Every finding on record at Hickory Creek at Winamac

Based on observation, record review, and interview , the facility failed to serve food under sanitary conditions related to dishes stored upright near the stove top, not allowing the blender pieces to air dry after washing and sanitizing between each use, the cook allowing blender pieces to touch his clothes, holding food temperatures not up to temperature before serving, storing a scoop in a food container, and the cook touching the inside of the blender blade with ungloved hands. This had the potential to affect all 24 residents who received food from the kitchen. (Main Kitchen)Findings include:1. The Initial Kitchen Tour was completed on 11/17/25 at 10:30 a.m. with the Dietary Manager (DM).Plates were observed stored upright and not covered next to the stove top. During an interview at the time of the observation, the DM indicated the plates were not stored inverted because the heating element would not work correctly if the plates were stored inverted. Plates were stored upright so that the heating element worked. The staff should keep the plates covered when they were stored. 2. On 11/20/25 at 11:29 a.m., with [NAME] 1 and the Executive Director (ED), the following was observed: The cook was pureeing meatballs, rice and broccoli for lunch. He was making two servings of pureed foods for lunch. He put six meatballs in a blender and then added 3/4 cup of beef broth to blender. He indicated he had been doing this for a while and knows how much liquid it would take. He blended the meat and broth, then had to add three scoops of thickener to get the correct consistency. The scoop was already in the thickener container, and he reached in with an ungloved hand and scooped three scoops into the blender. He then put the scoop back into the container and closed the lid. After the meatballs were pureed, the blender and its parts were washed and sanitized, but not allowed to air dry. When he got the parts of the blender out of the dishwasher they were dripping with water, and he touched the blender parts to his clothing. [NAME] 1 next pureed the broccoli. He measured two servings of broccoli and put it in the blender and added an unmeasured amount of water from the pitcher. After blending the broccoli and water, he reached in with an ungloved hand and got a scoop out of the container of thickener and proceeded to add two scoops of thickener to broccoli and blended it. He tested it with a fork and indicated it was the desired consistency. The blender and its parts were then washed and sanitized but again were still dripping with water when he added food to them again. He then added two servings of rice to blender; he reached in with an ungloved hand into the thickener container and put one scoop in the blender and blended with no liquid added. He then tested it with fork and indicated it was the correct consistency. [NAME] 1 then indicated he needed more rice as he did not have enough for two servings. He then put the blender through the dishwasher again. The blender parts were dripping water after cleaning, and he added another serving of rice to the blender then added one scoop of thickener from the container with an ungloved hand and unknown amount of water from a pitcher. He blended and then needed another scoop of thickener. This time he put the scoop for the thickener in a small cup outside of the thickener tub. He then proceeded to blend the mixture. After blending, he reached in with his ungloved hand, picked up the blender blade and then placed the blender blade back into the blender and proceeded to blend some more. He then tested the rice mixture with fork and indicated it was the correct consistency. 3. On 11/20/25 12:12 p.m., [NAME] 1 completed the holding temperature check for food on the tray line. The following foods were not at the correct holding temperatures:- meatballs were 127 degrees Fahrenheit (F)- pureed rice was 120 degrees FDuring an interview at the time of the observation, the [NAME] indicated the food was ready to be served and he was unaware what the holding temperatures should be. During an interview on 11/20/25 at 12:30 p.m., the ED was made aware of the above concerns and indicated she would follow up with the cook regarding the concerns. A policy titled, Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles and received as current from the ED on 11/20/25, indicated, . (B) Clean Equipment and Utensils shall be stored as specified.(2) Covered or inverted.A policy titled, Time/Temperature Control for Safety Food, Hot and Cold Holding, and received as current from the ED on 11/20/25, indicated, .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees Celsius (135 degrees F) or above.3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident received timely treatment for itching skin for 1 of 1 resident reviewed for non-pressure skin conditions. (Resident 8)Finding includes:On 11/17/25 at 11:51 a.m., Resident 8 was observed in bed. She was rubbing her left arm against her body and indicated she had a rash and her arm was itching. She indicated this had been ongoing for a few weeks and there was no treatment being applied. On 11/19/25 at 3:25 p.m., the resident was observed in bed again rubbing her arm against her body and indicated it was itching. The Director of Nursing (DON) was present and observed her left arm. There was a pink, slightly raised rash on her forearm. The resident indicated it had been there for several weeks and she had told the nurse about it, but was unable to identify the nurse she reported it to. The DON indicated she had not been made aware of the concern, and the rash had not been identified during a shower on the previous day. The resident's record was reviewed on 11/19/25 at 2:45 p.m. Diagnoses included, but were not limited to, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction (stroke) right side, unspecified dementia and unspecified convulsions. The Significant Change Minimum Data Set assessment, dated 9/3/25, indicated the resident had moderate cognitive impairment and was dependent for transfers and toileting. A Physician's Order, dated 4/14/25, indicated hydrocortisone lotion 1% (used to treat various skin conditions including eczema, dermatitis, psoriasis and insect bited by reducing inflammation and itching) apply a thin layer twice daily as needed. The October and November 2025 Medication Administration Record indicated the hydrocortisone cream had not been used. The cream was last used four times in July for itching skin. During an interview on 11/20/25 at 2:30 p.m., CNA 1 and CNA 2 indicated the resident had been complaining of itching to her forearm for about a week. They indicated they applied barrier cream or lotion to the area and had notified three different nurses. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure an ADL (activities of daily living) Care Plan was updated to include the use of a hand splint for 1 of 2 residents reviewed for range of motion. (Resident 2)Finding includes:On 11/17/2025 at 10:50 a.m., Resident 2 was observed lying in his bed. He had an edema glove on his left hand and there was a hand splint on the bed. He indicated he wore the hand splint at night only. The resident's record was reviewed on 11/18/25 at 10:20 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one-sided weakness) following a cerebral infarction (stroke) affecting the left side, diabetes mellitus, and hypertension. The admission Minimum Data Set assessment, dated 9/28/25, indicated the resident was cognitively intact and had hemiparesis and hemiplegia affecting the left side. A Physician's Order, dated 10/2/25, indicated to wear a resting hand splint to the left hand at bedtime. An ADL Care Plan, dated 9/22/25, indicated the resident requires assistance with ADLs including bed mobility, transfers, eating, and toileting related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus (DM), atrial fibrillation, hypertension (HTN), chronic kidney disease (CKD) and anemia. Interventions included, but were not limited to, a.m./p.m. care, assist with bed mobility as needed, and assist with bathing as needed per resident preference. There was no indication the resident used a resting hand splint.During an interview on 11/20/25 at 12:20 p.m., the Director of Nursing indicated the hand splint should have been included on the care plan. 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure twice weekly one-to-one activities were implemented for a cognitively impaired and dependent resident for 1 of 2 residents reviewed for activities. (Resident 11) Finding includes: On 11/17/25 at 10:03 a.m., Resident 11 was observed lying in her bed awake. On 11/17/25 at 11:29 a.m., Resident 11 was observed lying in her bed. On 11/18/25 at 12:34 p.m., Resident 11 was observed making noises while eating in the dining room, she was receiving assistance from staff at the time. After she had finished lunch, the staff assisted her to return to bed. On 11/19/25 at 11:37 a.m., Resident 11 was lying in her bed. There was a group activity going on in the dining room at the time. Resident 11's record was reviewed on 11/19/25 at 3:47 p.m. Diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities, legal blindness, and hearing loss. The Quarterly Minimum Data Set (MDS) assessment, dated 10/15/25, indicated the resident was severely cognitively impaired for daily decision making. She was dependent on staff for all activities of daily living including, but not limited to, bed mobility, transfers, personal hygiene, and bathing. The Care Plan, dated 3/24/22, indicated the resident enjoyed working on puzzles and sorting buttons. She also liked to participate in exercise and ice cream socials. She liked to sit in during group activities even though she might not be able to participate. The resident enjoyed being in the room during exercise activities. The goals included the resident would passively participate in group activities while awake and she would be provided with one-to-one activities twice weekly at 15 minutes each. Interventions included, but were not limited to, sign language book kept in resident room and at nursing station, provide hand massages, let resident sort buttons and work on puzzles, assist in smelling new flowers or scents, assist with feeling for new items, and use sign language to assist with resident's need or wants. The Activities Charting Report, dated 10/20/25 thru 11/20/25, indicated the resident attended karaoke and dancing with staff and visited with [NAME] the dog on 10/25/25, sorted buttons on 10/27/25 and 11/3/25, attended table talk with high school seniors on 11/7/25, and attended live gospel music on 11/12/25. There were no other activities documented. During an interview on 11/20/25 at 2:57 p.m., the Activity Director indicated the resident liked to sort buttons and put together puzzles. The puzzles were frustrating the resident lately so they had been providing her with buttons most of the time. They kept some in the dining area so that she could have them in there if she was out of bed. The CNAs helped with the one-to-one activities with the residents but had not completed the documentation. During an interview on 11/21/25 at 10:35 a.m., CNA 3 and CNA 4 indicated the resident preferred to stay in bed lately. The resident would sign when she wanted to stay in bed or eat. They would take her buttons into her room and sit with her while she sorted them. They had provided this activity to her this morning as well as doing passive range of motion exercises with her which she did every day. 3.1-33(b)(8)

Based on observation, interview, and record review, the facility failed to ensure food was prepared in form to meet the individual needs related to not making pureed food using the Pureed Food Preparation Guidelines to ensure nutritional value of food. This had the potential to affect the 2 residents who received a pureed diet.Finding includes:On 11/20/25 at 11:29 a.m., [NAME] 1 was observed making pureed foods. He started with two servings of pureed meatballs. He added six meatballs to the blender and a 3/4 cup of beef broth and blended the mixture. He then added three scoops of thickener and blended again. He tested it and indicated it was correct consistency. The cook indicated he had been doing this for a while and was aware of how much beef broth and thickener was needed. The cook then pureed two servings of broccoli. He put the broccoli in the blender and added an unmeasured amount of water from a pitcher, then added two scoops of thickener and blended again, then indicated it was the correct consistency. The cook indicated he normally put water in with vegetables when he pureed them and he just knew how much water to put in since he had been doing it for a while. The cook then pureed two servings of rice. He added two scoops of rice into the blender and then added one scoop of thickener. He then blended and tested it with a fork and indicated it was the correct consistency. [NAME] 1 then indicated he needed more pureed rice. More rice was added to the blender with one scoop of thickener and an undetermined amount of water from a pitcher. He then blended and added another scoop of thickener. The cook indicated he followed the Pureed Food Preparation Guidelines that was on the wall. The Pureed Food Preparation Guidelines, received as current from the ED on 11/20/25, indicated, .The Pureed Food Preparation Guidelines. indicated, .1. Add the desired number of servings of the regular consistency food item to a blender or food processor. 2. Begin processing the food until it starts to break down. 3. If the mixture is too thick or not blending smoothly, add 1-2 Tbsp (15- 30 ml) of fluid per 1/2 cup (125ml) of food. Refer to the table below for recommended types of fluids to use. 4. Continue blending, gradually adding more liquid as needed to reach a smooth, uniform consistency. Test the texture to ensure it meets IDDSI Level 4 standards per the testing methods below. 5. For thin or liquid foods, use a commercial thickener as needed (follow product-specific instructions) A typical amount is 1/4 to 1 tsp (1.25-5ml) per 1/2 cup of food.Sample Foods and Recommended Fluids.Cooked vegetables recommended liquid is residual cooking water or broth.During an interview on 11/20/25 at 12:30 p.m., the ED was made aware of the above concerns and indicated she would follow up with the cook regarding the concerns.3.1-21(a)(1)

Based on record review and interview, the facility failed to ensure there were 8 hours of consecutive RN (Registered Nurse) coverage for 9 out of 20 days reviewed. This had the potential to affect all 27 residents in the facility. Finding includes: On 9/6/24 at 11:21 a.m., the Nursing Staff Schedules dated 8/18/24 through 9/6/24 were reviewed. There was no RN scheduled for 8/18/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/27/24, 8/31/24, 9/1/24, and 9/6/24. During an interview on 9/6/24 at 11:49 a.m., the Administrator indicated there was not 8 hours of RN coverage on the above dates. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen related to expired foods, undated and/or unlabeled food, and foods open to air in the refrigerator and freezer. The facility also failed to ensure a cook cleaned a food thermometer probe correctly before checking temperatures of food. This had the potential to affect 27 residents who received meals prepared in the kitchen. Findings include: 1. On [DATE] at 10:46 a.m., during the initial kitchen tour with [NAME] 1, the following was observed: a. First refrigerator - There were 3 bags of lettuce. The best by used date was [DATE]. - There was a sealable bag of chicken [NAME] dated [DATE]. The use by date was [DATE]. - There was a sealable bag that was open to air. The bag contained scrambled eggs and was dated [DATE]. b. First freezer - There was a sealable bag with an unknown meat in the bag. There was no label on the bag that included the contents or when it was frozen. During an interview at the time of the tour, [NAME] 1 indicated she had not worked for the past couple of days and the items should have been labeled or thrown out when they expired. A sheet titled, Labeling and Dating and provided as current from the Dietary Manager, indicated, .The date the product must be consumed or discarded may not exceed the manufacturer's use-by-date . 45666 2. On [DATE] at 11:58 a.m., [NAME] 2 was observed checking temperatures of the meal being served for lunch. She began by washing her hands with soap and water. She wiped the food temperature probe with a sanitation wipe and proceeded to check the temperature of a hot dog. She removed the probe, wiped it with a new sanitation wipe, and checked the temperature of the [NAME] dog sauce. She repeated this process to check the temperature of mashed potatoes, the [NAME] dog puree, green beans, and pureed green beans. [NAME] 2 then checked the temperature of a hamburger, removed the probe, and then placed the probe directly into a soft bite-sized hot dog. She repeated this process for checking the temperatures of french fries, [NAME] dog sauce, and pureed [NAME] dog sauce without sanitizing the temperature probe between uses. During an interview on [DATE] at 12:05 p.m., [NAME] 2 indicated she needed to sanitize the temperature probe between each use, and she wanted to wash it. She proceeded to wipe the temperature probe with a cloth located inside of a sanitizer bucket. During an interview on [DATE] at 11:36 a.m., the Dietary Manager indicated the temperature probe should have been wiped in between each use and she would provide some in-servicing to her staff. A Policy titled, Proper Use of a Food Thermometer, indicated, Probe Thermometer .Thermometer is cleaned and sanitized before use. Thermometer is inserted, up to the dimple, into the thickest part of the food. Thermometer is left in the food item until the needle has stopped moving .Thermometer wiped with sanitizing wipe and allowed to dry before inserting into the next food item. 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure food was prepared in form to meet individual needs related to not making pureed food the correct consistency. This had the potential to affect the 2 residents who received a pureed diet. Finding includes: On 9/5/24 at 11:27 a.m., [NAME] 2 was observed preparing pureed food. She indicated she was going to puree 3 servings of [NAME] Dogs (hot dog with a meat sauce). She placed 3 hot dogs with an unmeasured amount of meat sauce into the blender and blended. She poured the mixture out into a container and indicated it was finished. The cook was asked how she was sure if there were no hot dog chunks in the puree. She then proceeded to take a fork and stir up the puree. There were visible chunks of hot dog still observed. The cook then poured the mixture back into the blender and added an unmeasured amount of water to the blender and blended. She poured the mixture back into another container. She stirred the container with a fork and indicated it was smooth. The container was still observed with chunks of hot dogs. The cook was interviewed if she saw the chunks of hot dog. She indicated no and then she stirred the container again and acknowledged there were still chunks of hot dog in the container. She poured the mixture back into the blender again and added an unmeasured amount of water to the blender and blended. She poured the mixture into a container, stirred it around with a fork, and the food was smooth with no chunks. During an interview after the observation, [NAME] 2 indicated they did not have any puree recipes to follow. The staff followed a food and liquid consistency chart. The chart did not say how much or what liquid to use in pureed food. During an interview on 9/5/24 at 12:57 p.m., the Dietary Manager (DM) indicated the cook should have made sure there were no chunks of hot dog in the puree before indicating she was completed with the puree. The facility did not have any puree recipes. The Dietician told them it did not matter what liquid they used to reach the proper consistency. A recipe, titled [NAME] Dog and received as current from the DM, indicated, .Notes: 1. Pureed Level 4: Smooth texture, NO lumps . 3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration for 1 of 12 residents observed during medication administration. (QMA 1, QMA 2, and Resident 9) Findings include: 1. On 9/4/24 at 11:33 a.m., QMA 1 was observed preparing Resident 9's medications. She popped one tamulosin (medication to improve urination) capsule from the medication card into her hand. She then opened up the capsule with her hands and poured the medication into a cup and administered the medication. During an interview at the time, QMA 1 indicated she normally just opened up the capsules with her hands and did not wear gloves. 2. On 9/5/24 at 12:37 p.m., QMA 2 was observed preparing Resident 9's medications. She popped one tamulosin capsule from the medication card into her hand. She then opened up the capsule with her hands and poured the medication into a cup and administered the medication. During an interview at the time, QMA 2 indicated she normally wore gloves when she opened the medication capsules. During an interview on 9/5/24 at 3:04 p.m., the Assistant Director of Nursing indicated the staff are expected to apply gloves and not to touch pills with their hands. A Skills Competency checklist titled, Medication Administration (Medication Pass Procedure) and received as current from the Director of Nursing, indicated, .5. Medications are opened without contaminating . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure a Physician's order was in place for a wound treatment for 1 of 2 residents reviewed for non-pressure skin issues. (Resident 4) Finding includes: On 8/18/22 at 4:10 p.m., Resident 4's right foot and leg wound treatment was observed with the Director of Nursing (DON) and the Clinical Nurse Specialist (CNS). The resident had wounds on the second and third toes, the top of the right foot, and in the middle of his calf. The DON completed the treatment to the right foot and calf. The toes were wrapped with gauze. The resident's record was reviewed on 8/17/22 at 3:09 p.m. The resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Physician's Order indicated the the right foot and lower leg were to be cleansed with wound wash, apply Calazine around wound, cover with an ABD pad (thick dressing pad) and wrap in gauze daily. There was no treatment order for the toes. The Wound Monitoring indicated the resident had abrasions to the right second and third toes and the top of the right foot that were initially found on 7/12/22. The CNS indicated at the time of the wound treatment, they did not have a treatment order for the toes and the Physician would need to be contacted. 3.1-37

Based on observation, record review, and interview, the facility failed to ensure an intervention was in place for the treatment and prevention of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 27) Finding includes: On 8/17/22 at 12:01 p.m. and 8/18/22 at 2:58 p.m., Resident 27 was observed in his bed. He had a cushion under his knees, and his heels were resting on the mattress. On 8/19/22 at 1:00 p.m., a staff member was talking to the resident while he was in bed. The cushion was on the chair, and his heels were resting on the mattress. At 1:44 p.m., the cushion remained on the chair and the resident's heels were resting on the mattress. The resident's record was reviewed on 8/18/22 at 3:52 p.m. The resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set assessment, dated 7/25/22, indicated the resident had moderate cognitive impairment and required extensive assistance from staff for bed mobility and transfers. The Wound Monitoring log indicated the resident had a stage 2 (partial-thickness skin loss into but no deeper than the dermis, includes intact or ruptured blisters) pressure ulcer to his right heel that was first identified on 7/26/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pressure Ulcer Care Plan, dated 7/26/22, included the intervention to have Heeleze cushion in place to offset pressure to heels when in bed. Interview with LPN 1 on 8/19/22 at 1:44 p.m., indicated the resident was to have the cushion at all times when in bed to elevate heels off the mattress. 3.1-40

Based on record review and interview, the facility failed to ensure there were 8 hours of consecutive RN (Registered Nurse) coverage in the facility for 8 out of 16 days reviewed. This had the potential to affect all 29 residents residing in the facility. Findings include: On 8/17/22 at 5:11 p.m., the Nursing Staff Schedules, dated 8/2/22 through 8/17/22, were reviewed. There was not an RN scheduled for 8 consecutive hours on 8/2, 8/4, 8/5, 8/8, 8/9, 8/10, 8/13, 8/14 On 5/10/22 at 10:52 a.m., the daily Nursing Staffing Postings, dated 8/2/22 through 8/15/22 were reviewed. There were no RN hours listed for 8/2/22-8/15/22. The Director of Nursing was hired on 8/15/22. Interview with the Executive Director on 8/17/22 at 5:19 p.m., indicated she completed the Nursing Schedules and was not aware that an RN had to have 8 consecutive hours in the facility. The facility had an RN to audit records 6 of the days from 8/4/22-8/14/22. On 8/2 and 8/10, there were 4 consecutive hours for an RN on duty. There was not a policy for RN coverage. 3.1-17(b)(3)

Based on interview and observation, the facility failed to promote and facilitate resident self-determination related to not having open dining available for the residents. This had the potential to affect any resident who would prefer the option for community dining. Finding includes: Interview with the Dietary Manager on 7/12/21 at 9:48 a.m., indicated they were not serving meals in the Main Dining Room and all the residents were still receiving all their meals in their rooms due to not being able to socially distance. On 7/12/21 at 11:00 a.m., Resident 21 indicated she did not know why they could not go down to the dining room for meals. She would be happy to go eat meals in the dining room. Several other residents interviewed on 7/12/21 indicated no preference. Interview with the Administrator on 7/12/21 at 11:30 a.m., indicated they were not having open dining in the dining room due to the residents not being able to socially distance. She indicated all the residents were COVID-19 vaccinated with the exception of 2 residents. The facility was going to open dining last month but the county positivity rate had gone over 10% for one week and then they never opened up after. She further indicated they had not opened dining because she thought they couldn't because they couldn't be 6 feet apart and was unaware the resident's didn't need to be socially distanced if they all had the COVID-19 vaccine. On 7/12/21 at 12:14 p.m., staff were observed passing room trays to all the residents in their rooms. No residents were observed eating together in the dining area. 3.1-19(f)(5)

Based on observation, record review, and interview, the facility failed to ensure an infection control program was maintained related to ongoing tracking, trending, and analysis of a resident with an active infection for 1 of 3 residents reviewed for infection control. (Resident 5) Finding includes: On 7/12/21 at 9:40 a.m., Resident 5's room had an isolation cart and a sign on the door that read : Enhanced Barrier Precautions. Personal Protective Equipment (PPE) was required with contact with the resident. The resident was lying in bed watching TV. On 7/15/21 at 2:02 p.m., Resident 5's room had an isolation cart outside the door and a sign on the door that read : Enhanced Barrier Precautions. Personal Protective Equipment (PPE) was required with contact with the resident. The resident was lying in bed watching TV. Interview with LPN 2 on 7/15/21 at 1:55 p.m., indicated the resident had ESBL (extended spectrum beta-lactamase, a bacteria) in her urine and was in precautionary measures for contact with the resident. Resident 5's record was reviewed on 7/15/21 at 3:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse Progress Note, dated 2/6/21 at 4:22 p.m., indicated the resident had returned from a hospital stay with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Infection Prevention Control Program log lacked an indication the resident was being followed, including tracking or trending, for an active infection of ESBL. Interview with the Nurse Consultant on 7/15/21 at 2:45 p.m., indicated the resident was not on the Infection Control Logs to be tracked and trended. A policy titled, Infection Control, Administrative Policy and Procedure, was provided by the Administrator upon the Entrance conference on 7/12/21. This current policy indicated, .Procedure: 1. The facility investigates, controls, and prevent infections in the facility, but not limed to , a surveillance system to: monitor, investigate, document, and analyze the occurrence of nosocomial infection 3.1-18(b)(1)(A)

Based on record review and interview, the facility failed to provide the Pneumococcal Vaccine (an injection to help prevent a lung infection), after consent was given for 1 of 5 residents reviewed for Infection Control. (Residents 23). Finding includes: Resident 23's record was reviewed on 7/15/21 at 2:45 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The May Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 23 was admitted into the facility on [DATE]. A consent form for the Pneumococcal Vaccine was signed by the resident's representative on 5/27/21. The Immunization Record indicated the Pneumococcal Vaccine had not been administered. Interview with the Nurse Consultant on 7/15/21 at 3:30 p.m., indicated the nurse who admitted the resident into the facility should have notified the pharmacy after having received the order by the physician. Once the pharmacy delivered the vaccine, the resident should have been immunized. A policy titled, Immunization, Influenza, Pneumococcal and [MEDICATION(S)] Vaccines, was provided by the Administrator upon the Entrance Conference on 7/12/21. This current policy indicated, .Procedure 9. If the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All immunizations for residents will be documented in the medical record on the immunization form 3.1-13(a)

Based on observation, interview and record review, the facility failed to ensure that an expired multi-use vial of [MEDICATION(S)] (TB) solution, which was in use, was discarded for 1 of 1 medication storage rooms observed. (Medication Storage Room ) Finding includes: On [DATE] at 11:16 a.m. with the Director of Nursing, the medication room was observed. In the refrigerator, an open and in use multi-use vial of [MEDICATION(S)] solution had an open date of [DATE]. Interview with the Director of Nursing on [DATE] at 11:18 a.m., indicated the TB vial should had been discarded 30 days after being opened. All nurses should be monitoring labels and discarding medications that are past their open expired dates. A guidance titled, Medication Storage Guidance, was provided by the Nurse Consultant. This current guidance indicated [MEDICATION(S)] Tests: [MEDICATION(S)] Injections: .Date when opened and discard unused portion after 30 days 3.,d+[DATE](o)

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect 22 of 22 residents who reside in the facility. Finding includes: During an interview on 4/10/21 at 11:40 a.m., the Administrator indicated the facility has one full time LPN and are using Agency staffing for all other shifts. The Nursing Staff Schedule, dated 3/15/21 to 4/10/21, was reviewed on 4/10/21 at 12:50 p.m. There was no RN coverage for 8 consecutive hours on March 27 & 28, 2021 and April 3 & 4, 2021. During an interview on 4/10/21 at 12:50 p.m., the Director of Nursing (DON) indicated she was on call 24 hours a day. There was no RN coverage for 8 consecutive hours for March 27 and 28, 2021 and April 3 & 4, 2021. This Federal tag relates to Complaint IN 087. 3.1-17(b)(3)

Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications, related to a lack of non-pharmacological interventions attempted before the administration of a PRN (as needed) pain medication, for 1 of 5 sampled residents reviewed for unnecessary medications (Resident 20) Finding include: Resident 20's record was reviewed on 5/21/19 at 9:36 a.m [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED] - 4/29/19 1:28 a.m. The (MONTH) 2019 MAR indicated [REDACTED] - 5/3/19 9:12 a.m. - 5/7/19 11:26 a.m. - 5/8/19 5:16 p.m. - 5/10/19 11:01 a.m. - 5/11/19 3:17 p.m. - 5/12/19 11:44 a.m. - 5/16/19 2:56 p.m. - 5/22/19 12:44 p.m. - 5/21/19 11:01 a.m. The record lacked any documentation of interventions attempted before the pain medication [MEDICATION NAME] was administered. A Care Plan for pain, dated 4/14/19, indicated an intervention was to provide non medicinal interventions prior to a pain medication administration (i.e.: reposition me, offer me a massage, provide me with food or fluids, provide me with 1:1). Interview with the Nurse Consultant on 5/22/19 at 2:44 p.m. indicated the midnight nurse should have clicked on a template in the computer system upon completing the resident's admission record. The facility did not have a specific policy for PRN pain medication and non pharmacological interventions. 3.1- 48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure skin discolorations were assessed and monitored for 1 of 3 residents reviewed for skin conditions (non-pressure related). (Resident 3) Finding includes: On 5/19/19 at 11:12 a.m. Resident 3 was observed sitting in her wheelchair in her room. Purple discolorations were observed to the tops of both hands. On 5/21/19 at 12:06 p.m. Resident 3 was observed seated in her wheelchair in the Dining Room waiting for lunch to be served. The same purple discolorations were observed to the tops of both hands. The Quarterly Minimum Data Set (MDS) assessment, dated 5/14/19, indicated the resident was cognitively impaired. The resident required extensive assistance of one staff with dressing, transferring, bed mobility, toilet use, eating, and personal hygiene. A Weekly Summary Assessment, dated 5/15/19, indicated there were no new changes to the resident's skin integrity. The resident's record lacked documentation the discolorations had been assessed or monitored. Interview with the Director of Nursing (DON) on 5/21/19 at 4:00 p.m. indicated she was unsure if the discolorations to the residents hands were new but she would look in to it. Interview with the Nurse Consultant on 5/21/19 at 5:01 p.m., indicated they had just started an investigation into how the resident obtained the discolorations. The resident had a previous discoloration to the left hand from (MONTH) 2019 which had slowly faded and may have not completely resolved. The discoloration to the right hand was new and had not been previously identified. A facility policy titled, Skin Conditions, Adverse, was provided by the Nurse Consultant on 5/21/19 at 5:38 p.m. The policy indicated, .2. Skin observations are made daily during the performance of bathing and dressing residents and administering treatment procedures .4. Nursing assistants are responsible for promptly notifying the charge nurse of all observations, for example: .b. bruises .g. any type of lesion, h. skin discolorations . 3.1-37(a)

Based on record review and interview, the facility failed to notify the resident's Physician that her Potassium (supplement) medication was not administered as ordered for 1 of 1 residents reviewed for discharges. (Resident 30) Finding includes: Resident 30's closed record was reviewed on 3/20/18 at 1:42 p.m. [DIAGNOSES REDACTED]. admitted was 12/21/17 and the resident was discharged on [DATE]. A physician's orders [REDACTED]. The (MONTH) MAR (Medication Administration Sheet), indicated Potassium tablet 99 mg was given on 12/21/17,12/22/17 and 12/26/17 in the evening. The following was documented on the MAR: - 12/23/17 8:18 p.m., Potassium not available - 12/24/17 9:24 p.m., resident indicated she does not take that - 12/25/17 8:21 p.m., medication unavailable and the resident refused Nurse Notes indicated the following: - 12/23/17 8:18 p.m., there were miscellaneous pills and capsules in the Potassium bottle without markings. - 12/26/17 2:52 p.m., a new bottle of Potassium 99 mg was obtained, the Physician was notified. The record lacked an indication that the resident's Physician was notified of the Potassium medication was unavailable to administer as orderedprior to 12/26/18. Interview with the Director of Nursing on 3/21/18 at 11:59 a.m., indicated the Physician was not notified until 3 days later that the Potassium was unavailable. The resident was a Respite stay (short term stay requiring medical supervision) and the Potassium bottle which was given to the facility had different shaped pills without dosage markings toward the end of her stay. The Nurse should have contacted the responsible party when the medication was unavailable since she did not use our pharmacy and obtain a new supply. The facility's EDK (Emergency Drug Kit) did not have the correct Potassium dose to administer. A policy titled, Preparation and General Guidelines was provided by the Director of Nursing on 3/21/18 at 3:15 p.m. This current policy indicated, Administration .10 .a. When the medication will not be available for the current medication administration, the nurse will contact the physician to obtain a hold order or work with the pharmacy to obtain an alternative medication to be used, when it arrives from the pharmacy, or from the emergency drug kit. 3.1--5(a)(3)

Based on observation, record review, and interview, the facility failed to accurately assess, and treat a pressure ulcer as ordered by the physician, which resulted in an acquired pressure ulcer worsening from a stage two (partial thickness loss of the skin) to a stage three (full thickness of tissue loss) for Resident #16 and failed to thoroughly assess two residents' stage two pressure ulcers for Residents #3 and #9. This deficient practice affected 3 of 3 residents with pressure ulcers in a total sample of 10. Findings include: 1. During an observation on 08/31/12 at 10:10 a.m. with the Director of Nursing (DoN) and the Corporate RN Consultant present, the DoN described Resident #16's right buttock/coccyx pressure ulcer as 3.5 centimeters (cm) by 3 cm. The DoN then indicated there was tunneling at 12 o'clock (area on the wound) and measured the tunneling with a paper measurement device at 0.1 cm, and the measured the depth of the rest of the wound at 0.5 cm. The DoN indicated that was all they had to measure depth of the wound. The Corporate RN Consultant indicated the depth needed to be measured with a Q-tip. The DoN then obtained a Q-tip and re-measured the tunnel area at 2.5 cm and the depth of the rest of the wound at 0.7 cm. The DoN described the wound as, "beefy red" and indicated the wound looked better than it did, "the other day." Resident #16's record was reviewed on 08/30/12 at 11 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired, was totally dependent for all activities of daily living, was at risk for pressure ulcers, and did not have unhealed pressure ulcers. A care plan, dated 07/24/12, indicated the resident was at risk for skin breakdown. The interventions included, "...observe my skin daily and document on wkly (weekly) and prn (as needed)..." An "Assessment of Other Skin Abnormalities," dated 07/25/12, indicated the resident had an open area on the coccyx area which measured 1.5 cm x 0.5 cm. A weekly pressure ulcer assessment, dated 07/25/12, indicated the resident had an in-house acquired stage one (intact skin with non-blanchable redness) area on the right buttock, which measured 2 cm x 3 cm x less than 0.2 cm (depth) (stage two), and the current treatment was [MEDICATION NAME] cream (fungal cream). During an interview on 08/30/12 at 1:45 p.m., the Administrator indicated the area on the buttock was open and was not a stage one. A fax form to the physician indicated the resident had an open area on her buttock at 1.5 cm x 0.5 cm and a [MEDICATION NAME] (skin protection dressing) was applied, and an order was requested to continue the [MEDICATION NAME] daily until the area was healed. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) indicated on 07/27/12, an order was written to apply a [MEDICATION NAME] to the open area on the buttocks daily until healed. The TAR indicated a [MEDICATION NAME] was applied on 07/27/12. The TARs dated 07/12 and 08/12 lacked documentation to indicate the [MEDICATION NAME] had been removed or changed. The Nurses' Notes indicated: 07/28/12 at 1:30 a.m.-"[MEDICATION NAME] intact..." 07/29/12 at 2:30 a.m.-"Intact [MEDICATION NAME] to buttock..." 07/31/12 at 1:50 a.m.- "checked resident [MEDICATION NAME] intact..." 08/01/12 at 4:40 p.m.- "New [MEDICATION NAME] applied, area to coccyx remains open. Tender to touch" 08/02/12 at 1:50 a.m.-"[MEDICATION NAME] intact to coccyx..." 08/03/12 at 4:25 p.m., "Cream applied to coccyx area. Remains tender to touch..." 08/04/12 at 2:45 a.m., "Coccyx area remains tender to the touch..." 08/04/12 at 8:45 p.m., "Coccyx area continues to be tender to the touch..." 08/05/12 at 4:30 a.m., "Coccyx area tender to touch..." 08/05/12 at 9:30 p.m., "Coccyx area tender to touch..." 08/06/12 at 9:40 p.m., "Coccyx area continues to be tender to touch..." 08/07/12 at 8:25 p.m., "Coccyx remains tender to the touch..." 08/10/12 at 2:55 p.m., "Coccyx remains tender to touch..." 08/11/12 at 1:40 a.m., "...Coccyx tender to touch and open...0/ (no) [MEDICATION NAME] open to air..." The physician's orders [REDACTED]. The Nurses' Notes indicated: 08/13/12 at 8 p.m., "Coccyx remains tender to touch..." 08/14/12 at 1:30 p.m., "...Skin assessment done. Skin on (R) (right) buttock cheak (sic) 3 cm x 2 cm open area Tender to touch...Hard area noted around area on (R) buttock. DON (Director of Nursing) notified and aware..." 08/14/12 at 4 p.m., "Rec'd (received) order from (Physician's Name) to use bioclusive (transparent dressing)...." The Nurses' Notes indicated the [MEDICATION NAME] had not been changed, and the open area was not assessed for description of the area after 08/02/12. The weekly pressure ulcer assessment indicated after 07/25/12 the next assessment of the open area was 08/17/12 (three weeks later), which indicated the area was now a stage three, with measurements of 3 cm x 3.5 cm with a 0.2 cm of depth, had no tunneling or undermining, and had moderate amount of exudate. The weekly pressure ulcer assessment indicated the next assessment of the open area was 08/29/12 (12 days later) and the area continued to be a stage three, measurements were 3 cm x 4.53 cm with less than 0.5 cm depth, had tunneling less than .02, moderate amount and the last treatment change was 08/15/12, which was Calcium Alginate (wound dressing). The Nurses' Noted lacked documentation the physician had been notified of the buttock area being tender to touch. There was a lack of documentation to indicate the physician had been updated on the area until the area became a stage three. There was a lack of documentation to indicate the physician had been notified when the tunnel area had been found in the open area. There was a lack of documentation on the weekly pressure ulcer assessment to describe the color and odor of the exudate. During an interview on 08/30/12 at 11:40 a.m., the DoN indicated the nurses are supposed to be monitoring, assessing, and measuring the open areas weekly. She indicated the resident's open area started as a shearing. She indicated she was unsure if the area had been measured from 07/25/12 through 08/17/12. During an interview on 08/30/12 at 1:50 p.m., the Administrator indicated the area was a shear from the sheet, not a pressure area. 2. During an observation on 08/30/12 at 3:35 p.m., with the DoN present, Resident #3's coccyx area had no open area. The area was described by the DoN as newly healed, pink, with fresh scar tissue. Resident #3's record was reviewed on 08/29/12 at 4 p.m. The resident's [DIAGNOSES REDACTED]. The Significant Change MDS assessment, dated 05/23/12, indicated the resident had cognitive impairment, required extensive assistance for bed mobility and transfers, was always incontinent of urine, was at risk for pressure ulcers, and had no unhealed pressure ulcers. The Physician's Recapitulation Orders, dated 07/12, indicated an order, dated 06/22/12, for [MEDICATION NAME] to reddened area on buttocks, change every three days. A Nurses' Note, dated 06/22/12 at 9:45 p.m., indicated, "[MEDICATION NAME] applied to area on buttocks...Area measures 0.5 cm x 1 cm. Area next to it measures 1 cm x 1.5 cm (R) lower (arrow down) buttocks. Resident states she has been itching it..." The Nurses' Note lacked documentation to indicate a description of the area. The Nurses' Notes, dated 06/23/12 at 12:15 p.m. through 08/07/12 at 1:30 p.m., indicated the treatment continued and the [MEDICATION NAME] was intact. A Nurses' Note, dated 08/07 12 at 1:30 p.m., indicated the open areas to the coccyx remained. A Nurses' Note, dated 08/09/12 at 1:30 p.m., indicated the open area to the coccyx remained. A Nurses' Note, dated 08/15/12 at 11 p.m., indicated the open area to the coccyx was close to healing. A Nurses' Note, dated 08/20/12 at 10 p.m., indicated the [MEDICATION NAME] on the coccyx area was intact. There was a lack of documentation after 08/20/12 to indicate the area on the coccyx had been observed and assessed. There was a lack of documentation the area on the buttock had been assessed after it was found on 06/22/12 until the weekly summary, dated 07/13/12, which indicated the area was a red scabbed area. During an interview on 08/30/12 at 11:40 a.m., the DoN indicated she could not find a weekly skin assessment for the resident. 3. Resident #9's record was reviewed on 08/30/12 at 5 p.m. The resident's [DIAGNOSES REDACTED]. The Annual MDS Assessment, dated 07/03/12, indicated the resident's cognition was impaired, required extensive assistance with bed mobility and transfers, was a risk for pressure ulcers, and had no unhealed pressure ulcers. A care plan, dated 07/10/12, indicated the resident was at risk for skin breakdown. The interventions included to observe the resident's skin daily for open areas and document weekly and as needed. A weekly skin assessment, dated 08/07/12, indicated the resident had an abrasion to the right buttock which was from shearing. A fax form, dated 08/13/12 at 12:40 p.m., indicated the resident had an open area 1 cm x 0.5 cm on the right buttock and requested a of [MEDICATION NAME]. A Physician's Telephone Order, dated 08/14/12, indicated an order for [REDACTED]. The Nurses' Notes indicated: 08/13/12 at 8 p.m., "[MEDICATION NAME] to (R) buttock remains..." 08/14/12 at 1:45 a.m., "[MEDICATION NAME] applied to coccyx...due to removal c/ (with) brief change..." 08/15/12 at 2 a.m., "[MEDICATION NAME] intact to coccyx area..." 08/30/12 at 10:35 a.m., "[MEDICATION NAME] intact to (R) buttock area..." The record lacked documentation to indicate the open area on the right buttock had been thoroughly assessed when found and assessed after 08/13/12. During an interview on 08/31/12, the Corporate RN Nurse Consultant indicated the weekly head to toe assessments of the residents had not been getting done. The Administrator indicated skin issues are discussed in morning meetings, and she was unaware of the area on Resident #9, and was unsure if she was aware of the area on Resident #3. The Administrator indicated if the nurses were doing the skin assessments like they were supposed to, she would have known about the areas. A facility policy, dated 06/04, titled, "Skin Assessments", received from the Administrator as current, indicated, "...The Director of Nursing or designated nurse will do weekly skin assessments on all residents...1. Head to toe assessments will be done weekly...Documentation of these skin assessments will be completed, using the 'Weekly Head-To-Toe Skin Assessment' form...." 3.1-40(a)(1) 3.1-40(a)(2)