Every finding on record at Addison Pointe Health & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure medications were stored appropriately related to nystatin powder, insulin pens were not used past the expiration date, and over the counter medications were labeled correctly for 2 of 2 residents observed with medications in their rooms and for 2 of 4 medication carts observed. (Residents 42 and 9, the 100 hall and 400 hall medication carts)Findings include:1. During a random observation on [DATE] at 9:30 a.m., Resident 42 was observed in bed. At that time, there was a small plastic medication cup filled to the top of white powder on her dresser. During an interview at that time, the resident indicated the nurse had brought some Nystatin powder for her rash under her breasts and left it there so she could apply it herself. The record for Resident 42 was reviewed on [DATE] at 1:21 p.m. Diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, type 2 diabetes, heart failure, high blood pressure, and acute kidney failure. The [DATE] Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no care plan indicating the resident could self-administer her own medications. A Care Plan, dated [DATE], indicated the resident had a skin integrity impairment under her breasts related to excessive moisture. A Skin/Wound Note, dated [DATE], indicated the resident had moisture associated skin damage (MASD) under the left breast. The wound bed was red and excoriated under the breasts. A Physician's Order, dated [DATE], indicated Nystatin Powder 100,000 units, apply under both breasts topically every day and evening shift for 14 days. There was no order to leave the powder in the resident's room so she could apply it herself. During an interview on [DATE] at 3:00 p.m., the Director of Nursing indicated the resident should have an order and an assessment to apply the powder herself. 2. During random observations on [DATE] at 9:34 a.m., 2:05 p.m., and 3:08 p.m., a bottle of nystatin (an anti-fungal) topical powder, was on Resident 9's bathroom counter next to the sink. It was labeled with Resident 9's name. The resident's record was reviewed on [DATE] 2:04 p.m. Diagnoses included, but were not limited to, osteoarthritis of the knee and cognitive communication deficit. The [DATE] Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required assistance with ADLs. A Physician's Order, dated [DATE] and discontinued on [DATE], indicated nystatin powder to be applied to the groin every day. There was no order to keep the medication at the bedside. There was no current order for the medication. During an interview on [DATE] at 1:18 p.m., the Director of Nursing (DON) was informed of the findings and offered no additional information. 3. During an observation of the 100 hall medication cart on [DATE] at 10:31 a.m., an insulin pen labeled with an expiration date of 4/22 was observed. At that time, RN 2 indicated the insulin pen should not be in the cart, and she would dispose it. 4. During an observation of the 400 hall medication cart on [DATE] at 10:55 a.m., the following was observed: a. An insulin pen was labeled opened on 4/6, expired on 5/4. LPN 3 indicated she could not tell if the written expiration date was 5/4 or 5/9 and she was unsure how long after opening it expired, they were always changing it. She then used a marker and changed the expiration date on the insulin to 5/9. b. A small medication bottle containing tablets was in a patient's medication drawer. TUMS was hand-written on the bottle. There was no other label or identifying information of the contents. At that time, LPN 3 indicated they were Tums (antacid medication), brought in for a resident by their family. LPN 3 indicated medications brought in by family were supposed to be labeled with the resident's name. She then wrote a resident's last name on the bottle and returned it to the drawer. During an interview on [DATE] at 1:18 p.m., the DON indicated insulin pens should be discarded 28 days from opening. A Policy titled, Labeling of Medications and Biologicals, received from the Administrator as current on [DATE] at 2:53 p.m., indicated, . 7. Labels for over-the-counter (OTC) medications must include: a. The original manufacturer's or pharmacy-applied label indicating the medication name; b. The strength, quantity, lot, and control number; c. The expiration date when applicable; d. Appropriate accessory and precautionary statements; e. Directions for use. 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured) . b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . 410 IAC (Indiana Administrative Code)16.2-3.1-25(j) 410 IAC (Indiana Administrative Code)16.2-3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure bruises were assessed and monitored for 2 of 3 residents reviewed for non-pressure related skin conditions, blood pressure medications were administered within parameters for 2 of 3 residents reviewed for medications with parameters, and an assessment was documented prior to and after an outpatient procedure for 1 of 3 residents reviewed for falls. (Residents 77, 48, 42, and 11)Findings include:1. The record for Resident 77 was reviewed on 5/4/26 at 1:34 p.m. Diagnoses included but were not limited to, stroke, dementia, fracture of right talus (ankle), major depressive disorder, and osteoarthritis of right and left knees. The Quarterly Minimum Data Set (MDS) assessment, dated 4/7/26, indicated the resident was moderately impaired for daily decision making. The resident had an impairment in range of motion to one side of his lower extremities and needed partial to moderate assist with transfers. An Outpatient Discharge Instruction sheet, dated 4/10/26, indicated the resident had a post medial branch block (spinal injection for pain management) at a surgery center. The instructions indicated not to shower until the next day and the bandage could removed the next day. There were no nursing progress notes regarding the procedure, when the resident left the facility, or when the resident came back to the facility. There was no assessment of the resident's bandage or an assessment of the resident's condition upon return. During an interview on 5/7/26 at 11:30 a.m., the Director of Nursing indicated there was no documentation or an assessment of the resident when he came back from his outpatient procedure. 2. During a random observation on 4/30/26 09:50 a.m., Resident 42 was observed with a dark purple bruise to the left antecubital (inner elbow) area. During random observations on 5/4/26 at 1:00 p.m., and 5/6/26 at 9:30 a.m., the dark purple bruise remained to the left antecubital area. The record for Resident 42 was reviewed on 5/6/26 at 1:21 p.m. Diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, type 2 diabetes, heart failure, high blood pressure, and acute kidney failure. The 3/4/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Care Plan, revised on 9/12/25, indicated the resident was at risk for abnormal bruising and bleeding related to the use of anticoagulant medication. A Care Plan, dated 3/30/26, indicated the resident had bruising to her upper extremities from needle sticks. Weekly Skin Observations, dated 4/23/26 and 4/30/26, indicated the resident had no bruises. A Skin/Wound Note, dated 5/1/26 at 1:22 p.m., indicated the resident had a new skin Issue under her left breast. Moisture associated skin damage (MASD) was observed under the breast with redness and excoriation. There was no documentation regarding any type of bruising to her left arm. During an interview on 5/7/26 at 9:15 a.m., the Director of Nursing indicated the resident had a blood draw on 4/28/26 and the weekly skin assessment indicated she had no bruising. 3. The record for Resident 48 was reviewed on 5/6/26 9:15 a.m. Diagnoses included, but were not limited to, type 2 diabetes, dementia, major depressive disorder, adult failure to thrive, and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 2/4/26, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 9/10/25, indicated Metoprolol Tartrate tablet 50 milligrams (mg) give one tablet by mouth two times a day for high blood pressure and hold if pulse was less than 60. The Medication Administration Record (MAR) for the months of 11/2025, 12/2025, 1/2026, and 4/2026 indicated the Metoprolol was administered outside of the pulse parameters on the following days: 11/20/25: pulse was 55 12/27/25 pulse was 56 1/4/25: pulse was 57 and on 1/26/26 pulse was 52 4/15/26 pulse was 59, 4/25/26 pulse was 59, and on 4/26/26 pulse was 56 During an interview on 5/7/26 at 8:30 a.m., the Director of Nursing indicated the medication should have been held if his pulse was less than 60. 4. On 4/30/26 at 9:16 a.m. and 5/6/26 at 1:06 p.m., Resident 11 was observed lying in bed. There were 2 purple discolorations observed to her left forearm/wrist area and a purple discoloration with a black scab to her left hand. The resident's daughter was in the room; she indicated the discolorations had been there for a few days and she was unaware how the resident received them. Record review for Resident 11 was completed on 5/6/26 at 1:08 p.m. Diagnoses included, but were not limited to, heart failure, hypertension, orthostatic hypotension, and diabetes mellitus. The Significant Change MDS assessment, dated 4/6/26, indicated the resident was moderately cognitively impaired. The resident had an impairment on both sides of her upper and lower extremities for a functional limitation in range in motion. The resident was dependent on staff with dressing, bathing, and transfers. A Care Plan, dated 4/26/22 and revised 12/21/23, indicated the resident needed assistance with activities of daily living. An intervention included staff assistance with bed mobility, dressing, toileting, personal hygiene, and bathing. The Weekly Skin Assessment, dated 4/30/26, indicated the resident had no bruising. There was no documentation to indicate the resident's discolorations had been assessed or were monitored. During an interview on 5/6/26 at 1:12 p.m., QMA 1 indicated she was unaware the resident had any discolorations. During an interview on 5/6/26 at 1:12 p.m., LPN 3 indicated she was unaware the resident had any discolorations. A Care Plan, dated 2/28/25 and revised 4/3/26, indicated the resident was on hospice care related to congestive heart failure. An intervention included to administer medications as ordered. A Physician's Order, dated 10/24/25, indicated to administer midodrine hcl (medication to treat low blood pressure) 5 mg three times a day. Hold if systolic blood pressure (SBP, top number of blood pressure reading) was greater then 110. The April and May 2026 Medication Administration Records (MARs) indicated the midodrine was administered when the SBP was greater than 110 on the following dates and times:-4/3/26 at 1:00 p.m., the BP was 124/65 -4/3/26 at 5:00 p.m., the BP was 124/65-4/4/26 at 9:00 a.m., the BP was 120/67-4/5/26 at 1:00 p.m., the BP was 112/59-4/11/26 at 5:00 p.m., the BP was 117/64-4/23/26 at 9:00 a.m., the BP was 115/68-4/24/26 at 1:00 p.m., the BP was 122/76-4/26/26 at 5:00 p.m., the BP was 113/67-4/29/26 at 1:00 p.m., the BP was 112/72-5/5/26 at 5:00 p.m., the BP was 115/61 During an interview on 5/7/26 at 9:10 a.m., the Director of Nursing indicated she could not provide any documentation the resident's discolorations had been assessed or monitored or why the midodrine was administered outside of parameters. A facility policy titled, Skin Assessment and received as current from the facility on 5/7/26, indicated, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter.7. Documentation of skin assessment: b. Document observations (e.g. skin conditions). 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation and interview, the facility failed to maintain a resident's dignity related to checking a resident's blood sugar and announcing the result in a common area for 1 of 2 residents reviewed for dignity. (Resident 97)Finding includes:During an observation on 5/1/26 at 11:21 a.m., RN 1 was preparing to check Resident 97's blood sugar. The resident was sitting in her wheelchair in the day room along with two other residents and a visitor. RN 1 approached the resident, and told her she was going to check her blood sugar. She stuck the resident's finger, checked her blood sugar, and announced the result loudly. RN 1 did not ask the resident permission to check her blood sugar in the common area with others present. During an interview on 5/1/26 at 11:43 a.m., Unit Manager 1 indicated the resident was alert and oriented, and new to the facility. They were working on a care plan that indicated the resident was ok with having her blood sugar checked in common areas. When informed that RN 1 did not ask the resident's permission and that she announced the results loudly with other residents and a visitor present, no additional information was received. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADLs) received the care and assistance needed related to trimming their fingernails for 2 of 7 residents reviewed for ADLs. (Residents 7 and 57)Findings include: 1. On 4/29/26 at 10:37 a.m., and again on 5/4/26 at 1:10 p.m., Resident 7 was observed lying in bed. The resident's fingernails were long, thick, and yellowed. The resident indicated she would like someone to cut her fingernails but had been told they could not cut them because she had a fungus in them. Record review for Resident 7 was completed on 5/4/26 at 9:47 a.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis on one side of the body) and depression. The Annual Minimum Data Set (MDS) assessment, dated 3/10/26, indicated the resident was cognitively intact. The resident had an impairment on one side of her upper extremities for a functional limitation in range of motion. The resident required substantial maximal assistance for personal hygiene. A Care Plan, dated 6/29/22 and revised 3/13/26, indicated the resident required assistance with ADLs related to having a stroke with hemiplegia to her left side. An intervention included staff assistance for personal hygiene. There was a lack of documentation to indicate the resident's fingernails had been trimmed or was offered to have them trimmed. During an interview on 5/4/26 at 1:13 p.m., LPN 2 indicated she was unsure why the resident's fingernails had not been trimmed. The nurses or the CNAs should trim the resident's nails when needed. During an interview on 5/4/26 at 1:17 p.m., the Director of Nursing (DON) indicated the resident had been treated before for the fungus in her nails. The staff should include trimming fingernails in the resident's ADL care and should have offered to cut the resident's fingernails. A facility policy titled, Activities of Daily Living (ADLs) and received as current from the facility on 5/7/26, indicated, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; . 2. During random observations on 4/30/26 at 9:55 a.m., 5/1/26 at 9:45 a.m., and 5/4/26 at 9:04 a.m., Resident 57 was observed resting in bed. Her left arm was flaccid (lacking muscle tone, limp), and the fingernails on her left hand were very long. The resident's record was reviewed on 5/1/26 at 10:47 a.m. Diagnoses included, but were not limited to, hemiplegia (paralysis of one side of the body) following a stroke, need for assistance with personal care, and generalized muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 4/17/26, indicated the resident was cognitively intact for daily decision making, had functional limitation in range of motion on one side, and was dependent in ADLs. A Care Plan, revised on 1/20/26, indicated the resident had hemiplegia on her left side due to a stroke. Interventions included staff to assist with ADLs. During an interview on 5/4/2026 at 9:04 a.m., the resident indicated she did not want her fingernails on her left hand to be that long and wanted them cut. During an interview on 5/4/2026 at 1:56 p.m., the DON was informed of the findings and offered no further information. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 2 residents reviewed for activities. (Resident 22)Finding includes:During random observations at the following dates and times, Resident 22 was observed lying in bed, the room quiet without television, music, or other stimulation: 4/29/26 at 11:31 a.m., 4/30/26 at 10:16 a.m. and 3:16 p.m., 5/1/26 at 10:13 a.m. and 2:53 p.m., 5/4/26 at 9:51 a.m., and 5/6/26 at 11:20 a.m. On 5/1/26 at 2:15 p.m., an activities event with live music was observed in the main dining room. Resident 22 remained in his quiet room, awake in bed.The record for Resident 22 was reviewed on 5/4/26 at 10:14 a.m. Diagnoses included, but were not limited to, Parkinson's Disease and cerebrovascular disease.The Quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had moderate cognitive impairment and was dependent in ADLs and transfers.An Activities Care Plan, revised 4/27/26, included the intervention that staff should invite the resident to groups of interest such as worship, music events, social groups and cognitive groups. The May 2026 Activities Calendar indicated a music activity on 5/3, art activities on 5/4, 5/5, and 5/6, and worship activities on 5/1, 5/2, and 5/3.The Activities Participation 30-day documentation indicated in the resident had received three one-on-one visits per week, one friendly visit, and one people watching. There was no documentation of the resident attending or refusing activities.During an interview on 5/6/26 at 2:18 p.m., the Activities Director indicated the resident liked music and art. He used to participate in activities with assistance, but had not been out of his room for an activity since March. She did not recall him refusing activities, but that it could take a lot of work to get residents into activities. The only activity interaction he was receiving was three 20-30 minute long one-to-one visits per week. When informed of the findings, the Activities Director indicated they would try to get the resident out more and provide more ongoing stimulation, like music, while in his room. 410 IAC (Indiana Administrative Code)16.2-3.1-33(a)

Based on observation, record review, and interview, the facility failed to provide oxygen at the correct flow rate and with protective padding as ordered for 1 of 1 resident reviewed for respiratory care. (Resident 22)Finding includes:During random observations on 4/30/2026 at 10:16 a.m. and 2:07 p.m., and 5/4/2026 at 9:50 a.m., Resident 22 was resting in bed. Oxygen was in use via a nasal cannula (small, soft prongs that go into the nostrils) at 3.5 lpm (liters per minute). There was no padding in place on the cannula tubing. The record for Resident 22 was reviewed on 5/4/26 at 10:14 a.m. Diagnoses included, but were not limited to, Parkinson's Disease, pneumonia, chronic respiratory failure, and dependence on supplemental oxygen. The Quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had moderate cognitive impairment and was dependent for activities of daily living (ADLs). A Physician's Order, dated 3/24/2026, indicated oxygen at 4 lpm per nasal cannula, continuously. A Physician's Order, dated 3/26/2026, indicated padding to oxygen tubing, ensure in place, and reapply as needed, every shift. A Care Plan, revised on 5/17/2024, indicated the resident had a change in his respiratory status related to emphysema (lung disease). Interventions included providing oxygen as ordered.During an interview on 5/4/2026 at 9:56 a.m., LPN 1 confirmed there was no padding on the cannula tubing, and the oxygen flow rate was set at 3.5 lpm, but should have been at 4 lpm. 410 IAC (Indiana Administrative Code) 16.2-3.1-47(6)

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a practitioner prescribing antibiotics for not true infections based on the McGeer Criteria (standardized definitions used for urinary tract infection (UTI) surveillance in long-term care, requiring both specific symptoms and microbiologic evidence) for 2 of 3 residents reviewed for urinary tract infections. (Residents 42 & 5)Findings include:1. During an interview on 4/30/26 at 9:50 a.m., Resident 42 indicated she has had frequent Urinary Tract Infections (UTI's) and as soon as the antibiotic was completed, the symptoms start again. During an interview on 5/6/26 at 9:30 a.m., the resident indicated she had seen an Urologist and had a procedure, however, she got sick with COVID and has not had the follow up appointment. She still would like to see this physician. The record for Resident 42 was reviewed on 5/6/26 at 1:21 p.m. Diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, type 2 diabetes, heart failure, high blood pressure, and acute kidney failure. The 3/4/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was occasionally incontinent of urine.The Care Plan, dated 5/4/26, indicated the resident had an acute Urinary Tract Infection and required the use of oral antibiotic therapy. A Nurse's Note, dated 3/16/26 at 7:10 p.m., indicated an order was received from the Nurse Practitioner (NP) for an urinalysis (UA) with a culture and sensitivity for agitation. The resident was notified the next time she went to the bathroom, to let the staff know so they can collect the urine sample. An NP Note, dated 3/17/26 at 4:32 p.m., indicated the NP reviewed the UA that was ordered by the psychiatric NP. The resident previously had Extended-Spectrum beta lactamase (ESBL) in the urine with 2 organisms and ended up on IV antibiotics in 1/2026. Will get a midline inserted and wait for final culture to treat.The UA report, dated 3/17/26, indicated the resident's urine color was clear and dark yellow and was negative for blood and nitrates. The urine had a large amount of leukocytes and a trace of bacteria. The preliminary findings was 10-50,000 gram negative bacilli.A Nurse Practitioner (NP) Note, dated 3/18/26 at 11:28 a.m., indicated the resident was seen for a high risk follow up visit and had a midline placed last night in anticipation of IV antibiotics starting for UTI. The resident had a cystoscopy (procedure using a camera to view the bladder) with an urologist on 1/23/26 and was told to follow up in 4-6 weeks. The staff reported the resident had an urinalysis ordered by the contracted behavioral agency for agitation and the patient also had previously reported frequency and urgency.A Nurse's Note, dated 3/18/26 at 1:12 p.m., indicated the urine showed few bacteria, the NP was aware, and awaiting the final culture. A Physician's Order, dated 3/19/26, indicated IV Meropenem solution 1 gram every eight hours for a complicated UTI for seven days.The Medication Administration Record (MAR) for 3/2026, indicated the resident received the IV antibiotic on 3/19/26 at 9:00 a.m. through 3/26 at 1:00 a.m.A NP Note, dated 3/21/26 at 7:50 p.m., indicated the final culture was reviewed final culture and Meropenem was susceptible, so no changes needed to the IV antibiotic regime.The final culture, dated 3/21/26, indicated the resident had 10-50,000 colonies of Proteus Mirabilis not ESBL.There was no documentation by the NP why the resident continued on the IV antibiotic after the final culture results. There was no documentation the resident had any physical signs or symptoms of an UTI. The resident was to follow up in four weeks with the urologist, however she contracted COVID on 2/22/26 and was moved to isolation. A Nurse's Note, dated 3/10/26 at 4:47 p.m., indicated the resident cancelled her appointment with the Urologist. The resident indicated she was not ready and her son was made aware. An NP Note, dated 4/27/26 at 10:22 a.m., indicated the resident reported she had a sore bladder and was peeing razor blades with frequency. A Nurse's Note, dated 4/27/26 at 11:18 p.m., indicated a urine sample (UA) was collected and placed in the refrigerator. The UA report, dated 4/27/26, indicated the urine color was clear and dark yellow. The UA was negative for nitrates, had a large amount leukocytes, with moderate bacteria.A Nurse's Note, dated 4/30/26 at 3:30 p.m., indicated the preliminary UA culture showed 10-50,000 gram negative bacilli. The NP was notified and indicated she would wait for the final culture. The final culture results, dated 5/1/26, indicated the organism of Morganella morganii 10-50,000 colonies was present. A Physician's Order, dated 5/1/26, indicated Levaquin oral tablet 250 milligrams (mg), give one tablet by mouth at bedtime for UTI for 10 days.The MEdication Administration Record (MAR) for 5/2026, indicated the Levaquin was administered from 5/1-5/6/26.There was no documentation from the NP on why the antibiotic was ordered nor was there any documentation the resident continued to have signs and symptoms of an UTI such as burning, pain, and frequency. During an interview on 5/7/26 at 8:30 a.m., the Director of Nursing indicated there was no documentation from the NP on why the resident was started on an antibiotic in 4/2026. The culture did not meet McGeer's criteriaDuring an interview on 5/7/26 at 9:30 a.m., the Nurse Consultant indicated the NP had ordered the IV antibiotic prior to the culture results and the final culture did not meet McGeer's criteria. 2. The record for Resident 5 was reviewed on 5/4/26 at 11:30 a.m. The resident was admitted on [DATE] and her diagnoses included, but were not limited to, acute cystitis, bacteremia, high blood pressure, dementia, disorders of the kidney and ureter, acute kidney failure, chronic kidney disease, heart failure, anxiety, retention of urine, neuromuscular of bladder, urinary tract infection (UTI), and Extended-Spectrum beta lactamase (ESBL).The admission Minimum Data Set (MDS) assessment, dated 3/21/26, indicated the resident was moderately impaired for daily decision making, and was always incontinent of bladder. A 4/13/26 Nurse Practitioner (NP) Note indicated the resident was being seen for staff and family concerns of the resident not eating or drinking well. The resident reported no appetite and was nauseated at times with some dizziness. Labs and IV fluids were ordered.A Nurse's Note, dated 4/15/26 at 6:03 p.m., indicated the family requested an urinalysis (UA) with a culture and sensitivity to rule out an infection. The NP was notified and a new order was received. A Nurse's Note, dated 4/16/26 at 7:12 p.m., indicated the UA results were received and the resident's urine color was yellow with a moderate amount of blood noted. The urine was positive for nitrates, many bacteria and a moderate amount of Leukocytes. The on call NP was notified and no new orders were received. A Physician's Order, dated 4/17/26, indicated Cipro tablet 500 milligrams (mg), give one tablet by mouth two times a day for infection.The 4/2026 Medication Administration Record (MAR) indicated the Cipro was administered on 4/17 at 5:00 p.m. and 4/18 at 9:00 a.m. The final culture results, dated 4/18/26, indicated Escherichia coli (ESBL) 10-50,000 colonies. The sensitivity results indicated the organism was resistant to Cipro. A Nurse's Note, dated 4/18/26 at 3:26 a.m., indicated the Medical Assistant was notified and instructed the facility to fax over the results and the on call NP would call back with any new orders if needed.A Nurse's Note, dated 4/18/26 at 3:28 a.m., indicated the on call NP called back and indicated no new orders at this time, just place lab results in binder for NP to review.A Nurse's Note, dated 4/18/26 at 10:46 a.m., indicated the NP was notified of the final culture results and orders were received to discontinue the Cipro antibiotic and follow up with the NP on Monday if the resident becomes symptomatic. A Physician's Order, dated 4/23/26, indicated Macrobid (an antibiotic) oral Capsule 100 mg, give one capsule by mouth every 12 hours for UTI/ESBL for seven days.The 4/2026 MAR indicated the Macrobid was administered to the resident on 4/24/26 through 4/30/26.There was no documentation from the NP on why the antibiotic was ordered nor was there any documentation the resident continued to have signs and symptoms of an UTI such as burning, pain, and frequency. During an interview on 5/7/26 at 8:30 a.m., the Director of Nursing indicated the NP just ordered the Macrobid because of the ESBL and had no documentation of why it was ordered when it did not meet McGeers criteria. There was no documentation the resident had any signs or symptoms of an UTI.The current McGeer Criteria policy, provided by the Administrator on 5/7/26 at 12:59 p.m., UTI without indwelling catheter must fulfill both 1 and 2. 1. At least one of the following sign or symptom Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and 1 of the following: Acute costovertebral angle pain or tenderness Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency If no fever or leukocytosis, then 2 of the following: Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency 2. At least one of the following microbiologic criteria 105 cfu/mL of no more than 2 species of organisms in a voided urine sample 102 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheterIAC (Indiana Administrative Code) 16.2-3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure a resident, dependent on staff for transferring from the chair to bed, had received adequate assistance and supervision to prevent accidents related to staff not following the manufacture's manual regarding keeping the legs of the lift at their maximum opened position before lifting a resident during a mechanical lift transfer for 1 of 2 residents reviewed for accidents. (Resident 21) This deficient practice resulted in the resident falling and receiving a fracture to her left upper arm. The deficient practice was corrected on 10/16/24, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed a house wide sweep of the Hoyer lifts (a mechanical lift) and Hoyer slings, an inservice was held related to transfer techniques, two person staff assist while using the Hoyer lift, and leg of the base in their widest opened position, and return demonstration by staff was observed, and audits related to the use of the Hoyer lift were completed. Finding includes: During an interview on 3/17/25 at 2:13 p.m., Resident 21 indicated she had fallen when the Hoyer lift had tipped over. She indicated she had laid on her arm and had not gotten up until an ambulance arrived. The record for Resident 21 was reviewed on 3/18/25 at 1:57 p.m. Diagnoses included, but were not limited to, fracture to the left humerus (upper arm) and need for assistance with personal care. The Annual Minimum Data Set (MDS) assessment, dated 9/16/24, indicated the resident was cognitively intact, dependent on staff for transfers and had had no falls since the prior assessment. A Quarterly Risk Evaluation Note, dated 9/16/24 at 3:31 p.m., indicated the resident was at moderate risk for a fall. A Nurse's Note, dated 10/11/24 at 7:15 p.m., indicated the resident had fallen in her room. The CNA reported to the nurse the resident had fallen when they tried to put her to bed with the Hoyer lift. The nurse indicated she saw the Hoyer lift tipped on it's side on the resident's wheelchair, the resident was on the floor on her left side. The CNAs reported the wheel on the Hoyer lift had gotten stuck when they tried to get the resident in bed, when they moved the Hoyer, it had tipped over and the resident had fallen. The resident was crying, grimacing, and favored her left hand. The resident was sent to a local hospital emergency room for an evaluation and treatment. The immediate intervention indicated the Hoyer lift was moved off of the unit and maintenance was notified. A Nursing progress note, dated 10/12/24 at 1:30 p.m., indicated the resident had returned to the facility at 8:40 a.m. She returned with the diagnoses of a contusion to her left elbow, a fracture to her left humeral head (upper arm), and a left wrist sprain. She had an order for Norco (an opioid pain medication) 5 mg (milligram) with 325 mg of acetaminophen every six hours as needed for pain. A Social Service progress note, dated 10/15/24 at 11:51 a.m., indicated the resident was encouraged to get out of bed as much as possible. The resident had reported having pain and some anxiety due to her recent fall. A Care Plan, dated 10/15/24, indicated the resident had a risk for falls related to a history of falls, use of psychotropic medications, involuntary movements, narcotic analgesics, and use of a mechanical lift. Interventions included, Hoyer lift for transfers. A Care Plan, dated 10/15/24, indicated the resident had a history of a traumatic fracture of the left shoulder. Interventions included, remind the resident about her weight bearing status to her affected extremity. During an interview on 3/20/25 at 9:03 a.m., CNA 5 indicated she had responded to Resident 21's room after hearing the call for assistance and she also indicated all staff had been re-trained on the use of the Hoyer lift. During an interview on 3/20/25 at 10:31 a.m., CNA 7 indicated she was the second staff member that had assisted with the transfer that resulted in the fall. She indicated a wheel on the lift got stuck on a wheel from the wheelchair and when they tried to turn the lift and it fell along with the resident and the other CNA. When the emergency medical personnel arrived, they assisted with getting the resident into the bed, then she was transferred to the emergency room . The CNA had been re-trained on use on the Hoyer lift and they were to keep the legs of the lift opened. A review of the investigation related to the fall, provided by the Director of Nursing on 3/20/25 at 11:32 a.m., included CNA 25's written statement, signed and dated 10/11/24, and indicated she had closed the legs of the Hoyer lift and pulled back the Hoyer, away from the wheelchair, when she turned the lift the wheelchair wheel got stuck on the Hoyer so she used her foot to pull the wheel over, all of the resident's weight went to one side, she tried to push the resident's weight back but couldn't and the Hoyer tipped over and the resident fell . During an interview on 3/20/25 at 11:38 a.m., the Administrator indicated the facility had the Hoyer lift go through preventative maintenance and nothing was found to be wrong with the lift. The facility had inserviced staff, performed competency skill checks, sling sizes, and began safety rounds. Documentation of facility inservices and subsequent auditing was reviewed and confirmed to be completed by 10/16/24. Staff interviews and observations also indicated adequate knowledge related to Hoyer lift transfers. The Hoyer lift manufacturer's recommendations included .Lift the Patient WARNING When using an adjustable base lift, the legs MUST be in the maximum Opened/Locked position before lifting the patient 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to maintain the kitchen in a sanitary manner and in good repair related to lack of monitoring of freezer, refrigerator, and dishwasher temperatures and food not labeled and dated, for 1 of 1 kitchen. This had the potential to affect 86 of 87 residents who resided in the facility and received food from the kitchen. Findings include: During the Initial Kitchen Sanitation Tour on 3/17/25 at 8:47 a.m., with the Kitchen Manager, the following was observed: 1. There was no thermometer in the walk-in freezer. 2. There was no thermometer in the reach-in cooler. 3. The dishwasher temperature log was already filled out for breakfast, lunch and dinner time temperature checks for 3/17/25. 4. There was an unlabeled and undated tray of pre-filled cups of juice in the walk-in refrigerator. 5. The following items were found undated in the walk-in freezer: a bag of cookies, a bag of bread, a package of unidentified meat, a container of ice cream, a bag of ground sausage, and an open box of tropical freezes. 6. The following bagged items were found open, unlabeled and undated in the reach-in freezer: chicken breasts, potato wedges, and breaded chicken patties. During an interview on 3/17/25 at 9:20 a.m., the Kitchen Manager indicated the thermometer from the freezer must have fallen behind some boxes and they could not find it, and there should have been a thermometer in the reach-in cooler, but there was not. The temperature log for the dishwasher should have been filled out at the time each of the meal time checks were completed, and all food items should have been labeled and dated when opened. A policy titled Dishwasher Temperature, received as current from the Kitchen Manager on 3/18/25 at 2:53 p.m. indicated, . Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. A policy titled Date Marking for Food Safety, received as current from the Kitchen Manager on 3/18/25 at 2:53 p.m. indicated, The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded . 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to implement a resident's care plan related to positioning for 1 of 3 residents reviewed for limited range of motion (ROM). (Resident 33) Finding includes: During an observation on 3/17/25 at 10:00 a.m., Resident 33 was observed resting in bed. He had limited movement of his left arm and his left hand appeared contracted (unable to open). At that time, the resident indicated he could only open his left hand if he used his right hand to open it since he had had a stroke. There were no rails or bars present on the bed. During the following observations on 3/18/25 at 9:54 a.m., 3/19/25 at 10:37 a.m. and 3/20/25 at 11:00 a.m., the resident was lying in bed and there were no rails or bars present on his bed. The resident's record was reviewed on 3/20/25 at 10:06 a.m. Diagnoses included, but were not limited to, disorders of the brain, vascular dementia, and chronic heart failure. The 2/24/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment and was dependent on staff for assistance for ADLs (activities of daily living) and transfers. A Physician's Order, dated 1/18/25, indicated the resident was to have a left side enabler bar (a bar that attaches to the bed for the resident to use to assist with turning and repositioning). A Care Plan, revised on 1/20/25, indicated the resident needed assistance with ADLs related to activity intolerance and impaired cognition. Interventions included the use of a left side enabler bar for turning and repositioning. During an interview on 3/21/25 at 9:04 a.m., the Unit Manager for the 100 and 200 halls indicated she thought the resident used to have an enabler bar, but she did not know what happened to it. She indicated she would have to look into getting him one. 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents, related to turning and repositioning for 1 of 2 residents reviewed for ADLs. (Resident 33) Finding includes: During an observation on 3/17/25 at 10:00 a.m., Resident 33 was observed resting in bed, lying on his back. He had limited movement of his left arm and his left hand appeared contracted (unable to open). During the following observations on 3/18/25 at 9:54 a.m. and 2:14 p.m., 3/19/25 at 10:37 a.m., and 3/20/25 at 9:35 a.m. and 11:00 a.m., the resident was lying in bed on his back. The resident's record was reviewed on 3/20/25 at 10:06 a.m. Diagnoses included, but were not limited to, disorders of the brain, vascular dementia, and chronic heart failure. The 2/24/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment, and was dependent in ADLs (activities of daily living) and transfers. A review of a Care Plan, revised on 9/4/24, indicated the resident had hemiplegia (paralysis of one side of the body) to his left side and required staff assistance with ADLs. Interventions included to assist/encourage him to change his position frequently. The Tasks section of the record indicated the resident should have been turned and repositioned every shift. There was no documentation of turning/repositioning or resident refusals to be turned for the following shifts: 2/24/25 night shift, 2/26/25 night shift, 2/28/25 night shift, 3/2/25 night shift, 3/4/25 night shift, 3/7/25 night shift, 3/8/25 night shift, 3/9/25 night shift, 3/13/25 day and evening shifts, 3/14/25 night shift, and 3/16/25 night shift. During an interview on 3/21/25 at 9:04 a.m., the Unit Manager for the 100 and 200 halls indicated the resident did not get out of bed, and the staff should have documented either repositioning or resident refusal every shift. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure areas of discoloration were assessed and monitored for 2 of 2 residents reviewed for non-pressure skin conditions .(Residents 62 and 44) Findings include: 1. On 3/17/25 at 9:47 a.m., Resident 62 was observed with two small areas of reddish/purple discoloration to his right elbow. On 3/18/25 at 2:03 p.m. and 3/19/25 at 10:01 a.m., the discoloration remained to the resident's elbow. The record for Resident 62 was reviewed on 3/18/25 at 2:55 p.m. Diagnoses included, but were not limited to, Parkinson's disease, anemia, and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident was moderately impaired for daily decision making and had no skin issues. The Weekly Skin Observation Assessment, dated 3/17/25 at 3:06 a.m., indicated the resident had no bruising. The March 2025 Physician's Order Summary (POS), indicated there were no orders to monitor the areas of discoloration to the resident's right elbow. During an interview on 3/19/25 at 1:50 p.m., the Wound Nurse indicated she had noticed the areas of purpura (a rash of purple spots) on the resident's arms on the morning of 3/19/25. She indicated there was more of the rash noted on the left arm than on the right and she had filled out a skin form. The Wound Nurse had been informed of the areas of discoloration near the right elbow which had been observed on 3/17/25. The Non-Pressure Ulcer Skin Condition Progress Report, dated 3/19/25 at 10: 56 a.m., indicated scattered purpura was observed to the upper extremities, more prevalent on the left arm. Continue to monitor. 43293 2. During a random observation on 3/17/25 at 10:31 a.m., large dark purple bruises were observed on the back of Resident 44's left and right hands. At that time, the resident's family member indicated the bruises had been there since the resident had left the hospital on 2/25/25. The bruises to both hands remained present during the following observations: 3/18/25 at 2:04 p.m., 3/19/25 at 3:10 p.m. and 3/20/25 at 9:28 a.m. The resident's record was reviewed on 3/18/25 at 2:17 p.m. Diagnoses included, but were not limited to, post-hip replacement, dementia, and muscle weakness. The 2/27/25 Admission Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment and was dependent in Activities of Daily Living (ADLs) and transfers. A Care Plan, revised on 2/27/25, indicated the resident was at risk for abnormal bruising and bleeding related to the use of blood thinners. Interventions included observing for bruising and bleeding. The treatment record included observing for side effects of blood thinners every shift. Each shift from 2/26/25 through 3/20/25 indicated no side effects were noted. The nurses' skin assessments from 2/25/25 through 3/20/25 lacked documentation of the bruises to the hands. During an interview on 3/21/25 at 9:19 a.m., the Unit Manager indicated the bruises should have been assessed and documented in the record. She indicated she could not find any documentation of the bruises to the hands in the record. A policy titled, PCC [Point Click Care--the electronic medical record program] Wound Documentation Protocol, received as current on 3/21/25 at 2:55 p.m. from the Unit Manager, indicated, . Weekly assessment of wounds and skin conditions will be documented weekly in the electronic medical record . Bruises and rashes may be evaluated using the skin and wound application or the non-pressure Ulcer Skin Condition Progress Report no later than every 7 days . When bruises are healing without complications . the nurse will monitor the site weekly. At the point of healing . the nurse will make a last entry in the medical record indicating the normal healing process has taken place without complications . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure pressure reduction devices were in use for a resident with a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 66) Finding includes: On 3/19/25 at 1:17 p.m. and 3:22 p.m., Resident 66 was observed in her room in bed. Her heel boots (a pressure reducing device) were observed on the chair next to the resident's bed. The resident's feet were not elevated while she was lying in bed. On 3/20/25 at 1:44 p.m. and 2:30 p.m., the resident was again observed in her bed. Her heel boots were in the chair, next to her bed and her feet were not elevated. The record for Resident 66 was reviewed on 3/19/25 at 10:07 a.m. Diagnoses included, but were not limited to, Alzheimer's disease and dementia without behavior disturbance. The Admission Minimum Data Set (MDS) assessment, dated 1/10/25, indicated the resident was severely impaired for daily decision making, was dependent on staff for rolling left and right and for chair to bed transfers. The resident was not identified as having any pressure areas on the assessment. A Care Plan, dated 3/12/25, indicated the resident had a suspected deep tissue injury (a purple or maroon localized area of intact discoloration) to the left great toe. Interventions included, but were not limited to, float heels off of the mattress when in bed or wear heel off loading boots. A Physician's Order, dated 3/11/25, indicated the resident was to receive skin prep to her left great toe every shift. The Skin and Wound Evaluation, dated 3/17/25, indicated the resident had a deep tissue injury to her left great toe that measured length 0.9 centimeters (cm) by width 1 cm. During an interview on 3/21/25 at 1:44 p.m., the Wound Nurse was informed the resident's heel boots were not in use and/or her heels were not off loaded while she was in bed. The Wound Nurse indicated she would look into it. During an interview on 3/21/25 at 1:50 p.m., the Director of Nursing indicated the resident's heel boots should have been in use or her feet off loaded while she was in bed. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure each resident requiring respiratory care received necessary services related to changing oxygen tubing for 1 of 4 residents reviewed for respiratory services. (Resident 44) Finding includes: During a random observation on 3/17/25 at 10:35 a.m., Resident 44 was observed sitting in her wheelchair. She was wearing a nasal cannula (a pronged tube that delivers oxygen through the nostrils), connected to a portable oxygen tank. The oxygen tubing was not dated. On 3/18/25 at 9:20 a.m., the resident was observed wearing her oxygen cannula. The oxygen tubing was not dated. The resident's record was reviewed on 3/18/25 at 2:17 p.m. Diagnoses included, but were not limited to, post-hip replacement, dementia, and muscle weakness. The 2/27/25 Admission Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment and was dependent in Activities of Daily Living (ADLs) and transfers. A Physician's Order, dated 2/25/25, indicated oxygen at 2 lpm (liters per minute) continuous, may titrate as needed. A Physician's Order, dated 3/11/25, indicated oxygen at 2 lpm continuous, may titrate for oxygen saturation less than 90% or shortness of breath. A Physician's Order, dated 3/19/25, indicated oxygen at 2 lpm per nasal cannula for oxygen saturation less than 90% or shortness of breath. A review of the eMAR (electronic medication administration record) indicated the resident used oxygen every day from 2/25/25 to 3/18/25. There was no documentation indicating the changing of the oxygen tubing. During an interview on 3/18/25 at 3:12 p.m., the Unit Manager for the 100 and 200 halls indicated oxygen tubing should be changed once a week if the oxygen was in use, and this change should be documented in the eMAR. A policy titled, Oxygen Administration, received as current on 3/21/25 at 1:57 p.m. from the Director of Nursing indicated, . Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to file and resolve a resident grievance for a missing wheelchair for 1 of 1 resident reviewed for grievances. (Resident M) Finding includes: On 7/30/24 at 1:20 p.m., Resident M was observed awake, sitting up in bed and talking with his son. Resident M indicated he was unhappy with how the facility handled his missing wheelchair. During an interview at that time, Resident M indicated he had been missing a personal wheelchair since before Father's Day. The facility was aware his wheelchair was missing and he was told they would get him fitted for another wheelchair. The resident's son talked with the the therapy director a couple weeks ago, and it was communicated that the resident would be measured for a new wheelchair the following day. They were unsure if the facility had a grievance on file for their concern. Resident M's record was reviewed on 7/30/24 at 3:59 p.m. Diagnoses included, but were not limited to, heart failure, chronic pain, arthritis, insomnia (difficulty sleeping), gout (excess of uric acid in joints), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident was moderately intact for daily decision making. The resident had impairment on both sides of his lower extremities and used a wheelchair. The resident was dependant with toileting, shower/bathing, and lower body dressing. Personal hygiene required partial/moderate assistance. A Therapy Note, signed by the Rehabilitation Director and dated 7/24/24, indicated due to the resident's weight gain, he would likely require a larger chair. The resident and son agreed to Resident M getting fitted for a new chair within the next day or so. During an interview on 7/30/24 at 3:01 p.m., the Social Service Assistant indicated Resident M's wheelchair was found shortly after it went missing. The wheelchair was returned to the resident and they refused it, indicating it was the wrong wheelchair. When they attempted to measure the resident, he refused to get out of bed. There was a wheelchair in the resident's room and the resident had it stored in the bathroom. A grievance for the missing wheelchair was filed today on 7/30/24 and there was not one previously filed. There was no additional information provided. During an interview on 7/31/24 at 9:38 a.m., the Administrator indicated she understood the grievance concern and had no additional information to provide. 3.1-7(a)(2)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident who was in Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for infection control isolation practices. (RN 1, CNA 1, and Resident E). Finding includes: During an observation on 7/30/24 at 11:45 a.m., Resident E was observed lying in bed in the room. There was a sign on the door that indicated the resident was in EBP and PPE of a gown and gloves was to be worn during high contact activities. CNA 1 brought a Hoyer (mechanical) lift to Resident E's room and attempted to transfer Resident E. CNA 1 then asked RN 1 to assist her in the transfer of Resident E. RN 1 sanitized her hands and entered Resident E's room, where she assisted with the Hoyer lift transfer. Both CNA 1 and RN 1 were not wearing the proper PPE which included gowns and gloves. During an interview with RN 1 on 7/30/24 at 11:50 a.m., she indicated the staff does not apply PPE unless they were actually touching the resident's wound. Resident E's record was reviewed on 7/30/24 at 11:30 a.m. The diagnoses included, but were not limited to, difficulty walking, dementia, and displaced mid cervical fracture of the left femur. A Physician's Order, dated 4/22/24, ordered enhanced barrier precautions for a chronic sacral wound. A Care Plan, dated 5/22/24, indicated the resident required enhanced barrier precautions related to a chronic sacral wound. Interventions included to follow enhanced barrier precautions with the resident's care as needed, and to provide the resident's treatments as ordered. During an interview with the Wound Nurse on 7/30/24 at 2:32 p.m., she indicated the resident had a coccyx wound that was infected with Methicillin Resistant Staphylococcus Aureus (MRSA) in April of 2024, and the staff should apply the appropriate PPE when providing care and transferring the resident. The facility policy titled, Infection Prevention and Control Program (IPCP), Enhanced Barrier Precautions, provided by the Director of Nursing as current on 7/31/24 at 10:24 a.m., indicated . staff can use gloves and gowns in order to prevent contamination of hands and clothing while performing high-contact resident care that poses the highest risk for MDRO (Multi Drug Resistant Organisms) transmission. These high contact activities include dressing, bathing, or providing hygiene, transferring, changing briefs, or assisting with toileting, changing linens, or providing any type of device or wound care This citation relates to Complaint IN00435593. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored, and treatment orders were obtained timely for a resident with a skin tear, for 2 of 2 residents reviewed for skin conditions non-pressure related. (Residents 66 and 79) Findings include: 1. During a random observation on 2/20/24 at 9:48 a.m., Resident 66 had two areas of reddish/purple discoloration to his right wrist. During a random observation on 2/23/24 at 11:03 a.m., the discoloration remained to the resident's right wrist. The record for Resident 66 was reviewed on 2/22/24 at 2:05 p.m. Diagnoses included, but were not limited to, Parkinson's disease, dementia without behavior disturbance, and atherosclerotic heart disease. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/24, indicated the resident was cognitively intact. He required extensive assistance with bed mobility and was dependent on staff for transfers. A Physician's Order, dated 1/4/24, indicated the resident was to have skin sleeves or a long sleeve shirt on when out of bed as tolerated. There was no order to monitor the discoloration to the right wrist. The Weekly Skin Observation, dated 2/19/24, indicated the resident had no skin concerns. During an interview on 2/23/24 at 1:40 p.m., the Director of Nursing indicated the areas of discoloration should have been assessed and monitored. 2. During random observations on 2/20/24 at 10:12 a.m. and 3:04 p.m., Resident 79 was observed with a foam dressing to his right elbow. The dressing was dated 2/10/24. During a random observation on 2/21/24 at 9:11 a.m., a foam dressing to the resident's right elbow was dated 2/21/24. The record for Resident 79 was reviewed on 2/21/24 at 1:23 p.m. Diagnoses included, but were not limited to, anemia, type 2 diabetes, and restlessness with agitation. The Quarterly Minimum Data Set (MDS) assessment, dated 1/4/24, indicated the resident was moderately impaired for daily decision making. He required extensive assist with bed mobility and was dependent on staff for transfers. A Nurses' Note, dated 2/10/24 at 9:24 p.m., indicated the resident was observed sliding in his chair. While being repositioned, a bleeding skin tear was observed to the right forearm, which measured 2.5 centimeters (cm) by 0.5 cm. The wound was cleansed with saline and a bacitracin dressing was applied. A Physician's Order, dated 2/12/24, indicated the resident was to receive a Bacitracin (an antibiotic ointment) dressing to the right forearm skin tear every 48 hours. The treatment was discontinued on 2/16/24. The 2/2024 Treatment Administration Record (TAR), indicated the treatment had been signed out as being completed on 2/12 and 2/14/24. A Physician's Order, dated 2/21/24, indicated the skin tear to the right forearm was to be cleansed with wound wash, pat dry, and cover with a foam dressing every day shift on Wednesday and Saturday and as needed (PRN). The Weekly Skin Observations dated 2/12 and 2/19/24, indicated there was no documentation related to the skin tear. During an interview on 2/22/24 at 1:24 p.m., the Wound Nurse indicated that she noticed the dressing to the resident's elbow yesterday. She confirmed the dressing was dated 2/10/24. She assessed the area and obtained an order from the Physician. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders to administer their own medications, as well as a self-administration of medication assessment, for 1 of 1 residents reviewed for self-administration of medication. (Resident 6) Finding includes: During a random observation on 2/19/24 at 11:22 a.m., a container of Nystatin cream (an antifungal medication) was on Resident 6's bedside table. During a random observation on 2/21/24 at 10:30 a.m., two containers of Biofreeze (a topical pain reliever) were on the resident's television stand. Resident 6's record was reviewed on 2/21/24 at 11:26 a.m. Diagnoses included, but were not limited to, type 2 diabetes, vascular dementia, hemiplegia (muscle paralysis) and hemiparesis (muscle weakness). The Annual Minimum Data Set (MDS) assessment, dated 2/12/24, indicated the resident was cognitively intact for daily decision making. There was no Care Plan for the resident to self-administer her medications. Physician's Orders, dated 4/13/23 and listed as current on the February 2024 Physician's Order Summary (POS), indicated the resident was to receive Nystatin cream to the buttocks every shift and Biofreeze external gel 4 % was to be applied to the left leg topically every 12 hours as needed (PRN) for left leg pain. There was no order for the resident to self-administer the medication and a Self-Administration of Medication Assessment had not been completed. During an interview on 2/21/24 at 11:02 a.m., LPN 1 indicated the resident's family had been bringing things into the room and she would inform Social Services. During an interview on 2/21/24 at 1:53 p.m., the Director of Nursing indicated the resident had not requested the Biofreeze that day and she wasn't sure why the containers were in the room. She was also not sure why the Nystatin cream was left in the room. 3.1-11(a)

Based on observation, record review, and interview, the facility failed to provide the necessary care and services for residents who received hemodialysis, related to not monitoring the dialysis access site, for 1 of 1 residents reviewed for dialysis. (Resident 199) Finding includes: On 2/20/24 at 9:22 a.m., Resident 199 was observed lying in bed in her room. During an interview at that time, Resident 199 indicated she went to dialysis on Mondays, Wednesdays, and Fridays. She recently had surgery on her left arm to fix her fistula, so they were not currently using that access as they were waiting for it to heal. She had a catheter to her chest that she used for dialysis. She indicated the facility would check the catheter sometimes but mostly the dialysis center would monitor it. The record for Resident 199 was reviewed on 2/22/24 at 2:32 p.m. Diagnoses included, but were not limited to, end stage renal disease, congestive heart failure, and hypertension. The Admission Minimum Data Set (MDS) assessment, dated 2/18/24, indicated the resident was cognitively intact and received hemodialysis services. A current Care Plan indicated the resident had end stage renal disease and required dialysis. There were no interventions listed related to monitoring the dialysis catheter site. The Physician's Order Summary, dated 2/2024, indicated the resident had dialysis on Mondays, Wednesdays, and Fridays at 9:30 a.m. There was to be no blood pressure or blood draws to the left arm. There were no orders related to monitoring the dialysis catheter. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 2/2024, lacked any monitoring of the dialysis catheter. There were Pre-Dialysis Data and Post Dialysis Data Assessments completed on the resident's dialysis days which included monitoring of the dialysis access site on those days, however, some of the assessments were incomplete. During an interview on 2/23/24 at 12:39 p.m., the Director of Nursing (DON) indicated the dialysis catheter was assessed on the Pre and Post Dialysis assessments on dialysis days. No further information was provided. A Facility Policy, titled Monitoring of Dialysis Fistula/Catheter, received as current, indicated, .6. If the resident has a catheter for dialysis the nurse will assess the catheter site for any signs of drainage and condition of the dressing to the site every shift. 7. The results will be documented on the MAR every shift. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure finger orthotics were available and worn as ordered, for 1 of 1 residents reviewed for range of motion. (Resident 12) Finding includes: On 2/19/24 at 3:09 p.m., Resident 12 was observed seated in her recliner in her room. A finger splint was observed to her right 4th finger with clear tape wrapped around it. During an interview at that time, Resident 12 indicated she wore the splint to her 4th finger for arthritis and kept it on at all times. Staff did not assist her with taking it off or tell her if/when she should take it off. On 2/21/24 at 10:26 a.m., the resident was observed seated in her recliner in her room. A finger splint was observed on her right 4th finger with clear tape wrapped around it. During an interview at that time, Resident 12 indicated she used to have a splint for her left pinky finger as well, but it had been missing for a while and she didn't know where it was. The record for Resident 12 was reviewed on 2/21/24 at 1:21 p.m. Diagnoses included, but were not limited to, hypertension, general anxiety disorder, and arthritis. The Quarterly Minimum Data Set (MDS) assessment, dated 2/13/24, indicated the resident had impaired range of motion to the upper extremities on both sides and was moderately cognitively impaired. A Physician's Order, dated 1/6/24, indicated left 5th digit and right 4th digit finger orthotics, on at 9:00 p.m. and off at 5:00 a.m. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 2/2024, indicated the finger splints had been applied and removed as ordered. During an interview on 2/22/24 at 1:36 p.m., the Administrator indicated the pinky finger splint was missing and therapy had ordered a new one. The resident preferred to wear the finger splints at all times. They would update the orders and care plan to reflect that. 3.1-42(a)(2)

Based on record review and interview, the facility failed to provide the necessary care and services related to blood glucose testing not completed and failure to clarify medication and diabetic blood sugar level testing orders at the time of admission which resulted in the need for transport to the emergency room for evaluation for an elevated blood sugar level for 1 of 1 residents reviewed for change in condition. (Resident C) Finding includes: The closed record for Resident C was reviewed on 10/26/17 at 9:30 a.m. The resident was admitted to the facility from the hospital on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. A Clinical Admission/Readmission Evaluation, completed on 10/21/17 at 4:41 p.m., indicated the resident was admitted to facility from the hospital. The Clinician was notified on 10/22/17 at 8:00 a.m. The hospital Patent Discharge Instructions forms indicated Resident C was discharged for continued rehabilitation. The Discharge Medication list included, but was not limited to, the following: - Carvedilol (a medication to treat [MEDICAL CONDITION]) 3.125 mg (milligrams) twice a day. The medication was last given on 10/21/17 at 9:12 a.m. and the next dose was due on 10/2/17 at 9:00 p.m. - Insulin [MEDICATION NAME] ([MEDICATION NAME]) (a medication to control diabetes mellitus by lowering blood sugar levels) 10 units subcutaneous (under the skin) injection every day. The last dose time and next dose time were not completed. Review of the 10/20/17 Physician order [REDACTED]. The 10/2017 Medication Administration Record was reviewed. No [MEDICATION NAME] was signed out on 10/21/17 or 10/22/17. No Blood Glucose levels were recorded on the Medication Administration Record. The Carvedilol 3.125 mg was first signed out on 10/22/17. No 9:00 p.m. dose was administered on 10/21/17 as per the above Discharge Medication listing provided to the facility. Review of the 10/21/17 Nursing Progress Notes indicated there was no record of Nursing staff contacting the Physician to obtain clarification of the [MEDICATION NAME] administration or blood glucose testing. Progress Notes indicated the following entries: 10/22/17 at 3:30 p.m. BP 136/74, Pulse rate 72, Respiratory rate 18, Temperature 98.0 degrees Fahrenheit. 10/22/17 at 4:30 p.m., the resident was taken to the bathroom per wheelchair and stood with one assist. 10/22/17 at 4:45 p.m. the resident returned to the wheel chair and was set up for dinner. He refused to eat and requested to go back to bed. 10/22/17 at 5:00 p.m., the resident was very diaphoretic, an accucheck (blood sugar level test) was completed with elevated results of 545. BP 110/76, Pulse rate 74, Respiratory rate 18, Oxygen saturation 94% on room air. 10/22/17 at 5:05 p.m., the Physician was called and instructions were given to send the resident to the hospital. 10/22/17 at 5:10 p.m., Ambulance was called and staff were instructed to call 911 due to the inability to transfer for 90 minutes. 10/22/17 at 5:20 p.m. Fall Note indicated the resident was found on the floor by the paramedics. (Resident C) was on the floor next to the bed with blood noted on his mouth and nares. The resident was unresponsive. Paramedics were in attendance. 10/22/17 at 5:25 p.m., Paramedics here, accucheck was 416, chest compressions and resident intubated. Hospital records indicated the resident was admitted to the emergency roiagnom on [DATE]. The clinical [DIAGNOSES REDACTED]. Blood glucose level was 441. The patient experienced cardiac death. During an interview on 10/26/17 at 2:15 p.m., the Director of Nursing indicated the hospital did send a Discharge Medication List with Resident C when he was admitted . The list noted the resident was to receive [MEDICATION NAME]. The time the insulin was given and the time the next dose was due were both not completed. The evening shift Nurse on 10/21/17 wrote the medication orders on 10/21/17 when Resident C was admitted . The order for the administration of the [MEDICATION NAME] injections should have been clarified with the Physician at the time of admission. The evening dose of Carvedilol should also have been administered on 10/21/17. Both [MEDICATION NAME] and Carvedilol medications were available in the EDK (Emergency Drug Kit) kept in the facility for the Nursing staff to administer. On 10/26/17 at 1:24 p.m., the Director of Nursing provided the Nursing-[MEDICAL CONDITION] policy and indicated the policy was the one currently being used by the facility. A physician's orders [REDACTED]. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide the necessary care and services for non pressure related skin conditions related to Nursing staff not addressing a new open area, not completing weekly skin assessments as per the facility policy, and not initiating a complete assessment and ongoing monitoring of a new open area which resulted in the development of slough in the wound for 2 of 3 residents reviewed with non pressure ulcer skin conditions in the sample of 3. (Residents #C and #D) The facility also failed to provide the necessary treatment and services for non pressure wounds related to failure to act upon the Registered Dietitian's recommendations for protein supplements for 1 of 3 residents reviewed with non pressure ulcer skin conditions in the sample of 3. (Resident #B) Findings include: 1. On 6/27/13 at 9:24 a.m., CNA's #3 and #4 were observed transferring Resident #C from the wheelchair to the toilet. The resident had a foam type dressing in place covering parts of both of her buttock areas below the coccyx. The dressing was dry and intact. The record for Resident #C was reviewed on 6/27/13 at 9:40 a.m. The resident's [DIAGNOSES REDACTED]. The 5/2013 and 6/2013 Weekly Skin Observation notes were reviewed. Weekly Skin Observation Notes were completed on 5/18/13, 6/1/13, and 6/15/13. There were no Weekly Skin Observations forms completed on 5/25/13 and 6/1/13. The 6/2013 Physician orders [REDACTED]. 6/12/13- Sensi-Care Protective Barrier Cream to be applied topically every shift to the rectal area for incontinence [MEDICAL CONDITION] for 7 days. 6/20/13- Cleanse left buttock with normal saline, pat dry, apply Santyl (a medicated ointment to debride non viable skin), cover with [MEDICATION NAME] fluff daily and prn (as needed) if soiled or detached. The order was discontinued on 6/21/13. 6/21/13- Cleanse right and left buttock with cleanser, apply [MEDICATION NAME] AG and cover with [MEDICATION NAME] every three days. The order was discontinued on 6/27/13. 6/27/13- Cleanse right buttock with cleanser, pat dry, apply [MEDICATION NAME] -AG and cover with [MEDICATION NAME] Foam every three days. [MEDICATION NAME] pad to the right buttock topically every three days for incontinence [MEDICAL CONDITION]. The 6/2013 Non-Pressure Ulcer Skin Condition reports and the Pressure Ulcer Reports were reviewed and noted as follows: 6/11/13 at 9:00 p.m.- Initial Non pressure Skin Report- rash first observed to the rectal area. Physician and family notified. 6/12/13 at 4:31 p.m.- Non-Pressure Ulcer Skin Condition- incontinence [MEDICAL CONDITION] surrounding rectum, Sensicare treatment, Physician and family notified. 6/19/13 at 8:35 p.m.- Initial Pressure Ulcer Report- Right buttock pressure ulcer measuring 2.1 cm x 3 cm, no stage noted, area darkened and peri wound are reddened, no drainage. Left buttock pressure ulcer measuring 3 cm x 3 cm, no stage noted, slough (necrotic or avascular tissue separating from viable portions of a wound) tissue with moderate drainage, peri wound are reddened. Physician and family notified on 6/19/13. Treatment- apply Sensicare to bilateral buttock, turn resident side to side. 6/20/13 at 4:29 p.m.- Non-pressure Ulcer Skin Condition- rectal excoriation resolved. Physician and family notified. 6/20/13 at 6:23 p.m.- Pressure Ulcer Progress Report Right buttock- unstageable pressure ulcer, 2.1 cm x 3.0 cm, no depth, 100% dark red with no exudate or odor, edges attached, periwound red and blanching Left buttock- unstageable pressure ulcer 3.0 cm x 3.0 cm, no depth, yellow slough with thin serous exudate, no odor, edges attached, peri wound red and blanching. 6/21/13 at 4:19 p.m.- Initial Non Pressure Skin Report- Right buttock - 2.1 cm x 3.0 cm x <0.1 cm , 100% yellow slough, scant serous drainage, no odor, periwound pink and blanching. Left buttock- 3.0 cm x 3.0 cm x < 0.1 cm, 100% [MEDICATION NAME], scant serous drainage, no odor, periwound pink and blanching. Treatment- cleanse with normal saline, apply Santyl and cover with [MEDICATION NAME] Foam. The above area identified as incontinence [MEDICAL CONDITION], not pressure area per clarification. 6/26/13 (no time) Incontinence [MEDICAL CONDITION]: Right buttock- 0.6 cm x 0.6 cm- 100% [MEDICATION NAME], scant serous (blood tinged) drainage, edges flat and attached, periwound pink, blanching and intact. Left buttock- 2.2 cm x 0.6 cm- 100% [MEDICATION NAME], scant serous drainage with no odor, edges flat and attached, periwound pink Physician and family here and aware. The 6/2013 Nursing Progress Notes were reviewed. An entry made on 6/11/13 at 9:39 p.m. indicated excoriation was noted to the resident's rectal area and the resident was complaining of pain when cleansing the rectum. The Physician was notified and moisture barrier cream was applied. An entry made on 6/12/13 at 6:09 p.m. indicated the excoriation continued to the resident's rectal area and Sensi-care barrier cream was applied as ordered. There was no documentation of any open area to the resident's buttock areas from 6/11/13 through 6/18/13. The first entry made on 6/19/13 was entered at 2:51 p.m. This entry indicated the Wound Physician was in to see the resident and new orders were noted. There was no documentation of any open areas on the resident;s buttock in this entry. A "Follow up Skin Note" entry was entered on 6/20/13 at 1:56 a.m. This entry indicated at 8:00 p.m. staff advised the LPN the resident was in bed so that the resident's treatment could be done and upon assessing, the resident open areas were noted to the right and left buttock areas, the areas were cleansed and measured. An entry made on 6/21/13 at 3:54 p.m. indicated the facility Nurse Consultant was in the facility to assess the resident's right and left buttock wounds. The wounds were identified as incontinence [MEDICAL CONDITION] and not as pressure ulcers as previously noted. The 6/26/13 Wound Physician note indicated the resident was evaluated for new Incontinence Associated [MEDICAL CONDITION] . The note indicated small open areas were observed to the resident's right and left buttock areas. The right buttock area measured 2.2 cm (centimeters) x 0.6 cm and the left area measured 0.6 cm x 0.6 cm. The treatment was identified as Aquacil/AG foam every three days. When interviewed on 6/27/13 at 11:00 a.m., the facility Nurse Consultant indicated the resident developed excoriation around the rectum around the date of 6/12/13 and orders were obtained to apply Sensicare (a moisture barrier cream) every shift for 7 days. The Nurse Consultant indicated later on 6/19/13 new areas were observed on the resident's buttock areas by Nursing staff when the resident's daughter was present. The Nurse Consultant indicated the Nurse who observed the area noted an area of possible slough and the Nurse coded the area as pressure due to slough being present. The Nurse Consultant assessed the areas on 6/21/13 and described the areas as a non pressure area as the areas appeared as kissing wound on both buttocks, were not on bony prominence, and had irregular borders and the wounds were then classified as non pressure based on her above assessment. When interviewed on 6/27/13 at 2:10 p.m., the DON (Director of Nursing) indicated Resident #C's family member voiced a grievance related to a new skin area observed on the resident and an investigation was initiated related the concern. The DON indicated she reviewed the resident's record and conducted interviews with CNA's and Nurses who provided care to the resident during the time. The DON indicated CNA #1 informed her she and CNA #2 were showering the resident on the day shift on 6/19/13 and she(CNA #1) did observe an open area on the resident's buttock and CNA #2 told her that staff knew about the area. The DON indicated she did interview CNA #2 but did not write the interview down and at this time did not recall what the CNA said. The DON indicated she interviewed the evening shift LPN #1 who had worked the days before 6/20/13. The LPN had signed out every shift treatment to the resident's rectum area on 6/15/13, 6/16/13, 6/17/13, and 6/18/13 for the evening shift. LPN #1 indicated to the DON there was an open area noted on the resident's left buttock and did not recall the day it was first noted. The LPN informed the DON that the Sensicare (moisture barrier cream) was being applied and felt this treatment covered the open area. The DON indicated LPN#2 was the LPN working the evening shift on 6/19/13 when the open area was observed with the family member present. LPN #2 indicated she had not been assigned to care for the resident for several days prior to 6/19/13 and the open area was not present when she last cared for the resident. The DON indicated the LPN #1 should have notified the Wound Nurse the first time the open area was noted and the CNA's were also to notify the Nursing staff on the day shift on 6/19/13 when they were showering the resident. The DON indicated interventions put into place on 6/20/12 included providing a speciality mattress and adding dietary interventions. When interviewed on 6/27/13 at 2:20 p.m., the Wound Nurse indicated Resident #C had a treatment for [REDACTED]. The Wound Nurse indicated the area had healed and the treatment was discontinued. The Wound Nurse indicated the area that developed on 6/19/13 was a different area as it was on the resident's buttock areas. The Wound Nurse indicated neither LPN #1 or other Nursing staff informed her of any open area prior to the observation of the open area on 6/19/13. The Wound Nurse indicated she assessed the area on the next day (6/20/13) and did note some slough to the area and chose to document the area on a Pressure Report sheet instead just based on the slough. The Wound Nurse indicated the Nurse Consultant saw the area the next day and then was classified as non pressure incontinence [MEDICAL CONDITION]. The Wound Nurse indicated the Wound Doctor was seeing the resident also. When interviewed on 6/27/13 at 4:15 p.m., the facility Corporate Nurse indicated Weekly Skin assessment were not completed weekly as per the facility policy. The facility policy titled "Procedure When Wound is Found" was reviewed on 6/27/13 at 1:50 p.m. The policy was provided and identified as current by the Director of Nursing. The policy had a revised date of 6/12. The policy indicated when an open area is identified on admission or is acquired the Licensed Nurse is to assess the wound, initiate an Initial Pressure Ulcer Report or an Initial Non Pressure Ulcer Report and notify the Wound Nurse. The facility policy titled "Wound Prevention Protocol" was reviewed on 6/27/13 at 1:50 p.m. The policy was provided and identified as current by the Director of Nursing. The policy had a revised date of 4/12. The policy indicated Weekly Skin observations were to be completed by Nursing and documented in the resident's record. The policy also indicated staff were to "Inspect the entire body for any areas with redness or open areas. Inspect for dry skin, moist skin or breaks in skin. Monitor any restrictive devices, i.e. casts, splint, ace wraps, etc." 2. On 6/27/13 at 10:40 a.m., Resident #D was observed in bed. The resident had a thin [MEDICATION NAME] type dressing in place over parts of both buttock areas. The skin around the dressing was pink and intact. On 6/27/13 at 4:40 p.m., the resident was observed in bed. There was a thin [MEDICATION NAME] type dressing covering over parts of the residents right and left buttock areas. The Nurse Consultant and the Wound Nurse were present at this time and rolled back the area of the dressing on the resident's left buttock area. The skin was bright pink and the skin was intact with no open area. The record for Resident #D was reviewed on 6/27/13 at 3:40 p.m. The resident's [DIAGNOSES REDACTED]. The 6/2013 Nursing Progress Notes were reviewed. An entry made on 6/24/13 at 3:18 a.m. indicated the [MEDICATION NAME] to the resident's coccyx was changed an a small open area approximately 1 cm (centimeter) x 1 cm was noted to the left inner buttock. The wound bed was pink and no drainage or odor was noted. The Physician was notified. Review of the Nursing Progress notes from 6/24/13 through 6/27/13 indicated there was no further documentation related to the above open area noted to the left buttock on 6/24/13 at 3:18 a.m. The following Non Pressure Skin Condition Progress reports were reviewed. 5/17/13- right and left buttock incontinence [MEDICAL CONDITION] almost resolved. 5/24/13- right and left buttock areas, intact, red and blanching. 5/31/13- right and left buttock areas pink and blanching. 6/7/13- right and left buttock blanching resolved. 6/14/13- fungal rash to the buttocks. Treatment [MEDICATION NAME] cream every shift. 6/21/13- left buttock with 1.0 cm x 1.5 cm light red blanchable area, coccyx 7.0 cm x 5.0 cm area 1 cm x 1.5 cm light red blanchable area. 6/27/14 - right buttock 2 cm x 2 cm x < 2.0 cm. superficial red, incontinence [MEDICAL CONDITION]. The 6/2013 TAR (Treatment Administration Record) was reviewed. The following treatment orders were noted: 6/14/13- [MEDICATION NAME] signal dressing- to apply to the coccyx topically every night for Stage I pressure ulcer. 6/14/13- Apply [MEDICATION NAME] cream (a topical ointment to treat fungal rashes or infections) to the buttock every shift. A Dietary Progress Note was completed by the RD (Registered Dietitian) on 6/26/13 at 11:46 a.m. The note indicated the RD was aware of new areas to the coccyx and left buttock. The note also indicated the resident was receiving tube feeding and an oral diet. When interviewed on 6/27/13 at 4:30 p.m., the Wound Nurse indicated she observed redness to the right buttock area but did not recall observing or being notified of an open area to the resident's left buttock on 6/24/13. The Wound Nurse indicated she was not aware of any pressure ulcers to the area. The Wound Nurse indicated the Nurses are to fill out an "Initial Pressure or Initial Non Pressure" wound note electronically in the computer and every morning she access the computer and is able to retrieve all new initial wound reports. The Wound Nurse indicated the Nurse on 6/24/13 should have completed one of the above. The facility policy titled "Procedure When Wound is Found" was reviewed on 6/27/13 at 1:50 p.m. The policy had a revised date of 6/2012. The DON provided the policy and indicated the policy was current. The policy indicated when an open area was identified the Nurse was to initiate either an initial pressure ulcer report or an initial non-pressure ulcer report and the Wound Nurse was to be notified of the area. 3. The record for Resident #B was reviewed on 6/27/13 at 3:30 p.m. The resident's [DIAGNOSES REDACTED]. The 5/29/13 Nutrition Risk progress note was reviewed. The note was completed by the RD (Registered Dietitian). The note indicated there was small crack in the resident's skin at the buttock. The note indicated the resident's nutritional assessment score was 6.0 which indicated malnourished, possibly from decreased food intake, limited mobility, and recent urinary tract infection. The RD noted the resident was receiving a pureed diet and her oral intake may not be meeting her estimated needs. The RD recommended Promod (a liquid protein supplement) 30 ml (milliliters) daily as the resident would benefit from extra protein. The 5/13 and 6/13 Physician orders [REDACTED]. Review of the 5/13 and 6/13 Nursing Progress Notes indicated there was no documentation related to the above RD 5/29/13 recommendation for a protein supplement. When interviewed on 6/27/13 at 5:05 p.m., the Nurse Consultant indicated the 5/29/13 RD recommendations had not been acted upon. The facility policy titled "Resident Weight Evaluation" was received from the Nurse Consultant on 6/17/13 at 5:20 p.m. The policy had a revised date of 6/2012. The Nurse Consultant indicated she just received the policy from Corporate. The policy indicated recommendations made by the RD were to be acted upon in timely manner by the charge Nurse and supervised by the DON or designee. This federal tag relates to Complaint IN 431. 3.1-37(a)