Every finding on record at Hamilton Grove

Based on observation, record review, and interview, the facility failed to ensure wound treatments were in place as ordered and neurological checks were completed following a fall for 1 of 3 residents reviewed for non-pressure skin conditions and 1 of 3 residents reviewed for falls. (Resident B)Finding includes: On 6/8/26 At 1:10 p.m., Resident B was observed in her room with CNA 1. CNA 1 lifted the resident's pant leg and removed her sock so the resident's wounds could be observed on the right lower leg and left heel. Neither wound had a dressing in place, both were open to air. During an interview at the time, CNA 1 indicated she was unaware if the resident required any dressings to the wounds.Resident B's record was reviewed on 6/8/26 at 11:00 a.m. The diagnoses included, but were not limited to, dementia, heart failure, COPD, kidney disease stage 3, panic disorder, history of falling, anemia (low iron), depression, and macular degeneration (vision loss).The Annual Minimum Data Set (MDS) assessment, dated 3/26/26, indicated the resident was severely impaired for daily decision making. Upper/lower body dressing required partial to moderate assistance. Toileting and shower/bathing required substantial to maximum assistance.A Care Plan, revised on 4/20/26, indicated the resident had an unwitnessed fall on 4/20/26. Interventions were to monitor/document/report for 72 hours any change in pain or mental status to the physician.A Neurological Check flowsheet, dated 4/20/26, indicated there was no documentation of neurological checks after 4/21/26 at 2:00 p.m. The documentation was incomplete for shifts five through nine of the 72 hour post fall period.A Nurse's Post Fall Evaluation Note, dated 4/21/26 at 10:26 a.m., indicated the resident had an unwitnessed fall in her room on 4/20/26 at 5:06 p.m. There was no incident note or assessment documented at the time of the fall. A Physician's Order, dated 5/27/26, indicated to cover the blister to the left heel with a dry dressing and wrap it with Kerlix every day at bedtime.A Physician's Order, dated 5/27/26, indicated to cleanse the right lower leg with wound wash, pat dry, apply ointment, and cover with a bordered gauze every night shift and as needed.A Care Plan, revised on 6/5/26, indicated the resident had blisters on the right shin, left heel, and left plantar foot. Interventions included to administer treatments as ordered and encourage repositioning every two hours and as needed. During an interview on 6/9/26 at 11:00 a.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) indicated the night nurse had completed the dressing changes and the resident must have removed them. The ADON agreed nursing staff should have replaced the dressings or documented the resident's removal. The neurological check flowsheet was not completed, but they continued to record vital signs. The DON indicated the computer system was less than a year old and the staff were having difficulty navigating some of the assessments. They understood the concern regarding vital signs with no neurological assessment post fall.This citation relates to Intake 3017146. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure the responsible party for 1 of 3 residents reviewed for discharge from the facility, received in writing, a Notice of Medicare Non-Coverage including the date of discharge. (Resident B) Finding Includes:On 12/1/25 at 1:14 P.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] and discharged home with family on 11/8/25. The residents' diagnoses included but were not limited to a fractured sacrum, chronic bronchitis, chronic obstructive pulmonary disease, repeated falls, altered mental status, depression, anxiety, and liver cancer.A facility admission Agreement form, dated 9/3/22 and signed by the facility Area Marketing Liaison and Resident B's family member on 10/3/25, indicated the family member was Resident B's Resident Representative. The admission Agreement indicated the Resident Representative was an individual the Resident had chosen to act on his or her behalf to support decision making; access medical.information; manage financial matters and receive notification. The Resident Representative was a person authorized to act on behalf of the Resident.Resident B's MDS (Minimum Data Set) assessment, dated 10/9/25 for a Discharge Assessment, indicated Resident B's diagnoses included altered mental state,the resident was cognitively intact, utilized a walker and wheelchair for locomotion and required supervision for toileting hygiene, transferring to chair and toilet, and required moderate assistance for dressing, personal hygiene, and tub or shower transfers. Resident B had participated in Physical and Occupational Therapies while at the facility. The MDS indicated Resident B had participated in goal setting in her Care Plan meeting and her goal was to be discharged back into the community or home. Neither the residents' family nor the responsible had participated in the Care Plan meeting.A Nursing Progress Note, dated 11/5/25 at 12:11 P.M., indicated the resident's last day of Medicare Part A for skilled nursing coverage was 11/7/25 and the resident had been notified of the right to appeal and had signed the Notification of Medicate Non-Coverage (NOMNC) form. The form had been placed at the bedside as requested by the resident.son, rehab and admission/discharge distro list. was documented in the progress note.Review of Resident B's Notification of Medicate Non-Coverage form, signed by the resident on 11/5/25, indicated skilled nursing facility services were to end on 11/7/25.The Nurse Practitioner's Discharge Note, dated 11/7/25, indicated Resident B's reason for admission to the facility included a desired nursing home placement due to memory issues.On 12/2/25 at 2:25 P.M., during an interview, the Director of Nursing indicated Resident B had been given a NOMNC but her responsible party, whom she was discharged to, had not given the NOMNC form/notice.On 12/3/25 at 1:00 P.M., during an interview with the Administrator, she indicated Resident B's Responsible Party had not been aent a NOMNC letter nor any bed hold information per the facility's policy.On 12/2/25 at 2:30 P.M., and on 12/3/25 at 9:30 A.M., a policy for Admission, Transfer, and Discharge was requested from the Director of Nursing and the Administrator, respectively, but was not provided.This Citation relates to Intake 2664672.3.1-12(a)(6)(ii)(iii)

Based on interviews and record review, the facility failed to ensure a discharge care plan was created for 1 of 3 residents reviewed for discharge planning. The facility also failed to ensure the Resident's Responsible Party was invited to participate in the care planning process for their family member for 1 of 3 resident reviewed for discharge planning. (Resident B).Finding Includes:On 12/1/25 at 1:14 P.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] and discharged home with family on 11/8/25. The residents' diagnoses included but were not limited to a fractured sacrum, chronic bronchitis, chronic obstructive pulmonary disease, repeated falls, altered mental status, depression, anxiety, and liver cancer.A facility admission Agreement form, dated 9/3/22 and signed by the facility Area Marketing Liaison and Resident B's family member on 10/3/25, indicated the family member was Resident B's Resident Representative. The admission Agreement indicated the Resident Representative was an individual the Resident had chosen to act on his or her behalf to support decision making; access medical.information; manage financial matters and receive notification. The Resident Representative was a person authorized to act on behalf of the Resident.Resident B's MDS (Minimum Data Set) Assessment, dated 10/9/25 for an admission Assessment, indicated the resident's diagnoses included altered mental state. The assessment indicated the resident was cognitively intact, utilized a walker and wheelchair for locomotion, required supervision for toileting hygiene, transferring to chair and toilet and required moderate assistance for dressing, personal hygiene, and tub or shower transfers. Resident B had participated in Physical and Occupational Therapies while at the facility. The MDS assessment indicated Resident B had participated in goal setting in her Care Plan meeting and her goal was to be discharged back into the community or her home. Neither the residents' family nor responsible party had participated in the Care Plan meeting.An MDS (Minimum Data Set) Assessment, dated 11/8/25 for a Discharge Assessment, offered no indication that Resident B or Resident B's Responsible Party had been involved in the discharge planning for the resident. A Nursing Progress Note, dated 11/5/25 at 12:11 P.M., indicated the resident's last day of Medicare Part A for skilled nursing coverage was to be on 11/7/25 and the resident had been notified of the right to appeal and had signed the Notification of Medicate Non-Coverage (NOMNC) form.On 12/2/25 at 2:25 P.M. during an interview, the Director of Nursing indicated there was not a discharge plan included in the residents' comprehensive care plans and that neither Resident B's family nor responsible were provided invitations or notification of care plan meetings.On 12/3/25 at 1:00 P.M. during an interview with the Administrator, she indicated Resident B's family had not been appropriately invited to care plan meetings though they should have been invited to the care plan meetings.On 12/3/25 at 12:38 P.M., the Administrator provided the policy titled, Comprehensive Care Plans, dated 1/29/25. The policy indicated, .The comprehensive care plan will describe, at a minimum, the following.The resident's goals for.desired outcomes, and preferences for future discharge.The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to:.The resident and the resident's representative.This Citation relates to Intake 2664672. 3.1-35(a)(1)(c)(2)(C)

Based on record review and interview, the facility failed to notify a Physician of a resident's change in condition related to blood pressures and missed doses of medication for 2 of 5 residents who were reviewed. (Resident 3 and 30 Findings include: 1. Resident 3's record review was completed on 5/6/2025 at 8:53 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, generalized anxiety disorder, hypercholesterolemia, supravalvular aortic stenosis, peripheral vascular disease, atrial fibrillation, nonrheumatic mitral valve disease and hypertension. Current Physician's orders indicated Resident 3 was to receive 2.5 milligrams (mg) of olanzapine (treats symptoms of mental health disorders), 10 mg of melatonin (sleep aid) and 40 mg of pravastatin (treats high cholesterol) at bedtime. A review of the April 2025 Medication Administration Record (MAR) indicated Resident 3 had refused her bedtime medications of olanzapine, melatonin and pravastatin on 4/8/2025. In addition, Resident 3 had not received her bedtime doses of olanzapine, melatonin or pravastatin on 4/23/2025. The record lacked the documentation indicating why the medications were not administered on 4/23/2025 or that the Physician had been notified the resident had refused any medications on either date. A review of the May 2025 MAR indicated Resident 3 had refused to take her scheduled doses of olanzapine, melatonin and pravastatin at bedtime on 5/2/2025. The record lacked the documentation a Physician had been notified. During an interview with the Assistant Director of Nursing (ADON) on 5/8/2025 at 10:20 A.M., she indicated Resident 3 did not receive her prescribed medications on 4/23/2025 and she was not able to identify why the medications were not given, or if the Physician was notified Resident 3 had refused or missed her bedtime medications on 4/8, 4/23, or 5/2/2025. 49229 2. The clinical record of Resident 30 was reviewed on 5/2/2025 at 9:58 A.M. The resident's diagnoses included, but were no limited to: vascular dementia, chronic kidney disease, depression, morbid obesity, obstructive sleep apnea, personal history of transient ischemic attack and cerebrovascular accident, dementia, encephalopathy, visual hallucinations and lymphedema. An Annual Minimum Data Set (MDS) assessment, dated 2/10/2025, indicated Resident 30 was moderately cognitively impaired. A current Care Plan, initiated 2/23/2025, indicated Resident 30 had a potential for an alteration in cardiac circulation. Interventions included, but were not limited to: vital signs as ordered, facility policy and as needed and update physician and family as needed. A Nursing Progress Note, dated 2/6/2025, indicated Resident 30 had the following vital signs: blood pressure 80/56 mmHg (millimeters of mercury). Resident 30's record lacked documentation the medical provider and/or the family was notfied of the low blood pressure assessment. During an interview, on 5/05/2025 at 9:39 A.M., RN 3 indicated if a resident's vital signs were out of a normal range, she would have looked to see if the physician had left vital sign parameters guidelines in the chart. RN 3 indicated if the physician had not left call parameters for vital signs, depending on the time and day, she would notify the physician either in person, if he was in the building rounding, by email message or by calling the on-call provider. RN 3 indicated for any blood pressure below a systolic of 80 mmHg she would have held the blood pressure medications and contacted the medical provider. During an interview, on 5/06/2025 at 11:24 A.M., the Director of Nursing (DON) indicated at the time of the low blood pressure assessment, on 2/6/2025 at 6:41 P.M. an agency nurse was caring for Resident 30. The DON indicated the nurse should have re-checked the blood pressure and notified the physician. On 5/8/2025 at 10:20 A.M. the ADON provided a policy, dated 2/28/2024, and titled, Medication Administration. The ADON indicated the policy was the one currently used by the facility. The policy indicated, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .14. Administer medication as ordered in accordance with manufacturer specifications .19. Report and document any adverse side effects or refusals On 5/6/2025 at 3:10 P.M., the DON provided a policy titled, Acute Condition Changes, dated 1/23/2024 and indicated the policy was the one currently used by the facility. The policy indicated .Licensed nursing team member(s) will assess residents for acute condition changes from the resident's baseline and will notify both the physician and family of such changes 3.1-5(a)

Based on record review and interview, the facility failed to ensure adequate monitoring of antipsychotic medications occurred medications timely for 2 of 3 residents who were reviewed for antipsychotic medications . (Resident 3 and 18) Findings include: 1. Resident 3's record review was completed on 5/6/2025 at 8:53 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, generalized anxiety disorder, hypercholesterolemia, supravalvular aortic stenosis, peripheral vascular disease, atrial fibrillation, nonrheumatic mitral valve disease and hypertension. A current Physician's order indicated Resident 3 received 2.5 mg of olanzapine (antipsychotic medication that treats symptoms of mental disorders) once a day at bedtime. Resident 3 had an AIMS (Abnormal Involuntary Movement Scale) assessment on 12/2/2024. There was no documentation to indicate another AIMS assessment had been completed after 12/2/2024 and before 5/6/2025. During an interview on 5/5/2025 at 2:20 P.M., the Director of Nursing indicated the facility's policy was to perform an AIMS assessment quarterly for residents receiving antipsychotic medications and Resident 3 had not received a quarterly AIMS assessment. 2. A record review was completed on 5/5/2025 at 8:58 A.M. for Resident 18. Diagnoses included, but were not limited to, psychotic disorder with delusions and major depressive disorder. A Quarterly Minimum Data Set assessment, dated 1/19/2025, indicated Resident 18's cognition was severely impaired and she received antipsychotic medication daily. Physician Orders included, but were not limited to - Abilify 2.5 milligrams by mouth daily for a psychotic disorder with delusions, on 6/27/2022 she may have a psychiatric evaluation with follow ups and on 5/10/2022 to monitor for antipsychotic side effects. A Care Plan, dated 5/10/2022, indicated Resident 18 was at risk for adverse side effects related to the use of an antipsychotic and included an intervention for an Abnormal Involuntary Movement Scale (AIMS) assessment to be completed per facility policy. Documentation of AIMS assessments completed for Resident 18 for the past 12 months was requested on 5/5/2025 at 2:15 P.M. There had only been one AIMS assessment completed, on 1/13/2025, for the past year. During an interview on 5/6/2025 at 10:50 A.M., the DON indicated the facility policy was for AIMS assessments to be completed quarterly but Resident 18 had not had any completed in 2024. A current policy titled, Psychotropic Medication Policy and dated 10/31/2022, was provided by the DON on 5/6/2025 at 12:18 P.M. The policy indicated, .Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a change in condition, change in antipsychotic medication, PRN (as needed) or as per campus policy 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to store food in a sanitary manner related to labeling and dating opened food and disposing of expired food in 1 of 1 kitchen that was reviewed. This deficient practice had the potential to affect 49 of the 49 residents who received their meals from the kitchen. Finding includes: During an observation of the kitchen on [DATE] at 8:15 A.M. with the Certified Dietary Manager (CDM), the following foods were in the walk-in cooler, but were expired or had no opened on or use by date: - 1 package of smoked turkey dated [DATE] - 1 container with cut up purple onion dated [DATE] - 1 container of premade chicken salad dated [DATE] - 1 package of Virginia ham dated [DATE] - A container with cut up white onion dated [DATE] During an observation of the kitchen with the CDM on [DATE] at 8:20 A.M., the following was observed: - Leaf tarragon was open but did not have an opened on or use by date. - Ranch powder was open but did not have an opened on or use by date. - Red food coloring was open but did not have an opened on or use by date. - Chopped chives was opened and had expired on [DATE]. During an interview on [DATE] at 8:21 A.M., the CDM indicated any food that was opened should have been dated with the day it was opened. All opened food should have been used in three days or thrown away. On [DATE] at 2:05 P.M. the Administrator provide an undated policy titled, Labeling and Dating Foods) and indicated it was the policy currently used by the facility. The policy indicated, .All foods stored will be properly labeled according to the following guidelines .2 .Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date .4. Prepared food or opened food items should be discard when: .The food item is leftover for more than 72 hours. 3XXX,d+[DATE] (i)(3)

Based on observation, interview and record review, the facility failed to provide a sanitary environment related to disposing of expired food in a resident's personal refrigerator for 1 of 3 personal refrigerators observed. Finding includes: During an observation on [DATE] at 9:51 A.M. of Resident 3's personal refrigerator, the following was observed: - A container of parmesan cheese with an expiration date of ,d+[DATE] - A single serve cup of chocolate pudding with an expiration date of [DATE]. - A single serve cup of vanilla pudding with an expiration date of [DATE]. - Two cups of juice were covered with no date. The juice in both cups had separated and a large buildup of a thick white substance covered the top third of the juice glasses. - One bowel with a lid that contained no made on or use by date. The food in the bowel had mold and was unidentifiable. During an interview on [DATE] at 9:55 A.M., RN 2 indicated she was not sure whose responsibility it was to clean out resident's personal refrigerators. She indicated expired food should not be in the resident's personal refrigerator. During an interview on [DATE] at 3:15 P.M., the Director of Nursing (DON) indicated it was the Nurse's responsibility to check the resident's personal refrigerators for expired food. On [DATE] at 3:15 P.M., the DON provided an undated policy titled, Food from Family, Visitors, Community and indicated it was the policy currently used by the facility. The policy indicated, .Food stored for residents should be labeled and dated appropriately and discarded per safe food storage guidelines 3XXX,d+[DATE](e)

Based on record review and interview, the facility failed to ensure medication and supplement orders were accurately transcribed and medications were administered timely to 2 of 3 residents reviewed for medication orders. (Resident C and J) Findings include: 1. The record for Resident C was reviewed on 10/21/2024 at 11:00 A.M. Diagnoses included but were not limited to, chronic obstructive pulmonary disease, diastolic congestive heart failure and left ventricular heart failure. A Physician's Order, dated 7/23/2024, indicated the resident's Lasix (a diuretic medication) was to be increased to 80 mg per day. The Medication Administration Records (MARs) for July 2024 and August 2024 indicated the order was documented on the administration record, but the resident only received the medication twice, on 7/27 and 8/3. On 8/13/2024 the Nurse Practitioner (NP) reordered 80 mg of Lasix medication per day. Another order, dated 9/18/2024, indicated to increase Occuvite (a vitamin supplement) to twice daily. The September 2024 MAR indicated the Occuvite was only being administered once daily from 9/19 - 9/30/2024 The order was correctly transcribed on the MAR, but the administration times were 9:00 A.M. and A.M. The A.M. box was grayed out on the boxes for the nurses to document their initials and only the 9:00 A.M. boxes were documented as administered. During an interview with the ADON on 10/21/2024 at 4:30 P.M., she indicated the NP put her own orders into the electronic record system and if there was an order entry issue, then the order would not come up for the nurses to verify and to administer. The ADON indicated the Lasix order was not assigned a time for administration so it was not initiated timely and the resident did not receive her Lasix medication as ordered. She indicated, on 7/27/2024, a nurse noted an issue with the order and administered the proper dose of Lasix for that day, but did not fix the entry order issue in the system. In July 2024, there was no system in place to audit new physician orders to ensure they were transcribed accurately and timely. Since September, the IDT team was now reviewing new orders during the morning meetings. However, the ADON indicated she could not tell why the Occuvite order was not transcribed properly and was not administered twice daily as ordered. The ADON did not elaborate on the system implemented in September other than to say the IDT team reviewed the new physician orders in the morning meetings. 44111 2. A record review was completed for Resident J on 10/17/2024 at 1:35 P.M. Diagnoses included, but were not limited to, multiple sclerosis, spastic quadriplegic cerebral palsy and seizures. Resident J was admitted to the facility on [DATE]. A Medication Administration Record (MAR), dated 8/2024, indicated the following medications were not administered as ordered for the following dates and times: Trazodone 150 milligrams (mg) every night, 8/25/2024, 8/26/24, 8/27/24, 8/28/24 and 8/29/24. Levothyroxine 200 micrograms (mcg) every morning on 8/23/24, 8/24/24, 8/25/24. Levetiracetam 500 mg twice a day on 8/ 24/24, 8/25/24, 8/26/24. Melatonin 5 mg at bedtime on 8/24/24 and 8/25/24. Saccharomyces 250 mg every day on 8/23/24, 8/24/24, 8/25/24, 8/26/24. During an interview on 10/22/2024 at 9:20 A.M., the DON and ADON indicated Resident J had been admitted on [DATE] and a nursing progress note, dated 8/24/2024, indicated some medications were not available and the day shift was to contact the family to sign the pharmacy consent or use their own supply of medications. The ADON indicated the resident's mother was adamant the facility was to use the supply of medications the resident had brought with him first, then use the facility's pharmacy. Both the DON and ADON indicated if the facility did not have the medication ordered available to administer, the physician should have been notified. There were no nursing notes from 8/22/24 through 8/29/24 indicating the physician was notified of the missed medication doses and there was no explanation given as to why the resident missed so many routinely ordered medications from his admission through 8/29/2024. During an interview on 10/22/2024 at 9:49 A.M., the Pharmacist from the facility's pharmaceutical service provider indicated physician orders for Resident J were initially received on 8/22/2024, but were not filled and medications were not sent out because the pharmacy was informed the resident had his own supply of medications and nursing staff had directed the pharmacy not to send medications at that point in time. The Pharmacist indicated mediations were sent to the facility on the following dates on a 7 day supply roll: Levothyroxine 8/31/24, Levetiracetam 8/26/24, Florator 8/27/24, melatonin 8/26/24 and trazodone 8/29/24. On 10/22/2024 at 9:10 A.M., the ADON provided a policy titled, Medication Reconciliation, dated 4/13/2023, and indicated the policy was the one currently used by the facility. The policy indicated, Admission Processes: a. Verify resident identifiers on the information received. b. Compare orders to hospital records etc. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. d. Have a second nurse review transcribed order for accuracy and cosign the orders, indicating the review. e. Order medications from pharmacy in accordance with facility procedures for ordering medications. f. Verify medications received match the medication orders 3.1-25(a)

Based on interview and record review, the facility failed to prevent unstageable pressure ulcers from developing and failed to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing on the bilateral heels of a resident who was admitted without pressure ulcers, for 1 of 3 residents review for pressure ulcers. (Resident C) This deficient practice resulted in the development of a facility-acquired Deep Tissue Injury (DTI) on the left heel that deteriorated to an unstageable pressure injury and the development of a facility-acquired Deep Tissue Injury (DTI) and DTI on the right heel that deteriorated to a stage three pressure injury with signs and symptoms of infection and required debridement. Findings include: The record for Resident C was reviewed on 6/28/2024 at 12:05 P.M. Diagnoses include, but were not limited to, multiple sclerosis (MS), edema, neuropathy, and hypertension A Quarterly Minimum Data Set (MDS) Assessment, dated 3/1/2024, indicated the resident was cognitively intact, had bilateral lower extremity impairment, and required substantial staff assistance for transfer and bed mobility needs. The assessment indicated the resident was at risk to develop pressure ulcers, but did not have pressure ulcers or impaired skin. A Braden Scale assessment (tool used for predicting pressure ulcer development risk), dated 5/14/2024, indicated the resident was at moderate risk for developing a pressure ulcer. A Care Plan, dated 2/20/24, indicated the resident was at risk for a pressure ulcer/skin breakdown due to her diagnoses of neuropathy and multiple sclerosis (MS). The interventions included, but were not limited to, observe skin daily for breakdown, complete a Braden Scale assessment per the facility's policy, diet as ordered, supplements as ordered, heel protectors to the resident's bilateral feet every shift, and moisturize her heels per the physician's order daily. A Nursing Progress Note, dated 4/21/2024 at 2:43 P.M., written by LPN 3, indicated the following, .Dark purple, intact areas found to bilat [bilateral] heels, with Right measuring 2.5 x 3.5 and L [left] measuring 2.0 x 1.0 The CDC (Centers for Disease Control and Prevention) Pocket Guide to Pressure Wounds indicated, Deep Tissue Injury (DTI) pressure ulcers are defined as purple or maroon localized areas of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The Nursing Progress Note, dated 4/21/24, indicated a physician's order was received for skin prep to the resident's bilateral heels The Treatment Administration Record (TAR) for April 2024 indicated a physician's order was received, on 4/21/24, for skin prep to bilateral heels, every shift. The treatment documentation indicated the treatment started on 4/22/24. The April TAR continued the previous preventative measures of heel protector boots and a turn/reposition intervention every two hours. A Nurse Practitioner's (NP) Progress Note, dated 4/29/24 at 4:52 P.M., indicated there was a face-to-face visit with the resident conducted. The NP documented the resident had 1+(swelling that stays pitted when pressed for 1 second) ankle edema, was negative for ulceration during the foot exam, and the resident had no new concerns. There was no explanation provided regarding the lack of assessment and documentation of the DTI to Resident C's right and left heels. A Skin Evaluation Form, dated 4/30/24 at 1:30 P.M., indicated the resident's right heel had a hard dark closed area on her heel which measured 2.5 x 3.0 cm (centimeters). The tissue type was marked as necrotic/eschar. According to the Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System, copyright 2016, an unstageable pressure wound is defined as a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow, tan, gray, green, or brown matter covering the wound bed] and/or eschar [a hardened, dry black or brown colored dead tissue that forms a scab-like covering over deep wounds, such as burns or ulcers]. A Skin Evaluation Form, dated 4/30/24 at 1:31 P.M., indicated the resident's left heel had a dark closed area to heel, which measured 2.0 x 2.8 cm. The issue type was marked necrotic/eschar. A Dietary Note, dated 5/13/24 at 10:55 A.M., indicated the resident's skin was free of pressure areas, the resident had no noted edema and was well nourished. The note indicated the following: .Appears nutritionally adequate with current intakes at this time. No new recommendations. Continue with current interventions .Will continue to monitor There was no explanation provided regarding the lack of recognition of new pressure ulcer development for Resident C. A Monthly NP Follow up Note, dated 5/2/24, indicated the resident denied any complaints of pain or discomfort and .Spoke with nursing who stated member is currently at baseline with no new concerns. Chart reviewed and member is compliant with medication and care regimen The note did not include any documentation indicating the NP was aware of the resident's unstageable pressure injuries on her bilateral heels. A Minimum Data Set (MDS) assessment, completed as an annual review, on 5/17/2024, indicated Resident C was cognitively intact, had impaired mobility to her bilateral lower extremities, and had a Stage II pressure ulcer (partial thickness loss of the dermis skin layer with a shallow open wound). The assessment did not accurately reflect the multiple unstageable pressure ulcer wounds. A Skin Evaluation Form, dated 5/17/24 at 10:35 A.M., indicated the resident's left heel had a dark closed area to heel, which measured 2.0 x 3.0 cm. The issue type was marked as necrotic/eschar. A Skin Evaluation Form, dated 5/17/24 at 10:36 A.M., indicated the resident's right heel had a pressure injury with part of eschar to R heel has come off. The wound measured 2.0 cm in length x 2.8 cm in width x 0.1 cm in depth. There was no further description of the exposed wound bed, periwound (skin immediately surrounding the wound) or any signs of infection noted on the form. A NP Progress Note, dated 5/17/24, indicated the NP examined the resident and the resident had an open wound to the right posterior heel, with 2+ (swelling that stays pitted for up to two seconds when pressed) swelling, slough (dead tissue that has separated from living tissue) and was foul-smelling. The NP indicated the wound was a Stage II pressure wound and measured 4.0 cm. The plan was to have a wound culture obtained and wound care, with Santyl (a treatment to remove damaged tissue from wounds) daily. A Physician's Order, dated 5/17/24, indicated .Culture R heel wound .Santyl 250 unit/gram topical ointment .Everyday Cleanse R heel with wound wash, apply Santyl to R heel wound cover The order did not include documentation related to the facility-acquired DTI on the left heel and did not include documentation to indicate complete pressure relief should be provided to the bilateral heels. A Nursing Progress Note, dated 5/17/24 at 1:26 P.M., indicated the wound culture was canceled and culture swabs were ordered. The Treatment Administration Record (TAR) for May 2024 indicated Santyl wound treatment was documented from 5/18/24 through 5/23/24. A Skin Evaluation Form, dated 5/20/24 at 11:31 A.M., indicated pressure area to right heel, Stage III (full dermis skin loss with adipose tissue exposed but no bone, muscle or tendons exposed), which measured 2.0 cm length x 2.5 cm width x 0.1 cm depth. The form indicated the wound edges were irregular, attached with no undermining and necrotic/eschar was documented. A Nursing Progress Note, dated 5/20/24 at 11:36 A.M., indicated the resident was seen by the wound nurse in regards to a Stage 3 pressure area to the resident's right heel. The note indicated the facility NP had ordered a culture to be completed, on 5/17/2024, but the facility was waiting for wound culture supplies to be delivered. The resident was encouraged and re-educated regarding the importance of wearing pressure reducing boots while she was in bed, and off-loading her heels. The resident verbalized understanding. The nurse applied a knitted heel protector to the resident's left heel for preventative measure. Resident C stated That is more tolerable than those big boots. CNA staff were made aware of the need to apply boots/or knitted heel protectors to the resident's feet while she was in bed or in the recliner. Treatments were completed as ordered. The resident denied any pain to the open area upon assessment. A Skin Evaluation Form, dated 5/21/24 at 2:58 PM., indicated the resident's left heel had a dark closed area to heel, which measured 2.0 x 3.0 cm. The issue type was marked necrotic/eschar. A Nursing Progress Note, dated 5/21/24 at 11:09 A.M., indicated a Care Plan meeting was conducted with the resident's family member via the phone. The care plans were reviewed and updated. Resident C was identified as having a new open area on her heel and treatments to the area were completed by nursing staff. The resident was documented as wearing heel protectors while in bed and when in a recliner. There was no documentation in the note of any new effective intervention to provide complete pressure relief to Resident C's bilateral heels, specifically when she was not in bed or the recliner. A Care Plan, dated 5/23/24, indicated the resident had a Stage II pressure wound to the left heel related to diagnoses of neuropathy and MS. The interventions included, but were not limited to, treatment to wound as ordered, observed wound daily for signs of infection such as redness, pain, purulent drainage, foul odor, edema, warmth to area, dietary supplements as ordered, labs as ordered, turning/repositioning every 2 hours, Registered Dietician to follow for dietary recommendations, encourage resident to elevate bilateral lower extremities one hour twice a day, and heel protectors to feet when in bed/recliner. The care plan did not provide interventions to ensure complete pressure relief to the resident's left heel was initiated and the care plan did not address the pressure injury on the resident's right heel. A Nursing Progress Note, dated 5/23/2024 at 1:40 P.M., indicated a physician's order for a Santyl treatment, (treatment to remove damaged tissue) to the resident's right heel, was discontinued because it was unavailable. A new physician's order for Medihoney (a treatment to provide and support autolytic debridement and provide a moist wound healing environment), Telfa dressing, foam padding and Kerlix wrap after cleaning the wound with wound wash was obtained. A Nursing Progress Note, dated 5/23/2024 at 4:47 P.M., indicated a call was placed to ensure the facility's order for wound culture swabs was being shipped. The supply company indicated the swabs were ready to be sent out and would be expedited. The TAR for May 2024, indicated the Medihoney treatment was started on 5/25/2024. A Nursing Progress Note, dated 5/25/2024 at 4:02 A.M., indicated when the old bandage was removed from the right heel, the scab fell off the right heel and exposed a pink wound bed. There were no other blackened areas remaining on the right heel. The left heel was documented to have a hard black area. The physician was notified of the wound changes. There were no measurements or any further descriptions of the wounds in the nursing progress note for 5/25/2024. A Wound Care Specialist Progress Report, dated 5/29/24, indicated Resident C presented with non-healing pressure ulcerations to the right midline heel and the right posterior heel. The wounds had been present for approximately 30 days with previous treatments of .Wound debridements for the midline heel area and Compression therapy for the posterior heel area. The right midline wound details indicated the wound was a Stage III pressure ulceration, which measured 0.75 cm x 0.8 cm x 0.1 cm. The Wound Evaluation indicated the following: Exudate amount: Moderate, Necrotic tissue: 100%, Wound bed: Full Thickness, Slough and Unavoidable wounds: N/A The right posterior heel wound was a Stage III pressure ulceration measured 2.0 x 1.0 x 0.1 cm. The Wound Evaluation indicated the following: .Exudate amount: moderate, Necrotic tissue: 100% Wound Bed: Full Thickness, Slough. Treatment notes for both wounds indicated to, .Keep are clean and dry. Apply barrier cream such as zinc oxide (Desitin, patient supply added today) There was no mention of the left heel pressure wound. There was also no specific documentation to support the wound care specialist documentation of previous treatments of wound compression therapy. In addition, although the right heel wounds displayed potential signs of infection, moderate exudate described as slough, there was no indication the physician was notified of the status of the wound and potential need for altered treatment. The TARs from April through June 2024 did not include documentation to show staff provided complete pressure relief to the bilateral heels of Resident C with interventions when the resident was both in bed and out of bed. The TAR for May and June 2024, indicated the nursing staff continued to document the application of the skin prep to the bilateral heels, every shift, even after the right heel wounds had opened and the eschar tissue had fallen off. A Nursing Progress Note, dated 6/2/2024 at 4:28 P.M., indicated the resident had refused to wear the pressure relieving boots and insisted on wearing her shoes. Staff had reminded the resident about the amount of pressure the shoes placed on her wound, but the resident still insisted on wearing her shoes. A Wound Care Specialist Progress Report, dated 6/6/24, indicated the resident presented with non-healing pressure ulcerations to the right midline heel and the right posterior heel. The wounds had been present for approximately 30 days with previous treatments of Wound debridements for both areas. The right heel, Stage III midline, pressure wound/ulceration measured 0.73 cm L(length) x 0.8 cm W (width) x 0.1 cm D (depth). The Wound Evaluation indicated Exudate: moderate, Granulation tissue: 80%, Necrotic tissue: 20%, Wound bed: Full Thickness, Slough, The right heel posterior Stage III, pressure ulceration/wound measured 0.3 L x 0.3 W x 0.1 cm D. The Wound Evaluation indicated Exudate: Moderate, Necrotic tissue: 10% and 76-99% epithelialization. There was no mention of the left heel pressure wound and no indication the physician was notified of the signs and symptoms of potential infection of the wound, i.e. slough and moderate exudate. A Nutrition At Risk (NAR) team Progress Note, dated 6/6/24 at 2:04 P.M., indicated the team met to review Resident C for impaired skin and right and left heel pressure areas. The note recommended a MVI (multivitamin) to assist with RDI's (Resident Daily Intake) for wound healing. The rest of the current interventions were to be continued. A Nursing Progress Note, dated 6/6/24 at 4:48 P.M., indicated the resident experienced a significant change in respiratory status and was transferred to an acute care center. Nursing documentation and an MDS assessment, completed due to the resident's discharge from the facility, on 6/6/2024, indicated the resident was discharged with a Stage IV pressure ulcer. According to the NPUAP's (National Pressure Ulcer Advisory Panel) revised pressure ulcer staging guide , copyright 2016 a Stage IV pressure wound reflects a full thickness and loss of dermis with exposed muscle, tendon or bone, During an interview, on 7/2/24 at 1:56 P.M., with RN 4 (previous wound nurse during April/May of 2024), RN 4 indicated the staff had not notified her of resident's eschar, on Resident C's bilateral heels, until 5/20/24 She indicated Resident C had a Stage III pressure ulcer to right heel when she first observed her pressure ulcers and a treatment of Santyl was initiated. She believed the nurses thought since the wound was covered with eschar, it was not a pressure ulcer. RN 4 indicated she did not know why the skin prep treatment was still being documented every shift for Resident C's bilateral heels. RN 4 indicated she was unable to locate any notes for the left heel pressure ulcer and did not know why the left heel was not assessed by the new wound specialist team. The most recent documentation regarding Resident C's left heel wound was completed on 5/21/24. RN 4 was unable to provide any more information regarding the left heel's condition after 5/21/2024. During an interview, on 7/2/24 at 1:56 P.M., with the DON she agreed with RN 4's opinion regarding why the nursing staff had neglected to notify the wound nurse of Resident C's pressure wounds. The DON was unable to provide any more information regarding the left heel's condition after 5/21/2024. During an interview, on 7/3/24 at 10:17 A.M., with the DON, she indicated there were no culture results for Resident C's right heel. In addition, there were no care plans addressing the resident's refusals of the heel protector boots: however, staff had documented some refusals on the TAR. The DON explained some nurses had documented n/a (not applicable) (due to the resident being out of bed) and others had documented R for refusal when the resident was actually out of bed. However, there was no additional documentation on the TAR to support the DON's comments During an interview, on 7/3/24 at 10:17 A.M., with the Assistant Director of Nursing (ADON) and DON, she indicated the new wound specialist's procedures were as follows: assess and observe the resident's wounds weekly on Thursday, the next day (Friday) the wound report would come to the facility, The ADON indicated although the wound reports ad recommendations were being sent to the facility weekly, no one was reading the reports or acting upon any instructions for wound treatments. The DON explained the facility had discovered the issues last week and now those reports were being reviewed timely and their treatments/instructions were being implemented. During an interview,on 7/3/2024 at 11:10 A.M., LPN 3 indicated she had informed the wound nurse, on 4/21/24, of Resident C's heel wounds and she had completed the Skin Evaluation Forms. She indicated the resident was to have a wound culture of the right heel wound, but there were no wound culture swabs available in the facility. LPN 3 indicated she had never received an order to discontinue the lab culture order. She indicated the resident had been declining some but had not displayed any major decline prior to being hospitalized . What is Unstageable Pressure Ulcer And How Can You Treat was retrieved , on 7/2/2024, from The Wound Pros Webster at www.thewoundpros.com (the Webster associated with the wound specialist's company). The Webster indicated .An unstageable pressure ulcer is a type of bed sore that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. It is a full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [a thick, black, or brown scab or crust that forms over the wound] in the wound bed. On 6/28/24 at 1:09 P.M., the DON provided a policy titled, Pressure Injury Prevention and Management, dated 12/2019, revision date 2/26/24 and indicated the policy was the one currently used by the facility. The policy indicated .This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries The facility policy defined an avoidable ulcer as .the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . This citation relates to Complaint IN00436622. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to develop person-centered care plans for activities, behaviors, ADLs (activities of daily living), and dementia care for 4 of 15 residents whose care plans were reviewed. (Residents 25, 23, 36 and 53) Findings include: 1. During a random observation on 4/30/2024 at 11:21 A.M., Resident 25 was not seen in an activity. During an observation, on 4/30/2024 at 1:19 P.M., Resident 25 was in bed sleeping, there was a small clock radio sitting on a dresser across the room, there was no television in the room. A record review was completed on 5/1/2024 at 2:22 P.M. for Resident 25. Her diagnoses included, but were not limited to, dementia, anxiety, depression, psychotic disorder and bipolar. An Annual MDS (Minimum Data Set) assessment, dated 5/31/2023, indicated it was not very important to her to have books, magazines, newspapers to read and it was somewhat important to listen to music she liked. A Quarterly MDS assessment, dated 2/18/2024, indicated the resident had a severe cognitive impairment, and had had delusions and physical behaviors. She received antipsychotics, antidepressants and anti-anxiety medications. A current Care Plan, dated 2/7/2024, indicated the resident preferred the comfort of her room to that of attending group activities. She tended to refuse groups when invited. She liked to watch TV, have family visits and work word puzzles. She was a florist. The goal was for the resident to be active with activity of choice in her room daily i.e.: TV, reading, talking on the phone, attend a group out on the unit i.e.: flower arranging occasionally at her leisure thru next review. Interventions included, but were not limited to, provide reading material, puzzle books, assist with TV or phone and radio PRN (as needed), and provide 1-1 interactions PRN. The activity log sheets dated for March and April indicated the resident had attended 10 activities in all. During an interview, on 5/6/2024 at 2:30 P.M., the Activity Director indicated the care plan was not person-centered and did not have interventions that would work for the resident. A Nurses' Note, dated 2/9/2024, indicated the resident kept yelling intermittently through out the night. She kept saying Dad! Mom! [NAME]! Help me! When staff went to her room and asked what she needed, she said I need to get into my car and go home. Staff diverted the resident's attention by providing fluids and some cookies as requested, but she still would go back to the habit of yelling after a few minutes. A Nurses' Note, dated 2/14/2024, indicated the resident was attempting to get out of bed, looking for Mother and Daddy. The resident was brought out to the nurses' station, given cookies and a pop. She continued to yell out ''help, mother and daddy''. The resident became angry with staff, thinking they were holding her back. A Nurses' Note, dated 2/15/2024, indicated Resident 25 was yelling and trying to get out of bed prior to breakfast. She was brought out to the common area for breakfast. She only ate bites, but took her medications. She continued to talk out loud to call her father and attempted to stand up from her wheelchair. The resident has had 3 pops and cookies, and was brought off the unit for a walk. Back in the common area, she was wanting staff to call her father with repetitive requests. A Nurses' Note, dated 3/21/2024, indicated the resident was up all night, alert and very confused. Resident kept yelling 'Please come in and save the dogs! They are in front of me!' Resident then started yelling 'Why are the cats here!', reassurance in a calm manner provided. A Nurses' Note, dated 4/11/2024, indicated the resident intermittently asked repetitive questions at breakfast. She believed her mother was coming to get her. A current Care Plan, dated 3/28/2023, indicated the resident had the potential for Impaired Psychosocial well-being related to loss of interest in doing things and preferred the comfort of her room and bed. Interventions included, but were not limited to, encourage and invite to activities, and facilitate development of peer relationships/participate in activities. A current Care Plan, dated 2/27/23, indicated the resident had an alteration in behavior as evidence by repetitive calling out related to diagnoses of dementia, Bipolar Disorder, and Pseudobulbar affect. Interventions included, but were not limited to: 1) Call Resident by preferred name. 2) Identify self and explain all procedures and reason before performing. 3) Keep communication simple, yes/no questions. Allow time for resident to process and respond. 4) Speak clearly and distinctly in a calm, re-assuring voice. 5) Always approach her calmly and in an unhurried manner. 6) Administer medication as ordered. 7) Attempt to redirect disruptive behavior to something positive when she is exhibiting inappropriate behavior. 8) Provide cognitive cues/reminders/redirection as needed. Resident 25 is calling out for [name of daughter] reorient her that daughter is not present and Resident is at [name of facility]. Reassure her that staff will send daughter down to her room when she visits, weekly. 9) Notify physician/ N.P. to any sudden, acute changes in resident's usual cognitive/mood/behavioral functioning levels for further follow up as indicated. 10) Alert nurse to any observations and/or expressions of pain/discomfort. 11) Alert nurse to any unmet ADL (activities of daily living) for follow up. 12) Encourage frequent family visits. 13) Praise resident when in a positive mood state and she uses her call light to summon staff. 14) Involve in low stress activities to keep occupied. 15) Provide expressions of comfort, emotional support and reassurance as needed. Encourage to discuss feelings. 16) Monitor interaction with peers and/or visitors in Common Area. Redirect away if inappropriate behavior is exhibited. 17) Offer in-between meal snacks as indicated. Keep daughter's cookie snacks in zip lock bags that resident is able to open close to her. 18) Keep call cord within residents reach. Re-orient and demonstrate usage as needed. During an interview, on 5/03/2024 at 10:42 A.M., the ADON indicated the care plans were not person-centered for the resident's specific behaviors. 49994 2. On 5/1/2024, at 1:41 P.M., a record review was completed for Resident 23. Diagnoses included, but were not limited to: dementia with behavior disturbance, major depressive disorder, psychotic disorder with delusions, and anxiety. A Care Plan, initiated on 12/12/2023, indicated Resident 23 demonstrated an altered level of cognitive function as evidenced by a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate impairment. Interventions included to call the resident by preferred name with each interaction to reinforce name recognition, introduce yourself and explain what you are doing in plain simple terms, keep the routine and caregiver as consistent as possible, present one idea, question, or command at a time, ask yes or no questions, break tasks into one step at a time, and provide cues and reminders as needed. During an interview, on 5/3/2024, at 2:27 P.M., the Infection Prevention Nurse indicated the resident's care plan for dementia was not person centered regarding interventions. 47419 3. During an observation, on 4/29/2024 at 11:11 A.M., Resident 36 was noted to not have been shaved and his fingernails were long with brownish yellow matter under them. A record review for Resident 36 was conducted on 5/01/2024 2:18 P.M. Diagnoses included, but were not limited to, Alzheimer's, dementia, major depressive disorder, general anxiety disorder, and psychotic disorder with delusions. An Annual Minimum Data (MDS) assessment, dated 2/1/2024, indicated no response to the question regarding cognition. No behavior concerns were noted. He was dependent for bathing, hygiene, and dressing. He needed set up help for bed mobility, transfers and walking. A Care Plan indicated Resident 36 had an actual or potential problem with activities of daily living (ADLs) secondary to impaired cognition, decreased mobility, incontinence, generalized weakness and medication use. Interventions included, but were not limited to, explain all procedures. The care plan lacked documentation that the resident sometimes refused shaving and trimming or cleaning fingernails. During an interview, on 5/3/2024 at 11:05 A.M., the ADON indicated there should have been a care plan for Resident 36 refusing ADLs. 48145 4. Resident 53's record review was completed, on 5/1/2024 at 9:16 A.M. Her diagnoses included, but were not limited to: dementia, Alzheimer's Disease and heart disease. A Quarterly MDS (Minimum Data Set) assessment, dated 2/6/2024, indicated Resident 11 had severe cognitive impairment. A Care Plan, dated 8/17/2023, indicated Resident 53 had cognitive loss related to short and long term memory loss, severely impaired cognitive skills and abilities. Interventions included, but were not limited to: ask yes or no questions; encourage and invite to activities to keep occupied; anticipate and meet needs. During an interview, on 5/03/24 at 3:06 P.M., the Assistant Director of Nursing indicated Resident 53's Care Plan was not person centered regarding interventions. On 5/3/2024 at 1:47 P.M., the Director of Nursing provided a policy, dated 1/29/2024, and titled, Comprehensive Care Plans. The Director of Nursing indicated it was the policy currently used by the facility. The policy indicated, It is the policy of this campus to develop and implement a comprehensive person-centered care plan for each resident . Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives 3.1-35(a)

Based on observations, record reviews, and interviews, the facility failed to provide activities of daily living (ADLs) for 1 of 4 residents reviewed for activities of daily living. (Resident 36) Finding includes: During an observation, on 4/29/2024 at 11:11 A.M., Resident 36 was noted to not have been shaved and his fingernails were long with brownish yellow matter under them. During an observation on 5/1/2024 at 9:10 A.M., Resident 36 was still not shaved and his fingernails were long. A record review for Resident 36 was conducted on 5/1/2024 2:18 P.M. Diagnoses included, but were not limited to, Alzheimer's, dementia, major depressive disorder, general anxiety disorder, and psychotic disorder with delusions. An Annual Minimum Data (MDS) assessment, dated 2/1/2024, indicated no response to the question regarding cognition. No behavior concerns were noted. He was dependent for bathing, hygiene, and dressing. He needed set up help for bed mobility, transfers and walking A Care Plan indicated Resident 36 had an actual or potential problem with activities of daily living (ADLs) secondary to impaired cognition, decreased mobility, incontinence, generalized weakness and medication use. Interventions included, but were not limited to, explain all procedures. The care plan lacked documentation that the resident sometimes refused shaving and trimming or cleaning fingernails. During an interview, on 5/1/2024 at 1:49 P.M., CNA 2 indicated showers and morning ADL care included shaving and nail care if needed. Resident 36 often refused shaving and nail care. On 5/3/2024, an aide report sheet did not indicate that Resident 36 refused ADL care at times or what to do if he refused. During an interview, on 5/3/2024 at 11:05 A.M., the ADON indicated there was no care plan for Resident 36 refusing ADLs and the aide should report to the nurse if a resident refused and the nurse would document in interdisciplinary (ID) notes. When a resident refused care, the aide should see if another staff member would be able to complete the care. On 5/3/2024 at 2:05 P.M., the ADON provided a current policy titled, Activities of Daily Living and dated 1/23/2024. The policy indicated, .Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to provide activities that support the physical, mental, and psychosocial well-being of each resident for 3 of 4 residents reviewed for activities. (36, 25, and 53) Findings include: 1. During an observation, on 4/29/2024 at 11:09 A.M., Resident 36 was sitting in the Center Unit common area with his back to the TV. There were no activities taking place. During a continuous observation, on 5/1/2024 from 9:16 AM to 11:22 AM, Resident 36 was sleeping on couch in the Center Unit common area. He woke up about 11:20 and is just sitting on couch. During a continuous observation, on 5/2/2024 from 9:28 A.M. to 11:11 A.M., Resident 36 was sitting in a wheelchair in the Center Unit common area. His head was dropped down to his chest and his eyes were closed. No activity taking place on unit at this time. During a continuous observation on 5/3/2024, the following occurred: At 9:04 A.M., Resident 36 was sitting in the Center Unit common area when the activity aide announced that she would be back later to play a game. At 9:36 A.M., the activity aide again announced she will be back soon to play a game. At 10:32 A.M., the resident was still sitting in the Center Unit common area and no game or other activity was taking place. The TV was on but he was not interested. 3 other residents in the area are not engaged in any activity and one was asleep on the couch. At 11:03 A.M. the Activity Aide gathered various residents to play a game on the [NAME] Unit. Resident 36 was not included and remained on the Center Unit. A record review for Resident 36 was conducted on 5/1/2024 2:18 P.M. An Annual Minimum Data (MDS) assessment, dated 2/1/2024, indicated no response to the question regarding cognition. No behavior concerns were noted. Activity preferences included it was somewhat important to listen to music and very important to get fresh air. Diagnoses included, but were not limited to, Alzheimer's, dementia, major depressive disorder, general anxiety disorder, and psychotic disorder with delusions. Physician orders included, but were not limited to: 2/25/2024 Seroquel 25 (milligram) mg tablet by mouth every evening for psychotic disorder with delusions. 2/11/2021 Zoloft 100 mg tablet with 25mg tablet (to total 125 mg) by mouth every day for major depressive disorder. A care plan problem indicated Resident 36 needed escorts to and from groups and assistance to turn on the TV to watch sports or musicals. His goal was to be included in groups, allowed to sit in the common area watching the daily life of the unit, and to participate in 1:1 interactions when presented. Interventions included, but were not limited to, he prefers sports on TV such as golf, staff will provide assist with transport to and from activities, and provide him with sports magazines and National Geographic, as requested. Documentation of 1:1 activities indicated that Resident 36 received 1:1 activities 2-3 times a week during March and April 2024. During an interview on 5/03/2024 at 1:21 P.M., the Activity Director indicated she did training with Resident Care Aides and Certified Nursing Assistants today on sensory stimulation for residents. Transporting dementia residents to the activity was sometimes an issue. There needed to be more activities on the Center unit. 38845 2. During an observation, on 4/30/2024 at 11:21 A.M., Resident 25 was observed in her room sleeping. During an observation, on 4/30/2024 at 1:19 P.M., Resident 25 was in bed sleeping. A record review was completed on 5/1/2024 at 2:22 P.M. Resident 25's diagnose included, but were not limited to heart failure, dementia, seizures, anxiety, depression, psychotic disorder and bipolar. A Quarterly MDS (Minimum Data Set) Assessment, dated 2/18/2024, indicated the resident had a severe cognitive impairment. Had delusions and physical behaviors and received antipsychotics, antidepressants and antianxiety medications. A current Care Plan, dated 2/7/2024, indicated the resident preferred the comfort of her room to that of attending group activities. She tended to refuse groups when invited. She liked to watch TV, have family visits and work word puzzles. She was a florists. Goal: the resident will be active with activity of choice in her room daily i.e.: TV, reading, talking on the phone. Attend a group out on the unit i.e.: flower arranging occasionally at her leisure thru next review. Interventions included, but were not limited to, provide reading material, puzzle books, other supplies for independent activity such as silk flowers. Assist with TV, phone and radio PRN (as needed). Respect the right to refuse. Encourage socialization with peers for psychosocial wellbeing. Provide 1-1 interactions PRN, and observe for changes. An April activity calendar indicated, on 4/30/2024, the activities for the day were: 10:00 A.M. exercise, 2:00 P.M. craft and 6:00 P.M. movie. Resident 25 was not documented as attending the craft activity at 2:00 P.M. The March and April activity participation calendars indicated the resident had attended 10 activities. During an interview, on 5/6/2024 at 2:30 P.M., the Activity Director indicated the care plans were not person centered and did not have interventions that would work for the resident. 48145 3. During an observation on 4/29/24 from 10:00 A.M. until 11:58 A.M., Resident 53 was observed sitting at table with two other female residents. She was not talking with anyone and was either fidgeting with her hands or resting her head on her hands. During an observation on 4/30/24 at 10:53 A.M. Resident 53 was sitting on the East Unit in front of the television, but no sound was on. Resident 53's record review was completed on 5/1/2024 at 9:16 A.M. Her diagnoses included, but were not limited to: dementia, Alzheimer's Disease and heart disease. A Quarterly MDS (Minimum Data Set) assessment, dated 2/6/2024, indicated Resident 11 had severe cognitive impairment and had unclear speech. She could only understand others and make herself understood some of the time. A Care Plan, dated 8/17/2023, indicated Resident 53 had cognitive loss related to short and long term memory loss, severely impaired cognitive skills and abilities. Interventions included, but were not limited to: ask yes or no questions; encourage and invite to activities to keep occupied; anticipate and meet needs. Resident 53's record lacked the documentation she had refused participation in activities and she did not have an Activities Care Plan. Resident 53's March 2024 Activities Log indicated she had participated in activities on the following dates: 3/4/2024, 3/5/2024, 3/8/2024, 3/13/2024, 3/18/2024, 3/20/2024, 3/26/2024 and 3/29/2024. Resident 53's April 2024 Activities Log indicated she had participated in activities on the following dates: 4/10/2024, 4/11/2024, 4/12/2024, 4/16/2024, 4/26/2024 and 4/29/2024. During an observation on 5/01/2024 at 9:40 A.M., Resident 53 was seen walking around East Unit. She went into room [ROOM NUMBER] and walked back out immediately. Resident 53 walked off the unit and was observed walking around Center Unit. The resident walked back to East Unit and sat in a recliner when staff offered her food. On 5/01/2024 at 10:05 A.M., a group activity, Drum on Ball, was observed. Resident 53 was not in activity. During an interview on 5/3/2024 at 9:54 A.M., CNA 9 indicated he did not invite Resident 53 to activities. Instead, he would get several of the residents who don't participate in activities and have them sit at a table together and encourage the residents to converse with each other. During an interview on 5/03/2024 at 10:12 A.M. RN 10 indicated she did not invite Resident 53 to activities. RN 10 spent one on one time with the resident singing as an activity. RN 10 indicated one on one with the resident didn't happen often but it did happen on Sundays when RN 10 had more time. During an interview on 5/3/2024 at 1:22 P.M., the Activities Director indicated the facility typically has two activities a day, except on the weekends. One to one activities are provided for residents who don't participate in group activities and the facility did not have a process to document when a resident is invited to an activity but refuses. She indicated Resident 53 did not get invited to all the activities and did not participate in many activities for the month of March and April. On 5/3/2024 at 1:45 P.M., the Activities Director provided a policy, dated 9/30/2020, and titled, Activities. The Activities Director indicated the policy was the current policy used by the facility. The policy indicated, .Facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community 3.1-33(a)

Based on observation, record review, and interview, the facility failed to secure a resident's cigarettes at the Nurse's Station for 1 of 1 resident who was reviewed for smoking. (Resident 11) Finding includes: During an observation on 4/29/24 at 11:37 A.M., Resident 11 had a long silver tray with an ashtray containing ashes, two cigarette butts, two cigarettes and a pack of opened cigarettes on a table in his room. Resident 11 had an empty ashtray sitting on his bedside table. Resident 11's record review was completed on 5/1/24 2:33 P.M. His diagnoses included, but were not limited to: cerebral infarction, hemiplegia following cerebral infarct, generalized anxiety, chronic atrial fibril, edema, anemia, chronic pain, arthritis, vascular dementia, type 2 diabetes. A Quarterly MDS (Minimum Data Set) assessment, dated 4/2/2024, indicated Resident 11 had intact cognition. A Care Plan, dated 2/8/2024, indicated Resident 11 had alteration in behavior as evidence by selling cigarettes to Assisted Living Residents. Interventions included, but were not limited to: if resident continued to curse at staff or sell cigarettes to Assisted Living Residents, ask his sister to speak to her brother; cigarettes, matches and lighters to be kept at nurses station; and assure any cigarettes were extinguished before coming back indoors. A Care Plan, dated 2/13/2024, indicated Resident 11 had potential for complications or injury related to smoking cigarettes. Interventions included, but were not limited to: educate resident and family/visitors as needed on smoking regulations; remind resident and family/visitors this is a smoke free facility; assist resident into courtyard when resident wants to smoke; make sure resident is dressed appropriately for the weather; make sure that any cigarettes are properly disposed of when resident comes indoors. During a random observation on 5/2/2024 at 2:04 P.M., Housekeeper 7 went into Resident 11's room and came out with a pack of cigarettes and took the resident outside to smoke. On 5/2/2024 at 2:25 P.M., an interview with Resident 11 was completed. He indicated he was a supervised smoker and was not allowed to have cigarettes in his room. During the interview, Resident 11 had a long silver tray with an ashtray containing ashes and two cigarette butts. Resident 11 had an empty ashtray sitting on his bedside table and a pack of cigarettes on his shelf. During an interview on 5/3/2024 at 10:04 A.M., CNA 9 indicated cigarettes were kept at the Nurse's Station and Resident 11 should not have cigarettes, cigarette butts or ash trays in his room. An interview with Housekeeper 7 was completed on 5/3/2024 at 10:07 A.M. Housekeeper 7 indicated she was Resident 11's sister and had taken him out to smoke the previous afternoon. She did not know if his cigarettes should be in his room or not. During an interview on 5/3/2024 at 10:20 A.M., RN 10 indicated Resident 11 should not have cigarettes in his room. An interview with the Director of Nursing (DON) was completed on 5/3/2024 at 1:15 P.M. The DON indicated Resident 11 should not have smoking materials in his room and the cigarettes had been removed. On 5/3/2024 at 1:47 P.M., the DON provided a policy, dated 9/2021, and titled, Smoking Policy. The DON indicated it was the policy currently used by the facility. The policy indicated, . 14. All smoking materials will be maintained by activities staff during the day and nursing staff after 5 PM and on weekends. Resident and family members will turn smoking materials in after completion of smoking 3.1-45(a)

Based on interview, record review, and observation, the facility failed to prevent a resident with dementia from wandering into other residents' rooms for 1 of 3 residents reviewed for dementia care. (Resident 53) Finding includes: During an interview on 4/30/2024 at 10:05 A.M., Resident 49 indicated Resident 53 came into his room often and sometimes she would take his belongings. He always got his belongings back. During an interview on 4/30/2024 at 2:30 P.M., Resident 40 indicated Resident 53 was confused and came into her room and took her things. Staff knew and kept the door closed, but Resident 53 still entered. Resident 40 indicated she always got her belongings back, but felt it frustrating to have the other resident in her room sometimes. Resident 53's record review was completed on 5/1/2024 at 9:16 A.M. Her diagnoses included, but were not limited to: dementia, Alzheimer's Disease and heart disease. A Quarterly Minimum Data Set (MDS) assessment, dated 2/6/2024, indicated Resident 11 had severe cognitive impairment and had unclear speech. She could only understand others and make herself understood some of the time. A Care Plan, dated 8/17/2023, indicated Resident 53 had cognitive loss related to short and long term memory loss, severely impaired cognitive skills and abilities. Interventions included, but were not limited to: ask yes or no questions; encourage and invite to activities to keep occupied; anticipate and meet needs. A Care Plan dated, 8/17/2023, indicated Resident 53 had potential for elopement and possible injury related to Alzheimer's Disease and dementia, poor safety awareness, wandering and exit seeking behaviors. Interventions included, but were not limited to: wandergard placement and function check; provide hazard free environment; invite/escort to low stress activities to keep time occupied; if wandering in and out of other resident's rooms, attempt to learn what she is looking for. Use Velcro STOP signs on other resident's rooms; redirect to common area chair to take rest breaks from repetitive pacing/wandering; escort to watch television. During an observation on 5/1/2024 at 2:10 P.M., Resident 53 was walking around East Unit and went into room [ROOM NUMBER]. The resident was playing with a stuffed toy in room [ROOM NUMBER] and no other residents were in the room. On 5/2/2024 at 2:27 P.M., Resident 53 entered room [ROOM NUMBER] while Resident 11 was being interviewed by a State Surveyor. Resident 53 walked around the room, picked up the call light and put it down, and exited the room without saying anything. Resident 53 then walked across the hall and into room [ROOM NUMBER]. During an interview on 5/2/2024 at 2:28 P.M., RN 7 did not know the location of Resident 53. RN 7 went to room [ROOM NUMBER] and walked out with Resident 53. During an observation on 5/2/2024 at 2:38 P.M., Resident 53 seen walking on East Unit and entering room [ROOM NUMBER]. The resident was seen entering the room by staff and was escorted out of the room. During an interview on 5/3/2024 at 9:54 A.M., CNA 9 indicated Resident 53 did wander in and out of other residents' rooms. The resident would enter the rooms when the door was closed. The only thing that helped is if staff take the resident by the hand and lead her somewhere else. The Velcro STOP signs did not help and staff did not use them. During an interview on 5/3/2024 at 10:12 A.M., RN 10 indicated she has worked on the unit regularly for the last couple of months and staff does not use the Velcro STOP signs on the resident's Care Plan because the signs were ineffective at keeping Resident 53 out of other resident's rooms. She had been alerted by other residents that Resident 53 was in their room or had taken their belongings. RN 10 tries to keep an eye on her and redirect her but the resident enjoys walking for most of the day. During an interview on 5/3/2024 at 1:33 P.M., the Director of Nursing (DON) indicated Resident 53 did wander in and out of other residents' room and had taken belongings from other residents, but all items were either returned or replaced. The care plan for the resident's wandering had ineffective interventions and the staff would work to find interventions that prevented the resident from wandering in other residents' room. On 5/3/2024 at 1:47 P.M., the DON provided a policy, dated, 3/1/2023 and titled, Elopement and Unsafe Wandering. The DON indicated it was the policy currently used by the facility. The policy indicated, The facility ensures that residents who exhibit wandering behavior and or are are risk for elopement receive adequate supervision to prevent . 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk . implementing interventions to reduce hazards and risks On 5/3/2024 at 1:47 P.M., the DON provided a policy, dated, 3/1/2023 and titled, Dementia Care. The DON indicated it was the policy currently used by the facility. The policy indicated, . 4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 5. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being 3.1-37

Based on observation, record review, and interview, the facility failed to ensure shift narcotic counts sheets were completed and documented every shift for 1 of 2 narcotic books observed. (West Hall) Finding includes: During a medication storage observation on 5/3/2024 at 1:26 P.M. with RN 11, the narcotic sheets, dated 1/12/2024 to 4/8/2024, indicated not all shifts had all signatures to indicate the narcotics were counted every shift. There were 7 missing signatures for the day shift and 26 missing signatures for the evening and the night shifts. During an interview on 5/3/2024 at 1:27 P.M., RN 11 indicated the narcotics should be counted every shift and documented on the sheet. On 5/3/2024 at 1:47 P.M., the Director of Nursing provided the policy titled, Controlled Substance Administration and Accountability Policy, dated 4/8/2023, and indicated the policy was the one currently being used by the facility. The policy indicated . 2. Storage and Security: .b. Areas without automated dispensing systems utilize substantially-constructed storage unit with two locks and paper system for 24 hour recording of controlled substance use 3.1-25(e)(2) 3.1-25(e)(3)

Based on record review and interview, the facility failed to ensure a resident who received an opioid and an anti-anxiety medication had an appropriate indication and was monitored for adverse side effects, for 1 of 5 residents whose medications were reviewed. (Resident 7) Finding includes: During an observation on 4/29/2024 at 12:27 P.M., Resident 7 was observed sitting in her wheelchair in the dining area yelling hey hey, and scratching her back on the wheelchair back. The resident, while being fed, was observed trying to scratch her back against the back of the wheelchair. During an observation on 4/30/2024 at 9:27 A.M., Resident 7 was observed sleeping in her wheelchair in the lounge area. During an observation on 5/2/2024 at 2:20 P.M., Resident 7 was observed sleeping in her wheelchair in the lounge area. During an observation on 5/2/2024 at 2:26 P.M., Resident 7's back had no red or open areas. A record review was completed on 5/2/2024 at 2:30 P.M. Resident 7's diagnoses included, but were not limited to, dementia, depression, anxiety and osteoarthritis. Current Physician Orders included: Lorazepam (anti anxiety) 0.25 ml (milliliter) give every 2 hours PRN (as needed) for anxiety disorder and Morphine (narcotic) 0.25 ml (0.5 milligram) every 2 hours as needed for pain and dyspenea (labored breathing). A Quartley MDS (Minimum Data Set) assessment, dated 2/5/2024, indicated the resident received an antidepressant medication only. A Care Plan, dated 10/14/2021, indicated the resident was at risk for alteration in comfort secondary to diagnoses of osteoporosis, chronic ischemic heart disease and depression. Interventions included, but were not limited to, administer analgesic medication as ordered, observe for effectiveness/side effects, observe for non-verbal signs and symptoms of pain such as: facial grimacing, crying, moaning, restlessness, agitation, guarding or withdrawing form touch to affected area. Provide alternative comfort measures such as: therapeutic touch/massage, repositioning, toileting, calm quiet environment. Complete a pain assessment quarterly and PRN (as needed). The Medication Administration Record (MAR), dated April 2024, indicated Resident 7 received the Lorazepam and the Morphine medications 10 times on the same dates and the same times. The clinical record lacked the documentation for why the medications had been given. Nurses's Notes, dated April 1st through the 30th, lacked the documentation of any nonpharmacological interventions tried prior to administering the narcotic pain medication or the anti-anxiety medication. During an interview on 5/02/2024 at 3:04 P.M., CNA 5 indicated when the resident yelled out, she would walk her, lie her down, or rub her back. During an interview on 5/3/24 at 2:49 P.M., the Assistant Director if Nursing (ADON) indicted the medications Ativan & Morphine should not be given together, staff should have tried a nonpharmacological interventions first, then given one of the medications. There should have been a pain scale documented when giving the morphine. The resident should have been assessed for pain and documented on the chart. On 5/3/2024 at 2:56 P.M., the ADON provided the policy titled, Pain Management, dated 10/24/2022, and indicated the policy was the one currently used by the facility. The policy indicated .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .Pain Management and Treatment: . f. Reassess and adjust the medication dose to optimize the residents's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects .8. Monitoring,, Reassessment and Care Plan Revision. a. Facility staff will reassess resident's pain management at establish intervals for effectiveness and/or adverse consequences such as: .viii. Itching On 5/3/2024 at 11:10 A.M., the ADON provided the policy titled, Unnecessary Drugs- Indications for Usage, dated 8/12/2022, and indicated the policy was the one currently used by the facility. The policy indicated: .3. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use 3.1-37

Based on observation, record review, and interview, the facility failed to ensure expired medications were removed from the medication cart and failed to monitor a medication refrigerator's temperature to prevent a large build up of ice in 1 of 1 medication cart and 1 of 1 medication rooms observed. (West Medication Cart & East Medication Room) Findings include: 1. On 5/3/2024 at 1:26 P.M. with RN 11 a medication storage observation was completed on the [NAME] medication cart. The following was observed: an opened bottle of lactulose liquid that had expired on 1/9/2024, and two opened bottles of Guafenesin syrup with expiration dates of 2/22/2024 and 3/2024. During an interview on 5/3/2024 at 1:35 P.M., RN 11 indicated the medications should have been removed from the cart. 2. During a medication storage observation on 5/3/2024 at 1:39 P.M. with RN 10, the following was observed on the East unit: the medication refrigerator had a large build up of ice in the freezer section of the fridge. The February temperature log sheet indicated the temperature was not documented 1 time for the AM temperature and 11 times for the PM temperature. The March temperature log sheet indicated the temperature was not documented 2 times for the AM temperature and 17 times for the PM temperature. During an interview on 5/3/2024 at 1:42 P.M., RN 10 indicated there should be no ice in the freezer section, and temperatures should be documented twice a day. A policy was requested on 5/3/2024 but one was not provided prior to the survey exit. 3.1-25(m) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure catheter orders and catheter care orders were in place for a resident with a catheter, and failed to ensure intake and output were consistently documented as ordered, for 1 of 2 residents reviewed for catheters. (Resident B). Finding includes: On 2/12/24 at 10:12 A.M., Resident B's clinical records were reviewed. Diagnoses included, but were not limited to, stroke, peripheral vascular disease, epilepsy, and chronic pain syndrome. Resident B's most recent Minimum Data Set (MDS) assessment, dated 2/3/24, indicated the resident had severe cognitive impairment, rarely made himself understood, and only sometimes understood others. The resident had functional limitation impairment to upper and lower extremities on both sides, and was dependent on others for all Activities of Daily Living. Resident B had an indwelling catheter for urinary retention and failed voiding trials. Resident B was in Hospice care. On 1/6/23 at 9:26 A.M., Resident B was transferred to a local emergency room (ER) for chief complaint of penis injury. The ER Physician's Report, dated 1/6/24 at 1:27 P.M., indicated the resident had hypospadias (a congenital condition in which the opening of the penis is on the underside of the penis rather than at the tip), and a urinary tract infection. The report indicated unlikely acute traumatic injury to the penis and recommended that the Foley catheter have plenty of laxity when tied to the resident's leg. Resident B was discharged back to the facility the same day on 1/6/24. Resident B's Hospice Certification of Terminal Illness, dated 11/12/23, indicated the resident had a Foley catheter in place secondary to urinary retention. A Hospice Skilled Nursing Visit Note, dated 11/13/23, indicated the resident had an indwelling catheter with 16 French 10 cc balloon, to be changed every 30 days, and that the catheter bag should be below the level of the bladder and emptied when 1/2 full. The insertion site should be cleansed daily and as needed, starting proximately and moving distally from the patient. The catheter was to be anchored at 2 sites. An Interdisciplinary Care Plan, dated 11/12/23, indicated the indwelling catheter bag should be below the level of the bladder, emptied when 1/2 full. The insertion site should be cleansed daily and as needed, starting proximately and moving distally from the patient, and to anchor the Foley at 2 sites. Review of Resident B's Physician's Orders included; - Flomax 0.4 mg capsule, take one by mouth daily for outflow obstruction, dated 10/29/23 with no stop date, - Intake and output fluid measurements every shift, dated 10/30/23 with no stop date, There were no orders regarding the Foley catheter, and there were no orders regarding Foley catheter care. Resident B's Treatment Records (TAR), from 12/1/23 to 1/30/24, was absent of catheter care documentation and absent of any place to document catheter care. There no documentation of intake and output as ordered by the physician on the following times and dates: 7:00 A.M. to 3:00 P.M., on December 13, 18, 19, 24, 25, and 26, 2023, January 2, 3, 8, 25, and 29, 2024 3:00 P.M. to 11:00 P.M., on December 4, 6, and 28, 2023, 11:00 P.M. to 7:00 A.M. on December 10, 21, and 26, 2023, January 27, 2024 Resident B's Care Plans included: Urinary Incontinence/Renal Diagnosis, dated 11/20/23 and most recently updated on 2/08/24. The care plan indicated the catheter change as ordered by the physician to assure patency, Maintain a closed drainage system, and record intake and output in the medical record. The Catheter Care Policy, provided by the Assistant Director of Nursing on 2/13/24 at 12:00 P.M., was dated 6/23/21, with the most recent revision dated of 1/29/24. The policy indicated, It is the policy of this campus to ensure that residents with indwelling catheters receive appropriate catheter care .Catheter care will be performed every shift and as needed by nursing personnel. On 2/14/23 at 11:12 A.M., during an interview, the Director of Nursing, indicted Resident B's catheter orders and catheter care should be in the facility's physician's orders, and that catheter care should be completed per order and per facility policy. This citation relates to Complaint IN00425874. 3.1-41(a)(2)

Based on observation, record review and interview, the facility failed to ensure the cook followed the recipes for pureed chicken. This deficient practice had the potential to affect 6 of 6 residents who required pureed food. (Cook 24) Finding includes: During an observation of the pureed food process, conducted on 3/28/23 at 9:29 A.M., Cook 24 placed 10 - 4 ounce scoops of diced cooked chicken into the food processor and added approximately 2 cups of water. After pureeing the mixture, she added two additional cups of water. Review of the recipe for pureed chicken indicated the chicken was to be pureed with chicken broth. During an interview with Cook 24 on 3/28/2023 at 9:40 A.M., she indicated the diced chicken had just been cooked in plain water and she had not added any flavoring nor followed the recipe using broth. Review of the facility policy and procedure, titled, Puree Food Prep Policy provided by the Director of Nursing on 3/30/2023 at 8:30 A.M., indicated: . It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance .5. Do not use water as an additive to prepare puree foods. Refer to your department's Dietary Services manual for additional policy and procedures .7. Puree Food Preparation Guidelines per Serving: (More or less may be used depending on the consistency of the cooked food): .Poultry: Add 1 teaspoon chicken broth or chicken gravy 3.1-21(a)(1)

Based on observation, record review and interview, the facility failed to ensure food was stored in accordance with professional standards for food safety for 1 of 1 kitchens. This deficient practice had the potential to affect 74 of 74 residents who received food from the kitchen. (Main Kitchen) Findings include: 1. During a tour of the kitchen, conducted on 3/27/23 at 9:44 A.M., with the senior FSS (Food Service Supervisor), the following was observed: There were 4 cases of unpasteurized eggs in the walk in refrigerator. The FSS indicated the eggs were supposed to be pasteurized and were ordered in error as the facility did serve fried eggs to residents.-The FSS immediately discarded the unpasteurized eggs and no under cooked, unpasteurized egg was observed being served during the survey process. During a review of Infection Surveillance, completed with the ADON, on 3/29/2023 at 11:00 A.M., there were no gastrointestinal outbreaks noted in the past year. One of two drainage pipes, located underneath an ice machine,was touching the side of the floor drain and no air gap was observed. 2. During an observation of the pureeing process for the noon meal food items, conducted on 3/28/2023 at 9:29 A.M., Cook 24 was noted to puree chicken in the food processor. After finishing the chicken and placing the pureed chicken into a steam table pan, Cook 20 took the dirty food processor and rinsed it out at a sink and then put the rinsed food processor and attachments into a tray and ran the tray through the dishwasher. Without washing her hands, she then retrieved the food processor, blade attachment and plastic lid and lid stopper, carried them back to the food processor motor and proceeded to puree carrots. The cook used her bare hands to adjust the blade onto the food processor motor. During an observation of the puree process, another dietary employee was observed, with gloved hands, grabbing handfuls of sliced and chunked ham and putting the meat into a large stand mixer. The dietary employee was noted to touch foil lids, outsides of pans and the stand mixer with her gloved hands and then without changing her gloves, continued grabbing handfuls of meat. The FSS indicated the cook was preparing ham loaf. The current facility policy, titled, Dietary Employee Personal Hygiene Policy, provided by the Director of Nursing on 3/30/2023 at 8:30 A.M. included the following instructions: . 3. Hands and Fingernails .b. g. Gloves are to be worn and changed appropriately to reduce the spread of infection. There were no specific instructions regarding when to change gloves and no instructions to wash hands after handling dirty items before coming in contact with clean kitchen utensils The current facility policy, titled, Safe Handling of Eggs included the following instructions: .1. Pasteurized shell eggs or liquid pasteurized eggs will be utilized for all products requiring eggs as an ingredient .7. For all other forms of egg preparation, including hot holding of eggs, and pooling the eggs must be pasteurized The policy regarding air gaps for ice machine drainage pipes was requested on 3/29/2023 at 2:00 P.M. and there was no policy submitted for review prior to the survey exit. 3.1-21(i)(3)

Based on record review and interview, the facility failed to identify a injury of unknown origin in the pelvic region and inner thigh/groin area as a potential injury of sexual abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in a delay in investigation, reporting and protection of the resident during the investigation. (Resident B) The immediate jeopardy began on 6/26/22 at 10:30 P.M., when the Director of Nurses was notified of purple bruising in streaks on the Mons Pubis (a rounded mass of fatty tissue lying over the joint of the pubic bones) and bilateral inner thigh/groin region. The Administrator was notified of the immediate jeopardy on 7/1/22 at 4:38 P.M. The Immediate Jeopardy was removed and corrected on 7/1/22 when the facility implemented a systemic plan of action which included, but was not limited to: perform skin assessments on all residents, interview all alert and oriented residents related to abuse and interview all families/POA of non interviewable residents, educate staff on abuse and reporting. Finding includes: The clinical record for Resident B was reviewed on 7/1/22 at 11:30 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Interdisciplinary Note, dated 6/26/2022 at 8:30 P.M., indicated .Discovered Bruising (purple) in streaks lined on Mons Pubis. Resident has 2 streaks measuring 4 cm [centimeter] by 2 cm wide with a streak above this measuring 3cm x 2 cm, then in entire groin has 3 cm on bilat [bilateral] groin sides. No obvious pain noted. Unknown etiology .bruising is conjoined, separation is noted in bruising but is located in pubic/groin area A Interdisciplinary Note, dated 6/27/2022 at 12:46 A.M., indicated .At approximately 22:30 [10:30 P.M.] this writer spoke with dispatcher from [local police department]. Dispatcher reports receiving a phone call from grandson of resident regarding possible sexual abuse to resident after receiving a phone call from [facility name] reporting a bruise to pubic area of resident. Information conveyed to dispatcher of no bruising to vaginal area or labia, the [sic] bruise is on Mons Pubis area only. Dispatcher stated she would call family and notify them of same. At approximately 22:45 [10:45 P.M.] this writer subsequently received a phone call from resident's daughter with inquiry of same. I reported to daughter there are no signs of sexual abuse, there is no bruising to labia or vaginal area. Bruise is only on mons pubis area An Interdisciplinary Note, dated 6/27/22 at 1:26 P.M., indicated .New orders received to send to ER for evaluation A History and Physical, dated 6/27/22 at 9:31 P.M., indicated . History of Present Illness: This is an elderly female brought from [facility name] with a concern for an assault. Nursing noted bruising to the vaginal area and notified staff, and she was brought to medical attention here for a SANE [Sexual Assault Nurse Examiner] evaluation .By report, a nurse who knows the patient from prior care episodes found the bruising earlier today .non ambulatory and has severe contractures of multiple joints; by report, it took four persons here to abduct the hips for a vaginal exam. Bruising was noted, as documented/photographed in SANE notes .Imaging was pursued and a rectus sheath hematoma is noted .IMPRESSION and PLAN: 1. Concern for assault: There is a rectus sheath hematoma, and it is possible that the vaginal bruising is caused by extension of blood from the hematoma; etiology of the hematoma is unclear, and these can be spontaneous. SANE RN is pursuing full protocol for evaluation of possible assault. RADIOLOGY: CT [Computerized Tomography, a method used to take internal pictures of the body] History: Bruising in the pubic region as well as the labia majora. Possible trauma. Evaluate for fractures or hematomas. Musculoskeletal: There is asymmetric thickening and stranding involving the inferior right rectus muscle. Potentially, this could represent a rectus hematoma or other injury. Soft tissue thickening and high density material extends inferiorly and collects in the right infrapubic region. In this location, there is an intermediate density collection, probably hematoma measuring 2.5 x 3.5 cm near the expected location of the patient's vagina and right labia .This could be traumatic or could be secondary to a spontaneous hemorrhage During an interview, conducted with the ADON, on 7/1/22 at 11:15 A.M., she indicated she was notified of the bruising to Resident B's Mons Pubis and inner thigh/groin area on 6/26/22. She then notified the DON. During an interview, conducted with Resident B's daughter, on 7/1/22 at 11:45 A.M., she indicated her mother was doing better and had been transferred to another facility. The hospital indicated she either had a fall or an injury plus she was dehydrated. She had lab work done. The lab work indicated her white blood count was increased indicating she had an infection. She had a CT scan to the lower abdominal muscle, and it showed that she had bleeding internally from some type of injury. They did a chest x-ray and a rape kit which they indicated would take 3-4 weeks for the results. They could not make a judgement of what happened. They did not think there was a laceration in the labia. During an interview, conducted with a forensic nurse at a local hospital, on 7/1/22 at 11:57 A.M., she indicated while in the ER, Resident B had a CT scan of the abdomen, and a rape kit performed. She was noted to be contracted at the knees with her hips straight, her legs fell to the left side and her injuries were noted to be on the right. Her labia majora and mons pubis were found to be bruised with dark maroon, deep purple coloring, irritation, redness and swelling noted to the vaginal area. There was faint bruising between the vaginal opening and the anus. The anal area was noted to be very red and swollen. She indicated rape kit results could take up to 3 to 4 weeks to obtain. A call and voicemail were placed to the local special victim's unit detective, on 7/1/22 at 12:15 P.M., but the call was unanswered and unreturned. During a review of photographs, sent by a local hospital on 7/1/22 at 12:45 P.M., the following was noted: Resident B had Dark Purple triangle shaped bruising from her abdomen to her mons pubis. A break in bruising was noted from the mons pubis to the labial region where dk. purple bruising and severe swelling was noted on the Right labia majora extending to the anal region. The Left labia was noted to be swollen and discolored but no bruising was noted. The anus region was swollen and red with dk. purple and green bruising. During a review of clinical records, provided by a local hospital on 7/1/22 at 1:30 P.M., . Pt. [patient] injuries and bruising are of concerns for sexual assault. Pt. is primarily non-verbal and only speaks with one word sentences intermittently when angry/upset. DON and ADON were notified reportedly Sunday evening. [Grandson] called and made a police report on 6/26/22. Today when Pt. being transported to the hospital DON upset that 'police were called again' .reported DON was fuming in regard to her anger about the situation and the police being present at the facility. A hospital Photo List had 83 documented skin concerns. The following are related to the incident: 46. mons pubis, bruising dark purple/maroon with diaper. 57. R over vagina, rectum bruising dark purple and light green 58. R labia majora swelling with bruising 67. vaginal redness outter, generalized 69. R labia majora swelling/bruising 70. L labia majora swelling, vaginal redness. 73. vaginal opening R labia majora bruising 77. mons pubis swelling with dark purple bruise During an interview, with the DON, on 7/1/22 at 2:00 P.M., she indicated she had been notified of Resident B's bruising the evening of 6/26/22 at approximately 10:30 P.M. She was told there was ecchymosis on Resident B's mon pubis and a small area on her groin. She was told 3 nurses examined the area and did not feel it was sexual assault, therefore she did not begin an investigation or report it to the State Agency (SA). The police had called the facility and a nurse told them there was no trauma to vagina or rectal area, so they did not come to the facility on [DATE]. The morning of 6/27/22 at approximately 9:30 A.M., the DON examined Resident B and reported the incident to SA. She, at that time, began interviewing staff to get a clearer picture as to what may have happened regarding the bruising, which was noted to be increased in size. At 1:00 P.M., the resident's daughter arrived looked at the area and took pictures. She told the DON that half of her family thought the bruising was a matter of sexual assault. An order was obtained to send the resident to the hospital for SANE examination. During the preparation for transport to a local hospital the police came to the facility to begin an investigation. She was told on 6/28/22 by the daughter that the hospital no longer thought the bruising was related to sexual assault but advised her not to send her mother back to the facility. During an interview, with CNA 1 on 7/1/22 at 2:59 P.M., he indicated he worked with Resident B on 6/24/22 and 6/26/22 on the evening and midnight shifts. He indicated he gave her a shower on 6/24/22 and transferred her to bed with CNA 2 via a two person lift as she cannot straighten her legs and does not bear weight. On 6/26/22 CNA 1 indicated Resident B had been up watching television with the other residents and between 6 and 7 P.M., he assisted her to bed and provided incontinent care. He noted bruising in the front of her body and went and got the nurse to assess. He indicated she did not have other swelling or discoloration at that time. During an interview, with LPN 1, on 7/1/22 at 3:35 P.M., she indicated she did the incident report and skin assessment for Resident B. Upon examination, she noted bruising with 2 lines going up and 2 lines on the side that looked like a buckle. She thought it could have been from a brief being too tight or from the hoyer lift pad. Resident B's perineum had no redness, swelling or discoloration. The mon pubis was bruised with 2 streaks up and one on each side. She indicated she measured them and put them on the skin condition form, the nurses' notes, and the incident report. A policy, titled Abuse, Neglect, Exploitation Policy was provided by the DON on 7/1/22 at 3:45 P.M. and indicated it was the one currently being used by the facility. The policy had a revision date of 9/30/21 and indicated .IV. Identification of Abuse, Neglect and Exploitation: A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by and individual of good and services. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source The Immediate jeoparday began on 6/26/22. The Immediate Jeopardy was removed and corrected on 7/1/22 when the facility had completed the investigation, assessed and interviewed all residents depending on their cognitive status, all staff in-servicing was completed regarding the abuse policy and reporting. This Federal tag relates to Complaint IN 317. 3.1-27(a)

Based on record review and interview, the facility failed to immediately investigate an injury of unknown origin in the pelvic region and inner thigh/groin area as a potential injury of sexual abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in a delay of the investigation of potential sexual abuse. (Resident B) The immediate jeopardy began on 6/26/22 at 10:30 P.M., when the Director of Nurses was notified of purple bruising in streaks on the Mons Pubis (a rounded mass of fatty tissue lying over the joint of the pubic bones) and bilateral inner thigh/groin region. The Administrator was notified of the immediate jeopardy on 7/1/22 at 4:38 P.M. The Immediate Jeopardy was removed and corrected on 7/1/22 when the facility implemented a systemic plan of action which included, but was not limited to: perform skin assessments on all residents, interview all alert and oriented residents related to abuse and interview all families/POA of non interviewable residents, educate staff on abuse and reporting Finding includes: The clinical record for Resident B was reviewed on 7/1/22 at 11:30 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Interdisciplinary Note, dated 6/26/2022 at 8:30 P.M., indicated .Discovered Bruising (purple) in streaks lined on Mons Pubis. Resident has 2 streaks measuring 4 cm [centimeter] by 2 cm wide with a streak above this measuring 3 cm x 2 cm, then in entire groin has 3 cm on bilat [bilateral] groin sides. No obvious pain noted. Unknown etiology .bruising is conjoined, separation is noted in bruising but is located in pubic/groin area An Interdisciplinary Note, dated 6/27/2022 at 12:46 A.M., indicated .At approximately 22:30 [10:30 P.M.] this writer spoke with dispatcher from [local police department]. Dispatcher reports receiving a phone call from grandson of resident regarding possible sexual abuse to resident after receiving a phone call from [facility name] reporting a bruise to pubic area of resident. Information conveyed to dispatcher of no bruising to vaginal area or labia, the [sic] bruise is on Mons Pubis area only. Dispatcher stated she would call family and notify them of same. At approximately 22:45 [10:45 P.M.] this writer subsequently received a phone call from resident's daughter with inquiry of same. I reported to daughter there are no signs of sexual abuse, there is no bruising to labia or vaginal area. Bruise is only on mons pubis area A History and Physical, dated 6/27/22 at 9:31 P.M., indicated . History of Present Illness: This is an elderly female brought from [facility name] with a concern for an assault. Nursing noted bruising to the vaginal area and notified staff, and she was brought to medical attention here for SANE [Sexual Assault Nurse Examiner] evaluation .By report, a nurse who knows the patient from prior care episodes found the bruising earlier today .non ambulatory and has severe contractures of multiple joints; by report, it took four persons here to abduct the hips for a vaginal exam. Bruising was noted, as documented/photographed in SANE notes .Imaging was pursued and a rectus sheath hematoma is noted .IMPRESSION and PLAN: 1. Concern for assault: There is a rectus sheath hematoma, and it is possible that the vaginal bruising is caused by extension of blood from the hematoma; etiology of the hematoma is unclear, and these can be spontaneous. SANE RN is pursuing full protocol for evaluation of possible assault. RADIOLOGY: CT [Computerized Tomography, a method used to take internal pictures of the body] History: Bruising in the pubic region as well as the labia majora. Possible trauma. Evaluate for fractures or hematomas. Musculoskeletal: There is asymmetric thickening and stranding involving the inferior right rectus muscle. Potentially, this could represent a rectus hematoma or other injury. Soft tissue thickening and high density material extends inferiorly and collects in the right infrapubic region. In this location, there is an intermediate density collection, probably hematoma measuring 2.5 x 3.5 cm near the expected location of the patient's vagina and right labia .This could be traumatic or could be secondary to a spontaneous hemorrhage During an interview, conducted with the ADON, on 7/1/22 at 11:15 A.M., she indicated she was notified of the bruising to Resident B's Mons Pubis and inner thigh/groin area on 6/26/22. She then notified the DON. During an interview, conducted with a forensic nurse at a local hospital, on 7/1/22 at 11:57 A.M., she indicated while in the ER, Resident B had a CT scan of the abdomen, and a rape kit performed. She was noted to be contracted at the knees with her hips straight, her legs fell to the left side and her injuries were noted to be on the right. Her labia majora and mons pubis were found to be bruised with dark maroon and deep purple coloring and irritation and redness and swelling noted to the vaginal area. There was faint bruising between the vaginal opening and the anus. The anal area was noted to be very red and swollen. She indicated rape kit results could take up to 3 to 4 weeks to obtain. During a review of clinical records, provided by a local hospital on 7/1/22 at 1:30 P.M., . Pt. [patient] injuries and bruising are of concerns for sexual assault. Pt. is primarily non-verbal and only speaks with one word sentences intermittently when angry/upset. DON and ADON were notified reportedly Sunday evening. [Grandson] called and made a police report on 6/26/22. Today when Pt. being transported to the hospital DON upset that police were called again .reported DON was fuming in regard to her anger about the situation and the police being present at the facility. A hospital Photo List had 83 documented skin concerns. The following are related to the incident: 46. mons pubis, bruising dark purple/maroon with diaper. 57. R over vagina, rectum bruising dark purple and light green 58. R labia majora swelling with bruising 67. vaginal redness outer, generalized 69. R labia majora swelling/bruising 70. L labia majora swelling, vaginal redness. 73. vaginal opening R labia majora bruising 77. mons pubis swelling with dark purple bruise During an interview, with the DON, on 7/1/22 at 2:00 P.M., she indicated she had been notified of Resident B's bruising the evening of 6/26/22 at approximately 10:30 P.M. She was told there was ecchymosis on Resident B's mon pubis and a small area on her groin. She was told 3 nurses examined the area and did not feel it was sexual assault, therefore she did not begin an investigation or report it to the State Agency (SA). The police had called the facility and a nurse told them there was no trauma to vagina or rectal area, so they did not come to the facility on [DATE]. The morning of 6/27/22 at approximately 9:30 A.M., the DON examined Resident B and reported the incident to SA. She, at that time, began interviewing and investigating the incident to get a clearer picture as to what may have happened regarding the bruising, which was noted to be increased in size. At 1:00 P.M., the resident's daughter arrived looked at the area and took pictures. She told the DON that half of her family thought the bruising was a matter of sexual assault. An order was obtained to send the resident to the hospital for SANE examination. During the preparation for transport to a local hospital the police came to the facility to begin an investigation. She was told on 6/28/22 by the daughter that the hospital no longer thought the bruising was related to sexual assault but advised her not to send her mother back to the facility. During an interview, with CNA 1 on 7/1/22 at 2:59 P.M., he indicated he worked with Resident B on 6/24/22 and 6/26/22 on the evening and midnight shifts. He indicated he gave her a shower on 6/24/22 and transferred her to bed with CNA 2 via a two person lift as she cannot straighten her legs and does not bare weight. On 6/26/22 CNA 1 indicated Resident B had been up watching television with the other residents and between 6 and 7 P.M., he assisted her to bed and provided incontinent care. He noted bruising in the front of her body and went and got the nurse to assess. He indicated she did not have other swelling or discoloration at that time. During an interview, with LPN 1, on 7/1/22 at 3:35 P.M., she indicated she did the incident report and skin assessment for Resident B. Upon examination, she noted bruising with 2 lines going up and 2 lines on the side that looked like a buckle. She thought it could have been from a brief being too tight or from the hoyer lift pad. Resident B's perineum had no redness, swelling or discoloration. The mon pubis was bruised with 2 streaks up and one on each side. She indicated she measured them and put them on the skin condition form, the nurses' notes, and the incident report. During an interview, with a local detective on 7/6/22 at 11:08 A.M., they indicated the facility had not reported the injury of unknown origin to local law enforcement. The report was made by a community member and their agency had opened an investigation. A policy, titled Abuse, Neglect, Exploitation Policy was provided by the DON on 7/1/22 at 3:45 P.M. and indicated it was the one currently being used by the facility. The policy had a revision date of 9/30/21 and indicated .IV. Identification of Abuse, Neglect and Exploitation: A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by and individual of good and services. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source The Immediate jeopardy began on 6/26/22. The Immediate Jeopardy was removed and corrected on 7/1/22 when the facility had completed the investigation, assessed and interviewed all residents depending on their cognitive status, all staff in-servicing was completed regarding the abuse policy and reporting. This Federal tag relates to Complaint IN 317. 3.1-28(d)

Based on record review, interview and observations, the facility failed to ensure infection control practices were followed during a pandemic for residents with symptoms of COVID-19 and/or exposure to positive COVID-19 residents for 2 of 3 residents reviewed for infection control (Residents B and C). These lack of infection control practices place other residents in the facility at risk of being exposed to the COVID-19 virus. The immediate jeopardy began on 6/4/2020 when the facility failed to ensure infection control practices for COVID-19 were followed when Resident B was experiencing symptoms of COVID-19 and no isolation precautions were put into place. Resident B continued to room with Resident C at that time. The Executive Director, Director of Nursing, Assistant Director of Nursing, and Director of Clinical Services were notified of the immediate jeopardy at 3:56 P.M. on 6/10/2020. The immediate jeopardy was removed on 6/12/2020, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The record for Resident B was reviewed on 6/10/2020 at 11:00 A.M. The [DIAGNOSES REDACTED]. A progress note, dated 6/4/2020 at 3:55 P.M., indicated Resident B had a non-productive cough, lungs sounds were diminished and wheezing was noted. The resident's temperature was 99.8, oxygen saturation (the amount of oxygen in the blood - normal is 90% or greater) was 90% and the physician was notified. A progress note, dated 6/4/2020 at 6:27 P.M., indicated Resident B had a temperature of 99.0 and no reply from the physician yet. A progress note, dated 6/4/2020 at 8:30 P.M., indicated Resident B had a nonproductive cough, and oxygen saturation was 87% on room air. The resident was placed on 2 liters of oxygen per nasal cannula, and a stat chest x-ray was ordered. A chest x-ray, dated 6/4/2020 at 10:41 P.M., indicated right basilar airspace disease, recommend follow up examination to confirm resolution findings. A progress note, dated 6/5/2020 at 9:25 A.M., indicated a new order was received for resident to be moved to private room on the skilled unit instead of staying in his current room. COVID-19 test was ordered, and the resident was started on [MEDICATION NAME] (antibiotic). An infectious disease lab report, dated 6/5/2020 at 11:50 A.M., indicated Resident B was positive for COVID-19. A physician note, dated 6/7/2020 at 8:00 P.M., indicated the physician was called to evaluate the resident due to respiratory distress and recent COVID-19 testing. The note indicated the resident was started on [MEDICATION NAME] for possible aspiration due to history. Assessment and plan indicated COVID-19 positive with [MEDICAL CONDITION]. A progress note, dated 6/7/2020 at 10:18 P.M., indicated Resident B tested positive for COVID-19. The ED (Executive Director), ADON (Assistant Director of Nursing), physician and power of attorney were notified. Resident was being transferred to designated isolation unit. Full PPE (protective personal equipment), including N95 mask, goggles, face shield, hair covering, gown and gloves were worn by staff during transfer. N95 mask, face shield, gown, and gloves were also placed on the resident during transfer. Full supply of all PPE, resident care supplies, state and federal, and OSHA approved and required cleaning and sanitizing chemicals with MSDS and placed into isolation, and policies and procedures inside COVID unit. Oxygen supplies with backups on hand as resident is currently on 3 liters of oxygen per nasal cannula. Orders received from physician per power of attorney to discontinue all medications and place resident on comfort measures only. Full PPE was worn by designated COVID unit healthcare staff at all times. A progress note, dated 6/8/2020 at 5:40 A.M., indicated Resident B showed accelerated decline. A progress note, dated 6/8/2020 at 10:15 A.M., indicated Resident B was absent of all vital signs, no sign of life, pupils fixed and dilated. During an anonymous interview, it was indicated Resident B presented with puffy eyes and a cough on 6/3/2020. The on-duty nurse did an internet search to see if the symptoms that presented were associated with COVID-19. It was indicated the cough did not sound like a COVID cough because it was not persistent. The next day Resident B's cough became more persistent and his oxygen level was 86% on room air. The resident's physician/facility Medical Director was notified to see if she wanted him sent out around 8:30 P.M. The physician declined sending resident out and ordered a chest x-ray. There was no isolation in place for Resident B. An email to the Director of Nursing from the Nurse Practitioner (NP) dated 6/10/2020 at 7:21 P.M., indicated the NP was the on-call provider, and was called by the nurse on 6/4/2020 around 8:00 P.M. The NP was notified that Resident B was experiencing a mild cough and decreased oxygen saturation around 87% on room air. The nurse placed the resident on oxygen and oxygen saturation increased to 98%. Per nursing, he was not exhibiting any shortness of breath, was afebrile, no fatigue and no gastrointestinal symptoms. She was concerned with fluid overload or possible early pneumonia. During an interview, on 6/10/2020 at 4:00 P.M., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) indicated COVID-19 testing was not requested because symptoms did not present as COVID-19 on 6/4/2020. When interviewed on 6/11/2020 at 11:29 A.M., the NP (Nurse Practitioner) indicated no orders were given for isolation on 6/4/2020. She indicated she was the NP on call for 6/4/2020. The physician order [REDACTED]. Confidential interviews were conducted during the course of the survey. During anonymous interviews, staff indicated they were not aware of the type of isolation required for presumed COVID-19 positive residents. During an interview, on 6/11/2020 at 10:58 A.M., the ADON indicated Resident B was not moved to the COVID unit on 6/5/2020 due not having staff available to work on that unit. There were no other residents residing on the COVID Unit. She indicated there was not dedicated staff to provide care for Resident B, and that may be a recommendation by CMS, but everyone knows that is impossible. During an interview, on 6/11/2020 at 1:13 P.M., the ADON indicated the symptoms that Resident B was exhibiting on 6/4/2020 were potential symptoms of COVID-19, and she indicated the NP should have been notified of increased temperature and other symptoms documented on 6/4/2020. 2. The record for Resident C was reviewed on 6/10/2020 at 11:30 A.M. The [DIAGNOSES REDACTED]. A progress note, dated 5/29/2020 at 8:34 P.M., indicated Resident C was sent to the local emergency room (ER) for increased blood sugar of 556 that had climbed after one hour. An ER physician report, dated 5/29/2020, indicated the resident presented with high blood sugar and was discharged back to the facility. During an anonymous interview, it was reported that staff expressed concern about placing the resident returning from ER back in a room with a roommate, and staff had communicated their concern to the Director of Nursing. A physician progress notes [REDACTED]. Assessment and plan for exposure to COVID-19 was to closely monitor for any signs and symptoms and COVID-19 testing. An ER physician report, dated 6/8/2020, indicated Resident C had been transported to the ER with concern of [MEDICAL CONDITION] today, oxygen saturation was 85% on room air and arrived on 6 liters of oxygen by nasal cannula. Resident was current resident at nursing home and apparently his roommate just tested positive for COVID-19. There was high suspicion for COVID-19. An immunology report, dated 6/8/2020, indicated Resident C was positive for COVID-19. During an interview, on 6/9/2020 at 4:36 P.M., the DON and ADON indicated the resident had been allowed to return to his room with roommate present upon return from hospital, because PPE had been worn by resident and all personnel that provided care during transport and at the local hospital. During confidential interviews, multiple staff members indicated aides have not been wearing masks and at times supplies have been scarce in the facility. It was reported that CNA 2 (certified nurse aide) had tested positive recently for COVID-19 and did not wear her mask when she worked about a week before she was diagnosed . They indicated there were days no masks were worn by staff and some wore them under their chin. Nurses indicated they would ask aides to put masks on, and some would ignore them and some put them on. They indicated they felt the CNAs were not taking the COVID-19 pandemic seriously. It was reported to a nurse that staff does not wear their masks on the weekends. One staff member indicated, I am not going to lie, I am one of the ones that doesn't wear it. It was reported that nursing staff on the weekend had been observed not wearing masks. Staff indicated, it is hard for them to make us wear them, when they don't. It was reported that residents had been out of their rooms in the common area recently, with no masks. Concern was expressed due to a resident who recently tested positive for COVID-19 and was always in close contact with another resident out in the common area. During an interview, on 6/9/2020 at 4:36 P.M., the ADON indicated there are no managers on duty over the weekends to ensure masks are being worn and infection control is being maintained. She indicated the floor staff nurses on the weekends were shift managers to ensure masks were being worn. During an interview, on 6/10/2020 at 9:25 A.M., the Medical Director indicated the COVID-19 spread was not directly related to improper mask wear. She stated that it is hard for staff to wear a mask appropriately for long durations. During an interview, on 6/10/2020 at 12:00 P.M., the housekeeper on the East Unit indicated residents have been allowed out of their rooms for the past few days, and meals were being served in the common area. On 6/10/2020 at 9:35 A.M., the ADON provided the Indiana Back on Track Plan for Long Term Care Facilities and indicated this is what they used to determine if Resident C could go back in his room with a roommate upon return from the local emergency room . It indicated the decision to place the resident in transmission based precautions (contact-droplet) upon return for 14-day monitoring of signs and symptoms of respiratory infection should be made by the facility with consideration for the type of appointment (e.g. close contact), the availability and use of appropriate PPE by resident and providers, and the frequency of leaving the facility. On 6/10/2020 at 9:35 A.M., the ADON provided a CMS memo QSO-20-28-NH, dated 4/24/2020, and indicated this is what they used to determine if Resident C could go back in his room with a roommate upon return from the local emergency room . The memo indicated the facility should monitor the resident upon return for signs and symptoms of respiratory infection for 14 days after the outside appointment (preferably in a space dedicated for observation of asymptomatic residents). On 6/11/2020 at 12:35 P.M., the ADON provided, Consideration for Admission/Readmission during COVID Pandemic, dated 5/2020, and indicated this is the policy currently be used by the facility. The policy indicated newly admitted and readmitted residents should be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE (personal protective equipment.) On 6/11/2020 at 12:35 P.M., on 6/11/2020 at 12:35 P.M., the ADON provided the Signs and Symptoms of COVID policy, dated 5/2020, and indicated this is the policy currently be used by the facility. The policy indicated signs of COVID to observe for were fever/chills, cough, shortness of breath or difficulty breathing, fatigue, muscle aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea/vomiting, and/or diarrhea. The policy indicated residents will be placed in contact-droplet precautions when identified as symptomatic. On 6/11/2020 at 12:35 P.M., the ADON provided the Isolation of COVID positive and suspected COVID residents policy, dated 5/2020, and indicated this is the policy currently be used by the facility. The policy indicated residents who are identified as having symptoms of COVID-19 will be placed in contact-droplet precautions. Residents will be placed in a single room, if possible, while awaiting results. Roommates of residents with COVID-19 should be considered exposed and potentially infected. On 6/9/2020 at 3:15 P.M., the ADON provided a resident of list of COVID-19 cases in the facility: 5 suspected cases, 7 confirmed cases, 1 currently in hospital confirmed, and 1 death. During an interview, on 6/9/2020 at 3:15 P.M., the ADON indicated only one staff member was confirmed positive for COVID-19. The staff member was tested on [DATE] and notified the facility of results on 6/7/2020. During an interview, on 6/9/2020 at 9:10 A.M., the ADON indicated the staff member who had tested positive had worked three shifts from 5/24/2020 through 5/26/2020. The staff member worked on all units: West, East, Center and Skilled. The staff member had not worked since 5/26/2020. The CDC's Preparing for COVID-19 in Nursing Homes, dated as last updated 5/19/2020, included the following: HCP (Health Care Personnel) should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. Implement Social Distancing Measures - Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Cancel communal dining and group activities, such as internal and external activities. Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene. Remind HCP to practice social distancing and wear a facemask (for source control) when in break rooms or common areas. The immediate jeopardy that began on 6/4/2020 was removed on 6/12/2020 when the facility completed education on COVID-19 that included signs and symptoms, isolations requirements, and mask wearing to prevent the spread of [MEDICAL CONDITION], but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the need for continued education and monitoring. 3.1-18(a)

Based on interview and record review, the facility failed to thoroughly investigate 3 of 3 staff to resident allegations of abuse and protect residents during an investigation. (Resident #17, Resident #86, Resident #25 and Resident #16) The Immediate Jeopardy began on 7/21/17 when the facility failed to to complete a thorough investigation of an allegation of abuse and protect other residents from potential abuse and during investigation The DON (Director of Nursing) and ADON (Assistant Director of Nursing) were notified of the Immediate Jeopardy at 11:15 A.M. on 9/15/17. The Immediate Jeopardy was removed on 9/20/17, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The clinical record was reviewed for Resident #17 on 9/14/17 at 2:00 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 7/2/17, indicated Resident #17 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact, required extensive assist with ADLs (activities of daily living), and was propelled by staff in a wheelchair. A combined written statement from FSA (Food Service assistant) #9, FSA #10 and FSA #11, dated 7/21/17, indicated CNA #2 was bringing Resident #17 into the assisted living dining room. One male resident was out to far in his chair and Resident #16 was in wheelchair at the table, leaving a small space to get through. CNA #2 told the male resident to move forward, but he did not understand. CNA #2 stated, Nevermind, stay where you are, if I hit you, I hit you. She then proceeded to push Resident #17 into Resident #16 (the one in the wheelchair). CNA #2 hit the Resident #17's wheelchair into Resident #16's wheelchair and stated, See, I told you. She then went up to the male resident and shoved him forward making him hit the table. The male resident let out a yell and CNA #2 just walked away. There was no investigation into the abuse directed at Resident #16, the report only included Resident #17. The Follow Up Report, dated 7/24/17, indicated the Administrator had confirmed the allegations. Through interviews with staff and Resident #17, CNA #2 had deliberately pushed Resident #17's wheelchair into the Resident #16's wheelchair. CNA #2 was suspended for 2 days and then returned without any additional supervision or monitoring in place. 2. The clinical record for Resident #86 was reviewed on 9/14/17 at 2:15 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 8/30/17, indicated Resident #86 had a BIMS (Brief Interview of Mental Status) score of 14, cognitively intact, and required extensive assist of one person with ADLs (activities of daily living). A written statement from cook #8, dated 8/10/17, indicated Resident #86 asked if CNA #2 could help her to her room, and CNA #2 responded, Hold on, baby girl, (another CNA) will come help you. A minute later, Resident #86 asked CNA #2 again because the other CNA did not attend her yet. Resident #86 indicated to CNA #2 that she would like to go back to her room because her legs were swelling up and CNA #2 responded, How can you see that your swollen, your blind. Resident #86 responded that she could feel them. CNA #2 stated to Resident #86, You are killing me, Smalls. That's what I am should start calling you, Smalls. The dietary staff felt it was abuse and unprofessional. The Incident Report, dated 8/11/17, indicated a dietary aide over heard a conversation between CNA #2 and Resident #86. Resident #86 had asked CNA #2 for help, CNA#2 allegedly stated, Hold on , baby girl. She indicated another aide would come help her. Later Resident #86 asked CNA #2 of help because her legs were swelling and CNA #2 allegedly stated, how can you see that, you are blind. Resident #86 replied she could feel it. CNA #2 stated, You are killing me in a joking manner along with other statements to this effect. The Immediate Action Taken, on 8/12/17, was CNA #2 was counseled at length regarding appropriate way to address residents. This was the second such situation involving CNA #2. The Follow up, dated 8/12/17, indicated CNA #2 was dismissed from resident contact and counseled. CNA #2 admitted taking liberties by using terms of endearment and inappropriately joking with the resident. The written staff statement and incident report were the only documents provided regarding any investigation into this allegation. Team Member Coaching and Counseling form, dated 8/11/17, indicated CNA #2 had received a counseling session. 3. During an interview, on 9/14/17 at 2:30 P.M., Resident #25 indicated CNA #2 had bullied her and jerked her around. Resident #56 indicated she had been more incontinent recently due to a urinary tract infection and CNA #2 was mean to her because she had to ask for more help and has episodes of incontinence. Resident #86 indicated she was afraid of CNA #2, she sets me in a spin, as soon as I would calm down she would mess with me again. The clinical record for Resident #25 was reviewed on 9/14/17 at 3:00 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 6/29/17, indicated Resident #25 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact, and required extensive assist of one to two person for ADLs (activities of daily living). The Incident Report, dated 8/14/17, indicated this report was a part of a previous report regarding how CNA #2 talked to residents. Resident 25 had report on 8/11/17 in the Resident Council Meeting that she felt bullied by some things that were said to her by CNA #2. The report indicated the administrator had already talked to CNA #2 and they reiterated the need for CNA #2 to guard what she said to residents. The Prevention Measures Taken were to continue to work with and monitor this staff member for compliance with resident interactions. The Follow Up indicated the facility would continue to work with CNA #2 to improve her conversations and verbal treatment of [REDACTED]. This incident report was the only document provided regarding an investigation into this allegation. During an interview, on 9/14/17 at 3:00 P.M., the ADON (Assistant Director of Nursing) and DON (Director of Nursing indicated CNA #2 had not been suspended during the allegations with Resident #86 or Resident #25. During an interview, on 9/14/17 at 3:30 P.M., the ADON indicated CNA#2 remained employed because the facility administration did not feel she was abusive. During an interview, on 9/14/17 at 4:07 P.M., the ADON indicated she considered the statement from Resident #25 indicating she felt bullied was abuse. During an interview, on 9/16/17 at 10:00 A.M., the Administrator indicated that he does not always do an investigation if the allegation was cut and dry. He indicated that not all requested incident reports had thorough investigations available or to indicate if each allegation was isolated or widespread. On 9/14/17 at 1:00 P.M., the DON provided the Abuse\Unusual Occurrences policy, dated 8/1/16, and indicated the policy was the one currently being used by the facility. The policy indicated any staff member who had knowledge of the abuse of a resident, had reasonable cause to believe that a resident is being or has been abused . shall make an immediate report to the Administrator, DON, or immediate supervisor. Ant staff member who intentionally abuses a resident or permits to exist an abusive situation which results in the physical, emotional, and psychosocial distress of a resident is subject to immediate dismissal. The Administrator/designee shall be responsible for initiating the investigation, including removing the staff member from the facility, in order to assume the resident is protected while the incident is being investigated. The Administrator shall immediately identify and investigate all reportable occurrences, including but not limited to suspected resident abuse, neglect . In house investigation should include a)date/time of administrator/DON notification, b) date/time of investigation, c)records of statement and interviews of eye or circumstantial witnesses, d) date/time of document reviews that preserve data, e) date/time of resident examination occurred, f) date/time steps taken to prevent further abuse, g) Actions taken as a result of the investigation, h) notification of state agencies , of corrective actions, and i) if resident is involved, a resident assessment should be completed. The Immediate Jeopardy that began on 7/21/17 was removed on 9/20/17 when the facility implemented systematic changes, such as: inservicing all staff members on the policy of reporting abuse allegations but the non-compliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy because of the facility's need to continue in-services. 3.1-28(d)

Based on record review, interview and observation, the facility failed to implement appropriate interventions to prevent the development or worsening of a pressure areas for 3 of 3 residents reviewed for pressure ulcers. This resulted in an unstagable pressure area to the left heel not present on admission (Resident #70), a Stage 2 pressure area on coccyx not present on admission (Resident #115) the worsening of Stage 2 pressure area to right gluteal fold to a Stage 4 with tunneling (Resident #17). Findings include: 1. The clinical record for Resident #70 was reviewed on 9/18/17 at 10:00 A.M. The [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 7/5/17, indicated Resident #70 was admitted with no pressure areas, required extensive assist of 2 people for bed mobility, and was totally dependent for transfers. The Braden Scale, dated 6/28/17, indicated Resident #70 had a score of 12, at risk for pressure ulcer development. A care plan, dated 7/12/17, for risk of pressure ulcers related to impaired mobility (left side [MEDICAL CONDITION] due to history of [MEDICAL CONDITION]) and incontinent of bowel/bladder included intervention, but were not limited to, use pressure reduction pad in wheelchair and mattress to bed to alleviate unwanted pressure to bony prominences and observe skin condition with routine care for red/open areas. The Interdisciplinary Notes, dated 7/11/17 at 4:04 P.M., indicated Resident #70's skin was free of pressure areas. The Interdisciplinary Notes, dated 8/2/17 at 7:54 P.M., indicated Resident #70 had a new pressure area on her left heel measuring 4.0 cm (centimeter) x 6.5 cm x 0 that was pale yellow with blue center. Area was found by CNA (certified nursing aide) when resident's shoe was removed. The Interdisciplinary Notes, dated 8/3/17, indicated Resident's husband felt pressure area was due to her kicking her legs and rubbing her heels against mattress at night. The care plan was updated on 8/4/17 with intervention to apply shin splint. The Skin Evaluation Form, dated 8/4/17 at 4:24 P.M., indicated Resident #70 had pressure area to left heel at 4.0 cm x 6.5 cm x 0 cm that presented as yellow skin with small 0.3 cm blue area in center and 6.5 cm x 6.5 cm area was the yellow area that originated on 8/4/17. The treatment was to float heels at all times, apply bunny boots when in wheelchair. No updates were noted to the care plan in regards to floating heels or bunny boots. The Skin Evaluation Form, dated 8/9/17 at 10:08 A.M., indicated pressure area to left heel present was soft mushy skin with darkened areas under skin. Treatment was to float heels at all times, apply bunny boots when in wheelchair, and skin prep. No physician notification was available in regards to changes in wound description. No updates were noted to the care plan. The Skin Evaluation Form, dated 8/16/17 at 8:45 A.M., indicated Resident #70's left heel pressure area presented darkened mushy skin. Treatment remained float heels at all times, bunny boots when up in wheelchair, skin prep. The Nursing Home Documentation Form signed by the physician, dated 8/18/17, indicated Resident #70 had a large closed blister to the left heel and assessment and plan was to pad area for decreased in friction, continue skin prep and monitor with wound care. No updates noted to care plan. The Skin Evaluation Form, dated 8/23/17, indicated the wound to the left heel presented with dark mushy skin with open areas to blister. The Interdisciplinary Notes, dated 8/23/17, indicated area to left heel had opened up but skin was still intact, area measured 4.5 cm x 6 cm, no depth noted. Area was dark and was very mushy, new treatment ordered for hydrogel dressing and foam, wrap in [MEDICATION NAME]. The Skin Evaluation Form, dated 8/30/17, indicated pressure area to left heel measured 4.5 cm x 6.0 cm x 0 depth, tissue type to wound base was slough (necrotic tissue) with purulent drainage, with mild odor. The Interdisciplinary Notes, dated 9/6/17, at 7:22 A.M., indicated the wound to the left heeled measured 5.5 cm x 6 cm, skin was peeling off heel, pink tissue with some dark spots towards the back of the heel with serosanguineous (bloody) drainage noted. No physician notification noted in regards to changes in the wound. No updates noted to the care plan. The Interdisciplinary Notes, dated 9/13/17 at 11:46 A.M., indicated area to left heel measured 5.2 cm x 6 cm, all the skin was off the area of the blister. There was a small back area to the center of the heel. The heel was mushy, surrounding tissue was pink. There was a small amount of serosanguineous drainage noted. Resident used air mattress. The Nursing Home Documentation Form signed by her physician, dated 9/21/17, indicated left heel wound with eschar (dry necrotic tissue) noted to base of wound. New order for Santyl to wound with [MEDICATION NAME] and kerlix daily. During an interview, on 9/19/17 at 2:47 P.M., the Wound Nurse indicated the pressure area to left heel started on 8/4/17 as a blister type wound, considered a Stage 2 pressure area and the pressure area had progressed to a Stage 3 according to last assessment with a heel mushy with skin still intact and a darkened area to center of wound with a little drainage serosanguineous. He indicated wound should be classified as unstageable pressure area due to the necrotic tissue that covered the center of the wound base and the current dressing was not appropriate for the type of tissue that was present in the wound. He indicated the outside facility wound nurse was following the wound progression and he had not notified the physician to visualize the wound. He indicated a care plan should have been developed and updated with changes in wound, treatments and preventative interventions and he was note aware of the pressure area to the heel was originally noted on 8/2/17 and that the physician should have been notified at that time and treatment orders should have been obtained. During an observation, on 9/19/17 at 3:15 P.M., Resident #70's pressure area to left heel was observed with RN #2. The wound presented 30% present granulation tissue and 70% dry eschar to center of wound. The RN #2 indicated the wound measured 6.4 cm x 5.2 cm x 0.2 cm. No air mattress was observed on the bed. During an interview, on 9/20/17 at 12:29 P.M., the ADON (Assistant Director of Nursing) indicated there was not an air mattress on bed as stated in note form 9/13/17 and care plans should have been developed for pressure areas and updates with changes to wound, treatments, and preventive interventions. She indicated the physician should have been notified with wound changes and family education should have been document and completed. During an interview, on 9/21/17 at 10:00 A.M., the physician for Resident #70 indicated she had not assessed the wound since her last visit on 8/18/17 and was unaware of any changes in the wound. On 9/21/17 at 10:13 A.M., Resident #70's physician was observed to assess the pressure area to the left heel. The physician indicated, at this time, the wound had eschar at the base and had worsened since last time she looked at it. She indicated to the resident's husband the dressing currently being used was for healthy tissue and the order would be changed that day. 2. A clinical record review was conducted on 9/18/2017 at 4:10 P.M. for Resident #17 and indicated resident was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #17 was admitted with a stage 1 and a stage 2 pressure ulcer to her buttocks and coccyx. A quarterly Minimum Data Set (MDS) assessment, dated 7/2/17, indicated the Brief Interview for Mental Status (BIMS) score, was 15, cognitively intact, and the resident currently had a stage 4 pressure ulcer. The care plan, undated, indicated Resident #17 had a stage 4 pressure ulcer to right buttock and the goal of the care plan indicated the unstageable pressure ulcer would decrease in size. During an observation, on 9/18/17 at 4:15 P.M., Resident #17 was in bed laying on her back. On 9/19/17 at 8:45 A.M., review of Resident #17's clinical record indicated the following: An assessment titled, Skin Evaluation Form, dated 3/15/17, indicated the wound to right buttock was a stage 4, it measured 2.6 cm long x 2.0 cm wide by 0.5 cm deep and no undermining or sinus tract was indicated. The assessment, dated 3/29/17, indicated the wound was unstageable, it measured 4.2 cm long x 1.2 cm wide x 0.5 cm deep and had slough with no sinus tract or undermining. The assessment, dated 4/12/17, indicated the wound was a stage 3 and measured 4.5 cm long x 2.2 cm wide x 0.4 cm deep with no sinus tract or undermining. The assessment, dated 4/26/17, indicated the wound was a stage 2 measured 4.6 cm long x 1.7 cm wide x 0.7 cm deep and no undermining or sinus tract but had maceration. No further assessments after 4/26/17 indicated the wound had been staged with weekly assessments and the last documented staging was a stage 2. Interdisciplinary notes, dated 7/30/17 at 2:03 P.M., indicated the wound was deeper and there was foul smelling drainage and black slough tissue and the wound had recently started to decline. Interdisciplinary notes, dated 8/23/17 at 9:47 A.M., indicated the wound bed had 80% slough and 20% necrotic tissue and a moderate amount of drainage with a slight odor, wound edges were slightly macerated. The resident indicated she could feel slightly more pain to the wound than before. Interdisciplinary notes, dated 9/4/17 at 12:39 A.M., indicated on 9/3/17 at 7:00 P.M., a new order was obtained for [MEDICATION NAME] sprinkles to the wound bed. Interdisciplinary notes, dated 9/5/17 at 4:32 P.M., indicated the wound had very heavy serosanguinous (thin, watery bloody drainage) exudate that soaked her skirt. Interdisciplinary notes, dated 9/6/17 at 2:18 P.M., indicated keflex 500 mg was to start for 7 days. Hospice Nursing visit note, dated 9/6/17 at 8:25 P.M., indicated the resident was currently on keflex for wound infection. A wound assessment, dated 9/13/17, indicated the wound was assessed by the wound nurse, it measured 5 cm long x 3.0 cm wide x 4 cm deep was macerated and had undermining and a sinus tract at 12 o'clock measuring 7 cm deep and no staging of the wound was documented. During an observation, on 9/19/2017 at 10:20 A.M., the resident was in bed laying on her back. On 9/20/17 at 9:15 A.M., RN #2 was observed providing a dressing change to the pressure ulcer on Resident #17's right buttock. She was observed to wash her hands, leave the room to get a different size box of gloves. She returned to the room and covered the over the bed table with a towel and laid out her dressing supplies. She moved the over the bed table around to the other side of the resident's bed and adjusted the track lights over the bed by moving the track lighting around, and then adjusted the bed height. She put on gloves and removed the dressing and washed her hands for 7 seconds and applied new gloves and then moved the table around again and opened gauze pads and squeezing [MEDICATION NAME] jelly onto the inside of an open package. She wet all of the gauze pads with wound cleanser and cleansed the wound using a clean gauze each time. She measured the wound and the wound measured 5.4 cm long x 2.9 cm wide x 5 cm deep at the 6 o'clock area on the wound and indicated that was the area that was tunneling. The hospice nurse, who was in the room, indicated the wound nurse had indicated the tunneling was at 12 o'clock. RN #2 changed her gloves without cleansing her hands and applied [MEDICATION NAME] jelly around the outside of the wound and then pushed calcium alginate dressing into the wound with her gloved finger. She removed her gloves put on new gloves without cleansing her hands and applied a fibersorb dressing. Observation of the wound showed the wound to be beefy red with granulation tissue (new tissue that forms on the healing surface of a wound) to the visible part of the wound at the surface and edges with maceration (softening and whitening of the skin that is kept moist) around the wound edge. Unable to visually see the base (bottom) of the wound. During an interview, on 9/20/2017 at 10:30 A.M., the Assistant Director of Nursing (ADON) indicated that wounds are not to be downstaged and if the stage of the wound had not changed the staging would not have to be documented weekly. During an interview, on 9/20/2017 at 11:16 A.M., MDS LPN indicated that Resident #17 has a stage 4 pressure ulcer to her right buttock. She indicated the staging was to be done on the Skin Evaluation form weekly. 3. A clinical record review was conducted, on 09/19/17 at 10:07 AM, for Resident #115 and indicated an admission date of [DATE]. His [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 08/21/17, indicated a BIMS (Brief Interview for Mental Status) score of 13, cognitively intact. The assessment indicated only skin tears were present upon admission, no pressure areas were documented. During an interview, on 09/19/17 at 3:10 PM, LPN #7 (Licensed Practical Nurse) indicated the pressure area to Resident #115's coccyx was identified on 08/24/17 and he first assessed it on 08/30/17. The wound documentation only indicated measurements on 08/30/17, which were as follows: 3.0cm x 2.0cm x 1.1cm. The wound was listed as a stage 2 pressure area with granulation tissue. No wound assessment information was available for the onset date of 08/24/17 and no further documentation was available. On 9/19/17 at 2:32 P.M., the DON provided the Skin Condition and Pressure Ulcer Assessment Policy, no dates, and indicated the policy was the one currently being used by the facility. The policy indicated at the earliest sign of a pressure or other tyrp of ulcer, or problems, the resident's legal representative, and attending physician would be notified. Weekly assessment of skin problems, would occur until areas were healed and physician and responsible party would be informed of progress. The nurse was responsible for notifying the physician of any suspected infection in the wound, lack of response to treatment and what nursing and dietary interventions had been initiated. The resident's care plan would be revised as appropriate, to reflect specific skin problem and care. Response to the treatment would be documented in the nursing progress notes. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review, observations and interviews, the facility failed to ensure a resident with dementia was free from physical and verbal abuse by CNA #5, for 1 of 3 residents reviewed for allegations of abuse. CNA #5 cursed at and forcefully pushed Resident B up against a wall. Finding includes: On 06/29/15 at 9:45 a.m., the Administrator provided a copy of the facility's investigation of physical and verbal abuse by CNA #5 to Resident B which occurred on 04/17/15 at approximately 5:05 p.m. On 06/29/15 at 9:50 a.m., during the initial tour, accompanied by the DNS (Director Nursing Services), Resident B was standing in his private room, talking on the phone, and smiled pleasantly and waved to the staff member. The DNS indicated the resident had no recall of the 4/17/15 incident immediately following the occurrence and had not demonstrated any adverse effects since the occurrence. The DNS indicated a CNA had witnessed the tail end of the event and reported it to her. The DNS indicated the other residents in the common area during the incident, were not reliable witnesses due to cognitive status and she did not believe it was to the degree of abuse until the full investigation, including viewing a video of the event, was completed. The DNS had not reported the incident to the Administrator prior to the 05/19/15 Stand-up meeting. On 06/29/15 at 10:10 a.m., the Administrator indicated the DNS had been aware of an incident but the investigation was not thoroughly done and not reported to him immediately as directed by the facility's Abuse/Neglect Policy & Procedure and postings throughout the building. At the time of the interview, the Administrator provided for viewing a DVD which had recorded the event. The Administrator had in turn shown the recording to the County Sheriff's Department as well as sent to ISDH (Indiana State Department of Health). The video, which did not include audio, indicated CNA #5 physically approaching, handling, and moving Resident B against a wall. It appeared CNA #5 was verbally interacting with Resident B. Although several other staff members were noted in the general area, the video did not distinguish what staff members might have observed the incident. It was noted the Unit Nurse, at the time, had entered another resident's room and was not in the area at the time of the incident. The record of Resident B was reviewed on 06/29/15 at 10:30 a.m. Resident B was admitted to the facility, on 03/31/15, with [DIAGNOSES REDACTED]. Review of a 14 day MDS (Minimum Data Set) Assessment, dated 04/13/15, indicated the resident ambulated with oversight and was not cognitive for interview. On 06/29/15 at 10:45 a.m., the facility's investigation of the 4/17/15 incident of abuse by CNA #5 to Resident B was reviewed. The report indicated Resident B sat down behind the nurse ' s station. The CNA tried to get the resident to move, but the resident did not move. A witness said CNA#5 picked the resident up by the collar and forcefully pushed him against the wall, away from the nurses station and said something to the effect ' you are not f---- coming back here again'. On 05/19/15, the Administrator immediately suspended CNA #5 and the investigation was initiated. The investigation, which included a video via the facility's closed circuit monitoring, resulted in termination of the CNA and arrest by the County Sheriff's Dept.(Department). Review of the Administrative Investigation handwritten statements by staff members working at the time of the incident indicated: 1. CNA #7: A written statement that she observed Resident B behind the nurses station and attempted to divert the resident to the common area. CNA #5 then gave verbal warnings to Resident B, before getting physical & (and) verbally abusive, followed by CNA #5 grabbed Resident B by the collar before slamming the resident against a wall. 2. LPN #2: A written statement that she was working on a connected unit and was walking by the nearby kitchenette between units when she heard a loud commotion. LPN #2 indicated she witnessed CNA #5 forcibly pushing Resident B up against a wall. 3. CNA #5: A written statement: .My recollection was that (Resident B name) gait appear (sic) to be unsteady when I came up to him he pushed on me which in turn caused him to stumble at that point. I helped him into a chair to negate a fall. On 06/29/15 at 9:45 a.m., the Administrator provided the facility's ABUSE/UNUSUAL OCCURRENCES Policy & Procedure, dated 06/2012, and indicated it was the one currently used by the facility. The Policy and Procedure indicated the following: PURPOSE: To establish guidelines for assuring residents are free of all abusive acts and establish guidelines for investigation, resolving, and reporting abuse; as well as recognizing employee burnout, stress, or frustration. POLICY: It is the policy of Hamilton Communities, Inc. to protect residents from all abusive acts and to comply with the state and federal laws and regulations for reporting suspected or actual acts or unusual occurrences. DEFINITIONS: 1. ABUSE: Abuse means - the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or anguish, or the deprivation by an individual, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Physical Abuse - includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through rough corporeal punishment, or restraining without authorization for discipline or convenience. Physical abuse includes: .2) Staff to resident abuse with or without injury;. Verbal Abuse - refers to any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance,. Verbal abuse includes: 1) Staff to resident - a single traumatic episode. This Federal tag relates to Complaint IN 861. 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to prevent the development of Stage III pressure ulcers for 2 of 3 residents in a sample of 16. Residents: #55, #51 Findings include: 1. Resident # 55's clinical record was reviewed on 4/11/11 at 3:20 P.M., and indicated [DIAGNOSES REDACTED]. During initial tour of the East Unit on 4/11/11 at 10:25 A.M., while accompanied by LPN #1, Resident # 55 was observed sitting slouched in the recliner in her room. LPN # 1 identified her as confused, ambulatory with one person assist with an acquired open area to her coccyx. LPN # 1 indicated in an interview, at the time of the above mentioned observation, the open area to the coccyx was a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). She further indicated Resident #55 had a low air loss mattress (a specialized mattress that intermittent distributes the fluctuation of air/pressure). When queried if Resident #55 had a specialized seat cushion to aid in the healing of the pressure ulcer, LPN #1 indicated the resident did have the specialized cushion and was seated on it. The cushion could not be observed under the resident at the time because of the way the resident was slouched in the chair. A Nurse's Note, dated 3/26/11 at 3:50 P.M., indicated, "During care CNA (Certified Nursing Assistant) called this nurse into Residents bathroom. Open area noted to below coccyx 1.5 x 0.5 x 0.3, Duo Derm (padded dressing) applied, M.D. (Medical Doctor) notified, POA (Power of Attorney) notified." A "Skin Care Management Form," dated 3/26/11, indicated: "Site: below coccyx...This condition developed after admission: Yes...Date: 3/26/11, Type: Pressure, Status III (stage III), Length/width (cm) (centimeters): 1.5 x 0.5 cm, Depth (cm): 0.3 cm...Color: pink, Drainage (amount/type): scant blood...Date: 4/2/11, Type: pressure, Status: Stage III, Length/Width (cm) 1.3 x 0.5, Depth: 0.5 cm...Color: pink, Drainage (amount/type): clear to yellow...Date: 4/9/11, Type: (blank), Status: III, Length/Width (cm) 1.3 x 0.5, Depth (cm): 0.4...Color: pink, Drainage (amount/type): yellow...." Resident #55's "Skin Care Management Form," indicated she did not have any previous pressure ulcers. During observation of wound care to resident # 55's Stage III pressure ulcer on 4/12/11 at 2:05 P.M., LPN #1 asked Resident #55 to stand up from her recliner to help facilitate the wound treatment. Resident #55's wound appeared to be about the size of a dime with a deep crater with a creamy yellow center (slough) and located at the coccyx (base of the vertebral column and sacrum). The old dressing removed by LPN #1 had a slight, yellow, moist, stain on it. It was observed, at that time, the pressure reducing seat cushion was not in her recliner, but rather in her wheel chair which sat vacant near her bed. CNA #20 who was assisting LPN #1 indicated she does not usually transfer Resident #55, but whoever did, forgot to put her seat cushion in her recliner before transferring her into it. Resident #55 was observed on 4/12/11 at 4:55 P.M., sitting in her wheel chair in the East Unit dining room. She did not have her seat cushion in the wheel chair. The seat cushion was observed in the recliner in her room at 4:57 P.M. At 5:00 P.M., the Director of Nursing confirmed Resident #55 was without her seat cushion while up in her wheel chair. Resident # 55's most recent quarterly MDS (Minimum Data Set) Assessment, dated 3/02/11, indicated she was frequently incontinent of urine and needed extensive assist of 1 for toileting. A Care Plan, initiated 10/05/10, indicated, "Problems: (Resident #55) is at risk for pressure ulcer development R/T (related to) impaired bed mobility...Approaches: ...Provide skin tx's (treatments) as needed/ordered...red Clock Program (turn and position every two hours). Turn (Resident #55) side to side when in bed to alleviate unwanted pressure to bony prominence's...3/29/11: Low Loss Air Mattress to bed...4/1/11: Calcium Alginate (topical wound treatment) with drsg (dressing) to lower coccyx wound...." Resident # 55's other Care Plans were reviewed, but they also lacked documentation of a pressure relieving seat cushion. An Interdisciplinary Care Plan Progress Note, dated 3/16/11, indicated, "...Not much motivation. Sits in common area and watches people. No mood behavior problems. Cooperative with care...." A "Braden Scale for Predicting Pressure Sore Risk," dated 2/28/11, indicated a score of 15 (low risk) for Resident #55. Review of the Resident Assessment Protocol Summary (RAP), dated 9/25/10, indicated, "...Pressure ulcers triggered for (resident #55) because her bed mobility is impaired, placing her at risk for pressure ulcer development and she has a hx (history) of pressure ulcers in the past...." 2. During initial tour of the East Unit on 4/11/11 at 10:25 A.M. while accompanied by LPN #1, she indicated Resident #51 was in contact isolation [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) to an acquired stage III pressure ulcer on the left heel. Outside the room was a free-standing 3 drawer cabinet which contained gloves and gowns to be worn when providing care to Resident #51. Laboratory reports, dated 3/02/11 and 3/21/11, indicated the wound to the left heel of Resident #51 was positive [MEDICAL CONDITION]. A "Change of Condition Form," dated 3/09/11, indicated, "...Problem:[MEDICAL CONDITION] to L (left) heel wound. Interventions: ...2. Contact Isolation...." During observation of wound care on 4/13/11 at 11:05 A.M. while accompanied by Physical Therapist (PT) #21, Resident #51 was observed lying in bed. PT #21 addressed the resident and set her supplies up to debride the stage III pressure ulcer on Resident #51's left heel. She removed the old dressing which contained a quarter-sized serosanguineous (thin and light red tinged drainage) spot. The wound was a beefy red dime-sized crater surrounded by creamy white tissue. No eschar (a dry crust that results from trauma) was present. A Nurse's Note, dated 12/11/10 at 10:30 P.M., was the first note indicating the development of the pressure ulcers to Resident #51's heels, "Res (resident) was found to have blisters on both heals (sic) this afternoon. Both are intact, both are black in color." A "Doctor Progress Notes," dated 12/17/10, indicated, "...Developed dark blisters to bilat (bilateral) heels. ? friction. No obvious injury...Ext (extremities): L (left) heel with soft large hemorrhagic blister. No SOI (sign of infection). R (right) heel with flat, dried blister? unopened. No SOI. Resident #51's annual MDS (Minimum Data Set) Assessment, dated 2/09/11, indicated, she had one "unstageable pressure ulcer with suspected deep tissue injury in evolution...Pressure ulcer length: 2.5 cm (centimeters); Pressure ulcer width: 1.5 cm.; Pressure ulcer depth: 0 cm...." A Care Plan, initiated 2/24/11, indicated, "Problem: (resident #51) has 2 unstageable pressure ulcers, one on each heel...Approaches: ...(3/17/11) cleanse L heel with NS (normal saline) or wound cleaner. Apply Santyl (chemical debrider) to wound bed then apply Calcium Alginate (thin pad with wound healing medication), cover with foam drsg (dressing) bid (twice daily)." The "Change of Condition Forms," indicated the following: "12/11/10: Issue/Concern: Both heals (sic) have intact blisters, both are black in color...Problem: blisters to both heals (sic), blisters are intact with no drainage, blisters are black in color...2/2/11: Problem: Abt (antibiotic)/ (left) heel...2/11/11: Problem: Open area bilat (bilateral) heel (s)...3/9/11: Problem:[MEDICAL CONDITION] to L heel wound...." A "Doctor Progress Note," dated 3/2/11, indicated, "...increased d/c (discharge) and odor to L (left) heel wound...L heel with enlarging wound with exudative base and redness surrounding...heel wound with infection...." A "Doctor Progress Notes," dated 3/16/11, indicated, "...R (right) heel healed. L heel + (positive)[MEDICAL CONDITION]." A Nurse's Note, dated 2/15/11 (no time) indicated, "...Tx (treatment) cont (continues) to bilat (bilateral) heels...Res (resident) has dx (diagnosis) [MEDICAL CONDITIONS] bilateral feet...." Review of Resident #51's [DIAGNOSES REDACTED]. During an interview with Dr. (Name) on 4/13/11 at 12:40 P.M., she indicated Resident #51 had a good pedal pulse. She further indicated, when queried about circulation in Resident # 51's lower legs, the right heel healed up without difficulty and the left heel should do the same as soon as [MEDICAL CONDITION] treatment is completed. She also indicated she did not give her the [DIAGNOSES REDACTED]. "The family has requested comfort measures only so I have not pursued an arterial blood flow study. That test would be the way to diagnose if she had [MEDICAL CONDITION]." Review of 40 clinical records in the facility indicated all of those residents had a [DIAGNOSES REDACTED]. 3.1-40(a)(1) 3.1-40(a)(2)