one at a time when a room was scheduled for remodel but since the accident, maintenance is performing an audit so that all heating units will be replaced. On 12/15/10 at 3:00 p.m., the Maintenance Director indicated additional heaters have been ordered and some should be here tomorrow. He further indicated, he has been at the facility for the past three years and he was not aware of anyone being burned by the heaters. On 12/16/10 at 11:00 a.m., Social Services staff #9 indicated Resident #B has not had any behaviors in the last couple of weeks. She indicated the resident has never made any comments about being hurt or questioning if she were dead. On 12/20/10 at 9:45 a.m., CNA #6 indicated Resident #B has never made any attempts to go towards the window/heating unit. On 12/20/10 at 10:05 a.m., the Maintenance Director indicated they had begun removing all of the adjustment knobs on the heaters so they couldn't be adjusted too hot until they were all replaced. Burn history and physical, dated 12/10/10, from the community burn unit, indicated Resident #B had second degree burns to her right elbow and thigh, and third degree (full thickness) burns to her knee and lower leg which will require surgical treatment. The Health Facility Administrator was interviewed on 12/15/10 at 2:00 p.m. During the interview, the Administrator indicated at 11:55 a.m., a nurse went in to check Resident #B's blood sugar. Upon entering the room, she heard a voice and thought it was the radio. The nurse found the resident laying under the roommates bed saying "I want to see the sun...I'm scared...Am I dead? During the assessment of the resident, they found some serious burns and she was sent to the hospital. He further indicated they could only assume the resident got up and the alarm didn't sound so there was no alert to respond to in order to assist her. Can only assume the burns were from the electric baseboard heat. Weekly "Life Safety Checklist" forms were provided by the Maintenance Director on 12/20/10 at 2:00 p.m. The checklist included, but were not limited to, check for any safety issues and check heaters. The reports provided were dated 12/17/10, 12/09/10, 12/02/10, 11/18/10, 11/11/10, 11/5/10 and 10/27/10. The reports did not list any concerns in those areas nor did it list any temperature checks for the baseboard heating. An electric baseboard owner's guide, for the heaters the facility were purchasing, was provided by the Maintenance Director on 12/15/10 at 3:40 p.m. The guide indicated "...burn hazard...This heater is hot when in use...To avoid burns, do not let bare skin touch hot surfaces. Use extreme caution when any heater is used by or near children or invalids an whenever the heater is left operating unattended. On 12/15/10 at 2:15 p.m., observations were made with the Health Facility Administrator of the resident heating units in random rooms throughout the facility. Room 301's heater registered 151 degrees, Room 220 registered 166 degrees, Room 105 registered 165 degrees, and Room 103 registered 162 degrees. The Administrator indicated the facility was in the process of replacing the old heaters with newer ones that don't get as hot. The Maintenance Director was interviewed on 12/15/10 at 3:00 p.m. and 3:40 p.m. During the interview, the Maintenance Director indicated the room involved with the burn incident, had the heating unit replaced after the incident. He further indicated he did not have any manufacture manuel's for the older heating units, only the new one. The Maintenance Director was interviewed on 12/20/10 at 2:00 p.m. During the interview, the Maintenance Director indicated no actual temperatures were checked on the heating units. Was just checking to make sure the heat came out and shut off and that there were no bent or sharp areas. This federal tag relates to complaint IN 546. 3.1-45(a)(1)