Every finding on record at Coventry Meadows

Based on interview and record review the facility failed to ensure staff were present during a change of condition to prevent a fall for 1 of 3 residents reviewed (Resident B).Findings include:A fall investigation file was provided by the Assistant Director of Nursing (ADON) on 3/4/26 at 9:45 AM. The file included the following:A report, dated 2/9/26, indicated Resident B was assisted to the toilet by a Certified Nursing Assistant (CNA) and began to vomit. The report indicated the aide left Resident B on the toilet alone and went to get assistance from the nurse. Upon return the nurse and CNA found Resident B face first on the floor with a laceration to the right side of Resident B's head. Resident B indicated he passed out and didn't remember what happened. The report indicated Resident B was sent to the hospital.A fall event report, dated 2/8/26 at 10:46 AM, indicated Resident B had an unwitnessed fall. The report indicated Resident B was found lying on the bathroom floor on his stomach with his head facing the wall.A fall investigation report, undated, indicated on 2/8/26 Resident B had an unwitnessed fall in the bathroom. The resident had been assisted to the bathroom by a CNA and began to vomit along with diarrhea. The report indicated the aide left Resident B on the toilet and went to get the nurse for assistance. Upon return the nurse and CNA found Resident B lying on the bathroom floor on his stomach with his head facing the wall. The report indicated Resident B indicated he passed out and didn't remember what happened. The report indicated Resident B had a laceration to the right side of his head with vomit present on the floor. The report indicated Resident B required assistance with a wheelchair.Resident B's record was reviewed on 3/4/26 at 9:30 AM. Diagnoses included amputation to left great toe, chronic kidney disease, asthma, hypertension and anemia.An admission fall risk assessment, dated 1/14/26, indicated Resident B was at moderate risk for falls.An admission care plan, dated 1/14/26, indicated Resident B was at risk for falls and required assistance or supervision for mobility, transfer or ambulation.An admission Minimum Data Set (MDS) assessment, dated 1/14/26, indicated Resident B had a Brief Interview Mental Status score of 15/15 (cognitively intact).An admission functional abilities collaboration report, dated 1/14/26, indicated Resident B needed partial to moderate assistance with toileting and transferring.A nursing note, dated 2/6/26, indicated Resident B participated in therapy and required 1-2 person assistance with transfers.A nurse practitioner note, dated 2/2/26, indicated Resident B tested positive for Clostridioides difficile (C-Diff) on 1/30/26 and an antibiotic was started. The note indicated Resident B's labs were monitored and intravenous fluids were administered.A nurse practitioner note, dated 2/8/26, indicated Resident B reported improvement in loose stools and the labs were improving. The note indicated the resident denied any nausea nor vomiting at the time of the visit.An interdisciplinary note, dated 2/8/26, indicated Resident B had been assisted to the toilet by a CNA and began vomiting. The note indicated CNA left Resident B alone on the toilet and left to get assistance from the nurse. The note indicated upon return the nurse found the resident had fallen off the toilet and was face first on the floor with blood pooling from the right side of his head. The note indicated Resident B indicated he did not remember what happened. The note indicated prior to the fall the resident was last assisted at 10 AM to the toilet.Emergency Department medical records from an area hospital, dated 2/10/26, indicated Resident B was transferred to the hospital on 2/8/26 due to a fall off the toilet at the facility. The records indicated the cause of the fall was due to hypovolemia (dehydration) and vasovagal response (fainting). During an interview, on 3/4/26 at 10:21 AM, CNA 3 indicated when the resident had a change of condition, such as vomiting, while on the toilet, the aide should never leave the resident. CNA 3 indicated the call light should be activated or call out for the nurse should be completed. CNA 3 indicated when an aide left the resident on the toilet after vomiting, the resident could fall.During an interview, on 3/4/26 at 10:23 AM, Licensed Practical Nurse (LPN) 4 indicated when a resident had a change of condition, such as vomiting while on the toilet, the aide should never leave the resident. LPN 4 indicated the aide should call out for help or activate the call light.During an interview, on 3/4/26 at 10:50 AM, the ADON indicated Resident B experienced diarrhea due to C-diff but the vomiting was new as of 2/8/26. The ADON indicated staff left residents alone on the toilet when the staff felt the residents were safe.A policy, last revised 6/25, titled Fall Management Policy, was provided by the ADON on 3/4/26 at 11:11 AM. The policy indicated all new admission residents are considered a fall risk due to the new environment.This citation relates to Intakes 2740759 and 2739739.483.25(d)(1)(2)- 3.1-45(a)

Based on record review and interview, the facility failed to ensure a follow up to an unwitnessed fall was completed for 1 of 1 residents reviewed. ( Resident 3)Findings include:A record review began on 7/21/25 at 10:32 AM, Resident 3's diagnosis included, other cerebral infarction due to occlusion or stenosis of small artery.A review of progress notes dated 4/19/25 at 2:54 PM, indicated Certified Nursing Aide (CNA) 6 reported to writer, Resident 3 was lying on the floor mat. She noted a right wrist purple bruise, assisted resident back to bed with help from 3 staff. The immediate intervention initiated was to encourage Resident 3 to use the call light for assistance. A review of event report, dated 4/19/25 at 2:50 PM, indicated a new skin event for right wrist bruising was completed.There were no other events or reports completed for this unwitnessed fall.In an interview on 07/23/25 at 12:05 PM, the Director of Nursing (DON) indicated they are unable to locate a fall event or any information regarding the fall. The DON indicated they were unable to locate neurological checks or any other assessments related to the fall. A current facility policy, titled Fall Management Policy, dated 3/24, was proved by the DON on 7/24/24 at 10:28 AM. The policy indicated . A fall event will be initiated as soon as the resident has been assessed and cared for .The report will be completed in full to identify possible root cause of the fall and provide immediate interventions 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident's right to be free from physical abuse was protected for 1 of 3 resident's reviewed (Resident B). The deficient practice was corrected on 10/24/24 prior to the start of the survey and was therefore past non-compliance. Findings include: An Indiana Department of Health (IDOH) incident report, dated 10/22/24 at 6:20 p.m., indicated the Administrator had been notified, Certified Nurse Aid 5 (CNA) had made contact with Resident B while he had been combative with staff. The resident's safety had been insured and he was provided quiet space. CNA 5 was immediately sent home and removed from the schedule pending investigation. On 11/6/24 at 11:06 A.M., Resident B's record was reviewed. Diagnoses included severe dementia with behavioral disturbance, mood disorder, and restlessness and agitation. A quarterly Minimum Data Set (MDS) assessment, dated 10/7/24, indicated the resident had severely impaired cognition. He required moderate to fully dependent care from staff for his activities of daily living. He resided on the secured memory care unit and was prescribed a mood stabilizer for his behaviors. A care plan, revised 10/15/24, indicated the resident had behavioral symptoms. He would hit staff when care was being provided and at times, had episodes of kicking, hitting, and grabbing staff's arms and fingers during care. The goal was for his behaviors to be altered with staff interventions. Interventions were: notify spouse to bring photo of herself to help calm him when he was agitated; allow resident time to calm; attempt care at a later time and with different care giver; and observe for indicators of pain. A care plan, revised 10/15/24, indicated the resident displayed anxious behaviors and at times, would try to hit staff when told to sit down so he wouldn't fall. Interventions were: offer to lay down; medication per order; assist him to go for a walk when he appeared anxious and was attempting to stand on his own; assist him with activities of his interest as a distraction-he liked listening to oldies, eating snacks, and being outdoors; talk calmly to the resident and explain to him to sit down so he doesn't fall and redirect. On 11/6/24 at 1:48 P.M., the Administrator was interviewed. She indicated, on 10/22/24, she had been notified by a staff member, they had witnessed an event. The Resident B had been agitated and hit CNA 5. CNA 5 then struck Resident B with an open hand on the back of his right shoulder while he was seated in the dining room. The Administrator came to the building, interviewed CNA 5 who indicated she was assisting the resident to eat dinner when he had punched her in the stomach. She swatted him back as a reflex but had not intended to harm the resident. CNA 5 was suspended pending investigation. Resident B was assessed, found with no injury, and was monitored for psychosocial distress. The Administrator interviewed witnesses and reviewed video recording of the incident. A thorough investigation was conducted. This included skin assessments, interviews of residents on the memory care unit, staff interviews, and family member interviews who were frequent visitors to the unit. All staff were re-educated on managing aggressive behaviors and abuse and on 10/24/24. A current facility policy, titled Abuse Prohibition, Reporting, and Investigation, was provided by the Administrator on 11/6/24, and indicated: It is the policy to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion The past non-compliance deficiency began on 10/22/24 and deficient practice corrected on 10/24/24 after the facility suspended and then terminated CNA 5's employment and reported the incident to IDOH as required. Resident B was immediately assessed for injury and monitored for psychosocial distress related to the incident. The facility completed education with staff on managing aggressive behaviors and abuse. This Citation relates to Complaint IN00445849. 3.1-27(a)(1)

Based on observation, interview, and record review the facility failed to implement an effective pain management regimen for 1 of 4 residents reviewed for pain. (Resident 20). Findings include: Resident 20 was observed lying on her left side in her bed on 8/22/23 10:20am, holding onto her lower back. Resident 20 complained of pain and indicated she was unsure if it was her sciatica or her hip. Resident 20 had no heat or ice applied. The light and tv were on and Resident 20 was wincing. On Resident 20's bedside table were 2 oblong red pills and a small round pill. Resident 20 indicated the red ones were for her eyes and the small one was a bowel softener. Resident 20 indicated they were, no big deal. Throughout the interview on 8/22/23 Resident 20 indicated her pain was not well controlled. She indicated she had not done much of anything the last couple days because she had been in so much pain. Resident 20 explained that she had recently been administered her pain medication, but it was not effective yet. Resident 20 indicated the nurses always watch her take that pill because it was a big deal. Resident 20 indicated the pain medication was helpful but did not last all day. Resident 20 indicated they did not offer ice, heat, a massage, or any other non-pharmacological intervention prior to administering the medication, therefore she was unsure if any of those things would be helpful. Resident 20's record was reviewed on 8/22/23 at 10:40AM. Resident 20's diagnosis included chronic pain syndrome, mild unspecified dementia, unspecified neuropathy, and unspecified osteoarthritis. Resident 20's orders included physical therapy to treat three times a week started 8/10/23, gabapentin 200mg three times a day started 11/22/21, icy hot advance relief patch apply as needed started 7/20/23, and hydrocodone-acetaminophen 5-325mg for severe pain every 6 hours as needed on 6/23/23. Resident 20's MDS (Minimum Data Set) comprehensive quarterly assessment; Section C (cognitive patterns) indicated her BIMS (Brief Interview Mental Status) score was 15, indicated no cognitive decline. The facility indicated Resident 20 was interviewable. Resident 20's MAR (Medication Administration Record), dated June, July and August 2023, indicated the following administration documentation: There were 7 documented times of non-pharmacological interventions not being offered or attempted. There was one refusal documented. There were 33 documented times nonpharmacological interventions were attempted. There were no pain assessments indicating the increased use of pain medication, the type of pain (stabbing, pinching, throbbing, sharp, dull, etc), what made the pain worse, what relieved the pain, if the pain could be anticipated by an activity, sleep position, or of any significant changes. Resident 20's current care plan indicated she had a problem of pain. Some of the approaches were to administer medication as ordered. Assist with positioning to comfort. Observe for nonverbal signals of pain. Offer nonpharmacological interventions such as quiet environment, rest, shower, back rub, and repositioning. Resident 20 was also care planned for mood distress and anxiety neither of them mentioned distress by offering nonpharmacological interventions for pain. The anxiety approaches were similar in nature to nonpharmacological interventions and included provide 1 on 1 time, give a diversional activity, offer snack or beverage, and maintain calm environment. On 8/24/23 at 12:03PM the DON (Director of Nursing) indicated she received a new order from primary care physician as follows: Acetaminophen 650mg every 4 hours as needed for mild pain. Indication non pharm interventions not needed prior to administering due to potential psychosocial distress. The tasks to be documented were pain, nonpharmacological tried yes or no, and pain location. Hydrocodone-acetaminophen (Schedule 2 drug; narcotic) 5-325mg tablet every 6 hours as needed for pain. Indication nonpharmacological interventions not needed prior to administering due to potential for psychosocial distress. The tasks to be documented prior to administering were pain, non-pharmacological tried yes or no, and location. In an interview, on 8/24/23 at 12:05PM, the DON indicated that resident was at increased risk of having a behavior if offered nonpharmacological interventions. The DON indicated she had no documentation prior to the interview to indicate Resident 20 had a psychosocial or behavioral event directly linked to nonpharmacological interventions being offered. The most recent 3 documented behaviors provided by the DON, on 8/25/23 at 11:03AM: On 7/29/23 Resident 20 was demanding her pain patch the nurse offered her an asper creme patch and Resident 20 indicated she didn't want that one, she wanted the other one she was ordered. Resident 20 had an order for an icy hot patch not an asper creme patch. 10/26/20 she was requesting an anxiety pill due to going to have a needle stuck in her eye. 10/11/20 seeing someone who recently passed poking her in the eye and smoke coming from under roommates' bed and hurting her eyes. A policy titled, Pain Management Policy provided by the DON on 8/24/23 at 12:03PM, the original date 01/03, revisions on 1/06, 3/10, 9/2013, 2, 2015, 1/2016, 9/2016, 7/20, 10/20, and last revised 4/2023. The policy indicated, 6. Physician orders for pain medication will be prescribed based upon the resident's intensity of pain The Policy did not mention or indicate a need for non-pharmacological interventions for as needed pain medication administration. No other information was provided at time of exit. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure dignity with dining for 2 of 8 residents reviewed(Resident 14 and Resident 51). Findings include: On 8/21/23 from 12:01-12:50 P.M., the dining room on the memory care unit was observed during mealtime. Per staff, there were 2 tables where a total of 8 residents sat who required supervision, cues, and/or assistance with eating. Lunch was to be served at 12:00 P.M. All residents, including those who required assistance, were observed with a glass of yellow juice on the table in front of them. The meal trays were late and hadn't arrived to the unit until 12:40 P.M. Resident 51 sat in a high back wheelchair at the end of a table where 3 other residents sat. She was observed trying to reach out and take hold of her drink placed out of her reach on the table. The Memory Care Support Specialist (MCSS) was observed to move quickly across the dining room to Resident 51 and moved her drink away from her. Resident 51 was not offered a drink and her glass was moved further away from her. Resident 51 reached out again to get the glass of juice and knocked the glass over which then spilled onto her tablemate's lap. The tablemate raised her voice at Resident 51 for spilling juice on her. The resident appeared confused and surprised and began to raise her voice to the tablemate. The 2 residents bickered back and forth until staff intervened. Resident 14 sat in her wheelchair at the end of a table where 3 other residents, needing assistance, sat. She had her eyes closed and her head hung over the back of the chair. She awakened prior to the trays arriving. She tried to take a drink of her juice on the table in front of her. A staff member gave her a small sip and then moved the drink out of her reach. She was observed to pick up her rolled silverware, put it up to her mouth and tipped it back trying to take a drink. Resident 14 then tried to suck on it like a straw, then began to chew on it. When lunch trays arrived, Resident 14 used her fingers to scoop the mashed potatoes off her plate. 1. On 8/22/23 at 2:08 P.M., Resident 14's record was reviewed. Diagnosis included severe dementia and generalized anxiety disorder. A significant change MDS (Minimum Data Set) assessment, dated 6/30/23, indicated the resident required extensive assistance of 1 staff member for eating. Care plans indicated the following: -Initiated 9/8/22 and revised 8/24/23: Resident was at risk for altered nutritional status. A mechanically altered diet was in place. She needed feeding assistance as needed (PRN) and had trending weight loss the past 30 days. Interventions included to serve a regular, soft bite-sized diet. -Initiated 9/8/22 and revised 7/17/23: Resident required assistance with bed mobility, transfers, eating, and toileting. The resident was able to feed self, but required cues/reminders. Nursing staff would provide cues/reminders to resident during meal times. Interventions included to assist with eating and drinking as needed. -Initiated 9/19/22 and revised 7/10/23: Resident was at risk for fluid imbalance due to impaired mobility, required cues/reminders; staff to anticipate fluid needs. Interventions included to encourage and give fluids. On 8/24/23 at 12:05 P.M., Resident 14 was observed seated in her wheelchair at the end of the table where residents passed by behind her and lunch tray carts sat. She was observed with an anxious and perplexed expression on her face as she spoke with the Executive Director (ED) about a trivia puzzle on a paper she held. After the ED left she continued with a frown on her face, talking to those around her although no one answered or spoke to her. Her chair was moved in 2 times so other residents could go past her wheelchair to their tables. CNA (Certified Nurse Aide) 2 sat at the other end of the table and began to assist another resident to eat. Resident 14 was served her plate with large uncut potato wedges and ground meat on it. She attempted to use her spoon to pick up the potato wedge, got it up to her mouth and spit it back out onto the spoon and back onto her plate. She used her spoon to try and eat the ground meat with barbecue sauce covering it. She spilled the ground meat onto her light colored pants and fiddled with wiping them off. The ground meat kept falling of the plate and onto the table and her pants due to difficulty scooping the meat off the plate with her spoon. Resident 14 then began to eat her applesauce with her fingers. After finishing the applesauce, she drank her drink and then put her fingers into the cup and tried to scoop up any remaining fluid/food from the empty cup. She then reached over and tried to take her tablemate's cup. CNA 2 took the cup away and told the resident it wasn't hers. Niether the CNA nor staff observing the dining room, offered the resident more food or drink. After finishing her meal, she began to move herself away from the table and propel herself toward the exit of the dining room where she asked a visitor if they could wash her soiled hands which had visible food debris on both hands. A staff member was summoned to assist the resident to wash her hands. On 8/25/23 at 9:42 A.M., CNA 2 was interviewed. She indicated Resident 14 required assistance at times with eating. She wasn't aware of any care plan to cut up the residents food or assist with drinking fluids and indicated the resident hadn't used a plate guard but would be a good idea to help keep the food from falling off her plate. 2. On 8/22/23 at 1:49 P.M., Resident 51's record was reviewed. Diagnoses included severe dementia with anxiety. A quarterly MDS assessment, dated 7/3/23, indicated the resident required extensive assistance of 1 staff member for eating. Care plans were: -Initiated 12/7/20 and revised 8/16/23: Resident required assistance with bed mobility, transfers, eating, and toileting. Interventions included to assist with eating and drinking as needed. -Initiated 12/18/20 and revised 7/10/23: Resident was at risk for fluid imbalance due to impaired mobility and dementia. Interventions included to encourage fluids. On 8/24/23 at 12:19 P.M., the resident was observed at the end of the table in the dining room, seated in her high back wheelchair. The wheelchair was not up close to the table. Her food was placed in front of her in bowls and she proceeded to eat from them with her fingers. On 8/25/23 at 9:40 A.M., Resident 51 was observed seated in her wheelchair, in the dining room, at the end of the table, with 2 bowls and a glass of juice. She was eating with her fingers while all other residents were gathered around the TV to watch an exercise video. On 8/25/23 at 9:42 A.M., CNA 2 was interviewed. She indicated Resident 51 hadn't liked staff assisting her to eat or drink so she was just given her food and allowed to eat by herself at each meal. She indicated Resident 51 did not require assistance with beverages. A current policy, titled Resident Rights, provided by the Director of Nursing on 8/25/23 at 9:06 A.M., stated the following: The resident has the right to a dignified existence .A facility must protect and promote the rights of each resident .The resident has the right to be treated with respect and dignity 3.1-3(a) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure showers and nail care were provided for 4 residents reviewed (Resident F, Resident K, Resident L, and Resident M). Findings include: On 2/27/23 at 1:38 P.M., the Resident Council President (RCP) was interviewed. She indicated everything was generally well within the facility except for some resident complaints about staffing. She indicated the facility used agency staff who were not familiar with residents routines. The RCP indicated there had been reports from some residents showers were not being given timely on 3 of the 5 hallways. 1. On 2/27/23 at 11:00 A.M., Resident F, identified by the facility as interviewable, was interviewed. They indicated they didn't always receive their shower 2 times per week as care planned. A quarterly MDS (Minimum Data Set) assessment, dated 1/22/23, indicated the resident hadn't received a bath/shower during the assessment period. A care plan, dated 4/17/20, indicated the resident required assistance with ADL's (activities of daily living). Staff were to offer showers 2 times per week and provide bathing assistance. Review of electronic and written shower documentation for scheduled showers on evening shift on Monday and Thursdays, indicated: -2/6/23-the resident received a bed bath rather than a shower. -2/23/23-the resident refused. -2/27/23-there was no shower documented. There was no other documentation to indicate bathing or showers had been offered. 2. On 2/28/23 at 10:35 A.M., Resident M, identified by the facility as interviewable, was interviewed. They indicated they didn't always receive showers 2 times per week as care planned. They indicated the facility was short staffed and when fully staffed, the care provided depended on who was working and how well they worked together. A quarterly MDS, dated [DATE], indicated the resident required physical help with transfers and set up support for bathing. A care plan, dated 6/25/20, indicated the resident required assistance with ADL's. Staff were to offer showers 2 times per week and provide bathing assistance. Review of electronic and written shower documentation for scheduled showers on evening shift on Monday and Thursdays, indicated: -2/6/23-Resident M received a bed bath rather than a shower. -2/27/23-there was no shower documented. There was no other documentation to indicate bathing or showers had been offered. 3. On 2/28/23 at 10:25 A.M., Resident K was observed seated in her room in a wheelchair. Her fingernails were observed with chipped and peeling fingernail polish. Her nails were long, ragged, and had dark material beneath the tips of the nails. A significant change MDS assessment, dated 1/17/23, indicated the resident required total assistance of 1 staff member with bathing. A care plan, dated 6/9/21, indicated the resident required assistance with ADL's There was no documentation to indicate bathing or showers had been offered. 4. On 2/28/23 at 10:35 A.M., Resident L, identified as interviewable, was interviewed. She indicated she wasn't sure when she was supposed to get showers-staff would just come and tell her it was time for one. She indicated they gave her bed baths which was okay with her. Her fingernails were observed to be long, ragged and she had dark material beneath the tips of her nails. A significant change MDS assessment, dated 1/31/23, indicated the resident required extensive assistance with personal hygiene and was dependent on 1 staff member for bathing. A care plan, dated 12/6/18, indicated the resident required assistance with ADL's. Staff were to offer showers 2 times per week and provide bathing assistance. The care plan didn't indicate she had refused of care. A review of electronic and written shower documentation for scheduled showers on evening shift on Wednesday and Saturdays, indicated: -2/1/23-Resident refused bath. -2/8/23-Resident refused shower. -2/15/23-Resident refused shower. There was no other documentation to indicate bathing or showers had been offered. On 3/1/23 at 1:34 P.M., the 500 hall Unit Manager was interviewed. She indicated residents were offered showers 2 times per week. Nail care was to be done following a shower/bath and any time they needed cut or cleaned. On 3/1/23 at 3:30 P.M., the Director of Nursing Services indicated the facility had no specific policy for showers or bathing. Staff were to offer 2 showers per week to the residents. This Federal tag relates to Complaint IN00402413. 3.1-38(a)(3)

Based on observation, interview, and record review the facility failed to ensure proper temperature of food. 124 residents resided in the facility. Findings include: During an observation on 10/03/22 09:06 AM, there was no thermometer observed in the walk in refridgerator. The Dietary Manager (CDM) was unable to provide temperature logs for October. In an interview, the CDM indicated October was a new month and she was unable to provide logs. The CDM indicated she was working 12hr days 7 days a week therefore she could ensure they were taken and within range. The CDM was unable to recall what the temps were on the night prior and asked a Cook for them. The Cook indicated the soup was 175 degrees and the tuna salad was 38. There were no temperatures relayed for any alternate menu or mechanically altered food. There was no documentation to indicate the temperatures were checked. Food temperature logs dated July 2022 through October 2022 indicated the following: No temperature logs dated July 1 to July 24 were provided. The log dated 7/24- 7/30 had no initials on any date and no entries for Saturday 7/30. The log dated July 31 - 8/6/22 had no initials documented to indicate staff responsibelf rochecking the temperatures. The log dated 8/7-8/13 had no initials documented. No log was provided dated 8/14-8/20 The log dated 8/21-8/27 had no initials documented. There were no entres for dinner on Monday. No entries for breakfast or lunch on Tuesday and Wednesday. No entries for breakfast, lunch, or dinner for Thursday or Saturday. No other logs dated for August 2022 were provided. No food temperature logs dated September 2022 were provided. No food temperature logs dated October 2022 were provided. The temperature logs for the high temp dish machine indicated the following: The logs dated July 2022 had no recordings for the 30th or 31st. An undated log was provided with no documentation for the 23, 24, 25, 26, 27, 28, 29, 30, or 31. There were no logs provided dated August, September, or October 2022. The temperature logs for the walk in freezer indicated the following: The logs dated July 2022 did not have documentation on 30 or 31. The logs dated August 2022 had no documentation for 24, 25, 26. 27, 28, 29, 30, or 31. No logs were provided for September or October 2022. The milk temperature monitoring form indicated the following: The forms dated July 2022 had no documentation on 30 or 31. The forms dated August 2022 had no documentation on 24, 25, 26, 27, 28, 28, 30, or 31. There were no forms provided for September or October 2022. The reach in freezer temperature monitoring logs indicated the following: The logs dated July 2022 had no documentation on 30 or 31. The logs dated August 2022 had no documentation on 24, 25, 26, 27, 28, 28, 30, or 31. There were no logs provided for September or October 2022. The walk-in refrigerator temperature logs indicated the following: The logs dated July 2022 had no documentation on 30 or 31. The logs dated August 2022 had no documentation on 24, 25, 26, 27, 28, 28, 30, or 31. There were no forms provided for September or October 2022. The reach in cooler temperature monitoring logs indicated the following: The logs dated July 2022 had no documentation on 30 or 31. The logs dated August 2022 had no documentation on 24, 25, 26, 27, 28, 28, 30, or 31. There were no logs provided for September or October. A policy titled, Recording Temperatures was revised 10/17, and was provided by Administrator on 10/5/22 at 1:58 PM. The recording temperatures policy indicated. food temperature logs shall be kept. temperature logs for dish machine shall be recorded and monitored routinely. The food service manager shall monitor temperatures for food and equipment routinely. 3.1-21 (a)(2)

Based on observation, interview, and record review the facility failed to ensure engaging activities were provided for 4 of 4 residents reviewed. (Resident 5, Resident 75, Resident 52, and Resident 30) Findings include: During a continuous observation, on 10/03/22 from 10:07 AM to 11:45AM, 20 residents were observed in the common area with no activities going on. There was 1 staff (activities) in an office with the door closed around the corner from the tables. The staff came handed out gallon size baggies with orbies (small squishy balls that swell with water) inside one to each table where people sat, 5 in total. After 18 minutes a second staff member came into the common area and activity staff began blowing bubbles. Resident 5 was not observed in the common room. An activities schedule dated October 2022 indicated sittercize was scheduled for 10 AM and Chronicles with coffee was scheduled for 11 AM on 10/3/22. During a continuous observation on 10/04/22 from 02:07 PM to 3:10 PM, 10 residents and a visitor were observed in the common room. No staff were present, and no activities were being conducted. Observed Resident 30 going into a peer's room, Resident 5 and Resident 52 were in the middle of the hall. A random CNA (Certified Nursing Assistant) was observed going in and out of resident's rooms, taking out trash. CNA 3, came onto the unit, went into common room and indicated it was color circle time. CNA 3 then handed out markers and printed coloring pages to residents who were willing to take them (6 in total). An activities schedule dated October 2022 indicated Activity stations followed by Movie and snack were scheduled for 2 PM on 10/4/22. In an interview on 10/04/22 at 2:42 PM, LPN 2 indicated one CNA and herself were scheduled for the unit. LPN 2 indicated activities were not done on evenings unless assigned a second CNA. LPN 2 indicated 2 CNAs working happened infrequently. In an interview on 10/4/22 at 2:45 PM, the Unit Manager indicated the unit had one part time activities person 3 days per week working an average of 18 hours a week. The Unit Manager indicated staffing was a nurse and 2 CNAs if possible 3 CNAs on 1st and 2nd shift with a nurse and aid on 3rd shift preferably. The Unit Manager indicated at times it was only a nurse from the hours of 10PM to 6AM. The Unit Manager indicated the aids and nurses were able to conduct activities. The Unit Manager indicated part of the criteria to reside in the secured unit was a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Unit Manager indicated being short staffed made it impossible to conduct activities at times. 1) Resident 5's record review began on 10/3/22 at 9:06 AM. Resident 5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5's physician orders indicated it was clinically indicated for the resident to reside on the secured unit. Resident may engage in therapeutic, structured, and work activities. Resident 5's current care plan indicated she enjoyed playing the piano, traveling, gardening, bingo, and listening to music. Resident 5's quarterly current MDS (Minimal Data Set) indicated Resident 5 was moderately cognitively impaired. Resident 5's activity documentation, a highlighted calendar with blue for passive and pink for participation with no indication if refused or not available, provided by Administrator on 10/6/22 at 8:30 AM showed no indication of the time the activity occurred and amount of time lasted. On the October activity calendar documentation indicated Resident 5 was a passive participant in sittercise at 10AM and participated in coffee with chronicles at 11AM on 10/3/22. Resident 5 was not in sittercise per observation and there were no chronicles between 11AM to 11:45AM. On 10/4/22 Resident 5 was marked as passive participation at 2PM during activity stations with participation at 3:00PM during a movie and snack. During the observation on 10/4/22 the activity station offered was coloring an no movie or snack began at 3:00PM. Resident 5 was observed in the hallway during the scheduled activity times on 10/4/22. 2) Resident 75's record review began on10/3/22 at 9:22 AM. Resident 75's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 75's physician orders included it was clinically indicated for the resident to reside on the secured unit. Resident may engage in therapeutic, structured, and work activities. Resident 75's current care plan indicated she enjoyed yard work, planting flowers, religious music, and country music. Resident 75's current quarterly MDS indicated Resident 75 was severely cognitively impaired. Resident 75's activity documentation, a highlighted calendar with blue for passive and pink for participation with no indication if refused or not available, provided by Administrator on 10/6/22 at 8:30 AM showed no indication of the time the activity occurred, occurrence of any enjoyment, and amount of time lasted. On the October activity calendar documentation, Resident 75 was indicated as an active participant in sittercise at 10AM and in coffee with chronicles at 11AM on 10/3/22. Resident 75 was not in sittercise or chronicles on 10/3/22 as observation of the activity indicated it did not occur. On 10/4/22 Resident 75 was marked as participation at 2PM during activity stations and at 3:00PM with a movie and snack. During the observation on 10/4/22 the activity station offered was coloring an no movie began at 3:00PM. 3)Resident 52's record review on 10/4/22 at 3:48 PM indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 52's current care plan did not indicate activities of preference. Resident 52's quarterly current MDS (Minimal Data Set) indicated Resident 52 was moderately cognitively impaired. Resident 52's activity documentation, a highlighted calendar with blue for passive and pink for participation with no indication if refused or not available, provided by Administrator on 10/6/22 at 8:30 AM showed no indication the time the activity occurred and amount of time lasted. On the October activity calendar documentation indicated Resident 52 was a passive participant in sittercise at 10AM and participated in coffee with chronicles at 11AM on 10/3/22. Resident 52 was not in sittercise per observation and there were no chronicles between 11AM through 11:45AM. Resident 52 was in her room visiting with her daughter during the time indicated. On 10/4/22 Resident 52 was marked as participation at 2PM during activity stations and at 3:00PM with a movie and snack. During the observation on 10/4/22 the activity station offered was coloring an no movie began at 3:00PM. During an interview on 10/3/22 at 10:52AM the daughter of Resident 52 indicated her mom had not been in activities and she was difficult to keep focused. 4) Resident 30's record review on 10/3/22 at 12:26 PM indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's physician orders included it was clinically indicated for the resident to reside on the secured unit. Resident may engage in therapeutic, structured, and work activities. Resident 30's current care plan indicated she enjoyed animals, watching crime shows, and listening to country music. Resident 30's quarterly current MDS indicated Resident 30 was moderately cognitively impaired. Resident 30's activity documentation, a highlighted calendar with blue for passive and pink for participation with no indication if refused or not available, provided by Administrator on 10/6/22 at 8:30 AM showed no indication of the time the activity occurred and amount of time lasted. On the October activity calendar documentation indicated Resident 30 was a passive participant in sittercise at 10AM and participated in coffee with chronicles at 11AM on 10/3/22. Resident 30 was not observed in either activity on 10/3/22 at the designated times. On 10/4/22, Resident 30 was marked as participation at 2PM during activity stations with passive participation at 3:00PM with a movie and snack. During the observation on 10/4/22 the activity station offered was coloring an no movie began at 3:00PM. In an interview on 10/6/22 at 1:26PM the Activity Director indicated she was not trained on calendar activity logs. The Activity Director indicated it lacked necessary information to ensure value, type of activity, attendance, and time spent in activity. The Activity Director demonstrated the charting the staff complete on activities on all other units, and would be doing in Auguste's Cottage (secured unit) in the future. A policy and procedure labeled, Auguste's Cottage, dated Spring 2019 was received from Administrator on 10/6/22 at 8:30 AM, indicated Guidelines for Initial Admission to Auguste's Cottage .Individual will benefit from socialization in daily group programs .Guidelines for Continued Stay on Auguste's Cottage. Individual actively participates daily in group programming. Individual passively participates in daily group programming. Individual enjoys group programming. This Federal citation is realted to Complaint IN 151. 3.1-33(a)

Based on observations, interviews and record reviews, the facility failed to properly prevent COVID-19 by wearing Personal Protective Equipment (PPE) properly for 11 of 11 observations. (Employee 1, Employee 2, Employee 3, Employee 4, Employee 5, Employee 6, Employee 7, and Employee 8) Findings include: During observation on 11/4/21 at 12:45 P.M., Employee 8 was sitting at the front desk screening visiting medical providers and employees. Employee 8 was wearing a mask, but no face shield or goggles. During an interview at the same time, Employee 8 indicated if she had to walk to resident areas, then she needed to wear a shield. During observation on 11/4/21 at 12:48 P.M., Employee 7 was wearing her N95 mask with the bottom strap undone, not around her head. The goggles she was wearing did not provide a barrier from splashes or droplets into her eyes. During interview at the same time, Employee 7 indicated she just didn't put the bottom strap on, and she thought she could wear goggles with space around the eyes and forehead. During observation on 11/4/21 at 12:49 P.M., Employee 6 was wearing goggles open at the top. The goggles did not provide a barrier from splashes or droplets into her eyes. During observation on 11/4/21 at 12:50 P.M., Employee 1 began to bring a tray out of room [ROOM NUMBER]. Her N95 mask was hanging down below her chin. She backed into the room, then exited with the N95 mask on, however, the bottom strap was undone and hanging below her chin. She then proceeded to enter room [ROOM NUMBER] without donning PPE, or performing hand hygiene, exited the room with a food tray and went to the tray cart down the hall. During an interview at the same time, Employee 1 indicated her mask had been off when she was in room [ROOM NUMBER] because she had been feeding and talking to Resident 1 and he could not hear her with the mask on. Employee 1 indicated room [ROOM NUMBER] was on droplet precautions because Resident 2 had coughing symptoms. During observation on 11/4/21 at 12:50 P.M., the sign for room [ROOM NUMBER] indicated Isolation Droplet Precautions hand hygiene when entering and exiting and wear all PPE listed below: Gown, N95 Respirator Eye Protection Gloves Keep Door Closed . During observation on 11/4/21 at 12:55 P.M., Employee 5 donned PPE and entered room [ROOM NUMBER] and then exited without doffing PPE. Employee 5 was carrying a dirty meal tray. Employee 5 went to the tray cart down the hall, then removed her gown, entered the DON office and exited without the dirty gown. During an interview at the same time, Employee 5 indicated the tray was from Resident 2, she did not remove PPE because she did not want to put the tray down. During observation on 11/4/21 at 1:05 P.M., on 500 hall, the DON was wearing goggles open at the top and did not provide a barrier from splashes or droplets into her eyes. She indicated the staff should not have been wearing PPE in the hallway. She indicated the facility had been putting up signs just today and it's been confusing for staff. During observation on 11/4/21 at 1:11 P.M., on 100 hall outside the Covid-19 unit, Employee 2 was wearing goggles open at the top and did not provide a barrier from splashes or droplets into her eyes. During interview at the same time, Employee 2 indicated she had grabbed wrong goggles. During observation on 11/4/21 at 1:12 P.M., on 100 hall, Employee 4 was wearing goggles open at the top and did not provide a barrier from splashes or droplets into her eyes. During interview at the same time, Employee 4 indicated they said she could wear those goggles. During observation on 11/4/21 at 1:13 P.M., on 100 hall, Employee 3 was wearing her N95 mask with the bottom strap not around her head. During interview at the same time, Employee 3 indicated she forgot to put it on after she ate. During interview on 11/4/21 at 2:00 P.M. the Administrator indicated the facility had been told that those goggles were fine. She indicated Employee 5 was activities personnel so she was not sure why she had gone into room [ROOM NUMBER], as she was not a Certified Nurse Aide (CNA). During interview on 11/4/21 at 2:21 P.M., the DON indicated she had just walked the PPE cart and put up the sign on room [ROOM NUMBER] so Employee 1 may not have realized or known about the isolation, and the orders were not even entered into the computer yet. The facility's Isolation Sign provided on 11/4/21 at 2:10 P.M. by the Administrator, indicated Stop Isolation Droplet/Contact Precautions Stop Only essential personnel should enter this room . Staff and Providers Must: Hand Hygiene: when entering and exiting and wear all PPE listed below: Gown (change between each resident) N95 Respirator (Fit tested N-95 or higher required) Eye Protection (Face shield or googles [sic]) Gloves The facility's sequencing sheet for putting on PPE, provided by the DON on 11/4/21 at 2:21 P.M., indicated Sequence for Putting on Personal Protective Equipment (PPE), . 2. Mask . Secure ties or elastic bands a middle of head and neck Fit flexible band to nose bridge Fit snug to face and below chin . 3. Goggles or face shield Place over face and eyes and adjust to fit . The facility's sequencing sheet for removing PPE, provided by the DON on 11/4/21 at 2:21 P.M., indicated How to Safely Remove Personal Protective Equipment (PPE) Example 1, . Remove all PPE before exiting the patient room 3.1-18(b)1

Based on observation, interview, and record review, the facility failed to ensure sanitation and storage practices were followed in the kitchen, pantries, and during meal service. There were 121 of 122 residents who ate their meals from the facility kitchen. Findings include: 1. An observation of the door entrance to the main kitchen on 10-6-2021 at 9:46 a.m., indicated the secured door entry was in the main dining room. The door was scuffed and appeared dirty with light brown areas on the door and frame. An observation of the walk-in refrigerator on 10-6-2021 at 9:55 a.m., indicated on the shelves to the right of the opening, there were containers without a label describing the contents and the date it was placed in the refrigerator or the use by date. The containers included a round container of ham slices and pineapple, a container of shredded cheese about 1/4 full, some type of chicken cut up, and shredded lettuce. An interview with Dietary 1 at this time indicated these items should have had labels on them. An observation of the dry storage room on 10-6-2021 at 10:02 a.m., indicated there was an opened container of soy sauce. The soy sauce had an opened date of 3/25 on the lid and the container was approximately 1/3 to 1/2 full. The label on the soy sauce indicated to refrigerate after opening. The Kitchen Manager was observed to discard the container of soy sauce. Continued observations in the main kitchen on 10-6-2021 at 10:03 a.m., indicated a reach in freezer located to the right of the walk-in refrigerator had grease splatters on the side. The floor next to the reach-in freezer and under the fryer was slick with grease. The convection oven and steamer were next to the fryer and the floor was observed to not be clean under those appliances. There were splatters with white dried areas on the outside of the convection oven and steamer, and crumbs were observed on top of the oven. The microwave on the counter had splatters on the inside door and crumbs on top and underneath the microwave. Inside the reach-in refrigerator to the left of the ice machine, a 32 ounce container of Thick and Easy was observed to be opened. There was not an opened date on the container of Thick and Easy and a use by date on the container was 9-11-2021. The ice machine was observed between two reach-in refrigerators. The ice machine was right across from the prep table, no more than three feet, where Dietary 1 was observed to be slicing turkey for the lunch meal. Two vents on the front of the ice machine above the opening were observed with feathery tan debris on the vent slats and at least 2 hair strands were observed sticking to the vent slats. A reach-in refrigerator was to the right of the ice machine and inside there were two 32 ounce containers of Thick and Easy with opened dates of 12-23-2020. Each container had a use by date of 9-11-2021 printed on the containers. An interview with the Kitchen Manager on 10-6- at 10:18 a.m., indicated she will check the walk-in refrigerator and freezer for outdated items and the dietary aides were to check the reach-in refrigerators and freezer for outdated items. 2. An observation of the 300 hall refrigerator/freezer on 10-6-2021 at 10:25 a.m., indicated the refrigerator had a dried sticky orange residue on the bottom shelf and under the bottom drawers. There was a plastic sack, which was sticky on the outside, without a date marked on the sack. The sack of food had a name and room number. A container of Thick and Easy [MEDICATION(S)] thickened water had an opened date of 9-15 on it and a use by date of 7-12-2022 on the lid. The label indicated to refrigerate the unused portion and discard if not used within 10 days of opening. An observation of the 100 hall freezer on 10-12-2021 at 9:17 a.m., indicated there was a clear plastic container with a green substance inside which was labeled with a name only. A date was not observed on the container. Inside the refrigerator, there were 2 clear plastic containers, one with 3 cookies and 1 with a piece of pie with a name on the containers. The containers were not dated. An observation of the 300 hall refrigerator/freezer on 10-12-2021 at 9:20 a.m., indicated a Thick and Easy container with 8/25 on the lid was opened and 1/2 of the 46 ounce container had been used. The label indicated to discard if not used within 10 days of opening. A snack tray with vegetables was opened and labeled with a name and room number. A date opened was not observed on the package. A plastic sack with a name and room number was on the 2nd shelf of the refrigerator. Inside the sack, there was a container with butter garlic shrimp with a sell by date printed on the package of 9-9-2021. A package of smoked [NAME] with a sell by date of 10-3-2021 on the package was observed in the sack. A nectarine, which was firm was also observed in the sack. There were no opened or use by dates observed on the shrimp or the [NAME]. A 46 ounce container of Thick and Easy apple juice with 8-25 on the cap was observed to be ½ full and the label indicated to discard if not used within 10 days of opening. The bottom of the refrigerator had a pinkish color, dry residue observed on the bottom under the drawers. An interview with the Corporate Dietitian on 10-12-2021 at 9:55 a.m., indicated the items in stored in the pantry refrigerators should have had opened and use by dates on the items. She indicated the nursing staff who would take the items from the residents to store in the refrigerator/freezer, should ensure the items were labeled with a resident name, date opened, and use by date. 3. An observation of the entry door to the kitchen from the main dining room on 10-12-2021 at 9:38 a.m., indicated the door was scuffed, not clean, and had light brown smudges on the door. The smudges were able to be rubbed off with a damp paper towel. Inside the kitchen, an observation in the walk-in freezer indicated a large package of breaded meat in the right back corner was opened and not labeled with the contents or dated. The gasket was observed upon leaving the walk-in refrigerator and the gasket had light brownish debris all along the edges of the opening. The brownish debris was able to be wiped clean with a paper towel. An interview with the Kitchen Manager on 10-12-2021 at 9:42 a.m., indicated the opened package of breaded meat were drumsticks and she did not realize the package was opened. The Kitchen Manager was observed to discard the opened package of drumsticks. The Kitchen Manager was also shown the walk-in refrigerator gasket and the need for it to be cleaned. Continued observation of the main kitchen on 10-12-2021 at 9:45 a.m., indicated there were storage racks along the wall with metal trays, containers, pots, and pitchers. The floor and baseboard underneath the storage racks were observed to not be clean. The baseboard edges had a brown, sticky type residue along it and there were crumbs underneath. An observation of the ice machine vent slats indicated the vents had a brown feathery sticky type debris on them with some hair strands stuck to the vents. The filters behind the vent slats were covered with brown feathery residue. The printing on the ice machine vents indicated to clean air filters 2 times a month. An interview with the Kitchen Manager on 10-12-2021 at 9:49 a.m., indicated a company came every 6 months to clean the ice machine. She indicated it had been cleaned 3 or 4 months ago. She indicated the kitchen crew probably last cleaned the ice machine around 9-20-2021. She indicated near the first part of the month, the side of the kitchen with the vent hood, fryer, convection ovens, steamers, and walk-in refrigerator/freezer were deep cleaned and then the other side with the 2 reach-in refrigerators, ice machine, and shelving were cleaned later in the month. The Kitchen Manager was interviewed about the cleaning of the floors under the equipment, and she indicated they were scrubbed monthly. The Kitchen Manager was shown the area behind the shelves with the pots and pans, and she indicated she did not know when the baseboards and the floor under the shelves were last cleaned. The Kitchen Manager was asked to provide her cleaning documentation and she indicated they did not have any cleaning documentation. The Kitchen Manager was asked about the cleaning schedules, and she indicated they did not use cleaning schedules. She indicated she didn't know they needed to have a cleaning schedule or documentation to indicate the cleaning of the kitchen was being done. The Kitchen Manager was shown the ice machine vent slats and filters and how the top of the ice machine was sticky on 10-12-2021 at 9:54 a.m. The Kitchen Manager indicated she did not know when the top of the ice machine was last cleaned. The Kitchen Manager indicated it was her and Dietary 1 who did the cleaning as she did not have enough staff. CNA 2 (Certified Nurse Aide) was observed in the kitchen assisting and she indicated this was her first day to help in the kitchen. Continued observation of the kitchen with the Kitchen Manager on 10-12-2021 at 10:03 a.m., indicated the cooler to the left of the ice machine had opened containers of thickened apple juice and orange juice with 8-25 written on the lid. Each of the 46 oz containers were 3/4 full. The label indicated to discard if not used within 10 days of opening. An interview with the Kitchen Manager at this time indicated the 8-25 dates written on the lids were the dates the products were delivered. There were no other dates observed to be written on the thickened apple or orange juice to indicate when they were opened. An observation with the Kitchen Manager of the convection oven and steamer on 10-12-2021 at 10:10 a.m., indicated the Kitchen Manager had cleaned the insides of the appliances but had not wiped down the outsides of the appliances. The floor under the fryer which was between the freestanding freezer and the convection oven, was not clean and had a greasy film covering the floor under the fryer and on the sides of the freestanding freezer. The ceiling vents were observed. The vent slats had a dark color debris on the slats and on part of the area surrounding the 4 ceiling vents. Another vent on the ceiling was observed to be centered between the walk-in refrigerator and the shelves with the pans. The vent slats had a brownish tan substance on the slats and parts of the rest of the ceiling had some black debris on it. 4. An observation in the main kitchen on 10-12-2021 at 11:40 a.m., indicated the maintenance man was on a ladder and was cleaning the vent outside the walk-in refrigerator as the dietary staff were trying to get the lunch set up to serve. The one vent cover was removed from the ceiling between the walk-in refrigerator and the shelves. The vent cover was later found by the sink in the dishwasher room and the slats had a brownish sticky substance on it. The maintenance man was observed to be using a spray to clean the side of the hood over the fryer. The fryer had not been covered. The black debris around the metal vents on the ceiling were observed to have been cleaned, but there was still some black debris left on other parts of the ceiling. These vents were located on the ceiling over the prep tables for the meals. The filters from the ice machine had been removed and the vent slats still had the brownish feathery debris on them. The maintenance man was observed to leave the kitchen on 10-12-2021 at 11:46 a.m. An observation of the dishwasher room on 10-12-2021 at 12:08 p.m., indicated on the wall by where the dishes were rinsed prior to being sent through the dishwasher, approximately a 4 foot long area, which was about 1 to 3 inches wide, had black debris along the edge of the short backsplash. A paper towel was used to rub the area and the black debris came off onto the damp paper towel. On 10-12-2021 at 12:15 p.m., the maintenance man returned to the kitchen while the dietary staff was plating the noon meal and was observed to use the sprayer from the dishwasher room sink to clean the ceiling vent slats. An interview with the Corporate Dietitian on 10-12-2021 at 12:28 p.m., indicated the facility had the black debris in the dishwasher room cleaned by a cleaning company, but she was not sure when it was done. 5. On 10-12-2021 at 12:30 p.m., Dietary 1 was observed to set up the meal service in the 100 hall steam table. At 12:32 p.m., Dietary 1 was observed to handle his glasses and place them back on his face. Without washing his hands, Dietary 1 began to take the temperature of the food. Dietary 1 was then observed to remove his glasses as they were fogging and then placed them back on and without washing his hands, he continued to take the temperatures of the food. At 12:42 p.m., Dietary 1 was observed to touch his face and glasses and then without washing his hands, he began to plate the food. There were no residents observed in the 100 hall dining room and the staff indicated the residents had their meals delivered to their rooms. There were 3 round serving trays and 3 dome lids observed at the steam table ready to use for delivering the residents meals. Dietary 1 indicated they only had these 3 round serving trays and dome lids to use as the facility did not have enough trays or dome covers to serve all the residents in their rooms. At 12:48 p.m., CNA 3 was observed to obtain a round tray from the dirty dish cart after CNA 4 had just placed the round tray on the dirty dish cart. CNA 4 had just returned from serving a resident's lunch meal in their room. An interview with Nurse 5 at this time indicated there were 25 or 26 residents to be served lunch on the 100 hall. At 12:52 p.m., CNA 4 was observed to deliver a lunch meal on a round tray to a resident in room 115. The CNA was observed to place the round tray on the over bed table. CNA 4 was then observed to remove the plate and bowl, drinks and pears from the round tray and carried the round tray back to the 100 hall dining room with a dirty glass and dome cover on the tray. CNA 4 was observed to set the tray and dome cover back on the steam table to be re-used for another resident. This tray and dome cover were not cleaned prior to re-use. At 12:55 p.m., Nurse 5 was observed to deliver a lunch meal on a round tray to a resident in room 111 and the nurse held the round tray while she placed the meal on the resident's overbed table. Nurse 5 was observed to return the dome and round tray to be re-used for another resident's lunch without being cleaned. At 12:56 p.m., CNA 4 was observed to deliver a lunch meal on a round tray to room 109 and the resident refused the lunch. CNA 4 was observed to return the items to the dirty cart in the 100 hall dining room and took the tray and dome cover to be re-used for another resident's lunch without being cleaned. At 12:57 p.m., CNA 3 was observed to deliver a lunch meal on a round tray to room 107 and returned to the 100 hall dining room and placed the round tray and dome cover for use for another resident's lunch without being cleaned. At 12:58 p.m., the Kitchen Manager was observed to deliver dome covers to the 100 hall dining room on a tray. Dietary 1 indicated 2 of the 3 dome lids they were using were dirty and they needed some more. The Kitchen Manager was observed to leave the tray, which was wet, for meal delivery for the residents. At 1:00 p.m., CNA 4 was observed to deliver a lunch meal on a round tray to room 106 and the resident refused the meal. CNA 4 was observed to return the lunch meal to the 100 hall dining room. She was observed to remove the items from the round tray and placed the round tray and dome cover to be used for another resident's lunch without being cleaned. At 1:01 p.m., Nurse 5 was observed to deliver a lunch meal on a round tray to room 105 and returned the round tray and dome cover to be used again, without being cleaned. At 1:04 p.m., CNA 4 was observed to deliver a lunch meal on a round tray to room 103A. The CNA was observed to place the round tray on a chair, while she placed the lunch meal on the resident's overbed table. The CNA returned the round tray and the dome lid to the 100 hall dining room to be used again without being cleaned. At 1:11 p.m., CNA 3 was observed to deliver a lunch meal on a round tray to room 119. This room was observed to have a droplet plus precaution sign on the door. Another staff member was observed to hold the round tray while CNA 3 donned a gown and gloves. CNA 3 was observed to deliver the round tray to the resident in room 119 and was observed to remove the lunch items off the tray and placed them on the overbed table. The CNA then took the tray and dome lid to the door and gave it to the staff. The CNA was observed to remove her gown and gloves and used hand sanitizer prior to leaving the room. The CNA was observed to return the round tray and dome lid to the 100 hall serving line to be re-used, but there were no more residents to be served. An interview with the Kitchen Manager on 10-13-2021 at 10:06 a.m., indicated the process for serving the 100 hall residents their meals using and re-using the 3 round trays and 3 domes was normal practice when she came to the facility. She indicated she did change the process for last evening's meal and found the number of trays/dome lids for each resident. The facility census and conditions completed by the MDS Coordinator (Minimum Data Set) on 10-6-2021, indicated the facility had one tube feeding and a total of 122 residents. An interview with the DON (Director of Nursing) on 10-13-2021 at 1:10 p.m., indicated there was 1 resident with a feeding tube and NPO (nothing by mouth) orders at the time the survey began. An undated copy of current instructions for Labeling and Dating, which was posted on the reach-in refrigerator, was provided by the Administrator on 10-12-2021 at 3:50 p.m. The instructions indicated .processed meats and any item that has been cooked and cooled should be kept no longer than 3 days .label with the day of storage and date of discard .examples: chili, soup, chicken breasts, ham, bologna, salami, cooked vegetables, cooked potatoes .any refrigerated opened item that has not been cooked can be stored for 7 days .label with the date item is placed in storage and date of discard .examples: canned fruit, cottage cheese, sour cream, yogurt and milk .food items that are not considered to be potentially hazardous will be labeled when opened and, to ensure quality, use or dispose of within 90 days of opening .follow manufacturer's directions regarding the need to refrigerate after opening in order to preserve quality .label with the date item is opened and discard within 90 days to ensure quality .examples: salad dressing, mayonnaise, BBQ sauce, ketchup, pickles, mustard, ect .Thickened Liquids can be kept refrigerated after opening according to manufacturer's directions A current policy, Food Brought in by Family and Visitors dated 6/21 was provided by the Administrator on 10-7-2021 at 12:00 p.m. The policy indicated .Food brought in by family and visitors will be stored to ensure food safety and will be easily distinguishable from facility food .If the food must be stored, it will be labeled with the resident's name, the date the item was brought in, and the date it should be consumed or discarded .These items may be stored in facility pantries, refrigerators or freezers .Staff will monitor for food in need of disposal A current policy, Food Storage dated 6/21, was provided by the Administrator on 10-12-2021 at 3:50 p.m. The policy indicated, .Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing .food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination .10. Leftover prepared foods are to be stored inn covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded .12. Food items that are not considered potentially hazardous including commercially prepared mayonnaise, salad dressing, mustard, ketchup, BBQ sauce, pickles, and pickle relish will be labeled when opened, and to ensure quality, used or disposed of within 90 days of opening or per the use-by-date, whichever comes first .Follow manufacturer's directions regarding the need to refrigerate after opening in order to preserve quality .All foods shall be covered or wrapped tightly, labeled, and dated A current policy, Hand Hygiene Policy dated 12/2020, was provided by the Administrator on 10-12-2021 at 4:22 p.m. The policy indicated, .Indication for Hand-rubbing but not limited to .After touching self or clothing during meal service A current policy, Sanitation of Kitchen dated 7/15, was provided by the Administrator on 10-12-2021 at 3:50 p.m. The policy indicated, .The dietary staff will maintain the sanitation of the dietary department through compliance with a written, comprehensive cleaning schedule .The Dietary Services Manager will record all cleaning and sanitation tasks for the department .A cleaning schedule will be posted for all cleaning tasks, and employees will initial tasks as completed 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the [CONDITION(S)] facility regarding [CONDITION(S)] care and services for 1 of 1 resident reviewed. (Resident 54) Findings include: Record review started 10/12/21 at 9:15AM indicated Resident 54's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No weight was recorded for the week of 8-15 to 8-21 in the vitals report.The DON (director of nursing) provided order and vitals report on 10-12-21 at 01:04 p.m. On 10/12/21 at 4:15 p.m., the DON called the [CONDITION(S)] center to get additional weight information The [CONDITION(S)] center provided weights for 7-26-21, the weight was 156.4 lb. (pounds) and on 8-12-21, the weight was 155.8 lb. Neither of which were in the time frame of missing weekly weight. No weights were recorded on communication tools during this time frame. The [CONDITION(S)] Center Communication Tool dated 8-3-21 to 10-12-21; excluding time frame of 8-27 to 9-13 at which time Resident 54 was in the hospital was provided by the DON on 10-13-21 at 12:53 p.m. None of the 23 communication tools were filled out completely. The communication tool documents included the following defiencies; 18 of 23 failed to indicate what medications were given, 19 of 23 failed to indicate if labs were drawn and 19 of 23 failed to give pre (before) and post (after) [CONDITION(S)] weights. The [CONDITION(S)] Center Communication Tool were completed as follows: On 8-3-21 No information regarding any changes by the licensed facility nurse writtten on [CONDITION(S)] Center Communication Tool; the [CONDITION(S)] nurse section was completely blank (no vitals, weights, lab information, access problems, indication of medications given, run time nor nurse signature). On 8-7-21 the [CONDITION(S)] nurse section was missing wts, change in condition/other pertinent information and run time recorded by [CONDITION(S)] nurse nor a signature of said nurse.The [CONDITION(S)] nurse noted medications given during/after treatment. On 8-10-21the section to be completed by the Licensed facility nurse was missing any changes or additional information as well as facility nurse signature. The [CONDITION(S)] nurse section was missing lab work completed. The [CONDITION(S)] nurse noted medications given during /after treatment. On 8-12-21 No information regarding any changes by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 8-14-21 No information regarding any changes by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 8-17-21 an arrow drawn on the paperwork making it difficult to conclude whom did not record vitals or when vitals weere taken. The Licensed facility nurse portion was missing any changes or additional information. The [CONDITION(S)] nurse section was missing weights, access problems, medications given, changes in condition/other pertinent information, any non compliance, run time as well as [CONDITION(S)] nurse signature On 8-19-21 No information was recorded regarding any changes by the licensed facility nurse. The communication tool was blank throughout the [CONDITION(S)] nurse section; except run time, [CONDITION(S)] nurse signature and date; (no vitals, weights, lab information, access problems, indication of medications given). On 8-21-21 No information was documented regarding any changes by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 8-24-21 Documentation regarding any changes by the Licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 8-26-21 Documentation regarding any changes by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 9-14-21 No information regarding changes or additional information from the Licensed facility nurse was filled out entirely by the [CONDITION(S)] nurse noted medications given during/after treatment [MEDICATION(S)], Iron, [MEDICATION(S)] and Protein. On 9-16-21 No information regarding changes or additional information from the Licensed facility nurse was filled out entirely by the [CONDITION(S)] nurse except post weight. On 9-18-21 No information regarding any changes by the licensed facility nurse and blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 9-21-21 No information regarding meal, medications sent, any changes or additional information or nurse signature on area to be completed by the Licensed facility nurse.The [CONDITION(S)] nurse portion was missing lab work completed. On 9-23-21 No information regarding any changes or a nurse signature by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 9-2-21 No information regarding any changes or a nurse signature by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time nor nurse signature). On 9-28-21 No information from the licensed facility nurse regarding meal sent, medication sent with resident, any changes or additional information was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time and nurse signature). On 9-30-21 No information regarding medications sent with resident, any changes or additional information was completed by the licensed facility nurse. The [CONDITION(S)] nurse portion was filled out entirely except changes in condition/other pertinent information, non compliance, run time and signature date. On 10-2-21 No information regarding any changes or nurse signature by the licensed facility nurses was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, run time, date and nurse signature). On 10-5-21 No information regarding any changes or nurse signature by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section except signature (no vitals, weights, lab information, access problems, indication of medications given, or run time). Something was written in across [CONDITION(S)] nurse section which was not legible. On 10-7-21 No information regarding any changes or nurse signature by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section except signature and no issues written across section (no vitals, weights, lab information, access problems, indication of medications given, or run time). On 10/09/21 No information regarding any changes by the licensed facility nurse was blank throughout the [CONDITION(S)] nurse section (no vitals, weights, lab information, access problems, indication of medications given, [CONDITION(S)] nurse signature, date or run time). On 10-12-21 No information regarding any changes by the licensed facility nurse was noted to be blank on [CONDITION(S)] nurse section regarding lab work completed, access problems, medications given during/after treatment, changes in condition/other pertinent information, any non compliance, run time and [CONDITION(S)] nurse signature. The DON was interviewed on 10-14-21 at 12:06 p.m., The DON indicated she was not responsible for [CONDITION(S)] nurses and is unable to ensure they properly fill out communication tool. The DON indicated she does not have a system in place to ensure communication between facility and [CONDITION(S)] center was timely and accurate. The DON indicated the facility nurses document when Resident 54 condition upon leaving and re-enter. The DON indicated she will contact sources at [CONDITION(S)] center. A policy dated 2-03 with revision dates: 12-03; 1-06; 3-10; 6-2012; 9-2012; 1-2015; 11-2017, titled, [CONDITION(S)] Care was provided by DON on 10-12-21 at 1:04 p.m. The policy indicated, .the facility will ensure that reach resident receives care and services including: ongoing assessments of and oversight of residents before, during and after treatments, monitoring for complications, implementing appropriate interventions .ongoing communication and collaboration with [CONDITION(S)] facility regarding [CONDITION(S)] care and services . the nurse in charge at time of return will review paperwork for new orders or notes accompanying resident. The facility will employ a method of communication between the facility and the [CONDITION(S)] center to relay changes in condition and response to treatment .The facility should maintain a current contract with each [CONDITION(S)] Provider at the facility A contract, Nursing Home [CONDITION(S)] Transfer Agreement between [NAME] Meadows and [Name] [CONDITION(S)] LLC, subsidiary of [Name] Inc. provided upon request from DON 10-12-21 at 1:04 p.m., was signed in 2017. 3.1-37 (a)

The facility failed to ensure that its medications error rates are below 5 percent. Of the 28 medications given there were 3 errors out of 25 opportunities equaling an error rate of 10.71%. Finding include observation and record review. During continuous observation of Employee 6 on 10-7-21 from 7:20 a.m. to 9:00 a.m. following errors occurred: 1. On 10-7-21 at 7:30 a.m., Staff 6 administered [MEDICATION(S)] 5mg ½ tab to Resident 59. Resident 59 was to receive [MEDICATION(S)] and Gummy Vitamin at this time. Neither [MEDICATION(S)] nor gummy vitamins were available in med cart. At Resident 59's bedside in pink tub, sitting on bedside table, was [MEDICATION(S)] and gummy multi-vitamin. Employee 6 left [MEDICATION(S)] with the resident to take and encouraged theresident to take gummy vitamin and [MEDICATION(S)]. The Record Review on 10-7-21 at 9:20 a.m. indicated Resident 59 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] should have been administered per orders by the nursing staff. Upon further review Resident 59 did not have medication self administration request/evaluation done during time of administration. A print out of Resident 59's ASC Self Administration of Medication Request/Evaluation provided by DON on 10-7-21 at 10:30 a.m., was dated 10-7-21. The DON verified the evaluation was done on this date at 7:43 a.m. which was after administration and medications being kept at bedside. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. At 7:52 a.m., Nurse 6 administered Fiber 625mg, [MEDICATION(S)] 10mg, [MEDICATION(S)]/acetaminophen 5-325, Vitamin D 25mcg, [MEDICATION(S)] 2.5mg, Metopolol 100mg, [MEDICATION(S)] 40mg, Allupurinol 300mg, [MEDICATION(S)] 1mg and [MEDICATION(S)] 75mg to Resident 390. The Record Review on 10-7-21 at 9:22 a.m., indicated Resident 390's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was given prior to breakfast. On 10-7-21 at 10:30 a.m., the DON provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. At 8:20 a.m on 10/7/2., Nurse 6 administered [MEDICATION(S)] 50mg; aspirin 81mg, [MEDICATION(S)], and [MEDICATION(S)] to Resident 391. Nurse 6 provided a glass of water. Writer did not allow water to be given to resident due to fact resident was to have Honey Thick liquids. Resident 391was upset and stated medications were late and therapy was sure to start prior to medication helping. A record review on 10-7-21 at 9:21 a.m., indicated Resident 391's order for [MEDICATION(S)] was scheduled at 7:00 a.m. The medication administration was outside of the appropriate time frame. On 10-7-21 at 10:30 a.m., the DON provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order prior to 10-7-21 [MEDICATION(S)] 50mg tid to be given 7a, 3p and 11p. On 10-14-21 at 11:40 a.m. in an interview Staff 8 indicated Resident 391 received occupational therapy on 10-13 from 630 am to 705am resident stated to therapist he did not receive any pain medication and therefore would not complete all the exercises. Staff 8 indicated Resident 391 received Physical therapy on 10-1-21 at 7:45 a.m. to 8:20 a.m. All other therapies were done in the afternoon per interview. A policy; provided by Director of Nursing (DON) 10/7/21 at 10:30 AM; titled General Dose Preparation and Medication Administration dated 12/1/07 revision date: 5/1/10 and 1/1/13 indicates .verify each time a medication is administered that it is the correct time administer medications within timeframes specified by facility policy observe the resident's consumption of the medication 3.1-48 (c) (1)

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical procedures were followed for medication/treatment storage, medication labeling and discarding medication for 2 of 4 medication carts observed. ( Resident 59, Resident 49, Resident 43, and Resident 10) Finding included: 1. During an observation of medication administration on [DATE] at 7:30 a.m., Nurse 6 was observed to prepare Resident 59's morning medications. Resident 59's [MEDICATION(S)] (a blood thinner) 5 mg, ½ tablet was put into a medication cup. Resident 59's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] and multivitamin gummy were not available in the medication cart. During the observation of Nurse 6 administering the [MEDICATION(S)] to Resident 59, observed a bottle of [MEDICATION(S)] and a bottle of gummy multivitamin in a pink container which was on top of the bedside table. Nurse 6 was observed to leave the medication cup containing the [MEDICATION(S)] and heard the Nurse encourage Resident 59 to take the [MEDICATION(S)] and gummy vitamin. Nurse 6 did not observe Resident 59 take their medications. The clinical record of Resident 59 was reviewed on [DATE] at 9:20 a.m., which indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 59's records, found no evaluation for self-administration of medications. 2. During an observation of the 500 Hall Medication Cart on [DATE] at 3:33 p.m., with Qualified Medication Aide (QMA) 7, in the right side top drawer, 2 boxes of insulin were observed for Resident 49. The medication Novolog (insulin) INJ 100/milliliter (ml) was observed and was not labeled with an open date on the box nor the vial. The Novolog prescription (Rx) had a date filled of [DATE] from [Name] Pharmacy. The medication [MEDICATION(S)] INJ (insulin) was also observed without an open date labeled on the box nor the vial. The [MEDICATION(S)] Rx had a date filled of [DATE] from [Name] Pharmacy. During an interview with the Director of Nursing (DON) indicated, she was not sure why the medications for Resident 49 were in the medication cart because both of the insulin medications were discontinued. The Novolog was discontinued in [DATE] and the [MEDICATION(S)] was discontinued in [DATE]. The DON indicated the staff were aware, as soon a medication was discontinued they were to take the medication out of the cart. 3. During an observation of the 400 Hall Medication Cart on [DATE] at 3:45 p.m., with License Practical Nurse (LPN) 6, in the right side top drawer, 1 insulin pen was observed for Resident 43. The medication insulin [MEDICATION(S)] 100 unit/ml pen (insulin pen) was observed to be labeled with an open date of [DATE] written on the medication bag and on the insulin [MEDICATION(S)] pen. In the same drawer of the 400 Hall Medication Cart was an insulin [MEDICATION(S)] pen for Resident 10. The insulin [MEDICATION(S)] 100 unit/ml pen, was observed to be labeled with an opened date of [DATE] written on the medication bag and on the insulin pen. During an interview with LPN 6, indicated they believed the insulin pens were good for 45 days after being opened. During the interview with the DON, she indicated the insulin pens were only good for 28 days. 4. The record for Resident 49 was reviewed on [DATE] at 2:09 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 49's Novolog and [MEDICATION(S)] insulin vials were expired and were stored in the medication cart after being discontinued. 5. The record for Resident 43 was reviewed on [DATE] at 2:35 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 43's [MEDICATION(S)] insulin [MEDICATION(S)] was expired [DATE] and was stored in the medication cart after the expiration date. 6. The record for Resident 10 was reviewed on [DATE] at 2:50 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR for Resident 10 was reviewed on [DATE] at 2:59 p.m., indicated on [DATE] at 5:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale, and at 8:00 p.m., Resident 10 was given 6 units of insulin [MEDICATION(S)] per sliding scale. The EMAR for Resident 10 was reviewed on [DATE] at 2:59 p.m., indicated on [DATE] at 8:00 a.m., Resident 10 was given 2 units of insulin [MEDICATION(S)] per sliding scale; at 5:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale and at 8:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale. The EMAR for Resident 10 was reviewed on [DATE] at 2:59 p.m., indicated on [DATE] at 8:00 a.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale, and At 5:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale. The EMAR for Resident 10 was reviewed on [DATE] at 2:59 p.m., indicated on [DATE] at 8:00 a.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale; at 12:00 p.m., Resident 10 was given 2 units of insulin [MEDICATION(S)] per sliding scale; at 5:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale, and at 8:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale. The EMAR for Resident 10 was reviewed on [DATE] at 2:59 p.m., indicated on [DATE] at 8:00 a.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale; at 12:00 p.m., Resident 10 was given 2 units of insulin [MEDICATION(S)] per sliding scale; at 5:00 p.m., Resident 10 was given 6 units of insulin [MEDICATION(S)] per sliding scale, and at 8:00 p.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale. The EMAR for Resident 10 was reviewed on [DATE] at 2:59 p.m., indicated on [DATE] at 8:00 a.m., Resident 10 was given 4 units of insulin [MEDICATION(S)] per sliding scale. Resident 10 was administered insulin [MEDICATION(S)] after it had expired on [DATE] and was stored in the medication cart after it was expired. A current facility policy, titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, dated [DATE], was provided by the DON on [DATE] at 2:42 p.m. The policy indicated . Facility should ensure that medications and biological that: (1) have an expired date on the label .Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .Facility should store bedside medications or biological's in a locked compartment within the resident's room 3.,d+[DATE](j)(m) and (n)

[NAME], [NAME] Based on observation, interview, and record review the facility failed to contain transmission of COVID-19 during 2 of 2 observations made (Employee 4, Resident 322). Findings include: 1. An observation was made on 10-6-21 at 10:17 a.m., signage on Resident 322's indicated the resident was on droplet plus precautions and personal protective equipment (PPE). A gown, gloves, eye protection and N95 mask were required before entering the resident's room. A continuous observation was made on 10-6-21 at 10:24 a.m., Employee 4 entered Resident 322's room with an N95 mask, gloves and eye protection. Employee 4 did not put on an isolation gown. Employee 4 exited Resident 322's room at 10:32 AM. Employee 4 was interviewed on 10-6-21 at 10:58 a.m., Employee 4 indicated whenever a resident was on droplet plus precautions, staff were required to put on full PPE, which included: gown, gloves, N95 mask and eye protection. Employee 4 also indicated Resident 322 was on droplet plus precautions and Employee 4 should have worn a gown when Employee 4 entered resident's room. A continuous observation was made on 10-6-21 at 12:06 p.m., Employee 4 entered Resident 322's room with an N95 mask, gloves and eye protection. Employee 4 did not put on an isolation gown. Employee 4 exited Resident 322's room at 12:08 PM. The Administrator was interviewed on 10-6-21 at 4:00 p.m., The Administrator indicated staff were required to put on full PPE, which included: an N95 mask, eye protection, gown and gloves, before entering a droplet plus precaution room. A current facility policy, updated 5-4-21, titled, COVID-19 Resident Policy, was provided by the Administrator on 10-6-21 at 2:00 p.m., indicated staff should don the following PPE prior to entering the droplet plus precaution room: gown, N95 mask, eye protection, gloves. 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure accurate and complete documentation regarding controlled substance medication administration for 4 of 5 residents reviewed. (Resident D, Resident C, Resident F, and Resident G) Findings include: 1. The record review for Resident D began 3-8-2021 at 11:00 a.m. [DIAGNOSES REDACTED]. A review of the current physician orders [REDACTED]. [MEDICATION NAME] 325 mg capsule give 650 mg (milligrams) (2 capsules) for mild pain 2x daily prn (as needed) was ordered on 7-10-2019. [MEDICATION NAME] 50 mg po (by mouth) for moderate or severe pain every 4 hours prn was ordered on 1-14-2021 . A review of the Controlled Medication Record for [MEDICATION NAME] 50 mg tablet correlated with the MAR (Medication Administration Record) documentation for Resident D indicated the following: On 1-17-2021 at 10:15 a.m., 1 tablet was signed out on the Controlled Medication Record. The MAR for 1-17-2021 lacked documentation the [MEDICATION NAME] was administered. On 1-23-2021 at 6:10 p.m., 1 tablet was signed out on the Controlled Medication Record. The MAR for 1-23-2021 lacked documentation the [MEDICATION NAME] was administered. On 1-24-2021 at 9:35 p.m., the MAR indicated [REDACTED]. On 2-6-2021 at 2021 (8:21 p.m.), 1 tablet was signed out on the Controlled Medication Record. The MAR for 2-6-2021 lacked documentation [MEDICATION NAME] was administered. An interview with the DON (Director of Nursing) on 3-8-2021 at 3:45 p.m., indicated some nurses like to document the pain medication administration in the progress notes and not on the MAR. A review of Resident D's progress notes for 1-17-2021 at 10:37 a.m., indicated a note was written that pain medication was administered. The progress note lacked documentation regarding which pain medication, [MEDICATION NAME] or [MEDICATION NAME], was administered. A progress note for 2-6-2021 lacked documentation pain medication, [MEDICATION NAME] or [MEDICATION NAME], was administered. 2. The record review for Resident C began on 3-8-2021 at 12:15 p.m. [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. [MEDICATION NAME] (pregabalin) capsule 50 mg was also ordered on 2-8-2021 twice a day as needed for restless leg syndrome. A review of the Controlled Substance Record for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablets dated 2-8-2021 indicated there were 26 tablets delivered. The record indicated: On 2-11-2021 at 8:00 a.m. and 1:15 p.m., 1 tablet was signed out each time. The MAR indicated [REDACTED]. On 2-12-2021 at 8:30 p.m., 1 tablet was signed out. The MAR indicated [REDACTED] On 2-16-2021 at 6:30 a.m. and 9:00 p.m., 1 tablet was signed out each time. The MAR indicated [REDACTED] On 2-20-2021 at 8:10 a.m., 1 tablet was signed out. The MAR indicated [REDACTED] A review of the Controlled Substance Record for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablets dated 2-19-2021 indicated there were 30 tablets delivered. The record indicated: On 2-21-2021 at 8:45 a.m., 1 tablet was signed out. The MAR indicated [REDACTED] On 2-22-2021 at 4:30 p.m., 1 tablet was signed. The MAR indicated [REDACTED] On 2-24-2021 at 3:00 p.m. and 4:00 p.m., 1 tablet was signed out each time. The MAR indicated [REDACTED] There were 18 tablets left when the medication was discontinued. 18 tablets were marked as disposed on 3-4-2021, signed by a nurse and was witnessed by a nurse. A review of the Controlled Substance Record for the Pregabalin 50 mg capsule dated 2-8-2021 indicated there were 14 tablets delivered. The record indicated: On 2-11-2021 at 8:00 a.m., 1 tablet was signed out. The MAR indicated [REDACTED] A review of the Controlled Substance Record for pregabalin 50 mg capsule dated 2-19-2021 indicated there were 14 tablets delivered. The record indicated: On 2-24-2021 at 4:00 p.m., 1 tablet was signed out. The MAR indicated [REDACTED] A review of the progress notes on 2-11, 2-12, 2-16, 2-20, 2-21, 2-23 and 2-24-2021 for Resident C indicated the notes lacked documentation regarding pain medication administered. 3. The record review for Resident F began on 3-8-2021 at 1:30 p.m. [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. A review of Resident F's the Pharmacy Controlled Substances Record and Medication Administration Record [REDACTED] On 11-4-20 the Controlled Substances Record indicated 1 table was signed out at 8:00 a.m. The MAR indicated [REDACTED]. On 11-9-20 the Controlled Substances Record indicated 1 table was signed out at 8:10 a.m. The MAR indicated [REDACTED]. On 11-10-20 the Controlled Substances Record indicated 1 table was signed out at 20:00 (8:00 p.m.) The MAR indicated [REDACTED]. On 11-11-20, the Controlled Substances Record indicated, 1 tablet at 10:00 a.m., and 1 tablet at 19:30 (7:30 p.m.) were signed out. The MAR indicated [REDACTED]. On 11-12-20, the Controlled Substances Record indicated, 1 tablet at 9:00 a.m., and 1 tablet at 11:00 p.m., were signed out. The MAR indicated [REDACTED] On 1-16-20 the Controlled Substances Record indicated 1 table was signed out at 7:00 a.m. The MAR indicated [REDACTED]. On 11-17-20, the Controlled Substances Record indicated, 1 tablet at 6:45 a.m., and 1 tablet at 1:45 p.m., were signed out. The MAR indicated [REDACTED]. On 11-22-20 the Controlled Substances Record indicated 1 tablet was signed out at 7:15 a.m. with a note the resident dropped the medication. This entry and was co-signed with initials. Another entry 1 tablet was signed out at 7:15 a.m. The MAR indicated [REDACTED] On 11-30-20 the Controlled Substances Record indicated 1 tablet was signed out at 7:30 a.m. The MAR indicated [REDACTED]. A review of Resident F's the Pharmacy Controlled Substances Record and Medication Administration Record [REDACTED] On 12-1-20 the Controlled Substances Record indicated 1 tablet was signed out at 9:45 p.m. The MAR indicated [REDACTED]. On 12-3-20 the Controlled Substances Record indicated 1 tablet was signed out at 5:00 a.m., the entry on the record listed a 12-3-20 10:45 p.m., dose. The MAR indicated [REDACTED]. On 12-4-20 the Controlled Substances Record indicated 1 tablet was signed out at 22:05 (10:05 p.m.) The MAR indicated [REDACTED]. On 12-5-20 the Controlled Substances Record indicated 1 tablet was signed out at 18:00 (6:00 p.m.) The MAR indicated [REDACTED]. On 12-6-20 the Controlled Substances Record indicated 1 tablet was signed out at 19:05 (7:05 p.m.) The MAR indicated [REDACTED] On 12-7-20 the Controlled Substances Record indicated 1 tablet was signed out at 9:00 a.m. and 1 tablet at 2:00 p.m. The MAR indicated [REDACTED] On 12-8-20 the Controlled Substances Record indicated 1 tablet was signed out at 18:00 (6:00 p.m.) The MAR indicated [REDACTED] On 12-9-20 the Controlled Substances Record indicated 1 tablet was signed out at 19:20 (7:20 p.m.) The MAR indicated [REDACTED] On 12-10-20 the Controlled Substances Record indicated 1 tablet was signed out at 03:30 (3:30 a.m.) The MAR indicated [REDACTED]. On 12-12-20 the Controlled Substances Record indicated 1 tablet was signed out at 6:30 a.m. The MAR indicated [REDACTED] The bottom of each Controlled Substance Record for Resident F contained the following statement, Note. Chart each dose administered. Review of Resident F's progress notes dated November and December 2020, indicated documentation was lacking regarding administration of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. 4. The record review for Resident G began on 3-8-2021 at 3:30 p.m. [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. A review of Resident G's the Pharmacy Controlled Substances Record and Medication Administration Record [REDACTED] On 2-7-21 the Controlled Substances Record indicated 1 tablet was signed out at 11:30 p.m. The MAR indicated [REDACTED]. On 2-8-21 the Controlled Substances Record indicated 1 tablet was signed out at 19:00 (7:00 p.m.) The MAR indicated [REDACTED]. On 2-15-21 the Controlled Substances Record indicated 1 tablet was signed out at 8:30 a.m. A note stated, wasted with 2 sets of initials. The MAR indicated [REDACTED]. The bottom of each Controlled Substance Record for Resident G contained the following statement, Note. Chart each dose administered. An interview Nurse 1 on 3-8-2021 at 2:07 p.m., indicated when a resident would complain of pain and had a prn controlled substance pain medication ordered, the nurse should first assess the resident's pain. Nurse 1 indicated she would ask the resident what the pain level was on a scale of 1 - 10 and the location of the pain. She indicated if a resident had more than one type or strength of pain medication, she would use the assessment to determine which pain medication or dosage from the order to administer to the resident. The nurse indicated for the controlled substance pain medications, she would sign out the medication on the Controlled Substance Record. The nurse indicated after administration of the controlled substance pain medication, she would document in the Medication Administration Record. The nurse indicated after 45 minutes to an hour, she would follow up with the resident to ensure the pain medication was effective and she indicated she would continue to follow up with the resident during her shift. An interview with the DNS (Director of Nursing Services) on 3-8-2021 at 3:50 p.m, indicated documentation regarding controlled substances were reviewed for the facility. She indicated they had found the staff had documented the administration of PRN medications on the progress notes and not always on the MAR. She indicated the staff had been in-serviced on documenting in the MAR indicated [REDACTED]. She indicated the facility did not have a specific policy regarding documentation of PRN medications. Review of a current facility's pharmacy policy, provided by the DNS on 3-8-2021 at 4:35 p.m., titled, 6.0 General Dose Preparation and Medication Administration, with a revision date 1-1-2013 , indicated, .This policy 6.0 sets forth procedures relation to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications .5.5 Document the administration of controlled substances in accordance with Applicable Law: 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 (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms . This Federal tag relates to Complaint IN 983 and Complaint IN 759 3.1-25

Based on observation, interview, and record review the facility failed to ensure measures to prevent the potential spread of COVID were implemented according to current CDC guidelines. This had the potential to effect 4 of 4 residents related to co-horting new admissions, linen transferring, and hand hygiene. ( Resident 3, Resident 4, Resident 5, and Resident 10) Findings include: 1. Progress notes dated 11/28/20 at 7:09 P.M., indicated Resident 3 was admitted to the facility from Hospital A and placed in room [ROOM NUMBER]. Progress notes dated 11/28/20 at 6:50 P.M., indicated Resident 4 was admitted from Hospital B. The residnet was cohorted in room [ROOM NUMBER] with Resident 3. The DON was interviewed on 12/1/10 at 4:47 P.M. During the interview the DON indicated Resident 3 and Resident 4 were put in the same room because they were admitted within 24 hours of each other and were from the same hospital. She indicated the admission and cohorting was done according to facility policy. The DON indicated the facility had empty rooms on the yellow unit when Resident 3 and Resident 4 were admitted , but the rooms had belongings in them from residents who had moved but the rooms had not been cleaned. The DON also indicated the facility's Medical Director was in agreement with Resident 3 and Resident 4 residing in the same room as new admissions. The DON indicated the facility followed CDC and ISDH guidance. The Administrator was interviewed on 12/1/20 at 5:51 P.M. During the interview the Administrator indicated the day Resident 3 and Resident 4 were admitted and placed in the same room was during a holiday weekend. She indicated the facility did not have anyone to terminally disinfect the rooms that did not have residents residing in them on the yellow unit, so they placed Resident 3 and Resident 4 in the same room. She also indicated the facility's Medical Director was in agreement with Resident 3 and Resident 4 being placed in the same room. There was no documentation available indicating the Medical Director was aware of Resident 3 and Resident 4 residing as new admissions in the same room on the yellow unit. A Census Report dated 11/30/20 provided by the Director of Nursing Services (DON) on 12/1/20 at 7:00 P.M., indicated the facility had 5 rooms on the yellow unit without residents residing in them. A Census Report from 12/1/20 indicated Resident 3 and Resident 4 were residing in the same room. According to the same Census report the yellow unit had 7 rooms without residents residing in them on 12/1/20. A policy, dated 11/20/20, was provided by the DON on 12/2/20 at 2:00 P.M., titled COVID-19 Resident Policy. The policy indicated, .1. New Admissions or Readmissions to facility a. Refer to ASC COVID-19 Admission Criteria Policy .Admissions and readmissions with unknown COVID-19 status should be placed in a designated area/unit/wing of the facility when possible. When possible, the facility should dedicate staff for this unit/area/wing only. All residents with unknown Covid-19 status will be placed in 14-day observation for COIVD-19, will be placed on Droplet Plus Precautions .g. New admissions/re-admissions in observation will be limited to their rooms for 14 days while on Droplet Plus Precautions except for exceptions in outdoor visitation and other guidance per ISDH/CDC. i. Residents may be transferred out of that area or private room if they remain afebrile and without symptoms for 14 days. A policy, dated 9/28/20, was provided by the DON on 12/2/20 at 5:00 P.M., titled ASC COVID-19 Admission Criteria. The policy indicated, .Guidelines for Admission to a COVID-19 Positive ASC Facility. Definition: An entire facility that has widespread COVID or suspected COVID within the building, or an entire building designated as a COVID building. The facility may admit or readmit negative, recovered, or suspected COVID-19 patients as bed availability allows. Responding to Coronavirus (COVID-19) in Nursing Homes (April 2020) was retrieved on 12/2/20 from the Centers for Disease Control (CDC) website. The guidance indicates to Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. 2. During an observation on 12/1/20 from 10:42 A.M. until 10:48 A.M, the following was observed: Staff 6 was observed to enter Residnet 5's room, then leave Resident 5's room, go to a closet, open it, obtain a blanket, and then return to Resident 5's room. Staff 6 did not use hand sanitizer or wash his hands prior to going in the room, prior to leaving the room for a blanket, or before going back into the room. Staff 6 then assisted Resident 5, was wearing the blanket, out of the room. Staff 6 did not used hand sanitizer or wash his hands prior to leaving the room with Resident 5. Staff 6 wheeled Resident 5 through a set of doors to the front of the facility and placed him and his chair by the front desk. Staff 6 went outside through the front doors to a bus and opened the side doors of the bus. He then returned inside and wheeled Resident 5 to the bus. Staff 6 did not use hand sanitizer or wash his hands during the observation. A policy, dated 3/2018, was provided by the DON on 12/2/20 at 6:05 P.M., titled Hand Hygiene Policy. The policy indicated, .B. Indication for Hand-rubbing but not limited to: Before having direct contact with a resident and/or equipment. Before any procedure that do (sic) not require a surgical procedure. Before the starting a medication preparation. Before entering a resident's room. After leaving a resident's room (except if a resident has [DIAGNOSES REDACTED] or Norovirus) .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. 3. During an observation on 12/1/20 at 11:54 A.M., Staff 8 was observed walking down the hall carrying a clean folded blanket. The clean folded blanket was touching Staff 8's cloth shirt. Staff 8 handed the blanket to Staff 9 through Resident 10's doorway. The DON was interviewed on 12/1/20 at 7:34 P.M. During the interview the DON indicated clean laundry should be carried away from the body and it should not touch clothing. 3.1-18(a)

Based on record review and interview the facility failed to ensure a pending COVID-19 test was included in a resident's Discharge Summary for 1 of 3 residents reviewed (Resident 12). Findings include: A COVID-19 [MEDICATION NAME] Screening form dated 11/9/20, indicated Resident 12 had a PCR (polymerase chain reaction) COVID-19 test. The form also indicated the facility received and relayed positive results to Resident 12 and to the [MEDICAL TREATMENT] center they used on 11/12/20. A Transition of Care/Discharge Summary from 11/9/20 indicated resident 12 was being discharged home with Home Health Care. There was no mention of Resident 12's pending COVID-19 test in the discharge document. There was no available documentation indicating Resident 12 knew of his pending COVID-19 test upon discharge. The Director of Nursing (DON) was interviewed on 12/1/20 at 4:47 P.M. During the interview the DON indicated facility staff are not able to type in any discharge information and that all of the information is pulled from other sources. She also indicated Resident 12's pending COVID-19 test was not included in Resident 12's Transition of Care/Discharge Summary. A policy, dated 11/2019, was provided by the DON on 12/1/20 at 6:05 P.M., titled Discharge Planning. The policy indicated It is the policy of this to implement an effective, interdisciplinary discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Discharge planning will include an ongoing person-centered evaluation of needs, caregiver support, goals and preferences. Procedure: .2. Resident's that are appropriate for discharge planning will have collaboration with desired representative/caregivers or other support persons as applicable, and appropriate IDT members for a discharge plan formulation .4. Education and teaching identified as needed (ie wound care, specialized diets, etc.) will be given to resident/representative or support person and documented in the medical record .6. For discharges with a physician's orders [REDACTED]. This Federal citation is relalted to Complaint IN 291 3.1-36(a)(3)(b)

Based on interview, and record review, the facility failed to ensure assessments were accurate for 3 out of 5 residents reviewed. (Resident 1, Resident 62, and Resident 84) Findings include: 1. A review of Resident 1's record on 12/16/2019 at 3:45 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 15 out of 15, meaning cognitively intact. The score was obtained from the MDS (Minimum Data Set) 5 day Admission Assessment, dated 7/31/2019. [DIAGNOSES REDACTED]. The MDS 5 day Admission Assessment, dated 7/31/2019 indicated Resident 1 had no serious mental illness [DIAGNOSES REDACTED]. Section I of the MDS Assessment indicated active [DIAGNOSES REDACTED]. 2. A review of Resident 62's record on 12/12/2019 at 3:14 p.m., indicated a BIMS score of 11 out of 15, meaning moderate cognitive impairment. The score was obtained from the MDS Quarterly Assessment, dated 10/31/2019. [DIAGNOSES REDACTED]. The MDS Admission Assessment, dated 8/15/2019 indicated Resident 62 had no serious mental illness [DIAGNOSES REDACTED]. Section I of the MDS Assessment indicated an active [DIAGNOSES REDACTED]. The MDS Quarterly Assessment, dated 8/30/2019, Section I indicated [MEDICAL CONDITION] as an active diagnosis. The MDS Quarterly Assessment, dated 10/31/2019, Section I indicated [MEDICAL CONDITION] as an active diagnosis. During an interview on 12/16/2019 at 10:12 a.m., the ED (Executive Director) indicated they would modify the assessment. During an interview on 12/16/2019 at 10:30 a.m., the MDS Coordinator, indicated the facility did not have the Level II Assessment back from Ascend (Pre admission screening company) yet was why the Section A had not been documented properly. During an interview on 12/16/2019 at 10:53 a.m. the MDS Coordinator indicated the facility ARD (Assessment Reference Date) specialist indicated they would not have documented Resident 62 had a serious mental illness because they did not have the Level I assessment back yet. The MDS Coordinator then indicated the resident was admitted with the [DIAGNOSES REDACTED]. 3. A review of Resident 84's record on 12/13/2019 at 11:45 a.m., indicated a BIMS score of 8 out of 15, meaning moderate impairment. The score was obtained from the MDS Quarterly Assessment, dated 11/9/2019. [DIAGNOSES REDACTED]. A Care Plan, implemented on 4/3/2019, indicated Resident 84 required a splint/brace program to her right hand. A Care Plan, implemented on 4/3/2019, indicated Resident 84 required passive range of motion to her right hand. The MDS Quarterly Assessment, dated 5/31/2019 indicated no PROM (Passive Range of Motion) services or brace/splint application documented in Section O. The MDS annual assessment, dated 8/14/2019 indicated no PROM services or brace/splint application documented in Section O. During an interview on 12/16/2019 at 12:05 p.m., CNA (Certified Nurse Aide) 1 indicated the Restorative CNA was the CNA who provided the splint and ROM (Range of Motion) programs for Resident 84, because they were part of the Therapy Department. During an interview on 12/16/2019 at 12:15 p.m., the Director of Therapy indicated the resident was receiving services and indicated the area should have been documented in the MDS Section O. During an interview on 12/16/2019 at 12:48 p.m., the Interim DNS (Director of Nursing Services) indicated the facility did not have a policy for accuracy of coding assessments, they would refer to the RAI (Resident Assessment Instrument) manual.

Based on interview and record review, the facility failed to ensure a Transfer Form was completed for 1 of 5 residents reviewed for transfers to another health care facility. (Resident 38) Findings include: A review of Resident 38's medical record on 11/29/2018 at 12:14 p.m., indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15 out of 15, meaning they were cognitively intact. Resident 38's [DIAGNOSES REDACTED]. During an interview on 11/28/2018 at 2:47 p.m., Resident 38 indicated he couldn't breath and was admitted to the hospital for 7 days in October. The MDS (Minimum Data Set) list indicated a discharge with return anticipated was completed on 10/25/2018. A Progress Note on 10/25/2018 at 9:00 p.m., indicated an order had been obtained to send the resident to the hospital. There was no Transfer form completed in the medical record. During an interview on 12/3/2018 at 11:45 a.m., the DNS (Director of Nursing Services) indicated there was no Transfer Form completed. A current facility policy, Hospital Discharge/Transfer, dated 10/2017, provided by the ED (Executive Director) on 12/3/2018 at 2:55 p.m., indicated the following: .Nursing will complete an Emergency transfer form and attach copies of the following information from the resident medical: . 3.1-12(a)(3)

Based on observation, interview, and record review the facility failed to document notification of a Personal Representative for 1 of 5 residents reviewed for documentation. (Resident 82) Findings include: A review of Resident 82's medical record on 11/29/2018 at 1:45 p.m., indicated the residnet had a BIMS (Brief Interview of Mental Status) score of 3 out of 15, meaning they had severe cognitive impairment. On 11/29/18 at 4:06 p.m., Resident 82 was observed sitting in the facility's main lounge, visiting with his wife. On 11/30/2018 at 5 p.m., Resident 82 was observed standing in the 400 hall, near the main dining room. On 12/3/2018 at 10:30 a.m., Resident 82 was observed sitting on the sofa, in the 400 hall lounge. During an interview on 11/27/2018 at 4:23 p.m., the Personal Representative of Resident 82 indicated they were not made aware that another facility was coming to assess the resident for placement in another facility. A Progress Note on 7/30/2018 at 11:10 a.m., indicated another health care facility was there to assess the resident for possible placement in an all male Memory Care Unit. A Progress Note on 7/31/2018 at 10:14 a.m., recorded as a late entered documentation on 8/1/2018 at 10:17 a.m., indicated the MCF (Memory Care Facilitator) had spoke to the Personal Representative regarding the possibility of transferring Resident 82 to another facility. The Personal Representative was adamant that they did not want the resident moved to another facility. During an interview on 11/30/2018 at 3:10 p.m., MCF indicated the other facility had assessed Resident 82 on 7/30/2018 and the discussion with the Personal Representative occurred on 7/31/2018. The MCF indicated they should have talked to the Personal Representative first and documented the conversation. The MCF indicated they thought they had documented the conversation prior to the assessment but could not find any documentation. During an interview on 12/3/2018 at 2:45 p.m. the ED (Executive Director) indicated the documentation of notification was not documented in the residents medical record. A current facility policy, Resident Change of Condition Policy, dated 11/2018, provided by the ED on 12/3/2018 at 2:55 p.m., indicated notifications to Family/Responsible Party about resident changes would be documented in the residents medical record. 3.1-50(a)

Based on observation, interview and record review, the facility failed to ensure a portable oxygen concentrator was stored a safe distance from the heat of a functioning hair dryer and the facility further failed to ensure salon equipment was inspected routinely for good operating condition as well as lack of supervision of a resident in the beauty shop. Further the facility failed to ensure beauticians had been trained in the use of fire extinguishers and not using aerorol hair spray in the presence of a resident with oxygen on for 1 of 1 resident observed who received salon services while a portable oxygen concentrator was stored next to the hair dryer's heat source and motor. (Resident # 113) The Immediate Jeopardy was identified on 10/17/16 and began on 10/17/16 when 1 of 1 residents with oxygen functioning, in the facility's hair salon was observed seated in her wheelchair under a hair dryer hood with oxygen source within two feet of the base of the hooded hair dryer. Upon interview with the beautician, it was identified she had no training in the use of a fire extinguisher or in the safe use of aerosol hair spray. Further, there was no preventative maintenance documentation regarding the hair dryer. The Director of Operations, Director of Nursing (DON), Assisted Living General Manager and Nursing Consultant were notified of the Immediate Jeopardy on 10/17/16 at 3:05 p.m. Findings include: 1. During observation on 10/17/16 at 10:02 a.m., the beauty shop door was observed opened. The salon sign on the wall outside the beauty shop indicated Salon .no oxygen allowed. Next to this sign, was a magnetic sign on the door jam, which indicated No smoking .oxygen. Resident # 113 was observed in her wheelchair (wc) in the beauty shop with oxygen being administered via nasal cannula, which was also attached to a portable oxygen concentrator. She was observed to be getting her hair rolled but was located within 5 feet of the hooded hair dryers. At 10:03 a.m., the resident was observed to be pushed in her wc, by the beautician, underneath a hooded hair dryer. The oxygen remained on the resident as the hair dryer was turned on by the beautician. The portable concentrator was placed beside the hooded hair dryer on the floor, within two feet of the base of the hair dryer. Oxygen tubing was observed to be coiled on the floor beside the concentrator. At least 1 can of aerosol hair spray was observed to be sitting on the counter in the beauty salon. The counter with the aerosol hair spray was approximately 8 feet from the closest hair dryer. Also observed in the beauty shop at this time, were two other residents. At 10:15 a.m., Resident #113 was observed in the beauty shop herself, with no other residents and no beautician in the beauty shop. The resident remained with her oxygen on via nasal cannula, while the hair dryer also remained on. The concentrator remained on the floor, 2 feet from the resident. At 10:16 a.m., the Beautician returned to the beauty shop with two additional residents. At 10:16 a.m., Beautician #14 was interviewed. She indicated she was one of the beauticians, who worked at the facility. She indicated even though the Salon sign by the door indicated No oxygen, when residents were brought to the beauty salon with portable oxygen devices, the nurses moved the resident's oxygen tubing from their portable tank to the rolling concentrator. The Beautician indicated the use of the concentrator was permissible in the beauty shop, but the small portable tanks were not. Resident #113 remained with her oxygen on via nasal cannula and the hair dryer hood on, over the resident's head, with the condenser 2 feet from the base of the hair dryer. At 10:30 a.m. the current policy and procedure for Oxygen Use in the Beauty Shop dated 1/2016 was received from the Nursing Consultant. The policy included, but was not limited to, the following: It is the policy of (Corporation Name) to promote the health and safety of the residents using the beauty shop services and all other residents. Procedure: If medically possible, consult with physician to remove oxygen while the resident is under the hair dryer or near any producing devices. If a resident is unable to be without oxygen therapy while in the beauty shop, the following will apply: The oxygen tank will be kept as far away from the dryer unit as the tubing will allow without creating a hazard for individuals walking in the area. Non-aerosol hairspray will be used on resident's hair using oxygen. Residents on oxygen therapy will not be left unattended while in the beauty shop .Beauty shop employees will be trained on the location and use of the fire extinguisher On 10/17/16 at 10:33 a.m., RN #15 and CNA #12 were observed in the beauty shop with the beautician. Resident #113 was not under the dryer anymore, and the hair dryer was now off. Resident #113 was still observed in the beauty shop with her oxygen on via nasal cannula. CNA #12 and RN #15 were observed to move the concentrator to the door of the beauty shop, which the concentrator had enough oxygen tubing to accommodate this distance. This was at least 13 feet from the resident's wheelchair underneath the hair dryer hood, to the door, where the concentrator was positioned. At this time, the resident was observed at the mirror/sink with her oxygen still on and the oxygen concentrator could be heard on. The beautician was observed to be spraying aerosol hair spray on the resident's hair as oxygen continued to be delivered to the resident via her nasal cannula. At 10:35 a.m., a fire extinguisher was observed in the beauty shop on the wall. At 11:00 a.m., Resident #113 was no longer observed in beauty shop. At this time, Beautician #14 was interviewed. The oxygen concentrator was observed in the beauty shop plugged in to the wall outlet but was not turned on. The Beautician indicated she was not trained on how to use the fire extinguisher. She indicated residents with oxygen were not allowed in the beauty shop as far as I know. The Beautician was made aware Resident #113 was just observed in the beauty shop earlier this morning, while Beautician #14 was in the beauty shop. The Beautician indicated at this time, it was her understanding that the portable oxygen tanks on the back of resident's wheelchairs were not allowed in the beauty shop. She indicated that the blue concentrator tanks have always been used in the beauty shop. The Beautician also indicated she had not been trained on oxygen used on residents in the beauty shop. She indicated she was just told portable tanks were not allowed but she was unsure who told her this or when she was told that. She indicated she was one of 3 beauticians who worked in this salon at the facility. She indicated the nurses were the ones that move the resident's oxygen tubing over from the portable small tan tank to the blue condenser. At this time, the hair dryer was observed in the Salon. No documentation was observed on the hair dryers as to the equipment having been serviced and/or maintained. At this time, the tag on the fire extinguisher in the beauty salon had a date of 9/12/16, which indicated it had been checked. On 10/17/16 at 12 p.m., LPN #8 was interviewed. She indicated she changed Resident #113 oxygen over from the portable oxygen to the concentrator. She indicated the concentrator should be kept far away from the heat source. She indicated she was not sure where the concentrator was located when LPN #8 changed the resident's oxygen tubing over from the portable tank to the condenser this morning. LPN #8 indicated she switched the oxygen from the portable tank to the condenser this morning when the resident was getting her hair washed. On 10/17/16 at 1:42 p.m., the Assisted Living General Manager provided a copy of the Manufacturer's Instructions for Everflo User Manual, dated 2007. This Manual included, but was not limited to, the following: .Warnings .Keep the device at least 6 to 12 inches away from walls, furniture .that could impede adequate airflow to the device .Oxygen vigorously accelerates combustion and should be kept away from heat .Operating instructions .Do no place the device near any heat source . On 10/17/16 at 2:07 p.m., the Nursing Consultant was interviewed regarding the beautician in charge of the beauty shop. She indicated the beauticians were independently contracted by the facility and she didn't think there was any one particular beautician in charge. She thought the hair dryer belonged to the facility but was not sure. She indicated there was only one resident, Resident #113, that was on oxygen and had her hair done in the salon. On 10/17/16 at 4:54 p.m., the Director of Nursing (DON) provided a copy of the Operating, Usage, and Maintenance Instructions for your Hair Dryer, dated 2006 included but were not limited to, the following: .This is a commercial use dryer and all servicing should be performed by an authorized representative .This dryer is equipped with a foam filter. To operate efficiently, it is imperative that the flow of air intake be free and not obstructed by dirty clogged filters. For best results, inspect filter every week and clean if necessary. Cleaning is simple and rapid. Remove filter from dryer, wash in warm soapy water and rinse in clear water, shake out excess water, replace filter . On 10/17/15 at 3:24 p.m., the DON was interviewed. She indicated Beautician #17, did her own cleaning of the hair dryer weekly. She indicated there was no policy on preventative maintenance for the hair dryer. The clinical record of Resident#113 was reviewed on 10/18/16 at 8:30 a.m. [DIAGNOSES REDACTED].heart failure The MDS (Minimum Data Set) assessment dated [DATE], included but was not limited to, the following: cognition score of 8, which indicated moderately impaired cognition; extensive assistance required for transfer between surfaces and ambulation in room did not occur. On 10/18/16 at 9:00 a.m., the Maintenance Supervisor and the Executive Director toured the beauty shop. At this time, the Maintenance Supervisor was interviewed. He indicated the motor/heating element portion of the hair dryer would be housed in the area between the legs of the hair dryer and hood, approximately 2 feet off the floor. At this time, the Maintenance Supervisor indicated it was approximately 8 feet from the area in front of the hair wash sink to the area where Resident #113 was sitting under the hair dryer yesterday. Resident #113 was sitting under the hair dryer closest to the hair wash sink. The Maintenance Supervisor also indicated at this time, the distance from the door to the hair dryer hood resident #113 was sitting under yesterday was approximately 13 feet. The maintenance man indicated yesterday, there were 4 hair dryers housed in the beauty salon which was 22 1/2 feet long x 10 feet wide. He indicated the head beautician, Beautician #17, had purchased a new hair dryer and the Maintenance Supervisor put the handles and the legs on the hair dryer. He indicated he did the initial inspection of the new hair dryer, just fired it up and made sure it ran ok. He indicated he typically does a quick glance over the equipment about once a month. He indicated he does not keep a log for this equipment of having been checked. The Maintenance Supervisor indicated the head Beautician #17 did a good job keeping the filters on the hair dryers cleaned. 2. An interview with the Director of Operations on 10-17-2016 at 11:03 a.m., indicated the facility staff had training and in-servicing completed on oxygen safety and the fire extinguisher. The Regional Director further indicated he was not sure about the oxygen safety and the fire extinguisher training for the beautician. An interview with the DON (Director of Nursing) on 10-17-2016 at 11:05 a.m., indicated she had the training records for the staff for the oxygen and fire extinguishers in-services and Human Resource #16 would have the information for the beautician. Further interview with the DON, indicated staff were provided training in general orientation by Maintenance and yearly during the annual compliance for fire safety. The DON also indicated the staff had completed training on the computer for fire safety. The DON provided the training records at this time for the CNAs (Certified Nursing Assistants) who were working in the 400 and 500 hall on 10-17-2016 during the day shift and for the LPN (Licensed Practical Nurse) in the 500 hall. CNA #5 had training on filling portable oxygen canister and Fire dated 4-23-2016. CNA #7 had training on filling portable oxygen canister validation packet dated 8-15-2006, a filling portable oxygen canister on 1-12-2013, and an undated Fire Drill/Fire Safety In-Service Test. LPN #8 had training a Nurse Orientation Skills Validations for filling Portable Oxygen and Oxygen Delivery Services which was dated 8-12-2016. CNA #9 had training documented on a nursing skills validation form with Filling Portable Oxygen Canister on 4-11-12. A Fire Drill/Fire Safety In-Service Test was dated 5-29-2012. CNA #10 had training on filling portable oxygen tank and Fire dated 12-9-2013. An undated Fire Drill/Fire Safety In-Service Test was also provided for CNA #10. CNA #11 had training on filling portable oxygen tank and Fire which was dated 4-26-2016. CNA #12 had training on filling portable oxygen tank dated 1-10-2013 and 2 of the Fire Drill/Fire Safety In-Service Tests, with one dated 5-29-2012 and the other undated. During an interview with the DON on 10-17-2016 at 11:25 a.m., the DON was asked how staff were educated on oxygen concentrators. The DON indicated staff were educated at orientation and during the annual compliance in-services. On 10-17-2016 at 11:32 a.m., Human Resources #16 provided the current beautician license for Beautician #14 and the signed Beautician Agreement which indicated the following: .(facility and printed name of Beautician) have entered into an agreement to provide hair care services for the residents of the community. This agreement is effective as of August 21, 2007 .(facility), as part of the salon space, will provide all utilities, including electricity and water .The beautician will provide all hair cutting utensils, shampoos and treatments, in addition to all other equipment necessary for her work. The beautician will also be responsible for assuring that all equipment and the salon area are maintained in a sanitary condition, and comply with the proper and safe storage of all chemicals and hazardous items . This was signed by the Beautician and the Executive Director. During a review of the 2016 in-service book on 10-17-2016 at 11:30 a.m., an entry of Fire Drill and Safety was listed and the record lacked a description of what was instructed. On 10-17-2016 at 11:50 a.m., the Assisted Living General Manager provided the information the Maintenance Supervisor used during staff orientation: .Disaster Preparedness Policy Section D Fire Prevention Fire Watch Policy and Procedure Procedure for Staff Response to Battery Powered Smoke Detectors Section E General Fire Action Plan The Assisted Living General Manager also provided the Mandatory All Staff In-Service (computer program) Calendar 2016 and the course completion history for the computer program for all staff for Fire Safety: The Basics and Fire Safety for Workers in Long Term Care - Retired 2-1-2016. Each of the above mentioned staff had completed the new Fire Safety: The Basics in 2016, except for the Beautician. An interview with QMA #13 on 10-17-2017 at 12:00 p.m., indicated if a fire was discovered QMA #13 indicated she would remove the resident and hopefully there would be another CNA around so they could get some direction for residents. She indicated she would ask staff to pull the alarm and if the fire could be extinguished she would use the fire extinguisher and pull the tab and aim and fire. An interview with CNA #12 on 10-17-2016 at 12:02 p.m., indicated if she discovered a fire in a resident room, she would pull the alarm and get the fire extinguisher and pull pin and sweep at the base of the fire. A current, undated policy .Disaster Preparedness Policy was provided by the Assistant Living General Manager on 10-17-2016 at 11:50 a.m. The policy indicated .things to remember during a fire .turn off oxygen A current, undated policy Fire Prevention was provided by the Assistant Living General Manager on 10-17-2016 at 11:50 a.m. The Fire Prevention policy indicated .the facility is equipped with portable fire extinguishers .employees will be advised during general orientation of the basic safety policies and procedures .and during specific job orientation to the specific safety practices related to the assigned tasks .monthly, quarterly and annual protection equipment testing will be performed and recorded .regularly scheduled drills on rotating shifts and at different times will be conducted to evaluate preparedness .documentation of such drills and participants will be kept on file .Class B combustibles are flammable liquids, gases and aerosols .combustibles include .oxygen .all items packaged in aerosol spray cans .the maintenance department is responsible for assuring all items are appropriately stored and labeled .all oxygen tanks must be turned off when not in use by the resident .Department Directors are responsible to ensure that all operation procedures include necessary safety precautions to prevent fires and supervise the departments' operations adherence to such policies .staff and subcontractors who fail to adhere to the facility's Fire Prevention Policy will be counseled in accordance with the Personnel Policies and service agreements. A current, undated policy, General Fire Action Plan was provided by the Assistant Living General Manager on 10-17-2016 at 11:50 a.m. The General Fire Action Plan indicated in case of fire follow R.A.C.E procedure .RESCUE - remove persons from the room .continue past fie doors with evacuated persons .ALARM - pull alarm .located at the fire exits .Confine - extinguish fire if confined (extinguishers in the hallways) .close doors and windows .turn off machinery .EVACUATE remove person(s) in rooms NEXT TO and ACROSS from the fire. Continue removing in sequence all persons in the area until all are PAST THE FIRE DOORS .do not go back through the Fire Doors unless necessary Further review of the policy indicated .IN CASE YOU HEAR OR SEE A FIRE ALARM .turn off machinery and proceed to area of fire .bring extinguishers to the announced area and Additional Steps to Follow .shut off oxygen Upon review of all of the information provided by the facility, there was no indication staff were educated on oxygen safety and the procedure for use of the fire extinguisher. Upon arrival to the facility on [DATE] at 8:14 a.m., a sign was posted on the Beauty Shop room door which indicated the following, Beauty Shop closed until further notice. Upon entrance to the facility on [DATE] at 8:15 a.m., a sign was posted on the beauty shop door Beauty Shop closed until further notice. An observation of the beauty shop door (which was closed) on 10-19-2016 at 4:45 p.m., indicated there was a sign posted Beauty Shop closed until further notice. Also to the left of the door a sign indicated Beauty Shop .No Pets Allowed .No Oxygen Allowed and on the left side of the door on the frame was a magnet Oxygen in Use .No Smoking An observation of the beauty shop door (which was closed) on 10-20-2016 at 8:57 a.m., indicated there was a sign posted Beauty Shop closed until further notice. Also to the left of the door a sign indicated Beauty Shop .No Pets Allowed .No Oxygen Allowed and on the left side of the door on the frame was a magnet Oxygen in Use .No Smoking An observation of the beauty shop on 10-21-2016 at 9:07 a.m., indicated the beauty shop room door was open and a resident was being wheeled inside by a CNA. An observation of another resident indicated she was having her hair washed by a beautician. The sign to the left of the door indicated Beauty Shop .No Pets Allowed .No Oxygen Allowed and on the left side of the door on the frame was a magnet Oxygen in Use .No Smoking 3. An interview with CNA #18, on 10/17/16 at 11:00 a.m., indicated the residents with oxygen did not go to the beauty solon to have their hair done. She indicated the CNAs use a shampoo cap to wash the resident's hair. She further indicated she did not know if they could ever go to the beauty salon at all and would have to check with her supervisor to find out. An interview with CNA #6 on 10/17/16 at 11:07 a.m., indicated she used to work in the Beauty Solon and indicated if a resident required oxygen, the nurse had to remove the oxygen tubing from the portable oxygen tank and connected the oxygen tubing to the oxygen concentrator in the Salon. The CNA indicated the oxygen concentrator remained in the beauty shop all of the time. She also indicated the oxygen concentrator could be moved around the solon if needed. The CNA pointed to the hairdryers and indicated the placement of the oxygen concentrator depended on the length of the resident's oxygen tubing. The CNA indicated the oxygen concentrator could be next to the resident while they sat under the hairdryer. The CNA also indicated the oxygen concentrator needed to be away from the electrical outlets. CNA #6 further indicated most of the residents, who have their hair done at the Beauty Salon required oxygen. On 10/17/16 at 11:10 a.m., an observation with CNA #6 , indicated the oxygen concentrator in the beauty salon was with the back of the concentrator against the wall and approximately 3 inches from an electrical outlet. An interview with the Maintenance Supervisor on 10/17/16 at 11:15 a.m., indicated the maintenance department did not do routine maintenance check on the oxygen concentrators in the facility. He indicated (Company Name, a contracted medical supply company) provided the oxygen and oxygen concentrators for the residents and indicated the routine maintenance for the oxygen concentrators was done by that Company. The Maintenance Supervisor also indicated he did not do any routine or preventive maintenance checks on the beauty salon's hairdryers. He indicated he believed the hairdryers belonged to the beautician and indicated the hairdryers were not the facility's equipment. He indicated he had fixed some of the Salon's equipment when there was a problem and also indicated he had recently put together a new hairdryer for the Salon. The Maintenance Supervisor indicated the facility's fire extinguishers were inspected monthly by the facility's maintenance staff and yearly by (Company Name, a the contracted Fire Safety Specialist Company.) He indicated the Fire Safety Company tagged the fire extinguishers with a new tag when inspected and the maintenance staff's monthly inspection date was written on the tag. An interview with the Maintenance Supervisor on 10/17/16 at 11:50 a.m., indicated the oxygen concentrators should have an adhered label with the date when last inspected by (Company Name). He also provided a copy of the Beauty Salon's fire extinguisher inspection tag. Review of the inspection tag indicated a date of 912/16 when last inspected by the facility's maintenance staff. The Fire Extinguisher Tag did not have the extinguisher's identifying information completed on the inspection tag. The Maintenance Supervisor also provided the fire extinguisher report from the (Company Name) Fire Safety Specialist, review of the document indicated the facility's fire extinguishers were inspected on 6/27/16. The Immediate Jeopardy that began on 10/17/16, was removed on 10/18/16 after the facility had inserviced staff and beauticians on the following: fire extinguisher procedure; use of non aerosol hairspray in the beauty shop when oxygen is in use; oxygen tanks to be kept as far away from the dryer unit as the oxygen tubing will allow (policy updated to be a minimum of 5 feet away from hair dryer); Beautician will continue to inspect hair dryers weekly including cleaning vents, hood and filters as necessary (this routine maintenance will be documented on a weekly log, with Maintenance insecting the log monthly) and residents are to be supervised at all times while in the beauty shop. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. 3.1-19(c)

Based on record review and interview the facility failed to follow physician orders [REDACTED]. Two of the three residents were readmitted to the hospital. (Resident B and D) Findings include: 1. On 2/3/11 at 1:30 p.m. review of the clinical record for resident (F) indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medication Orders sent from the hospital on [DATE], and listed under "Active Reported Home Medications-Last Verified 11/30/2010 " indicated the resident was to receive [MEDICATION NAME] ( a diuretic medication) 40 milligrams daily. Hold if systolic blood pressure less than 110. Review of the "Handwritten Progress Notes" from the hospital dated 11/30/10 indicated "Reviewed Meds, Parameter for [MEDICATION NAME] given for systolic blood pressure." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nursing notes dated 12/5/10 at 12:00 p.m. indicated "2+ [MEDICAL CONDITION] (swelling) to left ankle 1+ non [MEDICAL CONDITION] to right foot and ankle. Alert and oriented able to make needs known. Breath sounds clear no shortness of breath noted. Nurse Practitioner called new order received and noted chem 6 (laboratory test) on Wednesday 12/8/10 [MEDICATION NAME] 40 milligrams daily potassium 20 millequivelents daily. Ted hose on in the AM (morning) and off at HS (bedtime) Lab and daughter notified." A progress note written 12/6/10 indicated "Nursing concern with coarse breath sounds over the weekend (yesterday) nurse practitioner on call notified of [MEDICAL CONDITION] congestion ([DIAGNOSES REDACTED]. A physicians telephone order - (per nurse practitioner for the cardiologist) dated 12/7/10 indicated "Give [MEDICATION NAME] @ 40 milligrams per mouth daily - extra tab today & tomorrow for 80 milligrams. Decrease [MEDICATION NAME] (heart medication) to 3.125 milligrams per mouth twice daily. Oxygen per nasal cannula @ 2 liters per minute continuous. Chest x-ray Friday. Return to clinic Friday. Lab today BMP -BNP completed in office today." Nursing notes dated 12/9/10 at 9:30 p.m. indicated "Resident complaining of shortness of breath and was coughing frequently. Said she didn't feel well. Temperature 99.8 pulse 78 respirations 23 blood pressure 120/70. Oxygen saturation fluctuating between 88-90%. Doctor called, new orders received to sent to emergency room for evaluation. Daughter here. Report called to emergency room . Paramedics called and transported resident to emergency room ." An emergency room Report dated 12/9/10 indicated the resident was admitted to the hospital with [REDACTED]. 2. The clinical record for Resident D was reviewed on 02/03/11 at 2:00 P.M. The resident was admitted to the facility, from an acute care facility, on 01/25/11 with diagnosis, including but not limited to, [DIAGNOSES REDACTED], history of miocardial infarction, diabetes mellitus, impaired renal function, and mitral valve issues. The admission physician orders, faxed and sent from the acute care facility, included orders for the following medications: [REDACTED] medication), [MEDICATION NAME] 850 mg at bedtime (a oral antidiabetic medication), [MEDICATION NAME] .4 mg sublingual (a medication to dilate blood vessels and relieve chest pain) no frequency given but usually given as needed for chest pain, [MEDICATION NAME] 1 tab daily ( a medication to treat [MEDICAL CONDITION] reflux disease), [MEDICATION NAME] 40 mg daily (an antidepressant), [MEDICATION NAME] 200 mcg daily (a medication to treat [MEDICAL CONDITION] disorders), [MEDICATION NAME] 40 mg at bedtime (a medication to treat high cholesterol)" The acute care center discharge form listed some of the medication orders under a "Active Reported Home Medication" list and some medications, including some but not all of the medications listed under the home medication list, under the title "Active Inpatient Medications." Both sections had "Continue or Discontinue" marked for each individual medication listed. The Active Home Medications section of the form had a black pen line drawn horizontally through the orders. The transcription of the admission MEDICATION ORDERS FOR [REDACTED]. Thus only the following medications were transcribed and administered to Resident D: [MEDICATION NAME] 40 mg daily, [MEDICATION NAME] 200 mcg daily, [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 40 mg at bedtime, Calcium Carb with Vitamin D 600 mg three times a day, Aspirin 81 mg once a day, [MEDICATION NAME] Sodium 100 mg as needed daily, and [MEDICATION NAME] .4 mg sublingual every 5 minutes times 3 as needed for chest pain. The resident did not receive the [MEDICATION NAME], Imdur, [MEDICATION NAME], or the [MEDICATION NAME]. Interview with the Director of Nursing, on 02/03/11 at 1:45 P.M. indicated the long term care facility automatically disregarded the Home Medication List orders section from the 6 pages discharge form from the acute care facility. She indicated if the physician desired to have any other medications other than those the resident had received inpatient, there was a space to write the medication in at the end of the form. There was no specific time frame or person from the acute care facility that had directed the long term care facility to disregard the medication orders from the Home Medications list orders. The Director of Nursing indicated the issues with the discharge orders from this specific acute care facility started about 2 years ago and since the facility started disregarding the Home Medication order list, the need for clarification had been greatly reduced. She indicated the long term care facility had in the past had trouble trying to clarify the orders because the floor nurse's changed shifts and/or the chart was not always available on the nursing floor after the resident was discharged to the long term care facility. Interview with the acute care center's Nursing Administrative Director of Nursing, on 02/04/11 at 9:15 A.M. and phone interview with the Discharge Coordinator, on 02/04/11 at 9:15 A.M. indicated no one at the acute care center had ever instructed the long term care facilities to disregard the medication orders in the Home Medication list. The Nursing Administrative Director of Nursing indicated the discharging physician personally marked the six page form and intended all medications marked "Continue" to be administered after the resident was discharged to the long term care facilities or to their respective homes. She acknowledged the physicians were occasionally sloppy and sometimes marked the same medication with two different strengths or two medications from the same medication class in error and if the discharging nurse from the acute care facility did not "catch" the error and clarify the medications, then the long term care facility would need to "clarify" the orders. She indicated there was always a nurse working around the clock in the administrative nursing office of the acute care center with access to the electronic record who could assist the long term care facility with clarifying any questionable medication orders. Review of the discharge MEDICATION ORDERS FOR [REDACTED]. Review of the nursing progress notes, dated 01/27/10 at 10:20 P.M. indicated the resident had become short of breath, developed cool, clammy skin, elevated blood sugar of 258, oxygen saturation dropped to 89 - 94 percent on oxygen, resident had dry heaves, and blood pressure elevated to 181/100, pulse elevated at 100 beats per minute. The resident was transferred to the acute care center emergency room . Review of the physician assessment from the acute care center emergency room , dated 01/28/11 at 12:06 A.M. indicated the resident was assessed to be in [MEDICAL CONDITION] due to not receiving a number of her [DIAGNOSES REDACTED] medicines for the past 3 days. The resident was noted to be having chest pain and discomfort in the emergency room The chest x-ray, obtained on 01/28/11 at 12:05 A.M. indicated the resident's Xray suggested an increase in [MEDICAL CONDITION], increased from 01/22/11 with lung interstitial [MEDICAL CONDITION] and pleural fluid. The resident's blood sugar was also noted to be elevated when she was admitted to the acute care center. 3. Resident B's clinical record was reviewed on 2/4/11 at 10:00 A.M.. The record indicated the resident was originally admitted to the facility on [DATE] for rehabilitation following an above the knee amputation (AKA) of her right leg. On 1/24/11 through 1/28/11 she was in an acute hospital for a revision of the right AKA and readmitted to the facility on [DATE]. Review of the signed discharge physician's orders [REDACTED]. The active reported home medications included Aspirin EC 81 mg (milligrams) oral daily and [MEDICATION NAME] 3 mg oral daily on Monday, Wednesday and Fridays and [MEDICATION NAME] 2.5 mg daily on Tuesday, Thursday, Saturday and Sunday. The active inpatient medications included Aspirin EC 81 mg oral daily. The active inpatient medications did not include [MEDICATION NAME]. Review of the MAR (medication administration record) for January 2011 indicated upon return from the hospital on [DATE], the physician ordered Aspirin 81 mg was written to be given daily, orally at 10:00 P.M.. The MAR indicated [REDACTED]. The Physician ordered [MEDICATION NAME] was not written on the MAR. An interview with the DN on 2/4/11 at 10:45 A.M. .indicated the Aspirin 81 mg was not started due to pre-hospitalization on [DATE] the resident was on [MEDICATION NAME] but not Aspirin. The DN indicated the nurse practitioner ordered a lab test, a PT-INR on 1/29/11 due to [MEDICATION NAME] therapy and [MEDICAL CONDITION]. The DN stated she assumed that meant to not give Aspirin or [MEDICATION NAME] until the PT-INR results were completed. The PT-INR results were completed on 1/29/11 and the Nurse Practitioner was notified and no new orders were received. On 1/31/11 the physician ordered "no [MEDICATION NAME]". No new orders were written for the Aspirin. Aspirin EC 81 mg was started on 2/1/11. This federal tag relates to complaint #IN 677 3.1-35(g)(2)

Based on record review and interview the facility failed to ensure significant medication errors were not made and medications were administered as ordered for 3 residents (B, D, and F) in a sample of 9 records reviewed. Two of the three residents were readmitted to the hospital. (Resident B and D) Findings include: 1. On 2/3/11 at 1:30 p.m., review of the clinical record for resident (F) indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medication Orders sent from the hospital on [DATE], and listed under "Active Reported Home Medications-Last Verified 11/30/2010 " indicated the resident was to receive [MEDICATION NAME] ( a diuretic medication) 40 milligrams daily. Hold if systolic blood pressure less than 110. Review of the "Handwritten Progress Notes" from the hospital dated 11/30/10 indicated "Reviewed Meds, Parameter for [MEDICATION NAME] given for systolic blood pressure." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nursing notes, dated 12/5/10 at 12:00 p.m., indicated "2+ [MEDICAL CONDITION] (swelling) to left ankle 1+ non [MEDICAL CONDITION] to right foot and ankle. Alert and oriented able to make needs known. Breath sounds clear no shortness of breath noted. Nurse Practitioner called new order received and noted chem 6 (laboratory test) on Wednesday 12/8/10 [MEDICATION NAME] 40 milligrams daily potassium 20 millequivelents daily. Ted hose on in the AM (morning) and off at HS (bedtime) Lab and daughter notified." A progress note written on 12/6/10 indicated "Nursing concern with coarse breath sounds over the weekend (yesterday) nurse practitioner on call notified of [MEDICAL CONDITION] congestion ([DIAGNOSES REDACTED]." A physicians telephone order - (per nurse practitioner for the cardiologist), dated 12/7/10 indicated "Give [MEDICATION NAME] @ 40 milligrams per mouth daily - extra tab today & tomorrow for 80 milligrams. Decrease [MEDICATION NAME] (heart medication) to 3.125 milligrams per mouth twice daily. Oxygen per nasal cannula @ 2 liters per minute continuous. Chest x-ray Friday. Return to clinic Friday. Lab today BMP -BNP completed in office today." Nursing notes dated 12/9/10 at 9:30 p.m. indicated "Resident complaining of shortness of breath and was coughing frequently. Said she didn't feel well. Temperature 99.8 pulse 78 respirations 23 blood pressure 120/70. Oxygen saturation fluctuating between 88-90%. Doctor called, new orders received to sent to emergency room for evaluation. Daughter here. Report called to emergency room . Paramedics called and transported resident to emergency room ." The emergency room Report dated 12/9/10 indicated the resident was admitted to the hospital with [REDACTED]. 2. The clinical record for Resident D was reviewed on 02/03/11 at 2:00 P.M. The resident was admitted to the facility, from an acute care facility, on 01/25/11 with diagnosis, including but not limited to, [DIAGNOSES REDACTED], history of miocardial infarction, diabetes mellitus, impaired renal function, and mitral valve issues. The admission physician orders, faxed and sent from the acute care facility, included orders for the following medications: [REDACTED] medication), [MEDICATION NAME] 850 mg at bedtime (a oral antidiabetic medication), [MEDICATION NAME] .4 mg sublingual (a medication to dilate blood vessels and relieve chest pain) no frequency given but usually given as needed for chest pain, [MEDICATION NAME] 1 tab daily ( a medication to treat [MEDICAL CONDITION] reflux disease), [MEDICATION NAME] 40 mg daily (an antidepressant), [MEDICATION NAME] 200 mcg daily (a medication to treat [MEDICAL CONDITION] disorders), [MEDICATION NAME] 40 mg at bedtime (a medication to treat high cholesterol)" The acute care center discharge form listed some of the medication orders under a "Active Reported Home Medication" list and some medications, including some but not all of the medications listed under the home medication list, under the title "Active Inpatient Medications." Both sections had "Continue or Discontinue" marked for each individual medication listed. The Active Home Medications section of the form had a black pen line drawn horizontally through the orders. The transcription of the admission MEDICATION ORDERS FOR [REDACTED]. Thus only the following medications were transcribed and administered to Resident D: [MEDICATION NAME] 40 mg daily, [MEDICATION NAME] 200 mcg daily, [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 40 mg at bedtime, Calcium Carb with Vitamin D 600 mg three times a day, Aspirin 81 mg once a day, [MEDICATION NAME] Sodium 100 mg as needed daily, and [MEDICATION NAME] .4 mg sublingual every 5 minutes times 3 as needed for chest pain. The resident did not receive the [MEDICATION NAME], Imdur, [MEDICATION NAME], or the [MEDICATION NAME]. Interview with the Director of Nursing, on 02/03/11 at 1:45 P.M. indicated the long term care facility automatically disregarded the Home Medication List orders section from the 6 pages discharge form from the acute care facility. She indicated if the physician desired to have any other medications other than those the resident had received inpatient, there was a space to write the medication in at the end of the form. There was no specific time frame or person from the acute care facility that had directed the long term care facility to disregard the medication orders from the Home Medications list orders. The Director of Nursing indicated the issues with the discharge orders from this specific acute care facility started about 2 years ago and since the facility started disregarding the Home Medication order list, the need for clarification had been greatly reduced. She indicated the long term care facility had in the past had trouble trying to clarify the orders because the floor nurse's changed shifts and/or the chart was not always available on the nursing floor after the resident was discharged to the long term care facility. Interview with the acute care center's Nursing Administrative Director of Nursing, on 02/04/11 at 9:15 A.M. and phone interview with the Discharge Coordinator, on 02/04/11 at 9:15 A.M. indicated no one at the acute care center had ever instructed the long term care facilities to disregard the medication orders in the Home Medication list. The Nursing Administrative Director of Nursing indicated the discharging physician personally marked the six page form and intended all medications marked "Continue" to be administered after the resident was discharged to the long term care facilities or to their respective homes. She acknowledged the physicians were occasionally sloppy and sometimes marked the same medication with two different strengths or two medications from the same medication class in error and if the discharging nurse from the acute care facility did not "catch" the error and clarify the medications, then the long term care facility would need to "clarify" the orders. She indicated there was always a nurse working around the clock in the administrative nursing office of the acute care center with access to the electronic record who could assist the long term care facility with clarifying any questionable medication orders. Review of the discharge MEDICATION ORDERS FOR [REDACTED]. Review of the nursing progress notes, dated 01/27/10 at 10:20 P.M. indicated the resident had become short of breath, developed cool, clammy skin, elevated blood sugar of 258, oxygen saturation dropped to 89 - 94 percent on oxygen, resident had dry heaves, and blood pressure elevated to 181/100, pulse elevated at 100 beats per minute. The resident was transferred to the acute care center emergency room . The physician assessment from the acute care center emergency room , dated 01/28/11 at 12:06 A.M. indicated the resident was assessed to be in [MEDICAL CONDITION] due to not receiving a number of her [DIAGNOSES REDACTED] medicines for the past 3 days. The resident was noted to be having chest pain and discomfort in the emergency room The chest x-ray, obtained on 01/28/11 at 12:05 A.M. indicated the resident's Xray suggested an increase in [MEDICAL CONDITION], increased from 01/22/11 with lung interstitial [MEDICAL CONDITION] and pleural fluid. The resident's blood sugar was also noted to be elevated when she was admitted to the acute care center. 3. Resident B's clinical record was reviewed on 2/4/11 at 10:00 A.M.. The record indicated the resident was originally admitted to the facility on [DATE] for rehabilitation following an above the knee amputation (AKA) of her right leg. On 1/24/11 through 1/28/11 she was in an acute hospital for a revision of the right AKA and readmitted to the facility on [DATE]. The signed discharge physician's orders [REDACTED]. The active reported home medications included Aspirin EC 81 mg (milligrams) oral daily and [MEDICATION NAME] 3 mg oral daily on Monday, Wednesday and Fridays and [MEDICATION NAME] 2.5 mg daily on Tuesday, Thursday, Saturday and Sunday. The active inpatient medications included Aspirin EC 81 mg oral daily. The active inpatient medications did not include [MEDICATION NAME]. The MAR (medication administration record) for January 2011 indicated upon return from the hospital on [DATE], the physician ordered Aspirin 81 mg was written to be given daily, orally at 10:00 P.M.. The MAR indicated [REDACTED]. The Physician ordered [MEDICATION NAME] was not written on the MAR. An interview with the DN on 2/4/11 at 10:45 A.M. .indicated the Aspirin 81 mg was not started due to pre-hospitalization on [DATE] the resident was on [MEDICATION NAME] but not Aspirin. The DN indicated the nurse practitioner ordered a lab test, a PT-INR on 1/29/11 due to [MEDICATION NAME] therapy and [MEDICAL CONDITION]. The DN stated she assumed that meant to not give Aspirin or [MEDICATION NAME] until the PT-INR results were completed. The PT-INR results were completed on 1/29/11 and the Nurse Practitioner was notified and no new orders were received. On 1/31/11 the physician ordered "no [MEDICATION NAME]". No new orders were written for the Aspirin. Aspirin EC 81 mg was started on 2/1/11. This federal tag relates to complaint #IN 677 3.1-25(b)(9) 3.1-48(c)(2)