Every finding on record at Hickory Creek at Peru

Based on observation, interview and record review, the facility failed to ensure narcotics were reconciled for 2 of 2 medication carts reviewed for narcotic reconciliation. (Front and Back Medication Carts)Findings include:During a medication cart observation with LPN 2, on 12/18/2025 at 8:14 A.M., the Shift Change Verification of Controlled Substances was reviewed and the following dates did not contain signatures that the shift to shift reconciliation's had been completed. Front Cart-December 5, 11 and 12, 2025Back Cart-December 3, 10, and 17, 2025During an interview on 12/18/2025 at 8:20 A.M., the Director of Nursing (DON) indicated narcotics should have been counted after each shift and the narcotic log signed. A policy titled American Senior Communities policy-Controlled Substances: Storage, Documentation, Inventory, and Description was provided by the ADM on 12/18/2025 at 1:57 P,M., and deemed as current. The policy indicated: .The incoming nurse or QMA will count all controlled substances being stored at the facility while the outgoing nurse watches the process. Both staff members sign the that the count sheets and verification have been completed with no discrepancies 3.1-25(n)

Based on record review and interview, the facility failed to ensure a resident had qualifying criteria to warrant a new schizoaffective disorder diagnosis for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Finding includes:A record review for Resident 5 was completed on 12/18/2025 at 1:05 P.M. Diagnoses included, but were not limited to: schizoaffective disorder, bipolar disorder, depressive disorder, generalized anxiety and epilepsy.A Quarterly MDS Assessment, dated 10/22/2025, indicated Resident 5 had moderate cognitive impairment and received an antipsychotic medication.Nursing Progress Notes, dated 12/19/2024 through 1/27/2025, were reviewed. The following behaviors had been documented:-12/19/2024 10:09 A.M. Resident 5 exhibited sexual inappropriateness and verbal aggression. Resident 5 was redirected and removed from the situation. A recent gradual dose reduction of Depakote was noted.- 12/20/2024 at 10:44 A.M. Resident 5 had verbal aggression, yelling and cursing at staff in the main dining room and hallway. Resident 5 had been effectively re-directed to his room to finish his breakfast meal and educated on appropriate language.-12/20/2024 at 1:21 P.M. Resident 5 had refused radiation therapy. Resident 5 had been educated and responded with cursing language.-12/23/2024 at 12:25 P.M. Resident 5 had refused radiation therapy.-12/24/2024 at 9:26 A.M. Resident 5 had refused morning medications.-12/26/2024 at 10:40 A.M. Resident 5 had refused radiation therapy.-12/27/2024 at 11:31 A.M. Resident 5 had refused his radiation therapy.-12/30/2024 at 9:31 A.M. Resident 5 had verbal aggression towards staff with breakfast in room. Resident 5 was offered an alternative meal. The potential root cause per the interdisciplinary team included the behaviors could have been contributed to radiation treatment and dealing with a cancer diagnosis and treatment.-1/6/2025 at 12:11 P.M. Resident 5 had refused his radiation therapy.-1/7/2025 at 9:22 A.M. Resident 5 had cursed at nursing staff due to his breakfast had been sent to his room instead of the dining room-1/7/2025 at 3:28 P.M. Resident 5 had used vulgar language in the dining room. Resident 5 was effectively redirected and educated on language.-1/8/2025 at 4:17 P.M. Resident 5 had foul language directed at staff. Re-education had been attempted, but Resident 5 responded with racial slurs and cursing.-1/10/2025 at 10:25 A.M. Resident 5 had been cursing at staff. Resident 5 was redirected and reeducated on language. The interdisciplinary team indicated the root cause could have been ongoing stressors for radiation and chemotherapy.-1/17/2025 at 4:09 P.M. Resident 5 had refused all morning medications.-1/27/2025 at 11:24 A.M. Resident 5 had been belligerent in the main dining room. Resident 5 had been educated and removed from the dining room. The interdisciplinary team felt the behavior was related to the environment and his bi-polar disorder.-1/27/2025 at 5:33 P.M. Resident 5 had been hostile towards other residents and used vulgar language. Resident 5 returned to his room.A Nursing Progress Note, on 1/28/2025 at 10:40 A.M., indicated the interdisciplinary team had attempted to discuss inappropriate behaviors of vulgar language, disruptive behaviors in the dining room, mood swings, unprovoked irritability and lashing out at others with Resident 5. Resident had not been receptive to the conversation and used vulgar language towards the interdisciplinary team.A Nursing Progress Note, on 1/28/2025 at 4:45 P.m., indicated an order had been obtained from the psychiatric nurse practitioner for an in-patient psychiatric evaluation and treatment.A Nursing Progress Note, on 1/28/2025 at 5:01 P.M., indicated the social services staff member and Resident 5's power of attorney (POA) had attempted to meet with the resident in his room. Resident 5 had continued to be resistive to conversations, and yelled and cursed.A Nursing Progress Note, on 1/29/2025m at 11:11 A.M., indicated the interdisciplinary team, Resident 5's POA's and the resident had a care plan to discuss his behaviors. Resident 5 continued with vulgar language and threatened others in the meeting.A Psychiatric Nurse Practitioner (NP) Progress Note, on 1/9/2025 at 5:55 P.M., indicated a visit had occurred for an acute visit for medication follow-up for behaviors, psychotropic medication review and management and continued evaluation of moods and behaviors. Resident 5 had the current diagnoses of bipolar disorder, anxiety, other depressive episodes and restlessness and agitation. The NP indicated the Depakote medication would be increased for Resident 5's bipolar disorderA Discharge Summary , dated 2/5/2025, from the psychiatric hospital indicated Resident 5 had been admitted due to some increased physical aggression and agitation. He had received a new diagnosis of schizoaffective disorder, bipolar type, during this hospitalization. There was no documentation of any delusional or hallucinatory behaviors during the acute psychiatric hospital stay.A form titled, Schizoaffective Disorder Diagnosis Assessment had been signed by the facility nurse practitioner, on 3/12/2025. The Assessment indicated Resident 5 had had a major mood episode that had lasted for an uninterrupted period of time, mood symptoms had been present for the majority of the illness and the symptoms had not been caused by substance abuse. In addition, the nurse practitioner indicated Resident 5 had exhibit behaviors of aggression, verbal threats, irritability and mood swings. She indicated Resident 5 was sent for an inpatient psychiatric stay and had received the diagnosis of schizoaffective disorder. However, the assessment indicated Resident 5 had not had delusions or hallucinations for two or more consecutive weeks without a major mood disorder/symptoms sometime during the life of the illness.A policy was requested for schizoaffective disorder, on 12/23/2025 at 11:32 A.M. The Director of Nursing indicated at 12:36 P.M., the facility did not have a policy for schizoaffective disorder, and the facility followed the federal regulations.3.1-35(g)(1)

Based on observation, record review and interview, the facility failed to ensure interventions from a prior elopement were in place to prevent the potential of future elopements at the facility for 1 of 1 resident reviewed for elopement. (Resident 27)Finding includes:A record review for Resident 27 was completed on 12/19/2025 at 9:37 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, major depressive disorder and anxiety.An admission Minimum Data Set (MDS) assessment, dated 9/9/2025, indicated Resident 27 had severe cognitive impairment, was independent with mobility and had a behavior of wandering that placed Resident 27 at significant risk to potentially get to a dangerous place and intrude on the privacy of others. An Elopement Risk Assessment, dated 9/2/2025, indicated Resident 27 was at risk for elopement A Care Plan, initiated on 9/2/2025 and revised on 9/5/2025, indicated Resident 27 was at risk for elopement per the Elopement Risk Assessment related to Alzheimer's disease, was independently mobile, requested to go home and searched for home, wandered aimlessly and was often seen pushing or tried to open doors. Interventions included, but were not limited to: redirect Resident 27 to her room with the Food Network channel, all facility exits secured and a Wanderguard (magnetic door locking system) in place per the physician order.During an observation, on 12/19/2025 at 10:38 A.M., the dry food storage door was unlocked without a staff member in the room and the exit door, located within the dry storage room, had a key to the door, on a keychain ,hanging from the locked door.During an observation, on 12/22/2025 at 2:37 P.M., the Dietary Manager was observed walking into the dry storage room without using a key to unlock the door. A Nursing Progress Note, on 9/2/2025 at 3:15 P.M., indicated a nursing assistant had observed Resident 27 wandering the facility and standing at the back door. A Nursing Progress Note, on 9/2/2025 at 4:30 P.M., indicated Resident 27 had been walking the hallways looking for her husband. A Nursing Progress Note, on 9/3/2025 at 3:18 A.M., indicated Resident 27 was awake and upset her husband had left her at the facility. Resident 27 indicated she wanted to go home.A Behavioral Note, on 9/3/2025 at 9:59 A.M., indicated Resident 27 had been observed wandering in the hallway and at the facility's back door. The interdisciplinary team felt the root cause had been she was a new admission to the facility and unfamiliar with her surroundings. A Nursing Progress Note, on 9/5/2025 at 1:44 P.M., indicated Resident 27 had been walking in the facility and stated she needed to leave and go to her sister's house. Resident 27 also had stated she had been waiting on her husband to pick her up and she did not want to be at the facility. A Nursing Progress Note, on 9/5/2025 at 9:21 A.M., indicated Resident 27 had been wandering into other residents' rooms and lingering by the door. Resident 27 had indicated she did not need to be at the facility and wanted to go home. A Nursing Progress Note, on 9/7/2025 at 3:26 P.M., Resident 27 had been observed going to the facility side door. A Nursing Progress Note, on 9/8/2025 at 2:40 P.M., indicated Resident 27 had been walking the hallways all morning and afternoon. Resident 27 had not made any attempts to exit the facility, but had continued to make statements about going home and leaving the facility. A Behavioral Progress Note, on 9/9/2025 at 10:17 A.M., indicated Resident 27 had exited the facility through the dry storage door but had remained on the facility's property. A Care Plan, initiated on 9/2/2025 and revised on 9/5/2025, indicated Resident 27 was at risk for elopement per the Elopement Risk Assessment related to Alzheimer's disease, was independently mobile, requested to go home and searched for home, wandered aimlessly and often seen pushing or tried to open doors. Interventions included, but were not limited to: redirect Resident 27 to her room with the Food Network channel, all facility exits secured and a Wanderguard in place per the physician order.During an interview, on 12/23/2025 at 10:46 A.M., Qualified Medication Assistant (QMA) 4 indicated the dry storage door and the exit door inside the dry storage room should both have been locked. During an interview, on 12/23/2025 at 10:46 A.M., the Director of Nursing indicated the exit door in the dry storage room doors should have been locked, both the outside and inside doors. A current policy was provided, on 12/23/2025 at 12:36 P.M., by the Director of Nursing. The policy titled, Elopement Prevention and Response Programs, indicated, .It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensure appropriate action is taken.3.1-45(a)(1)

Based on observation interview, and record review, the facility failed to monitor for the continued need for a PRN (as needed) antianxiety medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 1)Findings included:A record review was completed on 12/19/2025 at 11:16 A.M. for Resident 1. Diagnoses included, but were not limited to, anxiety disorder.An admission Minimum Data Set (MDS) assessment, dated 11/26/2025, indicated Resident 1's cognition was intact she had not exhibited any behavior issues and she had received antianxiety medication.Current Physician Orders included, but were not limited to:-On 11/20/2025 lorazepam 1 milligram (mg) by mouth 3 times a day as needed (PRN) for anxiety, discontinue on 11/21/2025.-On 11/21/2025 lorazepam 1 mg by mouth 3 times a day as needed for anxiety, discontinue on 11/25/2025.-On 11/25/2025 lorazepam 1 mg by mouth 3 times a day as needed for anxiety, discontinue on 12/5/2025.-On 12/10/2025 lorazepam 1 mg by mouth 3 times a day as needed for anxiety, discontinue on 12/11/2025.-On 12/11/2025 lorazepam 1 mg by mouth 3 times a day as needed for anxiety, discontinue on 12/23/2025. A Care Plan problem, dated 11/26/2025, indicated Resident 1 was at risk for signs and symptoms of anxiety. Interventions included, maintain a calm environment or move to a quiet area, administer medications as ordered, and psychological services as needed.There was no documentation of Resident 1's symptoms of anxiety prior to administering an as needed (PRN) lorazepam. In addition, there was no documentation of any non-pharmacological interventions attempted and effectiveness of the interventions prior to the administration of the medication. Finally, there was no documentation of the effectiveness of the lorazepam medication.During an interview on 12/23/2025 at 9:48 A.M., Resident 1 indicated sometimes she could not sleep because her mind was racing and it (the lorazepam medication) helped to calm her so she could sleep. In addition, Resident 1 indicated the other reasons she asked for the medication was if it was not time for her pain medication, it helped to calm her and brought her anxiety down from 7 or 8 to 5 rate while she waited on her next dose of pain medication.During an interview on 12/23/2025 at 9:53 A.M., LPN 2 indicated Resident 1 was overall visibly very anxious and her pulse and respirations were elevated. She also indicated she does not usually document in the Nurses Progress Notes because when signing out the lorazepam in the medication administration record, she marked it was for anxiety. She indicated she had tried non-pharmaceutical interventions but she had not documented them.During an interview on 12/23/2025 at 9:58 A.M., the DON indicated that best practice would have been to document symptoms and reasons for the PRN lorazepam, non-pharmacological interventions tried, and the effectiveness of the lorazepam.On 12/23/2025 at 10:03 A.M. the DON indicated there was not a policy that specifically addressed PRN psychotropic medications.3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure the Surety Bond amount was sufficient to cover the Resident's personal fund account. This deficient practice had the potential to effect 31 of 31 residents in the facility. Finding includes: During an interview, on 9/30/2024 at 10:38 A.M., the Business Office Manager (BOM) indicated the Surety Bond amount was $25,000.00 and the resident funds accounts totaled $28,511.66 in June and $26,803.46 in July The Business Office Manager indicated the amount of the surety bond would not cover the total amount in the resident funds account. During an interview, on 9/30/2024 at 1:25 P.M., the Administrator indicated the surety bond would not always cover the total amounts in the resident fund account. She indicated she did not have a policy for the surety bond. 3.1-6(i)

Based on record review and interview, the facility failed to revise care plans for fluid consumption for 1 of 17 residents whose care plans were reviewed. (Resident 4) Finding includes: The record for Resident 4 was reviewed on 9/26/2024 at 1:46 P.M. Diagnoses included, but were not limited to, heart failure, end stage renal disease, diabetes and bipolar disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated the resident received dialysis. Current Physician's Orders included an order for regular diet and dialysis every Monday, Wednesday and Friday. A current Care Plan, initiated on 5/12/2023, indicated the resident was at risk for a fluid imbalance due to end stage renal disease, heart failure, hypo-osmolality and hyponatremia. Interventions included, but were not limited to: administer medications as ordered and encourage fluids. A current Care Plan, initiated on 5/12/2023, indicated the resident was at risk for constipation due to end stage renal disease, decreased mobility and polypharmacy (multiple drug use). Interventions included, but were not limited to: administer medications as ordered and encourage fluids. A current Care Plan, initiated on 5/15/2023, indicated the resident was at risk for altered nutritional status related to diagnoses of end stage renal disease, morbid obesity and diabetes type 2. Interventions included, but were not limited to: attends dialysis 3 x/week. regular diet. No water pitcher at bedside and communicate with the dialysis Register Dietician. A current Care Plan, initiated on 8/27/2024, indicated the resident had bruising to her left upper arm. Interventions included, but were no limited to: encourage fluids. The care plans for Resident 4 related to fluids contradicted themselves and were not revised to accurately reflect the resident's fluid needs and physician orders. During an interview, on 9/30/2024 at 9:30 A.M., the Director of Nursing indicated the care plans were not updated to and should have been. She indicated previously Resident 4 was consuming too much water. On 9/30/2024 at 10:38 A.M. the Social Service staff provided the policy titled, IDT Comprehensive Care Plan Policy, dated 8/2023, and indicated the policy was the one currently use by the provider. The policy indicated .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(d)(2)(B)

Based on observation and interview, the facility failed to ensure infection control practices were followed when administering insulin for 1 of 1 resident reviewed for insulin administration. (Resident 13) Finding includes: During an observation, on 9/27/2024 at 7:33 A.M., RN 4 washed her hands and applied gloves. She cleansed Resident 13's left outer arm with an alcohol pad and with an opened hand, she fanned the area she had just cleansed. During an interview, on 9/27/2024 at 7:35 A.M., RN 4 indicated she should not have fanned the area. On 9/30/2024 at 12:45 P.M., the Director of Nursing provided a Skills Competency titled Insulin Pen Administration, dated 10/2019, and indicated the policy was the one currently used by the facility. The policy indicated .14. Cleanse injection site with alcohol swab and allow to dry 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure medication carts were free from loose pills and failed to ensure medications were labeled in 1 of 2 medication storage areas observed. (Front hall medication cart) Finding includes: During an observation of the front hall medication cart, on 9/30/2024 at 10:28 A.M. with RN 4, the following was observed: - an opened bottle of Dr. Love [NAME] dietary supplement with no resident identifiers. - opened containers of Equate allergy relief, Equate gas relief and a container of Relaxium sleep tablets all with no resident identifiers. - and there were 3 looses pills in the mediation cart drawers. During an interview, on 9/30/2024 at 10:36 A.M., RN 4 indicated the pill containers should have had labels on them and there should be no loose pills in the medication cart. On 9/30/2024 at 12:45 P.M., the Director of Nursing provided a printed sheet titled Clinical Nurse Highlight- Medication Storage, and indicated this was the policy currently used by the facility. The policy indicated .Medication storage areas should always be clean and orderly . Medications are properly labeled with patient name, lot #, and expiration date. Over-the-counter med's for individual patients should have the patients name and expiration date noted on the medication (follow state regulations) 3.1-25(j)

Based on record review and interview, the facility failed to ensure a resident received the appropriate therapeutic diet for 1 of 1 residents reviewed for reviewed for dialysis. (Resident 4) Finding includes: The record for Resident 4 was reviewed on 9/26/2024 at 1:46 P.M. Diagnoses included, but were not limited to, heart failure, end stage renal disease, diabetes and bipolar. A Quarterly Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated the resident received dialysis. Resident 4's admission orders initiated 5/12/2023, indicated the diet order was: 3-4 GM (grams) NA (sodium) CCD (controlled carbohydrate diet), no orange or tomato juices or bananas. May have 8 oz milk every day, low NA bologna sandwich 1-2 times week if does not like what is served. A dialysis note/order, dated 10/11/2023, indicated the resident was to receive a diet-1GM K (potassium), 23 GM phosphorus, 2 GM or less NA and 48 oz. fluid restriction. A current Physician's Order Sheet, initiated on 10/25/2023, from the dialysis unit indicated a new order for Nephro (dietary supplement) twice a day until patient starts eating better. Resident 4's current Physician's Orders, dated 9/30/2024, included a regular diet, ordered on 5/12/2023, and there was no order for the Nephro. Resident 4's record lacked the documentation to show the diet order from admission on 5/12/2023 and the Nephro supplement order form 10/25/2023 had been followed. During an interview, on 9/30/2024 at 12:42 P.M., the Director of Nursing indicated she could not provide any further documentation for why the diet had been changed. She indicated the admission diet and the Nephro orders had not been transcribed correctly, and the resident had not received the Nephro supplement. On 9/30/2024 at 12:45 P.M. the Director of Nursing provided the policy titled, Dialysis Care, dated 11/207, and indicated the policy was the one currently used by the facility. The policy indicated . The facility will ensure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including: Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . 5. The nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident 3.1-46

Based on observation and interview, the facility failed to post daily nurse staffing data timely. Finding includes: During an observation on 9/25/2024 at 10:43 A.M., the nurse staffing data posting form was observed to be dated 9/24/2024. During an observation on 9/27/2024 at 8:02 A.M., the nurse staffing data posting fomr was observed to be dated 9/26/2024. During an observation on 9/30/2024 at 8:34 A.M., the nurse staffing data posting form was observed to be dated 9/27/2024. During an interview on 9/30/2024 at 10:44 A.M., the Executive Director indicated the Director of Nursing was responsible for posting the nurse staffing data every morning. A policy was provided by the Regional Director of Nursing on 9/30/2024 at 1:04 P.M. The policy, titled, Posted Staffing Data and Retention Requirements, indicated, .To allow public access to posted nursing staffing data per federal regulations .It is the policy of [facility organization name] to make staffing information readily available in a readable format and publicly posted to residents and visitors at any given time

Based on observation, record review and interview, the facility failed to develop a comprehensive person-centered care plan for a resident with positioning issues for 1 of 17 residents reviewed. (Resident 11) Finding includes: During an observation, on 9/25/2024 at 11:30 A.M., Resident 11 was leaned over to the left side of his wheelchair while in the dining room and there was a stuffed animal placed in between Resident 11's left arm and the armrest of his wheelchair. The medical record for Resident 11 was reviewed on 9/26/2024 at 3:32 P.M. Diagnoses included but were not limited to: diffuse traumatic brain injury, hemiplegia and hemiparesis following cardiovascular accident, conversion disorder with seizures, anxiety, depression, hypertension, chronic pulmonary obstructive disease, pulmonary embolism, cardiac arrest, contracture of left shoulder, difficulty in walking and coronary artery disease. The record lacked a person-centered care plan for the resident's positioning issues. During an interview, on 9/27/2024 at 9:21 A.M., CNA (Certified Nursing Assistant) 2 indicated if staff noticed Resident 11 was leaning to the left, staff would put the resident in bed and lay him down. During an interview, on 9/27/2024 at 9:28 A.M., the DON (Director of Nursing) indicated facility staff just used pillows to prevent Resident 11 from leaning to the left in his wheelchair. The DON indicated a half-lap tray to prevent the resident from leaning to the left was previously utilized, but Resident 11's mother had requested they quit using the tray. The DON indicated staff should have placed pillows between the resident's wheelchair and his left arm to prevent pressure. The DON indicated preventing Resident 11 from leaning to his left side with pillows should have been included in the resident's current care plan. On 9/30/2024 at 10:28 A.M., the Social Service Director provided a policy titled, IDT Comprehensive Care Plan Policy, dated 8/2023 and indicated the policy was the one currently used by the facility. The policy indicated .each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented .must include measurable goals and resident specific interventions based on resident needs . 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure food items in the freezer were dated/labeled with used by dates, dispose of expired foods, and failed to ensure the dishwasher, freezer, and toaster were clean and in good condition in the main kitchen. This deficient practice had the potential to affect 31 of 31 residents who received meals out of the kitchen. Findings include: During an observation of the kitchen on [DATE] at 9:34 A.M., with Dietary Staff 9, the following was observed: -The freezer had a zip lock bag of diced potatoes undated, a bag of frozen biscuits with a use by date of [DATE], an open bag of frozen fish filets with no use by date. -The refrigerator had 3 bowls of cream of wheat undated, an undated bowl of gravy, an undated bowl of mashed potatoes, an undated unopened bag of bologna, and an opened pack of gravy mix with no use by date. - The following spices were noted on the shelf and undated: garden seasoning, baking powder, parsley flakes and ground cinnamon. -The shelf and wall above the stove was covered in a grease like substance. -The top of the dishwasher was dirty and covered in crumbs. -The toaster had a dry substance around the knobs. -The bottom freezer shelf was covered in grit. During an interview, on [DATE] at 10:01 A.M., Dietary Staff 9 indicated the undated items should have dates on them, the expired items should have been thrown away and the wall, shelf, dishwasher, toaster and bottom freezer shelf should have been cleaned. On [DATE] at 12:35 P.M., the Executive Director provided the current policy titled, Cleaning Freezers, dated ,d+[DATE]. The policy indicated .Freezers will be kept clean and free of ice buildup. 2. Freezer racks and walls will be deep cleaned as needed. 3. Wash shelves and walls with sudsy water. Rinse and sanitize using sanitizing solution. Allow to air dry On [DATE] at 12:35 P.M., the Executive Director provided the policy titled, Cleaning Toaster, dated ,d+[DATE]. The policy indicated .The toaster will be cleaned after each use On [DATE] at 12:35 P.M., the Executive Director provided the policy titled, Labeling and Dating, dated ,d+[DATE]. The policy indicated .Processed meats and any item that has been cooked and cooled should be kept no longer than 3 days. Label with the date of storage and the date of discard. The date the product must be consumed or discarded may not exceed the manufacturer's use by date 3XXX,d+[DATE](i)(3)

Based on record review and interviews, the facility failed to ensure care plan meetings, including the resident and/or their representative were conducted timely for 3 of 14 residents reviewed. (Resident 3, 11 and 27) Findings include: 1. The record for Resident 27 was reviewed on 10/4/2023 at 1:26 P.M. Resident 27 was admitted to the facility on [DATE] with diagnoses, including but not limited to: right lower quadrant abdominal swelling, mass and lump, Chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The most recent Minimum Data Set (MDS) assessment, completed on 7/28/2023 for an initial admission assessment, indicated the resident was alert and oriented. During an interview with alert and oriented Resident 27, on 10/3/2023 at 11:31 A.M., the resident indicated she did not recall being invited to a care plan meeting. Review of the electronic record, including the observation documentation and the nursing progress notes indicated there was no care plan meeting summary notes. There were two Transitions of care meetings , dated 7/25/2023 and 8/1/2023 held but no care plan meeting held. The only meeting documented to have included the resident, was a Road to Recovery therapy meeting, held on 7/26/2023. The Transitions of Care meetings did not include all of the interdisciplinary department heads and did not include the resident and/or their representative. During an interview with the Administrator, on 10/10/2023 at 1:30 P.M., she indicated the Road to Recovery meeting was a therapy meeting and not a care plan meeting. During an interview with the MDS coordinator, on 10/10/2023 at 11:30 A.M., she indicated she was responsible for three buildings and was not always available for resident care plan meetings. She indicated the care plan meetings were documented in the Observation section of the electronic record and were labeled Care Plan Summary. 45120 2. During an interview with Resident 11 on 10/4/2023 at 9:04 A.M., Resident 11 indicated she does not have care plan meetings, and was not aware of the medications she received. A record review was completed on 10/4/2023 at 11:14 A.M. Diagnoses included history of malignant neoplasm of large intestines, heart failure, and chronic obstructive pulmonary disease. Care Plan Meeting Notes were identified for 2/17/2023 and 6/21/2023 with Resident 11 and her daughter in attendance. A Progress Note on 2/2/2023 at 11:13 A.M., indicated the Social Service Director spoke with Resident 11's daughter regarding a care plan meeting. On 6/19/2023 at 9:53 A.M., a Progress Note indicated Resident 11's daughter called and would schedule a care plan meeting after Resident 11's eye doctor appointment and the meeting was scheduled for 6/21/2023 at 1:00 P.M. During an interview on 10/4/2023 at 1:45 P.M., the Social Service Director indicated care plan meetings were completed with the Minimum Data Set (MDS) assessments. She indicated notification of the care plan meetings were documented in the progress notes. She indicated Resident 11 should have more than the two care meetings that were documented. A review of the MDS assessments indicated the following assessments were completed: 8/16/2023 Annual 5/31/2023 Quarterly 3/8/2023 Quarterly 1/11/2023 Quarterly 10/19/2022 Annual 38121 3. During an interview, on 10/3/2023 at 10:23 A.M., Resident 3 indicated she has not had a careplan meeting since admission. A record review was completed on, 10/4/2023 at 11:28 A.M., and indicated Resident 3's diagnoses included, but were not limited to: Hypertensive heart and chronic kidney disease with heart failure, Stage 5 chronic kidney disease/end stage renal disease, diabetes, arteriovenous fistula, hypotension, atrial fibrillation, bipolar II disorder, morbid obesity, anxiety, obstructive sleep apnea, and anemia in chronic kidney disease. A Quarterly MDS (Minimum Data Set) assessment, dated 8/16/2023 indicated Resident 3 has intact cognition. During an interview, on 10/04/2023 at 2:19 P.M., the Director of Nursing indicated the Resident had a careplan meeting in June and she should have had another one in September. On 10/10/2023, at 2:08 P.M., the Director of Nursing provided the policy titled,IDT Comprehensive Care Plan Policy, dated 8/2023, and indicated the policy was the one currently used by the facility. The policy indicated .Care plan review will be interdisciplinary and should include, to the extent possible, nursing, social services, activities, dietary, therapy, pharmacy, physician, direct care staff and hospice, if indicated. Resident, resident's representative, or others as designated by resident will be invited to the care plan review 3.1-35(c)(2)

Based on interview and record review, the facility failed to follow through with physician recommendations for 1 of 1 residents reviewed for urinary tract infections. (Resident 11) Finding includes: During an interview with Resident 11 on 10/4/2023 at 9:07 A.M., she indicated that she recently was on an antibiotic for a urinary tract infection, and had frequent urinary tract infections. A record review was completed on 10/4/2023 at 11:14 A.M. Diagnoses included, but were not limited to: hematuria, overactive bladder, and constipation. A Quarterly Minimum Data Set (MDS) assessment on 8/16/2023, indicated Resident 11 was always incontinent of bladder and bowel. Resident 11 was cognitively intact. A review of Resident 11's urinalysis indicated the following: -On 1/24/2023 she was positive for a urinary tract infection with Citrobacter koseri (a bacteria). Sulfamethoxazole-trimethoprim (an antibiotic) 800-160 milligram twice daily for 7 days was prescribed. -On 3/24/2023 she was positive for a urinary tract infection with Proteus mirabils (a bacteria). Cephalexin (an antibiotic) 500 milligrams three times daily for seven days was prescribed. -On 4/20/2023 she had a negative urinalysis. -On 5/25/2023 she was positive for a urinary tract infection with Citrobacter koseri. Cephalexin 500 milligrams twice daily for five days was prescribed. -On 7/22/2023 she had a negative urinalysis. A urology referral was requested by the nurse practitioner. -On 8/21/2023 she was positive for a urinary tract infection, bacteria unknown as page 2 of the urinalysis was not available. Cephalexin 500 milligrams twice daily for seven days was prescribed. A Nurse's Note on 4/6/2023 at 10:46 A.M., indicated the resident had blood in the urine, a urinalysis was collected and lab work completed. Resident 11 had a referral for urology consultation pending. On 4/10/2023 at 12:41 P.M., a Nurse's Note indicated a telephone call was made for a urology referral, and the receptionist indicated Medicaid was not accepted. A Urologist in the local area would be contacted. On 4/27/2023 at 12:45 P.M., a Nurse's Note indicated normal urinary ultrasound and lab work. The nurse practitioner indicated if changes occurred a referral to urology should be made. A Nurse Practitioner Note on 5/24/2023 at 2:30 P.M., indicated Resident 11 was being seen for blood in her brief, and nursing staff suspected it was coming from the bladder. The assessment/treatment plan indicated possible hematuria/hemorrhoids and if blood continued to have a urology consult. A Physician's Note on 7/5/2023 at 2:30 P.M., recorded as a late entry on 9/3/2023 at 3:06 P.M., indicated hematuria/hemorrhoids resolved, but if reocurred to send to urology. A Nurse Practitioner Note on 7/19/2023 at 12:30 P.M., indicated Resident 11 was visited due to hematuria, and it was a reoccurrence of hematuria. Resident 11 had a history of urinary tract infections. The nurse practitioner spoke with the Director of Nursing (DON), and the DON was concerned that Resident 11's masturbating was causing injury. Resident 11 denied this practice during interview with the nurse practitioner. The assessment/plan indicated hematuria/hemorrhoids: urology referral, and collection of urine for a urinalysis with culture and sensitivity. On 7/24/2023 at 1:49 P.M., a Nurse's Note indicated the nurse practitioner was notified of urinalysis results, and to continue with the urology referral. A Care Plan initiated on 4/9/2023, and revised on 8/29/2023 at 11:13 A.M., indicated Resident 11 had chronic urinary tract infections and was at risk for future infections. During an interview on 10/10/2023 at 10:47 A.M., LPN 5 indicated Resident 11 had not had a urology consultation, and she believed Resident 11 did not want to go to the urologist. On 10/10/2023 at 10:49 A.M., Resident 11 indicated she wanted to see urology, and she believed she currently had another infection. She indicated she had an established urologist that she saw three to four years ago. A current policy titled, Bowel and Bladder Program, was provided by the Director of Nursing on 10/10/2023 at 2:08 P.M. The policy indicated, .The care plan and resident profile must represent the appropriate program and resident specific interventions 3.1-41(a)(2)

Based on interview, and record review the facility failed to care plan interventions for gastrointestinal reflux disease, tremors, and the use of an antidepressant for 1 of 5 residents reviewed. (Resident 24) Finding includes: A record review was completed on 10/6/2023 at 8:57 A.M. Diagnoses included, but were not limited to: systemic lupus erythematous, polyneuropathy, rheumatoid arthritis, depression, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment on 9/6/2023 indicated Resident 24 received an antidepressant for seven days of the seven-day look back period. She had severe cognitive impairment. A review of Resident 24's medications indicated she received pantoprazole 40 milligrams daily for gastroesophageal reflux disease since 3/29/2023, benztropine 1.5 milligrams three times daily for tremors since 4/5/2023, and escitalopram oxalate 20 milligrams daily for depression since 7/29/2023. During an interview with the Director of Nursing on 10/10/2023 at 11:05 A.M., she indicated that the MDS (Minimum Data Set) Coordinator works in three buildings, so with the smaller building the Director of Nursing was responsible for making sure care plans were completed. On 10/10/2023 at 11:25 A.M., the Director of Nursing indicated that there were no care plans for gastroesophageal reflux disease, tremors, or use of an antidepressant. A policy titled, IDT [Interdisciplinary Team] Comprehensive Care Plan Policy, was provided by the Social Service Director on 10/4/2023 at 3:14 P.M. The policy indicated, .Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families, and/or representative regarding the resident goals, total health status, including functional status, nutritional status, rehabilitative and restorative potential, ability to participate in activities, cognitive status, psychosocial status, sensory and physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms .Improve relationships between resident, families and/or representative, and facility care givers through understanding of resident's social history, culture and preferences to enhance the resident's life .Resident, resident's representative, or others as designated by resident will be invited to care plan review .The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference 3.1-35(e)

Based on observation, record review and interview, the facility failed to ensure respiratory equipment was stored properly for 1 of 1 resident reviewed for oxygen therapy. (Resident 182) Finding includes: During an observation on 10/3/2023 at 9:38 A.M. and at 1:02 P.M., the portable oxygen nasal cannula was lying on the floor under Resident 182's wheelchair, and the nebulizer mask was lying on the bedside table. On 10/4/2023 at 8:56 A.M., the portable oxygen nasal cannula was lying on the wheelchair seat. A record review was completed on 10/4/2023 at 2:31 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, anxiety disorder, and respiratory failure with hypoxia. Physician's Orders included oxygen at three liters per nasal cannula continuously, and ipratropium-albuterol nebulizer solution 0.5 milligram-3 milligram give 3 milliliters via inhalation. A Care Plan indicated Resident 182 had symptoms of decreased oxygenation On 10/5/2023 at 9:57 A.M., and 10/6/2023 at 1:52 P.M., the portable oxygen nasal cannula was observed in a wash basin on the wheelchair cushion. During an interview on 10/10/2023 at 10:39 A.M., CNA 6 indicated nebulizer masks and nasal cannulas should be stored in a respiratory bag when not in use. A policy, titled Oxygen Concentrator, was provided on 10/10/2023 at 2:08 P.M. by the Director of Nursing. The policy did not identify storage of oxygen equipment when not in use. 3.1-47(a)4 3.1-47(a)5 3.1-47(a)6

Based on record review and interview, the facility failed to ensure a Resident with a history of constipation and ileus was assessed, medicated and had their physician notified of a lack of bowel movement after 5 days as a result the resident continued to experience bouts of constipation and nausea nad vomiting and was hospitalized 21 days later with a small bowel obstruction for 1 of 3 residents reviewed. (Resident 82) Finding includes: During an initial interview on 10/03/23 at 11:53 A.M., Resident 8 indicated she had recently been hospitalized for abdominal pain. See F684. A record review was completed on 10/05/23 at 9:09 A.M. Diagnoses included, but were not limited to: constipation, history of an ileus, gastroesophageal reflux disease, anemia, bilious vomiting, polycythemia vera, and abnormal weight loss. A Care Plan dated 6/10/2022, and revised 10/5/2023 at 9:52 A.M., indicated Resident 8 was at risk for constipation due to decreased mobility and medications. The goal was to have a soft formed bowel movement at least every three days. The interventions included for an abdominal assessment if no bowel movement for four days, bowel sounds, abdominal distension hyper/hypoactive bowel sounds, abdominal pain or tenderness, document and notify the physician of any abnormal findings, administer medications as ordered, encourage fluids, monitor bowel function, and notify the physician if no bowel movement after the third day. Resident 8's bowel movement record for June 2023, indicated the following: 6/1/2023 Medium 6/2/2023-6/6/2023 None (5 days, no treatment) 6/7/2023 Medium x 2 6/8/2023 Large 6/9/2023-6/10/2023 None (2 days) 6/11/2023 Medium 6/12/2023 None 6/13/2023 Large 6/14/2023-6/16/2023 None (3 days, no treatment) 6/17/2023 Large 6/18/2023 Medium 6/19/2023 Small 6/20/2023-6/21/2023 None (3 days, no treatment) 6/22/2023 Large 6/23/2023 Medium 6/24/2023 Medium 6/25/2023 Large x 2 6/26/2023-6/27/2023 (2 days) Resident 8 did not have any orders for routine bowel medications. She did have as needed medications of Milk of Magnesia suspension 400 milligrams per 5 milliliter give 30 milliliters daily for constipation, and loperamide 2 milligrams give 4 milligrams every four hours for loose stools. The Medication Administration Record for June 2023 indicated Resident 8 received loperamide 4 milligrams on 6/19/2023 at 12:07 P.M. for an unknown reason, 6/19/2023 at 6:11 P.M. for nausea and vomiting, 6/20/2023 at 2:56 P.M. for an upset stomach, and on 6/22/2023 at 9:42 A.M. for nausea and vomiting. Resident 8 received Milk of Magnesia 30 milliliters on 6/26/2023 at 2:39 P.M. for constipation. An SBAR (Situation, Background, Assessment, and Recommendation) form was completed on 6/27/2023 at 5:53 P.M., and indicated Resident 8 was lethargic and not talking clearly. Her skin was pale and warm. Her vital signs were blood pressure 158/95, pulse 99, respirations 16, temperature 97.3, and oxygen saturation of 90%. The nurse's request was for a chest x-ray. No further assessment was documented. A Progress Note on 6/27/2023 at 6:11 P.M., indicated a call was placed to the physician and updated on Resident 8's condition. A new order was obtained to send to the Emergency Department for evaluation and treatment. An emergency room History & Physical report on 6/27/2023, indicated Resident 8 started to complain of some right lower quadrant abdominal pain a few days ago that progressively worsened with associated headache, decreased oral intake and nausea, but no vomiting. The abdominal assessment indicated soft, mild distension to the right lower quadrant with tenderness to palpate, and absent bowel sounds. Resident 8 was admitted to the hospital with a partial small bowel obstruction, right lower quadrant pain, and chronic constipation. On 6/27/2023 at 7:56 P.M. a Computed Tomography scan was completed at the hospital. The results indicated, .Small bowel: Small bowel loops are mildly dilated and partially fluid-filled. There is a possible point in the right anterior pelvis. No bowel wall gas or free air. Colon: The sigmoid colon is filled with stool and was similar on the prior CT scan. Impression: 1. Findings consistent with early or partial small bowel obstruction. Small bowel loops are mildly dilated. Possible transition point in the right pelvis. No free air or bowel wall gas. 2. The sigmoid colon is filled with stool and could represent constipation During an interview with CNA 6 on 10/10/2023 at 10:40 A.M., CNA 6 indicated Resident 8 bowel movements can vary from constipation, loose stools, and sometimes Resident 8 stated she couldn't have a bowel movement at all. She indicated they document bowel movements every shift, informed the nurse if constipation or liquid diarrhea occurred, and informed the nurse if the resident requested a suppository or enema. On 10/10/2023 at 10:46 A.M., LPN 5 indicated the bowel protocol was to administer prune juice, Milk of Magnesia, a suppository, or enema if ordered after three days without a bowel movement and to notify the physician. The facility policy and procedure, titled, Resident Change of Condition Policy, provided by the Director of Nursing on 10/10/2023 at 1:55 P.M. included the following: .3. Non-Urgent Medical Change a. All symptoms and unusual signs will be documented in the medical recorded communicated to the attending physician promptly. Non-urgent changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. b. The nurse in charge is responsible for notifications of physician and family/responsible party prior to the end of assigned shift when a significant change in the resident's condition is noted 3.1-5(a)

Based on observation, record review and interview, the facility failed to ensure the physician responded timely to pharmacy recommendations for 1 of 5 residents reviewed for medication use. (Resident 4) Findings include: The record for Resident 4 was reviewed on 10/4/2023 at 2:05 P.M. Resident 4 was admitted to the facility with diagnosis, including but not limited to: chronic obstructive pulmonary disease, systolic congestive heart failure, chronic respiratory failure with hypoxia, bipolar disorder and emphysema. The most recent MDS (Minimum Data Set) assessment for Resident 4, completed as a quarterly review on 7/5/2023, indicated the resident was alert and oriented and required the extensive assistance of one staff for bed mobility, ambulation needs, personal hygiene, dressing, and toileting needs. The current physician's orders for medications included adult low dose aspirin and plavix (a medication to prevent blood clotting). A pharmacy recommendation, dated March 1, 2023, recommended the physician consider discontinuing either the aspirin or the Plavix. The physician did not respond to the recommendation until 6/7/2023. During an interview with the Director of Nursing, on 10/10/2023 at 10:30 A.M., she indicated the facility policy was to have the physician address the pharmacy recommendations within 30 days. The facility policy and procedure, titled, LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual included the following: .11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation . 3.1-25(h)

Based on record review and interview, the facility failed to ensure a resident received care planned interventions during periods of constipation for 1 of 3 residents reviewed for bowel management (Resident 82). Findings include: 1. During an initial interview on 10/03/23 at 11:53 A.M., Resident 8 indicated she had recently been hospitalized for abdominal pain. See F580. A record review was completed on 10/05/23 at 9:09 A.M. Diagnoses included, but were not limited to: constipation, history of an ileus, gastroesophageal reflux disease, anemia, bilious vomiting, polycythemia vera, and abnormal weight loss. A Care Plan dated 6/10/2022, and revised 10/5/2023 at 9:52 A.M., indicated Resident 8 was at risk for constipation due to decreased mobility and medications. The goal was to have a soft formed bowel movement at least every three days. The interventions included for an abdominal assessment if no bowel movement for four days, bowel sounds, abdominal distension hyper/hypoactive bowel sounds, abdominal pain or tenderness, document and notify the physician of any abnormal findings, administer medications as ordered, encourage fluids, monitor bowel function, and notify the physician if no bowel movement after the third day. Resident 8's bowel movement record for June 2023, indicated the following: 6/1/2023 Medium 6/2/2023-6/6/2023 None (5 days, no treatment) 6/7/2023 Medium x 2 6/8/2023 Large 6/9/2023-6/10/2023 None (2 days) 6/11/2023 Medium 6/12/2023 None 6/13/2023 Large 6/14/2023-6/16/2023 None (3 days, no treatment) 6/17/2023 Large 6/18/2023 Medium 6/19/2023 Small 6/20/2023-6/21/2023 None (3 days, no treatment) 6/22/2023 Large 6/23/2023 Medium 6/24/2023 Medium 6/25/2023 Large x 2 6/26/2023-6/27/2023 (2 days) Resident 8 did not have any orders for routine bowel medications. She did have as needed medications of Milk of Magnesia suspension 400 milligrams per 5 milliliter give 30 milliliters daily for constipation, and loperamide 2 milligrams give 4 milligrams every four hours for loose stools. The Medication Administration Record for June 2023 indicated Resident 8 received loperamide 4 milligrams on 6/19/2023 at 12:07 P.M. for an unknown reason, 6/19/2023 at 6:11 P.M. for nausea and vomiting, 6/20/2023 at 2:56 P.M. for an upset stomach, and on 6/22/2023 at 9:42 A.M. for nausea and vomiting. Resident 8 received Milk of Magnesia 30 milliliters on 6/26/2023 at 2:39 P.M. for constipation. An SBAR (Situation, Background, Assessment, and Recommendation) form was completed on 6/27/2023 at 5:53 P.M., and indicated Resident 8 was lethargic and not talking clearly. Her skin was pale and warm. Her vital signs were blood pressure 158/95, pulse 99, respirations 16, temperature 97.3, and oxygen saturation of 90%. The nurse's request was for a chest x-ray. No further assessment was documented. A Progress Note on 6/27/2023 at 6:11 P.M., indicated a call was placed to the physician and updated on Resident 8's condition. A new order was obtained to send to the Emergency Department for evaluation and treatment. An emergency room History & Physical report on 6/27/2023, indicated Resident 8 started to complain of some right lower quadrant abdominal pain a few days ago that progressively worsened with associated headache, decreased oral intake and nausea, but no vomiting. The abdominal assessment indicated soft, mild distension to the right lower quadrant with tenderness to palpate, and absent bowel sounds. Resident 8 was admitted to the hospital with a partial small bowel obstruction, right lower quadrant pain, and chronic constipation. On 6/27/2023 at 7:56 P.M. a Computed Tomography scan was completed at the hospital. The results indicated, .Small bowel: Small bowel loops are mildly dilated and partially fluid-filled. There is a possible point in the right anterior pelvis. No bowel wall gas or free air. Colon: The sigmoid colon is filled with stool and was similar on the prior CT scan. Impression: 1. Findings consistent with early or partial small bowel obstruction. Small bowel loops are mildly dilated. Possible transition point in the right pelvis. No free air or bowel wall gas. 2. The sigmoid colon is filled with stool and could represent constipation During an interview with CNA 6 on 10/10/2023 at 10:40 A.M., CNA 6 indicated Resident 8 bowel movements can vary from constipation, loose stools, and sometimes Resident 8 stated she couldn't have a bowel movement at all. She indicated they document bowel movements every shift, informed the nurse if constipation or liquid diarrhea occurred, and informed the nurse if the resident requested a suppository or enema. On 10/10/2023 at 10:46 A.M., LPN 5 indicated the bowel protocol was to administer prune juice, Milk of Magnesia, a suppository, or enema if ordered after three days without a bowel movement and to notify the physician. The facility policy and procedure, titled, Resident Change of Condition Policy, provided by the Director of Nursing on 10/10/2023 at 1:55 P.M. included the following: .3. Non-Urgent Medical Change a. All symptoms and unusual signs will be documented in the medical recorded communicated to the attending physician promptly. Non-urgent changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. b. The nurse in charge is responsible for notifications of physician and family/responsible party prior to the end of assigned shift when a significant change in the resident's condition is noted 3.1-37

Based on observation and interview, the facility failed to ensure PPE was worn and hand hygiene performed during medication pass for 1 of 1 observations. Findings include: During an initial medication administration observation on 8/3/22 at 8:28 AM, LPN 2 was observed dispensing tablets from the medication pack into her bare hand then placed them into a medication cup. LPN 2 was observed to do this several times. ABHS (alcohol based hand sanitizer) was not utilized between obtaining each resident's medication. LPN 2 also was observed touching the computer to chart, the top of the medication cart, and the narcotic record. on the medication cart. ABHS was not utilized prior to touching items on the medication cart and dispensing medications into her hand. LPN 2 then opened up the medication cart, obtained a liquid medication bottle (inside a plastic bag) with small plastic syringe. LPN 2 was observed placing the plastic syringe into the liquid medication bottle and drew some medication out. She then placed the plastic syringe (with the medication inside) directly on top of the medication cart without covering it. LPN 2 then picked up a log book, wrote in it, then put the book away, picked up the plastic syringe and emptied the liquid medication into a medication cup. LPN 2 placed the syringe back into the bag with the medication bottle and placed the bag in the medication cart. LPN 2 was observed to clean some of the liquid medication residue from the top of the cart with tissues, then used ABHS. LPN 2 was observed to go in front of her medication cart, obtain some tissues and blow her nose. LPN 2 then placed the tissue inside the trash can next to the medication cart. LPN 2 locked the medication cart, picked up the medication cups and proceeded to walk toward a residents room. LPN 2 did not her wash hands or use ABHS after blowing her nose. LPN 2 then walked into residents room, gave the medication cup to resident then adjust the resident's straw. LPN 2 did not don or doff gloves during the observation. During an observation on 8/3/22 at 8:38 AM, LPN 2 was observed dispensing medication tablets from a medication pack into her bare hands before placing then into medication cup. LPN 2 did not use ABHS in between obtaining medications. During an observation on 8/3/22 at 11:46 AM, LPN 2 explained she would be giving Insulin [MEDICATION(S)] 15 units injectable pen. LPN 2 obtained a disposable needle, cleaned around the insulin hub with an alcohol pad then twisted the disposable needle onto the insulin pen. LPN 2 gathered the rest of the supplies, turned to the cart next to her, and donned 2 disposable gloves. She walked through the hallway with the gloves on. LPN 2 knocked on the door with her gloves on. LPN 2 then cleaned the site, gave the insulin, then took one glove off and left the other one while holding the disposable needle inside. LPN2 Walked back through the hallway to her medication cart and placed the disposable needle inside the sharps container with a gloved hand. LPN 2 did not perform hand hygiene after the insulin administration. In an interview on 08/03/22 at 12:27 PM LPN 1 indicated when giving medications, the orders should be checked in the computer, the correct dose verified, as well as date, type of medication, and route reviewed. Then supplies are obtained, hand hyginene performed, and gloves donned. After medication is given, gloves would be doffed, hand hygiene performed, and charting completed in the computer. If insulin is to be given, hand hygiene would be performed, the pen prepped, correct dose verified, prep the resident's skin with alcohol, and insulin would be administered. When handling resident's oral medications, hand hygiene would be performed first, then the medications would be placed into the medication container without touching the medications. In an interview on 8/3/22 at 12:38 PM, the Director of Nursing indicated the facility expected the nurses, during a medication administration, to follow the five rights and perform hand hygiene. A current facility policy, Hand Hygiene Policy, dated 12/21, was provided by the Director of Nursing on 8/3/22 at 1:34 PM. The policy indicated . To provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees .5 moments of hand hygiene-term that describes the hand hygiene opportunities that prevent infection transmission lined to healthcare activities. Before touching a resident. Before clean/aseptic procedure. After body fluid exposure risk. After touching a resident. After touching resident surroundings A current facility policy, Medication Administration, dated 3/17, was provided by the Director of Nursing on 8/3/22 at 1:34 PM. The policy indicated . Proper hand hygiene is performed before and after and examination gloves worn for administration of topical, ophthalmic, injections, eneteral, rectal, and vaginal medications 3.1-18(a)

Based on record review and interview, the facility failed to ensure a resident who was at risk for falls, had her needs attended to, by a licensed staff member, thus putting her at an increased risk for falls and injury, and subsequently resulted in her sustaining a fall and fracturing her left humerous (arm). This deficient practice affected 1 of 3 residents reviewed for falls with fracture. (Resident G) Finding includes: The clinical record for Resident G was reviewed on 1/30/2020 at 11:00 [NAME]M., [DIAGNOSES REDACTED]. A Care Plan, dated 2/4/2019, indicated .I am at risk for falls r/t (related to) my history and fall since admission to facility, dementia, chronic confusion, Left hip fx with repair, medications .Interventions: Bed Alarm .Chair Alarm .Keep walker in reach when in bed Date initiated: 4/17/19 .Non-Skid socks on at all times Date Initiated: 4/17/19 A Progress Note, dated 5/18/2019 at 12:30 [NAME]M., indicated .Resident alarm sounding, resident noted to be ambulating in hallway near room, when staff noted resident trip and fall landing on right side but hitting head and left upper arm on doorway as she fell . Resident stated. I tripped .Resident assessed. Laceration above left eyebrow noted, measures 1.5 x (by) < (less than) 0.1 cm (centimeters) and upper arm swollen with hard protrusion noted. Obtained tx (treatment) for Marathon (a barrier cream) to left side of forehead, ice to LUE (left upper extremity) and to send to ER (emergency room ) for eval and tx (evaluation and treatment) for LUE pain/abnormality r/t (related to) possible fx (sic) (fracture) per NP (Nurse Practitioner) A Fall Investigation Report, dated 5/18/19 at 12:30 [NAME]M., indicated .Resident Name: (Resident G) .Date/Time: 5-18-19 at (sic) 0030 (12:30 [NAME]M.) .Active Diagnoses: [REDACTED].Assistive Devices: walker .Call light within reach: N/A (non applicable) .Alarm in use: Yes. If yes, what type: bed alarm. Did it sound: Yes .Other factors: Time last checked by CNA/nurse 0000 (12:00 [NAME]M.) Staff in attendance when fall occurred: Yes. Exact location of incident: In entrance of doorway to (room) . Description of incident: Res. (Resident) tripped causing her to fall, Res. hit her Lt. (left) arm et (and) Lt. side of head on door frame when she fell , landed on Rt. (Right)side .Description of Injury: Laceration 1.5 x < 0.1 cm above Lt. eyebrow, Lt. upper (sic) arm swollen with hard protrusion noted, c/o (complain of) severe pain .Treatment/First Aid Administered: VS (vital signs) obtained, ice applied to LUE (left upper extremity), Marathon (a house barrier cream) tx (treatment) applied to laceration, Res sent to ER for eval/tx for possible LUE fx (fracture) .Resident account of incident: I just tripped.Witnesses: (Employee 1) Maintenance Director .High Risk Factor Present: Date of last fall: 4/10/19 .Visual deficit .Incontinent .Unsteady gait .[MEDICAL CONDITION] meds .ST (short term) memory loss .Dementia .Functional Assessment (Section G ADL (activities of daily living) MDS (Minimum Data Set) Date: 3-4-2019 .If incident involved these functions, did staff supply appropriate assistance as assessed/care planned for resident? .Safety/Personal Alarm Type: Bed alarm Was alarm in place? Yes. Alarm function assessed? Yes. Fall prevention plan in place? Yes . What happened/What caused the fall? Resident tripped on her footwear causing fall, had on house slippers that were too large for her .How will this incident be prevented from occurring again? House slippers removed from availability to wear A Discharge Documentation, dated 5/19/2019 at 7:37[NAME]M., indicated .admitted : (MONTH) 18, 2019. Chief Complaint: Pt. (patient) brought to the ER by EMS (Emergency Medical Service) due to a fall at the nursing home where the pt. resides. pt has an (sic) injury to her left arm, there is obvious deformity, good CMS (circulatory motor sensory) poor ROM (range of motion) due to deformity and pain, pt is confused which is normal for pt due to dementia .Hospital Course: She has a 1 cm laceration of the left eyebrow area .She also has a closed mid shaft [MEDICAL CONDITION] humerous. Patient was splinted and admitted to the hospitalist service for pain control and further evaluation .She is not anticoagulated .Sling fitted for comfort and support The clinical record lacked documentation of who had checked on Resident B at 12:00 [NAME]M. and who, if anyone, placed the house slippers on the residents feet as she was to wear non-skid socks at all times as per her care of care. A Daily Report Sheet, dated 5/17/2019, indicated the following staff .Nights: (11-7) Nurse: DON (Director of Nursing) and CNA: Employee 1 A review of Employee 1's filed lacked documentation of a Certified Nursing Assistant certificate. Employee 1 was employed by the facility in the role of Maintenance Director. A Time Detail Report, dated 5/17/2019 through 5/19/2019, indicated Employee 1 had worked from 9:38 PM on Friday 5/17/19 to 6:23 [NAME]M. on 5/18/19. During an interview, on 1/30/2020 at 1:40 P.M., the Administrator indicated she had not been employed by the facility at the time of the incident and was unaware of the events of 5/18/2019. The employee's who were in the role of Director of Nurses and Maintenance Director, at the time of the occurrence, were no longer employed by the facility. She indicated she could only speak to the information that she was able to recover from the incident and that it is not a facility practice to schedule unlicensed staff to work in the role of a licensed staff person. The facility did not have a policy to address the staffing. This Federal Tag is related to Complaint IN 367. 3.1-45(a)(1) 3.1-45(a)(2)

A. Based on observation, record review and interview, the facility failed to provide care and services related to diabetic monitoring for a resident who exhibited high and low blood sugar readings at the facility resulting in a change of consciousness and hospitalization . The facility failed to ensure physician orders for a readmission to the facility were followed timely for intravenous fluids for hydration and care of a PICC (Peripherally Inserted Central Catheter) line physician clarification was obtained for the use of a Foley catheter for 1 of 7 residents reviewed for physician orders. (Resident #47) The facility failed to ensure diabetes and blood glucose monitoring was initiated timely for 1 of 10 residents with diabetes. (Resident #47) The Immediate Jeopardy began on 02/26/16 when Resident #47 was initially admitted to the facility with [DIAGNOSES REDACTED]. This deficient practice resulted in a hospitalization due to [DIAGNOSES REDACTED] (decreased blood glucose levels) for Resident #47. The Immediate Jeopardy continued as physician orders regarding intravenous fluids and care of a PICC line were not initiated timely. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 1:07 P.M. on 03/09/16. The Immediate Jeopardy was removed on 03/15/16 at 2:35 P.M., but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. Based on observation, record review and interviews the facility failed to ensure admission orders [REDACTED]. (Resident #45, #46, #49, and D) In addition, the facility failed to ensure insulin was administered timely for 2 of residents observed during a medication administration observation. The facility failed to ensure a system was in place to communicate with a [MEDICAL TREATMENT] center and complete post [MEDICAL TREATMENT] assessments for 1 of 1 residents reviewed regarding [MEDICAL TREATMENT]. The facility also failed to ensure impaired skin was assessed timely and thoroughly for 4 of 6 residents reviewed due to impaired skin or pressure ulcers. (Resident B, #49, #11 and #47) Findings include: A. During the initial tour, on 3/7/16 at 9:50 A.M., Resident #47's indwelling Foley was observed from the hallway. The Foley catheter was not in a dignity bag and was observed on the floor, slightly under the resident's bed. On 3/9/16 a 9:22 A.M., a review of the clinical record for Resident #47 was conducted. The record indicated the resident was initially admitted on [DATE] from the hospital. On 2/28/16 at 8:30 P.M., the resident was found unresponsive and sent to the emergency room (ER). He was released from the ER and returned to the facility on [DATE] at 3:15 P.M. On 3/2/16 at 12:54 P.M., the resident was again found unresponsive and sent to the ER. He was admitted to the hospital at that time. He was readmitted to the facility on [DATE] at 9:30 P.M. Resident 47's diagnoses, included but were not limited to: adult failure to thrive, [MEDICAL CONDITION], insulin dependent diabetic-uncontrolled, chronic embolism/[MEDICAL CONDITION] of deep veins of lower extremity (bilateral), [MEDICAL CONDITIONS] [MEDICAL CONDITION]. A hospital History & Physical (H and P), dated 2/26/16, indicated the resident had presented to the ER with complaints of lower extremity swelling and ulcerations of his lower extremities, increased falls poorly controlled diabetic and generalized weakness. The H&P indicated the resident was noncompliant with medications and diet. The resident's glucose upon admission (to the acute care facility) was 687 and he had a poor nutritional status. The H&P indicated the resident had a decubitus ulcer on his buttock, multiple abrasions on his lower extremities, some of the areas were open/seeping and others were scabbed. He also had pedal swelling and multiple abrasions on his forearms. A Nursing Progress note, dated 2/28/16 at 20:30 (8:30 P.M.), indicated a CNA (Certified Nursing Assistant) had entered the Resident #47's room and found him unresponsive. The resident was sent to a local ER. An Emergency Department Chart, dated 2/28/16, indicated the resident was seen in the ER with transient altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION]. There was no documentation there was a blood sugar blood test taken in the ER. A Nursing Progress note, dated 3/2/16 at 12:54 P.M., indicated Resident #47 was again found unresponsive and his blood sugar was assessed and was 67. The Nurse Practitioner was notified and an order for [REDACTED]. The only care plans for Resident #47, initiated on 3/2/16, indicated the resident did not wish to attend any activities and wished to have supervised smoking privileges. There were no other care plans documented on the electronic chart A Nursing Progress note, dated 03/05/16 at 2:10 A.M., the resident returned from the hospital with a Foley catheter and a PICC line in place. This progress note indicated the nurse practitioner wanted to hold the intravenous fluids until further clarification. There was no physician's order written regarding the withholding of the medication. There was also no documentation of any care of the resident's PICC line to ensure patency of the line. A Nursing Note, dated 3/8/16, completed by the Nurse Practitioner, indicated the resident was refusing care, refusing blood sugar tests and refusing any care including hygiene. On 3/9/16 during the survey process, hospital discharge orders, dated 3/4/16, were found in a large manilla envelope in the chart. The orders indicated .Begin taking these medications at these doses following discharge .[MEDICATION NAME] ringers intravenous solution 70 ml/hr (milliliters per hour)[MEDICATION NAME] ([MEDICATION NAME], an antioeplastics) 400 mg/10 ml (milligrams/milliliter) 400 mg Oral Daily Another form titled ORDERS TO BE FOLLOWED, dated 3/4/16, indicated the following .Flush/Maintain PICC per protocol Review of the Medication Administration Record [REDACTED]. The insulin orders were changed to [MEDICATION NAME] 10 units in the evening and [MEDICATION NAME] (insulin) 2 units with meals on his readmission back to the facility on [DATE]. There was no plan or documentation of any routine assessments of his blood glucose levels in the chart. During an interview, on 3/9/16 at 11:15 A.M., the Director of Nursing (DON) indicated she was unaware of any order for glucose monitoring or the use of a urinary catheter for Resident #47. She indicated she had checked the resident's blood sugar yesterday. She indicated the [MEDICATION NAME] Ringer intravenous fluid and [MEDICATION NAME] medication, ordered on [DATE] was on hold. She indicated the Nurse Practitioner had examined the resident on 03/05/16 and at that time she had put the fluids on hold pending clarification. The Director of Nursing indicated the Nurse Practitioner had seen the resident again on 03/08/16, and was checking with the physician regarding the 3/4/16 orders for IV fluids and [MEDICATION NAME]. She was unable to explain why the resident's admission orders [REDACTED]. She indicated the Foley catheter was still in place as the nurses were tracking the resident's input and output. She indicated there were no other care plans for the resident at this time. An untitled form, dated March 2016, indicated the start date for the documentation of the resident's input and output was 3/8/16. The form indicated the resident had 400 ml of catheter output for the 11 to 7 night shift. There were no other output documentation notes from 3/4/16 thru 3/8/16. On 3/9/16 at 12:30 P.M. the Nurse Consultant provided a policy titled Physician Orders - Monthly Recap, revised on 1/2013, and indicated the policy was the one currently used by the facility. The policy did not indicate a procedure for admission orders [REDACTED] dated June 2004, indicated .21. Address resident problems and needs identified during assessment on Initial Care Plan form During an interview, on 3/9/16 at 3:31 P.M., the Nurse Consultant indicated there was no policy or procedure regarding admission orders [REDACTED] During another interview, on 3/9/16 at 4:36 P.M., the Nurse Consultant indicated since the facility had gone to electronic charting regarding care plans and the initial care plan form was no longer being utilized by the facility. She indicated the facility had 21 days to develop a care plan for the resident. During an interview, on 3/10/16 at 3:39 P.M., the Nurse Practitioner indicated she was called during the night shift on 3/4/16, or possibly earlier AM on the 5th. She indicated she held the IV fluid and Magace order because she wanted to clarify what the physician wanted to do with the PICC line, as the resident was eating and drinking well. She indicated she thought the facility was doing accuchecks as the resident had episodes of very high and very low blood sugars. She indicated she had ordered blood sugars AC (before meals) and HS (bed time) with an insulin sliding scale. (Order was received on 3/9/16). When asked about her note dated 3/8/16, she indicated she was told by staff he was refusing blood sugars and she documented such in her note. The Nurse Practitioner indicated after 3 days the facility should have re-contacted her to clarify the hold orders, as standard practice. On 3/10/16 at 4:00 P.M., the Nurse Consultant provided a current policy titled Central Venous Caterer Procedures, undated. The policy indicated .Flush at least every 8 hrs (hours) when just using saline, every 12 hrs (hours) if using [MEDICATION NAME]. The Immediate Jeopardy that began on 02/26/16 was removed on 03/15/16, with an effective date of 03/15/16, when through observation, record review and interview, staff completed education related to glucose monitoring and demonstrated timely glucose monitoring. Staff also completed education related to accurate and timely completion of Nursing Admission Assessments and obtaining, transcribing and following physician orders. Even though the facility's corrective action removed the Immediate Jeopardy the facility remained out of compliance at a reduced scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy because of on-going monitoring to ensure the staff were knowledgeable and the resident's glucose monitoring and physician orders were completed correctly. B.1. On 03/08/2016 at 12:06 P.M., Resident B was observed to have a purple oval area on his left upper forearm/elbow area. On 3/10/16 at 2:47 P.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A care plan, dated 7/26/12, indicated the resident was at risk for bruising due to leaning in his wheelchair (w/c). The interventions included, but were not limited to: weekly skin assessments, notify MD (Medical Doctor) as needed, ensure harness in w/c fits properly with application, and side rails padded for [MEDICAL CONDITION] activity. Another care plan indicated the resident leans to the right while in his w/c and it was the resident's preference to lean in the w/c so he could propel himself. The Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/16, indicated the resident's Brief Interview Mental Status (BIMS) score was 10, moderate dementia. The MDS assessment further indicated the resident was totally dependent on staff for bed mobility, transfers, dressing, toileting and with personal hygiene. A Nurses Weekly Summary, dated 3/5/16, indicated the resident had no new changes to skin integrity. Another Nurses Weekly Summary, dated 3/13/16, indicated the resident had no new changes to his skin integrity. On 3/14/16 at 2:00 P.M., the resident was observed to have a oval light purple-yellow area on his upper left forearm/elbow and measured approximately 5 centimeters. During an interview, on 3/14/16 at 8:50 A.M., the Director of Nursing (DON) indicated she was aware of Resident #1's bruise last week and had contacted his Level 2 specialized work representative to inquired about the bruise. The DON indicated the representative wasn't aware of the resident's bruise. The DON indicated she wanted to know if his work area might be the cause of the bruise. The DON further indicated she was unable to identify the cause of the bruise. The DON also indicated the bruise had not been assessed, measured or documented on in the resident's chart and conversation with the representative from Resident's specialized service program was not documented. During an interview on 3/14/16 at 11:50 A.M., the DON indicated her expectation would be the nurse who did the assessment (weekly summary) on 3/13/16 would of documented the bruise on the Resident's left upper forearm/elbow area. She didn't believe the bruise was there on the 3/5/16 weekly assessment as she first observed the bruise on Wednesday the 9th of March. She further indicated she thinks the process of assessments was dropped when the facility changed from paper charting to electronic charting. On 3/14/16 at 11:55 A.M., a policy was provided by the Nurse Consultant titled Non-Pressure Skin Conditions, dated January 2005 and revised on October 2011 and indicated the policy was current. The policy indicated a licensed nurse will assess and document all non pressure skin conditions. Definition: . A non-pressure skin condition is one that does not meet the criteria of pressure ulcers or venous, arterial or diabetic ulcers Stage 1 -IV. Examples of non-pressure conditions include, but are not limited to: rashes, excoriation, bruises, skin tears, open lesion, abrasions, laceration, and surgical wounds B.2. On 3/9/16 at 7:56 A.M., Resident #6 was observed being administered 5 units of Humalog (fast acting insulin) by subcutaneous injection by LPN (Licensed Practical Nurse) #3. After the injection the resident was observed propelling himself toward the dining room. He positioned himself at 8:08 A.M. in front of a table at the place he would usually sit. The resident's table had a plastic cup with juice in it, however the lid had a small opening for a straw and there was no straw placed in the cup for the resident. During an interview, on 3/9/16 at 8:21, LPN #3 indicated the resident needed a straw to drink his juice as resident was a choking risk. On 3/9/16 at 8:34 A.M., Resident #6 took his first bite of food, and straws were placed in his juice at 8:37 A.M. B.3. On 3/10/16 at 11:55 A.M., Resident #27 received [MEDICATION NAME] (fast acting insulin) 15 units by subcutaneous injection. At 12:06 P.M., the resident was propelled to the dining room by a CNA (Certified Nursing Assistant) in his wheelchair and placed in front of a table. The resident's eyes were closed. The Social Service Director was observed placing the resident's lunch in front of him soon after he arrived at the table. The Social Service Director was observed walking away from the resident as soon as she placed the meal tray in front of him. The Social Service Director did not attempt to awaken the resident or ask him what he wanted to drink. At 12:19 P.M., LPN #3 was observed trying to awaken the resident, she asked for grape juice to be brought to the resident. LPN #3 attempted to have the Resident drink some juice. LPN#3 asked the resident to open his eyes and take a drink, and the resident responded and took several sips of the juice. LPN #3 then fed the resident a few bits of potatoes and the resident opened his eyes and completed his meal. During an interview, on 3/10/16 at 12:22 P.M., the Social Service Director indicated she was unaware of which residents in the dining area were obtaining insulin injections prior to their meal. She further indicated she had started at the facility 2 weeks ago. During an interview, on 3/10/16 at 12:30 P.M., LPN #3 indicated a resident who received fast acting insulin should eat or drink within 15 minutes. On 3/10/16 at 2:25 P.M., the Director of Nursing provided a policy titled, Medications-General Policies, revised on 5/2013, and indicated the policy was the one currently used by the facility. The policy indicated .Fast acting insulin, such as [MEDICATION NAME] or Humolog, will be administered within 15 of the scheduled meal time B.4. The clinical record for Resident #45 was reviewed on 03/08/16 at 2:45 P.M. Resident #45 was admtited to the facility on [DATE] with diagnoses, including but no limited to: [MEDICAL CONDITIONS], paralysis of dominant side, hypertension and diabetes. The discharge orders for Resident #45 included the following instructions: .4. Take medications for your diabetes as ordered and check sugars before each meal and at bedtime The February and March Medication Administration Record [REDACTED]. During an interview, on 03/09/16 at 9:00 A.M. she confirmed the facility had not been completing blood glucose assessments for Resident #45 because he was not insulin dependent. B.5. The clinical record for Resident #46 was reviewed on 03/08/16 at 3:00 P.M. and indicated he had been admitted to the facility on [DATE], with diagnoses, including but not limited to: massive [MEDICAL CONDITIONS] and [MEDICAL CONDITION] flutter. The discharge orders from the acute care facility, dated 03/02/16, included an order for [REDACTED]. During an interview with the Director of Nursing, on 03/15/16 at 3:00 P.M., she indicated she had just missed the order when she was admitting the resident to the facility. She indicated since the resident had already discharge from the facility to his home, she had called to inform him of the error so he could start taking the medication. B.6. The clinical record for Resident #49 was reviewed on 03/15/2016 at 2:58 P.M. Resident #49 was admitted to the facility on [DATE], with diagnoses, including but not limited to: [MEDICAL CONDITION], [MEDICAL CONDITIONS], diabetes mellitus, [MEDICAL CONDITION], gastro-[MEDICAL CONDITION] refux disease, [MEDICAL CONDITIONS] with behavioral disturbance, [MEDICAL CONDITION] and collapse, and hypertension. The initial nursing assessment, completed on 03/09/16 at 23:09 (11:09 P.M.) indicated there were no skin issues noted on the assessment. A Weekly skin assessment, completed on 0310/16, indicated the resident's lower legs bilaterally present with thick scaly skin. The resident stated she was being treated for [REDACTED]. The note indicated there was no [MEDICAL CONDITION] and no wounds present. The discharge orders from the hospital for Resident #49, dated 03/09/16, indicated the following: *skin integrity. BLE (bilateral lower extremities) with [DIAGNOSES REDACTED], moisture breakdown in pannus fold and under breast. *Additional skin care/wound treatments BLE BID (twice a day) *Skin Care Supplies Sent with Patient BAZA (Antifungal) Cleanse and Protect Lotion Cleanser, Baza Clear Barrier Ointment, cotton stockinet *Additional Information Wound care included: BLE: Cleanse skin thoroughly with Baza cleanse and protect and washcloth. Apply Basza Clear ointment liberally to legs and feet. Place cotton stockinet sock to knees to keep ointment from being rubbed off. Perform care BID. *Pannus/Breast fold: Cleanse under pt (patient) pannu and breasts with Baza cleanse and protect and pat dry. Place Interdry AG (Absorbant fabric with antimicrobial Silver Complex) in pannus fold, place to fold line and lay in single layer. Allow 1-2 inches of fabric to remain exposed from under skin to wick moisture out of area. Do not use any other powders or creams with Interdry as it can clog the pores of the fabric and decrease effectiveness. May change out PRN (as needed) and rinse fabric with plain tap water and allow to air dry for reuse. Perform Care BID. The Medication and Treatment Administrator Record for Resident #49 for March 2016, reviewed on 03/12/16 at 5:00 P.M., indicated there was no documentation of the skin treatments on the forms. During an interview on 03/12/16 at 5:50 P.M., the DIrector of Nursing indicated the wound care had not been done. She indicated the resident had dry skin but no other skin issues on her pannus fold or legs. The Director of Nursing indicated she had given the resident some [MEDICATION NAME] scented lotion to use on her dry skin. On 03/14/2016 at 930 A.M., Resident #49's feet and legs were observed in her room with the Director of Nursing. Resident #49 was noted to have long yellow thick gripper type socks and a very soiled stockinet underneath the socks on both legs As the resident attempted to pull the socks and stockinet down, large chunks of thick, brown colored dried skin fell on to the floor. The stockinet had a slightly yellowed tinge and multiple black colored chunks and crumbs of dried skin stuck to them. The resident's left and right leg from the knee clear through her feet were covered with a thick dried alligator looking cracked dried skin. The resident indicated she had came from the hospital with supplies and was using it herself. She indicated no one had treated her legs since she had been at the facility. During the observation, the DON attempted to tell the resident the facility needed to treat her skin, however the Resident argued with the DON about the issue. The resident was shown the physician's orders regarding her skin and a discussion indicated the resident would allow the treatment only twice a week but she felt like no one in the facility was qualified. She indicated someone had helped her get her socks on yesterday. The resident at times would agree to have staff assist her but she reiterated no one had been helping her since she had been at the facility. The resident was also noted to have very long, dark colored toenails all all of her toes on both feet. The resident indicated there was no podiatrist available at the hospital. The resident indicated she would like to see a podiatrist while here. The DON indicated the resident had not allowed her to see her legs prior to the observation. B.7. The clinical record for Resident D was reviewed on 03/10/2016 at 10:54 A.M. Resident D was admitted to the facility on [DATE], and readmitted on [DATE] and discharged on [DATE]. The resident's [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment, completed on 11/17/15, indicated the resident was moderately cognitively impaired, had no mood indicators, required extensive staff assistance of two staff for bed mobility, transfer needs, wheelchair locomotion, and toileting assistance and one person extensive assistance for dressing and personal hygiene. The resident only required supervision and set up help for eating needs. The resident was documented as having coughing and choking during swallowing medications and his weight was 141 pounds and had experienced significant weight loss and had one Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister.) pressure ulcer on admission. The acute care center discharge orders for Resident D included an order for [REDACTED]. During an interview on 03/15/16 at 3:45 P.M., the Director of Nursing (DON) indicated a transcription error had been made for the Metrolmidazole dose. She indicated the discharge order from the acute care center indicated the resident was to receive Metrolmidazole 500 mg every 6 hours but instead the resident was given Metrolmidazole 250 mg every 6 hours. The DON indicated the facility policy and to have the next nurse working double check the orders transcribed for all new admissions. There was no documentation for this process so there was no way to tell if the orders had been double checked. Resident D had a gastrostomy tube placed to aid in his nutritional status on 12/31/15. On 01/12/16, Resident D was admitted to an acute care facility to treat and abdominal abscess and infection of the gastrostomy tube insertion site. He was readmitted to the facility on [DATE]. The readmission orders [REDACTED]. The January 2016 Medication Administration Record [REDACTED]. During an interview, on 03/15/16 at 3:45 P.M., the Director of Nursing indicated there was a timing error for the [MEDICATION NAME] antibiotic which was ordered on the discharge orders from the acute care center on 01/26/16 and was to be given per intravenous route every 6 hours for 6 days but was only administered every 8 hours for 6 days. B.8. A clinical record review was completed, on 3/9/2016 at 12:25 P.M., for Resident #11. Resident #11 was admitted on [DATE]. The [DIAGNOSES REDACTED]. A care plan, dated 2/19/2016, indicated .Ask the [MEDICAL TREATMENT] center to send documentation back to the facility, with me, of anything that they have done for me during my [MEDICAL TREATMENT] visit and .Nursing to complete my post [MEDICAL TREATMENT] assessment after I return from [MEDICAL TREATMENT] During an interview on 3/9/2016 at 2:45 P.M., DON (Director of Nursing) indicated the facility does not have any documentation related to communication with the [MEDICAL TREATMENT] center and unable to locate any orders to monitor the residents [MEDICAL TREATMENT]. A physicians order indicated Resident #11 was to receive [MEDICAL TREATMENT] three times a week on Monday, Wednesday, and Friday. There was no diocumentation related to a [MEDICAL TREATMENT] assessment for Resident #11. During an interview on 3/10/2016 at 10:45 A.M., LPN (Licensed Practical Nurse) #3 indicated the facility did not have a form of communication related to [MEDICAL TREATMENT] services or assessments for Resident #11. She further indicated that there was no form of documentation she could access at the facility to inform her of the assessments performed at the [MEDICAL TREATMENT] center for Resident #11. On 3/7/2016 at 2:00 P.M., the DON provided a [MEDICAL TREATMENT] contract titled SNF (Skilled Nursing Facility) OUTPATIENT [MEDICAL TREATMENT] SERVICES AGREEMENT, dated July 1, 2013, and indicated this was the contract used for Resident #11. The contract indicated .D. Mutual Obligations 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) [MEDICAL TREATMENT] Unit. Documentation shall include, but not be limited to, participation in care conferences, continual quality improvements program, annual review of infection control of policies and procedures, and the signatures of team members from both parties on a Short Term Care Plan (STCP) and Long Term Care Plan (LTCP). Team members shall include the physician, nurse, social worker and dietitian from the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit and a representative from the Nursing Facility. The [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit shall keep the original the STCP and LTCP in the medical record of the [MEDICAL CONDITION] Resident and the Nursing Facility shall maintain a copy On 3/10/2016 at 11:15 A.M., the Corporate Nurse provided the policy titled [MEDICAL TREATMENT], dated June 2004, and indicated this was the policy currently used by the facility. The policy indicated .GUIDELINES: The [MEDICAL TREATMENT] Unit should provide a written progress note of some type regarding the pertinent issues that were observed or occurred during the [MEDICAL TREATMENT] visit. It should also include the amount of fluids that the resident consumed during his/her visit and .6. Assess resident upon return from [MEDICAL TREATMENT] and document findings on Post [MEDICAL TREATMENT] Assessment form. If there are additional observations, the nurse will document them in the residents's chart and .Document resident's status on the Post [MEDICAL TREATMENT] Assessment form when returning from [MEDICAL TREATMENT] This Federal tag relates to Complaint IN 960. 3.1-37(a)

Based on observation, record review and interviews, the facility failed to ensure a resident admitted without a pressure ulcer received appropriate assessments and interventions to prevent the development of a pressure ulcer for 1 of 4 residents reviewed for skin issues. (Resident #11) In addition, the facility failed to ensure a thorough assessment and appropriate treatment orders were obtained for a resident admitted with a pressure ulcer in a sample of 1 of 4 residents reviewed for pressure ulcers. (Resident #47) Lastly, the facility failed to ensure a resident was a chronic pressure ulcer had accurate assessments and interventions provided as planned to promote healing for 1 of 4 residents reviewed for pressure ulcers. (Resident #6) Findings include: 1. The clinical record for Resident #6 was reviewed on 03/11/2016 9:30:16 AM . Resident #6 was admitted to the facility on [DATE] with diagnosis, including but not limited to: diabetes, [MEDICAL CONDITION] disease, [MEDICAL CONDITION], dysphagia, hypertension, [MEDICAL CONDITION], major [MEDICAL CONDITION] single episode, enlarged prostate, [MEDICAL CONDITION] and hypothyroisidm. A [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment, completed on 01/15/16 indicated the resident had a stage 2 pressure area with granulation which had been present since 02/11/15. The resident also required extensive staff assistance for transfers, toileting, and was occasionally incontinent of urine and frequently incontinent of bowel. The care plans, current through 04/15/16, included the following interventions related to bowel incontinence to check the resident every two hours and assist with toileting as needed. A care plan related to the resident' s risk for skin breakdown included interventions to provide incontinent care with each episode, pressure relieving cushion to my wheelchair, pressure relieving mattress on my bed, turn and reposition every 2 hours while in bed and as needed, and weekly skin assessment by charge nurse. A plan to address the resident's refusal of care included a goal for the resident to agree to lay down after at least one meal daily to promote increased healing of the wound on his buttocks. The interventions included, but were not limited to: allow me to make decisions about my treatment regimen, educate me of possible outcomes of not complying with treatment of [REDACTED]. Resident #6 was observed, on 03/11/16 at 8:37 A.M., seated in his wheelchair in the assisted dining room. He was propelled in his wheelchair by staff back to the hallway just outside his room at 9:07 AM. He was then observed at 9:15 AM seated in the back hallway by his room door in his wheelchair. He indicated his wheelchair was newer but was not comfortable as the seat was too short. The resident's stomach protruded in his front and it was hard to determine if the wheelchair fit him properly. The resident's body obscured visualization of any wheelchair pad but he indicated he had all kinds of pads in the wheelchair seat. Resident #6 remained in his wheelchair sleeping, at times snoring from 9:14 A.M. to 11:53 A.M. when LPN (Licensed Practical Nurse) #50 took his blood sugar in the hallway. LPN #50 informed the resident he needed some insulin and she administered the insulin to the resident in the hallway because the resident did not want to go into his room. The resident remained in his wheelchair beside his room door until 12:08 P.M., when a Certified Nursing Assistant (CNA) took him down the hallway towards the dining room. She did not offer to toilet the resident or assist him to move in his wheelchair. The staff member pushed his approximately 1/2 way down the hallway and the resident was then observed to slowly propel himself in his wheelchair directly into the assisted dining room. The resident remained in his wheelchair at the table eating his meal and was still in the dining room at 1:15 P.M. At 1:26 P M., CNA #56 pushed Resident #6 from the dining room straight to the back hallway just outside his room door and turned the resident's wheelchair so he faced the hallway. She did not ask him to move or offer to toilet the resident but she did give the resident a hug when he requested a hug. The resident remained in his wheelchair with no position change or any care offering by staff until 2:05 P.M. when he rang a bell and informed CNA #52 he needed to go to the bathroom. She informed him she needed to go get some help and she would be back to assist him. On 03/11/16 at 2:27 P.M. Resident #6 was assisted with two nursing assistants to stand, pivot and sit on the toilet. After the resident used the bathroom, the resident's open area was observed with LPN #57. The resident's buttocks and scrotum were very discolored and pendulous. There was a covered, silver dollar sized open area with frank blood dripping from the wound noted on what appeared to be below the resident's buttocks area. LPN #57 indicated the dressing was usually changed by night shift so she was not aware of the status of the wound. There was a moderate to large amount of sanguineous drainage noted on the removed dressing. The edges of the wound, approximately soft ball sized was dark purple in color. The nurse then cut a silver dollar sized piece of the ordered alginate dressing and placed an absorbent dressing over the whole wound. The absorbent dressing was very large and did not adhere to the resident's skin. The nurse indicated she thought the open wound was on the resident's scrotum. There were several bloody thin elongated areas approximately 1/4 inch by 2 inches long on the other side of the resident's scrotum. The wound assessment information, completed on 03/09/16, by the Director of Nursing indicated the resident had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister.) pressure area on his right buttocks. The body diagram denoted a black circle in the middle of the resident's right buttocks as the location of the pressure area. The area was documented as measuring 6 centimeters long by 4 centimeters wide by .1 centimeters depth with 100 percent red granulation in the wound bed, no slough, and regular edges. The note indicated the resident's wound was healing. During an observation of Resident's pressure ulcer observation, with the Director of Nursing (DON), on 03/14/2016 at 3:18 P.M., the following was observed: There was a tennis ball sized red area on the residents right ischium, below the resident's buttocks. The center of the wound was opened, slightly smaller than a baseball size and had some slough, gray in color, y-shaped in the center and deepest point of the wound. There was also an odor noted. There was also some frank blood in the wound and in open wounds on the resident's scrotum. The DON indicated he was on [MEDICATION NAME] and his wound bled. The resident's right ishium as well as his scrotal area was discolored a dark purple. A wound assessment, documented by the Director of Nursing, on 03/14/16 at 2:56 P.M., (not actual time of observation and treatment), indicated the resident had a Stage II pressure area located on his right buttocks. A black circle on the body diagram still indicated the wound was in the center of his right buttocks. The assessment indicated the wound was 7.0 by 6.5 centimeters by .1 centimeters in depth, had no slough, was 100 percent granulated, and had irregular edges and the periwound was macerated, purple, dark, and scaly. There was a note that indicated the area was larger, the skin as peeling back in the upper portion of the right buttocks, and there was a moderate amount of bleeding noted The note indicated the resident had been refusing the treatment twice a day frequently and wound not lay down for the nurse to do the treatment during the day. There were also several small nope are on his scrotum with dry scaly skin noted. The note indicated the area was cleansed and barrier ointment applied. The open area had calcium alginate applied to the wound bed and [MEDICATION NAME] dressing over it. The documentation of twice a day dressing changes indicated the resident was receiving the dressing changes twice a day, even though the Director of Nursing indicated the resident refused to allow the day shift to change his dressing. Although there was a care plan to reflect the resident's refusal of care, including laying down after meals, there was no documentation the care was attempted and the resident refused. In addition, the resident was observed continually between breakfast and lunch and no staff attempted to offer the resident the planned interventions to promote pressure ulcer healing. 2. On 3/9/16 a 9:22 A.M., a review of the clinical record for Resident #47 was conducted. The record indicated the resident was admitted on [DATE] and re-admission on 3/4/16. The resident's [DIAGNOSES REDACTED]. A hospital History & Physical, dated 2/26/16, indicated the resident had a decubitius ulcer on his buttock, multiple abrasion on lower extremities, some areas open/seeping others scabbed and multiple abrasions on forearms as well. A form titled Licensed Nurse Weekly Skin Assessment, dated 2/26/16, indicated the resident was admitted with a pressure ulcer on his coccyx, a bruise on his left elbow and multiple scraps on his lower extremities. There were no measurements or staging of the coccyx pressure ulcer or measurements of other skin abnormalities. The resident's Braden score was 16 which indicated the resident was at high risk for skin breakdown. A physician's orders [REDACTED]. There were no orders for the treatment of [REDACTED]. The Treatment Administration Record (TAR) indicated the resident had not received wound care and/or dressing changes on 2/26, 2/27, 2/28 and 2/29/16. The Director of Nursing (DON) was unable to locate a treatment order and/or dressing changes for the Stage ll coccyx pressure ulcer when the resident was admitted on for 2/26. A care plan, dated 3/9/16, indicated the resident was at risk for a pressure ulcer and currently had a stage ll ulcer on his coccyx due to history of poor nutrition and failure to thrive. On 3/11/16 at 10:35 A.M., an observation of the Resident #47's coccyx wound ulcer was completed with the Director of Nursing (DON). The resident was observed to have a Stage ll coccyx pressure ulcer which measured 1.0 x 0.7 x 0.1 centimeters. On 3/14/16 at 9:20 A.M., the Administrator provided a current policy titled, Discovering/Reporting New Pressure Ulcers, dated January 2005 and revised on October . The policy indicated OBTAINING PHYSICIAN'S TREATMENT ORDERS: In order to heal pressure ulcers and other skin conditions, the nurse must get a treatment order from the physician 3. A clinical record review was completed on 3/9/2016 at 12:25 P.M., for Resident #11. Resident #11 was admitted on [DATE]. The [DIAGNOSES REDACTED]. A care plan, dated 2/19/2016, indicated .Observe my feet with baths and weekly skin assessments to ensure no other issues are occurring and Make my physician and family aware of any changes/worsening to my skin condition A care plan dated 2/25/2016 indicated .My skin condition will be monitored at least twice a week by the CNA (certified nursing assistant) during my shower and weekly by the charge nurse A care plan,dated 3/14/2016, indicated .Open skin area(s): stage 2 pressure area on left inner buttock A care plan, dated 2/25/2016, indicated .My skin condition will be monitored at least twice a week by the CNA during my shower and weekly by the charge nurse An MDS (Minimum Data Set), dated 2/18/2016, indicated Resident #11 was at risk for a pressure ulcer. A shower schedule, dated 1/28/2016, indicated Resident #11 was to be assisted with a shower every Monday and Thursday. A CNA(certified nursing assistant) documentation report indicated Resident #11 had not received a shower from March 2 thru March 9. During an interview on 3/10/2016 at 9:44 A.M., the Corporate Nurse indicated there was no documentation for Resident #11 receiving showers at the facility. She further indicated that there was no documentation of a complete skin assessment completed on Resident #11. During an interview on 3/14/2016 at 11:31 A.M., the DON (Director of Nursing) indicated she was unaware Resident #11 had a pressure ulcer until this morning. During an observation on 3/14/2016 at 9:25 A.M., LPN #3 indicated Resident #11 had a new Stage II pressure ulcer. She further indicated the area had a 1.5 cm (centimeter) x 1 cm open area and a 7 cm x 5 cm area of red/purple area to left buttocks. On 3/14/2016 at 10:54 A.M., the Coporate Nurse provided the policy titled Skin Assessments, dated June 2004, and indicated this was the policy currently used by the facility. The policy indicated .1. Head to toe assessments will be done weekly, with special attention being addressed to areas more prone to skin breakdown, such as ears, shoulder blades, elbows, coccyx, buttocks, heels, outer aspect of feet, inner aspect of feet 3.1-40(a)(1) 3.1-40(a)(2)