Every finding on record at Brickyard Healthcare - Lincoln Hills Care Center

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 2 ofv4 observations of medication administration. Gloves were not changed and hand hygiene was not performed between dirty and clean tasks during perineal care. The nurses dropped medications onto the medication cart, picked them up with their bare hand, and administered it to the residents. (Resident C, Resident B, Resident D, Resident G). Findings include:1. On 4/13/26 at 6:13 A.M., Licensed Practical Nurse (LPN) 5 was observed preparing medications for Resident G. When she poured the prepackaged medications into the medication cup, one pill fell onto the medication cart. LPN 5 picked it up with her bare hand and put it into the medication cup. LPN 5 took the medications into Resident G's room and administered them to the resident. 2. On 4/13/2026 at 6:49 A.M., LPN 22 was observed preparing medications for Resident D. When she poured the prepackaged medications into the medication cup, one pill fell onto the medication cart. LPN 22 picked it up with her bare hand and put it into the medication cup. LPN 22 took the medications into Resident D's room and administered them to the resident. During an interview on 4/15/26 at 9:50 A.M., Registered Nurse (RN) 35 indicated if a medication fell out of package while administering medications, nursing staff should use gloves so they aren't touching the medication with their bare hands and should dispose of the medication and not administer it to a resident. 3. During an observation of care on 4/13/26 at 11:03 A.M., Certified Nurse Aide (CNA) 6 and CNA 7 performed perineal care on Resident C. CNA 6 washed her hands and donned gloves and used her right gloved hand to raise Resident C's bed up. CNA 6 used the same gloved hand to wipe Resident C's perineal area with a washcloth. At that time, CNA 6 grabbed a clean incontinence pad and placed it on the bed with the same gloved hand. Then she removed gloves, sanitized, and donned new gloves while the soiled incontinence pad was still on the bed under Resident C. Resident C rolled to the right side and CNA 6 wiped Resident C's buttocks with a washcloth, removed gloves, sanitized, and donned new gloves. CNA 6 then removed the soiled incontinence pad from under the resident and failed to change gloves and sanitize before the clean incontinence pad was placed under Resident C. 4. On 4/13/26 at 9:20 A.M. Licensed Practical Nurse (LPN) 41 was observed performing perineal care for Resident B. Resident B gave permission to watch care. LPN 41 closed the curtains on the window and the curtain around the bed. She explained to Resident B what she was going to do, filled water basin with warm water, washed her hands, put on gloves, and took blankets off resident. LPN 41 unfastened the brief, pushed it between Resident B's legs, wet a washcloth and sprayed the washcloth with peri cleaner. LPN 41 washed down both sides of the front of Resident B's perineal area, and down between the labia. LPN 41 put the soiled washcloth in a trash bag on the bed and asked Resident B to turn to her left side. When LPN 41 took the brief that contained stool out from under Resident B, stool got on the pad under Resident B and the lift sheet. LPN 41 put the soiled brief into a trash bag on the bed and rolled the pad and lift sheet under the resident. LPN 41 changed gloves but did not sanitize her hands before putting clean gloves on. LPN 41 placed a clean pad and lift sheet on bed, used a wet washcloth with peri clean and washed buttocks with several clean washcloths until Resident B was clean, dried her with a towel and placed soiled linens in the trash bag. LPN 41 asked Resident B to turn to the right side, pulled pad and lift sheet through, pulled brief up between Resident B's legs and fastened. LPN 41 tied the trash bags shut, took gloves off, and cleaned hands with sanitizer. Resident B asked for a Pepsi and LPN 41 told the resident she had to wash her hands first. During an interview on 4/15/26 at 9:50 A.M., the Infection Preventionist (IP) indicated staff should change gloves and perform hand hygiene between dirty and clean tasks. On 4/16/26 at 8:30 A.M., a current non dated Medication Administration Policy was provided by the Administrator and indicated, . 14. Remove medication from source, taking care not to touch medication with bare hand . On 4/16/26 at 8:30 A.M., the Administrator provided a non dated Personal Protective Equipment (PPE) policy that indicated, 4. Indications/considerations for PPE use: .iv. Change gloves and perform hand hygience between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn . This citation relates to Intake 2971495. 410 Indiana Administrative Code (IAC) 16.2-3.1-18(b)(1) 410 Indiana Administrative Code (IAC) 16.2-3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure privacy was provided for the residents for 6 of 6 random observations on 2 of 3 halls. Resident information was visible on the computer screens in Hall A and Hall B and staff did not knock prior to entering a resident room. (Hall A, Hall B, Resident D)Findings include:1. On 4/9/26 at 8:37 A.M., Hall A's Medication Cart was observed in the hallway with resident information (resident name, picture, and room number) visible on the computer screen without staff present at the computer.2. On 4/13/26 from 6:13 A.M. to 6:19 A.M., Hall A's Medication Cart was observed in the hallway with resident information (resident name, picture, and room number) visible on the computer screen without staff present at the computer.3. On 4/13/26 from 6:24 A.M. to 6:29 A.M., Hall B's Medication Cart was observed in the hallway with resident information (resident name, picture, and room number) visible on the computer screen without staff present at the computer.4. On 4/13/26 at 6:49 A.M., Licensed Practical Nurse (LPN) 22 did not knock or announce herself prior to entering Resident D's room to get the blood sugar reading. When she got to the resident's bedside and said the resident's name, Resident D was startled and jumped. LPN 22 went back out to the medication cart to prepare Resident D's medications and walked back into Resident D's room with those medications and did not knock or announce herself prior to entering the room. LPN went back out to get the resident a snack and her prepare her insulin. LPN 22 did not knock or announce herself prior to entering Resident D's room.During an interview on 4/15/26 at 1:41 P.M., the Director of Nursing (DON) indicated nursing staff should knock before entering resident rooms and should not leave computer screens with resident information visible while they are not at the computer. On 4/16/26 at 8:30 A.M., a current non dated Medication Administration Policy was provided by the Administrator and indicated, . 5. Knock or announce presence . 7. Provide privacy . On 4/16/26 at 8:30 A.M., a current non dated Resident Rights Policy was provided by the Administrator and indicated, . The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents . 410 Indiana Administration Code (IAC) 16.2-3.1-3(o)

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for 2 of 5 residents reviewed for unnecessary medications, and an insulin pen was not primed for 2 of 2 insulin administration observations. A blood pressure medication was not held as indicated in the order parameters, and a resident's blood sugar was not re-checked as ordered. (Resident 5, Resident 4, Resident D)Findings include:1. On 4/14/26 at 9:46 A.M., Resident 5's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/15/26, indicated no cognitive impairment and 7 of 7 days of insulin injections. Current physician orders included, but was not limited to: Insulin Aspart FlexPen 100 unit/ml (milliliter), Inject as per sliding scale: if 100 - 150 = 4 units <100 eat small snack and recheck blood sugar in 15 mins then administer insulin; 151 - 175 = 5 units; 176 - 200 = 6 units; 201 - 225 = 7 units; 226 - 250 = 8 units; 251 - 300 = 9 units; 301 - 325 = 10 units; 326 - 350 = 11 units; 351 - 375 = 12 units; 376 - 400 = 13 units; 401 - 450 = 14 units If blood sugar is <60 or > 450 notify MD, subcutaneously before meals, dated 1/22/26. Resident 5's Medication Administration Record (MAR) indicated the following blood sugars below 100 with no documented re-check: 4/3/26 at lunch, blood sugar 85. 4/4/26 at lunch, blood sugar 74. 4/7/26 at dinner, blood sugar 96. Resident 5's MAR indicated on 4/2/26 at dinner, no blood sugar or insulin was administered. Resident 5's progress notes lacked documentation of a blood sugar re-check on 4/3/26, 4/4/26, or 4/7/26. The progress notes also lacked documentation of why a blood sugar was not completed or insulin given on 4/2/26 at dinner. 2. On 4/13/26 at 6:40 A.M., Licensed Practical Nurse (LPN) 22 was observed preparing insulin for Resident 5. She put on gloves, grabbed Resident 5's Novalog Flexpen 100 units/milliliter (u/ml), wiped the tip of it with alcohol, and applied the needle leaving the outer cover on it. The nurse held the pen horizontally and pushed the plunger of the pen to prime it with one unit of insulin. Then she dialed the pen to four units and administered the insulin to the resident. 3. On 4/13/26 at 6:49 A.M. LPN 22 was observed preparing insulin for Resident D. She put on gloves, grabbed Resident D's Humalog Kwikpen 100 u/ml, wiped the tip of it with alcohol, and applied the needle leaving the outer cover on it. The nurse held the pen horizontally and pushed the plunger of the pen to prime it with one unit of insulin. Then she dialed the pen to one unit and administered the insulin to the resident. During an interview on 4/13/26 at 7:04 A.M., LPN 22 indicated that she primed insulin pens with one unit of insulin. 4. On 4/10/26 at 12:38 P.M., Resident 4's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension (high blood pressure). The most recent annual Significant Change Data Set (MDS) assessment, dated 3/19/26, indicated Resident 4 was cognitively intact. Current physician orders included, but was not limited to the following: Hydralazine oral tablet 50 milligrams (mg) (hypertension medication). Give 1 tablet every by mouth 3 times a day for hypertension. Hold for a systolic (top number) blood pressure (bp) less than 140, dated 1/20/26. On the following dates and times, hydralazine was given when Resident 4's systolic blood pressure was less than 140: February 2, 2026: bp of 136/80—evening shift February 4, 2026: bp of 136/64—middle shift February 4, 2026: bp of 132/75—evening shift February 5, 2026: bp of 132/75—morning shift February 5, 2026: bp of 138/68—middle shift February 5, 2026: bp of 120/60—evening shift February 6, 2026: bp of 132/72—middle shift February 7, 2026: bp of 125/68—evening shift February 8, 2026: bp of 135/65—evening shift February 9, 2026: bp of 128/70—middle shift February 13, 2026: bp of 139/82—evening shift February 14, 2026: bp of 139/82—morning shift February 14, 2026: bp of 139/82—middle shift February 17, 2026: bp of 105/63—middle shift March 2, 2026: bp of 127/60—morning shift March 2, 2026: bp of 127/60—middle shift March 10, 2026: bp of 138/70—middle shift March 14, 2026: bp of 128/78—middle shift March 17, 2026: bp of 117/66—morning shift March 20, 2026: bp of 128/68—middle shift March 21, 2026: bp of 128/68—morning shift March 21, 2026: bp of 128/68—middle shift March 28, 2026: bp of 139/87—morning shift March 29, 2026: bp of 135/76—morning shift During an interview on 4/14/26 at 10:38 A.M., Registered Nurse (RN) 8 indicated if the resident's systolic blood pressure is less than 140, the medication should not be given. On 4/16/26 at 8:30 A.M., the Administrator provided a current non-dated Medication Administration that indicated, .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. On 4/16/26 at 8:30 A.M., the Administrator provided a current non-dated Insulin Pen policy that indicated Monitor blood sugar as ordered by physician . always review physician orders prior to administering any medication On 4/16/26 at 8:30 A.M., a current non dated Insulin Pen Policy was provided by the Administrator and indicated, It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing . insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir . Procedure: g. Attach pen needle: . iv. Twist open and remove outter cover from the pen needle. h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears . 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a) 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were provided activities to meet the interests of and well-being of each resident for 1 of 1 weekends reviewed for activities.Findings include:During the resident council meeting on 4/13/26 at 11:20 A.M., residents indicated they don't have activities on the weekends. One resident indicated he can't get around to host them or even tell people there are any. On 4/14/26 at 9:55 A.M., an activity calendar hanging in Hall 2 was reviewed and indicated the following dates and activities to be held:Saturday, 4/11/26 at 10:00 A.M. magnet game, 11:00 A.M. mealtime memories, 1:00 P.M. daily chronicles, 1:30 P.M. music and conversationsSunday, 4/12/26 at 10:00 A.M. tv time, 11:00 A.M. mealtime music, 1:00 P.M. daily chronicles, 1:30 P.M. friendly conversations, 3:00 P.M. church servicesTuesday, 4/14/26 at 10:00 A.M. nails on station 4. On 4/14/26 at 10:00 A.M., the Activity Manager was in the dining room sitting at a table with three male residents talking.During an interview on 4/14/26 at 9:45 A.M., the Activity Director indicated the activity department was not staffed on weekends and the weekend manager on duty should do the activities. They had church on Sunday. On 4/14/26 at 10:00 A.M., the Regional Consultant provided the weekend manager on duty schedule for April 2026, and it indicated on 4/11/26 the Business Office Manager (BOM) was manager on duty and on 4/12/26 the payroll staff was on duty.On 4/14/26 at 10:21 A.M., the Activity Director was asked to provide the participation list forms from 4/11/26 and 4/12/26. She indicated she would find them.On 4/14/25 at 10:45 A.M., the Activity Director provided handwritten activity participation lists (written in the same handwriting) for the following activities:4/11/26-Daily chronicles, magnet game (changed to TV time because there was no interest), music and conversations, and mealtime melodies 4/12/26-Daily chronicles (list was identical to 4/11/26 list except the date was changed), mealtime music, friendly chats, TV time, and church services.During an interview on 4/14/26 at 10:03 A.M., the payroll staff indicated they don't do activities on Sundays because they have church. On Saturdays, they will do activities such as crafts, daily chronicles, and music. The manager on duty should write on paper participation form and should provide it to the Activity Director on Monday or put it in her mailbox. She was currently out of the forms so she was not able to provide one.During an interview on 4/14/26 at 10:05 A.M., the BOM indicated she was on duty Saturday 4/11/26. She indicated they usually have puzzles and daily chronicles. But that Saturday, she had to do other tasks, so she was not able to help with the activities. She indicated staff really didn't round up the residents. There was usually a handful of residents that participated. Every resident had a copy of the activity calendar to see what was offered and if they wanted to come, they would. She also indicated they were to fill out a paper participation form.During an interview on 4/14/26 at 10:17 A.M., Certified Nurse Aide (CNA) 6 indicated sometimes there were activities on the weekend, it just depended what staff was available. She indicated they try to tell the residents when activities were going to happen, but most of the time the same residents went to activities, so they knew what was going on.On 4/16/26 at 8:30 A.M., a current non dated Weekend Manager Checklist was provided by the Administrator and listed, but was not limited to, the following duties: appropriate activities in lobby, Weekend activities with who participated list left for Activities Director.On 4/16/26 at 8:30 A.M., a current non dated Activities Policy was provided by the Administrator and indicated, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities . 410 Indiana Administration Code (IAC) 16.2-3.1-33(a)

Based on observation, interview, and record review, the facility failed to ensure residents were properly assessed for self administering medications for 2 of 2 random observations. A resident had a medication cup containing medications sitting on her bedside table and a resident was left alone with his medications. (Resident 14, Resident G)Findings include:1. On 04/13/26 at 6:40 A.M., Licensed Practical Nurse (LPN) 22 went to check a blood sugar on Resident 14's roommate. Resident 14 was laying in the dark, in her bed, with her eyes closed. A medication cup containing medications was on her bedside table. On 4/13/26 at 8:07 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, chronic heart failure, stroke, diabetes mellitus type II, atrial fibrillation, and bipolar disorder.The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/5/26, indicated Resident 14's cognition was intact.The clinical record lacked an order, care plan, and assessment of the resident to safely self-administer medications.During an interview on 4/13/26 at 7:04 LPN 22 indicated she was unsure what the pills were on the resident's bedside table. The night shift nurse may have given some medications depending on the time they were ordered. She indicated she did not prepare any medications for Resident 14 that morning. She was not sure if there were narcotics in the medication cup. At that time, the resident indicated she took one and would take the rest later. During an interview on 4/13/26 at 8:04 A.M., LPN 22 confirmed there were no narcotics in the medication cup at that time and they were the resident's medications for the morning medication pass. 2. On 4/13/26 at 6:19 A.M., LPN 5 was administering medications to Resident G in the dining room. The resident dumped the medications out from the medication cup onto the table. The resident requested more water and LPN 5 left the resident in the dining room with eight pills left to administer. LPN 5 went back to the medication cart at the Station 4 Nurse's Station to get more water while the resident continued taking his medications. The resident was blocked from LPN 5's sight by a wall that was between them. On 4/13/26 at 8:20 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, dysphagia (difficulty swallowing), anxiety, and diabetes mellitus type II. The resident was admitted on [DATE].The resident's admission MDS assessment was still in process.The clinical record lacked an order, care plan, and assessment of the resident to safely self-administer medications.On 4/15/26 at 1:41 P.M., the Director of Nursing (DON) indicated there were no residents in the facility who self-administer medications. At that time, she indicated the nursing staff should not leave medications alone with a resident to administer.On 4/16/26 at 8:30 A.M., a current non dated Medication Administration Policy was provided by the Administrator and indicated, . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . observe consumption of medications .410 Indiana Administration Code (IAC) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time at that facility. Documentation was not available to show how many hours were dedicated to the infection control program by the Director of Nursing (DON) who was certified and Registered Nurse (RN) 7 who had not completed training. Finding includes: During an interview on 2/21/25 at 11:34 A.M., the DON indicated she was the Infection Preventionist (IP) covering the DON position and the IP position for the last two months. She indicated RN 7 was assisting and would be the IP after completing training but was not certified at that time. The DON indicated she was the full time DON and did not have documentation of the hours she and RN 7 spent on IP duties. On 2/21/25 at 1:50 P.M., the DON provided an undated Infection Preventionist policy that indicated 1. The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program .11. The Infection Preventionist reports to the Director of Nursing .

Based on interview and record review, the facility failed to provide an Registered Nurse (RN) for 8 consecutive hours, seven days a week, for 4 of 26 days reviewed. Finding includes: On 2/20/25 at 2:30 P.M., review of weekend staffing from 7/1/24 thru 9/30/24 due to Payroll Based Journal (PBJ) triggering for low weekend staffing indicated there was no RN coverage for 8 consecutive hours on Sunday, 7/21/24, Sunday, 8/4/24, Saturday, 8/31/24, and Saturday, 9/28/24. On Sunday, 7/21/24, there was RN coverage for 4.03 hours. On Saturday, 9/28/24, there was RN coverage for 4 hours. On Sunday, 8/4/24 and Saturday, 8/31/24 there was no RN coverage. During an interview on 2/21/25 at 12:12 P.M., Director of Nursing (DON) indicated they tried their best to have RN coverage every day. They had the wound nurse and Unit Manager help cover on the weekends. On 1/21/25 at 1:50 P.M., the DON provided an undated nursing Services and Sufficient Staff policy which indicated .8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure physician orders and care plan interventions were followed for 2 of 5 residents reviewed for unnecessary medications. A resident's oxygen concentration was set incorrectly, the bedside table was not locked, and medications were given for blood pressure without checking the blood pressure prior to administration of the medication to ensure resident was within the perimeters to give the medication. (Resident 38, Resident 56) Findings include: 1. During an observation on 2/17/25 10:09 A.M., Resident 38 was sitting on the side of her bed coloring and wearing oxygen per nasal cannula. The oxygen concentrator was set at 2 liters per minute (LPM). During an observation on 2/18/25 8:55 A.M., Resident 38 was sitting on the side of her bed and the bedside table was not locked. She was wearing oxygen per nasal cannula at 2 liters per minute (LPM). During an observation on 2/20/25 8:25 A.M., Resident 38 was laying in a lowered bed and the bedside table was not locked. During an observation on 2/21/25 at 10:00 A.M., RN 7 observed Resident 38's oxygen concentrator with the rate indicator of the machine at the 4 LPM mark but indicated it was set at 3 LPM because it was the bottom of the rate indicator that mattered and it was just above the 3 LPM mark. At that time, another staff nurse observed the same and adjusted the setting at the 3 LPM mark and indicated that was were it should be set. On 2/19/25 at 9:10 A.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure, Chronic Obstructive Pulmonary Disease (COPD), hypertension, pneumonia, unsteadiness on feet, and other fractures of cervical (neck)vertebra and left hand. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/24/25, indicated Resident 38's cognition was moderately impaired, was a substantial/maximum assist (staff performed over half the effort) for bed mobility, transfers, toileting, and wore oxygen. Current Physician's Orders included, but were not limited to, the following: Bedside table to be locked at all times-check placement every day and night shift, dated 6/10/24 Metoprolol tartrate 25 milligram (mg) tablet, give one tablet by mouth one time a day related to hypertension (high blood pressure), hold if systolic under 60 millimeters of mercury (mmHg), dated 6/12/24 check oxygen saturation to maintain oxygen level above 90%, apply oxygen at 3 LPM per nasal cannula every day and night shift, initiated 1/24/23 A current Falls Care Plan, last reviewed 11/12/24, included, but was not limited to the following interventions: Locked bedside table, initiated 11/12/24 A current Altered Cardiovascular Status Care Plan, last reviewed 11/12/24, included, but was not limited to the following interventions: give medications as ordered, initiated 11/12/24 A current COPD Care Plan, last reviewed 11/12/24, included, but was not limited to, the following intervention: check oxygen saturation to maintain oxygen level above 90%, apply oxygen at 3 LPM per nasal cannula, initiated 11/12/24 The January and February 2025 Medication Administration Record (MAR) was reviewed and indicated Resident 38 received the Metoprolol 25 mg at 8:00 A.M. every day from 1/1/25 through 2/19/25. The clinical record lacked the resident's blood pressure on the following dates from 1/1/25 through 2/19/25: January 1, 3-8, 10-22, 24-31, February 2-21, 2025 During an interview on 2/21/25 at 9:40 A.M., Registered Nurse (RN) 7 indicated Resident 38's bedside table should be locked and the resident did not unlock the bedside table to move it or adjust her oxygen to her knowledge. Her blood pressure was not being checked daily, just protocol once a month and as needed. RN 7 indicated Resident 38 did not have any perimeters set that they needed to check her blood pressure before administering medications. Resident 38 was on oxygen per nasal cannula continuously, the oxygen concentrator should be set on 3 LPM, and staff checked the oxygen saturations once on day and night shifts along with checking the LPM setting on the oxygen concentrator. It should be documented in the Treatment Administration Record (TAR). RN 7 indicated it was expected that staff follow physician orders and interventions of the care plan. 45933 2. On 2/18/25 at 10:12 A.M., Resident 56's clinical record was reviewed. Diagnoses included, but was not limited to, Hirschprung's disease, Tourette's syndrome, hypertension, and autistic disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/28/25 indicated Resident 56's cognitive status could not be assessed due to Resident 56 not being understood, and he had no impairment to his upper and lower extremity's. Current physician orders included, but were not limited to, Metoprolol Tartate Tablet Give 12.5 milligrams [mg] by mouth two times a day for blood pressure hold if SBP [systolic blood pressure] less than 100 (manually), and/or HR [heart rate] less than 55, Order Date 8/21/2024. Resident 56's clinical record lacked a care plan related to hypertension. During an observation on 2/20/25 at 8:25 A.M., Registered Nurse (RN) 5 administered medications to Resident 56. Medications administered included, but was not limited to, metoprolol 12.5 mg and RN 5 failed to obtain Resident 56's heart rate. During an interview on 2/20/25 9:29 A.M., RN 5 indicated she only had to check Resident 56's blood pressure for his metoprolol. At that time, RN 5 and RN 7 indicated the record lacked Resident 56's heart rate prior to the medication being administered. During an interview on 2/21/25 at 11:01 A.M., the Director of Nursing (DON) indicated there was not a policy but it would be their policy to follow physician orders and interventions of the care plans. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was revised for 1 of 5 residents reviewed for unnecessary medications. A resident's care plan was not reviewed or revised to remove areas of concern that were no longer relevant to the resident's care, i.e. antibiotic use, fluid restriction, and daily weights. (Resident 38) Finding includes: On 2/19/25 at 9:10 A.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), hypertension, pneumonia, unsteadiness on feet, and other fractures of cervical (neck)vertebra and left hand. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/24/25, indicated Resident 38's cognition was moderately impaired, was a substantial/maximum assist (staff performed over half the effort) for bed mobility, transfers, toileting, took a diuretic, and was not monitored for fluid intake. Current Physician's Orders included, but were not limited to, the following: monthly weight in the morning starting on the first and ending on the 5th every month, ordered 7/31/24 weekly weights due to CHF, notify primary care physician if weight gain was more than five pounds in 1 week, ordered 12/21/24 The discontinued Physician's Orders included, but were not limited to, the following: 1800 cubic milliliter (ml) fluid restriction: dietary to provide 1080 ml total-360 ml at breakfast, 240 ml at lunch, and 480 ml at supper. Nursing to provide 720 ml total-300 ml day shift, 300 ml evening shift, and 120 ml night shift related to CHF, discontinued 6/26/24 Daily weights due to CHF in the morning, discontinued 8/7/23 Keflex 500 milligram (mg), give 1 capsule by mouth three times a day for ten days for upper respiratory infection, discontinued 1/18/25 A current Nutritional Care Plan, last reviewed 11/12/24, included, but was not limited to, the following interventions initiated 11/12/24: 1800 cubic milliliter (ml) fluid restriction: dietary to provide 1080 ml total-360 ml at breakfast, 240 ml at lunch, and 480 ml at supper. Nursing to provide 720 ml total-300 ml day shift, 300 ml evening shift, and 120 ml night shift daily weights due to CHF, notify primary care physician if weight gain was more then two pounds in 24 hours or 5 pounds in one week. A current Respiratory Infection Care Plan and intervention, initiated 1/9/25, indicated the resident was on antibiotic therapy as ordered by the physician. During an interview on 2/21/25 at 11:00 A.M., the Director of Nursing (DON) indicated care plans should be revised with changes to the resident's plan of care. order: On 2/21/25 at 1:50 P.M., a current non dated Care Plan Revision Policy, was provided by the DON and indicated, . the care plan will be updated with the new or modified interventions . care plans will be modified as needed by the MDS Coordinator or other designated staff member . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure respect and dignity was provided to a totally dependent resident. The resident's call light was not within reach for 1 of 16 residents reviewed for call lights. A resident's call light was not within his reach, staff did not respond promptly when he yelled for help and he was not able to use his call light to alert staff when he needed help. (Resident 47) Finding includes: On 2/17/25 at 11:59 A.M., Certified Nurse Aide (CNA) 9 brought Resident 47 his lunch, set it up, and left the room with call light pad on left side of pillow at head of bed. Resident 47 could not find it and was not able to reach it. At that time, he indicated the call light pad was not always where he could reach it, especially on the night shift. On 2/18/25 at 1:27 P.M., Resident 47 was observed hollering, Nurse's aide, I need your help finding something please multiple times. The nurse was at medication cart by the nurse's station. Two CNAs were observed to walk down the hall past his room without stopping to check on him. The nurse went into the room and the resident indicated his entire left side was hurting and he couldn't find his call light. The nurse told the resident she would attach it to his shirt so he could find it. On 2/20/25 at 8:20 A.M., Resident 47 was up in a Broda chair. His call light was laying on his bed out of his reach. He was asking his roommate to hit his call light because he needed the nurse. On 2/20/25 at 8:29 A.M., a staff member came into his room to check the refrigerator temperature and the resident asked him to hit his call light for him so he did. Staff went in and came out of the room without moving the call light within his reach. On 2/18/25 at 11:37 A.M., Resident 47's clinical record was reviewed. Diagnoses included, but were not limited to, stoke with hemiplegia and hemiparalysis of left non dominant side, and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated Resident 47's cognition was moderately impaired, impairment of upper and lower left extremities, he could eat with set up help, and totally dependent on staff for bed mobility, toileting, transfers, and bathing. A current falls care plan, last reviewed 11/20/23, included, but was not limited to, the following intervention: call light within reach, initiated 11/20/23 During an interview on 2/21/25 at 10:07 A.M., Registered Nurse (RN) 7 indicated Resident 47 used his call light and it should be within his reach when staff left the room. On 2/21/25 at 1:50 P.M., a current Call Light Policy, revised August 2024, was provided by the Director of Nursing (DON) and indicated, . Staff will ensure the call light is within reach of resident . the call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . all staff members who see or hear an activated call light are responsible for responding . 3.1-3(t)

Based on interview and record review, the facility failed to ensure a resident's code status was known during an emergency situation for 1 of 2 residents reviewed for death. During a change in condition and prior to starting Cardio-Pulmonary Resuscitation (CPR), a resident's physician was notified and informed of the resident's code status as Do Not Resuscitate (DNR) before staff realized the resident's full code status. (Resident D) Finding includes: The record review was started on, [DATE] at 11:40 A.M., indicated Resident D's diagnoses included but were not limited to, aortic valve disorder, pulmonary disease, type II diabetes, and heart failure. A signed Indiana Physician Orders for Scope of Treatment (Post) form, dated [DATE] indicated Resident D had chosen to receive resuscitation / CPR if the resident has no pulse and is not breathing. A physician's order included, Full Code (started [DATE]). Resident D's nurse's progress notes included, but were not limited to: [DATE] at 5:39 P.M. - Change of Condition - Resident was unresponsive and blue/gray in color with six respirations per minute. No blood pressure or oxygen saturation level could be monitored. Physician was notified and gave order to monitor resident due to the resident's DNR status. [DATE] at 6:27 P.M. - Change of Condition - Resident's code status was noted to be full code after assessing the resident. Resident was having six respirations per minute with a blood glucose level of 106. No pulse or blood pressure could be assessed. Nursing staff started an Automated External Defibrillator (AED) device. Resident had no respirations and pupils were fixed and dilated. Emergency Medical Technicians (EMT) were called and CPR was initiated when respirations stopped. EMTs took over when they arrived to the facility. Resident D expired at 6:08 P.M. [DATE] at 12:49 P.M. - Change of Condition - Late entry clarification for [DATE] at 5:39 P.M., nursing staff inadvertently notified physician of resident having a DNR status. Physician stated to continue to monitor. At 5:42 P.M., Resident D's code status was verified and noted to be full code. At 5:43 P.M., nursing staff entered Resident D's room and initiated emergency responses. On [DATE] at 12:00 P.M., Licensed Practical Nurse (LPN) 6 indicated after observing Resident D in her room on [DATE] at 5:39 P.M., the physician was notified and informed of the resident's code status of DNR. LPN 6 then called Resident D's family and realized that Resident D's record indicated a code status of full code. LPN 6 indicated that the incorrect code status was listed on a printed document of all residents' code status kept at the nurse's station. LPN 6 indicated that the printed document incorrectly listed Resident D as having a code status of DNR. The printed document had been removed from the nurse's station and disposed of on [DATE]. On [DATE] at 1:05 P.M., the Director of Nursing (DON) indicated that staff should verify residents' code status by referencing the resident's medical record. On [DATE] at 3:15 P.M., the DON provided an undated facility policy titled, Communication of Code Status. The policy indicated, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information . 4. The designated sections of the medical record are: an order / post form. 5. Additional means of communication of code status include: post form binder . 3XXX,d+[DATE](f)(7)

Based on interview and record review, the facility failed to ensure MDS (Minimum Data Set) Assessments were accurate for 4 of 19 residents in the initial sample. The MDS Assessment failed to indicate residents had a PASRR (preadmission screening and resident review) II. The MDS failed to indicate a resident received hospice services. (Resident 1, Resident 31, Resident 39, Resident 51) Findings include: 1. On 4/17/24 at 8:43 A.M., Resident 39's clinical record was reviewed. Diagnosis included, but were not limited to, epilepsy, developmental disorder of speech and language, spastic quadriplegic cerebral palsy, and severe intellectual disabilities. The most recent Annual MDS, dated [DATE], indicated Resident 39 did not have the following: .currently considered by the state level II PASRR [preadmission screening and resident review] process to have serious mental illness and/or intellectual disability or a related condition. On 11/5/21 a PASRR level II was completed by [name of company] and indicated the PASRR was valid for the duration of Resident 39's stay. During an interview on 4/22/24 at 9:23 A.M., the MDS Coordinator indicated social services previously completed that portion of the MDS, and due to the lack of a social services coordinator, it was an entry error. 46416 2. On 4/16/24 at 9:19 A.M., Resident 51's clinical record was reviewed. Diagnoses included, but were limited to, chronic obstructive pulmonary disease (COPD), stroke, and hemiplegia (paralysis) on the left side. The most recent Quarterly MDS Assessment, dated 3/29/24, indicated Resident 51 was not receiving hospice care. Current Physician's Orders included, but were not limited to, the following: (Hospice Company Name), ordered 1/5/2024 Resident 51's clinical record included a current hospice care plan, revised 1/4/24. During an interview on 4/22/24 at 9:25 A.M., the MDS Coordinator indicated hospice should have been marked and she missed it. 46882 3. On 4/16/24 at 10:51 A.M., Resident 31's clinical records were reviewed. Diagnosis included, but was not limited to bipolar disorder and major depressive disorder. On 4/19/24 at 8:54 A.M., the most current Annual MDS Assessment, dated 7/1/23, indicated Resident 31 was marked no for having a PASSAR II. On 4/22/24 at 8:15 A.M., the Business Office Manager provided a copy of the PASSAR II that was in Resident 31's chart. During an interview on 4/22/24 at 9:23 A.M., the MDS Coordinator indicated that marking Resident 31 did not have a PASSAR II was an error. She indicated Social Services normally filled that section out, and since the facility currently did not have a Social Worker, she filled it out. 4. On 4/16/24 at 12:54 P.M., Resident 1's clinical records were reviewed. The diagnosis included, but was not limited to paranoid schizophrenia. The most current Annual MDS (Minimum Data Set) Assessment, dated 6/3/23, indicated Resident 1 was marked No for having a PASSAR II. On 4/22/24 at 8:15 A.M., the Business Office Manager provided a copy of the PASSAR II that was in Resident 1's chart. During an interview on 4/22/24 at 9:23 A.M., the MDS Coordinator indicated that marking Resident 1 did not have a PASSAR II was an error on her part. She indicated Social Services normally filled that section out, and since the facility currently did not have a Social Worker, she filled it out. During an interview on 4/22/24 at 9:23 A.M., the MDS Coordinator indicated she did not have an MDS Policy. She indicated she use the RAI (Resident Assessment Instrument) Manual as the policy. 3.1-31(i)

Based on observation, interview, and record review, the facility failed to ensure palatable food was served for 1 of 1 meal tray reviewed. Finding includes: During the course of the survey, the following anonymous resident interviews were obtained: The food is horrid and temperatures are not what they should be. Half of the food is not worth eating. On 4/16/24 at 11:03 A.M., during the resident council meeting, the following anonymous resident interviews were obtained: We (the residents) have complained about the food but were told it was because corporate did the menus and restricted what the facility could have a choice of. Everything is overcooked and dry. On 4/22/24 at 8:10 A.M., a meal tray was obtained that contained oatmeal, a sausage patty, and a piece of french toast. All food items were bland and tasteless. The french toast had hard edges. On 4/22/24 at 9:54 A.M., the Dietary Manager indicated there had been no complaints about the taste of the food to her knowledge. She indicated sometimes french fries and french toast were troublesome due to not being steam table friendly, and often dry out. She indicated if any residents complained about the taste of the food, they would be offered seasonings such as salt and pepper. On 4/22/24 at 11:03 A.M., a current non-dated Food Preparation policy was provided and indicated Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature . Using spices or herbs to season food in accordance with recipes 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for 1 of 3 residents reviewed for falls. Interventions put into place after falls were not evaluated and modified and interventions were not followed for a resident at risk for falls resulting in multiple falls. (Resident 26) Finding includes: On 4/15/24 at 9:47 A.M., Resident 26 was observed laying in her lowered (but not lowest position)bed. Her call light was wrapped around hook on the wall above the head of bed. Resident 26 indicated she wanted to get out of bed. On 4/15/24 at 9:50 A.M., Resident 26 told staff, I need to get up. I have a hair appointment at 10. Staff told the resident, Hang on, let me check. and left the room. Resident uncovered, sat bedside, was restless, and repeating, I need to get up. On 4/15/24 at 9:54 A.M., staff came back to the room and notified resident that her hair appointment wasn't until the next day and left the resident's room. On 4/15/24 2:14 P.M., Certified Nurse Aide (CNA) 52 was observed putting Resident 26 in bed and telling the resident, Stay in bed. Try to get some sleep. The call light was not moved from the hook above the head of the bed where it was observed earlier. On 4/15/24 at 2:18 P.M., Resident 26 was observed getting out of her bed, stood by her wheelchair, and started to get in it. Once alerted, CNA 52 came back into the room, helped the resident get back in her wheelchair, and took the resident up to sit by the nurse's station. On 4/18/24 at 1:19 P.M., Resident 26 was observed sleeping in bed and her call light was laying over the raised bedside table with the button laying towards the roommate. On 4/19/24 at 7:49 A.M., CNA 80 was observed taking Resident 26 to her room from the dining room in her wheelchair and laying her down in her bed without toileting the resident. Her call light was laying on the floor between her and her roommate's bed. The bed was in lowered, but not in lowest position. On 4/19/24 at 8:20 A.M., the Director of Nursing entered Resident 26's room, lowered the bed to the lowest position while resident was asleep, and placed her call light in reach. On 4/18/24 at 10:04 A.M., Resident 26's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety, weakness and Alzheimer's disease. Resident 26 was admitted on [DATE]. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/19/24, indicated Resident 26's cognition was severely impaired and she was an extensive assist of 2 staff for bed mobility and toileting, an extensive assist of 1 staff for transfers. Resident 26 had 2 or more falls, 1 with injury. A current Falls Care Plan, dated 11/26/23 included, but was not limited to, the following interventions: 15 minute checks x 3 days, initiated 3/21/24 call light within reach, initiated 11/26/23 resident to be in low bed, initiated 12/8/23 Toilet plan: Toilet before and after meals, at bedtime and every 2 hours through night and as needed, 12/1/23 Wearing of appropriate footwear, 11/26/23 Fall Risk Assessments were reviewed from 11/22/23 through 4/16/24 and all of them indicated resident to be a high risk for falls. Progress notes were reviewed and included, but were not limited to, the following: On 12/6/23 at 9:47 P.M., Behavior Charting: Resident got up unassisted and was in hallway. Staff immediately went to get resident and assisted her into w/c [wheelchair]. Resident confused. Brought up by nurses desk. Repeatedly asking staff about writing them a check and when she can leave. Repeatedly standing up unassisted. Keeps stating she needs to leave because she has to go to work tomorrow. Unable to redirect. Resident had just been toileted and assisted back to bed . On 12/7/23 at 9:41 A.M., Change of Condition: Resident continues to be restless at night, goes to sleep and does not stay. Has been getting up unassisted and ambulating, gait very unsteady. Resident continues to be irritated in am (morning). Does have dementia . On 12/30/23 at 11:30 A.M., Change of Condition: Resident has been having increased episodes of confusion and anxiety. Has fell several times due anxiousness. When having periods of anxiety has become harder to redirect . On 1/7/24 at 6:30 P.M., Behavior Charting: Resident ambulated into dining room using bedside table for support. Resident attempting to open door to stairwell. Resident spilled liquids and bucket of colored pencils onto the floor while wheeling bedside table through dining room . Falls were reviewed from admission on 11/22/23 through 4/18/24. Resident 26 had the following 7 falls: Fall 1 On 12/1/23 at 9:30 A.M. Unwitnessed fall. Resident was sitting on the floor in her room in front of her wheelchair. Resident incontinent of urine at time of fall. Alert with confusion. Noted reddened area, measuring 4 (centimeters) cm x 2.6 cm to right clavicle area. A right clavicle and right shoulder STAT (immediately) x-ray was ordered and showed no fracture. Falls Care Plan was updated with an intervention to toilet resident before and after meals, at bedtime and every 2 hours through night and as needed, initiated 12/1/23. Fall 2 On 12/7/23 at 8:30 P.M. Unwitnessed fall. Resident noted to be sitting on the floor on her bottom between her bed and her roommate's bed. When asked what happened, resident stated, I fell on my butt. Bed was in low bed position at time of fall. Falls Care plan was updated with an intervention to be in low bed, initiated 12/7/24. Fall 3 On 12/29/23 at 6:55 P.M. Unwitnessed fall. Resident noted to be on the floor, barefoot, and on her bottom between resident's bed and roommate's bed. Upon speaking with roommate, roommate states that resident got up and stood next to her bed and then started to fall, grabbing the bedside table and taking it down with her. Resident often stands up without assistance. Confused at all times. Disoriented. Exhibits behaviors often. Intervention: 15 minute checks for 3 days (12/29/23 6:55 P.M. through 1/1/24 6:55 P.M.) 15 minute checks for this fall were reviewed and indicated they were performed every 15 minutes from 7:00 P.M. on 12/29/23 to 6:45 P.M. on 12/31/23. Then they weren't done until 1:15 A.M., 1:30 A.M., and 1:45 A.M., on 1/1/24 then not again until 5:45 A.M. and stopped. Fall 4 On 12/29/23 at 8:20 P.M. Unwitnessed fall. Resident had fallen on the floor between her wheelchair and the side of the bed facing the door. Resident attempts to get up on her own often. Resident has unsteady gait requiring 1 assist with transfers and wheelchair for ambulation. Neurological checks provided were reviewed, but started at 8:55 P.M. and then not done again until 9:50 P.M. Falls Care Plan was updated with an intervention for nonskid strips to floor by bed on door side, initiated 12/29/23. Fall 5 On 12/29/24 at 9:50 P.M. Unwitnessed fall. Resident laying barefoot on the floor in front of her wheelchair in front of the door. The wheelchair was not locked. Resident has been restless this night. Standing up and walking without assistance. Falls Care Plan was updated with an intervention for Dycem to wheelchair set, initiated 12/29/23. Fall 6 On 1/24/24 at 8:29 P.M. Unwitnessed fall. Resident was found yelling out for help sitting next to the bed on the floor. Resident stated she attempted to transfer from the wheelchair to her bed. Resident has dementia and history of falls. Falls Care Plan was updated with an intervention not to be alone in room sitting in wheelchair, initiated 1/24/24. Fall 7 On 3/20/24 at 1:55 P.M. Unwitnessed fall. Resident found sitting on the floor barefoot next to bed. Resident stated she rolled out of bed. Falls Care Plan was updated with an intervention of 15 minute checks for 3 days, initiated 3/20/24. Documentation of the 15 minute checks was requested but not provided for this fall. During an interview on 4/22/24 at 8:48 A.M., staff indicated they were not sure why Resident 26 fell often but she did get up by herself a lot and had to go to the bathroom quite often. At that time, they indicated they weren't sure if there was an intervention in place for that. The roommate will use her call light and alert us if she sees her getting up, we keep her bed lowered, and check on her. During an interview on 4/22/24 at 9:03 A.M., the DON indicated she did lower the bed Resident 26 was laying in earlier that morning because the bed was low but not in the lowest position. She expected it to be in the lowest position possible. At that time, she indicated she also laid the call light next to the resident within her reach. She indicated Resident 26 could not use her call light, but it should still be made available to the resident. She indicated she did expect interventions on care plan to be followed. A current Accidents and Supervision Policy, revised February 2023, was provided on 4/22/24 at 10:25 A.M., by the DON and indicated . Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) 2. Evaluating and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary . ensuring interventions are based on results of the evaluation . consistent with relevant standards, including evidence-based practice . educating staff . a. ensuring that interventions are implemented correctly and consistently b. evaluating the effectiveness of interventions c. modifying or replacing interventions as needed d. evaluating the effectiveness of new interventions . 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with dignity for 2 of 2 residents reviewed for choices. One resident continued to receive styrofoam dishes after a suicide watch was discontinued. A CNA (Certified Nursing Aide) was standing up to feed a resident and asked the nurse What do you want me to do with her? when she was done. (Resident 37, Resident 26) Findings include: 1. On 4/17/24 at 8:38 A.M., Resident 37 was observed sitting on the side of her bed while staff were putting TED (Thrombo-Embolic Deterrent) hose on her legs. Her breakfast tray containing Styrofoam dishes was sitting on the bedside table. On 4/17/24 at 8:53 A.M., Resident 37's clinical records were reviewed. Diagnosis included, but were not limited to depression and anxiety. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 1/19/24 indicated Resident 37 was cognitively intact. Progress Notes: 4/16/2024 8:52 A.M. General Note Note Text: suicide watch over this day. Res [Resident] has not threatened to harm self during watch not attempt [sic] to hurt self. Continue to await final UA [urinalysis] results. No c/o [complaint] voiced this am [sic]. During an interview on 4/17/24 at 8:42 A.M., QMA (Qualified Medication Aide) 19 indicated Resident 37 was receiving Styrofoam dishes because she was on 15 minute checks and suicide watch, but that had been discontinued so we just need to contact dietary to cancel the Styrofoam dishes. During an interview on 4/18/24 at 8:21 A.M., Resident 37 indicated she didn't like the Styrofoam dishes. 46416 2. On 4/19/24 at 7:30 A.M., Certified Nurse Aide (CNA) 80 was observed in the main dining room standing next to and feeding Resident 26. On 4/19/24 at 7:42 A.M., CNA 80 was observed pushing Resident 26 out of the dining room up to a nurse and asking What do you want me to do with her? On 4/18/24 at 10:04 A.M., Resident 26's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety, weakness and Alzheimer's disease. Resident 26 was admitted on [DATE] . The most recent Quarterly MDS Assessment, dated 1/19/24, indicated Resident 26's cognition was severely impaired and she was an extensive assist of 2 staff for bed mobility and toileting, an extensive assist of 1 staff for transfers, and supervision of 1 staff for eating. A Nutritional Assessment Report (NAR), dated 4/4/24 indicated Resident 26 had a significant weight loss and it was recommended the resident would eat meals in the dining room, need assistance to eat, and should be changed to a weekly weight. During an interview on 4/19/24 at 9:03 A.M., the Director of Nursing (DON) indicated she would expect staff to sit when feeding a resident. At that time, she indicated she wouldn't consider the statement made by CNA 80 a dignity concern, but would talk to staff and inservice them on using the proper names and not her when discussing the resident's care. A current nondated Promoting/Maintaining Resident Dignity Policy was provided on 4/19/24 at 11:00 A.M., by the Regional Consultant and indicated . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . 5. When interacting with a resident, pay attention to the resident as an individual . 10. Speak respectfully to residents; avoid discussions about residents that may be overheard . 3.1-3(t)

Based on interview and record review, the facility failed to notify the ombudsman of transfer or discharge for 3 of 4 residents reviewed for hospitalization s. (Resident 23, Resident 25, Resident 35) Findings include: 1. On 4/16/24 at 11:02 A.M., Resident 23's clinical record was reviewed. Resident 23 was sent to the hospital on 4/9/24. Resident 23's clinical record lacked documentation that notification of the hospitalization was sent to the ombudsman. 2. On 4/16/24 at 10:44 P.M., Resident 35's clinical record was reviewed. Resident 35 was sent to the hospital on 12/22/23. Resident 35's clinical record lacked documentation that notification of the hospitalization was sent to the ombudsman. 46416 3. On 4/17/24 at 10:30 A.M., Resident 25's clinical record was reviewed. Diagnoses included, but was not limited to, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and diabetes mellitus type II. Progress Notes indicated Resident 25 was hospitalized [DATE] through 7/10/23. A completed Notice of Transfer or Discharge Form was provided by the Director of Nursing (DON) on 4/18/24 at 2:55 P.M., with a transfer or discharge date of [DATE] (sic). On 4/19/24 at 9:57 A.M., the Regional Consultant indicated notification to the ombudsman could not be located for Resident 23, Resident 25, or Resident 35. On 4/19/24 at 4:10 P.M., the state ombudsman indicated via email that notification reports for July 2023, December 2023, or any months in 2024 had not been received from the facility. During an interview on 4/22/24 at 8:55 A.M., the Administrator indicated no one at the facility was sending the discharges to the ombudsman. A current, nondated Discharge Planning Policy was provided by the DON on 4/22/24 at 10:44 A.M., and indicated . the facility must notify the Office of the State Long-Term Care Ombudsman of all resident discharges from the facility. Social Services will notify the Ombudsman of all discharges, which are not due to an issue of a 30-day notice, by means of a monthly summary containing at minimum: the residents name, discharge date , and discharge location . 3.1-12 (a)(6)(A)(iv)

Based on observation, interview, and record review, the facility failed to ensure care was provided in accordance with the written plan of care for 2 of 2 residents reviewed for smoking. A resident smoked in a non-designated smoking area. Staff failed to lock up residents smoking materials.(Anonymous Resident, Resident 1) Findings include: 1. During an interview on 4/17/24 7:37 A.M., an Anonymous Resident indicated cigarettes are kept in the resident's room and supervision is not needed to smoke. During an observation on 4/19/24 at 1:42 P.M., an Anonymous Resident was unsupervised on the front porch. At that time, the resident lit a cigarette. On 4/16/24 at 10:30 A.M., the Resident's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus, hypertension, seizure disorder, and chronic obstructive pulmonary disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 3/10/24, indicated the Anonymous Resident was cognitively intact and had shortness of breath. A current smoking and safety assessment, dated 3/6/24, indicated that the resident used tobacco products and followed the facility's policy on location of smoking. A current at risk for smoking related injury care plan, initiated 7/18/23, included, but was not limited to, the following interventions, .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Storage of smoking materials per Living Center policy . During an interview on 4/22/24 at 8:42 A.M., LPN (Licensed Practical Nurse) 16 indicated Resident's should go out the back door to smoke, and Residents should not smoke on the front porch unless they are supervised. At that time, she indicated the Anonymous Resident could keep possession of the smoking materials. After the care plan was reviewed, LPN 16 indicated the Anonymous Resident's smoking materials must be held by staff. 46882 2. On 4/16/24 at 8:50 A.M., Resident 1 was observed sitting outside to the left of the door smoking, sitting on rollator walker with no smoking apron on and no staff present. On 4/17/24 at 10:02 A.M., Resident 1 was observed ambulating down the hall with a rollator walker, stopping at nurse's desk to sign smoking sign out sheet. At that time, he indicated he was going outside to smoke. On 4/22/24 at 8:42 A.M., Resident 1 was observed standing at nurse's desk with rollator walker and coat on signing smoking sign out sheet. He did not ask nurse for cigarettes. Resident 1 was observed getting on the elevator. Resident 1 was observed walking down hall on 1st floor to door to smoking area, putting code in, and walking outside without supervision and without a smoking apron. Resident 1 was observed sitting on rollator walker outside to the left of the door lighting a cigarette. On 4/16/24 at 12:54 P.M., Resident 1's clinical records were reviewed. Diagnosis included, but were not limited to paranoid schizophrenia, dementia, extrapyramidal movement disorder, and epilepsy. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 3/2/24 indicated Resident 1 was moderately cognitively impaired, and needed supervision of one for bed mobility, transfers, eating and toilet use. A current Smoking Care Plan dated 3/19/12 was provided on 4/19/24 at 10:15 A.M. Interventions included, but were not limited to the following: Patient not to have cigarettes or smoking material on person, date initiated 12/3/21 Supervision and wear apron, revision on 5/13/22 During an interview on 4/16/24 at 9:03 A.M., Resident 1 indicated he could go outside to smoke by himself whenever he chose. He indicated he kept his cigarettes in a blue bag in his rollator walker and kept cigars in his dresser. During an interview on 4/16/24 at 9:14 A.M., RN 24 indicated there was a sign out sheet at the nurse's desk for smokers to sign out, but they don't have to sign back in. She indicated the smokers go outside to smoke by themselves. During an interview on 4/22/24 at 8:42 A.M., LPN 16 indicated most of the time cigarettes for the smokers were kept at the nurse's desk. She indicated if a resident was cognitively intact they could keep their cigarettes with them. She indicated Resident 1 could keep his cigarettes with him. When asked to look at Resident 1's Smoking Care Plan, LPN 16 indicated the care plan said the resident was not to have cigarettes on his person. On 4/19/24 at 11:00 A.M., a Comprehensive Care Plan Policy, dated February 2023, was provided by the Regional Consultant which indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to accurately document care planned interventions for a resident. Restorative walking nursing tasks were not completed as documented for 1 of 2 residents reviewed for Activities of Daily Living (ADLs). (Resident 18) Findings include: On 4/15/24 at 10:39 A.M., Resident 18 indicated the therapy department had told her she needed to use her walker and walk as much as possible, but would need a staff member to walk with her. She indicated she had asked staff to assist her in the past and was told they were too busy. She indicated she had not asked since, as she did not want to bother anyone. On 4/19/24 at 10:30 A.M., Resident 18's clinical record was reviewed. Diagnosis included, but were not limited to, renal failure, heart failure, and depression. The most recent Annual and State Optional MDS (Minimum Data Set) Assessment, dated 2/22/24, indicated no cognitive impairment, active range of motion (AROM) was completed 7 of 7 days during the look back period for at least 15 minutes a day, and walking was completed 6 of 7 days. Resident 18 required limited assistance of 1 staff with transfers. A current restorative program in AROM to maintain current strength and range of motion (ROM) care plan included, but was not limited to, the following intervention: Performing AROM exercises while sitting to bilateral upper and lower extremities, 10 reps each plane with assistance of 1 for guidance and cues, dated 3/15/22. A current restorative program in walking to maintain current ability in walking on and off the unit care plan included, but was not limited to, the following intervention: Monitor and report changes in ROM ability, dated 3/15/22. Walking, assistance of 1 staff, dated 3/15/22. Walking on and off unit using walker or push wheelchair with assistance of 1 for supervision and safety cues for 50 to 100 feet twice a day, dated 3/24/22. Resident 18's clinical record indicated on 4/18/24 she had spent 15 minutes walking a total of 150 feet, and had spent 15 minutes performing AROM to bilateral upper and lower extremities, signed by Certified Nurse Aide (CNA) 17 on 4/18/24 at 6:08 A.M. Resident 18's clinical record indicated on 4/19/24 she had spent 15 minutes walking a total of 25 feet, and had spent 15 minutes performing AROM to bilateral upper and lower extremities, signed by CNA 50 on 4/19/24 at 7:17 A.M. On 4/18/24 at 8:45 A.M., CNA 17 indicated she hadn't walked with Resident 18 yet that morning, but planned to later that day. On 4/19/24 at 12:30 P.M., Resident 18 indicated a member of the therapy staff had been in her room that morning and watched her go to the bathroom and back with her walker. She indicated she did not walk in the hall alone or with staff, and did not do any exercises. On 4/19//24 at 12:40 P.M., CNA 50 indicated she sometimes walked with Resident 18 before dialysis on Monday, Wednesday and Friday, and sometimes after. She indicated most of the time Resident 18 was gone for dialysis by the time she got there in the mornings. At that time, CNA 50 indicated she had not seen Resident 18 yet that day as she had already left for dialysis by the time she got there that morning. On 4/22/24 at 6:37 A.M., Qualified Nurse Aide (QMA) 9 indicated staff should document tasks after they are performed just in case it's not correct or changes before it was documented. On 4/22/24 at 10:25 A.M., a current non-dated Documentation in Medical Record policy was provided and indicated Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of existing pressure ulcers for 2 of 2 residents reviewed for pressure ulcers. Residents admitted with a deep tissue injury (DTI) and incontinence associated dermatitis (IAD) worsened and resident developed a stage IV pressure ulcer on the right heel. (Resident 64, Resident 23) Findings include: 1. On 4/16/24 at 10:52 A.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure, weakness, and atrial fibrillation. Resident 64 was admitted on [DATE]. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/25/24, indicated Resident 64 was cognitively intact and an extensive assist of 2 staff for bed mobility, transfers, and toileting. Resident 26 noted to have a foley catheter, colostomy, and 1 unstageable pressure ulcer. Current Physician Orders included, but were not limited to, the following: Cleanse right heel open area with wound cleanser, pat dry, Apply Manuka (honey alginate) cut to size and cover with border dressing every night shift daily, every other day (sic), ordered 4/4/24 Cleanse wound to coccyx with wound cleanser and pat dry. Apply Honey alginate (Manuka) cut to size, cover with bordered foam dressing every night and as needed for soiling or dislodgement, ordered 4/11/24 House shake three times a day for wound care, ordered 3/13/24 Juven oral packet, give 1 packet by mouth two times a day at 7:00 A.M. and 8:00 P.M., ordered 3/13/24 A current Pressure Ulcer Care Plan, dated 3/24/24, included, but was not limited to, the following interventions: juven and house shake for wound healing as ordered, initiated 3/14/24 turning and repositioning every 2 hours and as needed, initiated 3/24/24 Skin and wound notes from admission on 2/8/24 through 4/17/24 were reviewed and indicated the following: Wound 1 On 2/14/24 at 1:30 P.M., Patient was seen today for a DTI (damage of underlying soft tissue of skin from pressure and/or shearing) on her sacrum acquired by the hospital. Location: coccyx (back of body above buttocks). Size: 0 centimeter (cm) x 0 cm x 0 cm. Initial weekly wound assessment of DTI pressure present on admission to sacrum/coccyx area completed 2/14/24 by Wound Nurse Practitioner (NP) and facility Wound Nurse. Wound appears with deep red/purple area. No drainage. Recommended TRIAD (sterile coating used on broken skin to keep it covered and protected from incontinence) cream to area every shift, leave open to air. On 2/21/24 at 11:24 A.M., Patient was seen today for a DTI on her sacrum acquired by the hospital. Location: sacrum. Primary Etiology: Pressure. Stage/Severity: DTI. Wound Status: Improving without complications. Size: 1 cm x 0.5 cm x 0 cm. Recommended cleansing with soap and water, pat dry, apply triad to base of the wound, leave open to air, and change twice daily and as needed. The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. On 2/26/24 at 10:20 A.M., Noted: discolored area to coccyx was being treated with Triad hydrophilic wound dress external paste. Wound noted to open. Wound measurement 2.0 cm x 2.0 cm x < 0.1 cm. Wound cleansed. Wound bed covered with Xeroform cut to size, covered with bordered foam gauze dressing. On 2/28/24 at 9:18 A.M., Patient was seen today for a DTI on her sacrum acquired by the hospital. Deep tissue pressure injury (DTPI) location: coccyx Size: 4 cm x 2 cm x 0.1 cm with moderate amount of serosanguineous drainage. Improving without complications. Weekly wound assessment of sacral wound completed 2/28/24 by Wound NP and facility Wound Nurse. Patient had unstageable (full thickness tissue loss but depth of ulcer can not be determine) DTI to sacrum. Recommended use of Honey alginate (Manuka) to wound bed, secure with silicone border foam dressing related to fragile skin and moderate drainage, change daily. Rest in bed with low air loss mattress, turn and reposition protocol. Heel protector to right foot, heels floated. On 3/6/24 at 3:13 P.M., Patient was seen today for a DTI on her sacrum acquired by the hospital. DTPI location: coccyx Size: 5 cm x 3 cm x 0.1 cm with moderate amount of serosanguineous drainage. Improving without complications. Weekly wound assessment of sacral wound completed 3/6/24 by Wound NP and facility Wound Nurse. Patient had unstageable DTI to sacrum. Recommend continuing the use of Honey alginate (Manuka) to wound bed, secure with silicone border foam dressing related to fragile skin and moderate drainage, change daily. Rest in bed with low air loss mattress, turn and reposition protocol. Heel protector to bilateral feet, heels floated. On 3/13/24 at 9:45 A.M., Patient was seen today for a DTI on her sacrum acquired by the hospital. DTPI location: coccyx Size: 4 cm x 2.5 cm x 0.1 cm with moderate amount of serosanguineous drainage. Improving without complications. Weekly wound assessment of unstageable sacral wound completed 3/13/24 Wound NP and facility Wound Nurse. Recommended continuing the use of Honey alginate (Manuka) to wound bed, secure with silicone border foam dressing related to fragile skin and moderate drainage, change daily. Rest in bed with low air loss mattress, turn and reposition protocol. Heel protector to bilateral feet, heels floated. On 3/20/24 at 12:58 P.M., Patient was seen today for a DTI on her sacrum acquired by the hospital. DTPI location: coccyx Size: 3.5 cm x 3 cm x 0.1 cm with moderate amount of serosanguineous drainage. Improving without complications. Weekly wound assessment of unstageable sacral wound completed 3/20/24 by Wound NP and facility Wound Nurse. Wound is stalled with moderate amount of serosanguinous drainage. Recommended continuing the use of Honey alginate (Manuka) to wound bed, secure with silicone border foam dressing related to fragile skin and moderate drainage, change daily. Rest in bed with low air loss mattress, turn and reposition protocol. Heel protector to bilateral feet, heels floated. Reviewed results of prealbumin, dietician notified. Juven and mighty shakes ordered with meals to aid in wound healing. On 3/27/24 at 11:08 A.M., Patient was seen for a DTI on her sacrum acquired by the hospital. This is now an unstageable. She always lays on her bottom. DTPI location: coccyx Size: 4 cm x 3.5 cm x 0.1 cm with moderate amount of serosanguineous drainage. Weekly wound assessment of unstageable sacral wound completed 3/27/24 by Wound NP and facility Wound Nurse. Wound was stalled with moderate amount of serosanguinous drainage, 100% slough to wound bed, wound debrided. Recommended continuing the use of Honey alginate (Manuka HD) to wound bed, secure with silicone border foam dressing related to fragile skin and moderate drainage, change daily. Turn and reposition every 2 hours from side to side. Rest in bed with low air loss mattress, heels floated. Juven twice daily and mighty shakes ordered with meals to aid in wound healing. On 4/2/24 at 11:45 A.M., Patient was seen for a DTI on her sacrum acquired by the hospital. She always lays on her bottom. DTPI location: coccyx Size: 4 cm x 3.5 cm x 1.5 cm with moderate amount of serosanguineous drainage. Community acquired pressure to sacral area. Improving despite measurements. Sacral wound culture showed Staph Aureus (is a type of germ that about 30% of people carry in their noses). Receiving doxycycline 100 (milligrams) mg twice daily for 10 days. PCP noted rectal fistula with drainage upon inspection. Will continue use of Dakin's moistened fluffed gauze to wound bed, secure with bordered gauze, change every shift. On 4/10/24 at 12:35 P.M., Patient was seen for a DTI on her sacrum acquired by the hospital. On 3/27/24, this is now an unstageable. She always lays on her bottom. On 4/10/24, her sacrum was now a stage IV (The Center for Medicare and Medicaid Services defined a Stage 4 pressure ulcer as: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). DTPI location: coccyx Size: 4 cm x 3.3 cm x 1.2 cm with moderate amount of serosanguineous drainage. Improving despite measurements. Continue doxycycline 100 (milligrams) mg twice daily. Wound measurements were done by 2 different nurses which may explain the difference in calculations. Denies any pain. Will change treatment to Manuka (honey alginate) to wound bed, secure with bordered gauze, and change daily. On 4/17/24 at 1:27 P.M., Patient was seen for a DTI on her sacrum acquired by the hospital. On 3/27/24, this is now an unstageable. She always lays on her bottom. On 4/10/24, her sacrum was a stage IV. DTPI location: Coccyx Size: 4 cm x 3 cm x 1.2 cm with moderate amount of serosanguineous drainage. Improving despite measurements. Denies any pain. Changed treatment to Manuka (honey alginate) to wound bed, secure with bordered gauze, and change daily. Wound 2 On 3/27/24 at 4:34 P.M., Patient noted for new Pressure ulcer. Location: right heel. Size: 2.8 cm x 2 cm x 0.1 cm. Pressure ulcer staging: Stage II (The Center for Medicare and Medicaid Services defined a Stage 2 pressure ulcer as: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister). Recommended xeroform to wound bed, secure with silicone border foam dressing, change every other day (QOD), to wear derma saver boots to bilateral feet while in bed. turn and reposition every 2 hours from side to side. Rest in bed with low air loss mattress, heels floated. Juven twice daily and mighty shakes with meals ordered to aid in wound healing. On 4/2/24 at 11:45 A.M., History of Present Illness (HPI) does not indicate resident has pressure on her right heel, but addresses it in the wound assessment. Pressure ulcer location: right heel. Size: 3 cm x 2 cm x 0.1 cm with scant amount of serous drainage. Unstageable pressure area to right heel. Weekly wound assessment of pressure areas to right heel and sacral area completed 4/3/24 by Wound NP and facility Wound Nurse. Recommended Manuka (honey alginate) cut to size to wound bed, secure with bordered gauze. Heels floated, rest in bed with low air loss mattress, turn and reposition protocol. Appetite was good, received supplements and Juven to aid in healing. On 4/10/24 at 10:36 A.M., Patient was seen on 4/10/24, her right heel now a stage IV. Pressure ulcer location: right heel. Size: 2 cm x 1.5 cm x 0.1 cm with scant amount of serosanguineous drainage. Improving without complications. Weekly wound assessment of pressure areas to right heel and sacral area completed 4/10/24 by Wound NP and facility Wound Nurse. Wound measurements were done by 2 different nurses which may explain the difference in calculations. Recommended cleanse with wound cleanser, apply Manuka (honey alginate) cut to size to wound bed, secure with bordered gauze. Heels floated, rest in bed with low air loss mattress, turn and reposition protocol. Appetite is good, received supplements and Juven to aid in healing. On 4/17/24 at 1:27 P.M., Patient was seen on 4/10/24, her right heel now a stage IV. Pressure ulcer location: right heel. Size: 0.8 cm x 1.2 cm x 0.1 cm with scant amount of serosanguineous drainage. Improving without complications. Weekly wound assessment of pressure areas to right heel and sacral area completed 4/17/24 by Wound NP and facility Wound Nurse. Recommended cleanse with wound cleanser, apply Manuka (honey alginate) cut to size to wound bed, secure with bordered gauze. Heels floated, rest in bed with low air loss mattress, turn and reposition protocol. Appetite is good, received supplements and Juven to aid in healing. On 4/17/24 at 10:38 A.M., wound care performed by the facility Wound Nurse and Wound Nurse Practitioner (NP) was observed. The Wound Nurse indicated Resident 26 came to facility with the sacral wound but it was not getting better. She indicated the Primary Care Physician (PCP) recently noticed drainage from rectal fistula and indicated it was feeding it.The Wound NP indicated the right heel was a facility acquired stage IV pressure ulcer. She measured the wound as length 1.2 x width 1.8cm x depth 0.1 cm, sprayed it with lidocaine and debrided the wound. Then she performed wound care on the sacral wound. She measured it as length 4.5 cm x width 3cm. She indicated it was looking better, sprayed lidocaine and debrided the wound. Both wounds lacked signs and symptoms of redness, odor, drainage, and swelling and were dressed as ordered prior to and after wound care. The observations at that time did not meet defining criteria for a stage IV wound. On 4/19/24 at 7:30 A.M., Resident 64 was observed laying on her back asleep in her bed. On 4/19/24 at 7:45 A.M., Resident 64 was observed with the head of her bed elevated, sitting in bed, and eating breakfast. At that time, staff indicated her meal ticket did not say Resident 64 was to have any supplements, so she doesn't know if she was supposed to have some or not. Resident noted to have heel protectors on both feet and heels floating. She was covered with sheet and blanket up to her waist. During a continuous observation on 4/19/24 from 8:05 A.M. to 10:15 A.M., the following was observed: On 4/19/24 at 8:05 A.M., Resident 64 was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 from 8:39 A.M. to 9:51 A.M., , Resident 64 was observed with her eyes closed, sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 9:51 A.M., Certified Nurse Aide (CNA) 34 went into room and answered the call light of Resident 64's roommate. She did not attend to Resident 64 who was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 9:57 A.M., Qualified Medication Aide (QMA) 19 entered the room and talked to Resident 26's roommate. She did not attend to Resident 64 who was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 10:00 A.M., CNA 34 walked past Resident 64's room. She was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 10:03 A.M., QMA 19 came into Resident 64's room to give roommate medication but did not attend to Resident 64 who was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 10:05 A.M., CNA 34 walked past Resident 64's room who was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 10:07 A.M., CNA 34 and QMA 19 walked past Resident 64's room who was observed sitting in her bed as she was when she was eating breakfast. On 4/19/24 at 10:15 A.M., Resident 64 was observed sitting in her bed as she was when she was eating breakfast. During an interview on 4/22/24 at 8:51 A.M., Licensed Practical Nurse (LPN) 16 indicated she came to the facility with the coccyx wound, but it kept getting worse until the PCP found the rectal fistula and they figured out that was where the drainage was coming from. Now it's getting better. The wound on her heel started here possibly from her rubbing her heels on her sheets while she was laying in bed. During an interview on 4/22/24 at 8:56 A.M., CNA 80 indicated she was aware that Resident 64 had pressure ulcers. She wasn't sure what they were doing for them because the nurses provided the treatments. At that time, she indicated she liked to sit in her bed but did get into her wheelchair at times. During an interview on 4/22/24 at 9:12 A.M., the Director of Nursing (DON) indicated Resident 64's wounds would stay staged as stage IV until they heal, despite improvement. At that time, she indicated staff were repositioning her off her wound and keeping heel boots on, and floating her heels while she was in bed. 38770 2. On 4/16/24 at 11:02 A.M., Resident 23's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, traumatic brain injury, and anxiety. The most recent Quarterly and State Optional MDS Assessment, dated 3/24/24, indicated a severe cognitive impairment, and one stage 3 pressure ulcer present on re-entry. Resident 23 required extensive assistance of two staff for bed mobility and transfers. Resident 23 returned from a hospitalization on [DATE]. Physician orders included, but were not limited to: Cleanse sacral area with wound cleanser, pat dry, apply polymem pink (an absorbent dressing) to skin breakdown and redness, cover with sacral border dressing and notify MD of deterioration daily, once a day, dated 4/13/24. Lantiseptic Skin Protectant Ointment 50 % (Skin Protectant) apply to buttocks topically every day and night shift for redness, dated 2/22/24. A current risk for pressure ulcers care plan, updated on 3/5/24 to reflect a current stage 3 sacral pressure ulcer, included but was not limited to, the following interventions: Treatments as ordered, dated 1/11/24. Turning and repositioning every 2 hours and as needed, dated 1/11/24. Skin and wound notes from the Nurse Practitioner (NP) included, but were not limited to, the following: 1/24/24 Bilateral buttocks with IAD. Cleanse with soap and water, apply barrier cream to base of the wound, leave open to air, change twice a day and as needed. 1/31/24 Bilateral buttocks with IAD measuring 0x0x0 (cm). Cleanse with soap and water, apply barrier cream to base of the wound, leave open to air, change twice a day and as needed. 2/7/24 Bilateral buttocks with IAD measuring 0x0x0 (cm). Cleanse with soap and water, apply barrier cream to base of the wound, leave open to air, change twice a day and as needed. 2/14/24 Bilateral buttocks with IAD measuring 0x0x0 (cm). Cleanse with soap and water, apply barrier cream to base of the wound, leave open to air, change twice a day and as needed. 2/28/24 Stage 3 pressure ulcer to sacrum measuring 5x5x0.1 (cm). Cleanse with soap and water, apply barrier cream to base of the wound, leave open to air, change twice a day and as needed. (A Stage 3 pressure ulcer as defined by the Center for Medicare and Medicaid Services is full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). The observation at that time did not meet defining criteria for a stage 3 wound. 3/6/24 Stage 3 pressure ulcer to sacrum measuring 6x3x0.1 (cm). Cleanse with wound cleanser, apply medical grade honey to base of the wound, secure with bordered gauze and change twice a day and as needed. 3/13/24 Stage 3 pressure ulcer to sacrum measuring 6x6x0.1 (cm). Cleanse with wound cleanser, apply medical grade honey to base of the wound, secure with bordered gauze and change twice a day and as needed. 3/20/24 Stage 3 pressure ulcer to sacrum measuring 7x6x0.1 (cm). Cleanse with wound cleanser, apply medical grade honey to base of the wound, secure with bordered gauze and change twice a day and as needed. 3/27/24 Stage 3 pressure ulcer to sacrum measuring 6x5x0.1 (cm). Cleanse with wound cleanser, apply medical grade honey to base of the wound, secure with bordered gauze and change twice a day and as needed. 4/17/24 Stage 3 pressure ulcer to sacrum measuring 4x1.5x0.1 (cm). Cleanse with wound cleanser, apply medical grade honey to base of the wound, secure with bordered gauze and change daily and as needed. Skin only evaluations from the wound nurse included, but were not limited to, the following: 2/22/24 Open lesion needs review. Right buttock measuring 3.5x1.3 (cm). 4/4/24 Stage 3 pressure ulcer to buttocks measuring 6x4.5x0.1 (cm). Hospital records dated 4/10/24 indicated Resident 23 was admitted to the hospital on 4/9/24 with an existing sacral pressure ulcer measuring 3x3x<0.1. Resident 23's clinical record lacked a re-entry sacral wound assessment on 4/12/24. On 4/17/24 at 9:34 A.M., the NP and wound nurse were observed to perform a dressing change for Resident 23's sacral pressure ulcer. The area measured 4x1.5 (cm). The wound nurse cleansed the wound with wound cleanser, pat dried the area, applied two medihoney pads that the wound nurse indicated contained calcium alginate also, and applied a foam border. At that time, the NP indicated she wanted the order changed to use medihoney, as the facility did not use polymem dressings that was currently ordered. On 4/18/24 at 9:40 A.M., Licensed Practical Nurse (LPN) 42 was observed to perform a dressing change for Resident 23's sacral pressure ulcer. At that time, she indicated the order had been updated that morning and would be using medihoney on the wound. LPN 42 removed the soiled dressing, dated 4/17/24, cleansed the area with wound cleanser and let air dry. LPN 42 then placed two pads of medihoney dressing on top of each other on the wound bed. The red areas surrounding the wound were not covered with medihoney. A foam border was placed over the entire area. At that time, LPN 42 indicated the medihoney should cover all red areas per the order. At that time, the wound was observed as open with area in the middle beefy red. The surrounding area was pink and very little pink drainage was observed. On 4/18/24 at 10:00 A.M., Resident 23's record was reviewed a second time. Current orders included, but were not limited to, the following: Cleanse sacral area with wound cleanser, pat dry, apply honey alginate to skin breakdown and redness, cover with border foam dressing and notify MD of deterioration daily, dated 4/18/24. On 4/18/24 at 10:50 A.M., the wound nurse indicated she believed Resident 23 has had a recent decline in overall status, although no decline had been identified in any other areas other than the pressure areas. She indicated Resident 23 was totally dependent on staff for all activities of daily living (ADLs) and had been that way for a long time now. She indicated the area on the sacrum had been there for over a year now, and had healed and re-opened. On 4/19/24 at 6:30 A.M., Resident 23 was observed lying on her back in bed. During a continuous observation on 4/22/24, Resident 23 was not turned/repositioned from 4:35 A.M. until 6:50 A.M. On 4/22/24 at 10:25 A.M., a non-dated current Pressure Injury Prevention policy was provided and indicated Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to provide care plan conferences quarterly for 2 of 5 residents reviewed for unnecessary medications. (Resident 35, Resident 52) Findings include: 1. On 4/18/24 at 12:50 P.M., Resident 35's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and anxiety disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/11/24, indicated a severe cognitive impairment. Resident 35's most recent care plan meeting was held 12/13/23. Resident 35's clinical record lacked a care plan meeting since 12/13/23. On 4/15/24 at 12:39 P.M., the Administrator indicated there was no current Social Services Director (SSD) as the most recent one quit in January 2024. She indicated the Activities Director was assuming the role of care plan meeting coordinator until a new SSD could be found. 45933 2. On 4/17/24 at 11:00 A.M., Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, Alzheimer's disease, and anxiety disorder. The most recent Quarterly MDS, dated [DATE], indicated a severe cognitive impairment. The clinical record lacked a care plan conference between 9/19/23 and 3/12/24. During an interview on 4/22/24 at 8:55 A.M., the Administrator indicated social services arranged the care plan conferences, but the activity director had been helping set the conferences up due to the facility not having a social services provider. At that time, she indicated she was unsure of how often care plan conferences should be completed. On 4/22/24 at 11:21 A.M., the Regional Consultant provided an undated Care Planning-Resident Participation policy that indicated, .10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes . 3.1-35(c)(2)(C) 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to prevent the development of and add interventions to aid in the healing of acquired pressure injuries for 2 of 6 residents reviewed for pressure ulcers. A stage II and unstageable pressure injury were acquired and dietary staff was not included in determining appropriate interventions. (Resident 45, Resident 216) Findings include: 1. On 10/16/18 at 10:20 A.M. and 11:57 A.M., Resident 45 was observed lying in bed on her back. During an interview on 10/17/18 at 10:27 A.M., Resident 45's family member indicated she had a pressure area on her right heel from digging into the mattress when in bed. On 10/17/18 at 12:48 P.M., Resident 45's clinical record was reviewed. The most recent quarterly MDS (Minimal Data Set) Assessment, dated 8/27/18, indicated the resident was severely cognitively impaired, required extensive assistance of 2+ persons with bed mobility, at risk of developing a pressure ulcer, and was not on a turning/repositioning program. Current orders indicated, but were not limited to: Zinc Capsule 220 mg (milligrams) in the morning for aid in wound healing for 30 days, ordered 10/9/18 Vitamin C Tablet 500 mg in the morning for aid with wound healing for 30 days, ordered 10/9/18 Skin/wound assessments included the following: 10/3/18 . During skin assessment resident was noted to have an area of dark purple and red skin discoloration to right heel measuring 2.3 cm (centimeters) L (length) x 2.5 cm W (width) . 10/8/18 . Area is dark purple and measures 2.25 cm circumference, no depth odor, or drainage . 10/15/18 . Unstageable area to Rt (right) heel . Area is dark purple in color and measures 2.1 cm in circumference. No odor, drainage or depth noted . 10/23/18 . Wound assessment to DTI (deep tissue injury)/Unstageable area to right heel . Area measures 2 cm x 2.2 cm with no depth. Area now has a small blister to center measuring 1 cm circumference. No drainage or odor . (National Pressure Ulcer Advisory Panel defines a deep tissue injury a pressure related injury to the subcutaneous tissue under intact skin. Unstageable defined as full thickness tissue loss in which the base of the ulcer is covered by slough (tan, brown or yellow) and /or eschar (tan, brown or black) in the wound bed.) Care plan included, but were not limited to: Potential for skin breakdown . 10-3-18 right heel-unstageable PU . and included interventions, but were not limited to . bil (bilateral) heels floated, and heel protectors when in bed (10/3/18), . derma saver in place underneath feet and BLE in bed as ordered (10/3/18), . low air loss mattress (6/7/17, revised 10/11/18) . Resident 45's clinical record lacked documentation that a nutritional assessment had been completed since the right heel pressure ulcer had been detected. On 10/23/18 at 1:41 P.M., Resident 45's right heel wound was observed. The area was quarter sized, dark purple in color, and covered with a clear dressing. The DON (Director of Nursing) measured it over the clear dressing at 2.0 cm x 2.2 cm and indicated it was an unstageable pressure ulcer. During an interview on 10/24/18 at 8:45 A.M., the DON indicated the resident moved around a lot in the bed, and sometimes will move her feet around so much her heel protectors have been kicked off of the bed. She further indicated interventions in place before development of the pressure ulcer were low air loss mattress, turn and reposition every 2 hours, and dietary supplements. On 10/24/18 at 9:30 A.M., Resident 45 was observed lying in bed on her back with heel protectors on her feet. On 10/24/18 at 10:07 A.M., Resident 45 was observed lying in bed on her back, with heel protectors on her feet. During an interview on 10/24/18 at 10:20 A.M., LPN 19 indicated Resident 45 had a recent decline in status and was spending most of the time in bed. She indicated Resident 45 had always required a 2 person assist, and required assistance with bed mobility. During an interview on 10/24/18 at 12:11 P.M., Resident 45's family member indicated once the pressure area on her heel was detected, staff initiated boots and offloading interventions. She further indicated that before the pressure area was detected, there were no specific interventions in place to prevent pressure ulcers on the heels. Resident 45 was observed lying in bed on her back at that time. During an interview on 10/24/18 at 1:58 P.M., the DON indicated the RD (Registered Dietician) came to the facility every Friday and was supposed to assess residents with concerns. She indicated she was unsure why a nutritional assessment for Resident 45 had not been done since the development of the right heel pressure ulcer. 2. During record review on 10/18/18 at 12:21 P.M., Resident 216's most recent MDS (Admission Assessment), dated 10/10/18, indicated the resident required extensive assistance with bed mobility, transfers, toileting, and eating, was always incontinent of bowel and bladder, and had an unhealed Stage II pressure injury. (The National Pressure Ulcer Advisory Panel defines a Stage II pressure injury as a Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) Resident 216's [DIAGNOSES REDACTED]. Resident 216's physician orders [REDACTED]. Resident 216's care plan included but was not limited to, a focus on potential for skin breakdown and coccyx Stage II with interventions including; weekly skin inspection, skin assessments, low air mattress, and treatments as ordered. A focus on nutrition risk with interventions including vitamins/supplements as ordered. A nutritional assessment completed 10/4/18 indicated the resident's skin was intact. Progress notes with skin assessments were documented as follows: 10/3/18 - resident admitted and skin areas included but were not limited to; coccyx - middle of coccyx, blanchable, pink, 1.5 cm (centimeter) x 1 cm. 10/6/18 - blanchable area to middle of coccyx 10/9/18 - weekly skin assessment - 1.6 cm x 0.5 cm slit to coccyx 10/15/18 - Stage II pressure ulcer to coccyx - 2.2 cm x 0.3 cm x 0.1 cm A progress note dated 10/8/18 stated Speech Therapy recommended a pureed diet with regular fluids. A progress note dated 10/23/18 stated RD (Registered Dietician) will recommend adding multivitamins with minerals and double meat at meals to aid in wound healing. No nutritional assessment was completed after Resident 216 developed the Stage II pressure injury. During an observation on 10/23/18 at 9:57 A.M., RN 12 and LPN 7 were changing Resident 216's dressing. RN 12 indicated the resident was incontinent of bowel and bladder and the resident was resistive to care and that could have contributed to the wound. The resident had soiled the dressing and the dressing had came off. RN 12 cleaned the wound and measured the wound at 1.6 cm x 0.4 cm x 0.1 cm. RN 12 indicated the wound was looking better since the previous week. The wound bed was pink in color, no drainage present, had defined edges, surrounding skin was intact. During an interview on 10/23/18 at 9:45 A.M., the RD (Registered Dietician) and DM (Dietary Manager) indicated that nursing staff alerts dietary when a resident acquires a wound and the dietician makes recommendations for supplements and then staff should get order from the physician. The RD and DM indicated they were unaware of Resident 216's pressure injury and that they should have been notified. During an interview on 10/24/18 the ADON (Assistant Director of Nursing) indicated the dietary staff is notified of resident wounds, a nutritional assessment should be completed following an acquired wound and recommendations are made for vitamins/minerals and supplements. On 10/24/18 at 9:35 A.M., a Skin Integrity Guideline was provided, and indicated . If identified at risk or with actual alterations in skin integrity of feet, footwear will be addressed for fit and appropriateness . Nursing notifies dietary of any patient/resident admitted with pressure ulcers or newly identified acquired pressure ulcers . Nutritional Assessment determines need for nutritional interventions . Documentation completed by Dining Services Manager or Registered Dietician (according o individual state regulations) occurs on initial notification of a new pressure ulcer and surgical wounds and continues monthly for non-healing Stage II or greater areas until healed unless otherwise noted . 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a hospital physician's order for a [MEDICAL CONDITION] (Continuous Positive Airway Pressure) was clarified in regard to use and settings, failed to document if and when the [MEDICAL CONDITION] was used; failed to notify the physician that the resident was not using the [MEDICAL CONDITION], and failed to do a thorough respiratory assessment when the resident complained of shortness of air, resulting in hospitalization for acute on chronic [MEDICAL CONDITION], for 1 of 3 residents reviewed who utilized oxygen or [MEDICAL CONDITION] machines, in a sample of 3.( Resident B) Findings include: The closed clinical record of Resident B was reviewed on 3/7/18 at 10:00 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary, dated 11/28/17, included: .She is to wear her [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) during all sleeping hours A hospital transfer form, dated 11/28/17, included: Oxygen Therapy, [MEDICAL CONDITION] @ 16 [MEDICAL CONDITION] O2 (oxygen) @ 35%. A facility admission assessment, dated 11/28/17 at 7:05 P.M., Alert, Memory OK, Cognitive Skills For Decision Making Independent - decisions consistent/reasonable. Requires oxygen: Yes. Experience difficulty breathing: Yes. Experience shortness of breath: Yes .C-Pap: Yes. The facility admission orders [REDACTED]>90 every day and night shift. The facility admission orders [REDACTED]. Nursing Progress Notes included the following notations: 11/28/17 at 10:17 P.M.: 1905 (7:05 P.M.) Resident admitted to facility .O2 sat 97% on 4LPM (4 liters per minute) per nasal cannula .resp (respirations) even, nonlabored. Does easily become SOB (short of breath) with any exertion .Alert et (and) oriented .Wears [MEDICAL CONDITION]. [MEDICAL CONDITION] brought from home. [MEDICAL CONDITION] hooked up et placed on resident. Resident adamant [MEDICAL CONDITION] isn't working right. [MEDICAL CONDITION] noted to be blowing out et appears to be functioning properly, checked by another nurse as well to make sure [MEDICAL CONDITION] was functioning properly with no issues found. Resident educated that [MEDICAL CONDITION] was functioning properly et machine was on the same settings as when she was at home, resident states its still not working properly et chose to take off [MEDICAL CONDITION] et put oxygen back on 11/28/17 at 10:35 P.M.: Resident moaning. This nurse went to check on resident et resident c/o (complains of) left side pain .Resident pulled up in bed, HOB (head of bed) elevated .Tylenol administered as ordered. 11/29/17 at 4:39 A.M.: (Sent to physician) Situation: 1) resident admitted .Has order for glucometer checks .Has Foley cath (catheter) .Background: Dx (diagnosis): [MEDICAL CONDITIONS] .Assessment: .Would you like to order standard sliding scale .Physician notified. Awaiting response. Documentation that the physician was notified to clarify the [MEDICAL CONDITION] orders, or that the resident felt like that the [MEDICAL CONDITION] was not working, was not found in the clinical record. Nursing Progress Notes continued: 11/29/17 at 2:29 P.M.: Resident complained of SOA (shortness of air); elevated HOB, offered fluids, and repositioned. Interventions unsuccessful. Documentation that a thorough assessment was completed, including lung sounds, vital signs and oxygen saturation, were not found in the clinical record. Nursing Progress Notes continued: 11/29/17 at 4:29 P.M.: Resident was frequently hollering out for help. Resident stated she couldn't breathe. Educated resident to take deep breaths and stop hollering because that was making it worse. Resident stated she understood. Documentation of a thorough assessment at that time was not found in the clinical record. Nursing Progress Notes continued: 11/29/17 at 5:55 P.M.: .O2 sat - 93% on 4LPM per NC .respirations even and labored at times. Alert and oriented x 4 .Resident has episodes of calling out for help periodically 11/29/17 at 7:12 P.M.: (Name of physician) here to see resident for initial assessment. Resident lethargic and slow to respond. Disoriented .(Physician) feels that resident is too sick to be in facility at this time .made decision to send resident to hospital A Physician's note, dated 11/29/17, included: .She was treated with [MEDICAL CONDITION] and it has been managed by being on [MEDICAL CONDITION] whenever she is not eating and then 4L to 5L of oxygen while eating .Assessment/Plan: 1. [MEDICAL CONDITIONS] resulting in chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] (low oxygen). She will be on [MEDICAL CONDITION] at 16 mm water with minimum pressure of 10 when not eating Addendum: I reevaluated patient. She is more awake and alert. I am instituting [MEDICAL CONDITION] treatment. She has a replacement [MEDICAL CONDITION] machine apparently from home. It was not on. I filled the humidifier and with the help of a nurse, have placed the nasal [MEDICAL CONDITION] on this patient. She was resistant to wearing it and only with considerable reassurances and begging and pleading were we able to get her to comply with it. She had had a titration in (name of hospital) and the settings for [MEDICAL CONDITION] are 16 mm water .that was on 11/27/2017, 2 days ago. I have concern that she was without her [MEDICAL CONDITION] for approximately 24 hours here. She came here with one provided by family, but the memory card was full. They brought another one over here that I have now hooked up .Given the above concerns and my inability to have basically any blood gas data in order to make any adjustments on this patient .I have decided to go ahead and send her back to the hospital, to the ER, and if her respiratory status is significantly worse from previous, then she would need to readmitted to the hospital An ambulance report, dated 11/29/17 at 6:43 P.M., included: .female in respiratory distress .Upon arrival found pt (patient) AO x 4 (alert and oriented) .Nurse advised (name of physician) had just seen pt and said that her CO2 (carbon [MEDICATION NAME]) was wrong .Pt was breathing through a tube that was connected to her room air [MEDICAL CONDITION] machine. Nurse stated that pt was supposed to be on 4 lpm of O2 by NC, but she was not .Administered low flow O2 by NC. Pt's SAO2 (oxygen saturation) improved to 98% from 89% A hospital ER note, dated 11/29/17 at 8:05 P.M., included: .presents to the ED (emergency department) for shortness of breath that is acute on chronic and altered mental status, onset today. 11/21/17, patient hospitalized for [REDACTED]. She had adjustments to the [MEDICAL CONDITION] and discharge to the nursing home. Last night, the patient went to bed 'fine.' Today, the patient was found to be ineffectively hooked up to her [MEDICAL CONDITION] and was suppose (sic) to be on nasal canula (sic) when awake however the nc was still 'still rolled up on the window seal (sic),' not hooked up to the patient. The patient was found altered and in respiratory distress, per (physician) at the nursing home. Her O2 was in 80s on room air A hospital ER note, dated 11/29/17 at 9:50 P.M., included: .EMS (Emergency Medical Service} states that upon arrival to the nursing facility they found the patient to be on nasal cannula without oxygen source attached. There is also a question of whether or not the patient was placed on [MEDICAL CONDITION] overnight. The patient was just discharged yesterday but her CO2 has risen to 120 (normal 23-27). She improved with [MEDICAL CONDITION] in the emergency department but not to the extent necessary for discharge A hospital history and physical, dated 11/29/17, included: .female who presents with shortness of breath and altered mental status .As per the emergency department provided, patient was found sleepy and ineffectively using her [MEDICAL CONDITION], her nasal cannula oxygen was rolled up on the window seal (sic). The patient was sent to our hospital to be evaluated .Assessment/Plan: Acute hypoxic/hypercapnia (elevated carbon [MEDICATION NAME] in blood) [MEDICAL CONDITION] PO2 less than 38 on admission (normal 80-100) .admit to ICU .[MEDICAL CONDITION], if no improvement, patient might need to be intubated .Acute [MEDICAL CONDITION], CO2 (carbon [MEDICATION NAME]) narcosis (drowsiness) secondary to [MEDICAL CONDITION] On 3/7/18 at 2:15 P.M., during an interview withe the Assistant Director of Nursing (ADON), she indicated she was with the physician during the evening of 11/29/17 when he decided to send the resident back to the hospital. The ADON indicated the resident was very restless, and was pulling at everything, at her clothes, at my clothes. The ADON indicated she knew her [MEDICAL CONDITION] was working. The ADON stated, Everything was working. I saw her wearing it. She wouldn't leave it on. The ADON indicated the [MEDICAL CONDITION] was from the resident's home. She indicated she was unsure why there was no order for the [MEDICAL CONDITION] or settings. On 3/7/18 at 3:20 P.M., a respiratory therapist at a local medical supply company was interviewed. She indicated the correct settings for the [MEDICAL CONDITION] or [MEDICAL CONDITION] should have been ordered and in the clinical record. She indicated that when a [MEDICAL CONDITION] or [MEDICAL CONDITION] machine was turned on, a read out would state what the settings were. On 3/7/18 at 3:30 P.M., during an interview with the Director of Nursing (DON) and ADON, the ADON indicated there was no order for the [MEDICAL CONDITION] from the hospital. She indicated there was no documentation on any treatment sheet of when or if the resident wore the [MEDICAL CONDITION]. The ADON indicated she disagreed with the ambulance report, because it was inconsistent with what she saw. The ADON indicated it was possible the resident took off her oxygen, or that an extra set of tubing was in the window sill. She indicated the DON had just called a local medical supply company, and had obtained the resident's [MEDICAL CONDITION] settings which she had used at home. The medical supply company document, dated 9/19/13, indicated the resident's pressure parameters were set at 5 to 12 mm water. The DON indicated at that time that facility nurses would be unable to change the settings if they weren't correct. On 3/7/18 at 4:00 P.M., the DON was made aware of the hospital transfer sheet which indicated the resident was to use a [MEDICAL CONDITION] at 16 with 35% oxygen. She indicated that the nurse had signed that order, but that it had not been signed by the physician. She agreed the nurse should have clarified the order for the [MEDICAL CONDITION]. At that time, the DON provided a resident care plan, dated 11/29/17. The care plan indicated, Alteration in Respiratory Status Due to [MEDICAL CONDITION] .sleep apnea, [MEDICAL CONDITION], use of [MEDICAL CONDITION] and O2. The Interventions included: Administer oxygen as needed per Physician order. Monitor oxygen saturations on room air and/or oxygen. Monitor oxygen flow rate and response. On 3/7/18 at 4:00 P.M., the DON provided the current facility policy, Continuous Positive Airway Pressure ([MEDICAL CONDITION]), reviewed 6/19/17. The policy included: Purpose/Indications: [MEDICAL CONDITION] is a treatment that uses mild air pressure to keep the airways open. [MEDICAL CONDITION] typically is used by people who have breathing problems such as sleep apnea .who exhibit medically unacceptable or worsening hypoxemia (low oxygen in the blood) despite administration of supplemental oxygen .It is important that the Living Center be knowledgeable of the brand-specific device, its functioning, and its settings when implementing this policy and process .Procedure: 1. Review Chart for order, diagnosis, indications, and other information .Connect oxygen tubing for supplemental oxygen .Verify machine settings are in accordance with written orders and turn on machine .Assess patient tolerance of device, fit, and efficacy . Document the following in the health record: specific [MEDICAL CONDITION] pressures and alarms if applicable. Note mask size and supplemental oxygen liter flow, as well as appropriate clinical data .Patients with home [MEDICAL CONDITION] device will need to have appropriate orders written by physician allowing use of device and settings used at home (define in order). This Federal tag relates to Complaint IN 489. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent pressure injuries for 1 of 3 residents reviewed for pressure injuries. This resulted in Resident 19 developing a Stage 4 Pressure Injury. (Resident 19) Findings include: On 8/24/17 at 10:35 A.M., Resident 19 was observed lying in bed. Resident 19 was observed to have a negative pressure vacuum dressing to the left posterior knee. Resident 19's left leg was observed to be extended to approximately forty five degrees. On 8/25/17 at 9:18 A.M., RN 1 indicated Resident 19 had a Stage 4 pressure injury to left posterior knee. RN 1 indicated the pressure injury had been acquired in the facility. On 8/29/17 at 9:54 A.M., Resident 19 was observed sitting in a wheelchair. Resident 19's left leg was 90 degrees flexed. At that time, the Wound Nurse indicated Resident 19's leg was flexed at 90 degrees due to medications administered prior to dressing changes which helped relax Resident 19's leg. The Wound Nurse indicated after an investigation it was determined the initial wound on 7/7/17 was from an injury during a transfer. On 8/30/17 at 9:18 A.M., Resident 19 was observed lying in bed. Resident 19 was observed to have a negative pressure vacuum dressing to the left posterior knee. Resident 19's leg was observed to be extended approximately forty five degrees. At that time, LPN 2 indicated Resident 19's leg was extended based on the residents pain level. On 8/28/17 at 9:03 A.M., Resident 19's clinical record was reviewed. Resident 19's [DIAGNOSES REDACTED]. A Significant Change MDS (Minimum Data Set) assessment, dated 8/14/17, indicated Resident 19 had a functional impairment in range of motion on the upper and lower extremity on one side. The MDS assessment further indicated Resident 19 had a Stage 3 pressure injury. The Care Plans included, but were not limited to: I have a physical functioning deficit interventions included, but were not limited to: Marissa (mechanical lift) times 2 assist (initiated 5/10/17), resident requires assist with ADL's (Activities of Daily Living) toileting, bed mobility, transfers, locomotion, personal care, bathing, eating, personal hygiene and is Marissa lift with transfers (initiated 1/11/17) The Progress Notes included, but were not limited to: 7/7/17 at 11:28 A.M., Situation: While resident was at therapy, therapist called nurse to assess resident's leg. therapist (sic) said that while doing exercises with the left leg, she noticed that she has an area behind the left knee. Background: resident has refused to wear leg brace all week. Assessment: upon assessment, resident was noted to have a bruise with an abrasion in it measuring 1.0 cm (centimeters) x (times) 1.1 cm Four days later the Progress notes included, but were not limited to: 7/11/17 at 6:13 A.M., Note Text: Left posterior inner knee- Cleanse bruised/abraised area with Normal Saline. Pat dry. Apply Allevyn Gentle border and change once daily until healed. Monitor for s/s (signs and symptoms) of complications until resolved. at bedtime. Start Date: 7/11/17 . 7/11/17 at 1:48 P.M., Situation: Area cont (continues) to Left inner knee (left posterior knee) Assessment: Open lesion to Left inner knee. Was Abraised area w/ (with) bruising initially. Wound bed is exposed et (and) pink w/ 75% scattered yellow slough. Moderate amount of [MEDICAL CONDITION] exudate noted. yeast like odor noted. Wound margins are macerated w/ surrounding [DIAGNOSES REDACTED] present. Has severe contracture to Left knee. Resident c/o (complains of) discomfort behind knee during transfers from lift pad and w/c (wheelchair) being possible causative factor of trauma. Resident has been refusing to wear brace to leg resulting in skin-on-skin tight moist environment to area r/t (related to) contracture. Therapy has recommended: 1) Brace to LLE (left lower extremity) when up in wc et during transfers to prevent further trauma 2) Dermasaver over pants and to make sure Left knee brace in on top of dermasaver 3) Brace to be placed loosely 4) Left knee brace schedule: 6 am-12 noon brace on 12 noon-6 pm brace off 6p-midnight brace on midnight-6a brace off 5) check left brace for placement et skin for redness/irritation q2hrs (every 2 hours) and may remove upon discomfort/irritation . 7/18/17 at 6:09 A.M., Situation: Resident cont (continues) w/ open lesion to left posterior knee Assessment: .Area remains w/ 90% stringy yellow adherent slough to wound bed. Moderate amount of [MEDICAL CONDITION] exudate present. Surrounding tissue is moist et peeling w/ [DIAGNOSES REDACTED], warmth. Strong/foul yeast-like odor noted . 7/24/17 at 8:06 A.M., Situation: 1) Resident cont. w/ open lesion to post. Left knee .Assessment: 1) upon assessment of wound noted fully exposed tendon from center of wound bed. Granulation tissue is now visible to outer wound bed. 25% slough noted at 9 and 3 o'clock. Tunneling of unknown depth at 12 o'clock 7/25/17 at 11:32 A.M., Situation: Spoke w/ wound clinic nurse, (Name of Nurse), this am. (Name of Hospital) wound clinic to begin seeing resident for open lesion w/ exposed tendon to left post knee 8/1/17 at 10:06 A.M., Note Text: Res returned safely for LOA (leave of absence) to wound center. Rec'd new orders from DR (name of doctor): Continues orders to LT post knee as per ordered until wound vac (negative pressure vacuum) arrives . 8/8/17 at 10:00 A.M., Note Text: Returned from appointment with wound vac in place to left posterior knee 8/15/17 at 9:40 A.M., Note text: (Name of Nurse) from Wound Care Clinic called and reported to this nurse will increase appts to clinic bid (twice) a wk (week) d/t (due to) increase tunneling to wound area. Actual measurements of wound shows improvement. D/T tunneling wound care will be doing wound vac treatments of Tues (Tuesday) and Fridays (sic) and nursing home home (sic) staff will not do wound care treatment unless dislodged or complications 8/16/17 at 7:48 A.M., Situation: Spoke with (Name of Hospital) wound clinic nurse, (Name of Nurse), States that open lesion to Left Posterior Knee initially caused from trauma during transfer to w/c has progressed into Stage 4 Pressure Injury . Resident 19's wound progressed from a bruised, abraised area into a Stage 4 Pressure Injury. The Wound Evaluation Flow Sheet Multiple Weeks, dated 7/11/17, included but was not limited to: Section 1. Wound Evaluation Week 1: Left knee (rear) open lesion, 3.0 by 1.2 by 0.1. Open lesion to left inner knee. Abraised are w/ bruising initially. Wound bed is exposed et pink w/ 75% scattered slough. Moderate amount of [MEDICAL CONDITION] exudate noted. On 8/29/17 at 9:28 A.M., PT (Physical Therapist) 1 was interviewed. PT 1 indicated she had found the initial injury to the left posterior knee. PT 1 indicated the nursing staff had thought the injury occurred during a transfer. On 8/30/17 at 10:41 A.M., the DON indicated Resident 19's wound to the left posterior knee was a post traumatic injury which later turned to a pressure injury. The DON indicated staff believed the injury initially occurred on 7/7/17 from a transfer and assisting the resident to sit back in the wheelchair, which resulted in the posterior knee rubbing against the wheelchair seat. The DON indicated Resident 19's wheelchair had not been changed since the original injury occurred. The DON indicated the staff immediately treated the area and on 7/11/17 added derma saver (a foam cushion) to prevent additional injury. The DON indicated she was unsure what interventions staff had initiated from 7/7/17-7/11/17 to prevent further injury. Resident 19 continued to be transferred via mechanical lift to the wheelchair. On 8/30/17 at 11:25 A.M., the DON indicated the nurse and therapist had discussed the use of derma saver to prevent further injury on 7/7/17, however, it had not been documented until 7/11/17, On 8/30/17 at 1:16 P.M., the DON provided the Skin Integrity Guideline, undated. The guideline included, but was not limited to: The interdisciplinary plan of care will address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. 3.1-40(a)(1)