Every finding on record at Mulberry Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when residents received new mental health diagnoses and were prescribed medications for 2 of 4 residents reviewed for PASARR (Resident 100 and 62). Findings include: 1. The clinical record for Resident 100 was reviewed on 6/20/25 at 2:41 p.m. The diagnoses included, but were not limited to, dementia, hypertension, anxiety disorder, and osteoporosis. A physician's order, dated 9/5/24, indicated to give Buspirone HCL (an anti-anxiety medication) three times a day for anxiety disorder. A PASARR level 1 was not repeated to reflect the new mental health medications ordered on 9/5/24, until 4/7/25. During an interview, on 6/20/25 at 3:05 p.m., the Executive Director (ED) indicated they did not complete a new PASARR for the Buspirone when the medication was added. 2. The clinical record for Resident 62 was reviewed on 6/20/25 at 9:35 a.m. The diagnoses included, but were not limited to, dementia-unspecified severity, major depressive disorder, anxiety disorder, and peripheral vascular disease. A PASARR level 1 screen outcome, dated 4/15/21, indicated the resident did not have any mental health diagnoses known or suspected and no mental health medications prescribed. The facility diagnosis list included, but were not limited to, dementia dated 4/8/21, anxiety disorder dated 11/14/24, and major depressive disorder dated 2/19/25. A physician's order, with a start date of 4/4/25, indicated to give Buspirone HCL 5 mg three times a day for anxiety disorder. A PASARR level 1 was not repeated to reflect the dementia diagnosis, new mental health diagnoses, or mental health medications, until 4/7/25. During an interview, on 6/24/25 at 10:15 a.m., the Executive Director (ED) indicated the PASARR should have been updated with any status changes, including new diagnoses or new mental health medications. A current facility policy, titled Pre-admission Screening and Resident Review (PASARR) Level 1 Policy, dated June 2025 and provided by the ED on 6/24/25 at 11:57 a.m., indicated .When applicable, a new Level 1 screening is initiated if resident status or care needs indicate a review is necessary .For residents already admitted , the facility assesses the need for updated PASARR screenings in accordance with requirements and significant changes in condition . 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to keep medication carts free of expired medications and to dispose of a controlled medication with compromised packaging in 2 of 4 medication carts (300 unit and 100 unit) and to properly store drug busters and chemical solutions in 2 of 2 medication storage rooms (300 unit and 200 unit) reviewed for medication storage. Findings include: 1. The 300-unit medication cart 1 was reviewed on 6/23/25 at 9:39 a.m. In the second drawer of the medication cart, the following were observed: a. Docusate Sodium (a laxative medication) 100 mg (milligram) oral tablets for Resident 75 were found with an expiration date of 5/31/25. b. Ondansetron (a nausea medication) 4 mg tablets for Resident 75 were found with an expiration date of 5/31/25. During an interview, on 6/23/25 at 9:55 a.m., RN 2 indicated the pharmacy audited the medication carts once a month and pulled expired medications from the cart. The nurses would also audit the carts for loose pills and narcotic book review. 2. The 100-unit medication cart 2 was reviewed on 6/24/25 at 8:59 a.m. In the second drawer of the medication cart, the following were observed: a. Acetaminophen (a pain reliever) 325 mg oral tablets for Resident 82 were found with an expiration date of 5/31/25. b. Ondansetron 4 mg oral tablets for Resident 82 were found with an expiration date of 5/31/25 which was last administered on 6/22/25. c. Alprazolam (a controlled medication) 0.25 mg oral tablet for Resident 124 was found with compromised packaging and was taped closed. 3. The 300-unit medication storage room, on 6/23/25 at 10:05 a.m., had a drug buster stored in the cabinet under the sink. 4. The 200-unit medication storage room, on 6/23/25 at 3:25 p.m., had a drug buster and drain chemicals stored in the cabinet under the sink. During an interview, on 6/23/25 at 3:27 p.m., LPN 4 indicated she was not aware items could not be stored under the sink. During an interview, on 6/24/25 at 9:37 a.m., RN 3 indicated medications with compromised packaging should be disposed of and medication cards should not be taped closed. During an interview, on 6/24/25 at 10:34 a.m., the Director of Nursing (DON) indicated nothing should be stored in the cabinets under the sinks in the medication storage rooms. Compromised medication cards should never be taped closed and if medication packaging was compromised, the medication would be disposed of. A current facility policy, titled Medications/Drug Disposal, dated January 2025 and received from the Executive Director (ED) on 6/24/25 at 12:15 p.m., indicated .To properly dispose of all unused portions of a resident's prescriptions, including controlled Drugs, expired medications .Responsibility: Licensed nurse, Pharmacy .Equipment: Drug Disposal Liquid Destroyer .Remove medicine from the med box .Return medications that remain sealed to the pharmacy for credit .Dispose of medication in drug destroyer A current facility policy, titled Medication Storage and Labeling, dated January 2025 and received from the ED on 6/24/25 at 12:15 p.m., indicated .Storage .In accordance with State and Federal laws .The facility will maintain safe storage .All medication storage and handling practices will comply with federal and state requirements, including CMS regulations and Indiana Department of Health guidelines .Disposal methods for controlled medications involve a secure and safe method to prevent diversion and/or accidental exposure 3.1-25(m) 3.1-25(o)

Based on observation, record review and interview, the facility failed to ensure a resident was dressed in her own clothing and to ensure staff was not standing while feeding a resident for 1 of 2 residents reviewed for dignity. (Resident 50) Finding includes: During an observation, on 5/1/24 at 12:52 p.m., CNA 6 was standing on the left side of Resident 50's wheelchair feeding the resident. During an observation, on 5/1/24 at 12:59 p.m., CNA 6 took a chair from another table and sat down to continue feeding the resident. During an observation, on 5/3/24 at 9:30 a.m., the resident was sitting at a table in the dining room facing the door. There was a resident sitting across the table from the resident and five other residents were in the dining room. The resident was wearing a long-sleeved shirt with the top of the shirt pulled down exposing a large portion of the resident's chest. The shoulder seams were touching her elbows. CNA 5 pulled the front of the shirt up to cover her chest. CNA 5 checked the tag on the back of the shirt and indicated the shirt belonged to the resident's roommate. The clinical record for Resident 50 was reviewed on 5/3/24 at 10:15 p.m. The diagnoses included, but were not limited to, depression, macular degeneration, legal blindness, chronic kidney disease, and anxiety disorder. A care plan, dated 3/31/23, indicated the resident had an activity of daily living (ADL) self-care deficit. The interventions included, but were not limited to, assist the resident with ADL's as needed, assist the resident with showers when needed, set up meals for the resident's convenience, and encourage, cue, or assist the resident with eating meals, snacks, and drinking fluids. During an interview, on 5/1/24 at 4:03 p.m., the resident's daughter indicated she saw the resident wearing a size 3 extra-large shirt. The shirt was huge, and the resident only wore a size large. The staff would place other residents' clothing in her closet, and they did not pay attention when dressing the resident. She had taken her concerns to the management before. During an interview, on 5/01/24 at 1:35 p.m., CNA 6 indicated she should not stand, and she should make sure she was sitting down when feeding the residents. During an interview, on 5/3/24 at 9:32 a.m., CNA 5 indicated she was unaware of why the resident was wearing her roommate's shirt. During an interview, on 5/3/24 at 9:34 a.m., QMA 7 indicated she was working in the resident's hall. The resident was dressed when she started her shift. The resident was on a night shift get up and was already dressed prior to QMA 7 starting her shift. During an interview, on 5/6/24 at 4:57 p.m., the Administrator indicated hospice had the resident dressed when the resident was observed wearing the oversized shirt and she knew the resident should be dressed in her own clothes. During an interview, on 5/8/24 at 12:14 p.m., the Assistant Director of Nursing (ADON) indicated when assisting the residents with eating, the staff were expected to sit down and assist the resident and not feed the resident standing. A current policy, titled Resident Rights, dated as revised on 11/28/16 and received from the Administrator on entrance, indicated .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section .The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: The resident has a right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishing, and clothing 3.1-3(t)

Based on interview and record review, the facility failed to complete an accurate level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 3 residents reviewed for PASARR. (Resident 105) Finding includes: The clinical record for Resident 105 was reviewed on 5/2/24 at 4:30 p.m. The diagnoses included, but were not limited to, major depressive disorder, dissociative identity disorder, and anxiety disorder. A physician's order, with a start date of 1/25/24, indicated the resident received alprazolam (an antianxiety medication) 0.5 milligrams twice a day. A notice of PASARR level 1 screen outcome indicated the resident did not have any mental health diagnoses known or suspected. The PASARR did not include the residents major depressive disorder diagnosis, dissociative identity disorder diagnosis, or the resident's alprazolam medication. During an interview, on 5/6/24 at 3:10 p.m., the Social Services Director indicated the diagnoses and medication should have been listed on the PASARR. The person who submitted the PASARR may not have had all the information. During an interview, on 5/9/24 at 9:10 a.m., the Administrator indicated the facility did not have a specific PASARR policy. The facility used the Resident Assessment Instrument (RAI) manual. A CMS (Centers for Medicare and Medicaid Services) document, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, indicated .All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure over the counter medications were labeled and beverages were not stored in the medication refrigerator for 3 of 3 medication carts and 1 of 1 medication room observed for medication storage. (cart 1 and 2 on the 100 hall, cart 1 on the 200 hall, and the medication room on 200 hall) Findings include: 1. During an observation, on 5/2/24 at 9:55 a.m., with LPN 2, the medication cart 2 on the 100 hall was observed to have the following: a. one bottle of chest congestion relief (guaifenesin) for Resident 69, with no pharmacy label. b. one bottle of aspirin 81 mg which contained 500 tablets had Resident 69's first initial and last name in black marker on the top of the bottle, with no pharmacy label. c. one bottle of melatonin 5 mg which contained 240 tablets with Resident 69's name written on the top, with no pharmacy label. d. one bottle of B12 1000 mcg had black ink and indicated morning, there was no resident name or pharmacy label. The clinical record for Resident 69 was reviewed on 5/2/24 at 11:26 a.m. There was no physician's order for the guaifenesin. 2. During an observation, on 5/2/24 at 9:58 a.m., with LPN 2, the medication cart 1 on the 100 hall was observed to have the following: a. one bottle of acetaminophen 650 mg had a white label with Resident 46's name written on it, the physician and 1 tablet daily, with no pharmacy label. b. one bottle of eye health complex 90 capsules had Resident 46's name on the top of the bottle and 1 capsule BID (twice daily), with no pharmacy label. 3. During an observation, on 5/2/24 at 10:00 a.m., with LPN 2 and 3, the medication cart 1 on the 200 hall was observed to have the following: a. one bottle of acetaminophen 500 mg containing 500 caplets with Resident 100's name, the physician, room number, and 2 tablets PO (by mouth) TID (three times a day) with no pharmacy label. b. one bottle of acetaminophen 650 mg containing 225 tablets with Resident 29's name, the physician's name, room number written in black marker with no pharmacy label. 4. During an observation, on 5/2/24 at 10:30 a.m., the medication refrigerator in the medication room on 200 hall contained food and beverage items. During an interview, on 5/2/24 at 10:30 a.m., LPN 4 indicated beverages and food should not be in the medication refrigerator. During an interview, on 5/8/24 at 2:19 p.m., the Pharmacist indicated the over-the-counter medications needed a resident name, date, the doctor's name, and instructions the same as prescribed medications. A current facility policy, titled Medication Storage and Labeling, dated January 2024 and received from the Executive Director on 5/6/24 at 9:15 a.m., indicated .medications/biologicals are maintained within secured locations, clean and sanitary conditions: and maintain proper temperatures .medications/biologicals are labeled in accordance with currently accepted professional principles . 3.1-25(j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(4) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7)

Based on observation, interview and record review, the facility failed to label, date and store food in a sanitary manner. This deficient practice had the potential to affect all residents who consume food from the kitchen. Findings include: During an observation, on 02/13/23 at 9:55 a.m., the kitchen cooler was noted with Dietary Manager (DM) and the following was observed: a. on the cooler shelf was a name brand open can of coffee like drink with no open date on the can. b. on the cooler shelf was a plastic bottle of name brand soda pop with no label or date on the bottle. c. on the cooler shelf was a large plastic cup from a gas station with an uncovered straw in the cup with no label or date on the cup. d. on the cooler shelf was a soft sided plastic lunch box with no label or date on the lunch box. During an interview, on 02/13/23 at 9:55 a.m., the DM indicated I don't know if the open and undated drinks and lunch container could be kept in the walk-in cooler. During an interview, on 02/16/23 at 2:28 p.m., the Registered Dietician (RD) indicated we (facility) do not have a policy on that for staff food in the walk-in cooler. The food should at least have their name and if food was open then labeled and dated to prevent potential food borne illness. A facility policy, titled Shelf Life and Labeling Procedure, undated and received from the Executive Director (ED) on 02/17/2023 at 11:30 a.m., indicated .Foods will be labeled and used within appropriate timeframes to ensure safety and quality .Open resident food items must have an open date and a use by date on the item 3.1-21(i)(1)

Based on interview and record review, the facility failed to accurately code a resident's discharge status in the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS assessments. (Resident 129) Finding includes: The record for Resident 129 was reviewed on 2/15/23 at 2:56 p.m. Diagnoses included, but were not limited to, fracture of left pubis, hypertensive chronic kidney disease, pulmonary fibrosis, chronic kidney disease, and hypertension. A discharge MDS assessment, dated 1/13/23, indicated the resident was discharged to an acute hospital on 1/1/23. During an interview, on 2/15/23 at 10:07 a.m., the Director of Nursing indicated Resident 129 was discharged home with daughter and not to the hospital. The discharge MDS assessment, completed on 1/13/23, was coded wrong. During an interview, on 2/17/23 at 11:00 a.m., the MDS Coordinator indicated the MDS assessment was coded wrong and should have been coded as discharged to the community. The facility followed the RAI manual. 3.1-31(i)

Based on interview and record review, the facility failed to document targeted behaviors in the comprehensive care plan for a resident receiving an antipsychotic medication for delusional behaviors for 1 of 3 residents reviewed for comprehensive care plans. (Resident 101) Finding includes: The record for Resident 101 was reviewed on 2/14/22 at 2:49 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, right femur fracture, vascular dementia, restlessness and agitation, Alzheimer's disease, delusional disorder, depression, and mood disorder. A history and physical, dated 6/15/22, indicated Resident 101 had a diagnosis of dementia and no diagnosis of schizoaffective disorder. A physician's order, dated 8/31/22, indicated to add a diagnosis of schizoaffective disorder due to hallucinations and delusions. A history and physical, dated 12/16/22, indicated Resident 101 had a diagnosis of schizoaffective disorder and the diagnosis was very unclear and there was no prior documentation to support. She had no documentation for schizoaffective disorder or no use of psychotropic medication prior to starting quetiapine on 11/22. A review of Resident 101's admission agreement, dated 10/13/22, had a document titled Consent for use of psychotropic medications therapy. The document lacked indication of resident information, medication she was prescribed, diagnosis, who the information was reviewed with, or a signature of consent for the medication. A care plan, dated 10/18/22, indicated Resident 101 had episodes of resisting care, verbally and physically abusive towards staff and other residents, agitated with redirection. She had diagnoses of Alzheimer's disease, dementia, schizoaffective disorder, and delusional disorder. A care plan, with a revision date of 2/14/23, indicated Resident 101 had episodes of delusions. She had diagnoses of dementia, Alzheimer's disease, schizoaffective disorder, and delusional disorder. She had trauma history. A document, titled Note from Prescribing Psychiatrist, dated 2/3/23, indicated Resident 101 had a schizoaffective disorder diagnosis from another facility. Schizoaffective disorder was not appropriate for the use of Olanzapine. The diagnosis was to be changed to delusional disorder effective 2/3/23. During an interview, on 2/17/23 at 9:20 a.m., the Social Service Director indicated Resident 101's care plan was not updated to remove the diagnosis of schizoaffective disorder. No policy on care plans was provided by the time of exit. 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview and record review, the facility failed to accurately assesses and document bruising on the skin for 2 of 2 residents reviewed for skin issues and skin assessments. (Resident 2 and 20) Findings include: 1. During an observation of Resident 2, on 02/13/23 at 12:39 p.m., the resident was found to have a red bruise on her left arm at the wrist area. During an observation of Resident 2, on 02/14/23 at 2:02 p.m., the resident was found to have a red bruise on her left arm at the wrist area. During an observation of Resident 2, on 02/15/23 at 1:10 p.m., the resident was found to have a red discoloration/bruise on her left forearm at the wrist area. The record for Resident 2 was reviewed on 02/13/23 at 2:48 p.m. Diagnoses included, but were not limited to, anemia, gastrointestinal hemorrhage, and thrombocytopenia (a low platelet count and platelets stop bleeding by clumping and forming plugs in blood vessel injuries). A physician's order, initiated on 11/24/22, indicated to give aspirin (a medication which was used to prevent platelets from sticking together and decreased the body's ability to form clots) 81 milligrams (mg) once a day for a history of stroke and atrial fibrillation (an irregular heart rhythm which could lead to blood clots in the heart). A care plan, initiated on 10/07/21, indicated the resident was at risk for bleeding related to the use of aspirin. The resident was to be observed for signs of abnormal bleeding. A weekly skin assessment, completed on 02/13/23 at 3:15 p.m., did not contain documentation or measurement of the bruise. During an interview, on 02/15/23 at 1:11 p.m., RN 3 indicated she was not aware of the bruising and was going to assess the resident. 2. During an observation of Resident 20, on 02/13/23 at 10:40 a.m., bruising was noted on the resident's right hand and forearm. The bruising was red and purple. Resident 20 indicated he hit his hand. During an observation of Resident 20, on 02/14/23 at 2:07 p.m., the resident continued to have bruising on his right forearm. During an observation of Resident 20, on 02/15/23 at 9:30 a.m., the resident continued to have bruising on his right forearm. During an observation of Resident 20, on 02/16/23 at 11:04 a.m., the resident continued to have bruising on his right forearm. The record for Resident 20 was reviewed on 02/16/23 at 1:14 p.m. Diagnoses included, but were not limited to, atrial fibrillation, congestive heart failure (when the heart muscle doesn't pump blood as well as it should) and hypertensive kidney disease (high blood pressure caused by the narrowing of your arteries which carry blood to your kidneys). A physician's order, initiated on 01/18/22, indicated to give apixaban (Eliquis-an anticoagulant medication used to treat and prevent blood clots) 5 mg twice a day for atrial fibrillation. A physician's order, initiated on 01/18/22, indicated to observe for side effects of (anticoagulant) medication to include bruising. A care plan, initiated on 12/28/21, indicated Resident 20 was a risk for side effects of the anticoagulant and to observed for signs of bleeding. A weekly skin assessment, completed on 02/15/23 at 5:59 p.m., did not contain documentation of the bruising. During an interview, on 02/16/23 at 11:04 a.m., RN 3 indicated she had completed the skin assessment on Resident 20 the evening before, and she would correct the assessment. A facility policy, titled Skin Prevention-Non-Pressure Incidents/Accidents, dated May 2022 and provided by the Administrator in Training (AIT) on 02/17/23 at 2:53 p.m., indicated .Nursing, in collaboration with the health care team, will assess and manage skin integrity for all residents .Observing skin for .bruises .PROCEDURE .Staff to report new areas to nurse .investigate areas 3.1-37(a)

Based on observation, interview and record review, the facility failed to date multi-dose bottles of medication when they were opened in 1 of 4 medication storage refrigerators reviewed for medication storage. (300 Unit) Finding includes: During a medication storage observation in the 300 Unit medication refrigerator, on 02/14/23 at 9:45 a.m., with LPN 8, two (2) bottles of Ativan concentrate were found open without a date to indicated when the multi-dose bottles had been opened. During an interview, on 02/14/23 at 9:47 a.m., LPN 8 indicated the bottles should have been labeled with the date they had been opened. A facility policy, titled Medication Storage and Labeling, dated January 2023 and provided by the Director of Nursing on 02/15/23 at 11:30 a.m., indicated .multi-dose vials which have been opened .should be dated 3.1-25(j)

Based on interview and record review, the facility failed to ensure residents were assessed, including neurological assessments, after falls and changes in condition and sent out of the facility for treatment in the emergency room in a timely manner, for 3 of 4 residents reviewed for falls (Residents B, C and E). This resulted in Resident B experiencing a delay in treatment for [REDACTED]. Findings include: 1. Resident B's record was reviewed on 3/1/21 at 11:26 a.m. The record indicated she was admitted on [DATE], and had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. a. Toilet resident upon rising, before or after each meal, at bedtime, and as needed every shift. b. [MEDICATION NAME] (used to treat antianxiety) tablet 0.25 mg (milligrams) give 1 tablet by mouth every 8 hours as needed for anxiety. Documentation indicated the medication was unavailable. c. [MEDICATION NAME] Bisulfate Tablet 75 mg ([MEDICATION NAME] (anticoagulant)) give 1 tablet by mouth one time a day. Documentation indicated, there was no order to monitor for signs and symptoms of bleeding. d. Aspirin Tablet Chewable 81 mg (antiplatelet drug used to prevent blood cells from clumping together to form a clot) give 1 by mouth one time a day, take with food. A Progress Note, dated 3/20/20 at 8:51 p.m., indicated Resident B was a new resident to the facility at 7:00 p.m. The resident had an order for [REDACTED]. A Morse Fall Assessment for Resident B, dated 3/20/20 at 7:00 p.m., indicated the resident the resident had a score of 40, was a moderate risk for falling, the resident's gait was weak, it was unknown if resident had ever fallen before, and the resident used crutches, cane, or a walker. A Morse Fall Assessment for Resident B, dated 3/20/20 at 11:15 p.m., indicated the resident had a score of 35, was a moderate risk for falling, the resident's gait was impaired, it was unknown if the resident had ever fallen before, and the resident did not use ambulatory aides. An Admission Care Plan Assessment for Resident B, dated 3/20/20, indicated decreased mobility, recent hospitalization , unsteady gait. Goal: This resident will be free from falls with significant injury through the next review. Nursing interventions: Keep call light within easy reach, orientate resident to room and facility, keep room free from clutter, therapy services as ordered, toilet schedule as ordered, and assistive devices for mobility. A Fall Progress Note for Resident B, dated 3/21/20 at 2:33 a.m., indicated on 3/20/20 at 11:15 p.m., the resident was found lying on the bathroom floor on her right side after attempting to transfer herself from the toilet to her wheelchair. Injury documentation indicated, a laceration to the right eyebrow measured 1.45 cm (centimeters) long, she had skin tears on the right and left fingers, mild redness to the right knee, scattered bruises to the right arm, and a bruise on the right shoulder measuring 7.0 cm x 7.0 cm. The fall was unwitnessed, and the bathroom call light was on at the time of the fall. The physician was notified, but the family would be notified in the morning. The resident complained of a headache with an intensity of 8 on a scale of 10. A physician order, dated 3/21/20 at 2:48 a.m., indicated 72 hours follow up every shift for 3 days, new skin/wound progress note due this shift for new skin area to right eyebrow, fingers to left and right hands, and bruise to right shoulder. Resident B's record lacked documentation of subsequent skin assessments with description of the injuries. A neuro check assessment for Resident B, dated 3/20/20 at 11:15 p.m., indicate initial assessment post fall the resident complained of pain 8/10 (intensity 8 out of 10). A neuro check assessment for Resident B, dated 3/20/20 at 11:30 p.m., indicated 15 minutes post fall the resident complained of a headache, pain level 8/10. A neuro check assessment for Resident B, dated 3/20/20 at 11:45 a.m., indicated 30 minutes post fall the resident complained of pain 6/10. A neuro check assessment for Resident B, dated 3/21/20 at 12:15 a.m., indicated 1 hour post fall the resident complained of pain 6/10. A neuro check assessment for Resident B, dated 3/21/20 at 4:14 a.m., indicated 5 hours post fall resident's pupil assessment for PEARL (pupils equal and reactive to light) was unable to be completed as the right eye was unable to assess due to swelling/hematoma from fall. A neuro check assessment for Resident B, dated 3/21/20 at 6:15 a.m., indicated 7 hours post fall unable to assess resident's right eye due to swelling and hematoma from the fall. The record lacked documentation the physician was made aware of injuries or the inability of staff to complete neuro checks. A Progress Note for Resident B, dated 3/21/20 at 9:09 a.m., indicated phoned husband and updated him on resident's fall the previous night. A Progress Note for Resident B, dated 3/21/20 at 2:51 p.m., indicated gait unsteady, transfers with extensive assistance of 1, and use wheelchair for locomotion. Resident complained of increased pain in right cheek and right side, Tylenol ([MEDICATION NAME]) given. A Progress Note for Resident B, dated 3/21/20 at 6:22 p.m., indicated resident complained of increased pain to right side of face and right side of body, Tylenol given. A Progress Note for Resident B, dated 3/22/20 at 3:18 a.m., indicated the resident complained of increased pain to her right side post fall. The Admission 5-day MDS (Minimum Data Set) assessment, completed on 3/22/20, assessed Resident B as requiring extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Her balance was not steady when moving from a seated to standing position, walking, turning around, or moving on and off the toilet, transfers between bed, chair, or wheelchair, and only able to stabilize with staff assistance. Resident had a fall in the past month prior to admission. Resident had a fall after admission, no fractures related to a fall. A Behavior Note for Resident B, dated 3/22/20 at 8:15 a.m., indicated the resident was calling out to staff in the hallway instead of utilizing the call light. She was asking staff to turn on the TV, and other things instead of using controls to do it herself. Precipitating factors: anxiety. Non-pharmalogical interventions: Encouraged resident to relax and perform relaxation techniques. Encouraged resident to do simple tasks without success. [MEDICATION NAME] ordered, but script (written prescription) needed. Tylenol given at 7:00 a.m. this morning. Outcome: behavior continues. A Progress Note for Resident B, dated 3/22/20 at 8:37 a.m., indicated the resident complained of pain to her left side and a headache. Tylenol given without relief per resident. The resident also complained of her heart racing, heart rate 130 apical (normal heart rate range is 60-100 beats per minute). The resident voiced anxiety, and the on-call physician was paged regarding the [MEDICATION NAME] script. A Progress Note for Resident B, dated 3/22/20 at 1:08 a.m., indicated the resident was administered her first dose of [MEDICATION NAME] 0.25 mg 1 tablet by mouth for anxiety. A Progress Note for Resident B, dated 3/22/20 at 2:20 p.m., indicated no change in pain. A late entry Progress Note for Resident B, documented 3/23/20 at 7:21 a.m., indicated on 3/23/20 at 1:55 a.m., the nurse was called to the resident's room for complaints of not feeling well. The resident states she woke up in a sweat and felt really hot, and that her heart was beating out of her chest. Vital signs included blood pressure of 79/54 (average normal was 120/80), heart rate 165 ([MEDICAL CONDITION], respirations 22, temperature 97.6 F (Fahrenheit), and oxygen saturations 97% on 2 L (liters) of oxygen by nasal cannula. A late entry Physician Communication note for Resident B, documented on 3/23/20 at 7:25 a.m., indicated on 3/23/20 at 2:10 a.m., the physician was notified of the resident having a rapid heart rate, low blood pressure, and not feeling well. The resident had a history a a-fib ([MEDICAL CONDITION]), and upon assessment had a heart rate of 165, blood pressure 79/54, her skin was cool to touch and she stated she was roasting. A new physician's orders [REDACTED]. If the resident was staying in house do a STAT (immediate) EKG (electrocardiogram). A physician order, dated 3/23/20 at 2:10 a.m., indicated [MEDICATION NAME] (used to treat high blood pressure) 6.25 mg give 1 tablet by mouth one time only, send to ER (emergency room ) if elevated HR (heart rate) does not return to normal in next 15 minutes. A late entry Progress Note for Resident B, documented on 3/23/20 at 7:34 a.m., indicated on 3/23/20 at 2:20 a.m., the resident was administered a onetime dose of [MEDICATION NAME]. The heart rate remained 160, and the blood pressure 83/64. The resident continued to complain of her heart beating hard in her chest. The resident was turned onto her left side, her feet elevated, and a cool cloth put on her head. The resident complained of a dry mouth and was given sips of water. A late entry Progress Note for Resident B, documented 3/23/20 at 7:36 a.m., indicated on 3/23/2020 at 2:30 a.m., calls were placed to 2 local ambulance services that were utilized for non-emergent transport, without success. Staff continued to monitor the resident's heart rate and blood pressure with no change noted. The record lacked documentation of the recorded values of the resident's heart rate and blood pressure. A late entry Progress Note for Resident B, documented on 3/23/20 at 7:39 a.m., indicated on 3/23/20 at 2:45 a.m., a call was made to the DON to notify of need for transport. Verified with the resident, husband, and granddaughter that the resident wanted to be sent out to the ER. The resident stated twice she wanted to be sent to the ER. There was no change in heart rate and blood pressure. The record lacked documentation of the recorded values of the resident's heart rate and blood pressure. A late entry Progress Note for Resident B, documented on 3/23/20 at 7:42 a.m., indicated on 3/23/20 at 3:10 a.m., 911 was called for transport to a local hospital. A late entry Progress Note for Resident B, documented on 3/23/20 at 7:42 a.m., indicated on 3/23/20 at 3:25 a.m., EMT's (emergency medical technicians) arrived and transported the resident to a local hospital ER. The resident's heart rate remained elevated. The record lacked documentation of the recorded values of the resident's heart rate and blood pressure. A Progress Note for Resident B, dated 3/23/20 at 6:30 a.m., indicated the nurse called the hospital and was informed the resident had been admitted with SVT ([MEDICAL CONDITION]) and a cardioversion (medical procedure by which an abnormally fast heart rate is converted to a normal rhythm using electricity or drugs). A Cardiac - General Staff Initial Consult Final Report, dated 3/23/20, indicated, Resident B presented to ED (emergency department) with complaints of chest pain that began early morning. The patient stated she had begun to have mild chest pain, heart palpitations, and diaphoresis (sweating). EMS (Emergency Medical Services) was called, and they noted the resident to be in SVT with a heart rate in the 170's and 180's. In route to the ED, EMS gave the patient 6 mg of [MEDICATION NAME] (to treat irregular heartbeats) with no improvement. With Resident B's blood pressure 60/40, EMS decided to cardiovert the patient. Resident B also had a history of [REDACTED]. The patient stated she fell 3 days ago and hit her head and had bruising to the right orbitus (around the eye) as a result of this fall .her aspirin and [MEDICATION NAME] will be on hold due to fall/severe bruising. An Echocardiographic Report, dated 3/23/20, indicated severe left ventricular dilatation, severely reduced left ventricular ejection fraction, moderately reduced right ventricular global systolic function, and moderate-to-severe tricuspid valve regurgitation. Compared to prior study of 3/23/20 abnormal shadows were seen on the tricuspid valve, suggest a TEE ([MEDICAL CONDITION] Echocardiogram, an ultrasound that provides highly detailed images of the heart and its structures) if clinically indicated. A CT (CAT scan/Computed tomography) of the head, dated 3/23/20 at 6:01 a.m., indicated recent fall with headache. Extensive subarachnoid hemorrhage of both cerebral convexities greatest in the posterior right sylvian fissure without underlying parenchymal hemorrhages or cortical contusions. Given the clinical history, this pattern may reflect extensive posttraumatic subarachnoid hemorrhage A CT of the chest, abdomen, and pelvis, dated at 6:01 a.m., indicated recent fall, right chest and abdomen pain, and multiple prior surgeries. Nondisplaced fractures of the posterior and medial right 10th and 11th ribs During an interview, on 3/1/21 at 10:18 a.m., Resident B's spouse indicated he did not feel his wife had received proper treatment after she fell in the nursing home on 3/20/20. She had only been in the facility for a few hours and the staff let her fall in the bathroom. Someone at the facility called him the next morning and told him his wife was allowed to go to the bathroom on her own and she had the right to fall, but the resident had just been in the hospital and she was supposed to be assisted with transfers and ambulation. The spouse indicated, on 3/23/20 when he arrived at the hospital, he was shocked at the sight of Resident B. Resident B had broken ribs, she was bruised all over, and she had a black eye. Resident B had told him, 2 staff members had been with her and let her fall. Staff at the nursing home had informed him, Resident B was on the toilet, and staff left to go get a towel and let her fall. Resident B was in the hospital for a few weeks for treatment of [REDACTED]. Resident B's spouse indicated, he was unhappy he was not notified of his wife's injuries at the time of her fall, or the extent of her injuries the next morning, as he would have requested she be sent to the hospital. On 3/2/21 at 11:00 a.m., RN (Registered Nurse) 11 indicated, fall protocol dictated the nurse assess a resident after a fall to include looking for injuries, taking vital signs, and if not injured transferring back to a bed or chair. If a resident had signs of injury from a fall or the fall was unwitnessed, neuro checks would be completed per protocol and documented on a Neurological Checks-Complete Assessment form in the electronic medical record. If a resident was taking anticoagulant medications, the nurse was to monitor for any signs of bleeding and document findings every shift. When a resident was on an anticoagulant medication, an order was written for monitoring of signs or symptoms of bleeding, and documentation was completed every shift on the MAR (medication administration record). Resident vital signs were monitored per physician's orders [REDACTED]. Review of Resident B's medical record with RN 11, she acknowledged there was no order for monitoring of Resident B's anticoagulant medication, and no documentation to indicated nurses had monitored every shift for signs and symptoms of bleeding. On 3/2/21 at 3:30 p.m., the Director of Nursing (DON) indicated, Resident B had been admitted to the facility post hospitalization for a cardioversion. On 3/20/20 the resident had been in the bathroom a few hours after her admission and fell while attempting to self-transfer from the toilet to her wheelchair. After Resident B fell , her fall assessments and neuro checks had been completed per protocol. On 3/22/20 when the residents heart rate was assessed at 130 and as the nurse attributed the high heart rate to anxiety, she notified the physician and requested the [MEDICATION NAME] medication. The resident was yelling out and had a high heart rate due to inability to get her [MEDICATION NAME]. Monitoring for signs and symptoms of bleeding should have been put in as part of the order for Resident B's anticoagulant medication. There was no documentation except for the neuro checks in resident record to indicate the resident was monitored. According to Resident B's documentation, besides a [MEDICAL CONDITION] and bruising, the resident had no injury from hitting her head. On 3/3/21 at 11:40 a.m., the DON indicated staff had been able to assess the resident's swollen eye and pupil immediately after the fall, then later in the neuro check process until she discharged to the hospital. On 3/22/20 the resident's heart rate was 130 and the physician was notified for a script for the [MEDICATION NAME]. There was no documentation to indicate staff had attempted to get a different medication for the resident's anxiety as they were waiting for the [MEDICATION NAME] script and medication to be filled. Resident B would sometimes have high anxiety due to her diagnoses, she admitted on [DATE] and was able to get her medication on 3/22/20. On 3/22/20 when the resident complained of left side pain, her head hurt, and her pulse racing, the DON believed the nurse had informed the physician of the change when asking for the [MEDICATION NAME]. The documentation did not indicate the side pain was assessed or reported to the physician. On 3/23/20 at 2:10 a.m., the Resident B was complaining of her heart racing and had a heart rate of 165. The physician was called, and the resident received an order for [REDACTED]. Non-emergent transport had been called first because facilities were instructed not to call 911 unless it was a true emergency. The spouse was not documented as having been notified of the fall until the next morning, Resident B was alert and oriented, and her own person. The resident had a history of [REDACTED]. 2. During a confidential interview, during the survey dates of 3/1/21 and 3/4/21, it was indicated, the facility did not do anything about Resident C's falls. There were concerns because family was not notified of his two falls until many hours later, which prevented the family from having the choice of sending Resident C to the hospital for evaluation. The confidential interview indicated after two falls, both with injuries, Resident C was never evaluated by a doctor for his increase of pain, and shortness of breath. The confidential interview indicated, Resident C should have been sent to the hospital after his first fall because he had a head injury and being sent to the hospital to get checked out may have prevented the second fall. He should have been sent out after his second fall because of recent back surgery and assessed for re-injury to his back. After he went home, Resident C continued to complain of pain in his back and being short of breath. On 3/3/21 at 11:00 a.m., Resident C's medical record was reviewed. Resident C was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident C had a physician order [REDACTED]. A nursing progress note, dated 5/2/20 at 3:12 a.m., indicated, at 2:30 a.m., Resident C was found in his recliner holding a tissue to his scalp with copious amounts of bleeding. Resident indicated, he couldn't remember exactly what happened, but thought he rolled his ankle while trying to get out of bed and tripped and hit his head on the chair corner. The nurse's description indicated the resident had an unwitnessed fall, transferring from his bed to the recliner and hit his head on the chair in his room. A head to toe assessment indicated the resident's pupils were sluggish, there was an injury to his scalp. The physician was notified, but family would be notified in the morning. Vital signs (VS) were within normal limits. Resident's pain was assessed as 2 out of 10 and tender to touch. A Neurological Check Assessment, dated 5/2/20 at 3:00 a.m., indicated, Resident C's pupils were non-reactive to light, upon immediate check, and at the 15 minute follow up check. A nursing progress note, dated 5/2/20 at 3:18 a.m., indicated, Resident C had a new skin issue, located on the top of his scalp described as having a red wound base, bloody drainage, with approximated margins, drainage, and large amounts of blood. Treatment included, pressure applied, cleansed with normal saline, and left open to air due to location. A New Skin Issue Assessment was documented on 5/2/20 at 3:29 a.m., indicated Resident C sustained a laceration to the top of his scalp that measured 6 centimeters (cm) long, by 0.4 cm wide, and 0.1 cm deep. A nursing progress note, dated 5/2/20 at 9:37 p.m., indicated, Resident C's family was notified of his fall. A nursing progress note dated 5/3/20 at 4:54 a.m., indicated, at 12:30 a.m., Resident C was found on the floor in front of the toilet after he lost his footing and fell . The nurse description indicated, resident was unsteady on his feet and a head to toe assessment indicated bruising/abrasion to mid-back. The physician was faxed, and the nurse would notify the family in the morning. Resident's pain was assessed as 3 out of 10 and resident indicated soreness to back and arms. A nursing progress note, dated 5/3/20 at 11:09 a.m., indicated, Resident C's family was notified of the fall. A nursing progress note dated 5/3/20 at 6:06 p.m., indicated, Resident C complained of increased pain in his ribs. His pain level was 7 out of 10. A New Skin Issue Assessment was documented on 5/4/20 at 8:27 p.m., assessment indicated Resident C sustained bruising to his right outer forearm which measured 5 cm long by 2.5 cm wide, bruising to his left inner elbow which measured 5 cm long by 4 cm wide, and bruising to his left forearm which measured 6 cm long, by 3 cm wide. Resident C's record lacked documentation of subsequent skin assessments or follow up documentation related to the bruise/abrasion on his mid-back. A nursing progress note, dated 5/4/20 at 10:05 p.m., indicated, Resident C had a change in mental status, noted with increased tremors, resident slow with responses, resident experiencing trouble focusing. The physician was notified. A nursing progress note, dated 5/4/20 at 11:27 p.m., indicated communication with the physician related to the change in mental status, no recommendations were noted. A nursing progress note, dated 5/5/20 at 7:48 p.m., indicated Resident C reported increased pain in his back. A nursing progress note, dated 5/5/20 at 7:48 p.m., indicated Resident C complained of increased pain in his ribs. His pain level was 8 out of 10. A nursing progress note, dated 5/8/20 at 5:23 p.m., indicated, Resident C was anxious about his pain. A nursing progress note, dated 5/10/20 at 6:18 p.m., indicated resident received [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (a narcotic pain medication). It was ineffective and his pain level was 8 out of 10. A nursing progress note, dated 5/12/20 at 2:25 p.m., indicated, Resident C continued to require oxygen especially during activity. Room air sat (saturations) were 88% and increased to 97% with oxygen on. A nursing progress note, dated 5/12/20 at 10:45 p.m., indicated, Resident C continued to require oxygen. A nursing progress note, dated 5/13/20 at 9:55 p.m., indicated, Resident C complained, The pain in my back is so bad it is making me anxious. A nursing progress note, dated 5/14/20 at 4:21 p.m., indicated, Resident C continued to require 1.5 liters per minute of oxygen. When his oxygen was removed, his saturation level dropped to 88%. Resident C's Medication Administration Records (MAR) from April and May of 2020 were reviewed. Resident C had a physician order [REDACTED]. a. From 4/22/20 until 5/1/20, (from time of admission to the day before his first fall), Resident C's average pain level was 6 out of 10. His highest level of pain during this time period was 8. b. From 5/2/20 until 5/15/20, Resident C's average pain level increased to 7 out of 10. His highest level of pain during this time period was 10, noted on 5/6/20 (two days post second fall). Resident C's Medication Administration Records (MAR) from April and May of 2020 were reviewed. Resident C had a physician order [REDACTED]. a. From 4/22/20 until 5/1/20, (from time of admission to the day before his first fall), Resident C received oxygen 52% of the time, at an average of 1.5 liters per minute. b. From 5/2/20 until 5/15/20 (from the time of his first fall until his discharge), Resident C increased his use of oxygen to 73% of the time at an average of 1.5 liters per minute, the highest being 2.5 L required on 5/6/20. During an interview on 3/3/21 at 1:40 p.m., Licensed Practical Nurse (LPN) 4 and a MDS (minimum data set) coordinator indicated, upon a fall, neurochecks should have been initiated immediately, or as soon as possible after a resident had or was suspected of a fall, and a full head to toe assessment should be completed. If a resident had any injuries, they should have immediately been treated and reported to the doctor for any further orders. If a resident had large amounts of bleeding, especially from the head area, the nurse should have talked to the doctor or on call to ensure no emergent action would be required. If a neurocheck indicated sluggish pupils that were not reactive to light, there could have been a bigger underlying problem and the resident would probably have needed to be sent to the ER. The family should have been notified as soon as feasible, especially if there had been injury, usually before the end of the shift. During an interview on 3/3/21 at 1:50 p.m., LPN 8 and LPN 22 indicated, if a resident was suspected of a fall, they would immediately be assessed from head to toe. If a fall was unwitnessed, neuro checks were always required, even if a resident said they didn't hit their head. If a resident was on an anticoagulant, and hit their head, and had a lot of bleeding, that would almost certainly warrant a trip to the hospital for follow up. The family should have been notified as soon as possible, preferably after the nurse had spoken to the doctor, so they could relay any doctor's orders or recommendations to the family. If it was clear a resident hit their head, had a head injury, sluggish pupils that were non-reactive to light, it could possibly mean a head injury or neurological damage, and they should have been sent out. Nurses should get a hold of the doctor, or on call representative by phone versus a fax. During an interview on 4/4/21 at 4:33 p.m., a Nurse Practitioner, acting as the liaison for Resident C's physician, indicated, there was no note or documentation of Resident C's falls noted until 5/6/20, (two days post his falls). The NP indicated, the resident's falls, injuries, and neurocheck findings would certainly have warranted great concern and the need for emergent action. After the first fall and resulting laceration with large amounts of bleeding to his head, there was the potential for head injury, risk of excessive bleeding due to his blood-thinning medication use, and the possibility of a brain bleed or concussion. After his second fall, and sustaining new bruising and abrasions to his back, there was a high risk of new or re-injury to his vertebra after recent back surgery. On 5/5/21 at 11:02 a.m., copies of Resident C's physician progress notes [REDACTED]. The progress notes indicated: On 4/23/20, Resident C was seen as a new admission. The note indicated, .Pt (patient) developed back pain and went to ER (emergency department)- found to have T8 wedge FX (fracture) L3 vertebra FX, T8 compression FX. Pt is S/P (status/post) Kyphoplasty (a surgical procedure designed to stop the pain caused by a spinal fracture, to stabilize the bone, and to restore some or all of the lost vertebral body height due to the compression fracture) of T8 . Pt discharged to (facility name) for rehab On 4/29/20, Resident C was seen for a weekly update. The note indicated, . is receiving PT/OT/ST (physical therapy, occupational therapy, and speech therapy) . cognitive function is high, but needs medical management needs . ambulates 20 feet x 2 with RW (rolling walker) and supervision On 5/6/20, Resident C was seen for a weekly update. The note indicated, .had recent fall over weekend. Per notes, family was made aware. No injuries reported . decline due to another fall There was no documentation to indicate the resident's [MEDICAL CONDITION], bruising/abrasion to his back, or the change in his mental status had been reported by the facility. On 5/13/20, Resident C was seen for a weekly update and discharge planning. The note indicated, . (Resident C) asked to have doses of Narcs (narcotic pain medication) increased There was no documentation to indicate the resident's [MEDICAL CONDITION], bruising/abrasion to his back, or the change in his mental status had been reported by the facility. On 5/15/20 at 2:11 p.m., a nursing progress note indicated, Resident C discharged from the facility. On 5/18/20 Resident C was readmitted to the hospital for shortness of breath. A CT scan of his chest indicated, . There is inferior endplate height loss (compression fracture) of T7 vertebral body, age indeterminate but new from MRI [MEDICATION NAME] spine on 4/16/20. Endplate concavity and [MEDICAL CONDITION] involving the L2-L3 level appears new from previous exam as well 3. During an interview on 3/2/21 at 1:58 p.m., Resident E's family member indicated, Resident E was discharged from the facility on the morning of 1/22/21. When they got home, the family member saw a follow up appointment was scheduled for later that day at 2:00 p.m. and had not been told by the facility. When Resident E stood up, she winced and cried out in pain, My arm! Her family member asked what was wrong, and Resident E indicated, she fell yesterday. The family member asked if she had been sent to the hospital, and Resident E indicated, no, she told the nurse she fell , and the nurse just put a bandage on her ear. The family member called the facility to ask what happened, and when she spoke the Director of Nursing (DON), the DON indicated there was no documentation of a fall, Resident E had scraped her ear on a box. The family member took Resident E to the follow up appointment with the NP (Nurse Practitioner) and requested an X-ray which indicated Resident E's shoulder was broken. On 3/2/21 at 3:00 p.m., Resident E's medical record was reviewed. Resident E admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when the facility did not designate a zone to cohort and manage the care of 8 of 8 residents under surveillance for COVID-19, four randomly observed staff members failed to wear appropriate personal protective equipment (PPE) (Activity Aide 11, Certified Nurse Aide 12, Housekeeper 8 and Laundry Aide 9), failed to put on and remove PPE in the proper sequence to avoid cross-contamination and/or properly wash or sanitize their hands during care for 2 of 8 residents on transmission-based isolation precautions (Residents C and G), 6 of 11 interviewed staff members who provided resident care in 5 of 5 resident units failed to be screened for fever and signs or symptoms of COVID-19 at the beginning of their shift (Registered Nurse 3; Therapist 4; Licensed Practical Nurse 5; and Certified Nurse Aides 1, 2 and 6), 13 of the 30 residents residing in the Memory Care unit were not socially distanced (positioned greater than 6 feet apart) during two observed group activities and 2 randomly observed staff members (the Medical Records Director and Certified Nurse Aide 15) failed to properly wear a medical grade face mask in 1 of 5 resident care areas (Memory Care). These deficient practices had the potential to spread infections, including COVID-19, to all 115 residents in the facility. Findings include: 1. During a tour of the facility, on 10/20/20 beginning at 9:30 a.m., the 8 residents identified by the facility as being under surveillance for COVID-19 were observed in private rooms in 3 different areas as follows: 2 residents on 2 different halls of the 20-bed 300 unit, 1 resident in the 13-bed 400 unit, 5 residents throughout the 14-bed 600 unit. Only two of the rooms were adjourning. Only one of the eight rooms had a sign(s) to indicate the resident was on isolation precautions and/or the use of specific PPE was required to enter the room. During an interview, on 10/20/20 at 9:15 a.m., the Administrator indicated there were eight residents who were on isolation precautions because, per facility protocol, recently admitted or readmitted residents were placed on isolation for 14 days and one of the residents left the facility for [MEDICAL TREATMENT]. At this time, the Administrator was requested to provide a facility floor plan color-coded with red/yellow/green zones to identify areas designated for positive COVID-19 cases (red), COVID-19 surveillance areas where residents are within 14 days of possible exposure (yellow) and areas where there were no suspected COVID-19 cases or exposure (green). During an observation and interview, on 10/20/20 at 10:43 a.m., in the 600 unit, Certified Nurse Aide (CNA) 12 was wearing a KN95 (medical grade) face mask and no eye protection. She indicated she did not know which residents were on isolation precautions for COVID-19. During an observation and interview, on 10/20/20 at 10:44 a.m., CNA 16 was wearing a KN95 face mask and no eye protection. When asked which residents in the unit were on isolation precautions for COVID-19, she identified only two of the five residents and indicated she did not know of any others on the unit. She learned who was on isolation and what type of PPE to wear by seeing the PPE in the residents' rooms. She indicated there were cloth gowns and gloves, but no face shields in the residents' rooms. She thought face shields were possibly kept at the nurses' station. During an interview, on 10/20/20 at 12:06 p.m., in the 600 unit, Licensed Practical Nurse (LPN) 13, indicated she was the unit manager. She indicated signs informing of isolation precautions were not on the five residents' doors in the 600 unit until after 11:00 a.m. on 10/20/20. When asked how the staff knew who was on isolation and what type of PPE they should wear, she indicated they knew by the equipment inside the residents' doors. She demonstrated there was a supply of face shields in a bottom drawer of the nurses' station. The facility's color-coded floor plan, provided by the Administrator on 10/20/20, reflected there was no yellow zone. The eight rooms identified by the facility as being used by residents under surveillance for COVID-19 were: one in the 400 unit, five throughout the 600 unit, and two in two different halls of the 300 unit. During an interview, on 10/20/20 at 3:00 p.m., the Administrator indicated there was no designated yellow zone. The Indiana State Department of Health Guidance for Out-of-Hospital Facilities, dated 8/17/20, reflected the following: The following is guidance for out-of-hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles .4. Reduce the movement of staff between patients with and without COVID-19. Cohort staff and patients in one area of the building if possible. Cohort equipment for these patients/residents to limit spread of infection 2. During an observation, on 10/20/20 at 10:48 a.m., in the 600 unit, there was no sign on recently admitted Resident C's door indicating she was on isolation precautions and what type of PPE staff should wear to enter the room. Activity Aide 11 was exiting Resident C's room wearing a KN95 face mask and carrying a cloth gown. She was not wearing eye protection. During an interview, on 10/20/20 at 10:48 a.m., Activity Aide 11 indicated she was completing Resident C's Minimum Data Set assessment tool. She indicated she did not wear a face shield or goggles while she was in Resident C's room. During an observation, on 10/20/20 at 11:58 a.m., a sign taped to the outside of Resident C's room in the 600 unit reflected she was on droplet isolation precautions. Another sign reflected: Make sure eye, nose and mouth are fully covered before entering room. CNA 12 entered Resident C's room wearing a KN95 face mask. A bedside table just inside the door had a pile of cloth gowns, gloves and one set of goggles. CNA 12 put on a gown and gloves, but no eye protection. She did not sanitize or wash her hands before putting on the gown and gloves. CNA 12 set up the resident's lunch tray leaning over the resident. She removed her PPE in the resident's restroom in the improper sequence by removing her gown and then gloves. She did not sanitize or wash her hands until after she left the room, closed the resident's door, went to the food cart down the hall, put the lunch tray lid in the cart, moved another lid and then closed the door to the cart. During an observation, on 10/20/20 at 10:01 a.m., on the 300 unit, Housekeeper 8 was standing outside recently admitted Resident G's room. There was no sign on or around the resident's door regarding isolation status or required PPE. Housekeeper 8 was wearing a KN95 face mask. The Housekeeper put on her PPE in the improper sequence by putting on a face shield first. She then put on a yellow cloth gown and disposable gloves which were stored just inside the resident's door. She did not wash or sanitize her hands before or while putting on the PPE. She entered the resident's room, picked up a disposable trash bag within six feet of the resident and disposed the trash bag into the basket attached to her cart just outside the room. With the contaminated gloves, she reached into her pocket and got the keys to the cart, opened the door to the cart and picked up a bottle of cleaning solution. She re-entered the resident's room, cleaned surfaces throughout the room and mopped the floor. She removed her PPE in the following improper sequence: gloves, then gown, then face shield. She did not sanitize or wash her hands after removing the PPE. She put on gloves, went into a near-by resident room, leaned over the resident in a chair, and removed the resident's trash. The surveyor stopped the Housekeeper before she touched the resident or other surfaces. During an interview, on 10/20/20 at 10:08 a.m., Housekeeper 8 indicated she did not sanitize her hands when she removed her PPE outside of Resident G's room and before entering the near-by resident room. During an observation, on 10/20/20 at 10:01 a.m., while Housekeeper 8 was in Resident G's room, Laundry Aide 9 was outside Resident G's room. The Laundry Aide was wearing an N95 respirator (filtered, medical grade face mask). She put on a yellow cloth gown and gloves. She was not wearing eye protection. She did not wash or sanitize her hands before putting on the gloves or entering the room. The Laundry Aide walked throughout the resident's room, within six feet of the resident as she checked both closets. When she exited the room, she removed her gloves and discarded the cloth gown into a bin in the resident's bathroom near the door. She did not sanitize or wash her hands. During an interview, on 10/20/20 at 10:05 a.m., when asked about a face shield or goggles, Laundry Aide 9 indicated she did not know she had to wear them in Resident G's room. She did not know why Resident G was on isolation precautions. She was in the room because she was inventorying the resident's clothing. During an interview, on 10/20/20 at 3:00 p.m., the Administrator indicated there was an adequate supply of N95 face masks. He did not require N95 face masks to be worn in the rooms where residents were in isolation for COVID-19 surveillance and considered KN95 face masks to be adequate. During an interview, on 10/20/20 at 2:37 p.m., the Director of Nurses (DON) indicated staff members were expected to wear eye protection in the COVID-19 isolation rooms. There were goggles and face shields inside the isolated residents' rooms. They followed the Centers for Disease Control and Prevention (CDC) guidance related to what PPE should be worn and for the sequence of putting on and removing. Staff members were expected to wash or sanitize their hands immediately after moving PPE and before touching other surfaces. The facility's PPE Policy and Procedure, dated 2020 and provided by the DON on 10/20/20 as their policy for COVID-19 related isolation rooms, reflected the following .How to properly don, use, and doff PPE in a manner to prevent self-contamination .Respirator or Face Mask. Put on an N95 respirator (or higher level respirator) or face mask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply .Eye Protection. Put on eye protection (i.e., goggles or a disposable face shield that covers the front and side of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT (emphasis as written) considered adequate eye protection. Gloves. Put on clean, non-sterile gloves upon entry into the patient room or care area .Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene Attached to the facility's PPE Policy, dated 2020 and provided by the DON on 10/20/20, were two undated flyers from the CDC which described what PPE to wear and the procedure for putting on and removing PPE. During an interview, on 10/20/20 at 3:30 p.m., the DON indicated the two fliers were the facility's current policy for putting on and removing PPE and indicated the following: - Sequence for Putting on Personal Protective Equipment .1. GOWN .2. MASK OR RESPIRATOR .3. GOGGLES OR FACE SHIELD .4. GLOVES .USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION. Keep hands away from face. Limit surfaces touched . Perform hand hygiene. - How to Safely Remove Personal Protective Equipment (PPE) Example 1 .Remove PPE in the following sequence: 1. GLOVES. Outside of gloves are contaminated! If your hands get contaminated during glove removal, immediately wash your hands or use an alcohol-based hand sanitizer .Discard gloves in a waste container. 2. GOGGLES OR FACE SHIELD. Outside of goggles or face shield are contaminated! If your hands get contaminated during goggle or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer .If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container. 3. GOWN. Gown front and sleeves are contaminated! If your hands get contaminated during gown removal, immediately wash your hands or use an alcohol-based hand sanitizer .4. MASK OR RESPIRATOR. Front of mask/respirator is contaminated - DO NOT TOUCH! .5. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER MOVING ALL PPE. PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE. The facility's Policy and Procedure Hand Hygiene, dated 2020 and provided by the DON on 10/20/20, reflected the following.HCP should perform hand hygiene before and after all patient contact, contact with potentially infections material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process 3. During an observation, on 10/20/20 at 1:30 p.m., upon re-entering the facility after being off-site for an hour, the main entrance was unlocked. There was no one at the reception desk or lobby to ask whether re-entry required a second screening. Continued observation revealed the main entrance and lobby remained unsupervised for 11 minutes, until Receptionist 7 returned to her desk at 1:41 p.m. During an interview, on 10/20/20 at 3:00 p.m., the Administrator indicated a receptionist was positioned at the front lobby from 8:00 a.m. to 7:00 p.m. every day. All other entrances to the facility were locked so that all vendors, visitors, and staff could only enter through the front door. The receptionist required all persons to sanitize their hands, take their own temperature and sign the screening log to document they self-screened for the absence of COVID-19 symptoms. The receptionist was not supposed to step away from the desk. If she did, she should get someone else to take her place. At one time, they audited the sign-in/screening logs to ensure all staff members were being screened for COVID-19 symptoms but they had not done so recently. During an observation and interview, on 10/20/20 at 3:30 p.m., CNA 1 and CNA 2 were at the nurses' station of the 400 unit. They indicated they had not been screened and had not self-screened for symptoms of COVID-19, including taking their temperatures, before or during her shift. During an observation and interview, on 10/20/20 at 3:30 p.m., Registered Nurse (RN) 3 was at the nurses' station of the 300 unit. She indicated she entered the facility through the back door and did not self-screen for COVID-19 symptoms or sign the screening log at the main entrance. During an observation and interview, on 10/20/20 at 3:20 p.m., Therapist 4 was walking into the 600 unit. She indicated she entered the facility through the back door and had not been screened for COVID-19 symptoms. She did not self-screen or sign the screening log at the main entrance. During an observation and interview, on 10/20/20 at 3:35 p.m., LPN 5 was at the nurses' station of the 200 unit. She indicated she entered the building through the side door and was not screened for COVID-19 symptoms. During an observation and interview, on 10/20/20 at 3:40 p.m., CNA 6 was walking in the Memory Care unit. CNA 6 indicated she entered the facility through the entrance at the employee parking lot and was not screened for COVID-19 symptoms. During an interview, on 10/20/20 at 4:00 p.m., the DON indicated staff members were expected to come through the front door, self-screen for COVID-19 symptoms and sign the screening log. She was not aware nursing staff were entering the facility through multiple entrances. The facility's screening log, dated 10/20/20 and provided by the DON on 10/20/20 at 3:50 p.m., was reviewed and the names of CNA 1, CNA 2, CNA 6, RN 3, Therapist 4, and LPN 5 did not appear on the log to document the absence of signs or symptoms of COVID-19. 4. During an observation, on 10/20/20 at 10:33 a.m., in the Memory Care unit, 13 residents were in a small portion of the common dining room closest to the main entrance onto the unit. The 13 residents were being guided in a word game by the Memory Unit Activity Director. They were not wearing face masks and were sitting in a semi-circle next to each other in wheelchairs or dining chairs which were less than a foot apart. The attached larger side of the dining room was occupied by only four residents. During an interview, on 10/20/20 at 10:33 a.m., the 100 Unit Manager, RN 14 indicated the residents observed in the activity were not socially distanced and could spread out more into the back, larger area of the dining room during their activity. During an observation, on 10/20/20 at 1:45 p.m., 12 residents were in a small common area at the end of the Memory Care unit. The larger dining area was empty except for two staff members. All 12 residents were not wearing face masks and were sitting side-by-side in a circle with less than a foot between them: five in wheelchairs, and seven in chairs. The Memory Unit Activity Director was wearing a KN95 face mask and was leading them in group singing. During an observation and interview, on 10/20/20 at 2:00 p.m., the DON observed the singing activity in the Memory Care unit just as it was concluding. She indicated the residents should have been spaced out more. They could have used the dining room after it was cleaned or done the activity in two sessions so there were not so many residents clustered together. The CDC's guidance: Considerations for Memory Care Units in Long-term Care Facilities dated 05/12/20 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/memory-care.html, reviewed on 10/21/20) reflected the following: .nursing homes and assisted living facilities providing memory care should consider the following: .Continue to provide structured activities, which may need to occur in the resident's room or be scheduled at staggered times throughout the day to maintain social distancing .Limit the number of residents or space residents at least six feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel 5. During an observation, on 10/20/20 at 10:33 a.m., in the Memory Care unit, the Medical Records Director was sitting at the nurses' station with two other staff members. She was wearing a cloth face mask. During an observation on, 10/20/20 at 10:35 a.m., in the same Memory Care unit, CNA 15 was walking out of a resident's room. She was wearing a KN95 face mask under her nose and carrying a trash bag. She took the trash bag into the trash/laundry room and came out with the KN95 face mask still under her nose. An unidentified CNA walked in and out of the trash/laundry room with CNA 15 and did not direct CNA 15 to lift her face mask to above her nose. CNA 15 did not raise her face mask above her nose until this surveyor asked her about it. During these continued observations, two male residents were walking in the hallway. One of the two residents stopped and chatted with the nurses at the same nurses' station. Seventeen residents were in the nearby common dining room. During an interview, on 10/20/20 at 10:33 a.m., the Medical Records Director indicated she was in the unit entering Face Sheets. She indicated she did not have another mask under her cloth mask. During an interview, on 10/20/20 at 2:37 p.m., the DON indicated cloth masks could not be worn in a resident area. All masks must be worn above the mouth and nose. The Indiana State Department of Health Epidemiology Resource Center guidance: COVID-19 Information for Long-Term Care Facilities, last updated on 08/17/20 (https://www.coronavirus.in.gov/files/IN_COVID-19_LTC_08.17.20.pdf accessed on 10/21/20), indicated: .Direct care providers should wear a surgical mask for the duration of their shifts 3.1-18(a) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure the dishwasher temperatures were maintained, according to the manufacturer's guidelines posted on the dishwasher to ensure the correct sanitizing of dishes/utensils. This deficient practice has the potential to affect 140 of 140 residents who received meals from this kitchen. Finding includes: During an observation of the kitchen, with the Kitchen Manager, on 08/19/19 at 10:36 a.m., the high temperature dishwashing machine wash cycle reached 150 degrees Fahrenheit. The manufacturer's guideline posted on the dishwasher recommended wash cycle should have been 160 degrees. During a return observation, on 08/19/19 at 2:15 p.m., the dishwasher cycled at a wash temperature of 150 degrees Fahrenheit and a rinse temperature was 190 degrees Fahrenheit. A work order was in place for dishwasher repair. During an interview at that time, the Kitchen Manager indicated the wash cycle did not reach 160 degrees Fahrenheit to properly wash and sanitize the dishes and utensils according to the manufacturer's recommendations posted on the front of the dishwasher. The dishwasher temperature logs for (MONTH) showed wash temperatures of 160 degrees Fahrenheit. A facility policy titled .Dish Machine Best Practice ., provided by Registered Dietician on 08/21/19 at 10:03 a.m., indicated, .Dishes and Cookware will be washed after each meal to assure that all dishes are clean and sanitary .4. Run through dish machine a. Wash temperature at or greater than 150 degrees .In the event that dish machine does not meet above temperature guidelines, paper items and/or handwashing/ sanitizing of reusable items will be utilized 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure a resident assessment to self administer medication was completed, failed to obtain physician's orders [REDACTED]. (Resident 5) Finding includes: During an observation, on 08/19/19 at 11:05 a.m., Resident 5 was sitting in her recliner with her meal on the bedside table. Next to her breakfast tray was a clear medication cup with pills inside, the nurse was not present to administer the medications. LPN 11 was called into the room to identify the pills left in the cup. LPN 11 indicated the medication cup included; one aspirin tablet, one [MEDICATION NAME] tablet, one [MEDICATION NAME] tablet, one [MEDICATION NAME] tablet, three [MEDICATION NAME] tablets, one multivitamin tablet, one potassium capsule and one [MEDICATION NAME] capsule. LPN 11 indicated she had just stepped out for a minute and Resident 5 was not to self administer the medications. The record for Resident 5 was reviewed on 08/19/19 at 11:20 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident 5 did not have a self administration assessment, a physician's orders [REDACTED]. A facility document provided by the Director of Nursing, on 08/20/19 at 2:00 p.m., titled Self-Administration of Medication indicated, .Assessment will be completed on resident's who wishes to administer own medications .physician's orders [REDACTED].Careplan will be completed 3.1-11(a)

Based on observation, interview and record review, the facility failed to follow fall interventions placed for a resident at risk for falls for 1 of 3 residents reviewed for accidents (Resident 112). Finding includes: During an observation on 08/20/19 at 2:06 p.m., Resident 112 was sitting upright in the recliner in his room. The call light was not within reach, but at bedside. During an observation on 08/21/19 at 2:55 p.m., Resident 112 was sitting in a recliner in his room. The call light was not within his reach. The call light was attached to the left side of his bed. The record for Resident 112 was reviewed on 08/21/19 at 2:30 p.m. [DIAGNOSES REDACTED]. A progress note, dated 06/06/19 at 6:02 p.m., indicated the resident was found sitting down leaning with his back against his recliner. The resident claimed he was trying to sit in his recliner and scooted back, he didn't feel the recliner and knew he was going to fall so he slowly sat down onto the floor. The fall was unwitnessed. A care plan, dated 6/30/16, indicated the resident was at risk for falls. Interventions included, but were not limited to, assist with call light within reach. A care plan, dated 6/30/16, indicated the resident had an ADL (Activities of Daily Living) self-care deficit related to impaired mobility due to visual hallucinations. Interventions included, but were not limited to, keep call light within easy reach. Prefers to have call light attached to recliner. During an interview, with CNA 3 on 08/21/19 at 2:57 p.m., she indicated it was a fall risk to not have the rolling walker or call light within his reach since he typically tried to get up to go to the bathroom for toileting. A facility document provided by the Administrator, on 08/26/19 at 9:20 a.m., titled Care Plan indicated, .Problems are care planned, including nursing measures to be carried out A facility policy provided by the Administrator, on 08/26/19 at 9:20 a.m., titled Fall Management indicated, .Purpose .to develop a plan of care with the appropriate interventions to decrease a resident's risk for falls A facility policy provided by the Administrator, on 08/26/19 at 9:20 a.m., titled Falls Policy Overview indicated, .Implement fall and injury prevention .Staff Nurses including .NAs (Nursing Assistants) are responsible for: Ensuring .call lights are easily accessible 3.1-45(a)(2)

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition in 1 of 1 kitchens reviewed. This deficient practice had the potential to effect 136 of 137 residents who received food from the kitchen. Finding includes: During the tour of the kitchen, on 08/20/18 at 10:05 a.m. with the Registered Dietician and Culinary Service Director in attendance the following were observed: a. clean dishes were placed on a 3 shelf rolling table and all 3 shelf's were dirty. b. pans were hand washed and placed near dirty dishes on a rolling carts, a dirty broom and garbage cans had visible debris. c. the area for clean dishes was observed to have dirty dishes with debris and breakfast garbage next to clean dishes. d. the kitchen floor drainage grate was dirty. e. a brick wall separating the cooking areas was dirty f. the heating oven was dirty. g. an overhead vent above the cooking area was dirty. h. two drawers with 30 knives and 30 spoons was dirty with debris. i. the fire alarm in the dishwasher area was covered with debris and dirt. j. the overhead ceiling in the clean dishwasher area was dirty with debris. k. 5 fans in the kitchen had dirt and debris. l. 3 of 7 lights in the food serving area had bugs and debris inside them. m. 5 of 27 lights in the kitchen prep and cooking areas had bugs and debris inside them. n. the juice compressor was dirty and had debris. During an interview, on 08/24/18 at 12:57 p.m., Culinary Service Director indicated the areas were divided to keep clean and dirty dishes separated. She indicated the lights and over head vent of the cooking area needed to be cleaned. A policy was not provided before the time of exit. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to accurately assess a resident for the limited range of motion in his upper and lower extremities for 1 of 27 residents reviewed for Minimum Data Set (MDS) assessments (Resident 24). Finding includes: During an observation, on 8/22/18 at 12:57 p.m., Resident 24 was sitting up in his Broda Chair (a positioning chair used for long term care) and was being fed lunch by a CNA. The resident did not move his arms or hands. His legs and feet were elevated on the leg rests of his chair and his right foot was turned with his toes pointing to the right and his left foot was turned with his toes pointing to the left. During on observation, on 8/23/18 at 12:41 p.m., the resident was sitting up in his Broda Chair in the dining room and was being fed his lunch by a female staff member. The resident's arms had pillows under them and both of his feet were elevated on the chair rests with his toes pointing out and away from his body. The record for Resident 24 was reviewed on 8/22/18 at 4:41 p.m. [DIAGNOSES REDACTED]. A MDS assessment, dated 5/31/18 indicated the resident had no impairment in the range of motion of his upper extremities and no impairment in the range of motion of his lower extremities. During an interview, on 8/24/18 at 1:16 p.m., the Director of Therapy indicated the resident was not able to use his arms or hands at all and had no functional use of his legs. During an interview, on 8/24/18 at 2:50 p.m., the MDS coordinator indicated the resident was not able to use his arms, hands or legs and was not able to complete any of his own activities of daily living (ADLs). She indicated the deficits were so far into his dementia and it would not be coded on the MDS assessment. During an interview, on 8/24/18 at 3:29 p.m., the MDS coordinator indicated the facility did not have a policy on MDS and used the Resident Assessment Instrument (RAI) Manual. 3.1-31(c)(3) 3.1-31(c)(4)

Based on observation, record review and interview, the facility failed to identify a bruise of unknown origin on the hand a resident for 1 of 4 residents reviewed for non pressure skin issues (Resident 38). Finding includes: During an initial observation on 08/21/18 at 1:44 p.m., Resident 38 was observed to have a nickel sized dark purple bruise on the top of her right hand. She indicated she did not know how she got the bruise. During an observation with LPN 5 on 08/24/18 at 2:54 p.m., Resident 38 was observed to have two bruises on her right hand. LPN 5 indicated she was not aware of the bruises and should have documented it on the weekly skin assessment. The record for Resident 38 was reviewed on 08/23/18 on 1:09 p.m. [DIAGNOSES REDACTED]. Review of a Weekly Skin Assessment, dated 8/22/2018, does not indicate the resident had a bruise on her right hand. A Care Plan indicated the resident was at risk for skin breakdown due to decreased mobility. Interventions included, but were not limited to, a (s)kin assessment weekly by licensed nurse. During an interview on 08/24/2018 at 12:50 p.m., the LPN 5 indicated the nursing staff was to do weekly skin assessments and if there were skin issues noted, including bruises it would be documented. On 08/24/2018 at 2:43 p.m., the Administrator indicated the facility did not have a policy addressing nonpressure skin issues. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure an assistive device was in place for 1 of 1 resident reviewed for accidents (Resident 13). Finding includes: The record for Resident 13 was reviewed on 8/22/18 at 9:15 a.m. [DIAGNOSES REDACTED]. A physician order [REDACTED].M. and remove in the P.M. A fall risk assessment dated [DATE] identified Resident 13 was at moderate risk for falling. During an observation on 8/21/18 at 11:19 a.m., Resident 13 was observed without hipsters. CNA 1 (Certified Nurse Aide) checked on Resident 13 and indicated during interview she did not have hipsters on. A plan of care dated 8/21/18 indicated Resident 13 was at risk for falling due to impaired mobility related to [DIAGNOSES REDACTED]. The plan of care included a goal indicating the resident would remain free from fall with significant injury, interventions included but were not limited to hipsters per order. During a interview with CNA 2 on 8/22/18 at 9:21 a.m., she indicated hipsters were placed by night shift aides and the direction for placement of hipsters should be on the CNA worksheet and was not currently on the worksheet for Resident 13. During an interview with the Unit Manager on 8/22/18 at 10:39 a.m., indicated the order for hipster placement should have been on the worksheet and was placed on the CNA worksheet on 8/22/18. A current policy titled Fall Management, dated 3/2017, obtained from Director of Nursing on 8/24/18 at 10:00 a.m., indicated .Purpose: To develop a plan of care with appropriate interventions to decrease a resident's risk of falls, and provide safety to resident while maintaining dignity, and honoring residents individual wishes . IDT Interdisciplinary Team) to review fall and current and future interventions 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure an appropriate indication of use for an antipsychotic for 1 of 7 reviewed for unnecessary medications (Resident 119). Finding includes: The record for Resident 119 was reviewed on 08/22/18 at 12:47 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Care Plan indicated the resident was at risk for side effects from [MEDICAL CONDITION] medications taken for dx (diagnosis) of [MEDICAL CONDITION] with behaviors, [MEDICAL CONDITION] The interventions included, but were not limited to, observe for adverse side effects from antipsychotics. The review date for this care plan was 08/07/2018 with a target completion date of 11/10/2018. The resident was discharged from the facility to a mental health facility on 07/11/2018. A review of the DISCHARGE SUMMARY from the mental health facility indicated the reason for the initial admission to the mental health facility was .due to aggressive behavior. He had been increasingly withdrawn and resistant to care. He had become aggressive with staff and other patients, which had been building over the past month The MENTAL STATUS ON ADMISSION summary to the mental health facility indicated .He denied hallucinations. No formed delusions were elicited The HOSPITAL COURSE summary indicated .The patient was admitted .Records were reviewed from the outside facility .[MEDICATION NAME] (mood stabilizer) was discontinued and a trial of duloxetine (antidepressant) was ordered due to a history of chronic back pain. [MEDICATION NAME] (antipsychotic) had been ordered for severe agitation which was used early in the hospital course. Due to [MEDICAL CONDITION] and significant restlessness, [MEDICATION NAME] (sedative and antidepressant) was scheduled at night. These interventions did not appear helpful early on. He was exhibiting significant restlessness. He was also quite aggressive with staff when providing care. [MEDICATION NAME] was discontinued due to lack of effect and [MEDICATION NAME] (natural hormone used as a sleep aid) was ordered on an as needed basis. Duloxetine was continued and moved to bedtime and [MEDICATION NAME] was scheduled. Despite 2 mg of [MEDICATION NAME] (antipsychotic) per day, the patient received continued doses of [MEDICATION NAME]. Due to continued [MEDICAL CONDITION], the [MEDICATION NAME] was discontinued and a trial of [MEDICATION NAME] (sedative) was initiated. The patient was significantly less interactive and mobility greatly reduced, and therefore, the [MEDICATION NAME] was discontinued and p.r.n. (as needed) [MEDICATION NAME] dosage reduced. A trial of [MEDICATION NAME] (used to treat anxiety) was initiated. The patient gradually become more alert. He became less resistant to care and his intake was improving. Despite improvement in his alertness and lack of overt parkinsonism related to the [MEDICATION NAME] antagonist, he did not resume walking and staff was moving him with a lift. Due to the lack of significant behavioral symptoms, the assisted living facility was contacted and felt they could work with him during his physical rehabilitation. On (MONTH) 24, (YEAR), the patient was felt to have achieved maximum benefit from hospitalization The DISCHARGE [DIAGNOSES REDACTED].did not appear to be hallucinating . and .(n)o formed delusions were present, he was making references to the fire department A review of the PSYCHIATRIC ASSESSMENT and Progress Notes from the facility from 07/11/2018 to 07/24/2018, indicated the resident did not have delusions. A Progress Note, dated 08/02/2018, was located in the resident's paper chart and indicated .(Resident 119) was started on [MEDICATION NAME] 10mg for [MEDICAL CONDITION] with behaviors. This medication was started on 8/2/18 related to behaviors listed below but not limited to. Notes were recorded by facility staff A Progress Note, dated 08/02/2018, provided by the facility but not in the resident's paper chart at the time of the record review, indicated .(Resident 119) was started on [MEDICATION NAME] 10mg for [MEDICAL CONDITION] with behaviors including delusions. This medication was started on 8/2/18 related to behaviors listed below but not limited to: The Behavior Notes indicated in the 08/02/2018 Progress Note are listed below: a. On 07/26/2018 at 9:48 p.m., Resident 119 urinated on the floor and refused to take his medication. He yelled and cursed and refused to eat dinner. The nonpharmacological interventions were successful and the resident accepted medications, his meal and apologized to staff for yelling. b. On 07/27/2018 at 10:15 a.m., the resident yelled and screamed at staff and refused morning medications. The nonpharmacological interventions were successful. c. On 07/28/2018 at 6:01 a.m., Resident 119 yelled and screamed at staff and refused care. The nonpharmacological interventions were successful and his behavior ceased after care was complete. d. On 07/28/2018 at 10:07 p.m., the resident yelled and screamed at staff. The nonpharmacological interventions were successful and no further behaviors were noted. e. On 07/29/2018 at 6:01 a.m., Resident 119 refused morning medications and yelled and screamed at staff. The continued to refuse his medications. f. On 07/29/2018 at 10:34 p.m., the resident urinated on the floor in the dining room. He yelled, screamed and cursed at staff. The nonpharmacological interventions were successful and the Resident 119's behavior stopped after care was completed. g. On 07/30/2018 at 3:07 p.m., Resident 119 cursed and yelled at staff. He urinated on the dining room floor. The nonpharmacological interventions were successful and his behaviors stopped once care was complete. h. On 07/30/2018 at 8:27 p.m., the resident cursed, yelled and screamed at staff. The nonpharmacological interventions were successful and the his behavior stopped once care was complete. i. On 07/31/2018 at 10:19 a.m., Resident 119 yelled and cursed at staff during care. The nonpharmacological interventions were successful and the resident was calmed down after care. j. On 08/01/2018 at 6:29 a.m., the resident cursed at staff and urinated on the floor and his bed in his room. k. On 08/01/2018 at 10:43 a.m., Resident 119 cursed and yelled at staff during care. Once care was complete, his behaviors stopped. l. On 08/02/2018 at 2:39 a.m., the resident yelled and screamed at staff. He attempted to hit and curse at staff. The resident's behaviors stopped once care was complete. m. On 08/02/2018 at 6:01 a.m., Resident 119 became physically aggressive with staff, resisted care, yelled and screamed at staff. Once care was complete, the resident's behaviors stopped. n. On 08/02/2018 at 7:04 a.m., the resident resisted care, yelled and screamed at staff, and became physically aggressive. His behaviors stopped after care was complete. A review of all the Behavior Progress Notes indicated the following behaviors, after [MEDICATION NAME] was started on 08/02/2018 through 08/12/2018: a. On 08/05/2018 at 11:08 a.m., the resident was physically combative during morning care. b. On 08/06/2018 at 6:05 a.m., Resident 119 was physically aggressive during morning care. When care was complete, the resident went back to watching television. c. On 08/06/2018 at 1:46 p.m., the resident cursed at staff during morning care. Once care was complete, the resident calmed down. d. On 08/06/2018 at 9:26 p.m., Resident 119 became physically aggressive during evening care, resisted care and cursed at staff. Once care was complete, he calmed down. e. On 08/07/2018 at 2:21 p.m., the resident yelled during his morning shower. He cursed at staff and became physically aggressive. f. On 08/07/2018 at 6:00 p.m., Resident 119 urinated on himself and surroundings and was making nonsensical statements. Once care was complete, be was watching television. g. On 08/08/2018 at 6:10 a.m., the resident refused morning care. He yelled at staff and became combative. h. On 08/09/2018 at 10:01 p.m., Resident 119 made delusional with nonsensical statements. Stated, 'Mom was here a week ago' 'She put together that chair and the door with those 39 kids' Tearful stated, 'No one loves me' i. On 08/10/2018 at 7:12 p.m., Resident 119 cursed at staff and became physically aggressive. The precipitating factors indicated the (d)isease process, et resident does not like being touched j. On 08/12/2018 at 2:27 p.m., the resident was combative with care, became physically aggressive and cursed at staff. During an interview on 08/24/18 at 1:29 p.m., the Director of Nursing indicated an antipsychotic is inappropriate for a [DIAGNOSES REDACTED]. A current facility policy, titled [MEDICAL CONDITION] Medication Policy and Procedures, dated (MONTH) (YEAR), received from the Administration on 08/24/2018 at 3:43 p.m. indicated, Policy: Physicians & Facility staff will use [MEDICAL CONDITION] medications appropriately working with the interdisciplinary team to ensure appropriate use and evaluation .Procedures: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. 2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. Psychopharmacological medications will never be used for the purpose of discipline or convenience 3.1-48(a)(4)

Based on record review and interview, the facility failed to ensure a resident's decrease in consumption at meals and her subsequent significant weight loss of 38.5 pounds, or 23.9% of her body weight, in 30 days, was monitored and addressed accordingly, to implement possible interventions to avoid further weight loss, for 1 of 4 residents reviewed for weight loss in a sample of 4. (Resident #B) Findings include: 1. Resident #B's record was reviewed on 2/14/12 at 11:20 a.m. The resident's [DIAGNOSES REDACTED]. The resident's annual minimum data set (MDS) assessment, dated 10/27/11, indicated the resident was moderately cognitively impaired. The resident ate independently with set up only. The resident was discharged to the hospital on [DATE] with the complaint of possible GI (gastrointestinal) bleed with red, watery stools. A physician's orders [REDACTED]. (Recommend) res. (resident) be NPO (nothing by mouth) status (c with a line over the c) (with) long-term alternative nutrition. However, son has declined PEG (feeding tube) tube and NPO. Res. to continue on mech. (mechanical) soft diet NCS (no concentrated sweets) and thin liquids as son will sign diet waiver and gave verbal agreement over phone. Informed nsg (nursing), DON (Director of Nursing), Social Services, and dietary mgr. (manager)." The resident's weights (in pounds (lbs.)) were indicated as follows: 7/4/11 - 160; 8/1/11 - 161; 9/2/11 - 160; 10/2/11 - 161; 10/30/11 - 122.5 with weekly weights initiated; 11/3/11 - 122 with a reweigh of 122.5; 11/8/11 - 119; 11/15/11 -118.5; 11/22/11 - 116.5; 11/29/11 - "in hosp (in hospital);" 12/01/11 per 24 hour report - 114. The Nurse's Notes indicated the following: On 7/25/11 at 10:00 a.m., the resident was found hoarding most of breakfast from the dining room and wrapped in her napkins. She stopped at the housekeeping cart in the hallway and proceeded to throw it away. The resident indicated she wasn't hungry. The resident was educated she did not need to take it from the table as her intake from the meal was calculated. On 8/8/11 at 6:45 p.m., the resident was observed to place wrapped items in the basket of the E-Z stand. Three-fourths of manicotti from supper was observed wrapped in a napkin. When this writer attempted to speak to the resident about her "behavior," the resident shook her finger at her and said "No, No, Liar, Liar." One to one and redirections were unsuccessful with the resident. On 8/11/11 at 11:00 a.m., staff reported to nurse the resident had placed her breakfast cereal and toast and put in into the Hoyer lift pad. 1 to 1 education was completed to leave the food in the dining room. On 8/15/11 at 12:00 p.m., the resident was observed to put her left over food wrapped in a napkin into a pocket on the stand up lift. The resident was educated she did not have to eat 100 % of her meals and was not good to hide her food. The resident indicated she understood and "won't do it anymore." On 10/16/11 at 11:10 (a.m./p.m. not specified), therapy was notified as resident was complaining of difficulty swallowing her small pills and while eating at times. On 10/16/11 or 10/17/11, no information was indicated related to the resident's weight. On 10/18/11 at 9:00 p.m., a new physician order [REDACTED]. On 10/21/11 at 3:00 p.m., the hospital notified the facility of the swallow study results. The resident had trace of aspiration with all consistencies except nectar thick. Recommendations were NPO (nothing by mouth) or pureed with nectar thick fluids. On 10/21/11 at 3:30 p.m., the diet was changed per Speech therapy order. The resident was in agreement to try the pureed diet over the weekend. On 11/7/11 at 12:50 p.m., order written for health shakes daily at 10 a.m. and 2 p.m. as nursing measure due to weight loss. Kitchen was notified. On 11/11/11 at 1:30 p.m., a CNA witnessed the resident throwing away something in housekeeping's trash after lunch. The CNA discovered the resident had thrown away her lunch wrapped in a napkin. On 11/13/11 at 2:05 p.m., a CNA reported the resident had thrown her lunch wrapped in a napkin away in her room's trash. Writer indicated she would advise Social Services Director. On 11/28/11 at 8:45 p.m., Resident ate bites of supper but hiding the majority of the food in her napkins. On 11/30/11 at 9 p.m., the resident was observed to keep hiding her food in her napkin and then threw it away in her room so staff would not know she wasn't eating. The "THERAPY COMMUNICATION TO NURSING," dated 10/17/11 and signed by the scheduled nurse on the unit and the speech therapist, indicated the problem/need was the resident was having difficulty with swallowing even small pills and had had a recent weight loss. Speech therapy was to evaluate and treat as indicated. The Speech therapy notes indicated the following: On 10/17/11, the Speech Therapist indicated an evaluation request was received for Resident #B due to nursing had reported the resident was having difficulty swallowing, including swallowing the smallest pills. She also had a recent weight loss. Staff had reported the resident would put her food in her wheelchair side bag and take it back to her room where she would throw it away when no one was looking. On 10/18/11, this Speech Therapist did see Resident #B hide her food, and this may have been due to her difficulty in initially swallowing or may be a contribution. She would await the results of the modified [MEDICATION NAME] swallow study which had been requested from her physician. The "VIDEO SWALLOW STUDY," dated 10/21/11, indicated the "History/Dysphasia Symptoms: weight loss, difficulty (c with line over it) (with) pills, food feeling stuck in throat." The recommendations were NPO, long-term alternative nutrition, and if patient/family would refuse NPO and/or alternative feeding, a pureed diet with nectar thick liquids was indicated. The ""NUTRITIONAL PROGRESS NOTES," dated 10/26/11, indicated the Registered Dietician had completed an MDS review as of 10/25/11 and to see the nutrition assessment. The "NUTRITION ASSESSMENT," dated 10/26/11, indicated the resident's weight was stable with the "actual" weight was 161 lbs. as indicated on 10/02/11. The resident's current diet/supplement/tube feeding was puree with nectar thick liquid changed to mechanical soft no concentrated sweets and thin liquids. Her eating ability indicated she needed tray set up with problems swallowing. She was indicated as alert and able to understand and follow directions. Her average oral intake was 25% to 75%. The "ASSESSMENT/NUTRITION [DIAGNOSES REDACTED]. The interventions were honor food preference, encourage intake, honor diet waiver and provide mechanical soft diet. The ""NUTRITIONAL PROGRESS NOTES," dated 11/2/11, indicated the Registered Dietician was "notified of new monthly wt (weight) = 122.5 # (pounds)." The resident was reweighed 4 times with a consistent weight at 122 #. The resident was with 38.5 # 23.9% wt loss in 30 days, down 36#, 22.7% in 180 days. After a discussion with the resident , the resident agreed to whole milk with meals, supercereal, ice cream at night, cottage cheese at lunch and pudding at dinner. The medication, [MEDICATION NAME] (appetite stimulant), was also recommended. The "CARE PLAN," originally dated 10/26/11 and updated 11/1/11, indicated the problem was "Potential for alteration in Nutritional and/or Fluid Balance status related to: difficulty swallowing / Dysphagia; Impaired skin integrity - shearing; h/o (history of) constipation; DX (diagnoses) of: Diabetes, hx [MEDICAL CONDITION]." The interventions were to weigh the resident per physician order [REDACTED]. The interventions to include specified fortified foods was added on 11/2/11. Review of nurses' notes indicated the resident acquired an open area on 8/7/11 at 10:00 p.m. A 1.5 centimeter (cm) by 1 cm sheared area was noted to the left lower buttock. The wound base was red with white/pink margins. On 8/8/11 at 4 a.m., the resident refused the writer to access the left buttock open area. On 10/11/11 (no time), the resident's left buttock remained clean and dry. The resident refused to get out of electric wheelchair "for a little while to be down" or get into her recliner. The "WOUND/SKIN CONDITION EVALUATION REPORT" indicated the following: Initially on 8/7/11- type was shearing and measured 1.5 cm in length (l) x (by) 1 cm in width (w)with less than (<) 0.1 cm depth; On 9/26/11 - shearing and measured 1.3 cm x 0.4 cm x 0.3 cm; On 10/3/11 - shearing and measured 1.2 cm x 0.4 cm x 0.2 cm; On 10/10/11 and 10/17/11 - shearing and measured 1.2 cm x 0.4 cm x 0.2 cm; On 10/24/11 - shearing and measured 1.2 cm x 0.4 cm x n/a; slow healing was noted; On 11/03/11 and 11/07/11 - shearing and measured 0.9 cm x 0.7 cm x 0.2 cm; On 11/15/11 - shearing and measured 0.9 cm x 0.7 cm x 0.1 cm; On 11/21/11 - shearing and measured 0.8 cm x 0.7 cm x 0.1 cm; On 11/29/11 - shearing and measured 1.7 cm x 0.6 cm x 0.1 cm; admitted to the hospital on [DATE]. The "SOCIAL SERVICE PROGRESS NOTES" indicated the following: On 8/12/11 the writer indicated she was notified this week the resident was hiding food in the Hoyer basket/sling on the unit. When this writer inquired, the resident indicated "too much, just too much." When the writer asked if she wanted smaller portions, the resident smiled and thanked this writer. Nursing and kitchen were notified. On 8/30/11 the resident continues to have episodes of hiding food although the food portions were made smaller. Nursing to continue to update Social Services. On 10/24/11 the resident asked why her diet was changed to pureed. The writer asked her if she was having problems swallowing or if she choked, and the resident stated "oh yes, and it was so scary." In addition, a note was added to include the resident was still having episodes of hiding food as reported by staff. Continue to encourage and educate resident on the importance of consumption. On 11/22/11 at 2:30 p.m., continue to observe and encourage resident to not take food back with her to throw away. The "MEAL TRACKER" indicated the following: August 2011 - meal consumption ranged from "bites" on 8/28/11 for breakfast to 100%. On 8/8/11 for dinner, the information indicated she had eaten 100%. On 8/11/11 and on 8/15/11 both at lunch, the resident had eaten 75%. September 2011 - meal consumption ranged from "bites" for lunch on 9/11/11 to 100%. October 2011 - meal consumption ranged from "bites" at breakfast for 10/22 and 10/23 and at lunch on 10/8 and 10/11 to 100%. On 10/18/11 the resident had eaten 25% for each meal. On 10/15 and 10/16, the resident was indicated as with family with no information of meal consumption. On 10/26/11 at supper/dinner, the resident had eaten in her room with no information of meal consumption indicated. No information was indicated for breakfast on 10/14, 10/20; for lunch on 10/23; and for dinner/supper on 10/08/11. November 2011 - meal consumption ranged from "bites" for supper/dinner on 10/27 and 10/28 to 100%. On 11/11 at lunch, 75% was indicated as consumed. On 11/13 at lunch, 100% was indicated as consumed. On 11/28 at supper/dinner, bites were only indicated as consumed. No information was indicated for the lunch meal on 11/23/11 or the supper/dinner meal on 10/30/11. On 2/14/12 at 10:00 a.m. during initial tour and during an interview, Unit Manager #1 indicated the weight book was located at the nurse's station. She also indicated several residents were on weekly weights due to not eating well, new admissions, had lost weight while in the hospital, and one resident was attempting to lose weight. On 2/14/12 at 10:35 a.m. during initial tour and during an interview, LPN #2 indicated some weights were ordered to be done weekly. She indicated staff would watch how well the residents were eating and if there were no issues, monthly weights would be done. She also indicated she attempted to have the same CNA do the same resident's weight if possible. On 2/14/12 at 3:00 p.m. during an interview, Unit Manager #1 indicated if a family would request a weight, the weight should be done with the weight documented. On 2/14/12 at 8:00 p.m. during a confidential interview, Resident #B's family member indicated while he was visiting Resident #B on 10/17/11, a staff member, who he could not remember her name, indicated the resident was having trouble swallowing her small pills. He indicated he asked staff to weigh Resident #B at this time. The resident was assisted from her electric wheelchair to the sitting scales where she was weighed at 122 pounds. He indicated he remembered the date/time due to several family members, including out of town relatives, had participated in a special occasion celebration on 10/16/11. He also indicated he found out she was hiding food from another resident in the facility, who had told him in July 2011. On 2/15/12 at 11:25 a.m. during an interview, the Dietary Manager indicated a resident would be put on the "NAR (Nutrition at Risk)" list if new admission for 4 weeks, who was identified as losing weight, and/or a resident who was not eating. On 2/15/12 at 11:35 a.m. during an interview, the Registered Dietician indicated Resident #B would move her food around on her plate as if she had eaten some of it. She indicated smaller portions were tried in August, but the resident still did not eat well. She also indicated she was unaware of the resident hiding her food and had thought she was spitting up into her napkins. She was unaware of the resident's weight loss until it was reported to her on 11/2/11. With weight loss she indicated she would recommend fortified foods per the resident's preferences before she would use supplements. On 2/15/12 at 12:00 p.m. during an interview, Speech Therapist #2 indicated the nurse reported to her Resident #B was having difficulty swallowing and did not want to eat. She also indicated nursing had informed her of a recent weight loss, which her son was concerned about this. She indicated she did not remember what her weight loss had been, but it should have been documented. She indicated she communicated information utilizing the "THERAPY COMMUNICATION TO NURSING" form. She would distribute this original form/information in the resident's record, and copies to the unit manager and/or charge nurse, Director of Nursing, Director of Therapy, and to the Unit Manager's office box to be sure the unit manager would be aware of the information. On 2/15/12 at 1:20 p.m. during an interview, the DON indicated a resident's meal intake was determined by what was left on the resident's plate. On 2/15/12 at 2:55 p.m. during an interview, CNA #3 indicated a resident's food intake was determined by how much was left on the plate. On 2/15/12 at 3:50 p.m. during an interview, the DON indicated the resident went to the hospital on [DATE] and not 11/29/11. At this same time, she provided a 24 hour report form indicating Resident #B's weight was completed on 12/01 with a weight of 114 lbs. The "WEIGHT TREND RECORD" policy was provided by the Director of Nursing on 2/15/12 at 10:45 a.m. This current policy indicated the following: "Purpose: 1. To consistently document a resident's monthly or weekly weight data. 2. To identify any significant unexpected and undesired weight gains or losses. Policy: A resident's weight will be monitored consistently to quickly identify any unexpected weight changes.... Responsibility: Dietary Manager, C.N.A., Licensed Nurses...." The policy for NAR (Nutritionally at Risk), which was kept in the weight book at the nurse's station, was provided by Unit Manager #1 on 2/15/12 at 12:10 p.m. This current policy indicated the following: "Policy: Residents at nutritional risk will be reviewed weekly by the NAR committee until stable. Subject: residents at Nutritional Risk Procedure and Guidelines: ...2. Any resident showing an unplanned or significant weight loss in 30-90-180 days will be placed on NAR and reviewed weekly until determined stable by committee. ...10. Any resident with a weekly weight difference of 3 pounds more or less will be reweighed. Monthly re-weights are required if weight is 5 pounds more or less." This federal tag relates to Complaint IN 421. 3.1-46(a)(1)