Every finding on record at Waters of Hartford City Skilled Nursing Facility

Based on observation, interview, and record review, the facility failed to ensure food was served at a comfortable and palatable temperature for 1 of 7 residents reviewed for dining services. (Resident 37)Findings include:During a dining observation on 2/24/26 at 12:08 p.m., Resident 3 indicated to her tablemate that the mashed potatoes were very hot and warned the tablemate to be careful when eating them. During the same meal service, Resident 37 was seated at a separate table and was being assisted by a hospice certified nurse aide (CNA). When the CNA provided a spoonful of mashed potatoes, Resident 37 immediately lifted her fingers to her lips and widened her eyes. The CNA continued offering other food items and subsequently re-offered the mashed potatoes. Resident 37 initially refused to open her mouth. The CNA held the spoon at the resident's mouth until she eventually accepted the bite. Again, Resident 37 raised her fingers to her mouth and widened her eyes. The CNA did not look at the resident directly during the observation.On 2/25/26 at 12:24 p.m., during a dining observation, Resident 37 was again served mashed potatoes. Upon receiving a bite, she lifted her fingers to her mouth and widened her eyes. The CNA asked the resident, Oh, is that too hot? and stated she would allow the potatoes to cool.During an observation, on 2/25/26 at 12:31 p.m., dietary staff checked the temperature of the mashed potatoes and reported the temperature to be 180 degrees Fahrenheit (F). Review of a test tray of mashed potatoes indicated the temperature was found to be uncomfortably hot for consumption, resulting in discomfort to the tongue and mouth.On 2/25/26 at 12:43 p.m., the Administrator and a visiting Dietary Manager indicated the mashed potatoes were not too hot for consumption. The Administrator indicated that hot food temperatures should range between 165 and 200 and indicated if residents complained, he would refer to that temperature range. Resident 37's clinical record was reviewed on 2/26/26 at 12:37 p.m. Diagnoses included pneumonitis (inflammation of lungs) due to inhalation of food/vomit, dysphagia (difficulty swallowing), anxiety, and dementia.A review of a comprehensive Minimum Data Set (MDS) assessment, dated 2/13/26, indicated the resident was non-verbal, rarely/never understood, but did understand others. Resident 37 was severely cognitively impaired and did not exhibit hallucinations, delusions, or behaviors. She required supervision/touch for eating, partial/moderate assistance for oral hygiene.A current care plan, initiated on 1/30/26 and revised on 2/3/26, indicated Resident 37 presented with an alteration in her ability to communicate related to dementia. Interventions included staff anticipating her needs, allowing her time to respond to questions, ask simple and direct questions requiring a yes or no response, repeat questions and/or answers to ensure understanding, and speak directly to the residentA current care plan, initiated on 1/30/26 and revised on 2/3/26, indicated Resident 37 had impaired cognition/function or impaired thought process related to dementia. Interventions included asking the resident yes or no questions in order to determine her needs, cue, reorient, and supervise as needed, face the resident when speaking, and make eye contact.During an interview with the Administrator, on 3/3/26 at 11:08 a.m., he indicated once mashed potatoes had been sitting on the steam table, the temperature would drop below the desired holding temperature of 135 degrees F and were returned to the steamer to get the temperature back up to 165 degrees F. Once the temperature raised to the desired 165 degrees F, the potatoes would be returned to the steam table where the temperature should be checked again. A current facility policy, titled General Preparation and Cooking Practices, provided by the ADON on 3/3/26 at 10:53 a.m., indicated the following: .Hot food prepped for serving will maintain a minimum temperature of 135 when on the steam table and prior to being served to the residents. If the food is below 135 , the staff must reheat the food 165 to assure time and temperature control.410 IAC (Indiana Administrative Code) 3.1-21(a)(1)(2)

Based on interview and record review, the facility failed to ensure a preadmission screening and resident review (PASRR) was completed when the initial authorization for placement expired for 1 of 4 residents reviewed for PASRR. (Resident 12) Finding includes: Resident 12's clinical record was reviewed on [DATE] at 11:12 a.m. Her current diagnoses included bipolar disorder, other schizoaffective disorders, and major depressive disorder, recurrent. Current physician orders included bupropion hydrochloride extended release (antidepressant) 300 mg daily, hydroxyzine 50 mg (used for anxiety) three times a day and quetiapine fumarate (antipsychotic) 100 mg daily and 150 mg at bedtime. An [DATE] quarterly minimum data set (MDS) assessment indicated the resident received antipsychotic, antianxiety, antidepressant, and hypnotic medications. A general progress note, dated [DATE] at 1:45 p.m., indicated the resident had 14 angry outbursts since admission and was being followed by a mental health services provider. A PASRR Level l screen outcome, dated [DATE], indicated the resident had an exempted hospital discharge. A 30-day approval or less stay in the nursing facility was authorized. Re-screening was to have occurred on or before the 30th day if the individual expected to remain in the nursing facility beyond the authorization timeframe. The end of authorization date was [DATE]. During an interview, on [DATE] at 9:03 a.m., the Admissions Nurse indicated she had missed the [DATE] date to resubmit the PASRR as she had not realized the PASRR had been for 30 days when the resident admitted . A new PASRR was submitted on [DATE]. A PASRR Level l screen, provided by the Social Services Designee (SSD) on [DATE] at 9:05 a.m., indicated the Level l had been submitted on [DATE] and indicated a Level 2 onsite evaluation must be conducted. A PASRR Level 2 screen, provided by the SSD on [DATE] at 9:05 a.m., indicated the Level 2 had a determination date of [DATE] and an effective date of [DATE]. According to a web document from Maximus, the Indiana PASRR screening provider, dated 2022, titled Indiana PASRR FAQs for Providers, accessed on [DATE] at 10:18 a.m. at https://maximusclinicalservices.com/sites/default/files/pasrr/documents/IN%20PASRR%20FAQ_S%202021%20-%207.15.22.pdf, .If the person requires a stay longer than the 30-day EHD [Exempted Hospital Discharge] approval period, a new Level I and a LOC [Level of Care] are required to complete the full Level II. Please submit a Level I and a LOC 7 days prior to the end of the 30-day approval to avoid Federal compliance issues A facility document, dated [DATE], titled Guidelines for PASRR Process, provided by the Administrator on [DATE] at 3:26 p.m., indicated .An initial PASRR Level l Screening (PL1) of every person, (resident), apply for NF [nursing facility] placement to identify people, (residents), suspected of having ID [intellectual disability], DD [developmental disability], or MI [mental illness]. If the initial screening is positive, (meaning the person may have ID, DD, or MI), a PASRR evaluation, (PE), is completed by a qualified and impartial reviewer. People, (residents), who are confirmed to have ID, DD, or MI are evaluated to determine the need for specialized services, and appropriate placement options are reviewed 3XXX,d+[DATE](d)(1)(B)

Based on observation, record review, and interview, the facility failed to implement and review individualized interventions to prevent the development of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 32) Finding includes: During an observation on 2/5/24 at 10:57 a.m., Resident 32 was sitting in her room in her wheelchair with a heel boot on her left leg and foot. During a wound observation on 2/7/24 at 9:11 a.m., the bandage was removed from the pressure injury to the left heel. The wound was the size of a half dollar in length, the size of a quarter in width, and had a 0.1 cm depth. The center of the wound was tan slough (nonviable tissue) with the length of the entire wound and the width of a pencil eraser. During an interview, at the time of the observation, the ADON indicated the area had started as a blood blister and developed an eschar cap (necrotic tissue). The Wound Nurse Practitioner (NP) had removed the eschar cap from the left heel wound prior to the resident being hospitalized on [DATE]. During an observation on 2/7/24 at 2:09 p.m., the resident was lying in bed on her right side with a heel boot on her left leg and foot. During an observation on 2/8/24 at 8:27 a.m., the resident was sitting in her recliner with a heel boot on her left leg and foot. Her legs were elevated. Resident 32's clinical record was reviewed on 2/6/24 at 3:09 p.m. Her diagnoses included diabetes mellitus with diabetic neuropathy, obesity, muscle weakness, and dementia. Current physician's orders included: cleanse area on left heel, apply medical grade honey to wound, and cover with gauze then wrap with fluff dried pre-woven gauze daily until healed, float heels at all times when in bed every shift, and pressure reduction boot to left foot at all times, may remove for transfers every shift. A 1/15/24 minimum data set (MDS) assessment indicated the resident was moderately cognitively impaired. She required partial/moderate assistance of staff to roll from left to right. She required substantial/maximal assistance of staff for dressing her lower body. She was dependent on staff for transfers. She was at risk of developing a pressure injury and had an unstageable pressure injury with suspected deep tissue injury in evolution. A care plan problem, created on 10/15/23, revised on 1/25/24, indicated the resident had developed a deep tissue injury that presented as a dark purple intact blister to her left heel. (1/15/24 - wound NP removed eschar from wound) - returned from hospital on 1/25/24 with the area as unstageable (wound bed cannot be visualized to determine wound stage). A care plan problem, created on 7/1/23, revised on 9/28/23, indicated the resident was at risk for skin breakdown. Her diagnoses included diabetes, obesity, chronic heart disease, and incontinence and edema. She had no right great toenail. She slept in a recliner and preferred to not have a bed in her room. She was noncompliant at times with interventions even with education and encouragement. The same care plan problem was revised on 10/30/23 and indicated the resident was at risk for skin breakdown. Her diagnoses included diabetes, obesity, chronic heart disease, and incontinence and edema. She had no right great toenail. She slept in a recliner and preferred to not have a bed in her room. She was noncompliant at times with interventions even with education and encouragement. On 10/12/23, the resident was noncompliant with floating heels off of bed surface for more than a few minutes, and will pull pillow out from under feet and kick pillow onto floor. A skin and wound progress note, dated 10/15/23 at 4:14 p.m., indicated a one inch by two-inch red/purple blister was found on the resident's left heel. A skin and wound progress note, dated 10/16/23 at 11:36 a.m., documented by the Wound NP, indicated the resident was being seen for left heel blister concerns. The resident did not have good bed mobility and preferred to be left alone. The area to the left heel measured 3 centimeters (cm) length (L) by 4.5 cm width (W). The area was staged as a deep tissue injury and coded as a pressure-induced deep tissue damage of the left heel. A skin and wound progress note, dated 11/13/23 at 4:28 a.m., documented by the Wound NP, indicated the wound status was stalled. The wound measurements were 4.5 cm L by 5.5 cm W. A skin and wound progress note, dated 12/18/23 at 8:08 a.m., documented by the Wound NP, indicated the wound measurements were 2.5 cm L by 2 cm W. A skin and wound progress note, dated 1/2/24 at 1:34 p.m., documented by the Wound NP, indicated the wound status was stable eschar. Removal of necrotic tissue was performed. Wound measurements were 2 cm L by 1 cm W. A skin and wound progress note, dated 1/15/24 at 2:22 p.m., documented by the Wound NP, indicated the wound was improving despite the measurements. Removal of necrotic tissue was performed. The wound measurements were 3 cm L by 1.5 cm W by 0.1 cm deep. A skin and wound progress note, dated 1/29/24 at 9:54 a.m., documented by the Wound NP indicated the wound staging was changed from deep tissue injury to unstageable following the recent hospitalization . Removal of necrotic tissue was performed. The wound measurements were 2.5 cm L by 2.5 cm W by 0.1 cm deep. A skin and wound progress note, dated 2/5/24 at a.m., documented by the Wound NP, indicated the wound was improving despite measurements and remained unstageable. The wound measurements were 1.0 cm L by 2.5 cm W by 0.1 cm deep. During an interview, on 2/9/24 at 8:39 a.m., CNA 5 indicated the resident's heels were floated. She wore heel boots. During an interview, on 2/9/24 at 11:32 a.m., LPN 6 indicated the resident wore a boot to her left foot and her heels were floated. During an interview, on 2/9/24 at 11:52 a.m., the DON indicated on a 10/12/23 24-hour report sheet, the nurse had documented the resident had kicked out her pillow from under her heels while in bed. She was unable to locate additional CNA or nurse documentation of the resident's noncompliance with interventions to prevent the development of pressure injuries. During an interview, on 2/9/24 at 12:44 p.m., the ADON indicated the resident had been sleeping in her recliner, then she began sleeping in her bed as she began in have increasing episodes of incontinence. She was uncertain of the date when the resident began sleeping in her bed. A facility policy, dated 5/20/23, titled Guidelines for Preventative Skin Care, provided by the DON on 2/9/24 at 4:04 p.m., indicated .It is the intent of the facility to provide residents with preventive skin care through careful washing, rinsing and drying of their skin, to keep them clean, comfortable, well-groomed and free from pressure sores 3.1-40(a)(1)

Based on observation, record review, and interview, the facility failed to prevent the development of a pressure injury for 1 of 3 residents reviewed for pressure ulcers. (Resident 31) During an observation, on 4/10/23 at 3:55 p.m., Resident 31 was in bed, with a pressure reducing boot on his left lower extremity and a pillow under his legs. During an observation, on 4/11/23 at 9:27 a.m., the resident sat in his wheelchair in his room, with a slipper on his right foot and a pressure reducing boot on his left lower leg. and his feet on the floor. During an observation, on 4/12/23 at 11:20 a.m., the resident sat in his wheelchair in his room with a slipper on his right foot and a pressure reducing boot on his left lower leg with his feet on the floor. During an observation, on 4/13/24 at 8:16 a.m., the resident propelled himself in his wheelchair in the hallway. He wore a slipper on his right foot and a pressure reducing boot on his left lower leg. The resident's clinical record was reviewed on 4/12/23 at 2:07 p.m. His diagnoses included fracture of the left femur, weakness, muscle wasting and atrophy, polyneuropathy, and depression. His current physician's orders included cleanse open blister to back of left heel, apply petrolatum gauze, cover with 4x4 gauze and secure with wrap gauze daily until healed (3/16/23), monitor open blister to back of left heel every shift until healed (3/16/23), pressure reducing boot to left foot at all times every shift (3/28/23), and use mechanical lift for transfers (2/9/23). A 2/14/23 5-day MDS (Minimum Data Set) assessment indicated the resident was moderately cognitively impaired, required extensive assistance for bed mobility, dressing, and toileting, was totally dependent on the assistance of two persons for transfers, and had a recent surgery for repair of a fractured hip. A current skin risk care plan, initiated 1/6/23, indicated as a goal, the resident would be provided with preventative measures in an attempt to avoid skin breakdown (revised 1/16/23). Interventions included float heels while in bed (1/6/23), lay down for rest during the day (2/28/23), monitor skin daily during care (1/6/23), remind or assist to turn at least every two hours (2/28/23), and skin assessment at least weekly by nurse (2/28/23). A wound care plan, initiated on 3/15/23 and revised on 4/11/23, indicated the resident had developed an actual pressure injury, an unstageable area to the left heel which had become a stage three pressure injury (full thickness tissue loss) on 4/11/23. Interventions included float heels off the bed (3/15/23), leave shoes off feet at this time (initiated 3/15/23, with revision 3/17/23), and pressure reducing boot to left lower extremity at all times (3/28/23). A General Note, dated 3/15/23 at 11:15 p.m., indicated the resident had a popped blister on the left heel. The area was cleaned, and a bandage was applied. A Physician's Order Note, dated 3/16/23 at 11:36 p.m., indicated a new physician's order had been received to cleanse the open blister to the back of the left heel, apply petrolatum gauze, cover with a 4x4 gauze and secure with wrap gauze every day shift until healed and as needed for soilage or dislodgement. A Weekly Wound Evaluation, dated 3/16/23 at 11:36 a.m., indicated a new pressure injury to the back of the left heel was identified on 3/15/23. The pressure injury was acquired in the facility. The pressure injury was a stage two (partial thickness skin loss with exposed dermis) and measured 4.0 centimeters (cm) long by 3.0 cm wide by less than 0.1 cm deep. The wound color was red. The wound was comprised of 10% granulation (new connective tissue with microscopic blood vessels) tissue visible with skin covering the rest of the wound. A Weekly Wound Evaluation, dated 3/21/23 at 1:58 p.m., indicated the pressure injury to the back of the left heel was a stage two, and measured 2.0 cm long by 1.5 cm wide by less than 0.1 cm deep. The wound color was red with 100% granulation tissue present and visible. A Weekly Wound Evaluation, dated 3/28/23 at 2:01 p.m., indicated the pressure injury to the back of the left heel was unstageable (obscured full thickness skin and tissue loss) and measured 2.0 cm long by 1.5 cm wide and less than 0.1 cm deep. The wound color was red with 5% granulation, 5% slough (dead tissue usually yellow or cream in color), and 90% necrotic tissue. Most of the wound was covered with thick eschar (dry, black, hard necrotic tissue) with open surrounding edges comprised of yellow slough and red granulation tissue. A General Note, dated 3/28/23 at 2:13 p.m., indicated the physician was updated on the status of skin breakdown. A new order for a pressure reducing boot to the left lower extremity at all times was received. A Weekly Wound Evaluation, dated 4/11/23 at 11:46 a.m., indicated the pressure injury to the back of the left heel was a stage three and measured 2.0 cm long by 1.5 cm wide by less than 0.1 cm deep. The wound bed was covered with 50% yellow, moist slough and 50% pink, moist tissue. During an observation, on 4/13/23 at 10:21 a.m., RN 3 removed the dressing from the resident's left foot. The pressure injury on the back of the left heel was approximately the size of a quarter, with a pink wound bed and a black area in the center. The black area was approximately the length of two quarter edges and the width of the diameter of a nickel. The depth of the wound was approximately the edge of a quarter. In an interview during the observation, RN 3 indicated an eschar cap on the pressure injury had come off recently. She was uncertain of the date. During an interview, on 4/13/23 at 3:08 p.m., CNA 4 indicated the resident was unable to put on shoes himself since he fractured his hip. He used a mechanical lift and was unable to scoot himself up on his own. During an interview, on 4/13/23 at 3:37 p.m., the ADON indicated the blister on the back of the left heel was where his shoe had rubbed. He had hard leather heavy-duty shoes. During an interview, on 4/14/23 at 11:40 a.m., CNA 5 indicated the resident was unable to apply his shoes or socks, though he could kick off his footwear. During an interview, on 4/14/23 at 11:51 a.m., the ADON indicated the resident propelled himself in the wheelchair and might have rubbed his heel prior to developing the blister to his left heel. During an interview, on 4/14/23 at 12:24 p.m., the ADON indicated after the blister was found on the resident's heel, he continued to have the staff put on his shoes even though she kept reminding him to not wear his shoes. An undated facility policy, provided by the DON on 4/14/23 at 11:53 a.m., titled Preventative Skin Care, indicated Guideline: It is the intent of the facility that the facility provide preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well-groomed, and free from pressure sores .Ensure proper fit of wheelchairs, braces, shoes, and prosthetic devices 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent resident to resident abuse for 5 of 6 residents reviewed for abuse (Resident 35, 42, 1, 43 and 6). Findings include: 1. Resident 35 had the following observations: On 3/23/22 at 1:48 p.m. she was lying in bed. On 3/24/22 at 9:54 a.m., she sat in her wheelchair across from the 300 hall nurses station. On 3/25/22 at 12:07 p.m., she was in the main dining room eating lunch a staff member was sat next to her and assisted her with her meal. On 3/28/22 at 10:41 a.m., she was lying in bed. Resident 35's clinical record was reviewed on 3/23/22 at 3:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (treat depression) 10 mg daily, [MEDICATION(S)] (treat [CONDITION(S)]) 125 mg daily, [MEDICATION(S)] (treat delusions) 5 mg daily and 2.5 mg at bedtime and 15 minute checks as nursing measure. Assist with any unmet needs during checks, signature page noted at nursing station every shift started on 4/5/21. An annual MDS (Minimum Data Set), dated 2/17/21, indicated she was moderately cognitive impaired, she had delusions and she wandered. Her behaviors were worse compared to the prior assessment. She required extensive assistance with one staff member for bed mobility, transfers and walking in her room. She used a walker and a wheelchair. She used a bed and chair alarm daily. Her Nursing-Occurrence Initial Assessments included, but was not limited to the following: On 3/8/21 at 2:30 p.m., in the hallway outside of room [ROOM NUMBER], she had an altercation with Resident 42. She was talking and Resident 42 told her to shut up. She pointed finger at Resident 42 and said, You shut up , the Resident 42 grabbed her finger. They were separated by staff when voices were raised. The new interventions were 15 minute checks and to keep residents separated. On 4/21/21 at 11:38 a.m., she was in the TV lounge and a staff member heard a scream, they went to investigate and she had hit Resident 1 who was sleeping. The residents were immediately separated with no injuries or distress noted. The new interventions were to continue 15 minute checks and to keep residents separated. On 7/22/21 at 7:50 a.m., she was involved in a verbal altercation in the hallway/TV lounge with Resident 42 that led to her swatting at Resident 42. Both residents were separated immediately. An assessment was completed with no injuries, range of motion and vitals all within normal limits, no pain or discomfort reported. She was easily redirected and remained cooperative with no further occurrences that shift. Safety checks initiated at time of incident and staff continued to monitor. The new interventions were 15 minute checks, the residents were separated and redirected immediately following the incident. Safety checks were initiated and continued to be monitored. On 8/16/21 at 4:30 p.m., she grabbed Resident 43's arm after Resident 43 yelled at her in the TV lounge. The new interventions were 15 minute checks initiated and to keep her separated from the resident she had a disagreement with. On 12/2/21 at 3:15 p.m., a QMA on the unit was tending to the needs and providing care to resident's roommate (Resident 6) when she started rummaging through Resident 6's belongings. QMA told her that the items were not hers and belonged to Resident 6. She became agitated and retorted with Well ok then, HERE! as she threw a small wall decoration at Resident 6's head. Staff immediately removed her from the room. Head to toe assessment was completed for Resident 6 and she was negative for any abnormal findings or injuries. Vitals were within normal limits and she denied pain. Staff assisted Resident 35 to a new room on another hallway, 15 minute safety checks were to continue. The new interventions was for safety checks to continue, she was immediately separated from her roommate and moved to a new room on another hallway. Her care plans included, but were not limited to: She had an episode of resident to resident altercation on 3/8/2, she was noted to be hitting another resident while in the TV lounge on 4/21/21, she had an episode of resident to resident altercation-per this resident her and another resident exchanged words and then began to swat each others hands while in the TV lounge this was unwitnessed by any other person. Resident's to be kept separated and monitored for distress. Reassurance and TLC provided on 7/22/21, she a physical altercation with other resident where I struck out at her grabbing her wrist on 8/16/21 and she had a resident to resident altercation, she threw a small canvas painting at her roommate and struck her in the head on 12/2/2. Her goal was she would not exhibit distress from altercation. Her interventions included, encourage residents to be separate from one another, residents immediately separated- no injuries and no emotional distress- will follow up for 24 hours, social service to visit as needed, supervise while in the dining room and other common areas, update physician as needed initiated on 3/8/21, residents were separated immediately, resident assessed for injury or distress, TLC provided, she was placed on 15 minute checks for 72 hours initiated on 4/21/21, residents were separated immediately, assessed for injury or distress. TLC and reassurance was provided. Safety checks continued initiated on 7/22/21, resident separated immediately, assessed for injury or distress and provided with TLC and reassurance, 15 minute safety checks continued, the resident involved in the altercation will not be in TV lounge area together and staff to monitor. Rounding Providers assessed and gave new medication order initiated on 8/16/21,medication review per rounding provider, psych provider and a new order was received initiated on 8/17/21, the nurse practitioner visit and assessment- new order received for labs related to increase in agitation/anxiety initiated on 8/18/21, custom activity basket for resident to utilize when feeling agitated/anxious and encourage increase in activity participation initiated on 8/20/21, she was separated from roommate immediately and moved to room [ROOM NUMBER], psychiatric nurse practitioner updated with no new orders, she was on 15 min checks initiated on 12/2/21, she displayed inappropriate behaviors, [MEDICATION(S)] increased by nurse practitioner initiated 12/3/21. 2. On 3/25/22 at 10:27 a.m., Resident 42 was observed in her room sitting in her wheelchair. On 3/25/22 at 3:24 p.m. she was propelling herself in her wheelchair in the hallway. Resident 42's clinical record was reviewed on 3/24/22 at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (treat anxiety) 5 mg twice daily. A Nursing-Occurrence Initial Assessment, dated 3/8/21 at 3:43 p.m., indicated on 3/8/21 at 2:30 p.m., in the hallway outside of room [ROOM NUMBER] she had an altercation with Resident 35 with no injury. Resident 35 was talking loudly and she told her to shut up. Resident 35 pointed a finger at her and said, you shut up. She grabbed Resident 35's finger. The new interventions was to keep them apart. A Nursing-Occurrence Initial Assessment, dated 7/22/21 at 1:27 p.m., indicated on 7/22/21 at 7:50 a.m., in the hallway/TV area she reported Resident 35 swatted her right hand during a verbal altercation that occurred between the two of them. An assessment was completed with no signs or symptoms of an injury and no redness was present, range of motion per usual and vitals were within normal limits. She was placed on routine safety checks immediately following incident. The new interventions were 15 minute checks were initiated. Both residents were immediately separated and redirected. Safety checks were initiated. Her care plans included, but were not limited to, on 3/8/21 she had an episode of resident to resident altercation, no emotional distress noted after the occurrence. On 7/22/21 she had an episode of resident to resident altercation she and another resident exchanged words and then began to swat at each others hands while in the TV lounge-this was unwitnessed by any other person. Resident were to be kept separated and monitored for distress, reassurance and TLC was provided. Her goal was she would not exhibit distress from altercation. Her interventions included, but were not limited to, residents were separated immediately- no injuries or emotional distress was noted, encourage residents to be separate from one another, she was given coloring supplies, speak with family to assist with developing a plan, social service to visit as needed and supervise while in the dining room and other common areas initiated on 3/8/21. Resident were separated immediately and assessed for injury or distress. TLC and reassurance was provided. 15 minute safety checks for 72 hours initiated on 7/22/21. 3. On 3/25/22 at 10:27 a.m., Resident 1 was observed lying in bed. Resident 1's clinical record was reviewed on 3/24/22 at 3:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His current orders, included but were not limited to, [MEDICATION(S)] (treat dementia) 10 mg daily, [MEDICATION(S)] (treat [CONDITION(S)]) 10 mg daily, [MEDICATION(S)] (treat dementia) 10 mg twice daily and [MEDICATION(S)] (treat depression) 25 mg on Wednesdays and 50 mg all other days. A Nursing-Occurrence Initial Assessment, dated 4/21/21 at 1:40 p.m., indicated on 4/21/21 at 11:38 a.m., there was a resident to resident altercation in the TV lounge, when he was asleep and Resident 35 hit him. A staff member heard Resident 35 scream out and went to the TV lounge to investigate. The residents were immediately separated with no distress. The new interventions was the resident was removed from the situation. His care plans included, but not limited to, he an episode of resident to resident altercation initiated on 4/21/21. His goal was he would not exhibit distress from altercation. His interventions included, monitor for any emotional distress from occurrence, report sent to the IDOH and occurrence investigated per policy, review completed IDT (Interdisplinary Team) assessment, social service to visit as needed and to supervise while in the dining room and other common areas and intervene as needed initiated on 4/21/21. 4. On 3/24/22 at 9: 43 a.m., she was observed in bed. On 3/25/22 at 3:12 p.m., she was observed in her wheelchair in the main dining room for an activity. Resident 43's clinical record was reviewed on 3/25/22 at 12:34 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing-Occurrence Initial Assessment, dated 8/16/21 at 10:30 p.m., indicated on 8/16/21 at 6:30 p.m., she had an altercation with another resident in the TV lounge, it began when both residents yelled at one another and other resident grabbed her arm, near her wrist. There were no injuries. The new interventions were 15 minute checks and to keep her separate from the other individual. Her care plans included, but were not limited to, she had an episode of resident to resident altercation initiated on 7/18/19. Her goal was she would have no further altercations. Her interventions included, social service tot visit as needed initiated on 7/18/19 and resident were separated immediately, assessed for injury or distress and provided with TLC and reassurance, 15 minute safety checks were initiated. The resident's involved in altercation will not be in TV lounge area together and staff to monitor initiated on 8/16/21. Resident 6 was observed on 3/25/22 at 8:21 a.m., sitting in her broda chair in her room. Resident 6's clinical record was reviewed on 3/25/22 at 10:24 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] 25 mg on Monday, Wednesday, Thursday, Friday, Saturday and Sunday. A Nursing-Occurrence Initial Assessment, dated 12/2/21 at 3:15 p.m. indicated the QMA on unit was tending to her needs and providing care when Resident 35 started rummaging through her belongings. QMA told roommate that the items were not hers and belonged to Resident 6. Resident 35 became agitated and retorted with Well ok then, HERE! as she threw a small wall decoration at Resident 6 which hit her on the forehead. Staff immediately removed Resident 35 from the room. A head to toe assessment for Resident 6 was completed and neurological checks were initiated. A small red area was noted to her forehead which quickly dissipated after the incident. There were no further injuries found. She did not show any signs or symptoms of distress and her vitals and neurological checks were within normal limits and she denied pain. Staff assisted her into her wheelchair and provided her with a snack and a nutritional supplement to drink. She happily accepted both. She had a 2/22/22 resolved care plan that indicated on 12/2/21 she had an episode of resident to resident altercation. She had a small canvas painting thrown at me striking me in the head. No emotional distress or injury was noted. Resident were to be kept separated and monitored for distress. Reassurance and TLC was provided initiated on 12/3/21. Her goal was she would not exhibit distress from altercation. Her interventions included, encourage residents to be separated from each other, the residents were separated immediately and was assessed for injury or distress, TLC and reassurance was provided, 15 min safety checks for 72 hours, speak with family to assist with developing a plan, social service to visit as needed, and supervise while in the dining room or common areas initiated on 12/3/21. During an interview with the Administrator, on 03/24/22 at 10:49 a.m., he indicated Resident 35's daughter finally admitted the resident had [CONDITION(S)] and had been diagnosed [AGE] years ago. She was put on [MEDICATION(S)] and that had helped her tremendously. During an interview with the Administrator and the DON, on 3/28/22 at 10:40 a.m., the DON indicated the Resident 35 was on 15 minute checks, she was sent to inpatient stay. The DON was not sure what more they could have done more related to supervision. Daughter was aware there was a problem and short of giving a 30 days notice (which they were thinking of doing) due to the behaviors. Some of the interactions were from other residents approaching her. Like the resident that went up to her and pointed her and she swatted her finger. During an interview with the DON, on 3/28/22 at 3:20 p.m., she indicated Resident 42 could be aggressive and Resident 43 could be as well and never forgets anything. Resident 6 was not an instigator and would talk about herself in a demeaning way and yell out or thinking she was talking to her niece or delusional but not an instigator. Resident 43, 42 and 35 would fit that description. Resident 1 had his days but was not the aggressor in that incident. Resident 35 tried to wake him up but hit him. Resident 35's interventions were 15 minutes checks, room moved, constantly adjust meds, one on one with family, psychiatric stay, personalized activities and group activities but sat by herself. A current policy, titled Abuse Prohibition, Reporting, and Investigation, provided by the Administrator at entrance to the facility on [DATE] indicated the following: Policy: 1. It is the policy of Miller's Health Systems that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .Residents will be protected from abuse through the provisions of this policy, the procedure 3.1-27(a) 3.1-27(b)

Based on observation, interview and record review, the facility failed to develop individualized interventions to prevent resident to resident abuse for 5 of 6 residents reviewed for abuse (Resident 35, 42, 1, 43 and 6) and for failed to develop individualized interventions and indication for use of an anti-psychotic for 2 of 5 resident reviewed for unnecessary medications (Resident 43 and 22). Findings include: 1. Resident 35 had the following observations: On 3/23/22 at 1:48 p.m. she was lying in bed. On 3/24/22 at 9:54 a.m., she sat in her wheelchair across from the 300 hall nurses station. On 3/25/22 at 12:07 p.m., she was in the main dining room eating lunch a staff member was sat next to her and assisted her with her meal. On 3/28/22 at 10:41 a.m., she was lying in bed. Resident 35's clinical record was reviewed on 3/23/22 at 3:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (anti-depressant) 10 mg (milligram) daily started on 11/16/21, [MEDICATION(S)] (mood stabilizer) 125 mg daily started on 3/23/22, [MEDICATION(S)] (anti-psychotic) 5 mg daily and 2.5 mg at bedtime started on 12/4/21, and 15 minute checks as nursing measure. Assist with any unmet needs during checks, signature page noted at nursing station every shift started on 4/5/21. An annual MDS (Minimum Data Set), dated 2/17/21, indicated she was moderately cognitive impaired, she had delusions and she wandered. Her behaviors were worse compared to the prior assessment. Her care plans included, but were not limited to: BEHAVIOR #1 she displayed mood issues as exhibited by: Delusions, such as thinking people were here to visit when not, looking for a doggy, bugs in food and male CNA and her are married and had two babies last week. Behavior #2: mood swings/violent behavior- laughing, talking loudly then crying loudly causing distress to self. Strikes out of staff and has history of striking out at other residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her interventions included, but were not limited to, discontinue [MEDICATION(S)] (anti-psychotic) for GDR (Gradual Dose Reduction) attempt initiated on 1/5/21. Discontinue Nudexta (treat mental/mood disorder) initiated on 3/25/21. Start [MEDICATION(S)] 25 mg twice daily for delusions initiated on 4/16/21. [MEDICATION(S)] 25 mg increased to three times daily for delusions initiated on 5/4/21. She preferred to eat meals in the North lounge on an over the bed table related to decreased stimulation initiated on 6/2/21. Medications reviewed by psychiatric NP (Nurse Practitioner), new order received for [MEDICATION(S)] (anxiolytic) 0.5 mg twice daily as need for 14 days for agitation and anxiety initiated on 8/18/21. Increase [MEDICATION(S)] to 50 mg twice daily for violent behaviors and add diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Taper dose [MEDICATION(S)] to discontinue and start [MEDICATION(S)] (anti-psychotic) 0.5 mg at bedtime initiated on 10/5/21. Give [MEDICATION(S)] 0.5 mg one time now (10:00 p.m.) for increased agitation-notify provider if medication was not effective in one hour initiated on 10/20/21. Increase [MEDICATION(S)] to 50 mg twice daily at 12:00 p.m. and 8:00 p.m. for increased behaviors initiated on 10/21/2021. Give one time dose [MEDICATION(S)] 0.5 mg and obtain labs as ordered initiated on 10/25/21. Increased behaviors were noted- new order received to start [MEDICATION(S)] (cognition enhancement) twice daily for anxiety initiated on 10/27/21. A new order was received to decrease [MEDICATION(S)] to daily from twice related to period of lethargy initiated on 10/30/21. A new order received for resident to be sent for inpatient psych stay initiated on 11/2/21. Document mood behavior #1: Delusions of people being here that are not, looking for doggy, bugs in food and on her Interventions: [1] provide reassurance/TLC, [2] listen to concern and allow ample time to vent, [3] provide activity: reminisce about family, [4] offer drink and walk and document mood behavior #2:mood swings- loudly,fast talking, laughing then next minute crying loudly causing distress to self. Interventions: [1] assess for pain, [2] listen to concern/offer TLC/offer snack, [3] offer to call son. [4] divert to activities initiated on 11/16/21. She returned from psychiatric unit with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 125 mg three times daily added for treatment initiated on 12/7/21. She had an episode of resident to resident altercation on 3/8/2, she was noted to be hitting another resident while in the TV lounge on 4/21/21, she had an episode of resident to resident altercation-per this resident her and another resident exchanged words and then began to swat each others hands while in the TV lounge this was unwitnessed by any other person. Resident's to be kept separated and monitored for distress. Reassurance and TLC provided on 7/22/21, she a physical altercation with other resident where I struck out at her grabbing her wrist on 8/16/21 and she had a resident to resident altercation, she threw a small canvas painting at her roommate and struck her in the head on 12/2/2. Her goal was she would not exhibit distress from altercation. Her interventions included, encourage residents to be separate from one another, residents immediately separated- no injuries and no emotional distress- will follow up for 24 hours, social service to visit as needed, supervise while in the dining room and other common areas, update physician as needed initiated on 3/8/21, residents were separated immediately, resident assessed for injury or distress, TLC provided, she was placed on 15 minute checks for 72 hours initiated on 4/21/21, residents were separated immediately, assessed for injury or distress. TLC and reassurance was provided. Safety checks continued initiated on 7/22/21, resident separated immediately, assessed for injury or distress and provided with TLC and reassurance, 15 minute safety checks continued, the resident involved in the altercation will not be in TV lounge area together and staff to monitor. Rounding Providers assessed and gave new medication order initiated on 8/16/21,medication review per rounding provider, psych provider and a new order was received initiated on 8/17/21, the nurse practitioner visit and assessment- new order received for labs related to increase in agitation/anxiety initiated on 8/18/21, custom activity basket for resident to utilize when feeling agitated/anxious and encourage increase in activity participation initiated on 8/20/21, she was separated from roommate immediately and moved to room [ROOM NUMBER], psychiatric nurse practitioner updated with no new orders, she was on 15 min checks initiated on 12/2/21, she displayed inappropriate behaviors, [MEDICATION(S)] increased by nurse practitioner initiated 12/3/21. A nurses note, dated 3/2/21 at 4:38 p.m., indicated her current medications and behaviors were reviewed with IDT and included a provider and the pharmacy consultant for last month. She had 18 episodes of delusions and 13 episode of being physically aggressive with staff. It was an increase from the previous month reviewed. She was not getting along well with her room-mate during the month and also had a rash which maybe irritating her, causing a behavior increase. She no longer had the roommate, and received medication for itching. Rash had started following a change from [MEDICATION(S)] to [MEDICATION(S)]. [MEDICATION(S)] would be discontinued and resume [MEDICATION(S)] (anti-depressant) 10 mg daily for depression to see if rash would resolve. She also had mood swings throughout the day from laughing/joking to crying/sobbing. At times her mood would change within a few minutes. A Nursing-Occurrence Initial Assessments, dated 3/8/21 at 2:30 p.m., indicated in the hallway outside of room [ROOM NUMBER], she had an altercation with Resident 42. She was talking and Resident 42 told her to shut up. She pointed finger at Resident 42 and said, You shut up , the Resident 42 grabbed her finger. They were separated by staff when voices were raised. The new interventions were 15 minute checks and to keep residents separated. A nurses note, dated 4/6/21 at 1:07 p.m., indicated her current medications and behaviors were reviewed with the IDT members, a provider and the pharmacy consultant for last the month. She had 21 episodes of delusions and 17 episodes of being physically aggressive with staff noted. She was also noted with 40 episodes of mood swings- resident would go from talking very loudly to sobbing/crying, all within the same conversation, which was causing distress to herself and other residents. This was an increase from the previous month reviewed. She previously had a rash which has since resolved, along with the itching, although has recently started complaining of itching again and as needed medication was restarted. She had a new roommate and they seemed to be getting along. She had several medication changes recently and was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing-Occurrence Initial Assessments, dated 4/21/21 at 11:38 a.m., she was in the TV lounge and a staff member heard a scream, they went to investigate and she had hit Resident 1 who was sleeping. The residents were immediately separated with no injuries or distress noted. The new interventions were to continue 15 minute checks and to keep residents separated. A nurses note, dated 5/4/21 at 12:49 p.m., indicated her current medications and behaviors were reviewed with IDT members, a provider and the pharmacy consultant for last the month. She had 15 episodes of delusions and 18 episodes of being physically aggressive with staff. She also had 42 episodes of mood swings and she would go from talking very loudly to sobbing/crying, all within the same conversation, which was causing distress to herself and other residents. This was an increase from the previous month reviewed for behavior #3 (mood swings). Resident noted with recent resident to resident altercation, her behaviors remained erratic even after initiation of [MEDICATION(S)] medication on 4/16/21. NP felt as though the medication was not being optimized and an increase in [MEDICATION(S)] medication was ordered from twice to three times daily. A nurses note, dated 7/6/21 at 10:52 a.m., indicated her current medications and behaviors were reviewed with IDT members, a providers and the pharmacy consultant for the last the month. She had 6 episodes of delusions and 2 episodes of being physically aggressive with staff. She also had 34 episodes of mood swings. This was a slight increase in all behaviors from the previous month reviewed. She continued to laugh and joke with staff and others as well. No change was made to her medication regimen. A Nursing-Occurrence Initial Assessments, dated 7/22/21 at 7:50 a.m., she was involved in a verbal altercation in the hallway/TV lounge with Resident 42 that led to her swatting at Resident 42. Both residents were separated immediately. An assessment was completed with no injuries, range of motion and vitals all within normal limits, no pain or discomfort reported. She was easily redirected and remained cooperative with no further occurrences that shift. Safety checks initiated at time of incident and staff continued to monitor. The new interventions were 15 minute checks, the residents were separated and redirected immediately following the incident. Safety checks were initiated and continued to be monitored. A nurses note, dated 8/3/21 at 10:43 a.m., indicated her current medication and behaviors were reviewed with IDT members and included a providers and the pharmacy consultant for last the month. She had 3 episodes of delusions and 3 episodes of being physically aggressive with staff. She also had 20 episodes of mood swings. It was a decrease in all behaviors from the previous month reviewed. She continued to laugh and joke with staff and others as well. There were no changes to her medication regimen. A Nursing-Occurrence Initial Assessments, dated 8/16/21 at 4:30 p.m., she grabbed Resident 43's arm after Resident 43 yelled at her in the TV lounge. The new interventions were 15 minute checks initiated and to keep her separated from the resident she had a disagreement with. A nurses note, dated 9/7/20 21 at 11:24 a.m., indicated her current medication were reviewed with IDT, a provider and pharmacy consultant for the last the month. She had 12 episodes of delusions and 12 episodes of being physically aggressive with staff. She also had 26 episodes of mood swings. This was an increase in all behaviors from the previous month reviewed. She continued with agitation and aggressive behaviors which were easily triggered. Plan to add diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses note, dated 10/5/21 at 3:15 p.m. indicated her current medication and behaviors were reviewed with IDT, a provider and the pharmacy consultant for the last the month. She had 14 episodes of delusions (two of which were unchanged with interventions in place) and 12 episodes of being physically aggressive with staff. She also had 26 episodes of mood swings (five of which were unchanged). This was an increase in two of the three behaviors from the previous month reviewed. She continued with agitation and aggressive behaviors which were easily triggered. She had a recent increase in [MEDICATION(S)] without a good improvement in behaviors. The worsened behavior tracker was started. New order received to initiate [MEDICATION(S)] and wean off of [MEDICATION(S)]. A nurses note, dated 10/30/21 at 12:43 p.m. indicated physician and family made aware of occurrence, on call physician gave new order to send her to ER for evaluation and treatment. A Nursing-Occurrence Initial Assessment, dated 10/30/21, indicated she made allegations of abuse against a staff member. She screamed at staff and said they were all liars. She was removed from room with one-on-one conversation with this nurse, her daughter was contacted to talk with her. She continued with the allegations of abuse. No injury was noted and the accused staff member was sent home. Physician contacted for new order to send to ER for evaluation and treatment. A nurses note, dated 11/2/21 at 11:48 a.m. indicated NP was called regarding recent behaviors and her increased distress. Family members were present for phone conference. NP felt it was in the best interest of the resident to be admitted for inpatient psychiatric stay, options reviewed with family and they had agreed to send her to psychiatric stay. A nurses note, dated 11/2/21 at 11:52 a.m., indicated a new order was received to send her for a psychiatric inpatient stay. A nurses note, dated 11/4/21 at 2:06 p.m., indicated she was to be transferred to psychiatric inpatient stay. A weight note, dated 11/16/21 at 2:42 p.m., indicated she had returned to the facility. On 12/2/21 at 3:15 p.m., a QMA on the unit was tending to the needs and providing care to resident's roommate (Resident 6) when she started rummaging through Resident 6's belongings. QMA told her that the items were not hers and belonged to Resident 6. She became agitated and retorted with Well ok then, HERE! as she threw a small wall decoration at Resident 6's head. Staff immediately removed her from the room. Head to toe assessment was completed for Resident 6 and she was negative for any abnormal findings or injuries. Vitals were within normal limits and she denied pain. Staff assisted Resident 35 to a new room on another hallway, 15 minute safety checks were to continue. The new interventions was for safety checks to continue, she was immediately separated from her roommate and moved to a new room on another hallway. On 12/7/21 at 10:24 a.m., the writer had called the resident's daughter about her behaviors. Daughter indicated the resident was diagnosed with [CONDITION(S)] over [AGE] years ago and had seen a psychiatrist for it. On 12/7/21 at 12:31 p.m., her current medications and behaviors were reviewed with IDT members, a provider and the pharmacy consultant. She had 6 episodes of delusions and 5 episodes of being physically aggressive with staff. She also had 18 episodes of mood swings. This was a decrease in behaviors from the previous month reviewed, however she was treated in a psychiatric hospital from [DATE] -[DATE]. She continued with agitation and aggressive behaviors which were easily triggered. She currently received [MEDICATION(S)] for behaviors. Daughter reported that she was diagnosed with [CONDITION(S)] approximately [AGE] years ago. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 3/25/22 at 10:27 a.m., Resident 42 was observed in her room sitting in her wheelchair. Resident 42's clinical record was reviewed on 3/24/22 at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (anxiolytic) 5 mg twice daily started on 12/7/21. An annual MDS, dated [DATE], indicated she was moderately cognitive impaired. She exhibited no behaviors. Her care plans included, but were not limited to, the following: BEHAVIOR: She displayed mood issues as exhibited by: agitation causing distress to herself. Examples: pacing rapidly, breathing heavily, packing belongings on over bed table, pushing it in hallway, searching for family etc . initiated on 8/6/15. Her interventions included, but were not limited to, document mood behavior #2: agitation causing distress to herself. Examples: pacing rapidly, breathing heavily, packing belongings, searching for family etc. Interventions: [1] assess for pain, [2] do not argue with her, [3] offer TLC and listen to what has upset her, [4] offer to call daughter or friend initiated on 2/26/21. [MEDICATION(S)] discontinued at this time. New order received to start [MEDICATION(S)] 2.5 mg daily for [CONDITION(S)] initiated on 8/3/21. Increase [MEDICATION(S)] to 5 mg daily for [CONDITION(S)] initiated on 9/8/21. [MEDICATION(S)] 5 mg twice daily added for signs of anxiety initiated on 12/7/21 Discontinue [MEDICATION(S)] and start [MEDICATION(S)] 25 mg at bedtime initiated on 1/4/22. Discontinue [MEDICATION(S)] initiated on 2/8/22. Start hydroxizine (anti-histamine) 10 mg three times daily initiated on 2/25/22. Discontinue hydroxizine initiated on 2/28/22. On 3/8/21 she had an episode of resident to resident altercation, no emotional distress noted after the occurrence. On 7/22/21 she had an episode of resident to resident altercation she and another resident exchanged words and then began to swat at each others hands while in the TV lounge-this was unwitnessed by any other person. Resident were to be kept separated and monitored for distress, reassurance and TLC was provided. Her goal was she would not exhibit distress from altercation. Her interventions included, but were not limited to, residents were separated immediately- no injuries or emotional distress was noted, encourage residents to be separate from one another, she was given coloring supplies, speak with family to assist with developing a plan, social service to visit as needed and supervise while in the dining room and other common areas initiated on 3/8/21. Resident were separated immediately and assessed for injury or distress. TLC and reassurance was provided. 15 minute safety checks for 72 hours initiated on 7/22/21. A nurse note, dated 1/5/21 at 3:22 p.m., indicated her behaviors and current medication was reviewed with IDT and included NP and the pharmacy consultant. She continued to have periods of tearfulness at times. NP recommended starting [MEDICATION(S)] 10 mg daily for depression. A Nursing-Occurrence Initial Assessment, dated 3/8/21 at 3:43 p.m., indicated on 3/8/21 at 2:30 p.m., in the hallway outside of room [ROOM NUMBER] she had an altercation with Resident 35 with no injury. Resident 35 was talking loudly and she told her to shut up. Resident 35 pointed a finger at her and said, you shut up. She grabbed Resident 35's finger. The new interventions was to keep them apart. A nurses note, dated 4/6/21 at 1:01 p.m., indicated her chart and current medications were reviewed with IDT, the NP and the pharmacy consultant. She had eight episodes of agitation, packing up personal belongings to leave, during the month reviewed, all which improved with current interventions. This behavior began being tracked last month. She has a good relationship with social service and can easily be redirected or distracted when social service was present in facility. She spends a lot of time in the social service office throughout the day talking and coloring. She was being praised if clothes were being changed daily, she enjoyed this. There were no changes made. A nurses note, dated 7/6/21 at 11:02 a.m., her chart and current medications were reviewed with IDT and included the NP and the pharmacy consultant. She had one episode of agitation-packing up personal belongings to leave, during the month reviewed, which improved with current interventions in place. This was a decrease from the previous month reviewed. She had a good relationship with social service and could easily be redirected or distracted when social service was present. She was being rewarded with stickers if clothes were being changed daily. She placed them on a calendar and enjoyed this. She was doing well with the addition of [MEDICATION(S)]. A Nursing-Occurrence Initial Assessment, dated 7/22/21 at 1:27 p.m., indicated on 7/22/21 at 7:50 a.m., in the hallway/TV area she reported Resident 35 swatted her right hand during a verbal altercation that occurred between the two of them. An assessment was completed with no signs or symptoms of an injury and no redness was present, range of motion per usual and vitals were within normal limits. She was placed on routine safety checks immediately following incident. The new interventions were 15 minute checks were initiated. Both residents were immediately separated and redirected. Safety checks were initiated. A nurses note, dated 8/3/21 at 10:50 a.m., indicated her chart and current medications were reviewed with IDT and included the NP and the pharmacy consultant. She had three episodes of agitation-packing up personal belongings to leave, during the month reviewed, which improved with current interventions in place. This was an increase from the previous month reviewed. Since the addition of [MEDICATION(S)], she had increased confusion, difficulty with word finding and was no longer able to recognize her daughter when she called. [MEDICATION(S)] would be discontinued at this time and start [MEDICATION(S)] 2.5 mg for [CONDITION(S)] that she had received in the past. 3. On 3/25/22 at 10:27 a.m., Resident 1 was observed lying in bed. Resident 1's clinical record was reviewed on 3/24/22 at 3:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His current orders, included but were not limited to, [MEDICATION(S)] (treat dementia) 10 mg daily started on 7/27/18, [MEDICATION(S)] (treat hypersexual behavior) 10 mg daily started on 7/8/21, [MEDICATION(S)] (treat dementia) 10 mg twice daily started 7/27/18, and [MEDICATION(S)] (anti-depressant) 25 mg on Wednesdays and 50 mg all other days started on 12/7/21. An annual MDS, dated [DATE], indicated he was moderately cognitively impaired. He exhibited no behaviors. His care plans included, but not limited to, the following: BEHAVIOR: I display mood issues a exhibited by: [CONDITION(S)] diagnosis, exhibiting high/low mood swings, (excessive talking, not sleeping, excitable, to not talking, sleeping all the time, withdrawing)., restlessness. Behavior #2: sexual comments to female visitors initiated on 9/7/17. His interventions included, but were not limited to, document mood behavior #1:RESTLESSNESS Interventions: [1]assess for pain, [2] offer TLC/ conversation, [3] check for unmet need, [4] set at station and offer snack/drink initiated on 10/9/17. Document mood behavior #2: sexual comments to female visitors/female staff, Interventions: [1] assess for pain, [2] inform comments are inappropriate, [3]redirect to divisional activity drink/ snack, [4] assist resident to different area initiated on 7/4/18. Start [MEDICATION(S)] 10 mg daily initiated on 7/6/21. [MEDICATION(S)] is clinically contraindicated to decrease at this time initiated on 9/7/21. He had an episode of resident to resident altercation initiated on 4/21/21. His goal was he would not exhibit distress from altercation. His interventions included, monitor for any emotional distress from occurrence, report sent to the IDOH and occurrence investigated per policy, review completed IDT assessment, social service to visit as needed and to supervise while in the dining room and other common areas and intervene as needed initiated on 4/21/21. A nurses note, dated 3/2/21 at 2:21 p.m., indicated his current behaviors and medications were reviewed with IDT members and included the NP and the pharmacy consultant for the last month. He had two episodes of restlessness (which improved with interventions) and no episodes of inappropriate comments to staff. His behaviors have been stable. There were no changes to his medication regimen. A Nursing-Occurrence Initial Assessment, dated 4/21/21 at 1:40 p.m., indicated on 4/21/21 at 11:38 a.m., there was a resident to resident altercation in the TV lounge, when he was asleep and Resident 35 hit him. A staff member heard Resident 35 scream out and went to the TV lounge to investigate. The residents were immediately separated with no distress. The new intervention was the resident was removed from the situation. A nurses note, dated 4/6/21 at 12:53 p.m., his current behaviors and medications were reviewed with IDT members and included the NP and the pharmacy consultant for the last month. He had six episodes of restlessness (which improved with interventions) and four episodes of inappropriate comments to staff, all which improved with current interventions. This was a slight increase from the previous months. There were no changes to his medication regimen. 4. On 3/24/22 at 9: 43 a.m., Resident 43 was observed in bed. On 3/25/22 at 3:12 p.m., she was observed in her wheelchair in the main dining room for an activity. Resident 43's clinical record was reviewed on 3/25/22 at 12:34 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (mood stabilizer) 500 mg twice daily started on 3/14/22, [MEDICATION(S)] [MEDICATION(S)] 100 mg three times daily for delusions (give with 50 mg to equal 150 mg) and [MEDICATION(S)] [MEDICATION(S)] 50 mg three times daily for delusions (give with 100 mg to equal 150 mg) started on 3/1/22. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She had delusions. She had verbal behaviors symptoms that occurred four to six day but less than daily. Her care plans included, but were not limited to, the following: BEHAVIOR: I display mood issues as exhibited by: screaming/yelling d/due to history of traumatic frontal lobe brain injury in 1972. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Behavior #2: Delusions exhibited by stated she and her husband were going home and he was going to take care of her initiated on 6/21/19. Her interventions included, but were not limited to, document mood behavior #1: Delusions exhibited by yelling for family members (husband) causing distress to self. Interventions: [1] assess for pain, [2] assess current need and assist, [3] remind her to use her call light instead of yelling, (4)offer TLC initiated on 11/18/20. Document mood behavior #2: delusions exhibited by stating her and her husband were going home and he is going to take care of her. Interventions: [1] assess for pain [2] assess for unmet need (toilet, thirst, hunger), [3] Change environment, [4] offer to call sister initiated on 8/13/21. New order received to increase Seoul to 150 mg three times daily related to failed GDR initiated on 3/1/22. Increase in behaviors was noted, new order received to increase [MEDICATION(S)] and monitor initiated on 3/14/22. She had an episode of resident to resident altercation initiated on 7/18/19. Her goal was she would have no further altercations. Her interventions included, social service tot visit as needed initiated on 7/18/19 and resident were separated immediately, assessed for injury or distress and provided with TLC and reassurance, 15 minute safety checks were initiated. The resident's involved in altercation will not be in TV lounge area together and staff to monitor initiated on 8/16/21. A nurses note, dated 8/3/21 at 10:35 a.m., indicated her behaviors and medications were reviewed with IDT and included the NP and the pharmacy consultant. She had 26 episodes of yelling out causing distress in the last month, all of which improved with current interventions in place. This was a decrease from the previous month reviewed. She was able to be redirected during most episodes. She had visits with her husband and sister which she enjoyed. She was eating meals in the dining room, watches television in the lounge and converses with staff and other residents at times. She had episodes of agitation with staff and others at times. A tracker for agitation with others would be added. There were no changes to her medication regimen. A Nursing-Occurrence Initial Assessment, dated 8/16/21 at 10:30 p.m., indicated on 8/16/21 at 6:30 p.m., she had an altercation with another resident in the TV lounge, it began when both residents yelled at one another and other resident grabbed her arm, near her wrist. There were no injuries. The new interventions were 15 minute checks and to keep her separate from the other individual. A nurses note, dated 9/7/21 at 11:12 a.m., indicated her behaviors and medications were reviewed with IDT and included the NP and the pharmacy consultant. She had 24 episodes of yelling out causing distress and 16 episodes of agitation with others noted for the last month, all of which improved with current interventions in place. This was a slight decrease in episodes of yelling out from the previous month reviewed. She was able to be redirected during most episodes. She continued to have routine visits with her husband and sister. There were no changes to her medication regimen. [MEDICATION(S)], [MEDICATION(S)] (anti-depressant) and Trazadone (anti-depressant) were clinically contraindicated to be decreased. 5. On 3/25/22 at 8:21 a.m., Resident 6 was observed sitting in her Broda chair in her room. Resident 6's clinical record was reviewed on 3/25/22 at 10:24 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] 25 mg on Monday, Wednesday, Thursday, Friday, Saturday and Sunday started on 10/13/21. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She exhibited no behaviors. Her care plans included, but were not limited to, the following

Based on observation, record review and interview, the facility failed to ensure consistant documentation in the clinical record related to code status for 1 of 7 residents reviewed for Advance Directives (Resident 7). Findings include: On [DATE] at 1:17 p.m., the resident was observed in bed with visitors at her bedside. On [DATE] at 8:38 a.m., the resident was observed in bed with visitors at her bedside. Resident 7's clinical record was reviewed, on [DATE] at 10:00 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired, she had a condition or chronic disease that may had resulted in a life expectancy of less than 6 months and she received hospice care. An order, dated [DATE], indicated the resident was followed by hospice care while in the facility for [DIAGNOSES REDACTED]. The clinical record lacked a code status order. A review of her Cardiopulmonary Resuscitation (CPR) form, in her hard chart, indicated CPR would not be initiated. A focused care plan, dated [DATE], indicated the resident's code status was a Do Not Resuscitate (DNR). An intervention indicated to ensure the code status form is signed and on the chart. A nurses note, dated [DATE] at 1:00 p.m., indicated the resident had passed away peacefully at 12:33 p.m., family and hospice were present. During an interview with LPN 35, on [DATE] at 1:56 p.m., she indicated she would not look in the resident's chart for the code status, she would look at the resident's medication sheet to find the resident's code status. LPN 35 could not locate the code status on the resident's medication sheet. She indicated she would know if a resident was a full code, because they would wear a full code bracelet, they would check every shift and document it in the resident's treatment record that the bracelet was present on the resident. During an interview with LPN 37, on [DATE] at 2:07 p.m., she indicated the residents who are full code have a blue bracelet on and she would look in the resident chart or on the face sheet for their code status. During an interview with the DON, on [DATE] at 2:09 p.m., she indicated there should have been an order for [REDACTED]. On [DATE] at 2:45 p.m., the DON indicated, the resident did not have an order on her EHR for her to be a DNR, but she had the code status in her hard chart. A current policy, titled Code Straus and Advanced Directive Determination, provided by the DON, on [DATE] at 2:41 p.m., the procedure indicated, but was not limited to, after the CPR decision had been made, the form signed by the resident/family will be placed on the medical record in the appropriate location and this information will be communicated to the nurse in charge of caring for th resident. 3XXX,[DATE](f)5

Based on record review and interview, the facility failed to provide a resident representative with a bed hold policy for a severely cognitively impaired resident for 1 of 3 residents reviewed for hospitalization s (Resident 50). Findings include: Resident 50's clinical record was reviewed on 8/22/19 at 3:22 p.m. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired. An interact change in condition note, dated 7/3/19, indicated the resident had abnormal vital signs and was unable to respond at first. The resident had attempted to self transfer and was pale and limp, she was unable to verbally communicate. A nurse note, dated 7/3/2019 at 4:57 a.m., indicated an order was received to send the resident to the emergency room for evaluation and treatment. The clinical record indicated she was in the hospital from 7/3/19 and returned to the facility on [DATE]. An interview, with the DON, on 8/26/19 at 8:32 a.m., she indicated they did not send bedhold information to the family representative. On 8/26/19 at 9:54 a.m. the DON indicated the bed hold policy was discussed during the admission process, it would be a little different if the resident was private pay, then office manager would call the family and talk with them about the bed hold policy. 3.1-12(a)(6)(A)

Based on observation, record review and interview, the facility failed to provide adequate supervision during resident dining for 3 of 4 residents reviewed for accidents (Residents 18, 34, and 37). Findings include: During a dining observation, on 8/21/19 at 11:42 a.m. in the small dining room, Residents 18, 34 and 37 were eating food from Burger[NAME]with two other residents, no staff was present. An interview with LPN 37, on 8/21/19 at 12:43 p.m., she indicated Resident 18's family member brought in the food. Resident 37 was the only resident who had restrictions and it was for sodium, there was no residents that were at risk for choking. She would not normally leave the residents in the dining room by themselves, and she would stay close by. She was not aware the wife had brought in the food for the residents and maybe the family needed to be educated to let them know when she has brought in the food, so they can be in the dining room. a. During a review of Resident 18's clinical record on 8/23/19 at 9:40 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. He was not to use straws, have pot roast and must have supervision and assistance with meal set up (food cut into 1/2 inch pieces) if family not present. A quarterly MDS, dated [DATE], indicated the resident was cognitively intact, he required limited assistance of one staff member for eating, he had no oral disorders and no swallowing difficulty. He had a focused care plan, initiated on 11/7/17, indicated the resident was at risk for aspiration and had swallowing difficulties related to [MEDICAL CONDITIONS]. His goal was to be free of aspiration/choking. His interventions included, but were not limited to, monitor for coughing or choking with meals. b. Resident 34's clinical record was reviewed on 8/22/19 at 3:04 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An annual MDS, dated [DATE], indicated the resident was moderately cognitively impaired, she required supervision of one staff member for eating, she had no swallowing issues, she had a therapeutic and mechanically altered diet and no oral disorders. A focused care plan, initiated 10/14/16, indicated she was at risk for aspiration and she had swallowing difficulties, she had a [DIAGNOSES REDACTED]. Her interventions included, but were not limited to, monitor for coughing or choking with meals. c. Resident 37's clinical record was reviewed, 8/21/19 at 2:00 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. She had a focused care plan, initiated on 3/13/17, indicated she was at risk for aspiration and she had swallowing difficulties, she had a [DIAGNOSES REDACTED]. Her interventions included, but were not limited to, monitor for coughing or choking with meals. A current policy, titled Dining Room Assist Procedure, provided by the DON, on 8/27/19 at 1:00 p.m. indicated the procedure was to observe residents during meals, some will need extra encouragement to eat, others will want second servings. Check every 10 - 15 minutes. 3.1-45(2)

Based on observation, interview, and record review, the facility failed to consistently provide fluids to drink for 1 of 24 residents reviewed for hydration (Resident 20). Findings include: During an interview, on 8/22/19 at 10:29 a.m., Resident 20 indicated she did not usually get anything to drink between meals. During the interview, a note on her end table instructed to see the nurse before offering the resident fluids. On 8/26/19 at 2:30 p.m., the resident was sitting in her wheelchair, outside of the conference room, drinking a red thickened liquid from a lidded sip cup. On 8/27/19 at 9:13 a.m., a lidded sip cup, labeled 8/27/19 0700, was sitting on the resident's end table, across the room from her recliner. LPN 31 indicated the cup was not supposed to be in her room, as the resident was not safe to drink on her own. Staff offered the resident something to drink every two hours, which was documented in either the medication or treatment record. Review of the medication and treatment records, immediately following the interview, indicated an order to offer fluids was initialed twice daily by a nurse. There were no amounts recorded. Review of Resident 20's clinical record was completed on 8/23/19 at 8:57 a.m. [DIAGNOSES REDACTED]. She had current, 5/31/19, physician's orders [REDACTED]. She had a current, 3/6/19, physician's orders [REDACTED]. A 6/4/19, quarterly, MDS assessment indicated she was cognitively intact, and required extensive assistance with ADLs, mobility, and eating. She received hospice services. She had a current, 3/4/19, care plan problem of needing assistance with all ADLs. She had a current, 3/6/19, care plan problem of needing limited assistance with eating and drinking. Interventions included, but were not limited to, assist with meal set up and eating as needed, and give verbal cues to take bites as needed. She had a current, 3/23/19, care plan problem of risk for aspiration, and she was not willing to comply with her diet order. She was to have thickened liquids as ordered. She had a current, 3/4/19, care plan problem of nutritional risk due to, but not limited to, poor oral intake. Interventions included, but were not limited to, CACTUS (hydration) program on 8/8/19 to have staff encourage fluids. Review of a 3/4/19 Dietary Full Review assessment indicated she received a mechanical soft diet. Thickened liquids were not mentioned. Review of a 3/5/19 Registered Dietician Assessment indicated she consumed greater than 1500 mL of fluid a day. Review of meal and additional fluid intake documentation for (MONTH) 2019 indicated she drank less than 1500 mL daily on 26 out of 31 days. She had no additional fluids between meals on six of those days. Review of meal and additional fluid intake documentation for (MONTH) 2019 indicated she drank less than 1500 mL daily on 21 out of 26 days of the month thus far. She had no additional fluids between meals on five of those days. Review of a Wound and Weight Meeting Minutes document, dated 8/15/19, indicated the resident was asked about her drink preferences, and had declined any changes. Review of a Wound and Weight Meeting Minutes document, dated 8/23/19, indicated she liked lemonade, and fluids would continue to be encouraged. During an interview, on 8/26/19 at 2:06 p.m., CNA 33 indicated thickened liquids were offered to Resident 20 once per shift when ice was passed to the other residents. The resident especially liked orange juice, so she tried to offer it when it was available. During an interview, on 8/27/19 at 9:05 a.m., CNA 33 indicated she had asked the nurse about the resident's drinks the day before, and was told they offered her water every two hours; she didn't know they did that. During an interview, on 8/27/19 at 9:50 a.m., the Dietary Manager indicated the resident's nutritional status was assessed annually, except for preferences, which were reviewed quarterly. During an interview, on 8/27/19 at 9:52 a.m., the DON indicated Resident 20 was offered fluids every two hours, and she would sometimes ask for something to drink. She also received fluids with her medications, and was reviewed during their weight and nutrition meetings weekly. She was not unsafe to drink on her own, it was just difficult for her due to her disease process. Review of a current facility policy, titled Hydration Management Program, dated 12/1/17 and provided by the DON on 8/27/19 at 1:00 p.m., indicated it was the policy of the facility to provide appropriate assessment and interventions to support adequate hydration for all residents. Efforts to seek alternatives to address hydration needs due to resident refusal or resistance would be indicated in the healthcare plan. Fluid of preference, along with any adaptive equipment, would be available to each resident on all shifts, unless medically contraindicated. Fluid intake from all sources would be documented in the electronic health record. 3.1-46(b)

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner during the intitial tour of the facility kitchen. Findings include: 1. During the initial tour of the facility kitchen, on 8/21/19 at 8:54 a.m., accompanied by Cook 34, the following was observed: a. In the three door prep refrigerator, a tray containing 24 cups of yogurt was uncovered. b. In the opposite refrigerator, two plastic storage bags of bologna, and one plastic storage bag of hot dogs, were each dated 8/10/19. Cook 34 indicated, at the time of the observation, they should have been discarded seven days after they were dated as opened. In the same refrigerator, a partially used bottle of citrus soda was observed on the shelf. c. A partially used bottle of cola was sitting on top of the milk cooler, with a wet, soiled washcloth next to it. d. In the dry storage area, eight onions were in a container, dated as having been cleaned on 8/1/19. The onions were all in various states of decay. During an interview, on 8/27/19 at 10:11 a.m., the Dietary Manager indicated the personal drinks should not have been in the area with resident food. Meats should be disposed of in seven days, and the onions were sorted through when the facility shipment arrived. Review of a Refrigerated Foods Chart document, dated 1/7/16, and provided by the Dietary Manager on 8/27/19 at 10:11 a.m., indicated hot dogs and luncheon meats were good for seven days, once opened. 3.1-21(i)(3)

Based record review and interview the facility failed to obtain specific annual influenza vaccine orders from physicians according to facility policy for 5 of 5 residents reviewed for immunizations (43, 27, 21, 18 and 34). Findings include: 1. Resident 43's clinical record was reviewed, on 8/26/19 at 9:45 a.m. It indicated the resident was administered the influenza vaccine, on 10/2/18. Her clinical record lacked a physician's orders [REDACTED]. 2. Resident 27's clinical record was reviewed, on 8/26/19 at 10:04 a.m. It indicated the resident was administered the influenza vaccine, on 10/2/18. Her clinical record lacked a physician's orders [REDACTED]. 3. Resident 21's clinical record was reviewed, on 8/26/19 at 10:19 a.m. It indicated the resident was administered the influenza vaccine, on 10/3/18. Her clinical record lacked a physician's orders [REDACTED]. 4. Resident 18's clinical record was reviewed, on 8/26/19 at 10:30 a.m. It indicated the resident was administered the influenza vaccine, on 10/3/18. His clinical record lacked a physician's orders [REDACTED]. 5. Resident 34's clinical record was reviewed, on 8/26/19 at 10:34 a.m. It indicated the resident was administered the influenza vaccine, on 10/3/18. Her clinical record lacked a physician's orders [REDACTED]. An interview, with the DON, on 8/27/19 at 3:00 p.m., she indicated they would obtain a telephone order for the influenza vaccine to be administered from the resident's attending physician, for all residents to be administered the influenza vaccine after they have consents from the resident or resident representative. The pharmacy only has one vaccine, once they would get the consent then they would let the pharmacy know how many vaccines they would need. It's done that way for every resident in the facility that receives the influenza vaccine. During the interview, the DON provided telephone orders, dated 10/2/18, from four physicians. The orders indicated, they may administer flu vaccine to all residents with consents and provided a current policy, titled Annual Influenza Immunization Procedure, and indicated the procedure for obtaining the orders included, but was not limited to, on an annual basis, the facility will obtain orders for administration of influenza vaccine .Contact each resident's attending physician and obtain an order to administer the vaccine .The order must be specific to the medication, dosage, and route .New orders must be obtained and written on an annual basis.

Based on observation, interview, and record review facility failed ensure resident safety during transfer for 1 of 1 residents reviewed for accidents (Resident 17). Findings include: Review of Resident 17's clinical record review began on 09/10/18 at 11:34 a.m. Diagnosis, included but were not limited to, unspecified dementia without behavioral disturbances and other [MEDICAL CONDITION] without current pathological fracture. A current, 6/1/16, care plan indicated the resident needed extensive to total assistance with ADL's (Activities of Daily Living), bed mobility, toileting, eating and remaining ADL tasks due to: memory deficit, dementia, and weakness. Interventions included, but were not limited to, utilize the mechanical lift with two staff members for transfers. A 6/27/18 MDS (Minimum Data System) annual assessment, indicated resident was severely cognitively impaired. She was totally dependent on two staff members for transfers. Review of the documentation of transfers for the MDS, dated from 8/12/18 to 9/8/18, indicated for the most support provided over all shifts, resident was transferred with one person physical assist 51 times out of 69. On 9/10/18 at 12:09 p.m., during an interview with CNA (Certified Nursing Assistant) 13, she indicated she was transferring the resident from her bed to her Broda chair (a high-backed wheelchair), as resident was suspended in the air, she turned to reach for the residents Broda chair and the resident slid through the bottom of the Hoyer pad and onto the floor. The resident had been transferred in the past with assistance with two staff members and the Hoyer lift until they got the new lifts in July. She would normally have had someone help her with transferring the resident, but did not on 9/8/18. A Nursing Home Transfer form from the Emergency Department, dated 9/8/18, indicated the resident had a laceration to her scalp from a fall and to remove the staples placed to close the laceration in 7-10 days. During an interview with the DON (Director of Nursing) and MDS Coordinator, on 9/10/18 at 1:57 p.m., the MDS Coordinator indicated the transfer careplan should have been updated after the Hoyer lifts were implemented but the careplan remained the same by mistake. The DON confirmed the careplan was in place at the time of the accident. Review of a current facility policy titled Joerns Hoyer Stature lift policy dated 11/1/16 received from DON, on 9/10/18 at 1:41 p.m., indicated the Hoyer lift may safely be used by one staff member if the resident can follow instructions or is cooperative with the transfer. If in doubt, a second staff member should be present during transfer. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for 1 of 1 residents reviewed with a gastrointestinal tube ([DEVICE]). (Resident 31) Findings include: Resident 31's clinical record was reviewed on 9/5/2018 at 1:31 p.m. The resident's [DIAGNOSES REDACTED]. He had current physician orders for, but not limited to, the following: Enteral Feed as needed for meal consumption less than 50%; Glucerna 1.2 cal. Meal consumption were reviewed and indicated the following: a. For (MONTH) there was no lunch documented for four of thirty days and no dinner documented for thirteen of thirty days. There were two days documented the resident ate less than 50% of the dinner meal. b. For (MONTH) there was no lunch documented for 2 of 31 days and no dinner documented for three of 31 days. There were two breakfasts, and one each of lunch and dinner documented the resident ate less than 50% of the meals. c. There were two days in (MONTH) the resident was documented as eating less than 50% of the meal. No enteral feedings were documented for the months of June, (MONTH) and (MONTH) (YEAR). During an interview on 9/6/2018 at 10:07 a.m., the Director of Nursing (DON) indicated if the meal consumptions were not documented on Medication Administration Record [REDACTED]. A current facility policy, dated 9/23/14, titled Point of Care Documentation & Legends was provided by the Director of Nursing (DON) on 9/7/18 at 1:45 p.m., and indicated the policy was the one currently used by the facility. The policy indicated, .A. Staff will document immediately following the completion of a task of by the end of their shift . No further information was provided at the time of exit. 3.1-44(a)(1)

Based on observation, interview, and record review, the facility failed to ensure medications were securely store for 1 of 3 medication carts (100 hall). Findings include: During a random observation, on 9/6/18 at 8:54 a.m., the medication cart was observed to be unlocked and unattended on the 100 Hall, near room [ROOM NUMBER]. At 8:58 a.m., the MDS Coordinator approached the medication cart. She locked it and went to find the nurse. At 9:00 a.m., LPN 6 indicated she would not normally leave the medication cart unlocked. During an observation at that same time accompanied by LPN 6, the cart contained, but was not limited to insulin vials, syringes, glucometer, lancets, wound treatment items, prepackaged and bottled medications. Review of current facility policy, titled Storage of Medications, dated 6/1/11 and provided by the DON on 9/10/18 at 10:07 a.m., indicated medication carts are locked or attended by persons with authorized access. 3.1-25(m)

Based on interview and record review, the facility failed to ensure neurological assessments were initiated following a fall for 1 of 4 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/12/18 at 9:59 a.m. [DIAGNOSES REDACTED]. Review of a nursing initial occurrence, dated 1/29/18 at 6:10 a.m., indicated the resident attempted to transfer himself to the restroom and fell to his knees on the floor, bumping the top of his head. A head to toe assessment was completed and neurological assessments were initiated for an unwitnessed fall. On 2/1/18 at 6:10 p.m., an initial occurrence assessment indicated the resident was found lying on the floor, appeared to be lethargic and his blood glucose was 30 milligram/deciliter (mg/dL). He received orange juice and a [MEDICATION NAME] injection (to treat symptoms of severe low blood glucose levels). The resident's blood glucose was then 38 mg/dL. The staff gave more orange juice and his blood glucose was then 44 mg/dL. Emergency Medical Services (EMS) was notified and when they arrived, his blood glucose was 72 mg/dL. The resident declined transfer to the local hospital. The initial occurrence, indicated a head to toe assessment was completed, but neurological assessments were not initiated for an unwitnessed fall An initial occurrence assessment, dated 2/2/18 at 6:10 p.m., indicated the resident was getting up to go to the bathroom and his foot slid. He was noted to have a skin tear to his left elbow. A head to toe assessment was completed and neurological assessments were initiated for an unwitnessed fall. The neurological checklist, indicated the assessments were first initiated on 1/29/18 at 6:10 a.m. The neurological checklist was restarted on 2/2/18 at 6:10 p.m. following the third fall. The assessments were as follows: Every 15 minutes for one hour, then every 30 minutes for two hours, then every 2 hours for twelve hours, then every 4 hours for twelve hours, then every 8 hours for three days, the daily for four days. During an interview on 2/12/18 at 12:33 p.m., the Director of Nursing (DON) indicated staff would initiate neurological assessments for any unwitnessed fall. During an interview on 2/12/18 at 12:33 p.m., RN 1 indicated Resident B was found lying on the floor not attempting any purposeful movement. She indicated he was trying to get up, but could not say where he was going. On 2/12/18 at 2:12 p.m., LPN 2 indicated neurological assessments were initiated even if a resident states they did not hit their head because it was unwitnessed. Review of a current policy, dated 8/28/2014, titled Incident/Accident Report Procedure & Form, which was provided by the DON 1/13/18 at 11:34 a.m., indicated the following: .3. PR(NAME)EDURE: .VI. If there is obvious injury to the head, begin neurological assessment. VII. If the fall was not witnessed and the resident is unable to accurately inform staff that they did not hit their head, begin neurological assessment. Assess neurological system during assessment of injuries for all un-witnessed falls. This Federal tag relates to Complaint IN 518. 3.1-45(a)(2)

Based on observation and interview the facility failed to ensure the narcotic medications were kept in a separately locked container within the medication cart for 1 of 3 carts. Findings include: During this same observation of the North Medication Cart, the narcotic compartment was unlocked. Employee 31 indicated she had a key to lock the compartment and proceeded to lock the compartment after multiple attempts. An interview with the DON, on 9/19/17 at 11:30 a.m., indicated all narcotic compartments should be locked at all times. On 9/20/17 at 10:27 a.m., a policy titled Storage of Medications, dated 6/1/11 was provided by the DON. This policy indicated, .f. Schedule II medications are stored in a separate area under double lock . 3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure hygienic handling of a urinary catheter for 1 of 1 residents observed with urinary catheter (Resident 58). Findings include: On 9/18/17 at 2:53 p.m., Resident 58 was sitting in his wheelchair in the activity room, with his urinary catheter drainage bag hanging from under his wheelchair, causing it to be folded onto the floor. The drainage tubing was laying against the lower part of his legs and across the bottom of his right foot. On 9/20/17 at 2:11 p.m., he was sitting up in his wheelchair in his room. His urinary drainage bag was again hanging from the underside of the wheelchair, causing the bag to be folded onto the floor. The drainage tubing was laying across his feet, which were tucked under the chair. Review of the clinical record began on 9/21/17 at 9:30 a.m. [DIAGNOSES REDACTED]. He had a current physician's orders [REDACTED]. During the Infection Control interview, beginning on 9/21/17 at 8:33 a.m., the DON indicated the drainage bag and tubing should be kept on the floor. Review of a policy, titled Foley Catheter Care & Maintenance, dated 8/30/07 and provided by the DON on 9/21/17 at 9:16 a.m., indicated to ensure bag or tubing was not touching the floor. 3.1-18(a)

Based on observation, record review and interview, the facility failed to ensure food was prepared, distributed, and served under sanitary conditions. Of the facility's 52 residents, this deficient practice had the potential to impact 52 who were served food from the facility's kitchen. Findings include: 1. Kitchen sanitation tour, accompanied by the Dietary Manager on 7/11/16 at 6:41 p.m., indicated the following: a. A 8-inch and 10-inch Teflon frying pans. The 8-inch pan was located on the stovetop and the 10-inch pan was located on the sink to be washed. The pans had multiple scratch marks that were down to the metal where the Teflon was removed. The Dietary Manager discarded the scratched up Teflon pans after they were brought to her attention. b. A ready to use meat slicer had multiple, dried food particles, cream, pink and brown in color, on the slicer, the meat holder, the base, the black knobs and on the stainless steel cart. The Dietary Manager indicated the whole meat slicer and stainless steel cart needed to be cleaned. During an interview with the Dietary Manager on 7/11/16 at 7:29 p.m., she indicated the meat slicer should be torn apart, washed, sanitized, ran through the dish machine, air dried, reassembled and a clean plastic bag placed over it with the date cleaned. She further indicated the Teflon skillets should be inspected weekly for missing Teflon on scratched skillets and discarded. During an interview with the Dietary Manager on 7/15/16 at 3:15 p.m., she indicated there were 52 residents who ate from the kitchen on 7/11/16. A review of the DAILY CLEANING SCHEDULE dated July 2016, provided by the Dietary Manager on 7/15/16 at 3:45 p.m. indicated the following: .Slicer - (clean) after (each) use The cleaning schedule indicated the meat slicer was last cleaned 7/10/16 and 7/11/16. During an interview with the Dietary Manager on 7/15/16 at 3:45 p.m., the Dietary Manager indicated she was unable to determine when the meat slicer was last used and the cleaning schedule indicated the meat slicer was last cleaned on 7/10/16 and 7/11/16, before it was observed unclean on 7/11/16. A review of a policy titled Equipment and Utensils-Cleaning and Sanitizing, was provided by the Dietary Manager on 7/12/16 at 8:10 a.m., and indicated the following: 1. .POLICY: It is policy that the food service area be maintained in a clean and sanitized manner. 2. PROCEDURE: The Dietary Manager is responsible for preparing, posting, and monitoring the daily, weekly, and monthly cleaning schedules. A. The Dietary Manager will check for the following: .II. All utensils, counters, shelves, and equipment is kept clean, maintained in good repair and is free from breaks, corrosions, open seams, cracks and chipped areas. .III. Plastic ware, china, and glassware that cannot be sanitized or is hazardous because of chips, cracks, or loss of glaze are discarded No further information was provided by exit from the facility on 7/15/16. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure proper handwashing practices and glove use were utilized for perineal care for 1 of 1 observations of perineal care (Resident #49). Furthermore, the facility failed to ensure proper handling of linens on the 100 Hall. This practice had the potential to effect 33 of 33 residents residing on the hall. Findings include: 1. During an observation of perineal care on 7/15/16 beginning at 11:18 A.M., CNA #1 donned gloves, and used a remote to raise Resident #49's bed. She then placed a gait belt around Resident #49's waist and asked Resident #49 to scoot up to the edge of bed a little more. CNA locked the brakes on Resident #49's walker and assisted her to standing with the gait belt. Resident #49 then used the walker to walk to the bathroom with the assistance of CNA #1. CNA #1 entered the bathroom and with her gloved hand, she grabbed a plastic trash bag and picked up a dirty brief from the floor. She then removed Resident #49's brief with the same gloves on and placed it in the plastic bag. CNA #1 then touched Resident #49's walker and doorframe to the bathroom as she walked out to retrieve a clean brief while wearing the same gloves. CNA #1 returned to the bathroom and with the same pair of gloves on, picked up a washcloth sitting on the sink and sprayed it with perineal cleanser. She then provided perineal care to Resident #49 and placed the washcloth in a plastic bag on the floor. CNA #1 used another washcloth and dried Resident #49's perineal area. CNA #1 removed her gloves, but did not wash her hands. She then used the gait belt and assisted Resident #49 as she walked out of the bathroom with her walker. CNA #1 picked up Resident #49's glasses and placed them on her as she walked out of her room into the hallway. She then assisted Resident #49 into her wheelchair. CNA #1 returned to Resident #49's bathroom, washed her hands, picked up the plastic bags and carried them out of Resident #49's room. During an interview on 7/15/16 at 11:32 A.M., CNA #1 indicated that was her normal routine for providing perineal care except she used the perineal care spray instead of soap and water to cleanse Resident #49 because she accidentally knocked one of the washcloths on the floor and because Resident #49 was not soiled. She did not mention anything regarding glove use or handwashing. During an interview with the Director of Nursing (DON) on 7/15/16 at 1:31 P.M., she indicated CNA #1 should have changed her gloves after removing Resident #49's brief. A review of a policy titled Peri Care, dated 01/01/2009, and provided by the In-service Director on 7/15/16 at 11:57 A.M., indicated the following: .1. PURPOSE * To cleanse the perineum for prevention of infection, irritation and to contribute to the residents positive self-image. .3. PROCEDURE A. Obtain necessary equipment and take to residents bedside. B. Explain procedure to resident and provide privacy. C. Wash hands. D. Position resident . E. Apply gloves. F. Remove disposable brief or pad. .I. Place brief or pad in plastic bag. J. Remove soiled gloves and wash hands. K. Fill wash basin with warm water and wet clean cloth with warm water from sink. L. Apply clean gloves. M. Female: Using peri care product and wet wash cloth, wash labia first. Always wash from front to back. Be sure to spread the labia and cleanse thoroughly. Rinse and dry completely. Turn the resident to the side and cleanse anal area thoroughly. Rinse and dry completely. .O. Place soiled wash cloth in bag. P. Remove gloves and wash hands. Q. Apply appropriate brief product and/or clothing. .U. Wash hands 2. During a random observation on 7/14/16 at 12:34 P.M., Laundry Aide #2 removed hanging clothing from an uncovered linen cart. She then carried the clothing against her body into room [ROOM NUMBER]. She exited room [ROOM NUMBER] with nothing in her hands. She then removed hanging clothing from the uncovered linen cart and carried them against her body into room [ROOM NUMBER]. She exited room [ROOM NUMBER] with nothing in her hands. During an interview on 7/14/16 at 12:59 P.M., Laundry Aide #2 indicated she did not know of any rules specifically in regards to passing linens. During an interview with the Environmental Supervisor on 7/14/16 at 1:48 P.M., she indicated Laundry Aide #2 had not been in-serviced on how to prevent the spread of infection with linen passing, but she was told during orientation to try and keep clothing away from scrub tops. A review of a document titled, Laundry Orientation Checklist, with a start date 9/19/13 and end date 10/22/13, and provided by the Environmental Supervisor on 7/14/16 at 2:11 P.M., indicated Laundry Aide #2 was checked off on Distributing Clean Linens. A review of a policy titled, Linen Handling, dated 6/9/10, and provided by the Environmental Supervisor on 7/14/16 at 2:08 A.M., indicated the following: .1. POLICY: * Linens and laundry are handled or transported in a manner to prevent the spread of infection and/or contamination. 2. GUIDELINES: .F. Linen should not be held against the staff member's uniform during transport or delivery 3.1-18(j) 3.1-19(g)(1) 3.1-19(g)(2) 3.1-19(g)(3) Based on observation, interview, and record review, the facility failed to place assistive devices as accessible leaving the resident restrained in bed for 1 of 30 residents reviewed (Resident #49). Findings include: On 7/12/16 at 11:35 A.M., Resident #49 had a dressing to her forehead and bruises that covered the right side of her forehead down to the right side of the bridge of her nose. On 7/14/16 at 9:08 P.M., Resident #49 was laying in a low bed in her room. Her wheelchair and walker were in the hallway. During an interview, on 7/12/16 at 11:11 A.M., the Director of Nursing (DON) indicated Resident #49 fell in her room on 7/10/16 and had obtained an abrasion to her back and a hematoma to her forehead. During an interview, on 7/14/16 at 9:10 P.M., CNA #3 indicated Resident #49's wheelchair and walker were kept in the hallway, so she would not get out of bed and try to get into her wheelchair or use her walker without help. During an interview on 7/15/16 at 9:46 A.M., the DON indicated Resident #49 was attempting to get up out of bed to use the bathroom when she fell on [DATE]. She further indicated Resident #49's walker and wheelchair were not in her room at the time of the fall. Furthermore, the DON indicated the walker and wheelchair were not kept in her room because she was more apt to use her call light if they were not in there, according to Resident #49's family. The DON indicated she felt the removal of the wheelchair and walker from Resident #49's room was justified to keep the resident safe. She indicated that safety trumped the risk of a head injury and acknowledged how removing the aids could be a restraint, but had not assessed for them being restraints. Resident #49's clinical record review began on 7/13/16 at 10:02 A.M. Resident #49's [DIAGNOSES REDACTED]. Resident #49 had a current, 6/17/16, quarterly Minimum Data Set (MDS) assessment which indicated she was moderately cognitively impaired and heard and saw adequately. She also could understand and be understood adequately. She required extensive assistance with one person for bed mobility and transfers. She required limited, stand-by assistance with walking and used a walker and a wheelchair for mobility. Review of Resident #49's current, 6/7/16, care plan included the following: .Focus NEEDS LIMITED TO EXTENSIVE ASSIST W/ADLS DUE TO: Weakness, Debility, occasional incontinence, unsteady gait without assistive device . Interventions/Tasks 8-7-15 per care plan meeting, family wishes that resident be able to ambulate to and from dining room and to and from bathroom with assist .Will plan to keep walker and wheelchair out of residents (sic) room to try and deter resident from getting up unassisted, son agreed with plan and requests that staff walk with resident to keep from loosing (sic) independence and the ability to go out the (sic) family on outings . Focus RESTORATIVE WALKING PROGRAM . Interventions/Tasks Remove walker and wheelchair from room following completion of task . Focus Fall risk characterized by risk factors .Resident does not always call for staff assist as previously educated to do so. Resident is to have 1-a (one person assist) although not willing to comply most times even after education . Interventions/Tasks 2-17-16 . Resident not to be left unattended in her room in her w/c (wheelchair) for safety concerns Review of documents titled, Facility-Post Occurrence IDT & fall risk Assessment, multiple dates, and provided by the DON on 7/15/16 at 1:31 P.M., included the following: .Date and time of occurrence 08/09/2015 15:00 (3:00 P.M.) . Root cause: Resident indicated that she was trying to get in her closet for her night gown .(resident did not ask staff for assistance in getting nightgown .) .Date and time of occurrence 10/21/2015 18:45 (6:45 P.M.) . Root cause: Resident attemtped (sic) to self transfer and change into night clothes . .Date and time of occurrence 02/17/2016 17:40 (5:40 P.M.) . Root cause: Resident indicated she was trying to get her night clothes from closet . Resident was sitting in chair resting prior to occurrence . IDT recommendations . Resident not to be left alone in room in wheelchair for safety concerns . .Date and time of occurrence 03/12/2016 11:00 (A.M.) . Root cause: Resident was attempting to mess with papers on top of her dresser. Resident was up in room unassisted . .Date and time of occurrence 07/10/2016 22:00 (10:00 P.M.) . Root cause: Resident attempting to get up to go to bathroom unassisted . Interventions that had been tried included: Staff to monitor when the resident leaves the dining room - staff to follow to her room to meet needs; brightly colored paper to remind the resident not to get up without assistance; educated multiple times on not getting up without assistance; Physical therapy ordered from January to March; and Offer to assist the resident to lay down in bed after lunch. 3.1-3(w) 3.1-45(a)(2)

Based on observation, record review and interview the facility failed to apply hot packs/heat packs by qualified staff resulting in a second degree burn for 1 resident in a sample of 4. (Resident # C) Findings include: During the initial tour of the facility with RN # 1 on 12/13/10 at 2:10 p.m., RN # 1 indicated Resident # C had a stroke resulting in decreased mobility of his left side. RN # 1 further indicated Resident # C was receiving a treatment to his left leg. Review of the clinical record of Resident # C on 12/13/10 at 3:50 p.m., indicated the following: Resident # C's [DIAGNOSES REDACTED]. Resident # C's progress notes, dated 11/24/10 at 4:34 a.m., indicated "Res (resident) c/o (complains of) pain to L (left) knee. PRN (as needed) pain medication administered. Res continued to c/o pain. Heat applied for 20 (twenty) mins (minutes). Res stated combination of medication and heat was effective. Will continue to monitor." Resident # C's progress notes, dated 11/24/10 at 5:01 a.m., indicated "...Res was laying on L side, with R (right) leg drawn up. Res c/o L knee pain. PRN pain medication administered at 11:25 pm. Res stated, 'Get those pads out of my closet by the TV, stick them in the microwave, then put them on my leg.' Hot pack wrapped in therapy cover with bath towel doubled on both sides. Hot pack in place only 20 min, between knees, while res laid on L side. When hot pack was removed therapy cover and towels in place. Not direct contact between heat source and res skin. Res did not c/o pain between time of removal to end of shift. Red area to L knee noted, skin intact. Will continue to monitor." Resident # C's progress notes, dated 11/24/10 at 11:13 a.m., indicated "Dr... made aware of left knee redness with blisters relate (sic) to heat pack. No New (sic) orders received at this time...." Progress notes, dated 11/24/10 at 10:54 p.m., indicated "...leave lt (left) leg area OTA (open to air) until blisters pop then clean area and dry and wrap with gauze (Klean (sic) and dry)[MEDICATION NAME] pain...." Resident # C's progress note, dated 11/26/10 at 11:36 a.m., indicated "...posted for nurses to no longer use hot packs until they can be evaluated by therapy department and re-trained on proper use/placement...." Resident # C's progress note, dated 11/28/10 at 3:49 a.m., indicated "Dressing change to L knee. Wound bed is beefy res, with moderate amount of drainage noted. Dry dressing adhering to area. Normal saline used to moisten dressing to remove...." Resident # C's progress note, dated 12/1/10 at 9:17 a.m., indicated "This writer and wound nurse assessed area to residents (sic) left inner knee earlier this shift, skin surrounding burn does appear red with slight yellowish drainage noted to wound bed....." A physician note/assessment, dated 12/2/10, indicated "...The patient was using a heating pad and burned an area approximately 6 to 8 cm on his let. It appears dull and [DIAGNOSES REDACTED]tous. The base may be slightly warm. It appears to be opened. He does not complain of any real pain in this or other discomfort...no significant ankle swelling...It is a second-degree burn. Possible infection. There is slight yellow drainage...we will start on Keflex (an antibiotic)...." Resident # C did not have a care plan or physician's orders [REDACTED]." On 12/14/10 at 9:27 a.m., Resident # C's wound on his left inner knee and lower leg was observed. The area was irregular in shape and was approximately three inches in length and one to one and one-half inches in with. The wound bed color was dark brown to black in color. Resident # C did not complain of pain and was not observed to grimace during the dressing change. Interview with LPN # 2, on 12/14/10 at 11:45 a.m., indicated she was the nurse responsible for inservices/training and the most recent facility inservice on pain management was the month of July 2010. LPN # 2 indicated the inservices are on their corporate computer system and staff have the entire month to complete the inservice. LPN # 2 further indicated she was not aware of any recent inservice for staff regarding the use of therapies heat packs/hot packs. Interview with the DON (director of nursing) on 12/14/10 at 11:50 a.m., indicated the hot packs/heat packs used on Resident # C were obtained from therapy's [MEDICATION NAME] and not Resident # C's closet. The DON indicated she was not aware of staff being trained on use of the hot packs/heat packs from therapy's [MEDICATION NAME]. Interview with PTA # 3 and COTA # 4 on 12/14/10 at 12:20 p.m., indicated the [MEDICATION NAME] in therapy is maintained at 162-164 degrees Farenheit. PTA # 3 indicated she has worked at the facility for around four years and does not recall any inservice regarding the use of hot packs/heat packs from the [MEDICATION NAME]. PTA # 3 and COTA # 4 indicated the heat packs/hot packs should have at least eight layers between the packs and a resident's skin. PTA # 3 and COTA # 4 further indicated a resident's skin should be checked every five minutes while the heat packs are in use. The pain management inservice content was received and reviewed on 12/14/10 at 2:00 p.m.. The inservice content did not contain guidance for staff regarding the use of "heat packs" for pain management. The inservice indicated "...Besides using medications, non-pharmacological means of pain management should also be considered in managing the resident's pain...Non-pharmacological means may include the following: ...positioning...massage therapy...ice packs..mild heat...." No licensed staff inservice documentation was received regarding the education of RN's or LPN's in the application of heat packs/hot packs from the [MEDICATION NAME]. Review of the Indiana Code of Professional Licensing code: 848 IAC 2-2-1 code IC 25-23-1-7 includes, but was not limited to, "The Registered Nurse or Licensed Practical Nurse shall do the following: seek educational resources to enhance his/her continuing competence in nursing practice." This federal tag relates to Complaint Number IN 115. 3.1-35(g)(1)

Based on observation, record review and interview the facility failed to protect 1 resident from receiving a second-degree burn in a sample of 2 residents who were provided heat packs for pain management in a total sample of 4. (Resident # C) Findings include: During the initial tour of the facility with RN # 1 on 12/13/10 at 2:10 p.m., RN # 1 indicated Resident # C had a stroke resulting in decreased mobility of his left side. RN # 1 further indicated Resident # C was receiving a treatment to his left leg. Review of the clinical record of Resident # C on 12/13/10 at 3:50 p.m., indicated the following: Resident # C's [DIAGNOSES REDACTED]. Resident # C's progress notes, dated 11/24/10 at 4:34 a.m., indicated "Res (resident) c/o (complains of) pain to L (left) knee. PRN (as needed) pain medication administered. Res continued to c/o pain. Heat applied for 20 (twenty) mins (minutes). Res stated combination of medication and heat was effective. Will continue to monitor." Resident # C's progress notes, dated 11/24/10 at 5:01 a.m., indicated "...Res was laying on L side, with R (right) leg drawn up. Res c/o L knee pain. PRN pain medication administered at 11:25 pm. Res stated, 'Get those pads out of my closet by the TV, stick them in the microwave, then put them on my leg.' Hot pack wrapped in therapy cover with bath towel doubled on both sides. Hot pack in place only 20 min, between knees, while res laid on L side. When hot pack was removed therapy cover and towels in place. Not direct contact between heat source and res skin. Res did not c/o pain between time of removal to end of shift. Red area to L knee noted, skin intact. Will continue to monitor." Resident # C's progress notes, dated 11/24/10 at 11:13 a.m., indicated "Dr... made aware of left knee redness with blisters relate (sic) to heat pack. No New (sic) orders received at this time...." Progress notes, dated 11/24/10 at 10:54 p.m., indicated "...leave lt (left) leg area OTA (open to air) until blisters pop then clean area and dry and wrap with gauze (Klean (sic) and dry)...Vicodin...prn pain...." Resident # C's progress note, dated 11/26/10 at 11:36 a.m., indicated "...posted for nurses to no longer use hot packs until they can be evaluated by therapy department and re-trained on proper use/placement...." Resident # C's progress note, dated 11/28/10 at 3:49 a.m., indicated "Dressing change to L knee. Wound bed is beefy res, with moderate amount of drainage noted. Dry dressing adhering to area. Normal saline used to moisten dressing to remove...." Resident # C's progress note, dated 12/1/10 at 9:17 a.m., indicated "This writer and wound nurse assessed area to residents (sic) left inner knee earlier this shift, skin surrounding burn does appear red with slight yellowish drainage noted to wound bed....." A physician note/assessment, dated 12/2/10, indicated "...The patient was using a heating pad and burned an area approximately 6 to 8 cm on his let. It appears dull and [DIAGNOSES REDACTED]tous. The base may be slightly warm. It appears to be opened. He does not complain of any real pain in this or other discomfort...no significant ankle swelling...It is a second-degree burn. Possible infection. There is slight yellow drainage...we will start on Keflex (an antibiotic)...." Resident # C did not have a care plan or physician's orders [REDACTED]." No facility policy/procedure was provided to show staff had guidance on how to use the "heat packs." On 12/14/10 at 9:27 a.m., Resident # C's wound on his left inner knee and lower leg was observed. The area was irregular in shape and was approximately three inches in length and one to one and one-half inches in with. The wound bed color was dark brown to black in color. Resident # C did not complain of pain and was not observed to grimace during the dressing change. Interview with LPN # 2, on 12/14/10 at 11:45 a.m., indicated she was the nurse responsible for inservices/training and the most recent facility inservice on pain management was the month of July 2010. LPN # 2 indicated the inservices are on their corporate computer system and staff have the entire month to complete the inservice. LPN # 2 further indicated she was not aware of any recent inservice for staff regarding the use of therapies heat packs/hot packs. Interview with the DON (director of nursing) on 12/14/10 at 11:50 a.m., indicated the hot packs/heat packs used on Resident # C were obtained from therapy's hydrocolator and not Resident # C's closet. The DON indicated she was not aware of staff being trained on use of the hot packs/heat packs from therapy's hydrocolator. Interview with PTA # 3 and COTA # 4 on 12/14/10 at 12:20 p.m., indicated the hydrocolator in therapy is maintained at 162-164 degrees Farenheit. PTA # 3 indicated she has worked at the facility for around four years and does not recall any inservice regarding the use of hot packs/heat packs from the hydrocolator. PTA # 3 and COTA # 4 indicated the heat packs/hot packs should have at least eight layers between the packs and a resident's skin. PTA # 3 and COTA # 4 further indicated a resident's skin should be checked every five minutes while the heat packs are in use. The pain management inservice content was received and reviewed on 12/14/10 at 2:00 p.m.. The inservice content did not contain guidance/training for staff regarding the use of "heat packs" for pain management. This federal tag relates to Complaint Number IN 115. 3.1-45(a)(2)