Every finding on record at Green Valley Care Center

Based on observation, record review and interview, the facility failed to ensure kitchen equipment, floors, ceiling vents were clean and in good condition and expired food was disposed of during 3 of 3 kitchen observations. This deficient practice affected 122 of 122 residents who received meals from the kitchen.Findings include:1.During the initial tour of the kitchen with [NAME] 1, on 1/5/26 at 10:00 a.m., the following concerns were observed:There were yellow/brown food particles in the fryer oil with a heavy accumulation of brown food particles on the inside shelf. Cook,1 indicated the fryer was last used the night before.Both stove ovens had cream colored food particles on the inside bottom. The outside doors of the oven and handles were sticky to the touch and had a heavy accumulation of white streaks running down the front doors.Around 3 sides of the fryer there were white and brown sticky streaks.The left side of the convection oven had yellow grease particles on it and felt greasy to the touch.The top and bottom of the convection ovens had brown and white streaks running down the front. The area underneath the door openings and the inside of the doors had a heavy accumulation of black and brown grease which was able to be scrapped.The floor under the convection ovens had a heavy accumulation of black and dark brown substance. This was also present under the fryer, under the left side of the stove, and under the 3 compartment sinks.The shelf under the slicer had a moderate amount of yellow/brown food particles and grease.One ceiling air vent directly above the pot and pan and steam table rack had a heavy accumulation of black substance on it.The dish machine switch below the rinse cycle section had a heavy accumulation of pinkish brown food particles which were able to be removed when touched.The ceiling air vent above the dish machine had a heavy accumulation of black greasy particals on it.The top and front of the dish machine had a heavy number of white streaks running down.One of two large ceiling air vents above the tray counter and steam table had a heavy flaking of black paint in the center.Two of three ceiling air vents had a heavy amount of greasy substance on them. This was above the preparation counter and clean pot and pan shelving.One of two ceiling air vents above the counter where the toaster and coffee machine were and the heated plate holder in which dishes were present had a heavy accumulation of black greasy substance.2. During a kitchen observation, on 1/7/26 at 10:05 a.m., the following concerns were observed:The same issues identified on 1/5/26 at 10:00 a.m. remained a concern.The shelf inside the fryer had a heavy accumulation of brown food particles. The [NAME] indicated at this time, the oil would be normally changed on Fridays, but after each use, the shelf inside was supposed to be wiped off.The grease trap on the flat top was full to the top with yellow and brown food particles. Per the Cook, it was supposed to be emptied after each use. It was the scrapings from whatever was cooked on the flat top.A container of fruit cocktail in the right side of the reach-in refrigerator had a use by date of 12/29/25.In the left side of the reach-in refrigerator were two five (5) pound containers of cottage cheese with a best by date of 12/26/25 and 12/13/25. Dietary aide 2 indicated the small dishes of cottage cheese on the shelf were not dipped from the outdated containers of cottage cheese.The ceiling vent above the salad dressing and condiment shelf in the dry storage were pulling loose with pieces of plaster hanging loose and was black in color.The dishwasher had lime streaks running down the length of the door in front.At the end of the clean side of the dishwasher shelf, there was a heavy amount of moist beige and green food particles in the end corner. There was also a light accumulation of dried green food particles on the edges.3. During an observation of the kitchen, on 1/9/26 at 9:40 a.m., the following concerns were observed:Both stove ovens had a moderate amount of cream-colored food particles on the inside bottom.The outside doors of the oven and handles were sticky to the touch and had a heavy accumulation of white streaks running down the front doors.Around 3 sides of the fryer had white and brown sticky streaks.The left side of the convection oven had yellow grease particles which felt greasy to the touch.The top and bottom of the convection ovens had brown and white streaks running down the front. The area under the door openings and inside the doors, there was a heavy accumulation of black and brown grease which was able to be scrapped.The floor under the convection ovens had a heavy accumulation of black and dark brown substance. This was also present under the fryer, under left side of the stove, and under the 3 compartment sinks.The shelf under the slicer had a moderate amount of yellow/brown food particles and grease.One ceiling air vent directly above the pot and pan and steam table rack had a heavy accumulation of black greasy dust on it.The ceiling air vent above the dish machine had a heavy accumulation of black greasy dust on it.The top and front of the dish machine had heavy number of white streaks running down.One of two large ceiling air vents above the tray counter and steam table had a heavy flaking of black paint in the center.Two of 3 ceiling air vents had a heavy amount of greasy substance on them. This was above the prep counter and clean pot and pan shelving.One of two ceiling air vents above the counter where the toaster and coffee machine were and the heated plate holder in which dishes were present, had a moderate accumulation of black greasy particles on it.The ceiling vent above the salad dressing and condiment shelf in the dry storage was pulling loose with pieces of plaster hanging loose and was black in color.The dishwasher had lime streaks running down the length of the door in front.Review of the AS-COMPLETED Daily cleaning schedule, dated 1/4/26 to 1/9/26, indicated the stove top, grill and the floors were cleaned every shift.Review of the AS COMPLETED Weekly cleaning schedule indicated the ovens were cleaned on Week 1 and 3 on Tuesdays; the reach In refrigerator was cleaned on Week 1 and 3 on Fridays; the fryer was cleaned on Week 2 and 4 on Tuesdays; and the dishwasher was cleaned on Week 4 on Fridays.Review of the Weekly cleaning list for the cooks indicated in the a.m. on Mondays the table under the Cooks preparation areas were cleaned, the deep fryer was cleaned on Fridays; the top over of the double stack ovens was cleaned in the p.m. on Monday; the bottom oven of the double stack ovens was cleaned on Tuesday; the bottom left oven was cleaned on Wednesday; and the stove top and bottoms right oven were cleaned on Fridays. Review of the Food Safety policy, dated 5/1/25, included, but was not limited to: Policy: Food is stored and maintained in a clean, safe, and sanitary manner following federal. state and local guidelines to minimize contamination and bacterial growth .Cold Food Storage: 10. Leftovers are dated properly and discarded after 72 hours unless otherwise indicated .Review of the Cleaning Schedule, dated 4/30/25, included, but were not limited to: Policy: The Director of Food and Nutrition Services shall develop a routine cleaning schedule to ensure that the Food and Nutrition Services Department is maintained in a clean and sanitary manner in accordance with regulation requirements . The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety .Procedure: 1. The Director of Food and Nutrition Services establishes a regular cleaning schedule to include equipment .3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure proper labeling on 6 of 24 residents receiving insulin during the review of medication storage. (Residents 28, 9, 2, 4, 115 and 23) Findings include: 1. During an observation of the 300 Hall medication cart, on 1/7/26 at 8:41 a.m., the following concerns were identified for Resident 28: a. Resident 28's Lispro (rapid acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. b. Resident 28's Rezvoglar (long-acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. The record for Resident 28 was reviewed on 1/8/26 at 10:08 a.m. The diagnoses included, but were not limited to, protein-calorie malnutrition, type 2 diabetes mellitus with diabetic neuropathy, stage 3 chronic kidney disease, and anemia. The care plan, dated 12/18/25, indicated the resident had a diabetes mellitus diagnosis and was at risk for abnormal blood sugar readings. The interventions, dated 12/18/25, included, but were not limited to, blood sugar checks as ordered, medications as ordered, observe and report as needed (PRN) any signs and symptoms of hyperglycemia, and observe and report PRN any signs and symptoms of hypoglycemia. The physician's order, dated 12/18/25, indicated staff were to administer the resident's 15 units of lispro subcutaneously with meals for diabetes mellitus. The physician's order, dated 12/18/25, indicated staff were to administer the resident's 30 units of Lantus SoloStar (Rezvoglar) subcutaneously, a long-acting insulin, in the morning. The Comprehensive Minimum Data Set (MDS) assessment, dated 12/30/25, indicated the resident was moderately cognitively impaired. The resident received insulin in the last 7 days prior to the assessment. 2. During an observation of the 400 Hall medication cart on 1/7/26 at 9:28 a.m., the following concerns were identified for Resident 9: a. Resident 9's Basaglar (long-acting insulin) had no pharmacy label with the KwikPen in the medication cart of in the refrigerator. b. Resident 9's Humalog (fast acting insulin) had no pharmacy label with the KwikPen in the medication cart of in the refrigerator. The record for Resident 9 was reviewed on 1/8/26 at 10:27 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia, and schizophrenia. The physician's order, dated 2/15/25, indicated staff were to administer the resident's 17 units of Basaglar KwikPen at bedtime for diabetes mellitus. The physician's order, dated 4/8/25, indicated staff were to administer the resident's Novolog (Humalog) KwikPen subcutaneously every morning and at bedtime per sliding scale: if the resident's blood sugar results were 251 to 300 milligrams per deciliter (mg/dL), staff were to administer 6 units; 301 to 350 mg/dL, staff were to administer 8 units; 351 to 400 mg/dL, staff were to administer 10 units; 401 to 450 mg/dL , staff were to administer 12 units for 451 for diabetes mellitus. The care plan, dated 10/17/25 and revised 11/25/25, indicated the resident was at risk for complications associated with hyper or hypoglycemia related to the diagnosis of diabetes mellitus. The Quarterly MDS assessment, dated 11/27/25, indicated the resident was severely cognitively impaired. The resident received insulin in the 7 days prior to the assessment. 3. During an observation of the 400 Hall medication cart on 1/7/26 at 9:28 a.m., the following concerns were identified for Resident 2: a. Resident 2's Glargine (long-acting insulin) had no pharmacy label with the KwikPen in the medication cart of in the refrigerator. b. Resident 2's Lispro (rapid acting insulin) had had no pharmacy label with the KwikPen in the medication cart of in the refrigerator. The record for Resident 2 was reviewed on 1/8/26 at 11:03 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, protein-calorie malnutrition, iron deficiency, dementia, and dysphagia. The care plan, dated 8/19/25 and revised 12/2/25, indicated the resident had a diabetes mellitus diagnosis and was at risk for abnormal blood sugar readings, The interventions, dated 8/19/25, included, but were not limited to, obtain blood sugar readings as ordered, administer medications as ordered, observe and report PRN any signs or symptoms of hyperglycemia, observe and report PRN any signs or symptoms of hypoglycemia. The physician's order, dated 11/24/25, indicated staff were to administer the resident's 5 units of glargine KwikPen subcutaneously, one time daily for diabetes mellitus. The physician's order, dated 11/25/25, indicated to administer Humalog KwikPen (insulin lispro) subcutaneously per sliding scale; if the resident's blood sugar results were 151 to 200 mg/dL, staff were to administer 2 units; 201 to 250 mg/dL, staff were to administer 4 units; 251 to 300 mg/dL, staff were to administer 6 units; 301 to 350 mg/dL, staff were to administer 8 units; 351 to 400 mg/dL, staff were to administer 10 units; Over 400 mg/dL, staff were to Call the MD; before meals and at bedtime. The Comprehensive MDS assessment, dated 12/2/25, indicated the resident was moderately cognitively impaired. The resident received insulin in the 7 days prior to the assessment. During an interview, on 1/7/26 at 9:35 a.m., Qualified Medication Aide (QMA) 6 indicated she was unsure why the labels were not with the insulin. 4. During an observation of the 500 Hall medication cart on 1/7/25 at 9:50 a.m., the following concerns were identified for Resident 4: Resident 4's Tresiba had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. The record for Resident 4 was reviewed on 1/8/26 at 1:46 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, hyperglyceridemia, history of diabetic foot ulcer, and protein-calorie malnutrition. The record lacked documentation of a care plan for diabetes mellitus. The physician's order, dated 10/13/25, indicated to administer to the resident, aspart KwikPen subcutaneously, per sliding scale; if the resident's blood sugar results were 151 to 200 mg/dL, staff were to administer 2 units; 201 to 250 mg/dL, staff were to administer 4 units; 251 to 300 mg/dL , staff were to administer 5 units; 301 to 350 mg/dL, staff were to administer 6 units; 351 to 400 mg/dL, staff were to administer 7 units; 401 to 999 mg/dL, staff were to administer 7 units and call the md; before meals and at bedtime for diabetes. The Quarterly MDS assessment, dated 12/23/25, indicated the resident was moderately cognitively impaired. The resident received insulin in the 7 days prior to the assessment. 5. During an observation of the 500 Hall medication cart on 1/7/25 at 9:50 a.m., the following concerns were identified for Resident 115. Resident 115's Aspart (rapid acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. The record for Resident 115 was reviewed on 1/8/26 at 2:29 p.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus. The care plan, dated 7/14/25 and revised 12/23/25, indicated the resident had diabetes mellitus diagnosis and was at risk for abnormal blood sugar readings. The interventions, dated 7/14/25, included, but was not limited to, blood sugar checks as ordered, diet as ordered, medication as ordered, observe and report PRN any signs and symptoms of hyperglycemia, observe and report PRN any signs and symptoms of hypoglycemia. The physician's order, dated 12/18/24, indicated the staff were to administer the resident's 10 units of Basaglar KwikPen (Tresiba) subcutaneously at bedtime. The Quarterly MDS assessment, dated 12/23/25, indicated the resident was moderately cognitively impaired. The resident received insulin in the 7 days prior to the assessment. During an interview, on 1/7/26 at 9:57 a.m., Licensed Practical Nurse (LPN) 7 indicated the pharmacy labels were discarded upon receiving and not placed on the medications. 6. During an observation of the 100 Hall medication cart on 1/7/26 at 9:55 a.m., the following concerns were identified for Resident 23: Resident 23's Lispro (rapid acting insulin) had no pharmacy label with the KwikPen or in the refrigerator. The record for Resident 23 was reviewed on 1/8/26 at 9:42 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, cognitive communication deficit, and protein-calorie malnutrition. The care plan, dated 8/17/25 and last revised on 12/1/25, indicated the resident had diabetes mellitus and was at risk for abnormal blood sugar readings. The interventions, dated 8/17/25, included, but were not limited to, obtain the resident's blood sugar readings as ordered, administer medications as ordered, observe and report as needed (PRN) any signs or symptoms of hyperglycemia, and observe and report PRN any signs or symptoms of hypoglycemia. The physician's orders, dated 11/16/25, indicated staff were to administer the resident's Humalog (insulin lispro) KwikPen subcutaneously per sliding scale, if the resident's blood sugar reading was 151 to 200 mg/dL, staff were to administer 2 units; 201 to 250 mg/dL, staff were to administer 4 units; 251 to 300 mg/dL, staff were to administer 6 units; 301 to 350 mg/dL, staff were to administer 8 units; 351 to 400 mg/dL , staff were to administer 10 units; 401 to 450 mg/dL, staff were to administer 12 units; 451 to 500 mg/dL, staff were to administer 14 units. Anything greater than 500 staff were to notify the MD; for diabetes daily and at bedtime for diabetes mellitus. The Quarterly MDS assessment, dated 12/2/25, indicated the resident was cognitively intact. The resident received insulin in the 7 days prior to the assessment. During an interview, on 1/8/26 at 2:27 p.m., LPN 3 indicated she did not know why the pharmacy label was not with the insulin. The Storage and Expiration Dating of Medications and Biologicals policy, last revised 6/30/25, included, but was not limited to, . 12. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions. 3.1-25(k)(2)3.1-25(k)(5)3.1-25(k)(7)

Based on observation, record review, and interview, the facility failed to ensure proper Personal Protective Equipment (PPE) was applied and the catheter bag drainage valve was kept off of the floor to prevent infection during 2 of 3 observations of care. (Residents 7 and 82) and to ensure glucometers were cleaned per guidelines for infections control when obtaining blood sugar readings for 2 of 2 residents observed. (Residents 32 and 2)Findings include:1. During an observation, on 1/6/26 at 9:38 a.m., Certified Nurse Aide (CNA) 5 entered Resident 7's room to empty the catheter bag, which was full of light-yellow urine and bulging. The urine was visible in the line leading up to the resident. She emptied the bag four to five times before it was empty. She applied gloves but did not apply a gown for Enhanced Barrier Precautions (EBP). There was signage on the entry door indicating the resident was in EBP related to wound and catheter care. The equipment to be worn during care, were indicated on the signage for gloves and a gown. During an interview, on 1/6/26 at 9:41 a.m., Resident 7 indicated the staff did not always wear gowns when they were performing his wound treatment. Staff didn't wear a gown when emptying the catheter bag. During an interview, on 1/6/26 at 10:30 a.m., CNA 5 indicated when a resident was in Enhanced Barrier Precautions (EBP), the staff put on the equipment they needed. She would apply gloves and if there was a risk of fluid splash you should wear a gown. She indicated she did not wear a gown when she emptied Resident 7's catheter bag. She indicated there was a chance of being splashed when she emptied the catheter bag. During a confidential interview, between 1/5/26 and 1/9/26, Staff A indicated there had been two instances where staff had not capped the catheter tubing on the catheter bag well enough. The record for Resident 7 was reviewed on 1/6/26 at 4:04 p.m. The resident's diagnoses included, but were not limited to, stage 3 chronic kidney disease, anemia, and need for assistance with personal care. The care plan, dated 5/16/25, indicated the resident had an indwelling catheter for urinary retention and presence of wounds to scrotum or perineal area. He was at risk for infection and injury with ongoing use of the catheter. The interventions, dated 5/16/25, included, but was not limited to, the use of Enhanced Barrier Precautions. The physician's order, dated 8/4/25, indicated the resident was in Enhanced Barrier Precautions for the diagnosis of a catheter and wounds. The Quarterly Minimum Data Set (MDS) assessment, dated 12/20/25, indicated the resident was cognitively intact. 2. During an observation, on 1/7/26 at 8:41 a.m., Licensed Practical Nurse (LPN) 8 entered Resident 82's room to apply oxygen to the resident. She placed the nasal cannula into the resident's nose. As the LPN was washing her hands, the resident requested to have a jacket applied. The LPN applied the jacket and performed hand washing. She looked over at the entry door at the signage for Contact Isolation and EBP. During an interview, on 1/7/26 at 8:45 a.m., LPN 8 indicated she was in the resident's room before she thought about the resident being in contact isolation. She indicated she had not applied the PPE and the resident was in isolation for Clostridium Difficile (C-Diff) and had a wound. The record for Resident 82 was reviewed on 1/9/26 at 8:38 a.m. The resident's diagnoses included, but were not limited to, enterocolitis due to clostridium difficile and sepsis. The physician's order, dated 12/15/25, indicated staff were to use Contact Precautions for C-Diff. The care plan, dated 12/16/25, indicated the resident was prescribed an antibiotic for C. Difficile. The interventions, dated 12/16/25, included, but was not limited to, Contact Precautions were in place. The Quarterly MDS assessment, dated 12/23/25, indicated the resident was moderately cognitively impaired. The skilled note, dated 1/4/26 at 1:26 a.m., indicated the resident received oral Vancomycin liquid related to C-Diff continues per order with no adverse side effects (ASE). The resident remained in isolation per order. Oral antibiotics were continued related to a UTI with no adverse side effects (ASE). Oral fluids were encouraged with fair results. The Foley catheter (F/C) was patent to the bedside drain (BSD) with clear yellow urine. The treatment was performed as per orders and tolerated well by the resident. The resident was compliant with heel protector boots. Turning and repositioning every 2 hours while abed. The skin-wound note, dated 1/7/26 at 3:00 p.m., indicated the resident was admitted with a pressure area to the left lateral foot. The Enhanced barrier Precautions policy, last revised 8/19/25, included, but was not limited to, . EBP are indicated for residents with any of the following. b. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. Examples of high-contact resident care activities requiring gown and glove use include. d. Providing hygiene. g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ ventilator h. Wound care: any skin opening requiring a dressing. 3.a. During an observation of LPN 3, after the use of a glucometer with Resident 32, on 1/7/26 at 11:20 a.m., the LPN 3 cleaned the glucometer by first performing hand hygiene. She then wiped all exterior surfaces with a Super Sani Cloth for approximately 30 seconds and then placed the glucometer on top of the medication cart to dry. The glucometer was not covered and left open to the air after it was wiped off. The glucometer had no visible containments. An interview, on 1/7/26 at 11:21 a.m., LPN 3 indicated proper clean of the glucometer was for the unit to remain wet for two minutes. 3.b. During an observation of LPN 4, after the use of a glucometer for Resident 2, on 1/8/26 at 11:05 a.m., the LPN 4 completed hand hygiene and then cleaned the glucometer by wiping all exterior surfaces for approximately 30 seconds with a Super Sani Cloth and then the glucometer was placed on a paper towel on top of the medication cart. The glucometer had no visible containments. An interview, on 1/8/26 at 10:18 a.m., with LPN 4 indicated that the glucometer needed to be cleaned for 2 minutes. The manufacturer guidelines indicated that any hard nonporous surface needed 2 minutes of wet contact time prior to letting the device air dry. Review of the infection control logs indicated the facility had no pattern of specific infections or blood borne pathogens. The current policy included, titled Cleaning and disinfection of the Glucometer, was provided by the Director of Nursing (DON) on 1/9/26 at 12:20 PM. The policy included, but was not limited to, Policy: To prevent the spread of infection.Procedure: This facility will utilize the Lippincott procedure.Glucometer- Assure Prism quality control checks and cleaning procedures. 3.1-18 (j) 3.1-18 (l)

Based on interview, observation, and record review, the facility failed to ensure residents were free of a medication error rate greater than 5 percent for 2 of 24 opportunities, resulting in a medication error rate of 8.33%. (Resident 32 and Resident 2)Findings include:1. During an interview, on 1/7/26 at 11:15 a.m., the Licensed Practical Nurse (LPN) 3 indicated that she had already checked Resident 32's blood glucose. She indicated the reading was 244 milligrams per deciliter (mg/dL) and after reviewing the physician's order it was determined that the resident would get 4 units of insulin Lispro Injection subcutaneously. During an observation, on 1/7/26 at 11:25 a.m., LPN 3 performed hand hygiene, primed the Lispro Insulin pen with 2 units without the needle intact at the time of priming. The needle was then put on the insulin pen; the LPN went to the resident's room and cleaned the lower right abdomen with alcohol and did not allow it to dry. LPN 3 injected the insulin and left it place for only 4 seconds before retracting the insulin pen. Review of the manufacturer requirements for Lispro indicated during the administration Lispro insulin required 5 seconds for the insulin to remain injected prior to retracting the insulin pen.The record for Resident 32 was reviewed on 1/9/26 at 11:52 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, dementia, peripheral vascular disease, and chronic kidney disease stage 3.A physician's order, dated 8/4/25, indicated the resident was to have Lispro Injection Solution. The instructions were as followed: Inject subcutaneously with meals as per sliding scale: if 151 to 200 mg/dL, staff were to administer 2 units; 201 to 250 mg/dL, staff were to administer 4 units; 251 to 300 mg/dL, staff were to administer 6 units; 301 to 350 mg/dL, staff were to administer 8 units; 351 to 400 mg/dL, staff were to administer 10 units; and If greater than 400 mg/dl, staff were to call the physician.The Quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, indicated the resident had moderate cognitive impairment.2. During an observation of Resident 2, on 1/8/26 at 11:00 a.m., LPN 4 performed hand hygiene, applied the needle and primed the insulin pen with 2 units for a glucose of 249 mg/dL. The LPN went to Resident 2's room and cleaned the abdomen with alcohol. The nurse injected the insulin and left it place for 3 seconds before retracting the insulin pen. Review of the manufacturer requirements for Lispro insulin indicated during administration the Lispro insulin required 5 seconds for the insulin to remain injected prior to retracting the insulin pen.The record for Resident 2 was reviewed on 1/8/26 at 8:30 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, dementia, alcoholic cirrhosis of liver with ascites, chronic kidney disease stage 4, cognitive communication deficit, hypertension, and ileostomy status.A physician's order, dated 11/25/25, indicated the resident was to have Humalog Kwik Pen subcutaneously. The instructions were as followed: Inject subcutaneously with meals and at bedtime as per sliding scale: If the resident's glucose was 151 to 200 mg/dL, the staff were to administer 2 units; 201 to 250 mg/dL, the staff were to administer 4 units; 251 to 300 mg/dL, the staff were to administer 6 units; 301 to 350 mg/dL, the staff were to administer 8 units; 351 to 400 mg/dL, the staff were to administer 10 units; and over 400 mg/dL, staff were to call the physician.The Significant Change MDS assessment, dated 11/30/25, indicated Resident 2 had moderate cognitive impairment.During an interview, 1/9/26 at 11:50 p.m., the Director of Nursing indicated she would provide the policy on insulin administration.The current policy included, titled Guidance for using Insulin Products, was provided by the DON on 1/9/26 at 12:20 PM. The policy included, but was not limited to, . 5. Clean the injection site with alcohol and allow to completely dry. 9. After injection, hold the needle in the skin in to ensure complete delivery of the dose. Needle should remain in the skin for 5 seconds after injection for Insulin Lispro . 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident with a history of Urinary Tract Infection (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system with sufficient emptying of the drainage system for 1 of 1 residents reviewed for catheter care. (Resident 7) Findings include:During an observation, on 1/5/26 at 10:01 a.m., Resident 7's catheter bag was full of urine and bulging. Urine was observed leading up the tubing to the resident. The urine was clear light yellow. The floor was sticky when walking on it. During an interview, on 1/6/26 at 9:24 a.m., Resident 7 indicated the catheter bag broke open and the urine was everywhere. The staff had mopped up the urine on the floor today. During an observation, on 1/6/26 at 9:38 a.m., Certified Nurse Aide (CNA) 5 entered the resident's room to empty the catheter bag which was full of light-yellow urine and bulging. The urine was visible in the line leading up to the resident. She emptied the bag four to five times before it was empty. She applied gloves but did not apply a gown for enhanced barrier precaution (EBP - infection control intervention designed to reduce transmission of multi drug-resistant organisms). There was signage on the entry door indicating the resident was in EBP and the equipment to be worn during care. During an interview, on 1/6/26 at 10:30 a.m., CNA 5 indicated this was the first time this morning she had emptied it. She felt the night shift had to have emptied the catheter bag during the night. During a confidential interview, between 1/5/26 and 1/9/26, Staff A indicated there had been two instances where staff had not capped the catheter tubing on the catheter bag well enough. There were two other instances where the catheter bag broke open because it was too full (one occurrence was the night before). The floor was sticky due to urine being on the floor. The record for Resident 7 was reviewed on 1/6/26 at 4:04 p.m. The resident's diagnoses included, but were not limited to, Stage 3 chronic kidney disease, anemia, and need for assistance with personal care. The care plan, dated 5/7/25 and revised 5/16/25, indicated the resident had a history of urinary tract infection and was at risk for recurrence. The interventions, dated 5/7/25, included, but were not limited to, report to the nurse practitioner (NP) if symptoms worsen, and conduct laboratory work and diagnostic work as ordered. report the results to the medical doctor (MD) and follow up as indicated, observe for and report to MD as needed (PRN) for signs and symptoms of a UTI. The care plan, dated 5/16/25, indicated the resident had an indwelling catheter for urinary retention and presence of wounds to the scrotum or perineal area. The resident was at risk for infection and injury with ongoing use of the catheter. The interventions, dated 5/16/25, included, but were not limited to, catheter care every shift, check the tubing for kinks and ensure that urine was free flowing, enhanced barrier precautions, observe for and document for pain or discomfort due to the catheter, observe for and report to the MD for signs or symptoms of a UTI, observe for signs or symptoms of discomfort on urination and frequency. The resident's urinalysis results, dated 6/19/25, indicated 4 plus glucose, 1 plus blood, 3 plus leukocytes. There was mucous, budding yeast, and WBC clumps present. The culture indicated 60,000 to 70,000 CFU/mL of pseudomonas. The nurse's note, dated 6/20/25 at 11:57 a.m., indicated the NP was at the facility and saw the resident and reviewed the final UA with culture and sensitivity. No new orders were received. The nurse's note, dated 7/2/25 at 1:24 a.m., indicated the indwelling urinary catheter was changed. The resident complained of pain with pressure and the catheter tubing showed signs of sediment. The resident indicated immediate relief after the change and immediate return of approximately 750 mL of dark yellow cloudy urine with sediment. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The Indwelling Urinary Catheter (Foley) Management policy, last reviewed 9/4/25, included, but was not limited to, . Additional care practices related to catheterization. 3. Use personal protective equipment, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. a. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. 3.1-41(a)

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of medications for 1 of 4 residents reviewed for misappropriation. (Resident D)Findings included: The record for Resident D was reviewed, on 8/4/25 at 12:37 p.m. The diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, generalized anxiety disorder, unspecified intellectual disabilities, major depressive disorder, front-temporal neurocognitive disorder, and dementia. The Quarterly Minimum Data Set (MDS) Assessment, dated 5/12/25, indicated the resident was severely cognitively impaired. The review of the incident report, dated 7/27/25, indicated a staff member was suspected of taking narcotic medications from the resident for her personal use. The staff member involved was a Licensed Practical Nurse (LPN). During an interview on 8/4/25 10:13 a.m., Certified Nurse aide 4 (CNA) indicated that the resident does not show signs of pain most of the time, but does get agitated from time to time. CNA 4 would let the nurse know if the resident needed something for pain or agitation. The CNA 4 indicated the resident was non-verbal and fully dependent on staff members for assistance. The review of the police report on 8/4/25 at 12:45 p.m., indicated that a police department had been notified of a misappropriation of narcotic medication at the facility. The physicians order dated 4/1/25 indicated on 8/4/25 at 12:47 p.m., the resident was to receive LORazepam Concentrate 2 milligrams/milliliter (MG/ML) 0.25 milliliter by mouth every six hours as needed for anxiety or restlessness. The physician order dated 7/14/25, indicated Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.5 ml by mouth every 2 hours as needed (PRN) for shortness of breath or pain. The record indicated that Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML 0.5 ml by mouth two times a day for pain.During an observation, on 8/4/25 at 10:00 a.m., the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) 5 were observed doing a narcotic count on the 100 hall. No discrepancies were observed.During an interview on 8/4/25 at 10:10 a.m., The ADON indicated management would randomly go to the units and do a narcotic count as part of their audit. She indicated they were doing the random counts because a staff nurse was caught stealing narcotics. She indicated on the 200 hall the Qualified Medication Aide 7 (QMA) observed LPN 6 going into resident room [ROOM NUMBER]. When the QMA entered the room, she did not see the LPN 6 in the resident room. After being in the room for 15 to 20 minutes, QMA 7 left the room and walked across the hallway and observed LPN 6 coming out of the resident's bathroom. She indicated LPN 6 was not acting right at that time. At 5:15 p.m., LPN 6 indicated to QMA 7 she accidentally urinated on herself and needed to go home. QMA 7 indicated LPN 6 wanted her to do a narcotic count with her. QMA 7 informed LPN 6 she could not do a narcotic count because she was not a nurse. The LPN 6 had signed out the Ativan tablets for a resident that was not in the building. LPN 6 wanted another nurse to count the narcotics at shift change because she was leaving the facility. The staff members refused to count the narcotics. When the night shift nurse came on duty and did the count the narcotic count was not accurate, and the liquid Ativan was removed, and the container was filled with water. LPN 6 was removed from the facility, and the police and management were notified.The Abuse, Neglect and Exploitation policy, provided on 8/4/25 at 1:20 p.m. by the Executive Director included, but was not limited to, .1. Misappropriate of property.deliberate misplacement, exploitation or wrongful of resident property without their consent.3. Examples of misappropriation.I. Missing prescription medication or diversion of a resident's medication included, but were not limited to controlled substances for staff use. The deficiency cited was past non-compliance, on 7/29/25 when the facility had completed staff education 7/29/25 related to abuse and misappropriation of medication; narcotic count at shift change policy; and education on medication documentation. Additionally, the Director of Nursing/Assistant Director of Nursing will audit narcotic count sheets twice a day for 14 days, and weekly for 2 weeks and report back to the Quality Assurance and Performance Improvement (QAPI) team weekly for 4 weeks.3.1-28 (a)

Based on interview and record review, the facility failed to ensure bed hold polices were provided to residents/resident representatives ( Resident C, Resident D, Resident F and Resident B) discharged to the hospital for 4 of 4 residents reviewed for transfers/discharges. Findings include: 1. The clinical record for Resident C was reviewed on 6/4/25 at 11:31 a.m. The resident's diagnoses included, but were not limited to, paraplegia and neuromuscular dysfunction of the bladder. The progress note, dated 5/26/25 at 1:00 a.m., indicated the resident was very lethargic and the catheter had blood tinged urine in the catheter bag. The physician was notified and a new order was received to send the resident to the hospital for evaluation. The clinical record lacked documentation of the bed hold documentation provided to the resident or the resident's representative at the time of discharge. 2. The clinical record for Resident D was reviewed on 6/4/25 at 2:49 p.m. The resident's diagnoses included, but were not limited to, dementia and subdural hemorrhage with loss of consciousness. The progress note, dated 5/29/25 at 11:14 a.m., indicated Resident D's son was at the facility and requested the resident be sent to the hospital for evaluation. They physician was notified with a new order to send the resident to the hospital for evaluation. The clinical record lacked documentation of bed hold documentation provided to the resident or the resident's family member at the time of discharge. 3. The clinical record for Resident F was reviewed on 6/4/25 at 2:58 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease and infection/inflammatory reaction due to joint prosthesis. The progress note, dated 5/27/25 at 8:30 p.m., indicated the resident was found with cyanotic finger tips and the resident's oxygen saturation was not registering. When the oxygen did register, saturation was in the 50's. Oxygen was placed on the resident per nasal cannula at 4 liters per minute. The resident's oxygen came up to 93%. The physician was notified with a new order to send to the hospital for evaluation. The clinical record lacked documentation of bed hold documentation provided to the resident or resident's representative at the time of discharge. 4. The clinical record for Resident B was reviewed on 6/4/25 at 9:54 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction and convulsion. The progress note, dated 12/25/24 at 3:55 p.m., indicated the resident was not responding, eyes were deviated and sternal rubs were ineffective. The family member was at bedside, the physician was notified with a new order to send the resident to the emergency department for evaluation. The transfer form and clinical record lacked documentation of bed hold documentation provided to the resident/resident representative at the time of discharge. The resident readmitted to the facility on [DATE]. The progress note, dated 1/17/25 at 12:57 p.m., indicated the resident's oxygen saturation was very low, ineffective sternal rubs, and breathing with his abdominal muscles. The resident was placed on oxygen. The physician was notified with a new order to send the resident to the emergency department and report was called to the hospital. The clinical record lacked documentation of bed hold documentation being provided to the resident prior to discharge. During an interview on 6/4/25 at 3:10 p.m., the Director of Nursing (DON) indicated she was aware the bed hold had to be sent with the resident, but if there was an emergent situation, it may not be done. On 6/4/25 at 3:28 p.m., the DON provided a current copy of the document titled Discharge Process and Bed Holds dated 1/3/22. It included, but was not limited to, Notice of bed-hold policy and returns .Bed-hold notice upon transfer .At the time of transfer of a resident for hospitalization .a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy This Citation relates to Complaint IN00458882 3.1-12(a)25(A) 3.1-12(a)25(B)

Based on observation, interview and record review, the facility failed to ensure the physician's orders were in place for weekly maintenance of nebulizer equipment and failed to ensure nebulizer respiratory assessments were completed prior and after administration for 1 of 3 residents reviewed for respiratory care. Findings include: The clinical record for Resident B was reviewed on 6/4/24 at 9:54 a.m. The resident's diagnosis included, but was not limited to, chronic obstructive pulmonary disease. Review of the December 2024 medication administration record (MAR) indicated the resident received pulmicort 0.5 mg (milligrams)/2 ml (milliliters). The resident was to received 2 ml, via nebulizer, twice daily. The resident's clinical record lacked documentation of the December weekly replacement of the nebulizer respiratory equipment. Review of the January 2025 MAR indicated the resident received pulmicort 0.5 mg (milligrams)/2 ml (milliliters). The resident received 2 ml, via nebulizer, twice daily upon readmission on [DATE]. The resident's clinical record lacked documentation of the January completed respiratory assessments and the weekly replacement of the nebulizer respiratory equipment. During an interview on 6/4/25 at 2:23 p.m., Licensed Practical Nurse (LPN) 3 indicated to ensure the effectiveness of a nebulizer treatment, a respiratory assessment should be completed prior to and after completion of the treatment. The nebulizer equipment should be changed out weekly. On 6/4/25 at 3:09 p.m., the Director of Nursing provided a current, undated copy of the document titled Nebulizer Treatment, small volume. It included, but was not limited to, Please included the following information when completing the procedure .Entire setup should be changed weekly .Implementation .Monitor the patient's heart rate and respiratory status during the procedure .After treatment, turn off the nebulizer, obtain the patients' vital signs, assess the respiratory status This Citation relates to Complaint IN00458882 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure staff to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/20/24 at 11:43 a.m. The resident's diagnosis included, but was not limited to, dementia. The incident report, dated 6/24/24 at 11:20 p.m., indicated Resident B was being assisted with toileting needs by CNA 4 when Resident B bit the side of CNA 4's arm. CNA 4 reported she made contact with Resident B's facial area in an attempt to stop the biting process. The written statement from CNA 4, dated 6/25/24 at 11:07 a.m., indicated Resident B was sitting in the dining room eating a snack and had been restless. On 6/24/24 at 11:30 p.m., CNA 4 tried to get the resident up to provide incontinent care but the resident was resistant and held onto the chair arms. CNA 4 waited a couple of minutes and tried again. CNA 4 leaned in and put her hand on the resident's waistline to help her up at that time the resident bit her right inner upper arm. Out of reflex, CNA 4 slapped Resident B's face. The written statement from CNA 3, dated 6/25/24 at 11:31 a.m., indicated CNA 3 was sitting in the dining room at another table when CNA 4 attempted to get Resident B up from the chair. Resident B was resistant to getting up. CNA 3 heard CNA 4 yell out and say she bit me and at that time, observed CNA 4 slap the resident. CNA 3 went to the nurses station and reported to RN 5 and both CNA 3 and RN 5 went to the dining room and removed the resident. The written statement from RN 5, dated 6/25/24 at 11:41 a.m., indicated around 11:30 p.m., CNA 3 came to nurses station and stated I need your help, [CNA 4] slapped a resident. They both immediately (CNA 3 and RN 5) removed the resident from the dining room and RN 5 assessed the resident for injury and distress. There were no marks, injury or distress. CNA 4 was instructed to clock out and go home. During a telephone interview on 8/20/24 at 1:43 p.m., CNA 3 indicated CNA 4 was trying to get the resident either changed or lay her down. Resident B was somewhat resistive. CNA 3 heard CNA 4 say ouch, she looked up and witnessed CNA 4 slap B on the left side of the face. Resident B then placed her hand on her left cheek. CNA 3 indicated It was not slap like you would do to a child's hand, it was a slap, slap. She had immediately got up, went to the nurses' station and told RN 5 she needed her help with Resident B because CNA 4 had just slapped her. Both CNA 3 and RN 5 immediately removed Resident B and took her to bed. After that, RN 5 went and spoke with CNA 4. During a telephone interview on 8/20/24 at 9:26 p.m., RN 5 indicated she was at the nurses' station charting. CNA 3 came up to the nurses' station and told her to come with her. RN 5 asked if everything was ok and CNA 3 said no, [CNA 4] had just slapped [Resident B]. Once RN5 entered the dining room, CNA 4 broke down and said it was a reflex. RN 5 and CNA 3 took Resident B to her room, assessed her and together, She and CNA 3 changed her. RN 5 immediately call the Executive Director and sent CNA 4 home. On 8/20/24 at 12:17 p.m., the Executive Director provided a current copy of the document titled Abuse - Prevention dated 10/4/2022. It included, but was not limited to, Policy .It is the policy of this facility to prevent and prohibit all types of abuse .Physical Abuse .includes, but is not limited to .slapping The Past noncompliance began on 6/24/24. The deficient practice was corrected by 6/26/24 after the facility implemented a systemic plan that included the following actions: A one-time review of progress notes over the past 30 days to validate no other issues (6/25/24); A one-time interview process completed with residents with a BIMS (brief interview of mental status) of 10 or higher to validate no other concerns not previously identified (6/25/24); Skin assessments completed for residents with moderately to severely impaired cognition to validate no signs of unreported issues (6/25/24); A one-time review of dementia care training completed to ensure up to date (6/25/24); Regional Director of Clinical Operations provided all staff re-education on abuse prevention, unusual occurrences, Elder Justice Act, reporting criteria and timeliness of reporting, notification to regional/division support, and re-education on behavior management interventions for residents with dementia (6/26/24); All facility staff were re-educated on abuse prevention, definitions of unusual occurrences, reporting immediately to abuse coordinator, and timeliness of reporting (6/25/24). This Citation relates to Complaint IN00439581 3.1-27(a)(1)

Based on observation, record review and interview, the facility failed to ensure the kitchen equipment and floor was clean and free from grease and food particles for 2 of 3 kitchen observations. This deficient practice had the potential to affect 120 residents currently residing in the facility. Findings Include: During an observation of the facility kitchen the following was observed: - The deep fryer had grease and a brown black substance buildup on the fryer baskets, and the top and sides of the fryer. - The gas stove knobs had a grease and food debris buildup. - The cart sitting beside the stove, had a sheet pan sitting on the shelf with a greasy food buildup on the utensils. - The employee sink had a black substance in the sink bowl, and on the front and sides of the sink. - The kitchen floor felt greasy and was slippery. The floor was dirty with grime and food debris build up. There were various items of trash laying on the floor. - Sitting on a table near the dishwasher there was a large bowl with a brown thick substance inside. The substance was up the sides of the bowl and was dried and crusty. Beside the large bowl was a container of a yellow substance and the top of the yellow substance was dried. - The handle on the refrigerator door was missing. - The refrigerator doors had food debris and smudges. - The stainless steel tables had dark brownish spots, food debris and grease on the shelves. The cleaning schedule was not posted and the Assistant Dietary Manager could not find the schedule. During an interview on 7/25/24 at 9:30 a.m., the Assistant Dietary Manager indicated she did not know where the cleaning schedules were. During an observation and interview on 7/25/24 at 9:40 a.m., Dietary Aide 5 and Dietary Aide 6, indicated they did not know what the brown substance was in the large bowl. They did not know how long the bowl had been sitting on the table. Dietary Aide 5 indicated whatever it was, it looked old to her. During an interview on 7/25/24 at 9:45 a.m., Dietary Aide 5 indicated the Dietary Manager took the cleaning schedules down. She thought he was going to update them. She presented a weekly cleaning schedule that was dated for the months of December 2023 to March 2024. She indicated she tried to clean up after she got done with her duties. She did not know how often the kitchen was deep cleaned and when the kitchen was last cleaned. The Dietary Aide indicated she thought the kitchen was dirty and needed cleaned. The night shift came in from 11:00 a.m. to 8:00 p.m. She indicated the staff was supposed to clean after dinner, but they were not cleaning. She indicated the staff had complained to the Dietary Manager, but nothing had been done about the problem. She indicated the Dietary Manager let the evening staff get away with not cleaning. During a return visit to the kitchen on 7/25/24 at 11:00 a.m., the same issues were observed as well as the following: - A towel was laying on top of the silverware table with a large amount of a light brown substance. The substance appeared to be oatmeal. - Plastic cup lids were laying on the floor beside the tray racks. During an interview on 7/25/24 at 11:30 a.m., the Dietary Manager indicated the kitchen would be cleaned daily. Deep cleaning would be done weekly. If he observed something dirty he would clean it up. The dietary staff had individual cleaning duties and they had to sign off when the job was completed. He indicated the facility used a cleaning service to clean the stove hoods, but he wasn't sure when the last time they were cleaned. The floor would be mopped 2 to 3 times a day especially after meals. The floor was old and it would probably help if they had new flooring. He indicated the second shift came in at 11:00 a.m., until closing around 8:00 p.m., and they were instructed not to leave dishes for the day shift. He could not remember when the last time the kitchen had a deep scrubbing. The Cleaning policy, dated 10/4/19, and revised on 4/30/24 included, but was not limited to, . The director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietitian, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times. 1. The Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned. 2. Designated cleaning task are assigned to each position. 3. The cleaning schedule is posted in a location where it can be easily read. 4. The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately . This Citation relates to Complaint IN00437132. 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/29/24 at 12:21 p.m. The resident's diagnoses included, but were not limited to, depression, anxiety and pain. The physician's order, dated 4/17/24, indicated Resident D was to receive Oxycodone (narcotic pain medication) 5 mg (milligrams), one half of a tablet (2.5 mg) twice a day and every 4 hours as needed for pain. The internal facility incident report, dated 4/23/24 at 4:05 p.m., indicated Resident D was missing one card with 22.5 tablets of Oxycodone and one narcotic count sheet. The Oxycodone was sent to the facility, from the pharmacy on 4/19/24. All statements had been obtained from staff that worked the medication cart except for QMA (Qualified Medication Aide) 9. The State incident report, dated 4/26/24, indicated a narcotic discrepancy had been identified on the Memory Care Unit for Resident D. The pharmacy delivery receipt, dated 4/18/24 at 10:16 p.m., indicated for Resident D there were four cards of Oxycodone 5 mg tablets, with 15 tablets in each card. The medication card were sent out for delivery to the facility and were received by the facility on 4/19/24. On 4/21/24 at 6:00 p.m., the Shift Change Controlled Substance Inventory Sheet indicated at the start of shift, there were 23 cards and 26 narcotic count sheets. One card and one narcotic count sheet were removed with an end of shift total of 22 cards and 25 narcotic count sheets. Resident D had 4 cards and 4 sheets related to her medication, Oxycodone. The resident's count were included in the facility Shift Change Controlled Substance Inventory Sheets total on 4/22/24 at 6:00 p.m. The night shift nurse was LPN 7 and the on-coming day shift nurse on 4/22/24 at 6:00 a.m. was QMA 9. During an interview on 4/30/24 at 2:50 p.m., LPN 7 indicated when she counted the narcotic cards and sheets with QMA 9, on 4/22/24 at 6:00 a.m., there were a total of 22 cards and 25 narcotic count sheets. On 4/30/24 at 11:45 a.m., the facility Shift Change Controlled Inventory Sheets were reviewed. The Shift Change controlled Substance Inventory Sheet, dated 4/22/24 at 6:00 a.m., had 22 cards and 25 narcotic count sheets documented at the start of the shift. One card and one narcotic count sheet were added and subtracted with an end of shift total of 22 cards and 25 narcotic count sheets. There was a single line drawn through the end of shift numbers from 22 cards and 25 narcotic count sheets. A handwritten total was changed to 21 cards and 24 narcotic count sheets written underneath the previous number. The day shift nurse was QMA 9 and the oncoming night shift nurse was LPN 6. During an interview on 4/30/24 at 2:31 p.m., LPN 6 indicated she worked on 4/22/24 from 10:00 p.m. until 6:00 a.m. on 4/23/24. She only counted the narcotics with QMA 9, not the cards or narcotic count sheets. When she came on shift at 10:00 p.m. there were no alteration or handwritten changes on the Shift Change Controlled Inventory Sheets. The LPN indicated she had not administered any Controlled medication to Resident D. There had not been any corrections, changes, or alterations to the Shift Change Controlled Substance Inventory Sheets upon her arrival or at the end of her shift. The Shift Change Controlled Substance Inventory Sheet, dated 4/22/24 at 10:00 p.m., indicated at the start of the shift, there were 22 cards and 25 narcotic count sheets. Those numbers were changed from 22 cards and 25 narcotic count sheets to 21 cards and 24 narcotic count sheets. There was a single line drawn through the end of shift numbers from 22 cards and 25 narcotic count sheets. A handwritten total was changed to 21 cards and 24 narcotic count sheets written underneath the previous number. The night shift nurse was LPN 6 and the oncoming day shift nurse was QMA 9. The Shift Change Controlled Substance Inventory Sheets, dated 4/23/24 at 6:00 a.m., indicated at the start of the shift, there were 21 cards and 24 narcotic count sheets. The night shift nurse was LPN 6 and the oncoming day shift nurse was QMA 9. Review of the April 2024 medication administration record (MAR) indicated the last dose of the Oxycodone that was administered from the missing narcotic count sheet was on 4/22/24 at 8:00 p.m. by QMA 9. On 4/29/24 at 9:25 a.m., the Director of Nursing (DON) indicated, on 4/23/24, once they realized there was a discrepancy she reached out to QMA 9 by telephone and both of the QMA's phone numbers were disconnected. The DON reached out by social media messenger and requested for QMA 9 to return her call. As of 4/29/24, the QMA 9 had not returned her call or reached out to her in any way. The DON spoke with Officer 20, who was over the case, on Saturday evening, 4/27/24. Officer 20 reported to her that he had gotten in touch with QMA 9. He reported QMA 9 told him she would not speak to him without legal counsel. During an interview on 4/30/24 at 2:24 p.m., Unit Manager indicated, on 4/23/24, LPN 8 was going through all the new pharmacy orders to double check and make sure they were correct. LPN 8 noticed the staff were using page two of the narcotic count sheets and should have been using page one for Resident D's Oxycodone. The Unit Manager and LPN 8 could not locate page 1 of the controlled substance record for Resident D's Oxycodone or the medication card that correlated with page one of the controlled substance records. There should have been a card of 22.5 Oxycodone tablets and a sheet that correlated. The resident's medication appeared to be missing. QMA 9 was the last to sign off of the page 1 controlled substance record based on the MAR and she was the first to sign off on the page 2 of the controlled substance record on 4/23/24 at 8:00 a.m. On 4/30/24 at 3:13 p.m., the Director of Nursing indicated an in-service was completed for the QMA's on 3/8/24. They had noticed QMA 9 had been administering more of the as needed narcotic medications to the residents who did not normally request as needed narcotic medications. On 4/30/24 at 12:10 p.m., the Director of Nursing provided a current copy of the document titled Abuse - Identification of Types dated 10/4/22. It included, but was not limited to, Policy .Misappropriation of Resident Property .the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident property .without the resident's consent .Misappropriation of Property .Examples of misappropriation of resident property include but are not limited to .Missing prescription medications or diversion of resident's medication 3.1-28(a)

Based on observation and interview, the facility failed to ensure food served was maintained at an appropriate temperature for 1 of 1 Hall tray carts observed for food temperatures. (300 Hall Cart) Findings include: On 1/29/24 at 12:58 p.m., during an observation of the lunch meal pass on the 300 Hall with the Dietary Manager, the following food temperatures were observed: - Beef Stew - 110 degrees - Fried tomatoes - 110 degrees - Biscuit - 100 degrees During an interview on 1/29/24 at 2:00 p.m., Resident E indicated that a lot of times, the food served was barely warm. During an interview on 1/29/24 at 2:20 p.m., Resident F indicated that 40 % (percent) of the time, the food was just not warm. Breakfast was the worst because no one wants to eat cold eggs. On 1/29/24 at 2:30 p.m., Resident H indicated she liked her food hot, but when they brought it to her, it had minimal warmth. On 1/29/24 at 2:38 p.m., Resident G indicated she liked her food served hot. The food was not even warm by the time she received it in her room. On 1/29/24 at 3:04 p.m., the Executive Director provided a current copy of the document titled Food Temperature Control dated 10/4/19. It included, but was not limited to, Policy .Food temperatures are maintained during mealtimes to ensure residents receive safe food served at acceptable temperatures .Guidelines .Hot foods are held at a minimum of 135F or per state requirements This Citation relates to Complaint IN00425590 3.1-21(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate storage and labeling of medications for 3 of 4 medication carts observed for medication storage and labeling. (100 Hall Front Medication Cart, 100 Hall Back Medication Cart, and 200 Hall Front Medication cart) Findings include: 1. During an observation of the 100 Hall Front Medication Cart on 10/6/23 at 11:05 a.m., the following concerns were observed: a. Resident 58's albuterol sulfate 90 mcg/act (micrograms per actuation) inhaler was stored lying on its side. The medication packaging storage instructions indicated to store the inhaler with the mouthpiece down. The record for Resident 58 was reviewed on 10/6/23 at 11:45 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and asthma. The physician's order, dated 5/21/23, indicated the resident received albuterol sulfate 108 (90 mcg base) every 6 hours as needed for COPD. b. There were two unlabeled bottles of lidocaine 200 mg/20 mL (milligrams per milliliters) lying in the top drawer. One of the bottles was opened and partially used, with visible puncture marks present on the rubber seal. During an interview on 10/6/23 at 11:07 a.m., LPN (Licensed Practical Nurse) 19 indicated the lidocaine was for Resident 100. She had been on an antibiotic, ceftriaxone, which had required being mixed with lidocaine. She was no longer on the medication. The record for Resident 100 was reviewed on 10/6/23 at 1:00 p.m. The physician's order, dated 9/9/23, indicated the resident received ceftriaxone sodium injection 1 gram reconstituted intramuscularly at bedtime for three days. The order was completed on 9/12/23. The record lacked documentation of any subsequent orders for lidocaine currently in use for the resident. 2. During an observation of the 100 Hall Back Medication Cart on 10/6/23 at 11:10 a.m., Resident 62's insulin aspart flex pen was observed to be opened, with an open date of 6/12/23 written on the pen. The pen had been opened and used, with approximately 100 units left in the pen. During an interview on 10/6/23 at 11:16 a.m., LPN 19 indicated she could see the open date of 6/12/23 written on the pen. She thought the insulin pen was good for 90 days once opened. The record for Resident 62 was reviewed on 10/6/23 at 12:05 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus and long term use of insulin. The physician's order, dated 6/12/23, indicated the resident received insulin aspart per sliding scale subcutaneously twice daily for diabetes mellitus. 3. During an observation of the 200 Hall Medication Front Cart on 10/6/23 at 11:18 a.m., the following concerns were observed: a. Resident 62 had a novolog flex pen on the medication cart. The pen was open with approximately 120 units left in the pen. The pen was located in a bag with another resident's name on it. The open date on the insulin pen was 6/1/23. During an interview on 10/6/23 at 11:20 a.m., QMA (Qualified Medication Aide) 1 indicated Resident 62's insulin should not have been on the 200 Hall Front Medication Cart. She was not on her hall and never had been. During an interview on 10/6/23 at 11:33 a.m., LPN 19 indicated Resident 62 was on the 100 Hall and there was no reason why her insulin should be on the 200 Hall medication cart. b. Resident 84's novolog flex pen was opened, with a date of 6/28/23 written on the bag in fading ink pen which was barely legible. During an interview on 10/6/23 at 11:21 a.m., QMA 1 indicated she thought the insulin was good for 30 days once opened and indicated the medication should have been pulled and discarded. She thought they had a reference for how long the medications were good for but she could not locate it. The record for Resident 84 was reviewed on 10/6/23 at 12:10 p.m. The diagnoses included, but were not limited to, diabetes mellitus type 2 and pre-diabetes. The physician's order, dated 11/7/22, indicated the resident received novolog flex pen per sliding scale every morning and at bedtime. c. Resident 53's insulin glargine pen was opened, with approximately 130 units left in the pen. The open date on the pen's bag was 8/21/23. The record for Resident 53 was reviewed on 10/6/23 at 12:15 p.m. The diagnoses included, but were not limited to, diabetes mellitus type 2 and long term use of insulin. The physician's order, dated 7/26/23, indicated the resident received insulin glargine 10 units subcutaneously daily. d. Resident 6's albuterol HFA 90 mcg/act was stored on its side. The medication package indicated to store the inhaler with the mouthpiece down. The record for Resident 6 was reviewed on 10/6/23 at 12:20 p.m. The diagnoses included, but were not limited to, congestive heart failure and obstructive sleep apnea. The physician's order, dated 6/18/23, indicated the resident received albuterol HFA 109 (90 mcg base) every 4 hours as needed for shortness of air. During an interview on 10/6/23 at 11:35 a.m., the DON (Director of Nursing) indicated the staff should have a reference for medication storage dates in their toolbox. The Novolog (insulin aspart) injection storage conditions insert, provided on 10/10/23 at 8:00 a.m. indicated the 3 mL single patient use flex touch pens were to be discarded after 28 days once opened. The insulin Lispro injection storage conditions insert, provided on 10/10/23 at 8:00 a.m. indicated the 3 mL single patient use pens were to be discarded after 28 days once opened. The insulin glargine injection storage conditions insert, provided on 10/10/23 at 8:00 a.m., indicated the 3 mL single patient use pens were to be discarded after 28 days once opened. 3.1-25(j)

Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 3 of 3 months reviewed. (August, September and October 2023). This had the potential to affect all 113 residents currently residing in the facility. Findings include: The review of the August through October 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: August: Sunday 8/6 = only 6.0 hours Saturday 8/12 = only 6.0 hours Sunday 8/13 = only 6.0 hours Sunday 8/20 = only 6.0 hours Saturday 8/26 = only 6.0 hours Sunday 8/27 = only 6.0 hours September: Saturday 9/2 = only 6.0 hours Sunday 9/3 = only 6.0 hours Saturday 9/9 = only 6.0 hours Sunday 9/10 = only 6.0 hours Saturday 9/16 = only 6.0 hours Sunday 9/17 = only 6.0 hours Saturday 9/23 = only 6.0 hours Sunday 9/24 = only 6.0 hours October: Sunday 10/1 = only 6.0 hours During an interview with the Director of Nursing on 10/5/23 at 3:30 p.m., she indicated she was aware of the RN coverage being short on the weekends and indicated they were trying to add more RNs to cover the daytime too. 3.1-17(b)(3)

Based on record review and interview, the facility failed to ensure staff completed dementia training for 8 of 10 employee records reviewed. Findings include: The Employee Records were reviewed on 10/6/23 and 10/10/23. The following staff had not completed their required initial and/or annual dementia training: - Laundry Aide 3 was hired on 1/30/12. The Laundry Aide's employee record lacked the annual 3 hours dementia training - CNA (Certified Nurse Aide) 4 was hired on 2/15/23. The CNA's employee record lacked the initial 6 hours dementia training - CNA 5 was hired on 10/11/18. The CNA's employee record lacked the annual 3 hours dementia training - CNA 6 was hired on 1/24/23. The CNA's employee record lacked the initial 6 hours dementia training - ADON (Assistant Director of Nursing)/RN 2 was hired on 4/4/23. The ADON's employee record lacked the initial 6 hours dementia training - RN 7 was hired on 12/13/16. The RN's employee record lacked the annual 3 hours dementia training - QMA (Qualified Medication Aide) 9 was hired on 1/21/21. The QMA's employee record lacked the annual 3 hours dementia training. - Cook 10 was hired on 1/25/05. The Cook's employee record lacked the annual 3 hours dementia training. During an interview on 10/10/23 at 9:00 a.m., the ED (Executive Director) indicated the staff reviewed had not completed their dementia training. During an interview on 10/10/23 at 9:34 a.m., the Dementia Unit Manager, indicated the ADON, RN 7, CNA 4, CNA 5, and QMA 9, had worked in the dementia unit. On 10/10/23 at 10:39 a.m., the DON (Director of Nursing) indicated they did not have a policy for dementia training, but they did follow the State Guidelines. They required 6 hours of dementia training within 6 months of hire. If a staff was working on the dementia unit the 6 hours would have to be completed within 30 days and the 3 hours of dementia training would have to be completed annually.

Based on observation, record review, and interview, the facility failed to develop and implement appropriate interventions to prevent falls for 1 of 5 residents reviewed for falls. (Resident 55) Findings include: The record for Resident 55 was reviewed on 10/5/23 at 8:11 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, lack of coordination, muscle weakness, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, dementia, overactive bladder, history of falling, and pain in right hip. The care plan, dated 5/21/22, indicated the resident had bowel and bladder incontinence at times and was at risk for skin breakdown and infection with ongoing incontinence. The intervention, initiated on 7/14/22, indicated staff were to check the resident every 2 hours and assist with toileting as needed. The Annual MDS (Minimum Data Set) Assessment, dated 4/19/23, indicated the resident was moderately cognitively impaired,usually incontinent of urine and always continent of bowel, and required extensive assistance of one staff member with toileting and personal hygiene. The nurse's note, dated 6/14/23 at 6:40 a.m., indicated the resident was found sitting on the floor next to her bed with her walker in front of her. She indicated she was going to the bathroom and had slippers on. She complained of minimal discomfort to her lower back and she felt fine to go back to bed. The nurse's note, dated 6/14/23 at 7:03 a.m., indicated the nurse went in to follow up on the resident and found her half off the bed with her right leg off and rotated out. The physician was notified with new orders were received to send the resident to the hospital to be evaluated and treated. The nurse's note, dated 6/14/23 at 3:53 p.m., indicated the resident was admitted to the hospital with a fracture of her left hip. On 6/15/23, the resident's risk for falls care plan was updated with a new intervention to provide a scoop mattress. The nurse's note, dated 6/17/23 at 3:07 p.m., indicated the resident was readmitted to the facility. She required assistance of 2 staff members. She was oriented times 2. She was educated on using her call light for assistance with toileting and any needs. The nurse's note, dated 6/20/23 at 9:50 p.m., indicated the resident was able to make her needs known, required maximum assistance of 2 staff with bed mobility and transfers, was incontinent of bowel and bladder, and staff provided perineal care every 2 hours and as needed. The Social Services note, dated 6/22/23 at 7:47 p.m.,indicated the resident had an assessment and scored a 12 on her BIMS (Brief Interview of Mental Status) assessment which indicated her cognitive functioning was moderately impaired. The nurse's note, dated 7/21/23 at 6:00 a.m., indicated the resident was found sitting on the floor, facing her bed, with her legs stretched out in front of her. The resident indicated she was trying to go to the bathroom. Staff encouraged the resident to use the call light for assistance. The IDT (Interdisciplinary Team) note, dated 7/24/23 at 10:00 a.m., indicated the root cause of the resident's fall was the resident transferring herself without assistance. The new intervention was to encourage the resident to seek out staff for assistance with transfers. The nurse's note, dated 8/12/23 at 2:11 a.m., indicated the resident was found lying on the floor. She had a large contusion of her left forehead that was bleeding. She also had a skin tear to her left arm. She was alert but slow to respond. She said she was going to the bathroom and did not want to bother anyone for help. Her call light was pinned to her blanket where she could reach it. The NP (Nurse Practitioner) ordered to send the resident to the hospital. The nurse's note, dated 8/12/23 at 4:30 a.m., indicated the hospital reported the resident was returning. She had no fractures. The resident's family member spoke to the nurse and voiced concerns over the amount of falls the resident had recently. He asked for a care conference ASAP (as soon as possible) because he felt the resident's needs were not being met when she put her call light on and he would like it addressed immediately. The resident had not put her call light on earlier. The nurse informed the son she would pass the message on to the DON (Director of Nursing) and unit manager. The resident was being toileted before being helped into bed. The IDT note, dated 8/14/23 at 9:49 a.m., indicated the intervention put into place was for staff to offer and assist with toileting every 2 hours throughout the night. The nurse's note, dated 8/19/23 at 6:25 a.m., indicated the nurse heard a noise while sitting at the desk and looked up. The resident was sitting on her buttocks on the floor with her back against the dresser. Her wheelchair was next to her. The resident stated she was getting up to go to the bathroom. Her call light was not on. She had three abrasions to her back and two hematomas. One hematoma was present on her right and between her ring and pinky fingers, and the other one was present to her shin. She was assisted to her wheelchair, toileted and assisted to bed. She was reminded to use her call light to ask for assistance and not self transfer. She was to wear hipsters at all times. The nurse's note, dated 8/23/23 at 3:33 a.m., indicated the nurse looked up and found the resident sitting on the end of her roommate's bed. No call light was on, and her wheelchair was not by her. The resident was toileted and assisted back to bed and encouraged to use her call light. During an observation, on 10/6/23 at 11:02 a.m., Resident 55 was sitting in her wheelchair in her room, in front of her bed. A orange neon sign was on the shelf hanging up reminding her to use her call light. Her call light was sitting on her bed, approximately 4 feet away from her and behind her, well out of her reach. During an observation on 10/6/23 at 2:02 p.m. CNA (Certified Nurse Aide) 15 assisted Resident 55 to toilet. CNA 15 stood by as CNA 15 assisted the resident to stand at the grab bar, removed her brief and pants and onto the toilet. During an interview on 10/6/23 at 2:03 p.m., CNA 15 indicated the resident toileted very well. She was an assist of one. The resident would let them know when she needed to use the resident. She never forgot to use her call light. She was really alert. She would use the restroom about every hour. She had some incontinence, but most of the time she was continent. During an interview on 10/10/23 at 9:21 a.m., RN 17 indicated she was the nurse for Resident 55 and she was somewhat familiar with her. She hadn't been here to see any of her falls or even had to do neurological checks on her. She did know she was a fall risk. The resident knew her name but she had a lot more confusion lately. She was not sure if the resident used her call light anymore. It was usually within reach. She could provide education as best as she could but she was not sure if the resident would retain the education. To her, the resident's memory was not as intact as it was before she had her hospitalization for the broken hip. A couple months ago she was trying to transfer herself and she would not put her call light on. As the nurse, if a resident had a fall, they could make a suggestion on an interventions. With each fall they had to have a intervention. They would look at what had been done in the past and see if something better or new could be done. They usually went off of what happened with the fall and if it was something they could prevent in the future. If a resident was trying to toilet, they should do every two hour checks. The aide needed to be going in there every two hours and asking if they needed to use the restroom and provide education on using the call light During an interview on 10/10/23 at 9:26 a.m., CNA 18 indicated if they did not ask the resident if she wanted to go to the restroom, she would lay there and be soaking wet. In regard to her mentality, she was very confused and it had been like that for a long time, as far as she could recall her being at the facility. She would try to take herself to the bathroom. As long as they asked her, she did really good. She offered the resident to go to the bathroom every two to three hours. She was not aware of any specific interventions for a toileting schedule. She did not think if staff told her to use her call light she would remember to use it. She would not put her call light on. To her knowledge, they had not tried any toileting schedules in the past. During an interview on 10/10/23 at 9:33 a.m., the DON indicated if there was a fall, the floor nurse would call the manager on call and they helped make a new intervention. If the nurse had a problem coming up with it on their own, the IDT would review it. They were supposed to put an intervention that would immediately help with the fall and those interventions were reviewed in morning meeting. They did a root cause analysis. They looked at the BIMs. The resident's BIMs score was not high enough for education. The every two hours intervention on 8/18/23 would not have been an appropriate intervention since it was already on her care plan. The Fall Management Policy, last revised 9/22/23, provided on 10/10/23 at 10:20 a.m. by the DON, included, but was not limited to, . Federal Regulations . The facility must ensure that . Each resident receives adequate supervision and assistance devices to prevent accidents . Avoidable Accident - This means an accident occurred because the facility failed to . Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan, and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident . Monitor the effectiveness of the interventions and modify the care plan if necessary . 4. The interdisciplinary team will review and revise the care plan, if indicated . upon a fall event and as needed thereafter . 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure a urine and blood work were sent to the laboratory for testing as ordered by the physician for 1 of 3 residents reviewed for laboratory testing. (Resident 45) Findings include: The record for Resident 45 was reviewed on 10/4/23 at 9:31 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplagic (BPH) without lower urinary tract symptoms, retention of urine, muscle weakness, rhabdomyolysis, hypertensive ischemic heart disease, and supraventicular tachycardia. The Quarterly Minimum Data Set (MDS) assessment, dated 9/26/23, indicated the resident had severe cognitive impairment; required extensive assist of 2 staff for bed mobility, transfers and toilet use; was non-ambulatory; was frequently incontinent of bladder; and had bilateral lower and upper impairments in functional range of motion. A care plan, initiated on 6/29/19 and revised on 8/3/21, indicated the resident had an altered cardiovascular status related to coronary artery disease and hyperlipidemia. The goal indicated the resident would be free from cardiac complications. The approaches included, but were not limited to, administer medications as ordered and labs as ordered. A care plan, dated 11/8/22, indicated the resident had a history of bladder incontinence and was at risk for complications of infection and had a diagnosis of history of BPH. The goal was for the resident to have a reduced risk for UTI (urinary tract infection). The approaches included, but were not limited to, labs as ordered and notify physician of s/s (signs/symptoms) of a UTI. A nurse's note, dated 9/11/23 at 11:32 a.m., indicated new orders for thyroid function testing (TSH - thyroid stimulating hormone, Free T3, Free T4) and Hepatic function ( CBC - complete blood count and CMP - comprehensive metabolic profile) to be drawn now (for baseline) and every 6 months per pharmacy recommendation related to the use of amiodarone. Documentation was lacking of the resident's laboratory test having been drawn now per order and were not drawn until 9/19/23 - 8 days later. A nurse's note, dated 9/29/23 at 4:15 p.m., indicated new orders for a UA (urinalysis) CS (culture and sensitivity) and a CBC and CMP related to possible UTI. Documentation was lacking in the clinical record of the UA and blood work having been collected. During an interview with QMA (Qualified Medication Aide) 1 on 10/6/23 at 9:55 a.m., she indicated that if a UA was ordered during the week, it would be collected and sent out the next day. If it was the weekend, then it would be collected on Sunday and then sent out Monday morning. Labs were done right away as there was only a limited time the specimen could sit. She had worked on the resident's hall and had not been made aware of that there was an order for a UA or blood work to be done. During an interview with RN 2 on 10/6/23 at 1:50 p.m., she indicated It was human error that the UA was not put into the lab book to be completed as ordered and that the only reason she could find for the nurse to get that order for a UA was because the NP (Nurse Practitioner) noted confusion in the resident. The UA and blood work should have been drawn as ordered. She also indicated that the reason the labs were never drawn until 9/19/23 was because he already had standing orders for those labs scheduled for 9/19, so they were just combined with his routine labs. It was a pharmacy recommendation on 8/31/23 that since he was on the amiodarone, he should have thyroid function tests and hepatic function test done every 6 months. When the pharmacy recommendation was shown to her that it was recommended for a baseline be drawn now and then compared again in 6 months, she indicated she did not see that part of the recommendation. 3.1-49(a)(2)

Based on observation, record review and interview, the facility failed to ensure treatment and interventions were provided for 1 of 5 residents reviewed for Quality of Care. (Resident 260) Findings Include: During an observation on 10/04/23 at 8:30 a.m., Resident 260's dressing to her left shoulder was saturated with a large amount of serosanguineous drainage, bright red blood, and dried dark colored blood. The dressing was falling off in places. The dressing had a foul odor and the resident indicated her dressing had not been changed. The resident indicated the odor had improved slightly but the wound still had a bad odor. The serosanguinous drainage was observed on the pad in her bed. During an observation on 10/04/23 at 11:00 a.m., Resident 260's dressing to her left shoulder was saturated with a large amount of serosanguineous drainage, bright red blood, and dried dark colored blood. The dressing was loose and was falling off in places. The dressing had a foul odor and the resident indicated her dressing had not been changed yet. During an observation on 10/04/23 at 1:00 p.m., Resident 260's dressing to her left shoulder was saturated with a large amount of serosanguineous drainage, bright red blood, and dried dark colored blood with a whitish colored drainage seeping through the dressing. The dressing was falling off in places. The dressing had a foul odor and the resident indicated her dressing had not been changed yet. The record for Resident 260 was reviewed on 10/3/23 at 9:30 a.m. The diagnoses included, but were not limited to, malignant neoplasm of the connective and soft tissue, hypertension, localized swelling, mass and lump of the left upper limb. The Admission MDS (Minimum Data Set) assessment, dated 10/9/23, indicated the resident was cognitively intact. The physician's order, dated 9/30/23, indicated staff were to cleanse the tumor to the left shoulder with normal saline, pat dry, crush the antibiotic and sprinkle directly on the wound, apply Dakin's half strength moist gauze to the area, cover with ABD (Abdominal Pads) and secure with tape. Flagyl 500 mg (milligrams) was to be applied to the resident's left shoulder topically three times a day for the tumor. The care plan, dated 9/28/23, indicated the resident had a break in her skin integrity. The interventions included, but were not limited to, educate the resident and family regarding her skin problem and treatment, a pressure reducing mattress, treatments as ordered by the physician and weekly skin assessments. The wound note, dated 9/28/23, indicated the wound measurements were 38 cm (centimeters) in length and 37 cm in width with 0 depth. The wound was a malignant tumor with slough and necrotic tissue. Drainage included a small amount of serosanguineous drainage and there was a foul odor. The treatment included cleanse with normal saline, pat dry, Alginate to area, cover with abdominal gauze pads and secure with tape every shift and prn (as needed). During an interview on 10/04/23 at 2:07 p.m., LPN (Licensed Practical Nurse) 13 indicated the resident's dressing would be changed 3 times a day. The dressing was last changed between 7:00 and 8:00 am. The resident's dressing had a lot of drainage and the nurses could change the dressing if it became saturated. The dressing had not been changed since the morning. She indicated the dressing was not holding up for 8 hours with all the drainage. During an interview on 10/5/23 at 11:30 a.m., the wound physician indicated she did see the resident per request of the facility. She indicated the tumor was inoperable and the resident's diagnosis was terminal. The tumor would eventually cave in on itself and there would be foul odor and drainage. During an interview on 10/5/23 at 11:35 a.m., LPN 4 indicated the staff tried to give the resident a shower daily due to the odor. The odor had improved but was still there and the resident had to be put in a private room. During an interview on 10/6/23 at 10:34 a.m., the DON (Director of Nursing) indicated if the resident's dressing was saturated, the nurse should have changed the dressing. The dressing change order was for three times a day and prn. The nursing staff should have changed the resident's dressing before it became that saturated. That was the reason the resident had an order for prn dressing changes. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide coverage and odor protection for a resident related to expressed embarrassment for 1 of 5 residents reviewed for dignity. (Resident 260) Findings include: During an observation, on 10/5/23 at 8:00 a.m., the resident's dressing to her left shoulder was laying in the bed. The malignant tumor was exposed. The resident indicated she wrapped a towel around the tumor to catch the drainage. The pad on the resident's bed was soaked with serosanguineous drainage. The dressing was not dated but the time indicated 6:00 a.m. The resident indicated she did not get out of her room much, but she thought she should. During an observation, on 10/5/23 at 10:00 a.m., the resident was sitting on the side of the bed and her tumor was exposed. The dressing remained in the resident's bed. During an observation, on 10/5/23 at 10:30 a.m., LPN (Licensed Practical Nurse) 12 was providing wound care. She wrapped the tumor in a warm towel and left it on for about 15 minutes. The resident indicated the warm towel felt good to her. The LPN cleansed the tumor with wound cleanser. She patted dry the tumor and applied the antibiotic. The tumor had several small to dime size abrasion areas that were open. The middle of the tumor had olive green tissue and the tumor had some bleeding with serosanguinous drainage. Areas of the tumor had medium to large size nodules. The tumor was vascular and the peri skin around the wound was a bluish color. The tumor was approximately the size of a medium pumpkin and irregular in shape. She indicated the dressing would be changed 3 times a day and prn (as needed). When the resident's dressing became saturated or fell off the staff should have changed or applied a new dressing as needed. The record for Resident 260 was reviewed on 10/4/23 at 9:30 a.m., the diagnoses included, but were not limited to, malignant neoplasm of the connective tissue and soft tissue, hypertension and localized swelling, mass and lump of the left upper limb and thyrotoxicosis. The Admission MDS (Minimal Data Set) assessment, dated 10/9/23 indicated the resident was cognitively intact. During an interview on 10/6/23 at 10:34 a.m., the DON (Director of Nursing) indicated if the residents dressing was off, and the tumor was exposed nursing should have replaced the dressing or at least covered it with a temporary dressing until she could do the wound care. The resident should not have to sit there with the tumor exposed and could be observed from the doorway. During an interview on 10/10/23 at 10:35 a.m., Resident 260 indicated she did not like for other people to see her tumor. She preferred to have it covered up or at least the door closed. The Resident Rights policy, dated 11/21/22 included, but was not limited to, . (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . 3.1-3(a)

Based on record review and interview, the facility failed to ensure residents were free of significant medication errors which resulted in Resident D being hospitalized for hypoglycemia after receiving an anti-diabetic medication without a diagnosis of diabetes for 1 of 3 resident's whose medication regimens were reviewed. Findings include: The record for Resident D was reviewed on 8/21/23 at 10:00 a.m. The resident did not have any diagnoses related to or including diabetes. The record lacked documentation of any blood sugar monitoring orders or blood glucose levels in the last 12 months prior to 5/11/23. The physician's order, dated 5/11/23 at 5:42 p.m., indicated RN 4 input an order for the resident to have glipizide (anti-diabetic medication) 5 mg (milligrams) daily for diabetes. NP (Nurse Practitioner) 3 signed off on the order on 5/12/23 at 12:45 p.m. The order note, dated 6/30/23 at 11:52 a.m., indicated the resident was prescribed Bactrim DS (double strength) tablet 800-160 mg 1 tablet daily for a UTI (urinary tract infection) and it had triggered a drug-to-drug interaction. The interaction severity was moderate and indicated the hypoglycemic action of glipizide 5 mg could be increased by the use of Bactrim DS. The record lacked documentation of any notification to the physician of the drug-to-drug interaction or any blood glucose monitoring. The nurse's note, dated 7/3/23 at 12:43 p.m., indicated NP 3 ordered blood tests including a CBC (complete blood count), CMP (complete metabolic panel), and Vitamin D level due to the resident's family member having concerns that his shakiness was getting worse, however the resident did not feel it was. The laboratory report, dated 7/4/23, indicated the resident's blood glucose level was critically low at a value of 40 mg/dL (milligrams per deciliter). The report indicated a normal value for fasting glucose was 65 to 99 mg/dL and normal value for non-fasting glucose was 65 to 125 mg/dL. The nurse's note, dated 7/4/23 at 11:53 a.m., indicated the laboratory called with a critical glucose level of 48 mg/dL. The resident's blood sugar after breakfast was 146 mg/dL and he had no signs or symptoms of hypoglycemia. NP 3 was notified and gave new orders for a CBC, CMP, and Vitamin D in the morning. She would review all labs before making any adjustments. The record lacked documentation of any further glucose monitoring or changes to the resident's medication regimen. The nurse's note, dated 7/6/23 at 9:51 a.m., indicated the resident was up in his wheelchair at the nurse's station and was observed to have involuntary movements and jerking with his head, legs, arms, and eyes. The on-call NP was notified and gave orders for immediate lab testing and to send to the hospital if he got worse or did not get better. The POA (Power of Attorney) was notified. While on the phone the resident had increased movements and confusion and the POA requested he be sent to the hospital. 911 was called. The resident had episodes of movement and jerking for approximately 20 minutes then left via ambulance. The resident's vitals were 128/95 blood pressure, 86 heart rate, 96% O2, and 18 on respirations. A blood sugar level was not documented. The laboratory report from the specimens obtained on 7/5/23 resulted on 7/6/23 after the resident had gone to the hospital. The report indicated the resident's glucose was less than 32 mg/dL, which was flagged as a critical low value. The hospital discharge summary, dated 7/11/23, indicated the resident had presenting problems including bradycardia, hypoglycemia, and urinary tract infection. The resident had no documented history of diabetes but was found to have glipizide on his medication list from the facility. His A1C was 5.2. The glipizide was discontinued, and he required D10 (dextrose 5% IV fluids) briefly and D5W (dextrose 5% in water), both of which had been weaned off and the blood glucose had improved. The resident developed bradycardia overnight, which was likely secondary to hypoglycemia and sepsis. He had acute metabolic encephalopathy also likely secondary to hypoglycemia and his Parkinson' disease. He had presented to the emergency department with hypoglycemia. His family confirmed he was not a diabetic. The emergency department found he had a heart rate of 48 and a blood sugar of 28 mg/dL. The lab report from 7/6/23 at 11:35 a.m. indicated the resident's blood glucose was 26 mg/dL. The typed DON's statement indicated, on 7/12/23, she spoke with RN 4 via telephone related to the order for Resident D for glipizide 5 mg daily. RN 4 indicated she did not remember putting the order in. She had no idea where the order came from. She did not remember speaking to the physician or NP and receiving the order. She normally always notified family and put in progress notes with any new orders or changes. During an interview on 8/21/23 at 11:43 a.m., NP 3 indicated she did not order glipizide for the resident, however she would take fault that she signed off on the order. She was only signing orders every month or so, and was not reviewing every single order. She missed it. She would not use glipizide as a first line medication for diabetes, and if she did order something she would document that she was ordering it and why. She did not see the resident and did not order the medication. She did not know how he got it. She was not aware of the drug-to-drug interaction warning for Bactrim and glipizide and should have been made aware. She would have written to monitor his blood sugars. In passing the nurse told here the resident had a critical glucose level and had just rechecked it and it was 168 mg/dL. She ordered to repeat the lab testing. From his record he did not have diabetes. They had not identified issues with the drug-to-drug interactions and that would have to be corrected. During an interview on 8/21/23 at 12:45 p.m., the ED (Executive Director) indicated they were unable to figure out how or why the resident ever received an order for glipizide. They could not locate any documentation to indicate any orders for glipizide for any other residents in the facility for the dates of the original order on Resident D. He did not know what had happened. The Physician Orders policy included, but was not limited to, . A physician, physician assistant, or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident . 9. Any orders written by a consulting physician must be reviewed and signed by the resident's attending physician . The LTC Facility's Pharmacy Services and Procedures Manual, included but was not limited to, . 6.3 Orders that may not be accepted by the pharmacy from the electronic medical record system include . Orders with missing diagnoses . 12. Facility should review any Pharmacy communication letters attached to medications dispensed by Pharmacy including . 12.1 Drug-drug interaction monographs providing resident monitoring information and adjust the resident's care plan, if necessary . Moderate Interaction . Assess risk to patient and take action as needed . 13.5 Facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of the Physician/Prescriber, and the signature of the person receiving the orders . 14. Facility should be able to identify the original Physician/Prescriber when the original Physician/Prescriber is someone other than the attending physician . The General Dose Preparation and Medication Administration policy included, but was not limited to, . 4. Prior to administration of medication, Facility staff should take all measures required by facility policy and Applicable Law, including, but not limited to the following . Facility staff should . Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route,, at the correct rate, at the correct time, for the correct resident . The deficiency cited was past non-compliance when the facility completed staff education, residents medication order audit, physician order process reviewed and monitored prior to the entrance of the survey. This Federal tag relates to Complaint IN00412769. 3.1-48(c)(2)

A. Based on record review and interview, the facility failed to ensure infection control practices were followed during the COVID-19 pandemic for residents with symptoms of COVID-19 and/or exposure to positive COVID-19 residents. The facility failed to identify symptoms of COVID-19, and did not isolate, and promptly provide testing or treatment to mitigate the potential spread of COVID-19 for 6 of 9 residents reviewed for infection control related to COVID-19. (Residents 2, 3, 4, 5, 6, and 7) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to identify signs and symptoms of COVID-19 for 5 COVID 19 positive residents, and 1 PUI (Patient Under Investigation), promptly notify the physician, isolate, and test the residents timely for COVID 19. The residents progressively worsened, and 4 passed away at the hospital. The Executive Director, Interim Director of Nursing, Divisional Vice President of Operations, and Regional Director of Clinical Operations were notified of the Immediate Jeopardy on [DATE] at 6:35 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of E. B. Based on observation and interview, the facility failed to ensure transmission based precautions on the COVID-19 unit were followed and appropriate sanitation of meal delivery carts. This deficient practice had the potential to affect all 18 residents residing on the COVID-19 Red Unit. Findings include: A. 1. During the clinical record review on [DATE] at 9:30 a.m., Resident 2's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. If O2 sat (oxygen saturation) was less than 90% administer O2 at 2 lpm (liters per minute) and notify the DON and MD immediately. The Vitals Report indicated the resident presented with the following above range temperatures on the following dates: - On [DATE] 99.6 F (Fahrenheit) at 2:58 p.m. - On [DATE] 99 F at 12:53 a.m., and 100.8 F at 8:00 p.m. - On [DATE] 99 F at 12:39 a.m. - On [DATE] 104 F at 4:36 p.m. and 100.6 F at 10:14 p.m. - On [DATE] 100.2 F at 3:23 a.m., 99.4 F at 9:54 a.m., 99.6 at 12:01 p.m., and 99 F at 11:52 p.m. - On [DATE] 99 F at 3:16 a.m., 99 F at 9:09 a.m., 101.3 at 1:32 p.m., 100.3 at 5:25 p.m., and 99.7 at 9:01 p.m. - On [DATE] 99.7 at 12:23 a.m., 99.8 at 3:39 a.m., 99.5 at 1:37 p.m., 99.5 at 1:42 p.m., and 99.5 at 9:33 p.m. - On [DATE] 100.6 F at 2:58 p.m. The clinical record lacked documentation of any notification to the physician of the increased temperatures prior to [DATE], and lacked any orders for isolation or COVID-19 testing prior to [DATE]. The nurse's note, dated [DATE] at 12:35 a.m., indicated the resident had one episode of fever 100.3 F. The NP (Nurse Practitioner) was notified. No orders for isolation or COVID-19 testing were written at this time. The orders administration note, dated [DATE] at 9:36 p.m., indicated the resident received 2 tablets of Tylenol 325 mg for a fever of 104.2 F. The DON and NP were notified. No new orders were given at that time. The nurse's note, dated [DATE] at 1:40 p.m., indicated the nurse communicated the change in vital signs to the nurse practitioner and orders were received. The Health Status note, dated [DATE] at 2:05 p.m., indicated humidified oxygen was applied at 2 lpm (liters per minute) via nasal cannula (NC). The resident's oxygen saturation was assessed at 87% (normal acceptable range is 90% or greater). The nurse's note, dated [DATE] at 2:10 p.m., indicated the resident's oxygen was increased to 4 lpm. The resident had an O2 sat of 93% and continued to receive Tylenol. The NP was updated on the resident's status, and the resident was placed in droplet precautions at this time. The Transfer to Hospital Summary note on [DATE] at 3:52 p.m., indicated the resident was transferred to the hospital related to an increased temperature of 100.7 and a decrease in oxygen saturation to 86%. The hospital discharge paperwork dated [DATE] indicated the resident passed on [DATE]. The cause of death was listed as COVID-19 infection with [MEDICAL CONDITION]. During an interview on [DATE] at 4:14 p.m., the Interim DON indicated the resident did run multiple temperatures over both 99 F and 100 F. She did not know why the resident was not tested when her symptoms began. She would have definitely tested the resident. This was right around the time when the facility's first patient had become positive. There were a lot of things that could have been done differently. She would have been isolated, sent to the red zone, and O2 would have been administered. When the resident's temperature was 104.2 F, she would have instructed staff to send her out to the hospital. 2. During the clinical record review for Resident 3, on [DATE] at 10:00 a.m., the resident's [DIAGNOSES REDACTED]. The resident was listed as a Full Code (all resuscitation procedures will be provided to keep them alive). A nurse's note, dated [DATE] at 4:37 p.m., indicated the resident had a possible exposure to COVID-19. A physician's orders [REDACTED]. If O2 sat (oxygen saturation) was less than 90% administer O2 at 2 lpm (liters per minute) and notify the DON and MD immediately. The clinical record lacked documentation of any orders to isolate the resident at that time. The Vitals Report indicated Resident 3 presented with the following above range temperatures on the following dates: - On [DATE] 99.3 F at 12:21 p.m., 99.4 at 4:55 p.m., 99.6 at 4:56 p.m., and 99.4 at 10:30 p.m. - On [DATE] 99.4 F at 3:23 a.m. The clinical record lacked documentation of physician notification of any of these elevated temperatures. The communication with physician note, dated [DATE] at 12:50 p.m., indicated the resident was lethargic, and would not open her eyes to verbal stimuli. The NP was notified and did not give any orders at that time. The nurse's note, dated [DATE] at 12:59 p.m., indicated the resident was lethargic, the NP was notified and gave no new orders. The nurse's note, dated [DATE] at 11:00 a.m., indicated the resident was in bed with labored breathing, respirations were labored, her O2 sat was 76 % on room air with elevated blood pressure of ,[DATE], pulse was 46, blood sugar read HI. The NP was notified and the resident was sent to the hospital. The hospital note, dated [DATE], indicated the resident presented in extremis with mottled skin, [MEDICAL CONDITION], and severe [MEDICAL CONDITION]. COVID was suspected due to a recent exposure. After discussion with the resident's POA (power of attorney) it was decided the resident would be a DNR (Do Not Resuscitate). The patient stopped breathing and went asystolic (their heart stopped beating). No further resuscitative efforts were given at that time and she was pronounced deceased . The final [DIAGNOSES REDACTED]. During an interview, on [DATE] at 3:50 p.m., the County Health Department Administrator indicated the resident had not been tested for COVID, and the health department may have listed COVID-19 as a contributing factor, but it was never confirmed. During an interview, on [DATE] at 4:33 p.m., the ED indicated she could not locate a test for the resident when her roommate tested positive on [DATE]. She did not know why the resident did not receive any new orders when she was lethargic. During an interview, on [DATE] at 4:45 p.m., the DON indicated she was not sure why the resident was never tested . If her roommate came up positive she should have been tested for contact tracing. The resident also should have been tested when her temperatures were elevated. 3. During the clinical record review, on [DATE] at 11:58 a.m., Resident 4's [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) Assessment, dated [DATE], indicated the resident was moderately cognitively impaired. The care plan, dated [DATE], indicated the resident had impaired cognitive ability. Interventions included, but were not limited to, observe for and report any changes in cognitive function. A physician's orders [REDACTED]. The census report indicated Resident 4 was readmitted from the hospital on [DATE] to a room on the 500 hall yellow zone (a temporary quarantine unit for residents exposed to COVID-19 within the facility). Her roommate (Resident 5) was moved to the yellow zone on [DATE] and was cohorted with Resident 4. On [DATE], Resident 4 was moved off of the yellow zone onto the green unit (a regular unit where no isolation precautions were in place). Resident 4's roommate, Resident 5, began having symptoms of COVID-19 on [DATE], and was tested for COVID-19 on [DATE]. The facility moved Resident 4 to a green unit, with no isolation precautions in place, on [DATE], after she had been exposed to her roommate (Resident 5) who had been having symptoms for 6 days and had been tested the day before, on [DATE]. Resident 5's COVID-19 test result came back positive on [DATE]. The clinical record lacked documentation of any isolation precautions for Resident 4 from [DATE] thru [DATE]. The nurse's note, dated [DATE] at 12:16 p.m., indicated the resident had refused her lunch. The nurse's note, dated [DATE] at 5:36 p.m., indicated the resident was gagging when staff attempted to feed her dinner. The nurse's note, dated [DATE] at 8:31 p.m., indicated the resident was despondent and was not responding regularly to questions, prompts, or conversation. The resident continued to refuse to eat, which was unlike her. The nurse's note, dated [DATE] at 4:27 a.m., indicated the resident was yelling out, shivering, and her skin was pale, but was unable to describe what was wrong with her. The nurse requested the oncoming shift nurse to closely monitor for further developments. The nurse's note, dated [DATE] at 10:13 a.m., indicated the resident was very restless, yelling out, had refused breakfast, and required much encouragement to drink. The clinical record lacked documentation of physician notification of the decreased appetite, restlessness, yelling, shivering, or paleness. The MAR (medication administration record) indicated the resident received routine [MEDICATION NAME] 500 mg on [DATE] at 8:00 a.m. The nurse's note, dated [DATE] at 11:15 a.m., indicated the resident was lethargic and her oxygen saturation was 84%. Her temperature was 99.7 degrees. New orders were obtained for a chest x-ray. The MAR indicated [REDACTED] On [DATE] at 10:06 p.m., Resident 4's temperature was documented as 99.6. The resident's former roommate (Resident 5) tested positive for COVID-19 on [DATE]. The clinical record lacked any documentation of the resident being placed on isolation or tested at this time. The nurse's note, dated [DATE] at 10:31 a.m., indicated the resident was placed in droplet precautions and was moved to the COVID unit due to testing positive for COVID-19. The nurse's note, dated [DATE] at 6:44 a.m., indicated the resident had lethargy, and oxygen saturation below 95% on 2 lpm of oxygen. The resident was sent to ER. The hospital discharge summary, dated [DATE], indicated the resident was admitted to the hospital on [DATE] presenting with a UTI, pneumonia,[MEDICAL CONDITION], and COVID-19. She presented from the facility with reports of increased confusion, altered mental status, and fever. Her temperature was 100.7, oxygen 100% on 4 lpm. She was admitted to the hospital [MEDICAL CONDITION] secondary to healthcare associated pneumonia, COVID-19 infection, UTI.The hospitalist medicine was called for admission for acute kidney injury dehydration UTI acute metabolic [MEDICAL CONDITIONS] and COVID-19 infection . During an interview on [DATE] at 1:38 p.m., RN 5 indicated they monitored residents any time staff went into the resident's room. Things she would monitor for as signs of COVID would include fevers, acting lethargic, low O2 sats. She would call the NP if she noticed any symptoms, and as soon as she got an order, would COVID test and isolate the resident at that time. When she had cared for Resident 4 prior to her being sent to the hospital, she was not COVID tested or placed on isolation, and she was unsure why the resident was not tested or isolated at that time. During an interview on [DATE] at 2:54 p.m., the Interim DON indicated she did not know why the resident was not placed in isolation or tested on [DATE]. Two temperatures in a row over 99 F would be considered a fever. She ran a report for out of range vital signs every morning and would follow up on the abnormal temperatures. For temperatures, she looked at anything above 99 F, and oxygen she looked at anything below 90%. If the vitals were documented in the nurse's notes and not in the vitals flow sheets, she would not see them. If she would have seen it, as soon as she recognized the temperature level elevated and the oxygen decreased she would have definitely been tested , and at that point right then been placed in isolation. Resident 5 being positive could have definitely contributed to Resident 4 being positive. If Resident 5 had been isolated sooner, the outcome may have been different. Resident 4 did wind up going out to the hospital, it looked like she went out for a UTI, pneumonia of both lungs,[MEDICAL CONDITION]. It was very possible the [DIAGNOSES REDACTED]. If her temperatures had been tended to earlier and they were aware of her COVID-19 diagnosis, it could have potentially prevented her going to the hospital. She was not in that position, there was nobody monitoring at that time. It should have been done. She was not sure if anyone was monitoring to see if nurses were documenting vitals in the proper place. During an interview on [DATE] at 3:26 p.m., the Interim DON indicated she could not locate any documentation to indicate the resident was on droplet precautions prior to [DATE]. During a subsequent interview on [DATE] at 5:00 p.m., the interim DON indicated with all of the symptoms considered together, Resident 4 should have been tested sooner. During an interview on [DATE] at 12:45 p.m., the Executive Director indicated the DON was responsible from [DATE] to [DATE] for reviewing the 24 hour report sheet from the electronic medical record dash board. The reports are discussed in the clinical meetings. 4. During the clinical record review on [DATE] at 9:45 a.m., Resident 5's [DIAGNOSES REDACTED]. The care plan, with a start date of [DATE], indicated the resident was in droplet isolation. The interventions included, but were not limited to, notify MD (Medical Doctor) of elevated temperature, abnormal 02 (oxygen) sats (saturation), shortness of breath, cough or congestion. The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. The record indicated Resident 5 was admitted to the hospital on [DATE]. On [DATE] the resident returned to the facility to a room on the green unit in droplet isolation. A physician's orders [REDACTED]. Resident 5 was admitted into the yellow zone with Resident 4 on [DATE]. A review of the vital sign record on [DATE] at 9:45 a.m., indicated Resident 5 presented with the following above range temperatures on the following on the following dates: - On [DATE] 100.3 F at 10:55 p.m. - On [DATE] 99.6 F at 12:12 a.m. The MAR (Medication Administration Record) indicated the resident was administered the following medications on [DATE]: [MEDICATION NAME] ,[DATE] mg at 3:18 p.m. and [MEDICATION NAME] 325 mg at 7:54 p.m. The clinical record lacked documentation indicating Resident 4 was moved to another room, after Resident 5 starting having symptoms of COVID-19 on [DATE]. A progress note, dated [DATE] indicated, while collecting vital signs for shift assessment, the nurse noted temperature at 100.3 degrees Fahrenheit. The resident appeared pale, and skin was warm and dry. An occasional moist productive cough was observed, and the resident reported nausea and vomiting. The resident was unable to report number of emesis episodes. A progress note, dated [DATE], indicated the resident was observed yelling out multiple times for staff assistance despite easy access to call light. The resident was also requesting cares be performed repeatedly despite them having been just completed, including requesting fresh cups of ice water despite having a fresh cup available for her use. Additionally, while in the presence of two CNAs, the resident began to state, Please don't hit me. Don't hit me please. I've been so good. The nurse stated she has never hit her and never would. The resident continued to make the same statement multiple times and also yelled at roommate to help her with tasks despite being told her roommate is unable to assist her with any tasks due to her current physical condition. Temperature was 99.6. A nurse's note, dated [DATE], indicated the resident was observed out in the hall without a mask on yelling for her mom and dad. The resident stated her mother was sound asleep on the other side of the room and she believed another male resident to be her father. Attempts were made to reorient to reality without success. The clinical record indicated the resident was tested for COVID-19 on [DATE], and the test came back positive on [DATE]. During an interview on [DATE] at 3:00 p.m., the IP (Infection Preventionist) indicated there were some issues with the lab at that time. She was not sure if Resident 5 was one of the residents with a lost specimen. As soon as the resident had a temperature, she should have been COVID tested , and sent directly to the yellow zone for isolation. During an interview on [DATE] at 4:05 p.m., LPN 7 (Licensed Practical Nurse) indicated if a resident was on Tylenol or [MEDICATION NAME] and have a fever, nursing would do a respiratory assessment, test for COVID-19, call the NP, and isolate the resident. If a resident has to be moved to the yellow zone or admitted from the hospital, they would have to be tested for COVID-19 before cohorting the residents. 5. During the clinical record review on [DATE] at 11:30 a.m., Resident 6's [DIAGNOSES REDACTED]. The discharge MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was severely cognitively impaired. A review of the vital sign record on [DATE] at 9:45 a.m., indicated Resident 6 presented with the following above range temperature on the following dates: - On [DATE] 99.9 F at 9:01 p.m., and 99.6 F at 11:34 p.m. - On [DATE] 99.6 F at 03:27. - On [DATE] 100.6 F at 10:03 p.m., and 99.6 at 11:45 p.m. - On [DATE] 99.8 F at 03:45 a.m. - On [DATE] 99.8 F at 04:00 a.m. The progress note, dated [DATE] at 4:23 p.m., indicated the nurse went in to check on Resident 6 and noticed that the resident seemed lethargic and more confused from baseline. Vital signs were taken and were as follows: 02 saturation 87%, pulse 113, blood pressure ,[DATE]. The progress note, dated [DATE] at 6:09 p.m., indicated the resident had slept all day, when normally Resident 6 was active and ambulating in the hallways. The resident did not open her eyes to verbal stimuli and continued to sleep while vital signs were taken. The progress note, dated [DATE] at 12:49 a.m., indicated the resident was lethargic, refused meals and had not eaten today. The progress note, dated [DATE] at 12:49 a.m., indicated Resident 6 was not responding, temperature 99.7, 02 saturation 83% with 2 liters of oxygen on, heart rate was 130, blood pressure ,[DATE]. Orders were received to send Resident 6 to the emergency room for evaluation. The clinical record did not indicate the resident was placed in droplet precautions at any time before she was transferred to the emergency room for treatment on [DATE]. Resident 6 tested positive for COVID-19 on [DATE]. A review of the hospital discharge medical record, dated [DATE], indicated severe COVID-19 [MEDICAL CONDITION] infection and pneumonia. The resident expired on [DATE]. The clinical record lacked documentation indicating the DON was notified and an order was received to COVID test the resident. 6. The clinical record for Resident 7 was reviewed on [DATE] at 1:00 p.m. [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. A review of the vital sign record on [DATE] at 1:30 p.m., indicated Resident 7 presented with the following above range temperature on the following dates: - On [DATE] 102.0 F at 5:53 p.m., and 99.0 F at 8:01 p.m. - On [DATE] 99.8 F at 7:05 a.m. The clinical record, dated [DATE], lacked documentation of notifying the doctor for a temperature of 102.0. The progress note dated [DATE] at 7:30 a.m. indicated, Resident 7 complained of a headache. His temperature was 99.8, and oxygen saturation 89% on 3 liters of oxygen. The resident had a green mucous cough and congestion, shortness of air and a blood sugar of 54. The clinical record did not indicate the resident was placed in droplet precautions at any time before being transferred to the hospital for treatment on [DATE]. The resident tested positive for COVID-19 on [DATE]. A review of the hospital discharge medical record, dated [DATE], indicated pneumonia due to COVID-19 virus. The resident expired on [DATE] at 1:06 p.m. During an interview at [DATE] at 9:15 a.m., RN 6 indicated if a resident was having symptoms of COVID-19, she would isolate the resident, call the NP and inform the DON or the supervisor. The resident would be tested for COVID-19. During an interview on [DATE] at 9:30 a.m., LPN 7 indicated if a resident were having COVID-19 symptoms, she would isolate the resident, call the NP, and inform the nursing supervisor. During an interview on [DATE] at 5:25 p.m., the Infection Preventionist and Interim DON indicated Resident 7 should have been tested when her temperature was 102.0 (on [DATE]). The DON has the testing kits in her office. She would be the one to get the order and hand out the test. With Resident 6, she should have been tested when she started having symptoms. The outcome could have been different if she had been tested . The policy titled Standard and Transmission Based precautions for [MEDICAL CONDITION] and dated [DATE], which was provided on [DATE] at 1:55 p.m., by the ED, included, but was not limited to, . Actively screen all residents daily for fever (T>100.0 F) and symptoms consistent with COVID-19, ideally to include oxygen via pulse oximetry . Older adults with COVID-19 may not show typical symptoms consistent with COVID-19 such as fever or respiratory symptoms. Atypical symptoms may include new or worsening malaise . Identification of these symptoms should prompt isolation and further evaluation for COVID-19 . Additionally more than two temperatures >99.0 F might also be a sign of fever in the facility population . if fever or symptoms consistent with COVID-19 are present, immediately isolate and implement appropriate Transmission Based Precautions. This resident should be prioritized for testing, refer to COVID-19 Testing policy for additional guidance . This policy included the same guidance as the CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, dated as last updated [DATE]. The CDC guidance, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, also included, If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario The ISDH Guidance for out-of-hospital facilities, dated [DATE], indicated, The following is guidance for out of hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles: 1. Placement of patient /resident in contact-droplet precautions with proper PPE, including gown, glove, mask with face shield or eye protection. 2. Proper donning and doffing of personal protection equipment when in contact with COVID-19 residents Reduce the movement of staff between patients with and without COVID-19 precautions with proper PPE- gown, glove, mask with face shield or eye protection .Patients/residents with known or suspected COVID-19 should be cared for in a single-person (private) room with the door closed. Airborne infection isolation rooms (AIIR) are not required. Patients/residents with known or suspected COVID-19 should not share bathrooms with other patients/residents. All patients/residents returning from the hospital with suspected or confirmed COVID-19 should be cared for in a private room, or Cohorted with other patients of the same status in the same unit, wing, hallway, or building. Patients with close contact with a confirmed COVID-19 patient (e.g., roommate or infected staff without wearing PPE) should be isolated and follow 14 day self-monitoring guidelines. If they develop symptoms, and are confirmed or suspected to have COVID-19, they should remain isolation until at least 7 days after symptom onset and 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms (e.g., cough), whichever is longer The immediate jeopardy that began on [DATE], was removed on [DATE] when the facility educated staff to recognize signs and symptoms of COVID-19, with special attention to temperatures above 99 F, and immediately isolate and the timely testing of residents who are symptomatic, 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, because the IP will need to review and log daily all residents with symptoms, conduct surveillance for potential infection outbreaks, and determine trends of all infections, and report any noted trends to the ED, DON, and Medical Director. B 1. During an observation of meal delivery service to the 300 hall COVID Unit, on [DATE] between 12:10 p.m. and 12:30 p.m., Dietary Aide 8 and the Dietary Manager delivered the meal cart outside of the COVID 19 unit doors. They handed the disposable containers of food directly to COVID unit staff, who then dispersed to the residents' rooms. The staff on the unit picked up the trays with their bare hands and delivered to the residents' rooms. They did not don gloves when entering the residents' rooms. During an interview on [DATE] at 12:52 p.m., QMA 9 indicated she figured since every time they entered a room and left they sanitized, they did not need to wear gloves. During an interview on [DATE] at 12:57 p.m., CNA 10 indicated she passed some of the trays during lunch, she did not wear gloves because she was washing her hands before and after each tray. This was how they had been doing it. During an interview on [DATE] at 1:00 p.m., LPN 11 indicated he did assist with delivering trays to the residents during lunch. He had not worn gloves because he was washing his hands after passing each tray. During an interview on [DATE] at 5:31 p.m., the Interim DON indicated when staff enter a COVID-19 positive resident's room she would expect them to wear goggles, an N95 mask, a gown, and gloves, every single time they enter the room, for any reason. The Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV-2) Policy and Procedure, dated [DATE], which was provided on [DATE] at 11:00 a.m., by the ED, included but was not limited to, . COVID-19 Positive . Place signage at the entrance to the COVID-19 care unit that instructs HCP (healthcare professionals) they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms . 2. During an observation on [DATE] at 12:40 p.m., after serving lunch containers to the COVID-19 unit, Dietary Aide 8 took the empty meal cart, 2 trays, and a metal pan to the back entrance of the kitchen. He proceeded to spray them with Clorox cleanup spray. After 11 seconds he took the water hose and sprayed the Clorox cleanser off. After returning the cart to the kitchen he delivered the trays, and pan to the dishwasher. The dietary aide was observed spraying the cart with Clorox cleanser, and immediately took a towel and dried off the 3 shelves. He did not allow the cleaner to sit according to manufacturers guidelines. During an interview on [DATE] at 4:10 p.m., the Dietary Manager indicated the Clorox cleanser was supposed to stay on for 30 seconds before spraying or wiping off. The manufacturer instructions for Clorox cleanup spray, provided on [DATE] at 4:10 p.m., by the Dietary Manager included but was not limited to, Eligible for use against [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, based on the EPA's (Environmental Protection Agency) Emerging [MEDICAL CONDITION] Pathogen Policy.Effective in 30 seconds . 3XXX,[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place when two residents with dementia, with security bracelets in place, exited the locked unit and facility without supervision and ambulated .03 miles to a subdivision next to the facility without staff awareness for 2 of 3 residents reviewed for accidents/supervision (Resident B and Resident C); and failed to ensure staff immediately notified the nurse when a resident (Resident D) was combative with care struck herself and, when turned, struck the side rail on the bed, which resulted in a split lip, bruising, and [MEDICAL CONDITION] to the left side of the mouth and cheek for 1 of 3 residents reviewed for accidents. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/1/2020 when two cognitively impaired residents with security bracelets exited the locked unit and the facility, without staff awareness, and were found by an off duty staff member 0.3 miles away from the facility in a subdivision next to the facility which was located 0.25 miles from a heavily traveled thoroughfare with a speed limit of 35 miles per hours. The interstate was located directly behind the facility with a speed limit of 65 miles per hour. The Administrator, Director of Nursing, and Regional Nurse were notified of the Immediate Jeopardy on 3/6/20 at 11:30 a.m. Findings include: 1. The incident report, dated 3/1/20 at 12:20 p.m., indicated Resident B and Resident C were found to be outside walking. During an interview on 3/5/20 at 12:45 p.m., the Administrator indicated she had not completed the investigation yet, but thought the residents walked off the unit with church members through the main 400 hall doors. They brought in musical equipment for church and upon leaving the 400 hall, the door may have been opened too long which would cause the alarm sound. The church members may have turned the alarm off since they knew the code. If a resident with a security bracelet would exit through the doors while the alarm was sounding, it would not make a different alarm sound. The church members were notified and did not recall any residents following them out. The facility was unsure as to how the residents exited the building. During an interview on 3/5/20 at 1:00 p.m., Staff Member 4 indicated she was off work at 11:20 a.m. on 3/1/20. She had an appointment at 12:15 p.m., to look at a house in the subdivision next to the facility. At 12:22 p.m., she looked out the window of the house she was viewing and Resident B and Resident C were observed walking on the sidewalk across the street. Staff Member 4 called the facility to let them know the residents were observed in a subdivision. The facility was unaware that the residents were out of the building. She walked the residents back to the facility where a staff member met them in the parking lot. Review of the facility investigation indicated Resident B and Resident C were last seen on the unit at 11:55 a.m. On 3/1/20, the residents were found outside of the facility at 12:22 p.m., and then brought back into the building at 12:33 p.m. The temperature outside was sunny and 60 degrees. On 3/5/20 at 3:28 p.m., the facility video from 3/1/20 was reviewed and the two church members were observed to exit through the main front doors alone. No residents were observed following them out of the building. a. The clinical record for Resident B was reviewed on 3/5/20 at 12:30 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 2/26/20, indicated the resident's cognition was severely impaired. The care plan, dated 11/23/18, indicated the resident was a risk for elopement with interventions of a code alert bracelet (security bracelet) and staff were to monitor the resident frequently. The physician's orders [REDACTED]. The elopement risk evaluation, dated 5/20/19, indicated Resident B was cognitively impaired, ambulated independently, had a history of [REDACTED]. The progress note, dated 3/1/20 at 1:00 p.m., indicated the resident was observed in the parking lot by a staff member and then escorted back into the building. On 3/5/20 at 3:05 p.m., Resident B was observed with a security bracelet to his left ankle. b. The clinical record for Resident C was reviewed on 3/5/20 at 12:14 p.m. [DIAGNOSES REDACTED]. The admission MDS assessment, dated 2/19/20, indicated the resident's cognition was severely impaired. The care plan, dated 2/10/20, indicated the resident was an elopement risk with interventions of a code alert bracelet, provide for safe wandering, and encourage to participate in activities to divert from exit seeking behavior. The physician's orders [REDACTED]. The elopement risk evaluation, dated 2/10/20, indicated the resident was cognitively impaired, ambulated independently, and had a history of [REDACTED]. The progress note, dated 2/28/20 at 9:40 a.m., indicated the resident paced throughout the unit, stated she needed to go home and redirection was unsuccessful. The resident was exit seeking and became more agitated with interventions. The progress note, dated 3/1/20 at 1:00 p.m., indicated the resident was observed in the parking by a staff member and escorted back into the building. On 3/5/20 at 3:07 p.m., Resident C was observed with a security bracelet to her left ankle. During an observation on 3/5/20 at 3:00 p.m., LPN (Licensed Practical Nurse) 3 put in the code on the main 400 hall door and held the door open. After 7 seconds the alarm sounded and RN 2 went through with a security bracelet and there was no change to the tone of the sound of the alarm. On 3/6/20 at 9:50 a.m., the Administrator provided a current copy of the document titled Elopement Policy dated February 2009. It included, but was not limited to, Residents have the right to live at ease in a safe and secure environment. The facility is responsible for ensuring that effective policies and procedures are developed and implemented to reduce the risk of elopement by residents .Definition of Elopement .An incident in which a resident leaves the facility grounds without staff knowledge; the resident has impaired decision making abilities and is unaware of his/her own safety needs 2. The clinical record for Resident D was reviewed on 3/5/20 at 4:29 p.m. [DIAGNOSES REDACTED]. The incident report, dated 2/11/20 at 5:50 a.m., indicated the resident had bruising and slight [MEDICAL CONDITION] to the left side of her lip and lower cheek area below the lip. The progress note, dated 2/11/20 at 6:05 p.m., indicated the resident was observed to have [MEDICAL CONDITION] to left cheek and lip and complained the area was sore. The Nurse Practitioner's note, dated 2/11/20, indicated the resident had bruising, purple/blue in color to the left lip, face, and cheek due to an unknown accident. The physician's orders [REDACTED]. The radiology report, dated 2/12/20 at 12:28 a.m., indicated the resident's bony orbits and mandible were intact. The skin assessment, dated 2/12/20, indicated Resident D's left cheek, at the crease by the side of the mouth, had a purple discoloration which measured 1.5 cm (centimeters) by 1.0 cm and the left lip had [MEDICAL CONDITION] with a slight amount of bleeding. During a telephone interview on 3/5/20 at 4:51 p.m., Resident D's NP (Nurse Practitioner) indicated she was told the resident may have hit her face on the side rail, but the investigation was still ongoing at the time. The resident had tried to bite a CNA (Certified Nursing Assistant) who had provided care and when the CNA pulled his had away, Resident D hit herself in the face. The bruising seemed too extensive for Resident D to have just hit herself in the face. During an interview on 3/6/20 at 6:20 a.m., CNA 5 indicated on the morning of 2/11/20 at 5:36 a.m., Resident D was in bed and was his last resident to get up. Resident D became combative, screamed, cursed and called him names. CNA 5 continued to do his work and asked her to please calm down. CNA 5 was dressing the resident and when he tried to get her up, Resident D grabbed CNA 5's hand, opened her mouth and tried to bite him. CNA 5 yanked his hand away and Resident D hit herself in the face with her own force. Resident D continued to be combative with care and when CNA 5 turned her to the side to pull her pants up, CNA 5 heard Resident D hit something, possibly the side rail. CNA 5 did not report either incident to the nurse because he did not see any injury to the resident. During an interview on 3/8/20 at 7:10 p.m., CNA 7 indicated the nurse should be notified immediately when any incident which could cause injury has occurred. The Immediate Jeopardy that began on 3/1/2020 was removed on 3/9/2020 when the facility completed staff education on the elopement policy, procedures for elopement follow-up, door locks checked for proper functioning, wanderguard system checked for proper functioning, door codes changed, staff education related to security measures of the secure unit door codes as well as placement of signage on the entrance/exit doors of the secure unit, elopement book reviewed and updated, elopement risk assessments updated, and care plans reviewed and updated. The Immediate Jeopardy was removed on 3/9/20 but non compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because not all care plans were updated. This Federal tag relates to Complaint IN 252 and IN 641 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure interventions were developed and implemented to prevent the development and/or worsening of pressure ulcers for 3 of 6 residents reviewed for pressure ulcers. (Resident 96's wound was identified as unstageable and developed to a stage III, Resident 104's wound worsened to a stage III and became infected, Resident 11's wound worsened to a stage III). The facility failed to ensure treatment was in place for 1 of 6 residents reviewed for pressure. (Residents 331) Findings include: 1. During an observation with LPN 24, on 1/27/20 at 9:45 a.m., Resident 96 had an acquired pressure wound to his left hip. The wound measured 1.3 cm in length and 0.8 cm in width. The clinical record for Resident 96 was reviewed on 1/23/20 at 11:52 a.m. The resident's [DIAGNOSES REDACTED]. The resident's current care plan, dated 12/30/19, indicated the resident had an open wound to the left hip. The interventions included, but were not limited to, encourage the resident to lay on his right side, Med Pass 30 ml (nutritional shake) tid (three times a day), and a pressure relieving mattress. Staff were to remind the resident and provide assistance as needed for the resident to reposition every two hours. The Admission MDS assessment, dated 12/23/19, indicated the resident required limited assistance with bed mobility. The physician's orders [REDACTED]. A Wound Observation Tool, dated 12/30/19, indicated the resident had a left hip unstageable pressure wound, acquired on 12/30/19. The record indicated this was the first observation of the pressure wound. The wound had 100 % slough. The wound measurement was 1.0 cm in length and 0.9 cm in width. A Wound Observation Tool, dated 1/6/20, indicated the pressure wound was acquired on 12/30/20 to the left hip. Slough tissue was present with a small amount of serous (clear, thin, watery plasma) drainage. The wound measured 1.8 cm in length by 1.2 cm in width by 0.1 cm in depth with yellow slough present. A Wound Observation Tool, dated 1/14/19, indicated the resident's left hip pressure wound, stage III, was improving. The wound had slough 25% and no drainage. The wound measured 1.5 cm in length, by 1.7 cm in width, and 0.1 cm in depth. A wound Observation Tool, dated 1/20/19, indicated the resident's left hip pressure wound, stage III, was improving. The wound had [MEDICATION NAME] tissue present ([MEDICATION NAME] tissue was seen in stage II or greater pressure ulcers). The wound measured 1.4 cm in length by, 1.5 cm in width, and 0.1 cm in depth. The clinical record lacked documentation for weekly skin assessments relating to the resident's left hip skin integrity prior to 12/30/19. During an interview on 1/27/20 at 11:58 a.m., LPN 24 indicated the resident had a skin assessment on admission, dated 12/16/19, at the time he had a wound on his left ankle. A second skin assessment was, dated 12/23/19, nothing was reported to me he had any issues with his left hip. The skin assessment, dated 12/30/19, indicated the resident had an unstageable pressure wound and the wound developed to a stage III to the left hip. There were no interventions related to the left hip prior 12/30/19. The resident had a low loss air mattress and liked to lay on his left side. During an interview, on 1/28/20 at 1:53 p.m., LPN 16 indicated the residents should have been turned and kept dry every two hours or more to prevent pressure wounds. The residents skin was assessed weekly and when care was given. 2. During an observation, on 1/23/20 at 11:11 a.m., RN 19 provided wound care to Resident 104. The resident's ankle wound had slight serous drainage on the dressing and a raised quarter sized area around the opening. The wound bed was pink with a red ring around one half of the opened area. During an observation, on 1/27/20 at 8:13 a.m., the resident was sitting in the Garden Terrace Restorative Dining Room. She had on cotton socks. No foot rests were on the geriatric chair and no protective padding was on the resident's ankles. The clinical record for Resident 104 was reviewed on 1/24/20 at 12:30 p.m. The resident's [DIAGNOSES REDACTED]. The care plan lacked documentation of interventions specific to relieving pressure on the residents ankles, prior to the development of the wound. The Weekly Skin Integrity assessments, dated 10/4/19, 9/27/19, 9/11/19, and 9/4/19, indicated the resident's skin was intact. The Wound Observation Tool, dated 10/9/19, indicated the wound to the left ankle was facility acquired on 10/9/19. The left outer ankle was a stage II pressure ulcer. The wound had a scab and redness to the surrounding tissue with no drainage. The wound measured 0.5 cm in length, by 1.0 cm in width, and no depth with signs of infection. The clinical record lacked documentation of preventative interventions prior to the resident's development of the left ankle pressure ulcer. The Wound Observation Tool, dated 10/11/19, indicated the wound measured 1.0 cm in length, by 0.5 cm in width, and no depth with no signs of infection. The MAR (Medication Administration Record) indicated the resident had an order, with a start date of 10/29/19, to encourage protective heel boots while in bed. The Wound Observation Tool, dated 11/3/19, indicated the wound worsened (Stage III). The wound had 10% Slough and scant serous drainage. The wound measured 1.0 cm in length, by 1.2 cm in width, and 0.1 cm in depth, and had no signs of infection. The Wound Observation Tool, dated 11/7/19, indicated the wound had 25% slough and scant serous drainage. The wound measured 1.3 cm in length, by 1.2 cm in width, and 0.1 cm in depth, with no signs of infection. The MAR indicated [REDACTED]. The Wound Observation Tool, dated 11/14/19, indicated the wound had 100% slough tissue present and small serous drainage. The wound measured 1.0 cm in length, by 1.5 cm in width, and 0.1 cm in depth, with no signs of infection. The treatment included, but was not limited to, Santyl and border gauze, protector boot when in bed, and an appointment with a wound center. The Wound Observation Tool, dated 11/20/19, indicated the wound had 100% slough tissue present and small serous drainage. The wound measured 1.1 cm in length, by 1.0 cm in width, and 0.1 cm in depth, with no signs of infection. The resident was seen by the wound center on 11/19/19. The Wound Observation Tool, dated 11/27/19, indicated the wound had 25% slough tissue present and scant serous drainage. The wound measured 1.0 cm in length, by 1.0 cm in width, and 0.1 cm in depth. The Wound Culture report, dated 11/29/19, indicated the resident had an infection in her left ankle wound. The wound infection was identified as Streptococcus, Beta [DIAGNOSES REDACTED], Group C (gram positive bacteria). The Wound Observation Tool, dated 12/4/19, indicated the wound had 25% slough tissue present and scant serous drainage. The wound measured 1.0 cm in length, by 1.0 cm in width, and 0.1 cm in depth. The wound had signs and symptoms of infection with an antibiotic started on 11/25/19. The Wound Observation Tool, dated 12/18/19, indicated the wound had granulation tissue present (beefy red) and no drainage. The wound measured 0.5 cm in length by 0.8 cm in width by no depth. The Wound Observation Tool, dated 1/22/20, indicated the wound measured 0.3 cm in length, by 0.3 cm in width, and 0.2 cm in depth. During an interview on 1/28/20 at 3:14 p.m., RN 19 indicated the wound didn't look infected, but when she went to the wound center they found something. She had a facility acquired pressure ulcer. 3. During an observation of wound care for Resident 11, on 1/27/20 at 11:18 a.m., LPN 6 removed the resident's brief and a dressing to the right hip. The resident had a dime sized wound to the right hip. The wound measured 1.3 cm in length, 1.8 cm in width, and 0.2 cm in depth. The wound had approximately 80% (percent) slough (shedding dead surface cells from the skin), with 0.2 cm of [DIAGNOSES REDACTED] (redness) around the edges of the wound. The clinical record for Resident 11 was reviewed on 1/23/20 at 9:17 a.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 4/22/19, indicated the resident was at risk for developing pressure ulcers due to the need for hands on assistance with ADL's and incontinence. The care plan lacked documentation of any preferences to lie on one side or refusal to turn and reposition. On 8/6/19 the resident weighed 96 lbs (pounds) and on 10/12/19 the resident weighed 90 lbs. The Nutrition/Dietary note, dated 10/16/19 at 4:10 p.m., indicated no new recommendations had been made even though the resident's weight had decreased. The Quarterly MDS assessment, dated 10/17/19, indicated the resident had not exhibited any rejection of care, did not have a pressure injury, was at risk of developing pressure ulcers, had a pressure reducing device for bed, did not have a turning and repositioning program in place, did not have nutrition or hydration interventions to manage skin problems, and required extensive assistance of 1 person for bed mobility. The weekly skin assessment, dated 10/24/19, indicated the resident's skin was intact, with areas of MASD (Moisture-associated skin damage) to the bilateral buttocks. The skin observation, dated 10/28/19, indicated a new stage II pressure ulcer was identified to the right trochanter (hip). The wound measured 1.5 cm in length, by 1 cm in width, and 0.1 cm in depth. The care plan, dated 10/29/19, indicated the resident had a stage III pressure ulcer to the right trochanter related to pressure. The resident preferred to lay on her right side despite staff education and repositioning. The clinical record lacked documentation of any preference to lie on the right side, refusal or resistance to turn and reposition, or any education provided prior to the wounds development on 10/28/19. The Quarterly MDS assessment, dated 11/6/20 indicated the resident did not exhibit any rejection of care, required extensive assistance of 1 person with bed mobility, did have a pressure ulcer, and did not have a turning and repositioning program in place. The Nutrition/Dietary Note, dated 11/6/19 at 2:26 p.m., lacked documentation of any new recommendations, though the resident had developed a new stage II pressure ulcer. A physician's statement, dated 11/22/19, indicated the wound was unavoidable due to . poor nutritional intake, limited mobility, and overall disease process . The Nutrition/Dietary note, dated 12/4/19 at 1:20 p.m., lacked documentation of any new recommendations, though the wound had worsen. The wound assessment, dated 12/27/19, indicated the wound continued to worsen. The wound had 50% slough to the wound bed and measured 1.5 cm in length and 2.8 cm in width. During a confidential interview, between 1/21/20 and 1/28/20, Staff B indicated rounds were supposed to be done every two hours, but . it's just impossible . We can turn them (the residents), but not as often as we should . During a confidential interview, between 1/21/20 and 1/28/20, Staff E indicated turning and repositioning was very hard and there was not enough time to get it done due to being short staffed. because of other CNA's calling in . During a confidential interview, between 1/21/20 and 1/28/20, Staff F indicated there were a lot of . home grown . wounds, and there was not enough time to alleviate all pressure sites. During a confidential interview, between 1/21/20 and 1/28/20, Staff G indicated the resident had the pressure ulcer for quite a while. It had started as a stage II and . unfortunately went to a III . The resident favored her right hip. She had been . getting on to them (staff) . to keep the resident positioned off of the hip, however some of the CNA's have not kept her turned and repositioned. When staff members call in it makes it hard for them to turn and reposition the residents. During a confidential interview, between 1/21/20 and 1/28/20, Staff H indicated the resident had always favored her right side, but . I guess I paid more attention to it when we started doing a treatment . During an interview on 1/28/20 at 3:30 p.m., the Registered Dietician (RD) indicated she would make recommendations based on wound condition and weight. If the wound was not improving, she would definitely make recommendations, even if weight was stable. She did not have a record of having made any new recommendations on 12/4/19 when the wound had declined. There was an interim DON at that time who did not do the Resident At Risk Meetings. She did not get wound reports for the week of 12/4/20 and was not aware the wound had worsened. If she had known it had gotten worse she would have made recommendations. 4. During an observation on 1/27/20 at 11:45 a.m., LPN (Licensed Practical Nurse) 26 removed Resident 331's brief. There was no treatment in place. LPN 26 indicated the treatment had been removed when she was laid down in bed just prior to the observation. The resident had a dime sized wound on the coccyx. The wound measured at 2.2 cm (centimeters) in length, by 1.0 cm in width, and the wound bed was pink/white. As LPN 26 went to wash her hands, the resident's private attendant indicated the treatment had not been removed just prior to the observation. The clinical record for Resident 331 was reviewed on 1/29/20 at 8:11 a.m. The resident's [DIAGNOSES REDACTED]. The admission assessment, dated 1/9/20, indicated the resident's skin was intact with excoriation (loss of epidermis, caused by prolonged moisture and friction) to the coccyx. The baseline care plan, dated 1/9/20, indicated the resident had a break in skin integrity. The Wound Observation Tool, dated 1/15/20, indicated the resident had a new stage II pressure area to the coccyx measuring 1.8 cm (centimeters) in length 1.8 cm in width and 0.1 cm in depth. The Wound Observation Tool, dated 1/22/20, indicated the resident preferred to lie on her back, despite encouragement to lay on her side. The clinical record lacked documentation of any preference to turn and reposition or refusal/resistance of care by the resident or the caregiver, prior to the development of the wound. During an interview on 1/27/20 at 11:08 a.m., Resident 331 indicated she had a pressure sore to her bottom from lying in the bed. She did not refuse to turn and reposition and would not mind laying on her side. During an interview on 1/27/20 at 11:10 a.m., the resident's private attendant indicated the resident was not being turned every two hours. The resident had not refused to turn or reposition. During an interview on 1/27/20 at 11:14 a.m. NP (Nurse Practitioner) 27 indicated the wound had been brought to her attention the week prior. She had been told the resident had a shearing wound that would be considered a stage II. I have not seen it . The NP had signed a letter of unavoidability because the facility had told her the resident had round the clock care givers who were resistive to staff coming in for care. The review on 1/27/20 at 9:12 a.m., of the Skin Integrity & Pressure Ulcer/Injury Prevention and Management policy dated 10/13/19, provided by the DON included, but was not limited to, . 1. A comprehensive skin inspection/assessment and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas surrounded by [MEDICAL CONDITION]; profound redness .and/or discoloration. These signs possibly indicated an unavoidable Stage 3 or 4 with slough, drainage, or even eschar within a few days .turning and repositioning as needed with ADL care/assistance .skin inspections with particular attention to bony prominences minimize skin exposure to incontinence using devices .reposition at least every 2-4 hours .utilize positioning devices to keep bony prominences from direct contact . 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a pressure ulcer was not acquired in the facility and wound treatments were completed related to a stage 2 pressure ulcer worsening to a stage 3 pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: During an observation with LPN (License Practical Nurse) 5 on 8/22/19 at 1:51 p.m., Resident B's coccyx wound was observed to measure 2.0 cm (centimeters) in length, 1.3 cm in width, and a depth of 0.5 cm. There was white and yellow slough in the wound bed. The clinical record for Resident B was reviewed on 8/22/19 at 10:52 a.m. The resident's entry date into the facility was 1/18/18. The resident's [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 11/26/18, indicated the resident was not at risk for developing a pressure ulcer and had no unhealed pressure ulcers. The quarterly MDS assessment, dated 6/1/19, indicated the resident required two staff members physical assistance with bed mobility. The resident was at risk for skin break down and had a stage 2 pressure ulcer. The wound care plan, dated 1/18/19, indicated the resident had a stage 2 coccyx wound with an initiated dated of 1/18/19. The resident's interventions indicated staff were to provide incontinent care every two hours and as needed and wound treatments were to be followed as ordered (initiated 1/21/19) A physician's orders [REDACTED]. The wound care plan, dated 1/18/19 with a revision date of 8/2/19, indicated the resident had a stage 3 pressure wound (Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue was often present) on the coccyx. The resident's interventions indicated the resident had a low air loss mattress (initiated 8/2/19) and a non-pressure cushion on the wheel chair (initiated 8/6/19). and wound center consults as needed (initiated 8/1/19). The ADL (activities of daily living) care plan, dated 2/25/19, indicated the resident required the staffs' physical assistance for repositioning when in bed (initiated 6/5/19). A physician's orders [REDACTED]. The treatment administration record lacked documentation that the resident's wound treatments were completed on 3/8/19, 3/12/19, 3/15/19, and 3/25/19. A physician's orders [REDACTED]. The wound observation report, dated 3/28/19, indicated the resident's pressure ulcer to the coccyx measured 0.5 cm in length, 0.4 cm in width, and a depth of 0.2 cm. The treatment administration record lacked documentation that the resident's wound treatments were completed on 4/10/19, 4/15/19, 4/22/19, and 4/25/19. A physician's orders [REDACTED]. The treatment administration record lacked documentation that the resident's wound treatments were completed on 4/26/19 (night shift), 4/27/19, 4/28/19, 4/29/19 (day shift), 5/6/19, 5/8/19 (day shift), 5/10/19 (day shift), 5/16/19 (night shift), and 5/31/19. A physician's orders [REDACTED]. The treatment administration record lacked documentation that the resident's wound treatments were completed on 6/3/19, 6/10/19, and 6/12/19. The wound observation report, dated 6/13/19, indicated the resident's pressure ulcer to the coccyx measured 2.0 cm in length, 2.5 cm in width, and a depth of 0.3 cm. A physician's orders [REDACTED]. The treatment administration record lacked documentation that the resident's wound treatments were completed on 6/18/19 and 6/22/19. The wound care center consult, dated 6/27/19, indicated to apply silver hydrogel to the resident's wound bed, cover with a foam dressing every other day; turn every 2 hours; limit side lying to 30 degree tilt; and turn every 2 hours when in bed. The clarification order, dated 6/28/19, indicated to cleanse the resident's coccyx with normal saline, patted dry, silver hydrogel applied to the wound bed, and covered with a foam dressing every other day. The treatment administration record lacked documentation that the resident's wound treatments were completed on 6/28/19, 6/30/19, 7/3/19, 7/19/19, 7/23/19, 7/25/19, 8/3/19, and 8/4/19. The wound center consult, dated 8/19/19, indicated the stage 3 coccyx wound measured 1.4 cm in length, 1.3 cm in width with a depth of 1 cm. Turn every 2 hours, limit side lying to 30 degree tilt, and turn every 2 hours when in bed. During an interview on 8/23/19 at 10:45 a.m., LPN 6 indicated when a treatment was completed, the electronic TAR (treatment administration record) was signed to show it has been completed. During an interview on 8/23/19 at 11:14 a.m., the Director of Nursing indicated she was not sure how the resident acquired the pressure ulcer or how it worsened to a stage 3 pressure ulcer. 3.1-40

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent Resident C from wandering into Resident A's room, resulting in Resident A falling and receiving a head laceration requiring four staples, for 1 of 3 residents reviewed with behavior symptoms, in a sample of 4. Findings include: 1. On 9/28/10 at 10:45 A.M., during the initial tour of the locked Alzheimer's Unit, the Unit Manager indicated Resident A was the "recipient of aggressive behavior." The Unit Manager indicated Resident C was in Resident A's room, pushed her and caused her to fall. The Unit Manager indicated Resident A received staples in the "top of her head." Resident A was observed at that time sitting in the activity room. The clinical record of Resident A was reviewed on 9/28/10 at 11:30 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 7/25/10, indicated Resident A had a short-term and long-term memory problem, and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident required limited assistance of one person for walking, and had not fallen in the previous 180 days. Nurse's Notes included the following notations: 9/13/10 at 4:15 P.M.: "Nurse heard resident scream out 'No.' While in route to room nurse witnessed this resident falling backwards out of the doorway of her room, fall to the ground and hit her head bluntly on the floor. (Resident C) was then seen walking out of this resident's room, lean over her and begin saying 'I'm sorry.' (Resident A) looked at the nurse and stated 'He pushed me.'...Ice and pressure was immediately applied to prevent swelling and to stop the small amount of bleeding noted to the occipital area of the residents (sic) head...Alert and able to state full name, # and names of children...Resident transferred to (name of hospital) @ approx (approximately) 5:00 pm per MD orders...." 9/13/10 at 11:30 P.M.: "Resident arrived back to facility via (name) ambulance. Very confused...noted that resident has 4 staples to laceration to occipital region of skull...New orders recieved (sic)...states it only hurts if you touch it...." 9/14/10 at 6:00 P.M.: "Resident complains of head pain. Repositioned, gentle ROM (range of motion). Robaxin 750 mg (a pain medication) given orally." 9/14/10 at 10:00 P.M.: "Resident states, 'My head still hurts.' Ultram 50 mg (a pain medication) given...." 9/17/10 at 2:00 P.M.: "Staples intact. Small amt. (amount) of redness noted around site...." 9/18/10 at 12:00 P.M.: "Treatment completed to staples...Tramodol (a pain medication) admin (administered) for general head/neck pain...." 9/23/10 at 10:12 A.M.: "Four staples removed from back of head...." The clinical record of Resident C was reviewed on 9/28/10 at 12:10 P.M. [DIAGNOSES REDACTED]. An admission MDS assessment, dated 7/12/10, indicated Resident C had a short-term and long-term memory problem and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident exhibited wandering behaviors daily in the previous 7 days. A Care Plan, dated 7/15/10, indicated a problem of "I am new to the facility and to the secured unit and I may wander." The approaches included: "Staff will direct me or assist me to dining, activities, and to my room. I will be invited and assistited (sic) to my choice of activities. Encourage my family to visit often. Personalize my room to things I can relate to, pictures, blanket, etc. Provide me safe wandering on secured unit. Involve me in activities I enjoy doing and praise me for my participation..." An additional Care Plan, dated 7/15/10, indicated a problem of "I have a dx (diagnosis) of dementia with bahaviors (sic) and I may display verbal/physical aggression towards staff." A care plan related to being aggressive toward other residents was not observed in the clinical record. Nurses Notes included the following notations: 7/12/10 at 4 A.M.: "...Resident is able to ambulate without difficulty must supervise Resident related to wandering...." 7/13/10 at 5:25 P.M.: "Ambulating in hallway. Steady gait. Wandering in and out of residents (sic) rooms. Alert with extreme confusion...Must be redirected several times..." A Social Service Progress Note, dated 7/13/10 and untimed, indicated, "Resident exhibited behavior of resident taking other Resident's foods during meal served. Staff redirected and assisted Res (resident) with another tray of food...." Nurses Notes continued: 7/16/10 at 4:10 P.M.: "...Alert and confused. Wanders in and out of rooms. Easily redirected for very short time only..." 7/17/10 at 6:00 A.M.: "...Resident redirected due to voiding in hallway and another residents room...." 7/21/10 at 11:00 A.M.: "Resident alert and confused, wanders the hallways and into other rooms. Easily redirectable (sic)...." 7/31/10 at 8:00 P.M.: "Recieved (sic) new order for resident to be sent to (name of hospital) for evaluation related to physical aggression towards another resident...." An Indiana State Department of Health facility reportable incident document, dated 7/31/10, received by the Director of Nursing on 9/29/10 at 11:00 A.M., indicated Resident C hit another resident while ambulating in the hallway. A hospital discharge summary indicated the resident was admitted to a behavior unit on 8/2/10 and was discharged on [DATE]. The summary indicated, "...He was transferred and admitted to the behavioral health unit due to pt (patient) was combative, and hit another resident and was becoming aggressive when redirected...." Nurses Notes indicated the following notations: 8/30/10 at 3:10 P.M.: "...Ambulates self (sic) without assistive devices needs redirection when wandering into rooms. Easily redirected by staff...." A Social Service Progress Note, dated 9/3/10, indicated, "Resident exhibits confusion on where his room, and bathroom are. Writer placed signs on doors and ask staff to continue to re-direct him as often as necessary. Resident displayed wandering and resisting care from staff on 9/1/10...Will continue to observe and redirect resident." A "Weekly Care Management Review," dated 9/7/10, indicated, "...Encourage into activities during waking hours due to wandering." Nurses Notes continued: 9/13/10 at 6:40 P.M.: "At 4:15 pm, writer witnessed (Resident A) falling backwards out of doorway of (Resident A's) room, after hearing other resident scream (and) proceeding to the scene. This resident then walked out of room after her. (Resident A) then pointed at this resident and told writer 'he pushed me.' This resident leaned over other resident and said 'I'm sorry' several times. This resident was immediately removed from the scene and provided 1:1 supervision...." On 9/28/10 at 2:30 P.M., the Director of Nursing (DON) indicated Resident C was up and ambulatory by himself. The DON indicated the facility could not do "one to one, 24 hours a day." This federal tag relates to Complaint # IN 942. 3.1-45(a)(2)