Every finding on record at Cobblestone Crossings Health Campus

Based on record review and interview, the facility failed to prevent physical and mental abuse of a resident by a staff member during resident transfer for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:An Indiana report form, dated 10/10/25 at 6:01 p.m., indicated CNA (Certified Nursing Aide) 2 had reported CNA 4 had rushed Resident B during care. CNA 4 was suspended, and an investigation was initiated. Residents with a BIMS (Brief Interview for Mental Status) of 8 or above were interviewed and skin checks completed on residents with a BIMS below 8 were completed. In-service trainings were started with staff. Resident B was to be monitored for psychosocial well-being.A clinical record review for Resident B was completed on 10/22/25 at 11:30 a.m. Diagnoses included Alzheimer's disease, depression, and total urinary and bowel incontinence.An admission Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident had severe cognitive impairment. She had difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and could usually understand although missed some part/intent of a message but comprehends most conversation. She had no behaviors, no delusions or hallucinations, and no rejection of care. The resident used a wheelchair for mobility and was dependent on staff for all activities of daily living. She was totally incontinent of bowel and bladder and had a fall in the last month before admission.A health care plan, dated 9/19/25, indicated resident was at risk for skin breakdown related to mobility, weakness, Alzheimer's disease, and received hospice services. The goal was for resident's skin to remain intact. Interventions included to avoid shearing skin during positioning, turning, and transferring.A health care plan, dated 9/19/25, indicated Resident B required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was the resident would have functional needs met safely by staff. Interventions included to allow resident sufficient time to complete all or parts of tasks and to not rush the resident.A health care plan, dated 9/30/25, indicated resident's profile care guide included maximum assistance of two staff members for transfers.An Investigation Summary, dated 10/12/25 at 6:00 p.m., provided by the Administrator on 10/22/25 at 12:01 p.m., indicated a staff member had reported a concern about an interaction with CNA 4 during care with Resident B. The staff member felt CNA 4 had rushed the resident during care.A nursing progress note, dated 10/10/25 at 4:40 p.m., (recorded as a late entry on 10/12/25 at 6:47 a.m.) indicated physical and psychological assessments were completed. The resident was smiling, responsive and without distress. No physical injuries were noted and no bruising was noted at this time. Will continue to observe and update as needed.A care conference note, dated 10/12/25 at 9:30 a.m., with resident's husband, indicated the following: Discussed occurrence regarding incident with team member and provided information to resident husband. Resident husband stated that resident does become combative at times, and DHS [Director of Health Services] stated that should not affect care that is given, and it is the resident's right to be treated fairly. Resident's husband stated that he was grateful for the follow-up with this situation. DSS [Director of Social Services] to continue to check on resident daily x3 days and assess for psycho-social well-being. Will continue to hold care conferences as needed and quarterly.During a telephone interview, on 10/22/25 at 12:12 p.m., CNA 4 indicated she only knew of one incident when the resident was in bed and when she reached for her brief to change her, she kicked her in the face and knocked her glasses off. She responded by picking up her glasses and leaving the room after making sure the resident was covered and safe. She returned a bit later and she was cooperative with care, and she was able to provide it. The staff told her that she had not explained what she was going to do with the resident prior to performing care and that was why she reacts in that manner. She had no problem with her prior to this. She reported that the resident kicked her in the face. She did not have any injury to her face except a small scratch where her glasses had scratched her. She was suspended about a week after this occurrence. She had no other incidents that she recalls following that. The DON (Director of Nursing) indicated that she had to jump through hoops not to report her license. The DON indicated that it was because of CNA 4's tone and attitude and that was why she was being suspended. She would not have had an attitude with Resident B due to her dementia, and she was very aware of how to care for a resident with dementia. If they start to become upset, she will leave and come back (if safe to do so). She was not told what incident they were referring too. She was fired without explanation except her tone, attitude. She has felt like the DON had it out for her since the DON started with the facility. During an interview on 12/22/25 at 1:58 p.m., the Corporate Nurse Consultant indicated she had received a phone call from the DON regarding an incident that had been reported to her where CNA 4 had rushed a resident during care. They did not think her approach was appropriate when transferring a resident. During investigation many resident's were interviewed. She indicated the residents had no concerns with the CNA or any staff members.During a telephone interview on 10/22/25 at 4:19 p.m., CNA 7 indicated when she entered Resident B's room on 10/9/25 around 8:00 p.m., the room chair (not her wheelchair) was scooted closer to the bed. CNA 4 had her left hand on the back of the chair and her right arm linked under the resident arm, pulling and yanking her up. She stopped yanking on Resident B's arm when she saw CNA 7 in the doorway. The resident was resisting getting out of the chair and trying to move away. The resident was laughing angrily with her teeth gritted and showing. CNA 4 was heard saying, come on get up, we gotta get up, in a loud voice, repetitively. CNA 7 indicated she asked CNA 4 to leave the room. CNA 4 started talking about what was going on and CNA 7 repeated her request that she leave the room. She would not leave the room. CNA 7 got on her knees next to the chair to speak with Resident B to calm her down as she was very upset. At that time, LPN 8 entered the room and asked CNA 4 to leave the room. CNA 4 left the room at that time. CNA 7 indicated she was able to calm Resident B down within about five minutes and was able to transfer her to bed without issues. During a telephone interview on 10/22/25 at 4:37 p.m., LPN 8 indicated she was outside the room when CNA 4 had been pulling and jerking Resident B's arm. Resident B had been asleep in the recliner and CNA 4 had entered the room and pulled the room chair close to the bed without speaking to the resident. The resident woke up with CNA 4 pulling her arm to transfer her to bed. Resident B got very upset. LPN 8 indicated to CNA 4 to stop what she was doing and leave the room. She indicated to CNA 4 she would find other help to transfer Resident B to bed. When she arrived back to the room, she observed CNA 7 on the floor next to Resident B's chair and CNA 4 standing on the other side of the chair. Apparently CNA 4 had returned to the room when she had gone to find CNA 7, and CNA 4 had observed her again tugging on Resident B's arm. She asked CNA 4 at that time to again leave the room.During an interview on 10/23/25 at 10:20 a.m., the Administrator indicated they had not felt the incident constituted abuse. CNA 4 would not return to the facility to speak with her about the incident, so they decided to part ways. When she spoke with CNA 4 on the telephone she was not willing to acknowledge the requests to leave the room, and truly could not understand any errors in her behavior. The Administrator did feel CNA 4 would be safe to work with a dependent resident given more training and she did not feel she needed reported to the Board of Nursing for investigation.During a phone interview on 10/23/25 at 1:04 p.m., Resident B's husband indicated the incident happened on a Friday and he was not informed until he received a phone call on Sunday at noon. The DON called and said there had been an incident on Friday. It was a little situation that escalated to a point they felt they needed to suspend the staff member. That was all he had been told. She indicated they had looked Resident B over and they had not observed any bruising or redness. He was told they were going to investigate the incident and would inform him of the details when completed. She told him that under no circumstances would they allow a resident to be treated like that and it should not have happened. The employees know it was not allowed at this facility. He felt she was trying to figure out if he was going to make a thing out of it. He remains in the dark about the specifics of what occurred. It had been a couple weeks now and he still had no specific information.During a telephone interview on 10/23/25 at 1:37 p.m., the DON indicated she had spoken to Resident B's spouse on the phone in the middle of the investigation and had told him the details of the occurrence. She indicated during her investigation she had spoken to residents and other staff members. She did not feel CNA 4 had intent to harm the resident. She did not feel it was an abuse situation due to the lack of intent. She felt CNA 4 was focused on getting her task completed of getting the resident to bed, so even though she was asked to leave by other employees, she returned to complete her task. She could not speak to what CNA 4 was thinking by returning after being asked to leave.An in-service document used for staff education, titled, Preventing, Recognizing, and Reporting Abuse & Neglect, provided by the Administrator on 10/22/25 at 12:01 p.m., included the following: Physical Abuse Definition includes hitting, slapping, pinching, spitting, holding or handling roughly, etc. It also includes controlling behavior through corporal punishment.Examples.Staff to resident abuse with or without injury; Staff member pulls a resident in order to make them move more quickly.This citation relates to Intake 2641594.3.1-27(a)(1)

Based on record review and interview, the facility failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:An Indiana report form, dated 10/10/25 at 6:01 p.m., indicated CNA (Certified Nursing Aide) 2 had reported CNA 4 had rushed Resident B during care. CNA 4 was suspended, and an investigation was initiated. Residents with a BIMS (Brief Interview for Mental Status) of 8 or above were interviewed and skin checks completed on residents with a BIMS below 8 were completed. In-service trainings were started with staff. Resident B was to be monitored for psychosocial well-being.A clinical record review for Resident B was completed on 10/22/25 at 11:30 a.m. Diagnoses included Alzheimer's disease, depression, and total urinary and bowel incontinence.An admission Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident had severe cognitive impairment. She had difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and could usually understand although missed some part/intent of a message but comprehends most conversation. She had no behaviors, no delusions or hallucinations, and no rejection of care. The resident used a wheelchair for mobility and was dependent on staff for all activities of daily living. She was totally incontinent of bowel and bladder and had a fall in the last month before admission.A health care plan, dated 9/19/25, indicated resident was at risk for skin breakdown related to mobility, weakness, Alzheimer's disease, and received hospice services. The goal was for resident's skin to remain intact. Interventions included to avoid shearing skin during positioning, turning, and transferring.A health care plan, dated 9/19/25, indicated Resident B required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was the resident would have functional needs met safely by staff. Interventions included to allow resident sufficient time to complete all or parts of tasks and to not rush the resident.A health care plan, dated 9/30/25, indicated resident's profile care guide included maximum assistance of two staff members for transfers.An Investigation Summary, dated 10/12/25 at 6:00 p.m., provided by the Administrator on 10/22/25 at 12:01 p.m., indicated a staff member had reported a concern about an interaction with CNA 4 during care with Resident B. The staff member felt CNA 4 had rushed the resident during care.A nursing progress note, dated 10/10/25 at 4:40 p.m., (recorded as a late entry on 10/12/25 at 6:47 a.m.) indicated physical and psychological assessments were completed. The resident was smiling, responsive and without distress. No physical injuries were noted and no bruising was noted at this time. Will continue to observe and update as needed.During an interview on 12/22/25 at 1:58 p.m., the Corporate Nurse Consultant indicated she had received a phone call from the DON on 10/10/25 at 4:40 p.m., indicating on 10/9/25 at around 8:30 p.m., LPN 8 had observed an incident with Resident B and CNA 4, where CNA 4 had was pulling on Resident B's arm in an effort to transfer her from her chair to her bed. An investigation was started at that time. LPN 8 had indicated to her that she had performed a head-to-toe assessment of Resident B, but had failed to document the incident or the assessment in the clinical record. She had not taken vital signs or completed a pain assessment following the incident. The facility follows their policy regarding any needed assessments. A current facility policy, undated, titled, Abuse and Neglect Procedural Guidelines, provided by the Administrator on 10/22/25 at 12:01 p.m., included the following: .Identification.ii. Any person with knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal.iv. Immediately notify the Executive Director.This citation relates to Intake 2641594.3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure foods were disposed of after the use by date, cold foods were maintained at a safe temperature on the salad bar, beard restraints were effectively worn, and employee drinks were not kept in food prep areas during 4 of 4 kitchen observations. This deficient practice had the potential to affect 40 of 40 residents who received food from the kitchen. Findings include:During an initial kitchen tour with the Food Services Director, on 8/21/25 at 10:20 a.m., a container of French toast mix was labeled with a use by date of 8/19/25. At the same time, the Food Service Director indicated the date on the container was the last date the food was able to be used, and she disposed of the French toast mix. During a continuous lunch observation, on 8/21/25 from 11:30 a.m. to 12:06 p.m., a salad bar was observed with cottage cheese and hard boiled eggs. Three residents were served food from the salad bar. At 12:06 p.m., the Food Services Director indicated the temperature of the cottage cheese was 53 degrees Fahrenheit (F), and the temperature of the hard boiled eggs was 55 degrees F. The Food Services Director indicated foods on the salad bar should have been held at 40 degrees F or below, and she removed the food from salad bar. During a kitchen observation, on 8/26/25 at 9:15 a.m., [NAME] 9 was placing food onto a plate. [NAME] 9 was wearing a beard cover, but it was pulled down below his mouth, exposing his mustache. During a kitchen observation, on 8/26/25 at 10:42 a.m., Dietary Corporate Support 10 was filling small cups with condiments. In the same area an unopened energy drink was observed. At the same time, the Food Service Director indicated employee drinks should not have been in food prep areas, and she threw the drink away. During an interview, on 8/26/25 at 10:53 a.m., the Food Services Director indicated all facial hair was required to be contained in the beard cover. The employee's beard cover should not have been pulled down below his mustache. On 8/22/25 at 8:55 a.m., the Executive Director (ED) provided a document titled, Food Production Guidelines, last revised on 7/9/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this policy is to: To provide clear direction and understanding of safe and sanitary handling of food during food production.Policy: Safe and sanitary handling of food will be employed during food production. Procedure.5. Food is served as soon after preparation as possible and is held at the following.Hold food-COLD = 41 F or below. 6. Leftovers must be dated, labeled, covered, and immediately refrigerated or frozen for later use. Refrigerated leftover must be used within 72 hours. On 8/26/25 at 11:35 a.m., the Regional Nurse Consultant provided a document titled, [NAME] and Hairnet, last revised on 7/9/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this policy is to: Beards and mustache hair must be covered while in kitchen food product areas. Facial hair restraints are required in any food production area. Facial hair is not exempt from the hair restraining standard.Procedure: Some common approaches include: cover all beard or mustache hair that is more than 1/8 of an inch growth. On 8/26/25 at 11:58 a.m., the Regional Nurse Consultant provided an untitled, undated document and indicated it was the policy currently being used by the facility. The policy indicated, .410 IAC [Indiana Administrative Code] 7-24-136 Eating, drinking.Sec. 136. (a) Except as specified in subsection (b), an employee shall.eat and drink food.only in designated areas where the contamination of: (1) exposed food.cannot result. (b) A food employee may drink from a closed beverage container if the container is handled in a manner that prevents contamination of the following.(3) Exposed food. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure assistance was provided for activities of living (ADLs) for residents unable to carry out ADLs on their own for 4 of 16 residents reviewed for ADLs (Residents 34, 3, 11, and 36). Findings include: 1. On 8/21/25 at 2:57 p.m., Resident 34 was observed with long, untrimmed fingernails, with dark debris underneath them, on both hands. On 8/25/25 at 10:06 a.m., Resident 34 was observed with long, untrimmed fingernails, with dark debris underneath them, on both hands. Resident 34's record was reviewed on 8/22/25 at 10:26 a.m. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia with agitation and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident had a moderate cognitive impairment and required substantial/maximal assistance from staff for personal hygiene. A profile care guide care plan, dated 3/22/25, indicated the resident was scheduled for a shower on Tuesdays and Fridays day shift. Point of care bathing documentation, dated July 2025, indicated the resident received four showers during the month. The point of care record lacked documentation the resident refused care. Point of care bathing documentation, dated August 2025, indicated the resident received one shower during the month. The point of care record lacked documentation the resident refused care. Progress notes, dated July and August 2025, lacked documentation the resident refused bathing, showers, or nail care. During an interview, on 8/25/25 at 10:38 a.m., Licensed Practical Nurse (LPN) 7 indicated fingernail care should have been completed with showers. Activities also provided manicures once a week. There were no paper shower sheets anymore, and bathing was documented in the electronic record. If the resident refused a shower, they should have had the resident sign something stating they refused, but that normally would have been the paper shower sheet. Since they no longer used paper, she was not sure what the resident should have signed with refusals. The aides should have documented any care refusals in the electronic record. During an interview, on 8/25/25 at 1:20 p.m., the Regional Nurse Consultant indicated nail care should have been provided with showers and as needed, but there was no specific facility nail care policy. Showers should have been provided as scheduled, and shower refusals should have been documented for each scheduled shower. Resident 34 refused care at times, but she was unable to provide documentation the resident refused showers or nail care. 2. On 8/21/25 at 2:06 p.m., Resident 3 was observed with a full beard and mustache. At the same time, the resident indicated he had not received a shower since his admission because he had a port in his chest for dialysis, and the staff did not want to get it wet. The resident wanted to be clean shaven and asked to be shaved several times. The resident indicated the staff told him he needed to be on the list to be shaved. On 8/25/25 at 10:07 a.m., the resident was observed with a full beard and mustache. At the same time, the resident indicated he had not been shaved since his admission to the facility despite asking staff for assistance numerous times. He did not want to have a beard. Resident 3's record was reviewed on 8/26/25 at 10:02 a.m. Diagnoses on the resident's profile included, but were not limited to, end stage renal disease (condition in which the kidneys have permanently lost their ability to function properly) and dependence on renal dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so). Census information indicated the resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the resident had a moderate cognitive impairment and required substantial/maximal assistance from staff for showers and bathing. Progress notes, dated July and August 2025, lacked documentation the resident refused showers or shaving. A Life Enrichment Assessment, dated 8/4/25, indicated it was very important to the resident to choose the type of bath he received, and he preferred showers. A profile care guide care plan, dated 8/5/25, indicated the resident was scheduled for a shower on Mondays and Thursdays, evening shift. An ADL care plan, dated 8/5/25, indicated the resident required staff assistance to complete self-care and mobility functional tasks completely and safely. Interventions included, but were not limited to, offer facial shaving on shower days, as needed, or as requested, and notify the nurse of refusals. Point of care bathing documentation, dated August 2025, indicated the resident received one shower during the month. The bathing record lacked documentation the resident refused showers. During an interview, on 8/26/25 at 1:57 p.m., the Regional Nurse Consultant indicated residents' bathing preferences were determined during the life enrichment assessment. The shower schedule was updated according to this assessment. During an interview, on 8/26/25 at 2:00 p.m., Certified Resident Care Assistant (CRCA) 11 indicated residents should have been shaved with showers and as needed. She was not told anything about Resident 3's beard and just thought he wanted a long beard. The resident was scheduled for showers. 3. On 8/21/25 12:09 p.m., during an initial observation and interview Resident 11 indicated there was not enough staff to provide for her care needs, and she had not received a shower since admission. She had requested a shower and none had been given. On 8/22/25 9:46 a.m., during an interview the resident indicated she still had not received a shower. Noted her hair was oily and unkept. Resident indicated she wanted her hair washed. On 8/22/25 at 10:00 a.m., the medical record of Resident 11 was reviewed. The record indicated the resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side and right dominant side, type 1 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and 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). An admission Minimum Data Set (MDS) assessment, dated 8/13/25, indicated the resident required assistance with bathing and transfers and indicated the resident's cognition was moderately impaired. A care plan, dated 8/20/25, indicated the resident required assistance with daily care needs. Interventions included but not limited to assist with ADL (activities of daily living) care as needed. A care plan, dated 8/11/25, indicated Profile Care Guide, interventions included but not limited to shower Tuesday and Friday evenings. The record lacked documentation of showers being administered since admission to the facility on 8/8/25. The nurse progress notes lacked documentation of resident refusals. On 8/22/25 at 2:10 p.m., during an interview the Regional Nurse Consultant (RNC) indicated the residents should have a shower at a minimum of twice weekly unless the resident had an alternate preference. On 8/25/25 at 10:13 a.m., during an interview the RNC indicated the resident had refused several offers of showers. She indicated the software system did not indicate the refusal by the resident. She indicated the care plan had not included shower preferences. 4. On 8/21/25 at 2:01p.m., during initial observation and interview noted Resident 36 with heavy beard growth. During interview the resident indicated he preferred to be shaved, and the staff usually shaved him or assisted him to shave. He could not remember the last time he had been shaved. On 8/22/25 at 2:45 p.m., the medical record of Resident 36 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but were not limited to paroxysmal atrial fibrillation and Congestive Heart Failure (CHF). A quarterly MDS, dated [DATE], indicated the resident required assistance with daily care needs and was cognitively intact. A care plan, dated 3/6/25, indicated resident will have functional needs met safely by staff. A care plan, dated 3/6/25, indicated showers will be administered on Monday and Thursday evenings. A care plan, dated 3/6/25, indicated to offer facial shaving on shower days, prn (as needed), or as requested. Notify nursing of refusals. A review of the medical record indicated the resident did not receive a shower from 5/26/25 to 8/7/25. From 8/7/25 to 8/25/25 the resident received two showers and the months of The record indicated other was provided 24 times. On 8/25/25 at 10:13 a.m., during an interview the RNC indicated she did not know what other indicated on the care record. On 8/26/25 at 9:27 a.m., during an interview Licensed Practical Nurse (LPN) 4 indicated she was not sure of the policy regarding shaving, but she assumed it was to be done on shower days or if they ask. On 8/26/25 at 9:34 a.m., during routine observation noted the resident had not been shaved and had a heavy beard growth. He indicated he was planning to have the staff assist him to shave. The resident could not recall when he had been administered a shower. On 8/26/25 at 11:35 a.m., the RNC provided a document titled, Guidelines for bathing preferences, dated 12/17/24, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The resident shall determine their preference for bathing upon admission. A. Day of week. B. Time of day – morning or evening. Type of bathing – tub bath, bed bath or shower.4. Bathing shall occur at least twice a week unless resident preference states otherwise. 3.1-38(a)(3)

Based on record review and interview, the facility failed to notify the physician and resident representative of the unavailability of medication and refusal of medication by the resident for 1 of 5 residents reviewed for unnecessary medications (Resident 4). Findings include:On 8/22/25 at 11:01 a.m., the medical record of Resident 4 was reviewed. The record indicated the resident was admitted to the facility on [DATE]. Admitting diagnosis included but was not limited to, respiratory failure (a serious medical condition where the lungs are unable to provide enough oxygen to the body or remove enough carbon dioxide, or both) with hypoxia (a condition where the lungs can't get enough oxygen from the air into the blood), unspecified dementia (a group of brain disorders that cause a gradual decline in cognitive abilities), unspecified mood affective disorder (a category of mental illness where a person's persistent emotional state is significantly disturbed, leading to extreme highs or lows).A care plan, dated 2/17/25, indicated social aspects, Dementia. Interventions included but were not limited to administer medications per orders.A care plan, dated 7/2/25, indicated the resident was at risk for pain. Interventions included but were not limited to administer medications as ordered and notify MD (medical doctor) for any side effects observed or lack of effectiveness.A physician order indicated to administer Colace 100 mg (milligram) 1 tablet once daily, for constipation.A physician order indicated to administer a multivitamin tablet 1 daily.A physician order indicated to administer Eliquis 5 mg twice daily for anticoagulant (blood thinner)A physician order indicated to administer Lasix 20 mg once daily for edema (swelling)A physician order indicated to administer Sertraline 100 mg once daily for depressionA physician order indicated to administer Tramadol - Schedule IV (narcotic) 50 mg three times a day for pain.A physician order indicated to administer Ciloxan (Ciprofloxacin) ointment 3%, 1 drop each eye every 4 hours, antibiotic eye drops.Review of the Electronic Medication Administration Record (EMAR) from 6/1/25 to 6/30/25 indicated the resident refused 18 doses of Eliquis 5 mg, refused 5 doses of Lasix 20 mg, and refused 34 doses of Tramadol 50 mg.From 7/1/25 to 7/31/25, the resident refused 18 doses of Eliquis and refused 37 doses of Tramadol.From 8/1/25 to 8/22/25, the resident refused 12 doses of Ciloxan, and refused 8 doses were unavailable from the pharmacy. The resident refused 6 doses of Eliquis and refused 23 doses of Tramadol.The medical record lacked documentation the Physician or resident representative were notified of medication refusal or of the medication being unavailable from the pharmacy for July 2025 or August 2025.A quarterly Minimum Data Set Assessment, dated 8/18/25, indicated the resident was cognitively impaired.On 8/26/25 at 9:00 a.m., during interview the Regional Nurse Consultant (RNC) indicated the resident had refused antibiotic eye drops several times and the staff had difficulty administering them to her.On 8/26/25 at 9:15 a.m., during interview Licensed Practical Nurse (LPN) 4 indicated the policy was to notify the physician and the family if a resident refused medications.She indicated if it was a more serious medication she would notify the physician immediately of any refusals.On 8/25/2025 at 1:19 p.m., the RNC provided a document, titled, Physician-Provider notification Guidelines, dated 12/17/24, and indicated it was the policy currently being used by the facility. The policy indicated, . The purpose of this policy is to ensure the resident's physician or practitioner.is aware of all diagnostic testing or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care.11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record.3.1-5(a)

Based on observation, record review, and interview, the facility failed to ensure resident's confidential information was maintained in a secure and private manner for 3 of 3 random observations (Residents 18, 3, and 43). Findings include:1.During a random observation, on 8/26/25 at 11:01 a.m., the 200-hall medication cart was unattended. The computer screen was open and Resident 18's medication screen was exposed. At the same time, another resident was standing directly next to the medication cart, looking on top of the cart as if she was looking for something. Two visitors were speaking with a resident outside of a room directly across from the medication cart. On 8/26/25 at 11:09 a.m., Certified Resident Medication Aide (CRMA) 5 returned to the medication cart, then immediately walked away from the cart again, and went into the pantry room to get a resident some ice, without closing the computer and securing Resident 18's personal information. On 8/26/25 at 11:11 a.m., CRMA 5 returned to the medication cart and began assisting another resident. She failed to close the lid to the computer until the screen went to sleep mode. Resident 18's record was reviewed on 8/26/25 at 11:23 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (a long-term condition where the lungs struggle to get enough oxygen into the blood, leading to a dangerously low oxygen level in the body's tissues and organs) and atrial fibrillation (a condition where the upper chambers of the heart [atria] beat irregularly and rapidly). A quarterly Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident had no cognitive deficit. During an interview, on 8/26/25 at 11:20 a.m., the Regional Nurse Consult indicated the resident's private information should not have been exposed. The computer should be closed when the staff is not at the medication cart. During an interview, on 8/26/25 at 11:39 a.m., Resident 18 indicated her privacy was very important to her and she did not want her personal information exposed for anyone to see. 2. During the medication administration pass, on 8/26/25 at 8:12 a.m., Certified Resident Medication Aide (CRMA) 5 walked away from the medication cart and entered a resident's room down the hallway. The computer screen was open and Resident 3's medication screen was exposed along with her name, date of birth , age, allergies, and code status. There were 2 residents sitting near the medication cart and other residents ambulating down the hallway at the time. The CRMA didn't return to the cart until 8:16 a.m. Resident 3's record was reviewed on 8/27/25 at 8:23 a.m. The profile indicated the resident's diagnoses included, but were not limited to, metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), meningitis (acute or chronic inflammation of the protective membranes covering the brain and spinal cord), and non-Hodgkin lymphoma (condition occurs when the body produces too many abnormal lymphocytes, a type of white blood cell). An admission Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the resident had moderate cognitive impairment. 3. During a random observation, on 8/26/25 at 1:19 p.m., the back 200 hall medication cart computer was open and Resident 43's medication screen was exposed along with her name, date of birth , age, allergies, and code status. There were no staff around at this time and 2 residents were in the sitting area by the medication cart. CRMA 5 returned to the cart at 1:20 p.m. Resident 43's record was reviewed on 8/27/25 at 8:27 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (a condition where the lungs are unable to provide enough oxygen to the body over a prolonged period, leading to low oxygen levels in the blood) and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated the resident was cognitively intact. During an interview, on 8/27/25 at 8:28 a.m., Licensed Practical Nurse (LPN) 12 indicated when she walked away from her medication cart, she would make sure that she minimized the computer screen, or hit the walk away button so that residents' private information wasn't exposed to anyone walking by. On 8/25/25 at 1:19 p.m., the Regional Nurse Consultant (RNC) provided a document with a date of 11/21, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.2. Our residents have a right to.C. Have their records containing personal and financial information kept confidential. 3.1-3(o)

Based on record review and interview, the facility failed to ensure medication was administered after a critical lab result and labs were re-checked as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications (Resident 34). Findings include:Resident 34's record was reviewed on 8/22/25 at 10:26 a.m. Diagnoses on the resident's profile included, but were not limited to, hypokalemia (low potassium) and unspecified atrial fibrillation (irregular and rapid heart rate). A quarterly Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident had a severe cognitive impairment. A lab report, dated 7/9/25, indicated the resident had a low potassium level of 3.4 millimoles (mmol)/liter (L). The normal range was 3.5 to 5.1 mmol/L. A lab report, dated 8/5/25, indicated the resident had a critically low potassium level of 2.6 mmol/L. The lab reported the critically low potassium to the facility at 5:42 p.m. An abnormal, critical lab event, dated 8/5/25, indicated the resident's potassium level was 2.6 mmol/L, which was a critically low level. The physician and resident representative were notified. A Medication Administration Record (MAR), dated August 2025, included the following physician's orders: -A physician's order, dated 6/27/25 and discontinued on 8/5/25, indicated potassium chloride extended release particles/crystals 20 milliequivalents (mEq) by mouth twice daily. -A physician's order, dated 8/5/25, indicated potassium chloride extended release particles/crystals 20 mEq, administer 40 mEq, one time only at 5:30 p.m. The MAR indicated the medication was not administered because it was unavailable. The MAR lacked documentation the physician was notified of the missed medication administration. -A physician's order, dated 8/5/25, indicated potassium chloride extended release particles/crystals 20 mEq, administer 40 mEq, one time only at 11:30 p.m. The MAR indicated the medication was not administered because it was unavailable. The MAR lacked documentation the physician was notified of the missed medication administration. -A physician's order, dated 8/6/25, indicated potassium chloride tablet extended release 20 mEq, give 40 mEq daily. A nursing progress note, dated 8/5/25, indicated the lab called to report a critical potassium level. The physician was notified, and new orders were received. An interdisciplinary team (IDT) progress note, dated 8/6/25, indicated a critical potassium lab was reported to the physician, and new orders were received. The note lacked documentation the physician was notified the medication was not administered as ordered. A pharmacy recommendation observation, dated 8/12/25, indicated the resident's potassium level was 2.6 mmol/L on 8/4/25. The resident's diuretic medication was reduced. The pharmacist recommended the lab be re-checked. The recommendation lacked documentation the extra doses of potassium were not administered as ordered by the physician. The physician accepted the recommendation and agreed to re-check the lab. A lab report, dated 8/23/25, indicated the resident had a critically low potassium of 2.7 mmol/L. The resident's record lacked documentation the resident's potassium level was re-checked prior to 8/23/25. A progress note, dated 8/23/25 at 10:41 a.m., indicated the lab notified the facility the resident had a critically low potassium level. The physician was notified and ordered a one-time dose of potassium 40 mEq by mouth. The note lacked documentation the physician was notified the previous extra doses of potassium were not administered. A progress note, dated 8/23/25 at 5:36 p.m., indicated the resident was given 40 mEq of potassium due to lab results. During an interview, on 8/22/25 at 1:40 p.m., the Regional Nurse Consultant indicated although the resident already had potassium ordered, medications came pre-packaged per med pass, and there were no extra doses of potassium available. Potassium was available in the emergency drug kit (EDK), but she thought the nurse had trouble accessing it. The potassium should have been pulled from the EDK and administered to the resident, on 8/5/25. If the potassium was not administered, the physician should have been notified. The physician did not order the lab to be re-checked at that time. During an interview, on 8/22/25 at 3:13 p.m., the Regional Nurse Consultant indicated she reviewed what was available in the EDK, and the potassium in the EDK was a different formulation than what was ordered. The nurse should have notified the physician what potassium was available in the EDK. There was also a back-up pharmacy they could have ordered potassium from to be delivered to the facility. During an interview, on 8/25/25 at 10:12 a.m., the Regional Nurse Consultant indicated the lab was drawn to re-check the resident's potassium level on 8/14/25, after the physician agreed to the pharmacy recommendation on 8/12/25. There was a problem with the specimen and the lab was not completed. She was not sure if the lab had been re-drawn. During an interview, on 8/25/25 at 11:52 a.m., the Regional Nurse Consultant indicated the lab was re-drawn on 8/23/25 to re-check the resident's potassium level. The lab should have been re-drawn before 8/23/25, but it had been missed. The lab faxed notifications if there were issues with labs, and the fax may have been missed. On 8/22/25 at 3:13 p.m., the Regional Nurse Consultant provided an undated list of medications available in the EDK. The list indicated potassium chloride 20 mEq/15 milliliters (ml) and potassium chloride extended release 10 mEq capsules were available in the EDK. On 8/22/25 at 3:13 p.m., the Regional Nurse Consultant provided a document titled, Medication Orders, last revised in January 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.Procedures.D. The prescriber is contacted by facility personnel for direction when delivery of a medication will be delayed or the medication is not or will not be available. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (catheter-a thin, flexible tube inserted into the bladder to drain urine, which is held in place by a small, inflatable balloon and connected to a drainage bag) was maintained in a sanitary condition, for 1 of 2 residents reviewed for urinary catheters (Resident 33). Findings include:During an initial observation, on 8/21/25 at 12:05 p.m., Resident 33 was in the therapy room sitting in her wheelchair (WC). The resident's catheter bag (receptacle to collect urine) was in contact with the floor. During a random observation, on 8/21/25 at 1:59 p.m., the resident was sitting in her WC in the lounge area. Her catheter bag was in contact with the floor. During a random observation, on 8/25/25 at 1:32 p.m., the resident was asleep in her bed. The catheter bag was hanging from the side of the bed. The bag was in contact with the base of her overbed table (a mobile, adjustable-height table designed to be rolled over a bed, chair, or couch to provide a convenient surface for eating, working, or holding personal items while a person is in a recumbent or seated position). Resident 33's record was reviewed on 8/26/25 at 9:00 a.m. The profile indicated the resident diagnoses included, but were not limited to, flaccid neuropathic bladder (when the bladder cannot effectively squeeze to empty itself, leading to urinary retention and potential overflow, caused by nerve damage). An admission Minimum Data Set (MDS) assessment, dated 7/17/25, indicated the resident had moderate cognitive deficit and had an indwelling urinary catheter. A care plan, dated 8/20/25, indicated the resident had an active diagnosis of urinary tract infection (UTI-an infection in any part of your urinary system, most caused by bacteria that enter the body and multiply in the bladder). Interventions included, but were not limited to, use proper infection control precautions as indicated and per policy. The record lacked documentation of a specific care plan related to the resident's catheter. A McGeer's criteria (standardized definitions and guidelines for diagnosing infections in long-term care [LTC] residents, used for surveillance to identify actual infections and estimate their prevalence, not for guiding immediate treatment decisions) infection tracking report, dated 8/19/25, indicated the resident had a healthcare acquired (developed in the facility) UTI. During an interview, on 8/26/25 at 9:16 a.m., the Regional Nurse Consultant indicated the expectation was that catheter bags, or the tubing should never be allowed to contact the floor or any other object. ON 8/26/25 at 11:36 a.m., the Regional Nurse Consultant provide a document, dated 12/16/24, titled, Preserving Dignity with Indwelling Catheter, and indicated it was the policy currently used by the facility. The policy indicated, .1. General guidelines.e) Urinary drainage bags and catheter tubing should be kept from touching the floor surface. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure lab tests were completed as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 6). Findings include:Resident 6's record was reviewed on 8/25/25 at 9:04 a.m. The profile indicated the resident's diagnoses included, but were not limited to, alcoholic cirrhosis of the liver (severe, irreversible scarring of the liver caused by long-term, heavy alcohol use) and unspecified psychosis (when a person exhibits symptoms of psychosis, such as hallucinations or delusions, but the information is insufficient to diagnose a specific psychotic disorder). A quarterly Minimum Data Set (MDS) assessment indicated the resident had no cognitive deficit and indicated no documented behaviors. A care plan, dated 12/17/24, indicated the resident had a history of inappropriate behaviors. A care plan, dated 2/21/19, indicated the resident had a history of altered behaviors. A pharmacy recommendation, dated 12/24/24, recommended to draw a CMP (complete metabolic panel-a group of blood tests that measures 14 different substances in the blood to assess the body's chemical balance and overall health), CBC (complete blood count- a common blood test that measures the number of different cells in the blood), B-12 ( a medical test that measures the amount of vitamin B12 [an essential nutrient vital for making healthy red blood cells, keeping nerves and brain cells healthy] in the blood), TSH (thyroid stimulating hormone- measures the amount of TSH in the blood, which is produced by the pituitary gland to signal the thyroid gland to make thyroid hormones), and FT3 (measures the amount of free or active triiodothyronine [T3 hormone- a thyroid hormone that regulates your metabolism, energy use, and body temperature by controlling the speed at which your body uses calories] circulating in the bloodstream). The document indicated the physician accepted the recommendation to get the lab work completed. The record lacked documentation that the lab work had been completed as ordered. During an interview, on 8/25/25 at 11:52 a.m., the Regional Nurse Consultant indicated she was unable to locate any of the labs that had been ordered. She was unaware why the lab work had not been completed as ordered. She was unable to find any progress notes to explain why the labs had not been completed. When the physician agreed with the pharmacy recommendation for the labs, it was the physician's order to complete the lab work. On 8/25/25 at 11:55 a.m., the Regional Nurse Consultant provide a document, dated 9/12/17, titled, Physician-Provider Notification Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure. 1. Resident.ordered labs and/or other diagnostic tests should be completed in a timely manner. 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure expired medication was disposed of and failed to ensure medication was stored properly for 1 of 4 medication carts reviewed for medication storage. (Resident 16).Findings include:1. On [DATE] at 8:45 a.m., the back 200 hall medication cart contained an opened insulin pen with an open date of [DATE]. The insulin pen contained a label that indicated it was for Resident 16. During an interview, on [DATE] at 8:46 a.m., Certified Resident Medication Aide (CRMA) 5 indicated insulin was good for 28 days once opened and the pen should have been discarded because it was expired.Resident 16's record was reviewed on [DATE] at 9:29 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus with hyperglycemia (a chronic condition that happens when you have persistently high blood sugar levels). A physician order, dated [DATE], indicated to administer insulin lispro (insulin medication) 100 unit/ml (milliliter), give 5 units by subcutaneous (under the skin) injection before meals, three times a day. 2. On [DATE] at 8:29 a.m., the back 200 hall medication cart contained an opened multi-use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution and had an open date of [DATE]. The vial contained a pharmacy label that indicated the vial was to be refrigerated. During an interview, on [DATE] at 8:30 a.m., Certified Resident Medication Aide (CRMA) 5 indicated she was unaware of how long the Aplisol vial had been in the medication cart and when the vial was not in use it should be refrigerated. She indicated the vial would have to be disposed of since it was not refrigerated and she had no idea how long it hadn't been refrigerated.On [DATE] at 11:36 a.m., the Regional Nurse Consultant (RNC) provided a document with a revised date of 11/18, titled, Medication Storage in the Facility, and indicated it was the current policy being used by the facility. The policy indicated, .1) A date opened sticker shall be placed on the medication.The expiration date of the vial of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guideline require different dating.E. The medication administration personnel will check the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. G. All expired medication will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.On [DATE] at 1:28 p.m., the RNC provided an undated document, titled, Tuberculin PPD-Aplisol Bioequivalent, and indicated it was the currently policy being used by the facility. The policy indicated, .The product should be stored between 2 degrees and 8 degrees Celsius (36- and 46-degrees Fahrenheit) and protected from light. 3.1-25(j)3.1-25(m)

Based on interview and record review, the facility failed to complete thorough assessments for a resident with edema, lower extremity conditions, and weight gain for 1 of 3 residents reviewed for quality of care (Resident B). Findings include: A review of Resident B's clinical record was completed on 6/19/25 at 10:46 a.m. Diagnoses included liver disease, dementia, acute kidney failure, ascites, localized edema, and severe protein-calorie malnutrition. The resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was severely cognitively impaired, was dependent on staff for showering, lower body dressing, bed mobility, and moving from sit to stand. The resident's weights were as follows: a. admission weight was recorded on 4/4/25 at 85.4 lbs (pounds); b. On 5/9/25, approximately 1 month post admission, the resident's weight had increased 15.22% to 98.4 lbs. c. At the time of discharge, on 5/29/25, the resident's weight had increased 24.12% to 106 lbs. Acute Care Hospital Progress note, dated 3/24/25, indicated Resident B had been admitted to the hospital on [DATE] following a right femur fracture as a result of a fall at home. The note included mild to moderate free fluid to right upper quadrant of the abdomen and moderate volume ascites (abnormal buildup of fluid in the abdomen, specifically within the peritoneal cavity), small-moderate left pleural effusion (fluid around the lung), difuse body wall edema complatible with anasarca (a severe, generalized swelling due to an excessive buildup of fluid in the body's tissues). The note included plans for further evaluation of ascites when medically ready following plan to discharge to the extended care facility. A Clinically at Risk assessment, dated 5/9/25, indicated the resident had a significant weight gain. The potential cause was indicated as due to a change in meal intake and eating much better. The resident had been receiving fortified foods and nutritional supplements. The physician was notified and agreed to changes of condition, new orders, and plan of care. The resident's family was notified and agreed to changes of condition, new orders, and plan of care. A New Onset of Edema Event, dated 5/25/25, indicated the resident had edema to her left and right legs and feet. The severity was indicated as 1 plus pitting edema and was present bilaterally. Interventions indicated to administer diuretic, apply elastic stockings, elevate extremities, and administer antibiotics. During a telephone interview on 6/19/25 at 1:20 p.m., Resident B's family member indicated she had complained to staff multiple times about the resident's increasing abdominal size and swelling in her lower legs. This just fell on deaf ears. The physician indicated not to worry about it and just blew off the swelling in the resident's legs. The staff ended up putting compression stockings on the resident that caused hematomas and dark discoloration and were very painful. She refused to allow staff to apply the stockings after seeing what the stockings did to the resident's legs after just one day. She took the resident to her regular primary care physician and he had her transferred to a local emergency room for evaluation because of her condition. The local emergency department performed multiple tests before transferring her to a larger hospital for treatment. She indicated the hospital performed a procedure to drain a large amount of fluid from the resident's abdomen. Her biggest complaint about the facility was they would not listen to her concerns about the resident's increased fluid retention. The facility told her over and over, the resident was just gaining weight from better nutrition. The facility basically just ignored her concerns and the resident's discomfort. When the resident was transferred to the acute care hospital from the emergency department visit, she was admitted and eventually had three liters of fluid drained from her abdomen. During an interview on 6/19/25 at 2:59 p.m., the Nurse Consultant indicated the resident had been see by the facility physician two times during her stay. When she first came into the facility she had swelling on her right lower extremity. She had some weight loss and was started on supplements. She began to develop edema in her bilateral lower extremeties and the physician was aware. She felt the physician was contacted and had provided orders. A nursing progress note, dated 5/29/25 at 12:26 p.m., indicated the resident had no edema to her bilateral lower extremities. The Emergency Department records were obtained on 6/20/25, and indicated on 5/29/25 at 5:11 p.m, the physician examined the resident's legs to be swollen and cold to touch. The resident had presented to the emergency room complaining of intermittent bilateral lower extremity swelling. The resident's family member indicated she was concerned about the resident's weight gain and development of a hematoma on the left lower extremity during her stay at the rehabilitation facility. The assessment indicated the resident had 2 to 3 plus pitting edema to her bilateral lower extremities. Her arms were equally cold to touch. There was a blood blister on the resident's left shin. The resident was sent to the emergency department by her primary care physician for concerns with leg swelling. The resident's family member had indicated she was treated for a femur fracture from a fall and had been at a nursing home for rehabilitation. She reported the resident had declined since being there, had bilateral lower extremity edema and a blister to her shin now. Her abdomen was more distended than usual per the resident. The resident was discharged to an another acute care hospital from the emergency department on 5/29/25 at 10:01 p.m. for further treatment. The acute care hospital was contacted and additional hospital records requested with no response. During an interview on 6/20/25 at 10:24 a.m., the Wound Nurse indicated the resident was examined 5/27/25. It had been reported that the resident had been having problems with edema in the evenings. She had 1 plus pitting edema to her bilateral lower extremities and her legs were discolored and a purpilish color for her entire stay. A blister developed after her compression stockings had been removed that had been applied on 5/25/25. She saw her on 5/26/25 and the blister had reabsorbed. She was not aware of any abdominal swelling or weight gain. During an interview on 6/20/25 at 3:03 p.m., the Nurse Consultant indicated the resident's edema had been documented as present in some assessments and absent in some assessments. On 5/29/25, the documentation of no edema was entered for the nursing assessment. The resident's emergency department documentation of 2 to 3 plus edema on assessment on the day of her visit which was 5/29/25 and the documentation of no edema, as entered by the facility nurse assessment, could have been in error, and she could not say if it was present, but she had to go with what the nurse had documented as no edema. A facility policy for Change of Condition was provided, but lacked a policy regarding this concern. This citation relates to Complaint IN00461032. 3.1-37(a)

Based on interview and record review, the facility failed to protect a resident during a dressing removal resulting in a laceration to her left lower extremity caused by bandage scissors for 1 of 3 reviewed for nursing services (Resident B). Findings include: During a telephone interview on 6/19/25 at 1:20 p.m., Resident B's family member indicated the laceration sustained during a wound dressing change had become infected and was treated with an oral antibiotic. It was almost healed now and had a small scab at the end of the cut remaining. She was upset when the event occured and she felt the nurse was not competent regarding the dressing removal. The laceration should have never occurred and was another thing the resident had to heal from. During an interview on 6/20/25 at 9:40 a.m., LPN 2 indicated she was in the middle of medpass on 4/1/25 when Resident B's family member asked her to come take off a dressing on the resident's left knee because she felt it was too tight. She paused her medpass and went to the resident's room. The dressing was gauze wrapped around her knee and was about 4-5 inches in width. She inserted the dull end of her bandage scissors under the dressing and to cut the dressing. The resident moaned a little as she was cutting the dressing. When she had finished and removed the gauze, she noted there was a superficial cut into the resident's skin that was about three inches long. The cut was scantly bleeding. She cleaned it with wound wash and covered it with a white bordered dressing. The gauze dressing that was removed was covering a small, V-shaped skin tear. She notified the ADON and the physician. The family member was very upset and LPN 2 apologized to the family member. She had not seen the wound since it happened and was unaware of the condition of the wound following the event. The resident had edema and the dressing was tight. She felt the skin was puffy under the dressing from the edema and caused the cut. She felt that since the dressing was so tight, she should have unwrapped the dressing as opposed to cutting through it. A review of Resident B's clinical record was completed on 6/19/25 at 10:46 a.m. Diagnoses included liver disease, dementia, ascites, and edema. An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was severely cognitively impaired was dependent on staff for showering, lower body dressing, bed mobility, and moving from sit to stand. A nursing progress note, dated 4/1/25 at 8:54 p.m., indicated LPN 2 was in Resident B's room when her family member pointed out a dressing on resident's left knee and indicated it was too tight and needed removed. The dressing was dated 3/30/25. LPN 2 cut off the old dressing to the left knee and the dressing scissors accidentally cut into resident's skin causing a cut 8 cm (centimeters) by 0.1 cm with scant bleeding. She cleansed the area and applied a dressing. The family member had been in the room and was very upset. The physician was notified by text message. The ADON was notified by phone call. Wound Management Detail Reports regarding a left calf skin tear below a wound on her left knee, included the following: a. Initial observation, dated 4/2/25, entered by LPN 2 indicated the resident had a cut to her left upper calf, measuring 8 cm by 0.1 cm. b. Observation, dated 4/9/25, entered by the ADON indicated the wound was improving with some bruising around the site. The physician had ordered a prophylactic oral antibiotic and bacitracin to the site. The measurements remained the same. c. Observation, dated 5/26/25, entered by the wound nurse, indicated the wound had healed. Measurements indicated 0 cm x 0 cm. An interdisciplinary team (IDT) note, dated 4/2/25 at 10:05 p.m., indicated the nurse from the evening shift was asked by Resident B's family member to remove a bandage that was in place to her left knee. The family member had concerns regarding the bandage being tight related to swelling that was present to her left lower extremity. When the nurse removed the dressing, the bandage scissors came in contact with the resident's skin making a very superficial linear cut. The nurse was able to stop the bleeding and cleansed the area and applied a dressing. The physician was notified. The family member was present when this occurred. Education was provided to the nurse on removal method of a bandage. Area was assessed today by the wound nurse and a dressing order was updated accordingly for the area of impairment. A nursing progress note, dated 4/6/25 at 8:17 a.m., indicated the physician observed the resident's wound to her left calf. The physician ordered laceration to be cleaned and bacitracin applied and covered with a dressing. The physician ordered Keflex (an antibiotic to treat infection) 500 mg (milligram), take three times daily for 10 days as a prevention measure to prevent infection. He ordered a tetanus booster to be administered. The resident's family member was notified. An infection control event, dated 4/6/25, indicated the resident had a laceration to her left lower leg. Infection developed after admission on [DATE]. The signs and symptoms were identified as redness, warmth, and sanguineous drainage. Medications administered on 4/6/25, included Booster Tdap (diphtheria, pertussis, and tetanus) intramuscular injection and cephalexin (generic for Keflex) 500 mg. A current facility policy, revised 2/23/23, titled, Guidelines for General Wound and Skin Care, provided by the DON on 6/20/25 at 5:53 p.m., included the following: Purpose Statement. The purpose of this policy is to: To provide measures that will promote and maintain good skin integrity .Procedure. The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity .19. Use care when removing all dressings and tapes. This citation relates to Complaint IN00461032. 3.1-45(a)

Based on observations, interviews, and record reviews, the facility failed to ensure medications were labeled and stored properly for 2 of 2 medication carts reviewed for medication storage (Residents 8, 6, 19, and 146). Findings include: 1. On 7/9/24 at 9:10 a.m., the 200 hall (front) medication cart contained an undated and opened Lantus (medication used to lower blood sugar) insulin pen. The insulin pen contained a label that indicated it was for Resident 8. During an interview, on 7/9/24 at 9:12 a.m., Registered Nurse (RN) 6 indicated insulin pens should have an open date placed on them when they are used. Resident 8's record was reviewed on 7/9/24 at 9:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A physician order, dated 5/1/24, indicated to administer Lantus Solostar (insulin medication) insulin pen 100 unit/ml (milliliter). Inject 25 units subcutaneously (under the skin) once a day in the morning. A physician order, dated 5/1/24, indicated to administer Lantus Solostar insulin pen 100 units/ml. Inject 70 units subcutaneously once a day at bedtime. 2. On 7/9/24 at 9:15 a.m., the 200 hall (back) medication cart contained the following items: a. An unopened and non-refrigerated box of 5 Basaglar (insulin medication) pens. The box of insulin pens contained a label that indicated it was for Resident 6. b. An unopened and non-refrigerated vial of Humalog (insulin medication). The vial of insulin contained a label that indicated it was for facility stock and was delivered from the pharmacy on 7/8/24. c. An unopened and non-refrigerated box of 5 Lantus (insulin mediation) pens. The box of insulin pens contained a label that indicated it was for Resident 19. d. An unopened and non-refrigerated bottle of Latanoprost (eye drop medication) 0.005%. The bottle contained a label that indicated it was for Resident 146. e. An unopened and non-refrigerated vial of Humalog. The vial contained a label that indicated it was for Resident 146. During an interview, on 7/9/24 at 9:20 a.m., RN 6 indicated insulin and eye drops that were not opened, should be refrigerated until used. She indicated the night shift had a new nurse and she must not have known to refrigerate the medications until used. Resident 6's record was reviewed on 7/9/24 at 9:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar). A physician order, dated 6/14/24, indicated to administer Basaglar Kwik-Pen 100 unit/milliliter. Inject 32 units subcutaneously (under the skin) at bedtime. Resident 19's record was reviewed on 7/9/24 at 9:55 a.m. The profile indicated the resident's diagnosis included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease (a serious complication that occurs when the kidneys are not functioning properly to remove waste products and excess fluid from the body). A physician order, dated 6/7/24, indicated to administer Lantus Solostar pen 100 unit/ml. Inject 55 units subcutaneously at bedtime. Resident 146's record was reviewed on 7/9/24 at 10:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes and glaucoma (a group of eye conditions that can cause blindness). A physician order, dated 7/5/24, indicated to administer Latanoprost 0.005%. Give 1 drop to each eye once a day. A physician order, dated 7/6/24, indicated to administer Humalog 100 units/ml. Inject subcutaneously per sliding scale before meals and at bedtime. During an interview on 7/9/24 at 11:00 a.m., the Regional Director of Clinical Services (RDCS) indicated the facility had a new nurse on night shift and needed to be educated on proper storage of medications. On 7/9/24 at 11:10 a.m., the RDCS provided and identified a document as a current facility policy, titled, Vials and Ampules of Injectable Medications, revised date 11/18. The policy indicated, .at a minimum the date opened should be recorded On 7/9/24 at 11:10 a.m., the RDCS provided and identified a document as a current facility policy, untitled, with a revised date of July 2021. The policy indicated, .Unused Pens: Store unused pens in the refrigerator On 7/9/24 at 11:10 a.m., the RDCS provided and identified an undated document as a current facility policy, untitled. The policy indicated, .Store unused Lantus in a refrigerator 3.1-25(j) 3.1-25(m)

Based on observations, interviews, and record review, the facility failed to ensure a medication self-administration assessment was completed for 1 of 3 residents reviewed for respiratory (Resident 11). Findings include: During an initial interview with Resident 11 on 7/7/24 11:12 a.m., observed an inhaler located on her bedside table. The label indicated it was Trelegy Elipta 100 micrograms (mcg)/62.5 micrograms (mcg)/ 25 mcg, and the dose indicator read to have 29 of 30 doses left. The resident indicated that the inhaler was hers, she always had it, and she also normally had her emergency inhaler in her room but could not find it, so staff were ordering her another one. During a random observation on 7/9/24 at 2:32 p.m., observed two vials of nebulizer solution medication on Resident 11's bedside table. The resident indicated that it was her medication, normally she would set it up herself, but the wrist brace made it difficult to open the vials. When asked about the inhaler that was on her bedside table, she indicated that staff left the Trelegy Ellipta inhaler in her room every day for her to take, and she gave it back to them later, then mentioned again that she was supposed to have a rescue inhaler in her room, but she lost it, and seemed to lose everything. A record review for Resident 11 was completed on 7/8/24 2:01 p.m. The profile indicated the resident's diagnoses included, but were not limited to, bipolar II (a form of mental illness), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), chronic obstructive pulmonary disorder (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A physician's order, dated 3/9/24, indicated to administer Trelegy Ellipta (fluticasone-umeclidin-vilanter )100-62.5-25 mcg blister with device (an inhaled combination medication that helps control symptoms of lung disease such as difficulty in breathing and shortness of breath), one puff, inhalation, once a day, rinse mouth with water after use. A physician's order, dated 3/9/24, indicated to administer ipratropium-albuterol 0.5 milligram (mg) -3 mg (2.5 mg base) solution (an inhaled medication that helps control symptoms of lung disease such as difficulty in breathing and shortness of breath) for nebulization, one unit dose, inhalation, four times a day for cough or shortness of breath. A physician's order, dated 3/9/24, indicated to administer albuterol sulfate 90 micrograms (mcg)/actuation, hydrofluoroalkane (HFA) aerosol inhaler (a quick-relief inhaled medication used to treat symptoms of lung disease), 2 inhalations every 6 hours and as needed (PRN). A care plan, dated 6/18/24, indicated Resident 11 had potential for complications, functional, and cognitive status decline related to respiratory disease, COPD. Interventions included, but were not limited to, respiratory therapy per orders. A quarterly minimum data set (MDS) assessment, dated 6/21/24, indicated Resident 11 had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview on 7/9/24 at 10:40 a.m., Licensed Practical Nurse (LPN) 9 indicated they did not have any residents who self-administer their own medications. On 7/9/24 at 2:58 p.m., during an observation with LPN 9, she observed two vials of solution on Resident 11's bedside table and indicated them to be medication vials for breathing treatment used in the nebulizer machine. She indicated that she knew Resident 11 would ask staff to bring extra to her but did not think they were leaving them in the room. The LPN confirmed again that no resident had an order to self-administer medications and for Resident 11, they never knew how she was going to be, so she should not do them on her own. During an interview on 7/9/24 at 3:28 p.m., the Director of Health Services (DHS) indicated she could not explain the medications at bedside for Resident 11. She could not locate a current or historical assessment to self-administer medications. The DHS indicated that Resident 11's daughter was moving to Florida, so the resident had been asking for certain things to be brought in to her. She was not sure what they had brought in but thought it was possible they could have brought her medications from home, so she wanted to check the expiration dates. During an interview on 7/9/24 at 3:30 p.m. with the Regional Director of Clinical Services (RDCS), she reviewed Resident 11's record and indicated that the resident receives nebulizer treatments four times daily, and could not find any current, or historical, documentation from the physician indicating the Resident could self-administer medications. The order was to administer one dose, which was one vial. She was not sure if it was possible that the nurse had accidentally laid the medications down and left them there. She also suggested checking the expiration dates on the vials. On 7/9/24 at 3:47 p.m., with the DHS, observed the two medication vials that LPN 4 indicated to be the ones removed from Resident 11's room. The expiration dates on both vials read 12/2025 with a lot number of 41a0022x2. This information was compared to Resident 11's package of medication in the facilities medication cart. The package in the facilities medication cart also read that the expiration date was 12/2025 with a lot number of 41a0022x2. The DHS indicated the information matched, and that the vials that were on the resident's bedside table had come from the facilities medication cart. On 7/10/24 at 3:11 p.m., the RDCS provided a document dated 12/31/23, titled, Guidelines for Self-Administration of Medications, and indicated it was the policy currently being used by the facility. The policy indicated, .To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is part of their plan of care .Procedures .1. Residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication .3. The medication will be kept in a locked drawer in the residents' room. The resident will maintain the key, as well as, a key will be maintained by the licensed nurse and or QMA .8. The assessment will be documented in the EHR On 7/10/24 at 3:11 p.m., the RDCS provided a document dated 11/18, titled, Specific Medication Administration Procedures, and indicated it was the policy currently being used by the facility. The policy indicated, .F. Administer medication and remain with resident .Do not leave medications at bedside, unless specifically ordered by prescriber 3.1-11(a)

Based on record reviews and interviews, the facility failed to ensure a choice of code status was accurately documented in the medical record for 2 of 2 residents reviewed for code status (Residents 34 and 196). Findings include: 1. On [DATE] at 11:04 a.m., a basic review of Resident 34's record was conducted. The face sheet indicated the code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) was do not resuscitate (DNR). A physician's order, dated [DATE], indicated the resident was a DNR. In the documents section, the most recent physicians order for scope and treatment (POST) form, signed and completed on [DATE], indicated the resident was a full code and resuscitation/cardiopulmonary resuscitation (CPR) was to be attempted. On [DATE] at 10:00 a.m. Resident 34's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), malignant neoplasm of the colon (cancerous growth in the colon), stage 3 chronic kidney disease (kidneys do not work as well as they should to filter waste and extra fluid out of the blood), chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart), and psychotic disorder with hallucinations (seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them). A care plan, dated [DATE], indicated that the resident or resident representative had chosen the following advanced directives: code status, with a problem start date of [DATE]. Interventions had an approach start date of [DATE] and included, but were not limited to, review the resident's code status quarterly and as needed, honor the residents right to change advanced directives at any time, provide information, education, and assistance to resident and family regarding advance directives, and provide treating entities with updated notification of advance directives. A quarterly minimum data set (MDS), dated [DATE], indicated Resident 34 had severe cognitive impairment with a brief interview for mental status (BIMS) score of 5. During an interview on [DATE] at 10:34 a.m., when asked what Resident 34's code status was, Licensed Practical Nurse (LPN) 9 checked Resident 34's record and indicated that, on the face sheet, he was a DNR. She checked the documents, and on the POST form, he was a full code. She indicated that was weird because she remembered it being a discussion when he signed up for hospice care. When she went to check the hospice binder, it could not be located. On [DATE] at 11:18 a.m., the hospice services binder was reviewed. The first page was a form titled, Facility Document Delivery dated [DATE], indicated copy of advanced directives, as applicable to patient .DNR .Post. The next two pages included a copy of the signed POST form, dated [DATE], that indicated the resident was a full code. During an interview on [DATE] at 12:02 p.m., the Regional Director of Clinical Services (RDCS) indicated she believed the discrepancy was a clerical error, they had a call out to hospice and were going to call the resident's wife to verify Resident 34's code status. 48226 2. On [DATE] at 2:11 p.m., a brief review of the clinical record for resident 196 was completed. The record indicated the resident was to be DNR (Do Not Resuscitate). The physician order indicated Code Status no other information was provided with the order. On [DATE] the resident signed a DNR form. On the same date, [DATE] a CPR (Cardiopulmonary Resuscitation) consent form was signed by the resident and indicated initiate CPR. On [DATE] at 9:30 a.m., during an interview with the Director of Health Services (DHS) she indicated she had noted the discrepancy with the code status for the resident and acknowledged the two different directives created a confusing situation regarding the residents advanced directives. On [DATE] at 1:00 p.m., review of medical record of resident 196. The resident was admitted on [DATE]. Diagnosis included but were not limited to, unilateral primary osteoarthritis, right knee, (a degenerative joint disease, in which the tissues in the joint break down over time), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), aftercare following joint replacement surgery, type 2 diabetes mellitus without complications (a disease that occurs when your blood glucose, also called blood sugar, is too high). Physician orders included but were not limited to. [DATE], Code Status. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact and required assistance from the staff for activities of daily living. The medical record lacked a care plan for advanced directives. On [DATE] at 11:14 a.m., the Regional Nurse Consultant provided a document, titled, Guidelines for Advanced Directives, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: to ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .Procedures .1. Advanced Directives will be reviewed with resident and or resident representative by the Customer Service representative or designee at the time of admission .2. The resident or representative will advise the CSR/designee regarding wishes for end-of-life directives and code status. The DNR form will be completed documenting these desires and scanned into the medical record .6. The nursing staff will obtain an order from the attending physician for the desired code status .8. Designation of code status and obtainment of physician order will be part of the medical record 3XXX,d+[DATE](f)(4)(ii) 3XXX,d+[DATE](f)(5)

Based on interview and record review, the facility failed to ensure care plan meetings were held at least quarterly for 1 of 2 residents reviewed for care plan meetings (Resident 8). Findings include: During an interview, on 7/8/24 at 8:54 a.m., Resident 8 indicated she could not recall having a care plan meeting for quite some time. Resident 8's record was reviewed on 7/9/24 at 9:05 a.m. The census indicated the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, displaced bimalleolar fracture of right lower leg (a type of ankle fracture that involve the distal [the area away from the point of attachment] ends of the fibula and tibia, respectively) and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). A quarterly Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident had no cognitive deficit. Review of the Resident First Meeting Minutes (care plan meeting minutes) lacked documentation that a care plan meeting had been held since 11/1/23. During an interview, on 7/9/24 at 9:46 a.m., the Resident Services Manager indicated the facility was behind in completing their care plan meetings. Meetings should be held every quarter for all residents. During an interview, on 7/9/24 at 11:15 a.m., the Regional Director of Clinical Services indicated they were unable to locate any documentation that indicated the resident had a care plan meeting since November 2023. On 7/9/24 at 11:15 a.m., the Regional Director of Clinical Services provided a document, dated 12/31/23, titled. Resident's First Meeting Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .2 .meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change. 3 .meetings for Medicare residents should be conducted minimally quarterly and prior to discontinuing Medicare services or being discharged from the facility 3.1-35(d)(2)(B)

Based on observations, record reviews, and interviews, the facility failed to assess and ensure that a physician was notified of a resident's change in condition related to edema for 1 of 1 resident's reviewed (Resident 7). Finding includes: On 7/7/24 at 11:08 a.m., Resident 7 was observed sitting up in her chair, the resident had edema (swelling) to her left foot and ankle. The resident indicated nothing really helps with the edema and she tried to elevate her feet as much as possible. She indicated she has had edema to her left foot off and on since she fractured it a couple years ago. On 7/8/24 at 2:37 p.m., Resident 7 was sitting up in her chair reading a book with her legs elevated on the seat of her wheelchair. Edema was noted to her left foot and ankle. On 7/8/24 at 10:23 a.m., Resident 7 was observed sitting in her chair in her room with her left foot on the floor and her right leg elevated on the wheelchair seat. The left foot was notably larger than the right foot. On 7/10/24 at 8:36 a.m., Resident 7 was sitting in her chair in her room and both feet were touching the floor. Her left foot and ankle were noted to be swollen. Resident 7's record was reviewed on 7/8/24 at 1:17 p.m. The profile indicated the resident's diagnosis included, but were not limited to, age-related osteoporosis without current pathological fracture (a bond disease that occurs when bone mass decreases, or when the structure or strength of the bone changes), history of DVT to left leg (occurs when a blood clot forms in one or more of the deep veins in the body), and chronic kidney disease, stage 3b (mild to moderate kidney damage and they are less able to filter waste and fluid out of your blood). A quarterly Minimum Data Set (MDS) assessment, dated 5/22/24, indicated the resident was cognitively intact and required supervision with toilet use and moderate assistance with showers. The record lacked a care plan related to edema to left foot/ankle. A care plan, dated 10/19/22, indicated the resident has chronic kidney disease, stage 3b. Interventions included, but were not limited to, assess for fluid excess (edema, worsening of edema, and weight gain) and administer medication as ordered. A progress note dated 4/29/24 indicated Resident 7 had edema to the left lower extremity. MD (medical doctor) was notified, and he ordered a venous doppler (a non-invasive diagnostic test that evaluates blood flow through the body's major veins and arteries). A progress note, dated 5/3/24, indicated Resident 7 had a red, swollen left leg and the doppler showed a DVT. MD ordered Xarelto (blood thinner). The record lacked any recent progress notes related to edema of the left foot/ankle. A physician order, dated 5/24/24, indicated to administer Xarelto 15mg (milligrams) by mouth daily. The record lacked continued monitoring of the edema and DVT by staff. During an interview, on 7/8/24 at 1:52 p.m., Certified Resident Care Assistant (CRCA) 5 indicated Resident 7 would elevate her legs and feet as much as possible because she had issues with swelling off and on. During an interview, on 7/8/24 at 1:53 p.m., Registered Nurse (RN) 6 indicated she had spoken to Resident 7 a couple months ago about the edema to her left foot, but she had not recently assessed the edema. The nurse indicated she had noticed in the past the swelling in her left foot is always worse than the right. During an interview, on 7/10/24 at 9:45 a.m., Regional Director of Clinical Services (RDCS) indicated the edema should be addressed with the physician, and she would make sure the resident was added to his list to be seen. During an interview, on 7/10/24 at 11:53 a.m., RDCS indicated a CAR (clinical assessment record) should have been completed on Resident 7 because it would have been a good way to ensure monitoring of the DVT had been completed and a good way to monitor for worsening or improving edema. On 7/10/24 at 11:50 a.m., the RDCS provided a document dated 5/10/16, titled, Clinically at Risk Program Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Every effort will be made to identify those residents who are clinically at risk and provide proactive interventions to manage their medical needs and minimize/eliminate further decline when possible . Resident is to be discussed in CAR meeting until it is determined the resident's condition has stabilized .5. The CAR team will review current interventions for effectiveness and potential changes and make recommendations based on individual resident's needs 3.1-37(a)

Based on observations, record review and interview, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which was attached to a urinary drainage bag (a bag that collects urine) and a biliary drain (a thin plastic tube inserted into the gallbladder to drain fluid) bag, did not touch the floor for 1 of 1 resident reviewed for catheter care (Resident 201). Findings include: On 7/07/24 at 12:01 p.m., during routine observation, the resident lying in bed, the urinary drainage bag lying on the floor. No covering over the bag. The biliary drainage bag was lying on the floor. No covering over bag. On 7/08/24 at 9:29 a.m., observed the biliary drainage bag drain touching the floor. No covering over the bag. The urinary drainage bag was attached to the side of the bed frame. No covering over the drainage bag. On 7/09/24 at 8:40 a.m., during routine observation resident observed sitting up in a wheelchair. The foley drain bag was attached to the lower left side of the wheelchair. No covering over the drainage bag. The biliary drainage bag was attached to the upper right side of the wheelchair without a covering, the bag was half full of a dark colored liquid. On 7/9/24 at 8:46 a.m., during an interview, Certified Resident Care Associate (CRCA) 3 indicated any resident with an indwelling catheter and or a drainage bag, both bags should always be covered. She indicated the drain bag for the biliary drain is covered with a pillowcase when the resident is up in a chair. She indicated the drainage bags should not touch the floor. On 7/9/24 at 9:30 a.m., during an interview with the Director of Health Services (DHS) she indicated a urinary drain bag should be covered if the resident was in a wheelchair or using a walker. Clinical record review completed on 7/9/24 at 11:00 a.m., for Resident 201. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, 5/31/24 acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), 4/12/24 cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), unspecified, chronic atrial fibrillation (an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), 11/4/20 chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), unspecified, obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep), dyspnea (difficult, painful breathing or shortness of breath). 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). Physician orders included but were not limited to. Albuterol sulfate solution for nebulization (used to prevent and treat wheezing, difficulty breathing); 2.5 mg (milligrams)/3 mL (milliliters) (0.083 %); amount: 3 ml; inhalation admin as needed for SOB (shortness of breath or wheezing every 6 Hours as needed. Eliquis (apixaban) tablet (used to treat blood clots) 5 mg; amt: 5 mg; oral twice a day. Empty biliary drain every shift three times a day. Change catheter bag PRN (as needed) based on clinical indications such as infection, obstruction, or when the closed system is compromised once a day PRN. Foley catheter care every shift three times a day, indwelling urinary catheter, medical reason BPH (benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland) with urinary retention (a condition in which you are unable to empty all the urine from your bladder). An admission Minimum Data Set (MDS) assessment dated , 4/17/24 indicated the resident was cognitively intact and required maximum assist of two persons for activities of daily living and had an indwelling foley catheter during the look back period. A care plan dated 6/24/2024 indicated the resident used a foley catheter. Interventions included, but were not limited to, maintaining a closed system with urinary bag below the resident's bladder and cover. A care plan dated 4/14/24 indicated a risk for skin breakdown related to biliary drain. The record lacked interventions specific to the biliary drain. The facility did not have a policy specific to biliary drain. On 7/9/2024 at 11:15 a.m., the Regional Nurse Consultant provided a document, titled, Preserving Dignity with Indwelling Catheter, dated 12/31/23, and indicated it was the policy currently being used by the facility. The policy indicated, .SOP Details .1. General guidelines .a) Keep drain bag covered with an appropriate device .Urinary drainage bags and catheter tubing should be kept from touching the floor surface 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure proper cleaning and storage of nasal cannula and CPAP (continuous positive airway pressure) mask and tubing for 1 of 2 residents reviewed for respiratory care (Residents 201). Findings include: On 7/7/24 at 12:05 p.m., observed Resident 201, lying down in his room, resting. Oxygen was being administered at 3 L (liters) per nasal cannula (a thin flexible tube device to provide supplemental oxygen therapy to people who have lower oxygen levels) there was no date indicated on oxygen tubing and did not observe a dated storage bag in the room. On 7/8/24 at 2:52 p.m., during routine observation, Resident 201 was lying in bed. Oxygen was being administered per nasal cannula at 3 L. There was no date on the oxygen tubing and did not observe an oxygen or CPAP (continuous positive airway pressure) (a machine that uses mild air pressure to keep breathing airways open while you sleep) dated storage bag in the room. On 7/9/24 9:13 a.m., observed the resident sitting in wheelchair. The oxygen nasal cannula tubing was lying on the couch next to the resident. Did not observe an oxygen or CPAP dated storage bag the room. On 7/9/24 8:46 a.m., during an interview Licensed Practical Nurse (LPN) 4 indicated the night shift changed oxygen tubing and the nurse did not normally date the tubing. On 7/9/24 at 9:30 a.m., during an interview the Director of Health Services (DHS) indicated the oxygen tubing was not dated; the bag was dated and changed monthly. She indicated the physician's order to clean the mask and place it in bag was for the CPAP mask not the oxygen mask. On 7/9/24 at 10:18 a.m., the clinical record for Resident 201 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, 5/31/24 acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), 4/12/24 cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), unspecified, chronic atrial fibrillation (an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), 11/4/20 chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), unspecified, obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep), dyspnea (difficult, painful breathing or shortness of breath). 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). Physician orders included, but were not limited to, Albuterol sulfate solution for nebulization (used to treat shortness of breath and wheezing) 2.5 mg (milligrams)/3 mL (milliliters) (0.083 %); amount: 3 ml; inhalation admin as needed for SOB (shortness of breath or wheezing every 6 Hours - as needed. Eliquis (apixaban) (used to treat blood clots) tablet; 5 mg; amt: 5 mg; oral twice a day. Empty biliary drain every shift three times a day. O2(oxygen) - Change oxygen tubing monthly once a day on the 1st of the month. O2- CPAP at 14 cm H2O (water) pressure with oxygen at 3 liters at NOC (night) as needed during the day at bedtime (continuous positive airway pressure) a machine that uses mild air pressure to keep breathing airways open while you sleep. (Oxygen) O2- mask and tubing should be cleaned weekly with soapy water and rinsed. Air dry and place mask in clean setup bag once a day on Sun. O2- Oxygen at 3L (liters) per nasal canula continuous three times a day. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact and required maximum assistance of two persons for (ADL) activities of daily living and required oxygen during the look back period. A care plan dated 4/14/2024 indicated the resident had potential for complications, functional and cognitive status decline related to respiratory disease related to: COPD, sleep apnea. Interventions included, but were not limited to, Administer oxygen per orders. CPAP at night, Resident to wear CPAP machine at night. On 7/9/2024 at 11:14 a.m., the Regional Nurse Consultant provided a document, titled, Respiratory Equipment, dated 12/31/23, and indicated it was the policy currently being used by the facility. The policy indicated, . SOP Details .2. j. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use .3 .f. Store circuit in plastic bag, marked with date and resident's name between uses 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure transportation to a medical appointment was set-up and completed for 1 of 1 resident reviewed for transportation (Resident B). Findings include: Review of a complaint intake form, dated 7/10/24, indicated Resident B had missed her appointment with her urologist (a physician who has special training in diagnosing and treating diseases of the urinary organs) because the facility had not scheduled transport services for her. Resident B's record was reviewed on 7/11/24 at 8:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic kidney disease (damage to the kidneys which makes them unable to filter blood the way they should), hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys) and obstructive uropathy (a blockage or obstruction where the ureter [the tube that carries urine] connects to the kidney or bladder). A care plan, dated 1/3/23, indicated the resident had an indwelling urinary catheter (a tube which is inserted into the bladder to drain urine) related to obstructive uropathy. A physician's order, dated 7/10/24, dated one time 6:00 a.m., to 2:00 p.m., indicated to set up transport for a visit with the urology nurse practitioner (NP) for a treatment appointment at 12:30 p.m. The order indicated Lifeloop (a software system used to set up transport for residents) request had been put in. During an interview, on 7/11/24 at 9:33 a.m., the Life Enrichment Director indicated she was responsible for the transport of the facility residents to their appointments. She did not have Resident B on her schedule to transport to an appointment on 7/10/24. Scheduling transport for appointments was set up by the nursing staff. During an interview, on 7/11/24 at 9:36 a.m., Registered Nurse (RN) 17 indicated the nurses were responsible for transport requests when an appointment order was received. Setting up transport requests for the facility bus was very easy, but to set up for an outside transport, they now were required to use a process that takes them to a government website. This made it very time-consuming to set up. Resident B cannot be transported by the facility bus, because she required stretcher transport. During an interview, on 7/11/24 at 10:10 a.m., the Regional Director of Clinical Services indicated she was not able to locate a specific policy on setting up transportation for resident appointments. The expectation would be that transportation would be set up by facility staff for any resident who had an appointment outside of the facility. During an interview, on 7/11/24 at 10:47 a.m., the Executive Director (ED) indicated the facility policy was that transportation would be set up and provided for all residents who required transportation to any appointment. This citation relates to Complaint IN00438476. 3.1-49(i)(3)

Based on observation, interview, and record review, the facility failed to provide supervision of a resident at high risk of falls when the resident was ambulaitng which resulted in the resident failling and obtaining a laceration to her head requiring hospitalization and 3 staples (Resident 5); and failed to provide an elopement assessment and supervision for a confused resident (Resident 26) for 2 of 2 residents reviewed for accidents. Findings include: 1. Resident 5's record was reviewed on 6/29/18 at 2:40 p.m. An event report, dated 4/23/18 at 2:00 p.m., indicated the resident had a fall in the doorway of her room. The fall was not witnessed, and the resident was not injured. An intervention put in place was to monitor resident closely when ambulating. An event report, dated 4/23/18 at 6:40 p.m., indicated the resident had a fall in her room while ambulating. The fall was not witnessed, and the resident was observed to have a laceration to her head. The wound was cleansed and pressure applied. A progress note, dated 4/23/18 at 6:40 p.m., indicated the resident was ambulating around her room when she fell and hit her head on a tray table. A 5 centimeter (cm) by 0.5 cm gash was noted to the back of her head. The Medical Director (MD) was notified and the resident was sent to the hospital to be evaluated and treated. A progress note, dated 4/24/18 at 11:53 a.m., indicated the nurse had spoke with the hospital and the resident would possibly return back to the facility today with a subdural hematoma. A review of progress, on 4/24/18, did not indicate the resident had returned from the hospital. A progress note, dated 4/25/18 at 9:37 a.m., indicated the resident had 3 staples to mid back of head, with slight bruising noted to the area. A progress note, dated 5/1/18, indicated the resident had fallen at approximately 6:40 p.m. on 4/23/18, and hit her head on a bedside table. Resident was sent out to the hospital and returned with a [DIAGNOSES REDACTED]. The resident's table was removed from her room. [DIAGNOSES REDACTED]. A care plan, dated 3/30/18, indicated the resident was at risk for falling related to [MEDICAL CONDITION] (a progressive disease that destroys memory and other important mental function), orthostatic [MEDICAL CONDITION] (a form of low blood pressure that happened when standing), [MEDICAL CONDITION] of central origin (a sensation of feeling off balance), major [MEDICAL CONDITION] (mental health disorder characterized by depressed mood or loss of interest), mycolonus (sudden involuntary muslce jerk), transient cerebral ischemic attack (brain dysfuction caused by an outside force). An approach, edited on 6/1/18, encourage resident to assume standing position slowly. During an interview, on 7/3/18 at 10:04 a.m., the Director of Health Services (DHS) indicated the resident went to the emergency roiagnom on [DATE] for an injury to the head from a fall. The resident returned to the facility on [DATE] with staples and a [DIAGNOSES REDACTED]. During an interview, on 7/3/18 at 1:26 p.m., LPN 7 indicated the resident was a fall risk. She could not recall the fall that occurred on 4/23/18, and that when an intervention to monitor the resident closely when ambulating was put in place, she would ensure someone had visual on the resident at all times because the resident would attempt to stand for no reason and was confused. On 7/3/18 at 11:54 a.m., the Director of Health Services (DHS) provided a document titled, Fall management program Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: Trilogy Health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .Procedure: .2. Should the resident experience a fall the attending nurse shall complete the Fall event this includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, .interventions to reduce risk of repeat episode .7. Discuss risks and interventions .communicate interventions during shift report 2. Resident 26's record was reviewed on 7/2/18 at 10:21 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/9/18, indicated the resident had a moderate cognitive impairment. The resident had no behaviors, including wandering. The resident was admitted on [DATE]. [DIAGNOSES REDACTED]. An admission assessment, dated 11/8/17, indicated the resident was not at risk for elopement. A progress note, dated 1/3/18, indicated the resident was agitated and turned on her call light every half hour to an hour to go to the bathroom. The resident became upset and cursed at the staff when reminded of the time. The resident did not believe what time it was even when shown a clock. Resident stated she would talk to a lawyer. An Interdisciplinary Team (IDT) note, dated 1/3/18, indicated nursing had reported confusion and agitation through the night. Resident was unaware of the time of day. The resident used the call light multiple times through the night to void, but was unable to. An IDT note, dated 1/23/18, indicated nursing reported increased confusion. The resident attempted to get up unattended and had not asked for assistance. A Clinically At Risk (CAR) Review note, dated 1/25/18, indicated the resident had increased confusion. The resident was on [MEDICATION NAME] (an anti-anxiety medication) twice daily for anxiety. The resident's family had noticed a change in her personality. The resident would be seen by psychiatric services. A CAR Review note, dated 2/8/18, indicated the resident was seen by psychiatric services for increased agitation and depression. A trial of anti-depressant medication was recommended. The physician was notified. A progress note, dated 2/10/18, indicated a new order was received for [MEDICATION NAME] (an anti-depressant medication). A progress note, dated 2/16/18, indicated the resident was toileted 10 times in a shift with little or no output. The resident continued to be unaware of time and the last time she went to the bathroom. When the Certified Resident Care Assistant (CRCA) encouraged resident to bend her knees when walking to the bathroom, the resident became agitated and elbowed the CRCA in her side and called her a name. The nurse talked with the resident, but the resident continued to be upset and agitated. A progress note, dated 2/17/18, indicated the resident was restless and wanted to go to bed prior to dinner. The resident was reoriented to the time of day and agreed to eat dinner. A progress note, dated 2/28/18, indicated the resident had a Deoxyribonucleic Acid (DNA) swab (a test to see what medications were most effective) completed related to increased delusional behavior. A Social Services Note, dated 3/1/18, indicated the resident was seen by psychiatric services on 2/27/18 per the family's request related to behaviors. The resident called her family multiple times at work. The resident's anxiety had increased, and her mood went from crying to anger. Resident had been very hateful to her family. A DNA swab was completed. A progress note, dated 3/12/18, indicated the DNA swab results recommended to discontinue [MEDICATION NAME] and start [MEDICATION NAME] (an anti-depressant) or [MEDICATION NAME] (an anti-depressant). The physician was notified. A progress note, dated 3/13/18, indicated a new order was received from the physician to discontinue [MEDICATION NAME] and start [MEDICATION NAME] A progress note, dated 4/13/18, indicated the resident had gotten up and down and stated she thought she heard something and came to see what it was. An IDT note, dated 5/8/18, indicated nursing reported the resident was confused, agitated, and uncooperative with care at times. The physician was notified. A Social Services note, dated 5/10/18, indicated the resident was seen by psychiatric services on 5/8/18 and recommended to increase resident's anti-depressant. The resident had been very upset, yelling at staff, and wandering the facility. The resident recently moved to a different room and thought someone gave her bed away. A progress note, dated 5/12/18, indicated the resident was verbally abusive and called the staff liars. When the staff attempted to provide incontinent care the resident said, I can lay in pee if I want to. A progress note, dated 5/15/18, indicated the resident was restless at night and started on [MEDICATION NAME] (a supplement to help with sleep) every evening. A progress note, dated 5/17/18, indicated the resident was on [MEDICATION NAME] 5 milligrams (mg) twice daily, which was not effective. The physician was notified and the [MEDICATION NAME] was increased to 10 mg twice daily. An IDT note, dated 5/18/18, indicated the resident had increased agitation and cognitive impairment. She had increased behaviors, and the [MEDICATION NAME] was increased. A physician's progress note, dated 5/19/18, indicated the resident was seen for increased aggressive behavior. The resident had hit a nurse. The family reported previous anger issues. Added [MEDICATION NAME] (a mood stabilizer), added [MEDICATION NAME] (an anti-anxiety medication), and taper off [MEDICATION NAME]. A CAR Review note, dated 5/30/18, indicated the resident remained able to propel herself throughout the facility. A Social Services note, dated 6/10/18, indicated the resident approached the Director of Social Services (DSS) at the nurse's station and asked, Do you know what I am running from? The resident stated, You know that stroke I had, well I feel like I am running from something. The resident was tearful. A progress note, dated 6/11/18, indicated the resident was seen in the dining room at 5:50 p.m. The resident left the dining room and was enroute to her room. At 5:55 p.m., a visitor to the facility saw the front wheel of the resident's wheelchair go off the sidewalk, and the resident fell to the pavement. The visitor ran inside the facility to get staff. An 8 centimeter (cm) X 4 cm hematoma (solid swelling of clotted blood in the tissue) was noted above the left eye with an 8 cm laceration (a deep cut) down the center. The wound was bleeding freely. There was a 1 cm X 1 cm skin tear between the left left third and fourth fingers, and a 2 cm X 1 cm skin tear between the left first and second fingers. The Executive Director (ED), physician, and family were notified. A wanderguard (a device to prevent the resident from leaving the facility) was placed on the resident. An alarm device event, dated 2/5/18, indicated the resident required an alarm device related to poor safety awareness threatening the resident's safety and well-being. A fall with elopement event, dated 6/11/18, indicated the resident had gone outside to look for her car. She had fallen outside on facility grounds. The fall risk re-assessment indicated the resident forgot to comply with safety measures and was very impulsive. Observations from 11/8/17 to 7/2/18 were reviewed, and no elopement risk re-assessment was observed. A Social Services Comprehensive Note, dated 2/7/18, indicated the resident had not wandered. A Social Services Comprehensive Note, dated 5/8/18, indicated the resident had not wandered. A sample, undated, elopement risk review indicated a resident was at risk for elopement if there was a history of exit seeking, voiced statements of leaving, or exhibited periods of pacing, agitation, or wandering toward an exit. Care plans were reviewed, and documentation lacked for exit seeking, wandering, and elopement risk at the time of the elopement. On 6/26/17 at 10:30 a.m., the front door of the facility was observed to be unlocked. No code was required to get in or out of the building. On 6/28/18 at 2:45 p.m., the resident was observed propelling herself in her wheelchair out of the dining room. On 7/2/18 at 10:17 a.m., the resident was observed propelling herself in her wheelchair up and down the hall by the therapy gym. On 7/3/18 at 8:41 a.m., the resident was observed propelling herself in her wheelchair up the hall, past the recreation room, and turned into the therapy gym. The resident sat in the therapy gym for a short time, then left the gym and continued toward the dining room. During an interview, on 7/2/18 at 2:32 p.m., the Assistant Director of Health Services (ADHS) indicated she was not sure if elopement risk should have been re-assessed routinely or with a change. During an interview, on 7/2/18 at 2:37 p.m., the Director of Health Services (DHS) indicated she was not sure if elopement risk should have been re-assessed routinely or with a change. During an interview, on 7/2/18 at 3:33 p.m., the DHS indicated the policy was for an elopement risk assessment to be completed quarterly and with any significant change. The quarterly elopement risk assessments were not completed. The social services assessment was completed, but it only addressed wandering. The resident had gotten out of the building and had fallen outside. During an interview, on 7/2/18 at 3:55 p.m., the DHS indicated the elopement risk assessments were not completed as required by the policy. An elopement risk assessment would be completed. During an interview, on 7/2/18 at 3:58 p.m., the ED indicated she was notified by phone after the resident got out of the building and fell on [DATE]. The resident's condition had declined. The doors of the facility were unlocked during the day. During an interview, on 7/3/18 at 8:45 a.m., the DHS indicated the door to the facility was unlocked and opened at will throughout the day. The door automatically locked and required a code for entrance and exit from 10:00 p.m. to 6:00 a.m. During an interview, on 7/3/18 at 10:32 a.m., the DHS indicated the wanderguard automatically locked the doors and sounded an alarm when a resident got close to the door. The resident had always wandered, and it was not a new behavior. She was unsure why the wandering was not documented. The only elopement risk assessment that had been completed was on admission. On 7/2/18 at 3:55 p.m., the DHS provided a document titled, Guidelines: Elopement Risk Assessment and Prevention, and indicated it was the policy currently being used by the facility. The policy indicated, PURPOSE: The campus strives to promote resident safety and protect the rights and dignity of the residents. A process to assess all residents for risk for elopement, implement prevention strategies for those identified as an elopement risk .DEFINITIONS: Elopements occur when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Wandering refers to a cognitively-impaired resident's ability to move about inside the facility aimlessly and without an appreciation of personal safety needs and who may enter into a dangerous situation. PR[NAME]EDURE: 1. Each resident will be assessed for elopement risk upon admission, quarterly, and with change in condition 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident admitted without pressure areas to her buttocks remained free of pressure areas on her buttocks causing the resident to be admitted to the hospital for treatment of [REDACTED]. Findings include: The record for Resident B was reviewed on 6/24/14 at 9:10 a.m. Her [DIAGNOSES REDACTED]. On admission to the facility on [DATE], the Resident Care Plan, dated 5/5/14, indicated an alteration in skin integrity on her right inner ankle, with additions to the care plan on 5/11/14 regarding the right ankle, and 5/14/14 regarding the right outer ankle, middle of right foot, right foot lateral top, top of right foot times 4, right lower leg times 2, and right shin. These areas were being treated by the hospital wound center and were listed as arterial wounds. This care plan indicated a stage 2 pressure area (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) on her right buttock and 2 stage 2 pressure areas on her left buttock on 5/27/14. Interventions included, but were not limited to, turn and reposition every 2 hours and as needed, and check and change every 2 hours and as needed. A "Change In Condition Form", dated 5/29/14 at 4:00 a.m., indicated "Res (Resident) left on bedpan for extended period of time. Dark red areas to bil (bilateral) outer buttocks. Res had been sleeping this shift, had not used call light....Did not acknowledge bedpan." A physician's orders [REDACTED]. The "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" form, dated 5/27/14 indicated a Stage 2 area on her right buttock measuring 2.5 cm (centimeters) long, 1.5 cm wide, 0.1 cm deep. On 6/3/14, it was documented as worsening and the record indicated a Stage 3 (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure area measuring 3.2 cm L (long), 1.3 cm wide (W), and 0.1 cm deep(D) on her right buttock. The Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" form indicated the left buttock had a Stage 2 pressure area measuring 1.5 cm L, 0.9 cm W, with no documented a depth on 5/27/14. On 6/3/14, the area was documented as a Stage 3 pressure area measuring 1.5 cm L, 0.8 cm W, and 0.1 cm D. A second area to the left buttock was documented as a Stage 2 pressure area measuring 4 cm L, 2 cm W, and no depth on 5/27/14. The area was documented as a Stage 3 pressure area, measuring 2.2 cm L, 1.1 cm W, and 0.1 cm D on 6/3/14. The "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" form, dated 5/29/14, indicated Resident B had a suspected deep tissue injury to the left outer buttock that was unstageable, measuring 23 cm L, 8 cm W, and an "unknown" depth. On 6/5/14, it remained unstageable, measuring 16 cm L, 6.5 cm W, and unknown depth. A skin assessment, dated 5/29/14, indicated an unstageable area on the right outer buttock, deep tissue injury, 29 cm L, 2 cm W, and unknown depth. On 6/3/14, it remained unstageable, and measured 20 cm L, 2.2 cm W, and unknown depth. The record indicated Resident B was treated weekly at the hospital wound clinic since admission to the facility. The record indicated treatment for [REDACTED]. During an interview on 6/23/14 at 2:10 p.m., Resident B's family member indicated when Resident B went to the wound clinic on 6/6/14, she was referred and admitted to the hospital for debridement of the buttock wounds. During an interview with CNA #1 on 6/24/14 at 3:40 p.m., she indicated Resident B was resistive to care, especially turning and repositioning, she would pull away from staff when they tried to turn her. She also indicated she would approach her later to try to care for her. During an interview with CNA #2 and CNA #3 on 6/24/14 4:00 p.m., both indicated Resident B did not want to be turned. They also indicated they would try again in a while to care for her. During an interview with CNA #4, she indicated Resident B had days when she would yell and scream and curse and hit you if she did not want to be turned and repositioned. CNA #4 also indicated she would go back later and try to provide care again. During an interview with the Executive Director on 6/24/14 at 4:55 p.m., she indicated an investigation was completed regarding the pressure areas on Resident B's buttocks. She indicated the resident was left on the bedpan for an undetermined amount of time. This federal tag relates to Complaint IN 618. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure adequate monitoring and implementing of approaches to prevent development of new pressure sores and provide care for current pressure ulcers in that wound care was not done in accordance with physician's orders [REDACTED]. 29 (Resident #'s 69, B, and #158) . The immediate jeopardy began on 2/28/12 when Resident #69 was observed without planned pressure relieving devices. The Executive Director (ED) and the Director of Health Services (DHS) were notified of the immediate jeopardy on 3/7/12 at 1 p.m. The immediate jeopardy was removed on 3/9/12, but noncompliance remained at the lowered scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B was observed on 3/2/12 at 10:35 a.m., to be in room in wheelchair. Both legs were observed in braces at the knees and pressure reduction boots on both feet. An abductor pillow was noted between the resident's knees. On 3/6/12 at 8 p.m., Resident B's bilateral heel treatments were observed to be completed. The right heel wound bed was observed to have pink granulation tissue with yellow slough present. The left heel wound bed was observed to have pink granulation tissue with yellow slough present. Review of clinical record of Resident B on 3/2/12 at 2:15 p.m., indicated the resident was admitted on [DATE], from a VA hospital with discharge [DIAGNOSES REDACTED]. The discharge summary instructions included Extended Care Facility instructions of OT/PT consult (evaluate and treat), fall precautions, decubitus ulcer prevention, and full assist with meals. The Nursing Admission Assessment, dated 9/27/11, indicated the resident was admitted "without foot problems present: infection of the foot, [MEDICAL CONDITION], or open [MEDICAL CONDITION] of the foot; does not have history of skin impairment; did not have diabetes, [MEDICAL CONDITION] [MEDICAL CONDITION] [MEDICAL CONDITION], para/[MEDICAL CONDITION], or liver disease; did not have the ability to change positions; compliant with turning/positioning and/or treatment interventions; no stage 1 wound or greater, scar over a bony prominence, non-removable device/dressing; no pressure area known to be present..." The skin plan of care identified the approaches which included, but were not limited to, turn and reposition for comfort and with care, prevent skin from touching skin, elevate heels off surface, use lift sheet to reposition in bed, provide pressure relieving device in bed/chair, and assist with positioning in bed and chair. Documentation of the use of TED hose was lacking. Review of the Treatment Administration Record (TAR), nursing notes and physician orders [REDACTED]. The 9/2011 TAR did not indicate elevating of heels. The TAR, dated 10/2011, indicated the order of "Keep Heels off of the bed at all times when in bed" with implementation on day shift 10/3/11 (after identification of the pressure ulcers on the bilateral heels). Interview of the Director of Health Services (DHS) on 3/5/12 at 11:33 a.m., indicated the "skin plan of care" on the Nursing Admission Assessment was utilized as the initial plan of care. Review of "Skilled Nursing Assessment and Data Collection," dated 9/29/11, 9/30/11, and 10/211, indicated surgical skin impairment only. The "Skilled Nursing Assessment and Data Collection," dated 10/3/11, indicated skin impairment of bilateral heels- black. A physician's progress note, dated 10/2/11, did not indicate concerns with skin impairment to heels. Review of Skin Impairment Circumstance Investigation, dated 10/3/11, on 3/5/12 at 1:30 p.m., indicated Stage 1, Suspected deep tissue injury, not arterial/diabetic/venous, positioning devices in place, pressure reducing devices in place, resident compliant with care plan interventions, Calazyme applied, resident compliant, resident can respond, resident cannot maintain position, physician and responsible party notified of skin impairment. A physician's orders [REDACTED]. Review of Pressure/Stasis/Arterial/Diabetic Ulcer Assessment sheets on 3/5/12 at 10 a.m., the following was noted: Left heel: 10/4/11 pressure identified on 10/3/11 (not present on admission), stage 2 , color black, measuring 7 centimeters x 6 centimeters depth UTD (unable to determine), pain to touch, black blister, treatment of [REDACTED]. 10/11/11 stage 2, 8 centimeters x 6.5 centimeters depth UTD, pain to touch, color black blister, treatment skin prep and speciality heel lift boot. 10/18/11 stage 2, 5 centimeters x 6 centimeters depth UTD, black scab, treatment wound cleanse, Santyl, foam dressing, Kerlix and specialty lift boot. 10/28/11 unstageable, 5.4 centimeters x 4.6 centimeters depth UTD, pain during cleaning, color black eschar, treatment of [REDACTED]. 11/1/11 stage 2, 5.5 centimeters x 4.5 centimeters depth UTD, pain to touch, color black scab with 10% gran (granulation)/ 90 % eschar, treatment of [REDACTED]. 11/8/11 stage 2, 6 centimeters x 4.5 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 11/15/11 unstageable, 4 centimeters x 5.5 centimeters depth UTD, pain to touch, color black, treatment of [REDACTED]. 11/22/11 unstageable, pain to touch, color black, and family refused treatment. 11/29/11 unstageable, 4 centimeters x 5.5 centimeters depth UTD, exudate yellow scant amount thin, pain to touch, color black, treatment of [REDACTED]. 12/6/11 unstageable, 4 centimeters x 4.5 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 12/13/11 unstageable, 4 centimeters x 5 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 12/20/11 unstageable, 4 centimeters x 4.5 centimeters depth UTD, exudate color yellow, odor foul, amount small with consistency of sticky, treatment of [REDACTED]. 12/27/11 unstageable, 4 centimeters x 5 centimeters depth UTD, exudate color yellow, odor foul, scant amount consistency thin, pain to touch, color unstable black eschar, treatment of wound cleanse, Santyl, Hydrogel, gauze [MEDICATION NAME], Kerlix roll and heel lift boots. 1/3/12 unstageable, 4 centimeters x 5 centimeters, exudate- yellow, foul odor, scant amount consistency thin, pain to touch, color unstable black eschar, treatment wound cleanser, Santyl, Hydrogel, gauze, [MEDICATION NAME], Kerlix and heel lift boots. Right heel: 10/4/11 unstageable, initial identification 10/3/11 (not present on admission) pressure to right heel 7 centimeters x 4 centimeters depth UTD (unable to determine), treatment of [REDACTED]. 10/11/11 unstageable, 8 centimeters x 6 centimeters depth, pain to touch, color black blister, treatment of [REDACTED]. 10/18/11 unstageable, 5 centimeters x 5 centimeters depth UTD, color black, treatment of [REDACTED]. 10/28/11 unstageable, 7.4 centimeters x 5.6 centimeters depth UTD, scant amount of thin exudate, pain during cleansing, color black eschar. 11/1/11 unstageable, 4 centimeters x 4.7 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 11/8/11 unstageable, 4 centimeters x 5 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 11/15/11 unstageable, 3.8 centimeters x 5 centimeters depth UTD, pain to touch, color black, treatment of [REDACTED]. 11/22/11 documented family refused treatment. 11/29/11 unstageable, 3.5 centimeters x 4.5 centimeters depth UTD, exudate color yellow, scant amount thin consistency, pain to touch, color black, treatment of [REDACTED]. 12/6/11 unstageable, 3.8 centimeters x 4 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 12/13/11 unstageable, 3.5 centimeters x 4 centimeters depth UTD, pain to touch, color black scab, treatment of [REDACTED]. 12/20/11 unstageable, 3.5 centimeters x 3.5 centimeters depth UTD, exudate color yellow, foul odor, small amount sticky consistency, treatment of [REDACTED]. 12/27/11 unstageable, 3.5 centimeters x 4.5 centimeters depth UTD, exudate color yellow, foul odor, scant amount thin consistency, pain to touch, color unstable eschar black, treatment of [REDACTED]. 1/3/12 unstageable, 3.5 centimeters x 4.5 centimeters depth UTD, exudate color yellow, foul odor, scant amount thin consistency, pain to touch, color unstable eschar, treatment of [REDACTED]. Radiology Report, dated 10/11/11, indicated x-rays of bilateral heels with results of normal left and right heels with no osteo[DIAGNOSES REDACTED]. Radiology Report, dated 1/4/12, indicated x-rays of bilateral heels with results of "calcaneus erosion along its cortex consistent with osteo[DIAGNOSES REDACTED]. There is associated soft tissue swelling. No fracture is seen. Conclusion: Right heel osteo[DIAGNOSES REDACTED] as described...Left heel osteo[DIAGNOSES REDACTED] as described." Culture Report for the right heel wound, dated 1/5/12, identified the bacteria of Proteus mirabilis, Pseudomonas aeruginosa, Corynebacterium and [MEDICATION NAME] species. Culture report for the left heel wound, dated 1/3/12, identified the bacteria of Proteus mirabilis, Mixed gram positive skin flora, and Methacillin Resistant Staphylococcus aureus (MRSA). Physician orders [REDACTED]. History and Physical from hospital, dated 1/9/12, indicated chief complaint of "worsening of pressure ulcers, both heels...History of present illness:...white male known to have dementia with medical history of [REDACTED]. Apparently, these sores began almost two and a half months ago...Less than a week ago, the patient had an x-ray of both heels which showed evidence of osteo[DIAGNOSES REDACTED]. Wound culture likewise was requested that later on came back [MEDICAL CONDITION] and Proteus mirabilis..." The Discharge Summary from hospital, dated 1/12/12, indicated the final [DIAGNOSES REDACTED]." Operative Report, dated 1/12/12, indicated "...Procedure performed: Subcutaneous excisional debridement that included muscle of both heels...Each ulcer measured approximately 3.5 cm (centimeters) in diameter. The bed of each ulcer was covered with necrotic material and a portion of the muscle was also involved in the necrosis..." The admission Minimum Data Set (MDS) assessment, dated 10/4/11, identified the resident required : extensive assist of two for bed mobility, transfer, toilet use, and personal hygiene; total dependence for bathing; at risk for developing pressure ulcers; two unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar that were present on admission; pressure reducing device for chair; pressure reducing device for bed; surgical wound care; application of non-surgical dressings; and applications of ointments/medications. Review of Treatment Administration Record (TAR) for resident dated October 2011 lacked documentation for completion of weekly skin assessment for 10/21/11 and 10/28/11. The November 2011 TAR lacked documentation for completion of weekly skin assessment for 11/4/11, 11/18/11, and 11/25/11. The December 2011 TAR lacked documentation for completion of weekly skin assessment for 12/13/11, 12/20/11, and 12/27/11. Interview of LPN #13 on 3/2/12 at 3:30 p.m., indicated the admission MDS assessment was inaccurate as the resident was admitted without pressure ulcers. Interview of the Director of Health Services (DHS) on 3/2/12 at 10:35 a.m., indicated the resident had pressure sores on both heels that were acquired in the facility. The DHS also indicated the treatment was completed daily by staff on the evening shift per family request so that the treatment could be observed. Interview of the resident's family (daughter and spouse) on 3/2/12 at 3:45 p.m., indicated the resident was admitted with only excoriation to the groin area and that the pressure ulcers to the heels developed a week after admission. The daughter indicated she was a registered nurse. The daughter stated the treatment was now being completed on the evening shift when she was present due to identifying the treatment was previously not being completed in November and December. The daughter indicated she had marked the dressings to see if the dressings were changed and she indicated they were not being changed as ordered. The daughter also indicated the only other area present since admission was small area between the knees from the brace that healed quickly. The daughter indicated the resident was on regular mattress initially but was then changed to scoop mattress. Interview of the daughter on 3/6/12 at 7:40 p.m., indicated the resident's heels were not floated from the mattress during the first week of admission. The daughter also indicated the resident lied flat in bed with the blinds closed and room dark. The daughter stated that when the TED hose were removed on 10/3/12 , both of the resident's heels were black in color. Interview of RN #9 on 3/6/12 at 8:30 p.m., indicated the resident's heels were black with yellow puss around the edges, and smelled awful. The RN indicated she contacted the attending physician at that time. The RN indicated she thought that was in December 2011. Review of Pressure/Stasis/Arterial/Diabetic Ulcer Assessment, dated 11/11/11, indicated onset of stage II pressure ulcer on right inner knee measuring 1 centimeter x 1 centimeter not present on admission. Weekly measurements were completed. The area was documented as healed on 1/3/12. Review of the clinical record of Resident B on 3/2/12 at 2:15 p.m., indicated the resident was admitted to the facility on [DATE]. physician progress notes [REDACTED]. Physician progress notes for November 2011 and December 2011 indicating visits every 30 days for the first 90 days were lacking. Interview of LPN #20 (Medical Records) on 3/12/12 at 2:20 p.m., indicated the physician had not seen Resident B in November 2011 and December 2011 for the every 30 days for the first 90 days. A physician's orders [REDACTED]. Interview of DHS and Administrator on 3/6/12 at 10:25 a.m., indicated Resident B was on the "house mattress" upon admission and currently was on scoop mattress. The Administrator indicated the "house mattress" was Panacea Support and the scoop mattress was the Panacea Support Plus. Review of the manufacturer's information for the Panacea Support and Panacea Support Plus on 3/6/12 at 10:25 am. indicated "...May be appropriate through Stage II wounds. Mattress wound Stage ratings are general usage guidelines. Resident -specific assessment could alter your particular usage of these mattresses...." The resident's current plan of care identified the problem of alteration in skin integrity as exhibited by pressure ulcers to bilateral heels unstageable and right knee related to insufficient circulation and immobility dated 10/27/11, and revised 1/12/12. The approaches included but were not limited to pressure/wound assessment per schedule; examine skin daily for signs of redness, discoloration; assess areas prone to breakdown especially over bony prominences; provide peri-care after each incontinent episode; pressure reducing mattress on bed; turn and reposition every two hours and as needed-avoid sheering; utilize pillows/pads to prevent skin to skin contact and enhance positioning; (10/3/11) keep heels elevated off of bed at all times;.." Review of Physician orders/Patient instructions from the wound center, dated 1/18/12, (first visit after debridement in hospital) on 3/5/12 at 1:30 p.m., indicated pressure ulcers of heels stage IV with treatment of [REDACTED]. The orders also included continue heel Medix boots to both feet at all times except for transfers. Right heel measured 2.8 centimeters x 4.2 centimeters x 0.5 centimeters /post visit same measurements. Left heel measured 3.9 centimeters x 4 centimeters x 0.5 centimeters/post visit same measurements. Review of Physician orders/Patient instructions from the wound center, dated 2/29/12 on 3/5/12 at 1:30 p.m., indicated pressure ulcers bilateral heels stage IV with osteo[DIAGNOSES REDACTED] with treatment of [REDACTED]. Measurements included: Right heel : 2 centimeters x 3.1 centimeters x 0.2 centimeters and post measurements 2.1 centimeters x 3.5 centimeters x 0.2 centimeters. Left heel: 3 centimeters x 3.5 centimeters x 0.2 centimeters and post measurements the same. 2. On, 2/28/12 at 2:20 p.m. LPN #7 was interviewed. The nurse indicated Resident #69 had an unstageable area on the right heel. On 2/28/12 at 3:15 p.m., Resident #69 was observed in a low bed on a blue pressure reduction mattress positioned on the right side. A Kerlix wrap was observed to the right foot. A Z-flow cushion was observed on top of the mattress; not close to the resident's feet. The resident was not wearing any pressure relieving boots. Manufacturer's information, provided by the DON on 3/6/12 at 10:25 a.m., indicated the mattress may be appropriate through Stage II wounds. Mattress wound Stage ratings are general usage guidelines. Resident-specific assessment could alter your particular usage of these mattresses. On, 2/29/12 at 10:00 a.m., LPN #1 was observed to do a treatment to the resident's right foot. A quarter sized area was observed on the right heel, a quarter sized area was noted on the right metarsal base with drainage noted. The nurse was observed to cleanse the areas with skin cleanser. The nurse then applied [MEDICATION NAME] to the areas utilizing sterile q-tips, then applied Santyl utilizing sterile q-tips. The nurse indicated a nickel thick application of the Santyl was to be applied and it was difficult to judge applying on top of the Bactraban. The nurse then applied sterile dressings to the areas and wrapped the foot with kerlix. (Rolled gauze bandage.) The nurse then dated the dressing. On, 3/6/12 at 11:30 a.m., CNAs #3 and #5 were observed to transfer the resident from bed to wheelchair. The resident was observed with the gauze dressing on the right foot. Drainage was observed on the dressing. The dressing was not dated. Documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation of the treatment being done was noted on 3/5/12, however dating of the dressing was not done in accordance with facility policy. Resident #69's clinical record was reviewed on 3/2/12 at 10:00 a.m. An admitted was noted of 1/19/12. [DIAGNOSES REDACTED]. A document titled "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment," provided by LPN #7 on 2/28/12 at 3:15 p.m., dated 1/19/12 documented the resident was admitted with "pressure Halifax right side inner foot Length 7 (centimeters) cm width 7 cm depth UTD (unable to determine.) The Color was documented of black, pain to touch. Surrounding tissue: pink. The Stage/Thickness was documented as E. The Key information included on the form of Stage E was noted of Un-stageable-non-removable dressing, slough/eschar; suspected deep tissue injury in evolution. Documentation of the area, dated 1/24/12 was noted of Stage E, 3 cm by 2.5 cm unable to determine depth, pain to touch, wound bed black scab. Current treatment: [MEDICATION NAME], Santyl, drsg, [MEDICATION NAME] roll. Current preventative interventions: Pressure reducing mattress. Documentation on the form, dated 1/31/12, was noted of the area stage E 3 cm by 2.6 cm pain, black eschar same treatments, preventative interventions: pressure boots, permanent reduction mattress. Documentation on the form, dated 2/6/12, was noted of stage E, 2.5 cm by 2.4 by 0.1 cm with pain, black/yellow. Continue same treatment and preventative interventions. Documentation was noted on 2/13/12 of Stage E 2.5 cm by 3 cm by 0.1 cm scant exudate pain wound bed yellow area was debrided at wound clinic on 2/12/12. Documentation on the form was noted, dated 2/21/12, of Stage E 2.5 cm by 3.8 cm yellow drainage, slight odor, thick, copious, Pain at time 25% black tissue, 75% yellow tissue. No change in treatments or preventative interventions. Documentation on the form, dated 2/28/12, was noted of the area Stage E 2.5 cm by 3.5 cm no depth. Thick, copious, yellow slight odor exudate. Yellow wound bed, pain at times. same treatment. Documentation on the form, dated 3/6/12, described the area as a Stage II, 2.5 cm by 3.5 cm by 0.2 cm. Scant exudate, wound bed pink, continue Santyl and [MEDICATION NAME]. Documentation on the form titled "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment was noted, dated 1/19/12 (admitted ), of pressure area to right heel Stage E 8 cm by 8 cm depth unable to determine. Color Black, pain to touch treatment: open to air. Documentation of the area was noted, dated 1/24/12, of unstageable area 2 by 2 unable to determine depth. Black wound bed, pain to touch. Under the comment section current treatment was noted of Bacroban, Santyl to center area, [MEDICATION NAME] role. Current preventative interventions Pressure reducing mattress. Documentation on the form, dated 1/31/12, was noted of the area stage E 3 cm by 2.6 cm pain, black eschar same treatments, preventative interventions: pressure boots, permanent reduction mattress. Documentation on the form, dated 2/6/12, was noted of stage E, 2.5 cm by 2.4 by 0.1 cm with pain, black/yellow. Continue same treatment and preventative interventions. Documentation was noted on 2/13/12 of Stage E 2.5 cm by 3 cm by 0.1 cm scant exudate pain wound bed yellow area was debrided at wound clinic on 2/12/12. Documentation on the form was noted, dated 2/21/12, of Stage E 2.5 cm by 3.8 cm yellow drainage, slight odor, thick, copious, Pain at time 25% black tissue, 75% yellow tissue. No change in treatments or preventative interventions. Documentation on the form, dated 2/28/12, was noted of the area Stage E 2.5 cm by 3.5 cm no depth. Thick, copious, yellow slight odor exudate. Yellow wound bed, pain at times. same treatment. Documentation on the form, dated 3/6/12, described the area as a Stage II, 2.5 cm by 3.5 cm by 0.2 cm. Scant exudate, wound bed pink, continue Santyl and [MEDICATION NAME]. Documentation on the form titled "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment was noted, dated 1/19/12 (admitted ), of pressure area to right heel Stage E 8 cm by 8 cm depth unable to determine. Color Black, pain to touch treatment: open to air. Documentation of the area was noted, dated 1/24/12, of unstageable area 2 by 2 unable to determine depth. Black wound bed, pain to touch. Under the comment section current treatment was noted of Bacroban, Santyl to center area, [MEDICATION NAME] role. Current preventative interventions Pressure reducing mattress. Documentation of the area was noted on 1/31/12 of unstageable 2 cm by 2.3 cm black/eschar wound bed. [MEDICATION NAME], Santyl with dressing, pressure boots pressure reduction mattress. Documentation of the area on 2/6/12 was noted of unstageable 2.2 cm by 2 cm depth 0.1 cm. Wound bed yellow and red. Same treatment and preventative interventions. Documentation for 2/13/12 was noted of unstageable area 2.2 cm by 2 cm by 0.1 cm, yellow and pink wound bed. Same treatment and preventative interventions. Measurements for 2/21/12 were noted of unstageable 1.8 cm by 2.4 cm by 0.1 cm, black wound bed surrounding tissue red no change in treatment or preventative interventions. Documentation of area on 2/28/12 was noted of area 2 cm by 2 cm by 0.1 cm. Wound bed pale. Continue same treatment. Documentation of the area on 3/6/12 was noted of Stage II, 2 cm by 2 cm by 0.1 cm no description of wound bed, periwound surrounding tissue Pink. Current treatment [MEDICATION NAME] Santyl with Kerlix. Documentation on the form titled "Pressure/Stasis/Arterial/Diabetic Ulcer" Assessment: dated 1/19/12, indicated the resident had a Stage II pressure ulcer to the right coccyx measuring 3 cm by 2 cm by less than 0.2 cm. The treatment was noted of Mediplex change as needed. Weekly measurements were noted with the last one noted, dated 3/6/12, of 0.5 cm by 0.5 cm x 0 cm Stage I. Current treatment: [MEDICATION NAME]. Current preventative interventions: Meplix. The resident's discharge instructions from the hospital included an appointment card for the resident to return to the wound center on 1/20/12. The resident had been seen by the wound center during hospitalization . Physician orders/patient instructions from the wound center, dated 1/20/12, included, but was not limited to, Apply to wound: Santyl/nickel thick to all foot wound beds apply [MEDICATION NAME] to sterile 4X 4 then apply to wound bed wrap with Kerlix daily. Pressure relieving boots on at all times no walking or standing in boots. Physician orders/patient instructions from the wound center, dated 2/17/12, included, but were not limited to right foot increased redness swelling Dx: pressure ulcer of heel, Stage III ulcer of other part of foot. Apply to all foot wound(s) "Santyl nickel thick to all wound beds. [MEDICATION NAME] to sterile gauze and apply to wounds daily. Leg elevation: elevate legs to level of heart or above as much as possible. Continue with heel Medix boots to bilateral feet remove only for transfers. Antibiotics: Zyrox 600 mg i tb po (by mouth) bid (two times a day) times 7 days-osteo[DIAGNOSES REDACTED]." Documentation on the form, dated 2/28/12, was noted of Stage E 2.5 cm by 3.5 cm no depth. Thick copious exudate with slight odor. Pain at time, tissue color yellow. Same treatment. Documentation of measurements, dated 3/06/12, was noted the area being a Stage II pressure area, no pain or exudate, periwound pink treatment [MEDICATION NAME] Santyl with Kerlix. A plan of care, dated 2/02/12, which addressed alteration in skin integrity as evidence by pressure ulcer, diabetic ulcer, immobility, and diabetes included but was not limited to interventions of : Pressure reducing mattress on bed and chair. An approach, dated 1/23/12, was noted of Heel lift boots to both feet at all times to relieve pressure. Not when walking or standing in boots. ...2/03/12: Promod 30 cc bid wound healing. Santyl and [MEDICATION NAME] with drsg, pressure reducing boots treat per wound center Right side inner foot, right heel. The admission Minimum Data Set (MDS) assessment, dated 1/26/12, coded the resident as requiring limited assistance of one for bed mobility, extensive assistance of one for transfers. Stage I or greater, a scar over bony prominence, or a non-removable dressing/device unhealed pressure ulcer. Three Stage II pressure ulcers present on admission, two unstageable pressure ulcers present upon admission/reentry due to coverage of wound bed by slough and/or eschar. Most Severe Tissue Type for any Pressure Ulcer. 4. Necrotic tissue (Eschar) black, brown, or tan tissue that adheres firmly to wound bed or ulcer edges, may be softer or harder than surrounding skin. The CAA (Care Area Assessment) dated 1/26/12, indicated the resident was admitted with pressure ulcer to right coccyx, Stage II, 3 by 3 by less than 0.2. Right side inner foot, unstageable 7 cm by 7 cm, unable to determine depth. Resident goes to wound center. ...Resident to wear boots to protect heels and refuses to do so at times. A plan of care, dated 2/02/12, addressed the problem of Pressure Ulcer, diabetic ulcer related to immobility and diabetes included an approach, dated 1/23/12, for heel lift boots to both feet at all times to relieve pressure not when walking or standing in boots. The plan of care did not address the resident's refusal at times to wear the boots. The resident was observed in bed with heels elevated on z-flow on 2/29/12 at 10:00 a.m.; on 3/06/12 at 10:00 a.m. in bed, feet elevated, boots on; 3/02/12 12:10 p.m. in wheelchair, bilateral boots on; 3/02/12 at 2:14 p.m. in bed with bilateral boots on; 3/05/12 10:00 a.m. in bed, heels elevated; 3/05/12 10:46 a.m. in wheelchair boots on, and 3/06/12 11:00 a.m. in bed, heels elevated, boots on. 3. LPN #7 was interviewed on 2/28/12 at 2:20 p.m. The nurse indicated Resident #158 had a Stage I pressure ulcer. On 3/06/12 at 3:00 p.m., with LPN #1, Resident #158's area were observed. A dressing was observed to the resident's coccyx, dated 3/01/12. The area was open with a small amount of drainage noted. A gauze dressing was observed to right foot with a small amount of drainage noted coming through the dressing. The dressing was not dated when changed. Resident #158's clinical record was reviewed on 3/02/12 at 2:16 p.m. An admitted was noted of 2/04/12 from the hospital after surgery for [REDACTED]. The initial Minimum Data Set (MDS) assessment, dated 2/11/12, coded the resident as has one or more unhealed pressure ulcer at Stage I or higher. Three Stage 1 pressure ulcers. One unstageable pressure ulcer present upon admission/reentry. Documentation on a form titled "Pressure /Stasis/Arterial/Diabetic Ulcer Assessment," provided b by LPN #7 on 2/28/12 at 3:15 p.m., included, but was not limited to Pressure ulcer to coccyx, d

A. Based on record review, and interview, the facility failed to monitor a resident receiving hot pack during therapy for adverse effects, with the resident having developed a second degree burn. Facility staff also failed to notify nursing staff of the resident having possibly received a burn from the hot pack treatment. This deficient practice affected 1 of 3 residents receiving hot pack treatments in a stage 2 sample of 29 (Resident # A). B. Based on observation, record review, and interview the facility, failed to remove protective footwear before transferring a resident to the wheelchair as directed by physician's orders [REDACTED].#B) Findings include: A.1. Record review for Resident # A on 03/05/12 at 11 a.m., indicated: Resident #A was admitted to the facility with the [DIAGNOSES REDACTED]. The resident had received a burn to the left shoulder from a hot pack treatment during a therapy session on 01/10/12. Silvadene cream was ordered daily until healed and the resident's family was notified. A document entitled "Skin Impairment Circumstance, Assessment and Intervention," dated 01/10/12 at 9:30 p.m., indicated the resident had been observed to have two clear fluid-filled blisters each measuring 1 cm (centimeter) by 1 cm to the left shoulder. Nurse's notes, dated 01/10/12 at 9:35 p.m., indicated the resident had been medicated with Tylenol 650 milligrams as needed for pain/discomfort. An admission MDS (Minimum Data Set) assessment, dated 01/18/12, indicated the resident had no cognitive impairment, required assist of 1 for transfers and ambulation with a walker/wheelchair, and required the use of non-medical interventions for pain control. A telephone order, dated 01/6/12, indicated "Occupational Therapy for 30 days (5 times a week). May include ultrasound/hot packs as needed." A care plan problem, dated 01/18/12, for "Skin condition, other: Burn to shoulder related to hot pack.." Interventions included, but were not limited to "Monitor for s/s (signs/symptoms) of ...redness, warmth, drainage, etc...Caregiver: Nursing..." This care plan problem failed to include therapy interventions, nor was there a care plan regarding the use of hot pack treatment by OT (Occupational Therapy) prior to the resident having received the burn on 01/10/12. During interview on 03/05/12 at 2:30 p.m., the resident indicated he had not felt any discomfort on 01/10/12, at any time during the hot pack therapy, even after the hot pack had been removed, but indicated the area had started hurting "a little bit that evening so had reported it to the nurse." During interview on 03/06/12 at 3 p.m., Certified Occupational Therapy Assistant (COTA) #12 indicated Resident #A had been receiving a hot pack treatment to the left shoulder on 01/10/12, concurrently with therapeutic exercise, with the area under the hot pack having been checked "2 or 3 times during the 20-25 minute treatment." COTA #12 indicated at the conclusion of the treatment the hot pack had been removed with slight reddish coloration having been observed to the top of the resident's shoulder, with the resident having had no complaint of pain/discomfort at any time. COTA #12 indicated redness of skin during the application of a hot pack was not normal. COTA #12 indicated he had first applied a non-medicated moisturizing lotion (could not remember the name of lotion but could be used as hand/body lotion) to the resident's left shoulder area, and then approximately 10 minutes later had applied BioFreeze as per the treatment regimen. COTA #12 had then indicated the resident had complained of discomfort later in the day on 01/10/12, with 2 blisters having been observed by the charge nurse "in the evening hours" (time uncertain). COTA #12 indicated he had seen two blisters on the resident's left shoulder the next day (01/11/12). COTA #12 indicated he had been counseled and all therapy staff had been inserviced regarding a new policy in which staff were to log start time and every 5 minute check times for residents receiving hot pack treatments. COTA #12 indicated on 01/10/12, the resident had on bib overalls and a T-shirt (as was the resident's usual dress), with the hot pack having been wrapped in heavy pad as well as a folded over towel as was the policy. When asked if he'd notified nursing staff of the redness, COTA #12 had indicated "no." Regarding how many layers of padding had been used, COTA #12 indicated he had used 2 layers of towel, 2 layers of pad, one layer of denim, and 1 layer of the resident's T-shirt. Review of the hot pack policy (revised January 2011) on 03/05/12 at 12:02 p.m., indicated: "Remove hot pack from the hydrocollator unit, place pack in cloth cover or wrap in 6-8 towels...Duration of the hot pack treatment is generally 15-25 minutes or to patient's tolerance...Skin must be checked every 5-10 minutes during the treatment. If the skin is bright red and/or feels hot to touch, add another layer of toweling...." This document did not address notification of the nursing department regarding any condition changes which might have taken place during hot pack therapy sessions. B. 1. On 3/2/12 at 11:20 a.m., Resident B was observed to be transferred from the toilet to the wheelchair per CNAs #22 and #23. The resident was observed to have Medix boots on bilateral feet and the resident bore weight on both feet during the transfer. The resident was observed to be transferred from the wheelchair to the toilet on 3/2/12 at 3:30 p.m., per CNAs #21 and #22. The resident's Medix boots were removed prior to the transfer. During interview of CNA #21 on 3/2/12 at 3:30 p.m., regarding removal of the Medix boots during transfer, the CNA indicated she realized the boots were slick on the bottom during the transfer at 11:20 a.m. Review of the clinical record of Resident B on 3/2/12 at 2:15 p.m., indicated the physician order, dated 1/18/12, of continue with heel Medix boots to both feet at all times except during transfers. The resident's current plan of care dated 10/27/11 and revision 1/25/12 addressed the problem of Alteration in skin integrity as exhibited by pressure ulcers to bilateral heels unstageable with approaches which included but was not limited to heel lift Medix boots to bilateral feet at all times except for transfers dated 2/10/12. Review of CNA assignment sheet on 3/6/12 at 4 p.m., for Resident #74 indicated Medix boots to both feet except for transfers. Review of manufacturer's guidelines for "HeelMedix Application Instructions" on 3/7/12 at 12:50 p.m. indicated "...HeelMedix heel protector is single patient use only. Product is used on patients while in bed to help prevent pressure ulcers. Patient must not walk or stand while wearing the HeelMedix heel protector...." This Federal tag relates to Complaint IN 286. 3.1-45(a)(2)

Based on observation, interview, and record review a. the facility failed to practice standard precautions to protect and prevent widespread nosocomial infections in that hand hygiene, linen handling, contact isolation were not maintained to prevent contamination as well as incomplete tracking of infections for 4 of 4 residents in a sample of 12 and 3 of 3 residents in a supplemental sample of 4 being treated for [REDACTED].#2, #42, #27, #25, #10, and #9); and co-horting of residents with Clostridium difficile infections (C-diff) was not maintained to prevent contamination for 1 of 5 residents in a sample of 12 and 1 of 1 resident in a supplemental sample of 4 without the [DIAGNOSES REDACTED].#28). Disinfectant and cleaning products utilized through out the facility, including isolation rooms, were not effective for[DIAGNOSES REDACTED]. b. The facility failed to ensure techniques were utilized to prevent contamination for 1 of 1 resident reviewed in a sample of 12 observed receiving dressing treatment to open areas. (Resident #25). This deficient practice had the potential to affect all 45 residents of the facility. This deficient practice resulted in Immediate Jeopardy. The immediate jeopardy was identified on 5/6/11 and began on 5/6/11. The Executive Director and Director of Nursing were notified of the Immediate Jeopardy on 5/6/11. The Immediate Jeopardy was removed on 5/10/11, but the facility remained out of compliance at the level of patter, no actual harm with potential for more than minimal harm that is not immediate jeopardy for continued monitoring of nursing and housekeeping staff and inservice training for compliance with infection control/isolation techniques and procedures; education of visitors of residents with[DIAGNOSES REDACTED]. regarding precautions; monthly review of infection control logs by the quality assurance committee; and auditing each shift, each wing by the charge nurse to verify protocol is followed for a minimum of 30 days. Findings include: a1. During interview of LPN #15, on 5/4/11 at 12:05 p.m. the LPN identified five residents, Resident #'s 2, 9, 10, 11 and 42 residing on the 100 and 300 units, as having[DIAGNOSES REDACTED]. a2. On 5/5/11 at 10:00 a.m., LPN #16 identified Residents' #27 and #25 on the 200 hall unit with[DIAGNOSES REDACTED]. Magnetic signs posted on the door frames were noted of "STOP SEE NURSE FOR INSTRUCTIONS." a3. During initial tour on 5/4/11 at 11:45 a.m., with the Assistant Director of Health Services (ADHS) Resident #25 was identified as returning from the hospital with four open areas, alert and oriented, had an indwelling Foley catheter. The resident was observed in the room on a specialty air alternating mattress. Upon entering the room on 5/5/11 at 10:05 a.m., CNA #5 was observed providing care to Resident #25. Soiled linens were observed on the carpeted floor. The CNA indicated the resident had just had a loose bowl movement kind of greenish and clear. While wearing gloves, the CNA bathed and dressed the resident's upper body. The CNA was observed to lean across the resident's body, and blue, air loss mattress cover while providing the care. The CNA was not wearing a gown or protective barrier covering. The CNA was observed to step on the linens on the floor at the end of the bed while moving back and forth around bed providing care. The CNA dressed the resident without wearing gloves, opened the privacy curtain, moved the resident's wheelchair entered the bathroom and washed hands. A pink wash basin utilized for the bathing, was observed on the resident's over bed table, and a towel utilized to dry the resident was placed on the table. Other items observed on the table next to the basin and towel were a box of snack crackers, a vase, a canned drink, container of wet wipes, and a box of body powder. After completion of the resident's care, the CNA, without wearing gloves or gown, picked the soiled linens up from the floor and bagged them, touching against uniform during the process. The bags were then discarded into cardboard boxes lined with red biohazard bags located in the bathroom. The CNA then washed hands and exited room. CNA#5 returned to the room with CNA #6. Both CNAs washed hands and donned gloves. The staff assisted the resident to sit on the side of the bed, and lifted the resident under the arms to transfer into a wheelchair. Gowns were not utilized while in close contact with the resident. On 5/6/11 at 11:10 a.m., RN #7 was observed to provide wound care treatments to the resident. During the treatment, while in close contact with resident, leaning against the resident's bed, the RN was observed to wear gloves, and not to wear a barrier, protective covering. After completing the wound treatments the RN removed the gloves, picked up the bed control from the floor and placed it next to the resident, adjusted the pillow, bagged linens and trash without gloves, opened the bathroom door and discarded the linens/trash into the biohazard boxes in the bathroom which were observed to be filled beyond capacity with refuse mounded above the tops of the containers. Resident #25's clinical record was reviewed on 5/5/11 at 11:25 a.m. The resident's admitted was noted of 11/12/10. The resident's [DIAGNOSES REDACTED]. Documentation was noted on a hospital history and physical report dated 4/13/11 of admitted to hospital with diarrhea, septic shock, pneumonia, and urinary tract infection. A hospital inter-agency transfer form, dated 5/2/11, indicated the resident had been treated for [REDACTED]. A hospital discharge note, dated 5/2/11 indicated the resident's[DIAGNOSES REDACTED] diarrhea was improved. RN #7 was interviewed on 5/6/11 at 9:30 a.m. and indicated the resident returned to the facility on [DATE]. RN #7 indicated gloves are worn for contact precautions and gowns were only utilized for MRSA (Methicillin resistant Staphylococcus aureus) infections. The RN indicated visitors who ask are instructed to wash hands when they go into a room with contact isolation and wash hands, before they leave. A physician's order was noted dated 5/2/11 for [MEDICATION NAME] 250 milligrams (mg) by mouth four times daily times seven more days for[DIAGNOSES REDACTED]. A physician's order was noted dated 5/4/11 for contact isolation. On 5/6/11 at 3:30 p.m. RN #21 indicated contact isolation is started if a positive[DIAGNOSES REDACTED] culture is reported or if resident is on oral [MEDICATION NAME]. Documentation on the May Medication Administration Record reviewed on 5/6/11,was noted of the [MEDICATION NAME] being administered May 3, 4, 5, and 6. Documentation on the form titled "CORP-Resident BM Description-NEW" provided by the Assistant Director of Health Services, on 5/6/11 at 10:50 a.m., contained documentation of the resident having loose stools on 5/3/11 and 5/4/11; soft stools on 5/4, and two times on 5/5/11. Documentation on the record for dates of 5/6-9/11 documented three formed stools and five soft stools. A plan of care which addressed the [DIAGNOSES REDACTED]. a4. During initial tour on 5/4/11 at 11:45 a.m. with the ADHS, Resident #26 was identified as a new Cerebral Vascular Accident (CVA) and was on peritoneal dialysis. The nurse indicated the dialysis is performed during the night. The resident's dialysis supplies and machine were observed in the room, just on the other side of the privacy curtain in a room shared with Resident #25, diagnosed with [REDACTED]. Resident #26's clinical record was reviewed on 5/5/11 at 2:15 p.m. an admitted was noted of 4/8/11 with readmission date of [DATE]. A physician's order was noted 4/27/11 for Dialysis 2.5 % (per cent) 10 L (liters) every hour of sleep start at 8:00 p.m. off in a.m. A [DIAGNOSES REDACTED]. On 5/6/11 the resident was discharged to the hospital with lethargy. a5. During initial tour on 5/4/11 at 11:45 a.m. with the ADHS, Resident #27 was observed in bed with a Foley catheter. The resident had been recently readmitted from the hospital had decreased oxygen saturation rates, was confused, on oxygen at 6 liters and had a PIC line (central intravenous access). The resident's call button was observed on the carpeted floor. The ADHS picked up the call button and placed it on the resident's bed within reach. On 5/5/11 at 1:00 p.m., CNA #5 was observed coming from the Resident's bathroom wearing gloves, carrying a bedpan and placing it in a plastic bag, opened the resident's closet door, and placed the bagged bedpan on top of personal items in the resident's closet. The CNA indicated the resident had a watery dark green stool and had three stools this shift. A protective barrier covering was not being worn. A pink, unbagged wash basin was observed on top of the resident's personal items in the closet. A red, isolation plastic bag was observed on the bathroom floor, underneath the sink. On 5/5/11 at 3:10 p.m., CNA #20 was observed to enter Resident #27's room with an electronic blood pressure monitor on a wheeled stand, a wrist blood pressure cuff, pulse oximeter, and temporal thermometer. The CNA was observed not to wear gloves or gown to protect uniform while in close contact with the resident. The resident's blood pressure, oxygen saturation, pulse, and temperature were taken with the devices. The CNA exited the room with the equipment, utilized hand gel and went down the hall. The CNA returned to the equipment and was observed going back into the room, to check the resident's roommate's vital signs. On 5/6/11 at 9:50 a.m., CNAs #18 and #19 were observed to provide a bed bath to Resident #27. The CNAs were observed to be wearing gait belts around their uniforms, to wear gloves, and to not be wearing a protective barrier covering. The CNAs' uniforms were observed to come into contact with the resident, and resident's bed during the care. After completion of the care, CNA #19 was observed to rinse the wash basin in the bathroom sink, placed it in a bag and put it in the resident's closet on top of personal items. The CNA was interviewed at that time as to how the resident's bedpan was cleansed and indicated she usually rinses it out with the shower sprayer. Resident #27's clinical record was reviewed on 5/5/11 at 3:20 p.m. A nursing note indicated the resident was readmitted from the hospital on [DATE] and a physician's order was noted dated 5/3/11 for [MEDICATION NAME] 250 mg two tabs by mouth for three days and an order was noted dated 5/4/11 for oral [MEDICATION NAME] 5 ml (milliliters) by mouth daily. A hospital [MEDICATION NAME] report, dated 4/25/11 indicated the resident had[DIAGNOSES REDACTED] colitis and currently was on [MEDICATION NAME]. Documentation on the form titled "Resident BM Description" was noted of the resident having three loose stools on 5/5/11. A care plan was noted dated 5/7/11 which addressed[DIAGNOSES REDACTED] and to follow contact isolation precautions. a6. During initial tour on 5/4/11 at 11:45 a.m. with the ADHS, Resident #28 was observed in bed on a speciality air mattress. The Resident was identified as having an open area on the middle of the back and [DIAGNOSES REDACTED]. The resident shared the room with Resident #27, with [DIAGNOSES REDACTED]. Resident #28's clinical record was reviewed on 5/9/11 at 11:50 a.m. The resident's [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. a7. On 5/5/11 at 1 p.m., Resident #42's private room was observed to have sign posted inside of the door frame indicating to see the nurse for instructions. A red barrel with red plastic lining was observed inside of the resident's bathroom as well as box with red plastic bags. RN #7 was observed to assist the resident with stand by assist to the bathroom. The resident utilized a walker. The RN was observed to not wear gloves or gown. The resident was observed to pull down her incontinent brief and pants. The resident voided. The RN was observed to apply new incontinent brief while the resident was seated on toilet. The RN was observed to apply gloves. The resident attempted to cleanse self with toilet paper. Bowel movement was noted on the toilet paper the resident was using. The resident stood up touching the grab bar and the walker. The RN cleansed the resident's buttocks with disposable cleansing cloths. Without changing the contaminated gloves, the RN picked up tube of "[MEDICATION NAME]" barrier cream, opened the tube, and applied the cream to the resident's buttocks. The RN then returned the tube of cream to the back of the sink. The RN then removed her gloves and assisted the resident in pulling up her pants. The RN and the resident washed their hands. The resident was transferred to the wheelchair. The RN was observed to pick up and move the walker (the walker previously touched by resident). The RN was observed to exit the room. On 5/6/11 at 10:20 a.m., Resident #42 was observed to be sitting on toilet in bathroom. CNA #5 was observed to apply gloves and removed the resident's brief which was wet from urine. The CNA did not wear gown. The CNA removed gloves and washed hands. The CNA assisted the resident with a new brief. The resident cleansed self with toilet paper. The resident and CNA were observed to wash hands. Interview of CNA #5 on 5/6/11 at 10:30 a.m. indicated Resident #42 was in contact isolation. The CNA indicated gloves were to be worn when a resident is in contact isolation. The CNA was unable to indicate whether or not the resident had been having loose stools or not. Review of the clinical record of Resident #42 indicated the resident was readmitted to the health center from the hospital on [DATE] with [DIAGNOSES REDACTED]. The history and physical dated 3/18/11 on admission to the hospital indicated the resident had some diarrhea/loose stools for the past few days and the resident was not eating and drinking well with diffuse lower quadrant abdominal pain. A lab result for Clostridium Difficile toxin A and B of the stool dated 3/21/11 indicated Clostridium Difficile toxin A and/or B were detected. The admission orders [REDACTED]. Nursing notes dated 3/29/11 at 2:45 p.m. indicated the resident was readmitted to the facility with isolation precautions due to Clostridium Difficile. The resident was readmitted to the hospital on [DATE] with [DIAGNOSES REDACTED].[REDACTED]. The resident completed the [MEDICATION NAME] treatment on 5/6/11. The "Resident BM Description" dated 5/7/11 and 5/8/11 indicated the resident continued to have "loose" stools. The resident's current plan of care indicated the problem of infection as exhibited by positive Clostridium Difficile dated 4/7/11 with approaches that included but were not limited to follow other appropriate precautions -contact; monitor lab/diagnostics as ordered and report abnormal findings to MD; and Administer/monitor effectiveness of treatments as ordered. Interview of Resident #42's family on 5/9/11 at 12:15 p.m. indicated the family had not been given information regarding Clostridium Difficile until this past weekend of 5/7/11 and 5/8/11. a8. Resident #2 was observed on 5/5/11 at 2 p.m. to be transferred from the wheelchair to the bed by CNA #1 and CNA #4. A sign was noted posted on outside of resident's door "to see nurse for instructions." A gait belt was noted to be utilized for transfer by the CNAs. A red barrel was observed in the resident's bathroom. The resident resided in private room. The CNAs were observed to wear gloves during the transfer. No isolation gowns were worn by the staff. Staff were observed to assist the resident with positioning the resident's feet into the bed. The CNAs were observed to remove their gloves and wash their hands. The gait belt was removed from the room after the transfer. Interview of CNA #4 on 5/5/11 at 2:10 p.m. indicated the resident usually had one loose stool a day. The CNA indicated the resident was worried when stool was loose that it was "C Diff" again. The CNA indicated the resident had been toileted earlier and requires extensive assistance. The CNA indicated the resident was in contact isolation and that gloves were to be worn during care. Review of the clinical record on 5/5/11 at 1:30 p.m. indicated the resident was readmitted to the facility on [DATE] without [DIAGNOSES REDACTED]. A laboratory result dated 2/25/11 indicated a stool culture for Clostridium Difficile Toxin A and B was negative for the Clostridium Difficile Toxin A and B. A laboratory result dated 3/14/11 indicated a stool culture as positive for Clostridium Difficile Toxin A and/or B. A physician's order was noted dated 3/15/11 of [MEDICATION NAME] 500 milligram one three times daily for 10 days for Clostridium Difficile. A physician's order dated 3/18/11 was noted of Contact isolation for Clostridium Difficile and may discontinued when stools are negative X2. A laboratory result dated 3/28/11 for stool indicated negative for Clostridium Difficile Toxin A and B. A laboratory result dated 3/30/11 indicated a stool culture as positive for Clostridium Difficile Toxin A and/or B. A physician's order dated 3/31/11 was noted of [MEDICATION NAME] 250 mg one by mouth four times daily for 14 days for Clostridium Difficile. A laboratory result dated 4/18/11 for stool indicated negative for Clostridium Difficile Toxin A and B. A laboratory result dated 4/23/11 for stool indicated Clostridium Difficile Toxin A and/or B detected. A physician order was noted dated 4/24/11 of [MEDICATION NAME] 250 mg one by mouth four times daily for 2 weeks then [MEDICATION NAME] 250 mg twice daily for 2 weeks then [MEDICATION NAME] 250 mg one every day for one week and then discontinue- Recheck stool for Clostridium Difficile after [MEDICATION NAME] treatment. The "Resident BM Description" dated 5/6/11-5/9/11 at 1:30 p.m. indicated a loose stool on 5/7/11. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident as cognitively intact; always incontinent of bowel; frequently incontinent of bladder; and requiring extensive assistant with toilet use, hygiene and bathing. The resident's current plan of care identified the problem infection as exhibited by positive for Clostridium Difficile dated 3/16/11. The approaches included but were not limited to follow other appropriate precautions- contact; administer/monitor effectiveness of medications as ordered; Administer/monitor effectiveness of treatments as ordered; and hold [MEDICATION NAME] until further notice due to Clostridium Difficile. Review of the infection control logs on 5/6/11 at 11:20 a.m. did not indicate Resident #2 with Clostridium Difficile infection on 3/14/11. Interview of the Director of Nursing on 5/6/11 at 11:45 a.m. indicated she was unsure why Resident #2 was not reflected on the infection control logging. a9. During initial tour on 5/4/11 which began at 11:30 a.m., with LPN #14, a sign was noted on the outside of a resident room, indicating " STOP SEE NURSE FOR INSTRUCTIONS." LPN #14 indicated Resident #11 had Clostridium difficile (c-diff). On 5/5/11 at 3:55 p.m., Resident # 11 was observed to be toileted by CNAs #9 and # 10. The staff were observed to wear gloves. Isolation gowns were observed not to be worn. The resident was noted to wear disposable brief. A posting was noted on outside of door to indicate to "see nurse for instructions." Red barrel and box lined with red plastic bags were observed in the resident bathroom. Interview of CNA #9 on 5/5/11 at 3:55 p.m. indicated the resident #11 was in contact isolation and the gloves were needed when caring for the resident. The CNA indicated the resident continued to have diarrhea. Review of the clinical record of Resident #11 on 5/5/11 at 12:40 p.m. indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order was noted dated 4/25/11 for contact isolation. A physician's order dated 4/25/11 was noted for [MEDICATION NAME] 500 milligram (antifungal ) every 8 hours for 2 weeks and then obtain stool specimens. "Infection Assessment and Review" dated 4/26/11 indicated proper infection control techniques by staff had been observed/monitored; isolation equipment were available; and equipment used on residents with like symptoms had been properly cleaned and disinfected. "Resident BM Description" dated 4/29- 5/6/11 indicated the resident continued to have loose stools with total of 7. The resident's current plan of care identified the problem of infection as exhibited by pneumonia and Clostridium Difficile dated 5/6/11. The approaches included but were not limited to follow other appropriate precautions i.e. contact isolation; and administer/monitor effectiveness of treatments as ordered. Interview of LPN #24 on 5/5/11 at 11:30 a.m. indicated Resident #11 required assistance of 1 and/or 2 during transfers and hygiene. The resident was also identified with confusion at times. a10. On 5/5/11 at 11:30 a.m., CNA #'s 1 and 4 provided incontinence care to Resident #9. CNA #1, while wearing gloves, cleansed loose bowel movement from the resident. Without changing the gloves the CNA placed a clean brief on the resident, touched the resident's top sheet, pillow and side rail. CNA #1 and #4 assisted with the repositioning and cleansing of the resident. Neither CNA wore a gown over their uniform. Both CNAs were observed during care to lean up against the mattress. Resident #9's clinical record was reviewed on 5/5/11 at 10:50 a.m. An admitted was noted of 4/21/11. An admission order, dated 4/21/11, indicated the resident was to be on "[MEDICATION NAME]" (antibiotic) due to[DIAGNOSES REDACTED]. A May 2011 MAR (medication administration record) indicated the resident received the [MEDICATION NAME] through the a.m. dose on the 5th. A plan of care, dated 5/3/11, indicated the resident with a[DIAGNOSES REDACTED] infection. An approach of, but not limited to, was noted of "Contact" precautions. Review of a form titled "Resident BM Description", documentation indicated the resident had three loose stools on 5/6/11, two loose stools on 5/7/11, two loose stools on 5/8/11, and one loose stool on 5/9/11. A physician's order was noted, dated 5/8/11, indicating the resident was to be started on "[MEDICATION NAME] 500 mg ( 2 tablets 1250 mg) R/T (related to) loose stools" along with "Start [MEDICATION NAME] 5 ml qid (four times a day) X (times) 14 days R/T (related to) loose stools." a11. On 5/6/11 at 10:40 a.m., CNA #11 entered Resident #10's room. The CNA opened the resident's closet, removed clothing, touched the resident's wheelchair and overbed table. Without washing hands, the CNA left the resident's room and went down the hall, opened the linen closet and removed a towel and washcloth. The CNA then went back into the resident's room and provided incontinence care to Resident #10. The CNA did not wear a gown over his uniform. While providing the care, the CNA leaned up against the resident's bed. While wearing gloves, the CNA cleansed loose bowel movement from the resident. Without changing gloves, the CNA picked up the resident's urinal, opened the bathroom door, flushed the toilet, touched the resident's privacy curtain and placed a clean brief on the resident. Resident #10's clinical record was reviewed on 5/5/11 at 12:45 p.m. An original admitted was noted of 3/25/11, with a readmission date of [DATE]. A nursing note, dated 3/29/11, indicated the resident was sent to the emergency room for respiratory problems. The nursing notes indicated the resident returned on 4/4/11. A physician telephone order was noted, dated 4/10/11, indicating "Obtain stool specimen related to frequent mucus foul smelling stool, send to (Lab) for testing[DIAGNOSES REDACTED]." A laboratory report was noted, dated 4/11/11, indicating "clostridium difficile toxin A and/or B detected." A physician's telephone order, dated 4/11/11, indicated the resident was to receive "[MEDICATION NAME] (anti-fungal) 500 mg one BID (twice daily) X (times) three weeks." A May 2011 MAR (medication administration record) indicated the resident received the [MEDICATION NAME] through May 1, 2011. A physician's telephone order was noted, indicating "Obtain 2 negative stool specimen (after) [MEDICATION NAME] therapy." A laboratory form, dated 5/4/11, indicated the resident was "negative for Clostridium difficile Toxin A and B". Review of form titled "Resident BM Description", documentation indicated the resident had a loose stool on 4/29/11, 5/4/11, 5/5/11, and 5/8/11. a12. During review of the infection control logs, provided by the DON on 5/6/11 at 11:20 a.m., Resident #'s 9 and 10 were not on the April 2011 logs. The DON was interviewed on 5/6/11 at 11:45 a.m. The DON indicated Residents #9 and #10 were not on the April 2011 infection log and was unable to indicate why the residents were not on the infection control logs. a13. On 5/6/11, at 11 a.m., Housekeeping staff #13 was observed to exit Resident #9's room. During interview of Housekeeper #13 on 5/6/11 at 11 a.m., the housekeeper indicated he was unaware of any special precautions other than wearing gloves while cleaning the resident's room. The housekeeper indicated if any resident was identified with MRSA (methicillin resistant staph aureus) they would have to wear gowns. The housekeeper indicated that he had not been made aware of any residents requiring special precautions other than gloves. The housekeeper indicated, Virex was the disinfectant used on hard surfaces including the bathroom sink and cabinets, tables, chair arms ect. that was used for the residents' rooms. The housekeeper indicated the residents' bathrooms are mopped daily and the mop heads are changed every third bathroom. The housekeeper indicated the carpet in the residents' rooms were vacuumed every day, but were only spot cleaned if needed. During interview of the Maintenance/Environmental Supervisor on 5/6/11 at 12:20 p.m., the supervisor was unsure if the disinfectant was effective against the[DIAGNOSES REDACTED]. The supervisor indicated the carpets in the resident rooms were spot cleaned as needed with a crystallized product type of cleaner. The supervisor indicated they try to cleanse the carpets quarterly with a cleaner titled "Krud Kutter." During review of the manufacturer's information concerning "Virex" received from the Maintenance/Environmental Supervisor on 5/6/11 at 12:25 p.m., documentation was lacking to indicate if the disinfectant was effective against[DIAGNOSES REDACTED]. During interview of the Maintenance/ Environmental Supervisor on 5/6/11 at 3:15 p.m., the supervisor indicated "Virex" did not kill[DIAGNOSES REDACTED]. During review of the products "KRUD KUTTER" and "iCapsol Encapsulating Interim Cleaning Chemical" received from the Maintenance/Housekeeping supervisor on 5/9/11 at 10:30 a.m., information to identify the product was a disinfectant was lacking. Review of the facility policy titled "Precautions Categories" received on 5/6/11 at 11:10 a.m., documentation was noted, under "Contact Precaution" indicating examples of, but not limited to, infections requiring Contact Precautions, was diarrhea associated with Clostridium difficile. Documentation indicated under "Resident Placement" "Individual requiring Contact Precautions should not be charted with someone who has indwelling tubes, catheters, or open wounds." Documentation indicated "clean, non-sterile gloves should be worn when entering the room. Gloves should be changed after having contact with infective material that may contain high concentrations of microorganisms (fecal material, wound drainage)" and "A clean, non-sterile gown should be worn when entering the room if: a. It is anticipated that clothing will have substantial contact with an actively infected resident, environmental surfaces, or items in the resident room. b. The actively infected individual is incontinent, has diarrhea, an ileostomy, a colostomy or wound drainage not contained by a dressing. Clothing should not come in contact with potentially contaminated environmental surfaces after removal of the gown. Documentation indicated under "Resident care equipment" "Disposable or dedicated use of non-critical resident care equipment items such as stethoscope, sphygmomanometer, bedside commode or electronic rectal thermometer to a single resident with an active infection to avoid sharing between residents is preferable. If use of common items is unavoidable, items should be adequately cleaned and disinfected before use for another resident." The facility policy titled "Surveillance Process," (no date) provided by the Executive Director on 5/9/11 at 2:25 p.m., included, but was not limited to: Infections surveillance is designed to accomplish several goals: 1. Enable the facility to quickly identify clusters and/or significant increases in the occurrence of infection. 2. Observe and evaluate the effectiveness of nosocomial infection prevention techniques of resident care delivery. A. Data Collection 1. Walking rounds provide the Infection Control Practitioner (IC) the chance, while visiting a unit, to talk with staff, observe residents, etc. Opportunities for a brief, on-the-spot infection control inservice may occur: ...Any resident who has had a culture should be evaluated for potential infection, regardless of the result. ...The Infection Control Committee provides guidance, recommendations to address problems suggested by the facility's nosocomial infection rate. Implement the recommended changes and evaluate their effectiveness. ..." b. On 5/6/11 RN #7 was observed to provide dressing treatments to open areas on Resident #25's back and left hip. While wearing gloves the RN removed dressings, dated 5/3/11 from the back and left hip. The RN applied normal saline to a gauze 4 by 4 dressing and cleansed the open area on the resident's back, observed with a yellow colored center. With the same gloves, the nurse utilized a second gauze and cleansed an open area on the resident's left hip. With the same gloves on the nurse dried the back, then hip, then removed the gloves. The nurse donned another pair of gloves, dated two [MEDICATION NAME] dressings, applied a dressing to the back area, then hip. RN #7 assisted the resident in repositioning after completing the treatment, then removed the gloves. A facility policy titled "General Guidelines for Dressing Changes," dated December 2009, provided by the DON on 5/13/11 at 10:35 a.m., included, but was not limited to, "Purpose: To ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize/control contamination. ...Procedure: 6. Put on first pair of disposable gloves. 7. Remove soiled dressing and discard in plastic bag. 8. Dispose of gloves in plastic bag. 9. Wash hands with soap and water. 10. Put on second pair of disposable gloves. 11. Follow doctors recommendations for treatment. 12. Apply dressing and secure with tape when done with treatment. ...14. Remove gloves and discard with all unused supplies in plastic bag. 15. Wash hands with soap and water. ..." An Immediate Jeopardy was identified on 5/6/11 at 4:30 p.m. The IJ began on 5/6/11 when the facility failed to practice standard precautions to protect and prevent widespread nosocomial infections. The Immediate Jeopardy was removed on 5/10/11 at 5:00 p.m. when through observations, interviews, and record review, it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. Through observations, residents without[DIAGNOSES REDACTED]. were not sharing rooms with residents infected. Isolation stations were set up outside of infected resident rooms and staff were observed e