Every finding on record at Envive of Berne

Based on observation, interview and record review, the facility failed to ensure recipes were followed for therapeutic diets. This had the potential to affect 6 residents that were on puree diets. (Resident 2, Resident 5, Resident 7, Resident 8, Resident 12, Resident 33)Findings include: An observation, on 08/10/25 at 10:59 AM, [NAME] 4 began puree preparation. In an interview, on 08/10/25 at 10:59 AM, [NAME] 4 indicated there was no recipe book for purees and was told just to add water and bread. She indicated she would eyeball consistency and would just open the lid of the puree to see how thick or thin it was. [NAME] 4 indicated she did not know how the nutritional value was maintained since she had just started with the facility. [NAME] 4 indicated she did not know the fork or spoon method for testing appropriate puree thickness. In an interview, on 08/10/25 at 10:59 AM, the Dietary Manager indicated there was no testing method for puree diets. There was a recipe book, however the cooks typically knew what to add, the menu was a 4 week rotation so the cooks knew how to prepare meals. For puree there were 6 slices of bread, a total of 6 puree diets. The Dietary Manger indicated pretty much everything the facility served was 4 ounces. 1. Resident 2's record review on 8/13/25 at 11:30 AM, indicated diagnoses included dysphagia, oropharyngeal phase. A physician order, dated 5/16/25, indicated to give a controlled carbohydrate diet, pureed texture. Nectar/mildly thick consistency to be given for aspiration prevention. 2. Resident 5's record review on 8/13/25 at 11:35 AM, indicated medical diagnoses included dysphagia, oropharyngeal phase. A physician order, 7/11/25, indicated to give a large portion diet, pureed texture, Nectar/mildly thick consistency, pudding as desired. May have comfort foods of any consistency as desired for dysphagia. 3. Resident 7's record review, on 8/13/25 at 11:40 AM, indicated medical diagnoses included dysphagia, pharyngoesophageal phase. A physician order, dated 7/30/25, indicated to give a regular diet, mechanical soft texture, regular/thin consistency. Resident requested food be pureed for diet. 4. Resident 8's record review, on 8/13/25 at 11:45 AM, indicated medical diagnoses included dysphagia, oropharyngeal phase. A physician order, dated 7/23/25, indicated to give a regular diet, pureed texture, regular/thin consistency. 5. Resident 12's record review, on 8/13/25 at 11:50 AM, indicated medical diagnoses included dysphagia, oropharyngeal phase. A physician order, dated 9/25/24, indicated to give a controlled carbohydrate diet, pureed texture, regular/thin consistency. 6. Resident 33's record reviewed on 8/13/25 at 11:55 AM, indicated medical diagnoses included dysphagia, oropharyngeal phase. A physician order, dated 3/18/25, indicated to give a regular diet, pureed texture, nectar/mildly thick consistency. A record review of pureed recipes-beef patty indicated cook temperature was 375.0 F, cook method was bake, serving size was 4 ounces, and total estimated prep time was 20 minutes. Preparation steps were: Measure desired number of servings into food processor. Blend until smooth. Use fork drip test and spook tilt. Test to confirm texture was specifications. Add small amounts of gravy, sauce, vegetable juice, water, fruit juice, milk, or half & half to meet desired consistency. Drain and discard excess liquid that has separated from the solid food pieces. Add commercial thickener if necessary. Based on liquid/thickener added, nutrition may vary. A current facility policy, titled Therapeutic Diets, dated 10/17, was provided by the Administrator on 8/11/25 at 10:35 AM. The policy indicated . Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences 1.3-21(a)(3)

Based on observation, interview, and record review the facility failed to ensure sanitization was completed of the ice machine/chest. This had the potential to affect 28 residents that receive ice from facility. Finding include: Based on observation, interview, and record review the facility failed to ensure the ice machine was maintained. 28 of 42 residents residing in the facility received ice from the ice machine.During an observation of the ice machine located in the main dining room, on 08/10/25 at 10:30 AM, the Director of Nursing (DON), the ice machine lid was opened, there were black and orange substances on the rubber surface. Ice cubes were located below. The DON indicated this was the only ice machine in the building and they would shut down the machine. In an interview, on 8/10/25 at 10:59 AM, the Dietary Manager indicated maintenance was responsible for the ice machine. Dietary staff did not clean or have anything to do with the ice machine. In an interview, on 08/10/25 at 11:52 AM, the DON indicated staff took all residents' mugs, emptied them and filled them with fresh ice water. In an interview, on 08/11/25 at 11:43 AM, the Maintenance Director indicated he did not internally clean the ice machine. He would just thaw and clean the inner workings of the ice machine. The Maintenance Director indicated he cleaned the water reservoir but did not clean where the ice sits. The Maintenance Director indicated they clean the machine once a year. In an interview, on 08/13/225 10:08 AM, the Administrator indicated the ice machine was back on and now clean. A repair technician came and looked at it before turning it back on. In an interview, on 08/14/25 at 10:14 AM, the Administrator indicated 28 of 42 residents residing in the facility receive ice from the ice machine water. A current facility policy, titled Infection Control: cleaning ice machine and scoop, dated 1/23, was provided by the Administrator on 8/11/25 at 10:35 AM. The policy indicated . The ice machine and equipment (scoop) will be cleaned on a regular basis to maintain a clean, sanitary condition .Unplug machine and remove ice .Wash interior thoroughly using detergent solution. Rinse and drain with clean hot tap water .sanitize .air-dry .turn machine on .clean exterior of machine with detergent solution. Rinse and allow to dry .Ice scoop will be washed and sanitized at least weekly in the dish machine and allowed to dry .Store ice scoop beside or on top of the ice machine in a clean non-porous container that allows water to drain off( and not pool around scoop) .If self-dispensing ice machine, wash and clean only the outside of the machine. Sanitize the ice dispensing mechanism and drain area. Maintenance will clean and maintain interior 3.1-21(i)(1) and (3)

Based on observation, interview, and record review, the facility failed to follow physicians orders for tube feeding for 1 of 1 residents reviewed (Resident 43). Findings include:During an observation, on August 11, 2025 at 11:24 AM, Resident 43 was observed to be alone in his room and sitting in his wheel chair to the left of the bed. An enteral pole was observed to be located to the right of the bed and the enteral feeding pump was turned off.During an observation, on August 11, 2025 at 1:03 PM, Resident 43 was observed to be alone in is room and sitting in his wheel chair to the left side of the bed in the same position as at 11:24 AM. An enteral feeding pole was observed to be located to the right of the bed in the same position as observed at 11:24 AM and the enteral pump was turned off. In an interview, on August 11, 2025 at 1:11 PM, Licensed Practical Nurse (LPN) 8 indicated she was unsure why Resident 43's enteral feeding pump was turned off. LPN 8 indicated she is aware that there is a hold feeding order for activities. LPN 8 indicated Resident 43 was by himself in his room and not participating in an activity. LPN 8 indicated Residents 43's enteral pump was usually restarted after an activity. LPN 8 indicated she was not Residents 43's nurse and was unsure why the pump was not restarted. LPN 8 indicated Resident 43's nurse was unavailable. In an interview, on August 11, 2025 at 1:52 PM, Registered Nurse (RN) 9 indicated she was Resident 43's nurse. RN 9 indicated Resident 43's enteral feeding pump had been on and Resident 43 had been receiving continuous tube feeding all day. RN 9 indicated Resident 43's enteral pump was off, however Resident 43 was now receiving the feeding as ordered. RN 9 indicated Resident 43 has a physician's order allowing the facility to stop the continuous feed when Resident 43 was participating in activities. During an observation, on August 13, 2025 at 12:06 PM, Resident 43 was observed to be alone in is room, eyes closed and sitting in his wheel chair to the left side of the bed. An enteral pole was observed to be located to the right side of the bed and the enteral feeding pump was turned off. In an interview, on August 13, 2025 at 12:08PM, RN 10 indicated she was unsure why Resident 43's enteral pump was turned off. RN 10 indicated she knew Resident 43 had a shower the morning of August 13, the enteral feeding was turned off and disconnected for showers. RN 10 indicated she was unsure how long Resident 43 had been back in his room from the shower. In an interview, on August 13, 2025 at 12:30 PM, the Director of Nursing (DON) indicated she was unable to provide a reason for Resident 43's enteral feeding pump being turned off. The DON indicated Resident 43 was technically always in activities because of the portable TV attached to his chair, however, indicated Resident 43 was alone in his room. The DON indicated she was unsure where the break down in communication was with the nurses being notified Resident 43 was back in his room after activities or a shower. The DON indicated they could provide CNA education on alerting nursing when residents requiring enteral feeding were back in their room after being engaged in an activity, therapy or shower so that the resident could return to receiving the feeding. Resident 43's record was reviewed on August 11, 2025 at 10:53 AM. Diagnoses included other specified disorder of brain, unspecified convulsions, disturbances of salivary secretion, dysphagia oropharyngeal phase and progressive multifocal leukoencephalopathy. Physicians Orders included NPO diet, Enteral Feed Order every shift Jevity 1.2 via G Tube at 65ml/hr continuous with 30 ml H2O Flush hourly and may stop feeding for activities, therapy, showers, etc. A review of Resident 43's current Care plan titled The resident requires tube feeding G-Tube r/t dysphagia secondary to PML, indicated the resident would maintain adequate nutritional and hydration status evidenced by a stable weight, no s/sx of malnutrition or dehydration through review date. Interventions included the resident was dependent with tube feeding and water flushes. Follow MD orders for current feeding orders and continue tube feeding as ordered. A current policy titled Medication and Treatment Orders dated 8/2024 was provided by the DON on August 13, 2025 at 1:50PM. The policy indicated Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state .A current policy titled Enteral Nutrition dated 8/2024 was provided by the DON on August 13, 2025 at 1:50PM. The policy indicated The dietitian monitors resident who are receiving enteral nutrition, and make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings .3.1-44(a)(2)

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen. 38 of 39 residents who riside in the facility eat food prepared in the kitchen. Findings include: During an observation on 09/30/24 at 09:22 AM, [NAME] 2 pulled the grease traps under the first set of burners. There were 2 layers of foil present. On the top layer of foil was burnt noodles, carrots, and other unidentifiable debris as well as other odd, shaped discolorations on top of each other. The oven under the first set of burners did not close fully. The walk in cooler had debris of various sizes and substance; cardboard, plastic, and paper were identified under the racks. There was a pipe coming from the top of the walk in freezer wrapped in black tape, at an elbow of the pipe was a square plastic container with green markings of 1 cup, 2 cups, 3 cups, and 4 cups underneath. There was liquid inside the container. The liquid was clear and frozen. There was a frozen substance coming out the left side of the container. The walk in freezer did not have a thermometer present on the inside. Within the kitchen there were 3 red buckets of sanitation solution. Dietary Aide 3 assisted in testing a bucket for correct strength. When Dietary Aide 3 removed strip he immediately indicated the strip was very light. The strip indicated a strength of 25 per Dietary Aide 3. He indicated the solution was weak as noted by the light color on the strip. During an interview on 09/30/24 at 09:22 AM, [NAME] 2 indicated the Dietary Manager (DM) was not in. [NAME] 2 indicated the oven was still operable and a work order was placed to fix the door to the oven. [NAME] 2 was unsure when the work order was placed. [NAME] 2 indicated to determine the temperature, the staff just guess. [NAME] 2 proceeded to show documentation of a recorded temperature for the deep freeze on 9/30/24. [NAME] 2 indicated there was not a thermometer present when the temperature was recorded as Zero. During an interview on 09/30/24 at 09:52 AM, Dietary Aide 3 was unable to determine where to get the information for a correct concentration. Records were reviewed 10/1/24 at 8:26AM, findings as follows: A work order for the right oven door was created on 8/4/24, then updated on 8/23/24. A comment on the document indicated hinges were worn out and parts needed to be located. The work order indicated the vendor would call when parts are found. In the comments section, a note indicated professional food service had been called on 9/30/24, the service would be sending out mobile service as soon as today to make correction to door on stove. The log for 3-Compartment Sink, dated August 2024, had an area for test strip PPM, wash temp, and rinse temperature. The log was blank for the effective or the expected numbers. The weekly cleaning task list contained: delime dishwasher, wipe down counter and drawers, clean coffee pots, clean hood filters, change aluminum foil in stove, clean stove burners, wipe down plate warmers, wipe down steam table, and wipe down all stainless steel appliances. At the bottom of the sheet were the directions: All cleaning jobs need to be done by the following Sunday. No monthly or daily cleaning lists were provided. During a continuous observation on 10/01/24 from 10:26 AM to 11:20 AM, A red bucket was tested slightly darker than 100. During the observation, the DM washed her hands 3 times. The first time she washed her hands was for 7 seconds. The second time was for 7 second seconds. The third time was for 7 seconds. The DM indicated the amount of time to wash hands was 20 seconds minimum. During an interview, on 10/01/24 at 11:20 AM, the DM indicated the sanitation buckets were to test between 100 and 200. The DM further indicated the sanitation requirements were at the top of the recording page where staff were expected to record the bucket sanitation. During an interview on, 10/2/24 at 11:06AM, the Maintenance Director indicated the pipe in the walk in freezer was cracked at the top at a joint. They were unsure where it was cracked and when they noticed it leaking, they wrapped it in heat tape and put a container under to catch the leak until it could be properly fixed. A policy titled, Cleaning and Sanitizing Equipment dated 1/23 was provided 10/1/24 at 8:26AM by the Administrator. The policy indicated dietary staff will maintain cleaning and sanitizing solution I clean receptacles and at proper concentration . A policy titled; Cleaning Schedules dated 01/12 was provided 10/1/24 at 8:26AM by the Administrator. The dietary staff will maintain the sanitation of the dietary department through compliance with a written, comprehensive cleaning schedule . 3.1-21(j)(2)(3)

Based on observation, interview, and record review the facility failed to ensure a nurse was appointed as charge nurse each shift. 41 residents resided in the facility. Findings include: In an observation on 11/12/23 at 11:04AM, a staffing sheet dated 11/10/23 was posted with an indicated census of 41. There was no indication the charge nurse was listed on the posting. There was no place on posting for a charge nurse to be indicated for any shift. In an interview, on 11/12/23 at 11:19AM, RN 8 (Registered Nurse) indicated there was no charge nurse. RN 8 indicated neither he nor the other nurse on duty were in charge, but both were RNs and equally trained. RN 8 indicated he was fairly sure the census posted on Friday, dated11/10/23 was still correct. In an interview on 11/12/23 at 11:24AM, RN 9 indicated she and the other RN on duty were of equal rank and neither were in charge. She indicated the DON (Director of Nursing) was notified and would be in within an hour. During an observation on 11/12/23 at 11:28AM, a staffing sheet was observed posted without a census indicated. The staffing sheet did not indicate the charge nurse. The staffing sheet did not have a place for a charge nurse to be indicated for any shift. During an observation on 11/13/23 at 9:19AM, a staffing sheet was observed posted with a census of 38 indicated. The staffing sheet did not indicate the charge nurse. The staffing sheet did not have a place for a charge nurse to be indicated for any shift. In an interview on 11/14/23 at 1:15 PM, the DON indicated she was in charge when she was in the building. The DON indicated when she was not in the building each nurse oversaw their assigned halls. The DON indicated when a family member or other staff member had any concerns, they were to call her directly. In an interview on 11/14/23 at 2:21PM, the DON indicated the facility did not have a policy regarding having an assigned charge nurse. A review of daily nursing assignments for the dates; 11/8/23, 11/9/23, 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/14/23, and 11/15/23; did not indicate a charge nurse was assigned on any shifts. 3.1-17(2)

Based on observation, interview, and record review the facility failed to ensure a consistently functioning call light system for 2 of 10 residents reviewed (Resident B and Resident C). Findings include: 1) During an interview and observation with Resident B, on 10/19/23 at 11:16 AM, she indicated that she waited long periods of time for her light to be answered and at times questioned if her call light worked at all. Resident B pushed her call light as requested. RN 1 (Registered Nurse) came into the room to administer noon medications approximately 10 minutes later. RN 1 indicated Resident B's call light was not on. The RN attempted to activate the call light. The RN indicated there was on as there was no way to tell if the call light was on. RN 1 indicated the call light system worked in waves with a transmitter located at the nurse's station. RN 1 explained when a resident pushes the light there was no audible or visual indication inside or directly outside of the resident room. The system required someone to be at the desk to see where the signal was coming from. RN 1 went to change the batteries to the call light. The RN 1 was able to understand Resident B had no way to know if the call light was functional. RN 1 was asked to ensure the call light in the bathroom was operating properly. The bathroom call light was operable as evidenced by a CNA responding promptly. Resident B's record review on 10/19/23 at 4:15 PM indicated her current comprehensive MDS (Minimum Data Set) assessment section C BIMS (Brief Interview of Mental Status) score was 15. A score of 15 indicated no cognitive decline. Section G of MDS for functional status indicated Resident B requires a one person staff assistance in mobility for transfers, toileting, locomotion, bathing, and position changes. Resident B used a wheelchair for mobility on and off the unit. Resident B's diagnoses included chronic obstructive pulmonary disease, heart disease, osteoarthritis, and muscle weakness. 2) An interview on 10/19/23 at 346 PM Resident C indicated her call light does not work. In an observation at the same time. Resident C activated her call light, but there was no indication at the Nurse's desk the call light had been activated. Resident C's record review began on 10/19/23 at 4:22 PM indicated her current comprehensive MDS (Minimum Data Set) assessment section C BIMS (Brief Interview of Mental Status) score was 15. A score of 15 indicated no cognitive decline. Section G of MDS for functional status indicated Resident C requires supervision for activities of daily living. Resident C's diagnoses included malignant neoplasm of lung, obstructive pulmonary disease, and age-related physical debility. A record review of facility grievances over the past 6 months, on 10/19/23 at 10:43 AM, indicated 3 grievances regarding call lights. One on 5/15/23 that replacement batteries were ordered, and call light was functioning. This room was checked, and call light was functioning. A grievance on 6/13/23 regarding Resident B's call light not being answered. Grievance indicated the battery was replaced and the call light was checked for functioning. A grievance on 10/2/23 a resident call light not being answered, and she missed an activity. During an interview the resident indicated her call light was functioning properly. During an interview with Maintenance Director, on 10/19/23 at 3:23 PM, indicated he randomly checked 2 or 3 rooms of each hallway weekly to determine if the call light system was functioning. The maintenance director was able to provide a weekly grid from 5/26/23 to 10/16/23. He indicated the 300 hall was closed due to remodel and the 400 hall had its own systems. He indicated the system the facility was using at time of survey was temporary and the remodel included a new call light system. The Maintenance Director indicated he had only replaced two batteries on call lights. The maintenance director did not have an exact date of how long the batteries should last or how long each were in use at time of survey. During an interview with the DON (Director of Nursing) on 10/19/23 she indicated they began using silver bells on or around 2/22/23 for a couple of weeks until the temporary system arrived and was fully available and operational. A policy and procedure was provided by DON, on 10/19/23 at 406 PM, titled Call Lights effective revised dated 8/2022. The policy stated purpose: To respond to residents' requests and needs in a timely and courteous manner. No policy regarding call light function was available for review. This citation is related to complaint IN00418275 3.1-19(u)

Based on interview and record review the facility failed to ensure food temperatures were monitored and documented for every meal. 39 of 39 residents residing in the facility received food from the kitchen. Findings Include: In an interview on 1/24/23 at 9:39 AM, Resident I, identified by the facility as interviewable, indicated the meals provided by the kitchen were not hot half the time. In an interview on 1/24/23 at 11:41 AM, Resident B, identified by the facility as interviewable, indicated the majority of the time the meals were not hot. In an interview on 1/24/23 at 11:49 AM, Resident E, identified by the facility as interviewable, indicated the meals were usually warm but not hot. In an interivew on 1/24/23 at 11:58 AM, Resident F, identified by the facility as interviewable, indicated the meals were often lukewarm or cold. In an interview on 1/24/23 at 12:15 PM, Resident G, identified by the facility as interviewable, indicated the meals provided by the kitchen were lukewarm, never hot, but could be warmer. In an interview on 1/24/23 at 12:42 PM, Resident J, identified by the facility as interviewable, indicated the meals were not very good as they were often lukewarm. In an interview on 1/24/23 at 10:21 AM, Dietary 2 indicated he took food temperatures prior to the food being served. They indicated 39 of 39 residents residing in the facility received food from the kitchen. Temperature logs, dated 1/1/23-1/23/23, were provided by the Dietary Manager on 1/24/23 at 11:06 AM. The logs indicated there were no food temperatures recorded for: 1/1/23: breakfast and lunch 1/2/23: lunch 1/3/23: lunch 1/4/23: breakfast and lunch 1/5/23: lunch 1/6/23: breakfast and lunch 1/9/23: breakfast and lunch 1/10/23: breakfast and lunch 1/11/23: breakfast and lunch 1/12/23: breakfast and lunch 1/13/23: breakfast and lunch 1/17/23: breakfast and lunch 1/18/23: breakfast and lunch 1/20/23: breakfast and lunch In an interview on 1/24/23 at 11:06 AM, the Dietary Manager indicated food temperatures should be taken and recorded for each meal. In an interview on 1/24/23 at 12:03 PM, Qualified Medication Assistant (QMA) 5 indicated residents complained about cold food daily. QMA 5 indicated she offerred to heat up the residents food or an alternative item from the kitchen. A current policy, dated 12/2022, was provided by the Director of Nursing Services on 1/24/23 at 2:29 PM. The policy indicated: Temperatures should be monitored and recorded on the weekly temperature record prior to the start of and throughout meal service to ensure adequate holding temperatures are maintained. This Federal citation is related to complaint IN00399520. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure smoking assessments were completed for 1 of 2 residents reviewed. (Resident 10) Findings included: During an observation on 12/12/22 at 9:34 AM, Resident 10 was observed smoking with other residents in the designated smoking area outside the facility. Resident 10 was wearing a protective apron and staff was assisting with smoking materials. During an observation on 12/12/22 at 1:36 PM, Resident 10 was observed smoking with other residents in the designated smoking area outside the facility. Resident 10 was wearing a protective apron and staff was assisting with smoking materials. During an observation on 12/14/22 at 9:49 AM, Resident 10 was observed smoking with other residents in the designated smoking area outside the facility. Resident 10 was wearing a protective apron and staff was assisting with smoking materials. Resident 10's record was reviewed on 12/12/22 at 11:38 AM. Diagnoses included major depressive disorder, recurrent, severe with psychotic symptoms, cognitive social or emotional deficit following cerebral infarction, other cerebral infarction due to occlusion or stenosis of small artery, polyneuropathy in diseases classified elsewhere, anxiety disorder, unspecified. A Minimum Data Set (MDS) assessment, dated 10/18/22, indicated Resident 10 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). A facility nursing admission/readmission evaluation, dated 3/25/22, indicated, under the smoking evaluation, Resident 10 did not smoke. A physician progress note, dated 4/14/22, indicated Resident 10 was a current daily smoker. Resident 10 had smoked 1 pack of cigarettes per day for [AGE] years. A supervised smoking policy/contract, dated 4/11/22, was signed by Resident 10. The policy/contract included rules to be followed by the resident who wished to smoke, the designated smoking times, the facility's right to implement a behavioral contract, monitor, document all smoking related behaviors and the facility's rights when a resident violated the smoking policy. The policy/contract did not include an assessment of a resident that wished to smoke. A supervised smoking policy/contract, dated 10/22/22, was signed by Resident 10. The policy/contract included rules to be followed by the resident who wished to smoke, the designated smoking times, the facility's right to implement a behavioral contract, monitor, document all smoking related behaviors and the facility's rights when a resident violated the smoking policy. The smoking policy/contract did not include an assessment of a resident that wished to smoke. An independent activity tracking log for Resident 10, dated November 2022, was provided by the Director of Nursing on 12/13/22 at 11:07 AM. The log indicated Resident 10 smoked on November 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 21, 22, 23, 25, 26, 28, 29, and 30. An independent activity tracking log for Resident 10, dated December 2022, was provided by the Director of Nursing on 12/13/22 at 11:07 AM. The log indicated Resident 10 smoked on December 1, 2, 3, 5, 6, 7, 8, 9, 10, and 12. A care plan, initiated on 12/13/22, indicated Resident 10's desire to use tobacco products. The goals indicated Resident 10 would adhere to the facility's smoking policy and would not have any injuries related to smoking through the next review. The interventions indicated the facility was to complete smoking assessments as indicated. No care plan was in place for smoking prior to 12/13/22. No smoking assessments were in Resident 10's record. In an interview on 12/12/22 at 12:06 PM, RN 2 indicated an admission assessment, completed by a nurse, included a smoking assessment. RN 2 indicated social services might, also, do an assessment. In an interview on 12/12/22 at 1:50 PM, the Social Service Director (SSD) indicated an initial smoking assessment was to be done by nursing and quarterly assessments were to be done by the SSD. In an interview on 12/13/22 at 9:37 AM, the Director of Nursing (DON) indicated a resident's smoking status was assessed by a nurse in the admission/readmission assessment. If the response indicated the resident was a smoker, additional questions would populate to be answered. The DON indicated quarterly smoking assessments were to be done by the SSD. The DON indicated a resident's desire to smoke did not require a physician's order but absolutely needed to be care planned. In an interview on 12/13/22 10:11AM, the Regional Director indicated a care plan should be completed if a resident desired to smoke. The Regional Director indicated when a resident signed the facility smoking policy/contract, it indicated the resident was assessed for smoking. No resident assessment questions were found within the facility smoking policy/contract. A current policy, titled Smoking Policy, dated 12/2022, indicated under Procedure: .3. Assessments of residents a. Each resident who smokes must have a smoking assessment completed upon admission, quarterly and with significant change in condition by Social Services or designee. b. Smoking assessment will determine the amount of supervision required for each resident. Supervision requirements will be care planned and communicated to staff monitoring smoking

Based on interview and record review the facility failed to ensure a medication prescribed had an appropriate diagnosis for 1 of 5 residents reviewed. (Resident 134). Findings include: In an interview on 12/12/22 at 9:26AM, Resident 134 indicated she took medications but was unsure for what purpose. Resident 134's record review began on 12/12/22 at 2:18PM, indicated Resident 134 had the following diagnoses: displaced fracture of right clavicle, pneumonia, chronic lung disease, recurrent and persistent hematuria, hyperglycemia, A fib, acute and chronic respiratory failure, major depressive disorder recurrent, anxiety disorder, coronary artery bypass, and burn of 2nd degree to thigh. Resident 134's diagnoses list did not include a history of migraines or a seizure disorder. An admission MDS (minimum data set) assessment section I (active diagnosis), completed on 12/1/22 indicated diagnoses were: fracture, A fib, pneumonia, anxiety disorder, depression, chronic lung disease, respiratory failure, recurrent hematuria, hyperglycemia, burn, and atherosclerosis. The MDS did not indicate a diagnosis of seizure or migraine. Resident 134's current care plan did not indicate a problem area of seizures or migraines. Resident 134 had an order for Topiramate Tab 200mg to be given by mouth twice a day for seizures started on 11/23/22. Resident 134's medication administration record (MAR) dated December 2022 indicated the medication was documented as given twice a day on December 1st through December 11th. In an interview on 12/13/22 at 8:29AM, the DON indicated Resident 134 was taking Topiramate for migraines. The DON indicated the diagnosis was entered incorrectly in system. The DON indicated for admissions a nurse was to put the orders in and a second nurse then was to verify the physician orders were correct. The DON indicated there was no diagnosis of migraine or treatment plan for migraines in Resident 134's record. On 12/13/22 at 2:40PM the current facility policy was reviewed. A policy titled, Physician Services/Orders effective 09/30/2022, provided by DON 12/13/22 at 2:30PM, indicated 3. The physician will perform pertinent, timely medical assessments, prescribe an appropriate medical regimen 3.1-48(a)(4)

Based on observation, interview, and record review the facility failed to ensure insulin was dated when opened for 3 residents, in 1 of 2 medication storage carts observed. (Resident 14, Resident 12, and Resident 1). Findings include: During an observation, on 12/13/22 at 8:02AM with QMA 3, 3 insulin pens and a bottle of insulin without an open date were observed. In an interview with QMA 3, she indicated all meds should be labeled with an open date when they are first opened. QMA 3 indicated insulin is considered opened when it is taken from the refrigerator and put into the cart. QMA 3 was unable to determine when the 4 containers of insulin were put into the cart. In an interview, on 12/13/22 at 9:06AM the DON indicated all medications should be labeled with a pharmacy label and should have an open date. 1) Resident 14's record review began on 12/13/22 at 9:22AM. The record indicated diagnoses included type 2 diabetes mellitus with diabetic neuropathy. Resident 14 had a physician's order for Lantus SoloStar solution pen injector, (an insulin) give 55 units twice daily. In the 400 hall med cart Resident 14's insulin pen was observed with approximately 160units remaining and no open date was found. Resident 14's medication administration record dated December 2022 indicated documentation insulin utilizing the pen was given twice a day from December 1st through December 12th. 2) Resident 12's record review began on 12/12/22 at 10:54AM. The record indicated diagnoses included type 2 diabetes without complications. Resident 12 had physician orders for Insulin Degludec solution injection 20units daily and Insulin Lispro solution per sliding scale. In the 400 hall cart Resident 12's Degludec insulin pen was observed without an open date and with approximately 20 units remaining. Resident 12's lispro (insulin) was observed in cart without an open date. Resident 12's medication administration record for December 2022 indicated documentation insulin Lispro was administered: December 1st at 8:00PM December 3 at 11:30am and 8PM December 4 at 11:30AM, 4:30PM, and 8PM December 5 at 4:30PM December 6 at 8PM December 7 at 4:30PM and 8PM December 8 at 4:30PM December 9 at 4:30PM December 10 at 11:30AM December 12 at 4:30PM and 8PM Resident 12's medication administration record for December 2022, indicated documentation of administration of Deglu[DATE]units daily in am for December 1st-14th. 3) Resident 1's record review began on 12/13/22 at 9:30AM. The record indicated diagnoses included type 2 diabetes mellitus without complications. Resident 1 had a physician's order for Insulin Lispro per sliding scale. In the 400-hall med cart Resident 1's insulin was observed without an no open date. Resident 1's medication administration record for December 2022 indicated documentation Resident 1 was administered Lispro at 8PM on December 1, 3, 4, 5, 6, 8, 9, 10, 11, and 12th. On 12/15/22 at 11:16AM the current facility policy was reviewed. A policy titled, Medication Receipt, Labeling, and Destruction Policy and Procedure effective 8/29/2022, provided by the Regional Nurse Constultant on 12/15/22 at 11:08AM, indicated 3. Items such as insulin, eye drops,, etc, will be dated when opened . 3.1-25(k)(6)

Based on observation, and interview, the facility failed to ensure the daily report of nursing staff directly responsible for resident care was accurately posted. 36 residents currently resided in the facility. Findings included: In an observation on 12/11/2022 at 11:28 AM, the daily staffing post located on the wall next to the nurse's station was composed of single sheet, dated 11/22/2022. In an observation on 12/11/2022 at 12:30 PM, the daily staffing post continued to show the date of 11/22/2022. In an observation on 12/11/2022 at 1:05 PM, the same daily staffing post continued to show the date of 11/22/2022. Floor staff walked past the daily staff post without acknowledgement. An interview with the Director of Nursing at 1:07 PM, indicated there was a floor nurse in charge of changing the staff post, this staff member worked during the week, and the post should be changed every day. An interview with RN 2 on 12/12/2022 at 12:05 PM, indicated she had not been told she was in charge of changing the daily staff post. The posting was usually done on 3rd shift since it was easier to change because the day would begin on their shift, she did not know it was her responsibility. A policy, Nurse staffing posting policy and procedure, dated 8/2022. Was provided by the Director of Nursing on 12/12/2022 at 11:57 AM. The policy indicated . Posting of information will be completed by the designated person in each facility .Data requirements, Facility name, current date, total number of actual hours worked in the categories of Registered Nurses, Licenses Practical nurses, Qualified Medication Aides, and Certified Nurses Aides and Resident Census

Based on interview and record review the facility failed to protect the resident's right to be free from abuse for 1 of 5 residents reviewed for abuse (Resident B) Findings include: An incident report, dated 10/7/22, was provided by the Administrator on 11/22/22 at 2:48 PM. The report indicated on 10/7/22 a third party had notified the facility that a former resident had alleged an incident of sexual assault. The report indicated the resident no longer resided in the facility and the Certified Nursing Assistant (CNA) no longer was employed by the facility. The resident did not have any grievances regarding the CNA alleged and the facility was unable to substanitate the allegation of abuse. A statement was provided by the Administrator on 11/22/22 at 2:48 PM. The statement indicated on 9/16/22 the Administrator was notified of an inappropriate interaction between a facility employee and a facility resident: Resident B and CNA 2. The statement indicated both individuals are alert and orientated x4 and highly aware of what they say and do and what is acceptable behavior and what is not, any inappropriate actvity between residents and employees are not acceptable and a violation of company policies. Other corporate individuals were notified of report and company [NAME] President of Human Resources was dispatched to the facility to facilitate investigation. The statement indicated the Administrator was present during the interview with CNA 2 and CNA 2 denied any inappropriate interactions with any resident, by self or other employees. HR 3 indicated the facililty had received reports of inappropriate interactions, then CNA 2 decided to resign her position. The report also indicated Resident B was interviewed and denied having any inappropriate interaction with any staff member while at the facility. In a confidential interivew on 11/22/22, an employee indicated CNA 2 had told another staff member about her sexual relationship with Resident B. The staff member then reported the allegation to the Administrator. In an interview on 11/22/22 at 2:48 PM, the Administrator indicated on 9/16/22 an employee reported Resident B and CNA 2 were in a sexual relationship. The Administrator indicated he interviewed CNA 2 and Resident B on 9/16/22 and both parties denied the relationship. The Administrator indicated CNA 2 resigned during the interview. The Adminsitrator indicated at a later date, the facility had found information posted on social media accounts by Resident B that he was in a relationship with CNA 2. The Administrator indicated on 10/5/22 the police department indicated Resident B had filed charges of sexual assault against CNA 2. The Administrator indicated there was no other documentation he could provide at the time. In an interview on 11/22/22 at 3:26 PM, Police Officer 5 indicated Resident B had called on 10/2/22 and filed charges against CNA 2 regarding sexual assualt. Police Officer 5 indicated the investigation was still pending and he was unable to give any other information at the time. The Surveyor attempted to call Resident B on 11/22/22 at 3:24 PM, but Resident B's phone went straight to voicemail and the voicemail was full. Resident B's record review was conducted on 11/22/22 at 3 PM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 7/15/22 indicated Resident B had a Brief Interview of Mental Status (BIMS) of 13/15 (cognitively intact). Progress notes were reviewed between 9/1/22 and 9/22/22, no notes indicated any allegation, distress or behaviors were exhibited from Resident B at the time. A policy, dated 9/2022, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines, was provided by the Administrator on 11/22/22 at 3:58 PM. The policy indicated abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical hamr pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abus including abuse facilitated or enabled through the use of technology. Willfull, as used means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .sexual abuse: is nonconsensual sexual contact of any type with a resident. This Federal Citation is related to Complaint IN 506 3.1-27(a)(1)

Based on interview and record review the facility to ensure an allegation of abuse was reported to the Indiana Department of Health within 24 hours of the allegation. (Resident B) Findings include: An incident report, dated 10/7/22, was provided by the Administrator on 11/22/22 at 2:48 PM. The report indicated on 10/7/22 a third party had notified the facility a former resident had alleged an incident of sexual assault. A statement was provided by the Administrator on 11/22/22 at 2:48 PM. The statement indicated on 9/16/22 the Administrator was notified of an inappropriate interaction between a facility employee and a facility resident. In an interview on 11/22/22 at 2:48 PM, the Administrator indicated on 9/16/22 an employee reported Resident B and CNA 2 were in a sexual relationship. The Administrator indicated he interviewed CNA 2 and Resident B on 9/16/22 and both parties denied the relationship. The Administrator indicated on 10/5/22 the police department indicated Resident B had filed charges of sexual assault against CNA 2. The Administrator also indicated he had not reported the allegation to the Indiana Department of Health until 10/7/22. A policy, dated 9/2022, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines, was provided by the Administrator on 11/22/22 at 3:58 PM. The policy indicated reporting/response: ii: ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. This Federal Finding relates to Complaint IN 506 3.1-28(c)

Based on interview and record review the facility failed to ensure 3 of 3 residents reviewed received at least 2 showers weekly. (Resident F, Resident G, Resident I) An interviewable list of residents was provided by the Vice President of Clinical Services on 9/11/22 at 1:20 PM. The list indicated Resident F and Resident G were interviewable. 1. In an interview on 9/11/22 at 12:20 PM, Resident F indicated most of the time she had received a shower at least 2x weekly. A point of care audit report, dated 7/11/22 - 9/9/22, was provided by the Director of Nursing (DON) on 9/11/22 at 2 PM. The report indicated Resident F was not given/offered a shower at least 2x a week for the following dates: 8/21/22-8/27/22: a shower was given only on 8/26/22 8/28/22- 9/3/22: a shower was given only on 9/2/22 2. In an interview on 9/11/22 at 12:02 PM, Resident G indicated he had not received showers at least 2x weekly. A point of care audit report, dated 7/11/22-9/10/22, indicated Resident G was not given/offered a shower at least 2x a week for the following dates: 7/24/22-7/30/22: a shower was given only on 7/30/22 7/31/22- 8/6/22: a shower was given only on 8/6/22 8/7/22- 8/13/22: no showers were given 8/14/22- 8/20/22: no showers were given 8/21/22- 8/27/22: a shower was given only on 8/27/22 8/28/22- 9/3/22: a shower was given only on 8/31/22 9/4/22- 9/10/22: shower was given only on 9/7/22 3. In an interview on 9/11/22 at 11:05 AM, Resident I indicated he had not received showers at least 2x a week. A point of care audit report, dated 7/13/22 - 9/10/22, indicated Resident I was not given/offered a shower at least 2x a week for the following dates: 8/7/22-8/13/22: a shower was given only on 8/10/22 8/28/22- 9/3/22: a shower was given only on 8/31/22 9/4/22- 9/10/22: a shower was given only on 9/7/22 In an interview on 9/11/22 at 11:55 AM, LPN 3 indicated residents received showers 2x a week unless requested differently. In an interview on 9/11/22 at 12:33 PM, CNA 4 indicated residents received showers 2-3x a week. CNA 4 indicated when a resident refused a shower, then multiple staff will attempt to ask the resident and the staff would document the refusals. In an interview on 9/11/22 at 2:14 PM, CNA 2 indicated residents received showers at least 2x weekly. A policy, titled Bathing Preference, dated 9/2022, was provided by the DON on 9/11/22 at 3:08 PM. The policy indicated .bathing shall occur at least twice a week unless resident preference states otherwise. This Federal citation is related to Complaint IN 080. 3.1-3(u)(1)

Based on interview and record review the facility failed to ensure a urinalysis (UA) was followed up on for 1 of 3 residents reviewed (Resident D). A record review was completed for Resident D on 9/11/22 at 1:28 PM. An order, dated 8/5/22, indicated to collect a UA with culture if needed. A nursing note, dated 8/7/22, indicated a UA was completed and sent to the hospital. An order, dated 8/22/22, indicated to start doxycyclin (antibiotic) 100 mg one by mouth, 2x daily x 7 days for Urinary Tract Infection ([CONDITION(S)]). In an interview on 9/11/22 at 11:15 AM, LPN 3 indicated once a UA was collected it would be sent to the lab immediately. LPN 3 also indicated once results were received, the doctor would be notified and give orders if needed. In an interview on 9/11/22 at 1:59 PM, the Director of Nursing (DON) indicated once a UA was sent to the hospital, results were usually available within 12 hours. The DON indicated when results are not received within 12 hours the staff were expected to follow up with the hospital. The DON also indicated once the UA results were received, the Nurse Practitioner was to be notified whether the results were normal or abnormal. A policy, titled Provider Notification Guidelines, dated 8/2022, was provided by the Vice President of Clinical Services on 9/11/22 at 3:13 PM. The policy indicated . ordered lab and/or diagnostic tested should be completed in a timely manner. The policy also indicated the provider should be notified of critical lab results or an immediate need by phone as soon as the results are known with a response received before the call is completed when possible. If staff are unable to reach the primary provider, the Medical Director should be notified. This Federal citation is related to Complaint IN 080. 3.1-41(a)(2)

Based on interview and record review the facility failed to ensure the residents' had a current physician's orders and Advanced Directives were completed and documented in the medical record for 7 of 7 records reviewed. (Resident 14, Resident 171, Resident 16, Resident 9, Resident 8, Resident 3, and Resident 5.) Findings include: 1. A record review for Resident 14 began on [DATE] at 3:52 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 14's record was not identified with a label to indicate Code Status. The Face Sheet for Resident 14 indicated there were no Advanced Directives selected for the resident. The face sheet was lacking a code status for the resident. The facility's form, Code Status/Advanced Directive, for Resident 14 indicated they did not want to have CPR (cardiopulmonary resuscitation) preformed as a life saving measure. The form was signed by the resident's representative, was witnessed by a nurse and was dated on [DATE]. The form lacked a date the physician was notified. The document, State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, was declared on [DATE], was signed by the resident's representative and was witnessed by 2 staff on [DATE]. The Physician signed the document on [DATE]. Review of Resident 14's Physician orders dated September, October, and [DATE], indicated there was no order for Do Not Resuscitate (DNR). Review of Resident 14's records provided by the DON on [DATE] at 2:03 p.m., indicated no Code Status on the face sheet, nor orders for a DNR on the physician orders. 2. A record review for Resident 171 began on [DATE] at 4:20 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record for Resident 171 was not identified with a label to identify the Code Status. The Admission Record was lacking a Code Status for the resident. A review found no documentation or forms to identify the resident's code status. On [DATE] at 12:45 p.m., n an interview, the Director of Nursing (DON) indicated she could not find a code status in Resident 171's record. She indicated the CODE STATUS/Advance Directive form was blank in the folder for the physician to sign. The DON also indicated if a resident does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:55 p.m., an interview with LPN 1 indicated she had found a document in the hospital records for Resident 171, and it indicated Resident 171 was a full code when in the hospital. LPN 1 indicated she had to look through the resident's records to find a code status and it was not easily accessible. On [DATE] at 1:05 p.m., an interview with the DON indicated she had found the facility document regarding Resident 171's CODE STATUS/Advanced Directive and provided the form for review. The form was checked and signed by the Resident's Representative on [DATE] and indicated do not perform CPR (a DNR) as a life saving measure. The form was also witnessed by the Social Service Designee. The DON also provided the document, State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order. The state DNR form was not completed, it was lacking the resident's name, but the form was signed by the Resident's Representative. The form was also not witnessed nor dated and was not yet signed and dated by the Physician. Review of Resident 171's records provided by the DON on [DATE] at 1:53 p.m., indicated no Code Status on the face sheet, nor orders for a DNR on the physician orders. 3. A record review for Resident 16 began on [DATE] at 9:44 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] chronic obstructive pulmonary disease, shortness of breath, and [CONDITION(S)] of liver. Resident 16's Face Sheet indicated there were no Advanced Directives selected for the resident. The face sheet was lacking a code status for the resident. The facility's form, Code Status/Advanced Directive, for Resident 14 indicated they wanted to have CPR (cardiopulmonary resuscitation) preformed as a life saving measure. The form was signed by the resident and was witnessed by an AIT (Administrator in Training). The form lacked a date signed by the resident or the AITand also lacked the date the physician was notified. Review of Resident 16's Physician orders for September, October, and [DATE], indicated no order for CPR. Review of Resident 16's records provided by the DON on [DATE] at 3:34 p.m., indicated no Code Status on the face sheet, nor orders for a CPR on the physician orders. 4. A record review for Resident 9 began on [DATE] at 10:19 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9's record, was identified with a bright green label on the inside of the front binder which read, FULL CODE. Review of the Face Sheet for Resident 9 indicated there were no Advanced Directives selected for the resident. The face sheet was lacking a code status for the resident. The facility's form, Code Status/Advanced Directive, for Resident 9 indicated they wanted to have CPR performed as a life saving measure. The form was signed by the resident and was witnessed by a Nurse. The form lacked a date signed by the resident or the Nurse and also lacked the date the physician was notified. Review of Resident 9's Physician orders for September, October, [DATE], indicated there was no order for CPR. Review of Resident 9's records provided by the DON on [DATE] at 1:45 p.m., indicated no Code Status on the face sheet, nor orders for a CPR on the physician orders. 5. A record review for Resident 8 began on [DATE] at 10:45 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8's records were not identified with a label for Code Status. The Face Sheet for Resident 8 indicated there were no Advanced Directives selected for the resident. The face sheet was lacking a code status for Resident 8. The facility's form, Code Status/Advanced Directive, for Resident 8 indicated they did not want to have CPR preformed as a life saving measure. The form was signed by the resident, was witnessed and was dated on [DATE]. The form lacked a date the physician was notified. Review of Resident 8's Physician orders for September, October, and [DATE], indicated no order for DNR. Review of Resident 8's records provided by the DON on [DATE] at 2:45 p.m., indicated no Code Status on the face sheet, nor orders for DNR on the physician orders. 6. A record review for Resident 3 began on [DATE] at 1:19 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's records were not identified with a label Code Status. The Face Sheet for Resident 3 indicated there were no Advanced Directives selected for the resident. The face sheet was lacking a code status for the resident. The facility's form, Code Status/Advanced Directive, for Resident 3 indicated they did not want to have CPR preformed as a life saving measure. The form was signed by the resident's representative and was witnessed by a facility staff and was dated on [DATE]. The form lacked a date the physician was notified. The document, State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, was declared on [DATE], was signed by Resident 8 and was witnessed by the DON and the Social Services Director on [DATE]. The Physician signed the form on [DATE]. Review of Resident 3's Physician orders forSeptember, October, and [DATE], it was lacking an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 3's records provided by the DON on [DATE] at 2:50 p.m., indicated no Code Status on the face sheet, nor orders for a DNR on the physician orders. During an interview, LPN 1 on [DATE] at 3:55 p.m., indicated she was not on staff at the facility, but had worked a few times. When asked what she would do if a resident was without pulse or respirations, she indicated she would check the resident's face page for the Code Status. LPN 1 then reviewed a resident record to look at the face page of a resident record, and she indicated there was not a Code Status listed on the face page. She indicated the facility's Report Sheets had the residents code status listed under the resident's name. She indicated the forms were used to write information she needed to know about the resident during report between shifts and to write information about the residents that needed to be done or documented and reported to the next shift nurse. LPN 1 provided the report sheets at that time. A review of the Report Sheets, 2 pages, which listed residents with room numbers and a code status was listed below the resident's name. Resident 171 did not have a code status listed on the Report Sheets. During an interview, the DON on [DATE] at 12:45 p.m., indicated the expectations would be to have the Code Status identified at admission and a temporary order would be written within 24 hours of admission, until the physician could sign the order for the resident's Code Status. The Code status should be a standing order for all residents and the Code status for should be on the residents' physician order summaries. 7. On [DATE] at 9:30 a.m., the record of Resident 5 was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not a code status sticker located on the medical record. The Face sheet indicated under the section titled advanced directive there are no advanced directive selected for this resident. A code status/advance directives form dated [DATE] indicated Resident 5 did not want to have Cardiopulmonary Resuscitation (CPR) performed as a life-saving measure and an Out of Hospital Do Not Resuscitate Declaration and Order, was provided to the facility. A State of Indiana Out of Hospital Do Not Resuscitate and Order form dated [DATE] was reviewed. At the bottom of the form, the signature of the attending physician, the printed name of the attending physician, the medical license number and date were not filled in. A review of the current physician's order dated [DATE], indicated no standing order for a code status. The current physician's order were reviewed on [DATE] and signed by the physician. During an interview on [DATE] at 11:23 a.m., the Administrator indicated the physician would sign the code status on the next visit. A current facility policy, Attending Physician Responsibilities, dated [DATE], was provided by the Administrator on [DATE] at 11:23 a.m. The policy indicated .Providing appropriate, timely medical orders. Providing appropriate, timely, and pertinent documentation A current facility policy, Admission Notes, dated [DATE], was provided by the DON on [DATE] at 1:25 p.m. The policy indicated .When a resident is admitted to the nursing unit, the admitting nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol. Notation as to whether or not advance directive apply 3.,d+[DATE](d)

Based on observation, interview and record review, the facility failed to ensure a person centered care plan was implemented for 1 of 3 residents reviewed for Care Plans. (Resident 5) Findings included: A review of Resident 5's medical record on 9/27/2018 at 5 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 4 out of 15, meaning severe cognitive impairment. [DIAGNOSES REDACTED]. On 9/27/18 at 10:56 a.m., Resident 5 was observed in his room, lying in his bed. On 9/28/2018 at 2:15 p.m., Resident 5 was observed sitting in his wheel chair across from the nurses station. On 10/1/2018 at 9:48 a.m., Resident 5 was observed walking in his room. On 10/1/18 at 12:03 p.m., Resident 5 was observed standing at the nurses station talking on the telephone. The Social Service Progress Notes dated on 5/2/2018 with no time, indicated the resident had stated he would be better off dead. A review of resident 5's care plans indicated a Mood Care Plan dated 7/4/2018. The care plan had not been updated with person centered interventions or implemented Mental Health Services. The Total Severity score for the PHQ-9 (Patient Health Questionnaire) was 10, meaning moderate depression. There was no care plan for depression or negative statements initiated. A current facility policy, Care Plan Development and Review, dated 9/2017, provided by the Director of Nursing on 10/1/2018 at 2:12 p.m., indicated the following: The facility shall develop and implement a person centered care plan for each resident, consistent with resident rights, measurable objectives and timeframes to meet the psychosocial and mental needs of the resident. 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure mental health services were implemented for 2 of 3 resident's reviewed for psychosocial wellbeing. (Resident 5 and Resident 9) Findings included: 1. A review of Resident 5's medical record on 9/27/2018 at 5 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 4 out of 15, meaning severe cognitive impairment. [DIAGNOSES REDACTED]. On 9/27/18 at 10:56 a.m., Resident 5 was observed in his room, lying in his bed. On 9/28/2018 at 2:15 p.m., Resident 5 was observed sitting in his wheel chair across from the nurses station. On 10/1/2018 at 9:48 a.m., Resident 5 was observed walking in his room. On 10/1/18 at 12:03 p.m., Resident 5 was observed standing at the nurses station talking on the telephone. The Social Service Progress Notes dated on 5/2/2018 with no time, indicated the resident had stated he would be better off dead. The Social Service Director had documented the resident had no plan or intentions to harm himself and would continue to monitor. The next documented entry in the Social Service Progress Notes was untimed, but dated 5/11/2018, and indicated it was a follow up note to better off dead statement. The follow up indicated Resident 5 had not remembered having those thoughts and had no thoughts of being better off dead. An Interview Follow Up form, dated 5/2/2018, indicated the IDT (Interdisciplinary Team) had a meeting to discuss Resident 5's statements. The IDT signatures included the SSD (Social Service Designee), the DON (Director of Nursing) and the ED (Executive Director). The form indicated the Primary Care Physician and Legal Representative were notified. The sections for Mental Health Provider and Mental Health services had no documented entry. The section that indicated reviewed, updated, and implemented appropriate care plan to include Social Service 1:1 sessions had no documented entry. A review of Resident 5's Nurses Notes indicated no documented entries of such negative statements. A review of a Mood Care Plan for PHQ-9 (Patient Health Questionnaire), meaning a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression, dated on 7/4/2018, indicated Resident 5 was feeling down, depressed, tired, and feeling bad about himself. The total severity score was a 10, meaning moderate depression. This care plan was found in the residents Care Plan file at the nurses station. The MDS (Minimal Data Set) Significant Change assessment, dated 5/2/2018, indicated under the mood section that Resident 5 answered yes to being better off dead and hurting himself. The MDS Significant Change, dated 7/4/2018 indicated Resident 5 had feelings of little interest or pleasure in doing things; feeling down, depressed, or hopeless; feeling tired or having little energy; several days of feeling bad about yourself or that you are a failure or have let self or family down. During an interview on 9/28/2018 at 10:56 a.m., the SSD indicated the following: During the MDS interview, she talked to Resident 5, the resident had no plan to harm himself, then she indicated she notified the physician and family. She also indicated she notified psych services. The SSD could not explain the 9 day gap between entries in the Social Service Notes. The SSD indicated she verbally communicated this information with the other staff members and indicated she knew it was not documented, but had taken no other action. A review of Social Service One to One Session Documentation forms, provided by the ED on 9/28/2018 at 1:30 p.m., indicated the following: On 5/3/2018 a 15 minute session was provided to Resident 5 by the SSD, and the SSD documented the resident expressed no thoughts of being better off dead. On 5/4/2018 a 15 minute session was provided to Resident 5 by the SSD and the SSD documented no concerns noted, no thoughts of better off dead expressed. On 5/7/2018 a 10 minute session was provided to Resident 5 by the SSD and the SSD documented no concerns or thoughts of better off dead noted or expressed. On 5/9/2018 a 15 minute session was provided to Resident 5 by the SSD and the SSD documented no thoughts of better off dead expressed. During an interview on 9/28/18 at 2:20 p.m., the Director of the Mental Health service group used by the facility indicated they did not have any information for Resident 5, nor had he been referred for Mental Health services. The Director indicated when they receive a referral for ideation of being better off dead, they would have responded within 24 hours. During an interview on 9/28/2018 at 2:55 p.m., LPN (Licensed Practical Nurse) 1 indicated they were not aware that Resident 5 had made such statements in May. They indicated Behavioral memos are completed and the SSD would pick them up and they review them in their morning meeting. They indicated when a resident would make a negative statement they would report it to the SSD and the DON. During an interview on 9/28/2018 at 3:06 p.m., the DON indicated Resident 5 had made the statement he would be better off dead, but he did not have a plan. She could not ensure that interventions were in place, and she viewed it more as a SSD's issue. 2. A review of Resident 9's medical record on 10/1/2018 at 11 a.m., indicated a BIMS score of 15, meaning cognitively intact. [DIAGNOSES REDACTED]. On 9/27/18 at 10:48 a.m., Resident # 9 was observed in her room, lying in her bed. On 10/1/2018 at 9:44 a.m., Resident # 9 was observed in her room, lying in bed. On 10/02/18 at 10:34 a.m. Resident # 9 was observed sitting in her wheel chair at the nurses station. The Social Service Progress Notes, dated 6/1//2018, with no time, indicated Resident 9 had thoughts of being better off dead, no intent or plan to harm self, and will continue to monitor. No Mental Health services were notified. On 6/19/2018 was the next follow up entry. There were no documented 1:1 Sessions documented after the initial statement and before the follow up. The Social Service Progress Notes, dated 6/20/2018, with no time, indicated Resident 9 had thoughts of being better off dead, no plan, and the facility would continue to monitor. No Mental Health services were notified. The next follow up entry was on 6/27/2018. The SSD documented on the 1:1 Session forms on the following dates: 6/22/2018 and 6/25/2018 indicating there had been no further concerns of being better off dead expressed by the resident. The Social Service Progress Notes, dated 7/18/2018, with no time, indicated Resident 9 had thoughts of being better off dead. The note indicated the physician and POA (Power of Attorney) were notified, but there was no documentation Mental Health Services had been notified. The next follow up entry was on 7/26/2018. The SSD documented on the 1:1 Session forms on the following dates: 7/23/2018 and 7/25/2018 indicating there had been no further thoughts of death expressed. The Nurses Notes indicated no documentation Resident 9 had expressed being better off dead. A Mood and Behavior Communication Memo was completed on 8/15/2018 at 4:30 p.m., by CNA 4 and indicated Resident 9 was upset because she wanted to die. SSD documented on the form a 1:1 with Resident 9, but Mental Health service notification had not been documented. During an interview on 10/02/18 at 10:55 a.m., CNA 4 was aware of what to do when a resident voiced concerns of being better off dead, she would report them to the charge nurse and the SSD. She could not be certain how it was communicated to staff if the statements had been made to someone else, they verbally would tell each other, CNA to CNA. A review of the Mood and Behavior Communication Memos regarding Residnet 9 indicated only one behavior or negative statement regarding wanting to die on 8/15/2018. A current facility policy, PHQ-9/ Mood Interview Follow Up, dated 8/2014, provided by the ED on 9/28/2018 at 12:24 p.m., indicated the following: A written notification of any response to a better off dead statement will be provided to the ED and SSD. The facility administrative personnel should prepare charge staff for the potential of notification. 3.1-34(a)

Based on observation, interview and record review, the facility failed to ensure staff performed hand hygiene adequately, handled food to prevent the potential for contamination, and failed to ensure the kitchen staff changed gloves adequately. These deficient practices had the potential to affect 30 of 31 residents who ate food prepared and served by the facility. Findings include: 1. During a lunch meal service in the dining room on 10/5/17 the following was observed: At 11: 57 a.m., the residents were seated in the dining room awaiting the lunch meal to be served. Five residents in wheelchairs or broda chairs (a positoning chair with wheels) were around two square tables pushed together and 1 staff was seated at the table with the residents. At 11:58 a.m., Staff 8 washed their hands with soap and water at the dining room sink, lathered their hands for 28 seconds covering all surfaces of their hands, rinsed with water and dried their hands with a clean, dry paper towel and turned the water off with a clean, dry paper towel, then discarded the paper towel into the trash. At 11:59 a.m., Staff 8 was observed to use both hands to pick up an armed chair and moved the chair beside a resident to assist the resident with their lunch meal. Staff 8 sat down in the chair, adjusted the resident's clothing protector, moved the resident's water glass, and then moved the plate in front of the resident with their right hand. Staff 8 was not observed to perform hand hygiene after touching the arms of the chair nor before touching the residents clothing protector, water glass or the plate. At 12:01 p.m., Staff 8 stood up from the chair and retrieved a drinking straw. Staff 8 removed the paper warpper from the straw as they returned to the table. Staff 8 was observed to put the drinking straw into the resident's beverage. Staff 8 sat down in the armed chair by the resident and then moved the resident's bowl. Staff 8 was not observed to perform hand hygiene before removing the paper from the drinking straw, before putting the drinking straw into the beverage, nor moving the resident's bowl in front of them. 2. During the observation in the facility kitchen staff preparing and plating the lunch meal on 10/6/17 the following was observed: At 11:05 a.m., the Dietary Manager (DM), indicated the lunch meal was ready to be plated. The DM indicated the 100/400 Hall meal carts were prepared first and then the 200/300 Hall meal cart before the lunch meal would be served in the dining room. At 11:06 a.m., Dietary Staff 4 had disposable gloves on their hands, the serving utensils were in place on the steam table, the meal tickets on metal stands, napkin wrapped silverware, the bowls of coleslaw, and a large package of square cheese slices were placed at the beginning, on the right end of the food line. Insulated plate bases and domed plate covers were stored on a rack and were on Dietary Staff 4's left side, the heated metal plate warmers were on the stove top behind Dietary Staff 4, and the plates were in the plate lowerator on Dietary Staff 4's right side. From 11:07 a.m. to 11:21 a.m., Dietary Staff 4 was observed to put a meal tray on the rolling food line, picked up the meal ticket and put it on the meal tray along with the napkin wrapped silverware, and the bowl of coleslaw. Dietary Staff 4 then retrieved the insulated plate base, stacked the plate warmer and plate, and placed the assembly in front of the steam table. Dietary Staff 4 used tongs with their gloved right hand to remove a bun from the package and put the bun on the plate. Dietary Staff 4 then used their left gloved hand to lift the top of the bun, while using tongs to put the fish on the bottom bun. Dietary Staff 4 continued to hold the top of the bun in their left gloved hand while retrieving a slice of cheese with their right gloved hand and put the cheese slice on top of the fish and returned the top of the bun on the sandwich. Dietary Staff 4 used tongs to plate corn nuggets on the plate, covered the plate with a domed plate cover, and placed the lunch meal plate onto the meal tray. Dietary Staff 4 continued to prepare the lunch meals for the 100/400 Hall. Dietary Staff 4 prepared 11 fish sandwiches and 1 sloppy joe sandwich using their gloved hands to remove the top of the bun and handle the cheese slices. At 11:22 a.m. the 100/400 Hall meal cart was taken from the kitchen to the unit for delivery to the residents. At 11:24 a.m. Dietary Staff 4 stepped away from the food line, with the same gloves on, retrieved the 200/300 Hall meal tickets on metal stands from the countertop next to the sink, put the meal tickets on the tray and arranged them in order of preparation. Dietary Staff 4 was not observed to change their disposable gloves before they returned to the food line. From 11:26 a.m. to 11:30 a.m., Dietary Staff 4 was observed to put a meal tray on the rolling food line, pick up the meal ticket, put it on the meal tray along with the napkin wrapped silverware, and the bowl of coleslaw. Dietary Staff 4 retrieved the insulated plate base, stacked the plate warmer and plate, and placed the assembly in front of the steam table. Dietary Staff 4 used tongs with their gloved right hand to remove a bun from the package and put the bun on the plate. Dietary Staff 4 then used their left gloved hand to lift the top of the bun, while using tongs to put a fish on the bottom bun. Dietary Staff 4 continued to hold the top of the bun in their left gloved hand while retrieving a slice of cheese with their right gloved hand, put the cheese slice on top of the fish, and returned the top of the bun on the sandwich. Dietary Staff 4 used tongs to plate corn nuggets on the plate, covered the plate with a domed plate cover, and placed the lunch meal plate onto the meal tray. Dietary Staff 4 continued to prepare the lunch meals for the 200/300 Hall. Dietary Staff 4 prepared 6 fish sandwiches using their gloved hands to remove the top of the bun and handle the cheese slices. At 11:32 a.m., the 200/300 Hall meal cart was taken from the kitchen to the unit for delivery to the residents. At 11:33 a.m., Dietary Staff 4 stepped away from the food line with the same gloves on, retrieved the dining room meal tickets on metal stands from the countertop next to the sink, put the meal tickets on the tray, and arranged them in order of preparation. Dietary Staff 4 retrieved the (Brand) protein and calorie supplements with a plastic scoop and put them on the counter by the left end of the steam table. Dietary Staff 4 was not observed to change their disposable gloves before they returned to the food line. At 11:36 a.m., Dietary Staff 5 returned to the kitchen and was observed to wash their hands with soap and water, lathered their hands for 30 seconds, rinsed with water and dried their hands with clean, dry paper towel, then turned the running water off with the used, wet paper towel, and discarded the paper towel into the trash. Dietary Staff 5 then went to the walk-in refrigerator, retrieved the prepared beverages which were coved with plastic wrap and labeled. Dietary Staff 5 placed the cart of beverages at the end of the food line. At 11:40 a.m., a staff knocked on the kitchen door and indicated they were ready for the lunch meal to be served. Dietary Staff 5 opened and propped the door open then placed a rolling 2 tiered cart into the doorway, to put the meal trays as it was ready to be served to the residents. Dietary Staff 5 washed their hands with soap and water, lathered their hands for 25 seconds, rinsed with water and dried their hands with clean, dry paper towel, turned off the running water with the same used wet paper towel and discarded into the trash. Dietary Staff 5 returned to the end of the food line to complete the meal tray with putting 1/2 of a banana and the beverages on the tray, then delivered the lunch meal tray to the cart in the doorway to the dining room. From 11:31 a.m. to 11:5 a.m., Dietary Staff 4 began to plate the food for the residents who eat in the main dining room. Dietary Staff 4 was not observed to change the disposable gloves from the beginning of food service. Dietary Staff 4 observed to put a meal tray on the rolling food line, picked up the meal ticket and put it on the meal tray along with the napkin wrapped silverware, and the bowl of coleslaw. Dietary Staff 4 retrieved the insulated plate base and stacked the plate warmer and plate and placed in front of the steam table. Dietary Staff 4 used tongs with their gloved right hand to remove a bun from the package and put the bun on the plate. Dietary Staff 4 then used their left gloved hand to lift the top of the bun, while using tongs to put a fish on the bottom bun. Dietary Staff 4 continued to hold the top of the bun in their left gloved hand while retrieving a slice of cheese with their right gloved hand and put the cheese on top of the fish and returned the top of the bun on the sandwich. Dietary Staff 4 used tongs to plate corn nuggets on the plate, covered the plate with a domed plate cover and placed the lunch meal plate onto the meal tray. Dietary Staff 4 continued to prepare the lunch meals for the main dining room. Dietary Staff 4 prepared 6 fish sandwiches, 2 of the sandwiches were fish chopped into small pieces with a cheese slice on the bun for the mechanical soft diets. Dietary Staff 4 continued to use their gloved hands to remove the top of the bun and handle the cheese slices. Dietary Staff 4 also plated 4 puree meals into divided plates or bowls. At 11:46 a.m., The DM entered the kitchen area and washed her hands with soap and water, lathered her hands for 30 seconds, covering all areas of her hands and wrist, rinsed with running water and dried her hands with clean, dry paper towels, then turned the running water off with the same used, wet paper towel. At 11:47 a.m., The DM retrieved a small plate and requested Dietary Staff 4 put a bun on the plate. Dietary Staff 4 used tongs to remove the bun from the package and put the bun on the plate. The DM requested Dietary Staff 4 to removed the top of the bun. Dietary Staff 4 used their gloved hand and removed the top of the bun and the DM proceeded to put some meat on the bottom bun and Dietary Staff 4 put the top of the bun back on the sandwich. The DM wrapped the sandwich and left the kitchen with the sandwich. At 11:49 a.m., the DM returned to the kitchen, she washed her hands with soap and water, lathered her hands for 25 seconds, covering all surfaces of her hands and wrist, then rinsed her hands with running water, dried her hand with a clean, dry paper towels, then turned the running water off with the same used, wet paper towel and discarded the paper towels in the trash. An interview with the DM on 10/6/17 at 11:50 a.m., indicated staffs hands should be lathered for at least 20 seconds and the entire process should take 40-60 seconds. The DM indicated hands should be dried with clean paper towels. She indicated the water could be turned off with the paper towels used to dry their hands. She also indicated food should not be handled with bare hands and indicated ready made foods could be touched with gloved hands. The DM also indicated foods with skin to peel could be handled with bare hands, like bananas. She further indicated the tongs should have been used to handle the top of the bun and tongs should have been used to retrieved and put the cheese slice on the sandwich. The DM indicated the laminated meal tickets and holders were sanitized after each meal service. The DM indicated she was not aware of the need to use a clean, dry paper towel to turn off the water. She indicated there was teachable moments on the use of gloves, use of tongs and turning off the water with a clean paper towel. A current, undated facility policy, titled, Hand Washing was provided by the DM on 10/6/17 at 12:30 p.m. The policy indicated, .It is the policy of the Dietary Department to prevent the spread of infection through proper handwashing. Hand sanitizer may not be used .1. Hands are washed: a. When entering and before starting work in the Dietary Department .b. After handling soiled dishes and utensils .d. Before and after handling foods .h. prior to putting on gloves .2. Handwashing Procedure: .e. Hands must be washed for a minimum of 20 seconds .f. Rinse thoroughly .g. Wipe dry with disposable paper towels .h. Turn off water faucet with paper towels A current , undated facility policy, titled, Glove Use & Meal Service provided by the Dietary Manager on 10/6/17 at 12:30 p.m., indicated, .In an effort to protect food products from contamination, all products should be served using utensils .Procedure: .3. Hands must be washed often per the Handwashing policy .4. Employees may not touch ready-to-eat foods with a bare hands, gloves must be worn .5. Hands should be washed thoroughly between tasks .6. Utensils should be clean, sanitized and in good repair (i.e free fro rust) .9. Hands must be washed and completely dried prior to putting on a pair of gloves .10. If an employee handles raw food, leaves and enters the kitchen, touches equipment handles (i.e refrigerators, trash can lids) or touches any area of their body - they MUST immediate wash their hands .11. Gloves may be worn during food preparation but only for single task items (handling raw chicken) An interview with the Corporate HFA (Health Facility Administrator) on 10/6/17 at 12:35 p.m., indicated the facility policy indicated to turn the water faucet off with a paper towel and did not indicated it needed to be a different paper towel. A current poster from the World Health Organization, dated , May 2009, titled, How to Handwash?, provided by the Corporate HFA and DM on 10/6/17 at 12:42 p.m., indicated, .8. Rinse hands with water; .9. Dry hands thoroughly with a single use towel; .10. Use towel to turn off faucet; .11. Your hands are now safe 3.1-21(i)(2)

Based on interview, and record review the facility failed to ensure the physician was notified of a need for clarification for 1 resident on a medication for mood stabilization. This affected 1 of 5 residents reviewed with medications. (Resident 4) Findings included: A review of Resident 4's clinical record on 10/4/2017 at 4:16 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 12 out of 15, meaning moderate cognitive impairment. Diagnoses included, but were not limited to: arthritis, kidney disease, diabetes, chronic pain, high blood pressure, chronic urinary tract infection, dementia, asthma, and [MEDICAL CONDITION]. A review of Resident 4's discharge paperwork from a hospital stay dated 9/21/2016 indicated the resident was discharged on [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] and often used as a mood stabilizer to treat a mood disorder) 125 mg (milligrams) give one tablet by mouth three times a day. The diagnoses list, on the discharge summary, dated 9/21/2016, had not included mood disorder or siezures. A review of Resident 4's physician's orders [REDACTED]. Another order dated 3/10/2017, for [MEDICATION NAME] 125 mg give one tablet with the 250 mg [MEDICATION NAME] tablet to equal 375 mg, by mouth, two times a day. there was no [DIAGNOSES REDACTED]. A review of the Mood and Behavior Monthly Monitoring Summary's from 9/2016 to 9/2017 indicated no GDR attempt was trialed for the [MEDICATION NAME] use. TheMood and Behavior Monthly Monitoring Summary dated 9/6/2017 indicated .[MEDICATION NAME] due for GDR - contraindicated . A review of Resident 4's physician progress notes [REDACTED]. A review of Physician Order's indicated no orders for laboratory tests had been given while Resident 4 was on the [MEDICATION NAME] medication regimen. A Care Plan Worksheet dated 8/24/2017, indicated .The resident requires the use of [MEDICATION NAME] to treat: mood stabilizer and is at risk for adverse side effects . and in interventions section .*Monitor labs as indicated . During an interview on 10/5/2017 at 11:54 a.m., the DON (Director of Nursing) indicated she did not know why there was no [DIAGNOSES REDACTED]. The DON indicated she was sure they had not ordered [MEDICATION NAME] levels to be drawn since the initial start of the medication, but should have notified the physician for clarification of the [DIAGNOSES REDACTED]. During an interview on 10/6/2017 at 2:30 p.m., the Regional Nurse had indicated they had no policy regarding lab draws for [MEDICATION NAME] levels. 3.1-5(a)(3)

Based on interview and record review, the facility failed to protect 2 of 5 residents (Resident #8 and Resident #22) who attended an outdoor facility activity from receiving a sunburn. This action resulted in resident #22 experiencing a severe sun burn with blisters to his forehead which caused him pain. Findings include: 1. Review of the clinical record for Resident #8 on 7/10/13 at 8:37 a.m., indicated the following: [DIAGNOSES REDACTED]. A Nursing Progress Notes for Resident #8, dated 5/22/13 at 6:30 p.m., indicated a new order was received for Aloe Vera topically to sunburn q (every) shift et (and) PRN (as needed) x (times) 3 days. The note also indicated [MEDICATION NAME] (anti-[MEDICATION NAME]) 25 mg(milligrams) orally q 4 hours PRN for itching and discomfort. Resident #8 was interviewed on 7/11/13 at 9:00 a.m. During the interview he indicated he went with other residents from the facility to a baseball game on 5/22/13. He also indicated he received a sunburn to his arms which eventually peeled. Resident #8 observed to have very fair skin. 2. Review of the clinical record for Resident #22 on 7/9/13 at 1:32 p.m., indicated the following: [DIAGNOSES REDACTED]. A Nursing Progress Notes for Resident #22, dated 5/22/13 at 5:30 p.m., indicated he had returned from an activity to a baseball game. The note also indicated the skin on his face, arms, head and neck were red from the sun. At 5:45 p.m., the note indicted a new order was received for Benedryl 25 mg orally q 4 hours PRN x 3 days. The order also indicated Aloe Vera topically to sunburn q shift PRN. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 4:00 p.m., indicated the skin on his face, arms, hands, and forehead remained very red from the sunburn. Resident #22 was admitted to the local hospital on [DATE]. A History and Physical Report from the hospital, dated 5/26/13, indicated..."It should be noted that the patient has relatively impressive sunburn on his face and arms....the patient has profound sunburn...Diffuse peeling sunburn on much of his face...Small area in the central part of his forehead that appeats to have likely blistered recently...." Resident #22 was interviewed on 7/10/13 at 1:45 p.m. During the interview he indicated he had attended a baseball game with other residents from the facility on 5/22/13. He also indicated he received a bad sunburn which caused him great discomfort. Resident #22 was observed to have very fair skin. The Director of Nursing was interviewed on 7/10/13 at 9:20 a.m. During the interview she indicated five residents went to the baseball game on 5/22/13 and 2 of the residents came back with sunburns. She also indicated sun screen had not been applied to the residents who attended the baseball game. She further indicated the residents were to be seated under an awning and the day was cloudy. The Director of Nursing was interviewed on 7/10/13 at 10:30 a.m. During the interview she indicated Activity staff #2 did not take sunscreen with her to the ball game for the residents since she thought they would be seated under an awning. She also indicated she thought the actual time of the game was 2 1/2 hours. Activity staff #2 was interviewed on 7/10/13 at 10:35 a.m. During the interview she indicated she was not given any sunscreen to take the baseball game. She also indicated the game lasted 3 hours. The Administrator was interviewed on 7/10/13 at 2:05 p.m. During the interview she provided a copy of the weather forecast for the day on the baseball game on 5/11/13. The forecast listed an actual temperature on 80 degrees on that day. She also indicated the severe weather policy was not implemented due to actual temperature being only 80 degrees. When queried, the Administrator indicated the use of sunscreen was not included in the severe weather policy. 3.1-37(a)

Based on interview and record review, the facility failed to provide 1 resident (Resident #22) with the calculated fluid needs required to keep him hydrated. This resulted in resident #22 being hospitalized with an acute kidney injury secondary to dehydration. Findings include: Review of the clinical record for Resident #22 on 7/9/13 at 1:32 p.m., indicated the following: [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment for Resident #22 indicated a score of 9 out of 15 on the Brief Interview for Mental Status, or moderate cognitive impairment. The MDS also indicated he required supervision with eating. A Nutritional Assessment Form for Resident #22, dated 9/2 8/13, indicated his fluid needs were calculated at 3400 cc's (cubic centimeters) per day. The assessment also indicated his diet provided 1860 cc's of fluid at mealtime and along with his fluids at bedside, his fluid needs would be met. The assessment further indicated he had a decline in self-feeding and shaking was noted with fluids. A history of increased BUN (blood urea nitrogen) and Creatinine was noted. A laboratory report for Resident #22, dated 11/25/12, indicated a BUN of 35 mg/dL (milligrams per deciliter), with a reference range of 8-23 mg/dL, and a Creatinine of 1.80 mg/dL, with a reference range of 0.7 - 1.20 mg/dL. A laboratory report for Resident #22, dated 2/4/13, indicated a BUN of 25 mg/dL, with a reference range of 8-23 mg/dL, and a Creatinine of 1.60 mg/dL, with a reference range of 0.7 - 1.20 mg/dL. A Nutritional Assessment Form for Resident #22, dated 2/19/13, indicated his fluid needs were calculated at 3100 cc's per day. The assessment also indicated his diet provided 1860 cc's of fluid at mealtime and along with his fluids at bedside, his fluid needs would be met. The assessment further indicated he ate his meals at the assist table and at times he needed to be fed by staff. The assessment did not address the elevated BUN and Creatinine on 2/4/13. No recommendation was made to increase the fluids provided by dietary at mealtime. A laboratory report for Resident #22, dated 5/6/13, indicated a BUN of 27 mg/dL, with a reference range of 8-23 mg/dL, and a Creatinine of 1.60 mg/dL, with a reference range of 0.70-1.20 mg/dL. A Nutritional Assessment Form for Resident #22, dated 5/31/13, indicated his fluid needs were calculated at 3600 cc's per day. The assessment also indicated his diet provided 1860 cc's of fluid at mealtime and along with his fluids at bedside, his fluid needs would be met. The assessment further indicated he ate his meals in the main dining room and required supervision and cueing. The assessment also indicated Resident #22 was recently hospitalized for [REDACTED]. No recommendation was made to increase the fluids provided by dietary at mealtime. A meal tray card for Resident #22, indicated he was to receive 360 cc's fluid at breakfast, 120 cc's fluid at lunch, and 240 cc's at dinner, or a total of 720 cc fluid per dietary service in a 24 hour period. Review of the physician orders [REDACTED]. RN #3, was interviewed on 7/11/13 at 11:40 a.m. During the interview she indicated Resident #22 took his medications orally and during each medication pass an 8 ounce glass of water was provided, or a total of 720 cc fluid per nursing service in a 24 hour period. Calculations for the fluids provided by nursing services and dietary service for Resident #22, indicated he received a total of 1440 cc's in a 24 hour period. His consumption of bedside fluids would need to be 2000 cc's or more to meet his calculated fluid needs. A Nursing Progress Notes for Resident #22, dated 5/22/13 at 5:30 p.m., indicated he had returned from an activity at a baseball game with red face, arms, head, and neck from a sunburn. The note did not indicate staff provided extra fluids for re-hydration due to the sunburn. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 1:30 a.m., indicated he had emesis x (times) 1 et (and) loose stools x 1. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 2:00 a.m., indicated emesis continued. The note did not indicate how much or how many times. A Nursing Progress Notes for Resident #22, dated 5/26/14 at 3:10 a.m., indicated small amount of emesis. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 5:00 a.m., indicated no further emesis or loose stools noted. The note did not indicate if any fluids were offered or consumed. A Nursing Progress Notes for Resident #22, dated 5/26/13, indicated his 8:00 a.m. medications were held. The note also indicated his nausea was improving. The note did not indicate if any fluids were offered or consumed. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 12:00 p.m., indicated no further emesis or loose stools noted. The note did not indicate if any fluids were offered or consumed. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 4:00 p.m., indicated he continued to have very red skin on his face, arms, hands, and forehead from the sunburn and was lethargic. The note also indicated he consumed 120 cc's fluid. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 4:05 p.m., indicated a large loose liquid stool. A physician's orders [REDACTED]. A Nursing Progress Notes for Resident #22, dated 5/26/13 at 9:30 p.m., indicated the hospital called and he was admitted with dehydration and elevated Creatinine. A History and Physical Report from the hospital, dated 5/26/13, indicated he was sent to the emergency room due to a concern with progressive lethargy. The note also indicated ..." When the patient arrived in the emergency room , his only complaint was that of thirst...The patient is continuing to complain of profound thirst and has been drinking vigorously throughout the morning...Evaluation there revealed what appeared to be acute onset [MEDICAL CONDITION] and dehydration....It should be noted that the patient has relatively impressive sunburn on his face and arms....the patient has profound sunburn...The clinical picture at this time seems to be most consistent with acute kidney injury related to dehydration..." The note further indicated he was given IV fluids and felt a bit better. A laboratory report for Resident #22, dated 5/26/13, indicated a BUN of 71 mg/dL, with a reference range of 8-23 mg/dL, and a high critical Creatinine of 4.40 mg/dL, with a reference range of 0.70-1.20 mg/dL. A laboratory report for Resident #22, dated 5/27/13, indicated a BUN of 74 mg/dL, with a reference range of 8-23 mg/dL, and a high critical Creatinine of 4.40 mg/dL, with a reference range of 0.70-1.20 mg/dL. Re-admission orders [REDACTED]. There was no indicated the fluids provided through dietary services and nursing services had been increased upon his return to the facility. The Consultant Nurse was interviewed on 7/10/13 at 10:25 a.m. During the interview she indicated the facility only kept track of all fluid intake if a resident was on I & O (intake and output). The Dietary Manager was interviewed on 7/12/13 at 11:45 a.m. During the interview she indicated she had only been working in the facility a short time. She also indicated she continued to provide those fluids to the residents which were already identified on their meal cards at mealtime. A facility care plan for Resident #22, with a start date of 2/4/13, indicated the problem area of resident is at risk for exhibiting signs and symptoms of dehydration due to increased BUN. Interventions to the problem area included, but were not limited to, encourage resident to drink all fluids offered, offer a variety of fluids at frequent intervals as residents orders allow, and monitor consumption for adequate intake. A facility care plan for Resident #22, dated 5/31/13, indicated the problem area of alteration in nutritional/hydration status and a history of dehydration. A goal to the problem area was for the resident to maintain adequate hydration status...At the time of admission, dietary will determine each resident's daily fluid needs...A fluid plan to increase fluid intake will be put into place to reach the resident's daily fluid need...Dietary will provide 1800 cc of fluid per day with meals, unless otherwise contraindicated...." 3.1-46(b)

Based on interview and record review, the facility failed to identify and implement a plan of action for the identified concerns of dehydration, fluid restrictions, protecting residents against sunburn, for labeling/dating food and drinks in the nourishment refrigerator, use of personal protective equipment for a resident in isolation and not following the Registered Dietician's recommendation. These deficient practices had the potential to affect 33 out of 33 residents residing in the facility. Findings include: An interview with the Administrator on 7-12-2013 at 11:05 a.m., indicated the facility has a QAA (Quality Assessment and Assurance) committee and an IDT (interdisciplinary team) committee that works on identified quality issues. The Administrator indicated some of the current issues being addressed by the QAA were staff turnover, staffing consistency with resident care and activities. The Administrator indicated the resident on a fluid restriction was non-compliant, umbrellas were provided for residents on an outing to prevent sunburn and the facility was not aware of the unlabeled/undated food stored in the nourishment refrigerator. An interview with the DON (Director of Nursing) on 7-12-2013 at 11:45 a.m., indicated she was not aware of the following: documentation of fluid intake was lacking for a resident with dehydration; residents participating in outdoor activities should be protected from sunburn; food/drink items were not labeled with contents, resident's name or a date when opened in the nourishment refrigerator; staff not following isolation procedures for residents identified with [MEDICAL CONDITION]; and didn't realize the Registered Dietician's recommendations were not followed. There was no evidence the QAA Committee had a system in place to identify concerns or a plan in place to address the concerns regarding dehydration, fluid restrictions, protecting residents against sunburn, for labeling/dating food and drinks in the nourishment refrigerator, use of personal protective equipment for a resident in isolation and not following the Registered Dietician's recommendation. 3.1-52(a)(2)