Every finding on record at Lincolnshire Health & Rehabilitation Center

Based on record review and interview, the facility failed to ensure the physician and responsible party (RP) were notified of low blood sugars, behaviors, a transfer to a behavioral hospital, and change of condition, for 2 of 3 residents reviewed for notification of change. (Residents C and D)Findings include:1. Resident C's record was reviewed on 5/21/26 at 1:12 p.m. The diagnoses included, but were not limited to, bipolar, dementia, Alzheimer's disease, and violent behavior.A Quarterly Minimum Data Set (MDS) assessment, dated 3/2/26, indicated a severely impaired cognitive status.a) A Nurse's Progress Note, dated 3/17/26 at 10:24 p.m., indicated the resident was verbally and physically aggressive towards staff. The interventions attempted were unsuccessful.A Nurse's Progress Note, dated 3/18/26 at 9:42 p.m., indicated the resident was cursing and threatening staff with physical behaviors. The interventions were unsuccessful.A Nurse's Progress Note, dated 3/20/26 at 7:12 p.m., indicated the resident exhibited verbal and physical aggressiveness toward the staff. The interventions were unsuccessful.There was no documentation that indicated the responsible party had been notified of the increase in behaviors.A Social Service Progress Note, dated 3/23/26 at 2:19 p.m., indicated a referral had been sent to the Behavioral Hospital. The Responsible Party had not been notified of the behaviors or the referral prior to the referral being sent.A Social Service Progress Note, dated 3/24/26 at 4:09 p.m., indicated the resident had been accepted to the Behavioral Hospital. The responsible party was notified per voicemail.A Nurse's Progress Note, dated 3/24/26 at 6:14 p.m., indicated the resident was transferred to the behavioral hospital.During an interview on 5/21/26 at 2:39 p.m., the Director of Nursing (DON), indicated she was unsure why the responsible party had not been notified of the behaviors prior to the transfer.During an interview on 5/21/26 at 2:56 p.m., the Social Service Director indicated she had been on vacation and came back to work on 3/23/26 and could not notify the responsible party if she was not here. b) A Nurse's Note, dated 5/6/26 at 11:54 a.m., indicated there was swelling to the left wrist with complaints of pain. The physician was notified and orders for an X-ray of the left hand and wrist were received.There was no documentation that indicated the responsible party had been notified of the left wrist swelling and order for the X-ray. 2. Resident D's record was reviewed on 5/21/26 at 10:28 a.m. The diagnoses included, but were not limited to dementia and diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/26, indicated a moderately impaired cognitive status.A Physician's Order, dated 10/6/25, indicated the physician was to be notified if the blood sugar was less than 60 or above 400.A Physician's Order, dated 10/20/25 and discontinued on 4/5/26, indicated the blood sugar was to be monitored by a glucometer before meals and at bedtime. Humalog insulin dose was to be given according to the results of the glucometer reading (sliding scale).A blood sugar result, dated 3/5/26 at 10:29 a.m., indicated the blood sugar was 44.There was no documentation that indicated the physician or Power of Attorney (POA) had been notified of the low blood sugar.A blood sugar result, dated 3/5/26 at 10:31 a.m., indicated the blood sugar was 189.During interviews on 5/21/26 at 2:23 p.m., the Regional Nurse Consultant indicated the blood sugar of 44 may have been an error in documentation. The DON indicated the Terminated LPN 1 who had completed the blood sugar testing and documentated the blood sugar result was no longer employed at the facility. An undated facility guideline for hypoglycemia, received from the DON as current on 5/21/26 at 3:22 p.m., indicated the physician was to be notified for a blood sugar below 60, unless ordered differently. The physician notification was to be documented in the clinical record.An undated facility change in condition policy, received as current from the DON on 5/21/26 at 3:22 p.m., indicated the physician and responsible party were to be notified when there was a change requiring a need to alter treatment, a significant change in a physical, mental, psychosocial status, or a decision to transfer the resident from the facility.This citation relates to Intakes 2985835 and 3005275.410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)410 IAC 16.2-3.1-5(a)(3)410 IAC 16.2-3.1-5(a)(4)

Based on record review and interview, the facility failed to ensure a resident received laboratory services as ordered by the physician for 2 of 3 residents reviewed for laboratory services. (Residents C and D)Findings include:1. Resident C's record was reviewed on 5/21/26 at 1:12 p.m. The diagnoses included, but were not limited to, dementia and Alzheimer's disease.A Physician's Order, dated 5/6/26, indicated a urinalysis (UA) with culture and sensitivity (C&S) test was to be completed.A Nurse's Progress Note, dated 5/6/26 at 9:44 p.m., indicated the resident had been incontinent and a urine sample was not obtained.There was no documentation a urine sample had been obtained or that the UA with C&S had been completed.During an interview on 5/22/26 at 8:15 a.m., the Director of Nursing (DON) indicated the UA with the C&S had not been completed. The physician had not been notified the test had not been completed. 2. Resident D's record was reviewed on 5/21/26 at 10:28 a.m. The diagnoses included, but were not limited to diabetes mellitus and chronic kidney disease.The Physician's Orders, dated 6/13/25, indicated a Comprehensive Metabolic Profile (CMP) (electrolytes) and a Complete Blood Count (CBC) was to be completed monthly on every third Tuesday. A lipid panel was to be completed every three months.The last CMP and CBC results located in the record were dated 1/27/26 and the lipid panel was dated 12/16/26.During an interview on 5/21/26 at 1:49 p.m., the DON indicated the laboratory tests had not been completed as ordered. The tests were supposed to be changed to every three months and the order was not put in by the Unit Manager.This citation relates to Intake 3005275.410 IAC (Indiana Administrative Code) 16.2-3.1-49(e)

Based on record review and interview, the facility failed to ensure the medical record was complete and accurately documented related to treatment of low blood sugars for 1 of 3 residents reviewed for low blood sugars. (Resident D)Finding includes:Resident D's record was reviewed on 5/21/26 at 10:28 a.m. The diagnoses included, but were not limited to diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/26, indicated insulin and a hypoglycemic medication had been administered daily in the past seven days.A Physician's Order, dated 10/6/25, indicated the physician was to be notified if the blood sugar was less than 60 or above 400.A Physician's Order, dated 10/20/25 and discontinued on 4/5/26, indicated the blood sugar was to be monitored by a glucometer before meals and at bedtime. Humalog insulin dose was to be given according to the results of the glucometer reading (sliding scale).A Physician's Order, dated 6/3/25, indicated a glucagon (glucose) emergency kit one milligram (mg) was to be administered intramuscularly as needed for hypoglycemia, blood sugars less than 70, and if symptomatic and not awake and alert. The blood sugar was to be rechecked every 15 minutes. The Emergency Medical System (EMS) was to be notified if the resident did not despond to the first dose of glucagon. The physician was to be notified and all actions were to be documented.A Physician's Order, dated 11/16/25, indicated Glutose 15 Oral Gel 40% (dextrose), 15 grams by mouth was to be given every 24 hours for blood sugars less than 70 and the physician was to be notified.A blood sugar result, dated 3/5/26 at 10:29 a.m., indicated the blood sugar was 44.The Medication Administration Record (MAR), dated 3/2026, had not indicated the glucagon or Glutose gel was used for the treatment of the hypoglycemia.The treatment for the low blood sugar and the status of the resident had not been documented in the medical record.A follow up blood sugar, dated 3/5/26 and timed at 10:31 a.m., indicated the blood sugar was 189.During interviews on 5/21/26 at 2:23 p.m., the Regional Nurse Consultant indicated the blood sugar of 44 may have been an error in documentation. The DON indicated the Terminated LPN 1 who had completed the blood sugar and documented the blood sugar was no longer employed at the facility.During an interview on 5/22/26 at 8 a.m., the Unit Manager indicated the blood sugar had dropped a few times and it was always treated. Terminated LPN 1 had never reported the low blood sugar to her.A Physician's Order, dated 3/10/26, indicated Glucose Oral Gel 40%, one vial by mouth was to be used for hypoglycemia/blood sugars less than 60. The physician was to be notified.A Physician's Order, dated 3/12/26, indicated Glucose Oral Tablet Chewable, four tablets by mouth was to be given for blood sugars less than 70.A Nurse's Progress Note, dated 4/3/26 at 8:20 a.m., indicated the blood sugar was 44. The resident was awake but unable to follow commands. Attempts were made to raise the blood sugar per physician orders and were unsuccessful. The physician was notified and EMS was called. EMS arrived and were able to treat the hypoglycemia. The blood sugar was 166.The MAR, dated 4/2026, indicated none of the treatments for the hypoglycemia had been used.During an interview with Terminated LPN 2 on 5/21/26 at 1:49 p.m., she indicated the resident had not been able to hold anything in his mouth. The glucose tablets his family brought in were used. The family was not here. The family had brought the tablets in when his blood sugar was low the last time. He had checked the blood sugar after the treatment, but did not remember what it was. An undated facility guideline for hypoglycemia, received from the DON as current on 5/21/26 at 3:22 p.m., indicated If unable to swallow, notify the physician and prepare glucagon from the emergency drug kit for administration as ordered. Document findings, interventions, and physician contact in the resident's clinical record.This citation relates to Intake 3005275.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC 16.2-3.1-50(a)(2)

Based on record review and interview, the facility failed to provide the required information and documents to the resident or their representative at the time of discharge for 1 of 3 residents reviewed for discharges. (Resident G)Finding includes: The closed record for Resident G was reviewed on 2/26/26 at 1:25 p.m. Diagnoses included, but were not limited to, hemiparesis (one-sided weakness) and hemiplegia (one-sided paralysis) following a cerebral vascular accident (stroke) and chronic obstructive pulmonary disease. The resident was admitted to the facility on [DATE] and discharged on 2/14/26.A Psychosocial Note, dated 2/11/26, indicated the resident had been notified their last covered day for their stay would be 2/13/26. There were no additional notes regarding the resident being discharged or what instructions the resident had received on discharge.A Discharge Planning Review, dated 2/14/26, was signed by the resident. The first two sections of the document were completed, however the remaining sections, including medications and follow up visits, were not completed. During an interview on 2/26/26 at 2:33 p.m., the Social Service Director (SSD) indicated the resident had been discharged to home and a referral had been made to home health. There was no documentation regarding the home health referral in the resident's record but there was an email related to the referral. During an interview on 2/26/26 at 2:40 p.m., the Director of Nursing indicated at discharge, residents should be given a discharge summary, a list of medications and any equipment orders and there should be a progress note completed in their record. The policy, Discharge summary, dated [DATE], was provided by the Administrator and indicated, .2. When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results c. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter. This citation relates to Intake 2745646.410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(3)

Based on observation, record review, and interview, the facility failed to ensure a dependent resident received assistance with activities of daily living (ADL's) related to the timeliness of assistance with a breakfast meal for 1 of 3 residents observed for meal intake assistance. (Resident F)Finding includes:During an observation on 2/26/26 at 8:16 a.m., Resident F was lying in bed with her head up and a tray table over the bed. On the tray table was an uncovered breakfast tray which consisted of scrambled eggs, a hot cereal, a muffin, a carton of milk, and a glass of orange juice. There were no attempts made to feed herself.During an observation on 2/26/26 at 8:24 a.m., the breakfast tray remained in front of Resident F on the tray table. Her fingers of her left hand were in the scrambled eggs and there were tremors of the hand when she raised her fingers off the plate. She was unable to communicate if she required help to eat. There were no attempts to feed herself.During an observation on 2/26/26 at 8:45 a.m., the breakfast tray remained in front of her. The tremors of the hands continued. The scrambled eggs were now in in the hot cereal bowl. There were no attempts made to feed herself. CNA 1 indicated the resident was a new admission and required assistance with the meal intake and she would assist the resident.During an observation on 2/26/25 at 8:49 a.m., CNA 1 was at the bedside and attempted to feed the resident. She indicated the resident didn't seem like she wanted to eat and did take a sip of the orange juice. CNA 1 had not warmed up the food nor obtained a new breakfast tray for the resident.During an observation on 2/26/26 at 1:00 p.m., a family member was assisting the resident with her lunch meal and indicated the resident was dependent for meal intake.During an interview on 2/26/26 at 1:06 p.m., the Director of Nursing indicated the resident should have been fed when the tray arrived and CNA 1 should have obtained a new tray for the resident. Resident B's record was reviewed on 2/26/26 at 1:22 p.m. The diagnoses included, but were not limited to Parkinson's disease and dementia. She was admitted into the facility on 2/25/26.A Baseline Care Plan, dated 2/25/26 at 1:49 p.m., indicated the resident required physical assistance of one person for eating.The Functional Abilities and Goals assessment, dated 2/25/26 at 10:04 p.m., indicated the resident was dependent for eating.This Citation relates to Intake 2745646.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure a resident's pressure ulcer treatment was provided as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident D)Finding includes:Resident D's record was reviewed on 2/26/26 at 9:45 a.m. Diagnoses included, but were not limited to, adult failure to thrive. The resident had pressure ulcers on her coccyx and left heel and received hospice services.The Significant Change Minimum Data Set assessment, dated 11/27/25, indicated the resident had significant cognitive deficits and required substantial/maximum assistance for bed mobility.A Physician's Order, dated 12/20/25, indicated to cleanse the coccyx wound with normal saline, apply calcium alginate and cover with a dry dressing daily.The January 2026 Treatment Administration Record indicated the wound treatment was not signed out as completed on 1/5 and 1/7.A Physician's Order, dated 12/17/25, indicated to cleanse the left heal wound with normal saline, apply calcium alginate and secure with Kerlix every Monday, Wednesday and Friday. The order was discontinued on 1/6/26.A Physician's Order, dated 1/7/26, indicated to cleanse the left heal wound with normal saline, apply calcium alginate and cover with a dry dressing every Monday, Wednesday and Friday. The order was discontinued on 1/16/26.A Physician's Order, dated 1/24/26, indicated to cleanse the left heal wound with normal saline, pat dry, apply triple antibiotic ointment to peri-wound, apply calcium alginate and cover with a dry dressing. The order was discontinued on 1/30/26.A Physician's Order, dated 1/31/26, indicated to cleanse the left heal wound with normal saline, apply calcium alginate and cover with a dry dressing daily.The January and February 2026 Treatment Administration Records indicated the wound treatment was not signed out as completed on 1/5, 1/7, 1/25, 1/31, 2/9, 2/16 and 2/17.During an interview on 2/26/26 at 2:25 p.m., the Wound Nurse indicated she did not know why the treatments weren't completed on the above dates. The February dates corresponded with dates hospice staff visited and they may have changed the dressing. Hospice records were requested by the nurse, but not received. The policy, Wound Dressing Change, dated 5/20/24, was received from the Regional Wound Nurse indicated, .11. Document the completion of dressing change on the treatment record.This citation relates to Intake 2745676.410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure residents' records were completed in a timely manner related to nutritional assessments for 2 of 6 residents reviewed for medical records. (Residents B and C) Findings include:1. Resident B's closed record was reviewed on 2/26/26 at 9:58 a.m. The diagnoses included, but were not limited to, diabetes mellitus. The resident was admitted into the facility on 1/28/26 and discharged from the facility on 2/13/26.A Care Plan, dated 2/10/26, indicated a poor appetite and frequent refusals of meals.There was no documentation located in the record that indicated a nutritional assessment had been completed to evaluate the resident's nutritional needs. 2. Resident C's closed record was reviewed on 2/26/26 at 11:03 a.m. The diagnoses included, but were not limited to, dementia. The resident was admitted into the facility on 1/19/26 and discharged from the facility on 2/5/26.An admission Minimum Data Set assessment, dated 1/26/26, indicated a deep tissue injury pressure ulcer was present on admission.A Care Plan, dated 2/2/26, indicated there was difficulty chewing and swallowing some foods with a moderate appetite.There was no documentation located in the record that indicated a nutritional assessment had been completed to evaluate the resident's nutritional needs.During an interview on 2/26/26 at 2:43 p.m., the Registered Dietician indicated she was a little behind and did not have enough hours at the facility to ensure the assessments were completed timely.This citation relates to Intake 2745646.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)

Based on observation, record review, and interview, the facility failed to ensure food was stored and served under sanitary conditions related to touching food with bare hands, glove use, beard restraints, dirty food equipment, ice on the freezer floor, food spillage in the walk in cooler, and food brought in by visitors or resident's food that was not labeled for 1 of 1 kitchen and 1 of 2 wings. (The main kitchen and the A Wing)Findings incude:1. During the Brief Kitchen Sanitation Tour on 11/17/2025 at 9:56 a.m. with the Dietary Food Manager (DFM) the following was observed:a. Dietary [NAME] 1 was observed with a disposable glove on her left hand and her right hand was bare. She was observed using her bare right hand reaching into the pan of the cheese and cracker crumbs and was putting it on top of the turkey noodle casserole she had in front of her.During an interview on 11/17/25 at 10:12 a.m., Dietary [NAME] 1 indicated right.b. Dietary Aide 1 was observed standing right by Dietary [NAME] 1 while she was preparing the food with his beard guard lowered down around his neck. The aide had facial hair on his face and chin. c. The convection oven was dirty on the inside with black dried food spillage noted on bottom. The inside of both doors had an accumulation of dried food spillage noted.d. There was moderate amount of dried milk spillage under the milk crates inside the walk in cooler. e. There was a large amount of ice build up on the floor in the freezer. During an interview at that time, the DFM indicated there were work orders out for the ice and the Maintenance Director was aware, as they were waiting for bids. During an interview on 11/20/25 at 12:00 p.m., the Maintenance Director indicated the freezer had been repaired a couple of months ago for the ice build up. He was not aware there was more ice on the floor since the repair. f. Underneath the steam table hood there was a moderate amount of grease, grime, and dirt noted. g. Another steam table that was not in use had a large amount of food crumbs and debris noted in all four of the pans. h. A non-functioning plate warmer was dirty with clean plates stacked on top of it. During an interview on 11/20/25 at 10:40 a.m., the DFM indicated all of the above was in need of cleaning and/or repair. 2. During an observation during the noon meal on 11/17/25 at 12:17 p.m., Dietary [NAME] 1 was observed serving food to the residents. She was wearing gloves to both hands and handling plates, utensils, lids, and other items. At 12:21 p.m., the cook was observed to scoop food onto a plate and used her gloved hand to move the food back on the plate after touching other items with those gloves. A CNA had asked for a hot dog for a resident. Dietary [NAME] 1 was observed wearing one glove to a hand and the other hand was bare. She proceeded to pick up utensils, handle plates, and then used her gloved hand to reach into the plastic bag and removed a hot dog bun with that same gloved hand and put it on the resident's plate. She put a hot dog inside the bun and gave the plate to the CNA, who then passed it to the resident. During an interview on 11/20/25 at 11:45 a.m., the DFM indicated the cook should have changed her gloves after touching other items and she should have not touched any food with her bare hands. The current 9/1/2020, Safe Food Handling policy, provided by the Administrator on 11/20/25 at 1:35 p.m., indicated all staff will use serving utensils appropriately to prevent to prevent cross contamination. 3. During an observation on 11/20/25 at 2:45 p.m., the A wing nourishment refrigerator was observed with the following:There was one open bottle of ice tea with no name or date opened. There was 1 Styrofoam box of vanilla strawberry cake with no name or date. There was a container of cake with no name or date on it. There was a container of fresh strawberries no name or date on it.There was a brown and green banana with no name or date on it.During an interview on 11/20/25 at 2:53 p.m., the Administrator had no additional information to provide. The current 9/1/202020, Food Items Brought from Outside-Safe Storage policy, provided by the Administrator on 11/20/25 at 3:00 p.m., indicated all resident foods and beverages shall be labeled with the resident's name and dated. 3.1-21(i)(3)

Based on observation and interview, the facility failed to keep the kitchen and residents' environment clean and in good repair related to dirty walls, ceilings, floor tile, ceiling vents and adhered dirty against the baseboard for 1 of 1 kitchen (The main kitchen); marred and water-damaged walls, grab bar not secured to the wall, and uncontained basins (Resident Rooms A02, B01, B08) Findings include:1. During the Brief Kitchen Sanitation Tour on 11/17/2025 at 9:56 a.m. with the Dietary Food Manager (DFM) the following was observed: a. The dish room walls were observed with dried food spillage. b. The floor drains under the dish machine were dirty with a large accumulation of dirt and debris under the dish machine. c. The floor tile grout was discolored near the steam tables. d. There was a moderate amount of adhered dirt and debris against the base board by the steam tables. e. There was a large amount of food spillage noted on random walls in the kitchen as well as areas on the ceiling. f. The ceiling vent was dusty, dirty and rusted over. During an interview on 11/20/25 at 10:40 a.m., indicated all of the above was in need of cleaning and/or repair 2. During the Environmental Tour on 11/24/25 at 11:15 a.m. with the Administrator, Maintenance Supervisor, and Housekeeping Supervisor, supervisors the following was observed: a. Room A02: There was a basin on the floor of the bathroom in the corner where a pipe was located. There was a hole in the wall, and visible water damage to the adjacent wall area. The grab bar next to the toilet was not securely connected to the wall. One resident in the room used the bathroom. b. Room B01: The wall was marred next to the resident's bed. c. Room B08: There were 3 uncontained basins on the floor of the bathroom. The wall next to the toilet had visible water damage. One resident used the bathroom. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure a treatment to a surgical incision was completed as ordered, areas of bruising and scabbing were assessed and monitored, and interventions were in place for areas of dry scaly skin for 5 of 6 residents reviewed for skin conditions non-pressure related. (Residents D, H, J, F, and G)Findings include:1. The closed record for Resident D was reviewed on 11/19/25 at 3:22 p.m. Diagnoses included, but were not limited to, aortocoronary bypass graft, atherosclerotic heart disease, and type 2 diabetes mellitus. The Medicare 5-day Minimum Data Set (MDS) assessment, dated 8/9/25, indicated the resident had moderate cognitive impairment and required partial/moderate assistance with bathing and dressing. The resident was also identified as having a surgical wound. A Care Plan, dated 8/6/25, indicated the resident had actual impairment to the skin integrity of her chest related to a surgical incision. Interventions included, but were not limited to, follow facility protocols for treatment of injury and monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, and signs and symptoms of infections to physician. Physician's Orders, dated 8/3/25, indicated the incision could be left open to air and if drainage was observed, apply gauze 4 x 4's and change daily or as needed (PRN). The incision was to be cleansed with antiseptic soap and water as follows: start at the top of the chest incision, using a clean wash cloth wipe down the chest incision once with soap and water. Use another clean washcloth and rinse the incision starting at the top and going down the incision one time a day for treatment. The surgical incision was assessed by the Wound Nurse on 8/5/25 and measured 8.6 centimeters (cm) in length by 0.3 cm in width by undetermined in depth. There was no odor, no signs of infection, and no exudate (drainage). The August 2025 Medication and Treatment Administration records indicated the treatment was not listed on either form and the treatment had not been signed out as being completed. A Nurse's Note, dated 8/9/25 at 6:15 a.m., indicated while the resident's morning medications were being administered, the resident informed the writer that she felt some drainage and discomfort to her mid chest surgical area. The surgical wound appeared open with some light greenish colored skin noted. The resident requested to go to the emergency room. The Physician was notified and orders were obtained to transfer the resident to the hospital for evaluation. During an interview on 11/24/25 at 11:02 a.m., the Director of Nursing (DON) indicated the Wound Nurse stated she did complete the treatment to the resident's incision but she didn't document it on the medication or treatment records. The DON indicated the treatment to the surgical incision should have been signed out as ordered. 2. On 11/17/25 at 3:36 p.m. fading bruises that were purplish/brown in color were observed on top of Resident H's right hand. On 11/20/25 at 9:45 a.m., the fading bruises remained to the top of the resident's right hand. The record for Resident H was reviewed on 11/19/25 at 10:26 a.m. Diagnoses included, but were not limited to, Parkinson's disease and anemia. The admission Minimum Data Set (MDS) assessment, dated 8/19/25, indicated the resident was moderately impaired for daily decision making. The resident required partial to moderate assistance rolling from left to right and with chair to bed transfers. There was no current care plan related to the bruising. The November 2025 Physician's Order Summary (POS) indicated the resident's skin was to be assessed weekly. The November 2025 Medication Administration Record (MAR) indicated a skin assessment was to be completed on 11/18/25. The box was coded with a 6 which indicated the resident was hospitalized . The resident was not in the hospital on [DATE]. During an interview on 11/20/25 at 3:10 p.m., the B Wing Unit Manager indicated the bruising to the resident's right hand was most likely from a lab draw and the area should have been monitored. She also indicated the resident was not in the hospital on [DATE] and the weekly skin assessment should have been completed. 3. On 11/18/25 at 11:18 a.m., Resident J was observed with a fading reddish/purple discoloration to the top of her left hand. On 11/20/25 at 11:40 a.m., the resident was observed in her room in bed. The fading reddish/brown bruise remained to the top of her left hand and a scabbed area was observed to her right knee. The resident was unable to state how she obtained the areas. The record for Resident J was reviewed on 11/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, lack of coordination and history of falling. A Significant Change Minimum Data Set (MDS) assessment, dated 10/31/25, indicated the resident was moderately impaired for daily decision making. The resident required partial to moderate assistance with rolling left to right and chair to bed transfers. A Care Plan, dated 10/16/25, indicated the resident was at risk for complications such as bleeding or bruising secondary to anticoagulant (a blood thinner) therapy. Interventions included, but were not limited to, daily skin inspections and report abnormalities to the nurse and observe/document/report as needed (PRN) adverse reactions of anticoagulant therapy such bruising. A Physician's Order, dated 11/1/25, indicated the resident was to receive Xarelto (a blood thinner) 10 milligrams (mg) daily. The medication was discontinued on 11/15/25 and orders were received to start Aspirin 81 mg daily. A Weekly Skin Assessment, dated 11/18/25, indicated the resident had no new skin issues. During an interview on 11/20/25 at 3:10 p.m., the B Wing Unit Manager indicated the bruising to the resident's right hand and the scabbed area to her knee were most likely from a recent fall and the areas should have been assessed and monitored. 4. During random observations on 11/17/25 at 10:35 a.m. and 3:30 p.m., 11/19/25 at 9:09 a.m., and 11/20/25 at 9:32 a.m., Resident D was observed lying in bed. The skin on his legs appeared dry and scaly. There were many dark skin flakes on bed sheet. The record for Resident was reviewed on 11/19/25 at 10:03 a.m. Diagnoses included, but were not limited to, heart failure, pain, and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs), and had 2 arterial ulcers to his lower extremities (wounds caused by poor blood flow). A Care Plan, initiated 6/5/25, indicated the resident had a pressure ulcer. Interventions included keeping skin clean and moisturized. The record lacked interventions or treatments for the dry, scaly skin. During an interview on 11/17/25 at 10:46 a.m., CNA 1 indicated she was not aware of any treatment for the resident's dry, flaking skin. During an interview on 11/21/25 at 1:07 p.m., the DON indicated the resident should have treatment for dry, scaly skin, and she would look into it. 5. During a random observation on 11/18/25 at 9:30 a.m., Resident G had dry, patchy, discolored skin to her elbows. At that time, the resident indicated she had psoriasis for years and had used a topical medication for it before she was admitted to the facility. She indicated the skin patches were itchy, and she was not receiving any treatment for them. The resident's record was reviewed on 11/20/25 at 2:57 p.m. Diagnoses included, but were not limited to, psoriasis. The record lacked assessments of or treatment for the resident's psoriasis. During an interview on 11/20/25 1:24 p.m., LPN 3 indicated she did not know the resident had psoriasis. During an interview on 11/24/25 8:55 a.m., the DON indicated she observed the resident's psoriasis and she did not find any documentation of it being assessed or treated in the record. A policy, titled Skin Care, received as current from the Nurse Consultant on 11/21/25 at 1:59 p.m., indicated, . Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR). Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse . This citation relates to Intake 2585462. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to insulin pens not labeled when opened, and loose pills observed in the medication carts for 1 of 2 units (A Wing) and medications at the bedside for residents who did not self-administer medications. (Residents G, 71)Findings include: 1. During an observation on 11/18/2025 at 1:12 p.m., the C hall medication cart on the A Wing was observed with LPN 4. There were many loose pills in all of the medication drawers. During an interview at that time, LPN 4 was unaware there were loose pills in the cart. 2. During an observation on 11/18/2025 1:16 p.m., the B hall medication cart on the A Wing was observed with LPN 4. There were many loose pills in all the drawers. There was one opened multiuse vial of Humulin Regular insulin with no date. There was one opened Lantus insulin pen with date opened. There was one opened multiuse vial of Lantus insulin with an open date of 10/8/25. During an interview at that time, LPN 4 indicated she was aware the insulin vials and pens should be dated after they were opened. During an interview on 11/19/25 at 2:00 p.m., the Director of Nursing indicated the insulin vials and pens should have been dated after opening. The current Medication Storage policy, dated 9/1/2020 and provided by Nurse Consultant 1 on 11/19/25 at 2:30 p.m., indicated once any medication was opened, facility should follow manufacture guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. facility should ensure medications were stored in an orderly manner in cabinets, drawers, and carts to prevent overcrowding. 3. During a random observation on 11/18/25 at 9:30 a.m., 11/19/25 at 9:16 a.m., 11/20/25 at 9:41 a.m., and 11/21/25 at 1:53 p.m., there was a bottle of Debrox (an earwax remover) eardrops and a bottle of nystatin (anti-fungal) powder on Resident G's nightstand. The resident's record was reviewed 11/20/25 at 2:57 p.m. Diagnoses included, but were not limited to, subarachnoid hemorrhage (bleeding between the brain and skull) and psoriasis. A Physician's Order, dated 11/7/25, indicated nystatin external powder, apply to groin / abdominal folds every day and evening shift. The record lacked a current order for Debrox. There were no orders or assessments for self-administration. During an interview on 11/20/25 at 1:24 p.m., LPN 3 indicated the resident did not self-administer any medications, and the resident received Debrox about a month ago, and someone must have left the medications in the room. During an interview on 11/21/25 at 1:11 p.m., the DON indicated medications should not be at kept at the resident's bedside. 4. During random observations on 11/17/25 at 12:50 p.m., 11/19/25 at 9:13 a.m. and 9:50 a.m., 11/20/25 at 9:50 a.m. and 1:51 p.m., and 11/21/25 at 9:42 a.m., Resident 71 was sitting in his wheelchair next to his bed. There was a bottle of nystatin powder on top of his refrigerator. The resident's record was reviewed on 11/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes, and left below the knee amputation. The Quarterly Minimum Data Set (MDS) assessment, dated 10/21/25, indicated the resident was cognitively intact for daily decision making, required moderate assist with activities of daily living (ADLs), and had an indwelling urinary catheter. A Physician's Order, dated 7/1/25, indicated nystatin external powder, apply to abdominal folds every 8 hours as needed for preventative. There were no orders or assessments for self-administration. During an interview on 11/20/25 at 1:24 p.m., LPN 3 indicated the resident did not self-administer any medications. During an interview on 11/21/25 at 1:11 p.m., the DON indicated medications should not be at kept at the resident's bedside. 3.1-25(k)(6)

Based on observation, record review and interview, the facility failed to follow the recipe for pureed spinach. This had the potential to affect the 5 residents who received a pureed diet. Finding includes:During a meal preparation observaton on 11/20/25 at 10:30 a.m., Dietary [NAME] 2 was observed preparing pureed spinach. He placed six scoops (1/2 cup) of cooked spinach into the blender and started the machine. He stopped the blender, stirred the spinach, and added an unmeasured amount of chicken broth into the blender. He started the machine again to mix it together. The cook stopped the machine, stirred the spinach and added more chicken stock, again it was not measured. He blended the spinach and stopped the machine again, removed the lid and stirred the mixture. He then added an unmeasured amount of the product Thick and Easy (a food thickening agent) to the spinach, turned the machine back on and blended it together. He continued to blend and stir the mixture three more times with adding an unmeasured amount of the food thickening agent. He poured the pureed spinach into a pan and placed plastic wrap over it. The spinach was smooth and thick. During an interview on 11/20/25 at 10:35 a.m., Dietary [NAME] 2 indicated he did read the recipe before he started to prepare the pureed spinach. The pureed spinach recipe for 5 servings indicated add one pound and 13 ounces of spinach. 3/4 ounce of margarine, and 1/8 teaspoon of salt. Add the spinach and margarine to the blender and mix until smooth. The recipe did not indicate to add chicken broth or food thickener. During an interview on 11/20/25 at 11:40 a.m., the Dietary Food Manager indicated the cook should have followed the recipe. 3.1-21(a)(3)

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 59) Finding includes:On 11/17/25 at 2:58 p.m., a bottle of nasal spray was observed on the resident's over bed table. Clotrimazole ointment was observed on the resident's nightstand. On 11/18/25 at 8:54 a.m., refresh eye drops and a bottle of nasal spray were observed on the resident's over bed table. Clotrimazole ointment and Neosporin ointment were observed on the resident's nightstand. On 11/20/25 at 10:10 a.m., refresh eye drops and a bottle of nasal spray were observed on the over bed table. Clotrimazole ointment was observed on the resident's nightstand. The resident's record was reviewed on 11/19/25 at 2:31 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, congestive heart failure, and hypertension. The Annual Minimum Data Set (MDS) assessment, dated 9/15/25, indicated the resident was cognitively intact. A Care Plan, updated 10/7/24, indicated The resident has a Physician's Order for unsupervised self-administration of the following medications. No medications were listed. The interventions included to assess the resident's ability to safely self-administer medications specified on admission/re-admission, quarterly, with change in medication orders, and with significant changes in condition. A Self Administration of Medication Assessment, dated 7/16/24, indicated the resident would not be self-administering any medications. There were no other self-administration assessments. A Physician's Order, dated 7/16/24, indicated the resident could self-administer medications with assistance of the facility to set them up. There were no Physician's Orders for the clotrimazole ointment or Neosporin ointment. During an interview on 11/21/25 at 1:00 p.m., the Director of Nursing (DON) was made aware of the medications at the resident's bedside. She indicated the resident's daughter would sometimes bring medications in for the resident and not make the facility aware. A facility policy, titled, Self Administration of Medication Program, indicated, .9. Once the resident had been deemed safe by IDT an order will be obtained from the physician or physician extender listing the medication(s) that may be self-administered, where the medications will be stored, who will be responsible for documentation and the location of administration .14. The resident will be re-evaluated on their ability to continue to self-administer medication in conjunction with the resident assessment instrument . 3.1-11(a)

Based on observation, record review and interview, the facility failed to ensure the call light was in reach for 1 of 14 active residents reviewed who were able to use the call light. (Resident 71)Finding includes:During random observations on 11/17/25 at 12:50 p.m., 11/19/25 at 9:13 a.m. and 9:50 a.m., 11/20/25 at 9:50 a.m. and 1:51 p.m., and 11/21/25 at 9:42 a.m., Resident 71 was sitting in his wheelchair next to his bed. His call light pad was clipped onto its cord on the wall, on the opposite side of the bed. The resident's record was reviewed on 11/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes, and left below the knee amputation. The Quarterly Minimum Data Set (MDS) assessment, dated 10/21/25, indicated the resident was cognitively intact for daily decision making, and required moderate assist with activities of daily living (ADLs). During an interview on 11/21/25 at 1:09 p.m., the Director of Nursing (DON) indicated the resident was able to use the call light, and it should have been kept in his reach. 3.1-3(v)(1)

Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to visual impairment for 1 of 1 resident reviewed for sensory / communication. (Resident F)Finding includes:During a random observation on 11/17/25 at 10:40 a.m., Resident F was observed in bed with a blanket pulled over his head and his television on. He indicated he kept his head under the blanket because it was comfortable, and he could not see the television anyway because he was blind. The record for Resident was reviewed on 11/19/25 at 10:03 a.m. Diagnoses included, but were not limited to, heart failure, pain, and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs) and had adequate vision.An Interdisciplinary Team Note, dated 6/9/25, indicated a contributing factor to the resident's recent fall was their vision impairment. A Physician's History and Physical, dated 4/21/25, indicated the resident was blind.During an interview on 11/21/25 at 9:38 a.m., LPN 3 indicated the resident was legally blind. During an interview on 11/21/25 at 1:07 p.m., the Director of Nursing (DON) indicated the resident was legally blind and there should be a care plan for vision loss. During an interview on 11/21/25 at 1:50 p.m., the MDS Coordinator was informed of the finding and offered no further information.3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure a dependent resident received assistance with activities of daily living (ADL's) related to nail care for 1 of 5 residents reviewed for ADL's. (Resident C)Finding includes:On 11/17/25 at 10:20 a.m., Resident C was observed lying in bed. Her fingernails were jagged and uneven with dark debris underneath. On 11/18/25 at 10:00 a.m., Resident C was observed lying in bed. Her fingernails were jagged and uneven with dark debris underneath. Resident C's record was reviewed on 11/19/25 at 9:51 a.m. Diagnoses included, but were not limited to, dementia, diabetes, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 11/5/25, indicated the resident was mildly cognitively impaired and was dependent on staff for assistance with bathing and personal hygiene. A Care Plan, updated 6/26/25, indicated the resident required assistance with ADLs. The interventions included to assist with personal hygiene including dressing and grooming as needed. A Care Plan, updated 10/7/25, indicated the resident had scattered scabs to her skin. The interventions included to keep fingernails short. During an interview on 11/21/25 at 1:00 p.m., the Director of Nursing (DON) was made aware of the resident's jagged fingernails with debris underneath. No further information was provided. 3.1-38(a)(3)(E)

Based on observation, record review and interview, the facility failed to ensure residents received foot care and had routine visits with a podiatrist related to long and thick toenails for 3 of 5 residents reviewed for ADL's (activities of daily living). (Residents C, 33, and G)Findings include:1. On 11/17/25 at 11:00 a.m., Resident C was observed lying in bed. Her toenails were long and thick. There was a dried dark red substance under her left great toenail. Her feet were scaly and dry. On 11/18/25 at 10:00 a.m., Resident C was observed lying in bed. Her toenails were long and thick. There was a dried dark red substance under her left great toenail. Her feet were scaly and dry. Resident C's record was reviewed on 11/19/25 at 9:51 a.m. Diagnoses included, but were not limited to, dementia, diabetes, and hypertension. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment, dated 11/5/25, indicated the resident was mildly cognitively impaired and was dependent on staff for assistance with bathing and personal hygiene. The Physician's Order Summary, dated 11/2025, indicated the resident may receive services of the eye care physician, audiologist, dentist and podiatrist. There were no podiatry consultation notes. During an interview on 11/21/25 at 1:00 p.m., the Director of Nursing (DON) was made aware of the resident's long toenails. She was unsure if the resident had seen the podiatrist. During an interview on 11/21/25 at 1:53 p.m., the Social Service Director indicated she had just had a care plan meeting with the resident's family yesterday and offered podiatry services. The family wanted the podiatrist consent sent to them to sign. She was unsure if the resident had been offered podiatry services prior to that as she was new to the position in September. 2. On 11/17/25 at 10:40 a.m., Resident 33 indicated his toenails were very long and thick. He had requested multiple times to see the podiatrist and had signed a consent to see the podiatrist in September. Resident 33's record was reviewed on 11/20/25 at 2:02 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and hypothyroidism. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, indicated the resident was cognitively intact. The Physician's Order Summary, dated 11/2025, indicated the resident may receive services of eye care physician, audiologist, dentist and podiatrist. A Podiatry Services Consent was signed by the resident on 9/15/25. There were no podiatry consultation notes. During an interview on 11/21/25 at 1:53 p.m., the Social Service Director indicated she was new to the position in September and was unaware the resident wanted to see the podiatrist. 3. During a random observation on 11/18/25 at 9:30 a.m., Resident G was observed sitting in her wheelchair, dressed and wearing shoes without socks. At that time, the resident indicated her feet hurt when her shoes were on because her toenails were too long. She removed her shoes, and her toenails were observed to be very long. During observations on 11/19/25 at 9:16 a.m., 11/20/25 at 9:41 a.m., and 11/21/25 at 1:53 p.m. the resident's toenails remained long. The resident's record was reviewed 11/20/25 at 2:57 p.m. Diagnoses included, but were not limited to, subarachnoid hemorrhage and psoriasis. The Physician's Order Summary, dated 11/2025, indicated the resident may receive services of the eye care physician, audiologist, dentist and podiatrist. The record lacked documentation of foot care provided or refused. During an interview on 11/21/25 at 1:53 p.m., the Social Service Director indicated the resident had not received podiatry services because they were private pay, but they could get it if they wanted to pay for it. 3.1-47(a)(7)

Based on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to splints not in place and lack of instructions for use of a splint for 3 of 4 residents reviewed for range of motion. (Residents 1, E, and F)Findings include: 1.On 11/17/25 at 3:00 p.m., Resident 1 was observed lying in bed. His left hand was in a fist and there was no splint in place. The resident indicated staff didn't usually put anything on or in his hand. On 11/18/25 at 8:55 a.m. Resident 1 was observed lying in bed. His left hand was in a fist and there was no splint in place. On 11/20/25 at 10:31 a.m. Resident 1 was observed lying in bed. His left hand was in a fist and there was no splint in place. Resident 1's record was reviewed on 11/21/25 at 12:54 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and left side hemiplegia. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively impaired, dependent on staff for all activities of daily living (ADLs), and had impairment to range of motion on one side upper and lower extremities. A Care Plan, updated 11/19/25, indicated the resident requires assistance with activities of daily living. The interventions included left upper extremity (LUE) resting hand splint to be worn in a.m./p.m. as tolerated. A Physician's Order, dated 8/29/25, indicated LUE resting hand splint to be worn in a.m/p.m. as tolerated. The Treatment Administration Record, dated 11/2025, indicated the LUE splint had been signed out as on at 9:00 a.m. and off at 5:00 p.m. daily. There were no refusals documented. During an interview on 11/21/25 at 1:00 p.m., the Director of Nursing (DON) was made aware the resident's splint had not been in place as ordered. During an interview on 11/21/25 at 3:15 p.m., the DON and Nurse Consultant indicated they had spoken with therapy and found the resident's splint. The resident was physically able to remove the splint himself and would do so at times. 2. During random observations on 11/17/25 at 11:51 a.m., 11/18/25 at 9:46 a.m. and 10:51 a.m., 11/20/25 at 9:38 a.m. and 11:10 a.m., and 11/21/25 at 9:40 a.m., Resident E was observed lying in bed. Her hands were contracted, fingernails long, and there were no palm protectors in place. The resident's record was reviewed on 11/18/25 at 3:09 PM. Diagnoses included, but were not limited to, Parkinson's, stroke, and epilepsy. The 8/24/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs) and transfers. A Physician's Order, dated 7/28/25, indicated palm protectors to both hands, may remove for care. Hospice to provide. A Care Plan, dated 7/30/25, indicated palm protectors to bilateral hands. The record lacked documentation of palm protectors used or refused. During an interview on 11/20/25 at 1:16 p.m., LPN 2 indicated she did not know anything about the resident's palm protectors. During an interview on 11/21/25 at 1:05 p.m., the DON indicated she did not know about the palm protectors, but would look into it. By the end of the survey, no additional information was received. 3. During random observations on 11/17/25 at 10:35 a.m. and 3:30 p.m., 11/19/25 at 9:09 a.m. and 1:43 p.m., and 11/20/25 at 9:32 a.m., Resident D was observed lying in bed. His right arm was contracted and there was a splint in his right hand. The record for Resident D was reviewed on 11/19/25 at 10:03 a.m. Diagnoses included, but were not limited to, heart failure, pain, and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs). A Physician's Order, dated 5/4/25, indicated to apply resting hand splint to the right hand for 2 hours daily or as tolerated in the morning, one time a day. The resident's record lacked documentation of the splint being removed and assessments of the skin underneath. During an interview on 11/21/25 at 9:38 a.m., LPN 3 indicated she did not do anything with the resident's hand splint, restorative care did that. During an interview on 11/21/25 at 1:07 p.m., the DON indicated splint application/removal was usually documented by the nurse on the treatment administration record (TAR). During an interview on 11/21/25 at 1:50 p.m., the restorative care coordinator indicated the resident was not receiving restorative care. A policy, titled Mobility, Range of Motion, received as current from the Nurse Consultant on 11/21/25 at 1:59 p.m., indicated, . The facility will ensure that . a resident with limited range of motion receives appropriate treatment and services to increase range of motion and / or to prevent further decrease in range of motion . 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 4 residents reviewed for accidents. (Resident 60)Finding includes:On 11/17/25 at 2:54 p.m., Resident 60 was observed getting out of bed unassisted. She had on non-skid socks and pushed her wheelchair to the bathroom. There were no non-skid strips on the floor by her bed.On 11/18/25 at 11:51 a.m., Resident 60 was lying in bed. There were no non-skid strips on the floor by her bed, and the bed was not in the lowest position.On 11/20/25 at 10:29 a.m., Resident 60 was lying in bed. There were no non-skid strips on the floor by her bed, no Dycem (anti-slip material) to her wheelchair seat, and no anti-tippers to her wheelchair.Record review for Resident 60 was completed on 11/19/25 at 3:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and nontraumatic subarachnoid hemorrhage.The Quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident was cognitively intact. The resident required supervision with bed mobility and transfers. She required partial/moderate staff assistance with walking and used a wheelchair. She had two or more falls since the prior assessment.A Care Plan, updated 8/22/25, indicated the resident was a high risk for falls. The interventions included non-skid strips next to bed, anti-tippers to the back side of the wheelchair, Dycem to the wheelchair cushion, and place bed in the lowest position.The Special Instructions tab in the resident's chart indicated the resident was a fall risk due to transferring self without assistance. Fall interventions included anti-tippers to the back of the wheelchair, Dycem to the wheelchair, and non-skid strips next to the bed.A Fall IDT Note, dated 9/24/25 at 10:59 a.m., indicated the resident had an unwitnessed fall while attempting to self-transfer from her wheelchair to her bed. The intervention was to add additional non-skid strips to the floor next to the bed.During an interview on 11/21/25 at 1:00 p.m., the Director of Nursing was made aware of the fall interventions not in place. No further information was provided.A facility policy, titled Fall Prevention and Management, indicated, .c. Safety interventions will be implemented for each resident identified and documented in medical record .Post fall documentation guidelines: .g. Post fall intervention should be documented in the medical record .k. The IDT team will meet within the next business day to discuss causative factors and implement fall interventions.3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure an urinary indwelling catheter collection bag was maintained below the level of the bladder for 1 of 3 residents reviewed for urinary catheters. (Resident 71)Finding includes: During random observations on 11/17/25 at 12:50 p.m., 11/19/25 at 9:13 a.m. and 9:50 a.m., 11/20/25 at 9:50 a.m. and 1:51 p.m., and 11/21/25 at 9:42 a.m., Resident 71 was sitting in his wheelchair next to his bed. The urine collection bag was hooked on the side of his wheelchair, near waist level. On 11/20/25 2:40 p.m., the resident was observed propelling himself in his wheelchair in the halls. The urine collection bag was hooked on the side of his wheelchair, near waist level. On 11/21/25 at 11:05 a.m., the resident was observed in the hallway, in his wheelchair. Multiple staff members walked by. The urine collection bag remained hooked on the side of his wheelchair, near waist level. The resident's record was reviewed on 11/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes, and left below the knee amputation. The Quarterly Minimum Data Set (MDS) assessment, dated 10/21/25, indicated the resident was cognitively intact for daily decision making, required moderate assist with activities of daily living (ADLs), and had an indwelling urinary catheter.A Care Plan, dated 5/4/24, indicated the resident had an indwelling catheter. Interventions included positioning the catheter bag and tubing below the level of the bladder.During an interview on 11/21/25 at 1:09 p.m., the Director of Nursing (DON), indicated the urine collection bag should be maintained lower than the level of the bladder.A policy, titled Urinary Catheter Care, received as current from the Nurse Consultant on 11/21/25 at 1:59 p.m., indicated, .Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing . 3.1-41(a)(2)

Based on record review and interview, the facility failed to provide continuous CPR (cardiopulmonary resuscitation) to a resident until EMS (Emergency Medical Services) arrived. The resident had an Advance Directive indicating the desire for CPR (full code status). The staff ceased CPR and canceled the EMS call after CPR was initiated for 7 minutes, without an order from the Resident's Physician, resulting in the death of a resident for 1 of 6 residents reviewed for Advanced Directives. The immediate jeopardy began on [DATE] when two RNs ceased CPR prior to EMS arriving at the facility and without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: Resident C's closed record was reviewed on [DATE] at 10:24 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order/Post Declination form, indicated the resident had chosen to be a full code. The form was signed by the Social Service Director on [DATE] and indicated the person making the decision was the resident. An Admission Minimum Data Set assessment, dated [DATE], indicated the resident had an intact cognitive status. A Nurse's Note, dated [DATE] at 5:05 a.m. and documented on [DATE] at 3:16 p.m., indicated the resident had shallow respirations, CPR was initiated and EMS was notified. After seven minutes of CPR, there was no pulse or respirations and the CPR was stopped. A Nurse's Note, dated [DATE] at 5:30 a.m. and documented on [DATE] at 3:22 p.m., indicated the resident's spouse was notified of the death. A Nurse's Note, dated [DATE] at 6:45 a.m., indicated the Physician's Office was notified of the resident's death. The Notification of Death form, dated [DATE], indicated the time of death was 5:25 a.m. on [DATE]. During a telephone interview on [DATE] at 12:20 p.m., RN 1 indicated she had just started the morning medication administration pass when RN 2 informed her she found the resident's pillow on the floor. They entered the room and RN 2 indicated the resident was not breathing. They started CPR, then she left the room to go to the Nurses' Station to call 911, RN 2 remained in the room and continued CPR. She then returned to the room and there was blood all over. The resident was bleeding from the mouth, nose, and rectum. RN 2 had informed her there were no respirations or pulse and directed her to cancel the EMS call. She then went back to the Nurses' Station and canceled the call. She and RN 2 had made the decision to stop the CPR. During a telephone interview on [DATE] at 2:43 p.m., RN 2 indicated she was checking her residents, she saw Resident C's foot hanging down off the side of the bed. The resident was gasping for air. She informed RN 1 the resident was not looking good. RN 1 then left the room to notify EMS and she started CPR. Blood gushed out of the mouth, nose, and anus with the first compression. She continued CPR. RN 1 returned to the room after calling EMS and assisted with the CPR. They called the TNA (Temporary Nursing Assistant) 3 in to assist. EMS had not arrived. CPR was administered for seven minutes and was stopped since he was no longer breathing. She indicated there was blood everywhere and TNA 3 assisted in caring for the resident. RN 2 was not sure who canceled EMS. She and RN 1 had both made the decision to stop the CPR due to the bleeding. During a telephone interview on [DATE] at 2:49 p.m., TNA 3 indicated RN 1 had asked her go with her to check on the resident and to assist with incontinent care. He had a reddish/brown bowel movements. They started the care and he started breathing heavily. He then stopped breathing. RN 1 left the room to call EMS and RN 2 went to get oxygen. No CPR was initiated. Post-mortem care was provided and when he was turned on his side, blood came out of his mouth. During a telephone interview on [DATE] at 8:17 a.m., the resident's spouse indicated there had been an autopsy performed on the resident. She was notified by telephone of the resident's death and informed he had heavy breathing, had a bowel movement, and was bleeding. The nurse indicated when she had gone back into the room, he had passed. She and a family friend then spoke to the Director of Nursing and two nurses over the phone later in the day and was told there was blood coming from the resident's mouth and nose, a low pulse, and then CPR was initiated. One of the nurses called 911, and the other continued CPR. CPR was completed for seven minutes and there was no pulse. The CPR was stopped and the Nurse then canceled the EMS. An Autopsy Report, received on [DATE] at 8:34 a.m. from the resident's spouse, indicated the autopsy was completed on [DATE]. The findings included, a malignant mass of the liver and there had been no evidence of CPR being performed. The cause of death was a malignant tumor of the liver. An Email, received from the County EMS and dated [DATE] at 9:57 a.m., indicated a call from the facility was received on [DATE] at 5:19 a.m. and a second call was received on [DATE] at 5:26 a.m. An interview with the Director of Nursing (DON) on [DATE] at 0:08 a.m., indicated RN 1 was called to come back to the facility to document the events of the code. She indicated it was not the facility's protocol to stop the CPR before EMS arrived/ without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All CPR events were investigated. RN 1 and RN 2 were interviewed but she had not interviewed TNA 3. There were 58 residents with Advance Directives indicating full code status residing in the facility. A facility policy, dated ,d+[DATE] and received from the DON as current, titled, Cardiopulmonary Resuscitation [CPR] and Basic Life Support [BLS], indicated if an individual was found unresponsive and without a pulse, a licensed staff person, who was certified in CPR/BLS, would initiate CPR unless there was a do not resuscitate (DNR) order. If there was not a DNR directive/order, CPR was to be initiated, a code was to be called, and EMS were to be notified. The resident's Attending Physician and family were then to be notified. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility reviewed the Advance Directives for all residents in the facility and placed all Advanced Directives in a binder on the CPR cart and ensured all Advance Directives were available in all the medical records. The facility educated 67 employees on the locations of the Advance Directives and initiating CPR for any resident with an Advance Directive indicating CPR or in the event the Advance Directive could not be found, Advance Directives and CPR were to be continued until EMS arrived at the facility, and notification of the DON/designee if CPR was initiated or a death occurred. The Administrator/or designee will continue to educate the remaining staff prior to the start of their next scheduled shift. The facility also initiated protocols for the DON/designee to investigate any death or CPR event immediately to ensure the facility policy was followed for Advance Directives. The Social Service Director/designee will audit the locations of the Advance Directives weekly. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been inserviced and monitoring of the implemented systems was ongoing. This Federal tag relates to Complaint IN 747.

Based on observation, record review and interview, the facility failed to ensure multiple stage 2 pressure ulcers did not develop on a resident assessed at severe risk for pressure ulcer development and failed to ensure pressure ulcers were assessed and treatment interventions were implemented timely after a readmission to the facility, resulting in deterioration in the pressure ulcers (Resident C) and failed to assess and revise the plan of care for pressure ulcers (Resident D) for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. During an observation on 10/21/19 at 7:55 a.m., with the Interim Wound Nurse, Resident C's treatments to multiple pressure areas were completed. The areas included, but were not limited to, two areas on the right inner knee which were not opened and had small brownish centers, the right hip with a reddish center surrounded by pink tissue, the left heel which was not open and brown in color, the left lateral hip with slough (moist dead tissue) covering the pressure area, the scrotum area which was open with red tissue present, and the right hip with a red center and pink tissue around the area. The Interim Wound Nurse also completed the treatments for the right heel, right ankle, and the top of the left foot. Resident C's record was reviewed on 10/21/19 at 11:05 a.m. The [DIAGNOSES REDACTED]. The admitted was 9/6/19. The Admission Minimum Data Set (MDS) assessment, dated 9/13/19, indicated short/long term memory problems, moderately impaired decision making skills, extensive assistance of two for bed mobility, was transferred once or twice with assistance of two, was dependent on staff for dressing, eating, hygiene, and bathing, required extensive assistance for toilet use, was incontinent of bowel, had a urinary catheter, and there were no unhealed pressure ulcers. An Admission Full Clinical/Body Observation, dated 9/6/19 at 1:32 p.m. indicated the resident was bed bound and had no pressure areas or open areas. An Admission Braden Scale (assessment for pressure ulcer risk), indicated a severe risk for pressure ulcers and a Care Plan was to be initiated. There was no documentation a base line Care Plan was initiated upon admission and no pressure ulcer prevention interventions were implemented. A Nurse's Progress Note, dated 9/10/19 at 2:50 p.m., indicated the CNA had observed an open area to the buttock and upon further assessment the following areas were observed: - Left buttock open area measured 5 cm (centimeters) x (by) 4 cm x < (less than ) 0.1 cm (depth) the wound bed is red, no necrosis, a small amount of drainage, with fragile unattached wound edges. - Open area on the scrotum measured 4 cm x 2.5 cm x <0.1 cm, with a red wound bed, no necroses, scant drainage, and fragile wound edges. - Right bunion area had intact skin, with a dry, crusted, non blanchable area, measured 1 cm x 1 cm. - Right lateral ankle had red, intact, non-blanchable area measured at 1 cm x 1 cm. - Right lateral foot with a dark read area at 1 cm x 1.5 cm. - Right heel with thick, dry, crusted skin and a dark reddish/purple area, measured 7 cm x 7 cm. - Left bunion area with dark, non-blanchable red area, measured 2 cm x 2 cm. - Left medial foot with intact skin at 1 cm x 1.5 cm. - Left heel with a 2 cm x 2 cm reddish purple area. The Physician was notified and orders received. The Event Forms, dated 9/10/19, indicated the following pressure ulcer assessments: - Right lateral foot had a dark red areas. - Right heel had an open area, reddish purple in color and measured 7 cm (centimeters) by 7 cm. - Left bunion area was dark read and measured 2 cm by 2 cm. - Left medial foot, had a dark red area which measured 1 cm by 1.5 cm. - Left lateral heel, was dry and crusted with a red wound bed, which measured 2 cm by 2 cm. - Right lateral ankle had a red wound bed and measured 1 cm by 1 cm. - Right bunion area had a red wound bed and measured 1 cm by 1 cm. - Scrotum had a red open area and measured 4 cm by 2.5 cm by <(less than) 0.1 cm depth. - Left buttock had an open area with a red wound bed, and measured 5 cm by 4 cm by <0.1 cm depth. The Physician's Orders indicated on 9/10/19, treatment for [REDACTED]. On 9/11/19 the Physician's Orders were to place a [MEDICATION NAME] (moist dressing) after cleansing with normal saline to the left buttock and scrotum, every Monday, Wednesday, and Friday. On 9/14/19 a low air loss (pressure reducing) mattress was ordered. The Wound Specialist Physician, observed and assessed the following wounds on 9/17/19: - Right Medial Heel - 1 cm x 0.9 cm x 0.8 cm, with 40% slough. The wound was debrided (necrotic tissue removed) - Right Lateral Ankle - 1 cm x 1 cm unstageable deep tissue injury (DTI) (pressure injury under intact skin) - Left medial foot - DTI, 2.5 cm x 1.4 cm. - Left distal medial foot - DTI , 1 cm x 8 cm. - Left lateral foot - DTI, 1.3 cm x 0.5 cm. - Right plantar Heel - DTI, 2.5 cm x 2 cm. - Posterior scrotum - 2 cm x 2 cm, 100% dermis (second layer of skin) - Left ischium - DTI, 5 cm x 4.3 cm - wound evolving not clear if necrotic or injured tissue at this time, suspect necroses by the next week. - Right Ischium - DTI, 1.2 cm x 2 cm. A Care Plan, initiated on 9/26/19, indicated the resident was a risk for pressure ulcers. The approaches included, conduct a systematic skin inspection - there was a blank spot to place the frequency of the skin inspections (weekly, daily, etc), turn and reposition, and specialty mattress. A Nurse's Progress Note, dated 9/23/19 at 3:55 p.m., indicated the resident was transferred to the hospital related to an urinary tract infection. A Nurse's Progress Note, dated 10/11/19 at 10:57 p.m., indicated the resident had returned to the facility from the hospital, with orders for an antibiotic for the urinary tract infection. The Re-Admission - Full clinical/Body Observation was not completed until 10/15/19 at 2:54 p.m., which indicated the resident had open areas on the right medial heel, right lateral ankle, left medial top of foot, left distal top of foot, left lateral top of foot, right heel plantar aspect, scrotum, sacrum/ right and left ischium, left medial leg, left heel, right knee, right medial upper knee, left lateral hip, and right hip. There was no assessment of the color, size, location of the wounds upon re-admission into the facility from the hospital. There were no Physician's Orders for treatment of [REDACTED]. A Nurse's Progress Note, dated 10/11/19 at 5:30 p.m., recorded as a late entry on 10/15/19 at 11:08 p.m., indicated the resident had returned to the facility. The resident was placed in isolation related to an urinary tract infection, a head to toe assessment was completed and an order was received to continue prior wound dressing orders and to dress the newly admitted wounds with a dry dressing until the Wound Specialist Physician assessed the wounds. The Medication Administration Record [REDACTED]. The Wound Specialist Physician assessed the wounds on 10/15/19 as follows: - Right Medial Heel - 0.5 cm x 0.5 cm, diabetic wound, improved with dried [MEDICATION NAME] exudate. - Right Lateral Ankle -3.5 cm x 1.5 cm DTI and deteriorated. an order for [REDACTED].>- Left medial foot - resolved - Left distal medial foot - resolved - Left lateral foot - 6.7 cm x 2.5 cm, DTI and deteriorated. an order for [REDACTED].>- Right plantar Heel - 3.5 cm x 1 cm, DTI, and improved. an order for [REDACTED]. - Posterior scrotum - 1.5 cm x 2 cm x 2 cm, improved with 100% granulated tissue. an order for [REDACTED]. - Left ischium - 5.5 cm x 4.5 cm with 100% necrotic tissue, deteriorated and a debridement was completed. an order for [REDACTED]. - Right Ischium - was resolved. - Left Heel - a new DTI, 2 cm x 2.5 cm. an order for [REDACTED].>- Right upper knee - a new DTI, 1 cm x 1.3 cm. an order for [REDACTED].>- Right lower knee - a new DTI, 0.5 cm x 0.5 cm. an order for [REDACTED].>- Left lateral hip - a new unstageable necrotic pressure area, 5 cm x 4 cm, with 100% necrosis. an order for [REDACTED]. - Right lateral hip - a new DTI, 4 cm x 3 cm. an order for [REDACTED]. - Left lower medial shin - a new DTI, 7.5 cm x 2 cm. an order for [REDACTED]. The Director of Nursing (DON) and the MDS Nurse were interviewed on 10/21/19 at 1:40 p.m. The DON and MDS Nurse indicated there had been no baseline Care Plan written and available with interventions to prevent pressure areas and the resident was assessed as a high risk for pressure areas. The MDS Nurse indicated pressure areas were found on 9/10/19, a Care Plan for pressure ulcer risk was not initiated until 9/26/19 and the plan of care was not specific when to complete skin assessments. During an interview on 10/21/19 at 2:25 p.m., the DON indicated the pressure wounds were not assessed on 10/11/19 when the resident returned from the hospital. The Wound Nurse had terminated her employment at the facility and there had not been another Wound Nurse. During an interview on 10/21/19 at 3:10 p.m., the DON indicated a thorough/accurate assessment had not been completed for the pressure areas on 10/11/19 and the assessment entered on the re-admission assessment was dated 10/15/19. There were also no treatments completed on the wounds upon return from the hospital on [DATE] until after the Wound Specialist Physician assessed the wounds on 10/15/19. 2. During an observation on 10/21/19 at 9:02 a.m., the Interim Wound Nurse completed Resident D's ordered treatments to the pressure areas on the right heel and sacrum. The area on the sacrum was open and the treatment consisted of cleansing with normal saline and then a collagen patch was applied. The Right heel was red around a darkened area. Skin prep was applied then a kerlix gauze wrap was applied. Resident D's record was reviewed on 10/21/19 at 3:39 p.m. The [DIAGNOSES REDACTED]. The resident had a re-admission into the facility on [DATE]. The re-admission Full Clinical/Body Observation, dated 8/9/19 at 7:01 p.m., indicated there were no pressure/open areas. A Significant Change MDS assessment, dated 8/16/19, indicated there were no unhealed pressure ulcers. An Event Charting, dated 8/19/19, indicated an open area was observed on the coccyx, which measured 1.5 cm by 0.5 cm. there was no description of the area. An Event Charting, dated 8/26/19, indicated a DTI was found on the right heel. There was no description or measurement of the area. A Quarterly MDS assessment, dated 9/13/19, indicated an intact cognition, required extensive assistance with bed mobility, dressing, and hygiene, was dependent for toilet assistance and bathing, was incontinent of bowel and bladder, had one stage two (superficial) pressure ulcer present on admission/re-entry and one unstageable pressure ulcer present on admission/re-entry. The Care Plan, dated 5/19/15, indicated a risk for pressure ulcers. The interventions included, conduct weekly skin inspections, provide incontinence care, report skin breakdown. The Care Plan had not been revised to include the actual pressure ulcers present. There were no further assessments of the pressure areas until a Nurse's Progress Note, dated 9/12/19 at 4:37 p.m., which indicated the coccyx (now called the sacrum) was 3 cm x 5 cm x 0.3 cm, a pale wound bed and scant serous drainage. The right heel area was reddish purple and measured 3 cm x 4 cm. The Wound Management Forms indicated the weekly assessments of the pressure ulcers began on 9/16/19. The right heel pressure area was present on admission ( found on 8/26/19), was measured weekly with the last measurement on 10/15/19 at 1.5 cm x 1.5 cm, closed and the wound was stable. The sacrum pressure area, was present on admission (found on 8/19/19), the last measurement was on 10/15/19 and was 3.7 cm x 0.5 cm x 0.2 cm with 80% slough. During an interview on 10/21/19 at 4:53 p.m., the DON indicated no other pressure assessments were located. A facility policy, dated 1/2017, titled, Prevention of Pressure Wounds, received from the DON as current, indicated, .The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and addressed .identify risk factors for pressure injury development .Routinely assess and document the condition of the resident's skin per facility wound and skin care program .immediately report any signs of developing pressure injury . This Federal Tag relates to Complaint IN 443. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident received adequate assistance to prevent accidents, related to a resident who required extensive assistance of two staff members for bed mobility receiving care from only one staff member, which resulted in the resident falling from the bed and sustaining a [MEDICAL CONDITION] femur (above the knee) for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: Resident D's record was reviewed on 7/1/19 at 10:22 a.m. The [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment, dated 2/15/19, indicated a moderately impaired cognition status, no behaviors, required extensive assistance of two for bed mobility and transfers, and had no falls since the last assessment. A Quarterly MDS assessment, dated 5/16/19, indicated an intact cognition status, no behaviors, required extensive assistance of two for bed mobility and transfers, and had a fall with a major injury. A Care Plan, dated 2/21/18, indicated a risk for falls. The interventions, dated 2/21/18, indicated keep the call light in reach at all times, skilled therapy, keep personal items and frequently used items within reach, and avoid restraints. On 4/30/19 a bolster mattress and staff education were added as interventions. A Nurse's Progress Note, dated 4/29/19 at 2:30 p.m., indicated the CNA (CNA 2) who was providing care called the Nurse into the room. Upon entering the room the resident was observed on her stomach with her left arm under her chest, on the floor. The resident indicated her left knee was, broke. The resident was transferred to the Hospital. A Nurse's Progress Note, dated 4/29/19 at 5:47 p.m., indicated an admission into the hospital due to a fracture. The emergency room Physician's Note, dated 4/29/19, indicated a closed [MEDICAL CONDITION] end of the left femur. A Physician's History and Physical from the Hospital, dated 4/30/19, indicated a knee immobilizer was placed on the left leg due to the resident was not a surgical candidate. The facility investigation of the fall, dated 5/2/19, indicated care was being completed and the resident fell out of the bed. The CNA (CNA 2) was bathing the resident, and asked the resident to turn on her side and when she turned over she fell from the bed. The CNA indicated she was putting a sheet on the bed and the resident's leg began to slide from the bed. She attempted to prevent the fall and was unable to hold the resident and the resident fell to the floor. The Care Card (list of personalized interventions for resident care) at the time of the fall indicated the resident was a two person assistance for bed mobility. During an observation on 7/1/19 at 10:14 a.m., CNA 1 was providing care to Resident D and no other staff were in the room. The right side of the bed was against the wall. There were mobility bars on both sides of the bed. CNA 1 asked the resident to reach toward the transfer bar on the right side and she assisted the resident to her right side. After she provided care CNA 1 assisted the resident to lie on her back, then pulled the bed from the wall, stood between the wall and the bed and assisted the resident to roll onto her left side to remove the soiled linen. A Care Card, dated 6/19/19, indicated the resident required two assistance with bed mobility. A Physical/Occupational Therapy Progress and Updated Plan of Care Note, dated 6/7/19, indicated a high risk for falls, and positioning required two assistance. During an interview on 7/1/19 at 10:29 a.m., CNA 1 indicated the Care Cards have the interventions on how much help is needed with care for each resident. During an interview on 7/1/19 at 10:49 a.m. with a Family Member and the resident, the Family Member indicated she visited daily and there was usually only one person who assisted the resident with care. The Resident then indicated sometimes there were two staff members to help her with the care. A facility policy, dated 8/2008, titled, Fall and Fall Risk Managing, received from the RN Corporate Consultant as current, indicated, .Staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . This Federal Tag relates to Complaint IN 923. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents, related to a bed alarm not being turned on, and a resident attempted to transfer herself, and fell resulting in pain and a left orbital floor and medial orbital wall fractures (facial fractures). The resident had not been thoroughly assessed, which resulted in a delay of diagnostic testing to diagnose the fractures, for 1 of 3 residents reviewed for falls in a total sample of 3. (Resident #B) Findings include: During an interview on 12/29/14 at 2:55 a.m., RN #1 indicated Resident #B had a fall with an injury and the resident was in the hospital with an orbital fracture. RN #1 indicated Resident #B's roommate had activated the call light to alert the staff Resident #B had fallen. RN #1 indicated the resident had been found on the floor next to the bathroom floor by CNA #2 and CNA #2 had alerted her to the resident's fall. RN #1 indicated Resident #B had slight bleeding from the nose and had no signs of pain. RN #1 indicated the resident had been observed closely and when the resident's family came in approximately 30-40 minutes later, the resident showed signs of pain and was sent to the hospital. RN #1 indicated the resident had facial swelling and had been being treated for [REDACTED]. RN #1 indicated she was unsure if the resident's safety alarm had been activated. During an interview on 12/29/14 at 3:13 a.m., RN #1 indicated the resident's fall was unwitnessed so neurological assessments were started on the resident. RN #1 indicated the resident was monitored every 15 minutes. RN #1 indicated when the resident's family came in the resident flinched when the family attempted to touch the resident's face. RN #1 indicated she paged the Resident's Physician and had not received a call back from the Physician. RN #1 indicated she had not attempted to page the Physician again. RN #1 indicated she did not think the resident needed to be sent out until the resident showed signs of pain. RN #1 indicated the resident had a, "little blood", from the nose, the resident's face was not deformed, and there was no bruising. RN #1 indicated the resident had facial swelling but the resident had swelling of the face prior to the fall. Resident #B's record was reviewed on 12/29/14 at 4:17 a.m. The resident's [DIAGNOSES REDACTED]. The 14-Day Minimum Data Set Assessment, dated 12/10/14, indicated the resident's decision making skill were severely impaired, required extensive assistance with one staff for transfers, had ambulated one time with one assistance in the past seven days, and had no falls. A Fall Assessment, dated 11/26/14, indicated the resident had a high risk for falls, with a score of 13 (score over 10-high risk). A care plan, dated 11/26/14, indicated the resident had a potential for falls, the interventions included, 11/26/14-bed alarm. A CNA Care Card, dated 12/12/14, indicated Resident #B had an alarm to the bed and the wheelchair. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Physician's Progress Note, dated 11/28/14, indicated the resident had a possible medication reaction, which caused the facial swelling and the Vasotec (cardiac medication) had been discontinued and the resident was ordered a Medrol Pack. A Nurses' Progress report, dated 12/06/14 at 5:42 a.m., indicated there was no facial swelling present. The Weekly Skin Observation forms, dated 12/05/14, 12/09/14, and 12/12/14 indicated there was no facial swelling present. There was no further documentation to indicate the resident had facial swelling from 12/12/14 through 12/16/14. A Post Fall Note, dated 12/16/14 at 2:40 a.m., indicated the resident had a small amount of blood from the nasal area, had swelling of the left side of the face and eye area and had normal range of motion of the extremities. A Nurses' Note, dated 12/16/14 at 3:16 a.m., indicated, "...Observed resident on the floor next to the bathroom door in a sitting position...Resident able to move all limbs without difficulty. Small amount of blood from nasal area noted. Swelling to left side of face and eye area noted...Cleaned blood from nasal area...Left message for resident (Family Member Name)." A Nurses' Note, dated 12/16/14 at 3:35 a.m., indicated, "Resident in bed asleep and easily aroused. No s/s (signs and symptoms) of hyper/[DIAGNOSES REDACTED]." There was no further assessment of the resident's facial swelling/injuries. A Nurses' Note, dated 12/16/14 at 4:36 a.m. (one hour later), indicated, "Resident in bed awake and alert. Facial grimacing (sic) noted at this time. Resident is guarding left side of face. (Family Member Name) at bedside. Sending to (Hospital Name) ER (emergency room ) for evaluation." A Nurses' Note, dated 12/16/14 at 5:41 a.m. (three hours after the fall), indicated, "(Ambulance Name)...here to transfer resident...Facial grimacing (sic) noted at this time..." The Neuro Check Form, dated 12/16/14, indicated a neurology assessment had been completed on 12/16/14 at 2:50 a.m., 3:50 a.m., and 4:50 a.m. with no changes in status. There was a lack of documentation to indicate the resident had been assessed for increased swelling, bleeding, bruising, pain, and neurological status every 15 minutes as indicated by RN #1. A CT Scan of the facial bones, dated 12/16/14, indicated, "...Blowout fracture of the left orbital floor...Fracture also involves the medial wall of the left orbit. Possible nondisplaced fracture of the posterior wall of the left maxillary sinus. Blood in the left maxillary sinus." A Hospital Otolaryngology consult, dated 12/17/14 at 1:04 p.m., indicated, "...Eye:...Left periorbital edema/ecchymosis (bruising)...Small but displaced orbital fractures. No surgical intervention is indicated..." A Charge Nurse Fall Investigation, dated 12/16/14 at 3 a.m., indicated the cause of the fall was unknown. The intervention on the care card indicated bed alarm and mattress on floor. The investigation indicated the Nurse had not heard the alarm sounding due to the call light in the resident's room was on at the time of the fall and the staff were responding to the call light and observed the resident on the floor. Further written investigation, received from the Director of Nursing (DoN) on 12/29/14 at 4:56 a.m., indicated CNA #2 responded to the call light and found the resident sitting on the floor. CNA #2 indicated the resident had received incontinent care around 12 a.m. CNA #2 indicated the resident was visual checked at 2 a.m. and the resident had been sleeping. CNA #2 indicated the bed alarm had not been activated. During an interview on 12/29/14 at 5:39 a.m., the DoN indicated CNA #2 indicated to her the alarm had not been sounding and indicated she had not checked to ensure the alarm was on. The DoN indicated the alarm was checked for proper functioning the morning of 12/16/14 and the alarm when on, worked without problems. The DoN indicated she completed an audit on 12/20/14 (four days later) to ensure all alarms were on and functioning and provided education to CNA #2 for ensuring the alarms were turned on. The DoN indicated no other interventions were initiated to prevent others from being affected by not having their alarms on. The DoN indicated she was unaware the resident's Physician had not returned the call from the facility. During a second interview with RN #1, on 12/29/14 at 6:32 a.m., RN #1 indicated she had attempted to call the resident's Physician first, then paged the Medical Director at 3:15 a.m. and left a message. RN #1 indicated the Physician's had not returned the calls to the facility by the time she left at 7 a.m. RN #1 indicated the resident had no open areas on her nose, and the blood had come from the nares. RN #1 indicated the resident had no further bleeding, had no signs of pain and did not feel the resident required an emergency room visit. RN #1 indicated the resident had been asleep after the fall and she had not checked the resident for an hour. RN #1 indicated the ambulance had not been called as a 911 call, so it did not respond immediately. During an interview on 12/29/14 at 7:45 a.m., CNA #2 indicated the resident's alarm had not been activated. CNA #2 indicated the alarm was turned off. CNA #2 indicated she was unaware the resident had a bed alarm intervention and only saw the alarm when the Medics transferred the resident. CNA #2 indicated she had not seen nor checked the alarm during her shift (10:30 p.m. to 7 a.m.). CNA #2 indicated she had not looked at the care card for the resident's hallway. CNA #2 indicated the resident had a little bleeding from the nose and the left eye was swollen. CNA #2 indicated the resident had not exhibited pain at the time of the fall. This Federal Tag relates to Complaint IN 659. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide to the necessary treatment and services for residents to attain or maintain the highest practicable physical well-being related to the failure to ensure Licensed Nursing staff had knowledge of the indication of the use of a medication prior to preparing and administering the medication to a resident. This resulted in the administration of a medication used to lower elevated potassium levels to a resident with a critically low potassium level. The resident was found unresponsive and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated. (Resident #B) (LPN #3) Findings include: The record for Resident #B was reviewed on [DATE] at 1:30 p.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the [DATE] admission Physician orders [REDACTED]. [MEDICATION NAME] (a diuretic) 80 milligrams once a day at 9:00 a.m. and Potassium [MEDICATION NAME] & Chloride 25 milliequivalent tablet one time a day at 9:00 a.m. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the laboratory test results indicated a BMP was collected by the Laboratory on [DATE] at 5:45 a.m. The test results indicated the resident's Potassium level was 2.7 (normal level 3XXX,[DATE].1). The level of 2.7 was identified as a Critical level. The report indicated the critical level was called to, faxed, and read back to LPN #3 on [DATE] at 3:52 p.m. There was handwritten documentation on the bottom of the above report. The documentation indicated the Physician was notified, new orders were received for Kionex (a medication to lower high potassium levels) 30 mls (milliliters) STAT and 30 mls at hour of sleep. The hand written documentation also indicated a repeat potassium laboratory test was to be completed on [DATE] and the Physician was to be called with the results and all orders were verified and carried out. LPN #3 signed her signature under the above documentation with the date of [DATE]. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the [DATE] Nursing Progress Notes indicated an entry was made at 8:28 p.m. This entry indicted a call was received from (Laboratory staff members name) reporting a critical low potassium level of 2.7, the Doctor was called, and orders were received for Kionex 15 grams/60 mls to give 30 mls Stat and 30 mls at bedtime. The entry also indicated all orders were verified and carried out and Kionex 15 grams/60 ml was pulled from the EDK (Emergency Drug Kit). The entry was made by LPN #3. An EDK sign out sheet was completed by LPN #3 on [DATE] at 5:00 p.m. The sheet indicated LPN signed as removing Kionex 15 gms/60 ml from the EDK for Resident #B. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials were entered on the above entry. The entry did not indicate the resident refused the medication, spit out the medication, or the medication was not given. When interviewed on [DATE] at 9:55 p.m., the Nurse Consultant indicated the resident's [DATE] critical Potassium level of 2.7 was called to LPN #3 on [DATE] at 3:52 p.m. The Nurse Consultant indicated the LPN was interviewed and had been suspended. The Nurse Consultant indicated the LPN was interviewed and stated she received the call from the lab and attempted to call the Physician and then spoke to him around 7:00 p.m. and received orders from the Physician. The Nurse Consultant indicated the LPN indicated the Physician was talking fast and she could not understand what he was saying and the fourth time she asked him he started to spell the name of the medication out to her and the LPN stated the said the letters K, A, Y, E . In the interview the LPN also indicated she had never heard of the medication and it was around 9:30 p.m. when she went to administer the medication to the resident. The LPN indicated she went to the EDK with the spelling the Physician gave and she had to ask the Evening Supervisor about the name and the Supervisor told her the medication name would be under "Kionex." The LPN indicated she then prepared 30 mls of the medication but the resident stuck her tongue in the medication cup and refused to drink it and she then went back to call the Physician to inform him the resident refused and the Physician told her he said K-lyte and not [MEDICATION NAME] and this phone call was around 10:30 p.m. LPN #3 indicated at the time there was about 25 cc's left in the med cup and she threw it away without having a witness. The LPN stated when the midnight shift Nurse (RN #4) went into the resident's room about 10:30 p.m. she yelled out there was a Code, the crash cart was pulled and CPR was initiated until the paramedics arrived. Continued interviewed with the Nurse Consultant at the above time, indicated LPN #3 indicated she did not know [MEDICATION NAME] decreased Potassium levels as she had never given the medication before. The Nurse Consultant indicated they had called the LPN to come back to facility for further interview and the LPN did not return to the facility. The Nurse Consultant indicated the facility request the Physician to come to the facility to further review the incident. The Physician indicated he reviewed his phone calls from [DATE] and indicated he had received a call at 4:27 p.m. that lasted 16 minutes. The Physician indicated this call was from LPN #3 as he recalled how he had to keep repeating himself to the Nurse during this call as she kept asking him what he said. The Physician indicated he finally said " K L Y T E , spelling out the letters and saying 25 milliequivalent. The Physician indicated he received the next call at 10:43 p.m. when the Nurse reported she had given [MEDICATION NAME] and wanted to know what she should do. The Physician indicated he responded to the Nurse that he had not given the order for [MEDICATION NAME] as that would decrease the potassium level. Continued interview with the Nurse Consultant at this time, indicated RN #4 had also been interviewed. The Nurse Consultant indicated RN #4 told them when receiving report from LPN #3 on [DATE] around 10:30 - 10:55 p.m., the LPN told her Resident #B's potassium level was 2.7 and she had given [MEDICATION NAME]. RN #4 indicated she asked the LPN if she was sure it was [MEDICATION NAME] and the LPN said yes. The RN indicated she then told the LPN she needed to call the Physician because [MEDICATION NAME] was to lower the potassium and that is when LPN called the Physician and RN #4 went to assess the resident, found the resident unresponsive breathing shallow, without a palpated pulse, yelled out for other staff to call 911, and CPR was started by herself and LPN #3 until the paramedics arrived. The RN also reported that LPN #3 told her the resident did not drink all of the [MEDICATION NAME] medication. This federal tag relates to Complaint IN 794. 3XXX,[DATE](a)

Based on record review and interview the facility failed to ensure the resident's drug regime remained free of unnecessary medications related to the continued administration of cardiac medications without adequate monitoring of vital signs for 1 of 4 residents reviewed for unnecessary medications in the sample of 15. (Resident #B) Findings include: 1. The record for Resident #B was reviewed on 8/27/13 at 1:30 p.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the 8/24/13 admission Physician orders indicated there were orders for the resident to receive the following medications: [REDACTED] -[MEDICATION NAME] HCL (a cardiac medication to control irregular heart beats) 200 milligrams twice day at 9:00 a.m. and 5:00 p.m. -Carvedilol (a cardiac medication to lower blood pressure) 12.5 milligrams twice a day at 9:00 a.m. and 5:00 p.m. -Spironalactone (a diuretic) 25 milligrams - give 1/2 tablet once a day at 9:00 a.m. -[MEDICATION NAME] (a diuretic medication to lower blood pressure) 80 milligrams once a day at 9:00 a.m. -[MEDICATION NAME] (a cardiac medication to decrease heart rate and control irregular heart rates) 0.125 milligrams once a day at 9:00 a.m. -[MEDICATION NAME](a diuretic medication to lower blood pressure) 5 milligrams once a day at 9:00 a.m. There were no Physician ordered parameters to hold the above medications for low heart rates or low blood pressure readings. There were no Physician orders for checking the resident's blood pressure or heart rate prior to administering the above medications. All of the above ordered medications were signed out as administered to the resident on 8/25/13. All of the above ordered medications were signed out as administered to the resident on 8/27/13 except the 9:00 a.m. dose of [MEDICATION NAME] .125 milligrams. Review of the 8/2013 Vital Signs record indicated the resident's pulse (heart rate) rates were recorded as below 60 beats per minute on the following dates/times: 8/25/13 at 5:09 a.m.- Pulse 46 and irregular 8/25/13 at 10:00 a.m.- Pulse rate 58 8/27/13 at 3:15 p.m.- Pulse rate 40 The 2010 Nursing Spectrum Drug Handbook was reviewed. The Drug Handbook indicated [MEDICATION NAME] was an antiarrthymic medication and indications for the use of the medication included, heart failure, [MEDICAL CONDITION] and [MEDICAL CONDITION] flutter. Adverse reactions to [MEDICATION NAME] included [MEDICAL CONDITION] (slow heart rate). Patient monitoring included assessing the patient's apical pulse regularly for one full minute. Patient monitoring also included to withhold the medication for a heart rate less than 60 beats/minute and notify the prescriber. The 2010 Nursing Spectrum Drug Handbook also indicated [MEDICATION NAME] was an antiarrthymic medication and indications for the use of the medication included,ventricular arrthymias. Patient monitoring included checking the resident's pulse and heart rhythm regularly. The 2012 Nursing Spectrum Drug Handbook also indicated Carvedilol as an antihypertensive medication and patient monitoring included monitoring vital signs. Contraindications to the use of the medication included [MEDICAL CONDITION](a slow heart rate). When interviewed via telephone on 8/29/13, the resident's Physician indicated he had not been informed of the resident's heart rates being below 60 since she was admitted . When interviewed on 8/29/13 at 2:10 p.m., the Nurse Consultant indicated inservicing was initiated on 8/28/13 related to the administration of medications, [MEDICATION NAME], and procedure for administering unfamiliar medications. The Nurse Consultant indicated the facility did not address the residents other medications or heart rates as this time as the main concern was related to the administration of the [MEDICATION NAME] medication. This federal tag relates to Complaint IN 794. 3.1-48(a)(3) 3.1-48(a)(5)

Based on record review and interview, the facility failed to ensure residents remained free of significant medication errors related to not administering the correct medication as ordered by the Physician for 1 of 5 resident's reviewed for the administration of medications in the sample of 15. This resulted in the resident being found unresponsive with shallow breathing and the absence of a palpated pulse requiring the initiation of CPR (Cardio [MEDICAL CONDITION] Resuscitation) and transport to the hospital via EMS (Emergency Medical Services) ambulance. (Resident #B) (LPN #3) Findings include: The record for Resident #B was reviewed on [DATE] at 1:30 p.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the [DATE] admission Physician orders [REDACTED]. [MEDICATION NAME] (a diuretic) 80 milligrams once a day at 9:00 a.m. Potassium [MEDICATION NAME] & Chloride 25 milliequivalent tablet one time a day at 9:00 a.m. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [DATE] Nursing Progress Notes indicated the first entry was made at 2:00 p.m. This entry indicated the resident was admitted to the facility via ambulance and was in stable condition. The entry also indicated the Physician was notified of the admission and orders were received for a BMP (laboratory test) to be drawn every three months. Review of the laboratory test results indicated a BMP was collected by the Laboratory on [DATE] at 5:45 a.m. The test results indicated the resident's Potassium level was 2.7 (normal level 3XXX,[DATE].1). The level on 2.7 was identified as a Critical level. The report indicated the critical level was called to, faxed, and read back to LPN #3 on [DATE] at 3:52 p.m. There was handwritten documentation on the bottom of the above report. The documentation indicated the Physician was notified, new orders were received for Kionex (a medication to lower high potassium levels) 30 mls (milliliters) STAT and 30 mls at hour of sleep. There hand written documentation also indicated a repeat potassium laboratory test was to be completed on [DATE] and the Physician was to be called with the results and all orders were verified and carried out. LPN #3 signed her signature under the above documentation with the date of [DATE]. A physician's orders [REDACTED].#0 mls at bedtime one time. Another physician's orders [REDACTED]. Review of the [DATE] Nursing Progress Notes indicated an entry was made at 8:28 p.m. This entry indicted the a call was received from (Laboratory staff members name) reporting a critical low potassium level of 2.7, the Doctor was called, and orders were received for Kionex 15 grams/60 mls to give 30 mls Stat and 30 mls at bedtime. The entry also indicated all orders were verified and carried and Kionex 15 grams/60 ml was pulled from the EDK (Emergency Drug Kit). This entry was completed by LPN #3. An EDK sign out sheet was completed by LPN #3 on [DATE] at 5:00 p.m. The sheet indicated LPN signed as removing Kionex 15 gms/60 ml from the EDK for Resident #B. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials were entered on the above entry. The entry did not indicate the resident refused the medication, spit out the medication, or the medication was not given. The [DATE] EMS ambulance service Final Patient Care Report was reviewed on [DATE]. The report indicated the ambulance service arrived at the facility on [DATE] at 11:00 p.m. The report indicated the ambulance was dispatched to the facility related to a full arrest with CPR in progress per the facility staff, CPR was paused, the patient was pulseless and anemic(not breathing), and CPR was resumed. The report also indicated the facility staff reported the resident had a low potassium level and was supposed to be given potassium but was mistakenly given [MEDICATION NAME]. The resident was transported to hospital. When interviewed on [DATE] at 9:55 p.m., the Nurse Consultant indicated the resident's [DATE] critical Potassium level of 2.7 was called to LPN #3 on [DATE] at 3:52 p.m. The Nurse Consultant indicated the LPN was interviewed and had been suspended. The Nurse Consultant indicated the LPN was interviewed and stated she received the call from the lab and attempted to call the Physician and then spoke to him around 7:00 p.m. and received orders from the Physician. The Nurse Consultant indicated the LPN indicated the Physician was talking fast and she could not understand what he was saying and the fourth time she asked him he started to spell the name of the medication out to her and the LPN stated the said the letters K, A, Y, E . In the interview the LPN also indicated she had never heard of the medication and it was around 9:30 p.m. when she went to administer the medication to the resident. The LPN indicated she went to the EDK with the spelling the Physician gave and she had to ask the Evening Supervisor about the name and the Supervisor told her the medication name would be under "Kionex." The LPN indicated she then prepared 30 mls of the medication but the resident stuck her tongue in the medication cup and refused to drink it and she then went back to call the Physician to inform him the resident refused and the Physician told her he said K-lyte and not [MEDICATION NAME] and this phone call was around 10:30 p.m. LPN #3 indicated at the time there was about 25 cc's left in the med cup and she threw it away without having a witness. The LPN stated when the midnight shift Nurse (RN #4) went into the resident's room about 10:30 p.m. she yelled out there was a Code, the crash cart was pulled and CPR was initiated until the paramedics arrived. Continued interviewed with the Nurse Consultant at the above time, indicated LPN #3 indicated she did not know [MEDICATION NAME] decreased Potassium levels as she had never given the medication before. The Nurse Consultant indicated they had called the LPN to come back to facility for further interview and the LPN did not return to the facility. The Nurse Consultant indicated the facility request the Physician to come to the facility to further review the incident. The Physician indicated he reviewed his phone calls from [DATE] and indicated he had received a call at 4:27 p.m. that lasted 16 minutes. The Physician indicated this call was from LPN #3 as he recalled how he had to keep repeating himself to the Nurse during this call as she kept asking him what he said. The Physician indicated he finally said " K L Y T E , spelling out the letters and saying 25 milliequivalent. The Physician indicated he received the next call at 10:43 p.m. when the Nurse reported she had given [MEDICATION NAME] and wanted to know what she should do. The Physician indicated he responded to the Nurse that he had not given the order for [MEDICATION NAME] as that would decrease the potassium level. Continued interview with the Nurse Consultant at this time, indicated RN #4 had also been interviewed. The Nurse Consultant indicated RN #4 told them when receiving report from LPN #3 on [DATE] around 10:30 - 10:55 p.m., the LPN told her Resident #B's potassium level was 2.7 and she had given [MEDICATION NAME]. RN #4 indicated she asked the LPN if she was sure it was [MEDICATION NAME] and the LPN said yes. The RN indicated she then told the LPN she needed to call the Physician because [MEDICATION NAME] was to lower the potassium and that is when LPN called the Physician and RN #4 went to assess the resident, found the resident unresponsive breathing shallow, without a palpated pulse, yelled out for other staff to call 911, and CPR was started by herself and LPN #3 until the paramedics arrived. The RN also reported that LPN #3 told her the resident did not drink all of the [MEDICATION NAME] medication. This federal tag relates to Complaint IN 794. 3XXX,[DATE](b)(9) 3XXX,[DATE](c)(2)

Based on observation, record review, and interview, the facility failed to ensure proper hydration was provided for a resident receiving feeding through a gastrostomy ( a surgically inserted tube placed into the stomach to provide nutrition) tube related to failing to initiate recommendation made by the Registered Dietitian to increase water flushes for hydration for 1 of 3 residents reviewed to be at risk for dehydration in the sample of 5. This resulted in the resident requiring emergency hospitalization related to critical laboratory levels. The facility also failed to ensure the resident was evaluated by a Registered Dietitian upon return from the hospitalization . (Resident #E) Findings include: On 6/12/13 at 4:00 p.m., Resident #E was observed in bed. The resident was receiving tube feeding of Glucerna 1.2 at 75 cc (cubic centimeters) via an PEG (percutaneous endoscopic gastrostomy) tube. The record for Resident #E was reviewed on 6/13/14 at 9:50 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was admitted from the hospital. The resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. Dehydration Risk Assessments were completed on 4/26/13 and 6/3/13. The 4/26/13 Dehydration Risk Assessment indicated the resident's score was 10 (High Risk). The 6/3/13 Dehydration Risk Assessment indicated the resident's score was 10 (High Risk). Review of the 6/2013 Physician orders [REDACTED]. An order was written on 6/11/13 to flush the gastrostomy tube with 200 cc's of water every shift for a total of 600 cc's daily. A Nutritional Risk Assessment was completed by the Registered Dietitian on 4/29/13. The assessment indicated the resident was NPO(unable to receive food or fluids by mouth). The assessment also indicated the resident's Mini Nutrition Assessment indicated the resident was malnourished. The assessment also indicated the resident was receiving 100 cc's of water flush per the gastrostomy tube per shift and the total water being infused was below the residents estimated needs for proper hydration. Recommendations made by the Registered Dietitian included to increase the water flush to 200 cc's per shift. Review of the 4/2013 and 5/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also received [MEDICATION NAME] (an antibiotic) 1 Gram once a day for 10 days beginning on 4/27/13. The antibiotic was ordered to treat a urinary tract infection. Review of the 4/2013 and 5/2013 Nursing Progress Notes indicated there was no documentation of the 4/29/13 Registered Dietitian's recommendations to increase the water flushes being addressed. Nutrition/Dietary Progress Notes were completed by the Dietary Manager on 5/3/13, 5/13/13, and 5/16/13. There was no documentation in the above Progress Notes related to the Registered Dietitian's 4/29/13 recommendations to increase the water flushes. Review of the 5/2013 laboratory tests indicated a renal function panel was completed on 5/28/13. The results were as follows: BUN: 106 (Critical level) Normal level (8-28) Creatinine: 1.88 (High level) Normal level (0.40-1.60) Potassium: 5.7 (High level) Normal level (3.7-5.1) Sodium: 159 (Critical level) Normal level (136-147) The 5/2013 Nursing Progress Notes were reviewed. There was an entry made on 5/28/13 at 8:45 p.m. The entry indicated the Physician was notified of the above laboratory test results. Orders were obtained from the Physician to send the resident to the hospital emergency room for evaluation and treatment A hospital Discharge Summary note for the resident's 5/28/13 hospitalization was reviewed. The Discharge Summary note was completed by the resident's Physician. The note indicated the resident's admitting [DIAGNOSES REDACTED]. The resident's treatment course included hydration and antibiotics. The note also indicated the following laboratory tests were as follows: 5/28/13 at 10:24 p.m. BUN: 112 Creatanine: 2.1 Sodium: 165 Urine culture: greater then 100,000 cfu/ml Proteus Mirabilis (a infection) A Nephrology Consult Note was completed in the hospital on [DATE]. The note indicated the Nephrologist indicated the reasons for the consultation were acute [MEDICAL CONDITIONS], dehydration, and urinary tract infection When interviewed on 6/13/13 at 11:45 a.m., the Nurse Consultant indicated the Registered Dietitian's recommendations to increase the water flushes were not addressed prior to the resident being admitted to the hospital with [REDACTED]. The Nurse Consultant also indicated there were no Dietary assessments or evaluations completed in the resident's record since she was readmitted to the facility on [DATE]. The Nurse Consultant indicated the facility policy indicated Dietary is make an admission note in the residents record within 48 hours of admission. The Nurse Consultant indicated the NAR (Nutrition at Risk) team met on 6/7/13 and the resident's name was on the list but there was no documentation of any nutritional assessment. When interviewed on 6/13/13 at 11:50 a.m., the Dietary Manager indicated the Registered Dietitian was in the facility on Monday 6/10/13. The Dietary Manager indicated the resident was not seen by the Registered Dietitian on 6/10/13. The Dietary Manager indicated the resident was recently readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The facility policy titled "Nutritional Assessment of Residents" was reviewed on 6/13/13 at 11:25 a.m. The policy had a revised date of 6/12. The Nurse Consultant provided the policy and identified the policy as current. The policy indicated a Dietary Admission note was to be entered into the resident's record with 48 hours of admission (or 72 hours in weekend admission). This federal tag related to Complaint IN 573. 3.1-46(b)

Based on record review and interview, the facility failed to monitor a PT (pro-time) and INR (international normalized ratio) (laboratory blood clotting test) for a resident who was receiving [MEDICATION NAME] (blood thinner), which resulted in the resident having a critically high PT and INR. The resident was admitted into the hospital with a [DIAGNOSES REDACTED]. This affected 1 of 3 residents who received [MEDICATION NAME] in a sample of 18. (Resident #67). In addition to the resident in immediate jeopardy, the facility failed to monitor and receive results timely for PT/INR's as ordered resulting in harm or the potential for harm that is not immediate jeopardy to 2 of 3 residents who received [MEDICATION NAME] in a sample of 18. And the facility failed to ensure resident's were free of unnecessary drugs related to a resident on a low potassium diet who was receiving a potassium supplement for 1 of 2 residents on a potassium restricted diet in a sample of 18. (Residents #E and #28) The immediate jeopardy began on 08/01/11 when the facility failed to monitor the resident's PT and INR after 08/01/11 and the resident continued to receive [MEDICATION NAME]. The Administrator, Director of Nursing (DoN), and the RN Corporate Consultant were notified of the immediate jeopardy at 4:35 p.m. on 09/15/11. The immediate jeopardy was removed on 09/16/11, but noncompliance remained at the level of isolated, no actual harm with potential for more than minimal harm. Findings include: 1. During an interview on 09/15/11 at 10:05 a.m., the B-Unit Manager #1 indicated Resident #67 was in the hospital due to a critical PT/INR. Resident #67's record was reviewed on 09/15/11 at 10:25 a.m. The resident's [DIAGNOSES REDACTED]. The resident's admission orders [REDACTED]. A physician's telephone order, dated 07/28/11, indicated an order for [REDACTED]. The resident's PT/INR laboratory results, dated 08/01/11, indicated the PT was 19.9 (normal 20.7-30.5) and the INR was 1.98 (normal 2.00-3.00). The PT/INR results indicated the physician had been notified of the results and the facility was to continue the same dose of [MEDICATION NAME]. There was a lack of documentation to indicate the resident's PT/INR was to be monitored after 08/01/11. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's MAR, dated 09/11, indicated the resident had received the [MEDICATION NAME] 5 mg daily September 1 through the 13, 2011. The resident's Nurses' Notes indicated: 09/10/11 at 00:00 (12 a.m.), "Infection Note...resident bilateral eyes reddened no drainage...(Physician's Name) notified...order for [MEDICATION NAME] (antibiotic) eye drops..." 09/10/11 at 18:56 (6:56 p.m.), "...bilateral eyes remains reddened with no drainage noted. resident (sic) denies itching or irritation..." 09/11/11 at 03:54 (3:54 a.m.), "...bilateral eyes remains reddened with no drainage noted. resident (sic) denies itching or irritation at this time..." 09/11/11 at 15:34 (3:54 p.m.), "...Bilartal (sic) eyes remain red..." 09/11/11 at 19:23 (7:23 p.m.), "...bilateral eyes remain reddened. (Physician's Name) made aware...no new orders..." 09/12/11 at 12:56 (12:56 p.m.), "...Bilateral eyes remain red. No complaints of discomfort..." 09/12/11 at 21:58 (9:58 p.m.), "...Bilateral sclera red. Denies any complaints of pain or itching..." 09/13/11 at 02:24 (2:24 a.m.), "...Hemmorhagic (sic) left eye...Denies pain or discomfort at this time..." 09/13/11 at 23:46 (11:46 p.m.), "...bilateral eyes remains red. no (sic) drainage noted. no (sic) complaint of visual disturbance..." 09/14/11 at 02:24 (2:24 a.m.), "...Bilateral sclera remains red..." 09/14/11 at 14:05 (2:05 p.m.), "... spoke with (Physician's Name) related to PT and INR, new orders for weekly PT and INR..." A physician's orders [REDACTED]. The PT/INR results, dated 09/14/11, indicated the resident's PT was high at 103.7 (normal 10-12) and the INR value was critical at 12.9 (normal 2-3). A physician's orders [REDACTED]. The emergency room notes, dated 09/14/11 at 9:44 p.m., indicated the resident's PT was 103.5 and INR was 12.8, and Aqua-[MEDICATION NAME] (blood clotting agent) 5 mg was administered to the resident. The emergency room History and Physical, dated 09/15/11, indicated, "...Conjunctivae/corneas subconjunctival hemorrhage present...Diagnoses: [REDACTED]. There was a lack of documentation to indicate the resident had a care plan for the [MEDICATION NAME] and risk factors of the [MEDICATION NAME] until 09/15/11. During an interview on 09/15/11 at 1:10 p.m., the B-Unit Manager #1 indicated the PT and INR had not been monitored after 08/01/11. She indicated she noticed the resident was on [MEDICATION NAME] on 09/14/11 and we called and received an order to check the resident's PT and INR. During an interview on 09/15/11 at 2:25 p.m., the DoN indicated the nurses should have questioned the residents red sclera. She indicated she was unsure if the facility had a policy for monitoring residents on a blood thinner. During an interview on 09/15/11 at 2:30 p.m., the DoN indicated she did not know about the resident's red eyes and if she had known she would have gotten an order to check the resident's PT and INR. She indicated the facility had went through all the resident's charts on 09/14/11 after concerns were voiced about some of the residents PT and INR's. A professional resource, titled, "2010 Nursing Spectrum Drug Handbook", page 1238, indicated, "[MEDICATION NAME] sodium ([MEDICATION NAME])...Monitor INR regularly in all patients..." 2. Resident #E's record was reviewed on 09/13/11 at 8:30 a.m. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The record indicated the resident had a PT/INR completed on 08/18/11 and 08/30/11 (12 days later). The record indicated the resident had a PT/INR completed on 09/02/11 and the facility received the results of the PT/INR on 09/06/11 (4 days later). During an interview on 09/13/11 at 1:10 p.m., the B-Unit Manager #1 indicated the resident should have had a PT/INR on 08/25/11. During an interview on 09/13/11 at 1:30 p.m., the B-Unit Manager #1 indicated the lab had been informed of the weekly PT/INR and they missed the lab on 08/25/11. She indicated the facility's fax machine was broke so the PT/INR results dated 9/2/11 had not come through until the machine was fixed on 9/6/11. 3. Resident #28's record was reviewed on 9/13/11 at 2:50 p.m. Resident #28's [DIAGNOSES REDACTED]. A. The resident's physician's orders [REDACTED]. A pharmacy form, dated 8/5/11, indicated "URGENT! [MEDICATION NAME] DRUG INTERACTION NOTIFICATION...Resident receives [MEDICATION NAME] cipro- recommend checking INR Q (every) 3 days while taking cipro. The combination of medications has potential for serious drug interactions..." Handwritten on the form "...order for PT/INR weekly..." A physician's orders [REDACTED]. A care plan, dated 4/6/11, indicated "...on anticoagulant therapy...labs as ordered..." A nurses' note, dated 9/8/11 at 3:40 p.m., indicated "writer spoke to (physician name) regarding bleeding from left and right feet, new orders to hold [MEDICATION NAME] for 4 days and then do PT/INR in one week..." The resident's record lacked documentation of any PT/INR laboratory results for 8/11/11 or weekly after that. During an interview on 9/13/11 at 4:55 p.m., the A Wing Unit Manager #6 indicated she was not able to find any PT/INR lab results. She indicated the nurse had called the doctor because the resident's wounds on his feet were bleeding and had gotten the order to hold the [MEDICATION NAME]. During an interview on 9/14/11 at 1:35 p.m., the Corporate Nurse Consultant indicated the PT/INR laboratory tests had not been done for the resident. She indicated the laboratory was coming to draw a stat PT/INR this afternoon. She indicated they were going to audit all other residents on [MEDICATION NAME] to be sure no other laboratory test had been missed. B. Resident #28's physician's re-admission orders [REDACTED]. The resident also had an order for [REDACTED]. During an interview on 9/15/11 at 11:00 a.m., the DoN (Director of Nurses) indicated she would try to find out why the resident was on a potassium restricted diet and was receiving a potassium supplement. During an interview on 9/15/11 at 2:47 p.m., the Registered Dietician indicated the resident had been readmitted to the facility on the low potassium diet. She indicated the resident had a renal [DIAGNOSES REDACTED]. She indicated she had missed the order for the potassium supplement when she had reviewed the resident's chart. The immediate jeopardy began on 08/01/11 when the facility failed to monitor the resident's PT and INR after 08/01/11 and the resident continued to receive [MEDICATION NAME]. The Administrator, Director of Nursing (DoN), and the RN Corporate Consultant were notified of the immediate jeopardy at 4:35 p.m. on 09/15/11. The immediate jeopardy was removed on 09/16/11, but noncompliance remained at the level of isolated, no actual harm with potential for more than minimal harm. The immediate jeopardy that began on 08/01/11 was removed on 09/16/11 when the facility had audited the residents who received [MEDICATION NAME] for PT/INR's and Physicians were notified and PT/INR lab orders were obtained if the residents did not have an order. The facility found no other resident on [MEDICATION NAME] with elevated PT/INR levels. PT/INR Quality Assurance flow sheets were initiated to monitor all PT/INR lab results and [MEDICATION NAME] dosage. An inservice on anticoagulants, PT/INR's, and side effects of the medication had been completed for the nurses at the facility. Five nurses were interviewed and they were able to state the facility protocol for [MEDICATION NAME] and signs and symptoms of adverse reactions to [MEDICATION NAME] usage. The Director of Nursing will review the PT/INR results, flow sheets, physician orders, and physician notification five days a week. The Consultant Pharmacist will review all residents receiving [MEDICATION NAME] monthly. The audits will continue to be completed and utilized by the Quality Assurance Committee. 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to provide treatment and assess residents with pressure ulcers for 5 of 7 residents with pressure ulcers in a sample of 18 residents, which resulted in 1 resident being admitted to the hospital with [REDACTED]. (Residents B, C, D F, and G) Findings Include: 1. Resident G's closed record was reviewed on 9/15/11 at 10:30 a.m. Resident G's [DIAGNOSES REDACTED]. An admission MDS (minimum data set) assessment, dated 3/18/11, indicated resident G had moderate cognitive impairment, required extensive assistance of two staff members for bed mobility and transfers. The resident had three stage IV pressure ulcers (full thickness of skin and subcutaneous tissue lost exposing bone or muscle), one stage III pressure ulcer (full thickness of skin is lost, exposing the subcutaneous tissues) and 2 unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) in the wound bed) upon admission. A care plan, dated 3/24/11, indicated the resident had unstageable pressure ulcers to the left and right heels, a stage IV pressure ulcer to the left buttock and a stage III pressure ulcer to the coccyx. The interventions included, but were not limited to, complete Braden scale per facility policy and keep heels elevated while in bed. The resident's record lacked documentation of a completed Braden scale assessment. An admission nursing assessment, dated 4/21/11, indicated the resident was readmitted to the facility and had pressure ulcers on both heels which were necrotic tissue (dead tissue) and had a stage I pressure ulcer on her coccyx. The resident's pressure ulcer assessments indicated the following measurements for the pressure ulcer to the right heel: 4/25/11 unstageable, 7.5 by 6.8 centimeters 100% black (eschar), with no drainage.. 5/2/11 unstageable 7.5 by 10 centimeters depth 0.1 centimeters 100% eschar, no drainage and no signs of infection. 5/9/11 unstageable 10.5 by 10.5 centimeters, depth 0.2 centimeters 100% eschar, with no drainage and no signs of infection. A physician's orders [REDACTED]. The resident's treatment administration record, dated 5/11, indicated the treatment had been completed on 5/10/10 twice, 5/11/10 twice and 5/12/11 once. The resident's nurses' notes, dated 5/12/11, indicated: 1:33 p.m., "...emesis x (times) 1, blood pressure up...(physician name) [MEDICATION NAME] (a medication for nausea and vomiting)...every 6 hours for emesis/nausea...Resident refused medication..." 1:52 p.m., "New order [MEDICATION NAME] ...every six hours as needed..." 6:07 p.m., "new order for [MEDICATION NAME] (pain medication) 50 mg (milligrams) one tablet every 6 hours as needed for pain..." 6:10 p.m., "(physician name) here today. Assessed residents feet and decided to send resident to (name of hospital) as a direct admit due to a possible infection to Left heel..." The Nurses' notes, dated 5/10/11 through 5/12/11 lacked documentation of an assessment of the resident's left heel pressure ulcer. A pressure ulcer progress report, dated 5/10/11, indicated the same measurements from the 5/9/11 assessment. During an interview on 9/15/11 at 2:23 p.m., the wound nurse indicated she had completed the assessment on 5/9/11, but had entered the assessment in the computer on 5/10/11 on the pressure ulcer progress report. During an interview on 9/13/11 at 10:20 a.m., the resident's family member indicated she had come to the facility and her mother had complained of pain to her foot. She indicated she had removed the dressing to check on her mother's foot. She indicated her mother's foot was red swollen and had puss coming from the pressure ulcer. She indicated she went to the nurses' station to get someone to come and check her mothers foot. She indicated a nurse came and checked the foot. She indicated the doctor was in the building and he came and looked at her foot and sent her mom to the hospital for infection. She indicated her mother had to have an amputation. During an interview on 9/15/11 at 2:23 p.m., the wound nurse indicated daily wound assessments should have been completed. She indicated there should have been an assessment of any changes in the wound documented in the nurses' notes. She indicated someone should have noticed a change in the pressure ulcer. During an interview on 9/16/11 at 10:48 a.m., the wound nurse indicated if the wound was 100 % eschar you could not determine the depth. She indicated the wound doctor came in and did rounds and she got the measurements from him. She indicated she was not sure how the wound doctor got the depth when the pressure ulcer was 100% eschar. During an interview on 9/15/11 at 4:10 p.m., the DON (Director of Nurses) indicated the resident's daughter came to the nurses' station and asked to see the wound nurse. She indicated the unit manager who no longer works at the facility went with the resident's daughter to check the resident's foot. She indicated the unit manager then got the doctor who was in the building to go look at the resident's foot. She indicated the physician said he was sending the resident to the hospital for a direct admit because the foot looked infected. She indicated she was not able to answer if the nurse had done the treatment to the resident's foot earlier that day or why she had not noticed the changes in the resident's pressure ulcer. A hospital history and physical, dated 5/12/11, indicated "...was seen in NH (Nursing Home), found to have infected LT (left) foot, was directly admitted to the hospital...LT foot pain...Left foot: she exhibits tenderness and swelling Infected LT heel with active drainage.." An infectious disease consult, dated 5/13/11, indicated "...was admitted [DATE] for infected left foot...nursing home resident who was noted to have swollen left heel associated with foul smelling drainage and eschar formation...Assessment: 1. Infected left foot with probable osteomylitis (bone infection)...Plan...may need amputation..." A MRI (Magnetic Resonance Imaging), dated 5/13/11, indicated "MRI of the left foot is abnormal and demonstrates findings indicative of soft tissue [MEDICAL CONDITION] process along the plantar (bottom) and posterior (back) aspect of the left calcaneum (heel bone). The infectious process do involve the plantar fascia and plantar muscular as well as the attachment of the Achilles tendon. Moderate changes or osteomylitis of the posterior aspect of the left calcaneum are noted and there is some bony instruction and bone marrow [MEDICAL CONDITION] visualized..." The culture of the left foot wound, dated 5/12/11, indicated many staphylococcus aureus ([MEDICAL CONDITION] resistant) (MRSA) and many escherichia coli..." An admission note, dated 6/24/11, indicated the resident was readmitted to the facility at 1:00 p.m.. The resident had a left AKA (above the knee amputation)..." 2. Resident D's record was reviewed on 9/13/11 at 9:35 a.m. Resident D's [DIAGNOSES REDACTED]. A Braden scale assessment for pressure ulcer risk, dated 8/10/11, indicated the resident was at mild risk for developing pressure ulcers. A quarterly MDS assessment, dated 8/11/11, indicated the resident was severely impaired with decision making. The resident required extensive assistance to total dependence upon staff for bed mobility, transfers, toilet use, dressing, and personal hygiene. The resident had one stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed). A physician's orders [REDACTED]." A care plan, dated 4/24/11 and updated 8/30/11, indicated "Stage III pressure ulcer present to right heel...Interventions: Administer treatments as ordered and assess effectiveness...heels up while in bed....Specialty mattress..." Resident D was observed on 9/13/11 at 9:30 a.m. and 10:02 a.m., sitting in her wheelchair. The dressing on the resident's right foot was dated 9/10/11. During an interview on 9/13/11 at 10:05 a.m., the DON indicated the dressing on the resident's right foot was dated 9/10/11. The DON indicated the dressing should have been changed if the order was to be changed every other day. The resident's TAR (treatment administration record), dated 9/11, indicated the treatment for [REDACTED]. The pressure ulcer assessment, dated 9/7/11,indicated the pressure ulcer on the resident's right heel was 0.7 by 0.6 centimeters with a depth of 0.3 centimeters. The wound base was 70 % granulation tissue and 30% slough. Resident D was observed on 9/13/11 at 11:05 a.m., lying in bed, with the wound nurse present. The resident's right heel was resting on the bed. The wound nurse indicated the resident's heel was resting on the bed and not elevated. The wound nurse indicated the nurse who worked on 9/12/11 had not changed the dressing and was counseled. The wound nurse removed the dressing from the resident's right heel. There was a quarter sized amount of brown/red drainage noted on the dressing. The wound nurse indicated the pressure ulcer measured 0.9 by 0.5 centimeters and was 0.2 centimeters in depth. The wound nurse indicated there was 80% yellow slough and 20% granulation tissue at the base of the pressure ulcer. There was a bath blanket which had been folded over twice (four layers) under the resident. The resident was lying on an air flow mattress. The wound nurse indicated the bath blanket was used for turning the resident in bed. She indicated she was not aware of any issues of having the bath blanket folded so many times placed under the resident on the air mattress. Resident D was observed with a shoe on her right foot on 9/13/11 at 2:15 p.m. and 5:20 p.m., 9/14/11 at 8:48 a.m., and 9/19/11 at 8:45 a.m. During an interview on 9/19/11 at 8:47 a.m., the Wound Nurse indicated the shoes could cause more pressure to the resident's heel and she would take the resident's shoe off. She indicated she would rather the staff put on footie socks than shoes on the resident. An undated CNA assignment sheet, provided by the A wing unit manager #6, on 9/16/11 at 10:30 a.m., as current, indicated for resident D there was a lack of documentation to indicate the resident was to have her heel off the bed. 3. Resident C's record was reviewed on 9/14/11 at 8:50 a.m. Resident C's [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 8/10/11, indicated the resident was severely impaired with decision making. The resident was dependent upon staff for bed mobility, transfers, toilet use, and personal hygiene. A care plan, dated 5/16/11 and updated 9/13/11, indicated "...pressure ulcer present...right heel and left lateral foot...heels up while in bed..." The pressure ulcer assessments, indicated the following: 9/7/11, Left lateral foot 9.5 by 2.7 centimeters 100% eschar 9/14/11, 9.5 by 4.0 centimeters, 30% granulation tissue and 70% eschar. 9/7/11, Right heel 2.3 by 1.6 centimeters 100% eschar. 9/14/11, Right heel 2.0 by 2.0 centimeters 100 % eschar. Resident C was observed with her heels resting on the bed on 9/13/11 at 2:05 p.m. During an interview at the above date and time, the Corporate Nurse Consultant indicated the resident's heels were not elevated. Resident C was observed with her right heel resting on the bed on 9/13/11 at 4:46 p.m. During an interview on 9/13/11 at 4:50 p.m., LPN #11 indicated the resident's right heel was resting on the bed. Resident C was observed on 9/16/11 at 10:45 a.m., lying in bed with her heels resting on the bed. CNA #16 was present at the time of the observation and she indicated she needed to get the resident another pillow to put under her legs. Resident C was observed on 9/16/11 at 12:05 p.m., the resident's heel was resting on the bed. During an interview on 9/16/11 at 12:10 p.m., the Wound Nurse indicated the resident's heel was on the bed. She indicated she was going to talk to therapy about something to help with positioning for the resident. An undated CNA assignment sheet, provided by the A wing unit manager #6 as current, on 9/16/11 at 10:30 a.m., indicated for resident C there was a lack of documentation to indicate the resident was to have her heels off the bed. 4. Resident #B's record was reviewed on 09/14/11 at 9:50 a.m. The resident's [DIAGNOSES REDACTED]. A care plan, dated 08/02/11, indicated the resident had a stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present) pressure ulcer present on the left great toe and a stage II (partial thickness loss) on the coccyx related to immobility. The interventions included, "...Heels up while in bed..." Resident #B was observed laying in bed with his heels on the bed, and no pillow or support located on the bed on 09/13/11 at 9:25 a.m., 09/14/11 at 9:15 a.m., and 09/15/11 at 8:23 a.m. During an observation of the resident on 09/15/11 at 8:30 a.m. with LPN #2 present, the resident's heels were on the bed. LPN #2 indicated she would get a pillow to float the resident's heels on. 5. During an observation of Resident #F on 09/13/11 at 9:15 a.m. with the B-Unit Manager #1 present, Resident #F was laying in bed. The bed had a low air loss mattress, the resident's right heel was on the mattress. There was a regular bottom sheet, a draw sheet, a paper incontinent pad under the resident. The resident also had an incontinent brief on. During an interview at the time of the observation, the B-Unit Manager #1 indicated there should not have been that much linen and a brief under the resident on a low air loss bed. Resident #F's record was reviewed on 09/13/11 at 1:20 p.m. The resident's [DIAGNOSES REDACTED]. The resident's care plan, dated 08/30/11, indicated the resident had a stage II pressure area to his right lateral foot related to immobility. The interventions included, "...Heels up while in bed...Specialty Mattress..." The manufactures directions for use for mattresses, received from the Wound Nurse LPN #4 on 09/14/11 at 3:10 p.m., indicated, "...LINEN NOTE: Deep-pocketed sheets are recommended...Multiple layering of linens or under pads beneath the resident can negatively affect the mattress's pressure management capabilities and should be avoided..." A facility policy, titled "Wound Prevention Protocol", dated 1/2005, received from the Corporate Nurse Consultant as current, indicated "... Identify those residents that are high risk for developing pressure areas using the Braden Scale...Use pillows, foam wedges...Elevate the heels by placing a pillow lengthwise under the resident's calves...Report any change in skin condition to physician and family. Document notification in the nurses' notes...Document the location of area, color, drainage if present...." A facility policy, titled "Skin Condition and Pressure Ulcer Assessment", dated 12/2004, received from the Corporate Nurse Consultant as current, indicated "...Pressure Ulcer Risk Assessment will be performed at the following times: a. Admission b. Updated quarterly...Skin observations are made daily, during the performance of...administering treatment procedures...Dressings which are applied to pressure ulcers...will include the date and initial of licensed nurse who performed the procedure. Dressings will be checked daily for placement, cleanliness and signs and symptoms of infection...The licensed nurse is responsible for notifying the attending physician and the Director of Nursing of any suspected infection in the wound and to initiate an Infection Report when appropriate...A licensed nurse will observe he condition of wound...daily, or with dressing changes as ordered, and document signs and symptoms of deterioration..." This Federal tag relates to complaints IN 562 and IN 566 3.1-40(a)(1) 3.1-40(a)(2)