Every finding on record at Markle Health & Rehabilitation

Based on record review and interview, the facility failed to ensure physician orders were followed, related to the timely administration of prescribed medications to resident. For 1 of 3 residents reviewed. (Resident K) Findings include:Resident K's record review began on 11/19/25 at 10:15 AM, diagnosis included, Hypothyroidism, unspecified.A review of the physicians orders indicated to give Thyroid tablet 60 mg, oral, once a day on Tuesday; at 5:00 AM. Start date of 10/13/25. Thyroid tablet; 90 mg, oral, once a day on Sunday, Monday, Wednesday, Thursday, Friday and Saturday at 5:00 AM. A review of the medication administration record (MAR) indicated Thyroid 60 mg was given on 10/13/25 at 10:00 AM. The reasons/comments section was noted administered late, with a further comment of given. The entry was created by Registered Nurse (RN) 4, and no specific reason was documented for the delay in administration.A review of the progress notes dated 10/13/25 indicated there was no documentation to indicate why the medication was administered late.In an interview, on 11/19/25 at 9:20, Resident K's husband indicated, on 10/13/25 all the medications were given at 10:00 AM and they were late. He indicated he told the facility, but they told him the medication could be given 1 hour before or 1 hour after the time that the medication was scheduled. The 6AM medication was given at 10:00 AM, the thyroid medication should be given early in the morning. In an interview, on November 19, 2025, at 11:45 AM, the Director of Nursing (DON), indicated Resident K came from home where her husband had been caring for her, giving her medications at specific times, and he wanted that practice continued at the facility. Resident K's husband was informed of the hour before and hour after window during which medication could be administered from the scheduled time. Staff educated RN 4 on ensuring medications are given on time, and it remains unclear why RN 4 did not make a note explaining the reason for a late administration.Resident K's MAR was reviewed at 9:14 AM on 11/20/25 with the DON. It was noted that a filter button, specifically for what's due, can be used to display a list of residents with pending medication or treatment administrations. The resident profiles utilize a color-coding system to indicate status: Pink signified an administration was late and had not yet been completed or acknowledged. Within the profile, nurses could document the reason for the delay (e.g., resident refusal) and add specific comments. Light blue indicated an administration was due but not yet late. [NAME] denoted all required administrations for the resident had been completed. A current facility policy, Medication Administration Times, dated 11/15/24, was provided by the Administrator on 11/19/25 at 1:11 PM. The policy indicated . Facility should that authorized personnel, as determined by Applicable Law, administer medications according to times of administration as determined by the facility's pharmacy committee and/or Physician/Prescriber .Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed no later than sixty( 60) minutes after the designated times of administration 3.1-37

Based on observation, interview and record review the facility failed to ensure residents were treated with respect for 1 of 1 residents reviewed. (Resident 30) Findings include: During an observation on 8/7/24 at 9:43 AM, Employee 4 used the term sweetheart to address Resident 30 when asking what hurt. Resident 30 became increasingly agitated when addressed by the label, sweetheart, rather than their name being used. Resident 30's record was reviewed on 8/6/24 at 1:05 PM. Diagnoses included dementia, chronic pain syndrome, history of stroke with residual deficits, and cognitive communication deficits. A review of Resident 30's current quarterly MDS (minimum data set) indicated their BIMS (basic interview for mental status) score was 1 (severely cognitively impaired). A review of Resident 30's current care plan indicated no care plan had been initiated regarding nicknames. In an interview on 8/6/24 at 1:18 PM, Resident 30's spouse indicated she would not like being called pet names, especially sweetheart. Resident 30 had not addressed others in that manner and would respond best to her own name being used in communication. In an interview on 8/8/24 at 12:57 PM Employee 5 indicated they had seen a trend of nicknames being used. They indicated they knew it was not appropriate. A current policy dated 8/8/24 provided by Administrator indicated residents have the right to be treated with respect. 3.1-3(a)

Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained during medication administration for 3 of 5 administration attempts observed. Findings include: During an observation on 8/5/2024 at 9:38 AM, Registered Nurse (RN) 2 on the 200 hall medication cart pulled a medication card from the cart, popped medication from the blister pack into their bare hand, then placed the medication into a medication cup that was on the cart. During an observation on 8/5/2024 at 11:24 AM, RN 2 at the 200 hall medication cart, popped medication from the blister pack into their bare hand, then placed the into a medication cup. During a medication pass observation on 08/06/24 08:16 AM, License Practical Nuse (LPN) 3 popped medication from the blister pack into their bare hands, then placed the medication into a medication cup. A record review of the Medication Administration ( Medication Pass Procedure) Skills Competency, Nursing skills competency, dated 7/2023 .Procedure steps: Medication are opened without contaminating . 3.1-18(a)

Based on observation, interview, and record review the facility failed to ensure care of communication deficit for 1 of 1 residents reviewed. (Resident 176) Findings include: During an observation on 07/24/23 at 10:21 AM, the Unit Manager was having difficulty understanding Resident 176. The Unit Manager requested Resident 176 start over from the beginning. The Unit Manager then repeated the parts she understood and asked Resident 176 if she was correct. There were no assistive devices used. Resident 176 was pacing with noted deficits to his left side. His lips and face had drooping on the affected side, he held left arm to his side, and he had an unusual gait. Resident 176 did not have oxygen on and was ambulating without assistance. In an interview, on 7/24/23 at 10:36, the Unit Manager indicated Resident 176 had a stroke prior to coming to facility. The Unit Manager was unable to understand him at times and at other times he was clearer. The Unit Manager indicated no assistive devices were used with Resident 176. Resident 176's record was reviewed, on 7/25/23 at 1:53PM, Resident 176 diagnoses included chronic obstructive pulmonary disease, cerebrovascular disease, history of cerebral infarction (stroke), and intermittent explosive disorder. Resident 176's current Quarterly MDS (Minimum Data Set) assessment Section B for hearing, speech, and vision indicated he had no deficits at the time of assessment. Section C of MDS for cognitive patterns assessed his BIMS (Brief Interview Mental Status) score to be 7 at the time of assessment. A score of 7 indicated moderate cognition deficit. Resident 176 had no speech therapy orders. In an interview, on 7/26/23 at 6:32AM, RN 6 indicated Resident 176 could be difficult to understand at times. RN 6 indicated agency staffing was utilized throughout the building. RN 6 indicated she was unaware of any communication assistive devices resident used i.e., pen and paper, dry erase board, cue cards, etc for any resident with communication difficulty. In an observation, on 7/26/23 at 8:00AM, Resident 176 was in a wheelchair. He was asked by LPN 7 where he would like to sit for breakfast. Resident 176 answered with what sounded like a possible name. LPN 7 stated a peer name in a questioning tone. Resident 176 shook his head no. LPN 7 asked if he wanted to sit by a different peer. Resident 176 shook his head no for a second time and repeated a name. LPN 7 asked if he wanted to sit by a 3rd peer. Resident 176 threw both hands up into the air and was visibly irritated. In an interview, on 7/26/23 at 1:36PM, the Unit Manager indicated Resident 176's speech was soft and at times mumbled, did at times get frustrated while attempting to communicate with others. The Unit Manager indicated Resident 176 care plan should include communication deficit. The Unit Manager indicated Resident 176 did not have any assistive devices for communication. Resident 176's comprehensive care plan did not include a problem of communication on 7/25/23. On 07/27/23 at 08:50 AM the Unit Manager provided a care plan updated to include the problem of communication. The problem with a start date of 7/26/23 indicated Resident 176 had difficulty making self-understood due to possible cerebrovascular disease. Resident 176's speech was soft and mumbled. Resident was able to communicate needs and wants when given time. The goal was: Resident will make self-understood. The approaches were documented as the following: Allow resident time to speak. Avoid interrupting. Gently inform resident you were unable to hear him and politely ask him to repeat himself. Observe for non-verbal signs of distress. Assess for pain. Provide liquids and food as needed. Provide a quiet, non-hurried environment, free of background noises and distractions. (The secured unit census had over a dozen other residents with activity room and dining area were close in proximity) Repeat what the resident said to validate him. Thank resident for communicating, conversing, and visiting with you, to praise him for continued communication. A policy dated 1/2010 with most recent revision 10/2019 titled, IDT Comprehensive Care Plan Policy was provided by DNS (Director of Nursing Services) on 7/27/23 at 9:48AM. The policy indicated each resident would have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan would include measurable goals and resident specific interventions based on resident needs to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial needs. 3.1-38(a)(2)(E)

Based on interview and record review the facility failed to ensure the residents' right to be free from verbal abuse for 2 of 4 residents reviewed. (Resident B, Resident C). Findings include: A facility reported incident, dated 5/28/23, was provided by the Administrator on 6/1/23 at 10:14 AM. The report indicated Certified Nurse Aide (CNA) 3 had accused CNA 2 of verbal abuse towards Resident B and reported her accusation to the Director of Nursing (DON). An investigation file was provided by the Administrator on 6/1/23 at 10:14 AM. The filed included statements, as follows: CNA 3's, statement, dated 5/28/23, indicated she and CNA 2 had assisted Resident B. CNA 3 indicated Resident B had become combative with care, by hitting and kicking. CNA 3 indicated CNA 2 yelled at Resident B to stop hitting then told Resident B she can hit faster than he can. CNA 3 indicated she told CNA 2 to leave the room. CNA 4 assisted CNA 3 with Resident B's care. Resident B had told CNA 4 about CNA 2 had yelled at him and told him what to do. At that time, CNA 2 returned to Resident B's room. CNA 2 indicated Resident B had tried to hit CNA 2 and CNA 2 indicated I told him I can hit faster than him. CNA 4 and CNA 3 told CNA 2 to leave the room. CNA 3 indicated CNA 2 stated whatever, rolled her eyes and left the room. CNA 3 indicated she had reported the incident to the DON and LPN 6 once Resident B was safe. CNA 4's undated statement indicated CNA 3 had asked her to help with Resident B's care. CNA 4 indicated she entered the room and Resident B was upset. CNA 4 indicated Resident B had indicated you want me up, you're going to push, push, push. CNA 4 indicated she asked Resident B what was wrong. Resident B had responded that girl wanted to yell at me and tell me what I had to do. CNA 4 indicated then CNA 2 entered the room. CNA 2 told Resident B you have to get up to eat .because I said so CNA 3 told CNA 2 to exit the room. CNA 4 indicated at the doorway CNA 2 stated Ya, he was trying to hit me too, I told him I can hit faster than he can. He ain' t gonna beat on me. CNA 4 indicated she notified the DON once Resident B was safe. LPN 6's statement, dated 5/30/23, indicated she had not been present when CNA 2 was with Resident B. The investigation file included additional staff and resident interviews, as follows: Resident C was interviewed on 6/1/23 by the DON. In the interview Resident C indicated CNA 2 talked nasty to me. Resident C had also indicated CNA 2 indicated we are not here to listen about that when the resident was talking about her health. Housekeeper 5 was interviewed on 6/1/23 by the DON. In the interview Housekeeper 5 indicated Resident C told him CNA 2 had been rude to her. In an interview on 6/1/23 at 11:11 AM, Housekeeper 5 indicated Resident C told him this week after the incident CNA 2 had a bad attitude towards Resident C and other residents. In an interview on 6/1/23 at 11:43 AM, Resident C indicated CNA 2 was mean and hateful. Resident C indicated CNA 2 talked nasty, especially at a time when the resident was discussing her health, the aide indicated we don't need to hear that. In an interview on 6/1/23 at 12:01 PM, the DON indicated on 5/28/23 she had worked the medication cart on the floor when CNA 3 and CNA 4 notified her of the verbal abuse allegations towards CNA 2. The DON indicated she had pulled CNA 2 into her office and called the Administrator. CNA 2 was escorted from the facility. The DON and Administrator indicated CNA 2 had not come into the facility but was instructed to write a statement and bring it in on 6/1/23. The Surveyor indicated CNA 2 could speak to her at the time of the survey. CNA 2's statement, dated 6/1/23 was provided by the DON on 6/1/23 at 2 PM. The DON indicated CNA 2 had left the building already. CNA 2 did not speak with the Surveyor. The statement indicated Licensed Practical Nurse (LPN) 6 alerted CNA 2 when Resident B had fallen and needed assistance. CNA 2 indicated Resident B was combative. CNA 2 indicated CNA 3, CNA 4 and LPN 6 all encouraged the resident to get up for dinner. CNA 2 indicated she did not abuse Resident B. 1. A record review was completed for Resident B on 6/1/23 at 11:21 AM. Diagnoses included depressive episodes and panic disorder. A quarterly Minimum Data Set (MDS) assessment, dated 3/13/2023, indicated Resident B had a Brief Mental Interview Status (BIMS) score of 10/15 (moderately impaired). 2. A record review was completed for Resident C on 6/1/23 at 11:16 AM. Diagnosis included depressive episodes. A quarterly MDS dated [DATE], indicated Resident C had a BIMS score of 15/15 (cognitively intact). A policy, revised January 2023, titled Abuse Prohibition, Reporting and Investigation, was provided by the Administrator on 6/1/23 at 10:14 AM. The policy indicated verbal abuse: oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend or disability. This Federal Finding relates to Complaint IN00409614. 3.1-27(b)

Based on interview and record review the facility failed to ensure security of medications from misuse for 1 of 10 residents reviewed. (Resident B) Findings Include: An investigation file was provided by the Administrator on 12/27/22 at 11:30 AM. The file included a facility reportable dated 12/15/22 the facility was notified by a detective from the local police department about an investigation regarding Registered Nurse (RN) 2. The detective indicated RN 2 was found to be in procession of a Resident B's bottle of gabapentin (anticonvulsant). A statement, dated 12/19/22, by RN 3 indicated she spoke with the detective. RN 3 indicated she had admitted resident B and no medication was brought into the facility by the family at the time of admission. RN 3 indicated the family indicated the medications were brought into the facility that evening and given to a floor nurse. The statement indicated after Resident B's discharge, RN 3 pulled cards out of the medication cart and placed them into the pharmacy return bag in the medication room. RN 3 and RN 2 were the only nurses in the building at the time with keys to the medication room containing the pharmacy return bag. RN 3 indicated she later returned to the medication room, found the medications pulled back out of the pharmacy bag in the sink. RN 3 indicated she thought RN 2 was under the impression the medications were new medications to be separated into the halls for distribution and RN 3 started to return them to the bag. RN 3 indicated she noticed 2 cards of gabapentin flipped the opposite direction and pulled away from the pile a bit. RN 3 indicated she felt uncomfortable so she sealed the bag of medication, placed them in the locked medication cart and passed the information onto the 3rd shift for pharmacy return. In an interview on 12/27/22 at 11:30 AM, the Administrator indicated on 12/15/22 a local police detective reported to the facility a bottle of gabapentin labeled with Resident B's name was found in possession of RN 2. The Administrator indicated she was unsure exactly how the nurse obtained possession of the medication as the nurse never administered medication to Resident B per documentation. The Administrator indicated she spoke with RN 3. She indicated on 10/13/22, RN 2 and RN 3 worked together. The Administrator indicated the resident's family had brought in medication from home after the resident was admitted . RN 3 indicated she did not receive any medication from the family at the time of admission or throughout her shift. In an interview on 12/27/22 at 2:35 PM, RN 6 indicated when a resident's family brought in medication from home the nurse obtained an order from the Nurse Practioner (NP) before administrating the medication. If the NP was not available, the medication would be placed in the locked medication cart or medication room until an order had been obtained. In an interview on 12/27/22 at 2:11 PM, the Director of Nursing (DON), indicated when a family brought in medication for a resident. The medication would be placed in the locked medication room and labeled with the resident's name until an order was received. In an interview on 12/27/22 at 11:04 AM, Licensed Practical Nurse (LPN) 7 indicated medications are only given to those who are prescribed the medication. A policy, last revised 2/2020, titled Abuse Prohibition, Reporting and Investigation, indicated .each resident should be provided an environment free from abuse, neglect, misappropriation of resident property misappropriation of resident funds or property: deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident's property or money without the resident's consent. This Federal Finding relates to Complaint IN00397437. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure kitchen sanitation was maintained. The deficient practice had the potential to affect 76 of 76 residents in the facility. Findings include: On 6/13/19 at 10:23 a.m., the kitchen tour was conducted. Dietary Staff #2 was interviewed and indicated the facility had an ice cream machine, which was observed on a counter in the kitchen. On 6/18/19 at 11:24 a.m., the lunch tray line was observed. Three servings of white ice cream were observed to be placed on meal trays. On 6/18/19 at 11:41 a.m., three more servings of white ice cream were observed to be placed on meal trays. On 6/19/19 at 8:30 a.m., Cook 1 was interviewed. She indicated she had turned off the ice cream machine at 6:15 a.m. today to clean it. She indicated it took approximately an hour to thaw the machine and about 30 minutes to clean it. She indicated to clean the machine, she would do the following: drain the remaining ice cream, run a cycle of water through the machine, scrub the interior out, run a cycle of sanitizer solution through, then take the machine apart and wash all the parts, then run a rinse cycle through. She indicated the rinse cycle took about 20 minutes. On 6/19/19 at 8:33 a.m., Cook 1 was interviewed. She indicated the ice cream machine was to be cleaned every 3 days. She indicated generally the day shift staff cleaned the ice cream machine or whoever had time to clean it. Cook 1 indicated the last time the ice cream machine had been cleaned was this past Sunday (6/16/19). She indicated she did not work last weekend and would look for the cleaning log from last weekend. On 6/19/19 at 8:35 a.m., Cook 1 was interviewed. She indicated the liquid ice cream mix in the ice cream machine was changed out every 3 days. She indicated the facility used a powdered mix, which was combine with water, to put in the ice cream machine. At this time, she provided a bag of the ice cream mix. The instructions on the bag indicated the following: mix 2 gallons of water with the contents of the bag and pour into the machine or cover and store in the refrigerator. The Federal Drug Administration (FDA) requires product temperature .remain at or below 41 degrees Fahrenheit. She indicated she did check the temperature of of the contents of the ice cream machine but did not document the temperature anywhere. On 6/19/19 at 8:37 a.m., the interior of the ice cream machine was observed with Cook 1. To access the lid of the machine, Cook 1 was observed to climb to the top of a 3 step ladder and remove the lid. The interior of the machine was observed to have the level of white foam, ice cream mix at least 6 inches below the top edge of the mixing pan. The interior corner of the mixing pan, was observed to have brown colored specks, in an area at least 2 inches by 2 inches. Cook 1 was interviewed and indicated the brown specks on the interior of the machine wound not come off. The gasket, which extended the perimeter of the mixing pan opening on the top of the machine, was observed. Along the 3 edges of the gasket, which were visible, there was observed to be dark matter. Cook 1 indicated the dark matter along the edges of the gasket was ice cream stuff. Cook 1 was able to remove the dark matter along the edges when the matter was scraped with her finger. At 8:38 a.m., a wet cloth was wiped across the brown specks which resulted in the brown specks being removed. On 6/19/19 at 10:00 a.m., Cook 1 was interviewed. She indicated the facility goes through enough ice cream, that the machine was cleaned every 3 days. On 6/19/19 at 10:15 a.m., the Director of Nurse (DON) provided a copy of the Weekly cleaning schedule for the kitchen, dated 6/9/19 (Sunday). The task of clean ice cream machine was documented as having been completed on 6/10/19 (Monday) and 6/13/19 (Thursday). On 6/19/19 at 10:16 a.m., the DON provided a copy of the Weekly cleaning schedule for the kitchen, dated 6/16/19 (Sunday). Documentation was lacking of the ice cream machine having been cleaned since 6/13/19. On 6/19/19 at 2:30 p.m., the Customer Service Representative (CSR) 3 from (name of ice cream mix manufacturer) was interviewed via phone. CSR 3 indicated the ice cream mix was acceptable for use for 48 hours after it had been mixed. CSR 3 indicated the 48 hour time frame applied to prepared ice cream mixture, regardless where it was being stored in the refrigerator and/or the ice cream machine. CSR 3 indicated the mixture should be kept at 41 degrees Fahrenheit. On 6/19/19 at 2:40 p.m., the Administrator (Adm) provided a copy of the current policy and procedure for Cleaning Ice Cream Machines dated 4/2011. The policy indicated .Soft serve ice cream machines will be disassembled, cleaned and sanitized after every use .Procedure .Follow manufacturer's directions for disassembling, cleaning, sanitizing and reassembling the ice cream machine. The manufacturer's directions will be readily available in the kitchen for staff to follow . On 6/19/19 at 2:51 p.m., the Administrator was interviewed. She provided clarification of the Cleaning Ice Cream Machines policy dated 4/2011. She indicated the reference to cleaned and sanitized after every use meant after the bag is empty or every 3 days, indicated the ice cream machine should be cleaned at least every 3 days. On 6/19/19 at 3:05 p.m., Cook 4 was interviewed. He indicated the ice cream machine had to be emptied and cleaned out at least once a week but it usually was emptied and cleaned out about every 3 day, due to the quantity of ice cream that was consumed by the residents. Cook 4 indicated when the machine was cleaned, it took anywhere from 30 minutes to an hour. Cook 4 indicated when the level of ice cream got to a certain point in the machine, it freezes up and the machine needs to be cleaned. Cook 4 indicated there was a cleaning log, where staff documented when they cleaned the ice cream machine. Cook 4 indicated the last time he cleaned the ice cream machine was 6 days ago. Cook 4 indicated he does check the temperature of the contents of the ice cream machine but does not write it down anywhere. On 6/19/19 at 4:41 p.m., the Adm was interviewed. She was made aware documentation was lacking of the temperature of the ice cream mixture being monitored and documentation of the ice cream machine having been cleaned as recommended. On 6/19/19 at 5:15 p.m., Cook 4 was interviewed. He indicated when he emptied the ice cream machine of the remaining contents to clean it, he throws the left over ice cream mix out. He indicated the mix emptied from the ice cream machine prior to cleaning, was thrown out and not reused. 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure restorative services wereprovided as recommended for 2 of 3 residents reviewed for restorative services. The deficient practice had the potential to effect 22 of 78 residents who had a recommendation for restorative services. (Residents 37 and 55) Findings include: 1. The record review for Resident 37 began 5-24-2018 at 3:30 p.m. The resident was admitted to the facility with [DIAGNOSES REDACTED]. The last quarterly MDS (Minimum Data Assessment) assessment for Resident 37, dated 3-20-2018, indicated a BIMS (Brief Interview of Mental Status) score of 8/15. A score of 8 indicated Resident 37 had moderate cognitive impairment. The resident required an extensive assist of 2 for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident required total dependence of 1 person for locomotion on/off unit, had impairment on one side for upper and lower extremities and used a wheelchair. The therapy and restorative sections were not marked which indicated the resident was not receiving those services. A review of the Occupational Therapy discharge summary dated 10-20-2017 for Resident 37, indicated .spouse educated on patient's plateau in performance and recommendations for D/C (discharge) and implementation of RNP (Restorative Nursing Program) A review of the most current Occupational Therapy discharge summary for Resident 37 was dated 1-19-2018 and indicated .D/C with RNP and continued nursing assistance A copy of the Restorative Program instructions for Resident 37 was provided by the Therapy Manager on 5-24-2018 at 10:42 a.m. The instructions indicated Resident 37 was to have .active range of motion to: Resident will tolerate 25 repetitions of Active range of motion to right upper and right lower extremity, 1 times per day, 6-7 days per week .Once a Day .Nursing .10-31-2017 Resident 37 was also to received .Passive range of motion program: Resident will tolerate 25 repetitions of passive range of motion to left upper and left lower extremity, 1 times per day, 6-7 days per week .Once a day .Nursing .10-31-2017 Two current care plans, both dated 10-31-2018 and last reviewed on 3-28-2018 for Restorative services for Resident 37, were provided by the MDS Coordinator on 5-25-2018 at 8:50 a.m. One care plan indicated .Resident requires active range of motion to maintain strength and to maintain current level of function Resident will tolerate 25 repetitions of active range of motion to right upper and right lower extremity, 1 times per day, 6 -7 times per week .observe for signs of pain .stop exercise if resident has pain or discomfort and notify nurse The second care plan indicated Resident requires passive range of motion to left upper and left lower extremity due [MEDICAL CONDITION].Resident will tolerate 25 repetitions of passive range of motion to left upper and left lower extremity, 1 times per day, 6-7 days per week .observe for signs of pain .stop exercise if resident has pain or discomfort and notify nurse. A review of the Restorative Flowsheets for Resident 37 for the active and passive range of motion, indicated the following: In (MONTH) (YEAR), Restorative services through the 24th were not received on these dates - 4, 5, 6, 11, 12, 13, 16, 18, 19, 20, 21, 22, and 23. In April, (YEAR), Restorative services were not received on these dates - 1, 7, 8, 14, 15, 21, 22, 28, and 29. In (MONTH) (YEAR), Restorative services were not received on these dates - 3, 4, 8, 9, 10, 11, 17, 18, 24, 25, 28, 30, and 31. In (MONTH) (YEAR), Restorative services were not received on these dates - 3, 4, 10, 11, 17, 18, 21, 23, and 25. In (MONTH) (YEAR), Restorative services were not received on these dates - 6, 7, 14, 20, 21, 27, and 28. An interview with Resident 37's family member on 5-21-2018 at 3:22 p.m., indicated she was concerned because the Resident 37 no longer received therapy. The family member indicated there was a girl who came and did exercises with Resident 37's upper and lower extremities, but the girl will come and let us know if she didn't have time to do them. The family member indicated she was worried that the resident would lose what mobility he had, if the exercises were not done. An interview with CNA 1 on 5-24-2018 at 9:21 a.m., indicated she was the only restorative aide in the building. CNA 1 indicated she provided the active ROM to Resident 37's non-affected side and passive ROM to his affected side. CNA 1 reviewed the Restorative Flowsheet for Resident 37 for his ROM for (MONTH) (YEAR) and 13 days lacked documentation for the ROM completion through 5-24-2018. (4, 5, 6, 11, 12, 13, 18, 19, 20, 21, 22, 23--no documentation). CNA 1 indicated she was off for a few days and then was assigned another hall earlier this week. She indicated the ROM services for the resident did not get completed when she was assigned to the other hall. 2. The record review for Resident 55 began 5-23-2018 at 10:18 a.m. Resident 55 was admitted on [DATE]. [DIAGNOSES REDACTED]. The last annual MDS assessment dated [DATE] for Resident 55 indicated a BIMS of 13/15, which indicated the resident was cognitively intact. The resident was not marked for behaviors or wandering. Resident 55 required extensive assist of 2 for bed mobility, transfers, dressing, toileting, and personal hygiene. He required a total dependence of 2 persons for bathing and an extensive assist of 1 for eating. There was no walking in room/corridor marked and Resident 55 was dependent on 1 assist for locomotion on/off unit. Resident 55 had speech therapy from 11-9-2017 to 12-8-2017, Occupational Therapy from 10-19-2017 to 11-1-2017 and Physical Therapy from 1-24-2017 to 2-10-2017. Restorative services were not marked on the MDS. A review of the Occupational Therapy discharge instructions dated 11-1-2018 for Resident 55, indicated for the discharge plans .Patient to continue with assistance as needed from nursing staff and FIT/RNP (FIT was the splint program) A review of the Restorative recommendations for Resident 55 was provided by the Therapy Manager on 5-24-2018 at 10:42 a.m. and included the following: .Passive range of motion program: Resident will tolerate 30 second hold each joint of passive range to left hand, 10 reps, 1 time per day .once a day .Nursing to provide A current care plan for Resident 55 for Range of Motion was dated 1-21-2015 and last reviewed on 4-17-2018. The care plan indicated Resident 55 .requires passive range of motion to left hand to decrease risk for contractures .Resident will tolerate 30 second hold each joint of passive range of motion to left hand, 1 time per day Approaches included .Notify nurse if resident has signs of pain, observed for signs of pain .passive range of motion program Resident will tolerate 30 second hold of each joint of passive range of motion to left hand, 10 reps, 1 time per day .day shift .rest breaks as needed .stop exercise if resident has pain or discomfort and notify nurse .verbal prompts: to relax A review of the Restorative Flowsheets for Resident 55 for the passive range of motion, indicated the following: In (MONTH) (YEAR), Restorative services through the 24th were not received on these dates - 4, 5, 6, 11, 12, 13, 16, 18, 19, 20, 21, 22, 23 and 24. In (MONTH) (YEAR), Restorative services were not received on these dates - 1, 7, 8, 14, 15, 21, 22, 28 and 29. In (MONTH) (YEAR), Restorative services were not received on these dates - 3,4 , 8, 9, 10, 11, 17, 18, 24, 25, 28, 30, and 31. In (MONTH) (YEAR), Restorative services were not received on these dates - 3, 4, 10, 11, 17, 18, 21, 23 and 24. In (MONTH) (YEAR), Restorative services were not received on these dates - 6, 14, 20, 21, 27, and 28. In (MONTH) (YEAR), Restorative services were not received on these dates - 9, 10, 23, 24, and 31. In (MONTH) (YEAR), Restorative services were not received on these dates - 4, 5, 11, 12, 25, and 26. An interview with Resident 55 on 5-21-2018 at 2:24 p.m., indicated his left arm and left leg did not move well and were not receiving range of motion exercises. An interview with Resident 55 on 5-24-2018 at 11:00 a.m. indicated he was not sure if staff came and did the range of motion exercises on his left hand fingers. An interview with the Therapy Director on 5-24-2018 at 10:31 a.m., indicated both Residents 37 and 55 were getting Restorative Nursing. The Therapy Manager indicated the therapist created the restorative plans and the MDS Coordinator supervised the programs. An interview with the MDS Coordinator on 5-24-2018 at 10:50 a.m., indicated the CNAs (Certified Nursing Aides) would provide the Restorative Nursing Program services for residents when the restorative CNA was not in the building or assigned to another units. The MDS Coordinator indicated the CNA would chart in the green binder with their initials for the ROM (range of motion) on the Restorative Flowsheet. When the current month (May (YEAR)) Restorative Flowsheets were observed with the MDS Coordinator for Residents 37 and 55, there were several dates without initials on the Restorative Flowsheet. The MDS checked the FIT documentation and indicated the CNA did the splints and they were supposed to do the range of motion prior to applying splints. The MDS Coordinator indicated the CNAs just didn't take the time to chart in the green book on the Restorative Flowsheets. The MDS Coordinator indicated she could have the CNAs document a late entry on the missing dates of services. Several more of Resident 37 and 55's Restorative flow sheets were reviewed with the MDS Coordinator and several dates were lacking staff initials to indicate the services were provided. The MDS Coordinator was asked about who reviewed the Restorative Program documentation and the MDS Coordinator indicated she did not review the documentation. The MDS Coordinator was also asked about the MDS, as no restorative services were marked for either Resident 37 or 55. The MDS coordinator indicated she will look at the 7 day period prior to the date of the MDS assessment and if the Restorative Flowsheet did not have the 7 days prior to the MDS assessment date marked for restorative services, she would mark no on the restorative question on the MDS. The MDS coordinator indicated CNA 1 was the only Restorative Nursing Aide, but all the CNAs were trained in the CNA classes and during the facility orientation on how to do the range of motion exercises. An interview with CNA 2 on 5-24-2018 at 11:07 a.m., indicated she would assist with the restorative services and would document in the black book. An interview with CNA 3 on 5-24-2018 at 11:29 a.m., indicated she was unable to provide restorative due to restrictions. An interview with CNA 4 on 5-24-2018 at 11:55 a.m., indicated she did not provide restorative services to the residents as CNA 1 was the restorative aide. A review of the nursing schedule for the week 5-21-2018 to 5-25-2018 which was provided by the DON on 5-21-2018 at 10:13 a.m., indicated the restorative aide was not assigned on 5-21-2018 and 5-23-2018 as the restorative aide was assigned to the Cottage. A interview with CNA 5 on 5-25-2018 at 8:42 a.m., indicated she was supposed to provide restorative nursing services when the restorative aide was not working. CNA 5 indicated she had not been trained on the restorative nursing services. An interview with the restorative nursing aide, CNA 1, on 5-25-2018 at 8:43 a.m., indicated when she was assigned as the restorative aide for her shift, she would complete the restorative services for all residents who had restorative services in the building. During an interview with the DON (Director of Nursing) on 5-25-2018 at 9:45 a.m., the DON indicated when the restorative nurse was not there, the CNA should have been completing the restorative program for all the residents who had restorative services and they should have documented the completion of the restorative services on the Restorative Flowsheet for the resident. The DON indicated all CNA had been trained in the restorative services. A current policy, Restorative Nursing Program last revised 11/2017 was provided on 5-24-2018 at 11:59 a.m. by the DON. The policy indicated .Purpose .To provide a nursing program for residents who no longer need skilled therapy, but still have functional goals to be met or maintained through practice and repetition .Process .The program is coordinated, supervised and carried out by nursing staff, preferably the MDS coordinator .A resident-centered Care Plan will be developed by the nurse and include measureable objectives, specific interventions to maintain or improve function . C.N.A. will document in Point of Care, or a monthly flowsheet, the number of minutes the program was provided .and their initials 3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure the policy and procedure for Pneumococcal Vaccinations was followed for 2 of 5 residents reviewed for Pneumococcal vaccines. (Resident 23), (Resident 24) Findings include: 1. On 5/23/18 at 10:00 a.m., the clinical record of Resident 23 was reviewed. [DIAGNOSES REDACTED]. The Preventative Health Care form indicated the resident had received on 9/15/14 administration of Pneumococcal vaccine. The type of Pneumococcal vaccine was documented as unknown. Notes indicated the vaccine had been administered given per MD (Medical Doctor) office. On 12/28/16, the resident's Power of Attorney (POA) signed the portion of the facility Pneumococcal Vaccination Consent which indicated I decline the administration of the Pneumococcal vaccine. The reason for declination was indicated as I have already received the Pneumococcal vaccine .Date .Sept (September) (YEAR) . Documentation was lacking on the form of which Pneumococcal Vaccine, the Pneumococcal [MEDICATION NAME] Vaccine (PPSV23) and/or the Pneumococcal Conjugate Vaccine (Prevnar 13), the POA declined administration of. Documentation was also lacking on the form of which Pneumococcal vaccine the resident had already received, the PPSV23 and/or the Prevnar 13. On 5/24/18 at 9:31 a.m., the Infection Control (IC) nurse was interviewed. She indicated the type of pneumonia vaccine the facility used was the Prevnar 13. She indicated she was not aware if the facility administered the Pneumococcal [MEDICATION NAME] Vaccine (PPSV23) to residents or not, as they usually give the Prevnar 13. She indicated the pneumonia vaccine was not kept on hand at the facility and she ordered the pneumonia vaccine as needed. She indicated the physician offices don't specify which vaccine is given .so how would you know? The IC nurse was made aware documentation was lacking in the clinical record of the which vaccine, the PPSV23 and/or the Prevnar 13, the resident received on 9/15/14 and/or which vaccine, the PPSV23 and/or the Prevnar 13, the POA declined administration of. No additional information was provided. The IC nurse indicated the facility would make an effort to clarify which specific type of Pneumococcal vaccine residents had previously received. On 5/24/18 at 2:15 p.m., the Director of Nursing (DON) and IC Nurse were interviewed. The IC nurse indicated it never occurred to her to designate between the Prevnar 13 and the PPSV23 in the clinical record regarding vaccinations. They were made aware the Pneumococcal Vaccination Consent forms lacked documentation as to which Pneumococcal vaccine was being declined and/or which Pneumococcal vaccine had already been administered. 2. On 5/23/18 at 10:30 a.m., the clinical record of Resident 24 was reviewed. [DIAGNOSES REDACTED]. The Immunization Summary from (name of hospital) indicated as of 5/24/18 the resident had the Pneumococcal [MEDICATION NAME] 9/22/14 . The Preventative Health Care form indicated the resident had a history of [REDACTED].yes . Type: PPSV23. Reason refused: Given per (name of physician) 9/22/2014 . On 1/12/17, the facility Pneumococcal Vaccination Consent was signed by the resident's responsible party, which indicated I decline the administration of the Pneumococcal vaccine. The reason for the declination was indicated as I have already received the Pneumococcal vaccine .where received (name of MD) .date Oct (October) (YEAR) . Documentation was lacking on the form of which Pneumococcal Vaccine, the PPSV23 and/or the Prevnar 13, the resident's responsible party declined the administration of. Documentation was also lacking on the form of which Pneumococcal vaccine the resident had already received, the PPSV23 and/or the Prevnar 13. On 5/24/18 at 9:31 a.m., the Infection Control (IC) nurse was interviewed. She indicated documentation indicated the resident had received the Pneumococcal Vaccine on (MONTH) (YEAR), when the resident was over [AGE] years old. The IC nurse was made aware documentation indicated the resident received the the PPSV23 vaccine in 2014 but documentation was lacking in the clinical record of the resident having been offered the Prevnar 13 vaccine. The Centers for Disease Control (CDC) and Prevention .September 19, 2014 .ACIP Recommendations for PCV 13 (Prevnar 13) and PPSV23 . Use .Both PCV 13 and PPSV23 should be administered routinely in series to all adults aged > [AGE] years . On 5/21/18 at 10:33 a.m., the Administrator provided a current copy of the facility policy and procedure for Pneumococcal Vaccination dated 8/2016. The policy and procedure included the following: It is the policy of this facility that resident(s) will be offered Pneumococcal vaccination (if appropriate) to help prevent the development and transmission of pneumonia .Purpose .reduce morbidity and mortality .by vaccination all residents who meet criteria established by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) .Administration Criteria: Pneumococcal [MEDICATION NAME] Vaccine (PPSV23) is recommended for resident(s) over the age of 65 .The . ACIP recommends a dose of Pneumococcal Conjugate Vaccine (PCV13) (Prevnar 13) in addition to the currently recommended PPSV23 in persons age [AGE] years and older .Those who have not previously received Pneumococcal vaccine or whose vaccination history is unknown should receive a dose of PCV 13 first, followed by a dose of PPSV23, 6 - 12 months later Procedure .On admission resident(s) will be screened for Pneumococcal vaccination .If resident meets criteria for Pneumococcal vaccination (see above) the resident will be offered the vaccination .Vaccination decline and reason for declination is documented on the consent form . 3.1-18(b)(5)

Based on interview and record review, the facility failed to follow treatment orders for a pressure area for 1 of 4 residents reviewed with pressure areas in a sample of 8. (Resident A) Findings include: Resident A's record was reviewed on 10-29-2015 at 3:22 PM. Resident A's [DIAGNOSES REDACTED]. A review of event notes dated 10-15-2015 at 1:12 PM indicated Resident A had developed an open area 3 centimeters (cm) x 3.5 cm x < (less than) 0.1 cm on the coccyx. The documentation further indicated the area was dark and dull red in color. Additionally, the documentation indicated the physician was notified, but there was no documentation of a new order being obtained. The document further indicated a pressure reducing mattress had been utilized on the bed. In an interview of on 10-26-2015 at 4:20 PM, the Director of Nursing (DON) indicated an order for [REDACTED]. A review of Resident A's (TAR) Treatment Administration Record dated 10-2015 did not indicate a dressing had been applied to Resident A's coccyx wound. In an interview on 10-29-2015 at 4:31 PM LPN #1 indicated the order for [MEDICATION NAME] had been received from the physician, but it had not been written on the order sheet or TAR. In an interview on 10-29-2015 at 4:22 PM, RN #2 indicated on 10-19-2015, the wound was reviewed. There was an [MEDICATION NAME] dressing on the wound dated 10-15-2015. RN #2 indicated the dressing should have been changed on 10-18-2015. A progress note dated 10-19-2015 at 3:57 PM indicated the physician was contacted regarding the condition of the wound, and new orders were received. A review of an event record dated 10-19-2015 at 3:57 PM indicated the area on the coccyx was 3 cm x 3.5 cm without depth. The description of the area indicated the wound was 90% covered with black eschar that was stable, with a moderate amount of thin drainage. The document further indicated the edges of the wound were pink, and attached. Skin tracking sheets indicated the following : On 10-2, Resident A received a partial bed bath with no new skin areas observed. On 10-6-2015, a partial bed bath was given with the private duty nurse refusing a full shower. No new skin areas were observed. On 10-9-2015, a Complete bed bath was given. No new skin areas were observed. On 10-13-2015, a shower was given with no new skin areas observed. A review of the 5 day MDS (Minimum Data Set) dated 10-6-2015 indicated Resident A was able to reposition himself in bed. A review of Nurse's notes dated 10-1 through 10-20-2015 did not indicate Resident A had complained of pain in the coccyx area. A review of an emergency room report dated 10-20-2015 indicated Resident A presented in the emergency room with increased confusion and a temperature of 100.3 F. The document indicated Resident A did not have 2 or more symptoms [MEDICAL CONDITION]. Additionally, the exam revealed a decubitus ulcer on the buttocks. The area was not described or otherwise referred to. This Federal tag is related to Complaint IN 596. 3.1-40 (a)(2)

Based on interview and record review, the facility failed to ensure physician's orders were followed for 1 of 4 residents reviewed for following physician orders in a sample of 8. (Resident A) Findings include: Resident A's record was reviewed on 10-29-2015 at 3:22 PM. Resident A's [DIAGNOSES REDACTED]. A review of event notes dated 10-15-2015 at 1:12 PM indicated Resident A had an open area 3 centimeters (cm) x 3.5 cm x < (less than) 0.1 cm on the coccyx. The documentation further indicated the area was dark, dull red. Additionally, the documentation indicated the physician was notified, but there was no documentation of a new order being obtained. In an interview of on 10-26-2015 at 4:20 PM, the Director of Nursing (DON) indicated an order for [REDACTED]. A review of Resident A's (TAR) Treatment Administration Record dated 10-2015 did not indicate a dressing had been applied to Resident A's coccyx. In an interview on 10-29-2015 at 4:31 PM LPN #1 indicated the order for [MEDICATION NAME] had been received from the physician, but had not been written on the order sheet or TAR. In an interview on 10-29-2015 at 4:22 PM, RN #2 indicated on 10-19-2015, the wound was reviewed. There was an [MEDICATION NAME] dressing on the wound dated 10-15-2015. RN #2 indicated the dressing should have been changed on 10-18-2015. A progress note dated 10-19-2015 at 3:57 PM indicated the physician was contacted regarding the condition of the wound, and new orders were received. This Federal tag is related to Complaint IN 596. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to provide frequent trimming of toenails to keep toenails short for 2 of 3 residents reviewed for toenail hygiene in a sample of 3. (Resident #E and Resident #G) Findings include: 1. An observation on 8-18-2015 at 10:13 AM indicated Resident #E had toenails approximately 1/4 inch longer then the end of his toes on the third and fourth toe of both the left and the right foot. Resident #E's record was reviewed on 8-18-2015 at 9:37 AM. Resident #E's diagnose's included, but were not limited to, depression, dementia, and high blood pressure. Resident #E's Quarterly MDS (Minimum Data Set) dated 7-13-2015 indicated in section G Resident #E required and received 1 person extensive assist with personal hygiene. In an interview on 8-18-2015 at 10:25 AM, the Memory Care Facilitator indicated Resident #E had seen the podiatrist on 6-17-2015, but she was unsure of the procedures performed for Resident #E as she had only begun employment with the facility on 7-13-15. A review of Resident #E's Podiatry Progress Note dated 6-17-15 indicated Resident #E's toenails were debrided using nail nippers and a rasp. In an interview on 8-18-2015 at 1:36 PM, LPN #1 indicated staff should trim toenails that could be trimmed, and if nails are long, and staff are not able to trim them, the staff should alert the nurse, and the Memory Care Facilitator to get toenails trimmed. 2. In an observation on 8-18-2015 at 10:13 AM, Resident #G was observed to have toenails approximately 1/8 inch longer then the end of his toes on the fourth toe of both the left and the right foot and the toenails had jagged edges. Resident #G's record was reviewed on 8-18-2015 at 11:37 AM. Resident #G's diagnose's included, but were not limited to, depression, dementia, and high blood pressure. Resident #G's Quarterly MDS (Minimum Data Set) dated 6-3-2015 indicated in section G the resident required and received 1 person extensive assist with personal hygiene. A review of Resident #G's Podiatry Progress Note dated 6-17-2015 indicated Resident #G's toenails were debrided using nail nippers and a rasp. This Federal tag is related to complaint IN 788. 3.1-38(a)(3)(E)

Based on observation, interview and record review the facility failed to ensure over the counter (OTC) medications, treatment creams/lotions/cleansers and an unidentified substance were properly labeled, and a vial of insulin was stored properly for 2 of 3 medication carts (200 Hall and Auguste's Cottage). Furthermore the facility failed to ensure 1 of 3 medication carts were maintained in a clean manner. (Auguste's Cottage) Findings include: 1. On 4/13/15 at 10:15 a.m., the 200 hall med cart was observed with LPN #30. The following OTC (over the counter) medications had no physician name documented on the opened medication bottle: Tylenol 500 mg tablets (tabs), Multiple vitamin (MVI) tablets, Colace 100 mg tablets, Tylenol 325 mg tablets, Benadryl 25 mg tabs, Bisacodyl 5 mg tabs, Calcium 600 mg with Vitamin D3 800 International Units (IU) tabs, MVI tabs, Iron tabs 325 mg, Zyrtec 10 mg tabs, Aspirin 81 mg tabs and Gummy MVI chews. On 4/13/15 at 10:20 a.m., an observation of the treatment cart drawer included an unlabeled bottle, which contained a bright green gel like substance. There was no labeling, resident name, physician name and/or open date on the bottle of unidentified substance. At the time, LPN #30 opened the bottle and smelled the contents. She indicated she thought it smelled like (name of topical heat rub) but was not sure. At the time, LPN #30 disposed of the unlabeled bottle of unidentifiable green gel. On 4/15/15 at 11 a.m., the DON (Director of Nursing) was interviewed. She indicated the unlabeled, unidentifiable bottle of green substance found in the 200 hall medication cart should have been labeled and dated with appropriate information. She also indicated the OTC medications should have been labeled with the resident and physician name. 2. During an observation of the medication and treatment cart in Auguste's Cottage, the memory unit, with LPN (Licensed Practical Nurse) #4 on 4/13/15 at 10:30 a.m., the following was observed: an unopened vial of Novolog insulin was stored in the medication cart. An interview on 4/13/14 at 10:30 a.m. with LPN #4 indicated the Novolog Insulin vial was not opened. During further observation of the medication and treatment cart in Auguste's Cottage with LPN #4 on 4/13/15 at 10:32 a.m., the following was observed: the bottom of the 2nd drawer contained 1/2 of an unidentified white pill and crushed pill residue was along the back of the drawer. An interview with LPN #4 on 4/13/15 at 10:32 a.m. indicated the night shift nurse was responsible to clean the medication carts and further indicated she did not know when the cart was last cleaned. On 4/13/15 at 10:35 a.m., during an observation of the medication and treatment cart in Auguste's Cottage with LPN #4, the following was observed: an opened OTC bottle of D3 (a vitamin) 1000 IU (International Unit) was not labeled with a resident's name or a physician's name; an opened OTC bottle of Aspirin 81 mg (milligrams) was labeled with a resident's 1st name, the aspirin bottle was not labeled with the resident's last name or a physician's name; an opened OTC bottle of Daily Multiple Vitamin for Men was labeled with a resident's 1st name, the bottle of multiple vitamins was not labeled with the resident's last name or a physician's name; an opened OTC bottle of Folic Acid 800 mg was labeled with a resident's 1st name, the bottle of folic acid was not labeled with the resident's last name or the physician's name; an opened OTC bottle of D3 1000 IU was labeled with a resident's 1st name, the bottle of D3 was not labeled with the resident's last name or a physician's name. An interview with LPN #4 on 4/13/15 at 10:35 a.m., indicated the OTC medications belonged to a resident who was recently admitted to the facility but was currently in the hospital. She further indicated the OTC medication bottles should have been labeled with the resident's name and the physician's name. An observation of the Treatment drawer in the medication cart for Auguste's Cottage with LPN #4 on 4/13/15 at 10:36 a.m., the following was observed: an opened 8 oz. (ounce) tube of (Brand) Sunblock Lotion was not labeled with an opened date or a physician's name; an opened 16 oz. spray bottle of Skintegrity Wound Cleanser was not labeled with a resident's name, an opened date or a physician's name; an opened 8 oz. spray bottle of Dermal Wound Cleanser was not labeled with a resident's name, an opened date or a physician's name; an opened 6.8 oz. bottle of Dandruff Shampoo was not labeled with an opened date or a physician's name. An interview with LPN #4 on 4/13/15 at 10:36 a.m., indicated she did not know which residents the wound cleanser sprays belonged too. She indicated there were no residents receiving wound care currently. She indicated the wound cleanser spray should have been labeled with a specific resident's name and a physician's name. She indicated the wound cleanser sprays would be discarded. An interview with the DON (Director of Nursing) on 4/13/15 at 4:32 p.m., indicated she had begun to educated the nursing staff to label the OTC medications with the resident's name, the physician's name, opened date and administration instructions. She further indicated the medication carts were to be cleaned every shift. An interview with LPN #4 on 4/14/15 at 1:00 p.m. indicated the unopened insulin was no longer on the medication cart since the resident's blood sugar level was only checked monthly. An interview with the DON on 4/15/15 at 10:55 a.m., indicated unopened insulin should be stored in the refrigerator until it was opened and indicated the insulin would be discarded if not stored properly. A review of the current facility's policy, provided by the DON on 4/15/15 at 11:57 a.m., titled, Medication Storage Requirements, with a revision date of 2-2014, indicated, "...To ensure drugs and biologicals are stored in a safe and secure manner in accordance to all manufacturer's recommendations and State and Federal laws, rules and regulations....The medicine preparation area is to be maintained by nursing staff in a clean and organized manner..." A review of the current facility's policy, provided by the DON on 4/15/15 at 11:57 a.m., titled, Labeling of Medications, with a revision date of 2-2014, indicated, "...All non-prescription (OTC) or vitamin supplements supplied by the resident or resident's family must bear a label which contains the following information:... Resident name...Prescriber's name...Original manufacturer's label containing, Product name and strength, expiration date and quantity...." A review of the facility's Pharmacy guide. provided by the DON on 4/15/15 at 3:22 p.m., titled, Medications Requiring Special Storage, dated 4/2011, indicated, "...Novolog...Refrigerate Prior to Opening...Expires 28 days after opening...Expires 28 days after removing from refrigerator opened or unopened...." 3.1-25(j) 3.1-25(l)

Based on observation, interview and record review, the facility Quality Assessment and Assurance Committee failed to implement an action plan for the identified concerns regarding ensuring resident's dignity by providing age appropriate activity items, ensuring adequate lighting in residents' rooms, assuring care plans were followed for eating and swallowing, ensuring [MEDICAL CONDITION] supplies were available in a resident's room in accordance with the plan of care and ensuring clean medication carts, properly labeled OTC medications and treatment creams/lotions/cleansers were properly labeled with a resident's name and/or a physician's name and/or opened date, ensuring an unidentifiable substance was labeled with a manufacture's label, a resident's name, a physician's name and opened date, and ensuring unopened insulin was properly stored in the refrigerator. Findings include: The CQI (Continuous Quality Improvement) committee, consisted of the Administrator, the DON (Director of Nursing), ADON (Assistant Director of Nursing) the Medical Director and the Managers of each of the Facility's Departments met monthly and they failed to identify and to implement an action plan to correct and monitor the following: ensuring resident's dignity by providing age appropriate activity items, ensuring adequate lighting in residents' rooms, assuring care plans were followed for eating and swallowing, ensuring [MEDICAL CONDITION] supplies were available in a resident's room in accordance with the plan of care and ensuring clean medication carts, properly labeled OTC medications and treatment creams/lotions/cleansers were properly labeled with a resident's name and/or a physician's name and/or opened date, ensuring an unidentifiable substance was labeled with a manufacture's label, a resident's name, a physician's name and opened date, and ensuring unopened insulin was properly stored in the refrigerator. An interview with the Administrator on 4/15/15 at 3:30 p.m., indicated the CQI committee met monthly and the committee was not aware of these identified concerns. The Administrator indicated she was aware of the inadequate lighting in some resident's rooms but it was not part of the facility's QAA process yet. She further indicated the CQI committee will develop action plans for the identified concerns. 3.1-52(a)(2)

Based on observation, interview and record review the facility failed to provide age appropriate items in an activity box for 1 of 2 residents (Resident #46) who met the criteria for dignity. Findings include: Review of the clinical record for Resident #46 on 4/14/15 at 3:13 p.m., indicated the following: [DIAGNOSES REDACTED]. An Activity Assessment for Resident #46, dated 6/27/14, indicated she participated in activities passively and actively. The assessment also indicated she liked to watch her peers and help staff, passively watched an activity more than actively participated, and needed encouragement and reminders of the activities. A Minimum Data Set assessment for Resident #46, dated 1/10/15, indicated severe cognitive impairment. Resident #46 was moved out of Auguste's Cottage (the memory care unit) on 4/3/15, since she was no longer an elopement risk and did not benefit from cottage programming. During an observation on 4/13/15 at 1:30 p.m., Resident #46 was observed seated in her wheelchair in the common area close to the nursing station and near the front entrance of the facility. An over-the-bed table was pulled up in front of her. On top of the over-the bed table was an activity box containing several toys designed for children - a plastic chain saw, a plastic wrench, a plastic block, and a plastic spinning top. Resident #46 was only observed to move the children's toys from one end of the table to the other. During an observation on 4/14/15 at 1:00 p.m., Resident #46 was observed seated in her wheelchair in the common area close to the nursing station and near the front entrance of the facility. An over-the bed table was pulled up in front of her. On top of the over-the-bed table was an activity box containing several toys designed for children - a plastic chain saw, a plastic wrench, a plastic block, a plastic spinning top, a plastic maraca, a plastic children's "Teenage Mutant Ninja Turtle" tambourine, and a small keyboard. During an observation on 4/14/15 at 4:02 p.m., Resident #46 was observed seated in her wheelchair in the common area close to the nurses station and near the entry to the facility. An over-the-bed table was pulled up in front of her. The same activity box containing the plastic children's toys was again on top of the over-the bed table. She was not observed interacting with the items. A facility care plan for Resident #46, with a review date of 4/14/15, indicated the problem area of resident doesn't understand an activity invitation to group activity. She is unable to self initiate an activity on her own. She will need set up of leisure pursuits. She will also need assisted to and from group activities and may need assistance with some activity. Past and observed activity interest: music, pet/animals, being around others, sensory groups, looking at magazines, holding a stuffed animal on occasions. Used to sell Avon. Approaches to the problem included, but were not limited to, assist during an activity as needed, assist resident to activity of potential interest and observe for signs of pleasure, offer resident items for leisure activities such as a stuffed animal, magazines, Avon books, sensory items, offer resident magazines and Avon books to look at, and stop by with visiting dogs. Activities #3 was interviewed on 4/15/15 at 11:00 a.m. During the interview, she indicated the items in the activity box on the over-the-bed table for Resident #46 were not provided by her family, but were provided by the facility. The Administrator was interviewed on 4/15/15 at 11:40 a.m. During the interview, she indicated the items in the activity box on the over-the-bed table belonged to another resident and not Resident #46. When queried she did not know why the activity box had been placed in front of Resident #46 when she was seated in the common area. A current undated facility policy "Resident Rights", provided by Medical Records on 4/15/15 at 11:15 a.m., indicated "...The resident has a right to a dignified existence...A facility must protect and promote the rights of each resident...." 3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure a plan of care was followed in regards to a resident with a [MEDICAL CONDITION] having emergency supplies available for 1 of 1 resident (Resident #2) reviewed for a [MEDICAL CONDITION]. The facility further failed to follow a care plan for eating/swallowing for 1 of 1 resident (Resident #87) reviewed for dysphagia (difficulty in swallowing). Findings include: 1. On 4/10/15 at 10 a.m. the clinical record of Resident #2 was reviewed. The resident had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Physician orders, dated 4/1/15, included but were not limited to the following: start date [MEDICAL CONDITION] (a surgically created opening in the front of the neck, which connects to the windpipe, and maintained patent with a small [MEDICAL CONDITION]) orders was 10/8/14: "Trach orders: [MEDICAL CONDITION] needed for secretions..type/size of trach: [MEDICATION NAME] 10...trach care as needed...change...filter on suction machine...on first Friday of the Month...change suction canisters once a day on Mon (Monday), thu (Thursday). 10 p.m. - 6 a.m...[MEDICAL CONDITION] every shift, normal saline and peroxide to be used [MEDICAL CONDITION] q (every) shift..." On 4/13/15 at 12:10 p.m. the resident was observed to have [MEDICAL CONDITION] place. A care plan which addressed the problem of "(Resident #2 name) is at risk for respiratory distress r/t (related to) [MEDICAL CONDITIONS] and [MEDICAL CONDITION]." The goal date was 4/18/15. The approaches included, but were not limited to the following: wears trach; assess respiratory status at least every shift and prn for congestion, cyanosis (bluish skin tone due to lack of oxygen), labored respirations...observe for congestion and suction as [MEDICAL CONDITION] as ordered. [MEDICAL CONDITION] order...keep [MEDICAL CONDITION] bedside. Keep Ambu (air mask bag unit) at bedside; Resident may [MEDICAL CONDITION] desired and keep at bedside. On 4/14/15 at 10:44 a.m. the LPN #33 was observed to [MEDICAL CONDITION] for Resident #2. In the process of [MEDICAL CONDITION], the resident was observed to cough and produce phlegm from [MEDICAL CONDITION] and LPN #33 was able to wipe the phlegm from the [MEDICAL CONDITION] site. The resident was able to clear his airway independently. LPN #33 was observed to assist the resident in cleansing [MEDICAL CONDITION] of phlegm by wiping it away with gauze. On 4/14/15 at 3 p.m. LPN #31 was interviewed. She indicated the suction machine was housed on the crash cart, which was located on another hall in the facility away from where Resident #2 resided. At the time, the closet in the resident's room was opened and a suction machine was observed. LPN #31 attempted to demonstrate how to assemble the suction machine and suction tubing together for use. LPN #31 was unable to locate suction tubing in the resident's room which would attach to the end of the connective tubing and actually be used to suction the resident down the [MEDICAL CONDITION] site. The only tubing LPN #31 was able to locate in the resident's room were 3 "non-conductive suction tube connections." LPN #31 was also unable to locate an [MEDICAL CONDITION] the resident's room. LPN #31 indicated the suction tubing catheter would be located in the facility crash cart. On 4/14/15 at 3:10 p.m. LPN #31 was observed to go to the crash cart located in another hall of the facility. When interviewed regarding location of a suction catheter for the [MEDICAL CONDITION], she produced a Yankaur (a hard plastic preformed wand type suction device) suction tip from the crash cart. At 3:20 p.m. on 4/14/15 the Director of Nursing was interviewed. She indicated they have a [MEDICAL CONDITION] Resident #2 and it was on her desk. She indicated staff had just now placed [MEDICAL CONDITION] the resident's drawer in his room. The DON indicated the [MEDICAL CONDITION]/or suction tubing should either be in the resident's room and /or the medication cart, which is either outside in the hall or close by at the nurses ' station. She indicated the resident had recently coughed out [MEDICAL CONDITION] and they had a difficult time finding a replacement as the resident has had [MEDICAL CONDITION] such a long time. The DON indicated the resident has had [MEDICAL CONDITION] at least [AGE] years. On 4/15/15 at 1:55 p.m. the DON was interviewed. She indicated the resident should have the [MEDICAL CONDITION] and an Ambu bag kept in the resident's room and indicated by the care plan. 2. Review of the clinical record for Resident #87 on 4/13/15 at 3:17 p.m., indicated the following: [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A New Order Documentation/Temporary Care Plan for Resident #87, dated 6/20/14, indicated he was discharged from Speech Therapy and would begin Speech Therapy 3 x (times) a week for dysphagia treatment. A Restorative FIT (Functional Independent Therapy Treatment) Referral/Recommendations for Resident #87, dated 6/18/14 and completed by the Speech Language Pathologist, indicated he consumed a Mechanical Soft diet with thin liquids via a sippy cup with minimal signs/symptoms of aspiration/penetration. The report also indicated he required set-up with meals, all food to be cut into small pieces, and verbal cues to eat slowly. Equipment required included a plate guard, a sippy cup, Mechanical Soft foods, and thin liquids. The report further indicated Resident #87 displayed poor safety awareness while eating increasing his risk of choking. A New Order Documentation/Temporary Care Plan for Resident #87, dated 6/20/14, indicated he was discharged from dysphagia treatment. A Speech Therapist Progress & Discharge Summary for Resident #87, dated 6/20/14, indicated he demonstrated the ability to safely swallow 1/2 tsp of Mechanical Soft diet using compensatory strategies from trained staff or caregivers given 50% verbal cue to ensure safety of intake with no outward signs/symptoms of aspiration/penetration. The summary also indicated he was seen by skilled speech therapy for oropharyngeal (oral cavity/upper esophagus) dysphagia. The summary further indicated he was currently tolerating a Mechanical Soft diet and thin liquids via a free flow cup. Resident #87 required moderate assistance with meals to ensure safety of intake. The summary also indicated a Restorative Nursing Program was recommended with no further Speech Therapy. A FIT Program Flowsheet for Resident #87, with a start date of 7/1/14 and open ended, indicated the eating/swallowing program of resident will feed self at least 75% of 3 meals daily and be free from signs/symptoms of aspiration daily TID (three times a day). The program did not include the additional recommendations made by the Speech Therapist. A New Order Documentation/Temporary Care Plan for Resident #87, dated 8/5/14, indicated to discontinue the 2 handle sippy cups with all meals due to regular cups preferred. A discharge Dental report for Resident #87, dated 9/17/15, indicated multiple dental extractions of his remaining teeth. The report indicated the discharge diet of Pureed with thickened liquids. A physician's orders [REDACTED]. A divided plate and a plate guard were to be used for all meals. A Speech Therapy Screen for Resident #87, dated 4/7/15, indicated he received a Mechanical Soft diet with thin liquids. The screen also indicated the areas of no loss of liquids/solids from mouth when eating or drinking and no coughing or choking during meals or when swallowing medications were marked not applicable. The screen further indicated for Speech Therapy to evaluate and treat as indicated. An Annual Review Progress Note for Resident #87, dated 4/8/15, indicated he continued on a Mechanical Soft diet. The note also indicated he continued to eat quick with his hands and filled his mouth with food. A facility care plan for Resident #87, with a review date of 2/11/15, indicated the problem area of resident requires eating/swallowing program to decrease the risk of aspiration. Interventions to the problem included, but were not limited to, specialized drinking cup, hands on support, resident may use straws, task segmentation, verbal prompts to chin tuck, alternate liquids and solids, chew thoroughly, take smaller bites, and observe for signs of aspiration, coughing, sneezing, tearing, runny nose, or gurgling voice. A facility care plan for Resident #87, with the review date of 2/11/15, indicated the problem area of resident eats fast and requires a mechanically altered diet. Interventions to the problem included, but were not limited to, provide Mechanical Soft diet, plate guard and divided plate at all meals, and observe for signs/symptoms of difficulty chewing/swallowing with current diet consistency. During an observation of the lunch meal in the main dining room on 4/9/15 at 12:11 p.m., Resident #87 was observed seated in his wheelchair at a dining room table. A glass of ice water was at his place setting. He was observed to take large gulps of water losing some of the water from his mouth, due to poor lip closure around the rim of the glass. He was observed to cough several times after drinking the ice water. His lunch meal of a ground Western burger on a bun, wedge fries, marinated cucumbers, and apricots was served in a divided plate with a plate guard. The staff who delivered his plate was observed to cut his sandwich in half, but did not cut the sandwich and other foods into small pieces. He was observed to eat at a very fast pace, shoveling a large amount of food into his mouth with either a spoon or his fingers. As he was eating he lost a portion of the food he placed in his mouth due to poor lip closure. Throughout the meal he was observed to forcefully cough when eating and drinking resulting in liquid and food being expelling from his mouth. Staff were not observed to encourage him to slow his rate of eating, to take small bites, or to alternate bites of food with sips of liquid. During an observation of the lunch meal on 4/13/15 at 11:48 a.m., Resident #87 was observed seated in his wheelchair at a dining room table. His lunch meal of a ground fish sandwich with cheese on a bun, potato triangle, cooked carrots, and applesauce was served in a divided plate with a plate guard. The staff who delivered his plate was observed to cut his sandwich in half but was not observed to cut the sandwich and other foods into small pieces. He was observed to eat at a very fast pace, shoveling a large amount of food into his mouth with either a spoon or his fingers. As he was eating he lost a portion of the food he placed in his mouth due to poor lip closure. Coughing was noted while he was eating his food. He was observed to finish his meal before drinking any of his liquids. He was observed to take large gulps of the liquids losing some of the water from his mouth due to poor lip closure around the rim of the glass. His coughing was forceful resulting in food and liquids being expelled from his mouth. Staff were not observed to encourage him to slow his rate of eating, to take small bites, or to alternate bites of food with sips of liquid. During an observation of the breakfast meal on 4/14/15 at 8:28 a.m., Resident #87 was observed seated in his wheelchair at a dining room table. He had completed his breakfast meal and was observed drinking his liquids. He was observed to take large gulps of the liquids losing some of the liquid from his mouth due to poor lip closure around the rim of the glass. He was observed to cough while drinking his liquids. His clothing protector was observed to be wet from his liquids and contained large pieces of food which had fallen from his mouth. Certified Nursing Assistant #1 was interviewed on 4/14/15 at 8:30 a.m. During the interview she indicated Resident #87 usually coughed during meals. She also indicated it varied from day to day on how much he coughed. Speech Therapist #2 was interviewed on 4/15/15 at 8:56 a.m. During the interview she indicated Resident #87 had been on a Pureed diet, but then refused to eat the pureed consistency and lost weight. His diet was upgraded to Mechanical Soft and a swallowing program was developed. She also indicated his lip closure during drinking was much better with the sippy cup, but it was changed to a regular glass due to his preference. She acknowledged Resident #87 ate too quickly, placed too much food into his mouth, and coughed while eating. She further indicated the swallowing program should be followed to keep him safe while dining. She also indicated staff were to notify her in person or through a screening form of any coughing or choking during dining. She further indicated she had recently picked up Resident #87 for speech therapy again due to his increased verbalizations. A current facility policy "IDT (Interdisciplinary Team) Care Plan Review" with a revision date of 4/2014 and provided by the Director of Nursing Services on 4/15/15 at 11:57 a.m., indicated "...It is the policy...that each resident will have a comprehensive care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the residents highest level of functioning including medical, nursing, mental and psychosocial needs...." 3.1-35(g)(2)

Based on observation and interview, the facility failed to ensure adequate lighting was provided for 3 residents in 3 resident rooms for 1 of 3 halls observed in the facility. (Resident #90, Resident #78, Resident #28) Findings include: On 4/9/15 at 1:54 p.m. Resident # 90 was observed in her room. She was observed to be in the bed closest to the door, farthest away from the window. She was observed to have her bed positioned in the room with the head of the bed in the corner of the room. The light positioned on the wall was not over the bed. A pull chain, which was used to activate the light, was hanging down the wall and was observed to be out of reach of the resident when she was in her recliner. The resident's recliner, which was observed to be a large, lift type chair, was positioned with the back of the recliner facing the wall with the light on it. An end type table was observed in the room with a lamp on it, which was positioned beside resident's chair. On 4/9/15 at 1:56 p.m. Resident #90 was interviewed in her room. She indicated there was not adequate light in her room. At the time, the light on the wall was activated by the pull chain and the only lights that illuminated were the lights which directed light upward toward the ceiling. No downward facing light from the light fixture on the wall was observed. The resident indicated she brought in a lamp from home to use in her room but there was still not adequate light for her. At the time, the blinds in the room were closed. The resident indicated when her roommate was put to bed, they close the blinds in the room. Resident #90 indicated she would prefer them left open as it provides more light for her. On 4/10/15 at 10:30 a.m. an interview with Resident #28 was conducted. She indicated there was not adequate lighting in her room. She indicated the small light on the wall over the bed and the 1 light on the ceiling, which was located over the entry path into her room, did not provide adequate lighting for her. At 1:30 p.m. on 4/15/15: the Maintenance Supervisor was interviewed. He indicated he does not have a preventative maintenance program for monitoring resident's lights in their rooms. He indicated nursing lets him know if they find a light out by completing a work order for him. He also indicated that housekeeping tests the lights daily and let's him know if there is a light out. He indicated he was unaware of any lights that were not functioning. During the interview, the Maintenance Supervisor was made aware of the wall mounted light not working on 4/10/15 at 10 a.m. in Resident #78's room. At the time, there was observed to be a covered light fixture on the ceiling just inside the entry door to the room of Resident #78. The Maintenance Supervisor indicated the light on the ceiling was a distance of approximately 4 feet from the first bed and 10 feet from the second bed. The Maintenance Supervisor indicated the covered light over the door, had two 60 watt bulbs in it. He indicated the light fixture on the wall had two 60 watt bulbs that faced upwards and one 60 watt bulb that illuminated down. The Maintenance Supervisor indicated the "lighting in the room is not bright" and he has "even seen the staff lift up the front part of the light to get brighter, direct lighting." He indicated the reason Resident #90's downward facing light didn't illuminate was because it was burned out. He indicated he was unaware this light was not working properly. On 4/15/15 at 1:35 p.m. Resident #78's room was observed with the Maintenance Supervisor. The Maintenance Supervisor pulled the chain to activate the wall light and the light didn't work at all. He indicated the light needed a new switch. At the time, he opened the front of the light appliance. After reviewing the light bulbs, he indicated the light switch was stuck. He indicated the staff had unscrewed the light bulbs instead of letting him know to replace the light switch. He indicated this resident's light over the bed in the rooms "isn't real bright." On 4/15/15 at 1:44 p.m. Resident #90's room was observed with the Maintenance Supervisor. The end table, with the lamp place on it, was now located behind the resident's recliner, between her recliner and the wall. At 1:46 p.m. the Maintenance Supervisor was interviewed. He indicated the top of the lamp on the end table, located behind the resident's recliner, was about 3 feet fall. He indicated the back of the resident's recliner was about 4 feet tall. At the time, the light located on the wall was activated by the pull chain. The only light which illuminated, was the light coming out of the top of the light fixture and there was none from the bottom of the light fixture. The resident indicated she really could use more light in her room and the lamp she brought in from home, which was behind her chair and the light on the wall, did not provide adequate light. On 4/15/15 at 2:14 p.m. CNA (Certified Nurses Assistant) #30 was interviewed. She indicated if she was aware a resident's room light was not working properly, she told her charge nurse immediately. On 4/15/15 at 2:15 p.m. the Administrator was made aware of the condition of the over bed lights and resident's concerns with inadequate lighting. She indicated the facility had started replacing the overbed lights in the dementia unit and their plan was to replace one light every month. On 4/15/15 at 4 p.m. the Administrator was interviewed. She indicated the facility had only completed the replacement of wall mounted lights in one room on the dementia unit. She indicated she was unsure of the exact date but indicated the replacing of the overbed lights began in December 2014 on the dementia unit. She indicated the facility's intent was to replace lights in one room per month. 3.1-19(dd)

Based on observation, interview and record review the facility failed to ensure staff washed their hands for the recommended amount of time and washed their hands after touching soiled surfaces and after coughing during meal service. The facility also failed to ensure staff did not handle the rims of drinking glasses, the rim of a bowl, and the drinking rims of nosey cups with their bare hands before giving it to the residents (Resident #24, Resident #30, and Resident #31). The facility further failed to ensure staff did not touch resident's food with their bare hands for 2 residents (Resident #83 and Resident #111) during 3 of 3 meal observations in 2 of 2 dining rooms and the facility kitchen potentially affecting 25 of 25 residents who ate their meals in the Auguste's Cottage dining room, 41 of 41 residents who ate their meals in the main dining room, and 12 of 12 residents who received room trays. Findings include: 1. During an observation of the lunch meal in Auguste's Cottage on 4/28/14 the following was observed: - At 11:31 a.m., CNA (Certified Nursing Assistant) #9 was observed assisting Resident #31 at the dining table. She was observed to move Resident #31's drinking glasses with liquids, which were already on the dining room table in front of her, by placing her fingers on the outside drinking rim of the glass. She was then observed to turn her head and cough into the air. She was not observed to cover her mouth or re-wash her hands before continuing to help Resident #31 with her lunch meal. - At 11:33 a.m., CNA #9 was observed to continue passing meal trays to other residents in the dining room without washing her hands. She was observed to handle a bowl of fruit for Resident #24 by placing her fingers on the rim of the bowl. 2. During an observation of the lunch meal in Auguste's Cottage on 4/29/14 the following was observed: - At 11:06 a.m., CNA #5 was observed to wash her hands for 6 seconds before passing meal trays to residents. - At 11:35 a.m., CNA #6 was observed documenting information in a notebook kept at the nursing station. When finished, she washed her hands for 9 seconds before passing meal trays to residents. 3. During an observation of the lunch meal in the facility kitchen and in the main dining room on 5/1/14 the following was observed: - At 11:18 a.m., Dietary #7 was observed to open the kitchen door and enter the dining room where she obtained several stir sticks. She re-entered the facility kitchen by opening the door. She was not observed to wash her hands and was observed to handle nosey cups by the drinking rims, and pat drinking glasses upright in a steam table pan with the palm of her hand. - At 11:40 a.m., CNA #8 was observed to pull apart two nosey cups which had been stacked together by placing her fingers on the drinking rim of the top glass. She then was observed to pour liquid into the nosey cup and provide the cup to Resident #30. The Certified Dietary Manager (CDM) and the Director of Nursing Services were interviewed on 5/2/14 at 9:42 a.m. During the interview they indicated staff were to cover their mouth when coughing and then wash their hands. They also indicated staff were to wash their hands when contaminated and before handling meal trays. They further indicated hands were to be washed for 20 seconds. The CDM was interviewed on 5/2/14 at 1:50 p.m. During the interview she indicated staff were to handle drinking glasses and bowls by the base, not by the rims. A current facility policy "Food Handling Policy", with a revision date of April, 2011 and provided by the Administrator on 5.2.14 at 10:10 a.m., indicated "...Employees will minimize the potential for food contamination...Food Employees (any individual working with food, food equipment or utensils, or food contact surfaces) will clean their hands and exposed portions of their arms...After coughing, sneezing, using handkerchief or disposable tissue...After handling soiled surfaces equipment or utensils...During food handling, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks...After engaging in other activities that contaminate the hands...." 4. During an observation of the lunch meal in the facility kitchen and in the main dining room on 4/28/14 the following was observed: -At 11:57 a.m., COTA (Certified Occupational Therapy Assistance) #12 washed her hands for 10 seconds and began serving meals to residents. 5. During an observation of the lunch meal in Augusta's Cottage on 5/1/14 the following was observed: - At 11:00 a.m., CNA (Certified Nursing Assistant) #5 was observed washing her hands for 15 seconds before she began serving beverages to the residents. -At 11:10 a.m., LPN #10 did not wash her hands before she took an unidentified resident cup with Koolaid in it and put ice into the cup using the ice scoop. -At 11:15 a.m., CNA #6 washed her hands for 15 seconds then began serving meal trays to residents. -At 11:17 a.m., CNA #9 washed her hands for 14 seconds before serving meal trays to residents. -At 11:17 a.m., CNA #6 washed her hands for 11 seconds between serving a meal tray to another resident. -At 11:20 a.m., CNA #5 washed her hands for 4 seconds after she assisted residents with clothing protectors and began serving a meal tray. -At 11:23 a.m., CNA #11, returned to the Cottage from the kitchen, provided salt packets to an unidentified resident without washing her hands. The CNA then washed her hands for 8 seconds before serving a plate with an egg salad sandwich to an unidentified resident. -At 11:28 a.m., CNA #6 washed her hands for 8 seconds before serving another meal tray. -At 11:30 a.m., CNA #6 washed her hands for 8 seconds before assisting a resident to eat. The CNA then went to the refrigerator to get butter and returned to assist the resident with her meal and did not re-wash her hands. On 5/2/14 at 10:10 a.m., the Administrator provided the Facility Policy titled, Hand Hygiene, with a review dated of 03/2012 indicated, "...Apply soap, rub hand together, between fingers to create a lather....Use friction for at least 20 seconds....Note: 5 Moments of required hand hygiene: *Before patient *Before an aseptic task *After body fluid exposure risk *After patient contact *After contact with patients surroundings...." 6. During an observation of the lunch meal for the 300 hall trays on 4-28-2014, the following was observed: -At 11:44 a.m., CNA #1 washed her hands for 10 seconds and began serving residents their meal tray. . -At 11:44 a.m., CNA #2 washed her hands for 15 seconds and began serving residents their meal tray. -At 11:53 a.m., CNA #2 washed her hands for 14 seconds and assisted Resident #111 with her lunch. -At 11:55 a.m., CNA #2 was observed to cut Resident #111's fish sandwich in half by placing her left hand on top of the bun and using a knife in her right hand. At 11:56 a.m., CNA #2 was observed to pick up Resident 111's fish sandwich with her hand. 7. During an observation of the lunch meal on 4-28-2014 in the main dining room, the following was observed: -At 12:03 p.m., CNA #3 sat down at table with residents, touched her gait belt with her hands and began assisting residents with their drinks. -At 12:13 p.m., CNA #3 was observed to wash her hands for 13 seconds and then began feeding a resident her lunch meal. 8. During an observation of the lunch meal in 300 hall on 4-30-2014 at 11:43 a.m., CNA #4 was observed to deliver a meal tray to Resident #83. CNA #4 set the tray on the overbed table, touched and moved Resident #83's oxygen tubing and the overbed table. Without washing her hands or using hand hygiene, CNA #4 picked up the resident's knife and fork and cut the resident's sandwich in half. An interview with the CDM (Certified Dietary Manager), DON (Director of Nursing), Administrator and the Corporate Nurse on 5-2-2014 at 9:55 a.m., indicated staff who assisted residents to cut their sandwich in half should use a knife and fork and not touch the resident's food with their hands. An interview with CNA #1 on 5-2-2014 at 10:30 a.m., indicated prior to serving residents their meal trays, handwashing was to be done for 20 seconds. CNA #1 indicated hands should be washed if an over bed tray table or a resident's oxygen tubing were touched and prior to assisting the resident with their meal. CNA #1 indicated when assisting a resident with cutting a sandwich in half, a knife and fork should be used and staff should not touch the food with their hands. A policy "Food Handling" dated 4/2011 and provided by the Administrator on 5-2-2014 at 10:10 a.m., indicated "employees will minimize the potential for food contamination. Any employee who makes contact with resident's food will wash hands prior to assisting and will use suitable utensils (deli tissue, spatulas, fork, knife...) when utensils can be used...." 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident's dehydration risks and/or fluid intake and/or output were adequately monitored which resulted in hospitalization for 1 of 3 resident's reviewed for hospitalization . Resident #99 Findings include: On 5/1/14 at 10 A.M., the clinical record of Resident #99 was reviewed. [DIAGNOSES REDACTED]. The admitted was documented as 1/4/14. The MDS (minimum data set assessment) dated 1/10/14 included, but was not limited to, the following: moderately impaired cognition; extensive assistance required for eating; weight was 119 lbs (pounds) and height was 66 inches. The clinical record included but was not limited to the following: NN (nurse's note) 1/4/14 at 11:45 A.M.: "... non-[MEDICAL CONDITION] to BLE (bilateral lower extremities) up to knees noted...Some weeping to RLE (right lower extremity) noted..." NN 1/6/14 at 9:23 P.M.: "[MEDICAL CONDITION] noted to BLE..." A physician order, dated 1/9/14, included but was not limited to, the following: "[MEDICATION NAME] (diuretic)...40 mg daily." A care plan date 1/12/14 addressed the problem of "nutritional status" and included but was not limited to, the following: "monitor food/fluid intake at meals, review labs as available." NN 1/9/14 - 1/13/14 documented the resident continued with BLE [MEDICAL CONDITION] and seeping and/or weeping clear drainage from BLE. A Dehydration Fluid Maintenance assessment was completed on 1/10/14 and included but was not limited to the following: "Symptoms of dehydration" was marked n/a (not applicable). Choices under this section included, but were not limited to: concentrated urine, decreased skin turgor and functional decline. The section titled "Diseases and conditions" was also marked n/a. Choices under this section included but were not limited to: "diarrhea and excessive sweating." Oral intake was also documented as n/a. Choices under this section included but were not limited to the following: "skips meals or consumes less than 25% of meals; dependent on staff for fluid intake, excessive output compared to fluid intake were all left blank. Comment: " No s/s (signs and symptoms) of dehydration." A Initial Nutrition Risk assessment dated [DATE] included but was not limited to the following: BMI (body mass index) 19; healthy weight; estimated fluid needs 1350 - 1620 cc daily; fluid consumes 1,500 - 2,000 cc/day; on [MEDICATION NAME] (Diuretic); pertinent Diagnoses: [REDACTED]. Lab work 1/13/14 of BUN (blood urea nitrogen) with a result of 60 (normal range 7-18 mg/dl (milligrams/deciliter) and creatinine 3.0 (normal range 0.6-1.3 mg/dl. NN 1/14/14 at 9:53 A.M.: "...BLE [MEDICAL CONDITION] cont (continued). BLE seeping clear drng (drainage)...Urine is cream color with foul odor. c/o (complained of) painful urination..." On 1/14/14 the RD (registered dietician) documented the following note: "...BMI underweight...res (resident) consuming avg (average) 45% meals. Res noted also needing some increased assistance with meals. Noted res with increased BLE [MEDICATION NAME] 40 mg daily..1/9 and may cause some wt (weight loss) r/t (related to) fluid loss. skin intact..." NN 1/15/14 at 2:03 P.M.: "...urine is cream colored with foul odor. c/o (complained of) painful urination. Urine sent to culture...BLE [MEDICAL CONDITION] cont (continue) BLE seeping clear drng (drainage)..." A physician order, dated 1/15/14, included but was not limited to, the following: [MEDICATION NAME] (diuretic) 2.5 mg daily on Monday, Wednesday and Friday. A progress note dated 1/15/14 included but was not limited to, the following: "IDT (interdisciplinary team) met to review res (res) for NAR (nutrition at risk) program...admission weight 119 #, current weight 116 #...feeds self...with extensive assist at night...in dining room...continue with current plan of care and on NAR program." A physician order, dated 1/16/14, included, but was not limited to, the following: "[MEDICATION NAME] 2.5 mg...prn (as needed) for diarrhea." A speech therapy (ST) note, dated 1/16/14, included, but was not limited to, the following: "referred to...skilled ST for possible diet upgrade d/t (due to) poor intakes and weight loss...POA (power of attorney) declined therapy..." NN 1/16/14 at 2:14 P.M.: "BLE [MEDICAL CONDITION] cont (continue). clear seepage (sic) noted/cont to BLE...urine cream colored w(with)/foul odor..." NN 1/17/14 at 1:30 P.M.: "...BLE [MEDICAL CONDITION] cont. BLE seeping clear drng (drainage)...urine cont to be cream/green color, w (with) foul odor, awaiting UA (urine analysis) culture." NN 1/17/14 at 2:07 P.M.: "has had loose stools x 5..." NN 1/18/14 at 6:39 P.M.: "BLE [MEDICAL CONDITION] cont. clear seepage (sic) noted/cont to BLE...urine cream colored w/foul odor noted...loose stools x 2..." A physician order, dated 1/18/14, included, but was not limited to, the following: "[MEDICATION NAME] (antibiotic)... increase [MEDICATION NAME] 2.5 mg daily..." NN 1/19/14 at 9:15 P.M.: "...Resident observed to be very confused and unable to sit up by herself...Disoriented but able to follow simple commands. Very pale/ashen in color. VS (vital signs) obtained and b/p (blood pressure) noted to be very low. Poor skin turgor. Mucous membranes moist...orders received to send resident to ER..." An "Emergency Resident Transfer Form" dated 1/19/14, included, but was not limited to, the following: "...reason for transfer: signs and symptoms of dehydration...poor skin turgor, skin tenting...usual mental status: alert, disoriented but can follow instructions..." A lab report, dated 1/19/14 at 11 P.M. included, but was not limited to, the following results: BUN (blood urea nitrogen) 100 (high); creatinine 4.5 (high); potassium 6.4 (high); glomerular filter rate (GFR) was 9, (an estimated glomerular filtr (sic) result less than or equal to 60 is indicative of renal impairment). A consultation form dated 1/20/14 from (name of hospital) included, but was not limited to, the following: "...patient is [AGE] year old...admitted for systolic blood pressure around 60. During the examination it was noted she had significant [MEDICAL CONDITION] of bilateral lower extremities...significant serous drainage from her lower extremities. She is currently being treated for [REDACTED]. Pedal pulses are diminished and nonpalpable...secondary to the [MEDICAL CONDITION] present. There is serous drainage with multiple ulcerations...She does have significant drainage noted in the bed from both legs...Assessment:...venous stasis ulceration...acute kidney injury secondary to dehydration, [MEDICAL CONDITIONS] stage IV..." A lab report, dated 1/22/14 included, but was not limited to, the following results: BUN 62; creatinine 2.2; potassium was 3.9 and GFR was 20. A Discharge Summary from the hospital,dated 1/24/14, included but was not limited to, the following: "...Dehydration secondary to Diuretics and poor p.o. (per os) intake...brought to...ER (emergency room )...found to have a marked dehydration with initial BUN (blood urea nitrogen) of 100 and creatinine of 4.5...maintaining hydration and nutrition is going to be very difficult..." A physician order [REDACTED]. On 5/2/14 at 8:40 A.M. the FSM (food service manager) was interviewed. She indicated she had calculated the resident's required daily fluid needs to be 1350 cc - 1620 cc. She indicated this calculation range was based using the 25 cc/kg - 30 cc/kg formula. She indicated the "nutrition 411 website" recommended 25 cc/kg intake for [MEDICAL CONDITION]. She also indicated the Indiana Diet Manual recommends 20-25 ml/kg for residents with [MEDICAL CONDITION]. On 5/2/14 at 9:15 A.M. the DON (Director of Nursing) was interviewed. She indicated the initial dehydration risk assessment was completed on 1/10/14. She indicated based on the results of this risk assessment, the resident would not have been at risk for dehydration at that time. On 5/2/14 at 10:10 A.M., the Administrator provided a current copy of the facility policy and procedure for Hydration Management, dated 6/2013. The policy included, but was not limited to, the following: "Resident hydration status will be assessed upon admission...and with significant change...identified risk factors will be assessed...and documentation will ...include but not limited to:...risk factors for dehydration...current fluid intake...assessment including mucous membranes, skin turgor, current labs...plan for hydration..." Documentation was lacking in the policy and procedure in regards to monitoring the output of resident fluids (diarrhea, skin weeping/seeping, diuretic usage) in relation to the resident's fluid intake. On 5/2/14 at 11:20 A.M. the DON was interviewed. She indicated the resident had one dehydration risk assessment completed on 1/10/14. The DON indicated the resident would not have had another dehydration risk assessment completed even though the resident had a UTI and diarrhea occurring simultaneously and had a additional diuretic medication started on 1/15/14 with an increase in the dose on 1/18/14. At the time, the DON indicted the facility had calculated the resident's daily intake to range from 1320 cc's - 2360 cc from the dates of 1/5/14 - 1/19/14. The DON indicated at the time, the resident's UTI and diarrhea were followed by "HOT charting" in the clinical record as these issues were considered a "routine medical change." She indicated these changes would have been addressed at the next NAR (nutrition at risk meeting) which would have met after the resident had been transferred to the hospital. On 5/2/14 at 1:55 P.M., the DON provided a copy of the facility reference for "estimating nutrient needs" dated 11/09. This reference included, but was not limited to, the following: "...comprehensive assessment is needed to determine the appropriate amount of...fluid are needed based on each resident's current medical status...Estimating fluid needs: decreased fluid = 20-25 mg/kg:[MEDICAL CONDITION]. Increased fluid = 30-35 mg/kg:...dehydration, diarrhea, draining wounds...The following factors can increase fluid requirements:...diarrhea,excessive perspiration...the following factors can decrease fluid requirements:..[MEDICAL CONDITIONS]" At the time, the DON also provided a copy of the facility policy for "Change of Condition", dated 3/10. This policy included, but was not limited to, the following: "...Routine Medical Change...are a minor change in physical...behavior...that are not life threatening...the licensed nurse responsible for the resident will continue assessment and documentation in the medical record every shift until the resident's condition has stabilized...the resident change of condition will be addressed, as appropriate, on the care plan update form (on the bottom of the MD telephone order form)..." 3.1-46(b)

Based on observation, interview and record review the facility failed to ensure cold beverages were served at the appropriate temperature in the Auguste's Cottage potentially affecting 24 of 24 residents who ate their meals in the Auguste's Cottage dining room. Findings include: 1. During an observation of the lunch meal on 5/20/13 at 11:05 a.m. in the Auguste's Cottage, a gallon of white milk, a gallon of chocolate milk, a clear pitcher of orange Kool-aide, and a clear pitcher of lemonade were placed on an open cart in the kitchen area ready for meal service. The temperature of the beverages was not checked prior to service and the beverages were not placed on ice to keep them cold. At 11:10 a.m., the open cart was moved through the Auguste's Cottage dining room delivering beverages of choice to the residents. Beverages continued to be offered throughout the meal service. The gallons of milk and the pitchers of beverages remained on the open cart throughout the entire lunch meal until they were returned to the refrigerator in the Auguste's Cottage kitchen at 12:20 p.m. They were never placed on ice. A large sheet pan containing individual bowls of Jello was also observed on the counter in the kitchen area for meal service. The bowls of Jello were not placed on ice to keep them cold. Activities Assistant #1 was interviewed on 5/21/13 at 11:50 a.m. During the interview she indicated the gallons of milk and the pitchers of juice and other beverages were kept in the refrigerator in the kitchen area of Auguste's Cottage. She also indicated they were brought out from the refrigerator and placed on the open cart for each meal service. 2. During an observation of the lunch meal on 5/21/13 at 10:55 a.m. in the Auguste's Cottage, a gallon of white milk, a gallon of chocolate milk, a clear pitcher of cranberry juice, a clear pitcher of orange Kool-aid, and a clear pitcher lemonade were placed on an open cart in the kitchen area ready for meal service. The temperature of the beverages was not checked prior to service and the beverages were not placed on ice to keep them cold. At 11:05 a.m., the open cart was moved through the Auguste's Cottage dining room delivering beverages of choice to the residents. Beverages continued to be offered throughout the meal service. The gallons of milk and the pitchers of beverages remained on the open cart through 12:00 p.m. They were never placed on ice. The Certified Dietary Manager (CDM) was interviewed on 5/22/13 at 1:10 p.m. During the interview she indicated the temperature of the cold beverages, especially the milk, should be taken prior to meal service. She also indicated all cold food should be kept on ice to maintain the appropriate temperature. A current facility policy "Food Temperatures", dated April, 2011 and provided by the CDM on 5/22/13 at 2:40 p.m., indicated "...The facility will prepare and serve food at the proper temperature to prevent food borne illness...foods that are potentially hazardous...cold foods at or below 41 (degrees) F (Fahrenheit)...Temperatures should be taken at the beginning of meal service and periodically during meal service to ensure...cold food stay below 41 (degrees) F during the portioning, transporting, and serving process...." 3.1-21(a)(2)