Every finding on record at Evansville Protestant Home

Based on observation, interview, and record review, the facility failed to revise care plans and follow interventions to reduce the risk of falls for 1 of 1 resident reviewed for falls with major injury. This deficient practice resulted in two falls with fractures requiring hospitalization and a significant decline in the resident's Activities of Daily Living (ADLs). (Resident 7) Finding includes: On 3/26/25 at 10:11 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, displaced comminuted fracture of shaft of right femur, fracture of upper end of right humerus, fracture of superior rim of right pubis, and vascular dementia. The most recent Annual Minimum Data Set (MDS) Assessment, dated 11/23/24, indicated Resident 7 had severe cognitive impairment, required setup assistance of staff (staff sets up/cleans up; resident completes the activity) with eating, required supervision of staff (staff provides verbal cues or touching/steadying assistance as resident completes the activity) for toileting and sit to stand transfers, was independent rolling left and right, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and had no falls since the prior assessment. An annual fall risk assessment was completed on 11/23/24 that indicated Resident 7 was at low risk for falls. A current falls care plan, initiated 5/7/23 and last revised on 3/3/25, indicated Resident 7 was at risk for falls due to weakness. Interventions included: Assure I have appropriate footwear before ambulating, dated 5/17/23 Fluorescent tape added to call light as a visual cue, dated 5/17/23 Keep call light and personal items within reach, dated 5/17/23 Educated resident to utilize the call light for assistance when not feeling well, dated 1/22/24 Gripper socks when shoes are not on, dated 4/1/24 Fluorescent tape to walker to remind resident to take walker to restroom, dated 12/29/24 Concave mattress, dated 3/3/25 A care conference was most recently completed on 3/20/25. Care plan conference notes indicated that all current care plans were reviewed. The clinical record indicated Resident 7 fell four times between 12/29/24 and 3/1/25. Fall 1 On 12/29/24 at 10:00 A.M., Resident 7 sustained an unwitnessed fall without injury while walking without her walker. Fluorescent tape to walker to remind resident to take walker to restroom was added to the care plan on 12/29/24. A fall risk assessment was completed on 12/29/24 that indicated Resident 7 was at low risk for falls. Fall 2 On 1/4/25 at 10:15 P.M., Resident 7 sustained an unwitnessed fall while getting out of bed. At that time, no injury was noted. A fall risk assessment was completed on 1/4/25 that indicated Resident 7 was at high risk for falls. A nursing progress note, dated 1/4/25 at 10:49 P.M., indicated staff notified the physician of the fall, confusion, and a high blood pressure of 154/80. An order was received for a urinalysis (UA) to check for infection. A nursing progress note, dated 1/4/25 at 11:26 P.M., indicated the resident complained of right hip pain with no bruising or swelling noted upon assessment. A nursing progress note, dated 1/5/25 at 6:02 A.M., indicated the resident complained of hip and back pain with difficulty ambulating. Pain medication was given. Urine was collected at that time. A nursing progress note, dated 1/5/25 at 10:52 P.M., indicated the resident complained of hip pain and was observed with a slow and unsteady gait. A nursing progress note, dated 1/6/25 at 3:35 A.M., indicated the physician was notified of the resident's continued complaints of bilateral hip pain and back pain. Progress notes from 1/6/25 at 3:35 A.M. to 1/7/25 at 1:14 P.M lacked documentation to indicate the physician responded or staff attempted to follow up with the physician or the medical director. An Interdisciplinary Team (IDT) note, dated 1/6/25 at 10:40 A.M., indicated Resident 7's 1/4/25 fall was reviewed. The new intervention was a clinical assessment. The care plan was not updated with a new intervention at that time. A nursing progress note, dated 1/7/25 at 5:08 A.M., indicated the resident complained of hip and back pain, was unable to ambulate, and required assistance of two staff for toileting and transferring. A nursing progress note, dated 1/7/25 at 1:14 P.M., indicated the resident complained of bilateral hip pain and had a decline in mobility. Staff attempted to call the physician to request an x-ray of the bilateral hips. A nursing progress note, dated 1/7/25 at 6:09 P.M., indicated a transfer order was received from the physician and the resident was transferred to the hospital for evaluation and x-rays. Hospital discharge paperwork, dated 1/7/25 at 10:50 P.M., indicated Resident 7 had superior and inferior pubic ramus fractures and multiple closed stable lateral compression fractures of the pelvis that did not require surgery. The resident was recommended to start physical therapy and follow up as needed. A nursing progress note, dated 1/8/25 at 1:45 A.M., indicated the resident returned to the facility from the hospital with no new orders. A therapy evaluation indicated Resident 7 began physical therapy on 1/9/25. A nursing progress note, dated 1/10/25 at 9:19 A.M., indicated the urine obtained on 1/5/25 was negative and did not indicate an infection was present. A review of progress notes from 1/6/25 to 1/20/25 lacked documentation to indicate the IDT met to follow up on the negative UA and determine a new intervention following the resident's fall on 1/4/25 to prevent further falls. Fall 3 On 1/20/25 at 12:15 A.M., Resident 7 sustained an unwitnessed fall while attempting to self-transfer to the bathroom. A fall risk assessment was completed on 1/20/25 and indicated that Resident 7 was at high risk for falls. A nursing progress note, dated 1/20/25 at 12:26 A.M., indicated the resident complained of pain and moved all extremities as normal for resident with a pelvic fracture. An IDT Note, dated 1/20/25 at 10:21 A.M., indicated Resident 7's 1/20/25 fall was reviewed. The new interventions were concave mattress and offer the opportunity to lay in bed between 9 P.M. and 11 P.M. The interventions were not added to the care plan at that time. A Significant Change MDS Assessment was completed on 1/20/25. It indicated Resident 7 had severe cognitive impairment, required setup assistance of staff (staff sets up/cleans up; resident completes the activity) with eating, required supervision of staff (staff provides verbal cues or touching/steadying assistance as resident completes the activity) for toileting and sit to stand transfers, was independent rolling left and right, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and had one fall since the prior assessment. A nursing progress note, dated 1/22/25 at 2:35 P.M., indicated the resident complained of pain while walking. A nursing progress note, dated 1/22/25 at 10:32 P.M., indicated the resident complained of pain in the right hip. Staff attempted to notify the physician of the increased pain. A nursing progress note, dated 1/23/25 at 11:56 A.M., indicated staff attempted to contact the physician about the resident's pelvic pain. A nursing progress note, dated 1/23/25 at 12:15 P.M., indicated the physician's nurse returned the call to obtain more information. Staff reported that the resident was having increased pain and more difficulty ambulating. The physician's nurse indicated she would forward the information to the physician. A nursing progress note, dated 1/23/25 at 1:47 P.M., indicated a new order was received for an x-ray of the pelvis and the hips. A nursing progress note, dated 1/23/25 at 4:44 P.M., indicated a mobile x-ray service completed a bilateral hip and pelvis x-ray in the facility. A nursing progress note, dated 1/23/25 at 10:34 P.M., indicated x-ray results were received. Results indicated Cannot exclude nondisplaced right pubic rami fracture. Consider follow up with a three view pelvis series vs. Computed Tomography (CT) scan (a medical imaging technique used to obtain detailed internal images of the body) for further evaluation. Therapy discharge paperwork, dated 2/6/25, indicated Resident 7 was discharged from physical therapy because she had reached her highest practical level. Fall 4 A nursing progress note, dated 3/1/25 at 5:50 P.M., indicated Resident 7 sustained an unwitnessed fall while walking in her room. The resident complained of pain in her right shoulder, right arm, and right hip. Her right leg was noted to appear shorter than her left leg, her right foot was rotated outward, and it was tender to touch. An ambulance was called and the resident was taken to the emergency room . A fall risk assessment was completed 3/1/25 that indicated the resident was at high risk for falls. A Hospital Trauma Services note, dated 3/2/25 at 12:51 A.M., indicated the resident was admitted to the hospital with diagnoses of a right humoral surgical neck fracture (shoulder) and a right femur fracture (long bone in the leg). An IDT note, dated 3/3/25 at 10:09 A.M., indicated Resident 7's 3/1/25 fall was reviewed. The new intervention was Resident sent to the hospital. Concave mattress was added to the care plan on 3/3/25. Hospital discharge paperwork, dated 3/5/25 at 2:25 P.M., indicated that the resident was being discharged back to the facility after receiving an open reduction and internal fixation (ORIF) (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods) on her right distal femur fracture. The right shoulder fracture did not require surgery and the resident's right arm was placed in a sling for comfort. A nursing progress note, dated 3/5/25 at 5:15 P.M., indicated the resident returned to the facility from the hospital with new orders. Admission physician orders included, but were not limited to: tramadol (an opioid pain-relieving medication) tablet - give 50 milligrams (mg) every six hours as needed, dated 3/5/25 Safety Device: Bed pad alarm. Check placement and function every shift, dated 3/5/25 Safety Device: Chair pad alarm. Check placement and function every shift, dated 3/5/25 Concave Pressure Relieving Mattress, dated 3/5/25 Sling in place to right arm, dated 3/5/25 Immobilizer in place to right leg. May remove for skin care and therapy only, dated 3/7/25 A nursing progress note, dated 3/6/25 at 2:17 P.M., indicated the resident returned from the hospital with a wound vacuum device to a right hip incision, a long leg immobilizer to the right leg, and a sling to the right arm. The skin underneath the immobilizer was intact with bruising at the back of the brace where the metal rod was positioned. There was a very large bruise on the right arm and shoulder. A review of progress notes from 1/23/25 to 3/26/25 lacked documentation to indicate the physician was notified of or reviewed the x-ray results or a follow up scan was completed. A Significant Change MDS Assessment was completed on 3/11/25. It indicated Resident 7 had severe cognitive impairment, required partial to moderate assistance of staff (staff does less than half of the effort) with eating, was dependent on staff (staff does everything) for rolling left to right, toileting, bathing, sit to stand and toilet transfers were not attempted, and there were no falls since the prior assessment. On 3/26/25 at 2:35 P.M., Resident 7 was observed lying in bed with a concave mattress with an immobilizer on her right leg. The call light did not have fluorescent tape on it. During an interview on 3/27/25 at 11:00 A.M., Physical Therapy Assistant (PTA) 9 indicated Resident 7 was up ad lib (as desired) for three years before she broke her pelvis. After she broke her pelvis, she was weight bearing as tolerated with assistance of one staff. She was discharged from therapy on 2/6/25 and was able to ambulate with a walker and assistance of one staff. After her fall on 3/1/25 she became non weight bearing on her right leg and right arm. At that time, she indicated the intervention put in place after the fall on 1/20/25 was to add a concave mattress. She was unsure why it was not added to the care plan until 3/3/25 and was unsure when the resident received the concave mattress. After the resident fell on [DATE], new fall interventions were not added to the care plan because the resident became non weight bearing, was not trying to get up, and was not using her walker. During an interview on 3/27/25 at 1:25 P.M., the Director of Nursing (DON) indicated that after a resident fell , the nurse created a fall event. IDT staff ran a report daily of the new fall events, and new falls were discussed in morning meeting to identify appropriate and new interventions. The new intervention determined went into the care plan at that time. If the intervention was a lab or assessment, the results were followed up on. If the lab or assessment was not the cause of the fall, the resident would not always get a new intervention because it was hard to find things that worked. On 4/1/25 at 10:47 A.M., the Administrator provided a current Falls - Clinical Protocol policy, revised March 2018, that indicated For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes . The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable . Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling . If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes. On 4/1/25 at 10:47 A.M., the Administrator provided a current Goals and Objectives, Care Plan policy, revised April 2009, that indicated When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly . Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment . Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition . On 4/1/25 at 10:47 A.M., the Administrator provided a current Physician Services policy, revised April 2013, that indicated The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. The attending physician will determine the relevance of any recommended interventions from any discipline . The medical director will identify attending physician qualifications and responsibilities, based on clinical and regulatory requirements . 3.1-45(a)

Based on record review and interview, the facility failed to ensure the Dietary Manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. Finding includes: During an interview on 3/25/25 at 9:01 A.M., the Dietary Manager indicated she did not have a dietary manager certification and had not enrolled in the program. During an interview on 3/26/25 at 11:27 A.M., the Dietitian indicated she was aware the Dietary Manager was not certified but had not increased her visits; she was currently in the facility once a week. On 3/28/25 at 1:16 P.M., the Dietary Manager's employee file was reviewed. The Dietary Manager job description, signed on 3/11/25, indicated qualifications to accepting the role of dietary manager required completion of state-approved food service management course, or presently enrolled in a program. During an interview on 4/1/25 at 10:59 A.M., the Administrator indicated the facility did not have a written policy related to qualifications of the dietary manager, and the policy was to follow state regulations. 3.1-20(e)

Based on observation, interview, and record review, the facility failed to safely store and label food under professional standards related to food items not labeled or stored properly for 1 of 1 dietary areas observed. Findings include: During a kitchen walk through on 3/25/25 at 8:44 A.M., the following was observed: Walk in refrigerator: Bag of mixed broccoli, carrots, and celery open to air, no date Chunk of ham, dated 2/15 Carton of molded strawberries A container of bran mixture labeled prepped 3/8 A container of banana cake labeled prepped 3/16 Dry storage room: Rice crispy treats directly on the floor Box of sandwich crackers directly on the floor Walk in freezer: Bag of pepperonis doubled bagged; inside bag dated 12/21/23 and outside bag dated 6/29/24 On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Food Storage, dated 2017, that indicated Food will be stored a minimum of six inches above the floor . leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be labeled and dated before being refrigerated. Leftover foods is used within seven days or discarded per federal food code. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the physician was notified when lab results were not obtained for a resident with a catheter associated urinary tract infection for 1 of 2 residents reviewed for indwelling catheters and when medication suggestions were made by the pharmacist for 1 of 2 residents reviewed for pharmacy reviews with recommendations. (Resident 27 and Resident D) Findings include: 1. On 3/26/25 at 10:22 A.M. Resident 27's clinical record was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, malignant neoplasm of bladder. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident 27 was moderately cognitively impaired, required partial to moderate assistance (staff does less than half of the effort) for toileting, and had an indwelling catheter. Physician orders included, but were not limited to: May re-anchor catheter if becomes dislodged or occluded as needed, Contact Medical Doctor (MD), dated 3/27/24 Foley catheter: Anchor 16 french, 30cc (cubic centimeters) balloon, provide catheter care every shift, supra pubic catheter(a thin tube inserted into the bladder through a small incision in the lower abdomen), cleanse around insertion site with soap and water, pat dry; Start date 3/7/25 Current care plans included, but were not limited to: Report signs of complications such as urinary tract infection (UTI) (acute confusion, bladder spasms, pain, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine), dated 3/27/24 A nursing progress note, dated 6/9/24 at 2:32 P.M., indicated a nurse was alerted to Resident 27's room by housekeeping that the resident was covered in blood. Resident was unsure of how it happened and he denied falling. There was no evidence that the resident had fallen. Family later came in to visit resident and were informed. Family expressed concern related to resident's catheter bag being purple. Leg bag examined per nursing and it did have a purple tint, however, urine output was darker yellow and concentrated. Minimal research revealed a possible cause being purple catheter bag syndrome which was usually indicative of a longstanding Foley catheter and chronic UTI. MD notified of all the above. A nursing progress note, dated 6/10/24 at 2:04 P.M., indicated a new order was received for a urinalysis and culture and sensitivity from a new catheter bag due to urine bag being purple in color. A nursing progress note, dated 6/10/24 at 11:32 P.M., indicated the current catheter was removed and a new catheter was placed suprapubic using aseptic technique with no urine return. A nursing progress note, dated 6/11/24 at 10:36 A.M., indicated Resident 27's suprapubic catheter was not in place. No urine return. The nurse adjusted catheter and when it was in place, yellow urine mixed with blood returned. Nurse attempted to replace catheter but was unable to re-anchor catheter. Orders received to send to [hospital] emergency department for catheter replacement. A nursing progress note, dated 6/11/24 at 11:13 A.M., indicated family arrived and transported Resident 27 to the emergency department. Catheter bag with blood noted. A nursing progress note, dated 6/12/24 at 4:07 P.M., indicated a urine report was faxed to facility. Nitrite positive, no new orders written with report. Nursing staff called the PAC (post acute care line for physicians) and there was no answer. The clinical record lacked notification to the physician or medical director of PAC not responding to the facility. A nursing progress note, dated 6/13/24 at 3:29 P.M., indicated a request was sent to PAC to follow up on resident's urine obtained during emergency room visit which was nitrite positive, no culture report available yet. A nursing progress note, dated 6/15/2024 at 5:03 P.M., indicated a nurse called PAC related to urine culture results. Unable to obtain results at that time. The MD was notified to try and obtain results. Resident continued to have purple catheter bags despite dark yellow urine output. A nursing progress note, dated 6/18/24 at 5:24 P.M., indicated Resident 27 complained of not feeling well in his abdomen. Encouraged to eat a good dinner and milkshake. The clinical record lacked notification to the medical director of PAC not responding to the facility, or notification to the physician about the new symptoms observed. A nursing progress note, dated 8/1/24 at 11:17 A.M., indicated the catheter was changed due to occlusion. A nursing progress note, dated 8/1/24 at 6:03 P.M., indicated Resident 27 complained of pain from the catheter site. The clinical record lacked notification to the physician related to Resident 27's pain from the catheter site. A nursing progress note, dated 8/29/24 at 11:25 A.M., indicated Resident 27 notified staff he was hurting and pointed to the right groin area. The area was assessed and PAC notified. A nursing progress note, dated 8/31/24 at 9:55 A.M., indicated Resident's catheter insertion site was red. The clinical record lacked notification to the physician related to the change in condition of the catheter site. 48147 2. On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, required setup assistance for eating, was dependent on staff for toileting, bathing, and transferring, and received an antianxiety medication during the 7-day look back period. A current care plan, revised 2/21/25, indicated Resident D received antianxiety medication related to an anxiety diagnosis. A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed. Current physician orders included, but were not limited to: buspirone tablet (an antianxiety medication) - 10 milligrams (mg) at bedtime, dated 9/27/24 Discontinued physician orders included, but were not limited to: buspirone tablet - 10 mg once a day, dated 7/11/23 with a discontinued date of 7/10/24 buspirone tablet - 10 mg at bedtime, dated 7/11/24 with a discontinued date of 9/27/24 A pharmacy recommendation, dated 6/11/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon. A pharmacy recommendation, dated 7/16/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon. The clinical record lacked documentation that facility staff attempted to contact the physician or Medical Director to respond to the pharmacy recommendation to decrease Resident D's antianxiety medication. During an interview on 3/27/25 at 11:05 A.M., Medical Records staff indicated Resident D's physician did not respond to the pharmacy recommendations on 6/11/24 or 7/16/24. At that time, she indicated that if a resident's physician did not respond, the pharmacy requests were sent to the Medical Director to accept or decline. The Medical Director did not accept or decline the pharmacy recommendations on 6/11/24 or 7/16/24. During an interview on 3/31/25 at 1:34 P.M., the Medical Director indicated that he was not aware that there was a physician who did not review pharmacy recommendations. At that time, he indicated he was aware that staff had difficulty reaching PAC staff. He had been told by facility administration that they had reached out to PAC administration many times with no meaningful results. Consequently, he was the default contact for nursing and clinical staff when PAC could not be reached, and could be contacted directly by his direct cell phone number or text message. On 4/1/25 at 10:47 A.M., the Administrator provided a Consultant Pharmacist Reports policy, revised December 2022, that indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Comments and recommendations concerning medication therapy are communicated in a timely fashion . Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Acute Condition Change Clinical Protocol, dated December 2015, that indicated Nursing staff will contact the Physician based on the urgency of the situation. The attending Physician will respond in a timely manner to notification of problems or changes in condition and status. 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure care plans related to high risk medications were developed for 3 of 6 residents reviewed for medication use. (Resident 3, Resident D, Resident 14) Findings include: 1. On 3/25/25 at 2:26 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, Fournier Gangrene, malignant neoplasm of prostate, and chronic pain syndrome. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated Resident 3 was cognitively intact, was dependent on transferring, toileting, bathing, and dressing, and received an antibiotic and an opioid during the 7-day look back period. Resident 3 had a pain assessment during this time. Current physician orders included, but were not limited to: daptomycin (an antibiotic) 600 milligrams (mg) daily Intravenous (IV) for 28 days per ID (infectious disease), infuse over 60 minutes dated, 3/16/25 to 4/13/25. oxycodone (pain medication) 5 mg administer 1 tablet orally every 4 hours as needed for pain, dated 1/16/25. The current care plan lacked care plans for pain and antibiotic monitoring. 48147 2. On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, required setup assistance for eating, was dependent on staff for toileting, bathing, and transferring, and received an anticoagulant medication during the 7-day look back period. Current physician orders included, but were not limited to: Eliquis (an anticoagulant medication) tablet - 5 milligrams (mg) twice a day, dated 11/7/24 A current activity intolerance care plan, initiated 9/30/24, indicated Resident D received Eliquis to prevent embolism. A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed. The clinical record lacked a care plan to identify interventions to monitor for the risks of side effects from the anticoagulant medication (such as risk for bleeding). During an interview on 4/1/25 at 11:05 A.M., the Administrator indicated there was not a care plan for Resident D that addressed the risk of bleeding. 3. On 3/26/25 at 8:41 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, generalized anxiety disorder, depression, and spinal stenosis. The most current Annual Minimum Data Set (MDS) Assessment, dated 1/31/25, indicated Resident 14 had moderate cognitive impairment, required setup assistance for eating, partial to moderate assistance of staff (staff does less than half of the effort) for toileting and bathing, and received an antipsychotic medication, antianxiety medication, antidepressant, anticonvulsant, and an opioid during the 7-day look back period. Current physician orders included, but were not limited to: Ativan Benadryl Haldol gel (an antipsychotic medication) 2 milligrams (mg)- 25mg-2mg - apply 1 milliliter (ml) topically to the inner wrist every four hours as needed for agitation, dated 11/18/24 citalopram tablet (an antidepressant medication) - 10 mg once a day for depression, dated 10/6/23 gabapentin capsule (an anticonvulsant medication) - 300 mg twice a day for pain, dated 10/4/23 hydrocodone-acetaminophen tablet (an opioid pain-relieving medication) 7.5-325 mg - give one tablet every four hours as needed for pain, dated 10/4/23 hydrocodone-acetaminophen tablet 7.5-325 mg - give one tablet twice a day for pain, dated 11/12/24 lorazepam concentrate (an antianxiety medication) 2 mg/mL - give 0.25 ml sublingually every four hours as needed for anxiety and restlessness, dated 1/26/24 Roxanol (an opioid pain-relieving medication) liquid 20 mg/ml - give 0.25 ml sublingually every four hours as needed for pain and shortness of breath, dated 1/26/24 A care conference was most recently completed on 1/29/25. Care plan conference notes indicated that all current care plans were reviewed. The clinical record lacked a care plan related to antipsychotic medications, antianxiety medications, antidepressants, anticonvulsants, and opioids, the disease processes that necessitated the medications, and interventions required to monitor side effects of the medications. During an interview on 3/27/25 at 1:25 P.M., the Director of Nursing (DON) indicated that all high risk medications should have a corresponding care plan. Anticoagulants should have a risk for bleeding care plan. During an interview on 3/27/25 at 1:43 P.M., the MDS Coordinator indicated that all high risk medications should have a corresponding care plan. Care plans were created upon admission or with a change of orders. Reports showing newly prescribed medications were run daily and care plans were updated as needed. During an interview on 4/1/25 at 10:35 A.M., the Administrator indicated there were no care plans for Resident 14 that addressed antipsychotic medications, antianxiety medications, antidepressants, anticonvulsants, and opioids, the disease processes that necessitated the medications, or interventions required to monitor side effects of the medications. On 4/1/25 at 10:47 A.M., the Administrator provided a current Comprehensive Assessment and the Care Delivery Process policy, revised December 2016, that indicated Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions . Define issues, including problems, risk factors, and other concerns . Identify the current interventions and treatments; and Link these to problems and diagnoses they are supposed to be treating . a person-centered plan of care includes: selecting and implementing interventions, based on the results of the above. 3.1-35(a)

Based on interview, observation, and record review, the facility failed to ensure a resident's plan of care was implemented for 1 of 1 residents reviewed for nutrition. (Resident 29) Finding includes: On 3/26/25 at 10:07 A.M., Resident 29's clinical record was reviewed. Resident 29 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 3/6/25, indicated Resident 29 was cognitively intact, required setup assistance (staff setup meals before dining) for eating, and had an unplanned weight loss of 5% or more in the last month. The current care plan included, but was not limited to: Recent significant weight loss in part related to increase in diuretic but also due to inadequate calorie intakes; Start date 2/17/25 Ice cream daily for added calories due to weight loss; Start date 3/6/25 During an observation on 3/26/25 at 11:45 A.M., Resident 29 was observed in the dining room and did not receive an ice cream with lunch. During an observation on 3/28/25 at 12:54 P.M., Resident 29 was observed sitting in her room eating lunch. Resident 29 indicated she was supposed to receive ice cream but did not receive it. There was not an ice cream on Resident 29's tray. The lunch ticket that indicated what Resident 29 should have received on the tray indicated vanilla ice cream was to be included. On 3/27/25 at 1:04 P.M., the Dietary Manager provided a list of residents who received supplemental foods. Resident 29 was not listed to receive ice cream supplement as care planned. On 4/1/25 at 10:50 A.M., the Administrator provided an undated policy titled Goals and Objectives, Care Plans that indicated Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives are reviewed and revised when there has been a significant change in the resident's condition; when the desired outcome has not been achieved; when the resident has been readmitted to the facility; at least quarterly. 3.1-35(g)(1)

Based on record review and interview, the facility failed to ensure a resident was treated for a urinary tract infection in a timely manner for 1 of 2 residents reviewed for indwelling catheter care. (Resident 27) Finding includes: On 3/26/25 at 10:22 A.M. Resident 27's clinical record was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, malignant neoplasm of bladder. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident 27 was moderately cognitively impaired, required partial to moderate assistance of staff (staff does less than half of the effort) for toileting, and had an indwelling catheter. Physician orders included, but were not limited to: May re-anchor catheter if becomes dislodged or occluded as needed, Contact MD (medical doctor); Start date 3/27/24 Foley catheter: Anchor 16 french, 30cc (cubic centimeters) balloon, provide catheter care every shift, supra pubic catheter(a thin tube inserted into the bladder through a small incision in the lower abdomen), cleanse around insertion site with soap and water, pat dry; Start date 3/7/25 Current care plans included, but were not limited to: Resident requires a suprapubic catheter related to obstructive uropathy; Start date 3/27/24 Report signs of complications such as urinary tract infection (UTI) (acute confusion, bladder spasms, pain, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine); Start date 3/27/24 Resident 27's clinical record indicated the following urinary tract infection occurrences since June 2024: UTI 1: A nursing progress note, dated 6/9/24 at 2:32 P.M., indicated a nurse was alerted to Resident 27's room by housekeeping that resident was covered in blood. Resident unsure of how it happened. He denied falling and there was no evidence that resident had fallen. Family later came in to visit resident and were informed. Family expressed concern related to resident's catheter bag being purple. Leg bag examined per nursing and it did have a purple tint, however, urine output was darker yellow and concentrated. Minimal research revealed a possible cause being purple catheter bag syndrome which was usually indicative of a longstanding Foley catheter and chronic UTI. MD notified of all the above. A nursing progress note, dated 6/10/24 at 2:04 P.M., indicated a new order was received for a urinalysis and culture and sensitivity from a new catheter bag due to urine bag being purple in color. A nursing progress note, dated 6/10/24 at 11:32 P.M., indicated current catheter removed and new catheter placed suprapubic using aseptic technique with no urine return. A nursing progress note, dated 6/11/24 at 10:36 A.M., indicated Resident 27's suprapubic catheter was not in place. No urine return. The nurse adjusted catheter and when it was in place, yellow urine mixed with blood returned. Nurse attempted to replace catheter but was unable to re-anchor catheter. Orders received to send to [hospital] emergency department for catheter replacement. A nursing progress note, dated 6/11/24 at 11:13 A.M., indicated family arrived and transported Resident 27 to the emergency department, catheter bag with blood noted. A nursing progress note, dated 6/12/24 at 4:07 P.M., indicated a urine report was faxed to facility. Nitrite positive, no new orders written with report. A facility nurse called the PAC (post acute care line for physicians) and there was no answer. A nursing progress note, dated 6/13/24 at 3:29 P.M., indicated request sent to PAC to follow up on resident's urine obtained during emergency room visit which was nitrite positive, no culture report available yet. A nursing progress, note dated 6/15/2024 at 5:03 P.M., indicated nurse called PAC related to urine culture results. Unable to obtain results at that time. MD notified to try and obtain results. Resident continued to have purple catheter bags despite dark yellow urine output. A nursing progress note, dated 6/18/24 at 5:24 P.M., indicated Resident 27 complained of not feeling well in his abdomen. Encouraged to eat a good dinner and milkshake. The clinical record lacked a direct call to the hospital laboratory to obtain culture results. A nursing progress note, dated 6/19/24 at 10:25 A.M., indicated urine culture was >100,000 E-Coli and faxed to physician triage for review. Resident was to receive an injection that day. The electronic medication administration record (EMAR) indicated Resident 27 started cephalexin 500mg (milligrams) twice a day for seven days on 6/20/24. A hospital culture report indicated the urine collected in the emergency department on 6/11/24 had a final culture and susceptibility result available on 6/13/24 at 7:57 A.M. UTI 2: A nursing progress note, dated 8/1/24 at 11:17 A.M., indicated catheter was changed due to occlusion. A nursing progress note, dated 8/1/24 at 6:03 P.M., indicated Resident 27 had complaints of pain from the catheter site. The clinical record lacked any observation or progress notes related to catheter, pain, or UTI monitoring from 8/2/24 to 8/19/24. A nursing progress note, dated 8/20/24 at 2:56 P.M., indicated the nurse practitioner (NP) was notified that Resident 27 had a purple urine bag again. The nurse indicated last time that happened, the resident had a UTI. No new orders at that time. A nursing progress note, dated 8/22/24 at 1:56 P.M., indicated the NP was in the facility and gave orders for urinalysis and culture and sensitivity tests, and to change catheter to obtain urine. A nursing progress note, dated 8/22/24 at 2:31 P.M., indicated the catheter was changed but unable to obtain enough urine at that time for urinalysis. A late entry nursing progress noted, dated 8/22/24 at 3:10 P.M., indicated urine obtained. A urine culture lab report, dated 8/22/24 at 3:35 P.M., indicated the method of urine collection was clean catch and indicated a contaminated specimen. A nursing progress note, dated 8/23/24 at 3:11 P.M., indicated urine results faxed to PAC. A nursing progress note, dated 8/24/24 at 5:05 P.M., indicated urine culture results received indicating contaminated sample. A voicemail was left for PAC. A nursing progress note, dated 8/24/24 at 10:24 P.M., indicated the PAC gave new orders to recollect urine specimen. Urine specimen collected with purulent urine return. A nursing progress note, dated 8/26/24 at 1:18 P.M., indicated an order for cephalexin was received on 8/23/24, but was not initiated. The resident was noted to be more confused and lethargic. Order received to start cephalexin 250mg (milligrams) three times a day for 10 days for urinary tract infection. A nursing progress note, dated 8/27/24 at 1:24 P.M., indicated lab stated the second urine specimen was also contaminated. A nursing progress note, dated 8/27/24 at 1:30 P.M., indicated resident always had his hands on his catheter tubing. The clinical record lacked a care plan related to frequent urinary tract infection and prevention of urinary tract infection including promoting hand hygiene for Resident 27. A nursing progress note, dated 8/29/24 at 11:25 A.M., indicated Resident 27 notified staff he was hurting and pointed to the right groin area. The area was assessed and PAC notified. A nursing progress note, dated 8/31/24 at 9:55 A.M., indicated the resident's catheter insertion site was red. UTI 3: A nursing progress note, dated 9/8/24 at 6:01 P.M., indicated Resident 27's family expressed concern related to the catheter insertion site. Site was red with drainage and swelling. The resident complained of severe pain and tenderness to touch. PAC notified and orders given for a urinalysis and culture and sensitivity tests. A nursing progress note, dated 9/9/24 at 6:33 A.M., indicated catheter changed and not enough urine to collect for specimen. A nursing progress note, dated 9/9/24 at 10:31 P.M., urine was obtained and notified lab to pick up. A nursing progress note, dated 9/12/24 at 3:04 P.M., indicated a new order was received for ciprofloxacin 250mg two times a day for seven days for UTI. During an interview on 3/28/25 at 8:22 A.M., the Director of Nursing (DON) indicated Resident 27 had a history of chronic urinary tract infections, culture reports often resulted as contaminated specimens, and resident was not receiving any type of prophylactic measures. During an interview on 4/1/25 at 11:31 A.M., a policy related to urinary tract infection protocol was requested. The Administrator indicated the facility did not have a written policy related to urinary tract infections and the facility's policy was to notify the physician and follow physician orders. On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Acute Condition Change Clinical Protocol, dated December 2015, that indicated Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. The physician will help identify and authorize appropriate treatments. On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Prevention and Screening Clinical Protocol, dated December 2012, that indicated Where medically indicated, the attending physician will identify primary, secondary, and tertiary preventative and screening measures. Primary prevention is aimed at reducing the incidence of a disease or condition by preventing its onset. Secondary prevention targets early identification of a condition to limit its course and complications. Tertiary prevention focuses on prevention of additional complications that is not preventable or fully correctable. 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident was assessed by a physician since admission for 1 of 2 residents admitted in the last 90 days reviewed for accidents. (Resident 22) Finding includes: On 3/26/25 at 1:55 P.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia. The most recent Admission Minimum Data Set (MDS) Assessment, dated 1/26/25, indicated Resident 22 was severely cognitively impaired and required partial assistance (staff does less than half of the effort) for toileting and bathing. The clinical record, including assessments, progress notes, and documents, lacked assessment of Resident 22 by a physician in the facility since admission. During an interview on 3/28/25 at 8:22 A.M., the Director of Nursing (DON) indicated she could not find a physician assessment for Resident 22. On 4/1/25 at 10:47 A.M., the Administrator provided an undated policy titled Physician Services that indicated The physician will perform pertinent, timely medical assessments; visit the resident at appropriate intervals . Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. 3.1-22(d)(1)

Based on interview and record review, the facility failed to ensure pharmacy recommendations were acted upon for 1 of 5 residents reviewed for unnecessary medications. (Resident D) Finding includes: On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, required setup assistance for eating, was dependent on staff for toileting, bathing, and transferring, and received an antianxiety medication during the 7-day look back period. A current care plan, revised 2/21/25, indicated Resident D received antianxiety medication related to an anxiety diagnosis. A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed. Current physician orders included, but were not limited to: buspirone tablet (an antianxiety medication) - 10 milligrams (mg) at bedtime, dated 9/27/24 Discontinued physician orders included, but were not limited to: buspirone tablet - 10 mg once a day, dated 7/11/23 with a discontinued date of 7/10/24 buspirone tablet - 10 mg at bedtime, dated 7/11/24 with a discontinued date of 9/27/24 A pharmacy recommendation, dated 6/11/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon. A pharmacy recommendation, dated 7/16/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon. During an interview on 3/27/25 at 11:05 A.M., Medical Records staff indicated the physician Resident D used did not come to the facility and all pharmacy reviews had to be faxed out. The resident's physician did not respond to the pharmacy recommendations on 6/11/24 or 7/16/24. At that time, she indicated that if an outside physician did not respond, the pharmacy requests were sent to the Medical Director to accept or decline. The Medical Director did not accept or decline the pharmacy recommendations on 6/11/24 or 7/16/24. On 4/1/25 at 10:47 A.M., the Administrator provided a Consultant Pharmacist Reports policy, revised December 2022, that indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Comments and recommendations concerning medication therapy are communicated in a timely fashion . Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . 3.1-25(i)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 2 of 3 residents reviewed for as needed anti-anxiety medication use. Residents' as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 29 and Resident 27) Findings include: 1. On 3/26/25 at 10:07 A.M., Resident 29's clinical record was reviewed. Resident 29 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 3/6/25, indicated Resident 29 was cognitively intact, and was dependent (staff does all of the work) for transfers. Current physician orders included, but were not limited to: alprazolam (anti-anxiety medication) 0.25 milligrams (mg), one tablet by mouth three times daily as needed for pain; Start date 2/27/25 (no end date) The clinical record lacked a physician reassessment of the medication, or indication of contraindication for discontinuation of the medication, beyond 14 days. 2. On 3/26/25 at 10:22 A.M., Resident 27's clinical record review was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident 27 was moderately cognitively impaired and required partial (staff does less than half of the work) assistance for toileting. Current physician orders included, but were not limited to: clonazepam (anti-anxiety medication) 1 milligram (mg) one tablet by mouth three times a day as needed for anxiety; Start date 3/14/25 (no end date) The clinical record lacked a physician reassessment of the medication, or indication of contraindication for discontinuation of the medication, beyond 14 days. During an interview on 3/28/25 at 8:22 A.M., the Director of Nursing (DON) indicated as needed anti-anxiety medication should only be ordered for 14 days and should be reviewed during monthly interdisciplinary team (IDT) meetings. On 4/1/25 the clinical record continued with the current order of clonazepam without stop date, the last recorded dose administered was 3/22/25. On 4/1/25 at 11:29 A.M., the Administrator provided a policy titled Medication Monitoring and Management, dated December 2022, that indicated As needed (PRN) orders for antipsychotic drugs are limited to 14 days without exception. If the attending physician or prescribing practitioner wishes to continue a PRN antipsychotic drug beyond 14 days, the attending physician or prescribing practitioner must first perform an in-person evaluation of the resident and then write a new order. 3.1-48(a)(6)

Based on record review and interview, the facility failed to ensure a catheter change was accurately documented for 1 of 2 residents reviewed for catheter associated urinary tract infections. (Resident 2) Finding includes: On 3/26/25 at 9:08 A.M., Resident 2's clinical record was reviewed. Resident 2 was admitted on [DATE]. Diagnoses included, but were not limited to, urine retention. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/26/25, indicated Resident 2 was cognitively intact, required maximal assistance (staff does more than half of the work) for toileting, bathing, and chair to bed transfers, and had an indwelling catheter. Physician orders included, but were not limited to: Change Foley catheter monthly: 18 French with 30 mL (milliliter) balloon on the 27th of the month; 2/1/25-3/2/25. Change Foley catheter monthly: 18 French with 30 mL (milliliter) balloon on the 2nd of the month; Start date 3/2/25. On 3/28/25 at 1:15 P.M., the Director of Nursing (DON) provided a document titled Treatment Administration History that indicated Qualified Medication Aide (QMA) 7 had changed Resident 2's catheter on 2/27/25. During an interview on 3/28/25 at 1:43 P.M., QMA 7 stated she did not change Resident 2's catheter on 2/27/25, and believed a nurse charted the catheter change under her username. A nursing progress note, dated 3/2/25 at 12:38 P.M., indicated Resident 2 stated that his catheter was due to be changed on 2/27, however, the task was not completed. Registered Nurse (RN) 16 then used sterile technique to change the catheter. On 4/1/25 at 11:29 A.M., the Administrator provided a document titled Charting and Documentation, dated July 2017, that indicated Documentation in the medical record will be objective, complete, and accurate. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to implement infection control practices to ensure the proper use of Enhanced Barrier Protocol (EBP) and Personal Protective Equipment (PPE) for 2 of 2 random observations of wound care. (Resident T and Resident D) Findings include: 1. On 3/26/25 at 11:44 A.M., Resident T's clinical record was reviewed. Diagnoses includes, but were not limited to, Parkinson's Disease. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated that the resident was severely cognitively impaired and was dependent on staff for eating, transferring, hygiene, and toileting. During that assessment, the resident was considered a risk for pressure wounds and had a stage 4 pressure wound present. Current physician orders included, but were not limited to: Skin preparation to bilateral heels every shift for protection dated 9/6/22. Wound: Coccyx Stage 4, clean area with wound cleanser and pat dry with 4 x 4 gauze. Cut a strip of calcium alginate (wound dressing) into a thin long strip and pack loosely into the 11 o'clock tunnel and spread to cover wound bed and pack wound also, skin prep peri wound and cover with 4 x 4 Foam border dressing PRN (As Needed) dislodgment or soiling, dated 3/7/25. Care plan conference notes indicated the care plan was reviewed on 1/13/25. The current care plan for infection indicated that the resident had a need for EBP related to wound care. Interventions included, but were not limited to: Enhanced Barrier Precautions Signs will be hung on the appropriate rooms, dated 4/10/24 PPE will be placed outside of rooms for staff use, dated 4/10/24. Staff will use appropriate PPE during resident care, dated 2/21/25. On 3/27/25 at 11:02 A.M., Registered Nurse (RN) 16 and RN 12 were observed performing wound care without a gown as noted on the Enhanced Barrier Protocol sign posted outside the resident's door. During an interview on 3/27/25 at 11:15 A.M., RN 12 indicated that she forgot to put on the gown prior to wound care. 48147 2. On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified ulcer on right buttock. The most current Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, was dependent on staff (staff does all of the effort) for toileting, bathing, and transferring, and had no pressure injuries. Current physician orders included, but were not limited to: Cleanse area to buttocks with wound cleanser and apply thin layer of hydrophilic wound paste (Coloplast) and cover with a large sacral foam border dressing daily and as needed when soiled, once a day every three days, dated 2/14/25 A current pressure ulcer care plan, initiated 12/12/24, indicated Resident D had a pressure ulcer on her buttock. A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed. A wound management report, dated 2/4/25 at 4:14 P.M., indicated an unspecified ulcer that was not present on admission was identified on Resident D's right buttock. The ulcer measured 1 centimeter (cm) in length and 0.8 cm in width. The most current wound management report, dated 3/22/25 at 9:00 A.M., indicated the ulcer on Resident D's right buttock measured 0.7 cm in length by 0.3 cm in width. The clinical record lacked an order or care plan that indicated Resident D was on Enhanced Barrier Precautions (EBP) due to the wound. On 3/27/25 at 10:31 A.M., Registered Nurse (RN) 16 and RN 5 were observed performing wound care on Resident D's ulcer on her right buttock. RN 16 and RN 5 were not wearing gowns during wound care. There was not an EBP sign observed in or near the resident's room. On 3/28/25 at 8:31 A.M., the Director of Nursing (DON) provided a list of all residents on EBP, and Resident T was listed. Resident D's name was not on the list. During an interview on 3/28/25 at 8:40 A.M., the DON indicated EBP was used for residents who had an indwelling catheter, wound, or open surgical incision. At that time, she indicated Resident D should be on EBP and staff should be wearing a gown and gloves while providing wound care to the resident. During an interview on 3/28/25 at 10:36 A.M., the Infection Preventionist (IP) indicated that staff should use EBP with direct patient care if the resident had a wound or an indwelling catheter. On 4/1/25 at 11:00 A.M., the Administrator provided a current undated Enhanced Barrier Precautions for Skilled Nursing Facilities policy that indicated .nursing staff ensures that the resident and staff are aware of need to use EBP and the necessary supplies are provided .EBP signage outside resident's room and provide readily available personal protective equipment (PPE), including gowns and gloves . This citation relates to complaint IN00451230. 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their room. (Resident 246) Finding includes: On 1/29/24 at 10:36 A.M., a tube of hydrocortisone 1% cream was observed on Resident 246's bedside table. Resident 246 indicated that she received it from the hospital upon discharge and kept it in her room to use on her face as needed for itchiness. On 1/30/24 at 9:05 A.M., a tube of hydrocortisone 1% cream was observed on Resident 246's bedside table. On 1/31/24 at 8:51 A.M., a tube of hydrocortisone 1% cream was observed on Resident 246's bedside table. On 1/30/24 at 8:23 A.M., Resident 246's clinical record was reviewed. Diagnosis included, but was not limited to, local infection of the skin and subcutaneous tissue. Resident 246 was admitted to the facility on [DATE]. The admission MDS (Minimum Data Set) Assessment was still in progress. A BIMS (Brief Interview for Mental Status) assessment, dated 1/29/24, indicated Resident 246 was cognitively intact. A Functional Abilities Assessment, dated 1/30/24, indicated the resident required setup assistance for eating, supervision for transfers, and partial to moderate assistance for bed mobility and toileting. Current physician orders lacked an order for hydrocortisone 1% cream and an order to self administer medications. The clinical record lacked a self administration of medication evaluation. Hospital discharge papers, dated 1/11/24, indicated the resident was discharged with hydrocortisone 1% cream - 1 application topically TID (three times a day). On 1/30/24 at 9:30 A.M., RN (Registered Nurse) 3 indicated that no resident on the North Unit self administered medications. On 1/30/24 at 2:16 P.M., the Administrator indicated that in order to keep medications at bedside, a resident needed a self administration of medication evaluation and a physician order. On 1/31/24 at 11:27 A.M., the DON (Director of Nursing) indicated that Resident 246 did not have a completed self administration of medication evaluation. At that time, she indicated that she could not find an order for hydrocortisone 1% cream and wasn't aware the resident used it. On 1/31/24 at 1:47 P.M., an Administering Medications policy, revised April 2010, indicated residents may self-administer their own medications only if the Attending Physician and Interdisciplinary Care Team, has determined that they have the decision-making capacity to do so safely. 3.1-11(a)

Based on observation, record review, and interview the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed for respiratory care. The facility failed to date tubing and label humidification bottles, place signs indicating oxygen use, and lacked a care plan for oxygen for a resident on oxygen. (Resident 246 and Resident 11) Findings include: 1. On 1/29/24 at 10:28 A.M., an oxygen concentrator was observed in Resident 246's room. The humidification bottle and tubing was not labeled or dated. There was no oxygen in use sign on the resident's door. At that time, Resident 246 indicated that she occasionally needed oxygen to help keep her oxygen saturation up and that she had used oxygen last night. On 1/30/24 at 9:05 A.M., an oxygen concentrator was observed in Resident 246's room. The humidification bottle and tubing was not labeled or dated. There was no oxygen in use sign on the resident's door. On 1/31/24 at 8:51 A.M., an oxygen concentrator was observed in Resident 246's room. The humidification bottle and tubing was not labeled or dated. There was no oxygen in use sign on the resident's door. At that time, Resident 246 indicated she used oxygen last night and the concentrator was just turned off. On 1/30/24 at 8:23 A.M., Resident 246's clinical record was reviewed. Diagnoses included, but were not limited to, essential hypertension, paroxysmal atrial fibrillation, chronic respiratory failure with hypoxia - PRN (as needed) oxygen use, and obstructive sleep apnea. Resident 246 was admitted to the facility on [DATE]. The admission MDS (Minimum Data Set) Assessment was still in progress. A BIMS (Brief Interview for Mental Status) assessment, dated 1/29/24, indicated Resident 246 was cognitively intact. A Functional Abilities Assessment, dated 1/30/24, indicated the resident required setup assistance for eating, supervision for transfers, and partial to moderate assistance for bed mobility and toileting. Current physician orders included, but was not limited to: Supplemental O2 (oxygen) 1-2LNC (liters nasal cannula) prn to maintain O2 sat (saturation) >92%, for respiratory failure, dated 1/27/24. Check O2 sat every shift (prn supplemental if <92%) for COPD (chronic obstructive pulmonary disease), dated 1/27/24. Hospital discharge paperwork, dated 1/27/24, indicated the resident needed to be on 1L continuous oxygen via nasal cannula. A current baseline care plan, dated 1/27/24, lacked indication of oxygen use. A vitals report indicated the resident received 2L oxygen on 1/27/24 at 11:16 P.M. and 1L oxygen on 1/29/24 at 6:55 A.M. The January 2024 TAR (treatment administration record) indicated the resident did not receive oxygen. On 1/31/24 at 8:56 A.M., the DON (Director of Nursing) indicated that nursing staff was responsible for changing out and dating humidification bottles and tubing. She indicated they performed the task when they saw the water in the bottle was getting low. On 1/31/24 at 11:27 A.M., the DON indicated oxygen should be included on the baseline care plan under the cardiac or respiratory problems. She indicated if the resident came into the facility with oxygen, it should be addressed on the baseline care plan somewhere. On 1/31/24 at 1:49 P.M., an Oxygen Administration policy, revised October 2010, indicated place an Oxygen in Use sign on the outside of the room entrance door. On 2/01/24 at 8:37 A.M., a Care Plan - Baseline policy, revised December 2016, indicated The Interdisciplinary Team will .implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission orders, physician orders . 46758 2. On 1/29/24 at 11:02 A.M., Resident 11 was observed lying in bed with oxygen tubing and a concentrator on the side of the bed without a date or initials. On 1/31/24 at 9:41 A.M., Resident 11 was observed sitting in a wheelchair wearing oxygen at 2 liters (L) via nasal cannula. The tubing lacked a label with initials and date. On 1/29/24 at 11:02 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, cardiomegaly, cardiomyopathy, and sleep apnea. The current quarterly MDS (Minimum Data Set) Assessment, dated 11/2/23, indicated Resident 11 was severely cognitively impaired. Resident 11 was dependent for transfer, eating, and toileting. Current physician orders included, but were not limited to: Supplemental oxygen at 2L/Minute for comfort measures as needed, dated 5/26/23. The clinical record lacked an order to change the tubing. During an interview on 2/2/24 at 10:34 A.M., RN (Registered Nurse) 3 indicated the oxygen tubing was changed out weekly on the night shift. At that time, she indicated there should be an order to change the tubing weekly and placed on the MAR (Medication Administration Record). A current Departmental (Respiratory Therapy) - Prevention of Infection policy, dated November 2011, was provided on 2/2/24 at 12:20 P.M. by the Administrator. The policy indicated . the purpose of this procedure is to guide prevention of infection associated with the respiratory therapy tasks and equipment among staff and residents .infection control consideration related to oxygen administration include .change the cannula and tubing every 7 days or as needed. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were implemented, appropriate hand hygiene was not performed for 2 of 2 residents observed for wound care. (Resident 38 and Resident 16) Findings include: 1. On 1/31/24 at 1:47 P.M. Registered Nurse (RN) 5 was observed performing a dressing change on Resident 38's right forearm. RN 5 entered Resident 38's room, put on gloves, used the bed remote to raise Resident 38's bed, and started wound care without performing hand hygiene. RN 5 removed Resident 38's previous dressing dated 1/29/24. RN 5 began pouring saline over Resident 38's wounds, touching the open areas of the wounds with the gloves. RN 5 then dried the wounds off using a wash cloth that was laying on Resident 38's bed. RN 5 removed gloves, applied hand sanitizer and rubbed hands together for 5 seconds, and put on another pair of gloves. RN 5 applied the dressings to the wounds and dated the wound. RN 5 removed gloves, assisted Resident 38 with pulling their shirt sleeve down, put gloves on, gathered soiled linens and trash, removed gloves before exiting the room, no hand hygiene was performed. 48147 2. On 1/30/24 at 1:10 P.M., Registered Nurse (RN) 5 and Certified Nurse Aide (CNA) 10 was observed performing a dressing change on Resident 16's stage 4 coccyx pressure ulcer. Upon entering the room and assisting the resident, RN 5 and CNA 10 put on gloves without performing hand hygiene. They rolled Resident 16 on to her side and removed her brief. Resident 16 had a liquid bowel movement which was cleaned with a washcloth using soap and water. RN 5 removed her gloves and put new ones on without performing hand hygiene. A new pad and clean towel were placed under the resident and a washcloth was used to clean the resident's bottom again. RN 5 removed her gloves and put new ones on without performing hand hygiene. RN 5 measured the wound. RN 5 removed her gloves and put new ones on without performing hand hygiene. RN 5 applied medicated gel and packing to the wound. RN 5 removed her gloves and put new ones on without performing hand hygiene. A dressing was placed on the wound. RN 5 rolled the resident to remove the dirty pad, wiped the front of the resident, put on a new brief, arranged the pillows and blankets on the bed, gathered trash, and handed the resident her call light. RN 5 removed her gloves and performed hand hygiene. On 2/2/24 at 10:35 A.M., the Infection Preventionist indicated hand hygiene should be performed before wound care, between glove changes, between dirty and clean tasks, and when finished. On 1/30/24 at 2:35 P.M., the Infection Preventionist provided a policy titled Handwashing/Hand Hygeine, revised 2015, that indicated Wash hands with soap and water a. when hands are visibly soiled. Use an alcohol based hand rub or soap and water b. Before and after direct contact with residents; g. Before handling clean or soiled dressings; i. After contact with a resident's skin; m. After removing gloves. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in 2 of 3 medication carts and 1 of 1 medication storage room. Loose pills were found in the bottom of the medication cart drawers and expired IV tubing that did not belong to a current resident was found in a medication storage room. (North Unit medication cart, South Unit medication cart and storage room) Findings include: On [DATE] at 12:45 P.M., an IV tubing set was observed in the South Unit medication storage room with an expiration date of [DATE]. At that time, LPN 23 indicated the name on the IV tubing set was unknown and not a current resident at the facility. On [DATE] at 12:55 P.M., the South Unit medication cart was observed with the following loose pills in the drawers: Blue oval capsule with markings G231 White circle tablet with marking 20 Pink circle tablet with marking 34 E Yellow circle tablet with marking M/721 ,d+[DATE] purple oval tablet with undistinguishable markings White circle tablet with undistinguishable markings Orange oval tablet with marking ,d+[DATE] ,d+[DATE] white oval tablet with undistinguishable markings x2 At that time, LPN 15 indicated the medication carts were cleaned out every other week by night shift. On [DATE] at 1:05 P.M., the North Unit medication cart was observed with the following loose pill in the drawer: White circle tablet with marking 1/z At that time, LPN 3 indicated the medications carts were cleaned out every Saturday and as needed through the week. On [DATE] at 1:04 P.M., a current Storage of Medications policy, revised [DATE], indicated Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . The nursing staff shall be responsible for maintaining medication storage . 3.,d+[DATE](o)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 7 of 9 residents observed for infection control. A blood glucose machine was cleaned with expired wipes, catheter tubing was on the floor, a bed pan on the floor, hands were not washed, and gloves were not changed between clean and dirty tasks. (South Hall treatment room, Resident 14, Resident 17, Resident 91, room [ROOM NUMBER], Resident 9, Resident 24) Findings include: 1. On [DATE] at 11:25 P.M., LPN 9 was observed testing a blood glucose for Resident 91. At that time, LPN 9 indicated residents did not have their own machines, and they were used for any resident that needed blood glucose testing on that hall, and the machine was cleaned after each use. LPN 9 then observed to go to the treatment room, obtained a cleaning wipe from a container with an expiration date of ,d+[DATE], then wrapped it around the blood glucose machine. The machine was not wiped with cloth. During an interview on [DATE] at 8:20 A.M., LPN 15 indicated blood glucose machines on their side of the hall were also cleaned with the wipes in the treatment room with expiration date ,d+[DATE]. 2. On [DATE] at 11:59 A.M., Resident 14 was observed in the dining room with urinary catheter tubing hanging from the end of their pant leg. The urinary catheter tubing was rested on the resident's side and bottom of their shoe. 3. On [DATE] at 1:33 P.M., LPN 9 was observed performing a dressing change for Resident 17's coccyx and foot wounds. When pulling down Resident 17's pants from the back, a dark brown substance was observed on the inside of the brief as the pants and brief were folded inward to expose the coccyx wound. After the dressing was changed, the pants and the soiled brief were pulled back up over the dressing. LPN 9 washed his hands for a total of seven (7) seconds and completed a dressing change for Resident 17's foot. LPN 9 did not change his gloves between taking off the old dressing and placing the new dressing. When completed, LPN 9 washed his hands, obtaining soap from the dispenser and directly placing them under the water to rub his hands together, for a total of 7 seconds. 4. On [DATE] at 12:55 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink. On [DATE] at 1:21 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink. On [DATE] at 1:18 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink. On [DATE] at 8:30 A.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink. During an interview on [DATE] at 9:27 A.M., CNA (Certified Nursing Assistant) 7 indicated bedpans should be stored in a bag inside the closet. 5. On [DATE] at 9:12 A.M., CNA 7 was observed to provide incontinence care for Resident 9. CNA 7 washed her hands, donned gloves, and moved Resident 9's bedside table. CNA 7 opened the closet door, took washcloths to bathroom sink, wet the washcloths, and laid a trashbag on Resident 9's bed. CNA 7 uncovered the resident, pulled down the soiled brief, cleaned the resident peri area with the wet washcloths, pulled the resident's blanket, and walked across the room to obtain a clean brief. CNA 7 removed her gloves. No hand hygiene was observed. CNA 7 opened the closet door and obtained a clean brief. CNA 7 washed her hands and donned new gloves. She pulled the residents blanket down, rolled the resident to the left side, and cleaned the residents buttocks. CNA 7 removed the soiled pad under the resident and placed a clean brief on the resident. CNA 7 removed gloves. No hand hygiene was observed. CNA 7 pulled Resident 9's blankets up, placed the resident's bed in low position, moved the bedside table in front of resident, placed the resident's drink on the bedside table, and wiped the bedside table. During an interview on [DATE] at 1:00 P.M., RN 4 indicated gloves should be changed immediately before care is performed if items were previously touched after putting gloves on. 6. During an observation on [DATE] at 2:11 P.M., LPN 9 was changing Resident's 24 surgical wound dressing. A biohazard container was in Resident 24's room with a sign that indicated Resident 24 should have contact precautions during the wound vac dressing changes. LPN 9 performed the dressing change while wearing an N95 respirator mask and surgical gloves. During an interview on [DATE] at 10:25 A.M., IP 4 (Infection Preventionist) indicated Resident 24's surgical wound was infected and the resident required antibiotics for the infection. IP 4 indicated a culture had not yet been completed and the type of infection had not yet been identified. Resident 24 should be on contact precautions during the surgical wound dressing changes. Staff should wear a gloves and a gown during the dressing change. On [DATE] at 10:00 A.M., a current Handwashing/Hand Hygiene policy, revised [DATE], was provided and indicated All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) . On [DATE] at 1:04 P.M., a current Urinary Catheter Care policy, revised [DATE], was provided and indicated, Be sure catheter tubing and drainage bag are kept off the floor On [DATE] at 11:50 A.M., the Facility Administrator supplied a facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated, ,d+[DATE]. The policy included, .Contact Precautions . 5. Gown .a. Wear a disposable gown upon entering the Contact Precautions room or cubicle . 3.,d+[DATE](b)(1) 3.,d+[DATE](l)

Based on interview and record review, the facility failed to ensure [CONDITION(S)] care was provided for 1 of 1 residents reviewed for [CONDITION(S)]. Communication between the [CONDITION(S)] center and the facility was not established and assessments were not obtained from the [CONDITION(S)] center. (Resident 142) Finding includes: During record review on 5/11/22 at 10:30 A.M., Resident 142's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 142's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of pre and post [CONDITION(S)] assessments from 4/30/22 thru 5/10/22, no [CONDITION(S)] communication was found between the facility and the [CONDITION(S)] center on the following dates; 4/30/22 (Saturday), 5/3/22 (Tuesday), 5/5/22 (Thursday), 5/7/22 (Saturday), and 5/10/22 (Tuesday). During an interview on 5/11/22 at 11:00 A.M., LPN 15 indicated staff used to send a [CONDITION(S)] communication form with residents requiring [CONDITION(S)] on their [CONDITION(S)] days, but did not know if the facility still used the forms. LPN 15 then supplied a copy of a [CONDITION(S)] communication form. The form included the following information from the facility to the [CONDITION(S)] center; resident vital signs, medications received, time of last meal, if the resident needs a meal or snack, the resident's diet, if the resident is on a fluid restriction. The form included the following from the [CONDITION(S)] center; pre and post [CONDITION(S)] weights, amount of fluid removed, vitals signs, lab tests and results, how the resident tolerated the procedure, new orders and appointments. During an interview on 5/11/22 at 1:00 P.M., LPN 9 indicated the facility did not use [CONDITION(S)] communication forms or communicate vitals or weights for Resident 142 on [CONDITION(S)] days. On 5/12/22 at 12:30 P.M., the Facility Administrator supplied a facility policy, titled, End-Stage [CONDITION(S)], Care of Residents with, and dated 09/2010. The policy included, Residents with end-stage [CONDITION(S)] ([CONDITION(S)]) will be cared for according to currently recognized standards of care.4. Agreements between this facility and the contracted [CONDITION(S)] facility include all aspects of how the resident's care will be managed, including: .b. How information will be exchanged between the facilities . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure accurate daily staffing sheets were posted for 3 of 3 days reviewed during the survey. (South Unit) Findings include: On 5/9/22 at 10:00 A.M., a staffing sheet was observed by the south hall nurses station with the date 5/9/22. The staffing sheet failed to indicate the number and actual hours worked by RN's (Registered Nurse), LPN's (Licensed Practical Nurse), QMA's (Qualified Medication Aid), and CNA's (Certified Nursing Assistant). On 5/11/22 at 12:03 P.M., posted nurse staffing sheets dated 5/9/22 to 5/11/22 were provided. All forms lacked the number and actual hours worked by RN's, LPN's, QMA's, and CNA's. On 5/12/22 at 12:04 P.M. a current staffing policy dated October 2017 was provided, but lacked information related to requirements of posted nurse staffing sheets. At that time, the Administrator indicated the facility's policy was to follow state regulations on posted nurse staffing.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program during the COVID-19 crisis for 2 of 2 resident rooms observed for staff doffing PPE. Staff were observed doffing PPE (Personal Protective Equipment) in the hallway after leaving resident rooms who were on transmission based precautions. ( Resident 1, Resident 2 ) Findings include: On 1/25/21 at 8:40 a.m., Housekeeper 1 was observed to donn a gown and gloves before entering Resident 1's room she also had a N95 mask and face shield on. Resident 1 was on transmission based precautions on the COVID-19 yellow zone. Housekeeper 1 was observed to exit the room and walk to the cleaning cart that was across the hall from Resident 1's room. She was observed to obtain something from the cart and walk back into the room. Housekeeper 1 was observed to exit the room, walk to the cleaning cart, doff her gloves, donn new ones, and reenter Resident 1's room. Housekeeper 1 was observed to exit the room, doff her gown and gloves by the cleaning cart, throw them into a trash bag that was attached to the cart, and perform hand hygiene. On 1/25/21 at 8:45 a.m., Housekeeper 2 was observed to leave Resident 2's room and doff her gown and gloves at the cleaning cart. Resident 2's room was a transmission based precaution room on the COVID-19 yellow zone. On 1/25/21 at 8:47 a.m., Housekeeper 2 indicated she always doffed her gown and gloves at her cleaning cart after leaving a room that was on transmission based precautions. At 8:50 a.m., Housekeeper 1 indicated you can take your gown and gloves off in a resident's room or in the hallway. At 8:53 a.m., Housekeeper 1 approached this surveyor and indicated the reason she doffed her PPE in the hallway was because she didn't want to put her PPE in Resident 1's personal trash can and fill it up, so she doffed the PPE in the hallway at her cart. On 1/25/21 at 11:32 a.m., the Administrator indicated in-services had been done on donning and doffing PPE, and trash cans with lids are available in all rooms on transmission based precautions to throw PPE into. On 1/25/21 at 9:30 a.m., the Administrator provided documents regarding infection control and donning and doffing PPE. A document titled Infection Prevention and Control Manual Standard Precautions included, but was not limited to, remove all PPE at doorway before leaving patient room or in anteroom. The document had a date of 2017. A document titled How to Safely Remove Personal Protective Equipment (PPE) Example 1 indicated, but was not limited to, remove all PPE before exiting the patient room except a respirator, if worn. The document did not contain a date. 3.1-18(b)

Based on observation, interview, and record review, the facility failed to provide supervision and assistance to prevent accidents for 2 of 2 residents reviewed for falls. Supervision and fall interventions were not in place, which resulted in a fracture requiring surgical intervention for Resident 36 and facial injuries for Resident 11. (Resident 36, Resident 11) Findings include: 1. On 7/29/19 at 10:07 a.m., Resident 36 was observed sitting in a chair in their room with a cast on the right arm on a pillow. Resident 36 indicated they had recently fell but was unable to indicate where the fall occurred. The clinical record for Resident 36 was reviewed on 7/30/19 at 11:19 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had moderate cognitive impairment. An admission Fall Risk Acuity form, dated 12/17/18 at 11:10 a.m., indicated the resident was at risk for falls. A history of falling care plan, dated 12/28/18, reviewed or revised 5/11/19, included, but was not limited to, the following: Offer to assist with toileting between 4 and 5 a.m., dated 1/5/19. Assure the floor was free of glare, liquids, and foreign objects, dated 1/5/19. Encourage the resident to use environmental devices, such as hand grips, hand rails, et cetera, dated 12/28/18. Keep bed in lowest position with brakes locked, dated 12/28/18. Keep call light within reach at all times, dated 12/28/18. Keep personal items and frequently used items within reach, dated 12/28/18. Orient resident when there was new furniture placement or other changes in environment, dated 12/28/18. Provide proper, well-maintained footwear, dated 12/28/18. Provide resident an environment free of clutter, dated 12/28/19. physician's orders [REDACTED]. Activity level: up with cane, start date 1/31/19, discontinued 7/9/19. Concave mattress, start date 7/10/19, discontinued 7/11/19. An progress note, dated 12/28/18 at 11:08 a.m., indicated the resident had a [DIAGNOSES REDACTED]. A progress note, dated 1/5/19 at 4:59 a.m., indicated the resident had an unwitnessed fall in their room. The note indicated the resident was found on the floor on the right side of the bed. The resident stated, I was putting on my shoes and standing up to go to the bathroom and I fell and hit my head on the bed frame. I need to go to the bathroom. Resident had a small abrasion on the left side above the eye brow and three (3) knots on the head, one on the left eyebrow, one on the forehead, and one on the left side of the top of the head. The resident was sent to the emergency room . An Event Report form, dated 1/5/19 at 4:15 a.m., indicated the resident had an unwitnessed fall at the right side of the bed in the resident's room. The location of the injury to the left side of the face, an abrasion above the eyebrow, knot on the left eyebrow, a knot on the left forehead, and a knot on the left side of the top of the head. The report indicated interventions in place prior to the fall included bed in the lowest position, hand rail on bed to aid with self-transfers into and out of bed. The Event Report indicated on 1/6/19 at 5:11 a.m., the resident was transferred to the emergency room by ambulance. A Fall Risk Acuity form, dated 1/5/19 at 2:14 p.m., indicated the resident was not at risk for falls. A progress note, dated 1/7/19 at 2:33 a.m., indicated the resident was found sitting on the floor on the bed holding onto the side rail with the right arm. The resident had slid off the side of the bed and was observed with the legs bent slightly and their back straight. The resident was capable of moving all their extremities and was assisted back to bed. An Event Report form, dated 1/7/19 at 2:22 a.m., indicated Resident 36 had a witnessed fall in their room with no injury. The interventions in place prior to the fall were bed in lowest position, hand rail on bed to aid with self-transfers into and out of bed, and toilet between 4 and 5 a.m. The interventions were somewhat effective. The report lacked documentation of new interventions. The Fall Risk Acuity, dated 1/7/19 at 2:35 a.m., indicated the resident was not at risk for falls. An IDT note, dated 1/8/19 at 11:16 a.m., indicated the resident had a fall in bathroom during early a.m., hours while toileting self without requesting assist. The resident requested to have a regular mattress back per their preference. The resident was being treated for [REDACTED]. The facility would return to the pressure relief mattress and bed in low position when in bed per the resident's request. The Fall Risk Acuity form, dated 4/24/19 at 4:05 a.m., indicated the resident was at risk for falls. A progress note, dated 6/27/19 at 5:30 a.m., the resident was found lying on the right side and back in another resident's doorway. The resident had hit their head, causing a five (5) cm (centimeter) x 5 cm bump to the left lower side of the back of their head and a skin tear to the left elbow measuring 1 (one) cm x 1.8 cm with minimal bleeding noted. The resident had shoes on with the laces untied. The note indicated all other interventions from care plan were in place except the proper footwear, which is now the intervention. An Event Report form, dated 6/27/19 at 5:25 a.m., indicated Resident 36 had an unwitnessed fall in the hallway. The report indicated the resident received a goose egg 5 cm x 5 cm to the left side middle back of the head and a skin tear to the left elbow 1 cm x 1.8 cm. Immediate interventions included first aid which were effective, shoes with laces were to be placed in the resident's closet at bedtime and out of the resident's reach. Interventions in place prior to fall included toileting between 4-5 a.m. and the bed in the lowest position. The Fall Risk Acuity form, dated 6/27/19 at 5:37 a.m., indicated the resident had intermittent confusion, poor recall, judgment, safety awareness, and was not at risk for falls. The IDT progress note, dated 6/28/19 at 11:23 a.m., indicated the resident had a fall in the hallway due to the resident putting on shoes per self that were tie instead of the usual slip-ons. The note indicated the resident's family member had brought the shoes in for the resident to walk in. The resident had slipped the shoes on and did not tie them, stepping on shoe string and causing the resident to lose their balance. Elastic strings were put in the shoes per therapy and staff would put them on a shelf in the resident's closet at bedtime and assist the resident in putting on the shoes in the a.m. A progress note, dated 7/1/19 at 10:40 p.m., indicated Resident 36 was observed to by laying in the floor in front of the chest of drawers. Resident 36 indicated they had been coming from the bathroom and fell . The resident complained of right wrist pain. The resident was assisted to a chair with no other injury noted. The note indicated the resident was wearing no shoes and regular socks. A progress note, recorded as a late entry on 7/2/19 at 12:03 a.m., indicated at 7/1/19 at 12:00 midnight the resident's arm was swelling more and the resident had increased pain. A progress note, dated 7/2/19 at 1:38 p.m., indicated the (Name of Hospital) called indicating the resident had a right ulna and radius fracture. A progress note, dated 7/2/19 at 5:41 a.m., indicated the resident returned from the hospital with the right arm in a soft cast in sling. The resident was assisted into bed with 2 persons. The call light was placed within the resident's reach and the resident was encouraged to use, and gripper socks applied. An Event Details report, dated 7/1/19 at 11:45 p.m., indicated Resident 36 had an unwitnessed fall walking back to bed from the bathroom. The report indicated the resident had an injury to the right wrist with abnormal alignment. The resident had painful/limited ROM (range of motion) in the upper extremity, rotation/deformity of the upper right extremity, and the upper right extremity movement/grasp was weak. Ice was applied to the right wrist. The form indicated, interventions in place prior to the fall: shoes with laces put in closet at night and offer toileting between 4-5 a.m. An IDT progress note, dated 7/2/19 at 2:58 p.m., indicated the resident was noted to have had a fall due to ambulating without shoes on and only having socks on. Resident was educated to use shoes at all times when up ambulating. Resident to have gripper socks on when in bed to assist with prevention of further falls due to slipping. Resident would currently use wheelchair at this time due to inability to utilize cane with fracture to right wrist. A progress note, dated 7/8/19 at 12:45 p.m., indicated the resident was transported to (Name of Hospital) for right wrist surgery. A progress note, dated 7/9/19 at 4:39 p.m., indicated the resident returned to the facility. A progress note, dated 7/9/19 at 4:5 p.m., indicated the resident was forgetful with conversation, confused with situation and a wander guard was placed on the resident's right ankle. The note further indicated the resident was assisted to bed with 2 persons. The Fall Risk Acuity form, dated 7/12/19 at 5:10 p.m., indicated the resident was disoriented x 3 (to person, place, and time) with diminished safety awareness and was at risk for falls. On 8/5/19 at 5:00 p.m., the Director of Nursing (DON) indicated the interventions should have been listed in the progress notes and the interventions in place prior to the fall should have been checked no. Some of the interventions listed were not relevant to the fall when the staff checked the box., yes. It was the responsibility of each nurse to document the interventions and also to update the care plans. The current facility policy, revised March, (YEAR), provided by the ADON (Assistant Director of Nursing) on 8/6/19 at 3:55 p.m., indicated residents should be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly. The current facility policy, revised , provided by the Director of Nursing (DON) on 8/6/19 at 4:12 p.m., indicated the facility would strive to make the environment as free from accident hazards as possible. The policy indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 2. On 7/29/19 at 11:17 a.m., Resident 11 was observed to be sitting in a wheelchair in the dining room. Resident 11 had discoloration around the eyes, on the forehead, on the nose, and bilateral upper cheek areas. RN 1 indicated the resident had fell out of the wheelchair and had a broken nose. The clinical record for Resident 11 was reviewed on 7/29/19 at 3:05 p.m. [DIAGNOSES REDACTED]. A quarterly MDS (Minimal Data Set) assessment, dated 5/7/19, indicated the resident had moderate cognitive impairment, required extensive assist of 2 persons for bed mobility, transfers, dressing, and personal hygiene. The resident required extensive assist of 1 person for locomotion on and off the unit and required a wheelchair as a mobility device. A physician's orders [REDACTED]. A care plan indicated the resident was at risk for falling related to history of falling, start date 11/8/18, included, but were not limited to, the following interventions: Do not leave alone in wc (wheelchair) in room, start date 5/26/19. Offer to lay down after meals, start date 3/1/19. Reacher given to resident/cell phone within reach at all times, start date 11/30/18. Staff education for 2 assist at all times, start date 11/26/18. Keep call light in reach at all times. Resident does use call light, start date 11/9/18. Provide proper, well-maintained footwear, start date 11/9/18. A progress note, dated 11/25/18 at 10:30 a.m., indicated the resident was found on the floor in their room, laying on their back with their legs slightly bent and their feet on the ground. The resident was in their wheelchair and was reaching to get their cell phone, and fell forward out of their wheelchair. Resident had a pink unopened abrasion to the upper right side of their back. Resident was assisted to their feet with 4 (four) persons. A Event Form, dated 11/25/18 at 10:38 a.m., indicated Resident 11 had an unwitnessed fall in the resident's room. The form indicated the resident had no injury noted at that time. An IDT (Intradepartmental Team) progress note, dated 11/26/18 at 12:48 p.m., indicated the resident had a fall from their wheelchair while attempting to reach the phone on the nightstand. Reacher was provided and resident encouraged to keep phone on bedside table in reach while up. Call light in reach, continue with 2 (two) assist with all ADLS (activities of daily living), ambulation, and transfers to and from wheelchair due to legs giving out and being lowered to floor. A Fall Risk Acuity form, dated 11/25/18 at 10:42 a.m., indicated the resident was at risk for falls. The clinical record lacked documentation of interventions present at the time of the fall. A progress note, dated 2/15/19 at 8:00 p.m., indicated at 7:10 p.m., the activity staff observed the resident on the floor by their wheelchair. The resident complained of pain and was assisted into bed with the use of the Hoyer lift. An Event Form, dated 2/15/19 at 9:16 p.m., indicated the resident had an unwitnessed fall in the resident's room. The resident had no pain and no noted injuries. The immediate intervention was to ensure the resident was in bed by 6:45 p.m. every evening. A Fall Risk Acuity from, dated 2/15/19 at 9:46 p.m., indicated the resident was at risk for falls. The clinical record lacked documentation of interventions in place at the time of the fall. A progress note, dated 7/20/19 at 6:25 p.m., indicated the resident was found on the floor, face down with the legs straight out. Resident 11 was bleeding from her face and indicated they hurt all over. The resident had a large hematoma on the forehead and the nose was bleeding, flattened, and deviating to the left at the bridge of the nose. The resident had been incontinent of bowel and bladder. The facility notified the family who requested hospice be consulted prior to deciding if the resident should go to the emergency room . An Event Form, dated 7/20/19 at 6:30 p.m., indicated Resident 11 had an unwitnessed fall in their room. The resident had been trying to get up just prior to the fall. The resident had a bloody nose and complained of pain all over, indicating the pain was a 7 (seven) out of 10 (ten) on the pain scale. The location of the injury indicated a nose bloody, deviated, large hematoma to the forehead. The form indicated the resident had fallen out of the wheelchair in their room, was incontinent of bowel and bladder, and fell face down. The form did not list any contributing factors and the immediate measure taken was to not leave the resident up in the wheelchair alone in the room. The form indicated Interventions in place/alarm sounding documented in the nurse's notes: yes, but no interventions were listed. A Fall Risk Acuity form, dated 7/20/19 at 6:40 p.m., indicated the resident was at risk for falls. A progress note, dated 7/20/19 at 11:00 p.m., indicated the resident was assisted to bed at 7:00 p.m., using the Hoyer lift (a mechanical lift) and 2 staff members. An IDT (Intradepartmental Team) fall review progress note, dated 7/22/19 at 11:24 a.m., indicated the resident was noted to have had a fall over the weekend. The resident had propelled self to room in wheelchair, leaned forward, and fell out. The note resident had facial bruising. The resident's family declined to send the resident to the emergency room at the time of the fall with the understanding that if there were any physical or mental status changes, the resident would be sent to the ER for evaluation. Resident intervention was to place in bed after the evening meal. The clinical record lacked documentation of interventions in place at the time of the fall. On 8/5/19 at 9:36 a.m., RN 1 indicated the resident's care plans were updated by the MDS Coordinator and that all the interventions listed on the care plan were in place when the Interventions in place/alarm sounding documented in nurse's notes was checked. On 8/5/19 at 5:15 p.m., the Director of Nursing (DON) indicated the Interventions in place/alarm sounding documented in nurse's notes should have been checked no. The DON indicated the interventions were not listed prior to the fall and the care plan should be updated after each fall. The facility had not obtained an x-ray of the resident's nose as hospice had evaluated the resident on 7/21/19 at 10:17 a.m., hospice had spoken with the family, and the resident declined an x-ray. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure residents who were admitted with no pressure ulcers, did not develop pressure ulcers for 1 of 2 residents reviewed for pressure ulcers during Stage 2 of the survey. This deficient practice resulted in a resident developing an unstageable pressure injury to the right heel. (Resident 48) Findings include: On 6/21/17 at 9:39 a.m., the clinical record for Resident 48 was reviewed. [DIAGNOSES REDACTED]. The hospital transfer orders, dated 5/5/17, indicated Discharge [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment, dated 5/12/17, indicated a BIMS (Brief Interview for Mental Status) Score 6, which indicated severe cognitive impairment, extensive assist of 2 persons for bed mobility, extensive assist of 2 persons for transfers, and always incontinent of bowel and bladder. A Weekly summary, dated 5/8/17, indicated the use of pressure reduction chair/seat cushion, pressure relief mattress/gel overlay/air mattress/concave, and turning and repositioning. A Care Plan, dated 10/22/2014, indicated Resident is at risk for pressure ulcers R/T (related to) decreased mobility. Interventions included: Heelzup (pillow type device to elevate heels) pillow while in bed dated 6/1/17 . report any signs of skin breakdown (sore, tender, red, or broken area) dated 10/22/14. The Interventions lacked any pressure relief interventions for heels prior to 5/25/17. The Wound Evaluation Flow Sheet, dated 5/25/17, indicated pressure area, unstageable (full thickness tissue loss in which the base of the ulcer was covered with slough: yellow, tan, gray, green or brown, and/or eschar: tan, brown, or black, in the wound bed), length 1 cm (centimeter), width 2 cm, and depth, blank. It further indicated no exudate, wound bed color as black. The current treatments were listed as skin prep Q (every) shift, booties in bed, dated 5/25/17. Current preventative interventions were listed as reposition Q 2 hours prn (as needed), float heels, booties. On 6/21/17 at 10:21 a.m., during observation of personal care, the family member for Resident 48 indicated he had fallen at home and broke his hip and he was here in facility for therapy. They further indicated he had acquired the area to his right heel since he had been admitted to the facility. On 6/21/17 at 2:24 p.m., the treatment for [REDACTED]. The wound to the right heel was visualized with black discoloration to edges with pale center. LPN 2 indicated the wound was no longer fluid filled and had stopped draining. On 6/26/17 at 8:21 am, RN 4 indicated she updated the CNA assignment sheets weekly or as needed. She provided a copy of the facility south nursing assignment sheet, updated 6/26/17, which indicated under misc. (miscellaneous): do not elevate legs with pillows, no straws, heelz pillow to bed, daily weight. She further indicated the do not elevate legs with pillows entry was indicated on the admission orders [REDACTED]. ON 6/26/17 at 9:15 a.m., the DON (Director of Nursing) provided the facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with revised date, March 2014. The policy indicated but was not limited to: Assessment and Recognition, the nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility utilized alarms in place of supervision for residents at risk for falling; failed to ensure alarms were used according to a resident's plan of care, and failed to ensure an alarm was in working order, resulting in a head laceration with sutures and a fractured hip, for 3 of 4 residents reviewed for falls, in a sample of 6. Resident C, Resident B, and Resident D Findings include: 1. On 5/24/17 at 6:32 P.M., RN 1 provided the current CNA assignment sheets for the South Unit. The assignment sheets documented 34 residents resided on the unit. 11 of those residents had some type of alarm, which would alert staff of unassisted transfers. 10 of those 11 residents had more than 1 type of alarm. The clinical record of Resident C was reviewed on 5/25/17 at 12:55 P.M. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 2/4/17, indicated Resident C scored a 7 out of 15 for cognition, with 15 indicative of no memory problems. Resident C required limited assistance of one staff for transfer and ambulation. A physician's orders [REDACTED]. A Nurses Note, dated 3/14/17 at 10:15 A.M., indicated, Staff alerted this nurse that resident was on the floor in her bathroom. Bed alarm in place on bed but not sounding. Resident has no acute injury and did not c/o (complain of) pain at this time .Resident stated that she was getting off of the toilet, turned around and lost her balance. Resident reminded and encouraged to call for help before getting up. Resident voiced understanding. Bed alarm was replaced A Nurses Note, dated 3/16/17 at 4:38 A.M., indicated, Residents (sic) pad alarm going off and went to room to investigate and resident was sitting on floor in front of closet with legs outstretched in front of her. C/O pain in RLE (right lower extremity) and unable to bear weight. Assisted to bed by staff x 3 and RLE shortened and externally rotated, pain with movement. MD notified and orders to send to ER for evaluation A Nurses Note, dated 3/16/17 at 4:13 P.M., indicated, Res (resident) is currently at (name of hospital), she is to have surgery for [REDACTED]. The resident returned to the facility on [DATE]. Physician orders, dated 3/20/17, indicated, Bed pad alarm in bed for safety, and Chair pad alarm. An admission MDS assessment, dated 3/27/17, indicated Resident C scored a 6 out of 15 for cognition, and required extensive assistance of two+ staff for transfer and ambulation. Nurses Notes included the following notations: 4/13/17 at 9:13 A.M.: Resident continues to work with (Physical Therapy) .Needs reminders to call for assistance when needed .1 assist with ADL's (activities of daily living) and transfers .alarms functioning to bed, chair, and recliner. 4/15/17 at 9:26 P.M.: .confused to time, place, and situation .Call light within reach; uses it occasionally. Bed alarm on and functioning 4/16/17 at 12:31 P.M.: .Frequent confusion and forgetfulness. Resident is post right hip fx repair .Needs frequent reminders to ask for help before getting up A Nurses Note, dated 4/18/17 at 7:18 P.M., indicated, Resident sitting in dining room after bingo and stood up by herself and fell . Resident noted to lying (sic) on her right side with feet towards her walker and her towards table .Verbalized she hit her head Documentation did not indicate if the resident had an alarm on, or if it was sounding. Nurses Notes continued: 4/19/17 at 8:06 A.M.: Received new order to send resident to ER for eval (evaluation) 4/19/17 at 5:45 P.M.: Called hospital resident admitted with fx right femur. 4/25/17 at 12:45 P.M.: Resident returned today from (name of hospital) following a fall here at facility. Resident had recent right hip fx and went to hospital for right hip revision 4/30/17 at 4:08 P.M.: .Frequent confusion and forgetfulness .Assist x 1-2 for transfers 5/3/17 at 10:04 P.M.: .confused to time, place, and situation .Assist x 1-2 for transfers and ambulation .Alarms to chair and bed on and functioning. Call light within reach; uses it appropriately at times 5/10/17 at 10:02 P.M.: Resident continues working with therapies .confused to time, place, and situation .Assist x 1 for transfers .Alarms to chair and bed on and functioning A Nurses Note, dated 5/12/17 at 4:08 P.M., indicated, This nurse was called to resident's room, upon arriving, resident was lying on the floor on her back, her alarm was going off. Resident complains of pain in right leg .Resident has a quarter sized knot on back of head from where she hit her head on floor .tabs alarm in place for intervention A Care Plan, initially dated 8/29/14 and updated with a Goal Target Date of 7/31/17, indicated, Problem, Resident is at risk for falling R/T (related to) medications and need for assist at times. The approaches included: 5/15/17 tab alarm .3/31/17 Staff to check resident approx. every 2 hours. 2/15/17 bed pad alarm for safety. 2/15/17 WC (wheelchair) pad alarm for safety On 5/25/17 at 1:50 P.M., Resident C was observed lying in bed. A bed alarm was on her bed. 2. The clinical record of Resident B was reviewed on 5/25/17 at 11:10 A.M. [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 11/12/16, indicated Resident B was unable to complete a brief interview for cognition, and required extensive assistance of two+ staff for transfer. The resident did not ambulate. A Care Plan, initially dated 8/5/14 and revised with a Goal Target Date of 8/15/17, indicated, Problem, Resident is at risk for falling R/T (related to) unsteady transfers, ostioporosis (sic), impaired cognition, confusion, history of falls. The approaches included: Provide resident with safety device/appliance: chair pad alarm. Nurses Notes included the following notations: 1/11/17 at 7:53 P.M.: Resident requires assist of 2 at all times 1/18/17 at 6:46 P.M.: Remains confused; resists care at times. Requires assist with eating .Incontinent 1/25/17 at 3:50 P.M.: Resident found lying on floor face first irregular shape laceration on forehead skin tear right hand resident was watching staff no verbal response for approx. 7 minutes pressure dressing applied to forehead .resident placed in w/c per 2 staff. 1/25/17 at 3:55 P.M.: (Physician's) office called and notified of fall and laceration on forehead. Orders received to send to ER (sic) to be evaluated. 1/25/17 at 11:52 P.M.: Resident returned from (hospital) .Resident with 4 cm laceration to forehead, sutures in place, no bleeding noted On 5/26/17 at 9:05 A.M., Resident B was observed sitting in a wheelchair in her room. No chair alarm was observed. On 5/26/17 at 10:15 A.M., during an interview with the Director of Nursing (DON), she indicated it appeared that the resident's chair alarm had been discontinued in December 2016, but had not been taken off of the resident's Care Plan. 3. On 5/25/17 at 2:45 P.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. An admission MDS assessment, dated 5/4/17, indicated Resident D scored a 7 out of 15 for cognition, and required extensive assistance of two+ staff for transfer. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Care Plan, dated 5/6/17, indicated, Problem, Resident is at risk for falling R/T weakness from recent hospitalization . The approaches included: Bed alarm. Chair alarm. Give resident verbal reminders not to ambulate/transfer without assistance Nurses Notes, dated 5/18/17 at 5:00 P.M., indicated, Resident had un-witnessed fall from W/C while in her room prior to evening meal. Resident noted to be on left side .Bruise noted to left forehead measuring 3.0 (length) x 3.0 cm (width); light purple in color. Resident lifted to sitting position in W/C with staff x 2. Intervention is that resident should not be left alone in her room while up in W/C. Documentation regarding an alarm being on and/or sounding was not found in the Nurses Notes. On 5/26/17 at 10:15 A.M., the DON provided an Event Report, dated 5/18/17. The report included: Interventions in Place/Alarm Sounding Documented in Nurses' Notes Yes - alarm. The DON indicated at that time that the facility was attempting to reduce the number of alarms in the facility. On 5/26/17 at 11:55 A.M., the DON provided the current facility policy Fall Management and Procedure, undated. The policy indicated, Purpose: To implement fall prevention and interventions. Guideline: During pre-admission determine if the potential resident has a history of falling or is unsteady in gait .Bed and chair alarms are put in place for 72 hours .and then re-assessed for risk .The interdisciplinary team evaluated the fall prevention plan of care for residents 'at risk' for falls .The plan of care is enhanced, if indicated, to further minimize the risk of falls This Federal tag relates to Complaint IN 244. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure 1 of 4 residents reviewed with skin impairments (Resident #4), in the total sample of 10, was provided treatment and services for the skin impairment in accordance with the physician's plan of care; in that, the physician ordered a physical therapy evaluation and to treat the resident with a post-op wound infection, and there was no evidence the Physical Therapist or nursing had followed the orders and evaluated and treated the area, and the area worsened. Finding includes: Resident #4's clinical record was reviewed on 1/10/11 at 3:22 p.m. The resident was admitted to the facility on [DATE], following an open reduction internal fixation of the left ankle. She was admitted in a post-operative boot to the left ankle/lower leg. The resident had a follow-up visit with the Orthopaedic Surgeon on 12/13/10. The progress note indicated the following: "On the medial incision some seepage at debridement site. There is no fluctuant area. The wound is healing well...." "PLAN: The patient at this point is nonweightbearing. She will wear the boot constantly. She will be referred to physical therapy for evaluation and treatment as well as compressive dressing changes and wound care. She will be placed on Keflex (antibiotic) 500 mg (milligrams) one tablet 4 times per day for the next 7 days as [MEDICATION NAME] as she may have some peri-incisional [MEDICAL CONDITION]. She will follow up next week for reevaluation." The resident returned to the facility on [DATE] with the following physician's orders [REDACTED]. "Physical Therapy Evaluate and Treat Notes: compressive dressing dressing changes/wound care NWB (non weight bearing) LLE (left lower extremity) in boot" The clinical record lacked any evaluation or treatment of [REDACTED]. Nurses' notes included, but were not limited to, the following: 12/13/10 "1100 (11:00 a.m.) "Ret. (returned) from ortho appt. (appointment). N.O. (New Order) for NWB (non-weight bearing) LLE (left lower extremity), compressive drsg (dressing) to LLE, Keflex 500 mg po (by mouth) qid (four times a day) X 7 days, wound inf. (infection)." 12/14/10 "0900 (9:00 a.m.) ...Post op boot to LLE. Ace wrap on underneath boot - no signs of wound drng (drainage) on ace. Did not undo ace wrap..." 12/16/10 "1450 (2:50 p.m.) Clarified order for wound care (with) (name), RN @ (orthopaedic office). PT (physical therapy) to do wound care/compressive drsg..." 12/17/10 "0945 (9:45 a.m.) ...Post op boot to LLE NWB until MD appointment on Monday..." 12/18/10 "10:15 a.m. ...Drsg. (changed) per order (with) compression drsg. in place. MD (attending) saw LLE during drsg (change)..." 12/20/10 "10:00 a.m. ...Drsg. to L ankle (changed) daily. No drng. (drainage)..." (summary note, dressing not done) 12/20/10 "2015 (8:15 p.m.) ...Drsg (changed) to LLE daily as ordered." (summary note, dressing not done) There was no indication therapy was made aware of the order to evaluate and treat, nor was there any evaluation or treatment of [REDACTED]. The attending physician's progress note, dated 12/18/10 (no time), indicated the following: "...required ORIF (open reduction internal fixation) was at ortho Dr. a day or 2 ago and they noted some [MEDICAL CONDITION] and started Keflex and was toe touch in PT now back to non wt. bearing...8 X 5 cm area medially ankle mild to mod. (moderate) [MEDICAL CONDITION]" The next visit to the Orthopaedic Surgeon, dated 12/21/10, indicated findings, "necrotic eschar medial wound." The progress notes indicated the following: "History of present illness: (Resident's name) has been taking Keflex. She has been having wound treatments performed by the therapist at (nursing facility)." "Physical Examination: There is still a great deal of [MEDICATION NAME] exudate over the medial side of the ankle." "Impression: Superficial wound infection following open left medial malleolus fracture." "PLAN: We need to be more aggressive with debridement and I am going to have our occupational therapist here at (orthopaedic facility) begin this..." "Evaluation: ...Wound measures 2.1 cm (centimeters) in width and 2.7 cm in length. Approx (approximately 2 mm (millimeters) in depth. Wound over medial malleolus is completely covered in yellow hard necrotic tissue. Wound is moist under yellow tissue..." The office therapist proceeded to debride the necrotic tissue and ordered the resident to return to the orthopaedic office three times a week for treatment. The Treatment Administration Record (TAR), for December, 2010, was reviewed for Resident #4. The record indicated the following orders from 12/13/10: NWB LLE in boot, and Compressive drsg to LLE. Initials were documented daily from 12/14/10 through 12/31/10. RN #1 was interviewed on 1/12/11 at 11:45 a.m., regarding the physician's orders [REDACTED]. She indicated she was the one who clarified the order for Physical Therapy to evaluate and treat the area and she thought they had looked at the area. She indicated LPN #1 was looking at the area daily. She indicated it was "back and forth" who was going to treat the area. When the resident went back to the physician on 12/21/10, they received the order for the resident to go to the Orthopaedic office three times a week for debridement and dressing changes. LPN #1 was interviewed, on 1/12/11 at 2:25 p.m., regarding the documentation on the TAR of the daily compressive dressing. He indicated he just checked the ace wrap for drainage and changed it if the drainage was present. He indicated he may have changed it once during the week and it was just a 4 by 4 gauze with the ace wrap for compression. RN #3 was interviewed, on 1/12/11 at 2:30 p.m., and indicated the physician had been in on 12/18/10 and had wanted to see the area. She indicated she unwrapped the ace wrap, and removed the gauze. She replaced with clean gauze and the ace wrap. She indicated the order was just for a compression bandage daily. She indicated LPN #1 primarily took care of it. Physical Therapist #1 was interviewed on 1/12/11 at 12:00 noon. She indicated therapy had looked at the area after 12/13/10, but had not done an official evaluation. She indicated it was "back and forth" who was going to treat the area, but therapy had not been involved in treating it until 1/4/11. 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure 1 of 4 residents reviewed with skin impairments (Resident #4), in the total sample of 10, received treatment and services for the skin impairment; in that the resident had physician's orders [REDACTED]. Finding includes: Resident #4's clinical record was reviewed on 1/10/11 at 3:22 p.m. The resident was admitted to the facility on [DATE], following an open reduction internal fixation of the left ankle. She was admitted in a post-operative boot to the left ankle/lower leg. The resident had a follow-up visit with the Orthopaedic Surgeon on 12/13/10. The progress note indicated the following: "On the medial incision some seepage at debridement site. There is no fluctuant area. The wound is healing well...." "PLAN: The patient at this point is nonweightbearing. She will wear the boot constantly. She will be referred to physical therapy for evaluation and treatment as well as compressive dressing changes and wound care. She will be placed on Keflex (antibiotic) 500 mg (milligrams) one tablet 4 times per day for the next 7 days as [MEDICATION NAME] as she may have some peri-incisional [MEDICAL CONDITION]. She will follow up next week for reevaluation." The resident returned to the facility on [DATE] with the following physician's orders [REDACTED]. "Physical Therapy Evaluate and Treat Notes: compressive dressing dressing changes/wound care NWB (non weight bearing) LLE (left lower extremity) in boot" The clinical record lacked any evaluation or treatment of [REDACTED]. Nurses' notes included, but were not limited to, the following: 12/13/10 "1100 (11:00 a.m.) "Ret. (returned) from ortho appt. (appointment). N.O. (New Order) for NWB (non-weight bearing) LLE (left lower extremity), compressive drsg (dressing) to LLE, Keflex 500 mg po (by mouth) qid (four times a day) X 7 days, wound inf. (infection)." 12/14/10 "0900 (9:00 a.m.) ...Post op boot to LLE. Ace wrap on underneath boot - no signs of wound drng (drainage) on ace. Did not undo ace wrap..." 12/16/10 "1450 (2:50 p.m.) Clarified order for wound care (with) (name), RN @ (orthopaedic office). PT (physical therapy) to do wound care/compressive drsg..." 12/17/10 "0945 (9:45 a.m.) ...Post op boot to LLE NWB until MD appointment on Monday..." 12/18/10 "10:15 a.m. ...Drsg. (changed) per order (with) compression drsg. in place. MD (attending) saw LLE during drsg (change)..." 12/20/10 "10:00 a.m. ...Drsg. to L ankle (changed) daily. No drng. (drainage)..." (summary note, dressing not changed) 12/20/10 "2015 (8:15 p.m.) ...Drsg (changed) to LLE daily as ordered." (summary note, dressing not changed) There was no indication therapy was made aware of the order to evaluate and treat, nor was there any evaluation or treatment of [REDACTED]. The attending physician's progress note, dated 12/18/10 (no time), indicated the following: "...required ORIF (open reduction internal fixation) was at ortho Dr. a day or 2 ago and they noted some [MEDICAL CONDITION] and started Keflex and was toe touch in PT now back to non wt. bearing...8 X 5 cm area medially ankle mild to mod. (moderate) [MEDICAL CONDITION]" The next visit to the Orthopaedic Surgeon, dated 12/21/10, indicated findings, "necrotic eschar medial wound." The progress notes indicated the following: "History of present illness: (Resident's name) has been taking Keflex. She has been having wound treatments performed by the therapist at (nursing facility)." "Physical Examination: There is still a great deal of [MEDICATION NAME] exudate over the medial side of the ankle." "Impression: Superficial wound infection following open left medial malleolus fracture." "PLAN: We need to be more aggressive with debridement and I am going to have our occupational therapist here at (orthopaedic facility) begin this..." "Evaluation: ...Wound measures 2.1 cm (centimeters) in width and 2.7 cm in length. Approx (approximately 2 mm (millimeters) in depth. Wound over medial malleolus is completely covered in yellow hard necrotic tissue. Wound is moist under yellow tissue..." The (orthopaedic facility) therapist proceeded to debride the necrotic tissue and ordered the resident to return to the orthopaedic office three times a week for treatment. The Treatment Administration Record (TAR), for December, 2010, was reviewed for Resident #4. The record indicated the following orders from 12/13/10: NWB LLE in boot, and Compressive drsg to LLE. Initials were documented daily from 12/14/10 through 12/31/10. RN #1 was interviewed on 1/12/11 at 11:45 a.m., regarding the physician's orders [REDACTED]. She indicated LPN #1 was looking at the area daily. She indicated it was "back and forth" who was going to treat the area. When the resident went back to the physician on 12/21/10, they received the order for the resident to go to the Orthopaedic office three times a week for debridement and dressing changes. LPN #1 was interviewed, on 1/12/11 at 2:25 p.m., regarding the documentation on the TAR of the daily compressive dressing. He indicated he just checked the ace wrap for drainage and changed it if the drainage was present. He indicated he may have changed it once during the week and it was just a 4 by 4 gauze with the ace wrap for compression. RN #3 was interviewed, on 1/12/11 at 2:30 p.m., and indicated the physician had been in on 12/18/10 and had wanted to see the area. She indicated she unwrapped the ace wrap, and removed the gauze. She replaced with clean gauze and the ace wrap. She indicated the order was just for a compression bandage daily. She indicated LPN #1 primarily took care of it. Physical Therapist #1 was interviewed on 1/12/11 at 12:00 noon. She indicated therapy had looked at the area after 12/13/10, but had not done an official evaluation. She indicated it was "back and forth" who was going to treat the area, but therapy had not been involved in treating it until 1/4/11. Physical Therapist #1 provided therapy progress notes on 1/14/11 at 10:15 a.m. The note from 1/13/11 (no time) indicated the weekly wound care summary as follows: "old dressing removed; yellow drainage, hypergranulation still present, no scent noticed, size about the same. [MEDICATION NAME] applied to wound bed, covered (with) gauze, Kerlix, et tape to tightly secure. Wound still same size as eval @ 2.0 cm L (length) X 1.4 cm W (width) X 0.2 cm depth." 3.1-37(a)

Based on record review and interview, the facility failed to ensure 1 of 6 residents with histories of falls (Resident #2), in the sample of 10, received supervision and assistance devices in an attempt to prevent falls, in that an alarm was not in use at the time of a fall which resulted in a fractured hip. Finding includes: Resident #2's clinical record was reviewed on 1/10/11 at 10:00 a.m. The resident was admitted to the facility on [DATE] following a mitral valve repair. The resident had a Fall Risk Assessment, dated 11/30/10, that indicated the resident was at high risk for falls. Resident #2 had an admission care plan, dated 11/26/10, for falls/safety risk. The care plan included, but was not limited to, the use of bed/chair alarms. The resident was hosptalized on [DATE] for pneumonia. She returned on 11/30/10 at 3:45 p.m. Nurses' notes indicated the following: "11/30/10 at 2130 (9:30 p.m.) Summoned to rm. (room) Resident lying in floor @ foot of bed on (L) (left) side. Assisted onto back. Resident attempted to pull knees up et grimaced. Up (with) assist of iii (three) (R) (right) ft. (foot) crossed behind (L) et unable to uncross et BW (bear weight) on (R) leg. Immed. (immediately) put to bed. Sl. (slight) external rotation of (R) leg noted (with) shortening. Immed. discolored hematomas noted on bil. (bilateral) sides of (R) knee et quarter size hematoma (R) temporal area of head." The clinical record lacked information as to whether or not the resident had any assistive devices, i.e. alarms, in place to alert staff to getting up out of bed. The Director of Nurses was interviewed, on 1/12/11 at 11:30 a.m. She indicated their investigation into the fall indicated the bed alarm was not in use at the time of the fall. "It was in the room," but not in use, she indicated. "There were lots of conversations about that after the fall." 3.1-45(a)(2)