Every finding on record at Asbury Towers Health Care Center

Based on record review and interview, the facility failed to ensure the rights and dignity of a resident were maintained for 1 of 3 residents reviewed for resident rights (Resident B). The deficient practice was corrected on 3/19/26, prior to the start of the survey, and was therefore past noncompliance. Findings include:An intake document, dated 3/23/26 at 11:57 a.m., indicated the resident's rights had allegedly been violated when a facility Registered Nurse (RN) had taken a photograph of Resident B's anal area and had sent the photograph to an individual who was not involved with the resident's care and had no connection to the facility.Resident B's record was reviewed on 3/26/26 at 11:26 a.m. The profile indicated the resident's diagnoses included, but were not limited to, rectal prolapse (a condition where the lower end of the large intestine [rectum] loses its internal support, turns inside out, and protrudes through the anus).An admission Minimum Data Set (MDS) assessment, dated 1/4/25, indicated the resident had no cognitive deficits. A Photo Release Form, signed on 1/11/25, indicated the resident had given his permission for pictures to be taken. The form indicated the resident's photo could be used for any lawful purpose, including, but not limited to, magazine publication, publicity, advertising, web content, and social media. The form lacked documentation of permission for photographs to be provided to people outside the facility or for private body parts to be photographed.Review of the residents' progress notes, from admission to present, lacked any documentation of any pictures being taken.An Indiana State Reportable Incident form, dated 3/17/26, indicated the facility administration had been made aware of the allegation. The facility investigation had confirmed that RN 10 had taken the picture on her personal electronic device during resident care. She had sent the picture to a friend who was working with a resident with a similar diagnosis, via the electronic device. The RN had been suspended and removed from the nursing schedule, pending the facility investigation. The resident was assessed for physical and psychological concerns with no findings. Resident and staff interviews were conducted, with no further concerns identified. Based on the findings of the investigation RN had been terminated from her employment. Staff re-education related to resident rights, dignity, and prohibition of photos and recordings were completed. The resident was monitored by the Social services Director for any psychological concerns for 72 hours, with no concerns identified.During an interview, on 3/27/26 at 9:45 a.m., with the Regional Clinical Consultant and the Director of Nursing (DON), they indicated they had confirmed that the incident had happened. RN 10 had admitted to taking the picture. After the completion of the facility's investigation, RN 10's employment had been terminated. The DON indicated all staff had been immediately re-educated on resident rights, dignity, and the policy on prohibition of taking photographs and/or recordings. If the staff could not attend the group education opportunities, they were provided with the education prior to beginning there next shift.During an interview, on 3/27/26 at 11:07 a.m., Resident B indicated he did not remember ever giving permission to a nurse to a picture of his back side. If he had given permission for that he would think he would remember. The staff helped him change his depends, but he could not recall anyone taking a picture.ON 3/27/26 at 11:36 a.m., the DON provided a document, dated February 2021, titled Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; be treated with.dignity.3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.The deficient practice was corrected on 3/19/26, prior to the start of the survey, and was therefore past noncompliance. The deficient practice was corrected after the facility implemented a systemic plan that included the following actions. The facility reported the incident to the State and completed a thorough investigation of the incident. The resident was assessed both physically and psychologically and resident and staff interviews were conducted. The investigation resulted in the termination of the employee who committed the offense. The facility staff were re-educated on resident rights, dignity and prohibition of photos and /or recordings.This citation relates to intake 2961258.410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on record review and interview, the facility failed to submit a death in the Minimum Data Set (MDS) assessment timely for 1 of 20 residents reviewed for MDS accuracy (Resident 21).Findings include:Resident 21's record was reviewed on 12/3/25 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, malignant neoplasm of brain (an aggressive, cancerous tumor characterized by rapid growth, invasion of surrounding healthy brain tissue, and potential spread within the central nervous system) and acute and chronic respiratory failure (occurs when a patient with pre-existing chronic respiratory inadequacy suffers a sudden, life threatening deterioration in oxygenation or CO2 (carbon dioxide) removal).Facility census information indicated Resident 22 was admitted to the facility on [DATE].A significant change in status Minimum Data Set (MDS) assessment, dated 1/16/26, indicated the resident was cognitively intact and was marked Yes the resident did have a condition or chronic disease that may result in a life expectancy of less than 6 months.A nursing progress note, dated 1/21/26 at 5:40 p.m., indicated the resident had stopped breathing at 5:08 p.m. in the presence of the hospice nurse.A nursing progress note, dated 1/21/26 at 7:00 p.m., indicated that the resident's body was transported from the facility to the funeral home.A death in facility MDS assessment was submitted on 3/25/26.During an interview on 3/27/25 at 9:10 a.m., the Regional Clinical Consultant indicated she was not aware of why the MDS Coordinator had not submitted the death in facility assessment timely. She indicated the facility's MDS Coordinator had been out on FMLA (Family and Medical Leave Act) intermittently since January 2026 and the assessment could have just been missed. The consultant indicated the facility had an MDS consultant that would be on calls weekly with the MDS coordinator and she was not sure why he had not caught the missed death in facility assessment. The facility policy was to follow the RAI (Resident Assessment Instrument) guidelines when submitting and completing assessments.Section A0310 of the CMS (Centers for Medicaid and Medicare Services) RAI Version 3.0 Manual, dated October 2024, indicated, .A0310 Type of Assessment.F. Entry/discharge reporting.12. Death in facility.Chapter 2 of the CMS RAI Version 3.0 Manual, dated October 2024, indicated, .RAI-OBRA (Omnibus Budget Reconciliation Act of 1987) .death in facility tracking record A0310 F=12.MDS completion date (death) date + 7 calendar days.transmission dated no later than discharge (death) date + 14 calendar days.

Based on record review and interview, the facility failed to ensure a physician's order for an assessment of a resident's dialysis access site (surgically prepared area on the body that allows easy, high-volume access to the bloodstream for filtering blood during hemodialysis [a medical treatment that acts as an artificial kidney for people with kidney failure]) was accurate and documentation of assessments of the site were completed for 1 of 1 residents reviewed for dialysis (Resident 1).Findings include:Resident 1's record was reviewed on 3/25/26 at 11:27 a.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (the final, permanent stage of kidney failure where function drops below 15% of normal, necessitating dialysis or a transplant to live) and dependency on renal dialysis.An admission Minimum Data Set (MDS) assessment, dated 12/25/25, indicated the resident had no cognitive deficit and received hemodialysis.A care plan, revised on 2/25/26, indicated the resident required hemodialysis related to renal failure. Interventions included, but were not limited to, nurse to assess AV Fistula (an abnormal, direct connection between an artery and a vein, allowing blood to bypass capillary systems) for bruit (an abnormal, rushing or whooshing sound heard with a stethoscope over a blood vessel, indicating turbulent blood flow, usually caused by narrowing) and thrill (the palpable, physical vibration of that same turbulence, felt on the skin like a cat's purr or a buzzing sensation).A physician's order, dated 12/18/25, indicated to check the resident's permacath site (a specialized, long-term catheter used for dialysis patients to access the bloodstream without needing repeated needle sticks) daily and upon return from dialysis every shift; including caps in place and tight, dressing dry and intact.The residents' January, February, and March 2026 medication administration record (MAR) lacked documentation of the order being completed on the day shift on 1/6/26 and 2/27/26, and the night shifts on 2/11/26 and 3/5/26. A physician's order, dated 12/30/25, indicated to check access of the resident's left upper extremity antecubital (the area situated in front of or inside the bend of the elbow) access site for bruit and thrill and record and report abnormalities every shift for dialysis.The residents' January, February, and March 2026 MAR lacked documentation of the order being completed on the day shift on 2/27/26, and the nights shifts on 1/17/26 and 2/11/26.A physician's order, dated 12/30/25, indicated to complete a pre and post dialysis evaluation prior to leaving and upon return, two times a day, every Tuesday, Thursday, and Saturday, for dialysis.The residents' January, February, and March 2026 MAR lacked documentation of the post-dialysis order being completed on 1/1/26 and 1/22/26, and the pre-dialysis order being completed on 2/14/26 and 3/21/26.During an interview, on 3/25/26 at 3:00 p.m., the resident indicated she had not had the permacath for a long time. She had it removed quite a while. She only had the AV Fistula site.During an interview, on 3/25/26 at 3:08 p.m., Registered Nurse (RN) 5 indicated she checked the resident's AV Fistula site on her shift for bruit and thrill. The resident did not have a permacath. She was aware that the order for the permacath was still on her records, but she was unsure why.During an interview, on 3/26/26 at 1:50 p.m., the Director of Nursing (DON) indicated the order to assess the permacath site was not an accurate order. She believed the permacath had been removed when the resident was on the assisted living unit, prior to her coming to the skilled unit and had been overlooked. It was the expectation that when an order was completed, the nurse would chart in the MAR that it had been completed as ordered.On 3/26/26 at 1:50 p.m., the DON provided a document, with a revised date of 5/2023, titled, Home Dialysis Treatment, and indicated it was the policy currently in use by the facility. The policy indicated, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders.Compliance Guidelines.23. The facility will ensure that the physician's orders.include: a. The type of access for dialysis.26. The nurse will ensure that the.hemodialysis site.is checked before and after dialysis and every shift for patency.28. Residents with external hemodialysis catheters will be assessed every shift.410IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation and interview the facility failed to ensure medications were discarded according to facility policy and manufacture guidelines during observation of 1 of 1 medication storage rooms.Findings include:On [DATE] at 9:30 a.m., during observation of the medication storage room with Registered Nurse (RN) 7, observed one multi dose vial of Tuberculin (TB) solution (a sterile liquid containing inactive proteins derived from the bacteria that cause tuberculosis. It is used in skin tests to determine if a person has been infected with TB bacteria). The vial was dated as opened on [DATE].On [DATE] at 9:35 a.m., during an interview RN 7 indicated the vial of Tuberculin solution was viable for 30 days. On [DATE] at 9:38 a.m., during an interview the Director of Nurses (DON) indicated she would have to check the policy regarding expiration date of the TB solution. On [DATE] at 10:00 a.m., during an interview the DON indicated the TB solution vial was expired but had not been used after the expiration date.On [DATE] at 1:00 p.m., the DON provided a document titled, Medication storage and Medication labeling, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .Medication labeling.5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated. If expired discarded after use.IAC (Indiana Administrative Code) 16.2-3.1-25(j)IAC (Indiana Administrative Code) 16.2-3.1-25(m)IAC (Indiana Administrative Code) 16.2-3.1-25(n)

2. Resident 5's record was reviewed on 3/25/25 at 10:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atypical atrial flutter (an abnormal heart rhythm where the electrical signals in the upper chambers beat too quickly and irregularly), and history of pulmonary embolism (a condition where a blood clot travels to the lungs and blocks one or more pulmonary arteries). A quarterly Minimum Data Set (MDS) assessment, dated 3/19/25, indicated the resident received anticoagulant (AC) medication (drugs that help prevent blood clots from forming). The census indicated that the resident had been hospitalized from [DATE] to 3/12/25. A progress note, dated 3/7/25 at 3:21 p.m., indicated the resident presented a tissue with liquid and dark red saliva, and indicated it was from him coughing. He indicated he had coughed up a big glob of blood like a clot earlier when out on LOA (leave of absence) with his friend. The nurse advised the resident he should go to the emergency room (ER) for a workup. The resident agreed and his family, the Director of Nursing (DON), and physician were notified that the resident had been sent to the ER. A progress note, dated 3/8/25 at 4:36 a.m., indicated that the resident was being held for observation. Resident had been diagnosed with lower lobe pneumonia (an infection that inflames the air sacs in the lower sections of the lungs) and influenza A (a highly contagious viral infection that primarily affects the respiratory system). The record lacked documentation of the facility communication to the receiving facility at the time of the transfer. 3. Resident 10's record was reviewed on 3/25/25 at 2:13 p.m. The profile indicated the resident's diagnoses included, but were not limited to, acute pyelonephritis (a sudden, severe bacterial infection of the kidney and renal pelvis), hydronephrosis with renal and urethral calculus obstruction (swelling of one or both kidneys due to a buildup of urine caused by blockages in the kidneys or the tubes carrying urine from the kidneys to the bladder), and unspecified psychosis (a diagnosis used when someone experiences psychotic symptoms [like hallucinations-seeing or hearing things that are not there] but doesn't meet the criteria for a specific psychotic disorder). A quarterly Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had no cognitive deficit and received an antipsychotic medication (medication used to treat psychotic symptoms). During an interview, on 3/24/25 at 1:38 p.m., the resident indicated she had been out to the hospital last week related to a kidney stone. The census indicated the resident had been hospitalized from [DATE] to 3/13/25, and again on 3/14/25 and had returned on the same date. A progress note, dated 3/7/25 at 10:35 a.m., indicated the resident had been sent to the hospital overnight due to fever and hallucinations. The resident was found to be septic (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing widespread inflammation and damage to multiple organs) and had been transferred to a second hospital location for kidney stone surgery and treatment. The record lacked documentation of the facility communication to the receiving facility at the time of the transfer. A progress note, dated 3/14/25 at 12:43 p.m., indicated the resident had been sent out to the ER due to complaints of shortness of breath (SOB) and hemoptysis (coughing up pf blood). The record lacked documentation of the facility communication to the receiving facility at the time of the transfer. During an interview, on 3/25/25 at 3:08 p.m., the DON indicated she had been unable to find any documentation of the nurses calling report to the hospital for the transfer. The expectation was that report should always be called to the hospital and documentation should be completed of who the nurse provided report to, at the time of the transfer. On 3/26/25 at 9:48 a.m., the DON provided a document, with a revised date of 10/17/24, titled, Transfer and Discharge (including AMA-against medical advice), and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .10. For a transfer to another provider .the following information must be provided to the receiving provider .d. All other information to meet the residents' needs, which includes, but may not be limited to, i. Resident status .; ii. Diagnoses and allergies; iii. Medications .; h. Additional information, if any, outlined in the transfer agreement with the acute care provider 3.1-12(a)(3) Based on record review and interview, the facility failed to ensure they communicated with the receiving hospital, and documented their communication when residents were transferred to the emergency room (ER) for 3 of 4 residents reviewed for hospitalization (Residents 6, 5, and 10). Findings include: 1. Resident 6's record was reviewed on 3/25/25 at 10:13 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/11/25, indicated the resident was cognitively intact and had a diagnosis of medically complex conditions. A Progress Note, dated 6/23/24 at 6:20 p.m., indicated the resident's sister stated the resident called her and cried with pain from not having a bowel movement (BM). The nurse explained to the resident's sister that the resident had already received an enema and had large results. The resident's sister wanted the resident to be given another enema, and if the pain continued wanted him sent to the hospital. The physician stated to send the resident to the hospital as he just returned from the hospital the prior week for an illeus (intestinal blockage). A Progress Note, dated 6/23/24 at 6:46 p.m., indicated the resident's sister called back and was notified the physician wanted the resident transferred to the emergency room (ER). 911 was called. The note lacked documentation the facility communicated with the receiving hospital. A Progress Note, dated 6/24/24 at 12:38 a.m., indicated the nurse called the hospital for an update, and the resident was admitted for observation related to constipation. A Progress Note, dated 1/14/25 at 1:09 p.m., indicated the resident complained he felt like his lungs were filling up and requested to go to the ER. The resident's family and the physician were notified. The note lacked documentation the facility communicated with the receiving hospital. A Progress Note, dated 1/14/25 at 7:05 p.m., indicated the resident returned to the facility from the hospital. A Progress Note, dated 3/18/25, indicated the resident was transferred to the hospital for evaluation and treatment due to episodes of projectile vomiting. The resident's family and the physician were notified. The note lacked documentation the facility communicated with the receiving hospital. A Progress Note, dated 3/19/25, indicated the resident returned to the facility from the hospital. During an interview, on 3/25/25 at 3:08 p.m., the Director of Nursing (DON) indicated she was unable to find documentation the facility communicated with the receiving hospital when the resident was transferred on 6/23/24, 1/14/25, or 3/18/25.

Based on interview, record review, and observation, the facility failed to ensure food was served at a palatable temperature for 3 of 15 residents reviewed for food temperatures (Residents 7, 13, and 10). Findings include: 1. During an interview, on 3/24/25 at 11:26 a.m., Resident 7 indicated the food was cold when it was served. Resident 7's record was reviewed on 3/26/25 at 9:41 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the resident was cognitively intact. 2. During a family interview, on 3/24/25 at 11:47 a.m., Resident 13's wife indicated the food was cold when it was served. Resident 13's record was reviewed on 3/26/25 at 1:28 p.m. A quarterly MDS assessment, dated 3/18/25, indicated the resident had a severe cognitive impairment. 3. During an interview, on 3/24/25 at 1:34 p.m., Resident 10 indicated the food was often cold when it was served in her room, and the staff had to warm it up for her. During a continuous observation, on 3/27/25 from 11:16 a.m. to 12:02 p.m., the following was observed. At 11:16 a.m., the first floor dining room steam table was observed with three covered dishes in place. There were no residents or staff in the area. At 11:33 a.m., lunch service began in the first floor dining room. At 11:43 a.m., lunch service was completed in the first floor dining room, the food dishes were placed on a cart, and taken to the dining room downstairs. At 11:45 a.m., Dietary Aide 10 placed the covered dishes on a food warmer in the downstairs dining room and checked the temperatures of the food prior to the start of the lunch service. The meatloaf was 155 degrees Fahrenheit (F), mashed potatoes 155 degrees F, broccoli and cauliflower 132 degrees F, gravy 130 degrees F, and mechanical soft meatloaf 130 degrees F. From 11:50 a.m. to 12:02 p.m., trays were passed in the downstairs dining room and to the rooms on the unit. After the completion of the last tray, at 12:02 p.m., a test tray was plated from the food warmer. At 12:02 p.m., directly after the completion of the last tray on the unit, meatloaf was 142 degrees F, mashed potatoes were 120 degrees F, and broccoli cauliflower was 98 degrees F. During an interview, on 3/27/25 at 12:02 p.m., Dietary Aide 10 indicated the food should have been 130 degrees F or above at the time it was served. Resident Council Minutes, dated 1/21/25, indicated the food was not so cold. On 3/27/25 at 1:40 p.m., the Administrator provided an undated document titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .Food Holding Temperatures/Service: Hot food should be served at 135 F or higher 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure hair and beard nets were worn in the food service area during meal service during 1 of 4 dining observations. Findings include: During an observation, on 3/24/25 at 11:31 a.m., [NAME] 5 verified the food temperature and served lunch from the kitchen in first floor dining room. [NAME] 5 had facial hair and did not wear a beard net. A contracted service provider cleaned the fish tank in the dining room during the meal service. The contracted service provider entered the kitchen area, with no hairnet, and obtained water from the sink to fill the fish tank while [NAME] 5 served lunch. Registered Nurse (RN) 3 and Certified Nurse Aide (CNA) 4 entered the kitchen area and obtained drinks. RN 3 and CNA 4 did not wear hairnets in the kitchen area. During an interview, on 3/24/25 at 11:35 a.m., [NAME] 5 indicated no staff should have entered the kitchen area without hairnets in place. During an interview, on 3/24/25 at 11:38 a.m., RN 3 and CNA 4 indicated they had not been told they needed a hairnet to enter the kitchen area. On 3/27/25 at 1:40 p.m., the Administrator provided an undated document titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .Sanitation .Hair restraints must be worn at all times when in or around food production areas 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a Physician's Order was obtained and documented for hospital transfers for 3 of 4 residents reviewed for hospitalization (Residents 6, 5, and 10). Findings include: 1. Resident 6's record was reviewed on 3/25/25 at 10:13 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/11/25, indicated the resident was cognitively intact and had a diagnosis of medically complex conditions. A Progress Note, dated 6/2/24, indicated the resident's sister came to the facility and requested the resident be sent to the hospital for pain. The nurse called 911. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 6/3/24, indicated the resident returned to the facility from the hospital. A Progress Note, dated 6/4/24, indicated the nurse went into the resident's room and found his bedside table covered in water, resident was asleep and holding the cup that had spilled. The resident was difficult to wake up, and not touched his dinner, and was unable to say who he was. The resident stated he did not feel well. The resident's sister, Director of Nursing (DON), and physician were notified. The resident was sent to the hospital. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 6/13/24, indicated the resident returned to the facility from the hospital. A Progress Note, dated 6/23/24 at 6:20 p.m., indicated the resident's sister stated the resident called her and cried with pain from not having a bowel movement (BM). The nurse explained to the resident's sister that the resident had already received an enema and had large results. The resident's sister wanted the resident to be given another enema, and if the pain continued wanted him sent to the hospital. The physician stated to send the resident to the hospital as he just returned from the hospital the prior week for an illeus (intestinal blockage). A Progress Note, dated 6/23/24 at 6:46 p.m., indicated the resident's sister called back and was notified the physican wanted the resident transferred to the ER. 911 was called. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 9/4/24 indicated the resident had tremors in his arms and hands, was lethargic, complained of severe back pain and his stomach cramping. The resident's sister visited and wanted the resident sent to the hospital. The physician and DON were notified, and 911 was called. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 9/6/24, indicated the resident returned to the facility from the hospital. A Progress Note, dated 1/14/25 at 1:09 p.m., indicated the resident complained he felt like his lungs were filling up and requested to go to the ER. The resident's family and the physician were notified. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 1/14/25 at 7:05 p.m., indicated the resident returned to the facility from the hospital. A Progress Note, dated 3/18/25, indicated the resident was transferred to the hospital for evaluation and treatment due to episodes of projectile vomiting. The resident's family and the physician were notified. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 3/19/25, indicated the resident returned to the facility from the hospital. During an interview, on 3/25/25 at 3:08 p.m., the DON indicated she was unable to find documenation a Physician's Order was obtained, written, or signed for the resident's hospital transfers. 34525 2. Resident 5's record was reviewed on 3/25/25 at 10:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atypical atrial flutter (an abnormal heart rhythm where the electrical signals in the upper chambers beat too quickly and irregularly), and history of pulmonary embolism (a condition where a blood clot travels to the lungs and blocks one or more pulmonary arteries). A quarterly Minimum Data Set (MDS) assessment, dated 3/19/25, indicated the resident received anticoagulant (AC) medication (drugs that help prevent blood clots from forming). The census indicated that the resident had been hospitalized from 3/7/25 to 3/12/25. A progress note, dated 3/7/25 at 3:21 p.m., indicated the resident presented a tissue with liquid and dark red saliva, and indicated it was from him coughing. He indicated he had coughed up a big glob of blood like a clot earlier when out on LOA (leave of absence) with his friend. The nurse advised the resident he should go to the emergency room (ER) for a workup. The resident agreed and his family, the Director of Nursing (DON), and physician were notified that the resident had been sent to the ER. The record lacked documentation a Physician's order was obtained, written, or signed by the physician for the hospital transfer. 3. Resident 10's record was reviewed on 3/25/25 at 2:13 p.m. The profile indicated the resident's diagnoses included, but were not limited to, acute pyelonephritis (a sudden, severe bacterial infection of the kidney and renal pelvis), hydronephrosis with renal and urethral calculus obstruction (swelling of one or both kidneys due to a buildup of urine caused by blockages in the kidneys or the tubes carrying urine from the kidneys to the bladder), and unspecified psychosis (a diagnosis used when someone experiences psychotic symptoms [like hallucinations-seeing or hearing things that are not there] but doesn't meet the criteria for a specific psychotic disorder). A quarterly Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had no cognitive deficit and received an antipsychotic medication (medication used to treat psychotic symptoms). During an interview, on 3/24/25 at 1:38 p.m., the resident indicated she had been out to the hospital last week related to a kidney stone. The census indicated the resident had been hospitalized from 3/7/25 to 3/13/25, and again on 3/14/25, and had returned on the same date. A progress note, dated 3/7/25 at 10:35 a.m., indicated the resident had been sent to the hospital overnight due to fever and hallucinations. The resident was found to be septic (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing widespread inflammation and damage to multiple organs) and had been transferred to a second hospital location for kidney stone surgery and treatment. The record lacked documentation a Physician's order was obtained, written, or signed by the physician for the hospital transfer. During an interview, on 3/25/25 at 3:08 p.m., the DON indicated she was unable to find documentation that a Physician's Order was obtained, written, or signed for the resident's hospital transfers. On 3/26/25 at 9:48 a.m., the DON provided a document, with a revised date of 10/17/24, titled, Transfer and Discharge (including AMA-against medical advice), and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .12. Emergency Transfers/Discharges .a. Obtain physician's order for emergency transfer or discharges .f. Document .the transfer in the medical record 3.1-50 (a)(1) 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a urinary catheter tubing (a flexible tube inserted into the bladder to drain urine) and a urinary drainage bag were kept off the floor (Resident 2). Finding includes: On 2/5/24 at 2:16 p.m., Resident 2 was asleep in bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/6/24 at 10:11 a.m., Resident 2 was asleep in her bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/6/24 at 12:02 p.m., Resident 2 was resting in her bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/6/24 at 1:37 p.m., Resident 2 was asleep in her bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/7/24 at 9:21 a.m., Resident 2 was asleep in her recliner and her catheter drainage bag and tubing were in contact with the floor next to her chair. Resident 2's record was reviewed on 2/6/24 at 10:20 a.m. The profile indicated the resident's diagnoses included, but were not limited to, urinary tract infection (is an infection in any part of the urinary system) and hematuria (blood in urine). A significant change in status Minimum Data Set (MDS) assessment, dated 12/19/23, indicated the resident was cognitively intact and on hospice services. A care plan, dated 9/26/23, indicated the resident had a history of UTI (urinary tract infections). Interventions included but were not limited to administer antibiotic therapy as ordered and monitor intake and output. A care plan, dated 12/28/23, indicated the resident had an indwelling Foley catheter for comfort. Interventions included but were not limited to, change catheter monthly and as needed if not functioning correctly, monitor for signs and symptoms of discomfort on urination, and staff to complete catheter care every shift. A physician order, dated 12/26/23, indicated staff may anchor a Foley catheter using a 16 Fr (French) (diameter of catheter tubing) and 10cc (cubic centimeter) balloon for the resident for comfort per hospice. A physician order, dated 12/26/23, indicated to change Foley catheter every month on the 26th, every night shift. A physician order, dated 12/26/23, indicated to perform Foley catheter care every shift. A nurse's note, dated 12/31/23, indicated the CNA (Certified Nursing Aide) reported foul smelling urine from Resident's 2 catheter. The nurse notified the hospice nurse for approval to collect a urinalysis. A physician order, dated 1/7/24, indicated Ciprofloxacin (antibiotic medication) 500mg (milligram) give 1 tablet by mouth two times a day for UTI for 5 days. During an interview, on 2/7/24 at 9:47 a.m., Registered Nurse (RN) 3 indicated the Foley catheter tubing or the drainage bag should not touch the floor. During an interview, on 2/7/24 at 10:24 a.m., Director of Nursing (DON) indicated the Foley catheter tubing, or the drainage bag should not touch the floor. On 2/7/24 at 11:03 a.m., the DON provided a document, with a revised date of 3/10/23, titled, Catheter Care, and indicated it was the current policy being used by the facility. The policy indicated, .11. Ensure catheter tubing and drainage bags do not touch the floor 3.1-38(a)(1)

Based on observation, interview, and record review, the facility failed to clean and store respiratory equipment according to policy, and failed to conduct resident's lung assessment before and after administering a nebulizer respiratory treatments in 2 of 2 residents reviewed for respiratory therapy (Residents 10 and 172). Findings include: 1. On 2/5/24 11:00 a.m., during a routine observation, Resident 10 was lying in bed with the head of bed slightly elevated. Oxygen administered at 2 Liters (L) per nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). The nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) equipment, the medication chamber for holding the liquid medication, tubing and mask were un-bagged and lying on top of the bedside table. On 2/7/24 at 9:56 a.m., during a routine observation of Resident 10 the nebulizer mask, tubing and reservoir was lying on the bedside table un-bagged. A clear liquid substance was inside of the medication chamber. On 2/07/24 at 10:39 a.m., Resident 10's record was reviewed. Diagnoses included but was not limited to, acute, chronic congestive heart failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). Physician Orders include but were not limited to, albuterol 2.5 mg/3 ml (milligrams/milliliters) solution (3 ml) inhale 1 vial orally via nebulizer every 6 hours as needed for shortness of breath (SOB) and/or wheezing; albuterol sulfate HFA 90 mcg (micrograms) inhalation 18 gm (grams) 2 puffs inhaled orally every 6 hours as needed for wheezing, SOB (shortness of breath); IPRAT-albuterol 0.5-3(2.5) mg/3 ml, 3 ML inhale 1 vial orally four times a day for SOB, wheezing via nebulizer. A quarterly MDS, dated [DATE], indicated the resident was on continual oxygen. A care plan, dated 3/9/23, indicated the resident had altered respiratory status related to Pulmonary hypertension (a condition that affects the blood vessels in the lungs), COPD, and sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep). Interventions were to administer medication/puffers as ordered. Oxygen settings: as needed (PRN) oxygen (O2) at 2L/min (liters per minute) via nasal cannula. The medical record lacked documentation of lung assessments prior to and after administration of nebulizer treatments for Resident 10. 2. On 2/5/24 at 1:57 p.m., during a routine observation of Resident (172), the nebulizer chamber, mouthpiece and tubing were un-bagged and laying on top of the bedside table. On 2/7/24 at 9:54 a.m., the nebulizer equipment and tubing were un-bagged and laying on top of the nebulizer machine. On 2/07/24 10:28 a.m., Resident 172's record was reviewed. Diagnoses included but was not limited to, acute, chronic congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), obstructive sleep apnea (a relatively common condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), and stage 4 (severe) chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Physician orders included but are not limited to. Oxygen at 4 liters per minute (LPM) continuously, via nasal cannula; monitor oxygen saturation every shift; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) (Ipratropium-Albuterol), 1 application inhale orally four times a day (via nebulizer). A baseline care plan was completed on admission. Record lacked documentation of a care plan for oxygen or nebulizer treatment. The medical record lacked documentation of lung assessments prior to and after administration of nebulizer treatments for Resident 172. On 2/7/24 at 10:05 a.m., during an interview, Registered nurse (RN) 3 indicated she checked the oxygen saturation level and the pulse before initiating a nebulizer treatment. She put the medication solution in the nebulizer chamber and placed the nebulizer mask on the resident. Once the treatment was completed, she cleaned the equipment with water and allowed it to air dry on a clean surface. Once dry she placed the equipment in the dated bag. The nurse acknowledged both residents received scheduled nebulizer treatments four times a day. On 2/7/24 at 10:05 a.m., during an interview RN 3 indicated she checked oxygen saturation and pulse before she began the nebulizer treatment and she put the medication solution in the nebulizer chamber and placed the mask on the resident. She indicated that after the treatment was completed she assessed the residents' lungs. She cleaned the equipment with water and allowed it to air dry on a clean surface, then placed it in the bag. She acknowledged both residents received scheduled nebulizer treatments four times per day. On 2/7/24 at 10:20 a.m., during an interview the Director of Nurses (DON) indicated the nurse should assess the resident before and after the nebulizer treatment. They were to clean the equipment, dry it, then place it back into the bag. Tubing should be dated as well as the bag. The DON acknowledged the pre and post assessments were not completed for the two residents reviewed. On 2/7/2024 at 11:04 a.m., the DON provided a document, titled, Nebulizer Therapy, dated 2/17/21, and indicated it was the policy currently being used by the facility. The policy indicated, . 2. Care of the Equipment .c. Disassemble parts after every treatment .d. Rinse the nebulizer cup and mouthpiece with sterile or distilled water .e. Shake off excess water .f. Air dry on an absorbent towel .g. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag .3. Documentation .a. Record the following information in the resident's medical record .d. Resident vital signs and respiratory assessment pre and post treatment 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week on July 1, 2023 for 1 of 31 days of staffing reviewed. Finding includes: During an interview, on 2/8/24 at 10:30 a.m., the Administrative Assistant indicated she was not sure if there was RN coverage on July 1, 2023, she would need to go back and check the daily schedules. Review of daily nursing schedules provided by the facility indicated there was no RN scheduled for the day of July 1, 2023. Review of the daily staffing report lacked documentation of RN hours for the day of July 1, 2023. During an interview, on 2/8/24 at 11:00 a.m., the Director of Nursing (DON) indicated there was not a RN in the building on the date of July 1, 2023. She indicated there was not one scheduled that day. During an interview, on 2/8/24 at 1:23 p.m., the Administrator indicated he was aware there was not a RN in the building on the date of July 1, 2023. On 2/8/24 at 1:05 p.m., the DON provided a document, with a revised date of 10/17/22, titled, Nursing Services-Registered Nurse, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week 3.1-17(b)(3)

Based on record review and interview, the facility failed to address pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents 121 and 7). Findings include: 1. Resident 121's record was reviewed on 2/6/24 at 10:06 a.m. The profile indicated the resident had been admitted to the facility on [DATE], with diagnoses which included, but were not limited to, personal history of pulmonary embolism (PE-when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung). A physician's order, dated 1/30/24, indicated to administer one tablet of Xarelto (anticoagulant medication-a substance used to prevent and treat blood clots in blood vessels) 20 milligrams (mg) oral tablet by mouth in the morning for history of PE. A Pharmacist consultation report, dated 1/31/24, indicated a recommendation to ensure the resident's care plan included guidance to use an alternative anticoagulant if the Xarelto was stopped for any reason other than pathological (being such to a degree that is extreme, excessive, or markedly abnormal) bleeding or completion of therapy, and to avoid use of neuraxial anesthesia (the placement of local anesthetic in or around the central nervous system) or spinal puncture (a procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid), if possible. The physician accepted the recommendation and documented the resident was on the medication due to a history of PE. The resident's care plans lacked documentation of any use of anticoagulant medication or history of PE. During an interview, on 2/6/24 at 2:00 p.m., the Director of Nursing (DON) indicated she had never seen a recommendation like that before. She was unsure why the recommendation or the residents use of an anticoagulant, had not been addressed in the resident's care plan. 48226 2. On 2/06/24 at 10:38 a.m., Resident 7's medical record was reviewed.Diagnosis included but were not limited to, encounter for orthopedic after care following surgical amputation (left foot amputation), iron deficiency anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). Physician Orders included but were not limited to, administer one oral 5 milligrams (mg) tablet of Eliquis (anticoagulant medication-a substance that is used to prevent and treat blood clots in blood vessels) by mouth two times a day for AFIB (atrial fibrilation) (an irregular and often very rapid heart rhythm). A Pharmacist consultation report, dated 1/22/24, indicated a boxed warning with a recommendation to ensure the resident's plan of care included recommendation to use an alternative anticoagulant if the Eliquis is stopped for any reason other than pathological (being such to a degree that is extreme, excessive, or markedly abnormal) bleeding or completion of therapy, and to avoid use of neuraxial anesthesia (the placement of local anesthetic in or around the central nervous system) or spinal puncture (a procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid), if possible. The physician accepted the and indicated to please implement as written. The medical record lacked documentation indicating the recommendation was implemented as ordered. On 2/7/24 at 8:56 a.m., the Director of Nurses (DON) provided a document titled, Medication Regimen Review, dated 5/20/21, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .7. Timelines and responsibilities for Medication regimen Review .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6)

Based on record review and interview, the facility failed to address pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident 2) Finding includes: Resident 2's record was reviewed on 2/6/24 at 10:20 a.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life) and unspecified dementia with mood disturbance (mild cognitive impairment with behavioral disturbances that can include anxiety, depression, and agitation). A pharmacy recommendation, dated 11/9/23, recommended to consider discontinuing Effexor (anti-depressant medication) and reinitiating alternative therapy with Pristiq (anti-depressant) 50mg (milligram) daily. The physician declined the recommendation and indicated he would get with the Psychiatric (Psych) NP (nurse practitioner) to see what she advised. The physician signed the recommendation on 11/14/23. The facility was unable to provide documentation that indicated the physician had spoken with the Psych NP regarding the above recommendation. A physician order, dated 9/26/23, indicated an order for Effexor XR (extended release) 24-hour 75mg. Give 2 tablets by mouth one time a day for anxiety and depression. Review of the resident's February MAR (medication administration record) indicated the resident was still receiving the Effexor medication as ordered. During an interview, on 2/7/24 at 11:37 a.m., the Director of Nursing (DON) indicated the physician should address the pharmacy recommendation in a timely manner and have a rationale for the declination. She indicated that they did not have documentation from the physician or the Psych NP regarding the pharmacy recommendation dated 11/9/23 for Resident 2. On 2/7/24 at 8:56 a.m., the DON provided a document with a revised date of 9/26/23, titled, Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure insulin medication was labeled and stored according to policy and manufacture guidelines for 1 of 2 medication carts reviewed for medication storage. Findings Include: On 2/8/24 at 9:15 a.m., observation of medication cart 2, with the Assistant Director of Nurses (ADON). An insulin pen labeled Lispro 100 units (U), within a clear plastic bag was unsealed and labeled with a green sticker indicating Refrigerate. A blank date opened was on the outside top of the pen cover. The ADON indicated the medication administration record for the resident of whom the insulin was prescribed, indicated the insulin had been delivered on 2/6/24. The medical record indicated the insulin had not been administered. The ADON acknowledged the insulin pen should have been refrigerated till opened and acknowledged the label lacked documentation of a date indicating when the insulin pen had been opened. On 2/8/24 at 9:30 a.m., during an interview, the Director of Nurses (DON), indicated all insulins must have a label indicating when the medication had been opened. If the insulin was un-opened it must be refrigerated. On 2/8/24 at 10:00 a.m., review of the manufacture guidelines indicated, .Lilly's Non-Branded Insulins Prescribing Information. Patient Prescribing Information, Instructions for Use Unused Pens, Store unused Pens in the refrigerator at 36 F to 46 F (2 C to 8 C). Do not freeze your insulin. Do not use if it has been frozen. Unused Pens may be used until the expiration date printed on the Label, if the Pen has been kept in the refrigerator On 2/8/2024 at 1:05 p.m., the DON provided a document, titled, Insulin Pen, dated 9/28/2, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy . It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing .Policy explanation and compliance guidelines .7. Store unopened insulin pens in a refrigerator .8. Once opened, clearly labeled pens, that have an opened date, may be stored at room temperature in a locked medication cart. Insulin pens do not require refrigeration after opening .9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation On 2/8/2024 at 1:05 p.m., the DON provided a document, titled, Storage of Medications Requiring Refrigeration, dated 6/11/21, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent potential alteration of medications by exposure to improper temperature controls .Policy Explanation and Compliance Guidelines .2. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable) and with appropriate accessory and precautionary instructions (such as shake well, take with meals, do not crush, special storage instructions) .3. Facility staff should label all medications with date opened .4. The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity .b. Refrigerated refers to temperatures maintained between 36 -46 degrees F 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, record review, and interview, the facility failed to ensure dental services were offered to a resident for 1 of 1 residents reviewed for dental services (Resident 5). Findings include: During the initial observation of Resident 5, on 2/5/24 at 1:43 p.m., the resident was observed with only 1 tooth on her lower jaw. At the same time, the resident indicated she had a partial denture, but it was uncomfortable, and she did not like to wear it. She had not seen a dentist for quite some time. Resident 5's record was reviewed on 2/8/24 at 9:22 a.m. The profile indicated the resident had been admitted to the facility, on 9/28/20, for diagnoses which included, but were not limited to, emphysema (a disorder affecting the alveoli [tiny air sacs] of the lungs), and chronic systolic congestive heart failure (a condition where the heart can't pump with enough force to push enough blood into circulation). A quarterly minimum data set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 1/27/23, indicated the resident had no cognitive deficit and no documented concerns with her dental status. A care plan, dated 10/13/20 and revised on 11/20/20, indicated the resident had potential for oral/dental health problems related to no natural teeth and the use of dentures. Interventions included, but were not limited to, coordinate arrangements for dental care and transportation as needed or as ordered. An ancillary services consent, dated 10/7/22, indicated the resident had declined dental services. The record lacked any follow-up documentation of dental services having been offered, consented to, or declined, after 10/7/22. A care plan note, dated 1/18/23 at 2:00 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 4/12/23 at 1:39 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 7/12/23 at 3:21 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 9/6/23 at 2:08 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 11/8/23 at 1:37 p.m., indicated the resident had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 1/31/24 at 5:49 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. During an interview, on 2/8/24 at 10:18 a.m., the Director of Nursing (DON) indicated the facility would address the desire of the residents to receive dental services. She indicated ancillary services were discussed at each care plan meeting. During an interview, on 2/8/24 at 10:31 a.m., the Social Services Director (SSD) indicated the resident had declined dental services in 2022. Ancillary services were discussed at each plan of care meeting. During a telephone interview, on 2/8/24 at 11:03 a.m., Resident 5's niece indicated she felt like her aunt needed seen for dental care. She participated in all of the resident's care plan meeting via telephone. She could not recall ever having been asked specifically about if they wanted dental care at the care plan meetings. They had used the facility contracted dental company before, but they were not happy with them because they didn't or wouldn't do anything for the resident and it costs her a lot of money. When they signed the declination for the service, it was to decline that specific dental carrier. She had told the facility that they would like someone to see her but had not been asked about any other dental services. During an interview, on 2/8/24 at 11:09 a.m., the DON indicated they have had residents who did not like the contracted dental services, in the past. The facility would work with those residents, and or their representatives, to find other dental options and would provide transport for the residents to be seen by the dental service of their choice. On 2/8/24 at 10:38 a.m., the SSD provided a document, dated 5/21/21, titled, Ancillary Services, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy .to ensure that residents have access to and receive proper treatment regarding vision, hearing, dental, and foot care .3. The social service designee and supply clerk will collaborate with family and residents in signing up for additional in-house services. If outside services are warranted, the Life Enrichment Director will set up the appointment and transportation for the resident On 2/8/24 at 10:38 a.m., the SSD provided a document, with a revision date of 5/20/21, titled, Dental Services, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes .b. Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care .2. Residents and/or representatives . are notified of dental services available .3. The Social Services Director maintains contact information of providers of dental services that are available to facility residents at a nominal cost. 4. The facility will .assist the resident with making dental appointments and arranging transportation to and from dental services locations 3.1-24(a)

Based on record review and interview, the facility failed to provide annual education for abuse prevention, and ensure employees had also completed dementia and resident rights training for 3 of 5 randomly selected Healthcare facility employees who had been employed at the facility for greater than one year. This deficient practice had the potential to effect 18 of 18 residents who resided in the facility. Findings include: On 11/21/22 at 1:00 p.m. 10 randomly selected employee files were reviewed, 5 new hires and 5 employees who had worked at the faccility greater than one year. The Director of Nursing (DON), hired on 9/13/16, did not have documentation of abuse training in the past 12 months (one year). Qualified Medication Aid (QMA) 17, hired on 11/1/21, did not have documentation abuse, dementia, or resident rights training in her employee file for the past 12 months (one year). On 11/21/22 at 2:30 p.m., during an interview, the Business Office Manager (BOM) indicated QMA 17 did not have any records of having completed any annual training in her file or the electronic system. Licensed Practical Nurse (LPN) 18, hired on 1/7/21 did not have documentation of abuse training in the past 12 months (one year). On 11/21/22 at 2:50 p.m., during an interview, the DON indicated the facility did not have annual trainings completed for abuse. She started doing annual in-services but has only gotten a few employees done. She was not aware she had to be trained by someone else (not herself). On 11/22/21 at 1:47 p.m., the DON provided a current policy, dated 10/17/22, titled, Continuing Education. This policy indicated Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs 3.1-13(2)

Based on observation, interview, and record review, the facility failed to ensure pureed food items were prepared in a sanitary manner during 1 of 1 observation of pureed food preparation. Findings include: Cook 9 was observed preparing pureed food, on 11/21/22 at 10:37 a.m. After washing his hands thoroughly and donning gloves, the Cook was observed to touch and adjust his facemask and immediately pick up rolls and place them in the blender, with his gloved hands. At one time, the handle from the lid of the blender came loose and fell to the floor. The Cook picked up the handle from the floor, placed it on the counter next to the blender, touched and adjusted his facemask with his gloved hand, removed the lid from the blender, and reached in and adjusted the blender blade, with the same gloved hand, without changing his gloves and performing hand hygiene. Throughout the entire procedure, the Cook was observed to touch and adjusted his facemask a total of 5 times, without ever changing his gloves and performing hand hygiene. During an interview, on 11/21/22 at 10:43 a.m., Cook 9 indicated he was not aware that he had touched his facemask during the pureed preparation. It had become such an automatic reflex to keep his mask up over his nose, since facemasks had become required. He understood that he should have not continued to prepare food, after touching his facemask with his gloves, without first washing his hands and putting on new gloves. During an interview, on 11/21/22 at 11:54 a.m., the Dining Services Supervisor indicated the Cook should have performed hand hygiene and changed his gloves when he touched his mask and when he had picked something up from the floor. On 11/21/22 at 10:53 a.m., the Dining Services Director provided an document, dated 3/13/22, titled, Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Policy Explanation and Compliance Guidelines .6. Additional considerations: a. The use of gloves does not replace hand hygiene 3.1-21(3)

Based observation, interview, and record review, the facility failed to ensure staff wore personal protective equipment (PPE) of a face shield when administering medication and providing care to a COVID-19 positive resident in transmission-based precautions (TBP) droplet isolation (used to prevent the spread of pathogens that are passed through respiratory secretions) for 1 of 1 random observation during medication administration (Resident 16). Finding includes: During a random observation of medication administration, on 11/21/22 at 11:18 a.m., a sign was observed posted on Resident 16's door which indicated, transmission-based precautions (TBP) contact droplet isolation room and to don (put on) personal protective equipment (PPE) of an N-95 face mask, a face shield or goggles, a gown, and gloves required to enter the isolation room. Registered Nurse (RN) 8 was observed to don an isolation gown, N-95 face mask, and gloves, then entered Resident 16's TBP droplet isolation room for the medication administration. RN 8 administered to Resident 16 a medication capsule and applied a medicated ointment to the resident's neck. On 11/21/22 at 11:31 a.m., RN 8 indicated she had forgotten to don a face shield prior to entering the droplet isolation room but should have put eye protection on before entering the isolation room. The Director of Nursing (DON), on 11/21/22 at 11:51 a.m., indicated on 11/19/22 Resident 16 had complained of a sore throat, headache, and runny nose, and tested positive for COVID-19. Resident 16 was placed on TBP droplet isolation in his private room. Staff should have worn a gown, gloves, N95 face mask, and a face shield or goggles when they entered the TBP droplet precautions isolation room. On 11/21/22 at 1:30 p.m., the DON provided and identified a document as a current facility policy titled, Transmission-Based Precautions, dated 3/13/22. The policy indicated, .Policy: it is our policy to take appropriate precautions to prevent transmission of infectious agents, based on the agents' modes of transmission .3. Contact Precautions .d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. VRE, C. difficile, noroviruses and other intestinal tract pathogens, RSV) .4. Droplet precautions .d. Healthcare personnel wear a mask for close contact with infectious resident 3.1-18(b)(1) 3.1-18(b)(2)

A. Based on observation, interview, and record review, the facility failed to prevent pressure ulcers from worsening, complete follow-up assessments, track wound progression, follow interventions, and notify the physician with worsening of wounds up to and including, infections for 1 of 2 residents reviewed for pressure ulcers resulting in Resident 19's stage II (partial thickness loss of dermis) pressure ulcer progressing to a stage III (full thickness tissue loss where subcutaneous fat may be visible) pressure ulcer and developing [CONDITION(S)] (bone infection) requiring hospitalization and surgical debridement resulting in a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. B. Based on observation, interview, and record review, the facility failed to prevent pressure ulcers, complete follow-up assessments, follow interventions, and notify the physician resulting in the potential for harm that is not immediate jeopardy to 1 of 2 residents reviewed for pressure ulcers (Residents 3). The immediate jeopardy began on 4/19/21 when staff failed to complete assessments, wound treatments, and notify the physician of a pressure ulcer with symptoms of infection which resulted in the pressure ulcer being a stage II when assessed and worsening to a stage III with [CONDITION(S)] which required hospitalization and surgical debridement The Executive Director (ED), Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified of the immediate jeopardy at 4:10 p.m. on 6/9/21. The immediate jeopardy was removed on 6/11/21 at 4:59 p.m., but noncompliance remained at a lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A. During an observation, on 6/7/21 at 11:52 a.m., Resident 19 was observed lying on her back in bed on a low air loss mattress. A record review was completed for Resident 19 on 6/7/21 at 11:45 a.m. A facility census indicated the resident admitted to the facility on [DATE]. An admission assessment, dated 4/19/21, indicated the resident had two pressure ulcers to the coccyx. The assessment lacked documentation of measurements and staging. A hospital discharge summary, dated 4/19/21, indicated the resident had a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough) sacral coccyx wound. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin observation assessment, dated 4/20/21, indicated the resident had a stage II pressure ulcer to the left buttock that measured in centimeters (cm) 1.3 length (l) by (x) 1.5 width (w) x 0.1 depth (d) and a stage II pressure ulcer to the right buttock that measured in cm 1.0 l x 1.3 w x 0.1. The record lacked documentation of treatment order or treatment from 4/20/21 to 4/23/21. A review of an admission Minimum Data Set (MDS) assessment for Resident 19, dated 4/26/21, indicated the resident was cognitively intact and an extensive assist of two for bed mobility, transfer, dressing, toilet use, and personal hygiene. The assessment also indicated the resident had one stage II pressure ulcer on admission. A Treatment Administration Record (TAR), start dated 4/23/21 and discontinued on 4/27/21, indicated to cleanse wounds on coccyx with normal saline and pat dry. Apply allevyn dressing (absorbent foam dressing) and change every seven days and as needed for displacement or soilage. The TAR lacked documentation this had been completed from 4/23/21 through 4/27/21. A care plan, initiated 4/23/21 and target dated 5/6/21, indicated the resident had a pressure ulcer to the sacrum related to weakness, assistance with activities of daily living, type II diabetes mellitus, [CONDITION(S)], coronary artery disease, hypertension, and renal insufficiency. The goal indicated the resident's pressure ulcer would show signs of healing and remain free from infection. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness. Assess, record, and 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 physician. Encourage resident to offload wound by laying on her sides during healing process. Follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A skin observation assessment, dated 4/28/21, indicated the resident had a stage II pressure ulcer to the left buttock that measured in cm 1.6 l x 1.5 w x 0.1 depth and a stage II pressure ulcer to the right buttock that measured in cm 1.2 l x 1.3 w x 0.1 d. Dressing removed and wound assessed. There was a small amount of blood noted on the bandage when removed with no odor noted. The wound was cleansed with normal saline, patted dry, and border foam gauze was applied to the area. A TAR, start dated 4/27/21 and discontinued on 5/1/21, indicated to cleanse wound on coccyx with normal saline and pat dry. Apply border foam dressing and change every other day and as needed for displacement or soilage. The TAR lacked documentation this had been completed. A TAR, start dated 4/28/21 and discontinued on 5/1/21, indicated to cleanse wound on coccyx with normal saline and pat dry. Apply border foam dressing and change every other day and as needed for displacement and soilage every shift for wound care. The TAR lacked documentation this had been completed on 4/30/21. The record lacked documentation a skin observation assessment had been completed from 4/29/21 through 5/11/21. A TAR, dated May 2021, indicated to cleanse wounds to coccyx with normal saline and pat dry. Apply hydrogel to wound bed, cover with non-bordered foam dressing, and secure dressing with transparent film. Change dressing every other day and as needed one time a day every other day for wound. The TAR lacked documentation dressing was completed on 5/1/21, 5/3/21, 5/7/21 and 5/11/21. A skin observation assessment, dated 5/12/21, indicated the resident had a stage III (full thickness tissue loss where subcutaneous fat may be visible, slough or eschar may be present on some parts of wound bed, and often undermining and tunneling) pressure ulcer to the coccyx that measured in cm 5.5 l x 3.5 w x 1.5 depth. A wound progress note, dated 5/13/21, indicated the coccyx pressure ulcer had a moderate amount of serosanguinous fluid, no odor, and no undermining or tunneling was noted. The wound was 80% granulation with 20% slough. The resident continued to be non-compliant with position changes and was incontinent of bowel frequently with a foley catheter in place. The nurses had reinforced with resident the importance of frequent position changes to help aide in wound healing and resident verbalized understanding. A dressing change was completed at this time. A new order was received to cleanse wound with [MEDICATION(S)] skin and wound cleanser mix, apply collagen powder to wound bed and cover with foam and secure with transparent film. Resident was started on [MEDICATION(S)], vitamin c and pro mod to promote wound healing. A TAR, start dated 5/14/21 and discontinued on 5/18/21, indicated to cleanse wound with [MEDICATION(S)] skin and wound cleanser, mix and apply collagen powder to wound bed, cover with foam and secure with transparent film as needed for soilage or displacement. The TAR lacked documentation this had been completed from 5/14 through 5/16/21. A skin observation assessment, dated 5/12/21, indicated the resident had a stage III pressure ulcer to the coccyx that measured in cm 6.l x 4.5 w x 1.8 d. A wound progress note dated 5/18/21 at 2:13 p.m., indicated the wound had a moderate amount of serosanguinous fluid, with no odor, and no undermining or tunneling noted. The wound was 70% granulation with 10% slough. The resident continued to be non-compliant with position changes and was incontinent of bowel frequently with a foley catheter in place. The nurses had reinforced with resident the importance of frequent position changes to help aide in wound healing and resident verbalized understanding. A dressing change was completed at this time. The resident continued [MEDICATION(S)], vitamin c and pro mod to promote wound healing. A wound culture report, collected on 5/21/21 and results noted on 5/24/21, indicated a final report for a wound culture of coccyx pressure injury. The result indicated there was a moderate growth of gram positive cocci and included enterococcus faecalis (gram positive bacteria), isolate 3- [MEDICATION(S)] resistant enterococcus (VRE) has been determined by [MEDICATION(S)] resistance and reported to infection control and heavy growth of gram negative rods and included [CONDITION(S)] pneumoniae (a gram negative bacteria), Proteus mirabilis (a gram negative bacteria), and enterococcus faecalis (gram positive bacteria), isolate 3- [MEDICATION(S)] resistant enterococcus has been determined by [MEDICATION(S)] resistance and reported to infection control. A nurse's progress noted, dated 5/25/21 at 2:28 p.m., indicated the resident continued contact isolation for VRE in wound to coccyx. A nurse's progress note, dated 5/25/21 at 5:18 p.m., indicated the nurse had called the hospital to inquire if an x-ray had been ordered the prior week and was told one had not been completed. A new order for x-ray of lumbar and sacral spine was obtained and would be completed that night. The physician was notified, lab results reported, and informed the pharmacy was unable to get [MEDICATION(S)] (antibiotic) and that was the only medication her VRE was susceptible to. A new order was received to refer resident to infection disease physician. A nurse's note, dated 5/26/21 at 8:55 a.m., indicated the x-ray had not been completed the night before and resident had not started the antibiotic due to not being available. New order received to transport resident to the hospital for treatment. A hospital operative report, dated 5/27/21, indicated the resident's preoperative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was then packed with moistened [MEDICATION(S)] gauze and [MEDICATION(S)] dressing was than applied. The postoperative plan indicated the dressing would change once per shift twice daily, or when soiled. The resident needed offloading on her side or stomach to allow for the wound to heal. The best course of action would be the resident being ambulatory but that seemed doubtful. A facility census document indicated the resident readmitted to the facility on [DATE]. A hospital discharge instruction, dated 5/30/21, indicated the resident had a decubitus with [CONDITION(S)] and had received [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (antibiotic). The medical record lacked documentation the wound had been assessed on 5/30/21 when the resident readmitted from the hospital. A nurse's note, dated 5/30/21 at 6:35 p.m., indicated the resident was readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was on two intravenous antibiotics until 6/24/21. A MAR, dated May 2021, indicated a start date of 5/30/21, [MEDICATION(S)] solution reconstituted to 1 gram intravenously one time a day for [CONDITION(S)] until 8/24/21. The TAR indicated the [MEDICATION(S)] was not administered on 5/30/21 and to see progress notes. A nurse's note, dated 5/30/21 at 11:47 p.m., indicated awaiting delivery from pharmacy and writer was unable to give estimated time of delivery. A MAR, dated May 2021, indicated a start date of 5/30/21, [MEDICATION(S)] solution reconstituted use 500 mg intravenously one time a day for [CONDITION(S)] until 8/24/21. The TAR indicated the medication was not administered on 5/30/21 and to see progress notes. A nurse's note, dated 5/30/21 at 11:48 p.m., indicated awaiting delivery from pharmacy and writer was unable to give estimated time of delivery. A TAR, start dated 5/30/21 and discontinued on 6/1/21, indicated to cleanse coccyx wound with normal saline, pat dry with gauze, apply [MEDICATION(S)]-soaked gauze, and apply dry gauze. The TAR indicated the resident refused on 5/30/21 during night shift. And to see progress notes for day and night shift on 5/31/21. A progress note, dated 5/31/21 at 5:57 p.m., indicated supplies were not available. A progress note, dated 5/31/21 at 7:29 p.m., indicated medication not available and pharmacy was notified. A progress note, dated 5/31/21 at 10:23 p.m., indicated treatment supplies were not available. A wound progress note, dated 6/2/21 at 2:37 p.m., indicated the resident had a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle with possible slough or eschar on some parts of the wound bed, and often includes undermining and tunneling) pressure ulcer with a large amount of serosanguinous fluid with no odor. The pressure ulcer measured at 6.5 w x 6.5 l x 3.0 d with tunneling noted at 11 o'clock of 3.5 cm x 3 cm at 6 o'clock 80% slough 20% granulation was noted. The resident continued to be noncompliant with position changes. The resident was educated of importance of frequent position changes to help to aide in wound healing. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received [MEDICATION(S)] and [MEDICATION(S)] IV for VRE. A TAR, dated June 2021, indicated cleanse wound with normal saline and pat dry. Mix [MEDICATION(S)] with collagen powder to a paste form and apply to wound bed, apply silver alginate to wound and cover daily every shift for wound care. The TAR lacked documentation this had been completed on 6/3/21 and 6/5/21. A MAR, dated June 2021, indicated [MEDICATION(S)] solution reconstituted to 1 gram intravenously one time a day for [CONDITION(S)] until 8/24/21. The TAR indicated the medication was not administered on 6/2/21 and 6/3/21 due to the resident sleeping. A MAR, dated June 2021, indicated [MEDICATION(S)] solution reconstituted use 500 mg intravenously one time a day for [CONDITION(S)] until 8/24/21. The TAR indicated the medication was not administered on 6/2/21 and 6/3/21 due to the resident sleeping. During an interview, on 6/8/21 at 2:04 p.m., the Assistant Director of Nursing (ADON) indicated she was the wound nurse. The resident admitted to the facility with two stage II pressure ulcers. The pressure ulcer had merged to one stage III pressure ulcer and had developed an infection of three different bacteria. The physician ordered the resident to be sent to the hospital on 5/26/21 due to being unable to obtain a susceptible antibiotic from the facility pharmacy. The resident readmitted back to the facility on [DATE] and had been diagnosed with [CONDITION(S)]. The pressure ulcer had not been documented as assessed upon readmission and the first assessment documented was on 6/2/21 and at that time was documented to be a stage IV pressure ulcer. The resident's treatments should have been completed as ordered and the resident's diabetes should have been managed appropriately to aide in wound healing. She was unsure why the treatments had not been administered as ordered. On 6/8/21 at 9:05 a.m., the Director of Nursing (DON) provided a document, revised on 5/20/21, and titled, Wound Treatment Management, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound On 6/8/21 at 9:05 a.m., the Director of Nursing (DON) provided a document, revised on 5/20/21, and titled, Pressure Injury Prevention and Management, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: [NAME] Towers is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .Policy Explanation and Compliance Guidelines: .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessments of pressure injuries will be performed by a licensed nurse, and documented in Point Click Care . The staging of pressure injuries will be clearly identified to ensure correct coding of MDS .5. Monitoring: .b. The attending physician will be notified of: .ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a [MEDICATION(S)] tract, etc.) as needed The immediate jeopardy that began on 4/19/21 was removed on 6/11/21 when the facility assessed all residents for risk of pressure ulcer development, and if at risk, interventions were implemented. Residents with current pressure ulcers were reviewed for appropriate care and treatment, and care plans updated. Physician and families were notified of wounds as needed. Nursing staff were in-serviced on pressure ulcer care. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. B. On 6/6/21 at 10:51 a.m., Resident 3 was observed sitting in the recliner with her heels resting on the footrest. No pressure relief devices were in place. On 6/6/21 at 2:28 p.m., Resident 3 was observed sitting in the recliner with her heels resting on the footrest. No pressure relief devices were in place. On 6/8/21 at 1:18 p.m., Resident 3 was observed sitting in her wheelchair, wearing house slippers. There were no dressings observed on the resident's heels. On 6/9/21 at 9:37 a.m., Resident 3 was observed sitting up in the recliner with her feet in house slippers and resting on the floor. There were no dressings observed on the resident's heels. Resident 3's record was reviewed on 6/7/21 at 11:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Census information indicated the resident was admitted on [DATE]. A nursing admission assessment, dated 2/15/21, indicated the resident did not have any open areas on the skin. Census information indicated the resident was hospitalized from 2/17/21 to 2/23/21. A re-admission nursing assessment, dated 2/23/21, indicated the resident's heels were soft and the coccyx (tailbone) was red. The assessment lacked documentation the physician or family were notified of the skin impairments or a treatment was initiated. A nurse's note, dated 2/23/21, indicated the resident returned from the hospital, and her son was at the bedside. The resident's coccyx was red and non-blanchable (does not turn white when pressed; stage 1 pressure areas included redness which does not turn white when pressed). The note lacked documentation the physician was notified of the skin impairment or a treatment was ordered. A Treatment Administration Record (TAR), dated February 2021, lacked documentation the resident received any treatments to skin impairments, including preventative treatments. Census information indicated the resident was hospitalized from 2/27/21 to 3/1/21. A re-admission nursing assessment, dated 3/2/21, was opened, but not completed. The assessment lacked documentation of a skin assessment. An admission Minimum Data Set (MDS) assessment, dated 3/2/21, indicated the resident had a moderate cognitive impairment, required extensive assistance of two staff members for bed mobility and transfers, and was at risk for developing pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). A skin assessment, dated 3/8/21, indicated the resident's coccyx was denuded (loss of the top layer of skin, caused by prolonged moisture and friction). The assessment lacked documentation the physician or family were notified, or a treatment was initiated. A skin assessment, dated 3/16/21, indicated the resident had a stage two (a sore extending into deeper layers of the skin which could look like a blister or crater) pressure ulcer, measured 3 centimeters (cm) in length, 2.5 cm in width, and 0 cm in depth. The assessment lacked documentation a treatment was initiated. A nurse's note, dated 3/16/21, indicated the physician and family were notified of the pressure ulcer to the left buttock. The note lacked documentation a treatment was initiated to the area. A skin assessment, dated 3/29/21, indicated the resident had a stage two area to the left buttock, measured 3.5 cm in length, 2 cm in width, and less than 0.1 cm in depth. A nurse's note, dated 3/29/21, indicated the resident had a pressure ulcer to the left buttock and a treatment was started, wound cleansed with normal saline, apply skin prep (a treatment that forms a barrier to protect intact skin) to the area around the wound, and a thin [MEDICATION(S)] (a breathable dressing which provides a moist, insulated environment for healing) dressing. A TAR, dated March 2021, indicated an undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR lacked documentation the treatment was offered, refused, or completed during the month, any other treatments were ordered or completed, and any preventative treatments. A skin assessment, dated 4/7/21, indicated the resident had a pressure ulcer, suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to the left heel and a pressure ulcer, suspected deep tissue injury to the right heel. The note indicated bilateral (both) heels were discolored, intact, and mushy. The unit nurse was notified and would obtain orders for skin prep. The previous open area to the coccyx was healed. The assessment lacked documentation the physician or family were notified and measurements of the areas. A skin assessment, dated 4/12/21, indicated the resident had a suspected deep tissue injury to the left heel measured 3 cm in length, 3 cm in width, and 0 cm in depth, a stage two pressure ulcer to the left heel measured 4 cm in length, 4 cm in width, and 0.1 cm in depth, and a suspected deep tissue injury to the right heel measured 3 cm in length, 4 cm in width, and 0 cm in depth. The note indicated a new order was obtained to clean the stage two area with normal saline and pat dry, apply [MEDICATION(S)] (prevents infection and promotes wound healing) or an equivalent to wound, and apply Unna boot (a special gauze dressing used to treat venous ulcers) dressings on Tuesdays and Fridays. A skin assessment, dated 4/27/21, indicated the resident had a stage two pressure ulcer to the right inner ankle, measured 7 cm in length, 2.5 cm in width, and 0.1 cm in depth, a stage two pressure ulcer to the left heel, measured 3.5 cm in length, 3.2 cm in width, and 0.1 cm in depth, a suspected deep tissue injury to the left heel, measured 3 cm in length, 2.5 cm in width, and 0 cm in depth, and a suspected deep tissue injury to the right heel, measured 2 cm in length, 2 cm in width, and 0 cm in depth. The area to the right inner foot was a weeping blister with moderate drainage. The assessment lacked documentation the physician or family were notified of the areas, or treatments were initiated. A TAR, dated April 2021, indicated an undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated the treatment was completed on 4/14/21, 4/16/21, and 4/20/21, but lacked documentation the treatment was offered, refused, or completed any other days. The TAR indicated an undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment was completed on 4/3/21 and 4/6/21. The TAR lacked documentation the treatment was offered, refused, or completed any other days during the month. The TAR indicated an undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated the treatment was completed on 4/27/21, but lacked documentation the treatment had been offered, refused, or completed any other days. The TAR indicated a preventative treatment to bilateral heels was ordered from 4/7/21 to 4/13/21, skin prep twice a day. A skin assessment, dated 5/12/21, indicated a stage three (a worsening sore extending into the area beneath the skin forming a small crater, fat may show) pressure ulcer to the left heel, measured 2 cm in length, 2 cm in width, depth not measured, and a stage three pressure ulcer to the right heel, measured 3.5 cm in length, 3 cm in width, and 1.2 cm in depth. Notes indicated new orders for dressing changed and heel boots to continue while in bed. A TAR, dated May 2021, indicated a preventative treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR lacked documentation the skin prep was offered, refused, or completed on 5/14/21 and 5/16/21. The TAR indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR lacked documentation the treatment was offered, refused, or completed on 5/7/21 and 5/14/21. The TAR indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR lacked documentation the treatment was offered, refused, or completed on 5/14/21 and 5/16/21. The TAR indicated skin prep to bilateral heels and float heels when in recliner or bed every shift, was initiated on 5/18/21. A weekly wound assessment note, dated 6/4/21, indicated a stage two pressure ulcer to the left buttock, measured 2 cm in length, 2 cm in width, and 0.1 cm in depth, and a stage two pressure ulcer to the right buttock, measured 2 cm in length, 2.3 cm in width, and 0.1 cm in depth. The physician ordered hydrogel (a treatment to keep the wound moist) to the open areas. The resident's lab testing lacked documentation vascular studies (testing to check blood flow) were obtained prior to compression dressings (treatments used for venous ulcers and contradicted in arterial ulcers) being applied. A care plan, target dated 7/22/21, indicated the resident had potential for pressure ulcer development related to required assistance with bed mobility, and weakness. The resident was admitted with red areas to the buttocks, coccyx, and bilateral heels. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, target dated 7/22/21, indicated the resident had a stage two pressure ulcer to the left buttock and a suspected deep tissue injury to the bilateral heels. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, assess, monitor, and record wound healing weekly including measurements of length width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress and report improvements and declines to the physician, follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 6/7/21 at 2:18 p.m., the Director of Nursing (DON) indicated she was aware the weekly wound assessments had not been consistently completed. During an interview, on 6/8/21 at 11:07 a.m., the Assistant Director of Nursing (ADON) indicated she was the facility's wound nurse. If a resident was readmitted to the facility with mushy heels and non-blanchable areas, the wound nurse should have been notified and a preventative treatment and care plan initiated. A skin assessment should have been completed with each admission and re-admission to the facility. Treatment orders should have been obtained when each new skin impairment was noted. The March 2021 TAR was reviewed, and indicated she was unable to find any documentation a treatment was provided to the left buttock pressure ulcer. There should have been a treatment provided. All wounds should have been measured weekly, including suspected deep tissue injuries. She was initially not aware she needed to measure suspected deep tissue injuries, so the measurements were missed. The resident was not able to walk, so Unna boots most likely were not an effective treatment. Vascular studies were not obtained, and should have been, prior to Unna boots or any compression dressings being applied. The April 2021 TAR was reviewed, and treatments were not consistently documented. She thought the fluid filled blister to the right inner ankle healed around 5/13/21, but this was not documented. When wounds healed, this should have been documented. She was not aware the pressure ulcers were ever staged at stage three, however upon further review, indicated she was the nurse who documented the bilateral heels as having stage three pressure ulcers. There should have been physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not aware of what was put in place to prevent the pressure ulcers to the buttocks from developing again after they initially healed. She was not sure if the resident wore the pressure relief boots in her recliner. The resident very rarely got into the bed, and normally slept in her recliner. During an interview, on 6/8/21 at

Based on observation, record review, and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity and number of deficiencies cited and to ensure active quality assessment and performance improvement (QAPI) plans were implemented to prevent deficiencies from re-occurring. This had the potential to affect 30 residents residing in the facility. Findings include: On 6/6/21 at 3:00 p.m., the Director of Nursing (DON) provided and identified a document as the current facility policy, titled Facility QAPI (Quality Assessment and Assurance/Performance Improvement) Plan, dated 2014. The policy indicated, .Our vision is to create a safe and secure person centered care environment where people are valued for their contributions, past and present, nurturing individuality and independence .The purpose of QAPI in our facility is to focus on our vision and mission by including all residents, staff members, and family members in the performance improvement process to support a safe and secure care environment that nurtures meaningful relationships .Our care practices are guided by a structured Quality Assurance and Performance Improvement process .We focus on systems and processes and encourage our staff to identify potential errors and system breakdowns .We set goals to improve performance, measure our progress towards the goal, and revise the goal when necessary During this recertification survey, 6/6/21 to 6/11/21, one deficiency was cited at immediate jeopardy harm level- F686 J. The facility also received twenty-three additional deficiencies cited at potential for harm F550, F561, F577, F636, F641, F657, F660, F661, F685, F689, F692, F698, F725, F732, F756, F757, F758, F760, F761, F790, and F880. The facility was cited F686 at harm and F761 at potential for harm on the previous recertification survey and F880 at potential for harm was cited on the two previous recertification surveys. The facility's Quality Assurance Committee did not identify, develop, and implement appropriate measures to prevent deficiencies as follows: 1. Pressure ulcers: The facility failed to prevent pressure ulcers from worsening, complete follow-up assessments, track wound progression, follow interventions, and notify the physician with worsening of wounds up to and including, infections for 1 of 2 residents reviewed for pressure ulcers resulting in Resident 19's stage II (partial thickness loss of dermis) pressure ulcer progressing to a stage III (full thickness tissue loss where subcutaneous fat may be visible) pressure ulcer and developing [CONDITION(S)] (bone infection) requiring hospitalization and surgical debridement resulting in a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. The facility failed to prevent pressure ulcers, complete follow-up assessments, follow interventions, and notify the physician resulting in the potential for harm that was not immediate jeopardy to 1 of 2 residents reviewed for pressure ulcers (Residents 3). There was no evidence the facility had identified, developed, or implemented an action plan with measures to prevent the occurrence and worsening of pressure ulcers Cross reference F686. 2. Accidents: The facility failed to implement fall interventions and follow post fall procedures resulting in a resident sustaining a [CONDITION(S)] after a fall for 1 of 1 resident reviewed for falls (Resident 26). There was no evidence the facility had identified, developed, or implemented an action plan to ensure fall interventions and post fall procedures were followed. Cross reference F689. 3. Sufficient Nursing Staff: The facility failed to ensure sufficient staffing to accommodate safe transfer when using a lift (Resident 24) for 1 of 1 resident reviewed for lift safety, to ensure timely dining service to 2 residents observed during 1 of 1 dining observation (Residents 10 and 232), to accommodate a resident's preference related to showers for 1of 3 residents reviewed for choices (Resident 30), and to complete Minimum Data Set (MDS) assessments timely and accurately for 6 of 13 residents reviewed for MDS assessment accuracy (Residents 19, 3, 20, 7, and 24). There was no evidence the facility had identified, developed, or implemented an action plan to ensure sufficient nursing staff for a resident's accommodations of safe and timely lift transfers, timely dining service for residents, and residents received scheduled showers. Cross reference F725. 4. Drug regimen is free from unnecessary drugs: One resident's medication was not administered and was without physician notification, daily weights were not obtained for another resident, and pharmacy recommendations were not addressed for a resident who received an antipsychotic medication for 3 of 5 residents reviewed for unnecessary medications. There was no evidence the facility had identified, developed, or implemented an action plan to ensure medications were administered according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross reference F757 and F758. 5. Nutrition: The facility failed to ensure interventions were put in place when a resident lost weight, and the physician and resident representative were notified of the weight loss for 1 of 2 residents reviewed for nutrition (Resident 3). Cross reference F692. During an interview, on 6/11/21 at 2:37 p.m., the Administrator (ADM) indicated the QAPI team met monthly, and team members brought concerns to the meetings to be addressed, so that they could find resolutions to the problems. The DON was fairly new to the facility. She had been at the facility for less than a year. The former DON brought pressure ulcers to QAPI, but after the new DON started, the issue of pressure ulcers was dropped. The pharmacy reviews of the physician not addressing the recommendations was overlooked due to COVID-19. The staffing was horrible, and it was hard to hire staff. The facility had had to use agency staff since COVID-19 started. They had to pull Certified Nursing Aides (CNA) shower aides to perform resident care, therefore the showers became limited due to the short staffing. 3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to ensure interventions and treatments for pressure ulcers were implemented for 1 of 3 residents reviewed for pressure ulcers resulting in harm when a resident developed a stage 2 (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) pressure ulcer on the right lower extremity (RLE) that worsened to a stage 3 (Full thickness tissue loss. Fat may be visible but bone, tendon or muscle are not exposed), and developed a stage 2 pressure ulcer to the left heel which worsened when treatments were discontinued (Resident 28). The facility failed to ensure interventions and treatments for pressure ulcers were implemented for a resident with an unstageable pressure (Full thickness tissue loss in which the base of the ulcer is covered by slough (A layer or mass of dead tissue) and/or eschar (thick leathery black or brown devitalized tissue) in wound bed) ulcer to the left heel (Resident 24) for 1 of 3 residents reviewed for pressure ulcers not resulting in harm. Findings include: 1a. During an interview on 5/10/19 at 9:26 a.m., Resident 28 indicated his right leg was paralyzed from a construction accident in the 1970's. He started wearing a brace in 1999 but due to the pressure ulcer on his right thigh he had not worn it since the pressure area developed. The open area to his right thigh was caused by the brace. During an observation of a dressing change, on 5/15/19 at 10:30 a.m., with the Wound Nurse of Resident 28's RLE, the resident was laying supine (face upwards) in bed and assisted to his left side, the resident required extensive assist of 2 for bed mobility (turning). The wound was pink with no slough (a layer or mass of dead tissue). At the same time, the Wound Nurse indicated the area was a stage 3 (Full thickness tissue loss. Fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer. It was acquired in house and caused by pressure from a brace worn. The wound measured at 1 centimeter (cm) length (l) by (x) 0.5 cm width (w) x 0.1 cm depth (d). Resident 28's record was reviewed on 5/13/19 at 1:50 p.m. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no documentation that indicated the resident was admitted to the facility with a pressure ulcer. A significant change Minimum Data Set (MDS) assessment, dated 4/17/19, indicated the resident was cognitively intact, and an extensive assist of 2 people for bed mobility. The resident had 1 stage 2 pressure ulcer, and 1 stage 3 pressure ulcer during the 7-day look back period. An internal investigation for in-house wounds and skin conditions form, dated 2/9/19, indicated the resident had an abrasion to the RLE (back of upper thigh), and measured 3.2 cm (l) x 2.3 cm (w) x <0.1 cm (d). The suspected cause of the wound was due to the leg brace. .What intervention could be added for new area: remove brace A review of care plans and physician's orders [REDACTED]. A Treatment Administration Record (TAR), dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation it was completed on 2/21/19. A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation the treatment was completed on 2/22/19 as ordered and was not completed until 2/25/19. During an interview on 5/14/19 at 11:41 a.m., the Director of Nursing (DON) indicated the area on resident's right thigh was only an abrasion on 2/9/19 and she was unsure why it was documented as an open area. It was not a pressure ulcer until 2/26/19. No explanation or documentation for why there was a change in treatments and missed treatments between 2/9/19 and 2/26/19 was provided. An internal investigation for in-house wounds and skin conditions, dated 2/26/19, indicated the resident had 2 stage 2 pressure ulcers to the RLE (back of upper leg). Wound 1 measured 2.2 cm (l) x 5 cm (w) x 0.2 cm (d), wound 2 measured 2.5 cm (l) x 4 cm (w) x 0.2 cm (d). The suspected cause of the wound was pressure from leg brace. .What intervention could be added for new area: remove brace once in chair. A review of care plans and physician's orders [REDACTED]. A nurse's note, dated 2/26/19 at 1:56 a.m., indicated the resident had plus (+) 3 pitting (pressure to the area leaves an indentation of 5 to 6 millimeters that takes up to 30 seconds to rebound) [MEDICAL CONDITION] to the RLE, and +1 [MEDICAL CONDITION] (pressure leaves an indentation of 0-2 millimeters that rebounds immediately) to the left lower extremity (LLE). The back of the RLE had 2 wounds that started out as abrasions and had progressed into 2 stage 2 pressure areas. Resident wore a brace to the RLE, and the writer felt after the assessment the brace had caused the pressure areas, physician was faxed. A nurse's note, dated 2/26/19 at 9:48 a.m., indicated the resident had +3 [MEDICAL CONDITION] to the RLE, and +1 [MEDICAL CONDITION] to the LLE. The resident agreed to wear the leg brace to the RLE on the outside of his pants. A review of physician's orders [REDACTED]. A wound note, dated 2/28/19, indicated the resident wore a leg brace and was believed to have caused the 2 pressure areas. Resident was asked to only wear the brace while transferring. The note lacked documentation the resident had refused to only wear the brace while transferred or that the resident had been educated for risk factors of wearing the brace. A physician's orders [REDACTED]. A TAR, dated (MONTH) 2019, indicated to check skin integrity on RLE brace every 2 hours. The TAR was signed off this was completed at every 2 hour intervals. The documentation indicated the resident wore the leg brace until 3/21/19. A nurse's note, dated 3/2/19 at 6:57 a.m., indicated the resident had a wound culture obtained to the open area of right posterior thigh. The site had a moderate amount of dark tan/green drainage with a foul odor. A physician's orders [REDACTED]. A wound note, dated 3/7/19 at 8:31 a.m., indicated the 2 stage 2 pressure areas to the RLE was now one large wound, and measured at 4.5 cm (l) x 11 cm (w) x 0.2 cm (d). Wound bed was pink with no granulation tissue, and drained a moderate amount of serosanguineous (containing or relating to both blood and the liquid part of blood) fluid. A physician's orders [REDACTED]. A wound note, dated 3/13/19, indicated the stage 2 pressure ulcer to the RLE now measured at 10 cm (l) x 4.5 cm (w) x 0.2 cm (d). The wound bed was pink with no granulation tissue noted. The resident no longer wore the brace that caused the pressure. A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation the treatment was completed on 3/15/19, and 3/29/19. A wound note, dated 3/20/19, indicated the resident had a stage 2 pressure ulcer to the upper back thigh of the RLE. The area measured 4 cm (l) x 10 cm (w) x 0.2 cm (d). The wound bed was pink with no granulation tissue noted, and was draining a minimal amount of purulent exudate. A wound note, dated 3/27/19, indicated the resident had a stage 2 pressure to the RLE measured at 4.1 cm (l) x 6 cm (w) x 0.2 cm (d). A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. Cover with waterproof adhesive foam dressing daily and PRN. The TAR lacked documentation this had been completed on 4/12/19, 4/17/19, 4/22/19, 4/23/19, 4/25/19, 4/26/19, and 4/28/19. There was no documentation the resident had refused. A wound note, dated 4/9/19 at 10:23 p.m., indicated the resident's stage 2 pressure ulcer to the upper back thigh of RLE was now classified as a stage 3 pressure ulcer, and measured 4 cm (l) x 4 cm (w) x 0.2 cm (d). A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation this treatment was completed on 4/17/19, 4/19/19, and 4/20/19. The nurses initials were circled (not completed) on 4/14/19, 4/15/19, 4/16/19, 4/18/19, and 4/24/19, but lacked documentation if the resident had refused. A TAR, dated (MONTH) 2019, indicated to apply [MEDICATION NAME] topically to right posterior thigh and cover with derma water proof adhesive daily and as needed due to wound ulcer. The TAR lacked documentation the treatment had been completed on 5/7/19, and 5/10/19. A care plan, initiated 3/6/19 and revised on 4/18/19, indicated the resident had a stage 3 pressure ulcer to the right lower extremity related to the brace rubbing. Interventions included, but were not limited to, initiated on 3/6/19, administer treatments as ordered and observe for effectiveness, assistance of 2 to turn and reposition at least every 2 hours and more often as needed or requested, pressure reducing mattress, and not put the leg brace on until the pressure ulcer heals, initiated 4/18/19. During an interview, on 5/14/19 at 10:46 a.m., the MDS Coordinator indicated the resident had refused against not wearing his brace but was unsure where the nurse's documentation to support that was. The pressure area to the RLE was determined to have been caused by the brace. During an interview, on 5/15/19 at 9:10 a.m., the Executive Director (ED) indicated the resident had refused against not wearing his brace and continued to wear his leg brace to his RLE. The nurses should document when a treatment had been completed, and if a resident refused a treatment. She was unsure why there was no documentation from the nurses for the refusal by the resident for the intervention of only wearing the leg brace during transfers. At one time, they had tried to have the resident wear the brace on the outside of his pants, but he would refuse to that at times. On two occasions she notified the physician of the resident's refusals. At this time, provided an internal document, dated 2/8/19, and indicated the physician's response was it was the right of the resident to continue to wear the brace if he wanted. Continue to monitor area on the back of the leg. She indicated she was unable to find an order for [REDACTED]. During an interview, on 5/15/19 at 11:36 a.m., the Director of Nursing indicated she could not find an order where the resident had stopped wearing the brace to his RLE until 3/21/19, but prior was educated to not wear it as much or only during transfers. The resident education was not documented. If a resident refused treatments or interventions it should be documented on the TAR or in the nurses notes and the physician should be notified. During an interview, on 5/15/19 at 3:13 p.m., the Medical Director indicated he had been notified of the resident's refusal but failed to document the notification. He felt the resident thought if he did not have the brace, he would lose everything. While he was wearing the brace and spending time in his chair, he had [MEDICAL CONDITION] which made his skin issues worse. 1b. During an observation of Resident 28, on 5/15/19 at 9:14 a.m., the resident was observed up in his wheelchair in his room. The resident had brown leather ankle boots to his bilateral (left and right) feet, and no compression stocking (for [MEDICAL CONDITION]) was observed to the resident's right lower extremity (RLE). At the same time, the resident indicated he wore his leather boots every day and was unsure if he had an open area to his left heel. He had worn boot protectors while in bed for a while, but was unsure of time frame. The staff stopped putting them on him. He had not refused to wear them. He did wear compression stockings to his bilateral feet, but the staff did not put them on him today. He was unable to turn and reposition himself in bed without the assistance of staff. The resident indicated he was not offered a different type of shoes and that if he was offered different shoes he would wear them. During an observation of a dressing change, on 5/15/19 at 10:30 a.m., with the Wound Nurse, Resident 28's left heel was scabbed over. At the same time, the Wound Nurse indicated the area was a stage 2 (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) pressure ulcer. It was acquired in house and determined to be caused by pressure from the bed. The wound measured at 0.5 cm (l) x 2.5 cm (w) x 0.1 cm (d). The resident's current treatment order for the left heel was to leave open to air because the resident was tired after the treatment to his RLE was completed so the physician discontinued the treatment order for the heel. She indicated since the area had worsened and opened back up and scabbed over since last week, she needed to call the physician for new orders. She had not tried to re-approach the resident at a later time to complete the second wound treatment prior to it being discontinued. Resident 28's record was reviewed on 5/13/19 at 1:50 p.m. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no documentation that indicated the resident was admitted to the facility with a pressure ulcer. A significant change Minimum Data Set (MDS) assessment, dated 4/17/19, indicated the resident was cognitively intact, and an extensive assist of 2 for bed mobility. The resident had 1 stage 2 pressure ulcer, and 1 stage 3 pressure ulcer during the 7-day look back period. An internal investigation for in-house wounds and skin conditions, dated 3/19/19, indicated the resident had a stage 2 pressure ulcer to the left heel. The wound measured 3.5 cm (l) x 5.3 cm (w). The suspected cause of the wound was pressure. The preventative measures that were put in place before the wound was found were vitamin C (supplement) and turn and reposition. .What intervention could be added for new area: float heels when in bed A wound note, dated 3/20/19, indicated the resident had a stage 2 pressure ulcer to the left heel and was noted to have a fluid filled blister. The area measured 3.5 cm (l) x 4.5 cm (w). Heel protectors while in bed and elevate heels with 2 pillows while in bed. There was no documentation the resident refused these interventions. A wound note, dated 3/27/19, indicated the resident had a stage 2 pressure to the left heel measured at 5 cm (l) x 3.5 cm (w) x 0.2 cm (d). Heel protectors while in bed and elevate heels with 2 pillows while in bed. There was no documentation the resident had refused these interventions. A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation this was completed on day or night shift for 3/20/19, night shift for 3/21/19, 3/25/19, and 3/26/19. There was no documentation the resident had refused. A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation this was completed on day and night shift for 3/20/19, 3/21/19, day shift for 3/28/19, and night shift for 3/25/19, 3/26/19, and 3/29/19. There was no documentation the resident had refused. A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation this had been completed on day and night shift for 3/20/19, and 3/21/19, day shift for 3/28/19, and night shift for 3/24/19, 3/25/19, 3/26/19, 3/28/19, and 3/29/19. There was no documentation the resident had refused. A TAR, dated (MONTH) 2019, indicated to float heels with 2 pillow while in bed (nurse to check). The TAR lacked documentation this was completed on N[NAME] for 4/9/19, 4/12/19, 4/23/19, 4/25/19, 4/26/19, and 4/30/19. There was no documentation the resident had refused. A TAR, dated (MONTH) 2019, indicated heel protectors while in bed (nurse to check). The TAR lacked documentation this had been completed on N[NAME] for 4/8/19, 4/9/19, 4/12/19, 4/23/19, 4/24/19, 4/25/19, 4/26/19, 4/29/19, and 4/30/19. There was no documentation the resident had refused. A TAR, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. The TAR lacked documentation the treatment was completed on 4/8/19, and 4/17/19. A wound note, dated 4/9/19 at 10:23 p.m., indicated the resident's stage 2 pressure ulcer to the left heel measured 2.5 cm (l) x 3 cm (w) x less than 0.1 cm (d). Heel protectors while in bed and elevate heels with 2 pillows while in bed. There was no documentation the resident refused these interventions. A wound note, dated 4/24/19 at 11:21 p.m., indicated the stage 2 pressure area to the left heel measured 2.5 cm (l) x 3.5 cm (w) x <0.1 cm (d). Heel protectors while in bed (resident is non-adherent to this intervention but will continue to encourage) and float heels with 2 pillows while in bed (will only use one and this was with great reserve). There was no documentation the physician was notified of the resident's refusal or the interventions had been re-evaluated at this time for the effectiveness. A wound note, dated 5/1/19 at 8:05 a.m., indicated the stage 2 pressure area to the left heel measured 3.5 cm (l) x 3 cm (w) x <0.1 cm (d). Treatment was to leave wound open to air and discontinue heel protectors due to the resident's refusal to wear. Continue to float heels with 2 pillows while in bed will only use one and this was with great reserve. A TAR, dated (MONTH) 2019, indicated to float heels with 2 pillows while in bed. The TAR lacked documentation this had been completed on 5/12/19, and 5/13/19. There was no documentation the resident had refused. A care plan, initiated 3/6/19 and revised on 4/18/19, indicated the resident had a stage 2 pressure ulcer to the left heel. Interventions included, but were not limited to, initiated on 3/6/19, administer treatments as ordered and observe for effectiveness, assistance of 2 to turn and reposition at least every 2 hours and more often as needed or requested, pressure reducing mattress, initiated 4/18/19, and float heels on pillow in bed. During an interview, on 5/15/19 at 9:33 a.m. Certified Nurse Aide (CNA) 9 indicated she had gotten the resident up that morning and the resident required extensive assist of 2 with bed mobility. She had not applied a compression stocking to the resident's RLE. She put the resident's leather boots on him and was unsure if the resident had a wound to his left heel because the resident had socks on already. During an interview, on 5/15/19 at 11:36 a.m., the Director of Nursing indicated if a resident refused treatments or interventions it should be documented on the TAR or in the nurses' notes and the physician should be notified. 2. On 5/10/19 at 9:05 a.m., Resident 24 was observed lying in bed with his heels not floated (elevated off of the mattress). On 5/13/19 at 9:49 a.m., Resident 24 was observed lying in bed with his heels not floated. On 5/15/19 at 9:29 a.m., Resident 24 was observed lying in bed with his heels not floated. On 5/10/19 at 10:13 a.m., Licensed Practical Nurse (LPN) 8, indicated Resident 24 had a Stage 3 pressure ulcer (full-thickness skin loss ulcer, in which adipose (fat) was visible in the ulcer and granulation tissue and epibole (rolled wound edges)) on his left heel, that was originally discovered on 3/21/19 as an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough (dead tissue, usually cream or yellow in color) or eschar (dry, black, hard necrotic tissue)) pressure ulcer with treatment of [REDACTED]. The Director of Nursing (DON), on 5/15/19 at 11:16 a.m., indicated Resident 24 Skin-Prep should have been applied to both of his heels every shift, two times a day, and the nurse should have signed the treatment record when the treatment was completed. The resident should have had his heels floated, while in bed with a wedge. LPN 8, on 5/15/19 at 11:52 a.m., indicated when the resident was in bed, Resident 24's heels should have been floated to offload his heels. On 5/15/19 at 3:51 p.m., LPN 8 was observed to perform a pressure ulcer treatment of [REDACTED].<) 0.1 cm. Resident 24's record was reviewed, on 5/14/19 at 9:55 a.m. [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (a disease that caused restricted blood flow to the arms, legs, or other body parts), and a deep tissue injury pressure ulcer to the left heel. A significant change Minimum Data Set (MDS) assessment, dated 4/10/19, indicated the resident was moderately impaired, an extensive assist of one person for bed mobility and an extensive assist of two persons for transfers. The resident had a pressure ulcer. A care plan, initiated on 4/11/19 and revised on 4/25/19, indicated Resident 24 had a stage 3 pressure injury to the left heel related to decreased mobility with a goal of the pressure ulcer will show signs of healing and remain free from infection with interventions to include, but not limited to, wedge in bed for elevation of feet and heels. An internal investigation for in-house wounds and skin conditions document, dated 3/21/19, indicated Resident 24 had acquired an unstageable pressure ulcer to his left heel, related to immobility, nutritional status, and pressure. Interventions included, but were not limited to, monitor effectiveness of/response to treatment(s) as ordered-(see physician's orders [REDACTED]. The unstageable ulcer injury measured 0.8 cm (centimeters) l (length) x 0.8 cm w (width) x <0.1 d (depth). A physician's orders [REDACTED]. A physician's orders [REDACTED]. while in bed with a wedge (nurse to verify). A MAR, dated (MONTH) 2019, lacked documentation the Skin Prep treatment to the left heel had been completed on 3/25/19 and 3/29/19. A MAR, dated (MONTH) 2019, lacked documentation the Skin Prep treatment to the left heel had been completed on 4/3/19, 4/6/19, 4/7/19, 4/10/19, 4/15/19, 4/16/19, 4/17/19, 4/18/19, 4/19/19, 4/20/19, 4/21/19, 4/23/19, 4/25/19, 4/26/19, 4/27/19, 4/28/19, 4/29/19, and 4/30/19. A MAR, dated (MONTH) 2019, lacked documentation the Skin Prep treatment to the left heel had been completed on 5/2/19, 5/3/19, 5/5/19, 5/6/19, 5/7/19, 5/9/19, 5/10/19, 5/12/19, 5/13/19, and 5/14/19. A MAR, dated (MONTH) 2019, lacked documentation Resident 24 was turned every 2 hours while in bed with a nurse verification, during 6 p.m. to 6 a.m. shift, on 3/25/19. A MAR, dated (MONTH) 2019, lacked documentation the resident was turned every 2 hours while in bed with a nurse verification, during the 6 p.m. to 6 a.m. shift, on 4/3/19, 4/6/19, 4/10/19, 4/15/19, 4/16/19, 4/18/19, 4/19/19, 4/25/19, 4/26/19, 4/28/19, 4/29/19, and 4/30/19. A MAR, dated (MONTH) 2019, lacked documentation the resident was turned every 2 hours while in bed with a nurse verification, during the 6 p.m. to 6 a.m. shift, on 5/3/19, 5/4/19, 5/10/19, and 5/12/19. A MAR, dated (MONTH) 2019, lacked documentation Resident 24's heels were floated with a wedge while in bed with a nurse verification on 3/25/19. A MAR, dated (MONTH) 2019, lacked documentation the resident's heels were floated with a wedge while in bed with a nurse verification on 4/25/19, 4/26/19, 4/28/19, 4/29/19 and 4/30/19. A MAR, dated (MONTH) 2019, lacked documentation the resident's heels were floated with a wedge while in bed with a nurse verification on 5/3/19, 5/10/19, and 5/12/19. On 5/15/19 at 10:53 a.m., the DON provided and identified as a current facility policy, titled Pressure Injury Prevention Guidelines, dated 11/1/18. The policy indicated, .Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present .Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them .In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders .Compliance with interventions will be documented in the medical record. a. For at-risk residents: treatment or medication administration records. b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting .The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics 3.1-40(a)(1)

A. Based on observation, interview, and record review, the facility failed to ensure portable oxygen tanks were stored at a safe distance from the heat of hair dryers, salon equipment was inspected routinely for good operating condition, and staff were trained what to do in case of a fire, including how to use the fire extinguisher for 3 of 3 residents who received salon services while 2 portable oxygen tanks were stored next to the hair dryer's heat source and motor (Residents #23, #9, and #35). B. In addition to the residents in the Immediate Jeopardy, the facility failed to ensure a cognitively impaired resident was supervised at all times during medical appointments resulting in harm or potential harm that is not Immediate Jeopardy for 1 of 1 resident reviewed for supervision during medical appointments (Resident #47). The Immediate Jeopardy was identified on 04/21/2016 and began on 04/21/2016 when 2 of 3 residents in the facility's hair salon were observed seated in wheelchairs with portable oxygen stored on the back of the wheelchair and within 6 inches of the heat source and motor of the hooded hair dryers. The Administrator was notified of the Immediate Jeopardy on 04/21/2016 at 4:15 p.m. Findings include: A1. During an observation on 04/21/2016 at 11:05 a.m., Resident #23 was seated in a wheelchair under a hooded hair dryer, while it was in operation, in the facility's hair salon. The resident had oxygen delivered via nasal cannula with a portable oxygen tank stored on the back of her wheelchair. A rolling, hooded, electric hairdryer was placed directly behind the wheelchair with the heat source and motor 6 inches from the oxygen tank. Eight cans of hair spray were stored on the stylist's rolling cart and had labels indicating contents were flammable. The rolling cart was 3 feet from the resident. Fourteen additional hair products with labels indicating items were flammable were stored in a stationary cabinet in the salon. A2. During an observation on 04/21/2016 at 11:05 a.m., Resident #9 was seated in a wheelchair under a hooded hair dryer, while it was in operation, in the facility's hair salon. The resident had oxygen delivered via nasal cannula with a portable oxygen tank stored on the back of her wheelchair. A rolling, hooded, hairdryer was placed directly behind the wheelchair with the heat source and motor 6 inches from the oxygen tank. A3. During an observation on 04/21/2016 at 11:05 a.m., Resident #35 was observed seated in the salon chair while the beautician was spraying her hair with aerosol hairspray identified as flammable. The resident was less than 5 feet from 2 other residents who were seated under hood hair dryers with portable oxygen tanks stored in close proximity of the heat source and motor. At 11:10 a.m. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) turned off the hair dryers and moved Residents #23 and #9, utilizing oxygen, into the hallway outside the salon. During an interview at that time, Beautician #1 indicated she was not aware of any precautions with oxygen tanks near the hair dryers. During an interview on 04/21/2016 at 11:33 a.m., the DON and ADON indicated the resident's portable, liquid oxygen tanks were approximately 6 to 8 inches from the hair dryer when stored on the back of the wheelchairs and the rolling dryers were placed directly behind the chairs. During an interview on 04/21/2016 at 11:53 a.m., the Administrator indicated he had not thought about residents wearing oxygen into the beauty shop and had not mentioned it to the beautician. During an interview on 04/21/2016 at 2:08 p.m., Beautician #1 indicated she had not been provided training regarding safe use of oxygen in the salon. She was not aware that if it was a safe option, the oxygen should be removed while the resident was under the dryer. She was not aware of an appropriate distance to store the oxygen tank when the resident was under the hair dryer. The beautician indicated all of the salon equipment belonged to the facility. She had not received training regarding heat temperatures for the hair dryers but tried to ensure temperatures were at a level that was comfortable for the resident. The beautician indicated residents from the facility's assisted living program had been left unattended in the salon with oxygen in place while under the hair dryer for a few minutes while she went to check the activity calendar or menu. No residents from the health center residents had been left unattended. The beautician had not been trained what to do if there was a fire but knew how to use a fire extinguisher. The facility had not trained her to use their extinguisher. During an interview with the Administrator and the Maintenance Director on 04/21/2016 at 2:30 p.m., the Maintenance Director indicated there was no system for routine inspection of salon equipment to ensure good operating condition and safe heat temperatures of hair dryers. The Administrator indicated he did not have a policy for the salon and had not provided training to salon staff in regard to safe use of oxygen. An undated NFPA (National Fire Prevention Association) document referenced in the LTC (Long Term Care) Newsletter # 09-36) indicated, .Oxygen should be stored at least 8 feet (2.4 meters) away from .heaters, heat-producing devices .hair dryers, and most other electrical appliances. Oxygen should be stored in well-ventilated areas. Storage in closets and behind drapes is not considered to be in a well ventilated area and should be avoided . A facility policy related to oxygen use in the hair salon was requested on 04/22/16 at 11:39 a.m. The DON indicated there was not a policy at 12:15 p.m. B. During an interview on 4/20/16 at 9:52 a.m., LPN #2 indicated a CNA (certified nurses assistant) will accompany a resident to a physician appointment when the resident requires physical assistant or are cognitively impaired. During an interview on 4/21/16 at 9:39 a.m., the DON indicated the driver stays with the resident at the doctor's appointment but will wait in the lobby while the resident is in the exam room. During an interview on 4/21/16 at 12:17 p.m., the Activity Director indicated the transportation driver is not trained to take residents to the restroom while out to doctor's appointments. She further indicated the driver does not go into the exam room with the residents. Resident #47's record was reviewed on 4/20/16 at 11:21 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 3/23/16, indicated Resident #47 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. A MDS assessment, dated 4/13/16, indicated Resident #47 required two persons physical assist with toileting and transfers. Resident #47 uses a wheelchair as a mobility device. A plan of care, initiated on 7/3/14, indicated Resident #47 has a communication problem related to hearing deficit. A plan of care, initiated on 8/11/14, indicated Resident #47 has bladder incontinence related to dementia. A Plan of Care, initiated on 6/4/15, indicated Resident #47 has an ADL (activities of daily living) self-care performance deficit related to impaired balance. A Plan of Care, initiated on 2/2/16, indicated Resident #47 has had an increase in confusion due to the dementia progress. A plan of care, initiated on 2/19/16, indicated Resident #47 is a high risk for falls related to general weakness. A progress note dated 4/18/16, indicated Resident #47 was seen by an Endocrinologist outside of the facility on the above date. The physician wrote the following statement, Patient is nonverbal to prior notes has DEMENTIA. Not accompanied by any family member??? Is here only with driver. A typed progress note dated 4/18/16, indicated Resident #47 was seen by an Endocrinologist for Thyroid dysfunction. The progress noted indicated Resident # 47 was with no family member and is non verbal. An undated policy titled, A Transportation/Scheduler Policy and identified as current by the Activity Director on 4/21/16 at 12:17 p.m. The policy indicated, . If an additional CNA is needed get with nursing scheduling or supervisor to arrange The Immediate Jeopardy that began on 04/21/16 was removed on 04/22/16 when the facility provided training to the beautician and facility staff regarding safe use of oxygen in the salon and the Maintenance Director inspected salon equipment to ensure good operating condition and safe heat temperatures of the hair dryers. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued training and monitoring for safe use of oxygen in the salon and how to respond if there was a fire. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer interventions of bilateral off loading boots were implemented for a resident identified as at risk for development of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers, which resulted in the development of an unstageable pressure ulcer to the left heel that continued to decline and a reddened area to right heel. (Resident #47). Finding includes: On 4/19/16 at 10:04 a.m., Resident #47 was observed resting in her bed. The resident was not wearing off loading boots on either foot. The resident's heels were lying on top of the mattress. On 4/19/16 at 10:48 a.m., Resident #47 was observed sleeping in her bed. The resident was not wearing off loading boots on either foot. The off loading boot for her left foot was observed to be lying in the window sill. On 4/19/16 at 2:07 p.m., Resident #47 was observed to have an unstageable pressure ulcer to left heel. ADON described the wound as 75% eschar, 15% mushy necrotic (dead tissue) soft tissue, and 10% granulation tissue with peri wound irregular. On 4/20/16 at 2:14 p.m., Resident #47 was observed awake in her bed with the hard off loading boot was in the window sill and not on the resident's left foot. Soft off loading boot was not observed to be on the resident's right foot. On 4/21/16 at 10:02 a.m., Resident #47 was observed sleeping in her bed. Hard off loading boot was lying in her wheelchair and not on her left foot. Soft off loading boot was not observed to be on the resident's right foot. On 4/21/16 at 11:03 a.m., Resident #47 was observed sleeping in her bed. Hard off loading boot was lying in her wheelchair and not on her left foot. Soft off loading boot was not observed to be on the resident's right foot. On 4/22/15 at 2:56 p.m., Resident #47 was observed resting in her bed. Hard off loading boot was lying in her wheelchair and not on her left foot. Soft off loading boot was not observed on the resident's right foot. During an interview on 4/19/16 at 9:38 a.m., ADON (assistant director of nursing) indicated Resident #47 had an unstageable pressure ulcer to the left heel and should be wearing a hard off loading boot to the left heel at all times. She further indicated the resident should be wearing a soft off loading boot to the right heel, while in bed, as a preventive measure. She further indicated a new wound treatment order was obtained on 4/18/16. During an interview on 4/19/16 at 2:07 p.m., CNA (certified nurses aid) #4 indicated Resident #47 should be wearing a soft boot to the right heel while she is in bed at all times. During an interview on 4/19/16 at 3:28 p.m., ADON indicated the CNA assignment sheet will contain the information needed for staff on interventions put into place for a resident with pressure ulcers. Review of CNA assignment sheet on 4/19/16 at 3:50 p.m., lacked documented interventions for placement of off loading bilateral boots. A copy of an updated and revised CNA assignment sheet was provided by the DON on 4/20/16 at 9:00 a.m., and included the following interventions: off loading boot to left foot at all times and soft off loading boot to right foot while in bed. Resident #47's record was reviewed on 4/20/16 at 11:21 a.m. Resident #47 had [DIAGNOSES REDACTED]. Review of pressure ulcer risk assessment dated [DATE] indicated, Resident # 47 had a score of 20, which indicated resident is at high risk for developing pressure ulcers. A Minimum Data Set (MDS) assessment, dated 3/23/16, indicated Resident #47 required assistance of two persons for mobility and identified the resident was at risk for developing pressure ulcers. A plan of care dated 12/3/14 and revised on 3/21/16, indicated the resident has a potential for pressure ulcer development related to being in bed most of the day. The following intervention included but was not limited to, . off loading boots bilateral while in bed . Review of weekly skin sheets indicated the following measurements: A. Dated 3/21/16 Stage 2 to left heel measuring 6.3 cm(centimeter) x 5 cm, suspected deep tissue injury with intact fluid filled blister. B. Dated 3/24/16 Stage 2 to left heel measuring 5.5 cm x 10 cm, intact blood filled blister. C. Dated 2/28/16 Stage 2 to left heel measuring 9.5 cm x 10 cm, non intact small opening. D. Dated 3/30/16 Stage 2 to left heel measuring 9.5 cm x 11 cm, non intact purple open area. E. Dated 4/3/16 Stage 2 to left heel measuring 3 cm x 4.8 cm, non intact skin flap peri wound. F. Dated 4/12/16 Stage 2 to left heel measuring 8.5 cm x 9.5 cm, less than 0.2 cm depth, full thickness 100% beefy wound bed. G. Dated 4/18/16 Unstageable to left heel measuring 5.9 cm x 5 cm, 25% gray moist necrotic and 75% dry black eschar. Physician orders [REDACTED]. According to weekly skin sheets the wound increased in size and worsened on 4/12/16. An undated facility policy titled, Pressure Ulcer and Wound Management Program, identified as current by DON on 4/21/16 at 1:35 p.m., included but was not limited to . 8. Physicians will be kept informed of progress or lack of progress of wound treatment measure and healing 3.1-40(a)(1) 3.1-40(a)(2)