Every finding on record at Cloverleaf of Knightsville

Based on interview and record review, the facility failed to ensure safe administration of peritoneal dialysis (a home-based treatment for kidney failure that uses the lining of the abdomen to filter waste and extra fluid from the blood) by staff trained and qualified to administer peritoneal dialysis for 1 of 1 resident reviewed for peritoneal dialysis (Resident 2). Findings include:During an interview, on 2/10/26 at 10:41 a.m., Resident 2 indicated he was on peritoneal dialysis and staff would place him on the dialysis in the evening and would remove it around 8 to 8:30 a.m. the next morning. Resident 2's record was reviewed on 2/12/26 at 3:09 p.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (the final permanent stage of chronic kidney disease where kidneys function less than 15% of normal capacity, requiring dialysis or transplant for survival) and dependence on renal dialysis (indicates a chronic, life-sustaining need for mechanical blood filtration). Facility census information indicated Resident 2 was admitted to the facility on [DATE]. A physician order, dated 11/19/25, indicated to administer peritoneal dialysis two 6 liters (L) bags total over 12 hours per machine. Start at bedtime (HS) remove when completed daily. A care plan, dated 11/20/25, indicated the resident had a diagnosis of end stage renal disease and was at risk for complications with dialysis treatment. Interventions included, but were not limited to, complete peritoneal dialysis daily, medications as ordered, observe for pain at site and notify physician if pain is present, and weights as ordered. A quarterly Minimum Data Set (MDS) assessment, dated 11/27/25, indicated the resident was cognitively intact and was on dialysis. Resident 2's Medication Administration Record (MAR) was reviewed since his admission on [DATE], until present February 2026. The following was documented by staff as administering the peritoneal dialysis to Resident 2:1. November 2025 MAR:a. Registered Nurse (RN)16 had documented she administered peritoneal dialysis 5 times since his admission. The record lacked in-service documentation that RN 16 had been trained by the dialysis center to be able administer peritoneal dialysis to Resident 2.b. Licensed Practical Nurse (LPN) 17 had documented he administered peritoneal dialysis one time since the resident's admission. The record lacked in-service documentation that LPN 17 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.2. December 2025 MAR:a. RN 15 had documented she administered peritoneal dialysis 2 times during the month of December. The record lacked in-service documented that RN 15 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.b. RN 16 had documented she administered peritoneal dialysis 15 times during the month of December. The record lacked in-service documented that RN 16 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.3. January 2026 MAR:a. RN 15 had documented that she administered peritoneal dialysis 2 times during the month of January 2026. The record lacked in-service documented that RN 15 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.b. RN 16 had documented she administered peritoneal dialysis 15 times during the month of December. The record lacked in-service documented that RN 16 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.4. February 2026 MAR:a. RN 15 had documented that she administered peritoneal dialysis one time from February 1st through the 12th. The record lacked in-service documented that RN 15 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.b. RN 16 had documented that she administered peritoneal dialysis 5 times from February 1st through the 12th. The record lacked in-service documented that RN 15 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2.c. LPN 17 had documented that he administered the peritoneal dialysis one time from February 1st through the 12th. The record lacked in-service documented that LPN 17 had been trained by the dialysis center to be able to administer peritoneal dialysis to Resident 2. During a phone interview, on 2/13/26 at 9:49 a.m., a Contracted Dialysis Center Administrator indicated that only trained and qualified staff were to administer peritoneal dialysis to residents in a long-term care facility. It was the expectation that the long-term care facility would notify the dialysis center of any new resident that was admitted to their facility and required peritoneal dialysis. The facility staff had to be trained for each specific resident that was admitted to the facility. The dialysis center would be the ones who trained staff on peritoneal dialysis for each specific resident. The Contracted Dialysis Center Administrator indicated RN 15, RN 16, and LPN 17 had not been trained on peritoneal dialysis for Resident 2. She was unable to provide documentation that they had attended an in-service training on 11/18/25. During an interview, on 2/13/26 at 10:03 a.m., the Director of Nursing (DON) indicated the dialysis center usually did training once a year at the facility. The DON indicated the staff called the contracted dialysis center when a new admission came to the long-term facility and was on dialysis. She was not sure why RN 15, RN 16, and LPN 17 had not been trained, she was unable to provide documentation that they had been trained on peritoneal dialysis administration for Resident 2. On 2/13/26 at 10:07 a.m., the DON provided a document with a revised date of October 2010, titled, Peritoneal Dialysis (Continuous Ambulatory), and indicated it was the current policy being used by the facility. The policy indicated, . The purpose of this procedure is to provide continuous ambulatory peritoneal dialysis that is safe and consistent with physician orders and instructions from the contracted dialysis facility. 1. This procedure must be performed by a nurse who has been specifically trained in peritoneal dialysis procedures, complications, and infection control for dialysis. 3.1-37(a)

Based on record review and interviews, the facility failed to ensure dementia (a decline in mental ability such as memory, reasoning, and communication) residents' person-centered specific care needs were communicated to facility staff for 2 of 5 residents reviewed for dementia care (Residents 45 and 8). Findings include:1. Resident 45's record was reviewed on 2/10/26 at 2:12 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease with late onset (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks, with symptoms worsening over time) and dementia with mood disturbance (the emotional changes and behavioral shifts that occur in people with dementia, often resulting from brain damage). A quarterly Minimum Data Set (MDS) assessment, dated 1/28/26, indicated the resident had severe cognitive deficit. A care plan, dated 5/31/25 and revised on 1/16/26, indicated the resident had a diagnosis of Alzheimer's disease and severe dementia with mood disturbance. Interventions included, but were not limited to, the resident liked to reminisce using photos of family and friends. The care plan lacked any further documentation of person-centered interventions. An activity evaluation, dated 5/19/25, indicated information of a personal level about the resident's past, favorite things, and preferences. During an interview, on 2/11/26 at 9:00 a.m., the Director of Nursing (DON) indicated the Activity Director completed the personal information about the resident on the assessment at admission and would update the information periodically and as needed. The Activity Director had been working on a plan to inform the floor staff of the person-centered information for each resident. To her knowledge this had not yet been set in place. During an interview, on 2/11/26 at 9:12 a.m., Certified Nursing Assistant (CNA) 8 indicated she did not know where she could immediately access the person-centered information on the residents. She would likely just go to the nurse and ask. During an interview, on 2/11/26 at 9:17 a.m., CNA 9 indicated he learned the person-centered information from the resident or through word of mouth. He had an assignment sheet but there was not any person-centered information on the document about the resident that he was aware of. He did not know where he could look to find the information. During an interview, on 2/11/26 at 9:26 a.m., Registered Nurse (RN) 6 indicated that the person-centered information about the residents would be somewhere in the resident's electronic medical record (EMR). She was unsure where the information could be found. On 2/11/26 at 10:48 a.m., the DON provided an assignment sheet for Resident 45 which included person-centered information on the resident. At the same time, she indicated the document had just been updated on 2/11/26 to include some residents' person-centered information. During an interview, on 2/11/26 at 2:00 p.m., the DON provided an education sign-in sheet, dated 6/6/25, and indicated it was the sheet when the staff was educated on use of the Kardex (a manual or electronic, cheat sheet used by nurses to quickly reference and update a patient's key information). The sign-in sheet lacked documentation that CNA 8, CNA 9, or RN 6, had participated in the education. During an interview, on 2/11/26 at 2:50 p.m., CNA 9 indicated he had been educated on how to access the Kardex about an hour after his initial interview, earlier on this date. He could not remember any education on the use of the Kardex, prior to what he had received on this date. 2. On 2/11/26 the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), HTN (high blood pressure). A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired and was dependent upon the staff for all daily care needs. Resident 8's record lacked evidence of a specific care plan for dementia care and interventions. An activity evaluation, dated 11/10/25, and completed by the Activity Director indicated the residents likes and dislikes, personal preferences and alternate activities to help to reduce anxiety. On 2/11/26 at 9:18 a.m., during an interview the Activity Director indicated they communicate with the staff regarding alternate activities to use if the resident was having behaviors and things to do to reduce anxiety. She indicated she was updating the assignment sheet and care plans to add this information for the staff. She indicated currently the information was not written down for the staff. On 2/11/26 at 9:20 a.m., during an interview Certified Nurse Aide (CNA) 4 indicated they received information in report and record it on their CNA report sheets. She indicated there was nothing written for them to review for interventions, but they passed the information on in their reports and given to the next CNA as well. On 2/11/26 at 1:30 p.m., during an interview the Director of Nursing (DON) indicated the staff had been educated to review the Kardex for guidance on interventions for behaviors. She indicated after she discussed the concern with the survey team, they reminded the staff about reviewing the Kardex (a specialized, concise, and frequently updated nursing documentation system used to summarize essential patient information). On 2/12/26 at 9:27 a.m., the Director of Nursing provided a document titled, Dementia – Clinical Protocol, dated November 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Treatment management 1. For the individual with confirmed dementia, the IDT will identify a resident centered care plan to maximize remaining function and quality of life. 2. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors, In-services will be conducted at least annually thereafter.5.a. Resident needs will be communicated to direct care staff. through written documentation.Monitoring and follow-up.2. The IDT will adjust interventions and the overall plan depending on the individuals responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.

A. Based on observation and interview, the facility failed to maintain separation between clean and soiled cleaning mops and cleaning linens for 1 of 1 observation of the laundry room. This practice had the potential to affect 83 of 83 residents residing at the facility. B. Based on observation, interview, and record review, the facility staff failed to ensure they wore gloves during an injection administration and failed to ensure proper hand hygiene was performed during medication administration for 2 of 5 residents reviewed for medication administration (Resident 61 and 26). Findings include:A. On 2/13/26 at 2:00 p.m., during initial observation of the laundry area with the Infection Prevention (IP) nurse and the Director of Nursing (DON), observed clean mopheads and cleaning linens stored on a shelf in the soiled laundry room next to the washing machine. In addition, cleaning linen items were stored on top of a plastic crate with cans of chemicals inside of crate next to the washer. On 2/13/26 at 2:05 p.m., during an interview the IP nurse indicated she had not noticed the clean linens were within the soiled laundry area. On 2/13/26 at 2:05 p.m., the DON indicated the cleaning linens had always been stored there but they would re-wash the items and find an alternate place for them in the clean linen storage area. On 2/9/26 at 11:30 a.m., the Administrator provided a document, titled, Surveillance for infections a revision date of July 2017, and indicated it was the infection control policy currently being used by the facility. The policy indicated, .3. Infections that will be included in routine surveillance include those with, a. Evidence of transmissibility in healthcare environment.9. If transmission based precautions or other preventive measures are implemented to slow or stop the spread of infection. B. During the medication administration pass the following was observed: 1. On 2/11/26 at 8:59 a.m., Registered Nurse (RN) 6 prepared insulin for Resident 61. She entered the resident's room with the insulin pen, needle, oral medications, and medication (med) pass drink (fortified nutrition shake is a calorie and protein dense beverage). RN 6 administered the resident's insulin without wearing gloves into the resident's right upper arm. She then handed the resident his oral pills in a medicine cup and the med pass drink to aid in swallowing the medications. No hand hygiene was performed before or after leaving the resident's room. 2. On 2/11/26 at 9:09 a.m., RN 6 prepared medication at the medication cart for Resident 26. She entered Resident 26's room with 9 oral pills to administer. Resident 26 swallowed the medication and RN 6 did not perform hand hygiene before or after the medication administration. During an interview, on 2/11/26 at 9:24 a.m., RN 7 indicated staff should wear gloves when administering an insulin injection. She further indicated staff should perform hand hygiene in between residents when administering their medications to them. During an interview, on 2/11/26 at 9:29 am., the Director of Nursing (DON) indicated staff should wear gloves when administering insulin injections and should use hand sanitizer in between residents during medication administration pass. On 2/11/26 at 10:49 a.m., the DON provided a document with a revised date of April 2019, titled, Administering Medications, and indicated it was the current policy being used by the facility. The policy indicated, .25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 2/11/26 at 1:30 p.m., the DON provided a document with a revised date of April 2019, titled, Insulin Administration, and indicated it was the current policy being used by the facility. The policy indicated, .17. Wash hands. [NAME] clean gloves.23. Remove gloves, Wash hands. 3.1-18(b)

Based on observations, interviews, and record reviews, the facility failed to ensure residents were addressed in a dignified manner and the facility failed to ensure a resident was assisted during meal service in a dignified manner for 2 of 3 dining observations. (Residents 56 and 31). Findings include: 1. During the lunch meal observation in the activity dining room, on 12/12/24 at 12:41 p.m., Resident 56 was sitting at a table eating her lunch when CNA 5 addressed the resident as Honey. CNA 5 stated from the opposite table, Honey use your silverware to Resident 56. Resident 56's record was reviewed, on 12/16/24 at 1:48 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified dementia, severe, with anxiety (a person who is experiencing a significant level of cognitive decline where the exact type of dementia is not known, and alongside this cognitive impairment, they are also exhibiting symptoms of anxiety) and cerebral infarction affecting right dominant side (a stroke (cerebral infarction) has occurred in the right hemisphere of the brain, which is considered the dominant side for most people causing symptoms like weakness or paralysis on the left side of the body. A quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, indicated the resident had severe cognitive impairment and was independent with eating. A care plan, dated 5/15/24, indicated the resident had personal preferences in regards to her care based on her personal preferences assessment. Interventions included, but were not limited to, call me by my first name. The record lacked a care plan indicating resident preferred to be called, Honey. 2. During the lunch meal observation on the rehab unit, on 12/16/24 at 1:17 p.m., CNA 5 was standing up next to Resident 31 assisting her with lunch meal. CNA 5 continued to assist with feeding the resident while standing next her. CNA 5 addressed Resident 31 as Honey. She asked Resident 31, How are you doing Honey? She proceeded to feed the resident and asked, Sweet girl, are you hungry? Resident 31's record was reviewed, on 12/16/24 at 2:01 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified dementia (a person who is experiencing a significant level of cognitive decline where the exact type of dementia is not known) and syndromes with complex partial seizures (most common type of seizures in adults, they can last between 30 seconds and 2 minutes). The record lacked a care plan indicating resident preferred to be called, Honey or Sweet girl. An annual Minimum Data Set (MDS) assessment, dated 10/1/24, indicated the resident had severe cognitive impairment and was a maximum assist with eating. During an interview, on 12/16/24 at 1:27 p.m., the Director of Nursing (DON) indicated staff should not stand up next to a resident to assist with feeding. The staff should sit next to the resident while assisting with a meal. She further indicated staff should address residents by their preferred name. She would do some training with staff on making sure to address residents by their preferred name and in a dignified manner. On 12/16/24 at 1:53 p.m., the Administrator provided a document with a revised date of July 2017, titled, Assistance with Meals, and indicated it was the policy currently being used by the facility. The policy indicated, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .3. Residents who cannot feel themselves will be fed with attention to safety, comfort, dignity, for example: a. Not standing over residents' while assisting them with meals On 12/16/24 at 1:53 p.m., the Administrator provided a document with a revised date of January 2019, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included resident's right to: a. a dignified existence b. be treated with respect, kindness, and dignity 3.1-3(a)

Based on interview and record review, the facility failed to monitor a resident's weight as ordered for 1 of 4 reviewed for nutrition (Resident 59). Finding includes: During an interview, on 12/12/24 at 11:14 a.m., Resident 59 indicated he had some weight loss when he first came to the facility, but he thought his weight had stabilized now. Resident 59's record was reviewed on 12/17/24 at 10:18 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic kidney disease, stage 3 (a person has moderate damage to their kidneys where they are not filtering waste effectively, resulting in mild to moderate loss of kidney function), prediabetes (you have a higher-than-normal blood sugar), and repeated falls. An admission Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively intact and had an admission weight of 210 pounds. A care plan, dated 11/20/24, indicated the resident was at risk for nutritional deficits related to chronic kidney disease stage 3 and prediabetes. Interventions included, but were not limited to, weights as directed and observe and report to MD (medical doctor) for signs and symptoms of malnutrition. A physician order, dated 11/20/24, to obtain a weight daily for 3 days then weekly times 4 weeks. Review of Resident 59's weights in the electronic health record indicated the following: a. dated 11/20/24 at 2:44 p.m. - 208.5 pounds and documentation was struck out in error on 11/25/24 by nurse. b. dated 11/20/24 at 2:51 p.m. - 210 pounds and documentation was struck out in error on 11/25/25 by nurse. c. dated 11/25/24 at 11:55 a.m. - 197 pounds d. dated 12/4/24 at 12:36 p.m. - 201.6 pounds e. dated 12/11/24 at 4:28 p.m. - 196 pounds f. dated 12/16/24 at 1:50 p.m. - 199 pounds The record lacked documentation of a weight being obtained until 11/25/24. Review of an admission evaluation, dated 11/19/24 at 5:37 p.m., the record lacked documentation of a weight for Resident 59 was recorded. Review of Treatment Administration Record (TAR) for November 2024 lacked documentation of a daily weight being completed on 11/21/24 and 11/22/24. The record lacked documentation of a resident's refusal to obtain his weight. Review of a care plan note, dated 11/25/24 at 12:23 p.m., indicated Resident's current weight was 210 pounds and on a regular diet. During an interview, on 12/17/24 at 11:54 a.m., the Director of Nursing (DON) indicated she could not find where Resident 59 had daily weights completed per the physician order in his electronic health record. Daily weights for 3 days and the weekly for 4 weeks was a standard order that would be placed in the electronic health record for new admissions. Review of a paper report sheet, dated 11/19/24, was provided by the DON and indicated it had a weight of 198.7 pounds for Resident 59. The DON indicated the weight was not placed in the electronic health record at the time of admission by the nurse and the DON placed it in the record on 12/17/24. On 12/17/24 at 12:57 p.m., the Administrator provided a document with a revised date of March 2019, titled, Weight Assessment and Intervention, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The nursing staff will measure weight on admission .2. Weights will be recorded in each individual's medical record .3. If a resident declines to participate in a weight loss goal or weights being obtained, the resident's wishes will be documented, and those wishes will be respected 3.1-37

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a thin, flexible tube that is inserted into the bladder through the urethra to drain urine), drainage bag and tubing were maintained in a manner to prevent contact with the floor for 1 of 2 residents reviewed for urinary catheters (Resident 1). Findings include: During the initial pool observation, on 12/13/24 at 8:50 a.m., Resident 1 was observed in her bed and the bed was in the low position. Her indwelling urinary catheter drainage bag (catheter bag) was observed in contact with the floor. At the same time, the catheter's tubing was observed sitting on the electrical cord for the resident's oxygen concentrator (a medical device that supplies oxygen-enriched air by removing nitrogen from the air around the patient). The electrical cord was observed in contact with the floor. During a random observation, on 12/13/24 at 3:10 p.m., the resident was observed in her bed. The bed was observed in the low position. The resident's catheter bag was observed to be in contact with the floor. During a random observation, on 12/16/24 at 1:10 p.m., the resident was observed in her bed in the hallway outside of her room due to a temporary power outage. Her bed was in the low position. The resident's catheter bag was observed to be in contact with the floor. During a random observation, on 12/16/24 at 1:53 p.m., the resident was observed in her bed which had been moved back into her room. Her bed was in the low position. The resident's catheter bag was observed to be in contact with the floor. Resident 1's record was reviewed on 12/16/24 at 2:10 p.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 3 chronic kidney disease (mild to moderate damage to the kidneys where they are less able to filter waste and fluid out of the blood), stage 4 pressure ulcer to sacral region (a very severe wound on the skin over the tailbone area where the damage extends through all layers of skin, potentially exposing muscle, bone, and tendons), and muscle wasting an atrophy (the loss of muscle tissue and strength). A significant change Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the resident had severe cognitive deficit, had an indwelling urinary catheter, and received hospice services. A care plan, dated 10/17/24, indicated the resident had a Foley (brand name) catheter related to wounds. The interventions lacked documentation of monitoring the catheter bag or tubing from coming in contact with the floor. A physician's order, dated 10/17/24, indicated that the resident have a 16 French (Fr) (size of a catheter described in French units) catheter. A physician's order, dated 10/17/24, indicated for staff to perform catheter care (a set of practices that help prevent infection and maintain the health of a catheter and the surrounding area) every shift two times a day. During an interview, on 12/16/24 at 2:41 p.m., the Director of Nursing (DON) indicated the resident's catheter bag was likely in contact with the floor due to her bed being in the low position. Catheter bags and tubing should never come in contact with the floor. On 12/16/24 at 3:01 p.m., the Administrator (ADM) provided a document, with a revised date of September 2014, titled, Catheter Care, Urinary, and indicated it was the policy currently being used by the facility. The policy indicated, .Infection Control .2.b. Be sure catheter tubing and drainage bag are kept off the floor 3.1-41(a)(2)

Based on observation, record review and interview the facility failed to assess a resident's condition for complications before and after hemodialysis treatments (a procedure that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) which were received at a certified dialysis facility for 1 of 2 residents reviewed for dialysis (Resident 49). Findings include: On 12/12/24 at 11:34 a.m., during observation and interview, Resident 49 indicated when she received hemodialysis on Monday, Wednesday, and Friday. The staff did not check the access site (also known as vascular access, a surgically created opening in the body that allows a patient to receive hemodialysis) in her left arm after returning from dialysis treatment. She indicated when she returned yesterday 12/11/24, the access site bled and soaked through the bandage on her arm. She indicated she changed the bandage using the supplies she had in her room. On 12/13/24 at 3:30 p.m., during observation after the resident returned from dialysis. A dressing was covering the left forearm dialysis access site. The resident indicated the nurse had not checked the dressing for bleeding since returning earlier. On 12/16/24 at 9:23 a.m., reviewed the medical record of Resident 49. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to sustain life), dependence on renal dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease (a disease that occurs when your blood glucose, also called blood sugar, is too high). A Physician order, dated 4/13/24, indicated the resident was to have dialysis - FYI (for your information) - Dialysis Treatments 3 X (times) week at 10 a.m. A care plan, dated 4/14/24, indicated Resident 49 had a diagnosis of end stage renal disease and was at risk for complications with dialysis treatment. Interventions included but were not limited to, go to dialysis 3 days a week, to administer medications as ordered, to observe for pain at site, and to notify physician if pain is present. The record lacked a care plan for access site observation for bleeding, swelling or abnormalities. A Physician order, dated 4/15/24, indicated staff were to check access site for bruit (a whooshing or swooshing sound that can be heard near the access site with a stethoscope) and thrill (a vibration or buzzing sensation that can be felt by placing your fingers just above the incision line) daily on return shift. Staff were to document Y (yes) if monitored and N (no) if thrill or bruit were absent. Staff were to select chart code Other/See Nurses Notes and record findings if N (no) was selected and document abnormalities. A Physician order, dated 4/15/24, indicated staff were to assess vitals (blood pressure, pulse, respiration, temperature) on return from dialysis every Monday, Wednesday, and Friday. Task was scheduled to be completed on return from dialysis-on-dialysis days. A quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was cognitively intact. On 12/13/24 at 3:20 p.m., during interview with Licensed Practical Nurse (LPN) 8, she indicated the nurse checked the access site each shift after administration of dialysis. On 12/13/24 at 3:40 p.m., during an interview, the Director of Nursing indicated the nurse should assess the resident after the dialysis resident returned from dialysis to ensure the site was not bleeding. The DON acknowledged an order to check for bleeding at the access site had not been obtained from the physician prior to interview. A Physician order, dated 12/13/24, indicated twice a day staff were to check dialysis access site for bleeding every shift, and notify MD (medical doctor) if symptoms. On 12/16/2024 at 10:40 a.m., the Director of Nursing provided a document, titled, Dialysis dated 11/28/2016, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Based on comprehensive assessment of a patient, the facility must ensure that patient(s) who require dialysis receive such services, consistent with professional standards of proactive .Post Dialysis .5. Monitor shunt site on a routine basis. Notify physician if any unusual problems are noted with shunt site (tenderness, bleeding) .General guidelines .4. Monitor for any complaints or observations at vascular access site 3.1-37(a)

Based on record review and interview, the facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications (Resident 30). Findings include: Resident 30's record was reviewed on 12/16/24 at 9:36 a.m. The profile indicated the resident's diagnoses included, but were not limited to, alcoholic cirrhosis of the liver with ascities (a condition where the liver is damaged by chronic alcohol consumption and has a buildup of fluid in the abdomen), visual hallucinations (seeing things that are not there), other chorea (a movement disorder that causes involuntary, rapid, and irregular muscle contractions that affect the face, arms, legs, and trunk), anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and uneasiness that interfere with daily life), major depressive disorder (a mental health condition that can cause a persistent feeling of sadness, hopelessness, and a lack of interest in activities), and irregular muscle contractions that affect the face, arms, legs, and trunk. A quarterly Minimum Data Set (MDS) assessment, dated 9/9/24, indicated the resident had no cognitive deficit and no documented behaviors. A care plan, with a revision date of 3/20/24, indicated the resident was at risk for ineffective coping related to a significant traumatic event. The resident was counseling a patient who committed murder. Interventions included, but were not limited to, administer medications as ordered and collaborate care with medical and psychiatric service providers as needed. A care plan, dated 2/4/20, indicated the resident was at risk for emotional and physical distress related to a history of physical, emotional, and mental abuse. The resident reported her former spouse threatened her with a gun. Interventions included, but were not limited to, administer medications as ordered and collaborate care with medical and psychiatric service providers as needed. A physician's order, dated 1/18/21, indicated to monitor behaviors of depression and tearfulness and document the number of episodes, interventions, and outcomes, every shift and as needed. A physician's order, dated 1/18/21, indicated to monitor behaviors of insomnia and document the number of episodes, interventions, and outcomes, every shift and as needed. A physician's order, dated 1/18/21, indicated to monitor behaviors of visual hallucinations and document the number of episodes, interventions, and outcomes, every shift and as needed. A Pharmacy recommendation, dated 2/28/24, indicated to evaluate the resident's medications of Cymbalta (antidepressant medication) 90 milligrams (mg) daily and Risperdal (antipsychotic medication) 0.5 mg at bedtime, for symptoms the depression, pain, and hallucinations, and consider dose reductions. The facility's behavior committee reported the resident was still symptomatic and recommended a dose reduction of the medications be contraindicated. The physician agreed with the behavior committee's recommendation and documented that no dose reduction should be completed. Review of the resident's February 2024 Treatment Administration Record (TAR) and progress notes lacked documentation that the resident had exhibited any behavioral symptoms during the month. A Pharmacy recommendation, dated 5/29/24, indicated to evaluate the resident's medication of Ativan (antianxiety medication) 0.5 mg two times daily for anxiety. The physician indicated to continue the therapy as ordered and documented that the resident continued to be symptomatic. Review of the resident's May 2024 TAR, and progress notes lacked documentation that the resident had exhibited any behavioral symptoms during the month. A Pharmacy recommendation, dated 8/26/24, indicated to evaluate the resident's medication of Cymbalta 90 mg daily for depression and pain. The facility's behavior committee reported the resident was still symptomatic and recommended a dose reduction not be completed at that time. The physician agreed with the behavior committee's recommendation and drew an arrow which pointed to the statement of the behavior committee's recommendation and documented the continued same-symptomatic. Review of the resident's August 2024 TAR lacked documentation that the resident had exhibited any behavioral symptoms during the month. The progress notes for August 2024, indicated the resident was stable and lacked documentation of any behaviors during the month. During an interview, on 12/16/24 at 2:07 p.m., the Director of Nursing (DON) indicated the physician made his decision regarding dose reductions based upon the recommendation from the behavior committee. The behavior committee received their information about the resident's behaviors by talking with the nurses. The nurses did need more education on completing the TAR resident's exhibit behaviors. During an interview, on 12/17/24 at 9:20 a.m., the Social Services Director (SSD) indicated she felt the reason that the behaviors were not being documented in the TAR was related to how the new system allowed for documentation by the Certified Nursing Assistants (CNAs). Under the old company's system, the CNAs should directly document behaviors into their Point of Care (POC) system, and it went to the TAR. The new system no longer allowed for that to happen. The nurses were the only ones who were able to document on the TARs. The nurses were laxed in documentation of behaviors. On 12/17/24 at 2:43 p.m., the DON provided a document, with a revision date of September 2022, titled, Behavioral Assessment, Intervention, and Monitoring, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .Assessment .3. The nursing staff will identify, document, and inform .about specific details regarding changes in an individual's .behavior .4. New onset or changes in behavior will be documented .Monitoring: 1 .the IDT (interdisciplinary team) will .document .improvements or worsening in the individual's behavior 3.1-43(a)(1)

Based on observation and record review, the facility failed to ensure a medication error rate of less than 5 percent with an error rate of 21.43 percent for 3 of 4 residents reviewed for medication administration (Residents 169, 14 and 26). Findings include: 1. On 12/17/24 at 7:45 a.m., observed Registered Nurse (RN) 15, prepare and administer medications to Resident (169). Ferrous Sulfate 1 tablet and Klor-Con 1 tablet were removed from medication card and crushed. Medications were then administered to the resident in applesauce. On 12/17/24 at 9:30 a.m., the medical records of Resident 169 were reviewed. The resident was admitted with diagnosis including but not limited to anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and hypokalemia (a condition where the level of potassium in your blood is lower than normal). Physician orders included but not limited to administer 1 tablet ferrous sulfate EC (enteric coated) (tablets or capsules with a coating that prevents the medication from dissolving in the stomach and instead allows it to pass into the small intestine, where it can be absorbed) 325 mg (milligrams) administer by mouth once daily for anemia, and administer 1 tablet Klor-Con 20 meq (milliequivalent) administer by mouth once daily for hypokalemia. On 12/17/24, the Director of Nursing (DON) provided a document titled, oral dosage forms that should not be crushed. The list included medications that were enteric coated (EC) and Klor-Con a slow-release medication (medications that release a consistent amount of the drug over a longer period of time). 2. On 12/17/24 at 8:05 a.m., observed Registered Nurse (RN) 15 prepare and administer medications to Resident (14). Ferrous sulfate 1 tablet and Myrbetriq ER 1 tablet were removed from medication card and crushed. Medications were then administered to the resident in applesauce. On 12/17/24 at 10:00 a.m., the medical record of Resident 14 was reviewed. The resident was admitted with diagnosis including but not limited to, anemia, benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal). Physician orders included but were not limited to an order, dated 2/2/24, for 1 tablet ferrous sulfate EC (enteric coated) 325 mg to be administered by mouth once a day for anemia. A physician order, dated 2/2/24, for 1 tablet Myrbetriq ER (extended release) to be administered by mouth once a day for overactive bladder. On 12/17/24, the Director of Nursing (DON) provided a document titled, oral dosage forms that should not be crushed. The list included medications that were enteric coated (EC) and Klor-Con a slow-release medication (medications that release a consistent amount of the drug over a longer period of time). The medications Myrbetriq (mirabegron) and Ferrous sulfate were listed as slow-release medication on the do not crush document. 3. On 12/17/24 at 9:00 a.m., observed Registered Nurse (RN) 17 prepare and administer Basaglar insulin and Admelog SoloStar insulin to Resident (26). RN 7 adjusted the insulin pens to the prescribed dose to be administered to the resident. The RN did not prime the insulin administration pen according to manufacture guidelines. Priming the pen ensures all of the prescribed insulin was administered to the resident by removing the air space within the needle. The RN went into the resident's room, left the door open and did not pull the curtain to provide privacy to the resident. The RN advised the resident that she was going to administer the insulin in his abdomen. The RN administered the insulin and counted to ten during administration of insulin, and immediately removed the insulin needle. On 12/17/24 at 10:30 a.m., the medical record of Resident 26 was reviewed. The resident was admitted with diagnosis including but not limited to Type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A Physician orders included but were not limited to. An order, dated 7/7/24, for Basaglar insulin 100 unit/ml (milliliter) 40 units subcutaneously (under the skin) two times a day for type 2 diabetes. A Physician order, dated 11/19/24, Admelog SoloStar insulin 100 unit/ml. Administer as per sliding scale (a type of insulin prescription that adjusts the amount of insulin a person takes based on their blood sugar level) before meals. On 12/17/24 at 9:05 a.m., during interview, RN 17 indicated she did not know if the insulin pen should be primed before administration, and indicated she counted to ten while administering the insulin. She acknowledged she should have closed the door when she administered insulin to the resident. On 12/17/2024 at 1:57 p.m., the Director of Nursing (DON) provided a document, titled, SOP-Insulin Preparation and Administration, dated 5/20/20, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Procedure .h. Procedure for insulin pen .v. Attach need to the pen .vii. Remove air from insulin pen .1. Turn the dial to 2 units .3. Gently tap pen to remove air bubbles .viii .Press the inject button .Select the correct dose of insulin on the pen by turning the dial to the number of units you need to inject .3. Insulin Administration Procedure .b. provide privacy .i. Close doors, curtains and or room curtains as needed .j. insert needle .k. push plunger with thumb at a moderate steady pace until insulin is completely administered, approximately 5-10 seconds 3.1-48(c)(1)

Based on observations, interviews, and record reviews, the facility failed to ensure medication were labeled properly for 3 of 4 medication carts reviewed for medication storage (Residents 58, 26, and 2). Findings include: On 12/17/25 at 8:00 a.m., medication storage cart A was observed. Tresiba Insulin pen prescribed for Resident 2. Pharmacy dispensed date was 11/14/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 8:20 a.m., medication storage cart 1 was observed. Lantus Insulin pen prescribed for Resident 58. Pharmacy dispensed date was 11/19/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 9:00 a.m., medication storage cart B was observed. Basaglar Insulin pen prescribed for Resident 26. Pharmacy dispensed date was 11/28/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 8:05 a.m., during interview Registered Nurse (RN) 15 indicated insulin pens should be dated when opened and an expiration date added to label. On 12/17/24 at 9:05 a.m., during interview Qualified Medication Aide (QMA) 18 indicated insulin pens should be dated when opened and an expiration date added. On 12/17/24 at 9:08 a.m., during interview RN 17 indicated insulin pens must be dated when opened, if no date was on the pen or if in doubt the pen was thrown out. On 12/17/24 at 9:30 a.m., the medical record of Resident 58 was reviewed. The resident was admitted to the facility with diagnosis including but not limited to, Type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and acute kidney failure (a condition where the kidneys suddenly stop working properly). A Physician Order, dated 12/12/24, for Lantus SoloStar insulin 100 units/ml (milliliter), iInject 10 units subcutaneous (under the skin) daily for diabetes. On 12/17/24 at 9:40 a.m., the medical record of Resident 26 was reviewed. The resident was admitted with diagnosis including but not limited to, Type 2 diabetes, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). A Physician order, dated 7/7/24, for Basaglar insulin 100 units/ml inject 40 units subcutaneous (under the skin) daily for diabetes. On 12/17/24 at 10:00 a.m., the medical record of Resident 2 was reviewed. The resident was admitted with diagnosis including but not limited to, type 2 diabetes, and chronic kidney disease (the kidneys are damaged and can't filter blood the way they should). A Physician order, dated 10/15/24, for Tresiba flex touch insulin solution 100units/ml, inject 15 units subcutaneous daily for type 2 diabetes. On 12/17/2024 at 1:57 p.m., the Director of Nursing (DON) provided a document, titled, Specific Procedures for all Medications, dated 5/20/20, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .5. Check expiration date on package/container. When opening a multidose container, place the date on the container, place the date on the container 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on interview, observation and record review, the facility failed to honor food preferences of 1 of 1 resident reviewed for dietary preferences (Resident 49) Findings include: On 12/12/24 at 11:25 a.m., during observation and interview, Resident 49 indicated she had asked several times not to be served vegetables and the facility continued to put them on her plate. On 12/12/24 at 12:27 p.m., observation of the dietary tray slip of Resident 49 indicated the dietary slip food dislikes did not indicate the resident did not want vegetables. On 12/16/24 at 9:00 a.m., the medical record of Resident 49 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life, dependence on renal dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys can no longer perform this function), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (the kidneys are damaged and can't filter blood the way they should). A Physician order, dated 4/15/24, ordered a CCHO (controlled carbohydrate) diet, regular texture, thin (liquids) consistency. Only one serving of dairy daily, no oatmeal or sausage no more OJ (orange juice) no more juices until CA (calcium) levels lower, no pudding, cottage cheese, no milk products, limit amount of breads, pizza, cereal, crackers. A quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was cognitively intact. A care plan, dated 4/14/24, indicated the resident was at nutritional risk. Interventions included but were not limited to RD (Registered Dietitian) to evaluate and make diet change recommendations as needed, and to provide Diet: CCHO regular texture, thin consistency, 1800 ml (milliliters) fluid restriction. Review of activity preference form, dated 4/16/24, which was completed on admission the record did not indicate any dietary preferences. On 12/12/24 at 12:25 p.m., during an interview, Employee 7 indicated the residents choose from a menu each day and decide what they want to eat. If they do not want what was served they could get the substitute. She indicated the activities department staff asked the residents their preferences and recorded it on the diet menu selection forms. On 12/16/24 at 11:01 a.m., during an interview, Employee 6 indicated she asked the residents daily if they wanted what was on the menu. She recorded choices and turned it into dietary department. She indicated the preferences were then recorded on the diet slip and indicated Resident 49 had told her previously she did not like vegetables. On 12/16/24 at 11:08 a.m., during an interview the Administrator indicated she updated the dietary tray slip all the time. She provided a copy of the current dietary tray slip for Resident 49 and indicated the resident did not like cooked vegetables and it was on the updated dietary slip. On 12/16/2024 at 2:45 p.m., the Administrator provided a document, titled, Resident Food Preferences , dated 7/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .Individual food preferences will be assessed upon admission and updated as needed. Reaseonable efforts will be made to accommodate resident choices and preferences .2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes 3.1-20(c)(7)

Based on observation, interview, and record review, the facility failed to ensure undated and expired foods were disposed of for 1 of 2 kitchen observations. Findings include: During a food storage observation with [NAME] 3 on [DATE] at 9:50 a.m., the walk in refrigerator contained a clear plastic container with a lid that had corn, the corn was dated [DATE]. There was a clear plastic bag of lettuce with a delivery dated [DATE], the lettuce was brown and wilted inside the bag. Three cucumbers were found on a shelf in an open and undated plastic bag. During an interview, on [DATE] at 9:52 a.m., [NAME] 3 indicated food was good for 3 days once it was opened and placed in a new container. She indicated the corn should have been disposed of by now and the lettuce was no longer good because it was delivered in October and was brown and wilted. She was unsure why they hadn't been disposed of them by now because she was not the person responsible for that. [NAME] 3 indicated food should be labeled once it was delivered to the facility and she had no idea when the cucumbers were delivered and how long they were in the walk-in refrigerator. The cucumbers would have to be disposed of since they were not labeled properly. On [DATE] at 10:30 a.m., the Administrator provided an undated document, titled, Keeping Food Safe for the Residents in Cloverleaf Facility, and indicated it was the policy currently being used by the facility. The policy indicated, .8. When to Discard Food .c. Food is over 72 hours old. d. If there is no identification or date on the item On [DATE] at 12:57 p.m., the Administrator provided a document with a revised date of [DATE], titled, Food Receiving and Storage, and indicated it was the policy currently being used by the facility. The policy indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) 3XXX,d+[DATE](i)(3)

Based on record review and interview, the facility failed to follow the antibiotic stewardship protocol program for 1 of 5 residents reviewed for antibiotics (Resident 46). Findings include: On 12/17/24 11:14 a.m., the medical record of Resident 46 was reviewed. The resident was admitted to the facility with diagnosis of, but not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), urinary retention (a medical condition that occurs when a person is unable to empty their bladder or has difficulty starting or maintaining a steady urine flow), and history of recurrent urinary tract infections (bacteria in the urine, resulting in an infection). A Physician order, dated 8/31/24, indicated to administer one capsule of Ampicillin 500 mg (milligram) via (by way of) G-tube (a tube that is surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine) daily for prophylactic (something that prevents or protects). A quarterly Minimum Data Set (MDS) assessment, dated 11/11/24, indicated the resident had a cognition deficit, required max assistance of two persons, received nutrition and medications through gastric tube and was currently on an antibiotic. A care plan, dated 11/11/24, indicated the resident was on antibiotic therapy related to recurrent urinary tract infections. Interventions included but not limited to, collect labs as ordered and report results to physician, administer medications as ordered, and notify physician of any change or worsening of condition. The medical record indicated the resident had been on an antibiotic since previous admission. Documentation lacked evidence of physician assessment to determine the need for prophylactic long-term use of an antibiotic. Documentation lacked evidence of physician education or education being provided to the responsible party regarding long term use of antibiotics. On 12/17/24 at 2:00 p.m., during an interview, the Director of Nurses (DON) indicated the resident was on antibiotic therapy for history of chronic urinary tract infections. She indicated the resident was admitted with the antibiotic and diagnosis of VRE (Vancomycin-Resistant Enterococci, is a type of bacteria that has become resistant to many antibiotics, including vancomycin) and indicated the antibiotic had been administered for some time at the previous facility the resident resided in. She indicated the resident had multiple urinalysis (analysis of urine by microscopical means to test for the presence of disease) and culture (a lab test that checks for bacteria or other microorganisms in urine to help diagnose a urinary tract infection (UTI) of the urine) while at the other facility. A urinalysis and culture were completed at the facility upon admission and no additional testing had been repeated. On 12/18/24 at 1:00 p.m., during review of the antibiotic stewardship program with the DON and Infection Prevention Nurse, both indicated the facility utilized the McGeer's criteria surveillance tools for infections in the long-term care facility. On 12/18/24 at 2:30 p.m., during interview with the Medical Director and the DON. The Medical Director indicated the resident was on long term antibiotics because the family wanted her to be on an antibiotic due to previous history of urinary tract infections. The Medical Director acknowledged the resident was probably resistant to penicillin, (resistance occurs when bacteria develop the ability to withstand the effects of antibiotics), since she had VRE when she was admitted . He indicated at the time of admission the bacteria causing the infection was sensitive to the antibiotic. (Sensitivity occurs when a bacterial pathogen is inhibited or not inhibited by exposure to certain antibiotics). The Medical Director indicated he would be discontinuing the medication and trying alternate non-antibiotic measures to prevent re-occurrence of infection. On 12/11/2024 at 11:00 a.m., the Administrator provided a document titled, Antibiotic Stewardship, dated July 20, 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents .4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements .d. Duration of treatment; 1. Start and Stop Date, or 2. Number of days of therapy The Centers for Disease Control and Prevention (CDC) webpage, The Core Elements of Antibiotic Stewardship, accessed online at: https://www.cdc.gov/antibiotic-use/hcp/core-elements, indicated, . Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance

A. Based on observation, interview, and record review, the facility failed to ensure an adequate infection control program was implemented to track the COVID-19 positive and potentially exposed residents which had the potential to effect 68 of 68 residents that reside in the facility. B. Based on observation, interview, and record review, the facility failed to follow infection control precautions, COVID-19 testing protocols, and ensure tracking for a COVID-19 outbreak for 68 of 68 residents reviewed for infection control. Findings include: A. On 11/2/23 at 9:01 a.m., the Infection Prevention Nurse (IP) indicated she was tracking for end dates to remove COVID-19 positive residents from the droplet isolation rooms. Residents would be in isolation for 10 days. She indicated she was given a new policy on 11/1/23 for droplet isolation end dates. Residents who had been exposed to COVID 19, would be in isolation for 10 days as well. The residents would be returning to their rooms once the 10 days of isolation was ended. If the resident was symptomatic after 10 days, they would stay on the designated COVID-19 unit. She was unable to identify or provide the exact number of COVID-19 positive residents at the facility. She would need to obtain the information. The staff were to report when they exhibit symptoms of COVID to a member of the management team. Once she received the notification, she had staff come to the facility and met the employee outside of the building to be tested . If it was after hours a nurse on the A unit would test the staff. She posted notification signs on the entry door. The notification signs indicated the facility was in an outbreak and should not come into the building if they were exhibiting symptoms. They were not assessing residents for COVID-19 symptoms unless they tested positive for COVID-19. She indicated if she was working on a unit, she would assess any resident who had symptoms such as cough, shortness of breath, fever. The IP nurse was testing the residents every 7 days, testing and testing results were in the medication administration record (MAR), in the tracking log, and or in the nurse's progress notes. Staff must clean all reusable equipment between resident use. If reusable equipment was used within an isolation room, the equipment must be disinfected immediately after it was removed from the isolation room. On 11/3/23 at 9:00 a.m., the IP nurse provided two documents titled, WEST Outbreak testing, dated 10/25/23 and Station A outbreak testing day 7, dated 11/1/23. The document identified each resident by name and room number. The IP nurse indicated this was what she used for outbreak tracking and testing. On 11/3/23 at 9:00 a.m., the IP nurse provided a document and indicated it was a tracking log for employees. The log had employee names with collection date, collection time, run time, result, applicator/cartridge lot #, testing employee's name and testing employee signature. Collection dates were from 9/19/23 to 11/1/23. On 11/3/23 at 9:00 a.m., the IP nurse indicated on 10/25/23, the Director of Nursing talked with the corporate office and a decision was made to do an isolation unit instead of just isolating residents in their rooms. Residents who tested COVID positive were moved to the C unit. The IP nurse indicated the first 3 residents were positive on 10/24/23, on 10/25/23, the facility had an overabundance of residents testing positive for COVID. The Medical Director advised he only wanted those residents tested who were symptomatic and she indicated the Medical Director was aware of what the facility policy indicated. On 11/3/23 at 11:27 a.m., the IP nurse provided a copy of the daily nursing schedule and indicated the employees who were highlighted in green were tested on the date they worked at the facility and had tested positive for COVID. On 11/2/23 at 9:05 a.m., a.m., the Administrator provided a document, titled, Coronavirus Disease (COVID-19)-Testing Residents dated, May 2023, and indicated it was the policy currently being used by the facility. The policy indicated, Testing Asymptomatic Residents .a. A symptomatic resident with close contact with someone with SARS0CoV-2 infection should have a series of three viral tests for SARSn-CoV-2 infection .b. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 .Testing is not generally recommended for asymptomatic people who have recovered from [NAME]-CoV-2 infection in the prior 30 days .Testing residents with Signs or Symptoms of COVID-19 .1. Any resident (regardless of vaccination status) with even mild symptoms of COVID-19 receives a viral test as soon as possible .a. Because it may be difficult to tell the difference between influenza, COVID-19, and other acute respiratory infections based on symptoms alone, testing for pathogens other than SARS-CoV-2 may be conducted based on recommendations from the infection preventionist and providers .Additional Measures During Outbreak Investigation .1. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration is given to use of empiric (observation) use of transmission-based precautions for residents and work restriction of staff with higher-risk exposures .3. As part of the broad-based approach, testing will continue on affected unit(s) of facility-wide every 3-7 days until there are no new cases for 14 days .Documentation .1. For symptomatic resident testing, the following is documented .a. The date and time the symptoms were identified .b, the date and time the test was conducted .c. the date and time the results were obtained and .d. actions taken by the facility .2. For facility outbreak testing, the following is documented .a. the date the case was identified .b. the dates that all other residents were tested .c. the dates that residents who tested negative were retested and .d. the results of all tests The facility documentation lacked evidence of empiric (observation) of all residents with respiratory symptoms. On 11/2/23 at 9:05 a.m., the Administrator provided a document, titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures dated, June 2023, and indicated it was the policy currently being used by the facility. The policy indicated, Policy interpretation and Implementation .c. identifying and managing ill residents and staff .e. a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria .(1) A positive viral test for SARS-CoV-2 .(2) Symptoms of COVID-19 or .(3) close contact with someone with SARS-CoV2 infection (for residents and visitors) or a higher risk exposure (for healthcare personnel [HCP]) .f. implementing source control measures .respiratory assessment of Covid-19 positive residents .following current environmental infection prevention and control recommendations CDC Viral Respiratory Pathogens Toolkit for Nursing Homes, Last Reviewed September 28, 2023, indicated, Continue active surveillance to identify others with respiratory viral illness (e.g., daily or every shift review of symptoms among residents and HCP) and manage people who were exposed or infected (e.g., use of source control, work restriction for HCP, use of Transmission-based Precautions). B1. On 11/2/23 at 9:27 a.m., the IP nurse provided a document titled, All Staff PPE Refresher Oct.19, 2023. The document indicated to please read and sign on signature sheet at back of in-service. The document contained information for glove use, wearing masks and gowns. The untitled and undated signature page contained 62 signatures. On 11/3/23 at 9:00 a.m., the IP nurse provided a document titled, Hand Hygiene Inservice-online. The instructions to the staff indicated .to read, sign signature sheet and follow directions on attached sheet. Print out the last page of online which shows you completed it, sign and date that copy and turn in. The untitled and undated signature sheet indicated; 8 employee's signatures. The IP nurse indicated she had not completed a handwashing competency with any of the staff at the time of the training or since the facility had been in outbreak. On 11/3/23 at 9:00 a.m., the IP nurse indicated she did not have verification of training for staff in correct hand hygiene and donning or doffing PPE. However, she tried to verbally communicate with staff and she had not completed staff competency in donning or doffing PPE. On 11/3/23 at 9:00 a.m., the IP nurse provided a document titled, Hand Hygiene Inservice Interactive. The document was dated, May 19. The in-service directed the staff to enter a QR code to register for the in-service. She indicated she had not completed handwashing competency of staff. B2. On 10/30/23 at 11:56 a.m., during a routine observation Certified Nurse Aide (CNA) 6 was observed entering into a droplet isolation precaution room (isolation precautions used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit) without first donning (to put on) personal protective equipment (PPE). Droplet Transmission based precaution signs were posted on the outside of the door and PPE was in a bin next to the door in the hall. CNA 6 stood in the room and spoke to Registered Nurse 7 regarding PPE equipment. CNA 6 left the isolation room and continued to provide care to other residents on the unit without washing or sanitizing her hands. On 10/30/23 at 12:00 p.m., CNA 3 was observed providing assistance to a resident in a droplet precautions isolation room. The CNA removed her PPE and removed the mechanical lift from inside of the isolation room and placed the lift in the hall against the wall. The CNA left the lift in the hall and failed to sanitize the mechanical lift after use in an isolation room. The CNA continued to provide assistance to other residents in the unit without first washing or sanitizing her hands after leaving an isolation room. On 10/30/23 at 1:00 p.m., CNA 9 was observed in a droplet isolation room doffing (take off) PPE. CNA 9 was observed placing gloved hands on the inside of her isolation gown and removing the gown from the inside outward. B3. On 10/30/23 at 12:09 p.m., Housekeeper 8 was observed mopping and cleaning rooms while the meal trays were being passed on the unit. The housekeeper entered several droplet isolation rooms and mopped the floors. Housekeeper 8 was not observed to change mop water or cleaning supplies. On 10/30/23 at 12:11 p.m., Housekeeper 8 entered a droplet isolation room. Transmission based precaution signs were posted on the door outside of the room. Housekeeper 8 failed to don PPE prior to entering the droplet isolation room. The housekeeper cleaned and mopped the room and continued to clean other rooms including non-isolation rooms on the unit. On 11/2/23 at 10:29 a.m., Housekeeper 24 indicated she used a housekeeping cart designated for COVID-19 use. She would clean two or more positive rooms, then would change the water and mop head before cleaning other non-isolation rooms. Housekeepers were not allowed to clean rooms when meal trays were being passed. 35317 B4. The following observations were observed on the COVID unit where the residents were in Droplet Isolation (when a resident has an infection with germs that can spread to others by speaking, sneezing, or coughing): On 11/1/23 at 2:09 p.m., the Certified Nursing Assistant (CNA) 22 exited a resident's room and removed her personal protective equipment (PPE). The CNA removed her gloves, gown, shoe covers, and then her face shield. She then went into the staff bathroom. The CNA exited the bathroom and placed on a gown, shoe covers, tied the gown around her neck, grabbed a face shield, and walked over to a resident still holding the face shield in her hand. She leaned down next to the resident holding her Broda (tilt in space position chairs with comfort seating) chair with one hand and face shield in another hand. The CNA pushed the resident while in her chair down the hallway and into her room. The CNA placed on her face shield just prior to entering the resident's room while holding it against the resident's chair down the hallway. On 11/1/23 at 2:21 p.m., CNA 21 went to the linen cart and grabbed washcloths and walked over to the nurse's station and set the washcloths on the counter while she talked to the nurse for a minute at the nurse's station and proceeded back to the linen cart to grab a brief (incontinence item). She obtained the sit to stand (a device to help assist residents from a sitting to a standing position) lift from the hallway and proceeded down the hallway to a resident's room. While the CNA was putting on her PPE she set the washcloths and brief on the sling (offers back support up to shoulder area and under the thighs) to the lift equipment. On 11/1/23 at 2:25 p.m., CNA 22 exited a resident's room and left the Hoyer (an assistive device that allows residents to be transferred between a bed and chair) lift in the hallway. The CNA removed her PPE in the following order: removed gloves, gown, show covers, then her face shield. No sanitizing of the Hoyer lift was observed. CNA 22 placed on new PPE and no hand hygiene was observed in between placing on new PPE equipment. On 11/1/23 at 2:30 p.m., CNA 22 exited room [ROOM NUMBER] and went to the linen cart. The CNA grabbed bed linens, washcloths, and towels, the CNA held the bed linens and other supplies against her isolation gown while walking down the hallway and proceeded back into the resident's room to assist the other CNA on the unit. No hand hygiene was performed before entering back into the resident's room. On 11/1/23 at 2:34 p.m., CNA 21 exited room [ROOM NUMBER] removed her PPE and went to linen cart and grabbed a fitted sheet. The CNA held the fitted sheet against her scrub top and took the sheet to CNA 22 in room [ROOM NUMBER]. On 11/1/23 at 2:39 p.m., CNA 22 exited room [ROOM NUMBER] with the sit to stand lift. The sit to stand lift and the sling were left in the hallway and no sanitization of the device or sling was observed. The CNA obtained the Hoyer lift from the hallway and placed it in room [ROOM NUMBER] for use. On 11/1/23 at 2:47 p.m., Licensed Practical Nurse (LPN) 23 entered room [ROOM NUMBER] with no face shield on. The nurse left the room and grabbed two incontinence briefs from the linen cart. She proceeded back into the room with no face shield on. She provided incontinence care and left the room with dirty trash. On 11/1/23 at 2:52 p.m., CNA 22 exited room [ROOM NUMBER] with the Hoyer lift and left it in the hallway. No sanitizing of the Hoyer lift was observed. On 11/1/23 at 2:55 p.m., CNA 22 obtained the Hoyer lift from the hallway and placed it in room [ROOM NUMBER] for use. On 11/1/23 at 3:06 p.m., CNA 21 brought the Hoyer left out of room [ROOM NUMBER] and placed in in the hallway. No sanitizing of the Hoyer lift was observed. On 11/1/23 at 3:12 p.m., CNA 21 pushed a female resident in her wheelchair to the shower room to toilet her. No PPE was worn by the CNA except for a face shield and mask. On 11/2/23 at 3:17 p.m., CNA 21 pushed a female resident in her wheelchair to the shower room to toilet her. No PPE was worn by the CNA except for a face shield and mask. During an interview, on 11/2/23 at 9:08 a.m., the infection control nurse indicated the lift equipment should be cleaned between residents. She further indicated bed linens, washcloths, and towels should not be held against the body. The staff should be holding it away from their body to avoid contact. The infection control nurse indicated the staff should be wearing PPE when providing care to a resident who was in isolation, this includes, bathing, toileting, and transferring. During an interview, on 11/2/23 at 9:18 a.m., the IP nurse indicated she had tried to speak with staff in regard to proper donning (placing on) and removing PPE but she did not have any documentation of the education being provided. She provided a policy that demonstrates the proper procedure for donning and removing PPE, she indicated staff should be aware of the procedures. The IP nurse indicated staff should be performing hand hygiene after they removed their PPE. On 11/2/23 at 9:05 a.m., the Administrator provided a document with a revised date of July 2014, titled, Cleaning and Disinfection of Resident Care Items and Equipment, and indicated it was the policy currently being used by the facility. The policy indicated, .3. Durable medical equipment must be cleaned and disinfected before reuse by another resident On 11/2/23 at 9:05 a.m., the Administrator provided a document with a revised date of January 2019, titled, Handwashing/Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .b. before and after direct contact with residents .l. after removing gloves .m. before and after entering isolation precaution settings On 11/2/23 at 9:05 a.m., the Administrator provided a document, titled, Infection guidelines for all nursing procedures dated, August 2012, and indicated it was the policy currently being used by the facility. The policy indicated, .General guidelines .2. Transmission based precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection .4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations .5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials On 11/2/23 at 9:40 a.m., the Administrator provided an undated document, titled, Example of Safe Donning and Removal of Personal Protective Equipment, and indicated it was the policy currently being used by the facility. The policy indicated, .remove gloves .goggles .gown .face mask .perform hand hygiene immediately after removing all PPE On 11/2/23 at 9:40 a.m., the Administrator provided a document with a revised date of February 2018, titled, Bed, Making an Unoccupied, and indicated it was the policy currently being used by the facility. The policy indicated, .1 . Do not let the sheet touch your clothing or the floor On 11/2/23 at 11:07 a.m., the Administrator provided a document, titled, Cleaning and Disinfecting Resident rooms dated, August 2013, and indicated it was the policy currently being used by the facility. The policy indicated, General Guidelines .6. Floor mopping solution will be replaced every three resident rooms or changed no less often than at 60-minute intervals .Steps in the procedure .Resident Room Cleaning .8. When cleaning rooms of residents in isolation precautions, use personal protective equipment as indicated .9. When possible, isolation rooms should be cleaned last, and water discarded after cleaning room The CDC guideline for transmission-based droplet precautions indicate, Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Source: CDC Guideline for Isolation Precautions, January 7, 2016 3.1-18(b)(1) 3.1-18(b)(4)

Based on observation, interview, and record review, the facility failed to ensure food was covered when delivered to the units and the facility failed to ensure hand hygiene was completed when assisting residents to eat for 1 of 2 dining observations. Findings include: 1. On 10/30/23 at 11:59 a.m., dietary staff delivered an uncovered meal cart with Residents' trays to the A hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:09 p.m., dietary staff delivered an uncovered meal cart with Residents' trays to the B hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:14 p.m., dietary staff delivered a second uncovered meal cart with Residents' trays to the B hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:36 p.m., dietary staff delivered an uncovered meal cart with Residents' trays to the A hall dining room, with an uncovered plate of food on a meal tray and uncovered brownies on disposable plates on all of the uncovered meal trays. On 11/02/23 at 11:56 a.m., the Dietary Manager (DM) indicated, food was to be covered when being transported to the units. On 11/02/23 at 12:51 p.m., the Administrator (ADM) indicated, all food items on meal trays delivered to outside of the designated meal area should be covered until they are served to the residents. At that time, ADM provided and identified a document as a current facility policy, titled, Serving of Food (Point of Service), dated 7/2023. The policy indicated, .Guidelines .1. All dishware/utensils being transported to point of service areas will be covered to prevent any cross contamination .8. Meals served outside of designated meal areas: .c. All food items on meal trays delivered to areas outside the designated meal area will be covered until they are served to the resident 35317 2a. During a dining observation, on 10/30/23 at 12:40 p.m., Certified Nursing Assistant (CNA) 3 used hand sanitizer in preparation of serving trays in the dining room. The CNA stood at the door in the dining room waiting for a tray to be handed to her, she adjusted the face mask on her face, moved her hair behind her left ear, touched her nose, and crossed her arms in front of her chest. The CNA obtained a tray from the kitchen and picked up the tray card, she then received another tray from the kitchen. The CNA held a tray in each hand and proceeded out of the kitchen down the hallway to take two residents their lunch trays. No hand hygiene was performed during this observation. 2b. During a dining observation, on 10/30/23 at 12:53 p.m., CNA 3 used hand sanitizer in the dining room and then placed her hands on her hips. The CNA moved a chair closer to a dining room table, adjusted her scrub top, moved a dietary card in front of a resident, and then sat down to assist the resident with her meal. No hand hygiene was performed before assisting the resident with her meal. During an interview, on 10/31/23 at 10:26 a.m., CNA 5 indicated staff should not touch their face, adjust their glasses, or adjust their clothes without performing proper hand hygiene when they are serving in the dining room. During an interview, on 11/1/23 at 1:51 p.m., CNA 21 indicated staff should use hand sanitizer in between residents when passing trays. She indicated if staff had to touch their face or clothing items then they should wash their hands before serving a resident their tray or when they assist a resident to eat. On 11/2/23 at 9:05 a.m., the Administrator provided a document, with a revised date of July 2014, titled, Preventing Foodborne Illness - Food Handling, and indicated it was the policy currently being used by the facility. The policy indicated, .3. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness On 11/2/23 at 9:05 a.m., the Administrator provided a document, with a revised date of January 2019, titled, Handwashing/Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Use an alcohol-based hand rub alternatively or soap and water for the following situations: .b. before and after direct contact with residents .n. before and after eating or handling food . o. before and after assisting a resident with meals 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to notify the dialysis center nurse of changes of condition related to low blood pressures for 1 of 1 resident reviewed for dialysis (Resident 53). Findings include: On 11/1/23 at 12:10 p.m., Resident 53 was observed in his room sitting on the side of the bed. The resident indicated he was very dizzy and had been vomiting. The resident indicated he had several episodes of dizziness and nausea. On 11/2/23 at 10:09 a.m., the clinical record of Resident 53 was reviewed. The record indicated the resident had diagnoses included but not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, was too high), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and dependence on renal dialysis (a treatment for people whose kidneys are failing. Dialysis does the work of your kidneys, removing waste products and excess fluid from the blood). A physician's order, dated 7/9/2023, indicated staff were to clean the Peritoneal Dialysis (PD) exit site, apply Mupirocin (Pea Size) amount to exit site daily, apply a dressing, and secure with paper tape one time a day. A physician's order, dated 7/9/2023, administer Peritoneal Dialysis solution two 6 Liter (L) bags total, over 12 hours per [NAME] Dialysis Machine. Start at 8 p.m., remove when completed one time a day. Call results to PD Nurse at 2 p.m. every day for new orders and set up peritoneal dialysis for night shift. A physician's order, dated 7/9/2023, follow instructions in book one time a day. Monitor PD exit site every shift for signs and symptoms of infection two times a day. Report any swelling or leaking of fluid to PD nurse immediately. A Physician's order, dated 7/27/23, indicated to check clarity of PD (peritoneal dialysis) drain fluid in toilet prior to resident using toilet and flushing in morning. If cloudy inform dialysis every night shift. A quarterly Minimum Data Set (MDS) assessment, dated 8/25/23, indicated the resident was on dialysis during the assessment period. He was cognitively intact during the assessment period. A care plan, dated 4/6/23, indicated resident was at risk for nutritional deficits related to ESRD (end stage renal disease), CHF (congestive heart failure). A care plan, dated 8/2/22 with a revision date of 6/19/23, indicated the resident had a diagnosis of end stage renal disease and was at risk for complications with dialysis treatment. The peritoneal dialysis flow sheet record indicated: on 1/23/23 B/P (blood pressure) reading 98/56, on 2/6/23 B/P reading 94/49, on 2/22/23 B/P reading 96/54, on 6/5/23 B/P reading 92/61, on 6/12/23 B/P reading 99/56, on 6/16/23 B/P reading 96/61, on 7/13/23 B/P reading 91/53, on 7/25/23 B/P reading 94/53, on 9/30/23 B/P reading 103/57, on 10/2/23 B/P reading 95/49, on 10/17/23 B/P reading 86/58, on 10/2/23 B/P reading 95/49, on 11/1/23 B/P reading 88/57. The medical record lacked documentation of dialysis center nurse notification of the low blood pressure readings of 9 out of 12 documented blood pressure readings. On 11/2/23 at 10:23 a.m., Registered Nurse 16 indicated if the resident has low B/P she would notify the dialysis unit. During a phone interview with the Dialysis Manager, on 11/2/23 at 11:08 a.m., she indicated the facility nurse was to call the dialysis center every day with a report of dialysis administration and information including vital signs. The facility nurse was to notify the dialysis center if a blood pressure was low, this would generate a call from the nurse to give additional orders. On 11/3/23 at 2:28 p.m., the Director of Nursing (DON) provided a document stating it was a record of when they were to call dialysis center for abnormal vital signs or changes in condition. The document titled, Clinical Education and Training, July PD Patient Lesson. When to call your nurse, dated 2017, indicated, the dialysis document indicated, .please call peritoneal dialysis nurse right away, cloudy . bag ., abdominal . pain ., fever ., drainage or crust at the exit site ., redness ., swelling ., pain . contamination ., transfer set . loose ., transfer set falls off ., cap falls off ., tip of transfer set touches anything The facility administrator did not provide a policy for notification of change of condition to dialysis center. 3.1-5(a)

Based on observation, interview, and record review, the facility failed to ensure nail care was provided to dependent residents for 2 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Residents 121 and 46). Findings include: 1. On 10/31/23 10:57 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/1/23 at 2:44 p.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 8:12 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 11:25 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 11:29 a.m., Registered Nurse (RN) 16 observed Resident 121's fingernails and indicated the resident's fingernails were too long and needed to be cleaned, trimmed, and the old nail polish removed. Resident 121's clinical record was reviewed on 11/3/23 at 9:23 a.m. The resident's diagnoses included, but were not limited to, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). An admission Minimum Data Set (MDS) assessment, dated 10/3/23, indicated Resident 121 had a severe cognitive impairment and required substantial/maximal assistance for showers and personal hygiene. A care plan, dated 9/26/23, indicated the resident required assistance with ADL's due to the diagnoses of dementia and Parkinson's disease. Interventions on the care plan included, but were not limited to, complete bathing and personal hygiene with staff assistance. Review of Resident 121's clinical record for October 2023 and November 2023 lacked documentation the resident had refused nail care. 2. On 10/31/23 at 11:47 a.m., Resident 46's fingernails were observed untrimmed and jagged, with dark debris underneath the fingernails. On 11/1/23 at 9:31 a.m., Resident 46's fingernails were observed untrimmed and jagged, with dark debris underneath the fingernails. On 11/2/23 at 11:47 a.m., Resident 46's fingernails were observed untrimmed and jagged, with dark debris underneath the fingernails. On 11/2/23 at 12:09 p.m., Registered Nurse (RN) 18 observed Resident 46's fingernails and indicated the resident's fingernails were too long and needed to be cleaned and trimmed. Resident 46's clinical record was reviewed on 11/2/23 at 2:18 p.m. The resident's diagnoses included, but were not limited to, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and heart failure. A quarterly Minimum Data Set (MDS) assessment, dated 8/9/23, indicated the resident had a moderate cognitive impairment and required substantial/maximal assistance for showers and personal hygiene. Review of Resident 46's clinical record for October 2023 and November 2023 lacked documentation the resident had refused nail care. The Administrator (ADM) provided and identified a document as a current facility policy, titled Fingernails/Toenails, Care of, dated February 2018. The policy indicated, .Purpose .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines .1. Nail care includes daily cleaning and regular trimming .2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Documentation .The following information should be recorded in the resident's medical record .1. The date and time that nail care was given .2. Any difficulties, abnormal conditions, problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure .3. If the resident refused the treatment and the intervention taken .4. The signature and title of the person administering the care and/or recording the data 3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications (Resident 11). Finding includes: On 11/1/23 at 11:43 a.m., Resident 11's clinical record was reviewed. The resident's diagnosis included, but were not limited to, osteoarthritis (degeneration of joint cartilage and underlying bone causing pain and stiffness) and pain in the left ankle and joints of the left foot. A current physician's order, dated 2/15/23, indicated Tylenol Tablet (acetaminophen) (pain medication) 325 milligrams (mg), give 650 mg by mouth three times a day related to pain in left ankle and joints of left foot and osteoarthritis. A current physician's order, dated 2/15/23, indicated Tylenol Tablet (acetaminophen) 325 mg, give 2 tablets by mouth every 4 hours as needed for pain/fever. A pharmacy consultation report, dated 4/30/23, indicated Resident 11 had current orders for Acetaminophen recommended the maximum of acetaminophen dose was 4000 mg in 24 hours, but may need to be lower for residents with impaired kidney and/or liver dysfunction. Review and check off if one of the following may be added to all orders containing acetaminophen, maximum dose of 4000 mg in 24 hours of acetaminophen from all sources, maximum dose of 3000 mg in 24 hours of acetaminophen from all sources, or other. The pharmacy consultation report had not been addressed nor signed by the physician. On 11/3/23 at 9:55 a.m., the Director of Nursing (DON) indicated the 4/30/23 pharmacy recommendation was not completed until today,11/3/23. DON indicated she had contacted the physician about the recommendation and wrote on the pharmacy recommendation to change the acetaminophen dose to every 8 hours. Resident 11 had not received acetaminophen more than 4000 mg in 24 hours at any time. All pharmacy medication regimen review (MRR) recommendations should be addressed in a timely manner by the facility and the resident's physician. On 11/3/23 at 12:07 p.m., the DON provided and identified a document as a current facility policy titled, 9.1 Medication Regimen Review, dated 11/28/16. The policy indicated, .7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon recommendations contained in the MRR .8. Facility should alert the Medical Director when MRRs are not addressed by the attending physician in a timely manner .11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure expired insulin medications were disposed of properly for 1 of 1 medication rooms reviewed for medication storage (Resident 9), and the facility failed to ensure medications and biologicals were labeled and stored according to policy for 1 of 1 treatment carts and 1 of 1 medication carts observed for medication and biological storage (Resident 46, 34, 10, 8, and 48). Findings include: During an observation of Hall, A medication storage room, on [DATE] at 2:10 p.m., the medication refrigerator had a Lantus Solostar insulin glargine (diabetic insulin injection for blood sugar) 100 units/milliliter (ml), 3 ml prefilled pen for Resident 9. The pen had an opened date of [DATE] with an instruction label to discard unused portion after 28 days. During an observation of the medication cart located on A hall, on [DATE] at 2:45 p.m., the cart had an opened bottle of Gentamicin (antibiotic eye drops) 0.3% eye drops for Resident 46 with no opened date. A received date of [DATE] was on the box with instructions to instill three drops in right eye three times per day for seven days. During an observation of the treatment cart located on A hall, on [DATE] at 2:55 p.m., to the following was found: a. An opened bottle of Nystatin powder (antifungal powder) 100,000 units/gram for Resident 34 was unbagged with no opened date and stored amongst an opened tube of benzoyl peroxide acne treatment gel 5% (topical skin treatment) for Resident 2 and an opened tube of Biofreeze gel (topical for pain relief) for Resident 2. b. An opened tube of Diclofenac Sodium topical gel 1% (used to treat pain and inflammation) for Resident 10 with no opened date and no lid cap. c. An opened tube of Venelex wound dressing (topical wound treatment) for Resident 10 not inside manufacturer's box with no opened date. A second opened tube of the Venelex for Resident 10 inside manufacturer's box with no opened date. d. An opened bottle of Nystatin powder 100,000 units/gram for Resident 8 with no opened date. e. An opened bottle of Nystatin powder 100,000 units/grams for Resident 48, unbagged with no opened date. f. Opened and unlabeled tube of Medihoney wound and burn dressing (topical wound treatment) with no opened date. During an interview, on [DATE] at 2:33 p.m., the Assistant Director of Nursing (ADON) indicated the insulin pen located in the refrigerator was expired and needed to be destroyed. On [DATE] at 11:47 a.m., the Administrator (ADM) provided a document, with a revised date of [DATE], titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, and indicated it was the policy currently used by the facility. The policy indicated, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label . are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened . When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle . 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions .17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law 3XXX,d+[DATE](j) 3XXX,d+[DATE](k) 3XXX,d+[DATE](o)

Based on record review and interview, the facility failed to review and track facility wide antibiotic stewardship for 4 of 12 months reviewed. Findings include: On 11/2/23 at 9:08 a.m., the Infection Preventionist Nurse (IP) indicated there was no documentation of tracking, facility mapping or antibiotic stewardship for the months of October 2022, November 2022, December 2022, nor October 2023. Review of April and May 2023 antibiotic use and infection tracking documentation indicated an increase in residents with urinary tract infections and upper respiratory infections. The IP nurse on 11/3/23 at 9:00 a.m., provided documentation indicating in-services were completed on 6/22/23 for perineal care and hand hygiene. Training record lacked documentation of education in urinary tract infection prevention, upper respiratory infection, and identification of signs and symptoms of infections. The IP nurse could not provide facility antibiotic stewardship policy and procedure. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented in a timely manner when the resident's pressure ulcer on the coccyx worsened in stage, increased in size, and developed an infection, and failed to provide treatments per manufacturer product guidelines and an appropriate mattress for the resident's stage 3 pressure ulcer to the right hip (Resident 48), and failed to provide an appropriate mattress and wheelchair cushion when the resident developed a stage 3 pressure ulcer which increased in size (Resident 59) for 2 of 4 residents reviewed for pressure ulcers. Findings include: 1. Resident 48's record was reviewed on 9/25/19 at 11:08 a.m. An admission Minimum Data Set (MDS) assessment, dated 7/15/19, indicated the resident had a severe cognitive impairment, a stage II (partial tissue skin loss) pressure ulcer (an injury to the skin caused by prolonged pressure) to the sacrum (the area at the base of the spine), and a stage III (full thickness skin loss) pressure ulcer to the right hip. [DIAGNOSES REDACTED]. a. A hospital physician's progress note, dated 7/4/19, lacked documentation that any of the resident's wounds had signs or symptoms of infection. An admission assessment, dated 7/8/19, indicated the resident had a pressure ulcer to the coccyx measured 1.6 centimeters (cm) by (x) 0.4 cm. A physician's orders [REDACTED]. A Pressure Ulcer Wound Sheet, dated 7/10/19, indicated the resident had a stage II pressure ulcer to the coccyx, measured 0.9 cm x 0.5 cm x less than 0.1 cm. The wound bed was 100 percent granulation (tissue at the wound's surface during the healing process) tissue. The resident had a pressure reducing mattress. A Pressure Ulcer Wound Sheet, dated 7/16/19, indicated the resident had a stage II pressure ulcer to the coccyx, measured 0.6 cm x 0.4 cm x less than 0.1 cm. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Cleanse coccyx with wound cleanser, apply [MEDICATION NAME], cover with a thin spot ([MEDICATION NAME]) dressing, change every 3 days and as needed. A nurse's note, dated 7/24/19, indicated the area to the coccyx was deteriorating. A new order for [MEDICATION NAME] was received. The mattress was changed to a low air loss mattress. A Pressure Ulcer Wound Sheet, dated 7/26/19, indicated the resident's pressure ulcer to the coccyx had deteriorated on 7/22/19, and was unstageable (covered with necrotic tissue), measured 3 cm x 2.5 cm, and unable to determine depth. The wound bed was 50 percent slough (dead tissue separating from an ulcer) and 50 percent necrotic. The treatment was changed to [MEDICATION NAME] and the resident received a low air loss mattress. The record lacked documentation any further interventions were initiated between 7/22/19 and 7/24/19. A Pressure Ulcer Wound Sheet, dated 8/1/19, indicated the resident had an unstageable pressure ulcer to the coccyx, deteriorated and measured 4.5 cm x 5.5 cm, and depth was unable to be determined. The wound bed was 25 percent slough and 75 percent necrotic. The corporate nurse assessed the wound with the Assistant Director of Nursing (ADON). A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A wound culture report, dated 8/5/19, indicated mixed growth of gram positive (types of bacteria) and gram negative (types of bacteria) bacteria, of questionable significance. A nurse's note, dated 8/6/19, indicated a peripherally inserted central catheter (PICC) line (intravenous access which can be used for a prolonged period of time) was placed in the resident's right upper arm, and the wound to the resident's coccyx had a foul odor. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Pressure Ulcer Wound Sheet, dated 8/8/19, indicated the resident had an unstageable pressure ulcer to the coccyx, deteriorated, measured 5 cm x 5.5 cm, and unable to determine depth. There was a foul odor and a large amount of purulent (thick and milky) drainage. The wound bed was 100 percent necrotic tissue. The physician debrided (removed necrotic tissue) the wound on 8/6/19, ordered a PICC line, and IV antibiotics. A culture was obtained on 8/2/19. The Santyl treatment was increased to twice daily. A physician's orders [REDACTED]. Give 1,250 mg IV once a day for coccyx wound. A Pressure Ulcer Wound Sheet, dated 8/15/19, indicated the resident's pressure ulcer to the coccyx was a stage IV, measured 6 cm x 5.5 cm x 1.5 cm, with a tunnel (a channel that extends from the wound out into the surrounding tissue) at twelve o'clock (a way to describe where a wound tunnel is based on a clock) of 1.6 cm, three o'clock of 1.7 cm, six o'clock of 3.5 cm, and nine o'clock of 1.1 cm. The wound bed was 25 percent granulation tissue, 25 percent slough, and 25 percent necrotic. The treatment was changed to wound vac therapy (vacuum assisted closure wound therapy. A physician's orders [REDACTED]. Cleanse the coccyx wound with normal saline, apply skin prep (protectant for the surrounding skin) to protect peri-wound (skin around the wound) skin, cut strip of moist white foam (moisture retaining foam) and place inside the wound tunnel at six o'clock. Place black foam (water repelling foam) into wound, apply transparent film over the area. A Pressure Ulcer Wound Sheet, dated 8/22/19, indicated the resident had a stage IV pressure ulcer to the coccyx, measured 5.5 cm x 5.5 cm x1.5 cm, with continued tunneling. The treatment was wound vac therapy. A nurse's note, dated 8/22/19, indicated the physician saw the resident and discontinued IV antibiotics, and all medications except pain medications. New orders for [MEDICATION NAME] intramuscularly (IM) were received. Physician indicated to change to a palliative care (focused on symptom relief) approach, continued the wound vac. A physician's orders [REDACTED]. A Pressure Ulcer Wound Sheet, dated 8/28/19, indicated the resident had a stage IV pressure ulcer to the coccyx, measured 5.5 cm x 4.7 cm x 1.5 cm. The wound bed was 50 percent granulation tissue and 50 percent slough, and had improved. A Pressure Ulcer Wound Sheet, dated 9/6/19, indicated the resident had a stage IV pressure ulcer to the coccyx, measured 5.8 cm x 4.3 cm x 1.2 cm. The wound bed was 75 percent granulation tissue and 25 percent slough, and had improved. A physician's orders [REDACTED]. Change the wound vac on Monday, Wednesday, and Friday. A care plan, goal target dated 10/21/19, indicated the resident had actual pressure ulcers. Interventions included, but were not limited to, pressure reduction mattress, dated 7/8/19, and low air loss mattress, dated 7/26/19. An undated mattress information sheet for the facility's standard pressure reducing mattress indicated the mattress was appropriate for residents with stage I and II pressure ulcers. During an interview, on 9/26/19 at 11:25 a.m., the ADON indicated she was unable to find any additional information any interventions were put in place when the coccyx wound worsened on 7/22/19. Interventions were put in place on 7/24/19. b. A hospital physician's progress note, dated 7/4/19, lacked documentation that any of the resident's wounds had signs or symptoms of infection. An admission assessment, dated 7/8/19, indicated the resident had a stage III pressure ulcer to the right hip that measured 7.3 cm x 7 cm. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Change every three days and as needed if soiled or dislodged. A Treatment Administration Record (TAR), dated (MONTH) 2019, indicated an as needed Santyl dressing change was completed to the resident's right hip on 8/27/19. The record lacked documentation a Santyl dressing change to the resident's right hip was done on 8/12/19, 8/13/19, 8/15/19, 8/16/19, 8/18/19, 8/19/19, 8/21/19, 8/22/19, 8/24/19, 8/25/19, 8/28/19, and 8/29/19. A TAR, dated (MONTH) 2019, indicated an as needed Santyl dressing change was completed to the resident's right hip on 9/2/19, 9/3/19, 9/4/19, 9/5/19, 9/8/19, 9/10/19, and 9/16/19. The record lacked documentation a Santyl dressing change to the resident's right hip was done on 9/1/19, 9/7/19, 9/11/19, 9/13/19, 9/14/19, 9/17/19, 9/19/19, 9/20/19, 9/22/19, 9/23/19, and 9/25/19. A Physician's Note, dated 9/26/19, indicated the treatment plan for the resident's right hip was every three days to limit exposure to pathogens from the sacral ulcer. The patient considered hospice (specialized care for the terminally ill) in (MONTH) of 2019, and the treatment was to prevent undo pain. The note lacked documentation as to why a dressing with manufacturer's guidelines to change every three days was not considered. An undated manufacturer's guidelines sheet for Santyl indicated Santyl ointment should have been applied once daily or more frequently if the dressing became soiled. During an interview, on 9/26/19 at 10:08 a.m., the ADON indicated the resident was admitted with a stage II pressure ulcer to the coccyx, stage III pressure ulcer to the right hip, and multiple unstageable pressure ulcers. She was on a standard pressure reducing mattress at the time of admission, until 7/24/19. She reviewed the information sheet provided for the facility's standard pressure reducing mattress, and indicated it was only appropriate for stage I and II pressure ulcers. She thought it was acceptable to do the Santyl treatment every three days because the physician ordered it that way. She reviewed the manufacturer's guidelines, and indicated they said the Santyl treatment should have been provided at least once daily. The wound to the resident's coccyx worsened on 7/22/19. The low air loss mattress was placed on 7/24/19. 2. On 9/23/19 at 10:26 a.m., Resident 59 was observed sitting on her bed and indicated, she had developed a sore on her bottom, since she had been admitted to the facility. The sore did not hurt badly, but was tender. Staff placed a medication and bandage on the area, which helped to make the sore feel better. Resident 59's record was reviewed on 9/26/19 at 9:16 a.m. Resident 59 was admitted to the facility without a pressure ulcer. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 8/28/19, indicated the resident was cognitively intact, required extensive assistance of one to two staff members for bed mobility, transfers, toilet use, and bathing, and was at risk for pressure ulcers with interventions of a pressure reducing device for the bed and chair. A nurse's note, dated 9/15/19, indicated during routine care, Resident 59 was noted to have 1 centimeter (cm) by 1 cm open area to coccyx A care plan, initiated on 9/16/19, indicated the resident had developed a stage 3 (full thickness tissue loss) pressure ulcer to the coccyx with the goals of pressure area will show signs of healing and will show no signs/symptoms of infection through next review. Interventions included, but were not limited to, administer treatments as ordered. Wound assessment documentation, dated 9/16/19 at 9:46 a.m., indicated the resident had acquired, on 9/15/19, a stage 3 pressure ulcer on the coccyx measured length of 1 cm. by width of 1 cm. by depth of 0.1 cm., with 50% tissue granulation and 50% tissue slough. Wound assessment documentation, dated 9/21/19 at 6:29 p.m., indicated the resident's stage 3 pressure ulcer on the coccyx measured length of 1.8 cm by width of 1.0 cm with the depth UTD (unable to determine), with 25% tissue granulation and 75% tissue slough with area is measuring larger at this time with a low air loss (LAL) mattress added on 9/19/19. On 9/26/19 at 2:33 p.m., the Director of Nursing (DON) indicated, Resident 59 had developed a stage 3 pressure ulcer on 9/15/19. At that time, the resident was on a standard mattress, designed for stage 1 or stage 2 pressure ulcers. The bed mattress was not available until 9/19/19, because another resident in the facility was using it. Resident 59 had a standard pressure reducing cushion to the wheelchair, but should have had a ROHO cushion in her wheelchair, designed for stage 3 pressure ulcers, but the ROHO cushion was not added to resident's wheelchair until 9/19/19, also. On 9/26/19 at 11:22 a.m., the Director of Nursing (DON) provided a document titled, Prevention of Pressure Ulcers, and indicated it was the policy currently being used by the facility. The policy indicated Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Preventive Measures: .2. For a person in bed: .b. Determine if the resident needs a special mattress .3. For a person in a chair: .b. Use foam, gel or air cushion as indicated to relieve pressure. c. All residents identified to be at risk for pressure ulcer development should have a pressure reduction chair cushion .3. Risk Factor-Bed-fast: .b. Use special mattress that contains foam, air, gel, or water as indicated .4. Risk Factor-Chair-fast: .d. Avoid use of wheelchairs with sling seats for prolonged periods. Consider the need for pressure relief/reducing device On 9/26/19 at 12:28 p.m., the DON provided a document titled, Weekly Skin Check, and indicated it was the policy currently being used by the facility. The policy indicated, Policy Statement: This facility shall inspect each Residents skin no less frequently than weekly. Policy Interpretation and Implementation: .5. Any new or worsening areas will be reported on the Weekly Wound Report and reported to the physician or wound nurse for re-evaluation. 6. The Resident's plan of care .is to be updated 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to comprehensively assess residents' weight loss and update weight loss care plan interventions to ensure residents maintained acceptable parameters of nutritional status resulting in severe weight loss and abnormal labs over a 30 day period (Resident 78) and significant weight loss and abnormal labs over a three month time frame (Resident 26) for 2 of 5 residents reviewed for nutritional status. Findings include: 1.) On 9/11/18 at 11:45 A.M., Resident 78 was observed sitting in her chair, in her room, and drinking from a cup. The resident grimaced as she drank and indicated she could not eat anything at this time. During an interview, on 9/11/18 at 11:48 A.M., Resident 78 indicated she had a poor appetite for the past 3 weeks, had been nauseous, was unable to keep much food down, lost weight, and was becoming increasingly weaker each day. She wondered if she should have been sent back to the hospital because of these concerns. The resident had her own natural teeth and reported when she was not nauseous, she had no problems with eating. On 9/11/18 at 1:30 P.M., Resident 78's clinical record was reviewed. [DIAGNOSES REDACTED]. The Minimum Data Set assessment, dated 8/18/18, indicated the resident was cognitively intact. On 8/12/18, the resident's weight was 144 pounds. On 9/2/18, the resident's weight was 132 pounds, a weight loss of 8 pounds, which indicated an 8.33% loss in 21 days. On 9/11/18, the resident's weight was 128.4 pounds, which indicated a severe weight loss of 15.6 pounds, a 10.83% loss in 30 days. Blood chemistry laboratory tests, drawn on 9/1/18, indicated the following results: -Protein level of 5.5 g/dL (grams per deciliter), below the normal level range of 6 - 8.3 g/dL. -[MEDICATION NAME] level of 3.2 g/dL, below the normal level range of 3.5 - 5.5 g/dL. Blood chemistry laboratory tests, drawn on 9/10/18, indicated the following results: -Protein level of 5.4 g/dL, below the normal level range of 6 - 8.3 g/dL. -[MEDICATION NAME] level of 3.0 g/dL, below the normal level range of 3.5 - 5.5 g/dL. -Hemoglobin (ar protein responsible for transporting oxygen in the blood) level of 7.7 g/dL, below the normal level range of 12.0 - 16.0 g/dl. -Hematocrit (the ratio of the volume of red blood cells to the total volume of blood) level of 23.3%, below the normal level range of 36 - 48%. A Dietitian progress note, dated 9/5/18, indicated, averaging 54% meal intake of regular NAS (no added salt) diet independently with no noted difficulties .anticipate fluid related weight loss .will continue current regimen and will follow for potential additional needs . The clinical record did not indicate fluid output was being monitored. physician's orders [REDACTED]. physician's orders [REDACTED]. A review of Resident 78's daily meal intakes, from 8/12/18 to 9/12/18, indicated the resident's meal intakes varied from refusal to 100% consumption. The clinical record did not indicate nutritional supplements were recommended or ordered prior to 9/10/18. The resident's advance directives indicated she wished to be a full code. Resident 78's care plan, initiated date 8/12/18, revised date 8/24/18, indicated, (Resident Name) is at risk for nutritional deficits ., and a goal of, will maintain stable weight with no variance of 5% +/- through the next review with weight to remain 140 lbs within 5% . The target date was 1/30/19. The care plan did not include implementation of new interventions after 8/24/18. During an interview, on 9/13/18 at 1:50 P.M., the Director of Nursing indicated an awareness of the resident's weight loss. The resident's family had brought in various foods the resident may like, however, the resident continued to have poor meal consumptions. A house supplement was ordered on [DATE]. 2. On 9/11/18 at 12:30 p.m., Resident 26 was observed in the dining room, missing multiple teeth, and being assisted with meal intake by staff's assistance. On 9/12/18 at 1:44 p.m., Resident 26's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 26's quarterly Minimum Data Set assessment (MDS), date 7/4/18, indicated the resident was severely cognitively impaired and required extensive assistance with eating meals. Resident 26's September, (YEAR), current physician's orders [REDACTED]. -On 1/8/18 (start date), Res (resident) to have build up utensils for meals. -On 3/29/18 (start date), General Diet: Pureed texture, Honey Thickened Liquids consistency, snack @ 2p no straws coffee cup to have lid at all times red divided plate at all meals may have mechanical soft pleasure foods for improved quality of life (sic). Resident 26's weights indicated the following: -On 6/1/18, the resident weighed 147 pounds. -On 7/1/18, the resident weighed 144.7 pounds. -On 8/3/18, the resident weighed 139 pounds. -On 9/1/18, the resident weighed 129.3 pounds. This is an assessed 12.05% significant weight loss in 3 months and an assessed 6.98% significant weight loss in 1 month. On 8/2/18 at 5:36 a.m., Resident 26's labs were drawn. The labs indicated the following: -Glucose: 63 (low). Normal range 65-99. -Protein: 5.3 (low). Normal range: 6.0-8.3. -[MEDICATION NAME]: 2.4 (low). Normal range 3.5-5.5. -White Blood Cells: 4.3 (low). Normal range 4.5-10.8. -Red Blood Cells: 3.41 (low). Normal range 3.90-5.40. -Hemoglobin: 10.3 (low). Normal range: 12.0-16.0. -Hematocrit: 32.3 (low). Normal range: 36.0-48.0. Resident 26's progress notes indicated the following: -On 5/4/18, Dietitian note: Significant weight loss X (times) 1 month on (MONTH) (YEAR). Monthly weight 140 lbs (pounds) . Dxs (diagnosis): dementia, CKD ([MEDICAL CONDITION]) state 3, depression. Documented averaging 72% meal intake of puree diet with honey thick liquids with no noted difficulties. Careplan updated. Will continue current regimen and will follow for potential additional needs. -On 5/23/18, Physician's Note: Now having dysphagia per staff . + (positive) weight loss per staff . significant decline noted overall . being ffed (sic) by st (staff). -On 8/1/18, Physician's Note: Been declining in last 2 weeks. Px (patient) has been not eating nor drinking well. -On 8/10/18, Care Conference Note: . Weight 139.0, diet and consumption reviewed . care plan reviewed. -9/5/18, Dietitian note: Significant weight loss X (times) 1 month in (MONTH) (YEAR). Monthly weight 129.3, 8/18: 139 lbs (pounds), 7/18: 144.7 lbs . Noted house supplement 120 cc (cubic centimeters) tid (three times a day) dc/d (discontinued) 7/14/18 due to refusals . Noted 8/2/18 labs: severely depleted visceral proteins per usual, elevated BUN (blood urea nitrogen), depleted CBC (complete blood count) noted . careplan updated. There were no updated interventions in the resident's care plan. A care plan initiated on 3/23/18 and current through 10/2/18, for Resident 26 indicated, (Resident Name) has nutritional problem or potential nutritional problems . indicated a revised goal date of, 9/5/18, but did not include new interventions and or revisions after 4/10/18. During an interview, on 9/13/18 at 11:32 a.m., the Director of Nursing indicated there were no new interventions implemented after 4/10/18, on Resident 26's care plan, which addressed the assessed significant weight loss. During an interview, on 9/13/18 at 2:13 p.m., CNA 1 indicated Resident 26 normally ate about 50% of her meals and was totally dependent on staff to assist her with her with eating. The resident used to feed herself and eat better, however, she had declined recently. A review of Resident 26's September, (YEAR), meal intakes indicated the resident's appetite varied from refusing, to eating 75% of meals. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was turned and repositioned every hour and the support surface had been inflated to reduce pressure as indicated by the care plan and facility policy, which resulted in a stage IV pressure ulcer for 1 of 3 resident reviewed for pressure ulcers. (Resident #102) Findings include: Resident #102' s clinical record was reviewed on 6/3/15. [DIAGNOSES REDACTED]. Resident #102 was admitted to hospice on 5/5/14. The current MDS dated [DATE], indicated Resident #102 needed extensive assistance of 2 persons physical assist for bed mobility, total dependence of 2 staff for transfer . A current Care plan dated 8/1/14, indicated, The resident has skin breakdown to the coccyx (area at the base of the spinal column/lower back) on admission (a stage 2, that healed) . On 6/1/15 at 2:33 p.m., interview with RN #1, she indicated, on 12/12/14, was when staff observed a stage 4 pressure ulcer to the coccyx on Resident #102 and the pressure ulcer was acquired in the facility. Skin assessment dated [DATE], indicated Resident #102 had stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to coccyx. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 12/26/14, indicated Resident #102 pressure ulcer measured 7.0 x 5.0 x <0.1 centimeter and was unstageable. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 12/26/14, indicated Resident #102 pressure ulcer measured unstageable 7.0 x 5.0 x <0.1 Review of Pressure Ulcer Evaluation Weekly Record documentation dated 1/2/15, indicated Resident #102 pressure ulcer measured 5.0 x 4.5 x 1.5 unstageable Review of Pressure Ulcer Evaluation Weekly Record documentation dated 1/9/15, indicated Resident #102's pressure ulcer measured 5.5 x 4.0 x 1.0 unstageable Review of Pressure Ulcer Evaluation Weekly Record documentation dated 1/16/15, indicated Resident #102's pressure ulcer measured 4.7 x 5.3 x 2.0 unstageable Review of Pressure Ulcer Evaluation Weekly Record documentation dated 1/23/15, indicated Resident #102's pressure ulcer measured 4.0 x 3.5 x 2.0 unstageable. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 1/30/15, indicated Resident #102's pressure ulcer measured 4.0 x 3.5 x 1.5 a stage 4. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 2/6/15, indicated Resident #102's pressure ulcer measured 4.0 x 3.0 x 1.5 a stage 4. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 2/13/15, indicated Resident #102's pressure ulcer measured 4.0 x 2.0 x 0.5 a stage 4. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 2/20/15, indicated Resident #102's pressure ulcer measured 3.0 x 2.0 x 1.5 a stage 4 Review of Pressure Ulcer Evaluation Weekly Record documentation dated 4/30/15, indicated Resident #102's pressure ulcer measured 3.5 x 1.5 x 1.0 tunneling 1.0 a stage 4. Review of Pressure Ulcer Evaluation Weekly Record documentation dated 5/8/15, indicated Resident #102's pressure ulcer measured 3.5 x 2.0 x 2.0 a stage 4 Review of Pressure Ulcer Evaluation Weekly Record documentation dated 6/3/15, indicated Resident #102's pressure ulcer coccyx wound measured a 3.5 x 2.0 x 1.0 x 1.0 a stage 4. On 6/1/15 at 10:45 a.m., Resident #102 was observed in bed with her back on the mattress and her hips turned on the left side. On 6/1/15 at 11:15 a.m., Resident #102 was observed on her back with her hips turned to the left side. On 6/1/15 at 11:45 a.m., with LPN #1 and CNA #1 (Certified Nursing Assistant) present Resident #102 was observed in bed on her back with her hips turned to the left side. CNA #1 indicated Resident #102 was turned every hour and it was documented in a chart at the nursing station on Hall B. On 6/4/15 at 11:15 a.m., Resident #102 was observed to be on her back in her bed. The waffle mattress was observed to be deflated at that time. Resident #102 was observed to be lying on a hard bed. LPN #2 entered the room was observed to walk over and touch Resident #102's mattress . LPN #2 indicated the waffle mattress was flat, All the way flat. And the mattress was not doing Resident #102 any good. LPN #2 indicated hospice would be called right away. On 6/5/15 at 12:00 p.m., Resident #102 was observed in bed lying on her back with a posie roll pillow on both sides. There was no dressing observed on Resident #102's wound. RN #1 indicated she was trying to get a new order for Duoderm dressing for the coccyx wound. RN #1 indicated the wound should be covered at all times and sometimes it may fall off when repositioning Resident #102. The CNA's should tell us (indicating the nurses) when the dressing is off. On 6/8/15 at 10:50 a.m., Resident #102 was observed lying on her right side with an alternating pressure mattress on her bed. With LPN #5 present, Resident #102 was observed to have a quarter size red area on Resident #102's left hip. LPN #5 indicated that was a new area to her. RN #2 indicated she was not aware of the redden area on Resident #102's left hip. The care plan dated 2/2/15, indicated, Resident noted to have. 1/30/14 coccyx areas stage IV . Goals: Resident will have no s/sx (sign and symptoms) of infection, . Intervention: .cover with [MEDICATION NAME] (wound dressing) daily & (and) PRN (as needed) daily Resident to be on bedrest, turn from side to side , to be on back for meals only. Wound nurse to monitor weekly & (and) PRN. waffle mattress to bed. The current care plan dated 4/30/15, indicated, The resident has potential for impaired skin r/t (related to) Disease process dementia, immobility. With actual stage 2 noted on admission 5/1/14. Goals the resident's Pressure ulcer will show signs of healing and remain free from infection, .Intervention The resident needs assistance to turn/reposition at least every 1 hour, more often as needed or requested, . Administer treatments as ordered and monitor for effectiveness, .Follow facility policies/protocols for prevention/treatment of [REDACTED]. On 6/4/15 at 2:30 p.m., the Administrator provided documentation labeled, Turn and Reposition Record and indicated that was the form currently used by the CNA staff to indicate turning and repositioning residents. The Turn and Reposition Record form indicated there was no documentation on the following dates at the specified times: a). On 3/1/15 from 10:00 p.m. to 3/2/15 at 1:00 p.m. b). On 3/2/15 from 11:00 p.m. to 3/3/15 at 1:00 p.m. c). On 3/3/15 from 11:00 p.m., to 3/4/15 at 1:00 p.m. d). On 3/4/15 from 11:00 p.m. to 3/5/15 at 1:00 p.m. e). On 3/5/15 from 11:00 p.m. to 3/6/15 at 5:00 a.m. f). On 3/16/15 at 1:00 p.m., and 2:00 p.m. g). On 3/24/15 from 11:00 p.m. to 3/25/15 at 5:00 a.m. h). On 3/26/15 from 11:00 p.m. to 3/27/15 at 1:00 p.m. i). On 4/15/15 from 12:00 p.m. and 1:00 p.m. j). On 4/20/15 from 7:00 a.m. to 1:00 p.m. k). On 5/17/15 from 12:00 a.m., to 6:00 a.m. l). On 5/26/15 from 12:00 a.m. to 5/27/15 to 6:00 a.m. m). On 5/29/15 from 11:00 p.m. to 5/30/15 at 6:00 a.m. n). On 6/4/15 at 1:00 p.m., and 2: 00 p.m. There were no turn and reposition forms provided by the facility for May 1 to May 16, 2015. On 6/4/14 at 2:00 p.m. the DON indicated if there is nothing written on the sheet (indicating the turn and reposition record) then someone didn't document. There should be something in every box. On 6/4/15 at 3:23 p.m., interview with Hospice nurse indicated Resident #120 was on a low air mattress and it was so slick she would fall out of bed. So we went to a waffle mattress. We put posie roll guard in place. Her wound was not getting better with the low air mattress. On 6/5/15 RN #1 provided a new order for Resident #102 dated 6/3/15 indicating, [MEDICATION NAME] (dressing to help prevent infection) Blue 4 x 4 dressing, cleanse wound with NS (normal saline), cut [MEDICATION NAME] to fit wound , moisten with NS & wring out excess and cover c (with) Exuderm ([MEDICATION NAME]) 4 x 4 change QOD (every other day) & PRN for soilage. On 6/5/15 at 2:23 p.m. the Minimum Data Set coordinator (MDS) provided policy Prevention of Pressure Ulcers dated 10/2010, and indicated the policy was the one currently used by the facility. The policy indicated, .General Preventive Measures .2. For a person in bed: a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress. c. All . at risk for pressure ulcer . should have a pressure reduction mattress. 3 . Risk Factor-Bed fast a. Change position at least . frequently as needed. b. Use a special mattress that contains foam, air, gel, or water, . c. should have a pressure reduction mattress in place.e. Consider off-loading pressure hourly, . On 6/5/15 at 2:23 p.m. the Minimum Data Set coordinator (MDS) with the Director of Nursing present provided policy, Pressure Ulcer Treatment & Evaluation dated 3/2011, and indicated the policy was the one currently used by the facility. The policy indicated, The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. 1. Review the resident's care plan to assess for any special needs . Stage IV (4) Pressure Ulcer Interventions/Care Strategies .3. Treatment: .b. Apply an alginate dressing, foam dressing or hydrogel to wound cavity . On 6/5/15 at 3:25 p.m., the MDS coordinator with the DON present provided documentation labeled Unavoidablility Statement for Impaired Skin Integrity dated 2/12/15, indicated Resident #102 had a stage 4 pressure ulcer and receiving supplements to promote healing, receiving hospice care, and further declines are anticipated due to the disease process. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure nails were not protruding from a bathroom door, which resulted in a resident severing the finger pad of the right index finger when the resident fell to the floor for 1 of 3 residents reviewed for falls and accidents in a sample of 3. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 03/05/12 at 10:40 a.m., and indicated the resident had [DIAGNOSES REDACTED]. Resident #B's most recent fall risk assessment, dated 01/14/12, indicated the resident was a high risk for falls. Resident #B's most recent annual Minimum Data Set (MDS) assessment, dated 01/24/12, indicated the resident was moderately impaired with cognitive skills for daily decision-making, had short term memory problems, and was hard of hearing and refused to wear hearing aides. The MDS assessment indicated the resident had unclear speech, usually understands what is being said, and is sometimes understood when he speaks. The MDS assessment indicated Resident #B needed extensive assist of 2 persons for transfers and toileting, extensive assist of 1 person for bed mobility, ambulation, and eating, and was totally dependent on 1 staff person for dressing, hygiene, and bathing. Resident #B's clinical record indicated the resident had a fall on 12/16/11 with no injury. Resident #B had been evaluated by therapy for decrease in range of motion, and a decrease in his ability to walk, but therapy had been discontinued on 01/13/12 due to lack of participation on the resident's part and lethargy. Resident #B's care plan with original date of 09/01/10 and most recent update of 03/01/12 for "At risk for falls d/t (due to) weakness and decreased mobility from recent hospitalization for UTI (Urinary Tract Infection/polyp removal/dehydration CVA (Cerebrovascular Accident) late effects c (with) decision making being effected" indicated a goal of "Resident free of falls resulting in serious injury through." Approaches/Interventions included, but were not limited to, demonstrate use of call light, encourage resident to use call light for assistance, ensure call light is within reach at all times, place personal items within easy reach, assist with ADLs (activities of daily living) if needed - extensive, complete fall risk assessment quarterly, be sure resident has on nonskid footwear before transferring, transfer bar to assist with bed mobility (dc'd 02/29/12), anticipate common personal needs, toileting, verbally reinforce as needed, PT/OT as ordered, transfer with extensive assist, pull alarm on at all times (dc'd 01/14/11), pressure alarm on at all times, alarming floor pad at bedside at all times, nursing to check placement and functioning every shift, pull alarm in chair (dc'd 02/08/11), dycem in wheelchair on top of cushion, dycem in wheelchair under cushion also pressure pad alarm at all times, pressure pad alarm at bedside, and floor pad alarm at bedside. Nurse's Notes, dated 02/11/12 at 6:25 a.m., indicated, "Res (Resident) alarm sounding, upon entering room found res on floor on (L) (left) side by bathroom door, noticed blood on floor beside res, upon assessment discovered res had severed the pad of his (R) (right) index finger off et (and) had a s/t (skin tear) to the top of his (R) finger as well, applied pressure to finger to stop bleeding, (name of transport service) was called by assisting nurse, VS (Vital Signs): 97.3, 82, 20, 110/61, SpO2 99% on ra (room air), res was alert et was communicating c (with) this nurse in his usual manor (sic), p (after) bleeding slowed, finger was cleansed et a pressure drsg (dressing) was applied, also noted a 1 cm (centimeter) in diameter hematoma to (R) elbow as well as a 5 cm x (times) 2 cm abrasion below the elbow on the back side of the (R) arm, neuro check wnl (within normal limits), - assisted res from floor to w/c (wheelchair) to await (name of transport service) to (initials of hospital) for evaluation." A Discharge/Transfer Nurse Note, dated 02/11/12, indicated, "VS: 97.3, 79, 18, 103/60, SpO2 99% on ra, alert, (R) (right) elbow hematoma, pad of (R) index finger was severed, areas were cleansed et drsg applied, also s/t (skin tear) to top of (R) index finger, abrasions noted of forehead above (L) eye et at hairline on (L) side et (L) side of head above temple, also abrasion noted to back of (R) lower arm right below elbow." Nurse's Notes, dated 02/11/12 at 8:55 a.m., indicated the resident returned to the facility and "upon return noted 3 abrasions to (L) side of head, a 1 1/2 cm x 1 cm abrasion to (L) forehead above eye, a 1 cm x 1 cm to (L) forehead at hairline et a 4 cm x 2 cm abrasion to (L) side of head above temple...." Review of IDT (Interdisciplinary Team) notes, dated 02/13/12, indicated, "IDT review for fall on 2/11/12 @ 625 (sic) AM, staff responded to alarm sounding in residents (sic) room, res (resident) found on the floor of his room by the bathroom door, res. had gotten out of bed unassisted, safety alarm functioned properly but res. fell before staff could get to him, res. appeared to be headed to the bathroom to use the toilet, he had not utilized his call light even though it was within his reach in bed, res was wearing non-skid footwear, resident was last checked 25 minutes prior to fall @ (at) change of shift, upon assessment the following injuries were noted: three small abrasions to (L) side of head @ hairline measurments (sic) were 1.0 x 1.0 cm, 4.0 x .5 cm, 1.5 x 1 cm, index finger to (R) hand c severed pad skin tear to top of (R) index, hematoma to (R) elbow 1 cm diameter, abrasion to (R) arm 5 x 2 cm resident had grabbed the door on the way down to the floor running his hand along the edge of the door, the bottom of the door had two very small nails protruding that contributed to the injury to his hand, first aid was provided, MD was notified & resident was transported to the emergency room via ambulance, x-rays were negative for fractures, no vascular or tendon involvement to wound on index finger, p (after) assessment & wounds dressed @ emergency room res. was transported back to our nursing facility, multiple attempts were made to contact legal guardian s (without) success until 2/13/12. 15 min (minute) checks were initiated on resident when he returned, nails on door were hammered in & maintenance man came in to make needed repairs on door, an audit of all doors will also be done by maintenance, 3 day bowel & bladder tracking to be done & review of this to help c toileting plan & better anticipate resident's needs, res. will follow - up c MD for any future treatment to wounds." Nurse's Notes, dated 02/13/12 at 8:30 a.m., indicated an appointment with an orthopedic doctor. The notes indicated the resident was then sent to the hospital for surgery to take off some of the bone and pull skin up over it to help prevent infection. Notes indicated the resident returned the same evening to the facility. Notes indicated Resident #B returned to the orthopedic doctor weekly. Hand Center notes, dated 02/13/12, indicated x-rays showed amputation of the distal tuft, approximately 1/4 of the distal phalanx is missing. The resident underwent [REDACTED]. Resident #B's room was observed on a walk through of the facility on 03/02/12 at 9:45 a.m., with the Administrator present. Resident #B's bathroom door was observed to have no nails protruding out and the area of concern was covered with putty. The Administrator indicated during interview at this time, that the bathroom door had a couple protruding finishing nails near the bottom of the door and when the resident fell he slid his hand down the bathroom door and the nails cut his right index finger. Interview with the Maintenance Manager on 03/05/12 at 3:19 p.m., indicated he got a call and was told Resident #B had hurt himself. The Maintenance Manager indicated evidently the lamination came loose on the door and someone had put 3 finishing nails in the bottom of the door at the corner. The Maintenance Manager indicated the nails were barely sticking out about 1/16 of an inch. The Maintenance Manager drove the finishing nails in with a hammer and used a nail set to drive the nails in further. The Maintenance Manager then applied putty over the area. The Maintenance Manager indicated he checked all the bathroom doors and the resident room doors and no other doors were found with nails sticking out. Resident #B's right index finger was observed on 03/05/12 at 3:30 p.m., during dressing change with LPN #1 present. Resident #B's right index finger had the tip of the finger missing, no nail bed was seen, and the tip of the finger was dark black/scabbed. LPN #1 applied a new Band-Aid. Resident #B grimaced when the old bandage was removed. This federal tag is related to Complaint IN 126. 3.1-45(a)(1)

Based on record review and interview, the facility failed to plan care to prevent pressure to the heels of a resident with history of a pressure ulcer on the heel. The resident developed an unstageable ulcer with necrotic tissue to the heel. The facility also failed to identify the pressure ulcer before it became an unstageable ulcer with necrotic tissue. The deficient practice affected 1 of 4 residents (Resident #50) reviewed with a pressure ulcer in a sample of 16. Finding includes: Resident #50's clinical record was reviewed on 12/13/10 at 1:30 p.m. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A plan of care was noted, dated 7/4/10 with an update of 10/25/10 identifying a concern of "Potential for skin breakdown related to decreased mobility and weakness with [MEDICAL CONDITION], dementia, arthritis and recent hospitalization for chest pain and UTI (urinary tract infection). Approaches were noted of, but not limited to, pressure relieving device on bed/pressure reducing cushion to wheelchair, float heels when in bed, Demi boot on right foot when in bed. An Episodic Care Plan Open Area, was noted, dated 11/22/10 identifying the resident with a current pressure area to the left heel with an approach of but not limited to, float heels at all times. A skin assessment form was noted, dated 11/20/10. Part one of the form indicated, "Directions: The CNA should complete the 1st part of this form on the resident's shower day. Turn the form into your charge nurse when complete. Check any skin concerns and note location on the diagram." Part one of the form indicated no skin issues and was signed by a CNA. Part 2 of the form indicated, "Directions: The licensed nurse should check the CNA documentation, take care of any noted skin concerns, and complete the 2nd part of this form on the resident's shower day. Total the score when complete. File in the shower books until the end of the month, then file in the clinical record." RN #22 filled out the second part of the form, indicating the resident was chairfast with limited mobility, with a pressure ulcer risk as a score of 15, which represented a mild risk. Documentation of observation of any skin breakdown was not noted. An Interdisciplinary Progress Note, was noted, dated 11/22/10 indicating "Found In House Acquired Unstageable Pressure Ulcer on left heel 3.0 X 3.2 X < 0.1 (no) drainage, (no) pain, ... dry, hard black with yellow hard peeling edges........ resident is up in personal recliner during daytime et (and) wears clog type shoes (with) open back when up in recliner and suspect pressure came from recliner....." A form titled "Note for Initial Pressure Wound" was noted, dated 7/10/09, indicating the resident was admitted to the facility with a stage 2 pressure ulcer on the right heel. The form indicated the area was healed on 12/11/09. A quarterly MDS (minimum data set) was noted, dated 10/23/10, indicating the resident required extensive assist of one person for bed mobility and transfers. A "WEEKLY WOUND EVALUATION FLOW RECORD" Provided by the DON on 12/14/10 at 9:25 a.m., indicated the area on the left heel was found on 11/21/10 and measured 3.0 cm (centimeter) length X 3.2 cm (centimeter) width, with less than 0.1 depth and tissue description as Necrotic. With the most recent description dated 12/7/10, indicating the area was 3 cm X 3 cm with less than 0.1 depth with the tissue description as necrotic. During interview of LPN #23 on 12/14/10 at 3:40 p.m., the LPN indicated CNAs filled out skin assessment sheets two times a week on each resident during their shower time. The LPN indicated a nurse is then responsible for filling out the second part of the shower form and signing the form on the same day. On 12/17/10 at 10:10 a.m. during interview of the ADON (Assistant Director of Nursing) the ADON indicated the resident had an unstageable area on the left heel. The ADON indicated prior to finding the area on 11/22/10, the resident wore clog type tennis shoes that did not have covering across the back of the foot. The ADON indicated upon investigation the staff felt the resident developed the area on the left heel from sitting in a recliner, and placing the heel on the foot rest of the recliner in her room. The ADON indicated the footrest of the recliner was pretty hard. The ADON indicated the resident had a history of [REDACTED]. During the exit interview on 12/17/10, which began at 5:30 p.m., the Administrator indicated Resident #50 had only had the current recliner for a few weeks. 3.1-40(a)(1)