Every finding on record at Gentle Care Strategies

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 5 of 18 residents sampled. Two residents were on Aspirin (ASA), a resident was on oxygen, a resident self administered eye drops, and a resident kept a urinal on the beside table but did not have care plans for them. (Resident 36, Resident 50, Resident 112, Resident 54, Resident 29) Findings include: 1. On 4/23/25 at 10:39 A.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, other frontotemporal neurocognitive disorder, anxiety, depression, and dementia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/12/25, indicated Resident 36's cognition was severely impaired and was taking an antipyschotic, antianxiety, antidepressant, diuretic, opioid, and antiplatelet medication. Current Physician's Orders included, but were not limited to, ASA (antiplatelet) 81 milligrams (mg), give one tablet orally one time a day, ordered 8/4/22 The clinical record lacked a care plan for Resident 36 receiving an antiplatelet medication. 46882 2. On 4/22/25 at 10:32 A.M., Resident 50's clinical record was reviewed. Diagnoses included but were not limited to, vascular Parkinsonism, cognitive communication deficit, delirium due to physiological condition and restlessness and agitation. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated Resident 50 had severe cognitive impairment, needed partial/moderate assistance - helper does less than half the effort- for eating, substantial/maximal assistance - helper does more than half the effort- for toilet use, bed mobility and transfers, and was on hospice. Current Physician Orders included, but was not limited to, the following: Aspirin Oral Capsule 81 MG (Aspirin) Give 1 capsule by mouth one time a day for antiplatelet, dated 10/29/2024 Resident 50's clinical record lacked a care plan for aspirin use. 3. On 4/21/25 at 11:58 A.M., Resident 54 was observed sitting in a chair in his room with his urinal sitting on the bedside cabinet with urine in it. On 4/23/25 at 9:16 A.M., Resident 54 was observed lying in bed, wife at bedside, talking with Social Services, and urinal sitting on bedside table with small amount of urine in it. On 4/23/25 at 9:28 A.M., Resident 54's clinical record was reviewed. He was admitted on [DATE]. Diagnosis included, but was not limited to, hypo-osmolality and hyponatremia. The Admission Minimum Data Set was in progress and export ready. Current Physician Orders included, but was not limited to, the following: Enhanced Barrier Precautions every shift for history of Extended-spectrum beta-lactamases (ESBL)(bacteria in the urine), dated 4/6/2025 Nurse's Note from 4/6/2025 at 10:02 P.M. Note Text: 72 hour charting: Resting quietly abed, eyes closed, respirations even and unlabored. Has denied pain or discomfort this shift. Using urinal without difficulty. Assisted with bed mobility per staff. Alert and oriented x 3, able to voice wants and needs, uses call light as needed. Plan of care ongoing. Nurse's Note from 4/7/2025 at 8:40 P.M. Note Text: 72 hour charting: Resting abed. Alert and oriented x 3, pleasant. Denies pain or discomfort. Respirations even and unlabored. Voiding per urinal without difficulty. Urine clear yellow. No s/s (signs/symptoms) distress. Call light in reach. Plan of care ongoing. Resident 54's clinical record lacked a care plan for resident's preference to use a urinal and to set it on the bedside table. 4. On 4/23/25 at 11:17 A.M., Resident 112's clinical record was reviewed. Resident 112 was admitted on [DATE]. Diagnoses included, but were not limited to, infection following procedure at surgical site, pulmonary fibrosis, and chronic respiratory failure. The Admission Minimum Data Set was in progress and export ready. Current Physician Orders included, but was not limited to, the following: Oxygen at 2 lpm (liters per minute) via NC (nasal cannula). Monitor oxygen saturations while on continuous oxygen, two times a day related to pulmonary fibrosis and chronic respiratory failure, dated 4/10/2025. Resident 112's clinical record lacked a care plan for oxygen. 45933 5. On 4/21/25 at 2:12 P.M., Resident 29's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 3/18/25, indicated Resident 29 had adequate vision and did not have corrective lenses. Physician's Orders included, but was not limited to the following: Refresh Tears Ophthalmic Solution 0.5 % .Instill 2 drop in both eyes every 4 hours as needed for Dry eyes MKAB (may keep at bedside) .start date 4/10/2024 During an interview on 4/22/25 at 1:58 P.M., Licensed Practical Nurse (LPN) 4 indicated Resident 29 self-administered her eye drops. The clinical record lacked a care plan related to Resident 29's self administration of eye drops. During an interview on 4/24/25 at 10:15 A.M., the MDS Coordinator indicated a care plan should be developed if a Resident self administered eye drops, received aspirin, utilized oxygen, and if a Resident utilized the bedside table for their urinal. On 4/24/25 at 10:31 A.M., the Administrator provided a Care Plans, Comprehensive Person--Centered policy, revised 2016, that indicated, .The comprehensive person-centered care plan will: .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Reflect the resident's expressed wishes regarding care and treatment goals . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was revised for 2 of 5 residents reviewed for unnecessary medications and 1 of 3 reviewed for Activities of Daily Living (ADL) decline. A resident's care plan was not reviewed or revised to remove areas of concern that were no longer relevant to the resident's care, i.e. antibiotic use, fracture care, and antipsychotic use. (Resident 112, Resident 46, Resident 12) Findings include: 1. On 4/23/25 at 11:17 A.M., Resident 112's clinical record was reviewed. Resident 112 was admitted on [DATE]. Diagnoses included, but were not limited to, infection following procedure at surgical site, pulmonary fibrosis, and chronic respiratory failure. The Admission Minimum Data Set was in progress and export ready. Current Physician Orders included, but was not limited to, the following: Cipro Oral Tablet 250 MG (milligrams), give 1 tablet by mouth two times a day related to infection following procedure, surgical site until 4/16/25, dated 4/10/25 and completed 4/16/25. A current antibiotic care plan, initiated on 4/11/25, included, but was not limited to, the following interventions: Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift, date Initiated: 04/11/2025 Care plan was not revised/removed after Resident 112 finished the antibiotic on 4/16/25. 45933 2. On 4/17/25 at 10:03 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and depression. The most recent Annual Minimum Data Set (MDS) assessment, dated 2/5/25 indicated Resident 46 did not have a fracture. Resident 46's clinical record lacked current orders related to a fracture. Resident 46's care plans included, but was not limited to the following: The resident has an alteration in musculoskeletal status r/t [related to] Left humerus fracture, revised 3/12/24. 46416 3. On 4/23/25 at 9:54 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, osteoarthritis, anxiety, and depression. The most recent Admission MDS assessment, dated 3/19/25, indicated Resident 12 was cognitively intact and was receiving an antipyschotic, antianxiety, antidepressant, diuretic, opioid, and an antiplatelet. Physician's orders included, but were not limited to, the following: Abilify 5 mg, give one 1 tablet by mouth one time a day, ordered 3/13/25, and discontinued 4/10/25 Current Care Plans included, but were not limited to, the following for Resident 12 currently receiving an antipyschotic: resident has a diagnosis of depression and was being treated with an antipsychotic to augment her antidepressant, initiated 3/19/25 I receive psychotropic medications, initiated 3/19/25 The Medication Administration Record (MAR) was reviewed for 4/1/25 through 4/23/25 and indicated the last dose of Abilify given to Resident 12 was 4/10/25. During an interview on 4/24/25 at 10:15 A.M., the MDS Coordinator indicated she was responsible for revising resident care plans. She indicated they were reviewed with MDS assessments and as needed for condition changes of the residents within a few days of changes to remain current for each resident. She indicated Resident 112 finished his antibiotic on 4/16/25 and the care plans should have been resolved. Resident 12 was previously on an antipyschotic that was discontinued and the care plans should have been resolved. Resident 46 no longer had a left humerus fracture and the care plans should have been revised to remove that diagnosis. On 4/24/25 at 10:31 A.M., a current Care Plan Policy, Revised December 2016, was provided by the Administrator and indicated, . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 2 medication carts observed. A medication cup with loose controlled substances was observed in a medication cart. (100 hall) (Resident 3, Resident 12, Resident 6) Finding includes: During an observation on 4/23/25 at 10:18 A.M., the medication cart on the 100 hall had 3 clear medication cups that included the following controlled substances: Resident 3--1 tramadol 50 milligram (mg) tablet Resident 12-- 1 Ativan 0.5 mg tablet Resident 6-- 1 hydrocodone-actaminophen 5-325 mg tablet During an interview on 4/16/25 at 10:25 A.M., the Director of Nursing (DON) indicated controlled substances should be stored under a double lock at all times. On 4/24/25 at 10:23 A.M., the Administrator provided a current Controlled Medication Storage policy, revised 1/2024 that indicated, .Controlled medications are stored under double lock . 3.1-25(r)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and a secured environment was in place to prevent a resident with dementia from exiting the facility unsupervised. On 9/21/24, while on 15-minute checks, a resident was noticed to be missing at 5:20 A.M. Staff quickly located the resident outside the Hall 2 emergency exit door where the resident exited the facility and apparently fallen while unsupervised. (Resident C) Finding includes: A review of facility reported incidents on 9/30/24 at 11:15 A.M., included an IDOH (Indiana Department of Health) Reportable Incident form completed by the Facility Administrator, with an incident date of 9/21/24 at 5:30 A.M., indicated that staff was notified that Resident C was missing from her room at approximately 5:20 A.M. Staff went to the Hall 2 exit door and found Resident C sitting on the ground outside of the facility. Resident C was noted to have a small abrasion on her palms with a scant amount of fresh blood around left temple area. Resident was assessed and assisted back into the facility at approximately 5:30 A.M. On 9/30/24 at 11:20 A.M., LPN 4 indicated that Resident C was at risk for wandering and elopement and wore a WanderGaurd bracelet (a device that triggers door alarms and locks monitored doors to prevent the resident from leaving unattended). Resident C was on one-to-one observation at that time due to exit seeking behaviors. During an observation on 9/30/24 at 11:25 A.M. Resident C was sitting in her room with a staff member sitting next to her. The emergency exit door on Hall 2 was observed to have a magnetic alarm attached to it that would sound if the door were opened. During record review on 9/30/24 at 11:30 A.M., Resident C's diagnoses included, but were not limited to vascular dementia with behavioral disturbance, unsteadiness on feet, altered mental status, and auditory hallucinations. Resident C's most recent Admission Minimum Data Set (MDS) assessment, dated 9/14/24, indicated the resident had severe cognitive impairment, had no functional impairments to extremities, used a walker for ambulation, could walk 10 feet with supervision of one staff, wandered daily, and that the resident's wandering behavior put the resident at significant risk of getting to a dangerous place (including outside of the facility). Resident C's comprehensive care plan included, but was not limited to: A focus of resident is at risk for elopement due to attempting to exit seek upon admission and wandering at previous facility (initiated 9/14/24) with interventions that included, check function of WanderGaurd every shift, respect resident's right to make decisions, and WanderGaurd placement on resident's wrist at all times. A focus of resident is at risk for wandering and elopement (initiated 9/14/24) with a goal of resident will not leave facility unattended. Resident C's elopement risk evaluation, dated 9/14/23, indicated Resident C had a history of elopement or an attempted elopement while at home and wandered aimlessly. Resident C's physician orders included, but were not limited to, WanderGaurd bracelet with an order date of 9/5/24, and 1:1 supervision to ensure safety with an order date of 9/21/24. Resident C's nurse's progress notes included, but were not limited to the following: On 9/9/24 at 5:55 P.M. - Resident had multiple attempts to exit seek today. WanderGaurd in place and functioning properly. On 9/15/24 at 3:50 P.M. - staff notified nurse that resident had been exit seeking. Thirty (30) minute safety checks changed to 15-minute safety checks. Physician, Administrator, and Direct of Nursing (DON) notified. 9/21/24 at 5:30 A.M. - Incident occurred when resident opened emergency exit door and stepped outside. As resident was going outside, she stepped down and lost balance causing her to scrape body against the brick on the outside of the facility. Resident has abrasions on her arms and on to her face. Resident redirected back inside facility. Administrator, DON, and family notified. A review of the facility's investigation of Resident C's elopement on 9/21/24 included a typed note dated 9/25/24, and signed by RN 6. The note indicated, on 9/21/24 RN 6 was alerted by LPN 9 that at approximately 5:20 A.M., that she needed assistance locating Resident C. LPN 9 indicated that Resident C had been exit-seeking earlier in the night on Hall 2. RN 6 immediately check outside the emergency exit door located on Hall 2 and found Resident C sitting on the ground outside of the facility. Resident C was noted to have a small abrasions on palms and scant amount of fresh blood on left temple area. Resident C was assisted back into the building at approximately 5:30 A.M. LPN 9 indicated that Resident C had been exit-seeking at around 2:00 A.M. but that staff was able to redirect resident back to room and that no administrative staff was notified of the behavior. CNA on hall indicated the last bed check was completed at 5:15 A.M. During an interview on 9/30/24 at 11:45 A.M., the Facility Administrator indicated that Resident C had been on 15 minute safety checks the morning of 9/21/24 and that the 15 minute checks were documented in the Point of Care (POC) charting system. A review of Resident C's 15-minute safety checks on 9/30/24 at 11:50 A.M., indicated the resident had been 15-minute safety checks the morning of 9/21/24. Documented 15-minute checks included the following times: 9/21/24 - 12:01 A.M. 9/21/24 - 1:09 A.M. 9/21/24 - 3:23 A.M. 9/21/24 - 3:29 A.M. 9/21/24 - 3:32 A.M. 9/21/24 - 3:33 A.M. 9/21/24 - 4:23 A.M. (last documented 15-minute check observation of resident before missing at 5:20 A.M.) During an interview on 9/30/24 at 1:10 P.M., the DON indicated after reviewing the incident and interviewing staff who were on duty the morning of 9/21/24, she did not believe the emergency exit door had alarmed as it should have when pushed open by Resident C when she was able to exit the facility unsupervised. It was not clear as to why the alarm did not sound as it was functioning correctly when all doors were checked following Resident C's elopement. Staff had not indicated that the alarm alerted them that Resident C had exited the door, rather LPN 9 realized Resident C was not in her room at 5:20 A.M. The DON also indicated that if LPN 9 had notified other staff of Resident C's exit seeking behavior on 9/21/24 at 2:00 A.M., an intervention of placing the resident on 1:1 observation could have been implemented. The DON also indicated that an additional alarming device was added the the emergency exit door on Hall 2. A review of daily door checks on 9/30/24 at 1:25 P.M., indicated all doors had been check the day prior to Resident C's elopement and all door alarms were functioning correctly. On 9/30/24 at 2:20 P.M., the DON supplied a facility policy titled Elopement/Wander Risk Policy, dated 07/2023. The policy included, .3. Staff members are asked to notify the nurse on duty of any Resident that is suspected of being an elopement risk or found trying to leave the building 5.All fire doors are equipped with an alarming mechanism regardless of wander-guard in place to alarm staff when a resident is attempting to go out the fire doors . This citation relates to Complaint IN00444101. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident's representative for 1 of 1 residents reviewed for hospitalization . (Resident 4) Finding includes: On 3/15/24 at 11:00 a.m., Resident 4's clinical record was reviewed. The diagnosis included, but was not limited to, hepatic encephalopathy. Resident 4's progress notes indicated the resident was sent to the hospital on 1/11/24 and 1/29/24. The clinical record lacked documentation of written notification of the Notice Transfer and Discharge forms having been provided to the resident and the resident representative. During an interview on 3/15/24 at 11:30 a.m., the Director of Nursing (DON) indicated the facility sent the Notice of Transfer and Discharge forms with Resident 4 when going to the hospital but did not provide the forms in writing to the resident's representative. On 3/15/24 at 11:58 a.m., the DON provided the facility policy, Transfer/Discharge Verification Checklist, dated 2/28/19, and indicated this was the policy currently being used by the facility. A review of the policy did not indicate sending a Notice of Transfer and Discharge form with the resident and resident representative when the resident was transferred to the hospital. 3.1-12(a)(6)(A)(ii)

Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with the written plan of care for 1 of 2 residents reviewed for nutrition and during random observations of a resident on isolation precautions. (Resident 23, Resident 242) Findings include: 1. On 6/6/22 at 10:56 A.M., Resident 242 was observed in a yellow zone precaution room. On 6/6/22 at 11:03 A.M., Resident 242's current orders included, but were not limited to .6/3/22 Admit to facility .INSTITUTE COV-19 [Covid] TRANSMISSION BASED PRECAUTIONS ON ALL ADMITS/READMITS PRN [as needed] . On 6/7/22 at 9:53 A.M., Resident 242 was observed sitting in the common area. At that time, the yellow zone precaution sign was observed on the resident's door. On 6/7/22 at 10:28 A.M., Resident 242 was observed sitting in the dining room. On 6/7/22 at 2:19 P.M., Resident 242 was observed sitting in the common area. At that time, the yellow zone precaution sign was observed on the resident's door. During an interview on 6/7/22 at 2:40 P.M., Registered Nurse (RN) 5 indicated Resident 242 was in the yellow zone isolation precautions due to being newly admitted from another facility. 2. On 6/8/22 at 1:47 P.M., Resident 23's clinical record was reviewed. The most recent annual Minimum Data Set (MDS) assessment, dated 5/1/22, indicated Resident 23 was severely cognitively impaired. Resident 23's current care plan, initiated 4/26/21, indicated I will consume 50%-75% of meals x 3 dly [daily]. On 6/8/22 at 2:45 P.M., Resident 23's meal consumption sheets were reviewed for May to June 2022. The meal consumption sheet indicated .offer replacement for consumptions of 50% or less . Resident 23 consumed less than or equal to 50% of the meal and was not offered a replacement on the following dates: 5/12/22- supper 5/13/22- supper 5/14/22- supper 5/15/22- supper 5/16/22- supper 5/31/22- lunch 6/2/22- supper 6/3/22- supper 6/4/22- supper 6/5/22- supper 6/6/22- supper 6/7/22- supper 6/8/22- supper During an interview on 6/10/22 at 10:48 A.M., Certified Nursing Assistant (CNA) 4 indicated Resident 23 consumes 25-75% of the meals offered. CNA 4 further indicated that Resident 23 is offered an alternate food option. On 6/10/22 at 2:00 P.M., a current Resident Care Plan policy, dated 8/16/11, was provided and indicated .Staff utilize the resident care plan to help provide appropriate care and documentation for each resident . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 during 1 of 1 observations of staff COVID-19 testing. Staff were observed performing a COVID-19 test without wearing the required PPE (Personal Protective Equipment) and staff failed to perform hand hygiene. Finding includes: During an observation on 6/7/22 at 2:31 p.m., LPN 1 was observed to perform a COVID-19 test on CNA 2. LPN 1 wore a KN95 mask and gloves for PPE but did not wear a gown or eye protection. LPN 1 performed the COVID-19 test, swabbing both nares of CNA 2. LPN 1 removed gloves following the test, and did not perform hand hygiene. LPN 1 indicated they usually wear a mask and gloves, but at one time they wore a face shield as well. However, they were told to not wear the face shield if the county COVID-19 positivity rate is low. During an interview on 6/7/22 at 3:14 p.m., the DON (Director of Nursing) indicated while routine testing, staff usually does not put on a gown and shield, but that they would if a staff member was symptomatic. During an interview on 6/10/22 at 9:10 A.M., the DON indicated the facility follows the CDC (Centers for Disease Control and Prevention) recommendations for PPE use while testing for COVID-19. CDC guidelines for collecting and handling of clinical specimens for COVID-19 testing, updated 5/18/22, included, Ensure that recommended personal protective equipment (PPE) is worn when collecting specimens. This includes gloves, a gown, eye protection (face shield or goggles), and an N-95 or higher-level respirator . On 6/10/22 at 3:40 P.M., the DON supplied a facility policy titled, Handwashing and Hand Asepsis, dated 2/9/22. The policy included, Specific indications for handwashing . After removing gloves. 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure a bed hold policy was sent with residents being discharged to an acute care facility for 5 of 7 residents reviewed. (Resident 36, Resident 27, Resident 43, Resident 44, Resident 34) Findings include: 1. On 1/25/19 at 10:31 A.M., Resident 36's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 10/26/18, indicated Resident 36 had moderate cognitive impairment. The Progress notes included, but were not limited to: 1/17/19, resident readmitted to facility 12/20/18, resident readmitted to the facility The Discharge Paperwork sent to the hospital with the resident on 1/14/19 lacked a bed hold policy. On 1/25/19 at 12:54 P.M., MRE (Medical Records Employee) provided the discharge paperwork sent with Resident 36 on the 12/16/18 discharge to the hospital. The MRE indicated that it was the complete packet of discharge paperwork. 2. On 1/28/19 at 9:18 A.M., Resident 27's clinical record was reviewed. The Admission MDS (Minimum Data Set) assessment, dated 10/26/18, indicated Resident 27 had moderate cognitive impairment. A form Notice of Transfer or Discharge indicated Resident 27 was transferred to the hospital on [DATE]. The forms sent to the hospital with the resident on 10/1/18 lacked a bed hold policy. 3. On 1/28/19 at 10:31 A.M., Resident 43's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 10/26/18, indicated Resident 43 was cognitively intact. A form Notice of Transfer or Discharge indicated Resident 43 was transferred to the hospital on [DATE]. The forms sent to the hospital with the resident on 10/4/18 lacked a bed hold policy. 4. On 1/28/19 at 10:55 A.M., Resident 44's clinical record was reviewed. The Admission MDS (Minimum Data Set) assessment, dated 10/9/18, indicated Resident 44 had moderate cognitive impairment. A form Notice of Transfer or Discharge indicated Resident 44 was transferred to the hospital on [DATE]. The forms sent to the hospital with the resident on 11/24/18 lacked a bed hold policy. 5. During record review on 1/24/19 at 10:02 A.M., progress notes indicated Resident 34 was admitted to the hospital on [DATE] for shortness of air (SOA) and pneumonia. A Notice of Transfer or Discharge form, dated 1/8/19, was found in Resident 34's medical record. No indication of a bed hold policy being given to Resident 34 (or family) at the time of transfer was found in the medical record. During an interview on 1/28/19 at 9:45 A.M., the Social Service Director indicated that nursing staff should supply a Bed Hold Policy at the time of transfer. On 1/25/19 at 1:01 P.M., the DON and MRE provided the required blank paperwork that was utilized for discharges. The paperwork included the Notice of Transfer or Discharge and Notice of Transfer or Discharge Request for Hearing. The DON and MRE indicated that was the only paperwork they had ever sent with residents being discharged . They further indicated they would speak with the Administrator about the bed hold policy. On 1/25/19 at 1:04 P.M., the MRE provided the bed hold policy and indicated it was only given to residents on admission. On 1/29/19 at 10:17 A.M., the Administrator indicated an entire packet is sent with residents being discharged but the facility only retained a copy of the first page for records per facility policy. On 1/29/19 at 10:21 A.M., the Administrator provided the Discharge/Transfer of the Resident, undated. The Administrator indicated at that time that the Notice of Transfer or Discharge, appeals information, and the Transfer or Discharge Request for Hearing was sent with residents to the hospital. The Administrator further indicated it should have been included in the packet the DON and MRE had provided on 1/25/19. The policy included, but was not limited to: retain copy of forms sent to hospital for the medical record. 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices were maintained during 1 of 2 kitchen observations. The walk-in freezer was found to have 3 boxes of packaged food stored on the floor and the dry storage room was found to have 2 canned food items stored on the floor. Findings include: During a kitchen observation on 1/23/19 at 10:00 A.M., 3 boxes of packaged frozen food were observed being stored on the floor during inspection of the facility's walk-in freezer and 2 canned food items were observed being stored on the floor of the dry storage room. During an interview on 1/28/19 at 12:08 P.M., the dietary manager (DM) indicated that the freezer was full, but food should not be stored on the freezer floor. During an interview on 1/29/19 at 11:00 A.M., the facility Administrator indicated the canned food items were being used by vendors to prop the door open and that a door stop had been supplied to stop the food items from being set on the floor. The Administrator also indicated that the walk-in freezer should be organized in order to fit all stored frozen food without having to store any on the floor. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review the facility failed to ensure dishwasher chemical composition was checked and documented and artificial fingernails were not worn for food preparation for 1 of 2 kitchen observations. (DE 1) Findings include: On 4/15/18 at 10:20 A.M., the kitchen was observed. DE 1 (Dietary Employee) was washing the dishes. DE 1 indicated the dishes were sanitized with a chemicals. DE 1 indicated in order to ensure the chemicals were accurate for proper sanitization she observed the soap dispensers and would add product if needed. DE 1 was observed to have long artificial fingernails. A note was observed to be taped to the wall which indicated the chemical composition needed to be 100 ppm (parts per million). DE 1 indicated she did not know how to check the chemical composition. DE 1 further indicated she only checked to ensure the temperatures of the dishwasher water were accurate On 4/15/18 at 10:55 A.M., the Dietary Supervisor indicated the chemical composition of the dishwasher was tested with special test strips and documented on a form. At that time, DE 2 indicated she had just arrived. DE 2 tested the dishwasher chemical composition and received a reading of 100 ppm. The Dietary Supervisor provided the Dish Machine form. The form indicated, PPM must be 100. Contact Dietary Manager if after 2 attempts you cannot obtain 100 reading The Dish Machine form, lacked a test reading for 4/15/18 at 6:00 A.M. and B (breakfast). On 4/19/18 at 1:38 P.M., the Administrator provided the current Dishwashing policy, undated. The policy included, but was not limited to: Procedure: Chemical Sanitation .PPM must be 100. On 4/19/18 at 1:38 P.M., the Administrator provided the current Infection Control policy, undated. The policy included, but was not limited to: Fingernails are maintained clean and trimmed. Nail polish is not worn. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure Foley Catheters did not touch the floor and Foley catheters were not stored hanging on the trash can for 2 of 2 residents reviewed for urinary catheters. (Resident 37, Resident 40) Findings include: 1. On 4/16/18 at 1:36 P.M., Resident 37 was observed laying in bed. Resident 37's Foley Catheter cover bag was touching the floor. On 4/17/18 at 1:17 P.M., Resident 37 was observed laying in bed. Resident 37's Foley Catheter cover bag was touching the floor. On 4/18/18 at 8:48 A.M., Resident 37 was observed laying in bed. Resident 37's Foley Catheter cover bag was touching the floor. 2. During record review on 4/19/18 at 9:00 A.M., Resident 40's most recent MDS (Minimal Data Set), dated 3/18/18 (Admission assessment), indicated the resident was cognitively intact, required extensive assistance with bed mobility, transfers, walking in room, dressing, and toileting, required limited assistance with personal hygiene, and had a [MEDICATION NAME]. Resident 40's [DIAGNOSES REDACTED]. Care plans for Resident 40 included, but were not limited to, [MEDICATION NAME] due to [MEDICAL CONDITION], potential for complications, assist with toileting tasks, and resident empties [MEDICATION NAME] bag per self at times. Interventions included; change ostomy as ordered, provide [MEDICATION NAME] care as ordered, encourage resident to perform toileting and hygiene care, and use drainage bag at night then leave off during day if desired. physician's orders [REDACTED]. During an observation on 4/15/18 at 12:45 P.M., Resident 40's drainage bag was hanging on the side of the trash can in the resident's room with the base of the bag resting on the floor. During an observation on 4/16/18 at 9:15 A.M. Resident 40 was sitting in a recliner in the resident's room. The resident's [MEDICATION NAME] bag was connected to a drainage bag draining urine. The tubing and drainage bag were resting on the floor next to the recliner. During an observation on 4/17/18 at 10:55 A.M., Resident 40's drainage bag was not connected. The drainage bag and tubing were being stored in bag hanging on the side of a trash can. During an interview on 4/17/18 at 2:13 P.M., CNA 2 indicated Resident 40's [MEDICATION NAME] bag is emptied by connecting the drainage bag. During the night, the drainage bag is left connected. Staff empties the drainage bag and record the output. Both CNA and nursing staff empty the drainage bag. During an interview on 4/18/18 at 1:39 P.M., CNA 2 and CNA 3 indicated Resident 40's drainage bag and tubing should be stored in a bag and hung on the holder next to the resident's recliner. A holder was made to hang the bag and tubing and was put in the room yesterday afternoon. Drainage bags and tubing should be kept off the floor. During an interview on 4/19/18 at 10:54 A.M., RN 2 indicated staff had been working with Resident 40 and provided education about washing hands. Resident 40 will empty the [MEDICATION NAME] bag but will not change the bag. For a while the resident would not care for the [MEDICATION NAME] but is starting to come around. A stand was provided to keep the drainage bag and tubing next to the resident's recliner. During review of Resident 40's progress notes on 4/19/18 at 11:05 A.M., a nurse's note dated 4/11/18 indicated someone would be coming on 4/17/18 to help educate Resident 40 on how to care for [MEDICATION NAME]. The resident stated, I don't care to learn about it because I'm not going to take care of it. A progress note dated 4/19/18 at 7:40 A.M., indicated Resident 40 was able to effectively demonstrate how to care for and clean appliances for [MEDICATION NAME]. Will continue to encourage resident to use aseptic technique when draining the [MEDICATION NAME]. During an interview with Resident 40 on 4/19/18 at 12:40 P.M., the resident indicated that staff had come in and educated regarding [MEDICATION NAME] care and had been completing own [MEDICATION NAME] care for 2 or three days. On 4/19/18 at 1:38 P.M., the Administrator provided the current Catheter Maintenance Procedures, revised in 2006. The policy included, but was not limited to: Ensure bag or tubing is not touching the floor. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure resident assessments were accurate for 1 of 18 resident assessments reviewed during Stage 2. An antianxiety medication was coded incorrectly. (Resident 6) Findings include: On 4/26/17 at 9:31 A.M., Resident 6's clinical record was reviewed. The most recent physician's orders [REDACTED]. The March and April MAR (Medication Administration Record) indicated Resident 6 had received [MEDICATION NAME], as prescribed, from 3/29/17 - 4/4/17. The Quarterly MDS (Minimum Data Set) assessment, dated 4/5/2017, indicated Resident 6 had not received an antianxiety medication during the seven day assessment period. On 4/27/17 at 1:20 P.M., the ADON, who is also the MDS Coordinator, indicated that Resident 6 is receiving [MEDICATION NAME] for anxiety. On 4/26/17 at 1:42 P.M. ADON provided a psychological consult sheet dated 10/9/12 with Klonopin listed as a medication Resident 6 had been receiving. The ADON indicated this was the first documentation of Klonopin they could find and that documentation was lacking in regard to when the physician first ordered Klonopin for Resident 6. On 4/28/17 at 9:00 A.M., the ADON provided the Resident Assessment (Comprehensive Assessment) (Quarterly Assessment) (PPS Assessment) policy, revised 6/11. The policy included, but was not limited to: All assessments will be completed using guideline from the RAI manual (Resident Assessment Instrument). 3.1-31(d)

Based on interview and record review, the facility failed develop comprehensive care plans for 1 of 18 residents reviewed during Stage 2 of the survey. Care plans for behaviors and psychiatric [DIAGNOSES REDACTED]. Findings include: On 4/26/17 at 1:51 P.M., Resident 11's clinical record was reviewed. Resident 11's [DIAGNOSES REDACTED]. The most recent signed physician's recapitulation orders, signed 4/18/17, included, but were not limited to: [MEDICATION NAME] (an anti-anxiety medication) 0.5 mg (milligrams), by mouth, three times daily, for anxiety. The Quarterly MDS (Minimum Data Set) assessment, dated 3/28/17, indicated moderate cognitive impairment. The MDS further indicated Resident 11 had active [DIAGNOSES REDACTED]. A discharge summary note from the behavioral health unit, dated 4/13/17, included, but was not limited to: . referred for inpatient admission because of severe anxiety, attention-seeking, using the call lights a lot, demanding, does not want to leave her room, intrusive, dominating conversations, irritable when room is cleaned and things that are old are removed for safety reasons, hoards food and linen A psychiatric evaluation from the behavioral health unit, dated 3/29/17, indicated Resident 11 had behaviors including, but not limited to: anxiety, depression, hoarding, frequent demands, and attention. The psychiatric evaluation further indicated Resident 11 had symptoms including, but not limited to: interrupted sleep and refusal to socialize. The clinical record lacked care plans for Resident 11's behavior and [DIAGNOSES REDACTED]. On 4/28/17 at 10:25 A.M., the Social Worker indicated he was responsible for care planning behaviors. The Social Worker further indicated Residents who had behaviors had care plans related to the behaviors. On 4/28/17 at 10:32 A.M., the DON provided the Resident Care Plan policy, undated. The policy included, but was not limited to: The results of the comprehensive assessment are used to develop, review, and revise the resident's comprehensive plan of care. 3.1-35(a)

Based on interview and record review, the facility failed to ensure behavior monitoring was in place for 1 of 5 residents reviewed for unnecessary medications. (Resident 11) Findings include: On 4/26/17 at 1:51 P.M., Resident 11's clinical record was reviewed. Resident 11's [DIAGNOSES REDACTED]. The most recent signed physician's recapitulation orders, signed 4/18/17, included, but were not limited to: [MEDICATION NAME] (an anti-anxiety medication) 0.5 mg (milligrams), by mouth, three times daily, for anxiety. The Quarterly MDS (Minimum Data Set) assessment, dated 3/28/17, indicated moderate cognitive impairment. The MDS further indicated Resident 11 had active [DIAGNOSES REDACTED]. A discharge summary note from the behavioral health unit, dated 4/13/17, included, but was not limited to: . referred for inpatient admission because of severe anxiety, attention-seeking, using the call lights a lot, demanding, does not want to leave her room, intrusive, dominating conversations, irritable when room is cleaned and things that are old are removed for safety reasons, hoards food and linen A psychiatric evaluation from the behavioral health unit, dated 3/29/17, indicated Resident 11 had behaviors including, but not limited to: anxiety, depression, hoarding, frequent demands, and attention. The psychiatric evaluation further indicated Resident 11 had symptoms including, but not limited to: interrupted sleep and refusal to socialize. The clinical record lacked behavior monitoring. On 4/27/17 at 10:07 A.M., the Social Worker indicated the facility was not tracking behaviors for Resident 11. The Social Worker further indicated Resident 11 had been readmitted from a behavioral health unit and had been better since readmission. On 4/28/17 at 9:39 A.M., the Social Worker indicated the facility utilized behavior flowsheets to monitor residents with behaviors. On 4/28/17 at 9:48 A.M., Resident 11's family member indicated Resident 11 had a [DIAGNOSES REDACTED]. Resident 11's family member further indicated Resident 11 had been doing well since readmission from the behavioral health unit. This past week the family member noticed Resident 11 had become more negative and was exhibiting attention seeking behaviors. On 4/28/17 at 9:10 A.M., the DON provided the Behavior Management Program, dated 4/3/16. The policy included, but was not limited to: All behaviors incidents will be referred to Social Services via Social Service Alert Form. Social Service Alert Form can and should be completed by any and all staff members witnessing behavior/mood symptoms. 3.1-48(1)(3)

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen and food storage area, active live roaches were present in the main kitchen area and the dry food storage area, for 1 of 2 kitchen observations for 45 of 46 residents who reside at the facility and consume food from the kitchen. Findings include: The following was observed on 8/26/16 at 11:55 a.m. through 12:15 p.m. 1. The main kitchen was toured in the presence of the Food Service Supervisor (FSS). Active live roaches were observed crawling on the electrical cord, the wheels, and the base of the plate lowerator. The lowerator was positioned by the gas range and adjunct to the food prep area. The FSS indicated she had never seen roaches before. Dead roaches were observed under the dish washing area on the floor. The dish washing area was an open front unit where dishes were sprayed off before washing. The shelves of the food prep cabinet were soiled with dried food debris and grease like substance. The open bins used to store the clean ladles, and scoops were soiled on the interiors with a grease like substance and food debris, as well in the ladles of the clean equipment. The floor throughout the kitchen was sticking with debris noted around the baseboards. 2. The dry food storage area was observed in the basement area of the building. A live active roach was observed on the wall near the food storage shelf. Dead roaches and other bugs were noted on the floor of the food storage area. Cob webs were noted on the wall pipes. The Administrator was interviewed at 12:25 p.m. on 8/26/16, regarding the preventative pest management plan. He indicated the company visits two times a month for pest control. On 8/26/16 at 1:00 p.m. the Daily Cleaning Schedules of the kitchen were reviewed, dates included 7/25/16 through 8/25/16. Those schedules were for the AM Cook, AM Aide, PM Cook, and PM Aide. The assignment list included the initials of employee who cleaned each area daily. One assignment included the down stairs store room on 8/25/16, during the evening shift where the dead and live bugs were noted. They did not include any recording of pest activity. None of the assignments addressed the sweeping and/or mopping of the floors, no signatures or initials to indicate the tasks were done was present on the forms. This Federal tag relates to Complaint IN 551. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to have an effective pest control program, live active roaches were observed in the main kitchen and the dry food storage area of the facility for 1 of 2 observations for 45 of 46 residents who reside in the facility and consume food from the kitchen. Findings include: The following was observed on 8/26/16 at 11:55 a.m. through 12:15 p.m. 1. The main kitchen was toured in the presence of the Food Service Supervisor (FSS). Active live roaches were observed crawling on the electrical cord, the wheels, and the base of the plate lowerator. The lowerator was positioned by the gas range and adjunct to the food prep area. The FSS indicated she had never seen roaches before. Dead roaches were observed under the dish washing area on the floor. The dish washing area was an open front unit where dishes were sprayed off before washing. 2. The dry food storage area was observed in the basement area of the building. A live active roach was observed on the wall near the food storage shelf. Dead roaches and other bugs were noted on the floor of the food storage area. Cob webs were noted on the wall pipes. The Administrator was interviewed at 12:25 p.m. on 8/26/16, regarding the preventative pest management plan. He indicated the company visits two times a month for pest control. The pest control contract and visit forms were provided by the Administrator on 8/26/16 at 1:00 p.m. The billing voucher for each visit only identified treatment was completed, it did not identify the area treated or if pests were observed prior to treatment. The facility was billed twice monthly for August, July and June 2016. The pest control contract was signed 9/29/03, it included the following Treatment includes general pest and rodent control, exterior and interior (and spider web removal for exterior). This Federal tag relates to Complaint IN 551. 3.1-19(f)(4)

Based on observation, interview, and record review, the facility failed to ensure effective behavior management was provided to a resident who experienced anxiety for 1 of 1 resident who met the criteria for review of social services. (Resident #13) Findings include: During a observation on 3/1/16 at 3:00 P.M., Resident #13 was observed sitting in a recliner in no apparent distress. The clinical record of Resident #13 was reviewed on 3/3/16 at 10:00 A.M. The record indicated the [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #13 experienced moderate cognitive impairment, no behaviors, and received anti-anxiety medication 0/7 days during the assessment period. The February 2016 Physicians Order Recap included, but was not limited to orders for, .Ativan (an anti-anxiety medication) 0.5 mg (milligrams) 1 tab by mouth 3 times daily as needed for severe anxiety or seizure activity . A Care Plan dated 1/26/16 for, .I have potential for feeling nervous and fidgety related to DX (diagnosis) Anxiety .Have had no anxiousness since admission included the following interventions: 1. Converse daily during care and in passing to monitor mood. 2. Encourage her to vent any anxious feelings as needed. 3. Provide Lorazepam (Ativan) per MAR (Medication Administration Record) 4. Monitor for S/E (side effects) 5. Report sudden (arrow up) (increase) anxiety to physician . 6. Attempt drug reduction per NH (Nursing Home) guidelines The plan of care lacked any documentation related to the attempt of non-pharmacologic interventions prior to the administration of the prn (as needed) anti-anxiety medication. The February 2016 MAR (Medication Administration Record) indicated Resident #13 was administered Ativan (an anti-anxiety medication) 0.5 mg (milligrams) 13 times for anxiety. The MAR lacked any documentation to indicate non-pharmacologic interventions were attempted prior to the administration of the prn anti-anxiety medication. The Nursing Progress notes dated 2/3/16 at 9:30 A.M. through 3/1/16 (no time indicated) were reviewed and lacked any documentation to indicate non-pharmacologic interventions were attempted prior to the administration of the prn anti-anxiety medication. The February 2016 Behavior Management Log lacked any documentation to indicate a Behavior Plan had been developed for Resident #13. The Social Service Progress notes from 1/26/16 through 2/29/16 were reviewed and lacked any documentation to indicate Resident #13 experienced anxiety. During an interview on 3/3/16 at 3:00 P.M. the SSD (Social Service Designee) indicated the Social Service staff was responsible to develop behavior plans. The SSD further indicated Social Service staff had worked closely with the family of Resident #13 to identify the root cause of the anxiety but, no documentation could be provided to indicate a specific, individualized behavior plan had been developed. The Policy and Procedure for Behavior Management provided by the DON (Director of Nursing) on 3/3/16 at 3:15 P.M. indicated, .The facility considers resident behavior problematic when: The behavior presents a risk of danger or harm to the resident or others .The behavior significantly reduces the staff's ability to provide care .The behavior is disruptive to others The Policy lacked any documentation to indicate a behavior plan should be implemented if a behavior affects the psychosocial well-being of a resident. 3.1-34(a)(1)

Based on observation, interview, and record review, the facility failed to ensure an anti-anxiety medication was clinically indicated for 1 of 5 residents who met the criteria for review of unnecessary medications. (Resident #13) Findings include: During a observation on 3/1/16 at 3:00 P.M., Resident #13 was observed sitting in a recliner in no apparent distress. The clinical record of Resident #13 was reviewed on 3/3/16 at 10:00 A.M. The record indicated the [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #13 experienced moderate cognitive impairment, no behaviors, and received anti-anxiety medication 0/7 days during the assessment period. The February 2016 Physicians Order Recap included, but was not limited to orders for, .[MEDICATION NAME] (an anti-anxiety medication) 0.5 mg (milligrams) 1 tab by mouth 3 times daily as needed for severe anxiety or [MEDICAL CONDITION] activity . A Care Plan dated 1/26/16 for, .I have potential for feeling nervous and fidgety related to DX (diagnosis) Anxiety .Have had no anxiousness since admission included the following interventions: 1. Converse daily during care and in passing to monitor mood. 2. Encourage her to vent any anxious feelings as needed. 3. Provide [MEDICATION NAME] ([MEDICATION NAME]) per MAR (Medication Administration Record) 4. Monitor for S/E (side effects) 5. Report sudden (arrow up) (increase) anxiety to physician . 6. Attempt drug reduction per NH (Nursing Home) guidelines The plan of care lacked any documentation related to the attempt of non-pharmacologic interventions prior to the administration of the prn (as needed) anti-anxiety medication. The February 2016 MAR indicated [REDACTED] .2/3/16 .5:10 P.M crying et (and) c/o (complaint of) (arrow up) anxiety . The MAR indicated [REDACTED]. .2/7/16 .2000 (8:00 P.M.) .c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/9/16 .6:15 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/10/16 .8:45 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/13/16 .8:30 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/15/16 .8:40 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/16/16 .11:00 A.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/22/16 .8:30 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/23/16 .11:30 A.M req (request) for anxiety . The MAR indicated [REDACTED]. .2/23/16 .8:30 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/24/16 .2000 (8:00 P.M) c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/26/16 .5:20 P.M c/o (arrow up) anxiety . The MAR indicated [REDACTED]. .2/29/16 .2000 (8:00 P.M.) .c/o (arrow up) anxiety . The MAR indicated [REDACTED]. The Nursing Progress notes dated 2/3/16 at 9:30 A.M. through 3/1/16 (no time indicated) were reviewed and indicated the following: The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/3/16 at 5:10 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/7/16 at 8:00 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/9/16 at 6:15 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/10/16 at 8:45 P.M. A Nursing Progress note dated 2/13/16 at 8:30 P.M. indicated, .no [MEDICAL CONDITION] activity. Pt. (patient) voiced c/o being anxious et req an [MEDICATION NAME] (sic) given as ordered . The note lacked any documentation related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/15/16 at 8:40 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/16/16 at 11:00 A.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/22/16 at 8:30 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/23/16 at 11:30 A.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/23/16 at 8:30 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/24/16 at 8:00 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/26/16 at 5:20 P.M. The notes lacked any documentation to indicate Resident #13 experienced anxiety/[MEDICAL CONDITION] activity or related to the attempt of non-pharmacologic interventions prior to the administration of the prn anti-anxiety medication on 2/29/16 at 8:00 P.M. The Social Service Progress notes from 1/26/16 through 2/29/16 were reviewed and lacked any documentation to indicate Resident #13 experienced anxiety. A Physician's Consult report dated 2/23/16 indicated, .Mental status exam performed with findings of .Oriented X3 with appropriate mood and affect. A Social Service Progress note dated 3/3/16 was provided by the DON (Director of Nursing) on 3/4/16 at 10:30 A.M. The note indicated, .shows moderate cognitive impairment .has used PRN [MEDICATION NAME] most daily past 2 weeks .SSD (Social Service Designee) has added some new interventions to this care plan to try so as not to use this medication as frequently . The Policy and Procedure for Administration of PRN [MEDICAL CONDITION] Medications provided by the DON on 3/3/16 at 3:15 P.M. indicated, .Prior to administration of a PRN [MEDICAL CONDITION] .the nurse must proceed as follows: .Attempt to identify cause of behaviors .Implement interventions that are specified on residents individual care plan . During an interview on 3/4/16 at 11:00 A.M. the DON indicated no further documentation could be provided to indicate non-pharmacologic interventions had been attempted prior to the administration of prn [MEDICATION NAME] on 2/3/16, 2/7/16, 2/9/16, 2/10/16, 2/13/16, 2/15/16, 2/16/16, 2/22/16, 2/23/16 at 11:30 A.M., 2/23/16 at 8:30 P.M., 2/24/16, 2/26/16, or 2/29/16. The DON further indicated, at that time, it was the usual practice of the facility to administer prn anti-anxiety medication only if clinically indicated. 3.1-48(a)(2) 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure a surety bond had been secured for the facility's resident personal funds account for 1 of 1 facility insurance policy reviewed. This had the potential to affect 43 of 43 residents who resided at the facility. Findings include: On 1/30/15 at 10:15 A.M., Licensed Practical Nurse #5 who managed the resident personal fund account at the facility was interviewed. LPN #5 indicated, at that time, the total resident fund account amount was $12,673.74. On 1/30/15 at 12:45 P.M., the Administrator provided documentation entitled "GUIDE ONE Insurance Building And Personal Declarations." The effective date of the policy was 6/1/14 with an expiration date of 6/1/15. The Administrator indicated the facility had in previous years had a surety bond policy but, now had the above policy which had replaced the facility surety bond. On 1/30/15 at 12:52 P.M., the Administrator provided a document from (Name of insurance) 1/30/15. The documentation included, but was not limited to, "This is to confirm that the employee dishonesty insurance for GC (Gentle Care) Healthcare Services, policy (numbers), effective 6/1/2014 to 6/1/2015, with (name of insurance), replaces a surety bond, and covers employee handling of resident's personal funds..." On 2/2/15 at 2:15 P.M., the Administrator was made aware documentation was lacking of a facility surety bond in regard to the resident personal fund account. The Administrator indicated, in the past the facility had a surety bond for $50,000 for personal funds, but now that policy had changed. On 2/2/15 at 2:15 P.M., the Administrator provided a facility policy entitled, "RESIDENT FUNDS (Revised 1/19/98)." The Administrator indicated the resident fund policy lacked documentation in regards to a surety bond. 3.1-6(j)

Based on interview, and record review, the facility failed to ensure the physician was notified timely in regards to a change of condition, in that, a change in a surgical wound condition was not reported to a physician for 38 hours following the onset of the change for 1 of 3 residents reviewed for hospitalization . (Resident #64) Findings include: The clinical record for Resident #64 was reviewed on 1/28/15 at 2:04 P.M., [DIAGNOSES REDACTED]. A nursing note dated 10/11/14 at 11:30 P.M., included, "...Pt having thin blood tinged drainage coming from bottom of sternal incision line. Unable to visualize opening in incision line. Skin next to incision is pink on both sides ... " A nursing note dated 10/12/14 at 2:00 A.M., included, "Pt again called this nurse to room. Drsg (dressing) saturated ... " A nursing note dated 10/12/14 at 8:30 A.M., included, "...Dressing saturated (2 folded 4x4's) that was (changed) @ (at) 7AM... " A nursing note dated 10/13/14 at 1:55 P.M., (38 hours following change in wound condition), included, "phoned (Name of surgeon) office... " The care plans include, but were not limited to, "I had recent heart surgery and have an incision initiated on 10/14. The interventions included, but were not limited to, "treatment as ordered, monitor for any redness, drainage, warmth, and report to medical doctor as warranted." During an interview on 01/30/2015 at 10:40 A.M., Licensed Practical Nurse #3 indicated any change in condition of a wound was to be reported as soon as possible to the physician. On 2/2/15 2:50 P.M., during an interview with the Director of Nursing she indicated documentation was lacking a physician had been notified of the change in Resident #64's wound condition prior to 10/13/15 at 1:55 P.M. A policy dated 9/10/10 titled "DRESSING CHANGE (Clean) " was reviewed on 1/30/15 at 12:54 P.M., it included, "...20. Notify physician and family of any unusual findings." 3.1-5(a) (2)