Every finding on record at Springs of Mooresville, The

Based on observation, interview, and record review, the facility failed to ensure a Braden Scale (an assessment to evaluate a resident's risk of developing pressure ulcer) was completed on a resident who had developed two pressure ulcers while in the facility for 1 of 3 residents reviewed for pressure ulcer. (Resident 42)Findings include: On 6/25/26 at 1:31 p.m., Resident 42 was observed to be resting on his back on a low loss air mattress (specialized mattress to treat or prevent pressure ulcers). On 6/29/26 at 10:05 a.m., Resident 42 was observed to be resting on his back on a low air mattress eating breakfast. On 6/30/26 at 9:38 a.m., Resident 42's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, dementia, and Parkinson's disease. A care plan, dated 6/26/24, indicated Resident 42 was at risk for skin breakdown. An admission Observation and Data Collection, dated 12/29/25 at 3:13 p.m., indicated the Braden Scale score was 11 which indicated Resident 42 was a high risk for pressure ulcers. The clinical record lacked any additional Braden Scale assessments. A Wound Management Detail Report indicated the following:On 5/28/26 at 6:59 p.m., Resident 42 had an unstageable-slough and/or eschar pressure ulcer to the right gluteal (under the buttock) fold. The measurements were 4 cm (centimeters) by 3 cm.On 6/24/26 at 3:24 p.m., Resident 42 had an unstageable pressure ulcer to the sacrum (bone at the base of the spine). The measurements were 3.5 cm x 4 cm. On 6/29/26 at 1:45 p.m., the Nurse Consultant indicated Braden Scale Assessments were completed on admission and quarterly.On 7/1/26 at 2:50 p.m., the Director of Health Services (DHS) indicated Resident 42's clinical record lacked any Braden Scale Assessments since 12/29/25.On 7/1/26 at 3:05 p.m., the DHS provided the facility policy, Guideline for Wound Risk Observation, dated 11/18/25 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .2. A Braden Scale will be completed a minimum of quarterly to identify any changes to risk factors that may predispose them to skin impairment . 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the urinary catheter tubing (flexible tube which passed through the urethra and into the bladder to drain urine) and drainage bag was not touching the floor for a resident with a urinary tract infection for 1 of 1 residents reviewed for urinary catheters. (Resident 66)Findings include: On 6/26/26 at 11:35 a.m., Resident 66 was observed to be sitting in her wheelchair in her room. A urinary drainage bag was observed to be resting on the floor. On 6/26/26 at 11:55 a.m., Resident 66 was observed to be sitting in the dining room eating lunch. A urinary catheter drainage bag was observed to be resting on the floor. On 6/26/26 at 1:46 p.m., Resident 66 was to be resting in a low bed, and the urinary catheter drainage bag was resting on the floor. On 6/30/26 at 1:47 p.m., Resident 66's clinical record was reviewed. The diagnoses included, but were not limited to, sacrum (bone in the lower back) fracture, urinary tract infection (UTI), and neuromuscular dysfunction of the bladder (lacks bladder control due to brain or nerve condition). The admission Observation and Data Collection, dated 6/16/26 at 11:53 p.m., indicated Resident 66 had an indwelling catheter. Her baseline care plan indicated to observe for signs and symptoms of a UTI. The care plan, dated 6/23/26, indicated Resident 66 had a catheter due to neurogenic bladder. Her interventions were to observe the tubing, avoid any obstructions, and to observe for any signs of a UTI. The Physician Order Report indicated the following:Catheter care every shift (start date 6/22/26).Change catheter as needed (start date 6/22/26).Indwelling urinary catheter (start date 6/23/26).Ciprofloxacin (antibiotic) 250 milligrams (mg) twice a day for UTI (start date 6/26/26). The Infection Control Event, dated 6/26/26 at 11:24 a.m., indicated Resident 66 had a UTI. She had a new onset of suprapubic (lower abdomen) pain. The IDT (interdisciplinary team) note, dated 6/26/26 at 11:28 a.m., indicated Resident 66 had increased confusion. Her urine was sent and the culture was indicated. The culture indicated Pseudomonas aeruginosa (bacteria). Resident 66 was started on ciprofloxacin 250 mg twice a day for UTI. On 7/1/26 at 10:22 a.m., Resident 66 was observed to be sitting by the nursing station in her wheelchair. The urinary catheter tubing was observed to be resting on the floor. On 7/1/26 at 11:35 a.m., Resident 66 was observed to be up in her wheelchair in the dining room. The urinary catheter tubing was observed to rest on the floor. During an interview on 7/1/26 at 2:34 p.m., CNA 1 indicated Resident 66 required assistance with all activities of daily living (ADL). The urinary tubing and drainage bag should not touch the floor. On 7/2/26 at 9:14 a.m., Resident 66 was observed to be sitting in her wheelchair at the table beside the nursing station. The urinary catheter tubing was observed to be resting on the floor. At that time, CNA 1 indicated the urinary catheter tubing was on the floor. The urinary catheter tubing needed to be off the floor. On 7/2/26 at 10:05 a.m., the Director of Health Services (DHS) provided the facility policy, Urinary Catheter Care, dated 12/16/24, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .11. Be sure the catheter tubing and drainage bag are kept off the floor . 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to revise a care plan for a resident who experienced significant weight loss for 1 of 1 resident reviewed for nutrition. (Resident 3) Findings include: On 9/20/23 at 2:40 P.M., Resident 3 was observed lying in bed in her room. The resident appeared thin in the face and all extremities. On 9/20/23 at 3:05 P.M., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, [NAME] Syndrome (a condition characterized by symptoms of a blockage of the intestine without any physical block) and chronic respiratory failure. The Annual Minimum Data Set assessment, dated 6/30/23, indicated the resident had experienced weight loss and was not on a physician prescribed weight loss program. On 3/27/23, the resident weighed 114.6 lbs. On 9/18/23, the resident weighed 100 pounds which was a 12.74 percent weight loss in 6 months. On 8/28/23, the resident weighed 101.3 lbs. On 9/4/23, the resident weighed 93 pounds which was a 8.19 percent weight loss in 1 week. A physician's order, with a start date of 4/25/23 indicated the resident was prescribed 120 ml (milliliters) of Ensure three times per day. A nutrition care plan with a problem start date of 4/27/23 indicated the resident had experienced significant weight loss. Interventions with a start date of 4/27/23 indicated .offer encouragement and assistance with eating .provide diets, supplements, medications, adaptive equipment, and snacks as ordered .weigh as ordered . No nutrition care plan interventions relative to the resident's weight loss were documented after 4/27/23. During an interview on 9/21/23 at 10:18 A.M., the resident indicated at times she had little appetite. The resident indicated she would consume ice cream milk shakes if offered to her to help increase her weight. During an interview on 9/26/23 at 10:05 A.M., the Director of Health Services, Assistant Director of Health Services, and the Administrator indicate staff was aware of the resident's weight loss, and no interventions had been updated or added to the nutrition care plan since 4/27/23. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure supervision of a resident assessed to be at risk for falls for 1 of 1 resident reviewed for accidents which resulted in repeated falls, a pelvic fracture, and a head hematoma (clotted blood within tissue) with a laceration (skin tear) which required staples for wound closure (Resident 40). Findings include: On 6/11/21 at 11:25 a.m., Resident 40's closed clinical record was reviewed. Diagnoses included, but were not limited to: toxic [CONDITION(S)], [CONDITION(S)], chronic [CONDITION(S)], congestive heart failure, [CONDITION(S)], anxiety, depression, and cataract of the eye. A quarterly Minimum Data Set (MDS) assessment, dated 12/5/20, assessed Resident 40 as cognitively intact. A discharge Minimum Data Set (MDS) assessment (sent out to the hospital due to hip fracture), dated 2/4/2021, indicated Resident 40 had 3 falls since the prior MDS assessment, dated 12/5/20: 1 with no injury, 1 with injury (skin tears, abrasion, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that cased the resident to complain of pain), and 1 with major injury (bone fractures, joint dislocations, closed head injury, with altered consciousness, subdural hematoma). The cognitive status section was blank. The quarterly Minimum Data Set (MDS) assessment, dated 3/7/21, indicated Resident 40 required extensive assistance of two staff members with transfers, had a history of falls in the last 2-6 months, had a fracture related to a fall in the last 6 months, and the cognitive status section was blank. A care plan, initiated on 11/25/20 and current through target date 6/12/21, for Resident 40 indicated, Problem State Date: 11/25/20 . Resident is at risk for falling R/T [related to] hx [history] of falls, incontinence, impaired balance and decreased mobility, side effect [sic] of meds, [CONDITION(S)], CHF [congestive heart failure], [CONDITION(S)] [chronic obstructive pulmonary disease] . Goal: Resident will remain free of falls with major injury. Approach: . Increase routine rounding in PM [evening] . The care plan lacked documentation of specific time intervals staff would provide supervision to implement routine rounding. A review of Resident 40's eleven Fall Event Reports indicated the following: -On 1/18/21 at 9:41 a.m., the resident had an unwitnessed fall in their bathroom while self transferring and obtained a small skin tear to the right thigh. A new fall intervention implemented was for staff to add break extenders to aid in the ease of locking wheels to the wheelchair. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident had a recent decline in ADL (Activities of Daily Living) and narcotic use. -On 1/22/21 at 8:57 p.m., the resident had an unwitnessed fall in their bedroom while self transferring to the bathroom. The new fall interventions were implemented for staff to rearrange room per resident's preference and for the bed to be placed next to the wall. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident refused to comply with safety measures such as call light use, alarms, appliance, etc., and [MEDICATION(S)] (pain reliever) use. -On 1/24/21 at 1:48 a.m., the resident had an unwitnessed fall in their bedroom while turning self in bed. The new interventions were for staff to rearrange the resident's room per preference and for bed to be next to wall. These were the same intervention which were implemented for the 1/22/21 fall. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident required assistance to transfer and the resident has poor, impaired vision or forgets to wear glasses. -On 2/4/21 at 8:21 p.m., the resident had an unwitnessed fall in the bedroom while self transferring. The resident was assessed as confused and was found laying on the floor with their head and left should resting on the metal part of the bed side table. The fall event indicated, .Upon assessment resident was unbale [sic] to move left arm & hip, c/o [complaint of] increase excruciating pain to hip . resident to ER [emergency room ] . Resident unable to tell staff what happened . Injury noted to left elbow . The resident was admitted to the hospital with pelvic fractures. A new intervention implemented was for staff to offer the resident assistance to bed after dinner. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident had cognitive or memory impairment that affected safety and judgement and antipsychotic use. -On 3/7/21 at 10:12 p.m., the resident had unwitnessed fall in their bedroom. Fall event indicated, . Mental Status: Confusion . Staff entered resident's room at approx. [approximately] 9:50 p.m. to discover her laying prone [on the belly] next to her be [sic] . The resident sustained multiple skin tears to their extremities with bruising and their right wrist was assessed to be red and swollen. A new intervention implemented was for staff to provide a bariatric bed (a bed designed for the comfort and functionality for an overweight or obese person) to allow the resident more room to move while in the bed. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident had cognitive or memory impairment that affected safety and judgement and narcotic use. -On 3/27/21 at 7:04 p.m., the resident had an unwitnessed fall in their bedroom while eating on the side of their bed. The fall event indicated, Mental Status: Anxiety . Remains with increased confusion during night, stating repeatedly that she 'need [sic] to get out of here and ge [sic] home.' Attempts to redirect not successful as res [resident] made same statement to day shift . Res has been awake all night shift. A new intervention implemented was for staff to encourage the resident to be up in the wheelchair for meals. A Fall Risk Re-Assessment, at that time, identified the risk factors: the resident had cognitive or memory impairment that effected safety and judgement, the resident had difficulty understanding and following directions, the resident required assistance to transfer, the resident required assistance to ambulate safely with or without assistive device, the resident had poor, impaired vision or forgot to wear glasses, the resident refused to comply with safety measure such as call light use, alarms, appliance, etc., and the resident was administered analgesics and narcotics. -On 4/7/21 at 4:30 p.m., the resident had an unwitnessed fall in their bedroom while self transferring. The fall event indicated, . Resident stays in room most of the day . often gets restless and transfers self back and forth. A new intervention implemented for staff to encourage resident to spend more time in common areas. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident had cognitive or memory impairment that affected safety and judgement and narcotic use. -On 4/9/21 at 6:39 p.m. the resident had an unwitnessed fall in their bedroom while self transferring. The fall event indicated, . staff responded to resident call light to find her laying on the floor beside her bed after attempt to self transfer from bed to w/c [wheelchair] . Resident noted with increased restlessness . A new intervention was implemented for their antianxiety medication to be increased from twice a day to three times a day. A Fall Risk Re-Assessment, at that time, identified the risk factors as the resident had cognitive or memory impairment that affected safety and judgement, there resident required assistance to ambulated safely, the resident had poor, impaired vision or forgot to wear glasses, the resident refused to comply with safety measures such as call light use, alarms, appliances, etc., analgesics, diuretics, narcotics, and sleeping medication use. -On 4/10/21 at 2:28 p.m., the resident had an unwitnessed fall in their bedroom. The fall event indicated, . heard loud noise . res [resident] noted to be laying supine [on the back] position on the floor with head at food of bed. Res stated, 'I was standing to pull my pants up.'. A new intervention was implemented for staff to increase rounding in the evening as most falls occurred in the evening. A Fall Risk Re-Assessment, at that time, identified the risk factors as the required use of an assistive devices and/or often forgot to use device, the resident required assistance to transfer, the resident required assistance to ambulate safely, the resident refused to comply with safety measures such as call light use, alarms, appliance, etc., analgesics, antihypertensives, diuretics, and narcotics use. -On 4/10/21 at 8:15 p.m., the resident had an unwitnessed fall in their bedroom while self transferring. The fall event indicated, Resident had an unwitnessed fall . Resident was found laying on the floor, diagonal to bed . Resident noncompliant with call lights . Will increase rounds and continue to monitor. This was the second fall on this day. A Fall Risk Re-Assessment, at that time, identified the risk factors as the required use of an assistive devices and/or often forgot to use device, the resident required assistance to transfer, the resident required assistance to ambulate safely, the resident has poor, impaired vision or forgot to wear glasses, the resident refused to comply with safety measures such as call light use, alarms, appliance, etc., diuretics, and narcotics use. -On 4/13/21 at 2:20 p.m., the resident had an unwitnessed fall in their bedroom. The fall event indicated, . found on the right side laying on floor calling out for help . Resident stated she was sitting on the side of bed, reached for object on table, and fell . Laceration to L [left] side of head forming hematoma appx [approximately] 4 cm [centimeters] with 2 cm laceration in middle . The resident also sustained skin tears to their knee and arm. They were sent to the hospital for emergency treatment which included staples to the head laceration for wound closure. A Fall Risk Re-Assessment, at that time, identified the risk factors as the required use of an assistive devices and/or often forgot to use device, the resident required assistance to transfer, the resident required assistance to ambulate safely, the resident has poor, impaired vision or forgot to wear glasses, the resident refused to comply with safety measures such as call light use, alarms, appliance, etc., antihypertensives, diuretics, and narcotics use. IDT (interdisciplinary team) notes and care plan lacked implementation of intervention(s) of a specific timeframe for supervision to prevent reoccurrence of unwitnessed falls. 06/16/21 10:42 a.m., QMA 1 indicated the resident was very independent and would continue to get up on their own despite having a decline in health and having intermittent confusion. QMA 1 did not mention anything in regard to an intervention of staff supervision and/or increased rounding to prevent falls. On 6/16/21 at 11:15 a.m., LPN 2 indicated the resident had cancer which metastasized to their brain and had confusion. LPN 2 did not mention anything in regard to an intervention of staff supervision and/or increased rounding to prevent falls. During an interview, on 6/16/21 at 2:53 p.m., the Assistant Director of Health Service indicated Resident 40's care plan was not time specific for the intervention to increase routine rounding and should have been. She indicated she was unable to provide documentation beyond the routine 2 hour check staff performed to reposition the resident. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the resident's physician and dietician were notified of an assessed severe weight loss, and failed to reweigh a resident with an assessed out of normal range weight as indicated by facility policy (Resident 197), and the facility failed to ensure a resident's weights were assessed as indicated by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1.) On 6/14/21 at 2:30 P.M., Resident 197's clinical record was reviewed. The resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nutritional Quarterly Observation, dated 6/4/21, indicated the resident had a swallowing disorder and was at risk for malnutrition. Care plan problems, with start dates of 1/3/21 and goal target dates of 7/5/21, indicated, .resident has potential for alteration in nutritional status .resident is malnourished/at risk for malnutrition . Recorded weights indicated on 5/10/21 the resident weighed 156.5 pounds. On 6/10/21 the resident recorded weight was 141.6 pounds, which indicated severe weight loss of 9.52% in a 1 month period. The clinical record lacked documentation neither the physician nor the registered dietician were notified of the weight which indicated severe weight loss. During an interview, on 6/16/21 at 10:47 A.M., Registered Nurse 1 indicated on 6/10/21 the resident was weighed as ordered by the physician with a resulting weight of 141.6 pounds. Residents were weighed on the 10th of each month unless otherwise ordered. The resident was not re-weighed at that time to verify the weight. The computerized clinical record system was to generate a report of any significant weight changes for the physician and dietician to review. The physician and the dietician were not directly contacted regarding the resident's weight. During an interview, on 6/16/21 at 2:55 P.M., facility's Registered Dietician indicated if a person showed a significant or severe weight loss or gain, the resident should have been re-weighed to confirm the accuracy of the weight. If the weight loss or gain was confirmed, the dietician and physician should have been contacted. She was not contacted on 6/10/21, regarding the severe weight loss of the resident. A re-weighing of the resident with that big of a change in weight should have taken place. 2.) On 6/14/21 at 11:00 A.M., the Resident 192's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .weight once a day on the 10th of the month . Vital signs report indicated the resident was weighed on 5/26/21. The clinical record lacked further documented weights for Resident 192. On 6/16/21 at 12:20 P.M., the corporate clinical nurse provided the facility's Guidelines for Weight Tracking, effective date 5/22/2018, and indicated this was the policy used by the facility. A review of the policy indicated, .residents will have their weight taken and recorded upon admission .residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .this should be completed when the discrepancy is noted and not wait until the dietician recommends a re-weigh .the physician, responsible party, and dietician shall be notified of a weight variance of >5% [greater than] unless on a planned weight loss or gain program . 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure all staff were tested twice a week per the county positivity rate for the month of January 2021. This systemic failure had the potential to affect all 48 residents who resided at the facility. Findings include: Review of the facility's policy titled, COVID-19 Trilogy Employee Mandatory Employee Testing Policy, dated 06/22/20, revealed, Pursuant to Federal and State guidelines mandating COVID-19 testing of long-term care employees, Trilogy is implementing mandatory COVID-19 testing for all existing employees and new hires. The government, to minimize risk of exposure of long-term care residents to COVID-19, has issued guidance recommending the testing of all long-term care employees. This policy is implemented for the protection of our residents, employees, and the public at large. All current employees will be required to undergo COVID-19 testing regardless of where the employee is exhibiting symptoms. All candidates who have received a conditional offer of employment will likewise be required to undergo COVID-19. Compliance with this policy is a condition of employment and continued employment with the Company .1. COVID-19 Testing of Current Employees: a. It is the policy of the Company to require all current employees to be tested for the presence of [MEDICAL CONDITION] COVID-19 .Initial baseline testing must be completed within the time frame determined by the Company. Re-testing, at scheduled intervals in accordance with Trilogy's testing plan and/or the state's COVID-19 testing plan must be completed. Additional testing may be required, at the sole discretion of the Company, in an effort to identify COVID-19 positive employees for work exclusion .including but not limited to: .circumstances that place an employee at a heightened level of risk of exposure to COVID-19 .the occurrence of an initial or additional COVID-19 outbreak at the campus (widespread or in a particular unit) .2. Testing Procedures: a. To the extent possible, testing will be conducted on-site at the employee's place of employment. Employees will be given advance notice of on-site testing to allow for schedule coordination .5. Consequences of Refusal to Submit to Testing: a. If any employee refuses to obtain the required COVID-19 testing, he/she may be subject to disciplinary action, up to and including being placed on unpaid leave and/or immediate termination of employment based on the failure to comply with mandatory Company policies. b. Any employee on approved leave will be required to be tested before being permitted to return to work. c. All employees are expected to have completed COVID-19 testing consistent with state requirements and/or company testing requirements including timeframes within which testing must occur . Review the Centers for Medicare and Medicaid Services (CMS) website titled COVID-19 Nursing Home Data, revealed the following county positivity rates and color for the month of January 2021: For the week ending 12/30/20, the county positivity rate was 18.9%, Red. For the week ending 01/06/21, the county positivity rate was 20%, Red. For the week ending 01/13/21, the county positivity rate was 20.25%, Red. For the week ending 01/20/21, the county positivity rate was 16.2%, Red. For the week ending 01/27/21 (current), the county positivity rate was 14.1%, Red. Review of the QSO-20-38-NH Memo, dated 08/26/20, revealed .483.80(h) COVID-19 Testing. The LTC facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC must: (1) Conduct testing based on parameters set forth by the Secretary, including but not limited to: testing frequency .(5) Have procedures for addressing residents and staff, including individuals providing services under arrangement and volunteers, who refuse testing or are unable to be tested . Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility .We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency . Routine Testing of Staff. Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg .County Positivity Rate in the past week > (greater than) 10%. Minimum testing frequency twice a week . Review of the county positivity rates for the facility revealed the facility was in the red testing classification for the month of January 2021 which required staff to be tested twice a week. The facility currently had no COVID-19 positive residents; however, the facility has had 28 cumulative COVID-19 positive residents. At the time of the survey, the facility had all 48 residents who resided in the facility under observation due potential exposure from a staff member who tested positive for COVID-19. Review of the staffing roster revealed the facility had 65 staff who were employed by the facility at the time of the survey. Review of the facility's Employee COVID Testing Roster and the undated and untitled document provided by the Executive Director (ED), revealed the following mandatory testing discrepancies for 21 employees: Week of 01/03/21 testing performed on 01/05/21 and 01/07/21: Certified Nursing Assistant (CNA) 8 was not tested the week of 01/03/21 and worked on 01/08/21 and 01/09/21. CNA32 was not tested the week of 01/03/21 and worked on 01/05/21 (testing day), 01/07/21 (testing day), and 01/08/21. CNA12 was tested on [DATE] and worked on 01/06/21, and 01/09/21. RN29 was tested on [DATE] and worked on 01/07/21 (testing day), 01/08/21, and 01/09/21. Cook13 was tested on [DATE] and worked on 01/09/21. LPN18 was tested on [DATE] and worked on 01/09/21. CNA30 was tested on [DATE] and worked on 01/08/21. LPN19 was tested on [DATE] and worked on 01/08/21. Week of 01/10/21 testing was performed on 01/12/21 and 01/14/21: CNA8 was not tested the week of 01/10/21 and worked on 01/10/21, 01/14/21 (testing day), 01/15/21, and 01/16/21. CNA12 was not tested the week of 01/10/21 and worked on 01/11/21, 01/12/21 (testing day), 01/13/21, 01/14/21 (testing day), and 01/15/21. LPN7 was tested on [DATE] and worked on 01/10/21 and 01/13/21. LPN16 was tested on [DATE] and worked on 01/14/21 (testing day) and 01/16/21. DS15 was tested on [DATE] and worked on 01/14/21 (testing day) and 01/16/21. Cook13 was tested on [DATE] and worked on 01/13/21. Week of 01/17/21 testing was performed on 01/19/21 and 01/21/21: CNA10 was not tested the week of 01/17/21 and worked on 01/19/21 (testing day), 01/20/21, and 01/21/21 (testing day). LPN19 was not tested the week of 01/17/21 and worked on 01/17/21, 01/18/21, 01/19/21 (testing day), 01/20/21, and 01/21/21 (testing day). LPN 16 was not tested the week of 01/17/21 and worked on 01/17/21, 01/19/21 (testing day), 01/20/21, and 01/21/21 (testing day). CNA8 was not tested the week of 01/17/21 and worked on 01/17/21, 01/22/21, and 01/23/21. CNA14 was not tested the week of 01/17/21 and worked 01/18/21, 01/20/21, and 01/22/21. LPN22 was not tested the week of 01/17/21 and worked on 01/19/21 (testing day), 01/20/21, and 01/21/21 (testing day). LPN18 was tested on [DATE] and worked on 01/19/21(testing day) and 01/20/21. DS15 had not been tested since 01/11/21 before being tested on [DATE] and worked on 01/17/21, 01/18/21, 01/19/21 (testing day), and 01/20/21. Activities Associate was tested on [DATE] and worked on 01/20/21. Cook13 was tested on [DATE] and worked on 01/22/21 and 01/23/2. Week of 01/24/21 testing was performed on 01/26/21 and 01/28/21: Cook13 was not tested the week of 01/24/21 and worked on 01/27/21, 01/28/21 (testing day), and 01/29/21. CNA10 was not tested the week of 01/24/21 (missed four testing times in two weeks) and worked on 01/25/21, 01/26/21 (testing day), and 01/29/21. Cook20 was not tested the week of 01/24/20 and worked on 01/24/21, 01/26/21 (testing day), 01/29/21, and 01/30/21. CNA14 was not tested the week of 01/24/21 and worked 01/27/21. LPN16 was not tested the week of 01/24/21 (last tested on [DATE]) and worked on 01/25/21, 01/26/21 (testing day), 01/29/21, and 01/30/21. DFS was tested on [DATE] and worked on 01/28/21 (testing day) and 01/29/21. DS23 was tested on [DATE] and worked on 01/26/21 (testing day) and 01/27/21. ESA17 was tested on [DATE] and worked on 01/26/21 (testing day), 01/27/21. DS15 was tested on [DATE] and worked on 01/26/21 (testing day), and 01/27/21. LPN7 was tested on [DATE] and worked on 01/26/21 (testing day) and 01/27/21. ESA24 tested on [DATE] and worked on 01/26/21 (testing day) and 01/27/21. LPN26 tested on [DATE] and worked on 01/26/21 (testing day) and 01/27/21. The ED was asked to verify that the 21 employees identified as noncompliant with twice a week testing had continued to work. On 02/03/21, the ED provided an untitled and undated facility document that verified all 21 employees identified as not being tested twice a week, worked after not being compliant with CMS's mandated testing requirements for each week. During an interview with the Medical Director on 02/02/20 at 4:55 PM, the Medical Director revealed it was his expectation that everyone followed the rules and do the best job they can with testing. During an interview on 02/03/21 at 2:28 PM, the Director of Health Services/Infection Preventionist (DHS/IP) stated it was her expectation all facility staff would be compliant with the mandatory testing requirements. The DHS/IP confirmed for the month of January 2021, all facility staff should have been tested twice a week. The DHS/IP stated it was important to test staff per the guidance to ensure the safety of residents.

Based on observations, interviews, and record reviews, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to ensure staff used required Personal Protective Equipment (PPE) for one of five sampled residents (Resident (R) 2). This failure had the potential to increase the risk of transmission of COVID-19 within the facility. Findings include: Review of the facility's policy titled, Guidelines for COVID-19, revised 03/11/20, revealed .a. Residents in a private room with suspected COVID-19 should remain isolated .c. Ensure that PPE is readily accessible and in close proximity to the resident's room .e. Appropriate PPE should be used by healthcare personnel when interacting with the resident . Review of the facility's undated Yellow Zone PPE Quick Reference Tool, policy revealed, .GLOVES: Gloves are required; discard between each resident use or sooner if soiled or damaged. Review of the Indiana State Department of Health document titled, COVID-19 LTC Facility Infection Control Guidance Standard Operating Procedure, updated 11/22/20, revealed .Unknown COVID-19 status (yellow): All residents in this category warrant transmission based (sic) precautions (droplet and contact.) HCP (healthcare personnel) will wear single gown per resident, glove, N95 mask and eye protection (face shield/or goggles) .Waiting for test results-These are residents whose COVID-19 status is unknown. This can include residents who have been tested and are waiting on results, or residents who are admitted , or readmitted , to a facility where they are likely to have been exposed to COVID-19 (e.g., transferred from a facility with an outbreak) .Residents in this category are to remain in TBP (transmission-based precautions) for 14-days. Review of R2's undated Resident Face Sheet, located in the resident's Electronic Medical Record (EMR), under the face sheet tab, revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R2's Physician order [REDACTED]. Observation on 02/01/21 at 12:47 PM, revealed Certified Nursing Assistant (CNA) 9 entered R2's room wearing the PPE of a mask, a face shield, and a gown; CNA9 did not don gloves prior to entering R2's room. Continued observation revealed using her ungloved, bare hands, CNA9 positioned R2's wheelchair and bedside table at the door of R2's room. CNA9 assisted R2 with the setup of her lunch meal, then doffed her gown, and then exited the room. CNA9 used an Alcohol Based Hand Rub (ABHR) to clean her hands upon leaving the room. R2's room had signage of Yellow Zone .contact/droplet precautions . and a PPE cart was stationed outside R2's room. During an interview on 02/01/21 at 12:50 PM, CNA9 verified R2's room was a Yellow Zone, room. CNA9 also verified she did not wear any gloves into R9's room. When asked her rationale for not using gloves when entering R2's room, CNA stated I did not pay attention (to the sign on the door). During an interview on 02/03/21 at 2:28 PM, the Director of Health Services/Infection Preventionist (DHS/IP) revealed it was her expectation CNA9 would have donned gloves prior to touching R2's environment. The DHS/IP revealed R2 was on a yellow zone due to potentially being exposed after a recent facility staff member tested positive for COVID-19.

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed for accuracy of the MDS (Resident 6). Findings include: On 3/27/19 at 10:17 a.m., Resident 6's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 6's wound management notes indicated the following for the resident's left heel: -On 9/5/18 at 2:50 p.m., the wound was unstageable (not stageable due to coverage of wound bed by slough (dead skin tissue) and/or eschar (scab).). -On 9/20/19 at 4:07 p.m., the wound was unstageable. -On 9/27/18 at 12:02 p.m., the wound was unstageable. During an interview, on 3/27/19 at 11:35 a.m., the Wound Care Nurse indicated Resident 6's left heel wound was discovered in (YEAR) and it was at first a deep tissue injury, then it progressed to an unstageable scabbed wound and it has remained unstageable. Resident 6's Significant Change MDS assessment, dated 3/28/18, indicated the resident had an unstageable pressure ulcer. Resident 6's Quarterly MDS assessment, dated 9/25/18, indicated the resident had a stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.). Resident 6's Quarterly MDS assessment, dated 12/3/18, indicated the resident had an unstageable pressure ulcer. During an interview, on 3/27/19 at 1:46 p.m., the MDS Coordinator indicated she probably clicked the wrong button when coding Resident 6's left heel wound, on the 9/25/18 assessment as a stage 3 pressure ulcer. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to keep the Foley catheter (flexible tube which passed through the urethra and into the bladder to drain urine) collection bag from touching the floor for 1 of 1 resident reviewed for urinary catheter (Resident 201). Findings include: On 3/22/19 at 10:40 A.M., Resident 201 was observed to be lying in bed in her room. The Foley catheter urine collection bag was hanging from the bed frame facing the window and resting on the floor. On 3/22/19 at 12:10 P.M., Resident 201 was observed to be lying in bed in her room. The Foley catheter urine collection bag was hanging from the bed frame facing the doorway and resting on the floor. On 3/22/19 at 2:45 P.M., Resident 201 was observed to be lying in bed in her room. The Foley catheter urine collection bag was hanging from the bed frame facing the doorway and resting on the floor. During an interview, on 3/22/19 at 2:50 P.M., the Assistant Director of Nursing indicated the Foley catheter urine collection bag was not to touch the floor. On 3/27/19 at 11:30 A.M., the Assistant Director of Nursing provided the policy, Urinary Catheter Care, revised date 5/11/16, and indicated this was the policy currently used by the facility. A review of the policy indicated, be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on interview and record review, the facility failed to follow a physician's order to hold insulin if the blood sugar was less than 150 for 1 of 5 residents reviewed for unnecessary medications. (Resident 16) Findings include: Resident 16's clinical record was reviewed on 3/26/2019 at 10:10 a.m. [DIAGNOSES REDACTED]. Resident 16 admitted to the facility on [DATE]. Physician Orders, dated 3/26/2019, indicated Resident 16 was ordered Humalog (insulin) Kwikpen 10 units subcutaneous (under the skin) with meals. Hold if blood sugar (BS) is less than 150. The start date was 10/8/2018. A review of Resident 16's Medication Administration Record [REDACTED] -On 1/3/2019 between 4:00 and 6:00 p.m. the BS was 137. 10 units of insulin given. -On 1/4/2019 between 7:00 and 9:00 a.m. the BS was 129. 10 units of insulin given. -On 1/5/2019 between 7:00 and 9:00 a.m. the BS was 132. 10 units of insulin given. -On 1/7/2019 between 4:00 and 6:00 p.m. the BS was 134. 10 units of insulin given. -On 1/11/2019 between 4:00 and 6:00 p.m. the BS was 143. 10 units of insulin given. -On 1/17/2019 between 4:00 and 6:00 p.m. the BS was 148. 10 units of insulin given. -On 1/18/2019 between 4:00 and 6:00 p.m. the BS was 144. 10 units of insulin given. -On 1/22/2019 between 7:00 and 9:00 a.m. the BS was 112. 10 units of insulin given. -On 1/24/2019 between 4:00 and 6:00 p.m. the BS was 145. 10 units of insulin given. -On 1/26/2019 between 7:00 and 9:00 a.m. the BS was 122. 10 units of insulin given. -On 1/27/2019 between 7:00 and 9:00 a.m. the BS was 109. 10 units of insulin given. -On 1/28/2019 between 7:00 and 9:00 a.m. the BS was 121. 10 units of insulin given. -On 1/29/2019 between 7:00 and 9:00 a.m. the BS was 134. 10 units of insulin given. -On 2/1/2019 between 7:00 and 9:00 a.m. the BS was 106. 10 units of insulin given. -On 2/9/2019 between 4:00 and 6:00 p.m. the BS was 128. 10 units of insulin given. -On 2/10/2019 between 7:00 and 9:00 a.m. the BS was 117. 10 units of insulin given. -On 2/10/2019 between 11:00 a.m. and 1:00 p.m. the BS was 130. 10 units of insulin given. -On 2/19/2019 between 11:00 a.m. and 1:00 p.m. the BS was 110. 10 units of insulin given. -On 2/19/2019 between 4:00 and 6:00 p.m. the BS was 143 10 units of insulin given. -On 2/20/2019 between 4:00 and 6:00 p.m. the BS was 126. 10 units of insulin given. -On 2/24/2019 between 11:00 a.m. and 1:00 p.m. the BS was 147. 10 units of insulin given. -On 2/26/2019 between 4:00 and 6:00 p.m. the BS was 144. 10 units of insulin given. -On 3/5/2019 between 11:00 and 1:00 p.m. the BS was 143. 10 units of insulin given. -On 3/5/2019 between 4:00 and 6:00 p.m. the BS was 143. 10 units of insulin given. -On 3/8/2019 between 4:00 and 6:00 p.m. the BS was 130. 10 units of insulin given. -On 3/9/2019 between 7:00 and 9:00 a.m. the BS was 84. 10 units of insulin given. -On 3/10/2019 between 7:00 and 9:00 a.m. the BS was 110. 10 units of insulin given. -On 3/10/2019 between 11:00 and 1:00 p.m. the BS was 134. 10 units of insulin given. -On 3/10/2019 between 4:00 and 6:00 p.m. the BS was 108. 10 units of insulin given. -On 3/17/2019 between 7:00 and 9:00 a.m. the BS was 136. 10 units of insulin given. -On 3/16/2019 between 7:00 and 9:00 a.m. the BS was 118. 10 units of insulin given. -On 3/26/2019 between 7:00 and 9:00 a.m. the BS was 116. 10 units of insulin given. On 3/26/2019 at 11:00 a.m., a review of Resident 16's Progress Notes from January, (MONTH) and March, 2019 lacked documentation of the resident suffering adverse effects from having insulin administered when the BS was less than 150. During an interview, on 3/26/2019 at 12:13 p.m., the Clinical Support Nurse indicated the facility would begin education immediately in order to ensure Resident 16 was getting her insulin correctly. On 3/27/2019 at 12:00 p.m., the Assistant Director of Nursing provided the facility's policy, Preparation and General Guidelines . IIA2: Medication Administration-General Guidelines with a revised date of 1/2017, and indicated it was the policy currently being used by the facility. Review of the policy indicated, . B. 2. Medications are administered in accordance with written orders of the presciber . 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure a gas burning stovetop range automatically ignited upon activation of the burner control switch for 3 of 6 burners, for 1 of 1 gas stove in the kitchen. Findings include: On 3/21/19 at 11:00 a.m., the Dietary Manager (DM) was observed to turn the stovetop burner switch to ignite. The burner did not produce a flame and the DM was observed to grab a handheld lighter. He indicated, sometimes you have to use this (the lighter) to light the burner. The burner was observed to produce a large flame upon ignition by the lighter. On 3/27/19 at 10:55 a.m., Cook 1 indicated two of the front burners and one of the back burners did not ignite properly and must be lit with a lighter. The cook was observed to turn on the three burners which did not light and manually placed a flame over the burners, which caused flames to combust from the burners. On 3/27/19 at 11:06 a.m., the DM indicated, it can be a bit nerve-wracking to light the burners, and they will run the tops (of the burners) through the dishwasher. On 3/27/19 at 12:01 the Assistant Director of Nursing provided the facility policy, Kitchen Equipment Preventative Maintenance, dated 2/8/18, and indicated it was the policy currently being used. A review of the policy indicated, Ranges . Confirm burner orifices are not restricted and clean as necessary . 3.1-19(bb)

Based on observation, interview, and record review, the facility failed to ensure a physician order [REDACTED]. (Resident 3) Findings include: On 04/27/18 at 02:14 p.m., Resident 3 was observed to be resting in bed with oxygen (O2) being administered via nasal cannula (NC) at 4.5 liters (L). Resident 3 indicated she was on O2 for shortness of breath (SOB). On 04/30/18 at 02:27 p.m., Resident 3 was observed to be resting in bed with oxygen (O2) being administered via nasal cannula (NC) at 4.5 liters (L). Resident 3 indicated she was on O2 at 4.5 L for SOB. On 05/01/18 at 02:16 p.m., Resident 3 was observed to be resting in bed with oxygen (O2) being administered via nasal cannula (NC) at 4.5 liters (L). On 05/01/18 at 02:50 p.m., Resident 3 was observed to be resting in bed with oxygen (O2) being administered via nasal cannula (NC) at 4.5 liters (L). On 05/02/18 at 09:52 a.m., Resident 3 was observed to be resting in bed with oxygen (O2) being administered via nasal cannula (NC) at 4.5 liters (L). On 4/30/18 at 2:37 p.m., Resident 3's clinical record was reviewed. The [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/22/18, indicated Resident 3 was cognitively intact and was receiving oxygen therapy. A review of Resident 3's physician orders, dated 5/2/18, lacked documentation of a physician order [REDACTED].>A review of Resident 3's progress notes indicated the following: -3/22/18 at 3:38 a.m., Resident 3 continues on O2 at 4 L per nasal cannula. -3/23/18 at 3:35 a.m., Resident 3 continues on O2 at 4 L per nasal cannula. A review of Resident's 3 Respiratory Observation indicated the following: -3/22/18 at 3:34 a.m., oxygen on 4 L per nasal cannula and refer to physician orders [REDACTED]. -3/22/18 at 2:38 p.m., oxygen on and refer to physician order [REDACTED].>-3/22/18 at 10:00 p.m., oxygen on and refer to physician order [REDACTED].>-3/23/18 at 3:18 a.m., oxygen on 4 L and refer to physician order [REDACTED].>-3/23/28 at 10:49 p.m., oxygen on and refer to physician order [REDACTED].>-3/24/18 at 10:47 p.m., oxygen on and refer to physician order [REDACTED].>A review of Resident 3's careplan, with a start date of 11/17/17 and revision date of 4/24/18, indicated potential for complications related to [MEDICAL CONDITION]. The careplan indicated an intervention of oxygen per medical doctor (MD) orders. A review of Resident 3's careplan, with a start date of 11/17/17 and revision date of 4/24/18, indicated potential for cardiovascular distress related to [DIAGNOSES REDACTED]. During an interview, on 05/02/18 at 03:17 p.m., the Director of Health Services (DHS) indicated Resident 3 did not have a physician order [REDACTED].>On 5/3/18 at 10:29 a.m., the Clinical Nurse Specialist (CNS) provided the SOP (Standard of Operation) for Administration of Oxygen policy, revision date 5/11/16, and indicated the policy was the one currently being used by the facility. A review of the policy indicated , To provide guidelines for safe oxygen administration when insufficient oxygen is being carried by the blood to tissues .1. Verify physician's orders [REDACTED]. 3.1-47(a)(6)

Based on interview and record review, the facility failed to administer a 1st and 2nd step [MEDICATION NAME] test (skin test to determine one is free from [MEDICAL CONDITION] (TB) ) upon employment for 1 of 5 newly employed employees reviewed for TB screening. (Activity Associate 1) Findings include: On 4/30/2018 at 2:30 p.m., a review of the facility employee files indicated the following: -Activity Associate (AA) 1 was hired on 2/27/2018. The employee file lacked documentation of a 1st and 2nd step [MEDICATION NAME] test being administered upon employment. A review of AA 1's time sheet indicated she had worked 2 days in February, (YEAR), 17 days in March, (YEAR), 16 days in April, (YEAR), and 1 day in May, (YEAR); without having a 1st and 2nd step [MEDICATION NAME] test completed. On 5/1/2018 at 9:30 a.m., the Administrator indicated the 1st and 2nd step [MEDICATION NAME] test for AA 1 had not been given prior to employment and AA 1 would not work until a [MEDICATION NAME] test and been given and read. On 5/3/2018 at 9:51 a.m., the Administrator provided the policy titled, Guidelines for TB Results Summary Documentation: Staff dated 5/11/2016, and indicated the policy was the one currently being used by the facility. A review of the policy indicated, . 1. Upon hire each employee shall receive a Two Step Mantoux PPD (Purified Protein Derivative) test to ensure they are free of [MEDICAL CONDITION] . 3.1-18(a)

Based on interview and record review, the facility failed to complete an admission MDS (Minimum Data Set) assessment within 14 calendar days after admission for 5 of 30 residents reviewed. (Resident 116, 151, 152, 153, and 154) Findings include: 1. Resident 152's clinical record was reviewed on 4/18/17 at 11:46 a.m. The record indicated the resident was admitted on [DATE]. The admission MDS assessment dated on 4/11/7, indicated the RN verified assessment completed on 4/19/17, which is 16 calendar days after admission. 2. Resident 151's clinical record was reviewed on 4/18/17 at 12:03 p.m. The record indicated the resident was admitted on [DATE]. The admission MDS assessment, dated on 4/10/17, indicated the RN verified assessment completed on 4/18/17, which is 16 calendar days after admission. 3. Resident 153's clinical record was reviewed on 4/20/17 at 9:51 a.m. The record indicated the resident was admitted on [DATE]. The admission MDS assessment, dated on 4/13/17, indicated the RN as of 4/21/17, had not verified a completed assessment , which is 16 calendar days after admission. 4. Resident 154's clinical record was reviewed on 4/20/17 at 9:53 a.m. The record indicated the resident was admitted on [DATE]. The admission MDS assessment, dated on 4/13/17, indicated the RN verified assessment completed on 4/21/17, which is 16 calendar days after admission. 5. Resident 116's clinical record was reviewed on 4/20/17 at 11:18 a.m. The record indicated the resident was admitted on [DATE]. The admission MDS assessment, dated on 1/29/17, indicated the RN verified assessment completed on 2/7/17, which is 17 calendar days after admission. On 4/21/17 at 11:05 a.m., the DON (Director of Nursing) was interviewed. The DON indicated the MDS Coordinator was a LPN, which can not verify the completion of MDS assessment. The DON indicated the RN verified the completion of the admission MDS assessment after the team completed their sections. The DON indicated there was not a policy on when the admission MDS assessment needs sent. On 4/21/17 at 12:05 p.m., the DON indicated she was not aware the RN needed to have the admission MDS assessment verified completed within 14 calendar days. On 4/21/17 at 12:15 p.m., the DON acknowledged admission MDS assessments were not verified complete within 14 calendar days. The CMS's (Centers for Medicare & Medicaid Service's) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2016, indicated, Federal statute and regulations requires that residents are assessed promptly upon admission (but no later that day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being .The IDT (Inter-Disciplinary Team) may choose to start and complete the Admission comprehensive assessment at any time prior to the end of day 14 .The MDS completion date (Item Z0500B) must be no later than day 14 . 3.1-31(d)(1)

Based on interview and record review, the facility failed to promptly notify the physician of a resident's significant weight loss for 1 of 3 residents reviewed for nutrition (Resident 48). Findings include: On 4/20/17 at 10:20 a.m., Resident 48's closed clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 48's weights indicated the following: On 10/26/16, admission weight was 162.8 pounds. On 10/27/16, weighed 157.4 pounds. On 10/28/16, weighed 153.6 pounds (significant). The resident had an assessed weight loss of 5.6% in 3 days. The resident did not have any additional recorded weights and was discharged on [DATE]. A Registered Dietician progress note, dated 11/2/16, indicated, Current weight: 153.6# . Weight history: 9.2# loss X 3 days . Weight change: Documented Sig (significant) wt (weight) change in < (less than) 30 days - 5.7% loss . On 4/21/17 at 2:30 p.m., the Director of Nursing indicated Notification of Physician is noted under Events in the computer. The clinical record lacked documentation of physician notification of the weight loss. On 4/21/17 at 3:00 p.m., the Clinical Nurse Consultant indicated the facility notifies the physician if the weight change is greater than 5%. The Director of nursing provided the policy Guidelines for Weight Tracking, review date 5/5/2016, and indicated it was the policy currently being used by the facility. The policy indicated, 8. The physician . shall be notified of a weight variance of > (greater than) 5% . 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure staff implemented treatment and services for assessed significant weight loss for 1 of 3 residents reviewed for nutrition (Resident 48). Findings include: On 4/20/17 at 10:20 a.m., Resident 48's closed clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 48's weights indicated the following: On 10/26/16, admission weight was 162.8 pounds. On 10/27/16, weighed 157.4 pounds. On 10/28/16, weighed 153.6 pounds (significant). The resident had an assessed weight loss of 5.6% in 3 days. On 4/21/17 at 2:30 p.m., the Director of Nursing indicated Notification of Physician is noted under Events in the computer. The clinical record lacked documentation of physician notification of the weight loss. The resident did not have any additional recorded weights and was discharged on [DATE]. A review of Resident 48's October through November, 2016 meal intake records indicated the resident consumed an average of 85% of meals. A review of Resident 48's October through November, 2016 physician's orders [REDACTED]. On 10/26/16 the resident was ordered a regular diet. There were no orders received which addressed the resident's weight loss. A Registered Dietician progress note,dated 11/2/16, indicated, Current weight: 153.6# . Weight history: 9.2# loss X 3 days . Weight change: Documented Sig (significant) wt (weight) change in < (less than) 30 days - 5.7% loss . Meal/snack Intake: 85% meals / 80% snacks . Appetite is good . Diet as ordered by physician . There were no recommendations of interventions for staff to implement in regard to the identified weight loss. On 4/21/17 at 2:30 p.m., the Director of Nursing indicated if a resident's BMI (Body Mass Index) was ok, supplements usually are not ordered. She further indicated Resident 48's biliary drain (a surgical procedure that is performed on a patient who is suffering from a blockage of one or more of the bile ducts) had a lot of unmeasured output, but would not have been 9 pounds of drainage output. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program to prevent the infestation of ants in 1 of 30 rooms observed. (Resident 155) Findings include: On 4/19/17 at 11:00 A.M., an observation of Resident 155's room indicated no fewer than 30 live ants crawling on the wall heating/cooling unit. The resident indicated the ants had been crawling inside and outside of the wall unit for at least one week. On 4/19/17 at 1:30 P.M., the Facility Manager indicated he was aware of the ant problem in the resident's room and was addressing it. No time frame was given regarding how long the issue had been addressed. On 4/20/17 at 10:00 A.M., an observation of the resident's room indicated 8 live ants crawling on the wall heating/cooling unit. The resident indicated he had killed 3 live ants on his bed this morning and hoped he would not be bitten by the ants. On 4/21/17 at 10:00 A.M., an observation of resident's room indicated 6 live ants crawling on the wall heating/cooling unit. The resident indicated he had seen ants crawling out of the unit vents this morning. On 4/19/17 at 2:30 P.M., the Marketing Director provided the Resident Rights, which indicated, the resident has a right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)(4)