Every finding on record at Clark Rehabilitation and Skilled Nursing Center

Based on interview and record review, the facility failed to ensure residents' (Residents B, C, D and E) medication administration records reflected medications administered for 4 of 4 residents reviewed for medical records. Findings include:1.The clinical record for Resident B was reviewed on 1/21/26 at 1:51 p.m. The resident's diagnoses included, but were not limited to, a history of a deep vein thrombosis (dangerous formation of a blood clot inside a vein or artery) and neuropathy (nerve damage or dysfunction). Review of the January 2026 medication administration record (MAR) indicated the resident was to receive the following medications:-Eliquis (blood thinner) 5 mg (milligrams) twice daily between 7:00 a.m. and 11:00 a.m. and again between 7:00 p.m. and 11:00 p.m.-Gabapentin 600 mg in the evening at 10:00 p.m. The January 2026 MAR lacked documentation of the administration of the above medications on the following dates and times:-Eliquis 5 mg, between 7:00 p.m. and 11:00 p.m., on 1/12/26, 1/13/26, 1/15/26, 1/16/26, 1/17/26 and 1/20/26.-Gabapentin 600 mg at 10:00 p.m. on 1/12/26, 1/13/26, 1/15/26, 1/16/26, 1/17/26 and 1/20/26. During an interview on 1/22/26 at 3:12 p.m., Licensed Practical Nurse (LPN) 5 indicated when a medication was administered, it should be signed off on the MAR by the nurse. 2. The clinical record for Resident C was reviewed on 1/21/26 at 2:05 p.m. The resident's diagnoses included, but were not limited to, hyperlipidemia (abnormally high levels of cholesterol and triglycerides in the blood) and chronic pain syndrome. Review of the January 2026 MAR indicated the resident was to receive the following medications:-Atorvastatin (cholesterol medication) 40 mg at bedtime-Pregabalin (pain medication) 50 mg twice daily between 7:00 a.m. and 11:00 a.m. and again between 7:00 p.m. and 11:00 p.m. The January 2026 MAR lacked documentation of the administration of the above medications on the following dates and times:-Atorvastatin on 1/12/26, 1/13/26 and 1/15/26-Pregabalin, between 7:00 p.m. and 11:00 p.m., on 1/12/26, 1/13/26 and 1/15/26 3. The clinical record for Resident D was reviewed on 1/21/26 at 2:45 p.m. The resident's diagnoses included, but were not limited to, insomnia (sleep disorder), depression, hyperlipidemia, nerve pain, chronic pain and muscle spasms. Review of the January 2026 MAR indicated the resident was to receive the following medications:-Aripiprazole (insomnia) 2 mg at bedtime between 7:00 p.m. and 11:00 p.m.-Atorvastatin 40 mg at bedtime between 7:00 p.m. and 11:00 p.m.-Gabapentin (nerve pain) 800 mg three times a day at 8:00 a.m., 2:00 p.m. and 8:00 p.m.-Methocarbamol (muscle spasms) 750 mg three times a day at 8:00 a.m., 2:00 p.m. and 8:00 p.m.-Pregabalin (chronic pain) 100 mg at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The January 2026 MAR lacked documentation of the administration of the above medications on the following dates and times:-Aripiprazole on 1/12/26 and 1/16/26-Atorvastatin on 1/12/26 and 1/16/26-Gabapentin at 8:00 a.m. on 1/18/26 and 8:00 p.m. on 1/15/26, 1/16/26 and 1/20/26-Methocarbamol at 8:00 a.m. on 1/18/26 and 8:00 p.m. on 1/15/26, 1/16/26 and 1/20/26-Pregabalin at 8:00 a.m. on 1/18/26 and 8:00 p.m. on 1/15/26, 1/16/26, 1/17/26 and 1/20/26 4. The clinical record for Resident E was reviewed on 1/22/26 at 9:10 a.m. The resident's diagnoses included, but were not limited to, hyperlipidemia, myocardial infarction (heart attack), insomnia, hypertension (high blood pressure), depression and enlarged prostate.Review of the January 2026 MAR indicated the resident was to receive the following medications:-Atorvastatin 40 mg at bedtime between 7:00 p.m. and 11:00 p.m.-Eliquis 5 mg twice daily at 12:00 p.m. and 8:00 p.m.-Melatonin (insomnia) 3 mg at bedtime between 7:00 p.m. and 11:00 p.m.-Metoprolol tartrate (high blood pressure) 37.5 mg twice daily at 12:00 p.m. and 8:00 p.m.-Mirtazapine (depression) 7.5 mg at bedtime between 7:00 p.m. and 11:00 p.m.-Tamsulosin (enlarged prostate) 0.4 mg at bedtime between 7:00 p.m. and 11:00 p.m. The January 2026 MAR lacked documentation of the administration of the above medications on the following dates and times:-Atorvastatin on 1/12/26, 1/13/26, 1/15/26, 1/17/26 and 1/20/26-Eliquis at 8:00 p.m. on 1/12/26, 1/13/26, 1/15/26, 1/16/26, 1/17/26 and 1/20/26-Melatonin on 1/12/26, 1/13/26, 1/15/26, 1/17/26 and 1/20/26-Metoprolol tartrate at 8:00 p.m. on 1/12/26, 1/13/26, 1/15/26, 1/16/26, 1/17/26 and 1/20/26-Mirtazapine on 1/12/26, 1/13/26, 1/15/26, 1/17/26 and 1/20/26-Tamsulosin on 1/12/26, 1/13/26, 1/15/26, 1/17/26 and 1/20/26 On 1/22/26 at 3:10 p.m., the Director of Nursing provided a copy of the current policy titled General Dose Preparation and Medication Administration dated 12/01/07. It included, but was not limited to, After medication administration .Document .medication administration .when medications are given .on appropriate forms This Citation relates to Intake 2708150 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure misappropriation of residents' property did not occur for 3 of 4 residents reviewed for abuse. (Residents B, C, and D) Findings include:1.The clinical record for Resident B was reviewed on 10/29/25 at 11:14 a.m. The residents' diagnoses included, but were not limited to, fibromyalgia, depression and chronic pain syndrome. The resident's admission minimum data set assessment indicated the resident's cognition was intact. The physician's order, dated 10/6/25, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 10-325 mg (milligrams) every 8 hours as needed for pain.Review of the October 2025 controlled substance record indicated on 10/9/25 at 4:00 a.m., the resident was administered a dose of the narcotic pain medication from Licensed Practical Nurse (LPN) 10.The October 2025 medication administration record, dated 10/9/25 at 4:53 a.m., indicated LPN 10 documented the administration of the resident's narcotic pain medication.Review of the timeline provided by the Executive Director on 10/29/25 at 2:26 p.m., indicated the following:-On 10/9/25 at 12:30 p.m., Resident B indicated she did not receive a dose of her narcotic pain medication on 10/9/25 at 4:00 a.m., but did confirm she received a dose at 10:00 p.m. on 10/8/25-On 10/9/25 at 1:15 p.m., video footage was reviewed from 3:00 a.m. to 6:30 a.m. on 10/9/25. LPN 10 did not enter the resident's room to provide any medication.During an interview, on10/29/25 at 2:42 p.m., Resident B indicated she had requested her pain medication in the morning and was told she could not have any yet because she had received pain medication at 4:00 a.m. She did not request her pain medication at that time nor did she receive one. The last pain medication she had requested was the night before. The nurse had given her nighttime medications, but her pain medication was not with the other medications. She requested her pain medication at that time, which was the last time she had received her medication until she requested it the next morning.During a telephone interview, on10/29/25 at 1:48 p.m., the Regional Nurse Consultant indicated she reviewed the video with the Executive Director and LPN 10 never entered Resident B's room to administer the pain medication that was signed out and documented. During an interview, on 10/29/25 at 3:00 p.m., the Executive Director indicated the timeline provided was accurate and with the new video system, it only held the video for 10 days.2. The clinical record for Resident C was reviewed on 10/29/25 at 11:26 a.m. The resident's diagnosis included, but was not limited to, rheumatoid arthritis. The resident's annual minimum data set assessment, dated 10/21/25, indicated the resident's cognition was intact.Resident C was unavailable for interview, on 10/29/25, due to a planned appointment.The physician's order, dated 4/22/25, indicated the resident was to receive Hydrocodone-Acetaminophen 5-325 mg every 8 hours as needed for pain.The October 2025 controlled substance record indicated Resident C was administered the narcotic pain medication from LPN 10 on 10/8/25 at 12:00 a.m. and on 10/9/25 at 2:00 a.m.The October 2025 medication administration record indicated the medication was administered by LPN 10 on 10/7/25 at 11:38 p.m. The narcotic medication administration was not documented as administered on 10/9/25.Review of the timeline provided by the Executive Director, on 10/29/25 at 2:26 p.m., indicated the following:-Camera footage for both administrations documented by LPN 10 indicated between 11:00 p.m. and 3:30 a.m., LPN 10 did not enter the resident's room.The written statement interview by Resident C, dated 10/19/25 at 4:15 p.m., indicated Resident C had not requested any pain medication on night shift between 10/7/25 and 10/9/25.During an interview on 10/29/25 at 1:48 p.m., the Regional Nurse Consultant indicated, per the video reviewed between 10/7/25 and 10/9/25 from 11:00 p.m. to 3:30 a.m., LPN 10 did not enter the resident's room to administer any medications. 3. The clinical record for Resident D was reviewed on 10/29/25 at 1:30 p.m. The residents' diagnoses included, but were not limited to, Parkinson's disease, chronic pain, depression and peripheral vascular disease.The physician's order, dated 7/30/25, indicated the resident was to receive Hydrocodone-Acetaminophen 5-325 mg every 6 hours at 12:00 p.m., 6:00 p.m., 12:00 a.m. and 6:00 a.m. for chronic pain.Review of the October 2025 controlled substance record indicated LPN 10 signed out the narcotic pain medication as administered on the following dates and times:-10/7/25 at 10:00 p.m.-10/8/25 at 2:00 a.m.-10/8/25 at 10:00 p.m.-10/9/25 at 2:00 a.m.Review of the timeline provided by the Executive Director on 10/29/25 at 2:26 p.m. indicated the following:-The video camera footage reviewed indicated on 10/7/25 at 9:13 p.m., LPN 10 entered Resident D's room with a medication cup and then exited at 9:17 p.m. From 9:17 p.m. on 10/7/25 to 3:30 a.m. on 10/8/25, LPN 10 did not enter the resident's room.-The video camera footage reviewed indicated, on 10/8/25 at 9:38 p.m., LPN 10 entered Resident D's room with a medication cup and water and exited at 9:38 p.m. From 9:38 p.m. on 10/8/25 to 3:30 a.m. on 10/9/25, LPN 10 did not enter the resident's room. On 10/29/25 at 9:47 a.m., the Executive Director provided a current copy of the document titled Abuse Prohibition, Reporting and Investigation dated June 2023. It included, but was not limited to, Policy.It is the policy.to provide each resident with an environment that is free from.misappropriation of resident property.Misappropriation of Resident.Property.Deliberate misplacement.wrongful.use of a resident's property.without the resident's consent.The Past noncompliance began on 10/8/25 at 2:00 a.m. The deficient practice was corrected by 10/15/25 after the facility implemented a systemic plan that included the following actions: A narcotic audit of all controlled records was conducted to review each resident for any discrepancies and unusual activity (10/9/25); All nursing staff were educated on misappropriation of resident property with an emphasis on medication administration and scope of practice for Certified Nursing Assistants (10/9/25); All appropriate residents were interviewed to determine if they had received all medications (10/9/25); Pain assessments were completed on all non-verbal residents (10/9/25); All employees that had potential access to divert medications were drug tested (10/10/25); The pharmacy conducted a 90 day audit for any narcotic discrepancies with no concerns (10/15/25). This citation relates to Intake 2639587 3.1-28(a)

Based on interview and record review, the facility failed to ensure a staff followed the scope of practice for certified nursing assistants for 1 of 3 residents reviewed for services provided. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/29/25 at 11:14 a.m. The residents' diagnoses included, but were not limited to, fibromyalgia, depression and chronic pain syndrome. During an interview, on 10/29/25 at 1:48 p.m., the Regional Nurse Consultant indicated it was identified that on 10/8/25, Licensed Practical Nurse (LPN) 10 provided Certified Nursing Assistant (CNA) 11 with a resident's pain medication in a cup and CNA 11 entered Resident B's room with the medication cup. Review of the timeline provided by the Executive Director on 10/29/25 at 2:26 p.m., indicated the following: -The video footage was reviewed starting on 10/8/25 at 10:30 p.m., LPN 10 entered Resident B's room at 10:40 p.m. with a medication cup and water. LPN 10 exited the room in less than a minute and then entered another resident's room, at which time, Resident B turned her call light on. After exiting the other resident's room, LPN 10 went to the medication cart. CNA 11 entered Resident B's room, turned the call light off, exited the room and walked to the medication cart where LPN 10 was and said something to her. LPN 10 pulled open a drawer on the medication cart and withdrew a medication cup which she handed to CNA 11 along with a cup of water. CNA 11 took both the medication cup and water into Resident B's room and came out of the room empty handed. The undated written statement from CNA 11 indicated, on 10/8/25, she had answered the call light for Resident B who told CNA 11 that LPN 10 brought in her medication but left before she could ask for pain medication. Resident B asked CNA 11 to ask LPN 10 for a pain pill. CNA 11 found LPN 10 to let her know Resident B wanted pain medication. LPN 10 told CNA 11 that she had a feeling she was going to ask for that. LPN 10 told CNA 11 she had the pain medication right here and would CNA 11 mind to walk the medication to Resident B. CNA 11 told her she did not mind and took the medication and water to Resident B.During an interview, on 10/29/25 at 2:50 p.m., CNA 7 indicated that CNA's could not administer medication to residents as it was not in their scope of practice. During an interview, on 10/29/25 at 2:52 p.m., LPN 5 indicated that nurses could not give medications to the CNA's to administer to residents. On 10/29/25 at 2:27 p.m., the Executive Director provided a current copy of the document titled Certified Nursing Assistant (CNA) dated 10/14/25. It included, but was not limited to, Summary of Position Functions.The Certified Nursing Assistant.provides nursing and nursing related services to residents.Essential Position Functions.Provides direct care.Bathing.Dressing.Elimination/Toileting.Mobility.Transfer.Eating.Grooming.The Past noncompliance began on 10/9/25 at 10:41 p.m. The deficient practice was corrected by 10/14/25 after the facility implemented a systemic plan that included that included the following: All nursing staff were educated on medication administration and scope of practice for Certified Nursing Assistants (10/9/25); One on one education completed with CNA 11 related to scope of practice and violation of company policy for completing a task outside of the scope of practice (10/14/25). 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure medication administration records accurately reflected the administration of controlled substances 4 of 4 residents reviewed for medical records. (Resident B, C, D and E) Findings include: 1. The clinical record for Resident B was reviewed on 6/30/25 at 10:45 a.m. The resident's diagnoses included, but were not limited to, diabetes, chronic pain and gastrointestinal stromal tumor of the rectum. The June 2025 medication administration (MAR) record indicated the resident was to receive Oxycodone 15 mg (milligrams) every 4 hours for pain at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The June 2025 controlled substance record indicated the resident received the Oxycodone on the following dates and times: - 6/02/25 at 8:00 p.m. - 6/03/25 at 8:00 p.m. - 6/04/25 at 12:00 a.m. - 6/05/25 at 12:00 a.m. and 8:00 p.m. - 6/06/25 at 12:00 a.m., 8:00 a.m. and 8:00 p.m. - 6/07/25 at 4:00 a.m. and 8:00 a.m. On 6/9/25, the resident was admitted to the hospital and returned on 6/16/25. The physician's order, dated 6/20/25, indicated the resident was to receive Oxycodone 15 mg (milligrams) every 4 hours for pain at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. The June 2025 controlled substance record indicated the resident received the Oxycodone on the following dates and times: - 6/21/25 at 2:00 a.m. and 10:00 a.m. - 6/22/25 at 2:00 a.m. The June 2025 MAR lacked documentation of the administration of the resident's Oxycodone on the above dates and times. During an interview, on 7/1/25 at 10:47 a.m., Registered Nurse (RN) 3 indicated when routine and as needed narcotics were administered, the medication administration record should be initialed by the nurse that administered the medication. 2. The clinical record for Resident C was reviewed on 6/30/25 at 11:20 a.m. The resident's diagnoses included, but were not limited to, displaced fracture of olecranon and left femur, gout, and depression. The physician's order, dated 4/30/25, indicated the resident was to receive Percocet 7.5-325 mg every 4 hours as needed for pain. The June 2025 Controlled Substance Record indicated the resident received the Percocet on the following dates and times: - 6/01/25 at 7:00 a.m. and 8:00 p.m. - 6/02/25 at 8:00 p.m. - 6/03/25 at 6:00 a.m., 7:50 p.m. and 10:15 p.m. - 6/04/25 at 8:00 p.m. - 6/06/25 at 7:30 p.m. and 11:30 p.m. - 6/07/25 at 6:00 a.m. - 6/10/25 at 11:30 a.m. and 7:30 p.m. - 6/11/25 at 12:01 a.m. and 8:00 p.m. - 6/12/25 at 6:00 a.m. and 7:25 p.m. - 6/13/25 at 12:00 a.m., 8:00 p.m. and 11:30 p.m. - 6/14/25 at 6:05 a.m. - 6/15/25 at 9:00 a.m. - 6/16/25 at 9:00 p.m. - 6/17/25 at 6:00 a.m. and 8:00 p.m. - 6/18/25 at 1:35 a.m. - 6/19/25 at 5:00 a.m. - 6/20/25 at 11:30 a.m., 5:30 p.m. and 7:00 p.m. - 6/21/25 at 12:00 a.m., 6:00 a.m., 7:19 p.m. and 11:30 p.m. - 6/23/25 at 8:00 p.m. - 6/24/25 at 6:00 a.m. and 7:00 p.m. - 6/25/25 at 9:00 p.m. - 6/26/25 at 6:00 a.m., 11:00 a.m. and 8:00 p.m. - 6/27/25 at 12:30 a.m., 2:00 p.m. and 8:00 p.m. - 6/28/25 at 12:00 a.m. and 8:45 a.m. - 6/29/25 at 12:00 p.m. The resident's June 2025 medication administration lacked documentation of the administered Percocet on the above dates and times. 3. The clinical record for Resident D was reviewed on 6/30/25 at 2:32 p.m. The resident's diagnoses included, but were not limited to, depression and chronic pain. The physician's order, dated 5/12/25, indicated the resident was to receive Oxycodone 5 mg every 8 hours as needed for pain. The June 2025 controlled substance record indicated the resident received the Oxycodone on the following dates and times: - 6/01/25 at 8:00 a.m. - 6/02/25 at 8:00 a.m. and 8:00 p.m. - 6/04/25 at 8:00 p.m. - 6/05/25 at 8:00 p.m. - 6/06/25 at 8:00 p.m. - 6/10/25 at 9:00 p.m. - 6/11/25 at 9:00 p.m. - 6/13/25 at 10:30 p.m. - 6/17/25 at 7:00 p.m. and 9:30 p.m. - 6/18/25 at 8:00 p.m. - 6/21/25 at 12:30 a.m. - 6/23/25 at 9:00 p.m. - 6/24/25 at 9:00 p.m. - 6/25/25 at 9:00 p.m. - 6/26/25 at 8:15 p.m. - 6/27/25 at 8:00 p.m. The resident's June 2025 medication administration lacked documentation of the administered Oxycodone on the above dates and times. 4. The clinical record for Resident E was reviewed on 6/30/25 at 2:54 p.m. The resident's diagnoses included, but were not limited to, diaphragmatic hernia, wedge compression fracture of the first lumbar vertebra and low back pain. The physician's order, dated 5/29/25, indicated the resident was to receive Lorazepam (antianxiety medication) 0.25 ml (milliliters) at bedtime for agitation/restlessness between 7:00 p.m. and 11:00 p.m. The June 2025 controlled substance record indicated the Lorazepam was administered on the following dates at bedtime: - 6/05/25 - 6/06/25 - 6/12/25 - 6/17/25 - 6/20/25 - 6/21/25 The resident's June 2025 medication administration lacked documentation of the administered Lorazepam on the above dates. The physician's order, dated 6/5/25, indicated the resident was to receive morphine (narcotic pain medication) 5 mg every 6 hours for pain at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The June 2025 controlled substance record indicated the resident received the morphine on the following dates and times: - 6/07/25 at 6:00 a.m. - 6/10/25 at 10:00 p.m. - 6/13/25 at 12:00 a.m. - 6/14/25 at 12:00 a.m. - 6/18/25 at 12:00 a.m. - 6/19/25 at 12:00 a.m. - 6/20/25 at 12:00 a.m. and 12:00 p.m. - 6/21/25 at 12:00 a.m. - 6/22/25 at 12:00 a.m. - 6/24/25 at 6:00 a.m. - 6/25/25 at 12:00 a.m. - 6/26/25 at 6:00 a.m. - 6/27/25 at 12:00 p.m. and 6:00 p.m. The resident's June 2025 medication administration lacked documentation of the administered morphine on the above dates and times. On 6/30/25 at 3:13 p.m., the Assistant Director of Nursing provided a current copy of the document titled Controlled Substances: Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) dated 11/24. It included, but was not limited to, Purpose of Policy .To prevent diversion, improper use and accidents related to controlled substances .Documentation .When a controlled substance is administered to a resident, it must be recorded in the resident's Medication Administration Record (MAR) This Citation relates to Complaint IN00462112 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a physician's order was in place for a resident (Resident B) for an additional dose of a narcotic pain medication and failed to ensure scheduled medications were administered to a resident (Resident C) on dialysis days for 2 of 4 residents reviewed for pharmacy services. Findings include: 1. The clinical record for Resident B was reviewed on 6/30/25 at 10:45 a.m. The resident's diagnoses included, but were not limited to, diabetes, chronic pain and gastrointestinal stromal tumor of the rectum. The physician's order, dated 2/27/25, indicated the resident was to receive Oxycodone (narcotic pain medication) 15 mg (milligrams) every 4 hours for pain at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. Review of the May 2025 controlled substance record indicated on 5/31/25 at 12:00 a.m., the medication was signed out as given twice by Licensed Practical Nurse (LPN) 4. On 7/1/25 at 9:53 a.m., the Executive Director and Assistant Director of Nursing provided a statement from LPN 4 and indicated the resident received 2 doses of the Oxycodone on 5/31/25 at 12:00 a.m. The written statement from LPN 4, dated 7/1/25 and untimed, indicated she had forgotten that she had already signed out the 12:00 a.m. Oxycodone and then signed out another one. The resident's other medications were on top of the one previously pulled and she did not realize until the resident tipped the pill cup to her mouth. That was when LPN 4 realized she had signed out 2 of them. The clinical record lacked documentation of a physician's order for the additional dose administered on 5/31/25 at 12:00 a.m. On 7/1/25 at 10:47 a.m., Registered Nurse (RN) 3 indicated medications could not be administered without a physician's order in place and physician's orders should be followed. On 6/30/25 at at 2:20 p.m., the Assistant Director of Nursing provided a current copy of the document titled General Dose Preparation and Medication Administration dated 12/01/07. It included, but was not limited to, This policy .sets forth the procedures to .medication administration .Prior to administration of medication, facility staff should take all measures required by facility policy .including, but not limited to .Verify each time a medication is administered that it is the .correct dose .Administer medications within timeframes On 7/1/25 at 9:53 a.m., the Executive Director provided a current copy of the document titled Medication Errors dated 11/2018. It included, but was not limited to, Policy .It is the policy of this provider to ensure residents residing in the facility are free of medication errors and the facility maintains a medication error rate of less than 5% 2. The clinical record for Resident C was reviewed on 6/30/25 at 11:20 a.m. The resident's diagnoses included, but were not limited to, dependence on renal dialysis, gout, history of myocardial infarction, human immunodeficiency virus (HIV), Gastroesophageal reflux disease (GERD), end stage renal disease and depression. The physician's order, dated 5/27/25, indicated staff were to hold the resident's blood pressure medications on dialysis days every Tuesday, Thursday and Saturday. The June 2025 medication administration record (MAR) indicated the resident was to receive the following medications: - Allopurinol 100 mg daily for gout between 7:00 a.m. and 11:00 a.m. - Aspirin 81 mg daily for myocardial infarction between 7:00 a.m. and 11:00 a.m. - Biktarvy 50-200-25 mg daily for HIV between 7:00 a.m. ad 11:00 a.m. - Eliquis 5 mg twice a day for prophylaxis at 8:00 a.m. and 8:00 p.m. - Omeprazole 20 mg daily for GERD between 7:00 a.m. and 11:00 a.m. - Renvela 800 mg three times a day for end stage renal disease at 7:00 a.m., 11:00 a.m. and 4:00 p.m. - Zoloft 50 mg daily for depression between 7:00 a.m. and 11:00 a.m. The June 2025 MAR indicated the above medications were not administered on the following mornings due to the resident was unavailable dialysis: - On 6/03/25 - Tuesday - On 6/05/25 - Thursday - On 6/07/25 - Saturday - On 6/12/25 - Thursday - On 6/14/25 - Saturday - On 6/17/25 - Tuesday - On 6/19/25 - Thursday - On 6/21/25 - Saturday - On 6/28/25 - Saturday The clinical record lacked documentation of the administration of the resident's medications upon the resident's return from dialysis. During an interview, on 7/1/25 at 9:50 a.m., the Assistant Director of Nursing indicated Resident C had dialysis on Tuesday, Thursday and Saturday. The resident left around 6:50 a.m. and returned to the facility at 11:30 a.m. During an interview, on 7/1/25 at 11:46 a.m., the Executive Director indicated she could not find any supporting documentation that the resident's morning medications were administered upon return from dialysis. During an interview, on 7/1/25 at 12:33 p.m., Resident C indicated he did not receive any medications prior to going to dialysis. When he returned, he was only given his Renvela that he takes before his meals. This Citation relates to Complaint IN00462112 3.1-25(b)

Based on observation, interview, and record review the facility failed to ensure a splint device was provided to prevent a decrease in range of motion for 1 of 3 residents reviewed for range of motion. (Resident 40) Findings include: The record for Resident 40 was reviewed on 4/3/24 at 2:07 p.m. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side, spastic hemiplegia affecting the left nondominant side, attention and concentration deficit following cerebral infarction, spastic hemiplegia affecting left dominant side, muscle weakness, and need for assistance with personal care. The care plan, dated 9/13/19, indicated the resident required assistance with ADLs (Activities of Daily Living) including bed mobility, and transfers related to a decrease in strength and an increase in weakness, and a CVA (cardiovascular accident) with left sided hemiplegia. The interventions, dated 11/12/19, included, but were not limited to, apply the LUE (left upper extremity) hand splint up to two hours per day and a LUE elbow splint up to six hours per day as tolerated. The physician's order, dated 6/27/22, indicated the resident was to wear a resting hand splint to her left hand for two to four hours per day as tolerated and to perform PROM (passive range of motion) to the left hand prior to the splint placement once a day from 7:00 a.m. to 11:00 a.m. The Quarterly MDS (Minimum Data Set) assessment, dated 7/25/23, indicated the resident was cognitively intact. She was dependent on staff for upper and lower body dressing, putting on footwear, and showering. The Annual MDS assessment, dated 12/15/23, indicated the resident was cognitively intact. During an observation on 4/1/24 at 9:50 a.m., the resident was sitting in her wheelchair. There was no splint on her left hand. She indicated it was in her drawer and she pulled it out of the drawer to show where it was. During an observation on 4/2/24 at 10:24 a.m., the resident's brace was not on her left arm and hand. She indicated if staff would assist her to put the brace on her, she would wear it. The resident's left hand was contracted. During an observation and interview on 4/4/24 at 10:25 a.m., the resident indicated it had been a while since the brace had been applied to her arm and hand, and it had been at least six months. She thought she was supposed to wear it for about six hours. She got the brace about a year ago. Therapy didn't work with her much now. The brace held her arm and hand in place when she wore it. The resident tried to pull the Velcro straps open, but had to catch it from dropping twice. She was unable to apply the brace on her own. During an interview on 4/4/24 at 12:59 p.m., Occupational Therapist 4 indicated the resident had contractures to the left hand from a stroke prior to admission. She was not currently on case load for therapy. The resident was discharged from occupational therapy, on 1/15/24, because she met her goals and achieved her highest strength level. Splinting was included in the therapy. She had a resting splint for her hand. The splint was still ongoing and nursing staff now applied the splint. It was part of the splint placement to do ROM (range of motion) exercises. She was screened quarterly to make sure that was being done. She had not come up for the quarterly assessment yet. During an interview on 4/4/24 at 1:21 p.m., CNA (Certified Nurse Aide) 3 indicated the resident used to have a leg brace and a wrist brace. She had not seen a brace on the resident's arm. The resident was very compliant and had come a long way. During an interview on 4/4/24 at 1:23 p.m., LPN (Licensed Practical Nurse) 5 indicated the resident was total care. She transferred with a sit to stand. Restorative nursing was a different area, she didn't know about that. She had a brace and therapy was working on getting her another one. She wasn't sure about the hand brace because it was applied by restorative. During an interview on 4/4/24 at 2:01 p.m., the Corporate MDS Coordinator indicated she filled in when the MDS restorative was out. She came in only when asked to see residents. The resident had a splinting program six days weekly for her left leg and a transfer program using parallel bars six days a week. Restorative performed a wheelchair to parallel bar transfer for fifteen minutes. The splint device area was washed, and a skin assessment was conducted for the left knee. The physician's order for the arm splint was not done by restorative. She had an order for the hand splint 2 to 4 hours per day and that would be performed by the nurse. During an interview on 4/5/24 at 8:47 a.m., LPN 5 indicated she put the hand brace on the resident this morning at 7:30 a.m., after being asked questions about the splint. The order indicated the brace was to be provided for the resident 2 to 4 hours. She would also perform ROM if needed. During an interview on 4/5/24 at 9:46 a.m., LPN 6 indicated the facility had no policy for applying splints or braces. 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure showers were provided consistently for 2 of 4 residents reviewed for Activities of Daily Living care. (Residents 19 and 67) 1. The record for Resident 19 was reviewed on 4/1/24 at 11:03 a.m. The resident's diagnoses included, but were not limited to, sepsis, muscle weakness, vascular dementia, personal history of traumatic brain injury, anxiety, flaccid hemiplegia affecting the left nondominant side and bipolar disorder. The care plan, dated 8/5/18 and revised on 2/20/24, indicated the Resident required assistance with ADLs (activities of daily living) included bed mobility, transfers, eating and toileting. The interventions included, but were not limited to, assist with oral care at least two times daily, and assist with bathing as needed per resident preference. Staff were to offer the resident's showers two times per week and provide a partial bath in between. The Quarterly MDS (Minimum Data Set) assessment, dated 2/15/24, indicated the resident was severely cognitively impaired. He was dependent on staff for his oral hygiene and bathing. The residents shower schedule indicated the following: - January 4 through January 31, 2024, the resident did not have a shower. - February 1 through February 29, 2024, the resident had a shower on 2/9/24 and 2/23/24. There were no other documented showers for the month of February. - March 1 through March 30, 2024, the resident had a shower on 3/22/24. There were no other documented showers for the month of March. During an interview on 4/5/24 9:25 a.m., LPN (Licensed Practical Nurse) 5 indicated the resident should have received a shower two times a week. The only reason a resident wouldn't receive a shower was if they were out of the facility or the resident refused. 2. During an observation on 4/1/24 at 11:36 a.m., Resident 67 was observed with a soiled brief, dried, peeling skin on his mouth and lips, and his teeth had a thick crusty yellowish buildup. The resident only had a tee shirt and a soiled brief. He was not covered and there was a strong urine odor. The resident's record was reviewed on 4/1/24 at 11:06 a.m. The diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage, aphasia, dysarthria and dysphagia following a nontraumatic intracerebral hemorrhage, abnormalities of gait and mobility, and dorsalis. The Quarterly MDS assessment, dated 2/22/24, indicated the resident was severely cognitively impaired. He was dependent on staff for his oral hygiene and bathing. The care plan, dated 2/20/24, indicated the resident required assistance with ADLs (included bed mobility, transfers, eating and toileting. The interventions included, but were not limited to, assist with oral care at least two times daily, and assist with bathing as needed per resident preference. Staff were to offer the resident's showers two times per week, and a partial bath in between. The residents shower documentation indicated for the months of February and March the resident did not receive a shower. During an interview on 4/4/24 at 1:49 p.m., CNA (Certified Nurse Aide) 8 indicated the resident was supposed to take his showers on the evening shift. She indicated the resident was able to get up in a chair. There would be no reason he could not take a shower. During an interview on 4/4/24 at 2:00 p.m., CNA 9 indicated she was able to complete her resident showers. Sometimes they would get backed up, but they usually got done. Sometimes the residents would refuse a shower and they didn't always get a chance to get back to to them. They were able to stay on schedule most of the time. If they had a refusal or hospice came in to give a hospice resident their bath they would go back and ask the resident that refused if they were ready to take their shower. The residents should receive two showers a week. The facility did not present a policy for Activities of Daily Living. 3.1-38(a)(3)

Based on observation, interview and record review, the facility failed to ensure radiology results were obtained, in a timely manner, for 1 of 3 residents reviewed for radiology services. (Resident B) Findings include: On 1/31/24 at 1:40 p.m., the resident was observed sitting up in his wheelchair with his call light in reach with no signs of any pain or discomfort. He indicated his shoulder was still a little sore but was much better. His pain was controlled and they check on him frequently. He had no concerns with his care. The clinical record for Resident B was reviewed on 1/31/24 at 10:56 a.m. The diagnosis included, but were not limited to, left sided hemiparesis and left clavicle fracture. Review of the August 2023 - December 2023 indicated the resident had not complained of any pain. The progress note, dated 8/27/23 at 2:13 p.m., indicated the resident was found on floor during rounds. The resident was assessed and denied any pain or discomfort. The IDT (Interdisciplinary Team) note, dated 8/28/23 at 12:06 p.m., indicated the resident had a fall on 8/27/23 and denied any pain or discomfort at the time of the fall. The resident had now complained of pain to the left upper extremity, the MD was notified and gave a new order for an X-ray. The radiology report, dated 8/28/23 at 6:20 p.m., indicated there was no shoulder fracture, separation or dislocation seen. There was modest degenerative joint disease of the left shoulder. The progress note, dated 9/13/23 at 12:31 p.m., indicated the the nurse practitioner was in to evaluate the resident and ordered an MRI (Magnetic Resonance Imaging) due to complaints of pain and decreased range of motion. The appointment was scheduled for 9/19/23. The progress note, dated 9/20/23 at 10:44 a.m., indicated a new order was obtained for a CT (Computed tomography) of the left shoulder. The physician's order, dated 10/9/23, indicated the resident was to have a CT of the left shoulder due to ongoing pain. The CT report, dated 10/9/23 and faxed to the resident's primary care physician on the same day, indicated the resident had a fracture of the medial clavicle with callus formation consistent with a subacute fracture. The physician's order, dated 10/13/23, indicated to obtain an X-ray of the left shoulder. The X-ray report, dated 10/13/23, indicated the left shoulder demonstrated no acute fracture. The progress note, dated 10/16/23 at 12:35 p.m., indicated the nurse practitioner evaluated the resident. New orders were obtained for Voltaren Gel 1% to the left shoulder three times a day and Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 8 hours as needed for pain. The physician's note, dated 12/3/23, indicated to follow up with an ortho (orthopedic appointment) at this time. The progress note, dated 12/14/23 at 2:19 p.m., indicated the resident returned from the ortho appointment with new orders for a sling to the left upper extremity and Meloxicam 7.5 mg daily for 3 weeks. The orthopedic report, dated 12/14/23 at 12:45 p.m., indicated a CT scan was completed which showed mild to moderate osteoarthritic changes and a subacute clavicle fracture with interval healing. During an interview on 1/31/24 at 11:45 a.m., the Director of Nursing indicated the resident was unable to get the MRI due to his cardiac pacemaker and the next day they scheduled a CT. The results of the CT scan on 10/9/23 were faxed to the resident's PCP (primary care physician). The PCP did not notify the facility of any abnormalities. He signed the report and brought it to the facility to upload to the residents record. However, the facility did not follow up with the CT scan after it was completed and should have. On 1/31/24 at 2:54 p.m., the Director of Nursing provided a current copy of the document titled Labs and Diagnostics dated 11/2017. It included, but was not limited to, Policy .It is the policy .to provide or obtain .diagnostic services to meet the needs of its residents. The facility is responsible for the equability and timeliness of the services The Past noncompliance began on 10/9/23. The deficient practice was corrected by 12/31/23 after the facility implemented a systemic plan that included the following actions: All charge/staff nurses were educated on the importance of and following up on labs for their assigned residents and communication on all pending and resolved labs during daily report; a 90 day audit was completed on all current residents to identify outside lab orders and ensure follow up was accurate and complete. This Citation relates to Complaint IN00424151 3.1-49(a)

Based on record review, interview and observation, the facility failed to ensure residents' Weekly Skin Assessments were completed and accurate, interventions were implemented, and treatment and monitoring was completed to identify and prevent the development or worsening of a pressure ulcer resulting in an unstageable pressure ulcer worsening to a Stage IV pressure ulcer for 3 of 6 residents reviewed for pressure ulcers. (Residents 62, 47 and 56) . Findings include: 1. The clinical record for Resident 62 was reviewed on 3/8/23 at 11:55 a.m. The diagnoses included, but were not limited to, difficulty in walking, unsteadiness on his feet, and a displaced intertrochanteric fracture of right femur. The weekly skin assessment, dated 1/10/23, indicated the resident had no pressure wounds observed. The weekly skin assessment, dated 1/16/23, indicated the resident had no pressure wounds observed. The current care plan, dated 1/20/23, indicated the resident had impaired skin integrity of a pressure ulcer to right heel. The resident was at risk for skin breakdown or further skin breakdown. The interventions included, but were not limited to, encourage the resident to wear heel lift boot to RLE (right lower extremity) while up in a wheelchair, encourage the resident to float his bilateral heels on a heel riser while abed, turn and reposition every 2 hours, assess wound weekly documenting measurements and description, assess for pain, and treat as ordered. Notify the physician of unrelieved or worsening pain, a pressure reducing and redistribution cushion in the chair, and Promat Plus Mattress with bolsters. The Physical Therapist (PT) note, dated 1/20/23, indicated the resident complained of right foot pain. PT 17 assessed the area and skin. Upon assessment she observed a black necrotic area on the right heel and reported it to the nursing staff for further follow-up. The current physician's order, dated 1/24/23, indicated to apply skin prep to the right heel as preventative, encourage the resident to float the bilateral heels on a heel riser while abed, encourage the resident to turn and reposition every 2 hours and PRN (as needed), with a start date 1/6/23. The wound care NP (Nurse Practitioner) to evaluate and treat, with a start date of 1/26/23. A heel lift boot to the right foot while up in a chair, if the resident was noncompliant with the heel riser encourage the resident was to use a wedge to elevate the right heel while abed, with a start date of 2/16/23. The clinical record lacked documentation indicating the resident's pressure wound was identified before it was observed to be unstageable (full thickness tissue loss obscured by slough or eschar in wound bed). The weekly skin assessment, dated 1/24/23, indicated the resident's bilateral lower extremities were observed to have edema and an open area to the right heel. The wound care note, dated 1/26/23, indicated the resident's wound status was open. The wound was currently classified as an unstageable or unclassified wound with etiology of pressure ulcer located on the right calcaneus. The wound measures 4.5 cm (centimeters) long by 4.5 cm wide. There was no drainage observed. There was no granulation within the wound bed. There was a large (67 to 100%) amount of necrotic (dead) tissue within the wound bed including eschar. The peri wound skin appearance had no abnormalities observed for color. The peri wound skin appearance exhibited: callus, scarring, dry and scaly. Peri wound temperature was observed as no abnormality. The peri wound had tenderness on palpation. The nurse's note, dated 1/29/23 at 3:25 a.m., indicated the resident's right heel continued with necrotic skin related to a pressure injury. The resident had complained of increased pain and that it was unbearable, and he wanted to cry. The nurse had continued with non-pharmacological and pharmacological interventions with no relief expressed from the resident. The physician was notified related to the infection. The Significant Change MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was cognitively intact. The resident had one unstageable pressure ulcer due to coverage of the wound bed by slough or eschar. The nurse's note, dated 2/9/23 at 10:15 p.m., indicated the wound NP assessed the resident and ordered a CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count), ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein), and an x-ray of the right heel. The nurse's note, dated 2/11/23 at 4:41 p.m., indicated the physician wrote an order to schedule an appointment with the hospital wound care. The nurse's note, dated 2/14/23 at 5:26 p.m., indicated the laboratory and x-ray results were reviewed by the wound NP with an order to schedule an MRI (magnetic resonance imaging) of the resident's right heel to rule out osteomyelitis. The hospital MRI report, dated 2/23/23, indicated the resident had moderate marrow edema in the posterior calcaneus tuberosity without evidence of significant marrow replacement. This was nonspecific and may represent reactive marrow changes. Osteomyelitis was considered less likely at that time, but not completely excluded. The Wound Care NP note, dated 3/2/23, indicated the resident's wound status was open. The wound had been in treatment for 5 weeks. The wound was currently classified as a unstageable or unclassified wound with etiology of pressure ulcer located on the right calcaneus. The wound measured 3.4 cm (centimeters) long by 3.4 cm wide. There was no drainage observed and no granulation within the wound bed. There was a large (67 to 100%) amount of necrotic tissue within the wound bed including eschar. The peri wound skin appearance had no abnormalities observed for color. The peri wound skin appearance exhibited callus, scarring, and was dry and scaly. The temperature was observed as no abnormalities. The peri wound had tenderness on palpation. The treatment included cleanse the wound with normal saline. pat dry, paint the wound base with betadine and cover with a bordered gauze daily and PRN (as needed) for soilage or dislodgement. During an interview on 3/10/23 at 8:35 a.m., Physical Therapist 17 indicated the resident came to them for therapy due to a right hip fracture. She found the resident's pressure wound to his right heel and it was necrotic. She informed the nursing staff. Resident 61 was blaming the physical therapy department for his pressure wound. She educated the resident on using his feet. He had no restrictions at that time. She would never tell a resident to use the footboard for strengthening exercises. Push and pull exercise using the foot board would not cause a pressure wound. Friction from the bed had caused the pressure wound. During an interview on 3/10/23 at 9:20 a.m., the DON (Director of Nursing) indicated the resident was admitted for rehab due to the surgical repair of a right hip fracture. They used skin prep and educated the resident on turning and repositioning at least every 2 hours, heel risers, and a wedge. She indicated RN 18 found the resident's pressure wound on 1/24/23 and filled out a skin event. It was an unstageable wound. He was followed by a wound management company. He had an MRI and it was negative for osteomyelitis. The resident was blaming physical therapy for his pressure wound. His wound was stable and had no decline. During an observation on 3/10/23 at 10:10 a.m., the Wound Care Nurse explained to Resident 62, that she was going to provide wound care. He indicated he was in pain and requested Tylenol. She indicated the pressure wound was facility acquired. She was not sure who found the pressure wound. She cleansed the wound with wound cleanser and there was no drainage or odor. The pressure wound was unstageable, and the wound was approximately the size of a silver dollar. The wound was covered with 100% eschar tissue. The treatment included betadine and cover with a dressing. During an interview on 3/10/23 10:10 a.m., the resident indicated he would slide his heel up and down the bed sheet and mattress to get traction so he could exercise his right leg. The physical therapist told him to move his leg for strength. The therapist found the wound and told the nurse. During an interview on 3/10/23 at 11:25 a.m., RN 18 indicated she would fill in sometimes and do the weekly skin assessments. On 1/24/23 she observed a pressure wound on the resident's right heel. The wound had large black eschar and was 3.4 cm x 3.4 cm. No drainage was observed. The pressure wound should have been found on the weekly skin assessment before it got to that stage. It should have been found when the heel was red then skin preventions should have been implemented. The resident was supposed to have skin prep every shift to his heels. 40240 2. The clinical record for Resident 47 was reviewed on 3/9/22 at 10:00 a.m. The diagnoses included, but were not limited to, Parkinson's disease, neurocognitive disorder with Lewy bodies (problems with thinking, movement, behavior, and mood), unspecified intellectual disabilities, moderate protein-calorie malnutrition, ESBL (extended beta-lactamase) resistance, osteomyelitis, and pressure ulcer of sacral region Stage IV(full skin loss extends below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments). The care plan, dated 3/31/21 and last revised 3/7/23, indicated the resident had impaired skin integrity including a pressure area to her coccyx. She was at risk for further skin breakdown due to sensory perception being slightly limited; skin was very moist; she was chairfast; had very limited mobility; her nutrition was probably inadequate; and friction and shear was a problem. She preferred to lay flat on her back most of the day, she would occasionally turn slightly for very short periods of time, despite education. She frequently refused to turn, and often refused to have dressings changed as scheduled. When she was up in her chair, the resident often refused to follow the recommendation of being up in 1 hour intervals and would refuse to lay back down. The interventions included, but were not limited to, gel cushion in chair, treatment as ordered, no brief, limit time up in wheelchair to 1 hours intervals to promote wound healing (initiated on 3/9/22), Wound NP to evaluate and treat, pressure relief boots at all times (initiated on 5/13/21), skin prep to bilateral heels for prevention, wound location to the coccyx, assess for pain and treat as ordered, notify the physician of unrelieved or worsening pain, assess the wound weekly, document measurements and description, house barrier cream at bedside to use as needed, incontinent care as needed with perineal wash and moisture barrier, lab work as ordered, low air loss mattress to bed, adjust per resident preference, notify the physician of changes in the wound such as worsening or signs of infection, observe for signs of infection, turn and reposition every 2 hours. The Wound Management Detail report indicated upon admission, on 3/28/21, the resident had an unstageable pressure ulcer which was identified on 3/28/21. The wound measured 9 cm (centimeters) in length, 6 cm in width, and was 2 cm in depth. There was light serosanguineous drainage, and the wound was 100% slough (necrotic tissue). On 8/11/21, the resident's wound progressed to a Stage IV and measured 5.4 cm in length cm in length, 3.5 cm in width, and had a depth of 2 cm. There was 1 cm of undermining at 12 o'clock and the wound was 100% granulation tissue. The nurse's note, dated 3/12/22 at 12:23 a.m., indicated the resident refused to have her dressing changed. She was normally compliant but refused. She was willing to turn on her side for offloading. The Wound Management Detail report indicated, on 3/31/22, the wound was improving and measured 3 cm in length, 3.5 cm in width, and was 100% granulation tissue. The wound was stable. The April 2022 TAR (Treatment Administration Record) indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing between 7:00 a.m. and 7:00 p.m. was not administered due to the resident's refusal on 4/6/22 at 5:45 p.m., 4/17/22 at 5:31 p.m., and 4/18/22 at 5:32. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 4/28/22, the resident's wound measured 4.5 cm in length, 2.5 cm in width, and was 1.8 cm in depth with 100% granulation. The May 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing, between 7:00 a.m. and 7:00 p.m., was not administered due to the resident's refusal on 5/2/22 at 5:15 p.m., 5/4/22 at 6:21 p.m., and 5/16/22 at 5:03 p.m. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance except for education on 5/4/22. The nurse's note, dated 5/4/22 at 6:26 p.m., indicated the resident continued antibiotics for osteomyelitis. She was up in her chair and refusing to lie back down. She was educated on issues related to skin breakdown. She also refused to have her dressing changed secondary to refusing to lay back down. The resident was educated on issues related to missing treatments but still refused. The nurse's note, dated 5/19/22 at 9:21 a.m., indicated a wound culture was obtained by the wound care NP. The nurse's note, dated 5/23/22 1:10 a.m., indicated the resident's culture showed a heavy growth of pseudomonas aeruginosa. The nurse's note, dated 5/23/22 at 3:57 p.m., indicated the Wound Care NP gave orders for the resident to have Ciprofloxacin in 5% (percent) dextrose 400 mg (milligrams) IV (intravenously) daily for 7 days. On 5/26/22, the resident's wound was 3.5 cm in length, 2.5 cm in width, and 1 cm in depth and was 100% granulation tissue. The nurse's note, dated 5/31/22 at 5:36 p.m., indicated the resident had been up in her chair and was refusing to lay down. The only intervention documented was education. The June 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing between 7:00 a.m. and 7:00 p.m. was not administered due to refusal on 6/25/22 at 6:48 p.m. and on 6/26/22 at 5:44 p.m. There was no documentation of the treatment being completed on either day or night shift on 6/23/22. The resident's order to limit time in the wheelchair to 1-hour intervals to promote wound healing was refused on day shift on 6/3/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. The nurse's note, dated 6/2/22 at 1:36 p.m., indicated the resident received orders to extend her antibiotics through 6/9/22. On 6/30/22, the resident's wound was 3.5 cm in length, 2 cm in width, and 1 cm in depth and was 100% granulation tissue. The July 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 7/24/22 at 5:19 p.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 7/5/22 at 5:39 a.m. and 7/7/22 at 4:58 a.m. On the 7:00 p.m. to 7:00 a.m. shift on 7/18/22 at 5:14 a.m. The nurse documented the treatment as not administered with a reason being nurse did not have time. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on night shift on 7/23/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. The nurse's note, dated 7/25/22 at 12:34 a.m., indicated the resident refused her dressing change three times, related to pain. On 7/28/22, the resident's wound was 3.4 cm in length, 2 cm in width, and 1 cm in depth and was 75% granulation tissue and had 25% slough. The Significant change MDS (Minimum Data Set) assessment, dated 7/29/22, indicated the resident was severely cognitively impaired, had no rejection of care behaviors, was totally dependent of two or more staff for bed mobility, and had a Stage IV pressure ulcer which was present on admission. The August 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 8/7/22 at 6:00 p.m., 8/20/22 at 3:28 p.m., and 8/24/22 at 10:58 a.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 8/6/22 at 7:21 a.m. The treatment was not documented as completed on the 7:00 a.m. to 7:00 p.m. shift on 8/21/22 and the 7:00 p.m. to 7:00 a.m. shift on 8/11/22, 8/21/22, and 8/18/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 8/25/22, the resident's wound measured 3 cm in length, 2 cm in width, and 1 cm in depth and was 75% granulation with 25% slough. There was a foul odor and moderate drainage. The nurse's note, dated 8/25/22 at 9:35 a.m., indicated the resident received new orders for a wound culture and cefdinir 300 mg every 12 hours for seven days related to odor to her wound. The NP's note, dated 8/29/22 at 12:19 p.m., indicated the wound culture showed the resident had growth of pseudomonas aeuroginosa and proteus mirabilis ESBL (extended spectrum beta lactamase). Her antibiotic was changed to Cipro for seven days. The nurse's note, dated 8/29/22 at 2:30 p.m., indicated the resident received new orders for Cipro 500 mg every 12 hours for 7 days. The September 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 9/12/22 at 4:57 p.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 9/2/22 at 8:30 a.m., 9/5/22 at 5:12 a.m., and 9/25/22 at 2:18 a.m. The treatment was not documented as completed on 7:00 p.m. to 7:00 a.m. shift on 9/13/22 and 9/15/22. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on day shift on 9/19/22 and 9/25/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 9/1/22, the resident's wound was 3 cm in length by 2 cm in width, 1 cm in depth, and had 75% granulation with 25% slough. There was no odor. On 9/29/22, the resident's wound was 2.6 cm in length, 1.5 cm in width, 1 cm in depth, and was 100% granulation. The October TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 10/2/22 at 5:39 p.m., 10/17/22 at 4:39 p.m., 10/18/22 at 9:20 a.m., 10/29/22 at 6:29 p.m., and 10/30/22 at 3:20 p.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 10/16/22 at 1:34 a.m., 10/22/22 at 10:39 p.m., 10/29/22 at 10:26 p.m., and 10/30/22 at 2:22 a.m. The treatment was not documented as completed on 7:00 p.m. to 7:00 a.m. shift on 10/4/22, 10/11/22, 10/18/22, and 10/25/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. The nurse's note, dated 10/17/22 at 8:57 a.m., indicated the resident was started on meropenem 500 mg every 12 hours IV for ESBL in her wound. The nurse's note, dated 10/31/22 at 2:23 a.m., indicated the resident's treatment had come off and she refused to allow another to be applied. The November TAR indicated the resident's treatment order to cleanse the wound with normal saline, pat dry, apply collagen and cover with a dry dressing once daily from 7:00 a.m. to 7:00 p.m. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on day shift on 11/11/22, 11/14/22, 11/18/22, and 11/19/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 11/3/22, the resident's wound was 2.5 cm in length, 1.5 cm in width, 0.8 cm in depth, with light purulent drainage and a slight odor. The wound was 100% granulation tissue. The December TAR indicated the order to cleanse the coccyx with normal saline, pat dry, apply collagen, followed by betadine gauze and a dry dressing daily from 7:00 a.m. to 7:00 p.m., was documented as not administered due to the resident's refusal or her being up in her chair on 12/5/22 at 1:44 p.m., 12/15/22 at 4:51 p.m., and 12/25/22 at 9:06 a.m. The resident's order to limit time in the wheelchair to 1 hours intervals to promote wound healing was refused on day shift on 12/5/22 at 1:44 p.m. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 12/1/22, the resident's wound was 2 cm in length, 1 cm in width, 0.5 cm in depth, with no exudate, no odor, and 100% granulation tissue. On 1/5/23, the resident's wound was 2 cm in length, 1 cm in width, 0.5 cm in depth, with no exudate or odor and 100% granulation tissue. The January 2023 TAR indicated the order to cleanse the coccyx with normal saline, pat dry, apply collagen, followed by betadine gauze and a dry dressing daily from 7:00 a.m. to 7:00 p.m., was documented as not administered due to the resident being unavailable and up in her chair on 1/16/23 at 6:05 p.m. and 1/21/23 at 4:17 p.m. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on day shift on 12/5/22 at 1:44 p.m. On 2/2/23, the resident's wound was 1.8 cm in length, 1 cm in width, 0.4 cm in depth, there was no odor, light exudate, and 100% granulation tissue. The nurse's note, dated 2/11/23 at 5:43 p.m., indicated the resident was refusing to lie down once up in her wheelchair and was noncompliant with turning and repositioning. The nurse's note, dated 2/21/23 at 6:41 p.m., indicated the resident had refused her dressing changes for the past two nights. She was educated on the importance of dressing changes to prevent infections and promote wound healing. The resident verbalized understanding. No further interventions were documented. On 3/9/23, the resident's wound was 1.2 cm in length, 0.6 cm in width, 0.4 cm in depth, with light drainage, no odor, and 100% granulation tissue. The resident's care plan and clinical record lacked documentation of any interventions to address the resident's refusal of care or non-compliance, or alternative interventions for when the resident refused treatments, to lie down, or reposition. During an interview on 3/9/23 at 8:58 a.m., Resident 47's family member indicated the resident had the pressure ulcer since before she got to the facility. When she first came in you could see her backbone and now it was down to almost nothing. During an observation on 3/9/23 at 9:03 a.m., PTA (Physical Therapy Assistant) 7 entered the resident's room to conduct a saline mist treatment. The resident's heels were resting directly on the bed mattress. She did not have any pressure relieving treatments in place. PTA 7 removed the resident's dressing. There was a nickel sized open area to the resident's coccyx which was approximately 80% granulation and 20% slough (yellow, necrotic tissue). There was no odor and observed and minimal serosanguineous drainage was on the dressing. During an observation on 3/13/23 at 3:11 p.m., Resident 47 was sitting in her wheelchair by the nurse's station. During an interview on 3/13/23 at 3:13 p.m., CNA 19 indicated he was caring for Resident 47 that day. He was aware of her pressure injury, but it was his first time on the hall in a little while and he was not up to date on her interventions. He knew they turned her every 2 hours, and when she was in her chair, they made sure she was repositioned often and that she was off her bottom. He had cared for her in the past. He had been aware of her refusing care and repositioning quite often. When she refused, he notified the nurse. The nurse would talk to her and try to get her to cooperate with them and then they would often be able to reposition her. During an interview on 3/13/23 at 3:16 p.m., LPN 20 indicated she was the nurse on the hall and CNA 19 was her only aide. She did not know why the resident did not like to get back in the bed. She cried, and they would try to explain it to her. They had pillows and try to offload each side every 2 hours and lay her down as soon as possible. She had tried to encourage her to lay down that same day, but it did not go over too well, she cried. She would take her back to her room and would use pillows to switch the sides, and the resident would allow her to do that. She thought it was because the resident had not wanted to lay down. The resident was adamant if she was not going to do it, she was not going to do it. She did not have any pillows in place. The LPN had helped get the resident up just before lunch at 11:30 a.m., and it was time to put the pillows back in place. She wasn't sure if the resident had those interventions on her care plan. During an observation on 3/14/2 at 8:52 a.m., CNA 21 and CNA 22 assisted Resident 47 from the bed into her chair via a Hoyer lift transfer. The resident did not have any pressure relieving boots in place, and the CNAs did not make any attempts to apply boots. During an interview on 3/14/23 at 9:03 a.m., CNA 22 indicated the resident did have pressure relieving boots, but she did not wear them anymore. CNA 21 indicated the resident did not wear the boots anymore. She had not worn them in a couple of weeks, maybe a couple of months. She didn't have them on in the mornings when they got her up. During an interview on 3/14/23 at 9:32 a.m., LPN 4 indicated the resident had the wound for a long time. She was not aware of the resident refusing any treatments unless she was up in her chair already. She believed she had done it a while back, but she tried to make sure, and do the dressing before she got up as she did not like to lay back down. She was to be laid down after an hour, but she refused, she didn't want to lay down. She wanted to be up during the day. She didn't know what they were doing additionally. She would allow staff to reposition her in the chair. Repositioning her in the chair would be an appropriate intervention. She did not know if the care plan had any interventions to address the resident's refusal of care. She did not see any specific interventions to address what to do when she refused care. She would say the resident was not able to be educated, as she was not cognitively intact. Her wound had improved. They had not discontinued the heel boots, she just put them on the resident. She didn't know why some staff didn't put them on, she did kick them off a lot, but she didn't know why they wouldn't apply them. There had been no determination to discontinue them. During an interview on 3/14/23 at 9:47 a.m., the DON indicated usually when the resident refused care they would step away and reapproach her, then notify the family. She liked being up in her chair and being social. When a resident refused, they would try to get to the root cause of why they were refusing. They would see if it was because she was in pain or if she wanted to stay up, or if she was not wanting the treatment done because she wanted to get up. The intervention of limiting time in her wheelchair would not be an appropriate intervention because she liked to get up. She would agree the resident needed alternative interventions. The boots on her heels were still an intervention. 34309 3. The clinical record for Resident 56 was reviewed on 3/9/23 at 2:37 p.m. The diagnoses included, but were not limited to, diabetes mellitus, moderate protein-calorie malnutrition, abnormalities of gait and mobility, and osteomyelitis of the right ankle and foot. The Quarterly MDS assessment, dated 1/31/23, indicated the resident was moderately cognitively impaired. The resident required extensive assistance of one staff for ADLs (Activities of Daily Living). The care plan, dated 4/21/22 and last revised on 2/6/23, indicated the resident was at risk for skin breakdown or further skin breakdown due to the pressure area to the right heel. The interventions indicated (initiated 5/20/22) to use a heel riser when in bed, (initiated 4/21/22) to assess and document the skin condition weekly and as needed. Encourage the resident to turn and reposition at least every 2 hours. The Wound Management note, dated 4/21/22 at 3:40 p.m., indicated the resident was admitted with a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to the right heel. The wound measured 4 cm long by 3.5 cm wide. There was light bloody exudate and 100% granulation tissue. The Wound Management note, dated 5/5/22 at 10:09 a.m., indicated the wound was unstageable to the right heel. It measured 3.4 cm long by 1.8 cm wide. There was 100% eschar tissue. The wound had declined. The nurse's note, dated 9/15/22 at 12:57 p.m., indicated the wound nurse practitioner was in to see the resident with a new order for a wound culture of the right heel. The Wound Management note, dated 9/15/22 at 3:08 p.m., the wound was a Stage IV to the right heel. It measured 2.4 cm long by 1.5 cm wide by 0.3 cm deep. There was 50% granulation tissue and 50% slough. Necrotic tissue was present. The wound culture results, obtained on 9/16/22, indicated the wound to the right foot had a heavy growth of Escherichia coli ESBL, MRSA (Methicillin Resistant staphylococcus aureus), and diptheroid bacillus. The Wound Management note, dated 12/15/22 at 6:22 p.m., indicated the Stage IV wound to the right heel measured 0.8 cm long by 0.4 cm wide, by 0.3 cm deep. There was light serous exudate and 100% granulation tissue. The Wound Management note, dated 1/26/23 at 4:16 p.m., indicated the Stage IV wound to the right heel measured 0.5 cm long by 0.4 cm wide by 0.2 cm deep The Wound Management note, dated 3/2/23 at 5:00 p.m., indicated the Stage IV wound to the right heel measured 0.5 cm long by 0.5 cm wide by 0.2 cm deep with light serosanguineous exudate. The April 2022 TAR (Treatment Administration Record) lacked documentation, on 4/29/23, of the completion on the 7:00 a.m. to 7:00 p.m. shift of the following interventions: the removal of the heel lift boots to the bilateral lower extremities for skin check, the positioning device of 2 half side rails while the resident was in bed, the turning and repositioning every 2 hours and prn, and Zinc oxide ointment 20% (percent) applied topically to the coccyx. The IDT (Interdisciplinary team) note, dated 4/21/22 at 4:06 p.m., indicated the resident was admitted from the hospital on 4/20/22 with a Stage II wound to the right and left heel. The interventions were in place prior to the wound development to assess and document skin weekly and as needed, encourage the resident to turn and reposition at least every 2 hours; a pressure reducing/redistribution mattress on bed and in chair. The new interventions initiated were heel lift boots to the bilateral feet. The current treatment order was to cleanse the left and right heel with normal saline, pat dry, apply venalax, cover with ABD (army battle dressing) pad, and wrap in kerlix every day. The physician's order, dated 5/9/22, indicated to apply a Proma [TRUNCATED]

Based on observation, record review and interview, the facility failed to ensure appropriate intervention to prevent a fall for 1 of 3 residents reviewed for falls, which resulted in the resident having broken bones, bruising, and skin tears. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on 3/9/23 at 2:18 p.m. The diagnoses included, but were not limited to, a fall slipping, tripping, and stumbling; muscle weakness; stiffness of the left ankle; pain in the right knee; stiffness of the right hip and right ankle; idiopathic peripheral autonomic neuropathy; contracture of the left and right ankle; mechanical complication of the internal fixation device of the right femur for a displaced supracondylar fracture; abnormal posture; and the need for assistance with personal care. The physician's order, dated 2/8/22, indicated the resident was to have two quarter side rails to enhance bed mobility related to weakness. The order was discontinued on 3/2/23. The care plan, dated 11/08/18 and last revised on 2/17/23, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to the resident having impaired mobility and decreased strength. The interventions, dated 11/8/18, indicated staff were to assist the resident with bathing as needed per resident preference; assist with bed mobility with two quarter side rails; assist with dressing, grooming, and hygiene as needed; assist with toileting or incontinent care; and assistance of two staff with the use of a Hoyer for transfers. The Quarterly MDS (Minimum Data Set) assessment, dated 7/22/22, indicated the resident was cognitively intact. The resident required the extensive assistance of two staff members for bed mobility, transfer, personal hygiene, and toileting. The physician's order, dated 8/12/22, indicated the resident was to have a low air loss mattress. The order was discontinued on 3/6/23. The Quarterly MDS assessment, dated 2/1/23, indicated the resident was cognitively intact. The resident required two plus staff assistance with bed mobility, transfer, and toileting. The nurse's note, dated 3/4/23 at 11:00 a.m., indicated CNA 12 alerted the nurse that the resident had fallen on the floor during incontinence care. The resident was found semi-prone on her right side between the wall and the bed. Resident's head was resting on the front left corner of her bed side table. A skin tear was observed to the right dorsal side of the hand. The resident was assisted by the nurse, a CNA (Certified Nurse Aide), and two additional nurses via Hoyer lift back into her bed. The resident complained of pain to her left ankle and left knee. Multiple skin tears were observed in addition to the left hand, including a laceration to the right side of the face, under the eyebrow, the dorsal side of left great toe, and right shin. The resident indicated she did not want to be sent to the hospital. The on-call NP (Nurse Practitioner) ordered x -rays of the areas indicated. The resident's family voiced concerns regarding the lack of a full-sized bed. The nurse's note, dated 3/4/23 at 6:18 p.m., indicated there was new swelling and bruising to the resident's medial side of the knee. The resident states extreme pain. The NP gave new orders for an x-ray of the right lower leg. The nurse's note, dated 3/5/23 at 10:01 a.m., indicated the resident continued to complain of severe pain in the BLE (bilateral lower extremity). The x-ray report concluded a possible subtle proximal tibial plateau fracture and an acute fracture of the proximal tibial metaphysis with mild impaction, but minimal displacement, other than a small anteriorly displaced fracture. The nurse's note, dated 3/5/23 at 12:16 p.m., indicated the resident was agreeable to being transferred to a local hospital. The hospital notes, dated 3/5/23 at 6:31 p.m., indicated the resident was being attended to by staff yesterday morning when she rolled out of bed striking her hip and bilateral knees. She had striked her head. She indicated a mild headache yesterday and was complaining of bilateral hip pain, bilateral knee pain and bilateral ankle pain. X-rays were obtained at the rehabilitation facility which indicated multiple fractures. The resident's history indicated two right hip fractures, right femur surgery, neck surgery and back surgery. The resident weighed 250 pounds and was 72 inches tall. The resident had diffused tenderness to the knee, a proximal left tibia, and the ankles were diffusely tender with chronic plantar flexion deformities. The x-ray results indicated a hairline fracture of the distal left tibia medial cortex just above the metaphysis. There was moderate swelling of the left ankle and moderate diffuse osteoporosis. The right knee x-ray revealed an acute fracture of the right proximal tibial metaphysis with minimal displacement of the tibia-fibula. The left tibia-fibula x-ray revealed a subtle proximal tibial plateau fracture. The resident was non-ambulatory, and the fractures were non operative. The plan indicated to place a right lower extremity knee immobilizer and left equalizer boot and to be worn at all times but may be removed for hygiene and sleep unless the device was in place for fracture. The IDT (Interdisciplinary team) Fall review note, dated 3/6/23 at 12:58 p.m., indicated a new intervention was put in place to address the root cause of the fall, for assistance of two staff at all times with bed mobility and incontinence care, to discontinue the low air loss mattress and to initiate the Promat Plus mattress. During an observation on 3/8/23 at 9:23 a.m., the resident had bruising to the right chin and a cut to the right eyebrow. During an interview on 3/9/23 at 2:47 p.m. a family member indicated the resident fell and this was her third fall. During the other two falls she slid out of bed with her head and torso first. A staff member was changing her with just one staff and she rolled out of bed. She may have been trying to hold onto the rail and she somehow fell out of the bed with this latest fall. She had bilateral tibial fractures, and she had a fibular fracture on one leg. When she fell the first time, the family asked about bed rails and was told by the Social Worker that they couldn't have bed rails. After staff mentioned that she could go from a small enabler rail to a longer side rail she just about lost it. The resident was in horrible pain. She had several bruises and a laceration above her eye. Her bones were not in good shape. The facility only reacted to things after the fact. They didn't put best practices in place from the beginning. You can't get two CNAs to come to the room. The resident use to be transported in a Hoyer lift and sometimes she would be stuck in bed for hours, because they couldn't get two people to come and get here up. Now she's on a lot of pain medication. The family didn't trust the staff to care that she's safe. I know we will have a big reaction if something happens, I can't foresee everything that might happen. The surgeon said her bones are like lace. The pain she had gone through with this fall should never have happened. The nurse's note, dated 3/10/23 at 3:55 a.m., indicated fall precautions remained in place and the resident continued to have facial bruising and a steri strip to the right temple. She had swelling to bilateral feet. During an observation on 3/10/23 at 12:55 p.m., the resident's right cheek and jaw were slightly swollen. During an interview on 3/10/23 at 12:58 p.m., CNA 12 indicated the resident could move her legs up and down and could open them a bit. She could raise her upper torso up and down and reach her face with her arms. She controlled her bed most of the time. When she rolled, she would get started and would rock and eventually roll over. She was not concidered a total assist, but a partial assist. She put her light on when said she was wet. She changed the resident daily and the bed was stripped at the same time. The resident was turning toward the wall and had ahold of the side rail. She rocked herself and went over. She just had a hold of her gown, and she went over. She didn't put her leg over. She would just wiggle over. She rolled a little too far. Her torso was twisted. Her leg and bottom went over first. She hit the bedside table against the wall first. She had always been considered a one person assist until the recent fall. The resident would let the CNA know what she wanted to do or not do. She was laying straight on the mattress and turned onto her left side. She got her sheets together and got the rolled-up sheets under the resident. She was already on her side. She was laying on the middle of the mattress and rolled too far and just kept going. During an interview on 3/10/23 at 1:05 p.m., the Therapy Director indicated the resident had previously been able to roll with maximum assistance (75% plus assistance). She could grab the quarter side rails. She just now got the new bed in and therapy still needed to check the bed. She was not currently in therapy, but when she came back from the hospital, an assessment was planned to be completed. Prior to the fall she could not move her legs in bed and required assistance. She had received therapy and received range of motion. The resident had always required the assistance of two for pulling her up in bed. For nursing care, she required position devices, and maximum assistance of two dated 2/8/22. She could not [NAME] her legs over to roll on her side. She required assistance and had a minimal amount of her own assistance. She could grab her rails to assist with rolling, but she could not move her legs. At therapy discharge, the resident could lean to her left and reposition herself independently to midline. She had a low air loss mattress. It could have led to her falling out of bed, due to the decompression when getting close to the edge. It should be on the firm setting for bed mobility. During an interview on 3/18/23 at 10:50 a.m., the MDS Coordinator indicated the MDS assessments was a collaboration of the nurses, charting, hospital records, the resident, and the family. The Functional Status section was based on the gathered information from huddles, and the decline of the resident. It would be addressed during meetings. The MDS had changed since she took over the MDS assessments. The DON (Director of Nursing) conducted the assessments prior to her coming in December 2022. During an interview on 3/13/23 at 11:14 a.m., the resident indicated CNA 12 was providing incontinence care, and gave her a push to roll over. The CNA had been getting ready to change her and was getting the wet brief out from under her. Her legs eventually went over, out of the bed. She had been hanging onto the rail to get her balance. The CNA was short and couldn't grab her in time to prevent her from rolling out of bed. They sometimes called for 2 CNAs to change her because she couldn't roll well. She now had pain from the fall. Her left forearm had a large circular bruise, approximately 2 1/2 inches and her right forearm had a small circular eraser sized bruise. They made braces for her legs. The Fall Management policy, last revised on August 2022, was provided by the DON on 3/13/23 at 1:36 p.m. The policy included, but was not limited to, . Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the oxygen concentrator filters were applied and maintained for 6 of 18 residents reviewed for respiratory care. (Residents 33, 35, 56, 170, 171, and 49). Findings include: 1. The clinical record for Resident 33 was reviewed on 3/9/23 at 12:55 p.m. The diagnoses included, but were not limited to, copd (chronic obstructive pulmonary disease) with acute exacerbation, malignant neoplasm of upper lobe, left bronchus or lung, emphysema, and anxiety disorder. The physician's order, dated 10/4/22, indicated staff were to change the resident's oxygen tubing and humidity, and clean the concentrator and filter once a day on Sunday. The care plan, dated 10/5/22 and last revised on 1/21/23, indicated the resident was at risk for impaired gas exchange related to the COPD with shortness of breath while lying flat, decreased mobility, opioid use, emphysema, and lung cancer. The interventions, dated 10/5/22, indicated staff were to administer oxygen as ordered at 4 L (liters) via NC (nasal cannula), and to monitor the resident's oxygen saturation rates as needed or ordered. The nurse's note, dated 12/6/22 at 3:42 a.m., indicated the resident had been coughing up yellow thick mucus, and running a low-grade temperature of 99.2 degrees F (Fahrenheit). The Significant Change MDS (Minimum Data Set) assessment, dated 1/17/23, indicated the resident was cognitively intact. She required supervision or was independent for mobility. The nurse's note, dated 1/25/23 at 4:43 a.m., indicated the resident had increasing SOB (shortness of breath). The NP (Nurse Practitioner) was notified and a new order was received for a STAT (urgent) 2-view chest x-ray. During an observation on 3/8/23 at 9:20 a.m., the filter was observed to be missing from the oxygen concentrator. During an observation on 3/9/23 at 8:56 a.m., the oxygen was set at 4 liters. There was no filter on the oxygen concentrator. During an observation on 3/10/23 at 11:25 a.m., the oxygen concentrator had no filter in place. The resident indicated the tubing was changed on Sundays. During an observation on 3/13/23 at 9:49 a.m., the oxygen concentrator had no filter in place. The tubing had a change date of 3/13/23. During a tour of the facility for oxygen use on 3/13/23 between 9:50 a.m. and 10:05 a.m., with the DON (Director of Nursing), Resident 33's oxygen filter was missing, and the tubing had been changed on Monday 3/13/23. During an interview on 3/13/23 at 9:55 a.m., the DON indicated the staff would blow out and rinse the filters every 2 weeks. The manufacturer would also check the machines weekly. If the filters were missing, they would not be filtering as they should. 2. The clinical record for Resident 35 was reviewed on 3/9/23 at 2:18 p.m. The diagnoses included but were not limited to chronic obstructive pulmonary disease with acute exacerbation and anxiety disorder. The Quarterly MDS assessment, dated 7/22/22, indicated the resident was cognitively intact. The resident required extensive assistance of two staff members for bed mobility, transfer, personal hygiene, and toileting. During a tour of the facility for oxygen use on 3/13/23 between 9:50 a.m. and 10:05 a.m., with the DON, Resident 35's oxygen concentrator filter had scattered clumped particles of white dust. 3. The clinical record for Resident 56 was reviewed on 3/9/23 at 2:37 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, atrial fibrillation, and acute pulmonary edema. The care plan, dated 4/21/22, indicated the resident was at risk for impaired gas exchange related to decreased mobility, opioid use, pulmonary edema, heart failure, and acute respiratory failure. The interventions, dated 4/21/22, indicated to administer oxygen as ordered, monitor oxygen saturation rates as needed or ordered. The physician's order, dated 10/19/22, indicated staff were to change the resident's oxygen tubing and humidity, and clean the concentrator and filter once a day on Sunday. The Quarterly MDS assessment, dated 1/31/23, indicated the resident was moderately cognitively impaired. He required extensive assistance of one staff member for ADLs (Activities of Daily Living). During a tour of the facility for oxygen use on 3/13/23 between 9:50 a.m. and 10:05 a.m., with the DON, Resident 56's oxygen filter had scattered particles of clumps of white dust. The tubing had been changed on Monday 3/13/23. 4. The clinical record for Resident 170 was reviewed on 3/13/23 at 11:03 a.m. The diagnosis included, but was not limited to, atrial fibrillation. The clinical record lacked documentation of a care plan related to the resident's oxygen use. The physician's order, dated 2/7/22, indicated staff were to change the resident's oxygen tubing and humidity, and clean the concentrator and filter once a day on Sunday. The Admission MDS assessment, dated 2/13/23, indicated the resident was cognitively intact. She required extensive assistance of 1 to 2 staff members for ADLs. During a tour of the facility for oxygen use on 3/13/23 between 9:50 a.m. and 10:05 a.m., with the DON, Resident 170's oxygen filter was missing and the tubing had been changed on Monday 3/13/23. 5. The clinical record for Resident 171 was reviewed on 3/13/23 at 1:25 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease with acute exacerbation, respiratory failure whether with hypoxia or hypercapnia, and emphysema. The care plan, dated 12/3/19, indicated the resident was at risk for impaired gas exchange related to shortness of breath while laying flat due to emphysema with oxygen use. The resident returned to the facility after hospitalization , with a new order for a bipap. The resident refused to use the bipap despite education. The interventions, dated 12/3/19, indicated to monitor oxygen saturation rates as needed or ordered, and O2 at 3 liters per minute via nasal cannula. The physician's order, dated 1/16/23, indicated staff were to change the resident's oxygen tubing and humidity, and clean the concentrator and filter once a day on Sunday. The Quarterly MDS assessment, dated 3/10/23, indicated the resident was moderately cognitively impaired. She required extensive assistance of 1 to 2 staff members for ADLs. During a tour of the facility for oxygen use on 3/13/23 between 9:50 a.m. and 10:05 a.m., with the DON, Resident 171's oxygen filter was missing on the left side of the oxygen concentrator and the filter to the right side of the oxygen concentrator was completely covered with white dust and the dust was hanging from the filter. 6. The clinical record for Resident 49 was reviewed on 3/10/23 at 1:57 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and atherosclerotic heart disease. The Quarterly MDS assessment, dated 2/11/23, indicated the resident was cognitively intact. The care plan, dated 8/9/21 and last revised on 2/14/23, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath while lying flat, CHF (congestive heart failure), acute respiratory failure, dependency on supplemental oxygen, and morbid obesity. The interventions, dated 8/9/21 indicated to administer oxygen as ordered at 3 liters per nasal cannula, and to monitor oxygen saturation rates as needed or ordered. During a tour of the facility for oxygen use on 3/13/23 between 9:50 a.m. and 10:05 a.m., with the DON, Resident 49's oxygen filter was missing and the oxygen tubing had been changed on Monday 3/13/23. The current Oxygen Concentrator policy, provided by the RDCO (Regional Director of Clinical Operations) on 3/17/23 at 10:35 a.m., included, but was not limited to, . Precautions and Hazards 1)DO NOT operate the oxygen concentrator without the filter or with a dirty filter . 4) Place unit AWAY from curtains, walls, or other obstacles that block the flow of air to the unit. 5) Check the inlet filter pad and ensure that it is in place and clean . Daily Maintenance . 3) Clean the air inlet filter PRN [as needed] and weekly . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure the kitchen, dry storage room and equipment were clean and in good repair during 3 of 3 kitchen observations. This deficient practice had the potential to affect 66 of 67 residents who received meals in the facility. Findings include: During the initial tour of the kitchen, on 3/8/23 at 9:17 a.m., the following concerns were observed: -There was various food debris, one straw, a sugar packet, an ink pen, and built up brown grime on the floor under the two compartment sink counter. -There was a heavy accumulation of black dust on the expanders of two window unit air conditioners above the prep counter. There was duct tape and foam which was poorly secured around the border of the air conditioners and a heavy draft of cold air could be felt coming in. - There was heavy gray dust and brown streaks of grease running down the wall beside the outlet next to the prep counter. - Inside the dry storage there were crumpled creamer packets by and under the ice machine. There was a silver tumbler and a styrofoam cup with a small amount of brown liquid in it, on the table by the ice machine. There was a heavy accumulation of white substance on the floor under the ice machine pipe, and a heavy build up substance on the pipe with moisture observed on the pipe. There were several empty salt, sweetener, and pepper packets behind the ice machine, as well as an opened soda can lying on its side. There was one hair net, several creamers, and sweetener packets under the dry storage shelves. There were several condiment cups and 1 black apron under the shelves as well as a heavy build up of brown debris. Several of the wire racks were observed to have a moderate amount of dust coating them. - In the chemical storage room the light fixture was broken and hanging by wires from the ceiling, there was a pipe running to wall with the cover hanging off of it where the internal structure of the building was exposed, the floor was covered in black grime, the sink fixture was rusted with the enamel coating peeling, and a musty odor was observed in room. - In the walk in fridge there were three butter packets and brown grime built up along the walls under shelves. - The flat top grill was completely caked in black grime which could be seen flaking off in areas. Only approximately 20% of the grill top was clean. - The oven vent hood had a moderate accumulation of dust. - In the walk-in freezer there was a heavy accumulation of ice on the pipe in the back corner. The foam protector was shredded and falling off the pipe. There were littered paper shred and broken plastic food containers under the shelf. There was a box of cinnamon swirl bread touching the ceiling and dangling over the edge of the shelf. -There was grease streaking down the side of the convection oven. - In the dish washing area the back splash had been removed and a heavy accumulation of black peeling buildup was observed where it used to be. The ceiling had multiple areas of peeling paint dangling over the dish washing areas. There were several very large chunks of paint dangling from the ceiling over the dish washing area. There was a heavy accumulation of white substance and food debris under the dishwasher. - There was a heavy buildup of dust on the wall behind the toaster. During a follow-up visit to the kitchen, on 3/8/23 at 11:31 a.m., all of the previously observed concerns remained the same. The Maintenance Director entered the kitchen and began rolling silverware. He did not have a beard net covering his beard which was approximately 3 inches long and full. During a follow-up tour of the Kitchen with the Corporate Dietary Manager on 3/10/23 at 1:50 p.m., the following concerns were observed: -There was various food debris, one straw, a sugar packet, an ink pen, and a build up of brown grime on the floor under the two compartment sink counter. -There was a heavy accumulation of black dust on the expanders of two window unit air conditioners above the prep counter. There was duct tape and foam which was poorly secured around the border of the air conditioners and a heavy draft of cold air could be felt coming in. - There was heavy gray dust and brown streaks of grease running down the wall beside the outlet next to the prep counter. - Inside the dry storage there were crumpled creamer packets by and under the ice machine. There was one opened energy drink, one styrofoam cup containing a small amount of clear liquid, one styrofoam cup containing a small amount of dark brown liquid, one half empty bottle of water, and one silver on the table by the ice machine. There was a heavy accumulation of white substance on floor under the ice machine pipe, and a heavy build up substance on the pipe with moisture observed on the pipe. There were several empty salt, sweetener, and pepper packets behind the ice machine, as well as an opened soda can lying on its side. There was one hair net, several creamers, and sweetener packets under the dry storage shelves. There were several condiment cups and 1 black apron under the shelves as well as a heavy build up of brown debris and a black pasta spoon. Several of the wire racks were observed to have a moderate amount of dust coating them. There was an orange splatter running down the wall beside the ice machine. - There was 2 boxes of vented lids, one box of foam containers, and a box of knives and spoons between 2 to 8 inches from the ceiling. - In the chemical storage room the light fixture was broken and hanging by wires from the ceiling, there was a pipe running to wall with the cover hanging off of it where the internal structure of the building was exposed, the floor was covered in black grime, the sink fixture was rusted with the enamel coating peeling, and a musty odor was observed in room. - In the walk in fridge there were three butter packets and brown grime built up along the walls under shelves. - The flat top grill remained with approximately 20% of the stove top covered in black grime which was flaking in some areas. - The oven vent hood had a moderate accumulation of dust. - In the walk in freezer there was a heavy accumulation of ice on the pipe in the back corner. The foam protector was shredded and falling off the pipe. There were littered paper shred and broken plastic food containers under the shelf. There was a box of cinnamon swirl bread touching the ceiling and dangling over the edge of the shelf. -There was grease streaking down the side of the convection oven. - In the dish washing area the back splash remained removed with a heavy accumulation of black peeling buildup where it used to be, the ceiling had multiple areas of peeling paint dangling over the dish washing areas. There were several very large chunks of paint dangling from the ceiling over the dish washing area. There was a heavy accumulation of white substance and food debris under the dishwasher. - There was a heavy buildup of dust on the wall behind the toaster. During an interview on 3/10/23 at 1:54 p.m., the Corporate Dietary Manager indicated she was filling in from another building and was training the facility's newly hired Dietary Manager. She indicated the pipe by the ice machine was disgusting. She could see the dust on the racks in the dry storage room. She knew it needed worked on and fixed upon her first impression. The racks should be swept under daily and cleaned at least weekly. Boxes should not be touching the ceiling. The concerns in the chemical room were a maintenance issue. There should never be drinks near the ice machine, the staff had a break room and it was a short walk away. There should be someone cleaning the vent hood. She had started working on the stove and it was looking better. During an observation on 3/10/23 at 1:57 p.m., a long-haired, blonde staff member entered kitchen, grabbed a cup of coffee and left. As she exited the door the Corporate DM indicated to the staff member to please use a hair net if entering. She indicated she did not know who the staff member was. During an interview on 3/10/23 at 2:21 p.m., LPN (Licensed Practical Nurse) 25 indicated she had entered the kitchen earlier to get coffee for a resident. She had not been aware she was supposed to wear a hair net as she usually did not go in the kitchen. During an interview on 3/13/23 at 2:28 p.m., Dietary Aide 26 indicated sweeping under shelves and counters was to be done daily. She was not sure how long the kitchen issues had been going on, but she did know the stove had been blackened for some time. It was to be cleaned after every meal. She was uncertain how long, but it would not have accumulated the way it had if it had been cleaned appropriately. The backsplash area in the dishwashing room had been that way for at least a couple of months. During an interview on 3/13/23 at 2:30 p.m., Dietary Aide 27 indicated floors were to be cleaned daily. Things had been chaotic without a dietary manager. They did not have anyone to oversee cleaning and tasks. During an interview on 3/14/23 at 2:35 p.m., the Dietary Cook indicated the hole in the wall in the chemical room had been there when she started working at the facility a week and a half prior. She had not noticed the light in the ceiling. The stove was completely black when she first came back. It would not have built up like that in a day or two. It was to be cleaned every day. Sweeping was supposed to be completed every day, before the evening cook went home. She was not sure if anyone was ensuring it was being done. She would sweep under the shelves in the freezer at least once a week. During an interview on 3/14/23 at 2:39 p.m., the Dietary Manager indicated they did have cleaning schedules, but they had just gotten them. They did not have any completed cleaning check offs they could provide for the last three months. He had been here for just shy of three months. There had not really been anyone ensuring the cleaning tasks were being completed. He wasn't sure how long the issues had been there. The stove top had been in that shape since he had started. They had been without a dietary manager about 3 months before he started,, and he started three months ago but was still in training and the culinary manager position he had only had for two weeks. So realistically there were without a culinary manager for about 6 months. The Cleaning Schedules, provided on 3/13/23 at 3:00 p.m., by the Executive Director, indicated the following tasks: -The AM Dishwasher Aide was to clean the soiled dish table in the dish room, including the legs, garbage disposal and the pipes, and sweep and mop the dish room area daily. -The PM Dietary Aide/Dish was to clean the aide prep table and the exterior of the ice machine daily. - Weekly, the walk in cooler and freezer floor were to be swept, the milk cooler was to be cleaned, the janitor closet was to be cleaned, and the dry storage was to be cleaned and organized. - Monthly, the filters in the hood exhaust, the walls and baseboards throughout the kitchen were to be cleaned. The floors were to be power scrubbed. The Cleaning Schedules policy, last reviewed 12/22, provided on 3/13/23 at 3:00 p.m., by the Executive Director, included but was not limited to, . Policy . The culinary staff will maintain the sanitation of the culinary department through compliance with a written, comprehensive cleaning schedule. Procedure 1. The Culinary Manager will schedule all cleaning and sanitation tasks for the department. 2. The cleaning schedule will be posted for all cleaning tasks, and employees will initial tasks as completed. 3. The Culinary Manager is responsible to ensure all cleaning tasks are completed timely and thoroughly. 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to respect the dignity of a resident with a Foley catheter by ensuring the urine side of the bag was not in sight of those who passed her room. This deficient practice affected 1 of 4 residents who had a Foley catheter. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 3/10/23 at 1:35 p.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, unspecified, paranoid schizophrenia, generalized anxiety disorder, moderate intellectual disabilities, and post traumatic stress disorder. The Annual MDS (Minimum Data Set) assessment, dated 12/15/22, indicated the resident had moderate cognitive impairment but good recall; had neuromuscular dysfunction of the bladder with an indwelling Foley catheter; and occasionally felt bad about herself. The care plan, dated 3/13/19 and last revised 12/30/22, indicated the resident required an indwelling Foley catheter due to neuromuscular dysfunction of the bladder with urinary retention. The goal was for the catheter to be managed appropriately. The approaches included, but were not limited to, provide assistance for catheter care and store the collection bag inside a protective dignity pouch. During observations of the resident between 3/8/23 and 3/10/23, the following concerns were identified: On 3/8/23 at 10:00 a.m., the resident's Foley catheter bag was hanging off the side of the bed with the urine side facing outwards which could be seen from the hallway. The resident was asleep in bed. On 3/9/23 at 8:45 a.m., the resident's Foley catheter bag was hanging off the side of the bed with the urine side facing outwards which could be seen from the hallway. The resident was asleep in bed. On 3/9/23 at 11:25 a.m., the resident's Foley catheter bag was hanging off the side of the bed with the urine side facing outwards which could be seen from the hallway. The resident was awake in bed watching TV. On 3/9/23 at 3:30 p.m., the resident's Foley catheter bag was hanging off the side of the bed with the urine side facing outwards which could be seen from the hallway. The resident was asleep in bed. On 3/10/23 at 8:20 a.m., the resident's Foley catheter bag was hanging off the side of the bed with the urine side facing outwards which could be seen from the hallway. The resident was asleep in bed. On 3/10/23 at 8:20 a.m., the resident was asleep in bed. The catheter bag was hanging off the bed frame with the urine side facing outward. During an interview on 3/10/23 at 1:22 p.m., the resident indicated that it bothered her if people could see the urine in her catheter bag. During an interview with CNA (Certified Nurse Aide) 8 on 3/13/23 at 1:50 p.m., she indicated the catheter bags were supposed to be in a cover or turned towards the bed so the urine side could not be seen. On 3/10/23 at 1:45 p.m., the DON (Director of Nursing) presented a copy of the facility's current policy titled Resident Rights dated effective November 2016. Review of this policy included, but was not limited to, Policy: .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care . 3.1-3(t)

Based on record review and interview, the facility failed to notify the physician when a resident's blood pressure was elevated and when staff withheld medication for 1 of 2 residents reviewed for notification of changes. (Resident 26) Finding included: The clinical record was reviewed for Resident 26 on 3/10/23 at 10:00 a.m. The resident's diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, essential (primary) hypertension, and ventricular tachycardia. The Significant Change MDS (Minimum Data Set) assessment, dated 12/12/22, indicated the resident was cognitively intact. The care plan, dated 9/16/22 and revised on 3/10/23, indicated the resident was at risk for ineffective tissue perfusion related to hypertension and end stage renal disease on hemodialysis. The interventions included, but were not limited to, monitor vital signs, observe and document variations in her blood pressure and notify the physician. The clinical record lacked documentation the physician was notified when the resident's blood pressure was elevated and when the nurse held the resident blood pressure medication for a low blood pressure. The nurse's note, dated 12/4/22 at 6:06 a.m., indicated the residents blood pressure was 250/103 at 5:00 a.m. The follow up blood pressure was 247/85 at 5:45 a.m. The staff continued to monitor. The nurse's note, dated 1/2/23 at 4:47 a.m., indicated the resident's blood pressure was 114/57. The nurse rechecked the resident's blood pressure and it was 107/75. The nurse and the resident agreed to hold the resident's blood pressure medication. During an interview on 3/13/23 at 10:40 a.m., LPN (Licensed Practical Nurse) 6 indicated she would notify the physician for any abnormal blood pressure. A normal blood pressure would be 120/80 but some residents would run a little higher than that. If the resident was a dialysis patient, she would call the physician if the blood pressure was elevated. She would not hold the medication without calling the physician first. During an interview on 3/13/23 at 3:00 p.m., LPN 9 indicated when a resident had an elevated blood pressure she would immediately call the NP (Nurse Practitioner) or the physician, and get a medication for the resident as a stat (urgent) order. She would treat the resident and after about 30 minutes if the blood pressure was still high or higher, she would send the resident to the emergency room . She would not hold medication without calling the physician. During an interview on 3/14/23 at 9:48 a.m., the DON (Director of Nursing) indicated the physician needs to be called before holding any medication. If a resident's blood pressure was elevated the nurse should have called the doctor. The Resident Change of Condition Policy, dated November 2018, as provided on 3/13/23 at 1:35 p.m., by the DON included, but was not limited to, . It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place. 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure an investigation was initiated and completed related to a resident's complaint of mistreatment for 1 of 17 residents reviewed for abuse. Findings include: The clinical record was reviewed for Resident 26 on 3/10/23 at 10:00 a.m. The resident's diagnoses included, but were not limited to, muscle weakness abnormalities of gait and mobility, reduced mobility, a nondisplaced intertrochanteric fracture of right femur, and the presence of a right artificial hip joint. The Significant Change MDS (Minimum Data Set) assessment, dated 12/12/22, indicated the resident was cognitively intact. The clinical record lacked documentation indicating an investigation was initiated and completed by the facility. During an interview on 3/9/23 at 8:55 a.m., the resident indicated in the month of February she went shopping with a group of residents and the staff from the activity department. When she came out of the mall the activity assistant was pushing her in her wheelchair. The activity assistant gave her a shove through the double doors and let go of her wheelchair to help another resident. The resident was unable to stop her wheelchair and she rolled out into the parking lot. She indicated if a car was coming, she would have been hit by the car. She informed the facility as soon as she returned, and the Admissions Director said he would take care of it. She was upset over the incident. During an interview on 3/10/23 at 10:50 p.m., the Director of Marketing and Admissions indicated the resident did come to him and mentioned the incident. An unknown CNA (Certified Nursing Aide) indicated the resident was trying to break away from the group and she had to go after her. He indicated he did not do an investigation, inform the Administrator, or fill out an event form. He didn't feel like it was an issue. During an interview on 3/10/23 at 1:00 p.m., the Activity Assistant indicated when the group was exiting the mall, she guided the resident through the double doors. She turned around to assist another resident through the doors and Resident 26 rolled out into the road. The resident was not pushed. She informed her supervisor of the incident. During an interview on 3/10/23 at 1:10 p.m., the Activity Director indicated when the incident occurred, she was on the bus helping another resident. She didn't see everything that happened, but she did see the Activity Assistant open the door and she pushed the resident through the doors. She told the resident to sit and wait when she went to assist another resident. Resident 26 rolled out into the parking lot. The resident was educated on waiting for staff. She did not report the incident to the Administrator. During an interview on 3/10/23 at 1:25 p.m., the Executive Director indicated she was not aware of the incident. Staff did not report it. She would start an investigation and talk to the resident. The Abuse Prohibition, Reporting, and Investigation Policy, dated 1/23, provided on 3/8/23 at 10:00 a.m., by the DON (Director of Nursing), included, but was not limited to, . 8. It is the responsibility of every employee of American Senior Communities to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director . 3.1-28(d)

Based on observation, record review and interview, the facility failed to ensure a resident who had a referral for an evaluation by an ophthalmologist received the proper treatment to maintain vision. This deficient practice affected 1 of 3 residents reviewed for vision services. (Resident 31) Findings include: The clinical record for Resident 31 was reviewed on 3/9/23 at 9:50 a.m. The diagnoses included, but were not limited to, multiple sclerosis (MS) and type 2 Diabetes Mellitus. The Significant Change MDS (Minimum Data Set) assessment, dated 1/18/23, indicated the resident was cognitively intact and her vision was adequate without glasses. The Monthly Physician's order, dated 7/13/22, indicated the resident may be seen by the Optometrist. A care plan, dated 2/23/22 and was last revised on 2/20/23, indicated the resident was at risk for impaired vision due to age related vision changes and diabetes. A goal included the resident would not experience negative consequences of vision loss as evidenced by participating in social activities. The interventions included, but were not limited to, observe for changes in vision or complaints of eye pain, document and notify the physician. The nurse's note, dated 1/5/23 at 12:48 p.m., indicated an appointment was made with an Ophthalmologist for 2/24/23 at 10:45 a.m. The resident would need an escort to accompany her to the appointment. Transportation arrangements were made, but the company indicated insurance would not pay for the resident to go by stretcher. The resident was going to be able to go in her powerchair, but needed to be transferred into one of their chairs for the examination. Management advised and indicated that this would be taken care of by appointment time. During an interview with the resident on 3/9/23 at 9:30 a.m., she indicated she could not distinguish between blue and green, or see as well as she used to. She liked to color and had to look carefully when she picked the colored pencils or crayons for her drawings. During an interview with the Social Worker on 3/13/23 at 9:45 a.m., she indicated either nursing or herself would make the follow up appointments when the eye doctor made a referral to an Ophthalmologist. She would have to check to see if the resident went to the 2/24/23 appointment with the ophthalmologist. During a second interview with the Social Worker on 3/13/23 at 10:40 a.m., she indicated that she spoke with the nurse who made the Ophthalmologist appointment and that the resident did not go to the 2/24/23 appointment. She did not go since she was not ready physically to go, as she was not as mobile with her walker. Management indicated they would ensure arrangements would be made by the time of the appointment, physical therapy needed to work further on her ambulation with a walker before she could go. A new appointment had been now scheduled for May. The resident's clinical record lacked documentation of the resident making or not making the appointment, or that the resident was not physically capable of attending the appointment with assistance. 3.1-39(a)(1) 3.1-39(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident with a history of UTIs was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 1 of 3 residents reviewed for urinary tract infections. (Resident 47) Findings include: The clinical record for Resident 47 was reviewed on 3/9/22 at 10:00 a.m. The diagnoses included, but were not limited to, UTI (urinary tract infection), extended beta-lactamase (ESBL) resistance, acute kidney failure, and pressure ulcer of sacral region Stage 4. The care plan, initiated on 4/12/21 and last revised on 3/7/23, indicated the resident had an indwelling urinary catheter due to pressure injury, incontinence, and neurogenic bladder. The interventions included, but were not limited to, do not allow the tubing or any part of the drainage system to touch the floor, and report signs of UTIs (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine). The NP's (Nurse Practitioner's) note, dated 6/27/22 at 9:08 p.m., indicated the resident had a urine culture which was positive for ESBL E.(escherichia) Coli. New orders were given for Bactrim DS (double strength) daily for ten days. The urinalysis, dated 6/28/22, indicated the resident's urine was positive for ESBL E. Coli greater than 100,000 CFU/mL (colony-forming units per milliliter) and proteus mirabilis 20-25,000 CFU/mL. The urinalysis, dated 7/15/22, indicated the resident's urine was positive for ESBL E. Coli greater than 100,000 CFU/mL. The NP's note, dated 7/18/22 at 9:25 a.m., indicated the resident's urine culture was positive for ESBL E. Coli. and she was started on imipenem 500 mg every 6 hours for seven days. The nurse's note, dated 9/18/22 at 8:54 p.m., indicated the resident had yellowish-green tinged urine with heavy sediment. The NP was notified. The nurse's note, dated 9/19/22 at 5:33 p.m., indicated the NP ordered to obtain a urinalysis with culture and sensitivity. The NP's note, dated 9/27/22 at 5:15 p.m., indicated the resident was started on imipenem 500 mg every 6 hours for seven days related to an ESBL UTI. The nurse's note, dated 12/1/22 at 1:03 p.m., indicated the resident had a large amount of sediment her urinary drainage bag. The NP was notified. The nurse's note, dated 12/1/22 at 6:49 p.m., indicated new orders were received for a urinalysis. The urinalysis report, dated 12/5/22, indicated the resident's urine was positive for ESBL E. Coli greater than 100,000 CFU/mL. The NP's note, dated 12/8/22 at 9:00 a.m., indicated the resident had a UTI and was started on Macrobid 100 mg (milligrams) twice daily for 7 days. The Quarterly MDS (Minimum Data Set) assessment, dated 12/9/22, indicated the resident was severely cognitively impaired and had an indwelling urinary catheter. The nurse's note, dated 1/31/23 at 5:39 p.m., indicated the resident complained of burning with her catheter. The NP was notified. The urinalysis report, dated 2/5/23, indicated the resident had klebsiella with a growth of greater than 100,000 CFU/mL. The nurse's note, dated 2/6/23 at 1:49 p.m., indicated the resident was started on augmentin 500/125 mg every 12 hours for ten days related to her urinalysis. The nurse's note, dated 2/20/23 at 7:07 p.m., indicated a new order for a urinalysis was obtained and the specimen was awaiting pickup. The urinalysis report, dated 2/26/23, indicated the resident had growth of greater than 100,000 CFU/mL of two colony types of E. Coli ESBL. The nurse's note, dated 2/27/23 at 12:36 p.m., indicated the NP had been in and gave new orders for a midline placement and IV (intravenous) meropenem to be administered every 8 hours for seven days related to ESBL. During an observation, on 3/10/23 at 11:25 a.m., Resident 47 was sitting in her reclining wheelchair in the main dining room. Her catheter bag was hooked to the bottom of her wheelchair. The bag was resting directly touching the floor. Pale yellow urine was observed in the tubing. The bag was approximately one-quarter full. During an observation on 3/10/23 at 1:21 p.m., Resident 47 was sitting in her wheelchair in the common area to the left of the nurse's station. Her catheter bag was hooked to the bottom of her wheelchair. The bag was resting directly touching the floor. Pale yellow urine was observed in the tubing. During an observation on 3/10/23 at 2:30 p.m., Resident 47 was sitting in her wheelchair in the common area to the right of the nurses station. Her catheter bag was hooked to the bottom of her wheelchair. The bag was resting directly touching the floor. Pale yellow urine was observed in the tubing. Two CNAs were standing directly next to the resident talking to her and each other and did not make any attempts to correct the tubing. During an observation on 3/14/2 at 8:52 a.m., CNA 21 and CNA 22 provided catheter care for Resident 47 and assisted her from the bed into her chair via a Hoyer lift transfer. CNA 22 grabbed the catheter tubing with her left hand and the bag hook with her right and lowered the bag to the ground to let the urine drain into the tubing. The bag was observed to directly touch the floor. During an interview on 3/14/23 at 9:03 a.m., CNA 22 indicated she didn't think she had let the catheter bag touch the floor. She knew it was not supposed to touch the floor. During an interview on 3/14/23 at 9:47 a.m., the DON indicated the resident's catheter bag should not be allowed to touch the floor. During an interview on 3/14/23 at 10:55 a.m., the DON indicated the Indwelling Urinary Catheter Care, Emptying Drainage Bag, & Catheter Removal Nursing Policy & Procedure, last reviewed on 12/2012, was the only policy she could locate for catheter maintenance. The policy did not address proper maintenance of the urinary drainage system off the floor. 3.1-41(a)

Based on observation, record review, and interview, the facility failed to ensure accurate documentation in the Controlled Substances Record sheet of the administered narcotics and an expired medication for 8 of 36 residents' medication storage reviewed. (Residents 55, 28, 33, 4, 10, 47, 43, and 39) Findings include: 1. During an observation of the 60 Hall medication cart on [DATE] at 9:45 a.m., with LPN (Licensed Practical Nurse) 6, the following discrepancy was observed: -Resident 55's Controlled Substances Record sheet indicated the Tramadol 50 mg (milligrams) half tablet (25 mg) had a count of 29 tablets remaining. The Tramadol medication card only contained 28 tablets. The last documented administration was on [DATE] at 8:00 a.m. The clinical record for Resident 55 was reviewed on [DATE] at 11:15 a.m. The diagnoses included, but were not limited to, osteoarthritis, gastrostomy, and hydrocephalus. The physician's order, dated [DATE], indicated the resident was prescribed Tramadol 25 mg by gastric tube once daily for mild to moderate pain. The [DATE] MAR (Medication Administration Record) indicated the Tramadol had been administered on [DATE] between 7:00 a.m. and 11:00 a.m. During an interview on [DATE] at 8:00 a.m., LPN 6 indicated she had administered the medication and forgot to sign the medication out. During an interview on [DATE] at 9:54 a.m., LPN 6 indicated she should have signed off the narcotic as soon as she gave it. 2. During an observation of the 60 Hall medication cart on [DATE] at 9:50 a.m., with LPN 5, the following discrepancies were observed: a. Resident 28's nitroglycerin give 0.4 mg sublingually every 5 minutes up to 3 doses for chest pain, had an expiration date on the bottle of ,d+[DATE]. The medication had not been administered. The clinical record for Resident 28 was reviewed on [DATE] at 11:02 a.m. The diagnoses included, but were not limited to anxiety and acute post-traumatic stress disorder. The physician's order, dated [DATE], indicated the resident was prescribed nitroglycerin 0.4 mg sublingually every 5 minutes up to 3 doses for chest pain. The [DATE] MAR indicated no nitroglycerin had been administered. b. Resident 33's Controlled Substances Record sheet indicated the clonazepam 0.5 mg had a count 25 tablets left. The clonazepam medication card indicated a count of 25 tablets left. The last documented administration was on [DATE] at 8:00 p.m. Resident 33's Controlled Substances Record sheet indicated the morphine sulfate extended release 15 mg give twice a day had a count of 3. The morphine medication card had a count of 2 tablets left. The last documented administration was on [DATE] at 8:00 p.m. The clinical record for Resident 33 was reviewed on [DATE] at 11:12 a.m. The diagnoses included, but was not limited to, malignant neoplasm of the upper lobe of the left bronchus or lung and the breast, and generalized anxiety disorder. The physician's order, dated [DATE], indicated the resident was to receive morphine extended release 15 mg every 12 hours for chronic pain. The physician's order, dated [DATE], indicated the resident was to receive clonazepam 0.5 mg twice daily for generalized anxiety disorder. The [DATE] MAR indicated the morphine had been administered on [DATE] at 9:00 a.m. The clonazepam had been administered on [DATE] between 7:00 a.m. and 11:00 a.m. c. Resident 4's Controlled Substances Record sheet indicated the hydrocodone-acetaminophen 7XXX,d+[DATE] mg, give 1 tablet 4 times daily had a count of 13. The hydrocodone-acetaminophen medication card indicated a count of 12 left. The last documented administration was on [DATE] at 8:00 p.m. Resident 4's Controlled Substances Record sheet indicated the clonazepam 0.5 mg, give 3 half tablets (0.75 mg) 3 times daily had a count of 3. The clonazepam medication card indicated a count of 0 left. The last documented administration was on [DATE] at 8:00 p.m. The clinical record for Resident 4 was reviewed on [DATE] at 11:18 a.m. The diagnoses included, but were not limited to, anxiety disorder, bilateral primary osteoarthritis of the first carpometacarpal joints, and right artificial hip joint. The physician's order, dated [DATE], indicated the resident was prescribed clonazepam 0.75 mg 3 times daily for anxiety disorder. The physician's order, dated [DATE], indicated the resident was prescribed hydrocodone-acetaminophen 7XXX,d+[DATE] mg 4 times daily for chronic pain. The [DATE] MAR indicated the hydrocodone-acetaminophen and clonazepam had been administered on [DATE] at 8:00 a.m. During an interview on [DATE] at 9:55 a.m., LPN 5 indicated she had administered the medication and forgot to sign them out. She should have signed the narcotics out right then and there. 3. During an observation of the 20 Hall medication cart on [DATE] at 9:57 a.m., with LPN 4, the following discrepancies were observed: a. Resident 10's Controlled Substances Record sheet indicated the Lyrica 100 mg give 1 capsule daily, had a count of 1. The Lyrica medication card indicated a count of 0 left. The last documented administration was on [DATE] at 8:00 a.m. Resident 10's Controlled Substances Record sheet indicated the Lyrica 100 mg give 1 capsule daily, had a count of 30. The Lyrica medication card indicated a count of 29 left. The last documented administration was on [DATE] with no time documented. Resident 10's Controlled Substances Record sheet indicated the Alprazolam 0.25 mg give twice daily, had a count of 29. The Alprazolam medication card indicated a count of 28 left. The last documented administration was on [DATE] at 8:00 p.m. The clinical record for Resident 10 was reviewed on [DATE] at 11:02 a.m. The diagnoses included, but was not limited to generalized anxiety disorder, idiopathic neuropathy, and chronic ischemic heart disease. The physician's order, dated [DATE], indicated the resident was prescribed Alprazolam 0.25 mg twice daily for generalized anxiety. The [DATE] MAR, indicated the Alprazolam was administered on [DATE] between 7:00 a.m. and 11:00 a.m. The physician's order, dated [DATE], indicated the resident was prescribed Lyrica 100 mg one daily for chronic pain. The [DATE] MAR indicated the Lyrica was last administered on [DATE] between 7:00 a.m. and 11:00 a.m. The physician's order, dated [DATE], indicated the resident was prescribed Lyrica 25 mg one daily for chronic pain. The [DATE] MAR indicated the Lyrica 25 mg was administered on [DATE] between 7:00 a.m. and 11:00 a.m. b. Resident 47's Controlled Substances Record sheet indicated the hydrocodone-acetaminophen ,d+[DATE] mg, give every 4 hours, had a count of 20. The hydrocodone-acetaminophen medication card had a count of 19 left. The last documented administration was on [DATE] at 4:00 a.m. The clinical record for Resident 47 was reviewed on [DATE] at 11:20 a.m. The diagnosis included, but was not limited to, a Stage 3 pressure ulcer to the sacral region. The physician's orders, dated [DATE], indicated the resident was prescribed hydrocodone-acetaminophen ,d+[DATE] mg every 4 hours for the Stage 3 pressure ulcer to the sacral region. The [DATE] MAR indicated the hydrocodone-acetaminophen ,d+[DATE] mg had been administered on [DATE] at 8:00 a.m. c. Resident 43's Controlled Substances Record sheet indicated the Tramadol 50 mg tablet, give 2 times daily, had a count of 28. The Tramadol medication card indicated a count of 27 left. The last documented administration was on [DATE] at 8:00 p.m. The clinical record for Resident 43 was reviewed on [DATE] at 11:31 a.m. The diagnosis included, but was not limited to, chronic pain syndrome. The physician's order, dated [DATE], indicated the resident was prescribed Tramadol 50 mg twice daily for mild pain. The [DATE] MAR indicated the Tramadol 50 mg had been administered on [DATE] between 7:00 a.m. and 11:00 a.m. During an interview on [DATE] at 10:24 a.m., LPN 4 indicated she should have signed them off when they were given. 4. During an observation of the Front Hall medication cart on [DATE] at 10:03 a.m. with LPN 3, the following discrepancy was observed: a. Resident 39's Controlled Substances Record sheet indicated the oxycodone-acetaminophen 7XXX,d+[DATE] mg, give two times daily, had a count of 30. The oxycodone-acetaminophen medication card indicated a count of 29 left. The last documented administration was on [DATE] with no documented time. The clinical record for Resident 39 was reviewed on [DATE] at 11:38 a.m. The diagnosis included, but were not limited to, peritonitis, and chronic inflammatory demyelinating polyneuritis. The physician's order, dated [DATE], indicated the resident was prescribed oxycodone-acetaminophen 7XXX,d+[DATE] mg twice daily for chronic pain. The [DATE] MAR indicated the oxycodone-acetaminophen had been administered on [DATE] at 7:00 a.m. During an interview on [DATE] at 10:13 a.m., LPN 3 indicated she should have sign them out. Resident 39 had just hovered over her. The General Dose Preparation and Medication Administration policy, last revised on [DATE], was provided by the RDCO (Regional Director of Operations) included, but was not limited to, . 4.1.2 Check the expiration date on the medication . 5.5 Document the administration of controlled substances in accordance with applicable law . 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given . 3XXX,d+[DATE](b)(3)

Based on record review and interview, the facility failed to ensure the residents were COVID-19 tested in accordance with their policy for 1 of 3 residents reviewed for COVID testing. (Resident 31). Findings include: The clinical record for Resident 31 was reviewed on 3/13/23 at 9:56 a.m. The diagnoses included, but were not limited to, mild intermittent asthma, personal history of COVID-19, and MS (multiple sclerosis). The Significant Change MDS (Minimum Data Set) assessment, dated 1/18/23, indicated the resident was cognitively intact. On 7/13/22, the resident received the following physician orders: Symbicort (budesonide-formoterol) HFA aerosol inhaler 160-4.5 mcg (micrograms)/actuation - give: 2 puffs inhalation for shortness of breath twice daily, and for COVID-19 testing as needed via POC (rapid viral test) Antigen or PCR (polymerase chain reaction) test per facility policy and CDC (Center for Disease Control) Guidance - as needed. On 7/14/22, the resident received another physician's order for albuterol sulfate HFA aerosol inhaler 90 mcg/actuation - give 180 mcg inhalation for shortness of breath every 6 hours. A care plan, dated 2/23/22 with a review date of 2/20/23, indicated the resident was at risk for impaired gas exchange related to MS and asthma. The interventions included, but were limited to, administer medication as ordered; assess vital signs and lung sounds as needed; and monitor oxygen saturation rates as needed or ordered. A nurse's note, dated 1/16/23 at 1:27 p.m., indicated the resident complained of sinus issues. The Nurse Practitioner (NP) saw the resident and gave a new order for ZPak (an antibiotic). A nurse's note, dated 1/16/23 at 2:02 p.m., indicated the resident was started on an antibiotic for sinus issues with the first dose being given at that time. The Respiratory Surveillance Line List for January 2023, indicated the resident was listed as having congestion, but documentation was lacking of the resident having been COVID tested before being given an antibiotic . During an interview, on 3/13/23 at 10:12 a.m., LPN (Licensed Practical Nurse) 6 indicated she would monitor for signs and symptoms of COVID like fever, congestion, cough, chills, nausea and vomiting, and any change in mental status. She would isolate the resident and do a Covid test. She would call the physician, DON (Director of Nursing) and the IP (Infection Preventionist). On 3/8/23 at 9:00 a.m., the Administrator presented a copy of the facility's current policy titled Infection Prevention and Control Guidelines During the COVID-19 Pandemic dated effective 11/7/22. The review of the policy included, but was not limited to, . Procedure: . 2. Core Principles of COVID-19 Infection Prevention: .h. Resident and staff testing conducted per policy .6. SARS-CoV-2 Viral Testing: a. anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for COVID-19 .

Based on observation, record review, and interview, the facility failed to ensure nursing services met professional standards of care for administration and documentation of insulin and blood glucose levels, pressure ulcer interventions, and change of condition. This deficient practice had the potential to affect all 68 residents residing in the facility. Findings include: 1. Standards of practice were not followed, related to blood glucose level monitoring and administration of insulin as ordered by the physician. Residents 24, 36, 33, and 29 had multiple incidents of missing documentation of ordered blood glucose levels and administration of insulin. Cross Reference F684. 2. Resident 51 developed a facility acquired pressure ulcer. Skin assessments conducted by nursing staff were inaccurate, and the wound was not identified until it had progressed to a stage 3. Cross Reference F686. 3. Resident 36 was experiencing changes in respiratory status. The clinical record lacked documentation of appropriate monitoring, assessment, and follow-up by nursing staff. Cross Reference F695 3.1-35(g)(1)

Based on record review, observation, and interviews, the facility failed to ensure residents were provided the care and services, related to treatments and interventions, to prevent the development of an Unstageable Pressure Ulcer and a Deep Tissue Injury for 2 of 4 residents reviewed for pressure ulcers.(Residents B and C). Findings Include: 1. Review of the clinical record for Resident B on 04/26/19 at 09:55 a.m. The resident's [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 3/12/19, indicated the resident was alert and oriented. The re-admission observation, dated 04/13/19, indicated the resident's skin was intact. The physician's orders [REDACTED].), and covered with an ABD (abdominal) pad daily and as needed for soilage or dislodgement. The resident's heels were to be floated while in bed and a pressure relief boot applied to the left foot at all times. The care plan, dated 10/18/2017 and last revised on 12/06/18, indicated the Resident is at risk for skin breakdown . Resident will be free from skin breakdown . preventative treatment as ordered . The care plan, dated 04/17/19, indicated the Resident has impaired skin integrity: DTI Location: L Heel . treatment as ordered . The Initial Wound Review, dated 04/17/19 at 11:57 a.m., indicated During skin sweeps resident noted to have DTI to L (left) Heel . DTI black with soft center Resident complains of pain with touch . The New Skin Event, dated 04/17/19 at 12:04 p.m., indicated the wound measured 2 cm in length and 4 cm in width. The review of the Treatment Administration Record, on 04/26/19 at 2:00 p.m., indicated the resident's treatment to the left heel had been documented as completed on both 04/24/2019 and 04/25/19. During an observation, on 04/25/19 at 9:04 a.m., the resident was observed lying in bed. The left heel was bandaged and lying directly on a pillow. The heel was not floated and the pressure relief boot was not in place. During an observation, on 04/26/19 at 1:52 p.m., LPN (Licensed Practical Nurse) 6 removed the wound dressing from the resident's left heel. The dressing was dated 04/23/2019. There was an intact, dark black area, to the resident's heel measuring 2 cm in length and 3.7 cm in width. During an interview, on 04/25/19 at 9:05 a.m., the resident indicated she had a pressure sore on her heel. They don't turn and reposition me. I can't do it at all myself. During an interview, on 04/29/19 at 2:08 p.m., the DON (Director of Nursing) indicated Upon removing the dressing to the residents left foot, the bandage had a date of 4/23/2019. The treatment was daily and should have been changed on 4/24 and 4/25. During an interview, on 04/30/19 at 8:57 a.m. the DON indicated the resident's heels should be off loaded at all times and the pressure relief boot should always be in place. 2. Review of the clinical record for Resident C on 04/26/19 at 08:56 a.m. The resident's [DIAGNOSES REDACTED]. The admission MDS assessment, dated 01/14/19, indicated in Section M of the skin condition determination of pressure ulcer risk, Resident C had no unhealed pressure ulcer. The discharge MDS assessment, dated 02/7/19, indicated in Section M of the skin condition determination of pressure ulcer risk, Resident C had an unstagable pressure ulcer. The care plan, dated 01/07/19 and revised on 01/24/19, indicated the .Resident is at risk for skin breakdown due to: impaired mobility, moisture, DM (Diabetes Mellitus) . Resident will be free from skin breakdown . Encourage resident to turn and reposition at least every 2 hours; provide assistance as needed . House barrier cream at bedside - use as needed . Incontinent care as needed using peri wash and moisture barrier . Pressure reducing/redistribution mattress on bed . A temporary care plan event, dated 01/24/19, indicated the resident had a new open area to the coccyx. A non-pressure wound skin evaluation, dated 01/25/19, indicated the resident had an area of MASD (Moisture Associated Skin Damage) measuring 4 cm by 4 cm. A treatment of [REDACTED]. The physician's orders [REDACTED]. The review of the Treatment Administration Record indicated the treatment had not been signed as completed on 01/29/19 or 01/30/19. A New Skin event, dated 02/06/19, indicated Resident noted to have unstageable area to Coccyx. Area is open with yellow slough, wound bed not able to be visualized through slough. Wound edges are regular. Surrounding skin intact no drainage noted. Skin is warm to touch. Surrounding skin noted to have blanchable redness from MASD . Resident has noted decline since admission to facility. Incontinent of B&B and not able to make needs known at all times. NP (Nurse Practitioner) notified of new skin area and monitoring with labs to monitor protein and [MEDICATION NAME]. Resident being followed weekly on NAR (Nutritionally at Risk). New treatment orders placed in matrix will be followed weekly on wound rounds. Low-air-loss mattress ordered for wound healing. Resident to have side to side offloading q2h (every 2 hours) while in bed. All needs currently being met. Will continue to monitor. The wound measured 4.5 cm in length, 4.2 cm in width, with an unable to be determined depth. The wound bed was yellow/red and the periwound was red. A progress note, dated 02/06/2019 at 12:28 a.m., indicated the condition of the wound was .much worse . The wound was deeper and red. During an interview, on 04/30/19 at 12:48 p.m., the DON indicated the treatment had not been signed out as completed on 01/29/19 and 01/30/19. There was no reason why they were not signed out and they should have been completed and signed out. The Skin Management Program policy, dated 03/2010 and last revised 04/2018, was provided on 04/30/19 at 11:15 a.m. It is the policy of (Name of Corporation) to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing . Deep Tissue Injury . This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface . 3. Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors to include but not limited to the following . Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) . This Federal tag relates to complaint IN 729. 3.1-40

Based on interview and record review, the facility failed to ensure the safety of a resident (Resident B) with elopement behaviors who exited the facility, unsupervised, for 1 of 3 residents reviewed for accidents. The Immediate Jeopardy began on 3/21/18 at 7:10 p.m. when a resident (Resident B) with elopement behaviors exited the facility unsupervised. The Executive Director was notified of the Immediate Jeopardy on 4/5/18 at 1:45 p.m. The Immediate Jeopardy was removed and corrected on 3/22/18 at 2:30 p.m. when the facility completed staff education/inservices on all aspects of the policy/procedure for elopements, elopement drills, and security devices were placed in all facility windows. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident B was reviewed on 4/4/18 at 8:03 p.m. [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 3/19/18, indicated severely impaired cognition and daily wandering. The elopement assessment, dated 3/12/18 at 4:08 p.m., indicated the resident had the ability to move about freely, a history of elopement, and had been assigned a security bracelet (Wanderguard). The elopement care plan, dated 3/12/18, indicated the resident was at risk for elopement due to being independently mobile and cognitive impairment. The interventions included to redirect to activity, secure all facility exits, provide one to one attention/conversation, and apply a Wanderguard per physician order. The progress note, dated 3/13/18 at 7:54 a.m., indicated the resident was awake all night, tried to go into other residents' rooms, and was redirected several times. The progress note, dated 3/19/18 at 12:38 a.m., indicated the resident was confused, disoriented to place and time, and became turned around easily. The social service note, dated 3/19/18 at 12:50 p.m., indicated the resident had exhibited daily behaviors of exit seeking and had a Wanderguard in place. The incident report, dated 3/22/18, indicated on 3/21/18 Resident B exited the building through the payroll office window, was found by staff in the back parking lot, then was brought back in to the facility. On 4/4/18 at 8:06 p.m., the security camera video feed for 3/21/18 was viewed. Resident B was observed to ambulate down the front hall towards the lobby, walked up to multiple windows in the lobby, then walked around the lobby desk to the front door. Resident B pushed on the door, turned around, and entered left into the business office. At 7:10 p.m., the resident was observed ambulating outside past the front door wearing a white sweater, black pants, and black shoes. The temperature outside was 39 degrees. At 7:25 p.m., the resident was observed in the back parking lot, found by staff, and brought back into the building through the back door at 7:27 p.m. Piles of snow were observed around the back parking lot and on the picnic table. The progress note, dated 3/22/18 at 3:26 p.m., indicated the IDT (Interdisciplinary Team) met to discuss the resident's recent behavior and that the resident had exited the building. The root cause was that the resident was unfamiliar with the surroundings and was still becoming acclimated to the building and staff. The clinical record for Resident B lacked nursing documentation of a head to toe skin assessment as well as physician and family notification on 3/21/18 after the elopement occurred. During an interview on 4/4/18 at 8:20 p.m., the Director of Nursing indicated the payroll office door, which was usually locked, was either left open or unlocked and the resident exited through the window, which was found open the next morning. During an interview on 4/5/18 at 9:26 a.m., the Social Service Director indicated the resident wandered daily, per her observations, and she informed staff of the exit seeking behaviors. During an interview on 4/5/18 at 9:37 a.m., the Director of Nursing indicated, on 3/21/18 at 7:15 p.m., the resident was unable to be found during medication pass and she was not aware of what the resident was doing prior to the elopement. On 4/4/18 at 8:30 p.m., the Executive Director provided a current copy of the document titled Elopement Prevention and Response Program, dated (MONTH) (YEAR). It included, but was not limited to, the following: Policy .It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents .Post Elopement Procedure .Upon return of the resident, the charge nurse will conduct a complete head to toe assessment, notify the physician and document the resident's condition in the medical record . The past noncompliance Immediate Jeopardy that began on 3/21/18 at 7:10 p.m. was removed on 3/22/18 at 2:30 p.m. when the facility completed staff education/inservices on all aspects of the policy/procedure for elopements, elopement drills, and security devices were placed in all facility windows. This Federal tag relates to Complaint IN 664 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure the safety of a resident (Resident E) who had elopement behaviors, and exited the facility, unattended, on two separate occasions for 1 of 3 residents reviewed for accidents. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/19/2016 at 2:24 p.m. when a resident (Resident E) with a security bracelet exited the facility, unattended. A second elopement occurred on 11/23/16 with the same resident unattended. The Executive Director and Director of Nursing were notified of the Immediate Jeopardy on 12/30/2016 at 11:22 a.m. Findings include: The clinical record for Resident E, admitted to the facility on [DATE], was reviewed on 12/28/16 at 2:10 p.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 11/17/16, indicated a BIMS (Brief Interview of Mental Status) score of 6 which signified impaired cognition. Behavior included, but was not limited to, the following: .Wandering .Behavior of this type occurred daily .Impact .Does the wandering place the resident at significant risk of getting to a potentially dangerous place .Yes . The care plan included, but was not limited to, the following: .Problem Start Date: 11/14/2016 .Resident is at risk for elopement d/t (due to) being mobile, wandering and altered mental status .Goal .Resident will remain safely in the facility through next review .Approach .All facility exits secured .1:1 attention and conversation .Redirect to activities of interest .Resident resides on a secure unit .Wanderguard per MD (medical doctor) order . The progress notes for Resident E indicated the following: Dated 11/13/16 at 1:00 a.m., the resident was to be checked every 15 minutes due to exit seeking behaviors. Dated 11/19/16 at 2:46 p.m., included, but was not limited to, the following: Resident continues to exhibit exit seeking behavior, all staff aware of residents exit seeking behavior, wanderguard in place to ankle and functioning properly, resident continues on 15min (15 minute) checks . Dated 11/23/16 at 12:00 p.m., the resident could not be found during a scheduled 15 minute check and, at approximately 1:00 p.m., the resident was located at a bar by staff and brought back to the facility. On 12/29/16 at 9:52 a.m., the security camera video feed for 11/23/16 was viewed. Resident E was observed ambulating down the 40 hall towards the back exit and exited through the double doors into a breezeway at the back of the building. At 12:10 p.m., the security camera on the outside of the back of the building showed a contracted painter entering the back of the building and Resident E was observed to exit the building. During an interview on 12/29/16 at 10:17 a.m., the ED (Executive Director) indicated the resident walked to a pawn shop, which was about a 1/2 mile up the road, and called a friend, who picked him up and took him to a bar. During an interview on 12/30/16 at 1:58 p.m., LPN (Licensed Practical Nurse) 7 indicated, I went to his room and he wasn't there. Searched the building and called a code silver. I don't know what time he was found. His security bracelet was found under his sock. He was one on one when he came back and social services sat with him. Prior to the elopement on 11/23/16, Resident E had been trying to leave all day. During an interview on 12/30/16 at 2:07 p.m., the SSD (Social Service Director) indicated Resident E had exited the building on 11/19/16, sometime between shift change, and on 11/23/16, around lunch time. During a telephone interview on 12/30/16 at 3:20 p.m., CNA (Certified Nursing Assistant) 5 indicated, on 11/19/16, during shift change, one of the CNA's coming into work (CNA 3) saw the resident walking down the road by (name of apartment complex), about a 1/2 mile away from the facility. We went to get him on foot and caught up with him. (CNA 3) and the (DON) were in the car and brought him back. During an interview on 12/30/16 at 4:10 p.m., the ED indicated the resident did get out of the building on 11/19/16. During an interview on 1/2/17 at 1:35 p.m., CNA 4 indicated on 11/19/16, she heard the alarm sounding during shift change, went around the corner, looked out the door and did not see anyone and entered the code to turn the alarm off. Another staff member was coming in for 2nd shift and said (Resident E's name) was seen walking down the street. Me (CNA 4) and (CNA 5) ran out the door to go get him. He was almost to the stop sign by the expressway when we caught up to him. We put him in (CNA 3's name) car and brought him back. On 1/2/17 at 2:12 p.m., the security camera video feed for 11/19/16 was viewed. Resident E was observed to walk past two staff members, with their backs to him, and exit through the side door off of the Front Hall, prior to the door closing after a patron had opened it. One of the staff members waited approximately 8 seconds, went to the door and began trying to enter the code. The staff member did not look to see if anyone was out in the parking lot. CNA 4 was observed to come around the corner to the exit where the alarm was sounding, look out in the parking lot, then entered the code to silent the alarm. At 14:27 p.m. (2:27 p.m.), CNA 3 was observed entering the side exit door off of the Front Hall, and approximately 7 seconds later, three staff members were observed rushing out of the side exit door to retrieve the resident. On 12/29/16 at 10:12 a.m., the ED provided a current copy of the document titled Elopement (Risk and Missing Resident), dated 10/13. It included, but was not limited to, the following: .Policy: It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action is taken The Immediate Jeopardy that began on 11/19/16 at 2:44 p.m. was removed on 12/31/16 at 3:50 p.m. when the facility completed staff education/inservices on elopement/service entry door alarm, elopement drill procedure, elopement risk management assessment, wanderguard, code silver, and vendor inservices on residents exiting/entering facility and alarms. The Immediate Jeopardy was removed on 12/31/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on elopement/service entry door alarm, elopement drill procedure, elopement risk management assessment, wanderguard, code silver, and vendor inservices on residents exiting/entering facility and alarms. This Federal tag relates to Complaint IN 417 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure adequate supervision was in place to prevent a resident (Resident #C) with a security bracelet (device placed on residents who are at risk for elopement) from exiting the facility without supervision and failed to follow policy and procedure to identify the resident had left the facility for 1 of 6 residents reviewed for accidents. Findings include: The clinical record for Resident #C was reviewed on 9/15/16 at 11:00 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 8/7/16, indicated Resident #C had a BIMS (Brief Interview of Mental Status) score of 15, which signified intact cognition. The nurses note, dated 8/16/16 at 12:55 p.m., included, but was not limited to, the following: .this nurse reminded resident to use w/c (wheel chair) or walker. Resident stated (his/her) walker was full of belongings because (he/she) was moing (sic) (moving) and going home . The nurses note, dated 8/18/16 at 1:38 p.m., included, but was not limited to, the following: .resident stating (he/she) wanted to leave but would stay one more day . The nurses note, dated 8/18/16 at 2:00 p.m., recorded as a late entry on 8/19/16 at 11:52 a.m., included the following: Resident is noted to be wandering throughout the facility, stating that (he/she) has to leave. This nurse also witnessed resident pushing rolling walker with belongings on seat of walker as though (he/she) was leaving. Resident is noted to have a [DIAGNOSES REDACTED]. Resident is exhibiting concerning behavior of being an elopement risk and a Wanderguard has been placed to the resident's left lower extremity at this time. The nurses note, dated 8/18/16 at 9:34 p.m., included the following: At approximately 8:30 p.m., resident eloped from facility. Resident returned to facility & (and) appears to be Alert (sic) and Oriented (sic) x (times) 3, but states (he/she) is wanting to go home. Physician & (and) family notified. Order for Wanderguard obtained and is now intact . The incident report, dated 8/18/16 at 8:45 p.m., included, but was not limited to, the following: .Residents Involved .(Resident #C's name) .Brief Description of Incident .Resident exited secured rear door after entering code . During an interview on 9/15/16 at 3:30 p.m., the Administrator indicated Resident #C had left the premises through the breeze way at the back door, which had a hint code listed above the key pad, and Resident #C put the code in and left the facility. The Administrator indicated the police found Resident #C ambulating approximately four blocks from the facility and took Resident #C to a local facility. The Administrator indicated the local facility then called their facility to verify Resident #C was a resident at their facility. The Administrator further indicated staff were unaware Resident #C had exited the building until the local facility notified them. During an interview on 9/16/16 at 9:50 a.m., the Maintenance Director indicated the back door alarm was only audible at the back door and the alarm was not audible at the nurses station. On 9/16/16 at 12:00 p.m., the Director of Nursing provided a copy of the document titled Elopement (Risk and Missing Resident), dated 10/2013. The document included, but was not limited to, the following: .Policy: It is the policy of the facility that staff who have residents under their care are responsible for knowing the locations of those residents, and in the case of missing resident, ensuring appropriated action is taken .MISSING RESIDENT PROCEDURE .1. If a resident's whereabouts is unknown, the following measures will be implemented immediately: a. The charge nurse of the missing resident is notified of the need to locate the resident .b. The charge nurse uses the overhead paging code: CODE SILVER followed by the unit of the missing resident .c. Each charge nurse coordinates a head count of every resident in their assigned area .d. The charge nurse of the missing resident will check for other explanations for the resident's absence .e. Each charge nurse coordinates a search of their assigned area including resident rooms, restrooms, closets, shower rooms, hallways, offices, service areas like kitchen, laundry, etc .f. Results of the search will be reported to the charge nurse of the missing resident. If the resident has not been located within 10 minutes of initiating the search, the charge nurse will notify the Executive Director and Director of Nursing Services .2. Assigned Search Coordinator .will coordinate another search of the facility as well as the facility grounds .3. If the resident is not located after this search, the responsible party, physician, and the police will be notified in that order .4. Staff will continue to search the facility and grounds, expanding into surrounding neighborhoods . This Federal tag relates to Complaint IN 106 3.1-45(a)(2)

Based on record review and interview the facility failed to ensure a resident, who had a history of [REDACTED]. This deficient practice had the potential to effect 1 of 5 residents reviewed for falls in a sample of 10. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/11/12 at 9 a.m. The resident's [DIAGNOSES REDACTED]. Review of the Progress Notes included, but were not limited to: 03/02/12 5:07 PM "res in w/c (wheel chair) in dining room for evening meal, removed chair alarm and took self to bathroom x 1 this shift thus far, bed and chair alarms functioning properly" 03/05/12 6:43 PM "pt continues to be noncompliant with transfers/alarms this shift x 3 attempting to take self to bathroom and to get in his closet, pt educated on safety and use of the call light, pt up in wheelchair at this time" 03/06/12 1:39 AM "Around 1249 resident was standing up in wheel chair attempting to adjust himself better in the chair and lost his balance landing on his right hip, CNA was entering residents room at the time of the incident and was a witness to the fall. apron (sic) assessment res c/o (complains of) some pain to right hip, (named nurse practitioner) notified n/o (nursing order) to send to ER for evaluation, residents V/S (vital signs) stable, resident instructed to remain in floor until ambulance arrive, CNA remained with resident for safety..." 03/06/12 6:19 AM "Called hospital for update of resident, resident was admitted with right hip fracture..." Signed physician's orders [REDACTED]. The Care Plan with last care conference of 03/30/2012 included but was not limited to: "Problem Start Date: 01/05/2011 Resident at risk for falls R/T hx (history) of falls, assessments, psychotropic (sic) med use, dx (diagnosis) of Parkinson, Tremors, DM (diabetes mellitus), dementia, R (right) hip fx, needs assist with functional mobility tasks, poor safety awareness, noncomplaint (sic) with seeking assist with transfers, disarms alarms, non compliant with use of devices, i.e. (for example) reacher, self release seat belt, call light use, etc. Goal Target Date: 06/30/2012 Will decrease resident's risk of falls. Approach Start Date 01/05/2011 Check placement and functioning of alarm q shift and prn. Approach Start Date: 01/05/2011 Keep call light in reach at all times. Approach Start Date: 01/05/2011 Provide toileting assistance per schedule toileting Review of the Monthly Summary form for Scheduled Toileting indicated "Program #2 Toilet upon rising, before or after meals, at bedtime and check and change through the night" On 4/11/12 at 2:30 PM, in interview with the Interim Director of Nursing, when queried as to whether or not the resident had an alarm on at the time of the fall she made no comment. On 4/11/12 at 2:55 PM, the Administrator in training provided the Fall Management Program revised 3/10 which included, but was not limited to: "Policy It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls. Procedure: Fall risk 4. Charge nurses will communicate the specific care required for each resident to the assigned caregiver on each shift. On 4/11/12 at 10:33 PM, in interview with LPN #1, she indicated "honestly I don't remember, if he had the seatbelt on. The resident tended to take it off so he could reposition himself." This federal tag relates to Complaint IN 884. 3.1-45(a)(2)