Every finding on record at Majestic Care of Fort Wayne

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed were free from a significant medication error. This error resulted in a change of condition and hospitalization (Resident K). Findings include: An anonymous complaint, submitted to the Indiana Department of Health, indicated Resident K had been administered a double dose of medication which was alleged to have contributed to his death. On [DATE] at 10:23 A.M., Resident K's record was reviewed. Diagnoses included Schizoaffective disorder, bipolar type, alcohol induced persisting dementia, moderate dementia with psychotic disturbance, generalized anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease (COPD) with current tobacco use. The resident was prescribed several psychotropic medications to treat his behavior symptoms. His behaviors included verbal fights with staff, verbal aggression with other residents, peer to peer altercations, and physical aggression towards staff. A nurse progress note, dated [DATE] at 2:11 p.m., indicated a call had been placed to the psychiatrist regarding Resident K's continued behaviors. Orders were given for Clozaril 150 mg (milligrams) by mouth-give 2 times per day and start weekly lab draws for complete blood counts. A physician order, dated [DATE], was for Clozaril 100 mg tablet by mouth-give 2 times per day along with Clozaril 50 mg tablet to equal Clozaril 150 mg by mouth, given 2 times per day. A timeline, provided by the Director of Nursing (DON) on [DATE] at 10:26 A.M., indicated: -On [DATE] at 2:29 p.m., Clozaril was delivered to the facility and one time order received to give the medication when it arrived. Clozaril 100 mg tablet and Clozaril 50 mg tablet equaled 150 mg was given by mouth to Resident K. -At 3:30 p.m., a second dose of Clozaril 100 mg tablet and Clozaril 50 mg tablet equaled 150 mg was given by mouth to Resident K. -At 4:00 p.m., the resident was observed to be lethargic. He was taken to his room and laid down in bed. Staff discovered the resident had erroneously been given 2 doses of Clozaril 150 mg which equaled 300 mg of Clozaril administered within an hour. A call was placed to the psychiatric Nurse Practitioner (NP) to notify of the medication error and resident's current condition. -At 4:17 p.m., the psychiatric NP returned call to the facility and indicated she would contact the Psychiatrist for further orders. -At 4:20 p.m., the psychiatric NP called back the facility with recommendations to monitor the resident's vital signs (blood pressure, pulse, respirations, temperature, and pulse oximetry) every 2 hours for 8 hours, then every 4 hours until the resident was awake. Vital signs on [DATE] were: -4:00 p.m., Blood pressure (BP): ,d+[DATE] (normal-,d+[DATE]); pulse (P): 77 (normal-,d+[DATE]); respirations (R): 18 (normal-,d+[DATE]); temperature (T): 96.4 (normal 98.6); Pulse oximetry (normal >90%): 90% on room air. -6:00 p.m., BP: ,d+[DATE], P: 81, R: 20, T: 96.5, Pulse oximetry: 92% on oxygen. -8:00 p.m., BP: ,d+[DATE], P: 91, R: 20, T: 96, Pulse oximetry: 88% on oxygen. -10:05 p.m., BP: ,d+[DATE], P: 79, R: 18, T: 96, Pulse oximetry: 83% on oxygen. Nurse progress notes indicated the following on [DATE]: -5:12 p.m., the NP and doctor were updated on the resident receiving Clozaril. Staff were monitoring vital signs with no concerns. -9:08 p.m., the resident was sleeping without change in condition. -9:20 p.m., the resident was started on a new medication on this day; his vital signs were monitored closely; he was currently resting in bed with the head of the bed elevated; oxygen in place; would continue to monitor. -10:05 p.m., the resident was resting comfortably in bed with oxygen in place and no apparent distress. There was no adverse reaction to the new medication observed; would continue to monitor. -11:00 p.m., the resident continued to rest comfortably with no adverse reaction or distress noted. -11:15 p.m., the resident was observed with no pulse or respirations. CPR (Cardiopulmonary Resuscitation) initiated and 911 called. Once medics arrived, they continued with CPR and resident taken to the hospital. A hospital History and Physical and Consultation notes, dated [DATE] at 11:19 a.m., indicated the resident had increased behaviors at his nursing home and had been started on Clozaril. The resident had accidentally received 2 doses in a very short length of time which had occurred yesterday ([DATE]). Yesterday evening, the resident was found unresponsive, around 11:,d+[DATE]:20 p.m., CPR was initiated and EMS called. The resident was asystole (no heartbeat) which required 4 rounds of epinephrine and intubation. While hospitalized he remained unresponsive, on the ventilator with questionable aspiration pneumonia (when food or liquid is breathed into the airways or lungs instead of being swallowed) and cardiac/respiratory arrest of unknown origin. On [DATE] at 1:40 P.M., the Psychiatrist was interviewed. He indicated he had been notified of the medication error and 2 doses of Clozaril 150 mg given within an hour of each other. He indicated there was no antidote to be given and the resident was to have his vital signs, including his oxygen saturation, monitored frequently. He indicated if there had been changes in his vital signs, the only intervention to have done was administer intravenous fluids until the resident's vitals stabilized. On [DATE] at 3:00 P.M., Clozaril information was obtained from the website, drugs.com. The website indicated Clozaril was an antipsychotic medication used to treat schizophrenia in adults after other treatments had failed. Clozaril came with a black box warning the medication could cause severe neutropenia (low white blood cell count), low blood pressure, slow heart rate, dizziness, seizures, inflammation of the heart and death in elderly patients with dementia related psychosis; side effects were dose related; starting dose was 12.5 mg one to two times per day which could be increased ,d+[DATE] mg per day if well tolerated; target dose of ,d+[DATE] mg in divided doses by the end of 2 weeks. Low blood pressure, slow heart rate, and cardiac arrest could occur with Clozaril treatment with the highest risk during the initial titration period, especially with rapid dose escalation. These reactions could occur with the first dose, at doses as low as 12.5 mg, which could be fatal. Overdosage: The most commonly reported signs and symptoms associated with Clozaril overdose were sedation, delirium, coma, fast heart rate, low blood pressure, respiratory failure, aspiration pneumonia, heart arrythmias and seizures. The past non-compliance deficiency began on [DATE] and deficient practice corrected on [DATE] after the facility in-serviced all nurses and QMAs (Qualified Medication Aid) on safe medication administration, including signing out of the MAR immediately after administering a medication. All resident MAR (Medication Administration Record) were reviewed for completion the prior 30 days, resident charts audited for documentation accuracy, medication administration policy and procedures reviewed and medication pass competencies completed on all licensed nursing and QMA staff. The facility is monitoring by completing medication pass observations routinely for 6 months. This tag relates to Complaint IN00437523. 3XXX,d+[DATE](c)(2)

Based on interview and record review, the facility failed to ensure safe medication administration was completed resulting in medication error for 1 of 3 residents reviewed. (Resident E) Finding includes: A self-reported incident, submitted to Indiana State department of health, Resident E was given a dose of the medication Clozaril 150 milligrams (mg) during day shift. Shortly after, on second shift a second dose of 150 mg was given. On 6/21/24 at 9:41 AM, Resident E's record was reviewed. Diagnoses included, bipolar disorder, current episode manic without psychotic features, moderate. Chronic Obstructive Pulmonary disease. A review of physician orders indicated the following: Clozapine oral tablet (clozapine): give 150 mg by mouth one time only related to bipolar disorder unspecified. Order date: 6/5/24. Start date 6/5/24. End date 6/6/24. Clozaril oral tablet 100 mg (clozapine): give 1 table by mouth two times a day related to schizoaffective disorder; bipolar disorder unspecified current episode manic without psychotic features. Give with 50 mg to = 150mg. Order date: 6/3/24. Start date: 6/4/24. Clozaril oral tablet 50 mg (clozapine): give 1 table by mouth two times a day related to schizoaffective disorder; bipolar disorder unspecified current episode manic without psychotic features. Give with 100 mg to = 150mg. Order date: 6/3/24. Start date: 6/4/24. A review of progress notes indicated: Dated 6/3/24 at 2:11 PM: Call placed to physician regarding Resident E's continued behaviors. Update physician on Resident E's lab levels, physician indicated no changes in those orders. The physician gave the following orders for behaviors 1). Start Clozaril 150 mg twice a day. 2). Weekly Complete Blood Count (CBC). 3). Discontinue Risperdal. Dated 6/10/24 3:39 AM by Nurse Practitioner: On Wednesday June 5, 2024, facility requested an update on the status of the Clozaril registry. Confirmed it had been registered for Resident E that morning. The DON was notified. Later in the day, a call was placed by the DON to the office. The writer called back, was informed that Resident E had been dosed twice with 150 mg of Clozaril and was very sleepy. Writer advised they would inform the physician, which was done. The physician agreed that Resident 6 should have vitals signs monitor every 1-2 hours for 8 hours. DON was notified, order given to monitor vitals every 1-2 hours and to call with any other concerns or questions. In an interview on 6/21/24 at 11:33 AM Licensed Practical Nurse 5 (LPN) indicated she was asked by a QMA trainee, when the order was yellow in the medication record administration (MAR), is she to give the medication to Resident E. LPN 5 indicated to the trainee the medication was to be given. In an interview on 6/21/24 at 11:43 AM Qualified Medication Aide 4 (QMA) indicated they had been waiting for the medication (Clozaril) for a couple of days for Resident E. Pharmacy dropped it off, QMA 4 asked if she was to give the medication, the nurse indicated they would ask the DON. The DON indicated to give it, put in a one-time only order and give it. The nurse was putting the order in and QMA 4 gave the medication. When she went back to sign it out, it would not allow her to. She checked it several times but could not sign it out. During that time, she was asked if she could train another QMA. This QMA told her they were experienced, so QMA 4 agreed. QMA 4 indicated they were leaving on break, but advised the trainee not to give any medications. There were some treatments to be done, but they would start when QMA 4 returned. On the way back from break, QMA 4 received a text message from the DON asking if Resident E received the dose of Clozaril 150 mg. QMA 4 indicated the resident had recevied the medication. QMA 4 indicated it wasn't that long between receiving and when she was told Resident E received a second dose of Clozaril 150 mg. IN an interview on 6/21/24 at 12:19 PM the DON indicated the nurse was supposed to put a one time only entry for the medication of Clozaril 150 mg for Resident E, and it was to be given right away. She was not sure why it was not signed out by QMA 4. The text message was sent to QMA 4, to ask about the early dose of medication because it was yellow in the computer, but they gave Resident E the dose due to him having a behavior. Then they found out that they did give the earlier dose. The DON indicated, the physician was called, they noticed Resident E was becoming sleepier. The physician indicated the adverse reactions were lethargic and drowsiness, to monitor vitals every 1-2 hours. The DON indicated they are not sure why the medication didn't show up for QMA 4 to sign out. But after this error, they did an audit/plan of action of the whole building to make sure that physician orders are getting entered, and medications are being given correctly. A review of the facility's plan of action dated 6/5/24: Deficiency: Resident E received a second dose of the medication due to the first dose not being signed out. GOAL: All residents will receive correct medication dosage. Actions to be taken . Nursing staff in-service on safe medication administration, including signing out of the EMAR, immediately after administering a medication . Statements obtained from nursing staff involved . All resident's MAR were reviewed for last 30 days for any missed documentation noted. Resident chart reviewed for accuracy of documentation . Audits to be completed each business day of the new order review/holes in MAR time 6 months and will evaluate in Quality Assurance and adjust accordingly . Interivews with staff indicated they had received reeducation regarding medication administration and signing out medications. Audits were visualized as having begun. A review of the current facility polices was provided by the Nurse Regional consultant on 6/11/24 at 9:48 AM: A policy, Administering medications, date 4/2019. The policy indicated . Medications are administered in a safe and timely manner, and as prescribed A policy, Charting and Documentation, dated 7/2017. The policy indicated . the following information is to be documented in the resident medical record .Medication administered A policy, Medication Error, dated 7/2020. The policy indicated .to ensure residents remain free from medication errors This citation is related to Complaint IN00436120. 3.1-48(b)

Based on interview and record review the facility failed to ensure residents with trauma had triggers identified for 3 of 3 residents reviewed (Resident 18, Resident 58, & Resident 270). Findings include: 1. Resident 18's record was reviewed on 01/11/24 at 10:31 AM. Diagnoses included Post Traumatic Stress Disorder (PTSD), dementia, and bipolar disorder. A review of Resident 18's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 10 (moderately impaired). The care plan for PTSD did not indicate specific triggers or intervetions to prevent re-traumatization of Resident 18. During an interview an observation on 1-8-24 at 8:10 AM, QMA 6 indicated Resident 18 always had the room dark and cluttered, but there was no direction given the staff on approaches or triggers to behavior. 2. Resident 58's record was reviewed on 01/08/24 at 09:38 AM. Diagnoses included PTSD, major depressive disorder, and anxiety disorder. A review of Resident 58's current quarterly MDS indicated their BIMS score was 15 (no cognitive impairment). The care plan for PTSD did not indicate specific triggers to prevent re-traumatization of Resident 58. A review of progress notes dated 11/2/2023 at 1:00 PM indicated Resident 58 continued to have nightmares when he slept, and flashbacks due to trauma from his past. The care plan did not indicate triggers or interventions to be utilized for his nightmares or flashbacks. 3. Resident 270's record was reviewed on 01/11/24 at 12:36 PM. Diagnoses included PTSD, dementia, and generalized anxiety disorder. A review of Resident 270's current quarterly MDS indicated their BIMS score was 99 (resident was unable to complete interview). There were no care plans, approaches, or triggers identifies regarding Residents 270's PTSD. A current policy dated 03/01/2019 provided by the Regional Nurse Consultant indicated the facility should provide care and services identifying triggers, and using multiple person centered approaches to address the needs of trauma survivors. An interview with the Social Service Director on 01/11/24 at 1:07 PM indicated trauma or PTSD should be documented in the care plans along with triggers. 46818

Based on interview and record review the facility failed to ensure 1 of 4 residents reviewed were free from abuse. (Resident 22) Findings include: During an interview with Resident 22 on 1/8/24 at 10:16AM she indicated; she did have water thrown on her once, she did not like living at the facility, and she had nothing further to say. During an interview with the Executive Director (ED) and Regional Consulting Nurse (RCN), on 1/08/24 at 1:24PM; they indicated beyond a reasonable doubt CNA 2 (Certified Nurse Assistant) threw a full cup of ice water on Resident 22 while Resident 22 was lying in bed after dinner and before bedtime medication pass on the evening of 12/21/23. The ED explained his investigation process and the difficulty regarding staff interviews not validating the abuse and not all cohesive. The ED indicated Resident 22's lack of extreme behavior he would expect if such an incident did occur was initially considered. The lack of eyewitnesses further increased the difficulty in determining if the abuse happened. Resident 22's roommate indicated she did not see the face of the person who came in and had some sort of altercation with Resident 22. The ED was able to determine Resident 22's hair, only a little of a sleeve, and some of the garment's collar was wet in one frame of the footage from a hall camera. The ED was able to see Resident 22 changed her shirt and returned to the nurses' station multiple times. He was further able to determine from cameras CNA 2 had a full pitcher of ice water, went down East Hall where Resident 22 resided and returned with an empty pitcher. CNA 2 was not assigned to East Hall on 12/21/23. The ED indicated in his interview with CNA 2 she denied taking any water down the hall and was unsure what he was talking about. He offered her to come watch the video and she declined. The ED indicated she was unable to account for why she took down a full pitcher of ice water and returned with an empty pitcher. The ED indicated she was unable to account for why she was on East Hall when she was assigned to West. The ED indicated CNA 2 had no prior accusations of abuse or reprimands for performance. Resident 22's chart was reviewed on 1/8/24 at 11:14AM. Resident 22's diagnoses included schizoaffective disorder, major depressive disorder, dementia, insomnia, and anxiety. Resident 22's most recent comprehensive MDS (Minimum Data Set) on 12/14/23 was reviewed. Section C: BIMS (Brief Interview of Mental Status) indicated a score of 13. The score of 13 shows mild cognitive loss. Section D Mood indicated Resident 22 had little or no interest in doing things most days, feeling down, depressed, or hopeless most days, trouble falling or staying asleep most days, feeling tired or no energy several days, poor appetite or overeating most days, and trouble of concentration on things most days. Section E behavior indicated resident had verbal behavior directed toward others and rejection of care for 1 to 3 days out of 14-day period reviewed for assessment. A review of the facility investigation on 1/9/24 at 3:29PM indicated the following: An altercation occurred on 12/20/23, involving Resident 22 and CNA 2. Resident 22 slapped CNA 2. Resident 22 reportedly got upset regarding showering, walked up to CNA 2 at the nurse' station and hit her. A verbal statement was taken from CNA 4 who worked in the evening on 12/21/22 on [NAME] Hall and was unaware of any events taking place. A written statement from CNA 3 who worked 12/21/23 in the evening indicated Resident 22 was asked about an incident between her and CNA 2 the day prior. Resident 22 indicated she apologized yet still felt CNA 2 deservedv to be hit. The statement indicated CNA 2 stated I'm about to go throw some water on her. Then CNA 3 indicated she observed CNA 2 go down East Hall with a full pitcher of ice water. Upon returning, Resident 22 was right behind CNA 2 stating she threw water on me. 30 to 45 minutes later, Resident 22 came back to nurses' station and indicated CNA 2 threw water on her again. CNA 3 could not confirm if the second incident occurred. A statement from the DNS (Director of Nursing Services) indicated she asked CNA 2 if she knew anything about water being thrown on Resident 22 and CNA 2 indicated she had no idea what she was talking about. A statement from SSD (Social Services Director) indicated a staff reported to her Resident 22 was very upset due to another staff pouring ice water on her. The statement indicated the SSD spoke with Resident 22 who confirmed the allegation and indicated there was a verbal altercation of statements, I don't like you and I'm going to get even with you. 7 resident abuse questionnaires were completed. Four of the seven indicated the residents also had an issue with CNA 2 but did not report it. CNA 2 was terminated for the abuse. CNA 3 was terminated for failure to report the abuse. During an interview with Resident 22 on 1/10/24 at 1:46PM she indicated she was not more or less depressed than she was prior to the holidays. She denied fearing staff or peers. She denied being bullied or harassed. A policy and procedure were obtained at entrance on 1/7/24 at 9:22AM from ED. The policy Abuse Prevention Program original date February 2019 with last revision date March 2021, indicated .The protection of resident during abuse investigations. The development of investigative protocols governing abuse . Striving to maintain adequate staffing on all shifts to ensure the needs of each resident were met; and expect all personnel, residents, visitors, to report and signs or suspected abuse to facility management immediately This citation is realted to Complaint IN00424619. 3.1-27 (a)

Based on interview and record review, the facility failed to ensure accurate reporting to the Payroll-Based Journal (PBJ) system regarding Nursing hours for third quarter 2023. Findings include: A record review on 1/7/2024 at 9:15 AM, of the Certification And Survey Provider Enhanced Reports (CASPER) report: the Payroll-Based Journal (PBJ) data report Quarter 4 2023, July 1-September-30, indicated are of concern that will be triggered (requires follow-up during the survey). The metric: One star staffing rating, triggered. Excessively low weekend staffing, triggered. Failure to have licensed nursing coverage 24 hours/day, triggered. The infarction dates for failure to have Licensed Nursing Coverage 24 hours/day: 7/1/23, 7/2/23, 7/15/23, 7/15/23, 7/29/23, 7/30/23, 8/12/23, 8/20/23, and 9/2/23. A record review on 1/10/24 at 11:28 of the following hours worked (clocked in/out) indicated, 7/1/23, 7/2/23, 7/15/23, 7/15/23, 7/29/23, 7/30/23, 8/12/23, 8/20/23, and 9/2/23 all had Licensed nursing coverage 24 hours/day but was not accurately reported to the PBJ. An interview on 1/10/24 at 1:03 PM with Director of Nursing and Regional Nurse Consultant indicated, they do not report all of the hours to the PBJ, especially if they are salary positions. When a salary employee would work 16 hours then the facility would report they worked 8 hours. The facility knew the problem of reporting, but the home office did the reporting to the PBJ. A currently facility policy, Staffing, was provided by the Director of Nursing on 1/10/24 at 1:03 PM. The policy indicated . Direct care staffing information per day (including agency and contract staff) is submitted to payroll-based journal system on the schedule specified by CMS, but no less once a quarter

Based on interview and record review, the facility failed to ensure facility abuse protocols were implemented for 1 of 3 incidents reviewed. (Resident B) Findings include: On 8/24/2023 at 9:45 AM, a review of a facility's self-reported incident of abuse reported to the Indiana Department of Health (IDOH) on 8/22/2023 indicated an incident of abuse had occurred on 8/22/2023 at 7:01 A.M. The report named Resident B and RN (Registered Nurse) 1 as the persons involved. The description of the incident indicated RN 1 told Resident B to stop crying and was not taking care of Resident B's needs. Resident B became upset, stood up to the nurse's desk and pushed the computer monitor over. RN 1 then reacted by slapping Resident B on the cheek. On 8/24/2023 at 10:08 AM, the Administrator provided the facility's investigation of the abuse incident. The administrator indicated they had substantiated the abuse by the nurse after they viewed the camera video. On 8/24/2023 at 1:30 P.M., A review of Resident B's records began and indicated diagnosis of paranoid personality disorder, intellectual disabilities, vascular dementia with severe anxiety and agitation, delusional disorders, major depressive disorder, and chronic pain syndrome. Resident B's current MDS (Minimum Data Set) assessment dated , 7/27/2023, indicated a BIMS (Brief Interview for Mental Status) Score was 09; moderately impaired cognition. The MDS assessment indicated during the time period of the assessment, the resident had wandered 1-3 days and the behavior had worsen from the prior assessment. The Functional Status and Activity of Daily Living (ADL) assistance required, indicated the resident required extensive assistance of 1 person to transfer but limited assist of 1 to walk. Their balance was not steady and could only stabilize with assistance of staff. The MDS also indicated a wheelchair was used for mobility. Resident B's progress notes indicated the following: On 8/22/2023 at 12:54 P.M., a Social Service note indicated the Social Service Director (SSD) had spoken with Resident B in their room. Resident B indicated they felt safe at the facility with staff. Resident B displayed signs of agitation and sadness by yelling out and crying. The resident reported they were emotional because their roommate would not talk to them since being kicked by the resident. Resident B stated they were not upset with facility staff, just wanted their roommate to forgive them. On 8/23/2023 at 9:17 A.M., an IDT (Interdisciplinary Team) note indicated the Team met to discuss the incident between the staff member and the resident. The incident indicated the resident was struck in the face by a staff member. The resident had no complaints of pain or injury on the initial assessment or the follow-up. The resident continued daily routine without changes, was participating in therapies and activities, and showed no hostility or fear towards other residents or staff members. Progress notes on 8/24/23 and 8/25/23 by IDT and SSD indicated Resident B continued typical daily routine, attended activities, showed no hostility or fear towards other residents or staff., had no displayed signs of psychosocial distress and was at their baseline behaviors. Resident B's Care Plan initiated on 1/24/2023 with a Revision Date of 2/8/23 indicated Resident B exhibits behavior related to anxiety. Resident B would ask repetitive questions and become obsessive with needs, obsessive with attention. Resident would also become impulsive when needs are not addressed at that very second. Resident would get tearful and lash out when feeling not enough attention was given. Interventions included the following: Allow resident to vent feelings and needs. Approach resident in a calm and friendly manor. Assess resident's needs including comfort level, pain and treat as indicated. Explain to resident what you were going to do before initiating task. If resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure, re-approach as needed. Listen to resident's needs and adjust plan as appropriate. Maintain a safe environment for the resident. The facility's investigation of the abuse incident regarding Resident B indicated RN 1 was suspended, the investigation began and included interviews with staff and residents. Written statements by staff on duty were collected. CNA (Certified Nursing Aide) 2's statement indicated on the morning of Monday, August 21st, she witnessed the nurse, RN 1 smack Resident B in the face at the nurses station. Resident B was agitated due to the nurse teasing the resident and things escalated. The statement was signed by CNA 2. The email sent to the facility DNS (Director of Nursing Services) from RN 1, dated 8/23/2023 at 5:31 AM., contained RN 1's written statement. The statement indicated on 5/21/23 around 5:20 A.m., Resident B was yelling to get up in their wheelchair. A CNA assisted Resident B up in the wheelchair and brought them out to the nurses station. Resident B wanted something for their foot. RN 1 indicated she administered Tylenol ordered for them. RN 1 indicated she had a hard time understanding Resident B. The CNA reported Resident B wanted the foot dressing (bandage) changed, even though it was intact. RN 1 indicated she changed the dressing, and applied the pressure relieving protector pillow. RN 1 seen a sock was missing. Resident B became mad and wanted the sock now. RN 1 indicated she told the resident she would get the socks when she finished entering computer information. She indicated Resident B walked to the computer, lifted the monitor as if to hit her with it. She indicated she told the resident to not be a jerk and please do not break the facility's equipment. She wrote, all she could think was to connect with the resident so she cupped Resident B's left cheek with her right hand. Resident B gave no eye contact. RN 1 indicated she did not know what set the resident off that morning. The follow-up to the facility's incident investigation conclusion reported to IDOH on 8/24/2023 indicated the following: The nurse reacted to the resident pushing over the monitor and made contact with the resident's face. The resident had become upset about their foot. The nurse had stated she was going to have day shift change the dressing, but a short time later she did the dressing change with no concerns. Resident B continued to be upset per the aide (CNA), the nurse not addressing the resident's concerns. The resident stood up at the nurses' station stating they wanted something to be done with their foot. The resident then pushed over the computer monitor onto the desk. The nurse grabbed the monitor, then reached out to the resident and made contact with the resident's cheek. RN 1 was suspended pending investigation, and was later terminated. Abuse in-servicing was initiated for all staff. The resident was assessed and no injury was noted. Multiple residents were interview with no concerns. There were no skin issues of unknown origin for residents in the past 2 weeks. The counselor will meet with the resident to continue to follow up for any psychosocial needs. Resident B had not shown any adverse side effects from the incident and continued in their normal daily routine. Resident B had not mentioned the incident further. The facility's Care Team Member Corrective Action Form indicated Investigatory Suspension pending determination for RN 1. The infraction date was listed as 8/21/2023. The Infraction/Policy Violation was related to resident abuse, neglect, or misappropriation. Description of Violation: RN 1 was witnessed on camera after another Care Team Member/Staff called the Administrator, the DNS and reported abuse. RN 1 was witnessed on camera to have slapped a resident, continued to taunt and then stick her tongue out at the resident. Corrective Action: RN 1 would be placed on suspension. The form indicated RN 1 was notified by phone of the suspension. The form was signed by the DNS and witnessed by LPN 3. In an interview on 4/24/2023 at 5:00 P.M., the DNS indicated CNA 2 had called the Administrator on 8/22/2023 in the morning before they arrived at the facility. CNA 2 reported Nurse 1 had hit Resident B in the face. The DNS indicated the Administrator was at the facility when she arrived and had begun the investigation. She indicated she notified RN 1 she was suspended pending the investigation of abuse. She indicated they viewed the camera video. The video indicated RN 1 was observed to slap Resident B on the face. She indicated RN 1 was terminated after the video was viewed. A current facility policy, titled, Abuse Prevention Program, with Revision Date of March 2021, was provided by the Administrator on 8/24/2023 at 10:08 A.M., indicated, .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents .Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm This Federal tag relates to Complaint IN00415764. 3.1-27(a)(b)

Based on interview and record reviews the facility failed to ensure 1 of 3 residents reviewed was treated with dignity and respect. (Resident B) Findings include: On 6/26/2023 at 10:15 A.M., Review of a facility's state reported incident investigation indicated Resident B was left in the shower room for several hours after shift change. A record review for Resident B began on 6/26/2023 at 10:15 AM, indicated diagnoses included but were not limited to Alzheimer's Disease, schizoaffective disorder and bipolar disorder. A review of Resident B's MDS (Minimal Data Set) Assessments dated 3/24/23 indicated a BIMS (Brief Interview for Mental Status) was 13/15, meaning cognitively intact. The annual assessment also indicated the resident required supervision with set up only for walking in room, halls and locomotion on and off the unit. A significant change MDS assessment, dated 5/21/2023 was completed when the resident was admitted to hospice. His BIMS was 07/15, meaning modreate cognitive impairment, although functional status remained as supervision and set up only for walking in room and halls, locomotion on and off the unit and dressing. A review of Resident B's Care Plans indicated the goal for needing assistance with activities of daily living was revised on 6/16/2023, and indicated Resident B would have care needs met daily with assistance of staff. The Intervention for Bathing/Showering was also revised on 6/19/23 and indicated Resident B required assistance of up one staff member for bathing task, may require CNA to exit and return due to history of behavioral outbursts and paranoia. The plan indicated the resident's needs could fluctuate and to encourage to be as independent as possible. Provide additional assistance as needed. A review of the facility state reported incident dated 6/8/2023 at 8:01 p.m., indicated Resident B was left in the shower during a staffing change. The report indicated the resident was a very private person, kept the door closed, preferred to not have visitors and often kicked people out of the room. Resident B preferred to do self-care despite needing assistance, and showers without direct over-sight. The investigation found the resident to have been given a shower, staff checked on the resident throughout the process. CNA (Certified Nurse Aide) 5 was scheduled to leave at 8:00 P.M. and handed off Resident B's care to the remaining aides. The investigation indicated CNA 10 thought Resident B's shower was completed. At the 10 PM, shift change, Resident B's room door was closed as normal for the resident. During midnight bed check round, Resident B was not in their room. A search for Resident B began and he was found sitting in the shower room. Resident B was in good spirits, dressed and stated they could not remember how to open the door. A review of the facility's investigation timeline of the incident dated June 8th indicated Resident B came to the nurses' station, asked for a shower and CNA 5 took the resident for a shower. CNA 9 indicated Resident B came to the nurses' station around 6:00 PM asking for a shower and CNA 5 took the resident for a shower sometime after supper. CNA 5 put Resident B in the shower room around 7:00 P.M., went back around 7:45 P.M. and got clean clothes for him to put on. It was time for CNA 5 to leave and Resident B was still in the shower room getting dressed. CNA 5 left at 8:03 PM. There was no indication in the report CNA 5 had reported to any staff Residnet B was in the shower room prior to leaving her shift. CNA 8 indicated she had gone into the shower room around 7:30 P.M., as Resident B had turned on the call light. The Resident requested CNA 8 to give them their clothes. CNA 8 handed the resident their clothes. CNA 5 came to check on the resident and CNA 8 told CNA 5 the resident was putting on dirty clothes. CNA 5 proceeded to get the resident clean clothes. CNA 8 left the shower room. CNA 10 indicated she was not aware Resident B was in the shower room, but when she went to the resident room for a complete bed check, Resident B was not there. CNA 10 indicated she checked the shower room and found the resident sitting there in good spirits. Resident B indicated they had forgotten how to open the door. CNA 11 indicated CNA 10 had found Resident B in the shower room around midnight. The facility investigation records dated June 8, 2023 indicated Care team Member Corrective action Forms were completed for the following staff, CNA 2, CNA 5, CNA 8, CNA 9, and CNA 13. On 6-26-2023 at 11:00 A.M. facility grievance records, provided by the Administrator at 10:10 A.M., indicated a grivance was filed by Resident B's family member on 6/12/2023 and was received on 6/12/2023 by Social Services. The Report of Concern indicated an incident date of 6/8/2023. Resident B reported to their family member, they were left in the shower room for several hours. The grievance was assigned to Nursing on 6/13/2023 and found Resident B was left to shower by themselves, as per they had always done. The CNA was unaware of Resident B's recent decline since hospice admission. Resident B was now unable to shower themselves. Corrective Actions were taken, staff education and in-service were completed. Staff was educated Resident B was not a total care and required assistance in the shower. Staff were educated on staff hand-off when changing staff providing care. On 6/14/2023 Resident B's family member was notified of the changed to the care plan. The family member was in agreement and signed the form as resolved and satisfied with the resolution. In an interview on 6/26/2023 at 9:40 AM, the Administrator indicated he had reported the incident per policy. He indicated through the investigation it was determined the resident was in the shower room for 4 hours. He indicated the facility did not have cameras on the south hall to determine the exact time in the shower. He indicated the resident was very private, did not like people coming into their room, always keeps the door shut, and rarely came out of their room. Resident B often yelled at persons coming into the room and has been known to throw items at the staff. The resident did not like to take a shower or be touched. He also indicated Resident B's family was very involved and visited often. The family reported the resident said they were in the shower room for 14 hours. The Administrator indicated the resident was known to have delusions, and knew the resident had been seen during the 14 hours reported in the shower. The Administrator indicated Resident B had a decline since being admitted to Hospice. He indicated the facility had a care plan meeting with facility staff, Hospice staff and family. All were in agreement with changes to the care plan to provide total assistance with care and showers. On 6/26/2023 at 10:50 AM, the DNS (Director of Nursing Services) was in interviewed. She indicated the education in-service was provided by herself, the ADON (Assistant Director of Nursing) and Unit Manager to cover all staff on all shifts. The DON indicated the hand-off report shift to shift was for all residents in the facility. She indicated she was not made aware of the incident until the family reported to the Administrator, and the investigation had already begun. As the investigation was completed, it was determined to report the incident to State on 6/19/2023. She also indicated written corrective action was given to all staff involved. On 6/24/23 at 2:10 P.M., in an interview, CNA 2 indicated at shift change a room to room hand-off report was to be given about each of the residents, and lay eyes on them. Report how they were doing on their shift, when last changed, if having behaviors. She indicated bed checks should be done every 2 hours. She indicated if a resident would tell her to get out of the room, she would report it to the nurse, and would attempt later with nurse or another staff member to come along. On 6/24/23 at 2:20 P.M., in an interview, CNA 3 indicated she worked day shift. There were usually 2 CNA's on East and [NAME] Halls, and 1 CNA on South Hall, since residents were mostly independent. She indicated a walk through shift to shift report was to be done and need to visualize the residents during the report. She indicated she usually does not work on the South Hall, but indicated Resident B was not on total care and was more accepting of care from staff. On 6/24/2023 at 2:42 P.M., in an interview, CNA 4 indicated the staff had assignment sheets and waould get a report from the prior shift. They would walk room to room, visualize the residents, and check to see if they needed changed prior to leaving. She indicated residents should be checked on at least every 2 hours. She indicated the staff were educated on visually seeing the residents during the report. On 6/24/2023 at 2:50 P.M., in an interview, CNA 5 indicated Resident B was not her assigned resident, The resident had come up to the nurses' station and wanted to get a shower. She indicated she assisted them to get in the shower and told him to pull the light cord. She indicated he didn't want to put on different clothes on, but she asked and he indicated he would put on clean clothes, so she went to get the clean clothes. She indicated she assisted with clean pants, but the resident would not allow her to put on a clean brief, and wanted to dress himself. She indicated she reported to the 4 CNA's who were at the nurses' station, Resident B still needed to get a shirt and jacket on. She indicated her shift ended and she left. She indicated they have been educated to do a shift to shift, room to room report on the residents. They were to inform the oncoming staff how the resident was, if the resident needed showered, or was having behaviors. The staff were instructed to go in the room and check on them. She indicated she waited until the next shift arrived and report was given before leaving, even if it was late and their shift had ended. A current facility policy, titled, Quality of Life-Dignity, revised on February 2020, was provided by the Administrator on 6/26/2023 at 4:55 P.M., indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem .1. Residents are treated with dignity and respect at all times. 2. The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values and beliefs .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents .12. Staff are expected to treat cognitively impaired residents with dignity and sensitivity This Federal tag relates to complaint IN00411119. 3.1-9(a)

Based on interview and record review, the facility failed to ensure adverse side effects and effectiveness of medication were monitored for 3 of 8 residents reviewed. (Resident 55, and Resident 12) Findings included: 1. Resident 55's record was reviewed on 1/5/2023 at 9:22 AM. Diagnoses included multiple sclerosis, type 2 diabetes mellitus without complications, restless leg syndrome, low back pain, unspecified, fibromyalgia, chronic pain syndrome, and migraine, unspecified, intractable, with status migrainosus. A Minimum Data Set (MSD) assessment, dated 11/23/2022, indicated Resident 55 had a brief interview for mental status (BIMS) score of 12 (moderate cognitive impairment). An order, dated 10/13/2022, indicated Lispro Insulin inject, per sliding scale (dosage based on resident's blood glucose reading): if resident's blood glucose reading was 150-200=2 units, 201-250 = 3 units, 251-300 =4 units, 301-350 =5 units, 351-400= 6 units, 401-450= 8 units, inject subcutaneously (beneath the skin) before meals ( 7:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (8:00 PM) related to type 2 diabetes mellitus without complications. Call provider if blood glucose reading was over 451. An order, dated 12/3/2022, indicated Hydromorphone HCl 4 milligrams (mg) tablet (an opioid pain medication), give 1 tablet by mouth every 4 hours as needed for pain/discomfort. An order, dated 10/13/2022, indicated Hydromorphone HCl 4mg tablet, give 1 tablet by mouth every 4 hours (12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM) for pain. Resident 55's orders did not include an order to monitor for signs and symptoms of hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level). Resident 55's record did not include an order to monitor for adverse side effects or effectiveness of opioids. A review of Resident 55's vital sign documentation for December 2022 indicated pain level documentation on 12/2/22 at 9:52PM 5, 12/2/22 at 11:50 PM 1, 12/3/22 at 10:06 PM 6, 12/4/22 at 12:38 AM 0, 12/5/22 at 3:34 AM 7, 12/5/22 at 4:09 AM 0, 12/06/22 at 1:10 AM 5, 12/6/22 at 5:47 AM 0, 12/13/22 at 6:21 AM 6, 12/13/22 at 6:24 AM 2, 12/29/22 at 1:39 AM 8, 12/29/22 at 4:59 AM 1, and 12/30/22 at 1:56 AM 2. No other pain level documentation was found in the December 2022 vital sign section in Resident 55's record. A review of Resident 55's vital sign documentation for January 1-6,2023 indicated pain level documentation on 1/6/2023 at 11:07 AM 8. No other pain level documentation was found in the January 2023 vital sign section in Resident 55's record. A care plan, dated 11/09/2022, indicated Resident 55 was at risk for complications and symptoms of hypoglycemia or hyperglycemia due to a diagnosis of diabetes mellitus. The goal indicated Resident 55 would be free from symptoms and complications of hypoglycemia or hyperglycemia. Interventions included administer diabetes medication as ordered by the doctor, observe for side effects and effectiveness, observe for signs or symptoms of hyperglycemia such as increased thirst and appetite, frequent urination, weight loss, fatigue (tiredness), dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (fast, deep breathing), acetone breath (fruity smelling breath), stupor (near unconsciousness) and coma (unconscious), observe for signs and symptoms of hypoglycemia such as sweating, tremor (shaking), increased heart rate, pallor (pale skin), nervousness, confusion, slurred speech ( unclear speech), lack of coordination and staggered gait (unsteady walking). A care plan, dated 9/1/2021, indicated Resident 55 had chronic pain (constant pain). The goal indicated Resident 55 would verbalize adequate relief of pain. The interventions included administer medication as ordered, observe and report changes in usual routine, sleep patterns, decrease in functional abilities (taking care of own needs like bathing, dressing), decreased range of motion (movement of arms and legs), withdrawal or resistance to care ( not allowing staff to assist), observe for symptoms of non-verbal pain: changes in breathing (noisy, deep, shallow, labored, fast/slow), vocalizations (grunting, moans, yelling out, silence), mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion), eyes (wide open, narrow slits/shut, glazed, tearing, no focus), face (sad, crying, worried, scared, clenched teeth, grimacing, body tense, rigid (stiff), rocking, curled up, thrashing), report to the nurse any change in usual activity attendance pattern or refusal to attend activities related to signs and symptom or complaint of pain. Resident 55's pain care plan did not include an intervention to monitor for side effects of opioid medication. A review of Resident 55's Progress Notes for December 2022 indicated no documentation for monitoring for signs and symptoms of hypoglycemia or hyperglycemia. There was no documentation for monitoring for side effects for scheduled and as needed opioid medication. There was no documentation of pain level or effectiveness for the administered scheduled opioid medication. A review of Resident 55's Progress Notes for January 2023 indicated no documentation for monitoring for signs and symptoms of hypoglycemia or hyperglycemia. There was no documentation for monitoring for side effects for scheduled and as needed opioid medication. There was no documentation of pain level or effectiveness for the administered scheduled opioid medication. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated December 2022 indicated Resident 55 received Lispro Insulin on 12/1 at 11:30 AM & 4:30 PM, 12/3 at 4:30 PM & 8:00 PM, 12/4 at 11:30 AM & 4:30 PM, 12/5 at 4:30 PM & 8:00 PM, 12/6 at 7:30 AM, 12/7 at 11:30 AM, 4:30 PM, & 8:00 PM, 12/8 at 11:30 AM,12/9 at 11:30 AM & 4:30 PM, 12/10 at 7:30 AM, 11:30 AM, 4:30 PM, & 8:00 PM, 12/11 at 8PM, 12/12 at 11:30 AM & 8:00 PM, 12/13 at 7:30 AM, 11:30 AM, 4:30 PM, & 8:00PM, 12/14 at 4:30PM, 12/15 at 11:30AM & 8:00 PM, 12/16 at 4:30 PM, 12/17 at 7:30 AM & 11:30 AM, 12/18 at 7:30 AM & 4:30 PM, 12/19 at 11:30 AM, 4:30 PM, & 8:00 PM, 12/20 at 11:30 AM, 4:30 PM, & 8:00 PM, 12/21 at 4:30 PM, 12/22 at 11:30 AM & 4:30 PM, 12/23 at 8:00 PM, 12/24 at 11:30 AM & 4:30 PM, 12/25 at 8:00 PM, 12/26 at 8:00 PM, 12/27 at 11:30 AM, 12/28 at 4:30 PM, 12/29 at 11:30 AM & 4:30 PM, 12/30 at 8:00 PM, and 12/31 at 4:30 PM & 8:00 PM. The MAR and TAR dated January 2023 (1/1 through 1/6 11:30 AM) indicated Resident 55 received Lispro Insulin on 1/1 at 8:00 PM, 1/4 at 8 PM, and 1/5 at 11:30 AM & 8:00 PM. The MARs and TARs for December 2022 and January 2023 indicated no documentation for monitoring for signs and symptoms of hypoglycemia or hyperglycemia. The MAR and TAR dated December 2022 indicated Resident 55 received Hydromorphone HCl 4mg tablet every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM on 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/18, 12/19,12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, and 12/31. Resident 55 received Hydromorphone HCl 4mg tablet on 12/16 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, and 4:00 PM. A dose was not given at 8:00 PM. Resident 55 received Hydromorphone HCl 4mg tablet on 12/17 at 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 AM, A dose was not given at 12:00 AM. There was no documentation of pain level or effectiveness of the scheduled pain medication on the MAR and TAR. The MAR and TAR dated January 2023 (1/1 through 1/6 12:00 PM) indicated Resident 55 received Hydromorphone HCl 4mg tablet every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM on 1/1, 1/2, 1/3, 1/4, and 1/5. On 1/6, Resident 55 received doses at 12:00 AM, 4:00 AM, 8:00 AM, and 12:00 PM. There was a pain level 8 documented with the 12/6 12:00 PM dose, no other documentation of pain level or documentation of effectiveness for the scheduled pain medication was found on the MAR and TAR. The MAR and TAR dated December 2022 indicated Resident 55 received Hydromorphone HCl 4mg tablet every 4 hours as needed for pain/discomfort on 12/3 at 10:06 PM, 12/5 at 3:34 AM, 12/6 at 1:10 AM, 12/13 at 6:21 AM, and 12/29 at 1:39 AM. A pain level was documented with each administration, effectiveness was documented in the progress notes. The MAR and TAR dated January 2023 (1/1 through 1/6 12:00 PM) indicated Resident 55 received Hydromorphone HCl 4mg tablet every 4 hours as needed for pain/discomfort on 1/6 at 11:07 AM. A pain level was documented with the administration but no documentation for effectiveness was found. The MARs and TARs dated December 2022 and January 2023 indicated no documentation for monitoring for side effects of opioid medication. In an interview on 1/6/23 at 9:25 AM, RN2 indicated side effects were monitored for psychotropic medications, antibiotics, insulin, and pain medication. Documentation was done in the MAR, a general note or progress note every shift. If the resident did not have any side effects, a general note indicated the resident was okay. RN2 indicated a pain level was documented before administering an as needed pain medication, noted on the MAR or in a progress note. RN2 indicated pain levels were not documented for scheduled pain medication. The Assistant Director of Nursing (ADON) was present during the interview with RN2 and indicated pain levels were only documented when as needed pain medication was administered. In an interview on 1/6/23 at 9:50 AM, the Director of Nursing (DON) indicated side effects were to be monitored for anticoagulants, antipsychotics, antidepressants, antibiotics, and any medication that had been changed. Residents who received insulin were to be monitored for hypoglycemia. This monitoring was part of the MAR and documented there. The DON indicated they had not been monitoring for side effects of opioids. The DON indicated monitoring side effects of medication was documented on the MAR, or nurse's notes. Pain levels were documented when an as needed pain medication was given and reassessed after for effectiveness, documented on the MAR which carried over to a progress note. The DON indicated they did not monitor pain levels for routinely scheduled pain medication, but she was working on adding this because more residents were receiving scheduled pain medication. 44531 2. The record review began on 1/5/2023 at 10:07 AM. Diagnosis for Resident 12 included, chronic pain syndrome, rheumatoid arthritis, contracture of muscle (left hand), and abnormal posture. A quarterly MDS assessment was completed on 11/7/2022 for Resident 12, indicated a BIMS (Brief Interview for Mental Status) score was 10 of 15, which indicated the resident was mildly cognitively impaired. A physician order for the medication Norco tablet 5-325 mg (Hyrdocodone-Acetmaninophen). Give 1 tablet by moth at bedtime for pain with a start date 11/22/2022. There was not an order to assess for pain/side effects for this medication. A physician order for the medication Mobic tablet 15 mg (Meloxicam). Give 1 tablet by mouth one time a day for chronic pain with a start date of 11/8/2022. There was not an order to assess for pain/side effects for this medication. A review of a vitals summary of the pain level, indicated one pain level was assessed on 1/2/2023 of 0 out of 10 for Resident 12. There was no other pain level assessed after this date. A care plan indicated Resident 12 is at risk for pain due to, abnormal gait/mobility, muscle weakness, contracture of right and left hand. The interventions indicated, administered medication as ordered. Observe for side effects of pain medication-constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician. A MAR (medication administration record) dated December 2022, indicated the medication of Noro tablet 5-325 mg was given at 8:00 PM, for the following dates: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, ,23, 24, 25, 26, 27, 28, 29, 30, and 31. There are no indications the assessment/effectiveness of pain level was asked. There are no indications the side effects for this mediations were monitored. A MAR dated December 2022, indicated the medication of Mobic tablet 15 mg was given at 8:00 AM for the following dates. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, ,23, 24, 25, 26, 27, 28, 29, 30, and 31. There are no indications the assessment/effectiveness of pain level was asked. There are no indications the side effects for this mediations were monitored. A MAR dated January 2023, indicated the medication of Noro tablet 5-325 mg was given at 8:00 PM, for the following dates: 1, 2, 3, 4, and 5. There are no indications the assessment/effectiveness of pain level was asked. There are no indications the side effects for this mediations were monitored. A MAR dated January 2023, indicated the medication of Mobic tablet 15 mg was given at 8:00 AM, for the following dates: 1,2, 3, 4, and 5. There are no indications the assessment/effectiveness of pain level was asked. There are no indications the side effects for this mediations were monitored. A current facility policy, Pain Management, dated 1/2022, was provided by the Regional Clinical Consultant on 1/6/2022 at 11:22 AM. The policy indicated . Residents are assessed for pain upon admission, quarterly, as needed and during medication administration .Residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass .Additional information including, but not limited to reasons for administration, and effectiveness of pain medication will be documented in the electronic medical record A current facility policy, Hypoglycemia management, dated 2022, was provide by the Regional Clinical Consultant on 1/6/2022 at 11:22 AM. The policy indicated . The facility will identify residents that are at risk for hypoglycemia and observed them for signs and symptoms of low blood glucose .Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatments of hypoglycemia, unless otherwise by the practitioner 3.1-48(a)(1)-(6)

Base on interview and record review the facility failed to ensure a resident was free from abuse for 1 of 5 residents reviewed. (Resident B) Findings include: Resident B's record review began on 7/11/2022 at 11:30 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident B's Quarterly Minimal Data Set (MDS) Assessments, dated 6/21/2022, indicated he had a BIMS (Brief Interview for Mental Status) score of 06, which indicated severely impaired cognition. A review of Resident B's progress noted indicated the following: A Health Status Noted dated 6/25/2022 at 11:00 AM, written by RN (Registered Nurse) 1 indicated the resident became agitated and was going after CNA (Certified Nursing Assistant) 2. After the CNA left, the resident was calm with 1:1 (one to one) attention, a snack and the resident was assisted to bed. An Alert Note dated 6/26/2022 at 01:21 (1:20 AM) was entered by the DON (Director of Nursing). CNA 2 had called the DON and reported Resident B had been agitated and was attempting to go back to their prior room, where now a female resident was residing. CNA 2 indicated Resident B had made contact with her and she had pushed the resident back to prevent Resident B from making contact again. The DON asked CNA 2 to clock out of work and leave the facility due to pending investigation of the incident. An Alert Note dated 6/26/2022 at 14:39 (2:39 PM) entered by the DON, indicated a head to toe assessment was completed with no injuries noted at the time. A Health Status Note dated 6/27/2022 at 05:15 (5:15 AM), entered by RN 3, indicated Resident B had a quiet uneventful night with no problems or complaints. Resident B was up in wheelchair wheeling self up and down the hall quietly and watched TV in the lounge. A Social Service (SS) Note dated 6/7/2022 at 14:11 (2:11 PM), indicated the SS wrote a not to Resident B, because he could not read her lips, to asked how he was doing. Resident B was in a pleasant mood and was smiling. An IDT Note dated 6-27-2022 at 14:33 (2:33 PM), entered by the DON, indicated the team discussed the incident between Resident B and CNA 2. Resident B had shown no latent injuries, no hostility towards or fear of staff at the time. Resident B continued to self-propel around without difficulty. Resident B's Progress Notes indicated they were being seen by Psychiatric Services routinely. A note dated 6-28-2022 indicated severe impairment of cognition and judgement and a GDR (Gradual Dose Reduction) of medications would not be considered due to presense of mood and behavioral disturbances in the last 90 days, and a prior failed GDR. A Social Service Note dated 6-28-2022 at 14:32 (2:32 PM) indicated due to Resident B's increase in episodes of aggression, no GDR would be attempted at this time. An IDT Noted dated 6-28-2022 at 14:43 (2:43 PM), entered by the DON, indicated the team discussed the incident between Resident B and CNA 2. Resident B had shown no latent injuries form incident. The investigation continued into the incident and CNA 2 remained off of the work schedule. Resident B continued with daily routine without difficulty but had shown no latent injuries form incident. A review of the facility's investigations of reportable incidents of abuse which was provided by the Administrator on 7-11-2022 at 10:10 AM. Indicated an investigation was completed for the ind=cident between Resident B and CNA 2. The investigation included statement from witnesses, staff working a the time, the DON and CNA 2. The statements indicated the following: RN 3's written statement dated, Saturday, June 25 at 11:00 PM, indicated, Resident B had their wheelchair in front of their previous room and CNA 2 in a raised, angry tone pulled them away, saying, that is not your room anymore. Resident B persisted on going back to the door and CNA 2 became more agitated and angry and hollered, Get Away. RN 3 indicated she went down the hallway and observed the resident sitting on the floor. RN 3 indicated she instructed CNA 2 to leave the resident alone. RN 3 indicated a few minutes later CNA 2 was screaming for help. RN 3 went to find Resident B in their wheelchair with their arms flailing. CNA 2 was observed to punch Resident B at least 3 times with a closed fist to Resident B's head. CNA 2 was screaming foul language at RN 3, crying, then using more foul language toward RN 3. CNA 2 indicated she was Getting the f*** out of here RN 3 told CNA 2 to calm down, and CNA 2 told RN 3, No, I will Not!, You didn't help me! RN 3 further indicated CNA 2 didn't seem to understand Resident B was deaf, had a [CONDITION(S)] and could not comprehend her request. A statement from LPN 4, dated 6-26-2022, indicated she had heard yelling from the COVID Unit, then heard what sounded like a slap sound, then heard crying and a door close loudly. LPN 4 indicated she ran around the building to the COVID Unit to verify if everyone was OK. CNA 2 stated Resident B had slapped her when she had tried to separate Resident B from the female resident in Resident B's prior room. CNA 2 stated she was calling the DON and going home. A statement from the DON dated 6-25-2022, indicated she had received a phone call from CNA 2, stating Resident B came after her and she pushed them away from herself. The DON then received a phone call from RN 3 stating CNA 2 had hit the Resident. The DON indicated CNA 2 was sent home pending an investigation. A statement from CNA 2, was not dated The copy was not a complete copy as it had cut off words. The statement indicated on Saturday, June 25, 2022, she had come to work on 3rd shift in the facility's COVID Unit. At approximately 11:00 PM, a female resident pushed the call light. The CNA found Resident B in the room standing over the female resident. Resident B was asked to sit in the wheelchair, removed from the room and the door was closed. Resident B immediately began swinging at her, saying it was their room. CNA 2 indicated she had explained to Resident B, the room was switched due to the hall being turned into (COVID Unit, missing text). CNA 2 indicated a commotion ensued with Resident B pushing the mechanical lift and wheelchair away from the room. CNA 2 indicated her first thought was Resident B was going to kick her because they were mad. CNA 2 indicated she pulled Resident B's wheelchair backwards from behind to take them to their room. Resident B got up from the wheelchair and slammed the chair backwards into her. CNA 2 indicated she called for RN 3. CNA 2 indicated her glasses when flying and she has horrible eye sight but could see Resident B coming towardsher. She indicated she pushed Resident B back so she could find her glasses. She indicated at this point RN 3 was coming down the hallway and Resident B kept trying to come towards her swinging. CNA 2 indicated RN 3 did nothing. When Resident B noticed RN 3, they stepped back and quit trying to hit her. CNA 2 indicated she began yelling at RN 3 and asked why she would leave her alone when Resident B had already been aggressive with her. CNA 2 indicated she gathered her things, called the DON and left. A review of a copy of the facility's Indiana State Department of Health Survey Report System, provided by the Administrator on 7-12-2022 at 10:00 AM. indicated, an incident was reported by the DON. The incident date was 6/25/2022 and incident time was 11:43 PM. The incident involved Resident B and CNA 2. Description of the incident indicated the resident was agitated and trying to hit a staff member. The staff member was trying to remove themselves and pushed the resident away. The staff member was sent home pending the investigation. The follow up to the investigation was added to the report on 6/29/2022 and indicated the investigation of the incident determined the aide, CNA 2, did make contact with Resident B. The statements were conflicting as the nurse stated there was a punch and the aide stated there was a push away in defense. There were no other witnesses to the event. The resident was unable to state in what form the aide made contact with them. In an Interview on 7-11-2022 at 11:20 AM, the DON indicated staff working during the incident were from Agency and Staff Pool. She indicated CNA 2 worked through the Corporate Staffing Pool. She indicated CNA 2's statement was a photograph taken of the statement written by the CNA, then texted from CNA 2's phone to the DON. The DON then sent the text to be copied and included in the investigation of the incident. In an interview on 7/11/2022 at 12:45 PM, PCA (Patient Care Assistant) 5 indicated she had only worked at the facility for a couple of months, and indicated she was educated on abuse, dementia and resident rights during orientation. She indicated she had never seen a staff abuse a resident, but would stop them, calm them and get them apart and report to the DON or Administrator right away. In an interview on 7/12/2022 at 2:00 PM, the DON indicated the staff were in-serviced after the 6-25-22 incident on abuse and reporting during Huddle Meetings at shift change, She indicated she used the facility's Abuse Policy and questions and answers. A review of CNA 2's employee file, provided by the Administrator on 7/12/2022 at 2:15 PM, indicated CNA 2 had a current CNA license, the orientation form indicated she was educated and received the policy and procedures for Resident Abuse / Elder Justice Act, Resident Rights and Dementia Training. The traning was signed by CNA 2. The Care Team Member Acknowledgement was initialed by CNA 2 and indicated, I understand [NAME] Care's no tolerance policy surrounding abuse, neglect and misappropriation of property was signed by CNA 2. In an interview on 7-12-2022 at 2:15 PM, the Administrator, indicated it could not be determined if CNA 2 hit or pushed Resident B. He indicated he had talked with Resident B on 3 different days and he could not say if he had been hit or pushed. A review of the current facility policy, non-dated, was provided by the Administrator on 7/11/2022, titled, Abuse Prevention Program, indicated, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers and staff from other agencies providing services to our residents, family members, resident representative, legal guardians, surrogates, sponsors, friends, visitors, or any other individual This Federal tag relates to complaint IN 913. 3.1-27(a)(b)

Based on observation and interview, the facility failed to ensure and maintain a clean and functional environment for 13 shared bathrooms affecting 44 residents residing in the facility. Findings include: On 4/19/22 at 10:45 A.M., an environmental tour was completed with the Environmental Services Managers (EVS). The following shared bathrooms were observed: A bathroom shared between 4 residents and located between rooms 101-102, was observed with brown black debris on the floor around the stool and the stool caulking was rust colored. There were torn non-skid strips on 3 sides of the stool. The walls had dried brown debris and the corners of the bathroom had dried black debris in them. The toilet seat had dried brown debris and there was BM (bowel movement) in the toilet bowl. A bathroom shared between 3 residents and located between rooms 103-104 had brown debris on the walls and black debris in all corners of the bathroom. A bathroom shared between 4 residents and located between rooms 105-106 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. A bathroom shared between 4 residents and located between rooms 107-108 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. A bathroom shared between 4 residents and located between rooms 110-111 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. A resident in room 111 indicated the bathroom never got cleaned and was unsanitary. A bathroom shared between 4 residents and located between rooms 112-113 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. A dirty adult brief laid on the floor next to the bed of a resident in room 113. Another resident in room 113 indicated the bathroom never got cleaned and believed the facility should be using Lysol to clean the germs. A bathroom shared between 4 residents and located between rooms 114-115 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. A bathroom shared between 2 residents and located between rooms 116-117 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored and the toilet bowl had black stains. A bathroom shared between 2 residents and located between rooms 124-125 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored and the toilet bowl had black stains. A bathroom shared between 2 residents and located between rooms 126-127 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. There was yellow amonia smelling liquid on the vanity near the sink. A bathroom shared between 4 residents and located between rooms 129-130 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. A bathroom shared between 4 residents and located between rooms 137-138 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. The toilet bowl was black and contained BM. The toilet seat had dried brown streaks. A bathroom shared between 3 residents and located between room 139-140 had brown dried streaks on the walls and black debris in all 4 corners of the bathroom. Caulking around the toilet stool was rust to black colored. The toilet bowl was black and contained BM. A commode seat sat over the toilet bowl and had brown streaked debris on it . On 4/19/22 at 11:35 A.M., in an interview, the EVS Manager indicated he currently had 1 other employee beside himself in the department. The facility normally staffed 3-4 housekeepers but he was having difficulty recruiting staff despite numerous attempts. The facility was replacing the flooring in all the bathrooms but would take time to complete. This Federal tag relates to Complaints IN 670 and IN 095. 3.1-19(e)

Based on interview and record review, the facility failed to initiate and revise care plans to prevent behaviors for 2 of 4 residents reviewed with behavioral health services (Resident P and Resident S) Findings include: 1. On 4/19/22 at 12:04 P.M., Resident P's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated 3/17/22, indicated a BIMS (Brief Interval Mental Status) score of 5. This indicated the resident had severely impaired cognition. He'd had physical behaviors towards others and behavior symptoms not directed at others 1-3 days of the assessment. He was non-ambulatory and required supervision for locomotion on/off the unit while propelling his wheelchair. A progress note, dated 3/10/22 at 3:32 p.m., indicated when the resident arrived to the facility and was taken to his room, he became upset and wanted to leave. He headed to the front entry way where he started kicking the front door glass windows. He eventually calmed down and went to his room. He shared his room with a roommate. An Indiana incident report, dated 3/15/22 at 3:31 p.m., indicated there was an altercation between Resident P and his roommate. Both had been watching their own TV's and became upset with each others volume. The roommate grabbed the TV remote from the resident who became upset and grabbed the roommate who in turn, hit Resident P. The residents were separated and attended to and Resident P agreed to a room move with a resident that didn't use a TV. A care plan, dated 3/16/22, indicated the resident had behaviors of being aggressive towards others who may ask him to turn down the volume of his TV. The resident had a [CONDITION(S)] and had indicated when he feels threatened, he may lash out. The goal was for the resident to demonstrate the ability to seek out staff support when feeling frustrated or provoked. Interventions included, but were not limited to, identify his triggers and reduce exposure to and document behaviors per behavior management program. An Indiana incident report, dated 3/28/22 at 4:01 a.m., indicated Resident P's new roommate indicated he had been hit. The roommate was found to have an abrasion to his nose and right eye. It was unclear to staff whether Resident P had caused the injury to his roommate. The roommate was removed and placed into another room for the rest of the night. Neither resident was able to state what had happened and the roommate indicated he wanted to go back into his room with Resident P. A care plan, dated 3/29/22, indicated the resident was at risk for negative interactions with his peers due to being territorial over his room. The goal was for the resident to have no indications of psychosocial well being problems. Interventions were: allow resident to make independent decisions when appropriate, allow resident time to answer questions and verbalize his feelings and fears, encourage resident and family involvement in care planning, increase social relationships, and when conflict arises, remove residents to a calm/safe environment and allow to vent feelings. A nurse progress note, dated 3/31/22 at 2:12 a.m., indicated Resident P approached the nurse station and told staff to call 911 because he was being held in the facility. He could not be re-directed and headed to the front door where he slammed a table against the glass on the door. He was combative with staff, threw a tissue box at a CNA (Certified Nurse Assistant), ripped the mouse out from a computer, tore the wire out of it, and threw linen off the linen cart onto the floor. He eventually calmed down, returned to his room and went to sleep in his bed. An IDT (Interdisciplinary Team) behavioral note, dated 3/31/22 at 4:25 p.m., indicated the IDT had met to review the resident behaviors from during the night. The resident hadn't remembered the incident. He indicated he was being held at the facility and wanted to leave to be closer to his son. He was pleasant and friendly during the afternoon but did demand that he be given a private room. He was to be seen by the psychiatric NP on the next routine visit and staff would continue to observe his behaviors. There were no revisions made to the care plan for how to manage the residents territorial behaviors while having a roommate and not being in a private room. An Indiana incident report, dated 4/4/22 at 12:30 a.m., indicated Resident P's roommate was in bed and heard yelling out. Staff entered the room and found Resident P sitting in his wheelchair on his roommates side of the room. He was agitated because he couldn't find his glasses. The roommate had scratches to his face. Resident P was directed out to the nurses station for direct supervision. Focused charting for physical aggression was initiated on 4/4/22 at 6:15 a.m. and indicated the resident had caused scratches to his roommate's face. He had been agitated because niether he nor staff were able to find his glasses. He was brought out to the nurses station in his wheelchair where he attempted to throw his chair over the nurses station desk and tried to grab a computer monitor screen. The resident was monitored and kept away from other residents. A care plan, dated 4/4/22, indicated the resident exhibited behaviors of cursing at staff when he didn't get his perceived needs met immediately. His behaviors could escalate from verbal to physical. The goal was for the resident to demonstrate the ability to seek out staff support when feeling frustrated or provoked. Interventions included provide positive feedback for good behavior, provide personal space, and remove resident from the situation. A nurse progress note, dated 4/4/22 at 12:05 p.m., indicated the resident had moved rooms. He was moved to a room with a different roommate. A care plan, dated 4/5/22, indicated the resident exhibited behaviors of getting upset when he had a roommate or saw peers in his room. Due to his short term memory, he still believed his room was his apartment. The goal was for the resident to demonstrate the ability to seek out staff support when feeling frustrated or provoked. Interventions included, but were not limited to, place a name identifier on his closet space. The care plan did not indicate how staff were to keep the resident's new roommate safe from physical altercations as he was placed in a room with another resident. 2. On 4/19/22 at 10:09 A.M., Resident S's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident admitted to the facility following a psychiatric hospital stay. A hospital history and physical indicated the resident had been living at a long term care facility where he had begun to display physical aggression towards staff and residents, intrusive and impulsive behaviors, had slapped a female nurse and ran over her foot with his wheelchair. The resident had intimidated nursing staff with verbal aggression and used racial slurs. He had gone into female resident rooms at night and sat on their beds watching them sleep. While hospitalized , the resident had been found nude in bed with a female resident and had been started on medication. An admission MDS assessment, dated 2/8/22, indicated a BIMS score of 8-moderately impaired cognition. The resident had no behaviors, was ambulatory with a walker, and required supervision when up in his room and in the hallways. A care plan, dated 3/21 and revised 4/12/22, indicated the resident exhibited behaviors of yelling and screaming. He would get louder and his words more garbled as he got upset if staff were unable to understand him. He could exhibit abusive language, cursing, and threatening behaviors. The goal was for the resident to demonstrate the ability to seek out staff support when feeling frustrated or provoked. Interventions included, but were not limited to, provide resident with personal space, remove him from a situation, listen to the resident needs, and approach him in a calm and friendly manner. An Indiana incident report, dated 4/4/22 at 6:01 p.m., indicated Resident S was alleged to have inappropriately touched a female peer on the thigh. The investigation indicated the resident had touched the female peer on the thigh but not on her private parts. There was no behavioral care plan initiated prior to the incident occurring nor was one initiated following the incident to prevent further occurrences with other female peers. On 4/19/22 at 11:27 A.M., the Social Services Director (SSD) was interviewed. She indicated behavioral care plans should indicate behaviors that affect the resident and others to prevent negative interactions and catastrophic reactions from occurring. When new behaviors were identified, a behavioral care plan should be put in place and the behavior monitored and care plan revised as indicated. A current facility policy, titled Mood and Behavior Management, was provided by the Administrator on 4/19/22 at 1:00 p.m. The policy stated the following: It is the policy of [facility] to provide interventions for all residents with behavioral and/or mood indicators that may be problematic or distressing. Residents are provided a supportive environment that is aimed at prevention, relief and/or accommodation of their behavior and/or mood in addition to interventions that are specific to the resident's individualized needs. Procedure: A care plan should be initiated for any behavioral symptom that affects, or has the potential to affect the resident or others This Federal tag relates to Complaint IN 096. 3.1-43(a)(1)

Based on interview and record review, the facility failed to prevent agency staff from yelling at 1 of 3 residents reviewed. (Resident E) Findings include: In an interview on 12-9-21 at 8:45 A.M. LPN 1 indicated she heard yelling coming from the West hall. She indicated she went down the hall with CNA 2 and CNA 3. When they arrived, Resident E was yelling at about an undisclosed resident having taken his hat. As his gesturing and yelling began to escaalte, CNA 2 began to yell back at Resident E using profanity. Staff attempted to intervene with CNA 2, CNA 3 even stepped between them, but interventions were unsuccessful. CNA 2 began to threaten Resident E. Resident E was finally redirected into his room. CNA 2 was sent home. In an interview on 12-9-2021 at 9:32 A.M., the DON (Director if Nursing indicated CNA 2 was an agencty CNA. She indicated the CNA would no longer be on the facility's roster of acceptable people to be working in the facility. She indicated the agency keeps a record of abuse training or each staff person, but she had no access to the training. A review of progress notes indicated there was no note to review regarding the yelling occurrance. A review of pscy notes indicated Resident E continued to be seen by the psyc provider without residual effects from the occurrance. 3.1-27(a)(b)

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free from pests 58 of 58 residents residing in the facility ate their meals from the kitchen. Findings include: During an observation of the kitchen on 11-7-2021 at 11:35 a.m., food was observed on the floor in the area to the left of the stove between the stove and the steamer. Ants were observed on the food on the floor and were observed crawling back to the wall behind the steamer. The kitchen manager indicated they were sprayed for ants recently and she did not know the ants were in the kitchen. An interview with the Kitchen Manager on 11-10-2021 at 11:28 a.m., indicated all 58 residents eat from the facility kitchen. An interview with the Maintenance Supervisor on 11-10-2021 at 12:29 p.m., indicated he was asked about the pest control documentation for the treatment of pests in the kitchen. He indicated he would have to get the invoices. On 11-10-2021 at 2:01 p.m., the Maintenance Supervisor provided an invoice from a named pest control company for the general pest control program for October 2021. A note on the invoice indicated the pest control service came back to the facility on [DATE], but there was not an invoice available. The invoice did not describe what type of treatments were done in the kitchen for ants. A current policy, Pest Control dated October 2019, was provided by the Kitchen Manager on 11-12-2021 at 10:53 a.m. The policy indicated, .It is the center policy that there is a program established for the control of insects and rodents for the Dining Services Department .The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis or as needed .All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin 3.1-19(f)(4)

During the initial tour of the facility on 11-7-21 at 11:34 a.m., a random resident indicated the shower had black mold in it. The resident then pointed to the shower room door, and said the mold was in there. The central bathing room was located on the west hall. A Certified Nursing Assistant 13 (CNA) was walking into the central bathing room. The CNA 13 explained she had to help another resident out and she would be leaving the room. During the observation, on 11-7-21 at 11:35 a.m. on the inside of the shower, in the left and right corners and along the back close to the ground there appeared to visible a black substance. More observation of the black substance was visible on the left side of the shower along and in between the tile. On the same side on the tile was a orange discoloration. Further observation of the shower room, past the shower down on the right side, there was a toilet located. Behind the toilet on the floor was black flecks and an orange discoloration. During an observation on 11-7-21 at 2:00 p.m., with the Director of Nursing (DON), in the west side central shower room, black substance all inside of the shower, the trash visible on the floor, the black flecks on the floor on the back side of the toilet, and the inside of the toilet that had yellow coloration inside were noted. During an observation on 11-7-21 at 2:03 p.m., with the DON, in the South Central Bathing room, inside of the room there was a clean linen cart with used towels on top of cart next to the shower. Inside of the shower on the edges there was a black substance along the side of the wall. The shower head had an orange discoloration that came down the wall to the shower handle. By the sink there was a small trash can observed, the small trash can was over filled with brown paper napkins and used briefs. The DON indicated, the staff knew better than this. During an observation 11-7-21 at 2:06 p.m., with the DON in the east side central bathing room, inside the shower, the drain had some plastic inside of the it. The DON indicated the shower rooms were used by all residents in the facility and then removed the plastic trash with bare hand from the drain. Near the toilet there was a wheelchair, and shower chair pushed against the toilet. The toilet was missing the toilet seat. During an interview on 11-7-21 at 2:00 p.m., the DON indicated they have contract housekeeping. They do not have housekeeping on the weekends. During an interview on 11-9-21 at 1:34 p.m. on 11-9-21 the EVS manager, indicated they do work on the weekends but they spilt the staff to do housekeeping and laundry. The nursing and EVS are the ones that will clean the shower rooms. Nursing is to clean after every use, EVS will leave the chemicals for them and they are to spray the shower after every use. During an interview on 11-10-21 at 4:34 p.m., the DON, indicated they do not have a policy/procedure for cleaning the shower rooms. 3.1-19(f) Based on observation, interview and record review, the facility failed to ensure a clean and sanitary environment the 58 residents who resided in the facility. Findings include: During an observation of the facility on 11-7-2021 at 11:00 a.m., there were splatters on the wall to the left of the electronic screening device at the receptionist area of the facility. The electronic screening device had crumbs and debris on the screen. The floors leading to the nurse station had dried and wet reddish and brownish spills observed. In the West hall, dried brownish spills were observed on the floor. A yellow mop bucket with a mop and dirty water was observed across from room 108. South hall was observed with dried brownish splatters and a spot of liquid on the floor outside the ice machine room. During an observation of the East hall sitting area on 11-8-2021 at 8:53 a.m., the sliding glass door in the sitting room had a white film which prevented anyone from being able to see outside. The floor was sticky, crumbs were on the floor and brown debris was throuhgout the floor. On 11-8-2021 at 9:01 a.m., the West hall lounge floor was observed to have food crumbs, dried spills and a cigarette butt on the floor. The door which was labeled, not an exit, was glass and padlocked. The glass was covered with a white film which could be wiped off. the film prevented anyone from seeing through the glass door. The bottom ledge of the door had brown debris on it and the corners of the entrance were dirty with brown debris in them. On 11-10-2021 at 8:39 a.m., the COVID-19 screening device was observed to have dried splatters on the screen. An interview with the Director of Environmental Services on 11-10-2021 at 12:09 p.m., indicated he did not have documentation for the specific rooms/lounges/showers/hallways which were cleaned in October or November. He indicated they just started documentation yesterday of the rooms/lounges/showers/hallways which were cleaned. He indicated we were just trying to get done what we could get done. He indicated for spills on the floor, if it was body fluids, the CNA (Certified Nurse Aide) would clean the spill and housekeeping would sanitize the area. For regular spills, he indicated it would be whomever got to the spill first would clean it.

Based on observation, interview, and record, the facility failed to ensure the kitchen equipment was in working order. 58 of 58 residents residing in the facility ate their meals from the kitchen. Findings include: The kitchen was observed on 11-7-2021 at 11:37 a.m. The Kitchen Manager, a cook and a dietary aid were observed to be preparing the noon meal trays. The Kitchen Manager indicated the oven was not working as the temperature of the oven could not be controlled and was overcooking the food. She indicated the temperature of the oven would be set at 350 degrees Fahrenheit and then while baking, the temperature would fluctuate up to 500 degrees Fahrenheit. She indicated there were baffles for the oven on order and were to be delivered by 11-10-2021. The Kitchen Manager indicated the steam table only had 3 of 5 wells working and a new steam table was to be delivered on 11-8-2021. The kitchen Manager indicated the corporation removed the prep sink which was on the same wall as the stove because it kept backing up. An interview with the Kitchen Manager on 11-9-2021 at 9:10 a.m., indicated the new steam table came on 11-8-2021, but needed to have a drain installed. The Kitchen Manager indicated the Maintenance Supervisor had to get the parts and was to install the drain. The Kitchen Manager indicated now the steamer was not working correctly to get the food up to temperature and they were still waiting on the oven parts. The Kitchen Manager indicated she was waiting on instructions on what they were going to do for lunch since all she had was a working stove. The cook indicated since the prep sink was removed, she did not have a place to rinse meat, drain pasta or clean the potatoes. An interview with the Kitchen Manager on 11-9-2021 at 1:30 p.m., she indicated for lunch, they served cold meat sandwiches. An interview with the Kitchen Manager on 11-10-2021 at 9:50 a.m., indicated the steam table was in use and working. She indicated the steamer was worked on yesterday and was still not heating the way it should. She indicated she called for the company to come out again to fix the steamer. The oven was not working as they were waiting on parts. On 11-10-2021 at 11:29 a.m., the Kitchen Manager was observed to begin to plate the food for lunch. The Kitchen Manager was observed to pick up a plate from the plate warmer. An observation of the plate warmer indicated the red light was not on. The Kitchen Manager indicated the stackable plate warmer did not work. An interview with the Maintenance Supervisor on 11-10-2021 at 12:29 p.m., indicated he had placed phone calls to a named repair company about the steamer and the oven. He indicated he did not have any paperwork on repairs. He indicated he was not aware the plate warmer was not working. He indicated he would see if he could get documentation on the repairs for the steamer and oven. Two invoices were provided by the Maintenance Supervisor for the oven on 11-10-2021 at 2:01 p.m. One invoice dated 6-3-2019 indicated the oven was not cooking evenly and the thermostats for the ovens needed to be replaced. The second invoice dated 7-11-2019 indicated the oven was not at temperature. The oven knobs were calibrated. The notes indicated the ovens should run a higher temperature now at the same settings. A current estimate dated 10-12-2021 was provided for the ovens. The estimate included 2 new thermostats and a burner baffle. A current policy, Equipment, dated October 2019, was provided by the Kitchen Manager on 11-12-2021 at 10:55 a.m. The policy indicated, .It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order .The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed .The Dining Services Director will notify the Administrator when repairs are complete .Copies of service repairs and preventative maintenance reports will be submitted monthly 3.1-19(bb)

Based on observation, interview and record review the facility failed to ensure the kitchen was maintained clean and sanitary. This affected 58 of 58 residents who ate their meals from the kitchen. Findings include: 1. During an observation in the dining room on 11-7-2021 at 11:35 a.m., several residents were seated in the dining room. The tables had been cleaned, but there was food (yellow scrambled eggs) on the floor in several areas. The residents indicated lunch had not been served. An observation on 11-10-2021 at 11:39 a.m., indicated there were scrambled eggs and pieces of cereal on the dining room floor from breakfast, which had not been cleaned. 2. During an observation of the kitchen on 11-7-2021 at 11:37 a.m., the dietary staff were plating the noon meal. There were ants observed on the floor to the left of the stove between the stove and the steamer. Food was observed on the floor (yellow scrambled eggs) There were ants on the food and crawling back to the wall behind the steamer. The Kitchen Manager indicated the kitchen was treated for ants recently, but she did not know the ants were currently in the kitchen. The wall behind the steamer was splattered with brown splatters. The area to the right of the stove on the wall was splattered with brown spatters and the side of the stove had whitish splashes. The light switch to the right of the stove had smears and brown splatters on it. The microwave was not clean on the inside and had yellow splatters on the inside walls and dried food debris on the glass tray. Continued observation in the kitchen of the walk in refrigerator indicated the floor had dark brown areas on it and the inside covering of the door had yellowish splatters on it. There were 2 gallon size bags of cooked sausage patties without a label on them. The Kitchen Manager indicated they were from this morning and should have been labeled. The vent in the dishwasher room on the wall was observed with brownish debris on the vent slats. During an observation of the kitchen on 11-10-2021 at 9:35 a.m., the walk in refrigerator floor was not clean and had brownish areas on the floor. The interior door was observed to have a large circular yellow splatter on the lower part of the door. The oven and stove area was observed and the wall behind and to the left and right of the oven had dried brown splatters on it. The floor along the baseboard behind the stove/oven had food debris, and trash. The light switch to the right of the oven was observed to have brownish smears on it. The screen to the window behind where the microwave and cooking pots were stored, was not secured in the frame. There was a feathery whitish web type material at the bottom between the screen and window. There was debris and small dead insects observed on the window sill. The cooking pots were observed to be stored right below this area. There were 2 circular vents on the ceiling in the main kitchen, one on each end and one above the steam table. There was a brownish color debris on the circular vent slats of each of the two vents and there was a brownish feathery type debris observed on the ceiling outside of these 2 circular vents. The floor area in the dish washing room between the 3 compartment sink and the end of the dishwasher counter had an approximate 8 x 12 inch metal cover with grooves around it with blackish debris, crumbs and dirt. The top of the metal piece had grooves in it which had brownish debris, crumbs and dirt. The 3 compartment sink had a named lab dispensers for the soap and the sanitizer. There were brownish gold areas on the sink and some darker rust color material on the sinks. Inside the sanitizer sink was a pink film covering the surface of the sink. An interview with the Kitchen Manager on 11-10-2021 at 9:45 a.m., indicated when she came to the facility, there was not any cleaning/scrubbing devices to clean the kitchen. She indicated she had tried to get the items she needed to clean the kitchen. She indicated she had scrubbed the 3 compartment sink, but had not been able to remove any of the stains and the pink film just smeared on the surface of the sink. The Kitchen Manager was interviewed about the ceilings and the cleaning schedule for the ceiling. She indicated the kitchen staff did not clean the ceiling and they only did the walls and the floors. On 11-10-2021 at 10:16 a.m., the Kitchen Manager provided the cleaning schedule for October 2021. She indicated it was one used at another facility and she was trying to incorporate it at this facility. She indicated she was cooking most of the time and a lot of the tasks were not completed. The Cleaning Schedule for October 2021 had the following areas designated to be cleaned and none of the days of October had any of the cleaning checked off to indicate the task had been completed. The task areas included but were not limited to: Three compartment sink Steam table Microwave interior and exterior Deep clean refrigerators inside and outside Sweep and mop serving line area Deep clean interior and exterior of plate warmer Wall and baseboard behind cooking equipment Sweep and Mop Dish room area Wall and baseboard behind 3-compartment sink Sweep and mop dry storage room Soiled dish table including legs and garbage disposal Interior and exterior of oven Wall behind oven Clean Hand washing sink, soap and paper towel dispenser in prep area Deep Clean all freezers inside and outside Sweep and mop cooking and in prep area Deep Clean Pot and Pan storage rack under table Clean the Diet Kitchen Refrigerator and Freezer Clean 3 tier cart 100 hall Clean 3 tier cart 200 hall Clean 3 tier cart 300 hall Monthly task--clean all light covers All ceiling vents Walk-in cooler fans Walk-in freezer fans Power scrub kitchen floor Instructions on the task sheet were to make sure to initial each task upon completion. None of these tasks were initialed on the October 2021 cleaning task form. On 11-10-2021 10:21 a.m., the Kitchen Manager provided a blank undated weekly sanitation audit she was going to use for cleaning tasks. The Kitchen Manager was interviewed about the November cleaning schedule and the cleaning schedules prior to October. She indicated she had not started the November cleaning schedule and there were no cleaning schedules prior to October. 3. During an observation of the facility pantry on 11-10-2021 at 1:55 p.m., the floor was sticky and there was a reddish color substance on the floor. The walls were splattered with brown debris. There was a blue sticky substance on the bottom of the freezer unit. An uncovered, unlabeled cup was observed 1/3 full with a frozen brown substance inside the freezer. A sealed plastic bag with 3 round brown items inside was labeled with a name and no date. There was an opened 128 ounce container (about 3/4 full) of fruit of the earth aloe vera wild berry juice, which did not have a label with a name or date on the container. There was an opened 128 ounce container of diet half and half ice tea/lemonade which was not labeled with a name/opened date. An opened 16 ounce container of coffee creamer was not labeled with an opened date. To the right of the refrigerator was a cabinet with a whole loaf of butter topped wheat bread with a best by date of 11-5-2021. There were 3 to 4 slices which was observed with a greenish feathery substance on it. An opened loaf of butter topped wheat bread with 7 slices left was observed with a white color feathery substance on the side of the bread and on the crust of several pieces of the bread. A staff member then was observed to have brought in an opened container of liquid Lemon Flavored thickener and placed it into the refrigerator. She indicated she had just gotten from the kitchen and it was not labeled. An interview with the Kitchen Manager on 11-10-2021 at 2:05 p.m., indicated they had just checked and cleaned the pantry refrigerator yesterday. She indicated the blue liquid in the freezer was not there and she did not know where the cup with the brown frozen liquid came from. The Kitchen Manager was interviewed about the lemon thickener not having an opened date on it and she indicated it was not opened. The Kitchen Manager was informed the staff had given some of the lemon thickener to a resident. The cap to the lemon thickener was opened and the seal had been punctured. An observation on the top of the container indicated a use by date of 7-21-2021. The Kitchen Manager was made aware of the 2 loaves of bread. She indicated she was unaware of the use by dates and the growth of the greenish and white feathery substances on the bread. She was observed to remove the bread from the pantry. The Kitchen Manager indicated housekeeping was supposed to keep the floor clean and she indicated it was still sticky. An interview with the Director of Environmental Services on 11-10-2021 at 12:09 p.m., indicated the dining room floor was to be cleaned by housekeeping two times a day, after breakfast and after lunch. He indicated he only had enough staff to clean the dining room floor twice a day. The Director of Environmental Services indicated he only had 1 laundry staff in the building this past Saturday and Sunday and the laundry person would have been responsible for housekeeping and laundry duties on Saturday and Sunday. He indicated they just started documentation on 11-9-2021 of the areas which were cleaned. An interview with Housekeeping/Laundry 1 on 11-11-2021 at 10:31 a.m., indicated if she was assigned to laundry on the weekend, it was impossible to clean the facility including the dining room and do the laundry tasks during her shift. A copy of the housekeeping cleaning check off list was provided by the Director of Environmental Services on 11-10-2021 at 12:30 p.m. The nourishment room was not on the check off list as an area to be cleaned. A current policy, Equipment dated October 2019, was provided by the Kitchen Manager on 11-12-2021 at 10:55 a.m. The policy indicated .the Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials .ensures all staff members are properly trained in the cleaning and maintenance of all equipment .ensures all food contact equipment is cleaned and sanitized after every use .ensures that all non-food contact equipment is clean 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure medications were labeled, stored per pharmacy guidelines and secured for 2 of 2 medications carts and 1 of 1 treatment carts observed. This affected 17 of 58 residents residing in the facility. (Resident 34, Resident 15, Resident 22, Resident 19, Resident 24, Resident 26, Resident 18, Resident 45, Resident 55, Resident 48, Resident 47, Resident 44, Resident 14, Resident 8, Resident 43, Resident 30 and Resident 57) Findings include: 1. An observation of a treatment cart outside the nurse station on [DATE] at 11:10 a.m., indicated the treatment cart was unlocked. The treatment cart drawers were able to be opened and treatments were observed. At least 8 residents who were mobile, were observed near or walked by the unlocked treatment cart. Staff were observed in the area, but were far enough away and did not observe the treatment cart drawers being opened. An observation of a treatment cart on [DATE] at 3:25 p.m., indicated it was outside the nurse station and was unlocked. There were several independently, mobile residents observed in the vicinity of the treatment cart. An observation of a treatment cart on [DATE] at 9:19 a.m., indicated the treatment cart was unlocked, outside of the nurse station, and near the medication storage room. Staff were observed sitting in the nurse's station with their backs to the treatment cart. At least 3 residents were observed in the area, two were independently walking and one resident was self-propelling their wheel chair. An observation of the East hall medication cart on [DATE] at 1:10 p.m., indicated the medication cart was unlocked and unattended. There were 2 staff observed at the nurse station who were unable to see the side of the medication cart with the drawers. Continued observation of the East hall medication cart on [DATE] at 1:20 p.m. indicated the medication cart was unlocked and unattended. Two staff remained seated at the nurse station, unable to see the front of the medication cart. Another staff member was observed down the hall with the Administrator. Three residents, independently mobile, were observed seated near the unlocked medication cart. On [DATE] at 12:19 p.m., Social Services provided a list of 44 confused and independently mobile residents who resided in the facility. She indicated medication and treatment carets are to be locked when unattended. 2. Observation of the East Hall medication cart with QMA 6 on [DATE] from 11:06 a.m. to 11:40 a.m., found the top drawer contained multi-dose medications, insulin, inhalers and eye medications. The following multi-dose medications were lacking open dates written on the label: A vial of [MEDICATION(S)] insulin (Insulin lsipro) for Resident 34 was opened but the Prescription (Rx) label was lacking an open date. The Rx label for the [MEDICATION(S)] Insulin was dated [DATE]. Resident 34's [MEDICATION(S)] insulin would expire 28 days after being opened per facility policy. A record review for Resident 34 began on [DATE] at 10:40 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 34's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 34's MAR (Medication Administration Record) for [DATE], [DATE] and [DATE], [MEDICATION(S)] insulin was not administered. 3. A vial of [MEDICATION(S)] insulin for Resident 15 was opened but the Rx label was lacking an open date. The Rx date for the [MEDICATION(S)] insulin was [DATE], and read to inject 20 units (a dose measurement for insulin) 3 times a day. A vial of [MEDICATION(S)] ,d+[DATE] insulin for Resident 15 was opened but the Rx label was lacking an open date. The Rx date for the [MEDICATION(S)] ,d+[DATE] insulin was [DATE], and read to inject 85 units SQ (subcutaneous) 2 times a day. The [MEDICATION(S)] and [MEDICATION(S)] ,d+[DATE] insulin were not expired. An inhaler of [MEDICATION(S)] Diskus ,d+[DATE] (dose per puff) was removed from foil pouch and was lacking an open date on the Rx label. The dose counter on the inhaler read 28. The [MEDICATION(S)] Diskus contains 60 doses. The Rx date for the [MEDICATION(S)] Diskus was [DATE]. The [MEDICATION(S)] Diskus would expire 28 days after being opened per facility policy. Interview with QMA 6 on [DATE] at 11:10 a.m., indicated Resident 15 had just returned from the hospital last night. Resident 15 was hospitalized from [DATE] to [DATE]. Review of Resident 15's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ,d+[DATE] Insulin, inject 50 units SQ 2 times a day before breakfast and dinner. [MEDICATION(S)] Diskus was not listed on current orders. Review of Resident 15's MAR for [DATE] indicated Wixeia Inhub Aerosol Powder (same as [MEDICATION(S)] Diskus) with a start date of [DATE] and discontinued on [DATE]. The Wixeia Inhub was administered 2 times a day from [DATE] to [DATE] for 34 doses after earliest expired date. Review of Resident 15's MAR for [DATE] indicated the Wixeia Inhub was administered 2 times a day from [DATE] to [DATE] for 10 doses after earliest expiration date. 4. Observation of Soothe Night Ointment tube for Resident 22 was opened but was not labeled with an open date. The Rx date was [DATE] and the Rx instructed to instill 0.25 inch at bedtime. The multi-dose tube was not labeled with an opened date. 5. Observation of an [MEDICATION(S)] Diskus AER ,d+[DATE] Inhaler for Resident 19 indicated the medication was opened and removed from foil package. The inhaler and Rx label were lacking an open date The Rx date was [DATE] and the Rx instructed 1 puff 2 times a day. The [MEDICATION(S)] Diskus would expire 28 days after being opened per facility policy. A record review for Resident 19 began on [DATE] at 10:50 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 19's current physician orders, printed on [DATE] at 10:26 a.m., listed Wixeia Inhub Aerosol Powder ,d+[DATE] 1 puff inhale orally 2 times a day related to [CONDITION(S)] with a start date of [DATE]. Review of Resident 19's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 19's MAR for [DATE] was administered 17 doses. 6. Observation of a Flutic/Salme ([MEDICATION(S)] Diskus-[MEDICATION(S)]/Salmeterol) for Resident 24 was opened and removed from foil package was lacking an open date on the Rx label. The Rx date was [DATE] and Rx instructed to inhale 1 puff 2 times a day. The dose counter was 57. The [MEDICATION(S)] Diskus would expire 28 days after being opened per facility policy. A record review for Resident 24 began on [DATE] at 10:55 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 24's current physician orders, printed on [DATE] at 9:21 a.m., listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 24's MAR for [DATE] indicated 36 doses were administered after [DATE]. Reviewed Resident 24's MAR for [DATE] indicated 19 doses were given from [DATE] to [DATE]. Interview with QMA 6 on [DATE] at 10:40 a.m., indicated the insulin, inhalers and eye medications should be labeled with an open date on the Open Date label or the vial or inhaler. 7. An observation of the West Hall medication cart with QMA 7 on [DATE] a.m., at 11:00 a.m. to 12:15 p.m., found the top drawer contained multi-dose medications, which included insulin, eye drops, inhalers and nasal sprays. The following multi-dose medications were lacking open dates written on the label and indicated the following: A [MEDICATION(S)] AER ,d+[DATE] (a respiratory medication) inhaler for Resident 26 was opened but was lacking an open date on the Rx label and the inhaler. The Rx date was [DATE]. The [MEDICATION(S)] inhaler would expire 3 months after being assembled per manufacture instructions and would not be expired until [DATE]. 8. An [MEDICATION(S)] AER HFA (a respiratory medication) inhaler for Resident 18 was opened but an open date was not written on the label nor the inhaler. The Rx date was [DATE] and the Rx instructed 1 puff every 4 hours as needed for shortness of breath. The [MEDICATION(S)] inhaler would expire 1 year after being being removed for foil pouch and would expire on [DATE]. 9. A Flutic/Salme AER ,d+[DATE] ([MEDICATION(S)] Diskus Inhaler) for Resident 45 was opened but an open date was not written on the label nor the inhaler. The Rx date was [DATE] and the Rx instructed 1 puff 2 times a day. the Dose Counter read 48. The Flutic/Salme/[MEDICATION(S)] Diskus would expire 28 days after being opened per facility policy. A [MEDICATION(S)] AER ,d+[DATE] Inhaler for Resident 45 was opened but an open date was not written on the label nor the inhaler. The Rx date was [DATE] and the Rx instructed 1 puff every 6 hours as needed for [CONDITION(S)]. The [MEDICATION(S)] inhaler would expire 3 month after being assembled per manufacture instructions and would not expire until [DATE]. A record review for Resident 45 began on [DATE] at 12:00 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 45's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 45's MAR for [DATE] indicated Wixeia Inhub Aerosol Powder ,d+[DATE] Inhaler indicated 32 doses were given from [DATE] to [DATE]. Resident 45's MAR for [DATE] indicated Wixeia Inhub Aerosol Powder Inhaler was administered 19 doses from [DATE] to [DATE]. 10. A [MEDICATION(S)] AER (a respiratory medication) Inhaler for Resident 55 was opened and was lacking an open date written on the label nor the inhaler. The Rx date was [DATE] and the Rx instructions were 1 puff daily for [CONDITION(S)]. The [MEDICATION(S)] inhaler would expire 6 weeks after the foil package was opened. The [MEDICATION(S)] inhaler would expire on [DATE]. A Flutic/Salme AER ,d+[DATE] Inhaler for Resident 55 was opened but was lacking an open date written on the label nor the inhaler. The Rx date was [DATE] and Rx instruction 1 puff 2 times a day. The Flutic/Salme/[MEDICATION(S)] Diskus would expire 1 month after being opened per manufacture instructions. Would expire on [DATE]. [MEDICATION(S)] AER HFA inhaler for Resident 55 was opened but was lacking an open date written on the label nor the inhaler. The Rx date was [DATE] and the Rx instruction 2 puffs every 4 hours as needed for shortness of breath. The [MEDICATION(S)] inhaler would expire 1 year after being being removed for foil pouch per manufacture instructions and would expire on [DATE]. A vial of [MEDICATION(S)] Soln ([MEDICATION(S)] insulin) 100 U (unit, and insulin dose measurement)/ml (milliliter, a measurement) for Resident 55 was opened, but was lacking an open date on the lable nor the vial. The Rx date was [DATE] and Rx instructed to inject 15 units SQ once daily for diabetes mellitus. The [MEDICATION(S)] insulin expires 28 days after being opened. A record review for Resident 55 began on [DATE] at 12:05 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 55's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 55's MAR for [DATE] indicated [MEDICATION(S)] Insulin had a start date on [DATE] and a discontinued date of [DATE] and was documented as administered once a day from [DATE] to [DATE]. Resident 55's expired [MEDICATION(S)] Insulin was discontinued and remained in the medication cart. 11. A Wixela Inhub AER ,d+[DATE] inhaler for Resident 48 was opened and removed from foil package. An open date was not written on the label nor the inhaler. The Rx date was [DATE] and Rx instructed 1 puff inhaled orally 2 times a day. Wixela Inhaler expires 1 month after removed from foil package per manufacture's instructions and would expire on [DATE]. A record review for Resident 48 begun on [DATE] at 12:10 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 48's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 48's MAR for [DATE] indicated Wixela Inhub inhaler was administered 40 doses after expired on [DATE]. Review of Resident 48's MAR for [DATE] Wixela Inhub inhaler was administered 62 doses. Review of Resident 48's MAR for [DATE] Wixela Inhub inhaler was administered 19 doses from [DATE] to [DATE]. 12. Observed a [MEDICATION(S)] AER ,d+[DATE].5 mcg (a measurement) inhaler for Resident 47 was opened but was lacking an open date written on the label nor the inhaler. The Rx date was [DATE] and the Rx instruction was to inhale 2 puffs 2 times a day. The [MEDICATION(S)] inhaler expires in 3 months after opening per manufacture's instructions. The [MEDICATION(S)] inhaler would expire on [DATE]. Observed a [MEDICATION(S)] and [MEDICATION(S)] Dihydrate Aerosol ([MEDICATION(S)]) inhaler ,d+[DATE].5 mcg for Resident was opened but was lacking an open date written on the label nor the inhaler. The Rx date was [DATE] and the Rx instruction was to inhale 2 puffs 2 times a day. The [MEDICATION(S)] inhaler expires in 3 months after opening per manufacture's instructions. The [MEDICATION(S)] inhaler would expire on [DATE]. An interview with QMA 7 on [DATE] at 11:20 a.m., indicated they did not know which inhaler was used and indicated the inhalers should be labeled with an open date. 13. A Flutic/Salme AER ,d+[DATE] inhaler for Resident 44 was opened but was lacking an open date written on the label nor the inhaler. The Rx date was [DATE] and the Rx instruction 1 puff 2 times a day for [CONDITION(S)]. The dose counter was 53. The Flutic/Salme/[MEDICATION(S)] Diskus would expire 1 month after being opened per manufacture instructions. Would expire on [DATE]. A record review for Resident 44 began on [DATE] at 12: 15 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 44's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order instructed 1 puff orally 2 times a day for [CONDITION(S)]. Review of Resident 44's MAR for [DATE] indicated Wixeia Inhub Inhaler was administered 9 doses after [DATE]. An opened vial of [MEDICATION(S)] Insulin [MEDICATION(S)] was loose in the medication cart top drawer. The vial was not labeled with a script from the pharmacy, no a resident name nor instructions for administration were on the [MEDICATION(S)] Insulin vial. An interview with QMA 7 on [DATE] at 11:25 a.m., indicated she does not give insulin and did not know who the insulin belonged too. 14. A [MEDICATION(S)] Sol 0.005% (eye drop dose) for Resident 14, was opened but was lacking an open date written on the label nor the bottle. The Rx date was [DATE] and the Rx instruction to instill 1 drop in both eyes at bedtime. The [MEDICATION(S)] Eye Drops expired in 6 weeks after being opened per manufacture's instructions. The [MEDICATION(S)] Eye Drops would expire on [DATE]. 15. A vial of [MEDICATION(S)] (Insulin [MEDICATION(S)]) for Resident 8 was opened but was lacking an open date written on the bottle. The Rx date was [DATE] and the Rx instructed to inject 12 units SQ at bedtime. The [MEDICATION(S)] insulin expires 28 days after being opened. The [MEDICATION(S)] insulin would expire on [DATE]. A record review for Resident 8 began on [DATE] at 12:25 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 8's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 8's MAR for [DATE], indicated Insulin [MEDICATION(S)] was administered 20 doses from [DATE] to [DATE]. Review of Resident 8's MAR for [DATE] indicated Insulin [MEDICATION(S)] was administered 10 doses from [DATE] to [DATE]. 16. Observation of a vial of [MEDICATION(S)] Insulin for Resident 43 was opened but was lacking an open date written on the label nor the vial. The Rx date was [DATE] and Rx instructed to inject 10 units SQ before meals and bedtime. The [MEDICATION(S)] Insulin would expire 28 days after opening. The [MEDICATION(S)] Insulin would expire on [DATE]. 17. Observation of a bottle of [MEDICATION(S)] Sol 0.02% Eye drop for Resident 30 was opened but was lacking an open date written on the label nor the bottle. The Rx date was [DATE] and the Rx instructed to instill 1 drop in both eyes at bedtime. The [MEDICATION(S)] Eye Drop could be kept for 6 weeks after opening per manufacture's instructions and would be expired on [DATE]. A record review for Resident 30 began on [DATE] at 12:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 30's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 30's MAR for [DATE] indicated the [MEDICATION(S)] Eye drops were administered 17 doses from [DATE] to [DATE]. Review of Resident 30's MAR for [DATE] indicated the [MEDICATION(S)] Eye drops were administered 9 doses from [DATE] to [DATE]. 18. A vial of [MEDICATION(S)] Sol (Insulin [MEDICATION(S)]) for Resident 57 was opened but was lacking an open date written on the label or the vial. The Rx date was [DATE] and Rx instructed to inject 20 units SQ at bedtime. The [MEDICATION(S)] insulin expires 28 days after being opened. The [MEDICATION(S)] insulin would expire on [DATE]. A [MEDICATION(S)] AER ,d+[DATE] ([MEDICATION(S)]/[MEDICATION(S)]) inhaler was opened but was not labeled with open date. The [MEDICATION(S)] inhaler was also lacking an Rx label and was not in a box nor a plastic bag with Rx label. Resident 57's name was written on the inhaler with a marker. The [MEDICATION(S)] inhaler expires 3 months after the inhaler was assembled per manufacture's instruction. A [MEDICATION(S)] Respi ([MEDICATION(S)] sulfate inhaler powder) was opened without an Rx label nor a box or bag with an Rx label for the [MEDICATION(S)] Respi inhaler. Resident 57's name was written on the inhaler with a marker. The dose counter was 198 of 200 doses. A [MEDICATION(S)] Respi inhaler expires 12 month after removed from the foil package per manufacture's instructions. A record review for Resident 57 began on [DATE] at 12:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 57's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Insulin [MEDICATION(S)] Solution, inject 30 units SQ at bedtime. [MEDICATION(S)] AER was not listed on current orders. A review of Resident 57's MAR for [DATE] indicated the Insulin [MEDICATION(S)] had a start date on [DATE] and discontinued on [DATE]. The Insulin [MEDICATION(S)] was administered for 5 doses after the expiration date. The [MEDICATION(S)] Respimat ,d+[DATE] inhaler with a start date of [DATE] and discontinued dated of [DATE]. The [MEDICATION(S)] Respimat ,d+[DATE] inhaler was administered 4 times a day from [DATE] to [DATE]. The [MEDICATION(S)] Sulfate Aerosol Powder inhaler 1 puff orally every 6 hours as needed for shortness of breath or wheezing had a start date of [DATE] and was not administered in [DATE]. A review of Resident 57's MAR for [DATE] indicated: Insulin [MEDICATION(S)] 20 units was administered at bedtime on [DATE]; Insulin [MEDICATION(S)] 25 units was administered at bedtime every night from [DATE] to [DATE]; Insulin [MEDICATION(S)] 30 units was administered at bedtime every night from [DATE] to [DATE]. The [MEDICATION(S)] Respimat inhaler was administered 4 times on [DATE] and 2 times on [DATE] and was discontinued on [DATE]. The [MEDICATION(S)] Sulfate inhaler was not administered in [DATE]. An interview with the Director of Nursing (DON) on [DATE] at 11:33 a.m., indicated insulin, inhalers and eye medications should be labeled with open dates. She indicated she would not be able to determine the open dates for the non-dated multi-dose medications. She indicated the Nurse or QMA should check for expiration dates before administering the medication. She indicated the pharmacy had not been in to check the medication carts since she began working at the facility. The DON indicated the medication and treatment carts should be locked when not using. Review of a current facility policy provided by the DON on [DATE] at 11:50 a.m., titled, Medication and Biological Storage Requirements, with an effective date of [DATE], indicated, .In accordance with state and Federal laws, and manufacturer or supplier recommendations, the facility must store al medications and biologicals in compartments or storage rooms under proper temperature controls, and permit only authorized personnel to have access to the keys .Access to medication(s) may be controlled by keys, security codes or cards, or other technology such as biometrics (i.e. fingerprints, retina scan) .21) Disposal of medication(s) should be completed for medication(s) that are without secure closure, outdate, contaminated and/or deteriorated. a. Disposal needs to be timely b. Removal medication(s) immediately from stock .*Note: Some medications have shortened expiration dates. Pleas refer to the expiration dating policy for information on these medications Review of a current facility policy provided by the DON on [DATE] at 11:50 a.m., titled, Labeling of Medication, with an effective date of [DATE], indicated, .To ensure that the facility, in coordination with the licensed pharmacist, provide for accurate labeling to facilitate safe administration of medications and considerations of precautions in accordance with the currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. 1) Medication labeling must be typed or printed and clearly indicated .a. Resident full name c. prescription number, d. Brand name, generic name or both, e. Strength of drug, f. Prescribed dose of drug/medication, g. Route of administration, h. Time of administration, j. Date dispensed, k. Expiration date (i.e. time-dated drugs) l. Prescriber/Physician name .3) Multi-dose medications vials/devices a. Should be labeled with date opened/accessed .Pharmacy recommends using a marker directly on vial/device if there is not adequate room for a Date Open sticker .Once opened/accessed the vial/device should be dated and discarded within 28 days unless the manufacturer specified a different (shorter or longer) date for vial/device after opened/accessed .After medication(s) with difficult labeling are used, they must always be returned immediately to the labeled box, baggy or vial 3.,d+[DATE](j) 3.,d+[DATE](k)(1)(2)(3)(4)(5)(6)(7) 3.,d+[DATE](m) 3.,d+[DATE](o)

Based on observation, interview and record review, the facility failed to ensure bathroom accommodations were honored for 4 of 4 residents reviewed. (Resident 14, Resident 12, Resident 55 and Resident 46) Findings include: An observation of the bathroom between rooms [ROOM NUMBERS] on 11-9-2021 at 9:25 a.m., indicated the toilet seat remained broken and not attached on one side to the toilet, the light did not work, and the light cover was on the counter. Resident 12, Resident 14, Resident 46, and Resident 55 shared this bathroom. The record review for Resident 55 began on 11-12-2021 at 11:33 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS (Minimum Data Set) assessment dated [DATE], indicated the BIMS (Brief Interview for Mental Status) score was 15/15, which indicated the resident was cognitively intact. The resident needed limited assist of one person for transfers, toilet use, and supervision with set up help for locomotion on and off the unit. The resident used a wheelchair. During an interview with Resident 55 on 11-7-2021 at 2:37 p.m., the resident indicated the bathroom light did not work, the light cover was on the counter, and the toilet wobbled. The resident indicated she almost slipped off the toilet and used the bathroom on her own. Resident 55 indicated she had asked Maintenance to fix the wobbly toilet. During an observation on 11-8-2021 at 2:15 p.m., Resident 55 was observed to ask the Maintenance Supervisor about fixing the broken toilet seat. The Maintenance Supervisor indicated to Resident 55, he would get to it this day. An observation of the bathroom shared by Resident 46 and Resident 12 on 11-7-2021 at 2:42 p.m., indicated the light did not work, the light cover was on the counter, the toilet seat was not secured to the toilet on one side and slipped back and forth easily. The floor tiles did not fit the floor, there were missing tiles and gaps between the tiles. The bathroom had dried spills on the floor. An observation of Resident 46 on 11-8-2021 at 9:15 a.m., indicated she was walking independently in the hall. An observation of Resident 12 on 11-8-2021 at 1:20 p.m., indicated the resident was walking in the hall independently. The record review for Resident 14 began 11-10-2021 at 3:59 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE], indicated the resident had a BIMS of 15/15. The resident needed supervision with set up help only for transfers, walking in room, and toilet use. An interview with Resident 14 on 11-8-2021 at 1:01 p.m., indicated the toilet seat was loose and not attached on one side causing it to shift back and forth and the light did not work. The light cover was observed on the counter. Resident 14 was observed in a wheelchair. She indicated she used the bathroom on her own. An interview with Housekeeping/Laundry 1 on 11-10-2021 at 11:40 a.m., indicated she had just cleaned rooms [ROOM NUMBERS] including the bathroom. She indicated the light was working. On 11-10-2021 at 11:42 a.m., the bathroom in rooms [ROOM NUMBERS] was observed. The light worked but the light cover was observed on the bathroom counter. The toilet seat was observed and was not secured to the toilet on one side. The toilet seat was observed to shift back and forth. At this time, Resident 46 was observed to open the bathroom door to use the bathroom. In an interview on 11-10-2021 at 12:29 p.m., the Maintenance Supervisor indicated he repaired the light in the bathroom for rooms [ROOM NUMBERS] and secured the light cover over the light. He indicated he had the bolts to fix the toilet seat, but had not fixed the toilet seat yet. He indicated if a maintenance request was not completed or if no one reported what items needed to be fixed, he would not know about the repairs needed. An interview with CNA 4 (Certified Nurse Aide) on 11-12-2021 at 10:37 a.m., indicated she worked routinely on the West hall and the 4 residents in rooms [ROOM NUMBERS] (Resident 14, Resident 12, Resident 55 and Resident 46) used the shared bathroom and were able to use the bathroom independently. She indicated the residetns had told the Maintenance Suprvisor about the needed repairs in the bthroom, so she did not fill out a work order. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure the Physician's Order for Scope of Treatment Form (POST Form, a Physician's order for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. A record review for Resident 7 began on [DATE] at 11:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advance Directive section on Resident 7's face page listed DNR (Do Not Resuscitate) Review of Resident 7's physician orders printed on [DATE] at 2:31 p.m., was provided by the DON on [DATE] at 2:59 p.m. There was an order dated [DATE] for DNR. Review of Resident 7's Indiana POST form listed Resident 7's name, date of birth, medical record number and was dated as prepared [DATE]. Resident 7's POST indicated Do Not Attempt Resuscitation/DNR. The Physician's signature, printed name, physician's office telephone number and physician's license number were typed on the form, but the physician signature was not dated. 2. A record review for Resident 13 began on [DATE] at 2:09 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advance Directive section on Resident 13's face page listed DNR. Review of Resident 13's physician orders dated [DATE] indicated the resident wished to be DNR. Review of Resident 13's Indiana POST form listed Resident 13's name, date of birth medical record number and had a date prepared of [DATE]. Resident 13's POST did not indicate to attempt CPR nor Not Attempt Resuscitation/DNR. The physician's signature, physician's office telephone number, physician's license number and the name of the professional preparing the form was blank, but was dated [DATE]. The box for the printed name of the physician was a copy of the Physician's last name. 3. A record review for Resident 1 began on [DATE] at 4:05 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advance Directive section on Resident 1's face page listed CPR Review of Resident 1's physician orders dated [DATE] was to initiate CPR (Cardiopulmonary Resuscitation). Review of Resident 1's Indiana POST form, prepared on [DATE] indicated to attempt Resuscitation/CPR. The physician's signature, date, physician's office telephone number, physician's license number and the name of the professional preparing the form was left blank. The box for the printed name of the physician was a copy of the Physician's last name. 4. A record review for Resident 41 began on [DATE] at 10:23 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advanced Directive section on Resident 41's face page listed DNR. Review of Resident 41's physician orders, dated [DATE] indicated the resident wanted to be DNR. Review of Resident 41's Indiana POST form listed Resident 41' s name, date of birth, medical record number and had a date prepared of [DATE]. Resident 41's POST indicated do not attempt resuscitation/DNR. The physician's signature, physician's office telephone number, physician's license number and the name of the professional preparing the form was blank, but was dated [DATE]. The box for the printed name of the physician was a copy of the Physician's last name. 5. A record review for Resident 48 began on [DATE] 10:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advanced Directive section on Resident 48's face page listed CPR. Review of Resident 48's physician orders, dated [DATE] was for CPR. Review of Resident 48's Indiana POST form listed Resident 48's name, date of birth, medical record number and was dated [DATE]. Resident 48's POST indicated to Attempt Resuscitation/CPR. The physician's signature, physician's office telephone number, physician's license number and the name of the professional preparing the form was blank, but was dated [DATE]. The box for the printed name of the physician was a copy of the Physician's last name. 6. A record review for Resident 49 began on [DATE] at 1:41 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advanced Directive section on Resident 49's face page listed DNR. Review of Resident 49's physician orders dated [DATE] was for DNR. Review of Resident 49's Indiana POST form listed Resident 48' s name, date of birth, medical record number and was dated [DATE]. Resident 49's POST indicatedn Do Not Attempt Resuscitation/DNR. The physician's signature, physician's office telephone number, physician's license number and the name of the professional preparing the from was blank, but was dated [DATE]. The box for the printed name of the physician was a copy of the Physician's last name. An interview with the DON on [DATE] at 2:05 p.m., indicated the POST Forms should be completed with all information, signed and dated by the physician. Review of the current Indiana Physician Orders for Scope of Treatment (POST) State Form Indiana State Department of Health-IC [DATE], indicated .Signature Page: This form consist of two (2) pages. Both pages must be present. the following page includes signatures required for the POST form to be effective Review of a current facility policy provided by the DON on [DATE], titled, Advanced Directives, dated [DATE], indicated, .It is the policy of [NAME] Care to provide information to resident/responsible party regarding his/her rights to formulate advanced directives including the right to refuse or accept medical care. The facility will not discriminate against any individual based on whether or not they have implemented and advanced directive. I a resident has a valid Advanced Directive, the facility's care will reflect the resident's wishes as expressed in the Directive, in accordance with state law. Policies regarding the implementation and use of DO Not Resuscitate and POST forms have a separate policy. Review of a current facility policy provided by the DON on on [DATE], Do Not Resuscitate Order, with revised date of [DATE], indicated, .Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident with there is a Do Not Resuscitation Order in effect .2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. a. Use only State-Approved DNR forms b. If no State forms is required, use facility-approved form .3. In addition to the advance directive and DNR order form, state-specified forms may be used to specify whether to administer CPR in case of a medical emergency. State specific forms include: .Physician Orders for Scope of Treatment (POST) 3.,d+[DATE](f)(5)(7)

Based on observation, interview, and record review, the facility failed to ensure the handrails were in good repair for 56 of 58 residents who were mobile in the facility. Findings include: During an observation of the facility on 11-7-2021 at 12:13 p.m., the curved part of the hand rail outside of the soiled utility room in South hall was cracked, broken and jagged. On 11-7-2021 at 2:27 p.m., the curved portion of the hand rail in the South hall right before ice machine was observed to be broken and jagged. Observations of the hand rails in the facility on 11-8-2021 at 8:50 a.m. indicated the following: The curved part of the hand rail in the East hall by the third door on the left was observed to be missing. The end of the plastic hand rail was rough. To the left of the Environmental Supervisor door, a curved piece of the handrail was observed to be broken with jagged edges. The curved piece of the handrails at the entrance to the East hall sitting area, were cracked and had jagged edges. In the West hall, the curved hand rail piece to the right of the nourishment room was loose. The curved hand rail piece to the right of room 102, was loose, cracked and jagged. The curved hand rail piece to the left of room 104 was cracked and jagged. The curved hand rail piece to the left of room 108 was cracked and jagged. An interview with the Maintenance Director on 11-10-2021 at 12:29 p.m., indicated he was aware of the broken corners on the handrails and had reported it to his supervisor. He was observed to contact his supervisor at 12:40 p.m. and the supervisor indicated he did not have access to his paperwork on the hand rails. An interview with the DON (Director of Nursing) on 11-12-2021 at 10:32 a.m., indicated 56 of the 58 residents were able to move about the facility independently or with a mobility device. 3.1-19(f)(3)

Based on observation, record review and interview the facility failed to ensure 1 of 3 residents reviewed received treatment to a diabetic ulcer per physician's orders [REDACTED]. This resulted in worsening of the diabetic ulcer. Findings include: a. In an interview on 9/24/18 at 9:30 a.m., Resident B stated his right foot was hurting and staff had not done the treatment to his foot all weekend. Resident B stated he did not want to lose his leg as he had lost his left leg above the knee due to a non-healing wound. The resident stated They are not going to remove this leg like they did the last one. The resident had a distraught look on his face and his voice had a tremulous quality. Review of the clinical record for Resident B on 9/24/18 at 2:00 p.m. indicated he had a BIMS (brief interview for mental status) score of 15 which indicated he was alert and oriented. Resident B's [DIAGNOSES REDACTED]. At 9:35 a.m. review of the TAR (treatment administration record), dated (MONTH) (YEAR), indicated a physician's orders [REDACTED]. Apply [MEDICATION NAME] ointment 0.1%. Place Xeroform directly over the wound then cover with foam dressing and wrap with Kerlix. Review of the TAR indicated the treatment was to be done on the 10p.m. to 6a.m. shift. The only documentation of the treatment being done was dated 9/21/18. During an interview on 9/25/18 at 11:03 a.m. Nurse #4 indicated if the treatment was not documented on the TAR, it probably had not been done. When queried regarding the Skilled nurse note dated 9/22/18, indicated Wound treatment done, Nurse #4 indicated she could not validate the treatment had been completed according to the physician's orders [REDACTED].>Observation of Resident B's right foot on 9/24/18 at 9: 33 a.m., when the resident was up in his wheelchair in the hallway, indicated the dressing was soaked in a dried brown colored drainage. The gauze on the undated dressing had rolled edges and was loose. On 9/24/18 at 9:40 a.m. the Director of Nursing (DON) was asked about the resident's treatment order and the concern of the treatment not being done since 9/21/18. The DON gathered the treatment supplies and proceeded to remove the dressing from the resident's right foot. Observation of the dressing indicated it was bunched together, had rolled edges, was loose, and had a moderate amount of brown drainage with a foul odor. The dressing was also noted to be undated. The DON proceeded to clean the wound with soap and water and was asked to measure the wound. The wound measured 5cm (centimeters) x 8 cm and had a depth of 0.4 cm. The DON was queried as to the type of tissue in the wound bed and she indicated it was granulated tissue. A review of the Nurse Practitioner (NP) note dated 9/19/18 at an unknown time indicated the wound had measurements of 5 x 7 x 0.3 before the NP debrided the area. Post debridement, the area measured 5.1 x 7.1 x 0.3. Review of the Wound Tracking Log dated for the week of 9/13-9/21/18 indicated Resident B had acquired the right diabetic heel ulcer on 12/13/14. The measurement for the week of 9/13-9/21/18 indicated the wound was 5.2 x 6.8 x 0.1. The log did not indicate the wound had drainage or an odor. A review of Resident B's Braden Scale risk assessment, dated 8/21/18 indicated he was at moderate risk for the development of skin impairment. A review of the Impaired Skin Integrity Care Plan dated 8/27/18 indicated Resident B was at risk for developing impaired skin integrity related to immobility and diabetes. Interventions for the diabetic heel ulcer included the following: Assess and document skin condition, assist with bed mobility, Check for incontinence and provide care as necessary, Notify physician of wound worsening, pressure reduction on bed and in chair, and wound treatment as ordered by the physician. b. On 9/24/18 at 10:30 a.m. review of the TAR also indicated a physician's orders [REDACTED]. An interview on 9/24/18 at 10:31 a.m. with the DON indicated she did not know about the order and called the laboratory to see if the result of the culture was available. The laboratory indicated the specimen needed to be redone and they had called the facility on 9/22/18 and told Nurse #2. The DON indicated Nurse #2 told Nurse #3, who was Resident B's nurse, and told her the culture needed to be redone. Interview with the DON, Administrator and Corporate Nurse Consultant on 9/24/18 at 1:45 p.m. indicated the facility would have caught the missed culture on 9/24/18 during morning meeting. Further discussion indicated they had reviewed the resident's clinical record. Also, there was documentation in the skilled nursing notes which indicated the nurses had done the resident's treatments on 9//22 and 9/23/18. Review of the skilled nursing note, dated 9/22/18 indicated the resident had a wound but no documentation the treatment was done was in the note. Review of the 9/24/18 skilled nursing note (facility indicated this was for 9/23/18) indicated the resident had a wound and the treatment had been done. A current policy titled Medication and Treatment orders, dated 7/16, provided by the Administrator on 9/25/18 at 8:40 a.m. indicated Medications and treatments will be consistent with principles of safe and effective order writing There was no indication in the policy the physician order [REDACTED]. A current policy titled Pressure Ulcers/Skin Breakdown indicated .resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection . This federal tag is related to complaints IN 976 and IN 232. 3.1-37(a)

Based on interview, and record review, the facility failed to ensure 4 of 6 residents (Resident B, Resident C, Resident D and Resident E) were free of verbal and mental abuse. This had the potential to effect 39 of 39 residents who resided in the facility. The Immediate Jeopardy began on 2/17/17 when Resident B had a verbal exchange with staff working at the facility. The Director of Nursing (DON), Administrator and Human Resource Director were notified of the Immediate Jeopardy at 12:50 p.m. on 3/31/17. The Immediate Jeopardy was removed on 4/3/17 at 2:10 p.m. but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. In an interview with Staff Member 1 on 3/30/17 at 10:00 a.m. indicated they had concerns regarding the Administrator being verbally aggressive with Resident B and getting in his face. In an interview on 3/30/2017 at 10:26 a.m., Staff Member 2 indicated she heard Resident B ask the Administrator who the Director of Nursing (DON) was (the DON was standing in the hall). The Administrator pointed her finger at the DON and said to Resident B, She is the one who is going to get you out of here. In an interview with Staff Member 3 on 3/31/2017 at 9:42 a.m., she indicated Resident E was in the dining room yelling at Resident C to stop yelling. Staff Member 3 indicated the Administrator came into the dining room, approached Resident C, pointed her finger at the resident and said, This will not be tolerated. Further interview with Staff Member 3 indicated Resident E was the one yelling which had agitated Resident C but the Administrator was pointing her finger at and telling Resident C the yelling would not be tolerated. In an interview on 3/ 31/2017 at 9:51 a.m., Staff Member 4 indicated the Administrator would come into the dining room and yell at Resident B and Resident C, telling them I am not going to take this from you, you need to be quiet. Staff Member 4 indicated, These residents are just who they are. Resident C is gone now. One day, they just packed her bags and sent her out. In an interview on 3/31/2017 at 10:22 a.m., Employee 5 indicated she had heard and seen the Administrator yell and point her finger at residents. Employee 5 stated she witnessed the Administrator yell and point her finger at Resident B in the hallway. Resident B approached Employee 5 after one of the incidents and stated Did you hear what she said to me? In an interview on 3/30/2017 at 2:48 p.m., Employee 6 indicated she had witnessed Resident E yelling and noted Resident B had become upset and he had started acting out. The Administrator came into the dining room and told Resident B he was too loud and removed him from the dining room. The Administrator came back into the dining room, shook her finger at Resident E and stated, You are inappropriate too, and took Resident E out of the dining room. Further interview with Employee 6 indicated she was afraid to report the abuse because she might loose her job. In an interview on 3/30/2017 at 3:10 p.m. Employee 7 indicated she was caring for a resident when she heard yelling coming from Resident B's room. Resident B was screaming Get out of my face and out of my room. Employee 7 attempted to go into the room but the door would not open. The employee then went into the next room and entered Resident B's room through the shared bathroom. Employee 7 indicated the resident's wheelchair was in front of the door, and the Administrator was in the room with Resident B yelling and pointing her finger at him and saying, You are not coming out until you lower your voice. Further interview with Employee 7 indicated she backed out of the room, went back into the hallway and saw Resident B walking fast out of his room after the door had been opened. Interview with Former Employee 8 on 3/29/17 at 11:20 a.m. indicated the Administrator is very loud and screams at some of the residents. She indicated she does this to Resident B, to antagonize him. 2. Review of the clinical record for Resident D on 3/31/17 at 1:30 p.m.indicated Resident D had [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set Assessment) dated 1/30/17 indicated the resident was assessed as being alert and oriented, and required assistance with all of her activities of daily living. In an interview with Resident D on 3/30/17 at 9:00 a.m., she indicated she had a concern with the Administrator. Resident D stated she had heard how the Administrator treats Resident B and other residents and felt like she would be the next person who would be made to leave the facility. Further interview with Resident D indicated staff had spoken to her about her fears, and she had even written a note to the Administrator, but never had even met her. Resident D indicated staff had encouraged her to file a grievance but she was afraid and did not want staff to loose their jobs. The resident was queried about why she had not called the Department of Health and she indicated she was afraid to call, and indicated she was afraid they would hear her on the phone. Resident D resided in a room which was diagonal to Resident B's room. Resident B no longer resides in the facility. On 3/30/17 at 10:30 a.m. review of the clinical record for Resident B indicated he was admitted with [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) dated 1/9/17 indicated the resident was alert with confusion, and required only supervision with his activities of daily living. Resident B was ambulatory per self. Resident B no longer resides in the facility. ON 3/31/17 at 1:30 p.m. review of the clinical record for Resident C indicated she was admitted with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE] indicated the resident was alert and oriented, was independent with ambulation and required minimal assistance with dressing, eating and hygiene. Interview on 3/31/17 at 1:37 p.m. with the Social Services Director indicated Resident C did not have behaviors but would become upset when other residents were having behaviors. Resident C no longer resides in the facility. 3. On 3/30/17 at 1:20 p.m. the Administrator was queried as to where the postings of the phone numbers for the Department of Health could be located. The Administrator could not find the sign and went to the front receptionist area and found the information, which was in a picture frame. The frame was on the floor, under the desk. The Administrator stated Resident F keeps taking it off of the wall. On 3/30/17 at 3:30 p.m. the Regional Director of Clinical Services was queried about the facility abuse policy. He indicated if staff witness abuse they are to report to the Administrator. Further discussion with the Regional Director indicated the staff could call the Corporate Office but upon searching the building with the Director of Clinical Services, there was no information in the building on how employees could contact the corporation. During staff interviews on 3/30 through 3/31/17, staff indicated they had been trained in abuse, knew how to report abuse but were fearful of losing their jobs if they reported the Administrator's behaviors. 4. Review of the current facility policy and procedure for abuse prevention, which did not have a date, indicated the following: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals. This Federal tag is related to complaint IN 170 3.1-27(a)(1)(4) 3.1-27(b)

Based on interview, and record review, the facility failed to implement their abuse prohibition policy for 4 of 6 residents (Resident B, Resident C, Resident D, and Resident E) who were reported to have experienced verbal and mental abuse. The facility also failed to have a work place environment which enabled employees the ability to be comfortable with reporting abuse, and having access to the corporate phone number. This had the potential to effect all 39 residents who resided in the building. The Immediate Jeopardy began on 2/17/17 when Resident B had a verbal exchange with staff working at the facility. The Director of Nursing (DON), Administrator and Human Resource Director were notified of the Immediate Jeopardy at 12:50 p.m. on 3/31/17. The Immediate Jeopardy was removed on 4/3/17 at 2:10 p.m. but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. In an interview with Staff Member 1 on 3/30/17 at 10:00 a.m. indicated they had concerns of the Administrator being verbal with Resident B and getting in his face. In an interview on 3/30/2017 at 10:26 a.m., Staff Member 2 indicated she heard Resident B ask the Administrator who the Director of Nursing (DON) was (the DON was standing in the hall). The Administrator pointed her finger at the DON and said to Resident B, She is the one who is going to get you out of here. In an interview with Staff Member 3 on 3/31/2017 at 9:42 a.m., she indicated Resident E was in the dining room yelling at Resident C to stop yelling. Staff Member 3 indicated the Administrator came into the dining room, approached Resident C, pointed her finger at the resident and said, This will not be tolerated. Further interview with Staff Member 3 indicated Resident E was the one yelling which had agitated Resident C but the Administrator was pointing her finger at and telling Resident C the yelling would not be tolerated. In an interview on 3/ 31/2017 at 9:51 a.m., Staff Member 4 indicated the Administrator would come into the dining room and yell at Resident B and Resident C, telling them I am not going to take this from you, you need to be quiet. Staff Member 4 indicated, These residents are just who they are. Resident C is gone now. One day, they just packed her bags and sent her out. In an interview on 3/31/2017 at 10:22 a.m., Employee 5 indicated she had heard and seen the Administrator yell and point her finger at residents. Employee 5 stated she witnessed the Administrator yell and point her finger at Resident B in the hallway. Resident B approached Employee 5 after one of the incidents and stated Did you hear what she said to me? In an interview on 3/30/2017 at 2:48 p.m., Employee 6 indicated she had witnessed Resident E yelling and noted Resident B had become upset and he had started acting out. The Administrator came into the dining room and told Resident B he was too loud and removed him from the dining room. The Administrator came back into the dining room, shook her finger at Resident E and stated, You are inappropriate too, and took Resident E out of the dining room. Further interview with Employee 6 indicated she was afraid to report the abuse because she might loose her job. In an interview on 3/30/2017 at 3:10 p.m. Employee 7 indicated she was caring for a resident when she heard yelling coming from Resident B's room. Resident B was screaming Get out of my face and out of my room. Employee 7 attempted to go into the room but the door would not open. The employee then went into the next room and entered Resident B's room through the shared bathroom. Employee 7 indicated the resident's wheelchair was in front of the door, and the Administrator was in the room with Resident B yelling and pointing her finger at him and saying, You are not coming out until you lower your voice. Further interview with Employee 7 indicated she backed out of the room, went back into the hallway and saw Resident B walking fast out of his room after the door had been opened. Interview with Former Employee 8 on 3/29/17 at 11:20 a.m. indicated the Administrator is very loud and screams at some of the residents. She indicated she does this to Resident B, to antagonize him. 2. Review of the clinical record for Resident D on 3/31/17 at 1:30 p.m.indicated Resident D had [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set Assessment) dated 1/30/17 indicated the resident was assessed as being alert and oriented, and required assistance with all of her activities of daily living. In an interview with Resident D on 3/30/17 at 9:00 a.m., she indicated she had a concern with the Administrator. Resident D stated she had heard how the Administrator treats Resident B and other residents and felt like she would be the next person who would be made to leave the facility. Further interview with Resident D indicated staff had spoken to her about her fears, and she had even written a note to the Administrator, but never had even met her. Resident D indicated staff had encouraged her to file a grievance but she was afraid and did not want staff to loose their jobs. The resident was queried about why she had not called the Department of Health and she indicated she was afraid to call, and indicated she was afraid they would hear her on the phone. Resident D resided in a room which was diagonal to Resident B's room. Resident B no longer resides in the facility. On 3/30/17 at 10:30 a.m. review of the clinical record for Resident B indicated he was admitted with [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) dated 1/9/17 indicated the resident was alert with confusion, and required only supervision with his activities of daily living. Resident B was ambulatory per self. Resident B no longer resides in the facility. ON 3/31/17 at 1:30 p.m. review of the clinical record for Resident C indicated she was admitted with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE] indicated the resident was alert and oriented, was independent with ambulation and required minimal assistance with dressing, eating and hygiene. Interview on 3/31/17 at 1:37 p.m. with the Social Services Director indicated Resident C did not have behaviors but would become upset when other residents were having behaviors. Resident C no longer resides in the facility. 3. On 3/30/17 at 1:20 p.m. the Administrator was queried as to where the postings of the phone numbers for the Department of Health could be located. The Administrator could not find the sign and went to the front receptionist area and found the information, which was in a picture frame. The frame was on the floor, under the desk. The Administrator stated Resident F keeps taking it off of the wall. On 3/30/17 at 3:30 p.m. the Regional Director of Clinical Services was queried about the facility abuse policy. He indicated if staff witness abuse they are to report to the Administrator. Further discussion with the Regional Director indicated the staff could call the Corporate Office but upon searching the building with the Director of Clinical Services, there was no information in the building on how employees could contact the corporation. During staff interviews on 3/30 through 3/31/17, staff indicated they had been trained in abuse, knew how to report abuse but were fearful of losing their jobs if they reported the Administrator's behaviors. 4. Review of the current facility policy and procedure for abuse prevention, which did not have a date, indicated the following: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals. If any employee witnesses or is aware of any type of abuse, neglect, involuntary seclusion, corporal punishment, or misappropriation of property, they will immediately report the situation to their supervisor and/ or the Administrator. This federal tag is related to complaint IN 170 3.1-28(a)

Based on interview, and record review, the facility failed to ensure staff was able to report abuse for 4 of 6 residents (Resident B, Resident C, Resident D, and Resident E) reviewed. The facility also failed to have a work place environment which enabled employees the ability to be comfortable with reporting abuse, and having access to the corporate phone number. This had the potential to effect all 39 residents who resided in the facility. The Immediate Jeopardy began on 2/17/17 when staff witnessed a verbal exchange between Resident B and other staff working at the facility. The staff members did not report the exchange. The Director of Nursing (DON), Administrator and Human Resource Director were notified of the Immediate Jeopardy at 12:50 p.m. on 3/31/17. The Immediate Jeopardy was removed on 4/3/17 at 2:10 p.m. but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. In an interview with Staff Member 1 on 3/30/17 at 10:00 a.m. indicated they had concerns of the Administrator being verbally aggressive with Resident B and getting in his face. In an interview on 3/30/2017 at 10:26 a.m., Staff Member 2 indicated she heard Resident B ask the Administrator who the Director of Nursing (DON) was (the DON was standing in the hall). The Administrator pointed her finger at the DON and said to Resident B, She is the one who is going to get you out of here. In an interview with Staff Member 3 on 3/31/2017 at 9:42 a.m., she indicated Resident E was in the dining room yelling at Resident C to stop yelling. Staff Member 3 indicated the Administrator came into the dining room, approached Resident C, pointed her finger at the resident and said, This will not be tolerated. Further interview with Staff Member 3 indicated Resident E was the one yelling which had agitated Resident C but the Administrator was pointing her finger at and telling Resident C the yelling would not be tolerated. In an interview on 3/ 31/2017 at 9:51 a.m., Staff Member 4 indicated the Administrator would come into the dining room and yell at Resident B and Resident C, telling them I am not going to take this from you, you need to be quiet. Staff Member 4 indicated, These residents are just who they are. Resident C is gone now. One day, they just packed her bags and sent her out. In an interview on 3/31/2017 at 10:22 a.m., Employee 5 indicated she had heard and seen the Administrator yell and point her finger at residents. Employee 5 stated she witnessed the Administrator yell and point her finger at Resident B in the hallway. Resident B approached Employee 5 after one of the incidents and stated Did you hear what she said to me? In an interview on 3/30/2017 at 2:48 p.m., Employee 6 indicated she had witnessed Resident E yelling and noted Resident B had become upset and he had started acting out. The Administrator came into the dining room and told Resident B he was too loud and removed him from the dining room. The Administrator came back into the dining room, shook her finger at Resident E and stated, You are inappropriate too, and took Resident E out of the dining room. Further interview with Employee 6 indicated she was afraid to report the abuse because she might loose her job. In an interview on 3/30/2017 at 3:10 p.m. Employee 7 indicated she was caring for a resident when she heard yelling coming from Resident B's room. Resident B was screaming Get out of my face and out of my room. Employee 7 attempted to go into the room but the door would not open. The employee then went into the next room and entered Resident B's room through the shared bathroom. Employee 7 indicated the resident's wheelchair was in front of the door, and the Administrator was in the room with Resident B yelling and pointing her finger at him and saying, You are not coming out until you lower your voice. Further interview with Employee 7 indicated she backed out of the room, went back into the hallway and saw Resident B walking fast out of his room after the door had been opened. Interview with Former Employee 8 on 3/29/17 at 11:20 a.m. indicated the Administrator is very loud and screams at some of the residents. She indicated she does this to Resident B, to antagonize him. 2. Review of the clinical record for Resident D on 3/31/17 at 1:30 p.m.indicated Resident D had [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set Assessment) dated 1/30/17 indicated the resident was assessed as being alert and oriented, and required assistance with all of her activities of daily living. In an interview with Resident D on 3/30/17 at 9:00 a.m., she indicated she had a concern with the Administrator. Resident D stated she had heard how the Administrator treats Resident B and other residents and felt like she would be the next person who would be made to leave the facility. Further interview with Resident D indicated staff had spoken to her about her fears, and she had even written a note to the Administrator, but never had even met her. Resident D indicated staff had encouraged her to file a grievance but she was afraid and did not want staff to loose their jobs. The resident was queried about why she had not called the Department of Health and she indicated she was afraid to call, and indicated she was afraid they would hear her on the phone. Resident D resided in a room which was diagonal to Resident B's room. Resident B no longer resides in the facility. On 3/30/17 at 10:30 a.m. review of the clinical record for Resident B indicated he was admitted with [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) dated 1/9/17 indicated the resident was alert with confusion, and required only supervision with his activities of daily living. Resident B was ambulatory per self. Resident B no longer resides in the facility. ON 3/31/17 at 1:30 p.m. review of the clinical record for Resident C indicated she was admitted with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE] indicated the resident was alert and oriented, was independent with ambulation and required minimal assistance with dressing, eating and hygiene. 3. On 3/30/17 at 1:20 p.m. the Administrator was queried as to where the postings of the phone numbers for the Department of Health could be located. The Administrator could not find the sign and went to the front receptionist area and found the information, which was in a picture frame. The frame was on the floor, under the desk. The Administrator stated Resident F keeps taking it off of the wall. On 3/30/17 at 3:30 p.m. the Regional Director of Clinical Services was queried about the facility abuse policy. He indicated if staff witness abuse they are to report to the Administrator. Further discussion with the Regional Director indicated the staff could call the Corporate Office but upon searching the building with the Director of Clinical Services, there was no information in the building on how employees could contact the corporation. During staff interviews on 3/30 through 3/31/17, staff indicated they had been trained in abuse, knew how to report abuse but were fearful of loosing their jobs if they reported the Administrator's behaviors. 4. Review of the current facility policy and procedure for abuse prevention, which did not have a date, indicated the following: If any employee witnesses or is aware of any type of abuse, neglect, involuntary seclusion, corporal punishment, or misappropriation of property, they will immediately report the situation to their supervisor and/ or the Administrator. This federal tag is related to complaint IN 170 3.1-28(c) 3.1-28(e)

Based on record review and interview, the facility Quality Assessment and Assurance (QAA) Committee failed to identify and implement a plan of action for the identified concerns of: following physician orders, lack of documentation on MARS (Medication Administration Record), the Pain Flow Sheet, the Nurses' Medication Notes and to monitor the complete and accurate documentation of narcotic administration. This deficient practice had the potential to affect 41 of 41 residents residing in the facility. Findings include: A review of the Facility's Plan of Correction that was provided by the facility on 10/24/13, indicated all the staff was educated by 9/20/13 on implementation of MD (Medical Doctor) orders, medication and treatment administration documentation and change over (nurse's shift change). The Plan of Correction indicated , "All medications and treatments will be administered per MD order as indicted on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). The DCS (Director of Clinical Services) and or a licensed nurse will review all MAR's and TAR's daily to validate medications and treatments were administered....Each licensed staff is responsible to review the MAR and TAR prior to the end of each shift to validate all medications and treatments were administered....Any discrepancies identified will be corrected immediately. Based on review of the clinical records there was no indication or documentation the QAA Committee was monitoring the orders and distribution to residents of narcotic medications. An interview with the Interim DCS (Director of Clinical Services) on 10/28/13 at 1:30 p.m., indicated the licensed nurse staff was re-educated on 10/24/13 regarding timely documentation. Timely documentation included PRN (as needed) medications which needed to be documented at time of administration and be signed out on the MAR,on the back of the MAR , the Pain Flow Sheet, the Narcotic Control Record. An interview with the Executive Director on 10/29/13 at 1:25 p.m., indicated the Quality Assessment and Assurance Committee had just revised and implemented action plans on 10/24/13 and began to re-educate the licensed nurses to address deficient practice in the following areas: All documentation was to be completed timely and PRN to be documented at time of administration, to be signed out on MAR, back of MAR (Nurses ' Medication Note), the Pain Flow Sheet and the Narcotic Control Record 3.1-52(b)(2)

Based on record review and interview, the facility failed to identify and implement a plan of action for the identified concerns of following physician orders, the development and following of resident's care plans, lack of assessments, identify individual needs of residents, medication administration and storage of medications, complete nutritional assessments, food intake documentation and obtain resident's weights, honoring resident's choices, provide adequate nurse staffing to provide resident care, infection control for hand hygiene. This deficient practice had the potential to affect 46 of 46 residents residing in the facility. Findings include: During an interview with the Executive Director on 8/20/13 at 1:25 p.m., indicated the Quality Assessment and Assurance Committee had not developed and implemented action plans to address deficient practice in the following areas: a. lack of development and following of resident's care plans, b. lack of nursing assessments and adequate documentation, c. significant medication administration errors and storage, d. not having complete nutritional assessment, documentation of food intake and obtaining residents' weights, e. honoring residents' choices, f. adequate nurse staffing and g. infection control for hand hygiene. There was no documentation the Executive Director and the Quality Assessment and Assurance Committee had a system in place to identify problems, to implement plans of action, and to monitor the implementation of the action plans through the Quality Assessment Assurance process. 3.1-52(b)(2)

Based on interview and record review, the facility failed to prevent a significant medication error for 1 Resident (#34). This resulted in Resident #34 requiring intravenous therapy and experiencing a temporary decline in mobility. The facility further failed to implement measures to properly identify Residents during medication administration to prevent future medication errors, potentially affecting all 46 of the 46 Resident's in the facility. The Immediate Jeopardy began on 8/10/12 at 8:15 a.m. when the facility failed to ensure a nurse could accurately identify a resident during medication administration resulting in medications being given to the wrong Resident. The Executive Director (ED) and the Interim Director of Clinical Services (DCS) were notified of the Immediate Jeopardy at 2:20 p.m. on 8/15/13. The Immediate Jeopardy was removed on 8/16/13, but non-compliance remained at the scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview on 8/12/13 at 11:07 a.m. with Resident #34, he indicated he was given his roommates medications on Saturday (8/10/13) morning when he was in the dining room. Resident #34 indicated he needed to have IV(intravenous) fluids to flush out the medication. The Resident indicated he took 9 pills that were not his medications. The Resident indicated he began to feel very weak and could not transfer to a wheelchair by himself and needed assistance of 2 staff. He also indicated he did not start feeling better until after 10:00 p.m. on 8/10/13. The Resident indicated the nurse that gave him the medications was in training, and the other staff nurse stood in the doorway of dining room and pointed to the table where he was seated. The Resident indicated the nurse did not verify who he was and he just glanced at the pills and swallowed them. After he swallowed the pills, he then realized the medications were not his usual medications because there was a purple capsule in the medication cup. He then reported to his usual nurse he was given the wrong medications. He indicated the nurse called the Physician and reported he was given the wrong medications and the Doctor ordered an IV to be started. The Resident indicated the nurse did not verify his name. The Resident expressed concern this had happened and indicated he no longer felt safe to stay at the facility. An interview on 8/15/13 at 12:15 p.m. with LPN #2 indicated she had worked at the facility for a while and she knew the residents. She indicated she assisted new staff by pointing out the residents for them during administration of medications. She indicated they have put pictures in the MAR indicated [REDACTED]. A Review of Resident #34's clinical record indicated his [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], dementia, [MEDICAL CONDITION], obesity, history of falls and history of [MEDICAL CONDITION]. Resident #34's BIMS (Brief Interview for Mental Status) was 14/15 which indicated he was alert and oriented. Review of Resident #34's nurses notes included the following: On 8/10/13 at 8:15 a.m., "...Writer approached resident asking if he was the (resident's roommate's name). Resident #34 smiled and accepted medications from writer. Resident took medications. Resident then after 15 minutes stated to another nurse that he knew he took his am meds from her at breakfast and thinks he took his roommate's pills from writer. Writer verified that this resident acknowledged himself as (roommates' name) and took medications handed to him. Resident asked why did he take medications if name was incorrect. Resident stated he didn't know. Dr. notified. Vital Signs being monitored. B/P (Blood Pressure) 90/35, P (Pulse)-81." Nurse's Note signed by LPN #1. On 8/10/13, 9:45 a.m., "...B/P 85/45, P 82...." Nurse's Note signed by LPN #1. On 8/10/13, 10:00 a.m., "...Dr. returned call to facility. N.O. (Nursing Order) obtained for IV NS (Normal Saline Solution) at 100 cc/hr until B/P comes up and hold B/P medications until B/P comes up...." Nurse's Note signed by LPN #1. On 8/10/13, no time documented, "...B/P baseline 120/60 for resident, new orders. IV to be D/C (discontinued) when B/P reaches baseline or greater...." Nurse's Note signed by LPN #1. On 8/10/13, 11:30 a.m., "...IV nurse here for peripheral line placement. Site noted to resident's L (left) hand. IV fluids were initiated. B/P continues to be monitored q (every) hour. Last B/P 99/54, P 77. Resident in bed at this time. HOB (head of bed) up 30 degrees...." Nurse's Note signed by LPN #1. On 8/10/13, 2:00 p.m., "...B/P obtained again, Resident up in recliner chair in room. Resident alert and oriented x 3. Resident continues to answer questions appropriately. No apparent S/S (sign and symptoms) of injury. Resident also has been socializing with other residents and visitors in his room. IV patent to L hand and infusing at 100 cc/hr. No S/S phlebitis. Res assisted x 2 staff to bathroom. Res. voided quantity sufficient...." Nurse's Note signed by LPN #1. On 8/10/13, 5:35 p.m., "...Resident alert and talkative no C/O (complaints of) pain or discomfort continuing to monitor B/P...." Nurse's Note signed by LPN #2. The next nurses notes for Resident #34 available were dated 8/12/13 and included the following: On 8/12/13, 10:30 a.m., "...N.O. (new order) CBC (Complete Blood Count) and Chem 6 (Blood Chemistry Screen) on 8/13/13, D/C IV...." On 8/12/13, 11:00 a.m., "...Resident's [MEDICATION NAME] (diabetes medication) (18 mg/3 ml pen) Give 1.8 mg(0.3 ml) daily clarification with pharmacy via nurse...." On 8/13/13, 2:30 p.m., :...D/C W/C (wheelchair), Bed alarm and check alertness d/t (due to) Resident up ad lib...." During an interview with the Interim DCS (Director of Clinical Services) on 8/15/13 at 11:28 a.m., the Interim DCS indicated there were no Nurse's Notes documented on 8/11/13. Review of Resident #63's MARs (Medication Administration Records) indicated these medication were given to Resident # 34 during 8:00 a.m. medication pass: 1. [MEDICATION NAME] 10 mg 1 tab po TID (8 a.m., 4 p.m. and 8 p.m.) (muscle relaxant, anti spasm). This medication was given to the wrong resident. 2. [MEDICATION NAME] 6.25 mg 1 tab po bid (8 a.m., 6 p.m.) ( beta blocker cardiac medication). This medication was given to the wrong resident. 3. Tab-A-Vit 1 tab po daily (8 a.m.) (vitamin supplement). This medication was given to the wrong resident. 4. [MEDICATION NAME] 5 mg 1 tab po daily (8 a.m.) (anti-diabetic to lower BS). This medication was given to the wrong resident. 5. [MEDICATION NAME] 600 mg 1 tab po BID (8 a.m. and 4 p.m.) ( anticonvulsant and for nerve pain). This medication was given to the wrong resident. 6. Levetracetam 500 mg 1 tab po q 12 hr (8 a.m. and 8 p.m.)( ) .This medication was given to the wrong resident. 7. [MEDICATION NAME] 10 mg 1 tab po daily (8 a.m.) (allergy medication). This medication was given to the wrong resident. 8. [MEDICATION NAME] powder 17 mg in juice or water po daily (8 a.m.) (for constipation). This medication was given to the wrong resident. 9. [MEDICATION NAME] 150 mg 1 tab po bid(8 a.m. and 6 p.m.) (GI, reduction of acid production). This medication was given to the wrong resident. 10. [MEDICATION NAME] 60 mg 1 tab po daily. (8 a.m.) (antidepressant). This medication was given to the wrong resident. Review of Resident # 34 MARs indicated his medications were: 1. [MEDICATION NAME] 3-pak 10 mg/3 ml inject 1.8 ml SQ daily (8 a.m.) (anti-diabetic to lower BS (blood sugar)). 2. [MEDICATION NAME] SQ per sliding scale TID before meals. Resident received at 7 a.m., 11 a.m. and 5 p.m. on 8/10/13 (Insulin). 3. [MEDICATION NAME] 40 units SQ q A.M. and eve (8 a.m. and 5 p.m.) (Insulin). 4. [MEDICATION NAME] 250-50 diskus inhale 1 puff BID( 2 x/day) (8 a.m. and 4 p.m.) (for asthma). 5. [MEDICATION NAME] 300 mg 1 tab po daily (8 a.m.) (for gout or kidney stones). 6. Aspirin 81 mg EC 1 tab po QOD (every other day) (8 a.m.) was given on 8/10/13 7. [MEDICATION NAME] 3.125 mg 1 tab po BID (8 a.m. and 4 p.m.) held at 4 p.m. (beta blocker, cardiac med). 8. [MEDICATION NAME] 2 mg 1 tab po TID (3 x/day) (8 a.m., 2 p.m., 8 p.m.) (for anxiety). 9. [MEDICATION NAME] 40 mg 1 tab po BID (8 a.m. and 4 p.m.) (diuretic). 10. [MEDICATION NAME] 137 mcg 1 tab po daily (7 a.m.) (for [MEDICAL CONDITION]). 11. [MEDICATION NAME] 50 mg 1 tab po daily (8 a.m.) (for hypertension). 12. [MEDICATION NAME] 1 gm 2 cap (2 gm) po BID (8 a.m. and 4 p.m.) (Omega-3). 13. [MEDICATION NAME] 500 mg 1 tab po daily (8 a.m.) ( for diabetes type II (Adult onset) control BS (Blood Sugar) with Insulin). 14. [MEDICATION NAME] 10 mg 1 tab po BID (8 a.m. and 4 p.m.) (for Alzheimer's). 15. [MEDICATION NAME] 300 mg 1 cap po daily at HS (bedtime) (9 p.m.)(anticonvulsant and for nerve pain). 16. [MEDICATION NAME] 10 mg 1 tab po daily (8 p.m.) (for dementia). 17. [MEDICATION NAME] XR 200 mg 1 tab po HS (9 p.m.) (antipsychotic). 18. [MEDICATION NAME] XR 50 mg 1 tab po HS (9 p.m.) (antipsychotic). 19. [MEDICATION NAME] 40 mg 1 tab HS (9 p.m.) (for [MEDICAL CONDITION]). 20. Spireva 18 mcg CP- handinhaler 1 cap orally via handinhaler device q (every) day (8 p.m.) (for [MEDICAL CONDITION]). A review of the facility's Medication Administration Investigation, dated August 10, 2013, provided by the Interim DCS indicated, "...LPN #2 reported to ED LPN #1 had given the wrong medication to Resident #34. ED directed nurse to notify MD of the medication administration and the name of the medications...Record review indicated the resident received the following medications which were not ordered for him: [MEDICATION NAME] 10 mg, Carveil 6.25 mg, Tab-A-Vit; [MEDICATION NAME] 60 mg, [MEDICATION NAME] 600 mg, Levetiracetan 500 mg, Loratidine 10 mg, [MEDICATION NAME] 150 mg....LPN #2 indicated she identified the resident to LPN #1....LPN #1 indicated she had called the resident by (first name of Resident # 63) and Resident # 34 stuck his hand out and took the medication cup....It was determined the MAR for Resident #63 did not have a photograph for identification...." A review on 8/15/13 at 11:38 a.m. of the Attendance Log for Medication Administration dated 8/13/13, provided by the Interim DCS, indicated only 3 nurses were in-serviced on Medication Administration. On 8/15/13 at 12:00 p.m., a review of all of the current Residents' MARs and TARs indicated 30 of the 46 MARs did not have Residents' photographs for identification and 27 or 46 TARs did not have Residents' photographs for identification. The Immediate Jeopardy that began on 8/10/13 was removed on 8/16/13 when the facility added photograph identification to every resident's MARS and Inserviced all nursing staff on accurate identification of residents during medication administration. Noncompliance remained at the scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of ongoing monitoring of accurate medication administration. 3.1-48(c)(2)

Based on interview and record review, the facility failed to assess, develop and implement dietary interventions for 2 residents (Resident #83 and Resident #85) of 4 residents who met the criteria for weight loss since admission, and 1 resident (#45) who had no weights and dietary assessments. This resulted in severe weight loss for Residents #83 and #85. Findings include: 1. Review of the clinical record for Resident #83 on 8/15/13 at 3:18 p.m., indicated the following: [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An Initial and Annual Nutrition Assessment for Resident #83, dated 5/29/13, indicated an admission weight 112.3 pounds and a usual weight of 108 pounds. The assessment also indicated she had increased nutrient needs related to her [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Skilled Nursing Progress Notes for Resident #83, dated 6/11/13, indicated she was sent to the hospital ER (emergency room ) for evaluation and treatment for [REDACTED]. An Admission - Data Collection Form for Resident #83, dated 6/26/13, indicated she had returned to the facility from the hospital. The form indicated a weight of 110.8 pounds. Physician orders [REDACTED]. The orders did not include the [MEDICATION NAME]. A Monthly Weights and Percentages for Resident #83 indicated the weight of 96.5 pounds on 7/20/13, or a loss of 14% since her admission on 5/24/13, indicating a severe weight loss. There were no other weights available in the clinical record from the admission weight of 112.3 pounds on 5/29/13 to the July, 2013 weight of 96.5 pounds. Review of the clinical record indicated there were no additional dietary interventions initiated to prevent further weight loss. Review of the Meal Intake Detail Report for Resident #83 indicated the following: for the breakfast meal - no meal intake was recorded for 5/25/13, 5/26/13, 5/27/13, 5/28/13, 5/29/13, 5/30/13, 6/3/13, 6/4/13, 6/5/13, 6/7/13, 6/10/13, 6/11/13, 6/25/13, 6/26/13, 6/27/13, 7/6/13, 7/7/13, 7/9/13, 7/11/13, 7/27/13, 8/3/13, 8/9/13, 8/12/13, and 8/13/13; for the lunch meal - no meal intake was recorded for 5/25/13, 5/26/13, 5/27/13, 5/28/13, 5/29/13, 5/30/13, 6/3/13, 6/4/13, 6/5/13, 6/7/13, 6/10/13, 6/11/13, 6/11/13, 6/25/13, 6/26/13, 6/27/13, 7/6/13, 7/7/13, 7/9/13, 7/11/13, 7/27/13, 8/3/13, 8/9/13, 8/12/13, and 8/14/13; for the dinner meal - no meal intake was was recorded for 5/24/13, 5/25/13, 5/26/13, 5/27/13, 5/28/13, 5/29/13, 6/1/13, 6/2/13, 6/3/13, 6/4/13, 6/5/13, 6/6/13, 6/7/13, 6/8/13, 6/9/13, 6/10/13, 6/11/13, 6/25/13, 6/26/13, 6/27/13, 6/28/13, 6/29/13, 7/1/13, 7/2/13, 7/3/13, 7/4/13, 7/5/13, 7/6/13, 7/7/13, 7/8/13, 7/9/13, 7/10/13, 7/11/13, 7/12/13, 7/13/13, 7/14/13, 7/15/13, 7/16/13, 7/17/13, 7/18/13, 7/19/13, 7/20/13, 7/21/13, 7/22/13, 7/23/13, 7/24/13, 7/25/13, 7/26/13, 7/27/13, 7/28/13, 7/30/13, 8/1/13, 8/2/13, 8/4/13, 8/5/13, 8/6/13, 8/7/13, 8/8/13, 8/10/13, 8/11/13, 8/14/13, and 8/15/13. A Nutritional Review for Resident #83, dated 8/14/13 and written by the Registered Dietitian, indicated a weight of 166 pounds plus chair. The review did not indicate the weight of the chair. Since the weight of the chair was not calculated, the weight of Resident #83 was not calculated. The review also indicated her intakes were 75-100% at mealtime, although there was no mention of the number of days missing from the Meal Intake Detail Report. The review further indicated there were no recommendations made from the Registered Dietitian. There were no additional weights to review for Resident #83. A current meal tray card for Resident #83 indicated she received a LCS NAS diet with a 4 ounce sugar free health shake with each meal A facility care plan for Resident #83, dated 5/24/13, indicated the problem area of at risk in nutrition/hydration. The goal for Resident #8 was not to have significant change in weight through next review. Approaches to the problem included, but were not limited to, diet per order, weigh weekly x 4 weeks then monthly or as ordered, and monitor intake and documentation on daily flow sheet. A facility care plan for Resident #83, dated 8/14/13, indicated the problem area of nutritional risk. Approaches to the problem included, but were not limited to, diet as ordered, monitor weight, and monitor intake. 2. Review of the clinical record for Resident #85 on 8/15/13 at 10:42 a.m., indicated the following: [DIAGNOSES REDACTED]. Resident #85 was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. physician's orders [REDACTED]. The order also indicated he received 20 mg [MEDICATION NAME] daily and [MEDICATION NAME] 30 mg HS (hour of sleep). A physician's orders [REDACTED]. An Initial and Annual Nutrition Assessment for Resident #85, dated 6/21/13, did not include a height and weight. A Nutritional Progress Notes for Resident #85, dated 6/24/13, indicated no height and weight were recorded on admission. A physician's orders [REDACTED]. A Weekly Weights and Percentages for Resident #85 indicated a weight of 149.8 pounds on 7/20/13. There were no other weights prior to 7/20/13 recorded for Resident #85. A Weekly Weights and Percentages for Resident #85 indicated a height of 68 inches and a weight of 136.7 pounds on 8/7/13, a loss of 8% since the weight of 149.8 pounds on 7/20/13, indicating a severe weight loss. Review of the Meal Intake Detail Report for Resident #85 indicated the following: for the breakfast meal - no meal intake was recorded on: 6/22/13, 6/23/13, 6/24/13, 7/6/13, 7/7/13, 7/11/13, 7/16/13, 7/21/13, 7/28/13, 8/3/13, 8/5/13, 8/9/13, 8/11/13, and 8/13/13; for the lunch meal - no meal intake was recorded on: 6/22/13, 6/23/13, 6/24/13, 7/3/13, 7/6/13, 7/7/13, 7/11/13, 7/16/13, 7/21/13, 7/28/13, 8/3/13, 8/5/13, 8/9/13, 8/11/13, 8/12/13, and 8/13/13; for the dinner meal - no meal intake was recorded on: 6/22/13, 6/23/13, 6/24/13, 6/25/13, 6/26/13, 6/27/13, 6/28/13, 6/29/13, 7/1/13, 7/2/13, 7/3/13, 7/4/13, 7/5/13, 7/6/13, 7/7/13, 7/8/13, 7/9/13, 7/10/13, 7/11/13, 7/12/13, 7/14/13, 7/15/13, 7/16/13, 7/17/13, 7/18/13, 7/19/13, 7/20/13, 7/22/13, 7/23/13, 7/24/13, 7/25/13, 7/26/13, 7/27/13, 7/28/13, 7/30/13, 8/1/13, 8/2/13, 8/4/13, 8/6/13, 8/8/13, 8/10/13,and 8/11/13. A Nutritional Progress Notes for Resident #85, dated 8/12/13, indicated a weight of 136.7 pounds, or a loss of 8.4%, with a usual weight of 145 pounds. The note also indicated his [MEDICATION NAME] was increased and weight loss was due to the diuretic. The note also indicated the resident described his appetite as "fine", but did not eat breakfast. The note did not consider any other reason for the weight loss, even though the resident was receiving [MEDICATION NAME] for his appetite and did not mention the number of days missing from the Meal Intake Detail Report. The note further indicated there were no recommendations made to prevent additional weight loss. A facility care plan for Resident #85, dated 6/21/13, indicated the problem area of at risk for alteration in nutrition/hydration. The goal for Resident #85 was to not have a significant change in weight through next review. Approaches to the problem included, but were not limited to, diet per order, monitor intake, and weight weekly x 4 weeks then monthly and as ordered. The Certified Dietary Manager was interviewed on 8/12/13 at 3:00 p.m. During the interview he indicated the facility procedure for residents weights were for staff to obtain the weight on each resident as ordered, complete a weight sheet for each month, and provide the sheet to dietary for review. He also indicated the procedure was not being followed. The Administrator was interviewed on 8/13/13 at 8:30 a.m. During the interview she indicated newly admitted residents were to be weighed weekly unless there were specific circumstances not to weigh. The Regional Dietitian was interviewed on 8/13/13 at 9:30 a.m. During the interview she indicated newly admitted residents were to be weighed weekly and at the recommendation of the Registered Dietitian. A current facility policy "Weighing the Resident", revised on 1/1/09 and provided by the Administrator on 8/16/13 at 9:00 a.m., indicated "...At a minimum, all residents of the facility shall be weighed upon admission and monthly...Weights will be completed monthly and documented in the nurses notes...Review prior month's weight and the scale that was used...Should the weight on the scale show a significant difference (a gain or loss of 5% within thirty day, 7.5% in ninety days, or 10% in six months) notify the nurse who will also alert the dietary department on the communication form...When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed...Record weight and alert nurse to any significant change...The nurse will: 1. Notify the physician of any significant weight change 2. Consult with the Director of Dietary Services and/or dietitian 3. Notify the MDS (Minimum Data Set) Coordinator in order to update the plan of care...The weight committee will review residents with a significant difference in weight...." 3. During the Admission Record Review for Resident #45 on 8-13-2013 at 1:30 p.m., there was no documentation weights were recorded for the resident. An interview with the Corporate Dietitian on 8-13-2013 at 1:30 p.m., indicated she was unable to find any weights done by the facility since admission on 7-5-2013 or an admission dietary assessment done by the dietician. She indicated the HCSG (Healthcare Services Group) dietitian was in the facility one time in July 2013. The Corporate Dietitian indicated the Corporate policy required completion of a dietary assessment within 7 days of admission. A "Dietary Services Agreement" provided by the Administrator on 8-14-2013 at 4:03 p.m., indicated "HCSG shall provide sufficient staffing to address the Facility's volume of admissions...and necessary nutritional assessments as required...." A policy "Clinical Dietary Policies and Procedures-Dietary Policy Status" dated 1-1-2007, provided by the Corporate Dietitian indicated "the Dietitian/DTR will complete a full nutritional assessment within the first 7 days and an Annual Reassessment. Residents at high nutritional risk will be assessed with [REDACTED].weight is also obtained by nursing when the resident is admitted and at least monthly thereafter...weight is also obtained by nursing when the resident is admitted and at least monthly thereafter...." 3.1-46(a)(1)

Based on observation, interviews and record review: A. The facility failed to assure heating units were operating at a safe temperature. This resulted in a resident sustaining a burn requiring hospitalization . This deficient practice affected 1 of 1 residents with a burn in a sample of 7 and potentially affected all 49 residents residing in the facility. (Resident #B) B. The facility also failed to assure a resident was transferred safely using a hoyer lift. This deficiency affected 1 of 1 residents, observed being transferred with a lift in a sample of 7. (Resident #U) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 3/10/11 and began on 1/18/11. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 3/10/11 at 2:30 p.m. The Immediate Jeopardy was removed on 3/14/11, but the facility remained out of compliance at the level of pattern, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A. During interview on 3/8/11 at 9:45 a.m., during the entrance conference, the Administrator indicated there had been a reportable incident involving resident #B in January, 2011. The Administrator indicated Resident #B had a low blood sugar, fell and burned his hand on the heater in his room. The Administrator indicated the resident had been sent to the hospital burn unit and did not return to the facility. On 3/8/11, during the orientation tour, accompanied by the DON (Director of Nursing) all heating units were checked on the east and south halls. Heating units in Rooms 135, 139 and 141 were found to be very hot to touch. The room thermostats were in a plastic enclosures that required a key to unlock. The thermostat dial was missing on the thermostat in room 135. The thermostats in rooms 141 and 139 were set at 65 and 75 respectively. The clinical record of resident #B was reviewed on 3/8/11 at 11:00 a.m. On 1/18/11 at 8:00 a.m., Nursing notes indicated, "Called to room per CNA et (and) med. (medical) records. Observed res. (resident) on floor between bed and window Rt (right) hand up against the register. Full ROM (range of motion). No c/o (complaints) of pain. res assisted back to w/c (wheelchair) et charge nurse entered room et began v/s (vital signs). Hand appeared s (without) redness was hard white area between thumb et 1st finger." Hospital records, dated 1/18/11, indicated Resident #B was admitted to the hospital with [REDACTED]. The hospital discharge summary, dated 1/21/11, indicated the resident was discharge to a nursing facility following excision and debridement of a full thickness wound of the right hand. The resident was to continue on wound vac therapy with follow up in the burn clinic prior to grafting. On 3/8/11 at 2:10 p.m., CNA #4 was interviewed regarding the heating units. He indicated the day after the incident with Resident #B, on (1/19/11), he was getting a resident up in room #110 on the west hall, smelled smoke and found a pillow laying on the register. The CNA indicated there was a burn mark on the pillow and he showed the burned pillow to the staff who had gathered for the morning meeting. The CNA indicated they "cut the heaters down," and started 15 minute checks. During interview on 3/9/11 at 11:30 a.m., the Maintenance Director indicated, after the incident on 1/18/11, he determined six thermostats were not working properly, including the thermostat in Resident B's room. He indicated he turned off the thermostat in resident #B's room but the unit continued to heat. He replaced all six thermostats, enclosed all of the thermostats in the rooms and put new covers on two of the heating units. He indicated he had an ongoing problem with the heating units being too hot or too cold and would check thermostats every day because of complaints but he did not keep records of which units were checked until after the incident. On 3/9/11 at 4:30 p.m., the electric heating unit in room 139 was noted to be hot. The temperature of the unit was checked and found to be 218 degrees Fahrenheit. The thermostat in the room was set at 64 degrees Fahrenheit and the room temperature was 77 degrees Fahrenheit. The Administrator was notified and during interview at that time indicated the thermostat would be changed. On 3/10/11 at 9:00 a.m., the Administrator indicated, after the incident on 1/18/11, all thermostats were checked and six were not working properly, including the one in Resident #B's room. On 1/19/11 all six thermostats were replaced. The Administrator indicated prior to 1/18/11 the thermostats were checked on an ongoing basis and in response to complaints about the room temperatures but nothing specific was documented and as result they were not sure when resident B's room thermostat had been checked last. In addition, the administrator indicated, after the incident on 1/18/11, the heating units were checked by a heating company and the thermostats were covered with a locked plastic enclosure so that the temperature setting could not turned up too high. On 3/10/11 at 9:05 a.m., three rooms on the south hall were checked. The electric heaters in room 124, 125 and 126 were very hot to touch. Resident #D, who resided in one of the rooms, and who was identified as interviewable, indicated her room was too hot and she had to open the window. The thermometer in the room was set at 52 degrees Fahrenheit. Resident #D said it was hard to regulate the temperature in the room and it was either too hot or too cold. B. On 3/9/11 at 5:45 a.m., CNA #4 was observed transferring dependent Resident #U from the bed to the wheelchair using a hoyer lift. The CNA did not obtain assistance and was the only staff person in the room during the transfer. On 3/9/11 at 1:00 p.m., the DON was asked about the transfer of Resident #U and indicated two staff persons should be present while transferring a resident using a hoyer lift. Resident #U's care plan, dated 12/24/10, was reviewed on 3/10/11 at 9:00 a.m. and indicated the resident was at risk for falls related to bilateral below the knee amputations and was to use a hoyer lift for transfers. The procedure for lift devices, revised 6/08, provided by the DON, was reviewed on 3/10/11 at 9:00 a.m. and indicated "...3. Review any special precautions or approaches to take when transferring a resident/patient. Obtain assistance as needed..." The procedure did not specify that two persons were required for a hoyer transfer. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 3/10/11 and began on 1/18/11. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 3/10/11 at 2:30 p.m. The Immediate Jeopardy was removed on 3/14/11, but the facility remained out of compliance at the level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Based on observation, interviews and record review, the facility removed the immediate jeopardy as follows: by inspecting the heaters in each room and installing new electric heaters and thermostats in all resident rooms; by turning off installed heaters pending the installation of insulated protective heater covers; by inservicing staff regarding the need to monitor heating units in resident room for safe operational temperatures, by identifying resident's who were at risk of sustaining burns on the heaters and developing plans to protect theses residents. Finally, the facility planned to provide ongoing monitoring of heating units for any potential hazards. This federal tag relates to Complaint Number IN 999. 3.1-45(a)(1)

Based on interviews and record review, the facility failed to assess a 3rd degree burn for 3.5 hours, failed to provide a follow-up assessment of a resident with a low blood sugar and failed to immediately notify the physician regarding low blood sugars and a 3rd degree burn. This deficiency affected 1 of 5 residents with in insulin dependent diabetes mellitus and 1 of 1 resident who sustained a 3rd degree burn in a sample of 7. This resulted in resident B requiring hospitalization , wound vac treatment, and planned future grafting to the burn site. (Resident #B) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 3/10/11 and began on 1/18/11. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 3/10/11. The Immediate Jeopardy was removed on 3/14/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: Upon interview 3/8/11 at 9:45 a.m., during the entrance conference, the Administrator indicated there had been a reportable incident involving resident #B in January 2011. The Administrator indicated Resident #B had a low blood sugar, fell and burned his hand on the heater in his room. The Administrator indicated the resident had been sent to the hospital burn unit and did not return to the facility. The clinical record of resident #B was reviewed on 3/8/11 at 11:00 a.m. and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. admission orders [REDACTED] 110-150= 2 units 151-200= 4 units 201-250= 6 units 251-300= 8 units. Call MD if > (greater than) 300 admission orders [REDACTED]. The [MEDICATION NAME] was discontinued on 1/11/11 and [MEDICATION NAME] (an oral medication used to lower blood glucose) 120 mg (milligrams) was ordered three times per day with meals. The January MAR (medication administration record) indicated the [MEDICATION NAME] was given at 7:00 a.m., 12 noon and 6:00 p.m.). There were no orders regarding what measures were to be taken if the resident had low blood sugars. On 1/15/11 at 11:00 a.m., the diabetic flow sheet indicated Resident #B had a low blood sugar of 44. An entry beside the 44 ("44/130") measurement indicated the Resident's blood sugar had been retaken, and was 130. There was no documentation the physician was notified about the low blood sugar. During interview on 3/10/11 at 9:00 a.m. the DON (Director of Nursing) indicated she was not able to determine if the physician had been notified about the low blood sugar on 1/15/11. On 1/18/11 at 6:00 a.m., the diabetic flow sheet indicated Resident #B had a blood sugar of 151 and 4 units of [MEDICATION NAME]were administered. On 1/18/11 at 8:00 a.m., Nursing notes indicated, "Called to room per CNA et (and) med. (medical) records. Observed res. (resident) on floor between bed and window Rt (right) hand up against the register. Full ROM (range of motion). No c/o (complaints) of pain. res assisted back to w/c (wheelchair) et charge nurse entered room et began v/s (vital signs). Hand appeared s (without) redness was hard white area between thumb et 1st finger." On 1/18/11 between 8:01 and 8:04 a.m., nursing notes indicated vital signs were taken and further indicated "Writer entered res room res on floor by window, diaphoretic. res B.S. (blood sugar) checked BS 51 protein supplement given breakfast here assisted with breakfast by staff. Scheduled transport here LOA (leave of absence) scheduled apt (appointment); (Dr name) called and NO (new order) received & (and) Noted. On 1/18/11 at 10:30 a.m., Physician orders [REDACTED]. three times daily. On 1/18/11 at 11:00 a.m., a physician's orders [REDACTED]." On 3/8/11 at 11:55 a.m., the medical records/van driver was interviewed about the incident with resident #B on 1/18/11. The medical records staff person indicated she was working on 1/18/11 and heard CNA #1 yelling for help so she ran to Resident #B's room. The medical records person indicated the resident was "out of it", lying on his right side with the index finger of his right hand in the gap of the heater and his thumb touching the heater. The medical records person indicated she took the hand out of the heater and called for assistance. The medical records person indicated LPN #2 and the charge nurse, LPN #3 arrived, checked the resident, and they lifted him into his wheelchair. She indicated Resident #B did not remember how he got on the floor and he had a white area on his right hand along the thumb and index finger which LPN #2 checked and thought was a callous. The medical records person indicated at around 9:00 a.m., she took the resident to an appointment at (name of Orthopedics center documented). She indicated Resident #B said he didn't fell well so she called the facility, the DON and Corporate nurse arrived at the orthopedics center and the corporate nurse put some ointment on Resident #B's hand and wrapped it. According to the medical records person, the orthopedics center Doctor did not look at the resident's hand. CNA #1, who provided care to Resident #B on 1/18/11, was interviewed on 3/8/11 at 1:30 p.m. CNA #1 indicated at 7:30 a.m. she saw the resident sitting on the edge of his bed, facing the door, dressed. The aide indicated she was passing room trays at around 7:45 a.m. and noticed the resident was not in his room so she put the tray back in the cart. She indicated she looked in the Resident's bathroom and when she turned around, she saw him on the floor by the window and called for help. The aide indicated she gave the resident orange juice and assisted the resident to eat his breakfast after the nurses had checked him. CNA #1 said the resident had a white area on his hand with brown "grill" marks and she thought it looked like a burn but she wasn't sure. The aide indicated the resident did not complain of pain. LPN #2, who was working on 1/18/11 was interviewed on 3/8/11 at 3:00 p.m. LPN #2 indicated at around 8:00 a.m., the charge nurse, who was working on Resident's B's hall, was on the phone, and she responded to a call for help in Resident #B's room. LPN #2 indicated the medical record's person was in the room and told her Resident #B's hand had been in the heater but when she checked his hand it did not look like a burn because there was no redness, swelling or blisters and appeared to be scar tissue. LPN #2 indicated she checked the resident's range of motion and helped him into the wheelchair while the charge nurse, LPN #3, took his vital signs and blood sugar. LPN #2 indicated, after she left the room, she did not see the resident again until he returned from his office appointment. The DON (Director of Nursing) was interviewed on 3/9/11 at 9:00 a.m. She indicated she had just started employment at the facility and on 1/18/11, it was her second day of orientation. The DON indicated she and the corporate nurse were in the facility, but were not made aware of the incident that occurred at 8:00 a.m. until after the resident left for an appointment at the orthopedic clinic. The DON indicated the medical record/van driver called the corporate nurse and told her she was with the resident at orthopedic clinic and he had a burn on his hand. The DON indicated the corporate nurse gathered up some supplies and she drove with the corporate nurse to orthopedic clinic. The DON indicated the corporate nurse applied some ointment and wrapped the resident's hand. She indicated she did not see the hand because she was talking to the doctor about the resident's foot. The DON indicated she did not examined the resident's right hand until he returned from the appointment at around 11:30 a.m. She indicated, when she looked at the hand, she recognized he had a third degree burn. The physician was notified and the resident was sent to the hospital. The DON indicated no treatment order was obtained prior to the administration of the ointment at the orthopedic clinic and the DON was unsure what ointment was used. The corporate nurse was no longer employed by the corporation. The charge nurse, LPN #3, who worked on Resident #B's hall on 1/18/11, was interviewed on 3/9/11 at 11:00 a.m. LPN #3 indicated she gave Resident #B 4 units of insulin coverage at around 7:00 a.m. and at around 8:00 a.m. she was on the phone when she heard the medical records person call for help. She responded to Resident #B's room and found him diaphoretic. His blood sugar was 51, she gave him a protein drink and took his vital signs three times with the last check being at 8:30 a.m.. LPN #3 indicated she heard the medical record staff person say Resident #B's hand had been on the heater but she did not look at his hand. LPN #3 indicated she left the room when the aide started feeding the resident. She indicated she did not recheck the resident's blood sugar, did not check the resident's hand and did not see the resident before he left for his appointment. Hospital records, dated 1/18/11, indicated Resident #B was admitted to the hospital with [REDACTED]. The hospital discharge summary, dated 1/21/11, indicated the resident was discharge to a nursing facility following excision and debridement of a full thickness wound of the right hand. The resident was to continue on wound vac therapy with follow up in the burn clinic prior to grafting. The policy for [DIAGNOSES REDACTED], revised 11/08, provided by the DON was reviewed on 3/9/11 at 3:30 p.m., and indicated the purpose of the policy was "To detect an acute hypoglycemic episode as soon as possible and initiate immediate management of the episode. A diabetic ...resident/patient with blood glucose below 70 mg/dl or experiencing signs or symptoms of [DIAGNOSES REDACTED] is evaluated to determine if treatment is needed unless physician orders [REDACTED]. 5. Check blood glucose approximately 15 minutes after treatment... 6. Notify physician of hypoglycemic episode for possible orders... 9. Observe resident/patient for signs of (sic) symptoms of [DIAGNOSES REDACTED]..." This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 3/10/11 and began on 1/18/11. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 3/10/11. The Immediate Jeopardy was removed on 3/14/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Based on observation, interview, and record review, the facility removed the immediate jeopardy as follows: by providing staff with inservices regarding diabetic management, identification [MEDICAL CONDITION] circumstances requiring notification of the physician; by assessing current residents for blood sugars outside the normal parameters; by assessing all residents who might be at risk for burns; and by updating care plans to reflect the assessed needs of diabetic residents and residents at risk for burns. Finally, the facility planned to provide ongoing monitoring of resident receiving insulin to assure appropriate treatment and services were provided. This federal tag relates to Complaint Number IN 999. 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide care and initiate additional interventions to prevent pressure areas for 1 of 5 residents reviewed with pressure areas in a total sample of 9, resulting in three stage II open areas combining into one unstageable area (Resident #C). Findings include: 1. Resident #C's clinical record was reviewed 11/04/10 at 2:00 P.M. Resident C's [DIAGNOSES REDACTED]. Resident #C was observed on 11/04/10 between 1:50 P.M. and 5:10 P.M. in bed on her back with no pillow behind her back for positioning, on 11/05/10 between 9 A.M. and 11:30 A.M. in bed on her back with no pillow behind her back for positioning, and on 11/08/10 between 9 A.M. and 11:30 A.M. in bed on her back with no pillow behind her back for positioning. In an interview on 11/08/10 at 9:32 A.M. CNA #11 indicated Resident #C turned onto her back despite positioning efforts. In an interview on 11/8/10 at 1:35 P.M. CNA #6 indicated Resident #C turned and moved in the bed without assistance and she preferred to stay on her back which is why she was put on a low air loss mattress after she got an open area. A review of the Minimum Data Set assessment dated [DATE] indicated Resident C had no memory impairment, was totally dependant on one staff for bed mobility, and required maximum assist by one staff with personal hygiene. A pressure area was coded as unstageable. A review of Resident #C's Braden scale dated 6/16/10 indicated a score of 13. The legend at the top of the form indicated the score of 13 represented a moderate risk of skin impairment. This was a decline from the Braden review on 3/22/10 when the score of 19 represented no risk. A review of weekly skin sweeps for June 2010 indicated no changes in skin conditions. In July 2010, the weekly skin sweeps on July 12th indicated an abscessed area on the right buttock near the top of the right leg that was being treated. On July 20th, the skin sweep indicated the abscessed area was showing healing, but there were no other changes to the skin areas. On July 23rd, the skin sweeps indicated there were three stage II areas on Resident #C's sacral area, right and left buttocks. There was no other indication of the status of the skin in that area. There were no nurse's notes between 5/10/10 and 7/24/10 to indicate the skin had been assessed on Resident #C. A current care plan entitled risk for impaired skin integrity dated 10/22/10 indicated approaches to prevent skin impairment were as follows, Braden scale on admission and quarterly, labs as ordered, skin sweep as ordered, Assist to turn and reposition frequently, provide incontinent care as needed. There was no care plan for skin integrity available for the period of 6/16/10 to 10/22/10. There was no care plan for the open area, and there was no care plan to promote healing during that time. A review of skin grids from 7/23/10 indicated the size of the areas as follows: area A was 1.2 x 1.3 .x 0.1 black eschar; area B was 0.9 x 0.9 x 0.1 yellowish slough; and area C was 0.4 x 0.4 x 0.1 reddened and open. There was suspected deep tissue injury indicated on the skin grid. The skin grids indicated a decline in the area on 7/29/10 with the three superficial stage II areas combining into one unstageable area measuring 1.9 x 3.1 x 0.1 with reddish open base and yellow slough on the coccyx. The skin grid indicated the skin around the open area was firm without redness. The skin grids indicated measurements each week after the initial identification of the breakdown and treatment changes were made as needed to promote healing. In an interview 11/08/10 1:35 P.M. the Director of Nursing indicated she was not sure how the deep tissue injury occurred. In a dressing change observation on 11/09/10 at 1:55 P.M., Resident C's open area on the coccyx presented as a brownish area the size of a small pea. The skin surrounding the area was pink in color with no redness noted. There was no drainage from the wound. A review of the Medication Administration Records from June 2010 and July 2010 indicated a gel cushion was added to Resident #C's wheel chair on 7/23/10 after the development of the three superficial stage II areas. A low air loss mattress was initiated on 7/29/10 after the three superficial areas combined into one unstageable area. In an interview on 11/05/10 at 9:45 A.M., the Director of Nursing indicated Resident #C had been able to walk until June then had been refusing to walk. Resident C's refusal behaviors interfered with turning and repositioning. In an interview on 11/08/10 at 2:20 P.M., the Director of Nursing indicated she was unsure if new interventions were initiated in response to the change in pressure area risk as indicated on the Braden scale dated 6/16/10. In an interview on 11/08/10 at 1:35 P.M. the Regional Quality Specialist indicated the skin assessment documentation should be on the skin sweeps or the nurse's notes. She additionally indicated if there was deep tissue injury, intervention changes should have been noted on the care plan. A current policy entitled Skin Care and Wound Management dated 8/10 provided on 11/09/10 at 9:30 A.M. by the Administrator indicated "...Overview The facility staff strives to prevent resident/ patient skin impairment and to promote the healing of existing wounds. Th Interdisciplinary team works with the resident/ patient and/or family/ responsible party to identify and implement interventions to prevent and treat potential skin integrity issues....Prevention Determine the reasons a resident/patient is at risk for pressure ulcer development...4. Develop a care plan ...Document individualized goals and interventions to manage risk factors...5. Communicate risk factors and interventions to the caregiving team...7. Modify and document goals and interventions as indicated...." This federal deficiency relates to complaint number IN 189. 3.1-40(a)(1)