Every finding on record at Hubbard Hill Estates Inc

Based on interview and record review, the facility failed to transfer 1 of 2 residents reviewed for sit-to-stand mechanical lift transfers safely. (Resident 58)Finding includes:During an interview on 12/9/2025 at 2:15 P.M., Resident 58's representative indicated the resident had fallen from the lift while transferring with the assistance of staff in September 2025. Resident 58's record review was completed on 12/10/2025 at 10:30 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, generalized osteoarthritis and adjustment disorder. A Quarterly Minimum Data Set (MDS) assessment, completed on 10/30/2025, indicated Resident 58 was dependent on staff for chair to bed transfers. A Therapy Progress Note, dated 6/24/2024, indicated Resident 28 was accessed and required the use of a sit-to-stand lift transfer for safety.A current Physician's order, dated 6/24/2024, indicated Resident 28 was to be transferred by staff using a sit-to-stand lift. A Nursing Progress Note, dated 9/7/2025 at 10:04 P.M., indicated the Nurse had been notified by a CNA that while the CNA had been using the sit-to-stand lift to assist Resident 58 with transferring from her wheelchair to bed, the resident's legs had become weak and had given out. The CNA indicated she had lowered the resident to the floor and the resident had remained on the floor.An Event Report, dated 9/19/2025 at 2:47 P.M., indicated the investigation into Resident 58's fall concluded the employee transferring the resident had not followed the facility's policy requiring two employees to operate the sit-to-stand lift while transferring residents.During an interview on 12/11/2025 at 11:07 A.M., the Director of Nursing (DON) indicated the employee assisting Resident 58 transferred the resident incorrectly because the facility required two staff members to be present while operating the sit-to-stand lift. On 12/15/2025 at 11:45 A.M., the DON provided an undated policy tilted, [NAME] Hill Estates Guidelines for Proper Use of the Mechanical Lifts and identified the policy as the one currently used by the facility. The policy indicated, .Two staff members will be present during any mechanical lift transfer for the safety of the resident and staff members 3.1-45(a)

Based on observation, record review, and interview, the facility failed to provide proper storage of oxygen accessories for 1 of 3 residents reviewed for oxygen. (Resident 11) Finding includes: During an observation on 9/6/2024 at 9:10 A.M., Resident 11's nasal cannula tubing, attached to the oxygen concentrator, was wrapped around the bedrail. During an observation on 9/10/2024 at 9:12 A.M., Resident 11's nasal cannula tubing, attached to the oxygen concentrator, was on the floor between the bed and the recliner. During an observation on 9/10/2024 at 11:06 A.M., Resident 11's nasal cannula tubing, attached to the oxygen concentrato,r was draped over the arm of the recliner. A record review for Resident 11 was completed on 9/9/2024 at 10:54 A.M. Diagnoses included, but were not limited to: asthma, acute respiratory failure and congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 7/17/2024, indicated Resident 11 used oxygen therapy. A Physician's Order, dated 11/23/2024, indicated oxygen was to be used at 2 liters per nasal cannula as needed. A Care Plan, with an effective date of 5/11/2023 to present, indicated Resident 11 was not able to maintain oxygen saturations and received supplemental oxygen. During an interview, on 9/10/2024 at 11:00 A.M., CNA 8 indicated the nasal cannula tubing should be stored in a respiratory bag when not in use. A policy was provided, on 9/10/2024 at 12:59 P.M. by the Director of Nursing. The policy titled, Use of Oxygen, indicated, .The following guidelines will be observed in oxygen administration .II. The tubing should be kept off the floor 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a resident was able to withdrawal her money on weekends and evenings for 1 of 1 resident reviewed for personal funds. (Resident 31) Finding includes: During an interview, on 9/4/2024 at 3:06 P.M., , Resident 31 indicated she was unable to get her money out of her account on the weekends or evenings. The record for Resident 31 was completed on 9/9/2024 at 11:05 A.M. Diagnoses included, but were not limited to: depression, hemiplegia, diabetes and vascular dementia. During an interview, on 9/10/2024 at 9:57 A.M., the Business office manager indicated the residents could get money out of their personal fund accounts from 7:30 A.M. to 8:00 P.M., when someone was working at the front desk. After 8:00 P.M. the money was locked up in a safe in the office and was not assessable to the residents. During an interview, on 9/10/20 at 10:11 A. M., the Administrator indicated the residents can get their money when the receptionist was at the front desk, between 7:30 A.M. to 8:00 P.M. She indicated they should have been able to get their money out at any time of the day or night. On 9/10/2024 at 11:08 A.M., the Administrator provided a policy titled,Availability of Resident Funds-After Business Office, dated 2018, and indicated the policy was the one currently used by the facility. The policy indicated . It is the policy of this facility to provide residents reasonable access to their personal funds after business office hours 3.1-6(f)(1)

Based on interview and record review the facility failed to have a care plan for a skin issue for 1 of 3 residents reviewed for skin. (Resident 18) Finding includes: During an interview, on 9/6/2023 at 1:27 P.M., Resident 18 indicated he had an area to his right toe. A record review was completed on 9/07/2023 at 11:34 A.M. Resident 18's diagnoses included, but were not limited to: fractured left leg, dysphagia, hypertension, diabetes, obstructive and reflux uropathy. A 5-day MDS (Minimum Data Set) assessment, dated 8/17/2023, indicated the resident required extensive assist of one staff for bed mobility, toilet use, dressing and two assist for transfers. A Nurses Note, dated 6/13/2023, indicated a scab was found during weekly skin assessment. Measured 1.2 x 2 cm (centimeters). Family notified and MD notified. No new orders to care for this site. A Nurse's Note, dated 6/16/2023, indicated Resident 18 was receiving therapy when the therapist found the wound to his toe. New order received for skin prep to resident's skin area on the Right 2nd toe. Area is scabbed over and there are no signs/symptoms of infection to this area. A Physician's order, dated 6/27/2023, included skin prep to the right 2nd toe three times a day, and notify the wound nurse if the area worsens or open. A Nurse's Note, dated 8/30/2023, indicated Resident 18 received doxycycline hyalite (antibiotic) 100 mg (milligram) capsule 2 times daily for right 2nd toe infection. A Physician's order, dated 8/30/2023, indicated to cleanse area to the toe with NS (normal saline), apply bacitracin (antibiotic ointment) and a dry dressing every day. The record lacked a care plan for the skin issue to the toe. During an interview, on 9/07/2023 at 2:17 P.M., the Infection Preventionist indicated there should have been a care plan. On 9/11/2023 at 12:45 P.M., the Director of Nursing provided the policy titled, Care Plan, dated November 2017, and indicated the policy was the one currently used by the facility. The policy indicated . 3. Each resident's Comprehensive Person Centered Care Plan has been designed to: a. Incorporate identified problem areas . 6. Care plans are revised as changes in the resident's condition dictate On 9/11/2023 a 12:45 P.M., the Director of Nursing provided the policy titled Wound Care/Treatment Guidelines, undated, and indicated the policy was the one currently used by the facility. The policy indicated . XIV. The care plan should reflect the current status of the wound and appropriate goals 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented related to fanning dry skin after cleansed with alcohol for 1 of 1 Accucheck (blood glucose level) observed and not wearing gloves for 1 of 1 insulin injections observed. (RN 4) Finding includes: During an observation of an Accucheck, on 9/11/2023 at 11:08 A.M., RN 4 put on gloves and cleansed Resident 49's right middle finger with an alcohol wipe. After cleaning the area, RN 4 used an open hand to fan the area she had just cleansed and then used a lancet to poke the skin that had been fanned dried. During an observation of an insulin injection, on 9/11/2023 at 11:12 A.M., RN 4 cleaned the left lower quadrant of Resident 49's abdomen and administered insulin without wearing gloves. During an interview, on 9/11/23 at 11:17 A.M., RN 4 indicated that she shouldn't have fanned the skin dry after cleaning and that she should have been wearing gloves while giving an injection. A policy titled Specific Medication Administration Procedures, dated 7/31/2017 and updated on 11/1/2017, was provided by the Director of Nursing, on 9/11/2023 at 12:45 P.M., and indicated the policy was the one currently used by the facility. The policy indicated .To administer medications via subcutaneous, intradermal and intramuscular routines in a safe, accurate, and effective manner .Equipment .E. Examination gloves .Gather supplies .gloves, alcohol wipes .Put on gloves .Inject medication .Remove & discard gloves. Clean hands by washing or using sanitizer . A 4/2019 policy titled, Blood Glucose Monitoring, and identified as the policy currently used by the facility was provide by the Director of Nursing, on 9/11/2023 at 12:45 P.M. The policy indicated, .7. Clean the intended site with an alcohol pad and allow to dry completely . 3.1-18(a)

Based on observation, record review and interview, the facility failed to ensure food was prepared and served in a sanitary manner in both the main kitchen and the healthcare kitchen. This deficient practice potentially affected 61 of 61 residents. Findings include: 1. During a sanitation tour of the main kitchen, located in the Assisted Living side of the facility, conducted on 6/20/2022 between 9:45 A.M. - 10:05 A.M., the following was noted: The regular oven and the convection oven had a build up of burnt food debris in the bottom and the convection oven doors had a heavy buildup of a brown greasy residue. The large, rolling plastic flour and sugar bins had splatters of a dried yellow substance and a gritty residue on the outsides and lids. The inside bottom of a reach in refrigerator had a dried light brown substance and a heavy accumulation of food crumbs. There was also a dried red residue noted on the outer lip of the bottom. The bottom of the warming/holding cabinet was very dirty with food debris/crumbs. During an interview with the Food Service Supervisor, during the sanitation tour, he indicated the stoves were to be cleaned every other week and the flour and sugar bins were to have been cleaned the past weekend. He also indicated some of the food served in both the assisted living and healthcare dining rooms were prepared in the main kitchen. 2. During an observation of the healthcare kitchen, conducted on 6/22/2022 at 9:52 A.M., the following was noted: The air vent above the reach in refrigerator had a heavy accumulation of dark colored dust. Three of 5 food scoops, put away as clean, had dried food substances on them 3. During observation of the lunch meal service, in the healthcare kitchen, conducted on 6/22/2022 from 11:10 A.M. - 11:40 A.M., the following was noted: The cook donned a pair of disposable gloves, after washing his hands. He then, with his gloved hands, sorted through a stack of food order paper tickets, touched handles of serving scoops, ladles and tongs, the bottoms of clean plates, plastic plate covers the counter attached to the steam table and then placed a few slices of roast beef onto the attached counter. With his contaminated, gloved hands, the cook them placed his gloved hand directly on top of the meat to position it, while he utilized a knife to chop the meat into bite size pieces. The cook then, after scooping the meat onto a plate for service, removed his gloves and washed his hands. After donning a clean pair of disposable gloves, the cook continued to touch various items in the kitchen with his gloved hands, such as paper tickets, plates, handles of scoops, ladles and tongs, the counter attached to the steam table, a steam table pan lid and then was observed to grab a loaf of bread. After opening the bread plastic bag, the cook reached into the bag and removed two slices of bread with his contaminated gloved hands and proceeded to touch the bread while he prepared a peanut butter and jelly sandwich for a resident. During an interview with the Assistant Food Service Supervisor, Employee 7, just after the noon meal observation, on 6/22/2022 at 11:45 A.M., she indicated she would review food handling with the cook. Review of the facilities current policy and procedure, titled, Dietary Services provided by the Director of Nursing on 6/24/2022 at 9:25 A.M. included the following: .1. Proper Food Handling C. Foods are prepared and served with clean tongs, scoops, spatulas or other suitable implements to avoid manual contact of prepared foods Review of the facilities current policy and procedure, titled, Dining Services Policy and Procedure Manual, provided by the Director of nursing on 6/24/2022 at 9:15 A.M., included the following .Follow the standards below to maintain clean equipment and work areas 7. Ovens a. All racks and drip trays are debris and grease free with no visible buildup of grease. b. Interior of oven is free of debris and grease, no carbonized grease. c. Doors, hinges an handles are free of grease and debris. d. Glass is clean .12. Hot Boxes/Warming Cabinets .b. Interior and exterior are smooth to the touch and free of grease build up .Refrigerators/Freezers .c. Walls, ceiling, and floors should be free of ice, stains, spots food, drippings and debris .k. Upright refrigerators and freezers clean and free of dirt and food build up inside and out 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to provide appropriate catheter care and failed to ensure the catheter drainage tubing tip was covered when not in use for 1 of 1 residents reviewed for catheter use. (Resident 25) Finding includes: During a random observation on 6/20/2022 at 3:07 P.M., Resident 25's catheter drainage tubing was dragging the floor. During an observation, on 6/20/2022 at 12:35 P.M., Resident 25 was being pushed in the wheelchair back to his room with the catheter drainage tubing dragging the floor. A clinical record review was completed on 6/22/2022 at 1:21 P.M. Resident 25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change MDS (Minimum Data Set) assessment, dated 6/20/2022 indicated Resident 25 was severely cognitive impaired, required extensive assist of 2 staff for bed mobility, transfer and toilet use, and used a Foley catheter. A Nurses' Note, dated 6/10/2022, indicated an aide informed a nurse that Resident 25's Foley was split in half. Physician was notified and stated to send to ER. A Nurses' Note, dated 6/10/2022, indicated Resident 25 was admitted to hospital with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Catheter was removed/replaced in ER without difficulty. On 6/24/2022 at 9:50 A.M., CNA (Certified Nursing Assistant) 3 was observed to provide catheter care to Resident 25. CNA 3 washed her hands and applied gloves. She then informed the resident what she was going to do. She removed the covers from the residents chest and peri area down to below the knees. She unfastened the brief on both sides, then washed from the tip of the penis down the Foley catheter and away from the opening. She dried the area and without removing her gloves, she then reapplied the brief, moved the covers onto the residents body, then used the bed control to put the bed in a lower position. She then took the supplies in the bathroom with the same gloves still on. During an interview, on 6/24/2022 at 10:00 A.M., CNA 3 indicated she should have removed her gloves and washed her hands after providing catheter care. On 6/24/2022 at 10:01 A.M., the catheter drainage bag was in a plastic bag hanging off the hand rail with the tip of the drainage tubing sticking out of the bag with the tip not covered. During an interview, on 6/24/2022 at 10:02 A.M., the Director of Nursing indicated the tubing tip should have been covered. On 6/24/2022 at 9:45 A.M., Unit Manager 6 provided the policy titled, Urinary Leg Drainage Bags, dated 9/1/2012, and indicated the policy was the one currently used by the facility. The policy indicated .General Guidelines: 1. Every attempt should be made to maintain a closed urinary drainage system. 2. The regular Foley drainage bag may be reconnected only if it appears that the integrity of the system has been maintained. Steps in the procedure: .7. Place the cover over the connection tip of the Foley drainage bag On 6/24/2022 at 11:05 A.M., Unit Manager 6 provided the policy titled,Catheter Care, dated March 2021,and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Guidelines: . 5). Assist resident to a lying position or the most comfortable position. 6). Drape resident to expose only the perineal area. 7). Perform hand hygiene. 8). Don gloves. Both: 1).Bag and gather supplies used, discarding disposable items in the trash can. 2). Assist the resident to a comfortable appropriate position. 3). Ensure call light is within reach. 4). Return room back to original order. 5). Perform hand hygiene. 3.1-41(a)(2)

Based record review, observation and interview, the facility failed to ensure proper infection control practices were implemented related to lack of handwashing during wound care for 1 of 1 nurses observed for wound care. (LPN 3) Findings include: On 4/16/2021 from 10:48 A.M. to 11:00 A.M, an observation of wound care/dressing change on Resident 53's right buttocks was conducted with LPN (licensed Practical Nurse) 3 and Unit Manager 4. LPN 3 washed her hands and applied clean gloves. LPN 3 removed the old dressing to the buttocks then removed her gloves. LPN 3 applied new gloves and cleaned the area with a wet gauze pad. LPN 3 removed her gloves and without washing her hands, applied new gloves. LPN 3 then placed [MEDICATION(S)] (wound paste) to another gauze pad and placed it in the open area on the right buttocks and covered the area with a dressing. LPN 3 removed her gloves and exited the residents' room. During an interview, on 4/16/2021 at 10:40 A.M., LPN 3 indicated she should have washed her hands after removing the old dressing and in between applying new gloves. On 4/20/2021 at 11:53 A.M., the Director of Nursing provided the policy titled. Wound Care Procedure, revision date 2017, and indicated the policy was the one currently used by the facility. The policy indicated . D. Wash your hands.G. Put on gloves. H. Remove the soilled dressing and place in bag at the bedside. I. Remove gloves and discard in the bag.K. Wash your hands. L. Put on clean gloves. M. Clean the wound according to the order. Clean from the center outward.O. Remove gloves and place in bag. P. Wash your hands. Q. Put on new gloves. R. Apply new dressing as ordered. S. Remove gloves and place in bag.W. wash your hands 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure infection prevention procedures regarding personal protective equipment (PPE) to prevent the potential spread of COVID-19 according to current Centers for Disease Control (CDC) guidelines were being followed by 8 of 16 employees observed. (Employees 1, 2, 3, 4, 5, 7, 8, 11) Findings include The facility provided guidance from the Indiana Health Care Association (IHCA) titled Eye Protection Guidance for Long-Term Care Facilities-IHCA, and indicated this was what they followed. The guidance stated ISDH is recommending the use of eye protection as a standard safety measure to protect long-term care health care personnel (HCP) who provide essential direct care within six (6) feet of a resident. During observation and interview on 12/21/2020 at 2:00 P.M., 4 staff were observed to not have eye protection on; at that time the Director of Nursing (DON) indicated the facility had only a green zone so staff did not need to wear eye protection. During observation on 12/21/2020 at 2:34 P.M., the following employees failed to be wearing eye protection: Employees 1, 2, 3, 7, 8, and 11; and the following employees wore their N95's with just one strap over their heads and the bottom straps hanging down off of their chins: Employees 2 and 11. During observation on 12/21/2020 at 2:38 P.M., the following employees failed to be wearing eye protection: Employees 4 and 5. During an interview on 12/21/2020 at 3:08 P.M., the facility Infection Preventionist (IP) indicated the policy is to wear goggles or a faceshield, and that staff are not to be wearing their N95's using only 1 strap. During an interview on 12/21/2020 at 3:30 P.M., the DON indicated they did not realize the staff still had to wear eye protection in the green zone, and they followed the IHCA guidance. 3.1-18(b)(2)

Based on record review and interview, the facility failed to implement an infection control surveillance tracking program which included the monitoring for culture results, signs and symptoms of infections, dose/duration of antibiotic use and resolved dates. This deficient practice had the potential to affect all residents residing in the facility. Finding includes: The Infection Control Surveillance book was reviewed on 4/25/19 at 1:00 P.M. The Infection Log, dated 1/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. The Infection Log, dated 2/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. The Infection Log, dated 3/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. The Infection Log, dated 4/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. During an interview on 4/25/19 at 2:39 P.M., the Infection Control Nurse indicated the facility should have been monitoring and documenting the cultures of new admissions and facility acquired infections, signs and symptoms of infections, dose and duration of antibiotic use and resolved dates of infections. On 4/25/19 at 3:00 P.M., the Infection Control Nurse provided the Infection Prevention and Control Program policy, dated 11/2017, and indicated this was the polciy currently being used by the facililty. The policy indicated the goal of the Infection Control Program was to monitor for occurrence of infection and implement appropriate control measures in accordance with the Antibiotic Stewardship Program. The major activities of the program were: surveillance of infections, implementation of control measures and prevention of infection. 3.1-18(b)(1)

Based on record review and interview, the facility failed to implement an Antibiotic Stewardship Program which monitored antimicrobial use for appropriate [DIAGNOSES REDACTED]. This deficient practice had the potential to affect all residents residing in the facility. Finding includes: The Infection Control Surveillance book was reviewed on 4/25/19 at 1:00 P.M. The Infection Log, dated 1/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. The Infection Log, dated 2/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. The Infection Log, dated 3/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. The Infection Log, dated 4/2019, had missing information for positive cultures for new admissions and/or facility acquired urinary tract infections, signs and symptoms of infections, dose and durations of antibiotic use and resolved dates for other sources of infections. During an interview, 4/25/19 at 2:39 P.M., the Infection Control Nurse indicated there had been no discussions with the Pharmacy consultant and/or physicians in regards to antibiotic use or an antibiotic use protocol. On 4/25/19 at 3:00 P.M., the Antibiotic Stewardship policy was requested and the Infection Control Nurse indicated the facility did not have one.

A. Based on observation, record review, and interview, the facility failed to ensure ice cream tubs were labeled with an open date and expired baked goods were removed from shelves. This deficient practice had the potential to affect 56 of 56 resident's who reside in the facility. B. Based on observation, record review and interview, the facility failed to ensure food was served in a sanitary manner for 1 of 2 dining rooms of the facility. This deficient practice had the potential to affect all residents who eat their meals in the dining room. Finding includes: A. On [DATE] at 11:15 A.M., a tour of the kitchen was conducted with the Executive Director of the facility and Dietary Employee 1. The following was observed: In the serving freezer 7 gallon tubs of opened ice cream had an undocumented open date. In the bread cart 1 package of hoagie buns had an expiration date of [DATE], 4 packages of hamburger buns had an expiration date of [DATE]. During an interview with Dietary Employee 1, at this time, he indicated the ice cream should have been labeled with an open date and the bread should have been pulled off the shelf and returned to the bread man. On [DATE] at 12:31 P.M., the Dietary Manager provided a copy of the policy titled, Labeling and Dating, with an effective date of ,[DATE]. The policy, indicated . Food products shall be labeled with received or use by date as appropriate to product and process stage 1. Upon receipt .a. All refrigerated, frozen and dry food products are dated with month and year of receipt .2. Upon removal from freezer B. During an observation, on [DATE] from 11:48 A.M. to 12:12 P.M., the following staff were visualized placing their thumbs on the eating surface of residents' plates and bowls. 11:48 A.M.- wait staff 6 was observed placing a thumb on the eating surface of a plate 11:55 A.M.- wait staff 6 was observed placing a thumb on the eating surface of 3 plates 12:03 P.M.- wait staff 7 was observed placing a thumb on the eating surface of 2 plates 12:05 P.M.- wait staff 6 was observed placing a thumb on the eating surface of 3 plates 12:07 P.M.- wait staff 6 was observed placing a thumb on the eating surface of 2 plates 12:10 P.M.- wait staff 8 was observed placing a thumb on the eating surface of 3 plates 12:12 P.M.- wait staff 7 was observed placing a thumb on the eating surface of 3 plates 12:13 P.M.- wait staff 6 was observed placing a thumb the on eating surface of a plate On [DATE] at 12:15 P.M., during an interview with the Dietary Supervisor, she indicated food should be served with the plate lying on the palm of the hand and the fingers of the server at the very edge of the plate without touching the plate or food. On [DATE] at 12:23 P.M., 2 policies were provided by the Dietary Supervisor. Neither policy addressed how food should be carried to the resident before it is served. 3XXX,[DATE] (i)(3)

Based record review and interview, the facility failed to provide residents with up to date information on the pneumococcal vaccine as indicated in the recommendations from the CDC (Center for Disease Control) for 4 of 4 residents reviewed for pneumococcal vaccines. (Residents 56, 55, 8 & 53) Finding includes: The pneumococcal consents for Residents 56, 55, 8 & 53 were reviewed on 4/26/19 at 11:57 A.M. The consents provided indicated it was the policy of the facility to provide immunization against pneumococcal disease in accordance with the recommendations established by the U.S. Center for Disease Control and Prevention. Vaccination was strongly recommended for all individuals [AGE] years of age and older, those with chronic health problems, and residents of extended care facilities and facility staff. Revaccination varies depending on age and on other factors. Those vaccinated prior to age 65, with chronic disease, should be vaccinated at age 65 if more than 5 years elapsed since the previous dose. During an interview, on 4/26/19 at 12:30 P.M., the DON (Director of Nursing) indicated the facility was unaware of the updated recommended vaccinations for pneumococcal for the CDC. The CDC Morbidity and Morality Weekly Report, dated 9/19/14, indicated that the ACIP (Advisory Committee on Immunization Practices) recommends both PCV13 and PPSV23 should be administered routinely in series to all adults aged [AGE] years. Adults aged [AGE] years who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23. The dose of PPSV23 should be given 6 -12 months after a dose of PCV13. If PPSV23 cannot be given during this time window, the dose of PPSV23 should be given during the next visit. The two vaccines should not be coadministered, and the minimum acceptable interval between PCV13 and PPSV23 is 8 weeks. Adults aged [AGE] years who have previously received 1 dose of PPSV23 also should receive a dose of PCV13 if they have not yet received it. A dose of PCV13 should be given 1 year after receipt of the most recent PPSV23 dose. For those for whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given 6-12 months after PCV13 and 5 years after the most recent dose of PPSV23. On 4/26/19 at 1:00 P.M., the DON provided the Immunizations: Pneumococcal Vaccination (PPV) of Residents policy, dated 9/2013, and indicated this was the policy currently being used by the facility. The policy indicated all residents of the facility should receive the pneumococcal vaccine of they are [AGE] years of age or older or younger than 65 with underlying conditions that are associated with increase susceptibility to infection or increased risk of serious disease and its complications. Re-vaccination with the pneumococcal vaccine should occur if 5 years or more years have passed since the previous dose and the person was less than 65 at the time of the previous dose. 3.1-13(a)

Based on record review and interview, the facility failed to develop comprehensive plans of care for specific behaviors with individualized interventions for 2 of 18 residents reviewed for care plans, (Residents 31 & 37) Findings include: 1. The clinical record for Resident 31 was reviewed on 4/25/19 at 8:52 A.M. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/13/19, indicated Resident 31 had severed cognitive impairment, no documented behaviors and was receiving an antipsychotic and antidepressant medication. The Resident Medication Profile, dated 4/2019, indicated Resident 31 had current orders for [MEDICATION NAME] (antidepressant) 45 mg (milligrams) every day for [MEDICAL CONDITION] and [MEDICATION NAME] (an antipsychotic medication) 25 mg twice per day for [MEDICAL CONDITION]. It lacked physician orders [REDACTED]. A current, undated, Care Plan problem indicated the resident required the use of a routine antipsychotic medication related to the [DIAGNOSES REDACTED]. A current, undated, Care Plan problem indicated the resident was at risk for sleep pattern disturbance related to [MEDICAL CONDITION]. Interventions included, but were not limited to, delay bedtime until drowsy and ready to sleep, monitor function throughout the day to establish triggers and offer bed time snack. There were no care plans for targeted behaviors, non pharmacological interventions or individualized interventions related to the diagnoses. During an interview on 4/25/19 at 2:45 P.M., Unit Manager 8 indicated there were no specific behaviors being addressed on the care plans. During an interview on 4/26/19 at 11:44 A.M., the Director of Nursing indicated target behaviors and interventions should be listed on the care plans. 2. The clinical record for Resident 37 was reviewed on 4/25/19 at 3:43 P.M. Resident 37's [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 3/20/19, indicated Resident 37 was cognitively intact, had no documented behaviors and had received anti-anxiety, antidepressant and hypnotic medications. The Resident Medication Profile, dated 4/2019, indicated Resident 37 had current orders for [MEDICATION NAME] (antidepressant) 50 mg (milligrams) daily for [MEDICAL CONDITION], [MEDICATION NAME] (anti-anxiety) 0.25 mg daily for anxiety,[MEDICATION NAME](hypnotic) 5 mg at bed time for [MEDICAL CONDITION], duloxetine 60 mg daily for [MEDICAL CONDITION] and [MEDICATION NAME] (antidepressant) 7.5 mg daily. A Nurses' Progress Note, dated 3/1/19, indicated Resident 37 was diagnosed with [REDACTED]. A current, undated, Care Plan indicated the resident was at risk for exhibiting signs and symptoms of anxiety related to anxiety diagnosis. Interventions included, but were not limited to, assess and record behaviors and assess the need for PRN (as needed) anti-anxiety medication if interventions do not relieve the anxiety. A current, undated, Care Plan indicated the resident was at risk for sleep pattern disturbance. Interventions included, but were not limited to, delay bed time until drowsy and ready for sleep and administer hypnotics as ordered. During an interview on 4/26/19 at 11:44 A.M., the Director of Nursing indicated target behaviors and individualized interventions should be listed on the care plans. On 4/26/19 at 9:48 A.M., the Director of Nursing provided the policy titled, Care Plan, dated (MONTH) (YEAR), and indicated the policy was the one currently used by the facility. The policy indicated . 3, Each resident's Comprehensive Person Centered Care Plan has been designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the residents strength. f. Aid in preventing or reducing declines in the residents functional status and/or functional levels; and g. Enhance the optimal functioning of the resident 3.1-35(a)

Based on interview and record review, the facility failed to ensure residents were invited to care plan conferences quarterly for 3 of 3 residents reviewed for care planning. (Residents 4, 29 & 5) Findings include: 1. During an interview on 4/23/19 at 10:10 A.M., Resident 4 indicated she had not attended any care plan meetings. The clinical record for Resident 4 was reviewed on 4/24/19 at 1:20 P.M. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 3/27/19, indicated Resident 4 had mild cognitive impairment. A Care Plan Conference sheet, dated 1/7/19, indicated Resident 4 was not invited. A Care Plan Conference sheet, dated 2/4/19, indicated Resident 4 was not invited. A Care Plan Conference sheet, dated 4/15/19, indicated Resident 4 was not invited. 2. During an interview on 4/23/19 at 9:41 A.M., Resident 29 indicated he had not attended any care plan meetings. The clinical record for Resident 29 was reviewed on 4/25/19 at 11:21 A.M. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 3/13/19, indicated Resident 29 had mild cognitive impairment. A Care Plan Conference sheet, dated 10/1/18, indicated the IDT (interdisciplinary team) had met to discuss, review an update care plans. There was no indication if Resident 29 was invited. A Care Plan Conference sheet, dated 3/20/19, indicated the IDT team had met to discuss, review an update care plan. There was no indication if Resident 29 or a family representative was invited. During an interview, on 4/24/19 at 2:11 P.M., the SSD (Social Service Director) indicated residents should be invited to care plan conferences and documentation should present if they chose not to participate. 3. During an interview on 4/23/19 at 10:06 A.M., Resident 5 indicated she had not attended or knew of care plan meetings. A clinical record review was completed on 4/24/19 at 1:38 P.M. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 1/9/19, indicated Resident 5's cognition was moderately impaired. A Care Plan Conference sheet, dated 10/16/18, lacked documentation to indicate the resident had been invited. A Care Plan Conference sheet, dated 11/9/18, indicated Resident 5 was not invited and did not attend the conference. A Care Plan Conference sheet, dated 4/12/19, lacked documentation to indicate the resident had been invited. During an interview on 4/24/19 at 1:40 P.M., Social Service Staff 4 indicated she did not know why the resident had not been invited. During an interview on 4/26/19 at 8:59 A.M., the Director of Nursing indicated they did not have a policy for care conference meetings. 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure a resident who was a risk for dehydration was assessed and provided adequate fluids for 1 of 2 residents reviewed for hydration. Finding includes: The clinical record for Resident 10 was reviewed on 4/25/19 at 9:33 A.M. [DIAGNOSES REDACTED].) infection and weakness. A quarterly MDS (Minimum Data Set) assessment, dated 1/30/19, indicated Resident 6 had severe cognitive impairment, required limited assistance from staff with food and fluid intake, had a weight loss of greater than 10% in 6 months, and was receiving antibiotics. An undated Care Plan indicated Resident 10 was at risk for dehydration related to [MEDICAL CONDITION] diagnosis. The interventions included, but were not limited to, keep fluids next to the resident and provide cues/assist to drink fluids, to observe for signs and symptoms of dehydration and record intakes and outputs. A quarterly Nutritional Assessment, dated 1/30/19, indicated Resident 10 had a 10% weight loss noted in the last 6 months. The clinical summary note indicated current weight was 134 lbs (pounds), weight loss over 10% since admission, and resident had recurring [MEDICAL CONDITION] four times. The Intake/Output Monitoring Report, dated 3/29/19 - 4/5/19, indicated Resident 10's fluid intake was 1260 on 3/29/19, 1280 on 3/30/19, 1440 on 3/31/19, 608 on 4/1/19, 1080 on 4/2/19, 1440 on 4/3/19, 920 on 4/4/19 and 720 on 4/5/19. A Progress Note, dated 4/4/19 at 2:19 P.M., indicated Resident 10 stayed in room for lunch, temperature was down to 100.7 and at 1:00 P.M., his temperature was back to 102.2. A Progress Note, dated 4/4/19 at 8:48 P.M., indicated his temperature was currently 101.3 and did not go down after Tylenol was administered. A new order to restart an antibiotic for [DIAGNOSES REDACTED] was received. Temperature was 99.9 at 9:00 P.M. A Progress Note, dated 4/4/19 at 8:30 A.M., indicated Resident 10 had large, loose, foul smelling stool and stated he felt weak and his temperature was 101.3. No further resident assessment was documented on 4/4/19. A Progess Note, dated 4/5/19 at 6:46 P.M., indicated Resident 10 had a temp of 101.1 and white blood cell count was 33.8. The physician was notified and Resident 10 was transferred to the local hospital. The Communication Form, dated 4/5/19, indicated Resident 10 had decreased level of consciousness (sleepy,lethargic), not eating, no activity, with elevated temperature of 101.1 and no relief noted from Tylenol . The History of Present Illness report, dated 4/5/19 at 6:37 P.M., indicated Resident 10 was sent to the ER for progressively worsening dehydration, multiple episodes of loose stools and recent diagnosed recurrent [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident 10 had presented to the local ER (emergency room ) with a temperature of 101.6, pulse of 121 beats per minutes, respiratory rate 28-30 breaths per minute and blood pressure of 89/54. Physical exam showed an elderly man, tachypnic and very dry mucous membranes. The admitting [DIAGNOSES REDACTED]. During an interview on 4/25/19 at 2:51 P.M., the Unit Manager indicated the CNAs document oral intake, and if they notice decreased intake they are to fill out stop and watch in the computer. The CNA should notify the nurse verbally and the computer pushed information to the nurse after stop and watch was completed. Then the nurse would follow up on hydration status. She indicated there was no stop and watch filled out for Resident 10 with decreased fluid intake. During an interview on 4/25/19 at 3:20 P.M., the Dietician indicated Resident 10's required fluid intake from 1/30/19 was 1800 ml (milliliters) daily. It was the nursing department's responsibility to monitor the hydration status and consumption of residents. Residents who were identified as at risk for dehydration should be monitored more frequently and the increased temperature and multiple loose stools increased Resident 10's risk for dehydration. On 4/26/19 at 2:00 P.M., the DON (Director of Nursing) provided the Hydration policy, dated 9/1/17, and indicated this was the policy currently being used by the facility. The purpose of the policy was to offer each resident sufficient fluid intake to maintain proper hydration and health. Interventions to improve a resident's hydration status may include, but not be limited to, offer resident variety of fluids during and between meals, provide assistance with drinking and alternate fluids. The facility will update the care plan as needed, such as when resident's condition changes or as new causes of hydration problems are identified. 3.1-46(1)

Based on record review and interview, the facility failed to ensure residents who were receiving [MEDICAL CONDITION] medications had appropriate diagnosis listed, orders to monitor for adverse consequences and monitoring/documentation of targeted behaviors and individualized interventions for use of anti-anxiety and antidepressant medications for 4 of 5 residents reviewed for unnecessary medications. (Resident 20, 34, 37 & 31) Findings include: 1. The clinical record for Resident 20 was reviewed on 4/24/19 at 9:47 A.M. Diagnoses included, but were not limited to, [MEDICAL CONDITIONS] and depression. The quarterly MDS (Minimum Data Set) assessment, dated 1/21/19, indicated Resident 20 had severe cognitive impairment, no documented behaviors and was receiving an antipsychotic and antidepressant medication. The Physician order [REDACTED]. There was a treatment order to assess/document behaviors, including interventions and efficacy. The targeted behaviors were paranoid delusions, hallucinations, garbled speech, frequent body movements, sleeplessness, sad statements, withdrawn and not eating. There were no individualized interventions listed. There were no orders to monitor for adverse consequences with the use of antipsychotics or antidepressants. An undated Care Plan for antidepressant drug use indicated to observe for changes in mood and behavior (sleep patterns, fatigue, appetite, ability to concentrate, participation in activities and crying) and document. There were no individualized interventions listed. An undated Care Plan for antipsychotic drug use related to nocturnal [MEDICAL CONDITION]/dementia with behaviors and outbursts indicated to initiate tracking forms for behaviors and side effects. An undated Care Plan for behavior symptoms indicated Resident 20 had behavior symptoms not directed at others. The behavior was yelling out and wanting to go to Philadelphia. The interventions included, but were not limited to, remind resident that the behavior was not appropriate and record behavior on tracking form. There were no other individualized interventions listed for behavior. The Behavior Tracking forms, dated 4/24/19, 4/25/19 and 4/26/19, did not contain any information documented for behaviors that occurred, the behavior section was blank. One did contain information for a mood that occurred with refusing medications and breakfast. There were no interventions documented. During an interview on 4/26/19 at 11:38 A.M., LPN 11 indicated there was no area to document for side effects of medications and behavior monitoring was only documented for residents who took antipsychotic medications. During an interview on 4/26/19 at 11:44 A.M., the DON (Director of Nursing) indicated target behaviors and interventions should be listed on the order to monitor to behaviors. The mood/behavior assessments were to be completed in their entirety for residents taking antipsychotics and progress note charting was completed for residents taking other [MEDICAL CONDITION] medications. 2. The clinical record for Resident 34 was reviewed on 4/24/19 at 1 :55 P.M. Diagnoses included, but were not limited to, anxiety and major [MEDICAL CONDITION]. A quarterly MDS (Minimum Data Set) assessment, dated 3/20/19, indicated Resident 34 had mild cognitive impairment, no documented behaviors and was receiving anti-anxiety and antidepressant medications. The Physician order [REDACTED]. There was treatment order to assess/document behaviors, including interventions and efficacy. There were no targeted behaviors or interventions documented. There were no orders to monitor for adverse consequences with the use of anti-anxiety or antidepressant medications. An undated Care Plan for anti-anxiety drug use did not include individualized interventions for verbal distress. An undated Care Plan for antidepressant drug use indicated to observe for changes in mood and behavior (sleep patterns, fatigue, appetite, ability to concentrate, participation in activities and crying) and document. There were no individualized interventions available. A Progress Note, dated 1/29/19 at 12:12 P.M., indicated Resident 34 had indicated she wished she was dead, the statements were not new and [MEDICATION NAME] was increased to 30 mg. There were no updates noted to the care plan for depression and no follow up documentation completed by social service. During an interview on 4/26/19 at 11:23 A.M., LPN 10 indicated there was no behavior charting for Resident 34 and no orders to monitor for adverse consequences of anti-anxiety or antidepressant medications. Behavior charting and monitoring was for residents receiving antipsychotic medications. 3. The clinical record for Resident 31 was reviewed on 4/25/19 at 8:52 A.M. Diagnoses included, but were not limited to, [MEDICAL CONDITION] with behavioral disturbance, depression, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The quarterly MDS (Minimum Data Set) assessment, dated 3/13/19, indicated Resident 31 had severed cognitive impairment, no documented behaviors and was receiving an antipsychotic and antidepressant medication. The Resident Medication Profile, dated 4/2019, indicated Resident 31 had current orders for [MEDICATION NAME] (antidepressant) 45 mg (milligrams) every day for [MEDICAL CONDITION] and [MEDICATION NAME] (an antipsychotic medication) 25 mg twice per day for [MEDICAL CONDITION]. It lacked physician orders [REDACTED]. A current, undated, Care Plan indicated the resident required the use of a routine antipsychotic medication related to the [DIAGNOSES REDACTED]. A current, undated, Care Plan indicated the resident was at risk for sleep pattern disturbance related to [MEDICAL CONDITION]. Interventions included, but were not limited to, delay bedtime until drowsy and ready to sleep, monitor function throughout the day to establish triggers and offer bed time snack. There was no care plan for the targeted behaviors or individualized interventions related to the diagnoses. During an interview on 4/25/19 at 2:45 P.M., Unit Manager 8 indicated the side effects of the medications were not being monitored and there were no specific behaviors being addressed on the care plans. During an interview on 4/26/19 at 11:44 A.M., the Director of Nursing indicated target behaviors and interventions should be listed and there should have been an order for [REDACTED].>4. The clinical record for Resident 37 was reviewed on 4/25/19 at 3:43 P.M. Diagnoses included, but were not limited to, hypertension, anxiety, [MEDICAL CONDITION], and depression. The quarterly MDS (Minimum Data Set) assessment, dated 3/20/19, indicated Resident 37 was cognitively intact, had no documented behaviors and had received antianxiety, antidepressant and hypnotic medications. The Resident Medication Profile, dated 4/2019, indicated Resident 37 had current orders for [MEDICATION NAME] (antidepressant) 50 mg (milligrams) daily for [MEDICAL CONDITION], [MEDICATION NAME] (anti-anxiety) 0.25 mg daily for anxiety,[MEDICATION NAME](hypnotic) 5 mg at bed time for [MEDICAL CONDITION], duloxetine 60 mg daily for [MEDICAL CONDITION] and [MEDICATION NAME] (antidepressant) 7.5 mg daily. A Physicians Order, dated 12/24/18, indicated Resident 37 was [MEDICATION NAME](hypnotic) 5 mg as needed (PRN) at bed time for sleep x 14 days. A Nurses' Progress Note, dated 1/4/19, indicated Resident 37 had been requesting the [MEDICATION NAME] due to the PRN [MEDICATION NAME] medication did not help her. Nurses' Progress Notes, dated 12/22/18 to 1/4/19 lacked documentation of Resident 37 having [MEDICAL CONDITION]. A History and Physical, dated 2/1/19, indicated Resident 37 was assessed by a psychiatric physician. The overall assessment and plan was to continue the duloxetine and [MEDICATION NAME] PRN (as needed), stop [MEDICATION NAME] just take the [MEDICATION NAME] for sleep because the resident should not require both medications for sleep. A physician's orders [REDACTED]. Nurses Progress Notes, dated 1/22/19 through 2/7/19 lacked supportive documentation of why the [MEDICATION NAME] order was changed to routine. A Pharmacy Recommendation, dated 2/25/19, recommended to discontinue [MEDICATION NAME] due to the resident was already receiving [MEDICATION NAME] for sleep. A Nurses Progress Note, dated 2/28/19, indicated Resident 37 had requested [MEDICATION NAME] for sleep. The nurses explained to the resident the physician had ordered [MEDICATION NAME] for sleep due to an interaction between [MEDICATION NAME]. Resident 37 indicated the [MEDICATION NAME] had never worked for her, and stated she would get [MEDICATION NAME] way or another. A Nurses Progress Note, dated 3/1/19, indicated Resident 37 received a new [DIAGNOSES REDACTED]. A Nurses Progress Note, dated 3/30/19, indicated to increase the duloxetine to 60 mg daily and add [MEDICATION NAME] 7.5 mg at bedtime for adjustment disorder and depressed mood. A current, undated, Care Plan indicated the resident was at risk for exhibiting signs and symptoms of anxiety related to diagnosis. Interventions included, but were not limited to, assess and record behaviors and assess the need for PRN (as needed) antianxiety medication if interventions do not relieve the anxiety. A current undated, Care Plan indicated the resident was at risk for sleep pattern disturbance. Interventions included, but were not limited to, delay bed time until drowsy and ready for sleep and administer hypnotics as ordered. During an interview on 4/26/19 at 11:44 A.M., the Director of Nursing indicated target behaviors and interventions should be listed and there should have been an order for [REDACTED].>On 4/26/19 at 9:48 A.M., the Director of Nursing provided the policy titled, Behavior Assessment and Monitoring, dated 3/1/18, and indicated the policy was the one currently used by the facility. The policy indicated .3.) The facility will comply with regulatory requirements related to the use of medications to manage problematic behavior. The staff will identify and discuss with the practitioner situations where non-pharmacological approaches are indicated, and will institute such measures the extent possible. Specific targeted behaviors will be documented in the note section of the order On 4/26/19 at 9:48 A.m., the Director of Nursing provided the policy titled, Medication Monitoring and Management, dated 7/31/17, and indicated the policy was the one currently used by the facility. The policy indicated . In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective and safe medication use. When selecting medication and non-pharmacological interventions, members of the interdisciplinary team participate in the care plan process to identify, assess, address, advocate for, monitor and communicate the resident's needs and changes in condition. A.) The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. 1.) When possible, non-pharmacological interventions are considered before initiating a new medication. 3.) Information gathered during the initial and ongoing evaluations are incorporated into a comprehensive care plan that reflects appropriate medication-related goals and parameters for monitoring the resident's condition and ongoing need for the medication(s), including, but not limited to, what is monitored, who will be responsible for monitoring 3.1-48(b)(1) 3.1-48(b)(2)

Based on observations, record review and interviews, the facility failed to ensure call lights were answered timely for 2 residents. (Residents B and C). In addition, the facility failed to ensure meals were served in a dignified manner to 2 dependent residents in 1 of 2 dining rooms observed. (Resident #13 and #65) Findings include: 1. During the dining observation in the Healthcare dining room, conducted on 04/20/16 at 5:05 P.M., Resident #65 was seated in the dining room at a circle shaped table with no food while all other residents at the same table were being fed. Resident #65 did not receive her food until 5:25 P.M., 20 minutes later. Resident #13 was observed on 04/20/16 from 5:05 P.M. - 5:23 P.M., seated at a circle shaped table with her food in front of her. Resident #13 was not being assisted to eat, but was awake staring at her food. A staff member was seated next to Resident #13 and was feeding another resident but made no attempt to assist Resident #13 with her food. On 04/21/16 at 8:31 A.M., Resident #65 was observed in the healthcare dining room at a circle shaped table. Resident #65 was awake and did not have her breakfast food even though there were other residents and three staff members seated at the table. The residents on both sides of her were being fed their breakfast by staff members. Resident #65 did not receive her breakfast food or any beverages until 8:44 A.M. Once Resident #65 was served her meal, she began feeding herself toast and gave herself a drink from her cup. During an interview on 04/27/16 at 11:30 A.M., the Director of Nursing indicated dependent residents were not fed until staff were available to feed them. She indicated they were also not fed until they arrived at the table. She indicated she would have to look into it regarding concerns with how long a dependent resident should sit while others at the same table are being assisted. The current, undated, facility policy titled Unidine, regarding dining was provided by the Director of Nursing on 04/26/16 at 1:35 P.M. The policy indicated .Open Dining Description: .Residents are waited on at their tables as they arrive to ensure them customized timely service. The exception to this is: Residents who need assistance to eat or to be cued or for any other designated safety concern, will be provided their meal once the caregiver arrives. 2. During an observation of the evening care and staffing, completed on 04/20/16 from 5:05 P.M. - 7:00 P.M., the following was noted: Resident #B's call light was first observed activated at 5:15 P.M. Resident #B was propelling his wheelchair around the Blue healthcare hallway. There were 6 nursing staff members in the health care dining room, and two staff members in the Rehab 2 dining room. There were no staff members noted on the Blue hallway or at the Healthcare nursing station. Resident B's call light was not answered until 5:29 P.M. Alert and oriented Resident B indicated he was very frustrated and his light had been on for 45 minutes. He indicated he needed to go to the bathroom. Resident #C's call light was first observed activated at 6:00 P.M. Resident #C was in her room and she had a visitor in the room with her. There were no nursing staff observed in close proximity to her room, CNA (Certified Nursing Assistant) #17 was serving meal trays and room meal trays in the Rehab 1 dining room and other sections of the rehab unit unit. There were no nursing staff members at the Rehab nurse's station. The was a non- nursing staff member seated in a chair in the lounge area just outside Resident C's room talking and visiting with visitors. At 6:17 P.M., Resident C's family member verbalized loudly she was p----. She indicated Resident C needed to go to the bathroom and she had waited 37 minutes for assistance. She indicated this was unusual and she had noted CNA #17 in the hallway holding a meal tray for a long time. Resident C's family member finally spoke to the non-nursing staff member, who had stood from his seated position, explained her frustration and he was overheard explaining to Resident C's family member that she would need to wait for help as staff were still delivering meal trays. At 6:21 A.M., CNA #18 was noted to answer Resident C's call light and assist her to the bathroom. During an interview with CNA #17 on 04/20/16 at 7:00 P.M. she indicated she was offended by the attitude of Resident C's family member because she (CNA #17) had to pass meal trays and could not answer the call light. The current facility policy and procedure titled Answering the Call Light, dated April 2013, was provided by LPN (licensed Practical Nurse) #19 on 04/27/16 at 11:30 A.M. The policy and procedure included the following: .8. Answer the resident's call as soon as possible. This Federal tag related to Complaint #IN 131. 3.1-3(t)

Based on record review and interviews, the facility failed to ensure 2 of 3 residents reviewed for abuse was free from abuse. (Resident D and Resident G) Findings include: During a confidential interview on 04/19/16 at 10:33 A.M., alert and oriented Resident E indicated the same gal who had disrespected him/her by being rude and bossy, had hit another resident on the mouth with a spoon during an evening meal. He/she indicated they did not recall the staff members name but knew they were from an outside source. Resident E indicated outside source meant a staffing agency. During a confidential interview on 04/21/16 at 2:44 P.M., Resident E indicated he/she had personally witnessed the staff member use a spoon to hit a female resident who was sitting at the round table in the healthcare dining room. He/she indicated the round table was positioned next to the dining table where Resident E was seated. He/she indicated Resident D was the resident who had been hit in the mouth with the spoon. Resident E indicated he/she did not report the abuse to staff because there were several staff in the dining room who had witnessed the abuse. He/she indicated they were uncertain to whom they had reported the disrespectful and bossy care given to themselves. Resident E indicated no staff member had asked him a bout the dining room incident after it had occurred. Resident E also indicated Resident D could not speak much anymore and when she did not want to eat, she would just not open her mouth and the nursing staff member had been upset when Resident D would not open her mouth and that is when she (staff) hit the resident in the mouth. During an interview on 04/20/16 at 6:25 P.M., CNA (Certified Nursing Assistant) #11 indicated a dietary staff member had notified her she had observed an agency staff member, Employee #10, hit Resident D in the mouth with a spoon. CNA #11 indicated she herself had not witnessed the abuse but she took the dietary staff member to the nurse and told the staff member she should report to the nurse her observations. During an interview on 04/20/16 at 5:58 P.M., the evening nursing House Supervisor, RN (Registered Nurse) #12 indicated she had heard about an incident of abuse that had occurred about a month ago involving an agency staff member who was feeding Resident D and when the resident would not open her mouth the agency staff had reportedly popped the resident on the mouth with the spoon. RN #12 indicated she was not working that particular weekend but she knew the agency staff member, Employee #10 had been sent home immediately. Review of the investigation into the incident with Resident D and agency staff member CNA #10 was reviewed on 04/21/2016 at 2:30 P.M. The form, titled Proof of Internal Investigation Report indicated an alleged incident occurred on 04/02/16 in the healthcare dining room. The allegation was reported to the State Department of Health on 04/03/16 at 2:00 P.M. The allegation was also reported to the Ombudsmen. The form indicated nurse, RN #16 had notified the Director of Nursing of the allegation. The form indicated on 04/02/16 at 6:30 P.M., CNA #11 had been notified of the allegation by dietary server, Employee #13. The form indicated agency CNA, Employee #10 was feeding Resident D. Resident D would not open her mouth so CNA #10 tried pushing the spoon in anyway. The investigation also indicated Employee #10 would not allow Resident G to eat his dessert in the dining room and forced him to leave the dining room. A staff interview summary form, completed on 04/03/16 at 10:00 A.M., by the Director of Nursing in her handwriting, indicated a phone interview had been completed for dietary server, Employee #13. The summary section indicated in the dining room CNA, Employee #10 was feeding Resident D, and when the resident did not open her mouth, Employee #10 shoved the spoon into her mouth. CNA #10 then tapped her (Resident D) on the mouth with the back of the spoon and Resident D still would not open her mouth. CNA #10 was visibly frustrated and was overheard commenting I'm sick of this s--- - these residents not wanting to eat. She quit trying (to feed Resident D) and walked away. The form also indicated CNA #10 would not let Resident G eat his dessert at the dining room table and she pulled the resident away from the dining room table even though he both verbalized and tried to pull himself up to the table. A staff interview summary form, completed on 04/03/16 no time given, in the Director of Nursing's handwriting, for dietary server, Employee #14 indicated CNA #10 was observed by Employee #14 bullying Resident G in the dining room and not letting him do what he wanted to do. The summary also indicated CNA #10 was feeding Resident D and was trying to push the spoon into her mouth. Resident D would not open her mouth so CNA #10 tapped Resident D on the lip with the spoon to get her to open her mouth. The Incident report and 5 day follow up form, submitted by the facility to the Indiana State Department of Health indicated the following: 04/03/16 Agency CNA (Agency Name) , (CNA #10's name) was feeding (Resident #D's name and age) with dementia. (Resident D's name) closed her mouth, per her usual, when she didn't want anymore to eat. (CNA #10's name) continued pushing the spoon to (Resident D's ) mouth to get her to eat. Agency CNA (Agency Name) (Resident #10's name) approached (Resident G's name) to take him back to his room He stated he wanted to eat dessert. (CNA #10's name) told him he could eat in his room. He stated he wanted to eat it in the dining room. She told him sharply No, we are going back to your room. (CNA #10's name) pulled his chair back from the table and helped him stand and walked him away from the dining room towards the nurses station Follow up added 04/07/16 As a result of the investigation, we have the alleged incident with CNA (Employee #10's name) and residents (Resident D and G's names) unsubstantiated. After discussion with (CNA #10's name) and other staff on duty, it was noted that there was no willful harm towards residents. Due to concerns brought forward, (CNA #10's name) will not be returning to Hubbard Hill at this time as she does not meet the professional standards of care. During an interview on 04/22/2016 at 11:46 A.M., RN (Registered Nurse) #15, the Vice President of Quality, indicated the accused aide sounded hurried not willful regarding abuse. She indicated there was documentation of tapping but not hitting Resident D on the mouth. During an interview on 04/22/2016 at 11:58 A.M., the Administrator indicated Resident G was taken care of ultimately by another CNA and the witnesses were young, high school girls and their observations were subjective when it came to abuse. Both the Administrator and RN #15 indicated the Director of Nursing (DON) had completed the investigation. The DON was not in the building on 04/22/16 to be interviewed regarding the incident. During a telephone interview on 04/26/16 at 8:57 P.M., dietary server, Employee #14, indicated she had witnessed a staff member who was not a usual staff member (nursing agency staff) hit another resident in the mouth with the back of the spoon. When asked if the employee had tapped the spoon against Resident D's mouth, Employee #14 indicated No, she hit her because she wouldn't open her mouth. It was not gentle and it made a noise when she hit her. Employee #14 indicated she and another staff member, Employee #13 had both witnessed the abuse and Employee #13 had reported the abuse. She indicated the staff member in charge of the nursing department had directed Employee #13 to provide a written statement. Employee #13 indicated both she and Employee #14 had written down their statements. Employee #13 confirmed she had written the word, hit and not tapped. She also indicated the same employee had tried to hurry and force feed Resident G also. During an interview on 04/27/2016 9:20 A.M., the DON indicated the staff involved in the CNA #10 abuse investigation did submit written statements but she also spoke to them on the telephone and read back their statements to them so she did not keep the written statements. She indicated she knew she should have kept copies of written statements for an abuse investigation. This Federal tag related to Complaint #IN 131. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to ensure chemicals were stored properly. This deficient practice had the ability to affect 1 of 7 residents reviewed for chemicals in their rooms. (Residents #67) Finding includes: On 4/19/16 at 9:42 A.M., a box of denture tablets and a bottle of air freshener was observed to be sitting on the sink in Resident #67's room. During an environment tour on 4/26/2016 at 10:27 A.M., the following was observed: A box of denture tablets and a bottle of mouth wash was observed to be sitting on the sink in Resident #67's room. A bottle of air freshener was observed sitting on a dresser in Resident #67's room. During an interview conducted on 4/26/16 at 10:27 A.M., the maintenance director and the director of housekeeping indicated they also observed the chemicals in Resident #67's room. A BIMS (Brief Interview for Mental Status) examination was performed on 2/11/2016 and indicted Resident #67s score was 4. A BIMS score of 4 indicated the resident was severely cognitively impaired. A policy for the proper storage of chemicals in the facility was requested on 4/26/16 at 11:00 A.M., and the facility indicated they did not have a policy for chemical storage. 3.1-45(a)(1)