Every finding on record at Health Center at Glenburn Home

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 1 residents reviewed for urinary catheters. The urinary catheter drainage bag was touching the floor. (Resident 72)Findings include: On 8/26/25 at 3:06 p.m., Resident 72 was observed to be resting in a low bed. The urinary catheter drainage bag was observed to be hanging on the side of the low bed and was touching the floor. On 8/27/25 at 9:13 a.m., Resident 72 was observed to be resting in a low bed. The urinary catheter drainage bag was observed to be hanging on the side of the low bed and was touching the floor. On 8/28/25 at 9:43 a.m., Resident 72 was observed to be resting in a low bed with a mattress beside the bed. The urinary catheter drainage bag was observed to be lying on the mattress beside the bed. On 8/28/25 at 10:09 a.m., Resident 72's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, diabetes mellitus, and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Resident 72's physician orders indicated the following:-Change 16 FR (French) (size of catheter) catheter with a 30 cc (cubic centimeter) balloon monthly due to urinary retention. (start date 3/15/24) -Catheter care every shift. (start date 3/9/24) -Maintain patency of catheter and catheter tubing free from kinking. Ensure catheter is cleansed with soap and water daily. (start date 3/9/24). Resident 72's care plan, undated, indicated he had a catheter for neuromuscular dysfunction of the bladder. The care plan lacked documentation of the placement of the catheter while in bed. During an interview on 8/28/25 at 1:35 p.m., Certified Nursing Assistant (CNA) 1 indicated they hung the drainage bag from the bed. The drainage bag was not to touch the floor. On 8/28/25 at 3:00 p.m., the Director of Nursing (DON) provided the facility's policy, Catheter Care, dated 4/3/25, and indicated it was the policy currently being used by the facility. The policy lacked documentation of the placement of the drainage bag while in bed. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed for significant weight loss. (Resident 10)Findings include:On 8/27/25 at 2:49 p.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, Parkinson's disease (a progressive neurological disorder affecting movement), congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), and type 2 diabetes (a chronic condition where your body becomes resistant to insulin).A review of the quarterly MDS assessment, dated 8/18/25, section K0300: Weight Loss was marked No for a significant weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days. A review of a Quarterly Nutrition Note, dated 8/18/25, indicated the Resident 10's most recent weight on 8/18/25 was 120.6 pounds (lbs) and the resident's weight 180 days prior, on 2/18/25, was 134 lbs. The percentage of weight loss in 180 days was 10%.During an interview with the MDS Coordinator and the Dietician on 8/28/25 at 2:22 p.m., they indicated the resident did have a significant weight loss of 10% or more in the last 6 months. The Dietician indicated this was not a provider prescribed weight loss regimen and the Quarterly MDS Assessment should have been marked yes for weight loss.During an interview with the MDS Coordinator on 8/28/25 at 2:35 p.m., she indicated the facility used the Resident Assessment Instrument (RAI) manual for coding the MDS Assessment and they also had a MDS policy.A review of the RAI manual on 8/28/25 at 3:00 p.m., indicated for section K0300: Weight Loss, .Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician .On 8/28/25 at 3:00 p.m., the Assistant Director of Nursing (ADON) provided a copy of the facility policy MDS Policy and Procedure, dated 7/15/25, she indicated this was a policy currently being used by the facility. The policy indicated .Follow the RAI manual instructions when completing MDS Assessments.3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure sit to stand lift foot platforms were clean for 4 of 4 sit to stand lifts observed. Findings include: 1. On the following dates and times, a non-mechanized sit to stand lift was observed in the hallway outside of room [ROOM NUMBER] with the foot platform containing food crumbs and debris: - On 9/27/24 at 10:10 a.m. - On 9/30/24 at 1:20 p.m. - On 10/1/24 at 11:45 a.m. 2. On the following dates and times, a non-mechanized sit to stand lift was observed in the hallway outside of room [ROOM NUMBER] with the foot platform containing food crumbs and debris: - On 9/27/24 at 10:20 a.m. - On 9/30/24 at 1:30 p.m. - On 10/1/24 at 11:55 a.m. 3. On the following dates and times, a mechanized sit to stand lift was observed in the hallway outside of room [ROOM NUMBER] with the foot platform containing food crumbs and debris: - On 9/27/24 at 10:25 a.m. - On 9/30/24 at 1:35 p.m. - On 10/1/24 at 11:58 a.m. 4. On the following dates and times, a non-mechanized sit to stand lift was observed in the hallway next to the Unit 500 soiled utility room with the foot platform containing food crumbs and debris: - On 9/27/24 at 10:30 a.m. - On 9/30/24 at 1:40 p.m. - On 10/1/24 at 12:02 .p.m During an interview on 10/1/24 at 3:00 p.m., the Administrator indicated the foot platforms of the sit to stand lifts were in need of cleaning before resident use. On 10/1/24 at 3:40 p.m., the Assistant Director of Nursing provided the Resident Rights, revised date 3/5/24, and indicated this was the Resident Rights policy used by the facility. A review of the policy indicated, .the resident has the right to a safe, clean, comfortable and homelike environment . 3.1-19(f)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 residents reviewed for Resident Assessment. (Resident 40) Finding includes: During an interview on 9/26/24 at 10:51 a.m., Resident 40 indicated she had limitation of her upper and lower extremities and staff assisted her with range of motion (ROM) exercise. On 9/30/24 at 3:15 p.m., Resident 40's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), right side hemiparesis (partial paralysis on one side of the body), and contracture (shortening of muscles that causes joints to stiffen). The Annual MDS assessment, dated 9/6/24, indicated Resident 40 was cognitively intact, had impairment on one side of her upper and lower extremity, had no days that PROM was preformed for at least 15 minutes a day, and had no days that AAROM was performed for at least 15 minutes a day. The Passive Range of Motion (PROM) Report, dated 9/1/24-10/1/24, indicated the following: - On 9/3/24 at 2:59 p.m., Resident 40 had 15 minutes of PROM. - On 9/4/24 at 2:59 p.m., Resident 40 had 15 minutes of PROM. -On 9/5/24 at 2:59 p.m., Resident 40 had 15 minutes of PROM. The Active Assisted Range of Motion (AAROM) Report, dated 9/1/24-10/1/24, indicated the following: - On 9/3/24 at 2:59 p.m., Resident 40 had 15 minutes of AAROM. -On 9/4/24 at 2:59 p.m., Resident 40 had 15 minutes of AAROM. -On 9/5/24 at 2:59 p.m., Resident 40 had 15 minutes of AAROM. The Restorative Nursing Progress Notes, dated 9/6/24, indicated Resident 40 received AAROM and PROM restorative program three times a week. During an interview on 10/1/24 at 9:35 a.m., the MDS Coordinator indicated the MDS assessment should of been coded for the three days Resident 40 received PROM and AAROM. On 10/1/24 at 3:42 p.m., the Assistant Director of Nursing (ADON) indicated they did not have a MDS assessment coding policy. They followed the Resident Assessment Instrument (RAI) manual for coding the MDS assessment. 3.1-31(d)

Based on observation, record review, and interview, the facility failed to provide respiratory care for 1 of 3 residents reviewed for oxygen therapy. Oxygen tubing and humidification water bottles were not labeled with a date. (Resident 26) Finding includes: On 9/26/24 at 10:15 a.m., Resident 26 was observed lying in bed with oxygen (O2) being administered via nasal cannula (NC) at 4 liters (L). There was no date observed on the NC tubing or humidification water bottle. On 9/26/24 at 1:52 p.m., Resident 26 was observed lying in bed with O2 being administered via NC at 4 L. There was no date observed on the NC tubing or humidification water bottle. On 9/27/24 at 10:30 a.m., Resident 26 was observed standing at bedside with oxygen being administered at 4 L via NC, no date observed on the NC tubing or humidification water bottle. On 9/30/24 at 9:15 a.m., Resident 26 was observed lying in bed with oxygen in use. There was no date observed on the NC or humidification water bottle. On 10/1/24 at 9:49 a.m., Resident 26 was observed lying in bed with oxygen in place at 4 L via NC. There was no date observed on the NC or humidification water bottle. On 9/27/24 12:51 p.m., Resident 26's clinical record was reviewed. The diagnoses included, but not limited to, Chronic Obstructive Pulmonary Disease (COPD), Type 2 diabetes mellitus, and dementia. The quarterly Minimum Data Set (MDS) assessment, dated 7/5/24, indicated Resident 26 received oxygen therapy. The care plan, revised on 10/30/23, indicated Resident 26 had oxygen therapy related to respiratory illness. The care plan indicated to change O2 nebulizer, tubing, and humidifier weekly. A physician's order, dated 4/15/24, indicated titrate oxygen to keep saturations greater than 92% on 2-5L per NC every shift. A physician's order, dated 9/6/24, indicated O2 tubing and humidified water change every week, night shift every Friday for oxygen usage. During an interview on 10/1/24 at 10:20 a.m., the Director of Nursing (DON) indicated Resident 26 had current order for oxygen therapy. The DON indicated that they changed the tubing and humidification bottle each week. The DON indicated the date should be written on the tubing and bottle. The DON indicated there was no date noted on nasal cannula tubing and humidification water bottle. On 10/1/24 at 2:30 p.m., the Assistant Director of Nursing (ADON) provided the facility policy, Oxygen Administration, dated 1/8/24, she indicated it was a policy currently being used. A review of the policy indicated, .5. Staff shall perform hand hygiene and don gloves when administering oxygen .Other infection control measures include: .b. change oxygen tubing and mask/cannula weekly .c. change humidification bottle every 72 hours or per facility policy, or as recommended by manufacturer . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 3 of 3 kitchen observations. Expired food was not discarded, juice in damaged cans were not separated for return, and food was stored beneath a leaking condenser. Findings include: During tours of the facility kitchen on [DATE] at 1:55 P.M., [DATE] at 10:45 A.M., and [DATE] at 12:30 P.M., the following was observed: 1. On a shelf in the walk-in refrigerator were two 5 pound containers of cottage cheese with the best by date of [DATE]. 2. In the walk-in freezer, beneath a condenser upon which water had leaked and formed ice was an open 29.7 pound box of biscuit dough upon and within which ice had fallen. 3. In the kitchen dry stock room, on the shelving unit upon which multiple canned goods were stored for consumption were three 46 ounce cans of pineapple juice. The double seal edges of the cans were deeply dented. During an interview on [DATE] at 2:20 P.M., the facility administrator indicated the expired cottage cheese should have been discarded, food should not have been stored beneath a leaking condenser, and the dented cans of pineapple juice should have been removed from the canned goods shelving unit. On [DATE] at 10:22 A.M., the facility administrator provided the Food and Supply Storage policy, revised date of [DATE] and indicated this was the policy used by the facility. A review of the policy indicated, .foods past the .best by date should be discarded .maintain designated area for items that are damaged (such as dented cans) . On [DATE] at 1:05 P.M., a review of the Indiana State Department of Health Retail Food Establishment Sanitation Requirements manual, effective date [DATE] indicated, .410 IAC [DATE] Food storage; prohibited areas Sec. 178. (a) Food may not be stored as follows: .(2) Under the following: .under lines on which water has condensed .410 IAC [DATE] .products that are held by the owner or operator in a retail food establishment for credit, redemption, or return to the distributor, such as damaged .products, shall be segregated and held in designated areas that are separated from (1) food . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident and the resident representative for 2 of 3 residents reviewed. (Resident 43, Resident 89) Findings include: 1. On 10/30/23 at 11:42 a.m., Resident 43's clinical record was reviewed. The diagnosis included, but was not limited to Alzheimer's disease with late onset. Resident 43's progress notes indicated the resident was sent to the hospital on 6/29/23. The Notice of Transfer or Discharge forms dated 6/29/23, lacked documentation the resident and the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the Office of the State LTC (Long Term Care) Ombudsman, after the resident was sent out to the hospital. 38312 2. On 10/30/23 at 11:35 a.m., Resident 89's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and depression. Resident 89's progress note, dated 10/3/23 at 8:26 a.m., indicated she was transferred to another facility. The clinical record lacked documentation of the resident or the resident's representative being notified in writing the reason of the transfer. During an interview on 10/30/23 at 1:10 p.m., the Administrator indicated the Notice of Transfer or Discharge forms were not sent to the representative in writing. The representative would be notified verbally by phone when a resident was transferred to the hospital. The forms would be sent when the resident goes to the hospital but there was no documentation the resident received it in writing. On 10/30/23 at 1:30 p.m., the Administrator provided the facility policy, Bed Hold and Return to Facility Policy and Procedure, undated and indicated this was the policy currently being used by the facility. A review of the policy indicated .The nurse will obtain the Bed Hold Policy and Return to Facility notice and provide the notice to the resident and their representative at the time of transfer or leave of absence .The nurse will inform the resident representative, on the telephone if necessary, about the bed hold and return to the facility policy and ask how best to provide a copy of notice to the representative . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for residents who transferred to the hospital was provided in writing to the resident or the residents representative for 1 of 2 residents reviewed for hospitalization . (Resident 43) Findings include: On 10/30/23 at 11:42 a.m., Resident 43's clinical record was reviewed. The diagnosis included, but was not limited to, Alzheimer's disease with late onset. Resident 43's progress notes indicated the resident was sent to the hospital on 6/29/23. There was no documentation that a written notice that specified the facility's bed-hold policy forms were provided to the resident or the resident's representative. During an interview on 10/30/23 at 1:10 p.m., the Administrator indicated the bed-hold policy forms were not sent to the representative in writing. The representative would be notified verbally by phone when a resident was transferred to the hospital. The forms would be sent when the resident goes to the hospital but there was no documentation the resident received it in writing. On 10/30/23 at 1:30 p.m., the Administrator provided the facility policy, Bed Hold and Return to Facility Policy and Procedure, undated and indicated this was the policy currently being used by the facility. A review of the policy indicated, . The nurse will obtain the Bed Hold Policy and Return to Facility notice and provide the notice to the resident and their representative at the time of transfer or leave of absence .The nurse will inform the resident representative, on the telephone if necessary, about the bed hold and return to the facility policy and ask how best to provide a copy of notice to the representative . 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to identify and respond to an assessed weight loss and failed to implement interventions for 1 of 2 residents reviewed for nutrition. (Resident 61) Findings include: Resident 61's clinical record was reviewed on 10/26/23 at 10:00 a.m. The diagnoses included, but were not limited to, dementia and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], assessed Resident 61 as being extensive assistance of 1 with eating. Resident 61's weights indicated the following: - On 8/1/23, the resident weighed 121.8 pounds. - On 9/1/23, the resident weighed 122.6 pounds. - On 10/4/23, the resident weighed 122 pounds. - On 10/16/23, the resident weighed 114.8 pounds. - On 10/17/23, the resident weighed 114.8 pounds. This was an assessed 5.90 percent weight loss in 12 days. The clinical record for Resident 61 lacked documentation of an assessment or implementation of a nutritional intervention after the resident was noted to have a weight loss on 10/16/2023. During an observation on 10/26/23 at 12:07 p.m., Resident 61 was observed to be sitting at a table in the dining room. The meal contained a tenderloin sandwich, ice cream, french fries, peach crisp and a coke. Resident 61 was feeding herself but only ate a small amount of ice cream before trying to stand up and roll away from the table in her wheelchair. Certified Nursing Aide (CNA) 1 attempted to have the resident sit back down and finish her meal but was unsuccessful. CNA 1 did not attempt to assist the resident with eating. The resident eventually rolled away in her wheelchair down the hall. During an observation on 10/26/23 at 12:14 p.m., CNA 2 was observed to bring Resident 61 back to the table to finish her meal. CNA 2 was observed to tell Resident 61, I have a cup of coffee for you and that would taste good with the peach crisp wouldn't it? The resident replied, yes. CNA 2 fed a bite of the peach crisp to Resident 61 and then walked off saying, enjoy. Resident 61 was observed to immediately roll away from the table and down the hall. During an observation on 10/27/23 at 12:12 p.m., Resident 61 was observed to be sitting at a table in the dining room. The meal contained beef stew, pie, a roll, ice cream, coffee and coke. Resident 61 was feeding herself and ate 100% of the pie, 1/2 carton of ice cream and 1 bite of the roll before trying to stand up and roll away from the table. Staff were not observed trying to assist resident with feeding or attempting to get her to keep eating. During an interview on 10/27/23 at 10:30 a.m., the Director of Nursing (DON) indicated the computer system would trigger a weight loss and would generate a report for them to discuss in morning meeting. The dietician would also run a report on all the residents in the facility. During an interview on 10/30/23 at 10:23 a.m., the DON indicated they weighed Resident 61 on 10/16/23 and noticed she had a weight loss. She ordered a reweigh for 10/17/23. She was unable to find any notes in the computer for recommendations and contact with the dietician. During an interview on 10/30/23 at 10:58 a.m., the Dietician indicated she was just looking at Resident 61 that morning for weight loss because she was a monthly weight and had been consistent with her weight for a long time. She did not have any recent progress except for the Quarterly evaluation on 10/3/23 when she had not lost the weight yet. She planned to put interventions in for her weight loss today. On 10/30/23 at 11:30 a.m., Resident 61's clinical record was revewed. A progress note dated 10/30/23 at 10:49 a.m., indicated, . Resident discussed in NAR [Nutrition at Risk] on 10/17/23 r/t [related to]wt [weight] loss of 7.8# in 30 days. Reweight obtained and is congruent with previous wt. Intake is sporadic with meal consumption averaging 26-50%. RD [Registered Dietician] spoke to nursing about resident preferences. House supps [supplements] ordered TID [three times a day] with meals as resident likes to walk around during meals. Will add he [sic] to NAR for closer monitoring . During an interview on 10/30/23 at 1:07 p.m., Registered Nurse 1 indicated she reweighed Resident 61 today and her weighed was 112.6 both standing and in the wheelchair. On 10/30/23 at 11:00 a.m., the Administrator provided the facility's policy, Weight Monitoring dated, 11/29/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 4. Interventions will be identified, implemented, monitored and modified [as appropriate] consistent with the resident's assessed needs . to maintain acceptable parameters of nutritional status . 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the known addresses and telephone numbers of the Indiana Department of Health, the office of the Secretary of Family and Social Services, the area agency on aging, the local mental health center, and adult protective service were posted in an area accessible to residents. Findings include: On 10/27/23 at 11:05 a.m., during a resident council meeting, the group indicated they were not informed of their right to nor given information on how to formally complain to the State about the care they received. They also did not know where the Ombudsman's contact information was posted. During an observation on 10/27/23 at 12:01 p.m., a small framed sign was observed approximately 4 and 1/2 feet off of the ground and positioned in a corner where the fire extinguisher was stored. The signage included the phone number and address of the Indiana Department of Health, the office of the Secretary of Family and Social Services, the area agency on aging, the local mental health center, and adult protective service. It was not observed to be in an area that would be easily accessible to residents. During an interview on 10/31/23 at 1:24 p.m., the Activities Director and the Administrator (ADM) indicated the sign was not in a good location for residents and needed to be moved to a more accessible and lower location. On 10/31/23 at 1:50 p.m., and ADM provided a copy of the facility's policy, RESIDENT RIGHTS, revised on March 15, 2017, and indicated it was the policy currently being used. A review of the policy indicated, . Information and Communication . You have the right to receive information from agencies acting as advocates and have the opportunity to contact these agencies . Grievances. You have the right to voice grievances . or other agency or entity that hears grievances .with respect to care and treatment . and other concerns regarding your facility stay . 3.1-4(j)(3)

Based on observation and interview, the facility failed to ensure the posted daily nurse staffing information sheet included the facility name, address, and the actual hours worked by licensed staff for 6 of 6 daily staffing sheets reviewed. Findings include: On 10/23/23 at 11:00 a.m., the daily nurse staffing information sheet was observed posted near the receptionist's window. The staffing information sheet lacked documentation of the facility name, address, and the actual hours worked by licensed staff. A review of the posted staffing sheets, dated 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, and 10/31/23 indicated the staffing information sheets lacked documentation of the facility name, address, and the actual hours worked by licensed staff. During an interview on 10/31/23 at 1:33 p.m., the staffing coordinator indicated she updated the staffing sheet in her computer to reflect the actual hours worked by staff the next day, but she did not know it should be on the posted form. She further indicated the name and address of the facility should be on the sheet and she would updated the form.

Based on interview and record review, the facility failed to protect the residents right to be free from misappropriation of resident property for 1 of 3 residents reviewed. (Resident B, RN 1) Finding include: During an interview on 5/25/23 at 2:00 P.M., the DON indicated she was approached by a nurse at the end of March 2023 who was concerned with a residents muscle relaxer. Resident B was running out of the muscle relaxer too soon. The DON indicated she waited until the next delivery and took a picture of the medication. At that time, the DON noticed the medication was missing but documented as administered on the MAR (Medication Administration Record). The DON indicated RN 1 was the nurse removing the medication from the EDK (Emergency Drug Kit). The DON indicated the following morning picture of the medication indicated 7 pills were missing and Resident B was only prescribed to take one pill three times a day. She also indicated RN 1 was the only person to have the keys to the medication cart. RN 1 denied taking any medication, didn't return to the facility, and stopped responding to their phone calls. The DON indicated during the facility investigation, the DON and Administrator checked RN 1's office and found 2 empty pill packets for the muscle relaxer, dating back to December 2022 in her file cabinet. The pill packet had contained tizanidine HCl Tablet 4 mg (milligrams). On 5/25/23 at 2:15 P.M., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, anxiety, and diabetes. The Annual Minimum Data Set (MDS) assessment, dated 3/4/22, indicated Resident B was cognitively intact. The Physician's Orders included, but were not limited to: Tizanidine HCl (muscle relaxer) 4 mg, three times a day, initiated on 6/15/22. On 5/25/23 at 2:45 P.M., RN 1 was unable to be contacted for interview. On 5/25/23 at 2:06 P.M., the Administrator provided the current Medication Management Policy, undated, and indicated it was the current policy in use by the facility. It indicated the policy was to promote a safe and accurate medication management system for each individual resident. This Federal tag is related to Complaint IN00406868. 3.1-28(a)

Based on interview and record review, the facility failed to develop policies and procedures for staff vaccination. The policy lacked what type of education would be provided quarterly to unvaccinated staff members, failed to have a deadline for staff members to be vaccinated, and what actions would be taken if the deadline was not met. Findings include: 1. During an interview on 3/10/2022 at 1:10 p.m., Employee 1 indicated she was not vaccinated for COVID-19 and had no knowledge of what additional education was required quarterly for unvaccinated staff members. During an interview on 3/10/2022 at 1:15 p.m., Employee 2 indicated she was not vaccinated for COVID-19 and had no knowledge of what additional education was required quarterly for unvaccinated staff members. A review of the policy title Employee COVID-19 Vaccination Exemption dated, 3/1/2022, indicated, 5.Exempted employees will be required continuing education quarterly . The policy lacked additional information on what specific continuing education the facility would provide for unvaccinated/exempted staff members. During an interview on 3/10/2022 at 2:25 p.m., Employee 3 indicated the facility planned to provide additional education for unvaccinated/exempted staff members however, the policy was not specific on what that education would be. 2. The Employee COVID-19 Vaccination Exemption Policy, dated 3/1/2022, lacked documentation of a deadline for staff to be vaccinated and what actions would be taken if deadline was not met. During an interview at 3/10/22 at 2:45 p.m., Employee 3 indicated the policy lacked documentation of deadline for staff to be vaccinated and what action taken if deadline was not met. This Federal tag relates to Complaint IN 092. 3.1-18(b)(1)

Based on interview and record review, the facility failed to notify the resident's guardian of a change in health status for 1 of 3 residents reviewed for notification of change (Resident B). Findings include: On 2/25/21 at 3:04 p.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident B's face sheet indicated his wife was his guardian and his first emergency contact. Resident B's admission Minimum Data Set (MDS) assessment, dated 12/10/20, indicated he had moderate cognitive impairment, required extensive assistance of two staff members for bed mobility, and extensive assistance of 1 staff member for personal hygiene. Resident B's progress notes indicated the following: -On 1/19/21 at 6:01 p.m., the Certified Nursing Assistant (CNA) informed the nurse Resident B had vomited. -On 1/22/21 at 5:31 a.m., Resident B had vomited one time this mooring. -On 1/22/21 at 12:00 p.m., Resident B had more episodes of vomiting while in the shower. -On 1/23/21 at 1:56 a.m., Resident B had one episode of vomiting. -On 1/24/21 at 2:21 p.m., Resident B's guardian was notified Resident B refusing medications and meals. The progress notes lacked documentation of Resident B's guardian was notified of his vomiting or change in health status until 1/24/21 (6 days after the onset of change in health status). During an interview on, 2/26/21 at 3:20 p.m., the Director of Nursing indicated Resident B's vomiting started on 1/19/21. The guardian was notified of change in condition on 1/24/21. Resident B's guardian should have been notified immediately after a change in health status. On 2/26/21 at 3:50 p.m., The Administrator provided the facility's policy, Notification of Changes Policy, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .The nurse will immediately notify .the resident representative(s) for the following (list is not all inclusive): A significant change in the resident's physical, status . This Federal tag relates to Complaint IN 266. 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to develop a care plan for a resident assessed to have a left hand contracture for 1 of 1 resident reviewed for range of motion (Resident 53) and the facility failed to develop a care plan for a resident who had an indwelling urinary catheter for 1 of 2 residents reviewed for catheter care (Resident 53). Findings include: 1.) On 10/15/18 at 2:15 P.M., Resident 53 was observed in her room. Her left hand was tightly contracted (shortening of the muscles from lack of use resulting in loss of range of motion) with no splint or relief device in place. On 10/16/18 at 11:00 A.M., Resident 53 was observed in her room. Her left hand was tightly contracted with no splint or relief device in place. On 10/17/18 at 1:30 P.M., Resident 53 was observed in her room. Her left hand was tightly contracted with no splint or relief device in place. On 10/18/18 at 1:30 A.M., Resident 53's clinical record was reviewed. [DIAGNOSES REDACTED]. The 6/1/18, quarterly Minimum Data Set Assessment indicated the resident had range of motion impairment on both sides. The resident's current care plans indicated no identification of left handed contracture and no interventions in regard to the assessed left hand contracture. During an interview, on 10/18/18 at 1:50 P.M., the manager of Unit 6 indicated Resident 53 received care for the skin of her contracted left hand during activities of daily living, such as dressing, showering, and dining time. She was unaware of a written plan of care for her left hand contracture. During an interview, on 10/19/18 at 2:50 P.M., the Director of Nursing indicated there was no care plan in place in regard to Resident 53's contracted left hand. 2.) On 10/15/18 at 2:15 P.M., Resident 53 was observed in her room. She had an indwelling urinary catheter in place. On 10/16/18 at 11:00 A.M., Resident 53 was observed in her room. She had an indwelling urinary catheter in place. On 10/17/18 at 1:30 P.M., Resident 53 was observed in her room. She had an indwelling urinary catheter in place. On 10/18/18 at 1:30 A.M., Resident 53's clinical record was reviewed. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's current care plans indicated no identification of [MEDICAL CONDITION] bladder and no interventions in regard to urinary catheter care. During an interview, on 10/18/18 at 1:50 P.M., the manager of Unit 6 indicated Resident 53 received urinary catheter care. She was unaware of a written care plan regarding catheter care. During an interview, on 10/19/18 at 2:50 P.M., the Director of Nursing indicated there was no care plan in place in regard to Resident 53's urinary catheter care. 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure staff posted signage at a resident's room door and failed to ensure staff implemented use of Personal Protective Equipment (PPE) during care of a resident on contact isolation for 1 of 3 residents reviewed for infections. (Resident 47) Findings include: 1. On 10/15/2018 at 11:00 a.m., during an initial tour of the facility, Registered Nurse (RN) 1 indicated Resident 47 was on contact isolation precautions (form of isolation in which anyone entering the patient's room and having direct contact with the patient wears gloves and a gown) for [MEDICAL CONDITIONS], a bacteria that causes diarrhea. On 10/15/2018 at 11:05 a.m., an observation of Resident 47's room did not indicate a sign on the outside alerting staff and visitors of the contact isolation precautions. On 10/16/2018 at 2:05 p.m., an observation of Resident 47's room did not indicate a sign on the outside alerting staff and visitors of the contact isolation precautions. On 10/17/2018 at 9:32 a.m., an observation of Resident 47's room did not indicate a sign on the outside alerting staff and visitors of the contact isolation precautions. Resident 47's clinical record was reviewed on 10/17/2018 at 10:00 a.m. [DIAGNOSES REDACTED]. A nursing progress note dated, 10/18/2018 at 3:02 p.m., indicated, . Continues on antibiotic therapy (ATB) for [MEDICAL CONDITION] . Contact precautions noted for this shift for [MEDICAL CONDITION]. During an interview, on 10/18/2018 at 2:02 p.m., the Infection Control Nurse indicated the facility did not want to violate HIPPA (Health Insurance Portability and Accountability Act) so they did not post a sign, which indicated Resident 47 was under contact isolation precautions, up on the door. They felt a posted sign would not be homelike as well. On 10/19/2018 at 3:20 p.m., the Director of Nursing (DON) provided the facility's policy, Resident Care Manual: Infection Control Policy, dated 9/25/2017, and indicated it was the policy currently being used by the facility. A review of the policy did not address using a sign on the outside of the residents door to indicate contact isolation precautions. 2. On 10/18/2018 at 1:27 p.m., Certified Nursing Assistant (CNA) 2 and CNA 3 were observed performing perineal care (peri-care) after toileting Resident 47. No gown was observed to be worn, by CNA 2 and CNA 3, during that time. Resident 47's clinical record was reviewed on 10/17/2018 at 10:00 a.m. [DIAGNOSES REDACTED]. A nursing progress note dated, 10/18/2018 at 3:02 p.m., indicated, . Continues on antibiotic therapy (ATB) for [MEDICAL CONDITION] . Contact precautions noted for this shift for [MEDICAL CONDITION]. During an interview, on 10/18/2018 at 1:28 p.m., CNA 1 and CNA 2 indicated they were not sure if the gown should have been worn during peri-care for Resident 47. During at interview, on 10/18/2018 at 2:02 p.m., the Infection Control Nurse indicated CNA 1 and CNA 2 should have worn gowns while performing peri-care for Resident 47. On 10/19/2018 at 3:20 p.m., the Director of Nursing (DON) provided the facility's policy, Resident Care Manual: Infection Control Policy, dated 9/25/2017, and indicated it was the policy currently being used by the facility. Review of the policy indicated, . Contact precautions . Staff Personal Protective Equipment . Gown and Gloves . Transmission Based Precautions (February 28, (YEAR)) was retrieved on 10/22/2018 from the Centers of Disease Control (CDC) website. The guidance indicated, the need to wear gown and glove when working with a resident under contact isolation precautions. 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure staff provided Activities of Daily Living (ADL) care for a resident's fingernails for 1 of 1 resident reviewed for ADL care (Resident 227). Findings include: On 10/15/18 at 11:31 a.m., Resident 227 was observed sitting a wheelchair in the dayroom. A dark brown substance was observed deeply pushed up underneath all of the fingernails on both hands. On 10/16/18 at 10:47 a.m., Resident 227's was observed with a dark brown substance deeply pushed up underneath all of the fingernails. On 10/17/18 at 2:05 p.m., Resident 227 was observed in bed with a dark brown substance deeply pushed up underneath all of the fingernails. On 10/17/18 at 3:00 p.m., Resident 227's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 227's Quarterly Minimum Data Set (MDS) Assessment, dated 7/20/18, assessed the resident as being severely cognitively impaired and needed extensive assistance from staff with personal hygiene. On 10/17/18 at 2:45 p.m., RN 1 observed Resident 227's fingernails and indicated they were dirty and should not be in that condition. At that time, she called a staff member down to clean under the finger nails of Resident 227. On 10/19/18 at 3:37 p.m., the Director of Nursing provided the facility policy, Activities of Daily Living (ADL), Supporting, dated 4/1/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Residents who are unable to care out activities of daily living independently will receive the services necessary to maintain . grooming, and personal . hygiene . 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to ensure a resident's feeding pump and feeding pump equipment pole was cleaned for 1 of 9 residents reviewed for environment (Resident 43). Findings include: On 10/16/18 at 2:15 P.M., Resident 43 was observed in her room receiving an enteral feeding (a method of feeding that uses the gastrointestinal tract to deliver part or all of a person's caloric requirements). The feeding pump and the feeding pump pole had a dried brown substance on it. On 10/17/18 at 2:50 P.M., the resident was observed in her room receiving an enteral feeding. The feeding pump and the feeding pump pole had a dried brown substance on it. On 10/18/18 at 2:00 P.M., the resident was observed in her room receiving an enteral feeding. The feeding pump and the feeding pump pole had a dried brown substance on it. On 10/18/18 at 2:30 P.M., Resident 43's clinical record was reviewed. [DIAGNOSES REDACTED]. During an interview, on 10/18/18 at 2:05 P.M., the manager of Unit 6 indicated the resident's feeding pump and feeding pump pole had a dried brown substance on it and was in need of cleaning by the nursing department. On 10/19/18 at 2:30 P.M., the Director of Nursing provided the facility's Residents Rights, undated, and indicated these were the resident's rights currently used by the facility. A review of the resident's rights indicated a resident has the right to .a safe, clean, comfortable, home-like environment . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure the safe storage of plastic tubs which contained small items that had the potential to be hazardous if placed in the mouth or swallowed observed during 1 of 1 random observation of the kitchen alcove area on the 100 and 200 units. This had the potential to affect 25 of 34 residents who were cognitively impaired and independently ambulatory who resided on the secure dementia care unit. Findings include: On 10/15/2018 at 3:00 p.m., a stack of plastic tubs were observed to be unlocked on the secure dementia care unit in the kitchen alcove area between the 100 and 200 units. The plastic tubs contained dime sized glass beads, half dollar sized rocks, quarter sized foam blocks, hard uncooked noodles, rubber jacks and fishing lures. The kitchen alcove area was not visible to staff from the nursing station or other resident activity areas. During an interview, on 10/15/2018 at 4:30 p.m., the Administrator indicated she did not know the plastic tubs were there. She was observed to remove them from the area and place them in a secure office. The 100 and 200 units occupancy rate, on 10/15/2018 at 3:30 p.m., included 25 residents who self ambulated by either a wheelchair or a walker and had a Brief Interview for Mental Status (BIMS) score which indicated they were cognitively impaired. On 10/19/2018 at 2:30 p.m., the Director of Nursing provided the policy titled, Nursing Home Resident Rights undated, and indicated it was the one currently being used by the facility. A review of the policy indicated, . Basic Rights . Living Accommodations and Care . a safe . environment . 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to keep the Foley catheter (flexible tube which passed through the urethra and into the bladder to drain urine) tubing and drainage bag from touching the floor for 1 of 2 residents reviewed for urinary catheter use. (Resident 327) Findings include: On 10/15/18 at 12:10 p.m., Resident 327 was observed to be sitting in a wheelchair (WC) on the 700 hall dining room with the Foley catheter tubing touching the floor. On 10/16/18 at 3:34 p.m., Resident 327 was observed to be sitting in a recliner, in her room, with the Foley catheter drainage bag resting on the floor. At that time, Resident 327 indicated she has had the Foley catheter for 5 years and was treated for [REDACTED]. On 10/17/18 at 9:16 a.m., Resident 327 was observed to be sitting in the dining room on 700 hall with the Foley catheter tubing touching the floor. On 10/17/18 at 9:17 a.m., Certified Nursing Assistant (CNA) 1 was observed to push Resident 327, in her wheelchair, from the dining room to Resident 327's room; with the Foley catheter tubing touching the floor. On 10/17/18 at 3:50 p.m., Resident 327's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 327's admitted was 10/5/18. Resident 327's Physician order [REDACTED]. During an interview, on 10/18/18 at 1:06 p.m., CNA 1 indicated Resident 327's Foley catheter tubing should not touch the floor. During an interview, on 10/18/18 at 1:34 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident 327 had a Foley catheter due to [DIAGNOSES REDACTED]. On 10/19/18 at 3:10 p.m., the Director of Nurses provided the facility's policy,Foley Catheter Care, dated 4/5/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Drainage bags will not be permitted to touch the floor . 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure staff prevented two second degree burns from the use of a non-physician prescribed heated wash cloth for 1 of 1 resident reviewed for accidents (Resident 112). Findings include: On 10/13/17 at 12:27 p.m., Resident 112's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 112's MDS (Minimum Data Set) assessment, dated 9/14/17, indicated a BIMS (Brief Interview for Mental Status) total score of 12, with a score of 8-12 indicating a moderate cognitive impairment. A review of Resident 112's progress notes indicated the following: 9/15/17 at 7:15 a.m., upon arrival to work, this nurse was notified of fluid filled blisters located on residents (sic) upper back, r/t (related to) use of a heat pack. resident noted to have two fluid filled blisters. 2.4x2.2 and 3.5x2.7(centimeters). resident denies discomfort at this time. blisters are intact. fluids clear, colorless. (QMA (qualified medical assistant) 1's name) states that when she arrived to work yesterday evening at 2200 (10:00 p.m.) (CNA (certified nursing assistant) 1's name) had reported to her that she had applied a heat pack to a black head located on residents (sic) upper back. (QMA 1's name) states that upon removing heat pack around 0100 (1:00 a.m.), she noted the blisters . heat pack consisted of wet warm wash cloth inside of a plastic bag. 9/15/17 at 8:37 a.m., Writer interviewed resident this am (morning) in reference to a complaint of a too hot towel placed on her back by staff due to a skin issue. Resident informed writer that towel (sic) was too hot et (and) she asked staff (girls) to remove it and that they (the girls) never did until this am . 9/15/17 at 19:51 (7:51 p.m.), MD (medical doctor) in facility. Seen resident (sic).Gave new order for silvadene (an antibiotic used to prevent the infection of burns) to blisters on right scapular (shoulder) region . 9/17/17 at 18:17 (6:17 p.m.), wound on upper back have opened up. will continue with silvadene and cover with non-stick dressing. no odor, no drainage, no s/s (signs or symptoms) infection . Physician visit, dated 9/15/17 at 18:24 (6:24 p.m.), indicated the following, Patient is being see today due to apparent injury from heat pack applied to the right scapular region. The details were reviewed with the patient and nurse currently on duty. The patient reported that the pack felt hot at the time of initial application. The hot pack, however, was unfortunately continued. Additionally, the pack apparently was applied directly to the skin without a barrier fabric . On 10/18/17 at 2:18 p.m., a review of Taber's Medical Dictionary, dated 2017, indicated, Second degree (burn): a burn that damages partial thickness of the epidermal (the protective outer layer of the skin) and some dermal (the layer which is beneath the epidermis and is much thicker) tissues but does not damage the lower-lying hair follicles, sweat, or sebaceous (sweat) glands. The burn is painful and red; blisters form, and wounds may heal with a scar . A review of Resident 112's October, 2017, physician's orders did not indicate an order for [REDACTED]. During an interview, on 10/16/17 at 12:07 p.m., CNA 1 indicated she warmed up a wet cloth in a plastic bag, in the microwave for 27 seconds, and gave it to Resident 112 on two separate nights; because she has a history of having boils on her back. This was done three nights in a row and the resident didn't ask her to remove it nor did she complain of the hot pack burning her. During an interview, on 10/16/17 at 12:15 p.m., QMA 1 indicated she took off the hot pack around 1:00 a.m. She did not notice the two large blisters until 6:00 a.m., when she assisted Resident 112 to the bathroom. QMA 1 often gives residents hot packs and she always puts a towel between the bag and the resident's skin. There was not a towel, between the bag and Resident 112's skin, when she took it off. During an interview, on 10/16/17 at 3:07 p.m., Resident 112 indicated she told the staff multiple times to take off the heat pack. The 3 staff members in her room were only talking to each other and would not listen to her. The blisters on her shoulders still hurt and the burns make it hard for her to do therapy. On 10/16/17 at 12:25 p.m., the Director of Nursing indicated the facility did not have a policy in regard to the use of heat packs. This Federal tag relates to Complaint IN 827. 3.1-45(a)(1)

Based on interview and record review, the facility failed to apply an assistive device to prevent an accident for 1 of 3 residents reviewed for accidents in that a mobility alarm had not been applied, which resulted in a fall with injury. (Resident #A) Findings include: Resident #A's clinical record was reviewed on at 04/30/2014 at 12:30 p.m. Resident #A's [DIAGNOSES REDACTED]. Resident #A's Brief Interview for Mental Status (BIMS) score dated 3/05/2014, was a 3; which indicated she had severe cognitive/thinking skills impairment. She was dependent on nursing staff for daily decision making. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #A was an extensive assistance of staff to transfers between surfaces and she did not ambulate/walk on her own. Resident #A's fall risk assessment dated [DATE], was scored at 13. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. No care plan available for falls. physician's orders [REDACTED]." On 5/01/2014 at 2:45 p.m. the DoN provided a copy of the seatbelt manufacture's information. Review of the information indicated, "seat belt alarm (a sound to alert staff a resident is attempted to self ambulate)." Interview on 5/1/2014 at 12:30 p.m., with LPN #1 indicated Resident #A fell to the floor in the morning on March 29, 2014. "I was doing my morning medications and _____ (Resident #A's name) was in her Broda Chair (a medical chair designed to provide comfort and support for individuals with muscle control and muscle support difficulties) between the activity table and tv on the wall. _____ (Resident #A's name) had a blanket on and I could not see the seat belt. I heard someone make on 'OH' sound and I turned to see _____ (Resident #A's name) on the floor. I called for a nurse stat and other staff called the EMTs (Emergency Medical Technicians) and fire department. _____ (Resident #A's name) was very vibrant and wide awake that day. The person who gets _____ (Resident #A's name) up in the morning puts the alarming seat belt on. That morning it was _____ (CNA #1's name) who should have put the seat belt on _____ (Resident #A's name). Interview on 5/2/2014 at 12:37 p.m., with CNA #1 indicated, "I got _____ (Resident #A's name) up and fed her breakfast. After I cleaned up breakfast, I pushed her chair into the table and went to give another resident a shower. I did not put her seat belt on. I heard about the fall after I had completed the shower with the other resident." Progress notes date 3/29/2014 thru 4/3/2014 indicated at 9:45 a.m., on 3/29/2014 Resident #A was observed on her left side on floor with a small amount of blood on the floor by her head. An assessment was completed, the doctor was called, and the son was called and updated. The resident was placed on a backboard with left arm being stabilized was then transported to hospital. Record review on 4/30/2014 at 1:30 p.m., of local acute care hospital History and Physical dated 3/29/2014 indicated, "The patient is a [AGE] year old female who sat up and fell out of her wheelchair at the extended care facility today. She was brought to the hospital and x-ray preformed and she was found to have a left distal humerus fracture (upper arm bone) and was transferred here for orthopedic care for fracture. The patient does have a dressing over her left eye brow area. It does have some bloody drainage, most likely from the laceration (irregular flesh tear) that she sustained during her fall today..." On 5/01/2014 at 1:29 p.m., the DoN provided a copy of CNA #1's Nursing Employee Counseling Report dated 3/31/2014. Review of the report indicated, "On 3/29/2014 ... at some point during the morning you provided a.m. care for _____ (Resident #A's name). As part of her care you transferred her from her bed into her Broda chair. ... At some point ... you did not apply _____ (Resident #A's name) self-releasing seatbelt. This resulted in ______ (Resident #A's name) falling from her Broda chair without an alarm alerting staff. ... _____ Resident #A's name) sustained a fracture to her left humerus and was hospitalized . ... It is unacceptable to refrain from following any and all precautions put in place to maintain the safety of the residents ..." This Federal tag relates to Complaint IN 121. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents at risk of pressure ulcers did not develop pressure ulcers, Resident # 57 developed a stage 4 pressure area to his heel and Resident # 112 developed a stage 2 pressure area to her right outer ankle and the facility failed to ensure changes in the residents skin was promptly called to the physician and new interventions implemented when areas changed, Resident # 74's physician was not notified when there was a change in his wound, Resident # 52 did not receive proper pressure relief to prevent two stage 2 pressure sores from developing and Resident # 200 did not receive a treatment to her pressure sore for 7 days after the facility was aware of the open area, for 5 of 6 residents reviewed for pressure in the sample of 24. Resident #74, 57, 52, 200, 112 Findings include: 1. On the initial tour with Unit Manager # 1, on 1/23/12 at 9:45 A.M., she indicated Resident # 57 was interviewable, had a history of [REDACTED]. On 1/24/12 at 2:15 P.M., Resident # 57 was observed to be in bed. Resident # 57's right heel was observed to have a quarter sized area with a approximately 20% of the wound base observed to have a yellow exudate. The clinical record for Resident # 57 was reviewed on 1/23/12 at 11:00 A.M. The record indicated Resident # 57 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 10/26/11, indicated Resident # 57 had moderately impaired cognition. Resident # 57 was dependent on two staff for bed mobility and toilet use. Resident # 57 required extensive assistance of two with transfers. Resident # 57 did not ambulate. Resident # 57 had a stage IV pressure ulcer. The admission MDS assessment, dated 5/10/11, indicated Resident # 57 had no pressure ulcers but was at risk to develop a pressure ulcer. A care plan, dated 5/16/11, indicated a problem of "Risk for impaired skin integrity R/T (related to) urinary incontinence occas (occasionally) other: decreased mobility." The interventions included but were not limited to "Weekly skin inspections by licensed nurse." The Nurses Notes, dated 7/20/11 at 9:30 A.M., indicated "Resident c/o (complains of) "burning" in R (right) leg at this time. Upon assessment, this writer noted a 3.0 cm x (by) 3.5 cm necrotic area with 0.5 cm bright red ring around outside of area to R heel. R heel is soft mushy with brown wrinkled skin noted at 5:00 on wound. Also, L (left) heel appears to be red, soft, mushy. Notified MD for treatment orders. Also EZ boots applied..." The Nurses Notes, dated 7/20/11 at 1315 (1:15 P.M.), indicated "Res (resident) has a 4 x 4 x 0 dk (dark) purple red soft deep tissue injury pressure wound to R heel. Periwound is pink et blanching. c/o (complains of) pain 6/10 (pain rated a 6 on a scale of 1 to 10 with 10 being the most intense pain) to heel. EZ boots on while in bed. Nonskid socks on while up in w/c, no shoes until wound is healed except for therapy. MD updated. Tx (treatment) requested. Boost given TID (three times daily). Spoke with dietary about high cal (calorie) high protein diet." The Nurses Notes, dated 7/20/11 at 1420 (2:20 P.M.), indicated "N/O (new order) rec'd (received) [MEDICATION NAME] to bil (bilateral) heels a shift x (times) 14 days then reeval (re-evaluate). EZ boot on while on bed heels floated nonskid socks while up in w/c no shoes until wound healed..." A care plan, dated 7/20/11, indicated a problem of "Resident has a pressure ulcer on Rt (right) heel D/T (due to) pressure area staged as deep tissue injury at this time. 8-11-11 wound is st (stage) IV." The interventions included but were not limited to "TX's (treatments) as ordered. Pressure reducing mattress on bed. Pressure reducing pad in w/c. Head to toe skin assessment. Labs as ordered. Enc (encourage) resident to consume 75-100% of meals/snacks. Keep skin C & D (clean and dry) if incontinent episodes. Turning and repositioning program. Watch for effectiveness of / response to TX ordered. Notify physician as needed. Bil (bilateral) heels floated while in bed. Nonskid socks wore at all times. Boost TID (three times daily). 7/27/11 waffle mattress on bed. 8/8/11 Foot cradle on bed. No shoes worn until wound healed." In an interview with the Wound Nurse, on 1/25/12 at 10:45 A.M., she indicated Resident # 57's deep tissue injury was caused by the pressure from his heels being on the mattress. A Weekly Pressure Ulcer Healing Assessment, dated 7/27/11, indicated "Deep Tissue Injury 4 x (by) 6 x 0...Purple nonblanching fluid filled intact blister soft. Peri wound pink et blanching. No drg (drainage). No odor. Denies pain but c/o burning to heel. Tx cont (continues) as ordered. Heels floated..." A Pain Assessment, dated 7/29/11, indicated "...Pain is constant R (right) heel...burning sensation, aching R foot/leg...date of onset/years of duration: 7/20/11...Cause of pain in this site- ulcer..." A Weekly Pressure Ulcer Healing Assessment, dated 8/11/11, indicated "Stage 4 3.3 x 3.8 x ?...Deep tissue injury wound is now a St (stage) IV due to black eschar over wound bed with moisture from 11 o ' clock to 1 o' clock. Periwound and edges are dk (dark) pink, dry et blanching. no drg. c/o burning to heel. MD aware Tx cont..." In an interview with the Wound Nurse, on 1/25/12 at 1:00 P.M., she indicated she could not find any documentation regarding the physician notification of the change in wound. A Weekly Pressure Ulcer Healing Assessment, dated 1/17/12, indicated "Stage 4 1.2 x (by) 2 x 0.4...wound bed pink moist with 5% yellow to center deepest part is in center of 0.4 cm. Peri wound pink et (and) blanching no pain no drg (drainage) no odor. Tx (treatment) cont (continues). Wound edges callous area was debrided per therapy...No change." 2. Resident #112 was identified on the initial tour of the facility on 1/23/12 at 9:30 A.M. by the unit manager, as having an open skin area on her right outer calf. Resident #112 was observed on 1/24/12 at 12:30 p.m. Her right ankle was observed to turn inward, with a large wound on the underneath side of her lower leg/ ankle area. The base was red with dark on the outer edges. Resident #112's clinical record was reviewed on 1/23/12 at 2:00 P.M. [DIAGNOSES REDACTED]. A care plan, dated 6/28/11, indicated a problem of "Resident has a pressure ulcer on right upper outer malleolus, stage 2, 7/7/11 stage 2 now , 7/14/11 wound is a stage 4 now with eschar noted, 9/15/11 area opened into two separate wounds now, upper wound is wound A, lower wound is wound B...interventions included: cushioned dressing between skin and brace to right foot until wound is healed, prevalon cushion boot on right foot at all times, turn and repositioning program The Weekly pressure ulcer healing assessments, indicated "date of onset 4/26/11 right outer malleolus, 5/5/11 stage 3 1.4 by .5 by less than .1, 5/26/11, area closed with epithelization and scar tissue to site, sure prep (a coating that protects the skin from breakdown, contains alcohol) to help toughen the skin. The skin wound logs indicated 5/26/11 right outer malleolus...wounds are closed. The log had entries each week with the next entry concerning the right outer ankle 6/17/11 with " dark pink in color 8.5 by 2 by 0 with .4 by .6 brown discoloration." "6/24/11 right outer ankle dark pink are with 8 by 3 with dark red brown discoloration 2 by .5 1 by 1 ..." "7/1/11 right outer ankle see pressure/vascular log." Physician orders [REDACTED]. The June 2011 treatment record indicated this was completed on 6/9/11, with "reeval (reevaluate)" written on the sheet. A telephone physician order [REDACTED]. A right ankle radiology report dated 6/18/11 indicated "there is not acute bony abnormality...there is mild diffuse osteopenia, there is some vascular calcification." Documentation was lacking of the physician having been notified of the findings on 6/17 of the wound assessment, or of any treatment to the area from 6/10 through 6/24/11. Nurses notes indicated: "6/24/11 1435 (1:35 A.M. )...new order sure prep wipes to right outer ankle bid (2 times daily) routinely to toughen skin..." "6/25/11 0600 (6 a.m.) area on right heel weeping fluid. sure prep wipe treatment done to outer ankle..." "6/25/11 1430 (2:40 p.m.) area on right ankle weeping clear watery fluid applied sure prep, covered with [MEDICATION NAME] and kerlix (dressings) res stated if felt better to be covered." "6/28/11 0720 11 -7 nurses brought it to this writers (wound nurse) attention that resident has drainage soaked gauze wrap on right foot and has odor for sure prep every shift. So writer went to assess right ankle area. res has an open area to right outer malleolus 2 by 1 by less than .1 with red wound bed and moderate serous yellow drainage and an open area to right outer upper ankle that is 1 by 2 by less than .1 with red wound bed...I believe both are caused from brace that resident wears. her foot is turned in more we have already removed her EZ boots at night. Both areas had a moderate amount of serous drainage noted...doctor updated, new treatment orders requested..." A telephone physician order, dated 6/28/11, indicated 7:30 p.m. new order for 2 wounds on right ankle, discontinue sure prep change to antibiotic ointment with [MEDICATION NAME] and cover with [MEDICATION NAME] and kerlix also for prostat 30 ml two times daily to aid in wound healing. The facility lacked evidence of having updated the physician of the worsening wound observed on 6/25 until 6/28/11 when the wound nurse did so. The weekly pressure ulcer assessments indicated; "date of onset 6/28/11 right outer malleolus (wound B) stage 2 2 by 1 by less than .1, red moist wound bed with dark pink blanching moist periwound moderate yellow dressing...padding done to area between skin and brace" and "date of onset 6/28/11 right outer ankle upper aspect (wound A) 1 by 2 by less than .1 stage 2..." The wound sheets indicated wound a healed on 12/1/11. Wound B was documented as a stage 3 on 7/7/11 with 2 by 1.4 cm, unknown depth, stage 4 on 7/14/11. Wound B continued through 1/18/12 documented as stage 4 (a full thickness of skin and subcutaneous tissue is lost, exposing muscle and or bone.) 4.5 cm by 2.3 c.m. by .1 cm depth, red moist wound bed with pink blanching periwound small amount of bright red bloody drainage, no odor no pain, treatment continues...mist treatment (sent out to hospital for weekly), improved..." A right leg arterial ultrasound, dated 7/19/2011 indicated "abnormal Doppler signal, but no visible evidence of a significant stenosis or obstruction. " During interview with the wound nurse on 1/24/12 at 11:00 A.m. she indicated the resident wore a brace to help support her ankle and provided information on the brace worn. She indicated she did not know when the resident wore the brace and could provided no documentation of the braces use. A physical therapy note, dated 10/09, indicated "fitted with ankle brace." A copy of a ortho lower ankle support, with Resident #112's name of it, indicated "ankle support needed when in weight bearing (sic)." The product information indicated " fits right or left foot, dual rigid v stirrup straps provide lateral and medial stability for reduced inversion and eversion movements..include 2 horseshoe foam pads." The picture of the product showed it would go over the foot and a few inches above the ankle, the back of the product would have covered the area on the residents right outer ankle. The wound nurse indicated on 1/25/11 at 9:30 A.M. that a podiatrist had stopped the black ankle support, but then started a clear plastic support that went under her foot and up the back of her leg, she provided a telephone order dated 9/30 which indicated to discontinue the brace to right foot and apply protective boots. She indicated she thought the brace referred to in this order was the clear plastic brace ordered by the podiatrist. The facility could find no documentation of this original order or of when this brace was used. During interview with the wound nurse on 1/24/11 at 1:30 P.M. she indicated the area on the residents right outer ankle was a recurrent problem and provided documentation that this area had been open as a stage 3 on 1/5/2010 and continued to have been opened through 9/14/10 when it had healed. 3 On the initial tour with the Assistant Director of Nursing, on 1/23/12 at 9:15 A.M., she indicated Resident # 74 was interviewable and had a wound to his heel that he had for years. The clinical record for Resident # 74 was reviewed on 1/23/12 at 10:00 A.M. The record indicated Resident # 74 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 12/21/11, indicated Resident # 74 had no cognitive deficits. Resident # 74 was independent with bed mobility, required extensive assistance with transfers and toilet use. Resident # 74 did not ambulate. Resident # 74 had a stage IV pressure ulcer. A Care plan, dated 5/26/11, indicated a problem of "Resident has a pressure ulcer on Rt (right) heel D/T (due to) Stage IV area is a reoccurring wound over an old Stage IV wound site. Res (resident) has had a lot of problems with this heel wound and it is almost unavoidable." A Weekly Pressure Ulcer Healing Assessment, dated 1/9/12, indicated "...R (right) heel...area closed per MD orders..." A statement from the physician, dated 1/9/12, indicated "In regards to (Resident # 74) right heel wound, even though area continues to be covered with eschar, the wound is the best it's going to be due to tissue loss from old wound and history osteomylitis. This wound will not completely close, nor heal and debridement is not recommended at this time. So I am going to say that this wound to right heel is basically healed. It is my understanding that a licensed nurse will be inspecting and assessing this area on a weekly basis and will inform me of any new concerns to wound site." A Nurses Note, dated 1/19/12 at 12:30 P.M., indicated "dry thick scab like tissue adhered to sock; when sock removed this scab came out of R heel wound leaving an open area 1.3 x (by) 0.8 x 0.7 no drainage no odor. Wound nurse and Unit manager examined. Res (resident) also has red sl (slightly) raised rash bil (bilateral) arms and face is flushed. Unit manager examined." A Nurses Note, dated 1/19/12 at 12:35 P.M., indicated "Wound bed is pale pink with small amount of tan eschar intact 0.2 x 0.2 to R heel. Dr (name) notified." A Care plan, dated 1/19/12, indicated a problem of "Resident has a pressure ulcer on Rt heel old wound reopened R/T (related to) Stage IV." In an interview with the Director of Nursing, on 1/23/12 at 2:55 P.M., she stated the Wound Nurse had left a message at the physician office on 1/19/12 regarding the area to the right heel but had not received an answer yet and had called him again today. A Nurses Note, dated 1/23/12 at 1430 (2:30 P.M.), indicated "Dr (name) office phoned per (name) wound nurse for tx (treatment) to heel open area. To return call today with N.O. (new order)." A Nurses Note, dated 1/23/12 at 1500 (3:00 P.M.), indicated "Dr (name) returned call in regards to R heel wound. N.O. left to cover wound with dry gauze et (and) kerlix wrap daily et let wound stay dry. If wound starts to drain MD wants us to notify him. UM (unit manager) aware of orders." 4. On the initial tour, with Unit Manager # 1, on 1/23/12 at 9:30 A.M., she indicated Resident # 52 was not interviewable and had an excoriation to her bottom. The clinical record for Resident # 52 was reviewed on 1/23/12 at 1:30 P.M. The record indicated Resident # 52 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 11/23/11, indicated Resident # 52 had moderately impaired cognition. Resident # 52 required extensive assistance of one with bed mobility, transfers, ambulation and toilet use. Resident # 52 had no pressure ulcers but was at risk to develop pressure ulcers. A care plan, dated 9/20/11, indicated a problem of "Risk for impaired skin integrity R/T (related to) urinary incontinence, thin/fragile skin, other: decreased mobility." A care plan, dated 1/16/12, indicated a problem of "Resident has a pressure ulcer on upper rt (right) buttocks wound A (top wound) R/T (related to) Stage II (from shearing)." The interventions included but were not limited to "Placed a 6 inch foam cushion in w/c. Encouraged to lay down on sides after each meal. In house barrier cream around open sheared area, on each shift as a preventative . Staff to reposition resident by standing while up in w/c. Resident is to be up in w/c only for 2 hours at a time as a preventative measure." A care plan, dated 1/16/12, indicated a problem of "Resident has a pressure ulcer on upper rt (right) buttocks wound B (bottom wound) R/T (related to) Stage II (from shearing)." The interventions included but were not limited to "Placed a 6 inch foam cushion in w/c. Encouraged to lay down on sides after each meal. In house barrier cream around open sheared area, on each shift as a preventative . Staff to reposition resident by standing while up in w/c. Resident is to be up in w/c only for 2 hours at a time as a preventative measure." The Nurses Notes, dated 1/16/12 at 10:30 A.M., indicated "Res (resident) has two open areas on R (right) buttock from shearing. We have a wound A- top wound et (and) Wound B- bottom wound of R buttocks. Res is up in w/c et is fidgety constantly shifting et scooting forward. I believe shearing was self inflicted. Old pressure reduced (sic) cushion in w/c was removed et a 6 inch foam cushion applied. This cushion will hopefully reduce discomfort to buttocks while sitting. Staff educated on repositioning resident while chair, there is an order for [REDACTED].< (less than) 0.1 open area St (stage) II from shearing with red bed et dk pink dry peeling peri wound. no drg (drainage) no odor. Res (resident) c/o (complains of) pain 7/10 (7 out of 10 on a scale of 1 to 10 with a 10 being intense pain) with touch only but refuses pain meds (medications). Wound B is 0.1 x 0.4 x <0.1 open area from shearing with red dry bed et dk pink peeling peri wound. no drg no odor c/o pain 7/10 with touch only but ref (refused) pain meds. St II area too. Coccyx is closed by peeling et dk pink. In house [MEDICATION NAME]. MD updated on both areas et tx (treatment) requested. Res is on Boost TID (three times daily) to help nutrition status. Pressure reducing mattress on bed. Staff will keep turned Q (every) 2 hours." A physician order, dated 1/17/12, indicated "Opsite to area on coccyx. Change Q 3 days or prn/soiling (as needed)." 5. The closed record for Resident # 200 was reviewed on 1/24/12 at 10:00 A.M. The record indicated Resident # 200 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 12/30/11, indicated Resident # 200 had moderately impaired cognition. Resident # 200 required extensive assistance of one with bed mobility, transfers, and toilet use. Resident # 200 had a stage II pressure sore. The Nurses Notes, dated 12/23/11 at 1735 (5:35 P.M.), indicated "...Small opening on coccyx measured wound nurse to see also..." The Nurses Notes, dated 12/23/11 at 2300 (11:00 P.M.), indicated "....Wound on coccyx had drsg (dressing) 1/2 off with blood on drsg. Assessed wound on coccyx to be at 0.5 x (by) 0.5 x 1. Cleansed, atb (antibiotic) ointment applied and dressed with [MEDICATION NAME] and medflex as nsg (nursing) measure..." A care plan, dated 12/23/11, indicated a problem of "admitted to the facility with the following skin problems Other: burn Rt (right) femur." The interventions were "Treatments per MD order. Use pressure reducing/relieving mattress on bed prn (as needed). Diet per order, dietary to assess protein and nutritional needs. Keep site clean and dry. Refer to wound team for follow-up prn. Follow all protocols per admission skin assessment." The Nurses Notes, dated 12/27/11 at 7:00 A.M., indicated "After further investigation per wound nurse of open area found on coccyx (pressure) on admission, area is not on coccyx it is R (right) inner buttocks. Coccyx is clear with skin intact. R inner buttocks has a superficial St (stage) II 0.4 x 0.3 x < (less than) 0.1 with dk (dark) pink wound bed et pink blanching peri wound. no pain no odor no drainage. MD updated for tx (treatment) orders..." In an interview with the Wound Nurse, on 1/25/12 at 1:00 P.M., she indicated she had faxed the physician on 12/27/11 and had not received a response by 1/3/12. She further indicated she had notified the Director of Nursing via email that Resident # 200 had went 7 days without treatment to her open area. 3.1-40(a)(1) 3.1-40(a)(2)