Every finding on record at Parker Health Care & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions (EBP) were followed during transfers and perineal care for 1 of 3 residents reviewed for transfers (Resident B). Finding includes:During an observation, on 1/29/26 at 11:11 a.m., Resident B was lying in a low bed with mats on either side of the bed. Her eyes were closed. An orange magnet indicating EBP was on the doorframe of the door entering the resident's room. Resident B's clinical record was reviewed on 1/29/26 at 11:12 a.m. Diagnoses included age related physical debility, Alzheimer's disease, delusional disorders, and dementia with other behavioral disturbance. Current orders included enhanced barrier precautions (EBP) due to a history of multidrug resistant organisms (MDRO), initiated 2/18/25. An annual Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident sometimes understood others and was sometimes understood. Her ability to make decisions regarding tasks of daily life was severely impaired. She exhibited physical behavioral symptoms (such as hitting, kicking, pushing, scratching, grabbing) directed toward others and rejected care four to six days of the assessment period. Her behavioral symptoms were unchanged from the previous assessment. She was dependent on staff assistance for toileting hygiene, lower body dressing, and transfers. She was always incontinent of bowel and bladder. A current care plan, initiated 5/5/23 and revised 1/24/24, indicated the resident had a history of a MDRO Proteus mirabilis and extended-spectrum beta-lactamase (ESBL) (enzymes produced by bacteria making them resistant to many antibiotics) in her urine. Interventions included monitor for symptoms of urinary tract infection (UTI) and notify physician if any symptoms noted (5/5/23) and staff and visitors will follow EBP (6/11/25). During an observation, on 1/29/26 at 3:07 p.m., CNA 3 and CNA 4 applied gloves and entered the resident's room. They utilized the mechanical lift to transfer the resident into her bed. They removed their gloves, performed hand hygiene, and applied new gloves. They removed the resident's pants and brief and provided perineal incontinence care. As they rolled the resident from right to left while performing perineal care, the resident's right arm and hand touched the front of each of the CNA's uniforms. They did not wear barrier gowns throughout the transfer or incontinence perineal care procedures. During an interview, on 1/29/26 at 3:19 p.m., CNA 3 indicated she should have worn a gown during the resident's transfer and incontinence care since she required EBP. During an interview, on 1/29/26 at 3:19 p.m., CNA 4 indicated she should have worn a gown during the resident's transfer and incontinence care since the resident required EBP. During an interview, on 1/29/26 at 3:55 p.m., the DON indicated both CNAs should have worn gowns during Resident B's transfer and incontinence care since the resident required EBP. A current facility policy, last reviewed/revised 1/26/26, titled Enhanced Barrier Precautions, provided by the Administrator on 1/29/26 at 4:21 p.m., indicated the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: 'Enhanced barrier precaution' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.4. High-contact resident care activities include: a. Dressing.c. Transferring.f. Changing briefs. This citation relates to Intake 2710013. 3.1-18(a)

Based on interview and record review, the facility failed to provide the resident group the opportunity to select a resident representative to serve as the Resident Council President for 10 of 10 residents interviewed in a group setting. Findings include: During a resident group interview on July 31, 2024 at 10:00 a.m. the following concerns regarding Resident Council were indicated: The facility had informed the members of Resident Council they would no longer have a resident council president. The residents did not initiate this practice. The Activity Director informed the council that this was how it was going to be going forward. The residents indicated the Activity Director had told them that other facilities did not have a president of Resident Council, so they would not either. This had occurred approximately three months ago. Ten of ten residents present during the interview indicated they were never given the right to vote on this decision. Ten of ten residents present during the interview indicated they would like a resident representative to serve as the Resident Council President. The group had previously chosen the Resident Council President by election and there had not been a term limit for the position. The group felt they did not have voice within the facility. Review of monthly Resident Council Minutes from January 2024 through July 2024 indicated the following: March 2024 listed the name of a Resident Council President. The monthly minutes lacked the name of a Resident Council President in April, May, June, and July 2024. The monthly minutes for 2024 lacked mention of a group decision to no longer having a resident council president. During an interview on 8/1/24 at 11:33 a.m., the Activity Director indicated the resident council had slowly dwindled down to 3 or 4 members. The members were discouraged about the low participation. The Activity Director talked to her consultant about her concerns and her consultant said many facilities did not have a resident council president, so she then informed the resident council they would not have a resident council president. This idea was not offered to the resident council for consideration. The resident council did not vote on the matter. She implemented this practice following the recommendations of the consultant. A 10/1/2016, document titled Resident Council By-Laws, provided by the Activity Director on 8/1/24 at 1:55 p.m., indicated the following: .Officers: The President shall preside at all meetings of the Resident Council 3.1-3(k)

Based on observation, interview, and record review, the facility failed to provide ongoing activity programs to meet individual resident needs for 2 of 2 physically dependant, cognitively impaired residents reviewed for individualized activities. (Residents 51 and 55) Findings Include: 1. During an interview on 5/16/22 at 1:30 p.m., Resident 51's family member indicated the resident required assistance from staff to get out of bed and move about in her specialized wheelchair. The family member indicated he would like the resident to leave her room and move about the building a little bit. Resident 51 was observed in her room during the following observations: a. On 5/16/22 at 11:46 a.m., the resident was in bed with the TV on. She was not looking at the television. b. On 5/17/22 at 9:50 a.m., the resident was in bed. The TV was on. Her eyes were closed. c. On 5/17/22 at 10:47 a.m., the resident was in bed. Her eyes were closed. She was making soft snoring noises. The TV was on. d. On 5/17/22 at 12:03 p.m., the resident was in bed in her room. The TV was on. The resident appeared to be asleep. e. On 5/27/22 at 1:09 p.m., the resident was in bed. The TV was on. She was not looking toward the TV. f. On 5/17/22 at 2:58 p.m., the resident was in bed. Her eyes were open. The TV was on. She was looking towards the TV. g. On 5/18/22 at 9:56 a.m., the resident was in bed. She was awake. Her TV was on. h. On 5/18/22 at 11:52 a.m., the resident was in bed. The TV was on. The resident appeared to be asleep. i. On 5/18/22 at 2:18 p.m., the resident was in bed. She was awake. The TV was on. j. On 5/19/22 at 10:12 a.m., the resident was in bed. Her eyes were closed. The TV was on. k. On 5/19/22 at 1:47 p.m., the resident was up in a specialized wheel chair/Broda chair. She was awake. Her TV was on. l. On 5/20/22 at 9:34 a.m., the resident was in bed. She was awake. The TV was on. m. On 5/20/22 at 10:31 a.m., the resident was in bed. Her TV was on. She was smiling and looking out the window. n. On 5/20/22 at 2:39 p.m., the resident was in bed. She was awake. Her TV was on. At no time during the survey process on 5/16/22, 5/17/22, 5/18/22, 5/19/22, or 5/20/22, was the resident observed out of her room. The resident was observed out of her bed only one day, 5/19/22, of the survey. Resident 51's clinical record was reviewed on 5/17/22 at 3:37 p.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current, 5/19/21, care plan regarding the inability to self initiate activities due to cognitive decline. The care plan indicated the resident enjoyed socializing and being around people. Approaches included, but were not limited to, Assist me to and from activities of my choice and Continue to encourage me to participate in group activities of my interest such as, music entertainment, porch visits and intergenerational activities. The resident had a current, 7/18/19, care plan related to a risk for cognitive decline due to dementia. Approaches included, but was not limited to, Invite and encourage me to socialize with peers. I enjoy music entertainment such as [entertainer's name]. The resident had a current, 7/18/19, care plan regarding feeling bad about self, little interest, feeling down and depressed. Approaches included, but were not limited to, Encourage me to participate in activities of my interest such as music entertainment, pretty nails and animal visits. The resident's 4/19/22 Activity Update Assessment indicated the following: Resident uses a Broda chair when she is up and out of bed. Assistance is needed to and from activities of interest Resident does not have any behaviors that cause any problems. Resident loves to visit with the dogs when they come in. Resident will sing along to the music at times and enjoys being around people. Resident loves to go outside when the weather is nice . The assessment did not indicate the resident refused activities. A quarterly Minimum Data Set (MDS) assessment, dated 4/8/22, indicated the resident had severe cognitive impairment, usually was understood, usually understands others, displayed zero maladaptive behaviors during the assessment period, required staff assistance to transfer out of bed, and required staff assistance for locomotion or mobility. An annual MDS assessment, dated 1/7/22, indicated it was some what important for the resident to have books, music, attend group activities, and attend religious activities. The MDS indicated it was very important to see pets, participate in group activities, and be outside in fresh air. The resident's activity attendance record for 5/16/22 to 5/20/22 (the days of the survey observations), indicated the resident was provided, was invited to, or participated in the following activities: a. On Monday, 5/16/22: Exercise was marked refused, Movie was marked refused, Outdoor activity was marked refused, Tea Time/Coffee Break was marked refused, Current Events/News (receiving The Daily Chronicle paper) was marked as active. The resident had no one to one activity offered. b. On Tuesday, 5/17/22: Television was marked as independent. Bingo was marked refused, Current Events/News (receiving The Daily Chronicle paper) was marked as passive. The resident had no one to one activity offered. c. On Wednesday, 5/18/22: Television was marked as independent. Current Events/News (receiving The Daily Chronicle paper) was marked as active. The resident had no one to one activity offered. d. On Thursday, 5/19/22: One to One Sensory activity, Television was marked as independent. Bingo was marked refused. e. On Friday, 5/20/22: Party was marked refused. Television was marked as independent. Current Events/News (receiving The Daily Chronicle paper) was marked as passive. During an interview on 5/23/22 at 11:15 a.m., the Activity Director indicated this resident did not refuse activities. If the resident was documented as refused, it should have been documented as unavailable. This was a documentation error due to coding typos on the activity attendance record. Review of the residents activity attendance records for April 2022 and May 1 to 22, 2022, indicated the following: The resident was documented as refused, 41 times in April 2022 and 30 times during May 1 to 22, 2022. 2. Resident 55 was observed in her room during the following observations: a. On 5/16/22 at 11:46 a.m., the resident was in bed. Her eyes were closed. She appeared to be asleep. b. On 5/17/22 at 9:50 a.m., the resident was in a specialized wheelchair (a Broda chair). Her TV was on. She was looking toward the TV. c. On 5/17/22 at 10:48 a.m., the resident was in a Broda chair. Her TV was on. She was looking toward her TV. d. On 5/17/22 at 12:03 p.m., the resident was in a Broda chair being wheeled down the hallway toward the dining room. e. On 5/17/22 at 1:09 p.m., the resident was in bed. One of the two TVs on her side of the room was playing. f. On 5/17/22 at 2:58 p.m., the resident was in bed. She appeared to be asleep. One of the two TVs on her side of the room was playing. g. On 5/18/22 at 9:56 a.m., the resident was in a Broda chair. The TV was on. Her eyes were closed. h. On 5/18/22 at 2:18 p.m., the resident was in bed. She appeared to be asleep. Her side of the room was darkened. i. On 5/19/22 at 10:13 a.m., the resident was in her Broda chair. She was awake. The TV was on. j. On 5/19/22 at 1:48 p.m., the resident was in bed. Her eyes were closed. She appeared asleep. k. On 5/20/22 at 9:34 a.m., the resident was in bed. She appeared asleep. Her eyes were closed and her mouth was open. l. On 5/20/22 at 10:32 p.m., the resident was in bed. The TV was on. m. On 5/20/22 at 2:39 p.m., the resident was in a Broda chair in her room, awake. Resident 55's clinical record was reviewed on 5/18/22 at 10:00 a.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current, 4/16/20, care plan regarding the inability to self-initiate activities. Approaches included, but were not limited to, Ask and assist me to and from activities of my interest, I love being around people but may not be able to talk much but may try to sing ., I will benefit from sensory activities, Provide group activities of my interest and see that I get to them, and Provide me with 1:1 activities as I need them. The resident had a current, 1/26/17, care plan regarding cognitive deficits related to vascular dementia. Approaches included, but were not limited to, I will have activities individualized based on my cognitive ability. A quarterly MDS assessment, dated 4/8/22, indicated the resident had severe cognitive impairment, understood others, was understood by others, required staff assistance to get in and out of bed, required staff assistance for locomotion or mobility, and did not display any maladaptive behaviors during the assessment period. An annual MDS assessment, dated 1/8/22, indicated it was very important to the resident to see family and friends. It was some what important to the resident to hear music, see pets, attend group events, be involved in her favorite group activities, be outside in fresh air, and attend religious activities. A 4/19/22, Activities Update Assessment indicated the following: Short attention span during activities .Resident is not able to make decisions regarding activity participation but staff will take resident to activities of her interest .Resident has always loved music and any kind of religious activity. The resident's activity attendance record for 5/16/22 to 5/20/22 (the days of survey observation), indicated the resident was provided, was invited to, or participated in the following activities: a. On Monday, 5/16/22: Exercise was marked refused, Movie was marked refused, Outdoor activity was marked refused, Sensory was marked as active participant. Tea Time/Coffee Break was documented as refused and being a passive participant, in contradiction to one another. Current Events/News (receiving The Daily Chronicle paper) was marked as passive. b. On Tuesday, 5/17/22: Television-independent activity. Bingo was marked refused, Current Events/News (receiving The Daily Chronicle paper) was marked passive. c. On Wednesday, 5/18/22: Sensory was marked both active and passive during this event. d. On Thursday, 5/19/22: Television was marked as passive. Bingo was marked refused, Current Events/News (receiving The Daily Chronicle paper) was marked as passive. e. On Friday, 5/20/22: Party was marked refused, Television was marked as independent. Current Events/News (receiving The Daily Chronicle paper) was marked as passive. The resident had no documented individualized one to one activities offered Monday, Tuesday, Wednesday, Thursday or Friday. During an interview on 5/23/22 at 11:15 a.m., the Activity Director indicated this resident did not refuse activities. If the resident was documented as refused, it should have been documented as unavailable. This was a documentation error due to coding typos on the activity attendance record. Review of the residents activity attendance records for April 2022 and May 1 to 22, 2022, indicated the following: The resident was documented as refused, 52 times in April 2022 and 31 times during May 1 to 22, 2022. The record indicated the resident was offered zero individualized one to one visits in April 2022 or May 1 to 22, 2022. During an interview on 5/23/22 at 11:15 a.m., the Activity Director indicated the following: a. The activity, 11:45 a.m.-Sensory Time was an activity offered in the South Dining Room generally for residents who need assistance to dine. The activity should consist of sensory stimulation such as smelling flowers, talking about the season, talking about what day it was, the weather, touching items, etc. The activity was for residents with dementia or cognitive impairment. b. She did not know why the activity Sensory Time was not offered in Thursday 5/19/22. c. The Interdisciplinary Team had not worked together to ensure physically dependent residents with dementia were out of bed and able to attend afternoon activities that may be in their area of interest. They did not have a system for reviewing declines in activity attendance and sharing such declines with the Interdisciplinary Team to ensure resident emotional and social needs were being addressed. d. The 9:00 a.m.- Current Events/Mail Pass Room to Room activity was passing mail and giving each resident the The Daily Chronicle paper which was like a short newspaper. e. Resident 55 had declined and did not usually respond verbally to interactions. She does smile to music. The resident was resting in bed most afternoons and was not always available for music activities. f. If Resident 51 was out of bed in the afternoon, she could attend music activities. Although she could not eat food by mouth, food being served did not negatively impact the resident. g. Both Residents 51 and 55 could attend outdoor activities in the afternoon if they were out of bed. h. Both Residents 51 and 55 did not refuse activities. If they are out of bed, they would attend unless ill. i. Any coding of refused to attend activities by Residents 51 and 55 was most likely a typo and should have been coded as unavailable. She indicated the codes for unavailable and refused were close in the coding system and at times resulted in errors. During an observation on 5/18/22 at 2:32 p.m., a movie activity occurred in the South Dining Room. Residents 51 and 55 were not present. During an observation on 5/19/22 at 11:47 a.m. to 12: 10 p.m., no activity was offered in the South Dining Room. The May 2022 Activity Calendar indicated the activity, Sensory Time, would be offered at 11:45 a.m. in the South Dining Room. During an observation on 5/19/22 at 1:52 p.m., a nail polishing activity occurred in the South Dining Room. Residents 51 and 55 were not present. During an observation on 5/20/22 at 10:34 a.m., an exercise and music activity occurred in the main dining room. Residents 51 and 55 were not present. During an activity observation of The Birthday Party on 5/20/22 at 2:23 p.m., which included upbeat music performance, Residents 51 or 55 were not present. 3.1-33(a)

Based on record review and interview, the facility failed to ensure timely completion of a required Level I Preadmission Screening and Resident Review (PASARR) assessment for 1 of 2 residents reviewed for PASARR. (Resident 21) Findings include: Resident 21's clinical record was reviewed on 5/18/22 at 2:17 p.m. He admitted to the facility on [DATE] and remained in the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His clinical record lacked a pre-admission Level I PASARR. During an interview on 5/18/22 at 3:09 p.m., the Director of Nursing (DON) was requested to provide the PASARR document for Resident 21. Further documentation was not provided. Review of a Level I PASARR Screen Outcome, provided by the Social Services Director (SSD) on 5/20/22 at 11:25 a.m., indicated the PASARR Level I was canceled. The PASARR Outcome Explanation indicated the screen was canceled because the health care professional did not complete either the Level I screening form and/or submit requested documentation within the required timeframe. During an interview on 5/20/22 at 11:42 a.m., the SSD indicated the Level I PASARR for Resident 21 was canceled. She indicated she was unaware why the PASARR was canceled and it should have been completed within 14 days of the resident's admission to the facility. She indicated the resident's Level I PASARR paperwork was resubmitted during the survey on 5/18/22 and was in queue to be reviewed. A current policy, titled LEVEL I AND LEVEL II PROCESS, provided by Registered Nurse Consultant on 5/20/22 at 1:56 p.m., included, but was not limited to, the following: Policy .The Level I and II process is designed to determine the most appropriate setting for persons with a mental illness and/or intellectual or developmental disabilities and to identify the rehabilitation or specialized services that the person requires. It is the policy of this facility to participate in the Level I/Level II process Procedure .1. A level I screen will be completed for all resident's admitted to the facility. If a Level II is indicated at the time of admission, the Level II also will be completed prior to the resident being admitted to the facility 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a resident with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 49) Findings include: Resident 49's clinical record was reviewed on 5/18/22 at 2:41 p.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record also indicated the resident had a current order for hospice services. The resident had a current, 7/7/21, care plan regarding, I had a cognitive deficit related to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I receive [MEDICATION(S)] for this. Approaches included, but were not limited to, I will have my activities individualized based on my cognitive abilities and preferences, I will have one to one activity program, and I will participate in small group activities. The resident had a current, 10/29/21, care plan regarding a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current, 6/2/21, care plan regarding depressive episodes. Approaches included, but were not limited to, I will report and you will observe for changes in my depression symptoms. The resident had a current, 6/11/21, care plan which indicated, I have a cognitive decline and would benefit from personal invites, encouragement & reminders. During groups I would benefit from simple directions, repeats and assistance as needed. Approaches included, but were not limited to, Please assist me to and from activities I have shown interest in, Provide me with sensory activities, and Invite and remind me of what it is that we are doing before . A quarterly Minimum Data Set (MDS) assessment, dated 4/7/22, indicated the resident had severe cognitive impairment, understood others, was understood by others, experienced little interest in previously enjoyable activity, had trouble sleeping, was tired, had trouble concentrating, required extensive assistance for locomotion or mobility, both on and off the unit, received anti-psychotic medications seven days a week, and received anti-depressant medication seven days a week. A significant change MDS assessment, dated 10/5/21, indicated it was very important to the resident to choose what clothing she would wear, have her belongings safe guarded, see friends and family, be involved in her favorite activities, and participate in religious activities. Activity attendance records for April 2022 and May 1 to 22, 2022, indicated the resident had declined activities 48 times in April 2022 and 31 times from May 1 to 22, 2022. Resident 48 was observed in her room seated in a wheelchair with an over the bed table in front of her. She was on the side of the room with the window. The curtain that divided the room was pulled to obscure the resident's view of the hallway and/or view of her roommate. The outside window curtain was open, allowing outside light to enter. There was no other light source on the resident's side of the room. There was no form of stimulation on the side of the room. There was both a radio and TV on the resident's side of the room, and neither were on. The room appeared to be very dimly light during the following dates and times: on 5/16/22 at 11:44 a.m., 5/17/22 at 9:53 a.m., 5/17/22 at 10:46 a.m., 5/17/22 at 02:57 p.m., 5/18/22 at 11:51 a.m., 5/18/22 at 2:19 p.m., 5/19/22 at 1:46 p.m., 5/20/22 at 9:33 a.m., 5/20/22 at 9:38 a.m., and 5/20/22 at 10:30 a.m. During an interview on 5/18/22 at 2:19 p.m., the resident indicated she would listen to music if someone turned her radio on for her. During interviews on 5/19/22 at 10:36 a.m. and on 5/20/22 at 11:42 a.m., the Social Services Director indicated Resident 49 displayed behavioral symptoms of mental illness, including but not limited to, delusions, tearfulness, not speaking when spoken to, yelling, and calling out or speaking very loudly. During an interview on 5/23/22 at 11:15 a.m., the Activity Director indicated the following: a. She did not have a system for reviewing declines in activity attendance and sharing such declines with the Interdisciplinary Team to ensure resident emotional and social needs were being addressed. b. Resident 49 sometimes went up and down in her activity attendance. She had not realized the resident's activity attendance had decreased. She had not discussed the resident's decline with the Interdisciplinary Team. During an interview on 5/20/22 at 2:26 p.m., CNA 2 indicated Resident 49 was at times emotional, teary or upset. During an interview on 5/20/22 at 2:30 p.m., CNA 4 indicated Resident 49 was often sad or depressed, but pleasant and kind to work with. During an interview on 5/20/22 at 2:33 p.m., CNA 5 indicated the resident was sometimes sad and once yelled out in confusion and was moved to another quiet calm area were she slowly calmed down. The nurse was aware and involved in this one event. 3.1-37(a)

Based on interview and record review, the facility failed to clarify a resident's end of life wishes for 1 of 3 residents reviewed for Advanced Directives. (Resident 4) Findings include: A review of Resident 4's clinical record was completed on [DATE] at 2:24 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had severe cognitive impairment, was able to understand and be understood, and did not have disorganized thinking. During an interview on [DATE] at 1:41 p.m., Resident 4 was able to identify the day of week and the calendar date within one day, and his location. He indicated he wished to be a DNR (do not resuscitate) and that he had let staff know that he felt it was time to just go if it came to that. A Code Status Form, dated [DATE], provided by the Director of Nursing (DON) on [DATE] at 3:11 p.m., indicated the resident did not want CPR (cardiopulmonary resuscitation). The form was signed by the resident and indicated verbal consent had been received by the resident representative. The form was signed by an LPN as the facility representative and dated [DATE]. A Code Status Form, dated [DATE], provided by the DON on [DATE] at 3:11 p.m., indicated the resident wanted CPR. The form indicated verbal-unable to sign for resident signature. The resident representative signature line was blank. The form was signed by an LPN as the facility representative and dated [DATE]. A Multidisciplinary Care Conference Summary, dated [DATE], indicated under the care level review, that the resident was a DNR. A Social Service Update Assessment and Plan, dated [DATE], indicated the resident had moderate cognitive impairment and was alert and oriented with short-term memory loss, was able to understand others and voice needs and wants with no communication barriers. Under the assessment and plan section of the assessment, the form indicated the resident was a DNR. During an interview on [DATE] at 1:20 p.m., the Social Services Director (SSD) indicated she did not ask about code status during the assessment, but had thought Resident 4 was a DNR. During an interview on [DATE] at 2:20 p.m., the DON indicated she had spoken to the resident and he had indicated his code status choice as DNR. She presented a Code Status Form, dated [DATE], signed by the resident and witnessed by a facility representative. A current facility policy, revised ,d+[DATE], titled, CPR, provided by the DON on [DATE] at 2:21 p.m., included, but was not limited to, the following: Staff Policy Interpretation and Implementation: .4. The Code status form must be completed and signed by the resident, or the resident's representative, facility staff witness (and physician if applicable according to state laws) and scanned into the resident's medical record. 3.,d+[DATE](4)(A)(ii)

Based on observations, interviews and record reviews, the facility failed to ensure proper infection prevention and control strategies were followed to prevent the spread of COVID-19 when they failed to properly identify and communicate the positive for COVID-19 status for 3 of 8 residents reviewed for COVID-19 (Residents 7, 21 and 5). The facility also failed to disinfect a multi-resident use glucose meter after use for 1 of 1 observations of disinfecting glucose meters. Findings include: 1. During entrance conference, on 1/11/22 at 10:00 a.m., the Administrator indicated eight residents were positive for COVID-19 and were identified as being in the Red Zone with a red stoplight on their door, the Director of Nursing, the Assistant Director of Nursing were both positive for COVID-19, and two additional nurses tested positive this morning. Review of a resident bed listing, provided by the Administrator on 1/11/22 at 10:43 a.m., indicated the residents that were positive for COVID-19 resided in rooms 1, 2, 3, and 27. On 1/11/22 at 10:50 a.m., an observation of the room where Residents 7, 21, and 5 lived, indicated the room was identified as being in the Yellow Zone with a yellow stoplight on the door. During an observation of the COVID Unit, on 1/11/22 at 11:28 a.m., a staff member was donning PPE (Personal Protective Equipment) prior to entering room [ROOM NUMBER], she placed a surgical mask over her N95 mask. During an observation of the COVID unit, on 1/11/22 at 11:30 a.m., two other staff members donned PPE prior to entering room [ROOM NUMBER], and placed a surgical mask over their N95 mask. During an interview, on 1/11/22 at 11:34 a.m., LPN 9 indicated she had placed the surgical mask over her N95 prior to going into a resident's room that was positive for COVID-19 because she had been told their supply of N95's was low and they needed to conserve them. During an interview, on 1/11/22 at 11:17 a.m., Housekeeper 12 indicated to enter a room with a red stoplight, in addition to her eye protection, she would don a gown, gloves and place a surgical mask over her N95, when leaving the room she would doff the gown, gloves, and the surgical mask so she could continue to wear that N95 through out the facility for the remainder of her shift. a. Resident 7's clinical record was reviewed on 1/11/22 at 11:59 a.m. She resided in room [ROOM NUMBER]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident COVID Testing/Screening Assessment, dated 1/10/22 at 8:00 a.m., indicated she had been tested related to an outbreak and the results were positive for COVID-19. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 1/11/22, indicated she was in droplet isolation due to testing positive for COVID-19. Interventions included, but were not limited to, you will wear personal protective equipment as designated by the facility policy. b. Resident 21's clinical record was reviewed on 1/11/22 at 12:02 p.m. She resided in room [ROOM NUMBER]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident COVID Testing/Screening Assessment, dated 1/10/22 at 8:00 a.m., indicated she had been tested related to an outbreak and the results were positive for COVID-19. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 1/11/22, indicated she was in droplet isolation due to testing positive for COVID-19. Interventions included, but were not limited to, you will wear personal protective equipment as designated by the facility policy. c. Resident 5's clinical record was reviewed on 1/11/22 at 12:16 p.m. She resided in room [ROOM NUMBER]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident COVID Testing/Screening Assessment, dated 1/10/22 at 8:40 a.m., indicated she had been tested related to an outbreak and the results were positive for COVID-19. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 1/11/22, indicated she was in droplet isolation due to testing positive for COVID-19. Interventions included, but were not limited to, you will wear personal protective equipment as designated by the facility policy. During an interview, on 1/11/22 at 12:04 p.m., the Nurse Consultant indicated the facility should have placed a red stoplight on the door of room [ROOM NUMBER] to communicate that the residents in that room were positive for COVID-19. The facility's supply of N95's was low and they had been instructed to wear a surgical mask over their N95 mask to conserve the N95 mask use. From the Indiana Department of Health, COVID-19 LTC Facility Infection Control Guidance, updated 12/14/21 and indicated .Red Zone: Place all positive/symptomatic residents in RED Zone 2. During an observation of checking a resident's blood sugar, on 1/11/22 at 11:05 a.m., LPN 15 removed the glucose meter from the medication cart, entered the resident's room and used the glucose to meter to test the resident's blood sugar level. He returned to the medication cart, retrieved an alcohol prep pad and wiped the glucose meter, then placed the glucose meter back into the medication cart. During an interview, on 1/11/22 at 11:07 a.m., LPN 15 indicated alcohol prep pad or bleach wipe was approved to disinfect the glucose meter. Review of a current facility policy, titled Glucose Meter Cleaning & Testing, with a revised date of 2/21 and provided by the Nurse Consultant on 1/11/22 at 4:52 p.m., indicated Purpose: To prevent cross contamination and minimize risk of transmitting blood-borne pathogens between residents that require blood glucose monitoring .Cleaning meter after use, prior to using on next resident: STEPS: .5. Wipe entire external surface of the blood glucose meter with one germicidal wipe and ensure meter stays wet for 2 minute time period .6. Place clean meter on clean paper towel, in plastic cup or on a clean barrier to store until next use 3.1-18(b)

Based on record review and interview the facility failed to complete a discharge assessment for 1 of 3 residents reviewed for discharged . (Resident 14) Findings include: The clinical record for Resident 14 was reviewed on 2/11/20 at 1:59 p.m. [DIAGNOSES REDACTED]. A nurses progress noted, dated 1/20/2020 at 6:00 a.m., indicated the resident left facility for surgery. Medication list sent with the resident. A signed bed hold policy and transfer policy sent with the resident. The Minimum Data Set (MDS) assessment on 2/14/20 at 8:54 a.m., indicated discharge Assessment Reference Date (ARD) was 1/20/20, and was eleven (11) days overdue. During an interview on 2/14/20 at 9:02 a.m., the MDS Coordinator indicated she missed Resident 14's discharge assessment, and he did not return within 24 hours, the assessment should had been completed. She indicated the facility referred to the RAI manual for policy and procedures. 3.1-31(d)(1)

Based on record review and interview the facility failed to accurately assess a resident for a [MEDICAL CONDITION] diagnosis, proper transfer, and a wrong [DIAGNOSES REDACTED]. (Residents 70, 60, and 65) Findings include: 1. The clinical record for Resident 65 was reviewed on 3/26/19 at 11:43 a.m., [DIAGNOSES REDACTED]. The resident was selected to review for [MEDICAL TREATMENT] care during the investigation process. The resident had a 2/15/19, quarterly Minimum Data Set (MDS) assessment, which indicated the resident had been receiving [MEDICAL TREATMENT] while a resident of the facility. During an interview on 3/26/19 at 11:44 a.m., LPN 1 indicated the resident had never been on [MEDICAL TREATMENT] within the last 6 years that she had worked for this facility. During an interview on 3/28/19 at 11:38 a.m., the MDS coordinator indicted the MDS was coded by mistake. The Resident had never been on [MEDICAL TREATMENT]. 2. The closed clinical record for Resident 70 was reviewed on 3/27/19 at 3:30 p.m., [DIAGNOSES REDACTED]. Current signed physician's orders [REDACTED]. a. Send the resident to the emergency room for evaluation and treatment. The order originated on 2/2/19. A nurses progress note on 2/4/19 indicated resident had discharged to home from the hospital. The resident had a 2/2/19, discharge - return not anticipated Minimum Data Set (MDS) assessment, which indicated the resident had discharged to the community. During an interview on 3/28/19 at 10:15 a.m., the MDS coordinator indicated the resident's discharge MDS should have been coded discharged to acute hospital, not to the community. During an interview on 4/5/18 at 2:18 p.m., the MDS Coordinator indicated the resident's discharge to acute hospital MDS was a mistake. 3. The clinical record for Resident 60 was reviewed 3/27/19 at 10:57 a.m. He initially admitted to the facility 5/20/16. His [DIAGNOSES REDACTED]. Onset of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A quarterly Minimum Data Set MDS assessment, dated 3/8/19, lacked indication of a [MEDICAL CONDITION]. During an interview on 3/28/19 at 9:59 a.m., the MDS Coordinator indicated the resident's [MEDICAL CONDITION] should have been marked in question I.5900 on the latest MDS assessment, as in previous assessments. The facility utilizes the Resident Assessment Instrument (RAI) manual for resident assessment policy and procedures. NOT IN STATE RULE

Based on observation and interview, the facility failed to ensure all medications had an opened date, failed to ensure open mediation had a resident identifier and failed to ensure expired medication were removed from the carts for 2 of 3 medication carts reviewed (North 1 and South 1 carts). Findings include: During an observation of the Medication cart North 1 with QMA 27, on 6/4/18 at 9:28 a.m., the following was observed: 1. A 427 mL (milliliter) bottle of Milk of Magnesium (used for constipation) was open with no opened date 2. A 10 mL vial of [MEDICATION NAME] (used for blood sugar control) was open with no opened date 3. A 10 Ml vial of Humalog insulin (used for blood sugar control) was open with no opened date 4. A 15 mL bottle of Dry eye relief drops (used for dry eyes) was open with no opened date 5. Two 15 mL bottles of Natural Tears eye drops (used for dry eyes) was open with no opened date 6. A 15 mL bottle of [MEDICATION NAME] drops (used to minimize oral secretions) was open with no opened date 7. A 45 mL bottle of nasal spray (used for allergies [REDACTED]. 8. A 10 mL vial of [MEDICATION NAME] with an opened date of 4/20/18 9. A 300 tablet bottle of Aspirin 81 mg (a blood thinner) with approximately 30 tablets left with no resident identifier 10. A 120 tablet bottle of Calcium 600 mg plus Vitamin D (vitamin supplements) with approximately half of the tablets left with no resident identifier During an interview with QMA 27, on 6/4/18 at 9:30 a.m., she indicated all opened medication should have had an opened date on them, expired medications should have been removed from the medication carts and all open medications should have had a resident identifier on them. She did not know who the Aspirin and the Calcium belonged to. During an interview with RN 22, on 6/4/18 at 9:39 a.m., he indicated insulins expired 30 days after opening. During an observation of the Medication cart South 1 with QMA 29, on 6/4/18 at 10:03 a.m., the following was observed: 1. A 15 mL bottle of Natural Tears (used for dry eyes) was open with no resident identifier 2. A 250 tablet bottle of Stool Softener (used for constipation) was open with no resident identifier 3. A [MEDICATION NAME] Inhaler (used for asthma or other respiratory conditions) with 55 of 120 inhalations left was open with no opened date 4. A 15.8 mL bottle of Fluctiasone nasal spray (used for allergies [REDACTED]. 5. An Alvesco inhaler (used for asthma) with 10 of 40 inhalations left was open with no opened date 6. A Breo inhaler (used for [MEDICAL CONDITION] and asthma) with 11 of 30 inhalations left was open with no opened date 7. An Incruse inhaler (used for [MEDICAL CONDITION]) with 1 of 20 inhalations left was open with no opened date 8. Three 10 mL vials of [MEDICATION NAME](used to manage blood sugar) were open with no opened date 9. Six 10 mL vials of Humalog insulin (used to manage blood sugar) were open with no opened date 10. Two 10 mL vials of [MEDICATION NAME] (used to manage blood sugar) were open with no opened date 11. A 3 mL Basalgar insulin pen (used to manage blood sugar) was open with no opened date 12. A 10 mL vial of [MEDICATION NAME]with an opened date of 2/28/18 13. Two 10 mL vials of [MEDICATION NAME]with an opened date of 5/2/18 14. A 10 mL vial of [MEDICATION NAME]with an opened date of 5/5/18 15. A 3 mL Basaglar insulin pen with an opened date of 5/5/18 During an interview with LPN 30, on 6/4/18 at 10:17 a.m., she indicated the insulin [MEDICATION NAME] was expired 45 days after opening and the other insulins expired 60 days after opening them. She indicated all medication should have had an opened date on them. During an interview with the Corporate Nurse Consultant, on 6/4/18 at 10:19 a.m., she indicated insulins expired 28 days after being opened, all medication should have had an opened date on them and all medications should have had an opened date on them. A current Insulin Storage Recommendation chart was provided, on 6/4/18 at 10:55 a.m., by the corporate Nurse Consultant. This chart indicated, .Humalog Insulin was expired 28 days after opening .[MEDICATION NAME] was expired 28 days after opening . [MEDICATION NAME] Insulin was expired 28 days after opening .Basalgar Pen Insulin was expired 28 days after opening . A current policy titled Guidelines for the Storage of Medication was provided, on 6/4/18 at 10:55 a.m., by the Corporate Nurse Consultant. This policy indicated, .3. All discontinued, outdated or deteriorated medication will be destroyed or sent back to the pharmacy . A current policy titled SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES was provided, on 6/4/18 at 12:21 p.m., the the Cooperate Nurse Consultant. This policy indicated, .D. Check expiration date on package before administering any medication. When opening a multidose container place the date on the container . 3.1-25(k)(o)

Based on observations, record review, and interview, the facility failed to ensure residents received an appropriate Level II screening for 1 of 2 residents reviewed for Pre-Admission Screening and Resident Review (PASRR) (Resident 45). Findings include: The clinical record for Resident 45 was reviewed on 6/6/18 at 9:30 a.m. [DIAGNOSES REDACTED]. A PASRR (Pre-Admission Screening and Resident Review) Level I certification, dated 10/8/13, was reviewed 6/8/18 at 9:37 a.m., and indicated the resident had [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. A physician's orders [REDACTED]. During an interview on 6/7/18 at 11:10 a.m., the Social Services Director indicated there was no paper Level II documentation or assessment for this resident in the PASRR binder, and one had not been scanned into the facility's electronic records. During an interview on 6/7/18 at 2:11 p.m., the Health Facility Administrator (HFA) indicated this resident did not have a Level II assessment and the outcome of a PASRR Level I screen completed on 6/7/18 indicated that a PASRR Level II onsite evaluation was required.

Based on interview and record review, the facility failed to notify the Long Term Care Ombudsman of transfer/discharge for 1 of 5 resident records reviewed for discharge (Resident 55). Findings include: The clinical record for Resident 55 was reviewed, on 6/6/18 at 10:03 a.m. Her [DIAGNOSES REDACTED]. A discharge Return Anticipated MDS (minimum data set) assessment, dated 5/27/18, indicated the resident was discharged . An entry MDS, dated [DATE], indicated the resident returned to the facility. During an interview with the Social Service Director, on 6/6/18 at 11:24 a.m., she indicated she sent monthly notifications to the Ombudsman for transfer/discharge notifications. She provided a copy of the (MONTH) (YEAR) notifications to the Ombudsman. She indicated Resident 55 was not on the list of notification, she was missed on the list. During an interview with the Administrator, on 6/7/18 at 8:45 a.m., she indicated the resident did not exhaust her five day bed hold, so the facility did not consider her discharged . A current policy titled Notice of Transfer or Discharge was provided by the DON, on 6/8/18 at 9:37 a.m. This policy indicated, When a resident is temporarily transferred in an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer or discharge must be provided to the resident and resident representative as soon as practicable .Copies of notices for emergency transfers must also be sent to the ombudsman . 3.1-12(a)(6)(A)(iv)

Based on interview and record review, the facility failed to obtain a discharge order for 1 of 3 resident records reviewed for discharge (Resident 70). Findings include: The clinical record was reviewed for Resident 70, on 6/7/18 at 1:31 p.m. She was admitted on [DATE] and was discharged on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record lacked an order for [REDACTED].>A discharge MDS (minimum data set) assessment, dated 3/31/18, indicated she was cognitively intact. A care plan, dated 9/25/17, indicated she planned to discharge to her desired setting. Interventions included, but were not limited to: resident participation of discharge planning. During an interview with the DON (Director of Nursing), on 6/8/18 at 9:56 a.m., she indicated the order for discharge was not in the clinical record at the time the resident discharged . A current policy titled Notice of Transfer or Discharge was provided by the DON, on 6/8/18 at 9:37 a.m. This policy indicated, .c. Documentation from the physician when .ii. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility . 3.1-12(a)(5)(A)

Based on record review and interviews, the facility failed to ensure the residents were made aware of information and contact information for the State Long Term Care Ombudsman program, for 4 of 4 residents interviewed in the resident council meeting. (Resident 30, 13, 122, and 7) Findings include: During a Resident Council meeting on 06/06/18 at 10:57 a.m. Resident's 7, 13, 30, and 122 indicated they did not know what or who the Ombudsman was, or why one would contact this person. During an interview on 06/06/18 at 11:33 a.m., the Activities Director (AD) indicated residents had been generally quiet during Resident Council, so she has run the monthly meetings. The AD also indicated the residents knew where the Long Term Care Ombudsman contact information was located in the facility, and it is had been discussed in Resident Council meetings. A review of the Resident Council meeting minutes for March, April, and (MONTH) (YEAR), was conducted on 6/6/18 at 1:52 p.m. A review of the area's Long Term Care Ombudsman position's purpose or contact information was not included in the minutes. 3.1-4(j)(3)(C)

Based on observations, interview, and record review, the facility failed to ensure the head of the bed was elevated degrees during feeding through a gastrostomy tube (a tube [DEVICE] that delivers nutrition directly into the stomach) for 1 of 2 residents reviewed for receiving [MEDICATION NAME] feedings (Resident 37). Findings include: During an observation on 6/4/18 at 10:30 a.m., Resident 37 was receiving her [DEVICE] feeding while in bed flat on her back with her head raised up against a pillow. The foot of the bed was slightly elevated. During a random observation on 06/05/18 at 2:37 p.m., the resident was sitting in a Broda chair. Resident was not receiving a [DEVICE] feeding at this time. The resident did not respond to her name. A rolled-up towel was at her neck to help position her head. Her arms were contracted and held against chest. The clinical record was reviewed for Resident 37 on 6/6/18 at 2:10 p.m. [DIAGNOSES REDACTED]. A comprehensive care plan for a gastrostomy tube related to dysphagia completed 5/9/18, was reviewed on 6/6/18 at 2:10 p.m., and included, but was not limited to, an intervention of The head of my bed will be elevated to at least 30 degrees during and at least one hour after infusion of feeding. During an interview on 6/4/18 at 10:49 a.m., the DON indicated the head of bed should definitely be elevated 30 degrees. physician's orders [REDACTED]. A policy titled, Gastric Tube Feeding via Continuous Pump, was provided by the RN consultant on 6/6/18 at 2:10 p.m. Item 4 under Procedure, indicated, Always keep a resident receiving a continuous feeding, in semi-Fowler's position or higher. 3.1-35(a)

Based on observation, interview and record review, the facility failed to accurately code resident status for 1 of 1 records reviewed for restraints (Resident 35). Findings include: The clinical record for Resident 35 was reviewed, on 6/5/18 at 10:21 a.m. His [DIAGNOSES REDACTED]. A 30 day MDS (minimum data set) assessment, dated 4/18/18, indicated he was cognitively intact and he required the use of a trunk restraint less than daily. The clinical record lacked a care plan that addressed the use of a truck restraint or a physician order [REDACTED].>During an interview with RN 22, on 6/5/18 at 11:12 a.m., he indicated the resident did not use a trunk restraint of any kind. During an interview with MDS Coordinator 2, on 6/5/18 at 11:29 a.m., she indicated the resident did not require the use of a restraint and the MDS was coded inaccurately.

Based on interview and record review, the facility failed to attempt a gradual dose reduction of psychoactive medications for 2 of 5 residents reviewed for unnecessary medications (Resident 16 and 55). Findings include: 1. The clinical record for Resident 16 was reviewed, on 6/5/18 at 11:38 a.m. Her [DIAGNOSES REDACTED]. An annual MDS (minimum data set) assessment, dated 3/23/18, indicated she was severely cognitively impaired with no depression. She required the use of an anti-psychotic and an anti-depressant medication. A care plan, dated 8/11/15, indicated she received an antidepressant medication. Interventions included, but were not limited to: allow her to express her feelings, encourage activities, receive medications as ordered, observe for any changes in depressive symptoms and report any side effects. A care plan, dated 8/11/15, indicated she required the use of an anti-psychotic medication. Interventions included, but were not limited to: allow her to participate in decisions, medicate as ordered, comfort when needed and remind her of the importance of following physician orders. A physician order, dated 3/12/16, indicated she was to receive [MEDICATION NAME] (anti-depressant)150 mg daily. A physician order, dated 8/5/15, indicated she was to receive [MEDICATION NAME] (anti-depressant)10 mg daily. A physician order, dated 5/11/17, indicated she was to receive [MEDICATION NAME] (anti-psychotic)10 mg at bedtime. An Interdisciplinary Psychopharmacological Review note, dated 12/14/17, lacked any information that a gradual dose reduction was attempted or that a reduction was contraindicated per a Physician note. It indicated he resident was adjusting well and she was coming out of her room more often. An Interdisciplinary Psychopharmacological Review note, dated 2/15/18, indicated no dose reduction had been attempted. It was recommended to reduce the [MEDICATION NAME] at this time. The resident voiced little interest/pleasure in doing things and feeling tired and having little energy on her PHQ9 (depression screening). No dose reduction was ordered. A physician progress notes [REDACTED]. her spouse most of the time. A pharmacy review note, dated 4/18/18, indicated a recommendation to evaluate [MEDICATION NAME] for a GDR (gradual dose reduction). An Interdisciplinary Psychopharmacological Review note, dated 4/19/18, indicated no gradual dose reduction was attempted. It was recommended to reduce the [MEDICATION NAME] at this time. The resident had a behavior of resisting to take a shower on 3/6/18. The resident had a behavior of repetitive verbalization and repetitive questions on 4/6/18. Due to these two behaviors, no dose reduction was ordered. A physician progress notes [REDACTED]. During an interview with LPN (Licensed Practical Nurse) 33, on 6/6/18 at 9:29 a.m., she indicated the resident did not tend to have any frequent behaviors. The resident asked about her mom at times and had severe confusion. She did not have any behaviors for awhile. She was pleasant and always thought she had a cold. She recently lost her husband and had been coping quite well. During an interview with the DON (Director of Nursing), on 6/6/18 at 9:44 a.m., she indicated the interdisciplinary team met monthly to discuss GDR recommendations. The resident's husband passed away in (MONTH) of (YEAR) and they were room mates. She did not have any behavior documentation to support not attempting a GDR for the resident. During an interview with the Social Service Director, on 6/6/18 at 10:46 a.m. She indicated the resident was due for her first GDR in (MONTH) of (YEAR), at this time the interdisciplinary team (including the physician) decided to give her a 6 month grace period due to the death of her spouse. 2. During a random observation, on 6/4/18 at 1:46 p.m., Resident 55 was in her room visiting with a family member. She interacted appropriately and was pleasant. No behaviors were noted during this observation. The clinical record for Resident 55 was reviewed, on 6/6/18 at 10:03 a.m. Her [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], indicated she had mild cognitive impairment. She required the use of insulin injections, antipsychotic medications and antidepressant medications. A care plan, dated 3/2/16, indicated she received an anti-depressant medication. Interventions included, but were not limited to: administer medication as ordered, encourage to communicate with her husband, encourage to share feelings and monitor and report any changes in mood/behavior. A physician order, dated 12/3/13, indicated she was to receive Duloxetine (anti-depressant) 60 mg daily. The clinical record lacked any dose adjustments noted. A Social Service Behavior note, dated 1/24/18, indicated she had a behavior of rejecting care. The note lacked information on what kind of care was being attempted. A Social Service Behavior note, dated 2/23/18, indicated she had a behavior of refusing medication. She was re-approached and took medication as ordered. A Social Service Behavior note, dated 3/26/18, indicated she had a behavior of being resistant to care. The note lacked information on what kind of care was being attempted. A Social Service Behavior note, dated 4/16/18, indicated she had a behavior of rejecting care. The note lacked information in what kind of care was being attempted. During an interview with the Corporate Nurse Consultant, on 6/6/18 at 1:14 p.m., she indicated there were no further records to provide as to why there was no gradual dose reduction attempted for the resident. A current policy titled, PSYCHOACTIVE MEDICATION/GRADUAL DOSE REDUCTION POLICY, was provided by the DON. This policy indicated, . POLICY: To ensure gradual dose reduction attempts are made unless contraindicated .PR[NAME]EDURE: 4. Gradual dose reductions will be attempted unless contraindicated . 3.1-48(a)(b)(2)

A. Based on observation, interview and record review, the facility failed to place residents nebulizer mouth piece in clean dated plastic bag for 1 of 4 residents receiving nebulizer treatments B. Based on observation, interview, the facility failed to administer medication in a sanitary manner for 2 of 6 medication observations. Findings include: A. Observation on 6/4/18 at 9:29 a.m., Resident 56's nebulizer mask was sitting on top of nebulizer machine without being in a plastic bag. Observation on 6/4/18 at 1:54 p.m., Resident 56's nebulizer mask was sitting on top of nebulizer machine without being in a plastic bag. The record for Resident 56 was reviewed on 6/4/18 at 3:08 p.m., [DIAGNOSES REDACTED]. Current signed physician's orders [REDACTED]. a. [MEDICATION NAME] Nebulization Solution (respiratory medication) 2.5 mg. inhale one vial orally every 4 hours as needed for shortness of breath. The order originated on 5/2/18. Review of the current facility policy, revised 9/17 , titled Nebulizer Therapy provided by the Director of Nursing on 6/8/18 at 9:52 a.m , included, but was not limited to, Policy: It is the policy of his facility to provide treatment an service to the resident, requiring aerosolized medications, by trained qualified nurses in a manner that is safe and adheres to infection control practices. PR[NAME]EDURE: . .12. Dissemble the nebulizer and T-piece and rinse with tap water. Reassemble nebulizer and pace in plastic bag that is clean and dated. .15. Nebulizer is to be rinsed after leach use. 16. Nebulizer is to be kept in a dated plastic bag when not un use. B. During medication observation on 6/7/18 at 9:37 a.m., QMA 1 was observed placing her index finger inside of a medication cup to lift it off a stack of cups. During an interview on 6/7/18 at 10:00 a.m., the QMA indicated she should not have picked up the medication cup in a manner that her finger touched the inside of the cup. During an interview with the DON (Director of Nursing), on 6/4/18 at 2:17 p.m., she indicated she expected infection control practices of the floor nurses and QMAs (Qualified Medication Assistants). The cup was a barrier and they should be handled in a manner in which fingers did not touch where the medications/pills would have touched. A current policy titled SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES was provided by the Corporate Nurse Consultant, on 6/4/18 at 12:21 p.m. This policy indicated, .G. Use a barrier to carry medication into resident's room. This will serve as a barrier . 3.1-18(a)

Based on interviews and record reviews, the facility failed to ensure residents were aware of, and understood, their rights and responsibilities during their stay, for 2 of 4 residents interviewed in the resident council meeting. (Resident 7 and Resident 122) Findings include: During a Resident Council meeting on 06/06/18 at 10:57 a.m., the following concerns were noted: a. Resident 7 indicated she could not recall any review of residents' rights by facility staff. b. Resident 122 indicated he knew where residents' rights were posted in the facility because he had seen them himself, but no staff member had reviewed the rights with residents during council meetings. During an interview on 06/06/18 at 11:33 a.m., the Activities Director (AD) indicated residents had been generally quiet during Resident Council meetings, so she has run the monthly meetings. She included a Residents' Right across the top of each monthly activity calendar distributed to residents, and had discussed that right at the corresponding meeting. A review of the Resident Council meeting minutes for March, April, and (MONTH) (YEAR) was conducted on 6/6/18 at 1:52 p.m. No review of any residents' rights were included in the minutes. A review of the facility's monthly Activity calendar for (MONTH) (YEAR), was reviewed on 6/6/18 at 1:52 p.m. Across the top, it read, You have the right .To be treated in a way and environment that promotes maintenance and enhance (sic) of every resident's quality of life.

Based on interview and observation the facility failed to post correct nursing staff information for 1 of 6 days of the survey. Findings include: During initial tour on 6/3/18 (Sunday) at 3:08 p.m., the facility daily staffing numbers was dated for 6/1/18 (Friday). An interview on 6/8/18 at 8:45 a.m., the Administrator indicated she was not sure who was responsible for insuring the posting was changed on the weekends. Review of the current facility policy, revised 4/17, titled ADMISTRATIE PSOTING DIRECT CARE DALY STAFFING NUMBERS provided by the Director of Nursing on 6/8/18 at 9:37 a.m., included, but was not limited to, Policy: This facility will post, on a daily basis prior to each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: . .1. Prior to the beginning of each shift, the number of licensed nurses (RNs and LPNs) and the number of unlicensed nursing personnel (i.e.:CNAs) who provide direct care to residnet's will be posted. .3. At the beginning of each shift, the shift supervisor will compute the number of nursing staff on duty and record the information on the Report of Nursing Staff Directly Responsible for Resident Care form. Such for will be posted in designated locations in such a manner that it can be easily seen and read.

Based on interview and record review, the facility failed to notify the physician regarding dietary recommendation and/or provide dietary interventions for a nutritionally at risk resident with ongoing weight loss for 1 of 5 residents reviewed for weight loss and nutrition (Residents #K). This deficient practice resulted in Resident #K losing 17.1 pounds within 29 days of admission. Findings include: 1. Resident #K's closed clinical record was reviewed on 6/16/16 at 1:21 p.m. Resident #K's [DIAGNOSES REDACTED]. Resident #K was readmitted to the facility on [DATE]. Resident #K's 4/4/16, admission weight was 119.7 lbs. Resident #K had a 4/4/16, admission order for Ensure (a high protein and high calorie supplement) 2 times daily. Resident #K had a current, 4/12/16, care plan problem/need which indicated I am at risk for malnutrition, I have a hx (history) of periods of nausea which is normal for me. I receive oral supplements. This care plan problem was created 6/5/15, during a previous stay at this long term care facility. The goal to this problem was My weight will maintain 115-125# (pounds). Approaches to this problem originated on 6/5/15 and were never revised during her stay in the facility. Approaches to this problem included, but were not limited to, I will receive my supplements as recommended and Monitor intakes, weights, labs, skin condition reports. A review of Resident #K's weight record for 4/4/16 to 5/2/16, included but was not limited to, the following: 4/4/16, admission weight 119.7 lbs. 4/10/16, weight 112.8 lbs, which was a weight loss of 6.9 lbs in one week. This was a weight loss of greater than 5%. 4/14/16, weight 107.6 lbs, which was a weight loss of 12.1 lbs in the 10 days following admission. This was a weight loss of 10%. 4/19/16, weight 106.2 lbs, which was a weight loss of 13.5 lbs in the 15 days following admission. This was a weight loss of greater than 10%. 4/27/16, weight 104 lbs, which was a weight loss of 15.7 lbs in the 23 days following admission. This was a weight loss of approximately 13%. 5/2/16, weight 102.6 lbs, which was a weight loss of 17.1 lbs in the 29 days following admission. This was a weight loss of approximately 14%. Resident #K's clinical record included, but was not limited to, the following Resident Progress Notes related to complaints of nausea and/or poor appetite: 4/18/16, 5:13 p.m., note indicated an as needed medication was given for nausea and vomiting. The medication was effective. 4/22/16, 1:56 p.m., note indicated an as needed medication was given for nausea and vomiting. The medication was effective. 4/26/16, 10:36 a.m., note indicated complained of nausea when first awakened. 4/28/16, 11:01 a.m., note indicated the resident continued to have complaints of nausea and vomiting with low meal intake. 4/30/16, 1:50 p.m., note indicated complained of nausea with no appetite. 5/1/16, 9:54 a.m., late entry note indicated the resident continued to feel nauseous and have poor appetite. 5/2/16, 10:36 a.m., note indicated the resident continued to have complaints of nausea. The resident continued to have a poor appetite. The clinical record indicated the doctor was notified of Resident #K's weight loss and/or nausea on the following dates and times: a. 4/12/16, 2:39 p.m., Resident has had a 9.9% weight loss in 20 days per RD (Registered Dietitian). (Doctor's name) and family notified. No dietary intervention to increase caloric intake was initiated at this time. b. 4/18/16, 7:42 a.m., Resident shows 4.8 pound weight loss in one day. Re-weighed. (Doctor's name) and family notified. No dietary intervention to increase caloric intake was initiated at this time. c. 4/19/16, 2:25 p.m., Resident has had 9.9% weight loss in 20 days per RD. (Doctor's name) and family notified. No dietary intervention to increase caloric intake was initiated at this time. d. 4/22/16, 1:50 p.m., The doctor was in the facility and decreased Resident #K's pain medication and gave a new order for [MEDICATION NAME] 5 mg (a medication used to treat heartburn and stomach upset) before meals and at bedtime. No dietary intervention to increase caloric intake was initiated at this time. e. 4/26/16, 2:33 p.m., Resident has had a 14.9% weight loss in 34 days, 10.9% weight loss in 3 weeks, and a 0.6 lb weight loss in 1 week per RD. (Doctor's name) and family notified. No dietary intervention to increase caloric intake was initiated at this time. f. 4/28/16, 11:10 a.m., resident continue (sic) to have nausea and vomiting, low intake on meals. (Doctor's name) aware, and social services to do mood assessment. No dietary intervention to increase caloric intake was initiated at this time. g. 4/29/16, 2:16 p.m., (Doctor's name) here. Based on score of depression scale completed by social services, received new orders for [MEDICATION NAME] 10mg daily. Pharmacy and family notified. No dietary intervention to increase caloric intake was initiated at this time. Resident #K's Nutritional Supplement consumption record for 4/4/16 to 5/2/16 indicated the resident consumed 75% or more of her supplement (Ensure) 41 of 50 times when her supplement was documented as offered. The record indicated Resident #K received her first Ensure supplement on 4/5/16. The record indicated Resident #K was offered ensure no more than 2 times daily during her entire stay in the facility. Resident #K's Meal Consumption records for 4/4/16 to 5/2/16 indicated: a. The resident consumed 0-25% of her food 36 of 83 of the documented meals. b. The resident consumed 26-50% of her meals 11 of 83 times meals were offered. c. The resident refused 11 of 83 documented meals. d. This resulted in 61 of 83 documented meals with a consumption of 50% or less. Resident #K had a 4/19/16, Dietary Progress Note which indicated .10.5% weight loss in 27 days .last week had a KUB (test to ensure no blockage in the digestive system) to rule out further small bowel blockage .recommended increasing Ensure frequency .will talk about accepting (brand name) yogurt. author Regional Dietitian. The clinical record lacked any documentation regarding the physician being notified of the 4/19/16, dietary recommendation to increase Ensure. Ensure was never increased during the residents stay in the facility. Yogurt was added to the tray card for breakfast with no indication of the date added. A physician's orders [REDACTED].#K's diet. The resident's record lacked any location for the specific consumption of the added yogurt. The yogurt consumption was calculated into total breakfast consumption. There was no method to determine if the yogurt was a successful intervention. Resident #K had a 5/2/16, Late Entry - Dietary Progress Note which indicated the resident had a 14.3% weight loss within 28 days of admission. The resident had nausea and vomiting and was sent to the hospital and admitted on this date. During a 6/22/16, 9:16 a.m., interview, the Dietary Manager indicated the nursing department contacted the resident's physician following the Nutritionally at Risk (NAR) committee meeting and informed the doctor of the committee's concerns and recommendations. She indicated the committee consisted of the Dietary Manager, Wound Nurse, Director of Nursing (DON) and usually another facility nurse. She additionally indicated she added yogurt to Resident #K's meal card and did not document when. She indicated she did not realize adding yogurt to the dietary meal card would not develop a place to document the yogurt's specific consumption. During a 6/22/16, 9:07 a.m., interview, the North Hall RN Unit Manager indicated the nursing department, usually the Unit Manager, would notify the resident's physician if a resident had weight loss or a pattern of poor consumption. She indicated as a rule she notified the doctor for a 2 lb weight change in a day and a 5 lb weight change in a week. A 5/2/16, 5:07 p.m., Hospital Nursing-Assessment indicated Resident #K had nausea for a long time. A 5/3/16, 3:04 p.m., hospital Nutrition Suggestions indicated Resident #K had admitted with complaints of nausea. The resident was receiving Ensure Complete during her past admission and it would be ordered again at this admission for additional calories and protein. The resident's weight on 5/3/16 was 115.7 lbs. A 5/4/16, 3:38 p.m., Hospital Nutrition Note indicated Resident #K had a primary nutritional [DIAGNOSES REDACTED]. Pt (patient) is on clear liquid diet with poor intake. Pt receiving Ensure Elive and states that she likes them; she is drinking most of it . Resident #K's weight was 115.7 lbs on 5/3/16 and 121.9 lbs on 5/5/16. A 5/9/16, Hospital Discharge Note indicated Resident #K was admitted to the hospital on [DATE] and had the following discharge [DIAGNOSES REDACTED]. 2. Dehydration with acute [MEDICAL CONDITION]. 3. [MEDICAL CONDITIONS]. 4. Hypertension. During her stay, the resident was treated with antibiotics and IV fluids. A current, 12/2014, policy titled WEIGHTS, provided by the RN Consultant on 6/21/16 at 10:45 a.m., indicated the following: Policy: In order to ensure effectiveness of interventions and evaluate changes if necessary, residents will be weighed monthly and/or weekly . 9. Dietary recommendations will be acted upon in a timely manner .13. The Registered Dietitian Consultant will assess all significant weight changes at their next scheduled visit and make recommendations for interventions. This federal tag relates to Complaint IN 643. 3.1-46(a)(1)