Every finding on record at Christian Care Retirement Community

Based on observation, interview and record review, the facility failed to ensure proper labeling, storage and sanitation were maintained in the kitchen. 58 of 58 residents residing in the facility ate food prepared in the facility kitchen.Findings include:1. During an initial observation of the kitchen on 8/18/2025 at 9:16 AM the following items in dry storage were open, undated and did not contain an expiration date: 1 box containing individual pouches of poppy seed salad dressing, 1 box containing individual pouches of ranch salad dressing, 1 box containing individual pouches of fat free raspberry vinaigrette salad dressing, 1 box containing individual pouches of thousand island salad dressing, 1 box containing individual pouches of Italian salad dressing, 1 bag of cherry gelatin tied with a rubber band, 1 bag of cream soup base tied with rubber band no date and 1 bag of graham cracker crumbs tied with a twist.In the freezer on the far-left wall in the stockroom the following items were open and undated: 1 box of open parmesan crusted salmon and 1 box of open chicken breast filets.On the bread cart in the kitchen the following items were open, tied in a knot and did not contain an open or an expiration date: 1 loaf of bread with 13 slices, 1 bag with 2 hot dog buns and 1 bag with 6 buns.In the refrigerator in the kitchen the following items were open, tied in a knot and did not contain an open or an expiration date: 1 loaf of [NAME] bread.In the freezer in the kitchen the following items were open, not in the original package and did not contain an open date: 15 pieces of fish in a freezer bag.During an interview, on 8/18/2025 at 9:30 AM, the Dietary Manager (DM) indicated the facility typically labels and dates all food items when opened and the found items should have been labeled and dated, except the salad dressing and the bread. The DM indicated the facility uses the items quickly and have never labeled and dated bread or boxed items. The DM indicated she would not be able to tell when a loaf of bread or salad dressing was opened and began being used in the kitchen when the opened food items are not labeled.A current facility policy, Sanitary Food Storage Policy, dated 2/14 was provided by the DM on 08/20/2025 at 10:55 AM. The policy indicated, All food items in Dining Services will be labeled either by its original packaging or by dining staff . Expiration dates on the manufactures package of items such as milks, cottage cheese, salad dressing, peanut butter, jelly etc. will be followed. If a food does not have expiration date and is commonly known to have an indefinite shelf-life food will be dated when opened and discarded in one year.2. During an initial observation of the kitchen, on 8/18/2025 at 9:16 AM, dining staff were observed getting ice machine. The ice machine was observed to have black dots and pink lines on the plastic flap. The DM was observed to wipe the plastic flap with a cleaning rag, and the black dots and pink lines were removed.On the sides and behind the stove and stacked ovens, the floor was observed to have brown build up, pasta, and other unidentifiable debris.During an interview, on 8/18/2025 at 9:40 AM, the DM indicated the last time the floor between and behind the stove and oven was cleaned was about 2-3 months ago.During an Interview, on 08/21/2025 12:53 PM, the DM and Administrator in Training (AIT) indicated the cleaning schedules were typically done once a month. The DM indicated the staff did not have the August 2025 cleaning schedule yet. The DM indicated the ice machine was cleaned monthly. The DM indicated the staff clean the ice machine between the monthly cleanings. The DM indicated she would let staff know when the machine needed to be cleaned throughout the month and she overlooked the cleaning, so the machine was not cleaned. The DM indicated cleaning behind and between the oven and stove had been an issue. The DM indicated maintenance cannot clean behind or between the stove and oven until the kitchen stopped serving food. The AIT indicated they had not been able to come up with a schedule for maintenance to clean as maintenance was not in the building when the kitchen closed. The DM indicated there was no current cleaning schedule for cleaning the floor around the stove and oven. The DM indicated this was something administration has been attempting to resolve. The DM indicated she could not provide a date for the last time the floor between and behind the oven and stove was cleaned. The AIT indicated 58 of 58 residents eat from the kitchen and 22 of 58 residents receive ice from the ice machine. A current facility policy, Dining Services, dated 8/14 was provided by the AIT on 08/21/2025 at 12:30PM. The policy indicated, Food service operations and areas shall be maintained in good repair and shall be kept thoroughly clean and free from any accumulation of filth, garbage, rubbish, or other waste. The AIT also provided a current facility policy, Cleaning Policy, the policy indicated The Dining Services manager or assistant will assign tasks to Dining Services staff. Cleaning will be included on position task sheets.

Based on observation, interview and record review, the facility failed to ensure protected health information was kept secured for 15 of 58 residents residing in the facility.Findings include:During an observation on 08/19/2025 10:00 AM a wooden wall unit was open with a shelf protruding about 12 inches into the hallway. The shelf held papers listing 16 resident names and information including treatment orders, shower schedules and instructions for certified nurse aide care. During an interview, on 08/19/2025 10:03 AM, Certified Nurse Aide (CNA) 2 indicated the papers on the shelf included shower schedules, linen changes, and shift report for CNAs to use to communicate resident care needs. She indicated the information contained on the forms was protected health information and should not be visible to individuals not providing care to the resident. She indicated the shelf of the wall unit should have been drawn up and fastened to keep health information from being seen by a passerby. She indicated 15 residents resided on hall, as one resident was currently hospitalized . During an interview, on 08/19/2025 1:44 PM, the Director of Nursing (DON) indicated the drop down shelf served as an informational CNA station. She indicated the drop down shelf contained CNA assignment sheets, shower schedules and special instructions for resident care. She indicated the information inside was protected health information and the unit should be closed when not in use. A current policy, titled Information Security Policy Overview, dated 10/23, provided by the DON on 8/20/25 at 8:26 AM, indicated health records should not be left on desks or unattended. A current policy, titled Policy and Procedure on Physical Security, undated, indicated health records should not be left on desks or cabinets unattended. The policy indicated records pulled from cabinets for future treatment should be left in a secured areas until needed by staff members. 3.1-3(o)

Based on observation, interview, and record review the facility failed to ensure open dates were labeled for opened medications in 2 of 2 medication carts reviewed. Findings include: During an observation on 08/19/2025 at 12:10 PM on 221-233 medication cart with the Director of Nursing (DON), inside of the medication cart the following was observed: At 12:12 PM Resident 45 had an opened medication of Airspura 90-80 MCG (inhaler) with no open date. At 12:13 PM Resident 60 had an opened medication of Wixela 250-50 inhaler with no open dateAt 12:16 PM Resident 44 had an opened medication of milk of magnesia suspension with no open date.At 12:17 PM Resident 52 had an opened medication of polythylene glycol 3350 powder with no open date.At 12:18 PM Resident 45 had an opened medication of Cal-Gest 200 (500) Mg chew tablet with no open date.During an observation on 8/19/25 12:20 PM on 201-212 medication cart with the DON, inside of the medication cart, the following was observed:At 12:23 PM Resident 10 had an opened medication of Levetiracetam 100 mg/ml solution with no opened date.At 12:25 PM Resident 29 had an opened medication of polyethylene glycol 3350 powder with no open date.In an interview, on 8/19/25 at 12:25 PM, the DON indicated all opened medications need to be labeled with an open date. 1. A record review on 8/20/25 at 12:25 PM, indicated Resident 45's medication diagnoses included Cerebral infarction, unspecified.A review of the physician orders indicated to give Airsupra 90-80 mcg inhaler 1 gram orally 4 times a day. After use, rinse mouth and spit with a start date of 7/27/24. Cal-Gest Antacid Oral Tablet Chewable 500 MG, ordered to be given 2 tablets by mouth as needed with a start date of 6/17/25.2. A record review, on 8/20/25 at 12:30 PM, indicated Resident 60's medical diagnoses included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.A review of the physician orders indicated to give Wixela 250-50 inhub 60 250-50mcg via oral inhalation. Give 1 Inhalation two times per day every day, with a start date of 5/31/25.3. A record review on 8/20/25 at 12:35 PM, indicated Resident 44's medical diagnoses included presence of left artificial hip joint.A review of the physician orders indicated to give Milk of Magnesia suspension, give 30 ml by mouth every 24 hours as necessary (prn) for constipation, with a start date of 7/17/24.4. A record review, on 8/20/25 at 12:40 PM, indicted Resident 52's medical diagnoses included chronic obstructive pulmonary disease, unspecified.A review of the physician orders indicated to give Polyethylene glycol 3350, give 17 grams by mouth once a day prn for constipation, with a start date of 7/17/24. 5. A record review on 8/20/25 at 12:45 PM, indicated Resident 10's medical diagnoses included nontraumatic intracerebral hemorrhage, unspecified.A review of the physician orders indicated to give Levetiracetam 100 mg/ml solution 5 milliliters by mouth two times per day at 8:00AM, and 8:00PM with a start date of 9/12/24. 6. A record review, on 8/20/25 at 12:50 PM, indicated Resident 29's medical diagnoses included Dementia in other diseases classified elsewhere, without behavioral disturbance.A review of the physician orders indicated to give Polyethylene glycol 3350 powder, give 17 grams by mouth one time per day every day at 8:00 AM, with a start date of 2/20/25.A current facility policy, titled Pharmacy Criteria, dated 12/08, was provided by the DON on 8/20/25 at 8:26 AM. The policy indicated .Medications are dispensed in accordance with all applicable regulations including labeling requirements 3.1-25(j)(m) and (n)

Based on interview and record review, the facility failed to ensure physician orders were in place related to code status for 2 of 3 residents reviewed. ( Resident 62 and 166) Findings include: 1. Resident 62's record review on 10/18/24 at 9:41 AM, indicated diagnoses included encephalopathy and generalized anxiety. A review of physician orders indicated there were no orders for Resident 62's code status - Do not resuscitate(DNR). A review of state of Indiana out of hospital DNR declaration and order was signed by physician on 10/3/24. 2. Resident 166's record review on 10/18/24 at 10:30 AM indicated diagnoses included chronic obstructive pulmonary disease. A review of physician orders indicated there were no physician orders for Resident 166's code status- Do nor resuscitate (DNR). A review of treatment option declaration (advance directives) indicated the resident wished no Resuscitation. The document was signed on 10/8/24. In an interview, on 10/18/24 at 9:48 AM, Registered Nurse 5, indicated code status should be on the face sheet, physician orders, and resident room doors. In an interview, on 10/21/24 at 9:55 AM, the Director of Nursing (DON) indicated there should have been a physician order for the DNR code status. A current facility policy, titled Medical Treatment Declaration Policy, dated 9/15, was provided by the DON on 10/21/24 at 10:30 AM. The policy indicated . to establish guidelines to ensure each resident is given the appropriate and required information in order to make informed choices in their medical treatment 3.1-4

Based on interview and record review the facility failed to ensure intervention were implented to prevent elopement for 1 of 4 residents reviewed (Resident B). Findings include: During an interview on 8/5/24 at 9:57 AM, the Administrator indicated on 5/18/24 Resident B was in the courtyard with Activity Aide 2. Activity Aide 2 told Resident B she needed to use the restroom and indicated for Resident B to stay in the courtyard. Activity Aide 2 returned from the restroom and Resident B was no longer in the courtyard. The Administrator indicated Resident B had exited the courtyard through the gate, walked around the building to door 8 and rang the door bell. The Administrator indicated Resident B was let in by staff and Resident B's nurse was notified. The Administrator indicated the gate exiting the courtyard was not locked. During an interview on 8/5/24 at 10:30 AM, the Director of Nursing (DON) indicated on 5/18/24, Activity Aide 2 entered the courtyard with Resident B. The DON indicated Resident B had a wanderguard/code alert attached to her walker. The DON indicated the door to the courtyard alarmed due to Resident B's wanderguard/code alert. Activity Aide 2 disarmed upon entering the courtyard. The gate did not have a code alert alarm. A statement, undated, was provided by Human Resources on 8/5/24 at 10:03 AM. The statement indicated the Activity Aide 2 did not realize Resident B shouldn't be unattended outside. The typical standard was to not leave residents outside alone. Resident B was able to walk herself, communicate her needs/wants and was alert. The statement indicated activity staff were given education regarding residents not to be outside alone when the following applied: the resident was a fall risk, unable to communicate needs/wants, confusion, dementia, and/or the resident is unable to move/transfer themselves. During an interview on 8/15/24 at 11:30 AM, Registered Nurse (RN) 3 indicated cognitively intact residents were allowed to be on the patio/courtyard area unattended. Residents who were unable to be alone, staff stayed with the residents while in the courtyard. RN 3 indicated Resident B had a wanderguard/code alert on her walker due to exit seeking. A record review was completed on 8/5/24 at 10:56 AM. Diagnosis include dementia and anxiety disorder. A progress note, dated 5/18/24, indicated around 3:20 PM, Resident B was outside, on patio with Activity Aide 2. Activity Aide 2 went inside to use the restroom and left Resident B outside, unattended on the patio. While unattended Resident B opened the gate, walked around the building to door 8 and rang the doorbell. A nurse let Resident B inside and called Resident B's nurse to assist resident back to the hall she resided on. The progress note also indicated Resident B's mental state was normally confused. A policy, revised 3/22, titled Elopement of a Resident, was provided by Human Resources on 8/5/24 at 10:03 AM. The policy indicated elopement is defined as an unplanned exit of a resident outside of the building educate all staff to at risk status and interventions developed to reduce or prevent elopement. This Federal citation relates to Complaint IN00434869. 3.1-45(a)

Based on interview and record review the facility failed to ensure safety devices were used with aresident known to be a fall risk for 1 of 3 residents reviewed. (Resident B) Findings include: Resident B's record review began on 8/31/2022 at 10:30 AM. Diagnoses included but were not limited to, hypertension, [CONDITION(S)], [CONDITION(S)], pain and age-related physical debility. A review of Resident B's Minimal Data Set (MDS) Assessments, the Quarterly MDS, dated [DATE] indicaated the resident's BIMS (Brief Interview for Mental Status) score was 12, cognitively intact. The functional status indicated Resident B required extensive assistance of 1 person for bed mobility, transfers, walking in the room and in the corridor, in and out of the facility. Extensive assist of 2 for toileting. Resident B's Mobility devices normally used were a walker and wheelchair. The Assessment also indicated Resident B had not fallen since admission to the facility. A review of Resident B's Falls Documentation indicated Resident B had a fall on 7/18/2022 at 2:50 PM The fall occurred when Resident B attempted to stand on their own. There was no apparent injury from the fall. Post fall assessment was completed, including Neurological assessment for 72 hours. A review of Fall Documentation indicated Resident B had a fall on 8/18/2022 at 7:45 AM, in the bathroom, was transferring with a walker and standby assistance of CNA (Certified Nurses Assistance). Resident B struck their head which resulted in a laceration measuring 3 cm (centimeter, a measurement) x 0.2 cm and was bleeding. The resident was assessed and the bleeding stopped. Resident B's POA (Power of Attorney) was notified. The NP (Nurse Practitioner) was notified and an order was given to transfer to the emergency room for evaluation and treatment. At 10:13 AM, Resident B was transferred to Hospital Emergency Department by family. An entry at 1:11 PM, indicated Resident B returned from the hospital at 12:50 PM and had received 5 staples to laceration on back of their head. The Neuro Assessments continued per facility protocol. A review of Resident B's Fall Risk Assessments, dated 7/18/2022 at 3:29 PM indicated, assist was needed for toileting (2 points), Balance problems when standing (1 point), Used an assistive devices (cane, wheelchair, walker, etc.) (1 point), Predisposing Disease/Condition: [CONDITION(S)] 1-2 conditions (2 points) Total of 7 points. The answer for number of of falls in past 3 months was answered 0. A review of Resident B's Fall Risk assessment dated [DATE] indicated Total Points of 26. The form indicated, a score of 10 or higher may represent a High Risk of Falling. A review of Resident B's current Guideline for Daily Care, provided by the Social Service Director on 8/31/2022 at 3:33 PM, indicated Resident B was at risk of falling. The guide for resident's care indicated for walking or moving, the resident needed a walker with extensive assist of 1 person, assist for longer distances. The Daily Care Guide also indicated, to move about the unit, walk to all meals to use a gait belt, walker and assist of 1. When using the bathroom, Resident B required extensive assist of 1 person with a gait belt. Review of Resident's B's Care Plans for falls, revised 8/31/2022 at 9:53 AM, indicated Resident B needed help moving from one place to the other and help with transferring due to their [CONDITION(S)] (as stroke), due to being unsteady when walking or transferring and a history of falls. The interventions included: Provide with assistive devices and ensure the resident had assistance to transfer. Provide assistance to walk and provide assistance to transfer and use and assistive device to help with a gait belt on and a walker. A Care Plan, added on 8/31/22 at 12:15 PM indicated Resident B had the potential to fall and get hurt due to a stroke and was unsteady on their feet. The interventions included: The Nurse needs to educate providing staff on the gait belt being on at all times during transfers. The aids need to use the following assistive devices to be able to help Resident B, to stay during toileting, frequently check and make sure important items are in reach, provide non-skid footwear, wear glasses and hearing aids, encourage to use assistance with transfers or when walking make sure and have a gait belt on when transferring at all times. Review of the Hospital Emergency Department (ED) records provided by the Administrator-In-Training (AIT) on 8/31/2022 at 4:32 PM, indicated Resident B was triaged on 8/18/2022 at 10:23 AM, the son stated the patient lost their balance at Christian Care and fell back into a table and struck her head. They got her cleaned up but could not get the laceration on the back of her head to stop bleeding. The Hospital ED identified Resident B as a fall risk. The ED documentation did not have treatment or discharge instructions printed for review. Review of the Indiana Department of Health's Reporting System for Incident 283, dated 8/18/2022, indicated the Director of Nursing (DON) reported Resident B's fall, which resulted in a hematoma and laceration to the back of Resident B's head. The description of the incident indicated a CNA was assisting the resident to walk out of the bathroom, but did not have a gait belt applied. The resident took a few steps, lost their balance, and hit their head on the toilet. The Resident sustained a 3 cm x 0.2 cm laceration and pressure applied due to the bleeding. Initially the bleeding stopped and resident was alert and neuro assessments were within normal limits. Resident B was sent to the ED when the bleeding was not stopped. Resident returned with 8 staples to laceration. Resident had not complaint of pain. Preventive Measures indicated the CNA was educated on use of a gait belt for all transfers. Follow up was added on 8/23/2022, which indicated Resident was doing well. Neuros were completed. Staples remained and will be removed on 8/26/2022. Resident had no complaint of pain. Review of CNA 1's Orientation CNA Checklist , dated 6/13/2022 indicated it was completed on 6/29/2022, signed by CNA 1 and the Trainer. The Checklist for Safety of Residents included Gait Belt-4 fingers between, was initialed by CNA1 and the Trainer. CNA 1 had passed the Indiana State Department of Health Nurse Aid Competency Evaluation for Written Test and Skills Evaluation on 7/21/2022. The Certified Nurse Aide License was issued on 8/30/2022. During an interview, CNA 2 on 8/31/2022 at 12:45 PM, indicated she had taken CNA classes at the facility and indicated she was trained on fall prevention. She indicated she checks on her residents frequently, and makes rounds to toilet residents, makes sure the bed is in low position, call light is in reach and assist with transfers. CNA 2 indicated to use a gait belt for transferring residents into a wheelchair or when walking with them with a walker. During an interview, CNA 3 on 8/31/2022 at 12:52 PM, indicated she had worked as a CNA for 5 years and had been at this facility for a year. CNA 3 indicated to prevent falls, she put the bed in a low position, made sure the floors were free of clutter, toileted the residents and used a gait belt for all transfers. During an interview, RN 4 on 8/31/2022 at 2:30 PM, indicated all residents were assessed for fall risk when they were admitted , if they have a fall and during their quarterly assessments. She indicated the staff are aware of a residents' fall risk on care guide. Resident falls were discussed in morning meeting to alert the staff of the fall. RN 4 indicated Resident B required cueing to stay on task. She also indicated Resident B's strength varies. She further indicated gait belts are to be used for all transfers. During an interview, CNA 5 on 8/31/2022 at 3:15 PM, indicated a gait belt was to be used for all transfers. She indicated gait belts were available in resident rooms, and at the nurses station in a basket. In an observation of Resident B on 8/31/2022 at 3:16 PM, the resident was seated in a chair, the over-bed table was in front of them with insulated water container, and tissues and other personal items within reach. The bed was in a low position, floor was free of clutter. During an interview, CNA 6 on 8/31/2022 at 3:25 PM indicated resident's fall risk were on the care guide. She indicated a gait belt was used for all residents who required assistance with transfers or ambulating. During an interview, the AIT on 8/31/2022 at 4:00 PM indicated they do not know why the gait belt was not used for Resident B at the time of the fall. The AIT also indicated he has spoken with the DON, and the DON indicated CNA 1 was educated verbally on use of the gait belt for all resident during transfers and ambulation. A review of the current facility policy provided by the AIT on 8/31/2022 at 12:11 PM, titled, Fall Risk Protocol, with a revision date of 12/11, indicated, .In an effort to reduce the incidence of falls, residents are assessed for their risk of falling at the time of admission and quarterly when the MDS is done. The Fall Risk Assessment is done by the licensed nurses. Information from the Fall Assessment is incorporated into the resident's care plan. All staff is continuously alerted to residents at risk and call plans are modified to prevent as many falls as possible . A review of the current facility policy provide by the AIT on 8/31/2022 at 4:32 PM, titled, Gait Belts, with a revision date of 10/12, indicated, .Gait belts are considered to be part of the CNA's uniform and are worn by all CNA's when on duty .The decision on which residents should be assisted with a gait belt is determined by the unit manager, nursing supervisor or therapy staff. Gait belts should be used unless otherwise noted .Gait belts must be used when transferring residents, Transfers include: bed to chair, chair to chair, supporting residents during ambulation, use of side boards and in some cases when guiding and controlling against falls or assisting a resident after a fall This Federal citation is related to Complaint IN 316 3.1-45(a)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 4 MDS assessments reviewed. (Resident 52) Findings include: On 9/13//2021 at 4:13 p.m., the clinical record for Resident 52 was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] indicated the assessment, Section A, Identification Information for Resident 52 the assessment was a new record and the resident was residing in a nursing home which provided Skilled Nurse and Long Term Care (SNF/NF) services. The MDS Assessment was for a discharge from the facility and a return to the facility was not anticipated. The Assessment also indicated the discharge was planned and was not a discharge form a Medicare Part A (Skilled Nursing) Services. The Assessment discharge date was 7/28/21 and the Discharge Status was documented as 03 which indicated teh resident had been discharged to an Acute Care Hospital. A review of Resident 52's written Physician Order, dated 7-27-21 indicated the resident may discharge to Assisted Living setting on 7/28/21 with current orders and medications. A review of Resident 52's Nurse's Note dated 7/28/21 at 11:07 a.m., indicated the resident was discharged to Assisted Living on 7/27/21. The resident was aware of discharge, all discharge papers were signed and instructions were given to the Assisted Living nurse. All of Resident 52's belongings were moved by the facility staff. The note also indicated Resident 52 was anxious to return to their apartment and ambulated well with their walker. A review of the Indiana State Department of Health Form, Notice of Transfer or Discharge, dated 7/28/2021 indicated Resident 52 was being transferred to an Assisted Living community. The reason for the Transfer or Discharge was marked as appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the nursing facility. On 9/14/2021 at 10:43 a.m., during an interview, the Director of Nursing (DON) indicated Resident 52 was discharged to an Assisted Living Community. The DON indicated the resident had been hospitalized for a planned shoulder replacement surgery while they were a resident, but had fallen with a fracture while they living in assisted living. The DON reviewed the MDS assessment dated [DATE]. She indicated the discharge should have been coded, 01. Community for a discharge to the assisted living community and not 03. Acute hospital. The DON indicated the MDS Assessment for the discharge would be corrected and resent to CMS (Centers for Medicare & Medicaid Services). She indicated the facility's policy was to follow the RAI (Resident Assessment Instrument) Manual to complete the MDS Assessment questions. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical procedures were followed for medication/treatment storage, medication labeling and discarding medication for 2 of 2 medication carts observed. Findings include: During an observation on 9-7-21 at 1:30 p.m., with Qualified Medication Aide 2 (QMA) for Cherry Hill unit medication cart, in the top drawer of cart, a [MEDICATION(S)] 100/unit/ML vial was observed with an opened date of 8-5-21 and labeled with Resident 42's name. QMA 2 indicated she does not know how long insulin vials may be open for since QMAs do not give insulin. The recird for Resident 42 was reviewed on 9-8-21 at 10:25 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . at 8:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Low dose regimen: sliding scale insulin: < (less than) 60 = (equals) initiate hypoglycemic protocol and call MD. 61-150 = 0 units, 151-200 = 0 units, 201- 250 = 3 units, 251- 300 = 4 units, 301- 350 = 6 units, 351- 400 = 9 units, > (greater than) 400 = 12 units and call MD for [CONDITION(S)]. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9-4-21 at 4:00 p.m. Resident 42 received 3 units of insulin per sliding scale. On 9-5-21 at 11:00 a.m. Resident 42 received 3 units, at 4:00 p.m. 3 units, and 8:00 p.m. 3 units of insulin per sliding scale. On 9-6-21 at 11:00 a.m. Resident 42 received 3 units, and at 8:00 p.m. 4 units of insulin per sliding scale. During an observation on 9-7-21 at 1:43 p.m., with Registered Nurse 1 (RN) on [NAME] Hall medication cart, in a middle drawer there was a bottle of Papaya Enzyme Complex Dietary Supplement. The bottle did not have any label located on it. RN 1 indicated the medication belonged to Resident 50. The record for Resident 50 was reviewed on 9-8-21 10:30 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9-8-21 at 10:25 a.m., the DON indicated the facility would follow the policies of labeling and storage from the pharmacy. A current facility policy, Medications Brought in at Admission, dated 6-2018, was provided by the DON on 9-7-21 at 3:36 p.m. The policy indicated . The medications must be able to be properly identified A current facility policy, Omnicare Insulin Storage Recommendations, was provided by the DON on 9-7-21 at 3:36 p.m. The policy indicated . Insulin [MEDICATION(S)]-opened refrigerated/room temperature 28 days . 3.1-25(j)(m)(n)

Based on interview and record review, the facility failed to ensure all staff were screened at the beginning of their shift for any signs or symptoms of illness (RN1, RN 2 and CNA 3). The facility also failed to ensure infection control practices were followed related CDC guidelines for Transition Based Precautions (TBP) isolation for 2 of 3 residents reviewed for admission or readmission to the facility. (Resident B and C) Findings included: 1. During review of the employee screening log at 11/12/20 at 1:29 p.m., RN 1 worked on the Covid-19 unit on November 6, 7 and 8. The facility was unable to determine if the employee had been screened prior to starting her shift. RN 2 worked on the Covid-19 unit on 11/9/20. The facility was unable to determine if the employee had been screened prior to starting her shift. CNA 3 worked on the Covid-19 unit on 11/2, 11/4, 11/5 and 11/8/20. The facility was unable to determine if the employee had been screened prior to starting her shift. During an interview on 11/12/20 at 3:06 p.m., the Director of Nursing (DON) indicated they recently transitioned all Covid-19 positive residents onto 1 hall. The previous unit was too small. Staff who had tested positive in the past for Covid were able to come through a separate entrance into the unit and all other staff should have come through the front door to be screened. She thought the entrance door should now be locked, but they just moved all the residents 11/11/20. Staff who were scheduled to work on the previous Covid-19 unit could have been going into the unit by the outside door and not get screened. All 3 staff tested negative for Covid-19. 11/12/20 at 3:10 p.m., the DON, along with the Administrator, indicated she sent out a video last night which indicated who needed to be screened at the front door. 2. The clinical record for Resident C was reviewed on 11/12/20 at 12:37 p.m. [DIAGNOSES REDACTED]. Resident C was admitted to the facility on [DATE] following a hospital admission. He was placed in room [ROOM NUMBER]-A with Resident B. A progress note, dated 10/10/20 at 3:43 p.m., indicated Resident C was up for lunch and then stated he did not feel well. The resident was pale and sweaty. His blood glucose level was 134 mg/dL. His vital signs included a pulse of 70 bpm, blood pressure 124/70 and temperature was 97.0 Fahrenheit. The nurse then checked his oxygen saturation and it was 82%. The nurse left the room to get an oxygen concentrator and found the resident unresponsive. A second nurse was called to assist and determined the resident no longer had a pulse. During an interview on 11/12/20 at 2:10 p.m., the DON indicated they were a little behind with starting the 14-admission isolation. She was not sure if it was related to bed availability. A current facility policy, revised 3/2020, provided by the Administrator on 11/12/20 at 4:50 p.m., titled COVID-19 RESPONSE PLAN, indicated the following: POLICY: In order to prevent and minimize the spread of infection related to the Covid-19 pandemic. PROCEDURE: .II. Prevention Steps a. Practice good hand hygiene b. Follow regulatory guidance on restriction of visitors. c. Direct all traffic through one entrance .d. Perform screening at the permitted entrance VII. Shelter in Place Protocol a. If a resident is confirmed or presumed to have COVID-19, facility will attempt to reduce the interaction i. When possible, utilize a private room with the door closed This Federal Tag relates to complaint IN 191. 3.1-18(b)(1)

Based on observation, interview and record review the facility failed to ensure the oxygen tubing was maintained for 1 of 1 resident reviewed (Resident 60) Findings include, Review of Resident 60's records began on 1/6/20 at 4:13 p.m., indicated [DIAGNOSES REDACTED]. Review of Resident 60's Admission MDS (Minimum Data Set) Assessment, dated 12/13/19, indicated the resident had a BIMS (Brief Interview for Mental Status) score was 15/15, which indicated the resident was cognitively intact. The MDS Assessment also indicated Resident 60 received oxygen therapy before and while they were a resident at the facility. Review of Resident 60's Physician order [REDACTED]. The orders were lacking for changing the oxygen tubing and humidifier. An order dated, 1/1/20, for an antibiotic, [MEDICATION NAME] 500 mg (milligram, a measurement) give one time a day for 7 days for right lobe infiltrates, with a start date of 1/1/20. Review of Resident 60's chest x-ray results, dated 12/31/19, indicated, slight right upper lobe infiltrates. An observation and interview with Resident 60 on 1/2/20 at 11:47 a.m., indicated they had just gotten pneumonia, and also indicated they had a pneumonia vaccine in the past. Resident 60 was observed be sitting in their wheelchair towards the end of the bed, they had an oxygen cannula in their nose, the tubing was draped over the bed from the oxygen concentrator which was behind the recliner chair. The oxygen tubing and the humidification bottle were lacking a date labeled on them, to when it was last changed. An interview with the Resident indicated they did not know if the tubing had been changed lately. An interview with Nurse 1 on 1/3/20 at 11:09 a.m., indicated the oxygen tubing and the humidification bottle were to be changed weekly, on Sundays, and as needed. The nurse indicated they do not label the oxygen tubing, nor the humidifier bottle with a date when it was first used. Nurse 1 indicated they document in the resident's TAR (treatment administration record) when the oxygen tubing and humidification bottle was changed. Review of Resident 60's TAR on 1/3/20 at 11:30 p.m., indicated the documentation was lacking for when the oxygen tubing or the humidifier bottle was changed. The TAR was lacking an entry to document the changing of oxygen tubing nor the humidifier. An interview on 1/7/20 at 4:00 p.m., the DON (Director of Nursing) indicated the oxygen tubing was to be changed every 2 weeks and the humidification bottle was to be changed monthly and as needed. Review of Resident 60's TAR for (MONTH) 2020, provided by the DON on 11/7/20 at 5:03 p.m., indicated an entry date of 1/3/20, to change the oxygen tubing every 2 weeks, on Sunday morning the first date was on 1/5/20. The TAR also indicated an entry date of 1/3/20, to change the humidifier one time a month, on the 1st Monday in the morning, the first date was on 1/6/20. An interview on 1/7/20 at 5:14 p.m., the DON indicated there were not any earlier entries in Resident 60's record which indicated the oxygen tubing was changed prior to 1/3/20. On 1/8/20 at 8:53 a.m., the DON provided the manufacture's recommendations for changing the oxygen tubing with cannula. She indicated the manufacture's recommendation was to replace the nasal cannula at least once every 14 days. Review of the current facility policy, provided by the DON on 1/7/20 at 4:00 p.m., titled, Oxygen Administration, with a revision date of 5/13, indicated, .Change oxygen tubing bi-weekly Review of the manufacturer's recommendation, provided by the DON on 1/8/20 at 8:53 a.m., titled, Nasal Cannula Technical Bulletin, with revision date of 4/2019, indicated, .Recommend replacing the nasal cannula at least once every 14 days . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure proper handling of dinnerware and glasses, affecting 42 residents out of 57 dining in the Orchard Café. 1. During an observation of the noon meal on 12/13/17, the following was observed: At 11:53 a.m., Wait Staff 1 was observed carrying two glasses of water to a table of two resident's with their hands over the top of the rims of the glasses. At 11:55 a.m., Wait Staff 1 was observed carrying a glass of root beer with their hand over the top of the rim to a female visitor at a table. 2. During an observation of the noon meal on 12-13-2017, the following was observed: At 12:24 p.m., Wait Staff 2 was observed to bring out a plate from the kitchen with a plate guard on the plate, her hand under the plate and her thumb was placed inside the rim of the plate. Wait Staff 2 returned from the kitchen with a bowl in her left hand with her left thumb placed on top of the rim of the bowl. At 12:41 p.m., Wait Staff 2 was observed to carry a plate to a resident with her thumb placed inside the rim of the plate. At 12:44 p.m., Wait Staff 2 was observed to carry 2 bowls from the kitchen with her thumb placed on the top rims of each bowl. During an interview with the Certified Dietary Manager on 12/19/2017 at 3:19 p.m., they indicated glasses should be carried with hands and fingers on the side of the glass, not over the top. An undated current policy, Policy on Handling Dinnerware provided by the Certified Dietary Manager on 12/19/2017 at 3:10 p.m., indicated the following: .Staff needs to handle the plates from the bottom. Staff should not touch the portion of the plate that the resident's food touches. Staff should grip cups from the sides. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure soiled linens were handled in a manner to prevent the spread of inecfiton for 42 residents that dine in the Orchard Cafe. On 12/13/17 at 12:14 p.m., Wait Staff 1 was clearing a table and tucked the rolled up, soiled linens under their arm touching their uniform. During an interview on 12/19/17 at 3:47 p.m., the Certified Dietary Manager indicated linens are not to be carried against the body or uniform, they are to be carried away from the body and disposed in the bin. A current policy, dated 7/2013, Soiled Linens-Handling, Storage And Transportation Procedure, provided by the Director of Nursing on 12/19/2017 at 4:16 p.m., indicated the following: .11. Never put soiled linens on floor or up against body . 3.1-18(a)

Based on observation, interview and record review the facility failed to ensure staff washed their hands or performed hand hygiene after touching soiled surfaces and before assisting residents with meals and feeding residents their meals and also failed to protect clean clothing protectors from potential contamination during 2 of 2 dining observations potentially affecting 21 of 21 residents who required staff assistance in the main dining room. Findings include: 1. During the initial tour of the facility kitchen on 10/3/16 at 10:45 a.m., the Certified Dietary Manager (CDM) informed the surveyor there was not water available in the kitchen or the dining room due to facility remodeling. She also indicated the water was to be shut off for approximately 2 hours, but there were hand sanitizer stations mounted on the walls in the main dining room. 2. During an observation of the lunch meal on 10/3/16 in the main dining room, the following was observed: At 11:20 a.m., Certified Nursing Assistant (CNA) #1 was observed to sit down on a stool at a table dining room table where 3 residents were seated to assist them with their lunch meal. She was observed to touch the resident on her right side with her bare hands to prompt her to wake up. She was then observed to begin feeding the resident seated on her left side her lunch meal without performing hand hygiene. At 11:22 a.m., CNA #1 was observed to get up from where she was seated to assist the third resident at the dining room table with her meal. She was then observed to sit back down on the stool by placing her hands on her uniform slacks. She was observed to start feeding the resident on her left side without performing hand hygiene. At 11:26 a.m., CNA #1 was observed to get up from the stool where she was seated, place her hands on her uniform slacks, and assist the resident who was seated on her right side. She was then observed to sit back down on the stool by hiking up her uniform slacks. She began to feed the resident who was seated on her left side without performing hand hygiene. At 11:35 a.m., CNA #1 continued to feed the resident on her left side and picked up a glass of juice for the resident seated on her right side to drink. She was observed to keep her hands in her lap with her bare hands resting on her uniform slacks in-between feeding the resident seated on her left side bites of food. At 11:37 a.m., CNA #1 was observed to pick up the eating utensils of the resident seated on her right side and placed them in her hand. She had not been observed to perform hand hygiene. At 11:42 a.m., CNA #1 was observed to get up from the stool where she was seated, place her left hand on the back of the resident's wheelchair seated on her left side, feed her several bites of salad, and sit back down on the stool. The table was observed to be next to one of the hand sanitizers pumps mounted on the wall. CNA #1 was not observed to use any hand sanitizer during the meal observation. At 11:45 a.m. at an adjoining dining room table, CNA #2 was observed to move a stool on wheels over to a dining room table where 3 residents were seated. She was observed to move the stool with her feet, but placed her left hand on the wall. She was observed to sit down on the stool by holding onto it with her bare hands. She was then observed to pick up a cup with a spouted lid and offer the resident a drink with her left hand. She was not observed to perform hand hygiene after touching the soiled objects. At 11:46 a.m., CNA #2 was observed to unwrap a resident's eating utensils, use them to prepare the resident's food, and start to feed the resident her lunch meal. She was not observed to perform hand hygiene. At 11:49 a.m., CNA #2 was observed to pick up the eating utensils of the resident seated on her right side and offer the resident a bite of food. The resident refused and CNA #2 continued to feed the resident seated on her left side. At 11:52 a.m., CNA #1 was observed to clean the place setting of a resident who had just finished eating. Another resident was brought into the dining room in that resident's place. CNA #1 was observed to sit back down on the stool placing her hands on her slacks and moved the resident's wheelchair up closer to the table with her bare hands. She was then observed to feed that resident who was seated on her right side. She was observed to keep her hands in her lap with her hands resting on her uniform slacks in-between giving the resident bites of food. At 11:55 a.m., CNA #1 was observed to get up from the stool where she was seated and use hand sanitizer. She was then observed to sit back down on the stool by placing her bare hands on the stool. She then began to feed the resident seated on her left side her lunch meal. She was not observed to perform hand hygiene after touching a soiled surface. At 11:58 a.m., CNA #1 was observed to continually keep her hands in her lap with her hands resting on her uniform slacks. At 11:59 a.m., CNA #2 was observed to get up from the stool where she was seated to obtain a package of disposable silverware. She was observed to use hand sanitizer on her hands and sit back down on the stool using her bare hands to steady the stool. She was then observed to feed the resident seated on her right side and the resident seated on her left side without performing hand hygiene. 3. During an observation of the lunch meal on 10/6/16 in the main dining room, the following was observed: At 11:18 a.m., Hospitality Aide #3 was observed to escort a resident into the dining room and into her dining room chair by holding onto the resident. She was then observed to push the resident's chair up to the dining room table and place a clean clothing protector on her without performing hand hygiene. At 11:24 a.m., CNA #4 was observed standing next to a resident seated in his wheelchair at a dining room table with her hands resting on the slacks of her uniform. She was then observed to place a clean clothing protector on the resident without washing her hands or performing hand hygiene. At 11:28 a.m., CNA #5 was observed to sit down on a stool in-between 2 residents seated in their wheelchairs at a dining room table. She was then observed to adjust her uniform top and offer the resident who was seated on her right side a drink without washing her hands or performing hand hygiene. At 11:30 a.m., CNA #5 was observed to get up from the stool where she was seated and walk around the dining room table to talk to another resident. When she sat back down on the stool where she was seated, she was observed to hike up her slacks with her hands. She was then observed to continue giving the resident seated on her right side a drink and started to give the resident seated on her left a drink without washing her hands or performing hand hygiene. At 11:33 a.m., CNA #6 was observed to touch the wheelchair of a resident who was at a dining room table and sit down on a stool between that resident, who was seated on her right side, and a resident who was seated on her left side. She was then observed to give both resident a drink of their fluids without washing her hands or performing hand hygiene. At 11:35 a.m., CNA #5 was observed to get up from the stool where she seated, pick up the silverware of a resident seated at the same table and proceed to pick up her eating utensils to cut her meat. She was not observed to wash her hands or perform hand hygiene. At 11:36 a.m., CNA #6 was observed to get up from the stool where she was seated and pick up the eating utensils of a resident who was seated at the same table to cut her meat. She was then observed to return to where she was seated and place her hand on the wheelchair of the resident who was seated on her right side, pick up her eating utensils, cut her meat and proceed to feed the resident her lunch meal without washing her hands or performing hand hygiene. At 11:37 a.m., CNA #6 was observed to touch her face with her fingers, then get up from the stool where she was seated, pick up the eating utensils of a resident seated at the dining room table and cut her meat. She was not observed to wash her hands or perform hand hygiene after touching her face. At 11:39 a.m., - CNA #6 was observed to sit back back down on the stool where she was seated and wake the resident up who was seated on her right side by rubbing her back. She was then observed to feed the resident her lunch meal without washing her hands or performing hand hygiene. At 11:40 a.m., CNA #6 was observed to pick up the eating utensils of the resident who was seated on her left side and prepare her lunch meal. She was then observed to feed the resident who was seated on her left side with the same hand she used to rub the back of the resident seated on her right. At 11:44 a.m., CNA #6 was observed to get up from the stool where she was seated and stand next to a wooden room divider where she placed she hands while talking with another staff. She was then observed to stand next to a resident and feed her a bite of her lunch meal without washing her hands or performing hand hygiene. At 11:51 a.m., CNA #6 was observed to get up from the stool where she was seated and adjust the top to her uniform. She was then observed to stand next to a resident who was seated at the same table, pick up her eating utensils, and feed her a bite of her lunch meal. She was not observed to wash her hands or perform hand hygiene. At 11:58 a.m., CNA #6 was observed to pick up an ink pen that was lying on the dining room table and wrote on a piece of paper. She then continued to feed the resident who was seated on her left side and the resident who was seated on her right side without washing her hands or performing hand hygiene. At 12:02 p.m., CNA #6 was observed to stand up from the stool where she was seated and adjust the top of her uniform. She then continued to feed the resident who was seated on her left side and the resident who was seated on her right side without washing her hands or performing hand hygiene. At 12:11 p.m., CNA #6 was again observed to pick up the ink pen from the dining room table and write on a piece of paper. She was then observed to pick up a spoon and hand it to a resident for her to use to eat her ice cream. She was not observed to wash her hands or perform hand hygiene. At 12:14 p.m., CNA #6 was observed to touch a resident's shoulder and push her high back wheelchair up to the table. She was then observed to unwrap the resident's eating utensils and use her spoon to add 2 packets of powered thickener to the resident's glass of a protein supplement. She then handed another resident who was seated at the same dining room table a glass of her beverage to drink. She was not observed to wash her hands or perform hand hygiene. The CDM was interviewed on 10/7/16 at 11:20 a.m. During the interview she indicated staff in the dining room were to wash their hands before assisting the residents to eat. She also indicated they were to wash their hands after touching a resident, after touching their clothing, after touching their skin, and after touching any soiled object. She further indicated staff were to have clean hands when placing a clothing protector on a resident. A current facility policy Hand Washing, with a revision date of February 2014 and provided by the Administrator on 10/7/16 at 12:14 p.m., indicated .Hand washing is the single most important procedure to prevent infections .Times when hand washing is critically important: Before feeding residents .After handling resident .clothing .Before handling clean linen A current facility policy Hand Sanitizers, with a revision date of February 2014 and provided by the Administrator on 10/7/16 at 12:14 p.m., indicated .To disinfect hands when soap and water are unavailable A current facility policy Assisted Area in Cafe, dated 2016 and provided by the CDM on 10/7/16 at 11:33 a.m., indicated .When food is set before the residents, nursing staff may NOT leave the assist area .Please do NOT stand up when assisting. You MUST be seated .Handwashing .use the hand sanitizer located on the wall when placing residents at the table .Wash hands for 40 to 60 seconds before feeding residents and after every 3rd use of hand sanitizer .Bus tables as needed and wash hands .Wash hands in-between seatings 3.1-21(i)(2)

Based on observation, interview, and record review, the facility failed to ensure the Hospitality Aides worked within their scope of practice, as the Hospitality Aides provided hands on care to residents with use of a gait belt for transfers and walking and hands on care to steady a resident during a dressing change. This deficiency had the potential to affect the 61 residents who needed 1 or 2 staff for assistance or were dependent on staff for transfers and walking. Findings include: 1. During an observation on 10-4-2016 at 10:45 a.m., Hospitality Aide #3 brought a wheelchair to a resident who was sitting by the nurses' station area. Hospitality Aide #3 and CNA (Certified Nursing Assistant) #5 were observed to transfer the resident from her chair to the wheelchair at 10:48 a.m. During an observation on 10-4-2016 at 12:26 p.m., Hospitality Aide #3 tried to transfer a resident in room [ROOM NUMBER]A from his wheelchair to his recliner. The hospitality aide was observed to place the gait belt around the resident and stand in front of the resident, grab onto each side of the gait belt and attempt to stand the resident. She was observed to try to transfer him at least twice, but was unable to transfer the resident to his recliner. The hospitality aide placed the resident back down in his wheelchair and turned on the call light for help. During an observation in the resident lounge by the nurses' station on 10-6-2016 at 8:48 a.m., Hospitality Aide #3 transferred a resident to the sofa using a gait belt. During an observation on 10-6-2016 at 9:03 a.m., Hospitality Aide #3 was walking with a resident with a gait belt used around the resident. Hospitality Aide #3 held on to the gait belt in the back as the resident pushed her walker. The resident then sat down on the walker seat and the hospitality aide pushed the resident while she sat on the walker seat, to her room. During an observation on 10-6-2016 at 9:06 a.m., Hospitality Aide #3 walked with a resident while holding on to the gait belt around the resident. The resident was pushing her walker with wheels. During an observation on 10-6-2016 at 9:13 a.m., Hospitality Aide #3 assisted a resident with a gait belt and transferred the resident from the dining room chair to her wheelchair. During an observation on 10-6-2016 at 11:38 a.m., Hospitality Aide #3 went into a resident's room (211) to assist a resident to transfer from her chair to a standing position. The hospitality aide first placed the gait belt around the resident, assisted the resident to stand by holding onto the gait belt and continued to hold onto the gait belt while the resident walked down the hall with her walker. The resident was then assisted to sit on the seat of her walker and the hospitality aide was observed to push the rolling walker to the dining room. The hospitality aide then assisted the resident to transfer from her walker seat while holding the gait belt, to the dining room chair. An interview with LPN #9 on 10-4-2016 1:55 p.m., indicated the Hospitality Aides were to assist to help move residents in and out of the dining room, would provide 1:1 with a resident when needed, especially those with behaviors, would pass water and snacks and would walk with and transfer residents. LPN #9 indicated the Hospitality Aides would not use the lifts, or would not give showers and would not see residents unclothed. An interview with Hospitality Aide #3 on 10-6-2016 at 10:00 a.m., indicated she had been here over 4 months. The hospitality aide indicated she had gait belt training and spent 2-3 days with the current hospitality aide for training. She indicated she was comfortable with transferring residents and can transfer all residents who walk. The hospitality aide indicated she was able to transfer 2-3 residents who were in wheelchairs by herself, otherwise there needed to be 2 assists. She indicated she could not use either lifts. An interview with the DON (Director of Nursing) on 10-7-2016 at 9:20 a.m., indicated for the Hospitality Aide duties included non-direct patient care, 1:1 with residents, walking ambulatory residents, walking with residents who needed an assist with the gait belt, transferring residents from the wheelchair to the recliner, assisting the CNA to put residents in bed, pass water, juice and snacks, dispose of the trash and soiled laundry, assist with activities and sit with residents for socialization. The DON indicated the hospitality aides could cue a resident during meals, but were not to feed the residents. The hospitality aides could also assist a CNA or a nurse to transfer a resident who required 2 assists, but two hospitality aides could not transfer a resident who needed 2 assists. The DON indicated the hospitality aides could also answer the call light but were only allowed to do non-direct hands on care. The DON indicated the physical therapist did the training on gait belts, transfers and ambulation prior to the hospitality aides providing care to the residents. 2. During an observation of wound care on the coccyx of a resident on 10-7-2016 at 9:44 a.m., the ADON (Assistant Director of Nursing) asked Hospitality Aide #13 to don gloves and to help hold the resident. The hospitality aide was observed to wash her hands and don gloves. The ADON pulled the resident's pants down while Hospitality Aide #13 was present. The ADON then instructed the hospitality aide to place her gloved hands on the resident to support and hold her during the dressing change. The hospitality aide was observed to place one hand on the top of the resident's bare upper right leg and her other hand at the top of the resident's bare right hip. When part of the dressing change was complete, the ADON removed her gloves and she washed her hands on the other side of the curtain. The hospitality aide stayed with the resident holding her on her bare right upper leg and bare right hip. When the dressing change was completed, the ADON asked the hospitality aide to obtain a clean pad. After the hospitality aide removed her gloves, she obtained the pad, washed her hands, donned gloves and the ADON asked her to hold the resident so she could change the resident's pad. The hospitality aide was present and supported the resident with her hands while the resident's bottom was exposed and as the ADON provided the perineal cleansing, pad change and re-dressing of the resident. An interview with Hospitality Aide #13 on 10-7-2016 at 10:16 a.m., indicated she could hold and assist residents, but could not do hands on care. She indicated she would help to hold a resident while the resident was in the bathroom, but the CNA would do all the perineal care. An interview with the ADON on 10-7-2016 at 10:05 a.m., indicated the hospitality aides could assist her by holding and supporting a resident during care. The ADON indicated the hospitality aides could also transfer and walk residents. A review of the Resident Census and Conditions Report provided by the Administrator on 10-5-2016 at 5:05 p.m., indicated 53 residents needed the assistance of 1 or 2 staff for transferring and 8 were totally dependent. No independent residents were listed for transferring and none were independently ambulatory. A current position description for Hospitality Aide was provided by the DON on 10-7-2016 at 9:35 a.m. and indicated the .Scope of Position .The primary purpose of the position is to meet the needs of residents assigned by your supervisor with non-direct patient care Essential Functions .walk or transfer ambulatory residents or push in a wheelchair as required A current copy of the Hospitality Aide Orientation was provided by the DON on 10-7-2016 at 9:35 a.m. The orientation under the Mobility/ADLs (Activities of Daily Living) section included, .Need to follow order-tell nurse if order needs changed .Transferring residents - if not comfortable with someone ask for help, follow assist x 1 or assist x 2 .Ambulating residents - gait belt, walkers - rolling (regular w/ wheels & rollator (fancy) .Gait belt-use 4 fingers on belt-Mandatory to use on residents that are identified .If injury results and resident should have been wearing, will result in written warning .Unlatch when not in use .Use on any resident that is unstable and has potential for a fall .Protects you and the resident A current copy of the C.N.A. Orientation was provided by the Administrator on 10-7-2016 at 12:23 p.m. Upon review of the Mobility/ADLs sections of both the C.N.A. and Hospitality Aide Orientation, the portion of the orientation content (as noted in the previous paragraph) was exactly the same for both the CNA and Hospitality Aide. 3.1-14(b) 3.1-14(b)(1) 3.1-14(b)(2)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident observed, received toileting assistance when requested in a timely manner. This had the potential to affect the 61 residents who were identified by the facility as needing the assist of 1 or 2 staff or dependent upon staff for toileting. (Resident #51) Findings include: Several observations of Resident #51 were made while the resident was sitting in the lounge by the nurses' station for Plum Tree and Cherry Tree hall. The observations took place on 10-4-2016 and 10-6-2016 and included the following: During an observation of Resident #51 on 10-4-2016 at 10:30 a.m., Resident #51 told Hospitality Aide #3 that she had to pee. Hospitality Aide #3 went to find an aide to assist the resident. Hospitality Aide # 3 returned and told Resident #51 that a CNA would be there right after she helped another resident. Resident #51 was observed at that time to moan again and said she had to pee. An observation on 10-4-2016 at 10:35 a.m., indicated 2 CNAs (Certified Nursing Assistants) brought 2 other residents to the lounge. The 2 CNAs then were observed to help another resident to transfer from a chair to her wheelchair. They were not observed to assist Resident #51 to the bathroom. An observation of Resident #51 on 10-4-2016 at 10:38 a.m., indicated Hospitality Aide #3 responded to the resident's call help me and Hospitality Aide #3 told the resident that someone was in the bathroom with the wheelchair. Hospitality Aide #3 was then observed to walk away from Resident #51. An observation of Resident #51 on 10-4-2016 at 10:41 a.m., indicated the resident told the Volunteer Coordinator #7 that she needed to go to the toilet. The Volunteer Coordinator #7 was observed at this time to tell Registered Nurse (RN) #12. RN #12 was observed to call CNA #5 on the phone to let her know Resident #51 needed to go to the bathroom. RN #12 was observed to go over to Resident #51 and told her CNA #5 was coming. Resident #51 was observed to groan and Hospitality Aide #3 told Resident #51 that CNA #5 was coming to take her to the bathroom. Hospitality Aide #3 indicated she would go get the wheelchair, so it would be ready. An observation of Resident #51 on 10-4-2016 at 10:45 a.m., indicated Hospitality Aide #3 brought a wheelchair to the resident. Hospitality Aide #3 picked something up off of Resident #51's lap and told Resident #51 to hold on twice. Hospitality Aide #3 was observed to use hand gel, obtain another tissue and Resident #51 asked are you ready to take me yet? Hospitality Aide #3 told Resident #51, I'm going to get you up and CNA #5 assisted with the transfer. CNA #5 was observed to take Resident #51 to the bathroom at 10:48 a.m. During an observation of Resident #51 on 10-6-2016 at 9:08 a.m., the resident yelled out loud to Hospitality Aide #3, I need the toilet. Hospitality Aide #3 responded hold on. Hospitality Aide #3 was not observed to tell any other staff member that Resident #51 had to go to the bathroom. Hospitality Aide #3 indicated to Resident #51 she would go and get the wheelchair. Hospitality Aide #3 was observed to go into the dining room and transported another resident down the hall to their room. An observation of another resident sitting next to Resident #51 on 10-6-2016 at 9:11 a.m., indicated this resident told CNA#1 that she had to go to the bathroom. CNA #1 came right away and assisted the resident to the bathroom while Resident #51 remained in her chair. An observation of Hospitality Aide #3 on 10-6-2016 at 9:13 a.m., indicated the Hospitality Aide #3 returned to the resident lounge and spoke to the nurse. Hospitality Aide #3 then went into the dining room and assisted 2 other residents out of the dining room, taking one resident to her room and another to the activity room. An observation of a male resident sitting by the nurses' station on 10-6-2016 at 9:19 a.m., indicated he told the Activity Director #8 that he had to pee. The Activity Director #8 was observed to tell staff and returned to tell the resident the staff would be right back. A nurse was observed to come right away to take the resident to the bathroom. An observation of Resident #51 on 10-6-2016 at 9:21 a.m., indicated the resident was heard to moan. Hospitality Aide #3 was observed to walk right by Resident #51 while transporting another resident to the dining room for breakfast. An observation of Resident #51 on 10-6-2016 at 9:25 a.m., indicated the resident told Hospitality Aide #3 that she needed more water. Another staff member came and offered to get her something to drink and Hospitality Aide #3 was observed to go into the dining room. During an observation of Resident #51 on 10-6-2016 at 9:27 a.m., she called out I need to go potty. The Activity Director #8 told the resident she would tell the girls. Activity Director #8 was observed to push another resident to the activity room and returned to assist another resident. The Activity Director #8 was not observed to let any other staff member know that Resident #51 needed to use the bathroom. An observation of Resident #51 on 10-6-2016 at 9:45 a.m. indicated she cried out and CNA #5 heard the resident and told the resident ok, let me get your wheelchair. CNA #5 returned with the wheelchair and CNA #1, and both assisted Resident #51 to the bathroom. An interview with LPN #9 on 10-4-2016 1:55 p.m., indicated the Hospitality Aides were to assist to help move residents in and out of the dining room, would provide 1:1 with a resident when needed, especially those with behaviors, would pass water and snacks and would walk with and transfer residents. LPN #9 indicated the Hospitality Aides would not use the lifts, or would not give showers and would not see residents unclothed. An interview with CNA #10 on 10-5-2016 at 3:45 p.m., indicated Resident #51 required 1 or 2 assists with transfers depending on the day. An interview with Hospitality Aide #3 on 10-6-2016 at 10:00 a.m., indicated for a resident who says they have to go to the bathroom, she would tell a nurse or an aide. Hospitality Aide #3 indicated if the nurse or the aide were busy, she would tell other nursing staff so they would be aware of a resident's need to use the bathroom. An interview with Hospitality Aide #13 on 10-7-2016 at 10:16 a.m., indicated if a resident told her they needed to go to the bathroom, she would tell the nurse or find a CNA. Hospitality Aide #13 indicated she would keep an eye on the resident to be sure they were taken to the bathroom. She indicated if they did not get help, she would tell the other CNAs and would keep reminding them. An interview with CNA #2 on 10-11-2016 at 10:38 a.m., indicated when a resident who was sitting in the activity area by the nurses' station requested to go to the bathroom, she would assist the resident with a gait belt, if the resident was a one assist and get them to the bathroom. The CNA indicated if the resident required 2 assists, she would find another CNA and both of them would assist the resident to the bathroom. An interview with RN #11 on 10-11-2016 at 10:40 a.m., indicated if a resident who was sitting by the nurses' station asked to go to the bathroom and there were no CNAs around, RN #11 indicated she would assist the resident to the bathroom. RN #11 indicated if the resident required 2 assists, she would find another nurse to help her. An interview with the DON (Director of Nursing) on 10-11-2016 at 11:00 a.m., indicated when a resident asked to go to the bathroom, it should be done in a timely manner. The DON indicated the CNAs would need to prioritize their tasks and indicated tasks such as bedmaking can wait. If the aide was helping another resident, they should finish that task and then get the resident to the bathroom in a timely manner. The DON indicated Resident #51 needed 1 or 2 staff to assist, depending on the day. The record review for Resident #51 began on 10-5-2016 at 4:05 p.m. [DIAGNOSES REDACTED]. During a review of the current physician orders [REDACTED]. The MDS (Minimum Data Set) quarterly assessment dated [DATE] indicated a BIMS (Brief Interview for Mental Status) score of 6/15 (severe cognitive impairment). For transfers and toileting, the resident required an extensive assist of 2 persons. The assessment indicated Resident #51's balance during transitions and walking was not steady and the resident was only able to stabilize with staff assistance when moving from a seated to a standing position and moving on and off the toilet. Resident #51 was not on a toileting program and was frequently incontinent . A care plan for self care deficit dated 4-22-2013 included an approach for transferring and toileting which was updated 3-22-2016. The approaches indicated the resident required an extensive assist with 1-2 assist and a gait belt for transfers and for toileting an extensive assist, to dependent with 1-2 assist for the Nurse aide. A care plan for LE (lower extremity) [MEDICAL CONDITION] dated 5-20-2016, included an approach updated on 9-24-2016 for nurses to administer diuretics as ordered. A care plan for potential for trauma-falls dated 9-11-2013, included an approach for the nurse aide, updated on 9-24-2016 for the nurse aide to encourage to ask for assistance .anticipate needs .gait belt. A review of the bladder incontinence care plan dated 1-14-2016 included approaches for use of appropriate absorbent products, report changes in voiding pattern or appearance of urine and to provide barrier ointments. A review of the CNA documentation on 10-3-2016 day shift indicated Resident #51 was toileted 3 times with an extensive assist of 1 and a gait belt. The resident was incontinent 3 times. On 10-4-2016 day shift, the resident was toileted 3 times. The resident needed the extensive assist of 2 with the gait belt and was incontinent of urine 3 times. On 10-5-2016 day shift, the resident was toileted 2 times and needed the extensive assist of 1 person. The resident was continent at both voidings. A review of the Resident Census and Conditions Report provided by the Administrator on 10-5-2016 at 5:05 p.m., indicated 53 residents needed the assistance of 1 or 2 staff for transferring and 8 were totally dependent. Sixty residents needed the assist of 1 or 2 staff and 1 was dependent upon staff for toileting. No independent residents were listed for either toileting or transferring and none were independently ambulatory. A current policy, Toileting of Residents revised on 3/10 and provided by the DON on 10-11-2016 at 11:58 a.m., indicated all residents upon admission upon toileting will have their .bladder activity charted in Electronic Medical Records. This information included how the resident was toileted, what the results were and whether the resident was continent. This information is used to complete the MDS and to develop the care plan. Nurses summarize the resident's toileting activity during the week of observation and as needed with an entry in the nurses' notes. The care plan is updated with each MDS as needed using information from the CNA documentation, the nurses' notes entries and in conversation with the nurses and nurse aides All reasonable efforts to improve continency are made through this process 3.1-37(a)

Based on observation and interview, the facility failed to protect juice served to residents during snack time from potential contamination in the common area, Plum Tree hall, and Cherry Tree hall, potentially affecting 49 of 63 residents. Findings include: 1. During an observation on 10/16/14 the following was observed: - At 10:20 a.m., a facility volunteer was observed pushing an open tiered snack cart through Cherry Tree hall. The top tier of the open cart contained a bag of cookies, a covered plastic pitcher of lemonade, and opened 46 ounce plastic bottles of apple juice and cranberry juice. The top tier also contained 4 pre-poured plastic glasses of apple juice. The lids were not placed back onto the plastic bottles of apple juice and cranberry juice and the plastic glasses of apple juice were left un-covered as the snack cart was pushed from room to room in Cherry Tree hall. - At 10:45 a.m., the same open tiered snack cart was pushed into the hallway next to the common area with the 46 ounce plastic bottles of apple juice and cranberry juice opened as well as 3 pre-poured plastic glasses of apple juice uncovered. After service to the residents in the common area, the open tiered snack cart was pushed down the Plum Tree hall room to room. The 46 ounce plastic bottles of apple juice and cranberry juice remained opened and the pre-poured plastic glasses of juice remained un-covered. 2. During an observation on 10/17/14 the following was observed: - At 10:15 a.m., Activities #4 was observed to ask residents seated in the common area if they would like any juice. As a resident requested a glass of juice, she went into the Activity room and poured a glass of juice into a plastic glass. She then was observed to carry the glass of juice into the hallway and common area to serve the resident. The glass of juice was not covered. A total of 7 glasses of juice were served un-covered. 3. During an observation on 10/21/14 the following was observed: - At 9:45 a.m., a facility volunteer was observed pushing an open tiered snack cart through Plum Tree hall. The top tier of the open cart contained a bag of cookies, a covered plastic pitcher of lemonade, and 46 ounce plastic bottles of apple juice, cranberry juice, and grape juice. The volunteer was observed to push the snack cart from room to room offering residents a snack. The lids of the 46 ounce plastic bottles of juice were removed as residents requested a certain beverage. The lids were not placed back onto the bottles of juice. - At 9:57 a.m., the same snack cart was pushed into the hallway next to the common area where residents were seated and staff were working. The bottles of juice remained opened as residents were served a beverage of their choice. Numerous staff were observed to walk past the opened bottles of juice. - At 10:11 a.m., the volunteer was observed to push the snack cart down Plum Tree hall room to room. The lids were not placed back on the bottles of apple juice, cranberry juice, and grape juice. The Certified Dietary Manager (CDM) was interviewed on 10/21/14 at 2:20 p.m. During the interview she indicated after removing the lid to a bottle of juice and pouring the juice into a glass, the lid should be placed back on the bottle. She also indicated the bottles of juice should not be transported through the halls without the lids on the bottles to protect the juice from contamination. She further indicated pre-poured glasses of juice should not be transported through the halls uncovered. The CDM was interviewed on 10/21/14 at 3:18 p.m. During the interview she indicated the facility did not have a policy concerning protecting food and beverages from potential contamination. 3.1-21(i)(1)

Based on observation, interview and record review the facility failed to transport clean linens and clean resident clothing in a manner to prevent potential contamination potentially affecting 49 of 63 residents who resided on Cherry and Plum Tree halls. Findings include: 1. During an observation of Cherry Tree hall on 10/15/14 at 11:52 a.m., Laundry #1 was observed carrying a stack of clean resident clothes through the common area and through Cherry Tree hall up against her uniform top. The clothes were not covered and not in a laundry cart. 2. During an observation of Plum Tree hall on 10/15/14 at 12:14 p.m., Laundry #2 was observed pushing an enclosed laundry cart from room to room. She was observed to remove clean resident clothing from the laundry cart. She then was observed to place and secure the items on hangers under her arm with the clean clothing pressing against her uniform top and uniform slacks. She was also observed to hold stacks of clean resident clothing up against her uniform top. 3. During an observation on Cherry Tree hall on 10/20/14 at 8:22 a.m., Laundry #2 was observed carrying clean clothing for residents securely under her arm with the clothing pressing against her uniform top and uniform slacks. She was also observed carrying a stack of clean linens up against her uniform top. 4. An observation on 10-15-2014 at 12:27 p.m., indicated Laundry #2 was moving a covered laundry cart from room to room on Plum Tree. Laundry #2 removed the clean resident clothing from the cart and placed the hanging clothes under her arm where the clothes were up against the uniform top and slacks. Further observation indicated Laundry #2 carried a stack of clean clothing in her arms and up against her uniform top and delivered the clean laundry to a resident room. 5. An observation in Plum Tree on 10-15-2014 at 12:34 p.m., indicated Laundry #2 obtained a resident's clean clothes from the laundry cart. Further observation indicated Laundry #2 carried the resident's clean clothes in her arms and up against her uniform top to a resident's room. Certified Nursing Assistant (CNA) #3 was interviewed on 10/21/14 at 2:55 p.m. During the interview she indicated an enclosed laundry cart was brought to the halls by laundry staff for the CNAs to put away. She also indicated laundry staff put clean clothes away. She further indicated clean linens and clean clothing should be carried away from staff's clothing. The Laundry Supervisor was interviewed on 10/22/14 at 8:23 a.m. During the interview she indicated clean linens and clean resident clothing should not touch staff clothing to protect them from contamination. A current facility policy "Clean Linens - Handling, Storage and Transportation Procedures, revised on February, 2008 and provided by the Director of Nursing on 10/22/14 at 9:15 a.m., indicated "...All clean linens transported through halls by laundry or nursing staff are to be covered...." 3.1-19(g)(1)(2)(3)

Based on interview and record review, the facility QAA (Quality Assessment and Assurance) Committee failed to implement an adequate action plan for the identified concerns which included but were not limited to the following: infection control regarding linen handling, activities, and significant weight loss. These deficiencies had the potential to affect 63 of 63 residents who resided at the facility. Findings include: On 10/22/14 at 9:45 a.m. the DON (Director of Nursing) was interviewed. She indicated the QAA committee included the following members: DON, Administrator, Executive Director, Pharmacy Representative, Medical Director, Residential Coordinator and Staff Development Coordinator. The DON indicated the departments of Activities, Nursing and Dietary relay the QAA concerns to her and she presents their concerns to the QAA committee as the departments of Activities and Dietary were not present at the meetings. The DON indicated they were in the process of changing the QA (Quality Assurance) process by including the actual department leaders in the meeting instead of the DON reporting for them. On 10/22/14 at 10:04 a.m. the DON was interviewed. She indicated she had not been made aware the laundry staff carried clean linens directly against their uniforms. She also indicated she was unaware of the lack of Activities for cognitively impaired residents and/or resident's who experienced weight loss had interventions implemented. On 10/22/14 at 1 p.m. the DON indicated the QA committed met quarterly and the facility was planning on having smaller QA meetings more frequently. The DON also indicated the QA committee did trend areas of concern to evaluate. The DON indicated she would receive reports and/or concerns from the Activities and/or Dietary Department and would have only looked at items if there was an issue. The DON indicated there have been no concerns with activities and/or that the Activity Department reported to her. Regarding Dietary, the DON indicated they "mention it" but "didn't discuss a lot because (name of Food Service Manager) wasn't involved." She indicated Dietary concerns are discussed more at the NAR (Nutrition At Risk) meetings. The DON indicated through the "old way" they were running the QA meetings, they wouldn't have identified the weight loss as an issue but with the "new way" they will. She indicated with the new way the QA meetings will be conducted, the Activity and Dietary Managers will actually be at the meetings to participate actively. On 10/22/14 at 10:48 a.m. the DON provided a copy of the facility policy and procedure for "Quality Improvement Program." This policy was dated 6/2007 and included but was not limited to, the following: "Continuous Quality Improvement (CQI) purpose: To identify outcomes resulting from the care and services provided. To use this information to maintain, improve or increase services as necessary...principle mechanism to direct the planned and systemic performance improvement...Efforts are focused on the outcome and will elicit multidisciplinary collaboration...monitors continually the...health care service compliance with the standards of the Indiana State Department of Health and other applicable government agencies...serves as the primary means through which the facility reviews medical/resident/staff recommendations concerning facility procedures and services...QI (Quality Improvement) committee is responsible for overseeing the QI process and activities and in particular:...identify problems relating to care and deficiencies...ensure resident care meets and/or exceeds state and federal regulations...Teams...involved in contributing data for identifying quality issues may include...Falls Team...other sources identifying quality issues are...incident reports...review areas may include but are not limited to...activities...dietetic care...safety issues, housekeeping and laundry services..." 3.1-52(a)(2)

Based on observations, interview and record review the facility failed to provide activities as care planned for 1 of 1 resident reviewed for activities (Resident #47). Findings include: Review of the clinical record for Resident #47 on 10/21/14 at 10:28 a.m., indicated the following: [DIAGNOSES REDACTED]. An Activity Progress Note for Resident #47, dated 1/30/14, indicated she sat in the commons area throughout the morning and was put to bed for an afternoon nap most days. The note also indicated she no longer made any type of activity decision, but would smile when spoken to and seemed to enjoy watching the activity going on around her. The note further indicated she sometimes held onto a doll baby or would flip through a magazine or rip up a newspaper when set in front of her. The note also indicated she had been taken off of the psychosocial care plan as she seemed to be very content and well-adjusted in the Orchard area. An Activity Progress Note for Resident #47, dated 4/24/14, indicated she sat in the commons area or in the activity room recliner in the morning and was put to bed in the afternoon for a nap. The note also indicated she no longer participated in group activities and did not make her own activity decision. The note further indicated she would smile when spoken to and would fiddle with objects on the activity table in the commons area. The note also indicated she would hold a stuffed animal occasionally or liked to pick at a blanket or an old telephone that was on the table. An Activity Progress Note for Resident #47, dated 7/17/14, indicated she usually napped in the activity room recliner during the morning hours and would nap in her bed in the afternoon. The note also indicated she would be in the commons area during the other times and would watch what was going on around her. The note further indicated she would sometimes fiddle with the things on the activity table. An Activity Progress Note for Resident #47, dated 10/9/14, indicated she was only passive in group activities and no longer made activity decisions, but would sit in the common area and watch what was going on. The note also indicate she would at times take a nap in the activity room recliner. The note further indicated she enjoyed when people would stop and talk to her and also liked to fiddle with things on the activity area table when she was sitting there. During an observation on 10/16/14 the following was observed: - At 10:00 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. A television and radio were present in the activity room, but neither were on. From the position of the recliner, Resident #47 would not be able to see the television as it was above and behind her right shoulder. - At 10:30 a.m., Certified Nursing Assistant (CNA) #5 and CNA #6 were observed to assist Resident #47 up from the recliner and escort her to the bathroom. At 10:40 a.m., the same CNAs walked her from the bathroom and assisted her to sit in her wheelchair. Her wheelchair was then placed at a small table next to the wall on the outside of the common area. The only item on the activity table was an old electric typewriter which was not close enough for Resident #47 to reach. - At 2:00 p.m., Resident #47 was observed resting in her bed in her room. During an observation on 10/17/14 the following was observed: - At 8:40 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. A television and radio were present in the activity room, but neither were on. From the position of the recliner, Resident #47 would not be able to see the television as it was above and behind her right shoulder. - At 9:00 a.m., the Administrator entered the activity room to speak with the surveyor and then walked over to Resident #47 to say hello. - At 9:10 a.m., facility staff began bringing residents into the activity room for a scheduled activity, but did not approach Resident #47 or ask her if she wanted to participate in the activity. During the continuous hour of observation she was seated in the lounge chair, Resident #47 was observed to sit upright in the chair and eventually return to a reclining position. She was also observed to continually pull at her slacks. - At 10:45 a.m., Resident #47 was observed seated in her wheelchair at the table next to the wall on the outside of the common area. The placement of her wheelchair at the table resulted in her facing the wall. She could not see the other residents or staff in the common area since they were at her back. The only item on the activity table was an old electric typewriter which was not close enough for Resident #47 to reach. During an observation on 10/20/14 the following was observed: - At 8:15 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. A television and radio were present in the activity room, but neither were on. From the position of the recliner, Resident #47 would not be able to see the television as it was above and behind her right shoulder. - At 10:38 a.m., Resident #47 was observed seated in her wheelchair at a small table next to the wall on the outside of the common area. She was not provided with anything to hold in her hands or any activity to do. - At 11:19 a.m., Resident #47 remained seated in her wheelchair at a small table next to the wall on the outside of the common area. The only item on the activity table was an old electric typewriter which was not close enough for Resident #47 to reach. - At 1:45 p.m., Resident #47 was observed resting in her bed in her room. During an observation on 10/21/14 the following was observed: - At 7:50 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. A television and radio were present in the activity room, but neither were on. From the position of the recliner, Resident #47 would not be able to see the television as it was above and behind her right shoulder. - At 10:00 a.m., CNA #7 and CNA #8 were observed to assist Resident #47 up from the recliner and escort her to the bathroom. At 10:10 a.m., the same CNAs walked her from the bathroom and assisted her to sit in her wheelchair. Her wheelchair was then placed at a small table next to the wall on the outside of the common area. The placement of her wheelchair at the table resulted in her facing the wall. She could not see the other residents or staff in the common area since they were at her back. The only item on the activity table was an old electric typewriter which was not close enough for Resident #47 to reach. CNA #3, was interviewed on 10/21/14 at 2:10 p.m. During the interview she indicated care plans described the care each resident required. The Administrator and Director of Nursing were interviewed on 10/21/14 at 4:08 p.m. During the interview they indicated care plans were to be followed. A facility care plan for Resident #47, with a review date of 10/14/14, indicated the problem area of activities. Approaches to the problem included, but were not limited to, offer resident something to hold while she is sitting at the activity table in common such as baby clothes, a blanket, magazine, or a bean bag, offer her a knotted comforter to look at and feel, try to get her to rest in the activity room, turn television to animal planet, put music on for her to listen to, and make verbal contact with her daily. 3.1-33(a)

Based on observation, interview and record review the facility failed to follow physician orders [REDACTED].#57) who met the criteria for pressure ulcers. The facility also failed to follow the care plan for a call light for 1 resident (Resident #47). Findings include: 1. Review of the clinical record for Resident #57 on 10/17/14 at 8:44 a.m., indicated the following: [DIAGNOSES REDACTED]. A Braden scale for Resident #57, dated 7/23/14, indicated he was at risk for skin breakdown. A physician's orders [REDACTED]. A Skin Assessment for Resident #57, dated 9/5/14, indicated heel lift boots while in bed or in recliner. A Certified Nursing Assistant (CNA) Assignment Sheet for all 3 shifts for Resident #57, provided by the Assistant Director of Nursing on 10/20/14 at 3:35 p.m., did not indicate heel lift boots while in bed or recliner. During an observation on 10/20/14 at 9:12 a.m., Resident #57 was observed resting in his easy chair with his feet elevated. He was observed to be wearing his shoes and not the heel lift boots as ordered. During an observation on 10/20/14 at 3:00 p.m., Resident #57 was observed resting in his easy chair with his feet elevated. He was observed to be wearing his shoes and not the heel lift boots as ordered. The Director of Nursing was interviewed on 10/21/14 at 8:36 a.m. During the interview she indicated the staff were to make sure his heels were floated off the foot rest of his chair. A Skin Assessment for Resident #57, dated 8/13/14, indicated intact fluid filled blisters to his bilateral heels. The assessment also indicated no shoes, to wear gripper socks. A Skin Assessment for Resident #57, dated 9/5/14, indicated no shoes, to wear gripper socks. A CNA Assignment Sheet for all 3 shifts for Resident #57, provided by the Assistant Director of Nursing on 10/20/14 at 3:35 p.m., did not indicate he was only to wear slipper socks and not shoes. Resident #57 was interviewed on 10/15/14 at 3:45 p.m. During the interview he was observed to be wearing his shoes. During an observation on 10/17/14 at 10:20 a.m., Resident #57 was observed riding an exercise bike in the therapy room. He was observed wearing his shoes. During an observation on 10/20/14 at 9:56 a.m., Resident #57 was observed riding an exercise bike in the therapy room. He was observed wearing his shoes. During an observation on 10/20/14 at 12:00 p.m., Resident #57 was observed seated in a chair near the entry into the facility. He was observed wearing his shoes. During an observation on 10/20/14 at 1:05 p.m., Resident #57 was observed visiting with a family member in his room. He was observed wearing his shoes. A facility care plan for Resident #57, dated 8/13/14, indicated the problem area of impaired skin integrity on bilateral heels. Approaches to the problem included, but were not limited to, no shoes, wear gripper socks, and heel lift boots while in bed or recliner. 2. Review of the clinical record for Resident #47 on 10/21/14 at 10:28 a.m., indicated the following: [DIAGNOSES REDACTED]. During an observation on 10/16/14 the following was observed: - At 10:00 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. There was no call light for Resident #47 to use. During an observation on 10/17/14 the following was observed: - At 8:40 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. There was no call light for Resident #47 to use. During an observation on 10/20/14 the following was observed: - At 8:15 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. There was no call light for Resident #47 to use. During an observation on 10/21/14 the following was observed: - At 7:50 a.m., Resident #47 was observed seated in a recliner with her legs elevated at the far end of the activity room. Only her lower legs were visible from the doorway. There were no staff or other residents present in the room. There was no call light for Resident #47 to use. A facility care plan for Resident #47, with a review date of 10/14/14, indicated the problem area of self care deficit. Approaches to the problem included, but were not limited to, call button in reach. A facility care plan for Resident #47, with a review date of 10/14/14, indicated the problem area of alteration in vision. Approaches to the problem included, but were not limited to, keep call button in reach. CNA #3, was interviewed on 10/21/14 at 2:10 p.m. During the interview she indicated CNA assignment sheets and care plans described the care each resident required. The Administrator and Director of Nursing were interviewed on 10/21/14 at 4:08 p.m. During the interview they indicated physician orders [REDACTED]. 3.1-35(g)(2)