Every finding on record at Briarcliff Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure staff used a sling in good working order to transfer 1 of 3 residents reviewed with a mechanical sit to stand lift (Resident K). Findings include:A confidential report, dated December 2025, alleged Resident K had a fall when being transferred from bed to his wheelchair. The fall occurred when the sling strap broke, causing the resident to fall to his knees, striking the back of his neck against the bed frame. Initially, the resident had no injuries but later in the day, had increased pain in his knees and neck and was sent to the ER for evaluation and returned the same day.On 3/18/26 at 1:05 P.M., Resident K's record was reviewed. Diagnoses included surgically repaired cervical stenosis (caused pressure on the spinal cord and nerves) with rod and screws in the neck and spinal cord dysfunction with weakness of extremities.A quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated Resident K had no cognitive impairment. He had impairment in range of motion and function of both upper and lower extremities. He was non-ambulatory and used a wheelchair for mobility. The resident was dependent on staff for transfers to/from bed to chair.Care plans, dated 5/29/24, indicated the resident required assistance with activities of daily living (ADL) due to spinal stenosis. An undated intervention indicated Resident K was to be transferred using an EZ stand mechanical lift with 2 staff. Resident K was at risk for falls due to weakness and decreased mobility. Interventions, dated 12/8/26, were for staff to inspect slings, used to transfer the resident, for visible signs of wear or signs of decreased integrity; and therapy was to confirm safety with sit to stand transfers and resident weight bearing ability.A Post Fall Evaluation note, dated 12/6/25 at 3:33 p.m., indicated Resident K had a witnessed fall on 12/6/25 at 11:31 a.m. 2 Certified Nurse Aids (CNA) were transferring the resident with a mechanical sit to stand lift, when the sling strap broke, causing the resident to fall to his knees. He had no visible injuries and initially, had no complaints of pain, however, he later complained of right knee pain which was dull and aching. He was given Tylenol per orders. The medication was effective in relieving his pain.A nurse progress note, dated 12/6/25 at 10:41 p.m., indicated the resident requested to go to the ER for evaluation of pain from the fall.A nurse progress note, dated 12/7/25 at 3:10 a.m., indicated the resident returned from the ER where scans had been done to check for injuries related to his fall. Per hospital report, a CT scan of his neck and x-rays of his knees were done and hadn't shown serious injuries.Emergency Department discharge instructions, dated [DATE], indicated Resident K was seen at the ER for a fall on 12/6/25. He was diagnosed with a neck strain and sprain to his right knee.On 3/18/26 at 1:50 P.M., the Administrator and Director of Nursing (DON) were interviewed. Both indicated they reported the broken sling strap to the company where purchased. The Administrator indicated the company replaced the sling and indicated they would be conducting an internal investigation. The Administrator indicated he'd not heard anything back from the company. The DON indicated she'd met with staff and re-educated them on inspecting slings prior to using them to transfer residents with a mechanical lift. The Administrator indicated he still had the broken sling strap. The Administrator and DON indicated after the resident's fall, they had gone through and observed all slings used in the facility and threw away slings appearing in poor condition. Both indicated they currently were not tracking when new slings were put into operation or when they needed replaced according to manufacturer guidelines.Observation of the sling on 3/18/26 at 2:05 PM, indicated the strap had torn off where the strap attached to the body of the sling. Rings on the strap were intact but stiff. The label on the sling was torn and faded without any visible manufacturer directions. The resident's name was written in black marker over the torn label.On 3/18/26 at 2:11 P.M., CNA 3 was interviewed. She indicated on 12/6/25, she and another CNA were going to transfer Resident K from his bed to wheelchair using the stand up mechanical lift. She checked the sling and saw no issues. Resident K was assisted to sit up on the side of his bed, the sling placed around his back, around and under his arms. Loops on the sling were attached to the lift and he was lifted up. He was in a standing position, bent slightly forward when the strap of the sling snapped off and the resident fell to his knees, part on the lift and part on the floor. CNA 3 indicated the resident grazed his head/neck on the bed frame. He had no initial complaints of pain as he and CNA 3 were in a state of shock at the occurrence. Manufacturer guidelines for slings used in the facility, was provided by the DON on 3/18/26 at 3:01 P.M. Manufacturer's Sling Maintenance Best Practices guide indicated: Condition of the sling should be done prior to using-if any fraying or visible wear and tear, do not use; Follow care instruction on wash tag, if illegible, do not use; and re-usable slings should be replaced every 6 months.A Guideline for Identifying Deteriorated Slings, retrieved from website Proactivemedical.com, on 3/18/26, indicated steps to detect accelerated deterioration from bleach, high temperature wash, and drying slings. These steps included:-Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident.-Completely Faded / Missing / Illegible Tag while the main body of the sling fabric is still intact and in relatively good condition can be a good indicator that the sling may have been washed with bleach at high temperature.-Strap Brittleness / Stiffness / Surface and Edge Abrasion are additional indicators that the sling may have been laundered in unsuitable conditions and has lost tensile strength. Loop straps that have stiffened or become brittle will remain in the state, position, or shape it is bent into instead of returning into a normal relaxed state.This Citation relates to Intake 2704736.410 IAC 16.2-3.1-45(a)

Based on record review and interview, the facility failed to implement effective, ongoing interventions to prevent behaviors for a resident with a history of behaviors. This deficient practice resulted in a hospitalization due to injuries incurred due to behaviors for 1 of 1 residents reviewed for behavior management. (Resident 1)Finding includes: Resident 1's record review was completed on 8/4/2025 at 2:10 P.M. Diagnoses included, but were not limited to: bipolar type schizoaffective disorder, mild intellectual disability, anxiety disorder and dementia.A Nursing Progress Note dated, 9/19/2025 at 12:15 P.M., and signed by the Director of Nursing (DON), indicated Resident 1 continued to insert foreign objects into his rectum. An Incident Note, dated 11/23/2024 at 6:35 P.M., indicated facility staff had found Resident 1 in his room with blood on his sheets. After staff had assessed the resident, he was found to have had a small pumpkin in his brief with the stem pointed up, toward the rectum with blood noted to the pumpkin stem. Resident 1's rectum was assessed and a butter knife with only the handle of the blade was observed outside of the rectum. The resident had indicated he had inserted a straw into his rectum as well. Staff had observed the resident's meal tray and all utensils were accounted for except for the straw. Emergency Services were called, the provider, Executive Director (ED) and Director of Nursing were notified. The Paramedics arrived and took Resident 1 to the hospital. A Nursing Progress Note dated, 11/24/2024 at 3:46 P.M., indicated Resident 1 had been admitted to a local hospital and had received an colostomy (surgically created opening in the body to allow for the discharge of bodily waste), had a Jackson Pratt (JP) drain (a type of surgical drain used to remove excess fluid from a surgical site) and had had an indwelling catheter (flexible tube inserted into the bladder to drain urine continuously) placed.A Quarterly Minimum Data Set (MDS) assessment, dated 8/23/2024, indicated Resident 1 had moderate impaired cognition. A current Care Plan, initiated on 9/12/2024, indicated Resident 1 had a history of placing foreign objects into his rectum. The goal of the Care Plan was for Resident 1 to not have any complications related to putting objects into his rectum. Interventions included, but were not limited to: Encourage resident to not put foreign objects in his rectum, has a history of placing bottle caps in rectum and staff to assist with limiting such objects to dissuade insertion. A current Care Plan, initiated on 2/14/2024, indicated Resident 1 had behavioral problems related to his diagnoses of schizoaffective disorder, anxiety, major depressive disorder, dementia and mild intellectual disability. A goal for the Care Plan was for the resident to have no evidence of behavior problems. Interventions included, but were no limited to: assist with removing unnecessary objects from room and personal space, or assist in ensuring objects are accounted for to prevent behavior of inserting inappropriate places. An Physician's order, dated 8/2/2024, indicated staff were to monitor the resident for behaviors of: hallucinations, anxiety, crying, repetitive questions/statements, withdrawal from daily activities, physical injury to self or others or verbally loud and disruptive behaviors. Resident 1's September, October and November 2024 Treatment admission Records (TAR) indicated the resident had only had one behavior documented, on 9/19/2024.A hospital Discharge Summary, for the 11/23/2024 hospitalization, indicated Resident 1 had a history of significant mental illness and had been admitted to the hospital after piercing his rectum with a butter knife. It was believed Resident 1 had tried to disimpact stool. The injury required an exploratory laparotomy and Resident 1 underwent loop colostomy placement as well as suture repair of two rectal wounds. Resident 1 had also required two units of packed red blood cells. During an interview on 8/5/2025 at 11:40 A.M., the Regional Nurse Consultant (RNC) indicated the facility had created a Care Plan to address Resident 1's behavior prior to the incident because inserting objects into his rectum was a known behavior. The RNC indicated the resident had inserted the butter knife into his rectum for sexual gratification and the facility staff had educated the resident in the past about inserting objects into his rectum. The RNC indicated the facility had reached out, in the past, to the resident's Guardian and had requested that some personal items be removed from the resident's room for his own safety. The Guardian had indicated to the facility she had not wanted the staff to take the resident's personal items away from him. The RNC believed Resident 1 understood the consequences of inserting objects into his rectum. During an interview on 8/5/2025 at 2:20 P.M., Resident 1's Guardian indicated Resident 1 had a history of inserting objects into his rectum and it had not been a new behavior. She indicated she had not requested the facility to keep unsafe items in his room and nobody from the facility had brought up the subject of removing his personal items. Resident 1's Guardian did not believe Resident 1 was capable of understanding the consequence of inserting a butter knife into his rectum. During an interview on 8/7/2025 at 2:05 P.M., the Executive Director, Director of Nursing and the Social Services Director indicated they had discussed Resident 1's behaviors at their Interdisciplinary Team meeting and it was decided in April 2024 to discontinue the Care Plan intervention to keep track of the resident's utensils at meals because the facility had not had the resident show that behavior. The current Care Plan interventions had been created through the IDT meetings and the staff believed they were doing everything possible to keep the resident from inserting objects into his rectum. During an interview on 8/7/2025 at 2:20 P.M., the facility's Psychiatric Mental Health Nurse Practitioner (PMHNP) indicated she had been treating Resident 1 for several years and, on 11/23/2024, Resident 1 had not understood the consequences of inserting a butter knife into his rectum. During an interview on 8/7/2025 at 3:10 P.M., Registered Nurse (RN) 6 indicated she was the nurse assigned to Resident 1 on 11/23/2024. RN 6 indicated she had not been aware Resident 1 had a history of inserting objects into his rectum before that incident and had not checked his rectum, checked his room for objects that could be dangerous or made sure all of his utensils were accounted for after meals. Before the resident had inserted the butter knife into his rectum, she had not observed any behaviors from the resident earlier in shift. During an interview on 8/7/2025 at 3:15 P.M., CNA 7 indicated she had been the CNA assigned to Resident 1 on 11/23/2024 and before the incident, had not noticed any behaviors. CNA 7 indicated she had not been aware Resident 1 had a history of inserting objects into his rectum before that incident and had not checked his rectum, checked his room for objects that could be dangerous or made sure all of his utensils were accounted for after meals.On 8/8/2025 at 10:15 A.M., the RNC provided a policy dated, 6/20/2022, and title, Behavior Management. The RNC identified the policy as the one currently used by the facility. The policy indicated, It is the policy of Sterling Healthcare to work as an IDT to review and determine the root cause of behaviors and provide behavior interventions for residents with problematic or distressing behaviors .4. The IDT review should be a discussion with the team as to the behavior event, an devaluation of interventions, presentation of new interventions if applicable and an assessment of any underlying causes of the distressed behavior 3.1-43

Based on observation, interview and record review, the facility failed to store food in a sanitary manner related to labeling and dating leftovers and throwing away expired food in the refrigerator for 1 of 1 kitchen and 1 of 1 kitchenettes observed. This had the potential to affect 93 of 95 residents who consumed food from the kitchen and the Memory Care Kitchenette.Findings include:1. During the initial kitchen tour on 7/29/2025 at 9:45 A.M with the Director of Dietary (DD), the following was observed in the three-door refrigerator:-Two premade ham and cheese sandwiches had not been labeled with a made on or use by date. -A plate had sliced tomatoes, onion and shredded lettuce, wrapped in clear plastic but did not have made on or used by dates. -A bag of shredded cheese had been opened but had not been labeled with an opened or use by date. -A container of leftover green beans had not been labeled with a made on or use by date. -A bag of celery labeled with a use by date of 7/26/2025.-A container of diced tomatoes labeled with a use by date of 7/25/2025. -A container of cheese labeled with a use by date of 7/20/2025. During an interview on 7/29/2025 at 9:58 A.M., the DD indicated all food should have been labeled with a made on and use by date and all food past the use by or expiration date should have been thrown away. She also indicated all food that had been removed from its original container was considered leftovers and leftovers were to be disposed of after three days. 2. During a tour of the Memory Care Units' Kitchenette with the DD on 7/29/2025 at 10:05 A.M., the following was observed in the refrigerator: -Two cups of pureed watermelon had not been labeled with a made on or use by date. -A microwave meal was in a grocery sack and had not been labeled with any resident information.-A container of cut up watermelon from a local grocery store had not been labeled with a resident name or an opened on or use by date. An interview with the DD was completed on 7/29/2025 at 10:08 A.M. The DD indicated all food should have been labeled with an opened on and use by date and any food brought into the facility for the residents should have been labeled with the resident's food. She could not identify if the store-bought watermelon and the microwave meal were for a resident or a staff member. On 8/7/2025 at 9:30 A.M. the Executive Director (ED) provided an undated policy titled, Food Safety and Sanitation, and identified it as the policy currently used by the facility. The policy indicated, .Refrigerated Storage: . All leftovers should be labeled and dated. Leftover food should be used with 72 hours of preparation The ED also provided undated procedure titled, Wrapping, Labeling and Dating and identified it as the procedure currently used by the facility. The procedure indicated, Purpose: All food items, whether stored in storeroom, coolers or freezer, shall be clearly wrapped and labeled with the date .A good standard of practice is a 3-day shelf life including date of preparation On 8/7/2025 at 11:39 A.M., the ED provided an undated policy title, Use and Storage of Food Brought in by Family or Visitors and identified it as the policy currently used by the facility. The policy indicated, .All food items that are already prepared by the family or visitors must be labeled with date .If not consumed within 3 days, food will be thrown away by facility staff. 3.1-21(i)(3)

Based on record review and interview, the facility failed to report an unusual occurrence that resulted in resident injuries to the Indiana State Survey Agency for 1 of 1 residents reviewed for injuries. (Resident 1)Finding includes:Resident 1's record review was completed on 8/4/2025 at 2:10 P.M. Diagnoses included, but were not limited to: bipolar type schizoaffective disorder, mild intellectual disability, anxiety disorder and dementia. An Incident Note dated, 11/23/2024 at 6:35 P.M., indicated facility staff had found Resident 1 in his room with blood on his sheets. After staff had assessed the resident, he was found to have had a small pumpkin in his brief with the stem pointed up, toward the rectum with blood noted to the pumpkin stem. Resident 1's rectum was assessed and a butter knife with only the handle of the blade was observed outside of the rectum. The resident had indicated he had inserted a straw into his rectum as well. Staff had observed the resident's meal tray and all his utensils were accounted for but there was no straw. Emergency Services was called, as well as the physician, the Executive Director (ED) and the Director of Nursing. The Paramedics arrived and took Resident 1 to the hospital. A Nursing Note dated 11/24/2025 at 3:46 P.M., indicated Resident 1 had been admitted to a local hospital and had received an ostomy (surgically created opening in the body to allow for the discharge of bodily waste), had a Jackson Pratt (JP) drain (a type of surgical drain used to remove excess fluid from a surgical site) and had an indwelling catheter (flexible tube inserted into the bladder to drain urine continuously) placed as a result of injuries suffered from the items being put into his rectal cavity. A review of the Facility Reported Incidents was completed on 8/5/2025 at 3:00 P.M. There had not been an incident related to a resident inserting an object into his rectum and requiring hospitalization and an ostomy reported to the Indiana State Survey Agency. During an interview with the ED on 8/7/2025 at 11:20 A.M., the ED indicated the facility's Interdisciplinary Team (IDT) had met and discussed the incident, but believed it was an extension of Resident 1's current behavior and the incident had not needed to be reported. On 8/7/2025 at 11:20 A.M., the ED provided a policy dated 5/9/2023, and titled, Incident and Reporting Policy. The ED indicated it was the policy currently used by the facility. The policy indicated, .All incidents, including but limited to abuse . or unusual occurrences, must be reported and investigated promptly. Sterling Healthcare adheres to all applicable state and federal laws and regulations . Regulatory Reporting: Facility will follow all federal state requirements for reporting incidents . Reportable incidents will be submitted to: State Survey Agency 3.1-28(e)

Based on observation, interview and record review, the facility failed to administer medication as needed prior to a dressing change. This deficient practice resulted in severe pain during a treatment for 1 of 1 residents observed for wound care. (Resident 35) Finding includes: During an observation of wound care for Resident 35, on 8/08/2024 at 3:13 P.M. with the ADON and the Unit Manager, the ADON indicated the resident's treatment was to cleanse the resident's wound with wound wash, apply calcium alginate and medi- honey ointment, sprinkle Flagyl (an antibiotic) n the wound bed, and cover the wound with a dry dressing. First, CNA 2 wiped away some zinc barrier cream from around Resident 35's wound with a wet rag. Next, the ADON removed the soiled dressing from the resident's wound. After she washed her hands and donned clean gloves and a clean gown, she cleansed the wound and applied the medi honey ointment and packed the wound. The Resident began yelling Ouch, it hurts! and Please, it hurts! numerous times, during the removal of soiled dressing and packing, cleansing and medication application and repacking of the wound. The ADON replied by saying, I'm sorry, and continued to complete the wound care. During an interview, on 8/08/2024 at 3:29 P.M., the ADON indicated the resident was not given pain medication, by her, prior to the dressing change and she was not sure if anyone else may have administered pain medication to the resident. When asked if the resident should have been given pain medication prior to a wound dressing change, she indicated, Yes, I believe that's fair that he should have been given medication prior to the dressing change. During an interview, on 8/08/2024 at 3:33 P.M., the Unit Manager indicated Resident 35 had been administered Norco (a pain medication) at 1:35 P.M. and he could have a dose of the medication every 8 hours. The resident had been administered Morphine (a pain medication) around 10-10:30 A.M. and could have a dose of the medication every 4 hours. She indicated the resident should have received another dose of Morphine prior to the dressing change. During an interview, on 8/09/2024 at 11:03 A.M., with the CNO (Corporate Chief Nursing Officer) and the DON, the DON indicated when the resident expressed sounds of pain, during the observed wound care, it would have taken more time to stop and address the resident's pain rather then to finish with what they were doing. The CNO stopped the DON and stated, So, at the first sign of pain, they should have stopped the dressing change and assessed the resident. The DON responded by indicating, Yes, and if you look, they did medicate him prior to the morning dressing change. On 8/7/2024 at 10:44 A.M., a record review was completed for Resident 35. Diagnoses included but were not limited to pressure ulcer of sacral region, mild cognitive impairment, and dementia. The residents' medications to address pain included: -Morphine Sulfate oral solution 20 mg/5 ml, give 0.25 ml every 4 hours as needed for shortness of breath and comfort. -Norco oral tablet 5-325 mg, give 1 tablet by mouth three times per day. -Fentanyl transdermal patch 12 mcg per hour, apply patch every 72 hours. A review of Resident 35's Medication Administration Record (MAR) for August 2024 indicated the resident received Morphine 5 mg, sublingual tablet, at 10:33 A.M. and Norco 5-325 mg oral tablet at 1:35 P.M on 8/8/2024. The resident could have received a PRN, as needed, dose of Morphine at 2:30 P.M., prior to the dressing change which was completed at 3:13 P.M on 8/8/2024. A Physicians Order, dated 7/6/2024, indicated may give as needed medication prior to dressing change. A Care Plan, dated 5/23/2024, indicated the resident was at risk for pain related to pressure injury to the right buttock. Interventions included, administer pain medication as needed, evaluate for non-verbal indicators of pain, and evaluate pain. On 8/9/2024 at 10:15 A.M., the CNO provided the policy titled, Pain Management, dated 11/1/2023 and indicated it was the policy currently in use by the facility. The policy indicated . 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming) . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure 2 of 2 laundry staff transported residents clothing appropriately when delivering them. Finding includes: During an observation on 8/5/2024 at 11:00 A.M., Laundry Aide 4 was pushing a cart with residents personal clothing partially covered with a draw sheet. The sheet only covered the top of the clothing to middle of the items and the lower portion of the clothing was exposed and uncovered. During an observation on 8/8/2024 at 12:55 P.M., Laundry Aide 5 was coming down the hall with a cart with residents' personal items covered with a draw sheet. The items were covered from the top of the clothing to middle of the items and the lower portion of the clothing was exposed and uncovered. During an interview on 8/8/2024 at 12:58 P.M., Laundry Aide 5 indicated they (the resident's clothing)probably should be covered up more. During an interview on 8/8/2024 at 1:03 P.M., the Housekeeping/Laundry Director indicated the draw sheet was what they had to cover the rack, they did not have a cover that covered the whole rack. On 8/8/2024 at 2:37 P.M., the Regional Nurse provided a policy titled, Handling Clean Linen, dated 2/2024, and indicated it was the policy currently used by the facility. The policy indicated, .4. Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport and unloading, such as: b. Placing clean linen in a properly clean cart and covering with disposable material or a properly cleaned reusable textile material that can be secured to the cart. c. Wrapping the individual bundles of clean textiles in plastic or other suitable material and sealing or taping the bundles . 3.1-18

Based on interview and record review the facility failed to include the resident, or representative, in meetings to review the plan of care for 1 of 3 residents reviewed for care planning. (Resident 17) Finding includes: A record review for Resident 17 was completed on 8/9/2024 at 1:27 P.M. Diagnoses included, but were not limited to, stage 5 chronic kidney disease, unspecified osteoarthritis, and type 2 diabetes mellitus. An Admission Minimum Data Set (MDS) assessment, dated 6/5/2024, indicated Resident 17's cognition was intact and she participated in goal setting. During an interview on 8/6/2024 at 9:28 A.M., the resident indicated she had not attended a care plan meeting since her admission on 5/29/2024. A Social Service Progress Note, dated 5/30/2024, included a brief medical history and her goal of returning to the community after therapy was completed. The record lacked any notes indicating a care plan meeting had been planned or had taken place since Resident 17 was admitted . During an interview on 8/12/2024 at 10:00 A.M., the Social Services Director indicated she had met with the resident and should have documented the discussion but had not. On 8/12/2024 at 8:52 A.M. the Director of Nursing provided a current policy titled, Comprehensive Care Plans. The policy indicated, .4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: .v. Family members, surrogate or others desired by the resident 3.1-35(c)(2)(C)

Based on interview, observation and record review, the facility failed to implement fall prevention interventions related to signage and an adaptive call light system for a resident with repetitive falls for 1 of 20 residents reviewed for falls. (Resident 10) Finding includes: During an interview on 8/7/2024 at 1:41 P.M., Resident 10 indicated she had fallen the previous day and her leg was sore. The staff had told her to call for help when she needed to use the bathroom. A record review was completed for Resident 10 on 8/7/2024 at 1:40 P.M. Diagnoses included, but were not limited to: glaucoma, dementia, type 2 diabetes mellitus, and syncope. A quarterly Minimum Data Set (MDS) assessment, dated 5/23/2024, indicated the resident had severe cognitive impairment and required extensive assistance for transfers. A quarterly Fall Risk Evaluation, dated 8/5/2024, indicated the resident was at high risk for falls. The clinical record indicated Resident 10 had fallen within the last year on the following dates: -8/14/2023 -8/16/2023 -9/6/2023 -9/23/2023 -10/28/2023 -12/6/2023 -5/15/2024 -8/5/2024 A Nursing Progress Note, dated 8/5/2024, indicated the resident had an unwitnessed fall when she attempted to self-transfer from the bed to her adjacent wheelchair. An X-ray was performed and an equivocal (positive or negative)fracture was noted. The recommendation was for follow-up care but the resident and the resident's family had elected not to seek further evaluation. A current Care Plan, dated 3/7/2018, indicated Resident 10 had a risk for falls with a goal for the resident to be free of minor injury from falls. Interventions to the Risk for Falls Care Plan included but were not limited to: -Place Call don't fall signs in bathroom and Resident's room. -Touch pad call light given with red tape with help put on it to encourage use when in need of assistance. Instruction and frequent reminders to be given. During an observation of Resident 10's room on 8/7/2024 at 1:45 P.M., no signs reading Call don't Fall could be located and the call light was not a touch pad with Help spelled out in red tape on it. During an interview on 8/7/2024 at 2:44 P.M., the Unit Manager indicated the Resident 10 did not have a touch pad call light and there were no signs that read Call don't Fall in her room or bathroom. The facility should have followed the Care Plan or should have removed any interventions that were no longer used. During an interview on 08/07/2024 at 3:06 P.M., the Regional Nurse indicated the policy on accidents was what the facility followed for creating and updating Care Plans related to falls. On 8/7/2024 at 2:20 P.M., the Regional Nurse provided a policy, dated 6/5/2023, titled Accidents and Supervision and identified it as the policy currently used by the facility. The policy indicated, It is the practice of this facility to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to accidents . 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff . d. Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) 3.1-45(2)

Based on observation, interview and record review, the facility failed to maintain a system for reconciliation of controlled substances for 1 of 3 medication carts reviewed. (800 hall medication cart) Finding includes: During an observation on 8/8/2024 at 9:41 A.M. of the Medication Cart on the 800 Hall, the Shift Change Accountability Record for Controlled Substances was missing signatures to indicate the controlled substances had been counted and reconciled by two staff members (the on coming an out going nursing staff member) on the following dates and shifts: -8/1/2024 fist shift did not contain two signatures. -8/4/2024 first shift did not contain two signatures. -8/4/2024 third shift did not contain two signatures. -8/5/2024 third shift did not contain two signatures. -8/6/2024 third shift did not contain two signatures. -8/7/2024 first shift did not contain two signatures. During an interview, on 8/8/2024 at 9:42 A.M., Qualified Medication Aide (QMA) 6 indicated there should not be any missing signatures and staff should always count the controlled substances with another staff member, and both staff members should have signed off on the controlled substance count by initialing the Shift Change Accountability Record for Controlled Substances form. On 8/8/2024 at 10:06 A.M., the Unit Manager provided a policy, dated, 1/2023, titled Controlled Substances, and identified it as the policy currently used by the facility. The policy indicated, . b. All scheduled II controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses . 4. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented 3.1-25

Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and addressed timely by a physician for 2 of 5 residents reviewed for medications. (Residents 55 and 10) Findings include: 1. Resident 55's record review was completed on 8/7/2024 at 9:58 A.M. A Consult Pharmacist's Medication Regimen Review, dated 12/14/2023, indicated the Pharmacist recommended discontinuing 500 micrograms of Cyanocobalamin (Vitamin B12). The order for Cyanocobalamin was discontinued on 2/12/2024. A Pharmacy Medication Regimen Review form, from the Pharmacist to the Physician, dated 11/13/2023, indicated the Pharmacist recommended discontinuing Biofreeze Gel 4% topical analgesic. The Physician responded to the recommendation form to discontinue the Biofreeze on 12/12/2023 and the Biofreeze Gel 4% was discontinued on 1/11/2024. A Pharmacy Medication Regimen Review form, from the Pharmacist to the attending Physician, dated 2/19/2024, indicated the Pharmacist recommended weekly blood glucose monitoring and the Physician had agreed to the recommendation but did not date the form. An order for weekly blood glucose checks was initiated on 3/28/2024. On 8/8/2024 at 11:10 A.M., the dates of the responses from the physician related to ordering weekly blood glucose checks and discontinuing Vitamin B12 were requested, but were not provided before the survey exit date. 2. Resident 10's record review was completed on 8/7/2024 at 1:09 P.M. A Pharmacy Medication Regimen review form, from the Pharmacist to the attending Physician, dated 11/13/2023, indicated the Pharmacist recommended discontinuing an order for 40 milligrams (mg) of Pantoprazole and the Physician had agreed, but did not date the form. The order for Pantoprazole was discontinued on 1/11/2024. A Pharmacy Medication Regimen review form, from the Pharmacist to the attending Physician, dated 12/14/2023, indicated the Pharmacist recommended discontinuing an order for 40 milligrams (mg) of Atorvastatin and the Physician agreed on 2/8/2024. The order for 40 mg Atorvastatin was discontinued on 2/12/2024. On 8/8/2024 at 11:10 A.M., the date of the response from the Physician related to discontinuing the order for 20 mg of Pantoprazole was requested, but one was not provided before the survey exit During an interview on 8/8/2024 at 11:05 A.M., the Director of Nursing (DON) indicated an acceptable time frame for the Medical Director to reply to the Pharmacists recommendations was two weeks. However, the facility had problems with their previous Medical Director responding timely to the Pharmacist recommendations and she had used her personal cell phone to reach out to the Medical Director to request he review the facility's Pharmacy recommendations numerous times. Documentation regarding the facility's attempt to contact the Medical Director about the Pharmacy recommendations was requested, but none was received before the survey exit. On 8/9/2024 at 11:02 A.M., the Regional Nurse provided an undated, unsigned letter and indicated it was a copy of a letter sent to the Medical Director from the Executive Director of the facility. The letter indicated the facility was terminating the recipient's position as Medical Director, effective 4/1/2024, due to the timeliness of reviewing compliance documents. On 8/7/2024 at 2:40 P.M., the Regional Nurse provided an undated policy, titled Addressing Medication Regimen Review Irregularities and identified it as the policy currently used by the facility. The policy indicated, .The pharmacist must report any irregularities to the attending physician, the facility's medical director and the director of nursing, and the reports must be acted upon 3.1-25(i)

Based on observation, interview and record review, the facility failed to store and prepare food in a sanitary manner in 1 of 1 kitchens. This had the potential to affect 88 out of 89 residents who ate food prepared in the kitchen. Finding includes: During an observation of the kitchen, with the Dietary Manager (DM), on 8/5/2024 at 9:07 A.M., the following was noted: -Vegetable burgers, strawberries, and 3 tubs of ice cream in the reach-in freezer were not dated. -Food processor bowls stacked together and stored as clean, were still wet on the inside. -The ductwork and ceiling in the food preparation area had a thick layer of dust. -The electrical outlet above the spices was dusty. -Two large and one small pans had missing and/or flaking Teflon coating on the cooking surface. During an interview on 8/5/2024 at 9:20 A.M., the DM indicated the food in the reach-in freezer should have been dated, the food processor bowls should have been dry before stacking them, the ceiling, ductwork, and electrical outlet should have been free of dust, and the Teflon pans should have been replaced. On 8/12/2024 at 10:52 A.M., the Director of Nursing provided a current policy titled, Food Safety and Sanitation. The policy indicated, .Label foods with delivery date and discard date , .Freezer temperatures should be 0 [degrees] or below to ensure frozen foods remain frozen . and .Follow a regular written cleaning schedule and document cleaning 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to maintain a sanitary environment related to clean air vents and dirty ceiling tiles on the 500 Hall. Finding includes: During an observation, on 8/8/2024 at 12:30 P.M., a food cart was sitting under an air vent on the 500 hall. The vent had a thick layer of dust and the dust was mixing with condensation, forming droplets of mud. The droplets were falling onto the food cart below it. During a environmental tour with the Director of Maintenance (DM) on 8/8/2024 at 12:30 P.M., the 500 hall had five vents on the ceiling and all 5 vents and the four ceiling tiles surrounding the vents and/or light covers had a thick build up of dust. One of the vents had condensation mixed with the dust and mud colored droplets were dripping down to the floor. During an interview with the DM on 8/9/2024 at 8:30 A.M., he indicated the reason there was condensation on the ceiling vents was due to residents opening their windows in their rooms and causing humidity in the facility. The vents and ceiling tiles should not be dirty and the DM was unsure if it was the maintenance department or housekeeping's role to clean the vents and ceiling tiles. During an interview with the DM on 8/12/24 11:29 A.M., the DM indicated it was the responsibility of the maintenance department to clean the ceiling tiles and vents. The facility was working on adding cleaning the vents and ceiling tiles to the maintenance department's current tasks to ensure the vents and ceiling tiles would be cleaned regularly in the future. On 8/12/2024 at 10:52 A.M., the Director of Nursing provided a policy, dated 4/2024, titled, Safe and Homelike Environment and identified it as the policy currently used by the facility. The policy indicated, . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment 3.1-19(f)

Based on interview and record review, the facility failed to ensure a cognitively impaired resident was not videoed with derogatory captions on a social media network. This deficient practice had the potential/likelihood of a negative psychosocial outcome, resulting from the facility's noncompliance to protect the resident from humiliation related to the derogatory video and captions. (Resident E) Finding includes: A facility self-report incident #444, dated 11/4/23 at 5:41 P.M., indicated Resident E had been posted on a social media network, titled (name), in a 15 second video, sleeping in bed and CNA 3 speaking in garbled slang speech with an inappropriate text below the video. It was requested CNA 3 immediately delete the video, which she stated she did. A typed statement, undated, indicated the Administrator and the Director of Nursing (DON) had spoken to CNA 4, . the individual/employee who allegedly posted the video of resident [name of resident] on (social Media application) .We became aware of the video via nurse manager on call, [name of Nurse Manager] who had seen the video via a C.N.A. [name of CNA 4 and phone number] who follows [name of CNA 3] and is related to her CNA 4 identified the originator of the video as being CNA 3. CNA 3 had last worked on Monday 10/30/23 and was a no call no show for her scheduled shifts since 10/30/23. The Administrator contacted CNA 3 via a phone call and left her a message to return his call, she contacted him on 11/4/23. The statement indicated .When we heard back from her we explained what we had seen regarding the (name of social media network) video. She initially denied the allegation (I don't know what you all are talking about) but when I pressed her further and said we had actually seen the video, she then acknowledged that yes that was her junk but she said she thought it was private and just to her friends. We explained to her that regardless of intent it is against our policy. We are to never to take videos or pictures of residents for personal purposes and post on our ( social media application) or other social media pages, even if just for our family or immediate friends. We questioned her about the text message that went with the video and she stated that her son had put that s**t on the video and denied posting any messages She was then informed of her suspension and likelihood of termination to which she responded she had already quit. On 11/28/23 at 9:45 A.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but were not limited to: nontraumatic subarachnoid hemorrhage, malignant neoplasm of prostate, depression and Alzheimer's Disease. A Quarterly Minimum Date Set (MDS) Assessment, dated 8/28/23, indicated the resident had severe cognitive deficits. A Care Plan, dated 8/11/23, indicated resident had behaviors of hitting, kicking staff and resistive to care. The interventions included but not limited to: intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner and caregivers were to provide opportunities for positive interactions. A Psychiatric Session Summary, dated 10/31/23/at 1:00 P.M., indicated .Writer met with resident in his room. Resident was appropriate and engaged. Resident denied concerns with mood, appetite or sleep. Writer began building rapport and provided supportive and cognitive stimulation therapy. Resident showed no signs of agitation or distress. Agreed to meet again. Facility staff consulted. Behavioral health services to continue A Progress Note, dated 10/31/23 at 6:32 P.M., indicated .Resident very combative this shift, refused medication. At dinnertime when resident was attempted to be changed and up with cna resident very combative and agitated During an interview, on 11/28/23 at 10:09 A.M., the DON indicated she had seen the video and it was of Resident E. He was lying in bed and cursing at CNA 3, who had posted the video. She did not remember any caption or what was being said during the video. During an interview, on 11/28/23 at 11:17 A.M., Nurse Manager indicated CNA 4 had received a notice that she had a new video and when she observed the video it was of Resident E. He was without a shirt and calling the CNA 3 a pain in the a *s. At the bottom of the video was a slang word which indicated the CNA 3 was taunting him. The Nurse Manager indicated there was an emoji with a picture of a skull laughing which means dying laughing. The Nurse Manager indicated it appeared CNA 3 was making fun of him and aggravating him in the video. During an observation of the video, on 11/28/23 at 11:18 A.M., with the DON, the resident said something, then CNA 3 stated That's why your teeth are moving and resident was heard to say you're a pain in the a*s. Resident was observed lying in a bed, shirtless. There was a caption, in the video, of several emojis-smiling faces with tears (laughing so hard you are crying) with words stating I'm so irritating. And caption, at the bottom of the video, was observed to say I be trolling they a*s, with several emojis of smiling faces with tears pouring out and skulls expressing dying laughing. The definition of a skull emoji was retrieved, on 11/28/23, from Emojipedia.org. a website which indicated the emoji skull was A whitish-gray, cartoon-styled human skull with large, black eye sockets. Commonly expresses figurative death, e.g., dying from laughter, frustration, or affection. An electronic dictionary (www.dictionary.com), indicated trolling was to .make a deliberately offensive or provocative online post with the aim of upsetting someone or eliciting an angry response from them On 11/27/23 at 5:11 P.M., the Administrator provided a policy titled, Abuse, Neglect and Exploitation, dated February 2023 and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s) On 11/28/23 at 9:59 A.M., the DON provided a policy titled, Social Media Use, dated February 2023 and indicated the policy was the one currently used by the facility. The policy indicated It is the policy of this company to avoid inappropriate use of social media and to protect the resident, staff, visitors, volunteers and practitioners of this facility against misuse of social media content .1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information This Federal tag relates to complaint IN00421297. 3.1-27(a)(1)

Based on record review and interview, the facility failed to facilitate self-determination through resident choice, for 1 of 3 residents reviewed, when the facility allowed a resident to be showered by a person who was not an employee and who was not given permission by the resident or resident's responsible party, to shower the resident. (Resident C) Findings include: On 8/31/23 at 3:10 P.M., Resident C's record was reviewed. The resident was admitted to the facility with diagnoses that included Alzheimer's Dementia, dementia, and debility. Resident C's most recent comprehensive MDS (Minimum Data Set), was a Quarterly assessment dated [DATE], and indicated the resident was severely cognitively impaired, had no speech, was rarely able to make herself understood and rarely understood others. The resident required the extensive assistance of 2 people for transfers, required the assistance of 1 person for personal hygiene, and was dependent on a wheelchair for locomotion. The MDS did not code the resident for bathing and showers, which indicated the resident had not been bathed or showered by the facility in the 7 day look back assessment period. Resident C's Care Plans included: [Resident C] is dependent on staff for meeting intellectual, physical, and social needs due to cognitive deficit . Dated 11/21/2019. [Resident C has and ADL (Activities of Daily Living) self-care performance deficit d/t [due to] cognitive impairment, restricted/impaired mobility, dementia .BATHING/SHOWERING: Showers twice/week [Resident C] requires staff assist . On 8/31/23 at 11:20 A.M., during an interview with the Administrator, he indicated that Family Member 1 notified him that a distant relative had been coming to the facility and showering Resident C without permission. The Administrator indicated upon his investigation; he learned the person was a distant relative of Resident C's late husband. The Administrator indicated on 8/21/23 the distant relative came to the facility and he spoke with her. He indicated the distant relative reported she came to the facility every couple of weeks to help shower Resident C and to do her hair. The Administrator indicated there was no permission from the POA in the resident's records. On 9/01/23 at 10:23 P.M., during an interview with Family Member 1, who was Resident C's POA (Power of Attorney), she indicated she received a call from her sister who had gone to the facility to collect the resident's laundry on 8/20/23 and was informed by RN 2 that another family member came in to shower the resident and also took the resident's laundry to wash. Family Member 1 indicated she questioned her family members, but no one had been in to shower her mother or take the laundry out. Family Member 1 indicated she called the facility and spoke to RN 2 who indicated she did not know who the person was that came to shower Resident C, but that she had been coming to shower the resident for about 4 months. On 9/01/23 at 10:38 A.M., during an interview with the Memory Care Unit Manager, she indicated she received a call on 8/20/23 from Family Member 1, who wanted to know who was coming to the facility to shower her mother. The Memory Care Unit Manager indicated she was not at work, so she called RN 2 who reported an unknown family member had been coming to shower the resident. On 9/01/23 at 11:28 A.M., during an interview with CNA 1, she indicated she had seen a person she thought was a family member come to shower Resident C at least 2 times. On 9/01/23 at 11:45 A.M., during a telephone interview with the distant family member, she indicated Resident C's late husband was her great uncle. The distant family member indicated she had been showering the resident for the past 3 or 4 months just to help out, and indicated she was given permission by someone in Resident C's family, but could not remember who. RN 2 was unavailable for interview. On 9/01/23 at 1:50 P.M., the Director of Nursing provided a current policy titled, Activities of Daily Living (ADLs), Supporting, dated 3/2018, that indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care . This Federal tag relates to complaint IN00416078. 3.1-3(a)(t)

Based on observation and interview, the facility failed to maintain clean exhaust ductwork and hoods in the kitchen and above food preparation area. This deficient pracice had the potential to affect 74 of 76 residents that had food prepared in the kitchen. Finding includes: During an observation, on 7/10/23 at 6:19 P.M., it was noted that the ductwork and hoods above the food preparation area were dusty and greasy. During an observation, on 7/11/23 11:50 A.M., ductwork and hoods above food preparation area was still dusty and greasy. During an interview, on 7/10/23 6:19 P.M., Employee 11 indicated she did not know who was responsible for cleaning the duct work and hoods above the food preparation area. During an interview, on 7/11/23 10:41 A.M., Employee 12 indicated he was unsure how often ductwork and hoods are cleaned, and that maintenance was responsible for cleaning them. During an interview, on 7/14/23 10:25 A.M., Employee 13 indicated that ductwork and hoods are cleaned once a month and that the ducts in the kitchen were cleaned on 7/12/2023. He indicated he was new to this position and unsure of what the procedure and cleaning schedule was for cleaning the ductwork and hoods prior and was unsure when they were last cleaned. On 7/14/2023 at 9:00 A.M., a current policy issued 9/01/2021 with no revision date was provided by the ED. The policy indicated .All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The dining services director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation 3.1-21(i)(2)

Based on record review, observation and interview, the facility failed to revise/update a resident care plan when a wander guard was discontinued for 1 of 21 residents whose care plans were reviewed. (Resident 46) Finding includes: The record for Resident 46 was reviewed on 7/13/2023 at 9:41 A.M. The diagnoses included, but were not limited to: Alzheimer's Disease, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depression. A Care Plan, dated 11/4/2021, indicated the Resident has a history of attempting to exit the facility. She utilizes a wander guard. During an observation, on 7/13/2023 at 2:26 P.M., there was no wander guard on the resident wrists or ankles. A Quarterly Minimum Data Set (MDS) Assessment, dated 6/26/2023, indicated wander/elopement alarm is not used. During an interview, on 7/14/2023 at 10:49 A.M., the Director of Nursing indicated that it was a joint effect of all Interdisciplinary Team (IDT) to update the care plans. They run off a report prior to morning meeting and review/update then on Wednesdays when the IDT meet and go over care plans due that week. She indicated does not exit seek as much as she used to and that her wander guard was not discontinued as she was still on the board in the Director of Nurses office. After the Director of Nursing reviewed the orders, she indicated it was discontinued on 9/16/2022 and the care plan should have been updated. On 7/14/2023 at 11:42 P.M., the Regional Nurse provided a policy titled, Care Plan Revisions Upon Status Change, dated 2022, and indicated the policy was the one currently used by the facility. The policy indicated .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. f. Care Plans will be modified as needed by the MDS Coordinator of other designated staff member 3.1-35(e)

Based on observation, record review and interviews, the facility failed to ensure showers and/or nail care was provided for 2 of 5 residents reviewed for Activities of Daily Living (ADL) needs. (Residents 44 and 48) Findings include: 1. The clinical record for Resident 44, reviewed on 7/13/2023 at 10:57 A.M., indicated the resident had diagnoses including, but not limited to: seizures, diabetes mellitus, end stage renal disease, dependence on dialysis, mild cognitive impairment, urine retention, hemiplegia, lack of coordination and weakness. The most recent Minimum Data Set (MDS) Assessment, completed for an annual review on 4/10/2023, indicated the resident required extensive staff assistance of one staff for personal hygiene needs and was dependent on staff assistance for bathing needs. The current care plan for Resident 44, included a plan to address the resident's ADL (Activities of Daily Living) self-care performance deficit. The plan included interventions to provide total care for bathing /showering needs twice a week on Wednesday and Saturday afternoons. The plan included the following intervention: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Resident 44 was observed, on 7/10/2023 at 7:00 P.M., lying in his bed, dressed in a hospital gown. His fingernails were observed to be very long and had a dark substance underneath them. Resident 44 was observed, on 7/12/2023 at 7:08 A.M., lying in his bed. His fingernails were long and had a dark colored substance. Resident 44 was observed, on 7/13/2023 at 9:47 A.M., lying in his bed in a hospital gown. His fingernails were long and had an orange-colored substance underneath them. The resident had just finished eating his breakfast from a tray on his over bed table. Resident 44 was observed, on 7/14/2023 at 10:17 A.M., up in his wheelchair in the main dining room. His nails were clean but were still very long. The shower sheet documentation for Resident 44 indicated he had received a shower on 7/8/2023 and had refused a shower on 7/12/2023. During an observation and interview of Resident 44's nails, on 7/14/2023 at 11:17 A.M., with the resident and RN 14, the resident's fingernails were long and had a slightly orange-colored substance underneath the nails. The resident shook his head no when asked if he preferred to have long fingernails. He agreed to have them trimmed when RN 14 offered the assistance after he returned from the dialysis center. RN 14 disclosed Resident 44' snails should have been trimmed during the showering/bathing care. During an interview, on 7/14/2023 at 10:45 A.M., the Director of Nursing indicated she would expect her staff to do the following care with showers: wash hair, provide pericare , put on deodorant, complete nail care, clean their body and get them dressed. 44111 2. The record for Resident 48 was reviewed on 7/13/2023 at 10:52 A.M. The diagnoses included, but were not limited to: dementia without behavioral disturbances, mood and psychotic disturbances, anxiety, and severe protein-calorie malnutrition. During an observation, on 7/11/2023 at 10:20 A.M., Resident 48 had a brown substance under her fingernails. During an observation, on 7/13/2023 at 1:21 P.M., a brown substance was under her fingernails. During observation, on 7/14/2023 at 10:25 A.M., a brown substance was under the residents fingernails. A Care Plan, dated 6/10/2021, indicated that she has an activity of daily living, self- care performance deficit due to her dementia, advanced age and lack of coordination. She requires extensive assistance from one staff member for bathing/showering, personal hygiene and dressing. During an interview, on 7/13/2023 at 3:22 P.M., Certified Nurse Aide (CNA) 15 indicated when she gives a shower, she gets all the supplies together, checks the temp of the water and washes the resident from top to bottom, including the hair, inspect the skin and cuts toe and finger nails. During an interview, on 7/13/2023 at 3:29 P.M., Certified Nurse Aide (CNA) 16 indicated that when she gives a shower, she gets the supplies together takes the resident to shower room and washes their hair, brushes their teeth, dries them off, applies lotion and puts on clothing. During an interview, on 7/14/2023 at 9:26 A.M., Certified Nurse Aide (CNA) 18 indicated when she gives a shower, she gathers all supplies needed, warms the water then assists with shaving and washing of the hair unless they go to beauty shop, washes them from top to bottom and gets them involved, then assists with drying and dressing. During an interview, on 7/14/2023 at 10:45 A.M., the Director of Nursing indicated she would expect her staff to totally give them a shower: wash hair, peri care, put on deodorant, do nail care, clean, and get dressed. On 7/14/2023 at 11:42 A.M., the Regional Nurse provided a policy titled, Nail Care, dated 2022, and indicated the policy was the one currently used by the facility. The policy indicated .3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person responsible for providing nail care 3.1-38(3)(E)

Based on observation, record review and interview, the facility failed to ensure 2 of 2 residents reviewed for hearing needs received timely treatment and received recommended hearing devices. (Residents 60 and 29) Findings include: 1. During the initial tour of the facility, conducted on 7/10/2023 between 6:15 P.M. and 7:15 P.M., Resident 60 was observed in her bed. She had a distorted speech pattern. She indicated she could not hear very well and needed to read the lips of the person speaking with her. During the conversation, at times, the resident would apologize and state I just do not know what you are trying to ask me. There was no paper or dry erase board noted within reach of the resident. During an interview with Resident 60, conducted on 7/12/23 at 9:43 A.M., she indicated she was waiting on hearing aids, could read lips but could not really hear very much at all. During an interview with Certified Nurse Aide (CNA) 3 at 7/13/2023 at 11:45 A.M., she indicated the resident sometimes does not understand as she reads lips and lately, with the seizures, the resident was more confused. The record for Resident 60, reviewed on 7/13/2023 at 9:13 A.M., indicated the resident was admitted with diagnosis, including but not limited [NAME] bilateral hearing loss. The most recent Quarterly Minimum Data Set (MDS) Assessment for Resident 60, completed on 2/8/2023, indicated the resident hearing was highly impaired and sometimes understood spoken word. A current care plan regarding hearing and communication needs, initiated on 11/25/2022 included the following: (Resident's name) had difficulty hearing. The interventions included Anticipate needs, (resident' name is able to communicate by: lip reading, writing, gestures, and talking loudly directly beside her ear During an interview with the Social Services Director (SSD), on 7/13/2023 at 2:30 P.M., she indicated she was not aware of any resident waiting on hearing aids, but after she researched she discovered the hearing aids for Resident 60 were not made or delivered yet because the audiology clinic was waiting on payment for the hearing aides from the resident's Power of Attorney (POA). During an interview with SSD, on 7/14/23 at 8:30 A.M., she indicated she had gotten ahold of the resident's POA/sister, and she had not received a bill for the hearing aides, just the hearing evaluation. The SSD indicated Resident 60's sister was going to call the audiology office and pay the bill for the hearing aids. The SSD indicated the resident had a hearing evaluation, on 3/16/2023 and she did not know where the breakdown in communication had occurred. She indicated the facility was without an in-house audiology provider off and on for the past year. She did not know why it took so long to get the resident scheduled for an audiology exam, after she was initially admitted . The consent for audiology services had first been signed, for Resident 60, on 4/12/2022. Review of the care plan meeting notes, from 2/28/2022 through 3/7/2023 indicated Resident 60's diagnosis were listed on some of the notes, including bilateral hearing loss, but there was no mention of the resident's highly impaired hearing loss and communication needs. 48054 2. During an interview, on 7/10/2023 at 8:28 P.M.,Resident 29 indicated he was having hearing issues and that he had hearing test one year ago, was supposed to have gotten hearing aids at that time but had not heard anything about hearing aids since testing. A record review, on 7/12/2023 at 3:18 P.M., indicated that Resident 29 had a hearing test on 5/11/2022 with (Name) audiology group. A hearing aid recommendation was made at that time with mold taken for hearing aid left shell. A medical clearance was requested at that time for approval of hearing aid. Resident 29 had diagnoses that included, but not limited to: hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side,epilepsy and anemia. A MDS dated [DATE], indicated resident had adequate hearing with ability to understand others and no hearing aid. A MDS dated [DATE], indicated resident had adequate hearing with ability to understand others and no hearing aid. A MDS dated [DATE], resident had adequate hearing with ability to understand others and no hearing aid. During an interview, on 7/12/2023 at 3:26 P.M., Employee 10 indicated that if resident sees the facility associated audiology group( Name) and a recommendation is made for hearing aids, social services receives the recommendation and they obtain the MD order and clearance. During an interview, on 7/12/2023 at 4:07 P.M., Employee 10 indicated that there was a change in the charting system and Resident 29 fell through the cracks and the order and recommendation for hearing aid were not received. She spoke with the office manager of audiology group and the resident will have to have new test and fitting for hearing aids in the future to obtain one. A current policy titled Hearing and Vision Services with no implementation or revision date, was provided by the DON, on 7/14/2023 at 1:48 P.M. The policy indicated that .It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social service designee is responsible for assisting resident, and their families, in locating and utilizing any available resources (e.g. Medicare or Medicaid programs payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs. Once vision or hearing services have been identified, the social worker/social services designee will assist the resident by making appointments and arranging for transportation. Assistive devices to maintain hearing include, but are not limited to, hearing aids and amplifiers 3.1-39(a)(1)

Based on observation, interview and record review, the facility failed to elevate the head of bed when an enteral feeding pump was infusing, and label feeding bags where appropriately for 1 out of 1 resident reviewed for tube feeding. (Resident 48) Finding includes: The record for Resident 48 was reviewed on 7/13/2023 at 10:52 A.M. The diagnoses included, but were not limited to: dementia without behavioral disturbances, mood and psychotic disturbances, anxiety, and severe protein-calorie malnutrition. A Physician Order, dated 6/21/2023, indicated to elevate HOB (head of bed) 30 - 45 degrees at all times. A Physician Order, dated 6/21/2023, indicated glucerna 1.5 to be ran at 45 ml/hr (milliliter per hour) continuously throughout 24 hours via G-tube. A Care Plan, dated 11/25/2022, indicated she needed the head of her bed elevated 45 degrees during and 30 minutes after tube feed. During an observation, on 7/11/2023 at 10:14 A.M., Resident 48 had a tube feeding infusing, there were 2 bags hanging both dated 7/11 with a time of 10 A.M. one with tan liquid and the other a clear liquid. During an observation, on 7/12/2023 at 2:46 P.M., the resident was in bed lying on her right side in a fetal position with the bed not elevated, and 2 bags infusing one with tan liquid and the other with clear liquid dated 7/12/23 infusing at 45 ml/hr. During an interview, on 712/2023 at 2:51 P.M., Licensed Practical Nurse (LPN) 19 indicated that her head of bed should be elevated when her feeding is running. During an interview, on 7/14/2023 at 9:12 A.M., the Director of Nursing indicated that she would expect her staff to check for placement and make sure bags are dated and appropriate, pumps on correct settings and pump cleared, head of bed up and check periodically that it is flowing correctly and verify the orders. On 7/14/2023 at 3:54 P.M., the Regional Nurse provided a policy titled, Enteral Tube Feeding via Continuous Pump, dated November 2018, and indicated the policy was the one currently used by the facility. The policy indicated .The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. 4. Position the head of the bed at 30-45 degrees for feeding. 5. On the formula label document pintails, date and time the formula was hung/administered, and initial that the label was checked against the order 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to ensure medications were labeled and stored appropriately in 1 of 2 medication rooms and 1 of 3 medication carts observed. (300/400 hall medication room, and Dementia unit medication cart) Finding includes: During observation of medication rooms, conducted on 7/12/2023 at 10:15 A.M., the following was observed in the 300/400 hall medication room: -2 bottles and one carton of dietary shake supplements were stored in the medication refrigerator along with two unopened vials of insulin. During an interview with Licensed Practical Nurse (LPN) 4, on 7/12/2023 at 10:20 A.M., she indicated there was no pantry refrigerator to store nutritional supplements in, so they just used the medication refrigerator. During an observation of a medication cart on the secured, Dementia unit, conducted on 7/12/2023 at 10:30 A.M., the following was observed: - A box containing a bottle of over- the- counter aspirin tablets. There was no label on the box or the bottle, the resident's name was written on the bottle but, the dose and physician's name were not written on the bottle and/or box. During an interview with LPN 22, an agency nurse, she indicated the pharmacy was actually sending the aspirin tablets in the plastic sleeve type bags, so the facility was not actually utilizing the bottle of aspirin. The facility policy and procedure, titled, Medication Storage and Medication Labeling, provided by the Director of Nursing, on 7/13/2023 at 4:08 P.M. included the following: .6. Medication are stored separately from food and are labeled accordingly .Medication Labeling: 1. Labeling of mediations and biological dispensed by the pharmacy is consistent with applicable federal and state requirement and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name; b. prescribed dose; c. strength; d. expiration date, when applicable; f. route of administration; and g. appropriate instructions and precautions .5. Multidose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial 3.1-25(j)

Based on observation, interview and record review the facility failed to implement interventions to prevent the development of a resident identified at risk for one out of one residents reviewed for skin integrity. (Resident 38) Finding includes: A clinical record review was completed, on 3/31/22 at 1:40 P.M., and indicated Resident 38's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated the resident was admitted on [DATE]. An Admission MDS (Minimum Data Set) assessment, dated 1/15/2022, indicated Resident 38's BIMS (Brief Interview for Mental Status) severely impaired cognition and he needed extensive assist with activities of daily living. A Braden Assessment, dated 12/28/2021, indicated he is at risk for pressure areas with a score of 16. On 3/30/2022 at 9:25 A.M., observed the Resident 38 sitting up in his bed eating breakfast, his feet were bare with no boots in place, and his right foot had an black and red area on the edge/ plantar area of the foot. On 3/31/2022 at 9:22 A.M., observed the resident lying in bed with socks on his feet, no boots in place, and right foot against the foot board of the bed. During an interview, on 3/31/2022 at 10:01 A.M., CNA (Certified Nursing Assistant) 16 indicated he gets up sometimes, and she's getting him up today, she does not think he has any other skin issues except the area on the bottom. During an interview, on 3/31/2022 at 10:15 A.M., RN (Registered Nurse) 12, indicated he only had the area on his sacrum and bruising on his arms. During an interview, on 3/31/2022 at 10:20 A.M., RN (Registered Nurse) 12 indicated the skin is checked weekly by the nurse, she indicated it will pop up in the Medication or Treatment Administration Record and a skin assessment is form is filled out. On 3/31/2022 at 10:56 AM., observed the RN (Registered Nurse) 12 remove Resident 38's socks and indicated that is eschar on the right side and bottom of the foot, and ball of left foot looks like pressure from staying in bed may have been hanger from the low air loss machine and the foot board, the right heel was palpated by nurse and she indicated the heel was soft and mushy but blanchable. A Physician Order, dated 3/29/2022, indicated float heels while in bed, every shift for prevention. A Physician Order, dated 3/29/2022, indicated pressure reducing/relieving boots as tolerated every shift. A Physician Order, dated 3/39/2022, indicated low air loss mattress, check placement and function of mattress/pump every shift. Set to resident comfort every shift. During an interview, on 3/31/2022 at 11:26 A.M., RN (Registered Nurse) 12 indicated he should have boots on his feet. During an interview, on 3/31/2022 at 11:21 A.M., CNA (Certified Nursing Assistant) 16, Indicated they have not been putting boots on him. She indicated she did look for some boots but none were found in the room. A Care Plan, dated 2/10/2022, indicated intervention boots to bilateral feet at all times when in bed to protect heels. A Care Plan, dated 2/10/2022, indicated intervention LAL mattress- set at resident comfort level. On 4/1/2022 at 10:20 A.M., the Director of Nursing provided a policy titled, Prevention of Skin Ulcers/Injuries, dated July 2017, and indicated the policy was the one currently used by the facility. The policy indicated .The purpose of this procedure is to provide information regarding identification of skin ulcer/injury risk factors and interventions for specific risk factors. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency, b. inspect pressure points(sacrum, heels, elbows, etc) 3.1-40

Based on record review and interview, the facility failed to ensure a Resident, who utilized a wheelchair as her main mode of transportation, was properly secured in the facilities transportation bus, while being transported to and from an appointment, resulting in the resident sliding out of the wheelchair onto the floor of the bus and fracturing her ankle when the bus driver had to break hard to avoid an accident. This deficient practice affected 1 of 1 residents reviewed for accidents. (Resident C) Finding includes: During an interview with Resident C, on 5/24/2021 at 1:30 P.M., she indicated she fell out of her wheelchair during transportation from a doctor's appointment and fractured her ankle. She indicated she was strapped into the transportation van but fell on to the floor and sat on her ankle and subsequently breaking it. A Reportable Incident, dated 4/22/2021, indicated .Brief Description of Incident: 4/22/2021 Facility transportation driver [name of driver] notified the facility that when transporting Resident (BIMs 15) [Brief Interview for Mental Status score, which indicated Resident is cognitively intact] he had to brake hard to avoid an accident and resident slid from chair to the floor of the van. Resident was transferred to the hospital by 911 for evaluation and treatment .Type of Injury: 4/22/2021 Hospital notified facility that resident had a fractured ankle .Immediate Action Taken: 4/22/2021 Resident is own responsible party. Physician notified. Driver returned to facility to demonstrate procedure of securing w/c [wheelchair] and seat belt. Driver returned to duties after demonstration of proper securing procedures .Follow up: 4/30/2021 Resident returned from hospital with left ankle fracture. Facility will continue to follow physicians orders and monitor though healing. No further concerns or incidents noted with transportation, driver was successful in demonstrating proper securing of wheelchair. Noted that seat belt and shoulder strap were placed on resident, but placement was above waist line so when bus stopped, resident slid forward under the seatbelt, then sitting on the floor. When resident sat on the floor, she also sat on her ankle resulting in a fracture. Facility did not substantiate any findings of intentional abuse or neglect During an interview with Transportation Driver 11 on 5/26/2021 at 2:30 P.M., he indicated he had been the driver who transported Resident C to her doctor's appointment on 4/22/2021, on the way back from that appointment another driver cut him off and he had to brake hard to avoid getting into an accident and that when he slammed on his brakes Resident C slid down onto the floor and landed on her leg and broke her ankle. The Transportation Driver then demonstrated how he secured the resident into the seat and indicated the belt was secured on her upper waist, above the wheelchair arms, not below and on her lower waist. During an interview with the Executive Director of the facility on 5/27/2021 at 11:30 A.M., he indicated the facility had reported an incident in which a resident had slid out of their wheelchair onto the floor landing on her leg and subsequently breaking her ankle. The driver, he indicated, had her secured with the seat belt and shoulder strap but the placement of it was above her waistline. The facility did education with him and he did a return demonstration and returned to duty and the facility has had no further incidents. The Executive Director indicated there was no policy or procedure for securing a resident. Best Practices For Using a Wheelchair as a Seat in a Motor Vehicle (January 2008) was retrieved on 5/28/2021 from the Wheelchair Transportation Safety website at www.umtri.umich.edu. The guidance indicated .8. Insist that the seat belt not loop over the arm rests or cover any devices mounted on the chair, such as an augmentative communication device or lap tray. Explanation: The seat belt protects the rider only when it fits snug and low across the pelvis. The farther away from the body it is, the less protection it can give This Federal tag is related to Complaint IN 288. 3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure a resident was adequately medicated for pain prior to and during dressing changes with extensive wounds that required daily dressing changes for 1 of 1 residents reviewed for pain, resulting in the resident having increased anxiety and pain prior to and during dressing changes (Resident 31). Findings include: On 5/24/21 at 1:59 P.M., the clinical record for Resident 31 was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was confined to bed and received hospice services. A quarterly MDS (Minimum Data Set) assessment, dated 4/16/21, indicated the resident had a BIMS (Brief Interview Mental Status) score of 11 which signified he had moderately impaired cognition. He required extensive assistance with 2 staff members for bed mobility. He had no behaviors, rejection of care, or mood indicators but did complain of occasional pain when questioned. Care plans indicated the following: -Resident had pain and discomfort at times related to poor mobility due to obesity, relied on staff to help him reposition, and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was to remain free from pain. Interventions were to assist with ADL's (care), document effectiveness or not of the medications, ensure call light is within reach, monitor daily for physical symptoms associated with pain, offer comfort measures and pain medications and offer pain medications as prescribed and monitor adverse reactions. -Resident has a terminal prognosis related to heart failure and utilizes hospice services (8/2/2019). The goal was the resident's pain would be managed at a level acceptable to him and his personal care needs would be met. Interventions included, but were not limited to, coordinate care with the facility and hospice to ensure an effective plan of care, hospice and facility CNA (Certified Nursing Assistant) to coordinate ADL's: shower, skin care, grooming, etc, hospice nurses and home health aids visit 2 times/week, hospice and facility nurse to monitor the resident's pain level and report ineffective pain control to the physician, and treatment to pressure ulcers per physician orders. -Resident has elected a DNR (Do Not Resuscitate) code status (2/7/2019). Interventions included, but were not limited to, keep the resident comfortable and pain free per physician orders. -Resident has a behavior problem related to anxiety and exhibits yelling out during care and will accuse staff of hurting him before they touch him to do treatments (Revised 1/14/20). Interventions included, but were not limited to, anticipate and meet the residents needs, assure the resident throughout care that staff are trying to make sure he has no pain, and monitor behavior episodes and attempt to determine the underlying cause. On 5/23/21 at 11:38 A.M., Resident 31 was observed lying in his bed. His legs were spread apart with a wedge in between them at the end of the bed. He complained of his feet hurting and indicated feels like someone took a ball bat to my feet. On 5/25/21 at 10:15 A.M., the resident was observed lying in bed with the head of the bed up at almost 90 degrees. He was lying in poor alignment and laid diagonally across the bed with his head and neck bent forward and lolling over to the right side. His left leg laid near the left side of the bed. At 2:42 P.M., Resident 31 was observed lying in bed. He laid diagonally across the bed with his head and neck bent forward and lolling over to the right side. His left leg remained near the left side of the bed. The resident indicated he hurt on his left leg and that it needed to be moved. At 2:50 P.M., 2 staff members came into the room and told the resident they were going to change and reposition him. The room to the door was closed but the resident could be heard in the hallway yelling that he hurt and for staff to stop and not to touch him. On 5/27/21 at 11:20 A.M., LPN 2 (Licensed Practical Nurse) was observed getting ready to go into Resident 31's room. She had a treatment cart with her and indicated she was going to give the resident his scheduled Tylenol for pain and then was going to change his dressings. At 11:29 A.M., the Director of Clinical Operations, DON (Director of Nursing), LPN 2 and 2 CNA's were in the resident's room to change his dressings. The resident indicated he needed to poop but couldn't. The dressings to his left calf were removed. The DON removed 1/2 of the dressing to the left calf which had dried red and brown fluids on it and which stuck to the wounds. The wounds started bleeding. She then used normal saline to moisten the remaining 1/2 dressing and removed it. The resident had a chronic wound to his calf that had 3 large open areas which were bordered by thick yellow slough. There were several pinpoint areas of bleeding and a large amount of bleeding from the large open area nearest to his knee which appeared after the dressing was removed. There were multiple dime sized areas of black tissue on the calf and the skin surrounding the wounds had thick, yellow scales. LPN 2 applied a large amount of [MEDICATION(S)] to an ABD pad and placed it on his calf-then wrapped it with a kerlix dressing. Resident 31 yelled throughout the procedure and stated it hurts and stop, stop. He begged staff not to cut me down there (resident has had necrotic tissue cut away from the wound in the past). The resident was then assisted to turn over where he was found to have 2 large foam dressings attached to his buttocks and upper thighs which were partially covering his anus making it difficult to have a bowel movement. Both foam pads had dried stool along the edges farthest away from his anus. LPN 2 pulled each foam pad off quickly and the resident yelled over and over that it hurt. He then had an extremely large bowel movement as soon as the dressing was removed. The area on his buttocks was cleaned of stool and his bottom and upper back of his thighs were observed to be excoriated with several open areas that were now bleeding. His entire bottom and back of his thighs were non-blanchable and were purple to black in color. There was a skin fold on the back of his left thigh that appeared to have yellow slough in the crease and there was an open area on the back of his right thigh that had undefined edges and appeared as beefy red, ground meat skin. The skin on his buttocks and upper back of his thighs had a foul, sweaty odor after being cleansed of BM. The resident continued to yell in pain to his bottom and his knee and again, stated for staff not to cut him down there. LPN 2 then reapplied the sticky foam pad to each side of his buttocks and thighs and he was positioned onto his back. Resident 31 stopped yelling in pain after staff no longer touched him. On 5/27/21 at 2:15 P.M., Hospice RN 9 was interviewed. During the interview, she indicated she had cared for the resident the past year. She indicated Resident 31 had had wounds since being admitted to hospice in 2019. The wounds were chronic and would heal and then reopen again. He was followed by hospice and the facility's wound doctor who visited each week. RN 9 indicated, in the recent past, she would look at his wound with the wound doctor and unit manager each week and his wounds would be measured and changes made to his treatments if needed. She and other hospice staff came into visit the resident and bathe and change his dressings on Tuesdays and Thursdays. RN 9 was aware the resident's dressing had been changed earlier but they were soiled and needed changed again. She and hospice CNA 10 were observed to turn Resident 31 over. RN 9 gently and slowly removed the foam pads from his buttocks. When questioned, she indicated his wounds looked worse than when she had seen them last on Thursday, 5/20/21. There was no bleeding noted to the open areas on his buttocks and upper thighs. She indicated, if staff pulled the sticky foam dressing off too quickly, it would tear his skin and make him bleed. She applied new foam pads to his buttocks and thighs and he was assisted to lie back on his back. During the procedure, Resident 31 yelled out in pain however, hospice staff were successful for short moments in diverting his attention. RN 9 indicated the resident always yelled out when moved and touched and was on a pain management program. A physician order, dated 11/23/2020, was for [MEDICATION(S)] solution 20 mg (milligrams)/ml (milliliter)-give 0.25 ml by mouth every 2 hours as needed for pain. Give a PRN (as needed) dose at 9:00 a.m. before wound care. Review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) indicated the following: -March 2021: The TAR indicated behavior monitoring for behaviors of yelling out during care and expressions of discomfort before being touched. His wound care with dressing changes were scheduled for 9:00 a.m. each day. The TAR indicated the resident had behaviors on day shift 1 time during the entire month which was on 3/31/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -April 2021: The TAR indicated behavior monitoring for behaviors of yelling out during care and expressions of discomfort before being touched. His wound care with dressing changes were scheduled for 9:00 a.m. each day. The TAR indicated the resident had behaviors on day shift on 4/11, 4/13, 4/16, 4/17, 4/18 x3, 4/20 x3, 4/29 x3, and 4/30/21 x5. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -May 2021: The TAR indicated behavior monitoring for behaviors of yelling out during care and expressions of discomfort before being touched. His wound care with dressing changes were scheduled for 9:00 a.m. each day. The TAR indicated the resident had behaviors on day shift on 5/1 x2, 5/2 x3, 5/4 x3, 5/14 x4, 5/15 x4, 5/16 x4, 5/17 x4 and 5/21/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/28/21 at 3:32 P.M., the Administrator provided a current copy of the facility policy titled Pain Assessment and Management which stated the following: Purpose is to help staff identify pain and develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain, Effectively recognizing the presence of pain .Addressing the underlying causes of the pain 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe, secure environment to prevent elopement for 1 of 1 resident reviewed for elopement (Resident B). The facility failed to ensure the resident's window was secure, failed to complete window safety checks, and failed to complete monitoring of the resident every 15 minutes as care planned, leaving the facility unaware Resident B had exited the facility unsupervised for 45 minutes until he was found 1.3 miles away on a busy street. The immediate jeopardy began on 8/04/2020 when Resident B exited the facility through his window in the memory care unit, resulting in Resident B being found 1.3 miles from the facility, on a busy street. The Facility Administrator and the Director of Clinical Operations were notified of the immediate jeopardy on 9/01/2020 at 4:57 P.M. The immediate jeopardy was removed on 9/3/2020, but 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. Finding includes: A clinical record review was conducted on 8/31/2020 at 11:35 A.M., and indicated Resident B was admitted on [DATE]. His [DIAGNOSES REDACTED]. A hospital discharge document, prior to admission of Resident B to the facility, indicated Resident B was medicated in the hospital due to .agitated and uncontrollable . and there was a recommendation for admission to .a monitored bed A nurse's note, dated 6/18/2020, indicated Resident B had a Wanderguard (a bracelet that has a sensor inside it to alert elopement attempts) on his left ankle and was moved to a different room closer to the nurses' station on the memory unit due to an elopement risk. An incident report, dated 6/19/2020 at 2:01 P.M., indicated the resident was seen through the therapy gym window climbing out of his window after breaking the set screw that only allows the windows to partially open. The resident resided on the memory care unit. Preventative measure taken was placing resident on 1:1 staff supervision. Follow up indicated, .visible through the therapy windows, resident was seen by another resident climbing out of their window, and remained there while putting the screen back in. Other resident notified the Physical Therapy assistant, who went outside, and walked the resident back into the facility. The resident stated that 'He had to get to work before dark.' The resident had broken the set screw which limits the space the window is able to be open. The screw was replaced, and other windows audited to ensure that the screw was in place, and functioning properly. Resident at this time was also placed on 1:1 supervision until 6/22/2020. Physician and family were notified about incident. On 6/22/2020, resident was discharged to Neuro Psych Hospital for evaluation and treatment A window check audit was made available for 6/21/2020, by the Administrator who indicated this was the only documented audit of the windows available. A nurse's note, dated 6/19/2020 at 2:29 P.M., indicated .Wandering, in hallway, requesting cigarettes. Multiple attempts to open secured doors only stopping behavior after alarms rang and attempted to elope out of his bedroom window by removing window screen. Unable to redirect from above behavior. Resident makes no eye contact when spoken to and repeats statement over and over 'how can I get out of here' A nurse's note, dated 6/19/2020 at 4:30 P.M., indicated .Resident remains on 1:1 on the unit d/t (due to) his multiple attempts to leave the unit (not easy to re-direct) currently showing no s/s (signs or symptoms) of agitation resident continues to pace throughout the unit. Family is aware of his behavior (climbing out of his window in his room as this is resulting in an emergency detention) he will remain on the 1:1 until he is transferred for further evaluation at a (local) medical behavior hospital sometime tomorrow A psychosocial note, dated 6/19/2020 at 4:51 P.M., indicated Social Service department made a referral to a neuro psych hospital; however, there were no available beds. A nurse's note, dated 6/20/2020, indicated Resident B continued on 1:1 supervision. A nurse's note, dated 6/20/2020, indicated .Observed up out of chair pushing on door, pacing at times, able to redirect back to seat A nurse's note, dated 6/21/2020, indicated 1:1 supervision continued. A nurse's note, dated 6/21/2020 at 4:00 P.M., indicated .Resident continues on 1:1 monitoring, in dining room for dinner, head on table, no s/s of distress or discomfort, oriented to person, able arouse easily. Up now pacing in dining room, looking out door, pushing on door, Wanderguard activated alarm A nurse's note, dated 6/21/2020 at 6:07 P.M., indicated .up in hallway pacing, says 'I need to get out, gotta get my drink and smoke.' 'Where is the bathroom.' Resident assisted to restroom, toileted self. Encouraged to rest, unsuccessful, continues to pace in hallway mumbling to self. Will continue to monitor 1:1. Reported off to next shift plans for possible discharge tomorrow 6/22/2020 for psychiatric treatment A physician progress notes [REDACTED].M., indicated .He removed his (wanderguard) ankle bracelet earlier today and does not seem to be able to explain the reasoning to the nurse. Pt (patient) is aphasic(speaking unrecognizable words) at times. He answers questions appropriately at times and then rambles on with word salad(speaking in random words or phases) at times. Nurse reported pt is exit seeking and has attempted to open alarmed door at times. Order was given to send to Neuro psych hospital for further evaluation and treatments. Neuro psych is still waiting for an available bed for pt A nurse's note, dated 6/23/2020, indicated Resident B was in the hospital. A nurse's note, dated 7/15/2020, indicated Resident B was admitted back to the facility. A behavior note, dated 7/20/2020 at 4:30 P.M., indicated .Upon making rounds by QMA (qualified medication aide) it was discovered that resident had removed security bolt from his rt (right) lower window ledge (Resident B's room number) and had removed the bottom screen. Resident was observed inside the room standing by the window and was never outside. Immediate 1:1 staff coverage for attempted elopement ordered until further notice A physician progress notes [REDACTED].Patient is seen today for follow up due to his recent neuro psych hospitalization . He was sent out to neuro psych hospital on June 23, 2020 for increased behavior that included yelling and throwing things in his room as well as trying to climb we know which (sic) comments that he has to go to work before it gets dark, he was also wandering 2 different rooms (sic), with increased confusion. At that time current psychiatric symptoms include and (sic) verbal aggression, impulsivity, delusions and [MEDICAL CONDITION]. He returned to (the facility) on 7/15. He is not in any acute distress at this time. However, he still seems confused and impulsive walking about the unit. No reports of fever, chills, or dyspnea noted. A referral order written for neurology consultation due to increased behaviors and history of recent brain lesion A MDS (minimum data set) Medicare 5 day assessment, dated 7/22/2020, indicated Resident B had severe cognitive impairment. A nurse's note, dated 7/22/2020 at 3:38 P.M., indicated Resident B was under 1:1 supervision and was wandering up and down unit. A nurse's note, dated 7/24/2020 at 2:24 P.M., indicated .1:1 staffing dcd (discontinued), and q (every) 15 min (minute) assessments initiated. No further evidence of attempts to elope thru window or elsewhere. Speech loud/garbled at time but is able to make needs known on most occasion (sic), Gait even/steady w/o (without) evidence of weakness or falls A behavior monitoring note, dated 7/26/2020 at 2:38 P.M., indicated .resident in his room seen by this nurse attempting to force open the window. Verbally redirected, unable to comprehend initially due to confusion. Resident eventually settled down on a chair in his room A physician progress notes [REDACTED].Patient is seen today for increased behavior follow up. He is observed walking about the unit. He has taken his bed apart but has not been aggressive today A nurse's note, dated 7/28/2020 at 2:45 P.M., indicated Resident B .Frequently requesting to leave building with staff to go to the bank. Able to redirect after several attempts A physician note, dated 8/3/2020, indicated .Patient is seen today for a follow up visit. He was reported to be exit seeking but not boisterous. He is observed looking out the window in his room. He appears to be calm at the moment but staff reports moments of him wanting to go outside when staff is leaving, saying that he needs to go the bank or such thoughts. Pt is very confused with obvious impaired judgement statements Documentation was lacking to indicate increased supervision was provided even though the resident attempted to exit the facility since 1:1 supervision was discontinued on 7/24/20. An incident report, dated 8/4/2020, indicated a .Brief Description of incident: resident was found to be outside of the facility, found by a staff member that was off duty. Resident was last seen in the secured dementia unit at 8:45 P.M., and noticed at 9:30pm. Resident was returned to the facility safely. Preventive Measures taken: resident was immediately placed on 1:1 supervision. Follow up: Resident was last seen at 8:45 pm on 8/4/2020 by the nursing station. At 9:30 pm approximately, another staff member (off work and not scheduled) was driving a few blocks away from the facility and noticed the resident. Resident went into the employee's car, and returned to the facility. Resident was immediately assessed with [REDACTED]. When interviewed by staff, resident stated he 'had enough of this place.' Upon interview with the family, they stated that he was out at night, and also would come and go, sometimes being gone for 2-3 days without anyone knowing his whereabouts. Upon investigation, resident had jarred set screw again, causing it to break off. Windows had recently had all new screws installed, also rods placed in casing so the windows could not be moved up and down, then out, for cleaning purposes. (Physician's name) Medical Director, and (nurse practitioner's name), NP also assessed the situation, and agree the facility is not the proper placement for this resident. Resident also has a physician appointment on 8/11/2020 with (a physician's name), neurologist for assessment and treatment of [REDACTED]. Prior to this, family states that his mood/cognition was not altered. Resident sent out to Neuro hospital on [DATE], evening time. Facility will work with hospital for future placement, and assist as needed A nurse's note, dated 8/5/2020 at 7:44 A.M., indicated .This nurse was informed by 3-11 supervisor that resident was seen walking near a (four lane highway). This nurse drove to the area, did not see resident. Called 3-11 supervisor, was informed that resident was in an employee's vehicle at (local restaurant name). Drove my vehicle back to the facility, parked, and ran next door to the restaurant. Seen resident in employee's vehicle. As vehicle doors were unlocked, this nurse entered in to the back seat. Verbalized with resident, then returned to facility with resident driven by employee. Resident refused to leave from the vehicle at the facility, various staff members spoke with resident. This nurse returned to unit as resident was in the company of other staff members A review of Resident B's behavior monitoring documentation showed no documented behaviors for 6/19/2020, 7/20/2020 or 8/4/2020, for elopement attempts. A care plan, dated 7/24/2020, indicated Resident B was to have every 15 minute checks completed .for safety/elopement risk until further noticed (sic) A form, titled Safety Checks, dated 8/4/2020, indicated Resident B was in the facility between 8:45 P.M. and 9:30 P.M. During an interview, on 8/31/2020 at 2:34 P.M., the Administrator indicated the facility did not know which window Resident B got out of, on 8/4/2020. During an interview, on 8/31/2020 at 2:48 P.M., the facility maintenance employee indicated there was no available documentation related to window safety checks being completed. On 8/31/2020 at 2:48 P.M., a window in the common area of the memory care unit was observed to have a plastic piece of the lower window sill sticking up the length of the palm of a hand and had the right safety screw removed from the window sill. At this time, the maintenance employee indicated he was unaware of this window being broken. During an interview, on 9/1/2020 at 11:10 A.M., the Social Service Director indicated there were no available assessments to indicate Resident B was safe to be removed from 1:1 supervision. She indicated the interdisciplinary team met and decided to remove Resident B's 1:1 supervision, due to him having a lack of behaviors for four days and staffing being a concern. During an interview, on 9/1/2020 at 4:30 P.M., Nurse 3 indicated she had made a mistake by filling in empty holes on the 8/4/2020 safety check documentation and indicated Resident B was not in the facility from 8:45 P.M. thru 9:30 P.M. A care plan, dated 6/19/2020, indicated Resident B was an elopement risk/wanderer with history of attempts to leave facility unattended, impaired safety awareness, cognitive decline. Resident wanders aimlessly. The care plan was dated as last revised on 7/21/2020. Interventions included: Complete head to toe assessment (8/4/20), Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) (6/19/20), Monitor location as needed. Document wandering behavior and attempted diversional interventions in behavior log (6/19/20 then revised on 7/21/20). Notify MD, POA (power of attorney), Administrator (8/4/20), Provide structured activities: toileting, walking inside and outside, reorientation strategies including sings, pictures and memory boxes (6/19/20). Q (every) 15 minute check for safety/elopement risk until further notice (7/24/20). Resident to be in staff line of sight unless sleeping in bed (8/4/20). Resident B's care plan lacked interventions to address him attempting to open windows or the facility ensuring the windows were secured. A policy was provided by the Clinical Operations Manager, on 9/2/2020 at 10:40 A.M., titled Wandering and Elopements, dated March 2019, and indicated this was the policy currently used by the facility. The policy indicated .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents The immediate jeopardy that began on 8/4/2020 was removed on 9/3/2020 when the facility reviewed and implemented safety checks for windows in the memory care unit, in-serviced staff related to individualized elopement care planning and implemented a monitoring system for the 15 minute checks and 1:1 supervision, but noncompliance remained at the lower scope and severity of isolated, no harm with potential for more than minimal harm that is not immediate jeopardy because of the need for continued education and monitoring. This Federal tag relates to complaints IN 926 and IN 423. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident admitted with [MEDICAL CONDITION] disorder received appropriate treatments, including medications and treatment during [MEDICAL CONDITION] activity, and failed to ensure a plan of care was developed for the [DIAGNOSES REDACTED]. (Resident B) Findings include: The record review for Resident B was completed on 2/11/2020 at 11:30 A.M. The diagnoses included, but were not limited, [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]. The quarterly MDS (Minimum Data Set) assessment, dated 12/27/2019, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 10, mild cognitive impairment, and required extensive assist with ADLs (activities of daily living). [MEDICAL CONDITION] disorders was not identified in Section I. There was no care plan available for [MEDICAL CONDITION] disorder. A care plan summary from discharging facility, dated 9/27/2019, indicated Resident B had a physician order [REDACTED]. A visit summary provided by the discharging facility, dated 9/12/2019, indicated Resident B had [MEDICAL CONDITION] listed in the problem list. A physician visit note, dated 10/4/2019, indicated Resident B had the [MEDICAL CONDITION] disorder documented as a problem that was reviewed. A psychology progress note, dated 10/9/2019, indicated Resident B had [MEDICAL CONDITION] disorder listed as active medical problem and medications included, but were not limited to, [MEDICATION NAME] 750 mg twice daily. A progress note, dated 2/3/2020 at 11:12 P.M., indicated a CNA (certified nurse aide) reported Resident B was in bed shaking. Resident was checked and was staring to left. Physician was paged and daughter was informed of [MEDICAL CONDITION] activity. A stat order for [MEDICATION NAME] IM (intramuscular) was received and IM [MEDICATION NAME] was not available in facility. Resident was transferred out of facility via EMS (emergency medical services). A pharmacy delivery manifest sheet, dated 8/22/2019, indicated injectable [MEDICATION NAME] was delivered to facility on 8/22/2019. A history and physical from the local hospital, dated 2/3/2020, indicated Resident B was brought to the facility via EMS after he was found to be having a [MEDICAL CONDITION]. The daughter indicated she was called by the facility asking if he had a history of [REDACTED]. A discharge summary, dated 2/6/2020, indicated Resident B's discharge diagnoses included, but were not limited to, [MEDICAL CONDITION] with known [MEDICAL CONDITION] disorder, not receiving antiepileptic medications at facility and [DIAGNOSES REDACTED] secondary to [MEDICAL CONDITION]. An incident report, dated 2/10/2020, indicated Resident B was admitted to local hospital and was discharging on 2/7/2020 to another facility. The admitting nurse that completed admission orders [REDACTED]. The report indicated the discharge information from previous facility did not list [MEDICAL CONDITION] disorders as a diagnosis. A review of the MAR's (Medication Administration Record) for Resident B's stay at the facility lacked documentatio to show he had received [MEDICATION NAME] during his entire stay from 9/30/19 to 2/3/2020 when he was sent to the ER. A written statement, dated 2/4/2020 at 3:00 P.M., indicated facility had called daughter to ask if Resident B had [MEDICAL CONDITION] disorders, the daughter showed up 20 minutes after phone call and EMS had not been notified from the time [MEDICAL CONDITION] activity started until daughter arrived. During an interview, on 2/11/2020 at 2:15 P.M., the Unit Manager indicated [MEDICATION NAME] was in facility at time order for IM [MEDICATION NAME] was given on 2/3/2020. She indicated the [MEDICATION NAME] was in the refrigerator in 300/400 hall and Resident B was on 500 hall. During an interview, on 2/12/2020 at 9:54 A.M., LPN (Licensed Practical Nurse) 3 indicated on 2/3/2020 a CNA had reported Resident B was in bed shaking. She indicated no [DIAGNOSES REDACTED]. She said she notified the daughter, and placed oxygen on the resident. She indicated 15-20 minutes later the daughter showed up and called 911. She did indicated the order for [MEDICATION NAME] IM was received from physician when daughter was present in the facility but she was not aware that [MEDICATION NAME] was available in facility. During an interview, on 2/12/2020 at 10:19 A.M., the Corporate RN (Registered Nurse) indicated that [MEDICAL CONDITION] disorder should have been identified on the MDS and that a care plan should have been developed. On 2/12/2020 at 12:00 P.M., the Corporate RN provided the Emergency Procedure- [MEDICAL CONDITION] Management, dated 3/2011, and indicated this was the policy currently being used by the facility. The policy indicated .residents would be screened for a history of [MEDICAL CONDITION] .obtain and have on hand equipment ans supplies to help manage an active [MEDICAL CONDITION] .if the resident is having a [MEDICAL CONDITION] while in bed, take measures to prevent the resident from falling out of bed and do not leave the resident unattended .if the tonic/clonic convulsions last longer than 5 minutes .this may constitute [DIAGNOSES REDACTED], which is a medical emergency. If this suspected, notify the physician. If the physician is not immediately available to discuss the situation, initiate emergency transfer On 2/12/2020 at 12:00 P.M., a policy for MDS accuracy was requested, but no policy was provided. On 2/12/2020 at 12:00 P.M., the Corporate RN provided the Care Planning- Interdisciplinary Team policy, dated 9/2013, and indicated this was the policy currently being used by the facility. The policy indicated a comprehensive care plan was to be completed 7 days after the completion of the resident assessment (MDS). On 2/12/2020 at 12:00 P.M., the Corporate RN provided the Emergency Dispensing Kit-Controlled Substances policy, dated 12/2018, and indicated this is the policy currently being used by the facility. The policy indicated the .contents of the emergency dispensing kits were to be listed on the outside of each box and lists were to, also, be posted at each nursing station .When a licensed nurse received an order for [REDACTED].>This Federal tag relates to complaint IN 625 & IN 465. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident who was at risk for pressure ulcers and had current pressure ulcers, did not develop a stage 3 to the right calf, unstageable to left heel and stage 4 to lateral plantar foot and provide treatments, assessments, follow physician orders [REDACTED]. (Resident B) The facility also failed to ensure residents with risk factors for skin breakdown did not develop multiple unstageable pressure ulcers for 4 of 8 residents reviewed for pressure ulcers. (Resident J, M, C & G) The immediate jeopardy began on 12/2/19 when the facility failed to ensure a resident who was at risk for pressure ulcers and had current pressure ulcers, did not develop a stage 3 to the right calf, unstageable to left heel and stage 4 to lateral plantar foot and provide treatments, assessments, follow physician orders [REDACTED]. The DON (Director of Nursing) and the ED (Executive Director) were notified of the immediate jeopardy at 3:20 P.M. on 12/13/19. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an observation on 12/12/19 at 1:15 P.M., Resident B was observed lying in bed with bilateral lower extremities not elevated and no pressure relieving boots present. He was positioned low in the bed with his left foot resting on spacing foam located at the end of his bed. During an interview, on 12/12/19 at 2:58 P.M., the DON (Director of Nursing) indicated Resident B's pressure relieving boots were missing. During an observation, on 12/12/19 at 3:01 P.M., Resident B was observed with stage 4 pressure ulcer to the bottom of left foot on the outer lateral aspect of foot with tendon present to wound and 3 pressure ulcers to left lower extremity. There was an indent in the foot where the stage 4 was present, the indent was in the same area where the foot was making contact with the foam cushion located at the end of the bed. The foam cushion had a sewn seam present on the side that had contact with the left foot, the other corners of the cushion where smooth with no seams. During an interview, on 12/12/19 at 3:01 P.M., the Wound Nurse Practitioner indicated the stage 4 to bottom of left foot on the outer lateral aspect of foot had worsened since the last time she had seen it and there was no visible tendon on her last observation that was on [DATE]. During an interview, on 12/12/19 at 3:04 P.M., the DON indicated Resident B was to have pressure relieving boots on at all times to prevent the foot for touching the foam cushion, the hard plastic foot board or the low air loss mattress pump located at the end of the bed. She indicated the wound to bottom of outer left lateral foot was present on readmission from hospital upon return on 10/2/19. On 12/12/19 at 3:45 P.M., the DON provided the wound measurements for Resident B's current wounds, the following were documented: stage 4 to left bottom of foot measuring 2 cm x 0.5 cm x 0.5 cm, stage 3 to left back of heel measuring 1 cm x 1 cm x 0.2 cm with 100% slough, stage 4 to middle left calf with tendon visible, measuring 7.5 cm x 2 cm x 2 cm, stage 3 to left ankle with 100% slough measuring 3 cm x 2 cm x 0.3 cm and stage 4 to top of left calf with tendon visible and undermining present from 6 o'clock to 12 o'clock, measuring 4.8 cm x 1.5 cm x 2 cm. During an interview, on 12/12/19 at 4:50 P.M., LPN (Licensed Practical Nurse) 2 indicated she was upset that she did not know about the wound to right leg and the pressure relieving boots that were supposed to be on Resident B had been missing for a few days. During an observation, on 12/12/19 at 4:51 P.M., Resident B presented with a large unstageable pressure ulcer to the right outer lateral calf. The wound was present at the area where his leg comes into contact with the mattress when his leg was not elevated. The DON and LPN 2 were present during observation. During an interview, on 12/12/19 at 4:52 P.M., the DON indicated the facility had just become aware of the wound to the right calf this day when the Wound NP and her when in doing wound treatments and measurements previously. No wound measurements had been provided for this wound at the time the wound measurements were provided for the other pressure ulcers. On 12/12/19 at 5:00 P.M., the DON provided the wound measurements that were completed by the Wound NP. The wound NP documented a Stage 3 with [AGE]% slough measuring 12 cm x 8 cm x 0.1 cm with new orders for [MEDICATION NAME] daily and cover with ABD (abdominal pad) and wrap with [MED]. The record for Resident B was reviewed on 12/12/19 at 3:18 P.M. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 11/5/19, indicated Resident B had a BI[CONDITION] (Brief Interview of Mental Status) score of 9, mild cognitive impairment, required total assist of two or more staff with bed mobility and hygiene, had 4 unstageable pressure ulcers that was not present on admission and was receiving hospice services. A care plan, dated [DATE], indicated Resident B had multiple pressure ulcers 1. left lower leg rear SDTI (suspected deep tissue injury) 2. left lower leg rear(top) SDTI 3. left foot SDTI 4. Left lower leg rear SDTI. The interventions included, but were not limited to, offload LLE (left lower extremity) at all times, turn and reposition every two hours, assess skin with daily care and any other activities and report to nurse for further assessment and interventions and treatments as ordered. There was no care plan for right lower extremity wounds. A progress note, dated 8/26/19, indicated wound to right lower extremity had changed. No physician notification documented. A progress note, dated 8/29/19 at 6:50 A.M., indicated Resident B had a new area noted to right ankle that was quarter size in diameter, wound bed was pink and moist with non-granulating tissue present, dry dressing applied. Evaluation to be completed by DON. A progress note, dated [DATE] at 6:59 A.M., indicated Resident B had 4 pressure wounds noted. A progress note, dated [DATE] at 10:42 A.M., indicated wound to right ankle measured 2 cm x 2 cm x 0.1 cm. A progress note, dated [DATE] at 11:09 A.M., indicated the wound to right ankle had reopened and new order was received that off-loading boots were to remain in place. There was no care plan in place for right ankle wound. The facility wound assessments, dated 9/10/19, indicated 2 wounds to left lower leg and one to left foot (total of 3). A hospice progress note, dated 9/12/19 at 9:19 A.M., indicated Resident B had 5 wounds at present time and confirmed all 5 wound and new measurements completed. Facility reports 3 wounds and measurements all vary from writer's measurements. Facility has wound on left foot at 3 cm x 2.5 cm, writer obtained measurement of 4 cm x 2 cm. Facility also had distal left calf as one wound and there were two present, facility measurement was 5 cm x 2 cm x 0.1 cm, the writer obtained on distal left wound closest to heel as 4 cm x 3 cm x 0.1 cm. The 2nd distal wound on left mid-calf measured 5 cm x 1.5 cm 0.1 cm. The mid proximal wound documented same with different measurements. Facility measurements were 8.5 cm x 4 cm x 5 cm. The writer obtained 8 cm x 6.5 cm x 2 cm. Patient had large deep wound with tendon visible and purulent drainage to left proximal calf. Facility was to be doing wound care as ordered every day on night shift. Dressing on left calf was saturated with drainage from wound. Writer placed ABD dressing and [MED] over dressing for heavy drainage and consulted with physician. A progress note, dated [DATE] at 12:41 P.M., indicated Resident B was seen for non-healing wound. The hospice nurse and unit nurse state the wound on left leg is not healing and the odor had returned. A culture is requested to determine specific antibiotics. A Hospice Visit note, dated 9/30/19, indicated Resident B had a stage 4 pressure ulcer to left mid- proximal calf with bloody drainage and moderate odor, a stage 4 to left distal calf, an ulcer to right ankle, and a stage 2 to left mid lower leg and a blood blister to left proximal plantar foot. A progress note, dated [DATE] at 11:55 P.M., indicated Resident B was sent out to local hospital for evaluation and treatment. His oxygen saturation was [AGE]% on 4.5 liters of oxygen, axillary temperature was 103.8, blood pressure was 164/90 and pulse was 109-125. The Emergency transport note, dated [DATE], indicated upon arrival Resident B was pale, diaphoretic and warm to touch. He was non-verbal and appeared septic. He was hypotensive. His temperature was 101.2. He had multiple wounds and decubiti on legs and buttocks. The emergency care notes, dated [DATE] at 11:26 P.M., indicated Resident B presented to the ER unresponsive and hypotensive with tympanic fever of 101.2. He was diaphoretic and has pallor. Resident had multiple wounds from proximal aspect of the left leg down to the foot, area on left forefoot appears dysvascular. There was a dark area of skin breakdown on the plantar aspect of the left foot. The area on the lateral leg was due to constant and chronic pressure. A History & Physical, dated 10/2/19, indicated Resident B was very debilitated resident that presented in the emergency room with altered mental status. Available information was very limited, the patient was unable to supply any information and there was no family available with him. The patient was reportedly febrile and diaphoretic and not responding appropriately. Patient's last hospital stay ended on 7/30/19 when he was treated for [REDACTED]. A Podiatry Consultation note, dated 10/2/19, indicated physician was consulted for ulceration to the lateral planter aspect of his left foot. The physical examination indicated there was a well-circumscribed ulceration noted to the plantar lateral aspect of this fifth metatarsal head, measuring 2.7 cm x 2.6 cm with a completely necrotic base. A physician progress notes [REDACTED]. A wound culture, collected 10/2/19, indicated [CONDITION], [CONDITION] [MEDICAL CONDITION] [CONDITION] were present. A blood culture, collected [DATE], indicated [CONDITION] growth was present. The discharge summary, dated 10/2/19, indicated the reason for visit [MEDICAL CONDITION], toxic [MEDICAL CONDITION]. The hospital course indicated Resident B was admitted [MEDICAL CONDITION] with unidentified specific cause, thought to be either from urinary source or pneumonia. Later was found to be had left lower extremity chronic wound and necrosis. A Care Coordination note, dated 10/2/19, indicated Resident B was transferred back to facility at 3:30 P.M. on this day. A progress note, dated 11/15/19 at 3:52 P.M., indicated new orders for wound care , left proximal calf wound to be cleansed with wound cleanser, apply [MEDICATION NAME] soaked gauze to wound bed and cover with NS (normal Saline), ABD pad and wrap in [MED] daily. Left mid-calf and distal calf, cleanse with wound cleanser, apply [MEDICATION NAME], cover with non-adherent dressing, ABD pad and wrap with [MED]. Wounds to be measured daily with each dressing change and given to the DON and Medical Director was the only one to give wound orders. A hospice progress note, dated [DATE], indicated Resident B had recently had wound care done and reported to be in a lot of pain. He had a dark colored fluid filled blister on his left heel that was still present. A hospice progress note, dated 11/20/19, indicated Resident B had a dark colored fluid filled blister on left heel measuring 3.9 cm x 2.7 cm and Prevalon boot was applied to left foot. There was no facility documentation of left heel blister until 11/20/19. A hospice progress note, dated 11/25/19, indicated Resident B's brief under him was saturated with urine however the facility LPN reports he had recently been laying on top of Foley catheter tubing and it had stopped flow. A hospice progress note, dated 12/2/19, indicated Resident B had a new pressure area to right calf from what appeared to be where the catheter tubing was under leg, dressing was applied to protect the leg. A weekly skin assessment, dated 12/3/19, indicated resident had open areas to thighs, buttocks and lower legs. A weekly skin assessment, dated [DATE], indicated resident had area to left heel, buttocks and both legs. A hospice progress note, dated [DATE], indicated Resident B was observed in bed with new wound on right calf uncovered and draining on sheet. She documented she reviewed plan of care with facility nurse. There was not facility wound documentation for wound to right calf. A wound NP note, dated [DATE], indicated wound to left leg and ankle in treatment with wound RN, wound to right leg. Wound assessment: bottom of foot 1.5 cm x 1.5 cm x 0.3 cm ([MEDICATION NAME] and gauze), dried blister to bottom of left foot 3.2 cm x 1 cm, dried blister to heel 0.8 cm x 1 cm, left calf top 5 cm x 2.5 cm x 2 cm ([MEDICATION NAME] and gauze) daily, middle 6 cm x 2 cm 0.3 cm with dark edges ([MEDICATION NAME] and gauze) and bottom left leg 4 cm x 1.5 cm x 2 cm with undermining at 5 o'clock. All wounds are healing well with the exception of the middle left wound, edges are darkened, suspect area has had pressure exposure. Facility to continue to offload pressure to leg and continue all current dressings. Nurses to call with any concerns. A hospice progress note, dated 12/6/19, indicated Resident B was lying in bed with dressing in place from writer's visit on Wednesday ([DATE]). A hospice progress note, dated 12/11/19, indicated facility had completed wound care and had used calcium alginate rolls on all wounds. Calcium alginate adheres to resident's wound making care very painful and causing bleeding. Writer used majority of bottle of wound cleanser trying to remove old dressings and after the wounds had moderate bright bleeding. The hospice wound assessment tool report, dated 12/2/19 - 12/11/19, and indicated the following: 12/2/19 indicated stage 2 pressure ulcer noted to right mid-calf 5.9 cm x 2.9 cm. [DATE] indicated stage 2 pressure ulcer noted to right mid-calf 6.5 cm x 6.2 cm. 12/6/19 indicated stage 2 pressure ulcer noted to right mid-calf 9.6 cm x 7.5 cm. 12/11/19 indicated stage 2 pressure ulcer to right mid-calf 10.4 cm x 4.5 cm x 0.1 cm. The TAR (Treatment Administration Record), dated 12/1/19 - 12/31/19, indicated an order for [REDACTED]. There was no documentation that the treatments were completed as ordered on [DATE] and 12/8/19. During an interview, on 12/12/19 at 4:17 P.M., the DON indicated that orders to measure wound with each dressing change were not followed up on as written. She indicated that hospice measured the wounds 3 x weekly. She indicated the physician had ordered daily measurements because he looked at the wound and wanted it monitored. He wanted to be sure the orders were being done as written. She indicated that hospice calls him three times weekly. She indicated there was no documentation available for measurements that were completed and no documented education was available. During an interview, on 12/12/19 at 5:02 P.M., the DON indicated that Hospice had known about this wound and indicated hospice had told her today that she had known about the wound to the right leg for about one week. The DON indicated the wound was not there last week when she completed her assessment. She indicated the facility nurse became aware of the wound today around 3:00- 3:30 P.M. During an interview, on 12/12/19 at 5:19 P.M., LPN 2 she did not have access to hospice documentation from visits. Reviewed hospice binder and there no notes available from [DATE] to present. During an interview, on 12/12/19 at 5:30 P.M., the hospice nurse indicated first noticed the wound on December 2nd to the right calf and it was superficial. During an interview, on 12/12/19 at 5:43 P.M., the hospice nurse indicated that new wound orders were received from physician for new wound to right leg. She indicated she had documented in her notes the new pressure area to right leg was from catheter tubing being placed under the leg. She documented that she reviewed plan of care with facility nurse at 1:30 PM. She indicated she gave verbal orders for wound care to [MEDICATION NAME], cover with ABD pad and [MED]. She indicated the physician had written the orders on 11/15/19 because the facility was not following the orders and were using the wrong stuff. She indicated she brought the concerns to physician's attention in a hospice IDT (Interdisciplinary team) meeting that she was having trouble with facility and resident's wound. She indicated the wound to the right calf had originally started as superficial had gotten worse. During on observation, on 12/13/19 at 1:08 A.M., Resident B was observed resting in bed, no off-loading boots present and legs were not elevated. During an interview, on 12/13/19 at 1:20 A.M., LPN 4 indicated his off-loading boots have been missing for a few weeks. During an interview, in 12/13/19 at 1:38 A.M., LPN 6 indicated a risk evaluation was supposed to be completed for new skin issues and should have been completed on the 3rd and 4th when the facility had documented the wound to right leg in the skin assessments. She indicated she was in charge of ensuring skin assessments were completed but she was never instructed to open the assessment to see what was documented. During an interview, on 12/13/19 at 12:28 P.M., the Medical Director indicated he was aware of wound to right leg and the hospice nurse brought to his attention. He indicated he gave orders through the hospice nurse on [DATE]. He indicated the hospice nurse was quite reliable about following up with wound care and so was the wound NP. He indicated the facility was not reliable and had not been notifying him of condition changes as he would of liked. 2. During an interview, on 12/25/19 at 11:20 A.M., Resident J indicated she had wounds to her left foot that had been present for the past two weeks and nursing staff had been treating the areas. During an observation, on 12/15/19 at 11:24 A.M., Resident J was in bed and 2 unstageable ulcers were noted to her left foot, one was located on the lateral portion of her foot and one was located on the bony prominence of the outer ankle bone. During an interview, on 12/15/19 at 11:25 P.M., LPN 2 and CNA 3 indicated the DON were made aware of the wounds on 12/14/19. The record for Resident J was reviewed on 12/15/19 at 11:30 A.M. The [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 10/24/19, indicated Resident J had a BI[CONDITION] (Brief Interview of Mental Status) score of 15, cognitively intact, and required extensive assist with transfers. A change of condition progress note, dated 12/14/19 at 2:29 P.M., indicated a fluid filled blister was noted to the outer left side of heel measuring 2 cm x 2.5 cm. There was no wound documentation present for the left ankle wound. During an interview, on [DATE] at 11:13 A.M., the NP (Nurse Practitioner) indicated she was unaware of the unstageable pressure ulcers to Resident J's left outer heel and ankle. She indicated she did see Resident J today and no one in the facility had informed her of the wounds. During an observation, on [DATE] at 11:50 A.M., the NP assessed the wounds to the outer left heel and ankle, she indicated to the resident that the areas were from pressure and she would have would have wound nurse assess. During an interview, on [DATE] at 1:45 P.M., the DON indicated she had just become aware of the wound to the outer right ankle today when the NP had informed her. She indicated she had faxed the primary physician on 12/14/19 to notify him of the wound and she did not speak to him to receive verbal orders. She indicated she wrote the order for skin prep to wound on her own with no physician communication. She indicated she was unable to state the staging of the blood filled blister noted to left lateral heel, she indicated she just called it what it was, a blister. A confidential interview indicated the facility staff had known about the wounds to left lateral heel and outer ankle to Resident J for 2 weeks and the nursing staff had been treating the areas with skin prep. The progress notes, dated 11/7/19 to 11/10/19, indicated Resident J was sent to the hospital on [DATE] and returned on 11/10/19. A Unit Nurse Skin Assessment, dated 11/12/19, indicated assessment was not completed because Resident J had refused her shower. A Unit Nurse Skin Assessment, dated [DATE], indicated assessment was not completed because Resident J had refused her shower. There were no skin assessments completed from [DATE] to 12/14/19. A Unit Nurse Skin Assessment, dated 12/14/19, indicated a fluid filled blister to left outer heel measuring 2 cm x 2.5 cm. There was no assessment available for pressure ulcer. 3. On [DATE] the facility provided the skin sweep that had been completed on 12/13/19 and 12/14/19, the skin sweep indicated Resident M had excoriation noted. During an observation, 1[DATE] at 10:40 A.M., Resident M was observed laying on his back in bed with his head slightly elevated. The DON turned resident on to his left side and removed duoderm dressing from sacral area. The sacrum presented with 2 pressure ulcers, one unstageable noted to on the left side and a stage 2 noted to the right side. During an interview, on 1[DATE] at 10:41 A.M., the DON indicated the wound to the left buttock measured 4.0 cm x 2.1 cm x 0.1 cm, the upper portion of the wound presented with dark area and was unstageable and the right buttock wound measured 2.4 cm x 1.8 cm x 0.1 cm. She indicated both of the wounds had started as excoriation. During an interview, on 1[DATE] at 10:44 A.M., the wife of Resident M indicated the facility left him on his back all the time. She indicated they were supposed to come in to turn and reposition but they never did. She indicated the wounds to the sacrum have progressively worsened, every day the wounds get bigger. She indicated she stayed in the facility 24 hours a day and no staff came into the room from 10:00 P.M. to 4:00 A.M. most nights. The record for Resident M was reviewed on 1[DATE] at 10:50 A.M. The [DIAGNOSES REDACTED]. A care plan, dated 12/5/19, indicated Resident M was at risk for potential pressure ulcer development related to impaired mobility and bowel/bladder incontinence. The interventions included, but were not limited to, turn and reposition every 2 hours, assess skin with daily care and report changes to nurse for further assessment and interventions and monitor skin and wound site daily for signs/symptoms of inflammation, infection, etc. No updates to interventions were noted since 12/6/19. A physician progress notes [REDACTED].M., indicated Resident M was admitted to the facility on [DATE] and his weakness was more progressive. The TAR (treatment administration record), dated 12/1/19 - 12/31/19, did not have an order present for the duoderm that was removed by the DON during the observation completed at 10:40 A.M. The hospice visit note, dated [DATE] at 11:30 A.M., indicated Resident M had stage 2 pressure to left upper buttocks measuring 4 cm x 1 cm x <0.1 cm (reverse L shape), a stage 2 to right buttocks measuring 2 cm x 1 cm x 0.1 cm and a stage 1 pressure ulcer to the left outer ankle, measuring 0.5 cm x 1 cm. The wife indicated she had first noticed the areas on 12/14/19. The ECF (extended care facility) nurse and NP were notified of these areas and the left outer ankle. There were no facility wound notes completed on [DATE] or care plan was initiated for identified pressure areas. The facility weekly wound observations, dated 1[DATE], indicated the wound to right buttocks was a stage 2 and the wound to left buttock (originally a stage 2, currently unstageable pressure ulcer) had originated on 1[DATE]. 4. During an interview, on 12/12/19 at 12:50 P.M., Resident C indicated she currently had a pressure ulcer on her buttocks that she has had for a while. She indicated that she did not get changed on some night shifts unless certain CNAs were working. She indicated there were times the evening aides put her to bed and no one comes back until the morning, she indicated she lays in a wet bed all night until morning. The record for Resident C was reviewed on 12/13/19 at 11:36 A.M. The [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set) assessment, dated 9/24/19, indicated Resident C had a BI[CONDITION] (Brief Interview of Mental Status) score of 11, mild cognitive impairment, total care with ADLs (activities of daily living) and had unhealed pressure ulcers that were present on admission. A care plan, dated 10/30/15, indicated Resident C was at risk for skin break down related to impaired mobility, incontinence and history of skin breakdown. The interventions included, but were not limited to, check and change every 2 hours, weekly skin checks with showers and assess skin daily with care and report changes to nurse for further assessment and monitor for changes in skin integrity and report any abnormals. A care plan, dated 9/6/19, indicated Resident C had pressure are on her left buttocks. The interventions included, but were not limited to, treatment as ordered (9/6/19), keep the bed as flat as possible to reduce shear and reposition every 2 hours (9/13/19) and monitor skin and wound site daily for signs/symptoms of infection (9/13/19) A physician note, dated 7/29/19, indicated Resident C had a stage 2 pressure ulcer to intergluteal cleft that had healed per nursing. A unit nurse skin review, dated 8/27/19 at 10:34 A.M., indicated Resident C had a skin alteration noted to left gluteal fold. A unit nurse skin review, dated 9/3/19 at 6:25 P.M., indicated Resident C had a denuded skin noted to coccyx and the wound nurse was made aware. A unit nurse skin review, dated 9/6/19 at 8:58 P.M., indicated Resident C had a denuded skin noted to coccyx. There were no wound assessments available for the alterations in skin noted on the assessments. an order for [REDACTED]. A hospital rehabilitation note, dated 9/13/19, indicated Resident C had stage 3 pressure ulcers over the sacrum, all present on admission. The stage 3 pressure sacrum ulcers were documented as: left 5.5 cm x 0.5 cm x 0.1 cm, midline 3.8 cm x 2.4 cm x 0.1 cm and right 4.6 cm x 1.1 cm x 0.1 cm. A hospital rehabilitation note, dated [DATE], indicated Resident C was communicating with speech therapy and was able to answer with 100% accuracy. A discharge summary, dated 9/17/19, indicated Resident C was discharged back to facility with a [MEDICATION NAME] dressing over the pre-admit pressure stage 3. A weekly wound observation, dated 9/18/19, indicated Resident C had stage 3 pressure ulcer measuring 4 cm x 2 cm x 0.4 cm with current treatment plan of triad paste, right buttock 2 cm x 1 cm x 0.1 cm with current treatment plan of triad paste and left buttock stage 3 pressure ulcer measuring 5 cm x 2 cm with current treatment plan of triad paste, all present on admission. During a confidential interview, it was reported that there had been a pressure ulcer to Resident C's coccyx before she went to the hospital in September. It was reported that nurses were aware and had been treating the area. There were no treatments documented in the TAR. During an interview, on [DATE] at 11:13 A.M., The NP indicated the DON had requested for her to look at wound on Resident C when it was a Stage 2 and she had not been asked to look at the wound again. She indicated there were no notes in the EHR (electronic health record) in regards to the wound. There were no care plan updates until 10/24/19 for pressure ulcers or at risk for skin breakdown. 5. A record for Resident G was reviewed on 1[DATE] at 10:00 A.M. His [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 11/25/19, indicated Resident G was cognitively intact and did not have any unhealed pressure ulcers stage 1 or higher and did not have moisture associated skin damage. A care plan for potential for pressure ulcers, dated [DATE], indicated Resident G would have intact skin and interventions included, but not limited to, dated [DATE], assess skin with daily care and any other care activities for abnormalities, report to the nurse for further assessment and intervention and monitor skin and wound site daily for signs and symptoms of inflammation, infection and intervention, dated 12/15/19, indicated to turn and reposition every 2 hours and as needed and apply barrier cream after every incontinent episode, offer fluids with every interaction, skin checks, showers per preference. A care plan for denuded skin to buttocks and coccyx, dated [DATE], indicated Resident G was admitted with the denuded skin on his buttocks and coccyx and would show signs of healing and remain free from infection. The interventions included, but not limited to, dated [DATE], administer treatments as ordered and monitor for effectiveness. A NP (Nurse Practitioner) progress note, dated 11/20/19, indicated Resident G had no rashes or skin breakdown. A NP progress note, dated 12/2/19, indicated Resident G had no rashes or ulcers. No progress notes from the wound NP was available for review. A nursing admission assessment, dated [DATE], indicated Resident G had an area measuring 3 by 2 cm (centimeter) of severely denuded skin to his coccyx that was red and moist. The description indicated he was incontinent of stool. A

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 of deficiencies cited and to ensure quality assurance procedures were followed and plans of action implemented to prevent deficiencies from re-occurring. This affected 5 of 8 residents reviewed for pressure ulcers. Actual harm resulted when residents acquired an unstageable pressure ulcers. Findings include: On [DATE] at 2:50 P.M., the ED (Executive Director) provided the QUALITY ASSURANCE PROGRAM GUIDELINES/PERFORMANCE IMPROVEMENT, dated 11/7/08, and indicated it was the policy currently being used by the facility. The policy indicated QA (quality assurance) and performance improvement equates to reaching for excellence, regulations were minimum acceptable standards, action oriented not information-oriented, departments should not review themselves. as good QA committee will not be used as just a post script venue after a poor survey, but will serve as a prescript venue and avoid a poor survey. During this complaint survey, 12/12/19 to [DATE], one deficiency was cited at an immediate jeopardy level of one resident who developed a stage 3 to the right calf, unstageable to left heel and stage 4 to lateral plantar foot. In addition to the resident in the immediate jeopardy, the failed to ensure the residents with risk factors for skin breakdown did not develop multiple unstageable pressure ulcers resulting in harm or the potential for harm that is not immediate jeopardy to 5 out of 8 residents reviewed for pressure ulcers. level - F6[AGE] K The facility's Quality Assurance Committee did not identify, develop, and implement appropriate measures to correct identified issues or prevent deficiencies as follows: 1. Pressure ulcers: One resident developed a stage 3 to the right calf, unstageable to left heel and stage 4 to lateral plantar foot. In addition to the resident in the immediate jeopardy, 4 other resident developed residents multiple unstageable pressure ulcers. 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 F6[AGE]. During an interview, on [DATE] at 1:50 P.M., the DON (Director of Nursing) and the ED indicated they had not been overseeing the audits from the annual recertification and complaint survey from with exit date of 7/4/19 as documented for the plan of correction for F6[AGE]. The ED indicated the monthly audit reviews were not completed. The DON indicated the unit managers were to audit if skin assessments were completed, they were not educated to open the assessments to ensure accuracy and the MAR (Medication Administration Record [REDACTED]. The DON indicated the staff was requested to come back to facility and fill in any missing documentation. The DON indicated there was no wound documentation audits completed because she was the wound nurse and would not audit herself. 3.1-52(b)(2)

Based on observation, interview and record review, the facility failed to ensure a resident who was admitted with intact skin did not develop multiple pressure ulcers, ranging from Stage 2 to unstageable, and provide treatments, follow physician orders for wound care, and complete timely skin assessments resulting in 16 total pressure ulcer wounds, including one unstageable and one Stage 3 wound to the left lower extremity and [DIAGNOSES REDACTED]. (Resident B and Resident D) The immediate jeopardy began on 1/28/19 when a resident was sent to the hospital and a Stage 2-3 pressure wound was identified on the left buttocks. The Regional Clinical Nurse and the Director of Nursing were notified of the immediate jeopardy at 4:24 P.M. on 7/1/19. The immediate jeopardy was removed on 7/4/19, but 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. Finding includes: The clinical record for Resident B was reviewed on 6/27/19 at 2:28 P.M. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 5/15/19, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 9, mild cognitive impairment, required extensive assist of two with bed mobility and total assist for transfers, and had a Stage 3 pressure ulcer that was not present on admission. A progress note, dated 1/11/19 at 1:14 P.M., indicated Resident B was admitted to the facility and was currently bed bound and needed total assistance in care. The Physical Therapy evaluation, dated 1/12/19, indicated Resident B was totally dependent with his overall functional mobility and was bed bound. A physician progress notes [REDACTED].M., indicated Resident B did not have any rashes or ulcers. A nursing note, dated 1/16/19 at 9:30 A.M., indicated Resident B was educated to turn and reposition self or call staff to help to turn every two hours to prevent skin breakdown. An occupational therapy note, dated 1/17/19, indicated Resident B required 4 people to roll right/left for pericare after incontinent episodes and brief changes, due to his size. A physician progress notes [REDACTED].M., indicated therapy had reported skin frailness on his buttocks. The site was not examined by NP (Nurse Practitioner) as resident was eating breakfast at the time, but the wound nurse was to evaluate. There was no documentation the evaluation of the buttocks was completed by the wound nurse. A physician progress notes [REDACTED].M., indicated Resident B was unable to move lower extremities and therapy again reported skin frailness on buttocks. A nursing note, dated 1/28/19, indicated Resident B was transferred to the local emergency room for evaluation and treatment for [REDACTED]. A history and physical report from a local hospital, dated 1/28/19, indicated Resident B presented to the ER (emergency room ) with a Stage 2-3 decubitus ulcer to his left buttock that was bleeding. The facility nurse had indicated to the ER physician Resident B was chronic bedbound and required a lift to transfer to the wheelchair. The [DIAGNOSES REDACTED]. A progress note, dated 2/2/19 at 9:11 P.M., indicated Resident B was readmitted back to the facility. A progress note, dated 2/3/19 at 12:45 A.M., indicated Resident B had a partial thickness wound located to back of right posterior thigh region that measured 2 cm (centimeters) x 1 cm x 0.5 cm. There were multiple scratches and open areas located to right posterior thigh and his sacrum had a deep tissue injury (a pressure related injury to the subcutaneous tissues under intact skin). He was referred to wound NP for evaluation and treatment. A skin note, dated 2/5/19, indicated Resident B had two partial thickness areas to right thigh, superior (higher) one measures 1.5 cm x 1.5 cm x 1 cm and the inferior (lower towards the feet) measured 2 cm x 1 cm x 0.5 cm with scant serosangious drainage and wound base pink. A change of condition note, dated 2/8/19 at 2:25 P.M., indicated the pressure ulcer to Resident B's right thigh was a Stage 2 measuring 1 cm x 5.8 cm x 0.1 cm. A weekly wound observation, dated 2/8/18, indicated Resident B had a Stage 3 pressure ulcer to right thigh measuring 1 cm x 5.8 cm x 0.1 cm with beefy red granulation tissue with small amount of blood noted. There was missing documentation noted in the wound assessment: no acquired date. A skin/wound note from the wound NP, dated 2/8/19 at 2:36 P.M., indicated Resident B was being evaluated for a pressure to right thigh that the facility reported was present on admission when pt (patient) returned from hospital. The assessment indicated the posterior left thigh had a stage 2 pressure ulcer measuring 1.0 cm x 5.8 cm x 0.1 cm. The order was for Triad daily and PRN (as needed). No other weekly wound observations were present to review for the wound to the right thigh. During an interview, on 6/28/19 at 2:00 P.M., the wound NP indicated the wound was on the resident's left buttock and she had made documentation error on her notes saying it was on the right. A physician progress notes [REDACTED].M., indicated Resident B had a pressure ulcer noted to left lower leg. A CNA (certified nurse aide) requested assessment to pressure wound on left leg. Slight bruised skin on left leg where his leg positioning device had indented his skin. A skin/wound note from the wound NP, dated 2/22/19 at 10:57 A.M., indicated was seen for improved thigh wound and new area to LLE (left lower extremity). The wound was a SDTI (suspected deep tissue injury) measuring 5.0 cm x 7.0 cm that presented as a fluid filled intact blister. The surrounding tissue was purple, and serous (clear) drainage was noted from wound. The order was for Xeroform to LLE (left lower extremity) with skin prep to edges, turn and reposition per facility policy and offload heels at all times. Facility was to review him for wheel chair cushion. A weekly wound observation, dated 2/22/19, indicated Resident B had a fluid filled blister to LLE, but there was no staging of the wound documented. A physician note, dated 2/26/19 at 1:13 P.M., indicated Resident B answered questions slowly but appropriately, and was oriented to self and place. A skin/wound note from the wound NP, dated 2/28/19 at 1:25 P.M., indicated Resident B had completed a dose of [MEDICATION NAME] for skin infection and the pressure area to the LLE was now an open Stage 2 measuring 3.0 cm x 6.0 cm x 0.1 cm, with minimal serous drainage and surrounding skins had purple discoloration. The Medication Administration Record, [REDACTED]. There was no skin check documented on 2/24/19. There was no order present to turn and reposition per facility policy, or to offload heels at all times. There was no order present for Triad daily as ordered on [DATE] or for Xeroform to LLE as ordered on [DATE] per the wound NP. A progress note, dated 3/3/19 at 8:14 A.M., indicated Resident B received a second course of [MEDICATION NAME] twice daily for wound healing. A skin/wound note from the wound NP, dated 3/7/19 at 10:45 A.M., indicated a new skin area was noted to left foot. The Stage 2 wound to LLE currently measured 3.4 cm x 2.5 cm x 0.1 cm and the new area to left foot was a SDTI (suspected deep tissue injury) that measured 3.4 cm x 2.5 cm and presented as a blister. The orders were to continue Xeroform to LLE wound, start sure prep to left foot wound and offload the left foot. An order to clean buttock and thighs daily and apply Triad daily as [MEDICATION NAME] was added. Facility to review wheelchair for cushion. A change of condition note, dated 3/8/19 at 12:10 P.M., indicated Resident B's LLE wound measured Stage 2 - 2 cm x 4.4 cm x 0.1 cm. There were no measurements documented for the SDTI to the left foot. Weekly wound observations, dated 3/8/19 and 3/22/19, indicated Resident B had a wound to LLE, but were no staging or measurements documented. A Nutrition at Risk note, dated 3/21/19 at 3:00 P.M., indicated Resident B's current weight was 472.6 lbs (pounds) and the resident was on a bariatric low air loss mattress. A skin/wound note, dated 3/29/19 at 12:47 P.M., indicated the wound to LLE was a Stage 2 measuring 6.0 cm x 1.4 cm x 0.1 cm and the SDTI to his left foot measured 2.8 cm x 2.4 cm. An order to discontinue Xeroform to LLE and start Hydrogel Ag (silver) saturated gauze and offload left foot was added. A weekly wound observation, dated 3/29/19, indicated Resident B had a wound to LLE, but there was no staging documented. A Treatment Administration Record, dated 3/1/19 - 3/31/19, had no documentation for hydrogel saturated gauze (start date 2/26/19) on 3/2/19. There was no documentation for the Xeroform to LLE (start date 3/2/19) on 3/2/19, 3/12/19 and 3/14/19. There was no order present to turn and reposition per facility policy, or to offload heels at all times. There was no order for the Hydrogel Ag or Triad as preventative care daily as ordered by the wound NP. There were no more wound observations completed until 4/11/19 for the LLE and the left foot. A skin/wound note, dated 4/11/19 at 10:07 A.M., indicated the wound to LLE now measured 4.0 cm x 4.0 cm x 0.1 cm and the wound to the left foot had healed. Order to discontinue Hydrogel Ag and start regular hydrogel due to wound bed being dry and to offload heels at all times. A nursing note, dated 4/18/19 at 7:32 A.M., indicated Resident B's LLE wound presented with 100% necrotic tissue. A skin/wound noted from the wound NP, dated 4/18/19 at 9:47 A.M., indicated resident was being seen for decline in LLE extremity wound and it was reported the wound was necrotic. The wound was an unstageable wound measuring 6.8 cm x 2.8 cm (unable to determine depth) and presented with 100% yellow slough and eschar. An order to start Santyl and offload LLE at all times and left leg x-ray was ordered. No weekly wound observations were documented between 4/18/19 and 4/27/19. A change of condition note, dated 4/27/19 at 2:42 P.M., indicated Resident B's wound to LLE now measured 7 cm x 3 cm x 0.5 cm. Treatment reports for Resident B's wound for the month of (MONTH) were requested, but were not provided. A skin/wound note, dated 5/3/19 at 4:31 P.M., indicated Resident B's wound to LLE was bleeding. The wound was debrided using a #3 dermal curette. The wound was now a stage 3 pressure ulcer measuring 7.0 cm x 3.0 cm with 50% slough and moderate drainage (serosanguineous - a mix of clear and bloody drainage). The order indicated to discontinue Santyl and trial hydroferra blue daily, turn and reposition per facility policy and to offload heels at all times. An administration note, dated 5/8/19 at 11:49 P.M., indicated hydroferra blue dressing was unavailable and hydrocellulate foam was used instead. Wound NP was not notified of this change. An administration note, dated 5/13/19 at 2:58 A.M., indicated the treatment to the LLE was not completed because there was no Hydroferra blue dressing available. Wound NP was not notified. A physician progress notes [REDACTED].M., indicated that nursing had reported to the wound NP the wound to the left lower extremity had been seeping and an antibiotic would be prescribed. [MEDICATION NAME] 100 mg (milligrams) twice daily was ordered for 10 days. No weekly wound assessments were documented between 5/3/19 and 5/17/19. An antibiotic therapy note, dated 5/17/19 at 10:22 A.M., indicated the wound to the LLE now presented with drainage and a foul odor. A skin/wound note from the wound NP, dated 5/17/19 at 11:39 A.M., indicated Resident B's LLE was debrided using a #3 dermal curette. There were no weekly wound observations completed by the facility wound nurse after 5/17/19. An administration note, dated 5/18/19 at 6:57 P.M., indicated the dressing change to the LLE was not completed. A skin/wound note, dated 5/24/19 at 11:40 A.M., indicated Resident B had new skin area noted to LLE and resident reported discomfort to the leg (rated 10/10 - extremely sharp pain that does not get better) and denied pain to other areas of the body, discussed repositioning and keeping LLE off the bed. Wounds were debrided with #2 dermal curette. Wound to LLE (wound 1) was Stage 3 measuring 6.8 cm x 2.0 cm x 0.4 cm with moderate drainage and 50% slough noted to wound bed. The new wound to LLE (wound 2) measured 5.0 cm x 1.2 cm x 0.1 cm with 25% slough and surrounding tissues had purplish discoloration. Orders were to continue [MEDICATION NAME] Blue daily to both wounds, arterial US (ultrasound) with BLE (bilateral lower extremities). A skin/wound note from the NP, dated 5/31/19 at 4:15 P.M., indicated the wound to LLE (wound 1) measured 7.0 cm x 4.0 cm x 0.5 cm and the other wound (wound 2) was an unstageable pressure ulcer measuring 4.2 cm x 1.2 cm x 0.1 cm with 100% slough. The doppler results were consistent with mild [MEDICAL CONDITIONS] to right leg and mild to moderate to left leg with no occlusions. Orders were to discontinue [MEDICATION NAME] blue dressing and start [MEDICATION NAME] daily to wound 2 and apply calcium alginate to wound 1 and to offload LLE. A skin/wound note, dated 5/31/19 at 4:16 P.M., indicated a wound vac was ordered to the Stage 3 pressure ulcer to LLE (wound 1) and that the wound vac should not come into contact to the unstageable (wound 2). The Treatment administration record, dated 5/1/19 - 5/31/19, indicated the [MEDICATION NAME] blue dressing change daily had not been completed on 5/9/19, 5/12/19 and 5/13/19 due to dressing not available and 5/8/19, 5/17/19 and 5/29/19 for other. The order for Dakins Solution to LLE was not completed on 5/3/19, 5/4/19 and 5/17/19 due to solution not being available and 5/12/19, 5/13/19 and 5/29/19 for other/refused. Order to offload LLE at all times present with start date 5/24/19. There was no order to turn or reposition. There was no order present for [MEDICATION NAME] or calcium alginate as ordered on [DATE]. A skin/wound note from the wound NP, dated 6/5/19, indicated wound vac was started on 6/4/19 and the Resident B reported discomfort to his leg, discussed positioning and keeping LLE off the bed, air to under LLE to revitalize tissue. Order to clean wound 2 with Dakins, apply [MEDICATION NAME], cover with ABD and kerlix daily and wound 1 to have wound vac at 120 mmHg to be changed on Mondays/Wednesdays/Fridays. A skin/wound note, dated 6/11/19 at 2:22 P.M., indicated the referral paperwork was sent to the wound center clinic and the resident was awaiting an appointment time and date. A progress note, dated 6/13/19 at 2:58 P.M., indicated an indwelling foley catheter was placed to promote wound healing to LLE. A skin/wound note, dated 6/14/19 at 9:47 A.M., indicated Resident B had an appointment at the wound clinic on 6/17/19. A skin/wound note from the wound NP, dated 6/14/19 at 11:43 A.M., indicated Resident B was seen for maceration to previous wound and a new wound to LLE. Wound 1 (Stage 3) measured 6.2 cm x 3.0 cm x 0.3 cm with 25 % slough, wound 2 (unstageable) measured 6.0 cm x 7.0 cm x 0.1 cm with 100% slough and a new Stage 2 (wound 3) measured 1.4 cm x 1.5 cm x 0.1 cm. Debridement completed to wounds with #3 dermal curette. Orders were to discontinue wound vac, apply dakins with calcium alginate to wound bed daily and off load LLE at all times and culture LLE wound. A progress note, dated 6/17/19 at 3:59 P.M., indicated Resident B was not seen at the wound clinic due to needing a consent signed first, which was not done. Wound culture, ordered on [DATE], was completed on 6/17/19. A progress note, dated 6/19/19 at 8:50 A.M., indicated Resident B had an another appointment at the wound clinic on 6/24/19 at 2:15 P.M. A progress note, dated 6/19/19 at 10:02 A.M., indicated wound culture results were not available. A physician progress notes [REDACTED].M., indicated Resident B was seen for wound to LLE. The resident reported tenderness to the site and pain when the leg was moved. The dressing was changed earlier in the morning and now was saturated with light brown drainage. An administration note, dated 6/22/19 at 6:14 A.M., indicated dressing change to LLE was not completed. No reason was given. An infection note, dated 6/23/19 at 12:30 A.M., indicated the results from the wound culture were received and new order for [MEDICATION NAME] 875 mg twice daily for 10 days and [MEDICATION NAME]/dakins topical compound was received. LLE foul odor continues. Resident B tested positive [MEDICAL CONDITION] (Methicillan-resistant Staphylococcus Aureus) in his LLE wound (wound 1). An infection note, dated 6/24/19 at 6:08 P.M., indicated Resident B returned form wound clinic and was again not see due to needing consent and history filled out first. A skin/wound note, dated 6/26/19 at 11:16 A.M., indicated Resident B had another wound clinic appointment scheduled for 7/1/19, and needed to be accompanied by a staff member. The Medication Administration Record, [REDACTED]. [MEDICATION NAME] order (start date of 6/5/19) was not completed on 6/5/19 or 6/10/19, there was no documentation for 6/9/19. The order for calcium alginate AG (start date of 6/11/19) was not completed on 6/14/19, 6/21/19 or 6/25/19. The wound vac to LLE had start date to 6/5/19 (order was obtained on 5/31/19. There was missing documentation to offload LLE on 6/6/19 (day), 6/9/19 (night), 6/18/19 (day), 6/20/19 (day), 6/26/19 (night). There was no order to turn and reposition. There was no documentation present for the administration of the [MEDICATION NAME]/Dakins compound (start date 6/25/19). On 6/28/19 at 9:15 A.M., wound care to Resident B's LLE was observed: (wound 1) now a stage 3 measuring 8.4 cm x 3.0 cm, (wound 2) was now unstageable 8.4 cm x 5 cm with necrotic tissue and (wound 3) now 4 cm x 1.2 cm x 0.1 cm. On 6/28/19 at 9:30 A.M., Resident B's buttocks was observed., There were 13 new pressure areas found to his buttocks at that time, and the resident currently had a total of 16 pressure areas. There were several open Stage 2 wounds and a SDTI to right buttocks (6 in total) and left buttocks had several open Stage 2 wounds, the largest area was 1 cm x 3 cm x 0.1 cm (7 in total). Wound nurse in room at the time indicated he was unaware of the 13 new areas. The NP wound nurse in the room at the time indicated she was also unaware of these new areas. The CNA's present at the time indicated they were aware and the floor nurses also were aware. The CNA's indicated they had been applying the Triad cream to his buttocks. The resident was on an air mattress with the setting at static, bed was firm. Mattress had mutliple brown substance stains noted from the middle to the end bed and there was a hole in the mattress cover under resident's left foot. No cushion was observed to wheelchair, and Resident B indicated he had never had one and indicated no one ever came to turn him. He rated the pain to buttocks/coccyx area at a 8/10. During an interview, on 6/28/19 at 10:36 A.M., the Corporate Nurse indicated she was not aware of the multiple pressure areas on Resident B's buttocks. During an interview, on 6/28/19 at 10:37 A.M., the wound nurse indicated he was not aware of the pressure areas currently on Resident B's buttocks, The resident had previously had pressure areas on buttocks, but those had healed back in February. He indicated he had not been educated on the use of low air loss mattresses, and the companies that deliver the mattress are supposed to place them on the appropriate setting. He indicated Resident B's LLE was to be elevated at all times and the facility had a wedge that was supposed to be used to elevate the leg. During an observation, on 6/28/19 at 10:59 A.M., Resident B was observed laying in bed and his left foot was not elevated, the wedge cushion was on the floor by the wall and low air loss mattress remained on static/firm setting. During an interview, on 6/28/19 at 10:59 A.M., the DON (Director of Nursing) indicated she had just found out today about the multiple wounds on Resident B's buttocks. She indicated the low air loss mattress settings go by weight, the wound doctor and ADON order the mattress. The setting should be on alternating and not static/firm when a resident was in resting in the bed. During an interview, on 6/28/19 at 11:16 A.M., the DON indicated that Resident B was able to answer appropriately to questions regarding care. During an interview, on 6/28/19 at 11:23 A.M., the DON indicated Resident B's mattress was disgusting, with stains and rips in the top layer of the mattress. She indicated there was not a cushion in his wheelchair. During an interview, on 6/28/19 at 11:24 A.M., Resident B indicated no cushion had ever been placed in his wheelchair. During an interview, on 6/28/19 at 2:00 P.M., the wound NP indicated Resident B was found in very poor condition today. She was unaware of the multiple pressure ulcers on Resident B's buttocks, and there had been a decline to the wounds on his LLE. Resident B's wounds had not been observed by her in 2 weeks because she was never notified he had not been treated at the wound clinic on 6/17/19 and 6/24/19. The treatments she had been orderering should have been completed as ordered and the facility did not follow the correct order during the dressing change they completed that morning. The progression of Resident B's wounds to his LLE were related to unrelieved pressure and his legs were frequently not elevated as ordered when she would arrive for her observations, and she had completed staff training on this issue multiple times already. On 6/29/19 at 4:00 P.M., Resident B was observed laying crookedly in his bed, with his left arm hanging out of the bed and the front of his gown was soaking wet. Resident indicated he spilled water on himself and it had been there for an hour, and he did not know where his call light was. Resident B's call light was observed hanging on the side of his bed out of sight and out of reach. His left lower leg was resting on the mattress, the wedge cushion ordered for elevating his leg was observed on the floor. There was strong foul odor noted to the wound dressing. A towel was observed under his left leg and the towel and sheet underneath were stained with brown substance seeping from the dressing his wounds. On 6/29/19 at 4:40 P.M., Resident B was observed with his left leg resting on the mattress, and no positioning wedge was in place. The wedge remained on the floor by the wall. On 6/29/19 at 6:00 P.M., Resident B was observed with his left leg resting on the mattress, and no positioning wedge was in place. The wedge remained on the floor by the wall. During an interview, on 7/1/19 at 4:33 P.M., the DON indicated weekly wound observations were to be completed weekly. Dressing changes should be completed as ordered, and Resident B should have been positioned and his foot elevated at all times, as ordered. She indicated the wound NP should have been notified of the missed wound clinic appointments on 6/17/19 and 6/24/19 to ensure the wound was assessed. 2. A record review was conducted, on 7/01/19 at 4:49 P.M., and indicated Resident D's [DIAGNOSES REDACTED]. Quarterly MDS (Minimum Data Set) assessment, dated 5/17/19, indicated Resident D was moderately cognitively impaired. A progress note, dated 6/22/19, indicated Resident D had an area to the right outer ankle and appeared to from a blister. The area measured 6 cm (centimeters) x 5 cm x 0.5 cm. The wound was cleansed with normal saline and wrapped with kerlix and the wound NP (Nurse Practitioner) would be notified to evaluate the wound. A progress note, dated 6/23/19, indicated Resident D had an open blister to the right outer ankle and an off loading boot was in place. A progress note, dated 6/24/19, indicated the wound measured 6 cm x 5 cm x 0.5 cm, had no drainage and the wound NP would be notified to evaluate Resident D's wound. A NP progress note, dated 6/24/19, indicated the NP visited Resident D and the nature of the presenting problem was a wound on the right ankle. The progress note indicated he had a pressure wound on the right ankle and would be referred to the wound NP. No other assessment of the wound was documented. A wound NP progress note, dated 6/28/19, indicated Resident D had an unstageable pressure ulcer measuring 2.3 x 2.0 cm. Documentation of Resident D's wound being debrided was not present in the wound NP's progress notes. A weekly wound observation documentation, dated 6/29/19, indicated Resident D acquired the wound on 6/28/19 and measured 2 cm x 2 cm x 0.2 cm and was a stage 2 and was the first observation documented by the wound nurse. The wound had 50-75% (percent) slough (moist dead tissue) present with no drainage, no odor and no tunneling (narrow opening underneath the skin) or undermining (the tissue under the wound edges become eroded, resulting in a pocket beneath the skin at the wound's edge). No further documentation, related to the right ankle wound, was found in the clinical record prior to or after 6/29/19. During a wound observation, on 7/2/19 at 1:50 P.M., LPN 4 measured the wound at 2 cm x 2 cm x 0.2 cm and indicated the wound would be staged between a 2 and a 3. During an interview, on 7/03/19 at 9:32 A.M., the wound nurse indicated the wound initiated on 6/28/19. He indicated he was to assess wounds as soon as he was notified of them by the nurse. He indicated he was on vacation but, came back to work on the 26th and looked at Resident D's wound on (MONTH) 28th. The wound nurse practitioner debrided it on the 6/28/19 and removed the slough and he indicated the wound was a stage 2 at that time. The wound nurse indicated he looked at the wound, on 7/3/19, and would say the wound was between a stage 2-3, but had not documented his observations. He indicated wounds are assessed weekly on Wednesdays or Fridays, when the wound NP visits. He indicated he has had no training and he follows the wound nurse around and does what she says. On 7/4/19 at 9:00 A.M., a policy was requested for wound assessment, but one was not provided. A job description was provided by the DON (Director of Nursing), on 7/3/19 at 3;25 P.M., titled, JOB DESCRIPTION - Certified Nursing Assistant, revised (MONTH) (YEAR), and indicated the job description was the one currently being used by the facility. The job description indicated .Positions residents to maintain body alignment per policy/guidelines and plan of care .Reports promptly to the nurse any changes in the resident condition .Reports any equipment malfunction to the charge nurse A job description was provided by the ED (Executive Director), on 7/4/19 at 9:00 A.M., titled, JOB DESCRIPTION - Wound Care Nurse, revised (MONTH) (YEAR), and indicated the job description was the one currently being used by the facility. The job description indicated .The Wound Care Nurse is responsible for ensuring that an adequate level of skin care is provided .documented and regularly evaluated following nursing best practice .4. Ability to apply principles of supervision of employees, and in monitoring wound care .monitors for compliance as it relates to skin care .responsible for wound care The immediate jeopardy that began on 1/28/19 was removed on 7/4/19 when the facility provided proper education to staff related to wound assessments/documention, positioning, pressure prevention and ensured the resident had appropriate positioning devices in place, but 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 need for countinued education and monitoring. This Federal tag related to complaint IN 174. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure adequate supervision and fall prevention interventions were provided for a dependent resident resulting in a fall from bed with a femur fracture and a fall from bed resulting in a wrist sprain for 2 of 3 residents reviewed for falls. (Residents K & M) Findings Include: 1. During an observation in Resident K's room, on 06/25/19 at 11:15 AM, no side rails were observed on the bed and the resident was observed to be visibly shaking in the wheelchair. A clinical record review was conducted on 07/02/19, at 11:13 AM, for Resident K and indicated a admission date of [DATE]. Her [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 05/09/19, indicated a BIMS (Brief Interview for Mental Status) score that was unable to be assessed. No falls were documented. Care plans were in place related to ADLs (Activities of Daily Living) and falls. The ADL care plan indicated Resdient K required a 2 person mechanical lift for transfers and required staff assistance to change brief when incontinent. A Progress Note, dated 07/01/19, indicated an unwitnessed fall occurred. A History and Physical, dated 07/01/2019, indicated Resident K was brought to the emergency room related to a fall from bed at the nursing facility and had a right femur fracture upon x-ray. A surgical report, dated 07/02/19, indicated a right hip cephalomedullary nailing was completed for a [DIAGNOSES REDACTED]. During an interview, on 07/02/19 at 2:45 PM, the DON (Director of Nursing) indicated she had began a fall investigation, but due to the residents non-verbal status she was unable to determine the cause of the fall. She indicated she had removed the low air loss mattress as a possible cause and a fall mat was in place, but she had fallen from the opposite side of the bed where one was not present. 2. The clinical record for Resident M was reviewed on 6/27/19 at 12:05 P.M. [DIAGNOSES REDACTED]. There was no MDS (Minimum Data Set) assessment completed, the resident was a respite stay. A hospice note, dated 6/10/19 at 4:15 P.M., indicated Resident M was complaining of pain to her right hip due to a fall from the night before. LPN (Licensed Practical Nurse) 3 had reported to the Hospice nurse the resident had a fall in the morning and that she did not have a chance to call hospice or the family yet or even look at the fall report. A progress note, dated 6/10/19 at 7:50 P.M., indicated Resident M was found in room laying on her back. There were no non-skid socks on resident at the time of fall and it was determined that resident had attempted to ambulate unassisted. A care plan for at risk for falls, initiated on 6/10/19, included interventions that included, but were not limited, to ensure Resident M had on appropriate non-skid footwear and fall mat at beside. A Post-Fall Risk Evaluation, dated 6/10/19 at 7:58 P.M. indicated Resident M had a fall at 12:00 A.M. on 6/10/19. A hospice note, dated 6/14/19 at 6:27 P.M., indicated Resident M had reported two falls during her respite stay. The assessment indicated resident did have bruising and skin tear on her left elbow measuring 2 cm (centimeters) x 0.5 cm and her left wrist was very swollen, hard and bruised, it appeared possibly fractured. An ER (emergency room ) Physician Report, dated 6/14/19, indicated Resident M had pain, swelling and bruising noted to left wrist and an abrasion to her left elbow. The [DIAGNOSES REDACTED]. There was no documentation from the facility for a second fall/incident. During an interview, on 7/2/19 at 11:26 A.M., the DON indicated she was aware of the fall on 6/10/19 and that nursing should have notified the family, hospice and the physician at the time of the fall. On 7/4/19 at 10:30 A.M., the DON (Director of Nursing) provided the Falls-Clinical Protocol policy, dated 9/2012, and indicated this was the policy currently being used by the facility. The policy indicated the staff would evaluate and document falls that occur while the individual was in the facility. The staff would document risk factors for the falling in the resident's record . If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether these measures were still needed the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falling. On 7/4/19 at 10:30 A.M., the DON provided the Accidents and Incidents- Investigating and Reporting policy, dated 2/2014, and indicated this was the policy currently being used by the facility. The policy indicated all accidents and incidents involving residents . shall be investigated and reported to the Administrator. The Supervisor/Charge Nurse should have completed a Report of Incident/Accident form and submit the original to the DON within 24 hours of the incident or accident. This Federal tag relates to complaint IN 026. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate supervision and care to dependent/high acuity residents resulting lack of resident supervision and assistance for residents, resulting in a fall with a [MEDICAL CONDITION] for one resident, the worsening of stage 2 into stage 3 and unstageable and the development of new wounds for one resident. (Resident K and B) Findings include: 1. An Incident Report, dated 7/1/19 at 2:00 A.M., indicated Resident K had fallen from a bed with a low air-mattress in place resulting in a right femur fracture. During an interview, on 7/2/19 at 2:45 P.M., the DON (Director of Nursing) indicated there was only on CNA (certified nurse aide) present in the facility at the time of Resident K's fall resulting in [MEDICAL CONDITION]. She indicated the fall had occurred on 7/1/19 around 1:22 A.M. and there had not been sufficient staff present in the facility. A review of employee time cards, dated 6/30/19-7/1/19, indicated one CNA was clocked in at the time of the fall. 2. During a confidential interview, a staff member indicated there were not two aides available for hoyer lift transfers for Resident B at times. The clinical record for Resident B was reviewed on 6/27/19 at 2:28 P.M. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 5/15/19, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 9, mild cognitive impairment, was an extensive assist of two with bed mobility and total assist for transfers, and had a stage 3 pressure ulcer that was not present on admission. An Occupational Therapy note, dated 1/17/19, indicated Resident B required 4 people to roll right/left for peri-care after incontinent episodes and brief changes. During an observation, on 6/28/19 at 9:15 A.M., the observation of wound care to LLE: (wound 2) now a stage 3 measuring 8.4 cm x 3.0 cm (wound 3) now unstageable 8.4 cm x 5 cm with necrotic tissue and (wound 4) now 4 cm x 1.2 cm x 0.1 cm. During an observation, on 6/28/19 at 9:30 A.M., Resident B's buttocks was observed., There were 13 new pressure areas found to buttocks during observation, the resident currently has 16 pressure areas. There was 4.0 cm x 2.2 cm x 0. SDTI to right buttocks (6 in total) and left buttocks largest area was 1 cm x 3 cm x 0.1 cm (7 in total). Wound nurse in room indicated he was unaware of the many areas. NP wound nurse was unaware. And CNAs indicated they were aware and the nurses did know. CNAs indicated they had been applying Triad cream to buttocks. The resident was on an air mattress with the setting at static, bed was firm. Mattress was stained and ripped. No cushion to wheelchair, resident indicated he has never had one and he indicated no one ever comes to turn him. He indicated the pain to his buttocks where areas are present is rated at 8/10. 3. During a confidential interview, a family member of a resident indicated the facility did not have enough staff to meet the needs of the residents. She indicated during an observation of her family member on a weekend, the resident was found in bed with her pants around her ankles and her bed was soaked from head to toe. She indicated the resident had been out of bed all day and had not eaten. The documentation survey report, dated 6/1/19 - 6/30/19, had missing documentation of ADL care (activities of daily living) for transfers and eating on the 6/16/19 as indicated by the family member. 4. During an interview, on 6/25/19 at 3:41 P.M., a responsible party for Resident M indicated that there were not enough staff available in the facility. She indicated Resident M had gone 2 days without being fed and had remained in the same clothes for two days in a row. She indicated Resident M had endured a fall that was not reported timely to family. A hospice note, dated 6/10/19 at 4:15 P.M., indicated Resident M was complaining of pain to her right hip due to a fall from the night before. LPN (Licensed Practical Nurse) 3 had reported to Hospice nurse that the resident had a fall in the morning and that she did not have a chance to call hospice or the family yet or even look at the report. A Post-Fall Risk Evaluation, dated 6/10/19 at 7:58 P.M. indicated Resident M had a fall at 12:00 A.M. on 6/10/19. 4. The Grievance book was reviewed on 6/27/19 at 2:00 P.M. The following grievances were filed regarding staffing in the facility. A grievance form, dated 6/11/19, indicated when there was no shower aide in the facility, the residents did not get showers. A grievance form, dated 6/11/19, indicated CNAs (certified nurse aides) were not passing ice water and some residents had to get it themselves. A grievance form, dated 6/11/19, indicated staff was not answering call lights and were just responding on the intercom or turning the call light off from the nurse's station. A grievance form, dated 6/11/19, indicated a resident was not receiving restorative therapy services as ordered. During an confidential interview, a staff member indicated there was not sufficient staff in the facility on the weekends and night shift. She indicated there had been a multiple midnight shifts with only one CNA present in the facility. During an confidential interview, a staff member indicated that the facility at times did not have adequate staffing to meet resident needs, and that there were multiple midnight shifts with only one CNA present in the facility. The Nursing Daily Staffing forms were reviewed on 7/3/19 at 2:00 P.M. The following dates indicated insufficient CNA hours: On 5/18/19, there were 7.5 CNA hours on a night shift for 68 residents. On 6/2/19, there were 15.25 CNA hours on a night shift for 66 residents. On 6/29/19, there were 13.75 CNA hours on a night shift for 62 residents. 0n 6/30/19, there were 14.5 CNA hours on a night shift for 62 residents. A facility assessment, dated 7/2/19, indicated the the facility's current staffing requirements were: CNAs 7 on das, 7 on evenings and 5 on nights. LPNs/RNs was 3 of days and 3 for nights. There were 2 restorative aides and 1 shower aide. On 7/4/19 at 9:00 A.M., the ED (Executive Director) provided the Staffing policy, dated 4/2007, and indicated this was the policy currently used by the facility. The policy indicated the facility would maintain adequate staffing on each shift to ensure that the resident's needs and services were met. CNAs were to be available on each shift to provided needed care and services of each resident as outlined on the resident's comprehensive care plan. This Federal tag relates to complaint IN 174 & IN 439. 3.1-17(a)

Based on interview and record review, the facility failed to ensure a safe transfer, resulting in a resident experiencing a fractured fibula on her right leg for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: A clinical record review was completed, on 10/3/2018 at 1:30 P.M., and indicated Resident B's [DIAGNOSES REDACTED]. A MDS (minimum data set) assessment, dated 6/6/2018, indicated Resident B is cognitively intact. A MDS assessment, dated 7/7/2018, indicated Resident B is totally dependent and requires two persons to assist her with transfers. A care plan, dated 7/11/2017, indicated Resident B requires the use of a mechanical lift with the assistance of two staff members, for transfers. A nurses note, dated 9/9/2018, indicated Resident B had a witnessed fall. The note indicated .res (resident) uses a stand up lift for transfers and during the transfer the aids reported that one side popped out and resident to the floor A nurses note, dated 9/9/2018, indicated .Call received from mobile medical regarding xray of fibula results A transfer/discharge report, undated, indicated Resident B had a right fibula fracture. An incident report, dated 9/10/2018, indicated Resident had a witness fall during a transfer, res uses a stand up lift for transfers and during the transfer the aids reported that one side popped out and resident to the floor, resident has no injuries and denies having any pain or discomfort d/t (due to) fall, res is now resting in bed at this time will continue to observe. Later that night resident complained of pain. Xray ordered and results found fracture of leg During an interview, on 10/3/2018 at 11:00 A.M., Resident B indicated staff took her to the bathroom and left her on the toilet while still hooked up to the mechanical stand lift. When the staff returned to her room to assist her off the toilet, they lifted the stand lift and heard a loud pop. She indicated one of the straps had come off of the stand lift and she fell from the lift and hurt her leg. Resident indicated staff frequently leave the mechanical stand lift hooked to her while she is on the toilet. During an interview, on 10/3/2018 at 11:15 A.M., the facility DON (director of nursing) indicated the straps may not have been under the metal part of the lift and this may be what made the pop sound. During an interview, on 10/3/2018 at 11:25 A.M., the facility administrator indicated staff should not be leaving a resident on the toilet while hooked up to the mechanical stand lift. She indicated the resident may have moved while on the toilet and accidentally loosened the strap, and staff must not have checked the straps for placement before performing the transfer using the lift. During an interview, on 10/3/2018 at 11:35 A.M., CNA (Certified Nurses Aide) 2 indicated she was unaware of any rules about leaving a resident on the toilet, while hooked up to a mechanical lift, and staff do this all the time. A policy was provided by the administrator, on 10/3/2018 at 11:31 A.M., titled Lifting Machine, Using a Portable, undated, and indicated this was the policy currently used by the facility. The policy indicated .Steps in the Procedure 7. Attach the sling to the lift. Be sure the hooks are placed so that they are facing away from the resident. 8. Instruct the resident to fold both arms across his or her chest, if possible. 9. Using the crank, raise the resident from the bed 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to implement interventions and treatment to prevent the development and worsening of pressure ulcers resulting in two unstageable ulcers on the right buttocks and coccyx for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 2/7/18 at 12:13 P.M. The [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 12/21/17, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 5, severe cognitive impairment, and required extensive assist of two with bed mobility and transfers. A care plan, dated 7/7/16, for potential development of pressure ulcers due to decreased mobility and history of wounds included interventions to keep skin clean and dry and use house barrier with incontinent care. The Medication Administration Record, [REDACTED]. Change daily and as needed every night shift (order start date 11/15/17) The Weekly Skin Altercation, dated 11/30/17 at 11:19 A.M., indicated the pressure ulcer to the right buttock was located on old scar tissue and had healed. The Progress Note, dated 1/30/18 at 10:26 A.M., indicated Resident B had an open area to right buttock that measured 3 cm (centimeters) x (by) 1.4 cm. A Skin & Wound Assessment, dated 1/30/18 at 11:27 A.M., indicated Resident B had a skin tear to right buttock that had been present for 1 week and measured 1.5 cm (centimeters) x 0.5 cm with [MEDICATION NAME] noted to wound base and macerated surrounding tissue. Resident B's record lacked documentation to show her physician had been notified of the new open areas. The Weekly Skin Alteration Record, dated 2/6/18 at 6:02 P.M., indicated Resident B had an open area to the right buttock measuring 4.5 cm x 4.75 cm with 50 % pink tissue and 50 % beefy red tissue noted to wound base with scant amount of drainage and no change noted in healing process. The Weekly Skin Alteration Record, dated 2/6/18 at 6:07 P.M., indicated Resident B had an abrasion to right buttock measuring 3 cm x 3.5 cm with 75% pink tissue and 25 % beefy red tissue noted to wound base with scant drainage noted and this was a new wound. Resident B's record lacked documentation to show her physician had been notified. During an observation, on 2/7/18 at 4:20 P.M., RN 1 removed the dressing from Resident B's buttocks and exposed an unstageable pressure ulcer to the right buttock measuring 3 cm x 2.6 cm with unmeasurable depth due to 100 % brownish yellow slough on wound base, a unstageable pressure ulcer to the coccyx that measured 4.2 cm x 4.0 cm with unmeasureable depth due to 70 % yellow slough and 30 % black necrotic tissue on wound base, and a stage 2 pressure ulcer to left buttock measuring 0.4 cm x 0.8 cm x < 0.1 cm. During observations, on 2/8/18 between 9:20 A.M. and 12:15 P.M., Resident B was sitting in her wheel chair in her room with an anti-thrust cushion in place under her. She was facing the recliner in room with her bed side table positioned to the left and behind her. During an interview, on 2/8/18 at 10:30 A.M., the therapy director indicated the anti-thrust cushion was placed in Resident B's wheel chair in early (MONTH) (YEAR) and he had not been notified of the development of pressure ulcers on the resident's buttocks. During an interview, on 2/8/18 at 1:42 P.M., the DON (Director of Nursing) indicated she had looked at Resident B's wound in (MONTH) and it was just an small opening at the time located on scar tissue from a previous wound and it had not appeared as a chronic wound. During an interview, on 2/8/18 at 3:20 P.M., Resident B's family member indicated she had been with resident since 12:15 P.M., and no one had attempted to toilet or reposition resident. During an observation, on 2/9/18 at 12:20 P.M., Resident B was sitting in her wheel chair at the nursing station since 10:58 A.M. stating, help me, help me, I am in pain. She complained of pain to her left foot and buttocks and indicated she wanted to stand up, but no one came to assist her. RN 1 administered Tylenol to her at this time. During an observation, on 2/9/18 at 2:10 P.M., Resident B continued to sit at nursing station in wheelchair crying about the pain in her foot and buttocks, she was pushing on arm rests of wheelchair attempting to reposition herself and shift her weight. During an observation, on 2/9/18 at 2:30 P.M., Resident B's pressure ulcers presented with moderate drainage to dressing and foul smelling odor, the stage 2 pressure ulcer to left buttock measured 1.2 cm x 0.6 cm x <0.1 cm, the unstageable pressure ulcer to coccyx measured 3.0 cm x 2.4 cm and presented with black center and brownish yellow slough, and the unstageable pressure ulcer to right buttock presented with no change. During an interview, on 2/9/18 at 2:45 P.M., the Administrator indicated the physician should have been notified with the changes in the wound noted on 2/7/19 and the treatment order form 11/15/17 should have been discontinued and new order received when new wound first appeared. On 2/9/18 at 11:45 A.M., the Administrator provided the Prevention of Pressure Ulcers policy, dated 9/2013, and indicated this was the policy currently being used by the facility. The policy indicated pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure and a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. For residents in bed their position should be changed at least every two hours and for residents in chair their position should be changed at least every hour. Report any signs of a developing pressure ulcer to the physician. The care process should include efforts to stabilize, reduce and remove underlying risk factors; to monitor the impact of interventions; and to modify interventions as appropriate. This Federal tag is related to complaint IN 428. 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on record review, observation and interview, the facility to failed to provide adequate monitoring and treatments to a surgical incision resulting in hospitalization for incision and drainage of [MEDICAL CONDITION] (Methacillin Resistant Staphylococcus Aureus) abscess for 1 of 3 residents reviewed for quality of care. (Resident F) Findings include: The clinical record for Resident F was reviewed on 1/11/18. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 11/6/17, indicated Resident F was readmitted to the facility on [DATE] and had a BIMS score of 13, cognitively intact. The physician progress notes [REDACTED].M., indicated Resident F was hospitalized for [REDACTED]. The note indicated the stump incision was approximated well, had minimal redness without [DIAGNOSES REDACTED] to stump and few scabbed areas with no drainage. There was no care plan available for the incision to RBKA. The Nursing Progress Note, dated 11/20/17 at 4:00 P.M., indicated therapy reported Resident F's incision was weeping today. .Nurse applied dressing, resident's incision to right stump has sutures intact with area to lateral aspect of incision that remains open with black tissue to middle . There was no physician notification documented. The Nursing Progress Note, dated 11/21/17 at 11:40 A.M., indicated the right stump was red, swollen and tender to touch. Mild purulent drainage was present. The physician was notified, and facility was waiting for call back. There was no call back confirmation documented with the physician. The Nursing Progress Note, dated 11/24/17 at 11:12 A.M., indicated Resident F's incision presented with redness, warmth, purulent drainage and the orthopedic physician was notified via phone. The Nursing Progress Note, dated 11/24/17 at 12:58 P.M., indicated Resident F had returned from orthopedic physician appointment with new orders for an antibiotic. There was no care plan was developed for infection to incision. The Medication Administration Record, [REDACTED]. The treatment was documented as completed only on 12/1/17, 12/3/17 and 12/5/17. The Nursing Progress Note, dated 12/3/17 at 12:28 A.M., indicated Resident F's wound to right stump was still draining purulent drainage and was tender. There was no physician notification noted. The Nursing Progress Note, dated 12/6/17 at 11:33 A.M., indicated Resident F was taken from the orthopedic appointment to the hospital for surgery related to infection at surgery site. The Physician Note, dated 12/6/18, indicated Resident F returned to the orthopedic office for follow up of her amputation below the knee on the right. Resident stated that she did have an open wound, about the size of a quarter that had been there for a one week. The skilled nursing facility she was staying at, once again did not contact us and had not contacted the orthopedic physician office. The plan was discussed with resident to take her right to surgery and plan on irrigation and excisional debridement of the right stump infection. The History and Physical, dated 12/6/18, indicated Resident F had longstanding history of diabetes and tobacco dependence who underwent a BKA approximately six weeks ago. Resident stated she had an open wound for about one week and the office was never notified. The resident presented with an open foul smelling wound, lateral part of the wound with expressible puss. The resident had been at ECF (extended care facility since discharge). The Consultation Note, dated 12/6/17, indicated Resident F had a right BKA on 10/20/17 due to osteo[DIAGNOSES REDACTED] and was discharged to ECF and had been doing well until mid November. The ECF staff members noted some [DIAGNOSES REDACTED] and weeping on lateral distal end of BKA. The day after Thanksgiving the resident had an appointment with the orthopedic physician and was prescribed bactrim and other wound dressing changes. Resident followed up with Nurse Practitioner at orthopedic office and noted open foul smelling wound on the lateral part of the wound with expressible puss. The Doctor Progress Note, dated 12/12/17, indicated Resident F had a right [MEDICAL CONDITION] post operative wound dehiscence with deep abscess, was status [REDACTED]. The plan was to complete at least 4 weeks of antibiotics. The Doctor Progress Note, dated 12/12/17, indicated Resident F had recent BKA on 10/20/17 and a festering wound on BKA stump for past 3-4 weeks not improved with Bactrim. She was on post operative day 3 and now status [REDACTED]. The wound [MEDICAL CONDITION], [MEDICATION NAME] and [DIAGNOSES REDACTED] with PICC line for antibiotics. The Physician Summary & Transfer Orders to ECF, dated 12/13/17, indicated Resident F was discharged back to facility with documented reason for hospitalization was for RBKA wound dehiscence with deep abscess and the procedure was incision and debridement was performed twice. The Medication Administration Record, [REDACTED]. an order for [REDACTED]. During an interview, on 12/12/18 at 10:04 A.M., the MDS Coordinator indicated the facility used secured messaging through the EHR (Electronic Health System) that was programmed with the primary physicians for the facility and no documentation was available for the physician notification in regards to Resident F's incision. During an interview, on 12/12/18 at 10:05 A.M., the DON (Director of Nursing) indicated the orthopedic surgeon should have been notified on regards to the incision from the first date symptoms presented and with no improvement after Bactrim was started. She indicated antibiotics and treatments should be completed as ordered, with hand washing performed between removal of dressing, cleaning of wound and redressing, and the incision should have been monitored at least daily for signs and symptoms of infection. On 1/12/17 at 9:47 A.M., a policy was requested for incision monitoring and treatments. The DON indicate no policy was available. On 1/12/18 at 11:02 A.M., the DON provided the Drug Administration policy, dated 12/31/14, and indicated this was the policy currently being used by the facility. The policy indicated medications were to be administered in accordance with written orders of the attending physician. This Federal tag is related to complaint IN 191. 3.1-37(a)

Based on observation, interview, and record review the facility failed to follow physician orders [REDACTED].#3). Finding Includes: A clinical record review was conducted on 06/28/2017, at 9:43 AM, for Resident #3 and indicated an admission date of [DATE]. His [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 05/13/17, indicated a BIMS (Brief Interview for Mental Status) score of 15, cognitively intact. The assessment indicated Resident #3 had unhealed pressure ulcers on admission; one stage 1, one stage 4, and four unstageable. Care plans indicated a skin impairment care plan, dated 05/16/17, was in place with interventions to administer treatments as ordered and monitor for effectiveness and to assess/record/monitor wound healing weekly, with measurements, wound bed/edge appearance and healing progress. The care plan also indicated areas upon admission: Unstageable-sacrum; Unstageable-right trochanter; Unstageable-left buttock, Unstageable-Left buttock, Stage IV-right trochanter, Stage II-left buttock. During an interview, on 06/28/17 at 12:42 PM, the Administrator indicated Resident #3 was admitted with three left buttock pressure areas, one pressure area to the sacrum, and one pressure area to each the right hip and right buttock. Hospital documentation, dated 05/06/17, indicated Resident #3 had a wound on the left and right buttock area each and a wound to the right hip area prior to admission to the facility. Wound assessment documentation indicated the Right Hip wound initially measured 3.44cm x 2.12cm x 1cm and the Left Buttock (Sacrum) wound measured 1.26cm x 1cm x 0.1cm. There was no documentation for the Right Ischium wound. Wound assessments were not being completed weekly as indicated on the care plan. No documentation was available for the right Ischium prior to 06/02/17 and no documentation on any of the three pressure areas from 05/09/17 to 05/24/17. Progress notes indicated only the Right Hip wound was assessed on 06/01/17 and on 06/02/17 the wound nurse measured the areas, without documenting the wound descriptions. No other assessments were documented until 06/05/17 and 06/26/17, when wound doctor saw Resident #3. The Wound Care Specialist Evaluation, dated 06/26/17, indicated the following measurements: Right Hip - 11cm x 6cm x 0.3cm, Sacrum - 3cm x 2cm x 0.3cm, and the Right Ischium - 3cm x 1cm x 0.3cm Physician orders, dated 06/27/17, indicated wound care orders as follows: Right Ischium - cleanse with NS/Wound cleanser, pat dry, cover with dry protective dressing. Right Hip - cleanse with NS/Wound cleanser, pat dry, apply Dakins solution to wound bed, cover with wet to moist dressing, cover with dry, protective dressing. Sacrum - cleanse with NS/Wound cleanser, pat dry, apply Dakins solution to wound bed, apply wet to moist dressing. On 06/29/17, at 11:30 AM, wound care was observed with the wound nurse. The wounds measured as follows: Right Hip wound - 11.5cm x 8cm x 0.3cm and 100% granulation. Sacrum wound (lower, left of anus) - 5cm x 3cm x 0.5cm and 75% granulation, 25% slough. Right Ischium (upper right of anus) - 4.5cm x 1.5cm x 0.5cm and 80% granulation, 20% slough. The Sacrum wound was observed to have a food particle on the wound ben after removal of the old dressing. She was observed washing her hands for 12 seconds before beginning the wound care and after changing gloves before applying the first dressing. After cleaning the third wound she did not change gloves or wash hands before applying the dressing. The wound nurse indicated the wounds were cleaned with wound cleanser and normal saline, then each was packed with saline soaked gauze from wet to moist, then [MEDICATION NAME] was applied. During a phone interview, on 06/29/2017 at 12:23 PM, the wound doctor clarified wounds. He indicated the wound listed as the Sacrum wound would be located to the left, lower area of the anus and he had listed it as such in error and would correct the documentation to reflect its proper location on the left side. During an interview, 06/29/2017 at 2:05 PM, the wound nurse indicated she did not document the wound appearance, for each wound, for the weekly assessment on 06/02/17. A policy was provided by the Administrator on 06/28/17 at 12:37 PM, titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 03/2014, and indicated this was the policy currently used by the facility. The policy indicated .the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue 3.1-40(a)(2)

Based on interview and record review, the facility failed to complete a root cause analysis and develope and implement interventions to prevent repeated falls for 1 of 3 residents reviewed for falls. Resident #67 experienced 27 falls from 11-13-15 to 5-9-16. The facility also failed to ensure a care plan intervention for falls was followed for 1 of 6 residents review for accidents. (Resident #77) Findings include: On 5-17-2016 at 1:09 P.M., during a staff interview, the MDS (Minimum Data Set) Coordinator indicated, (Resident #67) has had one fall in the last 30 days, on 5-9-2016. On 5-20-2016 at 1:42 P.M., a record review for Resident #67 was conducted. Resident #67 was admitted on [DATE]. The admission diagnoses from (local hospital) History and Physical, dated 11-7-2015, included peripheral vascular disease, stroke, carotid artery stenosis, osteoarthritis, BPH (benign prostatic hyperplasia), Atrial fibrillation, hypertension, elevated PSA (Prostate-specific antigen) and arthritis of the knees. The progress notes indicated Resident #67 had fallen on 11/13, 11/23, 11/26, 12/1, 12/3, 12/8, 12/9, 12/10, 12/16, 12/18 and 12/19, 2015 and 1/28, 1/30, 2/4, 2/13, 2/19, 2/23, 3/2, 3/12, 3/22, 3/26, 3/27, 4/8, 4/11, 4/14 and 5/9, 2016. The care plans for Resident #67 indicated, The resident is high risk for falls r/t (related/to) unaware of safety needs, poor trunk control, dated 11/13/2015. The care plan was updated on 11/23/2015, 11/26/2015, 12/9/2015, 12/18/2015, 1/28/2016, 02/01/2016 and 5/9/2016. The interventions related to falls were, Anticipate and meet the resident's needs, assist to wheel chair, assisted to bathroom, bed sensor pad, fall mat, tab alarm, dycem ( a non-skid material) added to wheelchair, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, frequent monitoring when up in wheelchair to prevent falls as an ongoing intervention, meds to be adjusted by Physician as needed, meds to be reviewed by Physician, pain assessed, pressure alarm to wheelchair, pt (physical therapy) evaluate and treat as ordered or PRN (as needed), resident will be kept around staff as much as possible during the day to avoid unassisted transfers, the resident needs a safe environment with: floors free from spills and/or clutter;adequate, glare-free light; the bed in low position at all times when in bed, toilet before and after meals, hs (hour of sleep) and prn during the night, and wing mattress. No other interventions were noted. The physician's orders [REDACTED]. *11-8-2015, Requip (Antiparkinsonians medication) 0.125 mg (milligram) PO (by mouth) T.I.D (three times a day). *11-11-2015, Requip .25 mg PO T.I.D for Parkinsons. *11-18-2015, Requip 0.5 mg one P.O. Tid. *12-2-2015, Requip 1 mg one P.O. Tid. *12-20-2015, Requip 2 mg P.O. T.ID. *1-9-2016, Requip 2.5 mg TID P.O. (parkinson's). *1-16-2016, Seroquel (Antipsychotic medication) 25 mg PO QHS (at hour of sleep). *1-20-2016, Seroquel 12.5 mg BID (two times daily) and Seroquel 50 mg P.O. QHS. *1-31-2016, Seroquel 12.5 mg PO TID. *2-6-2016, Depakote (Anticonvulsant medication) 125 mg QID (four times daily), Seroquel 25 mg one PO TID and Seroquel 50 mg QHS. *2-13-2016, Seroquel IR (immediate release) 50 mg po TID for behaviors. *2-18-2016, increase Depakote 250 mg PO TID, dx (diagnosis) behaviors. The current MARs (Medication Administration Records) for the month of May 2016, indicated current medications to include, Seroquel 50 mg, take 1 tablet by mouth three times daily and Depakote 250 mg 1 P.O QID. A record review of the MDS (Minimum Data Set) assessment, dated 12-5-2015 and 1-2-2016, indicated no documented behaviors. The MDS assessment, dated 2-4-2016, indicated, Rejection of care and wandering had occurred 1-3 days in the look back period. The BIMS (Brief Interview for Mental Status) score was 6 out of a possible15, indicating severe cognitive impairment. There are no behaviors noted in progress notes. On 5-23-2016 at 11:56 P.M., during an interview, the DON (Director of Nursing) indicated, Falls were bad related to medications and supervision, we didn't have enough staff and residents were being prescribed antiphyschotic medications routinely by our former medical director. Every fall should have an incident report and an intervention should be put in place. Interventions should be evaluated for effectiveness and changed if needed. The root cause for falls was not being done. They (the former management team) were not having fall meetings to make sure an intervention was in place and to find the root cause. The resident came in with no [DIAGNOSES REDACTED]. He (former medical director) then prescribed Seroquel on 11-11-2016 and the falls started soon after. On 05-23-16 at 12:31 P.M., the DON provided the policy entitled, Fall Prevention Guidelines, initiated on 6/10/2015, and indicated these were the guidelines the facility currently used. The guidelines indicated, .Post Fall .Incident/Accident Report .Fall Risk Assessment .Update Care Plan .72 hour charting (every shift) reflecting resident condition related to fall include vital signs .Put new interventions in place as needed .Document on 24 hour sheet .Notify Restorative Nurse The DON indicated, at this time, We currently don't have a Restorative Nurse. On 5-17-2016 at 1:11 P.M., during an interview, the DON (Director of Nursing), indicated Resident #77 had a fall on 5-14-2016. On 5-20-2016 at 4:30 P.M., the Resident #77's clinical records were reviewed. The diagnoses, included, but were not limited to, dementia with behavioral disturbances and major depressive disorder. The current physician's orders [REDACTED]. Resident #77's care plans, dated 2-5-16 and revised 4-18-16, included, but were not limited to, resident is at risk for falls related to unaware of safety and need, confusion. The interventions included but were not limited to, appropriated foot wear. On 5-26-2016 at 2:45 P.M., the resident's Incident Description was provided by the DON. The form indicated, .Writer was called to residents room by Certified Nursing Assistant on duty .Resident was noted sitting up on buttock playing with her hair. Pad alarm did go off in the bed. Resident was not wearing shoes or non-skid socks The form titled Fall Investigation was also provided by the DON at this time. The form indicated Resident #77 was not wearing non-skid socks, and that she was wearing regular socks. An interview with the DON on 5-26-2016 at 2:45 P.M., indicated the resident was not wearing appropriate foot wear when she fell . She indicated the resident was not wearing non-skid socks as directed in the care plan. 3.1-45(a)(2)