Every finding on record at Lutheran Life Villages

Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 12 residents observed (Resident 48). Findings include:In an observation, on 02/24/2026 2:04 PM, a bottle of Tums (over the counter antacid tablets) about 20% full, 1 full bottle of Tums, 1 full box of Pepto Bismol (over the counter medication for gastro-intestinal discomfort) tablets and a jar of Vicks Vapo Rub (topical ointment) with visible fingerprints in the gel and a small amount missing were observed on a bedside table beside Resident 48 in her room. In an interview, on 02/24/2026 2:05 PM, Resident 48 indicated her family brought the full bottle of Tums and the box of Pepto Bismol that day. Resident 48 indicated the partial bottle of Tums had been in her room for a long time and the bottle was normally on her bedside table. Resident 48 indicated she always kept a supply of Tums in her room but no one ever said anything about it. In an interview, on 02/24/2026 2:15 PM, Licensed Practical Nurse (LPN) 2 indicated Resident 48's family visited, probably brought in the unopened bottle of Tums and box of Pepto Bismol, but was not aware of when Resident 48 obtained the open bottle, about 20% full of Tums and open jar of Vicks Vapo Rub. LPN 2 indicated Resident 48 did not have current orders for Tums, Vicks Vapo Rub, or Pepto Bismol. LPN 2 indicated she removed the medications from Resident 48's room because all medications should be locked in a medication cart or medication room. Resident 48's record was reviewed on 02/24/2026 2:07 PM. Diagnoses included gastro-esophageal reflux disease without esophagitis. A current quarterly Minimum Data Set assessment dated [DATE] indicated Resident 48 had a Basic Interview for Mental Status score of 15 (cognitively intact). A self administration of medications kept at bedside assessment was not available for review. A review of current physicians orders for Resident 48 did not include orders for Tums, Pepto Bismol, or Vicks Vapo Rub. In an interview, on 02/26/2026 11:28 AM, the Director of Nursing indicated staff had not been aware of Resident 48 storing medication at her bedside prior to the surveyor bringing it to their attention. She indicated all over the counter medications should be secured in a medication cart or storage area. In an interview, on 03/02/2026 11:18 AM, the Administrator indicated a self- administration of medication assessment had not been completed for Resident 48. She indicated she did not believe Resident 48 would pass the assessment criteria for self-administration. A current policy, titled Medication Storage, dated 11/29/18, provided by the Administrator on 2/26/26 at 11:59 AM, indicated all drugs should be stored in a safe, secure, and orderly manner. A current policy, titled Self Administer Medications, dated 11/28/16, provided by the Administrator on 3/3/26 at 11:48 AM, indicated a resident desiring to self administer medications at bedside should be assessed for ability to do so safely. The policy indicated the assessment should be reviewed by the interdisciplinary team and documented. 3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure hand hygiene procedures were maintained during direct resident care for 1 of 2 residents reviewed (Resident 36).Findings include:During a continuous observation on 2/26/26 at from 8:40 AM -8: 55 AM, Certified Nurse Aide (CNA) 5 was observed providing indwelling urinary catheter care for Resident 36.Resident 36 was in their bed with the head of the bed up in a sitting position. CNA 5 sanitized their hands, lowered the resident's bed and filled a basin with warm water. CNA 5 moved the bedside table, folded the resident's blanket down, removed their plush toy and placed the bed in lying position. CNA 5 applied gloves and unfastened Resident 36's brief. CNA 5 cleansed the resident's genitalia using a different section of the washcloth for each fold. CNA 5 cleansed the catheter tubing in a downward motion away from the body using a different section of the washcloth. CNA 5 rinsed the area with a new washcloth and patted the area dry with a towel. CNA 5 then refastened the resident's brief, covered the resident with their blanket and replaced the resident's plush toy. CNA 5 did not remove their gloves or perform hand hygiene prior to touching Resident 36's personal items. CNA 5 raised the head of the bed up to the prior position and returned the bedside table. CNA 5 did not remove their gloves r perform hand hygiene prior to touching Resident 36's personal items. CNA 5 placed the used articles in a plastic bag. CNA 5 removed their gloves and discarded the gloves into the trash. The CNA washed their hands in the sink.In an interview, on 2/26/26 at 8:55 AM, CNA 5 indicated they had been instructed to only change gloves during direct resident care if the gloves were damaged or visibly soiled. CNA 5 indicated they should have removed their gloves prior to touching items in the resident's room.In an interview, on 2/26/26 at 11:25 AM, the Director of Nursing (DON) indicated CNA 5 should have removed their gloves after direct resident care. The DON indicated CNA 5 should have washed their hands prior to touching Resident 36's personal belongings.A current facility policy, titled Catheter Care, last revised 3/23/22, indicated after the resident was towel dried, all disposable items should be discarded, the resident should be assisted into a comfortable position, call light should be placed in reach and the room returned to the original order.483.25(d)(1)(2)- 3.1-18(a)(b)(1)

Based on observation, interview, and record review the facility failed to ensure privacy of medical records for 2 of 8 residents reviewed (Resident 50, and Resident 123). Findings include: 1. During an observation on 2/12/25 at 11:40 AM, a computer screen on top of the medication cart on the dementia unit contained a picture of Resident 123, her name, medications and other care related physician's orders. A worksheet containing a list of the residents on the dementia unit with notes pertaining to their personal care was lying on top of the cart, visible to passersby. No staff member was observed attending to the cart. Two unidentified ambulatory residents, a dietary staff member and two Certified Nurse Aides were walking in the area. Licensed Practical Nurse (LPN) 2 was observed seated in a nurse's station across the hall from the medication cart. On 2/12/25 at 11:45 AM, LPN 2 returned to the cart and closed the screen. Resident 123's record was reviewed on 2/14/25 at 9:55 AM. Diagnoses included vascular dementia and cerebral infarction. Resident 123's current Basic Interview for Mental Status (BIMS) score, dated 2/11/25, was 10 (cognitively impaired). 2. During an observation on 2/14/25 at 8:52 AM, a computer screen on top of the medication cart on the dementia unit was observed open to a page listing Resident 50's medications. A worksheet listing the names and care needs of the residents residing on the dementia unit was lying on top of the cart visible to any passerby. No staff member was present at the cart. Two unidentified staff and two unidentified residents passed the cart before Licensed Practical Nurse (LPN) 2 returned to the cart. Resident 50's record was reviewed on 2/14/25 at 9:03 AM. Diagnoses included Alzheimer's disease and hypertension. Resident 50's current Minimum Data Set (MDS), dated [DATE], indicated his BIMS score was 5 (cognitively impaired). During an interview on 2/14/25 at 9:03 AM, LPN 2 indicated he should have closed the screen on the computer and covered or turned over the worksheet with resident information prior to leaving the cart. In an interview, on 2/14/25 at 9:54 AM, the Administrator indicated private resident health information should not be visible on unattended medication carts and computer screens. A current policy titled Privacy and Confidentiality, dated 11/21/16, provided by the Administrator on 2/14/25 at 10:13 AM, indicated residents had the right to secure and confidential personal and medical records. The policy indicated the facility was responsible for safeguarding the personal and medical records from unauthorized access. A current policy titled Electronic Medical Records-Physical Safeguards, dated 12/21/16, provided by the Administrator on 2/14/25 at 10:13 AM, indicated display screens and keyboard devices should be placed in such a way that access was limited to those employees with a demonstrated need to know. 3-1(p)(5)

Based on observation, interview and record review the facility failed to recognize and identify triggers for a resident with a history of trauma for 1 of 6 residents reviewed. (Resident 5) Findings include: On 2/21/24 at 10:45 A.M. Resident 5 was observed to be tearful while sitting in a common area in a reclining chair. In an attempted interview on 2/21/24 at 12:06 P.M. Resident 5 responded with brief answers then looked away. Resident 5's record was reviewed on 2/22/24 at 1:58 P.M. Diagnoses included recurrent depressive disorder and anxiety disorder. Resident 5's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 11 (moderate cognitive impairment). The MDS indicated Resident 5 did not exhibit any behaviors. Resident 5's current Care Plan dated 10/25/23 for mood indicated the resident had mood changes related to anxiety. The target goal was for Resident 5 to display sadness or depression less than daily through 1/24/24. Interventions included identification of strengths, medication as ordered and documentation of mood or behavior changes. The Care Plan indicated the resident was at risk for episodes of crying, being withdrawn and not eating. Interventions included medication as ordered, documentation of withdrawal from usual activity, documentation of tearfulness, sadness, insomnia, negative statements and one on one support. Resident 5's current Care Plan dated 10/25/23 indicated the resident had a history of trauma related to violence and sexual abuse. The Care Plan Indicated Resident 5 was unaware of their current triggers. The Care Plan Indicated Resident 5 often wept, cried and became overwhelmed with emotions. The target goals were to engage in meaningful social situations, enable staff assistance with moving past triggers and staff assistance with avoidance of triggers by the next review date. Interventions included staff assistance with recovery and avoidance of re-traumatization by medication as ordered, allowance of independence, awareness of triggers to reactions, respect of personal space, the provision of meaningful activities, the monitoring of physical health and keeping the resident informed of possible changes. A progress note dated 8/10/23 at 12:20 P.M. indicated Resident 5 had displayed increased tearfulness due to memories of sexual abuse. A progress note dated 8/13/23 at 2:11 P.M. indicated Resident 5 was tearful due to fear of a necklace they had received as a gift. A progress note dated 9/11/23 at 12:15 P.M. indicated Resident 5 preferred female caregivers due to a history of sexual abuse. The progress note indicated Resident 5 became tearful when they felt others were upset with them. A progress note dated 10/24/23 at 4:50 P.M. indicated Resident 5 had been crying due to memories of past sexual abuse. In an interview on 2/26/24 at 2:31 P.M. the Director of Nursing (DON) indicated Resident 5 was extremely easily moved to tears. The DON indicated facility staff were unaware of specific triggers and had not tracked to be able to identify specific triggers related to the resident's tearfulness. The DON voiced understanding related to the need for the facility staff to identify specific triggers. The DON indicated they were aware of Resident 5's preference for female staff. The DON indicated the preference for female staff should be included as an intervention and all staff should be made aware of the preference for female staff. A current policy dated 9/20/19, provided by the Administrator, indicated the facility would account for resident specific experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization.

Based on interview and record review the facility failed to ensure behaviors were documented prior to the administration of an as needed medication for 1 of 5 residents reviewed (Resident 31). Findings include: Resident 31's record was reviewed on 2/23/24 at 9:13 AM. Diagnoses included dementia in other diseases classified elsewhere with anxiety, psychotic disorder with delusions, and delusional disorder. A review of Resident 31's current significant change Minimum Data Set (MDS), dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 31 had verbal behaviors directed at others 4 to 6 days weekly and behaviors had worsened since the last assessment period. A review of Resident 31's current care plan, dated 1/23/24, titled I have a diagnosis of dementia with anxiety disorder indicated the resident had a problem of anxiety with a goal date of 4/19/24. Interventions included signs of anxiety should be observed, recorded, and reported. A review of physician orders, dated 1/15/24, indicated diazepam intensol oral concentrate (an antianxiety medication) 5 milligrams (mg) per milliliter (ml), at a dosage of 0.5 ml was ordered to be given every four hours as needed for anxiety. A review of progress notes dated 1/17/24 at 12:00 AM indicated Registered Nurse (RN) 2 had given Qualified Medicine Aide (QMA) 3 permission to administer an as needed dose of diazepam. A description of the behavior requiring the use of the medication was not available for review in the medical record. A review of a Medication Administration Record dated 1/17/24 indicated diazepam intensol 5 mg/ml 0.5ml was administered by QMA 3 at 12:32 AM. In an interview on 2/23/24 at 2:30 PM, the Administrator indicated a new staff member was assigned to the unit and needed more training at that time on behavior documentation. She indicated documentation should have included a description of the behavior, interventions provided and whether they were successful prior to administering an as needed psychotropic medication. A current policy titled Psychotropic Medication policy, dated 4/28/17 provided by the DON at 2/26/24 at 8:50 AM indicated a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. The policy indicated anti-anxiety medications were an example of psychotropic medications. The policy indicated as needed orders for a psychotropic drug should be used only to treat a specific condition documented in the medical record. 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure orders, treatments, and assessments for a skin tear were completed for 1 of 3 residents reviewed. (Resident 57) Findings include: During an observation and interview 02/16/23 at 10:42 AM, Resident 57 had a clear dressing on the left forearm. the dressin had slightly rolled edges with greying under the edges. The dressing had no date to indicate when it was placed. Under the dressing appeared to be a thick brownish red straight mark, approximately 2 inches long. Resident 57 indicated he had a skin tear from his arm falling off of his wheelchair and hitting something. Resident 57 denied pain to the area, and indicated he was unable to feel much of anything on that side of his body. Resident 57 indicated the incident happened about a week or 2 ago. Resident 57 had no other disruptions of his skin observable at that time. Resident 57's record was reviewed on 2/16/23 at 12:17PM. Diagnoses included stroke, flaccid left nondominant side, anxiety, and heart disease. A review of physician orders indicated to assist resident in using Velcro strap on wheelchair for left upper extremity, monitor left upper extremity for skin integrity and circulation, and weekly skin assessment. A review of the TAR (Treatment Administration Record) date January and February 2023 indicated the following: There was no documentation of daily skin integrity documented on 1/23/23, 1/24/23, 1/26/23, 2/6/23, and 2/12/23. There was no documentation regarding assisting Resident 57 to use Velcro strap after 2/15/23. Weekly skin assessments were documented as completed as ordered. Resident 57's weekly skin assessments completed by nursing on 1/8/23, 1/13/23, 1/20/23, 1/27/23, 2/3/23, and 2/10/23 indicated no skin impairment was noted. There was no documentation regarding the condition of the skin tear to the left forearm. Resident 57's progress notes indicated the following: On 1/22/23, his daughter alerted nursing to the skin tear on his left forearm. The documentation indicated they cleansed it with normal saline, applied a tefla dressing then notified the doctor and wound care nurse. The progress note did not indicate an order was received for treatment. On 2/3/23, a note indicated the skin tear to the left forearm was resolved. On 2/16/23 at 7:48 am indicated Resident 57 had picked a scab from a skin tear on his left forearm and now it was bleeding. Resident 57's physician orders dated 1/23/23 included to change dressing to left forearm skin tear daily. The order was updated on 1/29/23 to include cleanse skin tears to left forearm with soap and water then apply tegaderm dressing change dressing every 5 days. A review of the TAR dated February of 2023 indicated the dressing had not been changed for the month February. In an interview on 02/16/23 at 02:30 PM, the DON (Director of Nursing) indicated the tegaderm was placed by LPN 3 (Licensed Practical Nurse). The DON indicated the dressing was not dated nor initialed due to not wanting to draw Resident 57's attention to the dressing. The DON stated, he is a picker and indicated Resident 57 had the behavior of picking at scabs. The DON indicated Resident 57 frequently had scabs on the left forearm. The DON indicated there was no order, assessment, or progress note completed becasue LPN 3 did not have time to do so. Resident 57's behavior monitoring for the last 30 days indicated no behaviors were noted. Resident 57 had no specific behavior tracking for picking. Resident 57's current care plan indicated a new intervention under skin integrity initiated on 2/16/23 of I have a tendency to pick skin/scabs. Staff to cover as needed. Another intervention included keep skin clean and dry. Use lotion on dry skin, initiated 8/7/20. The care plan addressed diagnosis of anxiety and indicated the anxiety shows as restlessness and seeking out staff attention. The behavior of picking at skin had not been addressed. On 2/18//23 at 2:30 PM, a current policy and procedure titled Skin Management, revised May 2019, was provided by ED (Executive Director) indicated; Residents who are at risk or with wounds are/or pressure injuries and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes Skin tear . can be partial or full thickness, usually due to friction an/or shear forces .15. Skin tears will be reported to the licensed nurse upon occurrence. An incident report will be completed in the electronic medical record if from unknown origin. The nurse will notify the physician and the resident representative of the kin tear. The Licensed nurse will initiate skin care with attending physician/s order until healed . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing changes were performed according to standards in 2 of 2 residents reviewed (Resident 15 and Resident 67). 1.During an observation at 11:31 AM on 2/14/23, Resident 15 was observed in bed with a nasal cannula in place delivering 3 liters of oxygen. A piece of tape attached to the oxygen tubing was dated 1/30/23. At 9:23 AM on 2/15/23, Resident 15 was observed in her chair using oxygen at 3 liters by nasal cannula. The tubing was dated 1/30/23. During a record review at 9:36 AM on 2/15/23, Resident 15 had diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and Alzheimer's disease with late onset. A Minimum Data Set (MDS) dated [DATE] was reviewed. The MDS indicated Resident 15 was cognitively impaired and unable to be interviewed. A physician's order dated 12/17/22 indicated oxygen should be administered at 3 liter per minute by nasal cannula continuously. Another physician's order dated 11/28/22 indicated oxygen tubing should be changed weekly on Sunday nights. 2. During an observation at 9:44 AM on 2/14/23, Resident 67 was observed sitting in a chair in her room with a nasal cannula in place delivering oxygen at 5 liters. No date was observed on the oxygen tubing. During an observation at 9:35 AM on 2/15/23, Resident 67 was observed sitting in her chair using oxygen at 5 liters by nasal cannula. No date was observed on the oxygen tubing. During a record review at 9:48 AM on 2/15/23, Resident 67 had diagnoses including chronic obstructive pulmonary disease (COPD), essential hypertension, and unspecified dementia. An MDS dated [DATE] indicated Resident 67 was cognitively impaired and unable to be interviewed. A physician's order dated 12/15/22 indicated oxygens should be administered at 5 liters by nasal cannula every shift for shortness of breath related to COPD. A physician's order dated 12/24/33 indicated oxygen tubing should be changed weekly every Sunday night. During an interview at 9:22 AM on 2/15/23, Licensed Practical Nurse 5 indicated oxygen tubing should be changed weekly on Sunday nights and dated. A current policy titled Policy and Procedure: Oxygen, last revised 2/16/18, indicated oxygen tubing should be changed every Sunday night on night shift. 3.1-47(a)(6)

Based on observation, interview, and record review the facility failed to ensure non-pharmacologic interventions were implemented for 2 of 5 residents reviewed. (Resident 8 and Resident 75) 1) During an observation and interview on 2/16/23 at 10:57 AM Resident 8 was observed grimacing, moving very slowly and cautiously. Resident 8 indicated she had been in a great deal of pain from kidney stones. Resident 8 indicated staff were aware of her continued pain and would administer pain medication. Resident 8 denied having any other interventions offered for pain. Resident 8's recorded review began on 2/16/22 at 1:18PM. The record indicated diagnosis included osteoarthritis of knee, deficit following a stroke, and muscle weakness generalized. Resident 8's physician orders included; Norco tablet 5-325mg give one every six hours for pain, observe for side effects related to opioid medication, offer at least 2 non-pharmalogical interventions prior to giving PRN pain medication, and access pain level every shift. A review of the Medication Administration Record (MAR) dated February 2023 indicated day shift there were 2 times the pain level was not documented. On 2/7/23 pain was documented a 2 on night shift. On 2/8/23 night shift documented pain level was 1. The MAR dated February 2023 indicated Resident 8 was administered Norco 5-325mg tablet at the following times: On 2/1/23 at 2045, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were ineffective. There was no documentation indicating what the interventions were. On 2/2/23 at 1734, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were effective, yet the PRN pain medication was given. There was no documentation of what the non pharmalogical interventions were or why the medication was still given. On 2/3/23 at 1812, 2 non pharmalogical interventions were offered. The documentation indicated the interventions were effective, yet the PRN pain medications was given. There was no documentation of what the intervetions were or why the pain medication was given. On 2/6/23 at 1852, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were effective, yet the PRN pain medication was given. There was no documentation of what the non pharmalogical interventions were or why the medication was still given. On 2/7/23 at 0153, there was no documentation of 2 non pharmalogical interventions offered. On 2/7/23 at 1719, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were effective, yet the PRN pain medication was given. There was no documentation of what the non pharmalogical interventions were or why the medication was still given. On 2/8/23 at 1908, there was no documentation of 2 non pharmalogical interventions offered. On 2/9/23 at 1747, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were effective, yet the PRN pain medication was given. There was no documentation of what the non pharmalogical interventions were or why the medication was still given. On 2/10/23 at 1640, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were effective, yet the PRN pain medication was given. There was no documentation of what the non pharmalogical interventions were or why the medication was still given. On 2/15/23 at 1110, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were effective, yet the PRN pain medication was given. There was no documentation of what the non pharmalogical interventions were or why the medication was still given. 2) Resident 75's record was reviewed on 2/16/23 at 11:43. Diagnosis included displaced fracture of right femur, type 2 diabetes, and history of stroke. Resident 75's physician orders included offer at least 2 non-pharmological interventions prior to PRN pain medication, observe for side effects related to opioid use, pain level every shift, and Norco 5-325mg give one tabled every 8hrs as needed for severe pain. Resident 75's pain level was documented three times a day from 2/1/23 to 2/15/23 as zero (no pain). She was given Tylenol on 2/4/23 at 1935 with pain documented as zero and twice on 2/12/23 with pain documented each time at a level of 1. Resident 75 was documented as receiving Norco 5-325mg as follows: On 2/1/23 at 2001 there was no documentation of 2 non pharmalogical interventions offered. On 2/2/23 at 2105 there was no documentation of 2 non pharmalogical interventions offered. On 2/3/23 at 0410, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were ineffective. There was no documentation of what the non pharmalogical interventions were. On 2/3/23 at 2008, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were ineffective. There was no documentation of what the non pharmalogical interventions were. On 2/4/23 at 0551 there was no documentation of 2 non pharmalogical interventions offered. On 2/5/23 at 0845, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were ineffective. There was no documentation of what the non pharmalogical interventions were. On 2/8/23 at 2000, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were ineffective. There was no documentation of what the non pharmalogical interventions were. On 2/10/23 at 2007 there was no documentation of 2 non pharmalogical interventions offered. On 2/12/23 at 1956 there was no documentation of 2 non pharmalogical interventions offered. On 2/14/23 at 1953 there was no documentation of 2 non pharmalogical interventions offered. On 2/15/23 at 2013, 2 non pharmalogical interventions were offered. The documentation indicated the non pharmalogical interventions were ineffective. There was no documentation of what the non pharmalogical interventions were. In an interview on 02/16/23 at 2:34 PM, LPN 5 (Licensed Practical Nurse) indicated there should had been non-pharmacologic interventions implemented and documented or marked refused on the MAR prior to the administration of pain medication. LPN 5 indicated if the non pharmalogical interventions were effective no pain medication should be dispensed. On 2/18//23 at 2:00 PM, a current procedure titled Pain Management, revised October 2020, indicated; approach for recognition, assessment, treatment, and monitoring of pain .Recognition: 1 .a. recognizes when the resident is experiencing pain. 2. d. facial expressions Pain assessment 2. b. asking the patient to rate the intensity of his/her pain using a numerical scale .Pain management and treatment. 5. Non pharmalogical interventions will include but are not limited to: a. environmental comfort .b. loosening any restrictive clothing.c. applying splinting . d. physical modalities.e . exercise to address stiffness f. cognitive/behavioral interventions . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure instructions for contacting the correct hospice company were clearly communicated to staff for 1 of 3 residents reviewed (Resident 67). During a family interview at 1:28 PM on 2/14/23, a family member of Resident 67 indicated they had previously used hospice services from Heart-to-Heart hospice but had recently changed to Parkview Noble Hospice services. The family had initiated and approved this change. During a record review at 9:48 AM on 2/15/23, Resident 67 had diagnoses including chronic obstructive pulmonary disease (COPD), essential hypertension, and unspecified dementia. An MDS dated [DATE] indicated Resident 67 was cognitively impaired and unable to be interviewed. A physician order dated 1/10/23 indicated Resident 67 was admitted to Heart-to-Heart Hospice for a diagnosis of end stage COPD. A phone number was listed in the physician's order with instructions to call Heart-to-Heart hospice for hospice care. A physician's order dated 2/6/23 indicated Resident 67 may have Parkview Noble Hospice care evaluate and admit. A care plan dated 12/15/22 indicated Resident 67 received hospice care from Heart-to-Heart hospice. During an observation with Licensed Practical Nurse (LPN) 6 at 10:25 on 2/16/23, red binder labeled Heart-to-Heart hospice was observed with Resident 67's name on it. The binder included records including physician's orders, care plans, and staff visit records and notes. Positioned next to that binder was a green binder labeled Parkview Noble Hospice with Resident 67's name on it containing physician's orders, care plans, and staff visit records and notes. During an interview during an observation at 10:25 on 2/16/23, LPN 6 indicated staff should refer to the current physician orders to determine which hospice service a resident is using. He indicated when there is a discrepancy in the orders, staff should refer to a daily assignment sheet. A current daily assignment sheet provided by LPN 6 indicated Resident 67 used Heart-to-Heart hospice service. LPN 6 indicated the physician's orders for Heart-to-Heart hospice should have been discontinued and the records should have been updated to reflect the change to Parkview Noble Hospice. A policy regarding clarification of hospice choice was not available for review.

Based on interview and record review, the facility failed to notify the physician of a resident's change in condition for 1 of 3 residents reviewed (Resident S). Findings include: On [DATE] at 12:42 P.M., Resident S's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident had no cognitive impairment. Care plans indicated the following: -[DATE]: Resident S had high blood pressure, a fast heart rate, and [CONDITION(S)]. The goal was for there to be no cardiac complications. Interventions included, but were not limited to, notify the physician as needed for complaints of chest pain and/or shortness of breath. -[DATE]: The resident was receiving hospice care due to a terminal prognosis of 6 months or less to live. His wishes were for comfort measures through symptom control and pain management. He hadn't wished to be hospitalized unless directed by hospice. The goal was for his wishes for end of life be honored and care given by staff and hospice personnel collaboratively in the best interest of his needs. Interventions included, but were not limited to, respect his wishes and communicate any changes of condition with the hospice team. Nurse progress notes indicated the following: -On [DATE] at 10:30 p.m., the resident complained of lower abdominal pain, pain with urinating, and dark colored urine. Family and resident requested urine to be dipped and was noted to be positive for blood and nitrates. A specimen was collected, sent to the lab, and the physician notified via fax. -[DATE] at 9:58 p.m., resident's urine was dark orange. His temperature was 100 degrees. There was no documentation the physician or hospice staff had been notified of his elevated temperature. -[DATE] at 9:51 a.m., the resident complained of being short of breath. His oxygen saturation was 83% on room air (normal is >90%). Oxygen was administered and his oxygen saturation went up to 90%. His lung sounds were dimished and he was spitting up excessive saliva. The resident requested to have 911 called. Hospice staff were notified and advised the nurse to administer pain medication, suction his oral cavity, and hospice staff would be out to evaluate the resident before sending him to the hospital. His urinalysis results were back and would be shown to the hospice nurse when she arrived. -At 10:35 a.m., the resident was found with no pulse or respirations and had passed away. On [DATE] at 12:06 P.M., LPN 5 (Licensed Practical Nurse) was interviewed. She cared for Resident S the day he passed away. She had contacted hospice staff 3 times during the morning events on [DATE]. Resident S had indicated he wanted to go to the hospital but it was her understanding because he was a hospice patient, she had to call hospice first. Hospice staff indicated to give the resident some pain medication, suction his oral cavity, and a hospice nurse would be out to evaluate him before sending to the hospital. She had not notified the residents physician of his change in condition or his request to have 911 called. On [DATE] at 12:23 P.M., the Chief Nursing Officer for the hospice company contracted to provide services for Resident S was interviewed. She indicated staff had received a call on [DATE] at 9:06 a.m. from LPN 5 who reported the residents oxygen saturation had dropped. She was advised to administer oxygen and oral suctioning, and give a pain medication to the resident. LPN 5 called hospice again at 9:26 a.m. and indicated the residents oxygen saturation had improved but he remained anxious. Hospice services indicated they would send out a nurse. The Chief Nursing Officer indicated there was not a policy residents could only be hospitalized upon hospice approval and staff should consult with the residents physician if they desired hospitalization or had an acute change that may be related to the disease the resident was receiving hospice for. On [DATE] at 1:20 P.M., the Administrator in Training (AIT) who also served as a Social Services staff member was interviewed about care plans for Resident S and other residents at the facility who were receiving hospice services. All hospice care plans indicated residents on hospice did not want to be hospitalized unless directed to do so by hospice. He indicated hospice or non-hospice residents could be hospitalized per their wishes, upon need for hospitalization , and after physician notification and order received to send to the hospital. On [DATE] at 2:25 P.M., the Coroners office indicated Resident S had died due to 1. Acute [CONDITION(S)] and 2. [CONDITION(S)]. A current facility policy titled Notification of changes (Resident Rights was provided on [DATE] at 3:29 p.m., by the Director of Nursing, which stated The facility will immediately inform the resident; consult with the resident's physician; and notify the resident representative when there is a change as listed .A significant change in the resident's physical, mental, or psychosocial status .A decision to transfer or discharge the resident from the facility in accordance with the facility transfer and discharge policies This Federal tag relates to Complaint IN 839. 3.,d+[DATE](a)(2)

Based on observation, interview and record review the facility failed to prevent multiple falls resulting in hospitalization with subarachnoid hemorrhage for 1 of 2 residents reviewed for accidents. (Resident 49.) The facility also failed to ensure proper water temperatures in 2 of 4 rooms observed (Rooms 204 and 208) affecting 3 residents. Findings include: 1. On 3/3/2022 at 4:00P.M., Resident 49's record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety disorder, [CONDITION(S)], and hypertension. She resided on the secure memory care unit. A significant change MDS (Minimum Data Set) assessment, dated 1/11/22, indicated the resident had severely impaired cognitio and she required extensive assistance of 1 to 2 staff members for all activities of daily living (ADLs). The MDS indicated the resident had multiple falls with one resulting in a major injury. A fall care plan, dated 4/14/21, indicated the resident was at risk for a fall related injury related to fall risk factors. The goal was Resident 49 would have no falls with injury. Interventions included, but were not limited to: offer the resident a broom to sweep, determine the direct factors of cause, and reinforce the resident's safety awareness. Review of fall reports indicated Resident 49 had the following falls and interventions put into place: -11/28/21 at 8:55 a.m., the resident squatted down to clean crumbs off the floor and fell on to her buttocks. An intervention, dated 11/29/21, was to offer a handled broom and dust pan when resident was attempting to clean/pick up items on floor. -12/5/221 at 4:45 p.m., the resident squatted down to pick up a piece of dirt off the floor and fell to onto her buttocks. An intervention, dated 12/6/21, was for staff to offer the resident a reacher device when picking things up off floor. -12/12/21 at 2:16 p.m., the resident was found on her hands and knees on the floor of the dining room. Interventions were dated 12/13/21 and indicated staff were to sweep the floor in dining room after meals. -12/24/21 at 11:48 p.m., the resident was found lying on her side in the dining room. She had an abrasion on her knee and a small knot/bruise on her scalp. An intervention, dated 12/27/21, was for staff to be educated but did not indicate what staff were to be educated on. Nurse Progress Notes indicated the following: -12/27/21 at 11:33 p.m. the resident had a large amount of emesis. -12/31/21 at 5:05 p.m., the resident was found to be drooling from the right side of mouth, had slurred speech, was leaning to right side and had right arm/leg twitching. EMS was called and the resident was transferred to a local hospital. -At 7:18 p.m., the nurse spoke with the hospital and was told was Resident 49 had a brain bleed and was going to be transferred to a trauma hospital. Resident 49 returned to the facility on [DATE] with orders for hospice care. Following re-admission to the facility, the resident continued to fall. The fall reports were as follows: -1/3/22 at 8:19 p.m., the resident was found in her room sitting on her buttocks with her back against the bed. An intervention dated 1/4/22 was to ask hospice for a different mattress and a broda chair. -1/12/22 at 9:43 p.m., the resident was found on the floor, sitting on her buttocks between the bed and recliner. The intervention, dated 1/13/22, was to try a new broda chair. -1/31/22 at 10:50 p.m., the resident was found sitting on the floor in the dining area. An intervention, dated 2/1/22 was for staff to not leave resident unattended while in the dining room. On 3/2/22 at 10:05 A.M., Resident 49 was observed in the dining room, sitting in a broda chair at a table, leaning heavily to the right side. On 03/08/22 at 12:51 P.M., the resident was observed seated in her broda chair in the dining room. There were no staff present. On 3/2/22 at 1:42 P.M., LPN 4 (Licensed Practical Nurse) was interviewed. During the interview, he indicated Resident 49 had been having multiple falls. The resident had recently been in the hospital for a brain bleed and had been released back to the memory care unit with hospice. The resident needed a shunt but the family had declined the treatment. Since returning to the facility, the resident had fallen a couple of times as she continued to try and pick up specks of dirt on the floor. On 3/8/22 at 1:30 P.M., the Director of Nurses (DON) was interviewed about the facility's fall policy and procedure. She indicated every time a resident fell , the nurse would email the DON of the fall. Every morning, the DON met with unit managers to discuss falls from the previous day. Previous interventions and new interventions were discussed and put into place. Falls were also discussed in the morning meeting with the IDT (Interdisciplinary team) present. In general, fall Inventions were used for 3 months and then re-evaluated. She indicated Resident 49 was constantly bending over to pick up specks of debris on the floor and would get upset if staff got too close to her in attempts to keep her from falling. The resident's falls usually occurred in the dining room where staff should always be present. On 3/4/22 at 2:15 P.M., the Administrator provided a current copy of the facility policy, titled Fall Policy-Resident Safety which stated the following: The Lutheran Life Villages ministry guiding principle is that all residents are at risk for falls .Definitions of Terms .RCA: Root cause analysis-a method of problem solving used for identifying the root causes of problems .If the resident falls: assess for injury related to fall and monitor vital signs .document all factors contributing to the fall, interventions currently in place and implementation of any additional safety measures and assessment of resident .An incident report will be completed .The details of the fall, including vital signs and physician/family notification, will be documented in the progress notes in the EMR. Neurological checks will be initiated for any fall with head injury and will be documented in the EMA under neuro assessment. The Fall Care Plan interventions will be reviewed and revised if necessary. The resident's fall risk will be communicated on the caregiver Kardex with fall interventions. Additionally, all resident falls will be reviewed daily during the RRR huddle by the IDT to ensure that all documentation and interventions are correct and RCA (root cause analysis) has been determined 2. On March 2, 2022 at 9:55am during an observation the writer overheard an unidentified staff member indicate the water was hot while washing her hands at the kitchen sink on the Memory Care unit. An observation with the Maintenance Director on March 2, 2022 at 11:30 A.M. with a calibrated thermometer indicated the temperature in room 204 was 124.1 degrees Fahrenheit and room 208 was 123. The Maintenance director indicated in an interview, on the department took temps of 5 rooms per week to ensure water temperatures remained in safe range. The maintenance director indicated that range should be 116 to 120 degrees Fahrenheit. A review of the resident roster indicated there were 2 residents in room 204 and 1 resident in room 208. A current policy provided by the Maintenance Director regarding safe water temperatures was a resources document referring to F323 and titled Water Temps Testing and Logging Water Temperatures. The document indicated Indiana patient room water temperatures should be between 100 degrees and 120 degrees Fahrenheit. 3.1-45(a)(1)

Based on observation, interview, and record review the facility failed to ensure proper care of indwelling catheter for 1 of 2 residents reviewed (Resident 67) resulting in hospitalization . Findings include: In an observation, on 3/2/22 at 2:00 P.M., Resident 67 was lying in bed with his catheter tubing going down his leg under his pants. The tubing was pulled tightly as evidenced by his pants pulling up at the spot where the tubing catheter came out from under his clothing. There was no urine present in the tubing. The catheter bag was placed up close to Resident 67's shoulder area on handrail. The bag was above the bladder. The bag was not covered; the urine in the bag was yellow in color with no observed blood or sediment. Resident 67 was alert but not oriented or responding to attempts to communicate. In an interview and observation on 3/2/22 at 2:06 P.M., LPN 2 indicated Resident 67 was generally more talkative, but he had been more tired than usual the last day or so. LPN 2 then put a privacy cover on his catheter bag. She proceeded to hang the catheter bag back on the bed rail again, resulting in the tubing being pulled tightly. When asked to inspect tubing she then moved catheter bag to end of bed, where it no longer pulled. LPN 2 indicated the tubing was pulled too tightly and the bag was not below the bladder level. LPN 2 was not going to complete an assessment of the catheter insertion site. The catheter tubing was observed to not have any means of keeping the catheter from getting pulled. LPN 2 then began an assessment of Resident 67's catheter insertion site. The resident grimaced and pulled away when she picked up his genitals for an inspection. There was no blood on the tip of the meatus. The catheter was still inserted in urethra, with no visible swelling. A record review, on 3/4/22 at 10:46 A.M., indicated Resident 67's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS in section H, under bowel and bladder, submitted on 2/7/22 indicated Resident 67 had no catheters, ostomies, or intermittent catheter needs. The MDS indicated Resident 67 was incontinent of urine frequently and occasionally incontinent of stool. Resident 67's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An order to monitor for signs and symptoms of infection related to indwelling catheter was dated 2/17/22. Orders started on 3/3/22 included; change of dignity bag as needed for soilage, check placement of the device to keep the catheter from pulling and change when needed. The administration record for medications and treatments indicated catheter care per shift was being completed. There was no indication the catheter had been changed in the months of February or March. A care plan with the problem of indwelling catheter was initiated on 2/9/22. The goal was to have no signs or symptoms of urinary infection. The interventions included- change the catheter prn (as needed), do cath care each shift, keep the appointment with urology (3/4/22), monitor and document signs of discomfort due to the catheter, and to monitor and report to the MD any signs of [CONDITION(S)] (pain, burning, altered mental status, change in behavior and change in eating patterns). Resident 67's progress notes indicated on 2/28/22 he was staying in bed, refused to get up and refused to eat. On 3/1/22, the resident was noted to have increased weakness, requiring more assistance, complaining of pain all over, with stable vital signs and the nurse was going to continue to monitor. On 3/2/22 at 1:45 P.M. a urinary assessment was completed and the doctor was notified. Orders were received for chest x-ray, pain medication, and urinalysis to be done. The chest x-ray was was completed and urine was collected from the catheter. Urinalysis results, collected on 3/2/22 at 11:34PM, showed the following abnormalities; ketones, blood urine, bacteria, and epithelial cells. The urinalysis order did not indicate for a culture to be completed. On 3/3/22 at 9:23 A.M. Resident 67's continued weakness, complaints of pain, hypoactive lung sounds, and increased lethargy was reported to the doctor and orders were recieved to transfer to ER for eval and treatment. Resident 67's POA (power of attorney) was notified and agreed with transport to the local hospital. On 3/7/22 Resident 67 returned to the facility. The paperwork received from the hospital, on 3/7/22 at 2:49PM, indicated Resident 67 was hospitalized for multidrug resistant Acinetobacter baumannii species in the urine determined by urine culture and sensitivity collected on 3/3/22. Resident 67 was placed in contact isolation. Resident 67's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview, the DON, on 3/8/22 at 1:42PM, indicated the doctor should have been called on 3/1/22 regarding Resident 67's change in condition. A current policy and procedure titled: Catheter Care indicated 2) privacy bags will be available and catheter drainage bags will be covered when in use. A current policy and procedure titled: Indwelling Catheter indicated .8) Indwelling urinary catheters will be utilized in accordance with current standards of practice, with interventions to prevent complications. 3.1-41 (a) (1)

Based on observation, interview and record review, the facility failed to develop a care plan for the use of a seat belt for safety for 1 of 20 residents reviewed for care plans (Resident 8). Findings include: On 3/3/22 at 10:50 A.M., Resident 8's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Assessment) dated 12/29/21, indicated the resident had moderately impaired cognition. She was non-ambulatory and was dependent on 2 staff and a mechanical lift for transfers. She'd had several falls without injury, used a bed and chair alarm daily for prevention of falls. On 3/3/22 at 11:01 A.M., Resident 8 was observed seated in her room in a wheelchair. A thin, buckled seat belt sat around the top part of her rounded abdomen. She was sleepy and slow to respond but when asked, indicated she could unbuckle the seat belt that she wore. A care plan, revised on 4/13/21, indicated the resident was at high risk for falls. The goal was that she would be free of falls. There were several interventions put into place to prevent falls but neither the fall care plan nor any other care plans indicated the resident wore a buckled safety belt when up in her wheelchair. On 3/3/22 at 11:46 A.M., LPN 7 (Licensed Practical Nurse) was interviewed. During the interview, she indicated the resident wore the seat belt while up in her wheelchair because the resident had numerous falls due to reaching out for items in her room. The seat belt prevented her from falling forward out of her chair. On 3/7/22 at 10:10 A.M., the Director of Nursing and Administrator were interviewed. Both indicated use of a seat belt for safety should have been placed onto the residents care plan. A current facility policy, titled Care Plans, was provided by the Administrator on 3/7/22 at 2:49 P.M. The policy stated the following: .LLV will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs 3.1-35(a)

Based on observation, record review, and interview the facility failed to ensure nutritional status was adequate to prevent significant weight loss for 1 of 3 residents reviewed. (Resident 54) Findings include: In an observation on 03/02/22 at 01:09 PM, Resident 54 was lying in bed with mouth open and snoring. Resident 54 appeared thin with marked bony prominences in their arms and neck. The resident's wife was present. She indicated he sleeps the majority of the time and when he was not asleep, he was tired. She indicated Resident 54 only leaves his room for [CONDITION(S)]. She could not remember when the increased tiredness and sleeping began. A record review, on 3/4/22 at 11:26AM, indicated Resident 54's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 54's weights were recorded as follows: On 3/2/22, his weight was 145lbs, On 2/9/22, 154 lbs., and on 9/22/21, 164lbs. These weights indicated a 5.8% weight loss in one month and a 11.6% weight loss in 6 months. A review of Resident 54's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 54 was ordered Pro-stat 30ml three times a day as a supplement on 3/3/2021. Resident 54's meal intakes from December 2, 2021, through March 7, 2022, indicated zero intake at all meals. A review of the administration records indicated the following: In December 2021 all the tube feeding totals were only documented on the night shift and varied between 360ml to 960ml starting on 12/4/21. In January 2022 the administration of tube feeding on evenings was documented from 80ml to 960ml and on night shift from 480ml to 960ml. In February 2022, the administration of tube feeding on evenings was documented between 30ml to 480ml and on night shift from 360ml to 966ml. In March 2022 for tube feedings, indicated intakes varied on evening shift between 90ml to 480ml in and on night shift between 480ml to 960ml. A review of the October 2021 behavior committee, attended by the pharmacist, and with physician approval. determined to discontinued Resident 54's [MEDICATION(S)] 15mg because of the length of use without increase to oral intake. The [MEDICATION(S)] was restarted at 15mg daily on 2/7/22 after hospitalization . Resident 54's care plan had target areas of tube feedings, weight changes, and diet orders. The focus, goals and revisions were last changed 11/2021. The goal was for the resident to accept diet as ordered. Interventions included to check tube placement, follow MD orders for feedings and meals, obtain labs as ordered, RD to evaluate quarterly, and record meal intakes each meal. The Registered Dietician's (RD) note on 2/18/22 indicated the resident's weight was down 8lbs possibly related to refusing [CONDITION(S)] and refusing foods. It indicated to continue eternal feedings and encourage food intake. There was no other interventions. The Registered Dietician's (RD) progress note dated 3/2/2022 indicated the weight fluctuations were due to [CONDITION(S)], refusal of meals, and the recommendation was to continue to monitor weights. There were no other interventions. In an interview on 3/7/22 at 2:40PM the RD indicated Resident 54 triggered for excessive weight loss at both the 30day marker and 180 days. She explained Resident 54 had an oral diet but did not really eat. She determined his needs were 1800 and he was getting 2000 with tube feeding and a pro-stat supplement. She indicated she would defer to the doctor because he was not having diarrhea or vomiting, it was recorded he was getting tube feedings and supplements. In an interview on 3/7/22 at 2:16 P.M., the social worker indicated the resident was on [MEDICATION(S)] for anorexia as an appetite stimulant. Social services further indicated they had been discussing comfort care and hospice with Resident 54 and his family. The Social service worker indicated it would be Resident 54's decision to make as he was competent. She indicated Resident 54 was becoming more resistant to [CONDITION(S)], and was refusing to give up at this point and time. In an interview on 3/8/22 at 11:10 A.M., the Medical Director, indicated Resident 54 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The doctor indicated the resident refused to eat and had not been taking food orally. Surveyor asked why he was being prescribed [MEDICATION(S)]. Doctor stated to increase appetite. Writer asked why it was restarted when not affective and discontinued in October 2021. Doctor indicated he returned from hospital on it again and he did not recall it was discontinued previously. Doctor indicated nursing goes over any changes between hospital discharge orders and what resident was on prior. Doctor indicated Resident 54 is on comfort measures and can be expected to lose weight at this time. Surveyor asked doctor who was able to make the determination of when Resident 54 is to go to comfort care therefore no longer doing [CONDITION(S)]. Doctor indicated Resident 54 is able to make the decision. When surveyor informed doctor if there is no documentation of Resident 54 being on comfort measures at this time; he indicated it is possible Resident 54 had a malignancy and will not withstand the testing. An interview with QMA 3, on 3/8/22 at 11:45AM indicated Resident 54 is asked about his menu prior to each meal. He frequently declines. Everyone is aware if he wants something he will ask for it and then only look at it; not actually consume it. She indicated a tray is not prepared and brought to him due to him not ordering food. An interview with DON on 3/8/22 at 1:25PM indicated when the facility increases Resident 54's tube feeding past the 80ml for 12hrs he gets CHF. 3.1-46 (2) (b)

Based on observation, interview and record review, the facility failed to ensure staaff maintained proper infection control procedures for 8 of 8 staff observed. Findings include: 1. During interview on 7/20/21 at 1:10 P.M., the Administrator indicated the facility had a Covid-19 positive resident on the [NAME] Street hallway who was waiting to be transferred to another facility, so all staff would be wearing N95 masks. During an observation on 7/20/21 at 1:30 P.M., on Oak Street hallway, Employees 2 and 4 did not have the bottom strap of the N95 around their heads and the strap was under their chins. Upon interview at the same time, Employee B indicated the mask was tight at the bottom and asked if they needed to have the strap on. Employee 4 made no comment. During an observation on 7/20/21 at 1:35 P.M., at the nurses' station for Oak and [NAME] halls, Employee 5 did not have the bottom strap of the N95 around her head. The strap was under her chin. She also had a surgical mask underneath the N95 mask. Upon interview at the same time, Employee E indicated she did not have the bottom strap on because she had a mask under the N95, as it is uncomfortable for her. When asked if that was how it was to be worn, she indicated the bottom strap should go over her head but left the surgical mask under the N95. During an observation on 7/20/21 at 1:50 P.M., Employee 6 was observed thru the kitchen serving window. Employee 6's N95 bottom strap was not around her head and was under her chin. During an interview at the same time Employee 6 indicated the strap must have slipped off. During an observation at 1:55 P.M., Employee 10 was observed in the therapy room with a resident. The resident was not wearing a mask and Employee 10 was right beside the walker. Upon interview at the same time, Employee 10 indicated this was an outpatient and that he usually did wear his mask but it gets hard for him to breathe due to his [CONDITION(S)]. Employee 10 indicated he was already on the schedule for today when the facility found out about the Covid positive resident, so they were not sure of the protocol, and that he was already in the building. During interview on 7/20/21 at 2:00 P.M., the Administrator indicated they were stopping outpatient therapy that was already in the building; and indicated she knew they would have to provide some education on N95 wearing since it's been a while. She indicated the (N95s) weren't effective not making a seal. During an interview on 7/20/21 at 2:35 P.M., the Administrator indicated the outpatient was informed of Covid being here, and he agreed to stay as he was fully vaccinated and wore his mask all the time but during the highest point of activity. During observation on 7/20/21 at 3:07 P.M., on the memory care unit, Employee 8 was bringing a resident out of the shower room, and had her N95 mask down below her nose. At the same time, it was observed that Employee 7 was getting report from Employee 11 in the nurses' room by the shower room. Employee 7 was not wearing her N95. 2. During observation on 7/20/21 at 2:45 P.M. on [NAME] Street hallway, Employee 4 was passing ice water. She entered room [ROOM NUMBER]-2, touched the pitcher, then touched the pitcher for 306-1. She then proceeded to move the ice cart, entered room [ROOM NUMBER] , obtained the pitcher, filled it with water in the bathroom (BR), then placed it on the table by the resident. She touched the resident's wheelchair, closed the BR door, entered the hallway and moved the ice cart. She then walked to room [ROOM NUMBER]. Employee 4 did not use hand hygiene during the observation. Employee 4 exited the room with the pitcher, put ice in it and then took back into the room. Employee 4 then brought a second pitcher out of room [ROOM NUMBER], added ice, then pulled the cart to room [ROOM NUMBER], obtained the pitcher, touched the door, added ice, and took the pitcher back into the room and closed the door. Employee 4 did not use habnd hygiene during the observation. During an interview on 7/20/21 at 3:00 P.M., Employee 4 indicated she had not been performing hand hygiene in between each resident's ice water change. She indicated [NAME] had ever told her to use hand hygiene while pssing ice water. During interview on 7/20/21 at 3:15 P.M., the Administrator indicated staff are to use hand hygiene between each resident when passing ice water. The facility policy titled IC Handwashing/Hand Hygiene, no number, revised 08/15, indicated III. Procedure 1. All staff shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. 7. Use an alcohol-based hand rub . for the following situations . b. Before and after direct contact with residents; . l. After contact with objects . in the immediate vicinity of the resident; The facility policy titled IC Personal Protective equipment (PPE)-N95 Face Masks; Contingency and Crisis Capacity & Extended Use, Re-use, no number, revised 3/21/20, indicated It is the policy of LLV to follow infection control principles and practices to prevent spread of infection. N95 respirators are the PPE most often used to control exposures to infections transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. It is not recommended to modify the N95 respirator by placing any material within the respirator or over the respirator. Modification may negatively affect the performance of the respirator and could void the NIOSH approval. How to Properly Put on and Take off a Disposable Respirator . The bottom strap is positioned around the neck and below the ears. Place your fingertips from both hands at the tip of the metal nose clip (if present) . Slide fingertips down both sides of the metal strip to mold the nose area to the shape of your nose. Fit Check: . Place both hands completely over the respirator and exhale. If you feel leakage, there is not a proper seal 3.1-18 (b)(1)

Based on interview and record review the facility failed to ensure restorative programs were provided for 2 of 5 residents reviewed (Resident 6 and Resident 84). Findings include: 1. The clinical record for Resident 6 was reviewed on 1/29/20 at 10:14 A.M. [DIAGNOSES REDACTED]. A care plan problem initiated 6/13/16 indicated Resident 6 had limited physical mobility related to left arm weakness and right knee pain. A restorative intervention initiated on 8/1/19 indicated Resident 6 was to participate in group exercises at least 6 days a week. A restorative look back report dated 1/1/20 through 1/31/20 indicated the following was recorded regarding a 6 day a week restorative exercise program (Monday through Saturday= 27 opportunities): PA (resident participated in exercises)-11 NA (restorative not available)-5 Blank (restorative did not take place)-6 Rf (resident refused)-5 Restorative Aide 9 was interviewed on 1/31/20 at 12:49 P.M. During the interview Restorative Aide 9 indicated she and another aide lead exercises 5 days a week (Monday through Friday) and someone else led exercises on Saturday. Restorative Aide 9 indicated she gets pulled to the floor to work at times and if that happens she is not able to lead exercises on those days. She also indicated a blank area in the record means restorative exercises did not take place and a NA means restorative exercises did not take place. The Director of Nursing Services was interviewed on 2/3/20 at 10:28 A.M. During the interview the DNS indicated Resident 6 should have been offered exercises 6 days a week per her restorative program and she had not been. A policy, dated 11/17/18, was provided by the DNS on 2/3/20 at 2:30 P.M., titled Restorative Nursing. The policy indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence .3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's care plan. 2. On 1/31/20 at 1:26 P.M., the Clinical Record of Resident 84 was reviewed, indicated [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognition was severely impaired and required extensive assistance of 1 to 2 persons for transfers. There were no care plans in the resident's record that addressed Resident 84's positioning while seated in a wheelchair. On 2/3/20 at 9:28 A.M., an interview, conducted with Certified Nursing Assistant (CNA) 6, indicated Resident 84 was confused and always leaned to the right side when seated in a wheelchair. CNA 6 used a pillow which helped the resident sit up straighter while seated in her wheelchair. On 2/3/20 at 9:51 A.M., an interview, conducted with OT Rehab Director, indicated Resident 84 had a inset that was used in the wheelchair and assisted with positioning. When staff cued the resident, she could adjust her own positioning and infrequently the resident herself could correct her positioning. The OT Rehab Director indicated if the resident continued to lean while seated in her wheelchai,r the OT Rehab Director would have offered more staff education such as a small pillow or a rolled up towel. The OT Rehab Director indicated Resident 84 had been discharged from therapy and an insert had been placed in the resident's wheelchair. The insert allowed the resident to sit up straighter. The OT Rehab Director indicated she was not aware the resident's upper torso was leaning to the right side and the insert placed in the resident's wheelchair might have come loose, may need tightened, and she would have re-educated staff in regard to the resident's positioning. On 2/3/20 at 11:28 A.M., an interview, conducted with Director of Nursing Service (DNS), indicated she had reviewed Resident 84's record and had not found a specific care plan that had addressed the resident's positioning. The DNS indicated when the resident had discharged from OT services, the OT Rehab Director should have communicated to nursing and nursing would have addressed the resident's positioning in a care plan. The DNS indicated Resident 84 should have probably been referred to a restorative positioning program. Observations were conducted of Resident 84 which included, but were not limited to the following: On 1/28/20 at 12:05 P.M., the resident was in the common area seated in a wheelchair with a blue insert placed in the resident's wheelchair. The resident's upper torso and head were leaned to the resident's right side. On 1/29/20 at 11:01 A.M., the resident was in the common area seated in her wheelchair with the blue insert the resident upper torso and head were leaned to her right side. On 1/30/20 at 09:30 A.M., during a continuous observation, Resident 84 was in the common area seated in her wheelchair with the blue insert in a group activity. CNA 4 had removed a pillow from the resident's right side, straightened the resident's upper body, then CNA 4 left the area. On 1/30/20 at 9:56 A.M., the resident's upper torso leaned to her right side with her left foot up on a wheelchair pedal, her right foot was on the floor. On 1/30/20 at 10:24 A.M., the resident continued to lean to the right with her right arm and hand hung down next to her wheelchair. Resident 84 awoke startled and brought her right arm and hand up onto the wheelchair armrest. The Activity Coordinator 5 walked over to the resident, stood on the resident's left side and encouraged the resident to sing. The resident's upper torso and head continued to lean to the right side. The continuous observation ended on 1/30/20 at 10:55 A.M. On 1/31/20 at 9:05 A.M., the resident was observed in the common area seated in her wheelchair. The blue insert was present, but her upper torso and head leaned to her right. On 2/03/20 at 9:25 A.M., the resident was in the common area seated in her wheelchair. CNA 6 had cued the resident to sit up straighter. The resident's upper torso and head continued to lean slightly to the right side. 3.1-42(a)(1)

Based on observation, interview and record review, the facility failed to monitor tube feedings as recommended for 1 of 1 residents reviewed. (Resident 76) Findings include: On 1/31/2020 at 10:30 a.m., the record of Resident 76 was reviewed. [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) Assessment, dated 12/20/2019, included the following: the resident had independent cognition, needed supervision with eating, was not on a prescribed weight loss program, and had over a 10 % weight loss in the last month. The report also indicated the resident had a tube feeding while a resident and prior to being admitted to the facility, obtained 51% or more proportion of total calories from tube feeding, and average fluid intake per day by the tube feeding was 501 milliliter (ml) or more. A plan of care, dated 12/23/19, had the focus of: Receives nutrition, fluids via [DEVICE]. Interventions included, follow physician orders [REDACTED]. A physician order, dated 12/24/2019 indicated to give: Enteral feeding-order every shift: nutrition via pump Nepro (liquid nutrition for residents on [MEDICAL TREATMENT]) at 40 ml/hr (milileters per hour) for 24 hours via pump. Hold while at [MEDICAL TREATMENT]. A nutritional note, dated 1/23/2020 at 11:35 a.m., indicated the following: the resident continued on [MEDICAL TREATMENT] 3 times a week, continued with a [DEVICE] for nutrition and fluids, the current order was for Nepro to run at 40 ml/hr with water 30 ml/hr continuous. The feeding tube was to be disconnected for [MEDICAL TREATMENT] treatments. The resident had an oral diet, but intakes varied per recorded food intakes. The resident's weight was 132 pounds, for a 12% weight gain in 30 days. A nutritional note, dated 1/29/2020 at 8:50 a.m., indicated the resident was gaining the weight that had been lost from hospitalization s. The January 2020 MAR was reviewed on 1/30/2020 at 2:10 p.m. and indicated the following: Enteral feeding order: every shift- enteral nutrition via pump, give Nepro at 40 ml/hr for 24 hours via pump, hold while at [MEDICAL TREATMENT]. Enteral feeding order: every shift flush tube with 30 ml water continuous. For all 3 shifts between 1/1/2020 through 1/30/2020, both the Nepro and flush order had been initialed as completed, with the exception of 4 shifts. These 4 shifts were documented as the resident had been out of the facility and/or to refer to progress notes. Documentation was lacking on the MAR/TAR (treatment administration record) as to the amount of Nepro and/or flush infused. On 1/28/2020 at 2:40 p.m., Resident 76 was observed in bed. A tube feeding pump was observed at the bedside. A clear bag, with clear fluid in it was attached. The bag was not dated and/or timed to indicate when the bag had been changed or initiated. Another bag, labeled Nepro was dated 1/28 but no time was observed to be labeled on the bag. The tube feeding pump was on and indicated the feeding was infusing at 40 ml/hr (hour) and the water flush was programmed to infuse at 30 ml every hour (hr). On 1/28/20 at 3:14 p.m., Resident 76 was interviewed. He indicated he consumed food orally and also had a tube feeding. On 1/30/2020 at 8:55 a.m., Resident 76 was not observed in his room. The tube feeding pump was observed off with no feeding and/or flush hanging. A female resident was observed at the bedside and was interviewed. She indicated she was the resident's wife, the resident had left the facility and gone to [MEDICAL TREATMENT]. She indicated she was unsure as to what time the resident left the facility and/or when he typically returned. On 1/30/2020 at 10:53 a.m. Resident 76 was observed to receive medications per the [DEVICE] by LPN 7. Upon entry into the room, the tube feeding was not observed to have been infusing. At 11:04 a.m. the medication administration was completed, the [DEVICE] was capped and the pump remained off with no infusion observed. On 1/30/2020 at 11:35 a.m., the tube feeding was observed to be infusing via the pump with the following: Nepro tube feeding dated 1/30/20, with no time labeled, was programmed at 40 ml/hr. The Nepro bag was observed to have 500 ml in it. The flush bag was programmed to infuse at 30 ml every hour with 850 ml hanging in the water flush bag. On 1/31/2020 at 3:10 p.m., the Director of Nursing Service (DNS) was interviewed. She indicated the intakes of the [DEVICE] (Nepro and flush) were documented on the medication administration record (MAR) and the treatment administration record (TAR). The DNS indicated you just have to add it up. On 2/3/2020 at 9:22 a.m., LPN 7 was interviewed. She indicated the resident went to [MEDICAL TREATMENT] three times a week, the time the resident left for [MEDICAL TREATMENT] and returned was pretty much the same time, he leaves at 5:00 a.m. - 5:15 a.m. and gets back between 10:30 a.m.-11:00 a.m. LPN 7 indicated for the date 1/30/2020, she was unable to find documentation regarding the time the resident left the facility. LPN 7 indicated the resident returned to the facility at 11:00 a.m. She indicated the feeding was turned off just before the resident left the facility and was turned back on when he returned at 11:00 a.m. LPN 7 indicated the tube feeding rate was set at 40 ml to infuse continuous except when the resident was at [MEDICAL TREATMENT]. She indicated she did not document anywhere how much Nepro she added to the tube feeding bag and/or when she added the Nepro. She indicated she did not document how much Nepro was infused on her shift. She indicated she was not aware what the level of tube feeding in the residents bag was when she came on duty this morning. She indicated the machine beeps when it needs more Nepro and so she just puts more in the bag. On 2/3/2020 at 12:46 p.m. the Registered Dietician (RD) was interviewed regarding how she monitored the resident's caloric intake. She indicated the resident was reassessed quarterly. She considered his weight and oral intake as well as his overall health. This would include wound healing, amount of feeding residual, et cetera. The RD indicated in December 2019, the Nepro was increased from 25 ml/hr to 40 ml/ hr. She indicated prior to the rate increase, the resident was only eating bites and his weight was trending down, and she considered the tube feeding intake, to arrive at the desired increase in Nepro rate. She was queried regarding how she was certain the resident had actually received the recommended amount of Nepro feeding. She indicated she would multiply the hourly rate by the time frame, 25 ml/hr x 24 hours. She indicated on [MEDICAL TREATMENT] days, she was unsure of the time the resident's tube feeding was stopped, but thought he is gone for about 4 hours. She indicated the following: on the days the resident does not get [MEDICAL TREATMENT], for 24 hour feeding, the resident would receive a total of 1700 calories, 76 grams (gm) of protein and approximately 1408 ml of water. On the 3 days the resident goes to [MEDICAL TREATMENT] and would be off the feeding for 4 hours, he would receive the following: 1440 calories, 63.1 gm of protein and approximately 1172 ml of water. The RD indicated if the resident's tube feeding was off for 6 hours a day, the resident would receive 1275 calories, 56.9 gm of protein and approximately 1056 ml of water. She indicated the nurses documented the amount of tube feeding infused on the MAR and by doing so, indicated the physician order [REDACTED]. The RD indicated the resident had not received the recommended amount of tube feeding she thought he was had received. On 2/3/2020 at 11:21 a.m., the RD provided a current copy of the facility policy and procedure for Tube Feeding - Enteral Nutrition dated 2/16/18. The policy and procedure included, but was not limited to, the following: the Dietician with input from the provider and nurse: determined whether the resident's current intake was adequate to meet his or her nutritional needs; enteral nutrition was ordered by the provider based on the recommendations of the dietician; the dietician monitors residents who received enteral nutrition and make appropriate recommendations for interventions; the nurse confirmed orders for enteral nutrition were complete. Complete orders included: volume and rate of administration and the volume/rate goals and recommendations for advancement toward these. 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure adequate monitoring was provided for [MEDICATION NAME] (blood thinner) for 1 of 2 residents reviewed. (Resident 62) Findings include: On 1/30/2020 at 1:30 p.m., the clinical record of Resident 62 was reviewed. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment dated [DATE] included the following: severely impaired cognition and resident had taken anticoagulants 7 days within the last 7 days. Nurses notes, dated 1/13/2020 indicated PT/INR ([MEDICATION NAME] time/international normalized ratio) (a lab test used to monitor and regulate medication [MEDICATION NAME]) drawn had been drawn in the a.m. on 1/13/2020. The January 2020 Medication Administration Record [REDACTED]. A PT/INR result, dated 1/13/2020 and reported to the facility at 6:00 p.m., indicated a critical result of 5.6 seconds (reference range of 0.9 - 1.1). A progress note, dated 1/14/2020 at 12:36 p.m., indicated the physician was in, labs were reviewed, and orders were reviewed. Documentation was lacking as to which labs were reviewed with the physician and what orders had been reviewed. The January 2020 MAR indicated [REDACTED]. Per the chart codes on the MAR, H, indicated on hold by physician. The current MAR indicated [REDACTED]. A PT/INR lab, dated 1/17/2020 reported to the facility at 16:00 (4:00 p.m.) had a critical result of 6.8 sec (reference range 0.9 - 1.1). A physician order [REDACTED]. On 1/31/2020 at 11:50 a.m., the DNS was interviewed. She indicated the critical high PT/INR of 5.6 (reference range 0.9-1.1), dated 1/13/2020, was reported to the facility at 6:00 p.m. On 1/13/2020 at 6:42 p.m., LPN 2 notified the physician of the critical high result. She indicated LPN 2 received a physician order [REDACTED]. She indicated documentation was lacking of a physician order [REDACTED]. She indicated on 1/14/2020, LPN 1 notified the physician to clarify the [MEDICATION NAME] orders. She indicated LPN 1 received an order to hold the [MEDICATION NAME] dose for 1/16/2020 and to recheck the PT/INR on 1/17/20. The DNS indicated documentation was lacking of the physician's orders [REDACTED]. The DNS indicated LPN 1 had written the hold order for [MEDICATION NAME] on the desk calendar for the date of 1/16/2020. The DNS indicated the [MEDICATION NAME] should not have been given on 1/16/20 before the PT/INR result had been obtained. The DNS indicated the resident had not had any complications related to [MEDICATION NAME] use. She indicated a PT/INR had been drawn on 1/17/2020 at 6:15 a.m. with the result reported at 4:00 p.m. to the facility. She indicated the result was a critical high of 6.8 sec. She indicated a physician order [REDACTED]. The [MEDICATION NAME] dose was not given on 1/17/2020. A repeat INR was obtained on 1/20/2020 with a result of INR 2.5. Also, 1/22/2020 the resident was started on Keflex (antibiotic) for a urinary tract infection. A progress note, dated 1/22/20 at 3:19 p.m., indicated .the order you have entered .has identified a possible drug interaction with the following orders .Interaction .The [MEDICATION NAME] effects of [MEDICATION NAME] ([MEDICATION NAME]) .may be increased by cephalaxin (keflex) .with possible increased risk of bleeding complications. The DNS indicated LPN 1 had indicated he had made the physician aware of this alert but documentation was lacking of this physician notification. The DNS indicated the INR on 1/27/2020 was 2.5 sec. On 1/31/2020 at 12:50 p.m., RN 3 was interviewed. She indicated when an order for [REDACTED]. She indicated the lab draw book was for the use of the lab personnel. On 1/31/2020 at 12:51 p.m., RN 3 was interviewed. She indicated when she was aware a resident had a PT/INR drawn on a specific day, she would wait to administer the [MEDICATION NAME] dose until she received the PT/INR result. She indicated to check when a PT/INR was to be drawn, she would review the treatment administration record (TAR) and/or the information should have been passed on in the nursing report. She indicated she would also check the physician order [REDACTED]. On 1/31/2020 at 2:18 p.m., LPN 1 was interviewed. He indicated he received a phone order from the physician on 1/14/2020 to hold the [MEDICATION NAME] on 1/16/2020. LPN 1 indicated he wrote the order on the calendar on the desk but he did not write the physician order [REDACTED]. He indicated if the [MEDICATION NAME] would have been on hold, this would have been indicated on the MAR by an H for the 1/16/2020 dose. Documentation was lacking of a physician order [REDACTED]. On 1/31/2020 at 2:25 p.m., LPN 1 was interviewed. He indicated he had obtained a verbal order from the physician on 1/16/2020 for a PT/INR to be drawn on 1/17/2020. Documentation was lacking in the record for a PT/INR to be drawn on 1/17/2020. LPN 1 indicated the PT/INR for 1/17/202 had been completed. On 2/3/2020 at 8:20 a.m. the DNS was interviewed. She indicated the physician order [REDACTED]. She indicated the resident was a hospice resident and the [MEDICATION NAME] had been discontinued on 1/28/2020. On 1/31/2020 at 2:30 p.m. the January 2020 MAR indicated [REDACTED].every Wednesday for monitoring . This had been documented as completed on 1/15/2020 and had a start date of 12/4/2020. On 1/31/2020 at 1:25 p.m., the policy and procedure for Anticoagulant ([MEDICATION NAME]) Therapy dated 2/8/18, was received from the Nurse Consultant. The policy and procedure included, but was not limited to, the following: This medication and other anticoagulants are marked with a Black Box Warning (the strictest warning put in the labeling of prescription drugs by the Food and Drug Administration when there is reasonable evidence or an association of a serious hazard with the drug). It is the policy of the facility to provide [MEDICATION NAME] in a safe and therapeutic manner while providing adequate monitoring. When obtaining an order for [REDACTED]. On 1/31/2020 at 1:25 p.m., the policy and procedure for Lab .Results dated 3/21/19 was received from the Nurse Consultant. The policy and procedure included, but was not limited to, the following: .a nurse will review all results .The person who is to communicate results to a physician will review and be prepared to discuss the following .how test results might related to the individual's current status .or medications .Any concerns or issues the physician will be expected to address upon receiving the result .Facility staff should document physician notification in the EMR (electronic medical record). This should be done in the progress notes section of the EMR . On 1/31/2020 at 1:50 p.m., the policy and procedure for Anticoagulants and [MEDICATION NAME] Orders dated 2/7/18, included, but was not limited to, the following: It is the intent orders for anticoagulants shall be prescribed only with proper clinical and laboratory monitoring. The nurse administering the anticoagulant [MEDICATION NAME], will review the INR and document the result in the eMAR before administering the medication. 3.1-48(a)(3)

Based on interview and record review, the facility failed to complete a significant change MDS (Minimum Data Set) assessment within 14 days after determining a resident had a significant change in condition (Resident 98) for 1 of 16 residents reviewed for MDS assessments. Findings include: On 3/14/17 at 9:26 A.M., Resident 98's record was reviewed and indicated diagnoses, including but not limited to, diabetes and falls. The significant change MDS assessment indicated it should have been completed on 2/9/17 but it was incomplete and still in progress on 3/14/17. On 3/14/17 at 10:06 A.M., the Director of Nursing (DON) was interviewed. During the interview, the DON indicted the significant change MDS assessment should have been completed by 2/23/17 and was late. 3.1-31(d)(1)

Based on observation, interview and record review, the facility failed to develop a plan of care with interventions to address behaviors and use of anti-psychotic medication for 1 of 16 residents reviewed for care plans (Resident 87). Findings include: 1. On 3/13/17 at 3:00 P.M., Resident 87's record was reviewed. The record indicated [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment completed on 1/10/17 indicated a BIMS (Brief Interview Mental Status) score of 14 which indicated Resident 87 was cognitively intact. The MDS indicated Resident 87 had hallucinations during the MDS assessment period. A Physicians order, dated 1/31/17, was for [MEDICATION NAME] (anti-psychotic medication) 25mg (milligrams) every night for dementia with hallucinations. Resident 87's Plan of Care did not indicate the resident had or was having hallucinations. The Plan of Care did not indicate Resident 87 had been prescribed an anti-psychotic medication to treat the hallucinations nor did it indicate how the behaviors were to be monitored in addition to possible side effects of the anti-psychotic medication. On 3/13/17 at 9:20 A.M., Resident 87 was interviewed and observed in her room sitting up on the side of the bed. Resident 87 indicated she previously had nightmares and hadn't been sleeping at night. She indicated her medications had been adjusted and she was sleeping better. On 3/14/17 at 10:39 A.M., SSD 1 (Social Service Designee) was interviewed. SSD 1 indicated SSD's write the plan of care for resident's with behaviors and/or use of anti-psychotic medications. SSD 1 indicated there was no plan of care written to address Resident 87's hallucinations or use of anti-psychotic medication to treat the hallucinations. On 3/14/17 at 11:36 A.M., SSD 2 was interviewed. SSD 2 indicated she would write a plan of care for resident's with behaviors and/or who are utilizing [MEDICAL CONDITION] medications. SSD 2 indicated she referred Resident 87 to psychiatric services contracted by the facility but did no further follow up for behavior monitoring nor did she write a plan of care to address Resident 87's hallucinations and use of anti-psychotic medication to treat the hallucinations. On 3/15/17 at 11:50 A.M., the Director of Nursing (DON) provided a current policy titled Care Plans with a revision date of 11/28/16. The policy indicated the following: B. Comprehensive Care Plans: (facility) will develop and implement a comprehensive person-centered care plan for each resident, consistent with Resident Rights that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs 3.1-35(a)