Every finding on record at River Terrace Health Care Center

Based on interview and record review, the facility failed to ensure adequate staffing levels were maintained to meet the personal care needs related to transfers for 2 of 6 residents reviewed (Resident B and Resident A).Findings include: In a confidential interview, on 7/27/26 at 8:20 AM, the interviewee indicated the facility was extremely short staffed on Saturday, 7/25/26 and Sunday, 7/26/26. The interviewee indicated residents who required the assistance of 2 staff members had to stay in bed all day. The interviewee indicated a resident fell trying to transfer themselves to the bathroom.1. In an interview, on 8/18/26 at 2:09 PM, Resident B indicated they had to wait for a long time on July 26th to get out of bed. Resident B indicated the aides routinely turned their call lights off to go get a 2nd person to operate the Hoyer lift. Resident B indicated they had attempted to transfer themselves to the bathroom on 7/26/26 due to waiting for help. Resident B indicated they had a bowel movement in their pants and fell trying to get to the bathroom. Resident B indicated it was hard to get 2 aides together to operate their Hoyer lift almost every day.Resident B's record was reviewed on 8/18/26 at 2:35 PM. Diagnoses included diabetes, peripheral vascular disease and age-related physical debility.Resident B's quarterly Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 14 (no cognitive loss). The MDS indicated Resident B was dependent upon staff for transferring, mobility and toileting.Resident B's care plan, dated 4/28/25, indicated the resident required a Hoyer lift with 2 staff members for transfers.A progress note, dated 7/26/26 at 2:51 PM, indicated Resident B had been found in front of the toilet with bowel movement on their clothing. Resident B had indicated they could not wait any longer for help.2. In an interview, on 8/18/26 at 2:14 PM, Resident A indicated they frequently had to wait about 45 minutes to be transferred from their bed with the Hoyer lift. Resident A indicated on 7/26/26 they had to stay in bed after lunch and miss bingo due to the inadequate number of aides available to get them back up. Resident A indicated the long wait for a second staff member to operate the Hoyer lift happened almost every day.Resident A's record was reviewed on 8/18/26 at 2:45 PM. Diagnoses included diabetes, obstructive sleep apnea and chronic kidney disease.Resident A's quarterly MDS, dated [DATE], indicated their BIMS score was 15 (no cognitive loss). The MDS indicated Resident A was dependent on staff for transferring, mobility and toileting.Resident A's care plan, dated 1/16/24, indicated the resident required 2 staff members using a Hoyer lift for transfers, 2 staff members to position and turn in bed, and up to 2 staff members for toileting.In an interview, on 8/18/26 at 3:10 PM, Licensed Practical Nurse (LPN) 3 indicated there were usually 2 staff members in the memory care unit (a QMA and an aide) and 2 staff members in the rehab unit (a nurse and an aide). LPN 3 indicated there were usually 4 staff members of a nurse or QMA and 3 aides on the healthcare unit. LPN 3 indicated there were many residents in the healthcare unit that required the assistance of 2 staff members. LPN 3 indicated residents must wait longer if 2 aides are on the unit and both aides are in a resident's room who requires 2 staff to assist.In an interview, on 8/18/26 at 3:35 PM, Qualified Medication Aide (QMA) 2 indicated residents who required mechanical lifts had to stay in bed on Saturday, 7/25/26 and Sunday, 7/26/26 due to not having enough staff. QMA 2 indicated Hoyer lifts required 2 staff members to operate. QMA 2 indicated most of the healthcare unit residents required 2 staff members to assist for transferring and toileting. QMA 2 indicated the nurse had notified management of the need for more aides. QMA 2 indicated nursing management came in on 7/25/26 at 2:00 PM. QMA 2 indicated there were 6 residents that required 2 staff members for Hoyer lift transfers in the facility.In an interview, on 8/18/26 at 3:50 PM, the Director of Nursing (DON) indicated QMAs were pulled to work as aides to cover call offs.The facility as worked schedule, dated 7/1/26 through 7/31/26, indicated 3 nurses, 2 Qualified Medication Aides (QMA) and 13 Certified Nurse Aides (aides) had worked on 7/25/26 throughout the 24 hour period. The schedule, dated 7/26/26, indicated 7 nurses, 1 QMA and 12 aides had worked throughout the 24 hour period.The Facility Assessment, (a tool used to determine what resources, including nursing staff, are necessary to care for residents) (FA), dated 4/23/26, indicated the facility's average daily census was 54 residents.The FA indicated 95% to 100% of residents required assistance with transfers, bathing and toileting.The FA indicated the average Certified Nurse Aide (aide) to resident ratio was 1 to 10.The FA did not indicate how many residents required assistance by 2 aides for transferring, bathing and toileting.The FA did not indicate how many residents required assistance by 2 aides for Hoyer lift transfers.The FA indicated the facility's calculated hours per resident per day (hours worked by aides in a 24-hour period divided by the number of residents) for aides was 2.35.On 8/18/26 at 4:35 PM, the DON provided timecards dated 7/25/26 and 7/26/26.The timecards, dated 7/25/26, indicated 5 nurses, 2 QMAs and 11 aides had worked for the 24-hour period.The timecards, dated 7/26/26, indicated 7 nurses, 2 QMAs and 8 aides worked for the 24-hour period.A calculation of timecard hours for 7/25/26, indicated there were 105.5 aide hours worked with a census of 58, and so the CNA to resident ration was 1.81. This would be a difference of 31.32 hours or 4 CNAs for the 24 hour period.The timecard hours indicated the hours per president per day for 7.75 aide hours worked for a census of 58 was 1.28 on 7/26/26.This would be a difference of 62.06 hours or 7 CNAs over the 24 hour period. In an interview, on 8/18/26 at 5:05 PM, the Administrator indicated the FA hours per resident per day would not match the worked hours due to the facility opening the rehabilitation unit after the FA was updated. She indicated the FA had not been updated to reflect staffing need for the new rehabilitation unitA current facility policy, revised 10/2017, indicated facility staffing for direct care staff would be determined by the residents' needs reflected in each resident's care plan.A current facility policy, dated 11/15/19, indicated the facility would ensure 2 staff members are present during Hoyer lift transfers.This citation is related to Intake 3117407410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on interview and record review the facility failed to ensure residents received bathing at least 2 times a week (Resident B, Resident C) and physician orders were followed for 2 of 3 residents reviewed (Resident C, Resident D).Findings include:Resident B's record was reviewed on 7/6/26 at 10:43 AM. Diagnoses included type 2 diabetes mellitus and chronic obstructive pulmonary disease.Point of Care charting, dated 5/29/25 - 6/15/26, indicated Resident B did not receive bathing from 5/29/26 to 6/15/26.Nursing notes, dated 5/29/26 - 6/15/26, did not show any bathing refusals from Resident B.2. Resident C's record was reviewed on 7/6/26 at 12:24 PM. Diagnoses included type 2 diabetes mellitus, neuromuscular dysfunction of the bladder and hyperlipidemia.Point of Care charting, dated 6/1/26 - 7/5/26, indicated Resident C only received 1 shower/bath from 6/29/26 - 7/4/26.Nursing notes, dated 6/29/26 - 7/4/26 did not show any bathing refusals from Resident C.During an interview, on 7/6/26 at 1:27 PM, the Director of Nursing (DON) indicated she did not have any documentation for bathing or refusals for Resident B from 5/29/26 - 6/15/26 or Resident C's 2nd weekly bathing offer from 6/29/26 - 7/4/26. The DON indicated residents are offered at least 2 showers/bathes a week.3. Resident C's Medication Administration Record (MAR), dated 6/1/26 - 7/5/26, was reviewed. The MAR indicated the following:An active order, dated 5/17/26, indicated to monitor and record character of Resident C's urine every shift for urinary catheter. There was no documentation for the following dates and shifts: 6/1/26: 1st shift 6/8/26: 1st and 3rd shift 6/11/26: 1st shift 6/12/26: 1st and 2nd shift6/13/26: 1st, 2nd and 3rd shift6/14/26: 2nd shift6/15/26: 1st shift6/18/26: 2nd shift6/22/26: 1st shift6/23/26: 1st and 2nd shift6/26/26: 2nd and 3rd shift6/28/26: 1st shift6/30/26: 1st shift7/1/26: 3rd shift7/2/26: 2nd shift7/3/26: 1st and 2nd shift7/4/26: 2nd shiftAn active order, dated 5/22/26, indicated to obtain daily weights for Resident C for fluid overload. There was no documentation for the following dates: 6/1/26, 6/8/26, 6/13/26, 6/15/26, 6/22/26, 6/23/26 6/26/26, 6/28/26, 6/30/26.4. Resident D's record was reviewed on 7/6/26 at 11:26 AM. Diagnoses included congestive heart failure.Resident D's Medication Administration Record (MAR), dated 6/1/26 - 7/5/26, was reviewed. The MAR indicated the following:An active order, dated 1/29/26, indicated to monitor and record character of Resident D's urine every shift for urinary catheter. There was no documentation for the following dates and shifts: 6/8/26: 1st and 3rd shift6/9/26: 1st shift6/11/26: 1st shift6/12/26: 1st and 2nd shift 6/13/26: 1st and 3rd shift6/16/26: 1st shift6/17/26: 3rd shift6/18/26: 1st, 2nd and 3rd shift6/23/26: 1st, 2nd and 3rd shift6/24/26: 2nd and 3rd shift6/26/26: 2nd and 3rd shift6/27/26: 3rd shift6/28/26: 1st and 3rd shift6/30/26: 1st shift7/1/26: 3rd shift7/3/26: 1st shiftAn active order, dated 1/29/26, indicated to complete catheter care every shift. There was no documentation for following dates and shifts: 6/7/26: 1st shift6/12/26: 1st and 2nd shift6/13/26: 1st and 2nd shift6/14/26: 2nd shift6/18/26: 3rd shift6/23/26: 1st shift6/24/26: 3rd shift6/26/26: 1st and 2nd shift6/28/26: 1st shift6/30/26: 1st shiftAn active order, dated 6/11/26, indicated to obtain daily weights for Resident D for congestive heart failure. There was no documentation for the following dates: 6/12/26, 6/13/26, 6/14/26, 6/15/26, 6/16/26, 6/22/26, 6/28/26, 6/30/26 and 7/3/26.In an interview, on 7/6/26 at 10:01 AM, Certified Nursing Assistant (CNA) 2 indicated catheter care was documented by the nurse. CNA 2 indicated catheter care consisted of emptying the catheter bag, and cleaning around the tubing every shift. CNA 2 indicated residents were weighed monthly or based on their orders. CNA 2 also indicated residents were offered bathing assistance at least 2 times a week or as preferred.In an interview, on 7/6/26 at 10:17 AM, Licensed Practical Nurse (LPN) 3 indicated catheter care was documented by the nurse or qualified medication aide (QMA) every shift. LPN 3 indicated the nurse or QMA emptied the catheter bag and cleaned around the insertion site. LPN 3 indicated residents were weighed monthly or based on their orders. LPN 3 indicated catheter monitoring/care and specific weight orders were documented in the MAR. LPN 3 also indicated residents were offered bathing assistance at least 2 times a week or as preferred.During an interview, on 7/6/26 at 1:27 PM, the Director of Nursing (DON) indicated catheter monitoring/care and weights were completed per the physician order and documented in the MAR. The DON indicated when there was no documentation in the MAR then the orders were not completed.A current policy, last revised July 2017, titled Charting and Documentation, indicated treatment or services performed were documented in the resident's chart per physician orders and resident preferences including the time/date and the name/title of the person who provided the care.This citation relates to Intake 3045308 and 3049114.410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on a record review and interview, the facility failed to ensure discharge paperwork related to the bed hold policy was completed, for 1 of 3 resident reviewed. (Resident 30) Findings include: On 12/3/25 at 8:57 AM, Resident 30's record was reviewed. Medical diagnosis included Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing. A review of Resident 30's census list, indicated the resident was transferred out to the hospital, effective date 8/5/25 at 2:30 PM. A review of the nurse progress notes indicated the following: On 8/5/25 at 2:16 PM, the physician sent a text and gave a new order to send Resident 30 to the emergency room for hemoglobin of 5.2, resident was aware and in agreement with the plan. On 8/5/25 at 2:32 PM, Register Nurse (RN) 3, called the hospital to inform them Resident 30 was headed their way. RN 3 also tried calling the family but there was no answer and no option to leave a voicemail. There were no progress note to indicate the facility informed the family or resident of the bed hold policy.In an interview, on 12/3/25 at 9:59 AM, the Director of Nursing (DON) indicated she could not find any discharge paperwork for Resident 30. She indicated they just didn't have it. A current facility policy, Bed Holds and Returns, dated 10/22, was provided by the DON on 12/3/25 at 11:44 AM. The policy indicated .All residents/representatives are provided written information regarding the facility and state bed-hold polices, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these polices at least twice: notice 1: well in advance of any transfer( e.g. in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) This citation is related intake 26297673.1-12(a)(25)(26)

Based on observation, interview, and record review the facility failed to ensure labeling of open date for 1 of 1 carts reviewed. (Resident 29). Findings include: During an observation, on 01/07/25 at 9:38 AM, in the medication room with Qualified Medical Assistant 3 (QMA) and Registered Nurse 2 (RN), Resident 29's insulins were observed in a compartment labeled with his last name. The half full bottle of Humalog in the compartment was not labeled with an open date or any identifying information. RN 2 indicated there was no way to determine when the medication was opened, who it belionged to, and it would be discarded. A Glargine pen was labeled with an open date of 12/3/24. RN 2 indicated insulin is only good for 28 days after being removed from the refrigerator. The pen was 7 days past the 28 day expiration. RN 2 indicated the Glargine pen would be discarded. Resident 29's compartment also had a half full bottle of Lantus insulin without any labeling to indicate resident name or the opened date. RN 2 indicated there was no way to ensure when the medication was opened, who it bleonged to, and indicated the Lantus insulin would be discarded. During an interview, on 01/07/25 at 9:38 AM, QMA 3 indicated all meds were to be labeled with an open date, residents name, room number, and a discard date or expiration date. Resident 29's record review began on 01/06/25 at 11:13 AM. Resident 29's diagnoses included type 2 diabetes mellutis. Resident 29 had a physcian order for Humalog Humalog Kwik pen 100 units/ml per sliding scale four times per day. Resident 29 also had a physician order for Glargine pen 100 units/ml, inject 50units once daily, hold for blood sugar less than 120. Resident 29's Medication Administration Record (MAR) for Humalog Kwik pen indicated he received the insulin multiple times a day from January 1- January 7, 2025 after blood sugar checks at 8am, noon, 4pm, and 8pm. Resident 29's MAR for the month of January 2025 indicated he received Glargine insulin daily at 8am. A policy titled, Medication labels, dated 5/21/2018 and reviewed 5/20/2020 was received by the Administrator on 1/7/25 at 12:51PM. The policy indicated .1. The labels are permanently affixed to the outside of the prescription container. If the label does not fit it can be affixed to an outside container or carton, the resident's name, at a minimum, must be maintained directly on the actual product container. 2. Each prescription medication label includes: a. Residents name. b. specific directions for use e. prescriber's name. f. date dispensed. g. quantity of the medication h. expiration date of the medication i. name, address, and telephone number of dispensing pharmacy . 3.1-25(j)(m)(n)

Based on interview and record review the facility failed to document catheter output for 1 of 1 resident reviewed. (Resident 12) Findings include: Resident 12's record review began on 1/6/25 at 11:35AM, diagnoses included Neurospasmatic bladder. Certified Nursing Assistant (CNA) task charting indicated Resident 12 only had one entry for urinary catheter output on the following dates, times and amounts: 12/14/24 at 9:28PM 1200ml 12/21/24 at 1:59PM 901ml 12/23/24 at 9:59PM 600ml 12/25/24 at 1:59PM 1000ml 12/27/24 at 9:59PM 2001ml 12/28/24 at 9:35PM 1100ml 12/31/24 at 1:59PM 701ml 1/4/25 at 1:59PM 1000ml 1/5/25 at 7:37PM 1500ml 1/6/25 at 1:59PM 1000ml No other entries for each shift was available for review by the time of exit. Resident 12's physician order, dated 5/3/24, indicated to give Lasix 20mg, take 1 tabled in am with a start date of 5/6/24. In an interview, on 1/7/25 at 1:37 PM, the Director of Nursing (DON) indicated the importance of keeping track of urinary output of residents with a catheter ensured the first sign of issues were addressed. The DON indicated it was especially important with Resident 12 due to her use of a diuretic medication Lasix. The DON indicated the expectation was for catheters to be emptied at the end of each shift and during routine catheter care or when bag was half full as necessary. The DON indicated education would be required if there were not at a minimum of 2 entries every day for catheter output. In an interview, on 1/7/25 at 1:42PM, CNA 4 indicated Resident 12 always required at a minimum one emptying of her catheter bag on each shift she has worked. CNA 4 indicated she did not always have time to document the output and therefore the numbers may be inaccurate at times. A current policy and procedure titled, Output, Measuring and Recording dated as revised October 2010, provided by the Administrator on 1/8/25 at 11:05am indicated .The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period .Steps in the procedure 7. Carefully observe the level of urine in the graduate. Maintain eye level so that you can see the number reached by the level of urine. 8. Record the amount noted on the output side of intake and output record. 9. Record the time the output was measured. Documentation The following information should be recorded on the bedside intake and output record and/or in the resident's medical record: 1. The date and time the resident's urine was measured and recorded. 3. The amount of output . 3.1-50(a)

Based on observation, interview, and record review the facility failed to ensure refrigerator temperatures were monitored for 1 of 1 medication rooms reviewed. Findings include: During an observation, on [DATE] at 9:15 A.M., in the medication supply room the refrigerator temperature log was not available. The log provided for the month of February 2024 had no entries for the following: ,d+[DATE] days, ,d+[DATE] day and nights, ,d+[DATE] days and nights, ,d+[DATE] days and nights, ,d+[DATE] days and nights. The refrigerator temperature was checked with the result of 30 degrees. According to the website Americanbiotechsupply.com (supplier of of pharmacy rated refrigeration) indicated Medication refrigerator temperature guidelines should be between ,d+[DATE] degrees. temperatures outside this temperature zone could result in a decease in efficacy of medications stored in the refrigerator. During an interview, on [DATE] at 10:10 A.M., the DON indicated she knew the recording of temperatures were a problem. She indicated she made a binder to record and keep temperatures. She provided an undated quality improvement worksheet dated. She indicated she had just completed writing the worksheet. She further indicated it was an expectation for nursing to check and record the refrigerator temperature twice daily. A record review of the prior 5 months of temperature logs provided by DON on [DATE] at 10:20 A.M. indicated the following: [DATE] No entries for the following dates/shifts: ,d+[DATE], ,d+[DATE], and ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] days and nights ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] , ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] nights ,d+[DATE] days A policy and procedure titled, Unit Refrigerators, was provided by the administrator on [DATE] at 10:50 A.M. The policy addresses refrigerators for nourishment. The policy does not address refrigerators for medications as indicated by, 6. The dietary staff will be responsible to monitor and log the refrigerator temperature. The dietary staff do not have access to the locked medication refrigerator in the locked medication room. No other information was provided at time of exit. 3XXX,d+[DATE](m)

Based on interview and record review, the facility failed to ensure adverse side effects of psychotropic medications were monitored for 1 of 5 residents reviewed (Resident 18). Findings include: Resident 18's record was reviewed on 1/20/2023 at 10:30 AM. Diagnoses included Alzheimer's disease with early onset, major depressive disorder, single episode, unspecified, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, unspecified, major depressive disorder, recurrent severe without psychotic features, adverse effect of other antipsychotics and neuroleptics, subsequent encounter, unspecified dementia, unspecified severity, with agitation, major depressive disorder, recurrent, severe with psychotic symptoms, dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance, generalized anxiety disorder, restlessness and agitation. A brief interview for mental status assessment, dated 11/15/2022, indicated Resident 18 had score of 3 (severe cognitive impairment). 1. A current care plan indicated Resident 18 had a behavior problem related to major depressive disorder with behaviors such as sense of hopelessness and anxiety. The goal indicated Resident 18 would have no more than 2 episodes of anxiousness each week and would not have more than 2 episode per week of feeling hopeless or feeling down through the next review. The interventions included administer medications as ordered and monitor for and document side effects and effectiveness. A physician order, dated 8/3/2022, indicated to give Buspirone HCl 5 milligram (mg) tablet (a medication used to treat anxiety- nervousness), give 1 tablet by mouth 2 times a day related to anxiety disorder. A physician order, dated 8/3/2022, indicated to monitor the following due to antianxiety medication use: observe closely for significant side effects: sedation (a state of calm or asleep), drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Click Y (yes) if monitored and none of the above symptoms was observed. Click N (no) if monitored and any of the above symptoms was observed and select chart code other/see nurse's notes and record findings. There was no documentation found in the Nurses Notes (NN) regarding monitoring for adverse (bad) side effects of antianxiety medication. An MAR ( Medicayion Administration Record), dated December 2022, indicated Resident 18 was given the medication, Buspirone HCL 5mg tablet, 1 tablet two times each day at 8:00 AM and 8:00 PM. There was no documentation to indicate side effects of this medication were monitored. An MAR, dated January 2023, indicated Resident 18 was given the medication, Buspirone HCL 5mg tablet, 1 tablet two times each day at 8:00 AM and 8:00 PM on January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, and 22. On January 15 and 23, Resident 18 had only been give the 8:00 AM dose. There was no documentation indicating side effects of this medication were monitored. 2. A physician order, dated 10/8/2022, indicated to give Venlafaxine HCl ER 150mg extended release 24-hour capsule (a medication used to treat depression), give 1 capsule by mouth 1 time a day related to major depressive disorder, single episode, unspecified. A physician order, dated 8/3/2022, indicated to monitor the following due to antidepressant medication use: monitor for significant side effects: drowsiness, dry mouth, blurred vision, urinary retention (unable to pass urine), tachycardia (fast heart rate), muscle tremor, agitation, headache, skin rash, photosensitivity (skin sensitive to the sun/light), excess weight gain. Click N (no) if monitored and any of the above symptoms was observed and select chart code other/see nurse's notes and record findings. There was no documentation found in the MAR or in the Nurses Notes (NN) regarding monitoring for adverse side effects of antidepressant medication. An MAR, dated December 2022, indicated Resident 18 was given the medication, Venlafaxine HCl ER 150mg extended release 24-hour capsule, 1 capsule every day at 8:00 AM. There was no documentation indicating side effects of this medication were monitored. A MAR, dated January 2023, indicated Resident 18 was given the medication, Venlafaxine HCl ER 150mg extended release 24-hour capsule, 1 capsule every day at 8:00 AM on January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23. There was no documentation indicating side effects of this medication were monitored. 3. A current care plan indicated Resident 18 took psychotropic medications related to major depressive disorder with behaviors. The goal indicated Resident 18 would have no side effects from the use of antipsychotic medication through the next review. The interventions iadminister ncluded medications as ordered, monitor for and document side effects and effectiveness, consult with pharmacy, the medical doctor was to consider dosage reduction when clinically appropriate, monitor, record and report to the medical doctor side effects and adverse reactions of psychoactive medication: unsteady gait (walking), tardive dyskinesia (uncontrollable movements of the face and body), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations (thoughts of harming self), social isolation (not wanting to interact with others), blurred vision, diarrhea, fatigue, insomnia (unable to sleep), loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the resident), and social service visits as needed. A physician order, dated 12/17/2022, indicated Risperidone 0.25mg tablet (a medication used to treat psychosis, a mental disorder characterized by a disconnection from reality), give 0.5 (1/2) tablet by mouth 1 time a day related to major depressive disorder, recurrent, severe with psychotic symptoms. A physician order, dated 12/17/2022, indicated Risperidone 0.25mg tablet, give 1 tablet by mouth 1 time a day related to major depressive disorder, recurrent, severe with psychotic symptoms. A physician order, dated 8/3/2022, indicated antipsychotic medication use: observe closely for significant side effects: sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction (inability to sit still, involuntary muscle contractions, tremors, stiff muscles, and involuntary facial movements), weight gain, edema (swelling from retaining fluid), postural hypotension (blood pressure drop with position change), sweating, loss of appetite, urinary retention. Click Y (yes) if monitored and none of the above symptoms was observed. Click N (no) if monitored and any of the above symptoms was observed and select chart code other/see nurse's notes and record findings. There was no documentation found in the Nurses Notes (NN) regarding monitoring for adverse side effects of antipsychotic medication. An MAR, dated December 2022, indicated Resident 18 was given the medication, Risperidone 0.25mg tablet, 1/2 tablet every day at 8:00 PM on December 18,19,20,21,22,23,24,25,26,27,28,29, 30, and 31. There was no documentation indicating side effects of this medication were monitored. An MAR, dated December 2022, indicated Resident 18 was given the medication, Risperidone 0.25mg tablet, 1 tablet every day at 8:00 AM on December 18,19,20,21,22,23,24,25,26,27,28,29, 30, and 31. There was no documentation indicating side effects of this medication were monitored. An MAR, dated January 2023, indicated Resident 18 was given the medication, Risperidone 0.25mg tablet, 1/2 tablet every day at 8:00 PM on January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, and 22. There was no documentation regarding the January 15 dose. There was no documentation indicating side effects of this medication were monitored. An MAR, dated January 2023, indicated Resident 18 was given the medication, Risperidone 0.25mg tablet, 1 tablet every day at 8:00 AM on January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23. There was no documentation indicating side effects of this medication were monitored. The Rounding Provider's Psychiatric Note (Nurse Practitioner), dated 1/5/2023, indicated the facility requested a visit for Resident 18 to follow up for dementia, anxiety, depression with behaviors and agitation history. Resident 18 was seen for psychiatric assessment of his described psychiatric conditions, assessment of mood and behaviors and continued evaluation of efficacy of his psychotropic medications. Staff reported Resident 18 was stable, had no weight loss or gain. Resident 18 had no reported anxiety or agitation that day. Resident 18 was described as quiet, calm with no restlessness, agitation, depression or overwhelming anxiety. Psychiatric medications included Buspar, Effexor, Aricept, and Risperidone. The Nurse Practitioner indicated she would continue to monitor Resident 18's response to the medication and note any trends in moods and behaviors, would also have staff continue to monitor for side effects from current medications. Staff was to continue to observe Resident 18 for any changes in sleep, moods, memory, appetite, and/or behaviors. Labs were reviewed for potential adverse effects to psychotropic medications. A review of Progress Notes, dated 12/24/2022 to 1/24/2023, indicated no documentation of monitoring for side effects of psychotropic medication by the facility nursing staff. In an interview, on 1/24/2023 at 10:05 AM, LPN 3 indicated side effects were to be monitored for antipsychotic, antidepressant, antianxiety, anticoagulant medications. Residents receiving antibiotics were monitored for side effects and temperature. Residents receiving Insulin had their blood glucose checked and were monitored for sign of high and low blood sugar levels. Residents were to be monitored for side effects throughout the shift and documented once a shift. Documentation was done on the MAR. In an interview, on 1/24/2023 at 10:10 AM, the Director of Nursing (DON) indicated side effects were to be monitored for antipsychotic, antidepressant, and anticoagulant medications. Monitoring should be done every shift and was to be documented on the resident's MAR. A current policy, titled Psychotropic Medication Use, dated 11/28/2017, was received from the DON on 1/24/2023 at 10:54 AM. The policy indicated, Policy A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: 1. Anti-psychotic 2. Anti-depressant 3. Anti-anxiety 4. Hypnotic . Residents who receive psychotropic medications will have their drug/medication regimen managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being . Guidelines .14. Nursing staff shall monitor for and report any of the following side effects and adverse consequences to the physician such as: a. general/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation b. cardiovascular: orthostatic hypotension (drop in blood pressure when changing positions), arrythmias (irregular heart rhythms), c. metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain d. neurologic: akathisia (feeling of muscle quivering, restlessness and inability to sit still), dystonia (disorder in which sustained or repetitive muscle contractions result in twisting and repetitive movements or abnormal fixed postures), extrapyramidal effects, akinesia (loss or impairment of movement), tardive dyskinesia ( a neurological disorder characterized by involuntary movements of the face and jaw), stroke or transient ischemic attack ( mini stroke). 15. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences 3.1-48(a)(3)

Based on observations, interviews and record reviews, the facility failed to ensure staff followed Transmission Based Precautions (TBP) for use of Personal Protective Equipment (PPE) to decrease the risk of COVID-19 transmission for 1 of 1 observation (employee 1), and failed to ensure cleaning of all equipment, with an approved cleaner and between each resident use for 1 of 1 resident observed for infection control (Resident 1). Findings include: During observations on 9/24/21 at 11:20 A.M., Employee 1 and Employee 2 were in the doorway of Resident 1 preparing to enter the room. The sign on the door indicated this resident was on Yellow Zone Precautions and indicated YELLOW ZONE universal eyewear: face shield or goggles Employee 1 entered the room without a face shield or goggles. During observation on 9/24/21 at 11:30 A.M., Employee 1 and Employee 2 exited the room. After Employee 1 cleaned the Sara lift, she draped the Sara lift pad over the lift without cleaning the pad. During an interview on 9/24/21 at 11:30 A.M., Employee 1 indicated she thought she did not have to use eyewear if she had been vaccinated. She also indicated she did not know what they were to do for the Sara lift pads between each resident, besides hanging them on the lift. She indicated she did use the pad for Resident 1 to provide care. During an interview on 9/21/21 at 11:50 A.M., the facility's Infection Preventionist indicated staff were to disinfect the Sara lift pads between each use with an alcohol based spray. She also indicated she was unclear about the eyewear issue since Employee 1 was vaccinated. During an interview on 9/24/21 at 12:40 P.M., the Administrator indicated their policy provided when the resident was asymptomatic in a yellow zone, then the staff would not need to wear a shield or goggles. She indicated they follow the Indiana Department of Health (IDOH) and Centers for Disease Control guidance in addition to facility policies. The United States environmental Protection Agency website located at https://cfpub.epa.gov/wizards/disinfectants/ did not indicate an alcohol-based disinfectant could be use on non-porous surfaces such as cloth. The facility policy titled Interim Infection Prevention and Control Guidance and Policy, revised 6/4/21, indicated Environmental: . Clean commonly touched surfaces . on regular basis throughout the day, and at increased intervals when warranted based on facility activity. Additional emergency planning/key measures in a potential outbreak and /or pandemic situation may include: Increased facemasks/PPE and Optimization of usage as per CDC guidance The facility policy titled Covid-19 Pandemic Guidelines, updated 6/4/21, indicated General Protocols . Shared equipment must be sanitized after each use The facility provided a copy of the IDOH document titled Changes for Toolkit Update, dated 8/12/21 which indicated Unknown Covid-19 status (Yellow): All residents in this category warrants (droplet and contact.) HCP will wear single gown per resident, glove, N95 mask and eye protection (face shield/or goggles). Symptom Observations- . Resident who develop symptoms while being observed should be tested and moved accordingly . 3.1-18(a)

Based on observation, and interview the facility failed to ensure that meals were served and delivered in an efficient timely manner, affecting 29 of 29 residents receiving meals. Findings include: On 3/4/2019 at 12:00 p.m., 20 Residents were observed in the Main Dining Room, and 4 Residents were observed sitting at a table in the small kitchenette just off the Main Dining room. DA (Dietary Aide) 3 and DA 4 were providing drinks to the residents. At 12:14 p.m., DA 3 was observed temping the food on the steam table. At 12:19 p.m., DA 3 was serving up dinner plates, and placed on trays. DA 4 delivered 5 trays individually to rooms down the hall, returning to the kitchenette as each tray was passed. At 12:24 p.m., DA 3 left the steam table, obtained a can of soup from the shelf, opened it, poured it in a cup and put it in the microwave. Then DA 3 washed their hands and started to serve up the next dinner plates. At 12:29 p.m., Residents seated at the kitchenette dining table had voiced how long it was taking to get their meal, and at this time DA 4 delivered 2 residents their plates of food. At 12:33 p.m., DA 4 poured residents more coffee who requested another cup. At 12:35 p.m., DA 4 went back into the kitchen, picked up plates and delivered to residents in the dining room. At 12:48 p.m., DA 3 and DA 4 were both delivering desserts to the residents in the dining room At 12:52 p.m., DA 3 and DA 4 served more coffee, and all the food was delivered to all the residents. An observation of a sign posted outside the dining room doorway indicated the lunch meal time was 12 p.m. to 1 p.m. No CNAs assisted in tray delivery. On 3/6/2019 at 12:14 p.m., DA 4 delivered a hall tray to room [ROOM NUMBER], then came back to the Main Dining Room, and poured coffee for residents seated and waiting for their lunch. At 12:17 p.m., DA 4 delivered the first plate to a resident in the Main Dining Room. On 3/8/2019 at 12:04 p.m., DA 3 completed temping the foods on the steam table and indicated they were waiting for the substitute foods from the main kitchen. At 12:20 p.m., the residents in the Main Dining Room asked an anonymous CNA (Certified Nurse Aide), who was seated and assisting a resident with a supplement cup, why their food was late. At 12:30 p.m., DA 3 served up plates and DA 7 put the fruit dish on the trays and carried them to the kitchenette doorway where CNA's were delivering the food to the residents on the hall and in the Main Dining Room. During an interview on 3/5/19 at 10 a.m. an anonymous resident indicated usually one dietary staff would come over and dish up the plates, and the CNA's delivered the meals. The resident indicated the residents that needed assisted would be served first and the hall trays would be served first also. They indicated they were scheduled to eat around noon. During an interview on 3/8/2019 at 10:40 a.m., the Administrator and Kitchen Manager indicated the CNA's deliver the meals to the resident rooms and to the residents in the dining room. During an interview on 3/8/2019 at 12:15 p.m., DA 3, indicated the following: that today they would be the only person serving up the food on dinner plates and would be delivering the plated dinnerware to the residents. Furthermore, they also would be delivering the hall trays to the residents in their rooms. They indicated they served two plates (for two residents) at a time, delivered them, then would come back in to the kitchenette, wash hands and would proceed to serve more plates. If there was another DA, they would deliver the hall trays and the plates to the residents in the dining room. It was indicated the CNA's did not assist with the delivering of meals. During an interview on 3/8/2019 at 12:25 p.m., the Kitchen Manager indicated that not all the time do the CNA's pass the plates and trays. During an interview on 3/8/2019 at 3:45 p.m., the Administrator indicated the CNA's were to be delivering the served plates and hall trays to the residents. A current facility policy, dated 2009, Tray and Dining Room Meal Service, indicated the following: The Nutrition Services Department will provide accurate, efficient and consistent meal service . 3.1-20(h)

Based on observation, interview and record review, the facility failed to ensure medications were administered safely for 1 of 1 residents reviewed. (Resident 13) Findings include: On 3/12/19 at 11:13 a.m., LPN 1 was observed in the medication room of the Assisted Living Unit. She opened the top drawer of the medication (med) cart. Observed in the med cart was a med cup which contained 5 pills. The med cup was not observed to have any type of labeling, resident name and/or identification of medications. LPN 1 was interviewed regarding the unmarked med cup. She indicated Resident 13 was a resident on the skilled nursing unit in the facility and would come to the Assisted Living area of the building to spend the day with a family member, who resided on the Assisted Living unit. LPN 1 indicated this morning, she had gone over to the skilled nursing unit to get Resident 13's medications. LPN 1 indicated when she went to get Resident 13's medication, she indicated she observed QMA (Qualified Medication Aide) 2 to pop the pills out of the card into the med cup. LPN 1 indicated she had not checked the medications QMA 2 had put into the medication cup against the Medication Administration Record [REDACTED]. LPN 1 indicated she was unable to identify the names of medications in the medication cup, with the exception one. She indicated she was the nurse who was going to give Resident 13 these medications but she was not going to be the nurse to document the resident had been given these medications. LPN 1 indicated QMA 2 was going to document Resident 13 had been administered these medications. On 3/12/19 at 11:25 a.m. the clinical record of Resident 13 was reviewed. The current Medication Administration Record [REDACTED]. On 3/12/19 at 11:30 a.m., QMA 2 was interviewed. She indicated she had prepared the medications for Resident 13 and given the cup of medications to LPN 1. She indicated LPN 1 had not verified the medications and/or dosages of medication contained in the cup. She indicated the med cup was not labeled, dated and/or had identification of the medication name and/or dosage of pills contained in the med cup. QMA 2 indicated she had prepared the medications for Resident 13 and documented she had given the medications to Resident 13, even though LPN 1 was going to administer the medications to Resident 13. On 3/12/19 at 1:27 p.m., the Administrator (Adm) provided a current copy of the facility policy and procedure for Administering Medications, dated 12/2012. The policy and procedure included, but was not limited to, the following: Medications shall be administered in a safe and timely manner. The individual administering the medication must verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. The individual administering the medication must initial the resident's Medication Administration Record [REDACTED]. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; and the signature and title of the person administering the drug. On 3/12/19 at 2:15 p.m., the Director of Nursing (DON) was interviewed. She indicated it was the facilities standard of practice when a resident was gone from the unit for the medication pass, the facility would typically use an envelope to put the resident's pills in. She indicated the envelope would be dated, labeled with the resident's name and list of the dosages and medications included in the envelope. She indicated it was the practice of the facility for the nurse who administered the medications to the resident to document in the resident's clinical record they had been given. The DON indicated the nurse on the Assisted Living Unit did have the capability to document Resident 13's medications had been administered by using the facility electronic medical record. 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure restorative services were provided as recommended for 4 of 4 residents reviewed for restorative services. The deficient practice had the potential to effect 21 of 28 residents who had recommendations for restorative services. (Resident 25, Resident 12, Resident 21, and Resident 6) Findings include: 1. The record review for Resident 25 began on 5-1-2018 at 2:00 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident 25 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). The functional assessment indicated the resident required an extensive assist of 2 for bed mobility, an extensive assist of 1 for transfers, locomotion on unit, dressing, toileting, and personal hygiene, a limited assist of 1 for walking in room/corridor, and locomotion off unit. The assessment indicated the resident was not steady, but able to stabilize without staff assistance from moving from seated to standing position, walking, turning around and facing opposite direction while walking, moving on/off toilet, and surface to surface transfers. Assistive devices marked were a walker and a wheelchair. No impairment of the upper or lower extremities was marked. Physical and Occupational therapy was marked from 3-5-2018 to 4-13-2018 and the restorative nursing program was not marked. The current physician orders, dated 5-2018, indicated Occupational Therapy was for therapeutic exercise, self care, neuromuscular re-education, therapeutic activities, manual therapy, wheelchair management, safety awareness 5x week for 8 weeks for treatment [DIAGNOSES REDACTED]. A copy of the PT (Physical Therapy) Progress & Discharge Summary for Resident 25 was dated 4-13-2018 and was provided by OTA (Occupational Therapy Assistant) on 5-18-2018 at 2:19 p.m. The summary indicated the .Discharge Plans & Instructions .Discharge planned for this patient .Recommendations discussed with patient and/or caregivers include following restorative program and riding theracycle on his own A copy of the OT (Occupational Therapy) Progress & Discharge Summary for Resident 25 was dated 4-13-2018 and was provided by OTA (Occupational Therapy Assistant) on 5-18-2018 at 2:19 p.m. The summary indicated the .Discharge Plans & Instructions .Resident to remain in Health care setting with set up with FMP (Functional Maintenance Program) to maintain strength demo improve motor planning with functional mobility/improve I (independence) with ADLS (Activities of Daily Living) tasks A copy of the Therapy Communication/In-Service to Nursing form for Resident 25 was provided by PTA (Physical Therapy Assistant) on 5-2-2018 at 9:34 a.m. The goals written for Resident 25 indicated .Resident to maintain UB /LB (upper body/lower body) dressing tasks requiring min A/mod A (minimum assistant/moderate assistance. 2) Resident to maintain strength .theracycle machine for 20 minutes to maintain strength There was no signature on the form by the Restorative Nurse Signature line. OTA signature was dated 4-13-2018. A care plan was initiated on 1-6-2018 for Resident 25 for [MEDICAL CONDITION] which placed the resident at risk for medical complications [REDACTED]. An intervention included .Restorative programs as indicated (See Restorative Care plan) date initiated 1-9-2018 A care plan was initiated on 1-6-2018 for Resident 25 for ADLS with an intervention of .Restorative Programs to be initiated by therapy as indicated A care plan for Resident 25 was initiated on 1-19-2018 for .risk for declines in his ability to complete AROM due to Parkinson The goal indicated Resident 25 .will complete active range of motion exercises as indicated in individualized restorative nursing program to increase dependence, strength through next review Interventions included .Provide 1 assist to complete AROM (active range of motion) to BLE/BLUE (bilateral lower and upper extremities) using Parkinson exercise bike through next review .Record minutes of task competed in P[NAME] (Point of Care-computer program) The P[NAME] documentation for the past 14 days for Resident 25 indicated the following, .Task: 3. NURSING REHAB: AROM using [MEDICAL CONDITION] exercise bike. Assist resident with getting on bike and with positioning. Observe biking exercise and assist as needed--Amount of minutes spent providing Range of Motion (active) The only dates marked with number of minutes were 4-18, 23, 24, 26 and (MONTH) 1, (YEAR). All other dates were marked NA (Not Applicable), except for 4-19-2018 where refused was marked. The question .How many reps did this resident complete with this exercise (with arm/floor bike place N/A) the answers were all marked NA except on 4-19-2018 where the resident refused. The P[NAME] documentation for the past 14 days for Resident 25 indicated the following: .Task: NURSING REHAB: Dressing/grooming. Assist resident to pick out clothes. Set resident up in bathroom or bedside per his choice. Allow resident to complete upper body dressing/grooming. Assist with lower body dressing. Assist as needed All dates for the last 14 days marked twice a day. An interview with Resident 25 on 4-30-2018 at 2:25 p.m., indicated he received no restorative services today and the Restorative aide was pulled quite a bit from her restorative duties to cover the CNA duties. An interview with Resident 25 on 5-1-2018 at 3:30 p.m., indicated he had not gotten on his exercise bike today and none of the staff offered to assist him. He indicated .sometimes they do and sometimes they don't offer An interview with the PT Supervisor on 5-2-2018 at 9:26 a.m., indicated FMP stood for functional maintenance program which meant Resident 25 would be getting restorative nursing. PT Supervisor indicated the therapist created the restorative plan and gave the plan to the restorative nurse. PT Supervisor indicated the Restorative CNA (Certified Nurse Aide) had been working as a CNA due to staffing issues. An interview with CNA 1 on 5-2-2018 at 2:28 p.m., indicated she was trained by the other Restorative Nurse Aide who was presently on leave, to provide restorative services to the residents. CNA 1 indicated she had a list of residents on her paper that required restorative services. She indicated when she finished providing the restorative services with the resident she would chart in the computer program. An interview with Resident 25 on 5-2-2018 at 2:29 p.m., indicated he had not been on the bike today and he was just going to ask CNA 1 about getting on the bike. An interview with CNA 1 on 5-2-2018 at 3:35 p.m., indicated she was working this shift as a CNA due to the staff shortage. CNA 1 indicated she did not work 1st shift as a RNA (Restorative Nurse Aide). An interview with the MDS Coordinator on 5-2-2018 at 3:45 p.m., indicated she was responsible for the Restorative Nursing Program. She indicated the RNP (Restorative Nursing Program) was typically completed 6 days a week. The RNA (Restorative Nurse Aide) working on the floor this shift (CNA 1) was working as a CNA due to staffing needs. The MDS Coordinator indicated the other RNA was on leave. The MDS Coordinator indicated the facility was trying to do the best they could to meet the needs of the residents who have Restorative Nursing programs. The P[NAME] Response History for Resident 25 for the last 30 days was provided by the DON on 5-2-2018 at 2:15 p.m. The documentation was reviewed with the MDS Coordinator. She indicated the RNA and the CNA both had access to charting on this form. She indicated the CNAs marked the Not Applicable and the minutes recorded were marked from the RNA. The Nursing Rehab AROM task for . using [MEDICAL CONDITION] exercise bike assist resident with getting on bike and with positioning .observe biking exercise and assist as needed . had documentation of minutes as follows: 4-3-2018 15 minutes 4-8-2018 15 minutes 4-10-2018 15 minutes 4-11-2018 15 minutes 4-12-2018 20 minutes 4-16-2018 10 minutes 4-18-2018 10 minutes 4-23-2018 20 minutes 4-24-2018 20 minutes 4-26-2018 25 minutes 5-1-2018. 15 minutes Since the therapy discharge on 4-13-2018, Resident 25 had this restorative nursing program 6 times, where the the restorative nursing program should have been provided at least 13. 2. The record review for Resident 12 began 5-3-2018 at 2:04 p.m. [DIAGNOSES REDACTED]. The quarterly MDS for Resident 12 was dated 2-21-2018 and indicated a BIMS score of 15/15. The score indicated Resident 12 was cognitively intact. The resident required an extensive assist of 2 persons for bed mobility, an extensive assist of 1 person for transfers, locomotion, dressing, toileting, personal hygiene and bathing. Walking in room/corridor did not occur. The resident required the supervision of 1 person for locomotion off unit. The resident was not steady and only able to stabilize with staff assistance for moving from seated to standing position, moving on/off toilet, and surface to surface transfers. For the tasks, walking and for turning around and facing opposite direction while walking, did not occur. There was no upper extremity impairment marked and an impairment on one side of lower extremity was marked. Resident 12 has a wheelchair. Resident 21 had a wheelchair and OT and PT services had end dates of 2-21-2018. Restorative services were not marked. A care plan for Resident 12 was in place for right and left leg contractures and was last revised on 1-24-2017. The goal was for the contractures to not increase and the interventions included .Restorative programs as indicated A care plan for Resident 12 was in place for .risk for declines in the her <sic> ability to complete AROM due to contracture . which was last revised on 1-24-2017. The goal was for resident not to experience declines in decreased muscle mass or contracture. Interventions included .3 sets of 10 reps .apply warm compress to right knee 15 min prior to Prom .nurse to review program routinely along with progress toward meeting goals .Record minutes of task completed in P[NAME] .rest breaks as needed .Therapy eval et (and) tx (treatment) as needed The PT Supervisor provided OT and PT discharge instructions for Resident 12 on 5-3-2018 at 10:25 a.m. for therapy services that ended on 2-21-2018. The PT discharge instructions indicated patient is being discharged with restorative nursing program training with correct hand positioning The OT discharge indicated .res continues to have decrease strength BUE. Continue assistance with grooming tasks A copy of the Therapy Communication/In-Service to Nursing was provided on 5-3-2018 by the PT Supervisor. The PT supervisor indicated the restorative plan was not updated and the plans were not usually updated. The PT supervisor indicated they just go back to the same plan. The treatment recommendations were for .1. therapeutic exercises with a number 3 dowel rod as directed with HEP (home exercise program) .2. w/c (wheelchair) mobility > (greater than) 100 ft (feet) with SPV (supervision) .3. 5x (times) pull up 'butt-lift' at grab-bar The note indicated resident had BLE (bilateral lower extremity) contractures, HOH (hard of hearing) and decreased posture due to kyphosis (curvature of the spine). The form was signed by the restorative level 1 aide in 3-28-2018 and by OTA on 3-25-2018. A review of the P[NAME] response history for the last 30 days for Resident 12 indicated .task 2 .Nursing Rehab-AROM BUE 3 sets of 10 reps .PROM RLE 10 reps .apply warm compress to right knee 15 min prior to PROM A review of the last 30 days (from 4-5-2018 through 5-3-2018) of documentation indicated the restorative aide provided 15 minutes of restorative services on 4-11, 17, 18, 19, 23, and 4-26. For Resident 12 to receive restorative nursing services for this task at 6 times a week, 24 dates should have been marked as receiving the services. An interview with Resident 12 on 5-3-2018 at 10:06 a.m., indicated she did not get exercises for her knees or a warm compress applied to her knees. The resident indicated that .costs too much, so I don't get it An interview with the PT supervisor on 5-3-2018 at 10:30 a.m., indicated she could only find a Therapy Communication/In-Service to Nursing form from the OT dated 3-25-2016. The treatment recommendations written at that time did not match what the resident was receiving from the current restorative documentation. 3. The record review for Resident 21 began on 5-3-2018 at 3:04 p.m. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated Resident 21 has a BIMS score of 5/15 which indicated severe cognitive impairment. There was no restorative nursing or therapy marked. Resident 21 required a limited assist of 1 for bed mobility and locomotion on unit; an extensive assist of 1 for transfers, and toileting; and walk in room/corridor activity did not occur. The resident was not steady but able to stabilize with staff assistance for moving from seated to standing position, moving on/off toilet, and surface to surface transfer. For the tasks, walking and for turning around and facing opposite direction while walking, both did not occur. The impairment on upper and lower extremities was marked no. The box for wheelchair was marked yes and the box for walker was marked no. The restorative service was not marked. A Therapy Communication/In-Service to Nursing was provided by the PT Supervisor on 5-4-2018 at 9:34 a.m. for Resident 21. The current functional status of the resident was supervision with transfers and gait. The goals were to maintain functional ambulation and LE (lower extremity) strength and functional transfers. The treatment recommendations indicated .AROM in sitting, 2 x 20 with 2 # (pound) or leg bike, gait activity with RW (rolling walker) 100 - 200 The form was signed by a Restorative level 1 aide on 2-5-2016 and by a PTA without a date marked. Therapy services ended 2-2-2016. A care plan for Restorative AROM was last revised on 12-22-2017 with a goal of continued participation in ADL functioning. The interventions were for .AROM BUE/BLE (Active range of motion bilateral upper extremities and bilateral lower extremities) 2 sets of 20 reps using 2# (pound) weights in a sitting position. Monitor for pain. Rest breaks as needed. Report changes to charge nurse. Offer encouragement and praise efforts A review of the last 30 days of documentation for the Restorative task AROM BUE/BLE for Resident 21, beginning 4-5-2018 in the P[NAME] response history, indicated 15 minutes of restorative were provided on 4-11, 17, 18, 19, 20, 23 and 26, (YEAR) through 5-2-2018. For the restorative services at 6 times a week, Resident 21 should have received at the restorative services 24 times. Documentation indicated she had received the services 7 times A care plan for Resident 21 for the restorative walking due to potential for decline in walking skills was last revised on 12-22-2017. The goal was .Resident will walk minimum of 200 feet thru next review The interventions were to .assist resident with gait belt and rolling walker. Assist to standing position. Proper footwear. Assist to walk 200 feet. Follow with wheelchair. Rest breaks as needed. Report changes to charge nurse .offer encouragement and praise efforts A review of the last 30 days of documentation beginning 4-5-2018 in the P[NAME] response history indicated for the task .walking. Assist resident with gait belt and contact guard assist. Assist to standing position. Ensure proper footwear. Follow with wheel chair. Rest breaks prn (as needed). Report changes to hall nurse. Goal is 100 - 200 feet. There was no documentation for this program from 4-5-2018 through 5-3-2018 of completion of this task. The Not Applicable box was checked each day. An observation of Resident 21 on 5-4-2018 at 11:22 a.m., indicated the resident was in her wheelchair dressed in dark slacks, a white shirt and had shoes on her feet. She was sitting in the area outside the nurse station and was observed to self propel her wheelchair. An interview with CNA 2 on 5-3-2018 at 11:19 a.m., indicated she did assist the resident to get dressed today, but did not chart in the Restorative Nursing Program for ADL's. CNA 2 indicated the restorative aide did that service. CNA 2 and CNA 5 both indicated the restorative nurse was the only one who could chart in the restorative program. An interview with QMA (Qualified Medication Aide) 6 on 5-4-2018 at 9:02 a.m., indicated she had not been trained as a restorative aide. QMA 6 indicated she can read instructions for the restorative and provide the restorative care. An interview with the DON (Director of Nursing) on 5-4-2018 at 11:08 a.m., indicated CNA 4 was the only staff trained in the Restorative Nursing Program duties who was working this shift. The DON provided copies of the training which was dated 4-17. The DON indicated CNA 5, who was working today, had not finished her Restorative Nursing Program training. An interview with CNA 5 on 5-4-2018 at 11:20 a.m., indicated she had not been trained to perform restorative services. She indicated the facility had yearly inservices but was not specifically trained to perform restorative nursing services. She indicated she will assist the residents in whatever she can such as stretch a resident's arms and legs when getting them up. CNA 5 indicated she would do this if she had the time. An interview with CNA 4 on 5-4-2018 at 11:21 a.m., indicated she had been trained to do restorative services and will provide those to the residents she was assigned. CNA 5 indicated she could not do all of the restorative services for all the residents as there was not a third CNA working. CNA 4 indicated there was not enough time to do restorative with only 2 CNAs working. An interview with the DON on 5-4-2018 at 11:41 a.m., indicated there was not a specific policy for who could provide the Restorative Nursing Services. The DON indicated each CNA was provided training during orientation. The DON provided the current Certified Nursing Assistant orientation checklist and it indicated .13. Restorative Nursing .a) Pressure reducing devices b) reporting skin c) Turning/positioning d) PROM/ARON/AAROM <sic> A current policy for Range of Motion (ROM) Splints, Braces, Orthotics dated 8/2009, was provided by the DON on 5-2-2018 at 3:45 p.m. The policy indicated .Residents identified as a risk for contractures will have a ROM program a minimum of 6 days/week unless that frequency is contraindicated. The ROM includes the programs provided to prevent contractures and keep joints as limber as possible .This policy does not include therapy delegated programs individually designed for muscle strengthening, stretching and other reasons The purpose was .to maintain a resident's ability to move a joint through its normal range of movement and perform activities of daily living (ADL) .To prevent pain, discomfort, swelling and stiffness when joint movement is limited or contracted .To prevent contractures and to provide comfort and support for a joint and prevent pain in an already deformed/contracted, weak joint The procedure described how to perform the range of motion for all the joints. 4. On 5/2/18, the clinical record of Resident 6 was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) assessment, dated 4/25/18, included the following: severely impaired cognition; transfer: extensive assistance (resident involved in activity, staff provide weight bearing support); walk in room and locomotion on unit required limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance); individual minutes of Physical Therapy: 0176; physical therapy start date 4/13/18 and end date is blank; this therapy was administered for 5 days in the last 7 days for at least 15 minutes. A PT (Physical Therapy) - Therapist Progress and Discharge Summary dated 12/1/17 was received from the PT Supervisor on 5/2/18 at 11:48 a.m. The form indicated the start of care was 11/1/17 and end of care was 12/1/17. The Discharge Plan and Instructions indicated DC (discharge) with restorative nursing program. The form had been electronically signed by the therapist and had been dated 12/12/17. A plan of care, revised on 2/2/18, addressed the focus of is at risk for ADL deficits in non late loss ADL's due to .tremors, diagnosis .Interventions .resident requires limited assist of one for locomotion .(2/10/17) .resident requires limited assist of one for walking. Uses a walker (7/7/17) . The Resident Council Minutes dated 3/27/18, were reviewed on 5/1/18 at 9:00 a.m. A Concern/Comment was documented as .will be nice to have (CNA (Certified Nursing Assistant) 1 name) back on restorative . The minutes replied to the comment It would be nice to have a restorative aide with As we fill our CNA shortages, the restorative aide will have more time to focus on the restorative program. The Therapy Communication/In-Service to Nursing .Physical Therapy .form, dated 5/19/17, was provided by the DON (Director of Nursing) on 5/2/18 at 2:00 p.m. The form included the following: .Level 1 Restorative Nursing Program, Level 2 Restorative Nursing Program .Current Functional Status: Mod(moderate)/Min (minimum) A (assist) Bed mobility, 100 ft. (feet) with RW (rolling walker) mod (modified) (I) (independence) supervision with transfers .Goals: continue LE (lower extremity) strengthening, balance and gait without risk for falls .Treatment Recommendations: AROM (active range of motion) in sitting 2 x 20 (2 sets of 20 repetitions), all planes of motion, gait with RW 100-200 feet to and from dining room .Precautions/Problems/Approaches: poor safety awareness, poor ability to follow directions .In-Service/Training Level 1 .Restorative nurse signature, (unsigned) .Restorative Level 1 aide signature, (unsigned) .Restorative level 1 aide's signature, (unsigned) .Inservice/Training Level 2 .Restorative nurse signature (unsigned) .Restorative Level 2 aide signature (unsigned) .Restorative level 2 aide signature (unsigned) .Therapist Signature (signed by Physical Therapy Assistant), date 5/19/17 .Date therapy decreased .(blank) .Date Therapy D/C'd (discontinued) .(blank) . On 5/2/18 at 2:00 p.m., the MDS coordinator provided a copy of the facility Task sheets from the computer system the CNAs document resident tasks on, dated (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). These form indicated the following: Nursing Rehab (Rehabilitation): AROM (active range of motion) all planes, 2 sets 15 reps provide rest breaks as needed. Offer cueing and encouragement . The Time indicated Q(every) shift. Documentation was lacking of a record of minutes of tasks completed. Documentation further indicated the AROM was completed once a day. Documentation was lacking on the Task form of restorative ambulation having been completed. The Task sheet documented the resident had walk in room, walk in corridor .locomotion on unit, locomotion off unit .every shift . Documentation of these tasks was indicated on the task sheet by initials of a CNA and a time. Documentation was lacking as to a distance completed and the amount of time the task took to complete. On 5/2/18 at 2:28 p.m., the DON provided a copy of the P[NAME] (point of care) Response History, dated 4/3/18 to 5/3/18. The form indicated the task .Nursing Rehab: AROM all planes 2 sets 15 reps provide rest breaks as needed . The form Task indicated the date and time, and provided the following documentation options: amount (amount of minutes spent providing range of motion (active), resident not available, resident refused and not applicable. The days of 4/3/18 to 4/12/18, indicated one day, on 4/4/18, the resident completed 15 minutes of AROM. All of the other days from 4/3/18 to 4/12/18, documentation indicated Not Applicable. The DON indicated when the option of Not Applicable was documented, this meant he CNAs did not complete the restorative task on those days. Documentation was lacking of ambulation having been included in the nursing rehab task from 4/3/18 to 4/12/18. On 5/2/18 at 3:30 p.m., the MDS coordinator was interviewed. At this time, she provided documentation of the Restorative Nursing, dated 12/1/17 to 4/12/18. Documentation from 12/1/17 to 4/12/18 was lacking on the forms of restorative ambulation as even being an option to have been attempted and/or completed. Documentation for each day in (MONTH) (YEAR), indicated the daily documentation the following: a time, initials and the numbers 8, 8. The MDS coordinator indicate the initials were those of the CNAs. The MDS coordinator provided a key which indicate the number 8 could represent Resident not available, Resident Refused and/or Not applicable. The MDS coordinator was unable to determine what each 8 represented. She indicated if a resident was not available and/or refused restorative services, the staff was to reapproach the resident at a later time and offer the services again. For (MONTH) (YEAR), it was documented 4 times, the resident was reapproached regarding restorative services. For (MONTH) 1, (YEAR) to (MONTH) 28, (YEAR), 26 of the 28 days had documented the numbers 8, 8 and documentation was lacking on those days of restorative services having been offered again. For (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR), 30 of the 31 days were documented the numbers 8, 8 and documentation was lacking on those days of restorative services having been offered again. For (MONTH) 1, (YEAR) to (MONTH) 12, (YEAR), 12 of 12 days were documented the numbers 8,8. One of those 12 days had documentation the restorative service had been offered at a later time. The Restorative Plan Program was provided by the MDS Coordinator on 5/2/18 at 2:58 p.m. She indicated this program had been implemented (MONTH) (YEAR) and would have rolled over when the resident completed her therapy in (MONTH) (YEAR). The instructions indicated the following: .will complete AROM 2 sets of 15 reps (repetitions) to all planes daily 6 days a week .notify nurse of any change Amount of minutes spent providing range of motion (active) not applicable . Documentation was lacking on the plan program regarding the Gait with RW (rolling walker) as was recommended on 5/19/17, on the Therapy Communication. The MDS coordinator was interviewed on 5/2/18 at 3:00 p.m., She indicated most restorative programs were to be completed 6 days a week. She indicated she put the notation in the Restorative Plan Program of 15 reps, in case they didn't think the resident would do 20 reps . The MDS coordinator was interviewed at 3:05 p.m. and indicated the resident had recently fallen and was placed back on Physical Therapy caseload on 4/13/18. A Physical Therapy Plan of Care, dated 4/13/18, was received from the Physical Therapy Supervisor on 5/3/18 at 8:22 a.m. The form included the following: .start of care 4/13/18 .Reason for referral: patient referral to physical therapy due to recent decline in functional mobility and strength .is on 2 liters oxygen .experiences extreme shortness of breath affecting activity tolerance .was assessed for bilateral lower extremity strength, balance, gait .and level of assistance needed for transfers and gait .Therapy Necessity .skilled PT necessary to assess for BLE (bilateral lower extremity) strength, gait .current level of function .identify weakness and deficits .implementation (sic) of P[NAME] (plan of care) for BLE strength, gait .reduced risk of falls and safety .previous therapy .was given therapy for BLE strength, gait and transfer . On 5/1/18 at at 9:00 a.m., the (YEAR) resident council meeting minutes were reviewed. The (MONTH) 27, (YEAR) meeting minutes indicated the following: .Concerns .will be nice to have ( CNA 1 name) back on restorative . The response from facility of concern was We are in the process of trying to hire additional CNAs to fill our staffing needs. We are working with a company called (name of company) that trains and places CNA's in a HC (healthcare) setting .as we fill our CNA shortages the restorative aide will have more time to focus on the restorative program . The (MONTH) 24, (YEAR) minutes were also reviewed with the following observed: .do (sic) to lack of staff there are things not getting done or not getting done right . The facility response to Do (sic) of staff there are things not getting done or not getting done right .We are trying to improve staffing, as new staff is hired we will make sure training is properly completed . On 5/3/18 at 9:35 a.m. the Physical Therapy (PT) Supervisor was interviewed. She indicated the resident has finished PT on 12/1/17. The PT supervisor indicated after PT was completed, the restorative program had been recommended to begin. She indicated if a prior restorative plan was in place before PT had been started, the resident was to continue with the prior restorative program. The PT supervisor indicated the program that would have rolled over was the 5/19/17 Therapy Comm/inservice to nursing. The PT Supervisor indicated the treatment/recommendations documented on 5/19/17, did not include a frequency for the AROM and the gait with the rolling walker because the restorative CNA 1, had been trained on the program and was aware of the frequency of the program. She indicated she thought CNA 1 was the Restorative CNA but CNA 1 had been working as a CNA and not as a Restorative CNA. The PT Supervisor indicated the resident's cognition did vary. She indicated Resident 6 would need to be reminded to ambulate to and from the dining room, but the resident was able to ambulate independently in her room with her walker. The PT Supervisor indicated the resident started back with physical therapy on 4/13/18. She indicated about every 3 months, the residents in the restorative program were reviewed to see if anyone had experienced a decline. She indicated physical therapy had observed this resident as this resident was cognitively unable to tell if she had declined. The Physical Therapy Supervisor indicated in the facility Morning meetings, the status of residents were reviewed and anyone with a potential decline would be screened. On 5/3/18 at 9:55 a.m. the DON (Director of Nursing) was interviewed. She indicated the resident's ADL status had been reviewed in (MONTH) (YEAR) and the resident had been started back on PT on 4/13/18. She indicated this was a result of the Quality Measure meeting where ADL performances were reviewed for the residents. The DON indicated staff were expected to go back and offer restorative services again if the resident initially refused or was unavailable for restorative services when initially offered. The DON indicated she was unable to differentiate what the 8 meant on the P[NAME] Response History Task form. She indicated it was important to know what specifically the 8 represented as services would be reoffered if the resident had (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure sanitary practices were followed for food preparation and food service. This deficiency had the potential to affect 28 of 28 residents who ate their meals from the facility kitchen. Findings include: 1. During an observation of the walk in kitchen refrigerator with the Dietary Manager on 4-30-2018 at 7:50 a.m., a box of eggs were observed on the bottom shelf without the P printed on the eggs. An interview with the Dietary Manager at this time indicated, the eggs were used for fried eggs and over easy eggs as the residents order. The Dietary Manager indicated the eggs were pasteurized. An observation at this time indicated the Dietary Manager picked up several eggs, looked at the labeling on the box and was unable to find the P printed on the eggs and unable to find pasteurized printed on the box. The box label indicated 30 dozen eggs (360) inside the box and there were 155 eggs left in the box. A date of 4/20 was written on the box and the Dietary Manager indicated the 4/20 date was the date the eggs were delivered. An interview with the Dietary Manager on 4-30-2018 at 7:55 a.m., indicated the residents in healthcare ordered the eggs as fried or however they would like them. An interview and observation on 4-30-2018 at 8:21 a.m., indicated a resident at breakfast in the healthcare dining room had ordered and eaten an over easy egg. The yellow yolk color was observed on the resident's plate. On 4-30-2018 at 2:42 p.m., the Dietary Manager provided the most recent egg orders. The orders indicated on 3-11-2018, 3-25-2018 and 4-15-2018 the brand choice medium Grade A shell eggs, loose, refrigerated, 30 Ct tray, 12/case item number 3. The information provided did not indicate pasteurized anywhere in the description. An interview at this time with the Dietary Manager indicated she ordered the wrong eggs. An interview with the Dietitian on 5-2-2018 at 10:45 a.m., indicated she did not know the facility did not use pasteurized eggs. She indicated the current Dietary Manager took over the job of ordering and thought she was ordering pasteurized eggs. An interview with Dietary Staff 13 on 5-2-2018 at 11:40 a.m., indicated he hadn't seen the P on the eggs before. Another Dietary Staff 12, who was present, indicated the P meant the eggs were pasteurized. 2. During an observation of the puree preparation with Dietary Staff 12 on 5-2-2018 at 10:00 a.m., the Dietary Staff was observed to puree the turkey in a blender container. Once she was finished and scraped out the contents of the turkey, Dietary Staff 12 was observed to rinse the blender container with water at a prep sink. Dietary Staff 12 was then observed to prepare the pureed broccoli. The blender container was not observed to be sanitized after use with the turkey and prior to pureeing the broccoli. An interview with the Kitchen Manager on 5-3-2018 at 2:36 p.m., indicated the following: The blender container should have been washed and sanitized after each use of the container. 3. An observation in the Healthcare Kitchen on 5-2-2018 at 12:20 p.m., indicated the Kitchen Manager was observed to wash her hands while soaping them under running water for less than 10 seconds. The Kitchen Manager was then observed to resume plating residents' food. An observation on 5-2-2018 at 12:23 p.m., indicated the Kitchen Manager was observed to push her glasses up with her right arm and then continued plating residents' food without washing her hands. An interview with the Kitchen Manager on 5-3-2018 at 2:36 p.m., indicated the following: The Kitchen Manager indicated hands should be washed 40 - 60 seconds and when staff would change tasks. The Kitchen Manager indicated the dietary staff did not make it a practice to use the hand sanitizer. 4. An observation of dining services in the healthcare dining room on 5/2/18 from 12:30 p.m. to 12:45 p.m., indicated the following: At 12:35 p.m., Dietary Staff 7 was observed to come out of the kitchenette caring several pieces of dinnerware of food. Dietary Staff 7 carried 2 small plates, on was in the palm of her right hand and the other balanced on her right inner right wrist. A beverage in a plastic drinking glass with a lid and plastic straw in the lid was carried between the Dietary Staff 7's bare forearm and against her uniform top. She also carried a small bowl in the palm of her left hand. Dietary Staff 7 delivered the bowl of food to 1 resident, the two plates of food to 2 other residents, and the beverage in the plastic drinking glass to the fourth resident. At 12: 45 p.m., Dietary Staff 7 was interviewed and indicated, drinking glasses should be handled from the outside of the glass and also indicated dinnerware and drinking glasses should not be carried against her uniform nor between her arm and uniform. She further indicated she was not aware she had carried the plastic drinking glass between her forearm and uniform and indicated she must have been trying to carry to much at one time. An interview with the Kitchen Manager on 5-3-2018 at 2:36 p.m., indicated the following: For handling dishware and glasses, the Kitchen Manager indicated for staff to carry cups or glasses at the bottom and not by the rim or carry the cups or glasses in the crook of their arm. A current, undated policy Purchasing was provided by the Dietary Manager on 5-3-2018 at 4:02 p.m. The policy indicated .Food and supplies are purchased in a standardized manner to ensure quality and to control costs .Whole, unbroken eggs are for limited use only and pasteurized eggs are for general use A current, undated policy, Hand Washing - Healthcare, Assisted Living, Memory Support was provided by the Dietary Manager on 5-3-2018 at 3:33 p.m. The policy indicated .Hand Washing will take place before starting food service and before starting any new task .1. Hands must be washed before starting your shift .2. Any time you enter the kitchen to start working with food, hands must be washed .3. Before service of meals and passing plates, hands should be washed .4. Anytime you stop doing a task and start doing another task that requires clean hands you must rewash your hands A current, undated policy Handling of Kitchen/Dining Room Utensils was provided by the Dietary Manager on 5-3-2018 at 3:33 p.m. The policy indicated .do not let your fingers touch parts of the dished that people will drink or eat out of .hold cups by the outer surface, not by the rim 3.1-21(2) 3.1-21(3)

Based on observation, interview and record review, the facility failed to ensure recipes were followed for 3 of 3 observed (at table side and/or as prepared) entrees. The deficient practice had the potenital to affect all 25 residents in the facility. Findings include: 1. On 4/17/17 at 12:01 p.m., the main dining room was observed. At this time, a total of 17 residents were observed in the dining room. From 12:10 p.m., to 12:30 p.m., the dining service was observed. At least 10 of the plates were observed to include the following: a scoop of white rice and a serving of what appeared to be some type of cubed beef in a large amount of gravy with a strip or two of red pepper, what resembled a slice of a water chestnut, scant cubed carrots and 1-2 small florets of broccoli on each plate. A single size serving dish of cubed carrots was also served. An anonymous resident indicated That doesn't even look good. On 4/17/17 at 12:35 p.m., a resident asked a CNA (Certified Nurse Aide) if they were having beef stew. The CNA indicated the entree was stir fry. On 4/20/17 at 9:40 a.m., Dietary Staff 20 provided a copy of the facility recipe for Beef Stir Fry with Vegetables. The recipe included cubed beef stew meat and frozen stir fry blend. The recipe included quantities for the various ingredients to correspond to various number of servings. For example, 25 servings were to have 7 pounds of beef and 5 pounds of the stir fry blend. On 4/20/17 at 3:24 p.m., the Food Service Manager (FSM) was interviewed. She was made aware of the scant amount of vegetables observed on the plated servings of stir fry for the noon meal on 4/17/17. She indicated she would expect to see more than 1-2 small florets of broccoli, water chestnut and a few peppers. She indicated the vegetables should be easily observed in the plated stir fry servings. The FSM indicated recipes should have been followed to maintain the nutritional content of the dish prepared. She indicated the facility was trying to consider residents' input regarding foods and if the recipe needed to be adjusted, the recipe would need to be approved by the Dietician to ensure the nutritional values were maintained. 2. On 4/19/17 at 9:20 a.m., Cook 1 was observed to be gathering ingredients to prepare beef stroganoff for the noon meal. No recipe was observed to be out on the counter. Cook 1 was interviewed regarding the receipe she was going to use. Cook 1 returned to the food prep area with a copy of the beef stroganoff recipe. The recipe indicated it was obtained from Allrecipes.com. The recipe lacked documentation as to how many servings the recipe provided. The recipe included the following ingredients: 1 pound ground beef; 1/2 cup chopped onion, 4.5 ounce can of mushrooms, 1/2 teaspoon (tsp) garlic powder, 1/2 tsp. mustard powder, 1/2 cup sour cream, 1/2 cup mayonnaise, 1/2 cup beef broth and an 8 ounce (oz.) package of wide egg noodles. On 4/19/17 at 9:27 a.m., Cook 1 reviewed the recipe and indicated This isn't normal, this doesn't tell the number of servings. Cook 1 was interviewed and indicated she was preparing 50 servings of the beef stroganoff. On 4/19/17 at 9:28 am., Cook 1 was observed to put a total of 8 cups of fresh mushrooms in the stock pot on the stove. At 9:29 a.m. Cook 2 was observed to put two diced red onions into the stock pot also. Cook 1 was interviewed and indicated 1 onion usually yielded 2 cups of diced onions. She was observed to place the two diced red onions in the stock pot and indicated this amount would be equivilant to 4 cups of onions. Cook 1 was then observed to use a total of 2 tsp. (teaspoons) of garlic powder, a total of 2 tsp. of mustard powder, a total of 2 cups of sour cream, a total of 2 cups of mayonaise and 2 quarts of beef broth (consisted of 2 quarts of water with total of 2 tsp. of beef broth concentrate). On 4/19/17 at 11:15 a.m., Cook 1 was interviewed regarding the quantity of noodles she used for the beef stroganoff. She indicated I don't remember what the receipe said. She also indicated she made 50 servings of the beef stroganoff. She indicated she used 12 lbs. (pounds) of hamburger. At this time, Cook 1 indicated she multiplied the recipe amounts by 4 to make the 50 servings of beef stroganoff. On 4/20/17 at 3:54 p.m., Cook 1 was interviewed. She indicated she used four 8 ounce bags of noodles for the beef stroganoff recipe for 50 residents. She provided the container of beef concentrate she used on 4/19/17 to make the beef broth for the beef stroganoff. The label indicated the following: 3/4 tsp base to 1 cup of water; 1 TBSP (tablespoon) beef base to1 quart of water. On 4/25/17 at 3:48 p.m., the FSM was made aware of the quantity of each ingredient Cook 1 used to make 50 servings of beef stroganoff. The FSM indicated the recipe provided for beef stroganoff yielded 4 servings. The recipe (with ingredients listed with quantity for 4 servings) was reviewed with consideration of the increase in quantity of ingredients which were needed to make 50 servings. The FSM indicated Cook 1 was short on the following ingredients: onions, garlic powder, mustard powder, sour cream, mayonaise and noodles. The FSM indicated the amount of beef base used per 1 quart of water was less than what was indicated on the instructions. 3. On 4/20/17 at 8:45 a.m., Cook 1 was observed in the kitchen standing at a food prep counter, mixing what appeared to be ground beef and some type of crumbs with her gloved hands. Cook 1 indicated she was making meat loaf for lunch today. Cook 1 indicated she used the following ingredients: 15 lbs ground beef; 1 gallon of ketchup, 1 box crackers, 1/2 cup steak sauce and 10 eggs. No recipe was observed to be out at this time. Cook 1 was interviewed regarding the number of servings of meat loat she was preparing and she indicated she would have to look. She indicated residents can place orders as to which entree they want and she usually rounds the number up alittle. After she reviewed the number of residents who ordered meatloat, she indicated she was making a total of 63 servings. On 4/20/17 at 9:40 a.m., the Kitchen Manager provided a copy of the recipe for Meatloaf. The recipe did not have ingredient amounts specifically listed for 63 servings. The closest quantity of servings to 63 was listed as 75 servings, with amounts of ingredients listed. Hand written on this recipe was the following: 15 # (pounds) hamburger; 1# (gallon) ketchup; 1/2 cup steak sauce; 6 packages (sleeves) of crackers and 10 eggs. On 4/20/17 at 3:29 p.m., the FSM was interviewed. She indicated the handwritten for meat loaf was the cook's recipe and the residents liked this recipe. The FSM indicated the cook should have used the corresponding measured quantiy of meat, crackers, ketchup and eggs for her recipe as was documented in the facility provided meatloaf recipe. The FSM calculated the quantity of ingredients the cook used for her recipe as compared to what was documeted in the facility recipe. The FSM indicated for 63 servings of meatloaf, the cook used too much ketchup (for 75 servings menu called for 1 1/2 quarts and the Cook 1 used 1 gallon for 63 servings). The FSM further indicated Cook 1 did not use enough eggs (for 50 servings menu called for 2 1/2 cups of egg mix and the Cook 1 used 2 cups (10 eggs) for 63 servings. The FSM indicated 10 shelled eggs was equivalent to 2 cups of egg mix. On 4/21/17 at 10:29 a.m. the FSM provided a current, undated policy and procedure titled Standarized Recipes .Standarized recipes for menu items will be provided to help ensure consistent quality, portion .Any recipe change made by Chef, Cook, Kitchen Manager .should be reviewed and approved by the Consulting Dietician .All recipes will be followed as written .Adjust the base recipe to the desired amounts by using the following formula On 4/25/17 at 10:59 a.m. the FSM was interviewed. She indicated documentation was lacking to verify the dietician had approved the hand written, modified meatloaf recipe. 3.1-28(a)(1) 3.1-28(a)(2)

Based on observation, interview and record review the facility failed to ensure staff washed their hand or preformed hand hygiene in-between the meal services to each resident, after touching contaminated surfaces and/or before assisting residents with meals and/or feeding residents their meals in 1 of 1 dining room, with the potential to affect 23 of 23 residents who received food and beverages provided by the facility. Findings include: 1. During observation of Dining Services for the Health Care Dining room on 4-17-17 from 12:01 p.m. through 12:35 p.m., the following was observed: At 12:03 p.m., Dietary Staff 15 was observed to handle the plates of food and dessert with her thumbs on the top of the plate rims. She then handed the plates of food to Dietary Staff 16, who served a resident. Dietary Staff 15 was observed to push her eye glasses up on her face with her hand. She then retrieved a coffee mug from the shelf and went back to the steam table and plated another lunch meal. Dietary Staff 15 was not observed to wash her hands or perform hand hygiene after she touched her eye glasses or before plating the food. At 12:05 p.m., Dietary Staff 16 was observed to talk on the telephone, which was located on the wall outside of the Health Care Kitchen's door and then hung up the phone receiver. She then talked to a resident about a peanut butter and jelly sandwich, which the resident had requested. Dietary Staff 16 was observed to pick up the telephone receiver, dial a phone number and then talked to the main kitchen about the resident's sandwich order. Dietary Staff 16 was then observed to hang up the phone receiver and she stood in the doorway of the Health Care Kitchen waiting for the next plate to be served. Dietary Staff 16 was not observed to perform hand washing or hand hygiene after touching the telephone or before serving another resident. At 12:06 p.m., while Dietary Staff 16 was waiting on the next plate to be served, she was observed to touch the side of her nose with her hand. She then entered the kitchen, retrieved a bundle of silverware, which was wrapped in a cloth napkin. She delivered the wrapped silverware to a resident. Dietary Staff 16 was not observed to wash her hands or perform hand hygiene after touching her nose or before retrieving the wrapped silverware to provided to a resident. Dietary Staff 16 returned to the kitchen doorway to retrieve plates of food and dessert to serve to another resident. Dietary Staff 16 was not observed to perform hand washing or hand hygiene before she served the plates of food to a resident. At 12:07 p.m., Dietary Staff 15 handled the plated food and dessert, with both of her thumbs touching the top of the rims of the plates, and handed the plates to Dietary Staff 16. Dietary Staff 16 was not observed to perform hand hygiene or hand washing in-between each of the plates served to residents. At 12:08 p.m., Dietary Staff 16 delivered 2 beverages to 2 different residents at 2 different tables, she then returned to the Health Care Kitchen door and retrieve a plates of food and dessert from Dietary Staff 15, who had her thumbs on the top of the rims of the plates as she handed the plates to Dietary Staff 16 to deliver to a resident. Dietary Staff 16 was not observed to perform hand washing or hand hygiene before serving the plates of food and dessert to a resident. At 12:10 p.m., Dietary Staff 16 was not observed to perform hand washing or hand hygiene before she delivered another lunch meal plate and dessert to a resident. At 12:11, CNA 17 (Certified Nurse Aide) was observed to washed her hands with soap and water in the kitchenette sink, she lathered her hands for 24 seconds before rinsing them with water. She dried her hands with clean dry paper towel and turned off the water with with a clean, dry paper towel. She walked to the Health Care Kitchen door and was talking to the Dietary Staff 16. CNA 17 was observed to put both of her hands on her hips as she talked. CNA 17 then turned around to walk back into the dining area. She was observed to use both of her hands to pull up her uniform pants at the waistband. CNA 17 then touched the dining room chair while she talked to 4 residents seated at the table. She then touched a resident's wheelchair and patted the resident on their back. CNA 17 was then observed to retrieve a plastic cup and dispensed a glass of fruit infused water from a beverage dispenser that was on the kitchenette countertop. CNA 17 was then observed to moved the dining chair out from the table with one hand on the back of the chair. She sat the glass of water on the table and seated herself in-between 2 residents. She was observed to pull the chair up to the table using her right hand on the arm of the chair to pull it up to the residents. The CNA took a sip of the water and visited with the residents. The CNA was observed to pat the resident on their right shoulder with her left hand. At 12:13 p.m., Dietary Staff 15 was observed to stand in the Health Care Kitchen doorway; holding a meal and dessert plate, one plate in each hand. Her thumbs were observed to be on the top rims of the plates and she handed the plate to Dietary Staff 16 to be served to a resident. At 12:14 p.m., CNA 17 was observed to open the silverware rolled in a cloth napkin. CNA 17 was not observed to wash her hands or perform hand hygiene after she had touched her uniform, the chair, and a resident. CNA 17 was observed to hand the silverware to the resident to use to eat. She then picked up the cloth napkin and placed the napkin on the resident lap. CNA 17 was then observed to rest the side of her face on her right hand and placed her left hand on the armrest of the resident's wheelchair as she talked with the resident. At 12:16 p.m., CNA 17 was observed to adjust the resident's cloth napkin. She was not observed to perform hand hygiene after touching her face and the resident's wheelchair or before touching the residents cloth napkin. At 12:18 p.m. through 12:21 p.m., Dietary Staff 15 was observed 4 additional times to handle the plates of food and dessert plates with her thumbs on the top of the plates rims as she handed the plates to Dietary Staff 16 which were served to the residents. Dietary Staff 16 was not observed to perform hand washing or hand hygiene in-between serving residents' their meals. At 12:20 p.m., CNA 17 was observed to touch the corner of her own mouth, and then pull the resident's wheelchair up closer to the table with her left hand. The CNA then moved the resident's small bowl of mashed potatoes and gravy in front of the resident to eat. CNA 17 was not observed to perform hand hygiene after touching herself and the wheelchair or before moving the resident's bowl of food to eat. At 12:22 p.m., Dietary Staff 15 was observed to have her thumbs on the top of the plates rims as she handed the meal plates to Dietary Staff 16. Dietary Staff 15 was observed to push her eye glasses up on her nose with one hand. She then returned to the steam table to plate the food for another resident. Dietary Staff 15 was not observed to perform hand washing or hand hygiene after touching her eye glasses. The plated food was served to a resident by Dietary Staff 16. At 12:24 p.m., Dietary Staff 15 was observed to have her thumbs on the top of the plate rims as she handed a meal plate to Dietary Staff 16. Dietary Staff 16 was not observed to perform hand washing or hand hygiene in-between each resident served. At 12:33 p.m., CNA 18 was observed to use her foot to move a chair up to be seated between 2 residents. The CNA was observed to retrieve a bottle of hand sanitizer from the pocket of her uniform, squirted the hand sanitizer onto her hand and rubbed her hands together for 10 seconds. She then pulled the pocket of her uniform top open with her fingers and put the bottle of hand sanitizer back into her pocket. She then proceeded to assist the 2 residents to eat their lunch meal. CNA 18 then stood up to adjust the cloth napkin and tucked the corner of the napkin in the collar of the resident's shirt. CNA 18 then returned to her chair, pulled the chair up with her foot and was seated between the 2 residents. She then removed the bottle of hand sanitizer from her uniform pocket, squirted the sanitizer onto her hand, rubbed her hands for 4 seconds. She then assisted the 2 residents to eat their meal. 2. During observation of dining services in the Health Care Dining room on 4-21-17 from 11:55 a.m. through 12:35 p.m., 21 residents were served their lunch meal and the following was observed: At 12:00 p.m., Dietary Staff 15 was observed to apply lip balm (a protective moisturizer) to her lips, she returned the lip balm stick into the pocket of her pants. She then washed her hands with soap and water in the Health Care Kitchen sink, lathered her hands for 25 seconds before rinsing her hands with water, then dried her hands with clean paper towels. Dietary Staff 15 was then observed to push up her glasses on her nose with her hand. She then retrieved the serving utensils and placed the utensils into food on the steam table. At 12:05 p.m., Dietary Staff 15 came to the doorway of the kitchen and asked the CNA 19 if she was ready to begin the lunch meal services. At 12:10 p.m., Dietary Staff 15 was observed in the kitchen to pick up a plate with her thumb touching the top rim of the plate and plated food from the steam table. She then picked up the dessert plate with her thumb touching the rim of the plate and handed the plates to the CNA 19. CNA 19 then delivered the plates to a resident. The CNA was observed to cut up the resident food with silverware and placed the silverware on the side of the plate for the resident to use. CNA 19 was observed to removed the bottle of hand sanitizer from her pocket, squirted the hand sanitizer on her hand, replaced the bottle of sanitizer back into her pocket and rubbed her hands together for 12 seconds. CNA 19 then returned to the kitchen door for another plate of food to serve a resident. At 12:13 p.m., Dining Staff 16 arrived to the Health Care Dining room. She was observed to enter the kitchen and she washed her hands with soap and water, lathered her hands for for 22 seconds before rinsing them with water, dried her hands with clean paper towel and turned off the water with dry clean paper towel. She then began serving the resident. Dietary Staff 15 was observed to hand Dietary Staff 16 the 2 plates. Dietary Staff 15 was observed to have her thumbs on the top of the plates rims as she handed the plates to Dietary Staff 16. At 12:14 p.m., Dietary Staff 16 was not observed to perform hand washing or hand hygiene after serving a meal to one resident and before retrieving the next plate to serve to a resident. Dietary Staff 15 was observed to have her thumbs on the top of the plates rims when she handed the plate to Dietary Staff 16. At 12:15 p.m., Dietary Staff 16 was observed to use hand sanitizer, squirted the sanitizer on her hand and rubbed hands for 5 seconds after she had served the 3rd plate. Dietary Staff 15 was observed to have her thumbs on the top of the plate rims when she handed the plate to Dietary Staff 16. From 12:16 p.m. to 12:21 p.m., there were multiple observations of Dietary Staff 15 touching the top of the plate rims while she was plating the food from the steam table. She was observed to touch the top of the plate rims when she carried the plates to the kitchen door to hand the plates of food to Dietary Staff 16. Dietary Staff 16 was also not observed to perform hand washing or hand hygiene in-between serving the plates of food to the residents. At 12:20 p.m., Dietary Staff 16 was observed to perform hand hygiene with hand sanitizer. She squirted the sanitizer onto her hand and rubbed her hands for 4 seconds before she served another plate to a resident. At 12:35 p.m., the last resident was served their lunch meal. 3. An interview with the Dietary Staff 15 on 4-24-17 at 8:50 a.m., indicated she was the dietary staff who read the resident's meal tickets and dished up the food for the residents. She indicated her hands should be washed for 45-60 seconds or she would sing the Happy Birthday song 2 times through. She also indicated hands should be washed in-between serving each resident. She indicated the plates should be handled from the underside, not touching the top of the plate's rim. She further indicated during breakfast she was usually the only dietary staff working in the Health Care Kitchen. She further indicated she should wash her hands every time she entered the kitchen. She further indicated Dietary Staff 16 assisted her in serving the lunch meals. An interview with the FSM (Food Service Manager) on 4-24-17 at 2:55 p.m., indicated the staff should perform handwashing for 45 to 50 second for the entire hand washing procedure. She indicated the staff need to wash their hands with soap and water upon entering the kitchen and whenever an action or task was changed. An example would be of serving beverages and then assisting residents with chairs or cutting their food, the staff should wash their hands. She also indicated hands should be washed when resuming a task which had been interrupted. She also indicated it was not a practice of the dietary department to use hand gel sanitizer. She indicated hands should be washed with soap and water after touching any contaminated surface, including touching themselves (such as touching their uniform or their face or pushing up their eye glasses). She also indicated the staff should wash their hands after every 3rd plate or sooner if a contaminated surface was touched, for example, a resident or a chair. She further indicated she was not sure how long hand gel sanitizer should be rubbed on the hands because it was not the practice of dietary department to use hand sanitizer. The FSM also indicated plates and bowls should be handled from the underside of the plate or bowl, or if cupped in the palm of the hand the outer rim of the plate could be touched to balance the plate. She indicated the staff's thumb or fingers should not be near the food. She also indicated dietary staff and nursing staff should wash their hands after touching contaminated surfaces, such as the arms of a chair or a resident and before assisting a resident to eat their meal. An interview with the DON (Director of Nursing) on 4-24-17 at 3:25 p.m., indicated the staff should wash their hands with soap and water for 40 to 60 seconds for the entire process. She indicated the staff should wash their hands with soap and water prior to the dining services. She also indicated hand gel sanitizer could be used to sanitize their hands when contaminated. She indicated their hands should be washed with soap and water if viably soiled. She further indicated hand hygiene should be done if the staff touched themselves or a contaminated surface, such as a chair, a resident and/or their uniform. She indicated hand hygiene should be done before assisting a resident to eat. The DON indicated she could provide a copy of the posters the facility had posted for hand washing and also for the use of hand sanitizer which included the length of time the procedures need to be done. On 4-24-17 at 3:46 p.m., the DON provided a copy of the facility's currently posted non-dated poster, titled , How to Handrub? published by the World Health Organization, Patient Safety, SAVE LIVES, Clean Your Hands. The poster indicated, .RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED .Duration of the entire procedure 20-30 seconds .1a and 1b: Apply a palmful of the product in a cupped hand, covering all surfaces; 2: Rub hands palm to palm; 3: Right palm over left dorsum (upper or back of the hand) with interlaced fingers and vice versa (the other way around or other hand); 4: Palm to palm with fingers interlaced; 5: Backs of the finger to opposing palms with fingers interlaced; 6: Rotational rubbing of left thumb clasped in right palm and vice versa; 7: Rotational rubbing backwards and forwards with clasped fingers of the right hand in left palm and vice versa; 8: Once dry your hands are safe On 4-25-17 at 10:00 a.m., the FSM provided a current policy she indicated she had worked on for hand washing. During the interview with the FSM, she indicated she was working on the other policy for handling of plates and dishware. She indicated she had been cooking this morning and had not had time to finish the policy at this time. She further indicated she did not have a policy for the use of hand sanitizer in dietary department because it was not a practice of the dietary staff to use hand sanitizer. On 4-27-17 at 10:00 a.m., the FSM provided the current non-dated policy, titled, Policy & Procedure Subject: Hand Washing .Food and Nutritional Services which indicated, .Policy: Employees will use proper hand washing techniques to prevent the spread of infection. Also, hand washing will take place before starting food services and before starting any new tasks Procedure: 1. a) Hands must be washed before starting your shift and before gloves are used. Gloves are not a substitute for hand washing b) Any time your enter the kitchen to start working with food hands should be washed c) Before services of meals and passing plates, hands should be washed d) Anytime you stop doing a task and start doing another task that requires clean hands you must rewash your hands 2) a) Wet hands with warm, running water b) Add soap and rub well (for at least 45-60 seconds), especially between fingers and around and underneath fingernails c) Rinse thoroughly with warm running water d) Wipe dry with disposable paper towels e) Turn off water faucet with paper towels f) Do not lift garbage can lid with hands to dispose of paper towels. On 4-25-17 at 10:56 a.m., the FSM provided a current non-dated policy she had written, titled Policy & Procedure Subject: Handling Dishes .Section: Food & Nutritional Services which indicated, .Policy: The purpose of this policy is to properly handle dishes and utensils safely Procedure: 1. a) Wash your hands before putting away dishes and utensils .b) Touch only the edges of plates and saucers .c) Touch only the outside of the glasses and cups .d) Touch only the handles of utensils .e) Place utensils with the handles pointing out towards you .f) The incorrect way to handle a dish or utensil is placing a thumb or finger on the rim .g) When serving residents, employees, visitors always use a clean plate or cup if they would like additional food or drink On 4-25-17 at 11:43 a.m., the Administrator provided the facility's currently posted, non-dated, poster, titled, How to Handwash? published by the World Health Organization, Patient Safety, SAVE LIVES, Clean Your Hands. The poster indicated, .WASH HANDS WHEN VISIBLY SOILED! OTHERWISE USE HANDRUB .Duration of the entire procedure 40-60 seconds .0: Wet hand with water; 1: Apply enough soap to cover all hand surfaces; 2: Rub hands palm to palm; 3: Right palm over left dorsum with interlaced fingers and vice versa; 4: Palm to Palm with fingers interlaced; 5: Backs of the fingers to opposing palms with fingers interlocked; 6: Rotational rubbing of left thumb clasped in right palm and vice versa; 7: Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa; 8) Rinse hands with water; 9) dry hands thoroughly with a single use towel; 10) Use towel to turn off faucet; 11: Your hands are now safe 3.1-21(i)(2)

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately to the Administrator for 1 of 3 incidents reviewed for allegations of abuse. (Resident 14) Findings include: The clinical record of Resident 14 was reviewed on 4/20/17 at 1:40 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) Assessment, dated 3/20/17, included the following: cognition was identified as moderately impaired; and Resident 14 did experience delusions (misconceptions/behaviors that are firmly held, contrary to reality). Nurses note dated, 1/14/17 at 9:23 p.m., indicated Resident put call light on for assistance, CNA (Certified Nurse Aide) entered room .CNA (12) reported .resident told her to get out of room. Resident put her light on a second time et (and) CNA responded. Resident grabbed CNA's arm and was holding her so the police could come. Nurses note was documented by LPN (Licensed Practical Nurse) 11. Nurses note dated, 1/14/17 at 9:24 p.m., indicated Writer at nurses station charting et heard resident calling out after (name of CNA 12) left the room. Unable to make out what resident was saying. Resident then put her light on and writer had a different CNA (13) answer her light. Nurses note was documented by LPN 11. Nurses note dated, 1/14/17 at 9:25 p.m., indicated Resident told CNA 13 that CNA 12 hit her and that she was calling the police. CNA 13 reassured the resident that she had not been hit and that CNA 12 is a nice girl however resident is unable to be directed. Nurses note was documented by LPN 11. On 4/20/17 at 1:30 p.m., incidents which were reported to the State Agency for the current year were reviewed. An incident dated, 1/14/17 at 9:30 p.m., indicated the following brief description of incident: 1/16/17, today, Monday January 16, 2017, the Administrator (ADM), Director of Nursing and the Social Service Designee discovered charting from the weekend nurse working the second shift that an allegation of physical abuse and alleged by one of the residents. The resident reported that the second shift CNA (certified nurse aide) had hit her on the arm. The second shift nurse investigated immediately and found no injury to the resident. This information was not reported to the Administrator or Director of Nursing at the time the allegation was made by the resident. The resident has a [DIAGNOSES REDACTED]. The resident has a history of [MEDICATION NAME] use. There is some concern that she is experiencing withdrawal symptoms as a result .Type of Injury: 1/16/17, no injury sustained by the resident .Actions taken .resident was assessed with [REDACTED]. The CNA (name of CNA involved in allegation) was suspended pending investigation. Investigation initiated immediately .Physician and family notified . On 4/20/17 at 1:52 p.m., the DON (Director of Nursing) was interviewed. She indicated the following regarding the incident on 1/14/17 at 9:30 p.m., which involved Resident 14: the Administrator was not made aware of this incident until he, the DON and the Social Service designee, reviewed nurses notes from the weekend on Monday, 1/16/17. She indicated the nurse, LPN 11 was aware the incident occurred but she did not notify the ADM immediately. At this time, the DON reviewed the nursing schedule to see if CNA 12 was sent home after LPN 11 was made aware of the allegation of abuse. The DON indicated CNA 12 was not sent home that shift, but did not work on 1/15/17. The DON indicated CNA 12 only works weekends. The DON indicated 2 CNAs worked the entire shift and 1 CNA worked a partial shift on 1/14/2017. The DON reviewed her records and indicated the census would have been approximately 25, so CNA(12) would have cared for only 8 residents. The DON indicated LPN 11 did assess the resident's skin after the incident with no findings. She indicated the nurse should have notified the Administrator immediately of the allegation and CNA 12 should have been sent home until investigation of the incident was completed. The DON indicated once the ADM was made aware of the allegation, a report was filed with the State Agency, the Sheriff Department was contacted and an investigation was initiated. She indicated statements were obtained from residents and also other staff. She indicated the results of the investigation indicated the allegation was unsubstantiated. On 4/21/17 at 11:42 a.m., the Social Service Designee (SSD) was interviewed. He indicated he was the facility contact for Abuse. He indicated when the nurse and/or CNA were made aware of the allegation of CNA 12 hurting Resident 14, the nurse should have contacted the ADM and the DON immediately. He indicated CNA 12 should have been send home until the investigation was complete. The SSD indicated after the investigation was completed, it was determined the allegation was unsubstantiated. He indicated the facility provided abuse training at least twice a year but now they will be providing abuse training quarterly. A current policy, Abuse Prevention, dated 7/2011, was provided by the Director of Nursing on 4/20/17 at 12:25 p.m. The policy included the following information: It is the policy of this facility to provide each resident with an environment .free from verbal .physical .abuse .abuse investigation .employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the administrator .allegations of abuse are reported to the state survey agency .reporting abuse to .It is the responsibility of our employees .to promptly report any incident, suspected incident or allegation .or resident abuse .to facility management .Employees .must report any suspected abuse, allegation of abuse or incidents to the Administrator immediately .The following information should be report to the nurse supervisor, Director of Nursing .or .the Administrator .name of resident .date and time incident . 3.1-28(c)

Based on interview and record review, the facility failed to ensure the facility policy and procedure for Abuse Prevention was followed for 1 of 3 incidents reviewed for allegations of abuse. (Resident 14) Findings include: The clinical record of Resident 14 was reviewed on 4/20/17 at 1:40 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) Assessment, dated 3/20/17, included the following: cognition was identified as moderately impaired; and Resident 14 did experience delusions (misconceptions/behaviors that are firmly held, contrary to reality). Nurses note dated, 1/14/17 at 9:23 p.m., indicated Resident put call light on for assistance, CNA (Certified Nurse Aide) entered room .CNA (12) reported .resident told her to get out of room. Resident put her light on a second time et (and) CNA responded. Resident grabbed CNA's arm and was holding her so the police could come. Nurses note was documented by LPN (Licensed Practical Nurse) 11. Nurses note dated, 1/14/17 at 9:24 p.m., indicated Writer at nurses station charting et heard resident calling out after (name of CNA 12) left the room. Unable to make out what resident was saying. Resident then put her light on and writer had a different CNA (13) answer her light. Nurses note was documented by LPN 11. Nurses note dated, 1/14/17 at 9:25 p.m., indicated Resident told CNA 13 that CNA 12 hit her and that she was calling the police. CNA 13 reassured the resident that she had not been hit and that CNA 12 is a nice girl however resident is unable to be directed. Nurses note was documented by LPN 11. On 4/20/17 at 1:30 p.m., incidents which were reported to the State Agency for the current year were reviewed. An incident dated,1/14/17 at 9:30 p.m., indicated the following brief description of incident: 1/16/17, today, Monday January 16, 2017, the Administrator (ADM), Director of Nursing and the Social Service Designee discovered charting from the weekend nurse working the second shift that an allegation of physical abuse and alleged by one of the residents. The resident reported that the second shift CNA (certified nurse aide) (12) had hit her on the arm. The second shift nurse investigated immediately and found no injury to the resident. This information was not reported to the Administrator or Director of Nursing at the time the allegation was made by the resident. The resident has a [DIAGNOSES REDACTED]. The resident has a history of [MEDICATION NAME] use. There is some concern that she is experiencing withdrawal symptoms as a result .Type of Injury: 1/16/17, no injury sustained by the resident .Actions taken .resident was assessed with [REDACTED]. The CNA (name of CNA involved in allegation) was suspended pending investigation. Investigation initiated immediately .Physician and family notified . On 4/20/17 at 1:52 p.m., the DON (Director of Nursing) was interviewed. She indicated the following regarding the incident on 1/14/17 at 9:30 p.m., which involved Resident 14: the Administrator was not made aware of this incident until he, the DON and the Social Service designee, reviewed nurses notes from the weekend on Monday, 1/16/17. She indicated the nurse, LPN 11 was aware the incident occurred but she did not notify the ADM immediately. At this time, the DON reviewed the nursing schedule to see if CNA 12 was sent home after LPN 11 was made aware of the allegation of abuse. The DON indicated CNA 12 was not sent home on 1/14/2017, but did not work on 1/15/17. The DON indicated CNA 12 only works weekends. The DON indicated 2 CNAs worked the entire shift and 1 CNA worked a partial shift on 1/14/17. The DON reviewed her records and indicated the census would have been approximately 25, so CNA 12 would have cared for about 8 residents. The DON indicated LPN 11 did assess the resident's skin after the incident with no findings. She indicated the nurse should have notified the Administrator immediately of the allegation and CNA 12 should have been sent home until investigation of the incident was completed according to their policy. The DON indicated once the ADM was made aware of the allegation, a report was filed with the State Agency, the Sheriff Department was contacted and an investigation was initiated. She indicated statements were obtained from residents and also other staff. She indicated the results of the investigation indicated the allegation was unsubstantiated. On 4/21/17 at 11:42 a.m., the Social Service Designee (SSD) was interviewed. He indicated he was the facility contact for Abuse. He indicated when the nurse and/or CNA were made aware of the allegation of CNA 12 hurting Resident 14, the nurse should have contacted the ADM and the DON immediately. He indicated CNA 12 should have been send home until the investigation was complete. The SSD indicated after the investigation was completed, it was determined the allegation was unsubstantiated. He indicated the facility provided abuse policy training at least twice a year but now they will be providing abuse training quarterly. A current policy, Abuse Prevention, dated 7/2011, was provided by the Director of Nursing on 4/20/17 at 12:25 p.m. The policy included the following information: It is the policy of this facility to provide each resident with an environment .free from verbal .physical .abuse .abuse investigation .employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the administrator .allegations of abuse are reported to the state survey agency .reporting abuse to .It is the responsibility of our employees .to promptly report any incident, suspected incident or allegation .or resident abuse .to facility management .Employees .must report any suspected abuse, allegation of abuse or incidents to the Administrator immediately .The following information should be report to the nurse supervisor, Director of Nursing .or .the Administrator .name of resident .date and time incident . 3.1-28(a)

Based on observation, interview and record review, the facility failed to implement fall interventions for 1 of 3 residents reviewed with falls. The facility also failed to investigate 3 accidents in a sample of 4. (Resident 27 and Resident 44) Findings include: 1. Review of Resident 27's clinical record on 4/19/17 at 4:36 p.m. Resident 27's [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) admission assessment dated [DATE], indicated Resident 27 had a BIMS (Brief Interview of Mental Status) score of 8 out of 15, meaningResident 27 had moderate cognitive impairment. Resident 27's functional status indicated a limited assistance with 1 person assist for bed mobility, transfers and walking in room. The assessment also indicated the following: Resident 27 walked in the corridor with supervision and 1 person physical assist, locomotion on the unit was limited assistance with 1 person physical assist and locomotion off the unit only occurred once or twice with 1 person physical assist. An Incident Note dated 3/27/17 at 8:47 p.m., indicated .Writer called to residents room by CNA (Certified Nurse Aide) with report that resident was on the floor. Writer entered room et (and) noted resident sitting on her buttocks at the foot of her bed without proper foot wear on. Writer asked resident how she fell , to which resident stated 'I lost my balance getting stuff out of my dresser to get ready for bed.' Writer noted several items sitting on the floor (powder, mouth wash, lotion). V/S (vital signs) obtained et recorded. ROM ( Range of Motion) WNL (Within Normal Limits) for this resident. Resident assisted to a standing position by writer et CNA. Resident denies any pain/discomfort. Gait WNL for this resident. Ambulated x (times) 1 assist to the bathroom for HS (bedtime) care. No injuries noted at this time. Resident denies hitting her head. MD (Medical Doctor), DON (Director of Nursing), ADON (Assistant Director of Nursing), Administrator and family made aware On 4/17/17 at 3:55 p.m., Resident 27 was observed in her room, and had walked by herself to a reclining chair in the corner, beside the bed. On 4/19/17 at 11:33 a.m., Resident 27 was observed in her room, lying in bed and indicated she had a headache. The resident indicated she had fallen too much. On 4/20/17 at 1:45 p.m., Resident 27 was observed out of her room using a rolling walker She indicated she was going to the dining room. On 4/25/17 at 11:04 a.m., Resident 27 was observed in her room, as she walked around the bed, a walker was parked at the foot of the bed, with personal hygiene items on the seat. The resident indicated she did not feel well. Fall Reports and care plans reviewed for falls dated on 2/10/17, 3/9/17 and 3/30/17 indicated interventions were initiated, implemented and added to the care plans after a fall had occurred. A review of the Fall Report dated on 3/27/17 indicated no initiated or implemented intervention after Resident 27's fall on 3-27. An interview with the DON ( Director of Nursing), on 4/24/17 at 2:33 p.m., indicated the IDT (Interdisciplinary Team) meet before morning meeting to discuss clinical information of residents and indicated this meeting included discussion of resident falls. The DON indicated a form was used in the meeting with the topics of discussion listed and no IDT notes were entered into the facility computer system, she also indicated Resident 27 had a history of [REDACTED]. The DON indicated she tracks and trends all resident falls, and intervention should have been put in place to prevent falls after the fall on 3-27. An interview with CNA (Certified Nurse Aide) 88, on 4/25/17 at 11:07 a.m., indicated Resident 27 needed supervision from staff at times and will put her call light on. CNA 88 indicated that Resident 27 had fallen a lot due to balance. CNA 88 indicated the CNA's had 3 assignment lists for the residents, titled Care At A Glance. CNA 88 indicated Resident 27 was on the list, marked as a fall risk and 1 assist. CNA 88 indicated the lists are updated by the nurse when plan of care changes. A current policy, titled Fall Prevention and Assessment, dated 9/2012, provided by the DON on 4/24/17 at 3:10 p.m., indicated under the Treatment/ Management section 1. .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, unit falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) A current policy, titled Interdisciplinary Team Process, dated 10/2010, provided by the DON on 4/25/17 at 10:59 p.m., indicated under Policy Interpretation and Implementation: .Appropriate interventions will be implemented based upon the resident's MDS, overall plan of care, and the interdisciplinary team assessments . The policy also indicated under Daily Clinical Meeting, section 3; Fall/Incident Reports; Residents who fall will be reviewed daily (M-F) during this clinical meeting. Review the clinical record, the incident report, the care plan, and the CNA/Resident Care assignment sheet. An IDT intervention note should be written at this time in the clinical record. Documentation should include an analysis of the fall to assure appropriate fall prevention strategies are implemented. Update the care plan and the CNA/Resident Care assignment sheet at this time 4. Resident 44's clinical record reviewed on 4/24/17 at 2:43 p.m. Resident 44's [DIAGNOSES REDACTED]. An Admission Care Plan review indicated a Fall Risk/Safety Risk/Elopement Risk was dated 11/22/16 and interventions were initiated. The assessment had a score of 17 which was considered high risk for falls. A review of the Nursing Admission assessment dated [DATE] indicated resident was oriented to person and place further indicated cognition function was intact with short term deficits. A progress note dated 11/26/16 at 8:00 a.m., indicated the resident was found on the floor in his room on 11/26/2016 at 7:35 a.m., with injuries to both knees and a bump on the left side of his head. The note also indicated the physician and family were notified of fall. In an interview, the DON, on 4/20/17 at 12:25 p.m., indicated there were no fall investigations for Resident 44's fall on 11/26/16. The DON indicted she did not feel an investigation was needed. A current policy, titled Accidents and Incidents-Assessing, Investigating and Reporting, dated 4/2011 and provided by the DON on 4/20/2017 at 2:17 p.m. indicated .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated 3.1-45(1)

Based on interview and record review, the facility failed to ensure a Hospice nurse informed the facility of an allegation of abuse which had been reported to her by a resident. (Resident #20) The facility further failed to ensure an allegation of abuse was thoroughly investigated prior to the alleged staff member returning to work. The deficient practice had the potential to affect all 30 residents in the facility. Findings include: On 3/9/16 at 3:30 p.m., the clinical record of Resident #20 was reviewed. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 2/23/16 included, but was not limited to, the following: total cognitive score of 15, which indicated independent cognition. A care plan with a revision date of 7/21/15, included but was not limited to, the following: (Resident #20) is on Hospice for [MEDICAL CONDITIONS] .Goal: Hospice will provide (Resident #20) with services and collaborate with facility staff to meet needs On 3/9/16 at 3:35 p.m., the Hospice chart, included, but was not limited to, the following: 2/19/16 at 2:00 p.m .Focus of visit: routine .Patient/Caregiver Issues: (Resident #20) is tearful as she talks about a night nurse that is cruel to her; she has increased anxiety for fear the nurse won't give her the needed medication. Writer assures her that a follow up with (sic) be made with the DON (Director of Nursing) when she returns next week but (Resident #20 name) needs to be sure to ask for what she needs .Spoke with: NF (name of nursing facility nurse) updated on visit .mental status: alert,oriented . This note was electronically signed by the Hospice RN on 2/20/16 at 2:19 p.m. On 3/9/16 at 3:45 p.m., the DON (Director of Nursing) was interviewed. She indicated the facility was not aware of any allegations of reported abuse in February 2016. The DON reviewed the Hospice note that had been documented on 2/19/16. She indicated she was not aware of this incident. The DON indicated she and the hospice nurse communicated frequently. The DON indicated the Hospice nurse did not communicate anything to her regarding the comment that was made by the resident on 2/19/16. A Social Service, note dated 3/9/16 at 5:33 p.m., indicated the following: Writer was informed by DON concerning a note that was written in a Hospice nurses note on 2/19/16, indicating (Resident #20) might be afraid of a nurse. Writer and DON talked with (Resident #20) concerning this. She stated she had not told us about her being afraid, but at the one moment she had felt that way. We asked if she felt that way now and she stated she did not. She stated that she felt safe even with the individual that she was referring to. Investigation began and initial report done. On 3/10/16 at 9:00 a.m., the DON was interviewed. She indicated they had started an investigation of the situation which they had been made aware of on 3/9/16 at 3:45 P.M. She indicated as of this time, the investigation included, but was not limited to, the following: She had interviewed staff to see if they had ever witnessed a coworker being rude or disrespectful to a resident. She provided documentation, which indicated she had interviewed 7 staff so far, with no staff having ever witnessed a coworker being rude or disrespectful. The staff interviews to date, included 4 CNAs (certified nursing assistants), 2 LPNs (Licensed Practical Nurses) and 1 RN (Registered Nurse). The DON indicated she and the Social Service Director (SSD) had talked to Resident #20 yesterday and she was not currently fearful. The DON indicated she had not talked to the Hospice nurse, who documented the note on 2/19/16, as that nurse was no longer employed by the hospice company. The DON indicated the Hospice nurse should have immediately made the facility aware of the documented incident. On 3/10/16 at 10:22 a.m., the DON was interviewed. She indicated the nurse who was involved in the allegation was LPN #20. The DON indicated she had spoken with LPN #20 and completed a communication paper on her in response to the allegation of abuse. The DON indicated LPN #20 worked again last night because Resident #20 indicated during interview yesterday, that she was not currently fearful. At this time, the DON provided a copy of a progress note, which the Social Service Director, had documented on 3/10/16 at 10:11 a.m. The note included the following: Writer clarified with (Resident #20) about what she was afraid of, she stated that she was concerned that she would not have received the medication she needed but she was not afraid of the nurse. Once again she states that she is not fearful now and she believes that she will receive her medication as needed. On 3/10/16 at 10:45 a.m., the current nursing schedule was reviewed. The schedule indicated LPN #20 had been scheduled to work 3/9/16 from 6 p.m. to 2 a.m. (3/10/16). The schedule indicated, in addition to the nurse, there were at least 2 CNAs scheduled to work the evening shift. The schedule indicated for the night shift, LPN #20 worked until 2 a.m. with 1 CNA. On 3/10/16 at 11:15 a.m., the Social Service Director was interviewed. He indicated the following: after the DON was made aware of the documented allegation of abuse by the Hospice nurse, he and the DON went and talked to the resident yesterday. He indicated the resident had indicated that the facility nurse (LPN #20) had talked to the resident about incontinence issues. The SSD indicated he thought that if the resident perceived the nurse had been upset with her about incontinence issues, then she (LPN #20) would not give the resident her pills. The SSD indicated this is what the resident inferred. The SSD indicated, after he and the DON talked to the resident, they made sure the resident felt safe and then they started the investigation and reporting. The SSD indicated he had not interviewed any residents on 3/9/16 but interviewed 4 residents this morning regarding the allegation of abuse. He indicated when his investigation had been completed, he will have interviewed 10-12 residents. He indicated LPN #20 had been permitted to work last night, based on the fact the resident stated she was not afraid. He indicated the investigation of this situation was ongoing and would be completed today or tomorrow. On 3/11/16 at 8:38 a.m., the Social Service Director was interviewed. He indicated he did not have his resident interviews completed at this time but would do so today. On 3/11/16 at 9:30 a.m., the Administrator was interviewed. He indicated the hospice nurse should have reported the allegation of abuse (documented on 2/19/16) by Resident #20 to the facility staff immediately. The Administrator indicated he was aware that LPN #20, had worked on the night of 3/9/16, after the facility was made aware of the documented allegation. The Administrator was also made aware the facility policy regarding Abuse investigation indicated the facility should interview other residents concerning allegations. He was also made aware LPN #20 had been permitted to work even though the additional resident interviews had not been completed. The Administrator indicated the facility had taken this situation very seriously and LPN #20 was currently removed from the schedule. The Administrator indicated he thought Hospice staff should be trained in abuse prevention. He also indicated the Hospice Nurse should have made the facility aware of the allegation of abuse immediately. On 3/11/16 at 10 a.m., the Social Service Director was interviewed. He indicated he completed two more resident interviews this morning in regards to abuse. He indicated there was a total of 30 residents in the facility and of those, at least 17 were considered alert, oriented and reliable for an interview. He indicated he had interviewed a total of 15 residents and none of those residents had voiced a concern regarding abuse. 3.1-28(c) 3.1-28(d) 3.1-28(e)

Base on interview and record review, the facility failed to ensure their policy and procedure for abuse prevention was followed in regard to reporting an allegation of abuse immediately to the Facility Administrator. The facility further failed to ensure a thorough investigation was completed prior to permitting the alleged staff member to return to work for 1 of 1 allegations of abuse the facility had been made aware of. (Resident #20) This deficient practice had the potential to affect 30 residents who resided in the facility. Findings include: On 3/9/16 at 3:30 p.m., the clinical record of Resident #20 was reviewed. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 2/23/16 included, but was not limited to, the following: total cognitive score of 15, which indicated independent cognition. A care plan with a revision date of 7/21/15, included but was not limited to, the following: (Resident #20) is on Hospice for [MEDICAL CONDITIONS] .Goal: Hospice will provide (Resident #20) with services and collaborate with facility staff to meet needs On 3/9/16 at 3:35 p.m., a binder which contained documentation from (name of Hospice) the hospice company, included, but was not limited to, the following: 2/19/16 at 2:00 p.m .Focus of visit: routine .Patient/Caregiver Issues: (Resident #20) is tearful as she talks about a night nurse that is cruel to her; she has increased anxiety for fear the nurse won't give her the needed medication. Writer assures her that a follow up with (sic) be made with the DON (Director of Nursing) when she returns next week but (Resident #20 name) needs to be sure to ask for what she needs .Spoke with: NF (name of nursing facility nurse) updated on visit .mental status: alert,oriented . On 3/9/16 at 3:45 p.m., the DON (Director of Nursing) was interviewed. She indicated the facility was not aware of any allegations of abuse in February 2016. The DON reviewed the Hospice note that had been documented on 2/19/16 and she indicated she was not aware of this incident. The DON indicated the Hospice nurse did not communicate to her anything in reference to the comment that was made by the resident on 2/19/16. A Social Service, note dated 3/9/16 at 5:33 p.m., indicated the following: Writer was informed by DON concerning a note written in a Hospice nurses note on 2/19/16, indicating (Resident #20) might be afraid of a nurse. Writer and DON talked with (Resident #20) concerning this. She stated that she had not told us about her being afraid, but at the one moment she had felt that way. We asked if she felt that way now and she stated she did not. She stated that she felt safe even with the individual that she was referring to. Investigation began and initial report done. On 3/10/16 at 9:00 a.m., the DON was interviewed. She indicated they had started an investigation of the situation they had been made aware of on 3/9/16 at 3:45 P.M. She indicated the investigation included, but was not limited to, the following: She had interviewed staff to see if they had ever witnessed a coworker being rude or disrespectful to a resident. She provided documentation, which indicated she had interviewed 7 staff so far, with no staff having ever witnessed a coworker being rude or disrespectful. The staff interviews to date, included 4 CNAs (certified nursing assistants), 2 LPNs (Licensed Practical Nurses) and 1 RN (Registered Nurse). The DON indicated she and the Social Service Director (SSD) had talked to Resident #20 yesterday and she was not currently fearful. The DON indicated she had not talked to the Hospice nurse, who documented the note on 2/19/16, as that nurse was no longer employed by the hospice company. The DON indicated the Hospice nurse should have immediately made the facility aware of the documented incident. On 3/10/16 at 10:22 a.m., the DON was interviewed. The DON indicated the nurse who was involved in the allegation was LPN #20. The DON indicated she had spoken with LPN #20 and completed a communication paper on her in response to the allegation of abuse. The DON indicated LPN #20 worked again last night because Resident #20 indicated during interview yesterday, that she was not currently fearful. At this time, the DON provided a copy of a progress note, which the Social Service Director, had documented on 3/10/16 at 10:11 a.m. The note included the following: Writer clarified with (Resident #20) about what she was afraid of, she stated that she was concerned that she would not get the needed medication that she needed not that she was afraid of the nurse. Once again she states that she is not fearful now and that she believes that she will receive her medication as needed. On 3/10/16 at 10:45 a.m., the current nursing schedule was reviewed. The schedule indicated LPN #20 had been scheduled to work 3/9/16 from 6 p.m. to 2 a.m. (3/10/16). The schedule indicated, in addition to the nurse, there were at least 2 CNAs scheduled to work the evening shift. The schedule indicated for the night shift, LPN #20 worked until 2 a.m. with 1 CNA. On 3/10/16 at 11:05 a.m. the Administrator provided a current copy of the policy and procedure for Abuse Prevention, with a revision date of 7/2011. The policy and procedure included, but was not limited to, the following: It is the policy of this facility to provide each resident with an environment that is free from verbal .abuse .We have established policies and procedures that will provide facility personnel with the knowledge and training to further ensure each resident is treated with individual respect and dignity .Our facility's resident rights abuse prevention in-service training programs consist of the following information: .What constitutes abuse, neglect Our facility will .continually monitor our facility's policies, procedures .systems to assist in preventing resident abuse .abuse prevention .program may include .the following .to aid in abuse prevention, all personnel are to report any signs and symptoms of abuse .to their supervisor or to the director of nursing services. The Administrator should then be notified immediately The policy and procedure also included, but was not limited to, the following: All reports of resident abuse .shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, at a minimum .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's .family members, and visitors .Interview other residents to whom the accused employee provides care or services .Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the administrator . On 3/10/16 at 11:15 a.m., the Social Service Director was interviewed. He indicated the following: after the DON was made aware of the documented allegation of abuse by the Hospice nurse, he and the DON talked to the resident yesterday. The SSD indicated he thought if the resident perceived the nurse had been upset with her about incontinence issues, then she (LPN #20) would not give the resident her pills. The SSD indicated this is what the resident inferred. The SSD indicated, after he and the DON talked to the resident, they made sure the resident felt safe and then they started the investigation and reporting. The SSD indicated he interviewed 4 residents this morning and when his investigation has been completed, he will have interviewed 10-12 residents. He indicated LPN #20 had been permitted to work last night, based on the fact the resident stated she was not afraid. He indicated the investigation of this situation was ongoing and would be completed today or tomorrow. He indicated at this time, he had completed 4 resident interviews, in regards to abuse, but was planning on completing 10 to 12 additional resident interviews. On 3/11/16 at 8:38 a.m., the Social Service Director was interviewed. He indicated he did not have his resident interviews completed at this time but would do so today. On 3/11/16 at 9:30 a.m., the Administrator was interviewed. He indicated the hospice nurse should have reported the allegation of abuse (documented on 2/19/16) by the resident to facility staff immediately. The Administrator indicated he was aware that LPN #20, had worked on the night of 3/9/16, after the facility was made aware of the documented allegation. The Administrator was also made aware the facility policy regarding Abuse investigation indicated the facility should interview other residents concerning allegations. He was also made aware LPN #20 had been permitted to work even though the additional resident interviews had not been completed. The Administrator indicated the facility had taken this situation very seriously and LPN #20 was currently removed from the schedule. The Administrator indicated he thought Hospice staff should be trained in abuse prevention. He also indicated the Hospice Nurse should have made the facility aware of the allegation of abuse immediately. On 3/11/16 at 10 a.m., the Social Service Director was interviewed. He indicated he completed two more resident interviews this morning in regards to abuse. He indicated there was a total of 30 residents in the facility and of those, at least 17 were considered alert, oriented and reliable for an interview. He indicated he had interviewed a total of 15 residents and none of those residents had voiced a concern regarding abuse. 3.1-28(a)

Based on interview and record review, the facility failed to develop a care plan for agitation and hallucinations for 1 resident (Resident #25) of 5 residents who met the criteria of unnecessary medication. Findings include: Review of the clinical record for Resident #25 on 3/9/16 at 11:12 a.m., indicated the following: [DIAGNOSES REDACTED]. Resident #25 was admitted to the facility on [DATE]. Physician orders [REDACTED]. dose for behaviors. A Progress Note for Resident #25, dated 2/4/16, indicated she was trying to stand up during exercise class and looked very unsteady. The writer asked her if she could sit down and she started to get agitated. The note also indicated the writer asked if she wanted to participate and she stated NO! The note further indicated Resident #25 asked if she would like to go somewhere else and she stated, yes. The writer removed her from the activity and she was much happier. A Progress Note for Resident #25, dated 2/17/16, indicated she was sitting up on the side of the bed and was refusing to lay back down, stating, I'm going home! The note also indicated she was placed in her wheelchair and brought to the nurses station with staff supervision. The resident stated her folks needed her home. When staff explained her folks knew she was here she got angry and grabbed the writers hand. Resident #25 began repeatedly hitting herself in the head (right forehead) and then (left forehead) with the palm of her hands. The note further indicated the writer was able to give her [MEDICATION NAME] 10 mg in yogurt. A Behavior Monitoring Record for Resident #25, dated for the month of March 2016, indicated she was receiving [MEDICATION NAME] for chronic anxiety, [MEDICATION NAME] for dementia with agitation and hallucinations and [MEDICATION NAME] as a mood stabilizer. The record also indicated her hallucinations were visual and care plan interventions included calm reassurance, validation of feelings/support, encourage to sit and rest, and enter her reality. A facility care plan for Resident #25, with a start date of 2/3/16, indicated the focus area of resident has a [DIAGNOSES REDACTED].) Review of the care plans for Resident #25 did not include a care plan for agitation and hallucinations. Certified Nursing Assistant #1 was interviewed on 3/10/16 at 10:24 a.m. During the interview, she indicated she did not know what specific interventions staff were to follow for the resident's behaviors. Social Service #2 was interviewed on 3/11/16 at 9:30 a.m. During the interview, he indicated a care plan should have been developed for the problems of agitation and hallucinations for Resident #25. He also indicated each discipline was responsible for developing the care plans for residents in their area of expertise. 3.1-35(a) 3.1-35(b)(1)