Every finding on record at Grace Village Health Care Facility

Based on record review and interview, the facility failed to provide a bed hold form for 2 of 4 residents reviewed for hospitalization. (Resident 1 & 35) Findings include: 1. During an interview, on 3/19/2025 at 8:43 A.M., Resident 1 indicated he had recently been hospitalized . A record review for Resident 1 was completed on 3/19/2025 at 1:19 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, congestive heart failure and acute respiratory failure. A Significant Change Minimum Data Set (MDS) assessment, dated 2/24/2025, indicated Resident 1 had moderate cognitive impairment. A Nursing Progress Note, on 2/12/2025 at 8:36 A.M., indicated Resident 1 was sent to the hospital because an in-house treatment was ineffective and confusion continued. A Physician's Progress Note, on 2/19/2025 at 8:56 A.M., indicated Resident 1 was readmitted to the facility after a hospitalization for an acute kidney injury. During an interview, on 3/20/2025 at 2:14 P.M., the Director of Nursing (DON) indicated a copy of Resident 1's discharge packet was not available. She provided a copy of the bed hold policy, but could not provide proof the bed hold policy was provided to Resident 1 for the hospital discharge on [DATE]. 2. During an interview, on 3/19/2025 at 11:06 A.M., Resident 35 indicated he had recently been hospitalized . A record review for Resident 35 was completed, on 3/19/2025 at 11:06 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, intellectual disabilities and anxiety disorder. A Significant Change MDS assessment, dated 2/7/2025, indicated Resident 35 was cognitively intact. A Nursing Progress Note, on 3/15/2025 at 12:29 P.M., indicated Resident 35's brother was called to provide transportation to the hospital for low blood pressure, difficulty walking and lack of eating. A Nursing Progress Note, on 3/15/2025 at 4:53 P.M., indicated Resident 35's brother called the facility and Resident 35 informed the facility that the resident would be staying at the hospital for an observation. During an interview, on 3/20/2025 at 2:14 P.M., the DON indicated a copy of Resident 35's discharge packet was not available. She provided a copy of the bed hold policy, but could not provide proof the bed hold policy was provided to Resident 35 and/or his representative for the hospital discharge on [DATE]. A policy was provided, on 3/24/2025 at 11:59 A.M., by the DON. The policy titled, Transfer/Discharge Policy, indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharge, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer or Discharge [Emergent or Therapeutic Leave] .5. Notice of Facility Bed-Hold and Return policies are sent with the resident at the time of transfer 3.1-12(a)(26)

Based on observation and interview, the facility failed to ensure staff providing care for a resident in EBP (enhanced barrier precautions) wore appropriate PPE (Personal Protective Equipment) for 1of 2 residents reviewed for EBP. (Resident 10) Finding includes: During an observation, on 3/20/2025 at 11:51 A.M., along the left side of the door frame going into Resident 10's room was a small 1'' x 2'' white magnet that was attached to the door frame on the left side with letters written in black EBP. Resident 10 had a Foley catheter for urine drainage. CNA's 2 and 4 were observed to enter Resident 10's room to transfer her to her wheelchair with a mechanical lift. The door was opened and both CNAs were observed with no gloves or gowns on. During an interview, on 3/20/2025 at 11:55 A.M., RN 3 indicated the aides were just putting on gloves when she had entered the residents room. RN 3 indicated the aides should have been wearing gloves and a gown when they provided care to Resident 10. On 3/20/2025 at 1:25 P.M., the Director of Nursing provided the policy tilled, Enhanced Barrier Precautions, dated 2/21/2025, and indicated the policy was the one currently used by the facility. The policy indicated .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure foods were stored appropriately and not expired and failed to ensure dishes and equipment was clean and in good working condition in 1 of 1 kitchens and 1 of 1 kitchenette observed. This deficient practice had the potential to affect 46 of 46 residents who receive meals from the kitchen and/or were served from the kitchenette. Findings include: 1. During an observation of the kitchen on [DATE] at 9:50 A.M., with the Dietary Manager, the following was observed: in the refrigerator: 3 containers of drinks with a used by date of [DATE]. 2. During a revisit of the kitchen, on [DATE] at 10:02 A.M.,with the Dietary Manager, the following was observed: 3 mini bowls with dried foods substances on them a dirty scoop a microwave with dried food on the sides and the ceiling of it 2 of 2 refrigerators with cracked seals along the bottom of the 2 top doors. During an interview, on [DATE] at 10:04 A.M., the Dietary Manager indicated the dishes should not be dirty, the microwave should be cleaned and the seals to the refrigerators should be repaired. 3. During an observation of the kitchenette on [DATE] at 10:02 A.M., with Dietary Staff 4, the following was observed: a. Refrigerator: -An opened and undated package of lunch meat not sealed and with a clear liquid coming from the package. -A package of sliced cheese not sealed. -Another package of cheese slices not dated with a liquid substance on it. -An opened stick of butter, with no date and not sealed tightly. -The refrigerator had a broken door on the left side with a hanging plastic part. -A container of pineapple chunks with no date. -A container of parmesan cheese with no date b. Pantry: -Two (2) buns in a bag that was not sealed tightly in the cabinet. During an interview, on [DATE] at 10:10 A.M., Dietary Staff 4 indicated the meat should have be thrown out, the foods should have a date on them, the buns should not be stored in that manner. On [DATE] at 2:51 P.M., the Dietary Manager provided the policy titled. Production, Purchasing, Storage, Food and Supply Storage, dated ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated . Foods past the used by, sell-by, best-by, or enjoy by date should be discarded. Cover, and label and date unused portions and open packages .Unused portions of canned fruits and vegetables must be transferred to clean, approved storage containers .Label the container On [DATE] at 2:53 P.M., the Dietary Manager provided the policy titled, Safety and Equipment Maintenance Equipment Inspection Program, dated ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated .Complete the Equipment Inspection Checklist monthly .Identify repairs needed .Refrigerators: Fans working. Condenser Clean. Seals on door in good repair 3XXX,d+[DATE](i)(3)

Based on record review, observation and interview, the facility failed to ensure nail care was provided and ensure residents who required staff assistance for toileting were toileted timely to prevent further incontinence for 4 of 20 residents reviewed for ADL (Activities of Daily Living) care. (Resident 19,12, 24 and 29) Finding includes: 1.During a meal observation, on 3/23/2023 at 11:45 A.M., Resident 19 was observed using her fingers to feed herself. During an observation, on 3/23/2023 at 1:53 P.M., Resident 19 was observed with a dark substance under her finger nails. During an observation, on 3/27/2023 at 11:56 A.M., Resident 19 was observed with a dark substance underneath her fingernails. During an interview, on 3/27/2023 at 12:03 P.M., CNA 4 indicated the residents fingernails should have been cleaned. A record review was completed on, 3/27/2023 at 3:00 P.M. Resident 19's diagnoses included, but were not limited to: Alzheimer's disease, chronic kidney disease, heart failure, diabetes, and dementia. A Quarterly MDS (Minimum Data Set) Assessment, dated 3/22/2023, indicated severe cognitive impairment. She had no rejection of care behaviors, required extensive assist of 1 staff for personal hygiene and total assist for bathing. A current care plan, dated 1/8/2022, indicated the resident had impaired functional status and required assistance with ADL's and care related to, Alzheimer's disease,dementia and weakness. Interventions included grooming and hygiene extensive staff assist of 1. Resident 19's nail care documentation dated 3/1/2023 to 3/27/203, indicated the resident received nail care fourteen (14) days out of 26 days from 3/1/2023 to 3/26/2023. On 3/29/2023 at 8:45 A.M., the Director of Nursing provided the policy titled,Nail Care, dated 6/7/2022. The policy indicated . 6. Procedure a. Perform hand hygiene and don gloves. b. Gently clean underneath nails with nail stick if resident is able to tolerate and allows. 2. During an interview, on 3/23/2023 at 2:54 P.M., Resident 12 indicated, I can't hold my pee. A clinical record review was completed on 3/27/2023 at 1:43 P.M. Resident 12's current diagnoses's included, but were not limited to: hypertension, dementia, over active bladder, edema and blind. Current physician orders included: Detral (bladder relaxant) 1 mg (milligram) daily for urinary frequency, and Furosemide (diuretic) 20 mg daily for edema. A Significant Change MDS (Minimum Data Set) Assessment, dated 1/30/2023, indicated Resident 12 was occasionally incontinent of bladder and bowels. She was not on a scheduled toileting program. A Significant Change MDS (Minimum Data Set) Assessment, dated 2/9/2023 indicated the resident had intact cognition. She required extensive assist of 1 staff for bed mobility, transfers, dressing, and toilet use. She was not on a toileting schedule and was frequently incontinent of bladder and bowel. Restorative programs included: walking and dressing/grooming. A current care plan, dated, 2/2/2023, indicated the resident had functional incontinence related to diagnoses of cognitive deficit, over active bladder, frequency of micturition (urinating). She had the potential for adverse effects related to incontinence and use of incontinence products. Interventions included, use of incontinent pads, administer medications per order, ask is she would like to be toileted before meals and bed time, check for incontinence q (every) 2 hours and provide incontinent care. Resident 12's incontinence documentation, dated 3/1/2023 to 3/29/2023, indicated Resident 12 was not checked every 2 hours for incontinence and had numerous incontinent episodes. Resident 12 had been incontinent 14 times at 7:00A.M., 9 times at 7:00 P.M., 7 times at 1:00 A.M., and 5:00 P.M., and lacked the documentation on the daily charting sheets 102 times to show that the checking for incontinence every 2 hours had been completed. During an interview, on 3/29/2023 at 1:43 P.M., the Director of Nursing indicated the resident was not on a scheduled toileting plan and she would evaluate the resident for a toileting program. 3. During an interview, on 3/23/2023 at 2:11 P.M., Resident 24 indicated she has accidents prior to getting to the bathroom. A record review was completed, on 3/27/2023 at 8:52 A.M. Resident 24's diagnoses included, but were not limited to: Huntington's disease, overactive bladder, and diabetes. A Quarterly MDS (Minimum Data Set) Assessment, dated 2/13/2023, indicated the resident required extensive assist of 1 staff for bed mobility, transfers, dressing, and toilet use, was frequently incontinent of bladder and occasionally of bowels. A current care plan, dated 2/14/2022, indicated the resident had functional incontinence issues of bowel and bladder related to disease process, overactive bladder, and UTI's. She had potential for adverse effects related to medication usage and disease process. Interventions included, but were not limited to: Resident uses incontinent products: briefs. Check and change at least every 2 hours, providing incontinence care each episode. A current care plan, dated 3/9/2023, indicated the resident was to be checked and changed every 2 hours. During an interview, on 3/29/2023 at 9:38 A.M.,CNA 2 indicated the resident will turn on the light to go to the bathroom. She will get into her wheel chair and they supervise her in the bathroom. CNA 2 indicated the resident had been wet on occasion and she does not walk her to the bathroom, she had never done that before. During an interview, on 3/28/2023 1:45 P.M., the Director of Nursing indicated the resident was not being checked/toileted per schedule. 4. During an interview, on 3/24/2023 at 9:21 A.M., Resident 29 indicated she had accidents in the mornings. A clinical record review was completed on 3/28/2023 at 9:32 A.M. Resident 29 was admitted on [DATE]. Her diagnoses included, but were not limited to: renal insufficiency, hypertension, anxiety, and heart failure. An Admission MDS (Minimum Data Set) Assessment, dated 3/5/2023 indicated Resident 29 had moderate cognitive impairment, required extensive assist of 1 staff for bed mobility, toilet use, transfers, and 2 staff for dressing and was occasionally incontinent of bladder and bowels. A current care plan, dated 2/27/2023, indicated the resident had functional bladder and bowel continence issues related to end of life status, reoccurring urinary tract infections, and disease process. Interventions included, the resident used incontinent products- pull-ups. Staff to assist resident with toileting as needed. Staff to provide peri care after incontinence episodes. Staff to check and change at least every 2 hours and PRN (as needed) to promote skin integrity. The Daily Charting for incontinence checks, dated 3/16/2023 through 3/28/2023, indicated Resident 29 was not checked and or toileted per care plan. Resident had incontinence episodes on: 3/18/23 3 times 3/21/23 2 times, 3/22/23 3 times and 3/26/23 of 4 times. The Daily Charting sheets lacked the documentation 42 times to show that the checking for incontinence every 2 hours had been completed. During an interview,on 3/28/2023 at 1:45 P.M., the Director of Nursing indicated she will evaluate the resident for scheduled toileting to see if it's appropriate. During an interview,on 3/29/2023 at 9:37 A.M.,CNA 2 indicated Resident 29 will turn on her light to go to the bathroom. She will assist her in to the wheelchair and then when she's done she will turn on the light and I will wipe her and assist with getting her pants pulled up. 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to revise care plans for changes in condition for 1 of 23 residents, whose care plans were reviewed. (Residents 44 ) Finding includes: During an interview, on 3/23/2023 at 2:08 P.M., Resident 44 indicated his left knee was sometimes painful and stiff due to an injury several years ago. A record review, on 3/27/2023 at 9:33 A.M., indicated a Quarterly MDS (Minimum Data Set) Assessment, dated 2/23/2023, included, cognition was intact, Resident 44 required extensive assistance of 1 staff person for bed mobility, dressing, and toileting. He required extensive assistance of 2 staff persons for transfers. He had no falls or other health conditions. Diagnoses for Resident 44 included, but were not limited to: acute kidney failure, other pulmonary embolism, acute deep vein thrombosis, and osteoarthritis. The Physician orders for Resident 44 included, on 2/3/2023 left knee brace as needed for osteoarthritis. Resident 44's care plan dated 2/2/2023 lacked care plan interventions for use of the brace for his left leg. During an interview, on 3/27/2023 at 1:42 P.M., the MDS coordinator indicated that she does most of the care plans but was not aware of the brace for Resident 44. She indicated that it should have been on the care plan. 3.1-35(c)(1)

Based on record review and interview, the facility failed to have a care plan for an open area for 1 of 3 residents reviewed for skin. (Resident7) Finding includes: During an observation, on 3/23/2023 at 2:37 P.M., Resident 7 was observed to have a red open area to right side of her nose. A record review was completed, on 3/28/2023 at 3:27 P.M. Resident 7's diagnoses included, but were not limited to: osteoporosis, hypothyroidism, depression, insomnia and bolus pemphigoid. A 5 day MDS (Minimum Data Set) Assessment, dated 6/24/2022, indicated Resident 7 had severe cognitive impairment. Current care plans for Resident 7 lacked a person centered care plan for the skin issue to the residents' nose. During an interview, on 3/29/2023 at 1:30 P.M., LPN 3 indicated the resident should have a care plan for the cancer area to her nose. During an interview, on 3/28/2023 at 1:45 P.M., the Director of Nursing indicated the care plan was not person centered. On 3/29/2023 at 2:32 P.M., the Director of Nursing provided the policy titled, Comprehensive Care Plans, dated 7/6/2022. The policy indicated . f. Resident specific interventions that reflect the resident's needs and preferences . 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure food items in the freezer were sealed securely after opening, failed to ensure refrigerators were clean in 1 of 1 kitchens and 2 of 2 pantries. (main pantry and rehab pantry) Findings include: 1. During an observation with the dietary manager in the main kitchen, on 3/23/2023 at 10:25 A.M., the following was observed: There was a buildup of ice along the left side of the air condenser. Opened bags of cod, breaded shrimp, and diced turkey were not sealed tightly. An opened box of corn with noted freezer burn, was not sealed tightly. The floors were dirty with debris under the racks. During an interview, on 3/23/2023 at 10:29 A.M., the Dietary Manager indicated the ice should be gone, the bags should have been sealed tightly, the floor should be cleaned 2. During an observation of the main pantry, with CNA 2 on 3/29/2023 at 9:43 A.M., the following was observed: the microwave had burnt areas to the inside of the door and on the back edge along the floor of the oven. The refrigerator was dirty inside and along the base and had a black substance along the seal of the front door. A container of ice cream was observed with no name on it. During an interview, on 3/29/2023 at 9:46 A.M., LPN 7 indicated she was aware and would have housekeeping look at the fridge. 3. During an observation of the rehab panty, with QMA 6 the following was observed: the refrigerator had black along the seal of the freezer, a dead fly was lying on a shelf, crumbs and a purple stain were on the base of the refrigerator. On the counter was an opened/undated/unnamed bag of potato chips not sealed completely. On 3/29/2023 at 1:10 P.M., the Director of Nursing provided the policy titled, Food and Supply Storage, dated 1/2023. The policy indicated . All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination too maintain the safety and wholesomeness of the food for human consumption .Cover, label and date unused portions and open packages . Frozen Storage. Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid. Use food grade plastic bags for food storage .Wrap food tightly to prevent cross contamination On 3/29/2023 at 1:10 P.M., the Director of Nursing provided the policy titled, Unit Pantry Stock, dated 1/2023.Food and Nutrition Services -Label, date and discard outdated items per the food policy .Nursing and/or Food and Nutrition Services Designee -Ensure all items are covered, labeled and dated. Procedures and responsibilities for cleaning and care area must be assigned. The responsible department(s) will maintain equipment temperature and cleaning logs per record retention policy. Cleaning and sanitizing of refrigerator/pantry: Nursing. Defrosting freezer and cleaning and sanitizing ice machine: Plan operation. Cleaning floors and counters , removal of trash, ect.: Housekeeping 3.1-21(3)

Based on observation, interview and record review, the facility failed to ensure a tube feeding solution was dated when hung, and a water flush bag was changed timely for 1 of 1 residents reviewed for tube feedings. (Resident 7) Finding includes: During an observation, on 3/29/2023 at 10:56 A.M., Resident 7's feeding bag was undated when it had been hung to administer, no orders of the flow amount were documented on the bag, there were no resident identifiers, the water bag had a sticky label with the date 3/27/2023 with 200 ml (milliter) flush. There was 750 ml of water remaining in the bag. Current physician orders for Resident 7 included: Nestle 1.2 via g-tube at 60 ml and hour continuously. Change feeding bag and water bag when empty- feeding is able to hang up to 49 hours. Flush g-tube with 200 ml every 6 hours. During an interview, on 3/29/2023 at 10:58 A.M., LPN 3 indicated the bags are to be replaced at the same time and water had been added to the bag that was dated 3/27/2023 instead of replacing the bag. On 3/29/2023 at 1:10 P.M., the Director of Nursing provided the policy titled,Care and Treatment of Feeding Tubes, dated 11/28/2022. The policy indicated .1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and it's caloric value, volume, duration, mechanism of administration, and frequency of flush . The resident's plan of care will address the uses of feeding tube, including strategies to prevent complications On 3/29/2023 at 2:15 P.M., the Director of Nursing provided the policy titled,Flushing a Feeding Tube, dated 10/7/2022. The policy indicated .13. If resident has water flushes that are hung in a feeding bag and programmed by pump, follow manufactures recommendations for changing out bags 3.1-44(a)(1)

Based on observation, interview and record review, the facility failed to ensure infection control measures were implemented related to medication administration without hand hygiene and proper glove use for 1 of 2 staff observed during medication administration for 4 of 6 residents. (RN 10 and Residents 299, 16, 13 and 22) Findings include: 1. During an observation of medication administration, conducted on 1/05/2022 between 11:25 A.M. - 12:00 P.M., RN 10 was noted to administer scheduled eye drop medication to Resident 16 without washing her hands and donning gloves. 2. During an observation of medication administration, conducted on 1/05/2022 at 12:02 P.M., RN 10 cleaned her hands with sanitizer, then touched her eye goggles and face mask to adjust them, pulled her mask down so the resident could hear her better, then donned a pair of gloves without sanitizing her hands, opened an alcohol swab package and wiped the resident's finger with the alcohol swab, wiped the resident's finger off with a tissue, pricked the resident's finger with a lancet, and then gently got a drop of blood and touched the blood glucose test strip to the drop of blood. The nurse then removed her gloves, wiped the top of a vial of insulin with an alcohol swab and drew up the required insulin into a syringe, discreetly moved Resident 13's shirt out of the way, cleaned the resident's skin with another alcohol swab and administered the insulin to the resident without wearing gloves or washing her hands prior to administering the medications. 3. During an observation of tube feed medication administration, conducted on 1/07/2022 at 1:07 P.M., RN 10 was noted to be positioned at the nurse's station, dumping tube feed cartons into a tube feeding bar that already had a new tubing set attached to it. The nurse then sanitized her hands with alcohol rub and obtained Resident 22's scheduled medications from the medication cart. She crushed on medication and measured the other liquid medication and dumped the medications together in a plastic cup. She then used hand sanitizer again to wash her hands. Next, the nurse gathered up her supplies and carried them into Resident 22's room. She then took the asepto container and went into Resident 22's bathroom, touching the sink faucet handles with her bare hands in order to fill the directed amount of water into the container. RN 10 then, without washing her hands or donning gloves proceeded to check the placement of the gastronomy tube and then administered the directed amount of water flush and medications. After RN 10 had completed the process of medication administration and water flush administration, she connected the tube feeding to the resident's gastronomy tube after running tube feed through the tubing. 4. On 1/07/2022 at 10:23 A.M., RN 10 was observed to take medications into Resident 299's room. After taking the resident's blood pressure, the nurse administered eye drops without washing her hands or donning gloves. The nurse was noted to directly touch the resident's eyebrow area on each side as she administered the medication. Interview with the ADON on 1/10/2022 at 10:30 A.M., indicated the nurse should have known better and performed hand hygiene after any contact and before and after glove removal. The facility policy and procedures, titled Hand Hygiene, was provided by the DON on 1/10/22 at 9:30 A.M. The policy indicated: 1. Staff will perform hand hygiene when indicated, using proper technique consisted with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE) including gloves, before preparing or handling medications, before performing resident care procedures, after handling items potentially contaminated with blood, body fluids, secretions, or excretions The facility policy and procedure, titled Gloves, Non-Sterile, was provided by the DON on 1/10/22 at 9:30 A.M. The policy indicated: 1. Non-sterile disposable gloves are to be worn during any procedure where exposure to blood or body fluids is anticipated. 2. Disposable gloves shall be replaced when contaminated, torn, punctured or when their function as a barrier has been compromised The facility policy and procedure, titled G-Tube Medication Administration, was provided by the DON on 1/10/2022 at 9:30 A.M. The policy indicated: Procedure: 1. Wash hands 2 Bring equipment to bedside and screen the resident's bed 3. Put on gloves The facility policy and procedure, titled Eye Drop Instillation, was provided by the DON on 1/10/2022 at 9:30 A.M. The policy indicated: Procedure: .2. Wash hands . The facility policy and procedure, titled Injection, Subcutaneous, was provided by the DON on 01/10/2022 at 9:30 A.M. The policy indicated: Procedure: 1. Wash hands. 2. Prepare the medication .5. Cleanse the site with an alcohol prep pad with circular motions starting from the center and working outward. 6. Insert the needle after pinching the skin .7. After confirming that you are NOT in a blood vessel via aspiration, continue to administer the medication 3.1-18(b) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure items in the freezer were dated/labeled and resealed after opening to prevent freezer burn and failed to ensure cooking utensils were clean and serving scoops were free of standing water for 1 of 1 kitchens observed. (Main Kitchen) This deficient practice had the potential to affect the 42 residents who received meals from the kitchen. Finding includes: During an observation of the kitchen on 1/4/2022 between 9:30 A.M. and 10:06 A.M., the following was observed: the freezer had an opened undated box with an opened plastic bag in it with pork cutlets that were freezer burned, a container with a broken lid with frozen pumpkin in it, dated 9/4/2021, that had ice crystals on it and an unlabeled, undated plastic bag of frozen biscuits. A drawer with serving utensils contained a hand scoop that had dried pink particles of food, 3 serving scoops with visible standing water in them and 2 scoops with water stains. On 1/4/2022 at 10:08 A.M., the Dietary Manager indicated the food that was freezer burned should be thrown out, the foods should have labels and dates on them and the cooking utensils were not clean. On 1/11/2022 at 1:45 P.M., the Director of Nursing provided the policy titled,Food Storage, undated and indicated the policy was the one currently used by the facility. The policy indicated . 11. Leftover food will be stored in covered containers or wrapped carefully and securely. 13. c. All foods should be covered, labeled and dated. All food will be checked to assure that foods will be consumed by their safe use dated or discarded On 1/11/2022 at 1:45 P.M., the Director of Nursing provided the policy titled,Cleaning Dishes/Dish Machine, undated, and indicated the policy was the one currently used by the facility. The policy indicated .8. During unloading process, visually inspect all items for cleanliness. If the dishes are not clean, repeat steps 2 thru 8. 9. Dishes should be air dried on the dish racks. 10. Inspect for cleanliness and dryness and put dishes away if clean 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to develop and implement a personalized care plan for 4 of 16 residents whose care plans were reviewed. (Residents 7, 28, 11, and 34) Findings include: 1. During an interview on 1/5/2022 at 9:09 A.M., Resident 7 indicated he had an area on his left upper thigh which had a skin discoloration. He had spilled hot coffee on himself and had a blister. A continuous positive airway pressure ([CONDITION(S)]) machine was also observed sitting on his nightstand. He indicated he used it when he sleeps. A clinical record review was completed on 1/6/2022 at 2:19 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 10/4/2021, indicated intact cognition. A Nurses' Note, dated 9/9/2021, at 6:37 A.M., indicated Blister to left upper thigh with one blister not intact. Wound bed moist, pink in color. Resident states area is tender when touched. No s/s [signs/symptoms] of infection observed. A Nurses' Note, dated 9/9/2021, at 10:29 P.M., indicated spilled coffee on his left thigh and lower abd. [abdomen] does have blisters that did open, has new orders to clean and dress on days. Skin is pink in those areas, he denies pain. The record lacked documentation of a care plan for the blister. A care plan was in place for potential for alteration in skin integrity related to: disease process and decrease mobility, but did not address the new issue. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation of a care plan for the [CONDITION(S)] machine. During an interview on 1/7/2022 at 9:40 A.M., the Director of Nursing indicated she could not find a care plan for the blister. She indicated they should have had a care plan in place for the blister. During an interview on 1/07/2022 at 3:00 P.M., the Director of Nursing indicated that he should have had a care plan for the [CONDITION(S)] machine. 2. During an interview on 1/4/2022 at 10:21 A.M., Resident 28 indicated she experienced pain to her knees and right hip, and received pain medication. The Clinical Record review for Resident 28 was completed on 1/6/2022 at 10:30 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 11/10/2021, indicated intact cognition. A pain assessment interview was conducted but no pain was present, she took opioids 7 of 7 days of the assessment period. The facility lacked documentation of a care plan for diabetes and medication ordered and a care plan for chronic pain. During an interview on 1/6/2022 at 2:04 P.M., the Assistant Director of Nursing (ADON) indicated if they were actively treating her for pain, then there should be a pain care plan. She could not find a care plan. During an interview on 1/10/2022 at 9:59 A.M., the Director of Nursing indicated she did not see a care plan for diabetes and indicated if she was diabetic and took insulin, she should have a care plan. 3. During an interview, on 1/5/22 10:50 A.M., Resident 11 indicated she had a pain pump. The clinical record for Resident 11 was reviewed on 1/6/22 at 10:38 A.M. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, completed on 12/8/21, indicated Resident 11 was admitted to the facility on [DATE] and was cognitively intact. A document from the local hospital, titled, Discharge Documentation, indicated an implanted [MEDICATION(S)] pain pump fill was performed. The pump would administer the prescribed amount of [MEDICATION(S)] daily. The form indicated that Resident 11 wanted to pull the plug prior to the refill of the pain pump, but after the refill, wanted to participate in physical therapy. There was no identifiable order related to the medication being administered via the pain pump, nor a care plan identifying the pain pump as an intervention for pain. During an interview, on 1/07/22 at 11:05 A.M., the Director of Nursing (DON) indicated the pain pump should be care planned and an order in the medical record should indicate the medication name and dosage being infused in the medical orders. On 1/10/22 at 3:10 P.M., the DON provided the Comprehensive Care Plans policy. The policy indicated, .The comprehensive care plan will describe at a minimum, the following: a. The services that to are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being 4. During the initial dining observation, conducted on 1/4/2022 between 11:50 A.M. - 12:40 P.M., Resident 34 was noted to be seated in her wheelchair at a dining room table in a corner of the south end of the dining room. She was noted to have her head bent over almost resting on table. She did not receive any staff assistance to eat, other than setting up her meal tray when her meal was delivered to the table. She was noted to drink from a gray plastic handled mug. During a meal observation on 1/7/2022 at 12:00 P.M., Resident 34 was noted seated at a corner table. Her meal was delivered at 12:23 P.M. and set up for her. She had previously been given a mug of hot chocolate with a disposable plastic lid and straw. She did not receive any assistance to eat her food from the time she arrived in the dining room until 12:48 P.M. when she was assisted to leave the dining room. She was only noted to have eaten some of her chocolate pudding and drank all of her hot chocolate beverage. The clinical record for Resident 34 was reviewed on 1/6/2022 at 1:40 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment, completed on 11/16/2021, indicated the resident required staff set up and supervision for meals. The Care Guide for Monday 1/10/2022 1st shift for Resident 34 indicated she required set up assistance for meals. Resident 34's most recent weight, recorded on 1/3/2022, was 86.8 pounds. Her weight on 7/5/2021 was 95 pounds - a 9.14% weight loss in 180 days. Although the resident's care plan indicated she only required set up assistance, per observation she was not feeding herself much of her meal and her care plan indicated staff were to assist her with meals. 3.1-35(a)

Based on record review and interview, the facility failed to follow pharmacy recommendations for 1 of 1 resident reviewed for medication regimen review (Resident 16). Finding includes: The clinical record for Resident 16 was reviewed on 1/6/22 at 3:27 P.M. Diagnoses included, but were not limited to, [CONDITION(S)] ([CONDITION(S)]), heart failure, and [CONDITION(S)]. A Psychiatry Progress Note on 10/21/21, indicated Resident 16 was receiving [MEDICATION(S)] 200 mcg-25 mcg for inhalation. A Pharmacy Medication Review on 10/25/21, indicated a recommendation for Please add 'Rinse mouth with water and spit after using inhaler' to the [MEDICATION(S)] inhaler order. A Pharmacy Recommendation, dated 11/29/21, indicated the same recommendation. The facility received this recommendation on 12/9/21 via email. A Physician's Order was placed on 12/10/21 for Rinse mouth with water and spit after using inhaler. On 1/6/22 at 3:46 P.M., the DON indicated the recommendation should have been completed in October when the recommendation was first received. On 1/10/22 at 3:10 P.M., the DON provided the Medication Regimen Review policy. The policy indicated, .4. The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed. a. The pharmacist shall document either no irregularity was identified or the nature off any identified irregularity. B. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation 3.1-25(e)(1)

Based on record review and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 38) Finding Includes: The clinical record for Resident 38 was reviewed on 1/10/22 at 11:55 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, completed on 12/6/21, indicated Resident 11 was cognitively intact and required supervision for transfers. The record indicated Resident 38 received [CONDITION(S)] on Tuesday, Thursday, and Saturday. Documentation could not be found in the electronic medical record or the [CONDITION(S)] communication binder for [CONDITION(S)] assessments on 11/6/21 (post [CONDITION(S)]),11/20/21 (Post [CONDITION(S)]), 12/4/21 (post [CONDITION(S)]), and 12/18/21 (post [CONDITION(S)]), and weights on 11/13/21 (pre [CONDITION(S)]), 11/20/21 (post [CONDITION(S)]), 11/22/21 (pre [CONDITION(S)]), 12/4/21 (pre [CONDITION(S)]), 12/9/21 (pre [CONDITION(S)]) and 12/22/21 (pre [CONDITION(S)]). Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan was in place for altered renal function and renal failure/[CONDITION(S)]. The interventions included a pre/post [CONDITION(S)] assessment on [CONDITION(S)] days prior to leaving for [CONDITION(S)] and upon returning from [CONDITION(S)] on [CONDITION(S)] days. During an interview, on 1/10/22 at 2:02 P.M., the DON indicated documentation for [CONDITION(S)] assessments and weights should be completed per the order. On 1/10/22 at 3:10 P.M., the Director of Nursing provided the Hemodialysis policy. The policy indicated, .2, The facility will coordinate and collaborate with the [CONDITION(S)] facility to assure that: b. The provision of the [CONDITION(S)] treatments and care of the resident meets the current standards of the practice for the safe administration of the [CONDITION(S)] treatment. C. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and [CONDITION(S)] team 3.1-4(5)

Based on observation, record review and interview, the facility failed to thoroughly reassess nutritional needs accurately after a change in condition for 1 of 4 residents reviewed for nutrition. (Resident 46) Finding includes: During an observation of the noon meal, conducted on 1/4/22 at 12:00 P.M., Resident 46 was observed to try to drink from a plastic coffee mug. The resident's left arm was in a foam arm wedge fastened to her left wheelchair arm. The resident only utilized her right hand/arm. The resident, who repeatedly asked for help, was observed to spill a portion of her hot chocolate all over the table. Staff cleaned up the spilt hot chocolate, placed a disposable lid and straw on her remaining hot chocolate mug. Staff also placed the resident's food in front of her. The resident was observed to attempt to feed herself with a fork but appeared to struggle to grasp the silverware. The resident very loudly repeatedly asked for assistance and staff did sit down and feed her at around 12:20 P.M. The clinical record for Resident 46 was reviewed on 1/6/2022 at 9:46 A.M. Resident 46 was initially admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, completed on 11/11/2021 indicated the resident was severely cognitively impaired, required extensive staff assistance of two staff for all transfers, could feed herself with supervision and set up assistance and weighed 185 pounds with a recent weight gain. There were no specific nutritional approaches marked as needing to be utilized in the seven days prior to the assessment completion date. A Quarterly RD (Registered Dietician) Nutritional review, completed on 11/1/2021 indicated the resident received a NCS (no concentrated sweets) , mechanical soft diet, received health shakes three times a day with meals, had no recent skin issues except 2+ pitting [CONDITION(S)] to left hand/fingers. The notes section of the assessment indicated the following: Resident with therapeutic diet r/t [related to] dx [diagnosis] DM [diabetes mellitus], on meds [medications] and insul [insulin] for BGL [blood glucose level] control. Reported to accept additional portions at meals. This and [CONDITION(S)] may be contributing to weight trends increasing. Continue with plan of care. RD available for f/u [follow up] as needed. The Care Plan related to nutrition included the following: Alteration in Nutritional Status . - Goal: My po [by mouth] will meet my nutritional needs aeb [as evidenced by] weights wnl's [within normal limits] for UBw [usual body weight]. Interventions included: Monitor weights, monitor food intake, provide ordered diet NCS< mechanical soft, supplement as ordered . Nursing Notes, dated 12/2/2021, indicated the resident had been lowered to the floor during an assisted transfer to the toilet, when her knees had buckled. Nursing notes, dated 12/5/2021, indicated the resident's left side was noted to be flaccid and she was sent to the acute care facility and tested positive for COVID 19 infection while at the hospital. The resident was readmitted to the hospital on 12/10/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An MDS assessment, completed on 12/21/2021 due to the resident's change to medicare status, indicated the resident now required mechanical lift assistance for transfer needs, required two staff extensive assistance for bed mobility, required staff extensive assistance for eating needs and her weight was listed as 187 pounds. The resident's weight, as documented in her electronic record for 12/3/2021, was 187 pounds, however, the weight listed for 12/20/2021 was 170.8 pounds. The weights for 12/21/2021, 12/28/2021 and 1/4/2021 were all listed as 175 pounds. The RD assessments, completed on 12/9/2021 and 12/16/2021 were almost identical in notations, did not mention the resident's recent COVID 19 infection or hospitalization , did not utilize a resident weight after returning from the hospital. but utilized her weight prior to hospitalization and did not mention the resident's new difficulty in self feeding. The Care Plan for Resident 46 was not updated. The electronic care guide for Resident 46, provided by the Assistant Director of Nursing, on 1/10/2022 at 10:36 A.M., indicated under nutrition: eating set up. There were no instructions to provide the resident with feeding assistance. During an interview with the ADON, on 01/10/2022 at 10:36 A.M., she indicated she would have expected the registered dietician to have addressed the resident's recent infection and weight change and change in feeding needs on her assessment.

Based on observation, record review and interview, the facility failed to ensure 1 of 2 residents reviewed for falls received adequate supervision and interventions to prevent fall recurrence. (Resident 34) Finding includes: Resident 34 was observed during the initial tour of the facility, conducted on 1/4/2022 between 9:25 A.M. - 9:38 A.M., seated in a recliner in the front lounge. The resident's legs were elevated on the foot rest of the recliner and the resident was wearing shoes. At 9:57 A.M. on 1/4/2022, the resident was assisted to transfer into her wheelchair by two staff members. The resident was observed to be able to stand and support her weight when directed by staff. She was pushed from the front resident lounge to her room without the use of foot pedals and was instructed by staff to hold up her feet. On 1/4/2022 during the noon meal observation, conducted from 11:50 A.M. - 12:48 P.M., Resident 34 was observed to spend most of the time leaning forward in her wheelchair and attempting to rest her head in her lap and/or hands. On 01/6/2022 at 11:12 a.m., Resident 34 was observed seated in front lounge in her wheelchair. She was wearing shoes, had her feet on the floor between the wheelchair pedals and was leaning forward with her head resting in her hands., On 1/7/2022 at 8:20 A.M., Resident 34 was observed seated in her wheelchair in front of the nurse's station. She was leaning forward with her arms and head resting on her thighs. There were no staff noted in the area at the time of observation. The resident was dressed and had tennis style shoes in place. On 1/7/2022 at 8:38 A.M., CNA 12 was observed to push Resident 34 back to her room. The resident declined an opportunity to use the toilet. CNA 12 assisted Resident 34 to stand from her wheelchair and transfer back into her bed. CNA 12 did not use a gait belt and Resident 34 was able to follow instructions. After lifting the resident's legs into the bed for her, CNA 12 removed the resident's shoes. The resident was wearing regular socks. She then pulled the covers up over Resident 34. Next, CNA 12 removed the resident's foot pedals and positioned the resident's wheelchair beside her bed and locked the wheelchair. A folded walker was noted at the end of the resident's bed, resting against a window. CNA 12 indicated Resident 34 used to use the walker, but had not due to a recent cold. On 1/10/2022 at 1:41 P.M., Resident 34 was observed in room her room, in bed. The resident's wheelchair was beside her bed, the walker was opened at the end of her bed but not within reach. The wheelchair was locked and the resident was wearing regular socks. The resident's shoes were noted to be on the wheelchair seat. The clinical record for Resident 34 was reviewed on 1/6/2022 at 01:40 P.M. Diagnoses included, but were not limited to: history of contusion to the scalp and right pubis fracture, chronic pain, [CONDITION(S)], dorsalgia, [CONDITION(S)], hypertension, [CONDITION(S)] and heart valve disorder with history of heart valve replacement and dementia without behavioral disturbances. The most recent MDS (Minimum Data Set) assessment, completed as a Quarterly review on 11/16/2021, indicated the resident was severely cognitively impaired, required extensive staff assistance of one for transfers, dressing and walking needs, required limited assistance for locomotion needs and toileting needs, utilized a walker and had not had any recent falls. The current care plans for Resident 34 included the following: History of falls - falls - r/t [related to] incontinence, unsteady gait, balance issues, poor safety awareness, falls in the past 30 days Goals: Resident will have less than 2 falls per quarter. Interventions: Resident to use walker when walking, call light in reach, safety checks as needed, labs as ordered per MD, call light in reach, floor/resident's path to bathroom is clear, anticipate needs, encourage resident to do as much for self as is able, safety checks as needed, ensure foot of recliner is down when resident is in it, keep res walker close to her when she is in bed, discuss with staff- including therapy, activities ways to keep resident safer in chair, provide ordered diet, inform of activities, encourage activity participation. Review of Nursing Progress Notes and Fall Assessments, completed on 12/8/2021, indicated at 6:55 A.M., the resident, who had been in a recliner in the front lounge, was found face down on the floor when she evidently tipped the recliner with an elevated footrest forward. Review of Nursing Progress Notes and Fall Assessments, completed on 12/19/2021 at 5:15 P.M., indicated the resident was found on the floor in her room when she attempted to self transfer from her bed to a wheelchair positioned next to her bed and slipped off the front of the wheelchair seat. Review of Nursing Progress Notes and Fall Assessments, completed on 1/2/2022, indicated at 10:30 A.M., Resident 34 was observed seated at the nurse's station in her wheelchair with her head bent forward and fell forward out of wheelchair. The resident hit the left side of her head and bit her tongue. The fall was observed by staff. A Fall Risk Assessment had been completed on the following dates after the resident's most recent falls: 8/30/2021 - fall risk score 18 (high), 12/8/2021 - fall risk score 13 (high), 12/19/2021 - fall risk score 16 (high) and 1/2/2022- with a fall risk score of 19 (high). During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 1/10/2022 at 2:35 P.M., both nurses indicated after the resident's first fall on 12/8/2021, a new intervention was implemented to ensure the footrest on the recliner was not elevated when the resident was utilizing the recliner. When they were informed of an observation of the resident in a recliner with the feet elevated, they indicated the resident could have put the footrest in the elevated position by herself. Discussion regarding the resident's second fall on 12/19/2021 indicated the intervention was to ensure the resident's walker was beside her bed, not the wheelchair. When multiple observations regarding the resident utilizing a wheelchair were mentioned, the DON indicated the resident had been needing the wheelchair more recently, but prior to that had been walking with a walker. Discussion regarding the resident's third fall on 1/2/2021 indicated the intervention was to have an interdisciplinary discussion regarding safety needs. The DON indicated the resident had been evaluated by the therapy department and an order was obtained for her to receive therapy services. A Physician's Order, dated 1/6/2022, was obtained for physical therapy to see the resident once a day for 10 visits for therapeutic exercise, neuro and gait training. During an interview with CNA 11, the staff member assigned to care for Resident 34 for the day, conducted on 01/10/2022 at 9:15 A.M., she indicated she had the current CNA assignment sheet with her. Review of the form indicated Resident 34 used a walker and was a set up assist for dressing and grooming needs. When the resident's use of a wheelchair was pointed out, CNA 11 indicated the resident now used a wheelchair due to recent falls. When asked how she knew how to care for the resident currently, she indicated she was verbally informed by the nurse and/or CNA she was replacing during report. A subsequent interview with CNA 11, on 1/10/2022 at 2:00 P.M. indicated the facility had switched to Matrix (a new electronic charting system) recently and her updated instructions were on the Kiosk for the her to review. Review of the Care Guide for Monday 1/10/2022 1st shift for Resident 34, provided by the DON on 1/10/2022 at 10:42 A.M., indicated the resident was denoted as requiring extensive assist for transfers, one person assist with a gait belt and walker if able, on person assist for toileting. There were no specific instructions for Safety/skin precautions except: If falls occur, notify family and physician, chart details of fall, and update care plan safety checks as needed, labs as ordered by MD. During an interview with LPN 7 on 1/10/2022 at 10:45 A.M. regarding Resident 34's fall interventions, she indicated they utilized standard precautions. She indicated standard precautions consisted of general interventions to try to keep the resident at risk for falls, those with snowflakes on their door frames, in the lounge, if they were in their bedroom - conduct frequent checks, make sure the call light and personal items are within reach, ensure there were no hazards or obstacles. When asked about any specific interventions for Resident 34, LPN 7 indicated she knew Resident 34 had been utilizing a wheelchair recently, was getting therapy services and could walker with staff if they used a walker and gait belt. LPN 7 then indicated she would have to look up the resident's individual care plans to look for specific interventions. LPN 7 then proceed to look up in the electronic record, Resident 34's care plan. LPN 7 indicated the plan had very general interventions like keep floor to bathroom clear, try to anticipate resident needs, keep foot down when in recliner, encourage activities. Although there were interventions indicated in the resident's clinical record, the fall assessment did not indicate a root cause analysis, the interventions in the care plan were either ineffective due to resident's ability to manually raise the recliner footrest and/or were not followed due to the resident's decreased ability to utilize a walker. The intervention to initiate therapy was completed 4 days after the fall. 3.1-45(a)

Based on record review and interview, the facility failed to update or revise a fall care plan with interventions to prevent falls and failed to update an ADL (activities of daily living) care plan for increased eating assistance for 2 of 16 residents whose care plans were reviewed. (Residents 40 and 46) Findings include: 1. A clinical record review was completed on 1/4/2022 at 11:17 A.M. Resident 40's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurses' Note, dated 12/24/2021 at 10:41 A.M., indicated Resident 40 was found on floor. A Nurses' Note, dated 1/2/2022 at 8:25 P.M., indicated Resident 40 was found on the floor with a laceration to her forehead. A current care plan, dated 9/17/2021, indicated resident 40 was at high risk for fall and injury related to decline in cognitive status, and poor safety awareness. The care plan was only updated with a new intervention following the fall which occurred on 1/2/2022. During an interview on 1/5/2022 at 11:15 A.M. with LPN 7, she indicated the care plan should be updated with every fall for additional interventions and the fall report would prompt staff to do these revisions. During an interview on 1/5/2022 at 11:25 A.M., the Director of Nursing (DON) indicated the fall care plan had not been revised following the fall on 12/24/2021. On 1/7/2022 at 8:30 A.M., the DON provided the policy titled, Care Plan Revisions Upon Status Change, dated 4/8/2020, and indicated the policy was the one currently used by the facility. The policy indicated .1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. A. If a resident experiences a fall, care plan should be evaluated to ensure that the resident has interventions appropriate in place. C. The care plan will be updated with the new or modified interventions 2. During an observation of the noon meal, conducted on 1/4/22 at 12:00 P.M., Resident 46 was noted to attempted to drink from a plastic coffee mug. The resident's left arm was in a foam arm wedge fastened to her left wheelchair arm. The resident only utilized her right hand/arm. The resident, who repeatedly asked for help, was noted to spill a portion of her hot chocolate all over the table. Staff cleaned up the spilt hot chocolate, placed a disposable lid and straw on her remaining hot chocolate mug. Staff also placed the resident's food in front of her. The resident was noted to attempt to feed herself with a fork but appeared to struggle to grasp the silverware, dropping most of the food she attempted to eat with her fork. The resident very loudly repeatedly asked for assistance and staff did sit down and feed her at around 12:20 P.M. On 1/7/2022 at 8:10 A.M., Resident 46 was observed to have her incontinence brief changed by CNA 9. She then had a sling placed under her by CNA 9 in preparation to transfer her with a mechanical lift. Interview with CNA 9 at the time indicated the resident was not really toileted anymore but was just checked and changed. CNA 9 went on to say the resident had recently had COVID and was so weak she could not even feed herself very well due to new dexterity problems. The clinical record for Resident 46 was reviewed on 1/6/2022 at 9:46 A.M. Resident 46 was initially admitted to the facility on [DATE] with diagnosis, including but not limited to: adjustment disorder, dementia without behavior disturbance, hyperosmolarity, hypertension, Type 2 diabetes and hyperlipedemia. A Quarterly MDS (Minimum Data Set) assessment, completed on 11/11/2021, indicated the resident was severally cognitively impaired, required extensive staff assistance of one staff for bed mobility, required extensive staff assistance of two staff for all transfers, could feed herself with supervision and set up assistance, weighed 185 pounds with a recent weight gain and was frequently incontinent of her bowels and bladder. Nursing Notes, dated 12/2/2021, indicated the resident had been lowered to the floor during an assisted transfer to the toilet, when her knees had buckled. Nursing Notes, dated 12/5/2021, indicated the resident's left side was noted to be flaccid and she was sent to the acute care facility and tested positive for COVID 19 infection while at the hospital. The resident was readmitted to the hospital on 12/10/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An MDS assessment, completed on 12/21/2021 due to the resident's change to medicare status, indicated the resident now required mechanical lift assistance for transfer needs, required two staff extensive assistance for bed mobility, required staff extensive assistance for eating needs, was totally dependent on staff for transfer needs and required the use of a mechanical lift and was totally incontinent of her bowel and bladder function. The Care Guide for Monday 1/10/2022 1st Shift for Resident 46 indicated she was transferred with one staff assist and a gait belt and only required set up assistance for eating needs. Review of the current health care plan, presented on 1/10/2022 at 9:08 A.M. by the Assistant Director of Nursing (ADON) indicated the interventions included transferring and toileting with two staff assistance, and nutritional set up needs only. 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure a comprehensive MDS (Minimum Data Set) assessment was completed due to significant declines for 1 of 16 residents whose care plans were reviewed. (Resident 46) Finding includes: During an observation of the noon meal, conducted on 1/4/22 at 12:00 P.M., Resident 46 was noted to attempt to drink from a plastic coffee mug. The resident's left arm was in a foam arm wedge fastened to her left wheelchair arm. The resident only utilized her right hand/arm. The resident, who repeatedly asked for help, was noted to spill a portion of her hot chocolate all over the table. Staff cleaned up the spilt hot chocolate, placed a disposable lid and straw on her remaining hot chocolate mug. Staff also placed the resident's food in front of her. The resident was noted to attempt to feed herself with a fork but appeared to struggle to grasp the silverware. The resident very loudly repeatedly asked for assistance and staff did sit down and feed her at around 12:20 P.M. The clinical record for Resident 46 was reviewed on 1/6/2022 at 9:46 A.M. Resident 46 was initially admitted to the facility on [DATE] with diagnosis, including but not limited to: adjustment disorder, dementia without behavior disturbance, hyperosmolarity, hypertension, type 2 diabetes and hyperlipedemia. A Quarterly MDS assessment, completed on 11/11/2021, indicated the resident was severally cognitively impaired, required extensive staff assistance of one staff for bed mobility, required extensive staff assistance of two staff for all transfers, could feed herself with supervision and set up assistance, weighed 185 pounds with a recent weight gain and was frequently incontinent of her bowels and bladder. Nursing Notes, dated 12/2/2021, indicated the resident had been lowered to the floor during an assisted transfer to the toilet, when her knees had buckled. Nursing Notes, dated 12/5/2021, indicated the resident's left side was noted to be flaccid and she was sent to the acute care facility and tested positive for COVID-19 infection while at the hospital. The resident was readmitted to the hospital on 12/10/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An MDS assessment, completed on 12/21/2021 due to the resident's change to medicare status, indicated the resident now required mechanical lift assistance for transfer needs, required two staff extensive assistance for bed mobility, required staff extensive assistance for eating needs and her weight was listed as 187 pounds. The resident's weight, as documented in her electronic record for 12/3/2021, was 187 pounds, however, the weight listed for 12/20/2021 was 170.8 pounds. The weights for 12/21/2021, 12/28/2021 and 1/4/2021 were all listed as 175 pounds. The current health care plans, provided by the ADON (Assistant Director of Nursing), on 1/10/2022 at 10:42 A.M., indicated interventions to provided two person extensive assist with transfers and toileting but no interventions to address the use of the mechanical lift for transfers, use of bedpan for current toileting needs or feeding assistance. The current care plans did not mention the resident's weight loss. There were several care plans related to the isolation and potential respiratory distress due to the resident's COVID-19 infection. The electronic care guide for Resident 46, provided by the ADON on 1/10/2022 at 10:36 A.M., indicated the resident only required set up assistance for nutritional needs, required transfer assistance with a gait belt and one person, indicated walking assistance with one person, indicated the resident utilized pull ups and utilized a walker. During an interview with the Director of Nursing (DON) and the ADON regarding Resident 46's declines and lack of MDS assessment, both indicated the MDS assessments were currently being completed by a consultant. They also indicated they were hoping Resident 46 would regain some of her ADL (Activities of Daily Living) function back after she recovered from COVID 19. The resident had been working with therapy after she was readmitted from the hospital, however, there was an abbreviated assessment completed on 12/29/2021 indicating the purpose was due to a discharge from skilled services. The MDS consultant was unavailable for interview regarding the lack of a change in condition assessment. 3.1-31(d)(1)

Based on record review and interview, the facility failed to maintain a resuscitation status in the medical record and a signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 11) Findings includes: The clinical record for Resident 11 was reviewed on 1/5/22 at 10:55 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment, completed on 12/8/21, indicated Resident 11 was admitted to the facility on [DATE] and was cognitively intact. The medical record indicated Resident 11 discharged from the facility on 11/20/21 and readmitted on [DATE]. There was no Cardiopulmonary Resuscitation Status Form available to specify Resident 11's wishes for resuscitation. A review of the Resident 11's orders indicated no physician signed orders for resuscitation status. During an interview, on 1/6/22 at 9:50 A.M., Administrative Services 16 indicated the advanced directive was not completed by the Power of Attorney (POA) for this admission and she had alerted the nursing staff of the need for the advanced directive to be completed. Administrative Services 16 reviewed the chart and indicated a signed physician advanced directive could be not located on the chart. During an interview on 1/6/22 at 9:56 A.M., LPN 5 indicated the advanced directive decision should be on the monthly physician signed orders and an advanced directive signed by the physician should be located on the chart. LPN 5 reviewed the chart and indicated there was not a signed advanced directive on the chart, and no order signed by the physician. On 1/10/22 at 3:10 P.M., the Director of Nursing (DON) provided the Communication of Code Status policy. The policy indicated, .2. When a code status is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: a. Full Code b. Do not Resuscitate c. Do Not Intubate d. Do not Hospitalize. 3. The nurse that notates the code status is responsible for documenting the directions in all relevant sections of the medical record. 8. The code status will be reviewed upon readmission to ensure that no changes have occurred and updated as needed 3.1-4(5)

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 by not ensuring the proper Personal Protective Equipment was worn by staff in an identified RED zone (COVID Unit) during a random Infection Control observation. (RN 1) Finding includes: During an observation of the RED zone, conducted on 10/27/21 at 3:00 P.M., RN (Registered Nurse) 1 was observed sitting in a yellow high backed lounge chair without a mask or eye protection on. The RED zone at that time, had one occupant and the doors were closed. Signage, in the form of a Indiana Department of Health RED stop sign, was observed on the wall and door of the RED zone occupant indicating the Personal Protective Equipment (PPE) required for the zone. The signage indicated a mask and eye protection should be worn. During an interview, conducted with RN 1 on 10/27/21 at 3:15 P.M., she indicated she did not know she was to wear a mask in the RED zone, she thought she had to wear a mask only when working within a resident's room. During an interview, conducted with the DON (Director of Nurses), on 10/27/21 at 3:20 P.M., she indicated the nurse should be wearing a N95 mask at all times while working in the RED zone. A policy, titled, Isolation Precautions with a revision date of 8/1/2021, was provided by the ED (Executive Director) on 10/27/21 at 3:35 P.M The policy indicated .Policy Explanation and Compliance Guidelines: 3. The facility will use standard approaches, as defined by the CDC [Centers for Disease Control], for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. (A table that depicts the types of PPE to use is attached to this policy. 5. Transmission-based precautions will be maintained in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .e. while the risk of transmission of the infectious agent persists or for the duration of the illness. 8. Information regarding the particular type of precaution to be utilized will be communicated through verbal reports, written in-house forms, and signage 3.1-18(a)

Based on record review and interview, the facility failed to ensure infection control guidelines were in place and implemented to properly prevent and/or contain COVID-19 related to lack of staff screening on 2 of 2 COVID units. (Halls 1 and Hall 5) Finding includes: Interview with LPN 1 on 12/15/20 at 2:43 p.m., indicated that she was one of the dedicated staff members working on the COVID unit. The LPN indicated her temperature was taken at the beginning of her shift but the screening sheets weren't available to fill out. Interview with the Assistant Director of Nursing (ADON) on 12/15/20 at 2:46 p.m., indicated staff working on the COVID units were to screen each other at the start of their shifts by taking temperatures and filling out the Fit for Duty screening sheets. Additional interview with the ADON at 3:15 p.m., indicated the staff working on the COVID units were taking their temperatures but did not fill out the screening sheets due to not having any available on the unit. The ADON indicated screening sheets were to be completed at the start of each shift and screening sheets were taken to both COVID units. The facility policy titled, COVID-19 Screening &/or Testing was reviewed on 12/15/20 at 3:30 p.m. The policy indicated all staff upon entering for work were to be screened at the start of their shift for COVID-19. The employee's temperature was to be taken and the employee was to be asked if they had any signs or symptoms that were posted on the COVID-19 poster (shortness of breath, new/change in cough, sore throat). 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure their policy indicated to immediately notify the Administration with an allegation of abuse and to follow facility policy related to investigating allegations of abuse. This deficient practice had the ability to affect 34 of 51 residents residing in the facility. Findings include: A clinical record review was conducted on 8/15/2017 at 10:30 A.M., and indicated Resident #37 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 7/3/2017, indicated Resident #37's BIMS (brief interview of mental status) score was 0, severe cognitive impairment. During an interview, on 08/16/2017 at 11:07 A.M., Resident #37's family member indicated she was informed on 3/20/2017 by the Clinical Instructor and DON (Director of Nursing) related to an event which occurred on 3/8/2017. She indicated she was told, CNA (certified nursing aide) #2 ripped off Resident #37's oxygen tubing and pulled her up out of bed and the resident started spitting. he family member indicated CNA #2 indicated to Resident #37 that if you want to breathe, stop spitting. During an interview, on 8/16/2017 at 3:34 P.M., the DON indicated a family member and a Clinical Instructor at the facility indicated CNA #2 had indicated to Resident #37 that if you want to breathe, stop spitting, on 3/8/2017. She indicated she was not aware of this allegation until 3/20/2017. The DON indicated when she found out about the incident she took care of it. During an interview, on 8/16/2017 at 4:57 P.M., Unit Manager #3 indicated she was told on 3/8/17 by the Clinical Instructor that one of the facility CNA's had put her hand over Resident #37's mouth because she was spitting and she put the oxygen tubing on too tight. She indicated she was told CNA #2 indicated to Resident #37 to stop spiting and I can put your oxygen tubing back on. Unit Manager #3 indicated the DON had been made aware of this event right after it happened. During an interview, on 8/16/2017 at 5:03 P.M., the DON indicated she had no documentation related to the allegation taking place on 3/8/2017. During an interview, on 8/16/2017 at 5:11 P.M., Social Services indicated she was unaware of this event taking place. During an interview, on 8/17/2017 at 11:30 A.M., the Clinical Instructor indicated the following: CNA #2 entered Resident #37's room, pulled off the resident's blankets and in one quick movement, sat her up on the side of the bed while she was still asleep. Resident #37 was startled, and became combative. She was swinging her arms, pinching and spitting. Resident #37 was at the side of the bed with just her coccyx on the mattress, I thought she was going to fall. I stood on her left side and instructed my CNA students to stand in front of her and on the other side to keep her from falling. CNA #2 removed the residents nasal cannula and threw it on the bed as the resident was getting more distraught. When I asked CNA #2 to leave the room, she indicated no, she acts out like this all the time .you guys don't know her like I do. She is always nasty like this. CNA #2 indicated to Resident #37 You can't breathe? Stop spitting and I will give you back your oxygen. CNA #2 then hooked Resident #37 onto the stand up lift to assist her to the bathroom. CNA #2 did not fully sit the resident down onto the toilet to toilet her, she was just hovering over the toilet. After peri care was completed, CNA #2 used the stand up lift to put Resident #37 in her wheelchair. CNA #2 attempted to put the resident's nasal cannula back on, but she became combative and started spitting again. CNA #2 then put her hand over and onto the resident's mouth, smacking her mouth. CNA #2 indicated to the resident If you want to be able to breathe, you need to stop spitting at people. CNA #2 trying to avoid being spit on, approached Resident #37 from behind to put on her glasses. Resident #37 was startled, put her hands up to protect her face and in doing so, knocked the glasses out of the CNA's hand, and they landed on the floor. CNA #2 indicated You are acting ridiculous, Now I am going to get in trouble for breaking your glasses. CNA #2 picked up the glasses, pushed Resident #37 down the hallway to the dining room and indicated to her You are acting ridiculous. On 8/17/17 at 2:30 P.M., Administration provided the policy titled ABUSE, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Mocking, insulting, ridiculing . Saying anything to a resident which might cause him/her to worry or become alarmed . Threatening residents, including but not limited to, depriving a resident of care . Verbal Abuse . Verbally threatening a resident with harm . Raising your voice to a resident in a scolding or abrupt manner . Physical Abuse . Actually laying hands on a resident in an abrupt manner (i.e. hitting, slapping, punching or kicking.) . Transporting or transferring a resident in an abrupt or careless manner . Suspicions of, or reports or (sic) any abuse or questionable behavior, will be thoroughly investigated and acted upon at the discretion of administrative personnel up to and including termination if warranted . Abuse by an Employee - Procedure . 2. Should an occurrence of abusive behavior be reported or witnessed, the Administrator, DON and/or Nursing Manager shall be notified immediately. Acceptable forms of notification are: phone and/or phone message, text message and in person. 3. Appropriate documentation should be completed relative to the individual incident (i.e. report of concern, statement, incident/accident report, etc.). 4. Should the incident be deemed an unusual occurrence, the state survey and certification/licensure agencies shall be notified as well as the ombudsman and/or Adult Protective Services as applicable. 5. The alleged violation shall be thoroughly investigated by the Administrator or his/her designee. The investigation will include, but not be limited to, interviews with any and all staff who witnessed an alleged abusive situation, interviews with other staff working with the alleged abuser and interviews of interviewable residents. The facility must prevent further potential abuse while the investigation is in process. For example, an individual who has been alleged as exhibiting abusive behavior will not be permitted to continue to care for residents until and investigation has been completed and the allegation found to be unsubstantiated. An employee accused of any kind of abuse will be suspended from work without pay during an investigation of any alleged abuse cases . 6. The results of all investigations shall be reported to the state survey and certification/licensure agencies as well as other related agencies within five (5) working days of the incident and /or reporting of the incident. 7. Verified occurrences of abuse will be reported to the applicable agency (i.e. state nurse aide registry, Health Professions Bureau, etc). 8. In-service training shall be conducted as deemed necessary by management to increase awareness of the prohibition of, as well as the ramifications of, resident abuse 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to investigate an allegation of abuse for 1 of 3 residents reviewed. This deficient practice had the ability to affect 34 of 51 residents residing in the facility. This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/8/17, when Resident #37 was startled, threatened, handled roughly, and smacked on the mouth, and was identified on 8/17/17. The Administrator was notified of the Immediate Jeopardy on 8/17/17 at 3:35 P.M. The Immediate Jeopardy was removed on 8/22/17, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A clinical record review was conducted on 8/15/2017 at 10:30 A.M., and indicated Resident #37 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 7/3/2017, indicated Resident #37's BIMS (brief interview of mental status) score was 0, severe cognitive impairment. During an interview, on 08/16/2017 at 11:07 A.M., Resident #37's family member indicated she was informed on 3/20/2017 by the Clinical Instructor and DON (Director of Nursing) related to an event which occurred on 3/8/2017. She indicated she was told, CNA (certified nursing aide) #2 ripped off Resident #37's oxygen tubing and pulled her up out of bed and the resident started spitting. The family member indicated CNA #2 indicated to Resident #37 that if you want to breathe, stop spitting. During an interview, on 8/16/2017 at 3:34 P.M., the DON indicated a family member and a Clinical Instructor at the facility indicated CNA #2 had indicated to Resident #37 that if you want to breathe, stop spitting, on 3/8/2017. She indicated she was not aware of this allegation until 3/20/2017. The DON indicated when she found out about the incident she took care of it. During an interview, on 8/16/2017 at 4:57 P.M., Unit Manager #3 indicated she was told on 3/8/17 by the Clinical Instructor that one of the facility CNA's had put her hand over Resident #37's mouth because she was spitting and she put the oxygen tubing on too tight. She indicated she was told CNA #2 indicated to Resident #37 to stop spiting and I can put your oxygen tubing back on. Unit Manager #3 indicated the DON had been made aware of this event right after it happened. During an interview, on 8/16/2017 at 5:03 P.M., the DON indicated she had no documentation related to the allegation taking place on 3/8/2017. During an interview, on 8/16/2017 at 5:11 P.M., Social Services indicated she was unaware of this event taking place. During an interview, on 8/17/2017 at 11:30 A.M., the Clinical Instructor indicated the following: CNA #2 entered Resident #37's room, pulled off the resident's blankets and in one quick movement, sat her up on the side of the bed while she was still asleep. Resident #37 was startled, and became combative. She was swinging her arms, pinching and spitting. Resident #37 was at the side of the bed with just her coccyx on the mattress, I thought she was going to fall. I stood on her left side and instructed my CNA students to stand in front of her and on the other side to keep her from falling. CNA #2 removed the residents nasal cannula and threw it on the bed as the resident was getting more distraught. When I asked CNA #2 to leave the room, she indicated no, she acts out like this all the time .you guys don't know her like I do. She is always nasty like this. CNA #2 indicated to Resident #37 You can't breathe? Stop spitting and I will give you back your oxygen. CNA #2 then hooked Resident #37 onto the stand up lift to assist her to the bathroom. CNA #2 did not fully sit the resident down onto the toilet to toilet her, she was just hovering over the toilet. After peri care was completed, CNA #2 used the stand up lift to put Resident #37 in her wheelchair. CNA #2 attempted to put the resident's nasal cannula back on, but she became combative and started spitting again. CNA #2 then put her hand over and onto the resident's mouth, smacking her mouth. CNA #2 indicated to the resident If you want to be able to breathe, you need to stop spitting at people. CNA #2 trying to avoid being spit on, approached Resident #37 from behind to put on her glasses. Resident #37 was startled, put her hands up to protect her face and in doing so, knocked the glasses out of the CNA's hand, and they landed on the floor. CNA #2 indicated You are acting ridiculous, Now I am going to get in trouble for breaking your glasses. CNA #2 picked up the glasses, pushed Resident #37 down the hallway to the dining room and indicated to her You are acting ridiculous. On 8/17/17 at 2:30 P.M., Administration provided the policy titled ABUSE, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Mocking, insulting, ridiculing . Saying anything to a resident which might cause him/her to worry or become alarmed . Threatening residents, including but not limited to, depriving a resident of care . Verbal Abuse . Verbally threatening a resident with harm . Raising your voice to a resident in a scolding or abrupt manner . Physical Abuse . Actually laying hands on a resident in an abrupt manner (i.e. hitting, slapping, punching or kicking.) . Transporting or transferring a resident in an abrupt or careless manner . Suspicions of, or reports or (sic) any abuse or questionable behavior, will be thoroughly investigated and acted upon at the discretion of administrative personnel up to and including termination if warranted . Abuse by an Employee - Procedure . 2. Should an occurrence of abusive behavior be reported or witnessed, the Administrator, DON and/or Nursing Manager shall be notified immediately. Acceptable forms of notification are: phone and/or phone message, text message and in person. 3. Appropriate documentation should be completed relative to the individual incident (i.e. report of concern, statement, incident/accident report, etc.). 4. Should the incident be deemed an unusual occurrence, the state survey and certification/licensure agencies shall be notified as well as the ombudsman and/or Adult Protective Services as applicable. 5. The alleged violation shall be thoroughly investigated by the Administrator or his/her designee. The investigation will include, but not be limited to, interviews with any and all staff who witnessed an alleged abusive situation, interviews with other staff working with the alleged abuser and interviews of interviewable residents. The facility must prevent further potential abuse while the investigation is in process. For example, an individual who has been alleged as exhibiting abusive behavior will not be permitted to continue to care for residents until and investigation has been completed and the allegation found to be unsubstantiated. An employee accused of any kind of abuse will be suspended from work without pay during an investigation of any alleged abuse cases . 6. The results of all investigations shall be reported to the state survey and certification/licensure agencies as well as other related agencies within five (5) working days of the incident and /or reporting of the incident. 7. Verified occurrences of abuse will be reported to the applicable agency (i.e. state nurse aide registry, Health Professions Bureau, etc). 8. In-service training shall be conducted as deemed necessary by management to increase awareness of the prohibition of, as well as the ramifications of, resident abuse The Immediate Jeopardy that began on 3/8/17 was removed 8/22/17, when, through interviews and record reviews, staff had completed education regarding abuse and abuse prohibition. This education included identification of abuse, how to report abuse, when to report abuse and to whom to report abuse. The facility administration contracted an outside authority to perform education on abuse to staff. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of the need for ongoing monitoring to ensure residents are free from abuse. 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview and record review, the facility failed to prevent a decline in range of motion, which resulted in a resident having pain to the contracted appendage for 1 of 1 residents reviewed for contractures. (Resident #37) Findings include: A clinical record review was conducted on 8/15/2017 at 10:30 A.M., and indicated Resident #37 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A MDS (minimum data set) assessment, dated 4/17/2017, indicated Resident #37 had no impairment to her upper extremities. A MDS assessment, dated 7/3/2017, indicated Resident #37 had impairment to both upper extremities. Resident #37's care plans indicated no contracture interventions were in place. A nursing restorative note, dated 4/17/2017, indicated Resident #37 had 75-100% of available range of motion to her bilateral fingers. An occupational therapy report, dated 8/21/2017, indicated Resident #37 had 67.9% available range of motion to the fingers of her right hand. During an interview, on 8/15/2017 at 2:57 P.M., the DON (Director of Nursing) indicated Resident #37 had contractured fingers and does not wear splints or have ROM (range of motion) services ordered. On 8/17/2017 at 10:31 A.M., Resident #37 was observed with no splint devices in place. On 8/19/2017 at 10:38 A.M. Resident #37 indicated she was having pain to her right hand. On 8/19/2017 at 10:45 A.M., Resident #37 was observed holding her hands in the air and no splint devices in place. Her hands were observed to have her fingers tightly closed into the palm of her hand with redness and swelling noted to the area of her knuckles. The DON attempted to assist her to extend her fingers. Resident #37 was able to be assisted to extend the fingers to her left hand, a small amount of range of motion was observed. The DON attempted to extend the fingers to her right hand and Resident #37 began grimacing. She asked Resident #37 if she was experiencing pain, Resident indicated she was. The DON indicated she should have a carrot (a splinting device) in place. A policy was provided by the DON, on 8/22/2017 at 6:00 P.M., titled RANGE OF MOTION, dated 8/17/2014, and indicated this was the policy currently used by the facility. The policy indicated .Purpose: To help prevent or minimize muscle contractures and joint deformity. Policy: Range of motion exercises are used to: Maintain joint mobility Prevent deformities that limit function Stimulate circulation 3.1-42(a)(2)

Based on observation, interview and record review, the facility failed to properly assess and treat pressure ulcers for 3 of 3 residents reviewed, resulting in an unstageable pressure ulcer developing from an ACE wrap on the ankle of Resident #41, a Stage 2 pressure ulcer worsening to an unstageable pressure ulcer for Resident #64, and inaccurate assessment completed for a Stage 2 pressure ulcer for Resident #37. Findings include: 1. A clinical record review was completed on 8/17/17 at 10:35 A.M., and indicated Resident #41 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 6/7/17, indicated Resident #41 had a BIMS (Brief Interview for Mental Status) of 15, cognitively intact, required two assistance from staff for bed mobility and was totally dependent on staff for transfers and bathing. A current, 6/9/17, care plan problem indicated the resident had self care deficits related to mobility deficit, disease progression manifested by decreased ADL (Activities of Daily Living) participation. Interventions for this problem included, put ACE wraps on in the morning after skin prep (a skin protectant) dry to blister and remove at bedtime. A current, 8/3/17, care plan problem indicated the resident had impairment of skin integrity related to altered skin turgor, disease process, decreased safety awareness and incontinent of bowel as evidenced by blisters. Interventions for this problem included, weekly wound assessment if wound present, keep physician informed, notify family/POA, refer to dietician, administer [MEDICATION NAME] as ordered, observe for non-verbal indicators of pain, treatments as ordered, creams/ointments as ordered, labs as ordered per physician, call light in reach, encourage food intakes, encourage fluid intakes, staff offer snacks each shift, medication administered per physician's orders [REDACTED]. A current physician's orders [REDACTED]. A current physician's orders [REDACTED].GENTLY CLEAN FOOT WITH WATER PAT DRY. APPLY SKIN PREP TO BLISTERS DAILY X7 DAYS - OPEN TO AIR. WOUND L(NAME)ATION: LEFT ANTERIOR FOOT WOUND TYPE: BLISTERS daily in the morning. A skin assessment, dated 8/1/17, indicated, .Left Heel Light pink. Not wrapped with ACE due to being left on last night and new blister to the area . blister fluid filled x2 on left foot A skin assessment, dated 8/16/17, indicated, .blisters to top of left foot. Area is flat non fluid filled light brown in color and blanchable all peri wound blanches. Tx (treatment) completed per order During an observation on 8/17/17 at 2:02 P.M., Nurse #8 unwrapped an ACE wrap from the resident's left lower extremity. There were two areas to the top of the resident's ankle, where the ankle bends, approximately 1.5 centimeters in length and 1 cm in width. During an interview on, 8/18/17 at 10:05 A.M., the DON (Director of Nursing) indicated the areas were caused by the ACE wrap and would be considered a pressure area. During an observation on, 8/18/17 at 10:18 A.M., the DON unwrapped the ACE wrap from the resident's lower left extremity and indicated the ACE wrap was in place from the previous day. The date on the tape keeping the ACE wrap in place had the date 8/17/17 on it. During an interview, on 8/18/17 at 10:30 A.M., the DON indicated it was a blistered area that was caused by ACE wraps and then scabbed over and because the wound bed could not be visualized, it would now be considered an unstageable pressure ulcer. 2. A clinical record review was completed on 8/17/17 at 9:56 A.M., and indicated Resident #64 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 5/24/17, indicated Resident #64 had a BIMS (Brief Interview for Mental Status) of 15, cognitively intact, required extensive assistance from one staff person for bed mobility and transfers, had frequent urinary incontinence and was at risk for developing pressure ulcers. A current, 5/26/17, care plan problem indicated the resident had the potential for impairment of skin integrity related to incontinence of bladder and altered skin turgor as evidenced by scratches to left buttocks. Interventions for this problem included, resident refuses low air loss mattress, tried facility air mattress and a mattress family brought in, weekly wound assessment if wound present, keep MD informed, notify physician and obtain treatment order, refer to dietitician, creams/ointments as ordered, treatments as ordered, complete Braden Scale assessment quarterly and with significant change, expose to air frequently, call light in reach, resident to receive bath/shower twice weekly, provide ordered diet, 1:1 visits, assess interests. A current physician's orders [REDACTED].Apply XEROFORM (a pressure ulcer dressing) GAUZE et. (and) dry dressing DAILY A weekly skin assessment, dated 8/16/17, indicated, .pressure area stage 2 to left inner buttock. Area is dark brown in color area measures 0.3cm length x1.2cm width. Peri wound blanches, no odor noted. Resident denies pain to area at this time During an observation, on 8/20/17 at 10:43 A.M., Resident #64 removed her pants and brief, a dark brown area approximately 1.5 cm length by 0.5 cm width was present to her left inner buttocks. There was no dressing in place. During an interview on 8/20/17 at 10:46 A.M., the DON indicated because the wound bed was covered, it would be considered unstageable. She verified that there was no dressing in place during the observation. 3. A clinical record review was conducted, on 8/15/2017 at 10:30 A.M., and indicated Resident #37 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A care plan titled High risk for alteration in skin integrity, dated 7/14/2017, indicated no interventions for repositioning Resident #37. A care plan, dated 7/14/2017, titled High risk for alteration in skin integrity, indicated an update dated 8/16/2017, indicating excoriation moisture related. A skin assessment, dated 8/15/2017, indicated Resident #37 had .excoriation blanchable left inner buttocks elongated to coccyx A skin assessment, dated 8/19/2017, indicated Resident #37 had .crevice of buttocks, close to coccyx Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg. 2). [MEDICATION NAME] tissue - new skin growing in superficial ulcer. It can be light pink and shiny A COMPLETE WEEKLY WOUND ASSESSMENT, dated 8/16/2017, indicated .excoriation Cleanse Soap and Water Remedy Skin Repair Cr (PURPLE) On 8/17/2017 at 10:23 A.M., Resident #37 was observed sleeping in her wheelchair in the common area. On 8/17/2017 at 10:29 A.M., Resident #37 was observed sitting in her wheelchair in her room. On 8/19/2017 at 10:00 A.M., Resident #37 was observed sitting in her wheelchair in the common room. Resident #37 was not observed to be out of her wheelchair, at any time during the observation dates of 8/14/17 through 8/22/17. During an interview, on 8/19/2017 at 11:10 A.M., the DON indicated Resident #37 had a stage 2 pressure ulcer to her coccyx area and it was not previously documented as a pressure ulcer area. A policy was provided by the DON on 8/21/2017 at 9:00 A.M., titled PRESSURE ULCER, undated, and indicated this was the policy currently used by the facility. The policy indicated .Purpose: to assure that residents having pressure sores will from developing and prevent infection and .Procedures: 6. Interventions to prevent further pressure ulcer formation should be instituted A policy was provided by the DON on 8/21/2017 at 9:00 A.M., titled PRESSURE ULCER - PREVENTION, undated, and indicated this was the policy currently used by the facility. The policy indicated .Procedure: 7. Turn resident approximately every two hours as possible and position resident with pillows or pads protecting bony prominences 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record reviews and interviews, the facility failed to complete a root cause analysis for 1 of 5 residents (Resident #85) and to ensure adequate interventions were developed and implemented to prevent falls for 2 of 5 residents reviewed for falls. (Resident #85 and Resident #31) This resulted in multiple falls with fractures for Resident #85. Findings include: 1. On 7/21/16 at 10:35 A.M., Resident #85 was observed in the activity room. She was seated in a wheelchair (wheels were unlocked) and was listening to music. Several times, the resident sang along with the music and indicated she liked the music. The resident was observed to have a hard cast/splint on her left forearm. The cast/splint was covered with an ace bandage. On 7/21/16 at 2:14 P.M., Resident #85 was observed alone, in her room, in her bed with her eyes opened. The bed was in the low position and the call light was within reach. A staff member entered the room and took a meal tray from the room. On 7/21/16 at 3:30 P.M., resident was observed in her room, lying in bed, a staff member was seated beside the bed. The staff member was talking with her and engaged the resident in a conversation. CNA (Certified Nursing Assistant) #21 came into the room to check on the resident. CNA #21 indicated the resident was on 15 minute checks and she was just checking on her. CNA#21 did not ask the resident if she needed to use the restroom or if she needed anything During an interview, on 7/21/16 at 3:35 P.M., CNA #21 indicated she thought the 15 minute checks were due to her recent fall. CNA #21 indicated the 15 minute checks were not on her CNA assignment sheet. On 7/22/16 at 8:56 A.M., the resident was sitting near the nurse cart. She had her shoes on and her feet were resting on the foot pedals. There was no nurse at the cart. On 7/22/16 at 10:11 A.M., a review of the clinical record for Resident #85 was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) Assessment, dated 3/18/16, indicated the resident's BIMS (Brief Interview Mental Status) score was 5 (severe dementia). The assessment indicated the resident needed the extensive assist of one person to dress and use the toilet. The resident required the limited assist of one person with transfers and walking. A Psychiatric Consult, dated 5/2/16, indicated the resident recently moved from the independent living, was exit seeking at times and paranoid about her medications. The Fall Risk Assessments for Resident #85 indicated the following: on admission (3/10/16) the resident scored a 21, on 5/6/16 the risk score was a 20, on 5/12/16 the resident scored a 12, on 7/7/16 she scored a 15 and on 7/14/16 she scored a 14. The assessment indicated a score of 15 or higher, meant the resident was at high risk for falls. A care plan, dated 3/11/16, titled High Risk of Falls due to poor safety awareness from Alzheimer and antidepressant use. The care plan indicated the following intervention to prevent a fall .Nurses-- if falls occur, Nurse notify family and physician, chart details of fall and update care plan. Fall assessment to be completed quarterly and after each fall .monitor for unsafe situations that may cause a fall A Fall Report, dated 5/6/16 at 2:15 A.M., indicated the resident fell in the hallway, near the nurses cart. The report indicated the resident was observed trying to get a tissue off the nurses cart. The resident fell on to the trash container, located on the cart, and hit her head. The resident complained of pain in her nose and started to have a nose bleed and headache. First aid treatment was given to treat nose bleed, the physician was called and the resident was sent to local emergency room (ER). The report indicated the resident's explanation for the fall: wanted a Kleenex. The fall report did not include old or new preventive interventions to prevent another fall. Another fall report, dated 5/12/16 at 10:50 P.M., indicated the resident fell in the hallway, had non skid slippers on and was lying on her left side. The resident said she was going to her room and she felt sleepy. The fall report indicated the resident had no injury related to the fall. The care plan was reviewed and ongoing and no new interventions were documented. The care plan for Risk of Falls, dated 3/11/16, had no updated interventions and remained the same after the falls on 5/6/26 and 5/12/16. Another fall report indicated the resident fell on [DATE] at 8:55 AM. The report indicated the resident was found sitting on the floor in her room. The resident was unable to recall what happened but reported her left hip area hurt. The resident's physician was notified with new orders to send to ER for evaluation. The clinical record indicated the resident returned to the facility, on 7/10/16 at 1:20 P.M., after receiving a left hip arthroplasty (surgical procedure to treat a hip fracture). A Falls care plan, related to a fall in past 30 days, dated 7/13/16, indicated falls were manifested by: fall (or near fall) in past 180 days, anti-hypertensive use, antipsychotic use, and hip fracture. The care plan inventions included but were not limited to .Nurses---If falls occur, Nurse notify family and physician, chart details of fall, and update care plan. Fall assessments to be completed quarterly and after each fall .Monitor food intake. Monitor fluid intake .CNA--Call light within reach, Show Resident the call light and tell how to use each time in room; Remind Resident to use for assistance, Remind to ask for assistance each time with Resident, Toilet q (every) hr (hour), assist as needed, upon rising, before and after meals and before bedtime. Do not leave unattended when toileting Another Fall Report, dated 7/14/16, indicated the resident fell at 8:15 P.M. The report indicated the resident was found in her room, lying on her back on the floor. The resident's wheel chair was located approximately 1-3 feet from the resident with the brakes off. The report indicated it appeared the resident had gotten clothes out of her drawers and was folding them on the bed and the resident had no explanation for the fall. The resident did not complain of pain, therefore the report indicated no apparent injury. The report indicated the resident was instructed on the use of her call light. The resident's physician was notified of the fall via a fax. No new interventions added to the 7/13/16 care plan. A Nursing Notes, dated 7/15/16, indicated the physician fax was received on 7/15/16 at 12:13 P.M., with no new orders. At 3:48 P.M. the physician was in the building and examined the resident due to swelling of her left wrist. The physician ordered an x-ray of the left wrist and hand. Another Nursing Note dated, 7/16/16 at 9:44 A.M., indicated a call was made to the on call physician regarding the x-ray findings and the physician directed staff to send the resident to the ER for an evaluation of fracture and application of cast/splint. A Radiology Report, dated 7/15/16, indicated the resident had an acute impacted, intra-articular distal radius fracture and mildly displaced ulnar styloid process fracture. A form titled Emergency Department Chart, dated 7/16/16, indicated the resident had a Colles fracture (a type of broken wrist ) of the left wrist . The resident presented to ER for care of the fracture and the resident could not give any history because of her chronic mental status. The fracture was stabilized in the department with a Sugar tong orthoglass splint and ace wraps (used to stabilize the forearm and wrist). An undated CNA (Certified Nursing Assistant) Assignment Sheet was received from the Assistant Director of Nursing (ADON), on 7/22/16 at 10:07 A.M. The CNA sheet indicated the resident used a wheel chair, a walker and need 1 person assist for transfers. The Needs section of the assignment sheet indicated extensive assist with toileting, bed mobility and no ambulation at this time. On 7/23/16 at 12:40 P.M., the ADON provided a policy titled Fall Management, undated, and indicated the policy was the one currently used by the facility. The policy indicated Purpose: To assess all residents for risk factors that may contribute to falling. To provide planned interventions identified by the team, as appropriate, for resident use in maintaining or returning to the highest level of physical, social and psychosocial functioning as possible .MONITORING OF RESIDENTS WITH RECURRENT FALLS .a resident with recurrent falls will be monitored and reviewed to determine if further intervention is applicable. On 7/23/16 at 2:00 P.M., the Assistant Director of Nursing (ADON) provided a policy titled Fall Procedure, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Assess and evaluate resident after any fall and communicate with physician and family. Complete follow up per physician and policy During an interview, on 723/16 at 2:30 P.M., the ADON indicated the reason the resident fell was due to her dementia. The ADON indicated the nurse assessment of the falls did not evaluate for the root cause of her falls or provide new interventions to prevent a fall. The ADON indicated she had not noted any patterns to the resident's falls. 2. The clinical record for Resident #31 was reviewed on 07/20/2016 at 3:30 P.M. Resident #31 was admitted to the facility, on 01/06/16 and readmitted on [DATE], with diagnoses, including but not limited to: chronic pai[DIAGNOSES REDACTED], traumatic hemorrhage of the cerebrum, insomnia, functional urinary incontinence, multiple fractures of the ribs, edema, osteoporosis, and weakness. The most recent Minimum Data Set (MDS) assessment, completed on 04/21/16, indicated Resident #31 required extensive staff assistance for transfers and wheelchair locomotion. The care plan related to falls, initiated on 04/26/16, indicated the resident was at high risk for falls. The interventions included administer medications per physician's orders [REDACTED].(Activities of Daily Living), extensive assist for transfers and mobility. Another fall care plan, initiated on 05/02/16, indicated the resident had a history of [REDACTED]. During an interview, on 07/19/2016 at 9:49 A.M., the Assistant Director of Nursing (ADON) indicated Resident #31 had fallen one time in the past month. She indicated the resident had fallen, on 07/18/16 at 3:00 A.M., in her room and suffered abrasions to her right forehead area. Review of the nursing notes and fall incident reports from May through July 2016, indicated the resident had incurred multiple falls. On 05/01/16 at 5:21 A.M., the resident had slid out of bed and she did not incur any injuries. On 05/01/15 at 11:45 P.M., the resident had been found on the floor by her bed. The resident had stated she had to go to the bathroom. She suffered an abrasion to her right knee. On 05/02/16 a fall care plan was rewritten and interventions to add a personal and bed alarm, and complete safety checks and remind the resident to ask for assistance was added. On 05/24/16 at 8:43 A.M., Resident #31 was found lying beside her bed. She indicated she had slid out trying to get to the edge of her bed. She suffered an abrasion to her right eye and a small lesion above her right eye The fall care plans were reviewed but there were no additional interventions implemented. On 06/11/16 at 6:48 P.M., the resident was found on the floor in her bathroom. The resident stated she was on the toilet and fell from the toilet. During an interview, on 07/22/16 at 2:00 P.M., the ADON indicated there were no interventions newly implemented due to the fall on 5/21/16. The ADON indicated Resident #31 was left in the bathroom alone and then fell on [DATE]. The ADON indicated the resident incurred a hematoma to her head and was sent to the emergency room to be evaluated for her head injury. There were no interventions added to the resident's care plan. The ADON indicated a butterfly program was initiated for Resident #31 and other resident's at fall risk to alert staff not to leave these residents in the bathroom alone. 07/1816 at 3:15 A.M., Resident #31 slipped out of her bed, hit her forehead on the floor, and was noted to be incontinent. She suffered an abrasion to her right forehead. There were no interventions implemented to address the resident's most recent fall. During an interview, on 07/22/16 at 2:00 P.M., the ADON indicated there were no interventions newly implemented due to the fall on 5/21/16. The ADON indicated Resident #31 was left in the bathroom alone and then fell on [DATE]. The ADON indicated the resident incurred a hematoma to her head and was sent to the emergency room to be evaluated for her head injury. There were no interventions added to the resident's care plan. The ADON indicated a butterfly program was initiated for Resident #31 and other resident's at fall risk to alert staff not to leave these residents in the bathroom alone. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to implement and monitor a health care plan for utilization of a hand splint for 1 of 3 residents (Resident #99) reviewed for pressure ulcers, resulting in a stage 3 pressure ulcer. Findings include: Resident #99's clinical record was reviewed on 7/21/14 at 12:54 P.M. Resident #99 was admitted to the facility from a hospital on [DATE] with diagnoses, including, but not limited to, [MEDICAL CONDITIONS], left-sided [MEDICAL CONDITION], and contracture to left hand. The record indicated the resident was admitted to the facility on [DATE] and developed a stage 3 pressure ulcer (full thickness tissue loss) to his left thumb on 6/15/14. The record indicated the pressure ulcer for Resident #99 was healed on 7/16/14. On 6/3/14 a Braden Scale skin risk assessment was performed and a score of 14 was obtained which indicated Resident #99 was at moderate risk for pressure ulcers. Review of an admission health care plan, dated 6/3/14, indicated: Potential for impairment of skin integrity related to [MEDICAL CONDITIONS] and diarrhea, as evidenced by excoriated groin, scrotum and bottom. The goal was for the resident to not develop any pressure ulcer, open area or excoriations. The interventions for CNAs was to encourage fluids, inspect skin every shift, and report skin issues to the nurses. The interventions for the nurses were for weekly skin assessments if skin issues present and to notify the physician and obtain treatment orders. Review of Resident #99's nurse's notes included a daily muscular/skeletal assessments from 6/3/14 throughout development of the stage 3 pressure ulcer to the left thumb on 6/15/14. The daily assessment generally noted contracture left hand, partial loss of movement noted. The daily assessments included comments on whether the resident had pain or no pain. The daily assessments did not include any mention of the condition of the skin for the left hand contracture. Review of Resident #99's nursing notes indicated daily skin assessments were completed from admission on 6/3/14 to the development of the pressure ulcer to the left thumb on 6/15/14. On 6/3/14, a new admission skin assessment was completed which noted "skin problems: excoriation groin, scrotum, buttocks; mole(s) located over body incision(s) right groin well approximated, staples intact. Has surgical wound(s) present in past 7 days. Bruises 5.0 x 3.0 cm (centimeters) bruise to left hand; 2.5 x 2.5 cm bruise to right antecubital space; 1.0 x 1.0 cm bruise to right forearm; 1.0 x 0.2 cm scab to right forearm; small pink spot to right side of face by ear where resident has picked measuring 0.5 x 0.3 cm." The daily skin assessments starting 6/4/14 noted no new skin issues noted . The daily skin assessments did include comments on the surgical wound, bruises, excoriation and a skin tear that occurred to the left elbow on 6/5/14. The daily skin assessments did not include specific assessments of Resident #99's left hand contracture. The final daily assessment done by nursing before noting the development of the pressure ulcer on 6/15/14 was documented on 6/14/14 at 5:09 P.M. Review of nurse's notes, from 6/15/14 at 9:04 P.M., indicated a stage 3 pressure ulcer to Resident #99's left thumb measuring 2.0 cm x 2.2 cm with a depth of 0.3 cm. The wound was noted as having a very foul odor with moderate greenish-yellow drainage/exudate. Pain was noted at the wound site. The wound was noted to be dark, tan. The physician was notified on 6/15/14 at 4:00 P.M. and orders were received to start treatment of [REDACTED]. physician's orders [REDACTED].M. to start [MEDICATION NAME] (a pain medication) every 6 hours as needed for pain. Resident #99 was seen by Occupational Therapy (OT) and Physical Therapy (PT) on 6/5/14. The OT evaluation and plan of treatment from 6/5/14 short term goals included, but was not limited to, the resident was to be fitted for appropriate left hand splint to manage contracture and decrease risk of skin breakdown. The assessment summary impressions noted Resident #99 presented with contracted left upper extremity (LUE). He tolerated very little passive range of motion (PROM) due to a high level of pain. The resident had a carrot splint which was mostly hanging out of his hand, really doing nothing to manage the contracture. OT was noted to have attempted to fully remove the splint but the resident could not tolerate it due to pain. The plan indicated therapy was to fit the resident for an appropriate splint. On 6/11/14 a weekly skilled therapy review note indicated staff were to try to keep the carrot splint in Resident #99's left hand. A PT therapy progress report for dates of service 6/5/14-6/13/14 indicated under assessment summary: Patient and caregiver training: Instructed patient and primary caregivers in safe transfer techniques, self care/skin checks and positioning/pressure relieving techniques in order to increase safety and decrease need for assistance and increase safety and reduce the risk of further medical complications [REDACTED]. On 6/13/14 a health care plan was initiated for: Potential [MEDICAL CONDITION] to [DIAGNOSES REDACTED]. The goal was for no injury to affected side or body part, no skin breakdown. Interventions for Certified Nursing Assistant"s (CNA's) included but were not limited to: good hygiene to left hand then place carrot in left hand; report changes to nurses. Interventions for nurses were: Support affected extremity with sling or arm/leg rest in wheelchair; keep items in reach; administer medications per physician's orders [REDACTED]. [REDACTED]. An interview with LPN #6, the MDS (Minimum Data Set assessment)/Care Plan nurse, on 7/23/14 at 2:00 P.M., indicated before the pressure ulcer development on 6/15/14, there was no documentation of the CNA's attempting to use the carrot splint before 6/15/14. An interview with LPN #1, on 7/23/14 at 2:10 P.M., indicated before the pressure ulcer development to the left thumb was noted on 6/15/14, the nurses were doing skin assessments but not assessing the left hand contracture in particular. An interview with CNA #2, on 7/23/14 at 2:20 P.M., indicated Resident #99 had the carrot splint for his left hand when he was first admitted . CNA #2 indicated the CNA's would clean and dry his left hand and then place the carrot back in the hand. CNA #2 indicated before 6/15/14 the resident would take the carrot splint out of his hand at least daily when she worked with him. CNA #2 indicated the CNA's had no place to document the use of the carrot splint. CNA #2 indicated the carrot splint was not on the CNA assignment sheet before the development of the pressure ulcer on 6/15/14. An interview with PTA (Physical Therapy Assistant) #4 / Rehabilitation Director, on 7/23/14 at 2:20 P.M., indicated Resident #99 had left arm and hand contracture's when he was admitted and indicated he had a carrot splint when he was admitted . PTA #4 indicated the resident did not like to wear the carrot splint and would take it out a lot. He noted therapy was trying to get the left hand loose enough for a spring loaded brace. PTA #4 indicated they educated staff for the use of the carrot splint and noted nurse's were educated with the expectation they would educate all of the CNAs and nurses, including weekend staff. An interview with Director of Nursing Services (DNS), on 7/24/14 at 1:30 P.M., indicated the facility had no specific interventions to prevent the pressure ulcer to the left thumb before the development of the pressure ulcer on 6/15/14. On 7/25/14 at 11:00 A.M., an interview with PTA #5 indicated Resident #99 had a carrot splint upon admission which was given to the therapy department, which the resident had been using at a different long term care facility. PTA #5 indicated therapy saw the resident daily from 6/5/14 through 6/15/14 and indicated an Occupational Therapy Aide (COTA) and a PTA would work together typically to do PROM to the left arm and hand and then try to insert the carrot splint to prevent skin breakdown. PTA #4 indicated Resident #99 was very resistive to the carrot splint. An interview with the DNS, the Assistant Director of Nursing Services (ADNS), and RN #3 on 7/25/14 at 11:00 A.M. indicated they did not know anything about the carrot splint for Resident #99 before the development of the pressure ulcer on 6/15/14. The ADNS noted the carrot splint was on [MEDICAL CONDITION] plan of 6/13/14 but it was not put on the CNA assignment sheet. The ADNS indicated CNA's can look at care plans on the computer but are not expected to look at them, it is not a policy. The ADNS indicated CNA's cannot be held responsible for following a care plan if the task is not on their assignment sheets. The ADNS indicated on 6/13/14 when [MEDICAL CONDITION] plan was written the carrot splint should have been added to the CNA assignment sheets. The ADNS indicated when [MEDICAL CONDITION] plan of 6/13/14 was written, the nurses should have been tracking and documenting the use of the carrot splint but they were not. The ADNS indicated nurses were doing daily documentation of the contracture under the muscular skeletal along with daily skin assessments. An observation was made on 7/23/14, 2:30 P.M. of Resident #99's dressing change to his left thumb by LPN #1 and RN #3. The pressure ulcer to the resident's left thumb was resolved, the skin was intact. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observations, record review, and interviews, the facility failed to ensure safe water temperature were maintained for 4 of 5 nursing units in the facility. This potentially affected 68 of 79 residents in the facility, including 21 of 79 residents who were cognitively impaired and able to ambulate and/or propel their own wheelchairs and could possibly burn themselves with the hot water. The immediate jeopardy began on 07/30/12 when the facility obtained unsafe, elevated hot water temperature readings and failed to take immediate action to remedy the situation to ensure safe water temperatures. There is a potential for a 3rd degree burn to occur in 2 (two) seconds when the water temperature reaches 148 degrees. The Administrator and the Director of Nursing were notified of the immediate jeopardy at 4:30 P.M., on 08/01/12. The immediate jeopardy that began on 07/30/12 was removed on 08/02/12 at 4:00 P.M. by immediately draining the hot water from the hot water heater tank, turning down the hot water heater, and replumbed the mixing valve and hot water heater access. The facility remained out of compliance at a scope and severity of pattern with no actual harm with the potential for more than minimal harm that was not immediate jeopardy as the facility needed to continue to monitor the hot water temperatures to ensure the newly plumbed system distributed water at safe temperatures. . Finding includes: During an observation of the bathroom for Room 424, conducted on 08/01/12 2:55 P.M., the hot water temperature in the bathroom sink was noted to be 150 degrees Fahrenheit. There was visible steam coming from the water and a "caution - water hot" sign was noted to be taped to mirror above the sink. The hot water in the bathrooms for resident rooms #417 - 432 were assessed, on 08/01/12 from 2:55 P.M. - 3:25 P.M. and all were noted to be 150 degrees Fahrenheit. Interview with CNA (certified nursing assistant) #10, on 08/01/12 at 3:00 P.M., indicated the hot water temperatures had been "too hot" for at least the last two weeks on Hall #5. Hall #5 included Room #417 - 432 and housed 15 residents. The hot water temperature in the shower room, located on hall #2 was assessed on 08/01/12 at 3:40 P.M. and noted to be 150 degrees Fahrenheit. The hall #2 shower room was utilized to shower residents on hall 1, 2, and 3 which totaled 54 residents. An interview with housekeeper, employee #11, on 8/1/12 at 3:40 P.M., indicated the hot water "really got very hot." The housekeeper indicated it had been like that ever since he had started working at the facility a few months ago. He indicated he thought it was supposed to be that hot. An interview with CNA #1 on 8/1/12 at 4:00 P.M. indicated there was no hot water last week but now the water is too hot. An interview with CNA #2 on 8/1/12 at 4:00 P.M. indicated there was no hot water last week but now the water is too hot. The resident rooms on hall #2 were assessed and noted to be between 146 degrees - 150 degrees. Hall #2 included rooms #399 - 415 and housed 18 residents. The bathrooms on hall #3 were assessed and noted to be 150 degrees Fahrenheit. Hall #3 included Rooms #433 - 233 and housed 17 residents. Hall #1 included Resident room #196 - 217 and housed 19 residents. The hot water temperatures were noted to be 150 degrees. Interview with the Maintenance supervisor, employee #12, on 08/01/12 at 3:40 P.M. indicated there was only one water heater for the health care and all of the water temperatures should read the same. The main water heater and mixing valve were observed on 08/01/12 at 3:45 P.M. with the Administrator, the Maintenance Director, employee #12, and a maintenance assistant, employee #13. The thermometer on the hot water heater was reading 136 degrees. Employee #13 indicated he had already turned the water heater down, "a few minutes ago", but could turn it down again. The Administrator indicated the mixing valve did not have a temperature setting just a hot/cold side with arrows. He indicated the thermometer just registered the temperature of the water coming out of the hot water heater. The Maintenance supervisor, employee #12 then instructed his staff to drain the hot water heater tank in the utility room and the Administrator directed other maintenance staff to run the hot water in the pipes going to resident room sinks out and recheck the temperatures. The hot/cold valve was turned again to the cold side to reduce the temperature of the hot water. A recheck of the water temperatures throughout the building, at 4:15 P.M. indicated they were all reading between 104 degrees - 110 degrees. Interview with the Maintenance supervisor, on 08/01/12 at 3:20 P.M. indicated the facility had been experiencing trouble with too cool of water temperatures and had replaced the mixing valve a few weeks ago. He indicated since the mixing valve had been replaced the facility had been experiencing "erratic" water temperatures. He indicated a plumber was scheduled to come to the facility on [DATE] around 9:00 P.M. to work on the water temperature problems. Review of the July 2012 hot water temperature logs indicated on 07/24/12, with water temperatures ranging from 97 degrees - 123 degrees Fahrenheit. Handwritten on the 07/24/12 date was "quarter turn at 3:30 P.M." There were no other temperatures recorded until 07/30/12. The hot water temperatures on 07/30/12 were noted to range from 111 degrees Fahrenheit - 152 degrees Fahrenheit. All of the health care water temperature documentation, except on the 100 unit, ranged from 144 degrees Fahrenheit - 152 degrees Fahrenheit. There were no other hot water temperatures documented from 07/30/12 - 08/01/12. The immediate jeopardy that began on 07/30/12 was removed on 08/02/12 at 4:00 P.M. by the facility immediately draining the hot water from the hot water heater tank, turning down the hot water heater, and replumbed the mixing valve and hot water heater access. The facility remained out of compliance at a scope and severity of pattern with no actual harm with the potential for more than minimal harm that was not immediate jeopardy as the facility needed to continue to monitor the hot water temperatures to ensure the newly plumbed system distributed water at safe temperatures. The water temperatures were noted to be safe and a system was put into place to adequately monitor water temperatures and staff were inserviced and knowledgeable regarding the correct procedure to notify administrative staff if water temperature exceeded 120 degrees. . 3.1.-45(a)(1)

Based on observation, record review, and interviews, the facility failed to implement measures to prevent pressure ulcers for 1 of 2 residents with pressure ulcers reviewed in a sample of 16. This resulted in resident # 31 developing "new area... a decub was found on right heel. It is eschar, very dark reddish brown color. Size 2.5 cm by 2.0 centimeters. (Resident #31) Finding includes: During the initial tour of the facility, conducted on 06/13/11 between 10:30 A.M. - 11:30 A.M., LPN #9 indicated Resident #31 required total staff assistance for transferring and mobility issues, was pushed in her wheelchair by staff, had a urinary catheter due to "retractable pain", received oxygen therapy, and had been readmitted to the facility with pressure ulcers on her right foot and heel. The clinical record for Resident #31 was reviewed on 06/13/11 at 2:35 P.M. The resident was initially admitted to the facility on [DATE]. She was transferred to an acute care center on 12/09/10 and readmitted to the facility on [DATE]. Interview with the Assistant Director of Nursing, LPN 8 on 06/16/11 at 1:45 P.M. indicated prior to her hospital stay, Resident #31 was able to be up and get around by herself but her mobility status had significantly decline after her hospital stay. Review of the initial MDS (Minimum Data Set) assessment for Resident #31, completed on 12/28/10 after she was readmitted to the facility, indicated the resident required extensive staff assistance for transferring needs, dressing, and hygiene needs, and moderate staff assistance for locomotion needs. The health care plans for Resident #31, current upon her readmission, included a plan for the potential for an alteration in skin integrity. The plan had been initiated on 08/30/10 with her original admission and reviewed as current upon her readmission. The plan had interventions to check [DIAGNOSES REDACTED]. There were no interventions added to prevent and/or reduce pressure while the resident was in bed or sitting in her chair. Review of a skin risk assessment, completed on 12/14/10, when the resident was readmitted from an acute care facility, indicated the resident had very limited mobility, a potential for friction and sheering, was chair fast, was occasionally moist, had adequate nutrition, and had no sensory impairments. Review of the CNA, (Certified Nursing Assistants), documentation, from 12/14/10 - 12/31/10 indicated the only preventative measure documented was applying ointment to the resident's excoriated buttocks and peri area. Nursing notes, dated 01/01/11 at 23:57 (11:57 P. M) indicated the following: "new area... a decub was found on right heel. It is eschar, very dark reddish brown color. Size 2.5 cm by 2.0 centimeters. Area was cleansed and Auaclear dressing was applied...." On 06/16/11 at 11:00 A.M., the pressure ulcers were observed for Resident #31. The resident had a dime sized shallow pressure ulcer on the top of her right foot. The center of the wound bed had yellow slough. There was an unstageable, quarter sized pressure ulcer on the resident's right heel. The wound bed was covered with thick black eschar with loose edges. There was a thick yellow green odorous exudate noted oozing from around the edges of the wound. Interview with Lpn #9 indicated the resident was supposed to see the wound clinic on 06/17/11 and she was sure they would remove the eschar as there was only a little bit holding the eschar on the wound bed in the middle. After the open area was discovered, the care plan was then updated on 02/16/11, to include interventions to elevate the resident's legs when she was in bed or the recliner, develop and implement a turning schedule, and the application of an air mattress on her bed. Although the area was first identified on 01/01/11 the care plan was not updated until 02/16/11. 3.1-40(a)(1)