Every finding on record at Towne House Retirement Community

Based on observation, interview, and record review the facility failed to ensure proper storage of nutritional supplements, medications, and testing supplies for 1 of 1 medication room reviewed.Findings include:During an observation, on 5/20/26 at 10:57 AM, the following was observed:The medication room refrigerator had five cartons of Boost Breeze Nutritional Supplements with a use by date of March 2026. The freezer held two single-serve Italian Ice containers without expiration dates and one frozen pink substance in a clear cup without a resident name, date, or identifying label. The medication room cabinets had one Ensure Clear carton with an expiration date of 5/1/26, four Ensure Max Protein cartons had an expiration date of 2/1/26. Four Covid test kits had an expiration date of 4/30/25.In an interview, on 5/20/26 at 11:15 AM, the Director of Nursing indicated monthly audits of the medication room, including storage, labeling, and expiration dates, were monitored by the DON and the Assistant DON. Third shift staff were responsible for ensuring proper storage of supplements and supplies each night. The DON indicated there was no log of audits or refrigerator temperature measurements for review. Nursing staff obtained Ensure from the pharmacy for residents requiring supplemental nutrition.A current policy, dated 6/2025, provided by the Director of Nursing, indicated expiration dates of nutritional supplements stored in the medication room, were monitored by nursing staff.410 IAC (Indiana Administrative Code) 3.1-25(j)

Based on interview and record review, the facility failed to ensure a person-centered, individualized Baseline Care Plan was developed with instructions needed to provide effective care for 1 of 1 resident reviewed with a catherter. (Resident 116) Findings include: Resident 116's record was reviewed on 5/28/24 at 2:35 PM. Diagnoses included an open reduction internal fixation (surgery to repair) of a fracture to the left femur, coronary artery disease, atrial fibrillation, (irregular heartbeat) anemia due to chronic blood loss, enlarged prostate gland and urinary retention. A physician order dated 5/20/24 indicated Resident 116 was to be administered acetaminophen (pain reliever) every 6 hours as needed for a pain rating of 1 to 5 on a 1 to 10 scale. A physician order dated 5/20/24 indicated Resident 116 was to be administered oxycodone (narcotic pain reliever) every 6 hours as needed for a pain rating of 6 to 10 on a 1 to 10 scale. A physician order dated 5/20/24 indicated Resident 116 was to be administered cyclobenzaprine (muscle relaxer) every 12 hours as needed for muscle spasms. A physician order dated 5/20/24 indicated Resident 116 was to be administered nitroglycerin every 5 minutes as needed for chest pain for a maximum of 3 doses. A physician order dated 5/20/24 indicated Resident 116 was to be administered apixaban (blood thinner) twice daily for atrial fibrillation. Resident 116's Baseline Care Plan dated 5/20/24 indicated Resident 116's Brief Interview for Mental Status (BIMS) score was 15 (cognitively intact), had an indwelling urinary catheter in place to drain urine, had been prescribed narcotic pain medications, anticoagulants, (blood thinner) and diuretics (water pill), and had post-surgical pain to their left hip. There was no documentation in the Baseline Care Plan section to evaluate pain on a 1 to 10 scale. The Baseline Care Plan did not indicate Resident 116 had skin issues. There was no documentation in the Baseline Care Plan's skin integrity section. A physician order dated 5/21/24 indicated Resident 116 was to have the indwelling urinary catheter removed. A physician order dated 5/21/24 indicated Resident 116 was to have a straight catheter procedure performed (urinary catheter inserted into the bladder and removed immediately after the release of urine) every 8 hours as needed for urinary retention. Resident 116's Care Plan focus dated 5/22/24 indicated the resident was at risk for infection. The target goal was to be free from signs and symptoms of infection through 8/18/24. Interventions included antibiotics, infection prevention education, standard precautions, encourage fluids and evaluation of wounds. The Care Plan was not individualized to Resident 116's infection risks related to their surgical incision or the straight catheter procedure. Resident 116's Care Plan focus dated 5/22/24 indicated the resident was on a regular diet and had a surgical skin impairment to the left hip. The target goal was to maintain adequate nutritional status through 8/18/24. Interventions included medications, observing for malnutrition, monitoring weight, serving diet as ordered, monitoring and recording intake at every meal. The Care Plan dated 5/22/24 did not include a focus, a target goal or interventions for the following care concerns: 1. unusual bleeding 2. chest pain 3. urinary retention 4. diuretic use 5. urinary drainage via straight catheter 6. infection risk from straight catheter 7. muscle spasms 8. surgical incision care 9. infection risk from surgical incision 10. pain assessment 11. effects of narcotic pain medication. In an interview on 5/29/24 at 3:02 PM, the Executive Director (ED) indicated the facility had completed Resident 116's Baseline Care Plan within 24 hours as required. The ED indicated the facility had 21 days after a resident's admission to complete an official Care Plan. The ED reviewed the Baseline Care Plan and the current Care Plan. The ED indicated neither the Baseline Care Plan, nor the current Care Plan were individualized to Resident 116. In an interview on 5/29/24 at 4:09 PM the Director of Nursing (DON) reviewed Resident 116's Baseline Care Plan and current Care Plan. The DON indicated neither the Baseline Care Plan, nor the current Care Plan were individualized to Resident 116. The DON indicated Resident 116's Baseline Care Plan did not include a pain scale rating or a surgical incision, straight catheter procedure or their specific infection risk. The DON indicated neither the Baseline nor current Care Plan included the minimum healthcare information necessary to provide individualized care to Resident 116. A current facility policy dated 4/06 and revised 10/19 provided by the DON on 5/30/24 at 12:20 PM indicated the care plan is a compilation of services to be furnished to each resident with the goal to reach or maintain the resident's highest possible physical, mental, and psychosocial well-being. The policy indicated an individualized plan of care would be initiated upon admission. The policy indicated the individualized care plan would identify each resident's needs related to health, disease, condition, impairments, physical function, mental status, nutrition, psychosocial health, safety, and discharge potential. The policy indicated modifications and additions to the care plan would be updated as the resident's needs changed. The policy indicated the resident's individualized care plan would be continual, reviewed quarterly or as needed.

Based on interview and record review, the facility failed to ensure physician orders were current for the provision of wound care to a surgical incision for 1 of 1 resident reviewed (Resident 116). Findings include: Resident 116's record was reviewed on 5/28/24 at 2:35 PM. Diagnoses included an open reduction internal fixation (surgery to repair) of a fracture to the left femur. Resident 116's Baseline Care Plan dated 5/20/24 indicated Resident 116's Brief Interview for Mental Status (BIMS) score was 15 (cognitively intact). Resident 116's Baseline Care Plan dated 5/20/24 did not indicate Resident 116 had skin issues. There was no documentation in the Baseline Care Plan skin integrity section. Resident 116's current, completed, and discontinued physician orders dated 5/20/24 through 5/29/24 did not include wound care instructions for the surgical incision of their left hip. Resident 116's current Care Plan dated 5/22/24 did not include a focus, a target goal, or interventions for wound care to the resident's left hip surgical incision. A hospital Discharge Summary dated 5/20/24 at 11:19 AM indicated Resident 116's left hip surgical incision's dressing was to be reinforced or changed daily as needed. The surgical incision was to be assessed for complications daily. The staples were to be removed in 2 weeks. A Skin and Wound Evaluation dated 5/21/24 at 10:51 AM indicated Resident 116 had a surgical wound to the front of their left thigh. The wound was present on admission to the facility on [DATE]. The wound was 1.7 centimeters (cm) long and 0.4 cm wide. The wound had 3 staples. The dressing was intact. A Skin and Wound Evaluation dated 5/21/24 at 10:52 AM indicated Resident 116 had a surgical wound to the left side of their left thigh. The wound was present on admission to the facility on [DATE]. The wound was 2.7 cm long and 0.4 cm wide. The wound had 4 staples. The dressing was intact. A Skin and Wound Evaluation dated 5/21/24 at 10:54 AM indicated Resident 116 had a surgical wound to the front of their left hip. The wound was present on admission to the facility on [DATE]. The wound was 3.8 cm long and 0.5 cm wide. The wound had 6 staples. The wound dressing was intact. A progress note dated 5/21/24 at 2:34 PM indicated Resident 116's surgical sites had been evaluated. The staples were intact and healing well. A progress note dated 5/21/24 at 5:25 PM indicated Resident 116 had experienced a fall in their room. A progress note dated 5/22/24 at 11:52 AM indicated Resident 116 had increased bruising and swelling around their surgical incision. The dressing had been saturated with bloody drainage. A Skin and Wound Evaluation dated 5/28/24 at 7:48 AM indicated Resident 116 had a surgical wound to the left side of their left thigh. The wound was present on admission to the facility on [DATE]. The wound was 2.3 cm long and 0.3 cm wide. The wound had 4 staples. The staples were removed by the Nurse Practitioner. The wound did not have a dressing. A Skin and Wound Evaluation dated 5/28/24 at 7:49 AM indicated Resident 116 had a surgical wound to the front of their left thigh. The wound was present on admission to the facility on [DATE]. The wound was 1.4 cm long and 0.2 cm wide. The wound had 3 staples. The staples were removed by the Nurse Practitioner. A Skin and Wound Evaluation dated 5/28/24 at 7:50 AM indicated Resident 116 had a surgical wound to the front of their left hip. The wound was present on admission to the facility on [DATE]. The wound was 3.5 cm long and 0.4 cm wide. The wound had 6 staples. The dressing was intact. The wound was cleansed with soap and water. The staples were removed by the Nurse Practitioner. A Nurse Practitioner progress note dated 5/28/24 at 9:45 AM indicated Resident 116 had experienced a fall in their room on 5/21/24 that caused bleeding from their upper most hip incision. The staples were removed. Adhesive strips (steri-strips) were applied to the upper most incision and the middle incision. In an interview on 5/30/24 at 12:25 PM the Director of Nursing (DON) indicated hospital discharge surgical incision care instructions should have been included on Resident 116's physician orders upon admission to the facility. A current facility policy dated 2/06 and revised 3/24 provided by the DON on 5/30/24 at 12:53 PM indicated physician orders for dressing changes would be verified to ensure dressing changes followed state regulations, federal regulations, and national guidelines. 3.1-37

Based on interview and record review the facility failed to ensure safe transfer assistance for 1 of 5 residents reviewed (Resident 115). Findings include: During an interview on 5/28/24, a family member of Resident 115 indicated he was concerned Resident 115 had a fall while transferring in the middle of the night the previous weekend, resulting in a skin tear to her arm, bruising and pain. He indicated her pain resulted in a setback in her progress in therapy. He indicated only one staff member was assisting her at the time of the fall. During an interview on 5/30/24 at 1:40 PM, Resident 115 indicated she was transferring from her bed to her wheelchair when one of her feet caught on the other causing her to lose her balance and fall backward to her buttocks, tearing the skin on her elbow on the table as she fell . She indicated only one staff member was in the room at the time of the transfer. Resident 115's record was reviewed on 5/28/24 at 12:28 PM. Diagnoses included displaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing, muscle weakness, generalized, and unsteadiness on feet. Resident 115's current admission Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated the resident was dependent for transfers from a bed to a chair. Progress notes dated 5/25/24 at 4:42 AM indicated a staff member was assisting Resident 115 to transfer from her bed to a wheelchair when her leg gave out. Resident 115 sustained a skin tear on her left elbow from the table as she tried to stop the fall. Resident 115's current care plan regarding limited physical mobility, dated 5/17/24, indicated the resident had a problem of limited mobility related to weakness, recent left femur surgery and pain with a goal date of 8/4/24. Interventions included referring to the green therapy binder for current assistance needs. An instructional document in the green therapy binder dated 5/17/24 and last updated 5/24/24, provided by Licensed Practical Nurse 10 indicated Resident 115 required maximum assistance of two staff for transfers. In an interview on 5/30/24 at 12:37 PM, the Director of Nursing (DON) indicated one staff member was assisting Resident 115 at the time of her fall on 5/25/24. She indicated two staff should have been assisting with the transfer. In an interview on 5/30/24 at 12:46 PM, Physical Therapist 11 and Physical Therapy Assistant 12 indicated Resident 115 had not been cleared at any time to transfer with one assist since her admission to the facility. A current policy titled General Policy- Falls Policy, last revised 7/22 provided by the DON indicated the facility should implement appropriate measures to ensure safety. 3.1-45(a)(2)

Based on observation, interview, and record review the facility failed to ensure kitchen sanitation was maintained, opened food items were labeled and dated in the kitchen. 12 of 12 residents residing in the facility consumed food prepared in the kitchen. Findings include: 1. During an observation and interview in the main kitchen on [DATE] at 9:20 AM, a package of cheese slices and two packets of cheese cubes were observed with no label or date visible on the package on a shelf in the walk-in cooler. The Dietary Manager (DM indicated the packages should have been labeled and dated when opened. A container of ground beef with an expiration date of ,d+[DATE] and a container of diced tomatoes with an expiration date of ,d+[DATE] were observed on the shelf in the walk-in cooler. The DM indicated the ground beef was expired and should have been discarded. Multicolored specks of debris, too many to count, a dry piece of pepperoni, and several dime-sized red, dried spots near the container labeled marinara sauce were observed on the work surface area on the front of the pizza station. A container of cut up peppers was not covered with a lid or label. The DM indicated the pizza station had not been used yet that day and should have been cleaned after each use. In the reach in cooler, a bag of cut up lettuce, undated, had yellowish liquid visible at the bottom of the package. The DM indicated it should be discarded. The reach in cooler also had a tray of cups of salsa, ketchup, sour cream, poppy seed dressing, and horseradish dated ,d+[DATE] and ,d+[DATE]. The DM indicated the cups should be discarded. In an observation and interview on [DATE] at 9:44 AM, the Executive Chef used a test strip to test a bucket of sanitizer water being used to clean work surfaces in the kitchen. He indicated the solution tested at about 150 parts per million (ppm) of QUAT solution. He indicated the solution should test between 200 and 400 ppm to be considered effective for sanitation purposes. He emptied the bucket, prepared a new supply of sanitizer water and conducted another test. He indicated the test also resulted in about 150 ppm and he intended to call a service person in to adjust the calibration of the sanitizer dispenser. 2. In an observation and interview in the Health Center kitchen on [DATE] at 9:53 AM, the Executive Chef indicated he could not locate the test strips for sanitizer solution. A current policy title Production, Purchasing, Storage, last revised ,d+[DATE] provided by the DM on [DATE] at 11:05 AM indicated all unused portions and open packages should be covered, labeled, and dated and food past the expiration date should be discarded. The policy indicated sanitizer test strips should be readily available wherever sanitizer is dispensed. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review the facility failed to ensure the code status was clearly indicated for 2 of 6 residents. (Resident 8 and Resident 11). Findings include: 1) A record review on 4/18/23 at 11:27 AM indicated Resident 11 had diagnoses of breast cancer, anxiety, and cancer related chronic pain to her right hip. A physician order dated 4/13/23 indicated the resident's advance directive status was Do Not Resuscitate (DNR). A care plan focus dated 4/6/23 indicated the resident's advance directive status was a Full Code. 46156 2) A record review on 4/18/23 at 11:27 AM indicated Resident 8 had diagnoses of unspecified cirrhosis of the liver, inflammatory polyarthropathy, retention of urine, essential hypertension, unsteadiness on feet, muscle weakness and history of falling. A physician order dated 4/7/23 indicated the resident's advance directive status was Do Not Resuscitate (DNR). A care plan focus dated 4/6/23 indicated the resident's advance directive status was a Full Code. During an interview on 4/19/23 at 2:50 PM, the Administrator she indicated the advance directive status should have been updated on the resident's care plan. During an interview on 4/21/23 at 9:14 AM, the Director of Nursing (DON) indicated Resident 11 and Resident 8 had a physician orders to indicate their advance directive was DNR, but their care plan indicated their advance directive as full code. The DON indicated Resident 11 and Resident 8's advance directive care plan was incorrect and should indicate an advance directive of DNR. A current policy titled Advanced Directives, revised 7/2017, provided by the Administrator on 4/19/23 at 3:35 PM, indicated copies of all Advance Directives will be kept with the resident's medical record. No further policies were provided at time of exit of survey. 3.1-4(l)(5)

Based on observation, record review and interview, the facility failed to ensure oxygen tubing and oxygen humidifier bottle were routinely changed 1 of 1 resident reviewed. (Resident 4). Findings include: During an observation on 4/18/23 at 11:24 AM, Resident 4's nasal cannula (NC) oxygen tubing (a lightweight tube split into two prongs on one end and placed in the nostrils used to deliver supplemental oxygen) and oxygen humidifier bottle (aids in preventing a patients airways from becoming dry when filled with distilled or filtered water) attached to his oxygen condenser (a medical device that gives you extra oxygen). The resident's oxygen tubing and oxygen humidifier bottle were not labeled. On 4/19/23 at 9:05 AM, Resident 4's record was reviewed. Diagnoses included pleural effusion, malignant neoplasm of the esophagus, secondary malignant neoplasm of the lung, chronic obstructive pulmonary disease, lymphedema, hypoxia, and shortness of breath. Resident 4's quarterly Minimum Data Set (MDS) assessment, dated 1/2/23, indicated the resident's Brief Interview for Mental Status (BIMS) score was 15, he was alert, orient and interviewable. The MDS indicated he received oxygen while a resident at the facility. A review of the resident's order, dated 1/6/23, indicated he received oxygen via NC at 2 liters for hypoxia. A review of Resident 4's care plan, last revised 4/17/23, indicated the resident was on oxygen therapy related to ineffective gas exchange, respiratory illness, and hypoxia with a goal for the resident to have no sign or symptoms of poor oxygen absorption. During an observation on 4/19/23 at 3:35 PM, the Director of Nursing (DON) indicated Resident 4's oxygen tubing and oxygen humidifier bottle were not labeled when last changed. On 4/19/23 at 2:50 PM, a current policy entitled Oxygen Concentrator, revised 1/2020, provided by the Administrator, indicated the humidifiers, tubing, and cannula were disposable and should be changed on a weekly schedule. The policy indicated the old humidifier bottle was to be throw away weekly and a new one attached. 3.1-47(a)(4)(5)(6)

Based on observation, record review and interview the facility failed to ensure garbage and refuse were contained inside the dumpster for 1 of 2 observations. Findings include: An observation was made of the dumpster with Chef 3 on 5/23/22 at 9:50 AM. There were 4 bags of trash, piles of plastic, plastic silverware and bowls lying on the ground around the dumpster. Chef 3 was interviewed on 5/23/22 at 9:50 AM. Chef 3 indicated all departments maintained the dumpster. Chef 3 also indicated there should not be trash lying on the ground around the dumpster. The Executive Directive (ED) was interviewed on 5/23/22 at 12:55 PM. The ED indicated there should not have been anything on the ground around the dumpster. A policy, revised 4/13/06, titled Waster Disposal/Recycling, was provided by the ED on 5/23/22 at 1:52 PM. The policy indicated the Environmental Services Department will assure that the facility buildings and grounds will be kept free from the accumulation of rubbish and trash. The policy also indicated there will be sufficiently large containers to hold all the garbage and refuse. 3.1-21(i)(5)

Based on observation, record review and interview the facility failed to provide supervision to 1 of 1 residents reviewed while smoking. (Resident 170.) Findings include: On May 23, 2022, at 9:35 a.m. Resident 170 was observed outside smoking alone. On May 23, 2022, at 9:55 a.m. during an interview with Resident 170, she indicated there were no scheduled smoking times and she went outside to smoke at will. An open pack of cigarettes and a lighter were observed on the resident's bedside table. On May 23, 2022, at 11:07 a.m. during an interview with the Director of Nursing, she indicated residents were to be supervised when smoking. She indicated cigarettes, lighters, and vaping devices were not to be kept in resident rooms. On May 24, 2022, at 11:39 a.m. during an observation, LPN 6 took medications to Resident 170's room but the room was vacant. LPN 6 went outside where Resident 170 was smoking and administered medications. There were no staff members present in smoking area. LPN 6 indicated Resident 170 usually made staff aware when she was going outside to smoke. LPN 6 also indicated that there were no designated smoking times, and the residents were not to keep lighters and cigarettes in their rooms. On May 23, 2022, at 1:55 p.m. a current policy titled Smoking Policy indicated all residents would be supervised while smoking for the duration of the smoking period. The policy also indicated residents were not to possess cigarettes or lighters on his/her person or in their room at any time. 3.1-45(a)

Based on observations, interviews and record reviews, the facility failed to follow prevention measures related to COVID -19 through resident monitoring and staff screening for 1 of 5 residents reviewed for infection control (Resident 4), and 1 employee for 12 shifts reviewed (Employee 5). Findings include: 1. The record for Resident 4 was reviewed on 9/21/21. The record did not indicate Resident 4 was monitored daily for signs and symptoms of COVID-19 since December of 2020. During an interview on 9/21/21 at 12:37 P.M., the Director of Nursing (DON) indicated the COVID-19 monitoring order for Resident 4 was not in the computer. The resident had changed rooms after he had Covid-19. She indicated the computer system required the facility to treat residents as new admits when they changed rooms and all orders would be re-entered. She indicated the COVID-19 monitoring must have gotten missed. The DON indicated there was no documentation of Resident 4 having been monitored for signs and symptoms of COVID-19 since the last order dated 12/5/2020. The DON indicated they only had vital sign checks for temperature and oxygen saturations daily. The DON indicated cough and shortness of breath would be included in the COVID-19 signs and symptoms monitoring. 2. The COVID-19 staff and visitor screening logs were reviewed. The screening logs for Employee 5, dated September 1, 5, 6, 7, 8, 10, 13, 14, 15, 16, 17, and 20, 2021 indicated Employee 5 had written HIPPA at the top of the questionnaires and failed to answer any of the questions. All except of the forms ecept the one dated September 1 were signed off as having had been checked by Employee 3, Employee 6, or Employee 7. During an interview on 9/21/21 at 10:30 A.M., the DON indicated Employee 5 was a nurse and was not vaccinated. During an interview on 9/21/21 at 10:45 A.M., Employee 5 indicated she screened herself at door 3 because she is a nurse so that was acceptable. Employee 5 indicated she did not answer any of the questions because it was HIPPA (HIPAA, Health Insurance Portability and Accountability Act) and was nobody's business if she had been vaccinated, or if she had signs or symptoms of COVID-19. When asked why she did not respond to the signs and symptoms questions, Employee 5 indicated she did not even know if the screening log was asking for signs and symptoms, and she indicated she was not told it was okay to self screen. During an interview on 9/21/21 at 10:46 A.M., Employee 6 indicated the receptionist screened her in upon arrival to work, and indicated the staff can't self screen. During an interview on 9/21/21 at 10:48 A.M., Employee 4 indicated the staff screen themselves in when nobody was there to review anything. During an interview on 9/21/21 at 10:49 A.M., Employee 1 indicated the receptionist screened her in around 7:10-7:15, and someone was always at door 4. During an interview on 9/21/21 at 10:52 A.M., Employee 2 indicated she came in around 10:00 A.M., so the receptionist screened her in at door 4. During an interview on 9/21/21 at 11:15 A.M., the DON indicated Employee 3 worked South hall, employees were not to self screen, and the receptionists should not be signing screening logs of people they had not screened. During an interview on 9/21/21 at 12:30 P.M., the Administrator indicated employees should be checking in with whomever was assigned at door 3 and if nobody was there they were to check with the nurse. She indicated the receptionists were responsible for monitoring the screening logs. During an interview on 9/21/21 at 10:58 A.M., Employee 3 indicated she worked 7 A.M. to 3:30 P.M. and would typically arrive around 6:40-6:45 A.M. Employees were to enter door 4, where her desk was located, to be screened in. She indicated there were other receptionists from 3 P.M.-6 P.M. at door 4. Employee 3 indicated between 6 P.M. and 7 A.M., staff were to go through door 3 and get screened. She indicated someone was supposed to be signing the screening sheets, but when nobody was screening at door 3, then she would sign them even though she was not here to do the screenings. Employee 3 indicated that sometimes nobody was stationed at door 3 so she signed the screening logs for Employee 5. Employee 5 entered the building through door 3. Employee 3 indicated she noticed Employee 5 had not been answering the screening questions, but did not tell anyone because Employee 5 had told her it was not their business. Employee 3 indicated staff were to enter door 1 or door 4 on arrival to work during the day shift. The facility policy titled Infection Infection Prevention & Control of COVID-19, undated, indicated The facility will determine which specific entrances to designate as the main entrances. These entrances shall have a means for actively screening all who enter, and a means to alert for illness or exposure presence. Once the screening tool is completed on the individual, the decision can be made to either allow the employee to work, or the essential visitor, to visit or to deny work or visits. Any person in close contact . would be considered potentially exposed. The risk for a person depends on various factors. Following these factors as a guide to make educated decisions on whether or not to isolate at home can be used. However, the CDC guidance demonstrates that an employee can continue to work and do not have to isolate for 10 days as long as they are symptomatic, . 4. Prophylactic measures and treatment Each community shall monitor for symptoms of fever, cough, and shortness of breath. 3.1-18(a)

Based on observation and interview the facility failed to ensure staff wore PPE (personal protective equipment) appropriately and performed hand hygiene prior to leaving a resident room for 1 of 5 residents residing on the skilled nursing hall (Resident 3). Findings include: During a continuous observation on 2/3/21 from 11:49 A.M. until 11:53 A.M. the following was observed: Dietary Staff 2 pushed a cart with food trays on it through a set of doors onto the skilled nursing hall and stopped about halfway down the hall. Dietary Staff 2 had on a pair of gloves while pushing the cart. Dietary staff 2 picked up a food tray off the cart with her gloved hands and carried it into Resident 3's room. Dietary Staff 2 came out of Resident 3's room and had on a pair of gloves. Dietary Staff 2 then wheeled the cart through the doors off the skilled nursing hall with her gloved hands. Dietary Staff 2 was not observed to remove her gloves, use hand sanitizer, or wash her hands during the observation. During an observation on 2/3/21 at 12:37 P.M., Dietary Staff 2 was observed wearing gloves. She pushed a cart through a set of doors onto the skilled nursing hall. She pushed the cart about halfway down the hall turned it around and then pushed it back out through the doors off the skilled nursing hall. Dietary Staff 2 was not observed to remove her gloves, use hand sanitizer, or wash her hands during the observation. Dietary Staff 2 was interviewed on 2/2/21 at 12:53 P.M. During the interview Dietary Staff 2 indicated when it was time to give residents meal trays she started in the kitchen area by washing her hands. She then put on a pair of gloves and loaded the cart with 6 food trays. She wheeled the cart with 6 food trays through the facility and delivered the trays to 6 different residents. She indicated she did not change her gloves, wash her hands, or use hand sanitizer between delivering trays to the 6 different residents. After delivering the 6 food trays she went back to the kitchen, removed her gloves, washed her hands, filled the cart with 6 more food trays and delivered them the same way. She indicated she did the same thing when she collected food trays after residents were finished eating She indicated she did not deliver trays to residents in transmission-based precautions, so she currently only delivered a tray to one person on the skilled nursing hall. The Director of Nursing (DON) was interviewed on 2/3/21 at 1:19 P.M. During the interview the DON indicated staff should not be wearing one pair of gloves into multiple resident rooms and staff should not be wearing gloves in the hallways. She indicated if staff used gloves they should be taken off before leaving a resident's room and hand hygiene should be performed. A policy was requested for glove use in resident rooms from the DON on 2/3/21 at 1:48 P.M. The DON indicated the facility did not have a policy addressing glove use in resident rooms. 3.1-18(b)

Based on observation, interview, and record review the facility failed to ensure measures to prevent the potential spread of COVID were in place according to current CDC guidelines.This had the potential to effect 6 of 6 residents residing in the Health Center at the facility. A Census Report was provided by the Executive Director on 10/16/20 at 11:00 A.M. The Census Report indicated 6 residents were residing in the Health Center at the facility. During an observation on 10/16/20 at 1:30 P.M., Resident 4 was in her room with the door open. There were no signs on the door or other information present to indicate Resident 4 was on isolation. Licensed Practical Nurse (LPN) 6 was interviewed on 10/16/20 at 11:54 A.M. LPN 6 indicated there were no residents currently on isolation in the Health Center. She indicated when a resident was admitted or readmitted from the hospital they followed an algorithm. If the resident had a negative COVID-19 test within 5 days of being admitted to the facility they were not placed on isolation. A resident would be tested at the hospital for COVID-19 prior to admission. The facility would also perform a POC (Point of Care) COVID-19 test when the resident arrived at the facility. A testing algorithm was provided by LPN 6 on 10/16/20 at 12:02 P.M. According to the algorithm if a resident was coming to the facility from the hospital with a negative COVID-19 test within the last 5 days they would not need to be placed on isolation. A Hospital to Post-Acute Care Transfer COVID-19 assessment dated [DATE] was provided by the Executive Director on 10/16/20 at 4:00 P.M. According to the document Resident 4 did not have a COVID-19 test at the hospital prior to being admitted to the facility. The Director of Nursing (DON) was interviewed on 10/16/20 at 2:22 P.M. During the interview the DON indicated the facility tried to get hospitals to do a COVID-19 test for residents prior to admission to the facility. If the hospital did not do a test the facility would do one. A resident would be placed on isolation until the resident had two negative COVID-19 tests. The Executive Director was interviewed on 10/16/20 at 4:33 P.M. During the interview the Executive Director indicated Resident 4 went to the hospital on [DATE] from a residential apartment and was admitted to the Health Center on 10/9/20. The resident was not placed on isolation at any time from her admission date of [DATE] to 10/16/20. Resident 4 was not tested in the hospital for COVID-19 prior to admission, but was tested at the facility on 10/12/20 and had a negative result. The Executive Director indicated the facility follows CDC and ISDH guidance in regards to COVID-19. Preparing for COVID-19 in Nursing Homes (June 2020) was retrieved on 10/19/20 from the Centers for Disease Control (CDC) website. The guidance indicated Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Responding to Coronavirus (COVID-19) in Nursing Homes (April 2020) was retrieved on 10/19/20 from the Centers for Disease Control website. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. 3.1-18(a)

Based on observation, record review and interview the facility failed to ensure weight loss was addressed in a timely manner for 1 of 1 resident reviewed. (Resident 144) Findings include: On 11/19/19 at 1:19 P.M., Resident 144 was observed in his room sitting in a reclining chair, the resident appeared thin. On 11/21/19 at 9:24 [NAME]M., Resident 144's Clinical Record was reviewed. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognition was severely impaired and required assistance with eating. The physician's orders [REDACTED].>The Vital Signs form for the resident indicated the following weights: Dated 10/15/19 at 12:00 [NAME]M., the resident weighed 154.6 pounds (lbs) Dated 10/20/19 at 2:21 P.M., the resident weighed 147.6 lbs Dated 10/21/19 at 5:52 P.M. the resident weighed 147.6 lbs Dated 10/22/19 at 1:52 P.M., the resident weighed 145 lbs Dated 10/26/19 at 3:23 P.M., the resident weighed 146.4 lbs Dated 10/30/19 at 1:06 P.M., the resident weighed 146.6 lbs Dated 11/3/19 at 10:18 [NAME]M., the resident weighed 139.4 lbs Dated 11/3/19 at 1:12 P.M., the resident weighed 138 lbs Dated 11/10/19 at 2:09 P.M., the resident weighed 138.8 lbs Dated 11/17/19 at 12:05 P.M., the resident weighed 139 lbs The Clinical Notes Report for Resident 144 included, but were not limited to, the following: The Certified Dietary Manager (CDM) note dated 10/16/19 at 3:30 P.M., indicated the resident received a puree diet, height was 69 inches and weighed 154.6. The Registered Dietician (RD) note dated 10/18/19 at 2:09 P.M., the resident was admitted to the facility from the hospital. The resident ate in the dining room at an assist table and could feed himself a puree diet. The note also indicated the residetn received a Special feeding program per speech (therapy). The RD note dated 11/8/19 at 11:18 [NAME]M., indicated the resident was seen by speech therapy for cognition and swallowing. The CDM note dated 11/13/19 at 9:37 [NAME]M., indicated on 11/4/19 the resident's weight was 138.8 lbs and his BMI (Body Mass Index) was 20.4. He had lost 6% over the last month. The CDM request that he be started on Medpass BID (2 times a day). The RD note dated 11/15/19 at 11:10 [NAME]M., indicated Resident 144 was started on Med Pass for a 6% weight loss. An email message dated 11/4/19 at 9:10 [NAME]M., sent by the CDM to the Director of Nursing Services (DNS) was received from the CDM on 11/21/19 at 10:00 [NAME]M., and indicated Resident 144 had lost 8 lbs and needed to be reweighed. The Weekly Weight Tracking Record dated the week of 11/3/19 indicated the resident weighed 139.4 lbs, however, documented underneath was an undated weight of 138 lbs. Two untitled forms were received from the CDM on 11/21/19 at 10:00 [NAME]M., the forms indicated the following: Late entry dated 11/6/19 at 7:30 [NAME]M., indicated on 11/3/19 the resident weighed 139.4 lbs. There was no documentation the resident was reweighed. Late entry dated 11/13/19 at 7:29 [NAME]M., indicated on 10/20/19 the resident weighed 147.6 lbs and on 11/10/19 the resident weighed 138.8 lbs. Documented under the Weight Variance column was -8.80 without discription of unit of measure, the forms indicated the resident's BMI was 20.49. There was a handwritten note on the forms Requested Med Pass BID (2 times a day) The (MONTH) 2019 Medications form indicated the resident had received 4 ounces of Med Pass supplement 2 times a day since 11/13/19. The care plan titled Nutritional/Hydration Risk dated 10/27/19 indicated the following: Resident 144 was at high risk due to difficulty swallowing with goals of to consume at least 50% or more of the meals and will maintain a weight of 145 lbs plus or minus 5%. The interventions included, but were not limited to, the following: Monitor the resident weights monthly or weekly, provide assistance as needed at meals and between meals and provide a regular .Cut- Up diet as prescribed. The Weight policy dated 1/2005 and last revised on 10/2019, was received from the DNS on 11/21/19 at 10:30 [NAME]M. The Weight policy indicated, but was not limited to, the following: The resident's weight will be obtained weekly and documented in the resident's medical record. .Residents are considered to be at nutritional risk .weight changes as follows .3% in one month. 5% in three months. 7% in six months. An individual nutritional intervention program will be implemented for each resident who has had a significant weight loss with in the above time frames. When there is a 3% difference, nursing will re-weigh the resident within 24 hours. If weight loss (sic)(is) verified, the attending physician will be notified, in addition the (cdm) will be notified by dietary manager. On 11/21/19 at 9:37 [NAME]M., an interview, conducted with Licensed Practical Nurse (LPN) 1, indicated the resident's weights were obtained by the Certified Nurses Assistant (CNA) and then documented in the electronic medical record (EMR). LPN 1 indicated if there is a 3 lb weight change the physician and family are notified and a copy of the weights are provided to the DNS. LPN 1 indicated Resident 144 received a puree diet because he was at risk for aspiration. On 11/21/19 at 9:46 [NAME]M., an interview, conducted with the DNS, indicated the CNA enters the weights into the EMR and the CDM is responsible to run a report of the resident's weights. The DNS indicated Resident 144 had not shown up as a weight loss on the report dated 11/4/19. The resident's diet was upgraded on 10/27/19 to regular diet with cut up foods. On 11/21/19 at 10:04 [NAME]M., an interview, conducted with the CDM, indicated on 11/4/19 she had requested from the nursing department that Resident 144 be reweighed. The CDM indicated she had not received a reweight back from nursing and if the resident's weight continued to show a weight loss the CDM would have recommended a supplement sooner. The CDM indicated she had printed a weight report on 11//6/19 and the resident had not triggered as a weight loss. The CDM indicated the computer program should have calculated the resident's percentage of weight loss. On 11/21/19 at 10:25 [NAME]M., an interview was conducted with the DNS and CDM present. The DNS indicated the resident had been reweighed by the CNA and the reweight was not documented in the resident's EMR. The CDM indicated if she had known the resident was reweighed at 138 lbs the CDM would have started the resident on a supplement sooner. On 11/21/19 at 11:31 [NAME]M., an interview, conducted with the RD, indicated Resident 144's 10/15/19 weight of 154.6 pounds was incorrect according to the nursing staff. On 11/21/19 at 1:45 P.M., an interview, conducted with the Speech Language Pathologist indicated the resident had 2 bedside swallow studies done while hospitalized and had received n order for a pureed diet with thin liquids. The Speech Language Pathologist indicated Resident 144's diet had been upgraded to mechanical soft diet on 10/18/19 and the resident was tolerating the diet well. On 11/22/19 at 9:05 [NAME]M , the DNS was interviewed, and indicated the nursing staff had obtained the resident's reweight on 11/4/19, but just had not documented the weight in the resident's EMR. 3.1-46

Based on record review and interview, the facility failed to notify the physician of significant weight loss for 2 of 2 residents reviewed for nutritional status (Resident 5 and Resident 10). Findings include: 1. The record for Resident 5 was reviewed on 12/6/17 at 2:38 P.M. [DIAGNOSES REDACTED]. A review of Resident 5's weights indicated an admission weight of 195.8 lbs (pounds) on 11/1/17, A weight obtained on 11/18/17 indicated Resident 5 weighed 178.4 lbs, which was an 8.89 % weight loss since admission. A weight obtained on 11/26/17 indicated Resident 5 weighed 165.8 lbs, which was a 15.3 % weight loss since admission. A weight obtained on 12/3/17 indicated Resident 5 weighed 163.8, which was a 16.3 % weight loss since admission. A physician order, dated 12/4/17, indicated Resident 5 was to begin receiving 4 ounces of Med Pass (nutritional supplement) twice daily. The facility Director of Nursing (DON) was interviewed on 12/7/17 at 12:15 P.M. During the interview, the DON indicated there was no documentation in the resident's record to indicate the physician had been notified of Resident 5's weight loss prior to the order obtained on 12/4/17 for the Med Pass supplement. 2. The record for Resident 10 was reviewed on 12/6/17 at 1:36 P.M. [DIAGNOSES REDACTED]. A review of Resident 10's weights indicated an admission weight of 124.4 lbs on 9/23/17, obtained when the resident was readmitted to the facility from the hospital. A weight obtained on 10/22/ 17 indicated Resident 10 weighed 118 lbs, which was a 5.1 % weight loss since admission. A weight obtained on 10/29/17 indicated Resident 10 weighed 112.8 lbs, which was a 9.3 % weight loss since admission. A weight obtained on 12/3/17 indicated Resident 10 weighed 108 lbs, which was a 13.1 % weight loss since admission. The facility Director of Nursing (DON) was interviewed on 12/7/17 at 12:15 P.M. During the interview, the DON indicated there was no documentation in the resident's record to indicate the physician had been notified of Resident 10's weight loss. A facility policy, entitled Weight Loss, with a revision date of August 2014 and a review date of December 2016, was provided by the facility DON on 12/7/17 at 11:45 P.M. The DON indicated the policy was current. The policy indicated To ensure a resident maintains acceptable parameters of nutritional status to include, but not be limited to, body weight. This is maintained unless the resident's clinical condition demonstrates that this is not possible. In addition, residents identified with weight loss will be provided with appropriate nutritional interventions as needed. The policy further indicated Residents are considered to be at nutritional risk if they are on enteral feedings (tube feedings), have pressure ulcers, and have documented evidence of poor intake/appetite, or weight changes as follows .3% in one month, 5% in three months, 7% in six months. The policy also indicated When there is a 3% difference, nursing will re-weigh the resident within 24 hours. If weight loss verified, the attending physician will be notified, in addition the certified dietary manager will be notified in writing by the nursing staff. 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure individualized non-pharmacological interventions and target behaviors were identified for 1 of 5 residents reviewed. (Resident 4). Findings include: Resident 4's medical record was reviewed on 12/6/17 at 11:28 A.M. and indicated a physician's orders [REDACTED]. Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/27/17, Resident 4 was seen by a psychologist due to behavioral problems at the facility. The psychologist recommended starting [MEDICATION NAME] 50 mg twice daily for mood stabilization and delusions. The psychologist noted the resident had acute paranoia at times. On 12/7/17, at 11:00 A.M., the Director of Nursing (DN) provided an undated care plan for Resident 4. The care plan was for use of an antipsychotic medication, [MEDICATION NAME]. The care plan had interventions which included, but were not limited to: Record behaviors and monitor patterns of behavior; Initiate non-pharmacological interventions for behaviors and monitor effectiveness. Review of mood/behavior monitoring for Resident 4, from 10/27/17 until 12/7/17, was provided by the DN on 12/7/17, at 11:00 A.M. The behavior monitoring for Resident 4 did not indicate specific behaviors to monitor, and did not include any specific behavior interventions to use. On the mood/behavior sheets from 10/27/17 and 12/7/17, 3 episodes were documented: On 12/1/17 at 4:21 P.M., Resident 4 was noted to be anxious, delusional, angry, exit seeking, and negative and behavior interventions attempted were approach later and call his wife. The interventions were noted to have minimal effectiveness; On 12/3/17 at 11:43 A.M., Resident 4 had a physically aggressive behavior and the intervention attempted was to approach later. The interventions was noted to be non-effective; On 12/3/17 at 5:59 P.M., Resident 4 was noted to be angry and the behavior intervention attempted was to call the wife. The intervention was noted to be non-effective. On 12/7/17 at 9:56 A.M., an interview was conducted with CNA 3. CNA 3 indicated Resident 4's behaviors mostly have to do with his wife not being there. CNA 3 indicated the E-charting system the facility uses has two area identified to chart on, mood and behaviors (verbal and physical). CNA 3 indicated the behaviors to chart on and the interventions are the same for all residents. An interview was conducted with the DN on 12/7/17 at 11:00 A.M The DN indicated on Resident 4's care plan for antipsychotic use there were no non-pharmacological interventions identified to reduce negative behaviors and no target behaviors identified. On 12/7/17 at 11:20 A.M., the DN provided a policy titled Behavior Management, last revised December 2016. Under Procedure, 2. all behaviors that are potentially a problem are documented in software documentation program. 3.1-48(b)(2)

Based on record review and interview, the facility failed to ensure weight was maintained without significant loss for 2 of 2 residents reviewed for nutritional status ( Resident 5 and Resident 10). Findings include: 1. The record for Resident 5 was reviewed on 12/6/17 at 2:38 P.M. [DIAGNOSES REDACTED]. admission orders [REDACTED]. A review of Resident 5's weights indicated an admission weight of 195.8 lbs (pounds) on 11/1/17, A weight obtained on 11/18/17 indicated Resident 5 weighed 178.4 lbs, which was a 8.89 % weight loss since admission. A weight obtained on 11/26/17 indicated Resident 5 weighed 165.8 lbs, which was a 15.3 % weight loss since admission. A weight obtained on 12/3/17 indicated Resident 5 weighed 163.8 lbs, which was a 16.3 % weight loss since admission. A note by the Registered Dietitian dated 11/12/17, indicated Resident was admitted to facility following hospitalization for a [MEDICAL CONDITION]. He is alert, feeds self, makes needs known. [AGE] years old, weight 189, height 70 BMI (body mass index) is good at 27.6. While in hospital he received six units of blood. Hospital labs HGB (hemoglobin) 8.8 and HCT (hematocrit) 27.4 are low. Appetite has been good. Eats meals in his room. Diet is Regular NAS (no added salt). Nursing monitors surgical wounds. Resident 's heels are treated with barrier cream by nursing to prevent tissue breakdown. He has orders for OT (occupational therapy) and PT (physical therapy). His goal is to be able to care for his [MEDICAL CONDITION] and return to his (former residence). There was no other documentation in Resident 5's record addressing nutritional status or loss of weight. A physician order, dated 12/4/17, indicated Resident 5 was to begin receiving 4 ounces of Med Pass (nutritional supplement) twice daily. The Registered Dietitian (RD) was interviewed on 12/7/17 at 11:31 A.M. During the interview, the RD indicated she had not been aware of Resident 5's continual weight loss since admission to the facility. The RD further indicated she would have implemented additional dietary interventions prior to 12/4/17 if she had been aware of the weight loss. 2. The record for Resident 10 was reviewed on 12/6/17 at 1:36 P.M. [DIAGNOSES REDACTED]. A physician order, dated 9/23/17, indicated Resident 10 was prescribed Boost High Protein (nutritional supplement) three times daily and was to receive a regular no added salt diet. A review of Resident 10's weights indicated an admission weight of 124.4 lbs on 9/23/17 obtained when the resident was readmitted to the facility from the hospital. A weight obtained on 10/22/ 17 indicated Resident 10 weighed 118 lbs, which was a 5.1 % weight loss since admission. A weight obtained on 10/29/17 indicated Resident 10 weighed 112.8 lbs, which was a 9.3 % weight loss since admission. A weight obtained on 12/3/17 indicated Resident 10 weighed 108 lbs, which was a 13.1 % weight loss since admission. On 10/23/17, a note by the facility Certified Dietary Manager indicated Resident 10's weight was weight was 118 lbs, which was a 5% loss in 1 month. The note indicated the resident received Boost three times daily as a supplement. On 10/28/17, a note by the Registered Dietitian indicated the resident currently had pneumonia. The note indicated the resident had lost 5% in 1 month and her weight was 123 lbs. The note further indicated the resident was receiving Boost three times daily. There was no other documentation in Resident 10's record addressing nutritional status or loss of weight. The Registered Dietitian (RD) was interviewed on 12/7/17 at 11:31 A.M. During the interview, the RD indicated she had not been aware of Resident 10's continual weight loss since admission to the facility. The RD further indicated she would have implemented additional dietary interventions, besides the Boost supplement, if she had been aware of the resident's continual weight loss. A facility policy, entitled Weight Loss, with a revision date of August 2014 and a review date of December 2016, was provided by the facility DON on 12/7/17 at 11:45 P.M. The DON indicated the policy was current. The policy indicated To ensure a resident maintains acceptable parameters of nutritional status to include, but not be limited to, body weight. This is maintained unless the resident's clinical condition demonstrates that this is not possible. In addition, residents identified with weight loss will be provided with appropriate nutritional interventions as needed. The policy further indicated Residents are considered to be at nutritional risk if they are on enteral feedings (tube feedings), have pressure ulcers, and have documented evidence of poor intake/appetite, or weight changes as follows .3% in one month, 5% in three months, 7% in six months. The policy also indicated When there is a 3% difference, nursing will re-weigh the resident within 24 hours. If weight loss verified, the attending physician will be notified, in addition the certified dietary manager will be notified in writing by the nursing staff. 3.1-46

Based on interview and record review, the facility failed to ensure the Physician was notified prior to administering Ectotrin (aspirin) for 1 resident who was allergic to aspirin. This deficiency affected 1 of 1 resident who was reviewed for an aspirin allergy (Resident #20). Findings include: On 2/8/16 at 2:53 P.M. Resident #20 declined an interview saying she was itchy and had asked the nurse for some medicine for the itching. The record of Resident #20 was reviewed on 2/9/16 at 3:01 P.M. and had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED].#20 for [MEDICATION NAME] 325 milligrams (mg) give 1 tablet daily for 30 days. The Discharge Orders from the local hospital dated 1/14/16 indicated Resident #20 was allergic to aspirin. The Medication Administration Record [REDACTED]. An interview with the Director Of Nursing (DON) on 2/10/16 at 9:30 A.M. indicated the admitting nurse RN #1 noted on the discharge orders from the hospital that Resident #20 was allergic to aspirin and called a family member because the aspirin was ordered for the resident. The DON indicated the family member indicated it was ok to give the resident the aspirin. The DON indicated RN #1 had also spoken with Resident #20 and the resident had told RN #1 it was ok to give the aspirin because the hives the resident had were not related to the aspirin. The DON indicated 1 week later RN #2 had observed the resident was allergic to aspirin and had called a different family member and the aspirin was discontinued by the Physician. The DON also indicated the resident had the hives prior to administering the aspirin in the first place and the resident had also indicated the aspirin could cause some swelling in her mouth. An Interdisciplinary Note dated 1/28/16 at 16:50 (4:50 P.M.) documented by RN #2 indicated Resident #20 .10 a (10:00 A.M.) Pt (patient) requested medication to help with hives, lip swollen and right side of tongue swollen, staff administered visteral ([MEDICATION NAME] used to treat hives and itching) .Pt returned from therapy and stated she was having some trouble swallowing .Physician (Physician's name) on call for ( Resident #20's Physician) (Physician's name) notified (sic) said to monitor pt, use prn (as needed) epi pen ([MEDICATION NAME]) (used to treat allergic reactions) if needed in emergency and send to hospital. Dr (Physician's name) (endocrinologist) notified, no new orders and have (Resident #20's Physician's name) see pt tomorrow. (On call Physician) ordered for [MEDICATION NAME] to be d/c'd (discontinued) said swollen tongue can be side effect of [MEDICATION NAME] and wants (Resident #20's Physician name) to review meds (medications) and maybe put her on a different b/p (blood pressure) med, but (family member) does not want this med d/c'd said this is the only b/p med that works well for her so following up with (Resident #20's Physician's name) tomorrow. (Family member) also wants pt to stop taking [MEDICATION NAME] said she has an allergy to this medication The Policy Physician Notification Procedure /Family/POA/ Administrative Personnel revised August 2014, received from the DON on 2/11/16 at 11:15 A.M. indicated .Procedure: 4. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences A document received from the DON dated 2/11/16 at 8:30 A.M. indicated RN #1 failed to notify the resident's Physician when RN #1 initially found the resident was allergic to aspirin. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure the Physician was notified prior to administering Ectotrin (aspirin) for 1 resident who was allergic to aspirin. This deficiency affected 1 of 1 resident who was reviewed for an aspirin allergy (Resident #20). Findings include: On 2/8/16 at 2:53 P.M. Resident #20 declined an interview saying she was itchy and had asked the nurse for some medicine for the itching. The record of Resident #20 was reviewed on 2/9/16 at 3:01 P.M. and had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED].#20 for [MEDICATION NAME] 325 milligrams (mg) give 1 tablet daily for 30 days. The Discharge Orders from the local hospital dated 1/14/16 indicated Resident #20 was allergic to aspirin. The Medication Administration Record [REDACTED]. An interview with the Director Of Nursing (DON) on 2/10/16 at 9:30 A.M. indicated the admitting nurse RN #1 noted on the discharge orders from the hospital that Resident #20 was allergic to aspirin and called a family member because the aspirin was ordered for the resident. The DON indicated the family member indicated it was ok to give the resident the aspirin. The DON indicated RN #1 had also spoken with Resident #20 and the resident had told RN #1 it was ok to give the aspirin because the hives the resident had were not related to the aspirin. The DON indicated 1 week later RN #2 had observed the resident was allergic to aspirin and had called a different family member and the aspirin was discontinued by the Physician. The DON also indicated the resident had the hives prior to administering the aspirin in the first place and the resident had also indicated the aspirin could cause some swelling in her mouth. An Interdisciplinary Note dated 1/28/16 at 16:50 (4:50 P.M.) documented by RN #2 indicated Resident #20 .10 a (10:00 A.M.) Pt (patient) requested medication to help with hives, lip swollen and right side of tongue swollen, staff administered visteral ([MEDICATION NAME] used to treat hives and itching) .Pt returned from therapy and stated she was having some trouble swallowing .Physician (Physician's name) on call for ( Resident #20's Physician) (Physician's name) notified (sic) said to monitor pt, use prn (as needed) epi pen ([MEDICATION NAME]) (used to treat allergic reactions) if needed in emergency and send to hospital. Dr (Physician's name) (endocrinologist) notified, no new orders and have (Resident #20's Physician's name) see pt tomorrow. (On call Physician) ordered for [MEDICATION NAME] to be d/c'd (discontinued) said swollen tongue can be side effect of [MEDICATION NAME] and wants (Resident #20's Physician name) to review meds (medications) and maybe put her on a different b/p (blood pressure) med, but (family member) does not want this med d/c'd said this is the only b/p med that works well for her so following up with (Resident #20's Physician's name) tomorrow. (Family member) also wants pt to stop taking [MEDICATION NAME] said she has an allergy to this medication The Policy Physician Notification Procedure /Family/POA/ Administrative Personnel revised August 2014, received from the DON on 2/11/16 at 11:15 A.M. indicated .Procedure: 4. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences 3.1-48(a)(4)

Based on record review and interview, the facility failed to ensure the physician was notified of a significant weight loss for 1 of 5 residents reviewed for nutrition (Resident #21). In addition the facility failed to notify the physician of elevated blood glucose levels for 1 of 3 residents (#9) reviewed for blood glucose levels. Findings include: 1. The record for Resident #21 was reviewed on 5/21/2014 at 9:00 A.M. [DIAGNOSES REDACTED]. Weights provided by the facility on 5/19/2014 indicated the following weights: 02/22/2014: 105.8 lbs 02/25/2014: 107.2 lbs 03/18/2014: 99.2 lbs (7.46% decrease from 2/25/14) 03/25/2014: 99.6 lbs (7.09% decrease from 2/25/14) 05/20/2014: 98.8 lbs (7.83% decrease from 2/25/14) There was no documentation in in the physician progress notes [REDACTED]. There was no documentation in Resident 21's record indicating the nursing staff had notified the physician of weight loss occurring on 3/18/14, 3/25/14, or 5/20/14. The facility DON (Director of Nursing) was interviewed on 5/21/2014. During the interview, the DON indicated there was no documentation in Resident #21's chart to indicate the facility had notified the physician of the resident's significant weight loss. A facility policy entitled "Weight Policy", with a revised date of 11/2006, was provided by the DON on 5/21/2014 at 10:30 A.M. The policy indicated residents with weight changes of 5% in one month, 7% in three months, or 10% in six months would be considered to be at nutritional risk. The policy further indicated "If weight loss verified, the attending physician will be notified...." 2. Resident #9's clinical record was reviewed on 5/20/14 at 3:00 P.M. and indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. The sliding scale indicated if the blood glucose was over 301, the resident was to be administered Humalog 10 units and physician was to be notified. Review of the Medication Administration Record (MAR) for May 2014, indicated from 5/2/14 through 5/10/14, the resident's blood glucose level was over 301 a total of 12 times. Review of the MAR and the nurse's notes indicated the physician was not notified on any of the 12 occasions when the blood glucose level was above 301. On 3/11/14, a physician's orders [REDACTED]. Review of the MAR from 5/11/14 through 5/19/14 indicated the resident's blood glucose level was above 351 a total of 8 times. Review of the MAR and the nurse's notes indicated the physician was not notified on 7 of the 8 occasions. An interview with the Director of Nursing (DON) on 5/21/14 at 11:00 A.M. indicated the physician should have been notified on each occasion when resident #9's blood glucose was above the appropriate levels (over 301 from 5/2/14 through 5/10/14 and above 351 from 5/11/14 through 5/19/14) as the physician's orders [REDACTED]. Review of a procedure provided by the DON on 5/21/14 at 11:15 A.M., with the subject of: "Physician Notification Procedure/Family/POA/Administrative Personnel" indicated: 1. Notify physician, family or POA and administrative personnel (on call nurse) immediately (day or night) of any significant changes in condition and/or accidents or injuries. 2, Notify physician, family or POA and administrative personnel (on call nurse) as soon as possible or by the next morning (if during night shift), minor occurances/incidents or weight loss (example: non emergency issues). 3.1-5(a)(2)

Based on record review and interview, the facility failed to obtain laboratory tests as ordered by the physician, for 1 of 5 residents reviewed for nutrition (Resident #21). The facility also failed to notify the physician of elevated blood glucose levels, per the physician's orders [REDACTED].#9) reviewed for diabetes mellitus. Findings include: 1. The record for Resident #21 was reviewed on 5/21/2014 at 9:00 A.M. [DIAGNOSES REDACTED]. A laboratory report, dated 2/23/2014, indicated results of a CBC (complete blood count) was received by the facility on 2/27/2014. A hand written note on the report from the physician, dated 2/28/2014, indicated "[MEDICAL CONDITION] noted - has patient had [MEDICAL CONDITION] panel or treatment for [REDACTED]." A physician order, dated 3/3/2014, indicated a ferritin level, serum iron level, reticulocyte count, folate level, and vitamin B 12 level were to be obtained on 3/6/2014. There were no results for the laboratory tests ordered on [DATE] in Resident #21's record. The facility DON (Director of Nursing) was interviewed on 5/21/2014 at 11:30 A.M. During the interview, the DON indicated the laboratory tests ordered by the physician on 3/3/2014 had not been obtained. The DON indicated when nursing staff receive an order for [REDACTED]. The DON further indicated she had called the lab and they had indicated they had not received the physician order [REDACTED]. 2. Resident #9's clinical record was reviewed on 5/20/14 at 3:00 P.M. and indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. The sliding scale indicated if the blood glucose was over 301, the resident was to be administered Humalog 10 units and physician was to be notified. Review of the Medication Administration Record (MAR) for May 2014, indicated from 5/2/14 through 5/10/14, the resident's blood glucose level was over 301 a total of 12 times. Review of the MAR and the nurse's notes indicated the physician was not notified on any of the 12 occasions when the blood glucose level was above 301. On 3/11/14, a physician's orders [REDACTED]. Review of the MAR from 5/11/14 through 5/19/14 indicated the resident's blood glucose level was above 351 a total of 8 times. Review of the MAR and the nurse's notes indicated the physician was not notified on 7 of the 8 occasions. An interview with the Director of Nursing (DON) on 5/21/14 at 11:00 A.M. indicated the physician should have been notified on each occasion when resident #9's blood glucose was above the appropriate levels (over 301 from 5/2/14 through 5/10/14 and above 351 from 5/11/14 through 5/19/14) as the physician's orders [REDACTED]. Review of a procedure provided by the DON on 5/21/14 at 11:15 A.M., with the subject of: "Physician Notification Procedure/Family/POA/Administrative Personnel" indicated: 1. Notify physician, family or POA and administrative personnel (on call nurse) immediately (day or night) of any significant changes in condition and/or accidents or injuries. 2, Notify physician, family or POA and administrative personnel (on call nurse) as soon as possible or by the next morning (if during night shift), minor occurances/incidents or weight loss (example: non emergency issues). 3.1-35(g)(2)