Every finding on record at Brookside Village Inc

Based on observation, interview, and record review, the facility failed to ensure resident's were treated with dignity and respect for 4 of 4 residents reviewed for call light response times. A resident was observed waiting on staff to answer her call light while she was in the bathroom and resident call light logs revealed long wait times. (Resident C, Resident G, Resident H, Resident F)Findings include: 1. During an observation on 5/8/26 at 5:36 A.M., Registered Nurse (RN) 20 was walking toward the medication cart from the nurse's station. A call light sounded. RN 20 went from the medication cart to look at the call light screen by the nurse's station which indicated room [ROOM NUMBER] was in the bathroom. RN 20 then went back to the medication cart, prepared a medication, and took it to room [ROOM NUMBER] at 5:38 A.M. At 5:47 A.M., RN 20 came out of room [ROOM NUMBER] and proceeded into room [ROOM NUMBER]. RN 20 came back out of the room at 5:49 A.M., and indicated Resident H requested more wipes.On 5/12/26 at 9:02 A.M., Resident H's clinical record was reviewed. Diagnoses included, but were not limited to, dementia.The most recent Quarterly Minimum Data Set (MDS) assessment, dated 3/20/26, indicated Resident H was cognitively intact, a partial to moderate assist of staff (resident performs over half the effort) for toileting and showering, and supervision of staff for transfers.A current Bladder Incontinence Care Plan, last revised 4/27/26, indicated the goal for the resident was to keep her from having skin breakdown, urinary tract infection (UTI), impaired social interaction, or lowered self esteem secondary to incontinence. It included, but was not limited to, an intervention to provide incontinence care after each incontinent episode.On 5/11/26 at 11:22 A.M., Resident H's call light logs from 4/27/26 to 5/3/26 were provided by the Administrator and included the following wait times over 15 minutes:4/27/26 at 3:07 P.M., bedroom call light duration 45 minutes4/28/26 at 3:29 A.M., bedroom call light duration 23 minutes 5/1/26 at 1:10 P.M., bedroom call light duration 15 minutes5/1/26 at 7:05 P.M., bedroom call light duration 33 minutes5/3/26 at 7:53 P.M., bedroom call light duration 17 minutes 2. During an interview on 5/6/26 at 10:57 A.M., Resident C indicated sometimes she waited 30 minutes after using the bathroom for staff to answer her call light. At that time, she indicated the delay made her frustrated and helpless. At that time, she indicated she could understand 5-10 minutes but not longer if the residents were in the bathroom. On 5/11/26 at 9:54 A.M., Resident C's clinical record was reviewed.Diagnoses included, but was not limited to, infection of hardware and disruption of a surgical wound to her left leg. The most recent admission MDS assessment, dated 4/27/26, indicated Resident C was cognitively intact, continent of bowel and bladder, and needed substantial to maximum assistance of staff (staff performs over half the effort) for toileting, bed mobility, and transfers. A current Behavior Care Plan, created 4/26/26, indicated the resident has an anxiety disorder diagnosis and perseverating and frustration were her most common symptoms. Interventions included, but were not limited to, establish and maintain a calm and trusting relationship by listening to the resident; displaying warmth, answering questions directly, offering unconditional acceptance, and being available.On 5/11/26 at 11:22 A.M., Resident C's call light logs from 4/27/26 to 5/3/26 were provided by the Administrator and included the following wait times over 15 minutes:4/27/26 at 6:40 A.M., bathroom call light duration 18 minutes4/27/26 at 9:06 A.M., bathroom call light duration 17 minutes4/27/26 at 10:43 A.M., bedroom call light duration 40 minutes4/27/26 at 2:59 P.M., bedroom call light duration 35 minutes4/27/26 at 5:08 P.M., bedroom call light duration 41 minutes4/27/26 at 6:56 P.M., bedroom call light duration 23 minutes4/27/26 at 7:27 P.M., bathroom call light duration 24 minutes4/27/26 9:41 P.M., bedroom call light duration 23 minutes4/28/26 at 1:03 A.M., bathroom call light duration 15 minutes4/28/26 at 5:45 A.M., bedroom call light duration 38 minutes4/28/26 at 12:07 P.M., bathroom call light duration 15 minutes4/28/26 at 7:20 P.M., bedroom call light duration 22 minutes4/28/26 at 8:53 P.M., bedroom call light duration 24 minutes4/29/26 at 12:58 A.M., bedroom call light duration 37 minutes4/29/26 at 6:19 A.M., bedroom call light duration 26 minutes4/29/26 at 11:33 A.M., bedroom call light duration 16 minutes4/29/26 at 5:04 P.M., bedroom call light duration 15 minutes4/29/26 at 6:55 P.M., bedroom call light duration 20 minutes4/29/26 at 8:24 P.M., bedroom call light duration 31 minutes4/29/26 at 10:46 P.M., bedroom call light duration 16 minutes4/29/26 at 11:40 P.M., bedroom call light duration 22 minutes4/30/26 at 6:34 A.M., bedroom call light duration 30 minutes4/30/26 at 7:14 P.M., bathroom call light duration 22 minutes5/2/26 at 7:54 P.M., bathroom call light duration 35 minutes5/2/26 at 9:40 P.M., bedroom call light duration 20 minutes5/2/26 11:49 P.M., bedroom call light duration 19 minutes5/3/26 at 12:57 A.M., bedroom call light duration 24 minutes5/3/26 at 6:50 A.M., bedroom call light duration 22 minutes5/3/26 at 2:22 P.M., bedroom call light duration 25 minutes5/3/26 at 4:00 P.M., bedroom call light duration 17 minutes5/3/26 at 5:17 P.M., bedroom call light duration 19 minutes5/3/26 at 6:03 P.M., bedroom call light duration 15 minutes 3. During an interview on 5/06/26 at 11:27 A.M., Resident G indicated after midnight, she had to wait longer for staff to assist her for toileting. At that time, she indicated she had waited 20 minutes to get off the toilet recently and almost got up herself because sitting there too long hurt her hip. On 5/12/26 at 8:48 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, a healing sacrum fracture. The most recent admission MDS assessment, dated 4/28/26, indicated Resident G was cognitively intact, continent of bowel and bladder, and needed partial to moderate assistance from staff for toileting and transfers. A current Behavior Care Plan, created 4/25/26, indicated the resident has an anxiety disorder diagnosis and restlessness and isolation were her most common symptoms. Interventions included, but were not limited to, establish and maintain a calm, trusting relationship by listening to the resident; displaying warmth, answering questions directly, offering unconditional acceptance, and being available.On 5/11/26 at 11:22 A.M., Resident G's call light logs from 4/27/26 to 5/3/26 were provided by the Administrator and included the following wait times over 15 minutes:4/28/26 at 6:33 A.M., bedroom call light duration 30 minutes4/28/26 at 7:08 A.M., bathroom call light duration 17 minutes4/28/26 at 7:17 P.M., bedroom call light duration 24 minutes4/28/26 at 9:41 P.M., bedroom call light duration 15 minutes4/30/26 at 5:09 P.M., bedroom call light duration 16 minutes5/2/26 at 8:54 A.M., bedroom call light duration 26 minutes5/3/26 at 6:30 P.M., bathroom call light duration 21 minutes5/3/26 at 8:46 P.M., bathroom call light duration 15 minutes 4. During an interview on 5/6/26 at 11:13 A.M., Resident F's family members indicated the resident had to wait greater than 30 minutes sometimes for staff to answer her call light and the resident agreed. On 5/11/26 at 10:43 A.M., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and depression. The most recent admission MDS assessment, dated 3/17/26, indicated Resident F was cognitively intact, incontinent of bowel and bladder, was totally dependent on staff for transfers, showers, and toileting, and needed substantial to maximum assist for bed mobility. A current Fall Risk Care Plan, last revised 3/16/26, indicated resident was at risk for falls related to: recentstroke, need for assistance with transfers and mobility. It included, but were not limited to, interventions to assist with Activities of Daily Living (ADLs) as needed and cue/remind resident to use call light to seek assistance if needed. On 5/11/26 at 11:22 A.M., Resident F's call light logs from 4/27/26 to 5/3/26 were provided by the Administrator and included the following wait times over 15 minutes:4/27/26 at 4:31 A.M., bedroom call light duration 30 minutes4/27/26 at 11:14 A.M., bedroom call light duration 28 minutes4/27/26 at 2:48 P.M., bedroom call light duration 44 minutes4/27/26 at 7:02 P.M., bedroom call light duration 44 minutes4/27/26 at 8:09 P.M., bedroom call light duration 16 minutes4/28/26 at 5:08 A.M., bedroom call light duration 24 minutes4/30/26 at 7:48 P.M., bedroom call light duration 19 minutes5/2/26 at 1:56 A.M., bedroom call light duration 17 minutes5/2/26 at 8:01 P.M., bedroom call light duration 35 minutes5/3/26 at 6:33 A.M., bedroom call light duration 26 minutes On 5/6/26 at 1:30 P.M., the facility grievances for the last 3 months were provided by the Administrator and included six specifically about call light response times being too long.During an interview on 5/8/26 at 5:24 A.M., Registered Nurse (RN) 20 indicated the busiest part of night shift (6:00 A.M.-6:00 P.M.) was between 6:00 P.M to 10:00 P.M. Call lights are probably answered slower because the nurse would be trying to do medication passes on both carts and Certified Nurse Aides (CNAs) were busy giving showers and putting residents to bed.During an interview on 5/8/26 at 10:29 A.M., the Administrator indicated if there was a concern or complaint, they would look at the call light logs but otherwise they don't audit them. After a call light has been on for 30 minutes or longer, the system would call the Director of Nursing (DON) and the Administrator to alert them.During an interview on 5/8/26 at 10:49 A.M., the Administrator indicated she contacted the call log company and the service that was supposed to call them if call light wait times were greater than 30 minutes was a paid service that they no longer had. She was unsure when it was discontinued. During an interview on 5/12/26 at 9:13 A.M., the Administrator indicated it would be hard to give a time frame of what an appropriate call light response time would be. At that time, she indicated some factors for longer wait times included, but were not limited to, waiting on another staff member to help if the resident was a two person assist and assisting another resident with a more pertinent concern. It was dependent on the resident and the situation. If the person was a two person assist, the first responding staff would leave the call light on and wait or go look for someone to come help them.During an interview on 5/12/26 at 9:45 A.M., Licensed Practical Nurse (LPN) 2 indicated the other nursing staff (unit managers and nurses) should help the CNAs perform their duties. They all have to work together to take good care of the residents.During an interview on 5/12/26 at 11:07 A.M., the DON indicated in regards to the call light grievances, the residents at the facility did not think the call lights were answered as fast as they should be. If there was a complaint, she would pull the call light log and go over it with the resident. Education on how staff answers the call lights was provided. For example, when staff have multiple lights, they give priority to those that need assistance first. At that time, she indicated when going over the times on the logs with the residents, most of the wait times were not concerning. If they do find times that were, they will educate the resident and/or staff. One of the grievances, dated 4/29/26, needed staff education because there was a newer nurse at that time who was unaware that when the CNAs were busy, she was responsible for answering call lights.On 5/12/26 at 12:03 P.M., a current non dated Resident Rights Policy was provided by the Administrator and indicated, [Company name] and its member communities are committed to protecting and promoting the rights of the residents who reside in our communities. It is our policy that residents shall be treated with kindness, respect, and dignity by associates, volunteers, contractors and visitors . This citation relates to Intake 2640082.410 Indiana Administrative Code (IAC) 16.2-3.1-3(t)

Based on interivew and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's medications for 3 of 5 residents reviewed for unnecessary medications. A resident was marked as receiveing an antibiotic but did not. A resident was marked as recieving an antiplatelet but did not. A resident was marked as recieving an anticoagulant but did not. (Resident 7, Resident F, Resident 23)Findings include:1. On 5/11/26 at 12:52 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and atrial fibrillation. The most recent Quarterly MDS assessment, dated 3/6/26, indicated Resident 7's cognition was moderately impaired and recieved an antiplatelet medication during the 7 day look back period. Resident 7's Physician's Orders were reviewed for the 7 day look back period and lacked an order for an antiplatelet medication. Resident 7's February and March 2026 Medication Administration Record (MAR) was reviewed for the 7 day look back period and lacked administration of an antiplatelet medication. 2. On 5/11/26 at 10:43 A.M.,Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and atrial fibrillation. The most recent admission MDS assessment, dated 3/17/26, indicated Resident F was cognitively intact and recieved an antibiotic during the 7 day look back period. Resident F's Physician's Orders for the 7 day look back period were reviewed and lacked an order for an antibiotic. Resident F's March 2026 MAR was reviewed and lacked administration of an antibiotic during the 7 day look back period. During an interview on 5/12/26 at 11:12 A.M., the MDS Coordinator indicated medications should not be listed on the MDS assessment if it was not given during the 7 day look back period. Resident 7 did not recieve an antiplatelet and Resident F did not recieve an antibiotic. At that time, the MDS Coordinator indicated for accuracy of the assessments, they would need to be modified to reflect those changes. 3. On 5/11/26 at 1:30 P.M., Resident 23's clinical record was reviewed. Diagnosis included, but was not limited to, atherosclerotic heart disease of native coronary artery. The most recent admission MDS assessment, dated 4/23/26, indicated an anticoagulant had been administered during the 7 day look back period for the assessment. Antiplatelet was not marked. Current physician orders included, but were not limited to: aspirin (an antiplatelet) 81mg (milligrams) once a day, dated 4/20/26. Resident 23's clinical record lacked an order for an anticoagulant. Resident 23's April 2026 MAR indicated aspirin was administered on 4/21/26, 4/22/26, and 4/23/26. On 5/12/26 at 9:25 A.M., the MDS Coordinator indicated anticoagulant was marked on Resident 23's admission MDS assessment instead of antiplatelet and needed to be modified. At that time, she indicated the Resident Assessment Instrument (RAI) manual was used as a policy for entering MDS information.

Based on observation, interview, and record review, the facility failed to follow the facility policy for medications administered during the medication time frame for 1 of 4 residents observed during a medication pass. A resident received an antibiotic after it was due. (Resident E)Finding includes:During an observation on 5/07/26 at 9:37 A.M., Resident E was sitting in her chair and indicated staff was often late getting her IV antibiotics started. It was supposed to start at 8:00 A.M During a medication administration observation on 5/7/26 at 9:48 A.M., Licensed Practical Nurse (LPN) 3 administered Resident E's IV antibiotic. On 5/11/26 at 12:50 P.M., Resident E's clinical record was reviewed. Diagnosis included, but was not limited to, surgical site infection. The most recent admission Minimum Data Set (MDS) assessment, dated 5/4/26 indicated Resident E was cognitively intact and received an antibiotic. Resident E's current Physician Order's included, but were not limited to:Cefepime (antibiotic) 1 gram in 100 milliliters (ml) intravenous (IV). Run 100 ml over 30 minutes at 8:00 A.M. and 8:00 P.M., start date 5/6/26 Resident E's Medication Administration Record (MAR) indicated Cefepime was given at 8:00 A.M. with a note that indicated on 5/7/26 at 9:50 A.M., charted late. Resident E's current care plans included, but were not limited to: Resident requires IV antibiotic related to surgical wound infection, has potential for complications. Interventions included, but were not limited to, administer IV medications as ordered, dated 5/4/26. During an interview on 5/11/26 at 10:41 A.M., the Administrator indicated there was an hour window for medications to be given from the time the medication was due. On 5/11/26 at 10:59 A.M., the Administrator provided an Administering Medications policy, revised April 2019 that indicated, .Medications are administered within one (1) hour of their prescribed time. This citation relates to Intake 2640082. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to provide sanitary incontinence care for 2 of 2 observations of incontinence care. The nursing staff failed to change gloves after touching multiple items in the room before starting incontinence care and hands were not sanitized and gloves were not changed between dirty and clean tasks. (Resident 5, Resident 2)Findings include:1. During an observation on 5/12/26 at 9:33 A.M., incontinence care was provided by Licensed Practical Nurse (LPN) 4 and LPN 7 on Resident 5. Both LPNs applied antibacterial hand rub (ABHR) and put on gloves. Both LPNs pulled down the resident's blanket and unfastened the resident's incontinence pad. LPN 4 held Resident 5's right leg while LPN 7 wiped the resident's vaginal area with disposable wipes. Resident 5 was assisted to roll onto her left side while LPN 7 held her. LPN 4 wiped bowel movement off the resident's buttocks with disposable wipes and discarded the soiled incontinence pad. LPN 4 then grabbed the clean incontinence pad and touched the inside of the incontinence pad with soiled gloves while she positioned it under Resident 5. At that time, LPN 4 removed her soiled gloves, used ABHR, and put on clean gloves. Resident 5 was rolled on her back and LPN 7 pulled the the clean brief out from under the resident and touched the inside of the incontinence pad while she repositioned it. Both LPNs pulled off the resident's pants and LPN 4 took off Resident 5's left sock and put it back on. Both LPNs pulled the resident up in bed and pulled up the blankets. LPN 4 did not sanitize hands or change gloves during the entire process. After care was provided, both LPNs went to the bathroom to wash their hands. Near the bathroom door, a saturated disposable pad was laying on the roomate's recliner. The LPNs came out of the bathroom and went out of the room without disposing of the saturated pad on the recliner. 2. On 5/11/26 at 9:15 A.M., Registered Nurse (RN) 6 and Licensed Practical Nurse (LPN) 7 performed incontinence care on Resident 2. LPN 7 donned gloves, removed the nasal cannula oxygen tubing from the portable concentrator to the oxygen machine, pushed the mechanical lift under the wheelchair, hooked the lift pad up to the lift, used the lift remote to raise the lift, and then used both gloved hands to push Resident 2 from the wheelchair to the bed. Then, LPN 7 unhooked the lift pad from the mechanical lift, handed a trashcan with soiled gloves in it to RN 6, and then LPN 7 placed a clean incontinence pad on the bottom of the bed. LPN 7 used the same gloves to assist RN 6 to remove Resident 2's pants, unfasten the soiled incontinence pad, clean the resident's perineal area with 3 wipes, and then placed both gloved hands on Resident 2's right leg to help her roll to her left side. LPN 7 scooped the stool with the incontinence pad and removed the soiled brief and then wiped Resident 2's buttocks with 4 wipes. LPN 7 failed to perform hand hygiene and change gloves before she placed the clean incontinence pad under Resident 2. LPN 7 used her soiled gloves and moved Resident 2's oxygen tubing and then pulled Resident 2's shirt down. During an interview on 5/12/26 at 10:00 A.M., the Infection Preventionist (IP) indicated gloves should be changed if items are touched prior to incontinence care and hand hygiene should be performed and gloves changed between dirty and clean tasks. On 5/12/26 at 11:49 A.M., the Administrator provided a current, undated Incontinence Care Skills Validations checklist as their policy that indicated, Gather supplies and place on clean surface.Wash hands and apply gloves.Remove soiled brief and gloves, discard, perform hand hygiene and re-glove.Wash hands and change gloves.Provide for the residents safety and comfort. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(l) 410 IAC (Indiana Administrative Code) 16.2-3.1-18b(1)

Based on interview and record review, the facility failed to notify appropriate parties of a resident's significant change of status for 2 of 5 residents reviewed for nutrition. The Medical Doctor (MD) or Registered Dietician were not notified of a significant weight loss, and the Doctor was not notified of a five pound weight gain as indicated in a weight order. (Resident 3, Resident 9) Findings include: 1. On 2/19/24 at 11:14 A.M., Resident 3's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent quarterly MDS (minimum data set) assessment, dated 12/8/23, indicated a mild cognitive impairment, and no weight loss or gain. Current physician orders included, but were not limited to: Weight once a day, dated 2/16/24. Monthly weight and vital signs on the first of the month, dated 11/1/23. A current nutritional status care plan, dated 9/5/23, included but was not limited to the following intervention: Monitor/record weight routinely, notify MD/RD (Registered Dietician) of significant weight changes, dated 9/5/23. Resident 3's weights included, but were not limited to, the following: 10/3/23 130.2 11/1/23 115.6 (11.21% decrease in one month) Resident 3's clinical record lacked a notification to the MD or Registered Dietician of the significant weight loss that occurred on 11/1/23. On 2/22/24 at 2:00 P.M., the Regional Clinical Support indicated notification following Resident 3's significant weight loss on 11/1/23 could not be located. 2. On 2/19/24 at 10:36 A.M., Resident 9's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent Quarterly MDS Assessment, dated 1/14/24, indicated a mild cognitive impairment, and no weight loss or gain. Current physician orders included, but were not limited to: Weight three times weekly. Notify MD if weight gain is 2 lbs (pounds) daily or 5 lbs in a week, dated 10/11/23. A current nutritional status care plan, dated 10/11/23, included but was not limited to, the following intervention: Monitor/record weight routinely, notify MD/RD of significant weight changes, dated 10/11/23. Resident 9's weights included, but were not limited to, the following: 2/7/24 235 lbs 2/9/24 240.8 lbs (5.8 lb increase in two days, 2/7-9/24)) 2/12/24 240.5 lbs (5.5 lb increase in five days, 2/7-12/24) Resident 9's clinical record lacked a notification to the MD of the weight gain that occurred on 2/9/24 and 2/12/24. On 2/22/24 at 2:00 P.M., the Regional Clinical Support indicated notification following Resident 9's weight gain on 2/9/24 and/or 2/12/24 could not be located. On 2/22/24 at 8:47 A.M., Licensed Practical Nurse (LPN) 5 indicated if a resident had a discrepancy in their weight, they should be re-weighed. The nurse working the floor was in charge of contacting the MD if the resident gained 2 lbs in a day or 5 lbs in a week. Once the MD was notified, it should be documented under the physician notification on the Medication Administration Record (MAR), and if a new order were to be obtained, it would be documented in the progress notes. On 2/26/24 at 12:05 P.M., a current Change in a Resident's Condition or Status policy was provided, revised 10/2010, and indicated Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . A significant change in the resident's physical/emotional/mental condition . The Nurse Supervisor/Charge Nurse will record in the resident's medical record 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented and maintained during 2 of 3 observations of care. Staff did not perform hand hygiene after removal of gloves during care and staff failed to properly sanitize an insulin pen prior to use. (Resident C, Resident D) Findings include: 1. During an observation on 10/10/23 at 11:52 A.M., LPN 4 was assessing Resident C's blood sugar levels with a glucometer. After washing hands and donning (putting on) gloves, LPN 4 pricked Resident C's finger to obtain a blood drop for the glucometer machine, however the glucometer failed to read the blood sugar level. LPN then removed gloves and donned new gloves with no hand hygiene. LPN 4 again attempted to read Resident C's blood sugar level and the glucometer gave an error message. LPN 4 returned to the medication cart, removed gloves, pulled another glucometer machine from the cart and donned new gloves without performing hand hygiene. After reading Resident C's blood sugar level, LPN 4 went to administer Resident C's insulin by preparing 10 units via Humalog KwikPen. While preparing the insulin pen, LPN 4 failed to wipe the end of the pen with an alcohol wipe prior to screwing on the needle. 2. During an observation on 10/10/23 at 1:27 P.M., CNA 8 and LPN 4 were assisting Resident D with incontinence care. CNA 8 pulled a stack of wet wipes from a package and provided peri care by pulling from the stack of wipes on 3 occasions. CNA 8 then applied cream and powder to Resident D's peri area. CNA 8 removed gloves and did not perform hand hygiene. CNA 8 assisted Resident D to pull her pants up and adjusted the resident in bed, pulled blankets over the resident, and then put the unused stack of wet wipes back into the original package. CNA grabbed a bag of trash and exited the room. During an interview on 10/10/23 at 1:40 P.M., CNA 7 indicated staff should perform hand hygiene after removing gloves. On 10/10/23 the IP (infection preventionist) supplied a facility policy titled Hand Washing/Hand Hygiene Policy, dated 3/24/16 as well as an undated Insulin Pen Skills Validation form. The Hand Washing/Hand Hygiene Policy included, .5. Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions . v. After removing gloves . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub . If hands are not visibly soiled, us an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: b. Before donning sterile gloves . f. Before moving from a contaminated body site to a clean body site during resident care . j. After removing gloves . 8. The use of gloves does not replace handwashing/hand hygiene . The Insulin Pen Skills Validation included, .12. Pull off pen cap 13. Wiped [sic] rubber stopper with alcohol swab 14. Removed [sic] protective cover from disposable needle and screw on pen . This Federal tag relates to complaint IN00417072. 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure resident's privacy for 2 of 10 residents observed during the survey. Staff entered a room without knocking, performed wound care without closing the door, and took vital signs in a common area. (Resident F, Resident H) Findings include: 1. During an observation on 4/12/22 at 10:44 A.M., LPN 7 entered Resident F's room without knocking or announcing themselves. LPN 7 then provided a treatment to the residents foot without pulling a privacy curtain or closing the residents room door. During that time, therapy staff were walking past the resident's room. On 4/12/22 at 11:00 A.M., LPN 7 was observed from the hallway in Resident F's room, crouched down performing wound care to Resident F's foot. The resident was in full view from the hallway. The door was observed to be open, and no curtain had been closed. 2. On 4/13/22 at 8:45 A.M., Resident H was observed sitting in the common area in front of the nurses station eating breakfast. LPN 13 was observed to stop Resident H from eating, took her vital signs without moving her, then after vitals were taken, Resident H returned to eating. During an interview on 4/13/22 at 12:38 P.M., LPN 9 indicated when entering a resident's room, staff should always knock and introduce self when entering, and door or curtain should be closed when performing any type of procedure with a resident. She further indicated vital signs should be taken in the resident's room, and not in any common area. On 4/13/22 at 12:30 P.M., a current Resident Rights policy, revised 1/16/20, was provided and indicated Federal and state laws guarantee certain basic rights to all residents of our community. These rights include the resident's right to . Privacy and confidentiality 3.1-3(o)

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents, resulting in multiple falls for 2 of 4 residents reviewed for accidents. Neurological checks and an initial fall assessment were not completed following resident falls, and fall interventions were not in place during observations. (Resident D, Resident H) Findings include: 1. On 4/13/22 at 7:30 A.M., Resident D was observed lying in bed (low position) with a fall mat sideways partly under the bed, with only the bottom half sticking out from under the bed. A call light was observed on the floor, between the bed and the wall. At that time, CNA 3, CNA 5, and CNA 14 were observed to walk past Resident D twice, and did not offer the call light or fix the mat. On 4/13/22 at 8:07 A.M. Resident D was observed still lying in bed with the fall mat partly under the bed, and call light out of reach. On 4/13/22 at 9:24 A.M., Resident D was observed lying in bed (high position) with no fall mat on the floor, and a call light was observed still on the floor, between the bed and wall at the foot of the bed. At that time, LPN 13 indicated staff was supposed to make sure all residents had their call lights within reach when leaving the room. On 4/12/22 at 11:00 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to; unsteadiness on feet, weakness, other fracture of upper and lower end of left fibula, subsequent encounter for closed fracture with routine healing, and age-related [CONDITION(S)]. The most recent significant change MDS (Minimal Data Set), dated 3/16/22, indicated the Resident D had a significant cognitive impairment, required extensive assistance with bed mobility and transfers, had a fall prior to admission, and had a fall with fractures prior to admission within the past six months. Resident D's care plan included, but was not limited to; resident at risk for falls related to femur fracture, hypertension, diabetes, weakness, and incontinence (initiated 11/9/21), and resident has need for monitoring due to left fibula fracture and left ankle fracture (initiated 3/11/22). Resident D's record included the following falls: Fall 1 11/10/21 at 10:30 P.M. - Resident D found to be sitting on the floor beside bed. Bed was in low position. Legs were straight out in front of resident. Right knee brace was on and positioned correctly. Resident states they wanted in recliner. No obvious injuries noted. Assist of three to put in recliner . Fall 2 11/22/21 at 1:00 A.M. - Resident lying perpendicular to bed with head and shoulders on bed and rest of body supine on floor between bed and wall. Bed in lowest position and near floor. Resident states they rolled out of bed. Had gown and gripper socks on. Resident was incontinent of bladder. No injuries noted. Assisted to bed with 3 assist. Brief and linens changed. Neurological checks initiated . Fall 3 12/4/21 at 1:15 A.M. - Resident heard yelling out for help. Upon assessment resident found kneeling on knees and hands on padded mat next to bed side. Resident states I felt better so I was going to get up by myself resident reeducated to call light, neurological assessment and vital sign monitoring started per protocol . Fall 4 12/30/21 at 11:00 A.M. - Resident found laying face first down on floor. Resident was in wheelchair prior to fall. Resident stated they were trying to get up and walk out of the room. Resident is non-weight bearing . Neurological checks started as fall was not witnessed . Fall 5 1/13/22 at 3:09 P.M. - Resident fell in room out of recliner while attempting to raise self out of the chair . Resident continues neurological checks from fall, no complaints of pain . Fall 6 3/2/22 at 3:13 P.M. (recorded 3/4/22 at 1:19 P.M.) - Reported by CNA staff that resident had a fall in the evening of 3/2/22 while attempting self transfer. An incident report submitted to the Indiana State Department of Health indicated Resident D was in involved in an incident on 3/1/22 at 5:40 P.M. The incident included, It was reported on 3/3/22 that resident had fallen in (their) room. An assessment was completed on (the) resident with no evidence of injuries or complaints of pain. On 3/4/22 resident complained of pain in left foot and thigh . A follow up to the incident dated, 3/9/22 included, On the morning of 3/2/22 the dayshift CNA was told that a fall had occurred on the evening shift the night of 3/1/22 but was not sure who it was. There was no documentation of a fall, and the nurse did not receive any information about a fall in the shift report. Multiple attempts were mad to contact the nurse that was on duty but (they) did not respond. Calls placed to CNA staff as well. Rounds were made on all residents to try to identify who had fallen. The following morning the CNA that witnessed the fall identified the resident as (Resident D) . A review of documented assessments and neurological checks indicated that neurological checks were initiated following a fall on 1/13/22 and were completed every 15 minutes for an hour following the fall, however, neurological assessments ceased to continue following the initial hour post fall. No documentation of neurological checks or an immediate post fall assessment following Resident D's reported fall on 3/1/22 was available in the resident's record. During an interview on 4/12/22 at 1:30 P.M., LPN 4 indicated the nurse on duty on 3/1/22 had to leave the facility early due to an emergency following Resident D's fall. That nurse did not document the fall or communicate details of the fall to the oncoming nursing staff. Staff were aware of a fall but did not know who had fallen. On 3/3/22 LPN 4 was notified that Resident D had fallen on 3/1/22. LPN 4 indicated they then completed an assessment on 3/3/22. Resident D was not alert and oriented but no obvious new injuries were identified during the assessment. Resident D complained of pain to the right lower extremity, however, that was not new for the resident as the resident had a previous fracture to the right lower extremity. The following day, on 3/4/22, Resident D complained of pain to their left lower extremity. An x-ray was ordered and indicated a fracture. Resident D was then sent to the hospital. 2. On 4/12/22 at 1:35 P.M., Resident H's clinical record was reviewed. Diagnoses included, but were not limited to; hip fracture and weakness. The most recent admission MDS, dated [DATE], indicated Resident H required extensive assistance of 2 (two) staff with bed mobility and transfers, had a fall within 1 (one) month prior to admission, and had a major surgical procedure during a prior hospital stay. Resident H's care plan included, but was not limited to; resident at risk for falls related to history of fall with fracture, poor safety awareness, weakness, impaired mobility, mental function varies, and pain(initiated 2/10/22). Interventions included the following: Staff to offer resident activities after breakfast, created 4/8/22 staff to stay with resident when transporting to other sides of the building, created 4/8/22 Staff to keep bedside table within reach of resident with activities on it while in lobby, created 3/31/22 Continue with therapy as ordered, created 3/22/22 Offer to toilet resident before lunch, created 3/23/22 Offer to get resident to be early get up [sic], created 3/23/22 Offer to assist to toiled [sic] after supper, created 3/23/22 offer and assist to toilet before supper, created 3/22/22 Assist with ADLs [activities of daily living] as needed, created 2/10/22 Cue/remind resident to use call lights to seek assistance as needed, created 2/10/22 Keep call light in reach at all times, created 2/10/22 Keep items necessary for communication, independent activities and any item specified by the resident within reach wher [sic] able, created 2/10/22 Reacher in place to assist resident with items, created 2/10/22 Resident H's record included the following falls: Fall 1 2/7/22 at 6:15 A.M. - Fall was unwitnessed. Resident H found sitting on the floor by recliner. Resident had one sock off and one sock on, and indicated to staff she was reaching for shoes. Care plan updated 2/10/22 to include a reacher for the resident. Neurological assessments were not indicated on fall event, and not initiated after fall. Fall 2 3/6/22 at 6:06 P.M. - Fall was witnessed. Resident H fell forward out of wheelchair at the nurses station. Resident hit head that caused a small laceration to left side of head. Resident complained of left hip pain, and was sent to the emergency room and returned same day after all tests were negative. Care plan updated 16 days later on 3/22/22 to include assist resident to toilet before supper. Neurological assessments were initiated, then resumed when resident returned from the emergency roiagnom on [DATE] at 10:00 P.M. However, every shift checks ceased to continue after 3/7/22 (7A - 7P), lacking the last 5 (five) checks. Fall 3 3/16/22 at 6:15 P.M. - Fall was witnessed and did not hit head. Resident H attempted to get out of recliner at nurses station and fell on to floor. Care plan updated 7 (seven) days later on 3/23/22 include assist to toilet after supper. Neurological assessments completed post fall. Fall 4 3/20/22 at 11:29 A.M. - Fall was unwitnessed. Resident H was found on the floor behind the nurses station. Resident had attempted to transfer self out of wheelchair, and was found lying on left side. Resident found to have a skin tear on upper back measuring 0.25cm (centimeter) x 0.25cm x less than 0.1cm, and a skin tear on the lower extremity measuring 0.5cm x 0.5cm. Resident complained of pain all over, but able to move all extremities without difficulty. Care plan was updated on 3/22/22 to include continue therapy as ordered, and 3/23/22 to include offer to toilet resident before lunch. Neurological assessments completed post fall. Fall 5 3/30/22 at 9:30 A.M. - Fall was unwitnessed. Resident H was found on the floor in the dining room lying on right side. Resident indicated she was trying to reach for something. No injuries. Care plan was updated 3/31/22 to include staff to keep bedside table within reach of the resident with activities on it while in the lobby. The fall event indicated neurological assessments were initiated, but the clinical record lacked documentation of any, and staff could not provide documentation of any neurological checks completed after this fall. Fall 6 4/5/22 at 8:15 P.M. - Fall was witnessed. Resident H was being pushed in wheelchair by staff, when staff stopped briefly and turned to check something. Resident then stood out of wheelchair, fell , and hit head on a medication cart. Resident had a quarter sized bump on left side of forehead. Care plan was updated 4/8/22 to include staff to stay with resident when transporting to other sides of the building. Neurological assessments completed post fall. Fall 7 4/6/22 at 9:30 A.M. - Fall was unwitnessed. Resident H was found on the floor next to the bed, lying on the right side. Resident complained of left wrist pain. An x-ray was ordered and negative for fractures. Care plan was updated 4/8/22 to include staff to offer activities after breakfast. Neurological assessments completed post fall. Fall 8 4/10/22 at 12:33 A.M. - Unknown if fall was witnessed. Resident H fell next to the bed, and was lying on the right side following the fall. The care plan had not been updated with a new intervention. Neurological assessments were completed post fall. Fall 9 4/12/22 at 7:15 A.M. - Fall was unwitnessed. Resident H was found on the floor in her room. Resident was lifted from floor with gait belt and onto the bed. The care plan had not yet been updated, as it was currently being reviewed. Neurological assessments were initiated, and currently being completed. On 4/13/22 at 5:48 A.M., CNA 8 was observed to exit Resident H's room, and indicated She is still sleeping During an interview on 4/13/22 at 5:53 A.M., LPN 15 indicated Resident H required a lot of assistance, and at times 1:1 from staff. She indicated Resident H's functional status had declined since admission, and did not believe the facility had the staff capable of caring for Resident H. On 4/13/22 at 7:30 A.M., CNA 3, CNA 5, and CNA 14 were observed to assist Resident H out of bed. Resident H was assisted from the bed to the wheelchair, and was not offered to toilet. Resident H was then brought out to the nurses station, and wheelchair sat next to a bedside table with a puzzle box on the opposite end of it, out of reach from the resident. At that time, CNA 3 indicated staff allowed Resident H to sleep in in the mornings, as she was restless when up. CNA 3 indicated they would get her up close to breakfast time. On 4/13/22 at 7:57 A.M., Resident H was observed still sitting in the same spot, with her head slumped over and eyes closed. During a continuous observation on 4/13/22 from 8:35 A.M. until 9:25 A.M., the following was observed: At 8:35 A.M., CNA 3 brought Resident H from her room to the common area by the nurses station. CNA 3 placed a bedside table with her breakfast in front of her. After eating, Resident H was observed closing her eyes with head slumped forward. At 9:06 A.M., CNA 5 removed the breakfast tray from the bedside table. She did not offer the resident to toilet, or any activities. The bedside table in front of Resident H had a clipboard with papers, a pen, a puzzle box, and a glass of water. At 9:22 A.M., LPN 13 approached Resident H, who had eyes closed and head slumped forward. LPN 13 indicated I hate to wake her, then woke up Resident H, and took her to her room. LPN 13 administered medications to Resident H, then transferred Resident H to the bed by herself. LPN 13 gave Resident H a call light, and left the room at 9:25 A.M. Resident H's reacher was sitting in a recliner, out of reach of the resident. During the continuous observation, several staff were observed walking past the resident, and sitting at the nurses station without speaking to her or offering activities. On 4/13/22 at 10:40 A.M., a current Fall Prevention Policy was provided dated May 2016, and indicated The fall event assessment will be completed by the charge nurse if a patient experiences a fall . and ensure effective interventions are put into place to prevent additional falls . On 4/13/22 at 11:05 A.M., the DON (Director of Nursing) indicated there was not a facility policy for post fall interventions, but that it was the facility's policy to immediately assess the resident post fall, and initiate neurological assessments. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 2 of 28 opportunities observed to administer medications correctly, resulting in an error rate of 7.14%. This affected 1 of 5 residents observed during medication administration. (Resident M) Finding included: On 4/13/22 at 8:01 A.M., LPN 13 (Licensed Practical Nurse) was observed to administer the following medications to Resident M: [MEDICATION(S)] [MEDICATION(S)] (an insulin delivery device), set to 6 Units [MEDICATION(S)] Pen (an insulin delivery device), set to 40 Units LPN 13 did not prime (perform a safety test) prior to administering either insulin injection. LPN 13 indicated at that time Resident H's blood sugar level was 186 prior to administering the insulin. LPN 13 also indicated at that time that insulin pens should have been primed prior to use. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] [MEDICATION(S)] U-100 Insulin pen; 100 units/mL (milliliters) (3 mL) per sliding scale; If blood sugar is less than 70, call MD. If blood sugar is 100 to 150 give 0 Units If blood sugar is 151 to 200 give 0 Units If blood sugar is 201 to 250 give 0 Units If blood sugar is 251 to 300 give 0 Units If blood sugar is 301 to 350 give 0 Units If blood sugar is greater than 350, call MD With meals (8am, 12pm, 5pm) [MEDICATION(S)] [MEDICATION(S)] U-100 Insulin pen; 100 units/mL (3 mL); amount 5 Units Three times a day (7-11am, 11am-1pm, 4-6pm) [MEDICATION(S)] U-100 Insulin pen; 100 unit/mL (3 mL); amount 40 Units Twice a day (8am, 9pm) On 4/13/22 at 10:42 A.M., the DON (Director of Nursing) indicated there was not a policy specific to insulin administration, but that the package inserts should have been followed in place of a policy. At that time, the following package inserts were provided: [MEDICATION(S)]: indicated . A safety test must be performed before each injection . Always perform the safety test before each injection. This ensures that you get an accurate dose by: ensuring that pen and needle work properly . removing air bubbles . Select a dose of 2 units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip . [MEDICATION(S)] [MEDICATION(S)]: indicated .Before each injection small amounts of air may collect in thee cartridge during normal use. To avoid injecting air and to ensure proper dosing . Turn the dose selector to select 2 units . Keep the needle pointing upwards press the push-button all the way in . This Federal tag relates to Complaint IN 524. 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers to develop, and failed to identify and monitor the pressure ulcers until they were at an advanced stage, resulting in the development of Stage 3 pressure ulcers, for 2 of 3 residents reviewed for impaired skin. (Residents C and D) Findings include: 1. On 12/2/21 at 9:15 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident C had skin impairments on her right lower leg. The DON indicated she thought the areas were possibly stasis areas due to circulation. Resident C was observed lying in bed with the covers over her feet at that time. On 12/2/21 at 9:45 A.M., the DON provided a CNA assignment sheet. The sheet indicated Resident C required the assistance of a mechanical lift and 2 staff members to transfer. The Special Instructions was left blank. Documentation that indicated the resident required a pressure relieving boot, or had a pressure ulcer, was not found. On 12/2/21 at 1:50 P.M., a wound assessment was requested. Resident C was observed sitting up in a recliner. Her feet were on a pillow. A pressure relief boot was on the floor. LPN 1 indicated that the resident liked to kick off her boot. After LPN 1 removed the resident's dressing, a scabbed type area was observed on the top of the right foot. The right heel had a pressure ulcer that appeared to be fully dry, black tissue. LPN 1 indicated the wound physician had visited the previous night, and may have changed the treatment orders. LPN 1 indicated she was not sure how the areas had developed. The clinical record of Resident C was reviewed on 12/2/21 at 2:10 P.M. The resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Assessment, dated 11/6/21 at 1:16 P.M., indicated Resident C was alert, had impaired memory, had dementia, had a right hip joint replacement, and had no skin ulcers. A Care Plan, dated 11/9/21, indicated, Resident is at risk for skin breakdown R/T [related to]: decreased mobility . The Approaches included: Assist with bed mobility as indicated. Elevate heels as resident will allow. Monitor skin for signs of skin breakdown. Turn and reposition (bed mobility) per resident individual need. A Care Plan, dated 11/9/21, indicated, Resident is unable to independently perform late loss ADLs [activities of daily living] R/T weakness, Fx [fracture] .and requires assistance/encouragement for bed mobility, transfers . The Approaches included: Maintain body in functional alignment when at rest. Provide assistance and encouragement with bed mobility as indicated. A Care Plan, dated 11/9/21, indicated, Resident has need for monitoring R/T (R) Femur Fracture. The Approaches included: Maintain body in recommended body alignment. Neurovascular checks - Assess affected extremity for skin temperature .circulation, motion, sensation. An admission Minimum Data Set (MDS) assessment, dated 11/14/21, indicated Resident C required extensive assistance of two or more staff for bed mobility and dressing, and total dependence of two or more staff for bathing. She was at risk for pressure ulcer development, and did not have any pressure ulcers at that time. A Skin Integrity Event, dated 11/14/21 at 1:50 P.M., indicated, Description: Right foot. The part of the evaluation which documented the size, character of the wound bed, drainage, and surrounding tissue was left blank. The New Skin Interventions initialed for plan of care was left blank. Documentation that the physician or family was notified at that time was left blank. There was no documentation describing the wounds at that time. There was no documentation of a wound assessment until the wound physician's note on 11/17/21. The next facility documentation regarding the right foot ulcers was on 11/17/21, from a wound physician's report. A wound physician's Initial Wound Evaluation and Management Summary, dated 11/17/21, indicated, Chief Complaint: This patient has multiple wounds .She has a wound on the right foot for at least 2 days duration. There is moderate serous [clear or light yellow color] exudate [drainage] .Stage 3 Pressure Wound of the Right Heel, Full Thickness. Etiology - Pressure .Duration >7 days. Wound size [length x width x depth] 2 x 3 x 0.1 cm [centimeters] .Exudate: Moderate Serous. Slough [dead tissue]- 100%. The note indicated the pressure ulcer was debrided to remove necrotic [dead] tissue. The Wound Evaluation indicated the resident had a second Wound of the Right Foot Full Thickness. The duration was more than 2 days. The wound size was documented as 1 cm x 3 cm x 0.1 cm, had moderate serous exudate, and had 100% healing tissue. Nurses Notes continued: 11/18/21 at 10:10 A.M.: [Name of wound care physician] here to evaluate resident on 11/17/21. New orders to apply calcium alginate and gauze island border dressing to bottom of (R) heel daily x 30 days .Also to apply calcium alginate and gauze island border dressing to wound on top of right foot daily x 30 days. Facility Wound Management documentation, dated 11/18/21 at 2:58 P.M., indicated a right heel wound, due to pressure, was identified on 11/16/21 [sic] at 2:57 P.M. The ulcer was not present on admission. Additional facility Wound Management documentation, dated 11/18/21 at 2:58 P.M., indicated a wound on the top of the right foot, due to friction, was identified on 11/16/21 at 3:05 P.M. The most recent wound physician's documentation, dated 12/1/21, indicated: Stage 3 Pressure Wound of the Right Heel .Wound Size (L x W x D) - 3 x 4 x 0.1 cm. Exudate: Moderate Serous. Slough: 100%. The pressure ulcer was debrided and necrotic tissue was removed. The Wound of the Right Foot Partial Thickness indicated the wound size was 1 cm x 3 cm x 0.1 cm, had no drainage, and was 100% dermis (skin). On 12/2/21 at 3:00 P.M., the Director of Nursing (DON) was interviewed. The DON did not respond when questioned if the resident's right brace was removed to assess the resident's skin on a regular basis, or why the resident's pressure ulcer was discovered at a Stage 3 instead of an earlier stage. According to AMDA, Stages of Pressure Ulcers, 2008: Stage III (3): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. 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 ulcer bed. 2. On 12/2/21 at 9:15 A.M., during the initial tour, the DON indicated Resident D had an area on her toe from her shoe rubbing. The resident was observed sitting in a wheelchair at that time. She was wearing slippers, and both of her feet were on foot rests. On 12/2/21 at 9:45 A.M., the DON provided a CNA assignment sheet. The sheet indicated Resident D required the assistance of a mechanical lift to transfer. The Special Instructions was left blank. Documentation that indicated the resident had a pressure ulcer was not found on the assignment sheet. On 12/2/21 at 2:00 P.M., a wound assessment was requested. Resident D was sitting in a wheelchair and wearing soft slippers. LPN 2 assisted the resident in removing her sock and slipper from her left foot. LPN 2 indicated it appeared as if there was a small amount of drainage on the sock. A dressing was not on the area. A small open area, with a yellowish wound bed, was observed on the outer left great toe. At the base of the great toe, a crease-like open area was observed. The foot appeared reddened and slightly swollen. LPN 2 indicated the wound physician had visited the previous evening. The clinical record of Resident D was reviewed on 12/2/21 at 2:40 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 9/14/21, indicated Resident D required extensive assistance of two or more staff for dressing, total dependence of two or more staff for bathing, and did not ambulate. She was at risk for pressure ulcer development, and did not have any pressure ulcers at that time. A Care Plan, initially dated 9/5/18 and updated 11/1/21, indicated, Resident is at risk for skin breakdown R/T potential for friction and shearing/weakness. The Approaches included: Monitor skin for signs of skin breakdown. Pressure reduction cushion in wheelchair. Weekly skin assessment. A Care Plan, initially dated 10/18/21 and updated 11/1/21, indicated, Resident has an area to left big toe. The Approaches included: Monitor weekly. Record location and size of skin tear. The first documentation regarding a left great toe ulcer was on 10/14/21, from a physician's note. A Physician's note, dated 10/14/21, indicated, Received communication from [name of facility] stating that res [resident] has an open area to left great toe. Measures 2.3 cm x 2.5 cm. Wound bed has yellow slough with purulent drainage. Periwound is red extending to top of foot. Placed absorbent dressing over wound and wrapped loosely with kerlix to keep from bumping. Painful with palpation A Physician's note, dated 10/15/21, indicated, On the left great toe is unstable erosion which is approximately 3 x 2 cm oval. Yellow slough without active drainage. There is some [CONDITION(S)] [redness] and swelling . Pressure area on the dorsum of the left big toe. I think we need to get wound care involved The first Nurses Note regarding the pressure ulcer was on 10/17/21. Nurses Notes included the following notations: 10/17/21 at 3:52 P.M.: Dressing changed to left great toe. [Name of physician] requesting wound care evaluation. Will consult [wound care physician]. 10/18/21 at 6:00 P.M.: Wound culture of left great toe obtained and sent to lab. 10/19/21 at 1:21 P.M.: [Name of physician] in to see resident this shift. No new orders received at this time. MD came in to address wound to L great toe. Dressing change completed A wound physician's Initial Wound Evaluation and Management Summary, dated 10/20/21, indicated: Patient presents with a wound on her left, first toe .She has a wound of the left, first toe for at least 7 days duration. There is moderate serous exudate .Wound Size (L x W x D): 1.1 x 0.9 x 0.1 cm, Exudate: Moderate Serous, Slough: 100%. She has a deformity of first toe consistent with arthritis, toe has rubbed against small toe box in shoe causing a wound .will change to socks only with gripping soles . The wound physician visited the resident weekly The most recent wound physician's documentation, dated 12/1/21, indicated the resident's wound had deteriorated. The wound size was 0.3 x 0.3 x 0.1 cm, with moderate serous exudate, and 100% slough. The note indicated, This wound is an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm. The wound was debrided to remove necrotic tissue and establish the margins of viable tissue. The new order was to apply alginate calcium [ointment] and apply a gauze island dressing with border once daily for 30 days. On 12/2/21 at 3:00 P.M., the interim Administrator and DON were interviewed. The DON indicated the facility did not have a designated wound nurse. A wound physician would visit the facility weekly, and the DON would scan the physician's notes and measurements into the computer. The measurements would be entered into the Wound Manager section. The DON did not respond when questioned why this resident's pressure ulcer was discovered at an advanced stage. On 12/2/21 at 4:10 P.M., the DON provided the current facility Wound Management Policy, dated 2/1/19. The policy included: It is [corporation] policy that a 'wound team' exists .The wound team members include: Director of nursing, Unit manager, Designated wound nurse, Dietary .The Wound Team meets each week .Each wound will be observed by the wound team to provide oversight of the care plan interventions and ensure that each resident's condition is accurately assessed in a timely manner. The skin conditions that the Wound Team should evaluate include .New wounds or open areas. Existing pressure and non-pressure open areas At that time, the DON provided an additional current facility Skin Assessment Policy, dated 2/1/19. The policy included: Residents .will have a head-to-toe skin assessment completed by a licensed nurse upon admission and weekly thereafter. The head-to-toe skin assessment will be charted as completed .The nurse doing the assessment will document any abnormal findings affecting the skin. If a new skin condition is identified by a licensed nurse while completing a skin assessment, the nurse will open the appropriate 'Skin Integrity Event' and complete all required sections. The licensed nurse that discovers a new open area will perform the following actions: 1. Notify the MD, obtain, and enter a treatment order. 2. Apply the initial treatment. 3. Notify the family. 4. Inform other caregivers to ensure preventative interventions actions [sic] are put into place to promote healing and inhibit development of additional areas. 5. Document these items in the medical record. This Federal tag relates to Complaint IN 351. 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on interview and record review, the facility failed to accurately assess and document the appearance and progress of a left diabetic heel ulcer and right heel ulcer; and failed to promptly notify family or the physician of the new ulcer, or 1 of 3 residents reviewed with skin wounds. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 12/2/21 at 11:30 A.M. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Assessment, dated 11/5/21 at 4:51 P.M., indicated Resident B was alert and oriented and his memory was intact. The resident had an immobilizer on his right lower leg, and a walking boot on his left lower leg. The resident had a surgical incision on his right knee, and an ulcer on the left heel. A Nurses Note, dated 11/5/21 at 5:12 P.M., indicated, Resident admitted to facility .Drsg [dressing] intact to right knee with immobilizer in place to be worn at all times. Walking boot to left foot A Care Plan, dated 11/9/21, indicated, Resident is at risk for skin breakdown R/T [related to]: Weakness, DM [diabetes mellitus], and Incontinence. The Approaches included: Assist with bed mobility as indicated. Elevate heels as resident will allow. Monitor skin for signs of skin breakdown. A Care Plan, dated 11/9/21, indicated, Resident is unable to independently perform late loss ADLs [activities of daily living] R/T weakness, DM .and requires assistance/encouragement for bed mobility, transfers The Approaches included: Maintain body in functional alignment when at rest. Provide assistance and encouragement with bed mobility as indicated. A Care Plan, dated 11/9/21, indicated, Resident has an area to Diabetic Ulcer to (R) Heel [sic]. The Approaches included: Assist resident with turning and repositioning, bed mobility. Administer treatment as ordered. A Care Plan regarding the ulcer on the left heel was not found in the clinical record. Nurses Notes including the following notations: 11/09/21 at 3:02 P.M.: Post surgery to R knee. Resident able to make needs known. Feeds self with set up help. Takes medications whole. Ext [extensive] assist of 2 with transfers and adl's. Gait unsteady. ROM [range of motion] limited to R leg. Immobilizer in place to R leg. Walking boot on left left .Treatment continues to L foot also. L foot followed by wound care center in [name of city]. Treatment continues to left heel 11/09/21 3:28 P.M.: Resident went to wound care center follow up appointment today. Clarified order with wound care center and they are as followed. Cleanse left heel with wound cleanser, paint with [MEDICATION(S)], apply abd pad, wrap with [MEDICATION(S)] [sic], and apply netting. Change daily. Follow up appointment in two weeks A Wound Care Center note, dated 11/9/21, indicated the resident had a diabetic ulcer on his left heel. The ulcer was debrided, or cleaned of dead tissue, at the visit. The note had a picture of the ulcer, but no other written assessment of the appearance of the ulcer. A facility Skin Integrity Event, dated 11/14/21 at 1:49 P.M., indicated the resident had an ulcer on his right heel. The size of the ulcer, wound characteristics, surrounding tissue appearance, or drainage of the ulcer, was left blank. The New skin interventions for plan of care was left blank. Physician and family notification was left blank. Nurses Notes continued: 11/15/21 at 12:20 P.M.: Wound Care Center returned this nurse [sic] call and gave new orders for R heel to be tx [treated] the same as left. [MEDICATION(S)] [dressing] to be applied after applying [MEDICATION(S)] to R and L foot .Wife and resident aware of new orders. Further documentation of the appearance of the right or left heel ulcer was not found in the clinical record. On 12/2/21 at 12:30 P.M., LPN 1 was interviewed. LPN 1 indicated Resident B had a brace on his right leg that he had brought from home. The resident had rubbed a blister on the right heel, from the brace falling down. The resident was unable to feel his feet due to his diabetes. It started as a blister, then it popped. The Wound Care Center said to just go ahead and do the same treatment to it. The wound measurements are recorded in the computer. Management fills out the Wound Manager in the computer. On 12/2/21 at 3:00 P.M., the interim Administrator and Director of Nursing (DON) were interviewed. The DON indicated the facility did not have a designated wound nurse. A wound physician would visit the facility weekly, and the DON would scan the physician's notes and measurements into the computer. The measurements would be entered into the Wound Manager section. Resident B did not see the facility wound physician, but went out to a wound clinic. On 12/2/21 at 3:20 P.M., the DON indicated there was no further documentation regarding Resident B's wounds. On 12/2/21 at 4:10 P.M., the DON provided the current facility Wound Management Policy, dated 2/1/19. The policy included: It is [corporation] policy that a 'wound team' exists .The wound team members include: Director of nursing, Unit manager, Designated wound nurse, Dietary .The Wound Team meets each week .Each wound will be observed by the wound team to provide oversight of the care plan interventions and ensure that each resident's condition is accurately assessed in a timely manner. The skin conditions that the Wound Team should evaluate include .New wounds or open areas. Existing pressure and non-pressure open areas. New admissions with any skin conditions documented on admission .The interdisciplinary team (IDT) will document the wound assessment weekly in the medical record .Each week a skin condition will be documented At that time, the DON provided an additional current facility Skin Assessment Policy, dated 2/1/19. The policy included: Residents .will have a head-to-toe skin assessment completed by a licensed nurse upon admission and weekly thereafter. The head-to-toe skin assessment will be charted as completed .The nurse doing the assessment will document any abnormal findings affecting the skin. If a new skin condition is identified by a licensed nurse while completing a skin assessment, the nurse will open the appropriate 'Skin Integrity Event' and complete all required sections. The licensed nurse that discovers a new open area will perform the following actions: 1. Notify the MD, obtain, and enter a treatment order. 2. Apply the initial treatment. 3. Notify the family. 4. Inform other caregivers to ensure preventative interventions actions [sic] are put into place to promote healing and inhibit development of additional areas. 5. Document these items in the medical record. This Federal tag relates to Complaint IN 351. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to adequately supervise and implement effective interventions for 2 of 3 residents who were fall risks. Resident 11 and Resident 23 acquired fractured nasal bones related to a fall, after having had multiple falls with interventions that were not effective with their cognitive status. (Resident 11, Resident 23) Findings include: 1. On 6/7/21 at 1:23 P.M., Resident 23 was observed to be propelling herself in a wheelchair in the hallway. On 6/3/21 at 1:22 P.M., Resident 23's clinical record was reviewed. Resident 23's diagnoses included, but were not limited to, 2-part nondisplaced fracture of surgical neck of left humerus. The Quarterly MDS assessment, dated, 5/12/21, indicated Resident 23 had severe cognitive impairment, required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further indicated Resident 23 was not steady and only able to stabilize with human assistance during transitions and walking. The Care Plans included, but were not limited to: Resident is at risk for falls related to fracture of left humorous and [CONDITION(S)], initiated 3/1/21. The interventions included, but were no limited to: Keep items necessary for communication, independent activities and any item specified by the resident within reach when able, initiated 3/1/21. Keep call light in reach at all times, initiated 3/1/21. Cue/remind resident to use call lights to seek assistance as needed, initiated 3/1/21. Assist with ADL's as needed, initiated 3/1/21. Gripper socks to be worn at all times, when in bed, initiated 3/26/21. Occupational therapy to evaluate and treat as indicated, initiate 4/12/21. Call don't fall signs in room, initiated 4/12/21. Cushion changed in wheelchair with Dycem added, initiated 4/13/21. Toilet resident after meals and before bedtime, initiated 4/28/21. Bright colored tape to call light, initiated 5/18/21. Keep in common area when up in bed[sic], initiated 6/2/21. Admission Care Plan-Nursing, initiated 2/5/21. The interventions included, but were not limited to: Call light in resident's reach, initiated 2/5/21. 1:1 staffing provided during initial admission assessment that included patient education of fall prevention such as using the call light for assistance, initiated 2/5/21. Resident has appropriate footwear in place to prevent sliding, initiated 2/5/21. Staff visit resident to anticipate needs more frequently upon admission for the first 4 hours, initiated 2/5/21. Fall 1 A Safety Event-Post Fall Assessment, dated 2/17/21, included, but was not limited to: Lying on back, bare feet. Incontinent of urine. Interventions initiated per care plan, non-skid footwear when in bed. 2/17/21 at 7:30 A.M., Resident found lying on back between bed and window. Dressed in gown and bare feet. Fall unwitnessed. Resident assisted to recliner and incontinence care given. Intervention to ensure resident wearing non-skid socks in bed. Fall 2 A Safety Event-Post Fall Assessment, dated 3/26/21, included, but was not limited to: Sitting on buttocks in bathroom. Poor footwear, lights were dim or not in use. Fully clothed, slippers on. Interventions initiated per plan of care, non-skid footwear when in bed. 3/26/21 at 12:34 A.M., CNA noted that resident was not in bed but was sitting in the bathroom floor in the dark. Resident was fully clothed with socks and slippers on her feet sitting in the floor next to the toilet. Urine was in the toilet, walker was near resident, light was off and room was free of clutter. Resident says she had to use the toilet and then was looking for her son and her legs gave out. Assist of two to help resident stand and use her walker to return to bed. Gripper socks placed on resident, reminded resident to use call light when needing help. Resident voiced understanding. Fall 3 A Progress Note, dated 4/9/21 at 10:39 P.M., included, but was not limited to: This writer called to resident's room by CNA's who found her lying face down on her left side in the shower in her bathroom. Resident was partially dressed and wearing regular socks and no shoes. Resident could not say what happened though she appeared to be ambulating and attempting to toilet herself. Head to toe assessment completed with small abrasion over lefty eyebrow and swollen nose with deviation to the left noted. Resident assisted by two staff persons with a gait belt to standing position, dressed and placed in her wheelchair. Gripper socks put on resident. Physician notified and new order to have facial x-rays completed. A Progress Note, dated 4/10/21 at 12:16 A.M., included, but was not limited to: X-ray results received. Nasal bone fractures noted. A Progress Note dated 4/12/21 at 1:09 P.M., IDT (Interdisciplinary Team) post fall: Resident noted to be on floor in bathroom shower. Resident appears to have transferred self. She is alert and oriented with periods of confusion. She has in place to use gripper socks, as she will allow. Resident is impulsive and non-compliant with calling for assistance. IDT feels that a bright colored 'Call Don't Fall' sign, OT (Occupational Therapy) to evaluate, and x-ray of left shoulder would be appropriate interventions for resident. A Radiology Report, dated 4/9/21, included, but was not limited to: Results: Recent fracture of nasal bones. Fall 4 A Safety Event-Post Fall Assessment, dated 4/13/21, included, but was not limited to: Found on back, next to bed (within 5 feet). Fully clothed, shoes on. No interventions initiated per plan of care. 4/13/21 at 12:07 P.M., CNA notified this nurse that resident was on the floor, unwitnessed fall. Upon entering the room, resident noted to be lying on the floor in room by divider curtain next to wheelchair. Resident was fully clothed with non-slip tennis shoes on feet. Resident stated to staff that she was trying to change her pants. Urine and toilet paper noted to be in toilet. Intervention that was initiated was to change resident chair cushion and add Dycem. Fall 5 A Safety Event-Post Fall Assessment, dated 4/26/21, included, but was not limited to: Found lying face down, in bathroom. Fully clothed, shoes on, incontinent of bowel. Interventions initiated per plan of care, resident to be toileted after meals and before bedtime. 4/27/21 at 12:39 A.M., At approximately 7:30 P.M., resident noted to be lying face down in the bathroom floor. She was fully dressed with shoes on, her pants and underwear were down at her ankles. She was incontinent of a small amount of stool. She told staff she had to use the bathroom then she just fell . Wheelchair noted to be next to resident's bed. Noted to have an egg sized bump to left side of forehead. Assist of three persons to help resident stand and sit in her wheelchair. New orders received to schedule resident a cat scan of her head/brain as soon as possible, or if neurological status changes, then may send to emergency room to be evaluated. Fall 6 A Safety Event-Post Fall Assessment, dated 5/14/21, included, but was not limited to: Lying on left side. Fully clothed, non-skid socks on. Interventions initiated per plan of care, brought to supervised area, immediately toileted. 5/14/21 at 7:50 A.M., Unwitnessed fall in bathroom. Resident with dementia stated she was attempting to self-ambulate into bathroom when she lost her balance and fell on to her left side. Root cause of fall is poor safety awareness related to dementia. Intervention: Resident will be gotten up for the day as soon as she is awake and placed in wheelchair in common area. Fall 7 A Safety Event-Post Fall Assessment, dated 5/18/21, included, but was not limited to: Lying on right side, next to bed (within 5 feet). Fully clothed. No new interventions initiated per plan of care. 5/18/21 at 3:15 P.M., Resident found on the floor in her room yelling for help to get up. Fall was unwitnessed and resident stated she hit her head but did not hurt her head. Resident inspected for Physical Trauma from the fall and no injury was noted. On 6/7/21 at 1:20 P.M., Staff Support 3 indicated no additional interventions were implemented between Resident 23's 2/17/21 and 3/26/21 falls. 2. On 6/3/21 at 2:29 P.M., Resident 11 was observed with Staff Support 3. Resident 11 was lying in bed. Resident 11 was not observed to be wearing slip resistant socks. Staff Support 3 indicated she was unsure if Resident 11 should have slip resistant socks on and would check the care plan. On 6/3/21 at 2:38 P.M., Staff Support 3 indicated Resident 11 is care planned to have slip resistant socks on in bed. Staff Support 3 further indicated slip resistant socks were placed on Resident 11. On 6/3/21 at 11:29 A.M., Resident 11's clinical record was reviewed. Resident 11's diagnoses included, but were not limited to, Alzheimer's disease, repeated falls, and complete traumatic amputation at knee level, right lower extremity. The Admission MDS (Minimum Data Set) assessment, dated 1/9/21, indicated Resident 11 had severe cognitive impairment. The Significant Change MDS assessment, dated 4/8/21, indicated Resident 11 had severe cognitive impairment, required extensive assistance of two persons for mobility, transfers, personal hygiene, and toilet use. The MDS further indicated Resident 11 was not steady and only able to stabilize with human assistance during transitions and walking. The Care Plans, included, but were not limited to: Admission Care Plan-Nursing, initiated 1/5/21. Safety interventions to minimize the risk of falling or sustaining injury during fall. The interventions included, but were not limited to: 1:1 staffing provided during initial admission assessment that include patient education of fall prevention such as using the call light for assistance, initiated 1/5/21. Resident has appropriate footwear in place to prevent sliding, initiated 1/5/21. Staff visit resident to anticipate needs more frequently upon admission for the first 4 hours, initiated 1/5/21. Resident is at risk for falls, initiated 1/17/21. The interventions included, but were not limited to: Keep items necessary for communication, independent activities and any item specified by the resident within reach when able, initiated 1/17/21. Keep call light in reach at all times, initiated 1/17/21. Cue/remind resident to use call lights to seek assistance as needed, initiated 1/17/21. Assist with ADL's (Activities of Daily Living) as needed, initiated 1/17/21. Bed in lowest position while in bed with safety mat to left side of bed (side closest to bathroom), initiated 2/22/21. Gripper sock to left foot while in bed, initiated 3/15/21. Cushion change out on 5/28/21, initiated 6/2/21. Resident is unable to independently perform late loss ADL's, initiated 1/17/21. The interventions included, but were not limited to: Provide assistance and encouragement with bed mobility as indicated, initiated 1/17/21. Provide assistance and encouragement with toileting as indicated, initiated 1/17/21. Provide assistance for transfers as indicated, initiated 1/17/21. Provide incontinence care with toileting as needed, initiated 1/17/21. Fall 1 A Safety Event-Post Fall Assessment, dated 1/8/21 included, but was not limited to: Sitting on buttocks, in front of recliner, fully clothed, shoes on, not incontinent. Interventions initiated per care plan, call light placed in reach. 1/8/21 at 2:07 P.M., Resident found on floor in front of recliner. Resident was sitting on buttocks leaned back on recliner. Resident was dry at time of incident. No new areas or bruising at this time. 1/8/21 at 6:28 P.M., Resident transferred to hospital for evaluation and treatment per physician. This nurse found resident face down on floor in front on chair. Resident right forehead had deep laceration and hematoma. 1/8/21 at 10:19 P.M., Resident returned via ambulance at 9:40 P.M. Assist of two with placing resident in bed. Residents' vital signs taken and are stable. Noted laceration to right forehead just above eyebrow. Area closed with approximately 7-8 sutures. New orders received to keep sutures dry for 24 hours then may be washed with soap and water. Sutures may be removed in 5-6 days. Resident resting quietly. Call light in easy reach. 1/9/21 at 11:10 P.M., Post fall monitoring continues. Resting quietly in bed at this time, bed in lowest position, call light and fluids within easy reach. 1/9/21 at 2:06 A.M., Post fall monitoring continues. Currently resting quietly in bed, bed in lowest position, call light in easy reach. Fall 2 A Safety Event-Post Fall Assessment, dated 1/15/21, included, but was not limited to: Sitting on buttocks, next to bed (within 5 feet), fully clothed, shoes on, not incontinent. Interventions initiated per care plan, offer rest periods between meals. 1/15/21 at 5:09 P.M., Resident found sitting on buttocks in front of wheelchair by bed. Resident fully clothed with shoes on, not incontinent at time of fall. Noted covers pulled down on bed. Vital signs and neurological checks within normal limits. New order to offer rest periods between meals. 1/18/21 at 3:58 P.M., Resident is alert to self, able to voice own needs. Physical/Occupational/Speech therapy services continue for strength, balance, endurance, cognition, and swallowing continue. Fall 3 A Safety Event- Post Fall Assessment, dated 1/28/21. Fall in room. Found on right side of bed. 1/28/21 at 4:57 P.M., CNA noted loud noise and went to check on resident who had been eating cake from activity. Resident found on right side on bedside table in room following fall. Resident was not incontinent at time of fall. Hematoma noted to right forehead. Interdisciplinary team reviewed fall. Intervention Resident to be offered rest periods in recliner or bed between meals. Fall 4 A Safety Event- Post Fall Assessment, dated 2/18/21. Found prone (face down), unwitnessed. Partially clothed, bare feet. Interventions initiated per care plan, bed in lowest position, padded mat next to bed. 2/19/21 at 12:13 A.M., At approximately 10:35 P.M., CNA passing ice water and noticed resident in the floor, face down, with blood on her face. Lights were off, floor free of clutter, resident in night gown and brief, bare foot and left prosthesis not worn. Resident assessed and assisted times 2 to help resident to recliner. Vital signs and neurological checks started per protocol and within normal limits at this time. Noted small laceration to top of nose and swelling to nose as well. Family notified and did not want to send resident out to hospital as this would upset her due to her mental status. Physician informed and agreed with family's wishes and gave order for x-rays of nose and facial bone to be done at facility. Bed was placed in lowest position and floor mat placed at left side of bed nearest bathroom. A Radiology Report, dated 2/19/21, included, but was not limited to: Reason for exam: Rule out fracture. Results. Very limited study. Fracture of the middle aspect of the nasal bones cannot be excluded. Conclusion: Limited exam. Probably nasal bone fractures. Fall 5 A Safety Event-Post Fall Assessment, dated 3/15/21. Laying on left side, next to bed (within 5 feet), poor footwear, partially clothed, bare feet. Interventions initiated per care plan, non-skid footwear when in bed. 3/15/21 at 8:45 P.M., recorded as a late entry on 3/16/21 at 3:07 A.M., IDT (Interdisciplinary Team) Reviewed Fall. While staff making rounds to check on residents, entered this resident room and noted resident lying on floor on left side of bed. Resident unable to voice reasoning for attempting to exit bed due to diagnosis of dementia. Resident was wearing hospital gown and brief at time of fall. Brief was dry. Resident had bare left foot (wears prosthesis to right as tolerated when up). Intervention: Resident to don gripper socks to left lower extremity while in bed to attempt to prevent resident from slipping off side of bed when sitting up on side of bed per self. Fall 6 A Safety Event-Post Fall Assessment, dated 5/28/21. Sitting on buttocks, fully clothed, non-skid socks on. Interventions initiated per care plan, brought to supervised area, resident education. 5/28/21 at 9:50 A.M., Resident was sitting in her wheelchair in front of the nurses station and was found to be sitting on her buttocks on the floor. Resident unable to tell us what she was doing or what had happened. This nurse thinks that resident was trying to pick up a crayon that had rolled off her table onto the floor. 6/2/21 at 4:47 P.M., IDT post fall: Fall noted at nurse's station. Resident in wheelchair. Upon investigation IDT feels that changing out cushion would be the best intervention for resident to prevent further falls from wheelchair. Resident noted to be at nurses' station when not in bed. On 6/7/21 at 12:49 P.M., Staff Support 3 indicated that on 1/11/21 the facility initiated an intervention for falls to include offer rest periods between meals following Resident 11's fall on 1/8/21. Staff Support 3 indicated that on 1/17/21 the facility-initiated interventions to include keeping call light within reach, cue/remind resident to use call lights to seek assistance as needed and assist with ADL's as needed following Resident 11's fall on 1/15/21. Staff Support 3 indicated she did not see any new interventions implemented following Resident 11's fall on 1/28/21 but would try to locate new interventions. Staff Support 3 indicated she was unsure if Resident 11 was alert and oriented for the interventions following the 1/15/21 fall to be effective. On 6/7/21 at 11:29 A.M., the Interim Administrator provided the current Clinical-Fall Prevention Policy and Procedure, dated 5/2016. The policy included but was not limited to: Strategies to prevent falls will be individual for each patient. Each section of the fall risk assessment tool should be considered, and staff should receive education pertaining to these risk factors to reduce falls. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was served at an appropriate temperature for 2 of 7 residents interviewed, and 1 of 1 lunch trays tested . (Resident 8, Resident 24) Findings include: On 6/2/21 at 10:39 A.M., Resident 8 indicated the hot food was cold sometimes, and cold foods were sometimes warm. On 6/2/21 at 10:50 A.M., Resident 24 indicated the hot food was sometimes cold. On 6/4/21 at 12:02 P.M., a food cart was observed in the hall by the nurses' station. The cart was open and held 6 residents' food trays. The last tray delivered from the cart was tested at 12:14 P.M., and the following temperatures were observed: Fish, with a temperature of 102 degrees Fahrenheit. Cornbread, with a temperature of 98 degrees Fahrenheit. French Fries were unable to have temperature obtained, but were cool to the touch, and tasted cool. Chocolate dessert, with a temperature of 56 degrees Fahrenheit. On 6/7/21 at 11:30 A.M., a current undated Food Preparation and Safety policy, indicated that .Trays are delivered promptly to ensure that food is served at a preferable temperature and to preserve the quality of the food . Hot foods will leave the kitchen at 135 [degrees Fahrenheit] or above and cold foods will be at 41 [degrees Fahrenheit] or below . 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to implement infection control practices to prevent the spread of COVID-19 for 2 of 2 meal services. Staff did not donn a N95 mask or eye protection when entering a room for a resident on transmission based precautions and masks were not worn over the nose. (Resident 78, Resident 79, Resident 23, Resident 10) Findings include: 1. On 6/2/21 at 12:00 P.M., CNA 2 was observed to donn an isolation gown and gloves and entered Resident 78's room (contact/droplet isolation room) to deliver the noon meal tray. CNA 2 did not donn an N95 mask or eye protection. CNA 2 removed her gloves and isolation gown. CNA 2 performed hand hygiene. CNA 2 walked to Resident 79's room (contact/droplet isolation room) and donned an isolation gown and gloves. CNA 2 delivered the noon meal tray and indicated she would return to assist the resident with the meal. CNA 2 was not observed to donn a N95 mask or eye protection. CNA 2 removed her isolation gown and gloves and performed hand hygiene. At 12:18 P.M., CNA 2 returned to Resident 79's room and donned an isolation gown and gloves. CNA 2 entered the room to assist the resident with the meal. CNA 2 did not donn an N95 mask or eye protection. 2. On 6/4/21 at 12:12 P.M., CNA 2 donned an isolation gown and gloves and entered into Resident 79's room (contact/droplet isolation room) and deliver the noon meal. CNA 2 did not donn an N95 mask or eye protection. CNA 2 remove her gown and gloves and performed hand hygiene. CNA 2 donned an isolation gown and gloves and entered Resident 78's room (contact/droplet isolation room). CNA 2 did not donn an N95 mask or eye protection. On 6/4/21 at 12:17 P.M., CNA 2 indicated the residents in Resident 79 and Resident 78 were on contact/droplet isolation because they were unvaccinated new admissions. On 6/7/21 at 10:49 A.M., CNA 2 indicated when entering the rooms of Resident 79 and Resident 78 staff should wear an isolation gown, gloves, and a N95 mask. CNA 2 further indicated if there was a face shield available they should wear that into the rooms. 3. On 6/2/21 at 11:30 A.M., LPN 4 was observed at the nurses' station wearing her mask below the nose. LPN 4 pulled it up, touched her keyboard, then entered Resident 10's room. After 4 minutes, LPN 4 exited the room while wearing her mask below her nose, went to the medication cart, pulled up the mask, then performed hand hygiene. 4. During a random observation on 6/2/21 at 11:33 A.M., CNA 2 walked down the hall by the nurses station while wearing a mask below her nose when a resident was seated in the hallway. 5. On 6/2/21 at 12:12 P.M., LPN 4 was observed taking a food tray from a cart in the hall while wearing her mask below the nose, pulled up the mask while walking in the hall, then touched the tray. 6. On 6/2/21 at 12:14 P.M., LPN 4 was observed serving lunch trays to residents sitting in the hall. While retrieving Resident 23's tray, LPN 4's mask was positioned below her nose. LPN 4 placed the tray on a bedside table, removed the lid from the plate, and pulled her mask up. She then removed the plastic wrap from the salad, fruit, dressing, and drinks. During that task, her mask slid below her nose. After pouring dressing on the salad, she pulled her mask up again, and it immediately slid below the nose. LPN 4 then washed her hands. On 6/7/211 at 11:29 A.M., the Interim Administrator provided the current PPE COVID-19 Quick Reference Guide policy, dated 12/28/20. The policy included, but was bot limited to: Face shield or goggles must be worn by healthcare personnel who provide essential direct care within 6 feet of the resident when .caring for a resident in TBP (Transmission Based Precautions). At that time, the Interim Administrator indicated he did not believe staff needed to wear eye protection when delivering meals to residents in transmission based precautions. 3.1-18(l) 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) were provided to residents dependent for care in a timely manner, for 3 of 3 residents reviewed for ADL care, in a sample of 4. (Residents B, C, and D) Findings include: 1. On 4/26/21 at 2:20 P.M., Resident B was observed sitting in her room in a wheelchair. Resident B was interviewed at that time. She indicated she required assistance of staff to transfer out of her bed and wheelchair, and assistance to go to the bathroom and get a shower. She indicated, They are short of help. Weekends are really bad. Resident B indicated, Sometimes you just have to wait for them to answer your call light. It's not their fault. They are just doing their jobs. She indicated medications were passed late at times. The clinical record of Resident B was reviewed on 4/26/21 at 3:00 P.M. A Care Plan, dated 4/15/21, indicated: Problem: Resident is unable to independently perform late loss ADLs R/T [related to] spinal stenosis and chronic pain, and requires assistance/encouragement for bed mobility, transfers, toileting and eating. The Approaches included: Assist/encourage resident in proper transfer, bed mobility, toileting/hygiene and eating techniques. Keep call light within reach. Provide assistance for transfers as indicated. An admission Minimum Data Set (MDS) assessment, dated 4/17/21, indicated Resident B did not have any memory problems, and required extensive assistance of two or more staff for bed mobility and transfer. 2. On 4/26/21 at 2:30 P.M., Resident C was observed lying in her bed. She had a sling on her left arm, and a brace on her right arm. At that time, Resident C was interviewed. She indicated the facility was short-staffed. She had received her bedtime medications around midnight the previous night. Resident C indicated she required assistance of staff to transfer, and she would use her call light to request help. She indicated she would have to wait at times. Resident C indicated her roommate usually had to wait even longer, because it took 2 staff to assist her. The clinical record of Resident C was reviewed on 4/26/21 at 3:15 P.M. A Care Plan, dated 4/23/21, indicated: Problem: Resident is unable to independently perform late loss ADLs R/T age related debility and [CONDITION(S)], and requires assistance/encouragement for bed mobility, transfers, toileting and eating. The Approaches included: Assist/encourage resident in proper transfer, bed mobility, toileting/hygiene and eating techniques. Keep call light within reach. Provide assistance for transfers as indicated. A Nurses Note, dated 4/25/2021 at 2:33 P.M., indicated, Resident is A&O x 3 [alert and oriented to time, place, and person], pleasant and cooperative with ability to voice needs to staff; ADLs and transfers with assist x 1 3. On 4/26/21 at 2:40 P.M., Resident D was observed sitting in a recliner in her room. Resident D was interviewed at that time. She indicated the facility was short-staffed. She indicated she had gone a couple of times when she only got 1 shower a week. Ice water was not always passed every shift. She would sometimes get ice water on an evening shift, and then would have to ask the next afternoon for more water. Her medications were late sometimes, and the previous night they were really late. She indicated it just depends on when you call on how fast call lights were answered due to the lack of staff. The clinical record of Resident D was reviewed on 4/26/21 at 3:25 P.M. An admission MDS assessment, dated 1/29/21, indicated Resident D had no memory problems, and required extensive assistance of two or more staff for bed mobility, transfer, dressing, toilet use, personal hygiene, bathing, and walking in room. A Care Plan, dated 2/26/21, indicated: Problem: Resident is unable to independently perform late loss ADLs R/T DM2 [diabetes mellitus type 2], repeated falls, anxiety and [CONDITION(S)] [hypertension], and requires assistance/encouragement for bed mobility, transfers, toileting and eating. The Approaches included: Assist/encourage resident in proper transfer, bed mobility, toileting/hygiene and eating techniques. Keep call light within reach. Provide assistance for transfers as indicated. On 4/27/21 at 1:17 P.M., during an interview with the corporate Assistant Director of Nursing and interim Administrator, they indicated they would expect a shower or bed bath to be given at least twice weekly. This Federal tag relates to Complaint IN 078. 3.1-38(a)(3)

Based on interview and record review, the facility failed to ensure adequate staff were provided to pass medications timely, to answer call lights, to provide personal care and showers, and to pass ice water, for 3 of 4 residents interviewed, in a sample of 4. (Residents B, C, and D) Findings include: 1. On 4/26/21 at 2:20 P.M., Resident B was interviewed. She indicated she required assistance of staff to transfer out of her bed and wheelchair. She indicated, They are short of help. Weekends are really bad. Resident B indicated, Sometimes you just have to wait for them to answer your call light. It's not their fault. They are just doing their jobs. She indicated medications were passed late at times. The clinical record of Resident B was reviewed on 4/26/21 at 3:00 P.M. An admission Minimum Data Set (MDS) assessment, dated 4/17/21, indicated Resident B did not have any memory problems, and required extensive assistance of two or more staff for bed mobility and transfer. 2. On 4/26/21 at 2:30 P.M., Resident C was interviewed. She indicated the facility was short-staffed. She had received her bedtime medications around midnight the previous night. Resident C indicated she required assistance of staff to transfer, and she would use her call light to request help. She indicated she would have to wait at times. Resident C indicated her roommate usually had to wait even longer, because it took 2 staff to assist her. The clinical record of Resident C was reviewed on 4/26/21 at 3:15 P.M. A Nurses Note, dated 4/25/2021 at 2:33 P.M., indicated, Resident is A&O x 3 [alert and oriented to time, place, and person], pleasant and cooperative with ability to voice needs to staff; ADLs [activities of daily living] and transfers with assist x 1 3. On 4/26/21 at 2:40 P.M., Resident D was interviewed. She indicated the facility was short-staffed. She indicated she had gone a couple of times when she only got 1 shower a week. Ice water was not always passed every shift. She would sometimes get ice water on an evening shift, and then would have to ask the next afternoon for more water. Her medications were late sometimes, and the previous night they were really late. She indicated it just depends on when you call on how fast call lights were answered due to the lack of staff. The clinical record of Resident D was reviewed on 4/26/21 at 3:25 P.M. An admission MDS assessment, dated 1/29/21, indicated Resident D had no memory problems, and required extensive assistance of two or more staff for bed mobility, transfer, and walking in room. On 4/26/21 at 10:10 A.M., the corporate Assistant Director of Nursing (ADON) provided the previous 2 week nursing schedule. The schedule indicated: Day shift: 1-2 nurses, 2-3 CNAs; Evening shift: 1-2 nurses, 2-2 1/2 CNAs; and Night shift: 1 nurse, 1-2 CNAs. On 4/26/21 at 11:05 A.M., the corporate ADON provided CNA assignment sheets, updated 4/20/21. The sheets indicated 26 residents resided on the skilled unit. 5 residents required a Hoyer lift (mechanical lift) for transfer, for which 2 staff members are required; 6 residents required 2 assist for transfer; 1 resident required a Stand Aid (mechanical lift) for transfer; and 11 residents required 1 assist for transfer. 25 of 26 residents required showers twice a week. The Special Instructions indicated 1 resident needed to be a 2 hr check and change, 1 resident was on a toileting schedule, and 1 was incontinent at times. 25 of 26 residents required some type of assistive device, such as a walker or wheelchair. On 4/26/21 at 10:20 A.M., during an interview with the local long term care ombudsman, she indicated she had received phone calls and emails to inform her that residents were not receiving showers and other care due to the lack of staffing. Staff were exhausted, working extra shifts, and unable to take breaks. During a confidential interview, they indicated there were 2 CNAs on the skilled unit, and there should be 3. They indicated medications were sometimes passed late. During a confidential interview, they indicated residents were not receiving showers or being weighed. They indicated residents had to wait 30-40 minutes for call lights to be answered sometimes. During a confidential interview, they indicated staff were unable to take breaks or meals, showers and weights were not always completed, and residents had to wait on call lights to be answered. During a confidential interview, they indicated morning medications were sometimes passed at 1:30 P.M. They indicated residents were not receiving good care due to the staffing problem. On 4/27/21 at 1:15 P.M., during an interview with the corporate ADON and interim Administrator, they indicated they would expect staff to pass ice water every shift, and that showers or bed baths would be given per the resident's preference, but at least twice a week. This Federal tag relates to Complaint IN 078. 3.1-17(a)

Based on observation and interview, the facility failed to ensure the daily staffing information was posted as required, for 2 of 2 days of the survey. Findings include: On 4/26/21 at 2:15 P.M., and 4/27/21 at 9:45 A.M., a Daily Nurse Staffing document, dated 4/23/21, was observed posted by the nursing station. The document indicated: Day shift: 2 LPNs at 8 hours and 3 CNAs at 8 hours each; Evening shift: LPNs - 2 - .5 from 3-7 P.M., and .5 from 7-11 P.M. for 12 hours, and 2 CNAs from 2-10 P.M., and .5 CNA from 2-6 P.M.; and 2.5 CNAs at 20 hours total; and Night Shift: 1 LPN at 8 hours, and 2 CNAs at 8 hours each. On 4/27/21 at 10:40 A.M., the corporate Assistant Director of Nursing indicated the Medical Records manager was responsible for updating the Daily Nurse Staffing. She indicated it had been done on Friday 4/23/21, and the Medical Records manager was terminated on Monday 4/26/21. This Federal tag relates to Complaint IN 078.

Based on observation, interview, and record review, the facility failed to actively monitor the employee screening process in order to prevent the spread COVID-19. Staff were permitted to screen selves at the facility entrance without being monitored by a designated screener for 1 of 1 entrance used by employees and visitors. Finding includes: During an observation 12/10/20 at 10:45 A.M., the main entrance of the facility was not being monitored by a designated screener. A COVID-19 screening table was set up at the entrance with a sign indicating all staff should sign in, check their own temperature, and answer screening questions. During an interview on 12/10/20 at 11:00 A.M. LPN 4 indicated that when entering the building all staff and visitors use the same door entering to the lobby. LPN 4 indicated the doors are locked, and that staff can enter by using a code and then screen themselves in at the screening table, including taking their own temperature and answer screening questions. All visitors are let in by staff and screened at the door by staff. During an interview on 12/10/20 at 11:50 A.M., the ADON indicated the screening station does not have a designated staff member to screen employees. Their corporate office had indicated to them that a designated screener was not required to screen in employees. Employees should screen themselves and, if symptomatic or detect a fever, should call their supervisor immediately from either their personal phone or the phone at the front desk near the screening table. All visitors and outside services would have to be let in by staff and then screened before entering the facility. During record review on 12/10/20 at 1:30 P.M., the Indiana Department of Health Visitation Guidelines for Long-Term Care Facilities included, .Continue staff screening and temperature checks at the start of each shift and do not permit entry if any symptoms of COVID-19 are present. We have seen multiple outbreaks in our state when HCP are allowed to work with symptoms of COVID-19 that do not include a fever. While a fever is one criteria whereby HCP should not report to the facility for work, facilities should be vigilant to not allow staff with runny nose and sore throats, as one example, to work without first testing for COVID-19 and improved symptoms . 3.1-18(a)

Based on interview and record review, the facility failed to ensure the accuracy of required assessments for 2 of 5 residents reviewed for unnecessary medications. A quarterly and annual MDS (Minimal Data Set) assessment did not include diagnoses, or medication. (Resident 18, Resident 14) Findings include: 1. On 9/24/19 at 10:15 [NAME]M., Resident 18's clinical record was reviewed. (Active status) [DIAGNOSES REDACTED]. The most recent MDS Assessment (annual), dated 9/12/19, indicated a severe cognitive impairment, [DIAGNOSES REDACTED]. Anxiety and dementia were not listed. The MDS indicated no opioids had been given in the 7 day assessment period. Current orders included, but were not limited to, [MEDICATION NAME] 25mg (milligrams) every 6 hours as needed, dated 5/11/18, and monitor resident with antipsychotic therapy for targeted behaviors of yelling out, anxiety and delusions. The (MONTH) 2019 MAR (Medication Administration Record) indicated [MEDICATION NAME] had been given to Resident 18 on 9/6/19, 9/7/19, and 9/8/19. Current care plans included, but were not limited to, The resident has a dx (diagnosis) that requires the use of antipsychotic medication AEB (as evidenced by) (anxiety/yelling out consistently/delusions), revised 8/1/19. The (MONTH) 2019 TAR (Treatment Administration Record) indicated Resident 18 had specific behaviors of anxiety on 9/8/19. During an interview on 9/26/19 at 11:00 [NAME]M., MDS Coordinator 7 indicated anxiety was not listed on the MDS Assessment because it was not being treated as an active diagnosis. She further indicated dementia should have been coded on the MDS Assessment and was missed. At that time, MDS Coordinator 3 indicated [MEDICATION NAME] was not considered an opioid and was not put on the MDS Assessment. 2. During record review on 9/24/19 at 10:00 [NAME]M., Resident 14's most recent quarterly MDS, dated [DATE], indicated the resident received antipsychotic medications, antidepressant medications, and opioid medications. No diagnoses were listed on the assessment. A physician's orders [REDACTED]. During an interview on 9/24/19 at 1:15 P.M., MDS Coordinator 3 indicated the diagnoses should be listed on the assessment, but were not because the physician had not signed off on Resident 14's L[NAME] (Level of Care). MDS Coordinator indicated the resident did receive medications during the assessment period. During an interview on 9/27/19 at 9:45 [NAME]M., the DON indicated the facility did not have a policy specific to the MDS assessments, but that it was the facility's policy to follow the RAI (Resident Assessment Instrument) Manual. 3.1-31(i)

Based on observation, interview, and record review, the facility failed to assess a resident for self administration of medications for 1 of 1 residents reviewed for medications left in the resident rooms. (Resident 125) Findings include: On 10/4/18 at 9:43 A.M., a bottle of multivitamins was observed to be sitting on a table in Resident 125's room. On 10/9/18 at 9:36 A.M., a bottle of multivitamins was observed to be sitting on a table in Resident 125's room. On 10/9/18 at 9:47 A.M., Resident 125 indicated the bottle was multivitamins and she took one at breakfast time, without staff assistance. On 10/9/18 at 9:43 A.M., Resident 125's clinical record was reviewed. The Admission MDS (Minimum Data Set) assessment, dated 9/22/18, indicated Resident 125 had no cognitive impairment. The Clinical Record lacked an assessment for Resident 125 to self administer medications. The Clinical Record lacked a physician's orders [REDACTED]. On 10/9/18 at 1:52 P.M., the DON indicated Resident 125 did not self administer her medications nor could she locate an assessment for Resident 125 to self administer medications. On 10/9/18 at 12:56 P.M., the DON provided the current Self-Administration of Drugs policy, revised 8/2006. The policy included, but was not limited to: As part of their evaluation to self administer medications, the staff will assess each resident's metal and physical abilities, to determine whether a resident is capable of self-administering medications .self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . 3.1-11

Based on observation, interview, and record review, the facility failed to ensure a resident admitted to the facility without pressure, developed pressure for 1 of 3 residents who met the criteria for review of pressure. This deficient practice resulted in Resident #1 experiencing an unstageable pressure ulcer on the left heel and right hip. (Resident #1) Findings include: During an observation on 7/18/16 at 8:00 A.M., Resident #1 was observed lying on back in bed with heel protectors on the bilateral feet. The left heel was observed to be askew in the heel protector, not to be floated, and in direct contact with the surface of mattress. The clinical record of Resident #1 was reviewed on 7/21/16 at 8:30 A.M. The clinical record indicated Resident #1 was admitted to the facility on [DATE] with no skin impairment to the left heel and [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #1 was at risk for developing a pressure ulcer, was cognitive intact, and needed the extensive assistance of 2 people for bed mobility and transfers. The Significant Change MDS assessment dated [DATE] indicated Resident #1 was at risk for developing a pressure ulcer, experienced severe cognitive impairment and needed the extensive assistance of 2 people for bed mobility and transfers. A Skin assessment dated [DATE] at 6:10 A.M. indicated Resident #1 experienced no skin impairment to the left heel or the right hip. A Care Plan for, .at risk for skin breakdown r/t (related to) friction and shear . dated 5/16/16 included the following interventions: Avoid shearing resident's skin during positioning, transferring, and turning, Conduct a systemic skin inspection weekly, Elevate /off load heels while in bed, Skin prep to bilateral heels and toes daily, Turn and reposition, Use cushion for pressure reduction when resident is in chair, Use pressure reduction mattress for pressure reduction when resident is in bed A Care Plan for SDTI to left heel dated 5/26/2016 included the following interventions: Heel lift boots at all times, No shoes on at any time at this time, Skin Prep TID (three times a day) to bilateral heel A Care Plan for bruise to right hip dated 6/13/2016 included following intervention: Monitor bruise/blister to right hip q shift til healed A Skin Risk assessment dated [DATE] indicated Resident #1 was at risk to develop pressure related skin impairment. The May 2016 physician's orders [REDACTED]. A Restorative Nursing Progress note dated 5/9/16 at 11:40 A.M. indicated, .Resident will utilize transfer bars, to pull self over and push up with legs . Development of Area to Left heel: An Event Report dated 5/26/16 at 1:59 P.M. indicated, .SDTI (Suspected Deep Tissue Injury) (A 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 .Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar) left heel .) 9.6 cm (centimeters) length X (by) 4.2 cm .area is light purple with small areas of deeper purple .2 cm ring of [DIAGNOSES REDACTED] surrounds entire area .area is fluid filled .interventions -Heels elevated in bed .heel lift boots at all times and no shoes at this time . A Resident Progress Notes dated 5/27/16 at 12:26 P.M., read as follows, .MD acknowledged SDTI to left heel . A Skin Condition Assessment note dated 6/2/16 at 11:34 A.M. indicated, .SDTI-left heel .8 x 4 cm, base dark red/grey with intact blister .Offload heels in bed .Heel lift boots at all times . A Skin Condition Assessment note dated 6/9/16 indicated, .SDTI-Left heel 8.2 cm x 4.3 cm .Stage .Unstageable .Eschar (black, brown, dry nonviable tissue) 100% . A Resident Progress note dated 6/9/16 at 3:00 P.M., indicated, A procedure was performed to determine the Ankle Brachial Index (ABI) (a test to determine blood profusion) of resident's lower legs .Right leg ABI .1.1 .Left leg ABI .1.2 .incate (sic) normal blood sufficiency .compressionable arteries . A Skin Condition assessment dated [DATE] at 4:57 P. M. indicated, .SDTI - Left heel .8.3 cm x 4.0 cm .Eschar 100% .Resident has a decline in health and mobility in past several months, and has had to be laid down or transferred to recliner between meals for increase in abnormal posture and leaning . A Skin Condition assessment dated [DATE] at 12:07 P.M. indicated, .SDTI - Left heel .5.0 cm x 3.0 cm .Eschar 100% .dark brown .25% serous drainage . A Skin Condition assessment dated [DATE] at 4:59 P.M., .SDTI - Left heel .2.0 cm x 1.2 cm .Eschar 100% . A Resident Progress Notes dated 7/17/2016 at 3:46 P.M., Open area found to L (left) heel when getting resident out of bed. CNA's noticed blood on heel lift boot that was coming from a small opened area to heel measuring 0.3 x 0.3 cm. Resident unaware of the area or how it was obtained . Development of Area to right hip. A Skin Condition assessment dated [DATE] at 2:15 A.M., indicated Resident #1 experienced no skin impairment to the right hip. An Event Report dated 6/12/16 at 10:06 P.M., read as follows, .Bruise to right hip measuring 6.0 x 2.0 cm .This started on: 6/12/16 at 6:30 P.M .A bruise was noted to resident's right hip measuring 6.0 cm x 2.0 cm. Bruise red in color. Resident favors/leans to right side. Resident repositioned et (and) is off right hip. No c/o (complaint of) pain voiced . An Event Report dated 6/21/16 at 5:43 P.M., indicated, Blister inferior right hip- Stage 2 .3.7 (cm) x 2 cm .has a custom wheelchair- decrease in alertness .less active .has outline of interior guard of wheelchair arm. Guard immediately removed from chair .Continue comfort foam dressing for protection- MD noted that even minor rubbing with the Xarelto (blood thinning medication that can cause bruises) can develop into a lesion as this . A Skin Condition assessment dated [DATE] at 2:25 P.M., indicated, .Stage 2-right hip .4.0 cm X 2.0 cm .Eschar- 50 % .[MEDICATION NAME] (Deep pink to pearly pink) - 50 % .Dark Red /brown base .Lift sheet when repositioning to avoid shearing . A Skin Condition assessment dated [DATE] at 12:07 P.M. indicated, .Stage 2-right hip .3.0 cm X 2.0 cm .Slough (non-viable tissue) - 50 % .Eschar- 50 % .Grey/brown base .Lift sheet when repositioning to avoid shearing . A Skin Condition assessment dated [DATE] at 4:56 P.M., read as follows, .Stage 2-right hip .4.0 cm X 2.0 cm .Slough-50 % .Eschar-50 % .Grey/brown base .Current nursing measures in place; Turn and reposition every 2 hours, Lift sheet when repositioning to avoid shearing . During an interview on 7/20/16 at 8:11 A.M., OT (Occupational Therapist) #1 indicated the root cause of the right hip wound was related to improper wheelchair positioning and the use of an arm guard in the wheelchair. During an observation on 7/20/16 at 3:15 P.M., Resident #1 was observed sitting in a recliner leaning towards the right with heel protectors on the bilateral feet. The left heel was observed to be askew in the heel protector, not be floated, and in direct contact with the surface of the recliner's footrest. During an interview, at that time, the WCN (Wound Care Nurse) indicated she was preparing to assess and provide wound care to Resident #1. The left heel wound bed was observed to be 100% black eschar and measure 2.0 cm X 1.2 cm. The right hip wound bed was observed to have 25% gray slough with 25% dark brown eschar. The WCN then indicated the left heel wound was facility acquired after a change in condition and the right hip wound was facility acquired and related to positioning equipment that caused Resident #1 to lean to the right side. A Policy and Procedure for, Pressure Ulcer Staging System provided by the HFA (Health Facilities Administrator) on 7/21/16 at 3:15 P.M. indicated, . A Pressure ulcer is (sic) localized injury to the skin .underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .friction . .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 .Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar .Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red (sic) pink wound bed, without slough . May also present as an intact or open/ruptured serum-filled blister .present as a shiny or dry shallow ulcer without slough or bruising .Bruising indicates suspected deep tissue injury .Stage III: Full thickness tissue loss .Slough may be present but does not obscure the depth of tissue loss .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 . During an interview on 7/21/16 at 3:50 P.M., the Director of Nursing (DON) indicated the area on Resident #1's heel could have been caused by Resident #1 using heels to assist staff during repositioning in bed. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to follow the resident's plan of care by not monitoring the skin under a resident's immobilizer, allowing a pressure area to develop, for 1 of 14 residents reviewed for implementation of care plans. Resident # 51 Findings include: 1. The clinical record of Resident # 51 was reviewed on 8/24/11 at 9:30 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated 6/5/11, indicated, "Immobilizer (left) knee @ all x's (times) may remove for bathing." A "Skin At Risk Assessment, dated 6/5/11, indicated the resident did not have a pressure ulcer. A Care Plan, dated 6/5/11, indicated a problem of "Potential for skin breakdown r/t (related to) (left blank)..." The Approaches/Interventions included: "Monitor skin q (every) shift...Monitor resident skin and report any changes to the MD...." An Occupational Therapy Progress note, dated 6/6/11, indicated, "...Precautions:...immobilizer to L (left) knee at all times except bathing...." A Physical Therapy Plan of Treatment, dated 6/6/11, indicated, "...Precautions: ...immobilizer to left knee at all times - no motion of any kind at knee...." A Weekly Skin Inspection Tool, dated 6/16/11, indicated, "...Skin integrity (sic) good. Interventions, Pressure Reduction Mattress, Pressure Reduction Chair Cushion, Pillows for positioning, Incontinence Care. 0 new areas to skin noted...." A "Skin - Pressure Ulcer Documentation," dated 6/22/11, indicated, "...Observation date: 6/22/11...Description, Left posterior ankle/heel...Stage 3, Size (Length x Width x Depth) 2 x 3 x 0.3 cm (centimeters), 6 x 3.8 cm. Exudate (drainage), Moderate. Exudate - color, Purulent. Wound Odor, Foul...Area suspected deep tissue injury measures 6 x 3.8 cm, with center Stage 3 pressure area of 2 x 3 x 0.3 cm, center of wound yellow with slough present, slight odor present...." A Resident Progress Note, dated 6/22/11 at 2:23 P.M., indicated, "M.D. paged re: area to left posterior ankle/heel new order received et (and) noted...." On 8/24/11 at 12:30 P.M., PTA (Physical Therapist Assistant) # 1 and the OT (Occupational Therapist) were interviewed. PTA # 1 indicated the resident received physical and occupational therapy, and the resident's immobilizer was not to be removed except for bathing. PTA # 1 indicated the immobilizer was too long, and caused an area on the resident's heel area. PTA # 1 and the OT indicated they did not remove the immobilizer or adjust the immobilizer during therapy, except for unfastening it during treatment. The OT and PTA # 1 indicated they did not inspect the skin during therapy. On 8/24/11 at 1:18 P.M., CNA # 3 was interviewed. CNA # 3 indicated she took care of Resident # 51 when he first came in. CNA # 3 indicated the CNAs did not remove the immobilizer. CNA # 3 indicated the resident had showers, and the staff would cover the immobilizer with a plastic bag. On 8/24/11 at 2:12 P.M., LPN # 4 was interviewed. She indicated the resident developed two areas from the immobilizer. LPN # 4 indicated the staff would have removed the immobilizer for bathing. LPN # 4 indicated she was unsure how the staff performed the weekly skin assessments. The resident's pressure ulcer was observed at that time. The pressure ulcer was located on the back of the resident's left upper heel/Achilles tendon area. The pressure ulcer was observed to be open, with a pink wound bed which contained yellow tissue. A small pinpoint, closed, dark area was observed above the pressure area. The resident indicated at that time, "The brace was too long and it rubbed." On 8/25/11 at 9:25 A.M., during interview with RN # 1, she indicated, "Therapy removed the immobilizer and found the pressure area. I initially assessed it." RN # 1 indicated she did not recall doing weekly skin assessments on the resident, and was unsure if staff removed the immobilizer during skin assessments. On 8/25/11 at 11:40 A.M., during interview with the Director of Nursing (DON), she indicated, "We did not have the CNAs remove the immobilizer." The DON indicated the nursing staff performed dressing changes nightly on the resident's knee and thigh area, and would have removed the immobilizer at that time. The DON indicated she did not know if a thorough skin assessment was performed, but that staff was trained on head-to-toe assessments. The DON indicated she probably would have staged the area as unstageable. 3.1-35(g)(2)

Based on observation, interview and record review, the facility failed to ensure a thorough skin assessment was performed on a resident who required a leg immobilizer, resulting in the development of a Stage 3 pressure ulcer from the immobilizer for 1 of 1 residents reviewed for pressure ulcers in a Stage 2 sample of 14. Resident # 51 Findings include: 1. "Stages of Pressure Ulcers," AMDA-2008, includes: "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 shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissues... Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Note: The depth of a Stage III or IV varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. 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 ulcer bed. 2. The clinical record of Resident # 51 was reviewed on 8/24/11 at 9:30 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital transfer sheet, dated 6/5/11, indicated the resident did not have a pressure ulcer on the left heel area. Physician orders, dated 6/5/11, indicated, "Immobilizer (left) knee @ all x's (times) may remove for bathing." A "Skin At Risk Assessment, dated 6/5/11, indicated the resident did not have a pressure ulcer. A Care Plan, dated 6/5/11, indicated a problem of "Potential for skin breakdown r/t (related to) (left blank)..." The Approaches/Interventions included: "Monitor skin q (every) shift...Monitor resident skin and report any changes to the MD...." An Occupational Therapy Progress note, dated 6/6/11, indicated, "...Precautions:...immobilizer to L (left) knee at all times except bathing...." A Physical Therapy Plan of Treatment, dated 6/6/11, indicated, "...Precautions: ...immobilizer to left knee at all times - no motion of any kind at knee...." An initial Minimum Data Set (MDS) assessment, dated 6/12/11, indicated the resident required extensive assistance of two + staff for bed mobility and transfer. The MDS assessment indicated the resident did not have pressure ulcers. A Weekly Skin Inspection Tool, dated 6/16/11, indicated, "...Skin integrity (sic) good. Interventions: Pressure Reduction Mattress, Pressure Reduction Chair Cushion, Pillows for positioning, Incontinence Care. 0 new areas to skin noted...." A "Skin - Pressure Ulcer Documentation" dated 6/22/11, indicated, "...Observation date: 6/22/11...Description, Left posterior ankle/heel...Stage 3, Size (Length x Width x Depth) 2 x 3 x 0.3 cm (centimeters), 6 x 3.8 cm, Exudate (drainage), Moderate, Exudate - color, Purulent, Wound Odor, Foul...Area suspected deep tissue injury measures 6 x 3.8 cm, with center stage 3 pressure area of 2 x 3 x 0.3 cm, center of wound yellow with slough present, slight odor present...." A Resident Progress Note, dated 6/22/11 at 2:23 P.M., indicated, "M.D. paged re: area to left posterior ankle/heel new order received et (and) noted...." On 8/24/11 at 12:30 P.M., PTA (Physical Therapist Assistant) # 1 and the OT (Occupational Therapist) were interviewed. PTA # 1 indicated the resident received physical and occupational therapy, and the resident's immobilizer was not to be removed except for bathing. PTA # 1 indicated the immobilizer was too long, and caused an area on the resident's heel area. PTA # 1 and the OT indicated they did not remove the immobilizer or adjust the immobilizer during therapy, except for unfastening it during treatment. The OT and PTA # 1 indicated they did not inspect the skin during therapy. On 8/24/11 at 1:18 P.M., CNA # 3 was interviewed. CNA # 3 indicated she took care of Resident # 51 when he first came in. CNA # 3 indicated the CNAs did not remove the immobilizer. CNA # 3 indicated the resident received showers, and the staff would cover the immobilizer with a plastic bag. On 8/24/11 at 2:12 P.M., LPN # 4 was interviewed. She indicated the resident developed two areas from the immobilizer. LPN # 4 indicated the staff would have removed the immobilizer for bathing. LPN # 4 indicated she was unsure how the staff performed the weekly skin assessments. The resident's pressure ulcer was observed at that time. The pressure ulcer was located on the back of the resident's left upper heel/Achilles tendon area. The pressure ulcer was observed to be open, with a pink wound bed which contained yellow tissue. A small pinpoint, closed, dark area was observed above the pressure area. The resident indicated at that time, "The brace was too long and it rubbed." On 8/25/11 at 9:25 A.M., during interview with RN # 1, she indicated, "Therapy removed the immobilizer and found the pressure area. I initially assessed it." RN # 1 indicated she did not recall doing weekly skin assessments on the resident, and was unsure if staff removed the immobilizer during skin assessments. On 8/25/11 at 11:40 A.M., during interview with the Director of Nursing (DON), she indicated, "We did not have the CNAs remove the immobilizer." The DON indicated the nursing staff performed dressing changes nightly on the resident's knee and thigh area, and would have removed the immobilizer at that time. The DON indicated she did not know if a thorough skin assessment was performed, but that staff was trained on head-to-toe assessments. The DON indicated she probably would have staged the area as unstageable. 3. The facility policy on "Skin Care and Pressure/Non-Pressure Ulcer Management Program," revised April 2011, was obtained from the Director of Nursing (DON) on 8/26/11 at 10:30 A.M. The policy included: "...Managing a skin prevention program is dependent upon many factors. There are certain clinical conditions along with limited mobility that may contribute to the development of pressure ulcers. These conditions may include, but are not limited to the following:...Cast or splint...Identify individual risk factors to direct specific interventions and plan care according to individual factors...The resident's skin should be checked daily paying particular attention to boney (sic) prominences. This can most easily accomplished during daily care...A licensed nurse should inspect skin on a weekly schedule and document findings...." 3.1-40(a)(1)