Every finding on record at Bell Trace Health and Living Center

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 2 of 2 kitchen observations. Food was stored under a water line which had condensed water. Findings include: On 9/10/24 at 10:50 a.m., food was observed in the kitchen walk-in freezer on shelving beneath a condenser line upon which large portions of ice had formed. The ice portions were on and in a large box of packaged brussel sprouts and a large box of packaged mixed vegetables. On 9/13/24 at 1:50 p.m., food was observed in the kitchen walk-in freezer on shelving beneath a condenser line upon which large portions of ice had formed. The ice portions were on and in a large box of packaged brussel sprouts and a large box of packaged mixed vegetables. During an interview on 9/13/24 at 1:58 p.m., the Dietary Manager indicated the food was stored beneath the iced over condenser line and the condenser line was in need of repair. On 9/13/24 at 2:10 p.m., a review of the Indiana State Department of Health Retail Food Establishment Sanitation Requirements, effective 11/13/04 indicated, .410 IAC 7-24-177 Food storage Sec. 177 . food shall be protected from contamination by storing the food as follows: .(5) In packages, covered containers, or wrappings ., and .410 IAC 7-24-178 Food storage; prohibited areas Sec. 178. (a) Food may not be stored as follows: .(2) Under the following: .under lines on which water has condensed . 3.1-21(i)(2) 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure an accurate MDS (Minimum Data Set) assessment for 1 of 5 residents reviewed for unnecessary medications. The Admission MDS assessment lacked documentation of an anxiety diagnosis. (Resident 65) Finding includes: On 9/12/24 at 2:00 p.m., Resident 65's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, anxiety disorder, hypertension, and pain. A review of the Admission MDS assessment, dated 7/9/24, anxiety disorder was not marked as an active diagnosis. A Review of Medication Administration Record (MAR), indicated Resident 65 had an active order on 7/8/24 for Ativan (medication used to treat anxiety) 0.5 milligram (mg) half a tablet (0.25 mg) oral (by mouth) three times a day for diagnosis of anxiety disorder. A review of Resident Assessment Instrument (RAI),Version 3.0 User's Manual, 10/2023, for section I5700 of MDS, on 9/12/24 at 2:45 p.m., indicated; a 7-day look-back period. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. An interview with the Director of Nursing (DON) on 9/13/24 at 11:15 a.m., indicated section I5700 on the Admission MDS Assessment, dated 7/9/24, was not marked to indicate a diagnosis of anxiety. The DON indicated Resident 65 had a diagnosis of anxiety on admission. She indicated the facility does not have an MDS Policy, but follow the RAI manual for MDS completion. An interview with the MDS Coordinator on 9/13/24 at 11:15 a.m., indicated the resident had a diagnosis of anxiety on admission and section I5700 should have been marked to reflect the diagnosis. The MDS Coordinator indicated the facility used the RAI manual to complete MDS assessments. An interview with RN 1 on 9/13/24 at 1:45 p.m., indicated the resident had multiple episodes of anxiousness and restlessness. RN 1 indicated the resident had an order for anxiety medication that did help with these episodes. She indicated the resident has had anxiety and restlessness since admission. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly for 2 of 3 medication rooms observed. Medications were not labeled with an open date and expired medications were not disposed of. (Skilled 3 Rehabilitation Medication Room, Skilled 1 Medication Room). Findings include: On 9/13/24 at 11:56 a.m., the refrigerator in the Skilled 3 Rehabilitation 1 Medication Room was observed to have a vial of tuberculin PPD (medication used to test for tuberculosis) and a vial of Humalog (insulin) without an open date. The Director of Nursing (DON) could not find an open date on the vials. On 9/13/24 at 12:04 p.m., the refrigerator in Skilled 1 Medication Room was observed to have a vial of tuberculin PPD opened and dated 4/16/24. The Unit Manager was unsure when to discard the vial after the vial was opened. On 9/13/24 at 1:46 p.m., the DON provided the facility's policy, Expiration dates for Certain Drug, Biologicals, and Records, undated and indicated it was the policy being used by the facility. A review of the policy indicated .Insulin .28 days refrigerated/unrefrigerated after 1st use .Tubersol/Aplisol tuberculin PPD vial .30 days after first use . 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 3 residents reviewed for urinary catheters. Urinary catheter tubing was observed on the floor. (Resident 14) Findings include: On the following dates, times, and locations, Resident 14 was observed in his wheelchair with his urinary catheter tubing beneath the wheelchair and lying on the floor: - On 9/11/24 at 10:55 p.m., in the resident's room. - On 9/12/24 at 1:30 p.m., on the front outside patio. - On 9/12/24 at 2:46 p.m., at the resident common room/puzzle station. On 9/11/24 at 11:15 am, Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and acute kidney failure. A physician's order with a start date of 6/20/24 indicated the resident had a Foley catheter secondary to diagnosis of obstructive and reflux uropathy. A care plan intervention with a start date of 1/14/24 indicated, .Do not allow tubing or any part of the drainage system to touch the floor . During an interview on 9/12/24 at 2:48 p.m., the Director Of Nursing indicated the resident's catheter tubing was in contact with the floor and in need of adjustment to stay off of the floor. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure a nurse administered medications to the correct resident, which resulted in the resident having received another resident's medication and change in health status that required inpatient intensive care hospitalization for 1 of 5 residents reviewed for medication administration (Resident B). The deficient practice was corrected on February 16, 2021, prior to the start of the survey, and was therefore Past Noncompliance. Findings include: On 2/22/21 at 2:15 p.m., Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident B's admission Minimum Data Set assessment, dated 2/10/21, indicated the resident was severely cognitively impaired, required extensive assistance of 1 staff member to complete activities of daily living (ADLs), and required staff supervision when eating. Resident B's vital signs indicated the following: -On 2/14/21 at 10:09 p.m., the resident's blood pressure was 106/67 (normal blood pressure range is less than 120/80). -On 2/15/21 at 12:06 a.m., the resident's blood pressure was 77/48 and heart rate was 44 beats per minute (normal resting heart rate range is 60-100 beats per minute). Resident B's progress notes indicated the following: -On 2/15/21 at 12:04 a.m., LPN 1 wrote, Resident assessed by (Nurse Practitioner 1's Name), recommended that resident be sent to ER (emergency room ) for eval (evaluation) and treat (treatment) . -On 2/15/21 at 12:37 a.m., Nurse Practitioner 1 wrote, (Resident B) is seen urgently at staff request tonight for [MEDICAL CONDITION] (low heart rate) and [MEDICAL CONDITION] (low blood pressure) after having taken the wrong medications. She was given [MEDICATION NAME] (sic) 100 mg (high blood pressure and chest pain mediation), Trazadone 200 mg (antidepressant and sedative medication), Atorvastin (sic) 20 mg (high cholesterol medication), [MEDICATION NAME] (sic) 1 mg (sedative medication), [MEDICATION NAME] (sic) 300 mg (anticonvulsant and nerve pain medication), [MEDICATION NAME] (sic) 10 mg (a hormone that is involved in regulating the sleep cycle). She is found resting in her bed, awakens easily. Heart tones are slow and distant. She is very drowsy . Last B/P (blood pressure) was 77/49 HR (heart rate) 43. Order to send to ER, 911 . -On 2/15/21 at 3:54 a.m., LPN 1 wrote, admitted to (Hospital Name) for vasopressor (a group of medicines which contract blood vessels and raise blood pressure) therapy. Resident B's hospital notes indicated the following: -2/15/21 at 12:48 a.m., . At the nursing home, pt (patient) was given [MEDICATION NAME] (sic) 1 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] (sic) 200 mg, [MEDICATION NAME] 5 mg (a bladder relaxant medication), guaianesin (sic) 200 mg (a cough medicine and cold medication), atorvastatin 20 mg, and [MEDICATION NAME] 10 mg . Her HR dropped into the 40's and SBP (systolic blood pressure) was in the 70's, which prompted the call to EMS (emergency medical services) . -2/15/21 at 12:50 a.m., Spoke . to poison control . Poison control instructed to give IV (intravenous) fluids and [MEDICATION NAME] (a hormone that raises the level of sugar in the blood) to start, and gave other advise (sic) as to the progression of the pt from here . -2/15/21 at 1:23 a.m., . BP 77/50. Pt given nasal cannula (oxygen given via a tube placed into the nostrils) at this time. -2/15/21 at 1:39 a.m., . BP 65/49 and HR 47 at this time. -2/15/21 at 2:35 a.m., . BP 88/56 and HR 46 at this time . suggested the option of putting in central line (a tube which is placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) or using vasopressors to elevate the pt's blood pressure. -2/15/21 at 3:56 a.m., .Upon arrival here her blood pressure was 85/63. She was profoundly bradycardic with heart rates in the 40's . the patient was started on a [MEDICATION NAME] drip as well as [MEDICATION NAME] (a hormone used to increase blood pressure). She was subsequently admitted to the ICU (intensive care unit) for further management . 1. Poisoning by beta-adrenoreceptor antagonists, accidental . Patient was given several incorrect medications included several sedating medications but the [MEDICATION NAME] seems to be the main issue at the moment . patient is currently on a [MEDICATION NAME] gtt (drip) will switch to norepi ([MEDICATION NAME]) and [MEDICATION NAME] (a hormone used to increase heart rate, blood pressure, and respiratory rate) given [MEDICAL CONDITION]. Admit to ICU. 2. [MEDICAL CONDITION] due to drugs During an interview, on 2/23/21 at 7:50 a.m., Licensed Practical Nurse 1 indicated, I work a different hall every night, so there are times when I will only see a resident 1 or 2 times before they discharge home. She was passing medications down the hall around 9:00 p.m., and the next name on the computer screen to give meds to was a resident who had the same first name as Resident B. They both had ostomys (an artificial opening in an organ of the body, created during an operation such as a [MEDICAL CONDITIONS], or gastrostomy) and Resident B had high blood pressure at the time. She went into her room, said her name, and the resident took all of the medication. Nothing clicked her head that it was the wrong resident until she went back to her med cart, and saw the picture on the screen did not match Resident B. By midnight, her vitals started to drop, and she was lethargic (tired). That's when she found the nurse practitioner in the building, who did an assessment, and wrote an order to send the resident to the ER. Lastly, she indicated if she would have looked at the picture before she gave the medications, it may have prevented the medication error from occurring. On 2/23/21 at 9:00 a.m., the Director of Nursing provided the facility policy, MEDICATION ADMINISTRATION: GENERAL POLICIES & PROCEDURES, undated, and indicated it was the policy currently being used by the facility. The policy indicated, . 1. Resident are to be identified before the administration of a drug. When in doubt . the nurse is to verify identity by: . b) Referring to the resident's photograph . The Past Noncompliance of isolated harm began on February 15, 2021. The isolated harm tag was removed and deficient practice corrected by February 16, 2021; after the facility implemented a systemic plan that included the following actions: All licensed nurses received education in regard to medication administration with focus on patient identification, double-checking medications, checking room numbers, and double-checking pictures. Return demonstration/skills validation with every nurse for medication administration. Systemic monitoring of skills validations, daily, for 4 weeks. This Federal tag relates to Complaint IN 745. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to monitor the expiration date of sanitation strips used to measure the level of sanitation in three compartment sink and the sanitization bucket. This had the potential to affect 76 of 76 residents who resided in the facility and were served meals from the kitchen. Findings include: On [DATE] at 10:26 a.m., the three compartment sink was observed to have had sanitizating solution in the the sink. The Certified Dietary Manager (CDM) indicated they wash pots and pans in the three compartment sink. The CDM was observed to use a sanitation test strip, with an expiration date of (MONTH) 2019, to measure the level of concentration of sanitizing solution in the three compartment sink. The CDM was then observed to use a sanitization test strip, with an expiration date of (MONTH) 2019, to test the sanitation bucket. The CDM went to her office, and the sanitization test strips in her office expired in (YEAR). During the test strip observation, on [DATE] at 10:26 a.m., meal preparation for lunch was in progress. Interview, on [DATE] at 10:30, the CDM indicated she did not know the sanitization test strips had an expiration date. On [DATE] at 4:00 p.m., the CDM provided the facility's policy, Environmental Sanitation/Infection Control, dated 2012, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .3. Sanitizing solution is tested for proper concentration according to manufacturer instructions; .6. Sanitizing solution concentration (ppm) is checked periodically throughout the day and recorded . 3XXX,[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure staff provided a adequate supervision of 2 staff and an assistance device during transfers to prevent accidents for 1 of 2 residents reviewed for accidents (Resident 17). Findings include: On 12/17/19 at 11:05 [NAME]M., Resident 17 was observed being transferred from her wheelchair to a reclining chair by Certified Nurse's Aid (CNA) 5. CNA 5 stood in front of the resident, placed her arms beneath and through the resident's armpits, lifted the resident to a standing position, pivoted, and lowered the resident into the reclining chair beside the wheelchair. On 12/17/19 at 2:05 P.M., Resident 17 was observed being transferred from a reclining chair to her wheelchair by CNA 5. CNA 5 stood in front of the resident, placed her arms beneath and through the resident's armpits, lifted the resident to a standing position, pivoted, and lowered the resident into the wheelchair beside the reclining chair. On 12/17/19 at 2:30 P.M., Resident 17's clinical record was reviewed. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident required extensive physical assistance of two persons during transfers between surfaces, including to or from bed, chair, wheelchair, and standing position. During an interview, on 12/17/19 at 2:08 P.M., Licensed Practical Nurse 1 indicated the transfer method observed was regularly utilized when transferring the resident, as the resident was not very heavy in weight. During an interview, on 12/17/19 at 2:15 P.M., CNA 5 indicated the resident was so light in weight she was able to transfer her in the manner observed, yet on occasions when the resident was less steady a gait belt would be utilized during transfers. During an interview, on 12/18/19 at 12:30 P.M., the Director of Nursing indicated when transferring a resident, a gait belt was to be utilized. On 12/17/19 at 11:50 [NAME]M., the Director of Nursing provided the Procedure: Transfer to Wheelchair, undated, and indicated this was the procedure currently used by the facility. A review of the procedure indicated, .stand in front of resident and apply gait belt around the resident's abdomen .grasp the gait belt securely on both sides of the resident . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to revise a care plan for a resident with a pressure sore who refused to be turned and repositioned for 1 of 24 residents reviewed for revision of care plans. (Resident 44) Finding include: During an interview, on 12/13/2019 at 10:14 a.m., Resident 44 indicated he had refused to be turned and repositioned at times. On 12/17/2019 at 10:45 a.m., Certified Nursing Assistant (CNA) 1 was observed to give Resident 44 a bath. Resident indicated he was comfortable and refused to be turned and repositioned at that time. On 12/17/2019 at 2:34 p.m., CNA 2 was observed to ask Resident 44 if he needed anything. Resident refused to be turned and repositioned at that time. CNA 2 indicated, during an interview at that time, the resident often refused to be turned and repositioned. On 12/17/2019 at 2:56 p.m., CNA 3 and CNA 4 were observed to ask Resident 44 if he would like to turn. Resident indicated he was comfortable and did not want to be turned and repositioned at that time. Resident 44's clinical record was reviewed on 12/18/2019 at 11:44 a.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/13/2019, indicated Resident 44 was cognitively intact, exhibited zero behaviors for rejection of care, needed extensive assistance of 2 for bed mobility, and had a one Stage 4 pressure ulcer. An Interdisciplinary Detail Team (IDT) note dated, 7/10/2019 at 3:45 p.m., for Resident 44 indicated, . Intervention: refused to turn and reposition. Yes to care plan updated . Nursing progress note dated, 12/12/2019 at 1:53 p.m., for Resident 44 indicated, . Patient still refuses to get OOB (out of bed) and be turned regularly . A care plan, initiated on 2/8/2019, for Resident 44 indicated, . Problem: Resident has a pressure ulcer to sacrum . Goal: Pressure ulcer will heal without complications . Approach: assist resident with turning and repositioning . Resident 44's care plan had not been updated with care interventions in regard to the refusal of resident being turned and repositioned. Interview on, 12/19/2019 at 10:25 a.m., Qualified Medication Aide (QMA) 5 indicated Resident 44 often refused to be turned and repositioned. Interview on, 12/19/2019 at 10:15 a.m., CNA 3 indicated Resident 44 often refused to be turned and repositioned if he was comfortable at the time. On 12/19/2019 at 3:30 p.m., the Director of Nursing indicated the facility did not have a policy related to the updating of care plans. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to implement interventions for a resident with assessed significant weight loss for 1 of 3 residents reviewed for nutrition (Resident 7). Findings include: On 12/17/19 at 10:45 a.m., Resident 7's clinical record was reviewed. [DIAGNOSES REDACTED]. Review of Resident 7's weights included the following: -On 9/23/19, the resident weighed 205.4 pounds. -On 10/1/19, the resident weighed 204.8 pounds. -On 11/1/19, the resident weighed 189.8 pounds. This was an assessed 5% weight loss in 30 days. -On 11/21/19, the resident weighed 188 pounds. -On 11/24/19, the resident weighed 187.1 pounds. -On 12/1/19, the resident weighed 183.8 pounds. -On 12/16/19, the resident weighed 183.2 pounds. This was an assessed 12.8% weight loss in 3 months. Resident 7's Registered Dietitian progress notes indicated the following: -11/20/19, Nutrition: Res (resident) w/ (with) some wt (weight) fluctuation. 9/4 (September 4th)-10/1 (October 1st) 205-211# (pounds) . ordered daily wts x5 days to establish baseline. Will monitor daily wts and make recommendations as needed. -11/27/19, Nutrition: CBW 187.2# (pounds), which show a stable wt (weight) x24 days now . No recs (recommendations) - weight now shown to be stable. Will cont (continue) to monitor. -12/4/19, Nutrition: CBW (current body weight) 183.8# (pounds), which is now stable x30 days. BMI (body mass index) is 25.6, which is overweight, but almost WNL (within normal limits). Res (resident) still shows a sig (significant) loss of 27# (12.8%) in 88 days . Not current nutritional supplements given . No recs (recommendations) at this time r/t (related to) weight loss-weight is stable . If res weight drops below mid 180#s (pounds) range, will consider supplemental nutrition . The clinical record lacked documentation for consideration of a nutritional supplement with assessed weight on 12/1/19 and 12/16/19, below the mid 180 pound range with accompanying 12.8% weight loss. Resident 7's physician's orders [REDACTED]. A care plan, initiated on 12/4/19, and current through 3/4/20, for Resident 7 indicated: PROBLEM: . Resident has experience significant weight loss . APPROACH: . Supplement as ordered . Interview, on 12/18/19 at 3:00 p.m., the Registered Dietician indicated Resident 7 was never recommended any nutritional supplements due to his weight being stable in December, 2019. She indicated the resident was not on a prescribed weight loss program. Interview, on 12/18/19 at 3:23 p.m., the Director of Nursing indicated since Resident 7's weights were being monitored and they were stable, the facility did implement any interventions related to the resident's weight loss. On 12/18/19 at 3:48 p.m., the Director of Nursing provided the facility policy, (Facility Name) Weight Management Policy, dated March, (YEAR), and indicated it was the policy currently being used by the facility. A review of the policy indicated, Weight loss remains unchanged: Resident who have lost weight and stabilize . implement additional interventions . 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure medication was administered to the right resident which resulted in a two day acute care hospitalization to monitor a change in pulse and blood pressure for 1 of 3 residents reviewed for correct medication administration. (Resident B) Findings include: On 4/3/2019 at 12:30 p.m., Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident B's Minimum Data Set (MDS) assessment, dated 2/21/2019, indicated Resident B was cognitively intact. Nurses notes, dated 3/17/2019, indicated Resident B was accidentally given the wrong medication by LPN (Licensed Practical Nurse) 1. Resident B's blood pressure and pulse had been monitored every 30 minutes for the first 2 hours after medication administration. Vital signs being taken indicated Resident B's blood pressure and pulse went down. Resident B had remained alert and oriented, however the NP (Nurse Practioner) was called and gave an order to send Resident B to the emergency room for evaluation and treatment. Resident B was admitted to the hospital for observation related to [MEDICAL CONDITION] (low blood pressure) and [MEDICAL CONDITION] (slow heart rate). Medications that had been administered were [MEDICATION NAME] 25 mg (anti-hypertensive medication) and [MEDICATION NAME] 5 mg (anti-hypertensive medication). Nursing Spectrum 2010 Handbook indicated, [MEDICATION NAME] was an anti-hypertensive medication with potential cardiovascular adverse reaction of [MEDICAL CONDITION] and [MEDICAL CONDITION]. [MEDICATION NAME] was an anti-hypertensive medication with potential cardiovascular adverse reaction of [MEDICAL CONDITION]. Nurses notes, dated 3/20/2019 at 4:11 p.m. (2 days later), indicated Resident B returned to the facility. Hospital notes, dated 3/17/2019, indicated Resident B had been placed on intravenous fluids for the [MEDICAL CONDITION] and [MEDICATION NAME] for [MEDICAL CONDITION]. On 4/3/2019 at 10:30 a.m., interview with LPN 1 (the nurse who have given Resident B the wrong medication) indicated he had pulled up medications and proceeded to go into Resident B's room. Once in the room asked the resident in bed if he was (name), to which Resident B answered yes. Resident B looked at the medications, took them, and then indicated to LPN 1 his name was not the name LPN 1 had indicated. It was at that time LPN 1 validated administration of medication to the wrong resident and reported the incident to their supervisor. LPN 1's teachable moment, dated 3/18/19, indicated LPN 1 had a medication administration error dated 3/17/2019. On 4/3/2019 at 11:02 a.m., the DON (Director of Nursing) provided Administering Medications, revised date of 07/2007, and indicated the policy and was the one being currently used by the facility. A review of the policy indicated, .the individual must verify the resident's identity before giving the resident his/her medications . This Federal tag relates to Complaint IN 165. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure 2 employees wore beard coverings while in the kitchen area. This had the potential to affect 72 of 72 residents served from the facility kitchen. Findings include: During a tour of the facility kitchen, on 3/5/19 between 11:00 A.M. and 11:10 A.M., Dining Services Aide 1 and Maintenance Staff 1, both of whom had beards, were observed to be in the food preparation area of the kitchen, where food preparation equipment and surfaces were exposed, while not wearing beard coverings. During an interview, on 3/6/19 at 10:30 A.M., the Dining Services Supervisor indicated all staff who are in the kitchen area were to wear hair and beard coverings. On 3/11/19 at 3:10 P.M., the Director of Nursing provided the policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated (MONTH) 2008, and indicated this was the policy used by the facility. A review of the policy indicated, hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident was awakened per his preference for 1 of 1 resident reviewed for choices. (Resident 41) Findings include: During an interview, on 3/6/19 at 9:48 a.m., Resident 41 indicated he was awakened daily at 7:30 a.m. He indicated he would like to be awakened daily at 9:00 a.m. On 3/8/19 at 8:59 a.m., Resident 41 was observed to not be in his room or in his bed. On 3/8/19 at 9:00 a.m., Resident 41 was observed to be in the dining room eating breakfast. On 3/11/19 at 8:52 a.m., Resident 41 was observed to not be in his room or in his bed. On 3/11/19 at 8:55 a.m., Resident 41 was observed to be in the dining room eating breakfast. During an interview, on 3/11/19 at 10:27 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident 41 was awakened daily between 7:00 to 7:30 a.m., for breakfast. Some mornings Resident 41 did not want to be awakened at 7:00 to 7:30 a.m. On 3/11/19 at 11:00 a.m., Resident 41's clinical record was reviewed. The [DIAGNOSES REDACTED]. The Resident Preference Worksheet, dated 2/9/18, indicated Resident 41 preferred to get up at 9:00 to 11:00 a.m. A care plan, initiated on 2/9/19 and current through target date 5/9/19, for Resident 41 indicated: Problem: Resident has specific personal preferences for ADLs (activities of daily living) .GOAL .Resident's preferences will be honored APPROACH .Honor/Awake resident at preferred awakening/sleeping time; awake time between 0900-1100 (9:00 to 11:00 a.m.) . The CNA assignment sheet, available to staff on 3/11/19 and undated, indicated Resident 41 preference for awakening was at 9:00 to 10:00 a.m. On 3/11/19 at 3:00 p.m., the Administrator (ADM) provided the facility's policy, Resident Rights, dated 11/2016, and indicated it was the policy currently being used by the facility. A review of the policy indicated, (1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care . 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to ensure 2 storage rooms in the resident and visitor common hallways were locked. Findings include: 1.) On 3/5/19 between 11:15 A.M. and 11:25 A.M., the door of the supply room on the 100 unit hallway, next to the therapy department was observed to be unlocked and unattended. Inside the room were wheelchairs, walkers, electrical wires, cable wires, and telephone wires. During this time, 1 unassisted ambulatory resident, 2 unassisted residents in wheelchairs, and 5 visitors passed by the unlocked and unattended door. 2.) On 3/5/19 between 11:25 A.M. and 11:40 A.M., the door of the supply room on the 200 unit hallway, across from the activity room was observed to have a key in the door lock, and the door was unlocked and unattended. Inside the room were medical supplies, which included wound dressings, catheters, tracheotomy care kits, iodine swabs, staple remover kits, and bottles of hydrogen peroxide. During this time, 1 unassisted ambulatory resident, 1 unassisted residents in wheelchairs, and 3 visitors passed by the unlocked and unattended door. During an interview, on 3/5/19 at 11:42 A.M., Certified Nursing Aid (CNA) 2 indicated the supply room was to be locked when not in use, and the key was to be placed on a hook above the door. During an interview, on 3/8/19 at 2:15 P.M., the Maintenance Supervisor indicated both the supply room on the 100 unit hallway and the supply room on the 200 unit hallway were to be locked when not in use, and new electronic key pads were being installed on them. On 3/11/19 at 3:00 P.M., the facility Administrator provided the Resident Rights, effective date (MONTH) 28, (YEAR), and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, the facility must provide a safe .homelike environment . 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to assist a resident with oral hygiene for 1 of 2 residents reviewed for dignity. (Resident 66) Findings include: On 3/6/19 at 11:20 a.m., a sign was observed posted up on the wall behind Resident 66's bed. The sign indicated, Please help (Resident's Name) brush her teeth EVERY DAY! On 3/8/19 at 10:30 a.m., Resident 66's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 66's quarterly Minimum Data Set (MDS) assessment, dated 2/20/19, indicated the resident was cognitively intact and an extensive assist of 2 staff members with personal hygiene. During an interview, on 3/8/19 at 11:21 a.m., Resident 66 indicated she is unable to brush her own teeth because she needs someone to bring her out all of the teeth cleaning supplies. There is only one CNA (Certified Nursing Assistant) at the facility who helps her brush her teeth, She is very good. (CNA 3) brings me out all of my supplies and even a basin for me to spit into. The staff put up the sign to remind other staff members to brush her teeth. On 3/11/19 at 11:40 a.m., Resident 66's teeth cleaning supplies were observed in a large plastic resealable bag in her bathroom. The tooth brush and supplies were observed to be dry in the bag. During an interview, on 3/11/19 at 2:52 p.m., CNA 4 indicated Resident 66 is able to brush her teeth, however, staff usually has to help her finish. We usually just push her right up to the sink and she brushes her teeth in the bathroom. She indicated there have been times when Resident 66's teeth have been missed for cleaning. During an interview, on 3/11/19 at 4:00 p.m., Resident 66 indicated it's been about a week since she has had her teeth cleaned. On 3/11/19 at 3:00 p.m., the Administrator provided the facility policy, Resident Rights, effective 11/28/16, and indicated it was the policy currently being used. A review of the policy indicated, . (e) Respect and dignity. The resident has a right to be treated with respect and dignity, including: . (3) The right to reside and receive services in the facility with reasonable accommodation of resident needs . 3.1-38(a)(3)(C)

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to 1 of 3 residents reviewed for SNF Beneficiary Protection Notification. (Resident 36) Findings include: On 3/11/19 at 9:46 a.m., Resident 36's clinical record was reviewed. [DIAGNOSES REDACTED]. The SNF Beneficiary Protection Notification form indicated, (Resident 36's Name) Medicare Part A Skilled Services Episode Start Date: 12/10/18. Last covered day of Part A service: 1/12/19 . The facility/provided initiated the discharge from Medicare Part A Services when benefit days were not exhausted . Was an SNF ABN, Form provided to the resident? . Other Explain: Resident was covered by Medicare services upon admission . During an interview, on 3/11/19 at 2:52 p.m., the Social Services Staff 1 indicated Resident 36 remained in the facility and was not given a SNF ABN form following the end of her Medicare Part A services, on 1/12/19. On 3/11/19 at 4:00 p.m., the Director of Nursing was requested a policy in regard to SNF ABN notification. No policy was provided in regard to issuing residents a SNF ABN form when a resident remained in the facility by 3/11/19 at 4:45 p.m. (survey exit). 3.1-4(f)(2)

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of a resident's personal and medical information during 1 of 1 random observation of a medication cart. (Resident 49). Findings include: On 5/15/18, from 2:00 P.M. to 2:15 P.M., the unattended computer on the medication cart between rooms [ROOM NUMBERS] was observed to display, on the computer screen, the medical record of Resident 49. Information displayed on the screen included, but was not limited to, the resident's name, date of birth, date of admission, room number, photograph and medical information. Residents, staff, and visitors were observed to walk by the computer. During an interview, on 5/15/18 at 2:15 P.M., Registered Nurse 1 indicated the computer was not to be left on and unattended when displaying resident personal and medical information in order to protect resident's confidentiality. On 5/18/18, at 11:30 A.M., the Clinical Nurse Specialist provided the Resident Rights, published date (MONTH) 4, (YEAR), and indicated these were the resident rights currently used by the facility. A review of the Resident Rights indicated, the resident has the right to secure and confidential personal and medical records . 3.1-3(o)

Based on observation, interview, and record review, the facility failed to ensure 2 of 5 medication carts and 1 of 5 treatment carts were locked while unattended. Findings include: 1.) On 5/14/18, from 2:25 P.M. to 2:45 P.M., a medication cart in the hallway between rooms [ROOM NUMBERS] was observed to be unlocked and unattended. Staff, residents, and visitors were observed to have walked by the cart. The cart contained resident medications. During an interview, on 5/14/18, at 2:45 P.M., Registered Nurse 1 indicated the medication cart was to be locked when unattended. 2.) On 5/15/18, from 2:00 P.M. to 2:15 P.M., a medication cart in the hallway between rooms [ROOM NUMBERS] was observed to be unlocked and unattended. Staff, residents, and visitors were observed to have walked by the cart. The cart contained resident medications. During an interview, on 5/14/18, at 2:15 P.M., Registered Nurse 1 indicated the medication cart was to be locked when unattended. 3.) On 5/15/18, at 10:10 A.M., a treatment cart in the hallway between rooms [ROOM NUMBERS] was observed to be unlocked and unattended. Staff, residents, and visitors were observed to have walked by the cart. The cart contained resident topical medications, alcohol wipes, staple removers, and other medical treatment materials. During an interview, on 5/15/18, at 10:15 A.M., Licensed Practical Nurse 1 indicated the treatment cart was to be locked when unattended. On 5/18/18, at 11:20 A.M., the Clinical Nurse Specialist provided the facility policy, Storage of Medications, revised date April, 2007, and indicated it was the policy currently used by the facility. A review of the policy indicated, compartments containing drugs and biologicals shall be locked when not in use . 3.1-25(m)

Based on interview and record review, the facility failed to ensure the accuracy of the resident's prognosis on the significant change Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice. (Resident 31) Findings include: On 5/17/18 at 3:04 p.m., Resident 31's clinical record was reviewed. The [DIAGNOSES REDACTED]. A review of Resident 31's physician's orders [REDACTED]. A review of Resident 31's hospice certification and plan of care, dated 1/13/18, indicated resident was terminally ill with life expectancy of six months or less. A review of Resident 31's significant change MDS assessment, dated 1/18/18, indicated, Health Conditions . Prognosis . Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . No . On 05/18/18 at 3:09 p.m., the MDS Coordinator indicated the significant change MDS assessment prognosis section was coded no and should have been coded yes. 3.1-31(d)

Based on interview and record review, the facility failed to ensure staff documented a residents meal intake for 1 of 4 residents reviewed for nutrition (Resident 30). Findings include: On 5/16/18 at 10:35 a.m., Resident 30's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 30's weights indicated the following: -On 2/21/18 the resident weighed 169 pounds. -On 2/26/18 the resident weighed 163 pounds. -On 3/12/18 the resident weighed 154 pounds. -On 4/11/18 the resident weighed 145 pounds. Resident 30's care plan, Resident at nutrition risk r/t (related to) nutritional deficiencies, varied intakes, dysphagia, dementia, start date of 2/23/18 and target date of 5/23/18, included an approach, Record meal and fluid consumption . Review of Resident 30's meal intake logs indicated the following: Dinner was not documented on 5/16/18, 5/15/18, 5/13/18, 5/3/18, 5/2/18, 5/1/18, 4/28/18, 4/26/18, 4/24/18, 4/21/18, 4/19/18, 4/17/18, 4/11/18, 4/3/18, 3/31/18, 3/29/18, 3/27/18, 3/21/18, 3/20/18, 3/15/18, 3/13/18, 3/10/18, 3/8/18, 3/7/18, 3/6/18, 3/2/18, 2/25/18, and 2/23/18. Lunch was not documented on 5/15/18, 5/13/18, 5/5/18, 5/3/18, 4/24/18, 4/21/18, 4/17/18, 4/14/18, 4/11/18, 4/3/18, 3/31/18, 3/29/18, 3/28/18, 3/20/18, 3/10/18, and 2/25/18. Breakfast was not documented on 5/15/18, 5/3/18, 4/17/18, 4/14/18, 4/11/18, 4/3/18, 3/29/18, 3/28/18, 3/20/18, 3/15/18, and 2/25/18. During an interview, on 5/18/18 at 10:35 a.m., the clinical nurse specialist did not deny staff had not documented all meal intakes. On 5/18/18 at 2:44 p.m., the clinical nurse specialist provided the facility policy, Medical Records, revised August, 2006, and indicated it was the policy currently being used. A review of the policy indicated, Appropriate medical/clinical records shall be maintained for each resident . 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure staff administered the prescribed amount of insulin for 1 of 1 resident reviewed for closed record (Resident 53). Findings included: On 5/17/18 at 10:20 a.m., Resident 53's closed clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 53's physician's orders [REDACTED]. A review of Resident 53's blood sugars on 5/17/18 indicated the following: - 7:00 a.m. the resident's blood sugar was 55. - 11:00 a.m. the resident's blood sugar was 212. - 4:00 p.m. the resident's blood sugar was 173. - 8:00 p.m. the resident's blood sugar was 265. A review of Resident 53's Medication Administration Record [REDACTED]. There was no further documentation in regard to the nurse having administered 60 units, rather than the prescribed 85 units. During an interview, on 5/18/18 at 10:30 a.m., the clinical nurse specialist did not deny the nurse did not give the prescribed dosage of insulin. On 5/18/18 at 2:42 p.m., the clinical nurse specialist provided the facility policy, Physician Medication Order, and indicated it was the policy currently being used. A review of the policy indicated the policy did not address administering the prescribed dosage for medications. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident with a history of falls and at risk of falls was provided supervision and measures implemented to prevent falls, with the resident falling and receiving a laceration which required sutures, for 1 of 8 residents reviewed for falls, in the sample of 15. (Resident #51) Findings include: During interview on the initial tour on 7/25/11 at 8:00 A.M., the Unit Manager indicated Resident #51 was confused and hard of hearing, and had no recent falls. The clinical record for Resident # 51 was reviewed on 7/26/11 at 1:00 P.M. The record indicated Resident # 51 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 7/5/11, indicated Resident # 51 had severely impaired cognition. Resident # 51 required extensive assistance of one with bed mobility, transfers and ambulation. Resident # 51 had fallen one time since admission without injury. A Care plan, dated 2/17/11, indicated a problem of "Resident has risk for falls/injuries R/T (related to) osteoporosis; dementia, vertigo, decreased mobility." The interventions were "Give resident verbal reminders not to ambulate/transfer without assistance. Keep personal items and frequently used within reach. Provide proper, well-maintained footwear." The Resident Progress Notes, dated 3/2/11 at 7:09 A.M., indicated, "At 4:45 A.M. resident sitting on floor at foot of bed, unable to tell how fell , denied pain, two assist up, able to bear weight w/o (without) pain/discomfort, assisted to BR (bathroom), AROM (active range of motion) w/o complaints pain/discomfort, no new marks/bruises noted, neuro checks started as precaution on call md Dr (name) notified at 530 am..." The 2/17/11 fall care plan was updated on 3/2/11 to include the intervention of "Resident's bed placed against wall, mat on floor beside bed." The Interdisciplinary Team Meeting Fall Interventions, dated 3/2/11, indicated, "...found on floor at FOB (foot of bed)...New Intervention(s) low bed with mat. Resident bed placed along wall..." The Resident Progress Notes, dated 4/10/11 at 2:19 P.M., indicated, "Resident found on floor bedside bed, PSA (personal safety alarm) was sounding. Head to toe assessment completed no injuries notes. Resident having no c/o (complaints of) pain or signs of distress. Family notified of fall and of new intervention..." The Interdisciplinary Team Meeting Fall Interventions, dated 4/11/11, indicated, "...4-10-11, 11:00 AM, resident's PSA sounded I entered resident's room to find resident on the floor beside her bed...New Intervention(s) Moved bed against wall, placed in low position, PSA to floor mat next to bed..." The 2/17/11 fall care plan was updated on 4/11/11, to include the intervention of "Equip resident with device that monitors rising (PSA in bed, floor beside bed and wheelchair)." The Resident Progress Notes, dated 4/15/11 at 6:50 P.M., indicated, "Resident was sitting in the wheelchair at bedside. Nurse came into the room to give resident her medication. Resident sneezed Resident pitched forward when she sneezed, and continued to fall forward onto the floor. Resident c/o pain to her forehead. Full skin and head to toe assessment performed. Neurostatus charting started. Resident has a 1 inch laceration to lower lip, and a 3 inch lump to forehead. Cleaned laceration, applied ice to lump on forehead." The Resident Progress Notes, dated 4/29/11 at 4:45 P.M., indicated, "Resident's PSA going off, resident yelling for help. Resident found to be laying on floor. Full head to toe assessment performed. Resident found to have a 1 inch laceration to forehead above L (left) eye, 1/2 inch laceration to side of L eye, and 1/2 inch laceration under L eye. Resident also noted to have a small laceration to back of head. Cleaned wounds, applied pressure to stop bleeding...Resident transported to (hospital name) to receive stitches." The 2/17/11 fall care plan was updated on 4/29/11 to include the interventions of "Keep bed in lowest position with brakes locked, Observe frequently and place in supervised area when out of bed, and Provide toileting assistance every 2 hours and PRN (as needed) while awake." The Interdisciplinary Team Meeting Fall Interventions, dated 4/29/11, indicated, "...Resident's PSA was alarming, resident was yelling. Resident found laying on the floor. 3 i (one) inch lacerations noted to L (left) cheek and above L eye. Cleaned wounds, applied pressure...New intervention(s) Provide toileting q (every) 2 hours and PRN while awake..." The Resident Progress Notes, dated 5/18/11 at 4:20 P.M., indicated, "This nurse heard resident's PSA sounding and entered resident's bathroom to see her standing between her wheelchair and the toilet. Before this nurse could reach her, resident twisted to sit on floor with her back to the sink, then fell back and hit the back of her head on the trash can. Two staff to place resident back in wheelchair. Res alert, never lost consciousness, denies any pain. No injuries noted. Neuro checks initiated and are within normal limits. Resident helped to toilet with no output..." The Interdisciplinary Team Meeting Fall Interventions, dated 5/23/11, indicated, "...Pt (patient) trying to transfer self to toilet without assistance...New intervention(s) encourage resident to be out of room when in w/c. Bathroom door to remain closed when not in use..." 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident at risk of pressure ulcer did not develop pressure ulcers, in that Resident #100 developed 2 unstageable pressure ulcers in the facility, for 1 of 3 residents reviewed for pressure ulcers in the sample of 9. Resident # 100 Findings include On 9/13/11 at 10:30 A.M., the Wound Nurse was observed to remove a gauze dressing from Resident # 100's right ankle/foot area. There was a pea-sized black area noted on the right outer ankle. There was a baseball-sized black area on the right heel. There was a black area noted to be the size of a deck of cards on the calf of the right leg. During this observation, Resident # 100's daughter indicated there was a red area on Resident # 100's right hip yesterday. In an interview with the Wound Nurse, on 9/13/11 at 10:30 A.M., she indicated Resident #100 had been restless while in his wheelchair. She indicated Resident # 100 had placed foot over the pedal of the wheelchair hitting the heel on the floor causing the area to the right heel. She indicated Resident # 100 was up in wheelchair most of time to prevent him from getting pneumonia. She indicated when staff became aware of this Resident # 100 was changed from a wheelchair with the an elevated leg rest to a Broda chair. The Wound Nurse indicated the resident's skin broke down very rapidly and in a matter of days would go from a red area to a large area covered in eschar. The Wound Nurse indicated she had not been informed of the red area to Resident # 100's hip by staff nor had she received any documentation concerning an area to the hip. On 9/13/11 at 12:45 P.M., in an interview with the Wound Nurse she indicated she had not looked at Resident # 100's right hip. She stated other staff members were working with the resident and she had not yet had time to observe the hip. On 9/13/11 at 3:00 P.M., in an interview with the Director of Nursing and the Wound Nurse, the Wound Nurse indicated she had observed the hip and there was a nonblanchable red area. She stated there had been no documentation in the resident's record. The Director of Nursing stated she had spoken with Resident # 100's daughter and was informed the daughter had assisted a CNA with Resident # 100's care on 9/12/11 when the area was observed on the right hip. The Director of Nursing indicated the area had not been reported to a nurse for assessment until the daughter informed the Wound Nurse on 9/13/11 at 10:30 A.M. The clinical record for Resident # 100 was reviewed on 9/13/11 at 10:00 A.M. The record indicated Resident # 100 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 8/2/11, indicated Resident # 100 had impaired cognition, required extensive assistance of two with bed mobility and transfers. Resident # 100 had one stage 1 (red area) pressure area. The CAAs (Care Area Assessment), dated 8/2/11, indicated "...pressure ulcer- 8/2/11 right lower extremity 0.8 x (by) 1.1 x 0.0 cm. 100% epithealization; pressure r/t (related to) use of knee immobilizer...." A Skin At Risk Assessment, dated 7/26/11, indicated "Risk factors- Impaired mobility, and or decreased functional ability (cast or splint), potential for increase in friction and shear, cognitive impairment and exposure of skin to urinary and or fecal incontinence...At Risk? Yes..." The Skin inspection tool, dated 7/26/11, indicated "...skin intact, no redness..." A Physician order, dated 7/26/11, indicated "Daily skin check under immobilizer." A Care plan, dated, 07/26/2011, indicated a problem of "Resident is at risk for skin breakdown R/T (related to) dementia, femur fracture, decreased mobility, poor PO intake and [MEDICAL CONDITION]. The approaches were "09/06/2011, Up for meals only. To be positioned from side to side with pillows between legs. Not to be placed supine or upon abdomen. Float dependent heel when turned side-to-side. 07/26/2011, Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominence's. 07/26/2011, Encourage physical activity, mobility, and range of motion to maximal potential. 07/26/2011, Float heels to relieve pressure on the heels. 07/26/2011, Keep clean and dry as possible. Minimize skin exposure to moisture. 07/26/2011, Keep linen clean, dry, and wrinkle free. 07/26/2011, Report any signs of skin breakdown (sore, tender, red, or broken areas). 07/26/2011, Turn and reposition every 2 hours and prn." A Physician order, dated 8/1/11, indicated "Monitor skin pressure points from brace R (right) leg qd (everyday)." The Nurses Notes, dated 08/15/2011 at 14:43 (2:43 P.M.), indicated " N/O (new order): 1) Continue non-wt. (weight) bearing RLE (right lower extremity); 2) Keep knee immobilizer on at all times except for checking skin daily; 3) Follow-up 4-5 wks (weeks) for repeat X-rays." The Nurses Notes, dated 08/22/2011 23:45 (11:45 P.M.), indicated "5 cm dark area noted to rt (right) heel. N.O.(new order) elevate heels when in bed, apply skin prep to Rt heel Q (every) shift." A Care plan, dated 08/22/2011, indicated a problem of "Discolored area to right heel - resident has poor PO (by mouth) intake and [MEDICAL CONDITION]." The approaches were "08/27/2011 Pillow to broda chair pedal to elevate right foot and decrease pressure on heel. Turn side to side in bed with pillow between legs." A skin inspection tool, dated 8/24/11, indicated "Top of L (left) foot with scratch marks ? toenails will have podiatrist see him. small areas inner buttocks less red. Dark area rt (right) heel firm. L (left) heel pink..." The Nurses Notes, dated 08/27/2011 16:14 (4:14 P.M.), indicated "Multipodus boot is being used to Right foot." A skin inspection tool, with no date or signature, located between the 8/24/11 note and the 9/1/11 note, indicated "Red areas inner buttocks area rt heel firm." A skin inspection tool, dated 9/1/11, indicated "R heel eschar, buttocks redness..." The Nurses Notes, dated 09/01/2011 14:58 (2:58 P.M.), indicated "left upper arm wound resolved. right heel 100% necrotic tissue no drainage or pain. will continue current tx (treatment) as ordered to right heel..." A Skin Inspection Tool, dated 9/3/11, indicated "1. 2 cm x 1 cm to R lateral calf. 2. 5 cm x 5 cm to R distal calf. 3. 2 cm x 2 cm to R inner ankle. All areas are intact, reddish brown areas. Allevyn foam drsgs (dressings) applied." The Nurses Notes, dated 09/03/20 12:48 (12:48 P.M.), indicated "Area to R outer calf 2cm x1cm, R inner ankle 5cm x 5cm, R Achilles 2cm x 2cm. All areas a reddened-brown (sic) color, c/d/i (clean/dry/intact). Covered with allevyn as ordered." A Physician order, dated 9/3/11 at 2:00 P.M., indicated "Dx (diagnosis}: Pressure areas. Apply allevyn foam drsgs (dressings) to pressure areas on 1. R later (sic) calf. 2. R distal calf. 3. R inner ankle. Change every 3 days." A Care plan, dated 09/03/2011, indicated a problem of "Resident has an open area to right calf and ankle." The approaches were "09/08/2011, Use blue soft boot to relieve pressure alternate to float heels in bed. Boot is to be off when up in padded broda chair. 09/03/2011, Assess the ulcer for location, size (length, width, and depth), presence/absence of granulation tissue and epithelization weekly. 09/03/2011, Conduct a skin inspection weekly. 09/03/2011, Keep bony prominences from direct contact with one another with: use pillow between legs when in bed. 09/03/2011, Treatment to areas per orders. 09/03/2011, Turn and reposition every bedcheck." The Nurses Notes, dated 09/04/2011 12:51 (12:51 P.M.), indicated "Alleyvn foam drsgs c/d/i to skin areas on RLE." The Nurses Notes, dated 09/06/2011 10:39 (10:39 A.M.), indicated "IDT intervention changed to up for meals only, turn side to side and do not place supine or prone." The Nurses Notes, dated 09/06/2011 15:57 (1:57 P.M.), indicated "New order received from (name) NP (nurse practitioner) to treat OA (open area) with santyl allevyn foam nonadherant (sic) dressing to be changed daily. To be up for meals only, turned side to side with pillow between legs, not to be placed supine or on back. Dr. (name) office was called concerning brace. Awaiting further orders." The Nurses Notes, dated 09/07/2011 13:53 (1:53 P.M.), indicated "New orders received: D/C immobilizer... Pt (patient) to remain NWB (nonweight bearing) to RLE (right lower extremity)..." The Nurses Notes, dated 09/07/2011 16:18 (4:18 P.M.), indicated "Dr (name) called and discontinued knee immobilizer on right leg. Boot also discontinued at this time." The Nurses Notes, dated 09/08/2011 11:36 (11:36 A.M.), indicated "Skin preped (sic) intact brown area to R calf. Did tx for R Achilles and heel, both wounds were intact and black in color." The Nurses Notes, dated 09/08/2011 16:55 (4:55 P.M.), indicated "Upon weekly evaluation to right heel, measurements and appearance shows signs of improvement. (name) NP was notified. Current TX remains in place. Family was notified." The Nurses Notes, dated 09/09/2011 13:53 (1:53 P.M.), indicated "After assessment of client's skin N.O. received per Dr. (name): Clarification: D/C heelz up, Soft boot on foot that is laying against bed when turned side to side. Boot is to be on only while in bed. Family is aware of this." A Weekly Wound Evaluation Flow Record, dated 8/22/11, indicated "...Site/Location: Rt heel. Date of Onset: 8-22-11. Pressure Ulcer. Acquired: in-house...4.2 x 3 cm, ? depth. Color: black...Current Tx: skin prep to R heel q shift...Date 9-1-11. Eschar...4.8 x 3.2...color black...current tx: skin prep; float heals (sic) 100% necrotic. Response to tx: no change...Date 9/7/11. Stage- eschar...6 cm x 4.1 cm...cont (continue) with current tx. Response to tx: improved." A Weekly Wound Evaluation Flow Record, dated 9/3/11, indicated "Date 9/3/11. Stage II (two). R outer calf. Size 2 cm x 1 cm. Depth none...Current Tx: Allevyn foam change Q 3 days...Date 9/7/11. Stage II...1.3 x 2 cm...Black...80% eschar. Current tx: Allevyn foam change every 3 days." A Weekly Wound Evaluation Flow Record, dated 9/3/11, indicated "Date 9/3/11. Stage II. R inner ankle. 5 cm x 5 cm. Depth none...Date 9/7/11. Stage II...1.5 cm x 1 cm..." A Weekly Wound Evaluation Flow Record, dated 9/3/11, indicated "Date 9/3/11. Stage I (one). R Achilles. 2 cm x 2 cm. Depth none...Current Tx: Allevyn change...Date 9/7/11. Stage III (three)...6.8 x 3.5 cm. Depth 0.1 cm...Current tx: santyl, cover with allevyn foam every day. 100% slough..." A Weekly Wound Evaluation Flow Record, dated 9/12/11, "Site: R outer ankle. Date of Onset: 9/12/11. Pressure Ulcer. Acquired in house...Stage II 1.0 cm diameter...Current Tx: skin prep..." This federal deficiency was cited on 7/27/11. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure a resident did not develop a pressure sore while residing in the facility, in that Resident #46 developed an unstageable pressure sore to her heel from a walking brace, for 1 of 3 residents reviewed with pressure sores in a sample of 15. Findings include: On the initial tour, on 7/25/11 at 8:00 A.M., the Unit Manager indicated Resident #46 was not interviewable. On 7/25/11 at 8:30 A.M., Resident # 46 was observed to be sitting in a chair in her room. Resident # 46 was observed to have a multipodus boot on her right foot. On 7/26/11 at 10:40 A.M., Resident # 46 was observed to be in bed on left side. Resident # 46's right heel was observed to be approximately 4 cm by 2.5 cm brown area. The clinical record for Resident # 46 was reviewed on 7/25/11 at 7:45 A.M. The record indicated Resident # 46 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 4/21/11, indicated Resident # 46 had severely impaired cognition, and required extensive assistance of two with bed mobility and transfers. Resident # 46 had no pressure areas. A Care plan, dated 4/13/11, indicated, "Resident is at risk for skin breakdown R/T (related to) demenita, poor po (by mouth) intake poor mobility splint/brace on RLE (right lower extremity)." The interventions were "Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences. Encourage physical activitiy, mobility and ROM (range of motion) to maximal potential. Keep clean and dry as possible minimize skin exposure to moisture. Keep linen clean dry and wrinkle free. Monitor skin every shift around splint/brace." A Physician Progress Notre, dated 7/6/11, indicated, "...OK to ambulate cont (continue) Cam walker x (times 2 weeks...swelling post (posterior) Rt (right) heel..." In an interview with the Unit Manager, on 7/27/11 at 10:30 A.M., he indicated Resident # 46 had her soft cast removed on 7/6/11, but continued to utilize the Cam walker. He indicated there was no documentation from admission until 7/13/11 concerning Resident # 46's right heel. A Skin Inspection Tool, dated 7/13/11, indicated, "Skin Description, Prevention and Treatment- Turning and repositioning per care plan, pressure device in chair, pillows/cushions used to prevent boney prominences from rubbing. 2.0 cm x (by) x unstageable area noted on R (right) heel edges flaky- center dry with drk (dark) center. Remaining W/D/I (warm/dry/intact)." A Physician order, dated 7/13/11, indicated, "Apply skin prep to Rt (right) heel BID (two times daily)." A Physician Wound Sheet, dated 7/19/11, indicated, "...R (right) heel 1.8 x (by) 1.3 x 0.1 cm...pressure devices related unstageable...100% [MEDICATION NAME]/slough...unstageable device related pressure ulcer heel..." A Physician order, dated 7/19/11, indicated, "...2. Cleanse R (right) heel wound with NS (normal saline) pat dry apply skin prep to edges and santyl to OA (open area). Cover with hydrogel and soaked fluffed gauze and secure . Change daily. 3. PT (physical therapy) to eval (evaluate) for footwear to offload R heel wound." A Skin Inspection Tool, dated 7/21/11, indicated, "...See Wound Dr. progress note- 7-19-11 for wound description and measurements. Remaining skin W/D/I lotion applied to skin with care." A Physician order, dated 7/22/11, indicated, "1. D/C (discontinue) PT order, pt (patient) to wear multipodus boot at all times, staff to do frequent checks for fitting/positioning to maintain proper heel off loading. 2. May D/C Cam walker boot per Dr (name) telephone order." In an interview with the Unit Manager, on 7/27/11 at 10:30 A.M., he indicated he thought the Cam walker boot was what had caused the area to Resident # 46's heel. 3.1-40(a)(1)