Every finding on record at Colonial Oaks Health Care Center

Based on observation, interview, and record review, the facility failed to ensure nonpharmacological interventions were attempted prior to the administration of an as needed (PRN) psychoactive medication for 1 of 2 residents reviewed for dementia care (Resident 6). Finding includes: During an observation on 8/21/23 at 11:50 a.m., Resident 6 sat in her wheelchair in the hall and yelled help repeatedly. She indicated she wanted someone to get her car keys. During an observation on 8/23/23 at 11:32 a.m., the resident sat in her room in her wheelchair and made repeated nonsensical sounds which were followed by utterances of oh, oh, oh repeatedly. During an observation on 8/24/23 at 10:50 a.m., the resident yelled help repeatedly. She indicated she wanted someone to help her with a note to give the people in the house down the street. Resident 6's clinical record was reviewed on 8/24/23 at 9:32 a.m. Her diagnoses included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, recurrent depressive disorders, and anxiety disorder. Her current physician's orders included buspirone (antianxiety) 5 mg two times a day and escitalopram (antidepressant) 2.5 mg daily. Her 6/24/23 quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and had verbal behavioral symptoms that were directed toward others and occurred one to three days of the seven-day assessment period. A care plan for anxiety, initiated on 5/28/19 and revised on 4/20/22, indicated the resident had anxiety as evidenced by chronic disease process and depression. The resident would become easily agitated when anxious or become anxious when she did not know what she was to be doing. She preferred to keep busy. Interventions included incorporate the resident's daily routine as much as possible during her stay (initiated 4/29/20), medications as ordered (initiated 5/30/19), and reassurance as needed (initiated 5/30/19). A care plan for behavioral symptoms, initiated on 12/20/17 and revised on 4/18/22, indicated the resident had behavioral symptoms related to cognitive deficit and dementia such as wandering, resistance to care, easily agitated, yelling/screaming, hitting at others, crying/tearful and cursing when she became confused. The resident would sometimes have repetitive questions such as I don't know what I am supposed to be doing when staff were letting her know it was time for bed, breakfast, or to get dressed. Interventions included allow the resident plenty of time to process what is being said before beginning the resident's care (initiated and revised 4/7/22), allow the resident to express her feelings (initiated 12/20/17), approach resident from the front and get her attention (initiated 12/20/17), diversional activity such as going to the next activity on the activities calendar (initiated 12/20/17), reassure and comfort resident when needed to calm her down (8/28/19), redirect the resident's behavior by offering her a crossword puzzle, word search, or offer to take her for a walk, or start a conversation with her about her daughter or her past job (initiated 8/28/19), remove her from stimuli when indicated (initiated 8/28/19), and when the resident becomes agitated allow her time to calm and reapproach at a later time (initiated 12/20/17). A Physician's Note, dated 6/13/23 at 7:57 a.m., indicated the resident was COVID-19 positive and placed on droplet isolation. The resident was very anxious and yelled out to get into her wheelchair to visit her brothers (who were not there). She appeared more dyspneic (short of breath) due to her anxiety. The resident experienced increased anxiety due to COVID-19 isolation restrictions and did not want to remain in her room. Lorazepam (antianxiety) 0.25 mg every 6 hours PRN for 10 days was prescribed. The resident's Medication Administration record for June 2023 indicated the resident received the PRN 0.25 mg lorazepam on 6/13/23 at 2:00 p.m. and 9:00 p.m., on 6/16/23 at 11:48 a.m., 6/19/23 at 4:13 p.m., and 6/23/23 at 12:07 p.m. A Nurse Note, dated 6/16/23 at 1:40 p.m., indicated the resident had anxiety due to not being able to leave her room. Lorazepam was given. A Nurse Note, dated 6/23/23 at 1:52 p.m., indicated the resident had anxiety and lorazepam was given. The clinical record lacked documentation of interventions provided prior to administration of lorazepam. During an interview, on 8/25/23 at 2:00 p.m., the Social Services Assistant (SSA) indicated the resident did not have any behavior reports for June 2023 for the resident. During an interview, on 8/25/23 at 2:53 p.m., LPN 51 indicated a resident should be assessed for anxiety symptoms and interventions should be attempted prior to giving a PRN antianxiety medication. If the non-medication interventions were not successful, then the PRN antianxiety medication would be given. The behaviors and interventions should be documented. She usually filled out a behavior sheet when a resident had behaviors and required a PRN psychoactive medication. During an interview, on 8/25/23 at 3:00 p.m., the Director of Nursing (DON) indicated behavior sheets should be completed for residents who had behaviors. Non-pharmacological interventions should be attempted prior to administration of PRN psychoactive medications. She was unable to locate documentation of the interventions provided for the resident prior to administration of the PRN lorazepam in June 2023. A current facility policy, dated 11/10 and revised 4/23, provided by the DON on 8/25/23 at 3:51 p.m., titled Psychoactive Medications/Gradual Dose Reduction (GDR)/Unnecessary Medications Policy, indicated the following: .Prior to the administration of a prn psychoactive medication, the nurse will attempt non-pharmacological interventions document the interventions attempted and outcomes of the interventions 3.1-37(a)

Based on interview and record review the facility failed to prevent neglect of 1 of 3 residents reviewed for neglect. (Resident D) Findings include: The clinical record for Resident D was reviewed on 2/14/2023 at 8:33 a.m. Diagnoses included chronic pain syndrome, paraplegia, acute cystitis with hematuria, anemia, hypertension, anxiety disorder, idiopathic peripheral autonomic neuropathy, ileostomy, stage 4 left hip pressure ulcer, stage 4 sacral region pressure ulcer, stage 4 left buttocks pressure ulcer, stage 4 right buttocks pressure ulcer, stage 3 left heel pressure ulcer, and stage 2 right heel pressure ulcer. The resident was assessed as cognitively intact. A facility self-reportable, dated 2/5/2023, indicated on 2/4 and 5/2023 CNA (Certified Nursing Aide) 1 failed to provide incontinent care to Resident D. The facility investigation substantiated the allegation and CNA 1 self-terminated employment from the facility. A written statement by QMA (Qualified Medication Aide) 2 indicated on 2/4/2023, between 12:30 p.m. and 1:30 p.m., CNA 1 came to her and asked her to follow him. He led her to the hallway for Resident D. On the way, they encountered LPN 4, and CNA 1 and LPN 4 started having an argument. QMA 2 and LPN 4 went to the resident's room and began doing his dressing changes, and provided incontinence care. CNA 1 told the QMA he had been taught he could not provide incontinence care to a resident with wounds. A written statement by the DON (Director of Nursing) indicated on 2/4/2023 she received a phone call from QMA 2 stating CNA 1 told staff he was taught he was unable to provide cares to a resident with wounds. The DON indicated she had been CNA 1's instructor and this was not taught in the class. QMA 2 then told the CNA he could provide cares to a resident with wounds. On 2/5/2023, around 5:30 p.m. to 6:00 p.m., the DON stated she received another phone call from QMA 2 indicating CNA 1 was still not providing incontinence care to Resident D. Staff were instructed to send CNA 1 home. A written statement by the DON indicated she had spoken with LPN 4 on 2/6/2023 about the incidents alleged on 2/4 and 2/5/2023. LPN 4 told the DON that between 9:00 a.m. and 10:00 a.m. on 2/4/2023, CNA 1 told her Resident D needed to be changed. LPN 4 told the CNA to go ahead and change the resident and she would do treatments when she completed her medication pass. Sometime after lunch, CNA 1 asked LPN 4 when she was going to do the resident's treatment, because the resident had not been changed all day. LPN 4 told the CNA he was supposed to have provided his care already. Sometime between 1:30 p.m. and 2:00 p.m., the nurse provided care and treatments for the resident. The resident had been incontinent of stool. A written statement by LPN 4 indicated, at approximately 4:30 p.m., she and LPN 5 were doing wound care for Resident D. The resident stated he had not been changed since 4:30 a.m. The resident was soiled up to the middle of his back with stool. The resident told them CNA 1 had come in several times throughout the day, and said they would come and change him, but they never did. A written statement by LPN 5 indicated on 2/5/2023, at approximately 4:30 p.m., he and LPN 4 went to provide wound care to Resident D's multiple pressure areas on his coccyx and hips. The resident told them he had not been changed since around 5:00 a.m. The resident told them he put his call light on and asked to be changed, and was told by CNA 1 they would be back to change him. LPN 5 indicated when they started the wound care, the resident had stool all over his bed, up his back and caked in his wounds. During an interview, on 2/14/2023 at 8:00 a.m., Resident D indicated he did not want to talk about the incident involving CNA 1. During an interview, on 2/14/2023 at 1:02 p.m., the DON indicated she had taught CNA 1 in class for the CNA certification about a year ago. The CNA told her he was taught in clinicals he could not care for a resident with wounds. She told him that was not taught and that he could provide care to a resident with wounds, he just could not remove the dressings. I had not worked with him in about a year. I have no idea where he got that. I do not know why he did not do what he should have done. During an interview, on 2/14/2023 at 1:17 p.m., CNA 8 indicated she was working the weekend of 2/4/2023. She was asked to assist with a dressing change for the resident by LPN 5. The CNA indicated she rolled the resident to his side, he had stool everywhere, and his dressings had come off. She indicated the stool appeared fresh. During an interview, on 2/14/2023 at 1:34 p.m., LPN 4 indicated she was the nurse for both halls. CNA 1 asked if she had looked at Resident D's wounds. She told him she would when she finished the medication pass. The CNA indicated the resident needed to be provided care. She told him to go ahead and change him, the dressings were foam, and if the water proof one came off to let her know. This was about around 9:00 a.m. At 1:00 p.m., she started doing the treatments. He had BM up his back, and some of it was dry. The resident said he had not been touched all day. Then, the next day, the same thing happened. The CNA did not touch resident all day. They called the administrator and he was sent home. Review of a current policy, dated 10/17/2022, titled Freedom from Abuse, Neglect, Exploitation and Misappropriation of Property indicated the following: Definitions: Neglect - the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress No other information was provided prior to exit. This Federal tag relates to complaint IN00401111. 3.1-27(a)(3)

Based on record review and interview, the facility failed to provide notification of transfer or discharge to a resident or the resident's representative and failed to provide notification to the Long Term Care Ombudsman for 1 of 5 residents reviewed for hospitalization s (Resident 66). Findings include: Resident 66's clinical record was reviewed on 6/15/22 at 9:12 a.m. Her nurses notes indicated, but was not limited to the following: On 4/27/22 at 9:20 a.m., she had a leave of absence to a hospital for surgery. On 4/28/22 at 8:03 p.m., she returned to the facility by ambulance. On 5/30/22 at 4:45 a.m., she had increased confusion, an order was received to send her to the emergency room . On 6/2/22 at 10:36 p.m., she returned to the facility by ambulance. Her clinical record lacked a transfer or discharge notification for both hospitalization s. During an interview, on 6/17/22 at 9:03 a.m., the Social Service Director indicated when residents were discharged to home or another facility, she completed the transfer or discharge notification form and it was included in the discharge packet. For residents who were sent to the hospital she ran a report at the end of the month and completed a transfer or discharge form was sent to the Ombudsman. She was observed running a hospitalization report for both hospitalization s for Resident 66 and neither hospitalization s were on the report. She indicated it maybe something they need to figure out and the Ombudsman had not been notified for either hospitalization s. During an interview with the Interact Nurse, on 6/17/22 at 11:23 a.m., she indicated when a resident was sent to the hospital the resident's code status, medication list, last physician notes, recent labs and x-rays, and the transfer/discharge and bedhold policy was sent with the resident. A current policy, titled Notice of Transfer or Discharge, provided by the DON, on 6/17/22 at 1:28 p.m., indicated the following: .Procedure .8. The nursing facility must place a copy of the notice in the resident's medical record and transmit/provide a copy to the following: a. The resident/resident representative; b. A family member of the resident, if known; c. The resident's legal representative, if known; d. The local Long Term Care Ombudsman program for any facility-initiated transfer 3.1-12(a)(6)(A)

Based on observation, interview, and record review, the facility failed to ensure residents did not receive [CONDITION(S)] medications without indication for use for 1 of 5 residents reviewed for unnecessary medications (Resident 67). Findings include: On 6/14/22 at 2:07 p.m., Resident 67 was observed in bed. On 6/15/22 at 9:31 a.m., she was in bed. During a wound observation, on 6/15/22 at 10:51 a.m., she asked the nurse for a pain pill for pain in her bottom and her shoulder. On 6/15/22 at 1:12 p.m., she was standing up at the side of her bed holding onto her overbed table talking with roommate. On 6/16/22 at 9:51 a.m., she was in bed. On 6/17/22 at 10:56 a.m., she was in bed. Resident 67's clinical record was reviewed on 6/14/22 at 1:59 p.m. Diagnoses included, but was not limited to, major depressive disorder single episode, anxiety disorder, cognitive communication deficit, unspecified dementia without behavioral disturbance, other malaise, abnormal weight loss, low back pain and chronic pain syndrome. She admitted to the facility on [DATE]. Her orders included but, were not limited to, [MEDICATION(S)] (anti-depressant) 75 mg (milligram) daily for major depressive disorder single episode (9/30/21) and [MEDICATION(S)] (anti-depressant) 30 mg daily for major depressive disorder single episode (9/30/21). A quarterly MDS (Minimum Data Set), dated 5/18/22, indicated she was moderately cognitively impaired. A resident mood interview indicated she felt tired or having little energy two to six days and she had a poor appetite or overeating seven to eleven days (half or more of the days). She did not exhibit behaviors. Her PHQ9 (Patient Health Questionnaire) score indicated she had normal or minimal depression. She received an anti-depressant. A 10/1/21 revised care plan indicated she had a diagnosis of depression and presented with signs/symptoms of depression such as poor appetite. Depression may be related to loss of loved one and/or disease process. Her goal was she would not display major depressive signs/symptoms such as self isolation; crying/tearful revised on 5/5/22. Her interventions were initiated on 10/1/21 and included, she would receive her medications as ordered, she would receive psychiatric services as needed, family involvement would be encouraged, emotional support and assistance would be provided as needed. A 10/4/21 revised care plan indicated she had anxiety as evidenced by history of anxiety, depression; change in environment and health status. Her goal was that her care plan interventions would maintain her anxiety as evidenced by her PHQ-9 score of five or less revised on 5/5/22. Her interventions were initiated on 10/1/21 and included medications as ordered and mental health services. A 3/18/22 revised care plan, indicated she had behavioral symptoms such as asking my roommate to feed her, repetitive verbalizations, delusions, yelling/screaming, cursing, related to cognitive deficit and major depression. Her goal was her behavioral symptoms would be managed through her care plan interventions as evidenced by three or less episodes through her care plan interventions revised on 5/5/22. Her interventions were initiated on 2/14/22 and included, allow her to express her feelings, approach her from the front and make sure you had her attention, encourage her family to actively participate with her behavior plan and medications as ordered Her interdisciplinary psychopharmacological reviews, nurses notes and behavioral sheets included the following: An interdisciplinary psychopharmacological review, dated 10/25/21 at 3:50 p.m., indicated she received [MEDICATION(S)] 30 mg at bedtime for depression and [MEDICATION(S)] HCL ([MEDICATION(S)]) 75 mg one time daily for depression. Her behavior target(s) to quantify was adjustment to new environment. Her antidepressant criteria was she was withdrawn to self. The IDT (Interdisplinary Team) reviewed her medications and did not recommend a GDR (Gradual Dose Reduction) at that time. She was new to the facility and was still trying to adjust to her long term stay at the facility. An interdisciplinary psychopharmacological review, dated 11/30/21 at 4:23 p.m., indicated she received [MEDICATION(S)] 30 mg at bedtime for depression and [MEDICATION(S)] HCL 75 mg one time daily for depression. Her behavior target(s) to quantify was adjustment to new environment and poor appetite. Her antidepressant criteria was she was withdrawn from interests and withdrawn to self. The IDT team reviewed her medications and did not recommend a GDR at that time. She was still trying to adjust to her long term stay in the facility. On 12/31/21 at 4:20 a.m., she had been sleeping throughout the night. No depression noted but the nurse had noted some crying off and on during the day. On 1/2/22 at 9:06 a.m., she remained on alert charting due to monitoring for signs and symptoms of depression. She remained in bed and slept most of the day. On 1/3/22 at 3:11 a.m., she remained on alert charting for signs of depression. She had slept through the night without difficulty. She remained friendly and cooperative with staff, and showed no signs of depression at that time. On 1/4/22 at 1:35 p.m., she stayed in room and mostly in bed. She lacked motivation to get up and made frequent negative statements. (nobody cares, why should I do anything, i.e.) On 1/5/22 at 1:37 p.m., she stayed in bed most of day, did not have any interest in doing anything, she said what was the point, there was nothing she wanted to do. On 1/21/22 at 1:30 p.m., Resident 67's sister telephoned the facility because Resident 67's roommate called her and told her that Resident 67 was very ill. The nurse explained the conversation that was had at the noon med pass. Resident 67's sister stated that she believed Resident 67 was depressed because she had not been able to visit and that her sister would be coming that afternoon to see Resident 67. No further concerns were voiced. The nurse would alert social services of the issue with roommate calling Resident 67's family member. A behavior sheet, dated 1/27/22 at 1:02 p.m., roommate was found feeding Resident 67 in their room and said she couldn't feed herself because her bottom hurt too much. Staff offered to feed her and she said her roommate would feed her. The roommate finished feeding her but she said she might want staff to feed her more later. She tried to get others to do things she was able to do herself. On 2/21/22 at 2:32 p.m., the pharmacy recommended a GDR of [MEDICATION(S)] and was denied by the nurse practitioner. An interdisciplinary psychopharmacological review, dated 2/21/22 at 2:42 p.m., indicated she received [MEDICATION(S)] 30 mg at bedtime for depression and [MEDICATION(S)] HCL 75 mg one time daily for depression. Her behavior target(s) to quantify was adjustment to new environment and poor appetite. Her antidepressant criteria was withdrawn from interests and withdrawn to self. The IDT team reviewed resident's medications and a GDR was not indicated at that time. She struggled with being in the facility and not at home. She has had some attention seeking behaviors. A behavior sheet, dated 3/5/2022 at 8:23 a.m., indicated upon giving resident medication that a.m., she became very aggressive, yelling Why are you holding me hostage? Why have you kidnapped me? Are you broke? What's wrong with you? I had to pi-- in the bucket over there because you are keeping me here! I hope you all get the electric chair and they fry your a----! The writer calmly explained to her, she was here currently for wound healing and the writer had some medications for her to take. She was resistive and she insisted staff was trying to poison her. A behavior sheet, dated 3/6/22 at 12:31 p.m., indicated she walked around her room unassisted and unsteady on feet. Her roommate alerted staff to the situation. Staff entered the room to assist her to bed. She yelled at staff members, proclaiming Why are you holding me hostage? Are you broke? Why are you keeping me here? Unable to reorient resident at that time, but was able to assist her safely to bed. On 3/16/22 at 1:42 p.m., she took off her wound vac that a.m. She said she did not know what it was for and it was replaced by the wound nurse. It was reiterated to her how important it was to keep it on. She was very confused and argumentative. A social service behavior note, dated 3/18/22 at 12:31 p.m., indicated as per behavior sheet written on 3/5 at 8:23 a.m. and 3/6 at 12:31 p.m.; she had repetitive questions, delusions, yelling/screaming, cursing - on 3/5 she became aggressive during a.m. med pass, yelled why are you holding me hostage? why have you kidnapped me?, what's wrong with you?, are you broke?, I had to pi-- in the bucket over there because you were keeping me here! and numerous other accusations. (see behavior note). On 3/6 she walked around unassisted and unsteady on her feet. Staff alerted to room by roommate. When staff entered room to assist her to her bed she yelled at them, why are you holding me hostage, why are keeping me here, are you broke?. Staff unable to be reoriented but was able to assist her safely to bed. Interventions used for both behaviors; approached in calm manner, identified self, established eye contact, called her by name, explained what they were going to do, used simple sentences, tasks broken down in small steps, non-verbal cues given, didn't argue or confront, offer fluids, offered a snack, changed a position, talk with her, validated her feelings, left alone and re-approached, medication was given. The outcome and prevention was the interventions were tried and the behavior was unchanged, her behaviors were care planned. She was to be seen by the nurse practitioner. On 3/20/22 at 5:02 a.m., she remained on alert charting for behaviors, for pulling off wound vac. No behaviors noted at that time. She asked about the wound vac, but it was causing some minor discomfort from her brief being bunched up in the back. The wound vac was in place and functioned at that time. An interdisciplinary psychopharmacological review, dated 3/28/22 at 2:27 p.m., indicated she received [MEDICATION(S)] 30 mg at bedtime for depression and [MEDICATION(S)] HCL 75 mg one time daily for depression. Her behavior target(s) to quantify was adjustment to new environment and poor appetite. Her antidepressant criteria was she was withdrawn from interests and withdrawn to self. The IDT team reviewed her medications and a GDR was not indicated at that time. She continued to adjust to the nursing home. A GDR would cause emotional harm to her. On 3/29/22 at 1:39 p.m., the pharmacy recommendation for GDR of [MEDICATION(S)] was denied by the nurse practitioner. The reason being that a GDR was not indicated at that time. She continued to adjust to the nursing home. A GDR would cause emotional harm to the resident. An interdisciplinary psychopharmacological review, dated 5/31/22 at 5:45 p.m., indicated she received [MEDICATION(S)] 30 mg at bedtime for depression and [MEDICATION(S)] HCL 75 mg one time daily for depression. Her behavior target(s) to quantify was adjustment to new environment and poor appetite. Her antidepressant criteria was she was withdrawn from interests and withdrawn to self. The IDT team reviewed her current medications and did not recommend a GDR at that time. During an interview with the SSD (Social Service Director), on 6/17/22 at 9:14 a.m., she indicated Resident 67 had not had any behaviors since March when she was agitated. She had two behaviors in March and one in January, yelled at staff that she was kidnapped and why was she at the facility. She came to facility on the antidepressants. During an interview with the SSA (Social Service Assistant), on 6/17/22 at 9:22 a.m., she indicated she thought she was on [MEDICATION(S)] for appetite but she was on it for depression, she should had been on it for appetite. Her appetite was poor and couldn't get hungry. She still struggled with being at the facility and her family says she still wanted to go home. She liked to lay in bed. The behaviors since she had been at the facility was on 1/27/22, 3/5/22 and 3/6/22. She would be looked at again for GDR in August. The new psychiatric provider may see her sooner. She was not wanting to eat and not motivated and did not socialize, family brought in snacks that she liked and she liked her cokes. She self isolated. Her previous stay at the facility she was friendly, carried on conversations and talked to others. Since she readmitted she was not very happy that she was at the facility. During and interview with the DON, ADON, SSD and SSA, on 6/17/22 at 11:41 a.m., the SSA indicated Resident 67 slept a lot and was hard to stir, she stopped into see her but it was hard to stir around and wake her up. The DON thought she was depressed and she wanted to stay in bed all the time, loss of her role and was not going home. Her family and activities had tried to get her out of the room. SSA indicated she believed Resident 67 was depressed and had not adapted to the facility, for along time she said she wanted to go back home and felt like she just lost her will. Her appetite was almost non existent. A current policy titled, Psychoactive Medications/Gradual Dose Reduction Policy, provided by the DON, on 6/17/22 at 11:34 a.m., indicated the following: Policy: It is the policy of this facility that a resident will receive psychoactive medications only when it is necessary to improve the resident's overall psychosocial health status. To ensure the resident is receiving the necessary medication at the lowest effective dose with an appropriate diagnosis. To ensure gradual dose reduction attempts are made unless contraindicated 3.1-48(a)(1) 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure a urinary catheter was managed in a hygienic manner for 1 of 1 residents reviewed with a urinary catheter (Resident 33). Findings include: On 6/13/22 at 10:04 a.m., he was in the hallway, in his wheelchair. His urinary catheter tubing was coming from the leg of his pants and the urinary catheter tubing was lying on the floor On 6/13/22 at 11:02 a.m., he sat in his room, in his wheelchair. His urinary catheter tubing was coming from the leg of his pants and the urinary catheter tubing was lying on the floor, he indicated his catheter leaks at night. On 6/16/22 at 9:48 a.m., he sat in his room, in his wheelchair. His tubing from his urinary catheter was coming from the leg of his pants. His urinary catheter drainage bag was partially lying on the floor. On 6/16/22 at 2:10 p.m., he sat in his room in his wheelchair. His tubing from his catheter was coming from the bottom of his pant leg and his urinary catheter tubing was lying on the floor. On 6/16/22 at 2:18 p.m., Nursing Assistant 22 indicated she would lift his tubing up a little higher and it was not supposed to be on the floor. On 6/16/22 at 2:51 p.m., he sat in his room, in his wheelchair. His urinary catheter tubing was coming from the bottom of his pant leg and his left foot was on top of the urinary catheter tubing lying on the floor. On 6/16/22 at 3:31 p.m., LPN 14 was taking his blood pressure as he sat in his wheelchair in his room. His urinary catheter tubing was lying on the floor. She indicated he just wiggles and she would take care of it. Resident 33's clinical record was reviewed on 6/15/22 at 10:23 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His current orders included, but were not limited to, cleanse area of supra pubic placement daily and cover with fenestrated boarder dressing daily and as needed, maintain suprapubic catheter and to be changed by doctor monthly and change catheter collection bag every 30 days and as needed. A quarterly MDS (Minimum Data Set) dated 4/27/22, indicated he was moderately cognitively impaired. He was totally dependent with toileting. He required extensive assistance with one staff member for personal care. He had an indwelling catheter. A 1/27/22, revised care plan indicated he had a suprapubic catheter related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A current policy titled, Catheter use care policy, provided by the Interact Nurse, on 6/17/22 at 11:31 a.m., indicated the following: .General Considerations .6. The drainage bag and tubing should not touch the floor at any time 3.1-18(a)

Based on record review and interview, the facility failed to ensure a resident received only medication ordered (Resident B) and failed to ensure a resident received a medication as ordered by physician (Resident C) for 2 of 4 residents reviewed for medication administration. Findings include: 1. The clinical record for Resident B was reviewed on 3/31/22 at 8:49 a.m. Diagnoses included, but were not limited to, fracture of right femur, [CONDITION(S)], protein malnutrition, and artificial right hip joint. The most recent admission Minimum Data Set (MDS) assessment, dated 12/24/21, indicated the resident admitted on [DATE] from the hospital. The resident was severely cognitively impaired. A progress note, dated 12/29/21 at 2:53 p.m., indicated the system identified a black box warning for [MEDICATION(S)] (used to treat [CONDITION(S)]). A progress note, dated 12/29/21 at 3:30 p.m., indicated the resident was seen for an acute visit by the Nurse Practitioner (NP). The NP was aware of the current medication regimen containing potential drug interaction and black box warning. A physician's order, dated 12/30/21, indicated to give [MEDICATION(S)] 175 mcg daily for low [CONDITION(S)]. A progress note, dated 1/4/22 at 2:28 p.m., indicated a new order was entered into the system for calcium 600 D twice daily. The order triggered a possible drug interaction with the following medication: a. Aspirin 325 mg b. [MEDICATION(S)] 175 mcg. A progress note, dated 1/4/22 at 2:39 p.m., indicated the NP reviewed laboratory results and ordered the following: a. Calcium 600/400 mg twice daily. b. [MEDICATION(S)] 5000 units weekly for 12 weeks. c. Vitamin D lab on 3/30/22. d. Ionized calcium lab level on 1/18/22. A progress note, dated 1/5/22 at 11:45 a.m., indicated a new order for oyster shell calcium with vitamin D 500-200 mg tablet identified a black box warning for [MEDICATION(S)] 175 mcg. The severity was considered moderate and indicated the calcium salts may decrease the pharmacologic effects of [MEDICATION(S)]. A progress note, dated 1/18/22 at 8:49 a.m., indicated the NP completed a discharge visit for Resident B. The NP was aware of the potential drug interactions and black box warnings. An NP discharge assessment/plan, 1/18/22 at 11:40 a.m., indicated the resident had [CONDITION(S)] and was stable on oral [MEDICATION(S)]. The resident was discharged to home with 24 hour care following surgical repair of a hip fracture. A Medication Review Report, signed by the NP on 1/18/22, indicated to take [MEDICATION(S)] 175 mcg daily for low [CONDITION(S)]. A new order, dated 1/19/22 at 2:37 p.m., indicated the NP was aware the ionized calcium was canceled. A ionized calcium lab test was completed on 1/20/22 and found to be within normal limits. Review of the Medication Administration Record (MAR), the medication was given daily from 12/30/21 through 1/20/22. A progress note, dated 1/21/22 at 4:34 p.m., indicated the resident's caregiver arrived to transport the resident home. A progress note, dated 1/21/22 at 4:45 p.m., indicated while reviewing the chart, it was noted Resident B had an order for [MEDICATION(S)] 175 mcg. The medication was ordered on 12/29/21 and was a medication transcription error. The physician and Power of Attorney (POA) were notified. 2. The clinical record for Resident C was reviewed on 3/31/22 at 11:44 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], chronic obstructive pulmonary disease, anxiety disorder, acute and [CONDITION(S)]. The most recent quarterly MDS assessment, dated 12/23/21, indicated the resident cognitively intact. A health care plan, dated 12/30/21, indicated the resident had below normal [CONDITION(S)] function. Interventions included, but were not limited to, receive [CONDITION(S)] replacement as ordered. A progress note, dated 1/25/22 at 9:28 a.m., indicated during chart review it was noted the resident was to have an increase in [MEDICATION(S)] 175 mcg on 12/29/21. A transcription error was noted in the chart and a follow-up [CONDITION(S)] Stimulating Hormone (TSH) level was ordered. An NP discharge assessment/plan, 12/29/21 at 10:19 a.m., indicated the resident had [CONDITION(S)] and a recent TSH level was 7.4 milliunits per liter ([NAME]/L). A repeat TSH was schedule for 12/29/21. A laboratory test result, indicated the TSH level on 12/29/21 was 6.280. The normal TSH level was between 0.465 and 4.680 [NAME]/L. A progress note, dated 12/29/21 at 2:50 p.m., indicated the NP was made aware of the current TSH level and it had improved sine the prior level. A new order was received to increase [MEDICATION(S)] [[MEDICATION(S)]] to 175 mcg QD [daily]. A Medication Review Report, signed by the NP on 12/29/21, indicated to take [MEDICATION(S)] 150 mcg daily for low [CONDITION(S)]. During an interview on 3/31/22 at 9:59 a.m., the Director of Nursing (DON) indicated the person who normally put in orders was on vacation so LPN 1 was doing her job, as well as, the charge nurses job. LPN 1 accidentally put in the order for the wrong person. Orders were read daily in their morning meeting and nothing triggered that is was an error. On 3/31/22 at 10:22 a.m., LPN 1 indicated the charge nurse was on vacation and she possibly had two screens up and put it on the wrong chart. Neither resident had any adverse drug reaction from the medication. When a resident was admitted , the charge nurse entered the orders and then the unit managers would read through the nurses' notes and orders. The error was caught when the nurse went over discharge instructions with Resident B's caregiver. When he got home, he call back and had questions about the medication and realized it was an error at that time. A current facility policy, dated October 2010, titled MEDICATION ERRORS AND DRUG REACTIONS, provided by the DON on 3/31/22 at 1:56 p.m., indicated the following: Policy: 1. To safeguard the resident. 2. To identify causes and prevent future errors General Guidelines: 1. All medication, treatment errors, and drug reactions must be reported promptly. Notify the attending physician or Medical Director This Federal tag relates to complaint IN 792. 3.1-37(a)

A. Based on observation, interview, and record review, the facility failed to ensure masks were worn and handled in accordance with professional standards and hand hygiene was performed as indicated to mitigate the risk of transmission of COVID-19 during 4 of 4 random observations on the Chestnut hallway (green and yellow zones) and Redbud hallway (green zone). B. Based on observation, interview, and record review, the facility failed to ensure shared glucometers were disinfected according to facility policy for 1 of 1 observations of glucometer use on the Hickory hallway. C. Based on observation, interview, and record review, the facility failed to ensure a visitor donned PPE as indicated while in the room with a resident on transmission based precautions (TBP) for observation of COVID-19 during a 1 of 1 random observation of the Walnut hallway (Resident 288). Findings include: A. 1. During a random observation of the Chestnut hallway, on 5/3/21 at 11:33 a.m., LPN 33 donned a gown outside of a resident room. She then removed her procedure mask and placed it on top of the PPE cart. She donned an approved KN95 mask, picked up the doffed mask, and walked away to remove gloves from a different PPE cart. She had not performed hand hygiene. She discarded the mask, and then dropped the gloves when she dispensed hand sanitizer into her hands while holding the gloves. She then retrieved another pair of gloves and donned them before entering the room. She indicated, at the time of the interview, the doffed mask should not have been placed on the cart. A. 2. During a meal tray passing observation on the Chestnut hallway, on 5/3/21 at 11:34 a.m., CNA 34's procedure mask was pulled below her nose as she delivered meals to residents in their rooms. She then approached a room with a TBP sign on the door. She donned an approved KN95 mask, leaving her procedure mask pulled down to her chin underneath it. After delivering the meal and leaving the room, she doffed the KN95 mask by touching the front of the mask and placed it in a paper bag. She labeled the bag and placed it on the handrail. She did not perform hand hygiene until after she had placed the bag on the railing. During an interview, at the time of the observation, CNA 34 indicated she couldn't get her procedure mask off (from the mask securing device on the back of her head), so she just pulled it down. A. 3. During a random observation, on 5/3/21 at 3:00 p.m. on the Redbud hallway, CNA 31 was in the hallway with her mask below her nose and the nose band not bent. She had to repeatedly pull the mask up with her hand and did not perform hand hygiene afterwards. During an interview, at the time of the observation, she indicated her mask should be above her nose. A. 4. During a random observation, on 5/3/21 at 3:40 p.m., a used approved KN95 mask was laying on the medication cart keyboard. During an interview, at 3:43 p.m., LPN 33 was wearing a KN95 mask and there was now a used procedure mask on the keyboard. She indicated she had changed out of the KN95 and donned a procedure mask, then changed back to the KN95 mask. She held the procedure mask in her hands during the interview, rubbing her hands on it as she spoke. She indicated she should not have left the masks on the keyboard and would throw away the procedure mask since she had rubbed her hands on it. During an interview, on 5/3/21 at 3:44 p.m., the DON indicated the staff had been trained to wear masks with them covering both their noses and mouths. Review of the IDOH COVID-19 LTC Facility Infection Control Guidance Standard Operating Procedure, updated 5/3/21, indicated the following: .Direct care providers should wear a surgical mask for the duration of their shifts. Indirect care providers should wear a mask during their shifts. N95 (or approved KN95) masks should be worn in COVID units and with any resident who is symptomatic or awaiting testing in transmission-based precautions (red or yellow zone) Review of the Your Guide to Masks, updated 4/6/21 and retrieved from cdc.gov, indicated the following: Be sure to wash your hands or use hand sanitizer before putting on a mask. Do NOT touch the mask when wearing it. If you have to often touch/adjust your mask, it doesn't fit you properly, and you may need to find a different mask or make adjustments. Covers your nose and mouth and secure it under your chin. Fits snugly against the sides of your face B. During a random observation, on 5/3/21 at 12:07 p.m., RN 7 walked up to the medication cart with a blood glucose meter in her gloved hands, she wiped the blood glucose meter with an alcohol pad, then placed the meter on top of the medication cart, no barrier had been between the meter and the medication cart. During an interview immediately following the random observation, RN 7 indicated she used the one blood glucose meter for all residents on Hickory Hall and there was not a specific time the meter needed to remain moist for it to be disinfected. During an observation of a blood glucose being obtained, on 5/3/21 at 12:14 p.m., RN 7 placed the blood glucose meter on top of the resident's bed, and donned gloves, the resident was lying in the bed, she picked up the meter and obtained the blood sample, placed the meter back onto the resident's bed until the results were shown, picked the meter up off of the resident's bed, exited the room, walked down the hall back to the medication cart, placed the meter on top of the medication cart, doffed her gloves, performed hand hygiene, retrieved an alcohol pad from the medication cart, picked up the meter and wiped it with the alcohol pad, and placed the meter in the top drawer of the medication cart. No barrier had been used between the meter and the top of the medication cart or between the meter and where she had placed it in the top drawer of the medication cart. Review of a current facility policy, titled Glucose Meter Cleaning & Testing, with a revised date of 9/19 and provided by the Nurse Consultant on 5/7/21 at 10:22 a.m., indicated .Cleaning meter after use . Steps: 1. Perform hand hygiene. 2. Place clean paper towel, plastic cup or clean barrier on hard surface. 3. Put on gloves. 4. Obtain (2) single use germicidal wipes. 5. Wipe entire external surface of the blood glucose meter with one germicidal wipe and ensure meter stays wet for 2 minute time period .6. Place clean meter on clean paper towel, in plastic cup or on a clean barrier to store until next use C. On 5/4/21 at 10:52 a.m., Resident 288's room was observed with a contact/droplet isolation sign on the door. During a random visitor interview, on 5/4/21 at 3:18 p.m., a visitor indicated the facility asked screening questions, obtained her temperature, and then directed her and another visitor to the resident's room. She indicated they did not receive any special guidelines to follow while they was in the facility visiting. During an observation, on 5/5/21 at 1:35 p.m., Resident 288 was sitting in her recliner without a face covering. A visitor was sitting next to her, in a chair, within 3 feet. Resident 288's room contained contact/droplet isolation signs on the door and the door was entirely open. The compassionate care visitor had a surgical mask on for personal protective equipment. The visitor did not wear an N95 (respirator) or KN95 (respirator) mask, face shield, gown, or gloves. During the visitor observation, Certified Nurse's Aide (CNA) 54 stopped at the resident's door, facing the resident and her visitor, and asked the resident if she needed to use the restroom. She did not redirect the resident to wear a mask for visitation nor did she educate the visitor to don additional personal protective equipment for the isolation room. CNA 54 continued on to address a call light in another room. During an interview, on 5/5/21 at 1:41 p.m., CNA 54 indicated Resident 288's spouse was visiting with her. She indicated residents in isolation were permitted to have visitors. She did not provide any redirection for the resident nor the visitor at this time and proceeded into another resident's room. During an interview, on 5/5/21 at 1:43 p.m., Resident 288's spouse indicated he had not received any information regarding specific PPE he had to wear during visits. He indicated his strap broke on the other mask they gave him previously and he asked an unknown staff member if he could wear the surgical mask and they told him it should be okay since his glasses sat on top of the surgical mask. During an interview, on 5/5/21 at 1:49 p.m., Licensed Practical Nurse (LPN) 53 indicated compassionate care visitors were screened by temperature monitoring and a questionnaire, but she was unsure about the details of education they received and referenced the Administrator. During an interview, on 5/5/21 at 1:54 p.m., the Administrator indicated compassionate care visitors were provided personal protective equipment (PPE) education prior to beginning compassionate care visits but were not educated each compassionate care visit. He indicated compassionate care visitors are required to wear a face shield, KN95 mask, and a gown in an isolation room. He indicated all staff monitor and are required to immediately notify the Administrator if a visitor is not complying with infection control procedures for intervention. During an observation and interview after the discussion of visitor requirements, on 5/5/21 at 1:57 p.m., LPN 53 indicated a visitor of Resident 288 was not wearing appropriate PPE for isolation. Review of a Visitor Screening Tool dated 5/5/21, and provided by Receptionist 52 on 5/5/21 at 2:26 p.m., indicated Resident 288's spouse arrived for his visit with the Resident 288 on 5/5/21 at 12:50 p.m. The screening tool indicated the visitor was not fully vaccinated. Resident 288's clinical record review was completed on 5/6/21 at 3:15 p.m. Resident 288 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders included, but were not limited to a COVID evaluation daily dated 4/21/21. The clinical record indicated the resident refused the COVID-19 vaccinations on 4/21/21 and indicated the resident had not received the COVID-19 Vaccination nor been diagnosed with COVID-19 in the past 90 days. A 4/22/21 care plan indicated Resident 288 was in droplet isolation for observation of signs and symptoms of COVID-19 infection due to a recent admission to the facility. Interventions included, but were not limited to the following: the resident was in 14 days of transmission based precautions; wear personal protective equipment as designated by the facility policy; follow the building re-opening/visitation plan; educate staff, resident, family and visitors of COVID-19 signs, symptoms and precautions; and follow facility protocol for COVID-19 screening and precautions. A 5/6/21 nurse's note indicated the resident completed her fourteen days of transmission based precautions. During a random visitor screening observation, on 5/7/21 at 9:05 a.m., Screener 51 was observed asking a visitor if she knew where she was going after the screening questionnaire was completed. The visitor was not escorted to the resident's room. During an interview with Screener 51, on 5/7/21 at 9:13 a.m., she indicated visitors were permitted to go to the resident's room by themselves, after they screened, if the resident was in a private room. She indicated this process was the same regardless of the visitor's COVID-19 vaccination status. During an interview, on 5/7/21 at 1:39 p.m., LPN 55 indicated neither Resident 288 nor her spouse were vaccinated for COVID-19. During an interview, on 5/7/21 at 1:56 p.m., the Administrator indicated he met with Resident 288's spouse on 4/20/21 to provide compassionate care visitor education. A copy of the compassionate care packet, provided by the Administrator on 5/7/21 at 1:56 p.m., and indicated each visitor must wear a mask while in the facility. It lacked mask detail for residents in Transmission Based Precautions and did not contain a date or acknowledgement signature. He indicated the facility could not ensure a visitor had donned proper PPE when they entered the resident's room without an escort, but they had the expectation that visitors followed the education they were provided in the original meeting before they started the compassionate care visits. He indicated the facility followed the Indiana State Department of Health guidelines. Review of a current facility policy, titled TRANSMISSION-BASED PRECAUTIONS (TBP's), dated 10/25/20 and provided by the Nurse Consultant on 5/7/21 at 10:22 a.m., indicated .2. Contact Precautions . Gloves and Handwashing: * .wear gloves (clean, non-sterile) when entering the room .Gown *Wear a disposable gown upon entering the Contact Precautions room or cubicle .3. Droplet Precautions .Masks/Eyewear * .mask and eyewear is universal when providing direct resident care A current Indiana State Department of Health document, titled Long-term Care Facilities Guidelines in Response to COVID- 19 Vaccination, provided by the Administrator on 5/7/21 at 1:56 p.m., indicated the following: .New Admissions or Readmissions: CDC recommends managing the unknown COVID-19 status for all new admission or readmissions to the facility Unknown COVID-19 Status: .All recommended PPE should be worn during care of newly admitted or readmitted resident under observation for unknown COVID status; .CORE PRINCIPLES OF INFECTION PREVENTION .As long-term care facilities move to a reopened phase in resident care, it is expected that COVID-19 infection prevention and control core principles be always adhered to and remain in place as long as the virus is present in epidemic levels. Facilities should be mindful of the core principles of infection prevention for COVID-19 when implementing visitation or conducting any activity for the residents: .VISITATION .Visitors: Visitors should be able to adhere to the core principles. Visitors that do not adhere to the core principles should be asked to leave the facility If resident or visitor is not fully vaccinated, ideally both should wear masks and physically distance . 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure narcotics were signed off as given after the medication was removed from the narcotic box for 2 of 3 narcotic administration observations. Findings include: 1. On 5/6/21 at 11:11 a.m., LPN 41 set up and administered [MEDICATION(S)] (narcotic pain reliever) 7.5 -325 (mg) milligram to a resident and she indicated her narcotic count binder was located at the nurses station, after she passed her meds, she recounted the medications in the narcotic drawer. At 11:48 a.m. LPN 41 retrieved the narcotic count binder from the nurses station. She signed off the [MEDICATION(S)] 7.5 - 325 mg that was administered at 11:11 a.m. and signed off narcotic medications that were administered at 8:00 a.m. that included, [MEDICATION(S)] (nerve pain reliever) 50 mg, [MEDICATION(S)] (anticonvulsant) 100 mg and a [MEDICATION(S)] (narcotic pain reliever) 50 mcg/hr (microgram/hour) patch. 2. On 5/6/21 at 11:55 a.m. RN 47 set up and administered [MEDICATION(S)] 5 -325 mg to a resident. RN 47 indicated she signed off her narcotics in the narcotic count binder at the end of her medication pass. A 10/17 revised policy, titled Controlled Substances, provided by the DON on 5/6/21 at 4:04 p.m., indicated the following: Policy: It is the policy of this facility to store, administer, verify, and destroy controlled substances in accordance with Federal, State, and Local laws .General Considerations: .5. When a controlled substance is not in the dispensing unit, a controlled substance count record will be maintained and the nurse/QMA (where applicable) will sign on the record when removing the medication for administration 3.1-25(e)3

Based on observation and interview, the facility failed to ensure heavy wooden doors were not held open in a potentially hazardous manner for two random observations on the Redbud hallway. Findings include: 1. During a random observation, on 5/3/21 at 2:55 p.m., the shower room door on the Redbud hallway was held open with a shower curtain (hanging from the interior ceiling) wrapped around the handle. The door had a keypad lock on the front of it. During an interview on 5/3/21 at 3:00 p.m., CNA 31 indicated the door was not to be held open with the curtain. Residents 67 and 11 were sitting in their doorways at the time of the observation; Resident 67 was propelling himself in and out of his room. 2. During a random observation, on 5/4/21 at 9:55 a.m., the shower room door on the Redbud hallway was held open with the shower curtain wrapped around the handle. During an interview on 5/3/21 at 9:57 a.m., CNA 32 indicated the door should be kept closed. 3.1-19(f)(5)

Based on interview and record review the facility failed to initiate transmission based precautions (TBP) for 23 residents who had the potential for exposure after a CNA (Certified Nursing Assistant) student tested positive for COVID-19. (CNA student 1) Findings include: On 11-13-2020 at 12:45 p.m., the COVID-19 staff testing and results were reviewed. The documentation indicated on 10-29-2020, CNA student 1 was tested for COVID-19. Review of facility contact tracing on 11/13/2020 at 1:00 p.m., indicated CNA student 1 was in the facility 10/26-10/29/2020. The CNA student left the faciity on [DATE] at 10:00 a.m. due to not feeling well. The documentation indicated the CNA student had been in close contact with four staff members and five residents. Review of the facility census indicated 23 residents lived on the unit CNA student 1 was working on 10/26 through 10/29/2020. During an interview on 11-13-2020 at 1:00 p.m., the Director of Nursing (DON) indicated the residents, who received care from CNA student 1, were not placed in TBP after the facility became aware of CNA student 1's positive test results. The DON indicated all residents have been routinely monitored and tested twice weekly as part of the routine outbreak testing. All test results have been negative. Review of a Center for Disease Control and Prevention (CDC) update, dated 10/22/2020, defined close contact as Someone who was within 6 feet of an infected person for a total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated. Review of a CDC COVID-19 update for contact tracing, dated 10-22-2020, indicated the following: Residents who are part of contact tracing in the facility exposed by HCP (Health Care Provider) who test positive either symptomatic or asymptomatic, designated by being a close contact with > 15 min cumulative exposure over 24 hours (HCP masked or unmasked) are considered exposed residents and are placed in TBP and facility begins outbreak testing. 3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to provide services to prevent the development and/or worsening of a pressure ulcer for 2 of 3 residents reviewed skin wounds (Resident B and C). This deficient practice resulted in debridement, osteo[DIAGNOSES REDACTED] and amputation (Resident B) debridement, osteo[DIAGNOSES REDACTED] and negative-pressure wound therapy (Resident C). Findings include: 1. The clinical record for Resident B was reviewed on 6/12/19 at 11:24 a.m. [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment, dated 4/24/19, indicated he was at risk for pressure ulcers, but had none on admission. The resident was cognitively intact and required two-person assistance with bed mobility, transfer, dressing and hygiene. The discharge MDS assessment, dated 6/7/19, indicated the resident had an unstageable pressure ulcer that was not present on admission to the facility. A current health care plan, dated 4/19/19, indicated the resident was at risk for developing pressure ulcers related extensive to total assistance for bed mobility and/or transfers. Interventions included, but were not limited to, assist in turning and repositioning at least every two hours and more frequently as needed and weekly skin checks. On 6/12/19, the interventions included encourage to off-load the right heel. Another health care plan, dated 5/2/19, indicated the resident had impaired skin integrity to the right lower extremity as evidenced by an unstageable area to the right heel. Interventions included, but were not limited to, heel lift positioning device and a low air loss mattress. A health care plan, dated 5/2/19, indicated the resident had a Deep Tissue Injury (DTI) on the left heel. Interventions included, but were not limited to, heel lift positioning device and a low air loss mattress. On 6/12/19, a new health care plan indicated the resident had behavioral symptoms that included non-compliance and resistance with care and/or treatments. Interventions included, but were not limited to, encourage to reposition, redirect behavior when resisting care and re-approach at a later time. An admission evaluation, dated 4/17/19, indicated a head to toe skin assessment was completed and the resident did not have any pressure injuries or other skin conditions. The skin was pink and intact. He had both right and left lower leg [MEDICAL CONDITION]. A Braden scale (predicting pressure ulcer risk), dated 4/17/19, indicated the resident was chair-fast with very limited mobility. He required moderate to maximum assistance in moving. The resident scored a 13, which indicated he was at moderate risk for developing a pressure ulcer. A physician visit, dated 4/18/19, indicated the resident was admitted for rehabilitation. He had bilateral swelling in the lower extremities. The plan included to continue [MEDICATION NAME] (diuretic). A physician visit, dated 4/18/19, indicated the resident had complained of worsening [MEDICAL CONDITION] to his bilateral feet and legs. The plan included to increase [MEDICATION NAME] for three days and start Ace wraps (compression bandages). A physicians order, dated 4/22/19, indicated to apply Ace wraps to bilateral lower extremities early in the morning and remove at bedtime. A physician visit, dated 4/29/19, indicated the resident had newly developed bilateral heel wounds. The nursing staff reported the resident developed blisters. The assessment indicated the wounds appeared to be a DTI with discolored skin. The plan included to start [MEDICATION NAME] (barrier cream) weekly. The heels were to be wrapped with and abdominal gauze pad then covered with a light compression wrap. The heels were to be placed in protective boots and to off-load the heels at all times. A physicians order, dated 4/29/19, indicated to cleanse wound with cleanser, apply abdominal gauze pad and wrap with Kerlix (gauze). The dressing was to be changed twice daily. A skin and wound evaluation, dated 4/30/19, indicated the resident had a stage 2 pressure area to the left heel that measured 2.9 cm x 3.5 cm. The right heel also had a stage 2 pressure area that measured 3.5 cm x 4.1 cm. A skin and wound evaluation, dated 5/8/19, indicated the resident had a stage 2 pressure area to the left heel that measured 2.6 cm x 4.8 cm. The right heel also had a stage 2 pressure area that measured 2.4 cm x 5.5 cm. A skin and wound evaluation, dated 5/15/19, indicated the resident had a stage 2 pressure area to the left heel that measured 3.6 cm x 5.1 cm. The right heel also had a stage 2 pressure area that measured 2.4 cm x 4.4 cm. A physician visit, dated 5/17/19, indicated the resident had bilateral DTI heels with black, necrotic, nonviable tissue. The left heel was open and draining and would require sharp debridement. The plan included to discontinue [MEDICATION NAME] and cover each heel with [MEDICATION NAME] (antiseptic) and off-load heels at all times. A skin and wound evaluation, dated 5/21/19, indicated the resident had a stage 2 pressure area to the left heel that measured 3.9 cm x 6.6 cm. The right heel also had a stage 2 pressure area that measured 1.9 cm x 4.5 cm. A skin and wound evaluation, dated 5/22/19, indicated the resident had a stage 2 pressure area to the left heel that measured 7.2 cm x 5.3 cm. The right heel also had a stage 2 pressure area that measured 3.8 cm x 1.9 cm. A physician visit, dated 5/22/19, indicated the resident had bilateral DTI heels with black, necrotic, nonviable tissue. The left heel was open and draining and the right heel had hard, black necrotic tissue with soft edges. The plan indicated Bilateral Stage 3 pressure injuries / Deep tissue injury- requiring sharp debridement .left heel measuring 7.2 cm x 5.2 cm x 0.2 cm, right heel measuring 4.4 cm x 1.9 cm x 0.2 cm .continue dakins (strong antiseptic) .final depth of the bilateral heels currently undetermined A physicians order, dated 5/22/19, indicated to apply Dakins solution to gauze and place on the black part of the wound twice daily. A skin and wound evaluation, dated 5/29/19, indicated the resident had a stage 2 pressure area to the left heel that measured 4.1 cm x 3.3 cm. The right heel also had a stage 2 pressure area that measured 2.2 cm x 2.3 cm. A skin and wound evaluation, dated 6/6/19, indicated the resident had an unstageable pressure area to the left heel that measured 7.0 cm x 4.2 cm. The right heel also had an unstageable pressure area that measured 3.3 cm x 3.0 cm. On 6/6/19, a runoff peripheral CT [MEDICATION NAME] (CTA) was performed to evaluate the lower limb vessels. The test indicated mild to moderate [MEDICAL CONDITION] disease throughout both lower extremities. A skin and wound evaluation, dated 6/7/19, indicated the resident had an unstageable pressure area to the left heel that measured 5.9 cm x 4.2 cm. The wound had a depth of 0.4 cm and 0.6 cm of tunneling (channels that extend into and through subcutaneous tissue). The clinical record lacked documentation of resident refusals or non-compliance for the time period prior to the development of the wounds. A physician visit, dated 6/7/19, indicated the resident was seen for foul odor from the left heel with increased drainage and a new area noted on the left plantar surface, midfoot. The plan included to send the resident to the emergency room for evaluation with possible Intravenous (IV) antibiotics and orthopaedic consult. An emergency room (ER) visit, dated 6/7/19, indicated the resident had bilateral lower extremity ulcers and abscesses on plantar surface of feet and heel. The left heel had a deep ulcer with tunneling and the right heel had an area of black. Both feet had a foul smell associated with them. A hospital progress note, dated 6/7/19, indicated the resident was admitted with various stages of wounds with necrotic, open, complex and purulent drainage. An orthopedic surgical team indicated a preliminary microbiology report of the left wound showed heavy growth of Gram-negative rods. A Gram stain showed moderate Gram-positive cocci (bacteria). The surgical team indicated the need for a below knee surgical amputation was very high. The resident was initially resistive to care, but consented to the surgery on 6/10/19. A orthopedic surgery consult, dated 6/7/19, indicated a left heel pressure ulcer with exposed calcaneus (bone in the heel) and left midfoot abscess. The physician indicated antibiotics and dressing changes would not heal the wound and an amputation was the only definitive solution. On 6/10/19, an Ankle-Brachial Index (ABI) indicated vessel hardening related to [MEDICAL CONDITIONS]. The resident underwent [REDACTED]. A post-operative note, dated 6/11/19, indicated calcaneal osteo[DIAGNOSES REDACTED], multiple wounds the the left foot with necrotic edges, [MEDICAL CONDITION] and [MEDICAL CONDITION]. During an interview on 6/12/19 at 1:58 p.m. the DON indicated they hired a new wound nurse 4/9/19. She indicated Resident B was at the hospital for a possible amputation related to diabetes and non-compliance. He was non-compliant in general. She was not able to find a care plan for the non-compliance, but staff were floating his heels the whole time. She did not know how staff missed the wounds 2. During an observation with the Director of Nursing (DON) on 6/12/19 at 2:18 p.m., Resident C was on a low air loss mattress and had a wound vac in place. The DON asked if she could look at the wound vac and the resident agreed. She rolled the resident onto her right side and the dressing was dated 6/12/19. During a second observation with the wound nurse on 6/12/19 at 2:50 p.m., the resident again was rolled onto her right side. The wound nurse indicated she only needed to reinforce the dressing because it was difficult to keep the seal since it was located on the intergluteal cleft. The clinical record for Resident C was reviewed on 6/12/19 3:05 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 5/26/19, indicated the resident had moderate cognitive impairment. She required two-person assistance for bed mobility. She was admitted to the facility with one unstageable pressure ulcer on the coccyx. A current health care plan, dated 2/26/19, indicated the resident had an unstageable pressure ulcer to the sacrum. Intervention included, but were not limited to, cushion to wheelchair, assist with incontinence care and dietary supplements. An alternating pressure relief mattress was added 3/8/19. An admission evaluation report, dated 2/16/19, indicated a head to toe assessment was completed. The resident had a skin condition and a medical device in place that may contribute to a pressure area. An initial non-pressure skin report, dated 2/16/19, indicated the resident had a rash on the coccyx area that was open, red and had some drainage. A physicians order, dated 2/16/19, indicated to apply white [MEDICATION NAME] ointment to the coccyx every shift for redness. A skin and wound evaluation, dated 2/16/19, indicated the resident was admitted with moisture associated skin damage on the sacrum. A Braden scale, dated 2/16/19, indicated the resident was bed-fast and slightly limited on mobility. She scored a 15, which indicated she was at risk for developing a pressure ulcer. A physician visit, dated 2/18/19, indicated the resident was admitted after a surgical repair for a fractured femur. A skin and wound evaluation, dated 2/22/19, indicated the resident was admitted with a stage 3 pressure ulcer to the sacrum. The wound measured 5.2 cm x 1.8 cm x 0.2 cm. A physicians order, dated 2/22/19, indicated to apply Santyl (enzymatic [MEDICATION NAME] ointment) daily to the wound. An initial pressure ulcer report, dated 3/4/19, indicated the resident was admitted with a pressure ulcer to the sacral area. The area measured 3.0 cm x 2.0 cm x 0.2 cm and was unstageable. A physicians order, dated 3/8/19, indicated to only apply the white [MEDICATION NAME] ointment to the gluteal and groin area, not the coccyx area. A skin and wound evaluation, dated 3/12/19, indicated a stage 3 pressure area that measured 1.4 cm x 0.7 cm. A physicians order, dated 3/15/19, indicated to apply Dakins solution twice daily to the wound. A skin and wound evaluation, dated 3/18/19, indicated the resident had an unstageable pressure ulcer that measured 2.0 cm x 1.3 cm x 1.9 cm with 0.8 cm of tunneling. A skin and wound evaluation, dated 3/25/19, indicated the resident had an unstageable pressure ulcer that measured 2.3 cm x 1.4 cm x 1.2 cm with 0.8 cm of tunneling. A skin and wound evaluation, dated 4/12/19, indicated the resident had an unstageable pressure ulcer that measured 1.3 cm x 1.2 cm x 0.1 cm with 0.1 cm of tunneling. A skin and wound evaluation, dated 4/18/19, indicated the resident had an unstageable pressure ulcer that measured 2.1 cm x 1.3 cm x 1.0 cm with 0.5 cm of tunneling. A skin and wound evaluation, dated 4/26/19, indicated the resident had an unstageable pressure ulcer that measured 1.3 cm x 0.9 cm x 1.0 cm with 0.5 cm of tunneling. A skin and wound evaluation, dated 5/2/19, indicated the resident had an unstageable pressure ulcer that measured 2.0 cm x 1.3 cm x 1.9 cm with 0.8 cm of tunneling. A physician visit, dated 5/3/19, indicated the resident was seen for worsening of the sacral wound. The wound measured 1.9 cm x 1.2 cm x 0.8 cm with 0.3 cm of tunneling. A skin and wound evaluation, dated 5/10/19, indicated the resident had an unstageable pressure ulcer that measured 2.1 cm x 2.0 cm x 0.4 cm with no tunneling. A physicians order, dated 5/14/19, indicated to [MEDICATION NAME] to bilateral buttocks twice weekly. A skin and wound evaluation, dated 5/16/19, indicated the resident had an unstageable pressure ulcer that measured 2.7 cm x 1.9 cm x 1.0 cm with no tunneling. A physician visit, dated 5/17/19, indicated the resident was seen for a 90-day visit and newly developed pressure injuries to the buttocks. The assessment indicated a stage 3 sacral pressure injury. She recently underwent sharp debridement. The order indicated to continue Endoform (collagen dressing) to wound bed and cover with a moist gauze. The dressing was to be changed every other day and as needed. The resident was to be turned and repositioned every 3 hours. The resident was also noted to have bilateral DTI to the buttocks. The order indicated to apply Calvilon twice weekly, turn and reposition every 3 hours. She would also need an alternating air mattress for pressure reduction. A skin and wound evaluation, dated 5/21/19, indicated the resident had an unstageable pressure ulcer that measured 2.7 cm x 2.2 cm x 1.2 cm with no tunneling. A physician visit, dated 5/22/19, indicated the resident was seen for worsening of a sacral pressure ulcer. The wound was black, necrotic tissue with yellow slough (dead tissue), moderate drainage and foul odor. The wound measured 3.0 cm x 2.6 cm and 3.2 cm of tunneling. The order included an abdominal Computerized [NAME]ography (CT) scan with contrast to determine final depth of the wound. A skin and wound evaluation, dated 5/29/19, indicated the resident had an unstageable pressure ulcer that measured 3.5 cm x 2.8 cm x 3.6 cm with no tunneling. A physician visit, dated 5/29/19, indicated the CT scan showed possible osteo[DIAGNOSES REDACTED]. A new order was received on 5/29/19 to start [MEDICATION NAME] (to treat bacterial infections) 600 mg three times daily for 14 days related to osteo[DIAGNOSES REDACTED]. A skin and wound evaluation, dated 6/9/19, indicated the resident had an unstageable pressure ulcer that measured 3.2 cm x 4.0 cm x 2.4 cm with no tunneling. A physicians order, dated 6/11/19, indicated to apply negative-pressure wound therapy at 125 mm/Hg and change every Monday, Wednesday and Friday. Review of a facility policy, dated 9/2017, titled,Skin Integrity and Pressure Injury was provided by the DON on 6/13/19 at 1:17 p.m. The policy indicated the following: Policy: It is the policy of this facility to provide care that is consistent with professional standards of practice to prevent pressure injuries and does not develop pressure injuries unless the individual's condition demonstrates that they were unaviodable .2. Any skin condition will be documented on admission 4. Full body skin assessments will be completed weekly and documented on all residents. .7. A daily observation of the wound will be completed by a licensed nurse for any open wound or skin condition requiring a dressing change. .17. The licensed nurse is responsible for notifying the physician of changes in the wound condition. .Pressure prevention: 1. Interventions will be initiated based on the resident's risk 6. Staff will assist and/or remind the resident to reposition and turn at least every 2 hours or more frequently depending on the resident risk and skin issues. .10. Float heels when in bed . 11. Observe for [MEDICAL CONDITION] or swelling This Federal tag relates to Complaint IN 959. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure room trays were distributed in a manner to protect the food from contamination for 3 of 4 halls observed (Redbud, Chestnut and Walnut halls) and for 14 of 18 residents observed receiving room trays (Resident 32, 17, 23, 12, 35, 2, 299, 75, 93, 61 42, 4, 198, and 300), and to ensure the food processor was sanitized following manufacturer's instruction during a puree meal preparation for 1 of 2 observations. (Cook 3) Findings include: 1. On 5/10/19 from 10:30 a.m. to 12:08 p.m., in the kitchen, the following was observed: a. After the food temperatures were completed, Cook 3 began to prepare the room meal trays for the halls. These room trays were observed to be placed in the meal carts without covers on the drinks, condiment containers (tartar sauce), or desserts. Upon completion of the room tray carts, they were transported to the hallways. b. At 11:38 a.m. the room tray cart was transported to Chestnut hall. CNA 4 was observed to start passing meal trays. As CNA 4 pulled Resident 32's meal tray from the cart, the plate cover came off. The Dietary Manager (DM) present at this time instructed CNA 4 to go ahead and deliver the resident's meal tray without the plate cover to her room, which was carried through the hallway to the resident's room. At this same time during an interview the DM indicated some of the plate covers had warped from the dishwasher and did not fit the plate well. c. Next, Resident 17, 23, 12, 35, 2, 299, and 75 meal trays were observed to be removed from cart with uncovered drinks, condiments and desserts and carried down the hallway to their rooms and were distributed by CNA 8, CNA 5, and CNA 4. d. At 11:56 a.m. the room tray cart was moved to Hickory Lane and then to Redbud hallway. Room trays were again observed to be carried down the hallway with uncovered drinks, condiment, and desserts. This observation included CNA 6 to pass a meal tray with a dish of uncovered cottage cheese also to Resident 93, and CNA 5 to Resident 61 and to Resident 42, and CNA 5 to Resident 4,198, and 300. Room carts were completed for these halls at 12:08 p.m. During an interview on 5/12/19 at 12:03 p.m., the DM indicated the room meal trays should not be taken uncovered down the hallway, especially 4 room doors away from the meal cart. The Meal Service to Dining Rooms or Resident Rooms policy was provided by the DM on 5/10/19 at 3:34 p.m. This current policy indicated the following: Policy Dining service to residents will be provided in an efficient manner, using standard sanitary procedures and providing residents with the assistance and attention they need to enjoy their meal. .Procedure .7. All food, dishware and utensils transported through hallways or common areas shall be covered or enclosed to protect from contamination 2. On 5/12/19 from 10:20 a.m. to 11:00 a.m. the pureed process was observed. Cook 3 indicated she would puree 10 servings although she had 8 residents presently who received a pureed diet. After completing the macaroni and cheese puree process, Cook 3 took the food processor to the 3 compartment sink. After rinsing out, washing and rinsing the food processor, Cook 3 was observed to put the food processor in the sanitizing sink and with her hand splashed the exposed side of the food processor with the sink contents, removed the food processor, and then, placed it on the drying rack. After she obtained the broccoli for the next puree process, she obtained the drained food processor from this drying rack and completed the puree process placing the pureed broccoli in a pan returning it to the steamer. On 5/12/19 at 11:00 a.m., during an interview Cook 3 indicated the food processor needed to be in the sanitizing solution of the 3 compartment sink for 30 seconds. On 5/14/19 at 10:26 a.m., during an interview the DM indicated the food processor should had been immersed for 1 minute in the sanitizing solution of the 3 compartment sink per information received regarding the ARRAY (Array Concentrated Ultimate Quaternary Sanitizer) solution used. The ARRAY information was provided by the DM on 5/14/19 at 10:26 a.m. This information included the following: .MAKING SURE TO IMMERSE THE WARE FOR AT LEAST 60 SECONDS 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to adequately monitor and assess pressure ulcers for 2 of 4 residents reviewed for pressure ulcers (Residents 77 and 93). Findings include: 1. On 5/8/19 at 10:08 a.m., Resident 77 was lying on her back in bed, an air mattress was on the bed, the head of the bed was elevated 30 degrees. On 5/10/19 at 9:46 a.m., the resident was sitting, in a Broda chair (a tilt-in-space positioning chair), in her room with her feet resting on the foot-rest. On 5/10/19 at 10:35 a.m., she was sitting in the Broda chair in her room with her eyes closed. On 5/10/19 at 2:22 p.m., the resident was lying in bed on her back, the air mattress was on the bed, the head of the bed was elevated 30 degrees. Resident 77's clinical record was reviewed on 5/13/19 at 3:08 p.m. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. A 4/19/19, quarterly, Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment. She required extensive assistance with bed mobility, dressing, locomotion, and eating, did not walk, and was totally dependent with transfers, toilet use, and personal hygiene. She had a stage 1 or greater, a scar over a bony prominence, or a non-removable dressing/device, and was at risk of developing pressure ulcers. She had a current careplan for the following: A 1/30/17 careplan for being at risk for developing pressure ulcers. Interventions included, but were not limited to, rest on a special support surface, have a cushion in my chair, a device or staff will assist me with turning and repositioning as needed, and you will observe my skin weekly and as needed. Review of Progress Notes and Assessments indicated the following: On 4/6/19 at 9:30 p.m., an open area to her coccyx was noted, a reddened area that measured 3.0 centimeters (cm) in length and 3.8 cm in width, and the open area measured 1.1 cm in length, 0.8 cm in width, and 0.1 cm in depth. The resident's daughter was notified. The Nurse Practitioner (NP) was notified, and new orders to cleanse area with wound cleanser, allow to dry, apply skin-prep, allow to dry, cover with foam dressing. During an interview, on 5/13/19 at 3:57 p.m., the Director of Nursing (DON) indicated she was not aware of the wound to the resident's sacrum. A wound observation, on 5/13/19 at 4:05 p.m., accompanied by the Wound Nurse and MDS Nurse 2, indicated the following: Resident 77 was laying in bed on her back, the Wound Nurse asked permission for us to look at her bottom, the resident agreed and indicated she was having pain back there. The Wound Nurse removed a foam dressing dated 5/12, there was an open area on her sacrum that was approximately the size of a pencil eraser. The Wound Nurse indicated she had not been notified of this area. A Skin and Wound Evaluation assessment, dated 5/13/19 at 4:20 p.m., indicated a Stage 2 pressure ulcer to the sacrum that measured 0.9 cm in length and 0.8 cm in width. 2. During an interview, on 5/9/19 at 9:28 a.m., Resident 93 indicated he had a sore on his buttocks, he thought this had been caused from him staying on his back too much. Resident 93's clinical record was reviewed on 5/13/19 at 9:00 a.m. He had admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. A 4/5/19, admission, MDS assessment indicated the resident was cognitively intact. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, did not walk, required limited assistance with locomotion on and off the unit, and supervision with eating. He had two Stage 1 pressure ulcers and was at risk for the development of pressure ulcers. He had current careplans for the following: A 3/31/19 careplan for at risk for developing pressure ulcers. Interventions included, but were not limited to, you will observe my skin weekly and as needed. A 3/29/19 careplan, with a revision date of 5/9/19, for an unstageable pressure ulcer (extent of skin damage unable to be confirmed because it is obscured by slough or eschar) on my sacrum related to skin failure and protein malnutrition. Interventions included, dietary supplements as indicated, provide extra protein in diet, initiate my pain careplan interventions, and my labs will be obtained as ordered. Review of Progress Notes and Assessments indicated the following: An Initial Pressure Ulcer Report, with an effective date of 3/29/19 and a signed date of 5/9/19, indicated an unstageable pressure ulcer to his sacrum was present on admission, had measured 2.8 cm in length and 3.4 cm in width, the wound bed was covered with 100% slough (dead tissue). The clinical record lacked Skin and Wound Evaluations until 4/15/19. A Skin and Wound Evaluation, dated 4/15/19, indicated an unstageable pressure ulcer, present on admission, 100% of wound bed covered by slough, wound progress was listed as new. During an interview, on 5/14/19 at 9:30 a.m., the DON indicated on 4/5/19 and 4/10/19 the facility had documented the wound information on a progress note instead of on the assessment. The DON provided two progress notes that had updated wound information, one with an effective date of 4/5/19 and the other with an effective date of 4/10/19, both had a created date of 5/9/19. Review of a current facility policy, titled PCC Wound Documentation Protocol, dated 11/2018 and provided by the Nurse Consultant on 5/13/19 at 4:17 p.m., indicated the facility wound nurse/designee would address each area using the skin and wound application weekly (no later than every 7 days) until resolved. When a wound is found after admission the nurse finding the wound will complete an initial pressure or non-pressure report or assessment using the skin and wound application. The wound nurse/designee will follow up on the report within 24 hours of the observation on Monday - Thursday and within 72 hours when observed on Friday - Sunday. 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to assess and evaluate a resident for self-administration of a nebulizer treatment for 2 of 2 residents observed receiving nebulizer treatments. (Resident 23 and 73) Findings include: 1. On 5/13/19 at 4:23 p.m., Resident 23 was observed sitting on the side of the bed receiving a nebulizer treatment. No staff was present in the room or hallway. At 4:37 p.m. RN 1 entered the resident's room and stopped the nebulizer treatment. On 5/13/19 at 4:56 p.m., the Administrator indicated she did not have any information for an assessment or evaluation regarding self medication administration for Resident 23. On 5/13/19 at 4:58 p.m., during an interview RN 1 indicated she was unaware of any assessment or evaluation for self medication administration for the resident and this resident would frequently take the treatment on her own. Resident 23's clinical record was reviewed on 5/10/19 at 9:53 a.m. The resident's [DIAGNOSES REDACTED]. The physician order, dated 1/14/19, was [MEDICATION NAME] Solution 0.5-2.5 (3) mg (milligram) per 3 ml (milliliter) ([MEDICATION NAME]-[MEDICATION NAME]) (assist to open airways) 3 ml inhale orally 3 times a day for [MEDICAL CONDITION]. The clinical record lacked an order or assessment for medication self administration. 2. On 5/13/19 at 4:38 p.m., Resident 73 was observed in his room, sitting in his recliner, holding a hand held nebulizer to his lips. At 4:41 p.m. RN 72 walked into the resident's room and turned off the nebulizer. Resident 73's clinical record was reviewed on 5/10/19 at 11:54 a.m. [DIAGNOSES REDACTED]. His medications included, but were not limited to, [MEDICATION NAME]-[MEDICATION NAME] solution inhale orally four times a day for shortness of breath, administered by clinician. The clinical record lacked an order or assessment for medication self administration. During an interview with RN 72, on 5/13/19 at 4:42 p.m., she indicated the resident did not have a self administration order and she was trying to do an admission at the same time as the breathing treatment. The SELF-ADMINISTRATION OF MEDICATION policy, dated 3/2012 and revised on 2/2018, was provided by the Nursing Consultant on 5/14/19 at 2:14 p.m. This current policy indicated the following: Purpose: To establish guidelines concerning the self-administration of drugs. General Guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician. 2. Should the resident's attending physician permit the resident to administer his/her medication(s), the following condition should apply: a. A self-administration of medications assessment will be competed that indicates the the resident is capable of self-administering drugs 3.1-11(a)

Based on observation, record review, and interview, the facility failed to correctly code the MDS (Minimum Data Set) Assessments for 3 of 26 residents whose MDS assessments were reviewed (Resident 93, Resident 13 and 30). Findings include: 1. Resident 93's clinical record was reviewed on 5/13/19 at 9:00 a.m. He had admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. A 4/5/19, admission, MDS assessment indicated the resident was cognitively intact. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, did not walk, required limited assistance with locomotion on and off the unit, and supervision with eating. He had two Stage 1 pressure ulcers and was at risk for the development of pressure ulcers. He had a current careplan for the following: A 3/29/19 careplan, with a revision date of 5/9/19, for an unstageable pressure ulcer (extent of skin damage unable to be confirmed because it is obscured by slough or eschar) on my sacrum related to skin failure and protein malnutrition. Interventions included, dietary supplements as indicated, provide extra protein in diet, initiate my pain careplan interventions, and my labs will be obtained as ordered. Review of Progress Notes and Assessments indicated the following: An Initial Pressure Ulcer Report, with an effective date of 3/29/19 and a signed date of 5/9/19, indicated an unstageable pressure ulcer to his sacrum was present on admission, had measured 2.8 cm in length and 3.4 cm in width, the wound bed was covered with 100% slough (dead tissue). During an interview, on 5/13/19 at 3:42 p.m., the MDS Coordinator indicated she had coded Resident 93 as having had two Stage 1 pressure ulcers. She indicated she gathered her information from the admitting orders, physical assessment that the nurses do, and the hospital discharge summary. 2. Resident 13's clinical record was reviewed, on 5/13/19 at 10:55 a.m. [DIAGNOSES REDACTED]. A current physician orders [REDACTED]. A quarterly, MDS assessment, dated 5/6/19, did not indicate the resident received [MEDICAL TREATMENT] while a resident at the facility. A focus care plan revised, on 4/26/18, indicated the resident had end stage kidney disease and she required [MEDICAL TREATMENT]. During an interview with the MDS Coordinator, on 5/13/19 at 3:23 p.m., she indicated the resident received [MEDICAL TREATMENT] and it should have been marked on the MDS assessment. 3. Resident 30's clinical record was reviewed, on 5/13/19 at 8:55 a.m. [DIAGNOSES REDACTED]. Her physicians order indicated she was to have an alarm when up in her wheelchair and in the chairs in her room. An annual MDS, dated [DATE], did not indicate the resident used a chair alarm. An intervention for a fall care plan revised, on 1/11/19, indicated a chair alarm was to be used to remind the resident that she should ask for staff assistance with transfers. During an interview with the MDS Coordinator, on 5/13/19 at 3:24 p.m., she indicated the resident used a chair alarm and it should have been marked on the MDS assessment. On 5/14/19 at 4:36 p.m., the DON indicated they did not have a policy for MDS assessments, they refer to the Resident Assessment Instrument (RAI) manual. 3.1-31(d)

Based on observation, record review and interview, the facility failed to ensure careplan interventions were implemented for protective sleeves and wound care for 2 of 5 residents reviewed for skin conditions (Residents 46 and 14). Findings include: 1. On 5/8/19 at 10:23 a.m., Resident 46 was observed in bed, he had a dressing on his left forearm and he was not wearing geri-sleeves (protective sleeves) on his arms. On 5/13/19 at 11:30 a.m., the resident was in his wheelchair, he had a dressing on his left forearm and he was not wearing geri-sleeves. The clinical record was reviewed, on 5/13/19 at 11:31 a.m. [DIAGNOSES REDACTED]. The current physician orders [REDACTED]. A quarterly, Minimum Data Set (MDS) assessment, dated 4/3/19, indicated the resident was severely cognitively impaired. He required extensive assistance of two staff members for bed mobility, transfers, dressing and personal hygiene. A focused care plan, dated 4/15/19, indicated he had a skin tear to his left forearm related to fragile skin. Interventions included, but were not limited to, his arms were to have protective covering on them. During an interview with LPN 71, on 5/13/19 at 12:25 p.m., she indicated the resident was to wear arm sleeves. 2. On 5/10/19 at 11:24 a.m., Resident 14 was sitting in a wheelchair in the hallway. On 5/10/19 at 2:19 p.m., the resident was sitting in the wheelchair in her room in front of the closed bathroom door. The Resident Matrix, provided by the DON on 5/8/19 at 3:24 p.m., indicated the resident had a pressure ulcer. Resident 14's clinical record was reviewed on 5/10/19 at 2:53 p.m. Her [DIAGNOSES REDACTED]. She had current orders for, but not limited to, clean right ischial with wound cleanser, allow to dry, apply skin-prep surrounding wound, apply barrier cream and cover with foam dressing. every evening shift every 3 days, start date 5/9/19. A 2/24/19, quarterly, Minimum Data Set (MDS) assessment indicated she had severe cognitive impairment. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene, and limited assistance with eating. She had a stage one or greater, a scar over a bony prominence, or a non-removable dressing/device and was at risk for the development of pressure ulcers. The clinical record lacked a careplan regarding the wound to her right ischial area. On 5/14/19 at 2:34 p.m., the ADON and Nurse Consultant indicated there was not a careplan for the area. Review of a current facility policy, titled CARE PLANNING, dated 12/2018 and provided by the DON on 5/14/19 at 4:35 p.m., indicated the careplans would be updated with any changes in the resident orders, care, or services that change the plan of care. 3.1-35(a)(b)(1)

Based on observation, record review and interview, the facility failed to ensure medications were securely stored, medications were properly labeled and expired medications were discarded for 1 of 9 medication carts. (Red Bud hall) Findings include: 1. On 5/10/19 at 2:29 p.m., the medication cart was observed to be unlocked and unattended, near room [ROOM NUMBER]. The cart remained unlocked and unattended until 2:34 p.m., when LPN 71 indicated the medication cart should have been locked. The medication cart included, but was not limited to, lancets, insulin pens and vials, bottled and pre- packaged pills. 2. An observation of Red Bud medication cart, on 5/13/19 at 2:23 p.m., accompanied by LPN 75 the following was observed: a. An opened vial of [MEDICATION NAME] (insulin) with no resident identifier or open date on it. b. A bottle of Vitamin B12 with an illegible factory expiration date on it, a date of 6/30/18 was written on the bottle in marker. LPN 75 indicated, the date, 6/30/18, was the expiration date and they would normally put resident identifiers on the insulin and put an open date on it after it had been opened. A policy titled Guidelines for Medication Storage and Labeling, provided by the DON, on 5/10/19 at 3:10 p.m., indicated compartments containing medication are locked when not in use and trays or carts used to transport such items are not left unattended. Multi-dose vials that have been opened or accessed should be dated when the vial is first accessed. 3.1-25(j)(m)

Based on observation, interview and record review, the facility failed to ensure the glucometer was disinfected according to the manufacturer's instructions after use for 2 of 3 accuchecks (Resident 81 and 43) observed and for 1 of 2 nursing staff observed (QMA 2), the facility also failed to ensure a resident's urinary catheter was managed in a hygienic manner for 1 of 1 residents reviewed with a urinary catheter (Resident 73). Findings include: 1. On 05/08/19 at 11:10 a.m., QMA 2 was observed to prepare and complete the accucheck on Resident 81. After returning to the medication (med) cart and disposing of the lancet, QMA 2 donned a pair of gloves, opened the Sani-Cloth germicidal disposable wipe and wiped the glucometer off for 17 seconds. The glucometer was then placed on a tissue at 11:16 a.m. On 5/8/19 at 11:18 a.m., QMA 2 prepared and completed the accucheck for Resident #43 with the same glucometer. Upon return to the medication cart, QMA 2 was observed to use one of the Sani-Cloth germicidal disposable wipe. The glucometer was wiped off for 20 seconds and then, was set on a tissue on top of the medication cart to dry. On 5/8/19 at 11:28 p.m., review of the Sani-Cloth germicidal disposable wipe packet indicated usage was to disinfect and deodorize : to disinfect non food contact surfaces only. Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. let air dry. On 5/14/19 at 8:31 a.m., during an interview QMA 2 indicated the glucometer was to be cleaned and wet for 2 minutes with the provided disinfectant wipe and then, allowed to dry for 2 minutes to disinfect. The Glucose Meter Cleaning & Testing policy was provided by the Director of Nursing on 5/13/19 at 9:06 a.m. This current policy indicated the following: Purpose: To prevent cross contamination and minimize risk of transmitting blood-borne pathogens between residents that require blood glucose monitoring. .Procedure: .Cleaning meter after use, prior to using on next resident: Steps: .5. Wipe entire external surface of the blood glucose meter with one germicidal wipe and ensure meter stays wet for 2 minute time period 2. On 5/09/19 at 8:18 a.m., Resident 73 was in his room, sitting in his recliner, his urinary catheter tubing was lying on the floor and the drainage bag was attached to his recliner. On 5/10/19 at 8:45 a.m., the resident was in his room, sitting in his recliner, his urinary drainage bag was attached to the frame of his wheelchair, his catheter tubing was lying on the floor and his left foot was resting on top of the tubing. On 5/10/19 at 4:11 p.m., the resident was in his room, sitting in his recliner, his urinary catheter tubing was lying on the floor. CNA 78 indicated they would normally hook his drainage bag on the side of his trash can and she was going to try to find his taller trash can so the tubing was not on the floor. On 5/14/19 at 9:01 a.m., CNA 76 was pulling the resident backwards from the bathroom, in his wheelchair, she laid his catheter urinary drainage bag on the floor, moved his wheelchair backwards and picked up the drainage bag and placed it on the resident's lap. CNA 76 indicated she would not normally put his catheter bag on the floor and she was trying to get him out of the bathroom. His clinical record was reviewed, on 5/10/19 at 11:54 a.m. [DIAGNOSES REDACTED]. An admission, Minimum Data Set (MDS) assessment, dated 4/18/19, indicated the resident was cognitively intact. He required extensive assistance with transfers, toilet use and personal hygiene. He had an indwelling catheter. A current policy titled Catheter Use and Care, provided by the Nurse Consultant, on 5/13/19 at 3:42 p.m., indicated the drainage bag and tubing should not touch the floor at any time. 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure the freezer in the kitchen was maintained in good working condition for 1 of 1 freezer observed. Findings include: On 5/8/19 from 8:50 a.m. to 9:13 a.m., the initial brief tour was conducted with the Dietary Manager (DM). The refrigerator was observed and then, the freezer, which was located in the back of the refrigerator. First, the freezer door was observed partially opened. Upon entering into the freezer, at least 1/2 inch of white ice/frost was observed present around the bottom and along the inside of the door. To the right of the door at least 1 inch of white ice/frost was also observed. Clear teardrop sized ice was observed on the ceilings above the 3 fans present. On 5/8/19 at 9:13 a.m., during an interview Cook 3 indicated maintenance cleans up the frost periodically, but she indicated no problem with the freezer. On 5/8/19 at 12:25 p.m., during an interview, Maintenance 9 indicated the freezer door in the kitchen had a heater in the door which probably needed to be replaced. He also indicated the frost was because dietary staff did not close the door tight enough although he had reminded them to do this. He indicated he may also need to replace a gasket related to the door soon. On 5/10/19 at 10:30 am with Dietary Staff 10, the refrigerator and freezer were observed. Upon entering the refrigerator, a tennis ball size clump of white ice was observed in the far right hand corner of the refrigerator's ceiling. Next, upon entering the freezer, one metal container was observed stored on the top shelf above the 18 inches. Dietary Staff 10 removed this container and indicated the container was the lasagna served last night. A thin layer of ice was observed along the freezer door gasket and also on the inside of the freezer door. The layer of ice was thicker at the bottom of the door and along the floor at the entry way. The teardrop sized ice was again observed on the ceiling next to the 3 fans. Dietary Staff 10 indicated maintenance was in yesterday and knocked (cleaned) the frost/ice off the door and floor. On 5/10/19 at 2:08 p.m., during an interview the DM indicated staff would close the freezer door tight. She also indicated the hinge/spring on the door caused the door to come open although staff had closed it tightly. On 5/13/19 at 10:20 a.m. with Dietary Staff 10, the top hinge of the freezer door was observed with a bulging metal hinge. A small layer of ice was observed in the middle of the inside of the freezer door below the handle. Also, a thin layer of ice remained around the edge of the freezer door. On 5/14/19 at 4:45 p.m., the Administrator indicated she was not aware of the problem with the freezer. The Refrigerator and Freezer Temperature Monitoring policy, dated 7/2008 and revised 9/2017, was provided on 5/10/19 at 3:34 p.m. by the DM. This current policy indicated the following: Policy A procedure shall be established for monitoring operating temperatures of cold storage equipment to assure they meet recommended guidelines for safe storage of perishable foods. .Procedure .6) All refrigerator and freezer units will be kept clean and in good working condition at all times 3.1-19(b)

Based on observation and interview the facility failed to ensure areas containing chemicals and potential hazards were secure. Findings include: 1. On 5/9/19 at 9:47 a.m., Resident 8 was on the Hickory Lane in her wheelchair, she had stood up from her wheelchair, entered the clean utility room through the opened door. House Supervisor 25 intervened and assisted her with getting ice. On 5/10/19 at 9:34 a.m., accompanied by CNA 22 into the clean utility room on Hickory Lane. Items that are kept in this room included, but were not limited to, mouth wash, protective skin barrier, anti-fungal cream, odor eliminator, 12 disposable razors, an opened box of denture tablets, deodorant, and an ice chest on a cart. The CNA indicated the room was to be kept locked. 2. On 5/10/19 at 10:22 a.m., the shower room on Walnut was open. On 5/10/19 at 10:24 a.m., accompanied by House Supervisor 25 the unlocked shower room was entered. There was a free-standing cabinet that had a combination lock that was through the cabinet door loops, but was not locked. The items in this cabinet included, but were not limited to, bottles of soap, shaving cream, hair spray, disposable razors, and a tub of opened sani-cloth wipes. He indicated the cabinet and the shower door were to be locked. 3. On 5/11/19 at 5:50 p.m., clean utility room on Hickory Lane was opened. CNA 27 was walking down the hall, turned towards the clean utility room and closed the door. She indicated the room should have been locked. 4. On 5/13/19 at 8:30 a.m., Maintenance 11 was observed working on the shower room leaving the shower room open on Chestnut Hall. The cabinet was observed unlocked but closed. Upon entering the shower room with LPN 12, two bottles designated for skin and hair care were removed from the shower area. In the unlocked cabinet 4 packages of 1 razor in each package, a large bottle of Sanitize germicidal cleanser container with wipes in the container, and various bottles of hairstyling bottles, lotion bottles, barrier cream, and at least 2 cans of shaving cream, and towels were present. At 8:35 a.m., LPN 12 indicated initially she did not know how to work the padlock used to lock the cabinet, but after checking she indicated the lock had to be turned to all O's to lock and then to keep it locked the O's had to be changed to different numbers. On 5/14/19 at 9:35 a.m., during an interview CNA 13 indicated she generally worked on the Redbud hall, but she was assigned to be on Chestnut Hall today. She indicated she was not sure if the code was the same on all halls for the shower room cabinets, but she indicated the lock in the shower room on Redbud had the code of 0000, and one needed to roll the numbers to relock. She indicated the lock was hard to work at times. 5. On 5/13/19 at 2:55 p.m., the door to the clean utility room on Hickory hall was observed to be opened and unattended, a keypad was on the door and a note on the door read STAFF IN THIS ROOM ONLY. The room contained, but was not limited to, incontinent briefs, mouth rinse, skin and hair cleanser, barrier cream, antifungal cream, disposable razors, exam gloves, facial tissues, wash clothes, hoyer batteries, a sandwich bag with suckers and fruit chews, and a Circle K styrofoam cup. At the time of the observation, CNA 79, indicated the door should not be open and sometimes it did not close. During an interview on 5/10/19 at 3:10 p.m., the DON indicated she did not have a policy regarding clean utility rooms or showers being secured.

Based on observation, record review and interview, the facility failed to prevent the development of an unstageable pressure ulcer for Resident #64, and to provide services to promote healing of a pressure ulcer for 2 of 3 residents who met the criteria for pressure ulcers (Resident #64 and #135). Findings include: 1. During an observation on 2/6/14 at 8:43 a.m., Resident #64 was seated in his high back wheelchair and was wearing brown leather slip-on shoes with white socks. During observation and interview with the DoN on 2/6/14 at 4:08 p.m., Resident #64 was laying in bed with no dressing to the left heel or heel protectors on. Resident #64 had a wound to the inner side of his left heel with black eschar (thick leathery necrotic or devitalized tissue, frequently black or brown in color). The DoN indicated the wound to the left heel was the size of a quarter and she needed to check to see why the dressing to his left foot was not on. During an observation on 2/6/14 at 4:18 p.m., the Director of Nursing (DoN) stated to LPN #9, "Resident #64 is to have a treatment to his left heel and needs to be done please." LPN #9 indicated yes. During an observation on 2/7/14 at 8:37 a.m., Resident #64 was seated in his high back wheelchair and was wearing brown leather slip-on shoes with white socks. A blue heel protector was on the dresser beside his bed just inside the door. During observation and interview with LPN #6 on 2/7/14 at 8:41 a.m., Resident #64 was seated in his high back wheelchair and was wearing brown leather slip-on shoes with white socks with his feet rested on the foot rests. LPN #6 stated " Resident does not like to wear the floating boot while he is up in his wheelchair, it would be better if he did wear it." LPN #6 asked Resident #64 if he would wear his floating boot. Resident #64 nodded his head up and down for yes. LPN #6 placed the heel protector on Resident #64's left foot. Resident #64 rested calmly with the blue heel protector boot on his left foot. During an observation and interview on 2/7/14 at 1:56 p.m., LPN #6 measured the wound to Resident# 64's left heel that was on the inner side of the left heel, circular in shape and was black in color. LPN #6 stated that the wound to left heel measured "2.5 centimeters in length and 2.5 centimeters in width." No depth was indicated. The clinical review for Resident #64 was reviewed on 2/6/14 at 10:35 a.m. Resident #64 had [DIAGNOSES REDACTED]. The current Physician orders [REDACTED]. Every day shift for wound float heels off of bed." A care plan problem for Resident #64 indicated, "...has a pressure ulcer present to left heel." Interventions related to the care plan problem indicated, "Administer treatments as ordered and assess for effectiveness, initiated 1/23/14." The review of the weekly skin documentation, dated 1/22/14, indicated an Unstageable (Unstageable; "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and /or eschar (tan, brown or black) in the ulcer bed.") pressure ulcer to the left heel with an onset date of 1/22/14 and not present on admission. The length was 2.5 centimeters by 2.5 centimeters width and no depth noted. The description indicated a "black eschar tissue, no drainage, no odor noted." The review of the weekly skin documentation, dated 1/27/14, indicated an Unstageable pressure ulcer to the left heel. The length was 2.5 centimeters by 2.5 centimeters width and no depth noted. The description indicated "black eschar remains to left heel..." The review of the weekly skin documentation, dated 2/3/14, indicated an Unstageable pressure ulcer to the left heel. The length was 2.5 centimeters by 2.5 centimeters width and no depth noted. The wound progress description indicated "black eschar remains..." Treatment included "Apply skin prep to left heel and wrap with [MEDICATION NAME] daily." "Preventative devices that resident is using this week include: foot/heel protectors, chair or w/c (wheelchair) cushion, skin barrier cream/oint etc..." During an interview with the DoN on 2/6/14 at 3:39 p.m., she stated that Resident #64 was to have heel protectors (float boots) when the resident was up in his wheelchair and to float his heels on a pillow when in bed... "With eschar you want to keep it dry and use skin prep to toughen up the skin a little bit and use gauze wrap to help protect it from the bed linens or slipper socks so it won't get knocked off..." During an interview with the Wound Nurse on 2/7/14 at 9:36 a.m., she indicated it would benefit the Resident #64's wound to the left heel if the resident wore the heel protector while up in his wheelchair as well. She stated "the heel protector/boot would be more beneficial than his shoe or sock. Especially if the treatment is not on the wound then it could inhibit the healing process along with not having the heel protector on as well. I will definitely address that. It's a know better type of thing. The daily treatment to the left heel is to use skin prep and wrap with [MEDICATION NAME]." 2. The Initial Tour was conducted on 2/3/14, beginning at 9:00 a.m. During the tour, Resident #135 was conserved in the recliner chair. The resident sat on a thick bath blanket. A pressure reducing cushion (RoHo) was on the resident's wheelchair. The resident was interviewed on 2/3/14 at 10:30 a.m. During the interview, Resident #135 indicated he sat in his recliner most of the day and slept in it most of the night. Certified Nursing Assistant (CNA) #2 was interviewed on 2/4/14 at 8:15 a.m. During the interview the CNA indicated Resident #135 was in the recliner every morning. She indicated she was not sure how long he did sleep in the bed. During an interview with LPN # 3 on 2/4/14 at 10:00 a.m., the nurse indicated she thought Resident #135 slept in the bed half the night and recliner chair the last half of the night. The clinical record of Resident #135 was reviewed on 2/4/14 at 10:40 a.m. The record indicated the resident's diagnoses, included, but were not limited to, [MEDICAL CONDITION], kidney disease, [MEDICAL CONDITION], chronic back pain, sleep apnea, and arthritis. The Admission Skin Assessment, dated 12/18/13, indicated, Resident #135 had two pressure sores on admission to the facility. A Suspected Deep Tissue Injury (SDTI) on the coccyx and a Stage Two on the right gluteal fold. The current, Physician orders [REDACTED]. Vitamin C and Zinc were also administered daily. A skin sheet dated 2/6/14 indicated the resident developed a Stage Two Pressure Area on the Left Gluteal Fold on 1/18/14. The Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident required staff assistance for transfers and ambulation. The MDS indicated the resident was continent of urine and bowel. The Care Plan, dated 12/26/13, indicated Resident #135 was at risk for pressure areas due to immobility and pain. The Care Plan interventions included, administration of pain medications, barrier cream, diet, pressure reducing mattress, toilet program, turn and reposition every two hours, and weekly skin assessments. On 1/20/14, the Care Plan was updated to include, (Resident's name) was admitted with pressure ulcer to coccyx and right gluteal fold, history of pressure ulcer to coccyx. The Care Plan interventions were updated to include, medications for wound healing, administer and evaluate treatments, weekly wound assessments, family education, diet as ordered, report changes to the physician, and a pressure reducing mattress. The Care Plan did not include the newly developed area to the left gluteal fold, a chair cushion, or the resident's routine of sleeping in the recliner. The personal care of Resident # 135 was observed with CNA #2 on 2/3/14 at 1:45 p.m. The CNA assisted the resident to stand from the toilet. The foam dressing was observed. The dressing was loose in the middle, exposing the Stage two pressure ulcer on the resident's left gluteal fold. The area was observed to be red, open and dry. CNA #2 was interviewed on 2/4/14 at 8:15 a.m. The CNA indicated she noticed the dressing was loose on Resident #135's pressure sore when she helped him on 2/3/14 at 1:45 p.m. The CNA indicated she did not report the loose dressing to the nurse. Resident #135 was observed in the recliner chair, with no RoHo cushion on the following dates and times: 2/3/14 at 9:00 a.m. 2/3/14 at 10:30 a.m. 2/3/14 at 2:30 p.m. 2/3/14 at 4:00 p.m. 2/4/14 at 8:30 a.m. 2/4/14 at 11:00 a.m. 2/4/14 at 1:15 p.m. 2/4/14 at 4:00 p.m. 2/6/14 at 8:45 a.m. 2/6/14 at 4:10 p.m. 2/7/14 at 8:15 a.m. 2/7/14 at 10:00 a.m. 2/7/14 at 1:30 p.m. The Wound Nurse/ADoN was interviewed on 2/7/14 at 9:20 a.m. The ADoN indicated she did not know how often or how long Resident #135 slept in the recliner at night and the information had not been added to the Care Plan. She indicated the RoHo cushion should be in the resident's recliner when he was sitting in the chair. The nurse indicated she did not monitor to ensure the resident's cushion was on the recliner and not in the wheelchair. The Wound nurse/ADoN further indicated CNAs were instructed to report any dressings that they observed loose/exposing the pressure sore, soiled,or missing to the charge nurse when the CNA noted a dressing problem. The nurse indicated she did not monitor daily dressings. She did assess and complete a weekly report. The facility policy, "Wound Prevention and Treatment Protocol", dated 10/10, was presented by the Nurse Consultant on 2/7/14 at 9:00 a.m. The policy indicated, "..." Effective pressure ulcer treatment plan should include: Management of tissue load.... Nursing management during daily rounds needs to observe and monitor that prevention interventions and care plan interventions are actually being done timely....". 3.1-40(a)(1) 3.1-40(a)(2)