Every finding on record at Colonial Nursing Home

Based on observation and interview, the facility failed to ensure a sanitary kitchen related to testing the dishwasher sanitation level with faulty test strips in 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect the 26 of 29 residents in the facility who received food from the kitchen. Finding includes: During the initial kitchen tour on 5/27/25 at 9:10 a.m. with the Dietary Food Manager (DFM), the dishwasher was observed and noted to be a low temperature, chemical system. The DFM obtained a testing strip, dipped it into the dishwasher water and compared it to the results on the side of the testing strip container. The strip did not have a readily discernable color change. He indicated they always used those strips and was unsure why they were not changing. He opened a new package of test strips and attempted to get another reading, however the strips still did not have a discernable color change. He indicated he would call the service company to address the dishwasher and go get another new package of strips. During a follow up interview on 6/2/25 at 11:45 a.m., the DFM provided a test strip that was the appropriate sanitation level for the dishwasher (50 parts per million). He indicated the other test strips were not working and was not sure the reason why. He had called the service company and they recalibrated the dishwasher on 5/27/25 and it had been working appropriately since that time. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to provide at least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208) Findings include: 1. The floor area of the following single resident room measured: a. room [ROOM NUMBER] - 1 resident, 96.2 SQ FT. NF. 2. The floor areas of the following multiple resident rooms measured: a. room [ROOM NUMBER] - 0 residents, 150.3 SQ FT, 75.2 SQ FT per bed. NF. b. room [ROOM NUMBER] - 1 resident, 145.0 SQ FT, 72.5 SQ FT per bed. NF. c. room [ROOM NUMBER] - 1 resident, 149.0 SQ FT, 74.5 SQ FT per bed. NF. d. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. e. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. f. room [ROOM NUMBER] - 0 residents, 140.0 SQ FT, 70.0 SQ FT per bed. NF. g. room [ROOM NUMBER] - 0 residents, 146.9 SQ FT, 73.4 SQ FT per bed. NF. The facility rooms with room variances were observed on 5/28/25 at 2:50 p.m. The rooms were observed with the following number of beds: room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed During an interview on 5/27/25 8:53 a.m., the Administrator indicated these were the rooms which had the room variance waivers and did not have the required square footage. 3.1-19(l)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services related to not obtaining treatment orders for a wound vac for 1 of 4 residents reviewed for pressure ulcers. (Resident 183) Finding includes: During an observation of wound care on 5/29/25 at 9:53 a.m. with RN 1, a dressing change was observed to Resident 183's proximal and distal left thigh. RN 1 indicated at the time that Resident 183 had a wound vac placed to her right heel the day before (5/28/25) and there was no treatment change due at the time. Resident 183's record was reviewed on 5/29/25 at 11:10 a.m. Diagnoses included, but were not limited to, cellulitis of the right lower limb, type 2 diabetes mellitus, and pressure ulcer to the right heel. The Discharge Minimum Data Set (MDS) assessment, dated 5/10/25, indicated the resident was cognitively intact for daily decision making. The resident had two unstageable pressure ulcers. A Skin and Wound Note, dated 5/28/25 at 6:23 p.m., indicated the resident had readmitted to the facility on [DATE]. The right heel pressure injury was surgically debrided during the recent hospital admission due to purulent drainage and evidence of infection. The wound vac was to continue to the heel wound at 100 mmHg (millimeters mercury) per the surgeon's request and a rescue dressing of calcium alginate with silver. The plan was discussed with the wound nurse. The right heel wound was an open surgical full thickness wound measuring 9.8 centimeters (cm) long by 5.5 cm wide by 1.7 cm deep. Treatment recommendations for the right heel open surgical wound were to clean with wound cleanser, apply a wound vac at 100 mmHg, rescue dressing of calcium alginate with silver with abdominal pad and rolled gauze to the base of the wound, secure with transparent film, change three times per week and as needed. There were no treatment orders for the right heel wound vac or rescue dressing in the May 2025 Physician's Order Summary. During an interview on 5/29/25 at 2:09 p.m., the Director of Nursing (DON) indicated there should have been physician's orders entered for the wound vac. A policy titled, Skin and Wound Management System, received on 6/2/25 at 1:05 p.m., indicated .5. Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. Wound location, characteristics and a physician's order for treatment are documented in the medical record. Wound status will be evaluated and documented in PCC [electronic record system] on the Wound Evaluation Flow Sheet form . 3.1-40

Based on record review and interview, the facility failed to ensure the resident's physician was notified of medication being held for 1 of 5 residents reviewed for unnecessary medications. (Resident 183) Finding includes: Resident 183's record was reviewed on 5/29/25 at 11:10 a.m. Diagnoses included, but were not limited to, cellulitis of the right lower limb, type 2 diabetes mellitus, and pressure ulcer to the right heel. The Discharge Minimum Data Set (MDS) assessment, dated 5/10/25, indicated the resident was cognitively intact for daily decision making. She received diuretic, opioid, antiplatelet, and hypoglycemic medications in the 7-day look-back period. The current May 2025 Physician's Order Summary indicated the resident received Novolog FlexPen (insulin injection) subcutaneous solution pen-injector 100 unit/milliliter, inject 12 units subcutaneously three times a day with meals. The May 2025 Medication Administration Record indicated the Novolog medication was coded 11= blood sugar level below parameters on the following dates and times: - At 8:00 a.m.: 5/1/25 blood sugar 97, 5/4/25 blood sugar 123, 5/8/25 blood sugar 80, and 5/9/25 blood sugar 75 - At 12:00 p.m.: 5/6/25 blood sugar 111, 5/8/25 blood sugar 106, and 5/9/25 blood sugar not applicable - At 5:00 p.m.: 5/6/25 blood sugar 107 and 5/8/25 blood sugar 89 There was a lack of any physician's orders for parameters for holding the medication, corresponding progress notes related to the medication being held, or documentation that the physician was notified when the medication was held. During an interview on 5/29/25 at 2:09 p.m., the Director of Nursing indicated the resident often refused her insulin dose based on what the blood sugar levels were and the nurse should have documented refusals instead of holding the medications. She had no further information to provide. 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen administration for 1 of 1 resident reviewed for respiratory care. (Resident 9) Finding includes: On 5/27/25 at 11:09 a.m., Resident 9 was observed in her room lying in bed. A nasal cannula was in place and oxygen was flowing. The oxygen concentrator was set at 2 liters. On 5/28/25 at 3:05 p.m., Resident 9 was observed in her room lying in bed. A nasal cannula was in place and oxygen was flowing. The oxygen concentrator was set at 2 liters. Resident 9's record was reviewed on 5/29/25 at 10:38 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, heart failure, and hypertension. A Physician's Order, dated 4/3/25, indicated oxygen 2 L (liters) via nasal cannula as needed (PRN) for shortness of breath, maintain oxygen saturation above 90. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively impaired, dependent on staff for all activities of daily living (ADLs), and had not received oxygen. A Care Plan, updated 5/14/25, indicated the resident was at risk for alterations in oxygen levels due to heart failure. The interventions included to administer oxygen as ordered. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 5/2025, lacked any documentation the PRN oxygen had been signed out as administered or that the resident's oxygen saturation had been monitored. During an interview on 5/29/25 at 1:50 p.m., the Director of Nursing indicated the resident would get short of breath when staff was doing wound care or repositioning, so they would just keep the oxygen on at all times. She would update the oxygen orders. No further information was provided. A facility policy, titled, Oxygen Administration, received from the Administrator as current, indicated .Steps in the Procedure .10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: .3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the disposal of used lancets into the garbage can for 1 of 1 glucometer (machine used to test blood sugar levels) testing observed. (Resident 183, RN 1) Finding includes: On 5/30/25 at 11:02 a.m., RN 1 indicated he was going to check Resident 183's blood sugar. The nurse washed his hands, applied gloves, and wiped the resident's left first finger with an alcohol wipe. He then poked the resident's finger with the lancet. Blood was observed on the resident's finger and he then proceeded to check the blood sugar with the glucometer. He discarded the lancet into the garbage can next to the resident's bed. He then proceeded back to the medication cart. During an interview at that time with RN 1, he indicated he should not have discarded the lancet into the garbage can, but instead into the sharps container. He was unsure what the blood sugar reading was and he would have to re-check the resident's blood sugar. The nurse then proceeded to wash his hands again, applied gloves, and wiped the resident's second finger with an alcohol wipe. He then poked the resident's finger with a lancet. Blood was observed on the resident's finger and then he proceeded to check the blood sugar again with the glucometer. He then discarded the lancet into the garbage can next to the resident's bed again. During an interview after the second observation with RN 1, he indicated he had thrown the lancet away again into the garbage can and he was aware it needed to be discarded into the sharps container. He also wrote down the blood sugar at that time so he would remember what it was. During an interview on 5/30/25 at 2:00 p.m., the Director of Nursing indicated the nurse should have discarded the lancets into the sharps container and not into the garbage can. A facility policy titled, Obtaining a Fingerstick Glucose Level and received as current from the Administrator, indicated, .Steps in the Procedure . .16. Dispose of the lancet in the sharps disposal containers . 3.1-18(b)

Based on observation and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to dirty kitchen walls and floors in the kitchen. (Main Kitchen) Findings include: During the initial kitchen tour on 5/27/25 at 9:10 a.m. with the Dietary Food Manager (DFM), the following was observed: a. The wall next to stove top was covered in splashed food and debris. b. The floor and baseboard underneath the dishwasher was dirty and covered in a build up of debris. During an interview at the time, the DFM indicated the above areas were in need of a deep clean. He was not supposed to be the main cook today, so he had not had time to get to those areas yet. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was implemented for a resident with a diabetic foot ulcer for 1 of 12 resident care plans reviewed. (Resident 13) Finding includes: During an observation of wound care on 5/29/25 at 10:00 a.m., Resident 13's left foot diabetic foot ulcer treatment was observed with RN 1. The area was located on the lateral foot and was open, light red in color, and had minimal drainage. RN 1 performed the wound care per the physician's order and then adjusted the resident in bed for comfort with a round cushion noted to the right leg. Resident 13's record was reviewed on 5/28/25 at 3:08 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (weakness and paralysis) affecting the right dominant side, cognitive communication deficit, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 4/4/25, indicated the resident was severely cognitively impaired. The resident had impairments in range of motion to one side of the upper extremities and both sides of the lower extremities. She was dependent on staff for all activities of daily living including, but not limited to, bed mobility and transfers. She had diabetic foot ulcer(s) and skin tear(s). A Physician's Order, dated 5/29/25, indicated cleanse with normal saline, apply calcium alginate, and cover with dry dressing to left foot (dorsal) every day shift. A Care Plan, revised on 10/2/23, indicated the resident was at risk for alterations in skin integrity. Interventions included, but were not limited to, adjust tubing to avoid skin breakdown, administer treatments as ordered, and turn and reposition as indicated. A Skin and Wound Note, dated 5/28/25 at 4:17 p.m., indicated the resident had a diabetic ulcer to the left lateral distal foot which measured smaller today. The resident had the wound on 9/11/24 and was receiving treatments at the time. The wound healed on 1/22/25, reopened on 3/5/25, healed on 4/16/25, and reopened on 5/28/25. The diabetic foot ulcer was a full thickness wound, measuring 1 centimeter (cm) long by 0.1 cm wide with 100% epithelial tissue, and had a scant amount of drainage. The recommendations were to continue ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. The record lacked a comprehensive care plan related to the diabetic foot ulcer. During an interview on 5/29/25 at 1:56 p.m., the Director of Nursing indicated there was no care plan at the time for the diabetic foot ulcer, as it was a wound that would heal out and then reopen again. The wound was currently open and being treated, so the care plan should have been initiated. 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure there were orders and/or monitoring completed for a resident on a fluid restriction. (Resident 183) Finding includes: During an observation and interview on 5/28/25 at 9:47 a.m., Resident 183 indicated she had returned to the facility the day before and had an infection, so she was now on antibiotic therapy. She had to have surgery on her leg. The resident indicated she has had to have fluid removed at the hospital before and was on a fluid restriction at the hospital; however, since being back in the facility, she was not required to be on a fluid restriction any longer. There was a large foam cup on her bedside table full of water. Resident 183's record was reviewed on 5/29/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes mellitus, and pressure ulcer to the right heel. The Discharge Minimum Data Set (MDS) assessment, dated 5/10/25, indicated the resident was cognitively intact for daily decision making. She received diuretic, opioid, antiplatelet, and hypoglycemic medications in the 7-day look-back period. The current May 2025 Physician's Order Summary indicated the resident received a carbohydrate controlled no added salt diet, received furosemide (diuretic medication) 40 milligrams (mg) daily, and spironolactone (diuretic medication) 100 mg daily. The Nursing Evaluation, dated 5/27/25 at 10:33 p.m., indicated the resident had readmitted to the facility. She had skin conditions noted to the right buttock, coccyx, groin redness, right elbow pressure, right hand bruising, right wrist bruising, left lower extremity healed surgical wound, left lower arm generalized bruising, left heel deep tissue injury, left thigh surgical wound, right heel surgical incision, left lower leg surgical wound, left lower leg lateral healed surgical wound, and was to receive a regular no added salt thin liquid diet with 1800 milliliter fluid restriction. There were no orders or documentation of fluid intake/restriction in the record. During an interview on 5/29/25 at 2:09 p.m., the Director of Nursing indicated she was going to add the order for the fluid restriction and monitoring now. A policy titled, Encouraging and Restricting Fluids, indicated .General Guidelines .1. Follow specific instructions concerning fluid intake and restrictions .Restricting Fluids: 1. Remove the resident's water pitcher and cup from the room. Store in designated area 6. Record the amount of fluid consumed on the intake side of the intake an output record. Record fluid intake in mLs . 3.1-46(b)

Based on observation, record review, and interview, the facility failed to ensure a resident with a reddened sclera (white part of eyeball) of the eye was assessed and monitored for 1 of 2 residents reviewed for vision/hearing services. (Resident 20). Finding includes: On 5/28/25 at 11:02 a.m., Resident 20 was sitting in a recliner in her room. She indicated her right eye had been red for some time, but could not say exactly when it began. The nursing staff had pointed it out to her the other day as she was not even aware of the redness noted to her eye. The right eyeball was observed to be solid red in color on the bottom portion of the sclera. On 5/30/25 at 1:20 p.m., Resident 20 was observed in the common area. Her right eye was still red in color. Resident 20's record was reviewed on 5/30/25 at 2:45 p.m. Diagnoses included, but were not limited to, schizophrenia and neuromuscular dysfunction of the bladder. The Quarterly Minimum Data Set (MDS) assessment, dated 4/8/25, indicated the resident was cognitively intact for daily decision making. The record lacked documentation of assessment or monitoring of the right eye discoloration. During an interview on 6/2/25 at 11:42 a.m., the Director of Nursing indicated she had no further information related to the resident's red eye. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure the residents' environment was clean and in good repair related to scraped paint, nicks and gouges on the walls, dried feeding on the feeding poles, a oxygen concentrator and on the floor, debris and trash on the floors, a dirty floor mat, and a stool with a cracked vinyl seat for 1 of 2 floors. (First Floor). During an environmental tour with the Director of Maintenance/Housekeeping on 3/18/25 from 12:59 through 1:29 p.m., the following was observed: a. room [ROOM NUMBER] - There were paint scrapes behind the head of the bed. During an interview at the time of the observation, the Director of Maintenance/Housekeeping acknowledged the scrapes and indicated when the residents were discharged or moved rooms, the walls were repaired. b. room [ROOM NUMBER], bed 2 - There was dried feeding on the feeding pump pole, the oxygen concentrator and on the floor. The Director of Maintenance/Housekeeping indicated the Housekeeper probably had not mopped due to all the cords. c. room [ROOM NUMBER], bed 2 - There were nicks on the wall, debris on the floor by the baseboard behind the bed and a plastic medication cup under the bed, which was also observed earlier at 6:06 a.m. The Director of Maintenance /Housekeeping indicated the Housekeeper may not have cleaned the room yet. d. room [ROOM NUMBER] bed 2 - There was dried liquid feeding on the feeding pump pole. There was a dried liquid substance on the floor mat and paper/debris on the floor. There was a rolling stool with a cracked vinyl on the seat in the corner of the room. e. room [ROOM NUMBER] - there were scrapes and a large gouge on the wall behind the bed. f. room [ROOM NUMBER], bed 1 - there was paper and a mask on the floor and nicks on the wall behind the head of the bed. During an interview on 3/18/25 at 1:15 p.m., Housekeeper 6 indicated the rooms on the first floor had all been cleaned. The Housekeeping Completion Form, received as current from the Director of Maintenance/Housekeeping on 3/18/25 at 1:18 p.m., indicated the rooms were to be dusted, swept, and mopped daily including underneath the bed. The walls, furniture, and bedrails were to be cleaned daily. This citation relates to Complaint IN00454373. 3.1-19(e)

Based on observation, record review, and interview, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (Agency CNA 1 and Agency CNA 5) when providing care to residents (Resident D and F) who were in Enhanced Barrier Precautions (EBP) for 2 of 2 residents reviewed for EBP. The facility also failed to ensure hand hygiene was completed by a staff member (Agency CNA 1) after care had been completed on a resident (Resident B) and care initiated on another resident (Resident C) and to ensure a personal care item was used for only 1 resident and was not used for multiple residents (Residents B, C, G, D, and H) by a staff member related to incontinent wipes. (Agency CNA 1) Findings include: 1. During an observation on 3/18/25 at 5:30 a.m., Agency CNA 1 entered Resident D's room to provide care. There was a sign on the outside of the entry door that indicated the resident required EBP during care. Agency CNA 1 applied gloves and was stopped prior to starting care. She indicated she had no idea if the resident required PPE due to EBP. The CNA then acknowledged the EBP sign on the outside of the door. She then applied PPE to provide incontinence care. Resident D's record was reviewed on 3/18/25 at 10:36 a.m. The diagnoses included, but were not limited to, stroke. A Physician's Order, dated 4/19/24, indicated EBP was required due to a feeding tube and pressure wounds. A Care Plan, dated 4/20/24, indicated EBP was required. The interventions included the guidelines for EBP would be followed. A Quarterly Minimum Data Set (MDS) assessment, dated 1/28/25, indicated a feeding tube and pressure ulcer were present. 2. During an observation on 3/18/25 at 6:11 a.m., Agency CNA 5 wore gloves and started to provide incontinence care to Resident F and was stopped. Agency CNA 5 indicated she was unsure if the resident required EBP. She then looked at the EBP sign located on the wall outside of the room door and applied the PPE. Resident F's record was reviewed on 3/18/25 at 11:09 a.m. The diagnoses included, but were not limited to, stroke. A Physician's Order, dated 4/19/24, indicated EBP was to be followed due to a feeding tube. A Care Plan, dated 4/20/24, indicated EBP was required due to the feeding tube. The interventions included EBP guidelines would be followed. A Quarterly MDS assessment, dated 12/28/24, indicated a feeding tube was present. A facility policy for EBP, dated 8/2022 and received as current from the Director of Nursing (DON), indicated EBP was to be used for high contact resident care activities. Gloves and gown would be applied prior to performing the high contact resident care activity. 3. During an observation on 3/18/25 at 4:58 a.m., Agency CNA 2 completed incontinence care on Resident B. Upon completion of the care, Agency CNA 2 removed her gloves and exited the room without washing her hands. She then started to enter Resident C's room to provide incontinence care and started to don gloves and was stopped. She then went to the sink in the common area and washed her hands. A facility policy for handwashing and hand hygiene, dated January 2019 and received from the DON as current, indicated hand hygiene procedures would be followed to help prevent the spread of infections. 4. During an observations on 3/18/25 from 4:58 a.m. through 5:51 a.m., Agency CNA 2 completed incontinence care on Resident B. Upon leaving Resident B's room, she removed the package of cleansing wipes. She indicated at the time of the observation that she didn't have any other wipes to use. She then entered Resident C's room to provide incontinence care and placed the package of wipes on the over the bed table and provided incontinence care using the wipes. Agency CNA 2 then entered Resident G's room and placed the cleansing wipes package on the resident's bed. She then completed incontinence care. After the care, she exited the room with the package of cleansing wipes. Agency CNA 2 then entered Resident D's room and used the wipes to complete incontinence care and exited the room with the cleansing wipes package. Agency CNA 2 then entered Resident H's room with the cleansing wipes package and used the wipes to complete incontinence care. During an interview on 3/18/25 at 6:29 a.m., the Central Supply Clerk indicated there were cleansing wipes in the store room and the nurses' had a key to the storeroom if they were needed. An observation of the store room indicated there were cases of cleansing wipes. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure residents had a clean and homelike environment related to soiled bed linens for 2 of 8 residents reviewed for a clean and homelike environment. (Residents B and D) Findings include: 1. During an observation on 3/18/25 at 4:58 a.m., Agency CNA 2 entered Resident B's room to completed incontinence care. A soiled incontinent brief was removed, pericare was completed and a clean brief was applied. When the resident was turned to the side, there was a dried urine ring under the resident's incontinent pad. Agency CNA 2 indicated she had not checked the bottom sheet under the incontinent pad when she provided care earlier in the night. Resident B's record was reviewed on 3/18/25 at 10:03 a.m. The diagnoses included, but were not limited to chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/16/25, indicated a moderately impaired cognitive status, was dependent for toileting, and was always incontinent of bowel and bladder. 2. During an observation on 3/18/25 at 5:40 a.m., Agency CNA 2 and RN 1 were providing incontinence care to Resident D. The resident had a urinary catheter and had been incontinent of bowel. There was a clean dressing located on her left knee. There was dried blood and other drainage on the sheet under the resident's knee. RN 1 acknowledged the dried drainage on the sheet. Resident D's record was reviewed on 3/18/25 at 10:36 a.m. The diagnoses included, but were not limited to, stroke. A Care Plan, dated 3/11/24, indicated a pressure ulcer was present on the left knee. The interventions indicated a treatment would be completed as ordered by the physician. A Quarterly Minimum Data Set (MDS) assessment, dated 1/28/25, indicated a short and long term memory problem, had a urinary catheter, and was always incontinent of bowel movement. She had one stage three (full thickness tissue loss) pressure ulcer present on admission. The Treatment Administration Record, dated 3/2025, indicated the treatment to the left knee had been completed on 3/17/25 on the day shift. This citation relates to Complaint IN00454373. 3.1-19(f)

Based on observation, record review and interview, the facility failed to ensure residents who were dependent on staff received incontinence care for 2 of 7 residents reviewed for activities of daily living. (Residents E and F) Findings include: 1. During an observation on 3/18/25 at 5:26 a.m., RN 1 and Agency CNA 2 entered Resident E's room on the C-Hall, to assist with positioning the resident in bed. The incontinence brief was saturated with urine. The incontinence pad under the resident was soaked with urine and there were circles of dried urine on the sheet under the incontinence pad. The staff repositioned the resident in bed and Agency CNA 2 informed the resident she would be back in a few minutes. She indicated she had last provided incontinence care at 3:00 a.m. During an observation on 3/18/25 at 6:08 a.m., incontinence care had not yet been completed. During an observation on 3/18/25 at 7:19 a.m., CNA 3 and LPN 4 entered the room and and completed incontinence care and a linen change. There was a strong urine odor in the room. LPN 4 acknowledged the saturated brief, wet incontinence pad, and the dried urine rings under the pad. Resident E's record was reviewed on 3/18/25 at 10:56 a.m. The diagnoses included, but were not limited to, chronic respiratory failure and vascular dementia. A Care Plan, dated 3/1/25, indicated there was urinary incontinence. The interventions included, incontinence care would be completed as needed. An Admission Minimum Data Set (MDS) assessment, dated 3/4/25, indicated a severely impaired cognitive status, maximum assistance was required for toileting and hygiene, and she was always incontinent of bladder and bowel. During an interview on 3/18/25 at 5:35 a.m., Agency CNA 2 indicated she was providing care to the best of her abilities. During an interview on 3/18/25 at 5:46 a.m., Agency CNA 2 indicated she had not completed care on the C-hall yet. 2. During an observation of Resident F, who resided on the C-Hall, on 3/18/25 at 6:07 a.m. with LPN 4, the incontinence brief, top sheet, and lift sheet were saturated with urine. There were rings of urine on the bottom sheet under the lift sheet. At 6:11 a.m., Agency CNA 5 entered the room and assisted LPN 4 with the resident's incontinence care and linen change. Resident F's record was reviewed on 3/18/25 at 11:09 a.m. The diagnoses included, but were not limited to, stroke. A Care Plan, dated 4/1/21, indicated there was incontinence of the bladder. The interventions included, incontinence care would be completed as needed. A Quarterly MDS assessment, dated 12/28/24, indicated a moderately impaired cognitive status, was dependent for toileting and hygiene, and was always incontinent of bladder and bowel. This citation relates to Complaint IN00454373. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to provide a least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208) Findings include: 1. The floor area of the following single resident room measured: a. room [ROOM NUMBER] - 1 resident, 96.2 SQ FT. NF. 2. The floor areas of the following multiple resident rooms measured: a. room [ROOM NUMBER] - 1 resident, 150.3 SQ FT, 75.2 SQ FT per bed. NF. b. room [ROOM NUMBER] - 0 resident, 145.0 SQ FT, 72.5 SQ FT per bed. NF. c. room [ROOM NUMBER] - 1 resident, 149.0 SQ FT, 74.5 SQ FT per bed. NF. d. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. e. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. f. room [ROOM NUMBER] - 1 resident, 140.0 SQ FT, 70.0 SQ FT per bed. NF. g. room [ROOM NUMBER] - 1 resident, 146.9 SQ FT, 73.4 SQ FT per bed. NF. The facility rooms with room variances were observed on 8/20/24 at 9:45 a.m. The rooms were observed with the following number of beds: room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed room [ROOM NUMBER] - 1 bed During an interview on 8/19/24 at 8:50 a.m., the Administrator indicated these were the rooms which had the variance waivers and did not have the required square footage. 3.1-19(l)(2)

Based on observation, record review and interview, the facility failed to ensure a resident's wounds were assessed and monitored for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident 10) Finding includes: On 8/19/24 at 3:10 p.m. and on 8/20/24 at 2:15 p.m., Resident 10 was observed lying in bed. She had two open areas, approximately 3 centimeters round each, on her right shin. She indicated they had been fluid filled blisters that had opened. The resident's record was reviewed on 8/20/24 at 11:33 a.m. Diagnoses included, but were not limited to, hemiparesis (one sided weakness) and hemiplegia (one sided paralysis) following a cerebral vascular accident, Diabetes Mellitus and heart failure. The Annual Minimum Data Set assessment, dated 6/30/24, indicated the resident was cognitively intact and was dependent on assistance for bed mobility and transfers. A Nursing Note, dated 8/14/24, indicated the resident had been up in a chair for five hours and fluid filled blisters developed to her right leg. The Nurse Practitioner was notified and orders were received to apply skin prep to the blisters. A Physician's Order, dated 8/19/24, indicated to apply Betadine external solution 19% to open blisters twice daily and monitor until resolved. There were no additional progress notes related to assessment or monitoring of the wounds. A Weekly Skin Assessment, dated 8/14/24, indicated the resident's skin was dry and intact. A Weekly Skin Assessment, dated 8/21/24, indicated the skin was dry and there was a treatment in progress to the right lower leg. During an interview on 8/21/24 at 11:20 a.m., the Wound Nurse indicated the Wound Nurse Practitioner had seen the resident that morning to assess the wounds and provided new treatment orders. There had not been an assessment completed before today. The policy, Skin and Wound Management System, dated September 2022, indicated, .5. Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. Wound location, characteristics and a physician's order for treatment are documented in the medical record. Wound status will be evaluated and documented in PCC [electronic medical record system] on the Wound Evaluation Flow Sheet form 3.1-37(a)

Based on observation, record review and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 resident reviewed for intravenous care. (Resident 25) Finding includes: On 8/19/24 at 2:00 p.m., Resident 25 was observed lying in bed in her room. There was a PICC line in place to her right upper arm. She indicated she had surgery last week and was now getting antibiotics through the line. Resident 25's record was reviewed on 8/20/24 at 3:03 p.m. Diagnoses included, but were not limited to, hypertension, abdominal aortic aneurysm, major depressive disorder. The Admission Minimum Data Set (MDS) assessment, dated 7/18/24, indicated the resident was cognitively impaired. A Care Plan, updated 8/17/24, indicated the resident was receiving IV (intravenous) antibiotics for a urinary tract infection. A Care Plan, updated 8/19/24, indicated the resident had a PICC line. An intervention indicated to flush line as needed/per policy. A Physician's Order, dated 8/17/24, indicated meropenem (an antibiotic) 1 g (gram) IV every 8 hours at 12:00 a.m., 8:00 a.m., and 4:00 p.m. A Physician's Order, dated 8/17/24, indicated normal saline flush, 10 ml (milliliters) every shift for IV patency. There were no Physician's Orders to indicate the PICC was to be flushed with saline before and after the administration of the antibiotic medication The Medication Administration Record (MAR), dated 8/2024, indicated the meropenem had been administered as ordered. The normal saline flushes were documented as given once each on the day, evening, and night shifts. There was lack of documentation to indicate the PICC was flushed with saline before and after the administration of the antibiotic medication. During an interview on 8/20/24 at 4:00 p.m., the Director of Nursing (DON) indicated the PICC line should have been flushed before and after the antibiotic administration. She would clarify the orders. A facility policy, titled Medication Infusion, received from the DON as current, indicated, .7. Intermittent medication administration with no continuous infusion .c. Flush IV access catheter with preservative-free 0.9% sodium chloride .g. Infuse medication as prescribed and per label instructions .j. Disinfect IV access port with alcohol swab and let air dry, flush with preservative-free 0.9% sodium chloride . 3.1-47(a)(2)

Based on record review and interview, the facility failed to ensure catheter care was completed and urinary output was recorded for 1 of 3 residents reviewed for urinary catheters. (Resident D) Finding includes: The closed record for Resident D was reviewed on 8/22/24 at 10:20 a.m. Diagnoses included, but were not limited to, cerebral infarction, type 2 diabetes mellitus, and malignant neoplasm of the prostate. The resident was admitted to the facility on [DATE] and discharged to the hospital on 4/12/24. The Admission Minimum Data Set (MDS) assessment, dated 3/11/24, indicated the resident was cognitively impaired and had an indwelling urinary catheter. A Care Plan, updated 3/26/24, indicated the resident had an indwelling urinary catheter. An intervention indicated to monitor and document intake and output. A Physician's Order, dated 3/8/24, indicated 10 cc (cubic centimeters) 18 fr (french, catheter size) Foley catheter with drainage bag to gravity, monitor every shift. The Medication Administration Records (MAR) and Treatment Administration Records (TAR), dated 3/2024 and 4/2024, lacked any documentation of catheter care or urine output. The Task documentation lacked any documentation of catheter care or urine output. During an interview on 8/23/24 at 10:43 a.m., the Infection Preventionist (IP) indicated the catheter order included monitoring every shift, but she was unable to provide any further documentation that catheter care was completed or urinary output was recorded. A facility policy, titled Urinary Catheter Care, received from the IP as current, indicated, .Input/Output .2. Maintain an accurate record of the resident's daily output, per facility policy and procedure .Infection Control .2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the periurethral area with antiseptics to prevent catheter associated UTIs while the catheter is in place. Routine hygiene [e.g. cleansing of the meatal surface during daily bathing or showering] is appropriate .Documentation. The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual[s] giving the catheter care. 3. All assessment data obtained when giving catheter care This citation relates to Complaints IN00433696 and IN00440056. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to follow up on an Occupational Therapy recommendation for a resting hand splint for 1 of 2 residents reviewed for position/mobility. (Resident 8) Finding includes: On 8/19/24 at 10:59 a.m., Resident 8 was observed seated in her wheelchair. Her right hand was contracted (tightening of muscle, tendons and skin that causes joints to shorten and become very stiff)and there was not a splint in place. The resident's record was reviewed on 8/20/24 at 2:40 p.m. Diagnoses included, but were not limited to, hemiplegia (one sided weakness) and hemiparesis (one sided paralysis) and unspecified dementia. The Quarterly Minimum Data Set assessment, dated 6/11/24, indicated the resident had severe cognitive impairment and was dependent for bed mobility and transfers. The resident received Occupational Therapy from 1/30/24 to 3/29/24. An Occupational Therapy Discharge Summary, dated 3/29/24, indicated the resident was to tolerate a resting hand splint for 5 hours a day to ensure joint protection and contracture management. There were no order Physician's Orders for a resting hand splint. During an interview on 8/20/24 at 3:11 p.m., the Director of Rehab indicated she had worked with the resident and she did well with the resting hand splint. She did not know why the splint had not been carried over after discharge from therapy. During an interview on 8/21/24 at 10:00 a.m., the Director of Nursing indicated the resident's mother had been trained on how to use the splint, but she did not want the resident to use it, so the order had never been completed. The record should have some documentation related to the refusal of the splint recommendation. 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure activities were implemented for a cognitively impaired dependent resident for 1 of 1 resident reviewed for activities. (Resident 14) Finding includes: On 8/19/24 at 11:16 a.m., Resident 14 was observed lying in bed with her eyes open and looking up at the ceiling. The room was dark, the television was off, and there was no music playing. On 8/20/24 at 1:07 p.m., Resident 14 was was observed lying in bed with her eyes open and looking up at the ceiling. The room was dark, the television was off, and there was no music playing. On 8/20/24 at 2:25 p.m., Resident 14 was was observed lying in bed with her eyes open and looking up at the ceiling. The room was dark and the television was not on. A bingo activity was being played in the dining area and in some resident rooms. Record review for Resident 14 was completed on 8/20/24 at 1:27 p.m. Diagnoses included, but were not limited to, stroke, aphasia (loss of ability to understand or express speech) and depression. The Annual Minimum Data Set (MDS) assessment, dated 7/22/24, indicated the resident was severely cognitively impaired. The resident had an impairment of both upper and lower extremities for a functional limitation in range of motion. The resident was dependent on staff for all ADLs (activities of daily living). The Preferences for Routines and Activities, completed by staff, indicated listening to music, keeping up with the news, doing things with groups of people, participating in favorite activities, and participating in religious activities were important to the resident. A Care Plan, revised 4/20/22, indicated the resident would passively observe in group activities when available. The resident was seen for one on one visits with staff three times a week for social and cognitive stimulations. The resident had a customary preference to love a specific singer and a specific actor. The resident would passively observe the roommate's television and music at times. Her roommate would play music and put on movies for them to watch together. When the resident was not participating in group activities, she would enjoy watching television in the common area and or passively observing the happenings around her. Interventions included to assist the resident to and from activities, and to the invite resident to daily activities. A Care Plan, dated 12/19/22, indicated the resident had a personal preference that she preferred 1 on 1 activities. Interventions included to allow the resident 1 on 1 activities, and to provide the opportunity to listen to music she preferred. A Care Plan, dated 6/28/23, indicated the resident was at risk for a decline in activity status due to health condition deficits. An intervention included the staff would invite and encourage the resident to participate in scheduled group activities. A Care Plan, revised 4/23/24, indicated the resident chose to remain in room related to her preference. An intervention included to provide activities of interest for resident to do in room. During an interview on 8/21/24 at 8:51 a.m., CNA 1 indicated the resident did not get out of bed to attend activities. The staff would talk with the resident when providing care but had not seen any activities being completed with her in her room. The resident's roommate did not like when they turned on the television or any lights being on in the room. She was unsure if the resident had a radio in her room. During an interview on 8/21/24 at 8:58 a.m., the Activity Director indicated she did not have any set curriculum for residents who received 1 on 1 activities. The residents who received 1 on 1 visits preferred conversations with her. She would do a daily visit with the resident and talk to her. She had not documented any 1 on 1 visits for activities when she completed them. She did not have a computer, so she would document the Activity Assessments on paper and she would provide a copy of the most recent assessment she had completed for the resident. A copy of the most current Activity Assessment completed was not provided by the Activity Director. 3.1-33(a)

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer assessments were completed at least weekly to determine the healing status of the pressure ulcers. Two of the pressure ulcers deteriorated, a surgical debridement was completed, and new treatment orders were received for the deterioration of the pressure ulcers when assessed by the Wound Physician, for 2 of 3 residents reviewed for pressure ulcers. (Residents C & D) Findings include: 1) During an observation on 1/10/22 at 10:09 a.m. with RN 1, Resident C was lying in bed with her head of the bed elevated. There was a heel protector boot on the right heel. RN 1 indicated the facility Wound Nurse works part time and the Wound Physician consulted on the pressure ulcers weekly. RN 1 completed the treatment to the coccyx pressure ulcer. The dressing was removed from the coccyx and there was a scant amount of drainage. The wound was clean and beefy red. RN 1 measured the area as 4.2 cm (centimeters) by 5 cm and 1 cm depth. She then applied Dakin's solution (antiseptic) to a gauze, loosely packed the wound and covered the area with a dry dressing. During an interview on 1/10/22 at 3:05 p.m., RN 1 indicated the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C's record was reviewed on 1/10/22 at 1:57 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated short and long term memory problems, extensive assistance with bed mobility and dependent for transfers. There was one stage two (partial thickness of skin loss) pressure ulcer present on admission, and one stage four (full thickness skin loss with extensive destruction, tissue necrosis or damage to the muscle bone, or supporting structures) pressure ulcer present. A Care Plan, dated 11/30/21, indicated pressure ulcers were present on the right heel and coccyx. On 12/7/21 a new pressure ulcer was present upon return from the hospital. The interventions included, a heel boot was to be used, air mattress for the bed, the Wound Physician was to be consulted, changes in the skin status were to be documented and reported to the physician as needed, which included appearance, color, wound healing, wound size and stage of the pressure ulcer. a. The Wound Evaluation Flow Sheet form, indicated a deep tissue injury (injury to underlying tissue below the skin's surface due to pressure) was found on the right heel on 11/3/21. The Right heel had been measured on 12/21/21, and was 1.1 cm by 1.5 cm, was 100% necrotic with no drainage, and the surface area measured 1.65 cm. The treatment to right heel was [MEDICATION(S)] daily and leave open to the air. The Wound Physician's Progress Note, dated 12/21/21, indicated the right heel measurements were 1.1 cm by 1.5 cm , the surface area was 1.65, there was no drainage, the area was 100% necrotic, and there was no change in the wound progress. The treatment was to apply [MEDICATION(S)] daily to the area and leave open to the air. The area was not infected and debridement was needed. The Right heel was measured on 1/4/22 and was 2.5 cm by 3 cm, with 40% necrosis and 60% dermis. There was moderate serous drainage (clear and thin), the surface area was 7.50 cm, and the pressure ulcer had deteriorated. The Wound Physician's Progress Note, dated 1/4/22, indicated the right heel measurements were 2.5 cm by 3.0 cm and the depth could not be measured. The surface area was 7.5 cm, there was a moderate amount of serous drainage, and the thick adherent black necrotic tissue was 40% with 60% dermis. The wound had deteriorated and a surgical decisional debridement was completed to remove the thick eschar and necrotic tissue. 3 cm of devitalized tissue and necrotic subcutaneous fat was removed at a depth of 0.4 cm and healthy bleeding tissue was observed. The treatment was changed to alginate calcium (promotes healing and the formation of granulation tissue) and was to be applied three times per week. There were no weekly assessments and measurements from 12/21/21 through 1/4/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Wound Evaluation Flow Sheet, indicated a deep tissue injury was found on the coccyx on 11/17/21. The measurement of the area was 3 cm by 4 cm with 0.6 cm depth and Santyl cream ([MEDICATION(S)] agent) with a dry dressing was used for the treatment. The coccyx measurement on 12/21/21 was 5.6 cm by 2.8 cm with 1.3 cm depth and there was moderate serous drainage. The treatment was Dakin's (antiseptic) solution and cover with a dry dressing twice a day for the treatment. The Wound Physician's Progress Note, dated 12/21/21, indicated the coccyx measured 5.6 cm by 2.8 cm with 1.3 cm depth. There was undermining at 7 o'clock of 2.7 cm, the surface area was 15.68 cm, there was moderate serous drainage with 80% granulated tissue and 20% dermis. There was no change in the progress and Dakin's solution was to be applied twice a day with a dry dressing covering the area. The coccyx measurement on 1/4/21 was 4.8 cm by 2.8 cm with 1 cm depth and there was moderate serous drainage. The pressure wound had improved and the Dakin's solution with a dry dressing was to be used twice a day for the treatment. The Wound Physician's Progress Note, dated 1/4/22, indicated the coccyx measured 4.8 cm by 2.8 cm and was 1 cm depth. The surface area was 13.44 cm. There was moderate serous drainage, with 80% granulation tissue and 20% dermis. The wound had improved. The treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no weekly assessments and measurements from 12/21/21 through 1/4/22. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Wound Evaluation Flow Sheet form, indicated a pressure ulcer was found on the right knee upon return from the hospital on 12/7/21. The area measured 0.7 cm by 0.6 cm with 0.2 cm depth. The area was covered with 100% epithelial tissue (shiny, light pink appearance). The area was to be covered with a dry dressing and changed three times a week. On 12/21/21 the right knee measured 0.4 cm by 0.4 cm with 0.1 cm depth. The dry dressing three times a week treatment continued. The Wound Physician's Progress Note, dated 12/21/21, indicated a stage two (partial thickness of the skin) area on the right anterior knee. The measurement was 0.4 cm by 0.4 cm with depth of 0.1 cm. There was no drainage and the surface area was 0.16 cm. The treatment order was a gauze island with a border dry dressing three times a week. On 1/4/21, the right knee measured 0.4 cm by 0.4 cm with 0.1 cm depth. There was improved progress and the treatment was changed to [MEDICATION(S)] cream (for redness and swelling) twice a day and cover with a border gauze dressing and kerlix gauze. The Wound Physician's Progress Note, dated 1/4/22, indicated the right knee measured 0.4 cm by 0.4 cm with depth of 0.1 cm. There was no drainage and the surface area was 0.16 cm. The area had no change in progress. The treatment order was for a gauze island with a border dry dressing three times a week. There were no weekly assessments and measurements from 12/21/21 through 1/4/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/20/22 at 3:21 p.m., the Director of Nursing (DON) indicated the Wound Nurse had not worked the days of 12/21/21 through 1/4/22 and the Wound Physician had also been off. The DON provided Skilled Nursing Notes, dated 12/22/21 through 1/4/22 on 1/10/22 at 4:26 p.m. and indicated the wounds had been assessed in the notes. The Skilled Nursing Notes, indicated: On 12/22/21 at 6:21 p.m., the coccyx open area dressing had been changed, the right heel was painted with [MEDICATION(S)] and the dressing to the right knee was intact. On 12/23/21 at 4:24 p.m., 12/25/21 at 3:16 p.m., 12/27/21 at 3 p.m., and 12/28/21 at 3:13 p.m., the dressing to the open area to the coccyx was changed, the dressing to the right knee was changed, and the right heel was painted with [MEDICATION(S)]. On 12/29/21 at 3:38 p.m., the dressing to the coccyx was changed, the right heel was painted with [MEDICATION(S)], and the dressing to the right knee was intact. On 12/30/21 at 4:16 p.m., the dressing to the the coccyx was changed, the dressing to the right knee was changed, and the right heel was painted with [MEDICATION(S)]. On 12/31/21 at 5:08 p.m., the dressing to the coccyx was changed and the right heel was painted with [MEDICATION(S)]. On 1/2/22 at 3:56 p.m., the dressing to the coccyx was changed, the dressing to the right knee was intact, and the right heel was painted with [MEDICATION(S)]. There were no wound measurements, descriptions, or actual assessments of the wound status documented. 2) During an observation with RN 1 on 1/10/22 at 10:20 a.m. Resident D was lying in bed. There were heel protector boots on the heels. There was a clean dressing on the right heel. RN 1 indicated she had already changed the right heel dressing earlier in the morning. Resident D's record was reviewed on 1/10/22 at 4:50 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change MDS assessment, dated 12/22/21, indicated an intact cognitive status, extensive assistance was needed for bed mobility and dependent for transfers, and there was one stage three (full thickness of skin loss with tissue damage or necrosis) pressure ulcer. A Care Plan, dated 11/17/21, indicated a pressure ulcer was present. The interventions included, the pressure ulcer would be assessed for location, stage, size (length, width, depth), type of tissue, and the condition of the surrounding skin. A Care Plan, dated 12/7/21, indicated a right heel pressure ulcer. The interventions included treatments as ordered and observe for effectiveness, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress. Report to the Physician as indicated. Document changes in skin status, appearance, color, wound healing, signs and symptoms of infection and report to the Physician as needed. The Wound Evaluation Flow Sheet form, indicated on 12/21/21, the right heel measured 0.5 cm by 0.9 cm with a depth of 0.3 cm, there was light serous drainage, and the pressure ulcer had improved. The treatment was Iodosorb gel (used for treating wet ulcers and wounds) dressing applied daily. A Wound Physician's Progress Report, dated 12/21/21, indicated a stage three pressure wound on the right heel. The wound measured 0.5 cm by 0.9 cm with a depth of 0.3 cm. The surface area was 0.45 cm, with light serous drainage, 100% granulation tissue, and the wound had improved. The treatment order was for Iodosorb gel to be applied daily and cover with a gauze sponge dressing. The Wound Evaluation Flow Sheet form, indicated on 1/4/21, the right heel measured 2.5 cm by 1.8 cm with 0.3 depth, there was moderate serous drainage, and the pressure ulcer deteriorated. The treatment was changed to calcium alginate three times a week. A Wound Physician's Progress Report, dated 1/4/22, indicated a stage three pressure wound on the right heel. The wound measured 2.5 cm by 1.8 cm with a depth of 0.3 cm. The surface area was 4.5 cm with moderate serous drainage, and 100% granulation tissue. The wound progress had deteriorated. The treatment was changed to alginate calcium to be applied daily and covered with a gauze sponge dressing. There were no measurements or assessments of the right heel pressure ulcer from 12/21/21 to 1/4/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skilled Nurse Assessment Notes, provided from the DON as assessments of the wound, on 1/10/22 at 4:26 p.m., indicated: On 12/23/21 at 3:25 a.m., the dressing to the right heel was changed. On 12/24/21 at 3:34 a.m., the skin was intact. On 12/26/21 at 1:29 a.m., the dressing to the right heel was changed. On 12/27/21 at 12:29 a.m. the skin was intact. There were no wound measurements, descriptions, or actual assessments of the wound status documented. A facility policy, dated 4/2017 and titled, Skin and Wound Management System, was received from the DON as current. The policy indicated an ongoing weekly evaluation of the resident's skin would be completed and documented. The wound status would be documented on the Wound Evaluation Flow Sheet form. This Federal tag relates to Complaint IN 308. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to not monitoring to make sure Agency Nursing staff were being tested for COVID-19 per the county positivity rate and tested for COVID-19 before and after the facility's outbreak started. The facility was unaware of any testing results of the Agency Staff who had been tested prior and after the outbreak occurred. The facility also failed to notify the Agency staff who worked in the facility prior to the outbreak and the Staffing Agency of the outbreak, which places the Agency staff, the facility and other facilities where the staff work at risk. Numerous Agency Staff as well as Facility Staff indicated they had not been screened for COVID-19 upon entering the building and review of the Screening Logs indicated not every person who entered the building was screened for COVID-19, which placed the 40 residents who were residing in the facility at risk for the COVID-19 virus. There were currently 35 COVID-19 positive residents, 6 of those residents were hospitalized and 3 of the residents remain in the hospital. The immediate jeopardy began on 10/17/21 when the first resident in the facility tested positive and the facility did not require a current negative test result from the Agency Staff nor tested the Agency Staff for COVID-19 prior to working. The facility also had not ensured all staff working in the facility were screened for for COVID-19 prior to entering the resident care areas. This placed 40 of 40 residents at risk for contacting the COVID-19 virus. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 10/28/21 at 9:41 a.m. The immediate jeopardy was removed on 10/29/21, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility also failed to have an ongoing surveillance program in place to identify communicable diseases and infections in the Infection Control Program, which had the potential to affect 34 of 34 residents who currently reside in the facility. The facility failed to identify 2 resident rooms in the Yellow Zone (potential risk for COVID-19), as having positive COVID-19 residents residing in the rooms for 2 of 2 residents, who resided in the rooms. (Residents B & C) Findings include: 1. During an interview on 10/26/21 at 9 a.m., the Administrator indicated there were 27 residents and 13 employees currently positive for COVID-19. The outbreak started on 10/17/21 when the first resident tested positive. During an interview on 10/26/21 at 10:55 a.m., Agency Staff 1 indicated she had not been tested for COVID-19 for a week or so. She scheduled her own testing and had not been tested by the facility. During an interview on 10/26/21 at 1:30 p.m., Agency Staff 2 & 3 were working the COVID-19 Unit. Agency Staff 2 indicated she worked at another facility and had tested negative for COVID-19 on 10/25/21. Agency Staff 3 indicated she had tested herself 10/25/21 and was negative. The Nursing Schedules, dated October 3 through the 27, 2021, were reviewed on 10/27/21 at 12:44 p.m., and indicated there were nine Agency Staff who had been scheduled and worked during these dates. The COVID-19 testing logs dated, October 3 through October 27, 2021, indicated Agency Staff 4 had worked at the facility on October 4, 5, 6, 9, 10, and 14, 2021 and had tested negative for COVID-19 on 10/5/21, 10/6/21, 10/9/21, and 10/22/21. Agency Staff 7 had had worked 10/5/21 at the facility and had tested negative for COVID-19 on 10/5/21. During an interview on 10/27/21 at 10:55 a.m., the Director of Nursing (DON) indicated she was unaware of the Agency Staff COVID-19 testing status and unsure if they were being tested twice a week. There was no policy she was aware of for Agency Staff to be tested for COVID-19. During an interview on 10/27/21 at 2:10 p.m., the Administrator indicated the Staffing Agency had not been notified of the COVID-19 outbreak. He indicated when staff were requested, there was a box to check that indicated COVID-19 was in the building. The Staffing Agency had not been notified for contact tracing. He was unsure the Staffing Agency had any results of their employee testing. During an interview on 10/28/21 at 11:18 a.m., the Administrator indicated the Agency Staff had not been tested previously. Agency Staff 5 had tested negative for COVID-19 at the facility on 10/26/21, and when tested for COVID-19 on 10/27/21, she tested positive. During an interview on 10/26/21 at 10:55 a.m., Agency Staff 1 indicated she had not been screened for COVID-19 when she entered the building on 10/26/21. During an interview on 10/26/21 at 1:30 p.m., Agency Staff 2 & 3 both indicated they had not been screened upon entering the building. They had been let in the building by the Night Shift Nurse. During an interview on 10/26/21 at 2 p.m., Facility Staff 6, indicated she had not been screened for COVID-19 when she entered the building. Review of random Screening Logs, dated 10/23/21, 10/24/21, and 10/26/21, was completed with the DON present on on 10/26/21 at 3 p.m. There were 8 of 16 staff scheduled on 10/23/23, 5 of 14 staff scheduled on 10/24/21, and 8 of 12 staff scheduled on 10/26/21 (day and evening shift), not screened for COVID-19. An undated policy, titled, COVID Testing Guidance, received from the Administrator on 10/27/21 at 11:46 a.m., indicated screening of all facility staff, including contractors and caregivers, would be done each day. Outbreak testing of all staff who are negative would occur every 3-7 days until the testing identified no new cases of COVID-19 for 14 days. The immediate jeopardy that began on 10/17/21 was removed on 10/29/21 when the facility had inserviced 20 of the 46 facility staff and had implemented screening and testing for COVID-19 for Agency staff who had worked after the immediate jeopardy notification on 10/28/21. All Agency staff will be tested prior to their shift to work. Staff were interviewed and indicated they are to be screened prior to starting their scheduled shift, where the screening was to be done, and what to do if someone is not present in the area to screen them. The facility staff indicated they are tested twice a week and the Agency staff indicated they are to be tested before each scheduled shift. All staff scheduled for 10/28/21 and 10/29/21 had been screened and Agency staff had been tested prior to their scheduled shift. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility still needed to inservice 26 more of their staff and any new Agency employee scheduled to work. The facility will continue to audit the screening and testing of employees to ensure all policy and procedures are followed. 2. Review of the Infection Control Surveillance Log indicated the last surveillance of any infections in the facility was dated July 2021. During an interview on 10/27/21 at 10:55 a.m., the Director of Nursing indicated the infection surveillance logs had not been completed since July. An, Infection Control Policy, dated 10/2017, received from the Administrator as current, indicated, .By collecting , analyzing, and trending data, actions can be instituted to improve resident outcomes .Monitor for occurrence of infection Surveillance of Infections - ongoing monitoring for occurrence of infections for all residents . 3. During an observation of the C-Hall on 10/26/21 at 10:42 a.m., the resident rooms were identified as Yellow Zone, by signs posted outside each door. There were no signs posted outside of Resident B and C's rooms that indicated the COVID-19 status of the residents. Agency Staff 1 indicated Residents B and C tested COVID-19 positive and the residents were getting ready to be moved to the Red Zone (COVID-19 Positive). A Social Service Progress Note, dated 10/25/21 at 1:39 p.m., indicated Resident C had tested positive and would be transferred to the Red Zone. A Social Service Progress Note, dated 10/25/21 at 1:54 p.m., indicated Resident B had tested positive and would be transferred to the Red Zone. During an interview on 10/26/21 at 11:16 a.m., the Administrator indicated there were no signs posted which indicated Resident B and C were positive for COVID-19 because they were supposed to be transferred to the rooms open in the Red Zone on 10/25/21. The staff had not yet transferred them to the rooms. This Federal tag relates to Complaints IN 461 and IN 465. 3.1-18(a) 3.1-18(b)(1)

Based on record review and interview, the facility failed to ensure the COVID-19 vaccination was offered to all residents of the facility, related to 2 of 40 residents who were not offered the COVID-19 vaccine after admission. (Residents D and E) Both residents have now tested positive for COVID-19. Resident D had the first positive COVID-19 test on 10/17/21 after presenting with a non-productive cough with diminished lung sounds and was transferred to the emergency room for [CONDITION(S)]. Resident E tested positive on 10/18/21. There are now 35 COVID-19 positive residents, of which 6 have been hospitalized , with 3 of those 6 residents remaining in the hospital, and 13 COVID-19 positive staff in the facility. The immediate jeopardy began on 5/27/21 when the facility failed to offer the COVID-19 vaccination on admission to Resident E and failed to offer the COVID-19 vaccination to Resident D when admitted on [DATE]. This placed the two residents at a risk for serious harm, serious impairment, or death related to the contracting the COVID-19 virus. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 10/28/21 at 9:41 a.m. The immediate jeopardy was removed on 10/29/21, but noncompliance remained at the lower scope and severity level of actual harm that is not immediate jeopardy. Findings include: 1. During an interview on 10/26/21 at 9:30 a.m., the Administrator indicated Resident E tested positive for COVID-19 on 10/20/21 and had a cough and lung congestion. Resident E's record was reviewed on 10/27/21 at 12:27 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitted d was 5/27/21. An Undated, Consent to Administer the Influenza Vaccination and the Pneumococcal Vaccination, form was signed by the Health Care Representative. The form was documented as effective on 6/2/21 in the record. The Influenza Vaccination was administered on 10/15/21. The Pneumococcal Vaccination had been administered on 6/16/21. There were no consent or declination forms signed for the COVID-19 vaccination in the record. A Nurse's Progress Note, dated 10/20/21 at 2:20 p.m., indicated the resident was not feeling well, was not wanting to eat and had an episode of diarrhea. A Rapid COVID-19 test was administered and resulted as positive. During an interview on 10/27/21 at 10:35 a.m., the Administrator indicated there was no declination or consent for the COVID-19 Vaccination. During an interview on 10/27/21 at 10:55 a.m., the Director of Nursing (DON) indicated the COVID-19 Vaccine had not been offered. A Nurse's Progress note, dated 10/27/21 at 11:24 a.m., indicated the Health Care Representative was notified about the COVID-19 Vaccine and informed the facility that due the resident being unable to leave the house prior to admission into the facility, she was unable to be vaccinated and consent was given to vaccinate the resident with the COVID-19 vaccine when it would be available and she would be eligible to have it. 2. Resident D's record was reviewed on 10/27/21 at 9:24 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitted into the facility was 8/12/21. Resident D was the first resident in the facility wide outbreak of 35 residents who tested positive for COVID-19 on 10/17/21. The, Consent to Administer the Influenza Vaccination and the Pneumococcal Vaccination, form was signed by the Resident Representative on 8/11/21. There were no consent or declination forms signed for the COVID-19 vaccination in the record. A Nurse's Progress Note, dated 10/17/21 at 10:05 p.m., indicated an intermittent cough throughout the shift and the lung sounds clear and diminished. A Rapid COVID-19 test was performed with positive results. A Nurse's Progress Note, dated 10/24/21 at 7:50 a.m., indicated the oxygen saturation level was 80% on room air, 4 liters of oxygen re-applied and the the oxygen saturations increased to 87%. The temperature was 100.9. A Nurse's Progress Note, dated 10/24/21 at 8:35 a.m., indicated an order to transfer the resident to the emergency room . The resident returned to the facility on [DATE] at 4:50 p.m. A Physician's Progress Note, dated 10/26/21 at 11:35 p.m., indicated [CONDITION(S)] when off of oxygen with oxygen saturations of 85% when oxygen was not being used. During an interview on 10/27/21 at 10:35 a.m., the Administrator indicated there was no declination or consent for the COVID-19 Vaccination and they were working with the family today on this. During an interview on 10/27/21 at 10:55 a.m., the Director of Nursing (DON) indicated the COVID-19 Vaccine had not been offered and the Resident Representative was notified today and he would like the resident to receive the vaccination. The immediate jeopardy that began on 10/17/21 was removed on 10/29/21 when the facility had inserviced 6 of the 12 facility staff Nurses, the Social Service Director and 3 Agency Nurses, who had worked after the immediate jeopardy notification on 10/28/21, to offer the COVID-19, influenza and pneumococcal vaccine to all residents upon admission into the facility. The facility audited to ensure all other residents in the facility were offered the COVID-19 vaccination and vaccinated if consent was given. The noncompliance remained at the lower scope and severity level of actual harm that is not immediate jeopardy because the facility will need to inservice the other 6 Nurses and any Agency Nurse who may be scheduled and will need to audit all new admissions to ensure the COVID-19 vaccination is offered. This Federal tag relates to Complaints IN 461 and IN 465.

Based on record review and interview, the facility failed to ensure a resident was allowed to remain in the facility which resulted in the resident's decline 21 days after she was discharged to the new facility. This resulted in the resident being admitted to the hospital 21 days after she was transferred to the new facility with sever dehydration and acute [MEDICAL CONDITION]. The resident also had weight loss for 1 of 3 residents reviewed for admission, transfer, discharge in the sample of 5. (Resident #B) Finding includes: The closed record for Resident #B was reviewed on 12/15/15 at 10:20 a.m. The resident's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely impaired for daily decision making. The resident had no mood or behavior issues and was totally dependent on staff for activities of daily living. An initial notice of transfer or discharge was issued on March 9, 2015 due to the transfer or discharge was necessary to meet the resident's welfare and the resident's needs could not be met in the facility. Another notice of transfer or discharge was issued on March 19, 2015 due to the safety of the individuals in the facility was endangered and the health of the individuals in the facility would otherwise be endangered. The resident's co-guardians filed an appeal and the appeal was denied on July 16, 2015. The Social Service progress notes dated 8/4/15 (no time), indicated the resident was being transferred to another long term care facility. The next entry completed on 8/4/15 (no time), indicated the resident was not being transferred at the present time. Documentation on 8/27/15 (no time) indicated the resident remained at the facility. An entry completed in the Social Service progress notes by the Administrator on 11/18/15, indicated the resident's son was notified of the resident being accepted by another facility (Facility #B) and the discharge meeting would be held on 11/30/15. The resident was scheduled to be discharged on [DATE]. A physician's orders [REDACTED].#B). A Resident Transfer form dated 1 2/1/15 indicated the resident was being transferred to Facility #B. Review of the record indicated no concerns in regards to individual's safety in the facility and there were no other notices of transfer/discharge completed after the one dated 3/19/15 . The emergency room Physician's Note, dated 12/22/15 at 1:01 p.m., indicated the resident had an associated [DIAGNOSES REDACTED]. The laboratory tests, dated 12/22/15 at 3:56 p.m., indicated the resident's white blood count was 14.9 (normal 4.8-10.8), urine was yellow and cloudy. The resident's sodium was 181 (normal 135-147), BUN (kidney function) 156 (normal 7-22), and Creatinine (kidney function) 3.6 (normal 0.4-1.5). The hospital History and Physical, dated 12/23/15, indicated the resident had severe [MEDICAL CONDITION], lethargy/metabolic [MEDICAL CONDITION], severe dehydration/AKI (acute kidney injury) (kidney failure), and leukocytosis. The plan indicated intravenous fluids, do not want to lower the Na (sodium) to acutely (cerebral [MEDICAL CONDITION] would be a concern) During an interview on 12/23/15 at 1 p.m., the Hospital Physician indicated the resident was very dehydrated upon admission to the ICU. He indicated this was due to not enough fluid intake. Review of the resident's record form Facility #B on 12/29/15 indicated, Speech Therapy Note, dated 12/15/15, .Dietary spoke with therapist today regarding patient's progress with current diet .Therapist also informed dietary that amount consumed by patient is decreased d/t (due to) difficulty initiating swallow .which creates concern for patient meeting daily nutritional/hydration needs. A Speech Therapy Note, dated 12/17/15, indicated, Therapist education to LPN (Licensed Practical Nurse) as patient was placed in a semi laying position in an attempt to feed her. This was being done to prevent anterior spillage to increase intake. Unfortunately, irregardless of position, the patient was unable to consume an adequate amount of food for nutrition/hydration. Consulted with nursing on feeding techniques including the possible use of a controlled bolus via a syringe. Nursing to track intake for the next 4 days and will speak with family about alternative feeding if patient continues to display an inability to swallow sufficiently to maintain weight and hydration .This appears to be related to an overall decline in medical status related to advancing dementia. The Nurses' Progress Notes indicated: 12/17/15 at 7:54 p.m.- resident consumed 0-25% of her evening meal 12/18/15 at 2:01 p.m.- (Written by LPN #1) Resident (sic) did not eat at am (morning) meal, kept pushing food out of her mouth. Resident did eat approx. (approximately) 50% of noon meal. 12/18/14 at 10:06 p.m.- (Written by RN, Registered Nurse, #4) Res. (resident) ate only a couple of bites at dinner. She pushes food out of her mouth and takes in very little. 12/19/15 at 4:04 p.m.- (Written by LPN #1) Resident at approx 50% of am meal, at noon meal resident did not swallow any food writer put in her mouth, resident held head down and food slid out of mouth. 12/19/15 at 10:16 p.m.- (Written by RN #4) Res. had poor food consumption this shift. She ate only bites at dinner even with many attempts to get her to eat. Res. had some sips of liquid but only very little. Res. had a dry brief at the end of shift .Res. has poor skin turgor as evidenced by tenting (skin pinched up) of the hands and sternum greater than a (sic) 3 second return (amount of time it takes for skin to return to normal after being pinched up) (test for dehydration); fluids were offered and resident did not drink well A Weight and Vitals Summary in the record, indicated resident's weights were 12/2/15-147 pounds, 12/9/15-146.8 pounds, and 12/16/15-144.6 pounds at the facility. The emergency room Physician's Note, dated 12/22/15 at 1:01 p.m. indicated the residents weight was 144 pounds. Interview with the Administrator on 12/16/15 at 12:30 p.m., indicated the co-guardian was notified of the transfer on 11/18/15. She indicated another 30 day notice was not issued at the time due to being advised it was not necessary since the facility won their appeal in July. The Administrator also indicated the official notice of transfer or discharge was not issued on 11/18/15. She indicated the resident was being transferred due to the safety of individuals in the facility was felt to be endanger. Interview with the Administrator on 12/29/15 at 2:06 p.m., indicate the resident was transferred due to the safety of the individual in the facility. She indicated she had no information of anything that had occurred in the facility after the appeals hearing in regards to the safety of the individual in the facility being at risk. This Federal tag relates to complaint IN 421. 3.1-12(a)(6)(A) 3.1-12(a)(7)

Based on observation, record review, and interview, the facility failed to provide adequate supervision to protect residents from injury related to the incorrect transfer of a dependent resident in a wheel chair down stairs in the facility resulting in the resident receiving an injury to her head and requiring hospitalization for 1 of 3 residents reviewed for falls and accidents in the sample of 14. (Resident #G) (Maintenance Supervisor) (Activity Staff #1) The facility also failed to ensure the residents environment remained free of hazards related to exposed sharp edges on register vents and an electrical outlet box and cover for 1 of 3 residents reviewed for falls and injuries in the sample of 14. (Resident #F) The facility also failed to provide adequate supervision related to medications left with a resident for 1 of 1 resident reviewed for medications left unattended in the sample of 14. (Resident # J) (RN #1) Findings include: 1. The closed record for Resident #G was reviewed on 5/9/13 at 8:25 a.m. The resident's [DIAGNOSES REDACTED]. The 2/21/13 Quarterly Nursing Assessment indicated the resident was alert to person, place, time and was cooperative. The assessment also indicated the resident required one person assist with transfers and ambulation and used a walker. A care plan initiated on 5/24/12 indicated the resident had impaired physical mobility related to an unsteady gait, multiples stokes, confusion, and a history of multiple falls. The care plan was last reviewed on 2/21/13. Care plan interventions included for staff assist the resident as needed and to maintain proper body alignment. A care plan initiated on 3/1/13 indicated the resident was at risk for decreased range of motion related to decreased mobility. Review of the 3/2013 Physician Order Statement indicated there was an order for [REDACTED]. The 3/2013 Nurses' Notes were reviewed. An entry made on 3/31/13 at 12:00 p.m. indicated the resident was being transferred from the 2nd floor to the 1st floor assisted by two employees via the stairs with the resident in her wheel chair. The Nurses' Note also indicated per employee (name of activity employee) while they were moving the resident to the 1st floor, the wheel chair "skid on the stair", the resident also "hit the side of her head on the wall first before hitting her head on the back of the floor stairs." The entry also indicated the resident stated she had "pain and numbness on the back & side of my head." The entry also noted the resident had a hematoma on the occipital area (back of the head). An entry made on 3/31/13 at 12:35 p.m., indicated the resident was sent to the hospital via ambulance. An Incident/Accident Report dated 3/31/13 at 12:00 p.m., indicated an occurrence occurred on the stairs. The section on the form reading "Describe exactly what happened; why it happened; what causes were. If an injury, state part of body injured...." was not completed. The body diagram picture on the form indicated the area on the back of the head was circled and the type of injury checked was "hematoma." The Physician was notified at 12:05 p.m. and the resident's family member/representative was notified at 12:10 p.m. The Incident/Accident Report was completed by RN #2. The back page of the 3/31/13 Incident/Accident Report indicated the resident was found on the stairs and the resident stated "I have pain and numbness in my back and top of my head." Interventions listed on this page included ice packs. There was a question on the form reading "What do you think contributed to the fall?" The response written in read "transfer using stairs." The Interdisciplinary Team Progress Notes completed with the report indicated a complete review was done of the 3/31/13 occurrence and noted the resident was being transferred from the second floor to the first floor with 2 male assistants and 2 CNA's and during the transfer the resident was eased to the bottom of the step and hit her head on the wall in the process. There was no documentation in this Team Progress Notes describing if staff were holding the wheel chair off the ground or pushing the wheel chair down the stairs. Medical records obtained from the hospital were reviewed. The records indicated the resident was seen in the hospital emergency roiagnom on [DATE] at 1:11 p.m. The emergency room Physician notes indicated the resident arrived at the emergency room after being transported down the stairs in a wheel chair and hit her head on the landing of the stairs. A physical exam was completed and indicated the resident was orientated to person, place, and time. A 5 cm (centimeter) x 5 cm hematoma was observed to the occipital crown of the head. The note also indicated the resident exhibited tenderness to the right hip, right knee, left knee, and right ankle. The Clinical Impression noted in the record included: 1. Fall involving wheelchair causing accident. 2. Cephalgia 3. Cericalgia 4. Right hip pain 5. Bilateral knee pain 6. Right ankle pain 7. Scalp hematoma. Review of 4/1/13 Hospital physician progress notes [REDACTED]. The Progress Note also indicated the resident complained of soreness all over and stated her "head hurt." The Physician's note also indicated there was a bruise to the crown of the head and the area was tender to touch. Superficial bruising was present diffusely over the skin. The Progress Notes indicated the resident's active problem included a "head contusion." Written staff interviews related to the above incident were reviewed. The interview completed by the Maintenance Director indicated he came to the facility at 11:30 a.m. and asked Activity Aide #1 to transfer Resident #G with him to the first floor due to the elevator being out. The written statement indicated two CNA's were spotting the above two employees. When they reached the final step the resident shifted and the wheel chairs right wheel "caught the stair." The statement also indicated the resident's head hit the wall and the Nurses responded immediately, called the Physician and family, and the resident was sent to the hospital. The above statement was signed by the Maintenance Director. A statement written by CNA #6 indicated she was in another resident's room and the Nurse called out saying it sounded like someone fell . This CNA, CNA's #7 and #8 went toward where the noise was. They were standing by the door at the stairwell and the Maintenance Director and Activity Aide got to the bottom of the stairs the two staff lost their balance Resident #G's wheel chair tipped back "with her in it." A statement written by Activity Aide #1 indicated he was asked to bring Resident #G downstairs from the second floor and as they were bringing her down the resident hit her head and they picked her up and took her to the Nurses station. A statement written by CNA #7 indicated she and CNA #6 and CNA #8 heard a noise and went to the stairwell and saw the Maintenance Director and Activity Aide #1 bring Resident #G down and the resident then hit her head for the second time. A statement written by CNA #8 indicated she heard a noise and she and CNA #6 and CNA #7 walked towards the stairwell and saw Maintenance Director and Activity Aide #1 bringing the Resident #G down the stairs and the resident hit her head. A statement written by LPN #7 indicated she heard a "yell" and the CNA's began looking into rooms to locate where the yell had been coming from. The LPN went to the stairs and observed Resident #G sitting upright in her wheelchair and Activity Aide #1 and the Maintenance Director were bringing the resident to the first floor and was told resident hit her head. When interviewed on 5/9/13 at 11:50 a.m., the facility Maintenance Director indicated the facility elevator has been out of service since March 2013. The Maintenance Director indicated Resident #G was transferred from the second floor to the first floor Easter (3/31/13) to go out of the facility on a pass with her family. The Director indicated he came into the facility on [DATE] to transfer the resident per the Administrators request. The Director indicated an Activity staff and two CNA's were present. The Director indicated the resident was seated in a wheel chair and he was behind the wheel chair and the Activity staff was in front of the wheel chair and they rolled her down the stairs in the wheel chair and at the bottom of the first landing the resident "shifted" and hit the right side of her head on the side of the wall while she was in the chair. The Director indicated they continued to push the wheel chair down the second set of stairs to the bottom of that landing and the Nursing staff checked the resident at that time. The Director indicated Resident #G "let out a yelp" when she hit the right side of her head. The Director indicated the facility Administrator did not give him specific instructions for transferring the resident in her wheel chair down the stairs. The Maintenance Director indicated the had transferred residents up the stairs many times the same way. When interviewed on 5/9/13 at 12:55 p.m., CNA #8 indicated she was working on the first floor on 3/31/13 when Resident #G was transferred down to the first floor. The CNA indicated she and other CNA's heard a noise and when she went to doorway of the stairs she observed the Resident being transferred in the wheel chair by the Maintenance Director and a male Activity staff member. The CNA indicated CNA #6 and CNA #7 were with her on the first floor and went to the door. CNA #8 indicated CNA's #6 and #7 were not involved in the transfer. The CNA indicated another CNA was up on the second set of stairs. CNA #8 indicated Resident #G "looked scared" when she saw her and she also had a big bump on her head. The CNA indicated she wrote her statement. The CNA indicated neither the Director of Nursing or the Administrator talked to her about the incident with Resident #G since it happened. When interviewed on 5/9/13 at 1:05 p.m., Activity Staff #1 indicated he was working the day Resident #G was transferred down the stairs in her wheel chair. The Aide indicated the Maintenance Director asked him to help transfer a resident down the stairs. The Aide indicated he and the Maintenance Director transferred the resident in a wheel chair from the first floor to the second floor. The Aide indicated it was the Maintenance Director and him when they were first bringing the resident down the stairs. The Aide indicated the resident was in the wheel chair and he was in front of the chair facing the resident and the Maintenance Director was in back of the wheel chair and the wheel chair was tilted back and the wheel chair went down the stairs step by step with the back wheel of the wheel chair touching the ground at at all times. The Activity Aide indicated the resident was in the wheel chair and the wheel chair was never picked up or carried down the stairs. The Aide indicated there were no staff members in between the sides of the wheelchair and the walls during the transfer. The CNA indicated the resident said she hit her head but he did not observed this where he was at. The Activity Aide indicated he stayed with Resident #G until the paramedics came to the facility. The Activity Aide indicated he had never transferred a resident down the stairs that way and was not given any special instructions by the Administrator. When interviewed on 5/9/13 at 12:25 p.m. the facility Administrator indicated Resident G's family member approached him in March and wanted the resident brought down to the first floor on Easter. The Administrator indicated he made arrangement for the Maintenance Director and another male staff member to be present to transfer the resident. The Administrator indicated the resident was transferred while in the wheel chair and two staff members lifted the wheel chair and carried the wheel chair with the resident in it down the stairs. The Administrator indicated the Nurse on duty got the statements from the Nursing staff involved and he then came into the facility and obtained the statement from the Maintenance Director. He indicated the Maintenance Director informed him they were carrying the resident down the stairs and CNA's were spotting him. The Administrator stated he had previously read the statements written by the other staff present. When the Administrator read the same statements made by the CNA's he indicated, he did not read the statement "close enough". The Administrator indicated that up until this time he was under the impression the two male staff members carried the wheel chair with the resident in it down the stairs. The Administrator indicated the Resident should have been carried down the stairs not pushed in the wheel chair. 2. On 5/8/13 at 7:55 p.m., Resident #F was observed asleep in a low bed in his room. The left side of the low bed was up against the wall. There was a mat on the floor on the other side of the bed. There were no staff members or visitors in the resident's room at this time. The wall register along the wall was approximately six inches above the level of the resident's bed. A metal bracket from the register vent was bent away from the vent and stuck out approximately two inches from the vent. The edges of the bracket were pointed and were not covered. There was an electrical outlet box on the wall next to the resident's bed. The electrical box extended approximately two inches away from the wall. There was a white face plate covering the front of the box. The pointed edges of the face plate were not covered or padded. On 5/9/13 at 4:50 p.m., the resident's room was observed with the Director of Nursing and the Maintenance Director. The metal bracket of the vent was still bent forward the pointed corners uncovered. The pointed corners of the electrical box remained uncovered. The record for Resident #F was reviewed on on 5/8/13 at 7:45 p.m. The resident's [DIAGNOSES REDACTED]. When interviewed of 5/9/13 at 4:50 p.m., the Maintenance Director indicated the bracket plate should have been folded down and the edges then would not be exposed. 3. On 5/8/13 at 6:18 p.m., Resident #J was observed sitting at a table in the hallway for dinner. The resident's meal tray was on the table in front of the resident. There was a small medication cup on the table also. The resident took a pill out of the medication cup and put it in her mouth. There were no staff members present at the table or in view of the resident. The record for Resident #J was reviewed on 5/9/13 at 10:50 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 5/2013 Physician Order Statement indicated there were orders for the resident to receive the following medications in the evening: 1. Levetiracetam 500 milligrams one tablet every evening at 6:00 p.m. 2. Metformin 500 milligrams orally every evening at 6:00 p.m. 3: Citalopram 35 milligrams twice a day at 10:00 a.m. and 5:00 p.m. There were no Physician orders for the resident to self administer her medications or for any oral medications to be left at the resident's bedside. The facility policy titled "General Dose Preparation and Medication Administration was reviewed on 5/13/13 at 9:45 a.m. There was a revised date of 5/01/10 on the policy. The Director of Nursing indicated the policy was current. The policy indicated facility staff were required to observed the resident's consumption of the medication(s). When interviewed on 5/8/13 at 8:50 p.m. RN#1 indicated she had administered evening medications. The RN indicated she recalled putting the resident's medications down at the table and told her she would be back. The RN indicated she was not sure if she saw the resident take the medication. RN #1 indicated the facility protocol when administering medication is to stay with the resident until the medications are taken. When interviewed on 5/13/13 at 11:00 a.m., the Director of Nursing indicated staff were to remain with resident's when medications were taken and the medications should not have been left with unattended with the resident. This federal tag relates to Complaints IN 550 and IN 379. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview the facility failed to ensure the resident;s drug regime was adequately monitored related to addressing a critical laboratory result for a resident receiving [MEDICATION NAME] ( an oral anticoagulant mediation requiring therapeutic levels) for 1 of 3 resident reviewed for monitoring [MEDICATION NAME] levels in the sample of 14. This resulted in hospitalization of the resident with a [DIAGNOSES REDACTED]. (Resident #F) Findings include: The record for Resident #F was reviewed on 5/8/13 at 7:45 p.m. The resident's [DIAGNOSES REDACTED]. Review of the 3/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was also an order [REDACTED]. No [MEDICATION NAME] had been signed out as give on 3/4/13. The 3/2013 laboratory test results were reviewed. The first laboratory test report indicated the laboratory collected a blood specimen for a PT/INR test on 3/4/13 at 4:50 a.m. The test report indicated the results were as follows: PT: 80.0 (critical level) INR: 8.4 (critical level) There was documentation on the report indicating the laboratory phoned the above critical levels to the Director of Nursing on 3/4/13 at 11:30 a.m. and Director of Nursing read back the results to the laboratory caller. There was no documentation written on the results report to indicate the staff had informed the Physician of the critical results. A second laboratory test report also dated 3/4/13 indicated a second PT/INR test was collected on 3/4/13 at 1:36 p.m. The test report indicated the results were as follows: PT: 92.3 (critical level) INR: 9.8 (critical level) Writing on the bottom of this laboratory report indicated the Physician was informed of the critical PT/INR results on 3/4/13 at 2:40 p.m. The 3/2013 Nurses' Notes were reviewed. The first entry made on 3/4/13 was at 2:40 p.m. This entry indicated the Physician was notified of the critical high PT/INR lab results. The resident's INR was 9.8. There was no assessment of the resident related to signs of bleeding related to the critical PT/INR levels reported on 3/4/14 at 11:30 a.m. and 2:40 p.m. There was no documentation of any interventions or increased monitoring of the resident for injury or signs of bleeding between 11:30 a.m. and 2:40 p.m. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The 3/7/13 physician progress notes [REDACTED]. When interviewed on 5/9/13 at 2:25 p.m., the Director of Nursing indicated she received the call from the laboratory on 3/4/13 at 11:30 a.m. The Director of Nursing indicated she requested the laboratory to re run the test due to the high levels reported. The Director of Nursing indicated there was no assessment of the resident or interventions put in place to monitor the resident for injury or bleeding when the first critical levels were noted. This federal tag relates to Complaint IN 504. 3.1-48(a)(3)