Every finding on record at Life Care Center of Valparaiso

Based on observation, record review and interview, the facility failed to ensure oral suctioning was completed and documented as ordered for 1 of 4 residents reviewed for respiratory care (Resident 4), medications were administered as ordered for 1 of 4 residents reviewed for accidents (Resident 1), wound assessments were completed and skin discolorations were monitored for 2 of 6 residents reviewed for non-pressure skin conditions. (Residents 24 and 67)Findings include:1.On 12/29/25 at 9:22 a.m., Resident 4 was observed in his bed. There was an oral suction machine on the nightstand next to his bed and the suction catheter was resting on his bed. The resident indicated he wanted the suction machine turned on. The Infection Control Nurse entered the room and turned the machine on for him; she indicated the resident suctioned himself. The resident picked up the suction catheter and put it in his mouth. The suction machine was observed to be on in the resident's room with no staff present on 12/30/25 at 8:30 a.m. and 1:00 p.m., and 12/31/25 at 8:23 a.m., 10:25 a.m. 1:13 p.m. and 2:33 p.m. The resident's record was reviewed on 12/31/25 at 8:45 a.m. Diagnoses included, but were not limited to, acute and chronic respiratory failure, dysphagia (difficulty swallowing) and congestive heart failure. The Quarterly Minimum Data Set assessment, dated 11/20/25, indicated the resident was cognitively intact and was dependent for toileting and transfers. A Physician's Order, dated 6/12/25, indicated may suction resident orally every four hours prn (as needed) for increased secretions. Resident may suction himself. The November and December 2025 Treatment Administration Record did not have any prn oral suctioning documented by staff or resident self-suctioning. During an interview on 12/31/25 at 3:10 p.m., the Director of Nursing indicated the resident needed to be assessed for self-suctioning. She was made aware there was nothing documented in the treatment record related to suctioning as needed. No additional information was provided. 2. Resident 1's record was reviewed on 12/31/25 at 10:11 a.m. Diagnoses included, but were not limited to, hypertension. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 11/19/25, indicated the resident was severely cognitively impaired. A Physician's Order, dated 2/14/25, indicated clonidine HCl oral tablet 0.1 milligram (mg), 1 tablet by mouth two times a day, hold if systolic blood pressure (first number) is below 110. The November and December 2025 Medication Administration Record indicated the resident's clonidine was not administered and there was no documented blood pressure on the following dates and times: at 8:00 p.m. on 11/15/25, 11/18/25, 11/19/25, 12/9/25, 12/15/25, 12/16/25, and 12/22/25. The November and December 2025 Medication Administration Record indicated the resident's clonidine was administered outside of the physician-ordered parameters on the following dates and times: 11/3/25 at 8:00 p.m., blood pressure 100/50 11/22/25 at 8:00 a.m., blood pressure 108/63 11/22/25 at 8:00 p.m., blood pressure 109/66 12/7/25 at 8:00 p.m., blood pressure 105/66 12/29/25 at 8:00 p.m., blood pressure 100/65 During an interview on 1/5/26 at 11:24 a.m., the Director of Nursing indicated she had no further information to provide. 3. Resident 24 was observed during wound care on 1/6/26 at 9:44 a.m. with the Director of Nursing (DON). The resident had two round-shaped open wounds that had a pink-red color wound bed observed to the right shin. Resident 24's record was reviewed on 1/2/26 at 8:32 a.m. Diagnoses included, but were not limited to, hypertension and stage 3 pressure ulcer of the left heel. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 10/6/25, indicated the resident was cognitively intact. She required substantial assistance from staff for toileting hygiene and showering, and moderate assistance with bed mobility, and was dependent for transfers. A Care Plan, dated 9/17/25, indicated the resident had a pressure ulcer to the left lateral heel and a right lower leg skin tear and was at risk for poor healing. Interventions included, but were not limited to, administer treatments as ordered, and assess for pain and administer medications as ordered. A Physician's Order, dated 9/17/25, indicated wound care to the right shin every day shift, cleanse area with wound wash, apply Hydrogel (a wound gel), and cover with a dry dressing daily and as needed for soiled or dislodged dressings. A Progress Note, dated 9/17/25 at 10:41 a.m., indicated the resident had open areas to the distal lower right shin measuring 2.5 centimeters (cm) long by 3.8 cm wide by 0.1 cm deep. The wound bed had exposed dermis with tissue that was pink. There was a scant amount of serosanguinous drainage (mix of clear/serous drainage and bloody drainage). The surrounding skin was pink with normal skin tone. The proximal wound measured 1.0 cm long by 1.5 cm wide by 0.1 cm deep with a pink/red wound bed that had a scant amount of serosanguinous drainage. The resident denied pain and stated that it was an old wound that had opened. She stated that it rubs on the lift when they transfer me. The resident used a princess lift (mechanical lift) for transfers. A treatment was put in place and the physician, family, and therapy were aware. The Weekly Skin Integrity Data Collection assessments, dated 10/7/25 at 12:21 a.m. and 10/14/25 at 12:16 a.m., both indicated the resident had a skin tear to the right lower leg. The Weekly Skin Integrity Data Collection assessments, dated 10/21/25 at 12:37 a.m., 10/27/25 at 1:51 a.m., 11/4/25 at 1:37 a.m., and 11/11/25 at 12:54 a.m., indicated the resident had open areas to the right and left heel. There was no documentation of the area to the right shin. The Weekly Skin Integrity Data Collection assessments, dated 11/18/25 at 12:22 a.m., 11/25/25 at 12:13 a.m., 12/2/25 a 12:25 a.m., 12/9/25 at 12:18 a.m., 12/16/25 at 12:12 a.m., 12/23/25 at 12:10 a.m., 12/30/25 at 12:24 a.m., and 1/6/26 at 2:19 a.m., indicated the resident had open areas to the right shin and left heel. There were no updated measurements available in the resident's record. During an interview on 1/6/26 at 11:54 a.m., the Director of Nursing indicated in the past, the resident had edema and open blisters in that area. They had healed at one time and now were reopened again. There were no updated measurements, and the physician would not usually address those kinds of skin conditions unless there was a major change or there were no improvements occurring with the wound. There should have been assessments completed with measurements to determine if the wound had any improvement. 4. Resident 67 was observed on 12/29/25 at 1:35 p.m. She was sitting in bed in her room. Her left hand had scattered discolorations around the thumb up to the wrist and on the forearm that were purplish blue in color. There was also a bandage in place. On 1/3/26 at 10:41 a.m., Resident 67 was observed sitting in her wheelchair. Her left hand and forearm remained with the scattered discolorations. There was no bandage in place at the time. Resident 67's record was reviewed on 1/2/26 at 10:43 a.m. Diagnoses included, but were not limited to, acute and chronic respiratory failure and chronic obstructive pulmonary disease. A Care Plan, dated 12/3/25, indicated the resident was at risk for alterations in skin integrity due to generalized weakness. Interventions included, but were not limited to, weekly skin checks. A Weekly Skin Integrity Data Collection assessment, dated 12/31/25 at 1:48 p.m., indicated the resident had no skin integrity concerns identified. During an interview on 1/5/26 at 11:24 a.m., the Director of Nursing indicated the bandage was from a blood draw on 12/29/25. She had no further information to provide. A facility policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention, indicated, .3. A skin assessment/inspection should be performed weekly by a nurse. A. Skin observations also occur throughout points of care provided by CNAs during ADL care. Any changes or open areas are reported to the Nurse.Nurse will complete further inspection/assessment and provide treatment if needed. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications, for 1 of 1 resident reviewed for self-administration of medication. (Resident 55)Finding includes:On 12/30/25 at 10:45 a.m., Resident 55 was observed sitting in her wheelchair in her room. A plastic bag with the Facility's Pharmacy label was on her overbed table. The bag contained two bottles of nystatin powder (an antifungal medication). The resident indicated the powder was used for a rash under her right breast that she would get from time to time. Staff was responsible for storing and administering all of the resident's medications.The resident's record was reviewed on 1/2/26 at 10:47 a.m. Diagnoses included, but were not limited to, type two diabetes mellitus, hypertension, and hyperlipidemia.The admission Minimum Data Set (MDS) assessment, dated 12/1/25, indicated the resident was cognitively intact.A Physician's Order, dated 11/29/25, indicated nystatin powder, apply to groin and folds topically every day and evening shift. There was no Physician's Order to indicate the resident could self-administer the medication.There was a lack of any self-administration of medication assessments.During an interview on 1/5/26 at 10:36 a.m., the Director of Nursing (DON) was made aware of the medications at the resident's bedside. No further information was provided.A facility policy, titled, Self-Administration of Medications, indicated, .2. Facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition.5. Facility should ensure that orders for self-administration list the specific medications the resident may self-administer.3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to following physician's orders for oxygen administration for 1 of 4 residents reviewed for respiratory care. (Resident 67) Finding includes:Resident 67 was observed on 12/29/25 at 1:35 p.m. She was sitting in bed in her room with a nasal cannula connected to a concentrator running at 6 liters per minute. The humidifier container was empty at the time. On 1/2/26 at 10:41 a.m., Resident 67 was sitting in her wheelchair. She had a nasal cannula that was only placed in one nostril. It was connected to a portable concentrator running at 5 liters per minute. Resident 67's record was reviewed on 1/2/26 at 10:43 a.m. Diagnoses included, but were not limited to, acute and chronic respiratory failure and chronic obstructive pulmonary disease. A Physician's Order, dated 7/15/25, indicated oxygen at 5 liters per minute continuously per nasal cannula every shift and change oxygen tubing, nebulizer circuit and humidifier bottle every night shift every Sunday and as needed. A Care Plan, dated 7/17/25, indicated the resident had oxygen therapy. Interventions included, but were not limited to, give medications and oxygen per the physician's orders. During an interview on 1/5/26 at 10:41 a.m., the Director of Nursing was notified of the concern and had no further information to provide. A facility policy titled, Oxygen Administration, indicated, .2. Residents receiving oxygen at 4 L/min or greater, via concentrator, should be connected to a humidifier.Infection Control.2. Humidifier bottles should be dated and replaced every 7 days regardless of H2O level.b. If reusable humidifier is used, refill using sterile water only. i. Sterile water is to be emptied and replaced daily. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure medications were given with adequate indication for use related to lack of non-pharmacological interventions prior to giving pain medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 93)Finding includes:Resident 93's record was reviewed on 12/30/25 at 1:08 p.m. Diagnoses included, but were not limited to, displaced fracture of right femur neck, history of falling and dementia. The Quarterly Minimum Data Set assessment, dated 12/5/25, indicated the resident had moderate cognitive impairment and used opioid pain medications. A Physician's Order, dated 6/29/25, indicated to give hydrocodone 5 milligrams (mgs)/ acetaminophen 325 mgs (an opioid pain medication) every 6 hours as needed for pain. A Physician's Order, dated 10/17/25, indicated to document two non-medication interventions prior to giving as needed pain medication. Interventions included heat, music, cold, gentle range of motion, positioning, TENS, massage, support group, meditation or other rest. The November 2025 Medication Administration Record (MAR) indicated the resident was given hydrocodone/acetaminophen 21 times, the December 2025 MAR indicated he was given the medication nine times. There was only one day that non-medication interventions were documented prior to giving the medication in November and December. During an interview on 1/5/26 at 10:31 a.m., the Director of Nursing (DON) indicated non-pharmacological interventions should be documented and there were none documented in December, she had not looked at November's MAR. The Pain Management Policy, revised 9/23/25, was received from the DON on 1/5/26 indicated, .2. The facility will address/treat the underlying causes of the pain, to the extent possible, a. Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether pain is episodic, continuous or both 3.1-48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to staff not wearing personal protective equipment (PPE) correctly when entering an isolation room for 2 of 2 residents reviewed for COVID-19. (Residents 88 and 55) The facility also failed to ensure infection control practices and standards were maintained related to medication administration for 1 of 7 residents observed during the medication administration observation. (Resident 53)Findings include:1. On 12/30/25 at 10:45 a.m. RN 1 was observed in room [ROOM NUMBER] providing care to Resident 88. She was wearing a gown, gloves, and N95 mask. She was not wearing any eye protection. There were signs on the door that indicated the residents in room [ROOM NUMBER] were in droplet/contact isolation.Record review for Resident 88, who resided in room [ROOM NUMBER], was completed on 1/2/26 at 10:15 a.m. Resident 88 had been sent out to the hospital on [DATE], she tested positive for COVID-19 at the hospital and returned to the facility the same day.Record review for Resident 55, who resided in room [ROOM NUMBER], was completed on 1/2/26 at 10:15 a.m. The resident tested positive for COVID-19 at the facility on 12/26/25.During an interview on 12/30/26 at 4:26 p.m., the Infection Preventionist was made aware RN 1 had not worn eye protection in the contact/droplet isolation room. She indicated eye protection should have been used, and she would provide further education.A facility policy, titled, Personal Protective Equipment PPE for SARS-CoV-2, indicated, .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH approved N95 or equivalent or higher level respirator, gown, gloves, and eye protection. 2. The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: a. Respirator .b. eye protection .c. gloves .d. gowns .2. During a medication administration observation on 1/2/26 at 9:31 a.m., LPN 1 was observed preparing Resident 53's medications which included Tums (an antacid medication) and atenolol (a blood pressure medication). She poured two Tums tablets out of the medication bottle into her hand and then placed them in a medication cup. She popped the atenolol tablet out of the pill card, and it landed on top of the medication cart. She picked up the medication with her bare hands and placed it in the medication cup. She then took the medications into the resident's room to administer.During an interview on 1/2/26 at 1:48 p.m., the Director of Nursing (DON) was made aware of LPN 1 touching the medications with her bare hands. No further information was provided.3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure palm protectors and/or splints were in place as ordered for residents with contractures (a shortening of muscles, tendons, skin and nearby soft tissues that causes joints to shorten and become very stiff) for 2 of 2 residents reviewed for range of motion. (Residents 56 and 40) Findings include: 1. On 10/28/24 at 11:05 a.m. and 10/30/24 at 9:42 a.m., Resident 56 was observed in her room. Her right hand was contracted and there was no palm protector in place to her right or left hand. On 10/29/24 at 10:41 a.m., 10/29/24 at 2:54 a.m. and 10/30/24 at 8:43 a.m., the resident was observed in her room. Her left hand was under the covers during these observations and not visible. Her right hand was contracted and there was no palm protector in place. Resident 56's record was reviewed on 10/29/24 at 10:52 a.m. Diagnoses included, but were not limited to, hemiparesis (one sided weakness) and hemiplegia (one sided paralysis) affecting right side, diabetes mellitus, and acute and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 9/24/24, indicated the resident had significant cognitive impairment and was dependent on staff for bed mobility, toileting, and transfers. A Physician's Order, dated 9/4/24, indicated to apply palm protectors to the right and left hands every shift for protection at all times as tolerated, may remove them for hygiene and skin checks. The October 2024 Treatment Administration Record indicated on 10/28/24 the palm protector was not on the resident's left hand, it was signed out for the right hand. There were no progress notes that indicated the resident was not able to tolerate the palm protectors. During an interview on 10/30/24 at 9:44 a.m., CNA 1 indicated the aides were supposed to apply the palm protectors. She indicated the resident's palm protectors were at the laundry, but she would find another pair. 32788 2. On 10/29/24 at 9:33 a.m., Resident 40 was observed in her room. There were no palm protectors in place to either hand. She indicated she was unable to use her left hand. On 10/29/24 at 1:57 p.m., Resident 40 was observed in her room. There were no palm protectors in place to either hand. Her left hand was in a closed fist. Resident 40's record was reviewed on 10/29/24 at 2:37 p.m. Diagnoses included, but were not limited to, hypertension, Parkinson's disease, and epilepsy. The Quarterly Minimum Data Set (MDS) assessment, dated 9/6/24, indicated the resident was moderately cognitively impaired, required staff assistance for all activities of daily living (ADLs), and had impaired range of motion to the upper extremity on one side. A current Care Plan, updated 4/11/23, indicated the resident had a left hand contracture. An intervention, dated 7/12/22, indicated palm protectors to bilateral hands as tolerated. The Physician's Order Summary, dated 10/2024, indicated orders for palm protectors to the left and right hands as tolerated every shift, may remove for bathing and skin assessments. The Medication Administration Record and Treatment Administration Record, dated 10/2024, indicated the palm protectors were in place as ordered. The only documented refusal was 10/29/24 evening shift. The Progress Notes, dated 10/1/24 through 10/29/24, lacked any documentation the resident was not tolerating wearing the palm protectors. During an interview on 10/30/24 at 9:45 a.m., the Administrator was made aware that the resident's palm protectors had not been in place. During an interview on 10/31/24 at 2:25 p.m., the Director of Nursing indicated the palm protector orders indicated to wear as tolerated. She had interviewed the QMA who worked on 10/28/24 and 10/29/24 and she had observed the palm protectors in place when she had completed morning medication administration. She was unsure what time the palm protectors had been removed. 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control measures were in place and implemented related to a glucometer (blood sugar monitor) used for multiple residents and not cleaned and sanitized after each resident use. (RN 1) This had the potential to affect two residents on the 200 hall who received glucometer testing. The facility also failed to ensure a resident with a Multi-Drug Resistant Organism was placed on Enhanced Barrier Precautions (EBP) as ordered. (Resident 71) Findings include: 1. During an observation on 10/30/24 at 11:30 a.m., RN 1 was observed checking Resident 14's blood sugar with a glucometer. The RN did not sanitize the glucometer afterward. She exited the resident's room and indicated another resident was also due to have his blood sugar tested . She gathered the resident's insulin, lancets, alcohol prep pads, and the same glucometer and entered Resident 61's room. She donned gloves and prepared to check the resident's blood sugar. The RN was stopped and asked to step into the hallway. She indicated the glucometer should have been sanitized and she had forgotten to do so. She then reentered Resident 61's room and cleaned the glucometer with an alcohol prep pad and proceeded to test his blood sugar. During an interview with the RN after the observation, she indicated the glucometers were supposed to be cleaned with Sani Wipe germicidal disposable wipes between each resident. The current policy, Glucometer-Assure Prism Quality Control Checks and Cleaning Procedures, indicated, The meter should be cleaned and disinfected after use on each patient . disinfecting procedure is needed to prevent the transmission of blood born pathogens . 2. On 10/28/24 at 1:50 p.m. and 10/29/24 at 11:22 a.m., Resident 71 was observed seated in her room. There was no signage on the door that indicated she was on EBP and there was no Personal Protective Equipment (PPE) present in or near the room. Resident 71's record was reviewed on 10/29/24 at 11:10 a.m. Diagnoses included, but were not limited to, congestive heart failure, fracture of the lower end of tibia with routine healing, and hypertension. The Admission Minimum Data Set assessment, dated 9/3/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfer assistance. A Physician's Order, dated 9/4/24, indicated the resident should be on EBP due to ESBL (extended spectrum beta-lactamase, a bacterial enzyme resistant to many antibiotics) and VRE (Vancomycin resistant enterococci, a bacteria resistant to some powerful antibiotics) every shift. During an interview on 10/29/24 at 11:25 a.m., LPN 1 indicated she did not know if the resident was supposed to be on EBP but would check with the IP (Infection Prevention) Nurse. During an interview on 10/29/24 at 11:30 a.m., the IP Nurse indicated she was aware of the EBP order and thought there was EBP in place for the resident. She later indicated the EBP had been placed on the incorrect room. The current policy, Infection Prevention and Control Program (IPCP) and Plan, indicated, .4. The program includes early detection, management of a potentially infectious, symptomatic resident that requires laboratory testing and/or the implementation of appropriate TBP/PPE . 3.1-18(b)(2)

Based on observation, record review, and interview, the facility failed to ensure an indwelling suprapubic (urinary) catheter tubing and collection bag was kept off the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 1) Finding includes: Resident 1 was observed on 10/28/24 at 2:39 p.m., 3:19 p.m., 3:54 p.m., and 4:11 p.m. She was asleep in her bed. The catheter tubing and collection bag were lying on the floor. The collection bag was uncovered and could be viewed from the doorway. Resident 1's record was reviewed on 10/29/24 at 10:49 a.m. Diagnoses included, but were not limited to, intellectual disabilities and epilepsy. The Quarterly Minimum Data Set assessment, dated 9/17/24, indicated the resident was severely cognitively impaired for daily decision making. She was dependent on staff for daily care including, but not limited to, toileting, showering, personal hygiene, and transfers. She had an indwelling catheter. The October 2024 Physician Order Summary indicated the resident had a suprapubic catheter and the catheter bag was to be placed below the level of the bladder. A Care Plan, dated 9/12/24, indicated the resident had a suprapubic catheter and was dependent on staff for the care and management of all catheter needs. Interventions included, but were not limited to, catheter care every shift, and position catheter bag and tubing below the level of the bladder. During an interview on 10/29/24 at 9:45 a.m., the Director of Nursing indicated she had no further information to provide. A policy titled, Indwelling Urinary Catheter (Foley) Management, indicated .General Urinary Catheter Maintenance Guidelines .2. Maintain unobstructed urine flow .b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed and in place for a resident with a history of MDROs (multi-drug resistant organisms) for 1 of 18 resident care plans reviewed. (Resident 71) Finding includes: The record for Resident 71 was reviewed on 10/29/24 at 11:10 a.m. Diagnoses included, but were not limited to, congestive heart failure, fracture of the lower end of tibia with routine healing, and hypertension. The Admission Minimum Data Set assessment, dated 9/3/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfer assistance. A Physician's Order, dated 9/4/24, indicated the resident should be on EBP (Enhanced Barrier Precautions) due to ESBL (extended spectrum beta-lactamase, a bacterial enzyme resistant to many antibiotics) and VRE (Vancomycin Resistant Enterococci, a bacteria resistant to some powerful antibiotics) every shift. There was not a care plan in place related to EBP or the MDROs. During an interview on 10/29/24 at 11:40 a.m., the Infection Prevention Nurse indicated there should be a care plan in place related to the EBP and MDROs. There had been a care plan previously when the resident was on antibiotics, but it had been discontinued. 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure care plans were implemented and/or updated for 2 of 21 resident care plans reviewed. (Residents 21 and 14) Findings include: 1. On 10/28/24 at 10:46 a.m., Resident 21 was observed lying in bed. She had a Geri sleeve (protective covering) to her left arm that was pushed down to her wrist area. Multiple small circular purple discolorations were observed to her left outer forearm. On 10/30/24 at 10:42 a.m., Resident 21 was observed sitting in her chair in her room. No Geri sleeves were in place. Multiple small circular purple discolorations were observed to her left outer forearm. On 10/30/24 at 2:48 p.m., Resident 21 was observed sitting in her chair in the Main Dining Room playing bingo. No Geri sleeves were in place. Multiple small circular purple discolorations were observed to her left outer forearm. The record for Resident 21 was reviewed on 10/31/24 at 9:04 a.m. Diagnoses included, but were not limited to, spontaneous ecchymosis, Alzheimer's disease, and chronic kidney disease. The Quarterly Minimum Data Set (MDS) assessment, dated 7/25/24, indicated the resident was cognitively impaired and received antiplatelet medication. A Care Plan, updated 9/4/24, indicated the resident was at risk for abnormal bruising and bleeding due to anticoagulant therapy. There was lack of any documentation related to the diagnosis of spontaneous ecchymosis or the skin discolorations. A Care Plan, updated 11/29/23, indicated the resident was at risk for breaks in skin integrity. There was lack of any documentation related to the diagnosis of spontaneous ecchymosis or the skin discolorations. The Physician Order Summary, dated 10/2024, indicated the resident was to receive Aspirin (an antiplatelet medication) 81 mg (milligrams) daily. The Medication Administration Record (MAR), dated 10/2024, indicated the resident had received the Aspirin medication as ordered. There was monitoring every shift for signs and symptoms of bleeding (black tarry stools, bleeding gums, bruising, or nose bleed) related to anticoagulant use. A negative sign (-) had been documented every shift, to indicate there were no signs and symptoms present. During an interview on 10/31/24 at 11:52 a.m., the Director of Nursing (DON) indicated she had updated the resident's care plan to include the spontaneous echymosis diagnosis. 45666 2. During an interview on 10/28/24 at 10:59 a.m., Resident 14 indicated she had a cancerous skin lesion on her left upper arm that she had for a long time. She had seen a skin doctor regarding the area, had it removed, and it came back later on. It did not hurt, but it itched. The staff were putting a cream on it twice daily. During an observation of Resident 14 on 10/31/24 at 10:01 a.m., her left upper arm had a round area, approximately 1.5 inches in diameter with flaky skin noted around the edges. It was reddish-pink in the center. Resident 14's record was reviewed on 10/30/24 at 9:01 a.m. Diagnoses included, but were not limited to, acute kidney failure, respiratory failure, and heart failure. The Quarterly Minimum Data Set assessment, dated 10/8/24, indicated the resident was cognitively intact for daily decision making. She had no skin issues. The October 2024 Physician Order Summary indicated the resident received triamcinolone acetonide external cream 0.1% (steroid cream) application twice daily to the right lower leg and left upper arm lesion. A Weekly Skin Integrity Data Collection, dated 10/17/24 at 3:16 a.m., indicated the resident had a left upper arm lesion. The triamcinolone acetonide cream was applied twice daily. There were no other skin abnormalities. A Weekly Skin Integrity Data Collection, dated 10/24/24 at 12:51 a.m., indicated the resident had redness to the right lower extremity. There were no other skin abnormalities. A Care Plan, dated 5/29/24, indicated the resident had a risk for break in skin integrity related to weakness, decreased mobility, incontinence, and chronic kidney disease. Interventions included, but were not limited to, apply moisturizers as needed, avoid prolonged skin to skin contact, CNA to inspect skin during activities of daily living (ADL) care for reddened or open areas and report to nurse if present, and nurse to perform weekly head to toe assessment and report abnormal findings to the physician as needed. There were no Care Plans related to the left upper arm skin lesion and treatment. During an interview on 10/31/24 at 10:54 a.m., the Director of Nursing indicated the resident's care plan should have been updated to reflect the skin lesion The resident had the lesion since before she arrived to the facility. 3.1-35(c)(1)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations and a skin lesion for 2 of 3 residents reviewed for non-pressure related skin conditions. (Residents 21 and 14) Findings include: 1. On 10/28/24 at 10:46 a.m., Resident 21 was observed lying in bed. She had a Geri sleeve (protective covering) to her left arm that was pushed down to her wrist area. Multiple small circular purple discolorations were observed to her left outer forearm. On 10/30/24 at 10:42 a.m., Resident 21 was observed sitting in her chair in her room. No Geri sleeves were in place. Multiple small circular purple discolorations were observed to her left outer forearm. On 10/30/24 at 2:48 p.m., Resident 21 was observed sitting in her chair in the Main Dining Room playing bingo. No Geri sleeves were in place. Multiple small circular purple discolorations were observed to her left outer forearm. The record for Resident 21 was reviewed on 10/31/24 at 9:04 a.m. Diagnoses included, but were not limited to, spontaneous echymosis, Alzheimer's disease, and chronic kidney disease. The Quarterly Minimum Data Set (MDS) assessment, dated 7/25/24, indicated the resident was cognitively impaired and received antiplatelet medication. A Care Plan, updated 9/4/24, indicated the resident was at risk for abnormal bruising and bleeding due to anticoagulant therapy. There was no documentation related to the diagnosis of spontaneous echymosis or the skin discolorations. A Care Plan, updated 11/29/23, indicated the resident was at risk for breaks in skin integrity. There was no documentation related to the diagnosis of spontaneous echymosis or the skin discolorations. The Physician Order Summary, dated 10/2024, indicated the resident was to receive Aspirin (an antiplatelet medication) 81 mg (milligrams) daily. The Medication Administration Record (MAR), dated 10/2024, indicated the resident had received the Aspirin medication as ordered. There was monitoring every shift for signs and symptoms of bleeding (black tarry stools, bleeding gums, bruising, or nose bleed) related to anticoagulant use. A negative sign (-) had been documented every shift, to indicate there were no signs and symptoms present. The Weekly Skin Integrity Data Collection assessments, dated 10/1/24, 10/8/24, 10/15/24, 10/22/24, and 10/29/24, lacked any documentation related to spontaneous echymosis or the left forearm skin discolorations. During an interview on 10/31/24 at 11:52 a.m., the Director of Nursing (DON) indicated she had updated the resident's Care Plan to include the spontaneous echymosis diagnosis. 45666 2. During an interview on 10/28/24 at 10:59 a.m., Resident 14 indicated she had a skin lesion on her left upper arm that she had for a long time. She had seen a skin doctor regarding the area, had the area removed, and it came back later on. It did not hurt, but it itched. The staff were putting a cream on it twice daily. During an observation of Resident 14 on 10/31/24 at 10:01 a.m., her left upper arm had a round area, approximately 1.5 inches in diameter with flaky skin noted around the edges. It was reddish-pink in the center. Resident 14's record was reviewed on 10/30/24 at 9:01 a.m. Diagnoses included, but were not limited to, acute kidney failure, respiratory failure, and heart failure. The Quarterly Minimum Data Set assessment, dated 10/8/24, indicated the resident was cognitively intact for daily decision making. She had no skin issues. The October 2024 Physician Order Summary indicated the resident received a triamcinolone acetonide external cream 0.1% (steroid cream) application twice daily to the right lower leg and left upper arm lesion. A Weekly Skin Integrity Data Collection, dated 10/10/24 at 8:58 a.m., indicated the resident had no skin abnormalities. A Weekly Skin Integrity Data Collection, dated 10/17/24 at 3:16 a.m., indicated the resident had a left upper arm lesion. The triamcinolone acetonide cream was applied twice daily. There were no other skin abnormalities. A Weekly Skin Integrity Data Collection, dated 10/24/24 at 12:51 a.m., indicated the resident redness to the right lower extremities. There were no other skin abnormalities. A Care Plan, dated 5/29/24, indicated the resident had a risk for break in skin integrity related to weakness, decreased mobility, incontinence, and chronic kidney disease. Interventions included, but were not limited to, apply moisturizers as needed, avoid prolonged skin to skin contact, CNA to inspect skin during activities of daily living (ADL) care for reddened or open areas and report to nurse if present, and nurse to perform weekly head to toe assessment and report abnormal findings to the physician as needed. There were no care plans related to the skin lesion. During an interview on 10/31/24 at 10:54 a.m., the Director of Nursing (DON) indicated the left upper arm skin lesion should have been documented on the weekly skin checks as it was an abnormal skin condition that she had since she came to the facility. The DON was not sure why the nurses did not document the area on each weekly skin assessment. A policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, indicated .A skin assessment/inspection should be performed weekly by a licensed nurse. a. Skin observations also occur throughout points of care provided by CNAs during ADL care. Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. 3.1-37(a)

Based on observation and interview, the facility failed to ensure a sanitary kitchen related to built up burnt food debris on the stove top and bottom inside of the convection oven. There was a build up of grease inside the convection oven doors, back splash on the oven, and side of the oven for 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect 96 residents who received food from the kitchen. Findings include: During the initial kitchen tour on 10/19/23 at 9:29 a.m., with the Dietary Manager (DM) the following was observed: a. The stove top had a build up of burnt food debris and a build up of grease on the back splash and side of the stove top. b. The convection oven had a build up of burnt food debris on the bottom inside and a build up of grease on the inside of the doors. Interview during the time of the observation with Cook 1 indicated the convection oven had a build up in the bottom for a long time and no elbow grease would be able to clean it. They would need to use a special degreaser for it. Interview during the time of the observation with the DM indicated the convection oven and stove was supposed to be cleaned weekly. He would make sure both were deep cleaned right away. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a Physician's Order was in place for a palm protector for treatment of limited range of motion for 1 of 1 residents reviewed for range of motion. (Resident 40) Finding includes: On 10/19/23 at 11:38 a.m., Resident 40 was observed seated in her room working on a puzzle. She had a palm protector in place to her right hand. On 10/23/23 at 2:48 a.m., Resident 40 was observed with the palm protector in place to her right hand. On 10/24/23 at 10:31 a.m., Resident 40 was seated in her wheelchair near the main entrance. The palm protector was in place to her right hand. The resident's record was reviewed on 10/23/23 at 11:31 a.m. Diagnoses included, but were not limited to, right hand contracture and hemiplegia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/30/23, indicated the resident required staff assistance for all activities of daily living (ADLs) and had impaired range of motion on one side to both the upper and lower extremities. The Physician's Order Summary, dated 10/2023, lacked any orders for a right hand palm protector or monitoring of the resident's skin. The ADL self care deficit care plan, updated 8/2/23, lacked documentation of the right hand palm protector as an intervention. Interview with the Assistant Director of Nursing (ADON) on 10/24/23 at 12:01 p.m., indicated there was no order in place for the palm protector. There was a note about it, but the order had not been put in the computer correctly. 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration flow rate for 1 of 1 residents reviewed for respiratory care. (Resident 1) Finding includes: On 10/20/23 at 9:37 a.m. Resident 1 was observed seated in the dining area at a table. His portable oxygen tank was set at 2.5 liters. On 10/20/23 at 10:55 a.m. Resident 1 was observed seated in the dining area. His oxygen tank was set at 2.5 liters. On 10/23/23 at 11:44 a.m. Resident 1 was observed sitting in the dining area. His oxygen tank was set at 3 liters. Record review for Resident 1 was completed on 10/23/23 at 11:56 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and dependence on supplemental oxygen. The Quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, indicated the resident was cognitively impaired. The Physician's Order Summary, dated 10/2023, indicated an order for oxygen 2 liters continuously per nasal cannula. Interview with RN 1 on 10/23/23 at 11:57 a.m., indicated the oxygen flow rate should have been set at 2 liters. A facility policy, titled, Oxygen Administration/Safety/Storage/Maintenance, received from the Assistant Director of Nursing as current, indicated .Oxygen will be administered in accordance with physician orders and current standards of practice . 3.1-47(a)(6)

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a Physician initiating antibiotic therapy for a non-true infection based on the McGreer's Criteria and prescribing a resistant antibiotic based on urine culture results for 1 of 1 residents reviewed for urinary tract infections. (Resident 28) Finding includes: The record for Resident 28 was reviewed on 10/23/23 at 9:27 a.m. Diagnoses included, but were not limited to, hypertension, heart failure, and Alzheimer's disease. The Significant Change Minimum Data Set (MDS) assessment, dated 9/21/23, indicated the resident was cognitively impaired. A Progress Note, dated 9/28/23 at 5:10 p.m., indicated the Physician had been in to see the resident and reviewed her blood work. Her white blood cell count was elevated so they completed a urine dip test, and it had abnormal results. The Physician then ordered for the urine to be sent to the lab for a urinalysis (UA) with culture and sensitivity (C&S). He ordered Keflex (an antibiotic) 500 mg (milligrams) twice daily for 3 days. The urine specimen was placed in the refrigerator for lab to pick up in the morning. The UA report indicated the urine sample was collected on 9/28/23. The urine was turbid, positive for nitrates, leukocytes and many bacteria were present. The urine culture and sensitivity report indicated 10-50,000 citrobacter freundii complex (under 100,000 not usually considered significant per McGreer's criteria). The organism was resistant to ceftriaxone. A hand written note on the bottom of the UA report, indicated it had been reviewed by the Physician and due to ongoing behavior issues, aggression, and decreased appetite, he had given a new order for ceftriaxone IM (intramuscular). A Physician's Note, dated 10/20/23, indicated on 10/9/23 he had reviewed the previous urine culture. The resident was having a recurrence of urinary symptoms and agitation and IM ceftriaxone was ordered. There was lack of documentation as to why he had chosen a resistant antibiotic based on the urine culture results. A Physician's Order, dated 10/13/23, indicated ceftriaxone (an antibiotic) 1 gram IM (intramuscular injection) every evening for 7 days for UTI (urinary tract infection). The Medication Administration Records (MAR), dated 9/2023 and 10/2023, indicated the resident received the full courses of the Keflex and ceftriaxone antibiotics. Interview with the Assistant Director of Nursing (ADON) on 10/24/23 at 2:20 p.m., indicated the Physician had indicated in his progress note that he had reviewed the urine culture and had ordered the ceftriaxone. She was unsure why he had chosen a resistant antibiotic. Interview with the Director of Nursing (DON) on 10/25/23 at 12:00 p.m., indicated she had spoken with the Physician, and he had ordered the ceftriaxone because it was what had worked for the resident in the past. She was having decreased appetite and some behavior concerns even though she had not met the McGreer's criteria for a urinary tract infection. 3.1-18(b)(1)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of a scabbed area on the skin for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 68) Finding includes: On 10/24/23 at 11:48 a.m., a family interview was conducted for Resident 68. The family member indicated the resident had a scabbed area to her left elbow and was unsure how she received it. The resident was observed sitting in a Broda chair in her room. The left outer elbow had a small black scabbed area. On 10/24/23 at 3:13 p.m., Resident 68 was observed sitting in a Broda chair in her room. The scabbed area was still observed to the resident's outer left elbow. Record review for Resident 68 was completed on 10/24/23 at 2:06 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia right dominant side (paralysis on right side of body), atrial fibrillation, hypertension, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 10/13/23, indicated the resident was severely cognitively impaired. The resident was dependent on staff for bathing, toilet use, dressing and personal hygiene. The resident had an impairment on side of the upper and lower extremities for functional limitation in range of motion. The resident had received an anticoagulant (blood thinning) medication. The Weekly Skin Integrity Data Collection, dated 10/22/23, lacked any documentation related to the scabbed area on the resident's left elbow. Interview with the Director of Nursing on 10/25/23 at 9:50 a.m., indicated she could not provide any documentation the scabbed area was observed, assessed and monitored prior to the day before. She had completed an assessment of the area and notified the family and Physician of the area. 3.1-37(a)

Based on observation and interview, the facility failed to have the results of the State survey findings easily accessible for all residents to review. This had the potential to affect the 99 residents who resided in the facility. Finding includes: On 10/24/23 at 9:14 a.m., a Resident Council Meeting was conducted with six residents. All six residents were unaware of where to find the most recent State survey results. On 10/24/23 at 10:26 a.m., a sign was observed posted by the Secretary's office that indicated the State survey results were located on the Secretary's door. A file folder was observed in a basket towards the top of the door. The folder was out of reach and not easily accessible for residents who were in wheelchairs. Interview with the Activities Director on 10/24/23 at 10:28 a.m., indicated she was new to the position and was unaware where the State survey results were located. Interview with the Administrator on 10/24/23 at 11:23 a.m., indicated they would move the State survey results to an area that was easily accessible to all residents. 3.1-3(b)(1)

Based on observation and interview, the facility failed to ensure a sanitary kitchen related to built up food debris on the stove top and testing the dishwasher sanitation level with faulty test strips in 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect all 84 residents who received food from the kitchen. Findings include: 1. During the initial kitchen tour on 10/24/22 at 8:50 a.m. with Cook 1 the following was observed: a. The stove top had a build up of food debris. b. The dishwasher was observed and noted to be a low temperature, chemical system. Cook 1 obtained a testing strip, dipped it into the dishwasher water and compared it to the results on the side of the testing strip container. The strip did not have a readily discernable color change. The results were unable to be compared as the bottle of test strips had a label that had disintegrated. The expiration date on the bottle was also unable to be read. 2. During the follow-up tour in the kitchen on 10/26/22 at 9:29 a.m., Cook 1 indicated whoever was working in the dish cleaning area was to check the temperature and sanitation level of the dishwasher at breakfast, lunch, and dinner shifts. The logs of the temperature and sanitation levels for the month of October were reviewed and indicated the wash temperature was 120 degrees Fahrenheit and 50 parts per million (PPM) for breakfast, lunch, and dinner shifts each day from October 1st thru October 25th, 2022. On 10/26/22 at 10:45 a.m., an employee from the contracted chemical company serviced the dishwasher and indicated the dishwasher had not been altered and the PPM tested appropriately according to his test strips. He would be providing these test strips to the facility to appropriately measure the chemical sanitation levels. He indicated the other strips were not working appropriately. The policy titled, Sanitation and Maintenance provided by the Administrator on 10/28/22 at 11:58 a.m. and identified as current, indicated .Procedure .9. Mechanical Ware Washing .Low Temp Dish Machine .The temperature and parts per million of the sanitizer (50-100 ppm for chlorine) will be recorded on the Low Temperature Dish Machine Log a minimum of three times per day. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure skin discolorations were assessed and monitored for a resident on anticoagulants and wound dressings were changed as ordered. (Resident 39 and 237) Findings include: 1. On 10/24/22 at 11:12 a.m., two areas of discoloration were noted to Resident 39's left forearm. Resident 39's record was reviewed on 10/26/22 at 10:17 a.m. Diagnoses included, but were not limited to, hemiplegia (one-sided paralysis) following cerebral infarction affecting his right dominant side, heart failure, high blood pressure, and atrial fibrillation (irregular heart beat). The Quarterly Minimum Data Set (MDS) assessment, dated 9/2/22, indicated the resident was cognitively intact for daily decision making. The resident required extensive assistance with one person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. A Physician's Order, dated 11/3/21, indicated Eliquis tablet (a blood thinner) 2.5 milligrams two times a day. A Physician's Order, dated 11/3/21, indicated to monitor for signs or symptoms for bleeding including black tarry stools, bleeding gums, bruising, and nose bleeds related to anticoagulant use and document every shift. A Care Plan, revised on 8/18/22, indicated the resident was at risk for abnormal bruising or bleeding related to anticoagulant therapy, Eliquis and aspirin, for management of atrial fibrillation. Interventions included, but were not limited to, observe and report any adverse reactions of anticoagulant therapy such as, blood in urine, black tarry stools, headaches, nausea, vomiting, diarrhea, bruising, or shortness of breath. Weekly Skin Integrity Data Collection assessments were completed on 10/7/22, 10/14/22, and 10/21/22. The assessments indicated the resident's skin was intact and there were no new findings. The resident had a shower completed on 10/26/22 at 1:55 p.m. There was no documentation of any new skin conditions. Interview with the Director of Nursing (DON) on 10/27/22 at 3:54 p.m., indicated she had no further information to provide. Interview with the Medical Director on 10/28/22 at 10:39 a.m., indicated he had just been notified of the discolorations and assessed the resident. He indicated the resident had purpura (purple spots due to small blood vessels leaking blood into the skin) on his left forearm due to the Eliquis that he had been taking for his atrial fibrillation. 2. On 10/24/22 at 11:26 a.m., Resident 237 was noted to have bilateral lower leg dressings dated 10/22/22. The resident indicated the staff did not always get to it every day. Resident 237's record was reviewed on 10/25/22 at 1:45 p.m. Diagnoses included, but were not limited to, cellulitis of the right and left lower limbs, high blood pressure, anxiety disorder, chronic lung disease, and venous insufficiency. The Admission Minimum Data Set (MDS) assessment, dated 10/23/22, was still in progress. The Physician's Order, dated 10/20/22, indicated cleanse bilateral lower extremities with wound wash, pat dry, apply Xeroform dressing, abdominal pads, and wrap with Kerlix (woven gauze) every day shift. A Care Plan, dated 10/19/22, indicated the resident had bilateral lower extremity cellulitis. Interventions included, but were not limited to, complete treatment as ordered. Interview with LPN 3 on 10/25/22 at 2:42 p.m., indicated the dressing should have been changed daily as ordered and she was unsure why the treatment was not completed on 10/23/22. Interview with Director of Nursing (DON), on 10/26/22 at 12:59 p.m., indicated she spoke with the resident and she had indicated she refused the treatment on Sunday 10/23/22. This was not documented in the chart as the nurse who was supposed to do the treatment had already checked it off as completed prior to doing the treatment. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a dependent resident was provided activities to meet her interests for 1 of 1 residents reviewed for activities. (Resident 10) Finding includes: On 10/25/22 at 2:32 p.m., 10/27/22 at 11:30 a.m., and 1:23 p.m., Resident 10 was observed in her bed with her eyes closed. On 10/26/22 at 12:54 p.m., 2:18 p.m., and 3:10 p.m., the resident was observed awake in her bed. On 10/26/22 at 8:23 a.m., 10:55 a.m., 10/27/22 at 8:51 a.m., and 10/28/22 at 8:56 a.m. the resident was observed seated in her wheelchair in her room. At no time during the observation days was the resident observed outside her room. The resident's record was reviewed on 10/26/22 at 10:14 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's dementia and failure to thrive. The current Activities Care Plan indicated the resident loved activities but needed reminders due to her diagnoses of dementia. She enjoyed bingo, current news, movies, music, games, radio, reading, sing a longs, socials and church. The goal was to have the resident attend at least one activity a week and provide her with blocks, crayons and an activity apron to give her something to do through the next review. The activity calendar posted in the main hallway, indicated there was a movie on 10/26/22 at 1:30 p.m., on 10/27/22 there were manicures at 9:00 a.m., and reading hour at 3:30 p.m. The resident's activity log indicated the resident attended church and had a visit one time in August. In September the resident was visited by a pet one time, and had a visit two times in October 2022. The activity log indicated the resident watched television daily and had a family visit daily. Interview with the resident's family member on 10/25/22 at 11:20 a.m., indicated someone in the family tried to visit her every morning. She said staff would often say they were going to take her to an activity, but she had never seen her go to one. Interview with the Activity Director, on 10/28/22 at 9:13 a.m., indicated they tried to visit the residents daily, but did not record on the resident's activity log. She indicated the events on the activity log were the only events the resident had attended. 3.1-33(a)

Based on observation, interview, and record review, the facility failed to provide necessary care and services to residents, related to not assessing the cause for the resident's increased pain and treating a resident's increased pain, after the Physician had decreased the resident's pain medication, the resident was moaning and groaning through out therapy treatments and was unable to tolerate the therapies as ordered due to the pain for 1 of 3 residents reviewed for therapy (Resident # D). The facility also failed to assess skin excoriations for 2 of 3 residents reviewed for excoriations, in a total sample of 6. (Residents #D and #G) Findings include: 1. Resident #D's record was reviewed on 11/09/15 at 11:04 a.m. The resident's [DIAGNOSES REDACTED]. A 5-Day Minimum Data Set (MDS) assessment, dated 09/29/15, indicated the resident's cognition was moderately impaired, required extensive assistance with bed mobility, transfers, toileting, and hygiene, had pain frequently rated 8 out of 10 on a scale of 1-10, received Occupational Therapy for 6 days and Physical therapy for 7 days. A physician's orders [REDACTED]. A Physician's Progress Note, dated 09/23/15, indicated the resident had a redo of a right knee replacement with post operation infection in the knee, and the plan included pain control. A physician's orders [REDACTED]. The Medication Administration Record, [REDACTED] 09/22/15 at 8 p.m. for pain rated at 7 and the medication was effective 09/23/15 at 6 a.m. for pain rated at 7 and the medication was effective 09/23/15 at 8:30 p.m. for pain rated at 8 and the medication was effective 09/24/15 at 8 a.m. for pain rated at 8 and the medication was effective 09/24/15 at 1 p.m. for pain rated at 8 and the medication was effective 09/24/15 at 8 p.m. for pain rated at 8 and the medication was effective 09/25/15 at 10 a.m. for pain rated at 8 and the medication was effective. A physician's orders [REDACTED]. There were no other as needed pain medications ordered. Physical Therapy Treatment Notes, dated 09/23/15 through 10/01/15, indicated the resident was treated for [REDACTED]. Physical Therapy Notes indicated: 09/29/15- .patient constantly moaning and groaning through tx (treatment) session . The Note indicated the resident had 30 total minutes of therapeutic exercise and no neuromuscular re-education and therapeutic activities. 09/30/15- .patient constantly moaning and groaning through tx session. Refusing to perform any exer (exercise) stating she cant (sic) .Patient is unable to complete home program stating she cant (sic) doing anything today. The Note indicated the resident had 42 minutes of therapeutic exercise and no neuromuscular re-education and therapeutic activities. 10/01/15- .patient constantly moaning through the tx session. Refusing to perform any exer stating she cant (sic) The Note indicated the resident had 40 total minutes of therapeutic exercise and neuromuscular re-education and no therapeutic activities. A Nurses' Progress Note, dated 09/29/15 at 2:23 a.m. (resident in bed), indicated the resident had no complaints of pain or discomfort. A Nurses' Progress Note, dated 09/29/15 at 11:20 a.m., indicated the resident's pain had not been assessed. A Social Service Note, dated 09/29/15 at 2:03 p.m., indicated, .Resident stated that she has had trouble with sleeping due to pain. Resident stated that she has been feeling tired due to lack of sleep relating to pain. Resident stated that she has had poor appetite due to not being hungry relating to pain . The Progress note did not indicate Nursing had been notified of the resident's concerns about the pain. A Nurses' Progress Note, dated 09/30/15 at 7:16 a.m. (resident in bed), indicated the resident had no complaints of pain or discomfort. A Nurses' Progress Note, dated 09/30/15 at 3:22 p.m., indicated the resident's pain had not been assessed. A Physician's Progress Note, dated 09/30/15, indicated the resident had increased complaints of pain from skin excoriation. A Nurses' Progress Note, dated 10/01/15 at 2:23 a.m. (resident in bed), indicated the resident had no complaints of pain or discomfort. A Nurses' Note, dated 10/01/15 at 3:09 p.m., indicated the resident complained of pain to the buttock. There was no assessment of the intensity of the pain. During an interview on 11/09/15 at 2:42 p.m., Physical Therapist #4 indicated the resident was, ok the first few minutes of the therapy then she would start moaning. The Physical Therapist indicated the resident was taken back to her room and she had informed the Nurse and the Social Service Director about the resident's moaning. She indicated she had informed the Nurse who was scheduled to take care of the resident, but was unable to provide a name. She indicated she had felt the moaning and groaning was more about the resident giving up and not pain. During an interview on 11/09/15 at 3:17 p.m., The Social Service Director indicated she had stepped in to encourage the resident. The Social Service Director indicated she had spoken to the resident's daughter about therapy and pain management prior to the moaning and groaning, and the daughter had wanted the resident to have less pain medications so the facility notified the Physician to decrease the pain medication. The Social Service Director indicated the resident had said the moaning was due to the wound on her buttock. the Social Service Director indicated she had informed the Nurse about the pain. During an interview on 11/10/15 at 12 p.m. with the Skilled MDS Coordinator, RN #5, the Skilled Unit Manager, the Social Service Assistant, and the Director of Nursing (DoN), the DoN indicated the resident had a [MEDICATION NAME] and was not sure if the resident realized she was moaning and groaning. The DoN indicated Physical Therapy had not informed the Nurse about the moaning and groaning and there had not been an assessment for the moaning and groaning. RN #5 indicated the resident had not been eating as well as she usually did. The Skilled Unit Manager indicated she had not been informed about the increased signs and symptoms of the pain. RN #5 indicated the Physician had assumed the pain was due to the knee surgery when he came in to see the resident on 09/30/15, and the resident had told him it was due to the excoriation on her buttock. RN #5 indicated the Physician had decreased the [MEDICATION NAME] due to the resident was lethargic. The Social Service Assistant indicated the family did not want the narcotic pain medications for the resident due to it made the resident, loopy. A facility policy, dated 03/07, titled, Pain Management Protocol, received from the DoN as current, indicated, .To control/manage the pain a resident may be experiencing due to any disease process or an identified cause .Nursing staff will monitor and document the effectiveness of the pain management program in the resident medical record .as appropriate for the resident condition .Each resident who has been identified to have pain will have their pain assessed at least once per shift .Documentation of this assessment and vital signs will be placed on the Pain Flow Sheet . An Initial Data Collection Tool, dated 09/22/15, indicated the resident had redness of the right leg and abdominal folds, bruises of the arms, surgical incision of the right knee, abrasion of the left buttock and a superficial pressure sore of the left buttock. Excoriated skin was checked, with no area indicated. A physician's orders [REDACTED]. Nurses' Progress Notes, dated 09/23/15 at 2:32 a.m. through 09/26/15 at 4:03 a.m., indicated an assessment of the resident's excoriation and abdominal fold redness had not been completed. A Nurses' Progress Note, dated 09/27/15 at 12:29 a.m., indicated treatments to the buttocks continued. Nurses' Progress Notes, dated 09/27/15 at 1:56 p.m. through 09/29/15 at 6:28 a.m. indicated an assessment of the resident's excoriation and abdominal fold redness had not been completed. A Nurses' Progress Note, dated 09/29/15 at 11:20 a.m., indicated treatment continued to the excoriation with each brief change. A Nurses' Progress Notes, dated 09/29/15 at 1:34 p.m., indicated an assessment of the resident's excoriation and abdominal fold redness had not been completed. A Physician's Progress Note, dated 09/30/15, indicated the resident had increased complaints of pain from skin excoriation of the buttocks and perineal regions. A Nurses' Progress Note, dated 09/30/15 at 3:22 p.m., indicated the Physician had examined the resident on rounds. A Nurses' Progress Note, dated 09/30/15 at 11:31 p.m., indicated an assessment of the resident's excoriation and abdominal fold redness had not been completed. A Nurses' Progress Note, dated on 10/01/15 at 3:09 p.m. indicated the resident was at an appointment with the Orthopedic Physician, outside of the facility. A Nurses' Progress Note, dated 10/01/15 at 3:26 p.m., indicated the resident had been transferred to the hospital emergency room from the Physician's office A Nurses' Progress Note, dated 10/01/15 at 11:38 p.m., indicated the resident was admitted into the hospital [MEDICAL CONDITION] and pneumonia. The Weekly Skin Integrity Data Collection form, dated 09/24/15 indicated the resident had right and left upper extremity bruises, a superficial pressure area on the left buttock and a surgical incision to the right knee. Excoriation of the skin had not been identified. The Weekly Skin Integrity Data Collection form, dated 10/01/15, indicated the resident had bruises on the right and left arms and left breast area, and incision on the right leg and redness of the buttocks and peri-area with treatment. There was not a thorough assessment of the redness of the buttock and peri-area. During an interview on 11/10/15 at 12 p.m. with the Skilled MDS Coordinator, RN #5, the Skilled Unit Manager, the Social Service Assistant, and the Director of Nursing (DoN), the Skilled MDS Coordinator indicated on the Admission Assessment, the excoriation box was checked but it was not indicated on the form where the excoriation was. The Skilled Unit Manager indicated there had not been an assessment of the redness of the resident's groin. The Skilled Unit Manager indicated she could not find an assessment of the resident's excoriation. RN #5 indicated she had looked at the excoriated area and the redness of the groin, but had not documented an assessment. 2. Resident #G's record was reviewed on 11/09/15 at 2:51 p.m. The resident's [DIAGNOSES REDACTED]. The Initial Data Collection Tool, dated 10/10/15 at 3 p.m., indicated the resident's skin was warm and intact, had a bruise on the right inner arm, and an incision on the right hip. The area for excoriated skin was not checked, which indicated the resident had no excoriated skin. A physician's orders [REDACTED]. The Nurses' Notes, dated 10/14/15, at 2:06 p.m. and 6:32 p.m., indicated the excoriation of the inner thighs had not been assessed. The Nurses' Progress Notes, dated 10/15/15 through 11/06/15, indicated the excoriation of the inner thighs had not been assessed. A Weekly Skin Integrity Data Collection form, dated 10/17/15, indicated the resident had a bruise on the right arm and was right hip post-op (operation). The area for rash, redness, and other had been left blank, which indicated the resident had no other skin concerns. The Weekly Skin Integrity Data Collection form, dated 10/23/15, indicated a bruise on the right arm and right hip post-op. The area for rash, redness, and other had been left blank, which indicated the resident had no other skin concerns. The Treatment Administration Records, dated 10/14/15 through 10/31/15 and 11/01/15 through 11/11/15, indicated the [MEDICATION NAME] ointment had been applied as ordered every shift A physician's orders [REDACTED]. The Nurses' Notes, dated 11/03/15 at 3:15 a.m. and 10:26 a.m., indicated the excoriated areas on the groin and peri-area had not been assessed. The Nurses' Notes, dated 11/04/15 through 11/06/15 indicated the excoriated areas on the groin and peri-area had not been assessed. The Weekly Skin Integrity Data Collection form, dated 11/06/15, indicated a right hip healing surgical incision and redness of the peri-area. A Nurses' Note, dated 11/07/15 at 3:24 p.m., indicated, .Per-area with excoriation barrier cream applied . During an interview on 11/10/15 at 8:31 a.m., the ADoN (Assistant Director of Nursing), indicated the excoriation areas had not been assessed. During an observation on 11/101/5 at 8:54 a.m., Resident #G was transferred from the wheelchair to the bed by CNA #1, QMA #2, and Physical Therapy Aide #3. CNA #1 and QMA #2 provided incontinence care to the resident. During the observation, the ADoN indicated the resident's peri-area and inner thighs were bright reddish/pink. During an interview on 11/10/15 at 9:24 a.m., the ADoN indicated the area of excoriation was over 10 centimeters. An undated facility policy, titled, Post-admission Weekly Skin Assessments, received from the Director of Nursing as current on 11/10/15 at 10:23 a.m., indicated, .On a weekly basis, a licensed professional searches for areas of skin that differ from surrounding tissue .The results of the skin assessment are documented on the Weekly Skin Integrity Data Collection form This Federal Tag relates to complaint IN 872. 3.1-37(a)