Every finding on record at Oakwood Health Campus

Based on interview and record review, the facility failed to provide a resident appropriate care and services for 1 of 1 resident reviewed for hospitalizations. The resident was not thoroughly assessed, physician's orders were not followed, and staff were not adequately trained to provide care of a resident with a recent vascular stent placement. This deficient practice resulted in the resident being hospitalized . (Resident 89) Finding includes:On 8/14/25 at 1:01 P.M., Resident 89's clinical record was reviewed. Diagnoses included, but were not limited to, peripheral vascular disease (PVD).The most recent quarterly MDS (Minimum Data Set) assessment prior to the resident's discharge, dated 3/1/25, indicated Resident 89 was cognitively intact, supervision of staff for bed mobility, transfers, showering, and toileting, and had not rejected care.The most recent discharge MDS assessment, dated 5/26/25, indicated Resident 89's cognition was not assessed, supervision of staff for bed mobility, transfers, showering, and toileting, and she did not reject care.On 4/24/25, the resident had an arterial doppler study of both legs for PVD and a nonhealing ulceration of the left lower leg. It was abnormal and showed significant disease in the left distal (far end) superficial femoral artery (SFA) and proximal (close end) popliteal (behind the knee) artery and stenosis (narrowing) of the iliac artery. Stent placement was recommended by the vascular surgeon.On 5/20/25, Resident 89 left the facility and underwent a planned, same day angioplasty and stent placement procedure in the left leg (a minimally invasive procedure using a balloon-tipped catheter to widen the artery and then placing a small mesh tube or stent inside the artery to keep it open and improve blood flow).Post Procedure (post-op) Discharge Instructions from the vascular surgeon were provided to the facility, dated 5/20/25, and included, but were not limited to, the following orders for Resident 89 after her procedure:-Observe the procedure site for signs of infection: redness, swelling, warmth, drainage, or foul odor-Resume medications as previously instructed, aspirin (antiplatelet) 81 milligrams (mg) by mouth daily and Plavix (antiplatelet) 75 mg by mouth daily (handwritten and circled under medication instructions)-contact the physician for increasing or severe pain, shortness of breath, weakness or dizziness, fever, redness, swelling, warmth, or bleeding at the puncture siteThe clinical record lacked a care plan for Resident 89's post-op stent placement.Nursing Progress Notes included, but were not limited to, the following:On 5/7/25, the resident returned, with family, from an appointment with the vascular surgeon. The resident was scheduled for the procedure on 5/20/25.On 5/20/25, the resident had returned to the facility from the procedure at 5:22 P.M., with pressure dressing on her left groin to be removed at noon on 5/21/25. Staff were to resume all medications and observe the procedure site for signs of infection: redness, swelling, warmth, drainage or foul odor.A New Skin Occurrence Assessment, dated 5/21/25, was completed for a bruise on the left upper thigh and groin area. New measures taken to prevent recurrence were to ensure the resident has appropriate treatments implemented, encourage the resident to drink fluids, and to apply moisturizer to keep skin supple.On 5/23/25 at 12:30 P.M., the nurse practitioner was there to evaluate the patient. Resident indicated she had pain in her left foot and did not sleep well. No lower extremity edema was observed, distal pulses were present, and vital signs were within normal limits. Current orders were reviewed and a new prescription for Melatonin (sleep aide) was ordered at that time.On 5/26/25 at 7:28 A.M., a weekly skin assessment was completed at this time with no new skin issues noted.Nursing progress notes continued:On 5/26/25 at 8:00 A.M., the nurse noticed the resident was upset, asking where she was, and saying she was more confused than usual at that time. The nurse reoriented resident and exited the resident's room.On 5/26/25 at 8:11 A.M., the Certified Nurse Aide (CNA) approached the nurse and indicated she was worried about the resident because the resident was unsure of her surroundings, had trouble comprehending what the CNA said to her, and was unable to carry on a conversation with the CNA like she usually did. Nursing would continue to monitor the resident. On 5/26/25 at 4:45 P.M., the resident was noted to have slurred speech and twitching. The resident's left lower leg was purple, cool to touch, and swollen. An order was obtained from the physician to send the resident to the emergency room (ER) for evaluation at that time.The history and physical from the hospital ER, dated 5/26/25, indicated the resident had peripheral arterial disease and was status post angioplasty and stent placement a few days ago who presented to (hospital name) from (facility name). The resident was on aspirin and Plavix for peripheral stent placement. Yesterday she was noted to have slurred speech and appeared tired as reported by her daughter. Testing on the left leg showed presence of a distal SFA popliteal stent which was occluded.A hospital progress note, dated 6/3/25, indicated it was discovered that the resident was not receiving Plavix 75 mg daily at the facility as ordered by the vascular surgeon.The Medication Administration Record (MAR) for May 2025 indicated the direct pressure dressing was removed at 10:42 A.M., (1.5 hours early) per the resident's request. The ordered medication Plavix 75 mg daily was not administered.The clinical record lacked documentation of the following:-a physician's order to remove the direct pressure dressing early-education provided to the resident about the risks and benefits of removing the dressing early-physical assessments and monitoring of the resident's temperature and left lower leg for pain, redness, swelling, warmth, drainage, bleeding, and foul odor, as ordered-notification to the physician about the sudden mental status changeThe facility assessment, last reviewed 8/7/25, indicated . If a resident who currently resides at the campus develops a new diagnosis, condition, or symptom which the campus is less familiar with, the campus Executive Director and Director of Health Services will review the skills and competencies of the current staff and may determine whether the current staffing provides the appropriate resources to care for the resident, or they may obtain additional resources (either internal or external) to meet the needs of that resident . During an Interview on 8/18/25 at 11:29 A.M., Registered Nurse (RN) 2 indicated the admitting nurse was responsible for putting orders from the hospital discharge into the electronic health record and another nurse would verify them for accuracy. For resident's that have incisions, nurses should assess for redness, swelling, pain, drainage and document findings in the Medication Administration Record (MAR) or a progress note. If abnormal findings occurred, the nurse should start an event for tracking purposes. Usually for post-op residents, there were protocols to put in place, but she was not sure if there was one for post op stent care. The nurse would use their discretion about notifying the physician of changes. If it was something out of the ordinary, they would text, fax, or call them depending on the urgency. During an Interview on 8/18/25 at 12:00 P.M., the Infection Preventionist (IP) indicated she administered the in services and education for the clinical staff. Post-op stent training for the nurses was not done because usually the hospital kept the residents until the dressing was removed and then sent very detailed follow up orders on what to do and how to monitor the resident post op. She indicated the Post Op Discharge Instructions from the procedures were placed in a binder at the nurse's station, so they were readily available for the nurse to refer back to for discharge orders. Nurses were trained to follow the orders for post op assessments and care. If the resident requested to take the direct pressure dressing off early, they should call the doctor for an order first. The orders for post-op-stent care and outcomes would be documented in progress notes and/or the MAR so staff could keep better track of findings. She was unable to provide additional documentation of a physician's order to remove the direct pressure dressing early, education provided to the resident about the risks and benefits of removing the dressing early, physical assessments and monitoring of the resident's temperature and left lower leg for pain, redness, swelling, warmth, drainage, bleeding, and foul odor, as ordered, and notification of the doctor being notified when the resident had mental status changes.Interview on 8/18/25 at 1:37 P.M., Regional Support indicated it was not ordered to check pulses or perform other assessments on the resident's leg post op, only monitor the bruising. Long Term Care (LTC) didn't do those kinds of assessments if they were not ordered. Usually, all the acute care was done at the hospital, and residents were stable when they were released back to the facility. She indicated Resident 89's condition was a sudden change before they sent her to ER.Interview on 8/19/25 at 8:37 A.M., the facility pharmacy indicated they did not receive an order for Plavix from the facility for the resident in May of 2025.Interview on 8/19/25 at 9:02 A.M., RN 4 indicated the staff usually did not have many post-op residents, but they have protocols to follow when they were post-op and she would assess the resident according to those and any physician discharge orders. They should follow orders on how to do the dressings. The discharge orders were entered within so many hours of the resident returning and they were verified by another nurse. Pharmacy requests for new medications should be sent by a nurse as soon as possible.Interview 8/19/2025 at 9:20 A.M., the Director of Nursing (DON) indicated she was aware the resident was going to have the procedure and return to the facility. The Post Op Discharge Instructions were placed in the binder at the nurse's station for the nurses to refer to for the orders. Nurses were trained to follow the orders for post op assessments and care. She was unaware of the reason the resident was not started on Plavix 75 mg daily as ordered on Post Op Discharge Instructions given to the facility on 5/20/25.Interview on 8/20/25 at 8:54 A.M., the Administrator and Clinical Support provided a Post Office Visit Summary from the vascular surgeon, dated 5/7/25, that indicated Plavix 75 mg daily should have been started on 5/7/25 when Resident 89 returned to the facility from that appointment. At that time, they both indicated they had not received that new order. They indicated if nursing noticed the Plavix 75mg daily handwritten under medications on the Post Op Discharge Instructions as a discrepancy, no one questioned it and clarified the medication order with the physician at that time.On 8/20/25 at 8:00 A.M., a current RN job description summary was provided by the administrator and indicated The Registered Nurse (RN) is primarily responsible to provide quality care . efficient, safe, and effective care of patients through use of available resources and adherence to the Health Campus Policies and Procedures . utilize the nursing process in delivering patient care and ensure continuity of care from admission through discharge . Notify the charge nurse, the physician, and/or the DHS [DON] when there is a change in the resident's condition . Administer and document medication and treatments per the physician's order and accurately record all care provided . Perform and document a comprehensive assessment on each assigned resident . Develop an accurate comprehensive care plan based on each resident's comprehensive assessment . Review and understand the care plan for each assigned resident . Document resident care provided and resident's response or lack of response to care provided . Assess resident needs and initiate development of individualized plans of resident care . Must be knowledgeable of nursing and medical practices and procedures . On 8/20/25 at 12:29 P.M., the Administrator indicated there was not a policy for monitoring post-op patient. At that time, she indicated they would follow the discharge instructions given.3.1-37(a)

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for dialysis. Care plans lacked resident specific diagnoses and interventions. (Resident 1, Resident 33, Resident 54, Resident 55, Resident 86)Findings include:1. On 8/15/25 at 12:34 P.M., Resident 54's clinical record was reviewed. Diagnoses included, but were not limited to, osteoarthritis, anxiety, and depression. The most recent admission Minimum Data Set (MDS) assessment, dated 7/30/25, indicated resident 54 was cognitively intact and partial to moderate assistance of staff (staff performs less than half the effort) for transfers and toileting. A current Activities of Daily Living (ADL) Care Plan, last reviewed 7/24/25, indicated Resident has potential for decline in functional status r/t [related to] ___DX ____ [diagnosis]. The care plan lacked resident specific diagnoses related to the potential for functional decline. 2. On 8/14/25 at 10:43 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety, and depression. The most recent admission Minimum Data Set (MDS) assessment, dated 7/1/25, indicated a severe cognitive impairment, and was independent with eating, toileting, showering, bed mobility, and transfers. Current physician orders included, but were not limited to: buspirone (an antianxiety medication) 15mg (milligram) twice a day for generalized anxiety disorder, dated 8/11/25. A current care plan for psychotropic drug use, dated 8/1/25, indicated receiving antianxiety medication for: The care plan did not indicate the reason for the antianxiety medication. Resident 33's clinical record lacked a care plan related to behaviors. Resident 33's clinical record lacked a care plan related to self harm and threats of suicide. Progress notes from July and August 2025 indicated, but was not limited to, the following behaviors: 7/7/25 Restless and anxious, cursing at staff, and throwing items. 7/19/25 Pacing, cursing at staff, punching walls and doors, screaming, hitting self, threats of suicide. 7/22/25 Repetitive questions, smacking self, cursing at staff. 7/23/25 Fixative, anxiety, yelling, cursing at staff, hitting walls and doors, smacking self. 7/24/25 Fixative, refusals, anger, threats of suicide. 7/26/25 Cursing, repetitive questions, smacking self, other self harm, agitation. 7/28/25 Threats of suicide, self harm. 8/13/25 Agitation and anxiety, cursing at staff, refusals. 8/16/25 Agitation, cursing at staff, anxiety. During an interview on 8/18/25 at 9:45 A.M., Certified Nurse Aide (CNA) 7 indicated staff were made aware at admission that Resident 33 had a history of suicidal threats and behaviors. 3. On 8/14/25 at 1:29 P.M., Resident 86's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, anxiety, and depression. The most recent significant change Minimum Data Set (MDS) assessment, dated 6/3/25, indicated no cognitive impairment, partial to moderate (helper does less than half the effort) assistance with toileting, showering, bed mobility, and transfers, and use of an opioid (pain medication). A current pain care plan, dated 7/22/24, indicated At risk for pain r/t [related to] __DX__ [diagnosis]. The care plan did not specify what diagnosis the pain was related to. A current activities of daily living care plan, dated 7/22/24, indicated Resident has potential for decline in functional status r/t ___DX____. The care plan did not specify what diagnosis the potential for decline was for. 4. On 8/15/25 at 9:40 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/26/25, indicated moderate cognitive impairment. A current pain care plan, dated 10/17/23, indicated At risk for pain r/t [related to] __DX__ [diagnosis]. The care plan did not specify what diagnosis the pain was related to. A current activities of daily living care plan, dated 10/17/23, indicated Resident has potential for decline in functional status r/t ___DX____. The care plan did not specify what diagnosis the potential for decline was for. 5. On 8/14/25 at 1:34 P.M. Resident 55's clinical record was reviewed. Diagnoses included, but were not limited to, end-stage renal disease, dependent on renal dialysis, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/12/25, indicated Resident 55 was cognitively intact. A current activities of daily living care plan, dated 3/23/24, indicated Resident has potential for decline in functional status r/t ___DX____. The care plan did not specify what diagnosis the potential for decline was for. Interview on 8/19/25 at 1:40 P.M., the MDS Coordinator indicated that she would not expect the diagnoses to be specific due to multiple comorbidities that each resident had. At that time, the Social Services director indicated she is in charge of implementing care plans related to behaviors and specific behaviors should be care planned and initiated within 7 days On 8/20/25 at 12:23 P.M., a Comprehensive Care Plan Guideline policy, dated 5/22/2018 was provided by the Administrator and indicated, .b. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan. d. A comprehensive care plan will be developed within 7 days of completion of the.comprehensive assessment .to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines . Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident . Comprehensive care plans need to remain accurate and current . 3.1-35(a)

Based on observation and interview, the facility failed to ensure food was served in accordance with professional standards for 1 of 1 kitchen observed. Staff picked food up with soiled gloves, placed on top of resident's food, and served plate to residents. (Kitchen)Finding includes:During a dining room observation on 8/13/25 at 11:39 A.M., three residents were observed sitting at a table. Each plate at the table was observed with a plastic packet of butter sitting on top of the food. At that time, kitchen staff member was observed to bring out a plate of food from the kitchen with a plastic butter packet sitting on top of the food on the plate. It was then served to a resident. On 8/13/25 at 11:52 A.M., Kitchen Staff 23 was observed plating food in the kitchen. Kitchen Staff 23 grabbed clean plates with both thumbs over the lip of the plates, and placed them in the serving line. After washing her hands, she put gloves on and grabbed meal tickets from Kitchen Staff 55 (that she brought in to the kitchen from the dining room). She shuffled through the meal tickets, grabbed a plate with her thumb over the lip of plate, and handled the serving utensils. Kitchen Staff 23 grabbed a piece of cornbread and a butter packet with the same gloves, and placed them on top of the food on the plate. During an interview on 8/15/25 at 9:27 A.M., the Dietary Manager indicated there was one kitchen for serving both assisted living and health center. At that time, she indicated staff should treat glove use like bare hands on serving line. Bread and other food should be picked up with tongs and placed on the resident's plate, not gloves. On 8/20/25 at 7:54 A.M., a current infection control policy related to food handling was requested and not provided during the duration of the survey. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's antipsychotic was changed without attempts of non-pharmacological interventions, and received more than the recommended dose of an antipsychotic medication when switching from one antipsychotic medication to another. (Resident 33)Finding includes:On 8/14/25 at 10:43 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. Resident 33 was admitted on [DATE]. The most recent admission Minimum Data Set (MDS) assessment, dated 7/1/25, indicated a severe cognitive impairment, and use of an antipsychotic medication. Physician orders included, but were not limited to:Rexulti (an antipsychotic) 2mg (milligram) tablet once a day, dated 6/24/25 through 7/21/25. Rexulti 1mg tablet once a day, dated 7/22/25 through 7/26/25.Risperdal 0.5mg tablet at bedtime, dated 7/21/25 through 7/23/25. Risperdal 1mg tablet at bedtime, dated 7/23/25 through 7/28/25. Risperdal 1.5mg at bedtime, dated 7/28/25 through 7/28/25.A current care plan for psychotropic drug use, dated 6/25/25, included, but was not limited to, an intervention to attempt to give the lowest dose possible. Behaviors leading up to the change of antipsychotic medication included, but were not limited to, the following:A nursing note on 7/17/25 at 2:35 P.M. indicated Resident 33 had been very anxious and agitated all day, consistently demanding to see her husband not remembering him coming that morning. Resident 33 cursed at staff and had no interest in activities offered. Resident 33 hollered out, cursed, and repeatedly smacked her hands together hard and loudly. Other than activities, no other intervention was documented. A nursing note on 7/19/25 at 7:48 A.M. indicated Resident 33 had been pacing the hall and repetitively asked for spouse. The resident had been verbally aggressive with staff for several hours. Every 10-15 minutes, resident asked for spouse and the reason she was in the facility, and after every episode staff reminded her that spouse would be there later to visit, resident became agitated, cursing at staff and punched the door and walls in her room. Staff suggested other methods of expressing anger but resident was unaccepting. Resident denied being a patient, refused to eat breakfast, and knocked medications out of the nurse's hands onto the floor. The nurse then left the resident in her room to calm down. A nursing note on 7/19/25 at 2:28 P.M. indicated Resident 33 was pacing the hall, cursing at staff, screaming, and punching walls and doors with fist. Resident was beating on chest and putting her hands around her throat as if to choke herself. Resident kept repeating threats to kill herself while placing her hands over her mouth and nose. No intervention was documented. A nursing note on 7/21/25 at 12:19 P.M. indicated the psych Nurse Practitioner (NP) had seen the resident and gave orders to decrease Rexulti to 1mg daily for 5 days, then discontinue and to start Risperdal 0.5mg. A nursing note on 7/22/25 at 2:11 P.M. indicated Resident 33 had two episodes of smacking herself when she did not get a desired answer, and continued to curse at staff. No intervention for the behavior was documented. A nursing note on 7/23/25 at 12:37 P.M., indicated Resident 33 remained fixated on wanting to be with spouse, was anxious about going home, continued to smack herself, and continued to curse and yell at staff. No intervention for the behavior was documented. A nursing note on 7/23/25 at 12:56 P.M., indicated Resident 33 had refused a weekly skin assessment. A nursing note on 7/23/25 at 2:22 P.M. indicated the NP was notified of resident's continued fixations and self harm. A new order was received to increase Risperdal to 1mg daily. During an interview on 8/18/25 at 9:48 A.M., Licensed Practical Nurse (LPN) 5 indicated prior to starting Resident 33 on Risperdal, non-pharmacological interventions included engaging in activities, assessing for pain or constipation, sensory activities, 1:1 with resident, and walks, and should have been documented in the clinical record. She indicated the resident had been started on Risperdal due to anxiety, agitation, and the previous antipsychotic had been ineffective. During an interview on 8/19/25 at 9:39 A.M., Resident 33's daughter indicated the resident had been taking Rexulti for about three months prior to her admission to the facility. During an interview on 8/19/25 at 8:44 A.M., a facility pharmacy representative indicated while there was no good conversion dose from Rexulti to Risperdal, Rexulti should have been immediately discontinued when starting Risperdal due to an increased risk of seizures when given together. On 8/20/25 at 11:29 P.M., the Administrator provided a current Use of Chemical Restraints policy, dated 5/11/16, that indicated Medication use is not the sole approach for behavioral intervention . Each resident's drug regimen must be free from unnecessary drugs 3.1-48(a)

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for receiving oxygen therapy. A resident's oxygen concentrator and portable oxygen tank were not set at the ordered Liters Per Minute (LPM). (Resident 13) Finding includes: On 6/24/24 at 10:23 A.M., Resident 13 was observed sitting in his room in his wheelchair wearing oxygen per nasal cannula (NC) that was connected to a portable oxygen tank on the back of his wheelchair with the setting at 2 LPM. The tubing was not dated. There was an oxygen concentrator machine at bedside with a dusty filter. On 6/27/24 at 9:49 A.M., Resident 13 was observed sitting in his room in his wheelchair wearing oxygen per NC that was connected to the oxygen concentrator machine at bedside with the setting on at 1.5 LPM and the NC tubing was resting on top of the resident's nose. The filter of the oxygen concentrator machine was dusty. On 6/27/24 at 1:25 P.M., Resident 13 was observed sitting in his room in his wheelchair wearing oxygen per NC that was connected to a portable oxygen tank on the back of his wheelchair with the setting at 0.5 LPM. On 6/27/24 at 1:30 P.M., Registered Nurse (RN) 26 observed the resident in the bathroom with staff toileting him and the resident wearing oxygen per NC that was connected to a portable oxygen tank on the back of his wheelchair with the setting at 0.5 LPM. The resident indicated he was not short of breath. She proceeded to take the resident's oxygen saturation and it read 91-92%. At that time, she adjusted the resident's portable oxygen tank setting to 2 LPM. On 6/27/24 at 12:21 P.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, hypertension, and heart failure. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/7/24, indicated Resident 13's cognition was moderately impaired, he was an extensive assist of 2 staff for bed mobility, transfers, toileting, and on oxygen. Current Physician's Orders included, but were not limited to, the following: Change oxygen tubing monthly once a day on the 1st of the month, dated 3/14/24 Clean external concentrator filter every two weeks once a day on Sunday, dated 3/14/24 Oxygen at 2 LPM per NC, continuously, three times a day, ordered 3/14/24 A current Congestive Heart Failure (CHF) Care Plan, revised 5/20/24, included, but was not limited to, the following interventions: Oxygen per MD orders, initiated 3/7/24 On 6/27/24 at 1:13 P.M., the June 2024 Treatment Administration Record (TAR) was reviewed and indicated the external filter was cleaned on 6/23/24 and the resident's oxygen saturation levels ranged from 94-98% while wearing oxygen. During an interview on 6/27/24 at 1:35 P.M., RN 18 indicated the nurse was responsible for making sure the oxygen setting was as ordered and moving the residents oxygen tubing from the portable tank to the concentrator should be done by the nurse. She was not sure how long the resident had been connected to his portable oxygen tank because she observed the resident on his oxygen via the concentrator machine before lunch but had not looked at his oxygen after. At that time, she indicated his normal oxygen saturation would be in the upper 90's, like 95-97%, with his oxygen on. She indicated the oxygen setting on the oxygen concentrator machine should be checked every shift when the resident was connected to it and as needed and the portable tank should be checked when resident was first connected to it and as needed. On 6/28/24 at 11:57 A.M., a current Respiratory Care Policy and/or a Following Physician's Orders Policy was requested and the Regional Support indicated there was not a policy for following the physician's orders but it would be the policy for staff to follow orders. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents observed for a medication pass and 1 of 3 observed for incontinence care. During a med pass, pills were dropped on the medication cart and administered to a resident. Staff did not use hand hygiene between glove changes during care. (Resident 35, Resident 9) Findings include: 1. On 6/27/24 7:14 A.M., Registered Nurse (RN) 12 was observed preparing and passing medications to Resident 35. After RN 12 prepped all 16 of the resident's pills into medication cups, she put on gloves and knocked one of the medication cups over spilling out the resident's Keppra (anticonvulsant), Namenda (cognition enhancing), and docusate sodium (stool softener) onto the medication cart. RN 12 picked them up with her gloved hand, put them back into the medication cup, took the pills out of the cup that needed to be crushed and crushed them. Then she opened the pills that were capsules and dumped all the medications together, put chocolate pudding into the cup, and administered them to the resident. During an interview on 6/27/24 at 2:38 P.M., the Infection Preventionist (IP) indicated any pills dropped onto a medication cart while preparing medications for a resident should be disposed of and the person preparing the medications should get new ones to administer to the resident. 45933 2. During an observation on 6/27/24 at 11:16 A.M., Certified Nurse Aide (CNA) 28 assisted Resident 9 to the restroom. CNA 28 removed Resident 9's soiled brief with gloved hands, grabbed the new brief, and placed it on the resident, removed gloves, donned new gloves, and wiped stool off resident 9's bottom. At that time, CNA 28 failed to remove gloves and perform hand hygiene before Resident 9's brief was pulled up. At that time, hand washing was performed for a 5 second lather. During an interview on 6/27/24 at 2:38 P.M., the Infection Preventionist (IP) indicated staff should perform hand hygiene between glove changes. During an interview on 6/28/24 at 9:46 A.M., Registered Nurse (RN) 12 indicated staff should lather for 20 seconds when hand hygiene is performed. On 6/28/24 at 8:00 A.M., a current Medication Administration Preparation General Guidelines Policy, revised January 2018, was provided by Regional Support and indicated Medications are administered as prescribed in accordance with good nursing principles and practices . after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration) . On 6/28/24 at 12:13 P.M., the Director of Nursing (DON) provided a Guideline for Handwashing/Hand Hygiene policy, revised 2/9/17 that indicated, .Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of antiseptic hand rub, also known as alcohol-based hand rub .d. After removing gloves .Wash well for at least 20 seconds, using a rotary motion and friction . 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure Posted Nurse Staffing sheets contained the correct information daily for 1 of 6 days reviewed during the survey. (6/24/24) Findings include: On 6/24/24 at 10:39 A.M., the Posted Nurse Staffing was observed hanging on the wall across from the 100, 200, and 300 nurses' station dated 6/14/24. During an interview on 6/28/24 at 11:58 A.M., the DON (Director of Nursing) indicated that the scheduler hung the Posted Nurse Staffing first thing in the morning. The DON indicated that she had been doing it while the scheduler was out for the last few days. On 6/28/24 at 12:07 P.M., the DON provided a Guidelines for Staff Posting Policy, revised 5/11/16, which indicated Purpose was to ensure compliance with federal regulations posting on a daily basis for each shift, the number of nursing personnel responsible for providing direct resident care.

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment during random room observations and including 4 of 7 resident restrooms reviewed for water temperatures. Water temperatures were greater than the maximum temperature of 120 degrees Fahrenheit (F), resident personal hygiene items were open to air or stored on the bathroom floor, and an air conditioning unit was leaking onto the carpet in a resident room. (Resident B, Resident C, Resident F, Resident G, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. During an interview and observation on 8/24/23 at 9:45 A.M., Resident B indicated that the air conditioning unit in their room (114) does not work well. While observing the unit, a large wet spot directly under the air conditioner unit and in front of the bathroom door was noticed. During an observation of the shared bathroom in room [ROOM NUMBER], a blue tooth brush was resting on the backside of the bathroom sink, unlabeled and open to air. During a review facility grievances on 8/24/23 at 12:15 P.M., a resident in room [ROOM NUMBER] made a complaint on 7/24/23 that, .the aides are not emptying the bath basin under the AC (air conditioner) unit and it is overflowing onto the carpet everyday . and a resident in room [ROOM NUMBER] made a complaint on 7/24/23 that, wet carpet - resident states 'I am tired of my carpet being wet all the time' carpet noted to be wet from AC unit . During an interview on 8/24/23 at 11:55, the maintenance director indicated they had have problems with the air conditioning units building up condensation when it is hot outside. The units start to lean inward and drip onto the resident floors. The units have to be jacked up so the condensation well drain outside of the building. The maintenance director indicated she had a work order for the same problem in room [ROOM NUMBER], but was unaware of the issue in room [ROOM NUMBER]. 2. During an observation and interview on 8/24/23 at 10:00 A.M., Resident C indicated that the water gets hot in her bathroom (room [ROOM NUMBER]). The bathroom sink water temperature was 121 degrees F. During an observation and interview on 8/24/23 at 11:20 A.M. the facility maintenance director along with the regional maintenance director checked the water temperature in room [ROOM NUMBER]. A water temperature of 123 degrees was observed. At that time, the regional maintenance director indicated the water is too hot and that he would adjust the mixing valve. 3. During an interview and observation on 8/24/23 at 10:15 A.M., Resident F's bathroom sink water temperature in room [ROOM NUMBER] tempted at 123 degrees F. Resident F indicated at times the water gets real cold, then gets real hot. 4. During an interview and observation at 10:25 A.M., Resident G's bathroom sink water temperature in room [ROOM NUMBER] tempted at 123 degrees F. The shared bathroom in room [ROOM NUMBER] also contained a large bag of personal hygiene items and other belongings that were spilling out onto the the bathroom floor. Resident G indicated that the her roommate needed a place to store her personal items so that they would not be on the bathroom floor. During an interview on 8/24/23 at 12:15 P.M., the DON (Director of Nursing) indicated the facility did not have a policy on the storage of resident personal hygiene items, but that the facility had recently purchased containers for residents to store their items in. Staff should observe for resident personal items being left out and should be sure that they are stored correctly. 5. During an observation on 8/24/23 at 10:40 A.M., in room [ROOM NUMBER], the bathroom sink water was tempted at 121 degrees F. On 8/24/23 at 11:30 A.M., the facility maintenance director also tempted room [ROOM NUMBER]'s bathroom sink water at 121 degrees F. During an interview on 8/24/23 at 11:15 A.M., the regional maintenance director indicated that water temperatures in resident rooms should range between 100 - 120 degrees F. Room water temperatures should be checked daily. During a record review on 8/24/23 at 11:45 A.M., a weekly water temperature check included the following: 8/24/23 - room [ROOM NUMBER]: 120.9 degrees F 8/24/23 - room [ROOM NUMBER]: 120.8 degrees F During an interview on 8/24/23 at 12:00 P.M., the Facility Administrator indicated that the facility maintenance director had been checking room water temperatures weekly, but not daily as according to their policy. On 8/24/23 at 12:00 P.M., the facility Administrator supplied a facility policy titled, Water Temperature Testing - Life Safety, dated 8/20/18. The policy included, It is [Facility] policy to test water temperatures daily.Testing must take place in the following areas: .One resident room at the end of each wing, on a rotating basis . Patient room temperatures are specified by state requirements.Indiana 100 - 120 (degrees Fahrenheit). This Federal tag relates to complaint allegation IN00415572. 3.1-19(f)(5) 3.1-19(r)(1) 3.1-19(r)(2)

Based on interview and record review, the facility failed to ensure a person-centered care plan was in place or revised to meet the resident's needs for 3 of 3 residents reviewed for developmentally disabled individuals. (Resident 39, Resident 34, Resident 3) Findings include: During record reviews on 4/4/23 from 10:00 A.M. to 12:30 P.M., 3 of 3 residents reviewed for intellectual disabilities/developmental delays (ID/DD) lacked a person-centered care plan that addressed their individual needs related to their diagnosis of ID/DD. 1. Resident 39's clinical record was reviewed and included, but was not limited to, a history of spinal meningitis which led to a developmental disability. Resident 39 was admitted to the facility on [DATE]. A current social aspects care plan, dated 4/19/19, indicated a diagnosis of developmental disability related to a history of spinal meningitis. All interventions were dated 5/29/19, and included the following: encourage resident to actively participate in activities of daily living daily, care planning, and intellectually appropriate leisure and structured activity, monitor for cognitive changes with cognition level quarterly and as needed as well as monitor mood, affect, and behaviors, provide routine in daily schedule, and to receive services from the DD Board per habilitation plan. On 4/4/23 at 1:00 P.M., a handwritten individual habilitation plan flow sheet was provided, dated for the month of February (no year). The Administrator indicated at that time the form was what the Social Services Director (SSD) had filled out for Resident 39 this past February, and had kept inside a binder in her office. The form included the following training step approaches for Resident 39: verbal cues and encouragement for self ambulation, physical prompts or gestures to dining room, and reinforcing support, encouragement, and positive ambulation. The form further indicated Resident 39 would use wheelchair independently one time a week to the dining room for the next 90 days. The information on the form was not used to update Resident 39's care plan for all staff to have access to. 2. Resident 34's clinical record was reviewed and included, but was not limited to, a diagnosis of Cerebral Palsy. Resident 34 was admitted to the facility on [DATE]. A current social aspects care plan, dated 3/7/22, indicated a diagnosis of intellectual disability and Cerebral Palsy. All interventions were dated 3/7/22, and included the following: complete evaluations for therapy (speech, occupational, physical), encourage family involvement in care and resident's participation in facility activities as appropriate to prevent isolation and promote wellbeing, provide discharge planning to explore community living, ongoing mental health case management to ensure proper treatment and medication effectiveness, supportive counseling to help resident through hard moments and support wellbeing, refer for individual or group therapy as needed, and refer for neurological evaluation. On 4/4/23 at 1:00 P.M., a handwritten individual habilitation plan flow sheet was provided, dated for the month of February (no year). The Administrator indicated at that time the form was what the SSD had filled out for Resident 34 this past February, and had kept inside a binder in her office. The form included the following training step approaches for Resident 34: have clothes laid out the night prior for visual care, staff to get towels and toiletries for shower and provide to resident, and give positive support and affirmations regarding tasks. The form further indicated Resident 34 would shower and dress self independently two times a week for 90 days without verbal prompts. The information on the form was not used to update Resident 34's care plan for all staff to have access to. 3. Resident 3's clinical record was reviewed and included, but was not limited to, a diagnosis of anxiety, obsessive compulsive disorder (OCD), and epilepsy. Resident 3 was admitted to the facility on [DATE]. A current social aspects care plan, dated 12/23/20, indicated a diagnosis of severe intellectual disability and epilepsy, OCD, anxiety, and other unspecified mental disorders due to known physiological condition. All interventions were dated 12/23/20, and included the following: encourage family involvement in care, resident's participation in facility activities as appropriate to prevent isolation and promote wellbeing, provide discharge planning to explore community living, ongoing mental health case management to ensure proper treatment and medication effectiveness, supportive counseling to help resident through hard moments and support well being, refer for individual or group therapy, neurological evaluation as needed, and outpatient mental health services. On 4/4/23 at 1:00 P.M., a handwritten individual habilitation plan flow sheet was provided, dated for the month of February (no year). The Administrator indicated at that time the form was what the SSD had filled out for Resident 3 this past February, and had kept inside a binder in her office. The form included the following training step approaches for Resident 3: encourage resident to get up out of bed and sit in a chair, invite and encourage resident to activities and gatherings, and support and encourage with positive affirmations. The form further indicated that Resident 3 would utilize wheelchair twice a week for social interaction outside of room for the next 90 days. The information on the form was not used to update Resident 3's care plan for all staff to have access to. During an interview on 4/4/23 at 1:10 P.M., the Director of Nursing (DON) indicated when selecting a care plan, staff would select a general care plan with already populated interventions. After selecting the care plan for the resident, staff should go into each intervention and make it resident specific. The DON further indicated revisions should have been made to care plans and interventions quarterly and updated as needed. On 4/4/23 at 1:15 P.M., a current comprehensive care plan guideline policy, dated 5/22/28, was provided and indicated Problem areas should identify the relative concerns . Interventions should be reflective of the individual's needs and risk influence as well as the resident's strengths . revised to reflect changes in the resident's condition as they occur 7-4(a)

Based on interview, observation, and record review, the facility failed to ensure the resident right to be free of chemical restraint for 1 of 6 residents reviewed for falls. An anti-anxiety medication (lorazepam) was used as a chemical restraint to control the resident's behaviors in an effort to keep them from falling. (Resident 47) Findings include: On 3/27/23 at 12:41 P.M., Resident 47 was observed sitting in a high back wheelchair in the commons area in front of the television sleeping. On 3/27/23 at 1:40 P.M., Resident 47 was observed laying in bed asleep. On 3/28/23 at 9:02 A.M., Resident 47 was observed sitting in a high back wheelchair in the commons area in front of the television sleeping. On 3/29/23 at 2:45 P.M., Resident 47 was observed laying in bed asleep. On 3/30/23 at 10:05 A.M., Resident 47 was observed laying in bed asleep. On 3/31/23 at 9:45 A.M., Resident 47 was observed laying in bed asleep. The resident did not arouse with knocking on the door or saying good morning in a normal tone voice. On 3/31/23 at 11:03 A.M., Resident 47 was observed laying in the same position as earlier in bed asleep. There were 2 visitors and her roommate having a normal tone conversation and the Hospice Nurse was in the room doing vitals on the resident and having a conversation in the room while the resident slept. On 3/31/23 at 12:41 P.M., Resident 47 was observed sitting in a high back wheelchair with her eyes closed. On 3/31/23 at 2:15 P.M., Resident 47 was observed in bed asleep and did not arouse to verbal stimuli. On On 3/29/23 at 12:26 P.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia with behavioral disturbance, history of falling, past CVA(cerebrovascular accident/stroke), and conduct disorder, unspecified. The most recent annual MDS (Minimum Data Set) Assessment, dated 1/4/23, indicated that Resident 47's cognitive status was unable to be assessed because they were rarely able to be understood and an extensive assist of 2 (two) staff for bed mobility, transfers, and toileting. It also indicated that Resident 47 was on hospice and the following behaviors were observed in the 7 day look back period: Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)-Behavior of that type occurred 1 to 3 days. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)-Behavior not exhibited. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)-Behavior of that type occurred 4 to 6 days, but less than daily. Did any of the identified symptom(s) put the resident at significant risk for physical illness or injury, significantly interfere with the resident 's care, significantly interfere with the resident 's participation in activities or social interactions, put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment-all answered no. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident ' s goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals-Behavior of that type occurred 4 to 6 days, but less than daily. How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or Scheduled PPS)-Same. Current physician's orders included, but were not limited to, the following: lorazepam intensol 2 mg(milligram)/ml(milliliter) 0.5 ml orally for restlessness/anxiety per hospice three times a day, ordered on 10/31/22 and discontinued 3/28/23. lorazepam intensol 2 mg/ml 1ml orally for restlessness/anxiety per hospice three times a day, ordered on 3/28/23. lorazepam intensol 2 mg/ml 0.5 ml orally PRN (as needed) every 30 minutes for anxiety/terminal restlessness; receiving hospice services and medication should continue until end of life, ordered 4/11/22. (hospice name) to treat for terminal diagnosis of Alzheimer's dementia, ordered 12/15/22. A current risk for falls care plan, dated 1/7/21, included, but was not limited to, the following interventions: ask hospice nurse to evaluate need for routine ativan r/t afternoon restlessness, initiated 7/27/22. A current hospice care plan, dated 2/28/22, included, but was not limited to the following interventions all initiated on 2/28/22: Administer drugs as needed for palliation per md order and administer pain medication as ordered and as needed A current conduct disorder care plan, dated 1/13/21, included, but was not limited to, the following interventions all initiated on 1/13/21: Assess for unmet needs such as need for toileting, rest, food, companionship, etc, determine cause for inappropriate behavior and refer to physician as needed for intervention, encourage participation in structured activities as appropriate, observe for triggers of inappropriate behaviors and alter environment as needed. A current activities care plan, dated 10/5/22, included, but was not limited to, the following interventions all initiated on 1/4/23: Introduce me to other residents who also enjoy socializing, please invite and assist me as needed to activities of my interest, such as spending time outdoors when the weather is warm enough and opportunities to socialize, I am of the Methodist faith, please provide appropriate cueing if you see that I am restless, I enjoy watching westerns such as Gunsmoke and Bonanza and also watching TV Land programs, I like to look through magazines and have a snack while doing so, listening to gospel music is one of my favorite genres. A current behaviors care plan, dated 7/28/22, included, but was not limited to, the following interventions all initiated on 7/28/22: Observe mood, affect and behaviors with all hands on care and contacts, re-direct me during periods of frustration and anger, refer to psych services as needed. A current psychotropic (lorazepam) drug care plan, dated 11/16/21, included but was not limited to, the following interventions all initiated on 11/16/21: Attempt GDR (gradual dose reduction) in two separate quarters (with at least one month between the attempts)during the first year the resident receives an anxiolytic (lorazepam) medication then yearly after unless contraindicated, attempt non-pharmacological interventions prior to administering PRN anxiolytic, and observe for drug effectiveness and adverse consequences. A review of Resident 47's progress notes included, but were not limited to, the following: 4/8/22 1:55 P.M.-Resident has been having more frequent episodes of restlessness the past few days. Has frequently been attempting to stand up out of w/c and get out of bed and cannot remember that she can no longer walk. Res [resident] is requiring frequent redirection and repositioning d/t scooting to the edge of w/c seat. Res [resident] is usually easily redirected and not mean or agitated, just very restless and unable to voice why she is trying to stand. Staff will provide toileting, offer food/drinks and ask if she is pain. After ruling all needs out resident remains restless. Hospice nurse [name of nurse] here for a visit and voiced that comfort meds for terminal restlessness would be appropriate at this time and asked this nurse to notify [name of doctor]. 4/8/22 3:25 P.M.-New orders per [doctor name]: Ativan (lorazepam) Intensol 2mg/mL give 0.5 mL q30 (every 30) minutes PRN for anxiety. 4/11/22 9:08 A.M.-IDT [interdisciplinary team] reviewed current mental health, pain, and infection events. Resident receiving hospice services and hospice pain/anxiety medications started due to resident's declining condition . No adverse effects noted from any medications . 4/11/22 3:12 P.M.- MD [medical doctor] responded to [pharmacy name] rec [recommendations] regarding rationale for Lorazepam. MD wanting res [resident] to continue on PRN med due to having episodes of anxiety. Will place new 14 day stop date at this time. 4/22/22 12:02 P.M.-The past few days when res [resident] is up in w/c [wheelchair] is constantly scooting self to edge of seat and several has [sic] almost scooted all the way off of seat. Has dycem on top and bottom of cushion but it is not preventing it. Res [resident] appears to be uncomfortable in the chair not matter how positioned and has lost quite a bit of trunk control d/t [due to] decline in condition. Call placed to hospice nurse [nurse name] and left voicemail requesting [specific name] chair for res [resident] comfort. 6/14/22 1:30 P.M.-Res [resident] yelling out for spouse after lunch. Reassured spouse was okay and in the building. Res [resident] accepting of this. 7/14/22 1:05 P.M.-Attempted to give prn ativan intensol d/t restlessness and agitation but res [resident] spit it out. 7/24/22 8:00 P.M.-Earlier today after lunch [resident] was yelling trying to out of her chair. interventions didn't help. assist to bed check and changed yelled whole time. tried giving her lorazepam she took it then spit it out this was before laying her down. she layed about 10 minutes still yelling trying to climb out of the bed but refuses to set in reclining w/c. staff administer morphine and she held it in mouth a few seconds then spit it out. continue to do the same been long enough and rn staff administer lorazepam and she didn't spit it out and she calmed down went out for supper been in her recliner w/c watching tv. going to bed now due to falling asleep in chair. 7/27/22 12:51 P.M.-Resident yelling out help. Unable to redirect. PRN ativan given at this time. 7/27/22 03:00 P.M. Resident observed on floor by CRCA [CNA]. Resident was sitting upright against her bed. Resident is alert and asking for staff to put her back to bed. VS 127/74, 80, 97%RA, 18, 97.9F. Moves all extremities without difficulty or pain at this time. No injuries noted. Resident assisted back to bed by staff. ADHS notified and resident to be engaged in activities during afternoon hours as an intervention. POA notified. MD notified. 7/28/22 3:53 P.M.-Reviewed current fall event. Resident was observed on floor by nursing staff at bedside. Resident has developed tendency to become by restless [sic] in the afternoon . Resident was offered PRN medication for anxiety [lorazepam], but spit this out, so staff attempted to lay resident down to nap. Root cause analysis determined that afternoon restless [sic] led resident to attempt to get up on her own, and fall from bed (root cause.) No injuries obtained as result of fall. Denies pain or discomfort. Neuro [neurological] status and ROM [range of motion] remain within normal limits. Coordinating care with [hospice name] nurse. Spoke with hospice nurse and she will be contacting MD for possible medication changes to address afternoon restlessness/anxiety (intervention.) Plan of care and profile up to date with safety interventions. 7/29/22 10:34 A.M.-Received a new order from hospice to make Ativan [lorazepam] routine. New dose is Ativan [lorazepam] 0.5 ml po [orally] every 8 hours and keep the prn dose the same. 8/2/22 9:19 A.M.-IDT reviewed current mental health event. Resident noted with increased s/s of agitation and restlessness. Non-pharmacologic interventions including providing calm environment, offering rest periods, offering food and fluids, and offering activities have been ineffective. Restlessness has resulted in resident to have fall without injury from her bed. Care coordinated with [hospice name], and new orders received for routine Ativan [lorazepam] to managed [sic] s/s [signs/symptoms] of terminal restlessness. No s/s of adverse reactions to change in medication. 8/10/22 1:02 P.M.-Resident continues to be monitored r/t [related to] fall. Resident continues with hospice services for terminal diagnosis of Alzheimer's dementia. Resident continues to have episodes of restlessness but has been better controlled with medication regimen for comfort. Resident continues with 1:1 services from activities and receives visits from Chaplain. Resident also has a volunteer that visits. Fall interventions continue to be in place and remain appropriate. Will continue with current orders and update POC as needed. 8/25/22 11:06 A.M.-Resident being monitored f/t [sic] fall. Resident has not made any attempts to transfer self without assistance. Resident is unable to propel self in wheelchair and requires staff assistance for transfers and mobility. Staff assisted with complete care. Resident does continue with hospice services for terminal diagnosis. Will review fall interventions and update as needed. 9/18/22 2:45 P.M.-Resident refusing medications and spitting this shift. Becomes combative when staff attempt to assist resident. Grabbed this nurse's hand and began twisting fingers stating I'm going to break your fingers to the bone! Resident left sitting safely in [chair name] chair near nurses station to calm down. 10/12/22 3:38 P.M.-Received [doctor name] response in regards to eval [evaluation] of Lorazepam use from [pharmacy name] recommendation.'No!!! She is dying.Stop with the GDR requests on hospice patients.I will never say yes.Pharmacy is wasting everyone's time with this.' 10/25/22 10:59 A.M.-Care conference held with resident husband, [resident in facility].no concerns voiced other than wished wife didn't sleep so much. 11/25/22 1:51 P.M.-This writer called to resident room . Resident found sitting on [the floor on] side of bed with feet stretched out towards bathroom. Soiled linen under resident on floor. Resident unable to state how she fell . Staff assisted resident to bed at 1:15 pm and provided incontinent care. No injuries reported or observed. Call light within reach. 11/26/22 5:55 P.M.-Res [resident] restless this shift calling out for spouse frequently. PRN roxanol and ativan intensol given for restlessness and anxiety. 11/26/22 10:51 P.M.-IDT reviewed current fall. Prior to fall resident was lying in bed, with call light in reach. Resident was found on floor next to bed with linens underneath her. Resident had recently been laid down, and incontinence care provided. Resident does have periods of terminal restless d/t [due to] terminal disease process and receives routine antianxiety [lorazepam] for this, and available PRN as well. Staff will provide smaller blanket for use in bed (intervention.) Plan of care updated. 11/30/22 2:00 P.M.-Called to room to find resident on floor with pillow under head.CNA (Certified Nurse Aide) had said resident was just asleep prior to passing room a few minutes to this incident.CNA assisted resident to floor from being half way to floor from bed. 11/30/22 2:49 P.M.-Discussed with management interventions for recent fall.Will do medication review. 12/2/22 11:04 A.M.-Resident did have recent fall on 11/30. Resident was laying in bed after noon meal for rest. Staff observed resident attempting to transfer out of bed and reported restlessness. Per staff, resident typically gets restless around 2pm daily. Staff were attempting to assist resident with getting up into chair when she did not stand completely causing staff to need to lower her to the floor (root cause). She continues to deny pain/discomfort. Resident does receiving [sic] routine ativan to help control restlessness and agitation. Time frame reviewed and adjusted to better meet resident's need (intervention). 12/6/22 8:40 P.M.-Res [resident] anxious yelling out restlessness attempting to climb out of bed. Res [resident] given prn Lorazepam 0.5ml 1mg per orders will continue to monitor. 12/8/22 1:44 P.M.-Resident remains free from s/s of injury. Change of medication administration times with last fall do appear to have decreased displays of restlessness, and calling out. 12/23/22 10:57 A.M.-Resident continues to be monitored r/t falls. Resident continues with hospice services and is occasionally restless. Resident does receive routine and PRN medications to assist with restlessness. Staff continue to offer and assist with all needs as they arise and continue to anticipate needs. 1/5/23 12:50 A.M.-Awake, trying to climb out of bed. 1:1 time spent with resident. Incont [incontinence] care given with protective cream to buttocks. Repositioned for comfort. HOB up <30degrees. Did offer and was accepted Pink Lemonade with Comfort meds. Continue to monitor thru shift for safety. 1/22/23 3:05 P.M.-Resident was resting in bed just prior to fall. Resident noted to be lying on her back next to her bed with her blankets underneath her body and head. Resident known to become restless at times in the afternoon while resting and unable to understand use of call light for assistance. Resident then assisted to wheelchair and taken to common area near nurses station and attempted to engage in activities. 1/25/23 3:00 P.M.-Resident noted to be sitting on the floor leaning against the side of her bed. She states she I want to get out of here When asked what she was trying to do at time of fall, resident responded Trying to get up. resident was assisted to TV room per her request. 2/5/23 4:36 P.M.-IDT reviewed fall event. Resident was restlessness [sic] and rolled out of her bed onto the floor. (root cause) Immediate intervention: resident was assessed with comfort med given, she was assisted back to bed and bed was placed in lowest position in attempt to prevent injury. 2/5/23 4:43 P.M.-IDT NOTE: Resident noted to be sitting on the floor leaning against the side of her bed. She states she I want to get out of here When asked what she was trying to do at time of fall, resident responded Trying to get up and fell off the bed. Immediate intervention: resident was assisted to TV room per her request. 3/12/23 4:35 P.M.-This nurse called to restorative dining room. CNA found resident perpendicular to reclining WC [wheelchair] on the floor. Unwitnessed. 3/13/23 10:34 A.M.-IDT reviewed fall event. Resident attempted to self transfer from her wheelchair to standing position and lost balance and fell . (root cause) Resident was unable to tell staff where or what she was planning on doing. 3/16/23 9:43 A.M.-Plan of care reviewed and continues to be appropriate for this resident. She continues with hospice services for end of life services. She does usually refuse to participate in group activities however does enjoy 1:1 visits with staff. She does continue to be high risk for falls and staff do frequent rounding in attempt to anticipate resident needs. 3/23/23 12:43 P.M.-Resident with much anxiety and agitation, yelling out et [and] attempting to get out of chair. Attempts made by several staff to calm resident down. Resident was changed et [and] new brief placed, taken to lunch but did not eat very much. One on one, talking about memories et [and] resident would calm when someone was one on one with her but would then resume screaming as soon as someone left. Resident spit out Ativan et [and] Morphine when given even though she was yelling that her back hurt. Unsure if any medication was ingested. 3/25/23 7:36 A.M.-Attempted to give morning medications (routine ativan prescribed to help prevent behaviors) resident was awake and sitting in her [chair name] chair. She was not receptive to taking even a sip of water. she grabbed the straw and cup and jerked it out of this nurses hand and threw it on the floor. Will reattempt at a later time. 3/25/23 9:40 A.M.-Plan of care reviewed and continues to be appropriate for this resident. She continues with hospice services for end of life services. She does usually refuse to participate in group activities however does enjoy 1:1 visits with staff. She does continue to be high risk for falls and staff do frequent rounding in attempt to anticipate resident needs. 3/28/23 11:34 A.M.-N/O [new order] received per hospice to increase Lorazepam to 1mL TID [three times daily] routine for increased anxiety. Review of the January 2023 TAR (treatment administration record) indicated Resident 47 received lorazepam intensol 2mg/ml 0.5ml orally routinely three times a day from 1/1/23 through 1/31/23. The January 2023 TAR also indicated that Resident 47 received lorazepam intensol 2mg/ml 0.5 ml orally every 30 minutes PRN on the following dates: 1/1/23 at 11:01P.M. restlessness 1/5/23 at 12:56 A.M. end of life care, confusion, attempting to climb out of bed 1/8/23 at 7:58 P.M. attempting to climb out of bed, redirected by staff multiple times 1/9/23 at 5:45 P.M for yelling 1/14/23 at 9:16 A.M. for behavior issue (not specified) 1/17/23 at 8:38 P.M. for restlessness 1/19/23 at 11:06 P.M. for restlessness 1/30/23 at 10:50 P.M. for restlessness 1/31/23 9:46 P.M. for hollering out Review of the February 2023 TAR indicated Resident 47 received lorazepam intensol 2mg/ml 0.5ml orally routinely three times a day from 2/1/23 through 2/28/23. The February 2023 TAR also indicated that Resident 47 received lorazepam intensol 2mg/ml 0.5 ml orally every 30 minutes PRN on the following dates: 2/4/23 at 9:15 P.M. for restlessness 2/7/23 at 4:29 P.M. for behavior issue (not specified) 2/25/23 at 4:21 P.M. for restlessness, anxiety 2/27/23 at 4:17 P.M. for behavior issue (not specified) Review of the March 2023 TAR indicated Resident 47 received lorazepam intensol 2mg/ml 0.5ml orally routinely three times a day from 3/1/23 through morning dose on 3/28/23. From 3/28/23 noon dose through 3/31/23, Resident 47 received lorazepam intensol 2mg/ml 1 ml orally three times a day. The March 2023 TAR also indicated that Resident 47 received lorazepam intensol 2mg/ml 0.5 ml orally every 30 minutes PRN on the following dates: 3/5/23 at 5:47 P.M. for anxiety 3/5/23 at 9:59 P.M. for restlessness 3/16/23 at 3:45 P.M. for restlessness 3/20/23 at 9:46 A.M. for behavior issue (not specified) 3/23/23 at 12:42 P.M. for behavior issue (not specified) 3/26/23 at 5:42 P.M. for restlessness 3/30/23 at 11:36 P.M. for restlessness Review of the hospice note, dated 3/31/23, indicated per the Edmonton Symptom Assessment system, Resident 47's drowsiness score (0-10) was 7 and goal for drowsiness score was 4. During an interview on 3/30/23 at 2:50 P.M., the DON (Director of Nursing) indicated Resident 47 has not been seen by mental health professional because she is on hospice. During an interview on 3/31/23 at 11:03 P.M. the Hospice Nurse indicated that they recently increased ativan because she has been combative and restless. She further indicated that she [Resident 47] has fallen a lot because she gets restless and falls. The resident stayed asleep the entire interview with the hospice nurse using normal tone voice and the resident's roommate and 2 visitors talking in normal tone voices. A current chemical restraints policy, dated 5/11/16, was provided by the DON on 4/4/23 at 10:49 and indicated . 5. Chemical restraints should not be used to limit or control resident behavior for the convenience of the staff or as a substitute for individualized care . 12. Nursing services, social series and other members of the interdisciplinary team will address the behaviors in progress notes, care plans, or other forms in electronic health record. a. Medication use is not the sole approach for behavioral intervention. b. Other interventions will be identified in the care plan . 3.1-3(w)

Based on observation and interview, the facility failed to provide proper storage of medications in 1 of 2 medication storage rooms, 1 of 1 IV (intravenous) storage cart, and 1 of 6 medication carts. Loose pills were found in the bottom of the medication cart drawers. Expired IV fluid bags were stored in the IV treatment cart located within the storage room. (100 Hall and 600 Hall) Findings include: 1. On [DATE] at 9:35 A.M., the IV storage cart located in the 600 Hall storage room was observed with the following expired bags inside: 1 (one) 1000 cc (cubic centimeter) fluid bag of Dextrose 5 percent with expiration date of [DATE] 1 (one) 1000 cc fluid bag of Dextrose 5 percent with Normal Saline 0.9% with expiration date of [DATE] 1 (one) 1000 cc fluid bag of Dextrose 5 percent with Normal Saline 0.2% with expiration date of February 2023 2 (two) 100 cc fluid bags of Dextrose 5 percent with an expiration date of [DATE] During an interview on [DATE] at 9:35 A.M., LPN (Licensed Practical Nurse) 8 indicated the night shift nursing staff should check the IV cart and reorder supplies. 2. On [DATE] at 12:27 P.M., 1 of 2 medications carts for the 100 Hall was observed in medication storage room with the following medications laying loose in the bottom of 2 drawers: 1 medium white round pill ,d+[DATE] (half) medium oblong purple pill 1 small round orange pill On [DATE] at 8:30 A.M., the same medication cart was observed in the medication storage room on the 100 Hall with the following medications loose in the bottom of 2 drawers: 1 small round orange pill 1 large white pill 1 small white pill During an interview on [DATE] at 8:45 A.M., QMA (Qualified Medication Aide) 12 indicated loose medications should be removed from drawers and disposed of using a a bottle of liquid drug disposal after notification of the DON ( Director of Nursing). During on interview on [DATE] at 8:49 A.M., DON (Director of Nursing) indicated the pharmacist would check the IV fluid bags once a month when she visits and the night shift nursing staff should check the IV cart once a week. A current Medication Storage in the Facility policy, revised November, 2018 was provided by DON on 11:23 A.M., indicated Medications and biological's are stored safely, securely, and properly . The medication supply is accessible only to licenses facility personnel, pharmacy personnel, or facility personnel lawfully authorized to administer medication .Policy H . Outdated, contaminated, medications .without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .Expiration Dating .C. Certain medications . such as IV solutions . require an expiration date . to insure medication and purity 3XXX,d+[DATE](m)

Based on interview and record review, the facility failed to ensure residents with change of conditions were immediately assessed by nursing staff; and resident symptoms were followed up by assessments and notification, for 2 of 4 residents reviewed for quality of care regarding changes in condition (Residents B and C). Findings include: 1. The clinical record of Resident B was reviewed on 1/27/20 at 1:45 P.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/20/19, indicated Resident B was severely impaired in cognition. A Care Plan, initially dated 9/28/18 and reviewed 11/26/19, indicated, Potential for cardiovascular distress r/t (related to) [DIAGNOSES REDACTED]. The Approaches included: Medications as ordered. Observe for and report side effects as needed. Observe for signs and symptoms of cardiovascular distress and report as needed. Obtain vital signs as ordered and needed. Physician orders, initially dated 10/1/18 and on the (MONTH) 2019 orders, included [MEDICATION NAME] 50 mg (given for high blood pressure) twice a day. Physician orders, initially dated 7/29/19 and on the (MONTH) 2019 orders, included [MEDICATION NAME] 10 mg (given for high blood pressure) once a day. Resident Progress Notes included the following notations: 12/31/19 at 10:15 [NAME]M.: therapy (sic) staff with resident he c/o (complains of) dizzy and tired. therapy took b/p (blood pressure) said b/p at 930 am 65/39 in bathroom after toileting and transfer (sic) to walker seat had walked in bathroom with walker 0935 b/p 62/38 continue to be seating in bathroom on seat of walker, assisted to his recliner put legs up b/p 109/64 at 0945 am, put feet down b/p 72/49 at 10 am feet up b/p 112/64 at 1015 am. had taken blood pressure meds at 0946 am. 12/31/19 at 2:25 P.M.: notification (sic) back from physician of low b/p this am after medications, new order to decrease [MEDICATION NAME] to 25 mg from 50 mg and to hold [MEDICATION NAME] and [MEDICATION NAME] if SBP (systolic blood pressure, or top number of blood pressure reading) <90 mmHg On 1/28/20 at 1:33 P.M., during an interview with the Administrator, Corporate Nurse, and Director of Nursing (DON), the DON indicated she had spoken with LPN 1, who had given Resident B his medications on 12/31/19. She indicated LPN 1 had stated that the therapist was in the room when she gave Resident B his medications. LPN 1 was not aware of the resident's low blood pressure readings and complaints of weakness before she administered his medication, and would not have given them if she had known his blood pressure was that low. The DON indicated she had been working that day, and was involved with notifying the physician regarding the low blood pressure, and obtaining parameters on when to hold the blood pressure medication. The Corporate Nurse indicated at that time that she would have expected the physical therapy assistant to immediately notify a nurse of a condition change. On 1/28/20 at 2:23 P.M., the DON indicated she had spoken to Physical Therapist Assistant (PTA) 1, who had been with Resident B on 12/31/19. PTA 1 indicated the nurse administered the medication prior to her notifying the nurse of the resident's change of condition. 2. The closed clinical record of Resident C was reviewed on 1/27/20 at 10:30 [NAME]M. [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 11/20/19, indicated Resident C was moderately impaired in cognitive skills for daily decision making. A Care Plan, initially dated 5/30/19 and reviewed 11/26/19, indicated, Potential for SOB (shortness of breath) while lying flat. The Approaches included: Administer oxygen per MD order and as needed. Oxygen per n/c (nasal cannula) per md orders. Elevate head of bed or place in upright position as needed. Resident Progress Notes included the following notations: (Saturday)12/21/19 at 6:22 P.M.: resident (sic) started a cough nonproductive, lungs clear .says just doesn't feel well. notified MD, awaiting response Documentation regarding the resident's status on 12/22/19 was not found in the clinical record. Documentation regarding the physician responding to the concern on 12/22/19 was not found in the clinical record. Resident Progress Notes continued: 12/23/19 at 4:33 [NAME]M.: client used call light to be assisted to toilet at this time, congested cough noted. per client able to move mucus but unable to expell (sic) .no present order for cough syrup noted. Communication sent to md .sats (oxygen content in blood) 88% noted not to be wearing oxygen before or now. placed o2 (oxygen) at 2lpnc (liters per nasal cannula), awaiting med response to cont. cough. 12/23/19 at 2:06 P.M.: New order received from (name of physician) for [MEDICATION NAME] DM 1-2 tsp po (per mouth) for cough. Documentation regarding the resident's respiratory status was not documented on 12/24-12/26/19. Resident Progress Notes continued: (Friday) 12/27/19 at 3:20 P.M.: Called (name of physician) office to speak to nurse about resident. No messages could be taken at this time. Sent C[NAME] (a faxed Change of Condition form) to MD due to residents (sic) condition. Resident complains of cough (non productive) and runny nose .Bilateral lung sounds crackles .Awaiting repsonse (sic) from MD. Documentation on 12/28/19 of the resident's condition, or the physician's response on 12/28/19, was not found in the clinical record. Resident Progress Notes continued: 12/29/19 at 9:21 [NAME]M.: Resident noted to have congested cough with runny nose. Afebrile .Appetite fair. 12/29/19 at 2:23 P.M.: C[NAME] (Change of Condition) returned with n/o (new order) for [MEDICATION NAME] .prn (as needed) for cough. On 1/28/19 at 11:00 [NAME]M., during an interview with the DON, she indicated a nurse can contact the physician by phone or by sending a C[NAME] form by fax. She indicated the physician would typically contact the facility that day or the next day to respond. If a resident was in distress, staff would phone the physician. The nurse did phone the physician's office on 12/27, but the office was closed, so she faxed a C[NAME] form. Nurses check the fax machines periodically through the day for physician responses. On 1/28/19 at 1:33 P.M., during an interview with the DON, Corporate Nurse, and Administrator, the Corporate Nurse indicated she was aware the physician did not respond to the C[NAME] for 27 hours, and no assessments were documented on 12/22/19 or on 12/28/19. The Corporate Nurse indicated an Event could have been started regarding the resident's change in condition, and that the Event would alert staff to do follow up assessments. On 1/28/20 at 1:33 P.M., the DON provided the current facility policy, Provider Notification Guidelines, effective 9/12/17 and reviewed 5/23/18. The policy included: Purpose: To ensure the resident's physician or practitioner .is aware of .change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care. Procedures: 1. Resident assessments for change in condition .should be completed in a timely manner .During non-office hour times the nurse should notify the physician/provider by phone .the need for physician/provider intervention .If the facility has not had a response to abnormal test results or request for physician/provider intervention within 12 hours .the nurse on duty will call the physician to obtain further instructions. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record On 1/28/20 at 2:50 P.M., the Corporate Nurse indicated the facility did not have a specific policy regarding assessment of a change in condition. The Corporate Nurse did provide the current facility policy, Notification of Change in Condition, undated. The policy included, Purpose: To ensure appropriate individuals are notified of change in condition .Procedures: 1 Resident assessments for change in condition .should be completed in a timely manner This Federal tag relates to Complaint IN 955. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 2 of 2 dining observations and 1 of 2 kitchen observations. A bug was observed on the steam table, hands were not washed or were not washed for appropriate times. (Resident 66, Resident 34, Resident 58) Finding includes: 1. On 11/1/19 at 11:21 [NAME]M., a bug was observed on the steam table. At 11:45 [NAME]M., the Senior Director of Dietary Services observed the bug. She obtained a cloth from the sanitizer bucket, wiped the steam table, and discarded any uncovered food from the steam table. At that time, she indicated it was the policy of the facility to sanitize the area, discard any uncovered food, and notify the Plant Operations Manager to contact pest control. At 1:20 P.M., the Director of Plant Operations indicated the pest control company would treat the kitchen that evening after the kitchen closed. He further indicated the pest control company visited monthly and there were no previous incident with pests in the facility. On 11/1/19 at 1:29 P.M., the Director of Plant Operations indicated provided the current Pest Control policy, revised 8/8/18. At that time the policy was reviewed and included, but was not limited to: It is (name of company) policy to maintain an effective pest control program . Maintain an ongoing pest control program to ensure the building is kept free of insects and rodents. 2. On 10/28/19 at 11:50 [NAME]M., LPN 12 touched Resident 66's shoulder. LPN 12 obtained milk from the refrigerator, refilled Resident 34's cup, placed the milk back into the refrigerator, and performed a four second hand wash, under running water. At 11:55 [NAME]M., AA (Activities Assistant) 1 was observed to wash her hands under running water, utilized her bare hand to turn off the faucet, retrieved an apron, donned a hair net and passed out resident plates. AA 1 then washed her hands under running water and utilized her bare hand to turn the faucet off. 3. During an observation on 11/1/19 at 11:58 [NAME]M., LPN 12 was assisting resident during dining service. LPN 12 washed hands for a total of 8 seconds before assisting Resident 58 with lunch. On 11/1/19 at 1:54 P.M., the Regional Nurse Consultant provided the current Guidelines for Handwashing/Hand Hygiene policy. At that time the policy was reviewed and included, but was not limited to: 1. Hand Washing a) Turn water on to a comfortable temperature (sic) b) Wet hands with running water. Apply liquid soap and work into a lather. c) Wash well for 15-20 seconds, using a rotary motion and friction. d) Rinse hands well under running water, allowing water to flush from wrist to fingertips. e) Dry hands with paper towel(s). f) Turn off faucet with paper towel to avoid recontamination (sic) hands from faucet. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to prevent accidents for 1 of 3 residents reviewed for falls. Care plan interventions were not in place for a resident with multiple falls. (Resident 28) Finding includes: During an observation on 11/1/19 at 8:22 [NAME]M., CNA 5 assisted Resident 28 from the dining room into a television (TV) room between the dining room and long term care hall nurse's station. Resident 28 was placed in front of the TV and left with other resident's in the room. No staff were in the room. At 8:32 [NAME]M., Resident 28 was observed sleeping in her wheelchair in front of the television. At 9:00 [NAME]M., nursing staff assisted Resident 28 out the TV room and into the bedroom. During record review on 10/30/19 at 9:18 [NAME]M., Resident 28's most recent quarterly MDS (Minimum Data Set), dated 8/30/19, indicated the Resident required extensive assistance with transfers, had severe cognitive impairment, and had 2 or more falls since the previous assessment. Resident 28's diagnoses, included but were not limited to, Alzheimer disease, dementia, and anxiety. Resident 28's care plan included, but was not limited to, at risk for falling due to impaired cognition and daily antianxiety medication. Care plan interventions included, but were not limited to, lay down after breakfast and check and change after meals. Resident 28 had falls on the following dates: 6/22/19 - fell in TV room [ROOM NUMBER]:01 P.M. 7/8/19 - fell in bed room [ROOM NUMBER]:15 P.M. 8/31/19 - fell in dining room [ROOM NUMBER]:24 P.M. 10/1/19 - fell by nurse's station 8:05 [NAME]M. 10/7/19 - fell in TV area 8:00 P.M. The following IDT (Inter-disciplinary team) notes corresponded with the listed falls, including new interventions: 6/23/19 - IDT note - Resident was sitting in living room with other residents watching TV moments prior to fall. Staff observed resident on floor in front of (wheelchair). Appears as if resident scooted self out of chair. New intervention - check and change resident after meals. 7/10/19 - IDT note - Staff was walking up hallway and noted resident to be on floor on bedside mat, playing with blankets and talking aimlessly to self . New interventions to lay resident down after breakfast for naps and left up in afternoon . 9/4/19 - IDT note - Resident was sitting in (wheelchair) without complaints.Resident leaned forward, reaching for something on the table and the chair tipped and resident slid to floor. 10/2/19 - IDT note - Resident had unwitnessed fall from relaxed back (wheelchair) . Staff had just brought her back from dining room from breakfast and placed resident in commons area by nursing station as a normal routine for resident . Intervention: provide sensory activity while in (wheelchair). 10/8/19 - IDT note - Resident was in (wheelchair), playing with lap blanket moments prior to fall. Resident finished eating supper meal. Staff assisted resident to TV area and provided resident with sensory item. Staff then returned to dining room to assist other resident's back to room/TV area. Upon return, another resident alerted staff resident had leaned forward and flipped her chair and fell to floor. During an interview on 11/1/19 at 8:40 [NAME]M., CNA 5 indicated staff should lay Resident 28 down after meals. During an interview on 11/1/19 at 9:30 [NAME]M., the DON (Director of Nursing) indicated staff places Resident 28 in a common TV area after meals while other staff members finish assisting other residents with breakfast. Staff can observe the resident while in common TV areas until other residents are finished eating, then staff assists the resident to bed. On 11/1/19 at 3:30 P.M., the Nurse Consultant supplied a facility policy titled Fall Management Program Guidelines, and dated 5/22/18. The policy included, .Care plan interventions should be implemented that address the resident's risk factors. Should the resident experience a fall the attending nurse shall complete the 'Fall Event.' This includes . interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff for 5 of 5 days during the survey. Finding includes: On 10/28/19 at 11:00 [NAME]M., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 11/1/19 at 9:00 [NAME]M., the DON (Director of Nursing) provided the Posted Nurse Staffing for 10/28/19 thru 11/1/19. The Posted Nurse Staffing lacked the actual hours worked. During an interview on 11/1/19 at 9:45 [NAME]M., the Administrator indicated the staff posting would include actual hours worked by staff. No Posted Nurse Staffing policy was supplied by the facility.

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices were maintained during 1 of 2 dining observations. A staff member made physical contact with a resident while assisting during lunch in the dining room, then moved to a different resident to assist with feeding without performing hand hygiene. (Resident 9, Resident 15) Findings include: During an observation on 9/10/18 at 12:15 P.M., LPN 4 was assisting Resident 15 with lunch by helping to feed the resident. Resident 9 was sitting across the table, not eating the meal. LPN 4 walked around the table, spoke with Resident 9, and then assisted by taking Resident 9's hand and placing it on a utensil. Resident 9 then began to feed self. LPN 4 then walked back to Resident 15, sat down, and assisted feeding. No hand hygiene was performed between residents. During an interview on 9/10/18 at 12:57 P.M. LPN 12 indicated that staff should perform hand hygiene in the dining room before assisting the residents with feeding and in between residents. On 9/13/18 at 12:40 P.M., the DON (Director of Nursing) supplied a copy of the facility policy titled, Guideline for Handwashing/Hand Hygiene, and dated 2/9/17. The policy stated, Health Care Workers shall use hand hygiene at times such as: .Before/after preparing/serving meals, drinks, tube feedings, etc . Before/after having direct physical contact with residents. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to serve residents three bean salad and coconut cream pie at the proper temperature. This was observed in 1 of 3 dining rooms. (600 Hall Dining Room) Findings include: On 6/22/17 at 12:14 P.M., lunch was observed being served in the 600 hall dining room. Dietary aide 12 indicated the temperature of three bean salad was 58 degrees Fahrenheit and coconut cream pie was 54 degrees Fahrenheit. On 6/22/17 at 12:20 P.M., the Dietary Manager indicated three bean salad and coconut cream pie temperature should be served at 32 degrees Fahrenheit. On 6/22/17 at 1:37 P.M., the Dietary Manager provided the recipes for three bean salad and coconut cream pie. The recipe for three bean salad indicated it must not exceed an internal temperature of 41 degrees Fahrenheit. The recipe for coconut cream pie indicated it must not exceed a maximum temperature of 41 degrees Fahrenheit. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the environment was free from disrepair. Drywall was observed to be gouged and scuffed, sinks and air conditioner units pulled away from walls, and plungers were uncovered in bathrooms for 13 of 32 rooms during Stage 1 of the survey. (Room 102, Room 208, Room 209, Room 211, Room 301, Room 305, Room 306, Room 308, Room 402, Room 407, Room 411, Room 602, Room 604) Findings include: 1. On 6/20/17 at 1:18 P.M., Room 102 was observed to have gouged out and ripped dry wall behind the bed under the overbed light. On 6/21/17 at 1:03 P.M., the same was observed. 2. On 6/19/17 at 10:59 A.M., Room 208 was observed to have chipped dry wall behind the bed, under the overbed light. On 6/21/17 at 1:06 P.M., the same was observed. 3. On 6/20/17 at 9:26 A.M., Room 209 was observed to have black marks on the bathroom walls, paint was scratched on the bathroom walls, and the bathroom door. On 6/21/17 at 1:10 P.M., the same was observed. 4. On 6/20/17 at 9:22 A.M., Room 211 was observed to have chipped drywall in the bathroom. On 6/21/17 at 1:08 P.M., the same was observed. 5. On 6/20/17 at 9:15 A.M., Room 301 was observed to have black marks and scrapes on the bathroom walls, door and frame. On 6/21/17 at 1:13 P.M., the same was observed. 6. On 6/20/17 at 9:01 A.M., Room 305 was observed with black marks on the wall in the bathroom. The toilet plunger was stored on the bathroom floor uncovered. On 6/21/17 at 1:15 P.M., Room 305 was observed with black marks on the wall outside the bathroom, black marks on bathroom walls, and an uncovered plunger with an uncovered urinal on top of it. 7. On 6/20/17 at 8:43 A.M., the shared bathroom in Room 306 was observed to have an unlabeled bath pan and urinal on the back of the commode and chipped walls. On 6/21/17 at 1:17 P.M., Room 306 was observed to have an unlabeled bath pan on back of the commode, an unlabeled urinal on the floor of the bathroom, chipped and black marks on bathroom walls, black marks on the wall between bathroom and air conditioner, black marks and scratches on bathroom door, and splinters of wood sticking out from interior corner of bathroom door. 8. On 6/20/17 at 8:50 A.M., Room 308 was observed to have black marks on bathroom walls and the floor was bubbled up by the commode. On 6/21/17 at 1:23 P.M., Room 308 was observed to have black marks on bathroom walls, the floor was bubbled up by the commode, bathroom door had chunks of wood missing with splinters hanging, and the bathroom door had scratches. 9. On 6/19/17 at 12:06 P.M., Room 402 was observed to have the sink in the bathroom pulled away from wall. On 6/21/17 at 1:27 P.M., the same was observed. 10. On 6/19/17 at 12:28 P.M., Room 407 was observed to have cracked dry wall around air conditioner unit. On 6/21/17 at 1:30 P.M., Room 407 was observed to have cracked dry wall around air conditioner unit and the wall in the bathroom was scraped up between the commode and the sink. 11. On 6/19/17 at 12:05 P.M., Room 411 was observed to have cracked and broken dry wall in the bathroom. On 6/21/17 at 1:34 P.M., the same was observed. 12. On 6/20/17 at 1:19 P.M., Room 602 was observed to have the sink pulled away from the wall in the bathroom. On 6/21/17 at 1:38 P.M., the same was observed. 13. On 6/19/17 at 11:16 A.M., Room 604 was observed to have the room door dragging the floor. On 6/21/17 at 10:26 A.M., the same was observed. On 6/22/17 at 9:28 A.M., the Administrator provided a document that was completed when residents moved out of rooms. One of the responsibilities of Plant Operations was to ensure the walls are in good condition. During an interview on 6/22/17 at 9:30 A.M., the Administrator indicated the marketing department walked through the facility daily, and filled out maintenance forms when needed, the Administrator monitored building, and maintenance did daily walk throughs. If maintenance found damaged walls they would address it immediately or within a reasonable amount of time. During an interview on 6/22/17 at 9:55 A.M., the Maintenance Supervisor 4 indicated if a resident was staying in a room, painting was not done. Painting/maintenance was done when residents moved out. If there was a need to paint or fix something, maintenance would ask the resident if it was okay. Also if staff sees something that needed maintenance, they would fill out a work order form for the maintenance department. On 6/22/17 at 10:00 A.M., Administrator indicated there was no specific policy for maintenance of facility. 3.1-19(f)

Based on interview, and record review, the facility failed to ensure a resident received adequate supervision to prevent falls for 1 of 2 residents reviewed for accidents. (Resident #123) This deficient practice resulted in Resident #123 experiencing a fractured left hip after experiencing 2 falls. Findings Include: During an interview on 5/23/16 at 8:25 A.M., with LPN #15 indicated, Resident #123 was out to the hospital due to an infection of his left hip surgical site. The clinical record for Resident #123 was reviewed on 5/23/16 at 9:51 A.M. The clinical record indicated Resident #123 had been discharged from the facility on 5/18/16 for an infection in his surgical site. The record indicated Resident #123 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record indicated Resident #123 had been discharged from facility on 5/2/16 with a left hip fracture. The progress notes from 3/30/16 to 5/18/16 were reviewed and included, but were not limited to, the following: A nursing note dated 3/30/16 at 3:57 P.M., included, but was not limited to, Res (Resident) admitted to room (number) from (local hospital) via facility van. accompanied by self. res has history of seizures and mild mental retardation. res able to voice needs, however is somewhat slow to respond and somewhat difficult to understand . A social service note dated 4/13/16 at 4:57 P.M., included, but was not limited to, Resident was interviewed .Resident alert, but oriented to person only. Resident has MMR (mild mental retardation) DX (diagnosis) and Bims (sic) (brief interview mental status score) 0 (severely cognitively impaired). An untimed therapy note dated 4/13/16, included, .Pt presented with good functional gains toward goals, however pt continues to demonstrate decreased safety awareness with impulsive behaviors and movements with transfers and mobility. Pt requires mod to max cues to attn to task in order to benefit maximally from recommended there ex (exercises) and ax (activity). Pt's cognitive deficits may prove as a barrier to achieve LTG's (long term goals) . Fall #1: A nursing note dated 4/22/16 4:08 P.M., included, but was not limited to, As staff outside of room heard loud bang and then call light initiated. Staff responded immediately. Upon entrance of room noted res fall to floor between toilet and wall. Resident denies any pain. Upon physical assessment, no injury noted. Abel to move all extremities without difficulty. Hand grasp within normal limits for resident. Assisted res back to W/C. Educated resident on importance of waiting for assistance. MD notified at this time, ADHS notified and n.o. (new order) to ensure non skid footwear is on before transfers and resident not to be left alone in bathroom. Communicated this to staff. Family phoned and aware. An IDT (interdisciplinary team) note 4/23/16 at 3:40 P.M., included, but was not limited to, .Resident agrees with current safety plan of care . will continue to monitor. Resident also agrees staff to stay in bathroom with resident in attempt of preventing further falls . Fall #2: A nursing note for 5/1/16 at 11:30 P.M.,was entered as a late entry on 5/2/16 at 1:11 A.M. The nursing note included, but was not limited to, Resident found crawling across floor of his room. States I am walking out of here Explained to that it was dark out and has been raining. V/s obtained and resident denies pain or discomfort at this time. No injuries found at this time. Resident assisted into w/c with assist of 2 and brought out to dining room for cookies and coffee, then assisted to bed after snack. An untimed therapy noted dated 5/2/16, included, but was not limited to, .pt demonstrated a decline of function on 5/2/16. He c/o (complained of pain to L (left) hip and was not able to perform LE (lower extremity) exercises properly. Pt required more assistance to ambulate and presented inability to bear weight to B (bilateral) LE. An IDT note dated 5/2/16 at 9:36 A.M., included, but was not limited to, Reviewed current plan of care related to safety. Root cause: Resident attempted to ambulate without assist and slid from his bed. Intervention was to add scoop mattress to bed in an attempt to prevent him from sliding from bed . A nursing note dated 5/2/16 at 6:26 P.M., included, but was not limited to, While resident was being transferred to bed her (sic) began c/o (complaints of) pain to Left (sic) hip and pelvis. As he was being T/R (turned and repositioned) he stated that the pain was worse. MD notified and ordered received for xray (sic) of the left hip and pelvis. A nurses note dated 5/2/16 at 10:06 P.M., included but was not limited to, (Name of Local hospital) EMT's (Emergency Medial Technician's) here and resident transferred to (Name of local hospital) . An X ray report of Resident #123's left hip and pelvis dated 5/2/16 at 11:40 P.M. The report indicated Resident #123 experienced a impacted subcapital fracture of the left femoral neck. A nurses note dated 5/7/16 at 2:00 P.M., included, but was not limited to, Resident arrived via (by) ambulance .Noted slight edema to bilateral feet. Has abductor pillow in place to prevent from crossing legs. To remain in place except for therapy and skin care . A physicians note dated 5/9/16 at 4:32 P.M., included, but was not limited to, See (name of local hospital) H &P for detail. Had fall at facility suffering femoral neck fracture on left . A nursing note dated 5/13/16 at 2:08 P.M., included, but was not limited to, res continues to yell out in pain. pain interventions have been ineffective. MD notified. new order to increase norco (a pain medication) .and obtain 2 view x ray of lumbar spine . Fall #3: A nursing note dated 5/13/16 at 5:55 P.M., included, but was not limited to, Resident found on floor by xray tech. no injuries noted. resident trying to transfer self from chair to bed. ADHS (Assistant Director of Health Services) notified plan to place pressure alarms on bed and wheel chair. MD (medical doctor) notified. Fall #4: A nursing note dated 5/13/16 at 6:15 P.M., included, but was not limited to, resident found crawling on floor out of doorway of room. no injuries noted, assist of 2 to get up. restless. coffee offered which seems to settle him down, brief changed. pads placed at bedside, personal alarm placed on resident call light within reach, bed in low position. A note entered by the DON (Director of Nursing) dated 5/15/16 at 9:31 P.M., included, but was not limited to, Resident continues with poor safety awareness. Root cause of event is resident attempted to get up unassisted without calling for assist. Is non compliant/forgetful with interventions in place. Ultimate goal is for resident to not have further falls; however if resident should fall the goal will be to avoid any further significant injuries secondary to falling. Resident currently has alarm to bed and wheelchair in attempt of alerting staff of (sic) resident attempting to ambulate by himself. Dycem is intact to wheelchair in attempt of preventing resident from slipping out of chair. It is unknown if resident attempted to ambulate by himself of slid from chair as he was unable to tell staff what he was doing prior to fall Bed will continue in lowest position with mats in place in attempt of preventing injury should he attempt to get up unassisted. He does have a scoop mattress in place . The fall event reports for Resident #123 were provided by the DON on 5/23/16 at 2:00 P.M., they included, but were not limited to the following: Fall #1: On 4/22/16 at 4:25 P.M., DESCRIPTION .unwitnessed fall .Location of fall .Residents Bathroom .What was resident doing just prior to fall? .Transferring self, toileting .Personal Inspection/Environmental .Improper or ill fitting footwear .Other contributing factors resident was attempting to transfer self as staff entered room to assist. Resident did not have nonskid footwear on at time of fall .Fall Risk Re-Assessment .Resident requires assistance to transfer .Resident requires assistance to ambulate safely with or without assistive device .Resident requires us of an assistive device and/or often forgets to use device .NEW INTERVENTIONS .Adaptive Equipment, describe - ensure non skid footwear in place before transfers .others, describe-Staff to remain in bathroom with res . Fall #2: On 5/1/16 at 11:30 P.M., DESCRIPTION .resident fall .Location of fall .Resident Room .What was resident doing just prior to fall? .Other, describe-crawled out of bed and across the floor .Personal Inspection/Environmental .Recent agitation or restlessness .Fall Risk Re-Assessment .Resident requires assistance to transfer .resident requires assistance to ambulate safely with out without assistive device .Resident requires us of an assistive device and/or often forgets to use device .Neurological disorder .Other, describe-DX: mild mental retardation .NEW INTERVENTION .Defined parameter mattress . Fall #3: On 5/13/16 at 11:40 P.M., DESCRIPTION .fall .Location of Fall .Resident Room .What was resident doing just prior to fall? .Transferring self .Personal Inspection/Environmental .Recent agitation or restlessness .List who witnessed fall/incident xray tech notified nurse that resident had crawled out of bed and was laying on the floor .Fall Risk Re-Assessment .Resident has cognitive or memory impairment that effects safety and judgement .Resident has difficulty understating and following directions .Resident requires assistance to transfer .Resident refuses to comply with safety measures such as call light use, alarms, appliances .NEW INTERVENTIONS .Bed in lowest position .Bed alarm pressure pad .wheelchair alarm pressure pad .dycem to w/c (wheel chair) . Fall #4: On 5/13/16 at 11:52 P.M., DESCRIPTION .found crawling out of room .Location of fall .Resident Room .What was resident doing just prior to fall .Other, describe-unknown if he crawled out of bed . Personal inspection/Environmental .Recent agitation or restlessness .Fall Risk Re-Assessment .Resident has cognitive or memory impairment that effects safety and judgement .Resident has difficulty understanding and following directions .Resident requires assistance to transfer .Resident requires assistance to ambulate safely with our without assistive device .Resident refuses to comply with safety measures such as call light use, alarms, appliances .NEW INTERVENTIONS .Bed in lowest position .Bed Alarm, describe-pressure pad .Wheelchair alarm, type-pressure pad .Personal Alarm-type-in bed and chair .Mat next to bed . The care plans included,but were not limited to the following : A care plan for poor decision making related to a [DIAGNOSES REDACTED].I lack education and decision making skills needed to make good sound decisions .Always give me praise when I make an appropriate decision .Please provide me with the proper cues and supervision for use of my call light when needing, get out of bed .Please provide calmness if I show signs of distress during the decision making process . A care plan for impaired functional mobility initiated 4/7/16 included, .Assist me as needed with dressing, assist me with personal hygiene as needed .I am presently non-ambulatory, require assist of 1 staff for my transfers . A care plan for fall risk initiated 4/7/16 included, assist me with one for transfers. I am presently non-ambulatory check and change every 2 hours. assist as needed with toileting needs .I am receiving therapy as indicated by my md .I would benefit from a clutter free environment .make sure my call light is in reach at all times .(initiated 4/7/16) .non skid footwear in place with transfers .staff to stay in bathroom with resident (initiated 4/25/16) I utilize a scoop mattress (initiated 5/2/16) .I have dycem to my wc (wheel chair) .I have a pressure alarm to my bed and wc .I have a low bed with mats (initiated 5/16/16) . A care plan for difficulty with communication initiated 4/6/16 included, but was not limited to, .I have difficulty making myself understood .Always remind me to speak slowly and clearly .Ask me to repeat slurred, mumbled words .Provide me with a quiet, non-hurried environment, free of background noise and distractions .Repeat what I tell you if there is a need to validate . A care plan for difficulty understanding others initiated 4/6/16 included, but was not limited to, .Always repeat phrases as needed and rephrase if necessary .Make sure that you obtain my attention before speaking to me (initiated 4/6/16) . An MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #123 had a BIMS (Brief Interview Mental Status) score 00 indicating he was severely cognitively impaired. The MDS also indicated Resident #123 experienced inattention and disorganized thinking. The MDS indicated Resident #123 required extensive assistance of 2 for transfers and bed mobility, and extensive assistance of 1 for toileting and dressing. During an interview on 5/23/16 at 2:20 P.M., with the Director of Nursing (DON) she indicated, Resident was admitted on [DATE] with a seizure disorder, weakness, Mild Intellectual Disability and was cognitively impaired. She indicated at entrance Resident #123 required use of a wheel chair and walker. and was assessed to be at risk to experience a fall. The DON indicated a care plan for falls was initiated on 4/7/16 with interventions including, but not limited to, assist me with one for transfers. I am presently non-ambulatory. Fall #1: The DON indicated Resident #123 had experienced fall #1 on 4/22/16 at 4:26 P.M. She indicated Fall #1 was an unwitnessed fall in the restroom of Resident #123's room. She indicated a CNA had assisted Resident #123 to the restroom and left so he could have privacy. She indicated Resident #123 had attempted to get up and fell while the CNA was not in the restroom. She indicated Resident #123 experienced no injuries and the immediate intervention was for staff to stay in the restroom with the resident and for him to wear gripper socks when he was up. Fall #3: The DON indicated Fall #2 had occurred on 5/1/16. She indicated the fall was unwitnessed and Resident #123 was found crawling on the floor in his room. She indicated the immediate intervention was to add a scoop mattress to prevent him from falling sliding off of the bed. She indicated, at the time, of the assessment after the fall Resident #123 showed no signs of an injury. The DON further indicated on 5/2/16 around 6:26 P.M., Resident #123 began to voice complaints of hip pain and an x ray was obtained showing a fractured left hip. She indicated the fractured hip was a result of the fall on 5/1/16. Fall #3: The DON indicated following readmission to the facility Resident #123 experienced a fall on 5/13/16 at 11:40 P.M. She indicated Resident #123 was found on floor by an x ray technician that had come to take an x ray his back. The DON indicated prior to the fall Resident #123 had been sitting up in his wheel chair and attempted to transfer himself to bed. She further indicated the immediate intervention was to place Dycem (an anti slip surface) to his wheel chair to prevent him from slipping and for Resident #123 to have a clip alarm placed when he is up in his wheel chair. Fall #4: The DON indicated Fall #4 occurred on 5/13/16 at 11:52 P.M., She indicated Resident #123 was found crawling on the floor in his room. The DON indicated Resident #123 had no injuries and the immediate interventions added was to place a pressure alarm to his bed, wheel chair, place his bed in the lowest position and place mats to both sides of Resident #123's bed. A policy titled FALLS MANAGEMENT PROGRAM GUIDELINES dated 6/2015 was provided by the DON on 5/25/16 ay 9:20 A.M. The policy included, but was not limited to, (Name of Company) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventive measures .A fall is considered to be: 'an unintentionally coming to rest on the ground, floor, or other lower level .An episode where a resident lost his/her balance and would have fallen is considered a fall .A fall without injury is still a fall Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .The fall risk assessment is included as part of the Admission and Monthly Nursing Assessment .Identified risk factors should be evaluated for contributions they may have .Care plan interventions should be implemented that address the resident's risk factors .Should the resident experience a significant change in condition affecting a resident's resident's (sic) functional status the monthly nursing assessment shall be completed again at that time . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff had hair completely contained in a hair restraint during 3 of 3 kitchen observations. This had the potential to affect 75 of 76 residents who resided in the building. Findings include: 1. Cook #1, DA (Dietary Assistant) #4, and DA #5 were observed on 3/12/15 at 8:45 A.M., in a food preparation area with hair extruding from a cap. 2. The CDM (Certified Dietary Manager), Cook #1, and DA #1 were observed on 3/13/15 at 9:00 A.M., in a food preparation area with hair extruding from a cap. 3. DA #2 was observed on 3/13/14 at 9:20 A.M., in a food preparation area with hair extruding from a cap. 4. The CDM, DA #6, DA #4, and Cook #1 were observed on 3/16/15 at 11:00 A.M., in a food preparation area with hair extruding from a cap. The Policy and Procedure for Dietary Hair Restraint provided by the CDM on 3/16/15 at 11:45 A.M. indicated, .All Dining Service employees will be required to wear hair restraints as required by the 2009 Federal Food Code.are designed and worn to effectively keep their hair from contacting exposed food. During an interview on 3/16/15 at 3:45 P.M. the HFA (Health Facilities Administrator) indicated the dietary employees should have hair completely contained in a hair restraint when in a food preparation area. 3.1-21(i)(2) 3.1-21(i)(3)