Every finding on record at Life Care Center of Fort Wayne

Based on interview and record review the facility failed to ensure safekeeping of residents' finances for 1 of 1 resident reviewed. (Resident 5) Findings include:Resident 5's record was reviewed on 03/10/2026 at 10:30 AM. Diagnoses included end stage kidney disease, cognitive communication deficit, and dependence on dialysis.A review of Resident 5's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 13 (normal cognition).A review of the incident report, dated 03/03/2026 at unknown time, indicated Fort [NAME] Police Department were called to make the initial report of Resident 5's money being misappropriated.In an interview, on 03/10/2026 at 11 AM, Resident 5 indicated he gave CNA 5 his card to buy him noodles from the gas station. Soon he found out that multiple charges were on his card for [NAME] Beverage, and purchases at the gas station that were not authorized.In an interview, on 03/12/2026 at 11 AM, the Administrator indicated CNA 5 was responsible for the multiple charges to Resident 5's card. The Administer indicated that abuse education, including financial abuse, was provided at the beginning of the year. Another inservice was completed on 03/03/2026 regarding misappropriation of funds. The administrator also indicated resident interviews were performed, and there were no other residents affected.No current policy was provided for misappropriation of funds.This citation is related to Intake 2794260.410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(a)

Based on interview and record review, the facility failed to ensure accurate neurological assessments were completed for 1 of 1 resident reviewed. (Resident 53)Findings include:Resident 53's record was reviewed on 03/09/2026 at 1:40 PM. Diagnoses included difficulty in walking and muscle weakness.A progress note dated 2/22/2026 at 6:33 AM indicated Resident 53 fell and neurological assessments were initiated.A review of the Neurological assessment dated [DATE] indicated the following:On 02/22/2026 at 5:45 AM, Resident 53's right pupil was non-reactive.On 02/22/2026 at 6:00 AM, Resident 53's right pupil was non-reactive.On 02/22/2026 at 6:15 AM, Resident 53's right pupil was non-reactive.On 02/22/2026 at 6:30 AM, Resident 53's right pupil was non-reactive.On 02/22/2026 at 7:00 AM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 02/22/2026 at 7:30 AM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 02/22/2026 at 8:00 AM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 02/22/2026 at 8:30 AM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 02/22/2026 at 2:30 PM, the assessment indicated the time slot was skipped as Resident 53 refused. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 02/23/2026 at 8:30 AM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 02/23/2026 at 4:30 PM, the assessment indicated the time slot was skipped. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.No documentation indicated the reason for Resident 53's non-reactive pupil. No documentation was located a follow-up assessment was completed or that the physician was notified.A progress note, dated 12/22/2025 at 5:40 AM, indicated Resident 53 fell and neurological assessments were initiated.A review of the Neurological assessment dated [DATE] indicated the following:On 12/22/2025 at 5:30 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 5:45 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 6:00 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 6:15 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 6:45 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 7:15 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 7:45 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 8:15 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 10:15 AM, Resident 53's right pupil was non-reactive.On 12/22/2025 at 12:15 PM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right pupil was nonreactive, and the left pupil was reactive. The assessment indicated Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 12/22/2025 at 2:15 PM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right pupil was nonreactive, and the left pupil was reactive. The assessment indicated Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 12/22/2025 at 4:15 PM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right pupil was nonreactive, and the left pupil was reactive. The assessment indicated Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 12/22/2025 at 8:15 PM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right pupil was nonreactive, and the left pupil was reactive. The assessment indicated Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 12/23/2025 at 8:15 AM, Resident 53's right and left pupil were equal and reactive, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 12/24/2025 at 7:15 AM, the assessment indicated the time slot was skipped as Resident 53 was sleeping. However, the assessment indicated Resident 53's right and left pupil were equal, Resident 53 was alert and his upper and lower motor function were equal and strong. The assessment indicated Resident 53's speech was clear and his face was symmetrical.On 12/24/2025 at 3:15 PM, Resident 53's right pupil was non-reactive.No documentation was located indicating the reason for Resident 53's non-reactive pupil. No documentation was located that a follow-up assessment was completed or that the physician was notified.In an interview, on 03/12/2026 at 2:00 PM, the Director of Nursing (DON) indicated she was unsure why Resident 53's pupil was nonreactive during the assessments completed on 12/22/2025 and 2/22/2026. The DON indicated she was unable to find any additional documentation pertaining to any follow-up regarding the nonreactive pupil. The DON indicated if a pupil is nonreactive during a neurological assessment the facility would notify the doctor or send the resident to the hospital. The DON indicated that in regard to the assessments indicating they were not completed, however an assessment being completed, staff indicated if the resident was asleep when an assessment was supposed to be completed, they would go back and put in what they saw when the resident woke up.In an interview, on 03/13/2026 at 9:34 AM, the DON indicated the facility would not necessarily send a resident to the hospital if they had a non-reactive pupil during a neurological assessment following a fall. The DON indicated it would depend on the type of medication and history of the resident. The DON indicated they would have notified palliative care or the nurse practitioner of the change in eye pupils.In an interview, on 03/13/2026 at 10:29 AM, the Administrator indicated nursing staff were using the previous assessment for neurological assessments when the resident was asleep.At the time of exit, the facility could not provide documentation they notified palliative care or the facility nurse practitioner regarding Resident 53's non-reactive pupil.A current policy, dated 8/29/2025, provided by the Administrator indicated, The nurse documents and reports any pertinent changes in the resident's neurological status immediately to the physician.

Based on observation and interview, the facility failed to ensure proper storage of respiratory supplies for 1 of 1 resident reviewed. (Resident 13)Findings include:During an observation on 03/09/2026 at 9:36 AM, Resident 13 was not in their room. Resident 13's oxygen tubing was observed lying on the floor and the oxygen machine was turned on.During an observation on 03/10/2026 at 9:46 AM, Resident 13 was not in their room. Resident 13's oxygen tubing was observed on an ottoman and the oxygen machine was turned on.Resident 13's record was reviewed on 03/10/2026 at 10:00 AM. Diagnoses included chronic obstructive pulmonary disease (COPD).In an interview, on 03/10/2026 at 9:52 AM, Licensed Practical Nurse (LPN) 2 indicated the oxygen machine should be turned off and the oxygen tubing should have been wrapped and placed in the plastic bag to prevent contamination.A current policy dated 03/03/2026 provided by the facility Administrator indicated, Store oxygen and respiratory supplies in a bag labeled (i.e., resident name) when not in use.410 IAC 16.2-3.1-47 (a)(6)

Based on interviews and record reviewed, the facility failed to ensure non-pharmacological interventions were completed for 1 of 1 resident reviewed. (Resident 13)Findings include:Resident 10's record was reviewed on 3/10/26 at 12:12 PM. Diagnosis included chronic pain syndrome. A review of Resident 10's current Care plan, dated 1/26/26, indicated a focus of pain secondary to diagnosis of spina bifida, chronic pain syndrome, chronic fatigue, protein calorie malnutrition, decreased mobility, history of left Below knee amputation, and generalized muscle weakness. Resident is very tactile sensitive and will complain of extreme pain. Per history, resident reports that she had to cut her hair short secondary to it causing pain when it touched her back. The goals included the resident will verbalize complaints of pain and/or adequate relief of pain with interventions. The interventions indicated administer medications as ordered/indicated, anticipate Resident 13's need for pain relief and respond immediately to any complaint of pain, educate resident and family regarding pain management, evaluate the effectiveness of pain interventions, identify and record previous pain history and management of that pain and impact on function, identify previous response to analgesia including pain relief, side effects and impact on function, notify physician of unrelieved or worsening pain, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Observe and report to Nurse any signs and symptoms of non-verbal pain, for example: changes in breathing (noisy, deep/shallow, labored, fast/slow), vocalizations (grunting, moans, yelling out, silence), mood/behavior (changes, more irritable, restless, aggressive, constant motion), face (sad, crying, worried, scared, clenched teeth, grimacing), body (tense, rigid, rocking, curled up, thrashing). Observe and report to nurse when resident has complaints of pain or requests for pain treatment. Observe for probable cause of each pain episode. Remove/limit causes where possible. Observe for side effects of pain medication such as constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Offer non-pharmacological interventions for pain such as position change, quiet environment, back rub, or diversional activities. Pain meds as ordered. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs or symptoms or complained of pain or discomfort. Report to the nurse loss of appetite, refusal to eat and weight loss.A review of physician orders indicated to give Morphine Sulfate Oral Tablet 15 Milligram (MG) Give 1 tablet 15 mg by mouth every 6 hours as needed for pain. A review of the Medication Administration Record (MAR), dated February 2026, indicated Resident 13 received Morphine Sulfate Oral tablet 15 mg for pain as follows:On the 1st at 1:17 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notes. On the 2nd at 5:21 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 4th at 3:015 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 5th at 11:45 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 6th at 12:19 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 8th at 12:30 AM and 3:30 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 10th at 3:17 AM and 2:49 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 11th at 1:34 AM and 12:32 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 12th at 11:00 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notes. On the 13th at 5:00 AM and 1:59 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 15th at 3:00 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 16th at 11:48 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 17th at 2:58 AM and 4:49 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 20th at 12:20 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 21st at 3:00 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 22nd at 1:22 AM and 3:06 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 24th at 4:09 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notes. On the 25th at 5:55 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 26th at 1:39 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 27th at 4:38 AM and 2:00 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesA review of Medication Administration Record (MAR), dated March 2026, indicated Resident 13 received Morphine Sulfate Oral tablet 15 mg for pain as follows:On the 1st at 2:24 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 2nd at 2:06 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 3rd at 3:35 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 8th at 3:35 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 9th at 5:50 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 10th at 12:05 AM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesIn an interview, on 03/1/2026 at 1:32 PM, the Administrator indicated she was unable to find any non pharmacological interventions for the dates provided.A current facility policy, titled, Pain Management, dated 11/25, was provided by the Administrator on 3/13/26 at 9:45 AM. The policy indicated .Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both 410 IAC 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure medication administration records were complete and accurately documented for 2 of 3 residents reviewed (Resident C and Resident D). Findings include:1. On 1/20/26 at 2:32 P.M., Resident C's record was reviewed. Diagnoses included Alzheimer's dementia, failure to thrive, and abnormal weight loss.A physician order, dated 12/24/25, indicated to give Morphine Sulfate Concentrate 100 mg/5 ml-give 0.25 milliliters (ml) by mouth every 2 hours as needed for pain or shortness of breath. A Medication Administration Record (MAR), dated December 2025, and Controlled Substance Record, dated December 2025, for Morphine Sulfate concentrate 100 mg/5 ml-give 0.25 milliliters (ml) by mouth every 2 hours as needed, indicated the following incomplete records: -On 12/27/25 at 10:00 a.m. and 12:00 p.m., the MAR indicated Morphine Sulfate had been administered to Resident C. The Controlled Substance Record did not indicate Morphine Sulfate was given on 12/27/25 at 10:00 a.m. or 12:00 p.m. -On 12/28/25 at 8:00 a.m., the MAR indicated Resident C had been administered Morphine Sulfate. The MAR did not indicate any doses of Morphine had been given on 12/28/25. The Controlled Substance Record indicated Morphine Sulfate had been administered on 12/28/25 at 8:00 a.m., 10:00 a.m., and 9:49 p.m. 2. On 1/20/26 at 2:54 P.M., Resident D's record was reviewed. Diagnoses included bladder cancer. A physician order, dated 10/18/25, indicated to give Oxycodone Oral Concentrate 100 mg/5 ml-give 1 ml by mouth every 4 hours as needed for breakthrough pain. A MAR, dated November 2025, and Controlled Substance Record, dated November 2025, for Oxycodone Oral Concentrate 100 mg/5 ml-give 1 ml by mouth every 4 hours as needed for breakthrough pain, indicated the following incomplete records: -On 11/2/25, the Controlled Substance Record indicated at 9:00 p.m., a dose of Oxycodone had been administered to Resident D. The MAR did not indicate Oxycodone had been given on 11/2/25 at 9:00 p.m. -On 11/9/25, the Controlled Substance Record indicated at 3:30 p.m., the resident was administered Oxycodone. The MAR did not indicate Oxycodone had been given on 11/9/25 at 3:30 p.m. -On 11/10/25, the MAR indicated Oxycodone had been administered to Resident D at 4:00 a.m. The Controlled Substance Record did not indicate Oxycodone had been given on 11/10/25 at 4:00 a.m. -On 11/11/25, the Controlled Substance Record indicated at 4:00 a.m., the resident was administered Oxycodone. The MAR did not indicate Oxycodone had been given on 11/11/25 at 4:00 a.m. -On 11/17/25 at 10:45 a.m. and 11/27/25 at 10:53 a.m., the Controlled Substance Record indicated a dose of Oxycodone had been administered to the resident. The MAR did not indicate Oxycodone was given on 11/17/25 at 10:45 a.m. nor given on 11/27/25 at 10:53 a.m. -On 11/27/25 at 10:31 a.m. and 11/29/25 at 3:00 p.m., the Controlled Substance Record indicated a dose of Oxycodone had been administered to the resident. The MAR did not indicate Oxycodone was given on 11/27/25 at 10:31 a.m. or 11/29/25 at 3:00 p.m. On 1/21/26 at 4:19 P.M., Licensed Practical Nurse (LPN) 2 indicated in an interview, whenever a controlled medication like opioids (pain medication) are administered, the dose must be signed off the Controlled Substance Record and documented on the MAR. LPN 2 indicated if a medication was not initialed on the MAR, it would mean the medication hadn't been given. A current policy, titled Managing Controlled Substances, was provided by the Director of Nursing on 1/20/26 at 11:30 A.M. which indicated medication administrations were to be documented timely following the administration to the resident. Controlled substances were to be signed out from the descending count sheet and documented on the MAR for each routine and as-needed doses of medication administered. This Citation is related to Intakes 2699670 and 2712821. 3.1 (a)(1)

Based on observation, interview, and record review the facility failed to follow physician orders for 1 of 1 resident reviewed. (Resident 11). Findings include: An observation, on 4/21/25 at 10:38 AM, in Resident 11's room observed Resident 11 resting with her eyes closed and mouth open. Resident 11 had oxygen on per nasal cannula. The oxygen concentrator was set at 3 liters per nasal cannula. A record review, on 4/22/25 at 11:02AM, indicated Resident 11 had physician orders as follows: Oxygen at 2 liters per minute continuously per nasal cannula. Document every shift with the start date of 8/13/24. Oxygen at 4 liters per minute per nasal cannula as needed with the start date of 11/10/24. Admit to hospice, life expectancy 6 months or less diagnosis chronic respiratory failure with congestive heart failure with the start date of 9/4/24. There was no order for oxygen at 3 liters per nasal cannula. In an interview, on 4/22/25 at 1:20PM, Registered Nurse 2 (RN) indicated she adjusted Resident 11's oxygen determined by oxygen saturation, by Resident 11 needs and reports of how she was feeling. RN 2 indicated currently the oxygen was set at 2 liters per nasal cannula. RN 2 indicated Resident 11 does not adjust the oxygen herself and Resident 11 was unable to do so due to her current limitations. A record review of Resident 11's hospice communication book indicated the only order for oxygen was 3 liters continuous per nasal cannula with the start date 9/4/24. There were no orders for oxygen at 2 liters, no orders for 4 liters, and no orders for a titration of oxygen per Resident 11 needs or comfort. An observation, on 4/22/25 at 1:34PM, Resident 11's oxygen was on at 3 liters per nasal cannula. RN 2 readjusted the oxygen back to 2 liters per nasal cannula at the time of observation. RN 2 indicated the oxygen should be set at 2 liters. In an interview, on 4/23/25 at 8:22AM, the Director of Nursing (DON) indicated she called the hospice and the ordering physician for the facility to clarify oxygen orders for Resident 11. At the time of interview, Resident 11 kept her order for oxygen 2 liters continuously per nasal cannula and had a new order dated 4/22/25 for may titrate oxygen up to 4 liters per minute per nasal cannula as needed. The DON further indicated an in-service was done regarding oxygen concentrators and ensuring proper settings. The facility provided a current policy and procedure titled Physician Orders revised 2/26/24 and reviewed 2/27/25. The policy indicated .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines . 3.1-37

Based on interview and record review the facility failed to ensure vision concerns were addressed for 1 of 1 residents reviewed (Resident 23). Findings include: An interview on 5/14/24 at 10:06AM Resident 23 indicated she was blind. She was sitting in a wheelchair within 5 feet of the speaker and indicated she was unable to see the face of the person speaking. Resident 23 indicated the facility was aware. Resident 23's record was reviewed on 5/15/24 at 9:52AM. Resident 23's current diagnoses included heart failure, myocardial infarction, end stage renal disease, type 2 diabetes, and hypertension. There were no diagnoses of macular degeneration or blindness. A history and physical from Lutheran Hospital on 11/17/23 did not indicate vision difficulties as past medical history on the problem list. A medical appointment at vision care ophthalmology on 1/16/24 indicated the diagnosis of macular degeneration and myopia (nearsightedness). The report requested a consultation with a low vision specialist due to geographic atrophy (chronic progression of macular degeneration). The appointment with the low vision center was made for 4/3/24 at 12 noon. There was an order note to indicate the appointment was cancelled. The appointment was rescheduled for 4/16/24. Resident 23 was in the hospital on 4/16/24 and therefore unable to attend the appointment. There were no other appointments made. Resident 23's current care plan was reviewed. There were no problems, goals, or interventions related to impaired vision. Resident 23's current comprehensive MDS (Minimum Data Set) assessment dated [DATE] was reviewed, and the following were identified: Section B: Hearing, Speech, and Vision B. 1000 0. Adequate Section C: Cognitive Patterns BIMS (Brief Interview for Mental Status) Score 15 indicated no cognitive decline. Section I. Active Diagnosis: Vision is not checked. (cataracts, glaucoma, macular degermation) And under other the following were listed (none were vision related) Left ventricular failure. Muscle weakness Chronic respiratory failure Insomnia Presence of heart device Patent foramen ovale Other symptoms and signs involving the nervous system. Dysphagia, oropharyngeal Difficulty in walking In an interview 5/15/24 at 12:14 PM the DON (Director of Nursing) indicated none of Resident 23's history and physicals included the diagnosis macular degeneration or nearsightedness. The DON further indicated the facility had scheduled a follow up appointment with the low vison center for Resident 23 for 8/6/24. The DON indicated Resident 23 missed her appointment on 4/16/24 due to being in the hospital and it should have been rescheduled then. The DON indicated her impaired vision should have been care planned, on the MDS, and listed as a diagnosis. The DON indicated Resident 23 did not complain to staff or the medical team about her vision. A policy titled, Vision and Hearing Assistive Devices, dated reviewed 9/8/23 indicated to ensure residents receive proper treatment and assistive devise to maintain vision and hearing abilities. 3.1-38(a)(1)

Based on observation, interview and record review, the facility failed to ensure unit pantry refrigerator cleanliness and temperatures were maintained. 71 of 73 residents residing in the facility ate food stored in the pantry refrigerators. During a tour of the [NAME] unit on 4/26/23 at 10:10 AM, the pantry refrigerator was observed. An undated, open carafe of orange juice and an undated container of applesauce were observed. No temperature log was available for review. During an interview on 4/26/23 at 10:10 AM Licensed Practical Nurse (LPN) 2 indicated all food and drink items in the refrigerator should be covered and dated. LPN 2 also indicated refrigerator temperatures should be logged daily. She indicated there was usually a temperature log form on the front of the refrigerator, but she did not know why there was not a log present at the time of observation. 18 of 18 residents residing on the [NAME] unit ate food from the pantry. During a tour of the [NAME] unit on 4/26/23 at 10:19 AM an uncovered, undated bowl of cereal was observed on the top shelf in the refrigerator. A covered Styrofoam cup containing a brown liquid was observed on the middle shelf of the refrigerator. The attached freezer had around 10 dime- to quarter sized splatters of a red substance on the floor and inside of the door. Brown specks of debris were found on the floor and door of the freezer. A container of ice cream was observed with no date in the freezer. No thermometer was observed inside the freezer. A temperature log observed on the front of the refrigerator did not include temperature recordings for the freezer. During an interview on 4/26/23 at 10:19 AM, LPN 2 indicated all refrigerators and freezers should be clean and free of liquid splatters or debris. She also indicated all food and drink items should be covered and dated, and temperature logs should include freezer temperatures. 38 of 40 residents residing on the [NAME] Unit ate food from the panry. During a tour of the [NAME] unit on 4/26/23 at 12:24 PM, a temperature log on the front of the refrigerator was observed to be blank. A cloth lunch bag was observed on the shelf of the refrigerator. A sandwich in a transparent plastic bag was observed in the refrigerator with no date. Two packaged ice cream bars were in a box along with an unpackaged ice cream bar. No dates were observed on the box. A half-inch layer of frost was observed covering the floor and all inside walls of the freezer. A thermometer was observed within the layer of frost. During an interview conducted on 4/26/23 at 12:24 PM, QMA ( Qualified Medication Aide) 3 indicated the temperature log should have been filled out. QMA 3 unsuccessfully attempted to remove the thermometer in the freezer, and the reading was not visible. QMA 3 indicated the cloth bag belonged to an employee. She also indicated employee's food items should not be stored in the unit refrigerator designated for residents' items. QMA 3 indicated the freezer should be free of frost, but she did not know when or how often defrosting occurred. 16 of 16 residents residing on the [NAME] unit ate food from the the pantry. During an interview on 4/26/23 at 2:09 PM, the Administrator indicated housekeeping staff was responsible to maintain pantry refrigerators and freezers. She indicated all food and drink items should be labeled and dated and all surfaces should be clean. A current policy titled Food from Outside Sources, last revised 7/27/22, indicated associate and resident food items should not be stored together in the same refrigerator. The policy addressed thermometer use, but did not specify placement in refrigerators or freezers, or maintaining temperature logs. A document titled Use by Date Guide, last revised 3/18/2020, indicated all open containers of food should be labeled and dated. A document titled Position Competencies and Performance Review- Housekeeping Aide, last revised 3/3/2017, indicated housekeeping aides should clean the insides and outsides of all refrigerators, exclusive of medication areas. A policy addressing defrosting of freezers was not available for review by the time of exit. 3.1-21(i)(3)

Based on interview and record review the facility failed to submit a disclosure form for the dementia unit. 17 residents resided on the unit. Findings include: In an interview, the ED (Executive Director) and corporate consultant on 6/24/22 at 1:27 PM, indicated they only had the forms filled out in 2021 requesting approval of Alzheimers Demenita Unit. In an interview, the ED on 6/27/22 at 10:11AM, indicated she had reached out to the Indiana Department of Health and recieved further instructions on how to apply for the disclosure for a dementia care unit. A review of the forms available and provided by DON on 1:18PM on 6/24/22 indicated of the information in the 4 page document were typed in and others were hand written. The form showed no indication of approval, licensure, or certification. A review of the resident roster provided by DON on 6/24/22 at 2:07PM, indicated the dementia care secured unit had 17 residents. The current policy and procedure for licensure, approval or certifications was requested and not received by the time of survey exit. At exit the ED provided a 7 page document titled Disclosure for Housing with Service Establishments. The ED indicated this was the first step in a process for receiving disclosure or approval. No other documentation was available at the time of exit. 3.1-13(w)

Based on observation, interview, and record review the facility failed to ensure least restrictive environment for 2 of 2 residents reviewed. (Resident 71 and Resident 76) Findings include: 1) Resident 71's record review began on 6/21/22 at 10:46AM. Resident 71 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 71's MDS (minimum data set) BIMS (Brief interview mental status) score (3) indicated severe limitations in mental status. The MDS indicated Resident 71 was nonverbal, had little to no interest in doing things, and had feelings of or appeared down for 2 to 4 days during 14-day period. Resident 71's most recent care plan indicated a focus of risk for alteration in psychosocial well-being due to requiring isolation. The care plan was initiated on 10/22/21 with the most recent revision dated 1/26/22. Resident 71 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order began on 10/21/21 and was still in effect during survey as of 6/23/22. In an observation on 6/27/22 at 9:10 AM, Resident 71 continued to have signage on their door but gowns and gloves were not in a cart in front of the room 2) Resident 76's record review began on 6/21/22 at 11:46 AM. Resident 76 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 76's MDS indicated her mental status was severely impaired. The MDS indicated mood had little interest or pleasure in doing things, feeling or appearing down, trouble falling or staying asleep, poor appetite for, and trouble concentrating for 7-11 days in the 14-day assessment period. Resident 76 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order began on 10/20/21 and was still in effect during survey as of 6/23/22. Resident 76's current care plan indicated a focus on risk for alteration in psychosocial well being due to requiring isolation. The care plan began on 10/20/21 with the most recent revision on 1/26/22. In an interview on 6/21/22 at 2:48 PM, Resident 76's mother indicated the plan of care was to keep Resident 76 on precautions and confined to the room for the remainder of their days. In an observation on 6/27/22 at 9:10 AM, Resident 76 continued to have signage on their door but gowns and gloves were not in a cart in front of the room. In an interview, on 6/22/22 at 1:14PM, the DON and infection control specialist indicated they had completed training on the difference between contact precautions and enhanced precautions. They provided a record of training dated 5/2/22. Attached to training was a policy titled enhanced barrier precautions dated 2/15/21 with the most recent revision of 6/6/22. The policy indicated it extends barrier precautions with high-contact care .Gown and gloves would not be required for resident care activities other than those considered high contact. Residents are not restricted to their rooms or limited from participating in group activities. 3.1-37

Based on observation, interview and record review the facility failed to ensure adequate nutrition for 2 of 4 residents reviewed. (Resident 9, Resident 63). Findings include: 1) Resident 9's record review, began on 06/22/22 09:08 AM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9 had a BIMS (brief interview of mental status) score of 3 last evaluated on 5/25/22, and indicated severe mental impairment. Resident 9's weight decline indicated by weight documented on 6/16/22 was 111lbs and on 5/2/22 documented as 122lbs a weight loss of 9.02% in 35 days. Resident was care planned for at risk for weight loss. Resident 9 had an order dated for med pass no sugar added twice a day with documentation of amount taken on 6/23/22. A note on 6/8/22 from Dietary indicated Resident 9 was underweight with a weight loss of 9% in 30 days. Weights were completed weekly on 6/1/22 (110.7 lbs.), 6/9/22 (118 lbs.), 6/16/22 (111 lbs.), and 6/24/22 (112 lbs.). Resident 9's recorded weight on 5/2/22 was 122 lbs. Resident 9's meal consumption records, dated 5/28 through 6/23/22, indicated the following: 5/28/22 1 entry at 6:09 PM 5/29/22 1 entry at 6:02 PM 6/8/22 first entry at 7:01AM, prior to meal 6/12/22 2 entries 11:02AM and 11:28 AM 6/14/22 2 entries 10:06AM and 7:45 PM 6/16/22 first entry at 7:18 AM prior to meal 6/18/22 first entry at 8:00 AM prior to meal 6/19/22 1 entry at 7:54 PM 6/22/22 first entry at 7:30 AM prior to meal 6/23/22 1entry at 8:17 AM A list of mealtimes provided by DON on 6/22/22 at 10:36 AM indicated meal serving times for unit Resident 9 resided on as follows 8-8:30AM, 11:45-12:15, and 5:15-5:30PM. In an observation, on 6/22/22 at 9:42AM, Resident 9 was observed with no food eaten from tray. A review of the meal intake documentation indicated at 730 AM percent eaten was 51-75%. In an observation on 6/23/22 at 8:38 AM, breakfast trays were being delivered on the memory care unit. In an interview, on 06/23/22 at 09:43 AM, CNA 2 indicated she charted before or after the meal, whenever she could find time. CNA 2 indicated she knews what they all generally eat. CNA 2 indicated when residents ate, she would go back and adjust it. When asked about Resident 9's breakfast charted at 7:30 AM on 6/22/22 she indicated Resident 9 was a room tray and CNA 2 may have missed rececking her. CNA 2 indicated the only thing Resident 9 ate well was Mexican food and sweets. In an interview, on 6/23/22 at 1:18 PM, the DON (director of nursing), indicated there was a prior issue with weight recordings and/or documentation. The DON indicated they would have only one person doing all of weights to ensure accuracy of documentation. The DON indicated residents should have all meal intake documented after meals were consumed. The DON indicated Resident 9 had food brought in from family and on occasion staff would order her food from Mexican restaurants. 2) Resident 63's record review began on 06/21/22 at 03:59 PM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (minimal data set), provided by DON on 6/27/22 at 10:28 AM, assessment completed on 6/2/22 indicated Resident 63's BIMS (brief interview mental status) score was fourteen indicating intact mental status. The MDS indicated weight loss with no difficulties with chewing or swallowing. Resident 63's meal consumption records for the last 30 days dated 5/9/22 through 6/25/22 indicated the following: 5/29/22 1 entry at 7:42 PM 5/30/22 2 entries 10:30 AM and 8:42 PM 6/2/22 1 entry at 7:49 PM 6/4/22 2 entries both at 1:57 PM 6/6/22 2 entries 9:24 AM and 1:52 PM 6/7/22 2 entries 8:10 AM and 12:14 PM 6/8/22 2 entries 9:41 AM and 1:36 PM 6/11/22 1 entry at 12:43 PM 6/12/22 1 entry at 9:40 PM 6/14/22 2 entries 10:49 AM and 1:01 PM 6/17/22 2 entries at 12:58 PM 6/25/22 2 entries 9:58 AM and 9:14 PM. Resident 63's weights were recorded as 95 lbs. on 6/23/22, no weight was recorded for 6/16/22, 98 lbs. on 6/9/22, 94 lbs. on 6/1/22, 108 lbs. on 5/2/22, and 116 lbs. on 12/30/22. Resident 63 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nutrition dietary note, dated 6/8/22, indicated Resident 63 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The dietary entry indicated Resident 63 did not like the taste of the med pass and teh facility would attempt to use it as creamer in coffee to drink more of it. The physicians note dated 6/20/22 indicated the plan of care was to continue the current plan as it met Resident 63's needs. Resident 63's MAR (medication administration record) and TAR (treatment administration record) dated May 2022 and June 2022, indicated the following Ensure intakes: 5/5/22 8AM 50% 5/9/22 0% at 12 noon 5/10/22 8AM 25% and at 12 noon 50% 5/13/22 8AM 75% and 50% at 5 PM 5/26/22 12 noon 75% 6/21/22 12 noon 237%, 5PM 237% 6/22/22 8AM 125 %, 12 noon 125%, 5PM 125% 6/23/22 8AM 237%, 12PM 237%, 5PM 236% 6/24/22 8AM 237%, 12PM 237%, 5PM 237% 6/27/22 8AM 237% May and June's documented intake of Ensure ordered 120ml twice daily documented the following: 5/3/22 8PM 120% 5/4/22 8AM 120% and 8PM 120% 5/5/22 8AM 120% and 8PM 120% 5/6/22 8AM 120% and 8PM 120% 5/10/22 8AM 25% and 8PM x 5/11/22 8PM 120% 5/12/22 8AM 120% 5/13/22 8AM 120% and 8PM 120% 5/14/22 8PM 120% 5/15/22 8PM 120% 5/16/22 8AM 120% 5/19/22 8PM 120% 5/20/22 8AM 120% and 8PM 120% 5/23/22 8AM 120% 5/25/22 8AM 120% 5/26/22 8AM 120% 5/28/22 8PM 120% 5/29/22 8AM 120% and 8PM 120% 5/30/22 8AM 120% and 8PM 120% 5/31/22 8AM 120% and 8PM 120% 6/1/22 8AM 120% and 8PM 120% 6/2/22 8AM x 6/5/22 8PM 120% 6/6/22 8PM 120% 6/7/22 8AM 120% and 8PM 120% 6/8/22 8AM 120% and 8PM 120% 6/9/22 8AM 120% and 8PM 120% 6/11/22 8PM 0% 6/12/22 8AM 0% and 8PM 0% 6/13/22 8AM 120% and 8PM 60% 6/14/22 8AM 120% and 8PM 120% 6/15/22 8AM 120% and 8PM 120% 6/16/22 8AM 120% and 8PM 120% 6/17/22 8AM 120% The order was discontinued on 6/17/22. May and June's documented intake of Ensure ordered 60 ml three times daily documented the following: 5/4/22 2PM 60% and 8PM 60% 5/5/22 8PM 60% 5/6/22 8PM 60% 5/7/22 8PM 60% 5/9/22 10AM 0% and 8PM 0% 5/10/22 8PM x 5/11/22 8PM 60% 5/19/22 8PM 60% 5/20/22 10AM 60%, 2PM 60%, and 8PM 60% 5/23/22 10AM 60% and 2PM 60% 5/24/22 10AM 60% and 2PM 60% 5/28/22 8PM 60% 5/29/22 10AM 60%, 2PM 60ml, and 8PM 60% 5/30/22 10AM 60% and 2PM 60% 6/1/22 10AM 60% and 2PM 60% 6/2/22 10AM 0%, 2PM 0%, and 8PM 0% 6/3/22 10AM 0%, 2PM 60%, and 8PM 120% 6/4/22 10AM 120%, 2PM 120%, and 8PM 120% 6/5/22 10AM 120%, 2PM 120%, and 8PM 120% 6/6/22 8PM 60% 6/7/22 10AM 60%, 2PM 60%, and 8PM 60% 6/8/22 10AM 60%, 2PM 60%, and 8PM 60% 6/9/22 10AM 60%, 2PM 60%, and 8PM 60% 6/10/22 10AM 60% 6/11/22 0% at 8PM 6/12/22 10AM 0%, 2PM 60%, and 8PM 0% 6/13/22 10AM 60%, 2PM 60%, and 8PM 60% 6/14/22 10AM 60%, 2PM 60%, and 8PM 60% 6/15/22 10AM 60%, 2PM 60%, and 8PM 60ml 6/16/22 10AM 60%, 2PM 60%, and 8PM 60% 6/17/22 10AM 60%, 2PM 60ml, and 8PM 60% 6/18/22 2PM 60% and 8PM 60% 6/19/22 10AM 60% and 8PM 60% 6/20/22 10 AM 60%, 2PM 60% and 8PM 60% 6/21/22 10 AM 60% and 2PM 60% 6/22/22 10 AM 60%, 2PM 60% and 8PM 60% 6/23/22 10 AM 60% and 2PM 60% 6/24/22 10 AM 60%, 2PM 60% and 8PM 60% 6/25/22 8PM 60% 6/26/22 10 AM 60% and 2PM 60ml The most recent care plan indicated the focus was at risk for potential nutrition problem, the goal was will not exhibit significant weight loss, and the interventions begun on 12/7/21. An intervention in the care plan was to document fluid and food intakes. In an interview, the RD (registered dietician) on 6/27/22 at 10:22 AM, indicated the importance of accurate documentation of intake to determine the best plans of action with weight loss. A policy titled Nutritional Intake last revised 12/6/21 provided by DON, on 4/24/22 at 10:29 AM, indicated maintains acceptable parameters of nutritional status, such as usual body weight or desired body weight 1) Food intake at each meal is recorded by percentages 3.1-46

Based on interview and record review, the facility failed to ensure the [CONDITION(S)] communication was consistent for 1 of 1 residents. (Resident 46) Findings included: A record review for Resident 46 began on 06/23/22 at 03:06 PM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A brief interview of mental status (BIMS) dated 6/20/22 indicated a score of 14 of 15, meaning the resident was cognitively intact. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Do not take blood pressure on left with fistula/shunt. A review of Resident 46's [CONDITION(S)] communication book indicated there was no current communication sheets from and to [CONDITION(S)] center. The last communication form was dated 2/22/22. The resident did not have a communication form for the dates 5/9/22, 5/11/22, 5/13/22, 5/16/22, 5/18/22, 5/20/22, 5/23/22, 5/27/22, 5/27/22, 5/30/22, 6/1/22, 6/15/22, and 6/17/22. A progress note dated 6/22/22 at 1:14 PM, indicated Resident 46 refused to go to [CONDITION(S)]. The Nurse Practitioner ordered a stat Basic Metabolic panel test due to a total of 3 hours [CONDITION(S)] from previous Monday (6/13/22) and Wednesday (6/15/22). Resident 46 refused [CONDITION(S)] on 6/17/22, 6/20/22 and 6/22/22. A progress note dated 6/6/22 at 10:34 AM, indicated Resident 46 refused to go to [CONDITION(S)] on 6/3/22. There were no more progress notes to indicate when Resident 46 refused to go to [CONDITION(S)] or when the resident left early from [CONDITION(S)] center. A care plan dated 5/17/22 indicated a focus: Resident 46 is resistive to care IE: [CONDITION(S)]. The goal: the resident will cooperate with care through the next review date. The target was dated 9/20/22. The interventions: allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome (s) of not complying with treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 5/16/22 indicated the focus: [CONDITION(S)]. No goal noted. The interventions: encourage resident to attend as she has a history of being non-compliant with attending scheduled [CONDITION(S)]. Do not draw blood or take blood pressure in left forearm. Do not take blood pressure on arm with shunt. Dry weights obtained from [CONDITION(S)] center. Fluid restrictions: 1500 milliliters/day. Observed for bleeding at [CONDITION(S)] access site. Observe/report as needed any signs and symptoms of infection access site: redness, swelling, warmth or drainage. Observe/ report as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On the May dates: 16, 18, 20, 23, 25, 27, and 30, Staff checked the resident went to [CONDITION(S)]. There was no documentationon the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff checked the residnet went to [CONDITION(S)]. There was no documentation to indicate the resident had refused. A blank pre/post [CONDITION(S)] communication form was provided by the DON on 6/24/22 at 11:46 AM. There were 3 sections on the form. The first section was a pre-[CONDITION(S)] to be filled out by facility. The second section was to be completed by the [CONDITION(S)] center. Then a post [CONDITION(S)] section was to be completed by facility. In an interview, the Director of Nursing (DON) on 6/24/22 at 9:15 AM, indicated Resident 46 was readmitted back into the facility in May 2022. The resident went out to the hospital, so she would not have anything for those dates. The Resident was known to refuse [CONDITION(S)] and or want to leave early, but there still should have been something in the communication book on the times she did go and when she left early. There should have been a progress notes to indicate the resident refused to go. A current facility policy, [CONDITION(S)], dated 12/29/21, was provided by the DON on 6/27/22 at 11:25 AM. The policy indicated . purpose: to provide care guidelines for the resident who receives [CONDITION(S)] at another facility .This facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal [CONDITION(S)] consistent with professional standards of practice including the: Arrangements for safe transportation to and from the [CONDITION(S)] facility .Ongoing assessment of the resident's condition and monitoring for complications before and after [CONDITION(S)] treatments received at a certified [CONDITION(S)] facility; and on going communication and collaboration with [CONDITION(S)] facility regarding [CONDITION(S)] care and services 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure recipes and menus were followed for pureed diets. This affected 4 of 4 residents who received pureed diets. Findings include: On 4/25/21 at 4:55 p.m., the kitchen was observed. Cook 9 was observed to obtain the following food temperatures (temps) of pureed foods from the steam table: pureed green beans, mashed potatoes and pureed chicken pot pie. No other pureed food items were observed in the kitchen to be served at this time. On 4/25/21 at 5:11 p.m., the food service began. At 5:40 p.m., Cook 9 prepared a pureed meal. She placed a serving of pureed peas and pureed chicken pot pie on the plate. She then handed the plate to the Dietary Aide, who put the plate on the cart to be served. At this time Cook 9 was interviewed. She was asked if she had prepared pureed bread. She indicated she had put the bread in the pureed chicken pot pie. She indicated she made 4 servings of pureed chicken pot pie because there were 4 residents who required pureed meals. She indicated she had pureed the following ingredients for the pureed pot pie: 4 scoops of chicken pot pie, 4 slices of bread and 4 ladles of gravy. Cook 9 indicated she had a recipe for the pureed chicken pot pie. On 4/25/21 at 5:30 p.m., the menu posted in the dining room for evening meal included: chicken pot pie, Capri vegetables, and dinner roll. On 4/28/21 at 10:05 a.m., Food Service Manager (FSM) was interviewed. She indicated the recipe for pureed pot pie was to prepare the pot pie according to the recipe for regular pot pie and then process it until smooth. She indicated with this recipe, there were to be no other items added to the pureed chicken pot pie. On 4/28/21 at 10:15 a.m. the FSM provided provided a copy of the recipe for pureed pot pie. The recipe indicated to prepare the pot pie according to the regular recipe. The recipe then indicated to process the pot pie until smooth. No other ingredients were listed to have been added to the pureed chicken pot pie. Bread had not been listed as an ingredient for the chicken pot pie. On 4/28/21 at 11:40 a.m., the 2021 Menu Spreadsheet, Cycle day 22, was reviewed. The spreadsheet indicated the pureed meal was to be, pureed pot pie and a #16 scoop of pureed bread. On 4/29/21 at 2:09 p.m., the Executive Director (ED) was made aware pureed bread had not been served for the evening meal on 4/25/21. He was also made aware the recipe for the pureed pot pie served on the same evening had not been followed. He indicated recipes should be followed and the spread sheet should also have been followed. On 4/29/21 at 2:55 p.m., the ED was interviewed. He indicated he had spoken with Cook 9 in the kitchen. The ED indicated Cook 9 acknowledged to him she did not follow the pureed pot pie recipe and also did not prepare pureed bread separately for the evening meal on 4/25/21. 3.1-20(i)(1) 3.1-20(i)(4)

Based on observation, interview, and record review, the facility failed to implement and maintain infection control practices during a pandemic, to mitigate the spread of infection for 4 of 58 residents. (Resident 32, Resident 107, Resident 35 and Resident 257) Findings include: 1. On 4/26/21 at 11:18 a.m., Activity Assistant 10 was observed to enter the [NAME] Unit hall through the service area. She was observed to not have a mask and shield or goggles on. In the hall by the nurses station were two residents seated in wheelchairs. One resident was observed without a mask on. Activity Assistant 10 was observed to speak to the residents as she walked by them. Activity Assistant 10 walked the entire length of the [NAME] Unit hall and was observed to enter the Memory Care unit. As she walked through the [NAME] Unit, she indicated I guess I should put my mask on. On 4/26/21 at 3:06 p.m., Activity Assistant 10 was observed on the memory care unit sitting at a table with a resident. She was observed to have on an N95 mask and a shield. At this time, she was interviewed. She indicated she was an Activity Assistant in Memory Care. She was made aware she was observed to walk into the facility through the hall of resident rooms without a mask and shield or goggles on. She indicated this was because she kept her mask and shield in her office, which was located inside the Memory Care unit. She indicated when she left the facility for the day, she removed her mask and shield in her office, and left them there. She further indicated after removing her mask and shield at the end of her shift, she then walked out of the Memory Care unit, with no mask or shield on, down the hall of resident rooms, by the dining room and back out the service entry by the kitchen. On 4/29/21 at 3:00 p.m., the Regional Director of Clinical Services was interviewed. She indicated Activity Assistant 10 had not been vaccinated for COVID 19. On 4/30/21 at 8:30 a.m. the LPN 5/Infection Preventionist (IP) was interviewed. She indicated it was facility policy all staff were to wear an N95 mask and shield at all times. She indicated the facility followed current Centers for Disease Control (CDC) guidance for wearing masks and shields and the nose and mouth were to be covered at all times. 2. On 4/25/21 at 4:28 p.m., the kitchen was toured. Cook 9 was observed with an N95 mask on but with nostrils visible over the top edge of her mask. Dietary Aide 8 was observed with an N95 mask and beard restraint on. Dietary Aide 8's mask was observed below his nose and mouth, with the mask covering most of the beard restraint. On 4/25/21 at 4:30 p.m., Dietary Aide 8 was observed to leave the kitchen and return at 4:40 p.m. When Dietary Aide 8 was observed to leave the kitchen and return, the mask remained below his nose and mouth. On 4/25/21 at 4:40 p.m., Dietary Aide 8 was observed to place baked cookies into individual serving bags. Dietary Aide 8 continued to be observed with mask still below nose and mouth. On 4/25/21 at 4:43 p.m., Dietary Aide 8 was interviewed as to how the mask was typically worn. Dietary Aide 8 indicated over his nose. Dietary Aide 8 continued to bag cookies with mask below nose and mouth. Dietary Aide 8 was then interviewed as if there was a reason the mask was below nose and/or mouth. Dietary Aide 8 indicated no and continued to bag cookies with mask below nose and mouth. Dietary Aide 8 was interviewed again if he was supposed to have mask covering nose and mouth. Dietary Aide 8 indicated yes. Dietary Aide 8 was then observed to pull mask over nose and mouth. Dietary Aide 8 was then observed to perform hand hygiene at the handwash sink. On 4/25/21 at 4:55 p.m., Cook 9 was observed to return to the kitchen. Cook 9's mask was still observed below nose. On 4/25/21 at 4:57 p.m., Cook 9 was observed to obtain food temperatures from the steam table. Cook 9's nostrils were visible over the top edge of the mask as the food temperatures were obtained. On 4/25/21 at 5:02 p.m., Dietary Aide 8 was observed at the handwash sink with mask observed below nostrils and mouth. On 4/25/21 at 5:03 p.m., Cook 9 was observed to remove pan of cauliflower from the steamer, with mask below nostrils. On 4/29/21 at 2:09 p.m., the Regional Director of Clinical Services and the Executive Director (ED) were made aware on 4/25/21 during the evening meal, two staff in the kitchen were wearing masks with nose and/or mouth exposed. They indicated the nose and mouth were to be covered with masks at all times. On 4/29/21 at 10:43 a.m., the Regional Director of Clinical Services was interviewed. She indicated Cook 9 had completed the COVID 19 vaccines series on 2/11/21. She further indicated Dietary Aide 8 and Activity Assistant 10 had no had the COVID 19 Vaccine. On 4/30/21 at 10:28 a.m., the Regional Director of Clinical Services provided a current copy of the undated procedure for Personal Protective Equipment (PPE). The policy included the following: Place the mask snugly over your nose and mouth and below your chin. On 4/30/21 at 12:00 p.m., the COVID 19 testing was reviewed for the facility. Cook 9, Dietary Aide 8 and Activity Assistant 10 had been tested for COVID 19 on 4/28/21, with all 3 test resulted as negative. 3. On 4/28/21 at 3:05 p.m., RN 2 (Registered Nurse) was observed to prepare to change the coccyx wound dressing for a resident. She was observed to remove the resident's old dressing. RN 2 then walked into the resident's bathroom and removed her gloves. She then turned on the water, put her hands under the water, pumped the paper towel dispenser and dried her hands, having turned off the faucet with the used, wet paper towels. The entire handwashing procedure lasted for about 6 seconds. On 4/30/21 at 8:30 a.m., LPN 5, the facility Infection Preventionist, was interviewed. She indicated the lathering portion of the handwashing itself should take at least take 20 seconds. 4. On 4-28-2021 at 12:20 p.m., QMA 1 (Qualified Medication Aide) was observed to walk into Resident 107's room, which had transmission based precaution (TBP) signage on the door and a personal protective equipment bin outside of the room by the door. The QMA was observed to be wearing an N-95 mask and a face shield. She walked into the room with out a disposable gown on and carrying gloves in her hand. She was observed to enter the bathroom and came out putting on the gloves. The QMA stood approximately 3 foot from the Resident 7's feet. The QMA was in the room approximately 2 minutes. When leaving the room, the QMA was observed to remove the gloves and performed hand hygiene with hand sanitizer as she left the room. An interview with QMA 1 as she left the room on 4-28-2021 at 12:22 p.m., indicated she was assigned to Resident 107 and was moved to a different room today. She indicated Resident 107 was on quarantine TBP prior to moving rooms today. She indicated she had not seen the four TBP signs on the opened door, when she entered the room nor had she seen the PPE bin outside of the room by the door. The QMA indicated she had not realized Resident 107 was still on TBP after being moved to a different room. She indicated Resident 107 was near completing the 2 week admission quarantine, but did not know the exact date. QMA 1 further indicated she should have worn a gown and gloves when she went into the room. An interview with the Infection Preventionist on 4-28-2021 indicated Resident 107 was admitted on [DATE] and was still on TBP quarantine. 5. An observation on [NAME] hall outside of the shower room on 4-26-2021 at 2:55 p.m., indicated the laundry cart was observed with the blue flap not covering the side of the cart. The blue flap was laying on top of the cart. There were blankets/linens observed on the cart. An observation on [NAME] hall outside of the shower room and on the opposite side of the hall on 4- 1 at 4:12 p.m., indicated the laundry cart was observed with the blue flap up on top of the cart. There were blankets/linens observed on the cart. An interview with CNA 6 (Certified Nurse Aide) on 4-29-2021 at 4:00 p.m., indicated the laundry cart in the hall should have the flaps down to protect the linens. 6. During an observation of a wound care for Resident 35 on 4-28-2021 at 3:30 p.m., RN 2 was observed to wash her hands in the bathroom for less than 10 seconds. The nurse donned gloves and assisted the resident to reposition. The nurse was observed to use a washcloth and dermal wound cleanser to clean the wound area. The nurse was observed to remove her gloves and wash her hands for less than 10 seconds. The nurse donned clean gloves and applied the prescribed dressing. The nurse was observed to remove her gloves and washed her hands for less than 10 seconds. After the observation of the wound care for Resident 35 with Nurse 2 on 4-28-2021 at 3:41 p.m., the nurse was observed to carry the soiled washcloth in her bare hand from the resident's room, down the hallway to the shower room. The nurse was observed to place the soiled washcloth in the covered linen barrel and return to the nurse station without washing her hands or using hand sanitizer. An interview with CNA 7 (Certified Nurse Aide) on 4-29-2021 at 4:02 p.m., indicated soiled linens from a resident room should be bagged when transported to the shower room and placed in the soiled linen container. An interview with RN 3 on 4-30-2021 at 9:30 a.m., indicated prior to a wound treatment, she would lather her hands with soap and water for 15 seconds, dry her hands, and don gloves. The old dressing would be removed and she would remove her gloves and use hand sanitizer. The nurse indicated she would then don clean gloves and apply the new dressing, remove her gloves and wash her hands or use hand sanitizer. 7. The record review for Resident 257 began on 4-28-2021 at 9:49 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview for Mental Status of 13/15 (cognitively intact). Resident 257 needed a limited assist of 1 person for bed mobility, an extensive assist of 2 persons for transfers, supervision with set up help for eating and locomotion on unit, supervision of 1 person for locomotion off unit and personal hygiene and a limited assist of 1 person for dressing and toilet use. Continuing the record review of the most recent hospital history and physical reports on 4-29-2021 at 1:50 p.m., Resident 257 had been diagnosed with MRSA ([CONDITION(S)] Resistant Staphylococcus aureus, a difficult to treat infection which was resistant to multiple antibiotics). The resident returned to the facility on [DATE] with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 4/25, 26, 27, 28, and 29, 2021 at the entrance of Resident 257's room, indicated there were not any type of contact precaution signs to indicate what personal protective equipment was required to enter the resident's room. There was not a personal protective equipment container observed outside the resident's room door. Staff had been entering the resident's room during the survey with a N95 or surgical mask and face shield for care. The facility staff had not been observed to wear a gown or gloves when entering Resident 257's room for care. An interview with the Infection Preventionist and the Regional Director of Clinical Services on 4-29-2021 at 2:47 p.m., indicated a resident who was positive for MRSA should have had contact precautions implemented. Both the Infection Preventionist and the Regional Director of Clinical Services indicated they were not aware Resident 257 returned from the hospital positive for MRSA. An interview with RN 4 on 4-29-2021 at 3:11 p.m., indicated at the beginning of his shift, Resident 257 was noted to have [CONDITION(S)] and a wound on his sacrum. RN 4 indicated he knew the resident was receiving [MEDICATION(S)] at [CONDITION(S)] per a progress note posted at the nurse station but the nurse was not aware the resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An observation of Resident 257's room door on 4-29-2021 at 4:03 p.m., indicated there was a yellow zone sign and a sign with donning/doffing instructions for PPE on the room door. A PPE cart with gowns, N95 masks, and face shields was observed outside of the room door. There were no gloves observed in the cart. On 4/29/21 at 2:31 p.m., the Regional Director of Clinical Services provided a current copy of the policy and procedure for Hand Hygiene, dated May 15, 2020. The policy and procedure included the following: Five moments for hand hygiene and included: before clean/aseptic procedures. With arms angled down, wet hands and wrists with warm water and apply soap. Work up a generous lather by vigorously rubbing your hands together for at least 20 seconds. Rinse your hands and wrists well. Pat your hands and wrists dry with paper towel. If the sink is isn't equipped with knee or foot controls, turn off the faucets by gripping the with a paper towels to avoid recontamination your hands. A current policy, Laundry Services revised on 12-21-2021, was provided by the ED (Executive Director) on 4-30-2021 at 8:05 a.m. The policy indicated .Facility staff should hand all used laundry as potentially contaminated and use standard precautions with with appropriate personal protective equipment .all soiled linen should be bagged A current policy, Use of a Linen Cart reviewed on 2-26-2021, was provided by the ED on 4-30-2021 at 8:05 a.m. The policy indicated, .Personnel must handle, store, process, and transport linens so as to prevent the spread of infection Carts must be covered at all times A current policy, Contact Precautions dated 2-15-2021, was provided by the Regional Director of Clinical Services on 4-29-2021 at 3:19 p.m. The policy indicated .Contact Precautions are used for disease transmitted by contact with the patient or the patient's environment. Diseases caused by organisms that have been demonstrated to cause heavy environmental contamination, such as .[CONDITION(S)]-Resistant Staphylococcus aureus (MRSA) .require gowns and gloves on room entry .when a resident is placed on contact precautions, the staff should implement the following: the type or type(s) of precautions and the appropriate PPE to be used .make PPE (e.g., gowns and gloves) readily available near the entrance to the resident's room .place contact precautions signage (may be more than one type), on the outside of the resident room in a conspicuous place such as the door or on the wall next to the doorway identifying the resident is on contact precautions .The sign should include the instructions for use of PPE, and/or instructions to see the nurse before entering On 4-30-2021 at 12:30 p.m., the Regional Director of Clinical Services provided the 4 signs posted on Resident 107's room door. Sign 1 stated, RESERVED FOR YELLOW. Sign 2 was the CDC's (Centers for Disease Control and Prevention) non-dated poster, titled, SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE), indicated, .1. GOWN .4. GLOVES .USE SAFE WORK PRACTICE TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION Sign 3 and Sign 4 were CDC's non-dated posters, titled, HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1 and HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2. 3.1-18(a)

Based on interview and record review, the facility failed to ensure activities of daily living were provided for 2 of 3 residents reviewed. (Resident 43, and Resident 10). Findings include: 1. The clinical record for Resident 43 began on 4-26-21 at 3:22 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment dated [DATE] was reviewed. Resident 43's BIMS (Brief Interview for Mental Status) score was 15/15, which indicated Resident 43 was cognitively intact. The functional status for ADL (activities of daily living) dated 3-31-21, indicated Resident 43's assistance with bathing (self-performance) required, physical help in part of bathing activity with a one person physical assist. A current care plan initiated on 3-18-21, indicated Resident 43 required assistance of one staff, with his activities of daily living, including bathing/showering. Resident 43 was interviewed on 4-26-21 at 9:52 a.m., and indicated the CNAs (Certified Nurse a Aide), did not consistently provide the resident with a shower/bath. On Saturday 3-24-21, the resident received the first bath in several days. Resident 43 indicated this usually happened often, going days without bathing/showering. ADL charting dated 4-10-21 through 4-16-21, indicated there was no documentation Resident 43 received a bath/shower. Further review of the charting, indicated on dates from 4-17-21 through 4-24-21, there was no documentation Resident 43 received a bath/shower. An interview with the Director of Nursing (DON) on 4-27-21 at 11:00 a.m., indicated there was no way to prove if Resident 43 did or did not receive a shower for those dates since there was no documentation. 2. The record review for Resident 10 began on 4-29-2021 at 3:43 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 10's Annual MDS (Minimum Data Set) Assessment, dated 2-12-2021, indicated the Brief Interview for Mental Status (BIMS) Score was 04/10, which indicated severe cognitive impact. Resident 10's functional status assessment indicated the resident required extensive assistance for personal hygiene and bathing did not occur during the assessment period. The assessment also reported Resident 10's balance was not steady and was only able to stabilize with staff assistance during transitions. The resident had functional limitations in range of motion due to impairment on one side and used a wheelchair for mobility with extensive assistance of 1 person to push them in the wheelchair. Resident 10's Care Plans, revised on 2-17-2021, indicated they needed assistance with activities of daily living related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal for Resident 10 was to wash face and hands during personal care and/or bathing/showering. Interventions included during bathing/showering, check nail length, trim and clean nails on bath day and as necessary, observe skin and report any changes/abnormalities to the nurse, and required assistance of one staff. Resident 10 was to be encouraged to wash face and hands and to be provided additional staff assistance as needed. Review of Resident 10's Point of Care (POC) documentation for ADL's (Activity of Daily Living) and CNA (Certified Nurse Aide) Bath Sheet/Skin Check forms indicated the following for bathing: The March 2021 POC documentation was lacking for bathing on 3-8-2021, a scheduled shower day. Documentation was also lacking for bathing from 3-5-2021 to 3-10-2021 and indicated Resident 10 did not receive a bath/shower for 6 days. The documentation was lacking for a scheduled shower day on 3-15-2021. The POC documentation for bathing on 3-12-2021, 3-13-2021, 3-14-2021, and 3-16-2021 reported the activity (bathing) had not occurred. The facility also lacked documentation on the POC and a CNA Bath Sheet/Skin Check on 3-17-2021, which indicated Resident 10 was not bathed for 10 days. There also was no documentation for the reason why the bath or shower had not occurred. The April 2021 POC documentation was lacking for bathing on scheduled shower days, 4-19-2021 and 4-22-2021. The documentation was lacking on POC and the CNA Bath Sheet/Skin Check forms from 4-16-2021 to 4-26-2021, and indicated Resident 10 was not bathed for 10 days. An interview with CNA 11 on 04-29-2021 at 10:45 a.m., indicated they had taken care of Resident 10 for a long time. The CNA indicated the residents' bath/shower schedules were in the shower binder. The CNA checked the shower binder and indicated Resident 10 was scheduled for showers on Mondays and Thursdays, on the evening shift. They also indicated their tablets (a portable computer) also inform the CNAs of which residents are due for showers. The CNA indicated the residents' showers or baths were documented on the tablet and a bath/shower sheet was also to be completed for the resident's shower. The CNA also indicated if a resident refused a shower, they were to document the refusal on the tablet and on the shower sheet. The resident's refusal was to be reported to the nurse. CNA 11 indicated if a CNA did not know Resident 10 well, they might receive a refusal from Resident 10, as he usually says no when asked, but Resident 10 really liked the showers. The current facility policy, Activities of Daily Living (ADLs), dated 5-5-20, was provided by the Regional Director of Clinical Services on 4-27-21 at 4:08 p.m. The policy indicated .The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living. This includes Hygiene-bathing, dressing, grooming, and oral care 3.1-38(a)(1)

Based on observation, interview, and record review, the facility failed to ensure enteral tube feedings (feeding using the gastrointestinal tract to deliver part or all of a person's caloric requirements) were monitored for 2 of 2 residents reviewed. (Resident 34, Resident 41) Findings include: 1. On 4/27/21 at 1:30 p.m. the record of Resident 34 was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The most recent quarterly Minimum Data Set (MDS) Assessment, dated 3/10/21, indicated the following: received 51% or more total calories through tube feeding; average fluid intake received per day by tube feeding was 501 or more cc (cubic centimeter)/day or more; no weight loss of 5% or more in last month or 10% or more in last 6 months. A physician order, dated 3/2/21, indicated to record total amount given from TF (tube feed) and to clear pump totals once recorded. A plan of care, revised on 3/12/21, addressed the focus of at risk for complications due to requiring tube feeding related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the following: Registered Dietician to evaluate quarterly and as needed. Make recommendations for changes to tube feeding as needed. Resident is dependent with the tube feeding and water flushes. Tube feeding and water flushes as per physician/Nurse Practitioner orders. A Nutrition/Dietary note dated 4/22/21 indicated the resident was NPO (nothing by mouth), and TF (tube feed) dependent. They received [MEDICATION(S)] 1.5 at 50 ml(milliliters)/hr (hour) for 24 hours daily, 250 ml fluid flushes every 6 hours. On 4/26/21 at 10:00 a.m., the following was observed: 1500 ml bottle of [MEDICATION(S)] 1.5 (therapeutic nutrition which provides complete, balanced nutrition) was hanging on a pump. A bag of clear fluid was observed hanging on the same pump, both were infusing. The screen, indicated the feeding was programmed to infuse at 50 ml/hr (hour). The flush was observed to be programmed on the pump to infuse 250 cc (cubic centimeters), every 6 hours. Both the bottle of [MEDICATION(S)] and the bag of clear fluid were dated 4/25/21 but did not have a time each was hung and/or no name or initials of who had hung each. On 4/27/21 at 11:16 a.m., the following was observed: bottle of [MEDICATION(S)] 1.5, 300 ml in bottle, infusing at 50 ml/hr, with a date of 4/26/21 written on the bottle. Documentation was lacking on the bottle of [MEDICATION(S)] as to time the bottle was hung and/or who had hung the bottle. The flush bag, with clear fluid hanging, was labeled with a sticker with the following information: formula [MEDICATION(S)] 1.5, hung at 12:00 a.m. on 4/27. The flush bag was observed to contain 900 cc of fluid. Both the [MEDICATION(S)] and flush bag were hanging on the same pole and pump. On 4/28/21 at 3:21 p.m., RN 2 was interviewed. She indicated Resident 34 was to receive 50 ml of feeding per hour continuously and 250 cc of flush every 6 hours. She indicated the flush amount was programmed into the pump and was automatically infused as a bolus. She indicated to document the amount of feeding and flush the resident received, she would look at the screen on the pump. She indicated on the medication administration record, the total intake for the feeding was documented in ml (milliliters) and the total documented for the flush was documented in cc's (cubic centimeters) for the flush. She indicated the measure of ml and cc are equal. She indicated if the totals documented on the medication administration record (MAR) were not the amounts that had been ordered, this indicated someone had not cleared the infusion pump. She indicated the intake totals from the pump were to be cleared at the end of every shift. She indicted if the total for the infusion was high for her 12 hour shift, and she thought someone forgot to clear the pump, she would then multiply the rate ordered by the number of hours in her shift to document the total infused. On 4/28/21 at 4:38 p.m., the Regional Director of Clinical Services was interviewed. She indicated the amount of flush was documented in cc's on the MAR. She indicated the resident was to receive 250 cc of flush every 6 hours. For intakes documented for each day shift and night shift, the resident should have received 500 cc each shift for a daily total of 1000 cc. She further indicted the tube feedings, documented in ml on the MAR, were 50 ml for 24 hours, so the resident should have received a total of 600 ml for each day and night shift, for a daily total of 1200 ml. On 4/28/21 at 4:39 p.m., the Regional Director of Clinical Services provided a current copy of Resident 34's April 2021 MAR . The daily totals for the flush, (ordered to receive daily total 1000 cc) ranged from 480 cc's on 4/24/21 to 2009 cc's 4/9/21. The daily totals for the tube feeding (ordered to receive daily total 1200 ml), ranged from 878 cc's on 4/21/21 to 2355 cc's on 4/9/21. On 4/28/21 at 4:41 p.m., progress notes for 4/9/21 and 4/24/21 were reviewed. Documentation was lacking for these dates regarding why the feeding and/or flush totals were not as ordered. On 4/29/21 at 3:00 p.m., the Director of Nursing (DON) and the Regional Director of Clinical Services were interviewed. They indicated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They indicated staff ensured physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They further indicated it's a documentation issue because the Dietician bases her recommendation of intake on the resident's weight and the documented intake. The Regional Director of Clinical Services indicated if an amount different than what was ordered was infused, this would be noted in the progress notes. They indicated the resident had not lost weight. On 4/30/21 at 8:30 a.m., LPN 5 and the DON were interviewed. They were made aware the flush bags and the tube feeding bottles were not always labeled with date and time hung and/or ordered rate. They indicated since the two bags of fluid were both connected on one pump, the staff thought they only needed to put information on either the bag and/or bottle of flush and/or feeding but not on both. LPN 5 indicated Resident 34 could not receive over 50 ml/hr of feeding as it was programmed and the flush was automatic. LPN 5 indicated the issue with Resident 34's intake amounts documented was the pump not being cleared at the end of the shift. She indicated the nurses work 12 hour shifts. LPN 5 indicated when nurses come to the facility, she assumed they know how to use the tube feeding pumps and /or if they don't, they would ask someone. LPN 5 indicated she was not certain who reviewed the tube feeding intakes which are are documented in the MAR. On 4/30/21 at 9:30 a.m., RN 3 was interviewed. She indicated she was familiar with how to use the tube feeding pumps. She indicated Resident 34's tube feed infused continuously. RN 3 indicated when she began her shift in the morning, she verified the feeding solution and the rate. She ensured the infusion pump was set at correct rate for the flush and the feeding. She ensured the bottles were labeled, each one with resident's name, date, time, rate and solution hung. She indicated the nurse who hung the flush bag and the solution also put their name on the bottles and/or bags. She indicated each bag was to be labeled separately. RN 3 indicated she knew how much tube feeding and flush solution had infused because when she cleared the pump at the end of her shift, she would get the totals from the screen of the pump. On 4/30/21 at 10:20 a.m., the Regional Director of Clinical Services was interviewed. She indicted on 4/24/21 and 4/25/21, documentation was lacking in the progress notes regarding why the tube feeding and flush were not documented and regarding the variance in the total infused. 2. On 4/27/21 at 3:30 p.m. the record of Resident 41 was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS dated [DATE], indicated the resident had independent cognition, weight loss of 5% or more in last month or 10% or more in last 6 months. A plan of care initiated 2/19/21, addressed the following focus: Resident at risk for complications related to requiring tube feeding as nutritional supplement secondary to progressing [CONDITION(S)], weight loss, and variable appetite/intakes. Interventions included the following: Tube feeding and water flushes as ordered. A physician order, dated 2/25/21, indicated to give enteral feed every night shift, [MEDICATION(S)] 1.2, 65 ml/hr for 12 hours. A physician order, dated 3/19/21, indicated to flush the G-tube with 240 cc water every shift. A Quarterly Nutrition Data Collection, dated 3/26/21, indicated the resident was currently receiving nutrition via gastrostomy tube of [MEDICATION(S)] 1.2 at 65 cc/hr for 12 hours of the day. She also received a regular mechanical soft diet for which she typically required assistance for feeding. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A note dated 4/22/2021 for RAR (Residents at Risk)/IDT (interdisciplinary team) indicated the following: the resident's current weight was 119 lbs (pounds). Weight was up 3 lbs from last week. Resident was on mechanical soft diet and consumed 25-100% of all meals. Resident was currently on enteral feeding from 6:00 p.m. to 6:00 a.m. at 65 ml per hour during that time. On 4/27/21 at 11:36 a.m., Resident 41 was not observed in her room at this time. A feeding pump (turned off) was observed at bedside with the tube feeding and flush bag attached to the same pump. A [MEDICATION(S)] 1.2 bottle (1500 ml capacity) was observed hanging with a total of 1200 ml in the bottle. On the bottle of [MEDICATION(S)] 1.2 tube feeding was the resident's name, date bottle was hung as 4/26 at 7:00 p.m., at a rate of 65 ml/hr. No nurse's name was on the sticker to indicate who had hung the bottle. The sticker on the flush bag, identified the tube feeding as [MEDICATION(S)] 1.2. Nurse initials on the sticker on the flush bag, indicated feeding hung at 7:00 p.m., on 4/26. A total of 900 cc of fluid was hanging in flush bag. On 4/28/21 at 9:30 a.m., Resident 41 was observed in her bed in her room. The resident was interviewed at this time. She indicated she only received the tube feedings during the nighttime hours. On 4/29/21 at 2:31 p.m., the Regional Director of Clinical Services provided a copy of the current policy and procedure, dated November 20, 2020, for Enteral tube feeding, continuous, gastrostomy . The policy included the following: Document the date, time and amount of each enteral feeding and the water volume instilled. Maintain total volumes for enteral formula and water separately to allow calculation of nutrient intake . On 4/29/21 at 3:30 p.m., the DON and Regional Director of Clinical Services were interviewed. They indicated the resident was ordered to receive [MEDICATION(S)] 1.2, infused at 65 ml/hr for 12 hours, for a total feeding of 780 cc. They indicated the resident was ordered to have 240 ml flushes every shift (day and night) for a total flush amount of 480 ml. They indicated if the amount infused was different than what was ordered, the nurses would document this information in the progress notes. They indicated they know the amount the resident received of feeding and flush because the pump would set for rate and amount of time, for each the feeding and/or flush. They indicated the tube feeding pump was set at 65 ml/hr to run from 6:00 p.m. to 6:00 a.m. They indicated it was up to the staff to start the feeding via the pump. The Regional Director of Clinical Services indicated the numerical amount of feeding and/or flush were not documented in the record. She indicated when the nurses documented on the MAR enteral feed order every night shift [MEDICATION(S)] 1.2, 65 ml/hour x (times) 12 hours via pump they are indicating the amount ordered was infused. She indicated when the nurses documented on the MAR flush G tube with 240 cc water q (every) shift . they indicated this was the amount infused. On 4/30/21 at 9:30 a.m., RN 3 was interviewed. She indicated she was familiar with how to operate the tube feeding pumps. She indicated she does not work the night shift but she hangs the feeding for Resident 41 before she leaves for the evening. RN 3 indicated the pump was preprogrammed for the amount to infuse but she verified this rate with the physician order. She indicated the night shift nurse turned the feeding and flush off in the morning. She indicated if the amount actually infused varied from what was ordered, she would note this in the progress notes. 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical procedures were followed for medication/treatment storage, medication labeling and discarding medication for 3 of 4 medication carts and 1 of 2 treatment carts observed. (Resident 1 and Resident 35) Findings include: An observation of the the Back treatment cart located near the nurse station in [NAME] hall and just outside room 49 on [DATE] at 5:05 p.m., indicated the Back treatment cart was unlocked. The Back treatment cart contained dressing supplies and prescription creams/ointments and powders. There were 3 tubes of [MEDICATION(S)] Cream, a tube of [MEDICATION(S)], Biofreeze, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and 4 tubes of [MEDICATION(S)] in the second drawer of the treatment cart along with a container of [MEDICATION(S)] Powder and [MEDICATION(S)] cream. There was a 16 ounce bottle of dermal wound spray observed out on top of the treatment cart sitting next to the Back treatment cart. There were no staff within eyesight of the unlocked treatment cart and no residents were observed near the treatment cart. In an interview on [DATE] at 5:12 p.m., Nurse 3 indicated the treatment cart was supposed to be locked. The nurse indicated she had just used some cream from the Back treatment cart and had not locked the cart. The nurse was observed to lock the Back treatment cart. An observation of the treatment cart on [DATE], at 5:45 p.m., indicated the bottle of dermal wound spray was still out on top of the treatment cart in [NAME] hall. An observation of the [NAME] Hall medication cart on [DATE] at 2:51 p.m., indicated the medication cart was parked at the [NAME] Hall nurse station. The [NAME] Hall medication cart was observed to be unlocked and facing outward toward the hall. Nurse 4 was at the [NAME] Hall nurse station. Nurse 4 was not able to see the unlocked medication cart from the nurse's station. In an interview with Nurse 4 on [DATE] at 2:53 p.m., she indicated she did not realize the [NAME] hall medication cart was unlocked and was observed to come from behind the [NAME] Hall nurse station to lock the medication cart. An interview with DON (Director of Nursing and the Regional Director of Clinical Services on [DATE] at 1:40 p.m., indicated medication and treatment carts should be locked at all times unless in use by the nursing staff to obtain medications and/or treatments. An observation of the medication cart on [NAME] and [NAME] hall with QMA 1 (Qualified Medication Aide) on [DATE] at 11:00 a.m., indicated a medication for Resident 1, an opened bottle of [MEDICATION(S)] 100 units/milliliters (insulin), with no opened date or expiration date was located in the top drawer of the medication cart. An observation of the medication cart on [NAME] hall (front) with QMA 1 (Qualified Medication Aide) on [DATE] at 11:15 a.m., indicated a treatment for Resident 35 was located in the bottom drawer of the medication cart. A treatment of [MEDICATION(S)] 0.1% cream was observed. An interview with QMA 1 on [DATE] at 11:00 a.m., indicated Resident 1's medication of [MEDICATION(S)] 100 units/ml was discontinued as they currently used a insulin injectable pen. QMA 1 was not aware when the insulin was discontinued, but indicated the resident no longer used the vial of insulin. An interview with QMA 1 on [DATE] at 11:15 a.m., indicated Resident 35's treatment should not have been in the medication cart. QMA 1 indicated Resident 35 did move to another hall and indicated all treatments should be stored in the treatment cart. A current policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised on [DATE], was provided by the Regional Director of Clinical Services on [DATE] at 2:48 p.m. The policy indicated, .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart of locked medication room that is inaccessible by residents and visitors .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened A current facility policy, 8.2 Disposal/Destruction of Expired or Discontinued Medications, revised date [DATE], was provided by Regional Director of Clinical Services on [DATE] at 2:48 p.m. The policy indicated .Facility staff should destroy and dispose of medication in accordance with Facility policy and Applicable Law, and applicable environmental regulations Once an order is to discontinue a medication is received, Facility staff should remove this medication from the resident's medication supply 3.,d+[DATE](m) 3.,d+[DATE](r)

Based on interview, and record review, the facility failed to ensure a residents medications were secured and recomciled for 1 of 3 residents receiving a controlled substance. (Resident B) Findings include: A review of Resident B's record on 8/12/2020 at 10:35 a.m., indicated they had a BIMS (Brief Interview of Mental Status) score of 12, meaning moderate cognitive impairment. The score was obtained from the MDS (Minimum Data Set) Quarterly Assessment, dated 6/29/2020. Resident B was also identified by the facility as being alert and oriented, to person, place, and time. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order also indicated the medication may be held if the residnet was sedated or sleeping. During a confidential interview on 8/12/2020 at 2:52 p.m., the interviewee indicated on Saturday morning, June 27, 2020, they counted the narcotics on the [MEDICATION NAME] Back Hall medication cart with day shift LPN 1, and the count was correct. The complainant indicated they went home because their shift was over. LPN 1 had indicated that she usually does not work that hall and was going to trade with LPN 6. The LPN's traded halls and medication carts, but never counted the narcotic medications when the personnel change was completed. They received a phone call from the ADON (Assistant Director of Nursing) that evening. she indicated they were missing 11 [MEDICATION NAME] belonging to Resident B. The ADON indicated to the interviewee, LPN 6 and the oncoming nurse, RN (Registered Nurse) 8 counted the narcotics. There were missing [MEDICATION NAME]. Four nurses had to write statements to give to the ADON. The 2 day shift nurses were drug tested . LPN 6 later bragged her test came back positive and she still got to keep her job. They no longer work there due to this problem, because it has happened before with LPN 6 and the administration has not done anything about it. During an interview on 8/12/2020 at 3:30 p.m., the ADON indicated she was called in on a Saturday, June 27, for a concern with narcotic discrepancy, involving Resident B's [MEDICATION NAME], 11 were missing and not accounted for. She indicated the narcotic sheet had a count of 12. The medications in the narcotic medication card were 1. The ADON admitted to drug testing LPN 1 and LPN 6 on 6/28/2020. The ADON indicated LPN 6's test came back positive for opiates. The ADON indicated LPN 6 informed her that she was on prescribed [MEDICATION NAME] (a narcotic used for pain). The ADON indicated she did not know that LPN 6 was on a prescribed narcotic before the discrepancy. The ADON indicated that Resident B had not missed any of his doses of [MEDICATION NAME]. During an interview on 8/13/2020 at 11:15 a.m., the facility Pharmacist indicated she knew nothing about the discrepancy due to working remotely because of Covid. She indicated she did learn of it when the ED (Executive Director) indicated to her they wanted to put cabinets in the medication rooms for the narcotics, so they could have cameras in the rooms. During an interview on 8/13/2020 at 11:30 a.m., the ED indicated that she did not know LPN 6 was on a prescribed narcotic before the medication discrepancy. She indicated that LPN 6 had showed her a picture of the prescription but the date was not visible, and a hard copy had not been provided to the facility. During an interview on 8/13/2020 at 4 p.m., LPN 1 indicated that her and LPN 6 had not counted the narcotics prior to trading halls and carts, she knows that was wrong and she was disciplined for it. She further indicated when she did the count with the off going QMA that morning of 6/27 the count was correct. She indicated she did not know what happened to the pills. The Pharmacist and the Pharmacist's General Manager, on 8/13/2020 at 12:55 p.m., indicated the following: The prescription of [MEDICATION NAME] for Resident B was filled on 6/22/2020. 42 tablets which would have been a 7 day supply; an every 4 hour routine scheduled medication. LPN 3 had called the pharmacy on 6/26 to obtain a refill, to make sure they did not run out over the weekend. At that time, the pharmacy technician noted that it was too soon to refill as the prescription could only be refilled on 6/29. LPN 3 had counted 20 tablets at that time (10 a.m. on 6/26). On 6/27/2020 30 tablets of [MEDICATION NAME] were filled and a note in the pharmacy dispensing system was made to bill the facility for 30 tablets per the ADON. A review of the Controlled Substance Record, narcotic count sheets, indicated on 6/22/2020 they started the count on the first line at 41 tabs, beginning quantity was 42 tabs. The last documented dose was signed out on 6/27/2020 at 4 p.m.by LPN 6, the count was 12 tabs, with 2 blank lines left to finish the sheet. The second narcotic sheet reviewed indicated the facility had 42 tabs. The first line was dated 6/27/2020, signed at 8 p.m., by RN 8 and ADON for 1 tab administered. The quantity remaining was 0. A third narcotic sheet was reviewed. The first date was 6/28/2020, 1 tab was signed out at 4 a.m. by RN 8 and 29 pills remained. A review of untitled forms used at shift change indicated LPN 6 never confirmed the narcotic card count on 6/27/2020 as the oncoming shift. A review of LPN 6's employee file on 8/13/2020 at 4:55 p.m., indicated there was no documented prescription from a medical professional, nor any documentation indicating the need for such narcotic prescription. During an interview on 8/14/2020 at 2:20 p.m., the ED indicated they had no confirmed evidence that LPN 6 had a prescription for a controlled substance. The ED further indicated LPN 6 was on FMLA(Family and Medical Leave Act) currently. This Federal citation is related to IN 589. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure Care Plans were developed, implemented and updated for 2 of 4 residents reviewed. (Resident C, Resident ) Findings include: 1. On 8/14/2020 at 12 p.m., Resident C was observed in their room, and laying in their bed. A review of Resident C's record on 8/11/2020 at 3:42 p.m., indicated the resident had a BIMS (Brief Interview of Mental Status) score of 14, meaning cognitively intact. The score was obtained from the MDS (Minimum Data Set) Annual Medicare 5 day Assessment, dated 7/9/2020. [DIAGNOSES REDACTED]. The MDS Annual Medicare 5 day Assessment, dated 7/9/2020 indicated the following Functional Status for ADL's (Activities of Daily Living): Bed mobility was limited assistance with 1 physical assist from staff. Transfers were extensive assistance with 1 physical assist from staff. Walking required a physical assist from staff. Dressing, toileting, and personal hygiene were extensive assistance with 1 physical assist from staff. A review of Resident C's Care Plans indicated no were developed or implemented Care Plan for ADL's. During an interview on 8/14/2020 at 1:25 p.m., the ADON (Assistant Director of Nursing) indicated they had been educating Resident C to request assistance from staff when he wanted to ambulate, she further indicated Resident C should have had a Care Plan for ADL's, and he did not. 2. A list of falls provided by the DON (Director of Nursing) on 8/12/2020 at 1 p.m., indicated Resident C had falls on the following dates: 3/24/2020, 4/27/2020, 6/19/2020, 8/7/2020, and 8/11/2020. A review of the Fall Care Plan indicated there were no updated interventions since 4/28/2020. During an interview on 8/14/2020 at 1:25 p.m., the ADON (Assistant Director of Nursing) indicated they had been educating Resident C to request assistance from staff when he wanted to ambulate, and the care plan should have had more current interventions in place. A current facility policy, Fall Management, dated 4/15/2019, provided by the facility, laying on the conference table on 8/14/2020 at 10:35 a.m., indicated the following: .The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS, upon a fall event and as needed thereafter . 3. On 8/11/2020 at 12:20 p.m., Resident M was observed in her room, lying in bed, slightly turned to her right side, and sheets were pulled up over her chest. On 8/13/2020 at 5 p.m., Resident M was observed in her room, lying in bed, sheets were pulled up over her chest. On 8/14/2020 at 11:45 a.m., Resident M was observed in her room, lying in bed, slightly on her right side, and sheets were pulled up over her chest. A review of Resident M's record on 8/11/2020 at 2:43 p.m., indicated a BIMS score of 15, meaning cognitively intact. The score was obtained from the MDS Quarterly Assessment, dated 7/11/2020. [DIAGNOSES REDACTED]. During an interview on 8/11/2020 at 12:20 p.m., Resident M indicated she prefered to just have the sheets cover her, as opposed to wearing clothing or a facility gown. A review of the ADL Care Plan did not indicate Resident M's preference for just a sheet preference under the dressing section. During an interview on 8/14/2020 at 1:25 p.m., the ADON indicated the preference to wear sheets was not care planned and it should have been. A current facility, Resident Assessment Instrument & Care Plan, dated 4/29/2019, provided by the facility, on the conference table, on 8/14/2020 at 10:35 a.m., indicated there had been no Care Plan updates. A current facility policy, Resident Assessment Instrument & Care Plan, dated 4/29/2019 and provided by the facility, laying on the conference table on 8/14/2020 at 10:35 a.m., indicated the following: .The Care Plan includes measure objectives, timeframes to meet the patient's, cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs . This Federal Citation is related to Complaints IN 570, and IN 402. 3.1-35(c)(1)

Based on interview, and record review, the facility failed to ensure that pain medication was administered at the ordered time for 1 of 3 residents reviewed. (Resident B) Findings include: A review of Resident B's record on 8/12/2020 at 10:35 a.m., indicated a BIMS (Brief Interview of Mental Status) score of 12, meaning moderate cognitive impairment. The score was obtained from the MDS (Minimum Data Set) Quarterly Assessment, dated 6/29/2020. Resident B was also identified by the facility as being alert and oriented, to person, place, and time. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of the EMAR (Electronic Medication Administration Record) indicated Resident B received his [MEDICATION NAME] pain medication early without the allotted 4 hour's between administrations. The following dates and times were documented: 3/5/2020 at 7:47 a.m., and 11:14 a.m., administered by LPN 6. 3/8/2020 at 11:06 a.m., and 1 p.m., administered by LPN 6. 3/9/2020 at 7:46 a.m., and 11:13 a.m., adminisitered by LPN 6. 3/12/2020 at 7:42 a.m., and 11:25 a.m., administered by LPN 6. 3/17/2020 at 7:44 a.m., and 11:26 a.m., administered by LPN 6. 3/19/2020 at 7:49 a.m., and 11:06 a.m., administered by LPN 6. 3/22/2020 at 8:57 a.m., and 12:39 p.m., administered by LPN 6. 3/26/2020 at 8:02 a.m., and 11:10 a.m., administered by LPN 6. 3/31/2020 at 8:02 a.m., and 11:39 a.m., administered by LPN 6. 4/4/2020 at 7:57 a.m., and 11:21 a.m., administered by LPN 6. 4/5/2020 at 12:09 p.m., and 3:24 p.m., administered by LPN 6. 4/10/2020 at 7:38 a.m., and 11:09 a.m., administered by LPN 6. 5/2/2020 at 8:02 a.m., and 11:39 a.m., and 3:04 p.m., administered by LPN 6. 5/3/2020 at 7:41 a.m., and 11:03 a.m., administered by LPN 6. 5/25/2020 at 8:06 a.m., and 11:29 a.m., administered by LPN 6. 6/5/2020 at 9:11 a.m., and 11:50 a.m., administered by LPN 6. During an interview on 8/13/2020 at 11:15 a.m., the facility Pharmacist indicated a prn (as needed) pain medications are to be given at the exact hour interval or later, but not before. She indicated if the order is to give every 4 hours as needed, there must be 4 hours between doses. If the medication is scheduled, she indicated the medication may be given an hour before or an hour after the scheduled time. During an interview on 8/14/2020 at 3:50 p.m., LPN 1 indicated a nurse would not give a prn narcotic for pain early. She indicated if they got one at 12 p.m., and it is for every 4 hours prn, they wouldn't get another pill until 4 p.m. A current facility policy, Medication Administration Times, dated 5/1/2010, indicated the following: .Facility should ensure that authorized personnel, as determined by applicable law, administer medications according to times of administration as determined by facility's pharmacy committee and/or physician/prescriber . The facility policy did not have documented information regarding prn pain medications. This Federal Citation is related to Complaint IN 589, IN 969, and IN 431. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure supervision and operation of a mechanical lift with 2 staff members for 1 of 3 residents reviewed for accidents (Resident B). This resulted in the resident falling from the mechanical lift. The resident sustained [REDACTED]. The deficient practice had the potential to affect 19 residents who were transferred with mechanical lifts. The immediate jeopardy began on 3/26/19 when the resident sustained [REDACTED]. Facility staff failed to ensure supervision and operation of the mechanical lift with 2 staff members. The Administrator and Regional Director of Clinical Services were notified of the Immediate Jeopardy at 10:20 A.M. on 4/4/19. The immediate jeopardy was removed on 3/27/19, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 4/1/19 at 12:49 P.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 2/15/19, indicated the resident had a BIMS (Brief Interview Mental Status) score of 15 which signified the resident had no cognitive impairment. The assessment indicated he required extensive assistance from 2 staff members for transfers. A care plan, with an onset date of 7/11/17, indicated the resident required total assistance from 2 staff members and the Hoyer mechanical lift for transfers. Interventions included, but were not limited to, provide adaptive/safety equipment: hoyer lift and 2 assists to transfer. A CNA Care Directive with unknown date, indicated the resident needed the assistance of 2 staff members and use of the hoyer mechanical lift for transfers. A Nurse Progress Note, dated 3/26/19 at 7:01 a.m., indicated the resident and CNA 7 (Certified Nurse Assistant) were heard yelling from the resident's room. The note indicated Resident B was observed still attached to the lift which was leaning against the wall. Resident B's head was leaning against the wall due to pressure of the lift, his back was leaning against the brake bar and his bottom was resting on the foot pedals of his wheelchair. The resident was unhooked from the lift and 4 staff members assisted the resident off the wheelchair foot pedals and onto the seat of the chair. Initially, the resident denied hitting his head but later indicated he had hit his head. New orders were received to send the resident to the emergency room for evaluation and treatment. On 4/2/19 at 10:27 A.M., Resident B was interviewed. During the interview, he indicated he had fallen from the hoyer lift and injured his back. He indicated the CNA who transferred him, never called or summoned another staff member to help transfer him with the lift. The CNA, incorrectly, moved his body off the bed first instead of his legs and then didn't bend his legs for him to sit into the wheelchair. He indicated he had hit the wall, that a picture frame had fallen off the wall and broken during the fall. He indicated the CNA said there wasn't anyone to help her to transfer him but after he fell and started yelling, 3 staff members immediately came running into the room. He indicated he ended up with his bottom on the wheelchair foot pedals and the brake knob (on left side of the wheelchair) in the middle of his back. He indicated he had pain in his lower back. A Nurse Progress Note, dated 3/26/19 at 11:51 a.m. indicated the resident returned from the hospital with spinal x-rays that showed a mild L2 (lumbar vertabrae) superior endplate compression fracture. An order was obtained for the resident to have an MRI of his spine and follow up with the Orthopedic doctors. Nurse Progress Notes from 3/26/19 to 4/3/19 indicated the following: On 3/26/19 at 12:41 p.m., the resident was medicated for complaints of back pain. On 3/27/19 at 2:17 a.m., he had complaints of pain from his fall and was medicated 2 times this shift. On 3/28/19 at 9:31 a.m., late entry for 3/26/19 at 12:15 p.m., the resident was medicated for back pain per order with effective results. The NP (Nurse Practitioner) was notified of his return from the hospital and his elevated blood pressures noted with neuro checks. On 3/29/19 at 6:52 a.m., late entry for 3/28/19 at 6:00 a.m., the resident was monitored for pain for compression fracture of his back. No increased pain noted. He was medicated 2 times this shift for pain and stated they were effective. On 3/31/19 at 12:33 a.m., Resident B complained of pain due to a compression fracture to L2. On 4/2/19 at 2:20 a.m., the resident was medicated 1 time for complaints of pain/discomfort to his back which was effective. On 4/2/19 at 1:55 p.m., the resident complained of increased pain this shift. The NP was notified and an order received to increase his pain medication from [MEDICATION NAME] 5/325 mg (milligrams) by mouth (PO) every 6 hours prn (as needed) for pain to [MEDICATION NAME] 10/325 mg PO every 6 hours prn pain. An MRI scan of the spine, dated 4/2/19 at 3:38 p.m., indicated the resident had [MEDICAL CONDITION] changes and a compression deformity of the lumbar vertebra at L2, L3, L4, and possibly at L1 without [MEDICAL CONDITION] currently representing remote injuries. No definite acute fracture. A physician progress notes [REDACTED]. On 4/2/19 at 10:00 A.M., the Administrator and Regional Director of Clinical Services were interviewed. During the interview, the Administrator indicated an investigation into the resident's fall was immediately undertaken. She indicated CNA 7 should have had another staff member assist her to transfer the resident with the hoyer lift as per the facility policy. CNA 7 was immediately suspended for not following the facility policy which required 2 staff members to be present when residents were transferred with a mechanical lift. Nursing staff were re-educated on the use of the mechanical lift by the facility Rehabilitation Director. All training and return demonstration for employees was to be completed by 4/3/19. No staff were permitted to care for residents until the training was completed. The Director indicated Resident B's care plan was reviewed at the time of the fall and had included the need for mechanical lift transfer with 2 staff members. The resident's CNA care directive was reviewed and correct in the need to transfer with a mechanical lift and 2 staff members. Maintenance reviewed the mechanical lift for sae operation and it was determined the lift had been functioning correctly. On 4/4/19 at 3:19 P.M., LPN 3 (Licensed Practical Nurse) was interviewed. During the interview, she indicated the morning of 3/26/19, she had been the nurse in charge of Resident B. She had just finished completing the resident's dressing changes, and left the room, while CNA 7 continued to assist the resident with dressing and personal care. She indicated, she and another nurse, were at the nurses station, getting ready to pass their morning medications when they heard the resident and CNA 7 yelling. She indicated when she and the other nurse entered Residnet B's room, the hoyer lift was lying on it's side with the resident still attached and sitting on the foot pedals of his wheelchair. LPN 3 indicated there was another nurse and a QMA (Qualified Medication Aid) at the nurses station when the fall occurred. She indicated the CNA never asked for assistance with transferring the resident. On 4/4/19 at 12:16 P.M., the Administrator provided an undated copy of the facility's policy titled Mechanical Lift Use which stated the following: Purpose: The purpose of this procedure is to help lift resident using a mechanical lifting device. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Follow manufacturer guidelines and recommendations with respect to use of device. 2. Staff will be competent in how to use a mechanical lifting device. 3. Two (2) persons are required to perform the procedure The immediate jeopardy that began on 3/26/19 was removed on 3/27/19 when the facility began inservicing CNA's on the procedure for mechanical lift transfers but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced prior to the start of the survey. This Federal tag relates to Complaint IN 711. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for quality of care was treated appropriately for scabies. This deficient practice caused the resident intense itching for three months, thick scales on the skin of the hands and treatment with drugs psychiatric conditions. (Resident G). Findings include: On 4/2/19 at 10:45 a.m., Resident G's record was reviewed. [DIAGNOSES REDACTED]. The resident received hospice services. A quarterly MDS (Minimum Data Set) assessment, dated 12/13/18, indicated the resident had a BIMS (Brief Interview Mental Status) score of 9 which signified moderately impaired cognition. The MDS indicated the resident required extensive assistance from 1-2 staff members with most ADL's (Activities of Daily Living). On 4/2/19 at 10:41 A.M., Resident G was observed sitting in his w/c (wheelchair) in front of the nurses station. He was talkative and engaged in conversation. He indicated he was in a lot of pain and held his hands-palm up to be observed. There were thick white to cream colored scales of skin at the tops of his palms where the palms met the fingers. There was thick scales between the fingers at the base where the fingers met the palms. There were numerous cracks in the skin. An unidentified CNA (Certified Nurse Assistant) approached the resident and asked if he wanted some lotion put on his hands. Resident G indicated he didn't want the lotion because it made his hands burn and hurt worse. The CNA indicated staff tried to lotion up his hands well but that it made no difference to the scaliness and rash he had. The resident was scheduled to see a dermatologist the following day (4/3/19). A Nurse Progress note, dated 11/26/18 at 4:32 p.m. with an addendum added at 5:14 p.m., indicated a new order had been received for [MEDICATION NAME] cream for rash and itching ([MEDICATION NAME] cream is a topical medication that kills scabies mites). A Physician order, dated 11/26/18 at unknown time, was for [MEDICATION NAME] 5% cream, apply topically from neck to toes; leave on for 8 hours and then shower. The order did not indicate a [DIAGNOSES REDACTED]. Guidance for medications used to treat parasites was retrieved on 4/5/19 from the Centers for Disease Control (CDC) website. The guidance indicated [MEDICATION NAME] topical cream was an approved and recommended treatment to treat and kill scabie mites and eggs. Classic scabies was an infestation of the skin by the human itch mite. The scabies mite burrowed into the upper layer of the skin where it lived and laid it's eggs. Scabies caused intense itching, especially at night, and a pimple like rash. The recommendation was to apply 2 or more applications of [MEDICATION NAME] topical cream, each about a week apart, to eliminate all mites. Crusted (Norwegian) scabies was a severe form of scabies that could occur in some persons who have a weak immune system. Persons with crusted scabies had thick crusts of skin that contained large numbers of scabies mites and eggs and were very contagious to other persons. The infestation could easily be spread to others by direct skin to skin contact and contamination of items such as clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for [REDACTED]. Resident G's MAR (Medication Administration Record) dated (MONTH) (YEAR), indicated the resident received the [MEDICATION NAME] topical cream as ordered, on 11/27/18. Nurse Progress notes indicated the following: 11/28/18 at 10:59 a.m., rash continued and was treated as ordered. 11/29/18 at 2:54 a.m., His rash continued and treatment continued as ordered. 12/1/18 at 8:26 a.m., late entry for 11/30/18 6p-6a shift: Resident was on an antibiotic and [MEDICATION NAME] (steroids) dose pack for a rash which continued to his body. (The physician order [REDACTED]. 12/2/18 at 2:21 a.m., resident complained of itching and was medicated with Benedryl (anti-[MEDICATION NAME]/itch). 12/5/18 at 3:46 a.m., Resident G continued with a skin rash that covered most of his body. He complained of sporadic itching. 12/28/18 at 10:25 a.m., a new order was received by the Nurse Practitioner (NP) for [MEDICATION NAME] 2.5 mg (milligram) by mouth every other day for rash/itching. A Hospice Plan of Care Update Report, dated 12/31/18 at an unknown time, indicated the resident had a recent skin rash with itching. The resident was started on low dose steroids to help with the itching. Hospice staff would collaborate with facility staff to increase the resident's comfort. There were no physician or NP progress notes for (MONTH) or December. There was no documentation that either the physician or NP had examined the resident's rash. A Care Plan Conference Record indicated a care plan conference had been held on 12/27/19. Staff from hospice were present in addition to facility staff. A conference summary note indicated the resident was itching but not in any particular spot. The resident had psoriasis and was being treated with a cream (the resident was not prescribed any creams or ointments for psoriasis or itching). The record indicated hospice was going to order [MEDICATION NAME] for the itching. On 1/9/19 at an unknown time, an NP progress note indicated the resident was seen for generalized itching. The assessment indicated the resident had pruritis (itching). Orders were given for [MEDICATION NAME] 25 mg (anti-itching medication) 1/2 tablet by mouth 3 times per day for 2 weeks and taper off the [MEDICATION NAME]. On 1/21/19 at an unknown time, an NP progress note indicated the resident was seen for itching. The physical exam of Resident G's skin was grossly intact. The plan was to continue with the plan of care which met the resident's needs. A Nurse Progress note, dated 2/14/19 at 4:02 p.m., indicated a new order had been received for the resident to be seen by the psychiatric NP for evaluation and treatment and start [MEDICATION NAME] (anti-anxiety) 2 times per day. On 2/15/19 at unknown time, an NP progress note indicated the resident was seen for generalized itching. The physical exam indicated Resident G's skin was grossly intact. The plan was to give [MEDICATION NAME] 25 mg 1/2 tablet by mouth 2 times per day and start [MEDICATION NAME] 25 mg by mouth at bedtime (medication used to treat depression, anxiety, and [MEDICAL CONDITION]). A Nurse Progress note, dated 2/18/19 at 10:42 a.m., indicated [MEDICATION NAME] was discontinued and another medication prescribed which was [MEDICATION NAME] ([MEDICATION NAME]) 50 mg by mouth at bedtime. The order indicated the medication was prescribed to treat [NAME]D ([MEDICAL CONDITION]). A Hospice Plan of Care Update Report, dated 2/19/19 at unknown time, indicated the resident had scabies and was currently taking steroids. The note indicated the resident had scabies scabs from head to toe in addition to psoriasis. The resident continued to complain of itching on the following dates and times: 2/20/19 at 12:43 a.m., complaints of intense itching and was observed scratching his arms and stomach. 2/21/19 at 1:47 a.m., itching at the start of the shift then calmed down and put into bed. 2/22/19 at 2:30 a.m., was observed scratching at the beginning of the shift. 2/25/19 at 12:11 a.m., resident had complaints of intense itching this shift. 2/26/19 at 3:54 a.m., continued to complain of itching but less frequently. 2/26/19 at 5:47 p.m., continued to complain of itching. 2/28/19 at 9:36 a.m., resident continued to itch/scratch this shift. 3/2/19 at 6:00 a.m., resident continued to complain of itching. 3/4/19 at 6:42 a.m., continued to complain of itching. 3/5/19 at 1:01 a.m., resident complained of itching. A Hospice Plan of Care Update Report, dated 3/5/19 at unknown time, indicated the resident was prescribed and taking [MEDICATION NAME] 25 mg 1/2 tablet by mouth 2 times per day for itching and [MEDICATION NAME] ([MEDICATION NAME]) 50 mg by mouth at bedtime for [NAME]D. Since the last report, the resident has had increased anxiety (per nursing staff), a fall from his w/c, and a skin integrity decline. The resident had increased redness, scabbing and increased pruritis. He continued with scabie scabs from head to toe. The plan of care recommended an immunosuppressant to facility NP possibility for psoriasis. A Care Plan Conference Record, dated 3/7/19 at an unknown time, indicated facility and hospice staff were present for the conference. A conference summary note indicated the resident had recent falls without injuries. He was on benedryl and cream for his itching (no orders found for cream for itching). The note indicated the resident was put on [MEDICATION NAME] for anxiety as he was not itching as much. An NP progress note, dated 3/15/19 at unknown time, indicated the visit was a regulatory (required) visit. The resident continued to have intermittent itching. The physical exam of Resident G's skin was grossly intact. The plan was to continue the plan of care which met the resident's needs. There were no further nurse progress notes completed from 3/18/19-4/1/19 until a nurse progress note, dated 4/1/19 at 2:56 p.m., which indicated the resident had a dermatology appointment scheduled for 4/3/19. On 4/3/19 at 3:05 P.M., LPN 5 was interviewed. During the interview, she indicated the resident had returned from seeing the dermatologist with new orders. She produced a copy of the orders which were difficult to read due to the handwriting. She indicated she didn't know what the medication was for so she had contacted the facility NP who indicated the prescribed medication was to treat a gastrointestinal disorder. The order for Resident G was for Ivermectin 3 mg tablets, take 8 tablets by mouth daily; 8 tablets now then each week for 4 weeks for crusted (Norwegian) scabies. On 4/3/19 at 4:20 P.M., the Regional Director of Clinical Services was interviewed. During the interview, she indicated she had a call out to the dermatology office to confirm the [DIAGNOSES REDACTED]. She was not able to find any documentation to indicate why the resident had been placed on [MEDICATION NAME] in (MONTH) (YEAR) but she was able to confirm there was no follow up documentation made regarding the resident's rash and possibility of scabies. It was unknown where the hospice documentation and [DIAGNOSES REDACTED]. This Federal tag relates to Complaint IN 711. 3.1-37(a)

Based on record review, observation and interview the facility failed to implement interventions for weight loss for 1 Resident (B) in a sample of 4 resident records reviewed. Findings include: On 11/30/16 at 2:00 p.m. review of the clinical record for Resident (B) indicated she was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly MDS (minimum data set) dated 11/2/16 indicated the resident was cognitively impaired, required extensive assistance of 1 for transfers, ambulation, dressing, eating, hygiene and bathing. Review of the Plan of Care for Resident (B), dated 8/8/16 indicated she was at nutritional risk and would leave 25% or more of food uneaten at most meals. The interventions included to observe and report to the physician signs and symptoms of malnutrition and significant weight loss. Interview with the Director of Nursing (DON) on 11/30/16 at 2:45 p.m. indicated the resident's weights were as follows: 6/14/16 - 112# 6/22/16 - 113# 6/29/16 - 111# 7/6/16 - 111# 8/10/16 - 107# 9/8/16 - 101# 10/6/16 - 102# 11/2/16 - 101# Further interview with the DON indicated residents are weighed every week for four weeks at time of admission and then monthly. She indicated if the resident showed a difference of 5 pounds they would be re-weighed. The DON indicated the Dietary Manager inputs the weights into the computer and she , the Dietary Manager and Speech Therapist have weekly meetings and look at resident weight loss. Calculation of the resident's weight loss from July to October, 2016 was 8.1% which is severe weight loss in a 3 month period. The DON was queried about dietary documentation in the clinical record and she presented this writer with the Initial assessment dated [DATE] at the time of admission and a Quarterly Nutrition Report dated 8/8/16 which indicated the resident received an Orange Nutritional Drink at breakfast. There was no further documentation the facility had been monitoring the resident's weight. The Dietary Manager was not in the building to be interviewed. Observation of Resident (B) on 11/30/16 at 12:00 p.m. during the lunch meal indicated she was seated at the dining table but would stand up and eat pudding with her fingers. Staff were observed to try to seat the resident, and the resident would sit down and then attempt to stand up again. The resident was observed to be very agitated, and was constantly moving her legs when seated. The staff would give her a spoon, which she would use and then again start eating the pudding with her fingers. On 11/30/16 at 4:30 p.m. review of the facility Policy and Procedure for Nutrition Management, with a revision date of 09/2006 indicated the following: All residents will be weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the NAR (Nutrition At Risk) Committee. All weights will be reviewed by the designated staff (usually the Dietary Manager) and the chairperson of the NAR committee to determine weight variances. If a significant weight loss is determined the Dietary Manager will initiate a Weight NAR Tracking Sheet with the following indicated: a. Resident name b. Room number c. Physician d. Date started on program e. Starting weight f. Date discharged from the program. g. Weight at the date of discharge h. Date and year i. Weekly progress note or lack of progress and actions taken including family and MD notification as indicated. This federal tag is related to Complaint IN 017 3.1-46(a)(1) 3.1-46(a)(2)

Based on interview and record review the facility, failed to provide 1 resident (Resident #36) with the calculated fluid needs required to keep her hydrated. This resulted in Resident #36 being hospitalized with an acute kidney injury, dehydration and urinary tract infection. Findings include: 1. Review of the clinical record for Resident #36 on 6/17/14 at 10:30 a.m., indicated the following: [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment for Resident #36 on 5/8/14 indicated a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) or cognitively intact. The MDS also indicated she required limited assistance of 1 person to physically assist her to eat and drink. The MDS on 3/31/14 indicated she required extensive assist of 1 person to physically assist her to eat and drink. A Nutritional Data Collection/Assessment form for Resident #36, dated 11/14/13, indicated her fluid needs were calculated at 2010 ml (milliliters)per day. The Registered Dietitian (RD) recommendations indicated the following, "... 1. Resident will eat 50-100% of meals to have no significant weight change 2. Show improvement in skin condition 3. Have no S/S (signs and symptoms) of dehydration...." A review of Resident #36's Hospital History and Physical Report, dated 4/9/14 at 21:34 (9:34 p.m.), indicated the following, "...was brought to ED (Emergency Department) from the Nursing Home on account of elevated BUN/Creatinine (a blood test to determine kidney function)....The BUN was 59, normal range is 7-20 mg(milligrams)/dL (deciliter) and the Cr (Creatinine) was 3.4, normal range for women is 0.6 - 1.2 mg/dL...Patient Active Diagnosis: [REDACTED].Assessment/Plan: gentle IV hydration with NS (normal saline); encourage oral fluid intake, monitor renal function, hold [MEDICATION NAME] (medication for high blood pressure), adjust medications per renal function, check urine electrolytes, CK ([MEDICATION NAME] kinase, blood test to detect inflammation of muscles) and uric acid; renal ultrasound; nephrology consult...". A review of Resident #36's Hospital Discharge Summary, dated 4/14/14, indicated, "...AKI...resolved...-baseline creat 1.7 and creat 2.9 on 4/11 from 3.4...4/12-creat trending down nicely, now 1.9 and close to baseline...4/13 creat at baseline A review of Resident #36's Fluid Monitoring sheets indicated the following: - For March 2014 indicated 26 of 31 days the fluid intake was not totaled or monitored. Resident #36's daily fluid intake for March 2014 were as follows: 3/1/14: 960 ml 3/2/14: 960 ml 3/3/14: 1440 ml 3/4/14: 1440 ml 3/5/14: 960 ml 3/6/14: 1440 ml 3/7/14: 1200 ml 3/8/14: 1320 ml 3/9/14: 1220 ml 3/10/14: 1080 ml 3/11/14: 1680 ml 3/12/14: 1800 ml 3/13/14: 1560 ml 3/14/14: 1680 ml 3/15/14: 1200 ml 3/16/14: 480 ml 3/17/14: 1740 ml 3/18/14: 1200 ml 3/19/14: 840 ml 3/20/14: 0 ml (none) 3/21/14: 1860 ml 3/22/14: 1560 ml 3/23/14: 0 ml (none) 3/24/14: 0 ml (none) 3/25/14: 1800 ml 3/26/14: 1800 ml 3/27/14: 0 ml (none) 3/28/14: 600 ml 3/29/14: 1680 ml 3/30/14: 1680 ml 3/31/14: 600 ml -In April 2014 for 25 of 25 days Resident #36 was in the facility, the fluid intake was not totaled or monitored. Resident #36's daily fluid intake for April 2014 were as follows: 4/1/14: 800 ml 4/2/14: 1000 ml 4/3/14: 960 ml 4/4/14: 1130 ml 4/5/14: 600 ml 4/6/14: 840 ml 4/7/14: 1020 ml 4/8/14: 840 ml 4/9/14:1560 ml hospitalized [DATE]. Resident #36 did not receive the RD's recommended amount of 2010 ml per day. Review of Resident #36 Care Plan dated 11/20/13 with revised target date of 06-14, indicated the following' "...At Risk for Dehydration...Problem: Resident is at risk for exhibiting aigns (sic) and or symptoms of dehydration due to antibiotic use and post op wound....Goals: Resident will be free from signs and symptoms of dehydration by next review date. (06-14)....Approaches: Observe for signs and symptoms of dehydration such as dry mouth, poor skin turgor, furrowed tongue, decreased output and elevated BUN....Roles: All Staff...Encourage resident to except all fluids offered to her. Roles: All Staff....2/19/14 IV fluids for Hydration...." Review of Resident #36's Intake/Output (I & O)records indicated the following: -For December 2013 the I & O was tracked for 72 hours after re-admission to the facility. The I&O record for December 2013 did not have a 24 Hour Total calculated. The record indicated the resident received 240 ml on 12/24/13, 360 ml on 12/25/13 and 240 ml on 12/26/13. -For February 2014 the I&O was tracked for 72 hours after re-admission to the facility. The I&O record for February 2014 did not have a 24 Hour Total calculated. The record indicated the resident received 480 ml on 2/10/14, 780 ml on 2/11/14, 360 ml on 2/12/13 and 360 ml on 2/13/14. -For April 2014 the I & O was tracked for 72 hours after re-admission to the facility. The I & O record for April did not have a 24 hour Total calculated. The record indicated the resident received 240 ml on 4/14/14, 600 ml on 4/15/14, 600 ml on 4/16/14 and 540 ml on 4/17/14. A review of Resident #36's Quarterly Nutrition Documentation, dated 5/9/14, indicated the following, "...Recently treated for [REDACTED]." There were no documented changes for the recommended Fluid Needs of 2010 ml per day. An interview on 6/18/14 at 2:20 p.m. with the DON (Director of Nursing) indicated each nurse was to calculate the Resident's fluid intake for the shift and it was the evening nurse who was responsible to calculate and monitor the resident's fluid intake for the day. She indicated the CNA's (Certified Nurses' Aide) report and document a Resident's fluid intake on the Fluid Monitoring sheet. She indicated the Fluid Monitoring sheet did not include fluids given by the nurse during medication administration. She verified the fluids were not being calculated or monitored daily by the nurses. On 6/18/14 at 9:59 a.m., the Administrator provided the Facility's current Policy titled Hydration and Nutrition, dated 10/08, which indicated, "...The nutrition and hydration status of each resident is maintained as close to optimal level as possible...Fluid is available to residents at all times....An ongoing assessment....by nursing personnel includes:..Nutritional balance or imbalance of intake...Weight loss or gain...Signs of dehydration....." On 6/18/14 at 11:53 a.m., the DON provided the non-dated Facility's Policy, titled Monitoring Intake and Output, which indicated, "...To monitor resident intake and output to assist and establish a baseline assessment in an attempt to identify potential fluid balance problems....I & O monitoring should be continued longer or restarted according to changes in resident condition, poor intake, poor output, swallowing difficulties and or according to the Nurse's judgement or physician order....CNAs will collect intake and output data throughout each shift and report their totals to the Nurse for each resident...The Nurse will evaluate the I & O data for that shift and notify the physician if there is a concern with intake or output....The 11-7 shift Nurse or Night Shift Nurse will total up the 24 hour intake and output and document in the "total" column on the record. If there are concerns with I & O, the physician will be contacted for interventions and recommendations. The Registered Dietitian (RD) may be contacted as needed...." 2. On 6/16/14 at 11 A.M., the clinical record of Resident #6 was reviewed. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] included but was not limited to, the following: moderately impaired cognition; extensive assistance required for transfers and supervision and oversight in regards to eating. A Nutrition Data Collection dated 1/25/14 indicated the following: daily fluid needs were 2100 cc/day. A Quarterly Nutrition Documentation form indicated the following for 5/2/14: "Plans/goals:...maintain adeq (adequate) hydration..." A urinalysis, dated 6/7/14 indicated the following: color was amber turbid (cloudy), 2+moderate leukocytes (which may indicate infection), 4+ bacteria, many and 4+ mucous..." On 6/17/14 at 2:30 P.M., the Administrative Assistant (AA) provided copies of the "Fluid Monitoring" form for 6/2014. This form included documentation of the "cc (measure of amount of fluid consumed) fluid consumed" for breakfast, lunch and dinner with "other fluids" between and after each meal. This form indicated the following: Total fluid intakes for the first 12 days were calculated, with the totals ranging from 1560 ccs -3840 ccs. Documentation of daily fluid totals were lacking for 6/14 - 6/16/14. Documentation was lacking on 6/16 and 6/17/14 of the breakfast, lunch and "other fluids" consumed. The daily total documented on 6/16/14 of 3840 ccs of fluid was recalculated and a total obtained of 1920 ccs for daily fluid intake. On the above form, of the first 12 days of the June, which were totaled, only one day did the resident meet his daily required fluid needs (6/12/14 total of 2180 ccs). Of the remainder of the days, the documented fluids were calculated with totals ranging from 600 cc - 1800 cc daily intake. A care plan, with a target goal date of 8/2014, addressed the problem of "...Resident has...UTI (urinary tract infection)..." Interventions included, but were not limited to, the following: "Encourage fluid intake if diet permits, document in nurses notes..." A care plan, with a target goal date of 8/2014, addressed the problem of "Resident has ADL (activities of daily living) self-care deficit as evidenced by needs assistance with...transfer...related to...dementia, [MEDICAL CONDITION], poor motivation, weakness [MEDICAL CONDITIONS], cognitive impairment..." Approaches included, but were not limited to, the following: "...provide the amount of assistance/supervision that is needed...cueing/prompting..." A care plan with a goal date of 8/2014 addressed the problem of "Alteration in nutritional/hydration status...approaches...monitor...intakes..." A physician progress notes [REDACTED]. Currently the condition is deteriorating. The differential [DIAGNOSES REDACTED]. On 6/16/14 at 8:33 A.M., the resident's plate and cup were observed in the dining room. One fourth of the fluid in a larger glass was left and 1/2 of the fluid in a coffee cup was left at the table. Documentation was lacking on the "Fluid monitoring" record of the resident's fluid intake. On 6/16/14 at 12:14 P.M. the resident was observed in the dining room. He had finished his meal and had drank a small juice size glass of fluid. He was observed to drink fluids independently from a glass. Documentation was lacking on the "Fluid monitoring" record for this fluid consumption. On 6/16/14 at 2:40 P.M., the FSM (food service manager) was interviewed. He indicated a coffee mug and large drinking glass hold 240 cc of fluid, a small juice sized glass holds 120 cc of fluid. On 6/16/14 at 3 P.M. CNA (certified nursing assistant) #11 was interviewed. She indicated the CNAs document the meal and fluid intake after the resident's meals are consumed. She indicated the resident's eat at the same places at the tables for each meal in the dining room. Nursing notes, dated 6/17/14, included, but were not limited to, the following: "at 3:29 A.M.: Resident continues to be on antibiotic therapy for urinary tract infection...Resident was started on [MEDICATION NAME] (medication used to treat symptoms related to irritation of the urinary tract) this shift. Resident was having complaints of dysuria (pain, burning or discomfort upon urination)...4:40 P.M.:...c/o (complained of) dysuria, medicated according to order to order, some relief...10:26 P.M. c/o pain upon urination. Resident moaning, grimacing, yelling out in pain, grabbing peri area....given prn (as needed) tylenol and [MEDICATION NAME] to manage symptoms. Currently resting in bed...noted to have excoriated area surrounding urethral opening...Dr. (name of physician) notified..." On 6/17/14 at 8 A.M., the resident's plate and drinking glasses were observed in the dining room. A mug of coffee, large glass each of milk and water and small juice glass were observed. The level of fluids in each glass was within an inch of the top and/or an inch and a half of the top. Documentation was lacking on the "fluid monitoring" log of the resident's fluid intake for this meal. On 6/17/14 at 9:20 A.M., the resident was observed in his bed. The overbed table, with beverages on it, were observed across the room from the resident. On 6/7/14 at 2 08 P.M., the resident was observed in his bed. The overbed table, with beverages on it, was observed on the other side of the room. On 6/18/14 at 9:05 A.M. the DON (Director of Nursing) was interviewed. She indicated the resident had much confusion and was not considered alert and oriented. The DON indicated the resident does have a tendency to push the bedside table away from his bed. She indicated the purpose of the fluid monitoring was to ensure the resident was getting the required fluid needs. She indicated there was no hydration assessment in the clinical record for this resident. The DON indicated the hydration assessment should be reviewed as part of the nursing assessment when the resident had a UTI. She indicated the resident was currently on an antibiotic for a UTI. 3. On 6/16/14 at 2 P.M., the clinical record of Resident #4 was reviewed. [DIAGNOSES REDACTED]. The MDS dated [DATE] included but was not limited to, the following: severe cognitive impairment and required extensive assistance with eating. The current MAR (medication administration record) indicated the resident was on [MEDICATION NAME] (diuretic) 40 mg twice a day. The nutrition data collection assessment dated [DATE] included, but was not limited to, the following: daily fluids needs were "2200 - 2400" cc daily. Registered Dietician goals were documented as "cont (continue) goals." A plan of care with the goal date of 9/2014 addressed the problem of "Alteration in nutritional/hydration status...[DIAGNOSES REDACTED]. On 6/16/14 at 12:19 P.M., the resident's place at the table was observed. She had two large glasses of thickened fluids, with one glass empty and the other remained full. On 6/17/14 at 3 P.M., the Administrative Assistant provided a copy of the "fluid monitoring" form for 6/2014. This form indicated the following: From 6/1 - 6/12/14, the daily fluid totals had been calculated. The totals ranged from 1680 cc - 2160 cc. The total of 2160 cc, on 6/11/14 was recalculated for a total of 1680 ccs. The days of 6/13 - 6/15/14 were not totaled and lacked documentation of "other fluids" after the lunch meal. For the days of 6/16 - 6/17/14 documentation was lacking of any fluid intake on 6/16 and 6/17/14 (breakfast and lunch). 3.1-46(b)

Based on record review and interview, the facility QAA (Quality Assessment and Assurance Committee) failed to identify and implement a plan of action for the identified concerns for 1 resident identified with dehydration and 2 residents who were not adequately monitored for hydration, sufficient nursing staff that would meet the needs of the residents, environmental cleanliness and lack of repairs, and medication cart cleanliness. The facility QAA Committee further failed to develop an action plan to address ineffective response to the Resident Council concerns regarding staffing and call lights. This deficient practice had the potential to affect 54 of 54 residents residing in the facility. Findings include: An interview on 6-18-2014 at 12:51 p.m., with the Administrator and DON (Director of Nursing) who were members of the QAA, indicated some of the clinical areas reported on each month included falls, weights, pressure areas, restraints, catheters, contractures and nutrition. The Administrator and DON indicated they had an audit in May of 2014 by their corporate staff and had not had time to work on any action plans. The Administrator and DON indicated they were aware of the concerns regarding the assessment of a [MEDICAL TREATMENT] resident and the incomplete or non-existent Pre/Post [MEDICAL TREATMENT] Communication form and the behavioral management concerns which would have included the GDR (Gradual Dose Reduction), but not the staffing concerns. There was no evidence the QAA had identified or implemented any action plans regarding identification of a resident with dehydration and adequate hydration for 2 residents, sufficient nursing staff, environmental cleanliness and needed repairs, medication cart cleanliness concerns, and ineffective response to the Resident Council concerns regarding staffing and call lights. 3.1-52(a)(2)

Based on observation, interviews and record review, the facility failed to assess the potential cause and implement interventions to prevent pressure sores for 2 of 3 residents in a sample of 5 who had skin breakdown. This resulted the development of a stage IV pressure area in one resident (Resident B) and a delay in treatment for [REDACTED]. Findings include: 1. During the orientation tour, on 5/8/12 at 10:30 a.m., Resident B was identified by the Director of Nursing (DON) as having pressure areas on both feet. She indicated she thought the areas were caused by the resident's shoes. The clinical record of Resident B was reviewed, on 5/8/12 at 1:40 p.m., and indicated he had been a resident since 6/20/11. His [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 3/26/12, indicated he was at risk for pressure areas, and Braden assessments for predicting pressure sore risk, dated 3/26/12 and 4/14/12, indicated he scored a 15, indicating risk for pressure areas. The predisposing conditions and risk factors included, [MEDICAL CONDITION], dementia, weight loss, impaired mobility and use of antipsychotic/antidepressants/hypnotic. The 3/26/12 MDS and weekly skin assessments of 4/3/12, 4/10/12 and 4/17/12, indicated no open areas or skin breakdown. The weekly skin assessment, dated 4/17/12, indicated new red areas on both feet. Nursing notes, dated 4/22/12 at 8:00 p.m., indicated the resident had a 2 cm by 2.1 cm area on the left inner aspect of the big toe, and the physician was notified. an order for [REDACTED]. Nurses notes, dated 4/24/12 at 9:30 p.m., indicated an order had been received for the right foot outer aspect also. The order was for Meplex Border gauze to the right foot and change as needed. The order also included a pre [MEDICATION NAME] laboratory test, a physical and occupational therapy evaluation and directions to wear no shoes. A "Pressure Ulcer Status Record" indicated the areas were first observed and assessed on 4/25/12. The description of the area on the left foot was 5.4 cm by 2.8 cm with a depth of 0.1 cm area which was black, red and yellow. The description of the right foot was an area of 2 cm with redness. This assessment was two days after the nurse had first identified the areas and obtained initial orders. The pre [MEDICATION NAME] returned 4/25/12 and was 16 (normal 17-34). The therapy evaluation, of 4/25/12, indicated Resident B had a stage IV area on the left foot and a stage II area on the right foot. The stage IV area was identified as 4.4 cm in length by 3.3 cm width and 0.2 cm in depth, with an open area of 1.6 cm in length by 1.6 cm width with 0.2 cm in depth with 2.45 cm area of 25% black necrotic tissue and 70 % slough. The entry indicated minimal purulent drainage with minimal odor and no tunneling or undermining. An undated care plan related to pressure areas indicated interventions which included: RD (registered dietician) consult. PT (physical therapy) consult, hold all shoes, elevate heels off bed as needed, reposition as needed for comfort and labs as ordered. On 5/1/12 the physician also ordered Vitamin C, one tablet daily and Prostat 30 cc (a protein supplement) 30 cc twice daily to aide in healing. physician's orders [REDACTED]. The report, dated 5/1/12, indicated "No occlusive disease is noted. Minimal to no arterial insufficiency/ischemia of the right and left leg arterial circulation. There are no areas of hemodynamicallly significant stenosis at rest." Observation of the areas on Resident B's feet, on 5/8/12 at 3:15 p.m., with LPN #15 removing the dressings, indicated the area on the right foot was dime-sized and healing. The area on the left foot was open with no redness and also dime-sized in appearance. LPN #15 indicated the therapy staff did the dressing changes Monday through Friday, and nursing did the treatments on Saturdays and Sundays. There was no documentation available for review, on 5/8/12, to indicate the dietician had been notified. The DON was interviewed, on 5/9/12 at 9:00 a.m., and indicated the dietician had not been notified of the areas on Resident B's feet when they were found. During an interview with Physical Therapist (PT)#16, on 5/9/12 at 8:30 a.m., she indicated the area on the left foot had been debrided and was healing. She indicated she thought Resident B's shoes had caused the problem. Observation of the two pairs of shoes on the shelf in Resident B's room, with PT #16, at 8:45 a.m., on 5/9/12, indicated both pairs were labeled with Resident B's name. The older pair were size 10 wide and the newer pair were size 7 1/2 medium. The resident had been sent to the hospital earlier in the morning on 5/9/12, and comparison of the shoes to his feet was not possible. PT #16 indicated the therapy department had become involved with the resident's care after the area on the left foot was seen on 4/22/12. 2. During the orientation tour, on 5/8/12 at 10:45 a.m., Resident C was identified by the DON as having an area of skin breakdown on the left heel. Review of the clinical record of Resident C, on 5/8/12 at 1:00 p.m., indicated the resident had been admitted to the facility 11/12/09. Her [DIAGNOSES REDACTED]. The most recent Braden Scale for predicting pressure sore risk was dated 11/28/11. The form indicated the assessment was to be done quarterly, indicating the one due in February 2012 had been missed. The 11/28/11 assessment score was 22 indicating the resident was not at risk. Review of the care plan, dated as originating 12/2/09, indicated the resident was at risk for skin breakdown due to decreased mobility, obesity, incontinence, [MEDICAL CONDITION], and a history of pressure areas. The care plan was dated as in effect through 6/2012. The care plan interventions included weekly head to toe skin assessments, quarterly Braden Scale assessments, restorative programs, diet as ordered, pressure reducing mattress and pressure reducing pad in wheel chair. It did not address the feet. Nurses notes, dated 4/5/12 at 1:00 p.m., indicated orders had been obtained for the skin areas on both feet. There was no assessment of the areas until 4/18/12, when the wound nurse indicated the right heel had a stage II 1 cm by 0.5 by 0.1 depth open area. This was 13 days after first being observed by the nurse on 4/5/12. The dietician recommended a multivitamin supplement, a pre [MEDICATION NAME] and Prostat 30 cc daily to aide in healing. This recommendation was on 4/6/12. An order was obtained, on 4/16/12 at 9:00 a.m., 10 days after the original recommendation. The pre [MEDICATION NAME] returned 4/17/12 and was recorded as 17 (normal being 17-34). This federal tag relates to Complaint IN 160. 3.1-40(a)(1) 3.1-40(a)(2)

2. The clinical record of Resident #E was reviewed on 1/24/11 at 2:00 p.m. and indicated the resident was readmitted to the facility from the hospital on [DATE]. The hospital admission orders local care" to right foot and multiple "decubs" (decubitus ulcers). Nursing notes, dated 1/6/11 at 5:15 p.m., indicated the resident had three pressure areas as follows: on the right buttocks measuring 2 cm by 2 cm, on the thigh under the right buttocks measuring 4 cm by 4 cm and on the right heel. The note indicated "R (right) heal (sic) has open area .5 x 2 cm in size 0 (zero) drainage noted, 0 (zero) odor." A treatment order, dated 1/6/11, was obtained for [MEDICATION NAME] to the buttocks every shift and after incontinent episodes as needed. There was no documentation on the January 2011, TAR (Treatment Administration Record) indicating Resident #E received a treatment for [REDACTED]. On 1/11/11, a physician's orders [REDACTED]. "[MEDICATION NAME] to rt. (right) heel daily cover w (with)/ gauze choice." On 1/24/11 at 2:30 p.m., Resident #E was observed in bed. A specialized bariatric mattress was on the bed. The resident's skin was checked by the DON (Director of Nursing). The resident had a dime sized, pink, superficial open area on the right heel. Resident #E had no open areas on the buttock or upper thigh. On 1/24/11 at 2:45 p.m., the ADON, who was the wound nurse, was queried about the delay in the treatment for [REDACTED]. The ADON indicated she thought [MEDICATION NAME] treatments had started when the resident was readmitted from the hospital. She was unsure why no treatment order was obtained and why a treatment was not started when the resident returned. This federal tag relates to Complaint IN 841. 3.1-40(a)(2) Based on observation, interviews and record review, the facility failed to assess, immediately obtain treatment orders and implement interventions to prevent the reoccurrence of skin breakdown for 2 of 2 residents in a sample of 4 with pressure areas. This resulted in 1 of the 2 residents (Resident D) developing a black, unstageable area on the right heel. Residents D and E. Findings include: 1. During the observation of skin areas on Resident D, on 1/24/11 at 11:00 a.m., with the Assistant Director of Nursing (ADON), an area on Resident D's coccyx was observed to be healing and only having a small open area. The ADON was queried about the condition of the resident's feet and the resident's socks were removed for visualization of both heels. The right heel was observed to have a 50 cent sized black area after a dressing dated 1/23/11, was removed by the ADON. The ADON indicated she was the facility wound nurse and had not been notified about the area on the resident's heel. She indicated the resident had returned from the psychiatric unit at the local hospital in November, as a hospice patient. The ADON indicated the resident had returned with areas on the coccyx and the heel, but the heel area had been healed in December, 2010. She was unsure when the current area had developed or what treatment was being used. She also indicated the present pressure area was in the same place as the earlier one on the right heel. She indicated the resident had been on hospice care, but had improved enough so hospice was discontinued in December of 2010. The ADON indicated the specialty mattress which had been supplied by hospice was removed and a regular facility mattress was placed on Resident D's bed after hospice was discontinued. During an interview with Resident D, on 1/24/11 at 11:00 a.m., while the observation of the heel was taking place, she indicated her shoes were tight and she thought the right heel area was caused by the shoe. The shoes were observed beside her bed and were diabetic shoes which the resident indicated the therapy department had helped her obtain. The clinical record of Resident D was reviewed, on 1/24/11 at 1:30 p.m., and indicated the resident had returned from the local psychiatric hospital unit on 11/22/10, with [DIAGNOSES REDACTED]. She was on hospice care at the time of readmission. Hospital doppler studies, dated 11/16/10, indicated the resident had extensive [MEDICAL CONDITION] in the left lower extremity and no evidence of [MEDICAL CONDITION] in the right lower extremity. A [MEDICATION NAME] level, dated 12/23/10, indicated the resident's [MEDICATION NAME] was 20.2 (normal limits being within 18.0 - 35.7). Hospice records indicated the hospice had been discontinued on December 21, 2010, due to the resident's improvement. The hospice clinical note, of 12/14/10, indicated she had a healed pressure area on the right heel and an area on the coccyx which had diminished in size to a stage II area. Facility skin sheets, dated 12/7/10, indicated the previous area on the right heel was healed on 12/7/10. Braden Pressure Sore Risk assessments, dated 11/22/10 and 1/3/11, indicated the resident was at risk for skin breakdown due to friction and shear, limited mobility, being bedfast or chairfast, occasionally moist and limited in sensory perception. The care plan, dated 12/30/10, related to skin breakdown indicated the resident was at risk due to a stage 4 area on the coccyx. The approaches included, but were not limited to: "Needs wound care as ordered by physician. Offer supplemental nutritional support to resident (multi-vitamin). Needs a daily observation of skin with routine care. Needs full skin evaluation weekly with bath/shower. Use pillows or other supportive/protective devices to assist in positioning. Avoid restrictive clothing. Monitor for changes in skin status that may indicate worsening of pressure ulcer and notify the physician." Weekly skin integrity sheets indicated Licensed Practical Nurse (LPN) #20 had first noticed the area on Resident D's heels on 1/3/11, and wrote "mushy heels-fluid filled areas to bilat. (bilateral) heels. Heels floated." There was no documentation to indicate she had notified the physician, dietician or wound nurse of the areas. The skin sheet, dated 1/10/11, completed by the same nurse, indicated the heels were "mushy" and on the 1/17/11 entry, she had written "dried blister." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The date the [MEDICATION NAME] was started was 1/15/11. No order for the [MEDICATION NAME] could be found on 1/24/11. LPN #20 was interviewed, on 1/24/11 at 3:15 p.m., and when queried about notifying the physician, wound nurse and dietician, she was unsure if/when she had notified them. She obtained an order for [REDACTED]. The facility dietician was interviewed, on 1/24/11 at 2:20 p.m., and indicated she was recommending a multivitamin being restarted and Prostat 30 cc (a nutritional supplement) twice daily. She indicated the resident had been on multivitamins prior to hospice, but the vitamin had been discontinued when hospice started. The 10/7/10 facility policy regarding pressure areas was provided by the Assistant Director of Nursing, on 1/24/11 at 3:00 p.m., and it indicated, in part, "The facility's procedures are such that all disciplines are alerted immediately if the resident either has skin breakdown or is at risk for the development of skin breakdown." Resident D was observed, on 1/24/11 at 1:30 p.m., in the lounge area, wearing the shoes she had earlier indicated "hurt" her foot. When queried about wearing the shoes, she indicated the staff had put the shoes on her. The most recent Minimum Data Set (MDS) assessment, of 1/3/11, reviewed on 1/24/11 at 1:45 p.m., indicated she needed help with dressing and transfers. The ADON measured the area on the right heel and provided the measurement on 1/25/11 at 8:45 a.m.. The black area on the right heel was 3.5 cm (centimeters) by 0.4 cm with no depth and was unstageable.