Every finding on record at Four Seasons Retirement Center

Based on record review and interview, the facility failed to notify the physician of residents' changes in condition related to blood glucose levels and weights for 4 of 10 residents reviewed for notification of change. (Residents 9, 2, 1, and 3)Findings include: 1. The clinical record for Resident 9 was reviewed on 07/07/2026 at 10:00 A.M. An admission Minimum Data Set (MDS) assessment, dated 06/10/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, diabetes (high blood sugar). A physician's order, dated 06/05/2026 through 07/02/2026, indicated the staff were to check the resident's blood glucose level four times a day. The physician was to be notified if the resident's blood glucose was less than 70 or greater than 300. The clinical record lacked indication that the physician had been notified of the blood glucose level being greater than 300 on the following dates and times: - On 06/06/2026 at P.M., when the blood glucose was 443 and at bedtime, when the blood glucose was 341, - On 06/08/2026 at P.M., when the blood glucose was 328 and at bedtime, when the blood glucose was 312, - On 06/09/2026 at midday, when the blood glucose was 359 and at bedtime, when the blood glucose was 337, - On 06/10/2026 at midday, when the blood glucose was 430, - On 06/11/2026 at bedtime, when the blood glucose was 304, - On 06/12/2026 at bedtime, when the blood glucose was 309, - On 06/13/2026 at bedtime, when the blood glucose was 311, - On 06/14/2026 at midday, when the blood glucose was 357, at P.M., when the blood glucose was 316, and at bedtime, when the blood glucose was 329, - On 06/15/2026 at midday, when the blood glucose was 353, - On 06/17/2026 at P.M., when the blood glucose was 353,- On 06/20/2026 at A.M., when the blood glucose was 322, - On 06/21/2026 at A.M., when the blood glucose was 339, at P.M., when the blood glucose was 313, and at bedtime, when the blood glucose was 311, - On 06/22/2026 at P.M., when the blood glucose was 321, - On 06/23/2026 at midday, when the blood glucose was 360, - On 06/27/2026 at P.M., when the blood glucose was 404, and at bedtime, when the blood glucose was 389, and - On 06/28/2026 at P.M., when the blood glucose was 369, and at bedtime, when the blood glucose was 387. 2. The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission MDS assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnoses included but were not limited to, hypertension (high blood pressure) and a hip fracture. A current physician's order, with a start date of 06/04/2026, indicated the staff were to weigh the resident daily on day shift. The resident was to be weighed at the same time and on the same scale with the same personal equipment. The physician was to be notified if the resident had a weight gain of greater than 3 pounds overnight. The resident had the following gains in weight without indication the physician had been notified on the following dates: - On 06/23/2026, the resident weighed 179.4 pounds and on 06/24/2026 the resident weighed 184.2 pounds, a 4.8 pound weight gain overnight and - On 06/29/2026, the resident weighed 180 pounds and on 06/30/2026 the resident weighed 186.4 pounds, a 6.4 pound weight gain overnight. During an interview, on 07/08/2026 at 1:07 P.M., the Director of Nursing (DON) indicated the staff should have documented that the physician was notified of the resident's weight gain. 3. The clinical record for Resident 1 was reviewed on 07/07/2026 at 1:39 P.M. An admission MDS assessment, dated 06/13/2026, indicated the resident had a diagnosis of hypertension. A current, open-ended physician's order, with a start date of 06/09/2026, indicated the staff were to weigh the resident daily on day shift. The resident was to be weighed at the same time and on the same scale with the same personal equipment. The physician was to be notified if the resident had a weight gain of greater than three pounds overnight, a weight gain of greater than five pounds in one week, or a weight gain of greater than five pounds since admission to the facility. The resident had the following gains in weight without indication the physician had been notified on the following dates: - On 06/10/2026, the resident weighed 285.8 pounds and on 06/11/2026 the resident weighed 291.4 pounds, a 5.6 pound weight gain overnight, - On 06/23/2026, the resident weighed 292.6 pounds and on 06/24/2026 the resident weighed 298 pounds, a 5.4 pound weight gain overnight, - On 06/26/2026, the resident weighed 287.8 pounds and on 06/27/2026 the resident weighed 293.4 pounds, a 5.6 pound weight gain overnight, - On 06/29/2026, the resident weighed 286 pounds and on 06/30/2026 the resident weighed 297.4 pounds, an 11.4 pound weight gain overnight, and - On 07/01/2026, the resident weighed 292.5 pounds and on 07/02/2026 the resident weighed 296.2 pounds, a 3.8 pound weight gain overnight. 4. The clinical Record for Resident 3 was reviewed on 07/07/2026 at 10:15 A.M. An admission MDS assessment, dated 06/15/2026, indicated the resident's diagnoses included, but were not limited to, heart failure and diabetes. A current, open-ended physician's order, with a start date of 06/10/2026, indicated nursing staff were to check the resident's blood glucose level before meals and at bedtime. The physician was to be notified if the resident's blood glucose was less than 70 or greater than 400. The clinical record lacked indication that the physician had been notified of the resident's blood glucose level being greater than 400 on the following dates and times: - On 06/15/2026 in the P.M., when the blood glucose was 427, - On 06/22/2026 in the A.M., when the blood glucose was 509, - On 06/23/2026 in the P.M., when the blood glucose was 439, - On 06/29/2026 at midday, when the blood glucose was 404, and - On 06/30/2026 in the P.M., when the blood glucose was 455. A current, open-ended physician's order, with a start date of 06/16/2026, indicated the resident was to receive short acting insulin three times a day based on their blood glucose level. The physician was to be notified if the resident's blood glucose level was less than 70 or greater than 350. The clinical record lacked indication that the physician had been notified of the blood glucose level being greater than 350 on the following dates and times: - On 06/17/2026 in the P.M., when the blood glucose was 375 and at bedtime, when the blood glucose level was 366, - On 06/18/2026 in the A.M., when the blood glucose was 360, - On 06/27/2026 in the A.M., when the blood glucose was 356 and, in the P.M., when the blood glucose level was 392, - On 07/05/2026 at bedtime, when the blood glucose was 366, and - On 07/07/2026 at midday, when the blood glucose was 354 and, in the P.M., when the blood glucose level was 385. During an interview, on 07/08/2026 at 10:43 A.M., Licensed Practical Nurse 20 indicated she would follow the resident's order and notify the physician if a blood glucose level was below or above the ordered parameters. Nursing could notify the MD or Nurse Practitioner (NP) via online communication. If it was on a weekend or after hours, she would call the on-call provider directly. She would also make a health status note in the resident's Electronic Health Record (EHR) that she notified the provider and if there were any new physician's orders, like to administer additional insulin, recheck the blood glucose level, etc. She would do the same thing if a resident's weight was outside of the ordered parameters. She would notify the provider of the weight gain and document it in the EHR, along with any new orders. During an interview, on 07/08/2026 at 11:32 A.M., the DON indicated there was an area in the residents' EHR where nursing staff could notify providers of changes in blood glucose levels, weights, etc. During an interview, on 07/08/2026 at 11:33 A.M., The Medical Records Nurse indicated she reviewed Resident 1's record and there were no electronic notifications related to weight gain. There were notifications related to Resident 3's high blood glucose levels, but just a few. If a nurse sent a notification via fax machine, those documents would be uploaded into the residents' records. There were no uploaded documents related to weight gain or blood glucose levels in the residents' EHRs. The current facility policy, titled Notification of Changes, implemented on 06/23/2025, was provided by the DON on 07/09/2026 at 11:21 A.M. The policy indicated, .The purpose of this policy is to ensure the facility.consults the resident's physician.when there is a change requiring notification. 410 IAC ( Indiana Administrative Code) 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to implement a resident's care planned intervention following a fall for 1 of 10 residents' care plans reviewed. (Resident 2)Findings include:The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnosis included but was not limited to, a hip fracture.A Progress Note, dated 05/01/2026 at 7:45 A.M., indicated the resident had an unwitnessed fall in her room. The resident was trying to reposition herself for breakfast using her walker. The walker slid to the side and she lost her balance, falling to the left. She put her left hand out to catch herself. The resident was found on the floor on her left side with the left arm to the left side of her body. The resident had visible injuries and complaints of left wrist pain and left hip pain. The resident was sent to the local emergency room. A Progress Note, dated 05/08/2026 at 2:41 P.M., indicated the resident had returned to the facility. A Care Plan, with start date of 04/27/2026 and a revision date of 05/12/2026, indicated the resident was at risk for falls related to gait/balance problems secondary to a recent hospitalization for a fracture. The resident had an intervention, with a start date of 05/12/2026, to put a sign in the resident's room to remind them that they needed assistance with transfers. During an observation and interview, on 07/06/2026 at 1:12 P.M., the resident indicated she had fallen in the facility and had broken her wrist. There were no signs observed hanging in the resident's room to remind the resident to call for assistance. During an observation, on 07/09/2026 at 9:17 A.M., the resident was sitting in her recliner in her room, she was getting ready for the day. There were no visible signs hanging in the resident's room.During an interview, on 07/09/2026 at 9:31 A.M., Licensed Practical Nurse (LPN) 12 indicated when a resident had a fall, she would complete the appropriate paperwork, phone calls, and have an immediate intervention put into place for the resident. The management team would review the fall and determine if the intervention was appropriate or if they needed to change it. If the intervention was to be changed, then they would let the nurse know and they would pass it along to other nurses and aides. During an interview, on 07/09/2026 at 10:42 A.M., Medical Records indicated when a resident had a fall a new intervention would be added to the resident's care plan. After Resident 2 fell in May, the new intervention was to put a sign in the resident's room. The management staff would be responsible for putting the interventions in place in the resident's room. During an observation and interview, on 07/09/2026 at 10:51 A.M., there was no visible signs hanging in Resident 2's room. Medical Records indicated the sign would usually be hung by the T.V. but there were no signs anywhere in the resident's room or the bathroom. There should have been a sign in the resident's room. The current facility policy titled, Falls with a revision date of February 2023, was provided by the Director of Nursing on 07/09/2026 at 12:48 P.M. The policy indicated, .Charge Nurses are responsible to ensure that interventions are implemented as discussed.410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a cardiac medication for 1 of 10 residents reviewed for quality of care. (Resident 14)Findings include:Resident 14's clinical record was reviewed on 07/06/2026 at 2:24 P.M. A 5-day Minimum Data Set (MDS) assessment, dated 06/25/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, high blood pressure. A current, open-ended physician's order, with a start date of 06/24/2026, indicated the resident was to receive atenolol 25 mg (milligrams), one time a day for high blood pressure. Nursing staff were to hold (not administer) the medication when the resident's systolic blood pressure (SBP, the top number) was less than 100. The Electronic Health Record indicated the medication was given on the following dates when the resident's vital signs were outside of the prescribed parameters:- On 06/26/2026, the resident's SBP was 97,- On 06/28/2026, the resident's SBP was 97, - On 07/02/2026, the resident's SBP was 88, - On 07/05/2026, the resident's SBP was 99, and- On 07/06/2026, the resident's SBP was 96. During an interview, on 07/07/2026 at 11:25 A.M., RN 11 indicated either she or the Certified Nurse Aide (CNA) would obtain the resident's vital signs each morning. She would usually make sure the vital signs were obtained 30 minutes prior to the medications being administered. The CNAs would document the vital signs on a paper form then transfer the information into the computer. If anything was out of range, she would not administer the medication. There was a place in the Electronic Medication Administration Record (EMAR) to indicate the medication was not administered and the reason it was held. The current facility policy titled Medication Administration, with a revision date of 02/12/2023, was provided by the Director of Nursing on 07/08/2026 at 1:30 P.M. The policy indicated, .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to follow physician's orders related to obtaining residents' weights for 2 of 3 residents reviewed for nutrition. (Residents 2 and 3) Findings include: 1. The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension (high blood pressure) and a hip fracture. A current physician's order, with a start date of 06/04/2026, indicated the staff were to weigh the resident daily on day shift. The resident was to be weighed at the same time and on the same scale with the same personal equipment. The clinical record lacked documented weights for the resident on 06/21/2026 and 07/04/2026. During an interview, on 07/08/2028 at 1:07 P.M., the Director of Nursing (DON) indicated the resident's weights should have been documented. 2. The clinical Record for Resident 3 was reviewed on 07/07/2026 at 10:15 A.M. An admission MDS assessment, dated 06/15/2026, indicated the resident's diagnoses included, but were not limited to, heart failure and diabetes. A current, open-ended physician's order, with a start date of 06/10/2026, indicated the staff were to weigh the resident daily on day shift. The resident was to be weighed at the same time and on the same scale with the same personal equipment. The clinical record lacked documented weights for the resident on the following dates: 06/10/2026, 06/11/2026, 06/12/2026, 06/21/2026, 07/01/2026, 07/02/2026, and 07/04/2026. During an interview, on 07/09/2026 at 11:30 A.M., the DON indicated the facility did not have a policy related to obtaining residents' weights or following physician's orders. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on interview, observation, and record review, the facility failed to appropriately manage a resident's respiratory needs for 1 of 1 resident reviewed for respiratory care. (Resident 10)Findings include:During an interview and observation, on 07/06/2026 at 11:10 A.M., Resident 10 indicated she required supplemental oxygen. She used it at home before she came to the facility and wore it all the time in the facility. The resident was sitting in a chair in her room. Oxygen tubing was in place under the resident's nose and connected to an oxygen concentrator set to administer three liters of oxygen per minute. An undated humidifier bottle was attached to the concentrator. The resident was not sure how often staff changed her oxygen tubing or the humidifier bottle. The resident was observed seated in the main dining room on 07/07/2026 at 11:39 A.M. The resident's oxygen tubing was in place and connected to a portable oxygen concentrator hanging from the back of the resident's chair. The resident was observed sitting in her chair in her room on 07/08/2026 at 10:40 A.M. The resident's oxygen tubing was in place and attached to the oxygen concentrator in her room. The concentrator was set to administer three liters.The resident's record was reviewed on 07/06/2026 at 2:32 P.M. An admission (Minimum Data Set) MDS assessment, dated 06/25/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, pneumonitis (inflammation of the walls of the tiny air sacs in the lungs) due to inhalation of food and vomit, pneumonia, and respiratory failure. The resident's current physician's orders were reviewed and lacked an order for supplemental oxygen.During an interview, on 07/08/2026 at 10:48 A.M., Licensed Practical Nurse (LPN) 20 indicated if a resident used supplemental oxygen, there would be a physician's order for it. There would be an order for the oxygen that would include the appropriate flow rate and parameters to keep the resident's oxygen levels within a certain range. There would be orders for oxygen tubing care and humidifier care. The LPN didn't usually work on the resident's hall, and she was not very familiar with her. Nurses had a 24-hour report document that included important information about the residents, like if they wore oxygen or etc. There was no indication on the 24-hour report document that the resident required supplemental oxygen. There were no physician's orders in the resident's clinical record that indicated she used supplemental oxygen. The current facility policy, titled Oxygen Administration, dated 10/2022, was provided by the Director of Nursing on 07/09/2026 at 10:31 A.M. The policy indicated, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.410 IAC (Indiana Administrative Code) 3.1-47(a)(6)

Based on record review and interview, the facility failed to verify the accuracy of a resident's healthcare physician/Nurse Practitioner (NP) order/assessment related to the resident's medication regimen for 1 of 10 resident records reviewed. (Resident 2)Findings include:The clinical record for Resident 2 was reviewed on 07/07/2026 at 1:46 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/11/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension (high blood pressure), anxiety, and depression. A Psychiatry Initial Consult Note, dated 04/15/2026, indicated the resident didn't feel like her current depression medication was working. It was discussed to start Lexapro (an antidepressant). The assessment and plan were to start the resident on Lexapro 10 milligrams (mg) once daily. New orders for the visit were Lexapro 10 mg daily. A physician's order, dated 04/16/2026 through 05/04/2026, indicated the resident was to receive Lexapro 20 mg daily. The order was entered into the Electronic Health Record by the Psychiatric Nurse Practitioner.The April 2026 Electronic Medication Administration Record (EMAR) indicated the resident had received Lexapro 20 mg daily from 04/16/2026 through 05/04/2026. During an interview, on 07/08/2026 at 1:15 P.M., Medical Records indicated when the Psychiatric NP came to the facility and assessed residents, she would usually transcribe new orders. The nurse would approve the order and send it to the pharmacy. The facility did not always review the NP's notes after they were transcribed into the system. If the resident's order in the EMAR was different than the order in the transcribed assessment note, the facility should have verified if the NP wanted the 10 mg or 20 mg of Lexapro to be given. During an interview, on 07/08/2026, the Director of Nursing indicated the facility did not have a policy related to reviewing physician notes. 410 IAC (Indiana Administrative Code) 16.2-3.1-22(C)(2)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheter care for 1 of 1 resident reviewed for Urinary Catheter Care. (Resident 116) Findings include: During an observation, on 06/16/25 at 12:29 P.M., Resident 116 was sitting in a recliner in his room. His indwelling urinary catheter bag was hanging on the side of a small trash can with an inch of the bag touching the floor. There was no barrier between the bag and the floor and the trash can was one third full. During an observation and interview, on 06/19/25 at 11:09 A.M., Resident 116's indwelling urinary catheter bag and cover had between one to two inches of the bag touching the floor. The resident indicated staff helped him move it when he wanted to get up. The bag was hanging under his recliner's footrest. During an observation and interview, with Certified Nurse Aide (CNA) 2, on 06/19/25 at 3:33 P.M., the resident was sitting in his room in his recliner. His indwelling urinary catheter bag was hanging under his recliner with 1/2 of the bag touching the floor. The bag was creased from touching the floor. CNA 2 indicated the catheter bag should not be touching the floor, donned gloves, and hung the bag higher up under his recliner to where the bag was no longer touching the floor. The CNA removed her gloves and washed her hands. During an interview, on 06/17/25 at 2:26 P.M., the Admissions Nurse indicated the resident was admitted to the facility from a hospital following treatment for a Urinary Tract Infection (UTI) and sepsis. During an interview, on 06/23/25 at 11:25 A.M., Physical Therapy Assistant (PTA) 4 indicated Resident 116 was supposed to have staff's assistance when getting up and ambulating. During an interview, on 06/23/25 at 11:26 A.M., Qualified Medication Aide (QMA) 5 indicated, while she was working, the resident had always used his call light if he needed to get up. The facility's Health Center Pre-admission Nursing Assessment, dated 06/11/25, was provided by the Director of Nursing (DON) on 06/20/25 at 2:08 P.M. The record indicated the resident's admitting diagnoses included, but were not limited to, UTI and sepsis. The current Indwelling Catheter Use and Removal policy, dated 2024, was provided by the DON on 06/20/25 at 2:08 P.M. The policy indicated, .If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice .adhere to professional standards of practice and infection prevention and control procedures . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure an extended-release medication was administered as recommended for 1 of 10 medication observations related to pharmacy services. (Resident 65) Findings include: During an observation, on 06/19/25 at 10:57 A.M., RN 3 sanitized her hands and prepared medications for Resident 65. She placed all the medications into a cup and handed the cup to the resident. The resident requested all large pills to be crushed and placed in applesauce. Upon returning to the medication cart, RN 3 poured the medications that included, but were not limited to, Klor-Con M20 Extended Release (a Potassium Chloride Microencapsulated Crystals Extended-Release 20 milliequivalent tablet), into a pouch, crushed the medications, placed them back into the medication cup, and added applesauce. The medications were then administered to the resident. The resident was not educated by the nurse related to the risk of crushing an extended-release tablet. The current, open-ended physician's order, with a start date of 06/07/25, indicated the resident was to receive Klor-Con M20 Extended-Release tablet, once a day. The clinical record for Resident 65 lacked a physician's order for staff to crush the resident's Klor-Con M20 Extended-Release tablet. During an interview, on 06/19/25 at 11:53 A.M., RN 3 indicated an Extended-Release medication should not be crushed. A pharmacy Medications Not To Be Crushed list with a revised date of 08/13, was provided by the Director of Nursing (DON) on 06/19/25 at 12:05 P.M. The list included but was not limited to, .Klor-Con tablet .2. Time release formulation . The current facility policy titled, Crushed Medication was dated 01/2025, was provided by the Director of Nursing on 06/19/25 at 3:33 P.M. The policy indicated, Medications shall be crushed in accordance with standards of practice for safety and accuracy in medication administration .Medications that typically should not be crushed include, but are not limited to, .extended release medications . 3.1-48(c)(2)

Based on record review and interview, the facility failed to obtain STAT (immediate) labs for 1 of 2 residents reviewed for laboratory services. (Resident 22) Findings include: The clinical record for Resident 22 was reviewed on 04/02/24. The resident's diagnoses included, but were not limited to, fracture of the right femur, anemia, kidney disease, and hypertension. A Progress Note, dated 03/28/24 at 12:08 P.M., indicated the resident completed and antibiotic for a UTI (Urinary Tract Infection) the day before, on 03/27/24. The resident had slightly bloody urine. The Nurse Practitioner was notified. A Progress Note, dated 03/29/24 at 11:51 A.M., indicated the resident continued with blood in her urine. A new order was received for a STAT CBC (Complete Blood Count) and UA (Urinalysis). The resident's Eliquis (a blood thinning medication) was put on hold for 48 hours. A Progress Note, dated 03/29/24 at 2:09 P.M., indicated the resident's urine specimen was obtained for the UA. They were waiting for the lab to come and draw the CBC and pick up the urine. A Progress Note, dated 03/29/24 at 6:29 P.M., indicated the STAT CBC had not been drawn. A phone call was made to the laboratory (lab) company to inquire about when the blood would be drawn. The nurse was told that the phlebotomist had acknowledged the order and could not be reached at the time. They were unable to say when the blood would be drawn but the phlebotomist was aware of the STAT order. A Progress Note, dated 03/30/24 at 3:03 A.M., indicated the lab had not been to the facility to pick up the urine or draw the lab. A Progress Note, dated 03/31/24 at 3:39 A.M., indicated the resident had no signs or symptoms of blood in the urine. The CBC was drawn by the lab and the urine was picked up per the physician's order. A physician's order, dated 03/29/24 at 7:00 A.M. through 03/31/24 at 5:41 P.M., indicated the staff were to obtain a STAT CBC and UA every shift. The order was to be discontinued when the blood was drawn. The March EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the blood draw was not completed on the following dates and times: - 03/29/24 on day shift, - 03/29/24 on nightshift, and - 03/30/24 on day shift. During an interview on 04/04/24 at 10:18 A.M., RN 2 indicated the lab came to the facility everyday Monday through Friday to obtain labs. If a resident had a STAT lab, it should be done by the next morning. She wasn't sure if they would come the same day as the order or the next day. If they didn't make it to the facility within 24 hours, then she would immediately go to her supervisor and call the physician. The nurses at the facility did not complete blood draws. The residents UA should have been followed up on. During an interview on 04/04/24 at 10:10 A.M., the Nurse Practitioner indicated if a resident had orders for STAT labs she would be done the same day they were ordered. The facility should notify her if the labs were not able to be done the same day. During an interview on 04/04/24 at 10:24 A.M., Medical Records indicated lab orders were transcribed to the lab company to be scheduled. The lab came Monday through Friday and would complete STAT labs on the weekends as needed. STAT labs should be obtained within 3 to 4 hours. If the lab couldn't come in that time frame, then they would obtain them in the facility and take them to the hospital or they could call the physician and see if they wanted to wait to obtain them. If a resident had a STAT lab the lab company should come the same day. The current facility policy titled, Scheduling and Tracking Labs with a revised date of May 15, 2013, was provided by Medical Records on 04/04/24 at 2:40 P.M. The policy indicated, .We will track results of labs from the printed lab requisitions when labs are scheduled into the computer . 3.1-49(a)

Based on interview and record review, the facility failed to ensure physicians' notes were provided by the physician in a timely manner for 4 of 14 residents reviewed for regulatory visits. (Residents 13, 18, 5, and 2) Findings include: 1. The clinical record for Resident 13 was reviewed on 04/03/24 at 2:56 P.M. An Admission MDS (Minimum Data Set) assessment, dated 01/25/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, atrial fibrillation, hypertension, and renal disease. The resident's physician conducted a regulatory nursing home visit on 01/23/24. The resident was a new admission to the facility. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff and NP (Nurse Practitioner) documentation, and the resident's plan of care was reviewed. The physician's visit documentation was electronically signed and provided to the facility by the physician on 02/06/24 at 7:39 A.M. 2. The clinical record for Resident 18 was reviewed on 04/05/24 at 10:28 A.M. An Admission MDS assessment, dated 01/20/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, a stroke, and hemiplegia. The resident's physician conducted a regulatory nursing home visit on 01/16/24. The resident was a new admission to the facility. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff and NP documentation, and the resident's plan of care was reviewed. The physician's visit documentation was electronically signed and provided to the facility by the physician on 02/04/24 at 6:07 P.M. 33613 3. The clinical record for Resident 5 was reviewed on 04/03/24 at 10:28 A.M. An Admission MDS assessment, dated 01/25/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, cancer, left humerus fracture, and a seizure disorder. The resident's physician conducted a regulatory nursing home visit on 01/23/24. The resident was a new admission to the facility. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff, NP documentation, and the resident's plan of care was reviewed. The physician's visit documentation was electronically signed and provided to the facility by the physician on 02/06/24 at 7:34 A.M. The resident's physician conducted a routine regulatory nursing home visit on 02/20/24. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff, NP documentation, and the resident's plan of care was reviewed. The physician's visit documentation was electronically signed and provided to the facility by the physician on 03/09/24 at 3:07 P.M. 38769 4. The clinical record for Resident 2 was reviewed on 04/03/24 at 9:56 A.M. A Quarterly MDS assessment, dated 03/18/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, fractures, hypertension, anxiety, and depression. The resident's physician conducted an admission assessment on 12/19/23. The resident was a new admission to the facility. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff documentation, NP documentation, and the resident's plan of care was reviewed. The physician's admission visit documentation was electronically signed and provided by the physician to the facility on [DATE] at 9:24 P.M. The resident's physician conducted a regulatory visit on 01/16/24. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff documentation, NP documentation, and the resident's plan of care were reviewed. The physician's visit documentation was electronically signed and provided by the physician to the facility on [DATE] at 6:34 A.M. The resident's physician conducted a regulatory nursing home visit on 02/13/24. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff documentation, NP documentation, and the resident's plan of care were reviewed. The physician's visit documentation was electronically signed and provided to the facility on [DATE] at 9:34 A.M. The resident's physician conducted a regulatory nursing home visit on 03/12/24. The resident was examined, and their medications and laboratory results were reviewed. The Nursing staff documentation, NP documentation, and the resident's plan of care were reviewed. The physician's visit documentation was electronically signed and provided to the facility on [DATE] at 6:28 A.M. During an interview on 04/04/24 at 10:24 A.M., Medical Records indicated when the physician or NP came to the facility to see a resident, they would give the facility written orders at the time of the visit. She would try to review their visit assessment progress note, but she didn't always receive them back from the physician in a timely manner. It was at least a week before she would get them. During an interview on 04/04/24 at 2:48 P.M., the DON (Director of Nursing) indicated after the physician assessed a resident in the facility, the staff would not get his notes until one to two weeks later. Medical Records would review his notes. The physician was in the facility at least once a week. During an interview on 04/05/24 at 9:52 A.M., Medical Records indicated she uploaded the physician's visits progress notes into the residents' clinical records the day she received them from the physician. The upload date was the received date in the clinical record. The current facility policy titled, Physician Visits was revised on February 11, 2004, and provided by the DON on 04/04/24 at 2:40 P.M. The policy indicated, .Orders, recertifications, telephone orders and any other pertinent documents will be signed at the time of the physician's visit, or per facility standards . 3.1-22(c)(2)

Based on observation and interview, the facility failed to administer medications appropriately for 1 of 9 residents reviewed for medication administration. (Resident 6) Findings include: During an observation and interview of medication administration on 02/03/23 at 8:57 A.M., RN 3 prepared the following medications for Resident 6 by placing them in a medication cup: - Aspirin 81 mg (milligrams), 1 tablet - buspirone 15 mg, 1 tablet - Cetirizine 10 mg, 1 tablet - Lasix 20 mg, 1 tablet - Daliresp 500 micrograms, 1 tablet, and At approximately 8:59 A.M., RN 3 took the cup of medications and a glass of water into Resident 6's room. She handed the medication cup to the resident. The resident tipped the medication cup into her mouth. The resident sat the medication cup on her breakfast tray. The medication cup still contained one pill. The nurse gave the resident her water glass and the resident swallowed the medications she had in her mouth. The resident administered 1 puff of her inhaler and rinsed her mouth. The nurse was leaving the resident's room when she was stopped by the surveyor and alerted that there was still a pill in the medication cup. The kitchen staff were in the vicinity picking up breakfast trays. The nurse went back to the resident and administered the pill. RN 3 indicated the resident would not have received the pill if she had not been alerted. The current facility policy titled, Medication Administration, with a revised date of 2/12/2019, was provided by the DON (Director of Nursing) on 02/07/23 at 2:47 P.M. The policy indicated, .Observe resident consumption of medication . The current facility policy titled, Medication Administration-General Guidelines with an effective date of January 2007, was provided by Medical Records on 02/07/23 at 1:36 P.M. The policy indicated, .The resident is always observed after administration to ensure that the dose was completely ingested . 3.1-25(b)

Based on observation, interview, and record review, the facility failed to follow physician orders related to laboratory services for 1 of 9 residents reviewed. (Resident 65) Findings include: During an observation on 02/06/23 at 9:50 A.M., Resident 65 was sitting in a chair in her room. The call light was in reach and had no concerns. The clinical record for Resident 65 was reviewed on 02/06/23 at 1:37 P.M. An Admission MDS (Minimum Data Set) assessment, dated 01/18/23, indicated the resident was moderately cognitively impaired. The active diagnoses included, but were not limited to, fractures, anemia, hypertension, renal insufficiency, UTI (Urinary Tract Infection) in the last 30 days, hyponatremia, thyroid disorder, and malnutrition. A current physician's order, dated 02/02/23, indicated the resident was to have a recheck of a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) on 02/06/23. The clinical record lacked indication that the laboratory services were completed on 02/06/23. During an interview on 02/07/23 at 10:25 A.M., RN 3 indicated the resident was admitted to the facility following a fracture. The resident had some subcutaneous fluids for a day last week for an elevated BUN and creatine. When a physician would order labs, the nurse would input them into the clinical record and then input them into the laboratory company web site for when they needed to be completed. The laboratory company came to the facility everyday between 3:00 A.M. and 5:00 A.M. During an interview on 02/07/23 at 1:05 P.M., the DON (Director of Nursing) indicated the residents labs were due on the 6th and didn't get completed and should have. During an interview on 02/07/23 at 2:21 P.M., Medical Records indicated the resident's labs for the CBC and CMP were ordered in 02/03/23 and had never been inputted into the laboratory companies system to be completed. The current facility policy titled, SCHEDULING AND TRACKING LABS POLICY with a revised date of 06/21/2019, was provided by Admissions Coordinator on 02/07/23 at 2:09 P.M. The policy indicated, .Laboratory orders will be entered into PCC on the computer .The Laboratory requisition in the Med Lab computer program must be completed by the nurse taking off the order . 3.1-25(b)

Based on observation, interview, and record review, the facility failed to follow physician orders for a STAT chest X-ray in a timely manner for 2 of 9 residents reviewed. (Residents 65 and 5) Findings include: 1. During an observation on 02/06/23 at 9:50 A.M., Resident 65 was sitting in a chair in her room. During an interview on 02/07/23 at 9:34 A.M., the scheduler indicated Resident 65 was being sent to the hospital. The clinical record for Resident 65 was reviewed on 02/06/23 at 1:37 P.M. An Admission MDS (Minimum Data Set) assessment, dated 01/18/23, indicated the resident was moderately cognitively impaired. The active diagnoses included, but were not limited to, fractures, anemia, hypertension, renal insufficiency, UTI (Urinary Tract Infection) in the last 30 days, hyponatremia, thyroid disorder, and malnutrition. A Skilled Evaluation Progress Note, dated 02/06/23 at 4:33 P.M., indicated the resident was having 2+ pitting edema in her bilateral lower extremities that was a new onset. The resident had wheezing in the lungs of her left and right posterior upper lobes on auscultationl. A cough was present that was moist, loose, and productive, with a moderate amount of secretions. The resident had been seen by the NP (Nurse Practitioner) with new orders for a STAT (immediately) chest x-ray, ProBNP (B-Type Natriuretic Peptide), and a CMP (Comprehensive Metabolic Panel). A Radiology Order, dated 02/06/23 at 4:28 P.M., indicated the resident was to have a STAT chest x-ray. The clinical record lacked indication that the chest x-ray had been completed before the resident was sent to the local emergency roiagnom on [DATE] or documentation that the physician had been notified that the chest x-ray was not able to be completed. 38239 2. Resident 5's clinical record was reviewed on 02/07/23 at 1:23 P.M. An Admission MDS assessment, dated 12/08/22, indicated the resident was moderately cognitively impaired. The resident's primary medical condition was a wedge compression fracture, first lumbar vertebra. The additional diagnoses included, but were not limited to, diabetes, hypertension, non-Alzheimer's dementia, and low back pain. A Progress Note, dated 02/06/23 at 6:39 P.M., indicated the resident had been seen by the NP regarding a persistent cough and wheezing. A new physician's order was received for a chest x-ray. A handwritten physician's order, dated 02/06/23, indicated a STAT chest x-ray was to be obtained. The order was signed by the NP, and initialed as noted by the nurse. A Radiology Order confirmation document indicated the facility ordered a chest x-ray on 02/06/23 at 4:31 P.M. The priority was listed as STAT. On 02/07/23 at 2:00 P.M., the resident was observed in bed in her room. The resident indicated she had a chest x-ray around 11:00 A.M. that morning. During an interview on 02/07/23 at 10:44 A.M., the DON (Director of Nursing) indicated that she believed the STAT chest x-rays were not completed because the x-ray company was short staffed. During an interview on 02/07/23 at 1:05 P.M., the DON indicated a night shift nurse had spoken with the x-ray company on the night of 02/06/23 and had indicated they would not be into the building until 02/07/23. The nurse should have documented that she contacted the physician. During an interview on 02/07/23 at 1:46 P.M., RN 3 indicated a STAT chest x-ray should be completed within 4 to 5 hours of getting the order. During an interview on 02/07/23 at 2:25 P.M., RN 3 indicated if the x-ray company was not able to come within the 4-to-5-hour window for a STAT x-ray, she would reassess the resident, call the Nurse Practitioner and see what she would want to do. She would have documented in the progress note the discussion with the x-ray company, and discussion with the Nurse Practitioner. She would also update the family as needed. The current facility policy, titled Laboratory Services and Reporting, and dated 08/22/22, was provided by the DON on 02/07/23 at 4:03 P.M. The policy indicated, .The facility must provide or obtain laboratory services when ordered . The current facility policy, titled PHYSICIAN and FAMILY NOTIFICATION POLICY, and dated October 1, 2017, was provided by the Admission Coordinator on 02/07/23 at 2:09 P.M. The policy indicated, .The resident's physician will be notified of the following .all labs . 3.1-49(g)

Based on interview and record review, the facility failed to properly secure a resident's wheelchair during transfer resulting in a fall for 1 of 2 residents reviewed for accidents. (Resident 5) Findings include: During an interview on 02/02/23 at 1:50 P.M., Resident 5's family member indicated he was in the resident's room when she fell a few days ago. A staff member was assisting the resident out of her wheelchair and they forgot to lock the wheelchair brakes. The resident fell to the ground. The resident was wearing a gait belt and the aide stood in front of her, took a hold of the gait belt from the middle of the resident and tried to pull her up from the floor by herself. That didn't work, so the aide went and got help. Another aide came in and the two aides assisted the resident up from the floor and onto the bed. The family member was concerned, because the resident was recovering from a broken back, but she didn't suffer any injuries from the fall. The resident's clinical record was reviewed on 02/07/23 at 1:23 P.M. An Admission MDS (Minimum Data Set) assessment, dated 12/08/22, indicated the resident was moderately cognitively impaired. The resident's primary medical condition was a wedge compression fracture, first lumbar vertebra. The additional diagnoses included, but were not limited to, diabetes, hypertension, non-Alzheimer's dementia, and low back pain. The resident's physical therapy orders, dated 01/11/23, indicated the resident may complete functional transfers with nursing staff using an up-right rollator (rolling walker) with minimal staff assistance. A Progress Note, dated 1/31/2023 at 1:00 P.M., indicated the nurse entered the room and the resident was sitting on the side of the bed being assisted by an aide. The aide reported the resident had been lowered to the floor while being transferred and was not injured. The resident was alert, in good spirits, and wearing a gait belt. The resident denied pain and no injuries were observed. A Progress Note, dated 2/1/2023 at 9:15 A.M., indicated the Interdisciplinary Team met to discuss the fall on 1/31/2023. The resident's wheelchair was not locked when the transfer occurred. The resident was lowered to the floor by staff and was assessed by nursing with no injuries or complaints. The staff member was re-educated. During a telephone interview on 02/07/23 at 9:47 A.M., BNA (Basic Nurse Aide) 4 indicated on the day of the incident, the resident was in her wheelchair and wanted to lay down in bed. She placed the resident's walker in front of the resident and placed a gait belt on the resident. She forgot to lock the wheelchair, and as the resident began to rise, she placed her hands on the wheelchair to push herself up. The wheelchair rolled back. The aide had a hold of the resident, so she lowered her to the ground. Another aide assisted her in getting the resident off the floor and onto the bed. The current facility policy, with a revision date of April 2018, and titled FALLS, MANAGEMENT AND PREVENTION OF, was provided by the Director of Nursing on 02/07/23, at 12:47 P.M. The policy indicated, .It is the responsibility of all staff to .providing a safe environment for residents .identify risk factors for falls and to act upon those risk factors by implementing appropriate, individualized fall prevention . 3.1-45(a)(2)

Based on interview and record review, the facility failed to monitor a resident's incision site (Resident 16) for 1 of 4 residents reviewed for quality of care. Findings include: During an observation and interview on 02/14/22 at 12:23 P.M., Resident 16 was sitting in her wheelchair in her room. Her left leg was elevated and had an open brace with an ace wrap visible. She indicated she had fallen at home and broke her leg. The facility didn't check her incision site or take the ace wrap off. During an observation on 02/16/22 at 11:22 A.M., Resident 16 was in her room in her wheelchair, her left leg was in an open brace with an ace wrap visible. She had no concerns. The clinical record for Resident 16 was reviewed on 02/16/22 at 10:00 A.M. An Admission MDS (Minimum Data Set) assessment, dated 02/03/22, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a surgical wound. The resident's clinical record lacked any documentation of assessments of the surgical wound since admission. During an interview on 02/17/22 at 12:39 P.M., RN 4 indicated Resident 16 had broken her femur (leg bone) at home. The resident was non-weight bearing with a brace and an ace wrap under it. The facility was allowed to take the ace wrap and brace off to assess the incision. The resident should have had orders to monitor the surgical incision. She believed the resident didn't have any orders to monitor the surgical incision site. During an interview on 02/17/22 at 2:44 P.M., the DON (Director of Nursing) indicated if a resident had a surgical incision, then they should have had orders to monitor the incision site. The current facility policy, titled Wound Treatment Management, dated 06/29/21, was provided by the DON on 02/17/22 at 3:14 P.M. The policy indicated, .To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The current facility policy, titled Documentation of Wound Treatments, dated 06/25/20, was provided by the DON on 02/17/22 at 3:14 P.M. The policy indicated, .The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change on condition, and changes on treatments .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .The following elements are documented as part of a complete wound assessment .Type of wound (pressure injury, surgical, etc) . 3.1-37(a)

Based on record review and interview, the facility failed to address a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications. (Resident 14) Findings include: The clinical record for Resident 14 was reviewed on 02/26/22 at 10:45 A.M. A Medicare 5-day MDS (Minimum Data Set) assessment, dated 02/02/22, indicated the resident was moderately cognitively impaired. Diagnoses included, but were not limited to, [CONDITION(S)], hypertension, non-Alzheimer's dementia, anxiety, depression, [CONDITION(S)], and GERD (Gastro-[CONDITION(S)] Reflux Disease). A Pharmacy Recommendation, dated 01/26/22, indicated Drug Interactions .Omeprazole (an antacid medication) can decrease the effectiveness of [MEDICATION(S)] (a blood thinner medication). Consider switching to [MEDICATION(S)] (an antacid medication). There was no indication in the clinical record the pharmacy recommendation had been reviewed by the physician. During an interview on 02/17/22 at 2:37 P.M., the DON (Director of Nursing) indicated the pharmacist conducted her audits and then sent them to the facility. After receiving the recommendations, the facility would print them off and give them to the MD or NP (Nurse Practitioner) for review. The MD or NP would review the recommendations, and indicate whether they agreed or disagreed. The nurse would enter any new orders and she would review the resident's record to ensure follow through. The physician's review and any new orders would be put into place within a week. During an interview on 02/18/22 at 9:32 A.M., Medical Records 5 indicated the recommendation on 01/26/22 should have been addressed. 3.1-48(a)(5)

Based on observation, interview, and record review, the facility failed to ensure infection control practices for COVID-19 were followed, related to proper PPE (Personal Protective Equipment) usage in contact and droplet isolation precautions to help mitigate the potential spread of COVID-19 for 1 of 14 residents reviewed for infection control. (Resident 8) During an observation on 02/17/22 at 7:39 A.M., Physical Therapy Assistant (PTA) 2 entered Resident 8's room wearing only a KN95 mask and face shield. During an observation and interview on 02/17/22 at 7:53 A.M., PTA 2 and Resident 8 stepped into the hallway. The resident was wearing a surgical mask. PTA 2 indicated she saw the yellow isolation sign on the resident's door and proceeded to walk the resident down the hall to the therapy room. During an observation on 02/17/22 at 7:56 A.M., PTA 2 and Resident 8 walked back from the therapy room to the resident's room. During an interview on 02/17/22 at 7:57 A.M., PTA 2 indicated she was unaware the resident was on isolation. During an interview on 02/17/22 at 8:01 A.M., the Director of Nursing (DON) indicated the therapy department was informed when the resident was placed on isolation and the PTA should have worn the proper PPE when caring for the resident. She should have been wearing an N95 mask, a face shield, a gown, and gloves. The clinical record for Resident 8 was reviewed on 02/16/22 at 1:37 P.M. An Admission MDS (Minimum Data Set) assessment, dated 01/03/22, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her Covid-19 vaccination dates were 01/19/21 and 02/27/21. She had not received the booster. The current undated CONTACT DROPLET PRECAUTIONS sign was provided by RN 7 on 02/17/22 at 9:14 A.M. The sign indicated, .YELLOW ZONE. TRANSMISSION BASED PRECAUTIONS. CONTACT DROPLET. PPE REQUIRED: N95 MASK .GOGGLES or FACESHIELD, GOWN .GLOVES . 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure appropriate physician orders were in place, and catheter care was provided for a resident with an indwelling urinary catheter for 1 of 9 residents reviewed for incontinence. (Resident 166) Findings include: On 10/15/19 at 11:16 [NAME]M., Resident 166 was observed in his room, seated in his wheelchair. The resident was noted to have an indwelling urinary catheter that was draining clear yellow urine into a catheter drainage bag that was hanging on the side of the wheelchair. The resident indicated he came from the hospital to the facility with the catheter. He had not had any problems with the catheter, and the nurse told him they would likely be removing the catheter soon. The clinical record for the resident was reviewed on 10/16/19 at 10:20 [NAME]M. The resident's [DIAGNOSES REDACTED]. A handwritten hospital discharge order, dated 10/12/19, indicated Wean (catheter) per protocol. The current physician's orders did not include any orders for an indwelling urinary catheter, indwelling urinary catheter site care, or monitoring of the catheter. The ETAR (Electronic Treatment Administration Record) and Nurse's Notes lacked documentation related to indwelling urinary catheter care. During an interview on 10/18/19 at 9:41 [NAME]M., RN 2 indicated when a resident had an indwelling urinary catheter, the catheter order set would be included in the resident's orders, and the nurses would document catheter care every shift. If a resident had a catheter they should have had a physician's order for the catheter. The resident's urinary catheter was removed on 10/17/19. During an interview on 10/21/19 at 12:04 P.M., RN 3 indicated she audited Resident 166's admission orders [REDACTED]. Another nurse was supposed to go in to the resident's electronic health record and add the catheter order and the care orders. The appropriate catheter orders were never added to the resident's orders. The current facility policy, titled Admission Care for a .Catheter, with a most recent revision date of (MONTH) (YEAR), was provided by the Director of Nursing on 10/21/19 at 1:28 P.M. The policy indicated, .Physician's order must state supporting diagnosis, size of catheter, bulb size, frequency of changes, and irrigation order, if warranted . 3.1-41(a)(2)

Based on record review and interview, the facility failed to document notification of the ombudsman in residents' clinical records related to the transfer and discharge of residents. This deficient practice effected 2 of 3 residents reviewed for discharge from the facility. (Residents 2 and 225) Findings include: 1. The closed clinical record for Resident 2 was reviewed on 10/17/18 at 03:11 P.M. An Admission MDS (Minimum Data Set) assessment, dated 08/03/18, indicated the resident was cognitively intact. The resident was admitted to the facility on [DATE] from the hospital and planned to return home after rehabilitation therapy and treatment. [DIAGNOSES REDACTED]. A Discharge assessment, dated 08/07/18, indicated the resident's discharge was planned and a return to the facility was not anticipated. A clinical note, dated 08/05/2018 at 05:35 P.M., indicated Resident 2 was discharged to home with his wife and home health services. There was no documentation in the clinical record that indicated the ombudsman had been notified regarding the resident's discharge from the facility. 2. The closed clinical record for Resident 225 was reviewed on 10/17/18 at 02:48 P.M. The most recent Admission MDS assessment, dated 07/27/18, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. A progress note, dated 08/09/18, indicated Resident 225 was transferred to the hospital for evaluation and treatment. There was no information included in the clinical record regarding notification of the ombudsman. During an interview, on 10/22/18 at 10:28 A.M., RN 2 indicated she notified the ombudsman via encrypted email messages when residents were discharged from the facility. There was no documentation of the ombudsman notifications in the residents' clinical records. 3.1-12(a)(6)(A)

Based on observation, interview, and record review, the facility failed to follow isolation precautions related to an infection. This deficient practice had the potential to affect 16 of 16 residents in the facility. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 10/17/18 and 03:03 P.M. The Admission MDS (Minimum Data Set) assessment, dated 09/17/18, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. During an interview, on 10/16/18 at 03:08 P.M., the MD (Medical Director) indicated parotitis (mumps) involved the two large salivary glands. In the elderly and sick the duct could become blocked and the gland swollen behind it. It was treated with antibiotics. He would not screen for[DIAGNOSES REDACTED] in older people. He did not recommend any extra precautions. During an interview, on 10/19/18 at 08:45 A.M., the MDS Coordinator indicated residents were put in isolation right away if they were suspected to have something highly contagious. She was aware of Resident 13's parotitis infection. She was not aware of doing anything extra for a resident who had parotitis. They did not do any blood work to determine if the resident had the[DIAGNOSES REDACTED]. She was not aware of the facility placing the resident in isolation. During an interview, on 10/19/18 at 09:50 A.M., the DON (Director of Nursing) indicated she was aware Resident 13 had swollen glands and had talked to the MD. The MD had assured her it was not the[DIAGNOSES REDACTED] and the resident did not need to be in isolation. The physician's orders [REDACTED].M. An order, dated 10/03/18, indicated Resident 13 was to receive [MEDICATION NAME] 1 gram, intramuscularly, every day for seven days for left sided parotitis. An order, dated 10/09/18, indicated the [MEDICATION NAME] was to be discontinued and Resident 13 started on [MEDICATION NAME], three times a day for seven days for parotitis. A Progress note, dated 09/30/18, indicated the MD had been notified that the resident had a firm, tender lump on the left side of his neck. A Progress note, dated 10/03/18, indicated the MD had seen the resident and the resident presented with tenderness in the jaw area and had a palpable mass along the jaw in front of the ear. A Progress note, dated 10/09/18, indicated the MD had seen the resident and the resident presented with left facial swelling. The pain and swelling had improved. A Progress note, dated 10/16/18, indicated the MD had seen the resident and the resident showed improvement in his facial swelling. The facial pain had also improved. The complete Care Plan for Resident 13 was provided by Medical Records on 10/17/18 at 03:21 P.M. An active Care Plan, with an effective date of 10/04/18, indicated the resident presented with an infection of left sided parotitis. The interventions included, but were not limited to, .Follow standard precautions . During an interview, on 10/19/18 at 10:51 A.M., the DON indicated standard precautions included wearing gloves when providing care for a resident. The facility could not provide laboratory results indicating the resident did not have[DIAGNOSES REDACTED]. The current Isolation Precautions policy, with a revised date of 10/17/17, was provided by the DON on 10/22/18 at 09:30 A.M. The policy indicated, .The facility will use standard approaches, as defined by the CDC (Center for Disease Control), for transmission-based precautions: airborne, contact, and droplet precautions .Mumps .Droplet .Until 9 days after initiation of treatment . Guidance for Updated Recommendations for Isolation of Persons with[DIAGNOSES REDACTED], dated (MONTH) 2008, was retrieved on 10/22/18 from the Centers of Disease Control (CDC) website. The guidance included, .In (MONTH) 2008 .the HICPAC (Healthcare Infection Control Practices Advisory Committee approved changes in its recommendations related to[DIAGNOSES REDACTED] in in-patient settings .As a result .CDC, AAP (American Academy of Pediatrics) and HICPAC all now recommend a 5-day period after onset of Parotitis, both for isolation of persons with[DIAGNOSES REDACTED] in either community or health-care settings and for use of standard precautions and droplet precautions. 3.1-18(j)