Every finding on record at Clinton Gardens

Based on observation, record review, and interview, the facility failed to ensure a medication prescription label matched the physician's order for 1 of 35 medication administrations observed (Resident 28). Findings include:On 8/8/25 at 8:47 a.m. Qualified Medication Aide (QMA) 9 administered mirtazapine (antidepressant) 15 milligrams (mg), 2 tablets to Resident 28. The label on the mirtazapine medication card, dated 7/8/25, indicated mirtazapine 15 mg, 1 tablet by mouth daily. There was no directions changed sticker or indication that two tablets were ordered. At the same time, QMA 9 indicated the medication order was changed to two tablets on 8/4/25. Resident 28's record was reviewed on 8/8/25 at 2:39 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 6/23/25, indicated the resident had a moderate cognitive impairment and received an antidepressant during the assessment look-back period. A physician's order, dated 7/9/25 and discontinued on 7/15/25, indicated mirtazapine 15 mg by mouth once daily for appetite stimulation A physician's order, dated 7/15/25 and discontinued on 8/4/25, indicated mirtazapine 7.5 mg by mouth once daily for appetite stimulation. A physician's order, dated 8/4/25, indicated mirtazapine 30 mg by mouth once daily for appetite stimulation. During an interview, on 8/8/25 at 2:26 p.m., QMA 8 indicated when a medication order was changed, and the order on the medication card was different than the physician's order, there should have been a directions changed sticker placed on the card. This alerted the staff of an order change. When the new medication card came in, the old one should have been removed from the medication cart. On 8/8/25 at 2:50 p.m., the Administrator provided a document titled, Reordering, Changing, and Discontinuing Orders, last revised on 1/1/13, and indicated it was the policy currently being used by the facility. The policy indicated, .Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order.If permitted by Applicable Law, Facility should notify Pharmacy not to send the medication by attaching a 'Change in Directions' sticker to the existing quantity of medications until Pharmacy permanently affixes the new label to the medication package or container. 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure a resident had effective pain management for 1 of 2 residents reviewed for pain management (Resident 43). Findings include:On 8/05/2025 at 2:42 p.m., during an interview, Resident (43) indicated she received pain medication twice daily and indicated it was not helping to control her pain. The resident had asked for an increase in pain medication but was told she could not have more. She indicated they did administer Tylenol, but it was not effective. The resident demonstrated physical signs of pain during interview. On 8/08/2025 at 9:39 a.m., the medical record of Resident 43 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to displaced intertrochanteric fracture of right femur (fracture of the right thigh bone), subsequent encounter for closed fracture with routine healing, Congestive Heart Failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs) and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A Minimum Data Set (MDS) assessment, dated 8/1/25, indicated the resident required extensive assistance for daily care needs and was cognitively intact. A 48 hour admission care plan and comprehensive care plan lacked documentation of a care plan for pain management. A physician order, dated 7/26/25, indicated to administer oxycodone (a narcotic pain medication) 5 mg (milligram) tablet twice a day (BID) and hold for sedation. The order was discontinued on 7/29/25. A nurse's note, dated 7/28/25 at 11:41 a.m., indicated Resident is having moderate pain to her right leg throughout this morning. Tylenol has no relief at present. Resident is post-op (post-surgery) right femur (long thigh bone). Resident has an order for oxycodone 5 mg by mouth, bid (twice daily). Resident does not have this prescription active in house. Notified attending physician of new admission to the facility and brief description of her pain and need for medication to be called in to Omnicare Indianapolis. The medical record lacked documentation of physician notification of increased pain. The July 2025 Medication Administration Record (MAR) indicated the facility failed to provide pain medication from 7/26/25 to 7/28/25. The record lacked documentation of notification to the physician of medication availability prior to 7/28/25. A physician order, dated 7/28/25, indicated to administer acetaminophen (Tylenol, a medication used to manage pain or fever) 650 mg orally as needed every 6 hours as needed (PRN) for mild pain or discomfort. Do not exceed 3g (grams) in 24 hours. A physician order, dated 7/29/25, indicated to administer Tramadol (a narcotic pain medication) - Schedule IV tablet 50 mg orally twice a day for pain. Review of the July 2025 Medication Administration Record (MAR) indicated the resident was not administered oxycodone pain medication from 7/26/25 to 7/28/25. The record indicated the medication was not available. The July 2025 MAR indicated Resident 43 received the following pain medications: On 7/28/25 at 9:12 a.m. Tylenol 650 mg was administered, and the PRN response indicated the medication was not effective for the resident's pain. No pain scale rating from 0-10 was provided. On 7/28/25 at 3:59 p.m., Tylenol was then administered, and the PRN response indicated the medication was somewhat effective for the resident's pain. No pain scale rating from 0-10 was provided. On 7/29/25 at 1:14 a.m., Tylenol was administered for pain of 8 out of 10 and the PRN response indicated it was effective. No follow up pain scale rating was provided to show the resident's pain level after the medication. On 7/29/25 between 7 a.m. and 11 a.m., Tramadol 50 mg was administered. On 7/29/25 at 3:31 p.m., Tylenol was administered for pain of 9 out of 10 and the PRN response indicated it was effective. No follow up pain scale rating was provided to show the resident's pain level after the medication. On 7/29/25 between 7 p.m. and 11 p.m., Tramadol 50 mg was administered. On 7/30/25 at 5:28 a.m., Tylenol was administered for pain of 8 out of 10 and the PRN response indicated the medication was somewhat effective. No follow up pain scale rating was provided to show the resident's pain level after the medication. On 7/30/25 between 7 a.m. and 11 a.m., Tramadol 50 mg was administered. On 7/30/25 at 12:23 p.m., Tylenol was administered for pain of 8 out of 10 and the PRN response indicated the medication was effective. No follow up pain scale rating was provided to show the resident's pain level after the medication. On 7/30/25 between 7 p.m. and 11 p.m., Tramadol 50 mg was administered. On 7/30/25 at 11:20 p.m., Tylenol was administered for pain of 8 out of 10 and the PRN response indicated the medication was effective. No follow up pain scale rating was provided to show the resident's pain level after the medication. A nurse's note, dated 8/4/25, indicated, Resident frequently stating she has right leg pain. Resident does take Tramadol 50 mg po [by mouth] bid with Tylenol in between. Pending further orders. On 8/8/25 at 10:20 a.m., during an interview Registered Nurse (RN) 7 indicated she would call the physician if a prescription were needed to obtain a narcotic from the Emergency Drug Supply Kit (EDK). If it was on a weekend, they would call the on-call physician to obtain an order. She indicated she would notify the Director of Nursing if pain medication was not effective. She had notified the physician the previous week regarding Resident 43's increased pain and advised the physician medication was not effective. She did not recall when she had the conversation with the physician and acknowledged she had not documented the notification to the physician. On 8/8/25 at 10:30 a.m., during interview the Director of Nursing (DON) indicated she did not know why the Oxycodone was not administered or why the documentation of pain medication lacked follow up pain scale to determine if medication was effective and pain was relieved. On 8/8/2025 at 11:57 a.m., the Administrator provided a document titled, Pain management policy, dated 7/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure 1. Residents are assessed for pain upon admission, weekly and during medication administration as outlined below. 2. The following will be used when assessing pain.ongoing nursing assessments can also be documented in matrix progress notes or matrix vitals. 3. Interviewable resident - Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10).Mild=(1-2) Moderate = (3-5) Severe = (6-8) Very severe, horrible = (9-10).5. The physician will be notified of unrelieved or worsening pain.9. Additional information including, but not limited to reasons for administration, and effectiveness of pain medication will be documented on the Electronic Medication Administration Record (EMAR). On 8/8/2025 at 11:57 a.m., the Administrator provided a document titled, Medication Shortages/Unavailable Medications, dated 1/1/13, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.3. If a medication shortage is discovered after normal pharmacy hours.3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action.5. If the medication is unavailable from the Pharmacy or a Third [NAME] Pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders as necessary. 3.1-37(a)

Based on record review and interview, the facility failed to ensure an influenza vaccination was offered or administered to 1 of 5 residents reviewed for immunizations (Resident 1). Findings include:Resident 1's record was reviewed on 8/11/25 at 10:39 a.m. Census information indicated the resident was hospitalized from [DATE] to 9/17/24, 10/31/24 to 11/1/24, and 11/17/24 to 11/18/24. The resident's preventative health care record, dated 10/31/24, indicated the influenza vaccine was not administered related to other-transferred to hospital for further evaluation. The preventative health care record lacked further documentation regarding the resident's influenza vaccine. Progress notes, dated September 2024 to December 2024, lacked documentation the influenza vaccine was offered or declined during the flu season, or evidence it was clinically contraindicated. During an interview, on 8/11/25 at 1:25 p.m., the Director of Nursing Services (DNS) indicated the resident was not given an influenza vaccine because of her condition. The DNS indicated the resident was hospitalized several times and had nausea and vomiting so it was not administered, but there was no documentation in the resident's record to support the vaccine was clinically contraindicated. It should have been documented. On 8/11/25 at 2:18 p.m., the Administrator provided a document titled, Employee Influenza (Flu) Vaccine Policy, last revised on 9/13/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The Centers for Disease Control (CDC) recommend that all persons aged 6 months and older get vaccinated against influenza unless there are specific medical contraindications as to why they should not. 3.1-13(a)(1)

Based on record review and interview, the facility failed to administer medication according to physician orders and held medications without a physician order for 1 of 5 residents reviewed for unnecessary medications (Resident 6). Findings include:On 8/7/25 at 11:00 a.m., the medical record of Resident 6 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Vascular Accident (CVA) (stroke), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high).A physician order, dated 7/16/25, indicated to administer insulin glargine (the process of administering the hormone, insulin to a person, by injection to help regulate their blood sugar levels) 100 unit/mL (milliliter) (3 mL); amount: 10 units; subcutaneous (under the skin) twice a day.A physician, dated 3/27/25, indicated to administer lispro insulin 100 unit/mL; amt: 8 units; subcutaneous four times a day.A physician order, dated 3/27/25, indicated to administer lispro insulin 100 unit/mL; subcutaneous four times a day, amt: Per Sliding Scale (a measurement to determine amount of insulin to be administered based on the blood sugar reading). If Blood Sugar is 141 to 180, give 1 Units. If Blood Sugar is 181 to 220, give 1 Units. If Blood Sugar is 221 to 260, give 2 Units. If Blood Sugar is 261 to 300, give 3 Units. If Blood Sugar is 301 to 340, give 4 Units. If Blood Sugar is 341 to 380, give 5 Units. If Blood Sugar is 381 to 420, give 6 Units. If Blood Sugar is 421 to 460, give 7 Units. If Blood Sugar is greater than 460, call MD (medical doctor).Review of the Electronic Medication Administration Record (EMAR) from 7/1/25 to 7/31/25 indicated the resident was to be administered insulin twice daily and sliding scale insulin coverage four times per day. The record indicated the resident refused insulin 39 times and the scheduled insulin and sliding scale insulin was held (not administered) 46 times. The EMAR from 8/1/25 to 8/6/25 indicated the resident's insulin was held 10 times and the resident refused insulin 24 times. The physician orders lacked documentation of an order to hold insulin. The record indicated a space was provided on the EMAR to record if the physician was notified. Each entry indicated the physician was not notified.A quarterly Minimum Data Set (MDS) assessment, dated 6/25/25, indicated the resident was severely cognitively impaired. The resident was administered daily insulin and was on the following high risk medications, hypoglycemic medications (medications administered to control diabetes), anticoagulant (blood thinner medication), and diuretic medication medications to reduce the excess fluid in the body). A care plan, dated 3/28/25, indicated resident was at risk for adverse effects of hyperglycemia (high blood sugar), or hypoglycemia (low blood sugar) related to use of glucose lowering medication and/or diagnosis of diabetes mellitusInterventions, dated 3/28/2025, included but were not limited to. Diet as ordered, monitor intakes and offer replacements for 50% or less consumption, medications as ordered, monitor blood sugars as ordered, document abnormal findings, and notify physician.The care plan lacked documentation of medication refusal or interventions.On 8/7/25 at 10:05 a.m., during an interview, the Unit Manager indicated if a resident refused to take their medication she would notify the physician after several refusals. She indicated she would hold insulin if a resident refused or if they were not eating. She indicated she would notify the doctor.On 8/7/25 at 10:17 p.m., during an interview, Licensed Practical Nurse (LPN) 3 indicated if the resident refused insulin she would notify physician and document the refusal and notification in the nurses' notes. She would hold insulin if there was an order to hold it based on the physician order. She would contact the physician before holding. If the resident refused insulin she would notify physician immediately.On 8/7/25 at 10:20 p.m., during an interview, Qualified Medication Aide (QMA) 4 indicated that if a resident refused medications she would document the refusal and ask the nurse to notify the physician if needed.On 8/7/25 at 10:28 a.m., during an interview, the Director of Nursing (DON) indicated the resident refused medications often and the physician was aware.On 8/7/25 at 12:04 p.m., during phone interview with the resident's Physician she indicated she was aware the resident had refused his medications and his insulin numerous times. She indicated she had asked pharmacy to review the medications to determine what could be reduced. She acknowledged she had not given an order to hold insulin if the resident did not eat or to hold insulin if there was a change in condition.The facility was unable to provide a specific policy for notification of refusal of medications or parameters and/or physician orders to hold medications.3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to ensure a physician ordered medication was administered and documented appropriately for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: During an interview on 6/9/25 at 1:35 p.m., Resident B indicated he had not received his nicotine patch 3-4 days last week and then again today. During the interview with Resident B, QMA 3 entered the room with his pain medication and indicated she had not applied his nicotine patch this morning because he had been in therapy. During a follow-up interview on 6/9/25 at 2:20 p.m., Resident B indicated QMA 3 had returned to his room, around 1:40 p.m., shortly after the initial interview and applied his nicotine patch. The clinical record for Resident B was reviewed on 6/9/25 at 12:21 p.m. Diagnoses included displaced right hip fracture with routine healing following surgical intervention, chronic obstructive pulmonary disease, and adjustment disorder with depressed mood. Current signed physician's orders for the resident included, Nicotine patch 21 mg (milligram)/24 hours, apply one patch daily between 7:00 a.m. and 11:00 a.m. Special instructions indicated to remove old patch before applying a new one and to rotate administration sites. The order was dated 5/30/25. A Proof of Delivery record, dated 4/30/25 to 6/9/25, for Resident B included Nicotine 21 mg/24 hour patch, shipped 30 patches on 5/30/25 and received 5/31/25 at 3:32 a.m. A review of the residents electronic medication administration record (eMAR) indicated the nicotine patch had been administered daily per physician's order, beginning on 5/31/25. An administration history record, provided by the DON on 6/9/25 at 3:14 p.m., indicated the nicotine patch had been administered on 6/9/25 at 10:44 a.m. by QMA 3, not the actual administration time of 1:40 p.m. A medication count for Resident B's nicotine patches was completed with QMA 6 on 6/9/25 at 2:05 p.m. QMA 6 indicated there were 23 patches remaining in the medication sleeve. The count according to the eMAR and administration history record, should have been 20 patches remaining in the medication sleeve. During a telephone interview on 6/10/25 at 4:01 p.m., QMA 3 indicated she had administered Resident B's medications at 10:44 a.m., but had forgotten to open the nicotine patch to place on the resident. When she returned to the resident's room, he had gone to therapy and she forgot about it until later in the day. It had been documented as given because she had intended to apply the patch at the time. She realized the medication should not be documented as given until it was administered. The eMAR for the administrations from the previous week was documented accurately and she had provided the patch to the resident. She had no knowledge of the patch not being administered as ordered. During an interview on 6/10/25 at 3:14 p.m., the DON indicated the patch had been pulled from the medication cart with the oral medications on 6/9/25 and had not been administered with his oral medications because he had gone to therapy. She must have forgotten and applied it after 1:00 p.m. and marked it as administered at 10:44 a.m. They prefer staff mark as administered following administration of the medications. She had interviewed the previous week's nursing staff who had documented administering the nicotine patch, and all had indicated they had administered the patch. She could not explain why there were three patches that were unaccounted as being administered remaining in the medication cart. A current facility policy, revised 6/30/23, titled, General Dose Preparation and Medication Administration, provided by the Administrator on 6/9/25 at 3:26 p.m., included the following: Procedure 7. After medication administration, the community should: 7.1 Document necessary medication administration/assistance/observation/treatment information (e.g., when medications are opened, when medications are give, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms or electronic medication records. This citation relates to Complaint IN00460788. 3.1-25(a)

Based on interviews and record reviews, the facility failed to ensure care plan meetings were completed timely for 2 of 24 residents reviewed for care plan meetings (Residents 12 and 24). Findings include: 1. During an interview on 8/12/24 at 11:10 a.m., Resident 12 indicated she could not remember having any care plan meeting in the last three years. On 8/13/24 at 2:24 p.m., Resident 12's record was reviewed. Care plan meeting documentation was located for 5/8/24, 2/13/24, and 9/11/23. The record lacked care plan meeting documentation from between 9/11/23 and 2/13/24. A quarterly Minimum Data Set (MDS) assessment, completed 7/29/24, indicated Resident 12 had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. During an interview on 8/14/24 at 10:39 a.m., the Social Services Director (SSD) indicated she might have done the assessment but did not complete the meeting note. During an interview on 8/14/24 at 11:17 a.m., the SSD indicated that she did not have any notes, documentation, or proof that the care plan meetings happened on paper or in the electronic medical record. During an interview on 8/14/24 at 12:01 p.m., the SSD indicated she did not do the care plan meetings at the time of the bedside assessments. She returned at another time to talk to do them. They did not use the care conference tab located in the electronic medical record. 35317 2. During an interview, on 8/12/24 at 9:55 a.m., Resident 24 indicated he did not remember being invited to or attending a care plan meeting recently. He could not recall when the last one was. Resident 24's record was reviewed on 8/13/24 at 1:47 p.m. A significant change in status, Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A Care Plan Summary note, dated 4/17/24 at 4:26 p.m., indicated a care plan meeting was conducted on this day for Resident 24. A Care Plan Summary note, dated 6/19/24 at 9:44 a.m., indicated a care plan meeting was conducted on this day for Resident 24. Resident 24's record lacked documentation of a quarterly care plan meeting being conducted between the months of August 2023 and April 2024. During an interview, on 8/14/24 at 11:56 a.m., Social Service Director (SSD) indicated the care plan meetings were to be conducted annually and quarterly. The SSD was unable to provide documentation that Resident 24 care plan meetings were conducted on a quarterly basis and that she must have forgotten to document the care plan meeting in his chart. During an interview, on 8/15/24 at 10:20 a.m., the Administrator indicated they do not have documentation to show where the care plan meetings were conducted quarterly. She further indicated it was their company policy that the SSD would open an observation and complete the documentation in the computer system when the care plan meetings were conducted. On 8/14/24 at 12:13 p.m., the SSD provided a document, with a revised date of 8/23, titled, IDT Comprehensive Care Plan Policy, and indicated it was the current policy being used by the facility. The policy indicated, .Resident, resident's representative, or others as designated by resident will be invited to care plan review. The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and or representative preference. Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(e)

Based on observation, record review, and interview, the facility failed to ensure a self-administration assessment had been completed for a resident who was observed to self-administer her medications for 1 or 1 random observation (Resident 15). Findings include: During a random observation of the breakfast meal in the main dining room, on 8/12/24 at 7:40 a.m., a medication cup containing 4 pills sat on the table in front of Resident 15. She self-administered the medications when her tray was delivered. No staff were present to observe the resident self-administer her medications. Resident 15's record was reviewed on 8/15/24 at 9:19 a.m. The profile indicated the resident's diagnoses included, but were not limited to, essential hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (a condition that occurs when the heart can't pump enough blood and oxygen to the body) and age-related macular degeneration (an eye disease that causes a breakdown of cells in the center of the retina, which is the light-sensitive tissue at the back of the eye). A quarterly Minimum Data Set (MDS) assessment, dated 7/17/24, indicated the resident had severe cognitive deficit and received medications, which included, but were not limited to, diuretic (a drug that increases the amount of urine the kidneys produce, helping the body get rid of extra fluid and salt) and antiplatelet (medications that prevent platelets from sticking together and forming blood clots). A review of the resident's record including assessments lacked documentation of an assessment to determine the resident's ability to self-administer medications. A review of the resident's record including care plans lacked documentation of her ability to self-administer her own medications. A review of the resident's record including physician's orders lacked documentation of an order for Resident 15 to self-administer her medications. A physician's order, dated 5/21/24, indicated to administer one 75 milligram (mg) tablet of clopidogrel (antiplatelet medication), one time a day. A physician's order, dated 5/21/24, indicated to administer one 20 mg tablet of furosemide (diuretic medication), one time a day. A physician's order, dated 5/21/24, indicated to administer one 50 mg tablet of metoprolol succinate (antihypertensive medication), one time a day. A physician's order, dated 6/12/24, indicated to administer one Preservision AREDS 2 tablet (medication to treat moderate to advanced macular degeneration), one time a day. During an interview, on 8/12/24 at 9:29 a.m., the Resident 15 indicated she requested the nurses to leave her pills on her table for her to take later because she took a water pill. If she took the water pill prior to coming down for her meal, she ended up having to go to the bathroom in the middle of her meals. Some of the nurses had been leaving them on her table, but the nurse on the evening shift refused to leave the pills on the table for her. During an interview, on 8/15/24 at 10:12 a.m., the Director of Nursing (DON) indicated there were not any residents in the facility that self-administered their own medications. The nurses should know better than to leave medications for any resident to take without their supervision. During an interview, on 8/16/24 at 10:39 a.m., Licensed Practical Nurse (LPN) 16 indicated the residents must always be supervised when giving medications. During an interview, on 8/16/24 at 10:45 a.m., LPN 17 indicated medications should never be left for a resident to take unsupervised. On 8/15/24 at 10:38 a.m., the DON provided a document, with a revision date of 1/2015, titled, Self Administration of Medications, and indicated it was the policy currently in use by the facility. The policy indicated, .Procedure .If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. A physician order will be obtained specifying the resident's ability to self-administer medications .The resident will be assessed for continued self-administration of medications quarterly and with any significant change of condition. The resident's care plan will be updated to include self-administration 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure medication storage areas were free from personal drinks, and failed to ensure expired medication was disposed of (Resident 38) for 2 of 4 medication carts reviewed for medication storage. Findings include: 1. During observation of medication storage and labeling on 8/15/24 at 10:58 a.m., in the bottom drawer of the A-hall medication cart, observed a plastic restaurant cup with a label on the outside indicating it to be iced coffee from 8/15/24. The drink was stored amongst residents medications. During an interview with Licensed Practical Nurse (LPN) 16 on 8/15/24 at 10:59 a.m., she indicated the drink belonged to her, and food or drink were not to be stored inside the medication carts. During an interview with the Administrator (ADM) on 8/16/24 at 9:57 a.m., she indicated staff were not supposed to have personal drinks in patient care areas, including the medication carts, and were supposed to keep them in the break room. 2. During an observation of medication storage and labeling on 8/15/24 at 11:19 a.m., in the top right drawer of the C-hall medication cart, observed latanoprost 0.005% eyedrops for Resident 38 with an opened date of 7/2/24. During an interview on 8/15/24 at 11:20 a.m., Licensed Practical Nurse (LPN) 10 indicated that she knew the eye drops were out of date, they were only good for six weeks after opening, and she had already ordered more. During an interview on 8/15/24 at 11:38 a.m., LPN 10 indicated she confirmed with the pharmacy that the eye drops were only good for six weeks after opening. They had been ordered, but the pharmacy did not get them delivered in time, they were on their way today. On 8/16/24 at 10:15 a.m. Resident 38's record was reviewed. Her diagnoses included, but were not limited to, acquired absence of eye (surgical removal of the eye), glaucoma (occurs when fluid builds up in the front part of the eye, increasing the pressure and causing damage to the optic nerve), and history of endophthalmitis (a serious infection of the fluid within the eye), A physician's order, dated 3/7/24, indicated to administer latanoprost 0.005% (medication used to decrease pressure in the eye) ophthalmic (eye), one drop at bedtime. A medication administration record (MAR) for Resident 38 indicated that the latanoprost 0.005% ophthalmic was administered on 8/13/24, 8/14/24, and held on 8/15/24 due to the medication not being available, with a comment that indicated they were waiting on arrival from the pharmacy. During an interview with LPN 10 on 8/16/24 at 10:22 a.m., she indicated a new bottle of eyedrops was delivered, they used the new bottle last night and it was dated. The last day the eyedrops should have been used was 8/13/24. Anything documented as given after that should have been documented as giving expired medications until the new bottle arrived. On 8/15/24 at 11:55 a.m., the LPN 10 provided a document with a revision date of 6/30/23 and identified it as the current facility policy, titled, Storage and Expiration Dating of Medications, Biologicals. The policy indicated, .3.5 The community should ensure food is not stored in the refrigerator, freezer or general storage areas where medications and biologicals are stored .4. The community should ensure that medications and biologicals that .(2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier 3.1-25(o)

Based on interview and record review, the facility failed to ensure the Qualified Medication Aide (QMA) followed proper standards of practice for 1 of 1 residents reviewed for pressure ulcer care (Resident 218). Findings include: During an interview, on 8/12/24 at 9:29 a.m., Resident 218 indicated she had several open areas to her bottom, and they had been there since before her admission to the facility. She acquired the areas while living at home. During an interview, on 8/14/24 at 7:50 a.m., QMA 3 indicated Resident 218 was getting ready to take a shower and therefore she would not be doing the dressing change until after her shower. She further indicated the dressing changes would be completed by the wound Nurse Practitioner, the Assistant Director of Nursing, or other staff working the hall. During an interview, on 8/14/24 at 8:30 a.m., Resident 218 indicated QMA 3 had completed her pressure ulcer dressing changes before to her bottom. Resident 218's record was reviewed on 8/13/24 at 2:23 p.m. The profile indicated the resident diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and wedge compression fracture of T11-T12 vertebra (a type of vertebral compression fracture that occurs when the bone in the front of the spine column collapses and loses height resulting in a wedged shape). An admission minimum data set (MDS) assessment dated [DATE], indicated the resident was cognitively intact and had one stage 3 (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer, two unstageable (when the stage is not clear due to the base of the wound being covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure ulcers, and three deep tissue injuries (purple or maroon area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear). A physician order, dated 8/5/24 with no end date, indicated to cleanse wounds to gluteal cleft, left and right gluteal folds with normal saline, apply skin prep to peri wound (the area of tissue surrounding a wound), apply medical grade honey (natural, non-toxic agent that can be used to treat wounds) to wound beds, cover with bordered foam, and change daily and as needed. A care plan, dated 8/5/24, indicated the resident had impaired skin integrity: Pressure injuries to gluteal cleft (a deep groove that runs between the buttocks from the sacrum to the perineum), right gluteal fold (a horizontal crease in the skin that separates the upper thigh from the buttocks), left gluteal fold, left heel, right heel, and left 5th toe related to wedge compression fracture of the thoracic vertebra, history of falls, and generalized weakness. Interventions included but were not limited to, assess wound weekly documenting measurements and description, float heels while in bed, and treat as ordered by physician. A skin and wound note, dated 8/7/24 at 9:01 a.m., indicated the following pressure wounds: a. An unstageable pressure ulcer to left gluteal fold. The wound measures 3 by (x) 2 cm (centimeters) with a depth of 0.1 cm. b. A stage 3 pressure ulcer to right gluteal fold. The wound measures 1.5 x 0.5 cm with a depth of 0.1cm. c. An unstageable pressure ulcer to coccyx. The wound measures 2 x 1.5 cm with a depth of 0.1 cm. During an observation, on 8/14/24 at 9:48 a.m., the Assistant Director of Nursing (ADON) removed an old dressing to Resident 218's left gluteal wound. The dressing had no date or staff initials on it. During an observation, on 8/14/24 at 9:56 a.m., the ADON removed an old dressing to the resident's coccyx and the dressing only contained a date of 8/13. There were no staff initials on the old dressing. During an observation, on 8/14/24 at 10:04 a.m., the ADON removed an old dressing to the resident's right gluteal fold and the dressing only contained a date of 8/13. There were no staff initials on the old dressing. During an interview, on 8/14/24 at 10:09 a.m., the ADON indicated nursing staff should place a date and their initials on the dressing when it was completed. Review of August 2024, Treatment Administration Record (TAR) indicated QMA 3 documented as completing the dressing changes to Resident 218's pressure wounds 4 out of 9 days. During an interview, on 8/14/24 at 10:52 a.m., Director of Nursing (DON) indicated QMAs were only allowed to do stage 1 dressing changes and anything over stage 1 must be completed by licensed nursing staff. During an interview, on 8/14/24 at 11:36 a.m., QMA 7 indicated she was allowed to do dressing changes on wounds that were a stage 1 or less. They were not allowed to do dressing changes on anything over a stage 1. During an interview, on 8/14/24 at 1:58 p.m., the DON indicated QMA 3 was questioned and the QMA thought she had accidently selected the complete all button when she was administering medications to Resident 218. The QMA indicated that explained how her initials got into the box as completing the dressing changes. The DON indicated when staff placed their initials in the documentation box that would be taken as they were the person who completed the treatment. On 8/14/24 at 1:55 p.m., the Administrator provided a document with a revised date of 07/23, titled, Dressing Change Clean Technique, and indicated it was the current policy being used by the facility. The policy indicated, .date and initial new dressing On 8/14/24 at 1:55 p.m., Administrator provided a document with a revised date of 07/24, titled, QMA Parameters and Scope of Practice, and indicated it was the currently policy being used by the facility. The policy indicated, .At no time should a QMA .8. Administer a treatment that involves an advanced skin condition, including Stage II, III, and IV pressure ulcers 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure proper food handling for 1 of 2 dining observations and failed to ensure proper handwashing for 3 of 3 dining observations. Findings include: 1. During a dining observation, on 5/30/23 at 11:32 a.m., Activity Assistant 14 was preparing drinks for the residents. She scooped ice into 2 glasses and returned the scoop into the ice bucket. The Activity Assistant served the drinks to 2 residents and returned to the cart to prepare more drinks. At 11:41 a.m., the ice scoop remained in the ice bucket. At 11:43 a.m., another staff member approached the ice bucket and placed the ice scoop into an empty pitcher next to the ice bucket. During an interview, on 6/5/23 at 11:01 a.m., the Culinary Manager indicated staff were not to leave the ice scoop in the ice bucket. They were to return it to the empty pitcher on the cart by the ice bucket. On 6/5/23 at 1:37 p.m., the Executive Director provided a document, dated 2/02 with a revised date 5/23, titled. Food Storage, and indicated it was the policy currently used by the facility. The policy indicated, .Scoops are not to be stored in the food 2. During a dining observation of the closed unit, on 5/30/23 at 12:15 p.m., Activity Assistant 5 was observed to wash her hands for less than 20 seconds and touched the faucet handles with bare hands, without paper towels, when turning off the water. Activity Assistant went to the food cart to begin serving trays to the residents. 3. During a dining observation of the closed unit, on 6/1/23 at 9:19 a.m., Certified Nursing Aid (CNA) 4 was observed to wet a washcloth at the sink. She proceeded to add soap to the washcloth and touched the faucet handles with bare hands, without paper towels, when she turned off the water. CNA 4 then went to the table and placed the washcloth down by the resident she assisted with the breakfast meal. The washcloth was later used to clean Resident 18's face and hands. During an interview, on 6/2/23 at 9:31 a.m., CNA 11 indicated staff were to wash their hands for a total of 40-60 seconds and they were to turn off the faucet handles by using a paper towel. Staff were not to touch the faucet handles with their bare hands. During an interview, on 6/2/23 at 10:47 a.m., the Culinary Manager indicated staff were not to touch the faucet handles with their bare hands and the process of handwashing should last 40-60 seconds in total. On 6/2/23 at 11:35 a.m., the Culinary Manager provided a document, dated 3/18 with a revised date 12/21, titled, Hand Hygiene Policy, and indicated it was the policy currently used by the facility. The policy indicated, .To provide a standardized approach to hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees 3.1-21(a)(3)

Based on observation, record review, and interview, the facility failed to ensure Activities of Daily Living (ADL, activities related to personal care) were completed for 4 of 24 residents reviewed for ADL care (Residents 57, 15, 34, and 38). Findings include: 1. During the initial observation of Resident 57, on 5/3/23 at 12:14 p.m., the resident was sitting in the dining room for her lunch meal. The resident was observed to have long chin hairs. During a random observation, on 5/31/23 at 10:10 a.m., the resident was observed during an activity in the dining room. The resident was observed to have long chin hairs. During a random observation, on 6/2/23 at 11:42 a.m., the resident was observed in dining room for her lunch meal. The resident was observed to have long chin hairs. During a random observation, on 6/5/23 at 9:31 a.m., the resident was observed sitting in the lounge area next to the bird aviary. The resident was observed to have long chin hairs. Resident 57's record was reviewed on 6/2/23 at 11:44 a.m. The profile indicated the resident's diagnoses included, but were not limited to the need for assistance with personal care. A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), on 4/20/23, indicated the resident had no cognitive deficit and required extensive assist of 1 with personal hygiene and was totally dependent with bathing. A care plan, dated 1/28/23, indicated the resident required assistance with ADLs. An intervention, dated 2/1/23, indicated to provide assistance with dressing, grooming, and hygiene. Review of shower sheets, dated 3/3/25 to 5/30/23, indicated the resident had been shaved on 4/14/23. The shower sheets lacked documentation of shaving having been completed on any other dates. During an interview, on 6/5/23 at 9:36 a.m., Certified Nursing Assistant (CNA) 12 indicated the resident's chin hair should have been removed during her daily care or during her showers. She could not remember a time when the resident refused her care. She was unsure why the care had not been completed. 48226 2. On 5/30/23 at 12:05 p.m., Resident 15 was observed during lunch meal in the main dining room with dark debris under her fingernails while feeding herself with her bare hands. On 6/1/23 at 11:00 a.m., Resident 15 was observed in the main dining room with dark debris under her fingernails. On 6/2/23 at 9:42 a.m., Resident 15 was observed with dark debris under her fingernails. On 6/5/23 at 11:45 a.m., Resident 15 was observed in dining room with dark debris under her fingernails. On 6/6/23 at 9:00 a.m., Resident 15 was observed sitting outside the front of the building in a wheelchair with dark debris under her fingernails. On 6/1/23 at, 2:17 p.m., Certified Nursing Assistant (CNA) 15 indicated, Resident 15 required total assistance for activities of daily living (ADL) (activities related to personal care to include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and staff were to trim and clean the residents' nails as needed. On 6/02/23 at 9:45 a.m., the Activity Director indicated the activity department staff provided nail care on Wednesdays and Sundays. If a resident's nails were soiled, staff would clean the nails and apply polish if the resident wanted it done. At times, when the residents were in bed, the activities department staff were not able to get the residents' nails done. On 6/2/23 at 9:51 a.m., CNA 7 indicated, she was supposed to clean the residents' nails during showers and when needed. On 6/2/23 at 9:56 a.m., the DON indicated the ADL care including nail care and shaving facial hair was normally done on the resident's shower days as the resident allowed it. The clinical record for Resident 15 was reviewed on 5/30/23 at 1:00 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks) and need for assistance with personal care. A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/13/23, indicated the resident was an extensive assist for ADLs including bed mobility, transfers, eating, toileting, bathing, and personal hygiene assistance from the staff. A care plan, dated 3/8/22, indicated the resident required assistance with ADLs including bed mobility, transfers, eating and toileting with a goal of the resident had a desire to improve current functional status. Review of the shower sheets from 5/2/23 to 5/31/23, indicated the resident received a total of 14 showers with nail care provided 7 times. 3. On 5/30/23 at 12:00 p.m., Resident 34 was observed during the noon meal in the main dining room with dark debris under her fingernails. On 6/1/23 at 11:00 a.m., Resident 34 was observed in the main dining room her fingernails were soiled with dark debris under the fingernails. On 6/5/23 at 11:45 a.m., Resident 34 was observed in the main dining room with dark debris under her fingernails. On 6/6/23 at 9:00 a.m., Resident 34 was observed sitting outside in the front of the building in a wheelchair with her fingernails heavily soiled under the nails with dark debris. On 6/2/23 at 9:50 a.m., the Activity Director indicated the activity department staff provided nail care on Wednesdays and Sundays. If a resident's nails were soiled, the activity staff would clean the fingernails and apply polish if the resident wanted it done. At times, when the residents were in bed, the staff were not able to get the residents' fingernails done. On 5/30/23 at 1:30 p.m., the clinical record for Resident 34 was reviewed. Diagnoses included, but were not limited, hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (a relatively mild loss of strength) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left non-dominant side, contracture of muscle left forearm, contracture of muscle left hand, muscle weakness, and need for assistance with personal care. A care plan, dated, 10/19/22, indicated Resident 34 enjoyed self-care of going to the beauty shop and the ability to express her preferences with a goal of the resident strengths will be maintained and encouraged. A care plan, dated 7/24/2018, indicated Resident 34 required staff assistance with ADLs including bed mobility, transfers, eating and toileting, with a goal of the resident had a desire to improve current functional status. Review of the shower sheets, from 5/1/23 to 5/29/23, indicated the resident received a total of 4 showers, refused 5 showers, and received nail care on one day. 4. On 5/31/23 at 9:58 a.m., Resident 38 was observed with dark debris under her fingernails. On 6/2/23 at 11:39 a.m., Resident 38 was observed with dark debris under her fingernails. On 6/5/23 at 12:00 a.m., Resident 38 was observed with dark debris under her fingernails. On 6/2/23 at 11:41 a.m., Resident 38 was observed sitting in a wheelchair in the main dining room at a table waiting on the noon meal service with dark debris under the resident's fingernails. Registered Nurse (RN) 17 indicated the Resident 38's fingernails were dirty with dark debris and should be soaked and cleaned to remove the debris. On 5/30/23 at 2:00 p.m., the clinical record for Resident 38 was reviewed. Diagnoses included, but were not limited, muscle weakness (generalized), atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain or discomfort that keeps coming back) and (a condition which affects the arteries that supply the heart with blood. It is usually caused by atherosclerosis which is a buildup of plaque inside the artery walls). A quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/27/23, indicated, the resident required extensive assistance which included assistance with personal hygiene care, nutrition, hydration, bathing and dressing. A care plan, dated 4/20/23, indicated the Resident 38 required assistance and/or monitoring AM/PM care, nutrition, hydration, and elimination with an intervention included, but not limited to, the resident will have activities of daily living (ADL) which included assistance with personal hygiene care, nutrition, hydration, bathing, and dressing. Review of the shower sheets from 5/1/23 to 5/29/23, indicated the resident received a total of 13 showers and nail care was provided on 11 days. On 6/2/23 at 1:48 p.m., the Executive Director provided and identified a document as a currently facility policy, titled Resident Rights, revised dated 11/16. The policy indicated, .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag did not touch the floor and staff failed to follow the proper procedure for changing a urinary drainage leg bag (a urinary drainage device attached to the resident's leg) to a standard urinary drainage bag for 1 of 1 resident reviewed for catheter care (Resident 55). Findings include: On 5/30/23 at 3:30 p.m., Resident 55 was observed sitting in a wheelchair with a urinary catheter drainage bag within a dignity bag (a cloth bag that covered the urinary catheter drainage bag) laying on the floor under the wheelchair. On 6/1/23 at 11:16 a.m., during an observation the resident was lying in a bed and the resident's catheter drainage bag and tubing was on the floor next to the bed. On 6/2/23 at 12:00 p.m., Certified Nurse Aide (CNA) 3 was observed removing an unbagged used urinary drainage bag from a grab bar in the resident's shared bathroom. CNA 3 detached Resident 55's urinary drainage leg bag tubing from the urinary catheter tubing and placed the drainage leg bag tubing on the bed, then attached a standard urinary drainage bag without cleaning the urinary drainage bag tubing tip with alcohol prior to attaching to the catheter tubing. At the same time CNA 3 indicated, she should have washed the urinary drainage tubing tip with hot water and then should have cleaned the tubing with an alcohol wipe, prior to attaching the urinary drainage tubing to the catheter tubing. On 6/5/23 at 11:59 a.m., the Director of Nursing (DON) and Executive Director (ED) were asked if they allowed the urinary drainage bag to touch the floor. The DON indicated, she had never been asked that question before and would have to look for a policy. The clinical record for Resident 55 was reviewed on 5/30/23 at 2:00 p.m. Diagnoses included, but were not limited to, unspecified displaced fracture of fifth cervical vertebra, (a bone broken in the cervical (neck) region of the spine.), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems), and need for assistance with personal care. The quarterly Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/10/23, indicated the resident had an indwelling urinary catheter related to the diagnosis of neuromuscular dysfunction of bladder. A care plan, dated 11/11/2022, indicated the resident had neuromuscular dysfunction of bladder and required a urinary catheter placement. On 6/5/23 at 1:37 p.m., the Executive Director (ED) provided and identified a document as a current facility policy, Titled Nursing, with a revised date of 6/2023. The policy indicated, .Component/Guidelines: .2 Resident Care Equipment .b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bag or tubing from touching the ground .ii. Place soiled equipment in plastic bag .v. Clean and disinfect equipment per facility guidelines .vii. Place cleaned/disinfected equipment in clean plastic bag On 6/5/23 at 1:38 p.m., the Executive Director (ED) provided and identified a document as a current facility policy, titled Converting A Urinary Drainage Bag To A Leg Bag, with a revised date of 3/2012. The policy indicated, .Procedure Steps: .7. Place paper towel or cloth towel under tubing at the point the catheter connects with the urinary drainage bag tubing .10. With the catheter tubing kinked in one hand to prevent urinary drainage during the transition, gently twist the catheter tubing and urinary drainage tubing in an effort to separate the two at the connection .12. Cap the open end of the tubing leading to the urinary drainage bad with an available cap or cover the open end of the tubing with alcohol swabs to prevent contamination .14. Remove the cape on the leg bag drainage tubing and gently insert and secure into the open end of the catheter tubing 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to document, report, and address a skin condition on a resident for 1 of 24 residents reviewed for skin conditions (Resident 28). Findings include: During an initial observation, on 5/30/23 at 12:11 p.m., a faded bruise-like discoloration was observed on Resident 28's left temple area. During a family telephone interview, on 5/31/23 at 9:44 a.m., the resident's family member indicated she was not aware of any incident or a discolored area on the resident's temple. She had visited the week prior and did not notice any skin issues at that time. During an interview, on 5/31/23 at 10:01 a.m., the Director of Nursing (DON) indicated she was not aware of the resident having a discolored area to the side of her head. During the initial pool record review, on 5/30/23 at 2:16 p.m., the record lacked documentation of any event where the resident had received an injury. Resident 28's record was reviewed on 6/2/23 at 10:19 a.m. The profile indicated the resident's diagnoses included, but were not limited to, encephalopathy (any disease of the brain that alters brain function or structure) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A significant change Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/18/23, indicated the resident was rarely/never understood, had no documented behaviors, was total dependence of 2 with transfers, had no fall history and had no documented skin issues. A care plan, dated 5/24/18, indicated the resident was at risk for skin breakdown. An intervention, dated 5/31/23, indicated when resident was agitated, staff were to support resident's head away from Hoyer bar during transfer. A weekly skin assessment, dated 5/28/23, lacked documentation of any discoloration or any abnormal markings on the resident's body/face. An event documentation, dated 5/31/23, indicated a discoloration to the resident's left temple had been discovered. The event lacked documentation of a cause. On 6/1/23 at 2:10 p.m., Licensed Practical Nurse (LPN) 9 provided a document which indicated on 5/25/23, she and a night shift Certified Nursing Assistant (CNA) had been transferring the resident via Hoyer Lift (a device which allows a person to be lifted and transferred with a minimum of physical effort). During the transfer the resident jerked forward and bumped her left temple on the side of the Hoyer lift. A small red mark appeared, but no bruising had been noted. The progress notes lacked documentation of the resident bumping her head on the side of the Hoyer lift and of any red mark as a result. A progress note, dated 6/1/23 at 2:18 a.m., indicated yellow discoloration continued to resident's left temple area. An IDT (Interdisciplinary team) Initial Wound Review progress note, dated 6/1/23 at 7:11 p.m., indicated the type of skin injury was a non-ulcer (i.e. skin tear, rash, bruise, abrasion, lesions, burns, surgical wound, other trauma) was described as yellow/green discoloration to left side of head, temple area. No pain noted. No signs or symptoms of infection. Interventions in place prior to wound / skin injury development included staff assist with ADLs (activities of daily living), transfers .Root-cause determination: hit head on bar of Hoyer lift. New interventions initiated: when resident is agitated, staff to support resident's head away from Hoyer bar during transfer. Therapy referral warranted: No. Current treatment order: observe site for complications. Family and physician had been notified. During an interview, on 6/2/23 at 11:13 a.m., the DON indicated the Executive Director (ED) had begun to look for a policy related to reporting findings when the issue had been brought to the staff's attention. Any new event involving a resident, should be reported and documented immediately. On 6/2/23 at 12:00 p.m., the DON provided a document, dated 7/2020, titled, Documentation Guidelines for Nursing, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To accurately document in an organized manner all information related to the resident in the medical record .8. New skin event: Initiate for any newly identified skin conditions 3.1-37(a)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed and initiated for 2 of 5 residents reviewed for unnecessary medications (Residents 22 and 25). Findings include: 1. Resident 22's record was reviewed on 6/1/23 at 11:36 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), and atherosclerotic heart disease ( a common condition that develops when a sticky substance called plaque builds up inside your arteries). An annual Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 9/6/22, indicated the resident had moderate cognitive deficit and received an anticoagulant medication (a substance that is used to prevent and treat blood clots in blood vessels and the heart). A physician's order, dated 8/30/19, indicated Plavix (clopidogrel-an antiplatelet medicine which reduces the risk of blood clots forming) 75 milligram (mg) tablet, once daily due to atherosclerotic heart disease. A physician's order, dated 6/3/22, indicated Xarelto (rivaroxaban-an anticoagulant medication) 15 mg tablet, once daily for atrial fibrillation. A pharmacy recommendation, dated 3/3/23, indicated the resident received the antiplatelet medication and had not received gastroprotection (protection of gastric tissue against aggressive conditions). The resident had additional risk factors for gastrointestinal (GI-the organs that take in food and liquids and break them down into substances that the body can use for energy, growth, and tissue repair) ulceration (the formation of a break on the skin or on the surface of an organ) which included, but were not limited to, age 65 and concomitant (occurring or existing at the same time as something else) use of anticoagulant medication. The recommendation was to initiate pantoprazole (a type of medicine called a proton pump inhibitor [PPI] which inhibits acid production in the stomach). A historical review of the resident's physician's orders lacked documentation that the pantoprazole had ever been ordered or initiated. During an interview, on 6/2/23 at 10:09 a.m., the Director of Nursing (DON) indicated she was unsure why the recommendation had not been addressed. The recommendations should always be addressed when received. 48226 2. Resident 25's record was reviewed on 6/1/23 at 9:45 a.m., The profile indicated the resident's diagnoses included, but were not limited to, Paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), Gastro-esophageal reflux disease without esophagitis (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). An admission Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) assessment, dated 4/20/23, indicated the resident had moderate cognitive deficit and did not receive an anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart).within the 7 day look back period. A physician's order, dated 12/1/22, indicated Clopidogrel (it prevents platelets (a type of blood cell) from sticking together and forming a dangerous blood clot) 75 mg tablet once daily. A physician's order indicated Xarelto (rivaroxaban-an anticoagulant medication which is used to prevent blood clots from forming due to a certain irregular heartbeat (atrial fibrillation) 15 mg tablet, once daily. Unnecessary medication record review indicated the resident was on Clopidogrel 75 mg daily (QD). Pharmacy recommendation, dated 3/3/23, indicated a recommendation to begin Pantoprazole 20 mg QD. Physician agreed and signed recommendation on 3/30/23. Medical record did not indicate this order was implemented. On 06/01/23 9:58 a.m., the DON reviewed the pharmacy recommendation and indicated she was unable to find supporting documentation in the medical record of the order being implemented. On 6/2/23 at 1:47 p.m., the Executive Director (ED) provided a document, with a revision dated of 3/3/20, titled, LTC (Long Term Care) Facility's Pharmacy Services and Procedure Manual: Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .7. Facility should encourage the Prescriber/Physician .receiving the medication regimen review (MRR) and Director of Nursing (DON) to act upon the recommendations contained in the MRR .8. Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner .11. The attending physician should address the consultant pharmacist's recommendation no later than their next visit to the facility to assess the resident, either 30 or 60 days per applicable regulation 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure residents were addressed in a dignified manner for 3 of 3 residents reviewed for dignity (Residents 18, 30, and 10). Findings Include: 1. During the lunch meal observation, on 5/30/23 at 12:20 p.m., Resident 18 was sitting at the lunch table and was being assisted with eating by Activity Assistant 5. Activity Assistant 5 addressed Resident 18 as Mama. She asked Resident 18, Mama, would you like to take a bite? Activity Assistant 5 proceeded to assist the Resident 18 with eating and asked, Mama, would you like to take a drink? Resident 18's record was reviewed on 6/1/23 at 10:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood. The record lacked a care plan indicating resident preferred to be called Mama. A significant change of status Minimum Data Set (MDS) assessment, dated 3/22/23, indicated the resident had a severe cognitive deficit and required a 1 person to assist with eating. 2. During the lunch meal observation, on 5/30/23 at 12:25 p.m., Resident 30 was sitting at the lunch table and was being assisted with eating by Activity Assistant 5. Activity Assistant 5 had addressed Resident 10 as Mama. She asked Resident 10, Mama, are you hungry? Activity Assistant 5 proceeded to assist the resident with eating and indicated, Mama, I need you to open your mouth to eat the food. Resident 30's record was reviewed on 6/2/23 at 9:58 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dysphagia (difficulty in swallowing), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). The record lacked a care plan indicating resident preferred to be called Mama. A quarterly Minimum Data Set (MDS) assessment, dated 3/27/23, indicated the resident had a severe cognitive impairment and was unable to complete the BIMS (brief interview for mental status) test and required a 2 person assist with bed mobility, dressing, toileting, and transfers. The resident required 1 person to assist with eating. 3. During the lunch meal observation, on 5/30/23 at 12:38 p.m., Resident 10 was observed to be sitting in a chair in the dining room with a small side table in front of her for eating. Activity Assistant 5 spoke with the resident and asked, Mama are you done eating? Activity Assistant immediately laughed and indicated she meant to say her name instead of Mama. Resident 10's record was reviewed on 6/2/23 at 9:54 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to your brain) without behavioral disturbance, hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) and need for assistance with personal care. The record lacked a care plan indicating resident preferred to be called Mama. A quarterly Minimum Data Set (MDS) assessment, dated 4/12/23, indicated the resident had a severe cognitive deficit and required a 2 person assist with bed mobility, dressing, toileting, and transfers. The resident required 1 person to assist with eating. During an interview, on 6/2/23 at 9:35 a.m., Dementia Care Director indicated staff were to address residents by their name unless care planned otherwise. It is not the expectation of the staff to call residents by the name Mama. On 6/2/23 at 1:48 p.m., the Executive Director provided and identified a document as a currently facility policy, titled Resident Rights, revised dated 11/16. The policy indicated, .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care 3.1-3(a)

Based on observation, interview, and record review, the facility failed to ensure the COVID-19 Infection Control vaccination policy and procedures were followed for 7 of 7 contracted staff working in the facility near residents for 6 of 6 days working in the facility. Findings include: On 3/11/22 at 9:50 a.m., during the initial tour of the facility, contractors, wearing medical face masks, were present in the C-wing unit, observed replacing the cove base and lower wall covering in the hall. On 3/11/22 at 10:37 a.m., during the initial tour of the memory care unit, contractors were present in the unit observed replacing the cove base and the lower wall covering. The contractors were present in the dining/activity room area during an activity with five residents present and one resident wandering around the area who was re-directed each time the resident began to walk towards the area where the contractors were working. All the contractors were observed wearing medical face masks. On 3/11/22 at 11:53 a.m., during the lunch meal observation of the memory care unit, the contractors were present prior to the meal trays being passed. Seven residents were present in the dining room and one resident was observed being redirected by staff, when the resident would walk to the area where the contractors were working. The contractors completed their work, left the unit, and exited the building through the front doors of the facility for a lunch break. On 3/14/22 at 1:39 p.m., contractors, wearing medical face masks, were observed in the central hall of the facility by the nurses' station, replacing the cove base and lower wall covering. On 3/14/22 at 1:47 p.m., contractors, wearing medical face masks, were observed in the memory care unit replacing the cove base and lower wall covering. On 3/15/22 at 1:18 p.m., the Administrator (ADM) indicated the lower wall covering had to be replaced due to the covering was not fire resistant and needed to be replaced with a fire-resistant covering. On 3/15/22 at 3:06 p.m., ADM indicated the seven contractors, sent by the facility's corporation, were working in the building on March 7, 8, 9, 10, 11, and 14, 2022. The contractors were screened with the COVID-19 questionnaire prior to entering the building. The contractors were not vaccinated nor tested for COVID-19 and were not exempted by the facility corporation for the COVID-19 vaccinations. On 3/16/22 at 2:38 p.m., ADM indicated the facility staff screened everyone including the contracted staff with the COVID-19 questionnaire. If the contracted staff were not vaccinated, facility staff would ask if they had an exemption with their contracted company. The facility had asked the contracted companies, like hospice companies, to only send vaccinated staff. ADM indicated the contractors, replacing the cove base and lower walls in the facility, were not vaccinated, but did not provide direct care to any of the residents in the facility. On 3/16/22 at 2:52 p.m., the Director of Nursing (DON) indicated all staff were instructed to redirect all residents away from the contractors that were replacing the cove base and lower wall covering in the building. On 3/14/22 at 3:00 p.m., ADM provided and identified a document as a current facility policy, titled COVID-19 Employee Vaccination Requirement, with a revision date of 2/11/22, which indicated, .The Company is committed to the safety and health of our team members, the community and most importantly, the residents we serve. The Company must implement a mandatory vaccination policy requiring COVID-19 vaccination(s) for all employees in all locations for all ASC affiliated healthcare employers. This will include new employees hired as well as all contractors, vendors and students as well as volunteers and trainees who provide any care, treatment or other services for the facility and the Company. This will be in accordance with the US Government's COVID-19 Vaccination Mandate for healthcare workers and the Centers for Medicare & Medicaid Services (CMS) 3.1-18(b)

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 2 of 5 residents reviewed for unnecessary medications (Residents 40 and 8). Findings include: 1. Resident 40's record was reviewed on 3/15/22 at 9:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 2/10/22, indicated the resident had a severe cognitive impairment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order lacked parameters for when the medication should be held. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR, dated March 2022, indicated the [MEDICATION(S)] was not administered on 3/6/22 related to blood sugar 139 and no intake, 3/8/22 related to the resident's condition, 3/9/22 related to resident lethargic and no intake, and 3/12/22 related to fasting blood sugar 101. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 3/15/22 at 1:27 p.m., the Director of Nursing (DON) indicated the insulin should have had parameters to hold the insulin if there were specific instances the physician did not want the medication administered. 2. Resident 8's record was reviewed on 3/14/22 at 1:41 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 3/4/22, indicated the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR, dated March 2022, lacked documentation the [MEDICATION(S)] and [MEDICATION(S)] were administered, offered, or refused at 7:00 a.m., on 3/2/22, 3/7/22, 3/8/22, 3/9/22, 3/12/22, and 3/13/22. During an interview, on 3/15/22 at 9:17 a.m., Licensed Practical Nurse (LPN) 20 indicated medications scheduled to be administered at 7:00 a.m., should have been administered by the day shift nurse. If the medication was not signed off, it was not documented as administered. On 3/15/22 at 1:27 p.m., the Director of Nursing (DON) provided a document titled, .General Dose Preparation and Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information 3.1-48(c)(2)

Based on record review and interview the facility failed to ensure treatments were completed as ordered by the physician for a resident with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 of 1 residents reviewed for pressure ulcers (Resident 53). Findings include: Resident 53's record was reviewed on 3/15/22 at 11:52 a.m. An annual Minimum Data Set (MDS) assessment, dated 6/15/21, indicated the resident had a moderate cognitive impairment and one stage four pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone), present upon admission to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation, dated 2/21/22, titled interdisciplinary team (IDT) wound review, indicated the resident had a stage four pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). The area worsened since the previous week, and the treatment was changed to [MEDICATION(S)] (a gel used to treat wounds and [CONDITION(S)]) with foam dressing change daily and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Treatment Administration Record (TAR), dated February 2022, lacked documentation the [MEDICATION(S)] treatment was offered, refused, or completed to the stage four pressure ulcer to the sacral region on 2/26/22 and 2/27/22. A TAR, dated March 2022, indicated the [MEDICATION(S)] treatment was not applied to the stage four pressure ulcer to the sacral region related to it being unavailable on 3/2/22, 3/3/22, 3/4/22, 3/5/22, 3/6/22, 3/7/22, 3/8/22, 3/9/22, and 3/12/22, but lacked documentation the physician was notified. On 3/11/22, the [MEDICATION(S)] was on back order, would arrive Monday, the physician was aware, but lacked documentation of a new treatment being ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, goal target dated 5/5/22, indicated the resident admitted to the facility with a stage four pressure ulcer that involved the sacrum, coccyx, and spine area. Interventions included but were not limited to treatments to be completed as ordered. During an interview, on 3/16/22 at 9:28 a.m., the Assistant Director of Nursing Services (ADNS) indicated there was an issue with the pharmacy getting the [MEDICATION(S)] delivered to the facility. She was not aware it was an issue until later. The facility now has it in the house stock supply and is Therahoney. The treatment was changed to Therahoney because that is the brand, they were able to obtain. The wound deteriorated on 2/24/22, so the treatment was changed at that time. The wound has not deteriorated since. On 3/16/22 at 11:25 a.m., the Medical Records Nurse provided a document titled, SKIN MANAGEMENT PROGRAM, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: It is the policy of .to ensure that .a resident with a pressure ulcer receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure the grievance policy was followed for a resident with missing personal property for 1 of 1 resident reviewed for personal property (Resident 5). Findings include: During an interview on, 3/11/22 at 10:11 a.m., Resident 5 indicated she had bras and slacks missing. Her daughter had purchased some other clothing items a couple of weeks ago. The staff had taken them to the laundry to mark them with her name, and she had not seen them since. 03/15/22 11:22 AM Resident 5's record was reviewed on 3/15/22 at 11:22 a.m. The record indicated the resident had been admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the events section of the resident's record lacked documentation of any reported missing personal items. A Concern/Grievance Form, dated 3/3/22, indicated the Memory Care Coordinator (MCC) had received a concern from the resident that she only had 6 of 8 bras that were with her at admission. The form indicated the department responsible for the concern was the laundry. The form indicated the MCC had went to the laundry to look for the items but lacked documentation of the laundry department's notification of the missing items. A Concern/Grievance Form, dated 3/16/22, indicated the MCC had received a concern from the resident's family that the resident was missing 2 tops, bras, and several pairs of socks. The form indicated the department responsible for the concern was the laundry. The form lacked documentation of the laundry department's notification of the missing items. During a telephone interview, on 3/17/22 at 9:25 a.m., the resident's family member indicated she had reported missing clothing items to the facility at least 3 weeks or so ago. She had requested to do the resident's personal laundry when she moved in but was told that the facility preferred to do the resident's laundry. The family member figured this was due to COVID-19. The missing items were again mentioned to the facility during a care plan meeting for the resident on 3/16/22. During an interview, on 3/17/22 at 9:29 a.m., the Social Services Director (SSD) indicated she was the person responsible for handling reported concerns of any resident's missing personal property. She had been notified of the resident's missing items, by the resident's family member on 3/3/22. She recommended the family member to report the missing items to the MCC. During an interview, on 3/17/22 at 11:15 a.m., the Laundry Supervisor indicated she had only been notified about the resident's missing items about 1 week prior to the date of this interview. She had been told of the missing items by the Registered Nurse (RN) on the Memory Care Unit. At that time, she went and spoke directly to the resident. When missing items are reported to the laundry, she would first look for the items and, if the items were not found, she would report the missing items so a grievance report could be established. When she was unable to located any of the missing items and had reported it to the MCC on 3/16/22. During an interview, with the Administrator (ADM) and the Director of Nursing (DON), on 3/17/22 at 10:02 a.m., both the ADM and DON indicated they were not aware of the resident's missing items. Any reported missing items should be documented as grievance on the grievance form. All reported grievances would be brought to the morning meeting of the Interdisciplinary Team (IDT) and discussed. The ADM indicated if the missing items had been reported and documented on a grievance form, they should have been brought to the morning meeting and discussed with all members of the IDT. On 3/17/22 at 11:45 a.m., the ADM provided a document, with a revision date of January 2019, titled, Resident Concerns and Grievances, and indicated it was the policy currently being used by the facility. The policy indicated, POLICY: Resident, representative or family concerns/grievances occurring during the resident's stay shall be responded to promptly .the Executive Director/Grievance Official shall review all complaints .PROCEDURE: .The Concern/Grievance Form is then referred to the Department .for review 3.1-7(a) 3.1-7(2)(b)

Based on observation, interview, and record review, the facility failed to ensure CDC guidance during a pandemic and infection control practices for COVID-19 were followed for screening of staff for symptoms of COVID-19 for 1 of 1 random observation of employees entering the facility (Maintenance Supervisor), and proper use of personal protective equipment (PPE) for 3 of 3 random observations of infection control (Licensed Practical Nurse 8, Dietary Aide 14, and Cook 13). Findings include: 1. On 12/4/20 at 11:49 a.m., the Maintenance Supervisor was observed entering the facility through the exit door at the end of hallway E, posted as a red zone. The Maintenance Supervisor was not observed to be screened upon entering the door. He was observed to don a blue isolation gown and enter the room of Resident E. Employee Sign-In Logs, dated 12/4/20, indicated the Maintenance Supervisor was not documented as having been screened. During an interview on 12/4/20 at 12:02 p.m., the front door screener indicated, the Maintenance Supervisor was not working on that day and had not signed in. During an interview, on 12/4/20 at 12:37 p.m., LPN 16 indicted the Maintenance Supervisor had left for lunch. All staff entered the facility daily through the front entrance and were screened. After entering their assigned red hallway, the staff only entered and exited the rest of the day through the end exit of the red hallways. LPN 16 indicated, it was her understanding that staff working the red zones ate lunch in their cars or could go through the drive thru at a nearby restaurant. During an interview, on 12/4/20 at 12:40 p.m., the ED indicated the Maintenance Supervisor had left and was not in the facility. A COVID-19 [MEDICATION NAME] Screening test for the Maintenance Supervisor, dated 11/24/20, indicated positive results. A Course Completion History, dated 2020, indicated the Maintenance Supervisor was documented as having completed electronic education to include, but were not limited to, Closely Monitor Residents for COVID-19 on 7/31/20, Using PPE Correctly for COVID-19 on 8/31/20, CDC Sparkling Surfaces: Stop COVID-19 Spread on 9/30/20, and CDC Clean Hands Combat COVID-19 on 10/31/20. During an interview, on 12/4/20 at 1:40 p.m., the ED indicated the Maintenance Supervisor had not been screening before entering the facility, and although he had been working, there was no recent documentation of him having been screened for signs and symptoms of COVID-19. The ED indicated, the Maintenance Supervisor called and checked in with a temperature before leaving home, but there was no documentation. During an interview on 12/4/20 at 12:03 p.m., Licensed Practical Nurse (LPN) 5 indicated all staff entered though the front door, and had to answer questions regarding COVID-19 symptoms, record their temperature, and sign-in. During an interview, on 12/4/20 at 3:17 p.m., the ED indicated all visitor and staff, including the COVID-19 positive staff, were currently being screened together at the front desk upon entry to the facility. The designated screener and receptionist, which were not socially distanced from those signing in and being screened, were wearing face masks. The screener and receptionist, who were COVID-19 negative, should be safe from the COVID-19 positive staff member as they all wore masks and sanitized their hands. On 12/4/20 at 3:20 p.m., the ED provided the COVID-19 Staff Screening Policy, revision date 7/9/20, and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose: To ensure that every employee is adequately screened for COVID-19. Procedure: A designated staff member will complete the staff screening questionnaire for all employees that will include temperature and screening for symptoms consistent with COVID-19 for each employee that is working at (company name) prior to the start of their shift .All staff will wear a mask while in the facility throughout the duration of their shift. All employees from all departments that are working at the facility will be screened for a temperature, and COVID-19 symptoms prior to the start of their shift .The department leaders or designee should ensure that all employees that were scheduled and worked in the building had a COVID-19 Employee Screening log completed each day. The CDC Guidance. - What you need to know about Coronavirus disease 2020 (COVID-19). Risk of infection with COVID-19 is higher for people who are close contacts with someone known to have COVID-19, for example healthcare workers, or household members .[MEDICAL CONDITION] is thought to spread mainly between people who are in close contact with one another (within about 6 feet) through respiratory droplets produced when an infected person coughs or sneezes. It may also be possible that a person can get COVID-19 by touching a surface or object that has [MEDICAL CONDITION] on it and then touching their own mouth, nose, or possibly their eyes .Prevent the introduction of COVID-19 into your facility. Long-term care centers should take everyday preventive measures to help contain the spread of COVID-19. Actively screen all healthcare personal (HCP), visitors, vendors entering the facility for symptoms of COVID 19 and any history of being a close contact or exposed to COVID 19 positive or symptomatic person. 2. On 12/4/20 at 12:23 p.m. to 12:35 a.m., Licensed Practical Nurse (LPN) 8 was observed on hallway C, posted as a red zone, walking in and out of rooms without protective eye wear, and wearing a face mask modified with a V-shaped cut out over the nose preventing close facial fit. LPN 8 indicated, all residents on the hallway were confirmed positive for COVID-19, and staff were required to wear N95 masks, and face shield or goggles while on the unit. Red zone signs on the entrances to hallways B, C, and D, undated, indicated, Perform hand hygiene before entering and prior to leaving unit. Put on N95 mask and eye protection before unit entry. If using KN95 mask, must use face shield as eye protection. Remove and discard PPE in trash before leaving unit (except mask and eye protection if extended use). Perform hand hygiene before exiting the unit. During the entrance conference with the Executive Director (ED) and Infection Preventionist (IP), on 12/4/20 at 10:15 a.m., the ED indicated hallway C was a red zone (COVIDE-19 positive residents) requiring transmission-based precaution (TBP) isolation. These were residents who were confirmed COVID-19 positive and required health care professionals (HCP) to wear a single gown with each resident, glove, N95 (or approved KN95) mask and eye protection (face shield/or goggles). During an interview on 12/4/20 at 11:57 a.m., Certified Nursing Assistant (CNA) 11 indicated staff on the hallway were supposed to be dedicated to that hallway, but they could leave through the exit door at the end of the red zone hallway, and then enter another red zone hallway. CNA 11 indicated, staff working with residents on a red zone had the option of wearing either goggles or face shields. During an interview, on 12/4/20 at 12:28 p.m., Certified Nursing Assistant (CNA) 10 indicated staff were required to wear a N95 mask and goggles or face shield when providing resident care. 3. On 12/4/20 at 12:42 p.m., three culinary staff members were observed working around each other in the kitchen. They were not socially distanced at least 6 feet apart. Cook 13 was observed without a face mask or eye protection, and Dietary Aide 14 was observed to be wearing a cloth face mask with goggles on top of her head. During an interview on 12/4/20 at 3:35 p.m., the ED indicated direct care staff used N95 masks and goggles or a face shield. Office personnel wore N95 or KN95 masks and goggles, or a face shield when within 6 foot of residents. The dietary staff wore N95 masks and goggles. Staff goggles and face shields were left at the front entrance door in a baggie in totes to store and re-use the next shift. Staff were to don PPE upon arrival to work and doff PPE when they left work. On 12/4/20 at 3:30 p.m., the ED provided the Protective Equipment Requirement Per Zone protocol, undated, and indicated the protocol was the one currently being used by the facility. The protocol indicated, red zone PPE included a N95 mask with eye protection (face shield, goggles, or protective eyewear). CDC Guidance - updated 10/19/20. COVID-19 Positive (Red) - These are residents who are confirmed COVID-19 positive and who, based on CDC criteria, still warrant transmission-based precautions. HCP will wear single gown with each resident, glove, N95 (or approved KN95) mask and eye protection (face shield/or goggles). Gowns and gloves should be changed after every resident encounter followed by hand hygiene: 1. Masks and eye protection may be used for the entire shift if not wet or visibly soiled . This Federal tag relates to Complaint IN 735. 3.1-18(b) 3.1-18 (b)(1)

Based on interview and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent bruising and fractures from falls for 1 of 4 sampled residents reviewed for falls (Resident B). Findings include: Resident B's closed clinical record was reviewed, on 02/13/14 at 1:45 p.m., and indicated the resident was admitted to the nursing facility on 01/02/14 at 6:15 p.m. Resident B's [DIAGNOSES REDACTED]. Resident B's Admission assessment, dated 01/02/14, indicated the resident had not fallen in the last month, had not fallen in the last 2 to 6 months, and expressed no fear of falling. Resident B's Progress Notes, dated 01/03/14 at 6:20 p.m., indicated the resident was found on the floor next to his bed. Resident B had indicated he slid out of bed. The resident was assessed and found with not injuries except for older bruising to left inner thigh. A Progress Note, dated 01/03/14 at 7:20 p.m., indicated the family informed the nurse the resident had fallen at home prior to admission to the nursing facility. The resident's bed was moved against the wall and an alarm monitor was applied to the bed after the resident fell . Progress Notes, dated 01/04/14 at 2:55 a.m., indicated the resident was found with large discoloration to left hip/lower back, left inner upper thigh, left back by shoulder. The resident stated he did not fall. Left arm and leg slightly weaker than right. Progress Notes, dated 01/05/14 at 9:19 p.m., indicated Resident B was admitted to the hospital with [REDACTED]. Interview with the Director of Nursing Services (DNS), on 02/13/14 at 3:45 p.m., indicated she got a phone call from the hospital telling her, the resident was admitted with to the hospital with 2 fractures of the pelvis, 3 fractured ribs, and sepsis. The DNS indicated she started an investigation immediately in efforts to determine the cause of the fractures. The DNS indicated she found the resident had fallen on 01/04/14 during day shift and the fall was not reported to the physician. The DNS indicated the nurse assessed Resident B who denied pain and no injuries were found. The DNS indicated there was no documentation in the clinical record regarding any other falls. Progress Notes, dated 01/08/14 at 12:26 p.m., indicated, "IDT Note: On 1/7/14 at 6:30P, DNS (Director of Nursing Services) notified that resident fell on [DATE] on day shift. Upon investigation, CNA's stated that resident had unwitnessed fall. When CNA asked what had happened, resident's roommate stated that resident attempted to get out of w/c (wheelchair) and fell . CNA's stated that resident was assisted up x (by) 2 staff to w/c with no c/o (complaint of) pain/discomfort noted. Family was made aware of fall later in shift. Physician was notified of fall on 1/8/14 during investigation. On 1/5/14, resident exhibited a decline in condition as evidenced by vital signs, nail beds blue, cool and clammy skin. Physician and family were notified of condition change and resident was sent to hospital for eval. DNS and 2 EMT's transferred resident x 2 assist pivot transfer to gurney which resident was able to do without difficulty. No s/s (signs/symptoms) pain/discomfort noted with transfer. Staff education provided regarding notification and charting r/t (related/to) falls, discipline given...." Review of a written statement by CNA #4, dated 01/04/14 at 9:00 a.m., indicated, "I was in the shower room, (name of Resident B's roommate) came and knocked on the door told me his roommate was on the floor. I immediately ran to see what happened. I saw (Resident B) on the floor in his doorway and called for the nurse. (CNA #5) came down to help along with (LPN #8), the nurse. We rolled him on his back and resident had no marks (sic) bruises or bleeding. Stated that he had to use the bathroom. So me and (CNA #5) picked him up and put him in his wheelchair and I took him to the bathroom. Resident remained in his wheelchair in Activity room until his daughter came and asked us to lay him down and was in bed until lunch and then layed (sic) back down after lunch until our shift ended." The statement indicated the resident stood up out of his chair and tried to push his breakfast tray in the hall. The statement indicated, "...His alarm was sounding, but was not heard by me because I was in the shower room with another resident...I also over heard the nurse (LPN #7) state to not start anymore paperwork on resident since he had fallen less than 24 hrs. (hours) ago." Review of a written statement by CNA #6, dated 01/04/14 at "around 9:00 AM," indicated, "... I overheard (LPN #7) telling (LPN #8) not to fill out the paperwork because they were still completing the forms from his previous fall....." Interview with LPN #3, on 02/13/14 at 11:15 p.m., indicated she did not know about the second fall, but noted the purple bruising on the upper shoulder, hip, and groin areas. LPN #3 indicated she was told Resident B was on neuro checks every hour. Interview with the DON and Administrator, on 02/14/14 at 9:20 a.m., indicated Resident B's alarm had sounded on the second fall, and the roommate had notified the CNA, who was in the spa area with another resident, that Resident B fell . Interview with Resident B's roommate, on 02/14/14 at 11:45 a.m., who had a BIM's score of "13", indicated Resident B was pushing his over the bed table out the door of their room, stumbled at the threshold of the room door, pushed the table out away from him, and fell rolling to right side. Interview with CNA #4, on 02/14/14 at 12:15 p.m., indicated Resident B's roommate came down the hall and called for help. CNA #4 indicated the resident's bed alarm was sounding, the resident was lying on his left side in the bedroom doorway with his head into the hallway. CNA #4 indicated she saw a bruise on his right side and on his lower back by his hip area. Review of the facility's Fall Management Program, with last revised date of 09/2013, indicated, "POLICY It is the policy ... to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls. ... A care plan will be developed at time of admission specific to each resident based upon the results of the fall risk assessment. ... Post Fall 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and provide necessary treatment. * A neurological assessment will be initiated on all un-witnessed falls * A neurological assessment will be initiated on all residents hitting their head. 2. If the resident experienced an injury from the fall, contact facility DNS/ED (Director of Nursing Services/Executive Director) per facility policy. 2. The physician will be contacted immediately, if there are injuries, and orders will be obtained. * If there are no injuries, notify the physician during normal business hours 3. The family will be notified immediately by the charge nurse of falls with injury. * If there are no injuries, notify the family during the day or evening hours (if a fall occurred during the middle of the night, wait until morning) 4. A fall circumstance report will be initiated as soon as the resident has been assessed and cared for. * The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. * An entry will be completed in the nurses' (sic) notes addressing the fall, any injuries, physician and family notification, and interventions initiated. 5. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls. * The fall circumstance report will be reviewed by the team * A CQI form will be completed for necessary follow-up * The care plan will be reviewed and updated, as necessary." This federal finding is related to Complaint IN 788. 3.1-45(a)(2)