Every finding on record at Eagle Valley Meadows

Based on observation and interview, the facility failed to maintain a clean and sanitary environment on 3 of 4 hallways observed for cleanliness (Hallways A, B, and D). Findings include: 1. On 11/24/25 Resident CC's family member e-mailed the Executive Director (ED) requesting a deep cleaning of the resident's bathroom. The e-mail indicated during a visit the resident's room and bathroom floors were filthy, and she was requesting they be cleaned. During the initial tour of Hallway D the following was observed: a. On 12/8/25 at 10:58 a.m., Resident D was observed propped in a bed positioned against the wall, watching videos on her cellphone, and the television on but muted. There was a large area of dried dark substances on the wall near the resident's head. On 12/9/25 at 10:38 a.m. a second observation was made of Resident D's room. The large area of dried dark substances remained on the wall near the resident's head. b. On 12/8/25 at 11:05 a.m., Resident E was observed sitting on the side of the bed with handwritten notes in his hand, plastic labels from soda bottles taped to the wall behind his bed, personal items stacked haphazardly on the foot of the bed, two fast food bags hanging from the slats of the window blinds, the floor was dirty, and there were unidentified dark substances smeared on his sheets where he sat. On 12/9/25 at 10:41 a.m., a second observation was made of Resident E's room. The plastic labels from soda bottles taped to the wall behind his bed, personal items stacked on the foot of the bed, two fast food bags hanging from the slats of the window blinds, and dirty/ sticky floor remaining unchanged. There were chunks of food on the floor under the over-the-bed table, and the bed sheets remained soiled with a large area of smeared dark substances. c. On 12/8/25 at 11:11 a.m., the handrails and walls behind the handrails were observed to be soiled with dried substances. There was no housekeeper observed in the D Hallway. On 12/9/25 at 11:15 a.m., the Housekeeping Supervisor was observed to sweep and mop in Resident B's room, then she left the hallway. A second observation was made of the soiled handrails and walls around the handrails. d. On 12/8/25 at 12:12 p.m., Resident B was observed sitting in a manual wheelchair in her room. The resident's personal items were sitting among debris and sticky substances on an over-the-bed table, and the floors in her room were littered with dirt, debris, and trash. The toilet, floor in the bathroom, walls around the toilet, and sink were soiled in the bathroom that was shared between rooms for Residents B, Z, and BB. Resident B indicated her room had not been cleaned over the weekend. On 12/9/25 at 10:37 a.m., Resident B was observed to be out of her room. The Housekeeping Supervisor was observed sweeping up a pile of debris to include paper, an empty plastic soda bottle, straw papers, and dirt. The Housekeeping Supervisor indicated she and Housekeeper 12, who was permanently assigned to clean Hallway D, had to clean while the resident was out of the room as Resident B had accused both of them of stealing her belongings. e. On 12/8/25 at 12:20 p.m., Resident Z was observed in her room, sitting in a manual wheelchair, eating from a snack bag of potato chips. There was a long strip of toilet paper and a soiled vinyl glove on the floor near the resident's feet. The resident indicated she and her roommate, Resident BB, shared the bathroom with Resident B. She indicated it was not easy, especially in the middle of the night, as the other room's door was always left open, and anyone would walk in, and there were sometimes three wheelchairs in front of the sink preventing her from getting to it. Resident Z indicated housekeeping was supposed to clean her room every morning. 2. During the initial tour of Hallway A the following was observed: a. On 12/8/25 at 11:15 a.m., Resident F was observed being taken from her room in a manual wheelchair, she indicated she was headed to a church service. The resident's bathroom was observed to have small dark balls on the floor around her toilet. Licensed Practical Nurse (LPN) 6 indicated the resident required assistance with activities of daily living (ADL's) to include transfers and toileting. On 12/9/25 at 10:45 a.m., a second observation was made of Resident F's bathroom. The small dark balls remained on the floor around her toilet, and the toilet was smeared with bowel movement (BM). b. On 12/8/25 at 11:19 a.m., Resident G was observed to be out of his room. The toilet riser in his bathroom was heavily soiled with dried BM, and there were pieces of crackers and crumbs on the floor around the bed. On 12/9/25 at 10:47 a.m., Resident G was observed being assisted to the bathroom by an unidentified nurse. At 11:08 a.m., a second observation was made of the bathroom, and the toilet riser and toilet lid both remained heavily soiled with dried BM. c. On 12/8/25 at 11:21 a.m., Resident H was observed propped up in a bariatric bed, wearing oxygen per a nasal cannula (NC), eating a snack, and looking through a shipped box. The resident or his bedding had a pungent sour smell that permeated into the hallway. The resident indicated the window in the room was opened 3 inches at his request due to him being hot despite the temperature being 25 degrees Fahrenheit (F) outside. On 12/9/25 at 10:48 a.m., a second observation was made of Resident H's room. The pungent sour smell remained that permeated into the hallway. During an interview on 12/9/25 at 12:39 p.m., the Director of Nursing Services (DNS) indicated Resident H was alert and oriented, he could assist with cleaning his upper body, he did not dress or get out of bed by choice, he fed himself, and he was incontinent in the bed. The DNS indicated she had spoken with the resident regarding refusals to get bathed or have incontinent care. d. On 12/8/25 at 11:39 a.m., Resident K was observed lying on the bed sleeping. The toilet in the shared bathroom with Resident J next door, was observed to heavily soiled on the inside and outside with BM, and there was stagnant urine with a film on top sitting in the toilet bowl. The bathroom emitted a heavy smell of old urine. On 12/9/25 at 10:53 a.m., a second observation was made of shared bathroom between Resident K and Resident J's rooms. The bathroom toilet remained heavily soiled on the inside and outside with dried BM, and there was stagnant urine with a film on top sitting in the toilet bowl. The bathroom emitted a heavy smell of old urine. A family member at bedside reminded Resident K to call for assistance when going to the bathroom. e. On 12/8/25 at 11:40 a.m., Resident L was observed to be out of his room. There was an opened bottle of orange liquid described as a citrus spray and wipe disinfectant cleanser observed sitting on the foot of the resident's bed positioned closest to the door and was visible from the hallway. The labeled indicated for commercial and industrial use, keep out of reach of children. f. On 12/8/25 at 11:45 a.m., Resident M was observed lying on the bed sleeping. The toilet and lid of a trash can in her shared bathroom were observed to be heavily soiled inside and outside with BM. There was an opened tube of toothpaste and toothbrush on the sink near a used tissue soiled with a dark substance. On 12/9/25 at 11:00 a.m., a second observation was made of Resident M's room. The resident was observed sitting on the toilet in the shared bathroom, her walker in front of her. At 11:13 a.m., the resident was observed leaving the bathroom. The inside and outside of the toilet, lid of a trash can, and the floor around the toilet in her shared bathroom remained heavily soiled with dried BM. On 12/8/25 at 11:48 a.m., room [ROOM NUMBER], documented as having no occupancy, was observed to have a clear trash bag containing a soiled sheet sitting on the floor in the doorway to the hall. On 12/8/25 at 11:49 a.m., and 12/9/25 at 11:02 a.m., there was no housekeeper observed on the A Hallway either morning. 3. During the initial tour of Hallway B the following was observed: a. On 12/8/25 at 11:51 a.m., Residents N and P were observed lying on their beds. The shared bathroom floor, toilet, and sink were heavily soiled with balls and smears of BM. On 12/8/25 at 11:57 a.m., Housekeeper 12 was observed pushing a broom down the center of B Hallway, not his assigned hall. b. On 12/8/25 at 12:00 p.m., observation of a shared bathroom toilet and sink between rooms for Residents R, S, T, and U, was observed heavily soiled with dirt and dark hairs. On 12/9/25 at 11:24 a.m. a second observation was made of the shared bathroom between rooms for Residents R, S, T, and U. The bathroom remained heavily soiled with dirt, hair, BM on the inside and outside of the toilet, and toilet paper soaked in urine was on the floor in front of the toilet. Resident R was observed sitting on the side of the bed wrapped in a bedspread, dressed in a brief and white t-shirt. There were soiled napkins on the bed, spilled liquid on and under the over-the-bed table, personal items lying among sticky substances on the over-the-bed table, the floor throughout the room was soiled, and the wall behind the bed was smeared with unidentified dried dark substances. c. On 12/8/25 at 11:52 a.m., Housekeeper 10 was observed sweeping the in room for Residents V and W. The housekeeper indicated he had not arrived until 9:00 a.m. that morning, and he was the only housekeeper for the hallway. On 12/8/25 at 12:04 p.m., observation of a shared bathroom between rooms for Residents V, W, X, and Y, after Housekeeper 10 left the room. The bathroom sink and toilet were heavily soiled with dirt, dark hairs, and the floor had scraps of torn paper, plastic, and debris. There were 2 gray wash pans under the sink filled with trash, unidentified white crystals, medicine cups, empty creamer cups, straws, the pans were covered in a dried white substance, and everything had a layer of dust on it. On 12/9/25 at 11:30 a.m., a second observation was made of the shared bathroom between rooms for Residents V, W, X, and Y. The dirt, debris, and wash pans under the sink remained in the bathroom which had not been cleaned. On 12/8/25 at 12:09 p.m., there were no housekeepers observed on the A or D Hallways, or common areas. On 12/9/25 at 11:33 a.m., the was no housekeeper observed on the B Hallway. There were wads of white paper debris observed on the floor in the walk areas around the central nurse's desk, on the floor at the entry of A Hallway, and the entry of the service hallway towards the main dining room. Staff from all departments were observed walking over the debris, with no attempt to pick it up. On 12/8/25 from 9:30 a.m. to 4:00 p.m., the public restrooms near the therapy gym were not observed to be cleaned or the floors mopped. Dust bunnies and debris remained on the floors with accumulation along the cove base and into the corners. During continuous observation of the A, B, and D Hallways, on 12/9/25 from 10:30 a.m. to 11:40 a.m., Housekeeper 10 was observed to mop 1 room on the B hallway, and the Housekeeping Supervisor was observed to sweep 1 room on the D hallway. There was no observation of housekeeping staff sweeping or cleaning common areas or resident bathrooms. A housekeeping schedule, dated 12/7/25, documented 2 housekeepers as having worked hours from 6:00 a.m. - 2:00 p.m. On 12/8/25, 3 housekeepers worked staggered hours from 6:00 a.m. - 5:00 p.m. On 12/9/25, 3 housekeepers were scheduled to work staggered hours from 5:00 a.m. - 10:00 p.m. During an interview on 12/9/25 at 12:14 p.m., the Housekeeping Supervisor indicated staffing for her department included, there were 3 housekeepers schedule to work on Monday and Wednesday, and 2 housekeepers scheduled on Tuesday, Thursday, Saturday, and Sunday. The housekeepers were assigned designated hallways and split the common areas to include the public bathrooms and offices. The Housekeeping Supervisor indicated part of the issue of resident's having dirty rooms was due to the nursing staff not assisting to wipe up messes including feces, spills, and picking up trash from the floor. The departments were not working together. The Housekeeping Supervisor indicated it was ultimately her responsible for making sure housekeeping staff performed their duties to and kept resident rooms and common areas cleaned. During an interview on 12/9/25 at 12:48 p.m., the DNS indicated disinfectant cleaners were supposed to be locked on the housekeeping carts, out of sight and reach of residents when not in use. During an interview on 12/9/25 at 12:52 p.m., the DNS indicated, if feces was found on surfaces in resident rooms or restrooms, nursing staff was supposed to have cleaned it up first, then housekeeping was to follow behind and clean/disinfect. During an interview on 12/9/25 at 1:45p.m., the Executive Director (ED) indicated the expectation was for nursing and housekeeping was to work together to keep the resident's rooms clean and tidy. Management staff were assigned hallways where they performed Angel Rounds on a daily basis and were supposed to report concerns back to her. The management staff had not reported there having been problems with resident rooms not being cleaned. The ED had not been rounding to verify housekeeping tasks were being completed and was unaware of concerns with bathroom cleanliness. On 12/9/25 at 3:00 p.m., the ED provided a Daily Cleaning Procedure policy, revised 12/21, and indicated this was the procedure currently being used by the facility. The facility did not have check-off lists for housekeepers to sign. The policy indicated, .5. Disinfect horizonal surfaces to include furnishings, tables, countertops, windowsills, overbed lights, bedside tables, and commonly touched items. 6. Follow the restroom cleaning procedure. 7. Sweep flooring to include under beds, corners, edging and under chairs/equipment. Post wet floor sign prior to mopping. 8. Mop flooring to include under beds, corners, edging and under chairs/equipment. When deemed necessary, when cleaning flooring [resident room, isolation rooms, shower rooms, soiled areas or as needed], may substitute neutral floor cleaner with disinfectant cleaner.12. Conduct final inspection.14. Refer to the daily cleaning guidelines to ensure all required cleaning tasks have been completed. On 12/9/25 at 3:25 p.m., the ED provided a Restroom Cleaning procedure policy, dated 12/21, and indicated the policy was the one currently being used by the facility. The policy indicated, .3. Empty trash and clean container with disinfectant. 4. Apply recommended disinfectant to exterior of toilet, sink, and counter tops allowing product to remain wet for ten [10] minutes. 5. Disinfect commonly touched items. 6. Clean toilet bowl and exterior of toilet. 7. Clean mirror, sink, and countertops. 8. Spot clean walls. 9. Clean/disinfect shower/tub and tile if applicable. 10. Post wet floor sign. 11. Sweep and mop flooring including corners, edges and cove base. This citation relates to Intake 2682909. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to respond to call lights for 2 of 3 residents reviewed for dependent residents call light response times (Residents B and L). Findings include:1. On 12/8/25 at 12/8/25 at 12:12 p.m., Resident B was observed sitting in a manual wheelchair (WC) in her room and indicated she had been waiting for 15 minutes for staff to come change her wet brief. The resident's call light was observed not to be activated, and she indicated staff had shut the light off and told her they would return. Certified Nursing Assistants (CNAs) 8 and 9 were observed in the hallway passing lunch trays, but they were not observed to enter the resident's room or speak to her. Resident B reactivated her call light. On 12/8/25 at 12:16 p.m., Licensed Practical Nurse (LPN) 13 was observed entering Resident B's room, she turned the call light off, left the room, and returned to the nurse's station. On 12/8/25 at 12:27 p.m., Resident B was observed sitting in the same position in her wheelchair eating her lunch. The resident indicated the nurse had shut the call light off and told her staff could not change her brief during lunch as it would cause contamination issues. LPN 6 was present during the conversation. On 12/8/25 at 12:49 p.m., Resident B remained in the same position in her wheelchair, her call light was activated and she indicated staff had not yet come to change her brief. CNAs 8, 9, and an unidentified CNA were observed walking up and down the hallway, they did not respond to the resident's call light. LPN 13 was observed standing at the nurse's station, and indicated she was responsible for resident care on the D Hallway to include Resident B. On 12/8/25 at 1:07 p.m., Resident B's call light remained activated and could be observed flashing in the hallway from the nurse's station. Resident B's clinical record was reviewed on 12/9/25 at 12:32 p.m. Diagnoses on Resident B's record included hemiplegia and hemiparesis (paralysis) affecting the left side, and Parkinson's disease. A quarterly MDS (Minimum Data Set) assessment, completed on 11/13/25, indicated Resident B was cognitively intact, had no behaviors and had no rejection of care. The resident required substantial/maximal assistance for toilet hygiene, transfers, standing, and used a wheelchair for mobility. The resident was frequently incontinent of bladder and bowel. A care plan for Resident B, dated 6/20/25, indicated the resident required assistance with toileting because she was incontinent, had impaired mobility, and she needed assistance with transfers. Approaches included assisting with elimination, assisting with incontinent care as needed, and checking every 2 hours for incontinence. A care plan for Resident B, dated 6/20/25, indicated the resident was at risk for falls due to hemiplegia/hemiparesis causing impaired mobility on the left non-dominant side and Parkinson's disease. The resident needed assistance with incontinence care, and she would attempt to self-transfer to and from bed into and out of her wheelchair. Approaches included environmental changes, and keeping her personal items and call light within reach. During an interview on 12/9/25 at 12:53 p.m., the Director of Nursing Services (DNS) indicated call light response times were not supposed to be over 5 minutes. All nursing staff and managers should answer call lights. 2. On 12/9/25 at 10:57 a.m., Resident L was observed lying on the bed watching the television, the sheet was partially covering his legs, and he was observed to be wearing an adult brief. The resident was alert, oriented, soft-spoken, and smiled during the conversation. The resident indicated he had a new below the knee amputation (BKA) and was in the facility for rehabilitation to learn to ambulate with a prosthesis. He could not transfer or ambulate on his own and used a bedpan versus getting up to the bathroom. Resident L indicated staff were often slow to respond to his call light which had caused him to have accidents and the need to wear an adult brief, all of which was embarrassing. Resident L's clinical record was reviewed on 12/9/25 at 12:32 p.m. Diagnoses on Resident L's record included acquired absence of left leg below the knee. An admission MDS, completed on 11/28/25, assessed Resident L as being cognitively intact, and having no rejection of care. The resident was dependent for toilet hygiene, transfers, personal hygiene, and was frequently incontinent of bladder and bowel. The resident used a wheelchair for mobility. A care plan for Resident L, dated 11/24/25, indicated the resident required assistance with toileting due to impaired mobility, incontinence, and needing assistance with transfers. Approaches included assisting with elimination, incontinent care as needed, and checking every 2 hours for incontinence. A care plan for Resident L, dated 11/24/25, indicated the resident was at risk for falls due to his age [AGE]-69, incontinence, needing assistance with transfers, activities of daily living, bed mobility, medications, unsteady gait, vision impairment, lack of understanding of one's physical and cognitive limitations, and a left BKA. Approaches included environmental changes, and keeping personal items and the call light in reach. During an interview on 12/9/25 at 1:45 p.m., the Executive Director (ED) indicated it was unacceptable for call lights to go unanswered for extended periods of time. During an interview on 12/9/25 at 3:00 p.m., the ED indicated they did not have a policy specific to call light response times. This citation relates to Intake 2682909. 3.1-38(a)(3)

Based on observations and interviews, the facility failed to date items when opened and prepped for 1 of 1 kitchen observation. Findings include: On 7/27/25 at 10:02 a.m., a tour of the kitchen was conducted. Observed a cell phone lying next to pies that were defrosting. [NAME] and chocolate milk had no date opened on the containers. A salad was prepped with no date on the wrap.On 7/27/25 at 10:30a.m., the cook indicated the milk should have had a date open on the container.A policy titled, Food Storage was provided by the Regional Director of Clinical Services (RDCS) on 7/30/25 at 11:30 a.m. It indicated, .All foods shall be covered or wrapped tightly, labeled and dated.3.1-21(j)(1)3.1-21(j)(3)

Based on observations, interviews, and record review, the facility failed to provide a clean, comfortable, and homelike environment for residents residing in the Memory Care (MC) unit for 6 days of observations and 4 of 4 months of grievances reviewed. These deficiencies had the potential to lead to increased risk of infection, safety hazards, and an institutional rather than homelike setting for 20 of 20 residents residing in the MC unit.Findings include: 1.On 7/27/25 at 10:38 a.m., an Air Conditioning (AC) unit mounted to the wall in the MC front lounge was observed actively dripping water from built up condensation. The water leaked down the wall, and dripped on top of a cushioned chair. The paint on the wall under the AC unit was observed to peel away and showed evidence of long-term water damage. On 7/29/25 at 9:55 a.m., Resident 48 was observed as she sat in the cushioned chair under the mounted AC unit which continued to drip onto the back of the chair. During an interview on 7/30/25 at 9:45 a.m., Housekeeper (19) was observed as he wiped water from the wall and floor under the leaking AC. He indicated, Maintenance was supposed to come fix the units which had been leaking for a while. It needs to be fixed or it will start molding the wall.The issue remained unresolved throughout the survey period, and with the excessive outside temperature, the units were observed to condensate and drip for multiple days.2. On multiple observations from 7/27/25 - 7/30/25 the following was observed in resident rooms and bathrooms:A shared bathroom for room [ROOM NUMBER] &139: Non-skid flooring in front of toilet was dirty, tacky, and had gunk buildup. The toilet riser was missing rubber grips on the front two legs of the chair increasing risk for it slipping. room [ROOM NUMBER]'s toilet riser was rusted and speckled with feces, the floor was filthy with black grout in between tile seams, and a dark ring around the toilet base. There was no toilet paper holder. The bathroom ceiling air intake vent was coated with dust/debris.room [ROOM NUMBER]'s bathroom florescent light cover was observed duct-taped in place.room [ROOM NUMBER]'s dresser drawer handle dangled loose in disrepair. room [ROOM NUMBER]'s dresser drawer handle dangled loose in disrepair and cobwebs were noted in the window.In rooms [ROOM NUMBERS], cobwebs in window.room [ROOM NUMBER]'s Call light was wrapped and hung up on the wall, inaccessible to the resident.3. Throughout the survey period, multiple wheelchairs (WC) were visibly dirty and in disrepair:Resident 8's WC had peeling tape and debris accumulated.Resident 49's WC was missing the rubber brake handle (noted on 7/31 and again on 8/1).Resident 7's WC brake handle were also missing. Resident 52 had a fall mat beside her bed which was observed to be built up with dirty and stains, the mat cover had become wrinkled and cracked on the edges. 4. Throughout the survey period, Resident 56 was observed in her room, lying in bed until it was brought to staff attention and she was assisted out of her room on 7/31/25. There was no visitor or personal chair in Resident 56's room for guests to visit. There were no pictures or decorations on the walls. There were no personalized items of comfort on her bed or bedside table. There were gauges in the wall with drywall debris on the floor behind the head of the bed. Several of the privacy curtains from the ceiling were noted to be detached and hung in disrepair. On 7/31/25 at 12:09 p.m., when Resident 56 was brought to main dining room, there was no available seat for her, and she was instead placed in a corner chair in the TV lounge. A CNA brought an over-bed table from another resident's room to set her lunch tray on. 5. Throughout the survey period, multiple observations of multiple residents were noted to be unclean, had torn or ill-fitted clothing, and lacked basic personal hygiene such as brushed hair and oral care. Multiple rooms were noted to feel warm and moist, and with the excessive heat outside, personal HVACs in rooms were not pulling the moisture from the air. The warm moist air contributed to lingering strong odors after incontinent episodes. Particularly rooms [ROOM NUMBERS]. 6. A grievance filed 1/23/25 indicated, family member states room is not being cleaned, the floors were a mess, need mopped. A grievance filed on 2/19/25 indicated, bathroom is left dirty after aides assist neighbor to use the toilet . the sink has been filled with waste before.A grievance was filed on 4/17/25 which indicated, lack of cleanliness in room, no trash can, things spilled not cleaned up.A grievance filed 4/17/25 indicated, bathroom was not clean.A grievance filed on 6/30/25 indicated, concern that there are many gnats in the room.A Resident Council Concern filed on 12/4/24 indicated, wheelchairs need to be cleaned. Cross reference to F677. On 7/31/25 at 1:10 p.m., the Administrator provided a copy of current facility policy titled, Deep Cleaning Practices, revised 12/21. The policy indicated, Deep cleaning of resident rooms and common areas shall be scheduled by and maintained by the Housekeeping Supervisor and/or Environmental Service Supervisor . Each Housekeeper when completing a deep clean shall fill out a quality control deep cleaning checklist signed and dated, and provide it to the housekeeping supervisor upon completion of the deep clean . This citation relates to Complaints IN00162849 and IN00162850.3.1-19(f)

Based on observations, interviews, and record review, the facility failed to provide necessary assistance with activities of daily living (ADLs) such as, dressing, grooming, hygiene, toileting, and repositioning for multiple dependent residents in the Memory Care (MC) unit for 5 of 8 residents reviewed for ADLs (Residents 27, 57, 34, 58 and 56). Findings include:During an initial observation in the secured memory care unit (MC) on 7/27/25 at 10:38 a.m., the following was observed:Multiple residents were observed in the main dining/activity lounge who wore unclean, ill-fitted socks and clothing with unkempt, tangled or greasy hair.Resident 27 sat in a wheelchair (wc) which had a copious about of bright orange duct tape to the brake handles and inside panel. The tape was peeled away in several areas with bits of unidentifiable debris, hair and lint stuck to the peeled sides. Her hair had been pulled into a ponytail, but the band was loose, and her hair was falling out around it, and appeared as if she slept on it. She wore a long-sleeve purple shirt which appeared too big for her and fell off her shoulder. She also had on a pair of blue non-skid socks that were dirty on the bottom.Resident 43 had on a pair of blue non-skid socks with a hole in the toe of her left sock, so that her toenail stuck out.Resident 71 was observed seated in a wc pulled up to a table. Her eyes were closed and her head was bowed, she appeared to be asleep. She had on a pair of yellow non-skid socks that appeared to be too small and cut into the skin around the top of her ankles as her feet.Resident 57 ambulated independently. As she spoke, her teeth and gums were observed with copious amounts of built up plaque/tarter, and/or unidentifiable, build up food debris. Her breath had a foul odor. Resident 58 ambulated independently with a rollator walker into the main activity/dining room briefly, but returned to her room. Her hair was observed flattened and matted at the back and appeared greasy and unbrushed. Resident 34 was observed lying in bed without pants or a brief. A saturated brief lay on the floor, and the room smelled of urine. Resident 34 indicated, she had removed the brief herself because no one came to change me.Resident 56 was observed lying in bed. She wore a badly faded hospital gown that fell off her shoulder. Her room was bare with no personalization. The TV was not on. There was no music, and she started blankly at the ceiling. The MC unit Spa room was observed. The tiles, sink, shower curtain and shower head were all dry. There was no moisture or humidity in the air to indicate recent showers had taken place.During a continuous observation on 7/28/25 from 11:00 a.m. until 11:20 a.m., following was observed:Resident 27 was observed. Her hair appeared to have been brushed and put back into a neat ponytail, but she remained in the same purple long-sleeve shirt, and had on the same blue dirty socks. Her wheelchair remained in unclean conditions with the orange duct tape and debris stuck in it.Resident 34 was observed dressed in a pink pull over style sweatshirt with what appeared to be a pink shirt underneath, grey velvet style lounge pants and a pair of house shoes.Residents 34, 58, 43 and 71 all appeared to be wearing the same dirty socks. Resident 56 remained in her bed and appeared to be in the same faded hospital gown. Resident 56 did not have a wc in her room, a visitors chair, or comfortable personal chair to sit in should she prefer to get out of bed. The CNA on the MC was observed as she briskly moved from one room to the next, at times she spent less that 2 minutes in a resident's room. She stepped into some residents rooms and simply asked, did they need to use the restroom, and did not encourage them to try before she moved on to the next resident. On 7/29/25 from 9:55 a.m. until 11:35 a.m., no residents were observed to be offered a shower. The MC unit Spa room was observed. The tiles, sink, shower curtain and shower head were all dry. There was no moisture or humidity in the air to indicate recent showers had taken place. Resident 34 was observed to wear the same outfit as the day before. On 7/30/25 from 9:20 a.m., until 9:45 a.m. the following was observed:Resident 27 remained in a long-sleeve purple shirt which appeared to be too big for her and fell off her shoulder. She worse the same dirty blue socks.Resident 58's hair remained flattened/matted at the back and appeared greasy.Resident 57's still had very poor hygiene and her breath had a foul odor.Resident 56 remained in the same faded hospital gown, and stared blankly at the ceiling with no TV or radio, no visitor chair and nothing on the walls to look at. The MC unit Spa room was observed. The tiles, sink, shower curtain and shower head were all dry. There was no moisture or humidity in the air to indicate recent showers had taken place.On 7/31/25 from 9:50 a.m., until 10:15 a.m., the following was observed:There were now 2 CNAs on the MC unit. One CNA was observed as she assisted a resident out of the spa room. Resident 43 was observed in her wc in her room as she was about to be assisted to bed. She was observed to have the same pair of dirty blue socks on with a hole in her left sock seam, her toenail jutted out and now there was a ball of dust and hair stuck to her toenail from under her foot. Resident 49 was observed in her room. She was lying on her left side/stomach with her head rested on her arm, as there were no sheets or pillows observed on her bed. Her incontinent brief was heavily soiled as it had seeped and stained the back of her pants and up to the bottom of her shirt. The room smelled strongly of urine, and the air was stagnant. Resident 27 had been put in a new bright orange shirt, but it also appeared to be too big for her and fell off her shoulders and there were two ripped holes in the bottom of the shirt.Resident 56 was observed dressed in a new shirt and was assisted out of her bed and into the main TV lounge for lunch. On 8/1/25 at 9:00 a.m., Resident 49 was observed laying directly on top of her mattress, as her bed remained without sheets. During a confidential interview, it was indicated, there was a nurse and only 1 Certified Nursing Aide, (CNA) on the MC unit. It was indicated, the CNA had to assist and take care of all 20 residents ADL and morning routines by themselves, and sometimes could not get everything done. During a confidential interview, it was indicated, there was only 1 CNA on the MC unit and they often struggled to get everything done for everyone. They were supposed to be able to ask for help from CNAs from other halls, but they were usually all too busy to help.On 7/31/25 at 10:00 a.m., Residents 27, 57, 34, 58, 56, 43, 71, and 49's records were reviewed for ADLs. Resident 27 was a long term care resident with diagnoses which included but were not limited to, Alzheimer's disease and was severely cognitively impaired. Her Resident Profile indicated, Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Prefers to have AM showers. Resident 27's shower sheets were reviewed for the month of July. She had a bed bath on 7/7 a shower on 7/14, shower on 7/17 and 2/21, then was given a shower during survey on 7/31. The shower sheets did not indicate a time it had been provided and did not include details of what if any items were competed. Resident 27 had a care plan initiated 11/11/21 which indicated, she required assistance with ADLs including bed mobility, transfers, eating and toileting related to her diagnoses. The care plan did address her preferences for clothing.Resident 57 was a long term care resident with diagnoses which included, but were not limited to, Alzheimer's disease and was moderately cognitively impaired. Her resident profile indicated, Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. There were only two shower sheets for Resident 57 on 7/8 and 7/22, she refused on both dates. The shower sheets did not indicated any re-approaches were attempted for either date. She had a care plan initiated on 8/7/24 which indicated, Resident does refuse to change clothing daily regardless of how many approaches and refuses showers. Family is aware and would like to be informed when this happen so they can assist her due to her behaviors. An intervention for this plan of care dated 4/17/25 indicated, Contact family to assist and come in for showers as needed, they are willing to complete if all interventions fail. The record lacked documentation that family had been contacted for the days she reused. She had a second care plan initiated 8/6/24 which indicated, she was at risk for impaired dental hygiene and had her own teeth with an intervention to assist her with oral care. The care plan lacked revisions if needed, that she would refuse oral care. The record lacked documentation that oral care had been provided or approaches to assist her were updated. Resident 58 was a long term care resident with diagnoses which included, but were not limited to, unspecified dementia and was moderately cognitively impaired. Her resident profile indicated, Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Her shower sheets for the month of July were reviewed. On the 3rd at 9:00 a.m., she allowed the CNA to wash her up in the bathroom but would not take a shower. A shower sheet dated the 7th at 10:15 a.m., was left completely blank. Nothing was checked off, and no notes were written so it was indeterminable if she had been given a shower. On the 10th a shower sheet was timed at 9:05 a.m., and indicated, she had refused the shower, but accepted a bed bath. on the 14th, (with no time) it was indicated in the comments: washed her up, but no additional details or checkmarks to indicate what that included. On the 28th (with no time) she refused a shower, with no noted redirection or additional attempts. She had a care plan initiated 1/29/25 which indicated she required assistance with ADLs including hygiene and showers. There was a second care plan initiated on 4/9/25 which indicated, Resident will refuse shower, care, and to get up from bed at times. There were only two interventions, both initiated 4/9/25 which indicated inform resident of risks of refusals in calm manner and offer different staff. The record lacked documentation of refusals since 4/8/25, and there was no documentation that different staff had been offered to assist her to shower for the July dates she refused. Resident 56 was a long term care resident with diagnoses which included bit were not limited to, Alzheimer's disease and frontotemporal neurocognitive disorder. She was severely cognitively impaired. Her profile indicated, Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Prefers AM showers. Her shower sheets for the month of July were reviewed. There was no documented shower sheet after 7/19/25. She had a care plan initiated on 6/19/2020 which indicated she required assistance with ADLs due to her diagnoses. No new interventions had been added sine 8/21/24 and the care plan was not revised to include her preference for staying in bed. Resident 43 was a long term care resident with diagnoses which included but were not limited to, Alzheimer's disease and she was severely cognitively impaired. There was only one documented shower sheet for the month of July on 7/28/25 which indicated, was not in a good mood and refused. The record lacked documentation of re-approaches or interventions for redirection. Her resident profile indicated, Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Prefers bed baths in the evening hours. Resident 34 was a long term care resident with diagnoses which included, but were not limited to, dementia and was severely cognitively impaired. Her Resident Profile indicated, Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Current preference for bathing. She had a care plan initiated on 2/22/18. The care plan indicated she required assistance with ADLs and sometimes refused assistance with care and an intervention created on 2/22/18 indicated, Resident sometimes refuses assistance with ADL care, but did not offer options/preference/redirections for her refusals. During an interview on 8/1/25 at 8:40 a.m., the Administrator (ADM) indicated, there was no policy for Resident ADLs, and the MC unit did not utilize CNA Assignment Sheets, but were instead were expected to follow instructions from their Resident Profiles. At that time the ADM provided a CNA to do list which included, but was not limited to, ensure all residents are provided am care and are up for breakfast and taken to the dining room . reposition and provide incontinences care for dependent residents . ensure unmade bed is clean and made . complete meal; and fluid documentation if applicable . toilet and lay down dependent residents . pass ice water . complete remaining showers . complete POC charting . pass trays . These tasks and more were required of one CNA for 20 residents who resided in the memory care unit and could have an additional layer of difficultly added considering residents who had behaviors. This citation relates to Complaints IN00162849 and IN00162850.Cross reference F725. 3.1-38(a)(3)

Based on observations, interviews and record reviews, the facility failed to ensure infection control practices were in place for 4 of 4 residents randomly observed for infection control during the survey (Residents 10, 47, 20, and 34).Findings include:1. On 7/28/25 at 10:00 a.m., Resident 10 was observed resting on her right side with her eyes closed. Resident 10 had a catheter bag in a basin on the floor draining urine. There was an EBP sign on the bathroom door and a PPE cart across the hall between two rooms. On 7/28/25 at 1:35 p.m., Resident 10 was observed as she received peri care from Certified Nursing Aide (CNA) 5. The CNA was wearing gloves only while providing care. On 7/29/25 at 12:04 p.m., Resident 10's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, chronic heart failure, chronic obstructive pulmonary disease (COPD) and personal history of methicillin resistant staphylococcus aureus infection (MRSA). A care plan that was last reviewed 5/14/25 indicated Resident 10 was at risk of transferring or becoming colonized with an Multidrug Resistant Organism (MDRO) and required EBP due to a history of MRSA and Extended-Spectrum Beta-Lactamase (ESBL) (enzymes produced by certain bacteria that make them resistant to many common antibiotics) in her urine- related to her urostomy (a surgical procedure that diverts urine away from a damaged or removed bladder, creating an opening on the abdomen to allow urine to exit the body and be collected in a pouch). The interventions for this care plan included, but were not limited to, wear gown and gloves prior to high contact resident care activities and EBP.2. On 7/30/25 at 9:00 a.m., Registered Nurse (RN) 9 was observed as she administered Gastrointestinal Tube (G-Tube) medications to Resident 47. There was an EBP sign on the wall above the head of the bed, but the RN 9 did not use proper PPE for EBP she only used gloves. At this time the Staff Development Coordinator was also in the room observing the nurse. She did not come into direct contact with Resident 47, but she failed to remind RN 9 of the proper use of PPE in rooms where the Resident was on EBP. 3. On 7/30/25 at 8:30 a.m., RN 9 was observed as she prepared medications for Resident 20. While preparing the medication she accidentally knocked the medication cup over and two unidentified pills fell out of the cup onto the top of the medication cart. RN 9 then took a spoon and scooted the pills back into the medication cup and proceeded to administer the medications to Resident 20. When speaking with RN 9 afterward, she indicated she didn't think about the potential for contamination and in the future would throw those medications away and prepare new ones. 4. On 7/29/25 at 11:32 a.m. an unidentified CNA entered Resident 34's room carrying linens pressed against their body (no linen cart).During the entrance conference on 7/27/25 at 11:45 a.m. a current facility policy related to infection control was requested and provided. The policy was titled, Infection Control and Prevention Program, and dated 11/2017. This policy indicated, . The facility shall establish and maintain infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The IPCP is a comprehensive system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under contractual arrangement, is based on the facility assessment and following accepted national standards. the goals of the infection prevention and control program are to:. 3. Implementation of acceptable standard of practice to correct problems related to infection control and prevention practices. 5. Maintain compliance with state and federal regulations related to infection prevention and control.3.1-18(b)

Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing was provided to meet resident care needs. This deficient practice had the potential to affect 20 of 20 residents who resided in the secured memory care unit and 1 of 3 residents reviewed for NOMNC notification. (Residents 17 and B)Findings include:1. On 7/27/25 at 11:00 a.m., the day shift time and attendance records for nursing staff assignments on the 6:00 a.m. -2:00 p.m. shift, with a resident census of 77, were reviewed. According to the timesheets, the following staff were physically present in the building during the 6-2 shift:Licensed Nurses:Registered Nurse (RN) 9: 6:52 a.m. - 2:52 p.m.Licensed Practical Nurse (LPN) 11: 7:45 a.m. - 11:40 a.m.LPN 12: 6:42 a.m. - 2:01 p.m.LPN 13: 5:44 a.m. - 2:13 p.m.Certified Nursing Assistants (CNAs):CNA 14: 5:44 a.m. - 10:00 p.m.CNA 15: 6:01 a.m. - 2:10 p.m.CNA 16: 5:56 a.m. - 10:00 p.m.CNA 17: 6:06 a.m. - 4:12 p.m.CNA 18: 6:04 a.m. - 2:11 p.m.The total actual CNA worked hours for the 6-2 shift was 72.43 hours, resulting in a staff-to-resident ratio of 0.94 hours per resident day (HPRD) for direct care staff. According to CMS expectations and industry benchmarks, this HPRD was below the recommended level of 1.5 - 2.0 HPRD for CNA coverage, not including licensed nursing staff.Multiple CNA and licensed nurse shift start times varied and overlapped slightly, with one licensed nurse, LPN 11, leaving the building prior to the end of the scheduled shift at 11:40 a.m., further reducing licensed coverage.This level of staffing did not reflect a sufficient number of qualified nursing personnel to meet the scheduled and unscheduled care needs of 77 residents, which included, but was not limited to, assistance with activities of daily living (ADLs), timely incontinence care, hydration needs, and a clean/comfortable homelike environment. On 7/27/25 at 10:12 a.m., Resident 17 was observed lying in bed with blankets over her. The room was very warm. She had a red face, and her lips were dry and cracked. She had long facial hair. Her bedside table was out of reach. On the table was a cup of warm water dated 7/23/25. On 7/28/25 at 10:30 a.m., Resident 17 was observed lying in bed with blanket over her. She continued to have a red face, and her lips were dry and cracked. She had long facial hair. Her bedside table was out of reach. She continued to have a cup of warm water with the date of 7/23/25 written on the cup. On 7/29/25 at 9:45 a.m., Resident 17 was observed lying in bed with a blanket over her. She had a face, and her lips were dry and cracked. She had long facial hair. Her bedside table was out of reach. She had a cup of water at her bedside that had warm water, and the cup did not have a date on it. On 7/30/25 a record review was completed for Resident 17. She had the following diagnoses which included but were not limited to Alzheimer's disease, schizophrenia, seizures, anxiety disorder, hypertension, and osteoarthritis. During an interview on 7/30/25 at 1:37 p.m., the Administrator (ADM) was notified of some staffing and environmental concerns and conducted a walk through in the memory care unit. The ADM indicated staffing was set to daily census and acuity needs. The CNAs in memory care did not utilize assignment sheets, but provided care based off the Resident Profile and should follow a CNA To Do List.On 8/1/25 at 8:40 a.m., the ADM provided a copy of the CNA To Do List which was reviewed at that time. The Day and Evening shift To Do List was broken into five sections: 1. Tasks before breakfast, (11 items) 2. Tasks after breakfast, (11 items) 3. Tasks after lunch, (9 items) 4. Tasks upon arrival and prior to evening meal, (13 items) and 5. Tasks after dinner, (13 items) for a total of 57 tasks. The list was not broken up or assigned shift by shift.The Night Shift To DO List was considerably shorter with only 18 tasks which included, but were not limited to: incontinent checks, safety rounds, wheelchair cleaning per schedule and ensuring supplies were stocked for the next shift. Several resident's wheelchairs were observed dirty and in disrepair during the survey.Considering a day shift, from 6:00 a.m., until 2:00 p.m. in the memory care unit, (addressing resident behaviors as needed) there were 31 tasks to be completed which included, but were not limited to: review CNA sheets (which were not available), ensure all residents are provided A.M. cares and up for breakfast, completing charting, ensure beds are made, pass ice water, turn and reposition dependent residents, toileting, showers and empty trash. Ice water was not observed passed in memory care during the survey period. Showers were not observed in progress until after 7/29/25 when it was brought to staff attention. Multiple personal hygiene and oral care concerns were observed. Cross reference F584, F677, and F692.2. On 7/29/25 at 11:19 a.m., Resident B's record was reviewed. He had been a short-stay rehab resident with diagnoses which included, but were not limited to, Parkinson's disease, Type 2 diabetes mellitus without complication and anxiety disorder.A NOMNC dated 4/20/25, was not signed as acknowledged by Resident B until 4/21/25, as the requirement states, residents must receive at least 48 hours notice for noncoverage. During an interview on 7/29/25 at 2:21 p.m., the Administrator (ADM) indicated, Resident B's NOMNC was faxed to the facility after business hours on a Friday, and there were no administrative or Social Service staff in over the weekend to check the fax and notify Resident B. 3. Resident Council Minutes were reviewed from September 2024 until July 2025. The following was noted:On 9/3/24 twelve residents were in attendance for the meeting. Previous concerns from 8/2024, which included, but were not limited to, need more nursing staff . were discussed but the resolution was not accepted and at the time of the meeting, the residents complained again that they needed more nursing staff. On 10/1/24 fourteen residents were in attendance for the meeting. Concerns for adequate nursing staff from the previous meeting was reviewed, but again not resolved, as they resident requested more nursing staff at the October meeting as well. On 3/4/25 fifteen residents were in attendance for the meeting. At that time, they brought up concerns for adequate nursing staff and requested, if the facility could please provide more staff on the halls. The council received a response, dated 3/5/25, which indicated, continue to actively interview applicants. Halls are staffed adequately to census. On 6/3/25 eleven residents were in attendance for the meeting. at that time they brought up concerns that weekend staff were not answering all lights and were on their cellphones. 4. Resident/Family grievances were reviewed from January 2025 until July 2025. The following was noted and revealed unresolved, ongoing concerns related to incontinent care, call light response time, and customer service. On 1/7/25, Resident stated that staff takes a long time to change her . On 1/11 and 1/12 2025, Residents POA [power of attorney] came to visit both days in afternoon. Both days she came, she noticed [the resident] was incontinent of bowel and bladder. On Sunday, POA notified nurse that urine was not accumulating in drainage bag, the nurse then told her she noticed it as well, but no action was taken to fix the problem. On 1/15/25 a resident expressed concerns for incontinent care and customer service was slow. On 2/14/25 a resident expressed concerns for slow call light response time. On 2/26/25 a resident complained, the turned on the call light and he didn't see staff turn off light but they did pick up a blanket off the floor and place it at the foot of the bed and didn't bother to even ask if he needed anything, staff later apologized and stated, the shift was ending and they had things to get done. On 2/20/25 a complaint was filed on behalf of a resident which indicated, resident reported that [named resident] is being change/cleaned up in the mornings between 5 a.m. and 7 a.m., but no one is changing her after that until the evening around 9 p.m.On 2/20/25 a resident expressed concerns for incontinence, incontinent care with ADLs did not receive water, aides said they would return but did not. On 3/24/25 a resident complained, strong odor in room, resident roommate needs a shower, couldn't eat breakfast in room due to odor.On 3/31/25 a family member complained on behalf of their loved one, concerns about checking and changing every 2 hours since she cannot push her call light button. Concerned about wound/skin breakdown with positioning.On 3/31/25 a resident expressed concerns that a CNA comes in with his phone in his hand [and] told he would clean [the resident] with wipes instead of warm soapy water. Resident feels wipes not good for him. On 4/3/25 a resident expressed concerns for, slow on incontinent care. On 4/17/25 a complaint on behalf of a resident indicated, he has to wait to get incontinent care . On 4/4/25 a resident expressed concerns, overnight staff slow on answering call light. On 6/3/25 a resident complained that staff overnight were not filling up oxygen tanks. On 6/28/25 a complaint on behalf of a resident indicated, they didn't get a breathing treatment until after waiting for over an hour. On 7/15/25 concerns on behalf of a resident were noted, oxygen tanks were not being checked/changed every 4 hours, and the residents oxygen tanks had been found empty on three separate occasions. During a confidential interview, it was noted there were not enough nursing staff to get what needed to be done completed or at least completed in an effective and appropriate manner. There were too many high acuity residents for so few aides, and ADLs often went undone. On 7/31/25 at 1:10 p.m. the ADM provided a copy of current facility policy titled, Staffing Policy, revised 9/2018. The policy indicated, The staffing policy of ASC is to maintain adequate staffing in each facility . Home Office and facility leadership determine the budgeted staffing for all department during budget meetings . adjustments/changes to the budgeted staffing PPD amount can be adjusted anytime based on specific circumstances . and increase in acuity of levels of the residents. This additional staffing coverage is determined at the discretion of the Executive Director and the Facility based interdisciplinary team During the survey entrance conference on 7/27/25 at 10:00 a.m., a copy of the Facility Assessment Tool was requested and provided. The Assessment was dated 8/2024 and indicated, the average daily census was 72 . minimum staffing required (these requirements may fluctuate due to PPD and census) Licensed Nurse Staff: 2 on day, 2 on evening and 1 on nights. Non-Licensed Staff (CNA): 5 on days, 5 on evening and 3 on nights. Qualified Mediation Aides (QMA): 1 per shift . On the weekends there is an assigned nurse on call who would fill vacant shifts from call-outs This citation relates to Complaints IN00162849 and IN00162850.3.1-17(a)

Based on record reviews and interview, the facility failed to ensure a resident's medical record accurately reflected the resident's wishes related to advance directives for 1 of 1 residents reviewed for advanced directives (Resident 75). Findings include: On 8/1/25 at 9:35 a.m. Resident 75's medical record was reviewed. She was a long term care resident whose diagnoses included but were not limited to atrial flutter (a heart rhythm disorder where the heart's upper chambers beat rapidly and regularly, but not in a coordinated manner with the lower chambers) and myasthenia gravis (a chronic autoimmune disease that causes weakness in the voluntary muscles.). Resident 75 had an order for Do Not Resuscitate (DNR), dated 4/15/25, with a discontinue date of 4/15/25.Resident 75 had an order for full code, dated 4/15/25 with a discontinue date of 5/9/25, when the resident was discharged . A progress note, dated 4/22/25 at 1:31 p.m., indicated social services found that the Out of Hospital Do Not Resuscitate (OHDNR) paperwork was not filled out correctly. The note indicated social services spoke to Resident 75 and the resident indicated she fully understood what it meant to be a DNR and that was what she wanted, not a full code status, but she felt more comfortable with her Power of Attorney (POA) filling the paperwork out for her. A progress note, dated 4/22/25 at 2:53 p.m., indicated social services left a blank OHDNR form in the resident's room to fill out. An OHDNR form, dated 4/14/25, was signed by the attending physician but was not filled out by the resident or Resident Representative. An OHDNR form, dated 4/23/25, was signed by the resident's POA but was not signed by the attending physician. In order for an OHDNR form to be valid it must be signed by both the resident or Resident Representative and the attending physician. A care plan, dated 4/14/25, indicated the resident was a full code. On 7/29/25 at 12:30 p.m. the Executive Director (ED) provided a current facility policy titled, Advanced Directives (POST, DNR, Health Care Rep) dated 7/23 and it indicated it was current. This policy indicated, . it is the policy of this facility to provide information to resident/resident representative his/her rights to formulate advanced directives. if a resident has capacity to make decisions, the resident makes decisions regarding their medical decisions, advanced directives and healthcare appointments. Resident representatives, health care representatives and/or power of attorneys should only make decisions when a resident no longer has capacity to make his/her own decisions and/or specifically designates the representative to make decisions on their behalf . Out of hospital do not resuscitate form:. new admissions: 1. The admitting nurse will review the hospital/admission paperwork for the presence of an existing out of hospital do not resuscitate form. If there is a form present the nurse will review the form for completeness including signature of the resident/representative, witnesses and physician, advanced practice nurse or physician's assistant. 5. A resident cannot be considered a DNR until the out of hospital do not resuscitate declaration and order form has been signed/dated by the resident/representative, 2 witnesses and the attending physician, advanced practice nurse or physician's assistant. (Note, the out of hospital do not resuscitate declaration form may be honored with a verbal order from the physician and signed by the physician, advanced practice nurse or physicians assistant within 10 days).3.1-4(d)3.1-4(e)3.1-38(f)3.1-4(l)(4)

Based on record review and interview, the facility failed to complete a pre and post dialysis assessment for a resident on his dialysis days for 1 of 1 resident reviewed (Resident 40) . The deficient practice was corrected 2/20/25 and was therefore past noncompliance. Findings include: On 7/29/25 at 12:43 a.m., a record review was completed for Resident 40. He had the following diagnoses which included but were not limited to end stage renal disease, essential hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), anxiety, sleep apnea, insomnia, and heart failure. Resident 40 had an order, dated 1/27/25, for dialysis on Monday, Wednesday, and Friday. He was missing dialysis pre and post assessments for the following days: 2/3/25, 2/5/25, 2/7/25, 2/10/25, 2/12/25, 2/14/25, 2/17/25, 2/19/25, 2/21/25, 2/24/25, 2/26/25, 3/5/25, 3/7/25, 3/14/25, 3/17/25, 3/21/25, 3/24/25, 3/26/25, 3/28/25, and 3/31/25. Resident 40 had a care plan dated 1/27/25. It indicated Resident was receiving hemodialysis and was at risk for complications such as fluid imbalance, bleeding or infection, right arm fistula. It lacked an intervention for pre and post dialysis assessments. On 7/30/25 at 10:32 a.m., during an interview with the Director of Nursing (DON), she indicated the pre and post dialysis events were missing due to staffing concerns prior to June 2025. Now that she has a stable nurse, the events have been completed. On 7/30/25 at 1:15 p.m., during an interview with the Executive Director (ED) and DON, they indicated after identifying dialysis pre and post assessment were not being completed in February 2025, they completed a Quality Assurance Performance Improvement (QAPI) plan to address the identified concern effective 2/20/25. A copy of the QAPI plan was provided. A policy titled, Dialysis Care was provided by the Regional Nurse Consultant Specialist (RNCS) on 7/30/25 at 12:35 p.m. It indicated, .Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.A dialysis event will be initiated in the electronic medical record (EMR) to include time of transfer and completed on return to the unit.3.1-37(a)

Based on observations, interviews, and record reviews, the facility failed to ensure all medications and treatments were stored and labeled properly for the facility in 1 of 1 medication storage rooms and 1 of 1 medication carts reviewed. This deficient practice had the potential to affect 78 of 78 residents that resided in the facility who received medications. Findings include: On [DATE] at 9:57 a.m., the medication storage room was observed with Director of Nursing (DON). The medication storage room was observed to have a large quantity of various medications and treatments which needed to be returned. The medications were stacked and scattered throughout the room. There were two full bins which overflowed on to the counter and floor and one sink was observed to be full of medications which overflowed into the second sink. The DON stated all the medications observed came off the medication carts this week. The DON indicated one bag of medication was mixed in with the to-be-returned to pharmacy medication and should not have been there. The DON indicated that the Medical Records Coordinator (MRC) was responsible for loading medication into the system to initiate the pharmacy return process. The medication refrigerator had Aplisol (an injectable solution to test for tuberculosis) with an arrival date of [DATE], with no open date. The DON indicated that she would dispose of it. On [DATE] at 10:49 a.m., the B Hall medication cart was reviewed with Licensed Practical Nurse (LPN) 8. The medications reviewed were as follows: Resident B had brimonidine/ bromidine 0.2% (a type of eye drop) no open date, manufactures expiration date ,d+[DATE]. Medication to stay on cart until manufactures expiration date. Resident F had latanoprost 0.005% (a type of eye drop) with no open date, manufactures expiration date ,d+[DATE]. Resident G had latanoprost 0.005% with an open date of [DATE], manufacture expiration date ,d+[DATE]. During an interview, on [DATE] at 11:30 a.m., the DON indicated, eye drops need to have open dates. When asked about why the medication storage was in disarray, the DON indicated, the MCR had left the position on [DATE]. The their absence, the facility relied on a Float MRC, but they only came to the facility on ce every 2 weeks to fill in until they could fill the position. The DON indicated, the facility staff looked at orders, but did not scan them into the computer. They were a paperless facility and the DON expected the nursing staff to scan in documents as needed. During an interview on [DATE] at 3:08 p.m., the Float MRC indicated, he had only been at the facility a couple of times since the previous medical records person left on [DATE]. No one from the building had requested him to return to the building. He indicated he scanned documents into the resident's electronic medical records and did nothing with medication storage or the medications that needed to be returned to the pharmacy. The facility would take care of the pharmacy returns. He was not made aware of the need to scan documents before they could be returned to the pharmacy. He indicated he did not have daily duties at the facility, he only did billing. On [DATE] at 11:30 a.m., the DON provided a copy of current facility policy titled, Storage and Expiration Dating of Medications and Biologicals, dated [DATE]. The policy indicated, .facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers, of sufficient size to prevent crowding .facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .when an ophthalmic solution or suspension has a manufacture shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container On [DATE] at 12:25 p.m., the DON provided a copy of current facility policy titled, Returning Medications to the Pharmacy, dated [DATE]. The policy indicated, .if returns are permitted under applicable law, facility should return medications with any associated paperwork or documentation to pharmacy immediately after such medications have been discontinued This citation relates to Complaint IN00443579. 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

Based on observation, interview, and record review, the facility failed to prevent the potential for the spread of a highly contagious virus when staff failed to perform hand hygiene and don personal protective equipment (PPE) in a COVID-19 positive isolation room for 2 of 2 days of observation. This deficient practice had the potential to effect 22 of 78 residents who resided on the D-hall of the facility. Findings include: During an interview on 10/9/24 at 11:36 a.m., Resident B indicated she was worried about catching COVID-19 because she knew staff were not using the appropriate PPE to enter isolation rooms. She indicated she often sat at the nurses station and watched as staff entered COVID-19 positive rooms and they did not put on a gown, gloves or new masks. On 10/9/24 at 1:30 p.m., Resident C's room was observed from the hallway. The door was open, but there was a bright red sign which indicated PPE was required to enter the room due to droplet isolation precautions. On 10/9/24 at 1:48 p.m., Certified Nursing Assistant (CNA) 6 entered Resident C's room. She did not perform hand hygiene, don a gown, gloves, N-95 or eye protection. She exited the room with a lunch tray, and carried the uncovered tray don't he hall, past the nurse station and down the hallway to the dining room where she placed the tray into a rolling cart. On 10/9/24 at 2:00 p.m., Resident C's room was observed from the hallway. There was no waste basket for discarded PPE inside the room. On 10/10/24 at 8:58 a.m., CNA 6 and CNA 7 entered Resident C's room to provider her breakfast tray. Neither CNA performed hand hygiene, donned gowns, gloves, N-95s or eye protection. CNA 6 and 7 exited the room. Neither CNA performed hand hygiene before they continued to other resident's rooms to distribute breakfast trays. During an interview on 10/10/24 at 9:00 a.m., the Director of Nursing Services (DNS) indicated, all staff and visitors should don appropriate PPE and perform hand hygiene before entering a covid positive and/or any isolation room. The DNS immediately educated the two CNAs. On 10/9/24 at 1:28 p.m., Resident C's record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, vascular dementia (a degenerative brain disease which affects conitive function and memory) and a history of cancer. A nursing progress note, dated 10/2/24 at 10:19 a.m., indicated Resident C had complained of a sore throat. She was tested for COVID-19 and found to be positive. She was placed in isolation. During an interview on 10/10/24 at 11:07 a.m., the Infection Preventionist (IP) indicated, Resident C had been on Memory Care, but was moved to a room on the D-hall before staff knew she was positive. When residents on the memory care unit started to test positive, Resident C and her roommate were tested due to contact tracing. Resident C tested positive, but her roommate was negative. Resident C's roommate had not become symptomatic and therefore had not been tested since her initial contact test. The IP indicated staff should perform hand hygiene before and after leaving any room and should follow all PPE precautions as indicated by the signs on the resident's doors. On 10/9/24 at 2:43 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Standard and Transmission-Based Precautions (Isolation) Policy, revised 4/2024. The policy indicated, .Purpose: to implement appropriate transmission-based precautions to prevent the transmission of infection . Always assume that every resident is potentially infected or colonized with an organism that could be transmitted in the healthcare setting . hand hygiene [should be completed] after touching resident surroundings (objects surfaces in the resident's environment) . Covid-19 positive resident . HCP [healthcare provider] should wear an N95 or higher-level respirator, eye protection . gloves and gown when caring for these residents . PPE must be appropriately doffed and discarded in trash prior to leaving room This citation relates to Complaint IN00443579. 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure medications were provided according to the physician's order (Resident B) for 1 of 2 residents reviewed for medication administration. Findings include: On 10/10/24 at 9:45 a.m., Resident B expressed concern about missing some of her medications. She indicated she missed her clonazepam (antianxiety) four times this week. On 10/10/24 at 11:24 a.m., Resident B's October Medication Administration Record (MAR) was reviewed for missing medications. According to the MAR: a. Her clonazepam 1 mg, a scheduled IV tablet (controlled substance), was not given on 10/3/24 at 10:00 p.m., 10/4/24 at 2:00 p.m. and 10:00 p.m., 10/7/24 at 2:00 p.m. and 10:00 p.m., 10/8/24 at 10:00 p.m., and 10/9/24 at 10:00 p.m. b. Her dicyclomine tablet (for irritable bowel), 20 mg was not given on 10/3/24 at 10:00 p.m., 10/4/24 at 10:00 p.m., 10/7/24 at 10:00 p.m., 10/8/24 at 10:00 p.m., 10/9/24 at 10:00 p.m., and 10/10/24 at 8:00 a.m. c. Her dorzolamide-timolol 2-0.5 % (treat glaucoma) was not given at 7:00 p.m. on 10/3/24, 10/4/24, 10/7/24, 10/8/24, and 10/9/24. d. Her hydrocodone-acetaminophen 10-325 mg, schedule II tablet (controlled substance) was not given on 10/3/24 at 10:00 p.m., 10/4/24 at 2:00 p.m. and 10:00 p.m., 10/7/24 at 2:00 p.m. and 10:00 p.m., 10/8/24 and 10/9/24 at 10:00 p.m. e. Her symbicort (budesonide-formoterol) aerosol inhaler was not given at 7:00 p.m. on 10/3/24, 10/4/24, 10/7/24 and 10/9/24. f. Her trazodone tablet (treats depression and anxiety) 100 mg was not given on 10/3/24, 10/4/24, 10/7/24, 10/8/24 and 10/9/24. g. Her albuterol inhaler was not given on 10/5/24 at 6:00 p.m. A current policy titled, General Dose Preparation and Medication Administration, dated 4/30/24, was provided by the DON, on 10/10/24 at 11:30 a.m., A review of the policy indicated, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident This citation relates to Complaint IN00443579. 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure medication was not left at bedside without a self-medication assessment for 1 of 1 resident reviewed for medication self-administration (Resident B). Findings include: On 10/10/24 at 10:16 a.m., Ventolin (albuterol) and Symbicort inhalers were observed on Resident B's over the bed table. On 10/10/24 at 11:24 a.m., Resident B's self-administration assessment was reviewed. It indicated on 9/5/24, she was approved to self-administer bacitracin (topical antibiotic) to her nose. No other medications were listed to self-administer. A current policy, titled, General Dose Preparation and Medication Administration, dated 4/30/24, was provided by the DON, on 10/10/24 at 11:30 a.m., a review of the policy indicated, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident This citation relates to Complaint IN00443579. 3.1-11

Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident B) was comprehensively assessed for her nutritional status and person centered interventions were implemented for 1 of 3 residents reviewed for nutrition. Findings include: During an interview on 10/9/24 at 11:36 a.m., Resident B indicated, she did not like the food and was tired of only being able to receive hamburgers as food substitutes. She was supposed to be on a low sodium diet, but did not feel like she had been provided with a variety of options or healthier options. Resident B indicated when she asked for alternative food options, staff told her the alterative menu would also be a hamburger. Resident B indicated she had never been visited by the Registered Dietician (RD). She wanted the RD to see her, review her new low sodium diet, and give more options than just a hamburger. On 10/9/24 at 1:11 p.m., Resident B's lunch tray was observed, and the meal had been consumed. Resident B pointed to her ticket which indicated she received a hamburger again. She indicated she ate it because she was hungry and when she asked about an alternative the nurse said it might be a while before she could get anything else. On 10/9/24 at 11:40 a.m., Resident B's medical record was reviewed. She was a long-term care resident who had diagnoses which included but not limited to, acute on chronic congestive heart failure, type II diabetes mellitus and anxiety. An admission Minimum Data Set (MDS) assessment, dated 8/18/24, indicated Resident B was cognitively intact. Her nutrition assessment, section K, was completed by the MDS Coordinator (MDSC) on 8/15/24. Section K indicated Resident B's height and weight, but weight gain and/or weight loss was listed as unknown. An admission Initial Nutrition Review, dated 8/12/24, was completed by the Culinary Dietary Manager (CDM). The Nutrition Review indicated, Resident B received a regular diet, and disliked pork and salty foods. Resident B's goal for nutritional health was, healthy heart diet. Resident B's record lacked documentation that a Nutrition Focused Physical Exam (NFPE) and/or a Estimated Nutrient Needs Assessment had been completed. A nursing progress note, dated 9/28/24 at 1:07 a.m., indicated, Resident B had complained of chest pain and was sent to the Emergency Department (ED). A corresponding hospital discharge summary, dated 10/1/24, indicated Resident B presented to the ED with complaints of chest pain and trouble breathing.diet is high salt as she cannot be on a heart healthy diet at her facility . patient was evaluated by medical nutrition and educated on a low salt diet and weight loss strategies. Patient's presentation was thought to be in part due to high sodium intake from diet . Barriers to care: availability of low salt diet . Active issues requiring follow-up: Acute on chronic heart failure . needs to be on a low salt diet to prevent exacerbation of heart failure Resident B's current physician's orders were reviewed, and she had a Regular Diet order dated 8/7/24 with no specifications of low-salt. Resident B's comprehensive care plans were reviewed. She had a care plan initiated 8/13/24 which indicated she was at risk for unintentional weight loss, but that weight loss would be warranted. Interventions included, but were not limited to monitor her weight, notify doctor of weight changes and provide diet per doctor's orders. Resident B's care plans lacked documentation of revisions to address what kind of weight loss may be warranted, goals for weight loss, preferences for a low salt diet and or interventions to address known behaviors related to her nutrition management. Resident B's weight was obtained upon admission on 8/7/24 but had not been taken since. During an interview on 10/9/24 at 1:57 p.m., the Regional Registered Dietician Consultant (RRDC) indicated, upon admission, a resident should be seen by the CDM within the first business day to obtain diet orders and preferences. After admission, but within 14 days, the resident should be assessed and evaluated by the RD. The RRDC reviewed Resident B's MDS and nutritional assessments and indicated, it appeared that the RD had not been to see Resident B since her admission. The MDS should trigger the comprehensive care plan, and additional revisions would have been made after the RD assessed the resident. On 10/9/24 at 2:40 p.m., the Director of Nursing Services (DNS) provided a copy of current facility policy title, Nutrition Review and Assessment, revised 9/2024. The policy indicated, .It is the policy of American Senior Communities that each resident and/or family will be interviewed to determine preferences surrounding meals as well as to assess nutrition status and factors that may pout the resident at risk for altered nutrition . A Nutritional Focused Physical Exam (NFPE) will be completed by the Registered Dietician upon admission and additionally at the RD's clinical discretion. The NFPE is used to assess the resident for fat and/or muscle wasting to determine nutritional status and to assist in developing an appropriate nutrition plan of care . The RD, or designee will complete the Estimated Nutrient Needs observation following admission and with each comprehensive assessment but, no less that annually . Information from the Initial Nutrition Review, Malnutrition Screening Tool, Estimated Nutrient Needs, Nutritional Focused Physical Exam, interviews with the resident . will all be used to complete the . Resident centered care plan and to update the tray ticket system This citation relates to Complaint IN00443579. 3.1-46

Based on observation, interview, and record review, the facility failed to ensure staff were competent with medication administration for 2 of 2 residents observed for medication administration (Residents B and E) Findings include: On 10/10 24 at 10:09 a.m., LPN 8 was observed at the B Hall Medication Cart. During a medication administration for Resident B, LPN 8 provided a Symbicort inhaler (treats asthma and COPD-chronic obstructive pulmonary disease), the resident took a puff of the inhaler. Immediately after, LPN 8 provided albuterol (treats asthma and COPD) and Spirva (dilates bronchial passage ways) with no delay between puffs. He provided water for the resident to rinse her mouth. She swallowed the water. On 10/10/24 at 10:35 a.m., LPN 8 was observed preparing medication for Resident E. He was observed pouring 15 mL (milliliters) Robitussin (cough suppressant) into a medication cup. He was observed lifting the round cardboard from the touch of the bottle with his bare fingers. He double checked the level of medication at eye-level and indicated 15 mL. The physician's order indicated the resident received 10 mL Robitussin. On 10/10/24 at 10:39 a.m., LPN 8 started to provide the 15 mL to Resident E. He was asked to confer in the hallway. He insisted the medication was at 10 mL until he removed his cell phone and used the flashlight to illuminate the markings on the side of the medication cup. Afterward, he indicated he needed readers (magnifying glasses). The correct amount of Robitussin was provided to the resident. A current policy, titled, General Dose Preparation and Medication Administration, dated 4/30/24, was provided by the DON, on 10/10/24 at 11:30 a.m., A review of the policy indicated, .Medications should not come in contact with any surface except for the medication cup .Facility staff should avoid touching the medication with bare hands when opening a bottle .Facility staff should verify that the medication name an dose are correct when compared to the medication order on the medication administration record This citation relates to Complaint IN00443579. 3.1-14(k)

Based on observation, interview, and record review, the facility failed to maintain the dignity and the right to refuse services of 1 of 5 residents reviewed for resident rights (Resident S). Findings include: On 8/20/24 at 11:43 a.m., during an initial observation and interview, Resident S was observed the resident lying in bed. The call light was within reach on the right side of her bed attached to her bed rail. She was on a low air loss mattress to facilitate comfort and prevent skin breakdown. The resident was cognitively intact, alert, and pleasant. The resident indicated she was able to stand and transfer to her wheelchair with assistance from the staff. She preferred to have meals in her room, but she was able to go to the dining room. The resident indicated on 8/17/24 (she was unsure of the time), she was in the lobby with her daughter, and she removed her oxygen tubing from her nose because she did not feel any air in the tube. She indicated Licensed Practical Nurse (LPN) 5 was sitting at the nurse's desk and she asked the nurse three times for help. She indicated LPN 5 yelled at Resident S and told her she was not her nurse. Another nurse, she did not recall the nurse's name, came to the area she was at and filled the portable oxygen tank for her. Later in the evening Registered Nurse (RN) 6 came into her room to give her the evening dose of medications. Resident S saw LPN 5 come into the room with RN 6. Resident S indicated she yelled at LPN 5 to get out of her room. She told LPN 5 she did not want her in her room because she was upset over the conversation she had with her earlier at the nurse's station about her oxygen. LPN 5 yelled at Resident S and said she was not going anywhere and continued to play on her phone. Resident S indicated she knew she should not have done it, but she picked up her styrofoam water cup and threw the water towards LPN 5. The cup hit the floor and splashed onto the nurse's pants. LPN 5 threatened to call the police and remained in the room. On 8/20/24 at 2:00 p.m., the medical record of Resident S was reviewed. Diagnosis included but were not limited to: Chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems) with (acute) exacerbation (sudden worsening), morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications (a disease that occurs when your blood glucose, also called blood sugar, is too high), hypertensive heart disease with heart failure, chronic systolic (congestive) heart failure (a group of heart problems that occur when high blood pressure is present over a long period of time), anxiety disorder (a feeling of fear, dread, and uneasiness). An Admission Minimum Data Set (MDS) assessment, dated 8/13/24, indicated the resident was cognitively intact. A care plan, dated 8/20/2024, indicated. Resident experienced behavior expressions such as at times cursing and yelling at staff, throwing cups at staff, refusing when offered a shower/bathing and then making accusations of staff not offering or bathing her, refusing peri care when staff offer stating No, I am asleep or No not right now and then accusing staff of not giving peri care. Approaches with start date of 8/20/2024 included continue with care in pairs, ensure safety, allow resident time to cool off, provide calm, unhurried, and supportive approach, notify family of refusals, notify MD of refusals, and remove from immediate area to further evaluate needs. On 8/20/24 at 2:31 p.m., during an interview with the Administrator. She indicated a care plan meeting with the resident and her daughter was completed on 8/17/24. She indicated the resident had said a nurse had spoken inappropriately to her and suggestions for her care were discussed. The Administrator indicated she had not received any reports from the DON or the Assistant DON (ADON), regarding reports of verbal abuse to a resident. She indicated if a resident was care planned for care to be provided in pairs it is for a specific reason. The staff member could ask another person to stand in the room if it was a non-clinical issue as a witness. A non-medical person could be a stand in if there was a need. She indicated Resident S had made false accusations against the staff and she was care planned for all care to be administered with two persons. A review of the progress notes lacked documentation of a care plan meeting on the date specified by the Administrator. On 8/20/24 at 2:45 p.m., during an interview with the DON and the Administrator. The DON indicated she had not received a report of anyone submitting a complaint about a nurse. She then indicated LPN 5 had called her regarding a situation with Resident S. She indicated Resident S, had yelled at her and she was 5 seconds from calling the police because the resident threw water on her. She indicated RN 6 was administering medication and she was there as a witness. She was on her phone looking up the resident's medication when the resident threw water on her. The DON acknowledged the nurse should have left the room when told to leave by the resident. The Administrator indicated the resident yelled and cursed at the staff and told false allegations about the staff. She indicated this was the first time she had heard about the incident; however, the staff should not be assaulted by the residents. The DON was unable to indicate why the nurse felt threatened to the point she would believe she needed to call the police for protection. The DON indicated she had not reported this to the Administrator, and she had not completed any employee education. The Administrator indicated the facility provided customer service education to all staff. On 8/21/24 at 10:31 a.m., during an interview with CNA 8. She indicated she has had education regarding dealing with residents with behaviors. She indicated she would leave the room if a resident request her to leave. If she was asked to be second person to assist and the resident asked her to leave, she would leave and ask another CNA to assist. On 8/21/24 at 10:43 a.m., during an interview with RN 9. She indicated she had no issues with residents refusing care. On August 17th she worked with Resident S for the first time and indicated the resident was very pleasant. She indicated she had received education on how to work with residents with behaviors and residents with dementia. She indicated if a resident asked her to leave their room, she would explain why she needed to be there. If the resident became upset, she would try to calm them but at some point, she would leave and ask another staff member to assist. On 8/21/2024 at 12:30 p.m., the provided an undated document titled, Your Rights and Protections as a Nursing Home Resident, and indicated it was the policy currently being used by the facility. The policy indicated, .At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. You have the right to .Be treated with respect: You have the right to treated with dignity and respect .Be free from Abuse and Neglect .You have the right to be free from verbal abuse .Make complaints .You have the right to make a complaint to the staff of the nursing home, or any other person This citation relates to Complaint IN00441304. 3.1-3(a)(1)

Based on observation, interview, and record review, the facility failed to ensure linens were not contaminated for 4 of 12 residents during dining service (Resident 3, 9, 7, 21, and 46) and failed to ensure kitchen temperature logs were completed. Findings include: 1 On 6/2/24 at 12:18 p.m., the Social Services Director (SSD) was observed bringing tablecloths and clothing protectors into the dining room. She was holding them up against her body and sleeve. She indicated she was just making sure everyone had tablecloths and clothing protectors. On 6/2/24 at 12:20 p.m., the SSD was observed putting a table cloths on a table while Resident 9 was sitting at the table, then she provided him with a clothing protector. On 6/2/24 at 12:23 p.m., the SSD was observed to pick up trash from the dining room floor and threw it away. She did not do any hand hygiene and put a table cloth on Resident 21's table and provided clothing protectors for Resident 21, Resident 46, Resident 7, and Resident 3. A current policy, titled, Laundry/Linen dated 12/2021, was provided by the Executive Director (ED), on 6/4/24 at 3:28 p.m. A review of the policy indicated, .To ensure the proper care and handling of linen and laundry to prevent the spread of infection .Clean linen must be protected from soiling or contamination .Clean linen should be carried away from body to prevent contamination A current policy, titled, Hand Hygiene Policy dated 12/2021, was provided by the Executive Director (ED), on 6/4/24 at 3:28 p.m. A review of the policy indicated, .to provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees .American Senior Communities will follow the Centers for Disease and Prevention (CDC) guidelines for the standards of hand hygiene 2. During a kitchen tour, on 6/2/24 at 10:36 a.m., several temperature (temp) logs were observed incomplete. a. The Prep Cooler had no morning temps for 6/1/24 or 6/2/24. b. The High Temperature Dish Machine had no temp logs for morning, lunch, or dinner on 6/1/24. A current policy, titled, Food Storage, dated 5/23, was provided by the Executive Director (ED), on 6/4/24 at 3:28 p.m. A review of the policy indicated, .Thermometers should be checked utilizing an internal thermometer at least two times each day. Temperatures should be recorded prior to breakfast preparation and again prior to dinner service. 3.1-19(l) 3.1-21(i)(2)

Based on observation, interview and record review, the facility failed to designate an Infection Preventionist (IP) who was available for a minimum of 20 hours a week and did not share the duties/responsibilities of other departments, to ensure daily monitoring and implementation of the Infection Control and Prevention program for 5 of 5 months reviewed. This deficient practice had the potential to affect 75 of 75 residents who resided in the facility: Findings include: Upon survey entrance, name and certification of the facilities IP was requested and provided. The Executive Director (ED) indicated the facility's IP was Licensed Practical Nurse, (LPN) 4, who also served as the full time Minimum Data Set (MDS) Coordinator. On 6/4/24 at 10:24 a.m., the Regional IP Consultant (RIPC) indicated the facility had been without a full-time IP for a couple of months, but he came to the building about 1-2 times a month in order to update the infection tracking binder, complete the infection mapping and antibiotic stewardship reports. The RIPC indicated, his time in the building was less than 20 hours per week, but in the absence of a full-time IP, the MDSC was responsible for the daily implementation and oversight of the program. During an interview on 6/4/24 at 1:34 p.m., with the RIPC and the MDSC present, the MDSC indicated, she did have an IP certification and had temporarily filled the position in January. The MDSC indicated, she spent the majority of her time on MDS tracking, scheduling and assessment submission. She also helped out with weekly wound rounds. On 6/6/24 at 10:07 a.m., the Facility Assessment was reviewed. The assessment was dated 1/23/24 and LPN 4 signed as the IP. Standard competencies for the IP position indicated, .Infection control and prevention program, daily surveillance of infection completed . Further, the assessment indicated the facility required a full-time IP and that, .if answered yes, they may not share other duties During an interview on 6/6/24 at 11:36 a.m., the IP program and position vacancy was reviewed with the ED. The ED indicated, in the absence of a full-time IP staff, the facility had the RIPC help out and the MDSC cover daily tasks. When the Facility assessment specifications were reviewed, the ED agreed that if the MDSC had been asked to fill the role of the IP, another staff member should have been appointed to fill the MDSC role, so that the IP would not share duties to maintain a comprehensive and effective daily program implementation.

Based on observation, interview, and record reviews, the facility failed to provide a safe, clean, comfortable environment to ensure pest control interventions were effective for 5 of 5 months of recommendations reviewed. This deficiency had the potential to affect 75 of 75 residents residing in the facility. Findings include: 1. During a kitchen tour, on 6/2/24 at 10:47 a.m., several dozen flying insects were observed alighting from clean dishes when the clean dish shelf was slightly wiggled. On 6/2/24 at 10:48 a.m., [NAME] 16 indicated she had seen flying insects all around the kitchen. On 6/2/24 at 10:49 a.m., the Dietary Manager (DM) indicated she had seen the Maintenance Man (MM) using a vacuum device to remove the flying insects. On 6/2/24 at 10:57 a.m., the DM indicated the large tub under the 3 compartment sink was there because the sink leaked. The tub was observed with standing water. On 6/2/24 at 11:00 a.m., a wet blanket was observed around the bottom of the ice machine in the kitchen. The DM indicated the blanket was there because the ice machine leaked. On 6/2/24 at 11:02 a.m., small flying insects were observed flying in the kitchen. On 6/2/24 at 11:03 a.m., the DM indicated a local pest control company was in the facility about a month ago. The pest technician showed her how to clean the drains in the kitchen. She indicated she cleaned a lot of junk out of 3 drains in the kitchen using a toilet brush, but the flying insects came back. 2. On 6/2/24 at 11:47 a.m., Resident 7's room was observed. Her mattress, without a mattress cover, had a dark stain in the middle of the mattress. Over 50 flying insects were observed on the mattress, on top of the stain. Flying insects were observed flying in her room. On 6/2/24 at 1:43 p.m., Resident 7 was observed in her room with her back to her bed. The stain on Resident 7's mattress was observed to be cleaned but the flying insects were still observed to be on the mattress where it had been cleaned. On 6/3/24 at 1:59 p.m., the Housekeeping Supervisor provided documentation, dated 6/2/24, Resident 7's mattress had been discarded and replaced. Her room was deep cleaned to include drawers where she had old snacks and food, drawing bugs and used placeware. Her curtains were changed. 3. On 6/2/24 at 11:59 a.m., Resident 65 indicated he had gnats in his room with a lot of gnats in the bathroom. Flying insects were observed in his room at this time. 4. On 6/2/24 at 12:04 p.m., Resident 12 was observed in his bed. His room was observed with flying insects. The floor had food debris, possibly crushed potato chips. 5. On 6/2/24 at 1:21 p.m., Resident 53 indicated he had gnats in his room. Flying insects were observed in his room at this time. 6. On 6/3/24 at 10:31 a.m., Resident 124 was observed to swat away flying insects during an interview. He indicated that was another thing he had concerns about was all these gnats. 7. On 6/3/24 at 1:51 p.m., Resident 25's record was reviewed. Her diagnoses included, but were not limited to, myxedema coma (severe hypothyroidism leading to decreased mental status, hypothermia and slowing of function in multiple organs), seizures (uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements), and dystonia (uncontrollable muscle contractions). On 6/3/24 at 2:23 p.m., flying insects were observed in Resident 25's room. She was in bed with her eyes closed, she was unarousable with her mouth open. On 6/4/24 at 9:53 a.m., Resident 25 was observed in her room, in her bed with her eyes closed and her mouth open. She was unarousable with her mouth open. Two flying insects were observed on her blanket and one flying insect was observed on her pillow 8. On 6/4/24 at 10:12 a.m., Qualified Medication Aide (QMA) 9 was observed to provide medications for several residents. On 6/4/24 at 10:26 a.m., QMA 12 was observed to swat away a flying insect as she was preparing medications for Resident 13. On 6/4/24 at 10:32 a.m., QMA 12 was observed to swat away a flying insect as she was preparing medications for Resident 13. On 6/4/24 at 10:47 a.m., QMA 12 was observed entering Resident 53's restroom to wash her hands. A flying insect was observed in the room. 9. On 6/10/23 at 4:08 p.m., a Resident Grievance form, dated 6/2/24, was reviewed for Resident 226. It indicated the resident reported an insect was on her. She saved it in a napkin. The ED spoke with the resident and the insect was a winged ant. The resident's room was deep cleaned. 10. On 6/10/23 at 4:10 p.m., a Resident Grievance form, dated 4/23/24, was reviewed for a resident no longer residing in the building. The resident complained of gnats. No follow-up for gnats was noted. 11. On 6/10/24 at 4: 15 p.m., the Resident Council Meeting Minutes were reviewed. a. On 4/2/24, the Resident Council indicated the gnats were getting better. b. On 6/4/24, a statement in the minutes, indicated, .chemicals received soon for more treatments for gnats On 6/2/24 at 12:42 p.m., the pest control documentation from the local pest company used by the facility was provided by the Executive Director (ED). The Pest Control Documents indicated, dated 1/11/24, indicated the targeted pests were mice and cockroaches. The structural and sanitation concerns that could cause pest problems found and provided to the facility were as follows with the pest company recommendations: a. Interior kitchen area had floor tiles or baseboards loose and or missing. Recommendation was made to repair floor tiles and baseboards to eliminate potential pest harborage and breeding sites. b. Front door an exit door did not close to seal properly with a 1/4 gap or greater existing. Recommendation was made to install/replace door sweep. c. Rear door floor tiles or baseboards were loose or missing. Recommendation was made to repair the tiles and baseboards to eliminate potential pest harborage and breeding sites. d. Interior kitchen issues, the floor drains were in need of cleaning. All of the floor drains in the kitchen had a thick layer of biofilm built up inside them that needed scrubbed out and cleaned thoroughly. Recommendation was made to clean in and around drains frequently to help prevent pest breeding sites. e. In the kitchen, underneath the dish sink, a recommendation was made that the area needed cleaned thoroughly as there was some standing water and a lot of grease and grime built up on the baseboards. Recommendation was made to address the sanitation issues. The Pest Control Documents indicated, dated 2/28/24, indicated the targeted pests were mice, cockroaches, and large flies. The structural and sanitation concerns that could cause pest problems found and provided to the facility were as follows with the pest company recommendations: a. Interior kitchen area had floor tiles or baseboards loose and/or missing. Recommendation was made to repair to eliminate potential pest harborage and breeding sites. b. Rear door floor tiles or baseboards were loose or missing. Recommendation was made to repair the tiles and baseboards to eliminate potential pest harborage and breeding sites. c. Interior kitchen issues, the floor drains were in need of cleaning. Recommendation was made to clean in and around drains frequently to help prevent pest breeding sites. The Pest Control Documents indicated, dated 3/29/24, indicated the targeted pests were mice and cockroaches. The pest activity found was in the interior kitchen area, small flies were found during pest control service. There were quite a few small flies noted. The structural and sanitation concerns that could cause pest problems found and provided to the facility were as follows with the pest company recommendations: a. Interior kitchen area had floor tiles or baseboards loose and or missing. Recommendation was made to repair the tiles and baseboards to eliminate potential pest harborage and breeding sites. b. Interior kitchen issues, the floor drains were in need of cleaning. Recommendation was made to clean in and around drains frequently to help prevent pest breeding sites. The Pest Control Documents indicated, dated 4/30/24, indicated the targeted pests were mice, cockroaches, and large flies. a. Interior kitchen area had floor tiles or baseboards loose and or missing. Recommendation was made to repair the tiles and baseboards to eliminate potential pest harborage and breeding sites. b. Interior kitchen issues, the floor drains were in need of cleaning. Recommendation was made to clean in and around drains frequently to help prevent pest breeding sites. c. Underneath the dish sinks, there was a lot of grease and dirt build up on the floor and on the walls. Recommendation was made to address these sanitation issues. d. Behind the cooler and the ice machine there was some grease and dirt build up. Recommendation was made to address this sanitation issue. The Pest Control Documents indicated, dated 4/30/24, indicated the local pest control technician indicated he had a conversation the Executive Director, .about the ongoing small fly issue, took a walk through of [sic] the kitchen and showed her all of the sanitation issues relating to the small flies, the floor drains being the main issues. I also pulled one of the covers off and showed the Executive Director and some of the kitchen staff the biofilm build up within a couple of the floor drains The Pest Control Documents indicated, dated 5/3/24, indicated the targeted pests were small flies. The structural and sanitation concerns that could cause pest problems found and provided to the facility were as follows with the pest company recommendations: a. Interior kitchen area had floor tiles or baseboards loose and/or missing. Recommendation was made to repair the tiles and baseboards to eliminate potential pest harborage and breeding sites. c. Interior kitchen area underneath the dish sink and some of the prep equipment, there was a lot of standing water. Recommendation was made to address this sanitation issue. d. Pest control company actions taken: Cleaned the drains and areas that were causing the small fly issue and fogged the kitchen to reduce the population. Pest activity was found during service. The Pest Control Documents indicated, dated 5/31/24, indicated the targeted pests were mice, cockroaches, and large flies. The structural and sanitation concerns that could cause pest problems found and provided to the facility were as follows with the pest company recommendations: a Small flies were noted during pest control service in the kitchen, specifically by the dish area. There were quite a few small flies harboring by the trash cans and the garbage disposal. b. Interior kitchen area had a hole/gap noted above the dish area. There were holes in the wall paneling that need fixed. Recommendation was made to seal the gap to prevent pest entry or harborage. Floor tiles or baseboards were loose or missing. Recommendation was made to repair tiles or baseboards to eliminate potential pest harborage or breeding sites. b. Interior hallways had holes and gaps noted in the hallway by the back door, kitchen, and the laundry room. There was a lot of messed up drywall by the floor wall junction. Recommendation was made to seal the holes to prevent pest entry or harborage. c. Front door entry point exit door did not close or seal properly and had a 1/4 gap or greater exists. Recommendation was made to install replace door sweep. d. Interior kitchen area had grease build up in/on/by under the cook line there was grease build up on the floor. Recommendation was made to clean buildup. e. Under the dish area, there was some sort of grease and grime build up on the floor and the wall that had attracted small flies. Recommendation was made to address the sanitation issue. f. Under the dish machine there was grease, grime and food build up on the underside of the dish machine that needs cleaned. Recommendation was made to address this sanitation issue. On 6/5/24 at 11:54 a.m., the Director of Nursing Services (DNS) indicated the facility was unable to provide any Maintenance Man's (MM) records of insect control. They had a pest company come out twice a month. The MM had ordered drain insect repellent, and it arrived 6/5/24. On 6/5/24 at 2:57 p.m., the ED provided a receipt for drain insect repellent. It was dated 5/31/24, for Drain [NAME] (drain fly treatment, attacks and consumes organic breeding grounds for drain flies, sewer flies, fruit flies, gnats and other common drain-dwelling pests). On 6/6/24 at 11:15 a.m., the ED indicated she was not satisfied with the facility's current local pest control company efforts. The facility had been using this pest control company twice a month, she wanted to change their schedule to every other week. She had been looking into using another pest control company. She indicated the MM acquired the drain pest control solution from another company. The MM would return from vacation next week and would instill the drain pest control solution. A current policy, titled, Pest Control, dated 9/23, was provided by the ED, on 6/4/24 at 3:28 p.m. A review of the policy indicated, .Purpose of the Policy: To provide an environment free of pests and rodents. Policy: The facility will maintain an effective pest control program so that the facility is free of pests and rodents .The facility should have a contract with a Pest Control Operator (PCO) .The PCO will make regular scheduled visits and additional visits as needed 3.1-19(a)(4) 3.1-19(f)(4) 3.1-19(f)(5)

Based on observations, the facility failed to label and date medications when opened and remove expired medications from use for 2 of 4 medication carts and 1 of 1 refrigerator. Findings include: 1. A hall medication cart a. Resident 64 had a vial of Haldol in the medication cart. The vial was a one time use only and lacked a date when opened. b. Resident 2 had breo in the medication cart. It lacked a date when opened. 2. B hall medication cart a. A bottle of Systane eye drops was in the medication cart. It did not have a label on the bottle. b. Resident 226 had a bottle of Systane eye drops in the medication cart with no date to indicate when it was opened. 3. Refrigerator had the following: a. Resident 54 had 2 bottles of lorazepam in the refrigerator. One bottle lacked a date to indicate when it was opened. The other bottle was opened on 2/22/24 that had expired. b. Resident 6 had a bottle of lorazepam in the refrigerator. It lacked a date to indicate when it was opened. c. There was a bottle of lorazepam in the refrigerator. It lacked a label on the bottle. A medication storage guidance was provided by the director of nursing services (DNS) on 6/5/24 at 11:56 a.m., it indicated Ativan oral solution, .store original . date when opened and discard 90 days after opening. Protect from light . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on interview and record review, the facility failed to clarify what kind of assistance was required for transferring a resident resulting in a laceration to the left lower extremity that required sutures to repair for 1 of 1 resident reviewed for accidents (Resident #59). Finding includes: During a telephone interview with Resident #59 ' s daughter on 04/21/2016 at 1:08 p.m., indicated her mother was injured during a transfer from her bed to a chair and had to be sent to the emergency room for sutures. Resident #59's record was reviewed on 4/18/2016 at 1:57 p.m. She had a [DIAGNOSES REDACTED]. A Minimum Data Set Assessment (MDS) tool, dated 5/11/15, indicated Resident #59 was dependent on staff for bed mobility, transfers, and locomotion; and had severe cognitive impairment. A physical therapy discharge summary, dated, 5/14/15, recommended Resident #59 be transferred with the use of a Hoyer lift (mechanical lift) to maximize safety. An occupational therapy note, dated 10/30/15, recommended Resident #59 be transferred with a Hoyer lift due to postural instability to maximize safety. An event report, dated 11/27/15, indicated Resident #59 had a laceration to her left lower extremity. The record lacked indication of cause of the laceration. An emergency room report, dated 11/27/15 at 6:45 p.m., indicated Resident #59 was evaluated in the emergency room due to a left lower extremity cut. The record indicated, .patient has a approximate 8 cm curved laceration to the left lower extremity. The wound is gaping and deep .It overlies the distal posterior medial aspect of the left lower leg . The record indicated she required 9 sutures to close the wound. During an interview on 4/21/16 at 10:13 a.m., Physical Therapist (PT) #33 indicated Resident #59 was a high fall risk and required a Hoyer lift for transfers. During an interview on 4/21/16 at 12:32 a.m., PT #33 indicated discharge recommendations on 5/14/15 were for staff to use a mechanical lift for transfers. He indicated she was on therapy's case load again from October 1-30, 2015, due to a decline in range of motion and to confirm her appropriate transfer status. He indicated at discharge staff was educated on her being a Hoyer lift for transfers. During an interview on 4/21/16 at 3:30 p.m., Certified Nursing Assistant (CNA) #34 indicated she and CNA #35 transferred Resident #59 from her bed to her wheel chair without a Hoyer lift on the day she required sutures. The CNA indicated she was on the resident ' s right side and indicated the resident ' s leg got caught on the rod of the foot rest during the transfer. She indicated the leg bled and the nurse was notified and assumed care of the resident. During interviews on 4/21/16 at 3:53 p.m., 4/22/16 at 9:20 a.m., and 11:50 a.m., the Director of Nursing (DON) indicated Resident #59 was not transferred with the Hoyer lift when she received the laceration on her leg that required sutures. She indicated she was aware therapy ' s recommendation for Hoyer lift for transfers, but had not clarified or obtained an order from the physician for the Hoyer lift. During an interview on 4/22/16 at 1:44 p.m., indicated a policy for incident/injury prevention was not available. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were implemented to prevent a resident who was admitted without pressure ulcers from developing a pressure ulcer to his right heal originally staged as unstageable - deep tissue pressure ulcer which became a stage 3 (partial thickness loss) pressure ulcer for 1 of 3 residents reviewed with pressure ulcers (Resident #104). Finding includes: During observations on 4/13/2016 at 9:56 a.m.,10:08 a.m.,10:20 a.m., 11:44 a.m., 12:30 p.m., and 1:20 p.m., and on 4/14/16 at 9:00 a.m. and 1:35 p.m., Resident #104 was observed seated in a broda chair (special wheel chair) He had gray non - skid socks on both feet and the heels of his feet were positioned flat against the foot board of his chair. During an observation on 4/15/16 at 9:17 a.m., Resident #104 was observed in his bed positioned on his back. The heels of both feet were positioned flat against his foot board. He was observed alternating his feet, pushing his heels into the foot board. Heels were not offloaded. During an observation on 4/15/16 at 10:06 a.m., Resident #104 was observed in bed positioned on his back. He had a blue soft pressure reducing boot on his right foot. His heels were not offloaded. During an observation on 4/15/16 at 11:18 a.m., Resident #104 was observed seated in a broda chair. His left foot was positioned on top of his right foot. The heel of his right foot was flat against the foot board. Pressure reducing boots were not observed. During an observation on 4/15/16 at 2:04 p.m., Resident #104 was observed in his bed positioned on his back. His left leg was bent at the knee with his left heel pressed into the mattress. His right leg and heel was flat on the mattress. His heels were not offloaded nor were pressure reducing boots observed. During an observation of wound care on 4/19/16 at 2:15 p.m., with the Director of Nursing (DON) present, the Wound Care Nurse, indicated the wound on the outer right heel measured 1 cm (centimeter) x 1.1 cm x 0.2 cm without including the purple colored tissue and indicted the entire wound measured 3.0 cm x 1.0 cm x 0.2 cm. The wound bed was 95 percent yellow slough with a small amount of pin granulation. The proximal end of the wound's peri-tissue was purplish in color. Resident #104's record was reviewed on 04/14/2016 at 2:33 p.m. Resident #104 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/13/15, indicated Resident #104 had severe cognitive impairment, did not have pressure ulcers, was a risk for pressure ulcers, and required extensive assistance from staff for bed mobility. An Admission/Readmission record, dated 12/6/15, indicated Resident #104 admitted to the facility on [DATE]. The record indicated he did not have pressure ulcers on admission. A Weekly Summary, dated 12/14/15, indicated Resident #104 did not have pressure ulcers. A Weekly Update Skin Event record, dated 12/16/15, indicated Resident #104 had developed an unstageable, suspected deep tissue injury to his right heel which measured 4.5 centimeters (cm) Length (L) x 3.6 cm Width (W) x 0.0 cm Depth (D). Weekly Update Skin Event records indicated wound measurements: a. 12/22/15 - 7.0 x 6.5 x 0.0, unstageable. b. 12/29/15 - 3.8 x 4.2 x 0.0 c. 1/05/16 - 5.9 x 6.5 x 0.1 d. 1/12/16 - 3.9 x 3.9 x 0.1 e. 1/19/16 - 2.9 x 3.9 x 0.1 f. 1/26/16 - 2.1 x 3.7 x 0.1 g. 2/2/16 - 2.3 x 3.0 x 0.1 h. 2/9/16 - 2.3 x 3.0 x 0.1 i. 2/16/16 - 2.8 x 3.5 x 0.2 j. 2/23/16 - 2.5 x 3.5 x 0.2 k. 3/1/16 - 3.5 x 2.5 x 0.2 l. 3/8/16 - 3/2 x 2.1 x 0.2 m. 3/15/16 - the staging was changed from an unstageable to a stage 3 pressure ulcer with measurements of 2.6 x 2.2 x 0.2 n. 3/22/16 - 2.5 x 3.0 x 0.2 0. 3/29/16 - 1.0 x 1.2 x 0.2 p. 4/5/16 - 1.4 x 0.9 x 0.2 q. 4/12/16 - 1.0 x 0.9 x 0 A physician's orders [REDACTED]. A physician's orders [REDACTED].#104's right heel with normal saline, pat dry, apply hydrogel to the wound bed and cover with foam dressing. Treatment Administration Records, dated from April 1-18, 2016 were reviewed on 04/18/2016 at 3:38 p.m. Interventions for heels floated had daily documentation for each shift that his heels had been floated. Interventions for the right heel protector had daily documentation for each shift that the boot was in place with the exception of 4/2/16 at 10:02 a.m., 4/3/16 at 10:20 a.m., 4/10/16 at 9:48 a.m., 4/10/16 at 2:35 a.m., and 4/16/16 at 9:40 a.m. The record indicated at these times the heel protective boot was not administered due to Refused. The record lacked indication attempts to reproach were made. During an interview on 4/18/2016 at 2:04 p.m., the Wound Care Nurse indicated Resident #104 developed a pressure ulcer on his right heel two weeks after he was readmitted to the facility from the hospital status [REDACTED]. She indicated areas at risk for pressure included heels, ankles, buttocks, head, and shoulders. She indicated at the time of readmission only standard interventions such as turn and reposition every two hours, weekly skin rounds, and pressure reduction mattress were implemented. She indicated interventions protect his heels were not implemented until after he developed a pressure area to his heel. During an interview on 4/18/2016 at 3:45 p.m., the Wound Care Nurse indicated a plan of care should be developed if residents refused services needed to promote healing or prevent the development of pressure ulcers. She indicated Resident #104 did not have a plan of care which indicated he refused services to prevent and/or promote healing of pressure ulcers. She further indicated if residents refused services of any kind, attempts to reproach should have been made. She indicated Resident #104 had refused care at times but would cooperate when reproached. She further indicated although the care plan indicated a 1/20/16, intervention for a pressure relieving boot as a preventative measure to the left heel, a physician's orders [REDACTED]. She indicated without a physician's orders [REDACTED]. During an interview on 4/19/2016 at 10:14 a.m., the Wound Care Nurse, indicated Resident was admitted to the facility with intact skin. She indicated he was at risk for the development of pressure ulcers due a [MEDICAL CONDITION], decreased mobility, and dependence on staff for bed mobility. She indicated within two weeks he developed a pressure ulcer to his right heel staged at an unstageable which later was staged a stage 3. A Skin Management Program policy, identified as current by the DON on 4/22/16 at 1:44 p.m., indicated, .it is the policy of American Senior Communities to assess each resident to determine the risk of potential skin integrity impairment, upon admission .A plan of care will be initiated to include resident specific risk factors with appropriate interventions .Residents identified at risk for skin breakdown will have appropriate prevention interventions put into place 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident at risk for development of pressure ulcers did not develop pressure ulcers. The facility failed to plan and implement care for prevention of pressure ulcers. The facility failed to clarify and implement physician's orders [REDACTED]. The defective practice affected 1 of 3 residents reviewed related to pressure ulcers in a sample of 3 (Resident B) and 2 of 3 residents reviewed for pressure ulcers in a supplemental sample of 3 (Residents D and E). Resident B developed two pressure ulcers, which increased in size and number to multiple pressure ulcers to the coccyx and buttocks, including wounds described as Stage 3 or 4. Resident B was hospitalized with [DIAGNOSES REDACTED]. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 4/19/11 and began on 3/27/11. The Director of Nursing Services, the Director of Nursing Services Specialist, and the Executive Director were notified of the Immediate Jeopardy on 4/19/11. The Immediate Jeopardy was removed on 4/21/11, but the facility remained out of compliance at a level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility continued to physically assess residents for pressure sore and nutritional risks, identify appropriate interventions, update care plans and nutritional assessments, and inservice all staff. Findings include: 1. A facility policy titled "Skin Management Program," dated 1/10, received from the Director of Nursing Services (D.N.S.) on 4/19/11 at 9:15 a.m., and indicated to be the facility's current policy indicated: "Policy: It is the policy of (name of the facility's parent company) to assess each resident to determine the risk of potential skin integrity impairment... Procedure: 2... Residents identified at risk as determined by the reason(s) indicated on the assessment will be provided with pressure relieving devices. A care plan will be developed specific to the resident's needs. including prevention interventions. Direct care givers will be notified of the resident's specific prevention interventions...Pressure reduction devices are to be put in place immediately...The licensed nurse will notify the wound nurse of any alterations in skin integrity. The facility assigned wound nurse will complete a further evaluation of wounds identified. The care plan will be initiated/revised addressing any new areas. Direct care givers will be notified of skin alterations and specific care instructions." A facility policy titled "IDT Review of Residents with Weight and Nutritional Concerns, dated 1/10, received from the D.N.S. on 4/19/11 at 9:15 a.m., and indicated to be the facility's current policy indicated: "Residents to review: ...Residents anticipated losing weight prior to triggering weight loss. Residents with significant weight loss. Initial IDT note documentation or residents with weight loss or nutritional concerns...Risk factors for the weight loss to include but not limited to: (1) diagnosis, (2) Medications, (3) Relevant lab results and (4) behaviors and (why the weight loss has occurred...Interventions that are specific to the resident include but are not limited to: (1) calorie dense foods, (2) large portions during bests meals and (3) supplements if food items are ruled out. (4) Pharmokinetics...Updates to nurse aide sheets...Updates to care plans including if possible resident input and preferences. Follow up IDT notes if not gaining weight:...New interventions specific to each resident...Update to care plans including if possible resident input and preferences and whether the resident or family were able to participate in the care plan." 2. The record of Resident B was reviewed on 4/18/11 at 10:30 a.m. [DIAGNOSES REDACTED]. An Initial Minimum Data Set (M.D.S.) assessment, dated 2/20/11, which indicated Resident B had poor appetite, required assistance for activities of daily living including extensive assistance- one person physical assist for bed mobility, and needed limited assistance-one person physical assistance for eating. A "Nursing Admission Assessment" for Resident B, dated 2/9/11, indicated the resident had no pressure sores on admission to the facility. A "Pressure Wound Risk Assessment," dated 2/9/11, indicated, "...the resident is at risk for developing skin breakdown. Proceed to care plan with appropriate interventions." The assessment did not document Resident B's level of risk for pressure wounds. Resident B had a care plan for the problem of "Potential skin breakdown related to impaired mobility, being incontinent of bowel and bladder and having a risk for developing pressure ulcers." The care plan had a "Problem Start Date" of 2/22/11. Approaches to this problem were: Turn and reposition every 2 hours. Offer to toilet every 2 hours. Incontinence care as needed using peri wash and moisture barrier. Assess and document skin condition weekly and as needed. Notify MD of abnormal findings. Encourage resident to eat at least 75% of meals. Pressure reducing/redistribution mattress on bed. An undated, hand written note was added to the care plan, indicating "Unstageable wound to coccyx...contributing factors include: poor dietary intake with low [MEDICATION NAME], noncompliant with repositioning at times." An approach was added stating the name of a nutritional supplement. There was no amount or frequency stated. There were no goals, timetables, or measurable objectives for this approach. The care plan included no approaches to address the stated problem of Resident B being noncompliant with repositioning. Resident B's "Weekly Skin Assessment" sheets indicated: 2/18/11: No concerns. 2/25/11: Skin tear on left knee 3/05/22: No concerns. 3/11/11: [MEDICATION NAME] port, site intact. 3/18/11: No concerns. 3/25/11: No concerns. 4/01/11: Open area to coccyx-odor noted. Yellow eschar noted. 4/11/11: (Symbol for "increased") Fluids encouraged...Tx (treatment) to coccyx cont (continued)...area (symbol for "with") dark center-white edges- increased odor... A Dietary Progress Note, dated 2/11/11, indicated Resident B's weight was 179.5 pounds at admission. An I.D.T. (Interdisciplinary Team) Note of 4/6/11 indicated a current weight of 161 pounds, a 10.3 percent weight loss since admission. During an interview with the Dietary Supervisor on 4/19/11 at 10:25 a.m. Resident B's meal consumption records were reviewed. The Dietary Supervisor indicated she had computed Resident B's average meal consumption for the month of March to be 50%. A Dietary Progress Note of 3/11/11 indicated Resident B was started on a dietary supplement on 3/2/11. There were no other resident-specific dietary interventions noted. There were no additional Dietary Progress notes after 3/11/11. A physician's orders [REDACTED]. The record contained no documentation of these weights. A physician's orders [REDACTED]. The resident's record contained no documentation of the amount of the supplement the resident consumed. Resident B's nurse's notes from admission on 2/09/11 through 3/26/11 found no documentation of any skin care issues or concerns. There was no documentation of any turning or repositioning in the nurse's notes during this period. A nurse's note, dated 3/27/11 at 2:00 p.m., indicated, "...open area found on coccyx 2 small openings on each cheek. (Symbol for "right") cheek wound is 5 cm (centimeters) x 1.5 cm wound bed is pink and clean. (Symbol for "left") cheek wound is 3 cm x 1.3 cm wound bed is yellow with black outer side..." During an interview on 4/18/11 at 1:45 p.m. the Assistant Director of Nursing indicated Resident B was noncompliant with care, including refusing treatment of [REDACTED]. Resident B's care plans contained no documentation of any plan or interventions to address his refusal of care. Nurse's notes concerning Resident B's participation in his care included: 3/06/11 2:00 p.m. "...refused to get out of bed for breakfast..." 3/07/11 2:00 p.m."Encouraged resident to do more with care. Refuses to attempt to do anything for himself." 3/08/11 2:00 p.m. "...C/O (complains) he can't feed himself..." 3/09/11 11:00 a.m. "Refuses to attempt to to assist with care...states 'I can't...'" 3/21/11 2:00 p.m. "Requires co-ercing (sic) to encourage resident to do anything. for himself. He states 'I can't...'" 3/22/11 2:00 p.m. "...always saying "I can't do it, you need to do everything for me.'" 3/29/11 6:00 p.m. "Repositioned...Resident refuses at times..." 3/30/11 2:00 p.m. "...Resident will wiggle self back to lying on back..." 3/31/11 11:00 p.m. "...Resident resistive to turning..." 4/02/11 2:00 a.m. "...Res has refused to turn from side to side..." 4/05/11 3:00 a.m. "...res continues to turn back to back-refuses to (arrow pointing down, symbol for "decrease") pressure on coccyx area..." Resident B had no care plan problems, goals, or interventions for Resident B's statements he was unable to help himself and was in need of staff interventions, or his refusal to comply with interventions, including positioning, identified for his pressure sores. During an interview on 4/19/11 at 10:45 a.m. the Director of Nursing Services indicated Resident B had been on a high density foam mattress, the standard for all residents in the facility, throughout his stay. A physician's telephone order order, dated 3/27/11 at 2:00 p.m., indicated, "Cleanse wound on coccyx (symbol for "with") NS (normal saline) pat dry apply (trade name of an enzymatic [MEDICATION NAME] ointment) to left sided wound bed cover with 2 x 2 cover with dry dressing". The order did not contain a frequency for this treatment. The treatment, when done, was done on a daily basis. A "Pressure Wound Skin Evaluation Report," dated 3/27/11, indicated Resident B had a Stage 1 pressure sore on both his right and left buttocks, with the left buttock wound measuring 5.0 by 1.5 centimeters, and the left measuring 3.0 by 1.3 centimeters. During an interview with the facility's parent corporation's Director of Clinical Services on 4/21/11 at 11:30 a.m., she indicated that based on the documentation of Resident B's pressure sores on 3/27/11 at 2:00 p.m. the pressure sore on Resident B's right buttock should have been identified as a Stage 2, and the pressure sore on the left buttock should have been identified as Unstageable. A "Pressure Wound Skin Evaluation Report," dated 4/1/11, indicated Resident B had a Stage 5 (unstageable) pressure sore on both his right and left buttocks, with the left buttock wound measuring 4.0 by 6.0 centimeters, and the left measuring 4.0 by 6.0 centimeters. Medication Administration Records did not document this treatment being done on 3/28/11, 3/30/11, 4/2/11, 4/9/11, or 4/10/11. A physician's orders [REDACTED]." The record contained no documentation of either mattress being used. A nurse's note, dated 4/11/11 at 8:15 p.m., indicated, "Res. (resident) noted to have several pink/purple discolorations, non-blanchable areas on left buttocks, hip and (arrow pointed down) lower back. Areas have appearance of deep tissue injuries. Left lower buttock: 4 x .5 cm, left buttock: 3 x 3 cm, left front of hip: 1 x 8 cm, yellow in color, left posterior hip: 9 x 10 cm, left lower hip: 7 x 11 cm. Multiple pink/purple areas across lower left back. Res. also noted to be warm to the touch, T (temperature) 103.1 axillary (under the arm). M.D. notified and order received to send res. to ER (emergency room )." Hospital records indicate Resident B was evaluated in the emergency roiagnom on [DATE], and admitted to the hospital on [DATE]. Admitting [DIAGNOSES REDACTED]. A hospital Admission Note, dated 4/12/11, indicated: "History was obtained by both the wife and the ECF (Extended Care Facility). Since his discharge from (acute care hospital) on 2/9, the patient has progressively declined in status from being ambulatory with assistance to being bed bound with decubitus ulcers and urinary incontinence. His nutritional status has diminished and per the ECF he has lost 20 lbs. in the last month. He has gradually lost ability to feed himself. Over the last week he has had more significant decline...In the last 3 days, he has had increased lethargy as well." A hospital Discharge Note, dated 4/20/11, indicated: "Admission Diagnosis: [REDACTED]. Discharge Diagnoses: [REDACTED]. Admission History...He was also found to have two sacral decubitus ulcers with large eschars for base. He has undergone progressively worsening decline in mental and physical status, developing decubitus ulcers, a UTI, loss of 20 lbs., and inability to feed himself...Sacral pressure ulcers: debrided 4/15...stage 3-4, unable to stage definitively due to debris. ..Pt. on air bed with frequent turning and BID (twice a day) wound changes. Plastic surgery was consulted 4/18, recommended hydrotherapy/pulse lavage daily and packing large ulcer with moist-to-dry dressings twice per day...verified need for regular, aggressive wound care..." 3. During an observation, on 4/21/11 at 11:15 A.M., Resident D was resting in bed, on a scoop mattress, on her back and the head of the bed was elevated 30 degrees. The clinical record of Resident D was reviewed on 4/21/11 at 9:45 A.M. [DIAGNOSES REDACTED]. An Nursing Admission Assessment, dated 5/4/10, indicated Resident D had "2 small pressure ulcers on buttocks" when admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 1/11/11, indicated Resident D was totally dependent on the assistance of two staff members for repositioning in bed and for transfers. Was incontinent of bowel and bladder, was at risk for the development of pressure ulcers and had no unhealed pressure ulcers. A Physicians order, dated 1/18/11, indicated, "Cleanse area to (left) buttocks (with) normal saline pat dry, cover (with) Allevyn (every) 3 days & PRN (as needed)...." An interdisciplinary Team (IDT) Progress Note, dated 1/27/11 (no time noted), indicated, "IDT review of wounds: area to buttocks is healed...." A Plan of Care, dated 8/10/10 and reviewed on 11/10/10, 1/27/11 and 4/11/11, indicated the resident was at risk for skin break down due to: "decreased mobility, being incontinent of bowel and having a [DIAGNOSES REDACTED]. Interventions included, but were not limited to: Turn and reposition at least every two hours, incontinent care as needed..., assess and document skin condition weekly..., pressure reducing/redistribution mattress on bed, pressure reducing/redistribution cushion in chair..., preventive treatment as ordered, bridge heels off bed while in bed every shift as a preventive. On 4/19/11 the following was added to the Plan of care: has open areas on bilateral buttocks, tx (treatment) as ordered and fortified cereal." No new interventions were put in place to prevent pressure ulcers. A Physicians' order, dated 4/19/11 at (:00 A.M., indicated, "Allevyn to bilateral buttocks q other day and PRN spoilage or dislodgement." A Pressure Wound Skin Evaluation Report, dated 4/19/11 (not time noted), indicated a stage II on the right buttocks .7 x .6 x <.1 centimeters and a stage II on the left buttocks .5 x .5 x <.1 centimeters. No drainage. There were no nursing notes regarding these new open areas to the buttocks. 4. During an observation, on 4/21/11 at 11:25 A.M., Resident E was resting in bed on a scoop mattress, on her left side and the head of the bed was elevated 20 degrees. The clinical record of Resident E was reviewed on 4/21/11 at 8: 45 A.M. [DIAGNOSES REDACTED]. An Annual MDS, dated [DATE], indicated Resident E required the extensive assist of two staff members to reposition in bed and for transfers, was incontinent of bowel and bladder, and was at risk for pressure ulcers. An IDT note, dated 11/24/10, indicated, "IDT review of wound: Res has Stage II open area to (right) buttocks. A Physician's Note, dated 11/30/10, indicated Resident E had a history of [REDACTED]. A Dietary Note, dated 3/8/11, indicated, "Con't (with) puree -(with) NTL (nectar thick liquid) et (and) 2-cal 120 ml BID (twice a day) - fortified foods - (no) noted skin issues but hx (history) of o/a's (open areas) noted...." A Plan of Care, dated 3/24/2011, indicated, "Resident is a risk for skin breakdown being dependent of staff for bed mobility, being incontinent of bowel and bladder, impaired mobility, resident slides down in bed, having [DIAGNOSES REDACTED]. Approaches included, but were not limited to, Turn and reposition at least every two hours, check and change every 2 hours, assess and document skin condition weekly...,pressure reducing/redistribution mattress on bed, supplements as ordered and elevate heels in bed check every shift." The Plan of Care was updated on 4/19/11, "open area to buttock and the approaches were updated to include "tx as ordered." No new approaches were put in place to prevent pressure ulcers. A Physician's note, dated 3/29/11, indicated Resident E had a redden area on the right buttocks. A Weekly Skin Assessment, dated 4/15/11, indicated the right buttocks continues (with) pink colored area. A physician's orders [REDACTED]." A Pressure wound Skin Report, dated 4/19/11, indicated a stage II pressure ulcer on the buttock: .5 x .4 x <.1 centimeters. No drainage. There were no nursing notes regarding this new open area to the buttocks. Information regarding any preventive measures to avoid future pressure ulcers that were put in place was requested from the Executive Director on 4/21/11 at 1:30 P.M. No information was received prior to exiting the facility. During an interview with the Executive Director, on 4/22/11 at 1:30 P.M., she indicated there was no air mattress in use in the facility. An Immediate Jeopardy was identified on 4/19/11 at 2:45 p.m. The Immediate Jeopardy began on 3/27/11 when the facility failed to ensure a resident at risk for development of pressure ulcers did not develop pressure ulcers, failed to plan and implement care for prevention of pressure ulcers, and failed to clarify and implement physician's orders [REDACTED]. The Director of Nursing Services, the Director of Nursing Services Specialist, and the Executive Director were notified on 4/19/11 at 3:20 p.m. of the Immediate Jeopardy related care and services for pressure ulcer prevention and treatment. The Immediate Jeopardy was removed on 4/21/11 at 4:50 p.m. when through observations, interview, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. Resident assessments, audits of all resident records by the facility, plans of correction for discovered concerns, and employee inservices were reviewed. Residents with pressure sores were observed to assess treatment and condition. Even though the facility ' s corrective action removed the Immediate Jeopardy, the facility remained out of compliance at reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to Complaint IN 400. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident at risk for weight loss and not maintaining therapeutic nutritional level received adequate nutritional interventions to prevent significant weight loss by not assessing nutritional needs in a timely fashion, monitoring nutritional supplement intake as ordered by the physician, not responding to the resident's repeated requests for additional assistance from staff, and not updating the resident's dietary care plan. This deficient practice affected 1 of 6 residents reviewed related to weight loss and nutritional status in a sample of 3 and a supplemental sample of 3. (Resident B). Resident B developed significant weight loss. The resident was hospitalized with [DIAGNOSES REDACTED]. Findings include: 1. A facility policy titled "Skin Management Program," dated 1/10, received from the Director of Nursing Services (D.N.S.) on 4/19/11 at 9:15 a.m., and indicated to be the facility's current policy indicated: "Policy: It is the policy of (name of the facility's parent company) to assess each resident to determine the risk of potential skin integrity impairment... Procedure: 2... Residents identified at risk as determined by the reason(s) indicated on the assessment will be provided with pressure relieving devices. A care plan will be developed specific to the resident's needs. including prevention interventions. Direct care givers will be notified of the resident's specific prevention interventions...Pressure reduction devices are to be put in place immediately...The licensed nurse will notify the wound nurse of any alterations in skin integrity. The facility assigned wound nurse will complete a further evaluation of wounds identified. The care plan will be initiated/revised addressing any new areas. Direct care givers will be notified of skin alterations and specific care instructions." A facility policy titled "IDT Review of Residents with Weight and Nutritional Concerns," dated 1/10, received from the D.N.S. on 4/19/11 at 9:15 a.m., and indicated to be the facility's current policy indicated: "Residents to review: ...Residents anticipated losing weight prior to triggering weight loss. Residents with significant weight loss. Initial IDT note documentation or residents with weight loss or nutritional concerns...Risk factors for the weight loss to include but not limited to: (1) diagnosis, (2) Medications, (3) Relevant lab results and (4) behaviors and (why the weight loss has occurred...Interventions that are specific to the resident include but are not limited to: (1) calorie dense foods, (2) large portions during bests meals and (3) supplements if food items are ruled out. (4) Pharmokinetics...Updates to nurse aide sheets...Updates to care plans including if possible resident input and preferences. Follow up IDT notes if not gaining weight:...New interventions specific to each resident...Update to care plans including if possible resident input and preferences and whether the resident or family were able to participate in the care plan." A facility policy titled "Nutrition Risk Assessment," dated 5/06, received from the Executive Director on 4/21/11 at 11:00 a.m., and indicated to be the facility's current policy indicated: "Policy: The Nutrition Risk Assessment will be completed...with each significant change in condition...If the resident is identified as MODERATE or HIGH RISK for any risk factor, follow the appropriate strategies/interventions developed and document in the nutrition progress notes and in the care plan....answer the following question: is the resident meeting his/her nutrient...needs? If not, identify changes that should be made in the plan of care to aid the resident in meeting their nutritional needs. Are the care plan goals being met? Do not expect a change to occur (i.e. weight gain/loss) without a change in the approaches..." 2. The record of Resident B was reviewed on 4/18/11 at 10:30 a.m. [DIAGNOSES REDACTED]. An Initial Minimum Data Set (M.D.S.) assessment, dated 2/20/11, which indicated Resident B had poor appetite, required assistance for activities of daily living including extensive assistance- one person physical assist for bed mobility, and needed limited assistance-one person physical assistance for eating. Resident B's Nutrition Risk Assessment done 2/9/11, the day of admission, indicated Resident B had a Nutrition Risk Assessment score of 7, with 3-7 being "moderate" and 8 or greater being "high risk." Resident B's record contained no other Nutrition Risk Assessment. This was confirmed by the Executive Director during interview on 4/21/11 at 11:30 a.m. Resident B had a care plan with a stated problem of "Requires a therapeutic diet related to related to need for [MEDICAL TREATMENT]" date 2/22/2011. The care plan's approaches to this problem were: Provide diet per MD order. Honor known food preferences that are within limitations of diet restriction. Monitor weights weekly. Notify MD/Family of significant weight changes. Monitor food/fluid intake at meals. Offer substitute if less than 75% of any meal is consumed. Educate resident on importance of diet compliance, re-direct if possible to accept diet plan. A Dietary Progress Note, dated 2/11/11, indicated Resident B's weight was 179.5 pounds at admission. An I.D.T. (Interdisciplinary Team) Note of 4/6/11 indicated a current weight of 161 pounds, a 10.3 percent weight loss since admission. A Dietary Progress Note of 3/11/11 indicated Resident B was started on a dietary supplement on 3/2/11. There were no other resident-specific dietary interventions noted. There were no additional Dietary Progress notes after 3/11/11. A physician's orders [REDACTED]. The record contained no documentation of these weights. A physician's orders [REDACTED]. The resident's record contained no documentation of the amount of the supplement the resident consumed. During an interview with the Dietary Supervisor on 4/19/11 at 10:25 a.m., with the D.N.S present, Resident B's meal consumption records were reviewed. The Dietary Supervisor indicated she had computed Resident B's average meal consumption for the month of March to be 50%. She indicated no changes to Resident B's diet care plan had been made in response to this assessment. The Dietitian and D.N.S. both agreed the dietary supplement consumption had not been documented as ordered, and that pre and post [MEDICAL TREATMENT] weights had not been recorded. During an interview on 4/18/11 at 1:45 p.m. the Assistant Director of Nursing indicated resident B was noncompliant with care, including refusing treatment of [REDACTED]. Resident B's care plans contained no documentation of any plan or interventions to address his refusal of care. Nurse's notes concerning Resident B's participation in his care included: 3/06/11 2:00 p.m. "...refused to get out of bed for breakfast..." 3/07/11 2:00 p.m."Encouraged resident to do more with care. Refuses to attempt to do anything for himself." 3/08/11 2:00 p.m. "...C/O (complains) he can't feed himself..." 3/09/11 11:00 a.m. "Refuses to attempt to to assist with care...states 'I can't...'" 3/21/11 2:00 p.m. "Requires co-ercing (sic) to encourage resident to do anything. for himself. He states 'I can't...'" 3/22/11 2:00 p.m. "...always saying "I can't do it, you need to do everything for me.'" 3/29/11 6:00 p.m. "Repositioned...Resident refuses at times..." 3/30/11 2:00 p.m. "...Resident will wiggle self back to lying on back..." 3/31/11 11:00 p.m. "...Resident resistive to turning..." 4/02/11 2:00 a.m. "...Res has refused to turn from side to side..." 4/05/11 3:00 a.m. "...res continues to turn back to back-refuses to (arrow pointing down, symbol for "decrease") pressure on coccyx area..." Resident B had no care plan problems, goals, or interventions for statements he was unable to help himself and was in need of staff interventions, or his refusal to comply with interventions, including feeding himself. A nurse's note, dated 4/11/11 at 8:15 p.m., indicated, "Res. (resident) noted to have several pink/purple discolorations, non-blanchable areas on left buttocks, hip and (arrow pointed down) lower back. Areas have appearance of deep tissue injuries. Left lower buttock: 4 x .5 cm, left buttock: 3 x 3 cm, left front of hip: 1 x 8 cm, yellow in color, left posterior hip: 9 x 10 cm, left lower hip: 7 x 11 cm. Multiple pink/purple areas across lower left back. Res. also noted to be warm to the touch, T (temperature) 103.1 axillary (under the arm). M.D. notified and order received to send res. to ER (emergency room )." Hospital records indicate Resident B was evaluated in the emergency roiagnom on [DATE], and admitted to the hospital on [DATE]. Admitting [DIAGNOSES REDACTED]. A hospital Admission Note, dated 4/12/11, indicated: "History was obtained by both the wife and the ECF (Extended Care Facility). Since his discharge from (acute care hospital) on 2/9, the patient has progressively declined in status from being ambulatory with assistance to being bed bound with decubitus ulcers and urinary incontinence. His nutritional status has diminished and per the ECF he has lost 20 lbs. in the last month. He has gradually lost ability to feed himself. Over the last week he has had more significant decline...In the last 3 days, he has had increased lethargy as well." A hospital Discharge Note, dated 4/20/11, indicated: "Admission Diagnosis: [REDACTED]. Discharge Diagnoses: [REDACTED]. Admission History...He was also found to have two sacral decubitus ulcers with large eschars for base. He has undergone progressively worsening decline in mental and physical status, developing decubitus ulcers, a UTI, loss of 20 lbs., and inability to feed himself...Sacral pressure ulcers: debrided 4/15...stage 3-4, unable to stage definitively due to debris. ..Pt. on air bed with frequent turning and BID (twice a day) wound changes. Plastic surgery was consulted 4/18, recommended hydrotherapy/pulse lavage daily and packing large ulcer with moist-to-dry dressings twice per day...verified need for regular, aggressive wound care..." At exit on 4/21/11 at 4:00 p.m. the facility provided no additional documentation of updated or modified nutritional interventions for Resident B. This federal tag relates to Complaint IN 400. 3.1-46(a)(1) 3.1-46(a)(2)