Every finding on record at Majestic Care of North Vernon

Based on observation, interview, and record review, the facility failed to appropriately store medications for 1 of 2 medication storage areas reviewed for Drug and Biologicals storage. (Director of Nursing Office) Findings include:During an observation, on 03/23/2026 at 2:18 P.M., a miniature refrigerator in the back right corner of the Director of Nursing (DON) office contained the following medication, vaccines, and personal food/drink items : Ozempic, two single dose vials of Prevnar 20 (pneumococcal 20 valent vaccine), two single dose vials of RSV (Respiratory Syncytial Virus vaccine), Unopened individually wrapped sandwich, dressing bottle half full, four 12 ounce cans of lemonade unopened, one bottle of water 3/4 full, and a personal water bottle. During an interview, on 03/23/2026 at 2:44 P.M., the DON indicated she had forgotten about the medications being in her refrigerator and resident medications should never be stored with personal food items. The current facility policy, titled Medication Storage, with a reviewed date of 12/12/2023, was provided by the DON on 03/23/2026 at 3:20 P.M. The policy indicated, .It is the policy of this facility to ensure all medications housed on our premises will be stores in the pharmacy and/or medication rooms .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . This citation relates to Intake 2791258. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(o)

Based on observation, interview, and record review the facility failed to dispose of medications after discharge for 2 of 9 residents reviewed for pharmacy services. (Resident G and Resident H) Findings include:1.a. During an interview, on 03/23/2026 at 2:09 P.M., the Director of Nursing (DON) indicated medications that required refrigeration were kept in the facility medication room refrigerator on the Unit C Hallway. At one time Ozempic (a medication used for weight loss) was stored in the refrigerator in her office, but it was no longer stored there. During an observation and interview, on 03/23/2026 at 2:18 P.M., a miniature refrigerator in the back right corner of the Director of Nursing's office was observed with three Ozempic medications. Two separate Ozempic medications for Resident G and one for Resident H. The DON indicated both residents had been discharged from the facility. The clinical record for Resident G was reviewed on 03/24/2026 at 9:30 A.M. A Discharge - Return not Anticipated Minimum Data Set (MDS) assessment, dated 01/31/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes mellites (high blood sugars caused by the body's inability to produce or properly use insulin), and anxiety. A physician's order, dated 11/19/2025 at 6:00 A.M, indicated Resident G was to receive Ozempic by a subcutaneous pen injector with 2 milligram (mg) / 3 milliliter (ml) solution at a rate of 0.5 mg one time a day every Wednesday for type two diabetes. The medication was discontinued on 01/31/2026 at 2:44 P.M. An, undated Pharmacy Record, indicated Resident G last received the Ozempic 2 mg/3 ml at a rate of 0.5 ml on 01/28/2026 at 12:23 P.M., and lacked how much was remaining. A physician's order, dated 04/04/2025 at 6:00 A.M., indicated Resident G was to receive 2 mg of Ozempic 8 mg/3 ml subcutaneously. The medication was discontinued on 04/21/2025. An, undated Pharmacy Record, indicated Resident G had received the 2mg dose at a rate of 0.5 ml of Ozempic on 04/04/2025 at 8:45 A.M., with three doses remaining and on 04/11/2025 at 1:00 P.M., with two doses remaining. 1.b. The clinical record for Resident H was reviewed on 03/24/2026 at 9:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/03/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes mellites and anxiety. A Progress Note, dated 01/31/2026 at 9:31 A.M. indicated Resident H had passed away. A physician's order, dated 09/24/2025 at 6:00 A.M. indicated Resident H was to receive 2 mg of Ozempic 8mg/3ml subcutaneously one time a day every Wednesday for type two diabetes. The medication order was discontinued on 11/20/2025. An, undated, Pharmacy Record, indicated Resident H received Ozempic 8mg/3ml on 11/19/2025 at 9:30 A.M., and there were 3 doses remaining. During an interview, on 03/24/2026 at 11:48 A.M., the DON indicated the medications for Resident G and Resident H should have been discarded before that day. American Nurses Association. (2010). Pharmaceutical waste: Non-controlled medication disposal in long-term care (LTC) after discharge requires adherence to federal (EPA/DEA), state, and facility policies, focusing on preventing environmental contamination and diversion. Medications should be disposed of via secured on-site receptacles, pharmacy return, or authorized hazardous waste procedures within days of discharge. The current facility policy, titled Medication Storage, with a reviewed date of 12/12/2023, was provided by the DON on 03/23/2026 at 3:20 P.M. The policy indicated, .Unused medications: The Pharmacy and all medication rooms are routinely inspected by a consultant pharmacist for discontinued, outdated, defective, or deteriorated medications . The current facility policy, titled Hazardous waste - Pharmaceuticals, with a reviewed date 12/12/2023, was provided by the DON on 03/24/2026 at 11:30 A.M. The Policy indicated, .To protect employees and the environment, this facility manages all pharmaceutical waste as hazardous in accordance with the applicable federal, state, and local rules and regulations . This citation relates to Intake 2791258. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(r)

Based on interview and record review, the facility failed to report a resident's allegation of abuse for 1 of 3 resident's reviewed for abuse allegations reviewed. (Resident C) Findings include:During an interview, on 03/23/2026 at 10:19 A.M., Resident C indicated she had been hit by Resident F in her left shoulder on Friday 03/20/2026. Resident C told the nurse, and another staff member in the front of the building. The nurse told her she would be okay. During an interview, on 03/23/2026 at 4:22 P.M., Licensed Practical Nurse (LPN) 2 indicated if there was an incident where a resident claimed to be hit by another resident, she would report it directly to the Administrator and Director of Nursing (DON) verbally. Outside of telling management verbally floor staff do not document about the occurrence. Management staff would be the ones to document the incident details. During an interview, on 03/23/2026 at 4:31 P.M., the Administrator indicated he was not informed about the incident that occurred on Friday until the Monday after. He had just begun his own investigation. During an interview, on 03/24/2026 at 10:22 A.M., Registered Nurse (RN) 3 indicated she had been sitting in her office when she heard a resident yell out He hit me. She exited her office to find Resident C in front of the nurse's station yelling. She took Resident C back to her room and looked at her shoulder and found no marks. She never completed a skin assessment, and she never notified the Administrator or Director of Nursing of the incident. During an interview, on 03/24/2026 at 10:11 A.M., the Social Services Director (SSD) indicated Resident C had come to her on Friday holding her left shoulder saying she had been hit by Resident F. The SSD then went and interviewed the staff working and created a soft file investigation. She never reported it to the Administrator or Director of Nursing. A Document titled 03/20/2026, was provided by the Social Service Director on 03/24/2026 at 10:15 A.M. The document indicated Resident C came to the Social Services Director to report she had been hit by Resident F. The clinical record for Resident C was reviewed on 03/23/2026 at 4:00 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/20/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, Non-Alzheimer's Dementia (cognitive decline that were not caused by Alzheimer's). The current facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, with a revision date of 06/05/2025, was provided by the DON on 03/24/2026 at 11:15 A.M. The policy indicated, .Care Team members should immediately report all such allegations to the Administrator and to the Department of Health in accordance with the procedures in this policy . This citation relates to Intake 2799730. 410 IAC (Indiana Administrative Code) 16.2-3.1-14(F)(vi)

Based on observation, interview, and record review, the facility failed to provide safe water temperatures for 5 of 9 resident bathrooms and 1 of 2 common area bathrooms observed. (Rooms C 101, C 102, D 114, D 115, D 116, and Women's Visitor Restroom)Findings include:During an observation, on 10/27/2025 at 10:35 A.M., the water in the Women's Visitor Restroom in the main hallway was hot to touch, not able to hold the hand under the water. The door was unlocked, unless it was in use and several residents had independently passed by the restroom.During an observation and interview, on 10/27/2025 at 10:40 A.M., Resident Room D 116's bathroom sink water was hot to touch. Resident E indicated she had no concerns with her water.During an observation, on 10/27/2025 from 10:47 A.M. to 11:01 A.M., the Maintenance Director checked the water temperatures in the following rooms:-Room D-116 the water temperature was 124.0 degrees Fahrenheit,-Room D-115 the water temperature was 122.5 degrees Fahrenheit,-Room D-114 the water temperature was 124.3 degrees Fahrenheit,-Room C-101 the water temperature was 123.3 degrees Fahrenheit,-Room C-102 the water temperature was 123.0 degrees Fahrenheit, and-Women's Visitor Restroom the water temperature was 134.5 degrees Fahrenheit.The Maintenance Director indicated the Women's Restroom had its own on demand water heater. They had placed a piece of tape over the dial that indicated to stop and do not touch. They had put the tape in place because people were adjusting the temperature on their own. The door to the restroom was only locked from the inside while in use. It was open for anyone to use but did have a sign on the door that the restroom was for visitors and care team members only. The water temperature should be 115 degrees Fahrenheit. He checked them daily in each hallway. He drained the water from the on-demand unit at that time and was going to adjust the water to the resident rooms.During an interview, on 10/27/2025 at 11:05 A.M., the Administrator indicated there had not been concerns of hot water temperatures or any burns from the water. During an interview, on 10/27/2025 at 11:07 A.M., the Director of Nursing (DON) indicated there had not been any reported burns in the building.During an interview, on 10/27/2025 at 11:20 A.M., the Administrator indicated the Maintenance Director was going to lock the Women's Bathroom at that time so no residents would be able to access it. They had also adjusted the temperatures for the residents' rooms. They would be monitoring the water temperatures until they were the correct temperatures.The September and October 2025 temperature logs were reviewed and indicated the water temperatures were 115 degrees Fahrenheit on the following dates:-09/01/2025 through 09/05/2025,-09/22/2025 through 09/26/2025,-10/06/2025 through 10/09/2025,-10/10/2025, and-10/20/2025 through 10/24/2025.No other dated temperature logs were provided.The current facility policy titled, Water Temperatures was provided by the Administrator on 10/27/2025 at 11:20 A.M. The policy indicated, .To maintain appropriate water temperatures in resident/patient care areas.Water temperatures will be set to a temperature of no more than the state's allowable minimum and maximum water temperature.

Based on observation, record review, and interview, the facility failed to meet the needs of a resident related to image acquisition by a contracted x-ray staff member. The resident's arm was improperly positioned and she cried out for 1 of 3 residents reviewed for diagnostic services. The resident's arm resulted with a fracture. (Resident B)Findings include:During an observation, on 10/15/2025 at 9:12 A.M., Resident B was lying in bed, her eyes were closed. There were no signs of distress. The resident had a red cast on her right arm that went from her hand up past her elbow. The clinical record for Resident B was reviewed on 10/15/2025 at 9:23 A.M. An Annual Minimum Data Set (MDS) assessment, dated 08/21/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, neurogenic bladder, arthritis, and aphasia. The resident had physical impairments on one side of the upper and lower extremities.A Progress Note, dated 08/27/2025 at 9:49 P.M., indicated the resident was noted to have redness to both elbows, warmness to touch, and complaints of pain. Nurse Practitioner (NP) 5 was notified, and a new order was obtained for the resident to receive doxycycline (an antibiotic), 100 milligrams (mg), twice a day for 7 days for cellulitis. The NP indicated they would be in the facility the next day to assess the resident. A Physician Note, dated 08/28/2025, indicated the resident was seen for bilateral elbow redness. The resident was having more pain on the right side, with difficulty moving the arm. An x-ray would be ordered along with ibuprofen 400 mg, twice a day for two to three days. An X-Ray Result, dated 08/28/2025, indicated the resident had no obvious fractures or dislocation. A Critical Note from the X-Ray Tech, dated 08/28/2025 at 8:50 P.M., indicated the patient was unable to position for exam, the patient (Resident B) screamed if the tech tried to position the arm/elbow.A Physician Note, dated 09/29/2025, indicated the resident was seen for right arm pain in the shoulder and wrist and was described as aching. There was no history of trauma or falls. The resident's Tylenol had been ineffective in managing the pain. A new order was obtained for the resident to receive ibuprofen 400 mg, every six hours as needed for pain management, and to discontinue the Tylenol. A Progress Note, dated 10/01/2025 at 1:00 P.M., indicated the NP was in the facility and ordered an x-ray of the resident's right shoulder. The resident and her family member refused to pursue with an x-ray at that time. A Physician Note, dated 10/02/2025, indicated the resident reported significant pain in her right upper extremity that was exacerbated with passive movement. The pain was not very well controlled presently. The resident's medications would be adjusted, and an x-ray would be ordered of the resident's right forearm. A Physician Note, dated 10/03/2025, indicated the resident's x-ray result showed a fracture and the resident reported that she thought the fracture was from the x-ray technician's (tech) procedure when they had obtained the previous x-ray. An X-Ray Result, dated 10/03/2025, indicated, Resident B had a mildly displaced healing distal diaphyseal fracture of the ulna as well as mildly angulated, mildly displaced, proximal diaphyseal fracture of the radius, two bones in the arm. The age of the injury was labeled as indeterminate. During an interview, on 10/15/2025 at 10:12 A.M., Resident B's family member indicated in August an outside x-ray company had come into the facility and completed an x-ray on the resident's right arm. The resident had a contracture, (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility), on the right arm and was non-verbal. The resident was able to answer yes or no questions but was very hard to understand. A facility nurse, RN 2 had heard the resident scream when the x-ray tech was conducting the x-ray procedure. The RN went into the room and stopped the x-ray tech because they were turning the resident's right arm in a way that it wouldn't turn due to the resident's contracture. The resident recently started having more pain and another x-ray was completed with a result of a fracture in the right arm. During an interview, on 10/15/2025 at 10:56 A.M., RN 2 indicated in August the resident had redness to her bilateral elbows. The physician ordered x-rays to check for gout and fractures. The x-ray tech had come into the facility to complete the x-ray, and the RN asked the tech if she needed help. The x-ray tech didn't need help, and the RN continued to stay at the nurse's station to chart. While she was charting, she heard the resident crying out loudly. She had never heard the resident yell out like that before, so she went to the room, and she saw the x-ray tech pull the resident's right arm straight out and turn it at the same time. The RN stopped the tech and told her the resident's arm wouldn't move like that because she had a contracture. The tech said she wouldn't be able to get any more images unless the arm was straight. The tech stopped and did not get anymore images after that. The RN had told the Director of Nursing (DON), and the resident was monitored for pain and discomfort. The x-rays at that time had come back without fractures. At the end of September, the resident had told her that her routine Tylenol was no longer helping her pain in the right arm. The physician saw the resident, discontinued the Tylenol, and started the resident on ibuprofen. The resident was having intense pain in the arm. The physician wanted another x-ray, and the resident had refused. After a few days she was not longer able to use her arm, so she agreed to an x-ray. The results indicated she had a fracture in the right arm. The resident was sent to an outside orthopedic physician where they placed a cast to the arm. She had never heard or seen any facility staff be abusive to this resident or any others. During an interview, on 10/15/2025 at 11:27 A.M., the DON and Administrator indicated in August both of the resident's elbows were red, swollen, and warm to the touch. The Nurse Practitioner (NP) ordered doxycycline (an antibiotic). The NP came in to see the resident the next day. The redness was gone, and the skin was no longer warm to the touch, but there was still a little swelling. The NP discontinued the antibiotic and ordered an x-ray of the right elbow. When the x-ray tech came in, she couldn't maneuver the resident's elbow to get the view she needed. The resident yelled out when the tech was in the room, so RN 2 went into the room. The resident had been taking routine Tylenol, but on 09/29/2025 the resident was having more pain. The Tylenol was discontinued, and she was started on ibuprofen. She was also started on an as needed, three-day order of Norco (a pain medication). On 10/01/2025, the resident was offered an x-ray of her right shoulder for pain and decreased range of motion, but she refused. The pain didn't get any better, so another x-ray was ordered and completed of the right forearm on 10/03/2025. The x-ray indicated the resident had two fractures. The physician was notified and ordered the resident's arm be placed in a sling and referred her to the orthopedic physician. The resident went to that appointment on 10/06/2025 and a cast was placed to the arm. The Administrator and the DON talked to the resident and her family member and think the fracture happened when the first x-ray was completed. The resident had not had any falls. During an interview, on 10/15/2025 at 12:02 P.M., Resident B indicated the x-ray in August was to check for gout. The x-ray tech came in and was trying to turn her arm. The x-ray tech thought the resident wasn't being cooperative. Facility staff were not present in the room until after the x-ray tech was done. During an interview, on 10/15/2025 at 1:15 P.M., Licensed Practical Nurse (LPN) 3 indicated when the x-ray techs came to the facility to complete x-rays on residents, they would obtain the resident's face sheet and the order for the x-ray. The tech then would go to the room and get the x-ray. Most of the time they would ask the facility staff for assistance if the resident was not cognitively intact or if they had concerns that the resident wouldn't be physically able to assist them. The facility staff was always available to help. For Resident B, the x-ray tech would not have been able to get an x-ray of the resident's right arm without facility staff assistance due to the resident having increased pain in the arm. During an interview, on 10/16/2025 at 10:24 A.M., NP 5 indicated the resident had a contracture to the right arm for many years from having a stroke. The resident was cognitively intact. If the resident's contracture arm got pulled, the resident would be able to let you know when it was hurting. The resident did have a diagnosis of osteoporosis. Anything could happen if the resident's contracture arm was pulled. During an interview, on 10/16/2025 at 10:31 A.M., NP 6 indicated she had reviewed the resident's x-ray results in October and referred the resident to see an orthopedic physician. If a resident had a contracture of the arm and the arm got pulled, it could put the resident in a lot of pain or could even cause a fracture. During an interview, on 10/16/2025 at 11:24 A.M., Certified Nurse Aide (CNA) 4 indicated the resident needed the complete assistance of two staff members for dressing, personal hygiene care, and turning and repositioning. The resident was able to feed herself some. CNA 4 was there when the x-ray tech came in August but the CNA was never asked to assist or never heard of anyone else being asked. She was unaware the x-ray tech was there, until they were gone. Almost always when the x-rays tech came to the facility she would go into the room and assist them. The x-ray techs would always ask for help or for staff to explain to them what assistance the resident needed. She had never seen them go into a room blindly and complete an x-ray. Resident B would not have been able to assist the x-ray tech with the x-ray of her right arm. During an interview, on 10/16/2025 at 11:32 A.M., the Administrator indicated the contract with the x-ray company should include verbiage that they would follow regulations and was unsure what their training was. The x-ray company would handle and have records of their training. The facility did not provide them with any training information. A portion of the x-ray tech procedure manual was provided by the x-ray company's Regional [NAME] President. The procedure manual indicated, If the resident must be transferred or significantly re-positioned to perform the exam, facility staff must assist in the transfer or re-positioning. A Portable Imaging and Diagnostic Testing Services Agreement, dated 04/01/2025, was provided by the Administrator on 10/16/2025 at 11:15 A.M. The agreement indicated, .COMPANY [facility] has in place a Code of Conduct.the goal of which is to ensure that all applicable federal, state, and local laws and regulations are followed. The Code includes a commitment to uphold a high standard of ethical and legal business practices and to prevent misconduct. Through the implementation of this Contract, each party acknowledges the commitment to compliance and agrees to conduct all transactions which occur pursuant to this Contract in accordance with all applicable federal, state and local laws and regulations.COMPANY has also implemented a policy to detect, address and prevent issues of fraud, waste, and abuse. This policy, the Code, and information regarding COMPANY'S Compliance Programs shall be made available to the Service Provider and Service Providers employees. COMPANY will educate all Service Provider employees and contractors who work on matters related to this Contract on such policy, the Code and other applicable requirements.This citation relates to Intake 2640227.3.1-49(a)3.1-49(g)

Based on interview, and record review, the facility failed to ensure staff treated a resident with respect and dignity for 1 of 3 residents reviewed. (Residents C)Findings include: During an interview on 07/28/2025 2:46 P.M., Certified Nurse Aide (CNA) 2 indicated in June of 2025 Resident C informed her she was hungry, and her cornbread was thrown away. CNA 2 then heard Licensed Practical Nurse (LPN) 3 talk about Resident C. LPN 3 stated that Resident C had asked her to microwave the cornbread she had saved from her lunch. LPN 3 agreed but told Resident C not to stand up while she was gone. Upon returning LPN 3 saw Resident C walking and told her she no longer can have the cornbread for not listening. LPN 3 then said she threw away the corn bread. CNA 2 reported it to her superiors. A facility document, dated 06/20/25 at 11:45 A.M., provided by the Director of Nursing (DON) on 07/28/25 at 3:18 P.M., indicated Resident C reported LPN 3 told her to sit down in her chair and not move until she got back. She pointed to the chair that was pushed in under the overbed table near the closet. The resident reported that LPN 3 went to go get her cornbread and milk. She returned with cornbread but forgot milk. LPN 3 again told her not to move. Resident C reported getting up to put her tablet away in a drawer. When LPN 3 walked into the room she acted mad and said, I told you not to move. Just for that, I'm not giving you this (milk). The resident reported LPN 3 took the cornbread and milk and threw it away in the trashcan at the nurse's station. During an interview, on 07/28/2025 at 2:18 P.M., the DON indicated LPN 3 refused to give a written statement of the incident and was terminated during the investigation. During an interview, on 07/28/2025 at 2:29 P.M., the Social Service Director indicated on June 20th Resident C's relative came to her with some concerns with a nurse who had taken care of Resident C recently. The relative indicated Resident C had asked LPN 3 for something to eat and drink after meal service, and LPN 3 told Resident C to not get out of her chair while she went and got the food. Upon returning Resident C had gotten out of her chair so LPN 3 threw away the food items and made a remark about her not getting it because of her actions. The Social Service Director then interviewed Resident C and was told the same story by the resident. Resident C added that she made the remark to LPN 3 that she didn't want it anyway after she threw away the cornbread and milk. The clinical record for Resident C was reviewed on 07/28/25 at 9:32 A.M. An Annual Minimum Data Set (MDS) assessment, dated 06/10/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, arthritis, and gastroesophageal reflux disease.During an interview, on 07/28/25 at 11:37 A.M., Resident C indicated she had no memory of this incident, and indicated the staff were always nice to her.The current facility policy titled, Dignity dated 12/12/2023, was provided by the DON on 07/28/25 at 3:18 P.M. The policy indicated, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life . This citation relates to Complaint 1599379. 3.1-3(t)

2. The D-Hall Dining room meal service was observed on 06/08/25 at 11:51 A.M. Certified Nurse Aide (CNA) 9 pushed a chair in the dining room using her hands, touched her nose with her left hand, sat down in a chair by three residents sitting at the table nearest the kitchen door, touched her face and ear with her right hand, then served a meal tray to Resident 6. CNA 9 touched the resident's plate and napkin, unrolled the napkin, took out the silverware, removed the foil from the resident's baked potato, chopped it up with the resident's fork holding the fork in her right hand, opened the resident's sour cream packet, and squirted the sour cream on the resident's potato. The resident picked up the fork and fed herself. CNA 9 used hand sanitizer then served a tray to another resident. During an interview, on 06/11/25 at 2:11 P.M., CNA 9 indicated when serving meal trays, staff were to use hand sanitizer after each tray and wash their hands after three to five trays. Staff were not to touch themself before serving meal trays. The current Handwashing-Hand Hygiene policy, with an effective date of 03/01/25, was provided by the DON on 06/12/25 at 10:26 A.M. The policy indicated, .If hands are not visible soiled, use an alcohol-based hand rub .for all the following situations . After direct contact with residents .After contact with objects .in the immediate vicinity of the resident . 3.1-21(i)(2) 3.1-21(i)(3) Based on observation and interview, the facility failed to follow appropriate guidelines related to the use of hair coverings in the kitchen and store foods in a sanitary manner related to unlabeled and outdated foods and for 1 of 3 kitchen observations, and failed to follow appropriate infection control guidelines related to hand hygiene for 1 of 4 dining observations. (D-Hall Dining Room) Findings include: 1. During the initial tour of the kitchen on 06/08/25 at 10:10 A.M., Activity Aide 12 was observed in the kitchen preparing drinks near the coffee pots. The Activity Aide had a long beard the touched his collar bone that was not contained in a beard net. The kitchen refrigerators were observed on 06/08/25 at 10:12 A.M. and contained the following: - An undated rectangular metal pan covered in plastic wrap that contained tuna salad, - A large, lidded container 3/4 full of Dijon pork. The label indicated the pork was prepared on 06/02/25, and was to be used 06/05/25, - A 1/3rd full gallon of milk, with a best by date of 05/26/25, and - A 1/3 full clear pitcher of tomato juice. The label indicated the juice was made on 06/03/25 and was to be used by 06/06/25. During an interview, on 06/08/25 at 10:18 A.M., the Assistant Dietary Manager indicated the Activity Aide's beard should have been covered. The tuna salad should have been labeled with a prepared on date. The pork, milk, and tomato juice were expired and should have been thrown out. The current facility policy, titled Staff Attire, dated 10/2023, was provided by the Administrator on 06/12/25 at 10:26 A.M. The policy indicated, .All staff members will have .facial hair properly restrained . The current facility policy, titled Food Storage: Cold Foods, dated 02/2023, was provided by the Administrator on 06/12/25 at 10:26 A.M. The policy indicated, .All foods will be .labeled and dated .

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines during a wound dressing change, and for indwelling urinary catheter management for 4 of 21 residents reviewed for infection control. (Residents 2, 100, 101, and 15) Findings include: 1. A wound dressing change for Resident 2 was observed on 06/10/25 at 10:41 A.M., with Licensed Practical Nurse (LPN) 7 and LPN 10. The LPN's donned gowns in the hallway from a cart of supplies sitting next to the resident's room door. LPN 10 donned gloves. With her gloves on, she reached into her pocket on her scrubs, got her treatment cart keys out, and used them to open the cart. She gathered treatment supplies, took them into the resident's room, laid the supplies on the over bed table, went into the bathroom located in the resident's room, did not turn on the water or change gloves, came out with paper towels, and put the paper towels on the over bed table. LPN 10 opened several gauze pads and made a stack, touching the gauze pads with her gloved hands. The LPNs rolled the resident towards LPN 7, who held the resident on their side. LPN 10 sprayed a wound cleanser, Hibiclens, on a gauze pad from the stack, and wiped the resident's tennis ball sized bleeding wound located on her left buttock. LPN 10 patted the wound with more gauze pads in an attempt to stop the bleeding. She applied a small amount of a protective paste, Triad, when LPN 7 indicated the treatment was supposed to be Xeroform gauze (a non-adherent mesh infused with healing ointment). LPN 10 wiped off the Triad paste with a gauze pad, applied the Xeroform gauze to the wound bed, applied a border dressing, removed her gloves, washed her hands, and donned clean gloves to treat the next wound. The clinical record for Resident 2 was reviewed on 06/11/25 at 10:09 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/27/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hypertension, and neurogenic bladder. The current physician's order for the resident's wound on her left buttock indicated the wound was to be cleansed with Hibiclens, rinsed thoroughly, patted dry, Xeroform gauze applied to the wound bed, and covered with a border foam dressing. The LPN failed to change their gloves after touching contaminated objects and failed the rinse the wound thoroughly after using the Hibiclens cleansing agent. During an interview on 06/11/25 at 3:26 P.M., RN 4 indicated when providing wound treatments, once you don your gloves you should not touch anything below your waist, including door knobs, anything in your pockets, or anything dirty that had not been cleaned immediately prior. Staff should wash their hands and change gloves if they come into contact with a possibly contaminated item. The current Handwashing-Hand Hygiene policy, with an effective date of 03/01/25, was provided by the Director of Nursing (DON) on 06/12/25 at 10:26 A.M. The policy indicated, .If hands are not visible soiled, use an alcohol-based hand rub .for all the following situations . After direct contact with residents .After contact with objects .in the immediate vicinity of the resident . 2. Resident 100 was observed in the A-Hall dining room on 06/10/25 at 12:12 P.M. The resident's indwelling urinary catheter drainage bag was hanging under her wheelchair and touching the floor. The resident's sling used to transfer her with a mechanical lift was visible at her shoulders. On 06/10/25 at 1:33 P.M., the resident was propelling themselves down the D-Hall in her wheelchair. Her indwelling urinary catheter bag was dragging on the floor. At 1:35 P.M., a staff member assisted the resident by pushing her down the D-Hall, down the hallway with the staff offices, and to the A-Hall dining room to an activity. The sound of the bag dragging the floor was audible. On 06/10/25 at 2:05 P.M., a staff member was observed pushing the resident down the A-Hall all the way to the A-Hall dining room with the bottom of the indwelling urinary catheter bag dragging on the floor. The blue cover on the bag was flipped back as it was dragging on the floor. The clinical record for Resident 100 was reviewed on 06/10/25 at 2:46 P.M. An Entry MDS assessment indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, diabetes and acute neurological disorder. During an interview and observation, on 06/10/25 at 2:57 P.M., Corporate Clinical Support, while observing the resident in the A-Hall dining room, indicated no part of an indwelling urinary catheter should be touching the floor. 3. On 06/10/25 at 1:51 P.M., Resident 101 was in bed in their room. His bed was in a low position and two to three inches of his indwelling urinary catheter bag was directly touching the floor. No barrier was noted between the catheter bag and the bare floor. During an interview and observation on 06/10/25 at 3:04 P.M., Qualified Medication Aide (QMA) 8 indicated the resident was a complete assist with care. His indwelling urinary catheter bag should not be touching the floor without a barrier between the floor and the bag. The bag had two to three inches directly touching the floor. The clinical record was reviewed on 06/10/25 at 2:41 P.M. An admission MDS assessment, dated 06/05/25, indicated the resident was rarely/never understood. The resident's diagnoses included, but were not limited to, stroke and benign prostatic hyperplasia. The resident had not had a urinary tract infection (UTI) in the last 30 days. 4. During an observation, on 06/11/25 at 9:10 A.M., Resident 15 was sitting in her recliner in her room. Her indwelling urinary catheter bag was hooked to the right side if the chair with approximately one inch of the bag resting on the bare floor. During an observation, on 06/11/25 at 11:02 A.M., Resident 15 was sitting in her recliner in her room. Her indwelling urinary catheter bag was hooked to the right side if the chair with approximately one inch of the bag resting on the bare floor. During an observation, on 06/11/25 at 2:12 P.M., Resident 15 was sitting in her recliner in her room. Her indwelling urinary catheter bag was hooked to the right side if the chair with approximately one inch of the bag resting on the bare floor. During an observation and interview, on 06/11/25 at 2:13 P.M., Resident 15 was sitting in her recliner in her room. Her indwelling urinary catheter bag was hooked to the right side if the chair with approximately one inch of the bag resting on the bare floor. CNA 5 indicated the resident's catheter bag should not have been lying on floor. She moved the urinary catheter bag and hung it on the bed frame. The clinical record for Resident 15 was reviewed on 06/10/25 at 10:30 A.M. A Quarterly MDS assessment, dated 03/06/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, neurogenic bladder, and aphasia. The resident had an indwelling urinary catheter. The current facility policy, titled Indwelling Catheter, dated 01/02/24, was provided by the Director of Nursing on 06/12/25 at 1:32 P.M. The policy indicated, .if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice . 3.1-18(b) 3.1-18(l)

2. During an observation and interview, on 06/08/25 at 10:19 A.M., Resident 37 was sitting on the side of the bed in her room. There were three medication cups sitting on the resident's bedside table. One medication cup contained three small white capsules, the second one contained a large white capsule, and the third one contained a large round pill broke in half, a medium round peach colored pill, one large round pill, one medium round white pill. The resident indicated the medications were hers and the nurse had left them for her to take. No staff members were in or near the resident's room or in the hallway outside the resident's room. The clinical record was reviewed on 06/10/25 at 11:03 A.M. A Quarterly MDS assessment, dated 04/21/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, heart failure, dementia, anxiety, and depression. During an interview, on 06/11/25 at 9:54 A.M., Licensed Practical Nurse (LPN) 3 indicated medications should not have been left at the resident's bedside. A resident should be watched while they take their medications unless they were assessed to self-administer. During an interview, on 06/11/25 at 11:17 A.M., the DON indicated the resident did not have a self-administration assessment. She was not safe to self-administer any of her medications. The current facility policy titled, Medication Administration, dated 01/02/2024, was provided by the DON on 06/11/25 at 11:40 A.M. The policy indicated, .23. Unless the resident has been assessed for safe self-administration of medications, medications are not to be left unattended for the resident to consume at a later time. The MEDICATION SELF-ADMINISTRATION SAFETY SCREEN records for the last six months for Resident 78 were provided by the Director of Nursing (DON) on 06/11/25 11:15 A.M. There was only one record for this resident. The record, with an effective date of 04/02/25, indicated the resident required assistance with medication administration and the Resident may NOT self-administer medications. Ongoing assessment should occur at a minimum of quarterly. 3.1-11(a) Based on observation, interview, and record review, the facility failed to ensure residents were deemed appropriate to self-administer medications prior to leaving medications at the residents bedside unsupervised for 2 of 2 residents reviewed for self-administering medications. (Residents 78 and 37) Findings include: 1. During an observation and interview, on 06/10/25 at 11:49 A.M., Resident 78 was reclining on her bed in her room. A medication cup was sitting on the resident's over the bed table. The medication cup contained one half of a round white tablet and one small red and white capsule. The resident indicated the medications were Lyrica (a pain medication) and her anxiety pill. She did not know the name of her anxiety pill. Sometimes the staff left them at the bedside and sometimes they stood at the bedside and watched her take them. If the staff member knew her, they would leave them at the bedside. If they did not know her, they would stand there and watch her take them. No staff members were in or near the immediate area of the resident's room. Other residents were independently mobile and propelling themselves down the hallway. The clinical record was reviewed on 06/11/25 at 10:05 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/05/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stoke, anxiety, depression, and respiratory failure. During an interview, on 06/11/25 at 11:40 A.M., the DON indicated there were no residents currently in the building who self-administered their medications.

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for cardiac medications for 3 of 21 residents reviewed for quality of care. (Residents 58, 15, and 7) Findings include: 1. Resident 58's clinical record was reviewed on 06/11/25 at 3:24 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hypertension, and coronary artery disease. The resident's current physician's orders included, but were not limited to, an open-ended order, with a start date of 01/11/25, for Midodrine 10 milligram (mg) tablet, three times a day. The resident was to receive one tablet by mouth, at 8:00 A.M., 12:00 P.M., and 8:00 P.M., for hypotension. The medication was to be held if the resident's systolic blood pressure (top number) was greater than 120. The Electronic Medication Administration Record (EMAR) for May 2025 indicated the resident received the medication when the systolic blood pressure was over 120 on the following dates and times: - On 05/02/25 at 12:00 P.M., when the blood pressure was 136/80, - On 05/03/25 at 8:00 P.M., when the blood pressure was 140/63, - On 05/05/25 at 12:00 P.M., when the blood pressure was 122/64, - On 05/06/25 at 12:00 P.M., when the blood pressure was 124/74, - On 05/08/25 at 12:00 P.M., when the blood pressure was 128/74, - On 05/11/25 at 8:00 A.M., when the blood pressure was 128/72, at 12:00 P.M., when the blood pressure was 132/70, and at 8:00 P.M., when the blood pressure was 124/78, - On 05/12/25 at 8:00 A.M., when the blood pressure was 128/74, and at 12:00 P.M., when the blood pressure was 124/72, - On 05/16/25 at 8:00 P.M., when the blood pressure was 128/68, - On 05/20/25 at 12:00 P.M., when the blood pressure was 126/70, and at 8:00 P.M., when the blood pressure was 123/67, - On 05/21/25 at 8:00 A.M., when the blood pressure was 136/68, at 12:00 P.M., when the blood pressure was 124/72, and at 8:00 P.M., when the blood pressure was 129/68, - On 05/24/25 at 12:00 P.M., when the blood pressure was 123/63, and - On 05/29/25 at 8:00 A.M., when the blood pressure was 128/70, at 8:00 P.M., when the blood pressure was 133/69. 2. The clinical record for Resident 15 was reviewed on 06/10/25 at 10:30 A.M. A Quarterly MDS assessment, dated 03/06/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, neurogenic bladder, and aphasia. The resident had an indwelling urinary catheter. An open-ended physician's order, with start date of 12/11/24, indicated the resident was to receive Losartan (a blood pressure medication) 50 mg, once a day for hypertension. The staff were to hold the medication if the systolic blood pressure was less than 120 or the heart rate was less than 60. The March, April, May, and June 2025 EMAR indicated the resident received the medication when their systolic blood pressure was less than 120 on the following dates: - On 03/06/25 when the blood pressure was 108/61, - On 03/11/25 when the blood pressure was 97/55, - On 03/19/25 when the blood pressure was 91/50, - On 04/01/25 when the blood pressure was 101/62, - On 04/03/25 when the blood pressure was 107/65, - On 04/06/25 when the blood pressure was 101/65, - On 04/10/25 when the blood pressure was 106/68, - On 04/23/25 when the blood pressure was 108/60, - On 04/30/25 when the blood pressure was 108/60, - On 05/01/25 when the blood pressure was 109/66, - On 05/21/25 when the blood pressure was 93/59, - On 06/04/25 when the blood pressure was 108/63, and - On 06/06/25 when the blood pressure was 103/63. 3. The clinical record for Resident 7 was reviewed on 06/10/25 at 02:32 P.M. A Quarterly MDS assessment, dated 05/30/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, amputation, anemia, hypertension, obstructive uropathy, diabetes, seizure disorder, anxiety, and depression. A current, open-ended physician's order, with a start date of 04/07/25, indicated the resident was to receive Midodrine 10 mg, three times a day at 8:00 A.M., 12:00 P.M., and 8:00 P.M. The staff were to hold the medication if the residents systolic blood pressure was greater than 120. The April, May, and June 2025 EMAR indicated the resident had received the medication when their systolic blood pressure was greater than 120 on the following dates and times: - On 04/27/25 at 8:00 A.M., when the blood pressure was 129/51, - On 04/28/25 at 12:00 P.M., when the blood pressure was 136/69 and 8:00 P.M., when the blood pressure was 129/74, - On 05/05/25 at 12:00 P.M., when the blood pressure was 129/47, - On 05/10/25 at 8:00 A.M., when the blood pressure was 134/50 and 12:00 P.M., when the blood pressure was 138/48, - On 05/17/25 at 8:00 A.M., when the blood pressure was 134/62 and 12:00 P.M., when the blood pressure was 134/62, - On 05/22/25 at 8:00 P.M., when the blood pressure was 151/63, - On 05/27/25 at 12:00 P.M., when the blood pressure was 136/43, - On 05/29/25 at 8:00 P.M., when the blood pressure was 127/45, - On 06/03/25 at 8:00 A.M., when the blood pressure was 140/60, - On 06/07/25 at 8:00 P.M., when the blood pressure was 122/60, - On 06/09/25 at 12:00 P.M., when the blood pressure was 128/59, and - On 06/10/25 at 12:00 P.M., when the blood pressure was 143/56. During an interview, on 06/11/25 at 11:10 A.M., Licensed Practical Nurse 2 indicated if a resident's medication had hold parameters, she would obtain the vital signs and if they were outside the parameters to give the medication then she would not administer it to the resident. She would document in the EMAR that the medication was not administered due to it being outside the parameters. The current facility policy titled, Medication Administration was dated 01/02/2024, was provided by the Director of Nursing on 06/11/25 at 11:40 A.M. The policy indicated, .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 3.1-37(a)

Based on record review and interview, the facility failed to revise a resident's care plan related to prophylactic antibiotic usage for 1 of 21 residents reviewed for care plans. (Resident 58) Findings include: Resident 58's clinical record was reviewed on 06/11/25 at 3:24 P.M. A Quarterly Minimum Data Set assessment, dated 02/28/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, diabetes, and renal insufficiency. The resident had an indwelling urinary catheter. The resident's current physician's orders included, but were not limited to the following: - An open-ended physician's order, with a start date of 02/13/25, for Cephalexin (an antibiotic) 500 milligrams, once daily for prophylaxis for recurrent UTIs (Urinary Tract Infections). The resident's Electronic Medication Administration Records for February, March, April, May, and June 2025 indicated the resident received the antibiotic daily since 02/13/25. The resident's complete Care Plan Report was reviewed on 06/12/25 at 10:45 A.M. and lacked a care plan for the prophylactic antibiotic usage. During an interview, on 06/12/25 at 11:05 A.M., the Director of Nursing indicated the resident's family reported the resident had a history of UTIs. The resident's urologist ordered the prophylactic antibiotic. The facility called to see about discontinuing the antibiotic, but the urologist wanted the resident to continue to receive the medication daily. The resident's care plan should have been updated to indicate she was receiving the prophylactic antibiotic. The current facility policy, titled Comprehensive Care Plan, dated 11/01/24, was provided by the Director of Nursing on 06/12/25 at 1:42 P.M. The policy indicated, .The comprehensive care plan will describe, at a minimum .services .to maintain the resident's/patient's highest practicable physical, mental, and psychosocial well-being . 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to follow physician's orders related to medication administartion for 1 of 21 residents reviewed for pharamcy services. (Resident 23) Findings include: During an observation, on 06/09/25 at 8:48 A.M., RN 4 sanitized her hands and prepared medications for Resident 23. After placing all the medications into a cup that included, but was not limited to, a Potassium Chloride Extended-Release 10 milliequivalent (MEQ) tablet, she poured the medications into a pouch, crushed the medications, placed them back into the medication cup, and added applesauce. The medications were administered to the resident. The current, open-ended physician's order, with a start date of 07/13/23, indicated the resident was to receive Potassium Chloride 10 MEQ Extended-Release tablet, once a day. The staff were to place the medication in applesauce and allow it to dissolve. The tablet was not to be crushed. During an interview, on 06/11/25 at 12:07 P.M., the Director of Nursing (DON) indicated if a physician's order stated to not crush a medication, then it should not have been crushed. The current facility policy titled, Medication Administration was dated 01/02/2024, was provided by the Director of Nursing on 06/11/25 at 11:40 A.M. The policy indicated, .Administer medication as ordered in accordance with manufacturer specifications .Crush medications as ordered. Do not crush medications with do not crush instructions . 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure proper placement of a urinary catheter drainage bag for a resident that received prophylactic antibiotics for Urinary Tract Infections (UTIs) for 1 of 4 residents reviewed for indwelling urinary catheters. (Resident 58) Findings include: On 06/09/25 at 10:28 A.M., Resident 58 was observed in her room in bed. The resident's urinary catheter drainage bag was hanging on the side of her bed. Dark yellow urine with sediment was visible in the tubing. There was a mat on the floor next to the bed and the bed was in a lower position. About two inches of the drainage bag was resting on the bare floor in the space between the bed and the floor mat. Resident 58 was observed in the A-Hall dining room on 06/10/25 at 12:12 P.M. The resident's catheter drainage bag was hanging under her wheelchair, with about an inch of the drainage bag resting on the floor. Resident 58's clinical record was reviewed on 06/11/25 at 3:24 P.M. A Quarterly Minimum Data Set assessment, dated 02/28/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, diabetes, and renal insufficiency. The resident had an indwelling urinary catheter. The resident physician's orders included, but were not limited to the following: - An open-ended physician's order, with a start date of 02/13/25, for Cephalexin (an antibiotic) 500 milligrams, once daily for prophylaxis for recurrent UTIs. The resident recieved the medication every day as ordered. During an interview, on 06/10/25 at 2:57 P.M., the Corporate Clinical Support Nurse indicated no part of an indwelling urinary catheter should be touching the floor. The current facility policy, titled Indwelling Catheter, dated 01/02/24, was provided by the Director of Nursing on 06/12/25 at 1:32 P.M. The policy indicated, .if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice . 3.1-41(a)(2)

Based on observation and interview, the facility failed to store medications appropriately related to outdated/undated medications for 3 of 4 medication carts observed. (A, B, and C Hall medication Carts) Findings include: The A-Hall Medication Cart was observed on [DATE] at 10:14 A.M., with Licensed Practical Nurse 2. The following was observed: - an unopened vial of insulin Lispro for Resident 59 that was undated, - an opened Symbicort inhaler for Resident 17 that was undated, and - an opened Albuterol inhaler for Resident 17 that was undated. The B-Hall Medication Cart was observed on [DATE] at 10:19 A.M., with LPN 6. The following was observed: - a Combivent inhaler for Resident 65, that was dated [DATE]. The C-Hall Medication Cart was observed on [DATE] at 10:27 A.M., with LPN 3. The following was observed: - an opened vial of Humalog for Resident 16 that was 3/4 full that was undated. The nurse indicated it came from the pharmacy on [DATE] and wrote that as the open date on the vial. During an interview on [DATE] at 11:37 A.M., the Director of Nursing (DON) indicated all insulins should have dates on them if they were in the medication cart. If they were not opened, then they should have been in the refrigerator. The albuterol inhalers were good for one year after they were opened, the Symbicort and Combivent were good for 90 days. The inhalers should have had open dates and should be discarded after they expired. The current Product Expiration Dates with a revision date of [DATE], was provided by the DON on [DATE] at 1:38 P.M. The policy indicated, .Insulin vials .Room Temperature Exp [expiration] date .28 days .Albuterol [aerosol] .12 months .Combivent .3 months .Symbicort .90 days . 3.1-25(o)

Based on record review and interview, the facility failed to notify the physician of a change in condition for 1 of 3 residents reviewed for Notification of changes. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/19/24 at 10:38 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/10/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia, hypertension, anxiety, and depression. Consumption Charting, dated 01/30/24 at 10:50 A.M., indicated Resident B had eaten less than a quarter of his meal. Consumption Charting, dated 01/30/24 at 1:50 P.M., indicated Resident B had eaten less than a quarter of his meal. A Progress Note made by Registered Nurse (RN) 2, dated 01/30/24 at 4:30 P.M., indicated Resident B was lethargic. A Progress Note made by Licensed Practical Nurse (LPN), 3 dated 01/30/24 at 7:19 P.M., indicated Resident B was found unresponsive and without a pulse at 6:05 P.M. During an interview on 12/19/24 at 12:40 P.M., RN 2 indicated she was unable to recall who the resident was and that she was unable to say anything other than what her documentation represents. During an interview on 12/19/24 at 3:40 P.M., the Director of Nursing (DON) indicated there was no documentation of the physician being notified on 01/30/24 when the resident was lethargic, and the last notification of change documented for Resident B was on 11/07/23. A current facility policy, titled Change in Condition / Physician Notification dated 01/02/24, was provided by the DON on 12/19/24 at 3:55 P.M. The policy indicated, . 2. When a change in condition is discovered, the nurse will evaluate the resident and notify the resident's physician/NP/PA with pertinent information to discuss care for the resident. 3. The nurse will notify the physician/NP/PA and the resident/resident representative when: . A significant change in the resident's physical, mental, or psychosocial status . This citation relates to Complaint IN00447341. 3.1-5(a)(3)

Based on interview and record review, the facility failed to report an allegation of verbal abuse in a timely manner for 1 of 3 residents reviewed for reporting of alleged violations. (Resident C) Findings include: During an interview on 09/04/24 at 8:38 A.M., Resident C indicated that a girl that worked at the facility had called him a B**** last week. He was unsure of their name but believed other staff had reported it. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 102 indicated that on 08/29/24, LPN (Licensed Practical Nurse) 3 was very rude to Resident C and was verbally abusive. The LPN was yelling at the resident over the top of the nurse's station. It was reported to the DON. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 103 indicated that on 08/29/24, LPN 4 was cussing/yelling at Resident C and pointing her finger at him over the top of the nurse's station. The resident told her that she was upsetting him. She started to walk away from the resident and said, Someone better get him the F*** away from me because the B*** nurse in me is about to come out. The DON was notified of the situation. During an interview on 09/04/24 at 9:04 A.M., the DON indicated it was reported to her that there was a situation with Resident C and LPN 4. She was told that LPN was verbally abusive to Resident C on 08/29/24. She had called the Executive Director and started an investigation immediately. It was determined that abuse had not occurred, and the nurse was able to finish her shift that night. She had asked the Executive Director if the nurse needed to be removed from the floor, and the ED deemed that the nurse was stern with the resident. She was trying to get him to turn his radio down due to over stimulation. She had talked with Resident C the next morning after the incident and he had no concerns and was his usual self. After talking with the new Executive Director and Clinical Support Nurse it was determined that the allegation needed to be reported. The incident was reported to the Indiana Department of Health on 09/03/24. During an interview on 09/04/24 at 9:59 A.M., the DON indicated she did not come into the building the night of the incident on 08/29/24. She did everything via phone. She had talked with the resident the following day. The investigation report for the, 8/29/24, allegation between Resident C and LPN 4 was reviewed. The investigation lacked an interview with Resident C or any other residents in the facility. The current facility policy titled, ABUSE, MISTREATMENT, NEGLECT, EXPLOITATION, AND MISAPPROPRIATION, dated 01/02/24, was provided by the Regional Clinical Support on 09/04/24 at 2:04 P.M. The policy indicated, .It is the facilities policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident .Initial Report .Timing .Department of Health. If abuse is alleged .If any form of abuse is alleged (e.g., physical, verbal,etc.) .related to any other reportable incident. The Administrator or his/her designee will notify the Department of Health immediately, but no later than 2 hours after the allegation is made . 3.1-28(c)

Based on interview and record review, the facility failed to appropriately investigate an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident C) Findings include: During an interview on 09/03/24 at 10:01 A.M., CNA (Certified Nurse Aide) 2 indicated she had heard that a nurse had gotten into a resident's face last Thursday, 08/29/24. She wasn't working at the time of the incident but had heard about it. She believed someone had reported it to the DON (Director of Nursing). During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 102 indicated that on 08/29/24, LPN (Licensed Practical Nurse) 3 was very rude to Resident C and was verbally abusive. The LPN had yelled at the top of her lungs that no one wanted to listen to his F***ing music. She was yelling at the resident over the top of the nurse's station. The nurse had turned away from the resident and said, You better get him the F*** away from me. It was reported to the DON. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 103 indicated that on 08/29/24, LPN 4 was cussing/yelling at Resident C and pointing her finger at him over the top of the nurse's station. She was telling him to shut up and that no one wanted to listen to his stupid music. The nurse had turned away from the resident and the resident had said something. The nurse turned back and asked what the resident had said, and no one had answered her, so the nurse asked the resident what he had said. The resident told her that she was upsetting him. She started to walk away from the resident and said, Someone better get him the F*** away from me because the B*** nurse in me is about to come out. The LPN walked off the hallway and the resident remained where he was crying and upset. The DON was notified of the situation. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 104 indicated that on 08/29/24, there was another resident sitting at the nurse's station being very loud. She was yelling for her family. Resident C had turned the music up really loud, to drown her out the other resident's yelling. During an interview on 09/04/24 at 8:38 A.M., Resident C indicated that a girl that worked at the facility had called him a B**** last week. He was unsure of their name but believed other staff had reported it. During an interview on 09/04/24 at 9:04 A.M., the DON indicated it was reported to her that there was a situation with Resident C and LPN 4. She was told that LPN was verbally abusive to Resident C on 08/29/24. She had called the Executive Director and started an investigation immediately. It was determined that abuse had not occurred, and the nurse was able to finish her shift that night. She had asked the Executive Director if the nurse needed to be removed from the floor, and the ED deemed that the nurse was stern with the resident trying to get him to turn his radio down due to over stimulation. She had talked with Resident C the next morning after the incident and he had no concerns and was his usual self. During an interview on 09/04/24 at 9:59 A.M., the DON indicated she did not come into the building the night of the incident on 08/29/24. She did everything via phone. She had talked with the resident the following day. When investigating allegations of abuse, she would make sure the resident was safe, and talk with staff and other residents. The aides had talked with the resident that night, but they did not initiate an investigation, it was to be done by the Executive Director. The Social Service Director usually talked to the other residents but that was not done. The investigation report for the, 8/29/24, allegation between Resident C and LPN 4 was reviewed. The investigation lacked an interview with Resident C or any other residents in the facility. The DON had talked with 5 staff members. The current facility policy titled, ABUSE, MISTREATMENT, NEGLECT, EXPLOITATION, AND MISAPPROPRIATION, dated 01/02/24, was provided by the Regional Clinical Support on 09/04/24 at 2:04 P.M. The policy indicated, .It is the facilities policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident .Investigation Protocol. The person investigating the incident should generally take the following actions: Interview the resident, the accused, and all witnesses .If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident . 3.1-28(d)

Based on observation and interview, the facility failed to provide a homelike environment related to odors for 1 of 4 Hallways reviewed. (B- Hall) Findings include: During an observation on 06/26/24 at 11:05 A.M., there was a strong urine odor upon entering the B-Hall secured unit. During an observation on 06/26/24 at 12:34 P.M., there was a strong urine odor in the B-Hall dining room during mealtime. A sticky substance with a foul urine odor was on the floor causing resistance when walking next to the juke box in the common area. During an observation on 06/27/24 at 10:00 A.M., there was a strong urine odor upon entering the B-Hall secured unit. During an observation on 06/28/24 at 9:40 A.M., there was a strong urine odor upon entering the B-Hall secured unit. The odor was observed while walking down the hallway on the unit, and in the common area. During an observation on 06/28/24 at 2:11 P.M., a strong urine odor was in the common area/dining room of the B-Hall secured unit. During an observation on 07/01/24 11:45 A.M., residents 95's room smelled strongly of urine. The resident's bedding was removed, and the bed left bare. During an observation on 07/02/24 at 1:34 P.M., there was a strong urine odor upon entering the B-Hall secured unit. During an interview on 07/01/24 at 3:29 P.M., the Head of Maintenance indicated he had been trying to control the urine smell on the B-Hall. New interventions were in place, but there was a resident that would constantly urinate on something then move a cart over top of it. They had installed new ventilation systems in the main building that maintain the building at one point five negative pressure. The system sucks the air out of the building constantly, but with the secured unit doors being closed it did not work as well back there. He indicated he was hoping to get a separate ventilation system for the B-Hall to help with the ventilation. During an interview on 07/02/24 at 1:13 P.M., CNA (Certified Nurse Aide) 5 indicated there was an issue with urine on the floor on the B-Hall. One resident urinated randomly in their room and another resident was going into other residents' rooms and urinating. During an interview on 07/02/24 at 1:34 P.M., the housekeeping supervisor indicated there was a urine odor on the B-Hall. There were a few residents on the unit that urinated in different spots. They tried to keep up with moping, but they could not mop all day and the smell came right back. Last year there was an issue with the dining room recliners holding the urine odor so those had all been replaced. She believed they were trying to get a ventilation system to get the air moving more. The current facility policy, dated 01/02/24, titled, Resident Rights was provided by the administrator on 07/02/24 at 2:07 P.M. The Policy indicated, .The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely . 3.1-19(f)(5)

Based on observation and interview, the facility failed to maintain residents' snack refrigerators related to the storage of non-food items and unlabeled food items, for 3 of 4 resident snack refrigerators reviewed. (C-Hall, A-Hall, and D-Hall snack refrigerators) Findings include: 1. The C-Hall resident snack refrigerator was observed on 07/02/24 at 9:40 A.M., with LPN (Licensed Practical Nurse) 2. An ice pack was lying in the bottom bin of the freezer. The nurse indicated Resident 67 occasionally used it for their shoulder and resident items should be labeled with a name and a date. 2. The A-Hall resident snack refrigerator was observed on 07/02/24 at 9:47 A.M., with LPN 3. The freezer contained six small tubs of ice cream that were sitting right next to a large blue ice pack. The nurse indicated the ice pack was for a resident who had been discharged . The resident had used the ice pack following a knee replacement surgery. 3. The D-Hall resident snack refrigerator was observed on 07/02/24 at 9:59 A.M., with RN 4. The refrigerator contained a pudding cup that was opened, half full, and not labeled. During an interview on 07/02/24 at 10:06 A.M., the DON (Director of Nursing) indicated pudding that had been opened for medication administration should be kept in the refrigerator and labeled. Ice packs that had been placed on a resident's body should not be stored in the resident snack refrigerators. The current Refrigerators and Freezers policy, with a revised date of December 2014, was provided by the DON on 07/02/24 at 10:28 A.M. The policy indicated, .This facility will ensure safe refrigerator and freezer maintenance .sanitation .All food shall be appropriately dated . The current FOOD BROUGHT IN BY FAMILY OR VISITORS policy, dated 01/02/24, was provided by the DON on 07/02/24 at 10:57 A.M. The policy indicated, .All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices . 3.1-21(i)(3)

Based on interview and record review, the facility failed to prevent a resident from being physically restrained for 1 of 3 residents reviewed for restraints. (Resident B) Findings include: During an interview on 01/28/24 at 2:35 P.M., LPN (Licensed Practical Nurse) 6 indicated there was an incident last month where a CNA (Certified Nurse Aide) put a blanket around a resident. A staff member indicated they entered the memory care unit and saw the blanket around Resident B. That staff member reported it to another staff member, and that person reported it to LPN 6. LPN 6 got the Weekend Manager and they both went to check it out. The resident was sitting in her wheelchair. A blanket was wrapped around the resident at her waist, and it was tied in the back. The resident's clinical record was reviewed on 01/29/24 at 10:00 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 11/21/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, manic depression, psychotic disorder, and malnutrition. The resident required substantial/maximal staff assistance for toileting, personal hygiene, sitting to standing, and upper body dressing. The resident was dependent on staff for showering and lower body dressing. The record lacked a physician's order for a restraint or seat belt device. During an interview on 01/28/24 at 3:25 P.M., CNA 2 indicated she provided care for Resident B. The resident would often try and get up from her wheelchair or a recliner on her own and she had experienced several falls. On that particular day, when the resident was in her wheelchair she was leaning forward. When she put her in a recliner, the resident would lean over the side, headfirst. She was worried the resident was going to fall. She tried to place the resident in her wheelchair near the nurses' station, but the nurse didn't want her by the medication cart because she was trying to administer residents' medications. She tried to put the resident in bed, but the nurse wouldn't let her lay the resident down until after she received her medications, and they had time to kick in. CNA 2 asked the nurse why the resident didn't have a seat belt or an alarm. The nurse said the resident had no alarms. CNA 2 picked up a fleece blanket from the floor, and indicated she was going to take the blanket and make a seatbelt. She took the blanket, put it around the resident, tucked it into the sides of the resident's wheelchair, and pushed the resident up to the table. The resident was no longer falling forward, the blanket was keeping her in the wheelchair. 38769 During an interview on 01/28/24 at 2:56 P.M., Dietary Aide 3 indicated she had walked onto the memory care unit to retrieve the dinner trays. Resident B was acting a little different than normal and CNA 2 had said the resident wasn't having a good day and that she had put a blanket around her so she wouldn't get up. The Dietary Aide told her she wasn't allowed to do that. The resident was sitting in her wheelchair and the blanket was around the resident's mid-section and tied around the back of the wheelchair. She went and reported it the LPN 6, who she believed reported it to the DON (Director of Nursing). The resident was put to bed shortly after the incident. During an interview on 01/28/24 at 3:27 P.M., CNA 4 indicated she worked on the memory care unit frequently. Resident B liked to get up and down a lot. On 12/31/23, she was working the memory care unit with CNA 2. She had stepped off the hall to make a phone call. When she returned, Resident B was in her wheelchair and had a fleece blanket around her mid-section and tied behind the back of the wheelchair. The resident would not have been able to remove the blanket. LPN 5 came back at the same time she did. The blanket was removed, the resident was laid in bed and CNA 2 was removed from the hallway and was not allowed to work back there. The incident was reported to the DON. During an interview on 01/29/24 at 10:18 A.M., the DON indicated LPN 6 had called her and told her that a staff member had alerted her that Resident B had a blanket around her. She had LPN 6 go and assess the resident and the situation. LPN 5 was already on the memory care unit when LPN 6 got there, and the resident had a blanket that was loosened around her. CNA 2 had put the blanket around the resident to keep her safe. During an interview on 01/29/24 at 10:25 A.M., the Administrator indicated a staff member had stepped into the dining room of the memory care unit and Resident B had a blanket tucked in tightly around her while she was in the wheelchair. The staff member said the resident wouldn't stay in her recliner, so she tucked the blanket in to keep the resident from falling out of the chair. The current facility policy, titled Use of Restraints, with a revised date of April 2017, was provided by the DON on 01/29/24 at 11:35 A.M. The policy indicated, .Restraints shall only be used to treat the resident's medial symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restraints normal access to one's body .Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor) . This citation relates to Complaint IN00425571. 3.1-26(b) 3.1-26(s)

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers that resulted in the development of Stage 3 pressure ulcers (Residents 16 and 103) and follow a physician's order (Resident 91) for 3 of 7 residents reviewed for pressure ulcers. Findings include: 1. During an observation of Resident 16's wound on 05/11/23 at 9:43 A.M., the Wound NP (Nurse Practitioner) cleansed the wound to the left heel. The area had slightly macerated skin. The wound bed was pink with no drainage. The wound measured 0.4 cm (centimeters) x (by) 0.4 cm. The Wound NP indicated she expected the wound to be macerated due to the treatment she had in place. The clinical record for Resident 16 was reviewed on 05/10/23 at 1:52 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/22/23, indicated the resident was rarely/never understood. The diagnoses included, but were not limited to, Alzheimer's disease, hypertension, anxiety, depression, and contracture. The resident required total staff assistance with transfers, locomotion, eating, toileting, personal hygiene, and bathing. The resident had an unhealed Stage 3 (Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure ulcer that was not present on admission. A Braden Scale for Predicting Pressure Sore Risk, dated 08/28/22, indicated the resident was a high risk for developing pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk, dated 11/17/22, indicated the resident was a high risk for developing pressure ulcers. A Weekly Nursing Assessment, dated 11/23/22, indicated the resident had no current issues and the skin was warm and dry. The Shower Reports for the resident indicated the resident had no skin issues for the following dates: - 11/02/22, - 11/05/22, - 11/09/22, - 11/12/22, - 11/16/22, - 11/19/22, - 11/24/22, A Shower Report, dated 11/26/22, indicated the resident had open areas. A physician's order, dated 06/23/22 through 11/27/22, indicated the resident was to have skin prep to the left heel once a day for a preventative. A physician's order, dated 12/29/22 through 04/18/23, indicated the resident was to have Z-flow (off loading) boots, every shift, to the bilateral feet. The boots were to be removed for bathing and skin assessments. A Weekly Pressure Ulcer Observation, dated 11/28/22, indicated the resident had a Stage 3 pressure ulcer to the left heel, plantar surface, that was acquired in house. The pressure ulcer measured 3.4 cm x 2.4 cm x 0.1 cm. There was slough (yellow, tan, white, stringy) tissue present. The wound was moist and dry. There was a scant amount of serous (watery clear or slightly yellow/tan/pink fluid that has separated from the blood) drainage. A treatment was initiated. The facility indicated the wound was caused by the staff elevating the resident's leg rest on the Broda chair (a specialized wheelchair) due to edema of the left lower leg. Elevation of the leg rest had increased the pressure on the heels due to the resident's contractures. A Weekly Pressure Ulcer Observation, dated 12/29/22, indicated the resident had a Stage 3 pressure ulcer to the left heel. The pressure ulcer measured 3 cm x 4 cm x 0.1 cm. There was slough present with a moderate amount of serosanguineous drainage (drainage that contains blood and the liquid part of blood). A Weekly Pressure Ulcer Observation, dated 01/26/23, indicated the resident had a Stage 2 (partial thickness skin loss with exposed dermis) pressure ulcer to the left heel. The pressure ulcer measured 1.8 cm x 1.8 cm x 0.1 cm. The pressure ulcer was moist and had a small amount of serosanguineous drainage. A Weekly Pressure Ulcer Observation, dated 02/24/23, indicated the resident had a Stage 3 pressure ulcer to the left heel. The pressure ulcer measured 2.5 cm x 2.3 cm x 0.1 cm. The pressure ulcer had a moderate amount of serosanguineous drainage. A Weekly Pressure Ulcer Observation, dated 03/30/23, indicated the resident's Stage 3 pressure ulcer to the left heel was resolved. A Weekly Pressure Ulcer Observation, dated 04/13/23, indicated the resident had a Stage 3 pressure ulcer to the left heel that measured 2.3 cm x 3.2 cm. There was no drainage present. A Weekly Pressure Ulcer Observation, dated 05/04/23, indicated the resident had a Stage 3 pressure ulcer to the left heel that measured 0.8 cm x 0.6 cm x 0.2 cm. There was a scant amount of serosanguineous drainage. The progress notes lacked indication the resident had open areas to the left heel until the initial observation on 11/28/22. During an interview on 05/11/23 at 9:36 A.M., the Wound Nurse Practitioner indicated the resident's wound to the left heel had closed for about a week and it had opened again. The wound had always been a Stage 3. The resident had severe contractures to the legs and had pressure no matter where her feet were placed. She always wore heel boots and had even tried a different boot recently, but it hadn't worked well so they had to switch back. During an interview on 05/11/23 at 1:39 P.M., the ADON (Assistant Director of Nursing) indicated at the time of the development of the pressure ulcer the resident was having increased swelling in her legs. She had contractures with no flexion, so when her legs were elevated on the footrest it made her left heel dig in more to the footrest even though she wore heel boots. It only took about a day and a half for it to develop. She felt that the footrest of the Broda chair was what caused the pressure. It was hard to float her heels in bed because they would dig in due to her body alignment. The nurses were to check the skin weekly, and the CNAs would check the skin when providing care and alert the nurse. The resident received showers or bed baths twice a week. The resident had received skin prep to the bilateral heels once a day until 11/27/22 and then it went to twice a day. On 11/23/22 the skin was intact. She would think that the staff would have noticed some skin impairment before the wound was a Stage 3. The resident had jerked a lot with tactile touch. She believed the staff probably were not inspecting the skin when they were applying the skin prep, they were probably just lifting the heel, wiping it on, letting it dry, and replacing the Z-flow boot. The area had healed in April, and she had switched the type of boot she was wearing to provide better relief, but it had the opposite effect and opened the wound back up. 2. During an observation on 05/11/23 at 11:04 A.M., Resident 103 was laying on her left side in bed. She was alerted that the staff were going to change her dressing to the coccyx. An old dressing was removed and dated 05/11/23. There was a moderate amount of purulent drainage. The wound was cleansed. The wound was covered in slough. The Wound Nurse Practitioner debrided the wound. There was tunneling present. The wound was packed with Dakin's (a bleach solution) soaked gauze and covered with a dressing. The wound measured 4.2 cm x 3.4 cm x 0.3 cm pre-debridement and was 6 cm x 7.2 cm x 1.2 cm with undermining from 10 o'clock to 3 o'clock at 5.5 cm, and 5 o'clock to 8 o'clock at 4.7 cm. During an interview on 05/11/23 at 10:54 A.M., the Wound Nurse Practitioner indicated the resident had started in March with blanchable redness to the coccyx. She had fallen and broken her hip. She mostly sat in her wheelchair or recliner and developed the pressure ulcer. She had seen her once week with the blanchable redness and then the next week it was unstageable. She was recently notified that the family had told the facility that she had an unstageable pressure ulcer to the same area that had healed prior to coming to the facility. The facility tried to culture the wound last week, but it was to dry. She had started the resident on an antibiotic for a potential wound infection. During an interview on 05/11/23 at 11:20 A.M., the Wound Nurse Practitioner indicated the wound was unstageable that day and had worsened. She had planned for it to be worse that week but not as bad as it was. There was bone palpable, and she was worried it would tunnel to the rectum, so she was going to request for a general surgery consult. An Admission MDS assessment, dated 03/27/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, fractures, hypertension, non-Alzheimer's dementia, anxiety, depression, and psychotic disorder. The resident was frequently incontinent of bowel and bladder. She was at risk for skin impairments and required extensive assistance of two or more staff for bed mobility, transfers, toileting, and personal hygiene. A Braden Scale for Predicting Pressure Sore Risk, dated 03/21/23, indicated the resident was at risk for pressure sore development. A Skilled Care Nursing Documentation, dated 04/12/23, indicated the resident had no current skin issues. A Skilled Care Nursing Documentation, dated 04/13/23, indicated the resident had no current skin issues. The Shower Reports for April 2023 indicated the resident had no open areas on 04/04/23 and 04/07/23. The Shower Report, dated 04/12/23, indicated the resident had and open wound and house barrier cream was applied. The report was signed by the nurse. A Wound Assessment Report, dated 04/13/23, indicated the resident had a Stage 3 pressure ulcer to the coccyx that measured 4.2 cm x 4 cm x 0.1 cm. The wound had 50 to 74% slough (non-viable yellow/tan/gray/green/brown tissue, usually moist, stringy, mucinous in texture), with a moderate amount of serous drainage. A treatment was initiated. A Wound Assessment Report, dated 05/04/23, indicated the Resident had a Stage 3 pressure ulcer to the coccyx that measured 4.2 cm x 3.4 cm x 0.3 cm. There was 75 to 99% slough with a moderate amount of serosanguineous drainage. During an interview on 05/12/23 at 10:45 A.M., LPN 6 indicated the resident should have orders in the EMAR/ETAR for a wheelchair cushion or offloading mattress that the nurse would document was in place, each shift. The Complete Care Plan, was provided by the DON on 05/15/23 at 8:30 A.M., the Care Plan included, but was not limited to, the following: - The resident was at risk for skin breakdown with a start date on 03/15/23 and a revision date of 04/03/23. The interventions included, to assist the resident with bed mobility to turn and reposition routinely, assist with routine toileting, check for incontinence, and provide incontinent care as needed. Notify the nurse of any redness or irritation, preventative skin care as ordered/indicated, skin inspection weekly and as needed, document and notify the MD of abnormal findings. The interventions were all initiated on 03/15/23. During an interview on 05/11/23 at 1:21 P.M., QMA 2 indicated the resident was admitted to the facility and then fell shortly after coming and broke her hip. Ever since the fall she had a decline in her health. She coccyx wound had gotten worse. The wound had started as a red area and then opened. The resident had a cushion in the wheelchair and the nursing staff would move it to the recliner when she wanted to sit in the recliner as she had not been in her bed a lot. She recently had an air mattress in place. She would alert the Unit Manager of any redness and they would document in a progress note. During an interview on 05/11/23 at 1:52 P.M., the ADON indicated the resident had not had very good nutrition. She believed the resident developed the area to her coccyx from pressure. The resident was thin. When she fell and broke her hip she liked to sit up in the den in her wheelchair or the recliner. She would grip the table and rock back and forth and cause friction on her coccyx. It didn't take long for the pressure to settle in. The resident had a cushion to the recliner and wheelchair. During an interview on 05/12/23 at 10:24 A.M., the ADON indicated she was told about the blanchable redness but had never documented it. The staff should have documented the blanchable redness on the skilled nursing assessments or shower sheets. During an interview on 05/12/23 at 10:36 A.M., CNA 11 indicated she would look for redness or open areas on residents skin while giving showers or daily care. She would alert the nurse of any redness or new open areas. During an interview on 05/12/23 at 1:35 P.M., the ADON indicated pressure reducing mattress and cushions were documented on the EMAR/ETAR. Every mattress in the building was offloading and every resident was issued a cushion when admitted to the facility. She didn't agree with the Wound Nurse Practitioners assessments that it was a Stage 3 when it was found. The current undated, facility policy titled, Prevention of Pressure Injuries, was provided by the DON on 05/15/23 at 8:30 A.M. The policy indicated, .The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .During skin assessment inspect presence of erythema, temperature of skin and soft tissue, and edema .Inspect the skin on a daily basis when performing or assisting with personal care of ADL's [Activities of Daily Living]. Identify any signs of developing pressure injuries .Evaluate, report and document potential changes in the skin .review the interventions and strategies for effectiveness on an ongoing basis . 38239 3. Resident 91 was observed in his room on 05/09/23 at 1:56 P.M. The resident was in bed, under the covers. The resident was not wearing pressure reducing boots. On 05/11/23 at 10:37 A.M., the resident had moved to a different room. The resident was in bed and appeared to be sleeping. The head of the bed was elevated, and the resident was wearing non-skid socks with his heels resting on the mattress. The resident's pressure reducing boots were observed on a dresser against the wall. On 05/11/23 at 1:20 P.M., the resident was observed in his room in bed. The resident's heels were not floated, and the boots were in same place on the dresser. On 05/12/23 at 10:22 A.M., the resident was observed in his room in bed. The resident was wearing non-skid socks. The resident's heels were resting on the mattress. The pressure reducing boots were sitting on the dresser. The resident indicated the last time he wore the boots was a few weeks ago. A CNA (Certified Nurse Aide) entered the room and asked the resident if he needed anything. The CNA did not reposition the resident's heels to ensure they were not touching the mattress, nor did she offer to apply the pressure reducing boots to the resident's feet. On 05/15/23 at 10:37 A.M., the resident was observed in bed. The resident had pillows under his legs, but his legs were bent in such a way that that resident's heels were resting on the mattress. The pressure reducing boots were in the closet on top of a folded blanket. The resident's clinical record was reviewed on 05/15/23 at 11:19 AM. A Quarterly MDS assessment, dated 01/20/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, stroke, hemiplegia affecting the left side, seizure disorder, and malnutrition. The resident received hospice services. The resident was at risk for pressure ulcers and utilized pressure reducing devices for the bed and chair. During an interview on 05/15/23 at 10:38 A.M., LPN 6 indicated the resident had no pressure ulcers at that time. He had pressure reducing boots and he usually wore them. Sometimes when he wore them, he might say his feet were stuck, but he was tall, so they usually would just need to pull him up in bed to reposition him so his feet wouldn't touch the end of the bed frame or the wall. The nurses signed off that the boots were in place every shift on the EMAR. If the resident refused to wear the boots it should be documented on the EMAR and in a Progress Note. The May 2023 EMAR was provided by the DON on 05/15/23 at 12:25 P.M. An open-ended physician's order, with a start date of 07/11/22, indicated the resident was to wear heel boots every shift as a preventative measure. The EMAR documentation indicated the boots were applied every day and night shift. A Care Plan, initiated on 04/15/2022, indicated the resident was at risk for skin breakdown. Interventions included, but were not limited to, bilateral heel protectors applied as a preventative measure, with a start date of 07/20/22. 3.1-40(a)(2)

Based on interview, observation, and record review, the facility failed to provide emergency basic life support of rescue breathing, immediately when needed, for a resident after staff witnessed the resident go unresponsive with no breathing and failed to have the necessary equipment available for staff to perform rescue breathing. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 1:50 p.m. While staff members were providing Resident B with a bed bath, the resident became unresponsive with no breathing. Staff members went to provide CPR (a medical intervention used to restore circulatory and respiratory function that has ceased), and neither of the two facility crash carts had an Adult Bag Valve Mask (BVM) or face shield. During the code no breaths were provided to the resident. Staff placed the resident's nasal canula on his nose with supplemental oxygen. The resident was provided only chest compressions until EMS arrived. The resident's full code status was signed by the physician on [DATE]. The resident expired on [DATE] at 2:16 p.m. Findings include: A record review for Resident B on [DATE] at 11:08 a.m., indicated the resident was cognitively intact, required two physical staff members' extensive assistance for mobility, he was totally dependent for transfer, and required one physical staff member's extensive assistance for ADLs (Activities of Daily Living). A Care Plan, dated [DATE], indicated Resident B had established advanced directive and wished to be a Full Code. Interventions included but were not limited to refer to Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated [DATE] at 1:50 p.m., indicated the nurse was notified Resident B was not breathing and had no pulse. CPR (Cardiopulmonary Resuscitation) was initiated, and AED (automated external defibrillator) pads were placed on the resident. 911 was called. Facility staff continued rescue efforts until EMS (Emergency Medical Services) arrived. The AED advised no shock times two, and to continue CPR. EMS team took over rescue efforts. EMS notified the doctor of status and code called, and the time of death was 2:16 p.m. The EMS report, dated [DATE] at 4:35 p.m., indicated EMS arrived at the facility at 2:05 p.m. and was directed to Resident B's room. Upon entering the room, the facility staff requested an BVM from the EMS staff and was provided one from the EMS equipment bag. Facility staff members indicated no shocks were given prior to EMS arrival, and EMS took over the code. EMS received a CPR cease order, and the resident was pronounced deceased . During an observation and interview, on [DATE] at 10:07 a.m., QMA (Qualified Medication Assistant) 2 was observed sitting at the D Hall nurses' station. She indicated the crash cart was behind her. The cart was observed. The cart had no cover, and there was a large purse and sweatshirt on top of the supplies. She provided a blank copy of the Night Shift Crash Cart Audit check list. The last audit completed for the cart was dated [DATE]. The items not located on the cart were the following: Clip board with Code Blue documentation, Adult BVM with Mask and Tubing, CPR rescue mask with valve, disposable gowns, non-rebreather mask, oxygen mask, bandage scissors, blood pressure cuff and stethoscope, 4 by 4 gauze sponges, adhesive and surgical tape. The AED was not on the cart. She indicated there was a code over the weekend; the AED was being serviced and pads had been ordered on Monday. During an observation and interview, on [DATE] at 10:12 a.m., RN 3 indicated the A Hall crash cart was covered with a blue blanket. She provided a blank copy of the Night Shift Crash Cart Audit check list for the A Hall. The last audit was dated [DATE]. The items not located on the cart were the following: Clip board with Code Blue documentation, extension cord, face shield, non-rebreather mask, and no AED. She indicated the AED was on the wall next to the main office. There was no AED observed on the wall next to the main office. During an interview on [DATE] at 10:20 a.m., the Unit Manager indicated the AED was in the DON's (Director of Nursing) office and a new one had been ordered. During an interview on [DATE] at 12:15 p.m., the EMS EMT (Emergency Medical Technician) indicated upon arrival at the facility, they were directed to Resident B's room. The EMT indicated a large male was observed lying on the bed next to the window. There was a crash cart in the room; but there was no suction and no BVM. A staff member was standing at the head of the bed, on the window side, she asked us for a BVM, so one was provided from the EMS bag. There was a staff member doing compressions, there were no rescue breaths being given until EMS arrived and took over the CPR. The paramedic received cease orders and the resident was pronounced deceased . The MT indicated EMS gave rescue breaths with a BVM out of their equipment during the code. During an interview on [DATE] at 2:05 p.m., RN 3 indicated it was around 2:00 p.m., she was out getting lunch, when she received a call concerning the Code Blue. She instructed the caller to notify someone in the building. She immediately returned to the building and staff were in Resident B's room, when she entered the room, he was lying in his bed next to the window, the ADON and DON were doing compressions. She cleared the hall of residents, staff, and equipment and went to assist the unit manager. She had sent Resident B out the day before due to critical hemoglobin and thematic labs. She did not see any rescue breathing while she was in the room, she had asked if they needed oxygen and the ADON said, no [NAME] bag [BVM]. She did not see a mouth shield and did not observe any rescue breathing. During an interview on [DATE] at 2:20 p.m., CNA 8 indicated when the code occurred on [DATE], the nurse on the A Hall and the QMA on the C Hall were gone to lunch. She went to the room and ask if the staff present needed anything. They sent her to look for the BVM, but she couldn't find one. During an interview on [DATE] at 2:26 p.m., QMA 9 indicated she had been working on the B Hall when they saw the management staff running down toward the C Hall. She went to assist and upon entry observed the resident lying on his bed, the privacy curtain was pulled, there was lots of staff in the room, and the crash cart was there, so she got in line to give compressions. She did not do rescue breathing and did not observe anyone doing rescue breathing. During an interview on [DATE] at 2:39 p.m., the Unit Manager indicated she was in a care plan meeting on [DATE], so it was several minutes before she arrived at the code. Upon entry to the room, staff were doing compressions. No one was doing rescue breathing because the resident was on oxygen. Normally he was on two litters of oxygen, but the concentrator was on five litters. There was no BVM on the crash cart and a staff member was sent for it. She then went to the nurses' station to make notification phone calls. During an interview on [DATE] at 2:45 p.m., LPN 10 indicated she was working the D Hall on [DATE]. She indicated the D Hall CNA notified her a nurse was needed right now on the C Hall. She heard a commotion as she arrived at Resident B's room and staff were coding the resident. One staff was doing compressions. Upon entry to the room, she observed Resident B lying in bed, he was blue, and compressions were being administered. No one was doing rescue breathing, he had a nasal canula, he normally was on two litters of oxygen, but she was not sure of the setting at the time of the code. There were multiple staff in the room, they took turns doing 30 compressions each and then would switch. No rescue breathing, no BVM, and no mouth to mouth was observed. When EMS arrived to the facility, they worked on him. During an interview on [DATE] at 3:13 p.m., the previous ADON indicated she was in her office when she was notified the CNA had been giving Resident B a bath, he coughed and then stopped breathing. She ran to the C Hall and upon entry the crash cart was there. No rescue breaths were being given. She stated, you can do CPR without rescue breathing. She does not know how many rounds of compressions were completed on the resident. When EMS arrived, she left the room, and the resident was a dusky purplish color. During an interview on [DATE] at 4:07 a.m., the MDS coordinator indicated, on [DATE], a CPR class was provided to staff in the building. During an interview on [DATE] at 4:10 p.m., CNA 8 indicated she had looked on both crash carts for an BVM during the code, but she could not find one anywhere. During an interview on [DATE] at 10:00 a.m., CNA 12 indicated on [DATE] she and CNA 13 started giving Resident B a bed bath around 1:30 p.m. He was talking to them the whole time, and after the bath and shaving, they had lifted him up in the Hoyer to get his weight. His oxygen tubing was off. CNA 13 read the weight and glanced back a Resident B and he had stopped breathing. That was around 1:45 p.m., CNA 13 ran to notify the nurse and she stayed in the room. She put his oxygen back on him and raised the head of the bed. During an interview on [DATE] at 10:03 a.m., CNA 13 indicated on [DATE] she and CNA 12 were giving Resident B a bed bath. He was talking to them the whole time, and after the bath, they had lifted him up in the Hoyer to get his weight. His oxygen tubing was off. CNA 13 read the weight and glanced back a Resident B and he had stopped breathing. She ran to notify the nurse and CNA 12 stayed in the room. The current facility policy Cardiopulmonary Resuscitation (CPR) with a revision date of [DATE], was provided by the Regional DON on [DATE] at 11:20 a.m. The policy indicated, .Policy: The facility must provide basic life support, including CPR, to a resident requiring such emergency care .Procedure: 1 .The facility must ensure that team members properly trained in basic lifesaving support .prior to the arrival of emergency medical services .Emergency Procedure - Cardiopulmonary Resuscitation .1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing .begin CPR: 1. d. initiate the basic life support (BLS) sequence of events .3. Chest compressions: .4 Airway: .clear airway .5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag [BVM] or manually (with CPR shield) . The American Heart Association described the steps for CPR as follows (https://ahainstructornetwork.org/idc/groups/ahaecc-public/@wcm/@ecc/documents/downloadable/ucm_ 8.pdf 2020). High-Quality CPR Components for BLS [Basic Life Support Providers] .Adults and adolescents .1 or 2 rescuers . Compression-ventilation ratio without advanced airway . 30 [compressions]: [to] 2 [breaths] .Compression rate ,d+[DATE] [compressions a minute] .Compression-ventilation ratio with advanced airway .Continuous compressions at a rate of ,d+[DATE]/min .give 1 breath every 6 seconds. The Immediate Jeopardy that began on [DATE] and was removed on [DATE], when the facility inspected, audited, and reviewed all crash carts for necessary equipment; educated staff on equipment checklist for all crash carts; staff were educated on Code status, Physician order, Code event, and CPR procedures; and CPR procedures were reviewed prior to next shift. But noncompliance remained at a lower scope and severity of actual harm that is not immediate jeopardy because the facility needed to continue to ensure all nursing staff were educated on CPR procedures, reviewed a Code event, and all nursing staff were educated on crash cart complete audits. This Federal tag relates to Complaint IN 741.

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers, complete assessments, correctly stage, and follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 59, 39, and 91). Findings include: 1. The clinical record for Resident 59 was reviewed on 05/13/21 at 12:56 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/26/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers, and had an unhealed stage 2 pressure wound. The resident had 3 venous/arterial ulcers, and open [CONDITION(S)] to the foot. The resident utilized pressure reducing devices to chair and bed, and treatments to skin. During an interview on 05/12/21 at 1:38 P.M., CNA (certified nurse aide) 8 indicated the resident had no wounds on his backside at this time, but he did have wounds on his bottom, some time ago. It seemed like it was just peeling skin, it looked like a sunburn. The nurse administered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility Pressure Ulcer Weekly Observation, dated 04/08/21, indicated the resident had a Stage 3 pressure ulcer on the left buttock that was acquired in the facility and identified by the wound clinic on 03/30/21 as a Stage 3 pressure ulcer. The first observation of the wound by the facility was 04/08/2021. The wound measured 1.8 cm (centimeters) x (by) 7 cm x 0.1 cm. There was epithelial tissue, slough, and necrotic tissue present. There was a small amount of serous drainage, no foul odor or inflammation. A facility Pressure Ulcer Weekly Observation, dated 04/08/21, indicated the resident had a Stage 3 pressure ulcer on the right buttock wound, that was acquired in the facility and identified by the wound clinic on 03/30/21 as a Stage 3 pressure ulcer. The first observation of the wound by the facility was on 04/08/2021. The wound measured 6.5 cm x 2.5 cm x 0.1 cm. There was epithelial tissue, slough, necrotic, and granulation tissue present. There was a small amount of serous drainage, no foul odor or inflammation. There were no other facility Pressure Ulcer Weekly Observations by the facility in the clinical record after 04/08/2021 through 05/03/2021. During an interview on 05/13/21 at 2:00 P.M., the Infection Preventionist indicated when a pressure wound was identified, there would be an initial wound assessment. The wound would be assessed and measured weekly until it was healed. If the wound was worsening, the MD would be notified, and the wound would be assessed more frequently. The wound clinic notes were provided by the DON on 05/11/21 at 12:02 P.M., and indicated the following: -On 03/30/21 the wound clinic identified new pressure ulcers to the resident's bilateral buttocks. The right buttock wound was a Stage 3 pressure ulcer that measured 13.5 cm x 11.5 cm x 0.1 cm. Subcutaneous tissue was exposed. The wound was debrided. The left buttock wound was a Stage 3 pressure ulcer that measured 19 cm x 13.5 cm x 0.1 cm. Subcutaneous tissue was exposed. The wound was debrided. -On 04/06/21 the buttock wounds were healing and were smaller that day. The right buttock wound measured 6.5 cm x 2.5 cm x 0.1 cm. There was a small amount of necrotic tissue present. The left buttock wound measured 18 cm x 7 cm x 0.1 cm. Red granulation tissue, and a small amount of necrotic tissue was present. -On 04/12/21 the buttock wounds were healing. The right buttock wound measured 14.5 cm x 9 cm x 0.1 cm. There was a large amount of granulation tissue, and a small amount of slough present. The left buttock wound measured 19.5 cm x 9 cm x 0.1 cm. There was a large amount of granulation tissue present, and a small amount of slough present. -On 05/03/21 the wounds on the resident's buttocks were healed. During an interview on 05/12/21 at 4:03 P.M., the wound clinic nurse indicated the resident did have a large area of wounds on his right and left buttocks. The wounds were small, like a cluster of open areas on each buttock. They were classified as Stage 3 pressure ulcers. The dermis was gone, and the fat layer was visible. The wounds were debrided at the wound center. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident 39's clinical record was reviewed on 05/13/21 at 11:19 A.M. The resident was admitted to the facility on [DATE]. The hospital discharge documentation indicated the resident had a Stage 1 (intact skin with non-blanchable redness of a localized area, usually over a bony prominence) wound to the coccyx. Interventions were to turn the resident every two hours. A facility Nursing Admission/Readmission Assessment, dated 03/05/21, indicated the resident had no skin issues or wounds on admission. An Admission MDS assessment, dated 03/12/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers, and was admitted with a Stage 2 pressure ulcer. The resident received pressure ulcer care, and utilized pressure reducing devices for his bed and wheelchair. A Pressure Ulcer Weekly Observation, dated 03/09/21, indicated the resident was admitted with a Stage 2 (skin breaks open or blister filled with clear fluid) wound on his coccyx. The area had a brownish/yellow flap on ¾ of the wound. The wound was 3.0 cm x 2.0 cm x 0.3 cm. Slough tissue was present. There was no drainage, odor, or inflammation. The current treatment plan was to apply a very small amount of barrier cream to buttocks/coccyx after changing the brief. Preventative measures were routine turning and repositioning. The resident's wound on his coccyx had an area of brownish/yellow flap with slough and should have been classified as a Staged 3 Pressure ulcer and not a Stage 2. A Nurse Practitioner's Progress Note, dated 3/9/2021 at 7:54 A.M., indicated a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment was to be administered daily, and as needed. There were no additional wound observations documented in the resident's clinical record. The resident's clinical record indicated the resident was sent to a local hospital for reinsertion of an indwelling urinary catheter on 03/19/21. The resident returned to the facility on [DATE]. A Nursing Admission/Readmission Assessment, dated 03/20/21, indicated resident had no skin issues or wounds. A Progress Note, dated 4/2/2021 at 5:29 A.M., indicated the treatment to the resident's coccyx was administered. A Progress Note, dated 4/3/2021 at 5:32 A.M., indicated the treatment to the resident's coccyx was provided after each incontinent episode. The resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Orders included an open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to the resident's sacrum topically one time a day for a pressure ulcer. The resident's EMARs/ETARs indicated the wound treatment was administered every day in March, April, and May 2021, except on the following days: 03/29/21, documented as other/see nurses' notes, but there were no notes in the resident's record. 05/10/21, documented das other/see nurses' notes, but there were no notes in the resident's record. The resident's skin was observed on 05/11/21 at 3:45 P.M. There were no wounds noted on the resident's coccyx, and there was no wound dressing in place. CNA 8 indicated the resident had not had a wound on his bottom for a long time. 3. The clinical record for Resident 91 was reviewed on 05/10/21 at 11:03 A.M. A Significant Change MDS assessment, dated 04/22/2021, indicated the resident was severely cognitively impaired. He required extensive physical assistance of two staff members for bed mobility, transfers, dressing, personal hygiene, and eating. He required total assistance for toileting. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan for at risk for skin breakdown was initiated on 08/13/20. Interventions included the following: - Assist with bed mobility - Assist with routine toileting - Pressure reducing cushion in chair started on 08/28/20 - Pressure reducing mattress on bed started on 08/28/20 - Preventive skin care as ordered started on 08/13/20 - Skin inspections weekly and as needed, document and notify the physician of abnormal findings, started on 08/13/20. A Care Plan, initiated on 03/18/21, indicated the resident had impaired skin integrity as evidence of an ulcer to the left heel. A Care Plan, initiated on 04/08/21, indicated the resident had a suspected deep tissue injury to the right heel. a. A Pressure Ulcer Weekly Observation, dated 03/18/21, indicated the resident had a Stage 2 (partial thickness skin loss involving the epidermis and/or dermis) pressure ulcer to the left heel. The wound measured 3 cm x 2.5 cm x 0.1 cm. The wound bed was covered with eschar (dead tissue). There were no indications that interventions were in place prior to the discovery of the wound. The resident's wound on his left heel had eschar covering the wound and should have been classified as an Unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by eschar). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Ulcer Weekly Observation, dated 04/08/21, indicated the stage 2 to the resident's left heel measured 3.8 cm x 4.2 cm x 0.1 cm. The wound was worsening and covered with eschar. The intervention of a pressure reducing mattress, a pressure reducing chair cushion, and pressure reducing boots were added to the assessment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Ulcer Weekly Observation, dated 04/15/21, indicated the pressure ulcer had changed from a Stage 2 to Unstageable (full thickness tissue loss in which the base of the ulcer was covered by slough ((yellow, tan, gray, green, or brown)) or eschar ((tan. brown, or black)) in the wound bed). The wound measured 5.5 cm x 4.0 cm x 0.2 cm. The wound was covered in slough and eschar. Prevention measures of a routine turning, and repositioning and a protein supplement were added to this assessment. b. A Pressure Ulcer Weekly Observation, dated 04/08/21, indicated the resident had a suspected deep tissue injury (an injury to the soft tissue under the skin due to pressure) on the right heel. The wound measured 3 cm x 4 cm. Prevention measures of a pressure reducing mattress, pressure reducing boots, a pressure reducing chair cushion, and routine turning, and repositioning were added to this assessment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Ulcer Weekly Observation, dated 04/15/21, indicated the pressure ulcer to the right heel measured 6 cm x 4.5 cm x 0.1 cm. The stage had been changed to an unstageable (covered with slough and eschar) There was small amount of foul smelling serosanguineous (thin water like) drainage. An intervention of protein supplement had been added to the assessment. A Pressure Ulcer Weekly Observation, dated 04/22/21, indicated the pressure ulcer to the right heel measured 12 cm x 9 cm x 0.1 cm. The wound remained covered with slough and eschar. An arterial Doppler test had been ordered by the Nurse Practitioner. During an interview, on 5/12/21 at 11:18 A.M., the NP (Nurse Practitioner) indicated she ordered an arterial Doppler test stat (immediately). She was aware that it was common for the mobile x-ray company to be unable to perform a Doppler for a few days after it was ordered. If she thought it was an acute blood flow concern, she would have sent the resident to the hospital. She was aware the resident had some contracture issues with his legs and often had his heels resting on the bed. c. A Pressure Ulcer Weekly Observation, dated 11/13/20, indicated the resident had a Stage 1 (superficial reddening of the skin) to the coccyx. The wound measured 1 cm x 1.2 cm. A Pressure Ulcer Weekly Observation, dated 12/17/20, indicated the pressure ulcer to the coccyx was healed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Ulcer Weekly Observation, dated 03/18/21, indicated the resident had a Stage 2 to the coccyx. The wound measured 1.5 cm x 1 cm. A Pressure Ulcer Weekly Observation, dated 04/22/21, indicated the Stage 2 to the coccyx measured 5.5 cm x 4 cm x 0.1 cm. with a scant amount of serous (clear or yellow drainage slightly thicker than water) drainage. The current facility policy titled Skin Management, dated October 2019, was provided by the ADON on 05/13/21 at 1:11 P.M. The policy indicated, Residents admitted or readmitted with alterations in skin integrity will be documented on admission evaluation .All newly identified areas after admission will be documented on the weekly pressure/non-pressure evaluation .Residents identified at risk for skin breakdown will have appropriate prevention interventions put into place .A care plan will be developed specific to the resident's needs including prevention interventions . This Federal deficiency relates to complaint IN 669. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review, interview, and observation, the facility failed to ensure appropriate interventions were in place for residents with a history of a pressure ulcers, and failed to prevent the development of a Stage III and Unstageable pressure ulcer for 3 of 7 residents reviewed for pressure ulcers. (Residents 53, 38, and 10) Findings include: 1. The clinical record for Resident 53 was reviewed on 01/15/20 at 2:39 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 11/22/19, indicated the resident was severely cognitively impaired. The resident required extensive staff assistance for all ADLs (activities of daily living), and was impaired on one side of his upper and lower extremities. [DIAGNOSES REDACTED]. The resident was at risk for pressure ulcers, and had one Stage III pressure ulcer. The resident received pressure ulcer treatments, and had pressure reducing devices to his bed and chair. A Pressure Ulcer Weekly Observation tool, dated 08/28/19, indicated the resident had a facility acquired Stage III (full thickness skin loss that may extend into the subcutaneous tissue) pressure ulcer to his left buttock. The wound measured 1.5 cm (centimeters) x (by) 1.2 cm x 0.1 cm, with some slough (yellow, tan, white, stringy tissue) present. This was the first observation of the wound. An IDT (Interdisplinary Note), dated 08/30/19 at 10:58 [NAME]M., indicated a review of a new Stage III wound to the resident's left buttock. The wound measured 1.5 cm x 1.2 cm x 0.1 cm. The treatment was to cleanse the wound with normal saline, pat dry, apply skin protectant to the skin around the wound, and an ointment used to remove dead skin tissue and aide in wound healing to the wound bed. The wound would then be covered with a foam dressing and changed daily, and as needed. The resident had a cushion in his wheelchair. The facility would order a low air loss mattress, request any additional orders as needed, and continue to monitor the wound weekly. A Pressure Ulcer Weekly Observation tool, dated 09/26/19, indicated the resident had a facility acquired Stage III pressure ulcer to his left buttock. The wound measured 0.6 cm x 0.6 cm x 0.1 cm. The wound was improving, with granulation tissue present. A Pressure Ulcer Weekly Observation tool, dated 10/24/19, indicated the resident had a facility acquired Stage III pressure ulcer to his left buttock. The wound measured 1.5 cm x 1 cm x 0.1 cm. The wound was unchanged, with [MEDICATION NAME] tissue present. A Pressure Ulcer Weekly Observation tool, dated 01/16/20, indicated the resident had a facility acquired Stage III pressure ulcer to his left buttock. The wound measured 0.5 cm x 0.6 cm x 0.1 cm. The wound was improving, with [MEDICATION NAME] tissue present. The resident's pressure ulcer was observed on 01/16/20 at 11:30 [NAME]M., LPN (Licensed Practical Nurse) 9 washed her hands, donned gloves, and exposed the wound dressing on the resident's left buttock. The dressing was clean, dry, intact, and dated appropriately. LPN 9 peeled back the dressing, and exposed the wound. The area was dime-sized with white, flaky skin in the wound bed, the skin around the wound was pink, and without signs of infection. There was no drainage or odor noted. LPN 9 noted that the wound has improved overall since the resident started receiving hospice services, and was almost healed. Current interventions included, but were not limited to, the use of a low air loss mattress, pressure reducing cushion for the chair, a protein supplement, and routine repositioning. During an interview on 01/17/20 at 3:20 P.M., LPN 9 indicated at the time the wound was identified, the resident had a wheelchair cushion and a standard pressure reducing mattress. Any resident with limited mobility should be repositioned at least every two hours. They did frequently reposition the resident; it wasn't an actual physician order, and it was not an intervention that was documented. The IDT note documented on 08/30/19 really didn't determine the cause of the wound. The resident went from no wound on his bottom, to a Stage III pressure area. It does seem like staff would have seen something prior to the development of a Stage III wound, especially since they provide care to the resident every day, and the nurses documented skin assessments weekly. The facility did not provide documentation that indicated the pressure wound was identified prior to the initial observation on 08/28/19. The current facility policy, titled Skin Management, and dated 10/2019, was provided by the ADON on 01/17/20 at 12:20 P.M. The policy indicated, .Resident identified at risk for skin breakdown will have appropriate prevention interventions put into place . 2. The clinical record for Resident 10 was reviewed on 01/15/20 at 10:26 [NAME]M. An Annual MDS assessment, dated 10/08/19, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. The resident required extensive staff assistance for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. The resident was at risk for pressure ulcers and had a Stage III pressure ulcer. The resident received pressure ulcer care, and had pressure reducing devices to his bed and chair. A Care Plan with a revision date of 03/03/19 indicated the resident needed assistance with activities of daily living due to [MEDICAL CONDITION] and activity intolerance. The resident would decline assistance at times. Interventions included, but were not limited to, bed mobility: staff assistance to turn and reposition routinely in bed, assist and encourage to reposition/shift weight when she was up in her wheelchair. The resident had a pressure ulcer to the buttocks from 12/20/18 through 03/14/19. When the wound healed the treatment was for protective cream twice a day and as needed for a preventative measure. A Pressure Ulcer Weekly Observation tool, dated 04/11/19, indicated the resident had a facility acquired Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with red-pink wound bed, without slough. (MONTH) also present as an intact open/ruptured blister) pressure ulcer to her left buttock. The wound measured 4.5 cm x 4 cm x 0.1 cm, with [MEDICATION NAME] (pink) and granulation (beefy red) tissue present. The was the first observation of the wound. The (MONTH) 2019 TAR (Treatment Administration Record) indicated the resident had intact skin on 04/25/19. A Pressure Ulcer Weekly Observation tool, dated 05/02/19, indicated the resident had a facility acquired Stage III pressure ulcer to her left buttock, proximal. The wound measured 1.0 cm x 1.5 cm x 0.1 cm, with granulation (beefy red) tissue and slough tissue present. This was the first observation of the wound. A Pressure Ulcer Weekly Observation tool, dated 05/23/19, indicated the resident had a facility acquired Stage II pressure ulcer to her left buttock, distal. The wound measured 0.4 cm x 0.6 cm x 0.1 cm. The wound was improving, with [MEDICATION NAME] tissue present. A Pressure Ulcer Weekly Observation tool, dated 05/30/19, indicated the resident had a facility acquired Stage II pressure ulcer to her left buttock, distal. The wound was healed. The current treatment plan was for calazyme cream to the buttocks every shift and as needed. A Pressure Ulcer Weekly Observation tool, dated 05/30/19, indicated the resident had a facility acquired Stage III pressure ulcer to her left buttock, proximal. The wound was healed. The current treatment plan was for barrier cream to the buttocks every shift and as needed. A Pressure Ulcer Weekly Observation tool, dated 08/15/19, indicated the resident had a facility acquired Stage III pressure ulcer to her left buttock. The wound measured 1.8 cm x 2.8 cm x 0.1 cm, with granulation and slough tissue present. The was the first observation of the wound. An IDT, dated 08/16/19 at 12:19 P.M., indicated a review of a new Stage III pressure wound on the resident's left buttock from 08/14/19. The wound measured 1.8 cm x 2.8 cm x 0.1 cm. The resident was encouraged to turn and reposition frequently, but typically was up in her wheelchair most of the day with pressure reducing cushion to the wheelchair. A Pressure Ulcer Weekly Observation tool, dated 08/29/19, indicated the resident had a facility acquired Stage III pressure ulcer to her left buttock. The wound measured 0.5 cm x 0.3 cm x 0.1 cm. The wound was improving, with [MEDICATION NAME] tissue present. A Pressure Ulcer Weekly Observation tool, dated 10/31/19, indicated the resident had a facility acquired Stage III pressure ulcer to her left buttock. The wound was healed and continued barrier cream as preventative. The resident was educated to not pick at the area. An at risk for skin breakdown Care Plan was initiated on 09/06/18 and a revision date of 12/17/18. The Care Plan lacked any new interventions since 12/17/18. The EHR (Electronic Health Record) lacked documentation of any resident education related to turning and repositioning in between the development of the pressure ulcers or that the resident was non-compliant with turning and repositioning. During an interview on 01/17/20 at 1:52 P.M., the ADON (Assistant Director of Nursing) indicated the resident had a pressure ulcer on her buttock that would heal and then reopen. The resident had interventions that included, a reducing pressure mattress, turn and reposition as she would allow, pericare, barrier cream to the buttocks as a preventative. The resident was non-compliant at times related to care. If the resident was non-compliant with care, then it should have been documented in a progress note. During an interview on 01/17/20 at 4:13 P.M., the DON indicated that resident education should have been documented in the progress notes. 3. The clinical record for Resident 38 was reviewed on 01/15/20 at 11:00 [NAME]M. A Quarterly MDS assessment, dated 11/14/19, indicated the resident was severely cognitively impaired. The resident required extensive assistance with all ADLs. [DIAGNOSES REDACTED]. The resident was at risk for pressure ulcers, and had one Unstageable pressure ulcer. The resident received pressure ulcer treatments and had pressure reducing devices to his bed and chair. A Pressure Ulcer Weekly Observation tool, dated 09/12/19, indicated the resident had a facility acquired Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and or eschar (area of dead tissue in the wound bed) pressure ulcer to his left hip. The wound measured 2.0 cm x 2.5 cm, with some slough present. This was the first observation of the wound. An IDT Note, dated 09/13/19 at 11:13 [NAME]M., indicated a review of a new Unstageable wound to the resident's left hip. The resident previously had an abrasion to the left hip that progressed into a pressure area. The wound measured 2.0 cm x 2.5 cm., with slough and necrotic (dead tissue cells) tissue present. The treatment was to place a foam dressing to the area and change every three days. The resident had an air mattress at the time. Resident is non compliant with T&R (turning & repositioning), constant with laying on left side. Resident was receiving Hospice care at the time. A Pressure Ulcer Weekly Observation tool, dated 10/10/19, indicated the resident had a facility acquired Unstageable pressure ulcer to his left hip. The wound measured 2.0 cm x 3.0 cm x 0.2 cm. The wound was unchanged, slough tissue present. A Pressure Ulcer Weekly Observation tool, dated 01/16/20, indicated the resident had a facility acquired Unstageable pressure ulcer to his left hip. The wound measured 0.6 cm x 0.4 cm x 0.2 cm. The wound was improving, [MEDICATION NAME] tissue present. The resident's pressure ulcer was observed on 01/15/20 at 1:51 P.M., the Hospice nurse washed his hands, donned gloves, and exposed the wound dressing on the resident's left hip. The dressing was clean, dry, intact, and dated appropriately. The Hospice nurse peeled back the dressing, and exposed the wound. The area was the size of a pencil eraser with the wound bed pale pink, the skin around the wound was pink, and without signs of infection. There was no drainage or odor noted. The Hospice nurse noted that the wound had improved overall, and was almost healed. The area started as an abrasion from a fall on 09/01/19. Current interventions included, but were not limited to, the use of a low air loss mattress, pressure reducing cushion for the chair, a protein supplement, and routine repositioning. During an interview on 01/17/20 at 3:53 P.M., the ADON indicated the resident was turned and repositioned frequently. He was non compliant with turning and would position himself on his left side. The EHR lacked documentation of non compliance to turn and reposition prior to the day before the discovery of the Unstageable pressure wound. A Care Plan for being at risk for skin breakdown, with a revision date of 07/11/19, had interventions of: Preventive skin care as ordered/indicated and Skin inspection weekly and as needed, document and notify MD of abnormal findings 3.1-40(a)(2)

Based on record review and interview, the facility failed to define and implement interventions for the prevention and treatment of [REDACTED]. This deficient practice resulted in harm in that Resident A, who was admitted to the facility without pressure ulcers, developed multiple stage II pressure ulcers and one stage III pressure ulcer following his admission to the facility(Resident A). Findings include: Resident A's closed record was reviewed on [DATE] at 2:10 p.m. [DIAGNOSES REDACTED]. Resident A was admitted to the facility on [DATE], following an in-patient hospitalization . He was admitted to Hospice on [DATE] and was deceased on [DATE]. Resident A's Minimum Data Set (MDS) assessment, completed [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating severe cognitive impairment. Resident A's functional status indicated that he required "extensive, ,[DATE]+ person(s) physical assistance" for all activities of daily living (ADLs), including transfers, eating, toileting, hygiene, and bathing. Resident A's bowel and bladder status indicated he had an in-dwelling Foley catheter and was "always incontinent" of bowel. The admission MDS assessment further indicated that Resident A was at risk for developing a pressure ulcer and that he did not have a stage I or higher pressure ulcer (stage I: "Intact skin with nonblanchable redness of the localized area, usually over a bony prominence.") at the time of his admission. Skin/ulcer treatments indicated as "checked" included, "pressure reducing device for chair", "pressure reducing device for bed", and "apply ointments/medications". Resident A's [DATE] Braden Scale for Predicting Pressure Sore Risk indicated that he was at "moderate risk". Resident A's quarterly [DATE] MDS assessment indicated that he was at risk for developing a pressure ulcer and he did not have a stage I or higher pressure ulcer. Skin/ulcer treatments indicated as "checked" included, "pressure reducing device for chair", "pressure reducing device for bed", "turning/repositioning", and "nutrition/hydration". The [DATE] Braden Scale for Predicting Pressure Sore Risk indicated that Resident A was at "moderate risk". Resident A's quarterly [DATE] MDS assessment indicated that he was at risk for developing a pressure ulcer and that he did not have a stage I or higher pressure ulcer. Skin/ulcer treatments indicated as "checked" included, "pressure reducing device for chair", "pressure reducing device for bed", "turning/repositioning", and "nutrition/hydration". The [DATE] Braden Scale for Predicting Pressure Sore Risk indicated that Resident A was at "high risk". A [DATE] MDS assessment again identified Resident A as being at risk for developing a pressure ulcer, and further included, but was not limited to, the following: ? "Resident has Stage 1 or higher pressure ulcer: Yes" ? "Stage 1 pressure ulcers: number present: 2" ? "Stage 2 pressure ulcers (stage II: "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister."): number present: 7" ? "Stage 2 pressure ulcers: number present at admit/re-entry: 0" ? "Stage 2 pressure ulcers: date of oldest: [DATE] " ? "Stage 3 pressure ulcers (stage III: "Full thickness tissue loss. Subcutaneous fat maybe visible but bone, tendon or muscle is not exposed. Slough maybe present but does not obscure the depth of tissue loss. May include undermining and tunneling."): number present: 0" ? "Stage 4 pressure ulcers: number present: 0" ? "Unstaged due to dressing: number present: 2" ? "Unstageable - deep tissue: number present: 2" ? "Worsened since prior asmt (assessment): stage 2 pressure ulcers: 7" ? "Pressure ulcers on prior assessment: 0" Skin/ulcer treatments indicated as "checked" included, "pressure reduce device for chair", "pressure reducing device for bed", "turning/repositioning", "nutrition/hydration", "pressure ulcer care", "application of dressings", "apply ointments/medications", and "apply dressings to feet". The [DATE] Admission-Data Collection Form indicated "Skin Condition: "Warm...Pale." The Braden Scale for Predicting Pressure Sore Risk indicated that Resident #A was at "moderate risk". The section entitled "Skin Treatments", included blank check boxes for "pressure reduction devices for chair", "pressure reduction devices for bed", "turning/repositioning program", and "nutrition or hydration Interventions (to manage skin problems)". Nursing Notes, dated [DATE] at 1:30 p.m., indicated, "Res (resident) alert eyes closed a lot...nonambulatory....No code status. Dependent on staff for ADLs mobility & (and) being fed....Multiple areas on skin bruising abd (abdomen) chest arms legs reddened areas that blanch R (right) ankle great L (left) toe L (left) ankle bil (bilateral) knees lower abd (abdomen) & (and) groin excoriated. XXX states was informed of staged pressure area but unable to find." The following entry, [DATE] at 3:15 p.m., indicated, "...Skin: Back and Buttock med (medium) pink blanches well...multi (multiple) bruising Bil (bilateral) arms." Resident A's [DATE] Admission Care Plan indicated care plans initiated for "Behavioral Symptoms", "Nutritional Status/Diet", "[MEDICAL CONDITION] Drug Use", "Oral/Dental Status", and "Safety for Hot Liquids". The document included a care plan for "Pressure Sores/Skin Care" which indicated, "Goal: Prevent/heal pressure sores/skin breakdown. Follow facility care protocol. Turn every 2 hours and PRN (as needed). Preventative measures: Immediately report any redness or skin breakdown to charge nurse." The care plan for "Pressure Sores/Skin Care" was not initiated and/or checked. An Initial Nutrition Assessment, dated [DATE], indicated, "Skin status: intact. Has lots of reddened areas....Intake reported poor at meals....At risk for Wt (weight) loss & (and) skin breakdown r/t (related to) poor appetite....Skin ('no' symbol) open areas but does have multiple reddened areas...." Resident A's First Nutritional Review, dated [DATE], indicated, "Skin Condition: Intact." Resident A's Second Nutritional Review, dated [DATE], indicated, "Skin Condition: R (right) heel PU (pressure ulcer) L (left) heel PU (pressure ulcer)." The only care plan related to pressure ulcer(s) and/or skin was initiated on [DATE] and indicated, "Problem onset: [DATE]. (Resident A) has multiple Stage 2 pressure ulcers." Approaches indicated, "Reposition (Resident A) every routinely and prn (as needed), Place (Resident A's) pressure-reducing air mattress on bed, Encourage (Resident A) to weight shift while sitting up in chair, (Resident A) needs wound care as ordered by physician, Maintain (Resident A's) head of bed at angle less than 30 degrees, (Resident A) needs assistance with repositioning to avoid skin friction/shearing, (Resident A) needs two persons to assist with repositioning to avoid skin friction/shearing, (Resident A) needs a mechanical lift to avoid skin friction/shearing, Encourage (Resident A's) good nutritional intake for healing, Offer (Resident A) supplemental nutritional support, (Resident A) needs weekly evaluation of wound healing, (Resident A) needs a daily observation of skin with routine care, Adjust (Resident A's) treatment plan if no healing within ,[DATE] weeks, Observe for changes in (Resident A's) skin status that may indicate worsening of pressure ulcer and notify the physician, Float heels and feet." During an interview with the Administrator, the Director of Nursing (DoN), and the Regional Director of Clinical Services on [DATE] at 5:55 p.m., all three confirmed that there were no additional care plans related to pressure ulcers, skin, and/or pressure ulcer prevention prior to the one initiated on [DATE]. physician's orders [REDACTED]." physician's orders [REDACTED]." physician's orders [REDACTED]." The [DATE] Weekly Skin Integrity Checks indicated, "Wound/Skin condition Present/No new change of condition. Documentation already established on all existing Wound /Skin Conditions." The [DATE] Weekly Skin Integrity Checks indicated, "New wound/change of condition noted. See Skin/Condition Assessment Form, for initial/ongoing documentation of assessed wound or skin condition." The [DATE] Weekly Skin Integrity Checks indicated, "New wound/change of condition noted. See Skin/Condition Assessment Form, for initial/ongoing documentation of assessed wound or skin condition." During an interview with the Administrator and DoN on [DATE] at 5:55 p.m., the DoN indicated, "He (Resident A) didn't have any skin issues back then to my knowledge." Both indicated that they were not aware of the "Skin/Condition Assessment Form" referred to above and provided Nursing Notes corresponding with the June, 2013 dates which indicated Resident A had a "skin tear". The Administrator indicated, "I came in June and she (DoN) came in July. We're fishing just like you are." The scheduled Weekly Skin Integrity Reviews scheduled for [DATE], [DATE], [DATE], [DATE], and [DATE], were completed on or around the scheduled dates and indicated, "Skin Intact." The scheduled Weekly Skin Integrity Reviews for [DATE] and [DATE] were not completed. The scheduled Weekly Skin Integrity Reviews for [DATE] and [DATE] indicated, "Skin Intact." The scheduled Weekly Skin Integrity Reviews for [DATE], [DATE], and [DATE] were not completed. The documented Weekly Skin Integrity Reviews for [DATE] and [DATE] indicated, "Skin Intact." The [DATE] Weekly Skin Integrity Review indicated, "Skin Intact." The [DATE] Weekly Skin Integrity Review indicated, "Other: Shearing. Open area (bilateral buttocks indicated on diagram) 1. .25 cm. x 0.5 cm. 2. 1cm. x .5 cm." A [DATE] physician's order [REDACTED]. Change q (every) 5 days and prn (as needed) for soiling or/and dislodgement. Once area healed change to prn (as needed) for redness as preventative." The October, 2013 Treatment Administration Record (TAR) indicated, "[DATE] Duoderm to shearing areas on buttocks. Change q (every) 5 days and prn (as needed) for soiling or dislodgement. Once healed change to prn (as needed)." The next Weekly Skin Integrity Review, scheduled for [DATE], was not completed. The next scheduled Weekly Skin Integrity Review was dated [DATE] and indicated, "Skin Intact." The next scheduled Weekly Skin Integrity Review, scheduled [DATE], was not completed. The next sequential Weekly Skin Integrity Review, dated [DATE], indicated, "Other: 0.2 cm. round left ankle. Blister 5 cm. round right heel. Blister 7.0 cm. round left heel. Blister 0.3 cm. round left inner thigh." The next Weekly Skin Integrity Review, dated [DATE], indicated, "Other: blister to bilat (bilateral) heels and shearing to buttocks. Red L (left) ant (anterior) ankle." The [DATE] Weekly Skin Integrity Review indicated, "Redness. Blister. Other: blisters & (and) dried open blisters to L (left) thigh. Red area L (left) anter (anterior) ankle. Bilat (bilateral) heels blisters. Open Area: to bilat (bilateral) buttocks duoderm is in place. Redness to penis." The [DATE] Weekly Skin Integrity Review indicated, "Redness. Reddened area. Other: blister like areas to bilat (bilateral) heels & (and) left ankle. Penis open area." The [DATE], [DATE], and [DATE] Weekly Skin Integrity Reviews were not documented for Resident A. The [DATE] Weekly Skin Integrity Review indicated 8 circled areas on the body diagram, numbered ,[DATE]. Current Skin Condition indicated, "Bruises. Other: [MEDICAL CONDITION]. Open Area." The [DATE] Weekly Skin Integrity Review indicated 15 circled areas on the body diagram, numbered ,[DATE]. Weekly Skin Integrity Reviews scheduled for [DATE], [DATE], [DATE], and [DATE] were completed on or around those dates. All indicated, "No new areas." A [DATE] Hospice Visit Note Report indicated, "Coccyx with open area and lg (large) area of deep prurple (sic) discoloration. Sponge dressing intact. Dressing left D/I (dry/intact). Verticle bruising to left side if (sic) left lower leg. Lg (large) bruise to left back skin appears to be peeling off of area. SM (small) bruising to right side of back." The Administrator, Director of Nursing (DoN), Assistant Director of Nursing (ADoN), Regional Director of Clinical Services (RDoCS), and Regional Dietitian were interviewed on [DATE] at 11:45 a.m. When asked to identify when Resident A's first pressure area(s) were identified, the Administrator indicated, "He was cruising all over the building and then he just went downhill. When he went into Hospice, he just shut down...stopped eating.... " The ADoN indicated, "He absolutely did. He deteriorated in no time. When he developed his wounds it was so quick." The DoN indicated, "It was overnight. It was strange." The ADoN indicated that she assumed the responsibility of wound care for the facility on or around [DATE], the date of the first documented Weekly Treatment Sheets. She indicated that the previous wound nurse used a different form. She further indicated, "He (Resident A) was my special project. I think he had 10 areas when I got him...every bony prominence. At the time he was deceased , all of them had healed but three." Regarding the [DATE] Hospice entry, the ADoN indicated, "It ('bruising') was lividity...he had such severe lividity. He hadn't been up to move in quite some time. We hadn't used the Hoyer lift or anything. The CNAs even asked me about it and I had to explain what it was. " Weekly Wound Assessment Sheets for Resident A for the dates [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] were provided by the Administrator on [DATE] at 2:35 p.m. Resident A's [DATE] Weekly Wound Assessment Sheet indicated, "Wound Type: press (pressure). R (right) heel. 15 cm. (centimeter) L (length) x 15 cm. W (width). Stage: unstageable. Avoidable/Unavoidable: Avoidable. Acquired/Admit: Acquired. Date of Last Skin Sweep: [DATE]. Wound Type: press (pressure). L (left) heel. 9 cm. L x 12cm W. Stage: unstageable. Avoidable/Unavoidable: Avoidable. Acquired/Admit: Acquired. Date of Last Skin Sweep: [DATE]. Wound Type: press (pressure). L (left) ankle. 2 cm. L x 2 cm. W. Stage: II. Avoidable/Unavoidable: Avoidable. Acquired/Admit: Acquired. Date of Last Skin Sweep: [DATE]. " Resident A's [DATE] Weekly Wound Assessment Sheet indicated 14 stage II, "avoidable" pressure ulcers and 2 " unstageable", "avoidable" pressure ulcers. The [DATE] Wound Treatment Sheet indicated 15 stage II pressure ulcer locations and 1 "non-observable" pressure ulcer location. The [DATE] Wound Treatment Sheet indicated one new stage II pressure ulcer locations, 9 stage 2 pressure ulcers, and 5 pressure ulcer locations indicated, "Resolved at present." One pressure wound location, Resident A's left lateral malleolus (the bony protuberance on either side of the ankle), previously documented as "non-observable", indicated a stage III pressure ulcer. The documentation indicated the pressure ulcer was "2.8 cm. (L) x 1.6 cm. (W) x 0.4 cm. (D)" with "yellow" drainage. The [DATE] Wound Treatment Sheet indicated no new pressure ulcer locations, 1 "non-observable" pressure ulcer and 6 stage II pressure ulcers. The left lateral malleolus stage III pressure ulcer documentation indicated, "2.2 cm. (L) x 2 cm. (W) x 0.2 cm. (D)" with no drainage. The [DATE] Wound Treatment Sheet indicated no new pressure ulcer locations, 8 pressure ulcer locations were "resolved", 6 stage II pressure ulcer locations remained, and 1 "non-observable" (previously indicated as stage II) pressure ulcer location remained. The left lateral malleolus stage III pressure ulcer documentation indicated, "1.8 cm. (L) x 1.6 cm. (W) x 0 cm. (D)" with no drainage. The [DATE] Wound Treatment Sheet indicated no new pressure ulcer locations, 3 stage II pressure ulcer locations, one "non-observable" pressure ulcer, and 3 locations were "resolved at present." The left lateral malleolus stage III pressure ulcer documentation indicated, "1.2 cm. (L) x 1cm. (W) x 0 cm. (D)" with no drainage. Resident A's [DATE] Wound Treatment Sheet, dated 6 days prior to his death, indicated that he had the following pressure ulcer locations: ? Right dorsal foot: stage II, 0.4 cm. L x 0.6 cm. W x 0 cm. D ? Left lateral lower leg: stage II, 0.2 cm. L x 0.2 cm. W x 0 cm. D ? Coccyx: stage II, 4 cm. L x 9 cm. W x 0 cm. D ? Left heel: " non-observable " , 2.4 cm. L x 2.4 cm. W x 0 cm. D ? Left lateral ankle: stage III, 1.2 cm. L x 1 cm. W x 0 cm. D No documentation of weekly skin checks prior to [DATE] or after [DATE] were located in Resident A's closed record. No Wound Treatment Sheets prior to [DATE] were located in Resident A's closed record or provided by facility staff. A copy of the facility's current policies and procedures for pressure ulcers, hydration, and positioning were provided by the Administrator on [DATE] at 9:50 a.m. and reviewed at that time. The document provided for pressure ulcers, entitled "Introduction to Pressure Sore Protocols", did not provide any specific interventions related to pressure ulcer prevention or treatment. The Administrator, Director of Nursing (DoN), Assistant Director of Nursing (ADoN), Regional Director of Clinical Services, and Regional Dietitian were interviewed on [DATE] at 11:45 a.m. When queried regarding specific policies and procedures (not addressed in the document provided) which the facility uses to prevent and treat pressure ulcers, the Administrator indicated, "That's what we use." The DoN indicated, "Our policies are vague." When asked how the facility monitors residents' skin condition, the DoN indicated, "We do skin checks at least weekly on shower days. In the meantime, if CNAs see something, we have 'stop and watch' forms to turn into the nurse. The ADoN indicated that she has been the facility's wound nurse since December, 2013. She indicated, "I do wound rounds once a week and prn (as needed) if an issue is brought up." The Administrator indicated, "We do daily meeting, daily QA (quality assurance) ...everything clinical we do daily, weekly, monthly...we all do rounds." The Regional Dietitian then indicated, "There's more to this policy. We'll get it for you." A copy of "Wound Care: Identification of 'At Risk' and Suggested Interventions" was provided by the Administrator on [DATE] at 2:40 p.m. and reviewed at that time. The policy and procedure included, but was not limited to, the following: ? "Use a turning/repositioning program for those residents confined to bed/chairs." ? "Moderate Risk: Suggested Interventions: ? Complete RAI ? Monitor for clinical changes ? Weekly skin audit ? Positioning protocols ? Place on pressure reduction mattress products ? Place on for (sic) pressure reduction chair cushions ? Risk Assessment Tool ? Request screen from other appropriate disciplines ? Assess for signs of Stage 1 ? Care plan to identify interventions ? Establish and record an individualized turning schedule if the resident/patient is immobile." ? " High Risk: Suggested Interventions: ? Complete RAI ? Monitor for clinical changes ? Weekly skin audit ? Positioning protocols ? Place on pressure reduction mattress products ? Place on for (sic) pressure reduction chair cushions ? Risk Assessment Tool ? Request screen from other appropriate disciplines ? Assess for signs of Stage 1 ? Care plan to identify interventions ? Increase frequency of continency care ? Establish and record an individualized turning schedule if the resident/patient is immobile." ? Frequency of position change is titrated for the individual resident/patient. Evaluate the skin after each turning interval; if there is non-blanchable redness, increase the frequency of turning." The section entitled, "Residents with Skin Breakdown Suggested Interventions" included, in full, the following interventions: "Complete RAI. Monitor for clinical changes/including further deterioration. Weekly skin audit/Pressure Sore Progress Note and Assessment. Appropriate topical treatment. Nutritional Assessment/dietary supplement if appropriate vitamins/minerals. Positioning protocols. Transfer protocols. Utilize pressure relieving products (i.e. specialty beds). Request screen from appropriate disciplines. Assess for signs/symptoms of infection. Care plan to identify interventions. Increase frequency of continency care. Hydration program." The Administrator was interviewed regarding the above policy and procedure on [DATE] at 2:38 p.m. When asked if the facility utilized the listed interventions, she indicated, "No. We work off of this." When asked how the nurses and CNAs know what interventions to provide for residents with pressure ulcers, she indicated, "They (nurses and CNAs) tell XXX (ADoN), she calls the doctor, he gives the orders, and we work off those." She further indicated, "They (residents) pretty much always have an air mattress...I expect weekly skin audits...I'd have to say yes, we pretty much do all those things." A copy of the current policy and procedure entitled, "Positioning" was provided by the Administrator on [DATE] at 9:50 a.m. The procedure indicated, in full, "Explain what you are doing and why. Change the resident's position every two (2) hours, as ordered by the physician, or as determined by the resident's needs. Incorporate range of motion exercises (as determined by the resident's needs) while positioning and turning. Distribute the resident's weight evenly when sitting up in chair or bed. Support the extremities of the head as needed." The Administrator was interviewed on [DATE] at 2:38 p.m. When queried regarding the "positioning protocols" and establishing and recording an "individualized turning schedule" as indicated in the pressure ulcer policy and procedure, the Administrator referred to the policy and procedure entitled "Positioning" and indicated, "We already gave that to you." During an interview with the Regional Director of Clinical Services on [DATE] at 5:20 p.m., she indicated that Resident A was provided with an air mattress on [DATE]. Regarding the intervention "place on pressure reduction mattress products" referred to in the policy and procedure provided, she indicated, "All of our regular mattresses are really good pressure reducing mattresses." LPN #1 was interviewed on [DATE] at 10:10 a.m. She indicated the facility has a turn schedule for residents at high risk for pressure ulcers and that the CNAs are supposed to "sign-off" every 2 hours. She provided a copy of the A-Hall "T-Time List", which indicated an every-two-hour turn schedule with boxes for staff to initial for each resident every two hours. She further indicated, "They ("T-Time List") are signed when they (CNAs) remember to sign." LPN #2 was interviewed on [DATE] at 10:20 a.m. She indicated that residents who are at high risk for pressure ulcers are put on an every-two-hour turn schedule and that CNAs have a "sign-off sheet." During an interview with the Administrator on [DATE] at 11:45 a.m., she was queried regarding the "T-Time List" and positioning documentation. The Administrator indicated, "I don't know why she gave that to you. It's not part of the chart...it's an internal document for QA (quality assurance). She shouldn't have given that to you." The Administrator declined to provide any T-Time Lists (or similar) related to Resident A. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)

Based on observation, record review and interview, the facility failed to provide pharmaceutical services to meet the needs of 1 of 4 residents reviewed for pharmaceutical services. (Resident #A). The resident was not provided with requested, ordered as-needed (PRN) pain medication, which resulted in unrelieved pain. This deficiency had the potential to impact all 104 residents residing in the facility. Findings include: Resident #A's record was reviewed on 2/4/2014 at 12:30 p.m. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) Assessment, dated 12/10/2013, indicated the resident's Brief Interview for Mental Status (BIMS) assessed her to be cognitively intact. During an interview with Resident #A, on 2/7/2014 at 11:05 a.m., she was observed to be lying in her bed with the lights out. She indicated, "I didn't get my pain pill last night. They said they didn't have any and had to order it." The resident further indicated that she continued to have a headache and that staff had not addressed her pain since requesting pain medication the previous evening. A record review of Resident #A's physician's orders [REDACTED].#A's "pain medication" order indicated, "Tramadol HCL 50mg tablet; Give 1 tablet orally 4 times a day as needed for pain." She further indicated that Resident #A had not been administered this medication since 2/1/2014. There was no documentation on either the Nurses Notes or the MAR indicated [REDACTED]. An inventory of the locked medication box in which Resident #A's Tramadol was to be held did not have any Tramadol for the resident. LPN #1 indicated, "I'll check with pharmacy about that." She further indicated that it is the responsibility of whoever discovers that a resident's medication is running low to notify pharmacy and that it should be done with enough medication remaining to account for delivery time (the following day). During an interview with LPN #1 on 2/7/2014 at 2:28 p.m., she indicated that she had contacted the pharmacy and that Resident #A's Tramadol would be delivered with the "evening delivery" of medications. A copy of a policy and procedure entitled "Medications - Oral Administration Of" was provided by the Administrator on 2/7/2014 at 4:50 p.m. The policy and procedure related specifically to the safe and accurate administration of oral medications. She indicated that she did not have any additional policies related to pharmacy services and/or providing resident medications. This federal tag relates to complaint #IN 583. 3.1-25(a)

Based on observation, interview, and record review, the facility failed to plan and implement services, including timely consultation at the wound care center, to prevent and treat pressure ulcers for a resident who entered the facility with a Stage 4 pressure ulcer. The resident developed a second pressure ulcer staged by the facility as Stage 3. The deficient practice affected 1 of 3 residents reviewed related to risk for pressure ulcers in a sample of 4 residents. (Resident D) Findings include: On 12/18/12 at 1:00 p.m., CNA #14 was observed providing care for Resident D. The resident had been incontinent of soft brown stool. During interview at this time, CNA #14 indicated this was the second day she had cared for Resident D, and the third time the resident had been incontinent of stool today. She indicated the nurse would come in to change dressings on the resident's wounds which were soiled with stool. As the resident's buttocks were cleansed, two soiled dressings were observed - one on the sacrum and one on the right gluteal fold. Visible on the sacrum was a partially taped abdominal (ABD) pad, soiled with some stool, and on the gluteal fold, the ABD pad covering the wound was off, and the packing in the wound was covered on the visible part with stool. The resident's buttocks were reddened, and a reddened indentation was observed on the left inner thigh. The area around the sacral wound was a deep reddish-purple color, and the buttocks next to the cleft on both sides were a deep reddish-purple color. The resident was wearing padded socks, and his heels were directly on the specialty mattress. CNA #14 indicated she would call the nurse into the room, and LPN #17 and CNA #22 entered. LPN #17 brought a medication cup filled with liquid and gauze. During interview at this time, LPN #17 indicated the cup contained sterile water and gauze for packing the gluteal fold. She indicated a [MEDICATION NAME] (antibiotic) tablet was crushed and dissolved in water and used for the gauze packing one time a day, and the packing is changed only if soiled with stool. LPN #17 removed the packing. The wound was not cleansed, and the fresh packing was inserted into the wound. An ABD pad was placed over the wound and taped. LPN #17 indicated the sacral wound required only a fresh ABD pad, since only the pad was soiled with stool, and the soiled pad was removed and a fresh pad was applied and taped. Smudges of stool were observed on the bed clothes beneath the buttocks. When interviewed in regard to Resident D's heels, LPN #17 indicated the resident had no heel wounds. The resident was rolled to the left, and a wedge cushion was placed behind his back. No pillows were placed between the knees, and the heels were not floated. The resident moaned whenever he was moved, and as the wounds were dressed. During interview on 12/18/12 at 2:30 p.m., the Director of Nursing (DON) indicated she was preparing to measure Resident D's wounds, because she did not think the most recent measurement of 10 cm. width was accurate on the wound tracking sheet for the gluteal wound. At this time, the DON entered the resident's room and prepared to measure the wounds. The resident was lying on the left side, with a wedge cushion behind his back. The DON indicated the resident's brief had stool on it, so staff would provide care, and then she would measure the wounds. The DON told the resident his pain medication had just been increased. The resident's heels were on the mattress. When interviewed in regard to the resident's heels on the mattress, the DON indicated the resident "did (previously) have bad heels," and "has boots" which may have been discontinued. At 2:45 p.m., CNA #10 and CNA #4 entered to provide care for the resident. As the CNAs rolled the resident to his back to provide care, a reddened area was observed along the length of the left shin, where the legs had been skin to skin. The ABD pads covering the wounds were soiled with very soft light brown stool, and the packing in the gluteal wound was observed to be brown with stool when it dislodged from inside the wound as CNA #10 cleansed the resident's buttocks. During interview at this time in regard to the redness and excoriation on the resident's buttocks, CNA #10 indicated sometimes the buttocks are red and sometimes not. As the wound was revealed, the DON indicated it was "bigger than I've seen it." The DON indicated the skin below the sacral wound and onto the buttocks was "more dusky." The area on the right and left buttocks near the cleft were observed to be a dark purple under the skin. The DON pressed her fingers over the area, and she indicated the area "blanches near the edges." The DON indicated the gluteal wound needed to be cleansed with normal saline and supplies were obtained. Using several prefilled syringes, the DON irrigated the gluteal wound and indicated the "tissue needs debridement." Observed deep within the wound was white substance on one area. The DON indicated the substance was the crushed [MEDICATION NAME]. The DON indicated the resident's wounds are discussed weekly at a team meeting, and she and another nurse "do the measurements." The DON used a centimeter ruler on the edge of a gauze dressing package, and indicated she would measure "just the opening" of the gluteal wound. She indicated she would not measure the depth of the wound at this time. The DON indicated if she measured the open area and the "abrased (sic)" area the wound would be 6.4 cm by 7 cm. LPN #17 worked with the DON to complete the wound care. After the wounds were redressed, CNA #4 and CNA #10 completed care. The resident was rolled onto the left side with a wedge cushion behind his back. CNA #10 indicated the resident is turned every two hours, and he is checked on every hour. During observation of Resident D on 12/19/12 at 1:00 p.m., he was wearing AFO (ankle foot orthotic) splints which suspended his heels off of the bed. CNA #6 was providing care at this time. She indicated the resident was not wearing the AFO splints when she came on duty at 6:00 a.m., but she had placed the splints on the resident. The clinical record for Resident D was reviewed on 12/18/12 at 2:00 p.m. The record indicated the resident was admitted from the hospital to the facility on [DATE]. The hospital Transfer Summary, dated 9/26/12, indicated [DIAGNOSES REDACTED]." The Pressure Ulcer Record for the wound present upon admission indicated the site of the wound was the coccyx, and the description on 9/26/12, was Stage 4 with measurements of 4 by 2.8 by 2.1 centimeters, positive for drainage, no odor and positive for granulation tissue. The treatment was indicated to be a wound vac. Nurse's Notes, dated 10/13/12 at 5:00 p.m., indicated the wound vac was discontinued. A physician's order, dated 10/12/12, indicated, "NS (normal saline) wet to dry drsg (dressing) to O/A (open area) on coccyx. (Symbol for change) q (every) day and PRN (as needed) for dislodgement/soiled until evaluated by wound team." The description grid for the wound indicated the following on the dates indicated: 10/6/12 - 3.8 x 2.8 x 2 cm (length by width by depth), no odor, no undermining, granulation tissue; 10/23/12 (This was the next measurement indicated.) - 5 x 4.2 x 2.1 cm, no drainage, no odor, undermining at 6 and 12 (o'clock), granulation tissue. Weekly measurements continued from 10/30 through 12/11/12 with the smallest length of wound on 11/21/11 at 4.2 cm, the smallest width of the wound on 11/15/12 at 2.8 cm, and the smallest depth of wound on 11/21/12 at 1.2 cm. On 12/11/12, the wound measured 4.8 x 3.2 x 2.2 cm. A Nurse's Note, dated 10/6/6/12 at 9:00 p.m., indicated, "...Noted O/A to R (right) buttocks. Center red, non-blanching. Profound white in color...." A Skin Grid - Pressure document, dated 10/6/12, indicated, a picture of a man with a circle on the gluteal fold of the right buttock. The documentation indicated a 3 cm by 2 cm Stage 1 pressure ulcer with no depth and red color. The measurements and wound stage for 10/10/12 were the same, with granulation tissue in the wound bed. On 10/16/12, the Visualized Stage of the wound was Stage 2 and the Wound Bed included granulation tissue and yellow slough. Measurements on the grid continued as follows: 10/23/12 - 1 X 2.5 X < (less than) 0.1; 10/30/12 - 2.1 X 2.9 X 0.8 cm with yellow slough; 11/6/12 - 3.4 X 3.2 X 1.4 cm with yellow slough; on 11/15/12 - the staging of the wound indicated Stage 3, with measurements of 4.5 X 3.8 X 1.8 cm and yellow slough in the wound bed; 11/21/12 - 4.3 X 3.0 X 1.7 with yellow slough; 11/29/12 - 2.8 X 3.8 X 1.7 cm with a small amount of serous drainage, and granulation tissue and yellow slough; 12/5/12 - 2.8 X 3.8 X 1.7 with a small amount of serous drainage with odor present, with granulation tissue and slough; and 12/11/12 - 6.0 X 10.0 X 2.2 cm, no drainage, with odor present, slough and eschar in the wound bed. A physician's order, dated 10/16/12, indicated, "Exuderm to R gluteal fold. (Symbol for change) Q3d (every three days) & PRN (as needed)." A physician's order, dated 10/23/12, indicated, "1. DC (discontinue) Exuderm to R gluteal fold. 2. Ca+ (calcium) Alginate et (and) cover (with) bordered gauze. (Symbol for change) Q3days et PRN to R gluteal fold." A physician's Progress Note, dated 11/1/12 indicated, "...Skin...He has large non-healing sacral decubitus ulcer and a smaller one on the upper inner thigh/gluteal area..." and "Assessment and Plan...Wound care consult for his non-healing wounds...." A physician's order, dated 11/1/12, included, but was not limited to, "Wound care consult (Dx (diagnosis): sacral decub)..." A handwritten notation indicated, "Notified (name of wound care center) 11/1/12." A Narrative Note, signed by the DON, undated and untimed, at the end of the "Care Track (Multi Shift)" documentation for 11/5/12, indicated, "Dis (discussed) upcoming procedure (with) wife. She is requesting that (name of Resident D) undergo procedure for S/P (suprapubic) cath (catheter) (before) F/U (follow-up) with wound clinic. States 'appts (appointments) are very difficult for (name of Resident D) physically.'" A Narrative Note for 11/6/12 at 4:30 p.m., indicated the resident returned to the facility after placement of the suprapubic catheter. A physician's order received 12/10/12 was clarified on 12/11/12 as follows: "Apply crushed [MEDICATION NAME] 500 mg to gluteal fold wound bed. Pack (with) NS (normal saline) wet to dry QD (daily). Cover (with) ABD pad. (Change) ABD pad prn for soiling. Only (change) wet to dry PRN if packing is soiled (with) BM (bowel movement)." A Care Review/Progress Review, dated 12/13/12, and signed by the Social Services Director (SSD), indicated attendees of Responsible Party, Director of Nursing Services, Social Services, and Other (with no name indicated). A check mark was next to "Reviewed progress towards goals and variances," and handwritten was, "Discussed plans to go to wound clinic...." In the section for Notes was indicated, "...(resident's wife) also says a wound clinic appt. was supposed to have been set after 11/8/12 mtg (meeting). SSD will f/u with DON & Administrator." The signature space for the resident and resident's family included the names of the resident and his wife. Copy of a faxed Outpatient Referral Request, dated 12/14/12, indicated the resident was being referred for "Wound care evaluation with follow-up treatment" for "Chief Complaint: Coccyx wound unchanged since admit. Gluteal wound deteriorating." The Physical Therapy Discharge Summary, dated 12/3/12, indicated in "Summary of Care: Skilled Services: Skilled interventions addressed in this reporting period....Therapeutic exercise...to reduce risk of skin breakdown....Summary of Progress...Initiated RMP/FMP (restorative/functional maintenance plan) for...application of resting splint for bl (bilateral) ankle." During interview on 12/19/12 at 5:00 p.m., the Assistant Director of Nursing (ADON) showed the CNA Resident Profile for care of Resident D in the kiosk computer system. The Profile indicated, "To wear ankle/foot splint/brace for heels up and foot drop." During interview on 12/19/12 at 3:10 p.m., the DON indicated therapy recommended the splints for Resident D. She indicated there was no physician's order for the splints. The DON also indicated Resident D has an appointment for the wound consult on 12/26/12. This federal tag is related to Complaint IN 819. 3.1-40(a)(1)

Based on record review and interview, the facility failed to ensure a resident received appropriate treatment and services to maintain or improve bowel function in that 1 resident had multiple documented days of no bowel movements, was admitted to the hospital with [REDACTED]. (Resident #D) Findings include: Resident #D's record was reviewed on [DATE] at 10:20 a.m. The record indicated Resident #D was admitted with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #D was severely impaired in cognitive skills for daily decision making, was dependent on two staff for toileting, and was usually incontinent of bowel and bladder. A care plan with a start date of [DATE], and a last review date of [DATE], indicated a problem need for "Constipation r/t (related to) (decreased) fluid intake, (decreased) fiber intake, and (decreased) mobility. Goals: Resident will have a BM (bowel movement) no less than every 3 days. Approaches: 1) MOM (milk of magnesia) 30 cc (cubic centimeters) po (by mouth) qd (every day) prn (as needed) 2) [MEDICATION NAME] Supp(ository) 10 mg (milligrams) PR (per rectum) qd prn for no BM in 3 days 3) Encourage activity w(with)/in tolerance 4) encourage fluids, DSS ([MEDICATION NAME] sodium) to 200 mg QD Senna (1) QHS. ([DATE])" Physician's monthly recapitulation orders dated ,[DATE] indicated these routine medications to prevent constipation: "[MEDICATION NAME] sodium 100 mg capsule, give 2 capsules (200mg) orally once a day" with a start date of [DATE], and "Senna Laxative 8.6 mg tablet, give 1 tablet orally daily at bedtime" with a start date of [DATE]. Physician's monthly recapitulation orders dated ,[DATE] also included these as needed medications to relieve constipation: "[MEDICATION NAME] 10 mg suppository, insert 1 suppository rectally daily prn for no BM X 3 days" and "Milk of magnesia susp(ension), give 30 ml (milliliters) orally once a day prn for constipation" and both had start dates of [DATE]. Medication administration records (MARs) dated ,[DATE] indicated documentation that the Senna Laxative had been given every day, and the [MEDICATION NAME] sodium had been given every day except one, on ,[DATE]. The MARs also included documentation a [MEDICATION NAME] 10 mg suppository had been given on ,[DATE] with results of "+" (positive), and 30 cc's of Milk of magnesia had been given on ,[DATE] with results of "eff" (effective), ,[DATE], ,[DATE], and ,[DATE], with results of "+". MARs dated ,[DATE] indicated documentation that the Senna laxative had been given every day between ,[DATE] and ,[DATE], except for ,[DATE], ,[DATE], and ,[DATE]. The [MEDICATION NAME] sodium was documented as given every day between ,[DATE] and ,[DATE]. Milk of magnesia had been given on ,[DATE], with no results, and on ,[DATE], ,[DATE] with no results documented. A "Bowel and Bladder Chart Detail Report" indicated Resident #D was incontinent of a medium BM on [DATE], then did not have any documented bowel movements until a small BM on [DATE]. There were no documented BM's until a medium BM on [DATE]. Nurse's progress notes dated [DATE] at 9:00 a.m. indicated: "Resident not responding to staff. Vitals ,[DATE] 62 (pulse) - 18 (respirations) O2 (oxygen) sat(uration) 96% temp 97.8. O2 on at 2L (liters)." Nurse's progress notes dated [DATE] at 11:00 a.m. indicated: "Resident still not responding held [MEDICATION NAME] and other pills. Resident unable to take in fluids & not voiding. (Nurse practitioner) into see Resident at this time O2 sat 86% HR 124. She ordered Resident to be seen at (local hospital). Res. prepared for transfer report called to (local hospital)." An "Emergency Nursing Record" from the local hospital indicated Resident #D was examined in the emergency department and then returned to the nursing home with new [DIAGNOSES REDACTED]. A CT scan of the abdomen was done for complaints of abdominal pain. The results of the CT scan indicated, but was not limited to "... There is a large amount of stool throughout the colon. The rectum is distended and measures 9 cm (centimeters) in diameter. No distended small bowel loops are seen...Impression: 1. Fecal impaction. 2. 4.5 cm abdominal aortic aneurysm without evidence of leak...." physician's orders [REDACTED]. IVF .9NS @ 100 cc/hrX24 (hours), Soap suds enema tonite...." Nurse's progress notes dated [DATE] at 6:15 p.m. indicated: "Res. returned to facility via ambulance from (local hospital) E.R. N.O.'s received and noted. Res awake but non-verbal. BP ,[DATE] p 58 R 18 T 97.7 O2 sat(uration) 93%. O2 per N/C @ 2 lpm (liters per minute). Returned (with) L) wrist SL (saline lock). Area (without) s/s (signs and symptoms) (of infection) or infiltrate. N.S. (normal saline) IV (intravenous) fluids @ 100 ml/hr cont(inues) Denies pain. (No) s/s acute distress." Nurse's progress noted dated [DATE] at 11:45 p.m. indicated: "Refused SVN (small volume nebulizer) - Tx (treatment) @ this time. States "no, not now". Nurse's progress notes dated [DATE] at 12:25 a.m. indicated: "CNA called this nurse to room. Upon entering room res was cyanotic. (No) pulse (no) resp(irations). CPR started @ this time and 911 called." Nurse's progress notes dated [DATE] at 1:00 a.m. indicated: "Transferred to hosp(ital) per amb(ulance) via stretcher (CPR cont)." emergency room narrative notes, dated [DATE], indicated Resident #D's time of death was 1:11 p.m. and that CPR and medications had been administered. The narrative included: "...called (name of) Coroner, per (name of Coroner) pt (patient) is not to be a Coroner's case...." During an interview on [DATE] at 6:30 p.m., the Director of Clinical Services indicated the soap suds enema was not given after the resident returned from the hospital because the nurse was concerned about giving the soap suds enema and overloading the resident with additional fluids. On [DATE] at 1:30 p.m., the Director of Clinical Services and the Administrator indicated they did not have a policy and procedure for Bowel Management. They said they use nursing practice, they follow the bowel sheets and watch for trends or alerts if the resident has not had a BM for greater than 72 hours, they go by the nursing assessments - what bowel sounds are like, and if the abdomen is tender. This Federal tag relates to Complaint IN 545. 3XXX,[DATE](a)

Based on observation, interview and record review the facility failed to ensure a residents who admitted continent of urine, continence did not decline while in the facility for 1 of 7 residents reviewed for incontinent in the sample of 7. Resident A Findings include: 1. Resident A was observed on the locked unit, on 10/18/11 at 10:45 A.M. sitting in the wheelchair in the dining room. The resident was observed to have an alarming lap belt and a harness restraint (a vest type restraint that holds her shoulders back and then has straps that cross behind her back and then ties in the back of the chair.) Resident A's clinical record was reviewed on 10/18/11 at 11:00 A.M. Resident A's MDS assessment (minimum data set) dated 8/11/11, indicated the resident was severely cognitively impaired, with memory loss, required supervision with transfers, one person limited assist with ambulation, limited assist of one staff with toileting and was continent of bladder, and had no toileting plan. The admission MDS dated [DATE], indicated the resident was continent of urine. A bladder incontinence evaluation, dated 9/8/11, indicated the resident was incontinent of urine, irreversible, and was not consistently able to communicate need to eliminate, yes to history of incontinence and question mark as to how long incontinent. The current care plan with problems, dated 5/9/11 through 5/20/11, did not include any plan for urinary incontinent or a toileting plan to address toileting needs. This was confirmed by LPN #1, the charge nurses for the dementia unit on 10/18/11. LPN #1 indicated the plan for care for the resident would be in the kiosk system where elimination was documented. The resident was documented to have fallen on the way to the bathroom on 6/24/11, in the bathroom on 8/5/11, 8/16/11 and 9/16/11. The MDS Coordinator, on 10/18/11 at 2:45 P.M. demonstrated the kiosk system. The care cues for this resident for toileting was "please check bed and resident often." The resident was documented to have been incontinent of urine 50 % of the time from 10/1/11 through 10/17/11. During interview with CNA #3 on 10/18/11 at 2:00 P.M. she indicated Resident A was toileted on and off, wears a brief. The facility lacks evidence of having implemented interventions to maintain the residents urinary continence. The policy and procedure for Bowel and Bladder Continence Management, policy and procedure, 8/10, was provided by the health facility administrator, on 10/19/11 at 9:30 A.M., indicated staff strives to assist residents in restoring and maintaining bladder incontinence to the extent possible...verify risk factors/underlying cause have been evaluated...determine interventions appropriate for resident/patient. Bladder retraining...Prompted /scheduled voiding require staff assistance as opposed to resident function...document care plan goals and interventions...communicate individualized interventions to the care giving team...modify interventions and goals as needed. document changes...evaluate effectiveness of interventions and document progress towards goal weekly..." This federal tag relates to Compliant IN 449 3.1-41(a)(2)

Based on observation, interview and record review the facility failed to ensure a resident at risk of falls was provided with interventions and supervision to prevent falls resulting in 8 falls in the facility, with fractures of both wrists, in a 5 month period, in that staff did not assure resident had assistance while ambulating, nor a plan to address her toileting needs, and was unable to respond to alarms in time to prevent falls, for 1 of 5 residents reviewed for falls in the sample of 7. Resident A Findings include: 1. Resident A was observed on the locked unit, on 10/18/11 at 10:45 A.M. sitting in the wheelchair in the dining room. The resident was observed to have a splint on both of her wrists. The resident was observed to have an alarming lap belt and a harness restraint (a vest type restraint that holds her shoulders back and then has straps that cross behind her back and then ties in the back of the chair.) The charge nurse, LPN #1, indicated at this same time, Resident A was in the harness for positioning and could release it told how to do so but did not attempt to on her own. She further indicated the resident had recent falls in the facility. Resident A's clinical record was reviewed on 10/18/11 at 11:00 A.M. The MDS assessment, (minimum data set), dated 8/11/11, indicated the resident was severely cognitively impaired, with memory loss, required supervision with transfer, one person limited assist with ambulation, limited assist of one staff with toileting, had fallen since admission,was continent of bladder, and no restraints were utilized at that time. A care plan problem, dated 5/9/11, for "Potential for falls injuries related to history of falls and weakness and unsteady gait." Interventions included "clip ppa at all times-dced (discontinued) 6/9/11," "therapy as ordered, 1 assist transfers (cga)(contact guard assist)" "walker for transfers/ambulation, wheelchair for distance," "6/24/11 keep personal items in reach," "8/6/11 remind to call for help," "8/12/11 refer to therapy; ambulating-no restraint or alarm indicated," "8/26/11 alarming seat belt on wheelchair." A bladder incontinence evaluation, dated 9/8/11, indicated the resident was incontinence. The current care plan with problems dated 5/9/11 through 5/20/11, did not include any plan for urinary incontinent or a tilting plan to address toileting needs. Progress notes, dated 5/4/11 indicated the resident was admitted to the facility with "resident instructed on how to use call light (may not be cooperative due to dementia when assist needed with call light). At 415 p.m. progress notes indicated "resident was evaluated by physical therapist and determined to be a fall risk. Had actually tripped and or almost fell times 3 whole with PT..placed a clip alarm on resident...." Progress notes indicated "6/24/11 2:20 p.m. Res was up walking to bathroom another male res was in her room and when res was attempting to get male res out of room, she tripped and fell over walker. Res was assisted up with 2 staff...res stated she fell on her buttocks..." "6/24/11 3:50 p.m. ...res stated that she was having a lot of back pain related to fall stated that her back hurt with her not moving, just lying in bed but it hurt even more when she was moving..." During interview on 10/18/11 at 4:00 P.M. with the Director of Nursing (DON) he indicated the resident who wandered into her room was Resident B. A Rehabilitation Screening Form Nursing Referral Form, dated 6/27/11, indicated "walking to bathroom with walker...clip alarm had been discontinued 2nd to no falls. staff feel isolated incident...wanderstrips to be placed across pt's doorway to deter wandering residents." Progress notes indicated "8/5/11 at approximately 315 p.m. CNA called writer to res room. Res found on floor in bathroom states slipped off toilet denies pain or discomfort no injury noted. res denies hitting head states landed on my butt and 'nothing hurts but my pride'..encouraged resident to use call light for assistance... non skid footwear was in place..." A Rehabilitation Screening Form Nursing Referral Form, dated 8/8/11 indicated "res has poor safety awareness secondary to poor short term memory." Progress notes dated 8/16/11 "745 p.m. called to res room by CNA Roommate turned on light to report res fell in bathroom. Res sitting on floor with back to cabinet, facing toilet. able to move all extremities without pain or difficulty...assisted to stand observed res back...reminded to call for assist..." A progress note dated 8/26/11 at 2:30 p.m. indicated "res up in wheelchair today, to the den for nail care...following lunch about 1 p.m. checked res still sitting up in wheelchair, by 115 p.m. housekeeper came to report res up walking in room by the time it took nurse to walk down hall, res sitting on buttocks on floor hanging to side of wheelchair and the bedside table...reported to (family members name) wants seat belt on wheelchair and should not be in room when up in wheelchair...4 p.m. alarming seat belt applied to wheelchair." "8/26/11 8 p.m. up in wheelchair with seat belt has tried to get out of chair several times set off the alarm-doesn't listen..." A progress note dated 9/3/11 at 8:40 a.m. res found on floor in B hall dining room lying on back complains aches generalized able to move all extremities...alarm belt was sounding at time...9:45 a.m. noted swelling right wrist medial lateral aspect..pea sized bruise over ulna...complains tenderness with palpitation...2:50 p.m. received x ray report right wrist fracture. Notes indicate the resident was sent out to a local hospital for treatment. A progress note dated 9/6/11 indicated 3-11 "fingers warm to touch remain discolored...new order for shoulder harness when up in chair for safety..." A note dated 9/7/11 120 p.m. "OT (occupational therapy) providing chest harness to remind her not to get up without assist..." 9/9/11 5 p.m. returned from Dr apt now has cast on right lower arm fingers warm..." A Rehabilitation Screening Form Nursing Referral Form, dated 9/6/11 indicated clip alarm added for resident safety. A form dated 9/7/11 indicated a shoulder harness was added for safety. A progress note dated 9/16/11 at 9:30 P.M. indicated "CNA's entered room last bed check and noted res OOB (out of bed) opened bathroom door and found res sitting in floor/. Res stated I knew you girls would come writer entered bathroom and assessed res head to toe...assessed PPA and noted clip string attached to res gown, alarm box found in front of roommates bed not sounding, noted battery ajar resulting in faulty alarm res assisted to and from toilet to bed. alarm replaced... family noticed and informed they were aware on 9/15/11 alarm was faulty..." A care review progress note, dated 9/19/11 indicated "met to discuss treatment options regarding falls resident fall again after removing PSA and walking to the bathroom on 9/16/11. Family member very upset at time..decided upon a low bed with mat at bedside and one side of bed against wall..." A progress note dated 10/12/11, "720 p.m. alarm sounded from res room CNA entered res found on floor sitting position...complaints in pain in left wrist and left knee, swelling noted sl (slight) bluish discoloration of knee swelling noted...8 p.m. x rays taken of left wrist and left knee..10 p.m. radiology report received...left wrist demonstrates an acute impacted distal radial metaphysical fracture, soft tissue swelling present...sent to hospital..." The resident wrist was too swollen to place in a cast and follow up appointment made with orthopedic physician. A progress note dated 10/15/11 indicated 420 a.m."splint in place to left wrist, cast in place to right wrist forearm..." The unit manager, LPN #2, during interview on 10/18/11 at 2 P.M., indicated she could find no added interventions following the falls in bathroom on 8/5 and 8/16/11 nor on 10/12/11. She indicated staff just monitored. This federal tag relates to Compliant IN 449. 3.1-45(a)(2)