Every finding on record at Lutheran Life Villages

Based on interviews and record reviewed, the facility failed to ensure non-pharmacological interventions were completed. For 1 of 1 resident reviewed. (Resident 10)Findings include:Resident 10's record was reviewed on 2/25/26 at 1:13 PM. Diagnosis included, chronic kidney disease, stage 4. A review of Resident 10's current significant change minimum data set indicated their BIMS (Basic Interview for Mental Status) score was 12.A review of Resident 10's current Care plan, dated 2/6/26, indicated a focus of chronic pain related to osteoarthritis, age-related debility, gout, GERD. The goals included the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included to administer routine/as needed, pain medication as ordered. Notify provider of any adverse reactions. Encourage and attempt to provide non-pharmacological interventions initially. Provide several choices if able (turn and reposition, back rub, emotional support, limb supports, flex/extend extremities, massage, distraction, heat/cold, remove/reduce environmental stimulants, controlled breathing, encourage prayer/meditation, pleasant imagery, relaxing music, breathing control, remove restrictive clothing, different seating, change linens, adjust room temp, etc) notify provider as needed if medicinal or pharmacological interventions are unsuccessful and follow new directions if indicated note any adverse side effects and notify provider of lethargy, change in level of consciousness, increased falls, hallucinations, nausea/vomiting, flaccidity, abnormal feelings of euphoria, increased swallowing difficulties, decrease rate of respirations. If indicated, note in the chart the following: notate characteristic, frequency, interruption in day-to-day activities or sleep, numerical rating of pain intensity on scale of 1-10 (10 being the worst pain you can imagine), duration, aggravating/relieving factors, anatomical location. A review of physician orders indicated to give oxycodone HCl Oral Concentrate 100 MG/5ML 0.25 milliliter (ml) by mouth every 4 hours as needed for pain 6-10 on the pain scale or dyspnea (shortness of breath) for pain. A review of Medication Administration Record (MAR), dated February 2026, indicated Resident 10 received oxycodone for pain as follows:On the 4th at 7:39 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notes. On the 5th at 8:04 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 9th at 7:00 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 10th at 12:58 PM and 9:21 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 17th at 8:28 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 18th at 6:05 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 19th at 7:59 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesOn the 24th at 8:02 PM. Non-pharmacological interventions were not documented as attempted in the MAR or progress notesIn an interview, on 02/25/2026 at 2:00 PM, the Director of Nursing (DON) indicated non-pharmacological interventions should be done prior to administering as needed pain medication. In an interview, on 02/26/2026 at 8:48 AM, Registered Nurse 4, indicated CNAs complete the non-pharmacological interventions, tell the nurse if the interventions were effective, then the nurses would chart it. A current facility policy, titled Pain Management, dated 10/20, was provided by the Director of Nursing on 2/25/26 at 10:57 AM. The policy indicated. Non-pharmacological interventions will include but are not limited to: Environment comfort measure (e.g adjusting room temperature, smoothing linens, comfortable seating or assistive devices).Loosening any constrictive bandage, clothing or device.applying splinting.physical modalities.exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility.cognitive behavioral interventions. 3.1-37(a)

Based on interview and record review the facility failed to ensure physician orders were followed though regarding a laboratory blood draw for 1 of 1 residents reviewed. (Resident 8) Findings include: A record review began on 3/14/25 at 2:04 PM. Resident 8's diagnosis included Alzheimer's disease, bipolar disorder, and depression. A review of the physician orders indicated the following: Lamotrigine oral tablet 150 MG (milligrams) (Lamotrigine), give 1 tablet by mouth one time a day related to Bipolar disorder, current episode depressed, mild or moderate severity, unspecified. Start date 7/26/24. Lamotrigine level every 6 months, due 8/28/24: one time only for labs until 8/28/24 at 11:59 PM. order date 2/26/24. start date 8/28/24. end date 8/28/24. A review of the lab results report, dated 3/3/24, indicated a lamtrigine level was not observed on the report. A review of the lab results report, dated 3/12/24, indicated a lamtrigine level was not observed on the report. A review of the lab results report, dated 3/25/24, indicated a lamtrigine level was completed for Resident 8 on the report. The next lab was due to be drawn in September 2024. There were no lab report with a lamtrigine level for Resident 8 between 3/25/24 and March 2025. In an interview, on 3/14/25, the Director of Nursing ( DON) indicated they missed the lamtrigine level lab for September 2024. She indicated the lab was ordered to be drawn every 6 months and that's when it should have been done. The order was put in as one time only and it was missed. She indicated the facility called the Nurse Practitioner, and will get the lab to come out to get it done. The facility fixed the order to reflect the lab was to be drawn every 6 months. A current facility policy titled Medical Record, dated 12/21/16, was provided by the DON on 3/17/25 at 9:31 AM. The policy indicated .the nurse is required to electronically acknowledge orders. The nurse should review the order for clarity and completeness, making an entry into the nurses notes, adding an additional Care Plan problem or augmenting an existing problem, an entry into a communication device or shift report and notify any ancillary department required to execute the order. When applicable, the nurse should notify pharmacy and dinning services. Acknowledging/noting orders takes place in the Electronic Medical Record (EMR), nurse notes to be in the EMR, care plans to be added, changed or updated within the EMR 3.1-37

Based on observation, interview and record review, the facility failed to ensure vascular access device was monitored and maintained for 1 of 1 resident reviewed (Resident 52). Findings include: On 3/14/25 at 10:25 AM, Resident 52 was observed sitting in their wheelchair in their room. Resident 52's right lower arm and right hand were observed to be swollen. Resident 52's right lower arm and right hand were observed to be red and purple in color. In an interview, on 3/14/25 at 10:40 AM, Resident 52 indicated their right arm and right hand were swollen and bruised due to a problem with an intravenous (IV) line. Resident 52 indicated an IV line had to be removed from their right arm. Resident 52 raised their left shirt sleeve. A transparent dressing above the left elbow bend was observed. A stabilization device (Stat Lock) securing an IV line was observed under the transparent dressing. A dark brown substance was observed on the Stat Lock and on Resident 52's skin at the IV insertion site. The dressing did not include a start or change date or time. On 3/14/25 at 10:43 AM, a sign, dated 3/9/25 at 9:22 PM, was observed taped to the wall in Resident 52's room. The sign had the name and phone number of an IV service. The sign indicated Resident 52 had a midline catheter in their left arm. The sign indicated Resident 52's left upper arm circumference was 26 centimeters. The sign indicated the external length of the PICC line was 0 centimeters. Resident 52's record was reviewed on 3/14/25 at 11:23 AM. Diagnoses included coronary artery disease, high blood pressure and irregular heartbeat. Resident 52's Annual Minimum Data Set (MDS) dated [DATE], indicated Resident Brief Interview for Mental Status (BIMS) score was 15 (no cognitive loss). The MDS indicated Resident 52 had 1 arterial or venous ulcer. The MDS indicated Resident 52 required the application of dressings to their feet. A physician order, dated 3/9/25, indicated a PICC line was to be inserted into Resident 52's left basilic vein for antibiotic use. A physician order, dated 3/10/25, indicated Resident 52's left arm PICC line was to be inspected for phlebitis and infiltration every shift. The order indicated the location and appearance of the PICC line site was to be documented in the progress notes. A physician order, dated 3/12/25, indicated Resident 52 required a PICC line dressing change every 7 days and as needed for soilage or dislodgement. The order indicated Resident 52's upper arm circumference and external catheter length were to be measured at each dressing change. A progress note, dated 3/9/25 at 5:40 PM, indicated a nurse had arrived for PICC line insertion. A late entry progress note, dated 3/11/25 at 11:40 AM, indicated there had been active bleeding from Resident 52's right arm PICC line insertion site. The PICC line was removed and a pressure dressing was applied. The dressing to the left arm PICC insertion site was changed and the area cleansed. Resident 52's progress notes, dated 3/6/25 at 1:46 PM through 3/18/25 at 8:15 AM, did not indicate the date or time of PICC line removal from the resident's right arm. Resident 52's progress notes, dated 3/6/25 at 1:46 PM through 3/18/25 at 8:15 AM, did not indicate the date or time of PICC line placement to the resident's left arm. Resident 52's Treatment Administration Record, (TAR) dated 3/1/25 through 3/31/25, indicated the following: PICC line dressing instructions: 1. Transparent dressing change to PICC site every 7 days as needed for soilage or dislodgement. The start date was 3/9/25 at 1:03 PM. The discontinued date was 3/12/25 at 12:19 PM. 2. Transparent dressing change to PICC site every 7 days, measure upper arm circumference and external catheter length upon admission and each dressing change and as needed. The start date was 3/16/25 at 11:00 PM. The discontinued date was 3/12/19 at 12:19 PM. 3. Transparent dressing change to PICC site every 7 days as needed for soilage or dislodgement. The start date was 3/12/25 at 12:30 PM. Resident 52's Treatment Administration Record, (TAR) dated 3/1/25 through 3/31/25, did not indicate the PICC dressing had been changed. The TAR did not indicate the resident's upper arm circumference had been measured. On 3/17/25 at 9:45 AM, Registered Nurse (RN) 2 was observed flushing Resident 52's PICC line. The PICC line dressing did not include a date or time. RN 2 indicated the PICC line dressing was to be changed the following day. RN 2 indicated they knew the PICC line dressing was to be changed tomorrow as they were sure the dressing was applied on Tuesday. On 3/18/25 at 9:42 AM, Registered Nurse (RN) 2 was observed changing Resident 52's PICC line dressing. RN 2 indicated they did not observe a date on the PICC line dressing. RN 2 removed the dressing and cleansed the resident's skin at the insertion site. RN 2 cleansed the Stat Lock. RN 2 allowed the area to air dry. RN 2 applied a transparent dressing over the Stat Lock and the PICC insertion site. RN 2 measured the external catheter and indicated the external catheter length was 1 centimeter. RN 2 applied a label with the date, time and their initials. RN 2 did not measure Resident 52's upper arm circumference. In an interview, on 3/18/25 at 9:47 AM, RN 2 indicated they were not aware of how often the Stat Lock should be changed. RN 2 indicated they did not know if the pharmacy supplied Stat Locks. RN 2 indicated they should have measured the resident's upper arm circumference. In an interview, on 3/18/25 at 10:35 AM, the Director of Nursing (DON) indicated the prior PICC line dressing should have been labeled with date, time and nurse initials. The DON indicated the resident's arm circumference should have been measured. The DON indicated the Stat Lock should have been removed and discarded prior to cleansing the area. A current facility policy, dated 8/3/24, provided by the DON on 3/17/25 at 11:35 AM, indicated PICC line dressings would be changed in a manner that decreased potential for infection. The policy indicated the Stat Lock should be removed and discarded. The policy indicated the PICC line dressing should be labeled with the date, time and initials. 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed through for 1 of 5 residents reviewed. (Resident 22) Findings include: A record review began on 3/18/25 at 9:14 AM. Resident 22's diagnosis included, chronic obstructive pulmonary disease. A review of the physician orders indicated: Methocarbamol oral tablet (methocarbamol) give 250 mg ( milligrams) by mouth every 8 hours as needed for Muscle relaxer. Start date 12/9/24. A review of the pharmacy consultation report dated February 25, 2025 through February 26, 2025: indicated Resident 22 received a muscle relaxant, Methocarbarnol. The medication had not been used since 12/18/24. Recommendation: please discontinue Methocarbmol. Rational for recommendation: Muscle relaxants have strong, sedating anticholinergic properties, are associated with increased risk for fractures and have questionable effectiveness at doses tolerated by old adults. The physician accepted the recommendations signed on 2/27/25. There was a note the Director of Nursing acknowledged the recommendation signed on 3/4/25. In an interview, on 3/18/25 at 9:52 AM, the Director of Nursing (DON) indicated, they did not discontinued the medication. A current facility policy, Pharmacy-Drug Review, dated 2/28/27, was provided by the DON on 3/18/25 at 10:15 AM. The policy indicated . It is the intent of facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist may need to conduct the medication regimen review more frequently depending on the resident condition, review of short stay residents and risk of adverse consequences. The licensed pharmacist will report in writing, any irregularities to the attending physician, the facility's medical director, and the director of nursing to be acted upon 3.1-25(h)

Based on interview and record review the facility failed to ensure an implanted intrathecal pump (ITP) morphine delivery system was monitored for 1 of 3 residents reviewed (Resident 8). Findings include: In an interview on 2/13/24 at 9:48 A.M., Resident 8 indicated their pain was managed by a pain management clinic. Resident 8 indicated they received a continuous infusion of morphine by a pump inserted in their spinal fluid. Resident 8's record was reviewed on 2/13/24 at 10:06 A.M. Diagnoses included degeneration of cervical spine, carpal tunnel syndrome, ulnar neuropathy, brachial neuritis, cervico-occipital neuralgia, degeneration of lumbar spine, post-laminectomy syndrome and chronic pain syndrome. A review of Resident 8's most recent annual Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS did not indicate Resident 8 was being administered morphine for pain control. A physician order, dated 12/12/23, indicated Resident 8 had an appointment for a morphine pump refill on 2/14/24. Resident 8's medication orders did not include morphine. Resident 8's current care plan, dated 7/20/21, indicated Resident 8 was at risk for chronic pain. The target goal was for Resident 8 to have no alteration in daily schedule through 2/20/24. Interventions did not include an implanted intrathecal morphine pump. A pain management clinic visit summary, dated 12/12/23, indicated Resident 8's ITP had been refilled with 40 milliliters of preservative free morphine. The concentration of morphine was 9 milligrams per milliliter. The ITP infusion rate was programmed to infuse at 0.2 milligrams per hour. In an interview on, 2/16/24 at 9:29 A.M., the Director of Nursing (DON) indicated the facility did not have a physician order for Resident 8's ITP due to the ITP being managed at the pain clinic. The DON indicated they were unaware of the medication in Resident 8's ITP due to the medication not being administered by the facility staff. The DON indicated the facility did not have a copy of Resident 8's ITP identification number. A pain management clinic visit summary, dated 12/12/23, provided by the DON on 2/19/24 at 9:02 A.M. indicated Resident 8's ITP had been refilled with 40 milliliters of preservative free morphine on 12/12/23. The concentration of morphine was 9 milligrams per milliliter. The ITP infusion rate was programmed to infuse at 0.2 milligrams per hour. A current policy, dated 8/15/08 and revised 6/1/21, provided by the DON on 2/16/24 at 10:26 A.M., indicated the facility must ensure nurses responsible for the care and management of an implanted intrathecal pump are knowledgeable and competent in the administration procedures and potential complications. The policy indicated potential complications interfering with the delivery of the medication could include migration of the ITP catheter, fracture of the ITP catheter or erosion of the ITP catheter. In an interview, on 2/16/24 at 1:41 A.M., the above stated policy The DON and the Administrator indicated the ITP medication should be included in the physician orders. 3.1-37

Based on observation, interview, and record review the facility failed to ensure pressure ulcer care was provided according to physician's orders for 1 of 2 residents reviewed (Resident 48). Findings include: During a dressing change observation on 2/16/24 at 11:07 A.M., Registered Nurse (RN) 10 removed Resident 48's right sock to reveal white gauze wrapped around Resident 48's right heel. No date was observed on the gauze or tape securing the gauze. RN 10 cut the gauze to remove it and the gauze was stuck to the right heel. RN 10 sprayed a liquid from a container labeled wound wash and allowed the liquid to soak for a few minutes before slowly pulling the dressing away from the right foot. The gauze removed from the right heel was white with no color or residues observed. RN 10 used the liquid on a clean piece of gauze to clean the right heel wound bed and surrounding skin. No residue of any color was observed on the gauze used to clean the area, on the wound bed, or surrounding tissue. Resident 48's record was reviewed on 2/16/24 at 10:33 A.M. Diagnoses included chronic diastolic heart failure, peripheral vascular disease, unspecified, and essential hypertension. A review of Resident 48's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 48 had an unstageable pressure injury presenting as a deep tissue injury on the right heel. A review of Resident 48's current care plan, titled deep tissue pressure injury, indicated Resident 48 had a problem of a pressure injury to her right heel with a goal date of 5/18/24. Interventions included administering treatments as ordered. Physician orders, dated 2/13/24 at 11:45 A.M., indicated the wound on the right heel should be washed with wound cleanser and patted dry. Skin prep should be applied around the right heel wound bed, betadine (a dark brown liquid) soaked gauze to the wound bed, then covered with an ABD pad (thick, padded gauze pad) and kerlix (rolled gauze used to wrap around a body part). In an interview, on 2/16/24 at 11:31 A.M., RN 10 indicated she saw no signs betadine had been used on the dressing she removed from Resident 48's right heel during the wound care observation that morning. She indicated brown residue would have been observed on the dressing, on surrounding tissue and the right heel wound bed if betadine had been used. RN 10 indicated when she prepared for the dressing change, she noticed the betadine had not been delivered by the pharmacy. She indicated she was able to use betadine contained in stock supplied betadine swab stick packets to perform her dressing change. RN10 indicated the pharmacy should have been contacted when the betadine did not arrive as expected and a stat delivery requested. When an item was not able to be delivered, the physician should have been contacted for an alternative treatment until the product was available. In an interview, on 2/16/24 at 11:37 A.M,, the Director of Nursing (DON) indicated pharmacy orders placed before 5:00 P.M. Monday through Saturday should be delivered the same night. Any undelivered items should have been reported to her. She indicated since the betadine had been ordered on a Tuesday, it should have been available for the ordered treatment to the right heel. The DON indicated betadine was readily available, an over the counter item, and could have been obtained from the local pharmacy. A current policy titled Wound Treatment Management, dated 3/22/20, provided by the DON 2/16/24 at 1:26 P.M., indicated wound treatments should be provided in accordance with physician's orders, including the cleansing method, type of dressing and frequency of changes. 3.1-40(a)(2)

Based on observation, interview, and record review the facility failed to ensure oxygen was addressed in the plan of care and tubing was contained when not in use for 1 of 5 residents reviewed (Resident 75). Findings include: During an observation on 2/12/24 at 09:37 A.M., an oxygen concentrator was observed beside Resident 75's bed, turned off with a nasal cannula lying across the top of the concentrator. The oxygen tubing was not contained in a bag. Resident 75's Broda (high backed semi-reclining style) wheelchair was across the room from the bed where Resident 75 was lying. A portable oxygen tank was attached to the back of the Broda chair was turned on to 2 liters per minute. The nasal cannula was draped across the top of the chair, not contained in a bag. An unidentified hospice aide came into the room carrying linens and indicated she was going to provide care for the resident. During an observation on 2/12/24 at 10:52 A.M., the oxygen supplies remained in the same positions as observed earlier that morning, with no coverings. During an observation on 2/14/24 at 9:40 A.M., Resident 75 was observed lying in bed with a nasal cannula lying across her abdomen. The nasal cannula was attached to the bedside oxygen concentrator and was turned on to 2 liters per minute. A Broda chair was observed sitting across the room from Resident 75's bed with a portable oxygen tank turned on to 2 liters per minute with an attached nasal cannula draped across the top of the chair. During an observation and interview, on 2/14/24 at 10:15 A.M., Licensed Practical Nurse (LPN) 11 indicated oxygen tubing not in use should be contained in a dated plastic bag to prevent contamination and oxygen equipment should be turned off when not in use. Resident 75's record was reviewed on 2/14/24 at 10:42 AM. Diagnoses included pulmonary embolism, unspecified dementia with other behavioral disturbance, and myocardial infarction. A review of Resident 75's current significant change Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). A review of Resident 75's care plan, dated 2/8/24, indicated a problem of dyspnea had been resolved on 11/30/23. A hospice care plan titled Safety Precautions, dated 1/26/24, indicated staff should maintain patient safety by ensuring all oxygen is functioning properly, stored correctly, and there were no open flames around. A review of physician orders, dated 12/8/23, indicated oxygen was ordered to be administered at a rate of 2 liters per minute by nasal cannula to keep oxygen saturation above 90 percent. In an interview, on 2/14/24 at 10:52 A.M., the Director of Nursing (DON) indicated oxygen tubing should be bagged when not in use, oxygen equipment should be turned off when not in use and oxygen should be incorporated into the nursing plan of care. A current policy, titled Oxygen, dated 2/16/18, provided by the Director of Nursing on 2/14/24 at 10:52 A.M., did not address storage of tubing when not in use nor incorporation of oxygen into the care plan. 3.1-47(a)(6)

Based on observation, interview, and record review the facility failed to implement intervention strategies for agitation and refusal of care for 1 of 1 resident reviewed for behavioral services (Resident 74). Findings include: On 4/11/23 at 10:01 AM Resident 74 was observed verbalizing to staff that she did not require any help and she preferred to be left alone. A record review on 4/11/23 at 10:14 AM indicated the resident had diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. A Comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on extensive staff assistance for activities of daily living. A behavior note dated 4/14/23 at 6:47 AM indicated the resident had formed fecal matter into balls. The progress note indicated a care plan intervention had been initiated for specific behavior. A behavior note dated 3/25/23 at 8:00 PM indicated the resident had hit staff during care. A behavior note dated 3/26/23 at 12:34 PM indicated the resident was sitting on a couch with her pants down. The resident had been incontinent of bowel. A behavior note dated 3/29/23 at 9:17 PM indicated the resident had refused care. A behavior note dated 3/30/23 at 6:33 AM indicated the resident had resisted care by pushing and pulling on staff. A behavior note dated 3/31/23 at 8:10 PM indicated the resident refused care by yelling at staff to get out of her house. A behavior note dated 4/3/23 at 7:42 AM indicated the resident refused care by physically pushing staff away. Verbal assurance was not effective. The provision of an alternate staff member was ineffective. A behavior note dated 4/3/23 at 5:37 PM indicated the resident refused vital sign assessment. A behavior note dated 4/4/23 at 6:24 AM indicated the resident was agitated with staff by yelling and pushing staff away. Behavior monitoring documentation dated 3/4/23 through 4/13/23 indicated the resident did not exhibit any behaviors. The resident's care plan did not address exhibited behaviors of care rejection, hitting staff, pushing staff, or yelling at staff. The resident's physician orders did not indicate the resident was a candidate for a psychiatric evaluation. During an interview on 4/12/23 at 1:13 PM LPN 2 indicated staff was made aware of new resident behaviors during daily morning meetings. She indicated the Social Service Director (SSD) was responsible for behavioral documentation and monitoring. During an interview on 4/12/23 at 1:19 PM, the Administrator indicated the SSD updated care plans for behavioral issues. She indicated the SSD would be made aware of behavioral issues at daily morning meetings. She indicated Resident 74 should have received a psychiatric evaluation. She indicated the resident's care plan should reflect the resident's specific behaviors. A current policy titled Behavior Monitoring/Documentation provided by the Administrator on 4/12/23 at 1:40 PM indicated new behaviors were to be care planned with targeted interventions and goals. The policy indicated residents who exhibited behaviors such as hitting, pushing, yelling, or rejection of care are candidates for behavior management. 3.1-43(a)(1)

Based on observation, interview and record review, the facility failed to ensure grievances were thoroughly investigated, contained required documentation and appropriate corrective actions were taken for 1 of 3 residents reviewed (Resident H). Findings include: An anonymous complaint, reported to the Indiana Department of Health, alleged staff yelled at Resident H, threw her things and said her room was messy. On 12/6/22 at 9:52 A.M., Resident H was observed seated in her wheelchair in the hall near the nurses station and indicated she needed assistance cleaning her room. She'd had a shower the day before and hadn't had her bed linens changed. There were no staff observed and the resident propelled herself back to her room. Her room was observed to be messy and had a foul odor of stool and vomit. In her bathroom, were wet, soiled towels and washcloths on the floor. Multiple personal items were on the floor, covering the sink, and overflowing in the corner where a small drawer stand sat. There were various personal items strewn across the floor of her room, included unraveled skeins of yarn, clothing items, blankets and pillows. There were several piles of personal items on the dresser, [NAME], and bedside stand. On the [NAME] near the door, sat a rotten banana-black in color. Her soiled bedding was wrapped up in a large pile in the middle of her bed. Resident H indicated she needed assistance with cleaning her room and staff hadn't wanted to help her. She was observed to be pale and fatigued. She wanted to stand and struggled to rise up from the wheelchair. She indicated she had pain, was short of breath and fatigued as she sat back in the chair. She indicated she needed to rest. On 12/6/22 at 10:55 A.M., Resident H's record was reviewed. Diagnoses included shortness of breath, chronic obstructive pulmonary disease (COPD), dementia, generalized anxiety disorder, and chronic pain. A quarterly MDS (Minimum Data Set) assessment, dated 9/30/22, indicated the resident had no cognitive impairment, no behaviors, and no rejection of care. A review of care plans indicated the following: -The resident required assistance from staff with her activities of daily living due to COPD, shortness of breath, chronic pain, and weakness. -The resident had a tendency to collect large amounts of personal items in her room. Staff were to encourage her to maintain order with collections of personal items and provide education as needed regarding personal choices and their effects on her health. -The resident was at high risk for falls due to decreased mobility, unsteady gait/balance, and potential for poor decision making. Staff were to assist her in keeping her room clutter free (revised 3/18/22) and encourage her to allow staff to clean her room (initiated 7/18/22). On 12/6/22 at 11:31 A.M., 2 grievance reports, submitted by Resident H, were reviewed and indicated the following: -On 11/1/22, Resident H reported a concern with a housekeeper. The form didn't indicate what the concern had been about, but involved customer service. The form indicated the housekeeper was spoken to about their actions and another housekeeper was assigned to clean the resident's room. The form didn't indicate what had actually occurred with the housekeeper nor further investigation of the incident. The grievance was neither confirmed nor unconfirmed and there was no documentation of the grievance completed in the resident's record. There was no documentation to indicate if the change in housekeepers was a permanent or temporary resolution to the concern and there were no changes made to the care plan. -On 11/17/22, Resident H reported concerns related to cleaning her room and emptying her trash. Nursing staff were educated on emptying her trash and housekeeping was to provide a schedule of cleaning. The form hadn't confirmed nor unconfirmed the grievance, there was no documentation of the grievance completed in the resident's record, and there were no changes made to the care plan to ensure staff would empty her trash and provide routine cleaning. On 12/6/22 at 2:03 P.M., the Director of Nursing (DON) and Director of Social Services were interviewed. When questioned, neither were able to say what actions the housekeeper had taken which resulted in the grievance. Both indicated there was no concern for abuse but had no documentation to indicate how the facility had determined the concern was not abuse related. The DON indicated staff cleaned the resident's room several times daily due to the resident's illness-related behaviors however, this was not on the care plan. A current facility policy, titled Concerns/Grievance Policy, was provided by the DON on 12/6/22 at 10:10 A.M. and stated the following: The resident has the right to voice grievances .Procedure .2. Staff will complete the concern/grievance form and document the issue/resolution in the EMR (Electronic Medical Record) .7. The grievance decision will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued This Federal tag relates to Complaint IN00395272. 3.1-7(a)(2)

Based on record review and interview the facility failed to ensure monitoring of [CONDITION(S)] medications for 5 of 6 residents reviewed. (Resident 14, Resident 2, Resident 59, Resident 79, and Resident 45) Findings include: 1. In a record review for Resident 14, began on 4/27/22 at 9:45 AM, diagnoses included: anxiety disorder, sedative dependence, psychoactive substance abuse, major depressive disorder, [CONDITION(S)] disorder, personality disorder, and hallucinations. Resident 14 had a BIMS (Brief Interview Mental Status) score of 9 according to most recent assessment dated [DATE]. Resident 14's provider orders included [MEDICATION(S)] 60 mg daily started on 7/15/21, [MEDICATION(S)] 5 mg twice daily started on 1/28/21, and [MEDICATION(S)] 50 mg at night started on 5/26/21. The most recent care plan dated 4/20/22, indicated Resident 14 had a problem of depressive issues with an intervention to administer medication, monitor side effects and therapeutic effects. Resident 14 had the focus of antidepressant medication with an intervention to monitor, document and report adverse reactions. Resident 14's MAR (Medication Administration Record) indicated to monitor antianxiety medication for several specific side effects (blurry vision, drowsiness, fatigue, dizziness, headache, loss of memory or concentration, problems with balance, coordination or speech, upset stomach) with the instruction to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed. The staff were to select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April, 2022 (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 27 marked as na (not applicable), 38 marked as N (monitored with side effects noted), and 38 noted both Y and N (monitored with both side effects noted and no side effects noted). There were no progress notes for the N documentation, as ordered. Resident 14's MAR indicated to monitor sedative or hypnotic specific side effects (burning or tingling in hands or feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, and weakness) with the instruction to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed. The staff were to select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 28 na (not applicable) documented, there were 45 N's (monitored with specific side effects noted) documented, and 38 documentation of both Y an N (monitored with both side effects noted and no side effects noted). There were no progress notes for the N documentation. Resident 14's order administration progress notes, indicated 45 documentation entries under; was a behavior observed? Yes. 34 of the 45 were charted by LPN 1. A RN (registered nurse), QMA (qualified medical assistant) and 2 other LPN's (licensed practical nurse) documented Yes for a behavior. None of the behaviors were documented regarding character of the behavior or interventions attempted. An interview with LPN 1, on 4/28/22 at 1:54 PM, indicated when she clicked yes, she was saying she monitored for behavior and side effects, she was not aware she had indicated Resident 14 had a behavior or specific side effect. LPN 1 indicated she had not seen the side effects or behavior being monitored. Resident 14's behavior documentation, dated 2/26/22 to 4/28/22, indicated no behaviors occurred. 2. Resident 2's record review began on 4/27/22 at 10:00 AM. diagnoses included anxiety disorder, major depressive disorder, and [CONDITION(S)] disorder. Resident 2 had a BIMS (Brief Interview Mental Status) score of 8 (Moderately impaired cognition) according to most recent assessment dated [DATE]. Resident 2's physician orders included [MEDICATION(S)] 30 mg, give daily started 4/20/22, [MEDICATION(S)] 75 mg every other day started 4/15/22, [MEDICATION(S)] 100 mg daily started 7/28/21 and [MEDICATION(S)] 0.5 mg three times a day started 2/1/22. Resident 2 had three orders to monitor for side effects one for an antidepressant, one for an antipsychotic and one for an antianxiety medication. Resident 2's MAR indicated to monitor antidepressant therapy for changes in mood, behavior, cognition, hallucinations, delusions, social isolation, suicidal thoughts, decline in ADL (activity of daily living), gait, continence, falls, dizziness, rigid muscles, tremors, and dry mouth. The order included instruction to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 5 N's documented (observed with noted effects). There were no nursing notes or other documentation regarding the behavior observed, the character, or intervetions attempted. Resident 2's MAR indicated under antipsychotic medication to observe for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, dark urine, yellow skin, lethargy, nausea, vomiting, drooling, tremors, disturbed gait, increased agitation, restlessness, and involuntary movement of lips or tongue. The order indicated to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 12 na (not applicable) documented and 53 documentation of both Y an N (monitored with both side effects noted and monitored with no side effects noted). There were no progress notes for the N documentation to indicate the behavior, the character, or the interventions attempted. Resident 2's MAR indicated under antianxiety medication to observe for blurry vision, confusion, dizziness, drowsiness, fatigue, headache, loss of memory, trouble with concentration, problems with balance, problems with coordination, problems with speech, and upset stomach. The order indicated to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 11 na (not applicable) documented and 52 documentation of both Y an N (monitored with both side effects noted and monitored with no side effects noted). There were no progress notes for the N documentation to indicate the type of behavior or the interventions attempted. 3. Resident 59's record review began on 4/27/22 at 10:15 AM. diagnoses included dementia with behavior symptoms, delusional disorder, and major depressive disorder. Resident 59 had a BIMS (Brief Interview Mental Status) score of 4 (severly impaired cognition) according to most recent assessment dated [DATE]. Resident 59's physician orders included [MEDICATION(S)] 20 mg daily started 1/25/22, [MEDICATION(S)] 0.25 mg daily started 1/22/22, and an additional order to monitor for effects of antidepressant. There was no indication to monitor for effects of antipsychotic medication. Resident 59's MAR indicated to monitor antidepressant therapy for changes in mood, behavior, cognition, hallucinations, delusions, social isolation, suicidal thoughts, decline in ADL (activity of daily living), gait, continence, falls, dizziness, rigid muscles, tremors, and dry mouth. The order included instruction to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. The day, evening and night rows required initials of person following the order. In the month of March (dates 3-1 through 3-31, 93 areas were available for documentation of Y or N) there were 11 N's documented (observed with noted effects). There were no nursing notes or other documentation regarding the behavior, the character, or the onterventions attempted. 4. Resident 79's record review began on 4/26/22 at 10:30 AM. diagnoses included dementia without behavior symptoms, [CONDITION(S)], mood disorder, anxiety disorder, and major depressive disorder. Resident 79 had a BIMS (Brief Interview Mental Status) score of 10 (moderately impaired cognition) according to most recent assessment dated [DATE]. Resident 79's physician orders included [MEDICATION(S)] 50 mg started 3/14/22 and [MEDICATION(S)] 20 mg. Resident 79 had two orders to monitor for side effects one for an antidepressant and one for an antipsychotic. Resident 79's MAR indicated under antipsychotic medication to observe for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, dark urine, yellow skin, lethargy, nausea, vomiting, drooling, tremors, disturbed gait, increased agitation, restlessness, and involuntary movement of lips or tongue. The order indicated to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 59 na (not applicable) documented and 8 documentation of both Y an N (monitored with both side effects noted and monitored with no side effects noted). There were no progress notes to indicated the type of behavior or attempted intervetions for the N documentation. Resident 79's MAR indicated antidepressant therapy to monitor for changes in mood, behavior, cognition, hallucinations, delusions, social isolation, suicidal thoughts, decline in ADL (activity of daily living), gait, continence, falls, dizziness, rigid muscles, tremors, and dry mouth. The order included instruction to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. The day, evening and night rows required initials of staff following the order. In the month of April (dates 4-1 through 4-26, 78 areas were available for documentation of Y or N) there were 15 N's documented (observed with noted effects). There were no nursing notes or other documentation regarding the behavior type or interventions attempted. Resident 79's most recent care plan, included interventions to observe and document adverse reactions to both antidepressant and [CONDITION(S)] medications. 5. Resident 45's record review began on 4/26/22 at 10:15 AM. diagnoses included depression, anxiety, [CONDITION(S)], dementia and [CONDITION(S)]. Resident 45's physician orders included [MEDICATION(S)] 0.5 mg twice daily started 3/8/22 and [MEDICATION(S)] 40 mg daily started 3/8/22. Resident 45 had an order to monitor for side effects one for an antidepressant. In an interview, the DON, on 4/27/22 at 2:03 PM, indicated they were not monitoring for side effects for the [CONDITION(S)] medication as required. Resident 45's current care plan, indicated a focus of use of [CONDITION(S)] medication. An intervention listed was to observe, document, and report side effects (unsteady gait, extra movements (EPS, tardive dyskinesia), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, social isolation, blurred vision, diarrhea, fatigue, [CONDITION(S)], weight loss, muscle cramps). Resident 45's MAR indicated to monitor antidepressant therapy for changes in mood, behavior, cognition, hallucinations, delusions, social isolation, suicidal thoughts, decline in ADL, gait, continence, falls, dizziness, rigid muscles, tremors, and dry mouth. The order included instruction to document Y if monitored with none of the effects noted and N if monitored and any of the effects were observed select chart code other see nurse notes and progress note. There was one N documented on 4/14/22 with no progress note indicating the side effect noted. In an interview, the DON, on 4/27/22 at 11:57 AM, indicated they should have an order set with each opiate, [CONDITION(S)], and antidepressant medication to be monitored for side effects specific to that medication class. The DON indicated the language of documenting an N for monitored with findings is complicated and has been mis documented. A policy, provided by DON on 4/27/22 at 1:19 PM, titled Medication Administration last revision 2/9/18, indicated .22. Residents will be monitored for medication side effects and documented in EMR accordingly . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure complete assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 4/25/2022 at 2:15 pm Resident 21 was observed sitting in her wheelchair in her room. The resident had a gauze dressing around her head. The bandage was soiled with a dark brown area located on the right side of her forehead. The resident indicated she was injured at home when a bottle fell from a cupboard. On 4/26/2022 at 9:45 am a record review indicated the resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] indicated the resident did not require an assessment of mental status (her cognition was severely impaired). The resident required extensive assistance for bed mobility, transfers and toileting. A CT head scan result dated 1/5/2022 indicated the resident had a right frontal scalp mass, possibly a hematoma. An admission assessment dated [DATE] indicated her scalp was normal. Weekly skin checks dated 1/15/2022 through 4/20/2022 indicated there were no skin impairments. A nurse note dated 3/21/2022 indicated there was a hematoma on the right side of her forehead area had opened and was draining copious amounts of bright red blood. On 4/28/2022 at 12:20 pm an interview with Registered Nurse (RN) 2 indicated the resident was admitted with a hematoma on the right side of her forehead. She indicated the area was not improving so the staff were watching it. She indicated the area eventually grew and burst open. She indicated the hematoma should have been documented on the admission assessment. She indicated she was unaware of where to record wound measurements becasue wound measurement was the responsibility of the wound management nurse. She indicated staff nurses only documented skin issues on the weekly assessments if they were a new occurrence. She indicated pressure injuries, bruises, hematomas and skin tears were considered skin issues. She indicated she would document the hematoma if she were the first to observe it. She indicated the hematoma should have been documented in the admission assessment and there was no need to monitor the area if it remained stable. She again indicated the staff nurses did not measure or document the enlargement of the area due to the wound management nurse being responsible for measurements. During an interview on 4/28/2022 at 12:47 pm, the Director of Nursing (DON) indicated she was also the wound management nurse. She indicated she did not monitor the area due to it being present on admission. She indicated the hematoma should have been documented on the admission assessment, but it was not. She indicated although the area should have been documented on admission there was no need to monitor due to the area being stable. She indicated she was aware of the hematoma becoming enlarged. In response to writer's inquiry related to why the area was not monitored after it enlarged and became open with active drainage, she stated, I can't answer that. In an interview on 4/29/2022 at 12:02 pm with the Administrator and the DON, the DON indicated the NP noted the hematoma on 2/1/2022. She stated she did not feel a closed area, documented by the NP, needed any follow up. The DON indicated she did not feel as if she should be expected to know it was cancerous. On 4/29/22 at 2:08 pm the DON presented a current facility policy titled Skin Management. The policy indicated all residents will have a head-to-toe assessment of skin integrity on admission, readmission, quarterly, annually, and with any significant change in condition. The policy indicated skin would be observed for pressure injuries, skin tears, redness, irritation, swelling, bruises, excoriations, macerations or other unusual skin conditions. The policy indicated skin impairments would be documented in the electronic medical record and the physician would be notified. 3.1-37(a)

Based on interview and record review, the facility failed to provide non-pharmacological interventions prior to administration of as needed pain medication for 3 of 3 residents reviewed. (Resident 14, Resident 45, Resident 76) 1. Resident 14 was interviewed on 4/25/22 at 12:13 PM. Resident 14 indicated staff had not offered non-pharmacological alternatives prior to administration of as needed pain medication. A record review was completed on 4/27/22 at 11:28 AM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) was completed on 4/14/22. This indicated Resident 14 had a Brief Interview Mental Status (BIMS) of 9 (moderately impaired cognition). Resident 14's care plan indicated suspected chronic pain related to [CONDITION(S)], age related debility, scoliosis, and [CONDITION(S)]. Interventions included: encourage and attempt to provide non-pharmacological interventions initially, provide several choices if able (reposition, back rub, emotional support, limb supports, flex/extend extremities, massage, distraction, heat/cold, remove/reduce environmental stimulants, controlled breathing, encourage prayer/medication, pleasant imagery, relaxing music, breathing control). Resident 14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An order, dated 2/10/22, indicated to give 2 tablets of [MEDICATION(S)] tablet 5-325 MG ([MEDICATION(S)]-acetaminophen) by mouth every 6 hours as needed for pain related to chronic pain syndrome and administer 1 tab for pain level of 6-10. Residents 14's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no non-pharmacologic interventions documented prior to administrated medication. An order, dated 2/11/22, indicated to give Resident 14 [MEDICATION(S)] Gel 1% ([MEDICATION(S)] sodium): apply to 2 grams topically every 4 hours as needed for pain- apply to the shoulders, back, hips and back of hands as requested. Resident 14's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No interventions were documented prior to administered medication. 2. Resident 45 was interviewed on 4/25/22 11:03 AM, they indicated staff had not offered non-pharmacological alternatives prior to administration of as needed pain medication. A record review was completed on 4/26/22 at 3:13 PM for Resident 45. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident 45 had a BIMS of 12 (mildly impaired cognition). Resident 45's care plan indicated suspected chronic pain related to cervical stenosis with radiculopathy and carpel tunnel. Interventions included: encourage and attempt to provide non-pharmacological interventions initially, provide several choices if able (reposition, back rub, emotional support, limb supports, flex/extend extremities, massage, distraction, heat/cold, remove/reduce environmental stimulants, controlled breathing, encourage prayer/medication, pleasant imagery, relaxing music, breathing control). Resident 45's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An order, dated 3/5/22, indicated to give [MEDICATION(S)] tablet 5-325 MG ([MEDICATION(S)]-acetaminophen) by mouth every 6 hours as needed for moderate to severe pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No interventions were documented prior to administered medication. 3. Resident 76 was interviewed on 4/25/22 12:13 PM, and indicated staff had not offered non-pharmacological alternatives prior to administration of as needed pain medication. A record review was completed on 4/27/22 at 11:28 AM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident 76 had a BIMS of 14 (intact cognition). Resident 76's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An order, dated 1/4/21, indicated to give [MEDICATION(S)] Acetaminophen tablet 7.5-325 MG every 6 hours as needed for pain. The medication was given 4/1/22-4/27/22. An order, dated 3/24/21, indicated Tylenol (acetaminophen) 325 MG 2 tablets was to be given every 6 hours as needed for pain. The medication was given on 4/7/22. No interventions were documented prior to either administered medication. Resident 76's care plan indicated the resident had chronic pain related to [CONDITION(S)], chronic back pain, polyneuropathy of bilateral feet/lower extremities. Interventions included: encourage and attempt to provide non-pharmacological interventions initially, provide several choices if able (reposition, back rub, emotional support, limb supports, flex/extend extremities, massage, distraction, heat/cold, remove/reduce environmental stimulants, controlled breathing, encourage prayer/medication, pleasant imagery, relaxing music, breathing control). RN 2 was interviewed on 4/27/22 at 11:59 AM. RN 2 indicated the nurse should offer and document non-pharmacological interventions provided to the resident prior to giving as needed pain medications. LPN 1 was interviewed on 4/27/22 at 12:01 PM. LPN 1 indicated the nurse should offer and document non-pharmacological interventions provided to the resident prior to giving as needed pain medications. The nurse should also document if the interventions were effective or not. The Director of Nursing (DON) was interviewed on 4/27/22 at 12:20 PM. The DON indicated the nurse should offer non-pharmacological interventions prior to giving as needed pain medications. The interventions should also be documented as effective or not. A policy, revised 10/10/20, titled: Pain Management, was provided by the DON on 4/27/22 at 1:19 PM. The policy indicated .based upon evaluations, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission .non-pharmacological interventions will include but are not limited to: environmental comfort measures, loosening any constrictive bandage, clothing, device, applying splinting, physical modalities, exercises, and cognitive/behavioral interventions. 3.1-37(a)

Based on record review and interview, the facility failed to provide family notification regarding medication for 1 of 1 residents reviewed. (Resident B). Findings include: A discharge list, provided by the Director of Nursing (DON) on 2/10/21 at 10:30 A.M., indicated Resident B had passed away on 9/10/20. A record review was completed on 2/10/21 at 2:30 P.M for Resident B. [DIAGNOSES REDACTED]. an order for [REDACTED].M. The facility did not document any communication with the family on 9/10/20 regarding [MEDICATION NAME] medication. The DON and Administrator were interviewed on 2/11/21 at 9:49 A.M. The DON and Administrator indicated the facility obtained verbal consent from the family on 9/10/20 to give Resident B [MEDICATION NAME]. The DON and Administrator were unable to provide documentation of the verbal consent. A policy dated 8/28/20 was provided by the DON and Administrator on 2/11/21 at 9:49 A.M., titled Physician Services. The policy indicated the physician will review the resident's total program of care .including medications and treatments The policy did not indicate to notify the family of any medication changes. The DON and Administrator were interviewed on 2/11/21 at 9:49 A.M. The DON and Administrator indicated the facility did not have a policy specifically for medication changes, the facility followed the physician services policy and ISDH guidelines. This Federal citation is related to Complaint IN 580. 3.1-5(a)

Based on observation, interview, and record review the facility failed to ensure measures to prevent the potential spread of COVID were in place according to current CDC guidelines. This had the potential to effect 14 of 75 residents residing in the facility. Findings include: 1. During an observation on the 200 hall on 10/20/20 at 3:14 P.M., no signs or information were observed to indicate Resident 4 was on droplet precautions after being admitted to the facility from the hospital. A Droplet Precaution Sheet provided by the Administrator on 10/20/20 at 5:02 P.M., indicated Resident 4 was to be on a 14 day quarantine with droplet precautions from 10/16/20 through 10/30/20. Registered Nurse (RN) 5 was interviewed on 10/20/20 at 3:16 P.M. During the interview RN 5 indicated if a resident was on a 14 day quarantine with droplet precautions they would have a sign on their door and a personal protective equipment (PPE) cart outside of the door . This would alert staff the resident was on droplet precautions and the sign would indicate the proper PPE that should be worn when entering the room. RN 5 also indicated Resident 4 did not have a sign or PPE cart outside of her door and there should have been both. The Director of Nursing (DON) was interviewed on 10/20/20 at 3:46 P.M. During the interview the DON indicated when a resident was admitted from the hospital they would be placed in quarantine with droplet precautions for 14 days. A sign would be on put on the door to alert staff appropriate PPE to wear when entering the room. There would also be a PPE cart outside of the door. A policy, dated 7/22/20, was provided by the Administrator on 10/20/20 at 11:00 A.M., titled Coronavirus (COVID-19) Prevention & Response. The policy indicated, .g. Promote easy and correct use of personal protective equipment (PPE) by: i. Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE. ii. Make PPE, including facemask, eye protection, gowns, and gloves available immediately outside of the resident's room. iii. Position a trash can near the exit inside any resident room to make it easy to discard PPE. 2. During an observation on the 200 hall on 10/20/20 at 3:14 P.M., RN 5 went into Resident 7's room. RN 5 had an N95 mask on and goggles. No other PPE was observed to be worn while RN 5 was in Resident 7's room. During an observation on the 200 hall on 10/20/20 at 3:28 P.M., Certified Nursing Assistant (CNA) 2 went into Resident 8's room. CNA 2 had on an N95 mask and goggles. No other PPE was observed to be worn while CNA 2 was in Resident 8's room. A Droplet Precaution Sheet provided by the Administrator on 10/20/20 at 5:02 P.M., indicated Resident 7 was to be on droplet precautions from 10/9/20 through 10/23/20 and Resident 8 was to be on droplet precautions from 10/20/20 through 11/3/20. Registered Nurse (RN) 5 was interviewed on 10/20/20 at 3:16 P.M. During the interview RN 5 indicated when a resident is on droplet precautions during a 14 day admission quarantine, staff are to wear a gown, gloves, N95 mask, and goggles when entering the room. The Director of Nursing (DON) was interviewed on 10/20/20 at 3:46 P.M. During the interview the DON indicated staff should wear protective eyewear, a gown, gloves, and an N95 face mask when entering a room of a resident on droplet precautions. The Administrator was interviewed on 10/20/20 at 4:32 P.M. During the interview the Administrator indicated the facility follows CMS, CDC, and ISDH guidance in regards to COVID-19. Preparing for COVID-19 in Nursing Homes (June 2020) was retrieved on 10/21/20 from the Centers for Disease Control (CDC) website. The guidance indicated Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. Findings include: On 8/19/19 at 2:31 P.M., Resident F's record was reviewed. [DIAGNOSES REDACTED]. A care plan, revised on 2/22/18, indicated the resident had diabetes. Interventions included, but were not limited to, give diabetic medication as ordered by the physician. A physician order, dated 5/10/18 at unknown time, was for [MEDICATION NAME] Solution 100 units/ml (Insulin [MEDICATION NAME])-inject 4 units subcutaneously three times a day. Hold if BS (blood sugar) is <100 or if resident does not eat. Call the NP (Nurse Practitioner) if BS <60 or >400. An (MONTH) 2019 MAR (Medication Administration Record) indicated the following: 8/3/19 at 8:00 a.m., Resident F was administered [MEDICATION NAME] Solution 4 units subcutaneously for a blood sugar of 83. 8/4/19 at 8:00 a.m., [MEDICATION NAME] Solution 4 units subcutaneously was administered for a blood sugar of 94. 8/13/19 at 8:00 a.m., Resident F's blood sugar was 100. He was not administered [MEDICATION NAME]as ordered. 8/14/19 at 8:00 a.m., the residents blood sugar was 100. The MAR indicated [REDACTED]. The resident was to have received [MEDICATION NAME]4 units subcutaneously at 8:00 a.m. as his blood sugar was not less than 100. On 8/19/19 at 3:25 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated she had not been aware that the resident's insulin had not been administered as ordered by the physician. The resident's insulin should have been administered or held according to the blood sugar parameters set by the physician's orders [REDACTED].>On 8/19/19 at 12:50 P.M., the DON provided a current copy of the facility policy titled Timely Administration of Insulin which stated the following: It is the policy of (facility name) to provide timely administration of insulin in order to meet the needs of each resident and to prevent effects on a resident's condition .Procedure: 1.All insulin will be administered in accordance with physician orders [REDACTED]. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure the correct dosage of insulin was administered at the correct time for 2 of 3 residents reviewed for medications (Resident D and Resident E). Finding include: 1. On 8/19/19 at 10:47 A.M., Resident D's record was reviewed. [DIAGNOSES REDACTED]. On 8/19/19 at 1:30 P.M., Resident D, who was identified by the facility as being interviewable, was observed in her room seated in her bedside chair. She had a frown on her face and her hands were shaking slightly. She indicated she had a headache and needed to eat. When questioned about her blood sugars, she indicated they had been low a time or two but did not indicate she was experiencing low blood sugar at this time. She indicated staff gave her insulin when they thought she needed it. Physician orders [REDACTED]. 4/18/18, at unknown time, Humalog solution 100 units/ml-inject per sliding scale: if (blood sugar/BS) 0-200 (milligram/deciliter)=0 units; if less than 60 call MD; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 401 and higher, call MD or NP (Nurse Practitioner), subcutaneous (SC) 4 times a day for [MEDICAL CONDITION] (high blood sugar). 5/23/18, at unknown time, was for Humalog (insulin) mix 75/25 Suspension 100 units/ml (milliliter)-inject 20 units SC one time a day for diabetes. 5/29/19, at unknown time, Humalog mix 75/25 Suspension 100 units/ml-inject 60 units SC one time a day for diabetes. An MAR (Medication Administration Record) for (MONTH) 2019, indicated Resident D was to have her blood sugars checked and sliding scale insulin administered at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. The resident was to be administered Humalog mix 75/25 60 units SC at 9:00 a.m. and Humalog mix 75/25 20 units SC at 8:00 p.m. daily. An NP progress note, dated 8/8/19 at unknown time, indicated the resident was seen for an acute visit due to [DIAGNOSES REDACTED] (low blood sugar). The facility had informed the NP that the resident's blood sugar was 96 after she was found to have been given 2 doses of Humalog 75/25 60 units SC. Staff were instructed to check Resident D's blood sugar every 1 hour and if her blood sugar was <80 mg/dl, she was to be given [MEDICATION NAME] 1 mg intramuscularly (IM). The resident's BS dropped to 88 mg/dl and she was administered [MEDICATION NAME] 1 mg IM. Fifteen minutes later, the resident's BS dropped to 56 mg/dl. Resident D was more lethargic and diaphoretic (sweating) and complained of not feeling well. The pharmacy was not able to deliver [MEDICATION NAME] or [MEDICATION NAME] quickly so orders were given to transport the resident to the hospital for evaluation and treatment. Nurse Progress Notes indicated the following: 8/8/19 at 1:03 p.m., the resident was out to the ER for evaluation and treatment of [REDACTED]. 8/8/19 at 6:17 p.m., Resident D returned from ER with no new orders. Her blood sugar was 165 mg/dl. 8/9/19 at 7:53 a.m., the Interdisciplinary Team reviewed the medication error that occurred on 8/8/19. The resident received 2 doses of Humalog 75/25 60 units totaling 120 units. The root cause of the error was that the medication had not been signed of in the MAR from the nurse that administered the first injection. The second nurse, administered a second dose due to lack of documentation of administration of the first dose of Humalog 75/25 60 units given. Medication Administration Audit Report and (MONTH) 2019 MAR indicated on 8/8/19, Resident D was not administered Humalog insulin per sliding scale at 8:00 a.m. as her BS was 134 mg/dl. LPN 4 (Licensed Practical Nurse) administered Humalog 75/25-60 units SC at 7:11 a.m. and did not sign the MAR to indicate the insulin had been administered. The MAR indicated Humalog 75/25-60 units SC was scheduled to be given at 9:00 a.m. LPN 6 administered Humalog 75/25-60 units SC at 8:49 a.m. On 8/19/19 at 11:12 A.M., LPN 4 was interviewed. During the interview, LPN 4 indicated she was scheduled routinely to work a specific hallway in the facility but was required to administer insulin to residents who resided on a different hall when QMA's (Qualified Medication Aides) were scheduled to work. QMA's were not allowed to administer insulin so licensed nurses were assigned to administer insulin to residents who required the injections in the QMA's assigned area in addition to their own assigned halls. LPN 4 indicated she administered all the insulin injections to residents on the (name) hall on 8/8/19 which included Resident D. She was walking back to her own hall when she passed by LPN 6 who was going down the hall to work on the (name) hall and told her that she had administered all the insulin injections for the hall but hadn't had time to sign off the MAR's. LPN 4 stressed that she informed LPN 6 not to give any insulin injections because they'd already been administered. When LPN 4 later went to initial the resident's MAR, she indicated she couldn't because LPN 6 had already initialed the MAR indicating LPN 6 had administered Humalog 75/25-60 units SC. LPN 4 indicated she notified LPN 6 immediately and confirmed the resident had received 2 injections of Humalog 75/25-60 units SC. On 8/19/19 at 11:41 A.M., LPN 6 was interviewed. During the interview, she indicated she came in to work at 7:40 a.m. on 8/8/19. LPN 4 reported to her that she had administered insulin to resident's on the hall and was headed back to her assigned hall. She indicated, she made the assumption that LPN 4 had only administered Resident D's Humalog sliding scale insulin which the resident received prior to eating breakfast. LPN 4 had not signed off the MAR's for the insulin injections she had administered so LPN 6 administered the resident's scheduled 9:00 a.m. dose of Humalog 75/25-60 units subcutaneous at 8:49 a.m. Resident D received Humalog insulin per sliding scale prior to breakfast and then would be administered Humalog 75/25-60 units SC after the resident ate breakfast. LPN 6 indicated the resident ate breakfast in room daily at around 7:30 a.m. When questioned, LPN 6 indicated upon notification that the resident had been given 2 doses of Humalog 60 units, the NP was notified and the resident monitored. Resident D was administered one dose of [MEDICATION NAME] 1 mg IM which was removed from the EDK (Emergency Drug Kit). She indicated the resident's blood sugar continued to drop and there had only been one dose of [MEDICATION NAME] available therefore the resident was sent to the hospital. Manufacturer directions for Humalog Mix 75/25 insulin was retrieved from the website uspl.lilly.com on 8/19/19 3:00 p.m. and indicated the following: Humalog Mix 75/25 insulin should be administered subcutaneous within 15 minutes before a meal. Humalog Mix 75/25 insulin is typically dosed twice-daily with each dose intended to cover 2 meals or a meal and a snack. The peak concentration and effects of Humalog Mix 75/25 was 60 minutes after dosing. [DIAGNOSES REDACTED] is the most commonly observed adverse reaction with Humalog Mix 75/25 insulin. Factors which may increase the risk of [DIAGNOSES REDACTED] include changes in meal pattern or timing of meals. 2. On 8/19/19 at 2:12 P.M., Resident E's record was reviewed. [DIAGNOSES REDACTED]. A physician order, dated 3/12/19 at unknown time, was for [MEDICATION NAME] (insulin) Solution 100 units/ml: Inject per sliding scale: 0-150 mg/dl=0 units with meals and HS; 151-200 mg/dl=2 units; 201-250 mg/dl=4 units; 251-300 mg/dl=6 units; 301-350 mg/dl=8 units; 351-400 mg/dl=10 units and call NP. Administer subcutaneous 3 times a day related to diabetes. Hold if BS is less than 150, and notify NP/MD if >400. Medication Administration Audit Report and (MONTH) 2019 MAR indicated the resident's blood sugar and [MEDICATION NAME]per sliding scale was scheduled to be done at 8:00 a.m., 12:00 p.m. and at 5:00 p.m. daily. The Medication Administration Audit Report indicated the resident's blood sugar check and administration of [MEDICATION NAME]per sliding scale was administered after the scheduled times on the following dates and times: 8/5/19 at 8:00 a.m.: [MEDICATION NAME]2 units administered at 9:35 a.m. 8/7/19 at 8:00 a.m.: [MEDICATION NAME]2 units administered at 10:10 a.m. 8/12/19 at 12:00 p.m.: [MEDICATION NAME]2 units administered at 2:16 p.m. 8/15/19 at 8:00 a.m.: [MEDICATION NAME]2 units administered at 9:15 a.m. Manufacturer directions for [MEDICATION NAME]was retrieved from the website rapidactinginsulin.com on 8/19/19 at 3:30 p.m. which indicated the following: [MEDICATION NAME]should be injected 5-10 minutes before a meal. [DIAGNOSES REDACTED] is the most common adverse effect of [MEDICATION NAME] insulin. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns, changes in kidney or liver function, and during acute illness. On 8/19/19 at 12:31 P.M., the Executive Director (ED) and Director of Nursing (DON) were interviewed. During the interview, both indicated LPN 4 and LPN 6 were re-educated to sign off the MAR's at the time medications/insulin were administered. The DON indicated all nursing staff were to be re-educated about signing off the MAR's on this date during their scheduled monthly nurse meeting. When questioned why the resident's Humalog 75/25-60 units SC had been administered at 7:10 a.m. instead of 9:00 a.m. as scheduled in the MAR, the DON indicated they were in the process of hiring a full-time nurse for that particular hallway so nurse's would not have to cover more than one assigned hall. Both indicated they did not have a facility or pharmacy policy that indicated the time frames insulin should be administered according to the type of insulin, onset of action, duration of effects, and administration times around meals. During the interview, the DON indicated the facility did not have a policy that resident's who received insulin would have a corresponding order for [MEDICATION NAME] to be available. The facility EDK had had only one dose of [MEDICATION NAME] available when the medication error occurred. On 8/19/19 at 12:50 P.M., the DON provided a current copy of the facility policy titled Timely Administration of Insulin which stated the following: It is the policy of (facility name) to provide timely administration of insulin in order to meet the needs of each resident and to prevent effects on a resident's condition .Procedure: 1.All insulin will be administered in accordance with physician orders [REDACTED].Administer insulin at appropriate times. Document on the medication administration record the time and location of the insulin injection The facility policy did not indicate what appropriate times were for insulin administration. This Federal tag relates to Complaint IN 405. 3.1-48(c)(2)

Based on record review and interview the facility failed to ensure 4 of 11 residents reviewed were able to vote in the (MONTH) 2019 election. (Resident 9, Resident 10, Resident 30 and Resident 55) This deficiency affected 4 of 11 residents reviewed for resident rights. Finding include: On 7/12/19 at 9:30 A.M., during a Resident Council meeting interviews were conducted. Four residents indicated they would had voted in the last election if they had been asked if they wanted to vote. On 7/17/19 at 10:29 A.M., during an interview, the Administrator indicated she could not find any documentation whether the residents were asked if they wanted to vote in the last election. The Administrator indicated it is the responsibility of the Activity Director to ensure the residents who wanted to vote in the last election had the opportunity to vote. The current policy titled Voting was revised on 3/24/17, and was received from the Administrator on 7/17/19 at 11:45 A.M. The Voting policy indicated it is the responsibility of the Activity Director or designee to ensure the residents who wanted to vote in the last election were registered to vote and to either make transportation arrangements for the residents to vote in their district or by absentee ballot. 3.1-3(a)(1)

Based on interview and record review the facility failed to ensure a resident was able to choose to eat a meal in his room for 1 of 1 residents reviewed (Resident 64). Findings include: The clinical record for Resident 64 was reviewed on 7/10/19 at 2:24 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment from 6/6/19, indicated Resident 64 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Resident 64 was interviewed on 7/16/19 at 11:21 A.M. During the interview Resident 64 indicated he had wanted to eat a cheeseburger and fries in his room on 6/30/19. He was told he was not able to eat a cheeseburger and fries in his room and he had to go to the dining room if wanted to eat a cheeseburger and fries. He indicated not being able to eat a cheeseburger and fries in his room had upset him. A behavior note dated 6/30/19 at 4:54 P.M., indicated Resident 64 was choosing to eat donuts for breakfast, lunch and dinner. The resident wanted to eat a cheeseburger for dinner, but did not want to go to the dining room. The resident was reminded of the room-order process and menu options and that the kitchen will only make him a burger if he joins the the dining room. Resident 64 indicated he hated the facility and he wanted to move. A behavior note dated 6/30/19 at 8:59 P.M., indicated Resident 64 still wanted a cheeseburger, but did not want to go to the dining room. He was being helped into his wheelchair at that time so he could self-propel himself around the facility. When he returned to his room after self-propelling himself around the facility he ate donuts in his room. Licensed Practical Nurse (LPN) 6 was interviewed on 7/16/19 at 11:52 A.M. During the interview LPN 6 indicated she had been caring for Resident 64 on 6/30/19. LPN 6 indicated she had called the dining room on 6/30/19 and asked if they would send a cheeseburger to Resident 64's room for dinner. The kitchen staff she spoke with indicated there was a specific menu to order from in the rooms and cheeseburgers were not on that menu. The kitchen staff indicated Resident 64 had to go to the dining room if he wanted to eat a cheeseburger. LPN 6 indicated Resident 64 was upset that he was not able to have a cheeseburger in his room. LPN 6 also indicated that other residents had tried to order items that were not on the room service menu to eat in their rooms, but they were told they had to go to the dining room if they wanted to eat the items. Kitchen Staff 7 was interviewed on 7/16/19 at 1:15 P.M. During the interview Kitchen Staff 7 indicated they really try to encourage residents to eat in the dining room. She also indicated if they have a note from nursing or therapy saying they are not able to eat in the dining room, they can eat in their room. They would like for the resident's to come down to the dining room. The resident's don't have to eat in the dining room and chicken and hamburgers are always available. The Certified Dietary Manager (CDM) was interviewed on 7/16/19 at 1:39 P.M. During the interview the CDM indicated Resident 64 should have been able to eat a cheeseburger in his room if he wanted to. The Administrator was interviewed on 7/16/19 at 2:48 P.M. During the interview the Administrator indicated Resident 64 should have been able to eat a cheeseburger in his room if he had wanted to. A policy, dated 4/3/17, was provided by the Administrator on 7/16/19 at 3:28 P.M., titled Dining Services and she indicated it was the policy currently used by the facility. The policy indicated .17. Resident room meal trays, if requested by the resident, will be delivered by Dining Services staff. Nursing staff will assist the resident and/or prepare the meal try (sic), if indicated, and assist with feeding when necessary. Nursing staff will communicate resident meal preferences for the room meal tray when a tray is requested. 3.1-3(u)(3)

Based on interview and record review, the facility failed to ensure resident specific baseline care plans were developed within 48 hours after admission for 3 of 5 residents reviewed (Resident 44, Resident 67, and Resident 77). Findings include: 1. The clinical record for Resident 44 was reviewed on 7/10/19 at 11:54 A.M. [DIAGNOSES REDACTED]. There was no documentation to indicate Resident 44 had a resident specific baseline care plan within 48 hours after admitting to the facility. The Resident Care Plan Summary dated 5/17/19, did not address resident specific health and safety concerns nor did it reflect the resident's specific healthcare needs at the time of admission. Care plans provided by the Director of Nursing Services (DNS) on 7/15/19 at 2:09 P.M., indicated resident specific baseline care plans for Resident 44 were initiated on 5/20/19. 2. The clinical record for Resident 67 was reviewed on 7/11/19 at 11:13 A.M. [DIAGNOSES REDACTED]. There was no documentation to indicate Resident 67 had a resident specific baseline care plan within 48 hours after entering the facility. The Resident Care Plan Summary dated 5/31/19, did not address resident specific health and safety concerns nor did it reflect the resident's specific healthcare needs at the time of admission. Care plans provided by the DNS on 7/15/19 at 2:09 P.M., indicated resident specific baseline care plans for Resident 67 were initiated on 6/4/19. 3. The clinical record for Resident 77 was reviewed on 7/10/19 at 11:16 A.M. [DIAGNOSES REDACTED]. There was no documentation to indicate Resident 77 had a resident specific baseline care plan within 48 hours after entering the facility. The Resident Care Plan Summary dated 6/13/19, did not address resident specific health and safety concerns nor did it reflect the resident's specific healthcare needs at the time of admission. Care plans provided by the Director of Nursing Services (DNS) on 7/15/19 at 2:09 P.M., indicated resident specific baseline care plans for Resident 67 were initiated on 6/18/19. The Director of Nursing Services (DNS) was interviewed on 7/15/19 at 1:49 P.M. During the interview the DNS indicated Resident 44, Resident 67 and Resident 77 should have had resident specific baseline care plans within 48 hours after being admitted to the facility and they did not have one. A policy, dated 11/28/16, was provided by the DNS on 7/15/19 at 1:11 P.M., titled Care Plans and she indicated it was the policy currently used by the facility. The policy indicated .A. Baseline Care Plans- The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will include the following: 1. Be developed within 48 hours of a resident's admission. 2. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders [REDACTED].

Based on interview and record review, the facility failed to ensure 1 of 1 residents (30) reviewed, had timely quarterly care plan meetings. Findings include: On 7/10/19, at 9:22 A.M., an interview was conducted with Resident 30. Resident 30 was admitted to the facility on [DATE] and had a BIMS (brief interview of mental status) score of 15, which indicated she was cognitively intact. Resident 30 indicated she did not think she had quarterly care plan meetings. On 7/11/19, at 11:38 A.M., an interview was conducted with the SSD (social service director). The SSD indicated Resident 30 had been identified in (MONTH) 2019 as not to have had a care plan meeting so the facility scheduled one right away. On 7/11/19 , at 12:02 P.M., the Administrator brought a copy of Resident 30's most recent care plan meeting which was dated 8/8/16. The Administrator also brought a policy titled Care Plans, last revision date, 11/28/16. The Administrator indicated the policy does not specify that care plan meetings are to be held every 3 months. Review of the Care Plan policy indicated: Section B. Comprehensive Care Plans: 9. The comprehensive person-centered care plan will be: a) Developed within 7 days after completion of the comprehensive assessment. b) Prepared by an interdisciplinary team, that includes but is not limited to: (1) The attending physician (2) A registered nurse with responsibility for the resident. (3) A nurse aide with responsibility for the resident. (4) A member of food and nutrition services staff. (5) To the extent practicable, the participation of the resident and the resident's representative(s). (6) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. c) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 3.1-3(o) w