Every finding on record at Aperion Care Lincoln

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment in resident spaces for 2 of 2 units observed. (100 unit, 200 unit ) Findings include: On 7/13/26 at 9:49 a.m., the following was observed on the 100 Unit: A wall across from a room marked medical suite had loose cove base. The wall beside room [ROOM NUMBER] and double unit doors had loose cove base. The double fire doors on the unit had dirt build up around the door frames and wall.The hallways on the unit had dirt build up in the corners and around door frames to resident rooms.A room that contained a fireplace had soiled stained carpets. A kitchenette by the main dining room had dirt built up around walls and under the cabinet, around the refrigerator. A black cart with 3 shelves in the dining room was observed with dirt/debris in the grooves of both handles.The two nurse's stations on the unit had dirt buildup on the floor under the desk and around the walls. A green recliner by room [ROOM NUMBER] had stained fabric, a chair by room [ROOM NUMBER] with a blue fabric seat was stained. Wallpaper was coming off the wall by room [ROOM NUMBER]. On 7/13/26 at 12:33 p.m., the floor under the desk at the 200 unit nurses station was observed to have dirt/debris. On 7/13/26 at 1:25 p,m., the library on the 200 unit was observed to have dusty bookcase shelves, dirt around wall edges, and edges of bookcases, cove base coming off of walls.On 7/13/26 at 2:23 p.m., the Housekeeping director indicated floors are mopped daily on the units. On 7/13/26 at 2:44 p.m., the Administrator provided the current undated housekeeping services policy. The policy indicated the facility was to maintain a clean, odor free, comfortable, and orderly environment in all health care and public areas.This citation relates to Intake 3045014.410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure food was served under sanitary conditions for 2 of 2 random observations. An ice scoop was located on top of the ice machine without a cover, food was left uncovered on the steam table prior to food service, and staff touched food with contaminated gloves while serving lunch. (Dietary Pantry and Dining Room)Findings include: 1. Continuous random lunch observation in the first-floor dining room on 5/18/26 at 11:58 A.M., staff were observed placing food trays in the steam table. The food was not covered. The food included chicken, potatoes, carrots, mashed potatoes, gravy, rolls, hot dogs, and cheeseburgers. The food remained uncovered until staff put lids over the food at 12:10 P.M. At 12:16 P.M., [NAME] 7 put on gloves, touched a towel, the tray tops, serving ware, and her face. At 12:19 P.M., [NAME] 7 began plating food without changing gloves. She placed rolls onto plates using her hand. Plating continued in that way until 12:33 P.M. when [NAME] 7 began to use tongs to plate the rolls. Interview on 5/22/26 at 11:41 A.M., the Director of Nursing (DON) indicated that staff should not touch food at all while serving food and that the appropriate kitchen tools should be used to serve food items to residents. At that time, the DON indicated food should be covered on the steam table prior to serving. 2. On 5/22/26 at 11:51 A.M., during a random observation of the Dietary Pantry the ice scoop for the facility ice machine was observed sitting on the top of the machine in a without an appropriate cover. Interview on 5/22/26 at 2:00 P.M., the Director of Nursing indicated ice scoops should be covered at all times when not in use. On 5/22/26 at 3:05 P.M., the Administrator provided a current, non-dated policy Ice Handling and Cleaning. The policy indicated .scoops will be stored in a protected manner to ensure the scoop handle does not make contact with the ice. All designated ice containers will be cleaned/sanitized at least daily . On 5/22/26 at 3:15 P.M., the Administrator provided a current undated Use of Disposable Gloves policy that indicated Utensils only should be used when serving food – do not use gloves during meal service . Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. This citation relates to intake 3009260. 410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)(2)410 IAC 16.2-3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were followed for 4 of 4 residents observed during medication administration (Resident S, Resident R, Resident L, and Resident K) and 2 random observations of wound care (Resident G and Resident H). The rubber injectable port for insulin was not cleaned prior to placing the needle on the insulin pen. The resident's arm was not cleaned with alcohol prior to insulin administration. Vital sign equipment was not cleaned in between residents. Gloves were not changed between touching contaminated surfaces and clean surfaces. A gown was not worn while providing care for a resident who required Enhanced Barrier Precautions (EBP). Findings include:1. On 5/21/26 at 7:24 A.M., Registered Nurse (RN) 3 was observed preparing medications for Resident S. RN 3 put on gloves, touched the medication cart, the computer, and the water jug. Without changing her gloves, RN 3 obtained two medication cards from the medication cart drawer, popped one tablet from each card into her hand, and placed them in a medication cup.Interview on 5/22/26 at 11:41 A.M., the Director of Nursing (DON) indicated that medication should be popped directly into the medication cup and never touched with a bare or gloved hand.2. On 5/21/26 at 7:35 A.M., Registered Nurse (RN) 3 was observed preparing a Basaglar Kwikpen (a long-acting insulin) for Resident R. RN 3 did not clean the rubber seal with an alcohol swab before attaching the insulin needle to the pen. RN 3 entered the room and administered 12 units of insulin glargine to Resident R's left arm. RN 3 did not clean Resident R's arm with an alcohol swab prior to administering the insulin.On 5/22/26 at 10:25 A.M., the insert for the Basaglar Kwikpen, revised 11/29/23, was reviewed. The insert indicated Step 1: Pull the Pen Cap straight off . Wipe the Rubber Seal with an alcohol swab . Wipe the skin with an alcohol swab, and let the injection site dry before you inject your dose.Interview on 5/22/26 at 11:41 A.M., the Director of Nursing (DON) indicated that staff should clean the rubber seal port on an insulin pen before attaching a needle, and that staff should clean the injection site with an alcohol swab prior to administering insulin.3. On 5/21/26 at 7:52 A.M., Qualified Medication Aide (QMA) 17 was observed taking Resident L's blood pressure using a wrist cuff. On 5/21/26 at 8:10 A.M., QMA 17 was observed taking Resident K's blood pressure using a wrist cuff. QMA 17 did not clean the blood pressure cuff after taking Resident L's blood pressure and prior to taking Resident K's blood pressure.Interview on 5/22/26 at 11:41 A.M., the Director of Nursing (DON) indicated that staff should clean vital sign equipment including blood pressure cuffs in between each resident.4. On 5/18/26 at 10:18 A.M., Registered Nurse (RN) 17 was observed providing wound care to Resident G. RN 17 was not wearing a PPE (personal protective equipment) gown.On 5/20/26 at 10:37 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, peripheral vascular disease.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/7/26, indicated Resident G had mild cognitive impairment, required substantial to maximal assistance of staff (staff does more than half the work) for transferring, and had one venous ulcer.An active wound report indicated that Resident G had a venous statis ulcer on the front of her left lower leg that was identified on 12/16/25 and last assessed on 5/19/26.Physician orders included, but were not limited to:Enhanced Barrier Precautions (EBP) related to wound, dated 2/10/26Current care plans included, but were not limited to:Enhanced barrier precautions related to chronic wounds, dated 4/9/26Interview on 5/22/26 at 11:41 A.M., the Director of Nursing (DON) indicated that EBP was required if a resident had a wound. Staff wore a gown and gloves for residents with an EBP order while providing high contact care for that resident.5. Random observation on 5/21/26 at 7:46 A.M., Licensed Practical Nurse (LPN) 15 was observed performing a dressing change for a wound on Resident H's leg. LPN 15 was sitting on the floor with gloves on. LPN 15 touched the floor and then the resident's leg without changing gloves.Interview on 5/22/26 at 11:41 A.M., the Director of Nursing (DON) indicated that staff should change gloves between dirty and clean tasks.On 5/22/26 at 3:15 P.M., the Administrator provided a current Glove Use - Nursing policy, dated 1/31/18, that indicated Gloves used for contact shall be removed and discarded after contact with each person, fluid item, or surface.On 5/22/26 at 3:15 P.M., the Administrator provided a current undated Medication Administration General Guidelines policy that indicated The person administering medications adheres to good hand hygiene.On 5/22/26 at 3:15 P.M., the Administrator provided a current Insulin Pen Procedure policy, dated 8/4/20, that indicated Wipe the rubber stopper with an alcohol wipe. Attach a new pen needle onto the insulin pen.On 5/22/26 at 3:15 P.M., the Administrator provided a current Enhanced Barrier Precautions policy, dated 5/7/24, that indicated Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following:.chronic wounds . Examples of chronic wounds include, but are not limited to:.venous statis ulcers . For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities.wound care.This citation relates to intake 3009260.410 Indiana Administrative Code (IAC) 16.2-3.1-18(b)(1)410 IAC 16.2-3.1-18(l)

Based on observation, record review, and interview, the facility failed to ensure residents were provided bathing on their scheduled days for 2 of 5 residents reviewed for bathing. ( Resident F, Resident T) Findings include: 1. Random observation on 5/20/26 at 11:00 A.M., Resident F was observed sitting in a wheelchair with greasy hair, unshaven face, and dark substance coming out of his nose. Random observation on 5/21/26 at 1:30 P.M., Resident F was observed lying in bed with greasy hair, an unshaven face, emesis in the bed and floor, and dried feces in the sheets. On 5/19/26 at 9:47 A.M., Resident F's clinical record was reviewed. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety, and depression.The current Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident F was cognitively impaired. Resident F was dependent on bathing. The Point of Care (POC) Task for Certified Nurse's Aide (CNA) was reviewed from 4/22- 5/20/26. The scheduled nights were Monday, Wednesday, and Friday. night per resident's preference. The resident did not receive showers on the following nights:5/13/26, 5/18/26. Was sent to the hospital on 5/15/26.2. On 5/19/26 at 9:17 A.M., Resident T's clinical record was reviewed. Diagnosis included, but was not limited to, chronic obstructive pulmonary disease.The current Annual MDS assessment dated [DATE], indicated Resident T was cognitively intact. Resident T was dependent on bathing.The Point of Care (POC) Tasks for CNA's were reviewed from 4/22- 5/20/26. The scheduled days for showering were Tuesday, Thursday, and Saturday evening per resident's preference. The resident did not receive showers on the following evenings: missed on 5/2, 5/9, and 5/12/26.Interview on 5/21/26 at 10:10A.M., with the DON, she indicated that some showers were missed on evenings especailly on the evening.Interview on 5/21/26 at 3:30 P.M., the Director of Nursing indicated she could not find the shower documents for the days that were not documented in the CNA tasks that were reviewed.On 5/22/26 at 3:08 P.M., the Administrator provided a current policy Shower and Tub Bath revised on 1/31/18. The policy indicated .a shower, tub bath, bed/sponge bath will be offered according to resident's preference two times a week or according to resident's preferred frequency and as needed or requested .document bathing task and assistance provided in the electronic record, including pertinent observations .This citation relates to Intake 2985807 and 2988173410 Indiana Administrative Code (IAC) 16.2-3.1-38(b)(2)

Based on observation and interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment in resident spaces on 1 of 2 units observed. (100 unit ) Findings include: On 4/8/26 at 9:37 a.m., the following was observed on the 100 Unit: The stairs leading up to the 100 Unit were observed to have debris build up on the surface and in the corners, a folded up band-aid was lying on the steps. The common area wall by the stairwell, and a wall across from a room marked medical suite had cove base coming off the walls.Dirt was built-up under the water fountains.The double fire doors on the unit had dirt build up around the door frames and wall.The hallways on the unit had dirt build up in the corners and around door frames to resident rooms.A room that contained a fireplace and piano had soiled stained carpets. A kitchenette by the main dining room had debris on the floor, debris under a metal storage rack, and a large dead bug under the rack.The outside of the trashcan was soiled, the inside of the refrigerator was soiled with a black and red substance throughout. The freezer had ice buildup. The two nurses' stations on the unit had debris buildup on the floor under the desk and around the walls. On 4/8/26 at 1:30 p.m., the Resident Council Meeting minutes were reviewed and included, but were not limited to:On 1/27/26, the Resident Council indicated rooms were not being cleaned well, bathrooms were being left dirty, toilets were not being cleaned.On 2/26/26, the Resident Council indicated the floors were not being cleaned well especially the edges along the walls and in the corners.On 4/9/26 at 9:11 a.m., the same was observed on the 100 Unit. On 4/9/25 at 2:45 p.m., the Housekeeping Director indicated floors were supposed to be mopped daily in the resident rooms and throughout the units. On 4/9/26 at 1:53 p.m., the Administrator provided the current undated housekeeping services policy. The policy indicated the faciltiy was to maintain a clean, odor free, comfortable, and orderly environment in all health care and public areas.This citation relates to Intakes 2965437, 2968109, 2969673. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a resident who was admitted with pressure ulcers was provided care and services to promote healing for 1 of 3 residents reviewed for pressure ulcers. (Resident D)Finding Includes: On 4/9/26 at 9:35 a.m., Resident D was observed in his room sitting in a power wheelchair. Resident D indicated he thought he had been at the facility for three weeks or longer. On 4/9/26 at 10:16 a.m., Resident D's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury, paraplegia, complete traumatic amputation of lower leg, and cognitive communication deficit. A Hospital After Visit Summary, dated 3/11/26 through 3/22/26, indicated throughout the admission, Resident D was supported with specialty beds and wound care for pressure injuries.The Facility Admission/readmission Observation document, dated 3/23/26 at 3:55 p.m., was reviewed and included but was not limited to, right trochanter (hip) stage 2 pressure ulcer.An admission Checklist form, dated 3/24/26, was reviewed and included but was not limited to, wound care to right great toe and right second toe with betadine (a broad spectrum anti-septic used to prevent infections)An admission Minimum Data Set (MDS) assessment, dated 3/26/26, indicated Resident D's cognition was intact, no pressure ulcer/injury, scar over bony prominence, or a non- removable dressing/device. Resident D admitted to the facility on [DATE]. The Care Plans included, but were not limited to: Potential for impairment to skin integrity, initiated 3/25/26. The interventions included, but were not limited to, assess/record changes in skin status, initiated 3/25/26. Pressure ulcer right great toe, initiated 4/8/26. The interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate, initiated 4/8/26. Physician orders for March - April 2026 were reviewed and included but were not limited to:Pillow boot to right foot, one time a day for wound, initiated 4/8/26.Iodine to right second and right great toe wounds daily, one time a day, initiated 4/7/26.Wound assessment notes were reviewed and included but were not limited to:Right first toe, facility-acquired, unsteagable pressure ulcer, date identified 4/7/26.Skin Assessment Report documents, dated 3/25/26 and 4/1/26, were reviewed and indicated Resident D had a surgical wound incision to the right shoulder, no other skin impairments were documented. On 4/9/26 at 11:16 a.m., the DON indicated the admission checklist dated 3/24/26 was an internal document the facility used to check off things that were done on a resident's admission. The DON indicated she saw the comments section that listed the skin areas to the buttock and toes but it was not followed up on. On 4/9/26 at 11:21 a.m., LPN 2 indicated she was Resident D's admitting nurse. LPN 2 indicated she filled out the facility admission/readmission form. LPN 2 had gotten in report from the hospital that Resident D had a stage 2 pressure ulcer to his right hip. She indicated she did not visualize his skin because he did not want to get in bed yet. LPN 2 indicated she documented the skin issues she got in report from the discharging facility. LPN 2 indicated she passed on the information to the night nurse that Resident D needed a skin assessment when he went to bed.On 4/9/26 at 1:42 p.m., Resident D's right hip was observed. The hip had what appeared to be pink scar tissue with a dry callous in the middle, no open areas were observed. Resident D indicated he had this area for a long time due to his condition. On 4/9/26 at 1:55 p.m., the DON indicated the nurses should have documented Resident D's right hip on the skin assessments. On 4/9/26 at 2:05 p.m., the DON indicated the expectation was the admitting nurse should have done the skin assessment, if she could not, the next nurse on duty should have, it should have been discussed the next day in report between the nurses, there was an internal communication board where it should have also been discussed. On 4/9/26 at 1:53 p.m., the Administrator provided the current policy on skin condition assessment & monitoring pressure and non-pressure, revised 6/8/18. The policy indicated pressure and other ulcers would be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. A skin condition assessment and pressure ulcer risk assessment would be completed at the time of admission/readmission. A wound assessment would be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions were identified by licensed nurse.On 4/9/26 at 1:53 p.m., the Administrator provided the current policy for assessment of resident, revised 4/18/22. The policy indicated to measure any areas of redness or skin breakdown on extremities or other skin surfaces, a skin condition report would be completed in conjunction with any wound, skin breakdown, or pressure ulcer.On 4/9/26 at 1:53 p.m., the Administrator provided the current undated policy on admission of resident. The policy indicated to conduct a head to toe nursing assessment of body systems, parts, and surfaces identifying functional status abilities, needs, or problems and measure any area of redness or skin breakdown on extremities or other skin surfaces.This citation relates to Intake 2965437 and 2968109. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure employees held an active license required to provide nursing care to residents. An employee did not have an active nursing license that provided care to residents. (100 unit, 200 unit) This deficient practice was corrected on November 3, 2025, prior to the start of the survey, and was therefore past noncompliance.Finding includes: On 3/25/26 at 11:15 a.m., an employee file for LPN 2 (Licensed Practical Nurse) was reviewed. The file did not contain documentation of a license for a Licensed Practical Nurse. LPN's hire date was 9/30/25, termination date 11/1/25. On 3/25/26 at 11:50 a.m., the Administrator indicated the facility was unable to verify LPN 2 had an active nursing license, she was hired without verifying she held a license, was sent home on [DATE] after she could not verify she held a nursing license. On 3/26/26 at 9:52 a.m., the Administrator indicated LPN 2 worked on all units in the facility during her employment. The Administrator indicated LPN 2 worked on the following dates:10/7/25- 10/10/25- orientationWorked on her own: 10/14/2510/15/2510/16/2510/18/2510/19/2510/20/2510/21/2510/22/2510/24/2510/28/2510/29/2510/30/2511/1/25On 3/26/26 at 10:16 a.m., the Administrator provided a page from the employee handbook with a date of 01/2023. The document included but was not limited to: .Proof of current status must be submitted upon application for employment and at least annually thereafter . On 3/26/26 at 10:39 a.m., the Administrator provided an undated policy titled Indiana Licensed Practical Nurse (LPN) Role Policy. The policy included but was not limited to: .Delegation and Accountability- The LPN accepts assignments consistent with education, training, and competency. The LPN is accountable for the safe performance of assigned nursing care. The LPN adheres to established standards, policies, and procedures . Professional Standards- Established nursing standards of care, Ethical principles of nursing practice, Facility policies and procedures, Applicable state laws and regulations . On 3/25/26 at 2:25 p.m., the Administrator provided the facility job description dated 5/2/17, for a Licensed Practical Nurse. The job description included but was not limited to: .Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required. Licensed Practical Nurse with current unencumbered state license .This deficient practice was corrected by November 3, 2025 after the facility implemented a systemic plan that included the following actions: The unlicensed employee was terminated from employment, all other licensed staff members were reviewed for current licenses, all licensed staff were inserviced using the personnel handbook, and the policy for verification of license status prior to hire. The plan for ongoing review and monitoring was in place.This citation relates to Intake 2806016. 410 IAC (Indiana Administrative Code) 16.2-3.1-14(s)

Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications for 2 of 3 residents reviewed for pharmaceutical services. Residents routine medications were not readily available from the pharmacy to be administered per the physician orders. (Resident C, Resident D)Findings include:1. During an interview on 2/4/26 at 9:25 A.M., Resident C indicated that she had recently not received her routine antianxiety medication due to the facility running out of the medication.During record review on 2/4/26 at 9:40 A.M., Resident C's diagnoses included, but were not limited to depression and anxiety. Resident C's physician orders included but were not limited to; Ativan 1 milligram (mg) 1 tablet three times daily (started 12/19/24). Resident C's January 2026 Medication Administration Record (MAR) indicated the order for Ativan 1 mg three times daily was not documented as administered on 1/27/26 for the 2:00 P.M. and 8:00 P.M. dose. Resident C's nurse's progress notes on 1/27/26 included but were not limited to:1/27/26 at 1:13 P.M. - Order Administration Note - Ativan Oral Tablet 1 mg related to anxiety disorder - Pharmacy waiting on new script. Nurse notified. 1/27/26 at 9:52 P.M. - Order Administration Note - Ativan Oral Tablet 1 mg related to anxiety disorder -Pharmacy aware of need for medication.2. During an interview on 2/4/26 at 11:35 A.M., Resident D indicated that she often does not have medications available or that the nursing staff is unable to find her medications. During record review on 2/4/26 at 1:00 P.M., Resident D's diagnoses included but were not limited to vitamin deficiency, cerebral palsy, and reduced mobility. Resident D's physician orders included, but were not limited to multivitamin women's tablet, one tablet one time a day for supplement (started 9/9/25), Replens gel, insert application vaginally one time a day for vaginal lubricant (started 9/9/25), and Chlorzoxazone oral tablet 500 mg four times a day (started 1/7/26). Resident D's January 2026 Medication Administration Record (MAR) indicated the order for multivitamin women's tablet, one time a day for supplement was not administered on 1/22/26. Replens gel, insert application vaginally one time a day for vaginal lubricant was not administered on 1/9/26, 1/14/26, 1/21/26, and 1/31/26. Chlorzoxazone oral tablet 500 mg four times a day was not administered on 1/7/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, and 1/22/26. Resident D's nurses progress notes included, but were not limited to:1/7/26 - Orders - Administration Note - Chlorzoxazone oral tablet 500 mg - pending pharmacy arrival1/9/26 - Orders - Administration Note - Replens gel - suppository on order1/14/26 - Orders - Administration Note - Replens gel - on order1/16/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - pending pharmacy arrival1/17/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - pending pharmacy arrival1/18/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - pending pharmacy arrival1/19/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - pending pharmacy arrival1/20/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - pending pharmacy arrival1/21/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - not available1/21/26 - Orders - Administration Note - Replens gel - on order1/22/26 - Orders - Administration Note - multivitamin women's tablet - waiting on pharmacy to deliver1/22/26 - Administration Note - Chlorzoxazone oral tablet 500 mg - waiting on pharmacy to deliver1/31/26 - Orders - Administration Note - Replens gel - out of Replens. Replens reordered this morningDuring an interview on 2/4/26 at 1:30 P.M., RN 7 indicated it was the nurse's responsibility to reorder resident medications prior to the medication running out. On 2/4/26 at 1:55 P.M., the Facility Administrator supplied a facility policy titled, Pharmaceutical Services, dated 12/2015. The policy included, .9. Resident's may use the pharmacy of their choice for medications administered by the facility, as long as the pharmacy: .c. Refills prescription drugs when needed, in order to prevent interruption of drug regimens.This citation relates to intake 2713960.3.1-25(a)

Based on observation and interview, the facility failed to report an alleged violation of sexual abuse to the State Survey Agency for 1 of 1 allegation of abuse reviewed. (Resident T)Finding includes:In an anonymous interview, it was indicated that Resident B asked Resident T for sex and to see her breasts, and that Resident T was not capable of giving consent.During an interview on 9/24/25 at 9:24 A.M., the Director of Nursing (DON) indicated that a few weeks prior, a Certified Nurse Aide (CNA) had reported to her that Resident B went into Resident T's room and asked her to be his girlfriend and if she had ever had sex. Resident T responded no and Resident B left. The DON was unable to remember when that incident occurred.During an interview on 9/24/25 at 11:00 A.M., the DON indicated that the CNA also reported to her that Resident T showed Resident B her breasts. She indicated that the incident occurred on or around 8/23/25.During an interview on 9/24/25 at 1:04 P.M., the Administrator indicated he was aware of the incident that occurred between Resident B and Resident T. He was unaware it needed to be reported to the State Survey Agency.During an interview on 9/24/25 at 1:10 P.M., the Regional [NAME] President of Operations indicated that she was aware of the incident that occurred between Resident B and Resident T, but was unaware that it needed to be reported to the State Survey Agency.During an interview on 9/24/25 at 2:27 P.M., the Administrator indicated that the facility did not have a policy related to reporting alleged violations and followed State regulations.This citation relates to Intake 2608809.3.1-28(c)

Based on interview and record review, the facility failed to ensure a resident's wound treatments were completed as ordered for 1 of 3 resident's reviewed for wounds. (Resident C) Finding includes:On 9/23/25 at 1:39 P.M., Resident C's clinical record was reviewed. Resident C's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications. The most recent Minimum Data Set (MDS) Assessment, dated 7/21/25, indicated Resident C was cognitively intact, and had a surgical wound. Physician orders included, but were not limited to: Wound vac to be changed every three days; Start Date 8/8/25 The electronic treatment administration record indicated Resident C's wound vac was scheduled to be changed on the following days in September 2025, but was not changed:9/7/259/10/25 During an interview on 9/24/25 at 12:32 P.M., the Director of Nursing indicated Resident C's wound vac was not changed on 9/7/25 or 9/10/25. On 9/24/25 at 3:02 P.M., the Administrator provided a policy titled Skin Condition Assessment and Monitoring, revised 6/2018, that indicated Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses note.' This citation relates to Intake 2615547. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications for 1 of 1 medication rooms reviewed. The medication room, treatment cart, and medication refrigerator were not locked. (First Floor Medication Room)Finding includes: On 9/23/25 at 1:04 P.M., the first floor medication room that contained the Emergency Drug Kit (EDK) was observed unlocked. Inside the room, the treatment cart and the refrigerator that contained insulin, suppositories, and other cold medication was observed unlocked. At that time, Qualified Medication Aide (QMA) 16 indicated that the medication room, treatment cart, and medication refrigerator were all supposed to be locked.On 9/24/25 at 2:27 P.M., the Administrator provided a current Medication Storage policy, revised 7/2/19, that indicated Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.This citation relates to Intake 2615731.3.1-25(m)

Based on interview and record review, the facility failed to provide necessary treatment and services for 1 of 3 residents reviewed for behavior management. An incident with another resident was not documented, a resident's care plan was not updated following the incident, and behaviors were not monitored. (Resident B)Finding includes:In an anonymous interview, it was indicated that Resident B asked Resident T for sex and to see her breasts, and that Resident T was not capable of giving consent.During an interview on 9/23/25 at 1:10 P.M., Resident B indicated that he struggled with mental health disorders due to his time in the war. He indicated that he would like to move to a facility closer to his family.During an interview on 9/23/25 at 1:22 P.M., Resident T indicated that a male resident would open her door sometimes and then leave, but she did not know who it was or recall any specific encounters with any male residents.On 9/23/25 at 2:08 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, schizophrenia, generalized anxiety disorder, and unspecified intellectual disabilities. Resident B was admitted to the facility on [DATE].The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/1/25, indicated Resident B was cognitively intact and had verbal behavior towards others that occurred between one and three days during the lookback period.Current care plans included but were not limited to:I have a history of & recently used illicit substances. I have used the following substances: tobacco, alcohol, excessive prescription medications, cocaine, crack, heroin, methamphetamine (crystal meth) and possibly other illegal substances, per my POA, initiated 7/15/25. Interventions included, but were not limited to, Psychiatric consult as needed.I have potential to be verbally aggressive related to not getting my way, initiated 7/15/25. Interventions included, but were not limited to, Psychiatric/Psychogeriatric consult as indicated and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.The clinical record lacked a care plan that addressed sexual behaviors.The clinical record lacked documentation to indicate Resident B was receiving mental health services.The clinical record, including progress notes, miscellaneous documents, and assessments, lacked documentation about a sexual incident with Resident T, indications that Resident B had sexual behaviors, or that Resident B was monitored for sexual behaviors.On 9/23/25 at 2:56 P.M., Resident T's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/29/25, indicated Resident T had moderate cognitive impairment and had no behaviors during the lookback period.A psychiatric encounter progress note, dated 8/29/25, indicated Pt (patient) was involved in an incident with another resident recently. She did not remember nor does she appear in any type of distress.The clinical record, including progress notes, care plans, miscellaneous documentation, and assessment, lacked documentation to indicate details about the incident with another resident that Resident T was involved in.During an interview on 9/24/25 at 8:31 A.M., Certified Nurse Aide (CNA) 9 indicated she had not heard of any residents with sexual behaviors.During an interview on 9/24/25 at 8:37 A.M., the Social Services Director (SSD) indicated that she was not aware of an incident between Resident T and another resident. At that time, she indicated Resident B was trying to transfer to a facility closer to family, but was denied admission to his first choice due to his sexual behaviors. The SSD indicated he did have a history of sexual behaviors, but was unsure if Resident B currently had any sexual behaviors or was being monitored for sexual behaviors at the facility.During an interview on 9/24/25 at 9:24 A.M., the Director of Nursing (DON) indicated that a few weeks prior, a Certified Nurse Aide (CNA) had reported to her that Resident B went into Resident T's room and asked her to be his girlfriend and if she had ever had sex. Resident T responded no and Resident B left. She completed a capacity for sexual consent assessments for both residents at that time and told Resident B he could not ask those questions to other residents. She indicated that since then he had asked staff inappropriate questions about sex, but those behaviors did not get documented. At that time, she indicated that there was no other documentation surrounding the incident between Resident B and Resident T. The DON was unable to remember when that incident occurred.On 9/24/25 at 9:50 A.M., Resident T's clinical record was accessed, and an assessment titled Capacity for Sexual Consent, dated 8/23/25 at 9:38 P.M and locked on 9/24/25 at 9:18 A.M., was reviewed. The assessment indicated Resident T had the capacity to consent to sex, did not wish to have sex, stated he asked me to show my breasts (not like that) and I did, and that family was notified.On 9/24/25 at 9:51 A.M., Resident B's clinical record was accessed, and an assessment label in progress titled Capacity for Sexual Consent, dated 8/23/25, indicated Resident B had the capacity to consent to sex and the resident was able to voice desire for sexual interaction as well as appropriateness of the interaction.During an interview on 9/24/25 at 9:56 A.M., Resident T's emergency contact indicated she was unaware of and had not been notified of any resident to resident interactions between Resident T and another resident.During an interview on 9/24/25 at 11:00 A.M., the DON indicated that the CNA also reported to her that Resident T showed Resident B her breasts, that Resident T wanted to do that, and that the family was notified the evening of the incident. She indicated that the incident occurred on or around 8/23/25.On 9/24/25 at 11:59 A.M., the Point of Care (POC) (a documentation system for CNAs) Task Response for monitoring of Substance Abuse Behaviors (which included crude behavior and inappropriate sexual advances) indicated the SSD or a nurse had been notified about behaviors ten times during the months of August and September. Notification did not occur on 8/23/25. The clinical record lacked documentation indicating what the behavior was, who was notified, and what follow up occurred.During an interview on 9/24/25 at 12:09 P.M., Licensed Practical Nurse (LPN) 5 indicated that Resident B had been exhibiting significant behaviors.During an interview on 9/24/25 at 12:13 P.M., CNA 11 indicated that she had marked yes on the POC Task Responses in error and meant to mark no.During an interview on 9/24/25 at 1:04 P.M., the Administrator indicated he was aware of the incident that occurred between Resident B and Resident T and thought it was mutual between the residents. He indicated both residents were interviewed, and the event was discussed in morning meeting following the event, but there was no documentation about the incident or their investigation.During an interview on 9/24/25 at 1:10 P.M., the Regional [NAME] President of Operations indicated that the residents were determined to have capacity to consent but was unsure how the facility determined if the resident was cognitively able to give consent. She indicated that she talked with Resident T but was not able to provide any documentation related to an investigation of the incident.On 9/24/25 at 2:27 P.M., the Administrator provided a current Behavioral Health Services policy, revised 10/24/22, that indicated Mental health rehabilitative services and behavior management program for Mental Illness (Ml) and Intellectual Disabilities (ID) and other related disorders such as Substance Use Disorder and residents with a history of trauma and/or post-traumatic stress disorder may include, but are not limited to: . Consistent implementation during the resident's daily routine and across settings, of systematic plans which are designed to change inappropriate behaviors while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety . The following are examples of measures that may be taken to monitor behaviors and the effectiveness of interventions. These measures may include, but are not limited to: . Review of behaviors and interventions implemented during daily or weekly clinical review meetings .Implementing 72- hour monitoring following a new or worsening behavior or behavior crisis .Review of care plan . The plan of care shall be reviewed and/or updated at least quarterly and with a change in condition such as a new or worsening behavior or a behavior event requiring increased monitoring.On 9/24/25 at 2:27 P.M., the Administrator provided a current Sexuality-Capacity to Consent Determination policy, revised 7/15/24, that indicated The facility will conduct an investigation and protect the resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent . During the course of the investigation of an allegation of resident sexual abuse or other situation as warranted, the Interdisciplinary Team shall assess and make a determination of whether the sexual activity was consensual on the part of the resident(s) and document the findings of the assessment in a progress note and/or in the plan of care.This citation relates to Intake 2608809.3.1-37(a)3.1-43(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a bath or shower was provided for 1 of 3 residents reviewed for bathing. (Resident C) Finding includes:On 9/23/25 at 1:39 P.M., Resident C's clinical record was reviewed. Resident C's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications. The most recent Minimum Data Set (MDS) Assessment, dated 7/21/25, indicated Resident C was cognitively intact and required moderate assistance (staff do part of the work) for bathing. During an observation on 9/23/25 at 1:00 P.M., Resident C indicated that bathing had not been completed or bed linen hadn't been changed in weeks. Resident C had a very pungent sour smell, greasy hair, and long, soiled fingernails. The point of care (POC, a certified nurses aide charting system) indicated Resident C preferred bathing twice weekly in the evenings. Paper and electronic shower records were reviewed for the last 30 days, and indicated Resident C had not received or refused a bath or shower on the following dates: 8/26/259/12/259/19/25 The bathing records indicated Resident C had not had their hair shampooed from 8/26/25 through 9/23/25. On 9/24/25 at 2:27 P.M., the Administrator provided a policy titled Bathing Shower and Tub Bath, revised 1/2018, that indicated A shower, tub bath, or bed/sponge bath will be offered according to the resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested. This citation relates to Intake 2588834. 3.1-38(a)(3)

Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 1 residents reviewed for abuse. (Resident T)Finding includes:In an anonymous interview, it was indicated that Resident B asked Resident T for sex and to see her breasts, and that Resident T was not capable of giving consent.During an interview on 9/24/25 at 9:24 A.M., the Director of Nursing (DON) indicated that a few weeks prior, a Certified Nurse Aide (CNA) had reported to her that Resident B went into Resident T's room and asked her to be his girlfriend and if she had ever had sex. Resident T responded no and Resident B left. She completed a capacity for sexual consent assessment for both residents at that time and told Resident B he could not ask those questions to other residents. She indicated that there was no other documentation surrounding the incident between Resident B and Resident T.During an interview on 9/24/25 at 11:00 A.M., the DON indicated that the CNA also reported to her that Resident T showed Resident B her breasts.During an interview on 9/24/25 at 1:04 P.M., the Administrator indicated he was aware of the incident that occurred between Resident B and Resident T. He indicated both residents were interviewed and the event was discussed in morning meeting following the event, but there was no documentation about the incident or the investigation.During an interview on 9/24/25 at 1:10 P.M., Regional [NAME] President of Operations indicated that the residents were determined to have capacity to consent but was unsure how the facility determined if someone was cognitively able to give consent. She indicated that she talked with Resident T but she was not able to provide any documentation related to an investigation of the incident.On 9/24/25 at 2:27 P.M., the Administrator provided a current Sexuality-Capacity to Consent Determination policy, revised 7/15/24, that indicated The facility will conduct an investigation and protect the resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent . During the course of the investigation of an allegation of resident sexual abuse or other situation as warranted, the Interdisciplinary Team shall assess and make a determination of whether the sexual activity was consensual on the part of the resident(s) and document the findings of the assessment in a progress note and/or in the plan of care.This citation relates to Intake 2608809.3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Floors were soiled, food unlabeled. (Kitchen) Findings include: On 7/3/25 at 8:17 a.m., during observation of the kitchen the following was observed: 1. The walk in freezer contained partially used bags of breaded chicken, mixed vegetables, and garlic bread. The bags were unlabeled. 2. The floor behind the stove and deep fryer, stainless steel table that contained a sink had soil buildup and debris. On 7/3/25 at 8:21 a.m., the Dietary Manager indicated the floors under equipment are usually cleaned once a week. On 7/7/25 at 1:00 p.m., the floors were observed to still be soiled. The walk in freezer contained a box of fish squares that were open to air, unsealed. On 7/7/25 at 1:06 p.m., Dietary Aide 2 indicated when food is opened, it is put in a plastic bag with the open date and dated 30 days out. On 7/7/25 at 2:41 p.m., the Administrator provided the current policy on labeling and dating foods with a date of 2020. The policy included but was not limited to: .Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines, or by the manufacture's expiration date . On 7/7/25 at 2:41 p.m., the Administrator provided the current cleaning rotation and cleaning instructions for floors with a date of 2020. The guidelines included but were not limited to: .items cleaned daily: kitchen and dining room floors .Floors will be kept clean and sanitary, washed daily or as needed . This citation relates to Complaint IN00462420 and IN00462798. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide food that was served at an appetizing temperature for 1 of 1 meal tested on unit 200. ( Unit 200, Resident F) Finding includes: On 7/3/25 at 8:55 a.m., Resident F indicated food was not always served hot, it was sometimes ice cold depending on what time it was delivered to her. On 7/7/25 food temperatures were taken on the 200 unit for the noon meal. The temperature of the herb roasted pork loin was 115, stuffing 85, peas 79. On 7/7/25 at 2:41 p.m., the Administrator provided the current guideline and procedure for monitoring food temperatures for meal service with a date of 2020. The guidelines included but were not limited to: Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at a palatable temperature .8. meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 F (Fahrenheit) or greater to promote palatability for the resident. Any complaint regarding food temperatures by residents will be documented on the Food Temperature Log. Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining above 120 F. The investigation is recommended to be completed within 72 hours of the complaint . This citation relates to Complaint IN00462420. 3.1-21(a)(2)

Based on observation and interview, the facility failed to ensure dignity was provided for 1 of 1 observations of meal trays passed. Staff were observed to enter resident rooms without knocking or announcing themselves. ( room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Resident F) Finding includes: On 7/3/25 at 10:14 a.m., resident council minutes dated 5/29/25 were reviewed and included a complaint of staff not knocking or introducing themselves before entering the room. On 7/7/25 at 12:34 p.m., CNA 2 was observed to deliver lunch trays to room [ROOM NUMBER], 211, 213, 214, and 216. CNA 2 did not knock or announce herself before walking in the rooms. On 7/7/25 at 1:10 p.m., CNA 3 indicated before delivering a meal tray to a resident in their room, you should knock and let them know you have food for them. On 7/7/25 at 2:41 p.m., the Administrator provided the current policy on resident rights with a revision date of 4/23/18. The policy included but was not limited to: .The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or hers individuality.protecting and valuing resident's private space (for example, knocking on doors and requesting permission before entering, closing doors as requested by the resident) . This citation relates to Complaint IN00462420. 3.1-3(t)

Based on interview, and record review, the facility failed to maintain complete and accurate records, quarterly assessments were completed and documented in the clinical record. The Facility elopement risks were not documented in the clinical record. (Resident E) Finding includes: On 7/7/25 at 9:08 a.m., Resident E's clinical record was reviewed. Diagnoses included but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident E's cognition was severely impaired, uses walker, once standing, the ability to walk at least 150 feet in a corridor or similar space, supervision or touching assistance, helper provides verbal cues or touching/steadying assistance as resident completes activity. Care plans were reviewed and included but were not limited to: Resident is at risk for elopement per elopement risk assessment, initiated 4/27/23, revision 8/22/24. Interventions included: reassess elopement risk at least quarterly, initiated 4/27/23, revision 3/7/24. A progress note dated 2/1/25 at 2:22 p.m. indicated Resident E's behavior as wandering around the facility the entire shift asking where her room was, staff redirected her to her room and she came out of her room again within 30 seconds asking where her room was. A progress noted dated 2/3/25 at 4:01 p.m., indicated no observed behaviors, or excessive wandering, nurse practitioner was notified and resident placed on a list to be seen on 2/4/25, staff continued to monitor, continue with the current plan of care. A progress note dated 6/13/25 at 3:44 p.m., indicated Patient wondered (sic) off the floor took a flight of stairs to the ground floor living (sic) her walker on the stair case. Patient stated that she was going for a basketball game. Patient was found outside the building by a co worker. Head count done at that time. Patient brought back inside the building placed on a wander guard monitor on her left lower extremity per nursing supervisor instruction. Examined resident and no bruises noted. Patient denies of falling any where during the episode of her going out of the building(sic). We'll continue to monitor patient throughout the shift. Will notify family and physician. July 2025 physicians orders were reviewed and included but were not limited to: Wanderguard for decreased safety awareness. Check placement and function every shift, order date 6/13/25. On 7/7/25 at 1:14 p.m., the Administrator indicated the Regional Nurse Consultant looked back on emails and in May of 2025 she was doing paper elopement risk assessments, but can't find where it was transcribed onto the clinical record, nor find the paper copy. The Administrator indicated she did not find a elopement risk assessment in the clinical record except for the one done in June of 2025 after Resident E eloped, assessments should be done at least quarterly and if a significant change, one should have been done after the 2/1/25 incident of wandering around the facility. On 7/7/25 at 2:41 p.m., the Administrator provided the current policy for resident assessment with a revision date of 4/18/22. The policy included but was not limited to: Purpose: To gather comprehensive information as a basis for identifying resident problems/needs and developing or revising and individual plan of care .d. Elopement risk- to identify resident at risk for elopement and ensure appropriate interventions are implemented if identified risk. Complete a new assessment after any actual or attempted elopement, or if exit seeking behaviors are identified . This citation relates to Complaint IN00462420. 3.1-50(a)(1)

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents reviewed for hospitalization . A resident did not receive blood pressure medications and was admitted to the hospital two times for hypertensive emergencies. (Resident B) Finding includes: On 4/7/25 at 9:24 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hypertensive encephalopathy. The most recent Annual Minimum Data Set assessment, dated 1/3/25, indicated Resident B was moderately cognitively intact. Care plans included, but were not limited to: Resident had a diagnosis of hypertension: Administer medications as ordered; Assess for side effects and effectiveness; Notify physician of noted signs/symptoms for further evaluation, initiated 2/17/24. Physician orders included, but were not limited to: Carvedilol (a medication used to treat high blood pressure) oral tablet 12.5 mg (milligrams) give one tablet by mouth two times a day for hypertension; Start date 2/9/24 Isosorbide Mononitrate (a medication used to treat high blood pressure) ER (extended release) oral tablet 60 mg give one tablet by mouth two times a day for paroxysmal atrial fibrillation; Start date 2/9/24 Lisinopril (a medication used to treat high blood pressure) oral tablet 10 mg give one tablet by mouth two times a day for hypertension; Start date 2/9/24 Clonidine (a medication used to treat high blood pressure) HCl Oral Tablet 0.1 mg give one tablet by mouth three times a day for hypertension, hold if systolic blood pressure is less than 160; Start date 3/26/24 Discontinued 7/3/24 The electronic medication administration record (MAR) indicated Resident B did not receive his blood pressure medications (Carvedilol 12.5 mg, Isosorbide Mononitrate ER 60 mg, or Lisinopril 10 mg) at 8:00 A.M. on 6/25/24. in accordance with the physician orders. A nursing progress note, dated 6/25/24 at 2:06 P.M., indicated Resident B was heard yelling from his bedroom, the CNA went to check on him, and found him kneeling with his elbows on the floor in front of the toilet, and his rollator was next to him. The resident was barefoot, this nurse and two CNAs assisted him to lie down in a comfortable position. This nurse then assessed the resident for injury and none was observed at this time. This nurse and two CNAs then tried to assist the resident off the floor but the resident started complaining of back and neck pain, the nurse then decided not to move the resident and notified triage (a physician communication line). Triage gave an order to send the resident to the emergency room , ambulance was called and came to assist the resident off the floor and transported him to the hospital. The blood pressure was 155/84. A hospital admission history, dated 6/25/24 at 10:10 A.M., indicated Resident B's blood pressure was 240/103 on admission and resident had a hypertensive emergency with encephalopathy- likely due to not receiving proper medication regimen in nursing home. On 10/1/24 a new physician's order for hydralazine (a medication used to treat high blood pressure) HCl oral tablet 25 mg give 1 tablet by mouth every eight hours as needed was initiated. The electronic medication administration record (MAR) indicated Resident B did not receive his previous doses of blood pressure medications (Carvedilol 12.5 mg, Isosorbide Mononitrate ER 60 mg, Lisinopril 10 mg) on 12/7/24 at 8:00 P.M., and did not have a blood pressure recorded or blood pressure medications (Hydralazine 50 mg) given on 12/7/24 at 4:00 P.M. A nurses note, on 12/8/24 at 4:04 A.M., indicated Resident B was having chest pain and was given nitroglycerin (medication used to treat chest pain). A nurses note, on 12/8/24 at 6:00 A.M., indicated Resident B had been transported to the hospital. A hospital history and physician note, dated 12/8/24 at 11:30 A.M., indicated Resident B's blood pressure was 224/174 and he was having a hypertensive emergency. During an interview on 4/8/25 at 1:23 P.M., the Director of Nursing (DON) indicated each resident had different blood pressure parameters to notify the physician about, nursing staff should use their nursing judgement if a blood pressure falls outside of normal parameters, and that the charting system flags systolic blood pressure above 139 as elevated. On 4/9/25 at 12:14 P.M., a policy relating to blood pressure parameters and following physician orders was requested and not provided. During an interview on 4/9/25 at 1:20 P.M., the regional nurse indicate the policy of the facility was for staff to follow physician orders. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored in sanitary manner for 1 of 2 kitchen observations. Food containers were not labeled in the reach in refrigerator and dry storage. Findings include: On 4/3/25 at 10:35 A.M., the following was observed in the dry storage area: - One bag of [NAME] noodles with no open date - One bag of marshmallows with no open date On 4/3/25 at 10:57 A.M., the following was observed in the reach in refrigerator: - One container of orange juice without preparation date or use by date - One container of apple juice without a preparation date or use by date - One green container with orange colored fluid without a label, preparation date, or use by date - One pink container with brown colored fluid without a label, preparation date, or use by date - One clear container with purple colored fluid without a label, preparation date, or use by date - Two green colored containers with fluid, without a label, preparation date, or use by date - One yellow container with fluid, without a label, preparation date, or use by date During an interview on 4/8/25 at 9:31 A.M., the Dietary Manager indicated containers should be labeled and have a preparation and use by date. On 4/9/25 at 12:14 P.M., the Director of Nursing provided a current, non-dated policy Food Storage (Dry, Refrigerated, and Frozen. The policy indicated .the general storage guidelines including all food items will be labeled. The label must include the name of the food and the date it should be .consumed by . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure effective treatment and services were provided to residents with Urinary Tract Infections (UTIs) in 2 of 3 residents reviewed for UTIs. Urinalysis (UA) and Culture and Sensitivity (C&S) tests were not completed or followed up on, antibiotics were not prescribed in a timely manner, and catheter care was not performed correctly. This deficient practice resulted in Resident 21 being hospitalized for the treatment of pyelonephritis (a kidney infection). (Resident 21 and Resident 9) Findings include: 1.On 2/29/24 at 11:19 A.M., Resident 21's clinical record was reviewed and indicated the resident was readmitted to the facility from a hospital on 10/25/23 with a newly initiated indwelling urinary catheter and diagnoses including, but not limited to, chronic kidney disease, obstructive and reflux uropathy, and acute kidney failure. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 1/17/24, indicated Resident 21 was cognitively intact, had an indwelling catheter, was always incontinent of bowel and bladder, and received an antibiotic during the 7-day look back period. The physician orders from 10/11/23 to 10/25/23 related to the indwelling urinary catheter, included: May irrigate/flush with 60cc (cubic centimeters) of normal saline PRN (as needed) plugged or leaking every 24 hours as needed, dated 10/25/23. Use catheter anchor and check every shift. Replace if necessary, dated 10/25/23. The most current indwelling catheter care plan, dated 10/26/23, indicated Resident 21 was readmitted from the hospital with an indwelling catheter related to an acute kidney injury and enlarged prostate. An IDT (Interdisciplinary Team) note, dated 10/26/23 at 11:57 A.M., indicated Resident 21 was readmitted into the facility on [DATE] after a hospitalization for an acute kidney injury with a foley catheter due to an enlarged prostate and obstructive uropathy. A nurse's progress note, dated 11/29/23 at 2:11 P.M., indicated the resident's catheter was removed that morning during an appointment from the urologist and an order was given to re-anchor the catheter if he did not urinate in 6 hours (by 5:30 P.M.). A nurse's progress note, dated 11/30/23 at 2:08 P.M., indicated the indwelling catheter was to remain in place following a failed trial at the urologist's office to discontinue the catheter, and the catheter was to be changed once a month. At that time, the resident was scheduled for a cystoscopy (a procedure to view the inside of the bladder). The progress note did not include documentation to indicate the urology physician's order to change the indwelling urinary catheter monthly was included in the resident's orders or was forwarded to the PCP for approval between 12/1/23 and 12/09/23. The urology physician orders included, but were not limited to: Change indwelling catheter 16fr [French] 10ml [milliliters] Q [every] month and PRN [as needed] every day shift every 30 day[s] for catheter change, dated 12/10/23. A nurse's progress note, dated 12/14/23 at 11:36 A.M., indicated a nurse from the urologist called to give report on Resident 21. The resident had a cystoscopy performed outside of the facility where a new catheter was placed and a urine sample was taken for culture. A nurse's progress note, dated 12/15/23 at 7:30 P.M., indicated (name of Nurse Practitioner) received the results of the cystoscopy and culture which the NP forwarded to the urologist. The note indicated the culture report showed growth of Morganella morganii (a bacteria commonly found in the intestinal tract). The nursing progress notes, dated 12/16/23 through 12/18/23, did not include documentation to indicate the facility staff attempted to contact the NP or the urologist to follow-up on the urine culture and sensitivity results received on 12/15/23. A nurse's progress note, dated 12/19/23 at 9:31 A.M., indicated (name of urologist office) was contacted requesting follow-up orders for the culture that showed growth of Morganella morganii. The skilled nursing evaluations, dated 12/19/23 through 12/31/23, indicated no urine or indwelling urinary catheter abnormalities were identified. The skilled nursing evaluation, dated 12/26/23, indicated the indwelling urinary catheter was last changed on 12/1/23. The December 2023 Medication Administration Record (MAR), Treatment Administration Record (TAR), and nursing progress notes did not include documentation to show the indwelling urinary catheter was changed between 12/14/23 and 12/31/23 or the facility followed up with the urologist after 12/19/23 to ensure the urine culture findings were effectively addressed. A skilled nursing evaluation, dated 1/4/24, indicated facility staff changed the indwelling urinary catheter on 1/1/24. The evaluation did not include documentation to specifically determine the characteristics of the procedure. A skilled nursing evaluation, dated 1/6/24, indicated facility staff changed the indwelling urinary catheter ten months in the future, on 12/14/24. A skilled nursing evaluation, dated 1/7/24, indicated the facility changed the indwelling urinary catheter seven days in the future, on 1/14/24. The January 2024 Medication Administration Record (MAR), Treatment Administration Record (TAR), and nursing progress notes did not include documentation to show the indwelling urinary catheter was changed between 1/1/24 and 1/10/24 or to show the resident was effectively monitored for signs/symptoms of adverse outcome of indwelling urinary catheter placement. The nursing progress notes and skilled nursing evaluations, dated from 1/1/24 through 1/10/24, indicated Resident 21 did not experience any adverse signs or symptoms related to the use of an indwelling urinary catheter. A nurse's progress note, dated 1/11/24 at 11:34 A.M., indicated that Resident 21 had been having milky drainage that was changing to a bright green tint. Orders were given by the NP (Nurse Practitioner) to change out the catheter and obtain a urine specimen to check for a UTI. The last UA (urinalysis) showed growth of Morganella morganii, but the urologist had never returned the facility's phone call to follow up. Documentation of attempted contacts to the urologist or Medical Director between 12/19/23 and 1/11/24 was requested from the Infection Preventionist (IP). During an interview on 3/4/24 at 10:10 A.M., the IP indicated no documentation could be provided to show attempts were made by facility staff to contact the NP or the urologist for follow-up of the culture and sensitivity results after 12/19/23. The January 2024 MAR indicated the indwelling urinary catheter was changed on 1/11/24. A nurse's progress note, dated 1/11/24 at 8:00 P.M., indicated the catheter was changed and approximately 120 ml of amber colored, cloudy urine with sediment and odor was observed on return. At that time, a urine specimen was obtained. A nurse's progress note, dated 1/12/24 at 10:32 A.M., indicated new orders were received to start ciprofloxacin (an antibiotic) twice a day for 5 days for UTI. A nurse's progress note, dated 2/4/24 at 5:21 A.M., indicated Resident 21 had greenish discharge around the catheter. A nurse's progress note, dated 2/5/24 at 9:50 P.M., indicated the catheter was changed and a urine specimen was collected and was sent off for testing at (name of hospital). A nurse's progress note, dated 2/7/24 at 4:43 P.M., indicated the urine culture showed colonization and no new orders were received. The February 2024 MAR indicated the catheter was changed on 2/11 and 2/12. The nursing progress notes did not include documentation to show the procedure was performed or the resident's response to the procedure. A nurse's progress note, dated 2/17/24 at 1:44 P.M., indicated the resident said he could feel urine leaking from around his catheter. An order was received for Pyridium (an analgesic pain reliever) three times a day for two days. The nursing progress notes and the skilled nursing assessments, dated from 2/17/24 through 2/18/24 at 2:00 A.M., did not include documentation to show the facility effectively assessed or monitored the resident for signs and symptoms of adverse outcomes related to indwelling urinary catheter use. A nurse's progress note, dated 2/18/24 at 2:14 A.M., indicated the resident's penis and scrotum were swollen and bright red, raw to the touch and painful with thick viscous yellow drainage come from the urethral opening. At that time, the resident complained of bladder spasms and indicated he never had them before arriving and his catether [sic] is pulled on daily causing irriation [sic]. At that time, an ABD (abdominal) pad was placed under the urethral opening to collect drainage. Blood pressure was 146/74 and resident was afebrile. PRN Tylenol was administered and was assessed to be slightly effective. The note did not include sufficient documentation to show Pyridium was administered for pain in accordance with the plan of care or to show staff implemented other interventions for pain relief. A nurse's progress note, dated 2/18/24 at 4:48 A.M., indicated the resident was given a dose of Pyridium once it arrived from the pharmacy. The provider was notified of the previous assessment and no new orders were given. The NP would see the resident on 2/19/24. A nurse's progress note, dated 2/18/24 at 9:53 A.M., indicated there was a moderate amount of urine and drainage on the ABD pad. The nurse's progress and skilled evaluation notes from 2/18/24 at 9:54 A.M. to 2/20/24 at 4:22 P.M. did not include sufficient documentation to determine facility staff updated the NP or urologist regarding the resident's significant change in condition or that the resident was seen by the NP or urologist on 2/19/24. A nurse's progress note, dated 2/20/24 at 4:33 P.M., indicated that the resident was noted to be confused, having difficulty forming complete sentences and trouble answering any questions. The urine in the catheter was dark amber with a large amount of thick sediment. A call was placed to NHT (Nursing Home Triage) (a communication line for the Physician) and orders were received for a CBC (complete blood count), renal panel, and UA (urinalysis) and C&S (culture and sensitivity). A nurse's progress note, dated 2/20/24 at 5:46 P.M., indicated the catheter was changed and a urine specimen was collected. The urine specimen was documented to have blood tinged dark amber urine during initial insertion of catheter and light-yellow urine at the end of the stream. A nurse's progress note, dated 2/21/24 at 1:23 P.M., indicated the resident was forgetful, had trouble finding his words, very shaky. An order was received to send the resident to the ER (emergency room ). A nurse's progress note, dated 2/21/24 at 10:22 P.M., indicated the resident had been admitted to the hospital for Acute Kidney Injury, Parotid mass (a tumor located in the parotid glands), and UTI. The emergency room (ER) physician note, dated 2/21/24, indicated a urine culture obtained from the facility on 2/6/24 was remarkable for Pseudomonas and Enterococcus secondary to colonization, and the resident had not received antibiotics at that time. The resident was admitted to the hospital for treatment. A hospitalist physician note, dated 2/22/24, indicated a CT (computed tomography) scan of the abdomen and pelvis was performed 2/22/24 and the catheter balloon was inflated within either the prostatic or membranous urethra. A urologist hospital progress note, dated 2/24/24, indicated gross hematuria and AKI [acute kidney injury] in the setting of complicated UTI with bacteremia with malposition of chronic Foley [indwelling urinary catheter] and chronic anticoagulation. Unclear when his Foley was last exchanged. The hospital discharge instructions, dated 2/27/24, indicated Resident 21 was being discharged to the facility with a diagnosis of Pseudomonas bacteremia due to pyelonephritis and an order for IV (intravenous) Zosyn (an antibiotic). A nurse's progress note, dated 2/27/24 at 4:24 P.M., indicated Resident 21 had been readmitted from the hospital to the facility. The re-admission physician orders, dated 2/29/24, included, but were not limited to: Zosyn Intravenous Solution 4-0.5 GM (grams) /100ML (milliliter) (Piperacillin Sodium-Tazobactam Sodium in Dextrose) - Use 4.5 gram intravenously every 8 hours for PBP (pseudomonas bacteremia pyelonephritis) until 03/08/2024. Infuse over 4 hours, dated 2/29/24. During an interview on 2/29/24 at 2:20 P.M., the Infection Preventionist (IP) indicated all communication including attempted contacts between staff and other providers should be documented in the progress notes. During an interview on 2/29/24 at 3:30 P.M., the Administrator indicated that the facility attempted to contact the urologist on 12/19/23 concerning the resident and there was no follow up after that until 1/11/24 when the NP looked back at the note. She indicated that the urologist did not get back with the facility. During an interview on 3/4/24 at 8:27 A.M., Certified Nurse Aide (CNA) 9 and CNA 11 were observed performing catheter care for Resident 21. CNA 11 was observed to not retract the foreskin of the penis during care. At that time, the catheter bag was observed to be completely full and urine was observed backed up into the tubing. During an interview on 3/4/24 at 8:45 A.M., CNA 9 indicated that the procedure to clean a male with a catheter was to clean with soap and water from the top of the penis down and then rinse. If the male was uncircumcised the foreskin should be retracted. At that time, CNA 9 indicated she did not retract Resident 21's foreskin because she was in a hurry and nervous. During an interview on 3/4/24 at 9:19 A.M., the Director of Nursing (DON) indicated when a catheter was changed it should be documented in both the MAR and progress notes. At that time, she indicated that all communication including attempted contacts between staff and other providers should be documented in the progress notes. During an observation on 3/4/24 at 9:30 A.M., the urinary catheter collection bag was observed to be completely full and urine was observed backed up into the tubing. During an interview on 3/4/24 at 10:10 A.M., the MDS Coordinator indicated the dates of catheter changes on the skilled evaluations should have read 12/14/23 and the dates listed were typos. She was unsure why other dates were listed. At that time, she indicated she wasn't sure if the catheter was changed on 2/11/24 or 2/12/24 or both, and that all foley catheter changes should be documented in the nursing progress notes and in the MAR. On 3/4/24 at 11:23 A.M., the Administrator provided a current Acute Condition Changes - Clinical Protocol policy, revised December 2015, that indicated The Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections . The nursing staff will contact the Physician based on the urgency of the situation . The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. On 3/4/24 at 11:23 A.M., the Administrator provided a current Perineal Care policy, revised October 2010, that indicated retract foreskin of the uncircumcised male . The following information should be recorded in the resident's medical record: the date and time that perineal care was given . any problems noted at the catheter-urethral junction during perineal care . how the resident tolerated the procedure. 2. On 02/27/24 at 01:06 P.M., Resident 9's Clinical Record was reviewed. Diagnoses included, but were not limited to, Multiple Sclerosis, epilepsy, and schizoaffective disorder. The most recent Annual MDS Assessment, dated 12/4/23, indicated Resident 9 was severely cognitively impaired, was always incontinent of urine and bowels, and required extensive assistance from two staff members for toileting. The nursing progress notes, dated from 6/2/23 at 2:15 P.M. through 7/9/23 at 4:30 A.M., indicated the Resident had abnormal vaginal discharge, the NHT (Nursing Home Triage) (a communication line for the Physician) was notified, and a new order to obtain a urine specimen with culture and sensitivity if indicated was received on 6/3/23 at 2:27 A.M. The notes indicated the facility made one unsuccessful attempt to obtain the urine specimen, but did not include documentation to show the facility staff updated the physician that treatment and services could not be provided in accordance with the plan of care. A Social Service progress note, on 6/7/23 at 11:10 A.M., indicated Resident 9 was interviewed by a social worker but displayed signs of agitation and was unable to answer questions asked. Resident 9's record indicated the following urinary tract infection occurrences since June 2023: Event 1 A nurse's progress note, dated 7/9/23 at 4:30 A.M., indicated Resident 9 had abnormal vaginal discharge. The progress note indicated NHT was notified and [NHT nurse] said resident has history of these symptoms, and in the past, they indicated a urinary tract infection. A nurse's progress note, dated 7/9/23 at 3:01 P.M., indicated NHT returned orders to the facility to collect urine and send to lab for a urinalysis, culture and sensitivity test, and vaginal culture. A nurse's progress note, dated 7/10/23 at 2:30 P.M., indicated urine was collected by in and out catheterization (a temporary catheter placed for the period of time to collect a urine specimen) using sterile technique and lab was notified to pick up sample. Documentation to show what time the specimen was picked up by the laboratory staff was not indicated. A nurse's progress note, on 7/12/23 at 10:26 A.M., indicated NHT called the facility and gave orders to start Macrobid (antibiotic) twice a day for 5 days for a urinary tract infection. A lab report, dated 7/12/23, indicated the urine previously collected, on 7/10/23, was contaminated and a culture could not be completed. A nurse's progress note, dated 7/13/23 at 1:02 P.M., indicated staff reported to NHT Resident 9 was still experiencing vaginal discharge and continued to display symptoms reported prior. A nurse's progress note, dated 7/13/23 at 5:12 P.M., indicated a second urine sample was obtained using in and out catheterization. A nurse's progress note, dated 7/14/23 at 4:05 P.M., indicated a vaginal swab was collected and sent to lab for culture. A lab report, dated 7/15/23, indicated the second urine sample, obtained on 7/13/23, was contaminated and a culture could not be completed. The clinical record did not include a lab report for the vaginal swab culture collected on 7/14/23. A nurse's progress note, dated 7/15/23 at 10:05 A.M., indicated new orders were received from the NHT to discontinue Macrobid and repeat urinalysis and culture if Resident 9 experienced vaginal discharge again. The orders did not include sufficient information to determine the clinical indication for stopping the antibiotic. Event 2 A nurse's progress note, dated 11/2/23 at 2:58 P.M., indicated Resident 9 was experiencing urine odor, increased frequency, and altered mental status. NHT gave orders for a urinalysis, and culture and sensitivity, to be collected with in and out catheterization. The clinical record did not indicate when the urine specimen was collected or sent to lab. A nurse's progress note, dated 11/3/23 at 1:59 P.M., indicated an abnormal urinalysis, awaiting final culture and sensitivity results. A lab report, dated 11/3/23, indicated an abnormal urinalysis, including bacteria, increased white blood cells, nitrites, and blood, but lacked a culture and sensitivity result. The clinical record lacked documentation, from 11/3/23 at 1:59 P.M. through 11/13/23 at 6:02 P.M., showing follow up for the UTI symptoms or the urinalysis results from the urine specimen collected on 11/3/23. Lab reports, including a urinalysis and culture and sensitivity report from urine collected on 11/10/23 at 12:10 A.M., indicated a urine specimen was obtained by clean catch midstream (urine collected during resident-initiated urination) and showed an abnormal urinalysis and culture results; The urine culture result indicated Resident 9's urine was positive for Proteus Mirabilis and E. Coli infections. A nurse's progress note, dated 11/13/23 at 6:02 P.M., indicated a Physician order to start Bactrim (antibiotic) twice a day for five days for the urinary tract infection. A nurse's progress note, dated 11/14/23 at 9:18 P.M., indicated Resident 9 was to remain in contact isolation due to E. Coli/ESBL, until antibiotic therapy was completed. Event 3 A nurse's progress note, dated 12/12/23 at 10:09 A.M., indicated Resident 9 was experiencing foul smelling urine, was more resistive to care than usual, and had a difficult time expressing pain due to cognition. The progress note indicated the NHT was notified. A lab report, dated 12/14/23, indicated the urine specimen, picked up by lab on 12/14/23 at 10:34 P.M., was contaminated during collection on 12/14/23 at 6:30 P.M. A culture and sensitivity result was not provided. A nurse's progress note, dated 12/15/23 at 10:58 A.M., indicated NHT notified the facility that the Nurse Practitioner reviewed the initial urinalysis results and indicated Resident 9 was positive for a urinary tract infection, but would await final culture and sensitivity results before giving antibiotic orders. The clinical record lacked documentation, from 12/15/23 at 10:58 A.M. through 12/22/23 at 3:05 P.M., showing follow up for the UTI symptoms, communication to the physician, or treatment for the positive urinalysis results from the urine specimen collected on 12/14/23. A nurse's progress note, dated 12/22/23 at 3:05 P.M., indicated no orders were given pertaining to the urinalysis on 12/14/23. Event 4 A nurse's progress note, dated 2/2/24 at 11:15 A.M., indicated Resident 9 was experiencing behaviors such as hitting and yelling at staff. A nurse's progress note, dated 2/7/24 at 12:34 P.M., indicated orders, in relation to increased combativeness, were given by the Nurse Practitioner to increase Xanax (sedative) to 0.5 mg (milligrams) twice a day on 2/7/24, and collect a urinalysis and culture and sensitivity. A nurse's progress note, dated 2/8/24 at 1:53 P.M., indicated orders to increase Zoloft (antidepressant) 150 mg (milligrams) on 2/8/24 and monitor for aggression and agitation, and that lab results collected 2/8/24 were contaminated during collection. A recollection of urine was not performed. A nurse's progress note, dated 2/13/24 at 10:50 A.M., indicated the Nurse Practitioner discontinued the order for a urinalysis, stating Resident 9 was no longer experiencing signs and symptoms of a UTI at this time. Event 5 A nurse's progress note, dated 2/22/24 at 12:51 P.M., indicated Resident 9 was experiencing dark urine with a strong foul odor and mucous vaginal discharge, and will continue to monitor. The nursing progress and skilled evaluation notes, dated from 2/22/24 at 12:51 P.M. to 2/29/24 at 2:37 P.M., did not include documentation to show facility staff notified the Physician regarding Resident 9's UTI symptoms or provided effective treatment and services for assessment and monitoring of the Resident's urinary status. A nurse's progress note, dated 2/29/24 at 2:37 P.M., indicated facility notified NHT that Resident 9 exhibited increased confusion and combativeness, in addition to foul odor dark urine. A nurse's progress note, on 2/29/24 at 3:06 P.M., indicated Resident 9 struck staff in the face at lunch. A nurse's progress note, dated 2/29/24 at 5:24 P.M., indicated new orders for a urinalysis and culture and sensitivity if indicated. A nurse's progress note, dated 3/1/24 at 2:43 P.M., indicated urine was collected, on 3/1/24 at 2:43 A.M., by in and out catheterization. On 3/1/24 at 6:53 P.M., a nurse's progress note stated NHT called the facility with orders for Cipro (antibiotic) twice a day for 5 days. During an interview on 2/29/24 at 11:52 A.M., the IP (Infection Preventionist) indicated NHT should be notified any time a resident shows symptoms of a urinary tract infection. The IP nurse indicated sometimes Resident 9 had behaviors when experiencing urinary tract infections and staff would stop attempts to collect urine for a urinalysis order due to Resident 9 attempting to strike staff, and sometimes the urine wasn't collected right away because staff would keep passing it off to the next shift to collect. The IP nurse called lab regarding the vaginal culture collected on 7/15/23; lab stated the culture was collected in the wrong tube. The IP nurse stated she was unsure why the facility never recollected the culture. On 3/4/24 at 11:24 A.M., a current Infections Clinical Protocol policy, revised 2013, was provided by the Administrator. The policy indicated For anyone who is suspected of having an infection, nursing staff will identify and document specific details of symptoms and physical findings. Nursing staff will notify the Physician of all pertinent details about the resident's condition. The nursing staff and Physician will identify possible complications of the infections such as sepsis and delirium. The nursing staff and Physician will monitor the progress of a resident with an infection until it is resolved. The nursing staff will evaluate and report to the Physician at least weekly until the individual is stable or improving, and more often if the individual is not improving. 3.1-41(a)(2) 48057

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for 2 of 4 residents reviewed. A cognitively impaired resident had medications in their room, unlocked and unattended. Resident 24 had six falls in two months, one resulted in a fracture to the left hip with one additional fall after the fracture. (Resident 24, Resident 13) Findings include: 1. On 7/29/22 at 9:07 A.M., Resident 24's clinical record was reviewed. Diagnosis included, but were not limited to, depression, dementia, and osteopenic bones. The most recent significant change MDS (minimum data set) Assessment, dated 6/2/22, indicated Resident 24 required extensive assistance of two staff with bed mobility, transfers, and toileting, and was completely dependent on one staff for bathing. The MDS indicated Resident 24 had a moderate cognitive impairment. A current care plan for risk for falls, dated 6/25/21, included the following interventions: anti rollback to wheelchair, dated 5/16/22 anticipate and meet needs, dated 6/25/21 call light within reach and encourage to use, dated 6/25/21 follow facility fall protocol if fall occurs, dated 6/25/21 non-skid strips to left side of bed, dated 5/23/22 notify family and physician of falls, dated 6/25/21 therapy evaluations and treatments as ordered and as needed, dated 6/25/21 resident not to be left in wheelchair in room alone, dated 6/20/22 Falls included the following: Fall 1 4/24/22 at 2:00 A.M. Staff heard a loud crash from the resident's room and calls for help. Resident was found on the floor lying on her left side. Resident was helped to bed and given pain medication. The resident had a bruise to the back of the right hand, and an abrasion on the left buttock. An IDT (interdisciplinary team) note, dated 4/25/22, indicated the new intervention related to the fall was to have staff ensure that walker was within reach at all times. The falls care plan was not updated with the new intervention. Fall 2 5/12/22 at 9:45 P.M. Resident was standing in the doorway holding onto the bed trying to reach the nurse. Nurse attempted to reach the resident, when the resident sat down on the floor. An IDT note, dated 5/13/22, indicated the new intervention related to the fall was to place wheelchair in locked position next to the bed. The falls care plan was not updated with the new intervention. Fall 3 5/13/22 at 8:49 P.M. Resident fell while attempting to transfer self from the wheelchair to the bed. Resident was found lying on her right side beside the bed. An IDT note, dated 5/16/22, indicated the new intervention related to the fall was to place anti roll backs on wheelchair. Fall 4 5/15/22 at 2:44 P.M. Resident was found on the floor on back without socks or shoes in front of recliner. The resident indicated to staff she was going to the bathroom and fell . [NAME] was not in reach, and the resident's wheelchair was in the bathroom. An IDT note, dated 5/16/22, indicated the new intervention related to the fall was to re-educate staff to ensure wheelchair is kept locked and next to the resident. The falls care plan was not updated with the new intervention. Fall 5 5/20/22 at 4:30 P.M. Resident was found in room lying on the right side with a wheelchair next to her. The resident indicated she was trying to get to the chair. At that time, the resident complained of left hip pain. A left hip x-ray was ordered the same day, and results showed a left hip fracture. An IDT note, dated 5/23/22, indicated the new intervention related to the fall was to place non skid strips to floor on left side of bed. Fall 6 618/22 at 1:56 P.M. Resident was found lying on her buttocks and left elbow on the bedroom floor. The resident was between the wheelchair and recliner, and indicated at that time she was trying to transfer self to the recliner. An IDT note, dated 6/20/22, indicated the new intervention related to the fall was to educate staff to not leave resident in her wheelchair in her room alone. On 7/27/22 at 1:21 P.M., Resident 24 was observed lying awake in bed. The call light was on the floor between the wall and the bed, and the resident's walker was observed on the other side of the room. On 7/28/22 at 9:04 A.M., Resident 24 was observed sitting in a recliner in her room with her feet up. The resident's walker was observed on the other side of the room. On 7/29/22 at 10:56 A.M., Resident 24 was observed sitting in a recliner in her room with her feet up. The resident's walker and wheelchair were observed in the bathroom with the door closed. On 8/1/22 at 9:57 A.M., Resident 24 was observed lying in bed with a call light on the floor between the wall and the bed. The resident's walker was observed on the other side of the room. At that time, QMA (Qualified Medication Aide) 5 indicated Resident 24 should have the call light in reach at all times. 2. On 7/26/22 at 9:41 A.M., a bottle of Omega 3 and a bottle of B Complex were observed in Resident 13's room. At that time, Resident 13 indicated she had several bottles of vitamins in her room, including a box of them in her closet. Resident 13 also indicated she had taken the medications in her room all her life. On 7/28/22 at 1:34 P.M., Resident 13's clinical record was reviewed. Diagnosis included, but were not limited to, depression and [CONDITION(S)] (post-traumatic stress disorder). The most recent quarterly MDS Assessment, dated 5/17/22, indicated a moderate cognitive impairment. The clinical record lacked a self-administration of medications assessment. The clinical record lacked a physician's order for self-administration of medications or storage of medications in room. During an interview on 7/29/22 at 10:35 A.M., LPN (Licensed Practical Nurse) 7 indicated she was unaware of any medications in Resident 13's room. At that time, LPN 7 gathered all medications from Resident 13's room, which included the following: a bottle of B Complex (supplement) two bottles of Omega 3 (supplement) Icy Hot spray and bottle a box of [MEDICATION(S)] (allergy medication) 25mg (milligram) tablets a tub of [MEDICATION(S)] (cream) three bottles of Advanced D (supplement) four bottles of Primal Force curcumin triple burn (dietary supplement) a bottle of [NAME] omega 50+ a bottle of Ginko Biloba two bottles of [MEDICATION(S)] 25mg (antihistamine) a tub of chest rub a bottle of Apple Cider vinegar seven tubs of [MEDICATION(S)] 0.05% (pain relief cream) a bottle of Trexar nerve sensation (dietary supplement) At that time, LPN 7 indicated Resident 13 was not supposed to have any medications in her room. Resident 13's clinical record lacked any orders for the medications found in her room except the following: [MEDICATION(S)] HCl tablet 25mg as needed, dated 4/28/22 During an interview on 7/29/22 at 11:35 A.M., the Administrator indicated it was Resident 13's sister that was bringing in medications to her, and the sister had also brought medications to another resident in the past. The issue of bringing in medications was addressed with the sister, and she had voiced understanding. The Administrator further indicated she was unaware that any other medications had been brought in to Resident 13 due to the fact Resident 13 was cognitively impaired, and did not understand to notify staff. On 8/1/22 at 12:24 P.M., a current care plans policy, revised September 2010, was provided and indicated Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans On 8/1/22 at 12:24 P.M., a current self- administration of drugs policy, revised August 2006, was provided and indicated Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for 2 of 2 residents reviewed for falls. Supervision and effective fall interventions were not in place for 2 residents, which resulted in one of the residents receiving a right tibial plateau fracture and one of the residents receiving a fractured right shoulder. (Resident 34, Resident 21) Findings include: 1. On 9/9/19 at 9:33 a.m., Resident 34 was observed to be sitting in a recliner with no socks or shoes on. Resident 34 indicated she had fallen last week and broke her right knee when she went to the bathroom. She indicated she was supposed to have assistance ambulating, but the facility did not have enough staff so she took herself to the bathroom. The resident had an ace bandage around the right knee area and bandages to the bilateral lower extremities. Resident 34 indicated she had swelling of both the lower legs and therapy had applied the bandages to the lower legs. During review of the State reportable incidents, provided by the Interim Administrator on 9/10/19 at 3:30 p.m., the reportable incidents indicated on 9/3/19 at 4:20 a.m., the nurse had entered the resident's room and found the resident on the floor in the bathroom. The nurse assessed the resident for injuries as the resident was yelling, Don't touch me, it hurts. The resident's physician was notified and the resident was sent to the emergency via ambulance. On 9/2/19 at 9:59 a.m., Resident 21 was observed ambulating in the hall to the nurse's desk. Resident 21 indicated Resident 34 had been yelling for help for approximately an hour. Resident 34 was heard yelling from the hall. Upon entering the resident's room, the resident was observed to be lying on her right side with the resident's call light hanging down off of the left side rail. The resident was unable to reach her call light. CNA 1 appeared in the hallway outside of the nurse's station. She would need to find some help as she did not know where any staff was on the unit at that time. Upon finding another CNA, CNA 1 and CNA 7 entered the resident's room. Resident 34 indicated she needed to go to the bathroom and had been yelling for help for approximately an hour. CNA 1 obtained the bedpan for the resident. The clinical record for Resident 34 was reviewed on 9/11/19 at 11:00 a.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 7/23/19, indicated the resident had slight cognitive impairment and required limited assist of 1 person for transfers and ambulation. A Self-Care deficit care plan, dated 8/26/19, included, but were not limited to the following interventions: Resident required limited to extensive assist of 1 person for bed mobility, initiated 8/26/19. Resident required limited assist of 1 person for transfers, initiated 8/26/19. A Fall, potential for related to weakness care plan, initiated 8/26/19, included, but were not limited to the following interventions: Anticipate and meet residents needs, initiated 8/26/19. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 8/26/19. Encourage resident to be compliant with limitations and to ask for assistance as needed, initiated 8/26/19. Ensure that resident is wearing proper footwear when ambulating or mobilizing in wheel chair, initiated 8/26/19. The resident needs needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, side rails. as ordered, handrails on walls, personal items within reach, initiated 8/26/19. Toilet every 2 hours and as needed, initiated 8/26/19. A nursing note, dated 8/30/19 at 5:00 a.m., indicated Resident fell this a.m. as she ambulated to the bathroom unassisted at 4:20 a.m. Resident noted on floor in doorway of bathroom on her right side The clinical record lacked documentation of any interventions in place prior to the resident's fall. Resident was yelling don't touch me, don't move me. Stated that she felt like she broke her shoulder.transported to (Name of Hospital). Resident left on stretcher at 4:40 a.m. Resident began c/o (complaining of) right leg pain as she was leaving. Resident told this nurse when I noted her on floor that she had hit her head. A nursing note, dated 8/30/19 at 10:55 a.m., indicated Resident 34 returned to the facility from the hospital via ambulance and was assisted to the recliner at her bedside. Report received from (Name of Nurse at Name of Hospital) the resident received a right tibial plateau fracture. New orders received were, no weight bearing and Orthopedic follow-up in 2 weeks. A Right Knee CT Without IV Contrast report on 8/30/19 at 7:04 a.m., included, but was not limited to, the following impression: There is subtle cortical step-off along the articular surface of the lateral tibial plateau which could reflect an acute impaction fracture. On 9/16/19 at 8:47 a.m., RN 3 indicated she did not really know what happened to the resident the night she broke her knee. She indicated she did not normally work on the unit and would need to read up on it. The clinical record lacked documentation of the resident's call light working or being within reach of the resident, whether the resident had the proper footwear on when she was ambulating without assistance, if the envrionment was free of clutter and safe, if the room had adequate, glare-free lighting, or if the resident had been toileted every 2 (two) hours or as needed prior to the resident's fall. 2. On 9/9/19 at 10:45 a.m., Resident 21 was observed sitting in her room, watching television. Resident 21 indicated she had fallen at the facility around June, 2019, and broke her right arm and shoulder. The clinical record for Resident 21 was reviewed on 9/10/19 at 10:31 a.m. The quarterly MDS (Minimum Data Set) assessment, dated 7/14/19, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. The MDS indicated the resident was an extensive assist of 1 person for transfers, and a limited to extensive assist of 1 person for ambulation. A XR (x-ray) Shoulder Left 3+ View dated 5/23/19 at 6:46 p.m., indicated the following findings: Internally rotated, eternally rotated and Y views of the right shoulder demonstrate an acute communicated [MEDICAL CONDITION] humeral head and neck. There is proximal migration of the distal fragment. An ADL Self Care Deficit care plan, initiated 7/16/17, included, but was not limited to, the following interventions: Up with assist only, initiated 8/26/19. Requires limited to extensive assist of 1-2 staff to use toilet, initiated 3/27/18. A Potential for Falls care plan, initiated 7/6/16, included, but was not limited to, the following interventions: The resident needed a safe environment with floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach, initiated 7/6/17. Encourage to wear strong, stable footwear, initiated 7/13/18. Proper foot wear on when up, initiated 3/27/18. A nursing note, dated 5/23/19 at 5:15 p.m., indicated the resident was observed lying on the floor by the bathroom door. The resident indicated she had tripped over something while going to the bathroom. The nursing note indicated the resident was able to do active range of motion to all her extremities, except the right upper arm. The note indicated the resident was transported to the emergency room . A nursing note, dated 5/24/19 at 8:00 p.m., indicated the resident returned from the hospital with a report of a [MEDICAL CONDITION] shoulder and was to wear a right shoulder sling at all times except while bathing. The clinical record lacked documentation if a safe environment was provided, adequate glare-free lighting was provided, if the resident's call light was working and within reach, or if the resident was wearing the proper footwear prior to the fall. On 9/19/19 at 10:17 a.m., RN 1 indicated she did not know how Resident 21 had fell and broke her shoulder. RN 1 indicated she had recently begun employment with the facility and did not know what had happened. This Federal tag relates to Complaint IN 094. 3.1-45(a)

Based on interview, observation, and record review, the facility failed to prevent pressure ulcer development and provide treatment as ordered for 1 of 4 residents reviewed for pressure ulcers and 1 random resident observed with a pressure ulcer. A resident acquired a stage 3 (full thickness skin loss) to the left lateral malleolus and a stage 4 (full thickness skin and tissue loss) to the right knee after being admitted to the facility and a resident who acquired an unstageable pressure area to the sacrum after being admitted to the facility. (Resident 7, Resident 34) Findings include: 1. On 9/9/19 at 10:41 a.m., Resident 7 was observed to be lying in bed on her back. The low air loss mattress was set on 400 and the resident's head was slightly elevated. On 9/9/19 at 1:59 p.m., RN 1 indicated the resident had pressure ulcers to her coccyx, outer right knee, and outer left ankle areas. RN 1 indicated she did not know if the resident acquired the pressure ulcers in the facility or not. RN 1 was observed to perform dressing changes to the areas. The dressing on the coccyx area was missing, the dressing to the left ankle was dated 9/3/19 (Tuesday), and the dressing to the right knee was undated. RN 1 was observed to cleanse each of the wounds, wipe the cleanser off with toilet paper, apply skin prep to the periwounds, and apply a foam dressing to each of the sites. On 9/10/19 at 9:35 a.m., Resident 7 was observed to be lying in bed on her back. The resident indicated her back was hurting. The mattress setting was 50. On 9/10/19 at 1:40 p.m., Resident 7 was observed to be lying on her back in bed. The mattress setting was 50. On 9/11/19 at 7:35 a.m., Resident 7 was observed to be lying on her back in bed, with the head of the bed elevated 45 degrees. The mattress setting was 50. On 9/11/19 at 1:25 p.m., RN 3 indicated she did not know when the pressure ulcers were found, as the wound nurse usually took care of the wounds and measured them. She indicated the wound nurse would use a camera to measure the wounds. RN 3 did not know where to obtain a measuring tape or any other device to measure wounds. The wound nurse usually worked on Tuesday and Friday each week but had called in on Monday and had requested Tuesday off this week. On 9/11/19 at 1:32 p.m., LPN 1 was observed to perform dressing changes and skin care. LPN 1 indicated the resident was admitted with a stage 4 pressure ulcer to the coccyx but acquired the pressure ulcers to the right knee and left lateral malleolus while a resident at the facility, but was unsure when the resident obtained the pressure ulcers. LPN 1 indicated the resident was to have her dressings changed on Tuesday and Friday each week and the wound nurse did the measurements. During the dressing change, LPN 1 was observed to apply Pomegran (used to kill bacteria and aid in healing pressure wounds) to the coccyx wound prior to placing a foam dressing on it. LPN 1 also changed the dressing to the right knee but not to the left lateral malleolus. LPN 1 was observed to apply skin prep to the right heel and ankle, the inner bilateral knees, and the left inner ankle and heel. The resident indicated she would like to get out of bed, but LPN 1 indicated the resident wears out easily when she gets up. The resident complained that her back was hurting. LPN 1 checked the mattress setting, indicated the setting should be the resident's weight, and set the mattress on 200. The clinical record for Resident 7 was reviewed on 9/11/19 at 8:08 a.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 6/13/19, indicated the resident had severe cognitive impairment The quarterly MDS (Minimum Data Set) assessment, dated 6/13/19, defined the following skin conditions: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable drsg/device. At risk for developing pressure ulcer/injury. Has unhealed pressure ulcer/injury. Number of Stage 3 pressure ulcer: 1 Number of Stage 3 pressure ulcer that were present upon admission/entry or reentry: 0 Number of Stage 4 pressure ulcer: 2 Number of Stage 4 pressure ulcer that were present upon admission/entry or reentry: 1 Number of unstageable pressure injuries presenting as deep tissue injury: 1 Number of unstageable pressure ulcer that were present upon admission/entry or reentry: 0 Total number of venous or arterial ulcers present: 0 Skin and Ulcer/Injury Treatments: pressure reducing device for bed Pressure ulcer/injury care: yes Application of nonsurgical dressing other than to feet: yes Application of ointments/medications other than to feet: yes Application of dressing to feet: yes A care plan, dated 9/10/18, included but was not limited to the following interventions: The resident needed physical assist of 1-2 staff members to turn/reposition at least every 2 hours, more often as needed or requested, initiated 9/10/18, revised 8/23/19. The resident required pressure relieving device on bed and in w/c (wheelchair), initiated 9/10/18, revised 8/23/19. Administer treatments as ordered and monitor for effectiveness, initiated 8/23/19. Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD, initiated 8/23/19. Monitor dressing to ensure it is intact and adhering. Report loose dressing to treatment nurse, initiated 8/23/19. physician's orders [REDACTED]. Sacrum/coccyx- cleanse wound with wound cleanser and pat dry. Apply skin prep to periphery and allow to air dry completely. Apply [MEDICATION NAME] to wound bed. Cover with border foam dressing every Tuesday and Friday, start date 8/30/19. Left out ankle malleolus- cleanse wound with wound cleanser, pat dry. Skin prep periphery and allow to air dry completely. Apply [MEDICATION NAME] to wound bed. Cover with border foam dressing every Tuesday and Friday, start date 8/30/19. B/L (Bilateral/left) inner knees/left outer knee and inner/outer ankle RLE (right lower extremity), inner ankle LLE (left lower extremity) apply skin prep allow to dry every shift, start date 8/27/19. May utilize low air low mattress with built in bolsters to help define bed perimeter. Setting is to be on 150, start date 5/21/19. OK to use Silver [MEDICATION NAME] sticks to rolled edges of sacral ulcer during wound care as needed, start date 11/1/18. Hoyer lift to be used for transfers, start date 10/9/18. Up with assist, may be in wheelchair no more than 2 hours at a time every day and evening shift for skin protection (9/5/18), start date, 9/8/18. Weekly skin assessment every evening shift every Monday preventative measures, start date 3/4/19. The Nursing Assessment, dated 4/21/19, indicated Resident 7 was admitted with only a stage 4 sacral pressure ulcer. A Nursing Note, dated 6/27/19 from 6:00 a.m.- 2:00 p.m., indicated the wound to the right knee was not improving and the wound nurse was to evaluate. A Nursing Note, dated 6/30/19 at 2:00 p.m., indicated the right outer knee had large scab area which had came off since the treatment was completed. The wound had no visible signs of infection present, had a moderate amount of serosanguineous drainage without odor, and the wound bed was red and moist. The note indicated the wound would be reevaluated on weekly skin/wound rounds on 7/2/19. The clinical record lacked documentation of any further nursing notes regarding the pressure areas. A Braden Scale for Predicting Pressure Ulcers, dated 4/30/19 at 12:30 p.m., indicated Resident 7 was a moderate risk for pressure ulcers. A quarterly Nutrition Assessment, dated 12/14/18, indicated the resident had weight loss with no significant change since admission with her weight at 150 lbs (pounds). The resident's ideal body weight (IBW) was between 117 pounds (lbs) and 143 lbs and the resident's basal metabolic rate (BMI, the measure of body fat in a person) was 24.2 The resident had a stage 4 pressure wound to the sacrum with was slow to heal, but stable. The note indicated the resident received 1 scoop of protein powder bid (twice a day) with meals, received daily laxative, received an iron supplement, a multivitamin with minerals, and [MEDICATION NAME] (an antidepressant) 7.5 mg (milligrams) daily related to her appetite. A Skin and Wound Evaluation dated 7/16/19, indicated the following: Type: (Blank - nothing documented) Location: Right Knee Acquired: In-house Acquired How long has the wound been present: unknown Wound Measurements: No measurements; undermining - not applicable; tunneling - not applicable Orders: Goal of Care: Healable Progress: Resolved A Skin and Wound Evaluation dated 9/3/19 at 7:04 p.m., indicated the following: Type: Pressure Stage: Stage 4 (Full thickness skin and tissue loss) Location: Right Knee Acquired: present on admission - had resolved in July, 2019, but reappeared in documentation for 9/3/19, unable to How long has the wound been present: unknown Wound Measurements: 2.5 cm (area) x 3.1 cm(L) x 1.2 cm (W) x 0.7 cm (D); undermining - not applicable; tunneling - not applicable Exudate: amount: moderate; type: serosanguineous; odor after cleansing: none Periwound: Edges: non-attached(edge appears as a cliff; rolled edge (epibole) - edge appears curled under;[MEDICATION NAME]: new, pink to purple, shiny skin tissue Surrounding tissue: intact: (Blank - nothing documented); [MEDICAL CONDITION]: no swelling or [MEDICAL CONDITION] Orders: Goal of Care: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration Progress: Improving A Skin and Wound Evaluation dated 9/3/19 at 7:04 p.m., indicated the following: Type: Pressure Stage: Stage 4 (Full thickness skin and tissue loss) Location: Sacrum Acquired: present on admission Wound Measurements: 0.5 cm (area) x 1.0 cm(L) x 0.6 cm (W) x 0.8 cm (D); undermining - not applicable; tunneling - not applicable Exudate: amount: none; type: none; odor after cleansing: none Periwound: Edges: non-attached(edge appears as a cliff; rolled edge (epibole) - edge appears curled under Surrounding tissue: intact: unbroken skin, normal in color, scarring; extent 0.0 cm; [MEDICAL CONDITION]: no swelling or [MEDICAL CONDITION] Orders: Goal of Care: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration Progress: Stable A Skin and Wound Evaluation dated 9/3/19 at 7:04 p.m., indicated the following: Type: Pressure Stage: Stage 3 (Full thickness skin loss) Location: Left Lateral Malleolus Acquired: (Blank - was not indicated on this record or in clinical record) Wound Measurements: 1.3 cm (area) x 1.6 cm (L) x 1.1 cm (W) x 0.1 cm (D); undermining - not applicable; tunneling - not applicable Exudate: amount: light; type: [MEDICAL CONDITION]; odor after cleansing: none Periwound: Edges: non-attached (edge appears as a cliff; rolled edge (epibole) - edge appears curled under; [MEDICATION NAME]: new, pink to purple, shiny skin tissue Surrounding tissue: fragile: skin that is at risk for breakdown; intact: unbroken skin, normal in color, scarring; extent 0.0 cm; [MEDICAL CONDITION]: no swelling or [MEDICAL CONDITION] Progress: Improving A Total Body Skin assessment dated [DATE] at 10:09 p.m., indicated the following: Skin Assessment: Turgor: good elasticity Skin color: normal for ethnic group Temperature: cool Moisture: moist Condition: dry Number of New Wounds: 0 A Total Body Skin assessment dated [DATE] at 5:58 p.m.: indicated the following; Skin Assessment: Turgor: poor elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: normal Condition: dry Number of New Wounds: 0 A Total Body Skin assessment dated [DATE] at 8:53 p.m., indicated the following: Skin Assessment: Turgor: poor elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: normal Condition: dry Number of New Wounds: 0 A Total Body Skin Assessment, dated 7/29/19 at 2:26 p.m., indicated the following: Skin Assessment: Turgor: poor elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: moist Condition: dry Number of New Wounds: 0 The clinical record lacked documentation of any further Skin and Wound Evaluations. 2. On 9/9/19 at 9:33 a.m., Resident 34 was observed to be sitting in a recliner with no socks or shoes on. She indicated she had fallen last week and broke her right knee when she went to the bathroom. She was supposed to have assistance ambulating, but the facility did not have enough staff so she took herself. The resident had an ace bandage around the right knee area and bandages to the bilateral lower extremities. She had swelling of both the lower legs and therapy had applied the bandages to the lower legs. On 9/9/19 at 2:35 p.m., Resident 34 was observed to be sitting in a recliner in her room. Her feet were elevated on the foot rest of the recliner. On 9/10/19 at 9:17 a.m., Resident 34 was observed to be sitting in a wheelchair in her room, watching television. Her feet were observed to be on the wheelchair foot rests. A cushion was observed in the wheelchair seat. On 9/10/19 at 1:37 p.m., Resident 34 was observed to be sleeping in a wheelchair in her room. On 9/11/19 at 7:30 a.m., Resident 34 was observed to be sitting in a wheelchair in her room. Her feet were observed to be on the wheelchair foot rests. A cushion was observed in the wheelchair seat. On 9/11/19 at 11:46 a.m., Resident 34 was observed to still be sitting in a wheelchair in her room. LPN 1 indicated the resident usually stayed up in the wheelchair all day long. On 9/12/19 at 7:50 a.m., LPN 1 indicated the resident had a new pressure area on her coccyx area. On 9/12/19 at 9:59 a.m., Resident 21 was observed to ambulate to the nurse's station. Resident 21 indicated Resident 34 had been yelling for a long time for help. Upon entering the resident's room, Resident 34 was observed to be lying in bed on her right side. The resident's call light was hanging off of the left bed rail. Resident 34 indicated she needed to use the bathroom and had been yelling for an hour for help. CNA 1 was observed out in the hall by the nurse's station. CNA 1 indicated she had just came out of another resident's room and did not know where any other staff were located, but she would need another staff member in order to provide care to the resident. CNA 1 and CNA 7 were observed to assist the resident onto the bedpan. Upon turning the resident to place the bedpan, a large foam dressing was observed on the resident's sacral area. The dressing was not dated. On 9/16/19 at 12:53 p.m., RN 3 was observed to provide wound care to the resident. RN 3 removed the old dressing from the resident's sacral area. The dressing was not dated. The wound bed had eschar and slough present, had sanguineous drainage present at the 5-6 o'clock area of the periwound area, and the periwound was red and excoriated. RN 3 obtained measurements of the wound with the wound being 3.5 inches in length and 3.0 inches in width. The wound had an odor to it. RN 3 was observed to cleanse the wound with wound cleanser, pat the wound dry, apply Santyl ointment (a [MEDICATION NAME] agent) to the wound bed, apply a [MEDICATION NAME] dressing (a dressing to aid unwicking exudate and debris form the wound bed), and cover the area with a foam dressing. RN 3 indicated the resident had just obtained the pressure ulcer and she had not seen the area prior to today. The clinical record for Resident 34 was reviewed on 9/11/19 at 11:00 a.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 7/23/19, indicated the resident had slight cognitive impairment, was at risk for pressure ulcers, and did not have any pressure ulcers present. The resident was to have a pressure reducing device to her chair and application of ointment/medications other than to her feet. physician's orders [REDACTED]. A Nursing Assessment, dated 4/21/19, indicated the resident was at risk for pressure ulcers. A Braden Pressure Ulcer Risk assessment, dated 4/21/19, indicated the resident was not at risk for pressure. A Skin breakdown, potential for care plan, initiated 8/26/19, included, but were not limited to, the following interventions: Assist/remind resident to change positions at least every 2 (two) hours and as needed, initiated 8/26/19. Pressure relief cushion to chair if needed, initiated 8/26/19. Treatments as ordered to prevent skin breakdown, monitor for effectiveness and adverse reactions, initiated 8/26/19. Weekly skin assessment, initiated 8/26/19. A Skin and Wound Evaluation dated 9/13/19 at 2:02 p.m., indicated the following: Type: Pressure Stage: Unstageable: Obscured full-thickness skin and tissue loss Due to: Slough Location: Left Buttock Acquired: In-house Acquired How long has the wound been present: exact date Exact Date: 9/6/19 Wound Measurements: 9.9 cm (L) x 8.0 cm (W) x not applicable (D); undermining - not applicable; tunneling - not applicable Wound Bed: Eschar Evidence of Infection: Increased drainage Exudate: amount: moderate; type: [MEDICAL CONDITION]; odor after cleansing: moderate Periwound: Edges: Attached: Edge appears flush with wound bed or as a sloping edge Surrounding tissue: intact: Discoloration - black/blue, [DIAGNOSES REDACTED]: redness of the skin-may be intense bright red to dark red or purple; Excoriated: Superficial loss of tissue; Fragile: Skin that is at risk for breakdown; Intact: Unbroken skin. [MEDICAL CONDITION]: No swelling or [MEDICAL CONDITION] Pain: At dressing Infection: Suspected Notes: Tx (treatment) ordered per PT (Physical Therapy reccs (sic) (recommendations) for anti-microbial drsg (dressing) & Santyl. PT to do selective sharps debridement 3 (three) x (times)/week. Wound care will be daily. PT will start - recommendations received today On 9/12/19 at 10:20 a.m., the Acting Director of Nursing (DON) indicated weekly skin assessments should be completed on any resident with a risk for skin breakdown. The current facility policy, Decubitus Ulcers (Pressure Sores), undated, obtained from the Regional MDS Coordinator on 9/16/19 at 2:12 p.m., indicated pressure sores would be assessed and treated according to facility policy and/or physician's orders [REDACTED]. The facility lacked documentation of a policy for the prevention of pressure ulcers. This Federal tag relates to Complaint IN 094. 3.1-40(a)

Based on observation, interview, and record review, the facility failed to ensure a resident admitted without a pressure ulcer, did not develop pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. This deficient practice resulted in Resident 24 developing a Stage IV ulcer to the left ischial tuberosity (bony prominence in buttock area) and an Unstagealble wound to left heel. The facility failed to comprehensively assess and implement interventions to treat and promote healing after the development of these wounds. (Resident 24) Findings include: On 6/12/17 at 10:32 a.m., the record for Resident 24 was reviewed. The clinical record indicated [DIAGNOSES REDACTED]. admission orders [REDACTED]., Turn and reposition approximately q (every) 2 hours. The Admission Nursing assessment dated [DATE] indicated Functional Status was Mechanical lift, non weight bearing, Wheelchair only, and Paralysis. The Admission Assessment further indicated no skin impairment and the Braden Pressure Ulcer Risk was 14 indicating Moderate Risk. The Care Plan dated 1/18/17 with revision dated of 1/26/17, indicated the resident has potential for impaired skin r/t (related to) Immobility with interventions of : The resident needs assistance to turn/reposition frequently, more often as needed or requested, dated 1/18/17, revised 2/9/17 EZ Boots bil-lower (bilateral lower) extremities dated 5/9/17 Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the resident/family/caregivers of any new area of skin breakdown. Dated 1/18/17 The Care Plan .has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) [MEDICAL CONDITION] .has mobility in arms and shoulders . dated 1/18/17 and revised on 1/26/17 listed interventions as: . requires extensive assist to total staff assist of 1-2 to assist with participation to reposition and turn in bed created on 2/8/17, revision date 5/24/17 Skin inspection: Observe skin during care for redness, open areas, scratches, cuts, bruises and report changes to nurse. Dated 1/18/17, revised on 2/9/17. The Nutrition assessment dated [DATE] per RD (Registered Dietician) indicated Risk Factors for Skin Breakdown marked as [MEDICAL CONDITION] and Catheter, Laboratory Data dated 1/13/17 with [MEDICATION NAME] 3.1, normals 3.5-5.5 gm (grams) / 100 ml (milliliters), BMI (Body Mass Index) 21.8 in ideal wt (weight range) . skin intact. The Admission MDS (Minimum Data Set) dated 1/24/17 was marked at not having one or more unhealed pressure ulcers at Stage 1 or higher. The Quarterly MDS's dated 2/5/17 and 2/21/17 were marked as having no pressure ulcers at a Stage 1 or higher. Non pressure Skin Condition Report dated 2/6/17 indicated excoriation to bilateral thighs, groin area, buttocks, coccyx and outer left thigh. Entry dated 2/13/17 indicated area remains red , and entry dated 2/20 was blank. Weekly Pressure Ulcer Record indicated on 2/21/17 Stage 2 measuring 2 centimeters length by 3 centimeters width and no depth to right upper lateral trochanter (right outer hip area over bony prominence). (In STAGES OF PRESSURE ULCERS, AMDA - 2008, the following was included: Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister). The Weekly Pressure Ulcer Record dated 2/22/17 indicated a Stage 2 measuring 1 centimeter in length by 0.3 centimeters width and depth of 0.4 centimeters in left gluteal fold and distal to left gluteal fold. The treatment was listed as: Clean area with normal saline and apply optsite daily and prn soilage - dislodgement . Entry dated 2/28/17 indicated Stage 2 measuring 0.5 centimeters by 0.2 centimeters with no depth. The Weekly Pressure Ulcer Record dated 2/28/17, with date of onset listed as 12/12/17 to left heel, indicated Stage as Eschar (In STAGES OF PRESSURE ULCERS, AMDA - 2008, the following was included: Eschar: dead black tissue that often forms a hard shell over an ulcer), 4 centimeters in length by 1 centimeter width with no depth, no exudate, no odor. The Record for Resident 24 lacked wound measurements for March and April. The Quarterly Nutrition assessment dated [DATE] indicated meal intake was good, no changes from past quarter and skin condition intact at risk. The Weekly Pressure Ulcer Record dated 5/28/17 indicated the right ischial tuberosity was a Stage IV (In STAGES OF PRESSURE ULCERS, AMDA - 2008, the following was included: Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling) measuring 2.2 centimeters in length by 1.5 centimeters in width and 0.4 centimeters depth. The comments included: bone no longer visible, granulation tissue noted in some parts of wound bed, good vascularization. The Preventative measures are listed as: refuses to turn, air mattress, EZ boot. Entry dated 6/5/17 indicated unknown stage,measuring 2 centimeters length by 1 centimeter width and less than 0.5 centimeter depth with serogangious drainage, and no odor. Note on 6/5/17 entry indicated: cleansed with wound cleanser and dressed with calcium alginate and Allevyn. The note by the RD dated 5/31/17 indicated resident had weight loss of 26 pounds in 3 months , weight loss of 9.9 pounds times 30 days . Stage 2 pressure areas on the buttocks crease and the trochanter patient refused to take vitamin C and zinc, refused [MEDICATION NAME] (powder supplement which may aid in wound healing) dietary supplements could be tried if resident accepts. The record lacked attempts at further nutritional supplementation for wound healing. On 6/14/17 at 8:54 a.m., the Physical Therapist 1 was observed to measure Resident 24's left heel. The measurements were 3.1 centimeters in length by 3.3 centimeters in width and less then 0.1 centimeters depth. The area appeared dark pink with slight bloody drainage observed. Physical Therapist 1 indicated the area had been debrided (dead tissue removed) and eschar (leathery dead tissue) had been removed during previous sessions of treatment. She further indicated wound healing to the left heel had not progressed and she was going to request cultures be obtained. On 6/14/17 at 2:12 p.m., RN 1 was observed to cleanse pressure ulcer to right ischial area during dressing change. The area was narrow at the top of pressure wound and widened toward the bottom of the wound in the crease of the right buttock at top of right thigh, pear shape in appearance, pink with white area with in center which RN 1 indicated was hard to touch, with appearance of bone. On 6/15/17 at 7:30 a.m., the Administrator provided the facility policy Skin Management revised November 2014. The policy indicated, but was not limited to: Wound are tracked as acquired (developed in house or admitted with) and are assessed and documented on the Weekly Pressure Ulcer Record. These forms are maintained in the resident's Treatment record while in use Pressure Ulcers are measured and staged weekly in accordance with the Practice Guidelines. The policy further indicated A Care plan is developed on Admission, identifying contributing risks for breakdown, including history of skin impairment and the interventions implemented to promote healing and prevent further breakdown. The Care plan should address, but is not limited to: Hydration, Nutrition, Preventative devices, Physical Activity, Pain, Positioning requirements, Proper Body Alignment. On 6/15/17 at 10:35 a.m., the DON was interviewed. She indicated no protein supplement or nutritional supplement had been ordered for Resident 24 to promote wound healing. On 6/15/17 at 1:35 a.m., the Nurse Consultant indicated there were no labs in the chart for measurement of protein levels. She further indicated the wound measurements were not complete in Resident 24's chart. 3.1-40(a)(1) 3.1-40(a)(2)