Every finding on record at Amber Manor Care Center

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the state agency timely for 1 of 1 allegations of abuse reviewed. Following an allegation of abuse, the facility failed to report the allegation to the state agency within the required timeframe. (Resident D)Finding includes:A review of grievances on 7/6/26 at 11:30 A.M. included a concern from Resident D's family member regarding the resident's care on 6/14/26. A review of facility reported incidents on 7/6/26 at 11:40 A.M. included an incident reported on 6/15/26 at 9:58 A.M. The facility reported incident included that Resident D stated she had been fondled during the night by a woman with short blonde hair. Record review on 7/6/26 at 2:00 P.M. included Resident D's progress notes that were not limited to a noted dated 6/14/26 at 5:30 P.M. The nurse's progress note indicated Resident D and her family member verbalized care concerns. The Facility Administrator and Social Service Director (SSD) were notified and a head to to assessment was completed without new findings. A review of the facility's investigation of the incident on 7/6/26 at 2:20 P.M. included a typed statement from the SSD signed 6/15/26. The statement indicated the SSD was notified by the Facility Administrator that Resident D's daughter filed a complaint that Resident D verbalized she had been sexually fondled. During an interview with the resident, she stated She fondled me, she fondled me and She also told me I had a pretty butt.Interview on 7/6/26 at 2:50 P.M., the SSD indicated she received a call on 6/14/26 (Sunday)regarding the incident. Since she lived closer than the Facility Administrator and Director of Nursing (DON) she came into the facility to speak with the resident and family. The SSD indicated she did not have access to report the allegation to the state agency and that the Facility Administrator usually reported incidents to the state agency. Interview on 7/6/26 at 2:55 P.M., the Facility Administrator indicated she reported the allegation to the state agency the following day on 6/15/26. On 7/7/26 at 10:05 A.M., the DON supplied a facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, dated 11/19/25. The policy included, .g) Reporting/Response . iii. Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 of 3 residents reviewed for death. Resident records contained documentation that the drug Morphine Sulfate was administered on multiple occasions while the resident did not receive the medication. (Resident D)Finding includes:A record review on 7/6/26 at 2:00 P.M., Resident D's diagnoses included, but were not limited to dementia and respiratory failure. Resident D's most recent Significant Change Minimum Data Set (MDS) assessment, dated 3/20/26, indicated the resident had severe cognitive impairment and received hospice services. A list of allergens for Resident D included, but were not limited to, Morphine Sulfate. Nurse's notes included, but were not limited to the following:6/7/26 at 2:45 P.M. - Resident continued to be lethargic. Morphine & Ativan given once that shift to keep comfortable. 6/8/26 at 11:54 A.M. - Triage updated with new orders. Morphine and Ativan given, resident had been comfortable.6/9/26 at 11:58 P.M. - Routine Morphine Concentrate and Lorazepam administered as ordered. 6/11/26 at 12:04 A.M. - Routine Morphine Concentrate and routine Lorazepam administered as ordered. 6/14/26 at 2:56 A.M. - Routine Morphine Concentrate and routine Lorazepam continued as ordered. 6/14/26 at 5:30 P.M. - Scheduled doses of Ativan and Morphine around 5:30 A.M. Medications given with effectiveness. 6/19/26 at 5:52 A.M. - Resident continued to receive routine Morphine and Ativan. As needed Morphine and Ativan given during the night.6/20/26 at 5:46 A.M. - Resident continued to get routine Morphine and Ativan every six hours.Physician orders did not include an order for routine or as needed Morphine. Resident D's Medication Administration Record (MAR) for the month of June, 2026 contained no documentation that the resident received Morphine Sulfate at any time. Interview on 7/6/26 at 2:25 P.M. RN 4 indicated Resident D did not have a physician's order to receive Morphine and the nursing staff may have documented in error that the resident had received the medication as the resident had received hospice services and Morphine being a typical routine hospice medication.Interview with the facility pharmacy on 7/7/26 at 9:55 A.M. indicated the pharmacy never filled an order for Morphine for Resident D and that Resident D had never been charged for the medication due to staff pulling Morphine from the facility Emergency Drug Kit (EDK). Interview on 7/7/26 at 10:00 A.M., RN 8 indicated the facility did not have a facility policy related to the accuracy of nursing documentation. This citation relates to intake 3040752 . 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to follow an antibiotic stewardship program that monitored unnecessary antibiotic use for 2 of 2 residents reviewed for antibiotic use. Residents did not receive antibiotics as ordered by the physician. (Resident 2, Resident 1)Findings include:1. On 8/6/25 at 1:00 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive uropathy. The most recent annual Minimum Data Set (MDS) Assessment, dated 6/18/25, indicated Resident 2 was cognitively intact, independent for transfers and toileting, and had an indwelling urinary catheter. A current Urinary Tract Infection (UTI) Care Plan, last reviewed 7/15/25, included, but was not limited to, an intervention to administer medications and treatments as ordered. Resident 2's clinical record indicated that from 1/1/25 through present, he had the following UTIs: UTI 1On 3/6/25, the resident complained of drainage from his penis. A urine culture, resulted 3/5/25, indicated multiple bacterial morphotypes which could be possible contamination. The Medical Doctor (MD), ordered treatment with Bactrim DS (antibiotic) 800-160 milligrams (mg) by mouth (po) twice daily for 7 days to start 3/6/25 due to the resident's positive urinalysis and symptoms. UTI 2On 4/3/25, the resident complained of burning from his penis at his urology appointment. The MD diagnosed him with a UTI and ordered treatment with Macrobid 100 mg (antibiotic) po daily for 5 days to start on 4/4/25. The resident received 6 doses of the antibiotic instead of the 5 doses as ordered.UTI 3On 7/14/25, the resident was taken to the Emergency Department with complaints of bladder spasms and urine leaking from his suprapubic catheter site. The urine culture, resulted 7/16/25, indicated >100,000 colonies/milliliter (col/ml) of Escherichia Coli (E. Coli-type of bacteria). The MD diagnosed him with a UTI and ordered treatment with Omnicef (antibiotic) 300 mg po twice daily for 5 days to start 7/15/25. The resident received 11 doses of the antibiotic instead of the 10 doses as ordered. 2. On 8/7/25 at 10:33 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, history of UTIs, and parkinson's disease. The most recent quarterly MDS assessment, dated 4/29/25, indicated Resident 1's cognition was moderately impaired, was independent for toileting and transfers, always continent of bowel and bladder, and had a UTI in the past 30 days. A current UTI Care Plan, last reviewed 7/23/25, included, but was not limited to, an intervention to administer medications and treatments as ordered. Resident 1's clinical record indicated that from 1/4/25 through present, she had the following UTIs: UTI 1On 4/16/25, the resident was experiencing increased incontinence episodes. A urine culture, resulted 4/18/25, indicated >100,000 col/ml of the bacteria aerococcus urinae. The MD diagnosed her with a UTI and ordered treatment with Amoxicillin (antibiotic) 500 mg po three times a day for 7 days to start 4/18/25. The resident received 25 doses of the antibiotic instead of the 21 doses as ordered.UTI 2On 5/13/25, the resident was experiencing increased urinary frequency. On 5/14/25, the resident became more confused, lousy feeling, and needed assistance of 2 staff for transfers. The MD ordered Rocephin (antibiotic) 1 gm intramuscularly (IM) once that day and indicated to wait on urine culture results for more orders. The urine culture, resulted 5/16/25, indicated >100,000 col/ml of E. coli. The MD diagnosed her with a UTI and ordered treatment with two additional doses of Rocephin 1 gm IM daily for 2 days to start 5/16/25.UTI 3On 7/21/25, the resident was experiencing increased urinary frequency and urgency. A urine culture, resulted 7/23/25, indicated >100,000 col/ml of E. Coli. The MD diagnosed her with a UTI and ordered treatment with Bactrim DS (antibiotic) 800-160mg po twice daily for 7 days to start 7/23/25. The resident received 16 doses of the antibiotic instead of the 14 doses as ordered. During an interview on 8/8/25 at 1:25 P.M., the Director of Nursing (DON) and the Regional Consultant were unaware of any facility concerns with antibiotics not being administered as ordered and would expect staff to follow the physician's orders. On 8/4/25 at 12:10 P.M., a current Antibiotic Stewardship Policy, last reviewed 11/10/17, was provided by the Administrator and indicated, Purpose: Optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. Encompass a facility-wide system to monitor the use of antibiotics .

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTIs) for 1 of 2 residents reviewed for urinary tract infections (UTIs). A resident with a history of UTIs and an indwelling suprapubic urinary catheter was observed with his urinary catheter bag hanging on a trash can containing used gloves and paper towels. (Resident 2) Finding includes:On 8/5/25 at 9:30 A.M., Resident 2 was observed sitting in the recliner in his room with his indwelling urinary catheter bag hanging on a trash can to his left next to the regular trash can. The trash can labeled for catheter use only contained used gloves and paper towels that were touching the urinary catheter bag. At that time, the resident indicated that he had a suprapubic urinary catheter, a history of UTIs, and slept and sat in his recliner. Staff instructed him to hang the urinary catheter bag on the trash can labeled for catheter use only. He indicated the trash can designated for his catheter was sometimes used by staff to discard trash before leaving his room, instead of his regular trash can. On 8/6/25 at 1:00 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive uropathy. The most recent annual Minimum Data Set (MDS) Assessment, dated 6/18/25, indicated Resident 2 was cognitively intact, independent for transfers and toileting, and had an indwelling catheter. Current Physician's Orders included performing suprapubic catheter care on Resident 2 each shift, last ordered 6/11/25. A current Indwelling Catheter Care Plan, last reviewed 7/9/25, included, but was not limited to, interventions to provide assistance with catheter care and observing the tubing and urinary catheter bag. The plan of care lacked documentation indicating the resident used a trash can to hang his catheter bag on or that he was non-compliant with keeping the trash can labeled for catheter use only, free of trash. Resident 2's clinical record indicated that from 1/1/25 through the present, he had the following UTIs: On 3/6/25, the resident complained of drainage from his penis. A urine culture, performed on 3/5/25, indicated multiple bacterial morphotypes, which could be possible contamination. The Medical Doctor (MD), ordered treatment with Bactrim DS (antibiotic) 800-160 milligrams (mg) by mouth (po) twice daily for 7 days due to the resident's positive urinalysis and symptoms. On 4/3/25, the resident complained of burning in his penis at his urology appointment. The MD diagnosed him with a UTI and ordered treatment with Macrobid 100 mg (antibiotic) po daily for 5 days. On 7/14/25, the resident was taken to the Emergency Department with complaints of bladder spasms and urine leaking from his suprapubic catheter site. The urine culture 7/16/25, indicated >100,000 colonies/milliliter (col/ml) of Escherichia Coli (E. Coli-type of bacteria). The MD diagnosed him with a UTI and ordered treatment with Omnicef (antibiotic) 300 mg PO twice daily for 5 days. On 8/7/25 at 10:42 A.M., suprapubic catheter care was performed by the Director of Nursing (DON) and the Infection Preventionist (IP). Upon entering the room, Resident 2's urinary catheter bag was observed hanging on the trash can to the left of his recliner, labeled for catheter use only. The trash can contained used gloves and a cup in it. At that time, the DON indicated the trash can containing the catheter bag should not have any trash in it and should only be used to place the catheter bag on, since there wasn't an acceptable place to hang it on the resident's recliner. Then, DON removed the bag of trash from the trash can and indicated they would have to do something different to keep trash out of the trash can designated for catheter use only. On 8/11/25 at 11:12 A.M., a current Urinary Catheter Care Policy, last reviewed 12/16/24, was provided by the Administrator and indicated, Objective: To prevent infection of the resident's urinary tract . After completion of the procedure: check drainage tubing and bag to ensure the catheter is positioned properly . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 1 of 3 observations of care. Staff failed to complete hand hygiene after removing their gloves and staff performed handwashing with less than a 20 second scrub time. (Resident D) Finding includes: During an observation on 1/15/25 at 11:15 A.M., Certified Nurse Aide (CNA) 3, CNA 6, and CNA 11 assisted Resident D with toileting. CNA 6 and CNA 11 assisted Resident D from her recliner to a bedside commode and removed the resident's brief. CNA 11 and CNA 6 both removed their gloves and performed handwashing. CNA 11 performed handwashing with a 10 second scrub time. CNA 3, CNA 6, and CNA 11 then assisted Resident D to stand from the commode, perform perineal care, apply a new brief, and pulled the resident's pants up. CNA 3 then placed a wheelchair behind Resident D as CNA 6 and CNA 11 lowered the resident into the chair. CNA 3 then removed gloves and performed handwashing with a 5 second scrub time. CNA 6 performed handwashing with a 9 second scrub time. CNA 6 removed her gloves and handed Resident D a tissue to wipe her face prior to performing hand hygiene. During an interview on 1/15/25 at 11:45 A.M., the Director of Nursing (DON) indicated that if/when contracted staff in the facility providing care to residents, they would be expected to follow the facility's policies. The DON indicated all staff should perform handwashing with at least a 20 second scrub time. On 1/15/25 at 12:40 P.M., the DON supplied a facility policy titled, Guidelines for Handwashing/Hand Hygiene, dated, 12/17/24. The policy indicated, .3. Health Care Workers (HCW) shall use hand hygiene at times such as: .c. Before/after having direct physical contact with residents. d. After removing gloves . 1. Handwashing . c) Wash well for at least 20 seconds, using a rotary motion and friction . This citation relates to complaint IN00449891. 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to adequately monitor signs and symptoms of adverse reactions to newly prescribed pain medications for 1 of 3 residents reviewed for pain. No routine monitoring of adverse reactions were documented in the resident's record while the resident displayed signs of decreased alertness and increased difficulty with mobilization and eating following an increase in the resident's pain medication regimen. (Resident D) Finding includes: During an observation on 1/14/25 at 11:15 A.M., Resident D was sitting up in a recliner in her room. Resident D did not respond when spoken to and appeared to be asleep. Resident D was holding a television remote control in her right hand, pushing the controller to cause the television channel menu to scroll continuously. During an observation on 1/14/25 at 11:42 A.M., Resident D was sitting in the same position in her recliner while the television channel menu continued to scroll. During record review on 1/14/25 at 12:00 P.M., Resident D's diagnoses included but were not limited to, migraines, chronic pain, convulsions, gout, opiod dependence, pain in left hand, and Parkinson's disease. Resident D's most recent Significant Change Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident was cognitively intact, had unclear speech, was able to make self understood, and required partial to moderate assistance with eating. Resident D's quarterly MDS assessment, dated 11/6/24, indicated the resident was cognitively intact, had clear speech, was able to make self understood, and required supervision with eating. Resident D's care plan included, but was not limited to, Resident is at risk for pain due to decreased mobility, oseoarthritis, migraines, and chronic pain (initiated 9/22/22). Interventions included, but were not limited to, administer medications as ordered and notify physician for any side effects observed. Resident D's physician order's included, but were not limited to, gabapentin 600 milligrams (mg) for chronic pain (started 9/29/23), acetaminophen 325 mg every six hours for pain (started 12/25/24), hydrocodone-acetaminophen 10-325 mg for moderate pain every six hours as needed (started 11/26/23), oxycodone 10 mg for severe pain every two hours as needed (started 12/28/24), and fentanyl 72-hour patch 50 micrograms (mcg) per hour for pain once every three days (started 12/31/24). Resident D's Medication Administration Record (MAR) for the months of December 2024 and January 2025 indicated that the resident received her first dose of oxycodone 10 mg on 12/28/24 at 5:27 P.M. Resident continued to receive oxycodone 10 mg as needed for pain on; 12/29/24 at 3:32 P.M., 12/30/24 at 1:10 P.M., 3:14 P.M., and 7:21 P.M., 12/31/24 at 1:23 A.M., 1/1/25 at 6:44 A.M., 1/2/25 at 10:38 P.M., 1/8/25 at 2:55 P.M., 1/10/25 at 5:36 P.M., 1/13/25 at 4:50 P.M., and 1/14/25 at 10:42 A.M. Resident D also received hydrocodone-acetaminophen 10-325 mg as needed for pain on 12/29/24 at 10:01 A.M., 1/2/25 at 5:15 A.M., 1/6/25 at 11:18 P.M., 1/7/25 at 6:59 P.M., 1/8/25 at 8:21 A.M., 1/9/25 at 8:58 A.M., 1/10/25 at 1:31 A.M., 1/11/25 at 11:23 A.M. and 8:00 P.M., 1/12/25 at 1:53 A.M., 1/13/25 at 12:29 A.M. and 8:13 P.M. Resident D's nurses progress notes included, but were not limited to, the following: 12/20/24 at 6:33 P.M. - Triage contacted regarding resident pain becoming unmanageable. Resident moans and yells out in pain. Resident has been on hydrocodone-acetaminophen (Norco) at home for several years per family which may be why this medication is not effective if resident has built up a tolerance over the years. 12/24/24 at 1:10 A.M. - Resident is alert and responsive. Speech is slurred a per typical for resident but resident is able to express wants and needs. 12/23/24 at 3:33 P.M. - Orders received for hospice evaluation. 12/30/24 at 5:21 P.M. - New order received and noted to apply a fentanyl patch 50 mcg once every 3 days for pain. 1/6/25 at 2:48 P.M. - Resident has been very hard to transfer today. During an observation and interview on 1/14/25 at 2:05 P.M., Licensed Practical Nurse (LPN) 8 indicated that Resident D was hard of hearing and that she could answer questions and make self understood. LPN 8 then tried arouse Resident D while she slept in her recliner. Resident D had saliva hanging from her chin to her chest. LPN 8 was unable to arouse Resident D at the that time. LPN 8 indicated that Resident D did go in and out of alertness. During an interview on 1/1425 at 2:40 P.M., Resident D's family member indicated the resident has had a decline in her alertness and had nearly stopped talking over the past two weeks. Resident D's family member indicated they had noticed Resident D would seem to be more alert in the evening hours. During an interview on 1/15/25 at 12:10 A.M., Registered Nurse (RN) 4 indicated that if a resident was experiencing increased pain and began a new pain regimen, nursing staff would create a pain event that would trigger staff to assess and monitor the resident for pain levels, effectiveness of medications, and for signs or symptoms of adverse reactions from the medications. RN 4 indicated if increased lethargy was observed, that would be documented in the pain event or in the nurse's progress notes. During an interview on 1/15/25 at 11:00 A.M., hospice nurse 7 indicated that the contracted hospice nurse had been visiting Resident D twice a week since her admission to hospice. Hospice nurse 7 indicated that hospice does monitor the resident for any adverse reactions to new medications, but that they rely on the routine monitoring by the facility nursing staff. Hospice nurse 7 indicated that she was not very familiar with Resident D as she was not typically her nurse and had not yet met the resident. During an observation and interview on 1/15/25 at 11:15 A.M., Certified Nurse Aide (CNA) 6 and CNA 11 entered Resident D's room to assist her with toileting. Resident D was sitting in her recliner and appeared to be sleeping. CNA 6 was able to arouse Resident D. CNA 6 spoke to Resident D and the resident stood with the assist of 2 and transferred to a bedside commode. Resident D responded quietly and was difficult to understand. CNA 6 indicated Resident D's level of consciousness and alertness had declined since starting hospice and the increase in pain medications. CNA 6 indicated that the resident used to hear her room door when staff knocked and would respond, but lately staff have been having to wake her up when they come in to assist her. During an interview on 1/15/25 at 12:35 P.M., RN 2 indicated that if a resident displayed increased pain or started a new pain regimen, a change in condition or pain event would be created and any signs of increased drowsiness or other adverse reactions to any new pain medications would be documented. If a decrease in alertness was noted, triage would be contacted and notified. During an interview on 1/15/25 at 12:40 P.M., the Director of Nursing (DON) indicated that no events were created for Resident D regarding her new pain medications because the chronic pain had been an ongoing issue. On 1/15/25 at 2:45 P.M., the DON provided Resident D's hospice notes. The notes included, but were not limited to: 12/26/24 at 6:45 A.M. - Resident is alert to name. Resident is hard to understand. Resident denies pain. 12/27/24 at 12:25 P.M. - Resident was in chair in her room. Resident was hard to understand because of a low voice level. Resident read from her newspaper during the entirety of the visit. 12/30/24 at 4:05 P.M. - Resident was sitting in wheelchair upon arrival and very uncomfortable, moaning in pain. Facility nurse gave oxycodone one hour prior to visit and resident still in considerable pain. New order for fentanyl Duragesic patch 50 mcg, change every 72 hours was obtained. 12/31/24 at 2:24 P.M. - Resident was very lethargic this morning. Facility staff stated the resident did not respond very well and was difficult to awaken this morning and did not want to eat breakfast. Resident had been continuing to require pain medication. Fentanyl patch was applied this morning after breakfast. 1/1/15 at 10:50 A.M. - Resident was not responsive during visit. Facility nurse state she was up for breakfast and did eat well and was awake and alert. Resident was moaning in pain this morning and nurse administered oxycodone. Resident relaxed after that. 1/2/25 at 1:24 P.M. - Resident is alert but very drowsy. She opens eyes to answer questions and then drifts back to sleep but remains easily rousable. 1/4/25 at 5:19 P.M. - Resident resting comfortably in recliner. Patient's pain is much more controlled. 1/9/25 at 6:29 P.M. - Resident asleep upon arrival. She did open her eyes but did not respond very much today. She did state, no when asked if any pain. On 1/15/25 at 3:00 P.M., a facility policy titled, Guidelines for Pain Observations and Management, dated 12/17/24, was reviewed. The policy indicated, Purpose . To ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual . 4. If there is a change in pain indicators or verbalizations from the resident, a pain event form will be completed to indicated the changes and care plan update . 7. Evaluate the effectiveness of pain management interventions and modify as indicated. This citation relates to complaint IN00449735. 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure physician notification prior to or after administration of an excessive dose of a medication as ordered for 1 of 2 residents reviewed for pain. (Resident 21) Finding includes: On 7/9/24 at 10:04 A.M., Resident 21's clinical record was reviewed. Diagnosis included, but were not limited to, epilepsy and arthritis. The most recent Annual MDS (Minimum Data Set) Assessment, dated 5/3/24, indicated a moderate cognitive impairment. Resident 21 had received scheduled pain medication. Current physician orders included, but were not limited to: acetaminophen capsule 650 mg (milligram) twice a day for mild pain (6:00 A.M. - 10:00 A.M., 6:00 P.M. - 10:00 P.M.), dated 7/27/23. acetaminophen capsule 650 mg oral every 4 hours as needed for fever, DO NOT exceed 3000mg acetaminophen in 24 hr period, dated 7/27/23. acetaminophen tablet 650 mg every 4 hours as needed for pain, DO NOT exceed 3000mg acetaminophen in 24 hr period, dated 7/27/23. Resident 21's Medication Administration Record (MAR) for July 2024 indicated acetaminophen 650mg was administered on the following dates: 7/5/24 at 1:27 P.M. (as needed dose) 7/5/24 6-10 P.M. scheduled dose 7/6/24 at 12:21 A.M. (as needed dose) 7/6/24 at 5:13 A.M. (as needed dose) 7/6/24 6-10 A.M. scheduled dose 7/6/24 at 1:03 P.M. (as needed dose) Total amount of acetaminophen administered for the 24 hour period was 3900mg. On 7/10/24 at 9:55 A.M., Licensed Practical Nurse (LPN) 5 indicated staff was expected to add up all acetaminophen milligrams that had been given prior to giving an as needed dose to ensure they did not go over 3000mg in a 24 hour period. LPN 5 indicated if Resident 21 required a dose over the 3000mg limit, staff could either ask the resident if she would want to wait until it could be given, or staff could call the physician to request a different pain medication to give. LPN 5 indicated any communication with the physician would be placed in the progress notes. On 7/10/24 at 2:13 P.M., the Director of Nursing (DON) indicated staff was expected to monitor Resident 21's acetaminophen intake to make sure it did not go over 3000 mg in a 24 hour period. On 7/12/24 at 10:14 A.M., the DON provided a current Physician Notification policy, dated 9/17/17 that indicated To ensure the resident's physician or practitioner . is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care . Attempts to notify the physician/provider and their response should be documented in the resident electronic health record 3.1-5(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 5 residents during observation of perineal care. Staff touched items with gloved hands, gloves were not changed between dirty and clean tasks during perineal care, and staff failed to wash hands or sanitize between dirty and clean tasks. During a random observation, staff failed to don gloves to empty a urinal (Resident 33, Resident 150, Resident 301) Findings include: 1. During an observation on 7/10/24 at 9:47 A.M., Certified Nurse Aide (CNA) 7 and CNA 9 performed incontinence care on Resident 33. CNA 9 used 1 wipe to clean Resident 33's vaginal area, then Resident 33 rolled to her right side and CNA 9 used 1 wipe to clean Resident 33's rectal area/buttocks. At that time, CNA 9 failed to removed gloves and perform hand hygiene before she obtained a clean brief. 2. During an observation on 7/10/24 at 11:10 A.M., CNA 7 and CNA 9 performed incontinence care on Resident 150. CNA 7 used her gloved hand to pull the curtain in the room and then used both gloved hands to use the remote to lower Resident 150's head of the bed. CNA 9 failed to change gloves before she cleaned Resident 150's perineal area and stool off of his rectal area/buttocks. 50827 3. On 7/8/24 at 10:45 AM a random staff member in blue uniform was observed emptying a urinal in a resident's room without wearing gloves. During an interview on 7/10/24 at 1:32 P.M., the Infection Preventionist (IP) indicated gloves should be changed and hand hygiene should be performed between dirty and clean tasks, and staff should obtain new gloves prior to providing direct care to a resident if they touched items in the room. On 7/12/24 at 10:20 AM a Standard Precautions Guidelines policy provided by the facility was reviewed. The policy indicated In addition to proper hand hygiene, it is important for staff to use appropriate protective equipment such as a barrier to exposure to any body fluids gloves and other equipment such as gowns and masks are to be used as necessary to control the spread of infections. On 7/10/24 at 2:17 P.M., the IP provided a Guideline for Handwashing/ Hand Hygiene policy, revised 2/9/17, that indicated, .Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub .1. All health care workers shall utilize hand hygiene frequently and appropriately .d. After removing gloves, worn per Standard Precautions for direct contact with excretions . 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with the resident's orders and care plans for 1 of 2 residents observed and reviewed for respiratory care (Resident 5). Findings include: On 7/8/24 at 1:48 PM Resident 5 was observed resting in bed, oxygen concentrator was observed to be set to 1LPM(liter per minute). On 7/10/24 at 1:54 PM Resident 5's clinical record was reviewed. Diagnoses included but were not limited to pulmonary fibrosis and COPD (chronic obstructive pulmonary disease). The most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 5 is cognitively intact, had no behaviors, required substantial or maximum assistance from staff with bathing, transfers, and toileting, and used oxygen while a resident. Current physician orders included, but were not limited to: Continuous administration of oxygen at 2LPM per nasal cannula, dated 4/27/24. Assess/observe for signs and symptoms of shortness of breath while laying flat related to chronic lung disease, dated 4/27/24. Head of bed to be elevated to alleviate or reduce shortness of breath while laying flat related to chronic lung disease, dated 4/27/24. A current oxygen care plan related to COPD, dated 7/19/2018. Care plan had interventions as following but not limited to administer oxygen per orders, dated 7/19/2018. Observe and report signs of respiratory distress such as restlessness, wheezing, dyspnea (shortness of breath), difficulty with expectoration (coughing up phlem), diaphoresis (appearing pale and sweating), crackles, bubbling, tachycardia (elevated heart rated above 100 beats per minute), cyanosis (skin appearing blue) decreased breath sounds dated 7/19/2018. Resident requires elevation of head due to shortness of breath while lying flat as needed, dated 7/19/2018. Care plan dated 8/17/2018 related to COPD included intervention elevate head of bed or place in upright position. That intervention was dated 8/17/2018. On 7/10/24 at 9:55 AM Resident 5 was observed resting in bed, oxygen concentrator was observed to be set at 1LPM. On 7/10/24 observed CNA 2 and CNA 4 perform incontinence care on Resident 5 prior to getting her out of bed. CNA 2 lowered the Resident's head of bed prior to performing incontinence care at 11:17 AM. Resident 5 then removed her nasal cannula, of which was administering her oxygen, and handed it to CNA 4. CNA 4 placed it in storage bag connected to the stationary oxygen concentrator in the resident's room. CNA 4 left room to get supplies for incontinence care at that time. Resident remained flat in bed without supplemental oxygen and nasal cannula in place. When CNA 4 returned, care was provided. CNA 2 and CNA 4 assisted resident to the side of the bed, preparing to transfer to wheelchair. Resident 5 was observed to be audibly wheezing. Resident 5 was observed for 20 minutes without supplemental oxygen or nasal cannula in place during care and was not offered oxygen during the process. On 7/10/24 at 2:18 PM DON (Director of Nursing) indicated that if a resident had a care plan for the head of the bed to be elevated due to chronic lung disease and staff observed signs of respiratory distress during care, staff would be expected to stop what they are doing and allow the resident to recover before finishing care. On 7/12/24 at 9:57 AM it was observed that Resident 5 was resting in bed without head of bed elevated. At that time resident indicated that it is common to have oxygen off and the head of her bed flattened when CNAs are caring for her. Indicated that if she were to tell staff she is short of breath, they would put her nasal cannula and oxygen back on her. Resident verbalized she feels like she is getting enough oxygen through her tank and nasal cannula. On 7/12 at 10:01 AM RN (Registered Nurse) 6 indicated Resident 5 has an order for 2L continuous oxygen via nasal cannula. Also indicated it is expected staff or CNAs caring for the residents to notify the nurse if oxygen was not administered correctly so that it may be corrected. Asked that RN 6 look at Resident 5's oxygen concentrator to ensure it is set correctly. RN 6 observed it to be set at 1L, increased it to 2L per what resident is ordered for. RN 6 also raised Resident 5's head of bed at that time, as it was not elevated. On 7/12/24 at 10:15 AM the ADON (Assistant Director of Nursing) indicated it is facility policy to follow a resident's orders and care plan. On 7/12/24 at 10:40 AM an Administration of Oxygen policy dated 5/2018 was reviewed. It indicated that oxygen setting must be set and adjusted by a licensed nurse and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to post daily staffing in 2 of 2 halls on 1 of 5 days and in 1 of 2 halls on 3 of 5 days during the survey. (East Hall, West Hall) Findings include: On 11/6/17 at 10:10 A.M., an observation of the East Hall found staff posting had not been updated. The posting was dated 11/3/17. On 11/6/17 at 10:20 A.M. an observation of the West Hall found staff posting had not been updated. The posting was dated 11/3/17. On 11/7/17 at 11:06 A.M., an observation of the West Hall found staff posting was dated 11/3/17. On 11/9/17 at 11:44 A.M., an observation of the East Hall found staff posting was dated 11/8/17. On 11/14/17 at 9:07 A.M., the DON (Director of Nursing) indicated staff posting is changed during the weekend by the TCU (Transitional Care Unit) Nurse and the Staffing Nurse posts daily staffing at 11:00 A.M. through the week. On 11/14/17 at 11:16 A.M., an observation of the East Hall found staff posting was dated 11/13/17. On 11/14/17 at 9:20 A.M., the DON provided the facility policy for staff posting. The policy read as follows: .1. At the beginning of the day the number and amount of hours of licensed nurses (RN and LPN) and the number and hours of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted .

Based on observation and interview, the facility failed to ensure the environment was sanitary and comfortable, in that, bathrooms were free of pervasive urine odor, walls were free from holes, and resident rooms and bathrooms were free from flies in 5 of 30 rooms reviewed during the survey. (Room 104, Room 112, Room 113, Room 117, Room 124) Findings include: 1. On 11/6/17 at 11:20 A.M., the shared bathroom in room 104 had a urine odor. On 11/8/17 at 1:08 P.M., the shared bathroom in room 104 had a urine odor, a yellow substance was observed in the bottom of the toilet bowl, a fly was observed on the bottom of the toilet, and multiple pencil eraser-sized holes were observed in the wall behind the toilet. 2. On 11/6/17 at 12:06 P.M., the shared bathroom in room 113 had a very strong urine odor. On 11/8/17 at 1:03 P.M., the shared bathroom in room 113 had a very strong urine odor, an open urinal was observed hanging on the handrail in the bathroom with a yellow substance in the bottom, and multiple flies were observed flying around in the room. 3. On 11/6/17 at 11:43 A.M., the bathroom in room 112 had a strong urine odor. On 11/14/17 at 9:01 A.M., the bathroom in room 112 had a urine odor. 4. On 11/6/17 at 11:46 A.M., a fly was observed flying around room 124. On 11/8/17 at 12:48 P.M., multiple flies were observed flying around in room 124 and in the doorway. An open bag of marshmallows and chocolate chips were observed lying on a shelf. A Styrofoam cup with a plastic lid and straw was observed on the bedside table halfway filled with a brown liquid, and a dark brown substance under the lip of the lid. 5. On 11/8/17 at 12:53 P.M., a fly was observed flying around the doorway of room 117. On 11/14/17 at 9:13 A.M., the Maintenance Man indicated the pest control company came once a month and as needed, and bathrooms were cleaned daily. On 11/14/17 at 10:49 A.M., an Environmental policy was provided. The policy indicated . 2. Every resident room is to be cleaned daily . 4. Each bathroom is to be cleaned and disinfected. The disinfecting of the bathrooms is to be the first task when entering the residents' room . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure residents' privacy was maintained for 2 of 2 residents reviewed for privacy. Audio monitors were placed in resident rooms without consent and/or signs to notify visitors. (Resident 51, Resident 43) Findings include: 1. During an observation on 11/6/17 at 10:10 A.M., Resident 51 was observed asleep in his bed. An audio monitor was observed sitting on Resident 51's two drawer table. A green light was observed to be on at that time. At that time, no notification was posted outside or inside the room to indicate that the room had audio monitoring. During an interview on 11/7/17 at 9:55 A.M., CNA 12 was observed in Resident 51's room where she assisted the resident with care. At that time, CNA 12 indicated she was unaware an audio monitor had been placed in Resident 51's room and that her conversations with Resident 51 had been monitored. CNA 12 further indicated she had not been instructed to turn the monitor off before providing care. During an interview on 11/7/17 at 10:05 A.M., LPN 16 entered Resident 51's room to assist the resident to the bathroom. Without turning the monitor off, LPN 16 was observed talking with the resident and she asked him if he had to go to the bathroom. At that time, LPN 16 indicated that Resident 51 had an audio monitor in his room because his room was located a long distance from the nurses' station and the audio monitor ensured the staff could hear the resident's call light and alarms. LPN 16 further indicated the receiver for the baby monitor was located at the nurses' station at the other end of the hallway. During an observation and interview on 11/7/17 at 10:51 A.M., Visitor 1 was observed in Resident 51's room talking with the resident. When Visitor 1 exited Resident 51's room, Visitor 1 indicated she was unaware there was an audio monitor in Resident 51's room and that their conversations could be monitored. The clinical record of Resident 51 was reviewed on 11/7/17 at 1:30 P.M. The record indicated the [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment, dated 9/22/17, indicated Resident 51 experienced severe cognitive impairment, required the assistance of two staff for transfers, the assistance of one staff for toileting, was not steady and only able to stabilize with human assistance, and had a history of [REDACTED]. A care plan for Resident 51, which was initiated on 4/5/16 included the following interventions: .10/19/17 Room monitor . 4/5/16 Keep my call light within reach at all times, encourage me to call . During an interview on 11/9/17 at 11:20 A.M., the Director of Nursing (DON) indicated the audio monitor located in Resident 51's room should have been turned off before starting a conversation and before providing care. The DON indicated no sign was posted in the resident's room to inform the clergy or public the room had audio monitoring. 2. On 11/7/17 at 9:34 A.M., a audio monitor was observed at the nursing station. LPN 4 indicated the audio monitor was a part of Resident 43's fall interventions. LPN 4 turned the volume on the audio monitor down, a male voice could be heard talking in Resident 43's room. LPN 4 indicated the audio monitor was in place because Resident 43's husband attempted to assist Resident 43. On 11/7/17 at 9:42 A.M., LPN 4 was observed walking down the East Unit with the audio monitor. On 11/7/17 at 9:46 A.M., Resident 43's room was observed. An audio monitor was sitting on the bedside dresser. No sign indicating the room was being monitored was observed. On 11/8/17 at 9:10 A.M. during an observation just outside of the nurses' station on East Unit a conversation between Resident 43 and a State Surveyor was overheard on the receiver of a audio monitor that located in Resident 43's room. Resident 43's room was located 8 rooms away from the nurses' station. On 11/8/17 at 10:53 A.M., Resident 43 was observed to be in her room. An audio monitor was sitting on the bedside dresser. No signs indicating an audio monitor was in place was observed. On 11/9/17 at 9:03 A.M., Resident 43 was observed to be in her room. An audio monitor was sitting on the bedside dresser. No signs indicating an audio monitor was in place was observed. During an observation and interview on 11/9/17 at 9:30 A.M., RN 14 was observed passing medications on East hall and had an audio monitor receiver on the top of her medication cart. RN 14 indicated that sometimes, whenever Resident 43's spouse visited, she would overhear their conversations and enter Resident 43's room to check on them. On 11/8/17 at 9:20 A.M., Resident 43's clinical record was reviewed. A Quarterly MDS (Minimum Data Set) assessment, dated 8/16/17, indicated Resident 43 had mild cognitive impairment and had no falls since the prior assessment. The clinical record lacked a signed consent form for Resident 43's room to be audio monitored. During an interview on 11/10/17 at 1:45 P.M., the Regional Nurse Consultant (RNC) indicated the facility had discontinued the use of audio monitors as an intervention to prevent falls for Resident 51 and Resident 43. The RNC indicated that, after interviewing staff about the effectiveness of the audio monitors, they were removed due to staff indicating the monitors were not effective in preventing falls. On 11/14/17 at 9:21 A.M., the Regional Clinical Support Nurse indicated the facility did not have a policy related to audio monitors in resident rooms. A copy of the Resident's Rights was provided by the Administrator on 11/8/17 at 1:30 P.M., and it read as follows: .Privacy and confidentiality .The resident has a right to personal privacy and confidentiality of his or her personal and medical records .Personal privacy includes accommodation, medical treatment, written and telephone communication, personal care, visits, and meetings of family . 3.1-3(o)(5)

Based on observation, interview, and record review, the facility failed to ensure residents received accommodation of needs. Call lights were out of reach for 2 of 30 residents reviewed. (Resident 28, Resident 86) Findings include: 1. On 11/7/17 at 1:27 P.M., Resident 28's call light was observed on the floor. 2. On 11/8/17 at 1:06 P.M., Resident 86 was observed lying in a recliner in her room. Resident 86's call light was observed behind the recliner, on the floor. During an interview on 11/14/17 at 10:41 A.M., CNA 11 indicated when leaving a resident room, staff should make sure the call light is within reach. On 11/14/17 at 11:08 A.M., the Nurse Consultant provided a current call light policy. The policy indicated .2. Ensure the call light is plugged in securely to the outlet and in reach of the resident .16. If nothing else is needed, return the call light to within reach of the resident. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident received necessary services to maintain personal hygiene. An incontinent resident was not toileted according to their plan. This deficient practice occurred in 1 of 3 residents reviewed for urinary incontinence. (Resident 73) Findings include: During an interview on 11/6/17 at 11:20 A.M., Resident 73 had a urine odor. The CNA assignment sheet was reviewed on 11/8/17 at 9:32 A.M. and indicated Resident 73 was to be toileted upon rising, before and after meals, at bedtime, every 2 hours at night, and as needed. On 11/8/17 at 10:50 A.M., Resident 73's record was reviewed. The most recent quarterly MDS (Minimum Data Set), dated 10/10/17, indicated Resident 73 was cognitively intact, was occasionally incontinent of bladder and bowel, and required extensive assist with toileting. Care plans for Resident 73 included, but were not limited to: Resident experiences episodes of incontinence .Please toilet me according to my plan which is upon rise, before and after meals, bedtime and every 2 hours at night, dated 10/18/17. Resident has [DIAGNOSES REDACTED].Provide assistance during ADL care to include but not limited to .toileting ., dated 10/22/17. During an interview on 11/8/17 at 2:09 P.M., LPN 16 indicated Resident 73 was continent but waited too long to ask for help, and was taking Senna (laxative) for bowels, and it make him go on himself before he could ask for help. During an interview on 11/8/17 at 2:13 P.M., CNA 9 indicated Resident 73 was supposed to be asked and assisted to the restroom every 1 1/2 hours, most of the time sooner, but he did not always tell staff when he had to go, so it was up to staff to remind and take him. During a continuous observation on 11/9/17 from 8:07 A.M. until 9:47 A.M., the following was observed: At 8:07 A.M., Resident 73 was observed to be wheeled back to his room from the dining room where he had eaten breakfast. Resident 73 was placed in front of his laptop and began playing games. The door was left open. At 8:11 A.M., QMA 17 indicated there were 2 CNA's assisting on that hall. At 8:16 A.M., CNA 9 walked by Resident 73's room, glanced in the room, and continued to walk by. At 8:19 A.M., CNA 9 walked by Resident 73's room. At 8:20 A.M., CNA 9 walked by Resident 73's room. At this time, CNA 9 indicated there were 18 residents on the hall who required assistance. At 8:24 A.M., CNA 9 and CNA 21 walked by Resident 73's room. At this time, CNA 9 indicated CNA 3 was in a room feeding a resident. At 8:26 A.M., CNA 9 walked by Resident 73's room with linen and entered another resident room. At 8:34 A.M., QMA 17 walked by Resident 73's room. At 8:36 A.M., QMA 17 walked by Resident 73's room. At 8:59 A.M., CNA 21 walked by Resident 73's room. At 9:07 A.M., Resident 73's roommate rang the call light and indicated to a physical therapy assistant he rang the light at 7 A.M., and someone said they would be back, and nobody had returned. At 9:12 A.M., CNA 21 and RN 33 entered Resident 73's room, walked by Resident 73 without communicating with him, and assisted his roommate. At 9:33 A.M., CNA 21 and RN 33 exited Resident 73's room without communicating with him. At 9:35 A.M., CNA 3 entered Resident 73's room, walked past him, spoke with his roommate, and exited the room. At 9:37 A.M., CNA 3 indicated the CNA's would try to toilet residents immediately after returning from a meal, and every 15 minutes after until they could go. At 9:38 A.M., CNA 9 walked by Resident 73's room. At 9:40 A.M., CNA 9 and CNA 3 walked by Resident 73's room. At 9:43 A.M., CNA 21 walked by Resident 73's room. At this time, RN 33 entered Resident 73's room, walked past him without communicating with him, spoke with his roommate, and exited the room. At 9:45 A.M., RN 33 entered Resident 73's room, walked past him without communicating with him, spoke with his roommate, and exited the room. At 9:47 A.M., LPN 16 indicated she thought the residents were toileted thirty minutes before and after meals. During this continuous observation, no staff was observed to communicate with Resident 73, or attempt to assist with toileting. On 11/14/17 at 8:57 A.M., Resident 73 was observed sitting in a wheelchair in his room, playing a game on a laptop, and had a urine odor. During an interview on 11/14/17 at 10:22 A.M., the DON indicated the CNAs knew to toilet the residents by what was printed at the bottom of the CNA assignment sheet. On 11/14/17 at 11:45 A.M., the DON provided a Bladder Continence policy. The policy indicated, .4. If the cause for incontinence is reversible or able to be partially mitigated a Continence Program should be established with, routine toileting times as indicated by the patters established in the Elimination Record or at designated times such as upon rising, before/after meals and at bedtime . 3.1-38(a)(2)(C)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and fall interventions were in place to prevent falls for 2 of 4 residents reviewed for falls. A resident had four falls in 30 days, call lights were not within reach. (Resident 51, Resident 28) Findings include: 1. During an observation on 11/6/17 at 10:08 A.M., Resident 51 was observed lying in bed with his eyes closed in no distress. The clinical record of Resident 51 was reviewed on 11/7/17 at 2:15 P.M. The record indicated the [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment, dated 9/22/17, indicated Resident 51 experienced severe cognitive impairment, required the assistance of two staff for transfers, the assistance of one staff for toileting, was not steady and only able to stabilize with human assistance, and had a history of [REDACTED]. A care plan for Resident 51, which was initiated on 4/5/16, included the following interventions: .10/19/17 Room monitor . 4/5/16 Keep my call light within reach at all times, encourage me to call for assist . 8/23/2017 .Pressure pad alarm to bed and chair. Check every shift foe placement and functioning . A July Quarterly Observation form dated 7/21/17 indicated Resident 51 had a history of [REDACTED]. A physician's orders [REDACTED].pressure pad alarm to bed and chair; check q (every) shift for placement and function . FALL 1 A Fall Event note dated 8/22/17 at 6:40 A.M. indicated Resident 51 experienced an unwitnessed fall while self-transferring from bed to wheelchair. A Progress Note dated 10/8/17 at 11:50 A.M. indicated: . res was found on floor in front of his wheelchair. he had been sitting on his bedspread, print side down on the wheelchair seat and sheet while in the wheelchair and slid off the wheelchair seat. res room was disorganized . FALL 2 A Fall Event note dated 9/1/17 at 6:00 A.M. indicated Resident 51 experienced an unwitnessed fall. A Progress Note dated 9/8/17 at 11:02 P.M. read as follows: .Alarm sounded, staff entered room, found res laying on floor beside bed on left side.Stated I rolled out of bed. Pajama pants and brief pulled down on lower legs. Bed sheets wet with urine . FALL 3 A Fall Event note dated 10/6/17 at 11:08 A.M. indicated Resident 51 experienced an unwitnessed fall while in the bathroom. A Progress Note dated 10/6/17 at 11:20 A.M. indicated: .this nurse was notified by qma that res (resident) was sitting on the floor in the bathroom. when res was asked what he was trying to do he stated he was trying to shut the water off. res had regular socks on with no grip. alarm was attached and not sounding. res got skin tear to rt (right) upper posterior arm . FALL 4 A Fall Event note dated 10/8/17 at 11:40 A.M. indicated Resident 51 experienced an unwitnessed fall while self-propelling out of the bathroom and Resident 51 slid out of the wheelchair. A Progress Note dated 10/8/17 at 11:50 A.M. read as follows: .Resident was propelling in w/c exiting the bathroom, slid out of his w/c onto floor landing on his side. Resident obtained skin tear to middle of his right back. FALL 5 A Fall Event note dated 8/22/17 at 6:40 A.M. indicated Resident 51 experienced a witnessed fall from the wheelchair while sitting in a supervised area. A Progress Note dated 10/30/17 at 9:02 A.M. read as follows: .Resident in well supervised area. Alarm sounded and staff reacted immediately and attempted to catch him. Resident leaned forward, lost control of trunk and slid out of w/c (wheelchair) and landed on his knees and hands . During an interview on 11/7/17 at 10:05 A.M., LPN 16 indicated that Resident 51 experienced falls and had an alarm on his wheelchair, on the door to the bathroom and an audio monitor to help prevent falls. 2. On 11/7/17 at 9:39 A.M., LPN 4 indicated Resident 28 had four falls in the last 30 days. On 11/7/17 at 1:27 P.M., Resident 28 was observed seated in a recliner. Resident 28's call light was on the floor. On 11/8/17 at 9:42 A.M., Resident 28's clinical record was reviewed. The Significant Change MDS (Minimum Data Set) assessment, dated 10/27/17, indicated Resident 28 had moderate cognitive impairment, required extensive assistance of two persons for transferring and toileting, and had no falls since the prior assessment. The Care Plans included, but were not limited to: Resident is at risk for falling related to multiple [DIAGNOSES REDACTED]. The interventions included, but were not limited to: Keep my call light in reach at all times, initiated on 3/8/16. A Fall Event, dated 10/17/17 at 3:50 A.M., included, but was not limited to: .As this nurse was walking in hallway, res (resident) roommate asked this nurse to check BR (bathroom) stating she thought her roommate may have fallen. Upon entering BR, this nurse found res sitting on BR floor with back against the wall. stated (sic) she did not hit head. Res did not have walker in BR with her. Res stated she lost balance et (and) sat in (sic) floor. denies (sic) injury at this time,, (sic) requesting to get up to use toilet. FROM (full range of motion) to upper et lower extremities WNL (within normal limits) for res. No rotation or deformity noted. Res does have scrape to back of R (right) elbow extending down back of forearm. No bleeding noted. No c/o (complaints of) pain to area. res (sic) assisted to feet per 2 assist. res (sic) toileted et ambulated with walker back to bed per 1 assist. FWB (full weight bearing) Gait steady. res (sic) cont (continued) to deny pain or injury. Call light in reach. Walker placed in reach and res reminded to utilize walker et ask for assist as needed. Call light in reach . 10/17/17 at 9:12 A.M.: .IDT (interdisciplinary team) review of fall- Resident ambulated to bathroom without walker, lost balance et fell to floor .Root cause identified as no walker with poor balance. Immediate intervention added for visual cue to remind resident to utilize walker for all ambulation . A Fall Event, dated 10/17/17 at 11:30 P.M., included, but was not limited to: .Heard res roommate holler she's falling. This nurse heard loud noise, entered room and found res lying on floor in room beside opened BR door on back with legs extended. Feet towards room door. Stated, 'I don't know what happened.' Res roommate stated that she looked like she lost her balance. Walker was turned on side beside res. Had been walking out of BR from toileting. This nurse had walked with res into BR a few minutes earlier and had assessed r/t (related to) previous fall. Lights on in room and BR. Non-skid strips in place in front to toilet on BR floor. Had shoes and socks on. Was using rolling walker at time of fall. Alert with typical orientation for res. 4.0 cm (centimeter) x (by) 2.5 cm raised area present to right occipital head. Neuro (neurological) checks initiated. PEARL (pupils equal and reactive to light) @ (at) 3 mm (millimeters), bilaterally. Speech clear. AROM (active range of motion) present to bil (bilateral) upper and lower extremities. No abnormal rotation or shortening to bil lower extremities. No discolored areas present. Abrasion from previous fall continued to right forearm. Denied any pain or discomfort. Extensive assist of 2 staff to transfer from sitting to standing position. FWB. Ambulated using rolling walker to bed with limited assist of 2 staff. Denied any pain or discomfort during ambulation. Assisted into bed with perimeter mattress on bed . 10/18/17 at 8:30 A.M., recorded as a late entry on 10/20/17 at 6:37 P.M.: IDT (interdisciplinary team) review of fall- Resident fell in room next to bed while ambulating to bathroom, currently being treated for [REDACTED]. Root cause identified as urinary urgency. Immediate intervention added for routine toileting plan et therapy eval (evaluation) A Fall Event, dated 10/18/17 at 8:00 A.M., included, but was not limited to: .Res up and starting to ambulated to the main dining room for breakfast, as resident crossed the threshold of her doorway resident fell . Fall was witnessed by this nurse. Resident immediately assessed. No internal or external rotation of extremities noted. Range of motion wnl. L (left) knee noted at this time to have some slight swelling and a purple/reddish bruise covering much of the kneecap. Resident voiced no complaint of pain. Resident alert but unable to voice what happened and when asked if she knew where she was, resident unable to answer. Speech noted to be clear with appropriate responses. Neuro-check complated (sic) and Right (sic) side was noted to be weaker than her left side in both hand grips and push/pulls on lower extremities. (Name of physician) notified via triage and new order was received to send resident to ER (emergency room ) of choice d/t (due to) change in medical condition . 10/18/17 at 11:22 A.M., recorded as a late entry on 10/20/17 at 6:28 P.M.: .IDT review of fall- Resident ambulating out of room with walker per usual routine, witnessed by nurse, resident fell to floor. Assessment revealed right sided weakness et change in resident condition. Root cause identified as new onset right sided weakness. Immediate intervention added for transfer to ER for further eval Will reassess upon return to facility . A Fall Event, dated 10/29/17 at 7:30 A.M., included, but was not limited to: .Resident tried to transfer herself from recliner to w/c (wheelchair) and lost balance & (and) fell . Her roommate (sic) turned on the call light and yelled for help. This nurse and CNA ran into resident's room immediately and found her sitting in front of her w/c. Neuro check completed. Residents neuro status unchanged. No injury noted. Vitals and ROM (range of motion) within resident's normal range. No c/o pain or other discomfort. MD, family & nurse manager notified. Fall intervention: pad alarm to chair & bed to alert staff for unsafe transfer . A Fall Management Program Guidelines was provided by the facility on 11/8/17 at 1:30 P.M. The policy included, but was not limited to, the following: .(facility name) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventive measures . 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. A gradual dose reduction was not attempted, and proper behavioral interventions and drug monitoring were not adequately performed for 2 of 5 residents reviewed for unnecessary medications. (Resident 73, Resident 15) Findings include: 1. On 11/8/17 at 10:50 A.M., Resident 73's record was reviewed. The most recent quarterly MDS (Minimum Data Set), dated 10/10/17, indicated Resident 73 was cognitively intact, was occasionally incontinent of bladder and bowel, and required extensive assist with toileting. Resident 73's current orders included, but were not limited to, Senna with Ducosate Sodium (sennosides-ducosate sodium) (laxative/stool softener combination) (OTC) tablet; 8.6-50 mg (milligrams); Amount to Administer: 2 tabs; oral. Twice a day, for bowel maintenance. The order was dated 3/3/17, upon admission. The Resident Bowel and Bladder by Shift Chart indicated Resident 73 had 16 loose stools from 8/14/17 to 10/23/17. The MAR (Medication Administration Record) for August, September, and October indicated Resident 73 received Senna with Ducosate Sodium as scheduled, every day. Review of the Pharmacy recommendations for reduction of medications for Resident 73 revealed no documentation of a review of Senna with Ducosate Sodium. Further documentation of the clinical record revealed no documentation contraindicating the decrease or cessation of Senna with Ducosate Sodium. During an interview on 11/8/17 at 2:09 P.M., LPN 16 indicated Resident 73 was continent but waited too long to ask for help, and was taking Senna (laxative) for his bowels, and it made him go on himself before he could ask for help. During an interview on 11/14/17 at 11:53 A.M., the DON indicated Resident had been on Senna with Ducosate Sodium since admission for bowel maintenance because he was on multiple other medications that had the potential for constipation. 2. On 11/6/17 at 11:43 A.M., Resident 15 was observed in her room, sitting on her bed, dressed, and hair combed. Resident 15 was pleasant, no behaviors were observed. On 11/8/17 at 9:21 A.M., Resident 15 was observed in her room, sleeping. On 11/9/17 at 8:22 A.M., Resident 15 was observed in her room, sleeping. On 11/8/17 at 10:23 A.M., Resident 15's record was reviewed. Resident 15 was admitted on [DATE]. Current [DIAGNOSES REDACTED]. Current orders included, but were not limited to, quetiapine tablet (antipsychotic); 50 mg (milligrams); amt (amount): 1 tablet; oral Special Instructions: Dx (diagnosis): Dementing illness with behavioral symptoms (DX: Dementia in other diseases classified elsewhere with behavioral disturbances) At Bedtime, ordered 12/30/16, upon admission. On 1/4/17, a request from the Pharmacist to change Resident 15's [DIAGNOSES REDACTED]. On 6/7/17, a GDR (Gradual Dose Reduction) for Resident 15 was requested by the Pharmacist for quetiapine. The GDR was denied, indicating Pt (patient) stable, dated 6/15/17. Review of Resident 15's MAR (Medication Administration Record) indicated behavior tracking for the use of quetiapine use and a [DIAGNOSES REDACTED]. There were no documented behaviors in 6/2017, 7/2017, 8/2017, 9/2017, 10/2017, or 11/2017. A psychological assessment, dated 3/17/17, indicated no behaviors for the last 7 days. The most recent quarterly MDS (Minimum Data Set), dated 9/28/17, indicated Resident 15 had no behaviors for the assessment period. During an interview on 11/14/17 at 9:58 A.M., RN 8 indicated, to her knowledge, Resident 15 had no behaviors since admission. During an interview on 11/14/17 at 11:42 A.M., the DON indicated Resident 15 had documented behaviors at another facility before admission, but no documented behaviors since admission on 12/30/16. She further indicated that there was no documentation of contraindication for decrease of quetiapine, and no attempt to decrease the medication since admission. On 11/14/17 at 9:20 A.M., a [MEDICAL CONDITION] Medication Usage and Gradual Dose Reduction policy was provided. The policy indicated: .1. Residents shall receive [MEDICAL CONDITION] medications only if designated medically necessary by the prescriber, with appropriate [DIAGNOSES REDACTED]. The medical necessity will be documented in the resident's medical record and in the care planning process .4. A gradual dose reduction (GDR) will be attempted for two (2) separate quarters (with at least one month between attempts) per the physician's recommendation . 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure medications were locked for 1 of 3 medication carts observed. (West Unit Medication Cart) Findings include: On 11/14/17 at 8:57 A.M., the West Unit medication cart was observed to be unlocked and unattended. At 9:01 A.M., QMA 2 was observed to open a resident room door and exit the room. QMA 2 indicated she thought the cart was locked. On 11/14/17 at 10:00 A.M., the Regional Clinical Support Nurse provided the Medication Storage In the Facility policy, revised 1/2017. The policy included, but was not limited to: Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . 3.1-25(m)

Based on interview and record review, the facility failed to ensure laundry employees knew where the gas shut offs were located. (LE 1, LE 2) Findings include: On 11/8/17 at 1:14 P.M., the laundry area was observed. LE (Laundry Employee) 1 and LE 2 indicated they were unsure if the dryers were gas or electric. LE 1 and LE 2 further indicated they were unsure where the gas shut off was located. On 11/8/17 at 2:05 P.M., LE 1 indicated she had found out the dryers were gas and indicated the gas shut off was located outside. On 11/14/17 at 10:00 A.M., the Regional Clinical Support Nurse provided the Campus Tour for new employee orientation. The Campus Tour included, but was not limited to: .Take the learners on a tour of the campus and ensure the following items were pointed out: Electrical and Gas Shut Offs . On 11/14/17 at 10:03 the Regional Plant Operations Employee indicated all personnel should know where gas shut offs were located. 3.1-51(b)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided or effective interventions were implemented for 1 of 3 residents who met the criteria for review of accidents. (Resident #18) Findings include: The clinical record of Resident #18 was reviewed on 9/27/16 at 2:31 P.M. The record indicated the [DIAGNOSES REDACTED]. On 9/26/16 at 11:45 A.M., Resident #18 was observed sitting on a scooter in no apparent distress. During an interview on 9/27/16 at 10:47 A.M., RN #5 indicated Resident #18 had a history of [REDACTED]. The most recent Quarterly MDS (Minimum Data Set) dated 7/7/16 indicated Resident #18 experienced severe cognitive impairment, unsteady gait, required the supervision and physical assistance of one staff to walk in the room and for toilet use, and required the extensive assist of one staff for dressing. The Annual MDS dated [DATE] indicated Resident #18 experienced severe cognitive impairment, unsteady gait, required the supervision and physical assistance of one staff to walk in the room and for toilet use, and required the extensive assist of one staff for dressing. The August 2016 physician's orders [REDACTED]. A Care Plan dated 8/27/16 for .at risk for falling R/T (related to) weakness, medication use and multiple [DIAGNOSES REDACTED]. Assure my floor is free of glare, liquids, foreign objects, Encourage me to assume a standing position slowly, I have floor grips on floor in front of my toilet, I have left mobility bar to my bed, I use an electric w/c (wheelchair) and walker for locomotion, Keep my call light in reach at all times, Keep my personal items and frequently used items within reach, Non-skid footwear while up, provide me an environment free of clutter, Refer for PT (Physical Therapy)/OT (Occupational Therapy) screen as needed A Monthly Nursing summary dated 8/11/16 at 1:48 A.M. indicated Resident #18 experienced no cognitive impairment and was at risk to experience a fall. Fall #1 A Nursing note dated 8/28/16 at 8:40 A.M. indicated, Resident, who is up ad-lib (sic) was ambulating self to the bathroom, lost balance and fell . The note lacked any documentation to indicate an immediate intervention was implemented to ensure the safety of Resident #18. A Fall Event Note dated 8/28/16 at 10:36 A.M. indicated Resident #18 experienced an unwitnessed fall in the bathroom while toileting and received bruising, swelling, skin tears to bilateral hands, and, .is up ad lib. States .thinks .ankle turned as .was reaching for the light switch .immediate measures taken .Encourage use of call light even if its just for stand by assist . A Social Service progress note dated 8/30/16 at 2:20 P.M. indicated, .Resident is able to initially state 3 words named, but unable to repeat any of these words named after 5 minutes. Able to state correct day of week, month (sic) and year with cueing and much thought process . A Nursing note dated 9/8/16 at 11:00 A.M. indicated, .Resident up ad lib . A CAR (Clinically at Risk ) progress note dated 9/8/16 at 11:00 A.M. indicated, .Res (resident) up ad lib; had fall in bathroom .Root cause identified as weakness in ankle; immediate intervention added for res to call for assist as needed et (and) therapy eval (evaluation) . A Nursing note dated 9/11/16 at 1:21 A.M. indicated, .Up ad lib . A Monthly Nursing Summary dated 9/11/16 at 10:53 P.M. indicated Resident #18 experienced no cognitive impairment and was at risk to experience falls. Fall #2 The September 2016 physician's orders [REDACTED]. A Fall Event report dated 9/19/16 at 6:05 A.M. indicated Resident #18 experienced an unwitnessed fall without injury in the bedroom. The note further indicated, .getting ready to get up for .shower .barefoot .not wearing socks or shoes .immediate measures taken .gripper socks/shoes when getting up to ambulate . A Nursing note dated 9/19/16 at 6:10 A.M. indicated, Resident sitting on the side of the bed getting ready to get up for .morning shower. Staff in and out of the room while resident getting ready for .shower. Resident sitting on the floor right beside .bed .was going to get up and unplug .wheelchair and slid off to the floor resident had not put .shoes on yet and was barefoot .will remind resident to wear gripper socks or shoes when .gets up to ambulate in .room . A IDT (Interdisciplinary Team) note dated 9/19/16 at 9:52 A.M. indicated, .Root cause identified as lack of footwear. Immediate intervention of socks, footwear to be on at all times when up . During an interview on 9/28/16 at 11:15 A.M. the DHS (Director of Health Services) indicated Resident #18 did not experience cognitive impairment and was at risk to experience falls. During an interview on 9/29/16 at 9:00 A.M. the DHS indicated Resident #18 should have received more supervision and interventions should have been implemented according to the plan of care. The Policy and Procedure for Fall Management provided by the DHS on 9/29/16 at 9:36 A.M. indicated, .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures . 3.1-45(a)(2)

Based on observation and interview, the facility failed to ensure the environment was sanitary and comfortable, resident rooms were not free of pervasive urine odor, bathroom lighting was not adequate, ceiling tiles were missing, and carpet had stains for 11 of 11 residents who met the criteria for review of environment on 2 of 3 nursing units. (Room #116, Room #127, Room #103, Room #104, Room #114, Room #112, Room #105, Room #107, Room #111, Resident #124) Findings include: 1. On 7/8/15 at 12:12 P.M., Room #116 was observed to have a pervasive odor of urine. On 7/10/15 at 9:02 A.M., Room #116 was observed to have a pervasive odor of urine. 2. On 7/8/15 at 12:15 P.M., Room #127 was observed to have a pervasive odor of urine and multiple carpet stains. On 7/10/15 at 9:03 A.M., Room #127 was observed to have a pervasive odor of urine and multiple carpet stains. 3. On 7/8/15 at 2:13 P.M., the bathroom of Room #103 was observed to have a missing ceiling tile. On 7/10/15 at 8:55 A.M., the bathroom of Room #103 was observed to have a missing ceiling tile and dim lighting. 4. On 7/8/15 at 2:24 P.M., Room #104 was observed to have multiple carpet stains. On 7/10/15 at 8: 58 A.M., Room #104 was observed to have multiple carpet stains. 5. On 7/08/15 at 2:45 P.M., Room #114 was observed to have multiple carpet stains. During an interview, at that time, Resident #8 indicated the lighting in the bathroom was not adequate and further indicated sometimes the bathroom door had to be left open during use to achieve proper lighting. 6. On 7/8/15 at 2:55 P.M., Room #112 was observed to have a pervasive odor of urine. The shared bathroom of Room #112 was observed to have dim lighting, and missing ceiling tiles. On 7/10/15 at 9:00 A.M., Room #112 was observed to have a pervasive odor of urine. The shared bathroom of Room #112 was observed to have dim lighting, and missing ceiling tiles. 7. On 7/8/15 at 3:08 P.M., Room #105 was observed to have a pervasive odor of urine and multiple carpet stains. The shared bathroom of Room #105 was observed to have exposed light bulbs and no cover on the fixture. On 7/10/15 at 8:56 A.M., Room #107 was observed to have a pervasive odor of urine and multiple carpet stains. The shared bathroom of Room #107 was observed to have exposed light bulbs and no cover on the fixture. 8. On 7/8/15 at 3:14 P.M., Room #111 was observed to have a pervasive urine odor and multiple carpet stains. The bathroom of Room #111 was observed to have dim lighting. On 7/10/15 at 8:59 A.M., Room #111 was observed to have a pervasive urine odor and multiple carpet stains. The bathroom of Room #111 was observed to have dim lighting. 9. On 7/9/15 at 2:04 P.M., Room #124 was observed to have a pervasive odor of urine and multiple carpet stains. On 7/10/15 at 9:04 A.M., Room #124 was observed to have a pervasive odor of urine and multiple carpet stains. During an interview on 7/10/15 at 9:05 A.M., the MS (Maintenance Supervisor) #1 indicated, the ceilings should not have missing tiles, the bathroom lighting was dim, lightbulbs should not be exposed, and light fixtures should have covers. During an interview on 7/10/15 at 9:10 A.M., the HS (Housekeeping Supervisor) #1 indicated urine odor and carpet stains were a problem in the facility. HS #1 further indicated, the facility had no specific policy related to containing odors, but it the usual facility practice to keep the facility free of odors. The Policy and Procedure for Floor Care provided by HS #1 on 7/10/15 at 10:00 A.M. indicated, .5. The individuals assigned to the vacuuming duties should be carrying spot cleaner to address spots as noticed. Work orders should be generated for any location with carpet spots needing special attention We do not want to wait for the carpet cleaning schedule to address. 3.1-19(f)

Based on observation, interview and record review, the facility failed to ensure a resident with antipressure devices in place to bilateral feet did not develop a pressure sore, initially discovered as a stage E (Eschar), to one heel (Resident #15) and/or develop and/or implement interventions to address noncompliance for turning and repositioning for 2 of 3 residents reviewed for pressure sores. Resident #15, Resident #99 Findings include: 1. On 5/16/13 at 2 P.M., the clinical record of Resident #15 was reviewed. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set Assessment) dated 3/26/13 indicated the following: resident was unable to complete the interview for mental status; bed mobility was a 3 (extensive assistance required); resident was non ambulatory; regarding pressure ulcers the resident did have a stage 1 or greater; was at risk to develop pressure sores; did currently have unhealed pressure sores; currently had 3 unstageable pressure sores "due to coverage of wound bed by slough and/or eschar (necrotic tissue)"; 3 of these were present on readmission; the longest pressure area was 2.5 centimeters (cm) with a width of 5.0 cm.; had a pressure reducing device for bed and ulcer care. An MDS dated [DATE] indicated the following for the resident: resident was unable to complete the interview for mental status; bed mobility was a 3 (extensive assistance required); resident was non ambulatory; had 4 unstageable pressure ulcers, 3 pressure ulcers were present upon admission/re entry; number of unstageable pressure ulcers with suspected deep tissue injury in evolution was 1; number of these unstageable pressure ulcers that were present upon admission or re entry was zero. The most severe type wound was necrotic tissue (eschar), black, brown or tan tissue that adheres firmly to wound bed or ulcer edges. On 5/17/13 at 9 A.M., the resident was observed in his bed. He was observed to have bilateral boot type devices on his lower legs. The boots extended from beyond the tips of the resident's toes to approximately 6 inches below his knees. The resident was observed with his bil legs in a flexed position. On 5/20/13 at 9:15 A.M., CNA (Certified Nursing Assistant) #20 and CNA #21 gave the resident a bed bath. The bilateral boot type devices remained in place to the resident's lower legs. The resident's legs were observed in the flexed position. During the bath, CNA #20 and #21 removed both boots attempted to straighten the resident's legs over a 45 degree angle but no more than a 90 degree angle, but the legs returned to the flexed position when the CNAs finished care. On 5/20/13 at 10:32 A.M., Physical Therapist #1 (PT) was observed changing the resident's dressings. At that time, she removed the dressing to the right heel. The right heel was observed to have had an open area which PT #1 measured at that time. PT #1 indicated the wound measurements were 2.4 cm length and 3.0 cm width. At that time, she attempted to remove some of the yellow tissue from the center of the open wound. The resident's right heel was also observed to have multiple closed areas which which were covered by white skin. PT #1 completed the treatment to the open area on the right heel. At that time, PT #1 then completed treatments to pressure sores to the resident's right hip, left buttock/coccyx and right buttock. On 5/21/13 at 10:30 A.M., the DON (Director of Nursing) was interviewed. She indicated the resident had originally been admitted on [DATE] and upon admission had several unstageable/E (eschar) level open areas to the right buttock,right hip and coccyx. The DON indicated the resident did not have any open areas to his feet at the time of admission on 2/7/13. The DON indicated the resident went to the hospital on [DATE] for a colectomy (bowel surgery) and returned to the facility on [DATE]. Upon return to the facility from the hospital on [DATE], the DON indicated when the resident was continue to have the pressure sores to the right (rt) hip, rt and left buttock and coccyx but did not have any open areas to either heel. The DON indicated the resident was wearing "yellow foam type boots" on his bilateral feel but did not have any open areas to his bilateral feet. The DON indicated at that time, the yellow foam type boots were a preventative device the resident received at the hospital as an intervention put in place to prevent pressure areas to the resident's feet. At that time, the DON indicated the yellow foam boots had a "lift type" device in the heel portion of the foam boot. At that time, she provided the following forms: Plan of care, dated 2/26/13, for "...skin impairment." Interventions left unchecked on the care plan included, but were not limited to, the following: "educate resident regarding risks associated with non-compliance of treatment and repositioning regarding pressure reduction and development/worsening of skin condition." The DON indicated at that time, the facility placed an air mattress on the resident's bed on 2/7/13 and the spouse did not like it. She indicated on 2/8/13, the facility tried a speciality, antipressure overlay on the mattress. The DON indicated the overlay was removed on 2/26/13 at the spouse's request. She indicated the resident currently has the standard pressure reducing mattress on his bed. The DON indicated at that time she had made a notation of the form "Spouse refused air mattress, attempted overlay but refused." At that time, the DON indicated she had educated the spouse of the risks and potential implications of not using the additional antipressure devices but was unable to locate documentation of such conversation she had with the spouse. "Assessment Review" dated 2/27/13. The form indicated for "skin breakdown risk potential" the following: The resident has the following risk factors that may contribute to skin breakdown: mobility impairment and incontinence. "Clinically at Risk Individual Monitoring Sheet' dated 2/28/13. The form indicated " t/r (turn and reposition) q (every) 2 hours and prn (as needed)...boots to BLE (bilateral lower extremities); Attempted use of air bed et (and) overlay mattress but spouse refused." "Resident First Conference Notes" dated 3/1/13 included, but was not limited to, the following: Skin: "arterial/venous ulcers: No; Pressure reduction devices: blank." Care plan for "Potential alteration in skin integrity" dated 3/8/13. Interventions included, but were not limited to, the following: Assess/record changes in skin status, administer/monitor effectiveness of/response to preventive treatment(s), 4/20/13 float heels, provide/monitor effectiveness of pressure relieving or reduction devices: pressure reducing mattress and chair cushion. The area for heel/elbow protectors was left blank; minimize pressure over bony prominences; 4/25/13 Z flow boots at all times. Documentation was lacking on the care plan of presence of the yellow anti pressure boot and instruction of their removal for skin inspection. "Pressure Ulcer Letter of Unavoidability" dated 3/27/13. The form indicated "Despite routine preventative care such as turning and proper positioning, application of pressure reduction or relief devices...this resident is at high risk for skin breakdown. Clinical conditions this resident exhibits that make the likelihood of this pressure ulcer unavoidable include...diabetes,[MEDICAL CONDITION] with L (left) sided weakness et (and) contractures), serum [MEDICATION NAME] below 3.4 g/dl (grams/deciliter); hgb (hemoglobin less than 12 mg/dl milligrams/deciliter);...resistive to positioning at times..." A physician order [REDACTED]." The DON indicated at that time, the E (eschar) unstageable area to the right heel was identified on 4/20/13. She indicated when the area was initially identified it was closed and had a "scabby" looking appearance underneath. The treatment record for April 2013 was reviewed at that time and indicated weekly skin assessments had been completed on 4/13/13 and 4/20/13. Both assessments indicated "old areas" as designated by the number 2. The form indicated other assessment options were "new area, no new area." At that time, she provided a copy of the "Pressure...Ulcer Assessment" form dated 4/20/13. The form indicated the following: right heel ulcer, stage E, was not present on admission, length 4.5 cm, width 5.5 cm, color brown scab. The measurement dated 5/20/13 indicated the area is decreasing in size. The DON indicated they received a doctors order on 4/20/13 to float the heels. She indicated the facility "always float the heels, even when there are boots on the resident." She indicated on 4/20/13, the yellow boots that caused the unstageable area to the right heel were removed and the resident's heels were floated using only pillows. The DON indicated the pillows were not keeping the resident's heels floated so on 4/25/13, they got an order to use the Z flow boots. The resident was currently wearing these boots. The DON indicated staff removed the boot when they perform care and also for baths. She indicated weekly skin assessments are performed also. The DON indicated at that time she is unable to find a care plan that directs how often the boots antipressure boots were to be removed and/or checked. She stated from 2/26/13 to 4/20/13, they always float the heels, even with boots on. She verified that the heel floating is not addressed on the care plans. The DON indicated she thought the lift type device (yellow boots) is what caused the blackened area to the residents right heel. On 5/20/13 at 1 P.M., the DON provide behavior logs for the resident from the dates of January 203 - May 20, 2013. Documentation was lacking of the resident resisting care. On 5/22/13 at 9 A.M., the DON provided a copy of the current facility policy and procedure for "Wound Plan of Care Guidelines." The form was undated. The form included, but was not limited to, the following: Purpose: To provide individualized care interventions to treat areas of skin impairment and contributory causes. Residents plan of care should also include goals, approaches and interventions within 24 hours of discovery of the wound. On 5/22/13 at 12 P.M., the DON provided a current copy of the facility policy and procedure for "The CNAs Responsibility in Wound Care Prevention." The form was undated. The policy included, but was not limited to, the following: Inspect each and every one of your resident's skin daily, especially bony areas such as hips, coccyx, feet, ears, shoulders, elbows, etc.; Protect elbows, coccyx feet (float heels), etc; check the skin with each repositioning; 2. The clinical record for Resident #99 was reviewed on 5/22/13 at 10:05 A.M. [DIAGNOSES REDACTED]. Resident #99 was admitted to the facility on [DATE]. On 2/19/13 an Assessment Review and Consideration form was completed. The form documented the following: "...skin breakdown risk potential, surgical incision to abdomen, mobility impairment, incontinence/moisture. An individual care plan has been initiated to address the above risk factors and minimize the risk of skin breakdown." The Nursing Admission Assessment form was completed upon admission on 2/18/13. The assessment read as follows: "... did not have a Stage 1 wound or greater, scar over bony prominence, non-removable device/dressing..." The Minimum Data Set Assessment (MDS) completed on 2/25/13 and 3/18/13 documented that Resident #99 was at risk of a pressure ulcer and that Resident #99's functional status documented the following: "...Bed mobility, 3/3 which indicates Resident #99 needed 2 person physical assist...Transferring was documented as 3/3 which indicated Resident #99 needed a 2 plus person physical assist with transferring..." An activity of Daily Living (ADL) Functional Status Worksheet dated 2/25/13 was reviewed. Analysis of findings read as follows: "... admitted after hospitalization for metastatic [MEDICAL CONDITION] and partial colon resection with [MEDICAL CONDITION]. Additional dx(diagnoses) included hypertension and [MEDICAL CONDITION] reflux. Alert and orient X 3, able to voice wants and needs. Requires variable extensive assist with bed mobility, transfers and toileting. Incontinent of bladder. Monitored for signs and symptoms Urinary tract infection...." The Other Skin Impairment Assessment form was completed on 3/11/13 for Resident #99. On 3/11/13 the form documented an area located on the coccyx 0.1 cm in length and 0.1 cm in width, noting the cause of the skin breakdown as shearing. On 3/18/13 the form documented the area as 1.1 cm in length and 1.3 cm in width. On 3/24/13 the form documented the area had been changed to Stage E pressure ulcer. (Unstageable-Non-removable dressing, slough/escar; suspected deep tissue injury in evolution). The Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form dated 3/24/13 documented the area on Resident #99's coccyx as Stage E pressure ulcer (Unstageable-Non-removable dressing, slough/escar; suspected deep tissue injury in evolution). It was documented as a Black area, 1.5 cm in length, 1.5 cm in width and Depth E. Treatment Santyl. Nursing notes dated 3/11/13 read as follows: "...Reported to this nurse a pin point area noted to coccyx..." Nursing notes dated 3/12/13 read as follows: "[MEDICATION NAME] on coccyx..." Care Plan for potential alteration in skin integrity dated 3/1/13 read as follows: "...Problem: Potential for alteration in skin integrity related to immobility, incontinence and metastatic [MEDICAL CONDITION]. Goals: resident will not develop alteration in skin integrity. Interventions: Assess/record changes in skin status. Report pertinent changes in skin status to physician. Discuss care plan non-compliance issues with resident. Monitor lab results as ordered and report abnormal results to physician. Provide diet as ordered and monitor nutritional status and dietary needs. Provide/monitor effectiveness of pressure relieving or reduction devices, Pressure reducing mattress and chair cushion. Provide incontinence care after each episode, avoid skin to skin contact. Minimize pressure over bony prominences. Avoid shearing: use lift sheet. Wrinkle free linens..." Care plan for ADL (activities of daily living) self care deficit dated 3/1/13 read as follows: "...Problem: Needs assistance or is dependent with bed mobility, transfer, walking, locomotion, dressing, toilet use, personal hygiene, bathing. At risk for developing complication associated with decreased ADL self performance related to disease process, weakness, pain. Goal: Resident will maintain existing ADL self performance. Resident will not develop any complications related to decreased mobility. Interventions: Assess/record self care status change. Report significant changes in ADL status to MD and responsible party. Monitor need for consultation and provide treatment as ordered. Occupational therapy and physical therapy. Assist with personal hygiene as needed including oral and dental. Encourage exercise during daily care (dressing and bathing). Provide only the amount of assistance/supervision that is needed with ADL's, weight bearing, assist of 1 person, hands on. Lacking documentation for turning and repositioning, shifting weight to enhance circulation..." Care plan for alteration in skin integrity dated 3/24/13 read as follows: "...Problem: Pressure ulcer to coccyx. Related to Immobility, incontinence, non-compliance with turning and repositioning, poor nutritional status, terminal medical diagnosis. Goal: Resident will have minimal impact of signs and symptoms of infection. Interventions: Examine skin daily for signs of redness, discoloration, monitor areas prone to breakdown especially over bony prominences. Pericare and apply moisture barrier after each incontinent episode. Pressure reducing mattress to bed. Pressure reducing cushion to chair. Monitor labs as ordered by physician, Nutritional risk assessment per registered dietician. Provide supplement as ordered. Monitor meal consumption...Treat per physicians order. Weekly skin assessment. Notify physician and responsible party of change in status..." Care plan for non-compliance dated 3/24/13 read as follows: "...Problem: Resident is non compliant/resistive to care with: Prevention precautions i.e. turning and repositioning, prefers to stay on back. Goals: Resident will have no/minimal negative outcomes from non-compliance. Interventions: Reorient and cue resident as needed. Explain all procedures. Encourage resident to be compliant. Educate resident/family of possible negative outcomes r/t non-compliance. Leave resident alone and reapproach later as needed. Have staff that is most compatible provide care..." On 5/22/13 at 12:00 P.M., the facility provided a copy of The CNA's Responsibility in Wound Prevention. It read as follows: "...2. (f). Turn and reposition every 2 hours..." On 5/22/13 at 11:45 A.M., the DON indicated the wound on Resident #99's coccyx was caused by shearing. The DON indicated she started to stage the wound as an E on 3/24/13. The DON indicated the resident had been non-compliant with turning and repositioning and a care Plan for non-compliance was started on 3/24/13. 3.1-40(a)(1) 3.1-40(a)(2)