Every finding on record at Hillside Manor Nursing Home

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the state agency timely for 1 of 1 allegations of abuse reviewed. After being made aware of an allegation of abuse the facility failed to report the allegation to the state agency within the required timeframe. (Resident D)Finding includes:A review of facility reported incidents on 8/24/26 at 10:40 A.M. indicated there had been no facility reported incidents during the previous 90 days. Record review on 8/24//26 at 10:45 A.M., included Resident D's progress notes that were not limited to a noted dated 8/14/26 at 10:15 P.M., Resident called the police - officers responded. Resident spoke with them in courtyard for privacy and she told them that a male resident forced her to have sex, she stated that it happened on Wednesday the 12th at around 7:00 P.M Resident was talking loud and did not appear to be anxious, nervous at that time.An interview on 8/24/26 at 11:30 A.M., the Facility Administrator indicated as she was reporting the incident, the hospital notified them that Resident D had indicated that she had made the allegation up and that it was not true. The Facility Administrator noted that in the resident record but did not submit the allegation to the state agency. On 8/25/26 at 10:00 A.M., the Facility Administrator supplied an undated facility policy titled, Abuse/Neglect Policy. The policy included, .Upon notification of an allegation of abuse/neglect . the administrator of designee shall 'immediately' meaning as soon as possible, but ought not to exceed 24 hours after discovery of the incident, notify the [state agency] via fax/email/telephone of the allegation .This citation relates to intake 3171816.410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to ensure residents did not develop new pressure ulcers and ensure services were provided for treatment of pressure ulcers for 2 of 3 residents reviewed for pressure ulcers (Resident B and Resident C). Resident B developed a Stage III pressure ulcer, and routine wound care orders were not followed. Full wound assessments were not completed routinely, and wound treatments were not documented as completed. Findings include:1. A record review on 5/18/26 at 10:30 A.M., indicated Resident B's diagnoses included, but were not limited to acquired absence of right and left leg below knee, type II diabetes, and peripheral vascular disease (PVD). The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/28/26, indicated the resident had no cognitive impairment, no unhealed pressure ulcers, had bilateral lower extremity impairment, and required substantial/maximal assistance (helper does more than half the effort) with transfers. A Braden scale assessment (tool used to predict the risk for developing pressure ulcers), completed 2/23/26, indicated Resident B was at risk for developing pressure injuries. Physician orders included, but were not limited to, weekly skin assessment (started 6/7/25) and resident see's wound center for treatments and consults (started 4/15/25).Resident B's care plan included, but was not limited to, has potential/impairment to skin integrity due to PVD and diabetes, per wound care stage III pressure ulcer to buttocks (revised 5/18/26). Interventions included, but were not limited to, follow facility protocols for treatment of injury and medications/treatments as ordered (revised 5/13/26).Nurse's progress notes included but were not limited to:5/4/26 at 8:57 P.M. - Resident with reports of worsening low back pain. He reports that pain is tension related and is due to sitting in his chair for long periods of time, and due to his mattress. He states the facility is working on getting him a better mattress to help relieve pressure from his coccyx.Wound center visit notes included:5/4/26 - Pressure ulcer located on the right buttocks has been present for two weeks. According to the National Pressure Injury Advisory Panel (NPIAP), the pressure ulcer is classified as a Stage III. The problem was identified after paralysis or immobility. The ulcer developed in the context of a major change in health status. The patient's mattress provides inadequate off-loading. The patient's wheelchair cushion provides inadequate off-loading. The ulcer occurred in the context of prolonged period of bed rest. Additional factors that contribute to non-healing included diabetes, difficulty implementing off-loading, and lack of adherence to medical recommendations. - Pressure Ulcer to right buttocks onset 4/24/26 - first noted 5/4/26. There is moderate serosanguineous exudate draining from ulcer. The ulcer bed has exposed subcutaneous tissue. This is a full thickness ulcer. The skin around the ulcer is dry/scaly, hyperpigmented, and non-blanchable. There is between 0 - 25% granulation with a confluent pattern of pale quality. There is over 50% nonviable material of slough/fibrin. Measurements - 0.5 centimeters (cm) (length) x 0.2 cm (width) x 0.1 cm (depth). Treatment orders included - cleanse the area with Vashe Wound Solution and apply Calmoseptine to peri-wound skin, daily for one week. Pressure to be offloaded using alternating air mattress. 5/8/26 - Stage III pressure ulcer to right buttock. There is a moderate amount of serosanguineous exudate draining from the ulcer. The ulcer bed has exposed subcutaneous tissue. This is a full thickness ulcer. The skin around the ulcer is dry/scaly, hyperpigmented, and non-blanchable. The ulcer is not malodorous. There are no signs of epithelialization. The ulcer border is well defined. There is between 0 and 25% granulation with a confluent pattern of pale quality. There is over 50% nonviable material of slough/fibrin. Measurements were taken of a well-defined single wound on the right buttock. The ulcer measures 0.4 cm x 0.2 cm x 0.1 cm. The wound had a bandage on it. Educated patient to have facility apply cream daily and do not add bandage. Treatment order - cleanse the area with Vashe Wound Solution. Apply Calmoseptine to peri wound skin. This treatment will be done daily for one week. Today's treatment will be performed by the wound care team and other care performed by the patient and the staff. The pressure ulcer was debrided using mechanical debridement. The pressure ulcer is to be offloaded using alternating air mattress.5/11/26 - The pressure ulcer to Right buttock measures 2.0 cm x 0.8 cm x 0.1 cm. The Pressure Ulcer has moderate amount of serosanguineous exudate. The Pressure Ulcer has exposed subcutaneous tissue. The Pressure Ulcer was debrided using mechanical debridement. Patient reports the facility has given several reasons why they feel he cannot have the air mattress that was ordered by this clinic last week. There is a moderate amount of serosanguineous exudate draining from the ulcer. The ulcer bed has exposed subcutaneous tissue. This is a full thickness ulcer. The skin around the ulcer is dry/scaly, hyperpigmented, and non-blanchable. The ulcer is not malodorous. There are no signs of epithelialization. The ulcer border is well defined. There is between 0 and 25% granulation with a confluent pattern of pale quality. There is over 50% nonviable material of slough/fibrin. The plan for the pressure ulcer is to cleanse the area with Vashe Wound Solution. Apply Calmoseptine to peri-wound skin. This treatment will be done daily for 1 week. Today's treatment will be performed by the wound care team and their care performed by the patient and the staff.Facility skin assessments included:5/3/26 - Skin Observation Tool - weekly skin assessment warm, dry, and intact. Left below knee amputation, right below knee amputation wound care at wound care center. 5/16/26 - Skin Observation Tool - weekly skin assessment warm, dry, and intact.No right buttock wound documentation was found on a facility record or wound care center records between 4/24/26 and 5/4/26. Resident B's facility medication administration record/ treatment administration record (MAR/TAR) included no treatment order or treatment documentation for the Stage III pressure ulcer on the right buttock from the wound care center on 5/4/26 through the review date (5/18/26). Observation and interview on 5/18/26 at 1:50 P.M., Resident B was sitting in a motorized wheelchair in his room. A cushion was placed in the wheelchair. The resident's bed did not have an air mattress but a pillow-top mattress per resident. The resident's bilateral below knee amputation stumps were wrapped with a protective covering. Resident B indicated he had a pressure ulcer to his buttocks that was painful. Resident B indicated despite having the bilateral amputation, he can and does transfer himself in his room and had been working with an outside therapy service with a transfer board, though he had not utilized one in the facility. Resident B indicated a concern with an air mattress potentially causing falls from his bed and that he was satisfied with his current mattress. The resident's right buttock wound was treated at the wound care center three times a week and the facility did not provide wound treatment to his buttocks. Interview on 5/19/26 at 1:00 P.M., the Director of Nursing (DON) indicated Resident B's pressure ulcer was found by the wound care clinic. The facility first learned of the wound following the 5/4/26 wound center visit. Unsure why the wound care clinic stated the wound developed on 4/24/26. The facility was unaware of any wound orders to be completed at the facility and had not seen the wound care order from the wound care center. The DON indicated the resident often refused the let nursing staff apply treatments and they had taken the resident's word that the wound care center was going completed all the wound treatments. No wound assessments were completed at the facility due to the resident assessments being completed three times a week at the wound care clinic.2. The record review on 5/19/26 at 10:00 A.M., indicated Resident C's diagnoses included, but were not limited to type II diabetes, hemiplegia affecting right dominant side, heart disease, dementia, and overactive bladderThe most recent quarterly Minimum Data Set (MDS) assessment, dated 4/30/26, indicated the resident had severe cognitive impairment, an unhealed stage II pressure ulcer, and was dependent for mobility and transfers. A Braden scale assessment (tool used to predict the risk for developing pressure ulcers), completed 4/30/26, indicated Resident C was at risk for developing pressure injuries. Physician orders included, but were not limited to, weekly skin assessment (started 6/9/25), Wound care orders for open area on left buttock: cleanse with normal saline, apply Puracol with silver or similar collagen product and cover with dressing. Change dressing daily one time a day (started 5/5/26.)Resident C's care plan included, but was not limited to, at risk for skin impairment due to weakness, impaired mobility, incontinence, and Stage II pressure ulcer to buttocks (revised 5/4/26). Interventions included but were not limited to follow facility protocols for treatment of injury, medications and treatments as ordered (revised 5/13/26). Nurse's progress notes included but were not limited to, 4/28/26 at 2:45 P.M. - Wound is on left buttock. On 4/28/26 at weekly wound observation tool was created but contained no information. The resident's record contained no other weekly wound observation tool assessments.Weekly skin observation tool assessments included:4/28/26 - First assessment - (Left) buttock Stage II pressure ulcer - 2.4 cm x 2.0 cm x 0.2 cm5/4/26 - Left buttock Stage II pressure ulcer - 2 cm x 2 cm x 0.1 cm5/12/26 (Left) buttock Stage II pressure ulcer - 2 cm x 3 cm x 0.1 cm5/18/26 (Left) buttock Stage II pressure ulcer - 3 cm x 3 cm x 0.1 cm - purplish in color Resident C's MAR/TAR for April and May 2026 indicated an order, Wound care for open area on (left) buttock: cleanse area with normal saline, apply Puracol with silver or similar collagen product, and cover with border foam dressing. Change dressing daily one time a day started 4/14/26 and discontinued 5/4/26. The order was documented daily. No documentation from 5/5/26 to the review date 5/19/26 was included that indicated a treatment order for the stage II pressure ulcer had been completed.During an interview on 5/19/26 at 1:00 P.M., the Director of Nursing (DON) indicated Resident C's treatment order for the Stage II pressure ulcer to buttocks was incorrectly entered into the computer system and was not populating for nursing staff to complete or document the wound order. Nursing staff should use the weekly wound observation tool to complete a full wound assessment, but staff were only using the weekly skin observation to document wound measurements. The DON indicated training was being completed for nursing staff on how to enter orders and what wound assessment tools should be used to fully assess resident wounds. On 5/19/26 at 1:35 P.M., the DON supplied a facility policy titled, [Facility Name] Pressure Ulcer Program dated 5/14/26. The policy included, .3. Nursing staff shall perform within Point Click Care, the Skin Observation Tool at least every 7 days for all residents within the facility. If during that observation a new pressure ulcer is found, then the nursing staff shall complete the Weekly Observation Tool sheet found within Point Click Care and make sure to report it immediately . 4. The DON or designee shall complete the ongoing Weekly Observation Tool with all results being reviewed to assure that healing in (sic) in progress. If after two weeks the skin condition is not improving, the physician should be notified for possible change in treatment .This citation relates to intake 3010925. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with food safety standards to maintain a sanitary environment and prevent foodborne illness during 2 of 2 kitchen observations. Frozen food was stored uncovered, kitchen staff rested a pair of tongs against a cleaning towel during meal service, the backsplash behind the three-compartment sink appeared unclean and discolored, and a live roach was observed in the kitchen. Finding includes: During a kitchen observation on 3/25/26 at 10:30 A.M., the kitchen backsplash behind a three-compartment sink appeared to be unclean, discolored, and contained several dried splattering's. A downstairs standing freezer contained a bag of individual cookie dough balls that was open to air. During a kitchen observation on 3/25/26 at 11:35 A.M., the Dietary Manager (DM) was using a pair of tongs to plate chicken. Between plates, the DM set the tongs down to the side on a tabletop. The serving end of the tongs rested up against a cleaning towel, then was picked up and used to plate the next piece of chicken. A live roach was observed on an outlet near the three-compartment sink. During an interview on 3/25/26 at 12:00 P.M., the DM indicated she had not seen any live roaches in the kitchen and that a pest control comes routinely to the facility. During an interview on 3/25/26 at 2:38 P.M., Kitchen Staff 4 indicated food should be covered when stored in the freezer and that kitchen staff clean during their shift and then clean the entire kitchen at the end of their shift, daily. The cleaning towel on the table during meal service was used a sanitizing towel that was dipped in a sanitizing solution. On 3/25/26 at 3:05 P.M., the Director of Nursing (DON) supplied a facility policy titled, Sanitization, dated 10/2008. The policy included, The Food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects . 17. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas .This tag relates to intake 2961439. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a registered nurse was serving as the Director of Nursing (DON) on a full time basis (40 hours per week) for 1 of 1 DON reviewed. The facility had an interim DON that was not working on a full-time basis. (DON)Finding includes:On 12/8/25 at 1:00 P.M., the employee records were reviewed and indicated the DON was interim. On 12/10/25 at 9:54 A.M., the Administrator provided copies of the posted nurse staffing form from 11/1/25 through 12/7/25 which indicated the DON worked the following hours per week:November 1-7=36 hoursNovember 8-14=36 hoursNovember 15-21=34 hoursNovember 22-30=31 hours December 1-7=39 hours The facility assessment, last revised 11/26/25, indicated facility staff would include 1 full-time DON. During an interview on 12/9/25 at 9:30 P.M., the DON indicated she did not clock in or out but was there 1-2 days a week and she works mostly on MDS assessments. She was not aware of any hiring processes or plan for a full-time DON at that time. She indicated she retired a year and a half ago and did not want the responsibilities of the DON but was here to help on an as needed basis. During an interview on 12/10/25 at 12:00 P.M., the Administrator indicated she knew the full-time DON position needs filled but they were having trouble finding someone. On 12/10/25 at 8:31 A.M., a non dated DON job description was provided by the Administrator and indicated, . The Director of Nursing (DON) is responsible for the overall management of the Nursing Department and for ensuring the delivery of high-quality, resident-centered care in accordance with CMS regulations, Indiana Department of Health (IDOH) requirements, and facility policies. The DON oversees nursing operations, supervises staff, ensures regulatory compliance, and leads quality improvement initiatives . 3.1-17(b)(4)

Based on interview and record review, the facility failed to ensure staff were certified to fill the role of a Certified Nurse Aide (CNA) for 1 of 5 CNA licenses reviewed. An employee was working as a CNA without being certified. (CNA 24)Finding includes: On 12/8/25 at 1:00 P.M., the employee records were reviewed. There was not a license found on CNA 24. She was hired 8/28/24 and her 120 days would have been up 12/26/24.During an interview on 12/9/25 at 9:50 A.M., the Administrator provided a certificate of completion for the 105 hour nurse aide training from the Indiana State Department of Health and said that was what was provided to them. She wanted to double check with the employee to see if she was under a different name because she was working as a CNA in the facility.During a 12/9/25 at 2:45 P.M., the Administrator indicated she was not aware that CNA 24 was not licensed. The license was not verified upon hire. She usually worked eight hours on night shift and had 35 shifts working alone as a CNA since September of 2025.On 12/10/25 at 8:31 A.M., a current non dated CNA job description was provided by the Administrator and indicated, . Must possess a current CNA license within the state of Indiana . 3.1-14(b)

Based on interview and record review, the facility failed to ensure appropriate certification of the Kitchen Manager for 1 of 1 employee identified as Kitchen Manager. The current Kitchen Manager was not certified in food safety or food service management. (Kitchen Manager)Finding includes:On 12/1/25 at 9:50 A.M., the Kitchen Manager indicated she did not have a certification in kitchen management. She indicated she started in the facility about 3 months ago and had experience in the kitchen, but did not have any type of certification. On 12/10/25 at 12:10 P.M., the Administrator indicated the Kitchen Manager was hired on 9/16/25. She indicated the plan was to train in the kitchen first, then obtain certification the first of the year. On 12/10/25 at 7:23 A.M., the Administrator provided a non-dated Food and Nutrition Services Staff policy. The policy did not indicate the specific training required of the Kitchen Manager. 3.1-20(e)

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Food items were open to air and not labeled, refrigerator temperatures were not recorded, and debris was observed in the refrigerators.Findings include: On 12/1/25 at 9:50 A.M., the kitchen was observed with the following:Three clear containers that contained cereal were under the food preparation counter not dated. Refrigerator #1:A baggie of cheese slices in the door not labeled. A pitcher of applesauce not labeled.A pitcher of clear liquid not labeled.An open package of deli meat in the door not labeled.A tray of bacon strips on the bottom shelf not labeled. Freezer #2:An open package of meat patties not labeled.An open package of breadsticks not labeled. Refrigerator/Freezer #3:One of the two drawers in the bottom of the refrigerator cracked with a large portion missing with exposed jagged edges.Debris in the freezer. An air conditioning unit was observed surrounded by silver duct tape that was coming off in several places. A brown paper towel was observed wadded up and stuffed into the lower left corner. A black substance was observed surrounding the unit. Basement: The large freezer was observed with a thick layer of frost surrounding the inside. A black substance was observed surrounding the suction part of the lid.The same was observed on 12/8/25 at 1:06 A.M. The black refrigerator/freezer was observed with a dried yellow substance and debris in the bottom of the refrigerator.The same was observed on 12/8/25 at 1:06 A.M. The white refrigerator/freezer was observed with October's temperature log attached to the front of it, partially filled out. At that time, the Kitchen Manager indicated the new December temperature log should have been posted, and once that was done the previous month was thrown out. There were no logs kept of previous months. The ice machine was observed with an ice scoop sitting on top of the machine not covered. A brown substance was observed on the top inside of the machine.The same was observed on 12/8/25 at 1:06 A.M. Refrigerator #8 and #9 were observed in the dry storage room with debris littering the inside of both.The same was observed on 12/8/25 at 1:06 A.M. On 12/8/25 at 1:06 P.M., Freezer #7 was observed with an open bag of cookies open to air and not labeled.At the time of the first observation, the Kitchen Manager indicated she was aware that items needed to be labeled, and was in the process of trying to get all staff to label the items. She indicated she was also in the process of cleaning out the refrigerators and freezers, and was aware that they needed to be done.On 12/10/25 at 8:49 A.M., the Administrator provided a current non-dated Food Receiving and Storage policy that indicated Foods shall be received and stored in a manner that complies with safe food handling practices . Food services, or other designated staff, will maintain clean food storage areas at all times . Dry foods that are stored in bins will be removed from original packaging, labeled and dated . All foods stored in the refrigerator or freezer will be covered, labeled and dated3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure waste was properly contained in dumpsters for 2 of 2 random observations. Staff observed to place garbage bags on top of the dumpster lid, and trash was observed on the ground around the dumpster.Findings include:On 12/1/25 at 1:30 P.M., during a random observation, the dumpster in the back parking lot was observed with several trash bags sitting on top of the front lids. At that time, a staff member was observed to place a bag of trash with the other bags sitting on the lids. Another staff member then went to the back of the dumpster, lifted the back lids, and placed a trash bag inside the dumpster. At that time, trash was observed on the ground surrounding the dumpster.On 12/8/25 at 2:02 P.M., during a random observation, the dumpster was observed overflowing with trash. Bags of trash were observed sitting on top of the lids, and empty boxes were observed on the ground surrounding the dumpster. On 12/10/25 at 12:10 P.M., the Administrator indicated trash pickup days were Tuesday and Friday. She indicated they were currently having issues with staff putting bags of trash on top of the dumpster and not inside of it. She also indicated at that time that although there was no policy, staff were expected to place bags of trash in the dumpster. 3.1-21(i)(5)

Based on interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification for 7 of 7 days of the survey. The facility did not have a current certified Infection Preventionist.Finding includes:During an interview on 12/1/25 at 9:56 A.M., the Director of Nursing (DON) indicated she was unsure who the Infection Preventionist was.During an interview on 12/9/2025 12:17 P.M., Registered Nurse (RN) 3 indicated she was the Infection Preventionist, but was not yet certified.On 12/10/25 at 8:25 A.M., the Administrator provided an Infection Preventionist job description that indicated, .Minimum Qualifications .Completion of a CMS-approved Infection Prevention and Control Training Course .

Based on observation, interview, and record review, the facility failed to provide an ongoing resident centered activity program for 2 of 2 halls in the facility. The activity calendar was not followed and resident's interviews indicated there weren't enough activities. (Front Hall, Back Hall)Finding includes:During anonymous interviews, the following comments were made about the activity program:I'm a busy body and there really isn't anything to do around here. We have asked them for more activities but they say they are limited. The director is gone a lot with transportation because all our appointments are out of the building. So if she isn't here, there usually aren't any activities. Sometimes if the activity director isn't available to hold the activity, a couple of residents will do it instead. A copy of the December 2025 activity calendar was observed hanging in the hallway between the Back and Front Hall. The facility assessment, last revised 11/26/25, indicated the facility would offer activities based on resident preference and would have one full time staff member for activity therapy. On 12/4/25 at 9:20 A.M., six residents were gathered out by the TV. Exercise activity scheduled for 9:00 A.M. was not observed. On 12/4/25 at 1:30 P.M., a resident was conducting bingo. No staff was present at that time. On 12/5/25 at 9:06 A.M., the Activity Director and a resident were walking out the front door. Exercise at 9:00 A.M. was not observed. On 12/8/25 at 11:00 A.M., the activity on the schedule was Walmart but was not done. On 12/8/25 at 9:07 A.M., exercise activity scheduled for 9:00 A.M. was not observed. On 12/8/25 at 1:00 P.M., movie and popcorn activity scheduled at 1:00 P.M. was not observed. On 12/8/25 at 1:09 P.M., the Administrator indicated the Activity Director was not there at the time because she was transporting a resident to an appointment.During an interview on 12/9/25 at 9:40 A.M., the Activity Director indicated some days were better than others. She indicated she was currently taking the Activity Director certification class. She indicated she was the only staff member that took residents to their appointments and that did activities in the facility. She had been trying to get them to schedule appointments in the morning if possible but there could be emergency ones. She would have to cancel activities if she can't be there which happened quite a bit. She was not aware of how to put in the resident's activity care plans so that's probably why some of the newer residents did not have one. On 12/10/25 at 12:38 P.M., a current non dated Activities Policy was provided by the Administrator and indicated, . It is the policy of this facility to provide an ongoing program of meaningful, person centered activities designed to meet the physical, cognitive, social, emotional, and spiritual needs of each resident, in accordance with their individual preferences, functional abilities, and comprehensive care plan. The activities program will comply with all federal regulations under 42 CFR 5483 and Indiana state regulations under 410 IAC 16.2 . 3.1-33(a)

Based on interview and record review, the facility failed to ensure the Activity Director was certified for 1 of 1 Activity Director reviewed. (Activity Director)Finding includes:On 12/8/25 at 1:00 P.M., the employee records were reviewed. On 12/9/25 at 9:40 A.M., the Activity Director indicated she was not certified at this time. On 12/9/25 at 4:05 P.M., the Administrator indicated she was hired for another position and took over the Activity Director position on 8/22/25. She was currently enrolled in the Activity Director course but had not taken the test to be certified. She was aware that she needed certification. On 12/10/25 at 12:38 A.M., a non dated current Activity Director Policy was provided by the Administrator and indicated, . PERSONNEL SPECIFICATION: High School graduate, aptitude and some training in arts and crafts, and ability to plan and organize recreation al activities . 3.1-33 (e)

Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 1 medication carts observed. Medication cups with loose pills and a narcotic was observed in a medication cart. (Resident 7, Resident 15, Resident 24, Resident 30)Findings include:During an observation on 12/1/25 at 10:09 A.M., Qualified Medication Aide (QMA) 5 opened the second drawer of the medication cart that was not under a double lock and pulled out a medication cup that was unlabeled and indicated the medications were for Resident 15. At that time, she indicated she was unsure of what the specific medications were and entered Resident 15's room. During the medication pass, QMA 5 indicated 1 of the 11 pills was a pain pill to Resident 15.During an interview on 12/1/25 at 10:15 A.M., QMA 5 indicated the pain pill was a 5 milligram (mg) oxycodone (narcotic).During an observation on 12/4/25 at 10:37 A.M., QMA 5 opened a medication drawer and an unlabeled medication cup had a yellow substance in it with a tablet. At that time, QMA 5 indicated it was for Resident 24 and she liked her medications soaked in applesauce. Another drawer was opened and contained a clear, unlabeled medication cup that QMA 5 indicated was for Resident 7, but she was unsure what medications were in the cup.During an observation on 12/4/25 at 10:41 A.M., QMA 5 removed a clear, unlabeled medication cup that had 10 pills in it. QMA 5 indicated the medications were for Resident 30, she was unsure what the medications were, and put applesauce in the medication cup and gave the medications to Resident 30.During an interview on 12/10/25 at 10:58 A.M., the Director of Nursing (DON) indicated medications should not be set up for multiple residents and unlabeled, and all narcotics should be under a double lock at all times in the medication cart.On 12/10/25 at 8:40 A.M., the Administrator provided a Storage of Medications policy, revised November 2020 that indicated, .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Schedule ll-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.3.1-25(r)

Based on interview and record review, the facility failed to ensure diets were provided that met nutritional and special dietary needs for 12 of 35 residents that ate facility provided meals. All residents were served a regular diet despite other therapeutic diet orders. (Resident 4, Resident 9, Resident 11, Resident 13, Resident 20, Resident 3, Resident 29, Resident 8, Resident 30, Resident 22, Anonymous Resident A, Anonymous Resident B)Findings include:During the survey, two anonymous residents indicated the facility did not provide a diabetic menu. One resident indicated their blood sugars had been three times higher than they needed to be since a diabetic meal was not provided. The other resident indicated it was up to the residents to know what they could and couldn't have from their meals and to not eat the items that were contraindicated with their diet. On 12/8/25 at 1:04 P.M., the Kitchen Manager indicated although several residents did have therapeutic diet orders, there were no alternative meals or selections for any diets other than regular that were provided. She indicated she was unaware of any diabetic or renal (low/no salt) diet meal options, and that all residents were served the same meals. She indicated the residents could choose alternative meals if they did not like what was provided that included ramen noodles, soup and crackers, or peanut and butter sandwiches. She indicated she had meal cards that indicated preferences and anything the resident could not eat, but other than that everyone was served the same regular diet. On 12/9/25 at 10:11 A.M., all current resident meal cards and all current resident diet orders were provided. The following residents had a therapeutic diet order different from a regular diet order:Resident 4 No concentrated sweets (NCS) diet, regular texture, thin consistency, finger foods and double protein with meals (meal card did not indicate finger foods).Resident 9 NCS diet, regular texture, thin consistency.Resident 11 NCS diet, regular texture, thin consistency.Resident 13 Regular diet mechanical soft texture, thin consistency, mechanical soft ground meat, low concentrated sweets (LCS), low carb diet with thin liquids (meal card did not indicate LCS or low carb diet).Resident 20 No added salt (NAS) diet, mechanical soft texture, thin consistency, ground meat.Resident 3 Regular diet, regular texture, thin consistency, LCS.Resident 29 Regular diet, regular texture, thin consistency, LCS.Resident 8 Regular diet, regular texture, thin consistency, LCS.Resident 30 Regular diet, regular texture, thin consistency, LCS.Resident 22 Regular NCS, think liquid diet.Anonymous Resident A Regular diet, regular texture, thin consistency.Anonymous Resident B Regular diet, regular texture, thin consistency, LCS.On 12/10/25 at 12:10 P.M., the Administrator indicated the Kitchen Manager had been in that position since 9/16/25 and she had not taken the food management certification course yet.On 12/10/25 at 9:24 A.M., the Administrator provided a current non-dated Therapeutic Diets policy that indicated Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his/her goals and preferences . A therapeutic diet is considered a diet order as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet or to alter the texture of a diet for example: NCS (No concentrated sweets) NAS (no added salt) or an altered consistency such as Mechanical soft or puree3.1-20(a)

Based on interview and record review, the facility failed to ensure residents had a diet ordered by a prescribing practitioner for 3 of 15 residents reviewed for diet orders. The resident orders did not include an order for a diet. (Resident 7, Resident 23, Resident 10)Findings include:1. On 2/5/25 at 1:17 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, Parkinson's disease, hypertension, and cancer of kidney and prostate. Resident 7 was admitted [DATE]. The most recent admission MDS assessment, dated 9/15/25, indicated the resident's cognition was severely impaired. Current Physician's Orders lacked a diet order. A current Nutritional Care Plan, last revised 9/8/25, included, but was not limited to, an intervention to provide and serve diet as ordered. 2. On 12/4/25 at 1:00 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, hypertension, anxiety, and depression. Resident 23 was admitted [DATE]. The most recent admission MDS assessment, dated 9/15/25, indicated the resident's cognition was severely impaired. Current Physician's Orders lacked a diet order.A current Nutritional Care Plan, last revised 9/15/25, included, but was not limited to, an intervention to provide and serve diet as ordered. 3. On 12/3/25 at 2:00 P.M., Resident 10's clinical record was reviewed. Diagnoses included, but were not limited to, constipation, unspecified vitamin D deficiency, insomnia, anxiety disorder, and unspecified protein calorie malnutrition. The most recent annual minimum data set (MDS) assessment, dated 9/12/25, indicated the resident's cognition was severely impaired. Current Physician's Orders lacked a diet order.A current Skin Care Plan, last revised 5/13/25, included, but was not limited to, an intervention to encourage food and fluid intakes within therapeutic diet.During an interview on 12/9/25 at 12:34 P.M., Registered Nurse (RN) 3 indicated there should be a diet order from the MD (Medical Doctor) for every resident. On 12/10/25 at 9:24 A.M., a current non dated Diet Policy was provided by the Administrator and indicated, . A therapeutic diet must be prescribed by his/her attending physician. 3.1-21(b)

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 2 of 2 observations of the basement and laundry room. The basement floor was full of dirt and debris, vent covers were caked with dust, and the laundry room had debris and dust. (Basement, Laundry Room)Findings include:1. On 12/1/25 at 10:00 A.M., the basement was observed with dirt and debris on the floor in the area where the refrigerators and freezers for the kitchen were stored. Two of two vent covers in the hallway from that room to the ice machine room were observed with a thick layer of dust between the vent slats. On 12/8/25 at 1:06 P.M., the same was observed. 2. On 12/8/25 at 10:05 A.M., the laundry room area had debris scattered throughout the floor where clean clothing was kept. Multiple pieces of debris accumulated where the wall and floor meet. There was multiple wires exposed on the ceiling with a thick layer of dust caked on the wires. The electrical panel box lacked a door to cover it, and had exposed wires caked with dust. A window air condition unit on the wall had a thick layer of dust caked on it. A carbon monoxide detector was observed sitting in the room caked with dust. On 12/9/25 at 9:55 A.M., the same was observed in the laundry room area. During an interview on 12/10/25 at 10:59 A.M., the Director of Nursing (DON) indicated she was unsure who was responsible for cleaning the laundry room. During an interview on 12/10/25 12:04 P.M., the Administrator indicated they do not have a specific policy related to the environment, but their policy would be to check the laundry room, basement floors, and vents monthly. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a resident was informed in advance by the prescribing practitioner of the risks and benefits of proposed treatment and treatment alternatives for 1 of 6 residents reviewed for unnecessary medications. A prescribing practitioner ordered an antipsychotic for a resident they had not seen and the clinical record lacked documentation of education provided to the resident prior to the medication being given. (Resident 23)Finding includes:During an interview on 12/3/25 at 10:23 A.M., Resident 23 indicated that before she came, she was not on any medications, and now she was on several, but she didn't know why. At that time, the resident was observed in the dining room walking with her hand along the wall and shuffling her gait. The resident indicated she thought it was from the different medications. On 12/4/25 at 1:00 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors, anxiety, and hypertension. Resident 23 was admitted on [DATE]. The most recent admission Minimum Data Set (MDS) assessment, dated 9/15/25, indicated Resident 23's cognition was severely impaired, supervision for transfers, and on an antipsychotic. Current Physician's Orders included, but were not limited to, the following:Risperadol 0.5 milligrams (mg) twice daily, ordered 9/15/25, related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis.)A current Psychotropic Medication Care Plan, last revised 9/15/25, included the following interventions:Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness prn, initiated 9/15/25Discuss with the Medical Doctor (MD) and family regarding the ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated 9/15/25Monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles,shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss ofappetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person, initiated 9/15/25 A progress note, dated 9/15/25 at 1:33 P.M., indicated the resident was witnessed as being very anxious and delusional at times. The Director of Nursing (DON) reported to the behavioral Nurse Practitioner (NP), who gave an order for Risperdal. The clinical record lacked documentation of the resident and/or representative being notified, education given on the medication regarding risks and benefits, black box warning, and alternative methods tried and/or contraindicated for the newly prescribed antipsychotic. On 12/10/25 at 12:40 P.M., the DON indicated they were not able to provide documentation that consent and notification were done prior to the resident receiving the medication. She indicated the documentation should be in the clinical record because if it was not documented, it was not done. The NP usually sees residents monthly. On 12/10/25 at 9:35 A.M., a current non-dated Antipsychotic Policy was provided by the Administrator and indicated, . people receiving health care have a right to participate in the planning of their treatment. Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a treatment. The patient must be competent to make a voluntary decision about the treatment. Written informed consent is required for the use of psychotropic medications. If written informed consent is not given, the psychotropic medication cannot be administered without a court order, unless in an emergency. 3.1-3(n)(2)3.1-4(c)3.1-48(b)(1)

Based on interview and record review, the facility failed to ensure accurate representation of advanced directive status for 1 of 2 residents reviewed for advance directives. A resident's actual code status was not reflected accurately in all documentation. (Resident 32)Finding includes:On 12/4/25 at 10:43 A.M., Resident 32's clinical record was reviewed. Diagnosis included, but was not limited to, anxiety.The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/27/25, indicated a moderate cognitive impairment.Current physician orders included, but were not limited to:Full code, dated 5/2/25.A POST (physician order for scope of treatment) form, dated 12/10/24, indicated Resident 32 had a DNR (do not resuscitate) code status. On 12/5/25 at 1:35 P.M., Registered Nurse (RN) 3 indicated all resident's code status were located in a binder at the nurses station. At that time, the binder was observed with Resident 32's face sheet. At the top of the face sheet, DNR was written. RN 3 indicated in the event of a code situation, Resident 32 would not be resuscitated due to the DNR in the binder. She indicated code status was also documented on the CNA (certified nurse aide) sheets. At that time, a current CNA sheet was provided that indicated Resident 32 was full code. On 12/5/25 at 2:00 P.M., the Administrator indicated she spoke with Resident 32 and he indicated he wished to be a full code. She indicated all information with code status needed to be changed to reflect the full code. On 12/10/25 at 9:13 A.M., the Administrator provided a current non-dated Advance Directive policy that indicated All residents of [facility name] are informed of their rights regarding healthcare decision making and advance directives . The facility will document using the Indiana POST form for each resident and maintain a copy in his/her record 3.1-4(l)(4)3.1-4(l)(5)

Based on interview and record review, the facility failed to ensure a resident was discharged with sufficient preparation for 1 of 1 closed records reviewed. A discharged resident was not educated to follow up with a specialist as needed, and a current list of medications was not provided. (Resident 38)Finding includes: On 12/8/25 at 9:45 A.M., Resident 38's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension.Resident 38 was admitted to the facility on [DATE] and discharged to home on 9/25/25.An admission minimum data set (MDS), dated [DATE], indicated a moderate cognitive impairment.Physician orders included, but were not limited to:Losartan Potassium-HCTZ (hydrochlorothiazide) oral tablet 100-12.5mg (milligram), give one tablet a day for hypertension, dated 6/21/25.Progress notes lacked information related to Resident 38's discharge.Resident 38's clinical record lacked any discharge assessments.Resident 38's clinical record lacked a referral or any other information related to a cardiologist appointment.An exam note from the local Health Department, dated 6/19/25, indicated Resident 38 had been homeless and was seen that day for admission to a nursing home. Her blood pressure in the office was 222/89. Notes from the provider indicated to start Losartan/HCTZ, and a concern about some epigastric pain and uncontrolled hypertension. The note indicated the resident would likely need a cardiology consult once insurance was fully established.On 12/8/25 at 1:38 P.M., a written discharge form, dated 9/25/25, was provided. The form indicated the current diet, and to make an appointment with a primary care doctor within 30 days. Resident 38's medication was not listed on the form, and information directing to see a cardiologist was not listed. On 12/8/25 at 10:45 A.M., the Interim Director of Nursing (DON) indicated that when a resident is discharged , a discharge summary sheet should have been completed in the clinical record. A copy of the sheet, along with any follow-up appointments and a medication sheet, should have been provided to the resident.On 12/9/25 at 11:55 A.M., Registered Nurse (RN) 3 indicated that if a resident had a long list of medications, staff would print it and send it with the discharged resident. She indicated that since Resident 38 was only taking one medication, her sheet was probably not printed and provided. On 12/10/25 at 12:16 P.M., the Social Services Director (SSD) indicated when Resident 38 was discharged , she was informed to follow up with the primary care physician, but no other specialties. On 12/10/25 at 1:30 P.M., a discharge policy was requested and not provided. 3.1-12(a)(21)

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 3 of 12 residents reviewed for MDS Assessments. Residents taking anticonvulsant medications, antianxiety, and hypoglycemic medications were not marked as administered. (Resident 3, Resident 8, Resident 2)Findings include:1. On 12/4/25 at 12:59 P.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/28/25, indicated no cognitive impairment and no use of a hypoglycemic medication. Current physician orders included, but were not limited to: Jardiance (a hypoglycemic) oral tablet, one daily, related to diabetes mellitus, dated 9/23/25. Humalog (insulin), inject 12 units with meals related to diabetes mellitus, dated 6/10/25. Tresiba FlexTouch (insulin) 50 units once daily related to diabetes mellitus, dated 6/4/25. Resident 2's medication administration record (MAR) indicated that during the MDS look-back period, Jardiance, Humalog, and Triseba FlexTouch were administered. 2. On 12/5/2025 at 11:17 A.M., Resident 3's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 11/5/25, indicated Resident 3 received insulin for 7 of 7 days on the look-back period, and lacked documentation that Resident 3 received an anticonvulsant. The most recent Quarterly MDS, dated [DATE], indicated Resident 3 received insulin for 7 days of the look-back period. Resident 3's clinical record lacked a current order for insulin. Current Physician's Orders included, but were not limited to, Gabapentin (anticonvulsant) 400 milligrams (mg), one tablet three times a day by mouth. A review of the October and November Medication Administration Record (MAR) indicated Resident 3 received Gabapentin 5 of 7 days on the look-back period. The MDS lacked documentation that Resident 3 received an anticonvulsant. During an interview on 12/10/25 at 10:50 A.M., the Director of Nursing (DON) indicated Resident 3's insulin was coded in error, and Gabapentin should have been coded as an anticonvulsant. 3. On 12/5/25 at 1:54 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but was not limited to, paranoid schizophrenia, diabetes mellitus, and bipolar disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 10/8/25, indicated Resident 8 received an antidepressant. The MDS lacked documentation that Resident 8 received an anticonvulsant and an antianxiety medication. Resident 8's clinical record lacked a current order for an antidepressant. Current Physician's Orders included, but were not limited to, Gabapentin (anticonvulsant) 300 milligrams (mg) three times a day by mouth and buspirone (antianxiety) 15 mg three times a day by mouth. A review of the October MAR indicated Resident 8 received Gabapentin and buspirone 7 out of 7 days on the look-back period. The MDS lacked documentation that Resident 8 received an anticonvulsant. During an interview on 12/10/25 at 10:50 A.M., the DON indicated the antidepressant was coded in error and buspirone should have been coded as an antianxiety medication. She further indicated that Gabapentin should have been coded as an anticonvulsant. On 12/10/25 at 10:45 A.M., the Director of Nursing (DON) indicated Resident 2's MDS should have been marked with a hypoglycemic. She further indicated that, in lieu of a policy, the facility used the Resident Assessment Instrument (RAI) was used for MDS accuracy.

Based on observation, interview, and record review, the facility failed to ensure the appropriate care and services for a suprapubic catheter were given for 1 of 2 residents reviewed for catheter care. Staff was not measuring output and not cleaning the insertion site of a resident with a suprapubic catheter. (Resident 7)Finding includes: During an interview on 12/1/25 at 2:17 P.M., Resident 7's wife indicated the doctor did not want the facility to change his catheter, he wanted to do it in his office. She was not sure what care the staff performed with the catheter. During an observation on 12/4/25 at 10:05 A.M., Resident 7's catheter bag and tubing were dragging on the hallway on floor while he was walking from his room to nurse's station, Qualified Medication Aide (QMA) 55 picked it up and hung it back on his pant's pocket. On 12/4/25 at 10:45 A.M., Resident 7's catheter site was observed in his room with small amount of yellow drainage, slight redness/irritation, no odor, and brownish crust around it. There was no signage for Enhanced Barrier Precautions (EBP) observed. On 12/5/25 at 1:17 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, Parkinson's disease, hypertension, and cancer of kidney and prostate. Resident 7 was admitted [DATE] with a suprapubic catheter. The most recent admission MDS assessment, dated 9/15/25, indicated the resident's cognition was severely impaired, he took a diuretic, had an indwelling catheter, and was a substantial/maximum assist of staff (staff perform over half the effort) for toileting. Current Physician's Orders, included, but were not limited to, the following:Document SP catheter output every shift, ordered 9/10/25Maintain suprapubic (SP) catheter per Medical Doctor (MD) orders/facility policy, ordered 9/18/25The Physician's Orders lacked an order for EBP to be used with catheter care. A current Indwelling Catheter Care Plan, last revised 9/15/25, included the following interventions:maintain catheter per MD ordersmonitor and document intake and output as per facility policyMonitor/record/report to MD for signs/symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The Treatment Administration Record (TAR) and electronic health record was reviewed from 11/1/25-12/5/25 and indicated the catheter was to be emptied daily for day and night shift, but there was not an amount of urine documented. The record also lacked care being done for the catheter.On 12/9/25 at12:35 P.M., Registered Nurse 3 indicated his wife changed his catheter bag from drainage to leg bag when she was there and has been educated on it. He has had UTIs in the past and he is uncircumcised, so the Certified Nurse Aides (CNAs) needed educated on how to pull the foreskin back and clean it. Catheter care should be done every day, nurses do the care and CNA's should drain the catheter bag to get the output measurement. I don't know if it was documented that it was cleaned every day but it was imperative that they do that. The only precaution used was gloves because it was contained. She indicated the in-services for catheter care had been by a handout or done by CNA 4. She was unsure when the last one was.On 12/10/25 at 10:32 A.M., the Director of Nursing (DON) indicated the orders were not put in to the electronic health record correctly because there should be a measurement of how much urine was emptied each shift to watch for renal failure, etc. Also for the care of the catheter, there should be an order to document when it was done every time.On 12/10/25 at 8:33 A.M., a current non dated Catheter Care Policy was provided by the Administrator and indicated, . Do not allow the catheter bag to touch the floor. Catheters should be emptied every shift. Avoid contact with the side of the collection container when emptying urine. Record the amount of urine output on the CNA documentation tool. Report the amount of urine output to the charge nurse. Also report any unusual findings such as blood in the urine. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a resident with a history of exit-seeking behavior and elopement from exiting the facility and leaving the property for 1 of 1 resident reviewed for elopement. This deficient practice resulted in an elopement that occurred on the evening of August 30, 2025. The resident was located with the assistance of the local police department, approximately 0.6 miles from the nursing facility, hiding behind an air conditioning unit near the intersection of National Highway and State Road 57. This Immediate Jeopardy began on August 30, 2025, when the facility failed to ensure Resident C did not exit the facility property by climbing a gazebo and jumping over a fence that enclosed an outside courtyard. Another resident observed Resident C and notified nursing staff, who notified the local law enforcement. Resident C was located between two buildings, hiding behind an outdoor air conditioning unit. When approached, the Resident ran from the officer. Resident C was apprehended prior to running into traffic on National Highway. The Director of Nursing (DON) was notified of the Immediate Jeopardy on 9/3/25 at 3:55 P.M.(Resident C) Finding includes: During record review on 9/3/25 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia.Resident C's most recent annual MDS (Minimum Data Set) assessment, dated 6/20/25, indicated the resident was rarely to never understood. The resident had moderately impaired cognitive skills related to daily function. The resident required supervision for mobility and transfers. Resident C's care plan included, but was not limited to, Resident at risk for elopement due to history of isolated incident to leave the facility unattended (initiated 4/3/24). Most recent interventions included but were not limited to monitoring for wandering and anxiety (revised 5/13/25). Resident C's most recent Psychiatric-Mental Health Nurse Practitioner (PMHNP) visit notes, dated 5/15/25, indicated Resident C presented with mental health disorders characterized as schizophrenia and depression. The resident had received psych services in a hospital setting since an incarceration in 2001. A general assessment of mental status and alertness indicated the resident was alert and oriented to person, place, and time.Resident C's most recent elopement assessment, dated 6/19/25, indicated the resident had a history of leaving the facility without informing staff and that no personal safety alarms or devices were used as an intervention. Resident C's nurse's progress notes included, but were not limited to:7/22/25 at 1:10 P.M. - Resident C exhibited exit-seeking behaviors and paranoia were noted.7/23/25 at 3:36 P.M. - Staff received orders to send Resident C to the hospital for behavioral evaluation due to a change in behavior. Two Emergency Medical Technicians (EMTs) arrived at the facility to transport the resident. Resident C ran to the courtyard and began to climb over the concrete wall. Staff accompanied Resident C in the facility yard and walked down the street with him. Resident C then walked into a clinic alongside the street and locked himself in a bathroom. The resident eventually calmed down and was transported for evaluation without injury. 7/25/25 at 2:28 P.M. - Resident C was noted to scoot chairs over closer to the wall outside, resident showing exit-seeking behaviors at this time. Staff was monitoring the resident closely. 8/30/25 at 6:45 P.M. - The nurse was alerted by another resident that Resident C had climbed the gazebo in the outside courtyard, jumped over the wall, and run towards the East. At the time of the incident, the nurse was in another resident's room helping the Emergency Medical Service (EMS) transfer another resident. Police were dispatched to locate resident C. A police report, dated 8/30/25, indicated an initial call was received at 6:59 P.M. that Resident C had run away from the facility. At 7:14 P.M., Resident C was seen by a vape store near Highway 57. At 7:25 P.M., Resident C was located by law enforcement behind an air conditioning unit at the vape store. The police report included, I located the male subject hiding behind an AC unit. He was behind the vape store between buildings. The male subject ran, and I gave chase. He was apprehended prior to running into traffic on National (Highway).During an observation on 9/3/25 at 11:30 A.M., two unlocked double doors near a common area and nurses' station led to a walled-off courtyard. A gazebo inside the courtyard was observed being approximately two feet away from a concrete wall. The outside concrete wall was approximately 66 inches tall. During an interview on 9/3/25 at 11:45 A.M., QMA 5 indicated that Resident C had climbed the gazebo and jumped the courtyard wall on 7/23/25 when EMTs arrived at the facility to transport him to a hospital. The resident did the same on 8/30/25 when the EMS arrived for another resident. QMA 5 indicated the resident was frightened by the EMTs. During an interview on 9/3/25 at 11:50 A.M., the Director of Nursing (DON) indicated Resident C had jumped the courtyard wall on 8/30/25 and left the facility property. Resident C had also jumped the courtyard wall on 7/23/25 after being frightened by the EMTS when they arrived at the facility for transport. On 8/30/25, Resident C was away from the facility for approximately one hour. Local law enforcement returned the resident to the facility. Resident C had also left the facility by himself to walk to a fast-food restaurant in June 2025; however, staff were aware of the resident's whereabouts and felt the resident was capable of walking to the restaurant by himself at that time. The resident was at risk for elopement after an isolated incident when the resident attempted to leave the facility property in April 2024. During an interview on 9/4/25 at 12:55 P.M., the DON indicated if a resident at risk for elopement began to show increased exit-seeking behaviors or attempted elopement, their care plan should be updated with new interventions to prevent elopement. During an interview on 9/5/25 at 10:45 A.M., the DON indicated an at-risk for elopement assessment should be completed quarterly and any time a resident exhibits an increase in exit-seeking behavior. On 9/4/25 at 11:45 A.M., the DON supplied a facility policy titled, Wandering and Elopements, dated 03/2019. The policy included, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Immediate Jeopardy was removed on 9/5/2025 at 11:20 A.M. The deficient practice remained at isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented a systemic plan that included the following actions: the facility completed audits of clinical records for all residents for all residents at risk for exit-seeking behavior or elopement. Removed the Gazebo from the courtyard, removed a tree in the courtyard, and secured patio furniture. All exit doors were equipped with Wander-guard key pad. In-service training was provided to all staff on the elopement exit seeking policy and on-going daily monitoring of changes in residents' behavior. This citation relates to intakes 2604869 and 2606469. 3.1-45(a)(2)

A. Based on interview and record review, the facility failed to ensure services were provided, in that, a resident who experienced pain upon admission to the facility did not receive pain medication timely for 1 of 1 residents who met the criteria for review of pain management. This deficient practice resulted in a resident experiencing severe pain without intervention for 6.5 hours. (Resident #6) The facility also failed to ensure care was provided for 1 of 1 resident receiving [MEDICAL TREATMENT] services related to not monitoring for bruit/thrill and vital signs on non-[MEDICAL TREATMENT] days and for not monitoring for complications after receiving [MEDICAL TREATMENT]. (Resident #33) Findings Include: 1. The record for Resident #6 was reviewed on 4/28/14 at 11:57 A.M. The record indicated Resident #6 was admitted to the facility on [DATE] at 5:00 P.M., with [DIAGNOSES REDACTED]. The undated initial care plan included, but was not limited to, activities of daily living decline, and pain. The admission physicians orders included, but were not limited to, [MEDICATION NAME] (a narcotic pain medication) 10/500 milligrams(mg) one twice daily as needed for pain, [MEDICATION NAME] (an anti-anxiety medication) 0.5 mg at bedtime, and Tylenol (an [MEDICATION NAME] medication) 650 mg every four hours for pain as needed. An un-timed Admission Pain assessment dated [DATE] indicated Resident #6 was experiencing leg pain upon admission. The assessment further indicated Resident #6 rated the pain a "9" on a pain scale 0 -10 (0 being no pain and 10 being the worst pain) with the resident's acceptable level of pain to be at "3" . The assessment also indicated Resident #6 had been experiencing non verbal signs of pain including, grimacing, moaning, irritability and fidgeting. A nursing notes dated 11/22/13 at 5:00 P.M., indicated Resident #6 was tearful and demanding upon admission. A nursing note dated 11/22/13 at 8:00 P.M., indicated, " Res (resident) c/o (complaint of) wanting meds (medications) " NOW " (sic) Assured (sic) res that she would get her meds when they arrived from pharmacy ... " A nursing note dated 11/22/13 at 11:30 P.M., indicated medications had arrived except for ordered [MEDICATION NAME] and [MEDICATION NAME]. The medications were retrieved and administered, at that time, from the facility emergency drug kit (EDK). The record indicated Resident #6 experienced pain upon admission to the facility at 5:00 P.M.and lacked any documentation pharmacological and/or non-pharmacological interventions were offered until 11:30 P.M. (6.5 hours) During an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 04/28/14 at 1:45 P.M., the DON indicated a newly admitted resident should be provided pain relief as soon as possible and the facility maintained an EDK (Emergency Drug Kit) for that reason. During an interview, at that time, the ADON agreed with the DON and indicated no documentation could be provided that pharmacological and/or non-pharmacological interventions had been attempted to relieve the pain of Resident #6. A policy titled " PAIN MANAGEMENT " was provided on 4/28/14 dated 3:48 P.M., it included, " ...1. The resident will be assessed for pain: a. On (sic) admission, quarterly and with any significant change in status .... 11. Licensed nursing personnel will receive pain management education on hire and no less that annually, This education will include but not be limited to: .... a. different types of pain and treatment modalities, b. Potential impact of pain on physical, mental and psychosocial (sic) well-being .... d. Storage and access of controlled substance ... " 2. Resident #33 was observed on 04/24/14 at 3:00 P.M. resting with eyes closed in a recliner. The record of Resident #33 was reviewed on 04/28/14 at 2:56 P.M. The record indicated the [DIAGNOSES REDACTED]. The most recent Quarterly MDS (Minimum Data Set Assessment) dated 02/26/14 indicated Resident #33 received [MEDICAL TREATMENT] treatments. A care plan dated 02/26/14 for [MEDICAL TREATMENT] included, but was not limited to, interventions of, "...check for bruit and thrill every shift...monitor for pain, numbness, tingling, change in color or temperature of extremity...check vital signs every shift...". The care plan lacked any interventions related to monitoring Resident #33 for complications after receiving [MEDICAL TREATMENT]. The April 2014 physician's orders [REDACTED]. The April 2014 [MEDICAL TREATMENT] Communication Records from 04/01/14 through 04/26/14 were reviewed and lacked any documentation related to monitoring the resident for complications after receiving [MEDICAL TREATMENT]. The nursing notes from 04/01/14 through 04/26/14 were reviewed and lacked any documentation related to the bruit/thrill being checked on non-[MEDICAL TREATMENT] days, monitoring of the resident for complications after receiving [MEDICAL TREATMENT], and/ or the vital signs being checked every shift. The April 2014 TAR (Treatment Administration Record) and MAR (Medication Administration Record) lacked any documentation related to checking the bruit/thrill, monitoring for complications, and/or checking the vital signs from April 1 through April 26., 2014. During an interview on 04/28/14 at 3:12 P.M., the ADON (Assistant Director of Nursing) indicated no documentation could be provided to indicate the bruit/thrill had been checked on non-[MEDICAL TREATMENT] days, Resident #33 had been monitored for complications after receiving [MEDICAL TREATMENT] and/or the vital signs had been checked every shift on non-[MEDICAL TREATMENT] days during April 2014. The ADON further indicated, at that time, the vital signs and bruit/thrill should have been checked every shift and Resident #33 should have been monitored for complications after [MEDICAL TREATMENT] treatments. During an interview on 04/29/14 at 10:30 A.M., the DON (Director of Nursing) indicated no documentation could be provided to indicate the bruit/thrill had been checked on non-[MEDICAL TREATMENT] days, the resident had been monitored for complications after receiving [MEDICAL TREATMENT], and/or the vital signs had been checked every shift during the month of April 2014. The DON further indicated, at that time, the care plan interventions had been added to the TAR/MAR. The Policy and Procedure for [MEDICAL TREATMENT] Communication provided by the HFA (Health Facilities Administrator) on 04/29/14 at 2:46 P.M. indicated, "...6. Upon return from the Treatment the Unit should document Shunt (sic) site s/s (signs/symptoms) infection, complication or any other problems that may have arise (sic) during the treatment. Any abnormalities should be followed up on and documented in the patients (sic) Nurses Notes..." 3.1-37(a)

Based on interview and record review, the facility failed to ensure care was provided, in that, 2 residents admitted without pressure ulcers, developed pressure ulcers for 2 of 3 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident #6 experiencing a deep tissue injury and Resident #8 experiencing a Stage 2 pressure area Findings Include: 1. The record of Resident #6 was reviewed on 4/28/14 at 11:57 A.M., The record indicated Resident #6 was admitted to the facility on [DATE] at 5:00 P.M. with [DIAGNOSES REDACTED]. The record further indicated Resident #6 was discharged on [DATE]. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated Resident #6 required extensive assist of two people to for transfers and toileting, extensive assist of one with bed mobility, unable to transfer self, and had limited range of motion in both upper and lower extremities. The undated initial care plan lacked any documentation related to pressure. The Admission Nursing assessment dated [DATE] at 5:00 P.M., indicated Resident #6 required the assistance of 2 staff for transfers and used a wheelchair. The assessment further indicated Resident #6 was admitted with no areas of pressure. A Braden Pressure Ulcer Risk scale dated 11/22/13, indicated Resident #6 was at risk for the development of pressure. A Nurses note dated 12/01/13 at 1:00 P.M., indicated, "...noted post (posterior) R(right) thigh an abraided (sic) area from edge of w/c (wheel chair) seat et legs swollen 2.2 x 0.5 red c(with) purple edges. 0 (no) drng(drainage)..." A Weekly Pressure Ulcer Progress Report dated 12/01/13, indicated Resident #6 experienced an, "...abrasion right thigh post (posterior) r/t (related to) w/c (wheel chair seat..." on 12/01/14. The report further indicated, "...2.2 cm (centimeter) length X 0.5 cm width (no depth recorded)...red purple edges..." and included a new intervention of "pad w/c edge-up in recliner". A Pressure Ulcer Staging form provided by the ADON (Assistant Director of Nursing) on 04/28/14 at 3:48 P.M. indicated, "...Bruising indicates suspected deep tissue injury...Suspected Deep Tissue Injury:...Purple or maroon localized area of discolored intact skin...due to damage of underlying soft tissue from pressure and/or shear..." 2. The clinical record for Resident #8 was reviewed on 04/28/14 at 2:00 P.M. The record indicated Resident #8 was admitted to the facility on [DATE] at 3:45 P.M. and discharged on [DATE]. The record indicated the [DIAGNOSES REDACTED]. The MDS (Minimum Data Set Assessment) dated 02/4/14 indicated Resident #8 required extensive assist of one person with transfers and bed mobility. The Initial Care Plan dated 01/28/14 lacked any documentation related to pressure. The Admission Nursing assessment dated [DATE] at 3:45 P.M., indicated Resident #8 required the assistance of 1 staff for transfers. The assessment further indicated, Resident #8 was admitted with no areas of pressure. A Braden Risk Assessment score dated 01/28/14 indicated Resident #8 was at risk for the development of pressure. A Weekly Pressure Ulcer Progress Report dated 02/11/14 indicated Resident #8 experienced a, "Stage 2 pressure ulcer 0.4 cm length X 0.3 cm width X 0.2 cm depth..." The report further indicated, "...Risk factors/cause...immobility..." and included, but was not limited to, an intervention of, "...turned q (every) 2 hours..." A Pressure Ulcer Staging form provided by the ADON on 04/28/14 at 3:48 P.M. indicated, "...Stage II: ...Partial thickness loss of dermis presenting as a shallow open ulcer..." 3. During an interview on 04/29/14 at 3:15 P.M. the DON (Director of Nursing) indicated pressure relieving interventions should have been initiated after Resident #6 and/or Resident #8 were identified as being at risk for the development of pressure. The DON further indicated, at that time, no documentation could be provided to indicate pressure relieving interventions had been initiated for Resident #6 and/or Resident #8 until after areas of pressure developed. An undated Policy and Procedure for Pressure Ulcers provided by the ADON on 04/28/14 at 3:48 P.M. indicated, "...An individual care plan will be...implemented to address...residents at risk for pressure ulcers..." 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a significant medication error did not occurr, in that [MEDICATION NAME] 75 mg ( a narcotic pain medication) was administered instead of [MEDICATION NAME] 5 mg, resulting in the resident being admitted to the hospital and receiving [MEDICATION NAME] (to reverse a drug overdose), for 1 of 12 residents reviewed for medication orders, in a sample of 12. Resident A Findings include: 1. On 7/10/13 at 8:45 A.M., the Director of Nursing (DON) provided a "Medication Error Report," dated 6/23/13. The report included: "...Medication Given, [MEDICATION NAME], Dosage given, 75 mg...What was physician's orders [REDACTED]. Could the error have endangered the life or welfare of the patient? Yes. Explain: Respiration decreased or ceasing. What was the actual effect of the error made on the patient? Respirations were found to be (decreased) (and) O2 (oxygen) saturations (decreased) Required [MEDICATION NAME] to be administer (sic) (and) sent to hospital for observation. How was the error discovered? During 7AM Medication Narc (narcotic) Count...What precautions can you take to prevent a similar error? Triple checking all medications with Medication Label to Medication Adminsitration Records, concentration of the '5' Rights to Medication Administration." During interview with the DON at that time, she indicated on 6/23/13, as LPN # 1 and LPN # 2 were counting the narcotics between shifts, they realized that [MEDICATION NAME] 75 mg had been mistakenly given to Resident A instead of [MEDICATION NAME] 5 mg. The DON indicated both of the medications were small, white pills, and the medication cards which held the pills were next to each other in the medication cart. The DON indicated Resident A was to receive 5 tablets of Lorazempam 5 mg, and instead received 5 tablets of [MEDICATION NAME] 15 mg. The DON indicated LPN # 1 did not check the label on the medication card. The DON indicated LPN # 1 received verbal counseling related to the incident. On 7/10/13 at 9:40 A.M., during interview with LPN # 1, she indicated she was working on 6/23/13, and at approximately 4:30 A.M., she administered medication to Resident A. LPN # 1 indicated she remembered counting 5 tablets, and that the [MEDICATION NAME] and [MEDICATION NAME] "were almost exactly the same color and shape." LPN # 1 indicated the [MEDICATION NAME] and Lorazempam cards were "right next to each other." LPN # 1 indicated she "guessed she didn't look at the label." LPN # 1 indicated she realized the error during the narcotic count with LPN # 2 during change of shift. LPN # 1 indicated they immediately stopped the count and went in to assess Resident A. On 7/10/13 at 9:50 A.M., during interview with LPN # 2, she indicated she was doing the narcotic count with LPN # 1 and noticed the [MEDICATION NAME] was "short." LPN # 2 indicated Resident A had 5 extra [MEDICATION NAME], and they "knew immediately what had happened." LPN # 2 indicated she went to assess Resident A, and found her to be lethargic, with her pupils constricted and her respiratory rate at 9. LPN # 2 indicated they immediately started the resident on oxygen, contacted the physician, and called the ambulance. The clinical record of Resident A was reviewed on 7/10/13 at 10:30 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 4/17/13, indicated the resident was unable to complete a brief interview for mental status, had a short-term and long-term memory problem, and was severely impaired in cognitive skills for daily decision-making. A physician's orders [REDACTED]...5AM, 4PM." an order for [REDACTED]. A monthly Vital Sign record indicated the resident's respirations were 16-20 breaths a minute from January 2013-June 2013. Blood pressure readings recorded from that time period ranged from 99/61-136/74. Nurses notes included the following notations: 6/23/13 at 7:45 A.M. (sic): "This nurse administered 75 mg of [MEDICATION NAME] to res (resident) instead of 5 mg of [MEDICATION NAME]. This was noticed while doing narc (narcotic) count (with) oncoming nurse. Phys (physician) was notified et (and) [MEDICATION NAME] was ordered et given IM. Res movement slower but responsive. Phys. ordered res to (hospital) ER for observation...." 6/23/12 at "7:00" (sic): "VS (vital signs) 88/48 - R (respirations) 9 - P (pulse) 60 - SpO2 (oxygen reading) 84%. Pupils constricted. Res. lethargic, responds when spoken to (with) a glance et occasional smile. O2 placed on res @ 2L per NC (nasal cannula). Res. saluating (sic) on bed small wet area noted. Res kicks leg slowly @ times. Awaiting EMS (emergency medical service) for transport." The resident was transferred to the hospital on [DATE] at 7:20 A.M. Emergency Department Nurses Notes included the following: "0753 (7:53 A.M.) - Arrived...Reportedly staff gave Pt (patient) [MEDICATION NAME] 75 ml (sic) @ approx 0430 (4:30 A.M.), was to give [MEDICATION NAME] 5 mg per report from N. Home (sic). Pt. resp - 9...Pt. reportedly lethargic - upon arrival...pupils pinpoint...R-24...0855 (8:55 A.M.) Resp 7-10, Dr. notified...0917 (9:17 A.M.) [MEDICATION NAME] 0.4mg IVP (IV push)...0955 (9:55 A.M.) Resp 6-10, Reported to Dr, asleep does not arouse...1003 (10:03 A.M.) [MEDICATION NAME] 0.4 ml IVP repeated...1100 (11:00 A.M.) No (change) Quiet R-10...1155 (11:55 A.M.) Transported to ICU." A hospital history and physical, dated 6/23/13, indicated, "...Reason for evaluation: Opiate overdose. History of Present Illness:...She apparently was given multiple doses of [MEDICATION NAME] inadverdently and was transferred because she was lethargic. She did receive two doses of [MEDICATION NAME] .4 in the nursing home before, and then also received two dosed of [MEDICATION NAME] .4 in the emergency room and she was subsequently admitted for observation. At present she is in the Intensive Care unit...Laboratory Data: Her urine drug screen was positive for benzo, opiates, and barbituates...Prognosis is guarded." 2. On 7/10/13 at 2:45 P.M., the Director of Nursing provided the current facility policy on "Medication Administration," undated. The policy included: "...Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." This federal tag relates to Complaint IN 623. 3.1-25(b)(9)

A. Based on observation, interview and record review, the facility failed to ensure a Hospice resident had pain assessments completed, and/or interventions implemented to attempt pain reduction in response to repeated complaints of pain for 1 of 1 residents reviewed for Hospice care. Resident #23 B. Based on observation, interview and record review, the facility failed to ensure a resident's extreme leaning position in her recliner was assessed for 1 of 2 resident's assessed for positioning in a recliner. The facility failed to follow their policy and procedure for administering oral medication with at least 4 ounces of water and failed to follow the manufacturers ' guideline for administering potassium chloride with a glass of water or juice for a resident who received crushed medications during the medication pass observation. Resident #10 Findings include: A.. On 4/17/13 at 10 A.M. the clinical record of Resident #23 was reviewed. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set assessment) dated 2/21/13 indicated the following for the resident: severely impaired cognition; extensive assistance required for bed mobility. A facility plan of care, dated 2/27/13 addressed the problem of: "Resident on Hospice: Failure to Thrive." Approaches included: "Staff will provide total care for resident." A Hospice nurse note dated 4/17/13, indicated the following: "Full assessment complete with collaboration of FS (facility staff)...alert with confusion, c/o (complained of) right ankle pain. FS nurse notified..." On 4/18/13 at 9:07 A.M., CNA #30 and #31 entered Resident #23's room to reposition her. As they turned the resident to her side, she stated "my ankle hurts." Both CNAs continued to turn the resident. On 4/18/13 at 12 P.M., LPN #32 was observed changing the resident's dressings. As LPN #32 was removing the resident's dressings to the right outer ankle, the resident was yelling "it hurts, it hurts." LPN #32 continued with her dressing changes. After applying skin prep to two scabbed areas on the arch of the right foot, she replaced the heel bows as the resident was yelling "it hurts, it hurts." On 4/18/13 at 12:30 P.M., Resident #23 was observed receiving medications from LPN #20. During the medication administration, Resident #23 moaned out, "My ankle hurts." LPN #20 continued with the medication administration through the G (Gastrostomy) tube. On 4/18/13 at 12:50 P.M., during a [DEVICE] feeding, Resident #23 cried out "my elbow hurts." The resident was observed lying on her right side at the time. LPN #20 did not stop to reposition or ask resident about the pain. A few minutes later the resident said "oh my ankle still hurts." LPN #20 replied, " Well it should be getting better soon. That is why we put the medication on it everyday." On 4/19/13 at 8:09 A.M., the ADON (Assistant Director of Nursing) was interviewed. She indicated the resident was able to relay pain by facial grimaces and "she will tell you." On 4/19/13 at 10:14 A.M., the ADON and DON (Director of Nursing) were interviewed. At that time, the DON reviewed the current MAR (medication administration record) and indicated the resident was not on anything routinely for pain. At that time, the prn (as needed) medication record was reviewed. The resident had not been medicated for pain on 4/17/13 or 4/18/13. At that time, the DON indicated the Pain assessment stated no pain. She indicated that was done in February and Hospice does the pain assessment weekly. At that time, the ADON and the DON were made aware of the resident having been observed voicing multiple complaints of pain and those complaints were voiced to multiple staff. Pain assessments and/or pain control attempts were not completed for the resident. B. On 4/16/13 at 10:10 A.M., Resident #10 was observed in her recliner at her bedside. The recliner was observed with the foot rest in the up position. The resident was observed leaning to her left side, with her left axilla area resting over the left arm rest. The level of the resident's head was below the level of the bedside standing sitting beside the resident. Her right shoulder was observed in the horizontal center, of the back of the recliner chair. The resident was eating potato chips, without difficulty. On 4/16/13 at 12:30 P.M., the resident was observed in her recliner at her bedside, again leaning to the left side. At that time, the resident was eating her lunch and the level of her head was above the level of the beside table. Her right shoulder was towards the horizontal center of the chair. The resident was eating independently, without difficulty. On 4/16/13 at 4:30 P.M., the resident continued to be observed positioned in her recliner, leaning to the left side with the resident's eye level at the top of the cabinet beside her. On 4/17/13 at 8:45 A.M., the resident was observed in her recliner as noted at 10:10 A.M. on 4/16/13. CNA #30 was observed entering the resident's room at that time. When CNA #30 left the room, the resident remained in the same position. On 4/17/13 at 12:30 P.M., the resident was again observed in the same position as noted above, eating lunch without difficulty. On 4/18/13 at 9 A.M., the resident was again observed in her recliner as noted above at 10:10 A.M. on 4/16/13. At that time, the resident was interviewed. She indicated she felt "OK" in her recliner. The resident demonstrated she was able to readjust her right shoulder over somewhat to her right horizontal center, approximately 1/3 of the way over from the back of the recliner. Within a few seconds of repositioning, the resident returned to the previous position of her left axilla resting on the left arm rest of the recliner. On 4/19/13 8 A.M., the DON (Director of Nursing) was interviewed. She indicated she was aware the resident leaned to the left in her recliner. She indicated the resident hasn't been evaluated for the leaning in her recliner. She indicate they would have the Occupational Therapy Department evaluate her. On 4/19/13 at 2:23 P.M., the DON was again interviewed. She indicated was unaware if the resident has ever been evaluated for her leaning to the left severely in her recliner. At that time, the DON reviewed the resident's current medical record. She indicated she didn't see an evaluation on the chart. The same resident was observed during the medication pass observation as follows: During an observation 4/18/13 at 9:20 A.M., LPN #32 prepared Resident #10's medication for administration. LPN #32 crushed seven medications and poured the crushed medications onto 15 cc of applesauce. The crushed medications were as follows: [MEDICATION NAME] 1 mg, [MEDICATION NAME] 500 mg, Clorpegogel 75 mg, Vitamin C, Spirolactone 25 mg, [MEDICATION NAME] 40 meq, Zinc 20 mg, Multivitamin. LPN #32 opened three Potassium Chloride 10 meq capsules and poured the medication onto the 15 cc of applesauce and the other eight crushed medications. Using a spoon, LPN #32 blended the mixture of applesauce and the eleven crushed tablets/capsules of medications together. LPN #32 took the prepared medications mixture into Resident #10's room and administered the medications to Resident #10 in two spoonfuls. After the second spoonful of medication was administered, Resident #10 made a grimacing face. Resident #10, opened and closed her mouth repeatedly as she tried to swallow the applesauce laden with the medications. As Resident #10, opened and closed her mouth, remnants of the crushed pills were observed on her lips and tongue. LPN #32 said, "OK." LPN #32 then turned and walked away without offering or encouraging Resident #10, to drink any fluids. On 4/18/13 at 9:35 A.M., LPN #32 indicated she mixed Resident #10's medications in applesauce because it was easier for the resident to swallow. The Clinical record was reviewed on 4/18/13 at 12:30 P.M. [DIAGNOSES REDACTED]. Minimum Data Set (MDS) indicated Resident # 10 had no signs or symptoms of swallowing disorders. On 2/19/13 at 4:40 P.M., a review of the 2012 Nursing Spectrum Drug Handbook procedure for administering potassium chloride under the section titled "Patient Teaching" read as follows: "...instruct patient to take the oral form with or just after a meal, with a glass of water or fruit juice." On 2/19/13 at 4:40 P.M., the facility's policy and procedure " Preparation and General Guidelines for Medication Administration" was reviewed. Section 9 of the Administration section read as follows: "At least 4 ounces of water or other acceptable liquid are given with oral medications." On 4/19/13 at 6:15 P.M., the DON was made aware no water was offered to Resident #10's medication administration. The DON was also made aware nine (9) medications crushed and mixed with 15 cc of applesauce were not palatable to the resident. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident with an NPO status (nothing by mouth), whose sole nutritional intake was dependent on a gastrostomy tube (g tube) did not experience unavoidable, significant weight loss (12%) in a 1 week period for 1 of 1 residents reviewed with a gastrostomy tube. Resident #23 Findings include: On 4/17/13 at 10 A.M. the clinical record of Resident #23 was reviewed. [DIAGNOSES REDACTED]. A hydration risk assessment dated [DATE] included, but was not limited to the following: swallowing difficulty; [DIAGNOSES REDACTED]. The most recent MDS (minimum data set assessment) dated 2/21/13 indicated the following for the resident: severely impaired cognition and extensive assistance required for bed mobility, at risk for pressure ulcers, had one or more pressure ulcers... A facility care plan, dated 2/22/13, addressed the problem of "At risk for Altered Nutritional Status with G tube placement. Approaches included the following: "continue feedings per MD order, dietician to see et (and) evaluate; monitor placement q (every) shift and prn (as needed); notify MD of any significant changes; monitor G tube site q shift , check patency q use prn." A facility care plan, dated 2/22/13, addressed the problem of "Res (resident) at risk for wt (weight) loss r/t (related to) dementia/weakness and G tube placement." Interventions included the following: " weight monthly and weekly if needed prn; notify MD, dietary mgr (manager) and dietician of potential wt loss problems;..." A facility care plan, dated 2/22/13, addressed the problem of "Res at risk for dehydration r/t g tube placement." Approaches included, but were not limited to, the following: "Administer feedings and fluid per tube as MD ordered..." A facility plan of care, dated 2/27/13 addressed the problem of: "Resident on Hospice: Failure to Thrive." Approaches included: "Staff will provide total care for resident." A physician order [REDACTED]. A Hospice plan of care dated 4/10/13, indicated the resident was NPO (nothing by mouth) and received Fibersource 1/2 can four times a day. On 4/16/13 at 2 p.m. the DON (Director of Nursing) provided a copy of the monthly weights for the current year. Weights for the resident were documented as followed: January 127 lbs. (pounds); February 125 lbs.; March 115 lbs. and April 116.8 lbs. On 4/18/13 at 6 P.M., the ADON (Assistant Director of Nursing) was interviewed. She indicated she had been employed at the facility since the fall of 2012. She indicated the following for the resident: Speech therapy began for the resident on 1/29/13 due to resident refusing to eat and was discontinued on 2/19/13 due to a lack of cooperation with the resident. On 2/20/13, a surgical consult was obtained for G tube (gastrostomy tube) placement. On 2/22/13, the G tube was placed. On 2/26/13, the resident became a Hospice patient, with the [DIAGNOSES REDACTED]. At that time, the ADON indicated the facility was taking weekly weights on the resident, which began on 1/29/13. The weekly weights were documented as follows for the year 2013: 1/29=130 lb; 2/5=125 lbs; 2/12=120 lbs; 2/19=115 lbs; 2/22 G tube placed; 2/26=115 lbs; 3/5=101 lbs; 3/9 = G tube replaced; 3/12= 104 lbs; 3/19=116 lbs.; 3/26=116 lbs and 4/2= 116.8 lbs. At that time, the ADON was interviewed as to the reason for the 14 lb weight loss from 2/26 until 3/5. The ADON indicated the following: "on 3/5/13 the physician was notified of excessive drainage to the G tube dressing." Documentation in the nurses notes (NN) on 3/5/13 at 9 P.M. indicated the following: "G tube drsg (dressing) changed d/t (due to) excessive drainage. Physician notified of drainage, new order received..." A physician order, dated 3/5/13 at 5 P.M. indicated the following: "Hold feeding x (time) 1 (one), hold free water till A.M." NN dated 3/6/13 at 10 A.M., indicated the following: "...yellow drainage pouring from [DEVICE] site...checked for residual et noted to have approximately 60 cc residual...meds (medications) flushes et feedings being held until (physician name) returns page." NN 3/6/13 at 1 P.M., indicated the following: "Hold feedings until 5 P.M., only give meds with water, updated MD after 5 P.M...." NN dated 3/6/13 at 6 P.M., indicated to "decrease free water...cut feeding to 1/2 can qid (four times a day)..." At that time, the ADON indicated on 3/9/13, the resident returned to the hospital to have a new feeding tube put into place. She indicated at that time, the flange portion of the G tube was not functioning properly. She explained the flange was a circular disc portion of the G tube, which was located below the level of the skin. She indicated the defective portion of the G tube had allowed tube feeding, which was instilled into the resident via the G tube, to "run back out" from the resident. The ADON indicated she doesn't know exactly the dated the problem started with the tube feeding running out from the resident. The ADON indicated the malfunctioning flange on the G tube and the tube feeding running out of the resident is the reason for the 14 lb weight loss from 2/26 to 3/5. At that time, documentation was reviewed in the nurses notes for February and March 2013. The ADON indicted the first documented NN of the problem with the G tube leaking was on 3/5/13 at 9 P.M. At that time, the MAR (medication administration records) were also reviewed for March 2013. The ADON indicated documentation was lacking on the March MARS of a problem with the tube feedings leaking, until the feeding was held on 3/5/13. On 4/19/13 at 8 A.M., the DON provided copies of the Nutritional Progress notes. The Registered Dietician (RD) note dated 2/8/13 included but was not limited to, the following: "...will continue to monitor po (per os) intake, wt (weight)..." The next RD note was dated 3/1/13 and included, but was not limited to the following: "Res is now on [MEDICATION NAME] 1.2 - 4 cans dly (daily)...Res with 60 cc water before et after meds (medications) et 300 cc water 8 x day to provide 2640 cc water flush daily, plus 768 cc water from feeding. Total 3408 cc dly (daily)...Res is tolerating feedings at this time to monitor TF (tube feeding) tolerance, wt (weight)..." The next documented Nutritional Progress note is dated 4/8/13 and included but was not limited to, the following: "RD Review: Orders reflect 1/2 can [MEDICATION NAME] 4 x's daily, pureed diet, shakes bid, magic cups bid and protein powder bid. Current wt 99.4 lbs. (sic) Nursing reports good tolerance to feedings and flushes. Hospice status." At that time, the ADON was interviewed as to the RD documentation of the resident's note above indicating the resident is consuming oral fluids. The ADON indicated at that time, the resident was NPO (Nothing by mouth) and only being administered the tube feedings via the G tube (for all nutrition). She indicated she didn't know why the RD documented the note she did on 4/8/13 and could not provide an explanation for the contents of the progress note but did indicate they were inaccurate (regarding the pureed diet, magic cups, protein powder and shakes). On 4/19/13 at 9:30 A.M., the ADON and the DON were interviewed. They indicated the first documentation of the nurses notes indicating the tube feedings were running back out of the residents abdomen was on 3/6/13. The ADON indicated at that time, she doesn't know how long that was occurring. She indicated documentation was lacking in the medical record to indicate exactly how long that was occurring. She indicated the physician came to the facility and saw the resident on 3/8/13 but did not document progress notes. She also indicated the physician spoke to the dietician but did not document progress notes. She indicated at that time, she was unable to find documentation the physician was notified on 3/5/13 of the significant weight loss. On 4/19/13 at 10:40 A.M., the ADON and the DON (Director of Nursing) were interviewed. The ADON indicated the weights documented on the Weight record for the year 2013 were accurate. She indicated the weights for the month had been rechecked and the scale recalibrated but the rechecked weights had not been documented. At that time, the current policy and procedure titled "Nutrition Risk/Weight Loss" was received from the ADON and DON. The undated policy indicated the following: "It is the policy of (name of facility) to avoid all unplanned significant weight loss...Each resident will have a Nutritional Risk Assessment completed be the Dietician upon...with any significant change...Weights will be reviewed by Nursing Administration and the Dietician to identify any significant weight loss. Significant weight loss will be identified if the resident has a weight loss...of 5% in one month...Residents who have been identified with a significant weight loss/gain will have that information reported to their physician for additional interventions warranted..." At that time, the ADON and DON also provided a copy of the current "Enteral Nutrition Therapy [MEDICATION NAME] Feeding" policy and procedure. The policy and procedure is undated. At that time, the ADON provided nursing progress notes in monitoring the resident. The ADON's notes indicated the following: 2/26/13: still declining in overall health; 3/5/13: "Resident is currently on G tube feedings. Will continue with monitoring. Residents family is aware of significant weight loss et Hospice is also aware. MD is currently monitoring." Progress note from 3/12/13: "Resident this week having trouble with G tube had to have it replaced...Feedings have resumed et are doing better..." Progress note 3/19/13: "...weight is improving." 3.1-44(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents received care to prevent pressure ulcers and to promote healing: in that Resident B was admitted with a pressure ulcer from a hospital stay that worsened to a Stage 3 pressure ulcer and Resident C developed a Stage 2 pressure ulcer. This deficient practice affected 2 of 4 residents reviewed for pressure ulcers in the sample of 10. Findings include: 1. On 2/6/12 at 5:50 A.M., the Administrator indicated Resident B had a stage I or II pressure area on coccyx when readmitted from a recent hospitalization . Resident B was identified as interviewable and required assistant with care. On 2/6/12 from 7:20 A.M. until 1:15 P.M., Resident B was observed to be sitting in a reclining chair in the lounge. On 2/6/12 at 1:15 P.M., Resident B was observed to be placed in bed with the assistance of LPN # 1 and CNA # 5. When Resident B was assisted to his left side, a dressing was observed on his coccyx. The dressing was dated 2/4/12. LPN # 1 indicated the dressing was supposed to be changed daily on the evening shift. Resident B was observed to be incontinent of bowel. CNA # 5 was observed to cleanse Resident B. Resident B had an area on the coccyx the approximate size of a penny. The wound bed was observed to have a yellow wound base. Both buttocks were observed and looked like the appearance of raw hamburger. On 2/6/12 at 1:40 P.M., in an interview with the Director of Nursing, she indicated the last time she saw Resident B's open area it was superficially open with small amount of drainage. She indicated the surrounding tissue was pink. On 2/6/12 at 1:45 P.M., in an interview with the Director of Nursing, she indicated the wound had a major change since she last observed the area last Wednesday. On 2/7/12 at 9:10 A.M., Resident B was observed to be assisted to his side. The facility Wound Specialist was present during the observation. Resident B was observed to have a half dollar size stage 2 ulcer on his right buttock, and a stage 3 on his coccyx, measured by the Director of Nursing during this observation, as 4 cm by 1.2 cm. There were 3 other superficial areas noted to the left buttock. The Wound Specialist at this time indicated the facility had received report from the hospital that Resident B had a stage 2 area on his coccyx. She stated the area should have been staged at stage 3 upon readmission to the facility instead of following the report received from the hospital. The clinical record for Resident B was reviewed on 2/6/12 at 10:00 A.M. The record indicated Resident B had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 11/28/11, indicated Resident B had modified independence with decision making. Resident B required extensive assistance of two with transfers, did not ambulate and was dependent on staff for personal hygiene. Resident B did not have a pressure sore. A "Nurses admission record and allergies [REDACTED]." Nurses notes indicated "1/14/12- 2:30 p.m. ...readmitted ...stage 2 noted to coccyx .7 c.m. by .7 c.m...." "1/14/12 1700 (5 p.m. ) ..cleanse wounds daily with normal saline, dress with collagen, hydrogel and bordered dressing, wound assessment done." Wound/Skin Healing Records, indicated: "1/14/12 stage 2, 1.0 c.m. by .5 c.m., no depth, serous exudate, scant amount exudate, pink wound bed." "1/21/12 stage 2, 1.0 c.m. by .5 c.m., no depth, serous exudate, scant amount exudate, pink wound bed," "1/28/12 stage 2, 1.0 c.m. by .5 c.m., no depth, serous exudate, scant amount exudate, pink wound bed," "2/6/12 not staged, 2 by 1.5 c.m. unknown depth, serous drainage, small amount exudate, granulation tissue , coccyx with excoriation sound wound, moderate pain." A care plan, dated 1/16/12, indicated "Altered skin integument R/T (related to) stage 2 coccyx." The approaches were "1. Dressing chg (change) daily. Clean NS (normal saline), Apply collegen et (and) hydrogel. 2. easy boots for feet protection. wear at all times except for ADL's (activities of daily living). 3. Notify Dr of ill effects. 4. measure coccyx wound weekly." On 2/7/12 at 1:30 P.M., the Director of Nursing provided the wound measurements for Resident B. "Coccyx 4 x (by) 1.2 x 0.2 depth, Stage 3. 50% granulation 50% slough with a thin layer of DTI (deep tissue injury) noted on the LTA (left) edge. Area is 2 wounds with a .2 cm bridge noted between both wounds. Periwound intact with slight redness noted. Recommend treatment change to Santyl to slough and collagen to granulation. Barrier cream to periwound. LT buttock 4 x 2 x < (less than) .2 depth Stage 2 Pale pink wound bed. Periwound intact. Hydrogel to wound bed. Barrier cream to periwound. RT (right) buttock 2 x 1 x <.2 Stage 2 Pale pink wound bed. Periwound intact Hydrogel to wound bed. Barrier cream to periwound." 2. Resident C was observed on 2/6/12 at 4:55 A.M., to have been dressed and transferred to a wheelchair with a pressure reducing cushion, by CNA # 4 and CNA # 5. Resident C was then taken in the wheelchair to the lounge area of the facility. Resident C was identified by the Director of Nursing, this same day, on the initial tour of the facility at 5:45 A.M. as having no skin issues, boots for protection to her heels, and requiring a cushion in her chair. The resident was observed to have been sitting in the lounge area at the time of the initial tour. The Director of Nursing provided a CNA assignment sheet on 2/6/12 at 6:30 A.M., which indicated the resident was to be turned every 2 hours. The resident was observed to continue to sit up in the wheelchair through 8:20 A.M. without a position change (3 hours and 25 minutes) when CNA #4 and CNA #2 wheeled the resident to her room from the dining room and transferred her into bed. During personal care, the resident was observed to have been incontinent of urine. Her buttocks were very red, and the top of the back of her left leg was very red, with deep indentations observed from the incontinence pad. A superficial open area was observed on Resident C's coccyx. The area was approximately the size of a dime with the top layer of skin missing, but minimal depth and no drainage. CNA #2 indicated she was going to go get the nurse. LPN #1 entered the room at 8:25 a.m., and indicated the area on Resident C's coccyx was first observed on Sunday 2/5/12 , and CNA's had told her about it. She further indicated she had provided a treatment of [REDACTED]. LPN #1 indicated she did not know when the dressing had fallen off or been removed. LPN #1 indicated she had not gotten an order for [REDACTED]. During interview the Director of Nursing, on 2/6/12 at 8:30 A.M., she indicated Resident C did not have any open areas last Wednesday when she did wound rounds, and was not aware the resident had an open area. Resident C's clinical record was reviewed on 2/6/12 at 8:30 A.M. The most recent Minimum Data Set, dated dated [DATE], indicated the resident was severely cognitively impaired with short and long term memory loss, required extensive assistance with bed mobility, transfers, was at risk of pressure ulcers with no current pressure ulcers. A care plan problem, dated 12/7/11, for "at risk for skin breakdown related to incontinence and decreased mobility," interventions included "check and change every 2 hours as needed," "barrier cream every incontinent episode and as needed," "float heels while in bed and chair," "moon boots at all times," "pressure relieving mattress to bed," " pressure cushion to chair," "notify MD of any skin problems," "turn every 2 hours." The wound sheets, dated 2/6/12, indicated a "stage 2" "1 by .5 cm," no exudate, pink wound bed, plan of care, hydrogel and collagen foam dressing, no pain. The policy and procedure for "Hillside Manor Pressure Ulcer Program,", no date as to when started, included, "each resident will have their skin assessed during the scheduled shower days by the CNA responsible for their care...if a new skin condition is identified the Charge Nurse is responsible for assessing the area, obtaining measurements and documenting in the nurses notes concerning the skin condition. The charge nurse will promptly notify the physician for appropriate treatment plan as well as notify the Director of Nursing or Designee of all skin conditions..." This federal tag relates to Complaint IN 197. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents were assessed and measures were implemented to prevent the development of new pressure ulcers for 4 of 8 residents reviewed for pressure ulcers in the sample of 12 and 1 of 1 resident reviewed for pressure ulcers in the supplemental sample of 2. 1. Resident B had a decline in her health resulting in the resident developing a Stage III pressure ulcer to her buttock and a Stage IV pressure ulcer to her right heel, with surgical debridement, while residing in the facility. 2. Resident C had a decline in her physical functioning following a medication change in September with the resident requiring more physical assistance and the facility failed to reassess or develop and implement interventions to prevent pressure areas with the resident developing Stage IV pressure ulcers on each heel that required surgical intervention. 3. The facility failed to provide position changes for Resident A that resulted in the development of 4 new superficial areas and failed to provide pressure relief while up in the wheelchair, an air flow mattress to the bed, maintain a dressing to the coccyx wound, failed to use clean technique during the dressing change or during measurement of the new pressure areas, and failed to notify the physician of an increase in the amount of drainage from the pressure area. 4. The facility failed to ensure Resident D with a Stage III pressure wound was turned and repositioned every two hours in accordance with their care plan. 5. The facility failed to ensure Resident E with a history of pressure ulcers was provided preventative pressure relief. This immediate jeopardy began on 11/24/10 when the facility failed to implement interventions to prevent pressure sores for a resident with a change in physical status and developed Stage IV pressure ulcers to her heels. The facility failed to assess the risk of pressure ulcers for all residents routinely and with changes in condition, and failed to develop and implement interventions to prevent and treat pressure ulcers. This immediate jeopardy was identified on 1/6/11 at 10:00 AM. The Health Facility Administrator and Director of Nursing (DoN) were notified on 1/6/11 at 11:00 A.M. The Immediate Jeopardy was removed on 1/7/2011, but the facility remained out of compliance at the level of a pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff members were inserviced on the new facility policy for prevention and treatment of [REDACTED]. Findings include: 1. Resident B was identified on the initial tour of the facility on 1/4/11, at 8:30 A.M., by the DoN (Director of Nursing), as having an open area on her bottom and one on her heel, requiring assistance with activities of daily living, and being cognitively impaired. The resident was observed on 1/4/11 at 8:45 A.M., to be sitting in a wheelchair in the lounge area by the nurses' station. The resident was observed to have a cloth incontinence pad in her chair, but no pressure reducing cushion. A Foley (urinary) catheter drainage bag was hanging under the chair. The resident was observed to have a moon boot on her right foot (a plastic device which provides pressure relief to the heel.) The resident was observed to have continued to sit in the wheelchair without benefit of a position change through 12:45 P.M. During interview with CNA (Certified Nursing Assistant) #1, at 12:45 P.M., she indicated she had gotten the resident up for the day at 6:30 A.M. RN #2, at this same time, verified the resident did not have a pressure reducing cushion for her chair, but indicated she would get one for the resident. Resident # B continued to sit in the wheelchair without a pressure reducing cushion and in the same position through 2 P.M., (7 1/2 hours). At 2 P.M., on 1/4/11, CNA #1 and #2 were observed to transfer the resident to her bed. The resident was observed to required extensive assistance of both CNA's to transfer. The bed was observed to have an alternating pressure relief mattress. The resident's buttocks were observed to be red with deep indentations from the folds in the incontinence pad. On 1/4/11 at 2 P.M., the resident was observed to have been incontinent of bowel through her pants and unto the incontinence pad on her chair. CNA #1 and #2 provided incontinence care. LPN #1 was observed to treat the resident's open areas. Resident B was observed to have a Stage II pressure area to her left buttock that was pinpoint in size, superficial depth and red in color. On 1/4/11 at 2 P.M., the left heel was observed to be a Stage III pressure area with a yellow base and approximately the size of a quarter. Resident B's clinical record was reviewed on 1/3/11 at 12:00 P.M. [DIAGNOSES REDACTED]. The most recent MDS assessment (Minimum Data Set), dated 11/30/10, indicated the resident required extensive assistance with bed mobility, ambulation and was occasionally incontinent of bowel and bladder. The MDS indicated the resident had no current pressure ulcers and had pressure relief in the bed and chair. During interview with the MDS Coordinator on 1/6/11 at 9:00 A.M., she indicated she had documented the resident to have pressure relief in the chair on the last MDS assessment, because the resident should have had pressure relief , but stated she had not verified the resident actually had the pressure relief device for the chair. During interview with RN #2, the Assistant Director of Nursing, on 1/5/11 at 8:45 A.M., she indicated the resident had a Foley catheter to allow the pressure areas to heal, as the resident was frequently incontinent of urine. She indicated the resident had an exacerbation of her [MEDICAL CONDITION], pneumonia and [MEDICAL CONDITION] and had become more dependant while she was very ill. The care plan, included a problem, dated 3/11/10, and updated through 12/3/10, for "Resident is at risk for skin breakdown due to urinary incontinence and decreased mobility." Approaches included: "provide pericare after each incontinent episode, assess skin weekly and prn (as needed) and report changes to medical doctor." A care plan problem, dated 12/1/10, indicated the resident had right lobe pneumonia. Another problem, dated 12/3/10, indicated a problem of "multiple impaired skin integrity." Approaches included " perform daily skin treatments as ordered by physician, weekly measurements, notify physician with improvement/decline to skin issues as needed and every 2 weeks, turn and reposition every 2 hours and prn (as needed), discuss resident's treatments areas prn and weekly with family/don/administrator/physician." The care plan did not include the need for any pressure reducing device in the wheelchair, the need to float heels to eliminate pressure or when the resident was to wear moon boots . A Braden Scale for predicting pressure sore risk for 9/3/10 indicated the resident was not at a risk for pressure ulcers, with a score of 19, which included the resident had no impairment of perception, skin was occasionally moist, walks occasionally, slightly limited mobility, makes frequent though slight changes in body or extremity, eats adequately, no apparent problem with friction or shear. The next Braden Scale, dated 12/3/10, indicated the resident, was at a mild risk of pressure, with answers changed to very limited mobility, and makes occasional slight changes in body or extremity. A nurse's note, dated 12/2/10 at 2 p.m., indicated: "...head to toe skin assessment complete and multiple areas found including pressure areas...refer to skin book and physician orders..." The Pressure/Stasis Ulcer Assessments, a form used to document all areas, indicated "left inner heel, pressure, not present on admission; Date identified 12/1/10; Measurements: 1 cm by 1 cm, no drainage. Color-black, green and yellow. Dr notified on 12/2/10, area not stageable due to necrotic tissue present. An entry of 12/22/10 indicated the area was debrided, a Stage III 1.5 cm by 2 cm by 0.4 cm depth, serosanguineous drainage, color pink, red and granulation tissue. The last documented measurements were 12/27/10, Stage III, 1.5 cm by 2 cm by .4 cm, serosanguineous drainage, heels elevated. On 1/6/11 at 9:00 A.M., the Assistant Director of Nursing, indicated the left heel was last measured on 12/27/10. Discharge instructions from the hospital indicated the left heel was surgically debrided on 12/22/10. Documentation from the wound consultant indicated the resident had been seen on 12/27/10, and included left heel- full thickness pressure, healing Stage III, 1.2 cm by 0.8 cm with 0.3 cm depth. Physician telephone orders for the left heel included: 12/2/10, Apply hydrogel gauze to left heel area cover with foam pad daily; 12/22/10, culture left heel now times 1, apply calcium alginate daily to left heel; and cover with dry dressing; 12/27/10, Apply collagen and [MEDICATION NAME] left heel wound bed, cover with foam dressing, and 12/29/10 continue wound care to left lateral heel as previously initiated. The Pressure Ulcer Assessment, for left inner buttocks indicated the area formed on 12/1/10,and was 2 cm by 0.5 cm. with no depth. Color yellow, red, and necrotic, non-stageable pressure area to left inner buttock- necrotic in color. The measurements for this area on 12/27/10 were Stage II- 1.7 cm by 0.2 cm. Color pink. The ADoN (Assistant Director of Nursing) provided an assessment for the left buttock, on 1/6/11 at 10:00 A.M., that indicated the left buttock area was measured on 1/5/11. The measurements were 0.3 cm by 0.1 cm, intact depth, red in color. Physician telephone orders for the left buttock indicated: 12/2/10, Apply hydrogel gauze to left buttock daily; 12/14/10, Foley catheter to promote wound healing, when healed remove Foley catheter, and 12/27/10, Apply collagen foam pad to left buttocks daily. During interview with the DoN on 1/4/11 at 2:50 P.M., she indicated her goal was to have a pressure relief cushion for every resident who was not ambulating and she had some cushions ordered. During interview with the DoN on 1/6/11 at 10:30 A.M., she indicated they did not know when the resident was provided with the alternating air mattress. She indicated she could remember doing so but did not chart it. During interview on 1/6/11 at 10:35 A.M., she indicated the air mattress was applied within a day or two of the resident developing the pressure ulcers on her left buttock and left heel. 2. Resident C was identified on 1/3/11 at 8:30 a.m., by the Director of Nursing on the initial tour of the facility as having an open area on each heel that were healing well, wears moon boots ( a hard plastic boot that relieves pressure by suspending the heel and relieving pressure) and is incontinent. The resident was observed at that time sitting in a gerichair with her feet up and moon boots on. The resident was observed to have been sitting on a cloth incontinence pad and had no pressure relieving cushion under her. The resident was observed on 1/3/11 at 11:55 A.M., to be in her room in a recliner with no cushion under her. At this time, LPN #1 indicated she was going to provide the treatment to the resident's heels. The resident was observed to have Stage III pressure areas on both heels. Both heels areas had a pink base with some yellow tissue noted. The right heel appeared to be approximately 2 cm by 2 cm and 0.2 to 0.3 depth. The left heel appeared to be approximately 1.5 cm by 1.5 cm with 0.2 to 0.3 depth. Resident C was observed to have a pressure reducing mattress on her bed. RN #2, the Assistant Director of Nursing, on 1/4/11 at 10:00 A.M., indicated the heel ulcers had developed in the facility when a medication had been discontinued and the resident had became much more dependant on staff. She indicated the medication, [MEDICATION NAME], (antipsychotic medication) was discontinued on 9/29/10. She indicated the resident reacted very badly, and had been in bed more and in the gerichair, the resident could no longer sit at the dining room table, was very lethargic and during that time the pressure ulcers to her heels were discovered. Resident C's clinical record was reviewed on 1/4/11 at 3:00 P.M. [DIAGNOSES REDACTED]. The MDS assessment, (Minimum Data Set), dated 10/18/10, indicated the resident had memory loss, required extensive assistance with bed mobility, transfers and ambulating, was incontinent of bladder and bowel, had no pressure ulcers, but had pressure reduction while in bed. A Braden Scale for prediction of pressure sore risk, dated 8/28/10, indicated the resident was at a mild risk for pressure. The next assessment, dated 10/18/10, indicated the resident was at mild risk pressure. The assessment, indicated the resident's mobility was slightly limited, makes frequent though slight changes in body position but unable to make frequent or significant changes independently, walked occasionally, potential problem with friction or shear. The care plan, included a problem, dated 6/7/10 and updated through 12/10, for "risk for impaired skin integrity." Approaches included: monitor pressure area with incontinent/peri-care/showers, turn and reposition while in bed/sitting every 2 hours, monitor meal consumption daily." Another problem, dated 12/3/10, for "Bilateral Stage II ulcers to heels," included approaches of " daily topical treatment to heels with treatment of [REDACTED]." A nurses note, dated 11/24/10 at 6:25 A.M., indicated: "CNA found necrotic Stage 3 pressure area on left and right heels, left heel has small necrotic area surrounded by pink tissue, no drainage or odor, measures approximately 0.3 by 0.4 cm by 0.1 cm depth, heel is mushy area to right heel measures approx. (approximately). .3 cm by .3 cm times .1 cm depth, right heel is mushy as well although not as severe as left heel, cleansed with normal saline and applied foam dressing until order could be received, paged Dr..." A telephone physician's orders [REDACTED]. The Pressure/Stasis Ulcer Assessment indicated the right heel was discovered on 11/24/10, pressure in origin, Stage II, 0.3 cm by 0.3 cm with 0.1 cm depth, color pink and black. The next measurement 11/29/10 indicated the area was non stageable due to necrotic tissue present, 1 cm by 2.5 cm , unable to determine depth. The left heel was discovered 11/24/10 as a Stage II pressure ulcer, 0.3 cm by 0.4 cm by 0.1 cm depth, necrotic area, black and pink in color. The next entry, dated 11/29/10, indicated the area was unstageable due to necrotic tissue, 2.0 cm by 2.5 cm- unable to determine depth, drainage -serosanguineous, mild odor. The most recent entry, dated 1/2/11, indicated right heel, Stage III, 2 cm by 2 cm by 0.2 cm depth, serosanguineous drainage, color, red, yellow, grey. Left heel, 1/2/11, Stage III pressure, 1 cm by 1.5 cm, small amount serosanguineous drainage, color red, yellow, grey. A Wound Care Consultant report, dated 11/29/10, indicated: right heel, "Onset 11/24/10, size 1 cm by 2.5 cm, depth unable to determine, full thickness, pressure-unstageable, wound bed 100 % gray thick slough, odor present" and left heel "full thickness, pressure suspected deep tissue injury, drainage serous, facility acquired, size 2 cm by 2.5 cm, unable to determine depth, wound bed 95 % mushy, soft black necrotic tissue, granulation around edges 5%." A report of operation, dated 12/2/10, indicated "Bilateral necrotic heels from pressure," Operation "Debridement of necrotic skin and sub q (subcutaneous) tissue from both heels." The report indicated the resident was negative for osteo[DIAGNOSES REDACTED]. The nurses admission record, dated 12/3/10, upon return from the debridement indicated the resident had ulcers on "left heel 3 cm by 3 cm pressure" and right heel "2.5 cm by 3.5 cm pressure." 3. On the initial tour with the Assistant Director of Nursing, on 1/4/11 at 9:10 A.M., she indicated Resident A was not interviewable and had a pressure area to coccyx. Resident A was observed to be sitting in her wheelchair in her room. On 1/4/11 at 10:15 A.M., Resident A was observed to be sitting in her room in a wheelchair, no pressure relief cushion was observed in the wheelchair. On 1/4/11 at 11:05 A.M., Resident A was observed to be assisted by two CNAs and use of a gait belt from the wheelchair to the bed. Resident A stated "My behind hurts." RN # 1 asked Resident A to rate her pain on scale of 1 to 5 with five being the worst. Resident A stated "a five or six." RN # 1 then re-explained the pain scale to the resident and Resident A stated "It's not a five." RN # 1 then asked the resident if she would like something for pain and Resident A stated "I asked for Tylenol last night but didn't get it yet." Resident A was then turned onto her left side for treatment to her coccyx wound. There was no dressing observed to the area, and there was a large amount of thick tan drainage observed to be on her adult incontinence brief that went all the way through her outer pants. There was also observed to be a small amount of bright red blood on the incontinence brief. In an interview with CNA # 3, at this time, she indicated Resident A's dressing fell off during her shower this morning between 6 and 6:30 A.M. CNA # 3 further indicated the night shift nurse had put a gauze dressing on the area but it had fell off. There were three different areas observed, one on the coccyx that was observed to be the size of a nickle with depth with the tan drainage, one on the lower left buttock that was actively bleeding, and one to the left of the coccyx. RN # 1 was observed to complete the treatment to the area to the coccyx while wearing gloves. RN # 1 then was observed to measured the lower left buttock at 1.5 cm by 0.8 cm and was superficially open and the new area to the left of the coccyx measured 3 cm and was superficially open. RN # 1 continued to be wearing the same gloves to measure the two new areas. RN # 1 was then observed to place 4 N 1 cream in the left lower buttock area and then to the new area to the left of the coccyx. RN # 1 continued to wear the same gloves. The product information for the 4 N 1 Rinse Free Wash Cream Protectant indicated uses: incontinence care, prevention program, protects and cleanses all types of skin. RN # 1 applied a foam dressing to the coccyx wound. Resident A was then assisted back to the wheelchair. CNA # 3 indicated Resident A's cushion for her wheelchair was soiled this morning, so there was nothing placed in her wheelchair. On 1/4/11 at 11:30 A.M., Resident A was observed to be sitting in her wheelchair in her room. Resident A was observed to have a wedge cushion in her wheelchair. On 1/4/11 at 11:35 A.M., in an interview with RN # 1 she indicated Resident A was to have a pressure relief cushion in her wheelchair, but Resident A was sitting on a wedge cushion. RN # 1 stated she was not sure where the CNA had got that cushion. On 1/4/11 at 11:40 A.M., in an interview with CNA # 3 she indicated the DoN (Director of Nursing) gave her the wedge cushion for Resident A to sit on. On 1/4/11 at 12:05 P.M., Resident A was observed to be sitting in her room in her wheelchair with a wedge cushion in the wheelchair. On 1/4/11 at 12:45 P.M., Resident A was observed to be sitting in her room in her wheelchair with a wedge cushion in the wheelchair. On 1/4/11 at 2:00 P.M., Resident A was observed to be sitting in the dining room in her wheelchair with a wedge cushion in the wheelchair. On 1/4/11 at 2:45 P.M., Resident A was observed to be sitting in her room in her wheelchair with a wedge cushion in the wheelchair. On 1/4/11 at 4:05 P.M., Resident A was observed to be sitting in her room in her wheelchair with a wedge cushion in the wheelchair. On 1/4/11 at 4:30 P.M., Resident A was observed to be sitting in her room in her wheelchair with a wedge cushion in the wheelchair. Resident A was observed to be resting her head on the over bed table. Resident A asked what time it was, and when told it was 4:30. She stated "I asked to lay down but I guess it is too late now." On 1/4/11 at 4:45 P.M., Resident A was observed to be sitting in her room in her wheelchair. The wedge cushion had been removed and a pressure relief cushion had been placed in Resident A's wheelchair. On 1/5/11 at 8:45 A.M., Resident A was observed to be in bed on her back. On 1/5/11 at 9:30 A.M., Resident A was observed to be in bed on her back. On 1/5/11 at 10:20 A.M., Resident A was observed to be in bed on her back. On 1/5/11 at 11:00 A.M., Resident A was observed to be in bed on her back. On 1/5/11 at 11:40 A.M., Resident A was observed to be in her room sitting in her wheelchair. On 1/6/11 at 10:50 A.M., Resident A was observed during the dressing change to her coccyx area. RN # 1 indicated "I will be glad when we get more pillows because she can't stay on her side without assistance." The dressing was observed to have a moderate amount of brown, greenish drainage. RN # 1 was observed to measure the coccyx area at 1.5 cm by 1 cm with 0.3 or 0.4 cm depth. The clinical record for Resident A was reviewed on 1/4/11 at 12:10 P.M. The record indicated Resident A had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 12/6/10, indicated Resident A had no memory or decision making problems. Resident A required extensive assistance of two with bed mobility, transfers, ambulation and toilet use. Resident A is at risk of developing a pressure ulcer. Resident A had a Stage III pressure ulcer. A Physician order, dated 3/15/10 and included on the current physician orders, dated 1/1/11, indicated "Follow facility protocol for pressure areas until specific treatment orders obtained." The Nurse's Readmission Record and allergies [REDACTED]." A Physician order, dated 7/27/10 and included on the current physician orders, dated 1/1/11, indicated "Keep turned every 2 hours." A care plan, dated 9/7/10, indicated a problem of "Stage 3 pressure ulcer to coccyx." The interventions were "Perform daily tx (treatment) as ordered by physician. Weekly skin measurements with daily assessments/tx application. Monitor residents response to daily tx application. Assess for pain/discomfort. Monitor response to pain interventions. Notify physician of any neg (negative) outcomes R/T (related to) area." The Wound Care Evaluation form, dated 11/1/10, indicated "...Foam dressing to prevent bacterial invasion due to incontinence of bowel and bladder. Turn pt (patient) side to side only. Up for meals only..." A Pressure/Stasis Ulcer Assessment, dated 11/24/10, indicated "...coccyx...Stage III. Length 1.4 cm. Width 1.0 cm. Depth > (less than) .4 cm. Drainage none..." A Care plan, dated 11/29/10, indicated a problem of "Stage II pressure area coccyx." The interventions were "1. Daily treatment as ordered monitor daily. Notify physician prn (as needed) Q (every) 2 wk (weeks) if no improvement. Assess for pain/discomfort to area, if present address (sic) pain/discomfort. Waffle cushion to chair and air flow mattress to bed. Notify family, DoN (Director of Nursing) and Adm (Administrator) on improvement or decline to area weekly and skin measurements." On 1/6/11 at 8:40 A.M., in an interview with the Director of Nursing she indicated Resident A did not have an air mattress to her bed at this time. She further indicated she did not know when it had been removed from the bed. The Wound Care Evaluation form, dated 11/29/10, indicated "...Foam dressing to prevent bacterial invasion due to incontinence of bowel and bladder. Turn pt (patient) side to side only. Up for meals only..." A Pressure/Stasis Ulcer Assessment, dated 12/15/10, indicated "...coccyx...Stage III. Length .8 cm. Width .75 cm. Depth > (less than) .3 cm. Drainage none..." A Physician order, dated 12/22/10, indicated "Hydrogel cleanse wound with NACL, apply collagen and hydrogel silver to wound bed cover with NACL moist guaze and foam dressing QD (everyday)." The Wound Care Evaluation form, dated 12/27/10, indicated "...Foam dressing to prevent bacterial invasion due to incontinence of bowel and bladder. Turn pt (patient) side to side only. Up for meals only..." A Pressure/Stasis Ulcer Assessment, dated 12/27/10, indicated "...coccyx...Stage III. Length 1 cm. Width 0.8 cm. Depth 0.3 cm. Drainage purulent (making or having pus)..." The Weekly Skin Assessment, dated 12/30/10, indicated "No new areas." A Pressure/Stasis Ulcer Assessment, dated 12/30/10, indicated "...coccyx...Stage III. Length 1.5 cm. Width 0.5 cm. Depth .5 cm. Drainage purulent..." In an interview with the Director of Nursing, on 1/6/11 at 9:25 A.M., she indicated the physician had not been notified of the purulent drainage. She stated she had spoke with RN # 1 who indicated Resident A had always had some drainage. The Director of Nursing indicated the physician would be notified today of the increased drainage and would get a culture today of the drainage. The Nurse's Notes, dated 1/3/11 at 4:30 P.M., indicated "Found open skin area on res (resident) rt (right) lateral buttock measuring 1.2 cm x .5 cm. Applied barrier oint (ointment) for time being." In an interview with the Director of Nursing, on 1/6/11 at 8:40 A.M., she indicated the barrier ointment the nurse had applied would have been the 4 N 1 wash cream. The Nurse's Notes, dated 1/3/11 at 10:20 P.M., indicated "Faxed request for order to treat new skin area to Dr (name) office. Waiting on reply back..." In an interview with the Director of Nursing, on 1/6/11 at 8:40 A.M., she indicated the nurse should have notified the physician at the time the open areas were discovered and not by fax late at night. An Other Skin Conditions Assessment, dated 1/4/11, indicated "...Abrasion. Initial Identification- Date- 1-4-11. Was the skin impairment present on admission? No. Site- upper L (left) buttock. Dimensions (in cm) Length- 1.5 cm. Width- .8 cm. Depth- UTD (unable to determine)..." An Other Skin Conditions Assessment, dated 1/4/11, indicated "...open area. Initial Identification- Date- 1/4/11. Was the skin impairment present on admission? No. Site- left upper buttock. Dimensions (in cm) Length- 0.5 cm. Width- 0.5 cm. Depth- none..." An Other Skin Conditions Assessment, dated 1/4/11, indicated "...open area. Initial Identification- Date- 1/4/11. Was the skin impairment present on admission? No. Site- left upper medial buttock. Dimensions (in cm) Length- 0.5 cm. Width- 0.5 cm. Depth- none..." An Other Skin Conditions Assessment, dated 1/4/11, indicated "...open area. Initial Identification- Date- 1/4/11. Was the skin impairment present on admission? No. Site- center coccyx below decub. Dimensions (in cm) Length- 0.5 cm. Width- 0.5 cm. Depth- none..." 4. During the initial tour of the facility on 01/04/11 at 8:30 A.M., Resident D was observed to be sitting in a wheelchair with a cloth incontinence pad. During the initial tour, the DoN (Director of Nursing) indicated Resident D was confused, had a tiny spot on her bottom, requires the assist of two staff members, and is incontinent of bladder. During an interview with the ADoN on 01/06/11 at 3:20 P.M., she indicated she had provided Resident D with a pressure relieving cushion on 01/04/11, later in the day when the new cushions came in. The clinical record of Resident D was reviewed on 01/04/11 at 4:30 P.M. The most recent physician's recaps for January 2011 indicated Resident D diagnoses, included but were not limited to, general weakness, confusion, Diabetes Mellitus, and [MEDICAL CONDITION]. The pressure/stasis ulcer assessment, dated 12/2/10, indicated an unstageable pressure ulcer was not present on admission. A Nurses's Note, dated 12/02/10 at 12:00 P.M., indicated, "Head to toe skin assessment completed at this time with 2 new found areas discovered. area to right lower buttock measures 0.3 cm (centimeters) X 0.5 cm X 0.1 cm, presents as shallow crater with pink with granulation tissue present. No odor or drainage present. Coccyx area exhibits necrosis, measures 0.7 cm X 0.7 cm X UTD (Unable to Determine) d/t (due to) necrosis." The Wound Care/Skin Integrity Evaluation, dated 12/27/10, completed by the Wound Consultant indicated Resident #32 had a "full thickness pressure wound on coccyx healing at a Stage III" and it was "facility acquired.". The Braden Scale for predicting pressure sore risk, dated 11/1/10, indicated Resident D was a moderate risk for developing pressure sores. A care plan, dated 12/03/10, indicated Resident D had a problem of impaired skin integrity issues to Right Buttock(stage II) and to coccyx (unstageable). The interventions included, but were not limited to ..."turn/reposition resident Q 2 hours and prn (as needed)...". The most recent MDS (Minimum Data Set Assessment), dated 11/29/10, indicated Resident D is cognitively impaired, requires extensive assist of 1 person for bed mobility, requires extensive assist of 2 for transfers, and was at risk for developing pressure ulcers. On 01/05/11 at 8:30 A.M., Resident D was observed sitting up in wheelchair in her room. On 01/05/11 at 11:00 P.M., Resident D was observed sitting up in wheelchair in her room. On 01/05/11 at 1:00 P.M., Resident D was observed sitting up in wheelchair in her room. The coccyx wound was observed on 01/05/11 at 1:50 P.M., and was observed to be a Stage II open area measuring 0.5 cm X 0.4 cm X <0.2 cm. 100% granulation tissue with no odor and periwound intact. In an interview with the ADoN on 01/05/11 at 1:50 P.M., she indicated "We should reposition her every two hours." 5. During initial tour of the facility on 01/04/11 at 9:00 A.M., the ADoN (Assistant Director of Nursing) indicated Resident E was not interviewable, required assist with ADL's and mobility and had no skin issues. The resident was observed at that time lying on a pressure reducing bed on her back. On 01/04/11, Resident E was observed lying in bed on her back from 11:30 A.M. until 5:30 P.M. without a position change. On 01/04/11 at 11:30 A.M., Resident E was observed lying in bed on her back in her room. On 01/04/11 at 3:30 P.M., Resident E was observed lying in bed on her back in her room. The ADoN performed a skin check at that time, which indicated the pressure ulcer was healed. Resident E was repositioned to left side for skin check and then immediately returned to position of lying on back in bed. On 01/04/11 at 5:30 P.M., Resident E was observed lying in bed on her back in her room. On 01/04/11 at 6:00 P.M., Resident E was observed up in wheelchair in her room with her daughter at her side. On 01/05/11, Resident E was observed lying in bed on her back from 8:30 A.M.-11:30 A.M. without a position change. On 01/05/11 at 8:30 A.M., Resident E was observed lying in bed on her back in her room. On 01/05/11 at 10:45 A.M., Resident E was observed lying in bed on her back in her room. On 01/05/11 at 11:30 A.M., Resident E was observed sitting up in wheelchair in her room with her daughter at her side. The clinical record of Resident E was reviewed 01/05/11 at 11:30 A.M. A physician's telephone order, dated 12/27/10 at 10:00 A.M., indicated " May d/c (discontinue) tx (treatment) to buttock (healed). A care