Every finding on record at Hammond-Whiting Care Center

Based on observation, record review, and interview, the facility failed to provide therapy or treatment for a resident with post-stroke hemiplegia resulting in a loss of range of motion to the affected hand for 1 of 2 residents reviewed for range of motion. (Resident 15)Finding includes:During random observations on 2/5/26 at 9:56 a.m., 2/6/26 at 1:03 p.m., and 2/9/26 at 10:00 a.m., Resident 15's left hand remained in a fist position. The knuckles on his left hand appeared larger than on his right. No visible intervention was observed for the left hand. During an observation of care on 2/9/26 at 10:41 a.m., the resident grabbed and pulled non-purposefully with his right hand when turned on his left side. When turned to his right side, minimal movement of his left arm was observed, and his left hand remained in a fist. At that time, CNA 2 indicated the resident did not really move his left hand or use his left arm. The resident's record was reviewed on 2/9/26 at 11:39 a.m. Diagnoses included, but were not limited to, hemiplegia (one-sided weakness or paralysis) of the left side after a stroke, and dementia. The End of PPS Part A Stay Minimum Data Set (MDS) assessment, dated 10/26/25, indicated the resident was not cognitively intact and was dependent in activities of daily living (ADLs). A Care Plan, dated 8/5/25, indicated the resident had a stroke. The goal was that the resident would be free from complications from a stroke, including contractures. Interventions included observing and reporting changes including weakness. A Care Plan, revised 8/5/25, indicated the resident had an alteration in his neurological status. The goal was that the resident would maintain status and quality of life within limitations imposed by neurological deficits. Interventions included physical therapy and occupational therapy to evaluate and treat as ordered. An Occupational Therapy Evaluation and Plan of Treatment dated 8/5/25, indicated the resident was totally dependent in ADLs and transfers. The evaluation of the resident's upper extremity (arm) ROM and strength were coded as Other (pt [patient] unable to follow simple one step commands for formal assessment; pt resistive at time of assessment).A Rehabilitation Services Screening Tool, dated 1/12/26, indicated the resident was not appropriate for skilled therapy at that time. The screening tool did not include the resident's hemiplegia or a range of motion (ROM) assessment. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) indicated she did not know if there were any interventions in place for the resident's hand, but she would check with therapy. In an evaluation, dated 2/10/26 at 11:52 a.m., Occupational Therapist (OT) 1 indicated the resident had arm mild hypertonicity (an abnormal increase in muscle tone, resulting in stiffness, rigidity, and reduced mobility caused by central nervous system damage, often linked to conditions like a stroke) throughout four of his fingers. OT 1 recommended therapy three times a week to trial a splint/palm guard. During an interview on 2/11/26 at 10:00 a.m., OT 1 indicated the last time the resident was on service, at the end of 2025, it was only for evaluation for a new chair. She indicated she thought the resident was using both hands at that time. She indicated normally nursing staff would inform them if there was a change in the resident's ROM, or they (therapist) would jump in if they observed it. She indicated during her assessment on 2/10/26, the resident did not follow commands, but through attempting passive ROM, she observed stiffness to his left fingers. She cleaned his hand and was trialing him with a palm guard. 3.1-42(a)(2)

Based on observation and interview, the facility failed to ensure a clean and sanitary kitchen was maintained related to food containers and boxes stored on the floor of walk ins, refrigerated food open to air and heavy debris build up on equipment for 1 of 1 kitchen observed. (Main Kitchen) This had the potential to affect 62 residents who received meals prepared from the kitchen.Findings include:On 2/5/26 at 8:50 a.m., the initial kitchen tour was completed with the Head Cook. The following was observed:a. In the portable walk-in refrigerator there were two loose containers of beef broth on the floor, There was a box of tortilla shells and two other food boxes sitting on the floor. There was a bag of biscuits open to air and discolored on the tops.b. In the portable walk-in freezer, there were no shelves. All food boxes were stacked in 22 stacks on the floor. c. The dishwasher had a heavy buildup of crumbs and debris.During an interview at the time of the kitchen tour, the Head [NAME] indicated food was not supposed to be stored on the floor, the biscuits should be thrown away, and the dishwasher was in need of cleaning.3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident who was risk for elopement had their wander guard pendant (personal exit door alarm) checked for functioning at least daily for 1 of 1 resident reviewed for elopement. (Resident 9) The facility also failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 1 of 2 units. (The North Unit) Findings include:1. During a random observation on 2/6/26 at 1:06 p.m., Resident 9 was observed sitting in a wheelchair at the nursing station with his legs crossed. At that time a wander guard was observed around the resident's ankle. The record for Resident 9 was reviewed on 2/9/26 at 11:43 a.m. Diagnoses included but were not limited to, intracranial loss of consciousness, fracture of the occipital lobe, altered mental status, mental disorder, obsessive compulsive disorder, high blood pressure, major depressive disorder, and history of falls. A Physician's Order, dated 6/5/25, indicated wander guard to right ankle for exit seeking behaviors. Check for placement every shift. A Care Plan, revised on 9/17/25, indicated the resident was at risk for elopement and had a history of attempts to leave the facility unattended. The approaches were to check wander guard every shift per order and replace per expiration date and as needed. The 11/28/25 Minimum Data Set (MDS) assessment indicated the resident was moderately intact for daily decision making, had no wandering issues, but had some physical behaviors during the assessment period. An Elopement Risk Evaluation, dated 1/27/26, indicated the resident had a history of elopement, and wandered aimlessly without purpose. There was no documentation in the clinical record that ensured the function of the wander guard was checked daily. During an interview on 2/9/26 at 1:12 p.m., LPN 1 indicated she visually checked the wander guard for placement by looking at the resident's ankle to see if it was there. She did not use any type of device to ensure it was functioning. She said she thought maintenance checked the wander guard but was unsure and she did not know if it was documented or not. During an interview on 2/9/26 at 1:20 p.m., the Maintenance Director indicated he does not check the wander guard for function once it was placed on the resident. He only checked it for function prior to placement. During an interview on 2/9/26 at 1:25 p.m., LPN 1 indicated she found the wander guard device to check the function in the bottom of the medication cart but it had a dead battery inside. She changed the battery and checked the wander guard and it did light up that it was working. She indicated she had not done that before and did not realize there was a device to check the wander guard. During an interview on 2/10/26 at 1:55 p.m., the Director of Nursing (DON) indicated they would follow the general manufacturer's guidelines for the wander guard function. The facility had no policy for checking the function of the wander guard. She indicated she would have thought maintenance would have been in charge of doing that. During an interview on 2/10/26, the DON brought in the guidelines for checking the function of the wander guard and indicated it should have been checked with a specific device to make sure it was working. The current and undated Transmitter Testing guidelines, provided by the Director of Nursing on 2/10/26 at 3:00 p.m., indicated You must test all wander management transmitters prior to use. It is recommended that you test your patient locking security transmitters on a regular basis to ensure proper operation. 2. During random observations on the North Unit, the hot water temperatures in resident rooms were too hot in the following rooms:a. The hot water in room [ROOM NUMBER] was checked on 2/5/26 at 11:07 a.m. and was too hot for a hand to hold under. There were two residents who shared the bathroom.The hot water was checked on 2/11/26 at 9:20 a.m., and was 118 degrees Fahrenheit.b. The hot water in room [ROOM NUMBER] was checked on 2/6/26 at 9:20 a.m. by the Maintenence Director and registered 130 degrees Fahrenheit. There were four residents who shared the bathroom. The hot water was checked on 2/6/26 at 10:30 a.m. and was 113 degrees Fahrenheit.c. The hot water in room [ROOM NUMBER] was checked on 2/6/26 at 9:23 a.m. by the Maintenence Director and registered 125 degrees Fahrenheit. There were four residents who used the bathroom.The hot water was checked on 2/6/26 at 10:30 a.m. and was 113 degrees Fahrenheit.d. The hot water in room [ROOM NUMBER] was checked on 2/6/26 at 9:25 a.m.by the Maintenence Director and registered 124 degrees Fahrenheit. There were four residents who shared the bathroom. During an interview at that time on 2/6/26, the Maintenance Director indicated the boiler was set at 130 degrees Fahrenheit. The facility had issues with the circulating pump a couple of days prior and the water was too cold and he had that fixed right away. He indicated he was going to set the boiler at 120 degrees Fahrenheit and recheck the water temperatures every hour. The hot water was rechecked on 2/6/26 at 10:30 a.m. and was 112 degrees Fahrenheit.3.1-45(a)2

Based on observation, record review, and interview, the facility failed to keep the resident's environment clean and in good repair related to marred walls, gouged bathroom door frames, dirty ceiling vents, dirty tube feeding poles, dirty floor registers, and no toilet paper holders in bathrooms for 2 of 2 units. (The South and North units)Findings include: During the Environmental Tour on 2/11/26 at 9:10 a.m., with the Maintenance Director the following was observed:South Unit:a. room [ROOM NUMBER] - there was no toilet paper holder in the bathroom and the floor register was observed with a dried substance. There were 2 residents who resided in the room and four residents who shared the bathroom.b. room [ROOM NUMBER] - the floor vent was observed with dried substance on it. There were two residents who resided in the room.c. room [ROOM NUMBER] - there was no toilet paper holder in the bathroom. There were three residents who shared the bathroom.d. room [ROOM NUMBER] - the wall by the floor register was dirty as well as the floor register. The bathroom walls were marred. There were two residents who resided in the room and three residents who shared the bathroom.North Unit:a. room [ROOM NUMBER] - the floor behind the bed was dirty and the baseboard was pulling away from the wall. The bathroom ceiling vent was dusty. There was one resident who resided in the room and used the bathroom.b. room [ROOM NUMBER] - the bathroom door frame was gouged. There were three residents who used the bathroom. c. room [ROOM NUMBER] - there was no toilet paper holder in the bathroom. The pedestal sink was loose and pulling away from the wall. The walls were marred in the bathroom. The tube feeding pole by bed two was dirty with dried feeding noted on the base of the pole. The wall and floor behind the pump had dried tube feeding spillage noted. There were two residents who resided in the room, and three residents who used the bathroom.d. room [ROOM NUMBER] - the bathroom room walls and door frame were gouged and marred. There were four residents who used the bathroom.During an interview on 2/11/26 at 9:30 a.m., the Maintenance Director indicated all of the above were in need of cleaning and/or repair. 3.1-19(f)

Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurate related to hospice services, diet, and medications for 4 of 19 residents whose MDS assessments were reviewed. (Residents 3, 18, 11, and 2)Findings include:1. The record for Resident 3 was reviewed on 2/9/26 at 1:30 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), Alzheimer's disease, heart failure, dementia, chronic kidney disease, stroke, peg tube (a tube that was inserted directly into the stomach for nutrition), and anxiety disorder. A Physician's Order, dated 11/26/25, indicated admit to hospice services. A hospice admission document, dated 12/1/25, indicated the resident was admitted to hospice. The Significant Change Minimum Data Set (MDS) assessment, dated 12/8/25, indicated the resident was not cognitively intact for daily decision making and received 51% or more of cubic centimeters (cc) a day of enteral feeding through the peg tube. Hospice services while a resident was not checked. During an interview with on 2/10/26 at 9:11 a.m., the MDS Coordinator indicated hospice services should have been checked while a resident. 2. The record for Resident 18 was reviewed on 2/9/26 9:30 a.m. Diagnoses included, but were not limited to, heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/25, indicated the resident was cognitively intact for daily decision making and was not on a therapeutic diet. A Physician's readmission Order, dated 12/9/25, indicated regular diet with no oranges, orange juice, bananas, potatoes, tomatoes, no salt packets, and diet condiments. During an interview on 2/10/26 at 9:11 a.m., the MDS Coordinator indicated a therapeutic diet should have been checked on the MDS assessment. 3. The record for Resident 11 was reviewed on 2/9/26 at 7:54 a.m. Diagnoses included, but were not limited to, stroke, heart failure, anxiety, major depressive disorder, psychosis, and dementia without behaviors. A Physician's Order, dated 1/14/26, indicated to discontinue Buspirone (an anti-anxiety medication) 10 milligrams (mg) one tablet twice a day. The 1/23/26 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and in the last seven days received an anti-anxiety medication. During an interview on 2/10/26 at 9:11 a.m., the MDS Coordinator indicated the anti-anxiety medication was coded inaccurately. 4. Resident 2's record was reviewed on 2/'9/26 at 2:01 p.m. Diagnoses included, but were not limited to, diabetes mellitus, atrial fibrillation and right and left below the knee amputation. A Physician's Order, dated 6/13/25, indicated hydrocodone-acetaminophen 5/325 milligrams (an opioid pain medication) one tablet every eight hours for pain. The Annual MDS assessment, dated 12/5/25, did not indicate the resident used opioid medications. During an interview on 2/10/26 at 9:11 a.m., the MDS Coordinator indicated she would correct the discrepancies. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure enteral feedings were infusing and administered as ordered by the physician, water flush bags were labeled and dated when hung, placement of the peg tube (a tube directly inserted into the stomach for nutrition) was checked prior to the administration of medication, and water flushes were not plunged via the peg tube for 5 of 5 residents reviewed for tube feeding. (Residents 3, 74, 76, 15, and 33)Findings include: 1. During a random observation on 2/6/26 at 8:45 a.m., Resident 3 was observed in bed and the enteral feeding was infusing at 60 cubic centimeters (cc) into the peg tube. At that time, there was a water flush bag hanging on the pole that was not dated or labeled. On 2/9/26 at 8:36 a.m. and 9:00 a.m., the resident was observed in bed and the enteral feeding was infusing at 60 cc per hour into the peg tube. On 2/9/26 at 12:50 p.m., the tube feeding was turned off. On 2/10/26 at 8:30 a.m., the enteral tube feeding was turned off and the water flush bag was not labeled or dated. The record for Resident 3 was reviewed on 2/9/26 at 1:30 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), Alzheimer's disease, chronic kidney disease, stroke, and peg tube (a tube that was inserted directly into the stomach for nutrition). A Physician's Order, dated 10/15/25, indicated Jevity (enteral feeding) 1.2 at 60 cc per hour times 20 hours for a total of 1200 cc. Flush with 125 cc of purified water every six hours. On at 12:00 p.m., and off at 8:00a.m. The Significant Change Minimum Data Set (MDS) assessment, dated 12/8/25, indicated the resident was not cognitively intact for daily decision making and received 51% or more of cubic centimeters (cc) a day of enteral feeding through the peg tube. A Care Plan, revised on 12/19/25, indicated the resident required a tube feeding. The approaches indicated the resident was dependent with tube feeding and water flushes and to see physician orders for current feeding orders. During an interview on 2/10/26 at 9:20 a.m., the Director of Nursing indicated the enteral feeding should be infusing according to physician orders. The water bags should be changed every 24 hours and the bag should be dated and labeled when hung. 2. During a random observation on 2/6/26 at 1:05 p.m., Resident 74 was observed in bed. At that time, and enteral feeding was infusing into the peg tube. The water flush bag hanging on the pole was not labeled or dated. The record for Resident 74 was reviewed on 2/6/26 at 2:20 p.m. Diagnoses included, but were not limited to, paraplegia, peg tube (a tube inserted directly into the stomach for nutrition), severe calorie protein malnutrition, and dysphagia (difficulty swallowing). The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment was still in progress. A Physician's Order, dated 1/29/26, indicated enteral tube feeding of Glucerna 1.2 at 45 cubic centimeters (cc) per hour times 24 hours via pump for a total amount of 1080 cc, and flush with 145 cc of purified water every four hours. A Care Plan, dated 1/30/26, indicated the resident required a tube feeding. During an interview on 2/10/26 at 9:20 a.m., the Director of Nursing (DON) indicated the water bag should be labeled and dated when hung and was to be changed every 24 hours. 3. On 2/5/26 at 12:05 p.m., Resident 76 was observed lying in his bed. There was a container of tube feeding hanging on pole that was not currently being infused, The resident indicated it was supposed to be for twelve hours a day from 6:00 p.m. to 6 a.m. and it didn't get turned on until 10:00 p.m. the previous night. The resident's record was reviewed on 2/6/26 at 2:50 p.m. Diagnoses included, but were not limited to, muscular dystrophy, functional quadriplegia and gastrostomy (feeding tube). The resident was admitted to the facility on [DATE]. A Physician's Order, dated 1/29/26, indicated the tube feeding should be administered at 100 milliliters (ml) an hour for twelve hours a day. The Brief Interview for Mental Status, dated 1/30/26, indicated the resident was cognitively intact. The February 2026 Treatment Administration Record indicated enteral feeding every shift at 100 ml an hour for twelve hours for a total amount of 1200 ml. There was no specified time for the feeding to be turned on or off. The tube feeding was signed out as turned on during the evening shift and turned off during the midnight shift. During an interview on 2/6/26 at 1:30 p.m., the DON was made aware there were no times specified for the tube feeding administration, she indicated she would get it corrected. During an observation of medication administration via a PEG tube on 2/5/26 at 4:21 p.m., LPN 2 crushed each of Resident 76's medications and diluted them with water. Prior to administration, LPN 2 instilled an air bolus into the tube. He did not use his stethoscope to verify tube placement and he did not check residual. He flushed the tube with water prior to administration, in between each medication, and after the medications were given. He used the syringe to plunge in the last of the water flush instead of infusing via gravity. During an interview on 2/11/26 at 1:54 p.m., the DON indicated PEG tube placement should be verified by checking residual before medications are administered, and flushes should be given by gravity, not by plunging with a syringe. The policy, Medication Administration via Enteral Access Device (EAD), was received from the DON on 2/11/26 and indicated, .6. Avoid administration of feeding, fluids or medications through the EAD until correct position has been confirmed 4. During a random observation on 2/5/26 at 9:54 a.m., a tube feeding water flush bag was hanging on a pole connected to Resident 15's feeding tube. The bag was dated 2/3/26. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) indicated the water flush bags for tube feedings should be changed every 24 hours. 5. The record for Resident 33 was reviewed on 2/6/26 at 1:18 p.m. Diagnoses included, but were not limited to, hemiplegia (weakness on one side of the body) following a stroke and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living. A Physician's Order, dated 2/4/26, indicated Glucerna (a liquid tube feeding formula) three times a day, one can, flush with 15 ml (milliliters) of purified water before and after feeding, hold if meal (oral intake) is 50% or more. The February, 2026 Medication Administration Record (MAR) indicated the following: 2/4/26 dinner intake 75%, no tube feeding given2/5/26 breakfast and lunch intakes 75%, no tube feeding given; dinner X, refused tube feeding2/6/26 breakfast and lunch intakes 75%, no tube feeding given; dinner 75%, no tube feeding given2/7/26 breakfast intake 75%, lunch and dinner 100%, no tube feeding given2/8/26 breakfast & lunch intake 100%, dinner 75%, no tube feeding given2/9/26 breakfast intake 0, lunch 75%, no tube feeding given The meal consumptions documented by the CNAs indicated the following:2/4/26 0-25% breakfast and lunch; 51-75% dinner2/5/26 breakfast 51-75%, lunch and dinner 0-25%2/6/26 breakfast and lunch 26-50%, dinner 76-100%2/7/26 breakfast 51-75%, lunch 0-25%, dinner 26-50%2/8/26 breakfast, lunch and dinner 0-25% 2/9/26 breakfast 26-50% During an interview on 2/9/26 at 9:38 a.m., RN 2 indicated she never gave the resident a tube feeding because it started at 6:00 p.m., and she worked day shift. The way she understood the order was that if the resident ate less than 50% of her meals throughout the day, she would get one can of Glucerna through her feeding tube at 6 p.m. When asked how the nurse knows how much the resident ate, RN 2 indicated she did not know how they figured that out. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) indicated the nurse should administer one can of Glucerna via the feeding tube, for each meal time when the resident consumed less than 50% of her meal. When informed of the findings, the DON indicated she did not know why there was such a discrepancy between the CNA and the nurse documented meal intakes, but that she was going to look into it. 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to ensure a skin rash was assessed and monitored for 1 of 2 residents reviewed for non-pressure related skin conditions, and blood pressure medications were administered as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications. (Residents 18 and 37)Findings include: 1. During an interview on 2/5/26 at 12:10 p.m., Resident 18 indicated he had a red area on the left side of his neck that had been there for about two months. He had told nursing staff and nurses at dialysis but still has not had any treatment for it. At that time, there was a red circular area on the side of his neck. He indicated it was starting to itch. On 2/9/26 at 12:45 p.m., RN 1 was asked to perform a skin assessment to the resident's neck area. At that time, she observed the red and raised area to the left side of his neck. During an interview at that time, RN 1 indicated she was unaware of the skin rash and was not provided any information during the end of shift report she had received in the morning. She indicated when a new skin condition was observed, it would be assessed and the doctor would be notified for a treatment. The record for Resident 18 was reviewed on 2/9/26 9:30 a.m. Diagnoses included, but were not limited to, heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/25, indicated the resident was cognitively intact daily decision making. The resident had no skin concerns. There were no physician orders for any type of cream or ointment to the area on his neck. The Weekly Skin Assessments, dated 11/2, 11/13, 11/20, 11/27, 12/10, 12/17, 12/24, 12/31/25, 1/7, 1/14, 1/21, 1/28, and 2/4/26, indicated the resident's skin was intact and there was no documentation regarding any redness to the left side of his neck. There was no documentation in nursing progress notes from 10/2026 until 2/2026 regarding the reddened area to the left side of the neck. A Physician's Order, dated 2/9/26, indicated Triamcinolone Acetonide Ointment 0.1%, apply to left anterior neck topically two times a day for rash for seven days. During an interview on on 2/10/26 at 9:20 a.m., the Director of Nursing (DON) had no additional information to provide. 2. The record for Resident 37 was reviewed on 2/10/26 at 2:27 p.m Diagnoses included, but were not limited to, congestive heart failure (CHF) and chronic kidney disease. A Physician's Order, dated 1/14/26, indicated metoprolol succinate (a medication for heart failure and high blood pressure) one time a day for CHF, hold if SBP (top number of a blood pressure reading) was under 100. The January 2026 Medication Administration Record (MAR) indicated the following: 1/3/26 BP (blood pressure) 86/56, metoprolol was given; 1/5/26 BP 85/65, metoprolol was given; 1/8/16 BP 90/53, metoprolol was given; 1/9/26 BP 90/68, metoprolol was given; and 1/10/26 BP 96/65, metoprolol was given. A Physician's Order, dated 1/15/26, indicated midodrine (a medication to treat low blood pressure) three times a day, hold if SBP (top number of a blood pressure reading) was over 110. The January 2026 Medication Administration Record (MAR) indicated the following: 1/5/26 at 2:00 p.m., BP 120/43, midodrine was given; 1/5/26 at 8:00 p.m., BP 116/46, midodrine was given; 1/7/26 at 2:00 p.m., no blood pressure was documented, no midodrine was given; and 1/10/26 at 2:00 p.m., BP 115/97, metoprolol was given. During an interview on 2/11/26 at 9:35 a.m., the DON was informed of the findings and offered no additional information. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to a dialysis fistula and pressure ulcer treatments for 1 of 1 resident reviewed for dialysis and 1 of 2 residents reviewed for pressure ulcers. (Residents 18 and 74)Findings include:1. During an observation on 2/6/26 at 12:10 p.m., Resident 18 was observed sitting in a wheelchair in his room. At that time, his shirt was off and a perma catheter was observed in his upper chest. He indicated, that was being used for his dialysis treatments. He had never had a fistula, as they were going to do that later. The record for Resident 18 was reviewed on 2/9/26 9:30 a.m. Diagnoses included, but were not limited to, heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety.A Physician's Order, dated 7/24/25, indicated dialysis resident, assess bruit/thrill (assessments performed on a dialysis fistula) upon return from dialysis every evening shift every Monday, Wednesday, and Friday. The order was discontinued on 12/4/25.The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/25, indicated the resident was cognitively intact for daily decision making.The Treatment Administration Record (TAR) for the months of 7/2025 through 12/2025 indicated the assessment for the bruit/thrill was signed out as being completed.A Physician's order, dated 1/9/26, indicated dialysis resident, assess bruit/thrill upon return from dialysis every evening shift every Monday, Wednesday, and Friday. The TAR for 1/2026 and 2/2026 indicated indicated the assessment for the bruit/thrill was signed out as being completed.During an interview on 2/9/26 at 12:45 p.m., RN 1, who was taking care of the resident, indicated she was unsure if the resident had a fistula for dialysis, but knew he had a perma catheter.During an interview on 2/10/26 at 1:55 p.m., the Director of Nursing indicated the dialysis orders were batch orders from the physician. She had no additional information to provide. 2. The record for Resident 74 was reviewed on 2/6/26 at 2:20 p.m. Diagnoses included, but were not limited to, paraplegia, severe calorie protein malnutrition, and neuromuscular dysfunction of the bladder. The resident was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) was still in progress.The Treatment Administration Record (TAR) for 2/2026 indicated the following treatments were not signed out as being completed on 2/2/26 and 2/3/26:Bilateral heels and lateral right big toe apply skin prep daily. Left heel and left pinky toe: cleanse with wound wash, pat dry, cover with calcium alginate with silver and cover with border gauze one time a day.Left outer ankle blister: cleanse with wound wash, pat dry, cover with xeroform and cover with border gauze, one time a day. Left thigh and leg: cleanse with wound wash, pat dry, cover with calcium alginate with silver and cover with border gauze, one time a day. Right middle back: cleanse with wound wash, pat dry and cover with xeroform and border gauze daily.Right thigh: cleanse with wound wash, pat dry, cover with calcium alginate with silver and cover with border gauze one time a day. Sacrum/ coccyx: cleanse with wound wash, wet to dry dressing and cover with border gauze one time a day.The Wound Physician assessed the resident on 2/3/26.During an interview on 2/9/26 at 10:05 a.m., the Wound Nurse indicated she did the wound treatments on Mondays, Wednesdays and Fridays when she worked. She also worked on Tuesdays when the Wound Physician made his rounds. The treatments were completed, however, she did not sign them out.During an interview on 2/10/26 at 9:20 a.m., the Director of Nursing had no additional information to provide. 3.1-50(a)(1)3.1-50(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident who needed assistance with ADL's (Activities of Daily Living) received help related to oral care and washing of hair for 1 of 3 residents reviewed for ADL's. (Resident 6)Finding includes: During an interview on 2/5/26 at 10:30 a.m., Resident 6 indicated her hair was not washed every week and staff do not set her up to brush her teeth. At that time, the resident's hair was unkempt. During an interview on 2/9/26 at 9:35 a.m., the resident indicated CNA 1 got her up and dressed, however, she did not set her up to brush her teeth or provide oral care. She also indicated her hair had not been washed recently. The record for Resident 6 was reviewed on 2/6/26 at 1:09 p.m. Diagnoses included, but were not limited to, heart failure, heart disease, chronic kidney disease, and depression. The 12/17/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident needed set up assistance with oral care and partial/moderate assist with personal hygiene. A Care Plan, revised on 9/11/25, indicated the resident needed assistance with ADL's. The approaches were to encourage the resident to participate in tasks as tolerated. The shower sheets, indicated the resident received a bed bath on 1/8, 1/12, 1/15, 1/19, 1/26, 1/29, and 2/5/26. The resident's hair was only washed on 1/26/26. During an interview on 2/9/26 at 10:25 a.m., CNA 1 indicated she provided morning care for the resident today and did not set her up to brush her teeth or assist her with oral care. During an interview on 2/10/26 at 9:20 a.m., the Director of Nursing had no additional information to provide. 3.1-38(a)(3)(B)3.1-38(a)(3)(C)

Based on record review and interview, the facility failed to invite and hold care planning conferences for residents and/or their family members. The facility also failed to update care plans related to medications for 3 of 19 residents whose care plans were reviewed. (Residents 6, 11, and 13)Findings include:1. During an interview on 2/5/26 at 10:33 a.m., Resident 6 indicated she has not been invited to a care conference. The record for Resident 6 was reviewed on 2/6/26 at 1:09 p.m. Diagnoses included, but were not limited to, heart failure, heart disease, chronic kidney disease, and depression. The 12/17/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Psychosocial Note, dated 3/27/25 at 10:30 a.m., indicated the IDT (interdisciplinary team) met with the resident for a quarterly care plan meeting. There were no other care plan meetings in the clinical record. During an interview on 2/10/26 at 9:20 a.m., the Administrator indicated the facility was without a Social Service Director (SSD) for a couple of months. The current SSD had been there for about two months. They were aware care planning conferences were missed. 2. During an interview on 2/5/26 at 11:06 a.m., Resident 11 indicated she does not recall going to a care plan meeting. The record for Resident 11 was reviewed on 2/9/26 at 7:54 a.m. Diagnoses included, but were not limited to, stroke, heart failure, anxiety, major depressive disorder, psychosis, and dementia without behaviors. The 1/23/26 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and in the last seven days received an anti-anxiety medication. Psychosocial Progress Notes, dated 4/10/25, 12/12/25 and 1/8/26, indicated the IDT met with the resident for a quarterly care plan conference. There were no documented care plan conferences between 4/10/25 and 12/12/25. A Care Plan, last revised on 11/10/25, indicated the resident was on pain medication therapy and had a prescribed opioid for pain. A Physician's Order, dated 1/14/26, indicated to discontinue Hydrocodone (an opioid medication). During an interview on 2/10/26 at 9:20 a.m., the Administrator indicated the facility was without a Social Service Director (SSD) for a couple of months. The current SSD has been here for about two months. They were aware care planning conferences were missed. During an interview on 2/10/26 at 9:20 a.m., the Director of Nursing indicated the care plan was outdated. 3. Resident 13's record was reviewed on 2/9/26 at 9:17 a.m. Diagnoses included, but not limited to, functional quadriplegia, cirrhosis of the liver and vascular dementia. The resident's medication list did not include any diuretics. A Care Plan, dated 11/7/25, indicated the resident was on diuretic therapy. Interventions included, but were not limited to, administer medications as ordered, monitor for side effects and monitor for weight changes. During an interview on 2/9/26 at 10:53 a.m., RN 2 indicated the physician had discontinued the diuretics. During an interview on 2/10/26 at 9:25 a.m., the Director of Nursing was made aware the care plan for diuretics was still in place. No additional information was provided. 3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure the care plan reflected the resident's current care needs and choices related to maintaining a bed in high position and indwelling catheter maintenance and care for 1 of 3 residents reviewed for accidents (Resident 33) and 1 of 2 residents reviewed for catheters (Resident 37).Findings include:1. During a random observation on 2/5/26 at 10:20 a.m., Resident 33 was observed lying in a diagonal position with both of her legs hanging off of side of bed. She indicated she was unable to move her legs back into the bed. The bed was in a high position. On 2/5/26 at 12:46 p.m., 2/6/26 at 1:14 p.m., and 2/9/26 at 9:57 a.m. and 3:02 p.m., the resident was observed lying in her bed, which was in a high position. The record for Resident 33 was reviewed on 2/6/26 at 1:18 p.m. Diagnoses included, but were not limited to, hemiplegia (weakness on one side of the body) following a stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living and transfers. A care plan, revised on 7/30/25, indicated the resident had an actual fall and was at risk for falling. Interventions included to anticipate and meet the resident's needs, and to keep the call light in reach. There was no care plan indicating the resident had a preference for keeping the bed in a high position.During an interview on 2/10/26 at 2:30 p.m., the Director of Nursing (DON) indicated the bed was in a high position due to the resident's preference, but they did not have a care plan for it. 2. During a random observation on 2/5/26 at 10:51 a.m., Resident 37 was observed resting in his bed. There was a urine collection bag hanging from his bedframe. At that time, the resident indicated he had an indwelling urinary catheter. The record for Resident 37 was reviewed on 2/10/26 at 2:27 p.m Diagnoses included, but were not limited to, congestive heart failure (CHF) and chronic kidney disease.A Progress Note, dated 1/21/26, indicated an indwelling urinary catheter was inserted in the resident.The record lacked a care plan related to the indwelling catheter.During an interview on 2/11/26 at 9:35 a.m., the Director of Nursing (DON) indicated they should have a care plan in place for the resident related to the indwelling catheter. 3.1-35(a)

Based on record review and interview, the facility failed to ensure a resident and/or their responsible party were sent the facility's bed-hold policy and State approved transfer form before and upon transfer to the hospital for 1 of 3 residents reviewed for hospitalization. (Resident 70)Finding includes: Resident 70's closed record was reviewed on 2/11/26 at 12:57 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, congestive heart failure and atrial fibrillation.The admission Minimum Data Set assessment, dated 11/26/25, indicated the resident was cognitively intact.A Health Status Note, dated 12/3/25 at 3:59 a.m., indicated the resident had called 911 and reported difficulty breathing. Emergency Services arrived and she was transported to the hospital. She returned to the facility later that morning with no new orders. A Health Status Note, dated 12/3/25 at 3:45 p.m., indicated the resident had called 911 again complaining of pain and shortness of breath. Emergency Services arrived and transported her to the hospital. She was admitted to the hospital at that time.There was no indication the bed hold policy or State approved transfer form had been provided to the resident or the resident's responsible party for either of the hospital transfers that day.During an interview on 2/11/26 at 2:25 p.m., the Director of Nursing indicated there were no transfer or bed hold policies provided.3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)3.1-12(a)(25)(A)

Based on record review and interview, the facility failed to ensure interventions were attempted prior to administering PRN (as needed) anti-anxiety medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 2)Finding includes: The record for Resident 2 was reviewed on 2/9/26 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes, heart failure and right and left below the knee amputation. The Annual Minimum Data Set assessment, dated 12/5/25, indicated the resident had moderate cognitive deficits.A Physician's Order, dated 1/20/26, indicated to give lorazepam (an anti-anxiety medication) 0.5 milligrams every 12 hours as needed for anxiety for 14 days. A Behavior Care Plan, revised on 7/29/25, indicated the resident had behaviors of yelling, exit seeking, and being aggressive. Interventions included, but were not limited to, engage calmly in conversation, guide away from source of distress, assess for needs and document attempted interventions. The January 2026 Medication Administration Record indicated the resident received lorazepam on 1/22, 1/24 and 1/29/26. There were no interventions documented prior to giving the medication. During an interview on 2/10/26 at 1:55 p.m., the Director of Nursing indicated there were no interventions documented prior to giving the medication.3.1-3(w)

Based on record review and interview, the facility failed to provide timely notification of changes to the physician related to complaint of a cough for 1 of 2 residents reviewed for respiratory care (Resident 63) and a change in respiratory status for 1 of 1 resident reviewed for change in condition. (Resident 15)Findings include:1.On 2/5/26 at 10:21 a.m., Resident 63 was observed in his room. He indicated he had a cough and had requested cough medicine but was told by nursing that he didn't have an order for any the previous day. The resident's record was reviewed on 2/10/26 at 10:36 a.m. Diagnoses included, but were not limited to, diabetes mellitus, hyperlipidemia and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 1/9/26, indicated the resident was cognitively intact. A Behavior Note, dated 1/26/26, indicated the resident had requested some cough syrup. The writer indicated he did not have an order for cough syrup and if he was having a cough or feeling congested the writer would contact the physician for an order. The resident became agitated and was redirected. There was no indication in the note the resident had been assessed for a cough or the physician had been notified. A Health Status Note, dated 2/9/26, indicated the resident had complained of a cough. The resident was assessed, the physician was notified and an order was received for Robitussin as needed for cough. During an interview on 2/11/26 at 9:51 a.m., the Director of Nursing was made aware of the delay in physician notification and order for cough syrup. She indicated she would look into it, but no further information was provided. 2. The record for Resident 15 was reviewed on 2/9/26 at 11:39 a.m. Diagnoses included, but were not limited to, hemiplegia (one-sided weakness or paralysis) of left side after a stroke, dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD). The End of PPS Part A Stay Minimum Data Set (MDS) assessment, dated 10/26/25, indicated the resident was not cognitively intact and was dependent in ADLs. A Care Plan, initiated 10/9/25, indicated the resident was at risk for rehospitalization. Interventions included that the staff was to provide timely communication to the physician or nurse practitioner regarding any change in the resident's condition. In a Progress Note, dated 12/13/25 at 10:31 p.m., the nurse indicated they were called to the resident's room by a co-worker, who informed them that the resident didn't look well. The nurse indicated the resident was not responding to verbal stimuli and had shallow breathing. At that time, the resident's blood pressure was 75/66, and his oxygen saturation was 85%. The nurse administrated oxygen at 5 lpm (liters per minute) per nasal cannula. After 20 minutes, the resident's blood pressure was 94/60 and his oxygen saturation was 93%. The nurse indicated she would keep resident on the oxygen at 5 lpm and monitor throughout their shift. The record lacked documentation that the physician was informed of the change in the resident's status. In a Progress Note, dated 12/14/25 at 1:30 a.m., the nurse indicated the resident was resting quietly, aroused to verbal stimuli, and had an oxygen saturation of 98%. A Progress Note, dated 12/14/25 at 6:00 a.m., indicated the resident was not responding to verbal stimuli or tactile stimuli. His oxygen saturation level was 83% with oxygen being administered at 5 lpm per nasal cannula. An ambulance was called, and the resident was sent out to the hospital. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) indicated the nurse should have notified the physician immediately of the change in the resident's status. A policy titled, Changes in Resident's Condition or Status, received from the DON as current on 2/10/26, indicated, . A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is . A significant change in the resident's physical, mental, or psychosocial status. 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to maintain a resident's dignity related to wearing a hospital gown during the day and posting of swallowing precautions/instructions in residents' rooms for 3 of 4 residents reviewed for dignity. (Residents 15, 33 and 42)Findings include:1. During random observations on 2/5/26 at 9:54 a.m., 2/9/26 at 10:31 a.m., and 2/9/26 at 3:33 p.m., Resident 15 was wearing a hospital gown during the day. The resident's record was reviewed on 2/9/26 at 11:39 a.m. Diagnoses included, but were not limited to, hemiplegia (one-sided weakness or paralysis) of the left side after a stroke, and dementia. The End of PPS Part A Stay Minimum Data Set (MDS) assessment, dated 10/26/25, indicated the resident was not cognitively intact and was dependent in activities of daily living (ADLs). The resident's care plan did not indicate the resident had a preference of wearing a hospital gown. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) was informed of the finding and offered no additional information. 2. During random observations on 2/5/26 at 10:15 a.m., 2/6/26 at 1:10 p.m., and 2/9/26 at 3:03 p.m., a sign was posted above Resident 33's bed that stated, PATIENT IS A SILENT ASPIRATOR. The record for Resident 33 was reviewed on 2/6/26 at 1:18 p.m. Diagnoses included, but were not limited to, hemiplegia following a stroke.The Quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the resident had severe cognitive impairment and was dependent in ADLs. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) indicated the speech therapist must have put up signs in the resident's room, but she was not aware they were there. 3. During random observations on 2/5/26 at 10:33 a.m. and 2/9/26 at 9:50 a.m., a sign indicating the she was a silent aspirator and a page of individualized swallowing instructions were posted on the wall next to Resident 42's bed. The resident's record was reviewed on 2/9/26 at 2:21 PM . Diagnoses included, but were not limited to, dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, indicated the resident was cognitively intact for daily decision making. During an interview on 2/10/26 at 9:35 a.m., the Director of Nursing (DON) indicated the speech therapist must have put up signs in the resident's room, but she was not aware they were there. 3.1-3(t)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff not donning personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), an indwelling Foley catheter bag observed on the floor, and the improper storage of personal care equipment during random infection control observations. (Residents 74 and 76)Findings include:1. During random observations on 2/5/26 at 9:49 a.m., 10:19 a.m., and 12:16 p.m., Resident 74 was observed in bed. At those times, the indwelling Foley catheter bag was observed on the floor. The record for Resident 74 was reviewed on 2/6/26 at 2:20 p.m. Diagnoses included, but were not limited to, paraplegia and neuromuscular dysfunction of the bladder. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) was still in progress. A Physician's Order, dated 1/29/26, indicated Indwelling catheter to straight drainage, size 16 French with a 10 cubic centimeters (cc) bulb. During an interview on 2/10/26 at 9:20 a.m., the Director of Nursing (DON) indicated the foley catheter bag should not have been on the floor. The current and updated 9/4/25, Indwelling Urinary Catheter Foley Management policy, provided by the DON on 2/9/26 at 3:00 p.m., indicated do not rest the bag on the floor. 2. During random observations of the bathroom in room [ROOM NUMBER] on 2/5/26 at 10:26 a.m. and on 2/11/26 at 9:20 a.m., there were two pink wash basins observed on the floor and a urinal hanging on the grab bar. All three were not labeled or contained in any bag. There were three residents who shared the bathroom. During an interview on 2/11/26 at 1:05 p.m., the Director of Nursing (DON) had no additional information to provide. The current 5/1/25 Keeping a Resident's Room in Order policy, provided by the DON on 2/11/26 at 3:13 p.m., indicated Bedpans and urinals must be covered with a plastic bag. Each plastic bag will be marked with the resident's name. 3. During an observation of medication administration on 2/5/26 at 4:21 p.m., LPN 2 prepared each of Resident 76's medications to be administered via his PEG tube (a feeding tube inserted through the abdomen). At 4:25 p.m., LPN 2 went into the resident's room to wash his hands. He donned gloves and proceeded with medication administration. He did not don a gown to administer the PEG tube medications. During an interview on 2/11/26 at 1:54 p.m., the Director of Nursing (DON) indicated a gown should be worn when administering medications via a PEG tube. 3.1-18(b)

Based on observation, record review and interview, the facility failed to ensure a resident's right to participate in her care related to not being informed on the medication she received during medication pass for 1 of 7 residents observed for medication administration. (Resident E)Finding includes:During medication administration on 9/15/25 at 9:22 a.m., RN 1 prepared the powdered medication Lokelma (given for high potassium level) in water for Resident E. RN 1 handed the resident the medication and the resident was gagging on the mixture and indicated how bad it tasted and did not want to finish it. RN1 instructed to drink the rest of the medication. RN 1 did not educate or inform Resident E what the medication was or why it was important to drink it all.During medication administration on 9/16/25 at 9:28 a.m., LPN 1 prepared the powdered medication Lokelma for Resident E. LPN 1 handed the medication to the resident and did not inform her what the medicine was for. The resident struggled to drink the medication fully and was starting to cry due to the poor taste. LPN 1 added more water to the mixture and instructed her to try and finish the medication drink.During an interview at the time, LPN 1 indicated the resident did not like the way it tasted and would ask for more water.Resident E's record was reviewed on 9/15/25 at 9:28 a.m. Diagnoses included, but were not limited to, high blood pressure, diabetes, and Bell's palsy.The admission Minimum Data Set (MDS) assessment, dated 5/29/25, indicated the resident was moderately impaired for daily decision making.A Physician's Order, dated 8/27/25, indicated to administer 1 packet of Lokelma once a day for high potassium.During an interview on 9/16/25 at 10:11 a.m., the Assistant Director of Nursing (ADON) indicated she would expect the nurses and qualified medication aides to inform the residents what medication they were receiving before they administered the medication.The current and revised Administration of Medications policy, provided by the Nursing Consultant as current on 9/16/25 at 10:09 a.m., indicated staff were responsible for adhering to the 10 rights of medication administration. Which included, . j. Right Education and Information. Provide enough knowledge to the resident of what drug he/she would be taking.This citation relates to Intake 2581285.3.1-3(n)(2)(3)

Based on observation, record review, and interview, the facility failed to ensure a dependent resident received assistance with ADLs (activities of daily living) related to bathing for 1of 3 residents reviewed for ADLs. (Resident D)Finding includes:On 9/15/25 at 3:33 p.m., Resident D was observed playing bingo. The resident's hair had a greasy appearance.Resident D's record was reviewed on 9/16/25 at 11:05 a.m. The diagnoses included, but were not limited to, heart failure, kidney disease, anxiety, and diabetes.The admission Minimum Data Set (MDS) assessment, dated 7/23/25, indicated the resident was moderately impaired with daily decision. The resident required partial to moderate assistant with toileting.A Care Plan, dated 7/23/25, indicated the resident required assistance with ADLs (activities of daily living) and needed therapy services. Intervention was to assist the resident with ADLs as needed.Showers Sheets indicated the resident had not received a bath/shower on the following dates:8/19/258/20/258/21/258/22/258/23/258/24/258/25/258/26/258/27/25There were no documented refusals for the above dates.During an interview on 9/16/25 at 12:33 p.m., the ADON indicated the resident had a caregiver and she would give her baths when she came. She understood the bath/showers should have been documented.This citation relates to Intake 2581285.3.1-38(2)(a)

Based on record review, and interview, the facility failed to administer medications as ordered related to antibiotic and antianxiety medication for 1 of 3 residents reviewed for medication administration. (Residents B)Finding includes:Resident B's record was reviewed on 9/15/25 AT 10:15 a.m. The diagnoses included, but were not limited to, paraplegia, osteomyelitis (bone and muscle infection), anxiety, hypertension (high blood pressure), muscle weakness, and ulcerative colitis (inflamed bowel).The admission Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident was cognitively intact and received an antibiotic and antianxiety medication.A Physician's Order, dated 7/8/25, indicated to administer alprazolam 1 milligram (MG) my mouth at bedtime for anxiety.A Physician's Order, dated 7/11/25, indicated to administer Vancomycin (antibiotic) 1.25 grams intravenously two times a day for a wound infection related to osteomyelitis.The 7/2025 Medication Administration Record (MAR), indicated the following medications were not signed out as being administered:Vancomycin was not signed out as given on 7/9/2025 for the morning and evening dose.Vancomycin was not signed out as given on 7/10/2025 for the morning and evening dose.Alprazolam was not signed out as given on 7/8, 7/9, 7/10, 7/11, 7/14, 7/15, 7/17 and 7/18/2025.During an interview on 9/25/25 at 1:22 p.m., the Assistant Director of Nursing (ADON) indicated discharge paperwork was sent with the resident to the facility but they did not receive the After Visit Summary (AVS). The vancomycin was not listed on the discharge paperwork, and she had called the hospital twice trying to get the AVS sent over . The next day they were able to reach someone to get wound treatment orders, and they were going to fax the AVS to the facility. They never received the fax, and she understood she should have followed up. The resident had complained to staff that she was supposed to be on antibiotics, and they reached out to the physician at that time. At 1:57 p.m., she indicated she had admitted the resident and should have verified with the doctor the resident's antibiotic orders since she came to the facility with a diagnosis of osteomyelitis and without an AVS. She understood this resulted in a delay in treatment and 4 missed doses of Vancomycin. At 2:52 p.m., the ADON indicated she contacted the pharmacy, and they indicated they were waiting on a prescription for Resident C's alprazolam, and the medication was not filled because they never had a prescription. She indicated she asked nursing if they knew why she did not receive her anxiety medication, and they did not have an answer.This citation relates to Intake 2560578.3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a wound treatment was completed and heels were floated as ordered for 2 of 3 residents reviewed for pressure-related skin conditions. (Residents B and C) Findings include: 1. On 5/5/25 at 11:59 a.m., Resident B was observed lying in bed on her right side. The resident's heels were resting on the bed, not off-loaded, and she had wounds on her left lateral and medial foot. During an interview at the time, the wound nurse indicated the resident did not have an order for off-loading boots but she would call the doctor today to get an order. She indicated the resident's heels were off-loaded the last time she was in the room. The record for Resident B was reviewed on 5/5/25 at 10:48 a.m. Diagnoses included, but were not limited to, dementia, anorexia, tube feeding support, and lymphedema (swelling in arms or legs). The Quarterly Minimum Data Set (MDS) assessment, dated 2/19/25, indicated the resident was cognitively impaired for daily decision making, dependent for all activities of daily living (ADL's) and was at risk for developing a pressure ulcer. A Physician's Order, dated 4/29/25, indicated to off-load heels while in bed as tolerated and confirm every shift. During an interview on 5/6/25 at 2:11 p.m., the Executive Director indicated she understood the concern and had no additional information to provide. 2. On 5/5/25 at 9:37 a.m., Resident C was observed lying in bed awake. The resident's dressing was checked with the wound nurse and there was no dressing in place covering the resident's sacral wound. The wound was pink, the size of a golf ball, and open to air. The resident's heels were lying flat on the bed and were not off-loaded. During an interview at the time, the Wound Nurse indicated she would put a dressing on the wound right away. On 5/5/25 at 10:38 a.m., the resident was observed in bed with 2 blankets covering her, she was lying on her back and crying she was cold. When the blankets were removed to observe the wound treatment, the resident's feet were lying flat on the bed. The Wound Nurse began the wound treatment, the resident's brief was opened and a new pad was placed underneath the resident. Hand hygiene was performed and a new set of gloves was donned. The wound nurse did not have a gown on and she began cutting the collagen dressing package open. She was stopped and asked if the resident was in Enhanced Barrier Precautions (EBP). There was an EBP sign observed on the resident's door. During an interview at the time, the Wound Nurse indicated she had forgotten to put on a gown. The record for Resident C was reviewed on 5/5/25 at 10:01 a.m. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body), dementia, high blood pressure, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 2/21/25, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of the lower extremities and used a wheelchair. The resident required partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene. The resident required substantial/maximum assistance with lower body dressing and shower/ bathing. The resident required dependent care with toileting and putting on footwear. The resident was at risk for pressure ulcers and injuries. A Care Plan, dated 3/5/25, indicated the resident was at risk for unavoidable pressure injury development related to decline of skin integrity. Interventions were to administer treatments as ordered, provide weekly skin checks, assist with turning and repositioning, and educate on causative factors and measures to prevent skin injury. A Physician's Order, dated 4/2/25, indicated to offload heels while in bed as tolerated and confirm every shift. A Physician's Order, dated 5/2/25, indicated to cleanse the Sacrum with normal saline, pat dry, apply collagen to the wound bed, and cover with a dry dressing. The dressing was to be changed every day shift on Monday, Wednesday and Friday and as needed. During an interview on 5/5/25 at 10:31 a.m., the Executive Director indicated she understood Resident C should have had a dressing on her wound and the resident's heels should have been offloaded. No additional information was provided. This citation relates to Complaint IN00458244. 3.1-40

Based on record review and interview, the facility failed to ensure a resident was free from physical abuse, related to a resident to resident altercation which resulted in Resident J being injured with bilateral non-displaced nasal bone fractures and a hematoma to the face for 1 of 1 resident to resident altercations reviewed. (Residents J and K) Finding includes: An Indiana Department of Health (IDOH) state reported incident indicated on 6/23/23 at approximately 7:36 p.m., Resident J and Resident K were roommates and an altercation occurred between the two of them in their room. Resident J was found to have bruising and bleeding from the face and Resident K was observed kicking Resident J as he exited the room to seek help. Resident J had been transferred to the emergency room and returned with diagnoses of nondisplaced bilateral nasal bone fractures, right periorbital soft tissue swelling and edema. There was facial bruising and swelling. A Police Report, dated 6/23/23 at 7:47 p.m., indicated Resident K was interviewed and informed the Officer Resident J had fallen asleep while watching TV and was awoken when Resident K turned the TV off. Resident J asked Resident K if he could turn the TV back on and was refused. Resident J grabbed his remote and turned the TV on. Resident K then physically attacked Resident J. Resident K admitted to striking Resident J numerous times in the face with a closed fist. Resident J was then interviewed and reported the same information, and indicated he wanted to press charges against Resident K. The Officer then interviewed staff at the facility, who informed him this was not the first altercation for Resident K, and Resident J had requested a room change earlier in the day due to fearing for his safety. Resident J was interviewed on 8/9/23 at 1:54 p.m. and indicated he had just been lying in bed. Both TV's in the room were on, he had dozed off, and Resident K turned his TV off. When he woke up, he told Resident K he wanted his TV on and when he attempted to turn his TV back on, it turned off Resident K's TV and then Resident K started beating on my face. He had been Resident K's roommate before and had been transferred to another room due to a prior verbal altercation. He had asked to be moved back into this room due to the window view and his belongings were still in the room. He had talked with the Social Service Director on 6/23/23 before the altercation occurred and requested a room change due to Resident K's aggression. He had not been fearful at the time. Resident J's record was reviewed on 8/9/23 at 11:13 a.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 8/4/23, indicated a moderately impaired cognitive status and had no behaviors. A Nurse's Progress Note, dated 6/3/23 at 11:56 a.m. indicated an intrafacility transfer to another room. There was no documentation why the intrafacility transfer occurred. A Nurse's Progress Note, dated 6/8/23 at 2:27 p.m., indicated he was moved back to his original room per his request. A Social Service Progress Note, dated 6/23/23 at 4:41 p.m., indicated the resident came to her office and requested a room change. He indicated the night before his roommate had verbal aggression with the staff. The roommate had not been aggressive toward him. He requested either his roommate be transferred out of the room or he would transfer to a room and requested a bed by the window. Social Service indicated she would need to locate a room for the possible transfer and would follow up to the request. A Nurse's Progress Note, dated 6/23/23 at 8:36 p.m., indicated screaming from the resident's room. Resident J was observed exiting the room with blood on his face and bleeding from the mouth, nose, and right eye. Resident K was behind the resident and kicked his buttocks. The Emergency Management System and Police were notified. An order was received from the Physician for a transfer to the emergency room . The family, Administrator, and Director of Nursing was notified. The resident indicated he had been sleeping and his roommate had turned off his TV, when he asked why he turned off his TV, Resident K began to beat him in the face. The Hospital emergency room Notes, dated 6/23/23 at 8:44 p.m., indicated the resident had been assaulted by his roommate. There was facial swelling present. A CT of the facial bones, indicated bilateral nondisplaced nasal bone fractures were present and a large soft tissue hematoma along the right side of the face, which extended from the inferior orbital region to the mandible. There were numerous small soft tissue hematomas. A laceration of the chin was observed. During an interview on 8/9/23 at 1:48 p.m., the Social Service Director indicated he came to her office and said his roommate had been verbally aggressive with the staff and he wanted a new roommate. He requested a bed by a window. He had informed her he was not fearful. She informed him she was the Week-End Manager and would work on the room transfer on the week-end. (6/23/23 was a Friday). She had not spoken to the roommate because he was out of the building with his family. Resident K's record was reviewed on 8/9/23 at 11:40 p.m. The diagnoses included, but were not limited to, dementia. A Quarterly MDS assessment, dated 5/3/23, indicated an intact cognitive status and no behaviors. A Care Plan, dated 5/4/23, indicated a potential for physical aggression. The interventions included, contributing sensory deficits would be assessed and addressed and when agitated, intervene before he escalates. He was to be guided away from the source of the distress, if he was aggressive, staff were to walk away calmly and approach at a later time. A Care Plan, dated 5/4/23, indicated a potential to be verbally aggressive. The interventions include his coping skills and support system would be assessed, he would be assessed for understating of the situation and given time to express feelings, if he becomes agitated, guide away from the source and reapproach. The Point of Care Behavior Tracking, from 5/26/23 to 6/23/23, indicated behaviors of physical aggression, cursing, anger at others, screaming at others, and threatening others occurred on the evening shift on 6/1/23 and 6/3/23. The Nurses' Progress Notes indicated the following: On 5/2/23 at 9:59 p.m., he displayed behaviors toward staff and his roommate. He was cussing at the staff and his roommate and was physically approaching the staff in an aggressive manner. The behaviors were reported to the Shift Manager. On 6/3/23 at 12:10 p.m., verbal aggression towards the roommate. Several attempts of redirection were unsuccessful. He continued to yell at the staff and his roommate. The roommate was transferred to another room. The Physician and Assistant Director of Nursing were made aware. Attempted to notify family and the voicemail was full. On 6/23/23 at 8:59 p.m., was physically aggressive toward roommate and battered the roommate in the face and kicked him in the buttocks. He stated the roommate had hit him first. He became verbally aggressive toward the Nurse when she entered the room. Police were notified. The Physician was notified of the aggression and removal from the facility. Three attempts were made to contact the family. There was no answer and no answering machine. The Supervisor notified the Administrator and Director of Nursing. A facility abuse policy, dated 10/4/22 and revised 7/18/23, received from the Regional Corporate Nurse as current, indicated the facility would ensure that all residents were protected from physical and psychosocial harm. The resident had the right to be free from abuse. 3.1-27(a)(1)

Based on observation, record review, and interview, the facility failed to monitor and assess the skin weekly for 1 of 3 sampled residents reviewed for pressure ulcers. This resulted in the development of an unstageable pressure ulcer to the right buttocks. (Resident 44) Finding includes: On 5/18/17 at 10:12 a.m., the Wound Nurse was observed to complete the pressure ulcer treatment for [REDACTED]. The wound bed was covered with dark purple/black tissue and the surrounding area was red. The depth of the ulcer was unable to be seen. The Wound Nurse measured the area to be 6.5 centimeters (cm) x 4.5 cm. After cleansing the area with normal saline, the Wound Nurse proceeded to apply [MEDICATION NAME] (an ointment used to treat pressure ulcers) to the wound bed with a q-tip and cover the wound with a clean dressing. Interview with the Wound Nurse on 5/18/17, following observation of the wound treatment, indicated she was not aware of any pressure area to the resident's buttocks until 5/2/17, when she was notified of the area by a CNA. At that time, when she first observed the wound, the wound was smaller in size but the wound bed was covered with the same type of purple/black tissue as it was today. She was unable to tell how deep the wound was, so she had to stage the area as an unstageable pressure ulcer. She was unsure of when the most recent weekly skin assessment had been completed. The record for Resident 44 was reviewed on 5/16/17 at 2:51 p.m. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 4/23/17, indicated the resident had one unhealed stage two pressure ulcer and was at risk for developing pressure ulcers. The current care plan, last updated on 4/24/17, indicated the resident had impaired skin integrity due to a left medial heel unstageable pressure area, right lateral heel unstageable pressure area, and a left hip stage two pressure ulcer. The interventions included .skin check weekly .inspect skin during bathing . The Braden Scale (a tool for assessing risk of skin breakdown), dated 5/6/17, indicated the resident was at moderate risk for pressure ulcers with a score of 13. The 5/2017 Physician order [REDACTED]. The 5/2017 Medication Administration Record [REDACTED]. The skin assessment was not signed off as completed. The 5/2017 Weekly Skin Integrity Data Collection sheet was blank. The 4/2017 Weekly Skin Integrity Data Collection sheet, indicated the last skin assessment had been completed on 4/27/17 and the resident had an old open area. A wound progress note, dated 5/2/17, indicated the resident had a new treatment for [REDACTED]. The area measured 2.0 cm x 1.5 cm and had a small amount of serous drainage. The Pressure Ulcer Status Record for the right buttocks, indicated the wound was first observed on 5/2/17, measured 2.0 cm x 1.5 cm and was unstageable (not stageable due to the coverage of the wound bed by slough and/or eschar). A physician's orders [REDACTED]. The Pressure Ulcer Status Record, dated 5/8/17, indicated the area had deteriorated and now measured 3.5 cm x 2.5 cm. The wound had scant drainage and was black in color. Interview with the Director of Nursing (DON) on 5/18/17 at 11:10 a.m., indicated the facility recently had a turnover in their Nurse Consultant position and pressure ulcers were something they were working on. A facility policy, received as current from the DON, titled Assessment of Wounds, indicated .1. It is the responsibility of a licensed nurse to complete the wound assessment and to document the findings on the Treatment Record .2. Assessment and documentation are completed upon admission, re-admission, weekly and PRN . 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to provide the necessary treatment and services for a pressure ulcer related to the failure to complete weekly skin assessments, failure to assessment a pressure ulcer at the time it was first observed, failure to notify the Physician of the ulcer, and failure to provide on going treatment to the unstageable pressure ulcer for 1 of 3 residents reviewed for pressure ulcers in the sample of 7. (Resident #F) Finding includes: The closed record for Resident #F was reviewed on 2/17/15 at 9:10 a.m. The residents [DIAGNOSES REDACTED]. The resident was sent to the hospital emergency roiagnom on [DATE] and was then admitted to the hospital A Braden Scale for predicting the risk of pressure ulcer development was completed on 11/28/14. The resident's score was (16). A score of (16) indicated the resident was at risk for the development of pressure ulcers. The 12/23/14 Minimum Data Set (MDS) quarterly assessment indicated the resident's BIMS (Brief interview for Mental Status) score was (5). A score of (5) indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident required extensive assistance of two staff members for bed mobility, transfers, and personal hygiene. The assessment also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) of one staff member for dressing. The assessment indicated the resident was at risk for the development of pressure ulcers and had no current pressure ulcers. A Care Plan initiated on 11/7/14 indicated the resident was at risk for the development of pressure ulcers. Care Plan interventions included for staff to complete weekly skin assessments, off load the resident's heels when in bed, and notify the Nurse immediately of any new skin areas noted. Review of the 2/2015 Physician Order Statement (POS) indicated there were orders to apply [MEDICATION NAME] ointment to both heels three times a day, apply Ammonium [MEDICATION NAME] 12% lotion topically to the the feet twice daily, and to off load the resident's heels when in bed. There were no further orders for any other treatments to any open areas, pressure ulcers, or blisters to the heels obtained between 2/1/15 and 2/8/15. The 2/2015 Nursing Progress Notes were reviewed. The 2/7/15 entries were reviewed. There was no documentation of the development of any blisters or pressure ulcers to the resident's left heel. There were two entries made on 2/8/15. The first entry was made at 7:44 a.m. This entry indicated the resident slept well without any complaints. There was no documentation of the development of any blisters or pressure ulcers to the resident's left heel. The next entry was made at 10:16 p.m. This entry indicated the resident was sent out to the hospital. There was no documentation of the development of any blisters or pressure ulcers to the resident's left heel. There were no SBAR (Change in Condition) Notes related to the presence of blisters or pressure ulcers to the resident's heels. The Weekly Skin Integrity sheets were reviewed. The most recent sheet available was dated 1/30/15. The sheet indicated the resident's skin was intact. The sheet was signed by a CNA. There was a line for the Nurse's signature on the form. There was no Nursing signature on this sheet. The 2/2015 Hospital records were reviewed. An entry was made by the emergency room RN on 2/8/15 at 8:30 p.m. This entry indicated the resident arrived to the hospital emergency roiagnom on [DATE] from a nursing home. The resident's temperature was 102.4 and his skin was hot to touch. An unstageable (a wound with full thickness tissue loss in which the base of the ulcer was covered by slough and/or eschar in the ulcer bed) wound to the left heel was noted with eschar (thick leathery necrotic or devitalized tissue, frequently black or brown in color) present. Gauze removed from the left foot had a date of 2/7/15 and a "smiley face" written on it. The dressing was adhered to the skin with minimal bleeding noted. The foot was soaked to remove the bandage. The wound to the left heel measured about 4 cm (centimeters) in length and was unstageable. The 2/11/15 Infectious Disease physician progress notes [REDACTED]. The 2/8/15 7:26 p.m. emergency room Physician notes indicated the resident was brought to the emergency room via EMS (Emergency Medical Services) from a Nursing Home with reported wheezing. The Physician's notes indicated [MEDICATION NAME] was applied to the left heel ulcer. The resident's [DIAGNOSES REDACTED]. When interviewed on 2/17/15 at 12:55 p.m., the Wound Nurse indicated she first observed an area to Resident #F's left heel on 2/7/15 during the Evening shift. The Wound Nurse indicated she was working as a floor Nurse on another unit and Resident #F's Nurse called her over to look at the new area to his left heel The Wound Nurse indicated the Nurse informed her a CNA had found the area. The Wound Nurse indicated the area appeared as an opened dark purple blister staged as "Unstageable." The Wound Nurse indicated she wrapped the area in Kerlix and signed the date of 2/7/15 on the Kerlix bandage and informed the Nurse to measure and assess the wound and notify the Physician and Family. When interviewed on 2/17/15 at 1:25 p.m., the facility Administrator indicated she was first made aware the resident had an ulcer to the left heel on 2/9/15 when the family voiced concerns about the heel pressure ulcer to her. The Administrator indicated the resident had been sent out to the hospital on [DATE] in the evening. The Administrator indicated the Nurse who provided care for the resident on 2/7/15 was interviewed and indicated she had been aware of the area on 2/7/15 and paged the Physician. There was no return call from the Physician. The Administrator indicated the Nurse did not pass the information of the new pressure ulcer and no return call from the Physician onto the next shift. When interviewed on 2/18/15 at 10:25 a.m., the facility Administrator indicated the above Nurse should have assessed the ulcer, notified the Physician and family, completed an ulcer assessment form, and documented all of the above in the resident's record. The Administrator indicated other staff providing care for the Resident indicated they had no knowledge of the resident having an ulcer to the area. The Administrator indicated there was no weekly skin check after 1/30/15 and the 1/30/15 skin check sheet should have been signed by the Nurse also. The facility titled "Skin Program Policy" was reviewed on 2/18/15 at 11:00 a.m. The policy had a revised date of 7/2008. The facility Administrator provided the policy and indicated the policy was current. The policy indicated all residents were to have a Weekly Skin Integrity checks performed by licensed staff. The policy also indicated documentation, reporting, and treatment of [REDACTED]. This Federal tag relates to Complaint IN 440. 3.1-40(a)(2) 3.1-40(a)(3)

Based on record review and interview, the facility failed to ensure the administration of an anticoagulant medication was discontinued as ordered by the Physician, to ensure Medication Administration Records and Physician Order Sheets were accurately carried over from month to month and accurately reflected the current Physician's orders, and failed to ensure a resident receiving an anticoagulant medication was monitored for potential adverse reactions or side effects and laboratory tests resulting in the resident needing multiple doses of Vitamin K after receiving anticoagulant medication for over two months after it was discontinued by the Physician and without any laboratory test of monitoring for excessive bleeding. This affected 1 of 4 residents reviewed for unnecessary medication in a sample of 9. (Resident #B) The Immediate Jeopardy began on July 1, 2014 when the facility failed to ensure Physician's orders to discontinue an Anticoagulant medication were not removed from the Medication Administration Record resulting in the continued administration of the medication without a Physician's order and without ongoing monitoring of laboratory values and potential adverse reactions or side effects of the medication. The facility Administrator, Director of Nursing, and the Corporate Administrator were informed of the Immediate Jeopardy on 10/9/14 at 12:35 p.m. The Immediate Jeopardy was removed on October 10, 2014, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more then minimal harm that is not Immediate Jeopardy. Findings include: The record for Resident #B was reviewed on 10/9/14 at 9:55 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 9/11/14 Minimum Data Set (MDS) annual assessment indicated the residents' BIMS (Brief Interview for Mental Status) score was (15). A score of (15) indicates the resident's cognitive patterns were intact. The MDS assessment also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) of two or more staff members for transfers and bed mobility. The assessment also indicated the resident required extensive assistance of one staff member for dressing and personal hygiene. Review of the 5/2014 Physician orders indicated there was an order written [REDACTED]. The [MEDICATION NAME] was originally ordered on [DATE] to be given for [MEDICAL CONDITION]( [MEDICAL CONDITION]) [MEDICATION NAME]. There was also an order to discontinue weekly PT/INR( laboratory tests to monitor clotting times) laboratory tests. The 5/2014 Medication Administration Record indicated the [MEDICATION NAME] was not given after 5/12/2014. The Nursing 2014 Drug Handbook was reviewed. The Handbook indicated [MEDICATION NAME] was an anticoagulant medication. The Handbook indicated the recommend INR range was usually 2-3. Nursing considerations included regular monitoring of INR levels in all patients. The Handbook also indicated elderly patients taking anticoagulants had an increased risk of bleeding and INR levels were to be monitored carefully. The 6/2014 Physician Order Sheet was reviewed. The Physician's order for [MEDICATION NAME] 10 milligram once a day appeared on the sheet. The date of 4/21/14 was written in the Order Sheet as the original start date of the [MEDICATION NAME]. There was a hand written line crossed through the [MEDICATION NAME] order with "DC/D" (discontinued) and the date of "5-12-14" both written by line through the [MEDICATION NAME] order. The Registered Pharmacist signed the Physician Order Sheet noting the resident's medications had been reviewed. The 7/2014 Physician Order Sheet was reviewed. The Physician's order for [MEDICATION NAME] 10 milligrams once a day appeared on the sheet. The date of 4/21/14 was written on the Order Sheet as the original start date of the [MEDICATION NAME]. The Order Sheet indicated the [MEDICATION NAME] was ordered for [MEDICAL CONDITIONS] [MEDICATION NAME](prevention). The Registered Pharmacist signed the Physician Order Sheet noting the resident's medications had been reviewed. The 8/2014 Physician Order Sheet was reviewed. The Physician's order for [MEDICATION NAME] 10 milligrams once a day appeared on the sheet. The date of 4/21/14 was written on the Order Sheet as the original start date of the [MEDICATION NAME]. The Registered Pharmacist signed the Physician Order Sheet noting the resident's medications had been reviewed. The 9/2014 Physician Order Sheet was reviewed. The Physician's order for [MEDICATION NAME] 10 milligrams once a day appeared on the sheet. The date of 4/21/14 was written on the Order Sheet as the original start date of the [MEDICATION NAME]. The Registered Pharmacist signed the Physician Order Sheet noting the resident's medications had been reviewed. The 6/2014 Medication Administration Records were reviewed. The [MEDICATION NAME] 10 milligrams did not appear on the Medication Administration Record. The 7/2014 Medication Administration Records were reviewed. The facility was unable to locate the page of the July Medication Record listing the [MEDICATION NAME]. There were no "[MEDICATION NAME] Side Effect Flow/Sheet Anti-Coagulant Therapy Signs and Symptoms" sheets completed in July. There were no PT/INR/[MEDICATION NAME] Flow Sheet" forms completed in July 2014 The 8/2014 Medication Administration Records were reviewed. [MEDICATION NAME] 10 milligrams was signed out as given daily at 5:00 p.m. There were no "[MEDICATION NAME] Side Effect Flow/Sheet Anti-Coagulant Therapy Signs and Symptoms" sheets completed in August. There were no PT/INR/[MEDICATION NAME] Flow Sheet" forms completed in August 2014. The 9/2014 Medication Administration Record indicated [MEDICATION NAME] 10 milligrams was last given on 9/8/14. There were no "[MEDICATION NAME] Side Effect Flow/Sheet Anti-Coagulant Therapy Signs and Symptoms" sheets completed in September. There were no PT/INR/[MEDICATION NAME] Flow Sheet" forms completed in September 2014. Review of the 5/2014 Laboratory test results indicated a PT/INR ( a blood test to monitor the clotting time of the blood) was completed on 5/12/14. The PT level was 15.4 and the INR level was 1.5. The results page indicated the resident was on [MEDICATION NAME] and the Physician had been notified on 5/12/14 at 3:30 p.m. and new orders were noted. Review of the 9/2014 Laboratory results indicated a PT/INR test was completed on 9/9/14 at 2:48 p.m. The PT level was > 120.0. This result was identified as a critical level. The INR level was 9.7. This result was identified as a critical level. The Physician was notified and orders were received for resident to receive Vitamin K (a medication to treat elevated PT/INR levels) 5 milligrams and to repeat another PT/INR level on 9/10/14. The results of the 9/10/14 PT/INR test indicated the PT level was 83.4 and the INR level was 6.9. Both of the levels were identified as critical levels. The Physician was notified of the results and orders were received for the resident to receive Vitamin K 5 milligrams on 9/10/14 and for a PT/INR level to be drawn on 9/11/14. The results of the 9/11/14 PT/INR test indicated the PT level was 14.7 and the INR level was 1.4. These results were not noted as high or critical. The Physician was notified and no new orders were received. The 9/2014 Resident Progress Notes completed by Nursing staff were reviewed. An entry made on 9/2/14 at 2:20 p.m. indicated the resident was being monitored for bleeding to the fistula and upon arrival the resident was noted with a pressure dressing to the left arm. No active bleeding was noted and the resident denied pain or discomfort. An entry made on 9/2/14 at 9:20 p.m., indicated the resident was being monitored for a pressure dressing noted to the left arm fistula. No active bleeding was noted and the resident had no complaints of pain or discomfort An entry made on 9/3/14 at 4:05 p.m., indicated monitoring continued for the pressure dressing to the left arm fistula site. The dressing was removed this shift and no active bleeding was observed. A Band-aid was applied. An entry made on 9/9/14 at 2:17 p.m. indicated a Stat PT/INR was drawn today due to bleeding at [MEDICAL TREATMENT]. The 9/9/14 "Pre/Post [MEDICAL TREATMENT] Communication" facility form was reviewed. The Pre-[MEDICAL TREATMENT] section was completed at 4:45 a.m. No bleeding was noted to the access/site. The [MEDICAL TREATMENT] Center section was completed by the [MEDICAL TREATMENT] Center Nursing staff at 6:11 a.m. This entry indicated redness was noted to the access/site. No bleeding was noted. The Post [MEDICAL TREATMENT] section was completed by the facility staff. The section noted bleeding. This entry was not signed or dated. Review of the 9/2/14 "Post Treatment" form completed at the [MEDICAL TREATMENT] Center indicated the Bleeding Stop time was 10. The 9/9/14 "Post Treatment" form completed at the [MEDICAL TREATMENT] Center indicated the Bleeding Stop time was 15. A "PT/INR/[MEDICATION NAME] Flow Sheet" form was reviewed. The form indicated the INR ranges for [MEDICAL CONDITIONS] treatment was 2.0-3.0. The form also indicated staff were to document the date/time of PT/INR levels, results of the PT/INR, the current dose of [MEDICATION NAME], Physician notification, dose change, and date next PT/INR was to be completed. A "[MEDICATION NAME] Side Effect Flow/Sheet Anti-Coagulant Therapy Signs and Symptoms" form was reviewed. The form indicated staff were to document "Y" (yes) or "N" (no) to the following every shift: Unusual bleeding, any noted bruising, rapid heart rate, abdominal tenderness, nausea, vomiting, bleeding of the gums, or none noted. A Mandatory Nursing Meeting was held on 9/22/14. The inservice record indicated staff were educated related to the following: -All residents on medications which put them at risk for bleeding were to have an Anticoagulant Flow Sheet in their Medication Record by Nursing staff. -Any resident receiving [MEDICATION NAME] must have a PT/INR weekly. Evening shift Nurses were responsible for this as they were the ones administering the medication. -When a resident is placed on an antibiotic, the Nurse who obtains the antibiotic order was responsible for getting PT/INR lab tests done three times a week. When interviewed on 10/10/14 at 10:53 a.m., the ADON (Assistant Director of Nursing) indicated she had spoken to staff at the [MEDICAL TREATMENT] Center and they informed her there were never any issues with the residents bleeding times noted above. The ADON also indicated the [MEDICAL TREATMENT] staff informed her the resident's bleeding times were considered normal. The ADON also indicated the [MEDICAL TREATMENT] staff also indicated if bleeding was present after [MEDICAL TREATMENT] they kept the resident until the bleeding was controlled and it is possible the ambulance staff could have told the facility the resident had bleeding when they returned her to the facility. When interviewed on 10/9/14 at 10:12 a.m., the Director of Nursing indicated a medication error for Resident #B was first noted on 9/9/14. The Director of Nursing indicated a Care Plan meeting was held for the resident on 9/9/14 and at the meeting staff reviewed the resident's current medications. They noted the 9/2014 Physician Order Statement indicated the resident was receiving [MEDICATION NAME] and upon further review it was determined the [MEDICATION NAME] had been discontinued in May 2014 per a Physician's order. The Director of Nursing indicated she spoke with Pharmacy the day the Medication Error was noted and was informed Pharmacy did not have a copy of the 5/12/14 or any of the June 2014 Physician Order Statements which would have identified the [MEDICATION NAME] had been discontinued on 5/12/14. The Director of Nursing also indicated she and the ADON began doing (10) audits a month of the monthly Physician Order Sheets and RN #2 was trained by watching audits as she was going to be the Nurse to check the Monthly Physician orders for all charts. The Director of Nursing indicated RN #1 had been responsible for checking each months Physician Order Sheet for discrepancies or errors. The RN had noted the June Physician order Statement noted the [MEDICATION NAME] order still appeared. RN #1 crossed out the order on the Physician Order Statement and the June MAR (Medication Administration Record) and wrote discontinued. The Director of Nursing indicated the Physician order for [REDACTED]. The Director of Nursing indicated the [MEDICATION NAME] 10 milligrams was given daily thru July 2014 and August 2014. The Director of Nursing indicated the Physician order for [REDACTED]. The [MEDICATION NAME] was discontinued on 9/9/14. The Director of Nursing indicated the Physician was notified at the time the medication error was discovered and orders were received. A head to toe assessment of the resident was completed and PT/INR laboratory tests were ordered. The Director of Nursing indicated 9/10/14 thru 9/12/14 Management staff reviewed every Physician Order Statement sheets for all the residents, not just those on [MEDICATION NAME]. No other [MEDICATION NAME] errors were found. The Director of Nursing also indicated on 9/15/14 they also went over Physician orders for all residents receiving [MEDICATION NAME] with Pharmacy. The Director of Nursing indicated a Mandatory inservice was held on 9/22/14 for all the Nurses. The Director of Nursing indicated on 9/15/14 they reviewed with Pharmacy the orders for each resident receiving [MEDICATION NAME] to verify they had not received any orders for the [MEDICATION NAME] to be discontinued. The Director of Nursing indicated PT/INR and Side effects for Anticoagulants flow sheets were not completed in July 2014 and August 2014. The Director indicated the above should have been done during all days Resident #B received [MEDICATION NAME] doses. The Director of Nursing indicated there were Physician orders for the weekly PT/INR levels to be drawn when the resident had been receiving [MEDICATION NAME] 10 milligrams daily and these orders were discontinued on 5/12/14 when the [MEDICATION NAME] was discontinued. The Director of Nursing also indicated she herself trained RN #2 to do the monthly Physician Order Statements after the error was made by RN#1 which resulted in the resident receiving the [MEDICATION NAME] in July, August and September 2014. The Director of Nursing indicated after the Medication Error was identified the facility started looking at lab results on Mondays, Tuesdays and Thursdays. The Director of Nursing indicated routine labs are drawn on Mondays, Wednesdays, and Friday and meeting on the above day would capture tests done on the scheduled days. The Director of Nursing also indicated a system was put into place for the Evening Shift Nurse to verify each night that all the [MEDICATION NAME] flow documents were completed. The facility policy titled "[MEDICATION NAME]" was reviewed on 10/10/14 at 10:12 a.m. The policy indicated residents receiving [MEDICATION NAME] were to be monitored for side effects and receive [MEDICATION NAME] (PT) studies and International Normalization Ratio (INR) studies regularly to determine the therapeutic dose. The policy indicated an INR above(4) had been "associated with a higher risk of bleeding without an increase in therapeutic benefit." For INR results of (4) or greater, the medication was to be held and the Physician was to be notified. The policy also indicated when an order for [REDACTED]. The MAR (Medication Administration Record) should noted the discontinued dose and then enter the new [MEDICATION NAME] dose on MAR. The policy also indicated the MAR and the "PT/INR [MEDICATION NAME] Flow Sheet" are to be initiated or updated. The Immediate Jeopardy that began on July 1, 2014 was removed on October 10, 2014 when the facility completed clinical audits for the current residents medication orders to ensure the medications were given as ordered and the required monitoring was being completed. The facility also completed inservicing to Licensed Nurses related to noting of Physician orders and the procedures to be followed for new orders including medication changes and monitoring of effects of the medications the residents were receiving. The facility Administrator verified effective 9/10/14 a new staff assumed the position for completing all monthly Physician order recaps with Nursing Administration managing the process with continued oversight by randomly auditing to ensure the Physician ordering process was followed. The survey team completed chart reviews related to unnecessary medications. Nursing staff interviews were completed to ensure staff knowledge of the identified plan outlined by the facility related to the Immediate Jeopardy citation and audits were reviewed. The noncompliance remained at the lower scope and severity of no actual harm with potential for more then minimal harm that is not Immediate Jeopardy because the facility remained out of compliance at the lower level due to the need of further monitoring and audits to be completed. 3.1-48(a)(3) 3.1-48(b)(2)

Based on record review and interview the facility failed to ensure a complete and accurate assessment was completed by the Registered Dietitian and failed to ensure the Registered Dietitian's recommendations for an appetite stimulant were followed which resulted in a significant weight loss for 1 of 3 residents reviewed for weight loss in the sample of 8. (Resident # H) Findings include: The closed record for Resident #H was reviewed on 11/23/13 at 9:26 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was hospitalized on the following dates: 05/27/13-05/31/13 06/12/13-06/18/13 07/01/13-07/11/13 10/30/13-11/05/13 The resident was readmitted to the facility after each of the above hospitalization s. The resident was discharged on [DATE]. The resident's Weight History record was reviewed. The following weights were recorded: 04/02/13-160 pounds 05/08/13-156 pounds 05/21/13-157 pounds 06/06/13-154 pounds 06/12/13-138 pounds 07/11/13-152 pounds 07/17/13-149 pounds 07/24/13-142 pounds 08/01/13-138 pounds 08/13/13-140 pounds 08/28/13-135 pounds 09/04/13-135 pounds 09/10/13-134 pounds 09/17/13-127 pounds 09/24/13-126 pounds 10/02/13-127 pounds 10/08/13-124 pounds 10/15/13-122 pounds 10/23/13-120 pounds 10/29/13-116 pounds The Nutritional Progress Notes from 5/2013 through 11/2013 were reviewed. The notes were all completed by the facility RD (Registered Dietitian). There were no RD Nutritional Progress notes completed in 5/2013. There was no RD assessment upon the resident's return from the hospital on [DATE]. The 6/2013 Nutritional Progress Notes were reviewed. The 6/19/13 Nutritional Progress Note indicated the resident returned to the facility after being hospitalized [DATE] - 6/18/13 with a new diet change. The resident was to receive a puree no added salt diet with nectar thick liquids. The note indicated the resident's weight was 154 pounds on 6/6/13 and showed a significant weight gain of 11.6 % in less then 30 days. The note also indicated the resident's [MEDICATION NAME] level was 2.3 on 6/18/13 and the resident also likely had a pressure ulcer at the buttock crease and the low [MEDICATION NAME] could have reflected depleted visceral protein. The RD's recommendations were for the resident to receive a Magic Cup(frozen ice cream supplement) twice a day and to discontinue the Ensure supplement (a liquid nutritional drink) previously ordered. The 6/19/13 Nutritional Progress Note did not address the 6/12/13 weight of 138 pounds which was 16 pound difference from the 154 pound weight used for the RD's nutritional assessment for the resident's dietary needs. The 7/18/13 Nutritional Progress Notes were reviewed. There was only one Nutritional Progress note completed by the RD. This noted was dated 7/18/13. The note indicated the resident was seen related to a hospital return. The note indicated the resident was hospitalized from [DATE] through 7/11/13 and multiple pressure ulcers were reported on the weekly wound report. The report indicated the weight report dated 7/17/13 (weight 149 pounds) noted the resident had a weight loss of (3) pounds. Recommendations were made for the resident to receive one can of thickened Ensure twice a day and a frozen nutritional treat. There were no further Nutritional Progress notes to address the 7/24/13 weight of 142 pounds (a loss of 7 pounds in one week). There was no RD noted complete upon the resident's readmission from the hospital on [DATE]. The 8/2013 Nutritional Progress Notes were reviewed. There were three notes completed by the RD. The first note was dated 8/1/13. This note indicated the resident current weight was 138 pounds per the weekly weight change report dated 7/17/13. The note also indicated a decline in the resident's wounds was noted. The RD recommendations include for the resident to receive a Multivitamin with mineral daily and to continue to monitor the weekly weights. The 8/22/13 Nutritional Progress Note indicated the resident's current weight was obtained on 8/1/13 and was noted to be 138 pounds. The note indicated the resident had a weight loss of 10% in less then 180 days, a loss of 11.5% in less then 90 days, and a loss of 9.2% in less then 30 days. The note indicated the weight loss was most likely due to decreased consumption of supplements and recommendations were for the resident to receive super cereal with a scoop of protein powder at breakfast and fortified mashed potatoes. The note did not address the 8/21/13 weight of 136 pounds. The 8/29/13 Nutritional Progress Note indicated the resident had new pressure ulcers and the wounds were being treated. The note also indicated a 8/23/13 pre-[MEDICATION NAME] level and [MEDICATION NAME] levels were low. The 8/29/13 note did not address the 8/28/13 of 135 pounds or the 8/21/13 weight of 135 pounds. The 9/2013 Nutritional Progress Notes were reviewed. There were two progress notes completed by the RD. The 9/20/13 note indicated the resident's current weight was 135 pounds on 9/4/13 and a significant weigh loss was noted. The recommendations were to continue the frozen treat and add super cereal with protein powder supplement. The note also indicated the resident's weekly weights and wound heeling were to be monitored. The note did not address the residents 9/17/12 weight of 127 pounds (a loss of 8 pounds from the 9/20/13 weight of 135 pounds. The 9/27/13 Nutritional Progress Note indicated the weekly wound report was reviewed and the resident had wound with the reports showing a decline in the wounds. Recommendations were to discontinue the Ensure and add Two Cal HN thickened twice a day and add Prostat. The note did not address the resident's 9/17/13 weight of 127 pounds or the 9/24/13 weigh of 126 pounds. The 10/2013 Nutritional Progress Notes were reviewed. There was one note entered for October. The 10/17/13 Nutritional Progress Note indicated the resident's weight on 10/8/13 was 124 pounds and the resident had a weight loss of 7.4% in 30 days and 18.4% in 90 days. The note indicted the resident's weekly weight history showed a weight of 134 pounds on 9/10/13, a weight of 152 pounds on 7/11/13, and a weight of 160 pounds on 4/2/13. The note also indicated the resident's oral intake had declined in the past week or two per the staff. The RD recommendations included for an appetite stimulant per the Physician and to follow weekly weights. This note did not address the 10/15/13 weight of 122 pounds. There were no further October 2013 RD notes to address the 10/23/13 weight of 120 pounds or the 10/29/13 weight of 116 pounds. The October 2013 Physician orders were reviewed. There was an order written [REDACTED].T.L (nectar thick liquid) consistency daily." The order did not contain the name of any appetite stimulant medication. The order was signed by the Physician on 10/20/13. There were no Physician orders for any type of appetite stimulant medication. The 11/2013 Nutritional Progress Notes were reviewed. The first note was entered on 11/8/13. This note indicated the resident was readmitted from the hospital on [DATE]. There was no weight listed for the 11/5/13 readmission. The note indicated the family did not want a PEG (Percutaneous Endoscopic Gastrostomy) tube placed for feeding and the resident was noted with multiple pressure ulcers. The note also indicated the resident was admitted on Hospice care on 11/5/13. The note also indicated the resident receive a nutritional frozen treat at 10:00 a.m. and Prostat (a protein supplement) 30 ml's (millimeters) twice a day to aid in wound heeling. The Monthly Flow Record for 11/6/13 through 11/9/13 was reviewed. The log indicated the resident consumed less then 25 % of the all three meals and less then 25 % of the AM and PM snacks on 11/6/13. No breakfast consumption was recorded for 11/7/13. The resident consumed less then 25% of his lunch meal on 11/7/13. The log indicated the resident was NPO (to receive nothing by mouth) for the dinner meal. The November 2013 Physician orders were reviewed. Orders were written on 11/8/13 for the resident to receive Prostat 30 ml's twice a day and a frozen nutritional treat once a day. The Director of Nursing and the Registered Dietitian (RD) were interviewed on 11/27/13 at 10:00 a.m. The Director of Nursing indicated the resident never received a medication to stimulate the appetite. The Director of Nursing indicated resident had been on other supplements which were thickened and believes the staff obtaining the order may have thought the appetite stimulant was coming from the kitchen. The RD indicated he wrote the recommendation for an appetite stimulant and was referring to a medication used to stimulate the appetite. The RD indicated the resident had significant weight loss and this recommendation for the appetite stimulant medication had not been addressed as the resident never received an appetite stimulant. The RD indicated the assessments made in the above months did not all have the most recent weights from for the resident at the time the resident's needs were assessed. The RD indicated there were weights lower then those referred to in his Progress Notes and those lower weights should have noted when assessing the residents' nutritional status. When interviewed on 11/27/13 at 7:55 a.m., the Director of Nursing indicated the RD comes in weekly on either Wednesdays or Thursdays. The Director of Nursing indicated the Dietary Manager notifies the RD of the weights. The facility policy titled "Weight Monitoring Clarification Protocol " policy was reviewed on 11/27/13 at 7:35 a.m. The policy was dated with a "last revised" date of 10/05/2012. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated weights were obtained within 24 hours of admission or readmission and were to recorded in the medical record and monthly weights were to done on the first Monday and Tuesday of every month. Physicians were to be notified of any significant weight changes by the end of Friday of that week. The policy also indicated The policy also indicated the DON or a designee were to review the weights for accuracy and then the list of weights was given to the Food Service Director by the end of the day. The policy titled "Nutrition Assessment Process" was reviewed on 11/26/13 at 2:00 p.m. The policy was dated with a "last revised" date of 7/23/2009. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated analysis of data is based on relevant information. The policy tilted "Nutrition Intervention Program Overview" was also provided by the Director of Nursing on 11/26/13 at 2:00 p.m. and identified as current. The policy indicated a systemic approach was to be used to identify and assess the resident's nutritional status and risk factors. This Federal tag relates to Complaint IN 156. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure the necessary treatment and services were provide to prevent the development of pressure ulcers and to promote healing of pressure ulcers related to accurately identifying the residents weight when assessing the residents nutritional need which resulted in a decline in wounds for 1 of 3 residents reviewed with ulcers in the sample of 8 (Resident #H) Findings include: The closed record for Resident #H was reviewed on 11/23/13 at 9:26 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was hospitalized for [REDACTED]. 05/27/13-05/31/13 06/12/13-06/18/13 07/01/13-07/11/13 10/30/13-11/05/13 The resident was readmitted to the facility after each of the above hospitalization s. The resident was discharged on [DATE]. The resident's Weight History record was reviewed. The following weights were recorded: 04/02/13-160 pounds 05/08/13-156 pounds 05/21/13-157 pounds 06/06/13-154 pounds 06/12/13-138 pounds 07/11/13-152 pounds 07/17/13-149 pounds 07/24/13-142 pounds 08/01/13-138 pounds 08/13/13-140 pounds 08/28/13-135 pounds 09/04/13-135 pounds 09/10/13-134 pounds 09/17/13-127 pounds 09/24/13-126 pounds 10/02/13-127 pounds 10/08/13-124 pounds 10/15/13-122 pounds 10/23/13-120 pounds 10/29/13-116 pounds The following Braden Scale for Predicting Pressure Sore Risk assessments were reviewed. The 7/11/13, 7/18/13, 7/25/13, and the 8/1/13 assessments all indicated the resident was at high risk for pressure sore development. The 10/1/13 and 10/10/13 assessments both indicated the resident was at high risk for the development of pressure sores. The resident's care plans were reviewed. A care plan initiated on 3/14/13 indicated the resident was at risk for pressure ulcers due to incontinence and a history of pressure ulcers. The care plan was updated on 6/10/13 related to the development of a Stage II (partial thickness loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer. The care plan was updated again on 8/16/13 related to the development of a blister to the resident's left calf. The care plan was updated again on 8/22/13 related to the development of ulcers to the feet, hips, sacrum, and the right gluteal fold. The care plan was last updated on 10/10/13 related to wounds on the ankle and a blister to the left side of the buttock. The target date on the care plan was 1/10/14. Care plan interventions included, but were not limited to, staff to observe the resident's nutritional status and dietary needs and to consult the Dietitian if needed, provide pressure relieving devices, minimize pressure on bony prominences, weekly skin assessments, and provide wound care as ordered by the Physician. The Pressure Ulcer Status Ulcer Records were reviewed. A Pressure Ulcer Status Record initiated on 7/11/13 indicated the resident had a Stage III(full thickness tissue loss with no bone or tendon exposed) ulcer to the sacrum upon readmission to the facility. The ulcer measured 4.0 cm (centimeters) x 2.0 cm x .2 cm. The ulcer remained a Stage III ulcer with the following measurements: 07/18/13- 3.0 cm x 2.0 cm x .2 cm 07/25/13- 3.0 cm x 2.0 cm x .2 cm 08/01/13- 5.0 cm x 2.0 cm x .5 cm 08/08/13- 5.0 cm x 2.0 cm x .5 cm 08/15/13- 5.0 cm x 2.0 cm x .5 cm 08/22/13- 11.0 cm x 7.0 cm x undetermined depth- Physical Therapy picked up treatment. 09/05/13- 11.4 cm x 4.8 cm x undetermined depth 09/12/13- 10.5 cm x 4.8 cm x 3.0 cm 09/19/13- 10.1 cm x 4.7 cm x 3.9 cm 09/26/13- 10.0 cm x 5.0 cm x 3.9 cm 10/03/13- 9.9 cm x 5.0 cm x 3.9 cm- The ulcer was now Unstageable 1010/13- 9.9 cm x 5.0 cm x 3.9 cm (undetermined)- Unstageable 10/17/13- 8.3 cm x 5.0 cm x 3.0 cm (undetermined)- Unstageable 10/24/13- 8.2 cm x 3.9 cm x 3.9 cm (undetermined)- Unstageable A Pressure Ulcer Status Record initiated on 7/11/13 indicated the resident had a Stage II ulcer to the right hip upon readmission to the facility. The ulcer measured 1.5 cm x 4.0 cm. x <0.1 cm. The ulcer remained a Stage II with the following measurements: 07/18/13- .5 cm x .5 cm x <0.1 cm 07/25/13- .5 cm x .5 cm x <0.1 cm 08/01/13- 3.0 cm x 2.0 cm x undetermined depth- The ulcer was now staged as Unstageable. 08/08/13- 3.0 cm x 2.0 cm x undermined depth 08/15/13- 3.0 cm x 2.0 cm x undermined depth 08/22/13- 3.0 cm x 3.0 cm x undermined depth 08/29/13 - 3.5 cm x 3.8 cm x 1.9 cm undetermined depth- Physical therapy treating. 09/05/13- 3.8 cm x 4.0 cm x 1.9 cm undetermined depth 09/12/13- 3.5 cm x 3.0 cm x 1.0 cm undetermined depth 09/19/13- 3.2 cm x 3.9 cm x undetermined depth 09/26/13- 3.2 cm x 3.9 cm x undetermined depth 10/03/13- 3.2 cm x 3.5 cm x 0.5 cm- The ulcer was now a Stage III 10/10/13- 3.2 cm x 3.5 cm x 0.5 cm 10/17/13- 3.2 cm x 3.4 cm x 0.3 cm 10/24/13- 3.0 cm x 3.4 cm x 0.3 cm The 7/30/13 Pressure Ulcer Status Record indicated a Stage II pressure ulcer was first observed on the right gluteal fold area. The pressure ulcer measured 2.3 cm x 1.0 cm x <.1 cm. The ulcer remained a Stage II ulcer with the following measurement documented: 08/08/13- 2.0 cm x 1.0 cm x .1 cm 08/15/13- 2.0 cm x 2.0 cm x 1.0 cm The ulcer was declined to a Stage III ulcer with the following measurements documented: 08/22/13- 4.0 cm x 3.5 cm x 1.0 cm 08/29/13- 4.0 cm x 3.8 cm x undetermined depth (1.9 cm) 09/05/13- 4.0 cm x 3.5 cm x undetermined depth (2.4 cm) 09/12/13- 4.0 cm x 3.5 cm x undetermined depth 09/17/13- 3.5 cm x 3.5 cm x undetermined depth 0926/13- 3.5 cm x 3.5 cm x undetermined depth 10/03/13- 3.4 cm x 3.4 cm x undetermined depth 10/10/13- 3.4 cm x 3.4 cm x 2.1 depth 10/17/13- 5.0 cm x 5.0 cm x undetermined depth 10/24/13- 5.0 x 5.0 cm x undetermined depth The 8/29/13 Pressure Ulcer Status Record indicated an Unstageable ulcer was first observed on the right foot/ankle. The ulcer measured 2.0 cm x 2.0 cm x undetermined depth and was purple in color. The ulcer remained Unstageable with the following measurements: 09/05/13- 2.0 cm x 2.0 cm x undetermined depth 09/12/13- 2.0 cm x 2.0 cm x undetermined depth 09/19/13- 2.3 cm x 2.0 cm x undetermined depth 9/26/13- 3.0 cm x 2.0 cm x undetermined depth 10/03/13- 2.5 cm x 2.0 cm x undetermined depth 10/10/13- 2.0 cm x 2.0 cm x undetermined depth 10/17/13- 2.0 cm x 2.0 cm x undetermined depth The ulcer was staged as a Stage II starting on 10/24/13. 10/24/13- 2.0 cm x 2.0 cm x .2 cm 10/30/13- 2.0 cm x 2.0 cm x .2 cm The 8/2013 Physician orders [REDACTED]. The order indicated the treatment was to include selective and sharp debridement. The 10/2013 Physician orders [REDACTED]. Physical Therapy was to continue with selective and sharp debridement. The Nutritional Progress Notes were reviewed. The Progress Notes were all completed by the RD (Registered Dietitian). A Nutritional Progress Note was completed by the RD on 7/18/13. This was the only noted completed in July 2013. The note indicated the resident was hospitalized [DATE] through 7/11/13 and the July pressure ulcer report indicated the resident had multiple pressure ulcers. The note indicated the weight report dated 7/17/13 (weight 149 pounds) noted the resident had a weight loss of (3) pounds with no significant weight loss. The above note indicated the resident's nutritional needs were not assessed by the RD until one week after readmission. The next Nutritional Progress Note was completed on 8/1/13. The note indicated there was a decline in the resident's current pressure ulcers to the right hip and sacrum. A new Stage II pressure ulcer was observed to the right gluteal fold. The note also indicated the resident's most recent weight was 149 pounds. The note also indicated the [MEDICATION NAME] level was low at 2.1. Recommendations were made for the resident to receive Ensure (a liquid nutritional supplement) one can twice a day and a frozen nutritional treat twice a day. The plan indicated to continue to monitor the resident's oral intake and wound healing progress. The note did not address the resident's 8/1/13 weight recorded on the Weight History report which was 138 pounds. This indicated the nutritional assessment for wound healing was based on a weight 11 pounds less then the resident's actual weight. The next Nutritional Progress Note was completed on 8/22/13. This note indicated the resident's current weight was 138 pounds and this weight was obtained on 8/1/13. The note also indicated the resident had a 9.2% weight loss in the last 30 days. The note also indicated the wounds to the resident's right hip and sacrum had declined. This 8/22/13 note did not address the weight of 136 pounds recorded on 8/21/13 on the Weight History report. The next Nutritional Progress Note was completed on 8/29/13. This note indicated the resident's wounds were still present with a decline noted in the wounds. There was no documentation of the resident's weight in this note. This RD progress not did not address the weight of 135 pounds recorded on 8/28/13 on the Weight History report. The next Nutritional Progress note was completed on 9/20/13. This note indicated the resident's current weight was 135 pounds on 9/4/13. A weight loss of 12.3% was noted in the last 90 days. The note also indicated the resident had multiple wounds and the weight loss was related to excessive protein energy needs due to the active wounds. This RD progress note did not address the 9/10/13 weight of 134 pounds or the 9/17/13 weight of 127 pounds on the Weight History report. The 9/17/13 weight of 127 pounds indicated the 9/20/13 RD assessment was based on a weight 7 pounds greater then the resident's actual weight of 127 pounds. The 10/17/13 Nutritional Progress Note indicated the resident had a weight loss of 7.4% in the last 30 days per the October 2013 weight change report. The 10/4/13 weight was 124 pounds. The note also indicated the resident had multiple wounds and the resident's oral intake had declined in the past week or two per the staff. The RD progress note did not address the 10/15/13 weight of 122 pounds recorded on the Weight History Report. When interviewed on 11/27/13 at 10:00 a.m., the Registered Dietitian indicated the resident had multiple wounds. The Registered Dietitian also indicated the current weight should have been addressed when assessing the resident's nutritional needs for healing. The Registered Dietitian also indicate the resident was not assessed at the time of the [DATE] readmission. The facility policy titled "Evaluations, Screening, and Assessments" from Chapter 2 of the "Pressure Ulcer Care Guide" was reviewed on 11/27/13 at 2:00 p.m. The policy was dated with a last revised date of 10/07/2010. The Director of Nursing provided the policy and identified the policy as current. The policy indicated all disciplines were to be alerted immediately if residents have skin breakdown. The policy also indicated information is reviewed upon admission and included an evaluation of the resident's dietary needs. The facility policy titled "Nutrition and Wounds" was also reviewed on 11/26/13 at 2:00 p.m. The policy was dated with a revised date of 7/23/2009. The Director of Nursing provided the policy and identified the policy as current. The policy indicated all residents identified with pressure ulcers were to be assessed by the RD per facility guidelines. The policy also indicated the RD was to assess resident's with Stage I-IV pressure ulcers and protein and calorie needs were to be compared with the actual intake for all wound stages. This Federal tag related to Complaint IN 156. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident with an acquired Stage Three pressure ulcer received the necessary treatment and services to promote healing related to providing nutritional interventions and changing treatment before the pressure ulcer deteriorated and increased in size for 1 of 3 residents reviewed for pressure ulcers in the sample of 13. (Resident #B) Findings include: The closed clinical record for Resident #B was reviewed on 4/4/12 at 9:00 a.m. The resident's [DIAGNOSES REDACTED]. Review of Nursing Progress Notes dated 9/26/11 at 8:00 p.m., indicated the CNA had reported to the nurse the resident had a pressure sore on her coccyx. Review of the Pressure Ulcer Status Record indicated the pressure ulcer was actually to the right buttock and was evaluated by the wound nurse on 9/27/11 and measured at that time. The pressure ulcer was identified as a Stage Three area that measured 1 centimeter (cm) by .5 cm. and the depth was undetermined. The pressure ulcer was 100% yellow slough (necrotic tissue). The pressure ulcer was then measured weekly with following measurements: 10/4/11: 1 cm by 1 cm by undetermined with 100% yellow slough and a scant amount of drainage. 10/12/11: 2 cm by 1 cm by undetermined with 100% yellow slough and no drainage. 10/19/11: 3 cm by 2 cm by undetermined with 100% yellow slough and no drainage. 10/26/11: 2.5 cm by 2 cm by undetermined with 90% yellow slough and 10% red tissue with no drainage 11/3/11: 3 cm by 2 cm by undetermined with 90% yellow slough and 10% red tissue. 11/10/11: 4 cm by 2.6 cm by undetermined with scant amount of drainage, with a side note from the wound nurse that wound had been debrided by a Wound Physician. The pressure ulcer at this time was now classified as being undetermined in Stage. 11/17/11 5.5 cm by 4 cm by undetermined and 100% black with small amount of drainage. Further review of the Pressure Ulcer Status Record indicated the wound nurse had indicated the pressure ulcer's "Response to Treatment" had deteriorated on 10/4, 10/12, 10/19, 11/10, and 11/17/11. Continued review of the Pressure Ulcer Status Record indicated there was documentation by the wound nurse the resident's Physician and Family were notified each week. Review of Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) for the month of 9/11 indicated the treatment was signed out as being completed on 9/27, 9/29, and 9/30/11. The same treatment was signed out as being completed for the entire month of 10/11 with no change in treatment. Review of the 11/11 TAR indicated the same treatment continued from 11/1-11/15/11. Review of the quarterly 9/15/11 Minimum Data Set Assessment indicated sometimes understood and sometimes understands and the resident made poor decisions and had memory problems. The resident needed extensive assist with a two person physical assist with bed mobility, transfers, and toilet use. The resident was always incontinent of bladder and bowel and there was no toileting program in place. The resident was coded as being at risk for pressure ulcers but currently did not have any pressure ulcers. Review of the Braden Scale Assessment (an assessment used for pressure ulcer) dated 9/13/11 indicated the resident's score was a 15 indicating she was at risk for developing a pressure ulcer. Another assessment was completed on 9/17 and 9/27/11 which indicated the resident's scores were 14 for both assessment. This indicated the resident was a "moderate risk" for developing a pressure ulcer. A score of nine or below indicated the resident was a "very high risk" for developing a pressure ulcer. Review of physician progress notes [REDACTED]. Review of laboratory results indicated on 9/26/11 electrolytes were obtained for the resident and they were within normal limits. Further review of laboratory results indicated there were no other labs completed after 9/26/11 and for the month of 10/11. A physician's orders [REDACTED]. Review of the laboratory results dated [DATE] indicated the CMP was completed and the [MEDICATION NAME] level was 3.2 (3.4-5.2 was normal) and the resident's total protein level was 5.8 (6.4-8.3 was normal) Review of physician's orders [REDACTED]. Review of Nursing Progress Notes dated 11/10/11 (two days later) indicated the Foley catheter was inserted. Review of the Foley justification assessment dated [DATE] indicated the resident may have an urinary catheter 16 French for a Stage three or four pressure ulcer. Review of Physician order [REDACTED]. Review Dietary Progress Notes by the Registered Dietician (RD) dated 10/3/11 indicated the resident was seen for the development of a stage three pressure sore to the right buttock. The dietician indicated the resident was receiving a healthshake at breakfast, supercereal at breakfast, super soup at lunch and dinner and her weight was 140 pounds. The RD further indicated the resident was receiving a therapeutic vitamin daily and her estimated needs for healing were within normal limits. The RD did not address any lab values nor did she make any recommendations at that time. Further record review indicated the resident was seen in a weekly Nutrition Intervention Program (NIP) for her pressure ulcer. A NIP note dated 10/6/11 indicated the wound had declined and the new intervention was to lay down after meals. The next NIP note was on 10/20/11 which indicated the wound had declined with the interventions of continue to monitor oral intake. The next NIP noted dated 11/3/11 indicated the wound has declined with the intervention of will have the RD to assess. The last NIP note was on 11/10/11 which indicated the wound continues to decline, wound Physician debrided wound, and Foley catheter inserted. There were no nutritional interventions documented or recommended at that time. Review of Dietary Progress Notes by the RD dated 11/3/11 indicated the resident's stage three pressure ulcer continues to decline. The RD addressed the same supplements as above and recommended the CMP lab draw. The next RD Dietary Progress Note by the RD was dated 11/10/11 which indicated the resident's pressure ulcer continues to decline. The RD recommended Prostat (a protein supplement used to promote wound healing) 30 milliliters daily. Review of Nursing Progress Notes for the month of October 2011 indicated there were two entries one on 10/6/11 which indicated the resident was seen in NIP and the wound had declined and the other was on 10/20/11 which indicated the resident was reviewed in NIP and the wound had declined. Review of Wound Professional Assessment completed by the Wound Physician dated 11/8/11 which was the initial assessment indicated the resident had an unstageable pressure ulcer to the sacrum. The area measured 4.1 cm by 2.6 cm. by .8 cm and had 100% of yellow necrotic tissue on it. At that time, the Wound Physician debrided the area at the resident's bedside. The Wound Physician had seen the resident again on 11/15/11 and wound measured 5.5 cm by 4.0 cm by 2.6 cm and had 100% necrotic tissue. The wound was again debrided by the Physician and the treatment was changed at this time. The Wound Physician had now made the recommendation the resident see a surgeon for inpatient debridement of the wound. The resident's primary Physician was notified and new orders were obtained. The resident was directly admitted to the hospital on [DATE] for surgical debridement of the pressure ulcer. Review of the current 7/23/09 Nutrition and Wounds policy provided by the Director of Nursing indicated for Stage three and four pressure ulcers, calorie needs are usually 35-40 calories and protein needs are usually 1.2-1.5 grams. Some residents may need protein up 2.0 grams after assessing visceral protein status. A vitamin C fortified Juice that is provided three times daily provides the same amount of vitamin C than that of 500 milligrams of Vitamin C tablet daily. Assessment/interventions are revised as needed if there is no progress or there is decline and when the wound heals. Interview with the Wound Nurse on 4/4/11 at 11:00 a.m., indicated she did not perform the treatment to the resident's buttock/coccyx area everyday, it was her responsibility to measure the wounds on a weekly basis. She indicated she made no recommendations for any other type of interventions to promote wound healing for the resident until November 8, 2011, after the Wound Physician had seen the resident. She indicated a Foley catheter was ordered at that time, labs were done and the RD had made additional recommendations to promote healing. Interview with the Director of Nursing on 4/4/11 at 11:22 a.m., indicated there were no other interventions to promote wound healing for the acquired stage three pressure ulcer until after the wound had significantly declined. This Federal Tag relates to Complaint IN 301. 3.1-40(a)(2)