Every finding on record at Brickyard Healthcare - Petersburg Care Center

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service for 1 of 1 kitchen observed. The Dietary Manager was not certified. (Dietary Manager)Finding includes:On 11/17/25 at 10:13 A.M., the Dietary Manager was asked to provide her certification certificate. During an interview on 11/21/25 at 11:10 A.M., the Administrator indicated the Dietary Manager failed the test, but she is registered to take the test again. The new test date was unknown. There was another dietary staff member certified until hers expired September 2025.On 11/21/25 at 11:10 A.M., a non dated current Dietary Services Policy was provided by the Administrator and indicated, The facility employs sufficient staff with the appropriate competencies and skill sets to cany out the functions of the Food and Nutrition Services . 3.1-20(a)

Based on observation, interview, and record review, the facility failed to ensure a resident who was underweight received the appropriate services to maintain weight for 1 of 2 residents reviewed for nutrition. Notifications of significant weight loss were not completed, the dietitian's recommendations of house shakes were not implemented until 15 days later, and additional interventions were not attempted after the underweight resident continued to lose weight. (Resident 13)Finding includes:On 11/21/25 at 9:31 A.M., Resident 13 was observed being weighed by Certified Nurse Aide (CNA) 36. Her weight, standing on the scale, was 93.4 pounds (lbs).On 11/19/25 at 1:16 P.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus type II, and anxiety. The resident was readmitted to the facility on [DATE] after being out of the facility on leave of absence, falling, and fracturing her hip.The most recent discharge Minimum Data Set (MDS) assessment, dated 10/23/25, indicated Resident 13 was cognitively intact and independent in decision making, no behaviors or refusals, 63 inches tall, weight of 94 lbs with no weight loss of 5% or more in the last month or loss of 10% in last 6 months, set up assistance from staff for eating and substantial to maximum assistance of staff (staff performs over half the effort) for transfers and toileting, and partial to moderate assistance of staff (staff performs less than half of the effort) for bathing.Current physician's orders included, but were not limited to, the following:house shake one time a day, daily with lunch as a supplement, ordered 10/31/25 weekly weight times 4 weeks or until stable every day shift every Saturday, 10/25/25 regular diet, regular texture, regular (thin liquid) consistency diet, 10/24/25 A current Nutrition Care Plan, last revised 10/14/25, included, but was not limited to, interventions to explain and reinforce to the resident the importance of maintaining the diet ordered.Encourage the resident to comply, explain consequences of refusal, obesity/malnutrition risk factors, and Registered Dietitian (RD) evaluate and recommend diet changes as needed, initiated 5/29/25. The following weights were documented in the resident's clinical record:10/10/2025 3:45 P.M., 101.2 lbs10/11/2025 3:11 P.M., 94.4 lbs (loss of 6.8 lbs and a 6.72% loss) 10/27/25 3:11 P.M., 96.4 lbs 11/6/25 3:13 P.M., 97.2 lbs11/8/25 1:31 P.M., 97.5 lbs11/15/25 11:59 A.M., 94.4 lbs (loss of 3.1 lbs)11/18/25 11:03 A.M., 94.0 lbs (loss of 4.4 lbs)On 10/10/2025, the resident weighed 101.2 lbs. On 11/18/2025, the resident weighed 94 lbs, which was a 7.11% weight loss.On 10/16/25, a Nutrition Assessment Review (NAR) note indicated the following:The resident's most recent weight was 94.4 lb on 10/11/2,5, standing on the scale. Returned from hospital 10/9/25, recent left hip surgical repair from fracture. Triggering for significant weight loss in the past month. Weight of 94 lb on 10/11/25 and 100 lb on 10/01/25. 6 lb weight loss in the past couple of weeks/month; 6% (significant). Current Diet orders: regular diet, regular texture. Current meal consumption ranges from 26-100%. Intakes have declined since the recent hospitalization. Recommendation: house shakes or fortified food given weight loss, poor/varied oral intakes, and recent surgery; the dietary service manager will discuss options with the resident. See the residents' care plan for a list of all focuses, goals, and interventions. The resident will continue to be evaluated for any weight changes, and the plan of care will be updated as appropriate. (The house shakes were not put in as an order for 15 additional days) On 10/23/25, a NAR note indicated the following:The resident's most recent weight was 94.4 lbs on 10/11/25, standing on the scale. Pending updated weight this week. Consuming variable intakes of 26-100% of meals. Likes/tried the chocolate house shakes. Current diet orders: regular diet, regular texture. Current Interventions: On a regular diet, regular texture, and consuming 26-100% of meals; intakes have declined since the recent hospitalization. See the residents' care plan for a list of all focuses, goals, and interventions. The resident will continue to be evaluated for any weight changes, and the plan of care will be updated as appropriate On 10/30/25, a NAR note indicated the following:The resident's most recent weight was 96.4 lbs on 10/27/25 on the scale in her wheelchair. She was up 2 lbs in the past two weeks. Consuming 26-100% of meals. Will place an order for house shakes daily with lunch. Recommendations: house shake daily with lunch; the resident prefers the chocolate flavor. See the residents' care plan for a list of all focuses, goals, and interventions.The resident will continue to be evaluated for any weight changes, and the plan of care will be updated as appropriate. On 11/6/25, a NAR note indicated the following:The resident's most recent weight was 96.4 lbs on 10/27/25 on the scale in her wheelchair. Pending updated weight this week. Consuming 51-100% of meals. Consuming 75% of the house shake daily at lunch. Current Interventions: house shake daily with lunch; the resident prefers the chocolate flavor. See the residents' care plan for a list of all focuses, goals, and interventions.The resident will continue to be evaluated for any weight changes, and the plan of care will be updated as appropriate. On 11/13/25, a NAR note indicated the following:The resident's most recent weight was 97.5 lbs on 11/8/25, standing on the scale. Weight of 98 lb on 11/08/25; up 2 lb in the past 2 weeks. Consuming 26-100% of meals; receiving house shake daily at lunch. Current Interventions: house shake daily with lunch; the resident prefers the chocolate flavor. See the residents' care plan for a list of all focuses, goals, and interventions. The resident will continue to be evaluated for any weight changes, and the plan of care will be updated as appropriate. On 11/19/25, a NAR note indicated the following:WEIGHT WARNING: Value: 94.0 Vital Date: 11/18/25 MDS: -10.0% change over 180 day(s) [ 12.1% , 13.0 ]Resident triggering for significant weight loss in the past 6 months; will continue to monitor weekly at NAR. The most recent 30-day follow-up physician's note, dated 11/11/25, lacked documentation of the resident's fluctuating weight, weight loss, and any documentation of education given to the resident or staff about her nutrition. The clinical record lacked notification of the physician and family about the resident's weight loss, education given to the resident about weight loss and nutrition risks, and any alternative interventions tried since the resident was continuing to lose weight on the current interventions. During an interview on 11/21/25 at 9:31 A.M., Certified Nurse Aide (CNA) 36 indicated Resident 13 was able to feed herself, did get a house shake with lunch, did refuse to drink it sometimes, and was sometimes weaker than others and needed more assistance with mobility. CNA 36 indicated she would try multiple times to get the resident to drink it before giving up, but they really didn't do anything else for weight loss that she was aware of. CNAs were supposed to weigh the residents, document it in the electronic record, and notify the nurse of big discrepancies. The nurse was to notify the MD and DON to get further orders, notify the family, and document in the electronic record. During an interview on 11/21/25 at 9:43 A.M., Licensed Practical Nurse (LPN) 24 indicated nurses should document when a resident was reweighed or when notifications were done. She indicated the Medical Doctor (MD) should be notified of significant weight loss, and the family should also be notified. During an interview on 11/21/25 at 10:15 A.M., the Director of Nursing (DON) indicated she would expect nurses to notify and report any changes in condition as soon as possible to the MD and family, as well as document it in the clinical record. They have discussed Resident 13 weekly in NAR meetings, but the dietitian had not recommended any alternative interventions besides the shake. She indicated she was not aware of other interventions tried on Resident 13 for her weight loss. On 11/21/25 at 10:02 A.M., a current non-dated Weight Monitoring Policy was provided by the Administrator and indicated, . the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range . The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary . Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. d. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietitian, Dietary Manager, or the nursing department may initiate this process. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. The interdisciplinary plan of care communicates care instructions to staff . 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure notification of change for 1 of 3 residents reviewed for nutrition and 1 of 1 residents reviewed for skin conditions (non-pressure ulcer related). The physician was not notified of significant weight loss and skin tears to the right wrist. (Resident 7, Resident 13)Findings include:1. On 11/18/25 at 8:59 A.M., Resident 13 was observed sitting in her room on her bed. A white bandage was observed on her right wrist, not dated. The resident indicated it had been there for a couple of days because she had hit her arm on her wheelchair. On 11/20/25 at 11:50 A.M., Resident 13 was observed lying on her bed. A non-dated white bandage was observed on her right wrist, falling off and brown colored discharge was able to be seen through the bandage. On 11/21/25 at 9:31 A.M., Certified Nurse Aide (CNA) 36 was observed to weigh the resident standing on the scale. Her weight was 93.4 lbs. On 11/19/25 at 1:16 P.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus type II, and anxiety. The most recent discharge MDS assessment, dated 10/23/25, indicated Resident 13 was cognitively intact and independent in decision making, had no behavior of refusals, had no skin conditions, was 63 inches tall, and weighed 94 lbs. She had no weight loss of 5% or more in the last month or loss of 10% in last 6 months, set up assistance from staff for eating and substantial to maximum assistance of staff (staff performs over half the effort) for transfers and toileting, and partial to moderate assistance of staff (staff performs less than half of the effort) for bathing. A general progress note, dated 11/15/25 at 3:34 P.M., indicated, Dried blood noted on resident's right wrist; 2 small skin tears, dry; area cleaned with wound cleanser and covered with border gauze for protection. A weekly Skin Assessment Form, dated 11/17/25, indicated, Small skin tear to top of right forearm, area covered with border gauze dressing. The resident says she scraped it on the brake of her wheelchair over the weekend. No other skin issues noted at this time. Resident 13's clinical record lacked documentation of the physician ever being notified and receiving orders for the resident's skin tears on the right wrist. The following weights were documented in Resident 13's clinical record: 10/10/2025 3:45 P.M., 101.2 lbs 10/11/2025 3:11 P.M., 94.4 lbs (loss of 6.8 lbs and a 6.72% loss) 10/27/25 3:11 P.M., 96.4 lbs 11/6/25 3:13 P.M., 97.2 lbs 11/8/25 1:31 P.M., 97.5 lbs 11/15/25 11:59 A.M., 94.4 lbs (loss of 3.1 lbs) 11/18/25 11:03 A.M., 94.0 lbs (loss of 4.4 lbs) On 10/10/2025, the resident weighed 101.2 lbs. On 11/18/2025, the resident weighed 94 lbs, which was a 7.11% weight loss. The clinical record indicated a NAR note was completed on the following dates: 10/16/25 10/23/25 10/30/25 11/6/25 11/13/25 11/19/25 The clinical record lacked documentation of the physician and family being notified about the resident's continued weight loss. During an interview on 11/21/25 at 9:31 A.M., Resident 13 was observed to have a scabbed area on her right wrist without a bandage. At that time, CNA 36 indicated she had a bandage on earlier in the week, and she wasn't sure if it should still be there or not. She would notify the nurse about it. She indicated the resident was able to feed herself, did get a shake with lunch, and did refuse to drink it sometimes. She would try multiple times to get the resident to drink it before giving up, but they really didn't do anything else for weight loss that she was aware of. CNAs were supposed to weigh the residents, document it in the electronic record, and notify the nurse of big discrepancies. The nurse was to notify the MD and DON to get further orders, notify the family, and document in the electronic record. During an interview on 11/21/25 at 9:43 A.M., Licensed Practical Nurse (LPN) 24 indicated nurses should document when a resident was reweighed or when notifications were done. She indicated that no information about the bandage or skin tear on Resident 13's right wrist was reported to her. At that time, she indicated she was not sure when the bandage was last changed, but staff should document the date and initials on the bandage when it was changed. The Medical Doctor (MD) should be notified of new skin conditions for orders, and the family should also be notified. During an interview on 11/21/25 at 10:15 A.M., the Director of Nursing (DON) indicated she would expect nurses to notify and report any changes in condition as soon as possible to the MD and family, as well as document it in the clinical record. 2. On 11/18/25 at 1:24 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure, type 2 diabetes mellitus, and hypothyroidism. The most recent quarterly minimum data set (MDS), dated [DATE], indicated no cognitive impairment, no weight loss or weight gain, setup assistance from staff with eating, and a therapeutic diet. Current physician orders included, but were not limited to: Consistent carbohydrate diet, regular texture, regular (thin liquid) consistency with double protein with all meals, dated 6/24/25. Weekly weight times 4 weeks or until stable, dated 4/27/25. A current nutrition care plan, dated 5/1/25 and last revised 11/17/25, indicated to report lab work to the MD, provide diet as ordered, a Registered Dietitian to evaluate and make diet changes as needed, and weigh per MD order, all dated 5/1/25. A current congestive heart failure care plan, dated 5/20/25 and revised 11/17/25, indicated to monitor/document/report as needed any signs or symptoms of congestive heart failure, such as weight gain unrelated to intake, dated 5/20/25. A current potential fluid deficit care plan, dated 5/20/25 and revised 11/17/25, indicated to monitor/document/report as needed any signs or symptoms of dehydration, such as recent/sudden weight loss, dated 5/20/25. A current diabetes mellitus care plan, dated 5/20/25 and revised 11/17/25, indicated to monitor/document/report as needed any signs or symptoms of hyperglycemia, such as increased thirst and appetite or weight loss, dated 5/20/25. Resident 7's weights included, but were not limited to, the following: 5/16/25 223.6 pounds 6/10/25 205.8 pounds 6/19/25 204.6 pounds (8.5% loss in 1 month) 7/7/25 201.4 pounds 7/20/25 199.8 pounds 8/17/25 197.2 pounds (11.81% loss in 3 months) 9/15/25 193.2 pounds 11/11/25 189.2 pounds (15.38% loss in 6 months) Interdisciplinary Team (IDT) Nutrition at Risk (NAR) meetings were held and documented on the following dates, but lacked notification to the physician for weight changes: 8/7/25 8/14/25 8/21/25 8/28/25 9/4/25 9/9/25 9/18/25 9/25/25 10/2/25 10/9/25 10/16/25 10/23/25 10/30/25 11/6/25 Progress notes lacked notification to the physician related to Resident 7's significant weight loss. On 11/19/25 at 1:31 P.M., the Director of Nursing (DON) indicated Resident 7 had been on weekly NAR meetings that included herself, the Registered Dietitian (RD), and the dietary manager related to an unexplained significant weight loss. She indicated that if anything needed to be added to the resident's orders, they would communicate with the physician for a consult. She indicated Resident 7 was still currently on weekly NAR meetings as he was having issues with edema, diabetes, and anemia. At that time, she indicated if the physician had been notified of Resident 7's significant weight loss, it was not documented. On 11/21/25 at 9:53 A.M., the Administrator provided a current non-dated Notification of Changes policy that indicated .to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. 3.1-5(a)

Based on observation, interview, and record review, the facility failed to ensure dependent residents, unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 1 residents reviewed for dental services. A resident's dentures were not cleaned or taken out at night as indicated. (Resident 27)Finding includes:On 11/18/25 at 10:19 A.M., Resident 27's family member indicated during visits, she had noticed Resident 27's hygiene to be poor. She indicated due to his cognition, Resident 27 would initially refuse care, and needed encouragement and often more than one attempt before he would agree to care. She indicated some staff would take the initial refusal and move on without trying further to get the care done. On 11/19/25 at 10:10 A.M., Resident 27 was observed sitting in a recliner watching television with the lights off. The resident's mouth and lips were observed with crusty debris. Dentures were not observed at that time. On 11/19/25 at 10:43 A.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, Parkinson's disease, and intellectual disabilities. The most recent quarterly minimum data set (MDS) assessment, dated 8/26/25, indicated a severe cognitive impairment, no behaviors, substantial to maximum (helper does more than half the effort) with oral hygiene, and no dental concerns. Current physician orders included, but were not limited to:May see podiatrist, dentist, audiologist, ophthalmologist, optometrist, dated 9/8/22. No salt packet (NSP) diet, mechanical soft/easy to chew texture, regular (thin liquid) consistency, dated 11/5/24. A current dental care plan, dated 12/16/24 and revised 9/15/25, indicated the resident wore upper and lower dentures. Interventions included, but were not limited to:Provide mouth care as per ADL (activities of daily living) personal hygiene, dated 12/16/24. A dental visit form, dated 1/10/25, indicated Resident 27 had been seen for dental services on 1/9/25. The Registered Dental Hygienist (RDH) indicated on the form, Denture has generalized extremely heavy orange thick mature plaque, heavy thick yellow calculus, and heavy brown staining. Spent 20 minutes cleaning dentures . Denture hygiene is extremely poor . Patient/Staff instructions for Dentures: Remove dentures nightly, soak in water/denture cleaning tablet. Brush with denture brush in a.m. Patient was cooperative. A dental visit form, dated 2/25/25, indicated Resident 27 had been seen for dental services on 2/25/25. The RDH indicated on the form, Denture has heavy plaque present . Pt [patient] states wears all the time and never removes. stressed the importance of cleaning nightly and soaking in water to help with plaque control. A dental visit form, dated 8/19/25, indicated Resident 27 had been seen for dental services the same day. The form indicated poor oral health with heavy plaque and debris. The form also indicated the resident would benefit from staff assistance to remove, clean, and soak dentures every night. On 11/20/25 at 6:39 A.M., Certified Nurse Aide (CNA) 5 indicated that when she assisted Resident 27 to get up that morning, his dentures were in the denture cup, soaking. However, she indicated that it was not always the case, as many times, he still had the dentures in his mouth in the mornings. She indicated that sometimes the dentures were still pretty slimy and covered in debris coming out of the denture cup, so staff should be brushing and/or wiping them with a cloth. On 11/21/25 at 9:53 A.M., the Administrator provided a current non-dated Activities of Daily Living (ADLs) policy that indicated The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care . 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment to help prevent the development and transmission of infections for 1 of 3 residents observed for care. During a dressing change, a wound care Nurse Practitioner (NP) did not remove or change gloves after touching several items and did not wash hands according to policy. (Resident 46)Finding includes: On 11/19/25 at 1:55 P.M., a wound care NP was observed to change a dressing on Resident 46's leg. The NP entered the room along with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) 3. She put on a gown and gloves without washing or sanitizing her hands first. The NP assisted the DON and LPN 3 with rolling the resident to the right side by removing the blanket from the resident and pushing her, touching the back of her gown as well as her skin. The NP then touched the side rail, the curtain, and removed her mobile phone from her pocket, touching the screen. Without removing the gloves, the NP removed the dressings, touching the wound beds with the same gloved hand/finger that was used to touch the other items. The NP continued to touch the screen of her phone in between removing dressings from the wound beds. Once the dressings were all removed, the NP removed her gloves and washed her hands for 3 seconds. She then put on a pair of clean gloves. The NP then assisted in rolling the resident again, touching the sheet and the visibly soiled incontinence pad. She then grabbed the trash can and moved it closer to the bed. She removed her gloves and put on a clean pair without washing or sanitizing her hands, then applied dressings to the wounds. The resident was then rolled back onto her backside on top of the visibly soiled incontinence pad observed with brown, yellow, and red substances. The NP then removed her gloves and washed her hands with a 4-second soap lather. Neither the DON nor LPN 3, who were present for the duration of the care, addressed the actions of the NP during or after the wound care. At that time, the NP indicated she was not the normal NP that was in the facility, and it was her first day there. The NP that was normally there was from the wound care service contracted by the facility and was currently on vacation. She explained she was a travel NP and was filling in that week. She indicated that hand washing should probably last about 20 seconds. She further indicated she needed to view pictures on her phone during the dressing change to view previous assessments of the wounds in order to compare. The NP was responsible for wound care for at least two other residents in the facility who received care from the wound care service.On 10/21/25 at 10:00 A.M., the Infection Preventionist (IP) indicated handwashing should last 40-60 seconds, with hand scrubbing no less than 20 seconds. She indicated that if any items, such as the bed or a phone, were touched with gloves on, staff should change gloves before touching the resident, and staff should never lay a resident on a soiled incontinence pad. She indicated that anytime staff soiled their gloves, they should wash their hands or sanitize them after removing them and before putting on a clean pair. On 11/21/25 at 9:53 A.M., the Administrator provided a current non-dated Hand Hygiene policy that indicated All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand hygiene technique when using soap and water: . Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. 3.1-18(b)3.1-18(l)

Based on observation and interview, the facility failed to ensure a clean and homelike environment for 6 of 13 resident rooms and 1 of 2 shower rooms observed for environment. Bathrooms had holes in the wall, exposed pipes, a baseboard peeling off, uncovered bedpans, and a floor that was badly scuffed. An air condition unit was falling off the wall in a room. Multiple sink water temperatures were higher then 120 degrees. (Rooms 136, 139, 138, 140, 141, 143, East Shower Room) Findings includes: 1. During an observation on 8/5/24 at 1:39 P.M., room [ROOM NUMBER]'s bathroom was observed with the baseboard behind the toilet peeling off and the floor had multiple scuffs. The water temperature was 120.8 degrees Fahrenheit. At that time, the resident indicated the water was hot but denied being burned. During an observation on 8/9/24 at 11:06 A.M., the same was observed but the water temperature was not rechecked. 2. During an observation on 8/5/24 at 1:50 P.M., room [ROOM NUMBER]'s water temperature was 123.3 degrees Fahrenheit. 3. During an observation on 8/5/24 at 1:52 P.M., room [ROOM NUMBER]'s wheelchair had food debris covering the seat and on the wheels. The water temperature was 122.9 degrees Fahrenheit. At that time, the resident indicated the water was plenty warm but denied being burned. During an observation on 8/9/24, the same was observed but the water temperature was not rechecked. 4. During an observation on 8/5/24 2:05 P.M., room [ROOM NUMBER]'s water temperature was 124.2. At that time, the resident indicated they hardly used it. 5. During an observation on 8/5/24 at 2:07 P.M., room [ROOM NUMBER]'s bathroom had a soap dispenser was not adhered to the stickers by the sink and was sitting on the back of the toilet. An uncovered bed pan was sitting on the floor between the sink and the toilet. In the room, the air conditioner unit was falling off of the wall on the left side. The water temperature was 127.5 degrees Fahrenheit. At that time, the resident indicated they used the sink water sometimes but denied being burned. During an observation on 8/9/24 at 11:05 A.M., the same was observed but the water temperature was not rechecked. 6. During an observation on 8/5/24 at 2:13 P.M., room [ROOM NUMBER]'s bathroom had 2 uncovered graduated cylinders with a syringe in one and multiple cups on the countertop of the sink, a plate and two bowls with silverware were in the sink. There were two holes in the wall behind the toilet with pipes visible and 8 clean uncovered wash cloths on top of the paper towel holder. The water temperature was 123.6 degrees Fahrenheit. At that time, the resident indicated he hardly used the water from the sink, but a visitor with him indicated it gets hot pretty quick. During an observation on 8/9/24 at 10:59 A.M., there were still 2 uncovered graduated cylinders with a syringe in one and multiple cups on the countertop of the sink and two holes in the wall behind the toilet with pipes still visible. The water temperature was not rechecked. 7. During an observation on 8/5/24 at 4:00 P.M., the East Hall Shower Room's water temperature was 120.7. During an interview on 8/5/24 at 3:26 P.M., the Maintenance Assistant indicated he checked the water temperatures in the rooms at the end of the halls around 6:30 A.M. every weekday morning. He expected the room water temperatures to be between 110 and 120 degrees Fahrenheit. At that time, he indicated the water lines were in the attic and with the hot temperatures outside, it could cause the water temperatures to elevate some. The East Hall is closest to the water heater. He hasn't been notified of any concerns with the water temperatures recently from staff or residents. During an observation on 8/5/24 from 3:39 P.M. to 4:00 P.M., the Maintenance Assistant checked the water temperatures on the East Hall and indicated the following: room [ROOM NUMBER] - 119-120 degrees Fahrenheit room [ROOM NUMBER] - 119-120 degrees Fahrenheit room [ROOM NUMBER] - 119-120 degrees Fahrenheit room [ROOM NUMBER] - 120 degrees Fahrenheit room [ROOM NUMBER] - 124 degrees Fahrenheit room [ROOM NUMBER] - 119-120 degrees Fahrenheit room [ROOM NUMBER] - 119 degrees Fahrenheit East Hall Shower Room - 120 degrees Fahrenheit During a resident council meeting on 8/7/24 at 2:12 P.M., 3 random residents from the [NAME] Hall indicated their water was usually cold and took almost 15 minutes to warm up enough sometimes. One random resident from the East Hall indicated his water was pretty hot but he had never burned himself with it. On 8/8/24 at 2:05 P.M., CNA (Certified Nurse Aide) 55 was observed saying That's hot referring to the water when she was washing her hands after performing incontinence care in room [ROOM NUMBER] on the East Hall. During an interview on 8/9/24 at 1:50 P.M., the Maintenance Assistant indicated he had that thermometer about a year and didn't know if it's ever been calibrated. He indicated he did turn up the temperature in the [NAME] Hall a smidge but did nothing to East Hall. On 8/5/24 at 3:35 P.M., the Maintenance Assistant provided the log book documentation from 7/1/24-8/5/24 excluding weekends and in the Steps to Test Water Temperatures, it indicated . the dial thermometer is accurate to 1 to 2 degrees Fahrenheit - however it is not precision instrument and should be calibrated on a regular basis . For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes . On 8/8/24 at 11:30 A.M., a current non dated Safe Water Temperatures Policy was provided by the Director of Nursing (DON) and indicated . Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperature . to the supervisor and/or maintenance staff . water temperatures will be set to a temperature of no more then 120 degrees Fahrenheit . On 8/9/24 at 3:55 P.M., a current non dated Safe and Homelike Environment Policy was provided by the Regional Nurse and indicated . the facility will provide a safe, clean, comfortable and homelike environment . On 8/9/24 at 3:55 P.M., a current non dated Cleaning and disinfection of Resident Care Equipment Policy was provided by the Regional Nurse and indicated . Reusable resident care equipment will be cleaned and disinfected . Direct care staff are responsible for cleaning single-resident equipment when visibly soiled . This citation relates to Complaint IN00437005. 3.1-19(e)

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessments were completed for 2 of 5 residents reviewed for unnecessary medications, 1 of 1 reviewed for hospice, 1 of 1 reviewed for dialysis, and 1 of 1 reviewed for smoking. The MDS Assessment indicated a resident received an anticoagulant but did not, a resident with the diagnosis of PTSD (Post Traumatic Stress Disorder) was marked as not having it, a resident with a diagnosis of schizoaffective disorder was marked as not having it, a resident with the diagnoses of anxiety and depression was marked as not having them, and a resident that did not have a diagnosis of atrial fibrillation was marked that she did have it. (Resident 35, Resident 43, Resident 11, Resident 1, Resident 23) Findings include: 1. On 8/6/24 at 1:32 P.M., Resident 35's clinical record was reviewed. Diagnosis included, but was not limited to dementia, atherosclerotic heart disease, and chronic systolic heart failure. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 6/25/24, indicated Resident 35 had severe cognitive impairment and administered an antianxiety, antidepressant, anticoagulant and antiplatelet during the 7 day look back period. Current Physician's Orders included, but were not limited to, the following: Aspirin EC (Enteric Coated) Tablet Delayed Release (antiplatelet medication) 81 mg (milligrams), give 1 tablet by mouth one time a day for STEMI (ST-elevation myocardial infarction) related to atherosclerotic heart disease of native coronary artery without angina pectoris, dated 6/17/24 Plavix Oral Tablet (antiplatelet medication) 75 mg, give 1 tablet by mouth one time a day for antiplatelet related to atherosclerotic heart disease of native coronary artery without angina pectoris, dated 6/20/24 alprazolam Oral Tablet (antianxiety medication) 0.25 mg, give 1 tablet by mouth two times a day related to anxiety disorder, dated 6/27/2024 trazodone HCl (hydrochloride) Oral Tablet (antidepressant medication) 50 mg, give 1 tablet by mouth two times a day related to depression, dated 6/26/2024 During an interview on 8/9/24 at 1:46 P.M., the Regional Nurse indicated the MDS Coordinator was out of the building at that time, but would have coded the aspirin as an anticoagulant and Plavix as an antiplatelet medication. 46416 2. On 8/6/24 at 1:31 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and depression. The most recent Admission MDS Assessment, dated 6/6/24 indicated Resident 1 was cognitively intact and did not have anxiety or depression. Resident 1's care plans included, but were not limited to, the following: I have a diagnosis of anxiety, initiated 6/3/24 I have a diagnosis of depression, initiated 6/3/24 During an interview on 8/9/24 at 3:28 P.M., the Regional Nurse indicated anxiety and depression were active diagnoses on Resident 1's list of diagnoses and should have been marked on the MDS Assessment. 3. On 8/7/24 at 11:13 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. The most recent Admission MDS (Minimum Data Set) Assessment, dated 7/25/24, indicated that the resident was cognitively intact and did not have PTSD. Resident 11's care plans included, but were not limited to, the following: I have a history of trauma related to being robbed at gunpoint. I have PTSD from the event and nightmares. I take psychoactive medication, initiated 7/19/24 During an interview on 8/9/24 at 3:28 P.M., the Regional Nurse indicated Resident 11 should have had PTSD marked on the MDS Assessment if he had a care plan related to it. 4. On 8/9/24 at 9:47 A.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, asthma, diabetes mellitus type II, depression, hyperlipidemia, hypertension, and hypothyroidism. The most recent Significant Change MDS Assessment, dated 7/9/24 indicated Resident 23's cognition was severely impaired and had a diagnosis of atrial fibrillation. Resident 23's clinical record lacked documentation of atrial fibrillation as a diagnosis. During an interview on 8/9/24 at 3:28 P.M., the Regional Nurse indicated if the resident didn't have atrial fibrillation as an active diagnosis, then it should not be marked on the MDS Assessment. 5. On 8/7/24 at 3:55 P.M., Resident 43's clinical record was reviewed. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease, anxiety, depression, and schizoaffective disorder. The most recent Admission MDS Assessment, dated 6/21/24 indicated Resident 43's cognition was moderately impaired, used tobacco and did not have schizophrenia. Resident 43's care plans included, but were not limited to, the following: I have a level two determination due to diagnosis of Schizoaffective Disorder, Anxiety disorder, Depressive disorder and Polysubstance Abuse . , initiated 6/22/24 During an interview on 8/9/24 at 3:28 P.M., the Regional Nurse indicated schizoaffective disorder was on Resident 43's diagnosis list and it should have been marked on the MDS Assessment. The High-Risk Drug Classes: Use and Indication section of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, was reviewed and indicated . Do not code antiplatelet medications such as aspirin/extended release, dipyridamole [[NAME]], or clopidogrel [Plavix] as N0415E, Anticoagulant During an interview on 8/9/24 at 3:28 P.M., the Regional Nurse indicated she would expect the active diagnoses of residents to be accurate and to be reflected on the MDS Assessment accurately. At that time, she indicated there was no policy for an MDS Assessment, but they used the RAI manual.

Based on observation, interview, and record review, the facility failed to ensure necessary care and complete assessments were provided for 1 of 1 residents reviewed for dialysis. The medical record lacked post dialysis assessment documentation. The facility also lacked a current dialysis contract at the time of the survey. (Resident 11) Findings include: On 8/7/24 at 11:13 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. Resident 11 was admitted [DATE]. The most recent Admission MDS (Minimum Data Set) Assessment, dated 7/25/24, indicated that the resident was cognitively intact and on dialysis. Current Physician's Orders included, but were not limited to, the following: Dialysis treatment on Monday, Wednesday, Friday at 11:45 A.M. (Name, address, and phone number of dialysis facility). Complete pre-dialysis form, ordered 7/23/24 Post dialysis assessment. Assess site for signs/symptoms of bleeding, infection, post dialysis complications. Notify MD (Medical Doctor) of any abnormal changes. Every day shift every Monday, Wednesday, Friday for monitoring, ordered 7/19/24 A current Dialysis Care Plan, dated 7/22/24, included, but was not limited to, the following interventions: Observe and document post-dialysis: vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache, severe leg cramps. Report abnormalities to MD. Resident 11's progress notes were reviewed from 7/18/24 through 8/6/24 and lacked documentation of the time the resident returned from dialysis, time of post dialysis vital signs including temperature, HR (pulse/heart rate), BP (blood pressure), and pain. The progress notes lacked post dialysis assessment of the access site, mental status, heart, edema (swelling)/redness/skin concerns, and symptoms post dialysis. Resident 11's vitals were reviewed and lacked documentation of post dialysis vitals including temperature, HR, BP, and pain. Resident 11's MAR (Medication Administration Record) was reviewed from 7/19/24 through 8/6/24 and lacked post dialysis assessment documentation. On 8/8/24 at 11:30 A.M., all dialysis/observation communication forms for Resident 11 were provided by the DON (Director of Nursing) and indicated the following: 7/22 post dialysis assessment section was not completed 7/24/24 post dialysis assessment section was not completed 7/26 post dialysis assessment section was not completed There was no form provided for 7/31/24 7/29/24 post dialysis assessment section was not completed 8/2/24 post dialysis assessment included resident's name, time completed, time returned from dialysis, temperature, HR (pulse/heart rate), BP (blood pressure), and pain but lacked assessment of access site, mental status, heart, edema/redness/skin concerns, and symptoms post dialysis. 8/5/24 post dialysis assessment included the temperature, HR, and BP, but lacked resident's name, time completed, time returned from dialysis, and assessment of pain, access site, mental status, heart, edema/redness/skin concerns, and symptoms post dialysis. 8/6/24 post dialysis assessment section was not completed 8/7/24 post dialysis assessment section was not completed On 8/5/24 at 9:50 A.M., during the entrance conference, a current dialysis contract was requested but not provided. During an interview on 8/7/24 at 2:40 P.M., LPN (Licensed Practical Nurse) 44 indicated staff was to fill out the pre assessment section of the dialysis form with the vitals and pre-assessment, then the form was taken to dialysis with the resident where their staff filled out the middle section of form with vitals and assessment during dialysis period, and sent the form back with the resident. When resident returned to the facility, staff should do post dialysis vitals, assess the fistula site, and fill out the post dialysis assessment section of the form. The form should get scanned into the resident's clinical record after it was completed. During an interview on 8/9/24 at 2:18 P.M. the DON indicated Resident 11 was scheduled for dialysis on Monday, Wednesday, and Friday at around noon and returned around 6:00 P.M. to the facility. At that time, she indicated staff should take the resident's vitals and assessments that were asked for on the dialysis form every time resident went to dialysis. She would expect the post dialysis assessment to be completed within 30 minutes after arriving back to the facility. She indicated ideally they would fill out the dialysis form entirely but it would be ok if they put pre and post vitals and assessments under the vitals section or the progress notes in the clinical record as well as scanned the form into the clinical record when completed. During an interview on 8/7/24 at 2:45 P.M., the Administrator indicated the facility did not have a current contract for (Name of dialysis company). On 8/7/24 at 3:08 P.M., a current non dated Hemodialysis Policy was provided by the Administrator and indicated . The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility .documentation requirements are met to assure that treatments are provided .monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment .5. the licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form, that will include, but not limit itself to, a. timely medication administration (initiated, held or discontinued) . b. physician/treatment orders, laboratory values, and vital signs. c. Advanced directives and code status . d. nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions . f. dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring and/or concerns related to the vascular access site. g. Changes and/or declines in condition unrelated to dialysis . 8. the nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding and other complications . 12 . There must be a systematic approach between the facility and the dialysis facility when handling situations where the resident has a condition change and/or becomes ill or unstable during dialysis . 14. The nurse will ensure that the dialysis access site (e.g. Arteriovenous fistula) is checked before and after dialysis treatments and every shift for patency . 3.1-37(a)

Based on observation, interview, and record review the facility failed to accommodate resident needs for 2 of 13 residents reviewed for call lights within reach. One resident failed to have an available call system in her room and one resident's call light was not within reach. (Resident 26, Resident 38) Findings include: 1. On 8/5/24 at 1:45 P.M., Resident 26 was observed sitting up in a recliner with her call light lying on the floor next to the dresser. On 8/8/24 at 9:47 A.M., Resident 26 was observed sitting up in a recliner with her head covered with a blanket and the call light lying on the floor next to the dresser. On 8/8/24 at 2:45 P.M., Resident 26 was observed sitting in her recliner while the call light was lying on the floor next to the dresser. On 8/9/24 at 11:20 A.M., Resident 26's medical records were reviewed. Diagnosis included, but was not limited to non-Alzheimer's dementia, lymphedema, chronic atrial fibrillation, and heart failure. The most recent Annual and State-Optional MDS (Minimum Data Set) Assessment, dated 7/2/24, indicated Resident 26 was severely cognitively impaired, needed supervision of one for bed mobility, transfers, eating and toilet use. The care plan for potential for physical functioning deficit related to: Mobility impairment due to diagnosis of lymphedema, and morbid obesity. Self care impairment r/t (related to) diagnosis of dementia, unsteady gait, muscle weakness, cognitive communication deficit, dated 4/22/2024. Interventions included, but was not limited to call bell within reach. During an interview on 8/9/24 at 9:31 A.M. CNA (Certified Nurse Aide) 14 indicated Resident 26 was able to use the call light and the call lights should be kept within reach of the residents. 2. On 8/7/24 at 9:32 A.M Resident 38 was observed lying in bed watching TV with no call light in reach. and unable to see a Wander Guard. On 8/7/24 at 9:45 A.M., CNA 14 entered Resident 38's room to locate the Wander Guard on her left ankle and was unable to locate it. At that time, CNA 14 indicated they were unable to keep a call light in her room due to her throwing things at the staff and breaking things like the clock, window and dresser. Due to Resident 38 becoming agitated that she was being disturbed while watching TV, CNA 14 left the room and notified LPN (Licensed Practical Nurse) 26 that the Wander Guard was no longer on Resident 38's ankle. On 8/8/24 at 9:38 A.M., Resident 38 was observed lying in bed watching TV (television) with a Wander Guard on left ankle and no call device in her room. On 8/9/24 at 9:26 A.M. Resident 38 was observed lying in bed watching TV with a Wander Guard on left ankle and no call device in her room. On 8/6/24 at 3:12 P.M., Resident 38's Medical Records were reviewed. She was admitted on [DATE]. Diagnosis included, but were not limited to dementia with behavioral disturbance, delusional disorders, anxiety disorder, and major depressive disorder. The most current Significant Change MDS (Minimum Data Set) Assessment, dated 6/27/24, indicated Resident 38 had a moderate cognitive impairment, needed supervision of one for bed mobility, transfer, eating and extensive assistant of one for toilet use. Behaviors indicated Resident 38 had verbal behavioral symptoms directed toward others on 1-3 days. Resident rejected evaluation or care on 4-6 days. Wander/elopement alarm was used daily. The Physician orders included, but were not limited to the following: Check placement and function of device every shift. Record location of device. Replace device if device is not working. Change device one month prior to expiration date. Wander Guard applied to (Location) left ankle, dated 7/15/24 A current ADL (Activities of Daily Living) Care Plan dated 4/19/24, included, but was not limited to the following intervention: Call bell within reach, dated 4/19/24. A current Wandering/Elopement Care Plan, dated 6/24/24, included, but was not limited to the following intervention: Test my Wander Guard every shift for placement/function. Left ankle, dated 4/19/24. A current Elopement Risk Care plan related to: Anger at placement in living center, attempts to leave Living Center, hx (history) of breaking window trying to escape/leave, dated 6/13/2024, included, but was not limited to, the following intervention: Remove all items that are a potential for breaking glass/window, dated 6/7/24. The TAR (Treatment Administration Record) for August 2024 was reviewed and indicated the placement and function of the Wander Guard had been checked every shift from 8/1/24 through 8/6/24. the placement and function of the Wander Guard had not been checked for the day shift on 8/7/24. During an interview on 8/7/24 at 1:44 P.M., LPN 26 indicated Resident 38 had calmed down and she had a new Wander Guard on her left ankle. LPN 26 indicated Resident 38 used to have a cowbell in her room since they couldn't keep a call light in her room. She was not sure what happened to the cowbell, but Resident 38 was incontinent so they checked her frequently. The clinical record lacked documentation of times Resident 38 was checked on by staff. During an interview on 8/8/24 at 1:28 P.M., LPN 26 indicated the Wander Guard was checked by the nurse with a box that checks the function. She indicated the Wander Guard was checked first thing of the morning when passing medication. This was done every shift. On 8/9/24 at 2:23 P.M., the Administrator provided a Call Lights: Accessibility and Timely Response Policy, dated 2023, which indicated .5. Staff will ensure the call light is within reach of resident and secured . On 8/9/24 at 2:23 P.M., the Administrator indicated they did not have a policy for the Wander Guard or following orders, but indicated it was their policy to follow provider's orders and care plan interventions. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure treatment orders were put in place, and weekly wound measurements were done for 1 of 3 residents reviewed. A treatment order for wounds was not put in place, wound measurements not documented weekly. (Resident B) Finding includes: On 11/15/23 at 12:15 p.m., Resident B's clinical record was reviewed. They had diagnoses that included, but were not limited to, chronic osteomyelites, left ankle and foot, type 2 diabetes mellitus with foot ulcer. Resident B admitted to the facility on [DATE] and discharged on [DATE]. An admission MDS (Minimum Data Set), assessment dated [DATE] indicated Resident B's cognition was intact and had diabetic foot ulcers. Care plans were reviewed and included, but were not limited to: I have chronic osteomyelitis to left foot and ankle. I am receiving IV antibiotic therapy date initiated 6/27/23. Interventions included, but not limited to: treatments as ordered, date initiated 6/27/23. I have diabetic foot ulcers to my left foot r/t dx of diabetes, date initiated 6/27/23. Progress notes were reviewed and included, but were not limited to: Date of service: 6/29/23 4:36 p.m., Visit Type: skin and wound note Details: [name of wound care provider] .patient has chronic diabetic foot ulcers to his left foot, patient states these wounds have been present since 2021 and is an established patient with his podiatrist who has been managing his wounds. Patient acutely diagnosed with osteomyelitis in his left great toeand(sic) left fifth toe. Patient under went TMA to right 1-5 toes due to osteomyelitis previously. Patient has a right upper arm picc line and is receiving 6 weeks of IV abx . Wound assessment: . 1. Left planter foot diabetic foot ulcer: calloused periwound, no odor, no drainage, 100% granulation tissue 2 cm L x 3 cm W x 0.2 D. 2. Left lateral fifth toe diabetic foot ulcer: calloused periwound, no odor, no drainage, 100% epithelial tissue 0.8 cm L x 0.5 cm W x 0.1 cm D. 3. Left lateral diabetic foot ulcer #1: calloused periwound, no odor, no drainage, 100% epithelial tissue 1 cm L x 1 cm W x 0.1 cm D. 4. Left lateral foot diabetic ulcer #2 calloused periwound, no odor, no drainage, 100% epithelial tissue 1.5 cm L x 1.0 cm W x 0.1 D. .Plan: Cleanse with wound cleanser. Apply betadine paint to diabetic foot ulcers on left foot daily and apply non-adherent, wrap with kerlix until follow up appointment with patients podiatrist 7/5 . Preventative Measures: The patient has a diabetic ulcer. Wound care discussed with the staff at the time of the visit. The patient needs offloading to the area of foot ulcer, glycemic control, and routine wound dressing management . New Recommendations: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments. Please follow up with podiatrist on 7/5 . A progress note date 7/26/23 at 3:53 p.m., indicated This nurse spoke with [name] clinical manager at [name ] Wound Care Center regarding resident's appointments. She informed this nurse that the resident has not been seen at office since May, 17, 2023. Resident has been making own appointments per his request during his stay and was informed by resident that he had an appointment on July 5, 2023 at wound center. Wound Care Center stated that he has missed multiple appointments during his treatment. Wound Center did inform this nurse that he does have an appointment scheduled for Wed August 2, 2023. Skin evaluation documentation was reviewed and the following dates indicated Resident B was seeing wound care: 7/7/23, 7/14/23, 7/21/23, 7/28/23, 8/2/3, The following skin evaluations did not have recorded measurements: 7/3/23, 7/14/23, 7/21/23, 7/23/23, On 11/16/23 at 11:06 a.m., the DON indicated Resident B refused any care to his feet, he had his own dressings in his room and did his own foot care, he had given his wound clinic appointments to the nurse, they had been put in the appointment book, but the book had been stolen twice during his stay from behind the nurses desk and she had no proof they were put in the book. The MDS Coordinator had told her they put in his care plans his non compliance with letting nursing staff to help with his treatments, but when she looked it was not in the care plans, the MDS Coordinator was no longer employed at the facility. The DON indicated when nursing staff do weekly skin assessments they are supposed to put measurements in weekly of wounds, she had asked the resident when he came back from his appointments if he had any paperwork, he said no, she had called the wound clinic and they did not call her back until 7/26/23 and that is when she found out he missed his 7/5/23 appointment, she had let his physician know he had not been going to his wound clinic appointments but she was unsure what day she notified the physician but she was sure it was that day or close to it. She indicated when a resident has an appointment it is supposed to be put in PCC(Point Click Care), and had not been put in the computer. The DON indicated Resident B left the facility saying he was going to his appointments and had his own transportation. On 11/16/23 at 12:34 p.m., LPN 1 indicated she had only taken care of Resident B for a short time, he only allowed certain nurses to do his foot care, he was very non compliant. On 11/16/23 at 1:23 p.m., the DON indicated the order from the wound care provider evaluation on 6/29/23 must have been missed. There was no documentation in the clinical record of Resident B doing his own treatments, being non compliant with treatments to his wounds, or the DON notifying the physician that Resident B had missed his wound clinic appointments. On 11/16/23 at 1:11 p.m., the DON provided the current policy on wound treatment management with a copyright date of 2022. The policy included, but was not limited to, .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . On 11/16/23 at 1:11 p.m., the DON provided the current policy on consulting physician/practitioner orders with a copyright date of 2023. The policy included, but was not limited to, .1. Consulting physician/practitioner orders are those order provided to, the facility by physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to a resident's : .c. wound clinic physician .2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. call the attending physician to verify the order. b. Document the verification order by entering the order and the time, date, and signature on the physician order sheet . c. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record . This citation relates to Complaint IN00415321. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure staff had the skills, experience, and knowledge to provide care related to PICC (peripherally inserted central catheter) line services for 2 of 2 residents with PICC lines. Residents did not receive antibiotics as ordered by the physician, lab results were not obtained timely, and staff was not in-serviced to provide PICC line care. (Resident C, Resident D) Findings include: 1. During an observation on 8/2/23 at 9:20 A.M., Resident C was observed in his room with a PICC line placed in his right upper arm. On 8/2/23 at 11:45 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to osteomyelitis left foot and diabetes mellitus type II. The most recent admission MDS (Minimum Data Set) Assessment, dated 6/20/23, indicated resident was cognitively intact and receiving IV (intravenous) medication. Current physician's orders included, but were not limited to, the following: Vancomycin HCl (antibiotic) IV solution, give 2000 mg (milligrams) IV every morning and at bedtime related to type II diabetes mellitus with foot ulcer until 8/5/23, dated 6/27/23 Vanco (Vancomycin) trough (level) lab to be drawn as directed related to vanco level monitoring, dated 6/27/23 A current PICC line care plan, dated 6/27/23, included, but was not limited to, the following intervention: Administer medications as ordered, observe for side effects and effectiveness, report to MD (medical doctor) adverse effects or ineffectiveness, initiated on 6/27/23 Resident C's July 2023 MAR (Medication Administration Record) indicated resident missed the following doses of Vancomycin: 7/15/23 8:00 A.M. 7/15/23 8:00 P.M. 7/16/23 8:00 A.M. 7/16/23 8:00 P.M. 7/17/23 8:00 A.M. Progress notes were reviewed and included the following: 7/15/23 5:00 A.M. Called [name of lab] to verify order received for vanc trough, bmp [basic metabolic profile lab test] this morning at 0700 [7:00 A.M.] [name of lab] states received order and will be in to draw vanc trough before next scheduled dose of vancomycin 7/16/23 9:40 P.M. Resident's Vanco continues to be on hold due to labs . 7/17/23 8:30 AM. Vanc [Vancomycin] Trough faxed to [name of pharmacy]. [Name of doctor] notified of Vanc Trough results for review 7/17/23 4:09 P.M. Vancomycin 2000 mg BID [twice daily] to be resumed at 2000 per [name of doctor] Vancomycin trough lab tests were reviewed and included, but were not limited to, the following results: Vancomycin trough collection date 7/15/23 at 6:19 A.M. Vancomycin trough received date 7/15/23 at 2:01 P.M. Vancomycin trough reported date 7/15/23 at 2:32 P.M. During an interview on 8/3/23 at 11:05 A.M., RN (Registered Nurse) 4 indicated they were not working the weekend of 7/15/23 and 7/16/23 so they weren't sure why the resident did not get their antibiotic. They indicated the lab results are sent back when completed and the nurses have access to view them. If the lab results were not back timely, they would have called the lab to find out if the results were completed and called the doctor so the resident would not have missed a dose of their antibiotic. During an interview on 8/3/23 at 1:40 P.M., the DON (Director of Nursing) indicated she was not working the weekend of 7/15/23 and 7/16/23 and she wasn't sure why the resident missed doses of their antibiotic. She indicated staff should have called the lab for the results and the doctor if they weren't back when the resident was due for his dose. At that time, she indicated 2 days was too long to wait for vancomycin trough results. 2. During an observation on 8/2/23 at 9:30 A.M., Resident D was observed in his room with a PICC line placed in his right antecubital fossa (inner elbow). On 8/1/23 at 1:30 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, osteomyelitis left foot and diabetes mellitus type II. The most recent admission MDS Assessment, dated 7/17/23, indicated resident was cognitively intact and receiving IV medication. Current physician's orders included, but were not limited to, the following: Daptomycin (antibiotic) IV solution, use 900 mg one time a day for wound infection for 28 days, dated 7/11/23 A current PICC line care plan, dated 7/12/23, included, but was not limited to, the following intervention: Administer medications as ordered, observe for side effects and effectiveness, report to MD adverse effects or ineffectiveness, dated 7/12/23 Resident D's July 2023 MAR indicated resident missed doses of Daptomycin on the following dates: 7/15/23 8:00 A.M. 7/16/23 8:00 A.M. Progress notes were reviewed and lacked documentation about missing doses of the antibiotic. On 8/3/23 at 1:35 P.M., in-services for PICC line care were requested. At that time, the DON (Director of Nursing) indicated there were no in-services given to staff for PICC line services. During an interview on 8/3/23 at 11:05 A.M., RN 4 indicated they were not working the weekend of 7/15/23 and 7/16/23 so they weren't sure why the resident did not get their antibiotic. If they are ordered by the physician, then they should be given as ordered. During an interview on 8/3/23 at 1:40 P.M., the DON indicated she was not working the weekend of 7/15/23 and 7/16/23 and she wasn't sure why the resident missed doses of their antibiotic. On 8/3/23 at 2:15 P.M., a current notification of lab results policy was requested. At that time, the DON indicated there was not a specific policy describing timelines that staff were to obtain Vancomycin trough results if they were not provided via the electronic system or getting an order from the physician, but she would expect a Vancomycin trough to be returned at least the same day and if results weren't available on the electronic system, then staff should contact the lab for them and if they didn't hear back from the doctor timely, they should call them for an order. On 8/3/23 at 2:15 P.M., a current following physician orders policy was requested. At that time, the DON indicated there was not a policy but it was the facility policy for staff to follow physician orders. On 8/3/23 at 3:00 P.M., a current qualified staff policy was requested. At that time, the Regional Director indicated there wasn't a specific policy but staff should have been in-serviced on PICC line care if there were residents with PICC lines residing at the facility. This Federal tag relates to complaint IN00413866. 3.1-35(g)(2)

Based on observation and interview, the facility failed to ensure infection control practices were in place during 2 of 4 resident medication administrations and 2 of 4 residents observed during incontinence care. Staff failed to sanitize hands and change gloves between dirty to clean tasks. Staff did not sanitize hands between residents during medication administration. (Resident 21, Resident 12, Resident 25, Resident 30) Findings include: 1. During an observation on 6/21/23 at 10:17 A.M., QMA (Qualified Medication Aide) 3 and CNA (Certified Nurse Aide) 7 performed incontinence care on Resident 21. Upon entering the room, both aides put gloves on. QMA 3 stood on the left side of bed and CNA 7 on right side of bed. QMA 3 took blankets off resident and placed them on the chair while CNA 7 raised the bed with the controller. QMA 3 opened the bathroom door and went into the bathroom to get a bedpan. Resident 21 was laying on her back and both aides unfastened her incontinence pad then rolled the resident to her right side and CNA 7 held the resident there while QMA 3 placed the bedpan under the resident. QMA 3 took off her gloves and put on new gloves before she raised the head of the bed to make the resident more comfortable then removed her gloves. CNA 7 lowered the head of the bed. QMA 3 and CNA 7 rolled Resident 21 onto her right side again. CNA 7 held the resident on her right side while QMA 3 took the bedpan out from underneath the resident, took it into the bathroom and dumped the urine into toilet, touched the facet handles, rinsed out the bedpan, flushed the toilet, and put bedpan into a bag and under the sink then closed the bathroom door. QMA 3 took off gloves and put on new gloves without sanitizing hands. Resident 21 was rolled to left side and CNA 7 wiped across Resident 21's buttocks only with a wet cloth, took off gloves and put on new gloves without sanitizing. Resident was rolled on her right side and CNA 7 held her while QMA 3 placed a new incontinence pad and bed pad under the resident and applied barrier cream to her buttocks. QMA 3 removed right glove and put on new right glove without sanitizing hands. Resident was rolled to her back. CNA 7 grabbed the new brief out from resident's right side, took off gloves, sanitized hands, and put on new gloves. QMA 3 took a wet cloth, and while CNA 7 held her right leg, QMA 3 wiped across the creases of the legs and lower abdomen. With the same cloth, QMA 3 wiped vaginal area. CNA 7 pulled the incontinence pad up between the resident's legs while QMA 3 applied cream to the left upper leg. Both aides fastened the incontinence brief. Both aides removed their gloves. CNA 7 sanitized her hands. QMA 3 grabbed 2 pillows and blanket from the chair and put the pillows under resident's legs and the blanket back over the resident. CNA 7 lowered the bed. QMA 3 went into the bathroom and washed hands. CNA 7 pulled privacy curtain open and then went into the bathroom to wash her hands with a 15 second lather. 2. During an observation on 6/21/23 at 10:17 A.M., QMA 3 and CNA 30 performed incontinence care on Resident 12. Upon entering the room, both aides put on gloves. QMA 3 closed the door and pulled the privacy curtain. CNA 30 used the controller to raise the bed. The resident was laying on his back in bed. Both aides unfastened the incontinence pad. QMA 3 stood on the right and CNA 30 on the left of the bed. They rolled resident to his left side. The resident had loose BM (bowel movement) in his incontinence pad. QMA 3 wiped backside first with a soapy wet wash cloth folding as she went, put the soiled cloth into trash bag, wiped again in the same manner then took off gloves and put on new gloves without sanitizing hands. QMA 3 placed new bed pad and new incontinence pad under the resident then applied barrier cream to buttocks with right glove, took off that glove put on new glove without sanitizing. The resident was rolled onto back. QMA 3 grabbed a new wet cloth to wipe down penis and scrotum. The cloth was soiled with BM, folded the cloth, and wiped the penis again with the BM touching the head of the penis. QMA 3 removed her gloves. Both aides fastened the incontinence pad. CNA 30 took off gloves and put new gloves on without sanitizing. QMA 3 put on new gloves without sanitizing. Resident was rolled to his right side. CNA 30 pulled the bed pad and incontinence brief out from under the resident and then rolled him to his back. CNA 30 took shirt off and pulled over left shoulder. QMA 3 grabbed the shirt and pulled it over the resident's head, took off O2 (oxygen) tubing pulled off shirt, and put on O2 nasal cannula tubing back into the resident's nose. They put a gown on the resident and CNA 30 took off her gloves and covered the resident up with blanket. QMA 3 dumped pan of water in the bathroom sink and then took off gloves. QMA 3 moved bedside table back to the side of the resident without sanitizing it and placed the call light in the resident's reach. During an interview on 6/22/23 at 10:15 A.M., QMA 3 indicated when doing incontinence care, she would first set up the room by opening and putting trash bags in the room for soiled linens and the soiled incontinence pad, get supplies ready-incontinence brief, wipes or cloths or dishpan and soap if needed. She would tell the resident what she was going to do. She would clean the front side first, get a different cloth then do backside. She would clean the resident, pull the soiled incontinence pad out, put clean incontinence pad and bed pad under the resident, roll them, and pull clean pads through. QMA 3 indicated hands should be sanitized before new gloves are put on and that gloves should be changed anytime they are soiled. Hands should be washed before leaving the resident's room for 20-30 seconds. 3. During an observation on 6/21/23 at 7:05 A.M., LPN (Licensed Practical Nurse) 18 was observed passing medications to Resident 25. After administering 12 medications from the medication cup into the resident's mouth, LPN 18 washed her hands in the resident's bathroom with a 4 second lather. Resident 25 asked LPN 18 to adjust her bed and after doing so, LPN 18 went back into the bathroom and washed her hands with a 12 second lather. She did not sanitize her hands before getting the next resident's medications ready. 4. During an observation on 6/21/23 at 7:20 A.M., LPN 18 was observed passing medications to Resident 30. After administering 5 medications from the medication cup and helping the resident drink 1/2 of her Miralax, LPN 18 washed her hands in the resident's bathroom with a 14 second lather. During an interview on 6/22/23 at 3:30 P.M., the ADON (Assistant Director of Nursing) indicated the nurse was supposed to perform hand hygiene before the start of the medication pass and when leaving the resident's room. During an interview on 6/22/23 at 10:45 A.M., the DON indicated staff need to change gloves between dirty to clean tasks, before and after touching a resident, and before and after medication passes. At that time, she indicated during incontinence care, the front of the resident should be cleaned first and then the backside of the resident. A current undated hand hygiene policy was provided by the DON on 6/22/23 at 11:50 A.M., and indicated . All staff will perform proper hand hygiene procedures to prevent the spread of infection . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . 5. Hand hygiene technique when using soap and water: a. Wet hands with water . b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for 20 seconds, covering all surfaces of the hands and fingers d. Rinse hands with water . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning [putting on] and immediately after removing gloves . A current undated perineal care policy was provided by the DON on 6/22/23 at 11:50 A.M., and indicated . a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate wash cloth or wipes. b. Thoroughly dry 11. Females: . c. Separate the resident's labia with on hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus). d. Repeat on opposite side using separate section of washcloth or new disposable wipe. e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke. f. Pat dry with towel. g. Turn the resident on her side. h. Clean and dry the anal area, starting at the posterior (back) vaginal opening and wiping from front to back. 12. Males: assist resident to supine position (unless contraindicated). b. Gently raise penis and place bath towel underneath. c. Wet washcloth and apply perineal cleanser . e. hold the shaft of the penis with one hand and was with the other [sic]. Begin cleansing tip of penis at urethral meatus using a circular motion and working outward . g. Cleanse the shaft of the penis, using downward strokes toward the scrotum. Use separate section of wash cloth or new disposable wipe with each stroke. h. Cleanse the scrotum, using a clean portion of the wash cloth, new wash cloth, or new disposable wipe with each stroke. i. Pat dry. j. Turn the resident on his side. k. Clean and dry the bottom of the scrotum and the anal area . Reposition as desired and cover resident. Remove gloves and discard. Perform hand hygiene . A current medication Administration policy was provided by the ADON on 6/22/23 at 3:38 P.M., and indicated . 4. Wash hands prior to administering medication per facility protocol and product . 16. Wash hands after using facility protocol and product . 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure significant changes in the resident's health condition were reported 1 of 1 residents reviewed hospice care and 1 of 1 reviewed for falls the Medical Doctor/Nurse Practitioner and/or family representative or POA (Power of Attorney) were not notified of the resident's change of condition. (Resident 12, Resident 8) Findings include: 1. On 6/20/23 at 11:00 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, emphysema, arteriosclerotic heart disease, peripheral vascular disease, and hemiplegia of right side following stroke. The most recent significant change MDS (Minimum Data Set) Assessment, dated 4/20/23, indicated the resident was severely cognitively impaired and an extensive assist of 2 staff for bed mobility, transfers, and toileting. Current physician's orders included, but were not limited to, the following: Observe for . change in usual mental status, lethargy . Notify MD [Medical Doctor] is [sic] s/s [signs/symptoms are observed ., dated 1/27/23 A current hemiplegia of right side from a stroke care plan, dated 1/18/23, included, but were not limited to, the following interventions: Notify MD with any changes prn, initiated 1/18/23 A current dementia care plan, dated 1/13/23, included, but was not limited to, the following interventions: Update my DPOA [power of attorney] as indicated, initiated 1/13/23 A current cardiovascular status care plan, dated 1/18/23, included, but was not limited to, the following interventions: Observe for changes in condition, initiated 1/18/23 Observe for abnormal vital signs and report, initiated 1/18/23 A nurse's progress note, dated 3/21/23 at 2:43 P.M., indicated [Resident has] been quiet today. Requested to stay in bed. Color pale . A nurse's progress note, dated 3/21/23 at 10:28 P.M., indicated Res [resident] spent this shift in bed . Res [resident] noted to have refused evening meal. Resting in bed at this time with eyes closed . A Wound Nurse Practitioner's progress note, dated 3/23/23 at 9:07 P.M. indicated . Upon assessment today, patient had slight labored breathing, wet cough, and fatigue. Per nursing, patient has had decreased intake this week. I am recommending a hospice consult at this time . A nurse's progress note, dated 3/24/23 at 7:30 P.M. (late entry) Resident noted to be breathing rapidly through mouth and staring ahead with right eye drooping. Vaguely answered yes when asked if he was ok. Vital signs at this time were: temperature 97.4, pulse 64, respirations 24, blood pressure 100/54, oxygen saturation 81% on room air. Noted resident's hands to be cold. Oxygen given as nursing measure but continued to breathe through his mouth. Vital signs recorded in the medical record lacked documentation of temperature, pulse, blood pressure, respiratory rate and oxygen saturation from 3/14/23 at 3:33 P.M. until 3/24/23 at 7:29 P.M. The medical record lacked documentation of resident's condition being monitored, notification of the physician and POA of the change in his condition until he was sent out to the hospital on 3/24/23. Hospital records were reviewed and included, but were not limited to the following: RN (Registered Nurse) triage assessment, dated 3/24/23 at 10:52 P.M., indicated RN [at facility] just arrived for her shift a few hours ago . she reports that during supper time this evening she noticed that patient was not eating his food and was 'breathing out his mouth like a fish' . She reports that the staff member who took care of the pt [patient] during dayshift [sic] today felt that patient was not acting right but she is unsure why this staff member did not do anything about it . A Physician's progress note, dated 4/11/23, indicated . The patient had an episode of decreased oxygen saturation to 70% and became poorly responsive with the decreased blood pressure of 70 [sic]. The patient was sent to [name of hospital]. It [sic] was found to have bilateral patchy pneumonia greatest on the right it was admitted to [name of hospital] for treatment [sic] . The patient received intravenous antibiotics and respiratory therapy, as well as intravenous fluids for hydration. The patient remained somewhat poorly responsive . the patient returned to [name of facility] for continuation of care, was placed on hospice, and was made comfort measures only by his healthcare power of attorney . During an interview on 6/21/23 at 2:30 P.M., the Nurse Practitioner indicated they had seen him weekly for skin assessment only so they did not do a full resident assessment and had not listened to his lungs. At that time, they did recall seeing the resident on 3/23/23 and that he had somewhat labored breathing, he seemed a little more confused, and he did not look good . 'I thought he looked like he was going to die' During an interview on 6/22/23 at 10:15 A.M., QMA (Qualified Medication Aide) 3 indicated if Resident 12's cognition changed, she would check his O2 (oxygen) saturation, other vitals, and check his color. If he was more lethargic and pale or vitals were different then normal, then those would be reported to the nurse as soon as possible. During an interview on 6/22/23 at 9:48 A.M., RN 5 indicated if the resident had decreased cognition or vitals worsened, they should report the changes to the doctor and POA and it'd be up to the doctor to give orders on what to do. At that time, they indicated when there was a change of shift, concerns that should be discussed with the oncoming nurse would be anything out of ordinary or a change like accucheck readings, time of last pain medication, confusion, lab results, eating or not eating, refusing care or medications. The staff had been documenting these things on a 24 hour reporting sheet that was kept at the nurse's station and then given to the DON who keeps it for so long. RN 5 indicated at the start of each shift, the nurse is responsible for taking an assessment of the residents on their hall. During their assessment, they will listen to lung sounds and bowel sounds, check pain level, and look for edema (swelling). During an interview on 6/22/23 at 10:45 A.M., the DON indicated when staff noticed a decline the family and doctor should have been notified even if the resident was on comfort measures only. Notification would not differ from anyone else. At that time, she indicated the symptoms documented on 3/21/23 should have been reported between nurses during shift change and the 24 hour documentation sheet should have been filled out with new orders, strange vitals, and anything abnormal about the resident. When the DON spoke with the day shift nurse, they indicated the resident was just tired and that he did act a little different, but nothing was out of the ordinary enough to notify the doctor or POA at that time. That afternoon the resident started with breathing difficulty and then they called the MD. The DON indicated the staff should do monthly vitals at least or prn if there is a reason to do vital signs and she would have expected vitals to be done and documented in the clinical record when resident's condition changed. After the resident's hospitalization , the DON did an investigation and it came to her attention that staff hadn't used 24 hour report sheets for approximately 6 months, staff wasn't getting vital signs timely, and things that should have been documented were not being documented in the clinical record. 2. On 6/21/23 at 3:09 P.M. Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, fracture of the right lower leg, diabetes mellitus, stroke, traumatic brain injury and vascular dementia. The most recent quarterly MDS (minimum data set) Assessment, dated 6/8/23, indicated Resident 8 was severely cognitively impaired and required total dependence from 2 staff members to transfer for all ADLs (activities of daily living). The resident had a total of six falls since February 2023, the clinical record lacked documentation about fall six. An incident report, dated 5/9/23, was reviewed and indicated on 5/7/23 Resident 8 was lowered to the floor by a CNA during a transfer.On 5/8/23, [resident name] complained of R [right] leg pain from his hip to his ankle. On assessment, edema was noted to the right leg. PRN [as needed] pain medication was administered and [name of doctor] was notified. A new order was received to obtain a portable x-ray of the R [right] hip, knee, and ankle. The x-ray indicated mild degenerative change of the R [right] hip. Moderate degenerative changes of the R [right] knee. Displaced fracture of the R [right] medial malleolus and distal fibula. [Resident name] was transferred to [name of hospital] for evaluation and treatment per order from [name of doctor] .He underwent an external fixation of the fracture . There was not a new care plan intervention put into place after the fall. Hospital records were reviewed and indicated on 5/9/23 at 6:27 P.M., a CT (computerized tomography) of the right ankle without contrast indicated Resident 8 suffered from a trimalleolar fracture with disruption of the ankle mortis [tibia, fibula, and foot]. During an interview on 6/22/23 at 3:43 P.M., the DON (director of nursing) indicated Resident 8 would use the call light to notify staff if he needed assistance, and when Resident 8 was in the bathroom staff did not need to supervise the resident while he was using the restroom. After the fall on 4/16/23, the DON indicated the new intervention was to place a Dycem in the wheelchair which was included in the care plan with a date of 4/19/23. At that time, the DON further indicated on 5/8/23, she was notified that Resident 8's foot was swollen and an investigation was started. During the investigation, the DON was told that the resident was lowered to the floor during a transfer in the shower room on 5/7/23, and the nurse did not document the fall because the staff member did not know an assisted fall needed to be documented. The facility failed to notify Resident 8's family, the DON, and the physician after the fall. On 5/8/23, Resident 8 complained of pain from his right hip to right ankle. At that time, an assessment was completed by the DON and Resident 8 had redness to his right lower leg and 2 blood blisters. The doctor was then notified and orders for an x-ray of the right hip, right knee, and right ankle were obtained. When the results were received on May 9, Resident 8 was transferred to [name of hospital] and underwent external fixation due to his foot being broke in 4 places. A current, undated vital signs policy was provided by the DON on 6/21/23 at 3:43 P.M., and indicated . 1. Routine vital signs include temperature, pulse, blood pressure, and respiratory rate . b. Licensed nurses are responsible for knowing the usual range of a resident's vital signs . and notifying the physician of abnormal findings 2. Oxygen saturation and pain are to be obtained and interpreted by licensed nurses 3. Vital signs shall be obtained at least in the following circumstances: . c. at least daily for a resident receiving skilled services .e. when the resident's general condition changes . g. when a resident reports nonspecific symptoms . A current, undated documentation policy was provided by the DON on 6/21/23 at 3:43 P.M., and indicated . Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation . 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred . documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . A current, undated 24 hour report policy was provided by the DON on 6/21/23 at 3:43 P.M., and indicated . It is the policy of this facility to record relevant information onto a 24 hour report form . in order to promote continuity of care . A report form will be completed daily for a 24 hour period and maintained on a clipboard . The 24 hour period will begin at midnight . each nurse with responsibility for a resident is also responsible for recording relevant information about each resident onto the shift report form. Examples include, but are not limited to: .unusual behaviors, change in condition of the resident . the unit manager or designee will review 24 hour shift report at the beginning of his/her shift to identify and prioritize resident needs . The paper form 24 hour reports will be kept on the clipboard for at least three days, then forwarded to the Director of Nursing. The reports will be maintained for a specified period of time by the Director of Nursing . A current, undated Notification of Changes policy was provided by the DON on 6/21/23 at 3:43 P.M., and indicated . The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . circumstances requiring notification include: . significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . On 6/21/23 at 3:43 P.M., the DON provided an undated Documentation in Medical record policy that indicated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to ensure the residents received the necessary respiratory care and services in accordance with the professional standards of practice for 3 of 3 residents reviewed for respiratory care. The facility failed to follow physician oxygenation orders, date oxygen tubing and humidification bottle, and document oxygen use and oxygen saturations. ( Resident 39, Resident 12, Resident 21) Findings include: 1. During an observation on 6/19/23 at 11:08 A.M., Resident 21 was observed laying in bed with oxygen on 2 LPM (liters per minute) via nasal cannula. Observation on 6/20/23 at 9:25 A.M., Resident 21 was observed laying in bed with oxygen on 2LPM via nasal cannula. Observation on 6/21/23 at 1:08 P.M., Resident 21 was observed laying in bed with oxygen on 2LPM via nasal cannula. On 6/21/23 at 8:57 A.M., Resident 21's clinical record was reviewed. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease, emphysema, Alzheimer's disease. The most recent significant change MDS (minimum data set) Assessment, dated 6/1/23, indicated Resident 21 had a severe cognitive impairment. The MDS did not indicate that Resident 21 was on oxygen. There was not a current order for oxygen use. A current alteration in respiratory status due to chronic obstructive pulmonary disease and emphysema care plan, revised 6/7/23, indicated to administer oxygen as needed per a doctor's order. Interview on 6/22/23 at 11:23 A.M., the DON (Director of Nursing) indicated Resident 21 was on oxygen, but she was unable to find the oxygen order at that time. She further indicated that a doctor's order was needed when a resident was placed on oxygen. 46416 2. During an observation on 6/19/23 at 8:22 A.M., Resident 12 was observed laying in bed wearing oxygen via nasal cannula. The oxygen concentrator was set between the 3.5 LPM and 4 LPM lines. Observation on 6/20/23 at 9:50 A.M., Resident 12 was laying in bed wearing oxygen via nasal cannula. The oxygen concentration was set between the 3.5 LPM and 4 LPM lines. On 6/21/23 at 10:30 A.M., the same was observed. On 6/20/23 at 11:00 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, emphysema, arteriosclerotic heart disease, peripheral vascular disease, and hemiplegia of right side following stroke. The most recent significant change MDS Assessment, dated 4/20/23, indicated Resident 12 was severely cognitively impaired, on oxygen, and an extensive assist of 2 staff for bed mobility, transfers, and toileting. Current physician's orders included, but were not limited to, the following: Continuous oxygen at 3 LPM via nasal cannula, dated 4/10/23 A current respiratory care plan, initiated on 1/18/23, included, but was not limited to the following intervention: Administer oxygen as needed per Physician order, dated 1/18/23 Interview on 6/22/23 at 9:44 A.M., RN (Registered Nurse) 5 indicated Resident 12's oxygen concentrator should be set at 2 LPM, it is the nurse's responsibility to check the concentrator setting every shift, and the resident would not change the setting. Interview on 6/22/23 at 3:43 P.M., the DON indicated that there was not a policy for following physician's orders, but it was the facility's policy to do so. 46882 3. On 6/20/23 at 8:59 A.M., Resident 39 was observed sitting in a recliner in her room wearing O2 (oxygen) at 2.5 LPM per nasal cannula with no date on oxygen tubing or humidification bottle. On 6/21/23 at at 8:36 A.M., Resident 39 was observed sitting at a table in the dining room with portable O2 on, no date on oxygen tubing, playing a game with another resident. On 6/22/23 at 10:30 A.M., Resident 39 was observed at the nurse's station in her wheelchair wearing portable O2 at 3 LPM per nasal cannula. There was no date on the oxygen tubing. On 6/20/23 at 10:59 A.M., Resident 39's clinical record was reviewed. She was admitted on [DATE]. Diagnosis included, but were not limited to, chronic respiratory failure with hypoxia, asthma, and congestive heart failure. The most recent quarterly MDS Assessment, dated 5/13/23, indicated Resident 39 was cognitively intact and required supervision of one for bed mobility, transfers, eating, and toilet use. Oxygen use was marked no. Current physician's orders included, but were not limited to, the following: May have 02, up to 4 LPM per n/c (nasal cannula) if sats (saturations) drop below 90% or c/o (complaint of) shortness of breath; as needed for chronic respiratory failure with hypoxia (J96.11); acute bronchitis, unspecified (J20.9) 3/5/2023 A current care plan for alteration in respiratory status due to asthma, chronic respiratory failure with hypoxia, congestive heart failure, initiated 11/3/22, included, but was not limited to, the following intervention: Administer oxygen as needed per physician order. Monitor oxygen saturations on room air and/or oxygen. Monitor oxygen flow rate and response 11/3/2022 A review of the TAR (treatment administration record) lacked documentation of the prn (as needed) O2 use and oxygen saturations for the months of April, May, and June 2023. A review of the vital signs lacked documentation of oxygen saturations after 4/26/23. Interview on 6/22/23 at 11:30 A.M., the DON indicated it was the facility policy to change O2 tubing every week on Saturday night, tubing should be dated when changed. If the resident was on prn O2, use should be documented on the TAR and O2 saturations should be monitored and recorded. A current non dated Oxygen Administration policy, provided by the DON on 6/22/23 at 11:50 A.M., indicated Oxygen is administered under the orders of a physician .Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy . Change oxygen tubing and mask/cannula weekly . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to provide appetizing and palatable meals on 1 of 1 lunch trays sampled. Residents interviewed during the survey complained of unappetizing food with varying temperatures of food. Findings include: During the survey period 6/19/23-6/22/23, the following confidential resident interviews were conducted: a. Sometimes cannot tell what the food is. b. The food taste is not good. c. The temperature varies. On 6/22/23 at 11:40 A.M., a sample lunch tray was provided and included: sloppy [NAME], tater tots, and carrots. Temperature were as follows: Sloppy [NAME] 116.6 degrees (Fahrenheit) tasted pasty. Carrots 110.1 degrees (Fahrenheit) tasted metallic. Iced tea 42.8 degrees (Fahrenheit) The tater tots were not palatable, cold, and tasted stale. The temperature was unobtainable. During an interview on 6/22/23 at 2:19 P.M., the dietary manager indicated that the internal temp of the meat should be 165 or better based on the meat, and that vegetable has a certain temperature. He provided the temperature log of the serving time: Entree meat 186 degrees (Fahrenheit) Vegetable 191 degrees (Fahrenheit) Starch 178 degrees (Fahrenheit) On 6/22/23 at 4:14 P.M., a current Food Preparation Guidelines, revised 11/2017 was provided and indicated . facility to prepare foods in a manner it preserve or enhance a resident's nutrition and hydration status. 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature . The policy did not include proper serving temperatures. 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 4 residents (Residents 8, Resident 25) observed during medication pass. Two medication errors were observed during 28 opportunities for error in medication administration. This resulted in a medication error rate of 7.14 %. Findings include: 1. During an observation on [DATE] at 10:29 A.M., RN (Registered Nurse) 3 was observed to administer 7 units of Novolog 100 units/ml (milliliter) from the FlexPen subcutaneously in the back of Resident 8's right arm. The open date on the Novolog Flexpen was [DATE]. During an interview on [DATE] at 11:20 A.M., the DON (Director of Nursing) indicated after the insulin pen was opened, it was good for 28 days. It should be discarded and another one opened after the 28th day. She indicated the open date should be checked before administering insulin from the pen. A package insert for the Novolog FlexPen, dated January of 2015, indicated once a NovoLog FlexPen was punctured, it should be kept for up to 28 days. 2. During an observation on [DATE] at 7:20 A.M., LPN (Licensed Practical Nurse) 18 was observed to administer 1 capsule of omeprazole 20 mg (milligram) by mouth to Resident 25. On [DATE] at 3:30 P.M., Resident 25's clinical record was reviewed. Current physician's orders included, but were not limited to the following: omeprazole 40 mg capsule by mouth in the morning, dated [DATE]. During an interview on [DATE] at 4:20 P.M., RN 20 indicated Resident 25's physician order was omeprazole 40 mg 1 capsule by mouth daily. The pill packet from the medication cart was labeled 1 x omeprazole 20 mg capsule. They indicated they would contact the physician and pharmacy to double check the order that was given and correct it so the resident would get the correct dosage. During an interview on [DATE] at 4:28 P.M., the DON indicated the current order from the physician was sent to (pharmacy name) and the medications were put in the machine. The DON indicated she was not sure how long the incorrect dose of medication had been administered. At that time, she indicated the day shift is responsible for having the machine get the pill packets ready for each resident for the next day, and night shift was responsible for putting the pill packets into the medication cart. The nurse or QMA (Qualified Medication Aide) administering the medication was responsible for checking that the medication matched the physician's orders. A current undated Insulin Pen policy was provided by the DON on [DATE] at 3:43 P.M., and indicated . 9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation . A current undated Medication Administration policy was provided by the ADON (Assistant Director of Nursing) on [DATE] at 3:38 P.M., and indicated Medications are administered . as ordered by the physician and in accordance with professional standards of practice . 11. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time . 12. Identify expiration date. If expired, notify nurse manager . 3XXX,d+[DATE](c)(1)

Based on observation, interview, and record review, the facility failed to ensure daily posted nurse staffing information was correct for 1 of 4 days during the survey. Findings include: On 6/19/23 at 7:45 A.M., a staffing record was observed posted on the front desk in the lobby of the facility dated 6/15/23, four days prior to the survey. On 6/22/23 at 1:30 P.M., the Director of Nursing(DON) indicated the scheduler places the daily direct staffing sheets for Saturday, Sunday, and Monday behind the posted Friday sheet. She also indicated the day shift nurse will change the staffing sheets each morning. On 6/22/23 at 3:22 P.M., the Administrator indicated the facility has no written policy. The staffing is based on facility assessment of daily resident acuity.

Based on observation, interview, and record review, the facility failed to accurately and completely assess and document multiple bruises on a resident, and failed to notify the primary physician of the bruises, for 1 of 3 dependent residents sampled for quality of care. (Resident B) Findings include: On 4/4/22 at 1:00 P.M., the clinical record of Resident B was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initially dated 11/16/19 and updated 2/4/22, indicated: Pressure ulcer actual or at risk due to: Assistance required in bed mobility, incontinence, malnutrition. The Intervention included: Conduct weekly skin inspection. Encourage proper nutrition and Hydration. An additional care plan regarding fragile skin, or bruising easily, was not found in the clinical record. A quarterly Minimum Data Set (MDS) assessment, dated 2/19/22, indicated Resident B had a short term and long term memory problem\, was severely impaired in cognitive skills for daily decision making, and required extensive assistance of two or more staff for bed mobility, dressing and personal hygiene. The resident did not have any skin impairment. Nurses notes included the following notations: 2/16/22 at 12:39 P.M.: Resident continues to bruise easily d/t [due to] poor nutritional status and overall declining condition. Purple colored discoloration noted of left outer leg from knee down. Discolored area reported to Hospice nurse. Family also updated. Continues to have bruised area on left outer arm also with little change noted of area. A Weekly Skin Review, dated 2/19/22 at 1:47 A.M., indicated, Bruising of arms and legs continue. A Weekly Skin Review, dated 2/26/22 at 1:47 A.M., indicated, Bruising of legs and arms unchanged from last week. A Weekly Skin Review, dated 3/7/22 at 9:17 A.M., indicated, Does remain prone to bruising of extremities. No bruising was indicated. A Weekly Skin Review was not completed on 3/14/22 or on 3/21/22. Nurses notes continued: 3/24/22 at 12:21 P.M.: Resident noted to have purple colored bruise on left on top of left hand. Resident unable to tell nurse how bruise happened. Hospice and family updated on bruise. 3/26/22 at 1:22 P.M.: Bruising of left hand and now arm continue. Hospice kept updated on bruising also family updated. Resident denies pain or discomfort of arm. Documentation that the physician was notified of the bruising was not found in the clinical record. A Weekly Skin Review, dated 3/28/22 at 9:17 A.M., indicated: Bruising of left and [sic] hand continues. No [CONDITION(S)] or contractures noted A hospice note, dated 3/30/22, included: Patient remains mostly non-verbal. Large bruises or [sic] discover on patient discuss [sic] with facility and patience [sic] daughter Previous hospice notes did not indicate any bruising on the resident. A Weekly Skin Review, dated 4/4/22 at 9:17 A.M., indicated: Remains very prone to bruising of extremities. Overall skin condition fragile. No contractures or [CONDITION(S)] noted Documentation of the measurements of the bruises, or of the physician being notified of the bruises, was not found in the clinical record. On 4/4/22 at 2:00 P.M., a skin assessment was requested. CNA 1 indicated at that time that Resident B's skin was fragile, and that she bruised easily. Staff used a draw sheet to turn her. A dark purple bruise covering her right knee, including above and below the knee, was observed. Dark purple bruising was also observed on the resident's left hand, left upper arm and elbow area, and right upper arm. CNA 1 indicated that staff report all bruises to the nurse. The resident had not fallen recently. On 4/4/22 at 2:30 P.M., LPN 1 was interviewed. LPN 1 indicated Resident B bruised easily due to poor nutrition. She indicated the bruises had been reported to the hospice nurse. The hospice nurse usually communicated with the resident's physician. On 4/5/22 at 10:05 A.M., an additional skin assessment was requested. Resident B was observed lying in bed. Cotton arm sleeves were observed on each arm. CNA 1 indicated that the sleeves were put on that morning. The resident was found lying on her right arm that morning, and she now had bruising on her right upper arm. Resident B smiled when spoken to, but did not verbalize. On 4/5/22 at 10:25 A.M., LPN 1 indicated she had phoned Resident B's physician that morning to request arm sleeves for the resident. The Director of Nursing (DON) indicated at that time that skin assessments would be in the electronic record, and there were no other skin assessments regarding the bruises. On 4/5/22 at 11:20 A.M., the Director of Nursing (DON) provided measurements and location of the resident's bruises. They included: Right knee: 11 cm (centimeters) length. Right upper arm: 17 cm x 25 cm. Left upper arm: 26 cm x 15 cm. Left hand: 8 cm width. Left wrist: 6 cm. On 4/5/22 at 10:50 A.M., the DON provided the current facility policy, Skin Assessment, undated. The policy included: A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse .weekly .Note any skin conditions such as redness, bruising .Documentation of skin assessment: .Document type of wound. Describe wound (measurements, color .) .Document other information as indicated or appropriate. On 4/5/22 at 11:30 A.M., the DON provided the current facility policy,Notification of Changes, undated. The policy included: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member .when there is a change requiring such notification This Federal tag relates to Complaint IN 254. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure insulin pens were labeled with the prescribing information and the opening date documented on the pen for 3 of 3 medication carts reviewed for medication storage, to ensure expired and/or discontinued medications were properly disposed of, and to ensure scheduled narcotic medications were properly locked for 1 of 2 medication storage rooms observed. (East Unit Medication Storage Room, East and West Unit Medication Carts, Resident 21, Resident 93, Resident 90, Resident 91, Resident 31, Resident 92, Resident 89, Resident 88, Resident 15, Resident 2, Resident 26, Resident 32, Resident 4, Resident 86) Findings include: 1. During an observation of the Center Hall medication cart on [DATE] at 2:30 P.M., a [MEDICATION(S)] insulin pen, which LPN 6 indicated belonged to Resident 26, did not have the date the pen was first used documented on the pen. 2. During an observation of the North Hall medication cart on [DATE] at 2:48 P.M., A [MEDICATION(S)] insulin pen, which LPN 6 indicated belonged to Resident 32, did not have the date the pen was first used documented on the pen. 3. During an observation of the North Hall medication cart on [DATE] at 2:48 P.M., small pieces of paper and powdered debris were observed in the medication drawer bottoms, and one loose pill was observed in the medication cart drawer bottom. 4. During an observation of the Hall medication cart on [DATE] at 2:48 P.M., a Novolog insulin pen, which LPN 5 indicated belonged to Resident 4, did not have the date the pen was first used documented on the pen and the prescribing information was not on the pen. 5. During an observation of the Hall medication cart on [DATE] at 2:48 P.M., a [MEDICATION(S)] insulin pen, which LPN 5 indicated belonged to Resident 86, did not have the date the pen was first used documented on the pen. During an interview on [DATE] at 2:48 P.M., LPN 6 indicated insulin pens were supposed to have the open date documented and the prescribing information on the insulin pen. On [DATE] at 1:00 P.M., the Facility Administrator supplied a policy titled, Insulin Pen and was dated, 2021. The policy included, .2. Insulin pens must be clearly labeled with the resident's name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used; a new pen must be ordered from the pharmacy.9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation . 6. During an observation on [DATE] at 9:35 A.M., several medications were observed in the East Hall Medication Storage Room counter with the following resident's names on them: Resident 21, Resident 93, Resident 90, Resident 91, Resident 31, Resident 92, Resident 89, Resident 88. At that time, the Regional Director of Nursing (RDON) indicated some of the residents remained in the facility and some of the residents had discharged from the facility. The RDON indicated that the night shift are responsible for filling out the return form and destroying the medications. An unlocked refrigerator in the Storage Room was observed with the following controlled substances: [MEDICATION(S)] (pain medication) belonging to Resident 15, and lorazepam (antianxiety medication) belonging to Resident 2. The refrigerator was also observed with an open bottle of applesauce, a container of chocolate syrup, and an unopened container of yogurt. The RDON indicated that the refrigerator with the narcotics should have been locked, and no food items should have been in the medication refrigerator. The RDON indicated they would fill out the destruction logs at that time, and provide a copy of them. On [DATE] at 10:04 A.M., the following Drug Destruction Sheets were provided and reviewed with the RDON: 1. Resident 88: [MEDICATION(S)] 40mg quantity 78 discontinued on [DATE]. 2. Resident 89: [MEDICATION(S)] 20meq quantity 76, and [MEDICATION(S)]-[MEDICATION(S)] quantity 7. Resident discharged [DATE]. 3. Resident 31: [MEDICATION(S)] 10mg quantity 2, donezezil 10mg quantity 2, vitamin D3 quantity 1, and arthritis pain 80mg quantity 2. RDON indicated all of these medications were refused on [DATE], [DATE], [DATE], [DATE], and [DATE], and she was unsure from which dates the medications were placed in the Storage Room. 4. Resident 92: [MEDICATION(S)] 83oz, Novolog flex pen 15cc, [MEDICATION(S)] [MEDICATION(S)] 10cc, and [MEDICATION(S)]-[MEDICATION(S)] quantity 100. Resident discharged [DATE]. 5. Resident 91: Siltussin DM 473ml. Resident discharged [DATE]. 6. Resident 90: Vitamin E 400units quantity 30, Peg 3350 2oz, [MEDICATION(S)] 7.5mg quantity 4, [MEDICATION(S)] 25mg quantity 26, Acet Supp 650 quantity 12, and Hyoscamine 125mg quantity 52. Resident passed away [DATE]. 7. Resident 21: [MEDICATION(S)] 3mg quantity 1. Resident refused medication on [DATE]. 8. Resident 93: SMZ/TMP [[MEDICATION(S)]] ,d+[DATE] quantity 7, discontinued [DATE]. On [DATE] at 11:26 A.M., a current Disposal of Medications and Medication-Related Supplies Medication Destruction policy, dated ,d+[DATE], was provided, and indicated All discontinued medications will be immediately removed from the resident's active medication and stored in a separate locked area for up to 90 days or as required by applicable law, and then destroyed by a manner in accordance with applicable state and federal laws. 3.,d+[DATE](k) 3.,d+[DATE](o) 3.,d+[DATE](r)

Based on observation, interview, and record review, the facility failed to ensure food was stored or prepared in a sanitary manner in accordance with professional standards for food service safety in 2 of 2 observations of the kitchen. Food in the freezer was open to air, food items were open and not dated, and staff observed not properly washing hands during food preparation. (Main Kitchen) Findings include: 1. During an observation on 9/13/21 at 10:08 A.M., the following food items were observed in the kitchen: A biscuit and gravy mix open and undated A container of cheese balls open and undated Italian seasoning open and undated Chili powder open and undated Pumpkin spice open and undated Ground cinnamon open and undated Garlic salt open and undated Roasted garlic bread seasoning open and undated A bottle of worcestershire sauce open and undated A bottle of catalina dressing open and undated A bottle of salsa open and undated A cardboard box with hamburger patties in the freezer was open to air A plastic container with potato chips was on the counter undated and unlabeled 2. During an observation on 9/16/21 at 10:30 A.M., the following was observed during lunch preparation: While preparing the puree trays, Cook 1 was observed to wash their hands for 7 seconds. While preparing hall trays, Cook 9 was observed to wash their hands for 4 seconds. On 9/16/21 at 1:45 P.M., the RDON (Regional Director of Nursing) indicated there was no specific written policy for open containers in the freezer, however, per the corporate office representative, all items in the freezer should have been closed, either in a box or a bag. On 9/16/21 at 1:00 P.M., an undated facility policy titled, Date Marking for Food Safety policy was provided. The policy included, The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. On 9/16/21 at 1:00 P.M., an undated policy titled, Handwashing Guidelines for Dietary Employees was provided. The policy included, Rub [hands] together vigorously for at least 20 seconds. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure residents who were at risk to fall were transferred safely, had functioning equipment, effective interventions, and adequate supervision provided for 4 of 7 residents who met the criteria for review of accidents. This deficient practice resulted in Resident 3 experiencing a laceration resulting in 10 sutures to the right forehead. (Resident 3, Resident 9, Resident 13, Resident 23) Findings included: 1. During record review on 9/4/18 at 9:45 A.M., Resident 3's most recent (quarterly) MDS (Minimum Data Set) assessment, dated 6/7/18, indicated the resident required extensive assistance with transfers, bed mobility, locomotion, toilet use, and personal hygiene. Resident 3's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Resident 3's care plan included, but was not limited to, a focus that stated the resident was at risk for falls due to medications, balance problems, and a history of leaning forward in the wheelchair. Interventions related to the focus included, but were not limited to, bed in low position, encourage resident to not be alone in room in wheelchair, and a mat beside bed for safety. Nurses' progress notes indicated Resident 3 had 5 falls in a 3 month time period. Fall 1. On 2/23/18 at 2:07 A.M., Resident 3 was found in the resident's room lying on left side in front of the wheelchair with face on the floor. Staff noted an area above left eye approximately 6 cm (centimeters) round, slightly red, and starting to discolor. The facility replaced the resident's wedge cushion to the wheelchair as the old wedge cushion was worn. Fall 2. On 3/2/18 at 4:00P.M., Resident 3 was found on the floor in the resident's room lying on the right side with blood coming from nose. The resident was slow to respond. Resident 3 complained of right leg pain. An order was received to send the resident to the emergency room to be evaluated and treated. Resident 3 had been sitting in wheelchair, in room, prior to fall. The facility recommended Resident 3 be encouraged not to be in room in wheelchair unattended and be offered to lay down in bed after lunch to rest. Fall 3. On 4/14/18 at 2:50 A.M., Resident 3 was found on floor in the resident's room lying face down on stomach beside the bed. Staff noted a laceration on small finger of right hand measuring 1 cm x 0.7 cm, a laceration to the outer aspect of right wrist measuring 1.4 cm x 0.7 cm, and an abrasion to the top of the right hand measuring 2.5 cm x 0.7 cm. The facility recommended Resident 3 continue on therapy caseload. Fall 4. On 5/7/18 at 2:25 P.M., Resident 3 was found on the floor in the hallway lying face down in front of the wheelchair. Staff noted a laceration above the right eyebrow. Resident 3 was in and out of consciousness for 2 - 3 minutes. An order was received to send the Resident to the emergency room to be evaluated and treated. Resident 3 received 10 sutures to the right forehead. The facility recommended Resident 3 receive therapy evaluation for wheelchair positioning and safety. Fall 5. On 5/17/18 at 4:25 P.M., Resident 3 was found lying on the bedside mat on floor next to the resident's bed. Resident 3's head was on floor above mat. Staff noted no injuries. The facility recommended Resident 3 be offered toileting between 3:00 P.M. and 4:00 P.M. During review of Resident 3's medication and treatment administration record, treatments ordered for bed to be in low position and a mat be in place at bedside every shift was not documented as completed on the following dates: 5/14/18 - night shift 5/19/18 - day shift, evening shift 5/20/18 - day shift 6/3/18 - evening shift 6/11/18 - night shift 6/14/18 - evening shift 6/21/18 - night shift 7/1/18 - night shift During an observation on 9/4/18 at 11:00 A.M., a staff member was observed assisting Resident 3 down the hallway in the wheelchair. Resident 3 was assisted into the bedroom, placed in front of the television, and left unattended. At 11:27 A.M., Resident 3 was observed in the bedroom, in wheelchair, watching television unattended. At 11:48 A.M., Resident 3 was observed in the bedroom, in wheelchair, watching television unattended. During an observation on 9/5/18 at 11:18 A.M., Resident 3 was observed in the room, up in wheelchair, watching television unattended. At 11:35 A.M., Resident 3 was in room, in wheelchair, watching TV unattended. During an interview on 9/4/18 at 11:15 A.M., RN 5 indicated staff should try to keep Resident 3 out of room in wheelchair whenever supervision in resident's room was not possible. Staff should try to keep the resident in front of the nurses' station and offer activities to keep the resident occupied. 2. On 8/29/18 at 1:12 P.M., Resident 9's clinical record was reviewed. [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment, dated 7/6/18, indicated Resident 9 was cognitively intact, had no behaviors, required 1 person physical assistance for transfers, walking in room, toilet use, and was not on a toileting program. Initial care plan for falls, dated 1/23/18, included interventions . Assess for pain, give prn (as needed) pain meds . Bed in low position . Call light or personal items available and in easy reach . Encourage proper footwear to prevent slipping . Grab bar in bathroom . Keep environment well lit (sic) and free of clutter . Observe for side effects of antidepressant Medications . PT/OT/St to eval (evaluation) and treat (treatment) . A care plan for physical functioning deficit, dated 1/23/18, included interventions, but were not limited to . toileting assistance of staff . transfer assistance of staff from bed to chair or to standing position . walking assistance staff and walker to and from bathroom . No physical activity order found. Resident 9 experienced 12 falls from 3/7/18 until 9/4/18: Fall 1 3/7/18 at 4:45 A.M. fell in room. Resident called staff to her room. She indicated she hit her walker against the door jam and fell trying to get to the bathroom quickly to urinate. Fall was unwitnessed. Skin tear to right lower leg. Predisposing factors included poor lighting, equipment, and narcotic. Intervention following fall was to encourage resident to leave bathroom light on with door slightly opened during nighttime hours. Neuro checks not found. Fall 2 4/1/18 at 9:41 A.M. fell in room. Resident was found sitting on the floor when nurse entered room with medications. Resident indicated she got up to get sugar for breakfast and slipped. Fall was unwitnessed. No new interventions implemented following fall. Neuro checks not found. Fall 3 4/12/18 at 9:52 A.M. fell in room. Call light sounded. Resident found sitting on the floor in front of the commode without wearing gripper socks. Resident indicated she started to go to the bathroom and moved quickly to get on the commode and slipped. Fall was unwitnessed. Predisposing factors included incontinence, responding to toileting needs, using walker. Interventions following fall were nonskid strips to floor in front of commode, recliner, and bed. Neuro checks not found. Fall 4 5/3/18 at 4:35 A.M. fell in room. Call light sounded. Resident found sitting on the floor of her room. Resident indicated her knees got weak and she fell . She was using her walker, indicated she did not hit her head. Fall was unwitnessed. Predisposing factors included weakness/fainted, and using walker. Intervention following fall was to encourage to use call light for assistance with transfers. Neuro checks not found. Fall 5 5/9/18 at 3:53 A.M. fell in room. Call light sounded. Gripper socks on. Resident found sitting on floor in room, indicated, .That room was black. I opened that stupid door (bathroom door). Down I went . Fall was unwitnessed. Predisposing factors included poor lighting, and responding to toileting needs. Intervention following fall was to begin scheduled toileting with assistance offered at 0200 and 0400. Neuro checks not found. Fall 6 5/21/18 at 2:26 P.M. fell in room. Call light sounded. Resident indicated she slipped off the commode and was found on the floor. Fall was unwitnessed. Predisposing factors included narcotic. Intervention following fall was toilet seat riser with handles. Neuro checks not found. Fall 7 6/25/18 at 3:00 P.M. fell in room. Therapy found resident sitting on the floor. Resident indicated her walker moved away from her as she was sitting down. Fall was unwitnessed. Predisposing factors included gait imbalance, using walker. Intervention following fall was to offer assistance with toileting upon rising, before and after meals, and prior to bedtime. Neuro checks not found. Fall 8 7/19/18 at 7:40 A.M. fell in room. Resident found on floor by bed. Resident indicated she was getting up and got tangled in her covers. Fall was unwitnessed. Predisposing factors included items on floor, cardiovascular, narcotic, improper footwear. Intervention following fall was to adjust bed height so that blankets were not touching the floor, and resident was at a comfortable height to stand. Neuro checks done. Fall 9 7/24/18 at 11:45 P.M. fell in room. Resident was not wearing gripper socks and fell entering bathroom. She was using her rolling walker. No injury. Interventions following fall included education and re-applied gripper socks. Bookshelf was also moved away from outside the bathroom door. Neuro checks done. Fall 10 8/24/18 at 11:45 P.M. fell in room. Resident found on the floor by the bathroom door with bleeding forehead, 5 cm (centimeter) scratch on back of right calf. Resident indicated she lost her balance while opening her bathroom door, and when the walker moved, she fell . Fall was unwitnessed. Predisposing factors included furniture, gait imbalance, crowding, responding to toileting needs, using walker. First aid done. Intervention following fall was to educate and encourage resident to use call light for assistance when transferring to the restroom. Neuro checks done. Fall 11 8/29/18 at 8:30 P.M. fell in room. Resident was calling out. Resident indicated she was trying to get up to go to the bathroom and was unable to lock her knees when standing. Fall was unwitnessed. Predisposing factors included equipment, narcotic, gait imbalance, laxative, weakness/fainted, ambulating without assist, responding to toileting needs, and using walker. Intervention included medication review. [MEDICATION NAME] was changed to give in the morning instead of the evening. Neuro checks done. Fall 12 9/4/18 at 8:30 P.M. fell in room. Resident was found sitting on the floor in bathroom doorway. Resident said, I went to the closet to get some diapers and did not take my walker. When I opened the closet doors, they knocked me down. Fall was unwitnessed. No new interventions had been put into place as of 9/5/18 at 11:00 A.M. Neuro checks done. During an interview on 8/30/18 at 9:20 A.M., Resident 9 indicated she just falls, that her knees were weak and could not stand or walk for a very long time before they give out. She indicated that staff asked her to use the call light when she had to go to the bathroom when she fell , but she did not have to currently use it. Indicated she could get up on her own to go to the bathroom when she needed to go. Grip strips were observed at this time in front of the commode, and a handle attached to the wall. No riser on the toilet seat was observed. During an interview on 8/30/18 at 9:25 A.M., the DON (Director of Nursing) indicated Resident 9 had refused to use the toilet seat riser, but agreed to use the handles on the sides of the regular seat. The DON indicated this had been ordered. She further indicated an alarm was being bought for the resident as well. She also indicated Resident 9 did not lock her rolling walker like she was supposed to, and that had contributed to her falling, and that she and PT had discussed with the resident that the rolling walker was not working for her. During an interview on 8/30/18 at 1:15 P.M., the DON indicated she could not find any neuro checks for the 5/21/18 fall or any prior fall. She indicated that if the resident was alert and oriented, and stated that they did not hit their head, neuro checks were not done. On 9/4/18 at 11:32 A.M., Resident 9 was observed sitting in her recliner, and indicated she needed a nurse. A call light was observed to be wrapped on a string which was attached to a light on the other side of the bed from where the resident was sitting. Resident 9 indicated she could not reach the call light. 3. During an observation on 8/28/19 at 10:20 A.M., Resident 13 was observed in bed with her eyes closed. Resident 13 had bruising around both eyes. QMA 10 was made aware the call light was outside the resident's reach. QMA 10 indicated Resident 13 had two black eyes due to a recent fall and had experienced several falls in the last couple of months. QMA 10 picked up the call light from the floor, at the foot of the bed, and clipped the call light within reach of the resident. QMA 10 indicated, at that time, Resident 13 used her call light whenever she needed assistance. During an observation on 8/29/18 at 9:50 A.M., CNA 1 was observed in the TV Den adjusting the window blinds while Resident 13 was sitting on the couch watching TV. The call light was located behind the couch on the floor and outside the resident's reach. CNA 1 exited the TV Den and walked down the hall to another resident's room. CNA 1 was made aware Resident 13 did not have a call light within reach. CNA 1 returned to the TV Den, pulled the call light out from behind the couch, placed it next to Resident 13 and stated, The call light should be within reach. During an observation on 8/29/18 at 10:02 A.M., without a gait belt around Resident 13's waist, CNA 1 walked Resident 13 from the TV Den to the bathroom located in the Resident's room. Resident 13 used her walker. After toileting was completed,CNA 1 walked Resident 13 from the bathroom to her bed without using a gait belt. During an interview on 8/29/18 at 10:10 A.M., CNA 1 indicated Resident 13 did not need a gait belt when walking. The ACU ASSIGNMENT SHEET dated 7/27/18 was provided by the Administrator on 8/29/18 at 9:55 A.M., and it read as follows: .Assist x (times)1 and gait belt .Offer and assist res. (resident) to lay down after AM and noon meals, visual aide to walker, recliner, and call light, use gait belt with transfers. The clinical record for Resident 13 was reviewed on 8/30/18 at 2:00 P.M. The record indicated Resident 13 was admitted to the facility on [DATE]. Resident 13's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 7/11/18, indicated Resident 13 experienced severe cognitive impairment, required the extensive assistance of two staff for bed mobility, transfers, walking in corridor, and toileting. The MDS indicated Resident 13 was not steady, only able to stabilize with human assistance, and was at risk to fall. A Care Plan At risk for falls dated 5/8/18 for Resident 13 included, but was not limited to: .Call light or personal items available and in easy reach .Date Initiated 1/29/18 . Gait belt with transfers .Date Initiated 8/24/18 . Fall 1 A progress note dated 6/14/18 at 9:45 A.M., read as follows: .Resident found on floor, laying on back. No noted injuries at this time . Fall 2 A progress note dated 6/16/18 at 11:55 P.M., read as follows: .CNA walking resident with assist x 1 and gait belt to dining room from her bedroom. when resident reached bedroom doorway she fell back without warning falling flat on her back with head hitting floor .Contusion noted with bleeding to back of head. no laceration noted. minor swelling measures 3 cm by 3 cm with .2cm raised area. bleeding stopped with light pressure after 3 minutes. resident taken to dining room via wheelchair for lunch. immediate intervention is to use wheelchair instead of walker at this time . Fall 3 A progress note dated 7/15/18 at 1:46 P.M., read as follows: .Res. noted to have an unwitnessed fall on 7/14/18. Prior to fall res. was ambulating in dining room .no injuries noted . Intervention recommended: visual aide to resident's walker. A progress note dated 7/14/18 at 6:19 read as follows: . Approximately 5:45 P.M., the resident had a non witnessed (sic) fall in the dining room before supper . Fall 4 A progress note dated 8/21/18 at 2:55 P.M., read as follows: .LPN had just walked away from resident to assist another resident. RN had just walked in nurse's station. Resident was sitting in common area with walker at side. RN heard a scream and thud. Resident on floor face down in front of chair with walker beside her. Hematoma noted to Left temple . Intervention recommended: resident to lay down for nap after noon meals. Fall 5 A progress note dated 8/23/18 at 11:30 A.M., read as follows: .Called to room and CNA said she was getting resident up from chair and resident fell straight backwards and hit back of head on wall. Stated she could not stop the fall. Resident was lying on back on floor with knees bent. No obvious injury noted to head .Resident was being toileted at the time of assessment was incontinent of urine . Intervention recommended: use gait belt when transferring. During an interview on 9/4/18 at 10:01 A.M., LPN 26 indicated Resident 13 needed a call light within reach. During an interview on 9/5/18 at 9:15 A.M., the Director of Nursing (DON) indicated a gait belt should be used when restorative CNA's are walking with a resident and when the care plan identifies the intervention. (use a gait belt with transfers) The DON further indicated call lights should be within easy reach of residents. 4. During an observation on 8/29/18 at 9:10 A.M., Resident 23 was observed lying in bed with her eyes closed. Her call light was outside of reach. The clinical record for Resident 23 was reviewed on 8/29/18 at 9:57 A.M. The record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 6/18/18, indicated Resident 23 experienced cognitive impairment, required the assistance of one staff for bed mobility, transfers, walking in corridor, and toileting. A Care Plan At risk for falls dated 7/31/18 for Resident 23 included, but was not limited to: .Call light or personal items available and in easy reach .Date initiated 11/21/17 . Assist to bathroom upon rising, before and after meals, hs (bedtime) and prn (as needed) .Date Initiated 7/3/18 . A Care Plan I have a physical functioning deficit related to: Self care impairment. I require total dependence with bathing; extensive assistance with .toileting, transfers, locomotion and ambulation . dated 7/31/18 for Resident 23 included, but was not limited to: .Ambulate with walker and staff .Date initiated 1/18/18 . Toileting assistance of staff .Date initiated 11/28/17 . Transfer assistance of staff from bed to w/c (wheelchair) .Date initiated 11/28/17 . FALL1 A progress note dated 6/12/18 at 12:30 P.M., read as follows: .Reported night shift nurse that resident was found on floor. Apparently resident had slid out of bed. Noted two small bruises to right cheek . Intervention recommended was a contour mattress. FALL 2 A progress note dated 7/2/18 at 9:15 P.M., read as follows: .Resident heard yelling from her room. staff responded to find resident laying prone on the floor next to her bed. Resident has had a history of [REDACTED]. FALL 3 A progress note dated 7/23/18 at 9:15 P.M., read as follows: .resident was yelling for help. This nurse walked into room to find resident laying supine position near her wardrobe. resident was fully dressed, shoes on, no tipping hazards noted. Resident did not utilize her walker. Resident has a history of falls. Forgets to use her walker and needs to be reminded to use it . Intervention recommended: visual aide to walker. FALL 4 A progress note dated 7/30/18 at 7:05 A.M., read as follows: .Called to residents (sic) room by CNA. Found resident laying on back on floor next to bed Feet tangled in O2 tubing and blankets. unwitnessed fall on 7/30/18 at 7:05 am, resident lying on back feet tangled in 02 tubing and blankets . Intervention recommended: use of side rails. FALL 5 A progress note dated 8/12/18 at 11:25 P.M., read as follows: . resident calling help from her room. upon entering room resident was found laying (sic) beside her bed on her right side with a large amount of blood around her head. upon inspection an abrasion and hematoma was found on her right parietal area of her head . bleeding slowed to ooze from the abrasion . Intervention recommended: low bed with mat to floor. During an interview on 8/28/18 at 11:45 A.M., the Director of Nursing indicated Resident 23 was hospitalized with aspiration pneumonia in July. During an interview on 9/5/18 at 9:15 A.M., the Director of Nursing indicated call lights should be within the resident's reach. On 8/30/18 at 10:50 A.M., a Falls Management policy was provided. The policy indicated: .Following a resident's fall: .The licensed nurse assesses the resident for injuries (including neuro checks if indicated) .Appropriate interventions are implemented .Care plan is updated . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care was provided to a resident admitted with pressure ulcers, did not experience deterioration of the pressure ulcer and did not develop an additional pressure ulcer for 1 of 3 residents who met the criteria for review of pressure. This deficient practice resulted in Resident #66 experiencing a Stage 3 pressure ulcer to the left buttock, and Unstageable pressure ulcers to the left heel and right buttock. (Resident #66) Findings include: During an interview on 10/17/16 at 2:23 P.M., LPN #5 indicated Resident #66 was admitted with a Stage 1 pressure ulcer to the left heel, a Stage 2 pressure ulcer to the left buttock, and had developed a Stage 2 pressure ulcer to the right buttock after admission to the facility. LPN #5 further stated, at that time, the left heel wound was currently, .dark in appearance, starting to harden .left buttock .30% slough .right buttock .found 10/5/16 .bruised looking . During an observation on 10/18/16 at 11:30 A.M., Resident #66 was observed in the therapy department, sitting in a wheelchair with foot pedals, with the left heel on the surface of the foot pedal. During an observation on 10/19/16 at 8:45 A.M., Resident #66 was observed in the hallway, sitting in a wheelchair with foot pedals, with the left outer heel on the surface of the foot pedal. During an interview, at that time, CNA #5 indicated Resident #66 was on the way to the therapy department. The clinical record of Resident #66 was reviewed on 10/19/16 at 9:30 A.M. The clinical record indicated Resident #66 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #66 experienced severe cognitive impairment, required the extensive assistance of two staff for bed mobility and transfers, experienced range of motion limitations to a lower extremity, experienced one Stage 1 wound, one Stage 2 wound, was at risk to develop pressure ulcers, and experienced no Stage 3 or Unstageable wounds. The Admission Nursing assessment dated [DATE] at 7:39 P.M. indicated Resident #66 was admitted with the following skin impairments: Wound #1: Left buttock, Stage 2 pressure ulcer, 1.0 cm (centimeter) L (length) X 0.5 cm W (width) X 0.0 cm D (depth) Wound #2: Left heel, Stage 1 pressure ulcer, red and soft to touch 3.0 cm L X 3.0 cm D. The assessment lacked any documentation to indicate Resident #66 experienced skin impairment to the right buttock. A Pressure Sore Risk assessment dated [DATE] indicated Resident #66 was at risk to develop pressure ulcers. The physician's orders [REDACTED]. A Plan of Care for, Pressure ulcer actual or at risk .admitted with Stage II (two) Pressure Ulcer to left coccyx and redness to left heel, Extensive(sic) assistance required with bed mobility, bowel incontinency . dated 9/21/16 included the following interventions: Assist to turn and reposition, Conduct weekly skin inspection, Encourage proper nutrition and Hydration (sic), Provide pressure reducing wheelchair cushion, Provide pressure reduction/relieving mattress, Provide thorough skin care after incontinent episodes, Treatments as ordered The Plan of Care lacked any interventions related to complete pressure relief to the left buttock or left heel. The CNA Assignment sheet provided by the DON (Director of Nursing) on 10/17/16 at 10:17 A.M. indicated Resident #66 required, .Turn every 2 hrs (hours) while in bed. Keep heels floated for pressure relief . The physician's orders [REDACTED]. Wound #1 Left buttock A Wound Evaluation Flow Sheet dated 10/12/16 indicated the Stage 2 wound contained an undocumented amount of slough and had deteriorated. The flow sheet lacked any documentation related to pressure relief interventions to the left buttock. The Wound Evaluation Flow Sheet further indicated, . NPUAP (National Pressure Ulcer Advisory Panel) Pressure Ulcer Stages, Definitions, and Descriptions .Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue .Stage 1 Intact skin with non-blanchable redness of a localized area usually over a bony prominence .Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister .Stage 3 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May included undermining and tunneling .Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan gray green or brown and/or eschar (tan brown or black in the wound bed . Wound #2 Left heel A Wound Evaluation Flow Sheet dated 10/12/16 indicated, .Stage/Type: ? .4 X 3 .dark in appearance starting to harden . Wound #3 Right buttock The Nursing notes from 10/01/16 through 10/11/16/ at 2:13 P.M. were reviewed and lacked any documentation related to a facility acquired pressure ulcer to the right buttock. A Wound Evaluation Flow Sheet dated 10/5/16 indicated Resident #66 experienced an area of non-pressure related skin impairment to the right buttock described as, .Other wound .other . The assessment further indicated, .Stage 2 .1.5 X 1.0 X 0 .bruised looking . A Wound Evaluation Flow Sheet dated 10/12/16 indicated, .Stage 2 .0.9 X 0.8 X <0.1 .wound bed red .improved . During an interview on 10/19/16 at 10:37 A.M., LPN #6 indicated Resident #66 was still in the therapy department. During an interview on 10/19/16 at 10:38 A.M. LPN #7 indicated Resident #67 had been in the therapy department since after breakfast. During an interview on 10/19/16 at 10:40 A.M., LPN #6 indicated care was going to be provided to Resident #66 after an episode of incontinence was experienced in therapy. During an observation of care on 10/19/16 at 10:45 A.M., LPN #6 and CNA #6 were observed to transfer Resident #66 from the wheelchair to the toilet and Resident #66 stated, at that time, Oh! That's sore back there! I can't sit here long . A foam wheelchair seat cushion was observed, at that time, to have a deep indentation of Resident #66 buttocks and upper legs. During an interview on 10/19/16 at 10:50 A.M., CNA #6 indicated Resident #66 was sitting up in the wheelchair when she arrived on the unit at 7:00 A.M. CNA #8 further indicated, at that time, this was the first time Resident #66 had been toileted on her shift because Resident #66 gone to breakfast, then straight to therapy. During an observation on 10/19/16 at 10:55 A.M., LPN #6 indicated she was preparing to assess and provide wound care to Resident #66 and the following was observed: Wound #1 The left buttock pressure ulcer measured 0.6 cm (centimeters) X 0.3 cm X 0.1 cm with 50% white tissue. During an interview, at that time, LPN #6 indicated the white tissue was not slough, because it was not thick. Wound #2 The outer left heel pressure ulcer measured 4.5 cm X 3.9 cm with a black skin cover intact. Wound #3 The right buttock pressure ulcer measured 3.0 cm X 1.7 cm X undetermined. During an interview, at that time, LPN #6 indicated the wound bed was 100% covered by yellow slough. During an observation on 10/19/16 at 1:30 P.M., Resident #66 was observed to be sitting on the side of the bed and CNA #6 and CNA #5 indicated they were preparing to assist Resident #66 to lay down bed. CNA #6 grasped Resident #66 around the shoulders and CNA #5 grasped Resident #66 around the legs and positioned Resident #66 into a supine position in one motion by pivoting on the buttocks. The CNA #5 was then observed to apply an abduction cushion between the legs and position a pillow under the heels of Resident #66. The heels of Resident #66 were observed, at that time, to be positioned directly on the pillow and to not be floated. CNA #6 was observed to reposition Resident #66 into a left side-lying position by pulling an incontinence pad across the surface of the bed. During an interview, at that time, CNA #6 indicated Resident #66 required the extensive assistance of two staff for all position changes and CNA #5 indicated Resident #66 had not been provided pressure relief to the buttocks from 7:00 A.M. through 1:30 P.M. (6.5 hours) The Policy and Procedure for, Skin Integrity Guideline provided by the HFA (Health Facilities Administrator) on 10/20/16 at 11:17 A.M. indicated, .To decrease pressure ulcer and/or wound formation by identifying those .who are at risk, and implementing appropriate interventions .promote healing of wounds of any etiology, whether admitted or acquired . 3.1-40(a)(1) 3.1-40(a)(2)

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE 2 OF 3 RESIDENT WITH PRESSURE SORES IN A SAMPLE OF 13 WHO ENTERED THE FACILITY WITHOUT A PRESSURE SORE DID NOT DEVELOP A PRESSURE SORE, IN THAT THE RESIDENT LAYED ON HER RIGHT HELL AND THIS RESULTED IN THE DEVELOPMENT OF A UNSTAGEABLE BLACK ESCHAR PRESSURE AREA ON THE RESIDENT E'S RIGHT HEEL AND A STAGE II PRESSURE AREA ON HER COCCYX, THE RESIDENT'S PRESSURE REDUCING MATTRESS WAS NOT SET ON THE CORRECT SETTING FOR THE RESIDENT'S WEIGHT. RESIDENT #D DEVELOPED A STAGE III AREA ON HIS LEFT BUTTOCK. RESIDENT #E AND RESIDENT #D FINDINGS INCLUDE: 1. ON 10/21/10 AT 8:25, A.M. THE FACILITY'S POLICY AND PROCEDURE TITLED, "SKIN CARE MANAGEMENT" WAS RECEIVED/REVIEWED FROM THE ALZHEIMER'S UNIT DIRECTOR ( DATED 2/25/10). THE POLICY AND PROCEDURE INCLUDED, BUT WAS NOT LIMITED TO, "PURPOSE: TO PROVIDE A SYSTEMIC APPROACH AND MONITORING PROCESS FOR SKIN. TO DECREASE PRESSURE ULCER FORMATION BY IDENTIFYING THOSE RESIDENTS WHO ARE AT RISK AND DEVELOPING INTERVENTIONS. 2. DURING THE INITIAL TOUR OF THE FACILITY ON 10/18/10 AT 9:10 A.M. WITH LPN #1 SHE INDICATED RESIDENT #E HAD A STAGE III OR IV OR HER COCCYX AND HAD AN UNSTAGEABLE AREA ON HER RIGHT HEEL. THE RESIDENT WAS LYING IN BED THE RESIDENT WAS LYING ON AN "ALPHA ACTIVE" PRESSURE REDUCING MATTRESS. THE MANUAL PRESSURE SETTING DIAL FOR THE MATTRESS WAS SET ON 220 PRESSURE. THE AREA ON THE RESIDENT'S RIGHT HEEL WAS OBSERVED AT THAT TIME. THE RIGHT HEEL WAS OBSERVED TO HAVE A 2 CM (CENTIMETER) X 2.0 CM (APPROXIMATED BY SITE) BLACK ESCHAR AREA, WITH PEELING SKIN ON THE OUTER PERIMETER. A STAGE II PRESSURE AREA ON THE RESIDENT'S COCCYX WAS 2. CM X 2.0 CM (APPROXIMATED BY SITE). RESIDENT #E'S CLINICAL RECORD WAS REVIEWED ON 10/18/10 AT 11:45 A.M. [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE] INDICATED PROBLEMS WITH SHORT/LONG TERM MEMORY AND HER COGNITIVE SKILLS FOR DAILY DECISION-MAKING WERE MODERATELY IMPAIRED. THE ASSESSMENT INDICATED SHE REQUIRED EXTENSIVE ASSISTANCE OF 2 PERSONS FOR THE TASK OF TRANSFER. THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE OF 2 STAFF MEMBER TO TURN FROM SIDE TO SIDE AND POSITION SELF WHILE IN BED. THE ASSESSMENT INDICATED THE RESIDENT WAS INCONTINENT OF BOWEL AND BLADDER. THE ASSESSMENT INDICATED NO PRESSURE ULCERS. THE "CLINICAL HEALTH STATUS" FORM DATED 7/15//10 (admitted ) INDICATED THE RESIDENT HAD NO SKIN ISSUES. THE "DIABETES FOOT SCREEN" PORTION FOR PREDICTING PRESSURE SORES INDICATED A SCORE OF 16, WHICH INDICATED "AT RISK". THE NURSES NOTES INCLUDED, BUT WERE NOT LIMITED TO THE FOLLOWING DOCUMENTATION: 9/20/10 AT 10:35 A.M. "NOTIFIED BY NITE NURSE THAT DISCOLORED AREA ON COCCYX NOW OPEN. CHECKED BY THIS NURSE AND AREA MEASURED AT 2 X 1.2 X 0.3 CM, WOUND BED PINK AND EDGES INTACT. NO DRAINAGE NOTED." THE "WOUND EVALUATION FLOW SHEET" INDICATED THE FOLLOWING: 9/20/10: MEASUREMENTS: STAGE II LENGTH: 2 CM WIDTH: 1.2 CM DEPTH: 0.3 9/28/10 AT 20:59 (8:59 P.M.) "FOUND A BLACK PRESSURE AREA ON INSIDE OF RIGHT HEEL IT IS NOT OPENED AT THIS TIME." THE "WOUND EVALUATION FLOW SHEET" INDICATED THE FOLLOWING: 9/28/10: MEASUREMENTS: UNSTAGEABLE LENGTH: 2.0 CM (CENTIMETERS) WIDTH: 3.0 CM DEPTH: ZERO COLOR: BLACK PERIWOUND: 2 X 3 DURING AN INTERVIEW WITH LPN #1 ON 10/20/10 AT 10:30 A.M. SHE INDICATED THE RESIDENT DEVELOPED THE AREA ON HER FROM LYING ON THE HEEL. LPN #1 INDICATED SHE DID NOT KNOW IF 220 WAS THE CORRECT SETTING FOR THE MATTRESS. ON 10/21/10 THE "USER MANUAL" FOR THE ALPHA ACTIVE MATTRESS WAS RECEIVED FROM THE ALZHEIMERS UNIT MANAGER AND WAS REVIEWED AT THAT TIME. THE MANUAL INDICATED, "LOCATED ON THE FRONT OF THE PUMP, THE MANUAL PRESSURE SETTING DIAL IS USED IN CONJUNCTION WITH THE PATIENT WEIGHT GUIDE. IT PROVIDES THE MEANS FOR ADJUSTING THE PRESSURE INSIDE THE MATTRESS AND, THEREFORE, THE AMOUNT OF SUPPORT THE PATIENT RECEIVES". ON 10/21/10 AT 11:30 A.M. THE MANUAL PRESSURE SETTING DIAL WAS SET ON 365. LPN #4 WAS PRESENT AT THAT TIME AND INDICATED "THAT IS TO HIGH". LPN #4 PROCEEDED TO CHANGE THE SETTING TO 90. REVIEW OF THE RESIDENT'S "WEIGHT RECORD" INDICATED HER WEIGHT ON 10/9/10 WAS 117 POUNDS, ACCORDING TO THE USER MANUAL THE BED SHOULD HAVE BEEN SET ON 117 ACCORDING TO THE RESIDENT'S WEIGHT OF 117 POUNDS. THE RESIDENT'S PLAN OF CARE TITLED, "AT RISK FOR SKIN BREAKDOWN DUE TO: ASSISTANCE REQUIRED IN BED MOBILITY, BRADEN SCORE 18 OR (BELOW), INCONTINENT OF BOWEL". (DATED INITIATED 8/1/10) GOALS: "SKIN WILL REMAIN INTACT. AREA WILL BE HEALED BY NEXT REVIEW". INTERVENTIONS (ALL DATED 8/1/10): "CONDUCT WEEKLY SKIN INSPECTION. ENCOURAGE PROPER NUTRITION AND HYDRATION. PROVIDE PRESSURE REDUCING WHEELCHAIR CUSHION. PROVIDE PRESSURE REDUCTION/RELIEVING MATTRESS (. PROVIDE THOROUGH SKIN CARE AFTER INCONTINENT EPISODES AND APPLY BARRIER CREAM. ASSIST TO TURN AND REPOSITION EVERY TWO HOURS. TREATMENT AS ORDERED, VIT C, ZINC AND MULTIPLE VITAMIN AS ORDERED. 3. DURING THE INITIAL TOUR OF THE FACILITY ON 10/18/10 AT 9:10 A.M. WITH LPN #1, SHE INDICATED RESIDENT #D HAD A STAGE II PRESSURE AREA ON HIS LEFT BUTTOCK. RESIDENT #D'S RECORD WAS REVIEWED ON 10/18/10 AT 12:30 P.M. [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], INDICATED THE RESIDENT HAD PROBLEMS WITH SHORT/LONG TERM MEMORY AND HIS SKILLS FOR DAILY DECISION WERE MODERATELY IMPAIRED. THE ASSESSMENT INDICATED THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE OF 2 STAFF FOR THE TASK OF BED MOBILITY AND TRANSFER. THE RESIDENT HAD LIMITED RANGE OF MOTION WITH PARTIAL LOSS OF VOLUNTARY MOVEMENT IN ONE ARM AND LIMITED RANGE OF MOTION WITH PARTIAL LOSS OF VOLUNTARY MOVEMENT OF BOTH LEGS. THE RESIDENT WAS INCONTINENT OF BOWEL AND BLADDER. THE ASSESSMENT INDICATED THE RESIDENT HAD A STAGE II PRESSURE ULCER. A "CLINICAL HEALTH STATUS" REPORT DATED 6/18/10 INDICTED THE RESIDENT HAD NO PRESSURE AREAS. THE "WOUND EVALUATION FLOW SHEET" DATED 8/19/10 INDICATED A STAGE III PRESSURE AREA ON THE RESIDENT'S LEFT BUTTOCK. THE AREA MEASURED 1.5 CM X 0.3 CM, WITH YELLOW ESCHAR NOTED IN THE WOUND BED. THE AREA ON RESIDENT D'S LEFT COCCYX WAS OBSERVED ON 10/19/10 AT 9:40 A.M. WITH LPN #1. THE AREA WAS OBSERVED TO BE (APPROXIMATED BY SITE) 1.0 CM X 1.0 CM , NO DRAINAGE, WITH PINK TISSUE IN THE WOUND BED, A CLEAR MARGIN WITH PINK TISSUE AROUND THE OUTER EDGES OF THE WOUND. THE RESIDENT'S PLAN OF CARE (DATED 9/3/10) TITLED, "RESIDENT HAS PRESSURE ULCER TO LEFT BUTTOCK. GOALS: PRESSURE ULCER WILL HEAL 50% MONTHLY UNTIL HEALED AND HAVE NO COMPLICATIONS. INTERVENTIONS: CONDUCT WEEKLY SKIN INSPECTION. ENCOURAGE PROPER NUTRITION AND HYDRATION. PROVIDE PRESSURE REDUCTION/RELIVING WHEELCHAIR CUSHION. PROVIDE PRESSURE REDUCTION/RELIEVING MATTRESS. TREATMENT AS ORDERED. ASSIST TO TURN AND REPOSITION EVERY TWO HOURS. MONITOR AREA FOR CHANGES IN SIZE, COLOR, DRAINAGE ODOR, DEPTH. NOTIFY MD (MEDICAL DOCTOR) OF CHANGES". 3.1-40(a)(1)

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE AN ALARM WAS FUNCTIONING AT THE TIME THE RESIDENT #E fell OUT OF HER WHEELCHAIR AND SUSTAINED A LACERATION TO HER HEAD AND A SKIN TEAR ON HER HAND AND THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT RESIDENT #H FROM FALLING, SHE fell AND SUSTAINED A FRACTURED CLAVICLE. RESIDENTS. THE FACILITY FAILED TO ENSURE AN ALARM WAS FUNCTIONING AT THE TIME RESIDENT # M fell . #E AND #H AND #M. FINDINGS INCLUDE: 1. DURING THE INITIAL TOUR OF THE FACILITY ON 10/18/10 AT 9:10 A.M. WITH LPN #1, RESIDENT #E WAS OBSERVED LYING IN BED. HER BED WAS IN THE LOWEST POSITION. A MAT WAS OBSERVED ON THE FLOOR BESIDE THE BED. LPN #1 INDICATED THE RESIDENT WAS AT RISK FOR FALLS. RESIDENT #E'S CLINICAL RECORD WAS REVIEWED ON 10/18/10 AT 11:45 A.M. [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE] INDICATED PROBLEMS WITH SHORT/LONG TERM MEMORY AND HER COGNITIVE SKILLS FOR DAILY DECISION-MAKING WERE MODERATELY IMPAIRED. THE ASSESSMENT INDICATED SHE REQUIRED EXTENSIVE ASSISTANCE OF 2 PERSONS FOR THE TASK OF TRANSFER. HER TEST FOR BALANCE WHILE STANDING INDICATED SHE WAS NOT ABLE TO ATTEMPT THE TEST WITHOUT PHYSICAL HELP AND HER TEST FOR BALANCE WHILE SITTING INDICATED SHE REQUIRED PARTIAL PHYSICAL SUPPORT DURING SUPPORT DURING THE TEST. AN ASSESSMENT TITLED, "RISK FOR FALLS" DATED 7/15/10, INDICATED A SCORE OF 12. A TOTAL SCORE OF 10 OR ABOVE DEEMS RESIDENT AT RISK. THE NURSES NOTES INCLUDED, BUT WERE NOT LIMITED TO THE FOLLOWING DOCUMENTATION: 8/18/10 AT 22:21 (10:21 P.M.) "RES (RESIDENT) WAS LAYING ON RIGHT SIDE OF BODY ON FLOOR, IN FRONT OF W/C (WHEELCHAIR). NURSE ASSISTANCE CAME & (AND) GOT THIS NURSE & THIS NURSE BEGAN TO ASSESS RES. RES WAS ALERT & QUIET. RES EXTREMITIES WERE MOVEABLE & THIS NURSE & TWO NURSE ASSISTANCE SAT RES BACK IN W/C. NOTED RES TO HAVE SKIN TEAR TO TOP OF RIGHT HAND MEASURING APPROX (APPROXIMATELY) 4 CM (CENTIMETERS) X 4 CM. NOTED TOP OF HEAD HAD LACERATION APPROX. 2 CM X 0.4 CM. CLEANED AREAS & STERI - STRIPS APPLIED TO RIGHT HAND. NOTIFIED DR. (DOCTOR) (NAME), FAMILY, ADON (ASSISTANT DIRECTOR OF NURSING), N.O.'S (NEW ORDERS) TO SEND RES TO ER (emergency room ) FOR EVAL (EVALUATION & TX (TREATMENT). (NAME OF AMBULANCE SERVICE) EMT'S (EMERGENCY MEDICAL TECHNICIANS) WEE NOTIFIED & WERE HERE TO PICK UP RES @ APPOX 7:45 P.M. RES LEFT IN SATISFACTORY CONDITION." 8/19/10 AT 14:48 (2:48 P.M.) "SKIN ASSESSMENT: SKIN INTACT WITH NO OPEN OR RED AREAS NOTED. CURRENTLY HAS 3 STAPLES IN RT (RIGHT) SIDE OF HEAD FROM LAST EVENINGS INCIDENT. STERI - STRIPS ON HAND ALSO INTACT WITH NO ACTIVE BLEEDING NOTED FROM EITHER." THE RESIDENT'S PLAN OF CARE, "AT RISK FOR FALLS RELATED TO USE OF PSYCHOACTIVE MEDICATIONS, NEW ENVIRONMENT" (DATED 8/1/10). THE GOAL WAS "RESIDENT WILL BE ASSIST AS NEED WITH ADL'S (ACTIVITIES OF DAILY LIVING) AND RESIDENT WILL NO (SIC) FALLS". THE INTERVENTIONS INCLUDED, BUT WERE NOT LIMITED TO, ALARM ON WHEN UP IN WHEELCHAIR AND KEEP IN VIEW OF STAFF @ ALL TIMES WHILE IN W/C." DURING AN INTERVIEW WITH RN #2 ON 10/20/10, 11:25 A.M. SHE INDICATED THERE WAS NO DOCUMENTATION AND OR VERIFICATION OF THE ALARM SOUNDING AT THE TIME OF FALL ON 8/18/10. 3. THE CLOSED CLINICAL RECORD OF RESIDENT H WAS REVIEWED ON 10/19/10 AT 10:30 A.M. RESIDENT H WAS admitted TO THE LOCKED ALZHEIMER'S CARE UNIT (ACU) ON 7/14/10. [DIAGNOSES REDACTED]. AN ADMISSION MINIMUM DATA ASSESSMENT (MDS), dated [DATE], INDICATED RESIDENT H HAD A SHORT-TERM AND LONG-TERM MEMORY PROBLEM, WAS MODERATELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION-MAKING, WAS EASILY DISTRACTED, HAD PERIODS OF RESTLESSNESS, AND THE MENTAL FUNCTION VARIED OVER THE COURSE OF THE DAY. THE MDS ASSESSMENT INDICATED RESIDENT H EXHIBITED BEHAVIOR SYMPTOMS OF WANDERING DAILY THAT WAS NOT EASILY ALTERED. THE RESIDENT WAS INDEPENDENT WITH LOCOMOTION. A TEST FOR BALANCE WHILE STANDING INDICATED, "PARTIAL PHYSICAL SUPPORT DURING TEST; OR STANDS (SITS) BUT DOES NOT FOLLOW DIRECTIONS FOR TEST." A RESIDENT ASSESSMENT PROTOCOL (RAP), DATED 7/26/10, INDICATED, "...WILL FALLS BE ADDRESSED IN THE CARE PLAN? YES...DESIRED IMPACT OF THE THIS PROBLEM/NEED ON THE RESIDENT AND YOUR RATIONALE FOR CARE PLAN DECISION...: ...WALKS LEANING BODY TO THE SIDE...NEEDS ASSISTANCE WITH DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING R/T (RELATED TO) ALZHEIMER'S...PROBLEMS WITH LONG/SHORT MEMORY AND DECISION MAKING SKILLS...OCCASIONALLY INCONTINENT OF BLADDER...RECEIVING HYPNOTIC (MEDICATION THAT CAN HAVE SIDE EFFECTS INCLUDING DROWSINESS, VERTIGO OR DIZZINESS, AND WEAKNESS) DAILY. DOES WANDER ON THE ACU. PROCEED TO CARE PLAN." A CARE PLAN ADDRESSING A POTENTIAL PROBLEM OF FALLS WAS NOT OBSERVED IN THE CLINICAL RECORD PRIOR TO 8/9/10. PROGRESS NOTES INCLUDED THE FOLLOWING NOTATIONS: 7/27/10 AT 9:26 A.M.: "UP AMBULATING IN HALL...WANDERS THROUGHOUT THE UNIT. GAIT SLOW AND STEADY, BUT DOES LEAN TO THE LEFT WHEN AMBULATING. AGITATES EASILY." 7/29/10 AT 10:30 P.M.: "4:30 PM WONDERING (SIC) IN HALL AND RAN INTO DOOR FRAME WITH HEAD DOWN CAUSING 1/2 INCH LACERATION ON FOREHEAD NEAR LEFT EYEBROW..." 8/8/10 AT 1:36 P.M.: "RESIDENT UP AMBULATING IN HALLWAY. HAS BEEN CALM THIS SHIFT...NEURO (NEUROLOGICAL) CHECKS CONTINUES." DURING INTERVIEW ON 10/20/10 AT 10:30 A.M., THE ACU DIRECTOR PROVIDED DOCUMENTATION, DATED 10/19/10 AT 12:29 P.M., WHICH INDICATED: "ON 8/8/10 AT 2:56 A.M., THE FOLLOWING OCCURRED: FALLS: AMBULATING - WITHOUT ASSISTANCE IN RESIDENT LOUNGE (RESIDENT WAS STANDING BY DOOR IN LOUNGE WHEN SHE LOSS (SIC) HER BALANCE AND fell BACKWARD. CNA AND QMA WITNESSED HEARD A BANG AS THEY WERE WALKING THROUGH THE CORRIDOR, AND SAW RESIDENT LYING ON HER BACK.) INJURIES: HEAD INJURY ON HEAD: OTHER (RESIDENTS (SIC) LEFT ARM WAS SWOLLEN, AND STARTED TO BRUISE IMMEDIATELY. RESIDENT ALSO WAS FAVORING HER LEFT ARM)...FIRST AID ADMINISTERED IN FACILITY, PHYSICIAN NOTIFIED, FAMILY NOTIFIED, RESIDENT TAKEN TO HOSPITAL..." A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 8/20/10 AT 2:56 A.M., INDICATED, "OBJECTIVE/UNDERLYING ILLNESS/DX (DIAGNOSIS): HX (HISTORY) OF FALLS...INTERVENTIONS USED PRIOR TO FALL: PAIN ASSESSMENT, CALL LIGHT W/IN (WITHIN) REACH...RECOMMENDATIONS AND INTERVENTIONS POST FALL: PAIN ASSESSMENT, SAFETY CUES/REINFORCEMENT/REMINDER, CALL LIGHT W/IN REACH." THE ACU DIRECTOR INDICATED AT THAT TIME THAT THESE DOCUMENTS WERE NOT PART OF THE RESIDENT'S CLINICAL RECORD, AND SHE OBTAINED THEM FROM PRINTING THEM OFF OF THE COMPUTER. CLINICAL PROGRESS NOTES CONTINUED: 8/16/10 AT 1:51 P.M.: "...HAS SEVERAL BRUISES ON BOTH ARMS AND ONE ON FOREHEAD FROM EARLIER FALLS. RED AREA ON RT. (RIGHT) CHIN..." 8/19/10 AT 2:27 P.M.: "NEW ORDERS RECEIVED YESTERDAY TO DECREASE THE RISPERDAL (AN ANTI-PSYCHOTIC MEDICATION) TO ONE TIME DAILY INSTEAD OF BID (TWICE DAILY). STAFF FELT THAT RESIDENT WANTING TO LEAN TO SIDE MORE SINCE THE RISPERDAL STARTED." 8/20/10 AT 7:19 A.M.: "RESIDENT fell AT 2340 (11:40 P.M.) ON 8/19/10. FALL WAS WITNESSES (SIC) BY ANOTHER RESIDENT WHO STATED THAT SHE HIT HER HEAD ON THE CLOSET. I ASSESSED HER AND FOUND A SMALL, RAISED RED AREA ON THE BACK OF HER HEAD THAT WAS TENDER TO TOUCH...INITIATED NEURO CHECKS. LEFT MESSAGE WITH ACU DIRECTOR. THIS MORNING NOTICED RESIDENT HOLDING HER LEFT ARM AGAINST HER ABDOMEN. REASSESSED THE ARM AND RESIDENT DENIED PAIN. LATER HEARD RESIDENT STATE TO A CNA THAT HER ELBOW WAS HURTING HER...NOTIFIED FAMILY AND DOCTOR...." ON 10/20/10 AT 10:30 A.M., THE ACU DIRECTOR PROVIDED A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 8/19/10 AT 11:40 P.M. THE REPORT INDICATED: "...OBJECTIVE/UNDERLYING ILLNESS/DX: IMPAIRED SAFETY AWARENESS/JUDGMENT DEMENTIA...RESIDENT LEANS TO THE BACK AND TO THE LEFT WHEN AMBULATING...ON 8/19/10 AT 11:40 PM, THE FOLLOWING OCCURRED: FALLS: AMBULATING - WITHOUT ASSISTANCE IN OTHER (RESIDENT fell IN (OTHER RESIDENT ROOM), INJURY: NO APPARENT INJURY...PHYSICIAN NOTIFIED, FAMILY NOTIFIED, CARE PLAN UPDATED. INTERVENTIONS USED PRIOR TO FALL: NIGHT LIGHT, CALL LIGHT W/IN REACH. RECOMMENDATIONS AND INTERVENTIONS POST FALL: CHANGE IN FOOTWEAR, NIGHT LIGHT, CALL LIGHT W/IN REACH...." CLINICAL PROGRESS NOTES INDICATED THE FOLLOWING NOTATIONS: 8/20/10 AT 10:15 A.M.: (PHYSICIAN) HERE TO SEE RESIDENT...." A physician progress notes [REDACTED].HEMATOMA (RAISED BRUISE) (LEFT) FOREHEAD...." PROGRESS NOTES CONTINUED: 8/21/10 AT 1:58 P.M.: "9 AM RESIDENT HAS BRUISE ON RT. CLAVICLE AND SWELLING. C/O'S (COMPLAINS OF) PAIN. REFUSED TO FEED SELF...RESIDENT fell on Thursday WITH NO APPARENT INJURIES. (PHYSICIAN) WAS HERE AND CHECKED RESIDENT ON Friday...11 AM DAUGHTER HERE AND INFORMED OF BRUISED AREA. WANTS X-RAY...12:30 PM (PHYSICIAN) CALLED AND N/O'S (NEW ORDERS) RECEIVED TO GET X-RAY OF RT CLAVICLE RT. ELBOW (SIC) RT. HIP RT SHOULDER...2 PM...X-RAYS DONE." A RADIOLOGY REPORT, DATED 8/21/10, INDICATED: "...RIGHT SHOULDER: THERE IS AN ACUTE FRACTURE OF THE MIDDLE 3RD OF THE RIGHT CLAVICLE WITH SLIGHT DISPLACEMENT..." PROGRESS NOTES CONTINUED: 8/22/10 AT 6:11 A.M.: "RES. (RESIDENT) RETURNED TO FACILITY FROM (NAME OF HOSPITAL) @ 6:50 A.M. DUE TO A FALL THE EVENING OF 8/21/10 VIA AMBULANCE. ORDERS FROM M.D. @ HOSPITAL STATED MANY X-RAYS WERE TAKEN, AND SHOWED RESULTS OF AN ACUTE FRACTURE ON THE LEFT CLAVICLE, DUE TO A PREVIOUS FALL BEFORE THIS LAST ONE THE EVENING OF 8/22/2010 (SIC). M.D. ORDERED FOR RESIDENT TO WEAR A SLING ON RIGHT ARM WHEN NOT SLEEPING, AND TO RESUME NORMAL ACTIVITIES. RESIDENT'S DAUGHTER AND POA (POWER-OF-ATTORNEY) (NAME) CALLED THIS NURSE, AND STATED THAT SHE DEMANDED HER MOTHER HAVE A BED ALARM AT ALL TIMES, A MATT PLACED BY BEDSIDE AND THAT RESIDENT BE MOVED TO A ROOM CLOSE TO THE NURSES STATION. SHE STATED THAT SHE HAD SPOKEN TO (PHYSICIAN), AND HE TOLD HER HE WOULD SIGN ANYTHING SHE WANTED FOR HER MOTHER TO KEEP HER SAFE...(RESIDENT H) DOES HAVE A PULL ALARM AT THIS TIME, AS A BED ALARM WAS NOT AVAILABLE. RESIDENT IS BEING MONITORED CLOSELY, AND DOES NOT SHOW ANY S/S (SIGNS OR SYMPTOMS) OF PAIN OR DISCOMFORT. CALL LIGHT IS WITHIN REACH." ON 10/20/10 AT 10:30 A.M., THE ACU DIRECTOR PROVIDED A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 8/21/10 AT 10:45 P.M. THE REPORT INDICATED: "...FALLS: AMBULATING - WITHOUT ASSISTANCE IN RESIDENT'S ROOM (NUMBER OF ROOM), INJURY; NO APPARENT INJURY...PHYSICIAN NOTIFIED, FAMILY NOTIFIED, RESIDENT TAKEN TO HOSPITAL, CARE PLAN UPDATED. INTERVENTIONS USED PRIOR TO FALL: (NONE INDICATED). RECOMMENDATIONS AND INTERVENTIONS POST FALL: (NONE INDICATED)." PROGRESS NOTES CONTINUED: 8/22/10 AT 2:30 P.M.: "10 AM RESIDENT SLEPT MOST OF MORNING...REQUIRED ASSIST OF TWO TO AMBULATE TO DINING ROOM. GAIT VERY UNSTEADY. BRUISING TO RT SHOULDER AND ARMS/BUTTOCKS/LOWER BACK FROM PREVIOUS FALLS...." 8/22/10 AT 7:53 P.M.: "RESIDENT HAS BEEN UP WANDERING UNIT MOST OF EVENING. VERY CONFUSED AND UNABLE TO COMMUNICATED (SIC) WANTS AND NEEDS VERY WELL...GAIT IS SOMEWHAT UNSTABLE AND REQUIRES FREQUENT MONITORING TO PREVENT AND (SIC) FURTHER FALLS OR ACCIDENTS...." 8/25/10 AT 6:34 A.M.: RESIDENT RETURNED TO FACILITY @ 0115 (1:15 A.M.). LAB AND CAT SCAN RESULTS ACCOMPANIED RESIDENT -FAXED TO DOCTOR...." ON 10/20/10 AT 10:30 A.M., THE ACU DIRECTOR PROVIDED A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 8/24/10 AT 6:10 P.M. THE REPORT INDICATED: "...ON 8/24/10 AT 6:10 P.M., THE FOLLOWING OCCURRED: FALLS: WHEELCHAIR IN CORRIDOR (...OUTSIDE OF SITTING AREA/DEN): NO APPARENT INJURY...PHYSICIAN NOTIFIED, FAMILY NOTIFIED, RESIDENT TAKEN TO HOSPITAL...INTERVENTIONS USED PRIOR TO FALL: (NONE INDICATED). RECOMMENDATIONS AND INTERVENTIONS POST FALL: OTHER." AN EMERGENCY DEPARTMENT NOTE, DATED 8/24/10, INDICATED: "...HISTORY OF PRESENT ILLNESS: PATIENT...WITH SEVERE DEMENTIA BROUGHT IN BY HER DAUGHTER BECAUSE OF INCREASING FALLS...ED COURSE AND PLAN: PATIENT DID QUITE WELL WHILE SHE WAS HERE...I EXPLAINED TO THE DAUGHTER THAT THIS COULD BE JUST PROGRESSION OF THE DISEASE, THAT I COULD NOT FIND ANY SOURCE OF INFECTIONS OR ANY OTHER REASONS WHEY THE PATIENT WAS HAVING INCREASED FALLS...." THE FIRST CARE PLAN WHICH ADDRESSED FALLS, DATED 8/9/10, INDICATED A PROBLEM OF "AT RISK FOR FALLS RELATED TO: fell IN THE PAST 30 DAYS, WANDERING." INTERVENTIONS INDICATED: "APPROPRIATE CALL LIGHT AVAILABLE. ENCOURAGE REST PERIODS DAILY TO AVOID OVERTIRING. EVALUATE NEED FOR BED ALARM." A CARE PLAN, DATED 8/19/10, INDICATED: "FOCUS: RISK FOR FALLS." THE INTERVENTION INDICATED, "GRIPPER SOCKS AT NIGHT." THE NEXT CARE PLAN RELATED TO FALLS, DATED 8/27/10, INDICATED, "FOCUS: AT RISK FOR FALLS RELATED TO: fell IN THE PAST 30 DAYS, WANDERING, USE OF MEDICATION, HISTORY OF FALLS." THE INTERVENTIONS INCLUDED: "ACTIVITY PROGRAMMING - EXERCISES, TV PROGRAMS. DATE INITIATED 8/23/2010...BED IN LOW POSITION. CALL LIGHT OR PERSONAL ITEMS AVAILABLE AND IN EASY REACH OR PROVIDE REACHER...OBSERVE FOR SIDE EFFECTS OF MEDICATIONS...TAMPER RESISTANT PRESSURE ALARM TO BED. DATE INITIATED: 8/26/10. PRESSURE ALARM TO CHAIR WHILE UNABLE TO AMBULATE ON OWN. DATE INITIATED: 8/26/10." 4. ON 10/21/10 AT 10:00 A.M., RESIDENT M, WHO RESIDED IN THE ALZHEIMER'S CARE UNIT (ACU), WAS OBSERVED SITTING IN A WHEELCHAIR WITH A SENSOR ALARM ATTACHED TO THE CHAIR. THE CLINICAL RECORD OF RESIDENT M WAS REVIEWED ON 10/21/10 AT 10:10 A.M. [DIAGNOSES REDACTED]. A MINIMUM DATA SET (MDS) ASSESSMENT, DATED 5/31/10, INDICATED RESIDENT M HAD A SHORT-TERM AND LONG-TERM MEMORY PROBLEM, WAS MODERATELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION-MAKING, WAS EASILY DISTRACTED, HAD PERIODS OF RESTLESSNESS, AND PERIODS OF LETHARGY. THE MDS ASSESSMENT INDICATED RESIDENT M HAD BEHAVIORS OF WANDERING, AND REQUIRED LIMITED ASSISTANCE OF ONE STAFF FOR TRANSFER AND WALKING IN ROOM AND CORRIDOR. A TEST FOR BALANCE WHILE STANDING INDICATED, "PARTIAL PHYSICAL SUPPORT DURING TEST; OR STANDS (SITS) BUT DOES NOT FOLLOW DIRECTIONS FOR TEST." THE RESIDENT HAD FALLEN IN THE PREVIOUS 31-180 DAYS. A PLAN OF CARE, DATED 6/8/10, INDICATED A PROBLEM OF "AT RISK FOR FALLS RELATED TO: WANDERING ON ACU. RESIDENT REQUIRES LIMITED ASSISTANCE WITH BED MOBILITY, TRANSFERS, AMBULATION, LOCOMOTION." THE INTERVENTIONS INCLUDED: "ASSIST IN TRANSFER IF NEEDED. CALL LIGHT AVAILABLE. ASSIST WITH MOBILITY IF NEEDED...SENSOR PAD TO BED TO ALERT STAFF WHEN GETTING UP EVERY SHIFT EVERY SHIFT (SIC)...." NURSING PROGRESS NOTES INCLUDED THE FOLLOWING NOTATIONS: 6/22/10 AT 6:40 P.M.: "6:15 PM. CALLED BACK TO ACU AT THIS TIME, FOUND RESIDNET (SIC) SITTING ON BOTTOM ON FLOOR IN FRONT OF W/C (WHEELCHAIR). RESIDENT WAS BY THE RESIDENTS FRONT PROUCH (SIC) AREA. STAFF STATED THAT RESIDNET (SIC) HAD BEEN AMBULATING IN HALLWAY DOING HER USUAL ACTIVITES (SIC), TRYIED (SIC) TO SIT IN W.C. (WHEELCHAIR) THAT WAS IN HALLWAY, CHAIR ROLLED OUT FROM UNDER HER CAUSING HER TO GO TO FLOOR...." ON 10/21/10 AT 11:30 A.M., THE ACU DIRECTOR PROVIDED A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 6/22/10. THE REPORT INDICATED: "...OBJECTIVE/UNDERLYING ILLNESS/DX (DIAGNOSIS): IMPAIRED SAFETY AWARENESS/JUDGMENT...DOING USUAL ACTIVITIES...INTERVENTIONS USED PRIOR TO FALL: SAFETY CUES/REINFORCEMENT/REMINDER. RECOMMENDATIONS AND INTERVENTIONS POST FALL: SAFETY CUES/REINFORCEMENT/REMINDER." 6/26/10 AT 3:42 P.M.: "2:00 PM CALLED TO RESIDENT ROOM PER CNA. RESIDENT WAS SITTING IN FLOOR IN BATHROOM. NO APPARENT INJURIES NOTED. RESIDENT UNABLE TO STATE WHAT HAPPENED...." ON 10/21/10 AT 11:30 A.M., THE ACU DIRECTOR PROVIDED A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 6/26/10 AT 2:00 P.M. THE REPORT INDICATED: "...FALLS: AMBULATING (WITH PHYSICIAN ORDERS) IN RESIDENT'S BATHROOM...NO APPARENT INJURY...INJURIES USED PRIOR TO FALL: NIGHT LIGHT, BED/CHAIR ALARM, SAFETY CUES/REINFORCEMENT/REMINDER, CALL LIGHT W/IN REACH. RECOMMENDATIONS AND INTERVENTIONS POST FALL: CHANGE IN FOOTWEAR, NIGHT LIGHT, BED/CHAIR ALARM, CALL LIGHT W/IN REACH." THE REPORT DID NOT INDICATE IF AN ALARM SOUNDED, OR IF THE RESIDENT WAS LEFT IN THE BATHROOM UNATTENDED. THE ACU DIRECTOR INDICATED AT THAT TIME THAT SHE DID NOT KNOW IF THE RESIDENT WAS LEFT IN THE BATHROOM, OR IF THE RESIDENT WAS IN BED OR IN A CHAIR PRIOR TO AMBULATING TO THE BATHROOM, OR IF AN ALARM SOUNDED OR MAY HAVE MALFUNCTIONED. ON 10/21/10 AT 11:30 A.M., THE ACU DIRECTOR PROVIDED A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA," DATED 8/22/10 AT 6:50 A.M. THE REPORT INDICATED: "...RESIDENT STATED SHE MISSED CHAIR...AMBULATING -WITHOUT ASSISTANCE IN KITCHEN...NO APPARENT INJURY. PHYSICIAN NOTIFIED, FAMILY NOTIFIED...RECOMMENDATIONS AND INTERVENTIONS POST FALL: NIGHT LIGHT, SAFETY CUES/REINFORCEMENT/REMINDER, CALL LIGHT W/IN REACH." THE ACU DIRECTOR INDICATED AT THAT TIME THAT SHE DID NOT SEE FURTHER DOCUMENTATION OF THE FALL IN THE NURSES NOTES. THE ACU DIRECTOR INDICATED SHE THOUGHT THAT WAS THE TIME THE RESIDENTS WENT INTO THE DINING AREA FOR BREAKFAST, AND SHE ASSUMED THAT WAS WHY THE RESIDENT WAS IN THAT AREA. THE ACU DIRECTOR INDICATED SHE WAS UNSURE WHEN THE RESIDENT STARTED USING A SENSOR ALARM WHILE IN THE CHAIR, BUT SHE THOUGHT IT WAS PROBABLY AFTER ONE OF THE RESIDENT'S FALLS. THE ACU DIRECTOR INDICATED SHE WAS UNABLE TO FIND THE INTERVENTION OF A SENSOR PAD TO THE WHEELCHAIR ON A physician's orders [REDACTED]. A CARE PLAN, INITIATED ON 8/31/10, INDICATED "FOCUS, AT RISK FOR FALLS RELATED TO: WANDERING ON ACU, FALLS IN THE LAST 31-180 DAYS." THE INTERVENTIONS INCLUDED: "ACTIVITY PROGRAMMING - EXERCISES, TV PROGRAMS...SENSOR PAD TO BED TO ALERT STAFF WHEN GETTING UP EVERY SHIFT. DATE INITIATED 7/26/2010." 3.1-45(a)(2)