Every finding on record at Englewood Health & Rehabilitation Center

Based on observation and interview, the facility failed to ensure residents' privacy and dignity by asking permission prior to entering residents' room for 4 of 13 residents reviewed. (Resident 18, Resident 17, Resident 34, Resident 40). Findings include: 1. During a medication administration observation on 8/14/24 at 7:38 AM, RN 3 entered Resident 18's room without knocking, announcing herself, or asking permission to enter. She proceeded to turn on his light and explain care she was to provide. Resident 18's diagnoses included stroke, heart disease, and dysphagia. Resident 18's BIMS (Brief Interview of Mental Status) most recent 7/17/24 score of 2 indicated a severe mental status deficit. 2. During a medication administration observation on 8/14/24 at 7:46 AM, RN 3 entered Resident 17's room without knocking or asking permission to enter. RN 3 did announce herself as she was walking into the room and tuned on the light, causing Resident 17 covered her head with her blanket. RN 3 announced the care she was to give. Resident 17's diagnoses included stroke, diabetes, adult failure to thrive, and heart disease. Resident 17's BIMS score was a 13 on 6/20/24 and indicated a minimal deficit in mental status. 3. During an interview on 8/14/24 at 11:12 AM during a resident council group interview, Resident 34 indicated the facility was her home. Staff did not respect her space. Resident 34 indicated staff frequently did not knock prior to walking into her room or if they knocked, they tapped once or twice and then entered. Resident 34's diagnoses included diabetes, heart disease, and kidney disease. Resident 34's BIMS score was 12 on 7/1/24 and indicated a minimal decline in mental status. 4. During an interview on 8/14/24 at 11:12 AM during a resident council group interview, Resident 40 indicated the facility staff just knocked on the door and then walked right in. There had been times they talked to her as if she was not an adult or was unable to understand English. Resident 40's diagnoses included heart disease, diabetes, arthritis, and sleep apnea. Resident 40's BIMS score was 14 on 6/16/24 and indicated minimal mental status deficit. An ongoing observation and interview on 8/15/24 from 9:10 AM to 9:36 AM indicated the following: An unidentified CNA (Certified Nurses Aid) knocked and called the resident's name in room [ROOM NUMBER], then entered without waiting for permission to enter. During an interview, RN 2 indicated when entering residents' rooms, staff should knock on the door and wait for an answer. If no answer, one should announce themselves and slowly open door and ask permission to enter. In an interview with the administrator on 8/15/24 at 10:03 AM, she indicated the expectation was for all staff to knock wait for permission to enter whether the door was open or closed. A policy and procedure titled Resident Care Procedure #01: Initial Steps dated 8/2016 and last revised 11/2022, indicated the following: Knock and identify yourself before entering the resident's room. Wait for permission to enter the resident's room. 3.1-3(p)(1)

During interview and record review the facility failed to ensure narcotic medications were handled securely for 4 of 4 residents reviewed. (Resident B, Resident C, Resident D and Resident E) Findings include: A review on 9/5/2023 at 12:10 P.M., of a facility's State Reported Incident provided by the Administrator in Training (AIT) on 9/5/2023 at 11:24 AM indicated on 8/30/2023 at 4:01 PM, an unnamed nurse reported the narcotic count sheet and the narcotic medication on hand did not match for Resident B. An investigation was initiated immediately, included interviews with nurses involved and reviewing the camera footage. The report indicated LPN (Licensed Practical Nurse) 1 was suspended pending the investigation. The facility's follow up report to the investigation, dated 8/31/2023, indicated LPN 1 admitted to placing a Percocet (a narcotic medication used for pain) in her pocket. She indicated she had signed out the Percocet thinking it was scheduled routinely instead of PRN (as needed). She indicated she planned to destroy the medication with the on-coming nurse, however she failed to destroy the medication. When questioned about the whereabouts of the medication, she indicated it had probably dissolved in her pocket when it went through the washing machine. The follow up report also indicated during the investigation it was discovered Resident C had a Medication Card of Ambien (a sedative-hypnotic, to help sleep) with 11 tablets on the card and a Controlled Substance Sign-out Sheet for Norco (a narcotic medication used for pain) indicated 11 tablets remained. However, there was no sign out sheet for the Ambien and no Norco to be counted. The follow-up report indicated the local Police department was contacted and a police report was filed. The facility's investigation included staff interviews on 8/30/23. RN (Registered Nurse) 2 indicated the narcotic count with the off going nurse was correct, but when she was giving medications to Resident C, she realized the narcotic count sheet for Ambien was missing and a pharmacy blister pack for the 11 Norco pills was also missing. RN 2 recounted all other narcotics and all the other medications were counted correctly. RN 2 indicated she notified the DON (Director of Nursing) and the Nurse Manager immediately. A written statement by LPN 1 indicated, on 8/29/23 she had double checked herself on the Narcotic count. She intended to waste one Percocet with oncoming nurse, but put it in her pocket and forgot about it. She indicated she had counted with the oncoming nurse and the count was correct. The statement was signed by LPN 1. 1. A review of Resident B's records began on 9/5/2023 at 2:00 P.M., indicated diagnosis included fibromyalgia, low back pain, atrial fibrillation, hypertension, and heart disease. Resident B's current MDS (Minimal Data Set) Assessments dated 7/18/2023 indicated a BIMS (Brief Interview for Mental Status) score was 14, cognitively intact. The Pain Assessment Interview indicated Resident B had frequent pain and the pain limited their activity. Pain was rated an 08/10 but the resident only received opioid medication on 1 day of the 7 day assessment period. A review of Resident B's orders indicated an order with a start date on 7/19/2023 for Percocet 5-325 mg (milligram, a medication dose measurement) to give 1 tablet by mouth (po) every 4 hours as needed for pain. On 9/5/2023 at 4:00 P.M., the AIT and Nurse Manager provided copies of Resident B's MAR (Medication Administration Record) dated August 2023 and Resident B's Pharmacy sign-out sheets for the Oxycodone/APAP (Percocet) 5-325 mg tablets. These documents were compared with the AIT and Nurse Manager. The pharmacy sign-out sheet beginning on 8/10/23 indicated 30 tablets were received by the facility on 8/8/2023. Documentation indicated the following: On 8/10/23 at 4:45 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/10/2023 at 4:45 PM. On 8/10/23 at 9:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/10/2023 at 9:00 PM. On 8/11/2023 at 5:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/11/2023 at 5:00 PM. On 8/11/2023 at 9:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/11/2023 at 9:00 PM. On 8/15/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/15/2023 at 4:00 PM. On 8/15/2023 at 8:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/15/2023 at 8:00 PM. On 8/17/2023 at 3:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/17/2023 at 3:00 PM. A new Pharmacy Controlled Substance Record for Resident B indicated 30 Percocet 5-325 mg tablets were received by the facility on 8/16/23 and indicated the following: On 8/17/2023 at 8:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/17/2023 at 8:30 PM. On 8/19/2023 at 5:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/19/2023 at 5:00 PM. On 8/19/2023 at 9:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/19/2023 at 9:30 PM. On 8/20/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/20/2023 at 4:00 PM. On 8/20/2023 at 8:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/20/2023 at 8:30 PM. On 8/22/2023 at 3:15 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/22/2023 at 3:15 PM. On 8/20/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/20/2023 at 4:00 PM. On 8/24/2023 at 3:00, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/24/2023 at 3:00 PM. On 8/24/2023 at 8:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/24/2023 at 8:30 PM. A new Pharmacy Controlled Substance Record for Resident B indicated 30 Percocet 5-325 mg tablets were received by the facility on 8/24/2023 and indicated the following: On 8/28/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/28/2023 at 4:00 PM. On 8/29/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/29/2023 at 4:00 PM. On 8/29/2023 at 8:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/29/2023 at 8:00 PM. On 9/6/2021 at 10:35 A.M., the AIT provided copies of Resident B's records labeled Pharmacy Controlled Substance Record for Percocet 5-325 mg. When compared the August 2023 MAR to the Pharmacy sign-out sheet, it indicated LPN 1 had signed out Percocet 5-325 mg tablets on 8/3/2023 at 5:05 PM and at 9:30 PM. The August MAR was lacking documentation the Percocet 5-325 mg tablets were administered on 8/29/2023 at 5:05 PM and at 9:30 PM. On 8/5/2023 LPN 1 had signed out Percocet 5-325 mg tablets on 8/5/2023 at 5:30 PM and at 9:30 PM. The August MAR was lacking documentation the Percocet 5-325 mg tablets were administered on 8/5/2023 at 5:30 PM and at 9:30 PM. On 8/6/2023 LPN 1 had signed out Percocet 5-325 mg tablets on 8/6/2023 at 3:30 PM and at 7:25 PM. The August MAR was lacking documentation the Percocet 5-325 mg tablets were administered on 8/6/2023 at 3:30 PM and at 7:25 PM. Review of the August 2023 MAR indicated LPN 1 had given evening shift medications on the following dates, 8/3/2023, 8/5/2023, 8/6/2023, 8/10/2023, 8/11/2023, 8/15/2023, 8/17/2023, 8/19/2023, 8/20/2023, 8/22/2023, 8/24/2023, 8/28/2023 and 8/29/2023. 2. A review of Resident C's records began on 9/5/2023 at 3:00 P.M., indicated diagnosis included medical complications of internal fixation device of bone of left lower leg, intervertebral disc degeneration, low back pain, venous insufficiency, heart disease and hypertension. The Admission MDS assessment dated , 7/10/2023 indicated a BIMS Score of 13, cognitively intact. The Pain Assessment Interview indicated Resident C had frequent pain and was rated an 08/10. Resident C had major orthopedic surgery and had received opioid medication on 6 days of the 7 day assessment period. Resident C had orders for Zolpidem Titrate (Ambien) 10 mg tablet, give 1 tablet every 24 hours prn for sleep at bed time, started on 7/14/2023 and discontinued on 8/15/2023. A new order for Zolpidem 10 mg tablet, give 1 tablet every 24 hours as needed for trouble sleeping, started on 8/15/2023. The Zolpidem was discontinued when Resident C was discharged on [DATE]. The facility did not have a Pharmacy Controlled Substance sign-off record for the Zolpidem. Review of the August 2023 MAR indicated Resident C was administered Zolpidem 4 nights in August. Resident C had orders for Norco (Hydrocodone-Acetaminophen) 5-235 mg 1 tablet every 4 hours as needed for pain, start date 7/18/2023 and a discontinue date of 8/2/2023. A new order for Norco 7.5-325 mg 1 tablet every 4 hours as needed for pain with a start date of 8/2/2023. The Pharmacy Controlled Substance Sign-out sheets were missing for Norco 5-325 mg tablets administered 8/1/23 to 8/2/2023 and Norco 7.5-325 mg administered from 8/2/2023 to 8/16/2023. A Review of the Pharmacy Controlled Substance record for 30 tablets of Norco 5-325 mg had a received date of 8/16 written on the 1st line and indicated the following: On 8/17/2023 LPN 1 had signed out Norco 7.5-325 mg tablets on 8/17/2023 at 5:00 PM and at 9:00 PM. The August MAR was lacking documentation the Norco 5-325 mg tablets were administered on 8/17/2023 at 5:00 PM and at 9:00 PM. On 8/19/2023 LPN 1 had signed out 7.5-Norco 325 mg tablets on 8/19/2023 at 5:30 PM and at 9:30 PM. The August MAR was lacking documentation the Norco 5-325 mg tablets were administered on 8/19/2023 at 5:30 PM and at 9:30 PM. On 8/20/2023 LPN 1 had signed out Norco 7.5-325 mg tablets on 8/20/2023 at 4:00 PM and at 8:30 PM. The August MAR was lacking documentation the Norco 5-325 mg tablets were administered on 8/20/2023 at 4:00 PM and at 8:30 PM. On 8/22/2023 LPN 1 had signed out Norco 7.5-325 mg tablets on 8/22/2023 at 2:15 PM and at 9:00 PM. The August MAR was lacking documentation the Norco 7.5-325 mg tablets were administered on 8/22/2023 at 2:15 PM and at 9:00 PM. Review of the August 2023 MAR indicated LPN 1 had given evening shift medications on the following dates, 8/3/1012, 8/5/2023, 8/6/2023, 8/10/2023, 8/11/2023, 8/15/2023, 8/17/2023, 8/19/2023, 8/20/2023, 8/22/2023, 8/24/2023, 8/28/2023 and 8/29/2023. A review of Resident C's progress notes indicated there was no documentation for administration of the Norco nor the effectiveness of the medication for the pain. An interview with Nurse Manager 3, on 9/6/2023 at 10:00 A.M., indicated she had called the Pharmacy and was informed the Pharmacy had sent the facility 1 blister card with 40 tablets of Norco 5-325 mg on 7/14/2023, and 7 blister cards with 30 tablets each of Hydrocodone/APAP 7.5 mg on the following dates, 7/18/2023, 7/25/2023, 8/2/2023, 8/7/2023, 8/15/2023, 8/23/2023 and 8/29/2023. Nurse Manager 3 indicated they could only find 2 of the 8 Controlled Substance Sign-out records: 1 blister card received on 8/16/23 for 30 tablets and 1 blister card received on 8/30/2023 for Resident C. 3. A review of Resident D's records on 9/6/2023 at 10:20 A.M., indicated diagnoses included , left thigh pain, contracture, stroke with hemiplegia/hemiparesis (weakness or paralysis on one side of the body), aphasia (loss ability to understand or express speech), dysphasia (difficulty swallowing), cognitive communication deficit, and hypertension. Review of the current Quarterly MDS Assessment indicated a BIMS score of 12, moderate cognitive impairment. A Pain Management assessment indicated the resident had pain rarely and rated it 04/10. Resident D received an opioid on 7 days of the 7 day of the assessment period. Resident D had an order for Hydrocodone-Acetaminophen 5-325 mg tablet, to give 1 tablet via Peg Tube (a type of feeding tube into the stomach) every 6 hours and had a start date of 3/5/2023. A review of the Pharmacy Controlled Substance Record for Resident D's Hydrocodone indicated the following when compared with the August 2023 MAR, indicated the Hydrocodone-Acetaminophen 5-325 was sign-out consistently at 12 A.M., 6 A.M., 12 P.M., and 6 P.M. The Pharmacy Controlled Substance Records were missing from 8/6/2023 to 8/19/2023. LPN 1 was the last nurse to sign off the Controlled Substance Record on 8/5/2023 at 6:00 P.M. On 8/29/2023 Resident D's MAR indicated the Hydrocodone-Acetaminophen 5-325 mg at 1800 (6:00 PM) was documented as administered by LPN 1, but was not signed out on the Controlled Substance Record. The sign out record was dated 8/29 and a line drawn through it. In an interview on 9/6/2023 at 11:40 A.M. Nurse Manager 3 indicated she had called the Pharmacy and was informed by the Pharmacy they had sent the facility the following quantities of Hydrocodone 5-325 mg tablets for Resident D. On 7/5/2023-56 tablets, 7/20/2023 - 60 tablets, 8/5/2023 - 60 tablets, 8/18/2023 - 60 tablets, 8/31/2023-60 tablets. She indicated the Controlled Substance Sheets were missing for the shipments on 8/5/2023 - 60 tablets. She also indicated LPN 1 had completed the last card prior to the missing sign-out sheet. 4. A review of Resident E's records on 9/6/2023 at 11:00 A.M., indicated diagnoses included chronic pain, insomnia, emphysema, epilepsy and anxiety. The most current Quarterly MDS Assessment, dated 8/31/2021 indicated Resident E's BIMS score was 10, moderate cognitive impairment. A Pain Management assessment indicated Resident E had pain occasionally, rated a 06/10, and had received opioid medications on 7 days of the 7 day assessment period. Resident E had an order for Hydrocodone-Acetaminophen 5-325 mg tablet, 1 tablet by mouth 3 times a day for pain, start date was 6/1/2023 and Discontinued on 8/4/2023. The Pharmacy Sign-out Sheet was received by the facility on 7/20/2023. It indicated LPN 1 administered the last tablet of the 45 tablets of Hydrocodone-Acetaminophen 5-325 mg on 8/3/2023. An order for Hydrocodone-Acetaminophen 5-325 mg tablet, 1 tablet by mouth 4 times a day for pain and was to be given routinely with a start date was 8/4/2023. The Hydrocodone-Acetaminophen 5-325 mg tablets were signed off consistently 4 times a day through 8/3/2023 at 8:00 PM when LPN 1 signed off the last tablet on the sign-out record. The facility was missing the Pharmacy Controlled Substance Sign-out for Resident E from 8/4/2023 through 8/31/2023, until a delivery on 8/31/2023 of 75 tablets Hydrocodone/APAP 5-325 mg with 2 sign off sheets, 1 sheet for 15 tablets and the other sheet for 60 tablets. These were started on 9/1/2023. On 9/6/2023 at 11:40 A.M., an interview with Nurse Manager 3 indicated she had called the Pharmacy and was informed the Pharmacy had sent the facility the following quantities of Hydrocodone 5-325 mg tablets. On 7/18/2023-45 tablets, 8/2/2023 - 42 tablets, 8/4/2023 - 60 tablets, 8/15/2023 - 60 tablets, 8/30/2023- 15 tablets and 60 tablets. She indicated the Controlled Substance Sheets were missing for the shipments on 8/2/2023 - 42 tablets, 8/4/2023 - 60 tablets and 8/15/2023 - 60 tablets. She also indicated LPN 1 had completed the last card prior to the missing sign-out sheets. LPN 1's employee file indicated LPN 1 had signed a Job Description for Licensed Practical Nurse (LPN) on 8/31/2022. The job description indicated, .Providing medical record documentation in accordance with facility policy and procedures. Completing (24) hour reports, end of shift reports, shift narcotic counts and documenting the destruction of outdated/discontinued medication in the medication destruction record according to facility policy and procedure During an interview with the AIT and Unit Manager 4 on 9/5/2023 at 4:30 P.M., they indicated the investigation for the missing narcotic had only reviewed the residents, who were receiving PRN narcotics on the 200 Hall. The AIT indicated they reviewed the camera footage and LPN 1 was observed to put something in her pocket. LPN 1 was suspended pending the investigation. Unit Manager 4 indicated they had not compared the Pharmacy Controlled Substance Sign-out records with the residents' MARS. LPN 1 admitted she had put the narcotic in her pocket and forgot to destroy it before leaving the facility. They indicated a report to the police and to the State Nursing Board was completed. They indicated they were not aware there were narcotics signed out by LPN 1 and not documented on the Resident's MARS. A current facility policy provided by the AIT on 9/5/2023 at 2:45 P.M., titled, Controlled Substances, revised on 7/2021, indicated, .It is the policy of this facility to store, administer, verify and destroy controlled substances in accordance with Federal, State and Local laws .documentation of a correct count will be maintained for each controlled substance .The facility will be maintaining a count record for the count sheets contained in the count book .Verify the order by checking the Medication Administration Record (MAR) .Obtain the controlled substance count sheet and verify the count is correct .Read label again and prepare the medication for administration according to the procedure for administration by route. Record the amount removed of the controlled substance on the count record and put the correct number of remaining doses on the record .Stay with the resident until the medication is swallowed if dose is orally administered .When a new medication is added to the controlled substance box, a new sheet will be added to the count book .When a medication is remove from the lock box for any reason, the count record will be removed for that drug .The destruction of controlled substances will be performed with 2 licensed nurses at a minimum .Controlled substances will be disposed of in accordance with Local, State, and Federal laws A facility in-service on 8/30/2023 related to Narcotic Counts, indicated, .BOTH nurses are to count together at the medication cart. One reviewing the medication cards and the other the narcotic sheets. Nurse reading off the medication cards should read the resident's name, and name of the medication for each item to be counted. Document that count is completed on the narcotic count sheet. Should the count be off or a discrepancy noted, no one leaves until search is completed of medication carts, MARs reviewed for missing entries and Nurse Manager notification to receive further instructions . A current facility policy, used for the In-service of nurses on 8/30/2023. The policy was provided by the AIT on 9/5/2023 at 2:45 P.M., titled Counting Controlled Substances and responding to Errors in a Controlled Substance Count, indicated, .If the count and sign-out log still disagree, check the sign-out entries to detect a prior error in recording or count .Check the resident's medication records and nurse's noted for doses that might have been given and not recorded This Federal tag relates to Complaint IN00416564. 3.1-28(a)

Based on observation, and interview the facility failed to ensure sanitary practices were observed in the kitchen. 53 of 56 residents to residing in the facility ate food prepared in the kitchen. Findings include: During an observation on, 7/17/23 at 9:03AM, noted floor was slippery. The floor had an oily feel. The area with the slippery, oily feel was from in front of the oven to just beyond the stove top range. The top of the oven had trays and multiple crumbs. The crumbs varied in size and color (yellow, brown, and black) There were 2 hamburgers in the refrigerator with cellophane covering. There was no date labeling on the hamburgers. The dietary aide was unable to determine when the hamburgers were prepared. A hamburger was listed on alternative menu for 7-17-23. The dietary aide 3 had her hair pulled into a bun, the bun was covered with a hair net but the remainder of hair was uncovered. In the walk-in freezer's left furthest corner under the rack was a black substance. It was approximately 1 inch high by a 1/2 inch wide by 9 inches long. The dietary aide could not identify the substance. In an interview on, 07/18/23 08:25 AM, the Administrator indicated the kitchen staff were to be in-serviced and the dietary manager was informed of cleaning issues. During an observation on, 07/18/23 11:13 AM, Dietary Aide 3 had her hair pulled back into a bun. The bun portion of her hair was covered with a hairnet, the remainder of her hair was uncovered. During an observation on 7/19/23 at 12:14PM Dietary Aide 3 had hair in bun and the hairnet was covering all of hair. The cleaning lists (month of July am and pm) were provided by Administrator on 7/18/23 at 12:18PM indicated the top of the oven was to be cleaned by day shift on 7/7/23 and the exterior of oven was to be cleaned on 7/23/23. There were no other times on cleaning list the outside of the oven was listed to be cleaned. The cleaning list indicated the floor was to be swept and mopped on 7/10/23 by the evening shift. No additional cleaning lists were provided. A policy titled, Freezers with a date 6/2021, provided by the Administrator on 7/18/23 at 12:18PM, indicated .4. Remove shelving units and clean the shelves and walls with warm sudsy water. Rinse and sanitize. Allow to air dry .7. For walk in freezers, mop floors, wash walls and ceilings as needed A policy titled, Floors, Tables, and Chairs with a date 6/2021, provided by the Administrator on 7/18/23 at 12:18PM, indicated .1. Sweep and clean kitchen floors after each meal. Mop thoroughly at least once daily. Move major appliances at least once a month to facilitate cleaning behind and underneath . A policy titled, Leftovers with a date 2/2020, provided by the Regional Nurse Consultant on 7/18/23 at 12:38PM, indicated .2. All foods stored for later use shall be covered, labeled with the food name, and dated with the current date as well as with a use by date . A policy titled, Personal Hygiene and Jewelry with a date 6/2021, provided by the Regional Nurse Consultant on 7/18/23 at 12:38PM, indicated .2. All Dining and Nutrition Services department must wear hair restraints to prevent hair from contacting exposed food . 3.1-4.5-5

Based on record review and interview, the facility failed to ensure family and hospice services were notified of a condition change for 1 of 3 records reviewed (Resident C). During an interview on 4/18/23 at 9:35 AM, Resident C's Power of Attorney (POA indicated she received a call at 5:15 AM on 4/6/23 informing her Resident C had passed away. Upon arrival at the facility, staff informed her Resident C had vomited and received medication for vomiting the evening before. The POA indicated the facility had not contacted her about a condition change. During a record review beginning 4/18/23 at 10:36 AM, a Minimum Data Set, dated dated dated [DATE] indicated Resident C had diagnoses including hemiplegia following cerebral infarction, gastro-intestinal reflux disease without esophagitis, and hypertension. A progress note dated 4/5/23 7:05 PM was reviewed. The progress note, written by Registered Nurse (RN) 2, indicated Resident C vomited during the evening meal. The progress note indicated Nurse Practitioner (NP) 3 was contacted and orders were received for Zofran, and anti-emetic medication. No attempts to notify the POA or hospice were recorded. An additional progress note written by RN 2, dated 4/6/23 at 9:53 PM, did not indicate any attempts to contact the POA or hospice. A progress note written by Licensed Practical Nurse (LPN) 4, dated 4/6/23 at 6:32 AM, indicated she notified the POA and hospice services upon finding Resident C unresponsive at 5:15 AM. No other attempts to contact the POA or hospice services were recorded on that shift. During an interview conducted on 4/18/23 at 11:58 AM, RN 2 indicated she did not personally attempt to contact the POA because Resident C had stabilized after the ordered medication was ingested. RN 2 indicated a person associated with the POA was present in the building and she assumed he had notified the POA. RN 2 indicated she made one attempt to call hospice services, but there was no answer. RN 2 indicated she might have dialed the wrong number. RN 2 indicated the POA and hospice services should be notified regarding the occurrence of vomiting. Resident C's face sheet, provided by the Director of Nursing on 4/18/23 at 2:20 PM, indicated emergency contacts for Resident C included the POA and Resident C. In an interview on 4/18/23 at 12:15 PM, the POA indicated she did not give the facility permission to notify anyone else of condition changes. In an interview on 4/18/23 at 2:20 PM the DON indicated she believed the POA was made aware, and staff had attempted to notify hospice. The DON indicated notification should be recorded in the medical record. A policy titled Clinician/Family/Resident Representative notification of Change in Condition, last revised 5/19, indicated physician, family and responsible party notification should be notified of condition changes including the presence of emesis. The policy also indicated notification should be documented in the clinical record. 3.1-5(a)(2)

Based on interview, and record review, the facility failed to ensure wound care and assessments for pressure wounds were completed as ordered for 1 of 2 residents reviewed. (Resident T) Resident T's record was reviewed on 9/8/22 10:49 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident T's Quarterly Minimum Data Set Assessment, dated 6/24/22, indicated a brief interview for mental status score of 13 (cognitively intact). Activity of daily living section indicated the resident required extensive assistance with bed mobility, locomotion on and off unit, toileting, and personal hygiene. Resident T required total assistance with transfers and bathing, had an indwelling catheter and was always incontinent of bowel. Resident T had a pressure ulcer and was at risk of developing a pressure ulcer. Resident T had unhealed pressure ulcers, 3- stage 3 pressure ulcers and did not exhibit behavior to reject evaluation or care. An active order, dated 6/23/22, indicated resident was to be referred to an outside wound clinic related to wounds. An active order, dated 7/25/22, indicated to document drainage amount from the left buttock stage 3 (bed sore that had gone through all layers of skin into the fat tissue but has not reached muscle or bone), the right buttock stage 4 (deep wound that reaches the muscles, ligaments, or bones), the sacral region stage 4 pressure ulcer pressure ulcer (bedsore), every shift, document pain with/without treatment every shift, document periwound (area around wound) skin appearance of the areas every shift, document if the physician was notified of each area's status every shift and to document drainage amount from pressure ulcer (bedsore) every shift. An active order, dated 8/1/22, indicated wound care was to be completed every shift to the pressure ulcer on the left buttock stage 3: apply vasche (prescribed liquid) moistened gauze to wound cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing). Apply sure prep around wound bed. An active order, dated 8/1/22, indicated wound care was to be completed every shift to pressure ulcer of right buttock stage 4: apply vasche moistened gauze to wound cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing). Apply sure prep around wound bed. An active order, dated 8/1/22, indicated wound care was to be completed every shift to pressure ulcer of sacral region stage 4: apply vasche moistened gauze to wound cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing). Apply sure prep around wound bed. An active order, dated 8/1/22, indicated the resident was to be up in a wheelchair no longer than 4 hours as ordered by the wound doctor. Activity was to be documented in the progress note, every shift, when the resident refused to get into bed. A current care plan, dated 2/21/22, indicated the resident was at risk for developing pressure ulcers related to a change in mobility. The goal was risk would be minimized through care plan interventions by no skin breakdown. Interventions included: resident would report any redness, tenderness, or changes in skin, resident would rest on a special support surface such as low air loss, alternating air mattress, mosaic/roho mattress, etc., staff would observe resident's skin weekly and as needed, staff would remind resident to turn and reposition when resident chose not to. A current care plan, dated 7/25/22, indicated the resident had a pressure ulcer stage 4 to right buttock, a pressure ulcer stage 4 sacral region, and a pressure ulcer stage 3 left buttock. Goals included Resident T's wounds would progress towards closing. Resident T's stage 3 wound would continue to progress towards closing even though the resident did not always follow care plan interventions. Interventions included: dietary supplements as indicated, the resident frequently refused the wound doctor to see wounds during routine wound rounds, at times refused for staff to perform scheduled treatments, at times chose to sit up in electric wheelchair for prolonged periods of time, staff continued to educate the resident on the importance of above with possible risk of declines with wounds, the resident had a catheter, the catheter care plan was initiated, the resident would receive treatments as ordered, the resident would use assistive devices to assist with turning and repositioning as needed, staff would assist the resident with incontinence care and apply barrier cream as needed, staff would assist the resident with turning and repositioning every two hours and more frequently as needed. An outpatient burn/wound center document, titled Therapy Plan of Care, dated 8/15/22, was received from the DON on 9/13/22 8:32AM. The document indicated Resident T's lower left buttock pressure ulcer stage 3 measured 4.5cm x 3.6cm x 2.5cm, had undermining (wound edges erode resulting in a pocket beneath the skin at the edge of the ulcer) 1.0cm from 9 to 12 o'clock. The Therapist comments indicated the resident returned to the clinic with no dressing in place, stated nursing had left off the dressing today, typed orders were sent with the resident for the nursing home, the resident was educated the dressing needed to be changed 3 times a day, the resident verbalized understanding of instructions. Resident T's sacral region pressure ulcer stage 4 measured 6.5cm x 6.5cm x1.5cm, had undermining 4cm from 5 to 11 o'clock. The Therapist comments indicated the resident returned to the clinic with no dressing in place. Resident T's right ischium pressure ulcer stage 4 measured 3.0cm x 4.5cm x 2.3cm. The Therapist comments indicated the resident returned to the clinic with no dressing in place. Clinician comments indicated typed orders were sent with resident to the nursing facility, DON was to be called about the need to change dressings tid (3 times per day) and the resident was to return to clinic with dressings intact. A document titled, Physician Testing Orders, dated 8/24/22 was received from the DON on 9/13/22 8:32 AM. The document indicated moist to dry dressings with vasche were to be continued 3 times per day, the resident was to return in 2 weeks, the resident was to use a trapeze bar for turning and keeping pressure off of wounds, and a wound clinic appointment was scheduled on 9/7/22 1:30PM, arrive 1:00PM. A Physician's Progress Note, dated 9/7/22, was received from the DON on 9/13/22 8:32AM. The progress note indicated physician comment, the ulcer was improving, progress might be attributed to better off loading. The treatment plan would remain the same. Resident T's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found for the Resident's left buttock pressure ulcer drainage amount, drainage type, dressing change, pain with/without treatment, peri wound skin, and doctor notification on night shift for 8/2, 8/5, 8/8, 8/12, 8/16, 8/19, 8/23, 8/26, and 8/30, evening shift 8/4, 8/18, 8/20, 8/26, and 8/27, and day shift 8/3 and 8/13. No documentation was found to indicate the Resident's left buttock pressure ulcer care, apply vasche moistened gauze to the wound, cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing) and apply sure prep around wound bed was completed on night shift 8/1, 8/2, 8/5, 8/6, 8/8, 8/10, 8/12, 8/13, 8/16, 8/19, 8/23, 8/26, and 8/30, evening shift 8/13, 8/18, 8/20, 8/26, and 8/27, and day shift 8/3 and 8/13. No documentation was found for the Resident's right buttock pressure ulcer drainage amount, drainage type, dressing change, pain with/without treatment, peri wound skin, and doctor notification on night shift 8/2, 8/5, 8/6, 8/8, 8/10, 8/12, 8/13, 8/16, 8/19, 8/23, 8/26, and 8/30, evening shift 8/4, 8/13, 8/18, 8/20, 8/26, and 8/27, and day shift 8/3 and 8/13. No documentation was found to indicate the Resident's right buttock pressure ulcer care, apply vasche moistened gauze to the wound, cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing) and apply sure prep around wound bed was completed on night shift 8/1, 8/2, 8/5, 8/6, 8/8, 8/10, 8/12, 8/13, 8/16, 8/19, 8/23, 8/26, and 8/30, evening shift 8/13, 8/18, 8/20, 8/26, and 8/27, and day shift 8/3 and 8/13. No documentation was found for the Resident's sacral pressure ulcer drainage amount, drainage type, dressing change, pain with/without treatment, peri wound skin, and doctor notification on night shift 8/2, 8/5, 8/6, 8/8, 8/10, 8/12, 8/13, 8/16, 8/19, 8/23, 8/26, and 8/30, evening shift 8/4, 8/13, 8/18, 8/20, 8/26, and 8/27, and day shift 8/3 and 8/13. No documentation was found to indicate the Resident's sacral pressure ulcer care, apply vasche moistened gauze to the wound, cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing) and apply sure prep around wound bed was completed on night shift 8/1, 8/2, 8/5, 8/6, 8/8, 8/10, 8/12, 8/13, 8/16, 8/19, 8/23, 8/26, and 8/30, evening shift 8/13, 8/18, 8/26, and 8/27, and day shift 8/3 and 8/13. Resident T's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found for the Resident's left buttock pressure ulcer drainage amount, drainage type, dressing change, pain with/without treatment, peri wound skin, and doctor notification on night shift 9/2, 9/6, and 9/9, evening shift 9/1, 9/3, and 9/13, and day shift 9/13. No documentation was found to indicate the Resident's left buttock pressure ulcer care, apply vasche moistened gauze to the wound, cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing) and apply sure prep around wound bed was completed on night shift 9/2, 9/6, 9/9, evening shift 9/1 and 9/3, and day shift 9/12. No documentation was found for the Resident's right buttock pressure ulcer drainage amount, drainage type, dressing change, pain with/without treatment, peri wound skin, and doctor notification on night shift 9/2,9/6, and 9/9, evening shift 9/1, 9/3, and 9/12, and day shift 9/12. No documentation was found to indicate the Resident's right buttock pressure ulcer care, apply vasche moistened gauze to the wound, cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing) and apply sure prep around wound bed was completed on night shift 9/2, 9/6, 9/9, evening shift 9/1 and 9/3, and day shift 9/12. No documentation was found for the Resident's sacral pressure ulcer drainage amount, drainage type, dressing change, pain with/without treatment, peri wound skin, and doctor notification on night shift 9/2, 9/6, and 9/9, evening shift 9/1, 9/3, and 9/12, and day shift 9/12. No documentation was found to indicate the Resident's sacral pressure ulcer care, apply vasche moistened gauze to the wound, cover with dry gauze, cover with [MEDICATION(S)] border (foam dressing) and apply sure prep around wound bed was completed on night shift 9/2, 9/6, 9/9, evening shift 9/1 and 9/3, and day shift 9/12. A nurse note, dated 8/1/22 11:52, indicated resident returned from wound clinic with orders to continue vashe wet/dry to wound 3 times per day, apply sure prep around wound bed prior to treatment. A nurse note, dated 8/15/22 11:02 AM indicated the resident returned from the appointment with the wound doctor, to continue vashe moistened gauze with [MEDICATION(S)] border 3 times per day. The physician narrative progress note, dated 8/15/22, indicated to follow up with the pressure ulcers and labs. Resident T was seen in the wound clinic, wounds reported as worsening. The resident was noncompliant with off loading, was up in wheelchair over 8 hours per day, and refused to go back to bed. No documentation was found regarding the resident refusing wound care. The Nurse Practitioner's progress note, dated 8/20/22, indicated the resident was noncompliant with only being up for 4-hour increments and not wanting to take prostat. The note did not indicate the resident refused wound care. A nurse note, dated 8/24/22 16:03, indicated the resident returned from the wound doctor appointment with orders to continue 3 times per day moist to dry dressing with vashe. The physician narrative progress note, dated 9/1/22, indicated the wounds worsening, wound clinic had discussed with resident. Resident continued to be noncompliant with keeping pressure off area, noncompliant with only being up for 4-hour increments, normally in his chair in the morning and did not want to be put back in bed until bedtime. No documentation was found regarding resident refusing wound care. The physician narrative progress note, dated 9/2/22, indicated to follow up labs and chest x-ray from 9/1/22. The resident was noncompliant with medical treatment and regimen, noncompliant with orders from the wound clinic to be only up in wheelchair for 4-hour increments. The plan indicated the resident was going to think what times he wanted to be up and would write up a schedule that he would adhere to, continue to encourage compliance to aid in wound healing. No documentation was found regarding resident refusing wound care. The physician narrative progress note, dated 9/5/22, indicated the resident continued to be noncompliant with keeping pressure off the areas, the resident was agreeable to plan a schedule to be in bed and be more compliant. No documentation was found regarding resident refusing wound care. A nurse note, dated 9/7/22 at 9:30 PM, indicated the nurse attempted x 3 to change Resident's coccyx and buttock wound dressings. The resident refused repeatedly, was educated on importance of wound care. The resident verbalized understanding but continued to refuse dressing changes. A nurse note, dated 9/11/22 at 7:39 PM, indicated the resident did not want to lay down after supper, would lay down after watching the game, encouraged to lay down, but the resident refused. A nurse note, dated 9/12/22 at 6:27 AM, indicated the resident refused to allow treatments to be done, sitting in the wheelchair and would not allow himself to be moved out of the chair to accommodate treatment needs. In an interview on 9/12/22 at 9:36 AM, the Wound Nurse indicated wound care was done by the hall nurse. The Wound Doctor measured the wounds, documented wound measurements and characteristics. The Wound Nurse indicated she documented in the progress notes after the Wound Doctor rounded and she did the wound assessments on new admits. The initial wound assessments were done by the nurse, wound care was documented in the MAR, daily wound documentation was in assessments. The DON was present during the interview and indicated that Resident T did not want the surveyor to observe his wound care or catheter care. In an interview on 9/12/22 at 10:08 AM, the DON indicated when a resident went to an outside wound clinic, the wounds were monitored by the clinic, measurements were done at the clinic. The floor nurses did wound care and documented in the MAR, daily wound assessments. Wounds were to be measured every week by a facility nurse when a resident did not go to the wound clinic weekly. Measurements were documented in a progress note under assessments. In an interview on 9/12/22 2:05 PM, LPN 4 indicated wound care was documented in the TAR when care was completed. The TAR prompted documentation to be completed regarding odor, drainage, peri wound area, pain, any changes noted. When changes in the wound was noted, the nurse notified the Wound Nurse and NP. Measurements were done by the Wound Doctor on weekly rounds, nurses did not measure. In an interview on 9/13/22 10:42 AM, the DON indicated Resident T was initially seen by the in house Wound Doctor. The resident's wounds were not healing so the resident elected to be seen by an outpatient wound doctor. No documentation of wound measurements done by the facility nursing staff or Wound nurse were found. No documentation of a wound assessment by the Wound Nurse was found in Resident T's chart. A current policy titled PCC Wound Documentation Protocol, dated 6/21, was received from the DON on 9/13/22 9:10 AM. The policy indicated . 4. The wound nurse/designee will document weekly, no later than every 7 days, on the areas using the skin and wound application. 5, Daily wound documentation to be completed by the staff nurse or wound nurse for any pressure ulcers, diabetic ulcers, vascular or arterial ulcers, and any other wound that required a daily assessment or a dressing. This was not an optional tool.13. The wound nurse or licensed nurse would complete weekly assessments of the skin condition using the skin and wound application .14 Measurements of the wound would be completed using the head-to-toe method. The application would measure the length, width, and calculate the area using the photograph of the injury. The nurse would measure depth, undermining and tunneling and document as it applied for pressure injuries and other wounds .16. Weekly assessments of wounds and skin conditions will be documented weekly, no later than every 7 days, in the electronic record .20. Physician ordered treatments would be documented on the TAR after each administration 21. A daily observation of the wound would be completed by a licensed nurse for any open wound or skin condition requiring a dressing change. A policy titled Wound Documentation Guidelines, dated 6/21, was received from the DON on 9/13/22 9:10AM. The policy indicated when charting a description of a pressure injury, the following components should be part of the weekly charting. 1.Location 2. Stage .3. Dimensions .4. Undermining/tunneling .5. Wound Base Description .6. Drainage .7. Wound edges .8. Odor .9. Pain . 10. Progress. This Federal Citation is related to Complaint IN 138. The state reference 3.1-40(a)(2)

Based on interview and record review the facility failed to ensure fall risk assessments were completed timely on 2 of 2 residents reviewed. (Resident 14 and Resident 151). Findings include: 1) Resident 14's record review began on 9/7/22 at 10:32 AM. Diagnosis included [CONDITION(S)], secondary Parkinsonism, Alzheimer's disease, muscle weakness, and stroke. Falls were documented as occurring on 6/18/22, 7/11/22, 7/12/22, 8/4/22, 8/17/22, 8/28/22, 8/29/22, 8/30/22, and 9/9/22. A fall risk assessment was completed on 3/1/22. There were no other documented fall risk evaluations. In an interview on 9/9/2022 at 2:45 PM, the DON (Director of Nursing) indicated she was unable to show any further documentation of fall risk assessment. The most recent care plan for Resident 14 included a focus of being at risk for falls initiated on 3/1/22. The most recent intervention update was 8/30/22. 2) An interview with Resident 151's POA (Power of Attorney) on 9/9/22 at 11:46 AM indicated Resident 151 fell in the facility on 8/18/22 and required medical care. Resident 151's record review began on 9/9/22 at 2:47 PM, and indicated diagnoses included dementia, [CONDITION(S)], stroke, and history of falls. Resident 151's most current MDS ( Minimum Data Set) assessment indicated their BIMS (Brief Interview for Mental Status) indicated she had moderate cognitive difficulties thus the need for a POA. Resident 151's progress note dated 8/18/22 at 10:23 PM indicated they were found on the floor. An ambulance was called, and Resident 151 was taken to the hospital. A fall risk assessment was not documented on admission or readmission from the hospital. The most recent care plan for Resident 151 included a focus on risk for falls was initiated on 8/19/22. The interventions for falls were last updated 9/1/22. An interview with DON on 9/12/22 at 12:04 PM indicated a fall risk assessment was done upon admission and quarterly thereafter for all residents. A policy titled, Fall Investigation and Risk Evaluation dated 6/2012 with most recent revision on 6/2022, indicated Complete risk evaluations on each resident on admission, quarterly, and with a significant change in the resident that may change their risk for falls 3.1-45(a)

Based on record review and interview, the facility failed to ensure catheter care was completed on every shift for 1 of 1 resident reviewed. (Resident 19) Resident 19's record was reviewed on 9/8/22 10:49 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident T's Quarterly Minimum Data Set Assessment, dated 6/24/22, indicated the brief interview for mental status score was 13 (cognitively intact). Activity of daily living indicated the resident required extensive assistance with bed mobility, locomotion on and off unit, toileting, and personal hygiene. The resident required total assistance with transfers and bathing, had an indwelling catheter, was always incontinent of bowel, had a pressure ulcer, was at risk of developing a pressure ulcer, and had unhealed pressure ulcers, 3- stage 3 pressure ulcers. The resident did not exhibit behavior to reject evaluation or care. An active order, dated 6/27/22, indicated change foley catheter 16 Fr (French) 10 cc (cubic centimeter) as needed for leakage. An active order, dated 6/13/22, indicated Resident to have a catheter leg strap to assist with pulling/tugging/dislodgement. Check for placement and replace if needed every shift. There was no order for foley catheter care. A current care plan, dated 2/7/2022, indicated the resident needed assistance with ADLs (Activity of Daily Living) related to [CONDITION(S)]. Goal: the resident would maintain current level using care plan interventions as long as disease process allowed. Interventions included Resident needed assist of 1-2 staff with toileting. A current care plan, dated 2/21/22, indicated the resident had an indwelling catheter related to [CONDITION(S)] bladder. Goals: The resident's care plan interventions would minimize risk for complications. Interventions included change catheter system when clinically indicated or ordered, extra fluids offered with medication, receive fluid of choice with meals, report and staff observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen, refer to the registered dietician for fluid recommendations, and have catheter leg strap to assist with pulling/tugging/dislodgement. Foley catheter care was not indicated on the resident's care plan. The Task List: Indwelling Catheters, dated 8/15/22-8/13/22 was reviewed. The task list indicated when catheter care was provided. No documentation regarding completion of catheter care was found for day shift on 8/21, 8/25, 8/29, 9/4, and 9/8, evening shift on 8/15, 8/16, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, and 9/12, night shift on 8/16, 8/17, 8/18, 8/20, 8/21, 8/23, 8/26, 8/28, 8/29, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/10, and 9/12. No documentation was found to indicate the resident refused catheter care. In an interview on 9/12/22 10:00 AM, C.N.A. 3 indicated catheter care was completed every day and when changing a resident's brief. Catheter care was documented on the form provided by the facility, the information went to administration for review to make sure staff were providing the care they should be providing. When a resident refused care, C.N.A. 3 indicated she would notify the nurse. In an interview on 9/12/22 2:05 PM, LPN 4 indicated catheter care was completed by C.N.A.s and nurses, mostly the nurses. Catheter care was done every shift, and documented in the TAR. An order to do catheter care was generated when a resident had a catheter. When a resident refused catheter care, LPN 4 indicated she would ask the resident why, document on the task, TAR and progress note, and notify doctor when resident refused after 3 attempts. In an interview on 9/13/22 10:42 AM, the DON indicated an order was not needed for catheter care, it was placed on a task sheet. C.N.A.s did the catheter care. Catheter care was performed when a resident was cleaned up after incontinence episodes, and should be done at least 1 time per shift. When a resident refused care, the C.N.A. reported to the nurse, the nurse would speak to the resident then document on the behavior sheet or progress note. A current policy titled Catheter Use Care Policy, dated 5/22, was received from the DON on 9/13/22 at 8:32 AM. The policy indicated Policy .provide proper care while a resident is catheterized including observing for signs of catheter related infections General considerations 1. Catheter care may be completed by licensed nurses or certified nursing assistants. 2 Catheter care will include cleansing the perineal area and external portion of the catheter, draining the collection bag, and placing the tubing and collection bag in the correct position to prevent infection, as well as providing dignity to the resident . Catheter Care: 1. Perform hand hygiene and put on clean gloves. 2. Cleanse the perineal area from center to the outside. 3. Using a clean washcloth to cleanse the catheter at the insertion site outward about 4 inches. 4. Remove gloves and perform hand hygiene. The policy did indicate a frequency for catheter care. 3.1-41(a)(1)

Based on observations, interviews and record reviews, the facility failed to utilize PPE to prevent COVID-19 during 3 of 3 observations ror infection prevention. Findings include: During an observation on 9/14/21 at 10:45 A.M., Employee 3 was observed sitting at the activity table in the memory care unit with 8 unmasked residents Employee 3 was wearing her N95 mask under her nose. During an observation on 9/14/21 at 10:0 A.M., Employee 1 was standing beside the screening table in the lobby. Her white surgical mask was under her nose. During an interview at the same time, Employee 1 indicated she forgot to put on the N95. During an observation on 9/14/21 at 12:18 P.M., Employee 2 was sitting at the nurses' desk with her N95 mask down below her nose. During an interview at the same time, Employee 2 indicated she needed to breathe for a minute. During interview on 9/14/21 at 3:10 P.M., the Infection Preventionist indicated masks are to be worn covering the nose. The facility policy titled Covid-19 Infection Control Guidance in Long-term Care Facilities, updated 9/7/21, indicated Masks (covering mouth and nose) This Federal citation is related to Complaint IN 571 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure medications were transcribed accurately for 1 of 3 resident's reviewed for transcribed medications. (Resident B) Findings include: At 3 p.m., on 8/3/2021, Resident B was observed in her room, lying in her bed, resting with her eyes closed. A review of Resident B's record on 8/3/2021 at 2:29 p.m., indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15. The score was obtained from the MDS (Minimal Data Set) Admission Assessment, dated 7/26/2021. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/3/ 2021 at 2:01 p.m., the complainant indicated Resident B had received a [MEDICATION(S)] (a medication used for anxiety) 1 mg (milligram), on 7/12/ 2021, and indicated the resident did not take [MEDICATION(S)], she took [MEDICATION(S)] (a medication used for anxiety). A review of the MAR (Medication Administration Record) indicated Resident B was administered a [MEDICATION(S)] (generic for [MEDICATION(S)]) 1 mg on 7/12/ 2021 at 2:53 p.m A review of the Physician Order's indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note, dated 7/12/2021 at 4:15 p.m. indicated Resident B had been drowsy and was slow to respond. Family was concerned. The nurse explained that the medication she had received earlier would relax her. A Progress Note, dated 7/12/2021 at 5 p.m. indicated Resident B was unresponsive to verbal and physical stimuli. Family was at the bedside, the POA (Power of Attorney) was notified, and decided to send Resident B to the emergency room . During an interview on 8/3/2021, at 2:55 p.m., the DON (Director of Nursing) indicated Resident B had been admitted from the hospital on both [MEDICATION(S)], and [MEDICATION(S)] for anxiety. A review of the 7 pages of Medication Information indicated 4 pages were Resident B's medications, completed at the hospital on 7/9/2021 at 14:41 (2:41 p.m.) and 3 pages were an unidentified patient, completed at the hospital on 7/9/2021 at 14:44 (2:44 p.m.). A review of the MAR, and the Medication Information forms indicated the admitting nurse put all 7 pages of medication orders on the MAR for Resident B. Resident B had received the following medications which were not hers: [MEDICATION(S)] 1 mg one time daily, for anxiety, administered on 7/12/2021 at 2:53 p.m. [MEDICATION(S)] suspension 15 mg/60 ml (milliliter), for high potassium, administered 60 ml, one time daily, on 7/10, and 7/12/2021. [MEDICATION(S)] 10 mg one time daily, for allergies, administered in the morning on 7/12/2021. [MEDICATION(S)] 10 mg, one time daily, for high blood pressure, administered on 7/10, and 7/12/2021. [MEDICATION(S)] 20 mg one time daily, for [CONDITION(S)], administered on 7/10, and 7/12/2021. Praaugrel HCL 10 mg, preventative blood thinner used with aspirin one time daily, administered on 7/10, and 7/12/2021. [MEDICATION(S)] 25 mg one time daily, for high blood pressure, administered on 7/10, and 7/12/2021. [MEDICATION(S)] 25 mg two times daily, for high blood pressure, administered on 7/10, and 7/12/2021 morning doses only. [MEDICATION(S)] monthly pak, 1 tablet two times daily, for smoking cessation, administered on 7/10, and 7/12/2021. [MEDICATION(S)] 500mg, 1 tablet two times daily, times 30 days for chest pain, administered on 7/10 (1 dose), 7/12, and 7/19 (1 dose). [MEDICATION(S)] 60 mg two times daily, for high blood pressure, administered on 7/10, 7/12, and 7/19/2021, she only received one dose each of those dates. Lactobacillus 1 capsule two times daily, for [MEDICATION(S)], administered on 7/10, 7/12, and 7/19/2021, she only received one dose each of those dates. [MEDICATION(S)] HCL 500 mg two times daily, times 90 days, for diabetes, administered on 7/10, 7/12, and 7/19/2021, she only received one dose each of those dates. [MEDICATION(S)] capsule 1000 mg two times daily, for a supplement, administered on 7/10, 7/12, and 7/19/2021, she only received one dose each of those dates. [MEDICATION(S)] 10 mg two times daily, for diabetes, administered on 7/10, 7/12, and 7/19/2021, she only received one dose each of those dates. During an interview on 8/3/2021 at 4 p.m., the DON indicated the nurses at the facility did request the nurses from the hospital go over resident medications during the telephone report, when they are getting an admission. She indicated the auditing of new admission paperwork had not been getting completed routinely. A policy, Admission Order Audit Protocol, dated 10/2019, and provided by the DON on 8/3/2021 at 5:53 p.m., indicated the following: .To ensure the resident is receiving care as prescribed by physician. To ensure that significant medication issues are addressed, physician is notified, and documentation is completed. admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DCS may choose to have 2 nurses complete the audits. The admission order audit must be completed within 24 hours of admission . This federal tag relates to Complaint IN 555. 3.1-48 (c)(2)

Based on interview, and record review, the facility failed to ensure residents were being assessed daily for signs and symptoms of Covid-19, and documented findings for 8 of 8 residents reviewed. (Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, and Resident 27) Findings include: 1. A review of Resident 20's record on 10/22/2020 at 1:20 p.m., indicated [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. There was no assessment, or evaluation completed for the month of October. 2. A review of Resident 21's record on 10/22/2020 at 1:25 p.m., indicated [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. There was no assessment, or evaluation completed for the month of October. 3. A review of Resident 22's record on 10/22/2020 at 1:30 p.m., indicated [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. There was no assessment, or evaluation completed for the month of October. 4. A review of Resident 23's record on 10/22/2020 at 1:35 p.m., indicated [DIAGNOSES REDACTED]. A review of the TAR's (Treat Administration Records), indicated no daily Covid-19 assessments had been completed for 9 days, on the following dates 10/13 through 10/21/2020. 5. A review of Resident 24's record on 10/22/2020 at 1:40 p.m., indicated [DIAGNOSES REDACTED]. A review of the TAR's indicated no daily Covid-19 assessment had been completed on 10/9/2020. 6. A review of Resident 25's record on 10/22/2020 at 1:45 p.m., indicated [DIAGNOSES REDACTED]. A review of the TAR's indicated no daily Covid-19 assessment had been completed on 10/2, 10/7, and 10/14/2020. 7. A review of Resident 26's record on 10/22/2020 at 1:50 p.m., indicated [DIAGNOSES REDACTED]. A review of the TAR's indicated no daily Covid-19 assessment had been completed on 10/2, 10/7, and 10/14/2020. 8. A review of Resident 27's record on 10/22/2020 at 1:55 p.m., indicated [DIAGNOSES REDACTED]. A review of the TAR's indicated no daily Covid-19 assessment had been completed on 10/2, and 10/7/2020. During an interview on 10/22/2020 at 1:15 p.m., the DON (Director of Nursing) indicated all residents were to be assessed daily for Covid-19 signs and symptoms that included the following: temperature, a change in eating habits, nausea, vomiting, diarrhea, and confusion. The residents were also to have a completed respiratory evaluation daily. During an interview on 10/22/2020 at 2:20 p.m., the DON indicated all residents should have had a Physician order [REDACTED]. During an interview on 10/22/2020 at 3 p.m., RN (Registered Nurse) 1 indicated that all residents were to be screened every day for Covid-19, and have their temperature taken. She further indicated that each area to be assessed popped up on the TAR on the computer. A current facility policy, Covid-19- Admission/Readmission/Transfer Criteria, dated 4/10/2020, provided by the DON on 10/22/2020 at 2:17 p.m., indicated that residents would be screened for the following: .presence of respiratory illness (cough, sore throat, shortness of breath, difficulty breathing (without underlying disease such as [MEDICAL CONDITIONS]), fever or new onset of confusion, nausea/diarrhea .Residents will be monitored for signs and symptoms of respiratory illness, fever, and changes in cognitive status every day . 3.1-18(a)

Based on observation, interview and record review the Quality Assurance and Performance Improvement Committee (QAPI) failed to ensure the facility the medication carts were locked and maintained and medications were stored per recommendations, which had the potential to affect 57 of 57 resident who received medications from the facility. Findings include, During an interview with the Administrator on 3/27/19 at 4:23 p.m., indicated the QAPI Committee and the QA&A (Quality Assessment and Assurance) Committee were comprised of the same staff and indicated the Committees met monthly. The Committee consisted of the Administrator, the Director of Nursing, the Assistant Director of Nursing, who is the QAPI Nurse, the MDS (Minimal Data Set) Coordinator, the Medical Records Director, the Maintenance Supervisor, the Business Office Manager, the Human Resources Director, the Admission Coordinator, the Social Service Director, the Dietary Manager, the Activity Director, and a CNA (Certified Nursing Assistant) if available. The Medical Director and the Pharmacy Consultant met with the Committees quarterly. The Administrator indicated concerns were identified by the QAPI Committee through many sources. Indicated the Committees looked at quality measures, grievances, ISDH (Indiana State Department of Health) surveys, the annual Corporation's mock survey, Q Source (a free services provided by CMS (Center of Medicare and Medicaid Services) for quality measures, employee concerns and complaints, employee satisfaction surveys, residents and families concerns and grievances, and LTC trend tracker (reports from MDS Assessment that tracks trends. The Administrator indicated the Committees were auditing, monitoring and tracking for the Medication carts being locked, refrigerator temperatures and labeling medications. He indicated had been monitored since the facility's mock survey. He indicated the audits had been doing well and had not required adjustments to the action plans. He further indicated the QAPI/QA&A continue to monitor until 100% compliance was achieved. He indicated the staff were already educated on locking medication carts and storage of refrigerator medications as recommended. He indicated the auditing would continue and adjustments to audits to include medications requiring specific storage. Review of the current facility's QAPI Plan, with an effective date of 12/31/2018 was provided by the Administrator on 3/21/19 at 10:45 a.m., indicated, .We are committed to providing the highest quality care and services in an efficient and cost effective manner .the outcome of QAPI is the quality of care and the quality of life for our residents .The QAPI program will aim for safety and high quality with all clinical interventions and services delivery .QAAPI provides a systematic approach to evaluating potential problem and opportunities for improvement through continuous cycles of data gathering and analysis .At the end of data collection periods, the QAPI committee will periodically review reports to identify areas for improvement 3.1-52(a)(2)

Based on observation, interview and record review, the facility failed to ensure accurate dispensing, administering, reconciling and disposal of medications for 12 of 57 residents in the facility. (Residents B, C, D, E, F, G, H, J, K, L, M, N and O) Findings include: 1. The record review for Resident B began on [DATE] at 1:59 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview of Mental Status) of ,[DATE] which indicated the resident was moderately cognitively impaired. The PHQ-9 (depression screen) was scored at a 6 (mild depression). There were no behaviors or [MEDICAL CONDITION]. The resident required a limited assist of 1 person for bed mobility, transfers, locomotion on unit, dressing, toileting and personal hygiene and supervision of 1 person for locomotion off unit and eating. The resident had scheduled and prn (as needed) pain medications, had occasional pain which did not make it hard for her to sleep at night or limit day to day activities. Pain was rated at 4 (moderate pain). The current Physician orders [REDACTED]. Both medications were controlled substances and required to be double locked and signed out by nursing staff A review of the (MONTH) (YEAR), January, February, and (MONTH) 2019 MARs (Medication Administration Records) as compared to the Controlled Drug Administration Record for Resident B for the [MEDICATION NAME] indicated on [DATE] at 7:15 p.m., 1 tab was signed out by QMA (Qualified Medication Aide) 13, but not documented on the MAR (Medication Administration Record) as administered. On [DATE], an [MEDICATION NAME] tab was signed out at 7:40 p.m. by LPN (Licensed Practical Nurse) 3 but not documented on the MAR as administered. An interview with LPN (Licensed Practical Nurse) 4 on [DATE] at 9:20 a.m., indicated if Resident B requested her [MEDICATION NAME] pain medication, she would obtain the medication from the locked narcotic drawer in the medication cart. She indicated she would sign out the medication on the Controlled Drug Administration Record, administer the medication to the resident and then document the administration on the resident's MAR. LPN 4 was asked if she would observe a narcotic medication signed out on the Controlled Drug Administration Record, but not documented on the MAR, what would she do. LPN 4 indicated she would go by the sign out of the narcotic on the controlled substance record as the MAR was not always accurate. She indicated the sure way of knowing a narcotic was administered was if it was signed out on the narcotic sheet or obtained from TED (Technology Enabled Dispensing, a medication dispensing machine). A review of the klonopin Controlled Drug Administration Record for Resident B as compared to the MARs from (MONTH) (YEAR) through (MONTH) 2019, indicated several dates were marked as administered on the MARs without the corresponding klonopin being signed out on the Controlled Drug Administration record. A review of the 4 MARs for the klonopin indicated entries by nursing staff were marked for the administration of the klonopin without the corresponding sign outs on the controlled substance records as follows: 3 entries for the (MONTH) (YEAR) MAR for ,[DATE], ,[DATE] and [DATE], all for the noon doses. 6 entries for the (MONTH) 2019 MAR for ,[DATE], ,[DATE] and [DATE] for noon administration and ,[DATE] , ,[DATE], and [DATE] for the 6:00 p.m. dose. 5 entries for the (MONTH) 2019 MAR for ,[DATE], ,[DATE], ,[DATE] and [DATE] for the noon dose and for [DATE] for the 6:00 p.m. dose. 2 entries for the (MONTH) 2019 MAR for [DATE] at noon and for [DATE] at 6:00 p.m. 2. The record review for Resident C began on [DATE] at 9:19 a.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment dated [DATE] indicated Resident C was rarely/never understood, was totally dependent on 1 person for bed mobility, eating, dressing, personal hygiene and bathing, and was totally dependent on 2 persons for transfers and locomotion on/off unit. The resident was marked as receiving routine and prn pain medications. The resident's indicators of pain or possible pain in the last 5 days were non-verbal sounds, facial expressions and had these indicators of pain ,[DATE] days in the past 5 days. The resident had 7 days of opioids administered in the last 7 days. The current Physician orders [REDACTED]. The (MONTH) (YEAR) through the (MONTH) 2019 MARs for Resident C's [MEDICATION NAME] were compared to the TED report for the [MEDICATION NAME] controlled substance access for the same time period. The nursing staff who accessed TED for the [MEDICATION NAME] were not always the same nursing staff who documented the administration of the [MEDICATION NAME] in the MAR. The comparison also indicated the following: The [DATE] and the [DATE] [MEDICATION NAME] doses were documented on the MAR as administered, but there was not a corresponding dispensing date and time for the 2 doses on the TED report. There were 3 doses of [MEDICATION NAME] dispensed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The MAR for the [DATE] bedtime dose of [MEDICATION NAME] was blank and the TED report indicated 2 doses of [MEDICATION NAME] were dispensed on [DATE] at 1:43 a.m. and 2:49 p.m. Resident C was transferred out of the facility on [DATE] in the late afternoon and returned on [DATE] in the evening. The TED report for the [MEDICATION NAME] indicated the medication was dispensed 5 times during the resident's absence (,[DATE] at 11:18 p.m., ,[DATE] at 12:10 a.m. and 2:56 p.m., and on ,[DATE] at 7:20 a.m. and 2:52 p.m.) The MAR for the ,[DATE] bedtime dose was marked LOA (leave of absence). The MAR for ,[DATE] for the morning and bedtime dose was marked with a number 6 (hospitalized ). The MAR for the ,[DATE] morning dose was marked with a number 6 and bedtime dose was marked with an X. The MAR for ,[DATE] morning and bedtime dose was marked with an X. The MAR for ,[DATE] was marked with nursing staff initials as administered at both times. A review of a Controlled Drug Administration Record with a [DATE] date on it indicated 4 [MEDICATION NAME] for Resident C were dispensed from TED and 1 was given at 8:00 p.m., with 3 remaining. An interview with the DON (Director of Nursing), ADON (Assistant Director of Nursing) and the RCO (Regulatory Compliance Officer) on [DATE] at 12:05 p.m., indicated Resident C had [MEDICATION NAME] signed out by nursing staff per the pharmacy report without documentation on the MAR. The ADON found 1 controlled substance record for Resident C for one [MEDICATION NAME] during the time of her hospitalization . 3. The record review for Resident D began on [DATE] at 2:52 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment dated [DATE] indicated a BIMS of ,[DATE] which indicated Resident D was cognitively intact. The resident required supervision with set up help for bed mobility, transfers, walk in corridor/room, locomotion on/off unit, dressing, eating, toileting, bathing and personal hygiene. The resident received scheduled pain medications and no pain at the present. The current Physician orders [REDACTED]. Resident D had taken 4 doses of the [MEDICATION NAME] since ordered, one time on ,[DATE] and ,[DATE], and 3 times on [DATE]. Documentation was present on the MAR and the controlled substance record for all 4 administrations. The resident had [MEDICATION NAME] HCL 50 mg ordered routine 4 times daily for pain on [DATE]. A review of Resident D's MARs from (MONTH) (YEAR) through (MONTH) 2019 and the TED reports for the controlled substance access were compared. The TED reports indicated the [MEDICATION NAME] was dispensed from TED on several occasions by one nursing staff and administered to the resident by another nursing staff. More than 1 dose of [MEDICATION NAME] was dispensed from the TED on several shifts, some at the same time or within minutes of each dispense. On [DATE] at 9:00 p.m. and on [DATE] at 1:00 p.m., the dose of [MEDICATION NAME] was recorded as being dispensed from TED but was not documented as administered in the MAR. The TED report indicated the [MEDICATION NAME] was removed from the TED on [DATE] at 8:11 p.m. and on [DATE] at 12:28 p.m. An interview and observation of the medication room with the CSR Pharmacy Tech and the ADON on [DATE] at 11:40 a.m., indicated the medication dispensing machine, TED packaged and dispensed the medications for the residents per hall each day. The CSR Pharmacy Tech indicated the nurse or QMA had to access the computer and enter the hall and the resident name for the controlled substance. She indicated TED would only dispense what was ordered and would not dispense a controlled substance if there was not an active order or the order was expired. There were 4 cameras observed in the room. An interview with LPN 6 on [DATE] at 3:05 p.m., indicated if she had observed or suspected any nursing staff of diverting narcotic medications, she would report it right away to the DON or Administrator. LPN 6 explained if she did not give a resident a medication, she would have documented it in the resident's notes, put the medication in a plastic bag, and placed it in the medication room with a note for the CSR Pharmacy Tech. An interview with LPN 7 and RN (Registered Nurse) 8 on [DATE] at 9:10 a.m., indicated they would get the narcotic medications from TED. RN 8 indicated there was an option to get all the narcotics at once for the resident for the day and the packages would have the date and times printed on them for administration. RN 8 indicated sometimes TED dispensed too many medications and they would create a facility controlled substance count sheet for these and would secure them in the locked drawer of the medication cart. RN 8 indicated she pulled only the narcotics she was going to dispense and if a resident refused the medication, she would document and then destroy the medication. She indicated she did not know how the facility destroyed refused medications. An interview with QMA 5 on [DATE] at 10:51 a.m., indicated she obtained narcotics from TED for each resident administration. She indicated at one time, for the routine narcotic medications, if you entered all, TED would dispense all the narcotics for the residents in your area. She indicated if a resident had a card for a controlled substance in the medication cart, she would sign out the narcotic at the time the medication was due. An interview with the DON, ADON, the RCO and the CSR Pharmacy Tech on [DATE] at 10:57 a.m., indicated they were not aware of the lack of documentation of the administration of the [MEDICATION NAME] in the MAR after it was signed out on the Controlled Drug Administration Record for Resident B. The DON indicated when a narcotic was signed out on the controlled substance record, it should be documented by the nurse/QMA on the MAR. The ADON indicated the staff had been educated about this. Further interview with the group, indicated they were not aware about several dates where Resident B's klonopin was marked as administered on the MAR but lacked a sign out on Resident B's klonopin controlled substance record. Continued interview with the group, indicated for Residents C and D, there were discrepancies in the pharmacy report for their controlled substance records as compared to the MARs. An interview with the DON, ADON, CSR Pharmacy Tech, RCO and the Administrator on [DATE] at 11:10 a.m., indicated TED would only dispense medications with active orders and there was not a need to reconcile the TED reports logs for the controlled substances with the residents' MARs. The DON indicated every nurse pulls their own narcotic medications to administer. The TED controlled substance reports were reviewed for Residents C and D and the staff initials who pulled the controlled substance from TED did not match the nursing staff who administered the narcotic medication. The TED report was reviewed and the group was made aware of 3 controlled substance tablets were dispensed in one day, where the order was for 2 of the controlled substance in a day. The ADON indicated the times in TED were wrong when she came to the facility and the CSR Pharmacy Tech had fixed them. The TED also dispensed more tablets than was requested and the extra would go on a facility narcotic count sheet. An interview with LPN 3 on [DATE] at 3:07 p.m., indicated for controlled substances, some are on cards in the medication cart locked drawer and there was a narcotic count sheet for the controlled substance that would be used to sign out the medication for administration. For the other controlled substances, they are obtained from the TED in the medication room. The nurse indicated a user name and password were required in order to access TED. She indicated she would get her controlled substance medication at the time it needed to be given and she preferred only to sign them out herself and administer them herself. The nurse indicated she had to get the controlled substances out of TED for agency staff. She indicated for new orders or prn orders, if the order was not in TED, she would have to contact the pharmacy to get the authorization code for the medication to dispense. This would require second nurse log into the system with their password in order to dispense the controlled substance. She indicated there was a time when TED dispensed more tablets than was requested and she reported it to the ADON and destroyed the excess medications in the sharps container. She indicated if she noted any discrepancies in the controlled substance counts or documentation, she would notify the DON, ADON and the Administrator. An interview with the DON and the Administrator on [DATE] at 8:35 a.m., indicated there was not a system in place where the facility checked the pharmacy report for the dispensing of the controlled substances against the MAR documentation, or to check if the nurse pulling the controlled substance was the same nurse who administered the controlled substance, or to verify the MAR was documented with the administration of the controlled substance and if more than one dose of the controlled substance was being pulled from TED by the nursing staff at one time. An interview with the Administrator, DON, ADON and the RCO on [DATE] at 9:19 a.m., indicated the DON received a TED report daily for the as needed controlled substances. The report was used to watch for drug diversions. The DON indicated this prn controlled substance TED report was a tool to investigate further a nurse was pulling several controlled substances, like 15, for prn administration. The DON indicated she did not get a report for the routine prescribed controlled substances from TED. They were made aware after a review of Resident C and Resident D's controlled substance report from TED, there were nursing staff that pulled 2 of the controlled substance doses at the same time and were not necessarily the same nurse that administered the medications. The facility policy indicated the routine daily controlled medications from the dispensing unit would be done each shift by the nurse administering the medication. The DON and the RCO indicated the facility policy may not have been the most current policy. They also indicated the when the staff would pull more than one dose of the controlled substance medications, a controlled substance paper record would be completed for the extra medications and placed in the narcotic book at the medication cart. Further interview with the group, indicated the third shift nurse at a previous time would pull all the routine medications for the next day including the routine controlled medications for the residents. An interview with the DON on [DATE] at 10:30 a.m., indicated she was changing the facility controlled substance policy as of today. She was deleting the part of the policy that indicated done each shift by the nurse administering the medication. 4. An observation of a cardboard box removed from the shred box by the nurse station on [DATE] at 11:52 a.m., indicated there were plastic medication sheets inside the box. An interview with the Social Service Director at this time, indicated the facility shreds the plastic medication sheets dispensed by TED as the residents' names were on the sheets. There were plastic medication sheets observed in the box with medications still inside them. One package contained 3 pills and another package had 1 pill. A total of 13 packages of medications were found in the shred box. A copy of the medication sheets with medications still inside the package was provided by the RCO on [DATE] at 2:14 p.m. There were 12 plastic medications sheets with 17 medications removed from the shred bin. The RCO indicated sometimes the TED dispenses more doses of medication than was requested. The RCO was unable to say why these medications were in the shred box and why they were not administered to the residents. A copy of each resident's MAR was provided by the CRO on [DATE] at 3:43 p.m. Fifteen medications were marked as administered on the 10 individual residents' MARs. Two medications dispensed from the TED did not have current orders from the physician and were not administered. The following residents had medications in the shred box: Resident C - [MEDICATION NAME] 2 x 325 mg take contents at ,[DATE] 08:00 p.m. This medication was not documented as given on the MAR for [DATE] at 8:00 p.m. Resident C had a [DIAGNOSES REDACTED]. Resident D - [MEDICATION NAME] CL ER give on Wednesday [DATE] at 20:00 (8:00 p.m.) This medication was documented as administered on [DATE] at bedtime. Resident D had a [DIAGNOSES REDACTED]. Resident E - [MEDICATION NAME] 150 mcg (microgram) give on Thursday [DATE] at 5:59 a.m. This medication was documented as administered on the MAR for [DATE] at 05:59 a.m. Resident E had a [DIAGNOSES REDACTED]. Resident F - senna laxative take contents at ,[DATE] 2:00 p.m. This medication was documented as administered on [DATE] in the day and evening box on the MAR. Resident F had a [DIAGNOSES REDACTED]. Resident G - [MEDICATION NAME] 600 mg give on Saturday [DATE] at 8:00 a.m. The physician order [REDACTED]. The [MEDICATION NAME] was not documented as administered. Resident H - Bacolfen 10 mg (,[DATE] tab) and [MEDICATION NAME] 300 mg give on Saturday [DATE] at 16:00 (4:00 p.m.) These medications were documented as administered for the 4:00 p.m. time. These medications were ordered 3 times per day. On [DATE], the MAR was documented in the morning and evening boxes as administered for both medications and the midnight time was documented as refused for both medications. Resident H had [DIAGNOSES REDACTED]. Resident J - levetiracetam 250 mg- quantity 2- give on Saturday [DATE] at 15:00 (3:00 p.m.) This medication was documented as administered on [DATE] in the evening box. Resident J had a [DIAGNOSES REDACTED]. Resident K - [MEDICATION NAME] 2 x 325 mg take contents at ,[DATE] 12:00 p.m. This medication was dispensed on [DATE] at 3:06 p.m. Resident 11 did not have an active order for [MEDICATION NAME]. There was an order in the system dated [DATE] at 4:00 p.m. and was discontinued on [DATE] at 3:28 p.m. The MAR reflected this medication was not administered to the resident. Resident L - [MEDICATION NAME] 600 mg give on Monday [DATE] at 07:00 a.m. and Vitamin D3 2,000 units give on Monday [DATE] at 08:00 a.m. Both medications were documented as administered on [DATE] in the morning box. Resident L had a [DIAGNOSES REDACTED]. Resident M - donepezil 10 mg take contents at ,[DATE] 08:00 a.m. The donepezil was ordered to be administered at bedtime and the MAR was documented as administered at bedtime on [DATE]. Resident M had a [DIAGNOSES REDACTED].>dementia. Resident N - 125 mg [MEDICATION NAME] and a 20 mg [MEDICATION NAME] take contents at ,[DATE] was what was left on the remaining label. The medications were documented as administered on [DATE]. (The medications were ordered daily) Resident N had [DIAGNOSES REDACTED]. Resident O - [MEDICATION NAME] 10 mg, aspirin chew 81 mg and cerovite advanced take contents at ,[DATE] 07:00 a.m. The medications were documented as administered on [DATE] in the morning. Resident O had [DIAGNOSES REDACTED]. An interview with the ADON on [DATE] at 10:01 a.m., indicated the facility would dispose of the unused medications by using the drug buster. A current policy, Controlled Substances revised on ,[DATE], was provided by the Administrator on [DATE] at 9:47 a.m. The policy indicated .The removal of routine daily controlled medications from the dispensing unit will be done each shift by the nurse administering the medication A current policy, Drug Disposition revised on ,[DATE], was provided by the RCO on [DATE] at 10:52 a.m. The policy indicated .All medications, with exception of narcotics, are to be placed into the designated medication disposal container A current policy, Following Medication-Physician orders/Parameters revised ,[DATE] was provided by CRO. The policy indicated the .purpose .to administer medications in a safe and effective manner and following physician ordered parameters .Procedures .after administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or TAR, and controlled substance sign out record, if indicated. This federal tag relates to Complaint IN 298. 3XXX,[DATE](b)(3) 3XXX,[DATE](b)(4) 3XXX,[DATE](s)

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed in 2 of 3 halls in the facility which had the potential to affect 19 of 57 residents. Findings include: 1. During an observation in the 200 hall on 3-21-2019 at 10:36 a.m., room [ROOM NUMBER] had an over the door caddy containing personal protective equipment of gloves, gowns, masks and red bags. A notice was on the over the door caddy to the the nurse before entering. An interview with QMA (Qualified Medication Aide) 5 on 3-21-2019 at 11:46 a.m., indicated the resident in room [ROOM NUMBER] in bed B was on isolation for a UTI (Urinary Tract Infection). The QMA did not know what the organism was, but indicated the resident had been on antibiotics since the beginning of the week. An interview with CNA (Certified Nurse Aide) 9 on 3-21-2019 at 11:53 a.m., indicated when asked about the over the door caddy on the door of room [ROOM NUMBER], CNA 9 indicated one of the residents in the room must be on isolation, but did not specify which resident was on isolation. An observation at this time of CNA 9 and CNA 10 indicated both CNAs donned gloves and transferred the resident in bed B with a hoyer lift using a royal blue hoyer pad with a green binding to a wheelchair. CNA 10 was observed to remove the lift from room [ROOM NUMBER] and parked it in the hall. CNA 9 or CNA 10 was not observed to clean the lift before or after moving it from room [ROOM NUMBER]. CNA 10 indicated there were 12 residents who required use of the hoyer lifts in the front and they tried to keep 1 lift in each of the 100 and 200 halls. An observation of room [ROOM NUMBER] on 3-21-2019 at 2:43 p.m., indicated the Administrator posted a Stop sign on the door frame. The sign indicated Contact Precautions, wear gown, gloves upon entering the room; wash hands with soap and water or use hand based alcohol rub after patient care or touching environmental surfaces. A review of the labs for the resident in 212B indicated an urinalysis and culture were completed on 3-15-2019. The results indicated EBSL (extended-spectrum-beta-lactamase) producer in the urine which was one of the multi drug resistant organisms. Antibiotics were ordered through 3-27-2019 evening. An observation of LPN (Licensed Practical Nurse) 2 on 3-25-2019 at 10:02 a.m., indicated the nurse entered room [ROOM NUMBER] without donning a gown or gloves. LPN 2 was observed to carry in 2 purple gloves from the over the door caddy and the medications for the resident in bed B. LPN 2 was observed in room [ROOM NUMBER] standing next to the resident in bed B and administering medications. The nurse was observed to return to the medication cart which was parked in the middle of the hall down from room [ROOM NUMBER] carrying the purple gloves which had been in the isolation room. The nurse was observed to use hand sanitizer at the medication cart. An interview with CNA 10 on 3-27-2019 at 8:30 a.m., indicated the hoyer lift should be cleaned with a spray and wipes after being used with a resident in an isolation room. 2. An observation on 3/22/19 at 10:44 a.m., indicated the following: When walking past room [ROOM NUMBER], a private room, there was an over the door caddy hanging on the outside of the open door. The caddy contained PPE (Personal Protective Equipment, disposable gowns and gloves) and a sign on the door which indicated the resident was in isolation. Observed a housekeeping cleaning cart parked just outside of room [ROOM NUMBER]. Observed Housekeeper 11 in room [ROOM NUMBER], mopping the floor. Housekeeper 11 was observed to not be wearing a disposable gown nor disposable gloves. At 10:46 a.m., Housekeeper 11 was observed to leave the room [ROOM NUMBER] with the mop in her hand and the microfiber mop pad remained on the mop. The housekeeper rested the used mop pad on the hallway floor with the mop handle rested against the cleaning cart. Observed the housekeeper don disposable gloves and was not observed to perform hand hygiene before leaving the isolation room, nor before donning disposable gloves. Housekeeper 11 was observed to remove the microfiber pad from the mop and put the used pad in a plastic bag hanging on the outside of the cleaning cart, then removed the gloves and was not observed to perform hand hygiene. At 10:48 a.m., an interview with Housekeeper 11 indicated she had only worked at the facility a short time. She indicated when she cleaned a resident's room she started by sweeping the floors, then cleaned the bathroom and finished with mopping the floors. The Administrator arrived while Housekeeper was being interviewed. Housekeeper 11 indicated when cleaning an isolation room, she was to wear gloves. The Administrator pointed to the isolation sign on by the door and the Housekeeper indicated a gown should be worn too. She indicated she had not worn a gown when she cleaned the isolation room and indicated she should have worn a gown on when she cleaned the isolation room. On 2/22/19 at 12:49 p.m., an interview with the Administrator indicated the 2 Housekeepers who were working, were provided education on the proper use of PPE and isolation procedures. the Administrator provided the facility policies for Isolation Procedures and Personal Protective Equipment (PPE)and also provided the Housekeepers in-service records. 3. On 3/25/19 at 11:43 a.m., LPN 2 was observed to have obtained a blood glucometer reading from Resident 54. At 11:50 a.m., LPN 2 was observed to clean the glucometer by rubbing the meter with a wet wipe she had removed from a canister labeled ProCare Hand Sanitizing Wipes. LPN 2 was interviewed at 11:51 a.m. She indicated she cleaned the glucometer for 2 minutes with the ProCare Hand Sanitizing wipes. She indicated there were two glucometers on her medication cart and they were used on multiple residents. On 3/25/19 at 11:55 a.m. the Director of Nursing (DON) was interviewed. She indicated the facility used a 1:10 concentration bleach wipes to clean glucometers with. She indicated the bleach wipes were in individual packets. At this time, the DON was made aware LPN 2 was observed to have cleaned a glucometer with the ProCare hand sanitizing wipes. On 3/25/19 at 12:27 p.m., the Director of Nurses (DON) provided a Super Sani-cloth which she indicated was to be used to clean the glucometers with. The DON indicated the glucometers should not be cleaned using the ProCare Hand Sanitizing wipes. On 3/25/19 at 2:40 p.m., the Regulatory Compliance Officer (RCO) provided a current copy of the facility policy and procedure, dated 1/2019, for Glucose Meter Cleaning and Testing. The policy included, but was not limited to, the following: Purpose was to prevent cross contamination and minimize risk of transmitting blood-borne pathogens between residents that require blood glucose monitoring; the blood glucose meter is to be disinfected between resident use; procedure for cleaning: obtain germicidal wipe, wipe entire surface and ensure meter stays wet for 2 minutes. On 3/27/19 at 12:10 p.m., the Assistant Director of Nursing (ADON) provided a copy of the ProCare Hand Sanitizing wipes. The label on the canister indicated the uses included, but were not limited to, antiseptic and handwashing to decrease bacteria. Review of the current facility's policy, provided by the Administrator on 2/22/19 at 12:49 p.m., titled, Isolation Procedures, with revision date of 01/18, indicated, .Isolation Precautions should be utilized in accordance with the CDC (Center for Disease Control and Prevention)/APIC (The Association for Professionals in Infection Control and Epidemiology) Guidelines .The nurse will explain to visitors which PPE will be needed during their visit with the resident The nurse will instruct the visitors on proper hand hygiene .Yellow bags will be used for the resident's linens and personal clothes .When removing yellow bags from the resident room, they will be taken directly to the soiled laundry holding area The policy was lacking information on which PPE the facility staff were to use when entering an isolation room. Review of the current facility's policy, provided by the Administrator on 2/22/19 at 12:49 a.m., titled, Personal Protective Equipment (PPE), dated 6/2017, indicated, .It is the policy of this facility to ensure PPE is available to staff and visitors and they understand when and how to use PPE .Employees required performing tasks that may involve exposure to blood or body fluids will be provided appropriated PPE .All tasks require differing levels of protection and the need for use of PPE is based on: .The fluid or tissue to which there is a potential exposure; .The likelihood of exposure; .The potential volume of material; .the route of exposure; and .The overall job requirements for the position .PPE provided to our employees and visitors include but is not limited to: Gowns (disposable and /or plastic); .Gloves; .Mask; and Eyewear .Staff will follow the policy for isolation precautions and the use of PPE .The use of gloves will vary according to the procedure and is indicated when: .When it is likely the employee's hands will come in contact with blood, body fluids, secretions, excretions .During all cleaning of blood, body fluids and decontaminating procedures A current policy Infection Control - Isolation Measures Policy last revised 9/18 was provided by the Administrator on 3-25-2019 at 12:06 p.m. The policy indicated .Transmission-Based Precautions are designed for individuals known or suspected to be infected and/or colonized with transmissible or epidemiologically important pathogens. These individuals need additional precautions beyond Standard Precautions to interrupt transmission in a health care setting .use contact precautions (e.g. gloves, gowns, masks, etc.) for specified residents known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident of environmental surfaces or resident-care items in the resident's environment .examples include .extended spectrum beta lactamase producing bacteria (ESBL) 3.1-18(a)

Based on interview and record review, the facility failed to provide the Resident or the Resident's Representative with the written facility Bed Hold Policy for 1of 1 resident reviewed for hospitalization . (Resident C) Findings include: The record review for Resident C began on 3-25-2019 at 9:19 a.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident C was rarely/never understood. Resident C was totally dependent on 1 person for bed mobility, eating, dressing and personal hygiene and bathing and was totally dependent on 2 persons for transfers and locomotion on/off the unit. The current Physician orders [REDACTED]. An interview with the SSD (Social Service Director) on 3-25-2019 at 3:14 p.m., indicated there was a bed hold and transfer form for Resident C's recent transfer to the hospital. On 3-25-2019 at 3:59 p.m., the SSD provided the Notice of Transfer or Discharge for Resident C dated 3-20-2019 along with the Bed Hold Authorization. The SSD indicated she contacted the family representative by phone for the bed hold on 3-20-2019 at 4:45 p.m. A copy of the Bed Hold Authorization for Resident C indicated the box was not checked next to the statement .copy mailed to resident representative on _____ by ______ An interview with the SSD on 3-26-2019 at 1:48 p.m., indicated the bed hold policy for Resident C was not mailed to the resident representative. A current policy, Bed-Hold/Readmission Policy revised 11/16 was provided by the RCO (Regulatory Compliance Officer). The policy indicated .the bed-hold policy applies to all residents .the facility will notify the resident and resident representative at the time of admission and again during an event of hospital transfer or therapeutic leave of its bed-hold and return policies. The notice of facility bed hold policy will comply with State and Federal laws and rules 3.1-12(a)(25)(26)

Based on interview and record review, the facility failed to ensure the advanced directive was completed as required for 1 of 2 residents. (Resident 11) Findings include: The record review for Resident 11 began on [DATE] at 2:58 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 11 was severely cognitively impaired with a BIMS (Brief Interview of Mental Status) of 2 out of a possible15. A review of the current physician orders [REDACTED]. A care plan was in place for Resident 11 for specific choices and was initiated [DATE]. One intervention for Resident 11 was updated [DATE] and indicated the advanced directive choices will be honored. Two documents were found scanned into Resident 11's electronic medical record, a Code Status document and a State of Indiana Out Of Hospital Do Not Resuscitate Declaration and Order, both dated [DATE]. A copy of both forms for Resident 11 was provided by the RCO (Regulatory Compliance Officer) on [DATE] at 4:58 p.m. The Code Status form was completed on [DATE]. The POA (Power of Attorney) for Resident 11 signed the form. A box with an X was next to the word No in answer to the statement would you like CPR (Cardiopulmonary Resuscitation). A facility representative signed the form. There was not a physician signature on this form, nor was there any line indicated for a physician signature on the Code Status form. A second form, the State of Indiana Out of Hospital Do Not Resuscitate Declaration Order was also provided at this time. The form was dated [DATE]. The POA of Resident 11 signed the form and a facility witness also signed form. At the bottom of the form, there was a box labeled Out of Hospital Do Not Resuscitate Order. Inside the boxed area, there was a space for the printed name and signature of the physician for Resident 11. The boxed area lacked the physician printed name, signed name, medical license number and the date. An interview at this time with the RCO indicated there was not a physician signature on the State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order dated [DATE] for Resident 11. An interview with the DON (Director of Nursing) on [DATE] at 9:10 a.m., indicated Resident 11 had a care plan which was current which indicated Resident 11 was a DNR. A current policy, Advanced Directives revised ,[DATE], was provided by the RCO on [DATE] at 10:52 a.m. The policy indicated .Facility will follow their state requirements and utilize any state specified forms 3XXX,[DATE](f)(7)

Based on interview and record review the facility failed to ensure the accuracy of MDS (Minimum Data Set) Assessments for 2 of 4 residents reviewed for PASRR Screening. (Resident 40 and Resident 17) Findings include: 1. A review of Resident 40's records on 3/26/19 at 9:37 a.m., indicated [DIAGNOSES REDACTED]. Delusional disorder was added to Resident's [DIAGNOSES REDACTED]. The most current Annual MDS Assessment, dated 08/02/2018, indicated Section A1500 Preadmission Screening and Resident Review, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The questions was answered, No. Section I, Active Diagnosis, Psychiatric/Mood Disorder was answered, Yes to Anxiety disorder and [MEDICAL CONDITION] (other than [MEDICAL CONDITION]). Level II PASRR conditions questions were disabled and not answered. 2. A review of Resident 17's record on 3/25/2019 at 2 p.m., indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15 out of 15, meaning the resident was cognitively intact. [DIAGNOSES REDACTED]. A PASRR (Preadmission Screening and Resident Review) Level II was completed on 10/11/2018 and indicated Resident 17 was mentally ill. The MDS (Minimum Data Set) Admission/Medicare 5 day Assessment, dated 10/18/2018, indicated the following: Section A 1500. Preadmission Screening and Resident Review (PASRR) .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental [MEDICAL CONDITION] in federal regulation) or a related condition? . The NO section was documented, and Section A 1510 was not completed at all. The MDS Active Diagnoses, in Section I, indicated: depression and [MEDICAL CONDITION]. During an interview on 3/25/2019 at 3:35 p.m., the MDS Coordinator indicated the Social Service Director (SSD) completed Section A of the comprehensive assessment, and that the SSD that documented on the MDS was no longer employed at the facility. A current facility policy, Level I and Level II Process, dated 11/2016, provided by the Administrator on 3/26/2019 at 8:53 a.m., indicated the following: . 7. Recommendations from the PASARR Level II determination and evaluation report will be incorporated into the resident's assessment and care plan, as appropriate. 9. Based on the comprehensive plan of care, if specialized services or specialized rehabilitation services such as but not limited to physical therapy, speech language pathology, occupational therapy, respiratory therapy, and rehabilitative services for a mental disorder or intellectual disability are required, the facility will not exclude the resident from participating . 3.1-31(d)

Based on interview and record review, the facility failed to ensure updated PASRR (Preadmission Screen and Resident Review) level 1 screens were submitted for 3 of 3 residents reviewed. (Residents 10, Resident 40 and Resident B) Findings include: 1. A review of Resident 40's electronic medical records on 3/26/19 at 9:37 a.m., indicated [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Resident 40's most current Annual MDS Assessment, dated 08/02/2018, indicated, Section A1500 Preadmission Screening and Resident Review, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The questions was answered, No. Section I, Active Diagnosis, Psychiatric/Mood Disorder was answered, Yes to Anxiety disorder and [MEDICAL CONDITION] (other than [MEDICAL CONDITION]). Level II PASRR conditions questions were disabled and not answered. Resident 40's PASRR Information was provided by the Administrator on 3/26/19 at 10:31 a.m. and indicated the following: The Level 1 PASRR dated 4/19/17 was completed by the Hospital and indicated [DIAGNOSES REDACTED]. Listed Mental Health Medications as [MEDICATION NAME] (an anti-anxiety medication) and [MEDICATION NAME] (an antipsychotic medication). The PASRR Level 1 outcome was dated 4/19/2017 indicated, a Level II PASRR was not required. The document also indicated, The Level I screen indicated, .If changes occur or new information refutes these findings, a new screen must be submitted The facility did not provide a completed a PASRR Level 1 for a resident review since the time Resident 40 was diagnosed with [REDACTED]. 2. A review of Resident 10's electronic medical records on 3/26/19 at 10:08 a.m., indicated [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Resident 10's most current Annual MDS Assessment, dated 3/13/2019, indicated, Section A1500 Preadmission Screening and Resident Review, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The questions was answered, No. Section I, Active Diagnosis, Psychiatric/Mood Disorder was answered, Yes to Anxiety disorder, Depression (other than [MEDICAL CONDITION]) and [MEDICAL CONDITION] (other than [MEDICAL CONDITION]). Level II PASRR conditions questions were disabled and not answered. Resident 10's PASRR Information was provided by the Administrator on 3/26/19 at 10:31 a.m. and indicated the following: A review of Resident 10's PASRR Level 1 which indicated was completed when resident was observed in the hospital for a new admission to NF (nursing facility) on 8/2/13. Indicated Resident 10 had [DIAGNOSES REDACTED]. Indicated Resident 10 was prescribed the medication [MEDICATION NAME] (an antidepressant) 75 mg orally 2 times a day. The document also indicated Resident 10 had not been hospitalized and did not had [DIAGNOSES REDACTED]. The document further indicated PASARR Level II Assessment Referral was not needed. The PASRR Level I was signed by a PAS agency representative on 8/14/13. The 4B Assessment Determination indicated Short-Term for 60 days and expires on 10/7/13. A review of Resident 10's Indiana's Pre-Admission Screening Program (PAS/PASRR) Assessment Determination dated 9/20/19, indicate Resident 10 my remain in the nursing facility and placement in the nursing facility was found to be appropriate. The document indicated the approval was effective for 90 days. The document further indicated, Level II is not completed at this time, although the above-named applicant's condition would ordinarily require PASRR Level II assessment. It is the responsibility of the NF to monitor the individual's condition. If the depressed condition behavior or mood either worsens, or has not improved within 90 days following NF admission, the NF must make a referral to the local CMHC (Community Metal Health Center) for a non-routine RR (Resident Review) A review of the Physician Certification for Long-Term Care Services indicated PAS: Approved for long term NF level of care effective 10/7/13. and was signed by PAS agency representative on 12/09/2013. A review of PASRR Level 1 was submitted by the facility's Social Services Director for a Resident review on 12/5/14, which indicated [DIAGNOSES REDACTED]. The form was not completed by a PAS agency representative. The facility did not provide a completed a PASRR Level 1 for resident review since the time Resident 10 was diagnosed with [REDACTED]. 3. The record review for Resident B began on 3-25-2019 at 1:59 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview of Mental Status) of 9/15 which indicated the resident was moderately cognitively impaired. The PHQ-9 (depression screen) was scored at a 6 (mild depression). There were no behaviors or [MEDICAL CONDITION]. The resident required a limited assist of 1 person for bed mobility, transfers, locomotion on unit, dressing, toileting and personal hygiene and supervision of 1 person for locomotion off unit and eating. An annual MDS assessment completed on 5-6-2018 indicated for section A1500 (Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition was answered no. The entry date of the resident was 4-27-2016. The BIMS was 9/15 and the PHQ-9 score was 10 (moderate depression). There were no indicators of [MEDICAL CONDITION] or behaviors marked. The active [DIAGNOSES REDACTED]., anxiety, depression, [MEDICAL CONDITION], asthma ([MEDICAL CONDITION]-[MEDICAL CONDITION]), abnormal weight loss, other chronic pain, muscle weakness, dysphagia, other abnormalities of of gait and mobility, other lack of coordination, and history of falling. A copy of the PASSR Level 1 dated 2-15-2014 was located in the resident's electronic medical record. The PASRR Level 1 question, .Does the individual have a documentable [DIAGNOSES REDACTED]. was answered No. The second question .Does the individual have a [DIAGNOSES REDACTED]. was answered No. Question 3, .Does the person have a [DIAGNOSES REDACTED]. was answered with anxiety secondary to [MEDICAL CONDITION] and the resident was prescribed [MEDICATION NAME] (a medication) for her anxiety related to the [MEDICAL CONDITION]. There was not a yes or no marked as to whether the resident needed a PASARR level II assessment referral needed. An interview with the Administrator on 3-26-2019 at 9:35 a.m., indicated the resident came to the facility on [DATE] with a PASRR completed at another facility. The Administrator indicated the resident was admitted with the [DIAGNOSES REDACTED].>03/26/19 09:35 AM interview with the Administrator indicated the resident came to the facility on [DATE] and her original PASRR was completed at another facility. This PASRR was sent with the resident when she was admitted to this facility. The Administrator indicated Resident B was admitted to this facility with the [DIAGNOSES REDACTED]. The Administrator indicated there was no other PASRR completed with the additional diagnoses. A current policy, Level I and Level II Process last revised 11/16, was provided by the Administrator on 3-26-2019 at 8:53 a.m. The policy indicated, .Social Service Director or designee will refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition to the state mental health authority or the state intellectual authority. Documentation will be made in the progress notes .6. The facility will notify the state mental health authority or state intellectual authority as applicable promptly after a significant change in mental or physical condition of a resident who has a mental disorder or intellectual disability for resident review .documentation of the referral will be made in the progress notes 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure the Physician and Responsible Party were notified of a pressure wound that worsened for 1 out of 1 resident reviewed for pressure ulcers. (Resident 41) Findings included: A review of Resident 41's record on 3/25/2019 at 4:25 p.m., indicated the residnet had a BIMS (Brief Interview of Mental Status) score of 14 out of 15, meaning the resident was cognitively intact. [DIAGNOSES REDACTED]. A Skin and Wound Evaluation form was completed for Resident 41 on the following dates: 3/1, 3/8, 3/15, and 3/22/2019. A review of the Skin and Wound Evaluation, dated 3/15/2019 at 8:59 a.m., indicated the following: A new, in-house acquired pressure wound on the right heel, with no staging documented. The wound measured 1.3 cm (centimeters) in length and 1.6 cm in width. The width had increased in size from 1.1 cm on 3/8/2019. The wound bed indicated 60 % of [MEDICATION NAME] (top layer of skin) tissue, 20% of slough (soft moist, dead) tissue, and 20% eschar ( dark, hard, dead) tissue. The wound had a light amount of serous (thin, watery) exudate (drainage). The treatment indicated no debridement (remove damaged tissue) had been done. No notifications to the Physician or Resident/Responsible Party had been completed on the form or in the Progress Notes. On 3/15/2019, the Wound NP (Nurse Practitioner) had documented they had been asked to re-evaluate Resident 41's wound, because staff had reported the wound had worsened. During an interview on 3/26/2019 at 4 p.m., the DON (Director of Nursing) indicated if there was a worsened or change in the wound, the Physician and Personal Representative should be notified. A current facility policy, Documentation Procedures and Guidelines, dated 5/2017, provided by the DON on 3/26/2019 at 1:41 p.m., indicated the following: .Documentation 3. Entries will be made whenever there is a change in the resident's condition. The entry will include interventions and appropriate notifications made in a timely manner. 7. Verbal and telephone communication with all parties concerning the care and treatment of [REDACTED]. A current facility policy, PCC (Point Click Care) Wound Documentation Protocol, dated 11/2018, provided by the DON on 3/26/2019 at 1:41 p.m., indicated the following: .6. Weekly Skin Observations - All new areas and areas that have worsened will require notification of the resident/ resident representative and physician. 13. Wound Application - The licensed nurse will notify the physician and family/responsible party and document notification in the medical record. 17. The licensed nurse is responsible for notifying the physician of changes in the wound condition . A current facility policy, Care Planning, dated 12/2018, provided by the DON on 3/26/2019 at 1:41 p.m., indicated the following: .5. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 17. Care plans will be updated with any changes in the resident orders, care, or services that change the plan of care . 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to ensure medications were administered and/or documented accurately for 3 of 9 residents reviewed regarding medication administration. (Resident 9, Resident 12 and Resident 31) Findings include: 1. On 3/25/19 at 10:04 a.m., LPN 2 was observed to take a medication (med) cup of pills from the med cart to Resident 9. At 10:05 a.m., she was observed to exit the room with the med cup of pills still in hand. At 10:05 a.m., LPN 2 was interviewed. She indicated Resident 9 refused to take her pills at that time. LPN 2 was observed to take the med up of pills and put it in the drawer of the med cart. LPN 2 indicated in 15 minutes, she would attempt to give the resident her pills again. On 3/25/19 at 10:11 a.m., LPN 2 was interviewed and indicated the medications listed on the electronic Medication Administration Record [REDACTED]. LPN 2 indicated she worked for an agency and this was the first time she had passed medications on this hall. On 3/25/19 at 10:53 a.m., the MAR indicated [REDACTED]. On 3/25/19 at 12:00 p.m., LPN 2 was interviewed regarding resident 9's pills that had been in a med cup and placed in the med cart. At this time, the med cart was observed and no pill cup with meds was observed in the med cart. LPN 2 indicated she had thrown the pills away that resident 9 had refused this morning. LPN 2 indicated she had put the pills in the sharps container to dispose of them around 11:45 a.m. today. She indicated the pills she threw in the sharps container were the residents morning pills. On 3/25/19 at 12:27 p.m., LPN 2 was interviewed. She indicated resident 9 had refused her 8:00 a.m. and 9:00 a.m. pills in addition to the morning medications today. LPN 2 indicated resident 9 had refused all her morning pills. On 3/25/19 at 2:40 p.m., the Director of Nursing (DON) provided a current copy of the medication pass times. The morning medication (med) pass was listed as 7:00 a.m. to 9:00 a.m. The DON was interviewed at this time and indicated medications can be passed an hour before the listed med pass time and/or an hour after the listed med pass time. She indicated the morning medication pass could be from 6:00 a.m. to 10:00 a.m. 2. On 3/25/19 at 10:14 a.m., LPN 2 was observed to prepare the following meds for resident 12: 1. cardiopa-[MEDICATION NAME] 25-100 mg 2. [MEDICATION NAME] 12.5 mg 3. tylenol 325 mg, two pills for total dose of 650 mg 4. [MEDICATION NAME] 50 mg ER (extended release) 5. senna 50 mg On 3/25/19 at 10:20 a.m., LPN 2 went to Resident 12's room with her meds and asked the resident how she wanted to take her pills, whole or crushed. The resident did not provide a clear answer. LPN 2 indicated she would go ahead and crush the pills. LPN 2 was observed to go to the med cart, crush the pills she had just prepared and put them in approximately a teaspoon of applesauce. LPN 2 was observed to go back into Resident 12's room and gave her a a small bite of the applesauce. Resident 12 made a distressed facial expression and indicated no .no more .give me water. LPN 2 was interviewed as to how she was made aware of the manner in which resident's take their pills. LPN 2 pulled out her report sheet where it was documented the resident took her pills W. LPN 2 indicated the W indicated the resident took her pills whole. At 10:30 a.m., LPN 2 documented in the electronic MAR indicated [REDACTED]. At 10:35 a.m., LPN 2 was observed to ask the Director of Nursing (DON) how resident 12 takes her pills. LPN 2 indicated the DON indicated resident 12 takes her pills whole. At 10:40 a.m., LPN 2 indicated she was going to lunch. She was observed to leave the unit. At 11:00 a.m. the MAR indicated [REDACTED]. The following was observed: 1. cardiopa-[MEDICATION NAME] 25-100 mg had been documented as administered by LPN 2 for the 8:00 a.m. dose on 3/25/19. The 12:00 p.m. dose had been documented as spit out. 2. [MEDICATION NAME] 12.5 mg had been documented as administered for the morning dose. 3. tylenol 650 mg, two times a day (order dated 10/6/17); the morning dose had been documented as having been given. An additional order for tylenol one time a day (order dated 6/28/18) was to be administered at 12:00 p.m. On 3/25/19, the 12:00 p.m. dose had been documented as having been spit out. 4. [MEDICATION NAME] 50 mg ER was documented as administered for the morning dose 5. [MEDICATION NAME] propionate suspension nasal spray, was documented on 3/25/19 for the 12:00 p.m. dose as having been spit out. 3. On 3/25/19 at 11:40 a.m., LPN 2 was observed to be reviewing Resident 31's MAR. LPN 2 was observed to be documenting on the medications which had been highlighted in red and now they were no longer red. At 11:41 a.m., LPN 2 was interviewed as to what she was doing. She indicated she was clicking off these resident's meds which she had already given. At 11:42 a.m., LPN 2 was interviewed as to when she had given the meds she was currently clicking off and she indicated at 9 something. She indicated she had given Resident 31 these meds earlier but it is hard to click them off. She indicated she felt like it was more important to give the resident the meds in a timely manner and she could document and click them off later. She indicated the meds she had given to Resident 31 earlier and was documenting the administration at this time were the following: 1. aspirin 81 mg 2. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 3. [MEDICATION NAME] 5 mg 4. [MEDICATION NAME] 750 mg 5. [MEDICATION NAME] 64.8 mg 6. senna 8.6-50 mg 7. omperazole 20 mg On 3/25/19 at 12:35 p.m., the MAR for Resident 31 was reviewed. The following meds were listed on the MAR indicated [REDACTED] 1. aspirin 81 mg 2. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 3. [MEDICATION NAME] 5 mg 4. [MEDICATION NAME] 750 mg 5. [MEDICATION NAME] 64.8 mg 6. senna 8.6-50 mg 7. omperazole 20 mg On 3/26/19 at 11:50 a.m. the Regional Compliance Officer (RCO) provided a current copy of the policy and procedure for Following Medication-Physician Orders/Parameters, dated 5/2018. The policy and procedure included but was not limited to, the following: Purpose: To administer medications in a safe and effective manner and following physician ordered parameters; after administration, return to cart and document administration in the MAR (medication administration record). If resident refuses medication, document refusal on MAR. On 3/26/19 at 1:41 p.m., the DON provided a current copy of the facility policy and procedure for Documentation Procedures and Guidelines, dated 5/2017. The policy and procedure included, but was not limited to, the following: Purpose: to reflect the quality of care provided to each resident, to document the resident's progress toward care plan goals, interventions and responses to treatment. Documentation: Each health care professional shall be responsible for making their own prompt, factual, concise, entries that are complete and appropriate. Required entries will be timely. On 3/27/19 at 12:45 p.m., the DON was interviewed. She indicated medication administration should be documented accurately and timely. She indicated LPN 2 should not have documented at 11:40 a.m. the administration of the medications she indicated she administered at 9 something. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure Physician's Orders had been followed, for 1 out of 1 resident reviewed for a tube feeding. (Resident 256) Findings include: A review of Resident 256's record on 3/26/2019 at 5:25 p.m., indicated a BIMS (Brief Interview of Mental Status) could not be completed due to severe cognitive impairment. [DIAGNOSES REDACTED]. On 3/22/2019 at 2:35 p.m., Resident 256 was observed in their room, and the feeding was running at 50 ml /hr (milliliters per hour) according to the settings of the pump. On 3/25/2019 at 9:45 a.m., Resident 256 was observed in their room, lying supine in bed, with the head of the bed elevated, and the tube feeding was running. On 3/26/2019 at 10:28 a.m., Resident 256 was observed in their room, lying in bed, with the head of the bed elevated, and the tube feeding was running. On 3/27/2019 at 3:19 p.m., Resident 256 was observed in their room, sitting up in their wheelchair, and the feeding was turned off. On 3/27/2019 at 3:28 p.m., LPN (Licensed Practical Nurse) 3 and the ADON (Assistant Director of Nursing) were observed in Resident 256's room and were attempting to start the feeding. An observation of the label on the completely full feeding bag, that was hanging on the enteral pump pole, indicated a date of 3/26/2019 and time of 12 p.m. The Physician's Orders indicated the following: Glucerna 1.5 (a calorically dense formula) at 50 ml/hr every shift for nutrition. Flush tube with 200 ml of water 4 times a day. Flush G tube with 30 ml of water before and after medication administration. Nothing by mouth. A review of the Medication Administration Record [REDACTED] On 3/11/2019 at 12 p.m. and 4 p.m., the tube was flushed with 120 cc (cubic centimeters) of water. On 3/18/2019 at 8 a.m. the tube was flushed with 120 cc of water. A review of Resident 256's weight record indicated the following: On 2/15/2019, an admission weight of 206 lb (pounds). On 2/26/2019, a weight of 205.4 lb. On 3/7/2019, a weight of 201 lb. A review of the resident centered care plan, dated 2/15/2019, indicated the following: .F[NAME]US: I have a gastrostomy tube related to my dysphagia diagnosis. I may be at nutritional and dehydration risk. GOAL: I will maintain my nutritional status utilizing my care plan interventions and my feeding tube. INTERVENTIONS: I will have RD (Registered Dietician) visits as indicated. I will receive free water flushes as ordered. I will receive my feeding as ordered. My orders for site care will be followed. The head of my bed will be elevated to at least 30 degrees during and at least one hour after infusion of feeding . A review of the resident centered care plan, dated 2/28/2019, indicated Resident 256 would need assistance with Activities of Daily Living due to paralysis from the stroke. An intervention indicated the resident was a tube feed and does not consume anything by mouth. There was no documented intervention of using mouth swabs for oral care. During an interview on 3/27/2019 at 3:10 p.m., the ADON, indicated the night shift nurse changes the feeding syringe, and they were unsure how often the new bag of Glucerna was to be hung, indicating maybe once it was empty. The ADON indicated how often Resident 256 received mouth care should be on the care plan. The ADON further indicated that the resident bites down on the toothettes (mouth swabs) so the resident may not be getting her mouth cleaned out, but the resident had been working with the Speech Therapist. During an interview on 3/27/2019 at 3:20 p.m., LPN 3, indicated the nurses clean Resident 256's mouth out with lemon [MEDICATION NAME] swabs, and they were unsure why the feeding was turned off at that time. LPN 3 indicated when speech therapy returns the resident from therapy they do not inform the nurse so they can turn back on the tube feeding. During an interview on 3/27/2019 at 3:23 p.m., the Speech Therapist indicated the resident had been discharged from therapy that day and had recommendations to have mouth swabbed out with toothettes. The Speech Therapist also indicated the resident had been in therapy earlier and had finished at 12 p.m. During an interview on 3/27/2019 at 4 p.m., the ADON indicated they had missed a weight on Resident 256, and they should have been weighed weekly for 4 weeks after admission. A current facility policy, Weights, dated 2/2018, provided by the ADON on 3/27/2019 at 4 p.m., indicated the following: .1. Residents will be weighed upon admission and weekly for 4 weeks after admission. The weight will be documented in the resident's clinical record. 7. After the 4 week admission weights are completed the Interdisciplinary team will determine if the resident is to continue on weekly weights or will change to monthly weights . A current facility policy, Care Planning, dated 12/2018, provided by the DON (Director of Nursing) on 3/26/2019 at 1:41 p.m., indicated the following: .a Baseline Plan of Care that includes: c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. d. Any updated information based on the detail of the comprehensive care plan . 3.1-44(a)(2)