Every finding on record at Westpark a Waters Community

Based on interview and record review, the facility failed to ensure controlled medications were obtained timely from the pharmacy for 3 of 3 residents reviewed for availability of medications. (Residents B, C, and D) Findings include: 1. The clinical record for Resident C was reviewed on [DATE] at 11:00 a.m. The diagnoses included, but were not limited to, gastro-esophageal reflux disease (GERD). An Annual [DATE] Minimum Data Set (MDS) assessment indicated Resident C was moderately cognitively impaired. A physician's order, dated [DATE], indicated Resident C was to receive two tablets of 5-325 milligrams (mg) of hydrocodone-acetaminophen three times a day. The medication was to be administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The two tablets of hydrocodone-acetaminophen medication was discontinued and changed, on [DATE], to one tablet. A physician's order, dated [DATE], indicated Resident C was to receive one tablet of 5-325 milligrams of hydrocodone-acetaminophen three times a day. The medication was to be administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The [DATE] Medication Administration Record (MAR) for Resident C indicated the following days the 5-325 milligrams of hydrocodone-acetaminophen medication was not available to administer: Two tablets of 5-325 milligrams of hydrocodone-acetaminophen: [DATE] at 10:00 p.m., and [DATE] at 6:00 a.m. One tablet of 5-325 milligrams of hydrocodone-acetaminophen: [DATE] at 2:00 p.m. and 10:00 p.m., [DATE] at 6:00 a.m. and 2:00 p.m. An interview was conducted with Resident C on [DATE] at 11:28 a.m. She indicated she takes pain medication for the pain in her legs. Resident C had fallen and broken both of her legs. She had to go without her hydrocodone-acetaminophen medication, because the facility often runs out of the supply of medication. An interview was conducted with the Director of Nursing on [DATE] at 2:26 p.m. She indicated if a script expired, the staff were not able to pull the medication out of the Emergency Drug Kit. The staff should be reordering medications from the pharmacy when the residents' medications were down to six to eight days left of their medication supply. 2. The clinical record for Resident B was reviewed on [DATE] at 10:20 a.m. The diagnoses included, but were not limited to, migraine and sciatica. An admission MDS assessment, completed [DATE], indicated she was cognitively intact and had experienced pain almost constantly. The pain had limited her ability to sleep and perform day to day activities almost constantly. She described her pain as moderate. A care plan, last revised on [DATE], indicated she had the potential for pain related to chronic pain and impaired mobility. The goal was for her to be free of pain with interventions as needed. The interventions included, but were not limited to, medication as ordered, notify the physician of uncontrolled pain, and observe for effectiveness of interventions. A physician's order, dated [DATE], indicated she was to receive oxycodone (narcotic pain medication) 10 mg; one tablet every four hours for pain. The order was discontinued on [DATE]. A physician's order, dated [DATE], indicated she was to receive oxycodone 10 mg; one tablet every four hours for pain while awake. The scheduled times were listed as midnight, 8:00 a.m., noon, 4:00 p.m., and 8:00 p.m. It did not include a 4:00 a.m. dose. The [DATE] Medication Administration Record (MAR) indicated she had not received her scheduled dose of oxycodone 10 mg on [DATE] at midnight, [DATE] at 4:00 a.m., [DATE] at noon, [DATE] at 8:00 a.m., [DATE] at noon, and [DATE] at 4:00 p.m. During an interview on [DATE] at 11:30 a.m., Resident D indicated the facility had not ordered her scheduled pain medication timely and that she had missed several doses. When she began receiving her scheduled oxycodone again, the nursing staff had stopped bringing it to her at 4:00 a.m. Resident B did not know why the times had been changed. Resident B indicated her pain was severe when she was not getting her scheduled oxycodone. During an interview on [DATE] at 2:40 p.m., the Corporate Nurse Consultant (CNC) indicated Resident B should have received her pain medication as ordered. The physician's order for oxycodone 10 mg, received on [DATE], should have included an administration at 4:00 a.m. 3. The clinical record for Resident D was reviewed on [DATE] at 11:00 a.m. The diagnoses included, but were not limited to, anxiety, schizoaffective disorder, and mood disorder. A care plan, last revised on [DATE], indicated she received psychotropic medications related to schizoaffective disorder, anxiety, and mood disorder. The goal was for her to be free of drug related complications. The interventions included to administer medications as ordered. A physician's order, dated [DATE], indicated she was to receive clonazepam (anti-anxiety medication) 1 mg three times a day. The order was discontinued on [DATE]. A physician's order, dated [DATE], indicated she was to receive clonazepam 1 mg three times a day. The [DATE] MAR indicated Resident D had not received her scheduled dose of clonazepam on the following days: [DATE] at 4:00 p.m., and 10:00 p.m., [DATE] at 4:00 p.m., and 10:00 p.m. During an interview on [DATE] at 1:45 p.m., the Director of Nursing indicated Resident D's scheduled clonazepam had not been reordered timely. The pharmacy was waiting for a new prescription to refill the medication. On [DATE] at 1:45 p.m., the Director of Nursing provided the current Ordering Medications policy, that read .Narcotics are ordered from the pharmacy after the pharmacy has received a valid prescription from the prescriber . This citation relates to Intake 2636594. 3.1-25(a)

Based on observation, interview and record review, the facility failed to have the interdisciplinary team determine and document that a resident was capable to safely self-administer medications for 1 of 1 resident randomly observed. (Resident C) Findings include: The clinical record for Resident C was reviewed on 10/10/25 at 11:00 a.m. The diagnoses included, but were not limited to, gastro-esophageal reflux disease (GERD). A physician's order, dated 7/8/25, indicated Resident C was to receive 500 milligrams of a chewable calcium carbonate tablet three times a day. An observation was conducted of Resident C's room on 10/10/25 at 11:27 a.m. The resident's room was observed with the door open. A medication cup with a pink tablet was observed on a bedside table. The resident nor staff member was present in the room at that time. An observation was conducted of Resident C's room with the Director of Nursing on 10/10/25 at 11:53 a.m. The resident's door was observed open with a medication cup that contained a pink tablet on a bedside table. The resident nor a staff member was present. The Director of Nursing indicated at that time, the medication was a chewable calcium carbonate tablet (TUMS). An interview was conducted with the Director of Nursing on 10/10/25 at 1:45 p.m. She indicated Resident C did not have a self-administration of medication assessment that had been conducted. She should not have medications left at bedside. A Medication Self-Administration policy was provided by the Director of Nursing 10/10/25 2:12 p.m. It indicated Purpose: To provide procedures for determining if the resident can safely self-administer and store medications in their room. Policy: 1. Residents who request to self-administer drugs will be assessed at the time of admission or thereafter to determine if the practice is safe, based on the results of the 'Resident Assessment-Self-administration Tool'. 2. The assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate.8. Prescription medications stored in the resident's room should be written on the medication record 'May keep at bedside'. 3.1-11(a)

3. On 6/6/25 at 11:04 a.m., Licensed Practical Nurse (LPN) 2 was randomly observed administering medications to Resident 33. LPN 2 removed the medication cards from the medication cart and began to place the prescribed medication doses into a plastic medication cup. LPN 2 indicated that Resident 33's folic acid, multivitamin, vitamin B-12 and Thiamine (Vitamin B-1) were not available to be given in the medication cart. LPN 2 went to the Cubex (machine that supplies medications at the facility) to obtain the folic acid, multivitamin, vitamin B-12 and Thiamine for Resident 33. LPN 2 was unable to obtain the medications from the Cubex. LPN 2 went to the drug overflow cart and attempted to find the folic acid, multivitamin, vitamin B-12 and Thiamine to administer. LPN 2 was unable to locate the missing medications from the overflow medication cart. LPN 2 indicated the medications had been previously reordered from the pharmacy and had been delivered to the facility yet. The pharmacy often did not deliver medications timely. LPN 2 indicated Resident 33 would not receive the folic acid, multivitamin, vitamin B-12 and Thiamine due to the medications being unavailable. LPN 2 then administered the Resident 33 nine of his thirteen prescribed morning medications. During an interview with the DON on 6/6/25 at 9:45 a.m., she indicated there was often a delay in the delivery of medications from the pharmacy once medications have been reordered electronically and often has to e-mail or call the pharmacy to expedite delivery. 3.1-48(c)(1) Based on observation, interview, and record review, the facility failed to ensure medications were available as ordered resulting in a medication error rate of greater than 5% for 3 of 3 residents observed during medication pass. There were 38 opportunities with 11 errors resulting in a 29% medication error rate. The errors involved 3 residents in the sample of 16. (Resident 8, Resident 33, and Resident 38) Findings include: 1. An observation of medication administration was conducted with the Director of Nursing (DON) on 6/6/25 at 9:21 a.m. The DON indicated Resident 8 had the following medications ordered to give that morning (06/06/25): benzonatate 100 milligrams (mg), Cranberry capsule 250 mg, fluoxetine hydrochloric acid (HCL) 40 mg, furosemide 20 mg, ipratropium - albuterol aerosol inhaler, gabapentin 300 mg, vitamin D 125 micrograms (mcg), Lidoderm patch, Singulair 10 mg, vitamin C 1000 mg, triamcinolone acetonide nasal spray, Eliquis 5 mg, ferrous sulfate 325 mg, and erythromycin 5 mg ointment. The DON indicated Resident 8's ipratropium-albuterol inhaler, vitamin D 125 mcg tablet, Lidoderm patch, Singulair 10 mg, ferrous sulfate 325 mg, and erythromycin ointment were unavailable, but had previously been reordered. The DON attempted to retrieve these medications from the overflow medication cart and the Cubex (a machine that supplies medications at the facility) and was unsuccessful due to unavailability. Resident 8 did not receive 6 of her 14 medications as ordered that morning. 2. An observation of medication administration was conducted with the DON on 6/6/25 at 9:55 a.m. The DON indicated Resident 38 had the following medications ordered to give that morning (06/06/25): buspirone 5 mg, clopidogrel 75 mg, apixaban 5 mg, Keppra 1000 mg, fluticasone propionate nasal spray, pantoprazole 40 mg, Folic Acid 1 mg, potassium chloride 10 milliequivalents (mEq) extended release, venlafaxine 150 mg, Geodon 20 mg, and vitamin B-12. The DON indicated the facility was out of Resident 38's fluticasone nasal spray and she would need to contact the pharmacy to have it reordered.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 15 of 16 residents reviewed for dignity. (Residents' 6, 8, 9, 12, 13, 14, 16, 24, 28, 34, 37, 42, 44, 47, and an Anonymous Resident) Findings include: 1. The clinical record for Resident 14 was reviewed on 6/4/25 at 11:18 a.m. The diagnoses included, but were not limited to, hypertension and congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, completed 3/5/25, indicated he was cognitively intact During an interview on 6/4/25 at 2:18 p.m., Resident 14 indicated he felt the facility staff did not care what the residents of the facility had to say. The staff sat in their offices and went to meetings but never came out and talked with the residents to find out about the problems they were having. He felt the upper management made it all about the budget and not about the residents. 2. On 6/4/25 at 2:12 p.m., Resident 44 was observed sitting in her wheelchair in her room. She turned on her call light to get assistance going back to bed. Her call light continued to be on at 2:29 p.m., and she continued to sit in her wheelchair by her bed. The call light was audible at the nurses' station and visible in the hallway. At 2:30 p.m., Licensed Practical Nurse (LPN) 2 walked to the nurses' station and then left the nurses' station, indicating she was heading to lunch. At 2:31 p.m., a dietary staff member walked by the nurses' station and down the hallway outside of Resident 44's room, where the call light was visible. At 2:42 p.m., a Certified Nurse Aide entered Resident 44's room and shut off the call light, shut the door, and assisted Resident 44. 4. An interview was conducted, on 6/4/25 at 11:15 a.m., with Resident 8. She indicated she had overheard aides in the hall warning each other about coming into her room and spending all their time on their phones. 5. A resident council meeting was conducted on 6/5/25 at 2:06 p.m. During this meeting, Resident 14 indicated call lights go unanswered for at least thirty minutes, and on the weekends it was worse. Staff will come into our rooms and turn the light off, say they will come back to assist us, and never return. Resident 14 indicated when staff do this it makes him feel helpless and not valued. Residents' 6, 9, 12, 13, 16, 24, 28, 34, 37, 42, and 47 indicated they agreed to Resident 14's comments. Resident 42 indicated having to wait so long for assistance after putting on his call light made him feel like he wanted to die. 6. A confidential interview was conducted during the course of the survey which indicated residents had to wait a long time for call lights to be answered. They had seen call lights be on for hours with no one answering them. When they would tell nursing staff about residents' requests or that a resident needed help the nursing staff would get attitudes with them. Some of the nurses were very nice, but some of the nurses were rude to the residents. The management staff rarely come out of the offices to see what was going on. They had seen urinals at bedside that were about to overflow, and no one would come and empty them. 7. During a confidential interview, an anonymous resident indicated QMA 8 called them a drug addict and was nothing but a junky. On a separate occasion, LPN 4 denied a resident was in that much pain when they had requested pain medication. The Director of Nursing (DON) was interviewed on 6/9/25 at 1:56 p.m. She indicated when staff members enter resident rooms, they were expected to knock first, announce themselves, and ask permission to come in. An interview was conducted with the DON on 6/9/25 at 4:10 p.m. She indicated LPN 4 had been educated regarding usage of her tone of voice. The DON indicated she was unaware of the allegation of LPN 4 denying resident's pain or of QMA 8 calling a resident a drug addict. During an interview on 6/10/25 at 3:20 p.m., the Executive Director indicated she would expect that no staff would walk by a call light and not answer it and attempt to assist the resident. Call lights should be answered timely. On 6/6/25 at 3:52 p.m., the Nurse Consultant provided the Dignity Policy, dated 8/9/2023, which indicated .Conversations 1.) Staff will be polite and respectful at all times- and will be positive in their approach to residents to include residents who make repetitive request and residents who are demanding or use inappropriate language toward staff . 2.) Staff will not speak in a manner that could be interpreted as even minimally condescending/ critical or argumentative nor in a volume any louder that is absolutely necessary as this can be interpreted as meeting abuse criteria .Privacy 1.) Staff will knock prior to entering a resident's room. They will announce themselves and ask permission to enter .Care .3.) Should a resident have an episode of incontinence, staff will change them upon discovery of the episode .Note: Residents are to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what is being said or done by others. 3.1-3(t) 3. The clinical record for Resident 24 was reviewed on 6/9/25 at 2:03 p.m. The diagnoses included, but were not limited to, atrial fibrillation (a heart condition where the heart beats chaotic and rapid), congestive heart failure (the heart becomes weak and cannot pump blood very well), and diabetes. A Quarterly MDS assessment, dated 4/17/25, indicated the resident was cognitively intact. Resident 24 was interviewed on 6/4/25 at 1:47 p.m. He indicated he has a hard time reaching his bottom to wipe after a bowel movement, due to his health conditions. He asked for help getting wiped, but the staff tells him it's not their job to help him wipe his bottom. Resident 24 was randomly observed activating his call light on 6/5/25 at 3:16 p.m. Qualified Medication Aide (QMA) 8 approached Resident 24's closed room door, put on a gown and gloves, and opened the door, asking Yeah? as she entered the room. She did not knock or identify herself. He asked for help getting cleaned up and she indicated she would be back to assist him.

Based on observation, interview, and record review, the facility failed to ensure palatable food was provided for 12 of 14 residents reviewed for food. (Residents' 6, 8, 9, 13, 14, 16, 24, 26, 28, 34, 37, and 42) Findings include: 1. The clinical record for Resident 14 was reviewed on 6/4/25 at 11:18 a.m. The diagnoses included, but were not limited to, hypertension and congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, completed 3/5/25, indicated he was cognitively intact. During an interview on 6/4/25 at 2:18 p.m., Resident 14 indicated the food was raggedy and low grade. The same things were served over and over. 5. The clinical record for Resident 8 was reviewed on 6/4/25. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease. A Quarterly MDS assessment, dated 5/14/25, indicated the resident was cognitively intact. During an interview on 6/4/25 at 11:12 a.m., Resident 8 indicated she did not like the taste of the food. 6. A resident council meeting was conducted on 6/5/25 at 2:06 p.m. During this meeting, Resident 28 indicated residents eat the same thing for breakfast 4 out of 7 days a week, and that the food was terrible. Resident 28 indicated the food used to be different and believed the facility had changed suppliers, once they switched the food quality went from bad to worse. Residents' 6, 9, 13, 14, 16, 24, 34, 37, and 42 indicated they agreed to Resident 28's comments. On 6/5/25 at 11:54 a.m., the Dietary Manager (DM) provided a lunch test tray which contained chicken parmesan, noodles, and green beans. The plate contained an unbreaded chicken breast in a thin red sauce and no cheese. The noodles were over cooked and had a slimy texture. The green beans were presented in a bowl on the plate. 3.1-21(a)(1) 3.1-21(a)(2) 2. The clinical record for Resident 9 was reviewed on 6/6/25 at 9:53 a.m. The diagnoses included, but were not limited to, depression, migraines, diabetes, and malnutrition. A Quarterly MDS assessment, dated 3/28/25, indicated the resident was cognitively intact. Resident 9 was interviewed on 6/4/25 at 11:30 a.m. He indicated the food at the facility was not good, and it had no salt or seasoning. 3. The clinical record for Resident 24 was reviewed on 6/9/25 at 2:03 p.m. Diagnoses included, but were not limited to, diabetes, congestive heart failure (the heart is weak and cannot pump efficiently), chronic obstructive pulmonary disease (a lung disease which restricts breathing), gastroesophageal reflux (heartburn), heart disease, and anemia. A Quarterly MDS assessment, dated 4/17/25, indicated the resident was cognitively intact. Resident 24 was interviewed on 6/4/25 at 1:47 p.m. He indicated some of the food was good but some of it was bad, and sometimes the meat smelled spoiled. He was supposed to get double portions of meat, but the portions were really small, and he had lost weight since being at the facility. Resident 24 was interviewed on 6/5/25 at 2:33 p.m. He indicated the lunch meal earlier that day was really gross. The meat in the sauce was so tough that he couldn't eat it. The food on the plate that looked like rice was extremely soggy and had no flavor or taste at all. He could not eat that either. 4. The clinical record for Resident 26 was reviewed on 6/5/25 at 1:37 p.m. Diagnoses included, but were not limited to, chronic pain syndrome, anxiety, and malnutrition. A Quarterly MDS assessment, dated 4/7/25, indicated the resident was cognitively intact. Resident 26 was interviewed on 6/4/25 at 11:57 a.m. She indicated the food usually tasted bad, was cold sometimes, and the portions were very small.

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained during medication administration by not performing hand hygiene before coming into contact with a resident and donning gloves, not donning new gloves before touching a resident's medications, ensuring medications were not touched with bare hands, administered medications after being dropped on to a medication cart, and not disinfecting insulin pen hubs prior to use for 3 of 3 residents randomly observed during medication administration (Resident 8, Resident 33, and Resident 47). Findings include: 1. The clinical record for Resident 33 was reviewed on 6/6/25 at 10:12 a.m. The diagnoses included, but were not limited to, hypertension. On 6/6/25 at 10:12 a.m., Licensed Practical Nurse (LPN) 2 was observed administering medications to Resident 33. LPN 2 performed hand hygiene and began gathering Resident 33's available medications from the medication cart. She was not observed to clean the top of the medication cart prior to preparing Resident 33's medications. She used her keys to open the cart and removed the medication cards from the cart one at a time. She removed a capsule of Cymbalta from the medication card and the Cymbalta capsule fell onto the medication cart. LPN 2 picked up the Cymbalta capsule with her bare hand and placed it in the medication cup with the other medications. LPN 2 indicated Resident 33 received his medication crushed with applesauce. The medication cup contained capsules and pills. LPN 2 removed the capsules from the medication cup and placed them into another medication cup. She poured the pills into a plastic sleeve and crushed them, then poured the crushed pills into a new medication cup. She then removed each capsule from a plastic medication cup and opened them, pouring the contents into the medication cup with the crushed pills. LPN 2 did not perform hand hygiene or wear disposable gloves while touching the capsules to open them. She put applesauce into the medication cup with the crushed medication. LPN 2 then took the medications to Resident 33 and administered them to him. During an interview on 6/6/25 at 10:35 a.m., LPN 2 indicated she did not consider a pill to be dropped unless it went onto the floor, and she cleaned the top of her medication cart often. She routinely opened capsules without gloves on. 2. The clinical record for Resident 47 was reviewed on 6/6/25 at 11:45 a.m. The diagnoses included, but were not limited to, diabetes. On 6/6/25 at 11:45 a.m., the Director of Nursing (DON) was observed administering insulin to Resident 47. She indicated his blood sugar was 186 and he was to receive two units of lispro insulin (fast acting insulin). She gathered her supplies and entered Resident 47's room. The DON removed the insulin pen from the box, removed the cap from the pen and placed the needle onto the pen. She did not cleanse the hub of the pen prior to placing the needle on. She did hand hygiene and donned disposable gloves. She dialed two units on the pen, cleansed Resident 47's skin, and injected the insulin medication. During an interview on 6/6/25 at 11:57 a.m., the DON indicated she should have cleansed the hub of the insulin pen prior to placing the needle on the pen. 3. The clinical record for Resident 8 was reviewed on 6/4/25 at 2:30 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic bronchitis. An observation of medication administration for Resident 8 was conducted with the DON on 6/6/25 at 9:21 a.m. The DON was observed performing hand hygiene upon arrival to the medication cart. She pulled and prepared Resident 8's medication from the [NAME] Hall medication cart. Due to multiple medications not being available, the DON went to the overflow medication cart and Cubex (a machine that supplies medications at the facility) to see if any of the missing medications were available. The DON then entered Resident 8's room with the medication cup and a cup of water. No hand hygiene was performed after contact with high traffic surface areas or before entering the resident's room. The DON donned a pair of gloves and administered the resident's nasal spray. Afterward, while holding Resident 8's medication cup, the DON touched and pushed around the resident's pills with her gloved finger. The DON did not perform hand hygiene after administering Resident 8's nasal spray or don new gloves before touching the resident's pills. An interview was conducted with the DON on 6/6/25 at 10:20 a.m. She indicated it was not best practice to touch the resident's pills without donning new gloves. During an interview on 6/6/25 at 2:38 p.m., the Nurse Consultant indicated medication should not be used when it was dropped on the medication cart and medications should not be touched with bare hands. A Hand Hygiene Policy, dated 8/21/13, was provided by the facility Nurse Consultant (NC) on 6/6/25 at 3:52 p.m. It indicated .If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations. Some of these situations include before and after contact with residents, before putting on and taking off gloves . On 6/6/25 at 3:52 p.m., the NC provided the current Gloves- Non Sterile Policy which indicated .Perform Hand Hygiene . Appy Latex free non-sterile gloves on at a time, stretching over wrists .If for any reason there is a need to remove the gloves and reapply new gloves, Hand Hygiene must occur between the removal of the used pair of gloves and the application of the new pair of gloves . On 6/9/25 at 3:26 p.m., the DON provided the Insulin Pen Injection Administration Policy, dated July 2024, which indicated .6. Remove pen cap and wipe rubber stopper with alcohol swab . 3.1-18(b)(1) 3.1-18(l)

Based on interview and record review, the facility failed to adequately document a discharge in a resident's electronic health record (EHR) for 1 of 1 resident reviewed for discharge in a closed record review (Resident 43). Findings include: The clinical record for Resident 43 was reviewed on 6/9/25 at 9:46 a.m. The diagnoses included, but were not limited to, congestive heart failure (the heart becomes weakened and cannot pump blood very well), dementia, and myocardial infarction (heart attack). Resident 43 admitted to the facility on [DATE] and was discharged to another long-term care facility on 5/23/25. A Care Plan Meeting progress note, dated 5/12/25, indicated Resident 43's friend discussed senior living for the resident, but facility nursing and the MDS (Minimum Data Set) Coordinator explained that Resident 43 had dementia and memory issues and would require supervision 24 hours a day. Resident 43's friend indicated she would investigate alternatives. A Discharge MDS assessment, dated 5/22/25, indicated Resident 43 was discharging to another long-term care facility on 5/23/25. The facility was not named. There was no documentation in the clinical record that a discharge order had been placed by the physician. No other documentation or discussion of discharge/discharge planning could be located in Resident 43's EHR. The Regional Director of Operations (RDO) was interviewed on 6/9/25 at 11:39 a.m. He indicated they did not have any other discharge documentation for Resident 43. A facility policy titled Guidelines for Discharge/Transfer, dated 8/26/23, was provided by the Director of Nursing (DON) on 6/9/25 at 12:07 p.m. It indicated A resident will be discharged /transferred [home or another entity] by order of their attending physician in accordance with the specific State/Federal standard and practice guidelines .1) Upon receiving an order from the physician to discharge the resident - the order will be processed into the resident's medical record. 2) Notification will be made to the resident, their responsible party, and any other interested family member as appropriate and indicated. This notification will be documented in the resident's medical record . 3.1-12(a)(5) 3.1-12(a)(6)(B)

Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 1 of 1 resident reviewed for care planning. (Resident 42) Findings include: The clinical record for Resident 42 was reviewed on 6/5/25 at 10:00 a.m. The diagnoses included, but were not limited to, paraplegia and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 4/30/25, indicated Resident 42 was cognitively intact. During an interview on 6/5/25 at 10:11 a.m., Resident 42 indicated he had not been invited to any care plan meetings since his admission in January of 2025. On 6/5/25 at 3:20 p.m., the Regional Director of Operations (RDO) provided a care plan meeting progress note dated 1/28/25. This progress note included a list of interdisciplinary team members present and a summary of his care plan meeting. No other care plan meeting progress notes were provided. During an interview on 6/6/25 at 1:59 p.m., the MDS Nurse indicated the facility conducted care plan meetings quarterly or as needed. Resident 42 was scheduled to have a care plan meeting after the week of 4/22/25, but it had been cancelled. She indicated she was unsure as to why a care plan meeting had not been rescheduled. On 6/6/25 at 3:52 p.m., the Nurse Consultant (NC) provided a Baseline Care Plan Assessment/Comprehensive Care Plans Policy, last revised 09/13/24. It indicated . Procedure .6. The facility Social Service Director or designee will notify the resident of their scheduled Care Plan Conference and will invite and encourage the resident to attend. This notification will continue for any subsequent Care Plan Conferences .9. The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide timely perineal (genital and anal area) care for 1 of 1 resident observed for activities of daily living (ADLs). (Resident 24) Findings include: The clinical record for Resident 24 was reviewed on 6/9/25 at 2:03 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD, lung and airway disease which restricts breathing), chronic heart failure, pulmonary embolism (clot in lung), weakness, vertigo (dizziness), and difficulty walking. A Quarterly Minimum Data Set (MDS) assessment, dated 4/17/25, indicated the resident was cognitively intact and needed set up or clean up assistance with toileting hygiene. A care plan for ADLs noted an intervention, initiated on 6/17/22, to where staff were to assist Resident 24 with toileting as needed. Another intervention, initiated on 6/17/22, indicated staff were to keep skin clean and dry, provide peri-care (genital/groin/anal area cleaning) and clothing changes as needed. An intervention, initiated on 3/25/25, indicated staff were to provide peri-care as needed with repositioning and keep linens dry, clean, and wrinkle-free. An intervention, initiated on 6/17/22, indicated staff were to promptly assist with toileting when the resident requested and assist with transfers on and off the toilet, adjusting clothing and peri-care as needed. Resident 24 was interviewed on 6/4/25 at 1:47 p.m. He indicated he had a hard time reaching his bottom to wipe after a bowel movement, due to his health conditions. He asked for help getting wiped, but the staff told him it's not their job to help him wipe his bottom. Resident 24 was interviewed on 6/5/25 at 2:33 p.m. He indicated his bottom still had stool on it from yesterday, and he could feel it itching and burning. He had asked the day shift Certified Nurse Aide (CNA) to help him get cleaned up about 20 minutes ago, but she left and had not been back since. No staff was observed entering Resident 24's room, so he activated his call light at 3:10 p.m. Qualified Medication Aide (QMA) 8 was observed entering the resident's room at 3:16 p.m. QMA 8 was interviewed on 6/5/25 at 3:24 p.m. She indicated there was no reason why Resident 24 couldn't clean himself. The Nurse Consultant (NC) provided a policy titled Activities of Daily Living on 6/10/25 at 1:30 p.m. It indicated Residents are given routine daily care and HS [nighttime] care by a CNA [Certified Nurse Aide] or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed. ADL care is coordinated between the resident and the care givers with emphasis on resident preference as much as possible .ADL care of the resident includes: Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care [as indicated and as per care plan] . 3.1-38(a)(2)(C) 3.1-38(a)(3)(A)

Based on interview and record review, the facility failed to hold cardiac medication when vital signs were outside of prescribed parameters and to administer insulin as ordered for 2 of 5 residents reviewed for unnecessary medications. (Resident 14 and Resident 17) Findings include: 1. The clinical record for Resident 14 was reviewed on 6/4/25 at 11:18 a.m. The diagnoses included, but were not limited to, hypertension and congestive heart failure. A physician's order, dated 4/9/24, indicated he was to receive digoxin (cardiac medication) 125 micrograms (mcg); one tablet daily for heart failure. The parameters were listed to hold the medication dose for pulse under 60 beats per minute. A physician's order, dated 4/9/24, indicated he was to receive metoprolol succinate extended release (ER) 50 milligrams (mg) twice daily for hypertension. The parameters were listed to hold the medication dose for systolic blood pressure below 100 or pulse below 60. A care plan, last revised on 6/19/24, indicated Resident 14 had the potential for cardiac distress related to a diagnosis of coronary artery disease. The goal was for him to be free of cardiac distress. The interventions included to serve diet as ordered and administer medications as ordered. The May 2025 and June 2025 Medication Administration Record (MAR) indicated the digoxin 125 mcg had been administered when Resident 14's pulse was below 60 on the following days: 5/6/25, 5/7/25, 5/19/25, 5/20/25, 5/21/25, and 6/5/25. The May 2025 and June 2025 MAR indicated the metoprolol succinate 50 mg had been administered when his pulse was below 60 on the following days: 5/6/25, 5/7/25, 5/19/25, 5/20/25, 5/21/25, 6/5/25, and 6/8/25. During an interview on 6/9/25 at 12:19 p.m., the Director of Nursing (DON) indicated the digoxin, and metoprolol should have been held when Resident 14's pulse was below 60. 2. The clinical record for Resident 17 was reviewed on 6/5/25 10:30 a.m. The diagnoses included, but were not limited to, cocaine abuse, opioid use, and major depressive disorder. An Annual Minimum Data Set assessment, dated 3/24/25, indicated Resident 17 was cognitively intact. A physician order, dated 1/9/25, was noted for insulin lispro-aabc injection solution (fast-acting insulin) 100 unit/milliliter (mL), inject per sliding scale subcutaneously four times a day for type 2 diabetes. A physician order, dated 1/9/25, was noted for Lantus SoloStar Subcutaneous Solution Pen-Injector (long-acting insulin) 100 unit/mL (insulin glargine), inject 90 units subcutaneously two times a day for diabetes. Review of the May 2025 MAR indicated Resident 17 was not administered his insulin lispro-aabc injection solution as ordered on the following days and times: 05/03/25 at 12:00 p.m., 05/10/25 at 12:00 p.m., 05/20/25 at 9:00 p.m., 05/25/25 at 12:00 p.m., 05/26/25 at 7:00 a.m. and 12:00 p.m., 05/27/25 at 07:00 a.m. and 12:00 p.m., and 05/28/25 at 5:00 p.m. and 9:00 p.m. Review of the May 2025 MAR indicated Resident 17 was not administered his Lantus SoloStar Injection Solution (insulin glargine) as ordered on the following days and times: 05/01/25 at 8:00 p.m., 05/26/25 at 8:00 a.m., 05/27/25 at 8:00 a.m., and 05/28/25 at 8:00 p.m. During an interview on 6/9/25 at 4:14 p.m., the facility Nurse Consultant (NC) indicated she was unable to find documentation as to why the doses of insulin had not been administered as ordered. On 6/9/25 at 3:26 p.m., the DON provided the Medication Administration Policy which indicated .Purpose: To administer medications safely and appropriately to aide residents to overcome illness, relieve and prevent symptoms, and help in diagnosis . 12. Obtain and record any vital signs as necessary prior to medication administration. 16. Give the resident the medication . 3.1-37(a)

Based on interview and record review, the facility failed to ensure medications were received timely from the pharmacy for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for tube feedings (Resident 14 and Resident 41). Findings include: 1. The clinical record for Resident 14 was reviewed on 6/4/25 at 11:18 a.m. The diagnoses included, but were not limited to, hypertension and congestive heart failure. A physician's order, dated 6/3/25, indicated Resident 14 was to receive trazadone (medication for depression) 50 milligram (mg); two tablets at bedtime nightly for insomnia. The June 2025 Medication Administration Record (MAR) indicated Resident 14 had not received his prescribed dose of trazadone on 6/3/25, 6/4/25, and 6/5/25. He began receiving the prescribed dose on 6/6/25. During an interview on 6/9/25 at 2:14 p.m., the Director of Nursing (DON) indicated Resident 14 had not received his trazadone on 6/3/25, 6/4/25, and 6/5/25 because the medication had not been delivered from the pharmacy and was not available in the Cubex (a machine located at the facility for obtaining medication as needed). 2. The clinical record for Resident 41 was reviewed on 6/4/25 at 2:56 p.m. The diagnoses included, but were not limited to, dysphagia (inability to swallow) and aspiration pneumonia (pneumonia caused by material from the stomach or mouth entering the lungs). A physician's order, dated 5/13/25, indicated he was to have a scopolamine transdermal patch (medication used to prevent nausea and vomiting) applied to the skin every 72 hours for nausea. A care plan, last reviewed 6/6/25, indicated Resident 41 had a feeding tube due to dysphagia and was at high risk for aspiration. The goal was for him to maintain adequate nutrition and hydration using his feeding tube without complications. The interventions included to monitor for intolerance of feedings such as vomiting or nausea and to elevate the head of his bed at least 30 degrees at all times. The June 2025 MAR indicated Resident 41's scopolamine transdermal patch had not been applied on 6/3/25 and 6/6/25 due to the patch not being available. During an interview on 6/9/25 at 2:14 p.m., the DON indicated the scopolamine patch had been reordered from the pharmacy and had not been sent to the facility timely. On 6/6/25 at 3:52 p.m., the Nurse Consultant provided the Pharmacy Services policy, dated October 2021, which indicated . is responsible for rendering the required services in accordance with local, state, and federal laws and regulation, facility policies and procedures, and community standards of practice .Providing routine and timely pharmacy services 7 days per week and emergency pharmacy service 24 hours a day, seven days per week . 3.1-25(a)

Based on interview and record review, the facility failed to ensure a partial dose of a controlled substance (oxycodone) was destroyed and recorded in the presence of two licensed personnel for 1 of 5 residents reviewed for unnecessary medications. (Resident 17) The clinical record for Resident 17 was reviewed on 6/5/25 at 10:30 a.m. The diagnoses included, but were not limited to, cocaine abuse, opioid use, and major depressive disorder. An Annual Minimum Data Set assessment, dated 3/24/25, indicated Resident 17 was cognitively intact. A physician's order, dated 4/3/25, noted to administer oxycodone 5 milligrams (mg) tablet, give one tablet by mouth every six hours as needed for pain. A nursing progress note, dated 5/21/25, indicated Resident 17 requested a dose of oxycodone for pain, but the facility had run out of oxycodone 5 mg tablets. Available in the Cubex (a machine that supplies medications at the facility) was oxycodone 10 mg tablets. Licensed Practical Nurse (LPN) 4 called the facility Nurse Practitioner (NP) to obtain a one-time order for a half tablet of oxycodone 10 mg. A nursing progress note, dated 5/21/25, indicated LPN 4 was able to pull the oxycodone 10 mg for Resident 17, split the pill in half and would save the other half for later. During an interview on 6/9/25 at 1:59 p.m., the Director of Nursing (DON) indicated if a narcotic was pulled and the full dose was not administered, the remainder of the dose should have been wasted or destroyed. A Controlled Drug Receiving Record/Disposition Form, dated 5/21/25, indicated a half tablet of oxycodone 10 mg was administered, with a half tablet remaining on 5/21/25 at 4:00 p.m. The record did not contain a signature from the administering staff member. An entry, dated 5/22/25 at 1:00 a.m., indicated the remaining half tablet was administered and signed off on by the administering staff member. An interview was conducted with LPN 4 on 06/10/25 at 2:19 p.m. She indicated Resident 17 was upset and acting out of character due to not having his available pain medication. She called the facility NP to obtain a one-time order for oxycodone 10 mg since that was what was available in the Cubex. LPN 4 split the oxycodone 10 mg in half to give Resident 17 the ordered 5 mg and then put the remaining half tablet in a medication cup and stored it in the narcotics lock box. LPN 4 indicated she saved it so the following shift would have a dose to give Resident 17 until the pharmacy refilled his pain medication. On my way home, I realized I had forgotten to fill out a narcotic record sheet. A Controlled Substance Medications Policy, dated March 2023, was provided by the facility Nurse Consultant on 6/10/25 at 9:15 a.m. It indicated Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations . The disposal of unused partial tablets and unused portions of single dose ampules must be destroyed and recorded in the presence of two licensed personnel . 3.1-25(r)

Based on interview and record review, the facility failed to ensure residents with severe cognitive impairment did not enter into binding arbitration agreements for 1 of 3 residents reviewed for arbitration. (Resident 20) Findings include: The clinical record for Resident 20 was reviewed on 6/6/25 and 2:30 p.m. The diagnoses included, but were not limited to, stroke. An admission Minimum Data Set (MDS) assessment, completed 5/2/25, indicated he was severely cognitively impaired. He was able to make himself understood and able to respond adequately to simple direct questions. On 6/6/25 at 2:27 p.m., the Executive Director provided a copy of a Voluntary Binding Arbitration Agreement, that was electronically signed by Resident 20, on 4/28/25, which indicated .This is a voluntary agreement. You are not required to sign this agreement as a condition of admission to this Facility or to continue to receive care at this facility .You are strongly encouraged to consult with an attorney or trusted advisor before signing this agreement. You have the opportunity to ask questions before signing this document . The Resident/ Resident's Legally Authorized Representative, by signing this agreement, also acknowledges that he/she had been informed and understands the entire agreement including that .b. The agreement may not be submitted to a Resident for approval when the Resident has been deemed incompetent by two physicians .d. The agreement waives the Resident's right to a trial in a court for any future malpractice claim the Resident may have against the healthcare provider, absent revocation of the agreement consistent with state law . During an interview on 6/9/25 at 1:40 p.m., the Regional Director of Operations (RDO) indicated that upon admission, there was not always a guardian or family member involved and able to complete the admission paperwork with the resident being admitted . During an interview on 6/9/25 at 3:50 p.m., the Executive Director indicated the admission paperwork was filled out electronically, and there was an option to sign all which puts initials or electronic signatures on all forms that need to be signed, including the Voluntary Binding Arbitration Agreement. She would ensure the Voluntary Binding Arbitration Agreement was not signed by residents without capacity to make the decision going forward.

Based on observation and interview, the facility failed to maintain the floors in good repair with the potential to affect 39 of 39 residents residing at the facility. Findings include: On 4/4/24 at 10:55 a.m., an environmental tour of the facility was conducted with the DOM (Director of Maintenance), RDO (Regional Director of Operations), and the ED (Executive Director). The following areas of concern were noted: 1. The flooring in the hallway outside of room [ROOM NUMBER] had a crack in the floor tiles approximately 4 ft long. 2. The flooring in the hallway outside of room [ROOM NUMBER] had cracks in the tiles which was approximately 25 ft long and 3 inches at the widest part. 3. the flooring outside of room [ROOM NUMBER] had a crack in the tiles which was the width of the hallway and 11/2 inch at the widest part. 4. The metal threshold between the new and older part of the building had a divot that was approximately 2 inches x 2 inches and 1/4 inch deep. There were 4 broken tiles present at the threshold. 5. The hallway flooring outside of room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had a broken tiles present. 6. The tiles outside of room [ROOM NUMBER] had a stained and dirty appearance. 7. The hallway flooring outside of room [ROOM NUMBER] had stained tyles. 8. The vinyl flooring by the janitors' closet was buckled and pulled from the floor. 9. The vinyl flooring in the hallway by room [ROOM NUMBER] was pulled up from the floor by the cove base. 10. The vinyl flooring at the thresholds of room [ROOM NUMBER] and 12 were pulling away from the floor. 11. The vinyl flooring in the hallway outside of room [ROOM NUMBER] had divots in the floor and cracks in the vinyl. During an interview on 4/4/24 at 11:10 a.m., Resident 94 indicated the floors were like a roller coaster in some parts of the building. The hallway flooring could use some work. During an interview on 4/4/24 at 11:12 a.m., Resident 1 indicated the flooring in the facility was bumpy in places. During an interview on 4/4/24 at 11:15 a.m., the ED, RDO, and DOM indicated the building floors had settled and caused the cracks in the tiles. The tiles were cleansed and waxed regularly, however due to the age of the flooring, some of the tiles were permanently stained. The vinyl flooring had been installed improperly causing a bumpy, unevenness to the floor. 3.1-19(a)(4)

Based on observation, interview and record review, the facility failed to ensure food items were stored closed and labeled with open dates. This had a potential to effect 38 of 39 residents that eat food prepared in the kitchen. Findings include: An observation was made of the kitchen with Cook 5 on 4/2/24 at 8:06 a.m. During the tour, the refrigerators and freezers were observed with the following food items opened and/or not labeled with open dates: One freezer had 1 half full container of orange sherbet and 1 cardboard box that contained 5 lime sherbet containers individual size with no open dates. A 2nd freezer was observed with a bag of french fries opened to air with no open date and 1 bag of chicken tied shut, but no open date. The refrigerator was observed with 1 half full bag of spring salad mix closed with no open date. An interview was conducted with Cook 5 on 4/2/24 at 8:30 a.m. She indicated all food items should be labeled with open dates and sealed shut. The food storage policy was provided by the Regional Director of Operations on 4/3/24 at 11:22 a.m. It indicated .Policy: Food shall be stored on shelves in a clean, dry area, from containments. Food shall be stored at appropriate temperatures and using appropriate methods to ensure highest level of food safety. Procedure: I. General storage guidelines to be followed: Label all food items. The label must include the name of the food and the date by which it should be sold, consumed or discarded . The date marking policy was provided by the Regional Director of Operations on 4/3/24 at 11:22 a.m. It indicated .Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date . 3.1-21(i)(1) 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to provide showers, as care planned and preferred, for 1 of 3 residents reviewed for ADL (Activities of Daily Living) care (Resident 35). Findings include: The clinical record for Resident 35 was reviewed on 4/2/24 at 1:17 p.m. The Resident's diagnosis included, but were not limited to, parkinsonism and tremors. A care plan, initiated on 8/1/23, indicated Resident 35 needed assistants with adl care related to his impaired mobility and tremors. The goal was for him to have all adl needs met by staff. The interventions included, but were not limited to, bathe per resident preference 2 x weekly and as needed, initiated 8/1/23. An Activity Resident Interview, completed 1/12/24, indicated it was very important to Resident 35 to choose between a tub bath, shower, bed bath or sponge bath. A Quarterly MDS (Minimum Data Set) Assessment, completed 2/5/24, indicated he was cognitively intact. During an interview on 4/2/24 at 1:17 p.m., Resident 35 indicated he did not always get his showers. He thought his shower day was on Fridays. He did not always get showers twice a week and that he preferred showers, not bed baths. During an interview on 4/3/24 at 1:44 p.m., the DON (Director of Nursing) indicated his showers were scheduled for Wednesday and Sunday evenings. During an interview on 4/3/24 at 3:15 p.m., CNA (Certified Nursing Assistant) 20 indicated Resident 35 normally did not refuse his showers. March and April showers should have been performed on 3/3, 3/6, 3/10, 3/13, 3/17, 3/20, 3/24, 3/27, 3/31, 4/3. On 4/3/34 at 3:30 p.m., the RNC (Regional Nurse Consultant) 1 provided shower sheets for Resident 35 for March 2024, which indicated that he had received the following: 3/6/24- shower, 3/9/24- shower, 3/16/24- bed bath, 3/20/24- he had refused, 3/23/24- shower, 3/27/24- shower, and 3/30/24- shower. On 4/4/24 at 10:06 a.m., the RNC 1 provided the current Activities of Daily Living policy which read .ADL care is provided throughout the day, evening and night as care planned and / or as needed. ADL care is coordinated between the resident and the care giver with emphasis on resident preferences as much as possible . 3.1-38(3)(b)(2)

Based on interview and record review, the facility failed to immediately notify the Administrator of an allegation of abuse for 2 of 2 residents reviewed for abuse. (Resident 1 and 28) Findings include: 1. The clinical record for Resident 1 was reviewed on 4/2/24 at 1:30 p.m. His diagnoses included, but were not limited to: anxiety, major depressive disorder, insomnia, and type 2 diabetes. An interview was conducted with Resident 1 on 4/2/24 at 1:33 p.m. He indicated Resident 6 grabbed him and kicked him in the back of his wheel chair last week, in the dining room. He told staff about it and they followed up with him. Now, he stayed away from Resident 6. The 3/30/24 Nursing Progress Note for Resident 1 read, Unwitnessed incident the resident was kicked by another resident in the back of his w/c [wheel chair] and pinched on his left upper arm and back, no apparent injuries, statement was taken from the resident whom was hit, head to toe assessment done on this resident who was stuck, he had no apparent injuries, NP [Nurse Practitioner,] DON [Director of Nursing,] and Family notified. An interview was conducted with the ED (Executive Director) on 4/2/24 at 1:45 p.m. She indicated she knew about the altercation between Resident 1 and Resident 6. It happened on Saturday, 3/30/24. She didn't find out about it until Monday, 4/1/24, at Monday Morning Meeting through a progress note and risk management entry. The nurse who created the progress note entered the altercation into a risk management entry for both residents. The nurse thought the ED would find out about the altercation through risk management. The nurse should have reported it to her immediately. An interview was conducted with Resident 1 on 4/4/24 at 10:30 a.m. He indicated the pinch hurt, but not too much, and didn't leave a bruise or anything. It hurt his feelings at the time, but he was okay now. 41129 2. The clinical record for Resident 28 was reviewed on 4/2/24 at 1:13 p.m. Resident 28's diagnoses included, but not limited to, borderline personality disorder, bipolar disorder, Lupus, anxiety disorder, major depressive disorder, and fibromyalgia. A nursing note dated 12/15/23 at 8:26 a.m. indicated, Resident 28 had told the writer of the nursing note of an incident that happened during the evening shift on 12/14/23. Resident 28 indicated, she was verbally abused by her roommate and wanted staff to be aware but did not want to move rooms. An interview with Resident 28 conducted on 4/2/23 at 2:36 p.m. indicated, when she was roommates with Resident 13, Resident 13 would yell at her to get off the phone, say that she is good for nothing, and that she needed mental help. An interview with ED (Executive Director) conducted on 4/2/24 at 3:17 p.m. indicated, the alleged verbal abuse between Resident 28 and Resident 13 on 12/14/23 had not been reported to her or the management staff. ED further indicated, the alleged verbal abuse had not been reported to the Indiana State Department of Health as of yet, but she was going to report it immediately and an investigation into the incident was to begin. The investigation file for the alleged verbal abuse was received on 4/4/24 at 1:20 p.m. It contained, but not limited to, an Indiana State Department of Health incident report dated 4/2/24 at 3:39 p.m. The incident report indicated, the actual identified date of the incident being reported had occurred on 12/15/23 at 8:26 a.m. The alleged verbal abuse incident was not reported timely. An Abuse Prevention Program policy received on 4/3/24 at 2:14 p.m. from ED indicated, . Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, or mistreatment they observe, hear about of suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator. The Administrator is the Abuse Coordinator .Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations, or suspicion of potential mistreatment. Upon learning of the report, the Administrator or in the absence of the Administrator, the person in charge of the facility shall indicate an incident investigation .The Administrator or designee utilizing the ISDH [sic, Indiana State Department of Health] Incident Report form will immediately notify the ISDH by email or fax .Verbal Abuse: Any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. 3.1-28(c)

Based on interview and record review, the facility failed to clarify and administer a resident's medication, as ordered; to ensure physician orders were followed, as ordered, for a resident with elevated blood sugars; and to monitor blood pressure, as ordered, prior to administering a medication for 3 of 5 residents reviewed for unnecessary medications. (Resident 10, 11, and 21) Findings include: 1. The clinical record for Resident 10 was reviewed on 4/3/24 at 1:49 p.m. His diagnoses included, but were not limited to paranoid schizophrenia. The paranoid schizophrenia care plan, revised 2/21/23, indicated he was at risk for the behavioral expressions of paranoia, delusions, and making false accusations at times. Interventions were to GDR (gradual dose reduction) per schedule and provide medications as ordered. The 3/18/23 Note To Attending Physician/Prescriber read, This resident is due for a trial reduction of Haloperidol 5 mg three times a day for schizophrenia. Please consider a gradual dose reduction, while monitoring for re-emergence and/or withdrawal symptoms .Recommend to change to: Haloperidol 5 mg twice daily and 4 mg in the afternoon for schizophrenia. The Physician/Prescriber Response section of the note, completed by the facility's Psyche NP (Nurse Practitioner) on 3/22/24, indicated she agreed with the recommendation and to change the order to the recommended Haloperidol 5 mg twice daily and 4 mg in the afternoon. The 3/22/24 psychiatry progress note, written by the facility Psyche NP, read, [Name of Resident 10] is assessed today in his room, he is resting in his bed underneath the blanket. Addressed his name, he barely responded that he wants to sleep. He appears without any distress. Staff reported resident is doing same and no concerns with sleep, appetite, anxiety or depression or any mood or behavior symptoms. So, reduced his haloperidol slightly as per GDR today. Continue psychiatric services to monitor resident's mood, behaviors, diagnoses, and medications, making appropriate adjustments when clinically indicated Paranoid schizophrenia Mod [moderately] stable - 1. REDUCE Haloperidol Lactate concentrate 5 mg [2.5 ml] BID [twice daily,] and haloperidol 4 mg daily in the afternoon. The March and April, 2024 MARs (medication administration records) indicated he received 2.5 ml of Haloperidol Lactate Oral Concentrate 2 mg/ml by mouth at bedtime only from 3/24/24 through 4/3/24, which was not in accordance with the facility Psyche NP's 3/22/24 pharmacy recommendation response or 3/22/24 psychiatry progress note. An interview was conducted with the DON (Director of Nursing) on 4/4/24 at 10:36 a.m. She indicated on 3/22/24 the Psyche NP put the Haloperidol order in for intramuscularly, the wrong route. Then the evening shift nurse, LPN (Licensed Practical Nurse) 5, noticed it, so she switched the order to 2.5 ml, but didn't have an order to do so. LPN 5 took it upon herself to change the order. Resident 10 should have been administered his Haloperidol, as ordered, in accordance with the 3/22/24 Psyche NP note and 3/22/24 pharmacy recommendation response. 34850 2. The clinical record for Resident 21 was reviewed on 4/3/24 at 9:03 a.m. The diagnosis included, but was not limited to: type 2 diabetes mellitus. A physician order dated 1/31/24 indicated Resident 21 was to receive novolog insulin with meals utilizing a sliding scale. The scale was the following: blood sugars 0 - 150 = 0 units of insulin, blood sugars 151 - 200 = 2 units of insulin, blood sugars 201 - 250 = 4 units of insulin, blood sugars 251 - 300 = 6 units of insulin, blood sugars 301 - 350 = 8 units of insulin, and blood sugars 351 - 400 = 10 units of insulin The staff were to call the medical provider if the resident's blood sugar was greater than 425. The March 2024 Medication Administration Record (MAR) indicated Resident 21's blood sugar reading was 486 on 3/6/24 at 11:00 a.m., and 497 on 3/7/24 at 5:00 p.m. A MAR nursing note dated 3/6/24 indicated Writer notified of resident's elevated BG [blood glucose] level; 486. Notified NP [Nurse Practitioner]. Order to give sliding scale per [DATE] units plus additional 2 units. Recheck after 1-2 hours. Will continue with plan of care. The resident's clinical record did not indicated the resident's blood sugar was rechecked in 1-2 hours as ordered. A MAR nursing note dated 3/7/24 indicated the resident's BS [blood sugar] is 497, Nurse notify And 13 units given and to be checked back in 1 hr [hour]. The resident's clinical record did not indicate the resident's blood sugar was rechecked 1 hour as ordered. An interview was conducted with Regional Nurse Consultant 1 on 4/4/24 at 2:08 p.m. She indicated she was unable to find any notations that Resident 21's blood sugars were rechecked as ordered after treating elevated blood sugars of greater than 425 on 3/6/24 and 3/7/24. 40287 3. The clinical record for Resident 11 was reviewed on 4/2/24 at 2:10 p.m. The Resident's diagnosis included, but were not limited to, hypertension and congestive heart failure. A care plan, initiated 10/5/2019, indicated Resident 11 had a diagnosis of hypertension. The goal was for her to have no complications with blood pressure. The interventions, initiated 10/5/2019, were to administer medication as ordered, monitor blood pressure per physician order or facility policy, and to notify the physician and family as needed. A physician's order, dated 2/24/24, indicated Resident 11 was to received metoprolol 75 mg (milligram) tablet twice daily. Hold if systolic blood pressure is less than 100. The March and April 2024 MAR (Medication Administration Record) indicated the metoprolol 75 mg had been administered twice daily. There were no blood pressure recorded on the MAR to indicate what the systolic blood pressure was at the time of administration. The blood pressures recorded in the vital signs section of the electronic health record were 3/15/24 -109/69, 4/2/24- 105/ 65, and 4/3/24- 110/76. On 4/3/24 at 3:40 p.m., the DON (Director of Nursing) indicated that the blood pressures should have been completed prior to administering the metoprolol. The Verbal Orders/Admission/Readmission Orders policy was provided by (Regional Nurse Consultant) 2 on 4/4/24 at 11:22 a.m. It read, Question the authorized prescriber if there is any uncertainty regarding the order. The following physician orders policy was provided by the Director of Nursing on 4/4/24 at 2:10 p.m. It indicated .Policy: It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission .4. All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure dental services were provided for 2 of 2 residents reviewed for dental (Resident 25 and Resident 38) Findings include: 1. The clinical record for Resident 38 was reviewed on 4/2/24 at 10:30 a.m. The diagnosis included, but was not limited to: type 2 diabetes mellitus. The resident was admitted to the facility on [DATE]. The dental consultant consent dated 12/6/23 indicated Resident 38 would like dental services. An observation was made of Resident 38 on 4/2/24 at 10:39 a.m. The resident's oral cavity was observed with missing and broken teeth. The resident indicated at that time he was having trouble with some of his teeth. He had several teeth missing and cavities. He had not seen a dentist since he had been in the facility. 2. The clinical record for Resident 25 was reviewed on 4/2/24 at 10:30 a.m. The diagnosis included, but was not limited to: type 2 diabetes mellitus. The resident was admitted to the facility on [DATE]. The dental consultant consent dated 8/9/23 indicated Resident 25 would like dental services. An observation was made of Resident 25 on 4/2/24 at 10:24 a.m. The resident was observed with a dark rotten front tooth. He indicated he would like to be seen by a dentist, but haven't seen one. The dental visits were provided by the Regional Nurse Consultant 2 on 4/4/24 at 2:00 p.m. It indicated the dental provider had been in the facility providing services on 3/22/24 and 4/3/24. Resident 25 nor Resident 38 had been seen on those dates. An interview was conducted with Social Services Director (SSD) on 4/5/24 at 9:12 a.m. She indicated Resident 38 and Resident 25 had signed consents to receive dental services. It should take approximately a month to set up for routine dental services. She was unsure why the residents had not been seen. She was unaware Resident 38 had been having trouble with his teeth until the care plan meeting that had been conducted on 4/2/24. She had received a dental report dated 12/18/23 indicating Resident 25's payer source was still pending. She had not followed up with the dental provider. A dental services policy was provided by Regional Nurse Consultant on 4/5/24 at 9:02 a.m. It indicated .Policy: It is is the policy of the facility to provide medically related social services to attain or maintained the highest practicable physical, mental and psychosocial well-being of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services . 3.1-24(a)(1)(2)

Based on interview and record review, the facility failed to ensure vision services was provided for 1 of 1 residents reviewed for vision services. (Resident 38) Findings include: The clinical record for Resident 38 was reviewed on 4/2/24 at 10:30 a.m. The diagnosis included, but was not limited to: type 2 diabetes mellitus. The resident was admitted to the facility on [DATE]. A eye consultant consent dated 12/6/23 indicated Resident 38 would like vision services. An interview was conducted with Resident 38 on 4/2/24 at 10:39 a.m. He indicated he was having trouble with his vision and would like to see an eye doctor. The eye visits were provided by the Regional Nurse Consultant 2 on 4/4/24 at 2:00 p.m. It indicated eye services was provided in the facility on 3/27/24. Resident 38 had not been seen. An interview was conducted with Social Services Director on 4/5/24 at 9:12 a.m. She indicated Resident 38 had signed a consent to receive vision services. She was unsure why the resident had not been seen. There have been some concerns with delays on vision services with the vision company the facility current uses. A vision services policy was provided by Regional Nurse Consultant 3 on 4/5/24 at 10:47 a.m. It indicated .The vision and hearing services standard has been to assist with achieving compliance standards found within the State Operations Manual pertaining to proper treatment to maintain vision and hearing abilities. Purpose: To promote, comply, and ensure compliance with state and federal regulations pertaining to vision and hearing services .Policy: It is the standard of the organization to ensure that residents receive the proper treatment and assistive devices to maintain hearing and vision abilities . 3.1-39(a)(1)

Based on interview and record review, the facility failed to ensure adequate supervision was in place when a resident with dementia (Resident H) exited the facility on 7/4/22 without supervision through an unknown point of exit. The resident was picked up by local police and was found walking along the interstate on 7/5/22 in the afternoon. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on 7/4/22 when a resident with dementia (Resident H) exited the facility without facility knowledge. The Executive Director (ED), Regional Director of Operations (RDO), Director of Nursing (DON), and Regional Vice President (RVP) were notified of the Immediate Jeopardy on 7/12/22 at 2:35 p.m. Findings include: The clinical record for Resident H was reviewed on 7/11/22 at 3:55 p.m. The diagnoses included, but were not limited to, [CONDITION(S)] disorder ([CONDITION(S)] type), anxiety disorder, major depressive disorder, and dementia. He was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) score, from previous facility, dated 3/28/22, indicated Resident H was cognitively intact. A Wandering/Elopement Risk assessment, dated 5/30/22, was conducted at his previous facility. Resident H was noted to be at risk to wander. A Wandering Risk Scale assessment, dated 6/30/22, indicated Resident H could follow instructions, was ambulatory, had no history of wandering, had no diagnosis of dementia/cognitive impairment. This calculated his score to be low risk. An Elopement Risk Review, dated 6/30/22, indicated no diagnosis of dementia, did not pace or wander, no attempt to get outdoors, no history of elopement, and he did accept nursing home placement. This calculated his score to be not at risk. There was no care plan in place for elopement risk due to Resident H not being identified as an elopement risk. A physician order, upon admission to the facility, indicated Resident H could go on a leave of absence (LOA) with family or responsible party. An activities of daily living (ADL) care plan, dated 7/1/22, indicated Resident H required staff assistance with ADLs due to debility and poor activity endurance. A fall care plan, dated 7/1/22, indicated Resident H was at risk for falls with potential for injury related to weakness, dementia, anxiety, and pain. A progress note, dated 7/4/22 at 11:17 p.m., indicated the following, .Writer noted during start of shift rounds that he [Resident H] was not in his room. all staff on duty informed to check every room, bathroom and open door inside facility, writer walked the facilities outside parameter [sic], checked 2 nearest gas stations and [name of fast-food restaurant], he was not seen, ED [Executive Director] notified of missing resident The investigative file was reviewed on 7/12/22 at 10:45 a.m. A statement from Qualified Medication Assistant (QMA) 2, dated 7/4/22, indicated she did not let any residents out of the facility but when she went to the parking lot there were residents out front watching fireworks. She wasn't sure how the residents got outside or what staff was watching them. A statement from Resident B, dated 7/5/22, indicated he was outside without staff present and a black lady let him out that was probably staff. States he was there for 20 minutes, and he saw Resident H leave and go left on (name of street facility is on). Staff brought Resident H back in when identified missing resident. A statement from QMA 3, dated 7/5/22, indicated at approximately 10:00 p.m. she had seen 4 residents coming up the middle hallway. A resident told her they were outside watching fireworks. None of these residents were Resident H. A statement from Registered Nurse (RN) 4, dated 7/5/22, indicated he last saw Resident H between 7:00 p.m. and 8:00 p.m. when he gave Resident H's roommate medications. When RN 4 went outside for a smoke break, at 10:25 p.m., he went towards the front of the facility and saw (names of 6 residents) entering the facility through the front door. There were no staff seen outdoors. A statement from Licensed Practical Nurse (LPN) 5, dated 7/4/22, indicated another resident (Resident J) mentioned seeing Resident H wearing a baseball cap, glasses, white t-shirt, and blue jeans walk off the facility premises. A statement from Certified Nursing Assistant (CNA) 6, dated 7/4/22, indicated she conducted a walking report during shift change. She recalled Resident H lying in bed looking at the window at that time. This would have occurred between 10:56 p.m. and 11:00 p.m. per the ED. An article from a local news station, published 7/5/22, indicated the following, .[name of Resident H] was last seen Monday, July 4 after watching fireworks .Police say Tuesday afternoon that he had been located and is safe An interview conducted with Family Member 12, on 7/11/22 at 2:14 p.m., indicated a police officer showed up to her front door on 7/5/22 at 3:30 a.m. She was informed that Resident H was missing, and they were in the process of searching for them. She was then later informed Resident H had been found walking along the interstate and was missing all night long. He had eloped at a previous facility he was at and resided on a secured unit. She was not aware that Resident H was going to a facility that didn't have a secured unit for him to reside in. An interview conducted with the ED, on 7/11/22 at 2:33 p.m., indicated she received a phone call on 7/4/22 at 11:17 p.m. that Resident H could not be found. After conducting an investigation, I was told there was a resident, Resident J, that would watch the receptionist leave and observe them punch the code to the front door. That's how he was able to retrieve the code to the front door. She believes it was around 8:30 p.m., to when the group of residents went outside to watch the fireworks. She was unable to recall the time Resident H was found by police. He was found walking along the interstate by the local police and then transferred to a local hospital. He remains there until they can find the best placement for him. An interview conducted with Resident K, on 7/12/22 at 11:30 a.m., indicated that she saw fireworks from a window inside the facility around 9:00 p.m. on 7/4/22. She and a few other residents decided to sneak out. There was a resident, Resident J, who knew the code to the front door. We all sat outside and watched the fireworks. She didn't recall seeing Resident H while she was outside. She mentioned there were concerns in the past with facility staff propping the side door open with a rock when they go outside to smoke. When the management staff leave for the day the nursing staff will prop the door open and leave it open. She mentioned that's probably how he got out. She was referring to Resident H. An interview conducted with RN 4, on 7/12/22 at 1:00 p.m., indicated he administered medications to Resident H between 7:45 p.m. and 8:00 p.m. on 7/4/22. The shift before him didn't mention any risk factors about Resident H. He conducted a walkthrough every 1-2 hours and he never observed Resident H outside of his room. An interview conducted with the ED, on 7/12/22 at 12:19 p.m., indicated Resident J commented about pressing the code pad once to the front door. She was unable to confirm if the residents had walked out after a staff member because Resident J was in a wheelchair and unable to hold the door open for others to exit. Resident J then commented about other residents coming outside behind him. The receptionist had left at 7:00 p.m. on 7/4/22. Resident J mentioned he would closely watch the staff press the touch pad to obtain the code to the front door. He never confirmed that he let anyone out because the other residents came behind him. She was unaware of any staff members propping the door open to the staff smoking area. There was a camera present to that location but there had been concerns recently regarding the camera being manually unplugged frequently. A policy titled Policy and Procedure Regarding Missing Residents and Elopement, undated, was provided by the RDO on 7/11/22 at 4:00 p.m. The policy indicated the following, .It is the policy of the facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk of elopement. All residents assessed to be at risk of elopement will have this issue addressed in their plan of care .Procedure for the Prevention of Missing Residents .1. All residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission .4. Unless otherwise identified in a plan of care, any resident at risk of elopement shall be accompanied by a responsible individual while outside the facility The Past Noncompliance Immediate Jeopardy began on 7/4/22. The Immediate Jeopardy was removed and corrected on 7/7/22 when the facility completed elopement assessments for all residents, door checks and audits implemented, changed door codes, staff education on securement of doors, elopement drill conducted, and ensuring all exit doors always remain secure. The correction date was prior to the start of the survey and was therefore Past Noncompliance. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to develop and implement effective treatment plans for residents with a history of drug and/or [CONDITION(S)] resulting in alcohol and illicit drug use in the facility and aggressive resident to resident behaviors for 13 of 43 residents in the facility (Residents B, C, 9, 2, 15, 20, 18, 1, 17, 11, 5, 31, and P) The immediate jeopardy began on [DATE], when 6 residents clinical records indicated the possible ingestion of an unknown illicit substance which was brought in by another resident. The Executive Director, Director of Nursing, Regional Support and Regional Nurse were notified of the immediate jeopardy at 3:47 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The clinical records of Residents' B, C, 9, 2, 15, and 18, each contained a telehealth visit note dated [DATE] from NP (Nurse Practitioner) 8, which indicated that they were each seen for the possible ingestion of an unknown illicit substance which was brought in by another resident. It was thought to be marijuana, but it was unknown if there were other substances as well. The plan for each resident was for a urine drug screen to be completed, for the narcotic medications to be held, and for them to be monitored for an alteration in mental status. The clinical records for Residents B, C, 9, 2, 15, and 18, did not contain results of a urine drug screen. During an interview on [DATE] at 10:45 a.m., the SSD (Social Service Director) indicated she had not been made aware of any residents possible ingestion of illicit substances. She would have liked to have been made aware. She had no knowledge that any illicit substance had ever been brought into the facility. During an interview on [DATE] at 10:55 a.m., the ED (Executive Director) indicated he had not been made aware of any possible illicit drug use on [DATE]. During an interview on [DATE] at 3:30 p.m., the DON (Director of Nursing) indicated she had not found any urine drug screens from [DATE] in Residents B, C, 9, 2, 15, and 18's charts. 2. During an interview with Certified Nursing Assistant (CNA) 3 on [DATE] at 3:30 p.m., she indicated approximately a month ago, she had walked into one of the resident's room and observed Resident 9, 15, 20, and 18 gathered around a table snorting a white powdered substance formed in a line pattern. On [DATE], she had been questioned about an incident that occurred on [DATE] involving Residents B and 42. During that time, she had reported what she had observed in the resident's room a month ago involving Residents 9, 15, 20, and 18 snorting the white powder substance to the Director of Nursing (DON). An interview was conducted with the DON on [DATE] at 2:39 p.m. She indicated she does not recall any staff informing her of any other allegations of drug use. During the investigation on [DATE], the DON does remember CNA 3 had mentioned walking into someone's room, but she does not recall what she said. The DON did write it down, but she would have to locate where she placed the written note. 3. The clinical record for Resident 17 was reviewed on [DATE] at 1:40 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. Resident 9's clinical record did not include a care plan that addressed his substance abuse, and he did not receive substance abuse treatment in the facility. 4. The clinical record for Resident 11 was reviewed on [DATE] at 1:20 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. 5. The clinical record for Resident 1 was reviewed on [DATE] at 1:50 p.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A confidential interview was conducted between [DATE] to [DATE]. They indicated Resident 17 played his music really loudly and had parties in his room. It was often Residents 11, 31, and 1 who attended. The residents argued a lot when they drank together. Resident 17 liked to be assisted to bed at 10:30 p.m., at which time, he would often be intoxicated. They stated, I try to keep myself safe. When [name of Resident 17] has parties, I don't go in there. 6. The clinical record for Resident 42 was reviewed on [DATE] at 11:20 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, completed [DATE], indicated she was cognitively intact. The clinical record for Resident B was reviewed on [DATE] at 11:50 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A care plan, revised on [DATE], indicated that Resident B had the potential for side effects related to the use of [MEDICATION(S)] for a history of [CONDITION(S)]. The goal was for him to have no drug related side effects. The interventions, initiated or revised on [DATE], were to assess effectiveness of medications, give medication as ordered, report any adverse side effects to the physician, and to report any observed adverse effects such as headache, blurred vision, gastric upset, [CONDITION(S)], or joint pain. A New Psychiatric Evaluation note, dated [DATE] at 2:04 p.m., indicated Resident B presented with alcoholism, [CONDITION(S)], generalized anxiety, physical aggression to objects, [CONDITION(S)], restlessness, and sleep disorder. Staff reported that he had been frustrated due to having had a [CONDITION(S)] and being admitted to the facility for rehabilitation. He had been known to check out of the facility on leave of absences and go to the gas station and the liquor store, he brought back alcohol to the facility for other residents. Staff reports he had mood swings and became angry staff. He [NAME] out of the front door of the facility during the day and night. He describes his situation as I need to get out of here! There was a cognitive defect due to a [CONDITION(S)] including difficulty acknowledging presence of psychiatric problem and moderated impairment in ability to make reasonable decisions. A care plan, revised on [DATE], indicated he required one on one observation 24 hours a day. The goal was that he would not display any inappropriate behaviors and remain under 24-hour observation through the next review. The interventions initiated on [DATE], indicated staff were to redirect him if he tried to behave inappropriately or refused observation, to calmy explain to him that the observation was for safety measures During an interview on [DATE] at 11:07 a.m., Resident B indicated he was receiving one on one care from the staff due to an event that had happened on [DATE]. He had been hanging out with some of the other residents who he would go to the store for. He had gone out to smoke with Resident 2 and Resident 42. When they returned from smoking, he had returned to his room with Resident 2 and Resident 42 had gone back to her room next door to his. He had been sitting on his bed watching the news and had heard a thud. He left his room to investigate and found the Resident 42 on the floor in her bathroom. He ran out to alert the nurse. The nurse came into the room, and they started providing care for her. The paramedics came and started to care for her. He was instructed by the staff to go back to my room. A little later that evening a detective came to his room and said that he needed to go downtown for some questioning. He went downtown with them, and they were concerned and had questions about a possible homicide. They brought him back to the facility on [DATE] and then the Executive Director and another person came in talked with him. They let him know that he would need to move to a different room and have one on one care until the autopsy results came back. During an interview on [DATE] at 11:44 a.m., The ED (Executive Director) and the RS (Regional Support) indicated that the facility had reported an unusual death incident which involved a resident being found down on the floor. Resident B was someone who had been associated with the unusual death. The facility was working on discharge for him, but his guardian would like for him to be without alcohol consumption for a while prior to him discharging. He had been known to go on leave of absences and consume alcohol. The detective on the case was waiting for the toxicology report, which could take up to 12 weeks to be completed. During an interview on [DATE] at 2:24 p.m., the ED indicated that the nurse on duty the evening of [DATE] had called him and let him know that Resident 42 had gone into [CONDITION(S)]. About an hour later the nurse supervisor called and asked me to come to the facility due to the death being unusual and detectives had been called. He had gotten to the facility about midnight. The detectives did not speak to him at first, but then indicated there was a concern and that Resident B would be taken downtown for some questions. Resident 42 had frequently made hypothetical reports that someone had put something into her drink. She was somewhat developmentally delayed. Upon Resident B's return to the facility, it was decided to have him receive one on one care as a protection to him and others due to the unusualness of the situation. The investigation file for the unusual death was provided for review by the ED on [DATE] at 2:24 p.m. The investigation file contained the incident report which indicated that the identified time of incident [DATE] at 10:10 p.m. No staff were involved in the incident. A brief description of the incident, added [DATE], was that she was found unresponsive on the bathroom floor by CNA (Certified Nursing Assistant) who immediately notified the nurse. The nurse called 911, and then immediately initiated CPR (Cardiopulmonary Resuscitation) The nurse and CNA continued CPR until EMT's (Emergency Medical Technicians) arrived. The Resident 2xpired. The immediate action taken was that the physician and family were notified. The preventative measures were that an investigation was started. The Follow up to the incident, added on [DATE], was during the course of the investigation and interview process, the possibility of the Resident M having ingested a substance other than prescribed by her physician or administered by the facility staff was suggested. The Police Department was notified and involved. The facility would make regular contact with them. Their investigation was currently ongoing and awaiting toxicology reports. The investigation file included a statement from Resident C, dated [DATE], which indicated he had not witnessed Resident B putting anything into anyone's drinks. The investigation file included a statement from QMA (Qualified Medication Aide) 12, which indicated she had discovered Resident 42 in the bathroom on the floor. Resident 42 had told her that Resident B had put something into her drink. Resident B had commented that she had told him to carry the cup. During an interview on [DATE] at 9:51 a.m., Resident B indicated that he would run to the store for Resident 42 often. He would check with her and her roommate and see if they needed anything. He would also bring things back for other residents if they asked him. He would pay for it himself some of the time, but at times he would ask them to contribute for the cost of the items. He usually brought coffee or snacks back to the facility for others. He had never given his medication to other residents and that he had never taken medications or recreational drugs from other residents. During an interview on [DATE] at 2:15 p.m., Resident C indicated that Resident B had been his roommate until recently. He had gotten up around 1:00 a.m. one night and moved himself into the room next door to Resident 42. They had not had a disagreement and he was unsure why he had moved out. He had been outside smoking at the same time as Resident B and 42 were on the evening on [DATE]. When they were coming in, she had mentioned that she wasn't feeling right. He had told her he would help her back to her room and was carrying her cup for her, which was strange, because she had a holder on her walker that she always used to carry her cup. He had gone back to his room after smoking and had not seen them again that evening. He had not seen him put anything into the cup. During an interview on [DATE] at 2:40 p.m., CNA (Certified Nursing Assistant) 9,10, and 11, indicated that Resident 42 was alert and very oriented. They had not seen her display any paranoia or heard her make any past accusations of people putting things into her drinks. She used a walker with a seat on to help her walk. She always carried her own cups by putting them on the walker. During an interview on [DATE] at 11:14 a.m., LPN (Licensed Practical Nurse) 5 indicated she had worked the evening of [DATE]. She had responded to the call for help when Resident 42 was found unresponsive. She had assisted in providing CPR until the EMT's arrived. She then stepped out of the room to gather paperwork to send with them. She found QMA 12 in the hallway hysterical and crying. She was saying something like why do they do this to each other. She was not sure why she was saying this and attempted to calm her down. She told me about Resident 42 reporting to her someone had slipped something into her drink. After the EMT's pronounced her dead, she informed one of them of that she had reported someone had slipped something into her drink. He informed her that he would be notifying the police department. During an interview on [DATE] at 1:52 p.m., QMA 12 indicated she had worked the evening on [DATE]. She was at the nursed station when Resident B and Resident 42 returned to the unit after smoking at around 9:15 p.m. She had been at her medication cart counting the narcotic medications. She had come to the desk and told me that she was not feeling well, and that Resident B had put something in her cup. He was there with her and holding her cup and commented that she had told him to hold her cup. Resident 42 then repeated that he had put something in her drink and that she did not feel well. QMA 12 had the narcotic medications out to count them, so she asked Resident 42 to go back to her room. QMA 12 then began putting the medications away so that she could inform the nurse of what she said, when Resident B came back out of her room and told QMA 12 that Resident 42 was on the floor. She entered the room and found Resident 42 on the floor in the bathroom. QMA 12 yelled for help and the other staff came to the room and began CPR. QMA 12 went to the phone and called 911. When the nurse came out of the room after the EMT's arrived, QMA 12 told the nurse about what happened. QMA 12 did not give medications to him that night. He had moved rooms, but he had not been officially moved in the computer system. During an interview on [DATE] at 8:00 p.m., Police Department Officer 15 indicated, that he had responded to a call at the facility on [DATE]. There had been a search warrant obtained for Resident B's room. During the search of his room, medications were found, which appeared to be prescription medications. The facility assessment, last revised on [DATE], was provided by Executive Director on [DATE] at 11:43 a.m. The assessment indicated the facility had zero residents with active or current substance use disorder and the number of residents with behavior health needs section was left blank. 7. The clinical record for Resident C was reviewed on [DATE] at 1:30 p.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. There was no substance abuse care plan regarding interventions or treatments to address his substancee abuse and he did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 8. The clinical record for Resident 9 was reviewed on [DATE] at 1:30 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A psychiatric progress note, dated [DATE], indicated he endorsed using marijuana for over [AGE] years. A [DATE] Trauma Screening indicated with a marked yes to the question on the screening tool, Resident 9 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . *Any symptomology (yes answers) should be assessed in the care plan. Resident 9's clinical record did not include a care plan that addressed the resident's drug or [CONDITION(S)] and he did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 11:50 a.m., the facility courtyard was randomly observed. Resident 9 was sitting in the facility courtyard smoking a cigarette. There were not staff members present in the courtyard with him. 9. The clinical record for Resident 2 was reviewed on [DATE] at 1:30 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated she had moderate cognitive impairment. A Nursing note for Resident 2, dated [DATE] at 2:07 p.m. indicated, Writer went to resident's room to request a urine drug screen. Resident was difficult to arouse. She said no in response to the drug screen. Writer gavre [sic, gave] the resident a refusal to sign and she was not able to sign it legibly. At that point it was determined that the resident may be impaired and should be assessed further. Resident 2 was sent to the emergency room . An observation of Resident 2 was made on [DATE] at 1:24 p.m. Resident 2 was found to be slow to react, groggy, lethargic, and unable to maintain a conversation without falling to sleep. An interview with LPN (Licensed Practical Nurse) 14 conducted on [DATE] at 1:34 p.m. indicated, she was told to hold all medications for Resident 2 for the day related to her being intoxicated. A Nursing note for Resident 2, dated [DATE] at 6:53 a.m. indicated, CNA [sic, Certified Nursing Aide] went to provide care and Resident 18ad 750 ml bottle of vodka in room, which about half of its contents was gone and resident also had large amount of emesis on self, bed and floor. A Nursing note dated [DATE] at 7:15 a.m. indicated, Resident 2's Nurse Practitioner was notified of Resident 2's alcohol consumption and all her medication orders were to be held for 24 hours. An interview with Resident 2 was conducted on [DATE] at 3:35 p.m. She indicated, she had gone on an overnight LOA (leave of absence) with her boyfriend. She admitted she had consumed alcohol while out of the facility. She stated, she did not remember bringing a bottle of Vodka back into the facility but,I know it's not allowed. She admitted to being talked to previously for alcohol consumption while living in the facility. A Social Services noted dated, [DATE] at 8:26 p.m. indicated, Resident 2 had attended a meeting with social services, the administrator, and her hospice provider which focused on Resident 2 going on LOA. It indicated, Resident 2 can go out for daytime LOA but, overnight LOAs were not recommended at this time. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] & medications (no narcotic medications) and the resident must have a urine drug screen done upon return. Resident 2's clinical record did not contain a urine drug screen result. A psychiatric evaluation note for Resident 2, dated [DATE] at 3:16 p.m. indicated, Patient states that she drank a fifth of Vodka for a lot of years and has lost count of when she had her last drink .She is a chronic alcoholic and has an extension medical history that includes: Alcoholism, Alcohol [CONDITION(S)] of the Liver with Ascites, Hepatic Failure .End Stage liver Disease .She is a polysubstance abuser. She admits that she has been doing drugs since the age of 20. Her drugs of choice were snorting cocaine 2 grams a day, snorting and injecting heroin 1 gram a day and going back and forth to the [MEDICATION(S)] clinics. After doing drugs and drinking alcohol for many years she ended up being homeless and living on the streets and was frost bitten. She lost both of her feet from frost bite and had to have them amputated in 2017. She has a psychiatric history of [CONDITION(S)] which she denies .She also stated that she was in an abusive relationship and suffers from [CONDITION(S)] [sic, Post Traumatic Stress Disorder]. She had a severely impaired ability to make reasonable decisions. An interview with NP (Nurse Practitioner) 7 was conducted on [DATE] at 10:42 a.m. NP 7 indicated, Resident 2 goes out on leave every day and she had told the facility to perform a drug test when she returns, but the facility does not do it. She indicated she had not been made aware of Resident 2 being intoxicated on [DATE] upon return to the facility. I don't understand why this wasn't reported to me, my guess is that they are being told not to tell me about it. Resident 2's care plan dated [DATE] indicated, she had a problem of being at risk for adverse effects from opioid use. The interventions included, but not limited to: will have no preventable complications from opioid use, encourage an adequate fluid and fiber intake to facilitate regular bowel movements, give medications as ordered, monitor effectiveness of medications, monitor vital signs as needed, particularly respirations, and report any observed adverse effects of opioid use to physician, including but not limited to: lethargy, dizziness, confusion, constipation, nausea, vomitting and respiratory depression/distress. Resident 2's care plan did not include an issue with alcoholism or polysubstance abuse. 10. The clinical record for Resident 15 was reviewed on [DATE] at 1:30 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A [DATE] Trauma Screening indicated with a marked yes to the question on the screening tool, Resident 15 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Comments .Has history of alcohol and crystal meth abuse. He suffers from depression. 12. *Any symptomology (yes answers) should be assessed in the care plan. Resident 15's clinical record did not include a care plan that addressed the resident's drug or [CONDITION(S)]. 11. The clinical record for Resident 20 was reviewed on [DATE] at 1:30 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 20 was admitted on [DATE]. An Admissions MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A [DATE] Trauma Screening indicated with a marked yes to the question on the screening tool, Resident 20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Comments .Resident 18as a history of .[CONDITION(S)] .12. *Any symptomology (yes answers) should be assessed in the care plan. A care plan dated [DATE] for Resident 20, indicated Resident 18as a history of substance abuse- Substance type: amphetamines .Resident will not obtain alcohol or illegal substances .Interventions: Allow resident time to express his feelings and concerns. Educate Resident 31n facility policies on the consumption of alcohol and illegal drugs. Educate Resident in the health risks when consuming illegal substances. Encourage community support. Notify SSD of any concerns. Provide resident with words of encouragement. 12. The clinical record for Resident 18 was reviewed on [DATE] at 1:30 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A [DATE] Trauma Screening indicated with a marked yes to the question on the screening tool, Resident 18 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Comments .He has abused heroin for [AGE] years. 12. *Any symptomology (yes answers) should be assessed in the care plan. A care plan for Resident 18 completed on [DATE] indicated Resident has a history of not following staff direction when its comes to being compliant with care and alcohol/drug use .Interventions: build resident's confidence and trust by having a quick and satisfactory respones to reasonable concerns, encourage family support, Encourage resident to voice feelings and other issues in an appropriate manner, Listen attentively to what Resident 18as to say, Notify MD, family, and SSD of changes in mood and behavior, offer reassurance and support, Refer to mental health services as needed, refer to SSD if necessary,Validate resident's feelings . 13. The clinical record for Resident 5 was reviewed on [DATE] at 2:10 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A care plan, last revised on [DATE], indicated Resident 5 can become combative and resistant to care. He would go LOA (Leave of Absence) outside the facility and bring back in alcohol and consume it in his room. He uses offensive language and curses at other residents and staff. The goal, initiated [DATE], was for him to have care given with the least amount of combative episodes through the next review. The interventions, initiated [DATE], are to approach him from the front and in a calm and friendly manner, explain what care is being provided before beginning and continually throughout care, if he becomes upset return at a later time to give care, provide a different staff member to provide care if he becomes combative, and validate his feelings. An intervention, initiated [DATE], was to search his room for alcohol related to history of drinking in room and falls during LOA. An intervention, added [DATE], was to not allow resident to go LOA unattended without family or caregiver to sign him out of the facility. A telehealth visit note, dated [DATE] at 4:16 p.m., indicated that Resident 5 presented with alcoholism. The staff reported that he had a fifth of vodka in his room under his pillow. All of his medications for the day were held and the bottle was retrieved and disposed of. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:27 a.m., Receptionist 16 provided Resident 5's Leave of Absence logs for [DATE] through [DATE], which indicated he had signed himself out on LOA on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 9:27 a.m., Receptionist 16 indicated that Resident 5 usually signs himself out to go the store. He walks to the store by himself. Sometimes, his sister comes and goes with him, but it's not very often. During an interview on [DATE] at 10:19 a.m., the RS indicated that Resident 5's clinical record did not contain a urine drug screen for [DATE]. 14. The clinical record for Resident 31 was reviewed on [DATE] at 10:45 a.m. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. A Quarterly MDS (Minimum Data Set) Assessment, completed [DATE], indicated he was cognitively intact. A care plan for Resident 31 dated [DATE] indicated Resident 18as a history of substance abuse-Substance type alcohol. Goal: Resident will not obtain alcohol or illegal substances by the next re-evaluation. Interventions: Allow resident time to express his feelings and concerns. Educate Resident 31n facility policies on the consumption of alcohol and illegal drugs. Educate Resident 31n the health risks when consuming illegal substances. Encourage community support. Notify SSD [Social Services Director] of any concerns. Provide resident with words of encouragement. A nursing progress note for Resident 31, dated [DATE] at 3:40 p.m., indicated .rounding with res for revisit resident stated that he has been drinking. smell of liquor on the breathe admitting to drinking all weekend. NP [Nurse Practitioner] 7 held medications for 24 hour. educated residence of risk of drinking while taking medications. Will continue to monitor. A Psych progress note for Resident 31, dated [DATE] indicated, .Patient [Resident 31] is complaining of being an alcoholic and is drunk.(History of Present Illness) HPI: [Resident 31] presenting to the facility for a aneurysm of the carotid artery after the patient slit his own throat. Patient admits that he has a problem with drinking and drinks a fifth a day. When he was out in the community, he became depressed and starting hallucinating auditory and visually. He became delusional and paranoid and took a knife to his throat. Today the patient is drunk. He got a pass from the facility to leave and went to get a bottle. He states that he needs help to stop drinking. This NP [Nurse Practitioner] 7 asked the nurse to obtain a urine and she stated that she would ask but the administrator states no urine test are to be done. This information was relayed to the doctor in charge. The staff can not tell us what the policy is on leaving and coming back intoxicated so the medications were held for 24 hr, a 1:1 [supervision] was given and 15 minute checks were initiated .He is a risk for suicidal ideation and homical ideation .His thought process is circumstantial, his concentration is impaired at times due to hearing voices, his recent memory is impaired and his long term memory is impaired. He has nightmares. His judgement is poor, and his insight on life is poor .Psych Hx [history]: Alcoholism, [CONDITION(S)], [CONDITION(S)], Anxiety, Restless, Agitation, [CONDITION(S)], Suicidal Ideation, Homicidal Ideation .Psychiatry Assessment: Intervention / Plan: 1. Generalized Anxiety - Increase [MEDICATION(S)] to 10 mg po TID, 2. Mood Disorder- [MEDICATION(S)] 100 mg 1 tab po BID, 3. [CONDITION(S)] - [MEDICATION(S)] 10 mg 1 tab po daily, 4. Hallucinations - [MEDICATION(S)] 0.5 mg 1 tab po at HS, 5. Nightmares - Prasozin 1 mg 1 tab po daily,6. Alcoholism - Suggest [MEDICATION(S)] 50 mg 1 tab po daily, 7. Prophylaxis - Congentin 1 mg 1 tab po daily . A Psych note for Resident 31 dated [DATE] indicated, .Staff reports that the patient is just walking around in the facility and has a attitude with everyone does not know why. He has a strong background history for drinking a fifth or more a day and went out on pass, brought alcohol and intoxicated himself a few days ago. He is not intoxicated this assessment but remains with a fractured pelvis and this provider instructed the charge nurse to obtain a xray of the pelvis because his pain medication which is scheduled for 10 days will expire and either be discontinued or prn. The patient is sneeking and drinking and admitted this to the nurse and the provider that he has a problem with drinking. As the provider, I would like to start the patient on [MEDICATION(S)] for his alcoholism. It is suggested that the staff and the provider educate the patient on the importance of not drinking while on [MEDICATION(S)] and taking pain medications. Patient voices an understanding so we will trial the [MEDICATION(S)] wit [TRUNCATED]

Based on interview and record review, the facility failed to conduct comprehensive pain assessments and address a resident's pain for 2 of 3 residents reviewed for pain management. This resulted in a resident's pain that was uncontrolled and had become severe. (Resident W and Y) Findings include: 1. The clinical record for Resident Y was reviewed on 3/23/22 at 9:30 a.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE] and discharged on [DATE]. An Admission MDS (Minimum Data Set) Assessment, completed on 1/28/22, indicated that he was cognitively intact. Hospital discharge paperwork dated 1/21/22 indicated a pain assessment was completed. Resident Y was in constant pain to right wrist, right ankle, and back. As of 1/17/22, .Patient [Resident Y] currently in [CONDITION(S)] crisis Patient has no complaints besides a generalized/joint achiness . The resident has current prescriptions of [MEDICATION(S)] and was to resume for pain control. The clinical record for Resident Y did not have a completed baseline careplan that includes a pain assessment for the resident's 1/22/22 admission. A care plan dated 2/2/22 indicated Resident Y had potential for pain Interventions meds a as ordered. notify MD [medical doctor] of uncontrolled pain. observe for effectiveness of intervention. observe for s/s [signs and symptoms] of pain. pain assessment upon admit, quarterly and prn [as needed]. A care plan dated 2/2/22 indicated At risk for adverse effects from opiod use .Interventions give medications as ordered . The vitals tab in the the resident's clinical record did no include recorded pain assessments on 1/22/22 and 1/23/22. A progress note dated 1/23/22 at 7:59 a.m., indicated Resident Y had no complaints of pain at that time. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A medical provider note dated 1/24/22 indicated Resident Y was admitted on [DATE] and has complaints of pain.He has a PMH [past medical history] of [CONDITION(S)] and takes [MEDICATION(S)] 20mg (sic) BID [twice a day] + [MEDICATION(S)] 20mg q4h [every 4 hours] prn for [CONDITION(S)] pain. He has been without his pain medication since he was admitted to the facility. He is currently having withdrawals, including shaking, sweats, and irritation .RX [prescription] sent for [MEDICATION(S)] and [MEDICATION(S)] . The clinical record did not indicate non-pharmacological interventions were attempted for pain control. The 1/24/22 Controlled Drug Receipt/Record/Disposition Form indicated Resident Y received his first dose of his scheduled 20 milligrams of [MEDICATION(S)] on 1/25/22 at 12:05 a.m. The EDK (Emergency Drug Kit) transaction form was provided by the Director of Nursing (DON) on 3/30/22 at 2:00 p.m. It indicated on 2/2/22 at 7:04 p.m., the staff had obtained 5 milligram tablet(s) of [MEDICATION(S)] for Resident Y. An interview was conducted with Resident Y on 3/29/22 at 2:20 p.m. He indicated he was in constant pain his whole life. He normally stays around a 3 in a pain scale of 1 being the least and 10 being the most. There was a delay in getting pain medications when he was admitted in the facility. By the time, the staff provided pain medications his pain had reached a severe level. An interview was conducted with License Practical Nurse (LPN) 23 on 3/30/22 at 10:24 a.m. She indicated the facility has a checklist for new admissions. The checklist includes: vitals, assessments which include skin and pain, and verifying medications with the discharge orders. If the nurse does not have a hard script to send to the pharmacy for the resident's narcotics; the staff should call the provider, and he or she will send them over electronically to the pharmacy. The staff should pull from the EDK if the resident's pain medication was not available. The baseline care plan should be completed in 48-72 hours, and it does include a pain assessment that should be completed on admission to assess the resident's pain. An interview was conducted with the DON on 3/31/22 at 11:18 a.m. She indicated she was unable to provide any additional dosages of 20 milligrams of [MEDICATION(S)] that was pulled from the EDK prior to the 2/2/22, administration for Resident Y. 2. The clinical record for Resident W was reviewed on 3/22/22 at 10:30 a.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, completed on 2/15/22, indicated that the resident was moderately cognitive impaired. A care plan dated 9/2/21 indicated Potential for alteration in comfort r/t [related to] decreased mobility neuropathic pain left lower extremity, [CONDITION(S)] brain damage .Interventions: .pain assessment on admission, with each MDS, and at least quarterly . A pain assessment for Resident W was completed on 11/12/21 indicated .C. Pain Interview. 1. Ask resident: 'Have you had pain or hurting at any time in the last 5 days?' [marked on form resident responded as yes] 2. Ask resident: 'How much of the time have you experienced pain or hurting over the last 5 days?' [marked on form resident responded as frequently] Pain assessment indicated the resident was a 4 using a pain scale of 1 being the least and 10 being the most in the last 5 days. The intensity of her pain in the last 5 days was moderate. A medical provider progress note dated 2/24/22 indicated .the staff reports that the patient is pale and her blood pressure is 90/65. We will obtain some baseline labs to see how the patient is doing .PICC [Peripherally inserted central catheter] placement for hydration status dehydration. A nursing progress note dated 2/25/22 indicated Resident W was to be sent to hospital. The clinical record did not include a comprehensive pain assessment that was conducted for Resident W when she had a change of condition nor readmission from the hospital. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Resident W on 3/22/22 at 10:44 a.m. She indicated her pain was always a 7-8 using a pain scale of 1 being the least and 10 being the most. An interview was conducted with the Director of Nursing (DON) on 4/1/22 at 8:50 a.m. She indicated a pain assessment should be done on admission, change of condition, readmission. She was unable to provide any additional comprehensive pain assessments that were conducted for Resident W when she had a change of condition nor readmission from the hospital. A pain assessment policy was provided on 3/24/22 at 10:15 a.m. It indicated Policy. Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and lift involvement A standard format for assessing, monitoring and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the 'fifth' vital sign at the facility, .For the purpose of this policy, pain is defined as 'whatever the experiencing person says it is, existing whenever person says it does'. Procedure .3. Nursing involvement A. Pain assessment - completed upon admission, readmission, each MDS assessment and change of resident condition. The Comprehensive Pain assessment measures the impact of pain on the resident's function assessing the resident's physical condition, history, mental status and ADLS's [activities of daily living] . A baseline care plan policy was provided by the DON on 3/24/22 at 9:47 a.m. It indicated Policy: It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of admission. The Baseline Care Plan is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .Procedure: 1. Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concern .c. In the event that the resident is admitted over the weekend (Friday Admissions after 5:00 p.m.) and the IDT [interdisciplinary] Team is not available to participate in the completion and implementation of the Baseline Care Plan, it will be the responsibility of the admitting nursing staff and the scheduled in-house weekend manager to ensure that the Baseline Care Plan is completed and implemented within 48 hours . This Federal tag relates to complaint IN 908. 3.1-37(a)

Based on interview and record review, the facility failed to timely administer fluids as ordered to a resident showing signs and symptoms of dehydration for 1 of 1 residents reviewed for hydration. This resulted in delayed treatment and resident was discharged to hospital. (Resident W) Findings include: The clinical record for Resident W was reviewed on 3/22/22 at 10:30 a.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, completed on 2/15/22, indicated that the resident was moderately cognitive impaired. Resident W's blood pressure was recorded on 2/23/22 at 2:05 p.m., as 74/56 and 2/24/22 at 11:10 a.m., as of 101/67. A medical provider progress note dated 2/24/22 at 1:30 p.m. indicated .the staff reports that the patient [Resident W] is pale and her blood pressure is 90/65. We will obtain some baseline labs to see how the patient is doing .Obtain the following labs - CMP [Comprehensive Metabolic Panel], Ammonia level, Vit [Vitamin] D, [MEDICATION(S)] level, CBC with diff [Complete Blood Count with differential], liver function, renal panel, lipid panel, PICC [Peripherally inserted central catheter] placement for hydration status dehydration - Sodium Chloride 0.9% Use 65 ml/hr [milliliter/hour] intravenously every 24 hours for dehydration for 3 days . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 2/24/22 at 4:14 p.m., indicated nursing staff had made arrangements with the intravenous team for Resident W's PICC line to be placed. A nursing progress note dated 2/24/22 at 4:49 p.m., indicated Res [Resident W] seen by NP [Nurse Practitioner] chief complaint nausea and weakness. NP ordered stat [urgent] labs and IV [intravenous line] normal saline. Vitals 90/68 B/P [blood pressure], 117 pulse .Normal Saline 1000 @ [at] 65ml/hr for 72 hours pending stat lab results. Will continue to monitor resident. A medication administration note dated 2/24/22 at 6:30 p.m., indicated nursing staff was unable to administer fluids waiting for the resident's PICC line to be placed. The resident's clinical record did not indicate the physician was notified the fluids were unable to be administered. An intravenous consult dated 2/24/22 indicated the intravenous team arrived at 10:30 p.m., and left the facility at 11:20 p.m. Resident W had received a PICC line and confirmation was needed by x-ray prior to use. The resident's clinical record did not include an x-ray was ordered for confirmation of resident's PICC line. The lab results dated 2/25/22 faxed at 7:31 a.m., indicated elevated Blood Urea Nitrogen (BUN) of 24 mg/dl (milligrams/deciliters) using a reference range of 7-17 mg/dl and elevated Creatinine level of 1.09 mg/dl using a reference range of 0.52-1.04 mg/dl. A nursing progress note dated 2/25/22 at 11:40 a.m., indicated, Unable to give resident fluids at this time due to PICC line placement not verified. Res BP low, continue to push liquids. NP notified n.o. [new order] received to send resident to hospital. resident transferred to hospital per 911. An interview was conducted with the Director of Nursing on 4/1/22 at 12:00 p.m. She indicated after Resident W had received her PICC line , the nursing staff should have obtained an x-ray to verify placement. The x-ray was missed and never ordered. The hospital records were provided by the Regional Support on 4/1/22 at 1:00 p.m. The hospital records dated 2/25/22 indicated Resident W was seen at 12:20 p.m., that day and received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-46

Based on interview and record review, the facility failed to provide ongoing assessment to a cognitively impaired resident after an unwitnessed fall and administer their [CONDITION(S)] medication, as ordered, resulting in a hospitalization with break through [CONDITION(S)] for 1 of 3 residents reviewed for hospitalization . (Resident T) Findings include: The clinical record for Resident T was reviewed on 3/22/22 at 1:33 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/20/22 Quarterly MDS (Minimum Data Set) assessment indicated she was severely cognitively impaired. The seizures and at risk for injury related to tremors and/or [CONDITION(S)] activity care plan, revised 8/31/20, indicated an intervention was to provide medications as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The January, 2022 MAR (medication administration record) indicated the [MEDICATION(S)] was not administered the evening of 1/28/22 or the morning of 1/29/22 with entry codes indicating to see the nurse's notes for the reasons the medication was not administered. The 1/28/22, 4:36 p.m. electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The note read, [MEDICATION(S)] Tablet 300 MG Give 2 tablet by mouth every 12 hours related to OTHER SEIZURES (G40.89) on order. The 1/29/22 at 11:52 a.m. electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The note read, [MEDICATION(S)] Tablet 300 MG Give 2 tablet by mouth every 12 hours related to OTHER SEIZURES (G40.89) NEED TO BE REORDER. The 1/29/22, 7:07 a.m. nurse's note, written by RN (Registered Nurse) 18, indicated Resident T had an unwitnessed fall that occurred between the 2 missed administrations of [MEDICATION(S)]. The note read, Resident found lying on ground between bathroom and room door laying on side, resident able to move extremities WNL [within normal limits,] resident unable to state what happened, vitals WNL, resident placed back into bed, bed placed in lowest position call light with in reach, condition currently stable, husband and MD notified will continue to monitor and update as needed. RN 18 was agency staff who was unavailable for interview. There was no verification in the clinical record that neurological checks or follow up assessments were conducted after Resident T's fall. An interview was conducted with the DON (Director of Nursing) on 3/30/22 at 2:25 p.m. She indicated she looked into Resident T's 1/29/22 fall to see if there was anymore information about it, but she was unable to locate any. There was no accident report, no verification of neurological checks, and no 72 hour follow up. All of those things should have been done after her fall. The 1/29/22, 3:56 p.m. nurse's note read, Patient was sent out per nurse due to health issues steaming [sic] from possible seizures. The 1/29/22, 7:34 p.m. nurses note, written by RN 17, read, Resident had kept displaying an altered mental mind state according to staff members that are familiar with her. When this writer accessed [sic] he had noticed that resident was constantly shaking and her BP [blood pressure] and Pulse were elevated 169/107 [BP]-114 [pulse]-97.5 [temperature]-20-97% R/A [oxygen saturation on room air.] NP [Nurse practitioner] notified and orders were given to send to [name of hospital] ER [emergency room ] for Eval [evaluation] and treatment. 911 was called and they took her to the ER around 3pm, DON and family notified. RN 17 was agency staff who was unavailable for interview. The 1/29/22 to 1/30/22 hospital notes read, Chief Complaint with Duration: Altered mental status and fall .Apparently patient fee [sic] in the morning at ECF [extended care facility] and later in the day staff concerned her mental status was altered so sent to the hospital. Unfortunately tried called ECF to get more info [information] but no one picked up, patient unable to provide any hx [history] fu [follow up] to baseline [CONDITION(S)]. In the ED [emergency department] noted to be hypoxic requiring 2-3 liters 02, also concerns for focal seizures by ED so loaded with [MEDICATION(S)] and received 1 mg IV [intravenous] [MEDICATION(S)] Assessment/Plan: .[CONDITION(S)] disorder Break through [CONDITION(S)]. Neurology consulted. [MEDICATION(S)] load. Continue with [MEDICATION(S)] [[MEDICATION(S)]] and [MEDICATION(S)]. The Incidents/Accidents/Falls policy was provided by the DON on 3/29/22 at 1:30 p.m. It read, After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management (usually Risk Management section of electronic health record). The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated, and resolved. Procedure: .Further, residents who have an unwitnessed fall must have neuro checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed fall. 3 The nurse responsible for the oversight and care of the resident will complete an incident/accident report. When possible, a descriptive statement(s) will be obtained from the resident and/or any witnesses 6. The incident/accident report will be completed as soon as information is obtained. The report should be finished as much as possible before the nurse ends the shift. The nurse who completes the report is the nurse who signs the report. An exact description of the circumstances (not opinion or conjecture) surrounding the incident/accident are to be documented 9. Documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over the next 72 hours or until the resident(s)'s condition improves. Neuro checks will be completed after any head trauma as well as after any unwitnessed fall (even if the resident states they did not hit their head) as per policy 11. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. The Medication Administration policy was provided by the DON on 3/29/22 at 12:15 p.m. It read, Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration. Policy: Unless otherwise specified by the physician, medications will be administered within 60 minutes before or after the facility's dosing schedule, except before or after meal orders and non-routine time ordered medications. This Federal tag relates to Complaint IN 439. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely provide Covid-19 vaccination to 2 residents and have documentation education was provided regarding the benefits and potential side effects of the Covid-19 vaccine, and that the resident (or representative) either accepted and received or did not receive the vaccine for 10 residents who wanted vaccinated of 38 residents in the facility and 3 of 7 Covid-19 positive residents who transferred out of the facility. (Residents B, C, D, F, G, H, J, L, N, P, Q, R, S, and Z) The Immediate Jeopardy began on 8/25/21, when Resident C had a care plan meeting requesting to be offered the Covid-19 vaccination and the facility did not take immediate action to provide vaccination. The Director of Nursing (DON) and the Nurse Consultant (NC) were notified of the Immediate Jeopardy on 9/10/2021 at 4:10 p.m. The immediate Jeopardy was removed on 9/13/2021 at 3:15 p.m., but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The clinical record for Resident C was reviewed on 9/10/21 at 12:37 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted to the facility on [DATE]. The Immunization Report did not include any information regarding the Covid-19 vaccination, whether she accepted and received or did not receive it. On 9/10/21 at 10:45 a.m., the NC (Nurse Consultant) provided the Covid-19 vaccination education information provided to Resident C. There was a note at the top that read, Son consented 8/24/21 CP [care plan] meeting. The 8/25/21, 12:31 p.m. social services note read, During meeting resident's family requested that she be offered the vaccine for Covid-19. An interview was conducted with the SSD (Social Services Director) in the presence of the MDS (Minimum Data Set) Coordinator and DON (Director of Nursing) on 9/10/21 at 11:56 a.m. She indicated there was a care plan meeting with Resident C's son, and he indicated he wanted Resident C vaccinated against Covid-19. An interview was conducted with the MDS Coordinator in the presence of the SSD and DON on 9/10/21 at 11:56 a.m. She indicated Resident C was not vaccinated after her care plan meeting, because they were unsure as to how to get her vaccinated. She stated, We were unaware of how to get residents vaccinated at that time. The ED wanted a clinic versus sending them out. I don't understand why this facility can't get the doses and administer ourselves. She'd worked at other facilities, and that's what they did. An interview was conducted with the DON in the presence of the SSD and MDS Coordinator on 9/10/21 at 11:56 a.m. He indicated the information from Resident C's care plan meeting about Resident C and her son wanting her vaccinated should have been given to him and it wasn't. They didn't know how to get residents vaccinated with working out all of the details, like transportation. He expressed to corporate the previous Friday (9/3/21) that the vaccine needed to get into the facility. An interview was conducted with Resident C on 9/10/21 at 11:15 a.m. She indicated she wanted the Covid-19 vaccination. 2. The clinical record for Resident B was reviewed on 9/9/21 at 11:58 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the facility on [DATE]. The Immunization Audit Report indicated Resident B refused the Covid-19 vaccination on 4/19/21. An observation was made on 9/9/21 at 11:32 a.m. at the nurse's desk. Resident B walked up to the DON (Director of Nursing) and inquired about the status of his ability to receive the Covid-19 vaccination. The DON informed him they were working it and would let him know. An interview was conducted with the DON on 9/9/21 at 11:32 a.m. He indicated Resident B informed him several days ago, that he wanted vaccinated against Covid-19. An interview was conducted with Resident B on 9/9/21 at 11:53 a.m. He indicated he refused the Covid-19 vaccination a while back, because he didn't like shots and heard he would have to have multiple shots, but since the Delta variant and it being more deadly, he now wanted vaccinated and had been asking for it for about 2 weeks. An interview was conducted with the DON, VPO (Vice President of Operations), and the ED (Executive Director) on 9/9/21 at 12:38 p.m. The DON indicated he was unsure as to why there was a delay in getting Resident B vaccinated. He stated, I haven't made an appointment for [name of Resident B] and am not aware that anyone else has either. Resident B's roommate, Resident K, tested positive for Covid-19 from a 9/7/21 PCR (polymerase chain reaction) test with results on 9/9/21. 3. An interview was conducted with the NC (Nurse Consultant) on 9/10/21 at 10:21 a.m. She indicated they could not locate Covid-19 vaccination consent forms for residents, so they went around yesterday (9/9/21) and asked all of the residents if they wanted vaccinated, and there were quite a few who said yes. On 9/10/21 at 10:32 a.m., the NC provided a list of residents who indicated wanting vaccinated on 9/9/21. The list included Resident J, Resident C, Resident L, Resident G, Resident N, Resident P, Resident H, Resident Q, Resident R, and Resident S. Documentation education was provided regarding the benefits and potential side effects of the Covid-19 vaccine, and that the resident (or representative) either accepted and received or did not receive the vaccine was requested for the above 10 residents. The NC provided this information on 9/10/21 at 1:00 p.m. The documentation for Residents J, L, G, N, P, H, Q, R, and S were all dated 9/9/21. An interview was conducted with Resident S on 9/10/21 at 11:00 a.m. He indicated the facility had never offered him the Covid-19 vaccination before yesterday, 9/9/21. An interview was conducted with Resident R on 9/10/21 at 11:05 a.m. He indicated yesterday, 9/9/21 was the first time the facility had offered him the Covid-19 vaccination. An interview was conducted with Resident Q on 9/10/21 at 11:17 a.m. She indicated yesterday, 9/9/21, was the first time the facility offered her the Covid-19 vaccination. An interview was conducted with Resident H on 9/10/21 at 11:20 a.m. He indicated the facility had not offered him the Covid-19 vaccination until yesterday, 9/9/21. An interview was conducted with Resident L on 9/10/21 at 11:25 a.m. She indicated she had never been offered the Covid-19 vaccination in the facility until yesterday, 9/9/21. 4. During interview with the DON (Director of Nursing) and ED (Executive Director) on 9/8/21 at 11:45 a.m., the ED indicated the facility's Covid-19 vaccination rate amongst residents and staff was about 30%. The facility was currently in an outbreak with 8 residents and 5 staff testing positive for Covid-19 since 8/23/21. All of the positive residents transferred to a sister facility and the remaining residents were all in transmission-based precautions in an attempt to contain the spread. Of the 8 positive residents, 5 of them were unvaccinated, including Residents D, F, and Z. Residents D, F, and Z were already transferred to a sister facility for being positive. The facility was unable to provide documentation education was provided to the 3 residents regarding the benefits and potential side effects of the Covid-19 vaccine, and that the resident (or representative) either accepted and received or did not receive the vaccine. An interview was conducted with the ED on 9/9/21 at 1:36 p.m. She indicated there was a local pharmacy from which she'd completed 2 clinic interest forms, the last time approximately 3 weeks ago, and returned them indicating no interest. The Offer for Covid-19 Vaccine Administration policy was provided by the DON on 9/9/21 at 2:55 p.m. It read, It is the policy of this facility to offer and to make available, (to the best of their ability considering supply and demand and preferences), approved Covid-19 vaccines to the resident who reside in the facility and to the staff who work in the facility.

Based on observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 by not ensuring residents in droplet transmission precautions were 6 feet apart during a smoking activity. Resident K was present at the smoking activity and tested positive for COVID-19 via a PCR [polymerase chain reaction] test obtained on 9/7/21, with results received on 9/9/21, potentially exposing the 5 other residents that were within 6 feet of him during the smoking activity to Covid-19. The facility also failed to ensure the appropriate personal protective equipment (PPE) was utilized in residents' rooms who were in droplet/contact isolation; residents in contact droplet transmission based precautions properly wore masks while outside of their rooms; staff properly wore PPE; staff performed Covid-19 screening prior to allowing entry into the facility; and provide staff Covid-19 testing timely per county positivity rates for 5 of 5 staff sampled for Covid-19 screening, 1 of 1 staff member randomly observed, and 2 of 3 unvaccinated staff sampled for Covid-19 testing. (Housekeeper 2, Housekeeper 10, Housekeeper 24, Licensed Practical Nurse 9, Registered Nurse 20, Housekeeper 2, Licensed Practical Nurse 9, Resident K, Resident J, Resident T, Resident V, Resident W and Resident X) The Immediate Jeopardy occurred on 9/8/21 at 1:00 p.m., when Residents' K, J, T, V, W and X were in the facility's courtyard at a scheduled smoking activity when they were currently in droplet transmission precautions while the facility was in outbreak testing. The staff present did not ensure those residents were 6 feet apart during the activity. The Director of Nursing (DON) and the Nurse Consultant (NC) were notified of the Immediate Jeopardy on 9/10/2021 at 4:10 p.m. The immediate Jeopardy was removed on 9/13/2021 at 3:15 p.m., but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: An interview was conducted with the DON on 9/8/21 at 11:15 a.m. He indicated all the residents in the facility were in droplet transmission precautions in the facility. They were currently in outbreak testing due to positive staff and residents. All activities had been stopped except for the scheduled smoking activity. The residents are 6 feet apart during the activity. The smoking activity times were provided by the DON on 9/8/21 at 11:30 p.m. The residents were scheduled to smoke at 9:00 a.m., 1:00 p.m., and 6:00 p.m. An observation was made of a scheduled smoking activity on 9/8/21 at 1:00 p.m. The residents were observed lined up in the hallway for the scheduled smoking activity, and then entered the outside courtyard from the hallway with two staff persons present. Resident K, T, and V propelled themselves in their wheelchairs to the left side of the courtyard until they all had reached the end of the sidewalk. At that time, they parked themselves next to each other. Resident K was observed to be positioned in the middle of Resident T and V. Resident J and X walked and sat on a bench on the same side of the courtyard as Resident K, T and V. The staff stood on the right side of the courtyard speaking to one another by a resident in a wheelchair, and another resident was standing at the backside of the courtyard. All the residents removed their masks and began smoking. During that time, Resident J was observed handing his lit cigarette to Resident X. Resident X utilized Resident J's cigarette to light her own cigarette, and then handed it back to him. Resident W then entered the courtyard with his face mask below his nose and walked and stood next to Resident K, T and V. Resident K was observed propelling himself in his wheelchair back and forth on the sidewalk within 6 feet of Residents T, V, X, J and W. Resident's K, T, V, X, J and W were not observed to be 6 feet apart during the activity. There was no observation of the staff addressing the residents that were not appropriately distanced. An observation was made with License Practical Nurse (LPN) 1 of the remaining 1:00 p.m., smoking activity on 9/8/21 at 1:13 p.m. LPN 1 indicated at that time Resident K, T, V, X, J and W were not 6 feet apart in the activity as they should be. She would speak with them. 1. The clinical record for Resident K was reviewed on 9/8/21 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident K was unvaccinated. An Admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident K was moderately impaired. A care plan for Resident K dated 6/22/21 indicated Resident is a smoker, at risk for injury .resident will be supervised during smoking . 2. The clinical record for Resident X was reviewed on 9/8/21 at 2:10 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident X was unvaccinated. A care plan dated 8/4/21, indicated Resident X was moderately cognitively impaired. Interventions .Resident requires minimal involvement in daily decision making and activity (specify: limit choices, use cueing, task segmentation, written lists, instructions) . A care plan dated 8/24/21, indicated Resident X was a smoker that would be provided supervision during the activity. A care plan dated 9/8/21, indicated Resident X prefers not to wear a mask/shield at times. She/he may not wear it correctly. She/he is reminded and encouraged to wear a mask for their (sic) and others' safety to prevent infection .Interventions .observe for social distancing, move 6 ft [feet] from other residents as able . 3. The clinical record for Resident V was reviewed on 9/8/21 at 2:20 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident V was unvaccinated. A care plan dated 8/23/21 indicated the resident smoked and supervision would be provided during the activity. 4. The clinical record for Resident T was reviewed on 9/8/21 at 2:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident T was unvaccinated. A Quarterly MDS assessment dated [DATE], indicated Resident T was cognitively intact. A care plan dated 8/10/21 indicated Resident T was a smoker and would be supervised when he participated in the activity. 5. The clinical record for Resident J was reviewed on 9/8/21 at 2:40 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident J had received his first dose of the COVID-19 vaccine on 6/25/21. He was not fully vaccinated. A Quarterly MDS assessment dated [DATE], indicated Resident J was moderately impaired. A care plan for Resident J dated 8/17/21, indicated he was .increase risk for developing a serious illness from COVID-19 .Interventions .Transmission-Based Precautions (Contact and/or Droplet Isolation): Respiratory, until discontinued by the physician . A care plan dated 9/8/21 indicated Resident is a smoker .Interventions .resident will be supervised during smoking . A care plan dated 9/8/21 indicated Resident insists on visiting with other residents when yellow zone, isolation protocol is in effect .Interventions .Reminders to wear mask and wear mask correctly if noted not covering his mouth or nose. Reminders for social distancing at least 6 feet apart, even when smoking . 6. The clinical record for Resident W was reviewed on 9/8/21 at 2:50 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident W was fully vaccinated. A Quarterly MDS assessment dated [DATE], indicated Resident W was cognitively intact. A care plan dated 1/13/21 indicated Resident is a smoker .Interventions .resident will be supervised during smoking . A care plan dated 9/8/21 indicated Resident insists on visiting with other residents when yellow zone .Interventions .reminders for social distancing at least 6 feet apart, even when smoking . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plans for Resident K, X, T, V and W dated 8/31/21, indicated Preventative Isolation Precautions .is at risk for developing a transmission-based infection (COVID-19), which could result in untoward outcomes such as Pneumonia and/or Acute Respiratory Distress. The resident has the following Co-Morbidities which can increase risk for developing a serious illness from COVID-19: .Unit: Yellow Zone Protocol .Interventions .Transmission-Based Precautions (Contact and/or Droplet Isolation): Respiratory, until discontinued by the physician . A lab report dated 9/9/21 indicated Resident K had tested positive for COVID-19. An interview was conducted with the DON on 9/9/21 at 11:20 a.m. He indicated he had received the test results that morning for Resident K that was obtained on 9/7/21 via PCR testing. The resident had tested positive for COVID-19 and had been discharged to a COVID facility that day. The Guidance for Wearing Masks policy was provided by the DON on 9/9/21 at 8:55 a.m.Situations where wearing a mask may not be possible. Make sure to maintain physical distance from others when you cannot wear a mask . The COVID-19 LTC [Long Term Care] Facility Infection Control Guidance Standard Operating Procedure dated 6/22/21 indicated .The best way to protect yourself and to help reduce the spread of the virus that cause COVID-19 is to limit your interactions with other people as much as possible and take precautions to prevent getting COVID-19 when you do interact with others. Those steps include wearing a face covering, maintaining social distance of 6 feet, and sanitizing your hands frequently .Activities . Residents in outbreak testing, yellow and red zones may not participate in communal activities .If any one person congregates in group activity .and is not fully vaccinated, all residents should wear facemask during the activity and unvaccinated persons must physically distance [greater than] 6 feet . 7a. An interview was conducted with the DON on 9/8/21 at 11:15 a.m. He indicated all the residents in the facility were in droplet transmission precautions in the facility. They were currently in outbreak testing due to positive staff and residents. An observation was made of Certified Nursing Assistant (CNA) 5 delivering room trays at the lunch meal on 9/8/21 at 11:55 a.m. CNA 5 was observed standing in the hallway with a gown on, N95 mask, and face shield at the food cart. She then grabbed a food tray from the cart and walked into Resident W's room. There was a sign on the resident's door indicating the residents in the room were in contract/droplet precautions. CNA 5 was observed placing the food tray on Resident W's bedside table and using her bare hands setting up the food items and, on his tray, and moving items off the bedside table. She had not used hand hygiene or donned gloves prior to entering the resident's room. After, CNA 5 left the resident's room and went to a wall in the hallway and used hand sanitizer. She then went to the food cart and retrieved another food tray and walked into the same room and delivered that food tray to Resident T. At that time, she was observed wearing a N95 mask, face shield and the same gown she had on delivering Resident W's tray at his bedside. There was no observation of donning gloves prior to entering the resident's room. After setting up the food tray and moving items off bedside table for Resident W with her bare hands, she left the resident's room without doffing her gown and returned to the food cart. There was no hand hygiene observed after leaving Resident W's room. CNA 5 then grabbed another food tray and delivered a food tray to Resident V. The resident's door had a sign on it indicating the resident was in contact/droplet precautions. CNA 5 was observed wearing N95 mask, face shield, and the same gown she was wearing in Resident T and W's room. She then left Resident V's room wearing the same gown and returned back into Resident T and W's room. There was no hand hygiene observed prior to returning back into Resident T and W's room nor donning a new gown. She then was observed at the bedside of Resident T. After, CNA 5 then doffed her gown and walked back into the hallway. There was no observation of hand hygiene after the doffing of the gown. An interview was conducted with CNA 5 on 9/8/21 at 12:05 p.m. She indicated the PPE supply was good. She was told she was able to wear the same gown in the residents' rooms that were in isolation as long as she was just delivering food trays. 7b. The clinical record for Resident N was reviewed on 9/8/21 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident N was unvaccinated. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made of LPN 3 in Resident N's room on 9/8/21 at 12:19 p.m. Resident N's door had a contact/droplet transmission precaution sign on her door. LPN 3 was observed at the bedside speaking with the resident. She had not donned on a gown prior to entering the room. An interview was conducted with the DON on 9/8/21 at 3:30 p.m. He indicated the staff should be donning the appropriate PPE prior to entering the rooms as noted on the transmission precaution signs. A contract droplet transmission-based precaution signage was provided by the DON on 9/8/21 at 4:00 p.m. It indicated Yellow Zone. Transmission Based precautions. Contact Droplet. PPE required: N95 mask - Approved KN95. Universal Eyewear: Faceshield or goggles. Single gown - with each encounter. Gowns Must Be Single Use Per Resident. If Crisis Capacity - follow this rule one gown per each staff member, per each resident, per shift. Gloves (hand hygiene donning/doffing). The COVID-19 Zone Guidelines dated 4/5/21 was provided by the DON on 9/9/21 at 8:55 a.m. It indicated .I. Scope a. The scope of this guidelines includes all interdisciplinary members, visitors, and individuals that partake in the resident plan of care .B. Yellow Zone (Potentially/presumed positive .potentially or directly exposed) .1.) Gown, N95 mask, faceshield or goggles gloves as usual. 2.) Gowns cannot be worn throughout unit and must be changed from resident to resident .7.) All patients in the Yellow Zone should have a sign on their door indicating their zone and the proper PPE to be worn upon entering the room . 7c. On 9/8/21 at 10:55 a.m., Resident X was randomly observed standing at the front desk bending over her rollator. She was not wearing a mask and talking to the Receptionist. The Receptionist did not educate her to don a mask while out of her room. She then was taken back into the Social Service Director's office. She did not have a mask on when she went into the office. 7d. On 9/8/21 at 10:55 a.m., Resident W was randomly observed standing in the hallway outside of the Social Service office behind the front desk. His surgical mask was below his nose. He went to the front of the desk, where the Receptionist was sitting, and told Resident X to come back to an office so that the staff could help her. He then went by the front desk and lowered his mask to speak to people in the lobby and went through a door to the units. Staff did not educate him on placing his mask above his nose. During an interview on 9/8/21 at 12:20 p.m., the Social Service Director indicated Resident W had come to her office to talk with her, and she had not noticed if she had a mask on while she was talking with her. The residents should be wearing face masks while outside their rooms and that the staff continue to remind them to wear their masks. 7e. A random observation was made of Housekeeper 2 and Housekeeper 4 on 9/8/21 at 12:05 p.m. Housekeeper 2 and 4 was observed in an unoccupied room with a sign on the door indicating it was in droplet/contact transmission precautions. During that time, they were cleaning and talking to one another. Housekeeper 2 was wearing a surgical mask below her nose with a face shield, and Housekeeper 4 was wearing a N95 mask, face shield and gown. Housekeeper 2 and Housekeeper 4 was less than 6 feet apart during their conservation. During an interview on 9/8/21 at 12:05 p.m., Housekeeper 2 indicated she did not think about changing to a N95 mask and putting on a gown when she came from the laundry to assist with cleaning the room. 7f. The clinical record for Resident HH was reviewed on 9/8/21 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made of Housekeeper 2 in Resident HH's room on 9/8/21 at 12:45 p.m. Resident HH's room was observed to have signage on the door indicating he was in droplet/contact isolation. Housekeeper 2 was in Resident HH's room removing trash in the resident's bathroom. She had not donned on a gown at that time. 8a. On 9/9/21 at 9:15 a.m., the BOM (Business Office Manager) provided the Employee Screening Tool for Covid 19 for 8/10/21 through 9/8/21. On 9/9/21 at 9:15 a.m., the BOM provided the Archived Timecard Report for Housekeeper 10, which indicated he had worked in the facility on 8/19/21 and 8/23/21. The Employee Screening tool did not contain information that screening had been performed for him prior to entering the facility on 8/19/21 and 8/23/21. During an interview on 9/8/21 at 11:45 a.m., the DON indicated that Housekeeper 24 had tested positive for Covid-19 on 8/23/21. 8b. The Archived Timecard Report for Housekeeper 10 indicated she had worked in the facility on 8/16/21, 8/19/21, and 8/20/21. The Employee Screening Tool did not contain information that screening had been performed for her prior to entering the facility on 8/16/21, 8/19/21, or 8/20/21. During an interview on 9/8/21 at 11:45 a.m., the DON indicated that Housekeeper 10 had tested positive for Covid-19 on 8/24/21. 8c. The Archived Timecard Report for LPN (Licensed Practical Nurse) 9 indicated she had worked in the facility on 8/25/21. The Employee Screening Tool did not contain information that screening had been performed for her prior to entry of the facility on 8/25/21. 8d. The Archived Timecard Report for Housekeeper 2 indicated she had worked in the facility on 9/3/21 from 3:37 p.m. until 8:01 p.m. The Employee Screening Tool indicated screening for Covid 19 had not been performed on 9/3/21 until 7:00 p.m. On 9/4/21 she had worked in the facility from 2:30 p.m. until 8:26 a.m. Covid 19 Screening had not been performed until 8:00 p.m. 8e. The Nursing Schedule indicated that RN 20 had worked in the facility on 8/25/21, 8/27/21, 8/29/21, 9/4/21, and 9/5/21. The Employee Screening Tool did not contain information that screening had been performed for her prior to entry to the facility on [DATE], 8/27/21, 8/29/21, 9/4/21, and 9/5/21. On 9/8/21 at 12:30 p.m., the DON provided the Infection Control: Covid-19 Prevention, Surveillance and Education Guidelines Policy, effective date 3/4/2020, which read .b. Surveillance i. All persons entering the facility will be asked to provide information requested on the Infection Screening Tool prior to entry to any resident area. This includes a body temperature. ii. If 'yes' is answered to any question on the Infection Screening Tool and / or a temperature above 100, entrance to the resident areas will be restricted . 9a. On 9/9/21 at 3:30 p.m., the NC (Nurse Consultant) provided the Covid-19 routine test results from 8/1/21 through 9/1/21 for the following unvaccinated staff members: Housekeeper 2 and LPN 9. She indicated that the facility does routine Covid-19 testing for staff per the county positivity rate. Housekeeper 2 had [CONDITION(S)]-CoV-2 POC (Point of Care) test results present for 8/5/21, 8/17/21, 8/19/21, and 8/25/21. There were no test results provided for the week of 8/8/21 through 8/14/21. The CMS (Center for Medicare and Medicaid Services) County Positivity Rate of Covid-19 for the Week of 8/8/21 was 9.4 percent, indicating weekly testing of non-vaccinated staff was required. 9b. LPN 9 had [CONDITION(S)]-CoV-2 POC (Point of Care) test results present for 8/12/21 and 8/24/21. A PCR (nasopharyngeal) Covid-19 test result was provided for 8/31/21. There were no test results provided for the week of 8/1/21 through 8/7/21. The CMS County Positivity Rate for Covid- 19 for the Week of 8/4/21 was 7.7 percent, indicating weekly testing of non- vaccinated staff was required. There were no test results provided for the week of 8/15/21 through 8/21/21. The County Positivity Rate for Covid-19 for the week of 8/17/21 was 10.8 percent, indicating twice weekly testing of non- vaccinated staff was required. On 9/8/21 at 2:30 p.m., the DON provided the COVID-19 Testing Protocol, revised 8/3/2020, which read . It is the goal of the facility to detect and contain possible infections as early as possible . All state and federal COVID-19 testing mandates will be followed. On 9/13/21 at 2:15 p.m. the CMS Memo, revised 4/27/21, was retrieved the CMS website and reads .Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . 3.1-18(a) 3.1-18(b)(1) 3.1-18(l)