Every finding on record at Meadow View Health and Rehabilitation

Based on record review and interview, the facility failed to develop a care plan which addressed the use of blood thinners in a timely manner for 1 of 32 resident care plans reviewed. (Resident 4)Findings include:The record for Resident 4 was reviewed on 3/23/26 at 12:57 p.m. The resident's diagnoses included, but were not limited to, unspecified atrial fibrillation ( A common heart arrythmia characterized by rapid, disorganized electrical signals in the upper chambers leading to an irregular and often fast heartbeat); long term (current) use of anticoagulants (blood thinners); and a personal history of transient ischemic attack (TIA - a mini stroke) with a cerebral infarction without residual deficits.The admission Minimum Data Set (MDS) assessment, dated 2/18/26, indicated the resident was able to make cognitive daily decisions; had no mood or behavior issues; and received an anticoagulant on a daily basis.A physician's order, dated 2/13/26, indicated the resident was to receive for Eliquis (blood thinner) 5 milligrams (mg) tablet twice daily (BID) due to her history of TIAs.Review of the current care plan list lacked documentation of a care plan which addressed the use of Eliquis and the need for monitoring, laboratory tests, and side effects until 3/23/26 at 3:12 p.m.In an interview with the Director of Nursing (DON), on 3/24/26 at 8:10 a.m., she indicated that there was no overall care plan policy. There were separate care plans for specific medications. Anticoagulants had their own care plan. The Interdisciplinary Team (IDT) would write, add and update the care plans as a group. In a second interview with the DON, on 3/24/26 at 9:00 a.m., she indicated that after she checked with the Corporate Nurse, there was no care plan policy. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)410 IAC 16.2-3.1-35(b)(1)

Based on record review and interview, the facility failed to ensure a resident who required radiation therapy to treat skin cancer, was provided the follow care related to arrangements made to begin treatment as soon as possible for 1 of 1 resident reviewed for Quality of care. (Resident 79)Findings include:The record was reviewed on 3/24/26 at 8:10 a.m. The resident's diagnosis included, but was not limited to, basal cell carcinoma (skin cancer).The Quarterly Minimum Data Set (MDS) assessment, dated 2/3/26, indicated Resident 79 was alert and oriented and able to make cognitive daily decisions.On 12/4/25, the resident underwent biopsies of the left upper arm (LUA), the right lower arm (RLA) and upper arm (RUA), and the left knee. The review of the skin biopsies results indicated the results were reported to the facility on [DATE]. Among the Post Biopsy Instructions, the center indicated to call immediately if there were questions or concerns about healing, infection, or bleeding.The results of the 12/4/26 biopsies indicated the following:RUA shave biopsy - Atypical cystic proliferation. This could represent a epidermoid cyst, but a regressing keratocamithoma or cystic squamous cell carcinoma could not be entirely excluded.LUA shave biopsy - cystic squamous cell carcinoma, well differentiated. Tumor thickness was at least 5 mm (millimeters).Left thigh shave biopsy - cystic squamous cell carcinoma, well differentiated. Tumor thickness was at least 5 mm.LUA and thigh - Microscopic Exam: There was a cystic proliferation with atypical squamous cells demonstrated an invasion into the surrounding stroma.A nursing note, dated 1/6/26 at 3:17 p.m., indicated the resident had returned from her appointment with the dermatology center via the facility bus with no new orders. A follow up appointment was made for April 7, 2026 at 1:10 p.m. at the dermatology center in the local town.A nursing note, dated 1/7/26 at 3:05 p.m., indicated a call from the dermatology center was received related to the return of the biopsy results. The results showed that 3 out of the 5 areas were cancerous. The center indicated that they had communicated with the resident about her treatment options and that the resident decided on radiation treatments. The treatments were to be Monday through Friday for 8 weeks. The nurse was advised that she should be receiving a phone call from scheduling in 48 hours to set up times and would try to work in for the facility to transport for treatments. The resident indicated that she could possibly have some friends help out in transporting her if needed.A nursing note, dated 1/12/26 at 3:41 p.m., indicated a radiation consult was rescheduled at the Cancer Center for 1/22/26 at 9:00 a.m. at her prior treatment center an hour away. The method of transport was for the facility bus to transport. The type of appointment was for a Radiation Treatment Consult.A nursing note, dated 1/28/26 at 4:26 p.m., indicated a voice message from the cancer care center was received. The nurse attempted to return the call in regards to possible radiation treatment, but was unable to reach and a voice message was left. Awaiting return call at this time.The record lacked documentation in which the cancer care center had returned the call and no further attempts by the facility were made to contact the center.A nursing note, dated 2/3/26 at 2:16 p.m., indicated the Social Service Director (SSD) met with the resident in her room to complete a quarterly social services assessment. The resident indicated she was doing well and was waiting to start her radiation treatments.During an interview, on 3/23/2026 at 10:35 a.m., the resident indicated she was waiting on the arrangements for the transportation to the cancer center so she could get her radiation treatments for 8 weeks at 5 times a week. The old cancer area to her shoulder was coming back and now she had new areas coming up on her left shin. She indicated that there was no reason to call her cancer physician if she couldn't go to the treatments. She spoke with the people who drove the facility bus and they told her they could not take her 5 times a week. She indicated she had no family and her friends were either old and gave up driving or they were dead. Her Power of Attorney was also not able to drive her to the treatments. The facility indicated to her that she could pay privately to someone but that she would have to have someone go with her and she was not happy with that.A nursing note, dated 3/24/26 at 10:31 a.m., indicated a discussion was held with the resident representative related to the resident's radiation plans moving forward. The resident indicated she had family that would attend appointments with her and she had decided she would like to proceed with the radiation plans. Facility would call the Cancer Center to attempt to have the radiation schedule generated. The resident and representative would be notified of the radiation schedule and transportation schedule was set up.A nursing note, dated 3/24/26 at 11:49 a.m., indicated a call was placed to the community transportation system who reported that they could not do a daily appointment schedule due to the lack of resources within the company. The resident was aware.During an interview, on 3/26/26 at 8:45 a.m., the resident indicated she was ready to start radiation therapy as the facility had made arrangements for transportation to the radiation center. She also indicated the church had now made arrangements for someone to go with her to each session. She was just waiting on the staff to tell her about the transportation and when the radiation sessions were to begin. She further indicated the facility informed her that they would not be able to transport her, but arrangements were made with a company that she would have to pay privately for. During an interview with the Director of Nursing (DON), on 3/26/26 at 8:55 a.m., she indicated the arrangements for transportation had not been set up yet because the resident kept going back and forth deciding if she wanted to do the radiation or not. She indicated the resident did not need to see her cancer physician first because she had already seen him in January after a follow up with the dermatology center. The DON indicated she had spoken with the radiation center on 1/26/26 and they indicated that although the resident did need radiation treatments, it was not urgent. She further indicated the resident also told her she wanted to wait until her 4/7/26 appointment with the dermatology center to check if there were a different option for treatment. They were trying to set up transportation, but the one company they had called indicated they could not commit to every day. They now were looking at other options. When asked about the facility's transportation policy indicating the facility would provide transportation if all other options had been exhausted, she indicated the policy indicated the facility would only provide transportation locally.The resident's record lacked documentation of these conversations the DON had with the resident and the dermatology and cancer centers.When questioned what the resident was supposed to do since her physician and the treatment center were not local, but were about an hour away and if that meant the resident could not go to her treatment sessions due to transportation issues, the DON indicated they would just have to find other options for transportation. She could not say what the other options were, only that they were exploring other options.On 3/23/26 at 8:27 a.m., the ED presented the facility's current policy on Facility Bus/Van Transportation Guidelines. Review of this policy included, but was not limited to, Policy: Transportation will be provided by the facility bus/van for residents participating in activities outside of the facility. Procedure: 1. Transportation will be provided by the facility bus/van for residents going to and from physician appointments (local) when no other option is available. a. Families should be involved in transportation to and from physician appointments when able. b. Families should be involved in transportation to and from .other medical related appointments when able. c. Outside transport should be the chosen option prior to utilizing facility bus/van for physicians and/or other medical related appointments .410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)410 IAC 16.2-3.1-37(b)

Based on record review and interview, the facility failed to ensure a resident was free of falls for 1 of 3 residents reviewed for accidents. (Resident 26) Findings include:The record for Resident 26 was reviewed on 3/23/26 at 1:23 p.m. The resident's diagnoses included, but were not limited to, extrapyramidal and movement disorders (drug induced involuntary movements), Alzheimer's disease with early onset, muscle weakness (mental decline affecting people under 65), abnormal posture (improper body alignment causing reduced mobility), dementia with mood disturbance (mental decline causing rapid shifts in emotion), contracture of the right and left knee (stiffening or tightening of muscles or skin preventing full extension), cognitive communication deficit (impairment in conversation), primary osteoarthritis (chronic joint disease). The Quarterly Minimum Data Set (MDS) assessment, dated 4/27/25, indicated the resident was severely cognitively impaired. She was dependent on staff for eating, toileting, personal hygiene, and mobility. The resident needed substantial/maximal assistance for dressing The care plan, dated 5/7/15 and last revised 1/22/26, indicated the resident needed assistance with ADLs including bed mobility, transfers, eating and toilet use related to: osteoporosis (low bone mass), osteoarthritis, chronic pain, recurrent spinal fractures, chronic fatigue, weakness, dementia, decline in cognition and condition due to dementia, extensive to total assistance with care, feeding, turning and repositioning, contracture of right and left knee, history of left humeral fracture. The interventions, dated 5/7/15, included, but were not limited to, assistance with toileting and/or incontinent care: incontinent of bowel and bladder and unable to voice the need to use restroom or bedpan, assistance with transfers as needed; mechanical assistance of two staff members. The resident's family preferred for the resident to remain in bed. The care plan, dated 5/7/15 and last revised 1/22/26, indicated the resident required assistance with toileting for bowel and bladder incontinence, was not aware of toileting needs, current bed rest orders, required assistance with hygiene and clothing management. The interventions, dated 5/7/15, included, but were not limited to, assistance with elimination, incontinent of bowel and bladder, and assistance by two staff with incontinent care/bed mobility. The care plan, dated 5/7/15 and last revised 1/22/26, indicated the resident was at risk for falls due to age, incontinence, chairfast, high risk medication use, tethering equipment, required assistance or supervision with transfers, mobility, or ambulation, lack of understanding of one's physical and cognitive limitations, altered awareness of immediate physical environment. osteoporosis, recurrent spinal fractures, chronic pain, narcotic pain medication, weakness, and dementia. The interventions, dated 3/6/26, included, but was not limited to, assistance by two staff with bed mobility. The care plan, dated 4/25/25 and last revised 1/22/26, indicated the resident had impaired mobility related to diagnoses of osteoporosis, osteopenia (loss of bone density), history of multiple fractures, end stage dementia, contractures to the right and left lower extremities. The interventions, dated 4/25/25, included, but was not limited to, staff assistance with incontinence care. The therapy evaluation, dated 5/29/25, indicated staff education was documented on turning and repositioning. The physician's order, dated 6/11/25, indicated an activity level with a specialized high back positioning wheelchair and assistance by two staff with a mechanical lift. The nurse's note, dated 6/23/25 at 5:48 p.m., indicated RN 3 heard a commotion in the main dining room just before the dinner service. Certified Nurse Aide (CNA) staff yelled for the RN. Upon entering the room, Resident 26 was lying on her back, on the floor, with her feet towards the high back positioning wheelchair. The resident had dime sized bright red blood to her gums initially. Her pupils were round and reactive to light. Upon further observation, the vital signs and neurological assessment indicated bruising and swelling to the chin and around the mouth, purple in color with medium pink surrounding the area. The nurse's note, dated 6/24/25 at 11:52 a.m., indicated the resident had a moderate amount of purple discoloration to her chin with generalized swelling to the right side of the jaw. The Interdisciplinary Team (IDT) Fall Review note, dated 6/24/25 at 2:12 p.m., indicated the resident was sitting in her high back positioning wheelchair at the dining room table prior to dinner. The CNA was adjusting the chair to an upright position to feed the resident her meal and the resident slid out of the chair before staff could intervene. The resident was fully clothed with non-skid footwear in place. The injuries sustained were bruising to the chin, and a small amount of bleeding at the gum line. The immediate/short term interventions put into place at the time of the fall was for the resident to have two assistants with chair mobility. The Comprehensive Minimum Data Set (MDS) assessment, dated 1/28/26, indicated the resident was severely cognitively impaired. The resident had impairment on both sides of her body for Range of Motion. The nurse's note, dated 3/5/26 at 2:32 p.m., indicated Resident 26 had a witnessed fall, in her room while receiving incontinence care. The nurse was called to Resident 26's room by CNA 4. The nurse cleansed the laceration to the resident's head and applied pressure. The Emergency Medical Service (EMS) was called, and the resident was transported to the hospital. The nurse's note, dated 3/5/26 at 5:49 p.m., indicated the resident returned from the hospital with lacerations to the left eyebrow, which had eight stitches present. No new orders were received from the hospital. The IDT Fall Review note, dated 3/6/26 at 4:01 p.m., indicated the description of the incident was the resident was receiving incontinence care when she slid off the edge of the bed before staff could intervene. The injuries sustained were lacerations to the left side of the forehead, and sutures were in place. The immediate/short-term interventions put into place at the time of the fall was for the assistance of two staff for activities of daily living (ADL) care. The nurse's note, dated 3/20/26 at 10:06 a.m., indicated the lacerations to the middle of the forehead and the left brow had resolved. During an interview, on 3/25/26 at 9:55 a.m., RN 3 indicated she heard a commotion and went into the dining room where the staff were sitting the resident up after she went over the side. The resident fell forward and sideways at the same time and clipped her chin or mouth area on the side of the table. Someone came to get RN 3, but she couldn't remember who it was. Unit Manager 5 may have been in the dining room. It was CNA 4 who tried to lift the back of the chair alone. The resident's family member didn't want the resident sent to the hospital. The resident couldn't move on her own. She could scoot herself around a little. During an interview, on 3/25/26 at 10:07 a.m., Licensed Practical Nurse (LPN) 7 indicated CNA 6 was performing the incontinence care on the resident. She was not told if the CNA was alone performing the incontinence care on 3/5/26. The CNA was cleaning the resident and the resident rolled off the bed. The resident could not do anything on her own. CNA 6 had rolled the resident over and was cleaning the resident's backside and the resident rolled or slid off the bed. The resident had a laceration to her left brow line and another laceration between the eyebrows on the forehead area. There was a little bruising under the eye. LPN 8 was with the resident after she was notified of the incident. LPN 6 did the charting. LPN 7 was given an in-service which indicated if a resident required two-person assistance for transferring; they would require two-person assistance for incontinence care, also. During an interview, on 3/25/26 at 10:13 a.m., LPN/Infection Preventionist (IP)/Unit Manager 5 indicated the resident required total staff assistance. After looking at the care plan intervention for the resident she indicated the resident required the assistance of two staff members for mobility. During an interview, on 3/25/26 at 10:32 a.m., the Director of Nursing (DON) indicated the resident fell from her wheelchair in June 2025. The resident had a high back positioning wheelchair at that time and went to the dining room. She was being sat up for her meal. She wasn't sure what happened, but the resident came out of her chair during that process. The DON was asked by staff to come to the dining room after the fall. The resident was still on the floor when she arrived. The Nurse Practitioner (NP) was in the facility and came to the dining room to assess the resident. They both assessed the resident. The location of the bleeding appeared to be from her gum line. The resident was bruised across the chin. She was off of hospice during the fall. The resident was not up for meals after the fall. Two CNAs were in the dining room, but one CNA was adjusting the Broda chair. The other CNA was close, but in the isle between the tables, but was not able to catch or help her. The DON was told about the fall on 3/5/26. The CNA was changing the resident and the resident's leg slid from the bed, which pulled her off the bed. The resident hit her head, but it was unclear what she hit her head on. She indicated she was surprised that the resident's care plan interventions since 2015 indicated the resident was a 2 person assist, because at that time, the resident could ambulate. She was only assisted by one staff for both falls. The Fall Management Policy, last revised August 2022, included, but was not limited to, It is the policy of [corporation name] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls.410 IAC (Indiana Administrative Code) 16.2-3.1-45(1)(a)410 IAC 16.2-3.1-45(2)

Based on observation, record review, and interview, the facility failed to follow appropriate infection control guidelines related to perineal care, bathing, and isolation for 6 of 8 residents reviewed for infection prevention. (Residents E, F, G, B, C, and D)Findings include:1.During an observation on the North Left Hall, on 12/18/25 at 9:09 a.m., Certified Nurse Aide (CNA) 5 was leaving a resident's room with a trash bag of soiled briefs and wipes. She brought the trash bag to soiled utility room and disposed of it in the bin. She performed hand hygiene after disposing of the bag. During an observation, on 12/18/25 at 9:57 a.m., of Resident E receiving incontinence care by CNA 3 and she walked into the resident's room without performing hand hygiene. She applied gloves and removed the sheet from the resident. It was soiled, so she laid it on the floor beside the resident's bed. She provided incontinence care and removed her gloves. She placed the pillow under the resident's right side and covered him. The blanket was removed from the foot of the bed and placed on top of the soiled sheet on the floor. Without performing hand hygiene, she applied clean gloves to gather the soiled sheet and blanket from the floor and then placed them into a trash bag. She took the soiled linen and soiled brief and wipes in another trash bag to the soiled utility room. She removed her gloves and left the soiled utility room without performing hand hygiene. She went to the nurse's station and used the phone at the desk. During an interview, on 12/18/25 at 10:11 a.m., CNA 3 indicated she would knock at the door, enter the resident's room, and ask if it was okay to perform incontinent care. She would use one wipe with each swipe or fold the wipe for each swipe. She should wash her hands after leaving the resident's room. She indicated she did not perform hand washing during the care. The record for Resident E was reviewed on 12/18/25 at 11:40 a.m. The diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage, frontotemporal neurocognitive disorder, depression, severe dementia with a behavioral disturbance, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or chronic kidney disease, acute on chronic diastolic (congestive) heart failure, chronic kidney disease, stage 3b, atherosclerosis of the autologous vein of the coronary artery bypass grafts with forms of angina pectoris, the presence of a cardiac pacemaker, acute embolism and thrombosis of the deep veins of the left proximal lower extremity, persistent atrial fibrillation, thrombocytopenia, hemiplegia and hemiparesis following a cerebral infarction, type 2 diabetes mellitus with diabetic chronic kidney disease, anemia, chronic normocytic anemia, and obstructive sleep apnea. The care plan, dated 10/8/25 and revised 10/17/25, indicated the resident required assistance with toileting due to incontinence, impaired mobility, altered awareness. The interventions, dated 10/8/25, indicated to check for incontinent care as needed, check every 2 hours for incontinence. The care plan, dated 1/8/26, indicated the resident had a desire to improve or maintain his current functional status. The interventions, dated 10/8/25, included, but were not limited to, assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. The admission Minimum Data Set (MDS) assessment, dated 10/14/25, indicated the resident was severely cognitively impaired. He had impairment with upper and lower extremities and was dependent for eating, toileting hygiene, showers or bathing, and personal hygiene. 2.During an observation, on 12/18/25 at 10:14 a.m., CNA 3 used hand sanitizer and applied Personal Protective Equipment (PPE) of a gown, gloves and mask to enter Resident F's room. He was in isolation for a urinary tract infection (UTI) and later vomiting. The resident requested that his cup be filled with ice water. The CNA exited Resident F's room into the hallway and removed her PPE. She brought it down the hall to the housekeeping cart and threw it away in the cart trash bag. She returned and opened the resident's door and stepped just inside the room to place the cup on the bedside table of the resident. She left the room without performing hand hygiene and entered the room of Resident H to answer his call light. She was behind the privacy curtain but indicated the resident didn't want anything. She used hand sanitizer once she left the room. The record for Resident F was reviewed on 12/18/25 at 11:50 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, paraplegia, hypertension, mononeuropathies of the left lower limb, gastro-esophageal reflux disease, neuromuscular dysfunction of the bladder, major depressive disorder, sleep disorders, hypokalemia, psychotic disorder with hallucinations due to a known physiological condition. The care plan, dated 4/5/24 and revised 12/17/25, indicated the resident was at risk of transferring or becoming colonized with a Methicillin Resistant Organism (MDRO) and required enhanced barrier precautions due to (an indwelling medical device, a chronic wound that required a dressing, or colonization or infection with a MDRO in which contact precautions do not apply. The interventions, dated 4/5/24, included, but was not limited to, use standard precautions including hand hygiene in addition to Enhanced Barrier Precautions (EBP). The care plan, dated 6/28/23 and revised 12/17/25, indicated the resident required assistance with toileting due to neuromuscular dysfunction of the bladder, paraplegia, dependence on his wheelchair, history of falls, age, medications, tethering equipment, required staff assistance with ADLs, history of cystostomy, and a boil to the right. The interventions, dated 6/28/23 included, but were not limited to, assist with incontinence care as needed, and observe for signs of a urinary tract infection. The physician's order, dated 12/17/25, indicated the resident was in isolation due to having an active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. The type of isolation is droplet contact related to vomiting. The Quarterly MDS assessment, dated 9/24/25, indicated the resident was cognitively intact. He required set up or clean up assistance with eating, substantial to maximal assistance with toileting and showering or bathing. 3.On 12/18/25 at 10:20 a.m., CNA 3 observed drips of what she called water were down the length of the hallway. The CNA obtained a clean towel and using her foot cleaned down the drips on the floor. She stopped halfway down the hall to turn the towel over and continue cleaning. She folded the towel again and dried the floor up to the housekeeping cart. The towel was brought to the soiled utility room with her bare hand. She walked down another North Right Hall and applied PPE. Resident G was in isolation for lice. His roommate, Resident K, indicated he wanted a drink of Kool-Aid. The CNA removed her PPE and placed it in the trashcan in the room. She brought the trash bag to the soiled utility room and left. She had not performed hand hygiene. She walked to the nurse's station and handled the paperwork on the desk. She then used hand sanitizer. 4.During an observation, on 12/18/25 at 10:35 a.m., CNAs 3 and 4 entered Resident E's room. CNA 3 had gathered the towels, washcloths, clean blanket, sheet and pillowcases and brought them into the resident's room and placed them on the nightstand. CNA 3 found the bath basins under the resident's sink. She filled the basins with warm water, placed them on the bedside table, and placed washcloths into both basins. At that time CNA 3 indicated there had been no issues with having bath basins. She had never seen staff use any other pan for resident baths. She started looking for clothes for the resident with the help of CNA 4. The resident's liquid baby soap was placed between the basins. CNA 3 obtained a wet washcloth and added the soap to it. She washed the resident's hair and CNA 4 began washing the resident's legs. The soiled washcloths were placed into a trash bag in the trashcan. CNA 3 removed her gloves and applied clean gloves. They dried the resident and placed clothes on him. The soiled linens were bagged. Both CNAs transferred the resident into his wheelchair. CNA 4 removed the bags to soiled utility. She was not observed performing hand hygiene before and during the resident's care. CNA 3 removed her gloves and made the resident's bed. At this time, CNA 3 indicated she had washed her hand prior to the care. 3. The record for Resident G was reviewed on 12/18/25 at 12:20 p.m. The diagnoses included, but were not limited to, cerebral infarction due to occlusion or stenosis of the left middle cerebral artery, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with hyperglycemia, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, gastro-esophageal reflux disease without esophagitis, glaucoma-left eye-blindness, unqualified visual loss, left eye, normal vision right eye, dysphagia, oropharyngeal phase, other speech and language deficits following nontraumatic intracerebral hemorrhage, hypothyroidism, hyperlipidemia, obstructive sleep apnea, major depressive disorder, recurrent, mild, insomnia, cerebrovascular disease, dysphagia following cerebrovascular disease, and generalized anxiety disorder. The care plan, dated 5/22/23 and revised 12/4/25, indicated the resident required assistance with toileting due to age, history of falls, medications, requires staff assistance/supervision with transfers, ambulation and mobility, unsteady gait, chairfast, altered awareness, stroke, left side hemiplegia, vision loss, glaucoma, anxiety, weakness, left knee pain, anemia, obesity. The interventions, dated 5/22/23, assist with incontinent care as needed and observe for signs of urinary tract infection. The physician's order, dated 12/18/25, indicated to apply [NAME] Crème Rinse topically for Lice once a day. The physician's order, dated 12/25/25, indicated to apply [NAME] Crème Rinse. Apply to the hair and beard per box instructions one time. The physician's order, dated 12/18/25, indicated the resident was in isolation due to having an active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. During an observation, on 12/10/25 at 11:55 a.m., the drink cart had already arrived on the North Left Hall. At 12:02 p.m., The lunch meal cart had arrived and the lunch trays were delivered to residents on the North Left Hall and the North Right Hall. The CNAs were using hand sanitizer between trays. At the end of the early meal trays, there was one lunch tray on the top shelf of the meal cart. A CNA pushed the cart into the Main Dining Room and left it near the windows between two tables. During an interview, on 12/18/25 at 12:14 p.m., Licensed Practical Nurse (LPN) 6 indicated the CNAs took the meal trays that had been refused, back to the kitchen for disposable. They kept the cart in the dining room to place meal trays once residents finished eating. During an interview, on 12/18/25 at 12:16 p.m., CNA 3 indicated the trays that were refused by residents were put back on the cart. No staff should eat the meal once it was refused. She had not seen any staff eating the food on the trays. During an interview, on 12/18/25 at 12:24 p.m., the Director of Nursing (DON) indicated staff should foam their hands going in a room for care and upon leaving a room from care. The should perform hand hygiene before touching a resident and after touching the dirty areas during care. The soiled linens should be bagged and removed from the rooms. The PPE should be removed inside the resident's room and placed inside the isolation bag in the resident's room. 4. During an observation, on 12/18/25 9:20 a.m., CNAs 7 and 8 were about to start incontinence care for Resident B. CNA 7 did not wash her hands prior to putting on gloves and starting the procedure. CNA 8 used a small hand sanitizer for hand hygiene and put on gloves. The brief was removed by CNA 7and the resident rolled to her left side by both CNAs. The used brief was placed in the trash can along with their dirty gloves. CNA 8 gathered clothes from the closet for the resident to be changed into. CNA 7 cleaned the resident front to back with 2 wipes and a new brief was put back on the resident. No hand hygiene after cleaning the resident. CNA 8 had gloves on and dressed the resident then removed her gloves and performed hand hygiene. CNA 7 sat the resident up to the side of the bed, the fabric incontinence pad was removed gloveless by CNA 7. Both CNAs transferred the resident from the side of the bed to her wheelchair. The record for Resident B was reviewed on 12/18/25 at 10:25 a.m. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, contracture-left hand, type 2 diabetes mellitus, and hypertension. The care plan, dated 7/16/23 and revised 12/12/25, indicated the resident required assistance with toileting due to age, required staff assistance with ADL's, history of falls, left arm contracture, left side hemiplegia, stroke, weakness, seizures. The interventions, dated 7/16/25 and revised 12/12/25, included, but were not limited to, assist with incontinent care as needed, check every 2 hours for incontinence, document any abnormal findings and notify Medical Director (MD), and assess and document skin condition weekly and as needed. The Quarterly MDS assessment, dated 12/1/25, indicated the resident was cognitively intact. The resident was always incontinent of bowel and bladder. The resident required substantial assistance with toilet hygiene, bath, upper/lower body dressing, footwear, and personal hygiene. During an interview, 12/18/25 at 10:00 a.m., CNA 7 indicated that she should wash her hands before touching the resident, during the process of care when her gloves had to be removed, and after she finished with the resident's care. 5. During an observation, on 12/18/25 at 9:56, CNA 7 performed hand hygiene and put gloves on. She took off Resident C's brief and CNA 7 cleaned the resident front to back with one wipe and a new brief was put back on the resident. The dirty brief was put in the trash with dirty gloves. CNA RW then washed her hands and put new gloves on to take the trash to the room labeled Pantry and placed the trash in the appropriate spot. The record for Resident C was reviewed on 12/18/25 at 10:45 a.m. The resident's diagnoses included, but were not limited to, dementia, chronic pain syndrome, difficulty in walking and paranoid schizophrenia. The care plan, dated 10/16/22 and revised 12/17/25, indicated the resident required assistance with toileting due to weakness, decreased mobility, incontinence, dementia, irritable bowel syndrome (IBS-C). The interventions, dated 10/16/22 and revised 12/17/25, included, but were not limited to, assist with incontinent care as needed, check every 2 hours for incontinence, document any abnormal findings and notify the MD, assess and document skin condition weekly and as needed. The Quarterly MDS assessment, dated 12/1/25, indicated the resident was cognitively intact. The resident required supervision/touch assistance for toileting, personal hygiene and lower body dressing. The resident required maximal assistance for showering/bathing and putting on footwear. 6. During an observation, on 12/18/25 at 10:10 a.m., Resident D was a non-verbal resident and needed incontinence care. CNA 8 washed her hands at the sink and applied gloves. The bed was raised, then the CNA removed the resident's pants. The brief was taken off and using one wipe the CNA made a swipe front to back, used another side and wiped again front to back. She then repeated the cleaning with another wipe. The CNA turned the resident to her left side against the wall. The brief and dirty gloves were placed in the trash. The CNA performed hand hygiene and put on gloves. The rectum was cleaned with one wipe and new brief placed on the resident. The bed was lowered. The CNA used hand sanitizer, picked up the trash and clothes without gloves. The CNA took the dirty clothing and trash to the room labeled Pantry and placed the items in the appropriate spot. The CNA did not use hand sanitizer until she made it to the nurse's station and touched the counter The record for Resident D was reviewed on 12/18/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage with loss of consciousness, speech and language deficits, epilepsy, sleep difficulty, and dysphagia. The care plan, dated 5/16/19, and revised 12/11/25, indicated the resident required assistance with toileting due to impaired mobility, impaired cognition, incontinence, history of subarachnoid hemorrhage, weakness, severe intellectual disabilities, epilepsy, encephalopathy, required assistance with transfers, hygiene and clothing management. The interventions, dated 5/16/19 and revised 12/11/25, included, but were not limited to, incontinent of bowel and bladder- check every 2 hours for incontinence, assist with elimination, assist with incontinent care as needed, document any abnormal findings and notify the MD. The Quarterly MDS assessment, dated 11/20/25, indicated the resident's cognition was not assessed. The resident was non-verbal. The resident was dependent on staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing, footwear, and personal hygiene. The skills competency for bed baths was provided by the Director of Nursing Services, on 12/18/25 at 12:47 p.m. It included: 3. Perform Hand Hygiene.18. Change bath water and gloves, complete hand hygiene, and use clean gloves and towel.23. Change bath water and gloves, complete hand hygiene, and use clean gloves and towel.29. Perform hand hygiene. The skills competency for donning and doffing PPE was provided by the Director of Nursing Services, on 12/18/25 at 12:47 p.m. It included: 1. Perform hand hygiene.12. Perform hand hygiene and exit the room.16. Perform hand hygiene and exit the room. The hand hygiene policy was provided by the Director of Nursing Services, on 12/18/25 at 12:47 p.m. It included, but was not limited to,: To provide a standardized approach to hand hygiene.5 moments of hand hygiene: before touching a resident, before a clean or aseptic procedure, after body fluid exposure risk, after touching a resident, and after touching a resident's surroundings . This citation relates to Intake 2612775. 3.1-18 (a)

Based on interview and record review, the facility failed to ensure medications were available for administration, as ordered by the physician, for 2 of 4 residents reviewed for pharmaceutical services. Findings include: 1. The clinical record for Resident B was reviewed on 5/30/25 at 11:10 a.m. The resident's diagnosis included, but was not limited to, hyperparathyroidism. The admission order, dated 4/25/25, indicated the resident was to receive Cinacalcet (medication used to treat hyperparathyroidism) 30 mg (milligrams) daily. The April 2025 medication administration record indicated between 4/26/25 through 4/30/25, the resident's medication was unavailable and not administered. The clinical record lacked documentation of the physician and pharmacy notification due to the unavailability for administration. During an interview on 6/2/25 at 8:45 a.m., Licensed Practical Nurse (LPN) 4 indicated if a medication was not available, it can be pulled from Omnicell (emergency drug kit). If the medication was unavailable in the Omnicell, the pharmacy should be called to find out why and then notify the physician. 2. The clinical record for Resident C was reviewed on 5/30/25 at 12:26 p.m. The resident's diagnoses included, but were not limited to, hypertension and indigestion. The physician's order, dated 5/22/25, indicated the resident was to receive Metoprolol Succinate (medication for high blood pressure) 25 mg extended release 24 hour once daily. The physician's order, dated 5/22/25, indicated the resident was to receive Aluminum hydroxide/magnesium hydroxide/simethicone, 200-200-20 mg/5 ml (milliliters), 15 ml daily for indigestion. The May 2025 medication administration record indicated the Metoprolol was not administered between 5/25/25 through 5/29/25 due to the unavailability of the medication; the Aluminum hydroxide/magnesium hydroxide/simethicone was not administered between 5/25/25 through 5/29/25 due to the unavailability of the medication. The clinical record lacked documentation of physician and pharmacy notification due to the unavailability for administration. On 6/2/25 at 2:55 p.m., the Director of Nursing provided a current copy of the document titled Medication Shortages/Unavailable Medications dated 12/01/07. It included, but was not limited to, Procedure .If a medication is unavailable during normal Pharmacy hours .A Facility nurse should call Pharmacy to determine the status of the order .If a medication is unavailable .after normal Pharmacy hours .A Facility nurse should obtain the ordered medication from the Emergency Medication Supply .If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action This Citation relates to Complaint IN00458683 3.1-25(a)

Based on record review and interview, the facility failed to ensure appropriate social services follow-up, monitoring, and documentation for 5 of 20 residents reviewed for Social Services. (Residents 40, 56, 31, 53, and 65) Findings include: During an interview on 2/29/24 at 1:06 p.m., Resident 56 indicated he felt useless. He was unhappy being in a long-term care facility. He felt locked up. He wanted to get back to his family in another State. He was unable to move his legs since he'd had a stroke. He would like to do therapy so he could build up his strength to get stronger and go home. He had not been out of bed in months. He had relayed these concerns to the SSD (Social Services Director) and the DON (Director of Nursing). The Admission MDS (Minimum Data Set) assessment, dated 10/24/24, indicated the resident was admitted from the hospital. He was cognitively intact. Scored a 10 on the PHQ-9 (a screening tool for depression) which indicated he was moderately depressed. He exhibited no behaviors of rejection of care. He required substantial to maximum assistance with bed mobility and transfers. The diagnoses included, but were not limited to, acute infarction of spinal cord and paraplegia. The care plan, dated 9/28/23, indicated the resident required assistance with ADLs (Activities of Daily Living) including bed mobility, transfers, eating, and toileting related to left femur fracture, anemia, hypertension, chronic pain, paraplegia major depression, anxiety, allergies, vitamin deficiency, neurogenic bladder, neuropathy, low back pain, GERD (gastroesophageal reflux disease), spinal cord embolism, and malnutrition. The interventions included, but were not limited to, assist with ambulation as needed, encourage resident to do as much for self as possible, occupational therapy as needed, and physical therapy as needed. The admission road to recovery form, dated 9/28/23, indicated the resident's discharge goals were to transfer to another State. The admission social services assessment, dated 9/28/23, indicated the resident wanted to remain in long term care, and wanted to hopefully transfer to his home State. The care plan, dated 9/29/23, indicated the resident's return to the community was not feasible due to a need for 24-hour care. His discharge goal was to remain in the facility unless he could transfer to a facility in his home State, which could only happen if he was approved for that State's Medicaid. The resident lacked motivation to start the application process. The interventions included, but were not limited to, only ask the resident about returning to the community on comprehensive assessments, encourage and offer for the resident to express thoughts and feelings regarding placement, encourage family involvement and support, and invite and encourage the resident to attend and participate in goal setting in care plan meetings. The Social Services MDS documentation and progress note, dated 10/4/23, indicated the resident reported little interest or pleasure in doing things, feeling down, depressed, or hopeless, had trouble sleeping, feeling tired or having little energy, and was bothered by this 7 to 11 days of the last 2 weeks. The SSD note, dated 10/11/23 at 1:07 p.m., indicated the resident requested a referral to be sent to a facility in his home State and the referral was sent. The record lacked documentation of any Social Services follow-up on the referral or the resident's adjustment to the facility or inability to return to his home State. The nurse's note, dated 12/13/24 at 8:45 a.m., indicated the facility received a phone call from the resident's family member who was requesting to attend the resident's care plan meeting on 12/29/23 via phone. She would like Social Services to contact her with the time. Her phone number was verified, and the SSD was informed. The SSD note, dated 12/13/23, indicated the care plan meeting was scheduled with the resident's family member for 12/29/24 at 1:00 p.m. The SSD note, dated 12/29/23 at 2:28 p.m., indicated the care plan meeting was held with the resident. The resident's family member could not be reached via phone. A message was left requesting a return phone call. The record lacked documentation of any further attempts by Social Services to reschedule the appointment with the family member or reach out to them. The Behavioral Health Progress note, dated 1/22/24, indicated the resident was seen by the facility's psychiatric services provider. The resident was born and raised in another State. He presented with depressed mood with congruent affect. He expressed a desire to leave the facility and go home. He identified concerns and processed related feelings and thoughts. He questioned why he had yet to engage in physical therapy. He wasn't interested in most of the activities at the facility. He agreed to try and socialize more. He described experiencing social anxiety and identified settings and triggers. These concerns were relayed to staff. The record lacked documentation of social services following up on the resident's desire to attend therapy, reasons for not wanting to get out of bed, or his feelings regarding placement at the facility or inability to return to his home State. During an interview on 3/4/24 at 9:37 a.m., The PT Director indicated Resident 56 had not been on therapy case load since he had been admitted . They had talked to him several times. If he would like to get out of bed, they could look at wellness programs and formal PT, but the resident tended to not get out of bed to participate in therapy. There was no formal documentation on that in the therapy software. To provide skilled care to a long-term care patient they would need to get up out of bed and come to therapy and he chose to stay in bed. They had to want to do it. Anytime they tried to talk ask him to do that he did not want to consistently get up. On 1/23/24 they documented that if he was willing to get up with staff and come down, they would put together a wellness exercise program. He used to get up in his wheelchair and use the hand bicycles and lift weights. The PT Director stated, We said if he would get dressed and get up, we would do all those things with him. They had told the CNAs (Certified Nurse Aides) about it, and to encourage him to try and get up. If he came down, they would attempt to find time to evaluate him. During an interview, on 3/4/24 at 10:14 a.m., Resident 56 indicated he had not refused to get up. He stated, Why wouldn't I get up? They don't ask me to get up. He had not worked with therapy. He would like to build up his upper body muscles and work on transferring himself. He wanted to go back to his home State, but he didn't know how to get back there. During an interview on 3/4/24 at 10:23 a.m., CNA 8 indicated she took care of Resident 56. He would sometimes get out of his bed and he had been wanting to get up in his wheelchair lately and sit up for lunch. He got up the other day, but hadn't been up since. He had expressed wanting to go to therapy and wanting to go home. That was his original goal. If the resident refused care, they would tell the nurse. He did have times where he didn't feel good. The resident had told her they were supposed to be getting him up, but she had heard it from him, and it wasn't a part of his plan of care. It was what he wanted. During an interview on 3/4/24 at 10:39 a.m., the SSD (Social Services Director) indicated if there was something simple going on she would do a progress note. If it was more in depth, she would do care plan observations. The resident did not have a power-of-attorney. When he came in originally, he was going to go back to the community with a family member. Then he had brought up wanting to return to his home State. She had sent a referral to one facility in his home State and had talked to his family member a few times. They'd attempted to get him on that State's Medicaid. The family claimed at some point his name was tied to a water claim and received payment for a class action suit. The resident was supposed to bring her paperwork on that and give it to her but had not. She had not talked to him about it since December. She'd asked if he had any updates, but he did not. She had not asked family for any paperwork. She did not know if he could apply for his home State Medicaid. They would have to find a facility he wanted to transfer to, and then send all the information. She would then have to get him to that State. She'd given him a list of facilities in his home State, but had not documented that. She had not reached out to any other facilities to see if anyone would accept him. She could reach out to his family and see if he had any more mail. She could give him another list of facilities and help him call around to see if anyone would accept him. There were a lot of times the resident didn't want to get out of bed to go to the therapy gym, but he hadn't mentioned it to her. He hadn't mentioned an interest in in-room therapy to her. They were limited, but they could provide in-room therapy. She did not know why he wanted therapy, she assumed to try and help with his transition back to where he wanted to go, but she had not had that conversation with him. Nursing had told her he wasn't getting out of bed, but she hadn't gone and spoken to him about that. She could try to figure out why he wasn't wanting to get up and maybe educate him on the benefits of getting out of bed. There was not anything on his care plan to reflect a desire to attend therapy or a plan to get him out of bed. During an interview on 3/4/24 at 2:07 p.m., the Director of Nursing (DON) indicated the resident had requested therapy and a referral to therapy was made. The concern was he did not always participate in things. He was encouraged to start getting out of bed daily. His goal was to go home. He did not like to get out of bed, so what therapy said was if he took the initiative to get out of bed every day, they could re-evaluate him. They could do therapy in the room. During an interview, on 3/4/24 at 2:25 p.m., Physical Therapist 9 indicated he did complete therapy screens at times, but usually the PT Director did them. They would first screen the resident to determine if they would do an evaluation unless someone referred the resident to therapy. Then they would do an evaluation. If the patient didn't want to get up and go, they would try and encourage them to come down. If they were not willing, they would work at the bedside and after a certain amount of time with refusals they would be discontinued. During an interview on 3/4/24 at 2:32 p.m., QMA (Qualified Medication Aide) 13 indicated Resident 56 usually got up to go to the doctor and that was it. No one had talked to her about getting him up daily or any goals for him to get up. No one had told her he needed encouragement to get up to go to therapy. Sometimes she could talk with him and reason with him. She didn't think mornings were good for him because he got his pain medication. She thought trying to get him up later in the day would be a better idea. No one had talked to her about insight, input, or ideas on why he wasn't getting up. During an interview on 3/4/24 at 2:43 p.m., CNA 14 indicated she did take care of Resident 56 and was familiar with him. He would usually get up for appointments. If he asked her to get him up, she would. He had not refused to get up unless he was sick or something. No one had told her about any plans or goals for him to get up. He was usually wide awake. She had not been advised about him wanting to get up and go to therapy. He was more alert in the afternoons. She could carry on full conversations with him. He was more of an afternoon person. He did spend most of his time in the bed. He had not ever refused care from her. If he did refuse care, she'd offer it again and if he refused care again, she'd get the nurse and let her know. During an interview on 3/4/24 at 2:45 p.m., CNA 8 indicated the resident told her he would get up for supper. 2. During an interview on 2/29/24 Resident 40 indicated the dentist had ordered him dentures over a year ago, said they would be in two weeks later, and they had never come in. Now he was told he had to be fitted again. He had trouble eating some things, meatloaf was not so easy. The resident had no natural teeth remaining. The record for Resident 40 was reviewed on 2/29/24 at 1:00 p.m. The Significant Change MDS assessment, dated 8/17/23, indicated the resident was cognitively intact. The care plan, dated 2/10/21, indicated the resident was edentulous. The interventions included, but were not limited to, assist resident with oral care, does not utilize dentures, and dental consult as indicated. The SSD (Social Services Director) note, dated 4/7/23 at 3:52 p.m., indicated the resident requested a VA (Veterans Affairs) dentist appointment and was reminded prior attempts resulted that he must be 100% VA connected to receive outpatient services from the VA. He provided a direct number and insisted an appointment be made. A message was left, and a return call was requested. The record lacked any further documentation by Social Services regarding dental care until 8/22/23. The SSD note, dated 8/22/23 at 3:43 p.m., indicated a note was left with VA dental services to determine dental status. The SSD note, dated 8/22/23 at 4:26 p.m., indicated the SSD spoke with VA dental and they indicated he did not qualify through VA services. An enrollment form was sent to the facility's in house dental provider. The record lacked any further documentation by Social Services regarding dental care or the resident being scheduled for dental services until 2/5/24. The SSD note, dated 2/5/24 at 11:28 a.m., indicated an appointment was scheduled for the resident with an outside provider. The SSD note, dated 2/26/24 at 3:29 p.m., indicated the outside dental provider indicated the resident's insurance still showed the facility's in house provider as his primary dental provider and they could not see him, despite cancellation forms being sent to both the provider and to Medicaid. The resident was informed and indicated he would just try to see the in-house provider again. During an interview on 3/4/24 at 1:04 p.m., the SSD indicated the in-house provider had never seen the resident. She had sent them an email in between to check up on the status and she sent another application form. She did not know if they never received the application, but she had it where he signed it in August. They had been into the facility but for whatever reason they had not seen him. She didn't realize it until just recently. She had sent them an email asking what the status was on his account. So, then she another application. In February she'd gotten him set up with an outside provider and they couldn't see him due to his insurance. It was a whole big deal. Even after he canceled it was showing up. They couldn't resolve it and it wouldn't go anywhere. He was now on the list for their in-house provider. She didn't know why it wasn't noticed between October and February. During an interview on 3/5/24 at 10:06 a.m., the SSD indicated she sent the request to reinstate the services on 8/23/23 to the in house provider but had also canceled it the same day. The resident did want dental services. He said he didn't want it after he said he did. She probably did not document that conversation. He said he wanted to sign up with the in-house dentist. She got the consent signed, sent it to the provider, then he came back and said he did not want to see the in-house dentist. That's when it was canceled. He wanted to see an outside dentist. She could not remember why he wanted to cancel. During an interview on 3/5/24 at 10:14 a.m., the Business Office Manager indicated the VA dental services would not see the resident. The resident had a previous balance due with the in-house provider and it was still showing on his Medicaid portal as his primary dental provider. So, no outside dentist would see him. The had canceled it and it still showed on his portal. 35732 3. The record for Resident 31 was reviewed on 3/5/24 at 10:45 a.m. The diagnoses included, but were not limited to, vascular dementia, anxiety disorder, a mild single episode of major depressive disorder, sleep disorder, and dependence on renal dialysis. The care plan, dated 10/4/23, indicated the resident was at risk for signs and symptoms of anxiety. The resident had a diagnosis of anxiety and takes prescribed anxiolytic medication. The interventions included, but were not limited to, psychiatric services as appropriate, maintain a calm environment and move to a quiet area as needed, encourage the resident to verbalize his fears and anxiety, offer validation and reassurance. The psychiatry progress note, dated 10/23/23, indicated the nursing staff reported the resident had increased and worsening episodes of anxiety. The resident got restless with difficulty redirecting. The follow up plan was for nursing to document any new or worsening moods or behaviors and notify psychiatric services. The resident was ordered Zoloft 50 mg once a day. The care plan, dated 11/17/23, indicated the resident was at risk for signs and symptoms of depression. The resident had a diagnosis of depression and took prescribed antidepressants. The interventions included, but were not limited to, encourage family support and involvement, medications per physician order, obtain a psychiatric consult or psychotherapy consult, emphasize and promote independence and feelings of control or choice, allow the resident to express feelings and frustrations; offer validation and support. The physician's orders, dated 1/19/24, indicated the resident received Ativan (lorazepam) 0.5 mg (milligram) tablet twice a day for generalized anxiety and Trazodone 50 mg tablet at bedtime for sleep disorder. The Quarterly MDS (Minimum Data Set) assessment, dated 1/26/24, indicated the resident was moderately cognitively impaired. No behaviors of anxiety or depression were exhibitied. The physician's order, dated 3/3/24, indicated the resident's zoloft was increased to 100 mg tablet once a day for depressive disorder. The record lacked documentation indicating the SSD (Social Service Director) completed quarterly reviews on the resident for the dates of 10/3/23 and 1/26/24, or any documentation indicating the SSD interviewed the resident about his depression and anxiety. The MDS indicated the behaviors did not occur. During an interview on 3/5/24 at 10:06 a.m., the SSD indicated she would do her Quarterly assessment in the MDS. She agreed the MDS assessment was a seven day look back only. If the resident had behaviors nursing would open up a behavioral event and she would review it the next day with IDT (Interdisciplinary Team). They would come up with appropriate interventions, and notify psychiatric services. She would document in the progress notes. She indicated the facility didn't document the quarterly and significant change assessments in the progress notes anymore. The assessments would also be documented in observations. She wasn't sure if she could document the quarterly or significant changes in the progress notes. She indicated the MDS section did not have a place to write comments and she did not interview the resident. 4. The record for Resident 53 was reviewed on 3/1/24 at 8:45 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, and generalized anxiety disorder. The Admission MDS (Minimum Data Set) assessment, dated 1/27/24, indicated the resident was cognitively intact. The physician's order, dated 1/30/24, indicated the resident received Vraylar (cariprazine) 4.5 mg (milligram) capsule, once a day, and bupropion HCl 150 mg tablet sustained-release every 12 hours twice a day. The nurse's note, dated 12/11/23, indicated the staff heard random episodes of screaming followed by cursing. The bathroom door was opened and then slammed shut repeatedly. The privacy curtain was opened and closed rapidly and forcefully. The bed side table drawers were opened and slammed closed repeatedly. The resident cursed at the CNAs (Certified Nurse Aides) The resident stated, go on and laugh you f-----g b-----s, every one is a f-----g b---h. The nurse attempted to converse calmly with the resident. The resident stated I can't talk about it, it's not you it's all the f-----g b-----s around here and everywhere. The nurse inquired if anything was wrong, upsetting or bothering her. The resident stated no no one is bothering me, I just can't talk about it. The resident had stopped taking her prescribed psychiatric medications. The SSD was to place a call to an outside mental healthcare provider to resume services upon discharge. The nurses note, dated 12/16/23 at 4:44 p.m., indicated the resident was observed to be repeatedly slamming her door to her room and screaming stop talking to me and shut up. The nurse went in to her room and asked her what was going on, offered re-assurance, provided time to vocalize her frustrations. The resident stated I'm pi**ed off and I don't want to talk. The nurse asked the resident to please stop yelling because the other residents were scared someone was hurt. The resident agreed to not yell out. The nurses note, dated 12/17/23 at 2:32 a.m., indicated the resident was screaming in her room and when asked why she was screaming she didn't answer. When staff asked that she use her call light and not scream she stated, get out of my g-----n room and I will. When the resident was reminded not to yell she stated and close the door on your way out. The resident had been going to the bathroom and slamming the bathroom door. The nurse's note, dated 12/19/23 at 7:50 a.m., indicated the resident was observed at 7:50 a.m., to have yelled shut up after staff were discussing job duties with each other in a normal conversational voice. The resident yelled very loudly, Shut up! The resident was reminded by staff at that time that it was not polite nor appropriate to yell that. The resident was also reminded that staff were conversing in a normal conversational tone. At 11:40 a.m., the resident slammed her door upon re-entering her room. Staff were across the hall in another resident's room, and heard the door being slammed shut very loudly. Staff then left the other resident's room across the hall, and reminded and educated the resident that it was not appropriate to be slamming doors. At 3:10 p.m., the resident approached the nurse while she was on the phone. The resident got tired of waiting and stated, I am due for my pain pill. I was supposed to have it around 10:00 a.m. I thought that I told someone that I wanted it, but she never came in with it. The resident returned to her room after advising the CNA's that she wanted her PRN (as needed) pain medication. Upon returning to her room, the resident slammed the door very loudly. The SSD was notified and conversed with resident in regards to her behaviors. The nurse's note, dated 12/28/23 at 10:20 p.m., indicated staff spoke with the resident's mother regarding the resident's behavioral outbursts and the start of 15 minute checks. Staff was unable to contact the residents friend because the number was not a working number. The resident's family member indicated he was just a friend and not her POA (Power of Attorney). The resident did not have a POA. The resident's family member verbalized concern that we can't have her back home like this because its just my [family member] and I and we aren't able to take care of her. The resident's family member stated she has these fits where she slams door, screams, breaks things and will not take her medications. We just can't do it. Staff advised the resident's family she would leave a message for SSD regarding concerns. The nurse's note, dated 12/29/23, indicated the resident had socially inappropriate behavior and was verbally and physically aggressive towards her peers. The residents were separated, safety was ensured and the resident was put on 15 minute checks. The root cause was a busy environment, a diagnosis of schizoaffective disorder, and the resident often refused her psychiatric medications. The clinical record lacked documentation indicating the SSD followed up on the residents behaviors or called the resident's family member to follow up on concerns. The care plan, dated 1/10/24, indicated the resident had a diagnosis of Schizoaffective disorder. Resident 53 had fluctuations in moods with behaviors of irritability and takes an ordered antipsychotic. The interventions included, but was not limited to, maintain an environment with as much routine and consistency as possible, psychiatric consult to evaluate and treat as needed, The care plan, dated 1/10/24, indicated the resident was at risk for signs and symptoms of anxiety and prescribed an anxiolytic. The interventions included, but were not limited to, the resident would not have increased signs and symptoms of anxiety, psychiatric services as appropriate, maintain a calm environment; and move the resident to quiet area as needed, and encourage the resident to verbalize fears and anxiety and offer validation and reassurance. The care plan, dated 2/6/24, indicated the resident had a history of suicidal ideations and suicidal attempt by taking multiple medications when she resided at home. The interventions included, but were not limited to, room search and safety checks as needed with the residents consent per policy. Talk with resident one on one and allow her to vent feelings; establish a trusting relationship with resident. Psychiatric services routinely and PRN (as needed) During an interview on 3/4/34 at 1:30 p.m., the Clinical Education Coordinator (CEC) indicated behaviors would be documented in the progress notes and the behavior event in the clinical record. If it was a new behavior or worsening behavior staff would make an event. Continual charting should be done if the resident had any behaviors by nursing and social services. During an interview on 3/5/24 at 10:22 a.m., the RDCO indicated when the resident had behaviors or a change in medications SSD would follow up with the resident and document in the progress notes. The Quarterly Social Services assessments could be documented in the progress notes. The MDS was a seven day look back. For a behavior staff would open an event. The IDT team would would review it and social services would be involved. 15251 5. The record for Resident 65 was reviewed on 3/4/24 at 9:30 a.m. The diagnoses included, but were not limited to, displaced interotrochanteric fracture of the left femur, type 2 diabetes mellitus, vitamin deficiency, and alcohol dependence. The care plan, dated 11/27/23 with a review date of 2/19/24, indicated the resident was at risk for impaired dental hygiene. The approaches included, but were not limited to, dental consult as indicated. The Quarterly Minimum Data Set assessments, dated 12/15/23 and 2/14/24, indicated the resident was cognitively intact. The nurse's note, dated 1/8/24 at 12:04 p.m., indicated the Nurse Practitioner (NP) came into see the resident due to a complaint of tooth pain. Among the new orders received was a referral to see the dentist. The Social Services note, dated 1/12/24, indicated an application was submitted to the facility's contracted dental service provider on this date, which was four days after the original order was received. During an interview with Resident 65 on 3/4/24 at 12:45 p.m., he indicated he still wanted to see a dentist as he was having some pain and did not know what the hold-up was. During an interview with RN on 3/4/24 at 12:46 p.m., she indicated she did not see it anywhere in the notes or on the calendar that there had been follow up to the original dental referral. During an interview with the SSD on 3/4/24 at 12:50 p.m., she indicated that when she got a referral for a resident to see the dentist, she usually would set it up pretty much immediately. She was unable to say why it took her four days to make the dental referral. She did not have a date yet as to when the dentist would actually be coming to the facility to see residents as she was waiting for them to call her. The residents did not have to wait for the contracted dental group to come in as they had the choice to see an outside dentist if they wanted. The resident told her he wanted to wait for the contracted dentist to come in. During an interview with the resident on 3/4/24 at 1:00 p.m., he indicated he was never given the choice of seeing a local dentist or waiting to see the facility dentist. He was just told to sign the form to see the facility's contracted dentist. He indicated he was not told when that would be. The Social Service Director's Job Description, signed on 8/7/23, included, but was not limited to, Summary Of Position Functions: The Social Service Director provides medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and shares a responsibility towards creating and sustaining an environment that humanizes and individualizes each residents living area. ESSENTIAL POSITION FUNCTIONS: Assess each resident's psychosocial needs and develops a plan for providing care. Reviews resident's needs and care plan with progress notes indicating implementation of methods to respond to identified needs. Provides assistance to residents to utilize community resources through referral when the services needed are not provided by the facility . provides assistance to residents adjusting to the facility . Advises appropriate referrals to minimize social and economic obstacles to discharge. Coordinates discharge planning and communicates to those who need to know any obstacles the resident may have upon discharge. Coordinates relocation planning, including advise and referral to community resources before or during relocation . Collaborates with other departments, physicians, consultants, community agencies, and institutions to improve quality of services and to resolve identified problems . 3.1-34(a)

Based on observation, record review, and interview, the facility failed to ensure timely dressing change of a burn dressing when it became soiled and dislodged for 1 of 20 residents reviewed for Quality of Care. (Resident 56) Findings include: During an interview on 2/29/24 at 1:06 p.m. Resident 56 indicated he had a burn to his groin and thigh from where he had spilled hot coffee down his leg. During an observation on 2/29/24 at 1:07 p.m., the resident pulled back his blankets and showed he had a dressing, dated 2/28/24, which surrounded his right upper thigh. The record for Resident 56 was reviewed on 3/1/24 at 9:00 a.m. The diagnoses included, but were not limited to, acute infarction of spinal cord and paraplegia. The nurse's note, dated 11/23/23 at 5:59 p.m., indicated the resident had spilled his coffee and had a non-blanchable reddened area stretching from the top of his right thigh to his right hip with skin intact. The area measured 40 centimeters (cm) by 20 cm, by 0.01 cm, with a dime sized waxy clear skin to the top of his right thigh. The skin began to peel off. He had several scattered areas of skin flaps. The resident refused to go to the emergency room . The Nurse Practitioner (NP) was informed and gave new orders for Silvadene and an abdominal pad dressing daily. The care plan, dated 11/27/23, indicated the resident had a second degree burn to his right lower extremity and was at risk for skin break down due to very limited sensory perception, occasionally moist, chairfast, very limited mobility, friction and shear problem, left femur fracture, low back pain, malnutrition, and history of back pain. The interventions included, but were not limited to, observing for signs and symptoms of infections such as drainage, fever, and increased pain, and treatments as ordered. The physician's order, dated 1/30/24, indicated to cleanse the burn to the resident's right thigh with wound cleanser, pat dry, apply collagen to areas of hyper granulation, cover collagen and entirety of wound with xeroform and cover with abdominal pads daily and as needed. During an observation on 3/1/24 at 12:58 p.m., CNA (Certified Nurse Aide) 3 was in the room with Resident 56 assisting him to change his sheets. She indicated she had informed QMA (Qualified Medication Aide) 4 and the Infection Preventionist (IP) that the resident needed his wound dressing changed at 8:00 a.m. that morning because it had come undone. It had a lot of that clear stuff, she indicated, referring to the drainage. The resident was lying in bed, with the kerlix down around his knee. The kerlix was dated 2/29/24. The abdominal pads were dislodged and hanging loose with the wound and xeroform observed to be uncovered. The xeroform was saturated with a moderate amount of serosanguinous drainage. The resident had blood staining his brief. Both the resident and the CNA indicated the wound had been uncovered since 8:00 a.m. and nursing staff were aware. During an interview on 3/1/24 at 1:02 p.m., QMA 4 indicated CNA 3 had told her earlier something about the resident wanting his dressing changed, however they usually completed it after lunch. She thought she might have been told around 9:30 a.m. She had not told anyone else the resident wanted it done. The nurse did his dressing changes. She hadn't let anyone know because they usually did it after lunch. During an interview on 3/1/24 at 1:04 p.m., the Infection Preventionist indicated no one had told her Resident 56's dressing needed changed. During an interview on 3/1/24 at 1:08 p.m., CNA 3 indicated she had informed both the Infection Preventionist and QMA 4, as well as the Clinical Education Coordinator (CEC). It was dislodged. During an observation on 3/1/24 at 1:10 p.m., CNA 7 and CNA 3 removed Resident 56's brief. There was a small amount of bright red blood on the brief where the wound drainage had saturated from being uncovered. The resident was rolled and the absorbent pad underneath him was observed to have a small amount of bright red blood staining underneath the resident from where his wound had been uncovered. During an observation on 3/1/24 at 1:21 p.m., the Infection Preventionist and the CEC provided wound care to Resident 56. The resident had a moderate amount of tan and bright red drainage. There was a total of three open wounds to his groin and outer thigh which were fully granulating. The Infection Preventionist cleansed the wounds with wound cleanser, applied collagen to the open areas, xeroform, and an abdominal pad, which she secured with kerlix and tape. During an interview on 3/1/24 at 2:01 p.m., the CEC indicated he had been told the resident wanted his dressing changed. He did not ask why or any other clarifying questions. He told the IP the resident was asking for his treatment to be changed. It was after 10:00 a.m., but it was before 12:00 p.m. when he had told her. He educated staff on wound care and dressing changes. If a treatment became soiled or dislodged they had orders to change it as needed. He did not know if there was an exact time, however if a dressing became dislodged or soiled they would change it as soon as they could. They would not put it off. He would expect CNAs to report the dressing being soiled or dislodged and they would change it. The most current Skin Management Program policy, included, but was not limited to, It is the policy of [Name of Corporation] to ensure that each resident receives care, consistent with professional standards of practice . Procedure for alterations in skin integrity - pressure and non-pressure . 2. Treatment order will be obtained from the MD/NP . 3.1-47(a)

Based on record review and interview, the facility failed to ensure there was an indication for the use of antidepressants and antianxiety medications; and appropriate documentation of behaviors for a patients with dementia for 1 of 5 residents reviewed for dementia. (Resident 31) Findings include: The record for Resident 31 was reviewed on 3/5/24 at 10:45 a.m. The diagnoses included, but were not limited to, vascular dementia, anxiety disorder, a mild single episode of major depressive disorder, sleep disorder, and dependence on renal dialysis. The care plan, dated 10/4/23, indicated the resident was at risk for signs and symptoms of anxiety. The resident had a diagnosis of anxiety and takes prescribed anxiolytic medication. The interventions included, but were not limited to, psychiatric services as appropriate, maintain a calm environment and move to a quiet area as needed, encourage the resident to verbalize his fears and anxiety, offer validation and reassurance. The psychiatry progress note, dated 10/23/23, indicated the nursing staff reported the resident had increased and worsening episodes of anxiety. The resident got restless with difficulty redirecting. The follow up plan was for nursing to document any new or worsening moods or behaviors and notify psychiatric services. The resident was ordered Zoloft 50 mg once a day. The care plan, dated 11/17/23, indicated the resident was at risk for signs and symptoms of depression. The resident had a diagnosis of depression and took prescribed antidepressants. The interventions included, but were not limited to, encourage family support and involvement, medications per physician order, obtain a psychiatric consult or psychotherapy consult, emphasize and promote independence and feelings of control or choice, allow the resident to express feelings and frustrations; offer validation and support. The Quarterly MDS (Minimum Data Set) assessment, dated 1/26/24, indicated the resident was moderately cognitively impaired. The physician's orders, dated 1/19/24, indicated the resident received Ativan (lorazepam) 0.5 mg (milligram) tablet twice a day for generalized anxiety and Trazodone 50 mg tablet at bedtime for sleep disorder. The physician's order, dated 3/3/24 indicated the resident's Zoloft was increased to 100 mg tablet once a day for depressive disorder. The record lacked documentation of any behaviors such as depression or anxiety and any documentation indicating why the Zoloft was increased and the Ativan was ordered. During an interview on 3/4/34 at 1:30 p.m., the CEC (Clinical Education Coordinator) indicated behaviors would be documented in the progress notes and the behavior event in the clinical record. If it was a new behavior or worsening behavior staff would make an event. Continual charting should be done if the resident had any behaviors. He indicated the resident was stable as far as he knew. During an interview on 3/5/24 at 12:00 p.m., the DON (Director of Nursing) indicated the resident got really anxious at the dialysis center and was unable to finish dialysis. He would get anxious before going to dialysis. No documentation was presented to indicate the resident had anxiety before going to dialysis. The most current Behavior Management policy, included, but was not limited to, . 3. When a behavioral expression occurs, the staff communicates to the nurse what behavior occurred. The nurse records the behavior in [Name of Electronic Health Record system]. 4. If the behavioral expression is new, worsening, or high risk, the nurse will record the behavior using the New/Worsening Behavior Event. New or worsening behaviors are reviewed by the IDT [Interdisciplinary Team] for assessment and preventative actions . 5. If the behavioral expression is not new, worsening or high risk; the nurse will record the behavior in the progress notes using the Behavioral Communication Note. The IDT will review the progress notes the next business day to determine if immediate follow up action is required for the Behavioral Communication. If the behavior requires and interdisciplinary response as described above, the IDT will complete the IDT Behavior Review. If not, the plan of care will be reviewed and updated if needed to include a description of the behavior and effective interventions . 3.1-37(a)

Based on record review and interview, the facility failed to promptly obtain requested dental services for 1 of 2 residents reviewed for dental services. (Residents 65) Findings include: During an interview with Resident 65 on 3/4/24 at 12:45 p.m., he indicated he still wanted to see a dentist as he was having some pain and did not know what the hold-up was. The record for Resident 65 was reviewed on 3/4/24 at 9:30 a.m. The diagnoses included, but were not limited to, displaced interotrochanteric fracture of the left femur, type 2 diabetes mellitus, vitamin deficiency, and alcohol dependence. The care plan, dated 11/27/23 with a review date of 2/19/24, indicated the resident was at risk for impaired dental hygiene. The goal was for the resident to be free of mouth pain. The approaches included, but were not limited to, dental consult as indicated, observe and document symptoms of pain, and observe for decreased ability to chew food. The Quarterly Minimum Data Set (MDS) assessments, dated 12/15/23 and 2/14/24, indicated the resident was cognitively intact and had no chewing or swallowing issues. The nurse's note, dated 1/8/24 at 12:04 p.m., indicated the Nurse Practitioner (NP) came into see the resident due to a complaint of tooth pain. New orders were received for a referral to see the dentist, viscous lidocaine solution 2% swish and spit three times daily, and for amoxicillin 500 mg (milligrams) three times a day for 5 days. The Social Services note, dated 1/12/24, indicated an application was submitted to the facility's contracted dental service provider on this date, which was four days after the original order was received. During an interview with RN 16 on 3/4/24 at 12:46 p.m., she indicated she did not see it anywhere in the notes or on the calendar that there had been follow up to the original dental referral. During an interview with the Social Worker on 3/4/24 at 12:50 p.m., she indicated she was unable to say why it took her 4 days to make the dental referral and did not have a date when the dentist would actually be coming to the facility to see residents as they have not called her yet. She also indicated residents did not have to wait for the contracted dental group to come in as they had the choice to see an outside dentist if they wanted. The facility's current policy titled Dental Services/Missing Dentures, included, but was to limited to, Policy: The facility obtains needed dental services, including routine and emergency dental services; assists in providing these services and makes prompt referrals for dental services as needed .Procedure: DENTAL SERVICES: 1. The facility will obtain contracted outside dental services to meet the routine and emergency dental needs of each resident .4, The facility will assist in scheduling .residents to dental appointments as needed . 3.1-24(a) 3.1-24(b) 3.1-24(3)(b)

Based on record review, interview, and observation, the facility failed to ensure a resident's Weekly Skin Assessments were completed and accurate to identify and prevent the development or worsening of a pressure ulcer resulting in an unstageable pressure ulcer worsening to a Stage IV pressure ulcer for 1 of 5 residents reviewed for pressure ulcers. (Resident 62) Findings include: During an observation on 2/6/23 around 9:00 a.m., Resident 62 was sitting in his room in a wheelchair. The clinical record for Resident 62 was reviewed on 2/9/23 at 9:25 a.m. The diagnoses included, but were not limited to, a fracture of the right femur, joint replacement surgery, nondisplaced fracture of the surgical neck of the left humerus, muscle weakness, and abnormalities of gait and mobility. The Significant Change in Status MDS (Minimum Data Set) assessment, dated 12/7/22, indicated the resident was moderately cognitively impaired. He required extensive assistance of two staff members for bed mobility and toilet use. He required total dependence of two staff members for transfer and one staff member for bathing. The care plan, dated 2/9/22 and last revised on 2/6/23, indicated the resident was at risk for skin breakdown due to slightly limited sensory ability, spending a majority of the shift in a wheelchair or bed, slightly limited ability to move in bed independently, required maximal assistance with bed mobility, a fall at home which resulted in a right femur fracture that needed a right total hip replacement with surgical incision to the right hip. The interventions, dated 2/6/23, indicated staff were to notify the physician of worsening or no change in the wound, signs or symptoms of infection; dated 1/12/23, staff were to assess for signs of infection, assess and document skin condition weekly and as needed; dated 2/11/22, staff were to apply a pressure reducing or redistribution cushion in his chair or wheelchair, and treatment as ordered; dated 2/9/22, staff were to encourage the resident to turn and reposition at least every 2 hours, provide assistance as needed, apply a house barrier cream at the bedside and use as needed, a pressure reducing or redistribution mattress, and a low air loss mattress. The nurse's note, dated 12/1/22 at 12:38 a.m., indicated the resident refused to turn and reposition other than for incontinence care. The resident's sacrum was reddened and blanchable. The clinical record lacked documentation of the physician's notification of the resident's new area to the coccyx identified on 12/2/22 until 12/13/22. The Weekly Skin and Vital Sign Assessment, dated 12/2/22, lacked documentation of any resident refusal of care. The clinical record lacked documentation of the weekly skin assessment being conducted on 12/9/22. The care plan, dated 12/13/22 and last revised on 2/03/23, indicated the resident had impaired skin integrity with a pressure area to the coccyx. The interventions, dated 1/12/23, indicated to use a house barrier cream as needed, to provide incontinent care as needed, apply a low air loss mattress, and to provide supplements as ordered; dated 12/13/22, staff were to assess the resident for pain, treat as ordered, notify the physician of unrelieved or worsening pain, assess the wound weekly, documenting measurements and description, encourage the resident to eat at least 75% of meals, notify the physician of worsening or no change in the wound and signs of infection, observe for signs of infection, pressure reducing or redistribution cushion in his chair, treatment as ordered, turn and reposition every 2 hours, wound healing vitamins as ordered, and treatment as ordered. The nurse's note, dated 12/15/22 at 1:11 a.m., indicated an open area was observed to the resident's coccyx. The area measured 1 cm long by 1 cm wide by 0.5 cm deep. The area was cleansed with normal saline, patted dry, a skin prep was applied to the periwound, and a gentle foam border dressing was applied. The order was discontinued on 12/16/22. The wound management note, dated 12/15/22 at 1:12 a.m., indicated a pressure ulcer to the resident's coccyx was observed. The wound measured 1.5 cm long by 1.4 cm wide by 0.5 cm deep. There was a moderate amount of seropurulent exudate with an odor. The IDT note, dated 12/16/22 at 6:06 p.m., indicated the unstageable pressure ulcer to the coccyx measured 1.5 cm long by 1.4 cm wide by 0.5 cm deep with full thickness, and 100% slough. There was a moderate amount of seropurulent drainage with an odor present and the periwound was red, but blanchable. Signs and symptoms of infection were present. A new order was obtained to pack the wound with a Dakin's soaked gauze. The interventions were to encourage and assist the resident to turn and reposition every 2 hours while in bed, the root-cause determination was the resident's refusal of turn and reposition every 2 hours while in bed, a recent surgical repair of the left shoulder fracture, and recently recovered from covid. The new interventions initiated was a low air loss mattress, Pro-stat liquid supplement 30 mL(milliliters) twice daily, and a Thera M vitamin daily. The current treatment order indicated to cleanse the area with a wound wash or normal saline, pat dry, apply skin prep to the periwound, pack the wound with a Dakin's soaked gauze and cover with a dry dressing every shift and as needed. The nurse's note, dated 12/23/22 at 2:13 p.m., indicated the coccyx wound had a dark necrotic wound bed with dark edges. He refused to get out of bed. The air mattress was inflated and functioning properly. The nurse's note, dated 12/25/22 at 1:52 p.m., indicated the treatment was continued as ordered to the coccyx with a slight odor to the old dressing. The nurse's note, dated 12/26/22 at 3:49 a.m., indicated the dressing change was completed to the coccyx. The wound bed appeared black in color. There was serous drainage to the brief due to the old dressing dislodgement. The edges of wound appeared macerated. The nurse's note, dated 12/26/22 at 4:14 p.m., indicated the coccyx wound had yellow slough to the wound bed. The surrounding tissue was pink in color. No odor or drainage was observed. The Weekly Skin and Vital Sign Assessment, dated 12/26/22, lacked documentation of any wound areas or the use of a low air loss mattress. The wound management note, dated 12/29/22 at 3:33 p.m., indicated the pressure ulcer was now a stage IV to the coccyx. The wound measured 2 cm long by 2 cm wide by 1 cm deep. There was a moderate amount of serosanguineous exudate with 75% granulation tissue and 25% eschar tissue. The current treatment was to be continued with weekly rounds. The nurse's note, dated 1/3/23 at 3:31 a.m., indicated the coccyx wound had a moderate amount of brown drainage to the old dressing. No foul odor was observed. The wound bed was black in color. The nurse's note, dated 1/4/23 at 6:32 p.m., indicated the area to the coccyx was a medium red in color with a moderate odor observed with the cleansing. The left heel area was resolving. The skin was intact, dull tan in color, with a rough texture. The Weekly Skin and Vital Sign Assessment, dated 1/6/23, lacked documentation of any wounds. The nurse's note, dated 1/9/23 at 3:09 a.m., indicated the wound to the coccyx had a moderate amount of grey drainage to the old dressing. The wound bed was covered in slough. No foul odor was observed. The nurse's note, dated 1/15/23 at 5:26 p.m., indicated the wound to the coccyx was a medium pink in color with white waxy edges. A moderate amount of yellow-green drainage was observed on the old dressing. The nurse's note, dated 1/17/23 at 3:22 a.m., indicated the wound to the coccyx had bright red drainage. The old dressing was saturated with brown drainage. No foul odor was observed. The wound management note, dated 1/19/23 at 2:29 p.m., indicated the stage IV pressure ulcer to the coccyx measured 1.2 cm long by 1.2 cm wide by 0.5 cm deep with full thickness, a small amount of serosanguineous exudate, and 100% granulation tissue. The Weekly Skin and Vital Sign Assessment, dated 1/20/23 and 1/28/23, lacked documentation of any wounds. The nurse's note, dated 1/29/23 at 12:48 a.m., indicated the treatment was continued per order to the coccyx. The wound bed had light yellow slough with a small dime sized amount of light-yellow drainage on the old dressing. The nurse's note, dated 2/1/23 at 4:20 p.m., indicated the treatment was performed for the wound to the coccyx. The area had a medium red color with gray-white edges. There was quarter sized yellow-green drainage to the old dressing and no drainage with cleansing. The wound management note, dated 2/2/23 at 2:27 p.m., indicated the stage IV to the coccyx measured 0.8 cm long by 0.8 cm wide by 0.5 cm deep with full thickness, 100% granulation tissue, and a small amount of serosanguineous drainage. The nurse's note, dated 2/9/23 at 12:48 a.m., indicated the wound to the coccyx had a red wound bed. The edges were intact and white in color. The surrounding skin peri-wound was pink with a small amount of light-yellow drainage on the old dressing. During an interview on 2/9/23 at 12:46 p.m., the DON (Director of Nursing) indicated she did not think a wound culture had been performed on the wound to the coccyx. During an interview on 2/10/23 at 8:10 a.m., the DON indicated the wound nurse informed her the pressure ulcer did not have any signs or symptoms of an infection or osteomyelitis. During an interview on 2/10/23 at 8:23 a.m., the Wound Nurse indicated the interventions to prevent pressure ulcers were for a regular pressure reducing mattress, pro stat supplement, a multivitamin, and to turn and reposition. She was not sure if he would turn and reposition. He was on his side one time when she performed an assessment. He was on his back in bed most of the time. He would get up to his wheelchair before his fall, but then stopped because of his fear of falling or he just didn't feel like it. He was better about getting up to his wheelchair now. The low air loss mattress was good for people who would not turn. A wedge was good for those residents. He wouldn't use the wedge. She wasn't sure if he would us a pillow. She and the wound NP (Nurse Practitioner) would tell the resident about the healing process and the need for turning and repositioning. He had the possibility of the need for antibiotics if he developed an infection. She did not believe it was an infection of the wound to the coccyx. He had more drainage at one point, and they discussed a wound culture. He had drainage from the start, but the increased drainage lasted only a few days, then it stopped. The order was to pack the wound with a Dakins soaked gauze and that could what made it look like drainage. She felt it would be healed soon. She conducted the wound assessments, but the nurse conducted the Weekly Skin Assessments. If the nurse observed a new wound, she would put in a new Skin Event and that told her to perform wound care. If the Weekly Skin Assessment wasn't conducted, then the nurse would not know to inform her of a new area. During an interview on 2/10/23 at 9:03 a.m., the DON indicated the low air loss mattress was ordered the day the wound to the coccyx was found. The resident received his low air loss mattress the day after that. The cushion to the wheelchair was obtained on admission. The resident was up for smoke break since admission and she didn't feel he would develop a pressure ulcer to the coccyx, so the low air loss mattress would not have been needed. During an interview on 2/10/23 at 9:17 a.m., RN 4 indicated the skin assessments would be conducted during his shower days. The management would also do monthly skin sweeps. The wound to the coccyx should have been found before it got to an unstageable area, when it was found. The wound was in the folds of the buttocks of the coccyx, which may have made it hard to discover. He had a cushion on his wheelchair, the resident was encouraged to turn and reposition, and she tried to educate him on that need. The Skin Management Program policy, dated May 2022, was provided by the Executive Director on 2/9/23 at 3:06 p.m. The policy included, but was not limited to, . Purpose . prevent development of additional pressure ulcer/injury . implement interventions that are consistent with resident needs . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . 3. Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors to include but not limited to the following . Redistribute pressure . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate labeling and storage of medications for 4 of 5 medication carts and 1 of 2 medication rooms observed. (Annex Right Medication Cart, Annex Left Medication Cart, North Hall Left Medication Cart, North Hall Medication Room, and North Hall Right Medication Cart) Findings include: 1. During an interview and observation of the Annex Right medication cart with Unit Manager 5 on 2/8/23 at 10:59 a.m., the following concerns were observed: - An unlabeled insulin glargine 100 unit/mL (milliliter) pen had an open date written on it in black permanent marker, which was dated 1/6/23. There was no pharmacy labeling or packaging for the medication. Unit Manager 5 indicated the medication belonged to Resident 61. It should have had a bag or a label, but it might have gotten knocked off. The medication should have been discarded, as it was only good for 28 days after opening. - Resident 65's budesonide and formiterik fumarate dihydrate 106/4.5 mcg/act (micrograms per actuation) inhaler, was stored lying on its side in the top right hand drawer of the cart. The packaging to the medication indicated it was supposed to be stored upright. 2. During an observation of the Annex Left medication cart with Unit Manager 5 on 2/8/23 at 11:05 a.m., the following concerns were observed: - Resident 68's diclofenac sodium 1% (Voltaren) topical gel was located in the drawer with Resident 13's Pro-Stat oral supplement. Both medications had been previously opened. Unit Manager 5 indicated they kept the Voltaren in the drawer because Resident 68 received it routinely. - Resident 279's opened bottle of nystatin 100,000 units/gram powder was located in the same drawer as her oral medications, which included glimepiride 4 mg (milligrams) tablet, potassium chloride 10 meq (milliequivalents) ER (extended release) capsule, metformin 500 mg tablets, lasix 40 mg, hydrochlorothiazide 12.5 mg capsule, lisinopril 10 mg tablets, 4 cards of omeprazole 40 mg capsules, zoloft 100 mg tablets, sotalol 80 mg tablet, 2 cards of plavix 75 mg tablets, and phenergan 25 mg tablet. 3. During an observation of the North Left medication cart with LPN (Licensed Practical Nurse) 6 on 2/8/23 at 11:16 a.m., the following concerns were observed: - Residents 52 and 2's Symbicort (budesonide-formoterol) 160/4.5 mcg/act inhalers were located in the top drawer lying on their sides. The packages indicated to store the medication upright. - Resident 29's biofreeze 4% menthol gel was located in the same drawer as oral medications for multiple residents on the North Hallway. The bottle had been opened and did appear used. - Residents 6 and 52's diclofenac sodium 1 % topical gel and Residents 29 and 53's biofreeze 4% menthol topical gel were located in the same drawer as Resident 6, 29, and 25's polyethylene glycol 3350 powder 17 gram/dose oral medication. The topical medications appeared to be opened and partially used. 4. During an observation of the North Hall Medication Storage Room with LPN 6 on 2/9/23 at 10:01 a.m., the medication refrigerator indicated the temperature was 46 degrees Fahrenheit. The temperature log for the month was lacking documentation of the temperature having been checked on the night prior, 2/8/23. The refrigerator contained several resident's insulin pens, suppositories, a vial of tuberculin, and an emergency drug kit (EDK). During an observation of the North Hall Medication Storage Room with LPN 6 on 2/9/23 at 10:08 a.m., LPN 6 indicated the thermometer was reading 50 degrees Fahrenheit and she would obtain another thermometer and recheck it. The temperature was supposed to be checked every night by the night shift staff. LPN 6 obtained a new thermometer and placed it in the refrigerator and closed the door. During an observation of the North Hall Medication Storage Room with LPN 6 on 2/9/23 at 10:19 a.m., she indicated the new thermometer was registering the temperature of the refrigerator at 52 degrees Fahrenheit and she needed to adjust the temperature setting to a lower temperature. During an observation on 2/9/23 at 2:23 p.m., several medications were observed to have been relocated to the Education Room Medication Storage refrigerator. The DON indicated they were all the medications that had been located in the North Hall Medication Storage refrigerator. The medications included 5 insulin lispro 100 unit/mL pens belonging to Resident 76, 2 lantus solostar 100 unit/mL pens belonging to Resident 52, 7 novolog 100 unit/mL pens belonging to Resident 2, 1 vial of novolog 100 unit/mL and 2 levemir 100 unit/mL pens belonging to Resident 7, 1 box containing 2 pens of Repatha 140 mg/mL belonging to Resident 34, 4 insulin glargine 100 unit/mL pens and 9 novolog 100 unit/mL pens belonging to Resident 18, 9 bisacodyl 10 mg suppositories belonging to Resident 4, 10 bisacodyl 10 mg suppositories belonging to Resident 26, and 1 unopened EDK which contained 2 acetaminophen 650 mg suppositories, 2 mL lorazepam 2 mg/ml (milligrams per mL) vials, 2 prochlorperazine 25 mg suppository, 2 promethazine 25 mg suppository, 3 vials of humalin 70/30, 1 3 mL insulin lispro pen, 1 3 mL insulin glargine pen, 1 3 mL levemir flex touch pen, and 1 30 ml lorazepam intensol 2 mg/ml vial. 5. During an interview and observation of the North Hall Right Medication cart with Unit Manager 5 on 2/9/23 at 10:29 a.m., Resident 46's Symbicort 160/4.5 mg/act was located in the top drawer lying on its side. The medication did not have any pharmacy labeling and was only identified as the resident's by his name being written on the plastic bag in black permanent marker. Unit Manager 5 indicated she did not see a pharmacy sticker on the medication and she was not aware Symbicort inhalers needed to be stored upright. During an interview on 2/9/23 at 10:36 a.m., the Director of Nursing (DON) indicated she had contacted the pharmacy and they had instructed her to move all medications from the refrigerator to another refrigerator until the temperature came back down to a normal range. During an interview on 2/9/23 at 2:41 p.m., LPN 7 indicated she was not aware they were not supposed to store topical medications with oral medication, or that Symbicort needed to be stored upright. The Storage and Expiration of Medications, Biologicals, Syringes, and Needles policy, last revised on 10/31/16, was provided on 2/9/23 at 9:55 a.m. by the DON. The policy included, but was not limited to, . 3. General Storage Precautions . 3.2 Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals . 3.5 Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened . 6 . Facility should destroy and reorder medications and biologicals with . incomplete, damaged or missing labels . 7. Facility should store all medications and biologicals requiring special containers for stability in accordance with manufacturer/supplier specifications . 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the Unites States Pharmacopeia guidelines for temperature ranges. Facility Staff should monitor the temperature of vaccines twice a day . 11.2 Refrigeration 36 - 46 F . The budesonide and formoterol fumarate dihydrate inhalation aerosol 80 mcg/4.5 mcg and 160 mcg/4.5 mcg package insert was provided on 2/10/23 at 8:00 a.m. by the DON. The package insert included, but was not limited to, . 16 . storage and handling . Store the inhaler with the mouth piece down . The drug information sheet for insulin glargine solostar U100 (common brand names including Basaglar and Lantus) was provided by the DON on 2/10/23 at 8:00 a.m. The information sheet included, but was not limited to, Discard all containers in use after 28 days, even if there is insulin left . 3.1-25(j) 3.1-25(k) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7) 3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure oxygen was provided in a sanitary manner to 7 of 14 residents reviewed. (Residents 18, 50, 60, 55, 24, 6, and 19) Findings include: 1. During an observation, on 2/23/22 at 10:10 a.m., the filter on the side of Resident 18's oxygen (O2) concentrator was coated in a thick layer of white fuzzy buildup and hair. During an observation, on 2/24/22 at 10:39 a.m., the filter on the side of the resident's O2 concentrator was coated in a thick layer of white fuzzy buildup and hair. During an observation, on 2/25/22 at 8:12 a.m., the filter on the side of the resident's O2 concentrator was coated in a thick layer of white fuzzy buildup and hair. During an observation, on 2/28/22 at 9:44 a.m., the filter on the side of the resident's O2 concentrator was coated in a thick layer of white fuzzy buildup and hair. The clinical record for Resident 18 was reviewed on 3/1/22 at 8:24 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) Assessment, dated 12/6/21, indicated the resident was cognitively intact and required oxygen therapy. The care plan, dated 11/30/21, indicated the resident was at risk for impaired gas exchange related to restrictive lung disease with shortness of breath while laying flat. Interventions included, but were not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxygen at 2 liters per minute (lpm) via nasal cannula (NC) every shift, which started on 12/16/21. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Thursdays, which started on 12/23/21. During an interview, on 2/28/22 at 3:21 p.m., the DON (Director of Nursing) indicated Resident 18's concentrator filter needed to be cleaned immediately. 2. During an observation, on 2/28/22 at 11:22 a.m., there was a moderate amount of gray buildup on the air intake to the back of Resident 50's oxygen concentrator. The clinical record for Resident 50 was reviewed on 3/1/22 at 8:26 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS Assessment, dated 1/24/22, indicated the resident was severely cognitively impaired and required oxygen therapy. The care plan, dated 10/21/19, indicated the resident was at risk for impaired gas exchange related to shortness of breath while lying flat related to [CONDITION(S)] requiring oxygen. Interventions included, but were not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxygen at 2 liters per minute via nasal cannula every shift, which started on 8/30/20. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Tuesdays, which started on 8/30/20. 3. During an observation, on 2/28/22 at 11:24 a.m., Resident 60's O2 concentrator had a very heavy coating of gray fuzzy buildup to the air intake on the back of the concentrator. More than half of the intake was fully obscured with dust. The clinical record for Resident 60 was reviewed on 3/1/22 at 8:28 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS Assessment, dated 1/28/22, indicated the resident was cognitively intact and required oxygen therapy. The care plan, dated 8/25/21, indicated the resident was at risk for impaired gas exchange related to shortness of breath while lying flat related to [CONDITION(S)] with shortness of breath while lying flat. Interventions included, but were not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxygen at 1 to 2 lpm via NC every shift, which started on 8/18/21. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Sundays, which started on 8/18/21. 4. During an observation, on 2/23/22 at 9:59 a.m., Resident 55's O2 concentrator had a very heavy coating of gray fuzzy buildup to the air intake on the back of the concentrator. During an observation, on 2/28/22 at 11:36 a.m., Resident 55's O2 concentrator had a very heavy coating of gray fuzzy buildup to the air intake on the back of the concentrator. The clinical record for Resident 55 was reviewed on 3/1/22 at 8:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS Assessment, dated 1/18/22, indicated the resident was cognitively intact and required oxygen therapy. The care plan, dated 7/8/21, indicated the resident was at risk for impaired gas exchange related to shortness of breath while lying flat related to [CONDITION(S)] with shortness of breath while lying flat. Interventions included, but were not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxygen at 2 lpm via NC every shift, which started on 7/7/21. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Sundays, which started on 7/7/21. 5. During an observation, on 2/23/22 at 10:05 a.m., Resident 24's O2 concentrator had a very heavy coating of white fuzzy buildup to the filter on the side of the concentrator. During an observation, on 2/8/22 at 9:37 a.m., Resident 24's O2 concentrator had a very heavy coating of white fuzzy buildup to the filter on the side of the concentrator. The clinical record for Resident 24 was reviewed on 3/1/22 at 8:32 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS Assessment, dated 9/17/21, indicated the resident was cognitively intact and required oxygen therapy. The care plan, dated 9/24/20, indicated the resident was at risk for impaired gas exchange related to shortness of breath while lying flat related to [CONDITION(S)] with shortness of breath while lying flat. Interventions included, but was not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [CONDITION(S)] Auto min: 5 max: 20 PS 4-8. Oxygen bleed in with [CONDITION(S)] at 2 lpm every night at bedtime, which started on 5/18/21. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Sundays, which started on 2/28/22. During an interview, on 2/23/22 at 11:50 a.m., Resident 24 indicated she had never seen staff clean the filter on her oxygen concentrator. 6. During an observation, on 2/28/22 at 11:34 a.m., Resident 6's O2 concentrator had a moderate coating of gray fuzzy buildup to the air intake on the back of the concentrator. The oxygen tubing was dated 1/14/22. The clinical record for Resident 6 was reviewed on 3/1/22 at 8:34 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS Assessment, dated 11/15/22, indicated the resident was cognitively intact and required oxygen therapy. The care plan, dated 7/8/21, indicated the resident was at risk for impaired gas exchange related to shortness of breath while lying flat related to [CONDITION(S)] with shortness of breath while lying flat. Interventions included, but was not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxygen at 3 lpm via NC every shift, which started on 2/4/20. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Tuesdays, which started on 3/8/20. During an interview, on 2/28/22 at 3:12 p.m., Resident 6 indicated her oxygen tubing had not been changed in quite a while. 7. During an observation, on 2/28/22 at 11:22 a.m., Resident 19's O2 concentrator had a small amount of gray fuzzy buildup coating the air intake on the back of the concentrator. The clinical record for Resident 19 was reviewed on 3/1/22 at 8:36 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS Assessment, dated 12/7/21, indicated the resident was cognitively intact but did not indicate whether the resident required oxygen therapy. The care plan, dated 3/1/22, indicated the resident was at risk for impaired gas exchange related to hypertensive heart disease. Interventions included, but was not limited to, administer oxygen as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxygen at 2 lpm via NC every shift, which started on 2/19/22. - Change oxygen tubing and humidity. Clean concentrator and filter once daily on Sundays, which started on 2/19/22. During an interview, on 2/28/22 at 3:08 p.m., the DON indicated oxygen tubing was supposed to be changed weekly. Staff should change the tubing, date it for when they change it. Filters were supposed to be changed or cleaned weekly, but she didn't know if it was on their orders anymore. It should still be completed weekly or as needed. The most current, undated, Oxygen Concentrator policy, provided on 3/1/22 at 8:55 a.m., by the DON, included, but was not limited to, . Precautions and Hazards 1) DO NOT operate the oxygen concentrator without the filter or with a dirty filter . Procedure . 5) Check the inlet filter pad and ensure that it is in place and clean . Daily Maintenance . 3) Clean the air inlet filter PRN [as needed] and weekly . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure the dignity of the residents during meal service for 2 of 3 random observations of resident rights. (Resident 11) Findings include: During an observation, on 2/28/22 at 12:13 p.m., Resident 11 was sitting in her wheel chair, at a table in the Main Dining Room, next to Resident 32. Resident 32, along with several other residents who were eating in the dining room, had already received their lunch trays and some were more than halfway done with their trays. Resident 11 did not have a lunch tray. Resident 32 was observed to tell the Dietary Manager, and a CNA (Certified Nurse Aide) Resident 11 had not gotten her tray yet. Resident 11 appeared to be disgruntled, she was raising her hands in the air motioning to Resident 32's tray, and then back to the empty space in front of her. During an observation, on 2/28/22 at 12:40 p.m., Resident 11 still did not have a lunch tray. Resident 32 had finished his lunch tray and it had been picked up. All of the other residents in the dining room had finished their trays as well. The clinical record for Resident 11 was reviewed on 3/1/22 at 9:33 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 11/23/21, indicated the resident was moderately cognitively impaired. The Care Plan, dated 2/21/22, indicated the resident was cognitively impaired. Interventions included, but were not limited to, encourage to participate in daily activities, provide resident with prompts and cues as needed, and give resident choices throughout the day regarding decisions as able. During an interview, on 2/28/22 at 12:41 p.m., Resident 11 indicated she still had not eaten, because no one had brought her a tray. Resident 32, who was still sitting beside the resident, indicated Resident 11 had not received a meal tray. During an interview, on 2/28/21 at 12:42 p.m., CNA 12 indicated it had probably been about 30 minutes since she had passed lunch trays. Resident 11's tray was in her room, but no one had brought it down to her. The resident usually ate in her room, but she didn't want to go to her room today. She could not answer as to why no one had called down to get the resident a new tray or had brought her tray to her from her room. During an interview, on 2/28/21 at 12:43 p.m., CNA 13 indicated Resident 11's tray had been sent to her room instead of the dining room. She could not answer as to why no one had called down to get the resident a new tray or had brought her tray to her from her room. During an interview on 2/28/22 at 12:50 p.m., the Executive Director indicated Resident 11 sometimes ate in her room, and sometimes ate out in the dining area. The resident ate in her room more frequently, so they put her tray on the hall cart and asked her if she would prefer to go back to her room, but she had not been interested in going back to her room. Her expectation would be to get the woman a tray so she could eat where she wanted to eat. It had been too long. 3.1-3(t)

Based on record review, and interview, the facility failed to ensure timely revision of the care plan to reflect pressure ulcer interventions for 3 of 6 residents whose care plans were reviewed for care plans. (Residents 10, 26, 27) Findings include: 1. The clinical record for Resident 10 was reviewed on 2/24/22 at 2:03 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status MDS (Minimum Data Set) assessment, dated 2/7/22, indicated the resident was severely cognitively impaired. The resident was dependent on staff for all ADLs (Activities of Daily Living). The care plan, dated 8/27/15 and last revised on 2/18/22 at 11:22 a.m., indicated the resident was at risk for skin breakdown due to her slightly limited sensory ability, very moist skin related to incontinence, very limited ability to change position independently, very limited ability to transfer or stand. She required maximum assistance with moving was required, only adequate intake, weakness, peripheral vascular disease, and inability to make wants and needs known. The last intervention prior to the current unstageable pressure ulcer, dated 12/2/21, indicated wheelchair positioning by elevating the leg rests with a leg buddy, lateral support on the right side. The new interventions, dated 1/26/22, indicated to provide a low air loss mattress to bed. The care plan lacked documentation of interventions of the low air loss mattress prior to the development of the pressure ulcer. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check the settings every shift. The IDT (Interdisciplinary Team) initial wound review note, dated 1/28/22 at 10:35 a.m., indicated the resident had an unstageable or deep tissue injury to the coccyx.The root-cause determination was pressure related to immobility and incontinence. The new interventions initiated were treatment as ordered, wound nurse practitioner to assess weekly with treatment, and a low air loss mattress to the bed was ordered. The current treatment order was to clean the wound with a wound cleanser, apply medical grade honey, cover with a foam dressing and change every day and as needed, soiled, or dislodged. The IDT additional comments indicated the area was dark with adherent eschar, moist and soft. The surrounding tissue was pink and intact. Will monitor and continue with treatment as ordered. During an interview, on 3/1/22 at 10:40 a.m., the RDCS (Regional Director of Clinical Support)indicated Resident 10 had interventions for turning every 2 hours and incontinence care. It's been years since she could get up on her own. She thought the resident had an air mattress prior to the pressure ulcer developing. It turned out to be a convex mattress. 2. The clinical record for Resident 26 was reviewed on 2/25/22 at 9:42 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Annual review assessment, dated 2/22/22, indicated the resident was cognitively intact. She required supervision for toileting, partial to moderate assistance for bathing, and supervision for dressing. The care plan, dated 8/22/17 and last revised on 2/21/22, indicated the resident was at risk for skin breakdown due to spending a majority of the shift in a wheelchair or bed, slightly limited ability to move independently, potential for friction or sheer with movement, left below the knee amputation with prosthesis, peripheral vascular disease, overactive bladder, diabetes, stump shrinker. The interventions, dated 7/14/21, indicated to keep the skin clean and dry. The interventions, dated 8/22/17, indicated to assess and document the skin condition weekly and as needed. Notify the MD (medical doctor) of abnormal findings. Encourage the resident to eat at least 75% of meals. House barrier at the bedside and to use as needed. Incontinent care as needed using peri wash and moisture barrier. Pressure reducing/redistribution cushion in chair or wheelchair. Pressure reducing or redistribution mattress on bed. Preventative treatment as ordered. Supplements as ordered. Turn and reposition at least every 2 hours. The care plan lacked documentation of the actual pressure ulcer with interventions. The nurse's note, dated 2/11/22 at 10:32 a.m., indicated the resident alerted the nurse to a sore area on her right lower buttock. A small open area was noted. It was red in color with a scant amount of bloody drainage. The MD was updated with orders to cleanse the wound with normal saline, pat dry, and apply a barrier cream to the area, and repeat every shift. The IDT initial wound review note, dated 2/17/22 at 1:30 p.m., indicated a new wound, skin injury to the right lower buttock with no drainage or odor.The root-cause determination was the wound was moisture related. New interventions initiated were to cleanse the area, pat dry and apply a barrier cream every shift. Continue with weekly wound rounds. Continue to monitor the area until healed. During an interview, on 3/1/22 at 10:40 a.m., the RDCS (Regional Director of Clinical Services)indicated the MDS Coordinator was supposed to update the care plan from the IDT meetings held daily, but anyone could update the care plan. New admissions would receive an at risk care plan with every intervention they could think of to put into place. Then when a new area appeared, new interventions would be put into place. 3. The clinical record for Resident 27 was reviewed on 2/25/22 at 10:45 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 9/8/21, indicated the resident's BIMS (Brief Interview for Mental Status) had decreased to severe cognitive impairment and was a decline from the previous score of moderately impaired. The resident spoke with a clear speech to make responses understood. She only sometimes appeared to understand. Questions had to be repeated in a simple manner for her to respond. She did not participate in vision assessment. No behaviors were noted. The resident required extensive assistance with activities of daily living with one-person physical assistance. The care plan, dated 9/18/15 and revised 1/13/22, indicated the resident was at risk for skin breakdown due to dementia, weight fluctuations anorexia and a history of pressure to the left heel. The interventions included, but were not limited to, assess and document skin condition weekly and as needed. Notify the physician of abnormal findings, educate the resident on proper technique on getting into bed, encourage the resident to eat at least 75% meals, pressure reducing and redistribution mattress on the bed, preventative treatment as ordered and supplements as ordered. The care plan lacked documentation for updated and revised preventive interventions for pressure wounds. The nurse's note, dated 10/30/21 at 2:14 p.m., indicated the resident had a fluid filled blister to left inner heel. The blister was pink in color and measured 5 cm (centimeters) long by 4 cm wide. The resident denied pain or discomfort. Staff reported the resident's shoes did not fit correctly. They were too tight. The wound review IDT note, dated 11/05/21 at 1:36 p.m., indicated an ulcer or suspected deep tissue injury. Unstageable to the left heel. The resident would grimace when her foot was manipulated. There were signs and symptoms of infection. The wound had redness, tenderness, edematous and no odor. Nutritional concerns was a weight loss in the past 6 months. There were no interventions in place prior to the wound or skin injury because the resident was a frequent walker. The significant change assessment, dated 11/9/21 at 3:02 p.m., indicated the resident appeared to rarely understand communication. When asked how you are, she responded sweet. She made no other attempts to respond to simple direct communication. She did give eye contact but did not respond. She did not make self understood verbally or with gestures. She attempted to assess long term memory by asking her when her date of birth was and what her daughter's name was. She gave no response. The resident could not decide between two blouses which she liked best. Staff were to anticipate and meet needs. During an interview, on 2/28/22 at 2:50 p.m., LPN (Licensed Practical Nurse) 10 indicated for the prevention of a pressure wound, a resident should be turn and repositioned every 2 hours, provided incontinent care, float heels, skin prep, weekly skin assessments, and air loss mattress. The CNAs (Certified Nursing Aides) would check the resident's skin when they gave a bath or shower. They would report any skin issues to the nurse. If a pressure wound was found she would immediately fill out an event record for skin. She would call the physician for orders and the care plan would be updated with the event. The Comprehensive Care Plan Policy, dated 1/10 and revised on 10/19, provided on 3/1/22 at 11:00 a.m., by the DON, included, but was not limited to, .Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families and/or representative regarding the resident's goals, total health status, including functional status, nutritional status rehabilitation and restorative potential, ability to participate in activities, cognitive status, oral health status, psychosocial status, sensory and physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms . 3.1-35(a) 3.1-35(b)(1)

Based on observation, record review and interview, the facility failed to ensure preventive measures were in place to prevent the development of pressure wounds for 3 of 6 residents reviewed for pressure wounds. (Residents 27, 10 and 26) Findings include: 1. The clinical record for Resident 27 was reviewed on 2/23/22 at 12:52 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 6/18/21, indicated the resident was moderately impaired cognitively. The resident has had significant continued weight loss. The resident had clear speech and she could communicate effectively. She required supervision with activities of daily living. She was not in need of any ancillary services currently. The Quarterly MDS assessment, dated 9/8/21, indicated the resident's BIMS (Brief Interview for Mental Status) had decreased to severe cognitive impairment and was a decline from the previous score of moderately impaired. Resident spoke with clear speech to make responses understood. She only sometimes appeared to understand. Questions had to be repeated in a simple manner for her to respond. She did not participate in vision assessment. No behaviors were noted. The resident required extensive assistance with activities of daily living with one-person physical assistance. The care plan, dated 9/18/15 and revised 1/13/22, indicated the resident was at risk for skin breakdown due to dementia, weight fluctuations anorexia and a history of pressure to the left heel. The interventions included, but were not limited to, assess and document skin condition weekly and as needed. Notify the physician of abnormal findings, educate the resident on proper technique on getting into bed, encourage the resident to eat at least 75% (percent) of meals, pressure reducing and redistribution mattress on the bed, preventative treatment as ordered and supplements as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Encourage the resident to turn and reposition every 2 hours as tolerated every shift. Positioning devices, pressure relieving boots to the left heel. Pressure relieving boot to the right foot. The nurse's note, dated 10/30/21 at 2:14 p.m., indicated the resident had a fluid filled blister to the left inner heel. The blister was pink in color and measured 5 cm (centimeters) long by 4 cm wide. The resident denied pain or discomfort. Staff reported the resident's shoes did not fit correctly. They were too tight. The nurse's note, dated 10/31/21 at 1:57 a.m., indicated a new order for a foam dressing to the open blister on the left heel and change every day. The nurse's note, dated 11/02/21 at 10:59 a.m., indicated a foam dressing and treatment change to the left heel. The wound was observed to have moderate serosanguinous drainage on the old dressing. There was 75% slough and 25% granulation to the wound bed. The wound care nurse's note, dated 11/03/21 at 10:00 a.m., indicated the wound was assessed and the treatment orders were changed. The new orders were to cleanse the left heel with a wound cleanser, pat dry, apply a silver alginate dressing, and cover with a foam dressing everyday and as needed. A wound culture was ordered and obtained of the wound and sent to the laboratory. A CBC (complete blood count), CRP (C-Reactive Protein Test), and an ESR (erythrocyte sedimentation rate) was obtained on 11/4/21. The nurse's note, dated 11/04/21 at 12:01p.m., indicated a topical treatment to the left interior heel per order. The wound bed had a yellow center. The surrounding tissue was a dull waxy color with medium red areas also observed. The resident denied pain with treatment, but was observed to flinch a couple of times during treatment. There was a moderate amount serosanguinous drainage on the old dressing. The wound review IDT (Interdisciplinary Team) notes, dated 11/05/21 at 1:36 p.m., indicated an ulcer or suspected deep tissue Injury. Unstageable to the left heel. The resident would grimace when her foot was manipulated. There were signs and symptoms of infection. The wound had redness, tenderness, edematous and had no odor. There was a nutritional concern with a weight loss in the past 6 months. There were no interventions in place prior to the wound/skin injury because the resident was a frequent walker. The nurse's note, dated 11/6/21at 2:09 p.m., the resident's culture results were positive for gram positive cocci and staphylococcus aureus. The nurse's note, dated 11/8/21 at 10:04 a.m., indicated contact precautions in place due to infection of the left heel wound. Topical treatment to the left inner heal wound was performed per order. There was a large amount of serosanguinous drainage gushed from the wound when cleansing. The center of the wound was medium red to pink in color. The surrounding tissue was white and waxy in color with a reddish colored ring around it. The resident would flinch when the treatment was done. The significant change assessment, dated 11/9/21 at 3:02 p.m., indicated the resident appeared to rarely understand communication. When asked how you are, she responded sweet. She made no other attempts to respond to simple direct communication. She did give eye contact but did not respond. She did not make self understood verbally or with gestures. She attempted to assess long term memory by asking her when her date of birth was and what her daughter's name was. She gave no response. The resident could not decide between two blouses, which she liked best. Staff anticipated and met needs. The nursing note, dated 11/19/21, a treatment was completed to the left heel and the wound was improving quarter size improving. The treatment note, dated 11/21/21, the resident left heel wound was improving to a pea size with a small scabe. The nursing note, dated 11/27/21, indicated the resident's left heel wound had healed. During an interview, on 2/28/22 at 9:30 a.m., LPN (Licensed Practical Nurse) 11 indicated during the Covid-19 outbreak the residents had to be in isolation and her dementia escalated very rapidly. There were no gatherings or activities. Once she got Covid-19 she did not recover from it. She would randomly say hi, but she did not respond. She was unable to have a conversation or communicate. She required total dependence for her ADLs from staff. She was unable to turn herself. She had a decline in her cognition after isolation, but she was able to feed herself with setup. The staff had to walk her to the bathroom. At that time, her picking at her skin increased. She developed a blister on her left inner heel. Staff thought it might be from her shoes. She was assisted up in her chair daily. At that time, she could move her arms. She was unable to do her ADLs and reposition herself. During an interview, on 2/28/22 at 11:20 a.m., the DON (Director of Nursing) indicated for pressure wound prevention staff should be turning the resident every 2 hours, floating the heels, air mattress, provide incontinent care, and weekly skin assessments. During an interview, on 2/28/22 at 2:50 p.m., LPN 10 indicated for the prevention of a pressure wound a resident should be turn and repositioned every 2 hours, provide incontinent care, float heels, skin prep, weekly skin assessments, and air loss mattress. The CNAs (Certified Nursing Aide) would check the resident's skin when they gave a bath or shower. They would report any skin issues to the nurse. If a pressure wound was found she would immediately fill out an event record for the skin. She would call the physician for orders and the care plan would be updated with the event. 2. During an observation of Resident 10's wound care on 2/28/22 at 2:10 p.m., the LPN (Licensed Practical Nurse) wound nurse 6 with turning assistance of Charge Nurse 7 provided wound care. The resident was observed lying on her left side in bed. She had a pillow behind her back and a pillow under her calves. The dressing, dated 2/28/22, was removed and had scant serosanguineous drainage on the dressing. The wound measured 1.9 cm long by 1 cm wide and was open. Wound cleanser was sprayed on the wound and was patted dry with 4 separate gauze. Hydrogel was sprayed onto the open area and was spread with a swab. Barrier cream was applied around the wound. A foam border dressing was placed over the wound. The resident was placed onto her right side and a pillow was placed behind her back and under her feet. Her feet were not floating. During an observation, on 3/1/22 at 10:28 a.m., the resident was lying on her back and asleep in bed. The clinical record for Resident 10 was reviewed on 2/24/22 at 2:03 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS assessment, dated 2/7/22, indicated the resident was severely cognitively impaired. The resident was dependent on all ADLs. The care plan, dated 8/27/15 and last revised on 2/18/22 at 11:22 a.m., indicated the resident was at risk for skin breakdown due to her slightly limited sensory ability, very moist skin related to incontinence, very limited ability to change position independently, very limited ability to transfer or stand, requires maximum assistance with moving was required, only adequate intake, weakness, peripheral vascular disease, inability to make wants and needs known, inflamed cuticle to right 2nd toe. Interventions dated 1/26/22 indicated to provide a low air loss mattress to bed. The intervention, dated 12/2/21, indicated wheelchair positioning by elevating the leg rests with a leg buddy, lateral support on the right side. The interventions dated 9/25/20 indicated to encourage the resident to turn and reposition at least every 2 hours and provide assistance as needed. Encourage the resident to float her heels while [NAME]. The interventions, dated 8/27/15, indicated to assess and document the skin condition weekly and as needed. Notify the MD of abnormal findings. Encourage the resident to eat at least 75% of meals. Keep a house barrier at bedside and use as needed. Provide incontinent care as needed using a peri wash and moisture barrier. Use a pressure reducing and redistribution convex mattress on the bed. Preventative treatment as ordered. Supplements as ordered. The wound management note, dated 1/26/22 at 12:07 p.m., the unstageable deep tissue area to the coccyx measured 2.5 cm long by 1.5 cm wide was discovered. It had 100% dark eschar in the wound bed. There was no drainage. The treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check the settings every shift. The IDT initial wound review note, dated 1/28/22 at 10:35 a.m., indicated the resident had an unstageable or deep tissue injury to the coccyx. The root-cause determination was pressure related to immobility and incontinence. The new interventions initiated were treatment as ordered, wound nurse practitioner to assess weekly with treatment, and a low air loss mattress to the bed was ordered. The current treatment order was to clean the wound with a wound cleanser, apply medical grade honey, cover with a foam dressing and change every day and as needed, soiled, or dislodged. The IDT additional comments indicated the area was dark with adherent eschar, moist and soft. The surrounding tissue was pink and intact. Will monitor and continue with treatment as ordered. The wound management note, dated 2/2/22 at 11:47 a.m., the unstageable deep tissue area to the coccyx measured 6.5 cm long by 3 cm wide. There was 50% slough and 50% granulation with light serosanguineous (pale red to pink, thin and watery) exudate. The area was larger but no longer had eschar. A mild musky odor and scant serosanguinous drainage was observed. The treatment was changed to cleanse with Dakins, do not pat dry, apply Santyl to the wound base and cover with a dry dressing. The nurse's note, dated 2/4/22 at 1:04 p.m., indicated the coccyx wound was medium red in color with a large amount of yellowish-brown slough. A moderate amount of serosanguineous drainage was on the old dressing. There were no complaints of pain to the wound. The air mattress was in place. The resident was to be up for meals only. Positioned side to side in bed. The nurse's note, dated 2/6/22 at 10:22 a.m., indicated wound care per order. The wound bed had a large amount of yellowish-green slough. No noted pain to area with treatment. The nurse's note, dated 2/7/22 at 2:07 p.m., indicated a referral was received from the nurse practitioner for hospice of choice to evaluate and treat as indicated. The nurse's note, dated 2/9/22 at 2:53 p.m., indicated the wound care per order to the coccyx. A moderate amount of yellow slough to the wound bed was observed. No pink or granulation tissue was noted. The surrounding tissue was medium pink in color. A moderate amount of yellow drainage was on the old dressing. The wound management note, dated 2/10/22 at 2:29 p.m. the unstageable deep tissue area to the coccyx measured 2.5 cm long by 1.5 cm wide. 50% slough and 50% granulation. There was light Serosanguineous (pale red to pink, thin and watery). Area is improving, size has decreased, continues with slough, continues with serosanguinous drainage with no odor, continue same treatment, continue to monitor with weekly wound rounds with wound NP. The nurse's note, dated 2/14/22 at 8:16 a.m., indicated an order was received to increase fluids to 240 ml (milliliters) every shift, add Juven twice daily for 60 days to assist with wound healing and change MVI (multivitamin) to MVI with minerals daily. The nurse's note, dated 2/15/22 at 4:29 p.m., indicated the following new orders were received: -Discontinue the current treatment to the coccyx. -Cleanse area to the coccyx with a wound wash or normal saline, pat dry and cover with a foam border dressing two times daily and as needed. The wound management note, dated 2/16/22 the unstageable deep tissue area to the coccyx measured 2.5 cm long by 1.5 cm wide. There was light Serosanguineous (pale red to pink, thin and watery). The slough had decreased down to 25% and granulation tissue was now 75%, scant amount of serosanguinous drainage was noted, no odor was present, no signs or symptoms of infection or pain. The periwound was normal to skin tone but maceration was noted. Continue with weekly wound rounds and current treatment. The resident was now on hospice service. The nurse's note, dated 2/18/22 at 9:00 a.m., indicated the hospice nurse was in to assess the resident this shift. Vitals were stable. The nurse ordered a tilt in space positioning chair during today's visit. The wound management note, dated 2/24/22 at 12:39 p.m., the unstageable deep tissue to the coccyx measured 2 cm long by 1.3 cm wide. There was light Serous (clear, amber, thin and watery). Area remains stable with 75% granulation tissue and 25% slough noted, light Serous drainage, and no odor. The periwound had some macerated areas to it with slight redness. The rest of periwound was normal to skin tone. There was no signs or symptoms of pain or infection. Continue with current treatment and add a house barrier cream to the areas of maceration with the dressing change. Continue with weekly wound rounds. The nurse's note, dated 2/24/22 at 2:45 a.m., indicated the treatment to the coccyx was completed per the order. The wound bed was pink with slight yellow area in middle of wound bed. The skin around the wound was noted to be intact. There was no redness, warmth, or odor. There was quarter size drainage to the old dressing and the drainage was serosanguinous. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply a house barrier cream to the macerated areas of the periwound and cover with a foam border dressing, twice daily and as needed. During an interview, on 2/28/22 at 2:19 p.m., Charge Nurse 7 indicated the wound was a black spot when the resident was moved onto her hall, so she didn't know how it developed. The nurse practitioner followed the resident for care. During an interview, on 2/28/22 at 2:20 p.m., LPN 6 indicated she kept in touch with hospice about the wound. There had been no change to the wound, but it had improved. The wound had slough to the wound bed, but was still unstageable. Charge Nurse 7 indicated no new interventions were in place, but the resident was on a specialty bed. Supplements were also added for wound healing. LPN 6 indicated the pillow should have been placed to float the heels and not be placed under the heels. During an interview, on 3/1/22 at 10:40 a.m., the RDCS (Regional Director of Clinical Services) indicated the MDS Coordinator was supposed to update the care plan from the IDT meetings, held daily, but anyone could update the care plan. New admissions would receive an at risk care plan with every intervention they could think of, to put into place. Then when a new area appeared, new interventions would be put into place. Resident 26 had interventions for turning every 2 hours and incontinence care. It's been years since she could get up on her own. She felt the resident had a [NAME] mattress prior to the pressure ulcer developing. She looked at documentation and found it to be a convex mattress. She could not confirm as to whether the old interventions would have prevented the pressure ulcer from developing. 3. During an observation, on 2/28/22 at 2:26 p.m., Resident 26's pressure ulcer to the right buttock had healed. The clinical record for Resident 26 was reviewed on 2/25/22 at 9:42 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Annual review assessment, dated 2/22/22 indicated the resident was cognitively intact. She required supervision for toileting, partial to moderate assistance for bathing, and supervision for dressing. The care plan, dated 8/22/17 and last revised on 2/21/22 indicated the resident was at risk for skin breakdown due to spending a majority of the shift in a wheelchair or bed, slightly limited ability to move independently, potential for friction/sheer with movement, left below the knee amputation with prosthesis, peripheral vascular disease, overactive bladder, diabetes, stump shrinker. The interventions, dated 7/14/21, indicated to keep the skin clean and dry. The interventions, dated 8/22/17, indicated to assess and document the skin condition weekly and as needed. Notify the MD of abnormal findings. Encourage the resident to eat at least 75% of meals. House barrier at the bedside and to use as needed. Incontinent care as needed using peri wash and moisture barrier. Pressure reducing/redistribution cushion in chair/wheelchair. Pressure reducing andnredistribution mattress on the bed. Preventative treatment as ordered. Supplements as ordered. Turn and reposition at least every 2 hours. The care plan lacked documentation of the MASD (moisture associated skin damage) pressure ulcer with interventions. The nurse's note, dated 2/11/22 at 10:32 a.m., indicated the resident alerted the nurse to a sore area on her right lower buttock. A small open area was noted. It was red in color with a scant amount of bloody drainage. The MD was updated with orders to cleanse the wound with normal saline, pat dry, and apply a barrier cream to the area, and repeat every shift. The wound management note, dated 2/14/22, indicated the MASD pressure ulcer to the right lower buttock measured 0.5 cm (centimeters) long by 0.3 cm wide. The area remained open with no drainage or odor. The periwound was pink and normal to skin tone. The treatment remained in place. The wound management note, dated 2/16/22 indicated the MASD pressure ulcer to the right lower buttock measured 0.5 cm long by 0.4 cm wide. No drainage or odor was indicated. The periwound remained pink and normal to skin tone with 100% epithelial tissue. Weekly wound rounds and current treatment were continued. The IDT initial wound review note, dated 2/17/22 at 1:30 p.m., indicated a new wound, skin injury to the right lower buttock with no drainage or odor. Interventions in place prior to wound / skin injury development was a house barrier cream to the buttocks. The root-cause determination was the wound was moisture related. New interventions initiated were to cleanse the area, pat dry and apply a barrier cream every shift. Continue with weekly wound rounds. Continue to monitor the area until healed. The wound management note, dated 2/23/22, indicated the area was resolved, and the skin was intact. The nurse's note, dated 2/25/22 at 10:02 a.m., indicated the barrier cream was applied to the open area on the right lower buttock. The nurse's note, dated 2/25/22 at 2:39 a.m., indicated the treatment to the buttock continued as per order with no complications noted. During an interview, on 2/28/22 at 2:26 p.m., LPN wound nurse 6 indicated the wound had healed. During an interview, on 3/1/22 at 10:30 a.m., CNA 9 indicated she would roll residents with pressure ulcers every 2 hours. If there was no order in place, she would apply a barrier cream to the site. She would elevate the feet of residents with pressure ulcers to the heels. If the resident couldn't take being rolled, she would turn them as often as she could. Maybe 3 times per shift. If the pressure ulcer were on the bottom, she would keep the area clean and dry. If the dressing became soiled, she would remove the dressing and notify the nurse to apply a new dressing. The Skin Management Program, provided by the RDCS on 3/1/22 at 12:40 p.m., and dated July 2021, included, but was not limited to, .To promote the prevention of pressure ulcers/injury development; promote the healing of existing pressure ulcers/injuries and prevent development of additional pressur eulcer/injury . Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk facgtors to include but not limited to the following: All resident will have a pressure redistribution mattress .Minimize exposure to moisture and keep skin clean, espcially for residents requiring incontinence care . 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to implement fall safety measures for 1 of 5 residents reviewed for accidents. (Resident 17) Findings include: An observation during the initial tour, on 2/23/22 at 9:30 a.m., indicated there was no mat to the floor next to the resident's bed. The resident was in bed at the time. During an interview with the resident at this time, he asked where the fall mat was and indicated it had not been beside his bed for some time. During an observation, on 2/24/22 at 11:30 a.m., the mat was missing from the floor, while the resident was in bed. The resident again indicated the mat had been missing for awhile now, but had been there in the past. Two additional observations of the residents room, on 2/24/22 at 3:22 p.m. and on 2/25/22 at 9:30 a.m., the resident was in his bed without the floor mat being in place. The clinical record for Resident 17 was reviewed on 2/25/22 at 10:18 a.m. Diagnoses included, but were not limited to, personal history of [CONDITION(S)], unspecified intellectual disabilities and repeated falls. The Quarterly MDS (Minimum Data Set) assessment, dated 12/6/21, indicated the resident required extensive assist of 2 for bed mobility and assist to transfer at times; was non ambulatory and had an unsteady balance for surface transfers and moving from seated to standing position and required help to stabilize self. He also had impairment on one side of upper extremities in functional range of motion. The Fall Risk Quarterly assessment, dated 2/21/22, indicated the resident was incontinent; on 2 or more high fall risk medications; required assistance or supervision for mobility, transfer, or ambulation; had an unsteady gait;.and for cognition, he had a lack of understanding of one's physical and cognitive limitations. His Fall Risk Score was 15 points which indicated he was a high fall risk. The physician's order, dated 8/6/20, indicated Mat to floor next to bed while in bed. A Fall Risk care plan, dated 5/20/19, indicated the resident was at risk for falls due to a history of falls, incontinence, on high risk medication use, required assistance with ADLs (Activities of Daily Living) and transfers, impulsiveness, lack of understanding of cognitive and physical limitations, intellectual disabilities, history of [CONDITION(S)] episode, and [CONDITION(S)] to bilateral legs. Approaches included, but was not not limited to, mat next to bed on floor while in bed. The order for the mat next to the bed, on floor while the resident was in bed, was also listed on the Resident Profile, the staff follow, when they cared for the resident. During an interview with RN 3, on 2/25/22 at 9:35 a.m., she indicated that because he had a high air mattress, he should have had a floor mat beside his bed with the bed against the wall. During an interview with CNA (Certified Nurse Aide) 4, on 2/25/22 at 9:45 a.m., she indicated she was just going to check with the nurse to see if he was supposed to have a floor mat next to his bed, since there wasn't one there. She also indicated he did at one time, but didn't know if he was still supposed to. On 3/1/22 at 11:30 a.m., the Executive Director presented a copy of the facility's current policy titled Fall Management Program last updated 11/2017. Review of this policy at this time included, but was not limited to, Policy: It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Procedure: Fall Risk: .4. All residents with a score greater than 0 are considered at risk for falls. 5. Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors. 6. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet . 3.1-45(2)

Based on observation, record review and interview, the facility failed to ensure a resident was free from unnecessary medication for 1 of 7 residents reviewed for unnecessary medications. (Resident 27) Findings include: During an observation, on 2/25/22 at 12:35 a.m., Resident 27 was observed in the dining room. Staff were assisting her with eating. She was unable to feed herself. She did not respond when the staff talked to her. During an observation, on 2/28/22 at 12:10 p.m., staff were observed feeding the resident in the dining room. The resident had to be told by staff to open her mouth to eat. The resident did not respond when asked a question or follow commands. The clinical record for Resident 27 was reviewed on 2/25/22 at 10:45 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 5/7/15 and last revised on 1/7/22, indicated the resident was at risk for adverse side effects related to use of [CONDITION(S)] medication, antianxiety antidepressants, and hypnotics. The interventions included, but were not limited to, administer medications as ordered, observe for effectiveness, document side effects as observed and notify the physician, observe for side effects: Non antipsychotic medications, such as dry mouth, drowsiness, dizziness, [CONDITION(S)], decreased appetite, nausea, depression, confusion, and pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] tablet; 7.5 mg (milligram) oral three times a day with a start date of 8/24/21 - [MEDICATION(S)] 0.5 mg oral two times a day with a start date of 4/6/21 - [MEDICATION(S)] 100 mg tablets, 200 mg oral, at bedtime with a start date of 2/10/21. The Quarterly MDS (Minimum Data Set) assessment, dated 6/18/21 indicated the resident was moderately impaired cognitively. The resident had significant continued weight loss. She had clear speech and she can communicate effectively. She required supervision with activities of daily living. She was not in need of any ancillary services. The Quarterly MDS assessment, dated 9/8/21 indicated the resident's BIMS (Brief Interview for Mental Status) had decreased to severe cognitive impairment and was a decline from the previous score of moderately impaired. The resident spoke with clear speech to make responses understood. She only sometimes appeared to understand. Questions had to be repeated in a simple manner for her to respond. She did not participate in vision assessment. No behaviors were noted. She required extensive assistance with activities of daily living with one-person physical assistance. The Behavior Administration History reports for November 2021 indicated the resident had only 3 behaviors. The Behavior Administration History reports for December 2021 thru February 2022 indicated the resident had no behaviors. The nurse's note, dated 12/26/21 at 4:44 p.m., indicated the staff was educated on assistance level of the resident for meals. She was observed in her room with full cups of liquids and straws, however, when attempting to get the resident to utilize a straw for medications, she would not suck on the straw, she only sat with the straw in her mouth or chewed on it. Staff removed the straw to provide a drink for her medications. The staff was educated to monitor fluid consumption, regularly offer and observe the resident taking in fluids. The nurse's note, dated 2/14/22 at 1:55 p.m., indicated a note was placed in the binder updating the NP (Nurse Practitioner) that the resident was not cognitively able to comprehend how to utilize an inhaler anymore. The speech therapy notes, dated 2/1/22 at 12:25 p.m., indicated a recommendation to downgrade the resident's diet to mechanical soft with ground meats. During an interview, on 2/25/22 at 2:30 p.m., the SSD (Social Service Director) indicated the resident was seen by psychiatric services on a regular basis. She started having odd behaviors with her dementia. She started excessively picking and was confused. The doctors could not find anything wrong physically to cause her decline. She used to walk everywhere, and she had other residents she would stop and talk to. She just had her routine, and she was comfortable with it. When the facility had an outbreak of COVID-19, the residents had to go into isolation and gathering for activities stopped. She started to decline. She had her routine severely disrupted and it really affected her dementia. She contracted Covid and was on the red zone and she really declined after that. She just quit eating and lost weight. She was now in an unresponsive state. She depended on staff for everything. She indicated she felt, at this point the resident did not need her psychiatric medications. During an interview, on 2/28/22 at 11:20 a.m., the DON (Director of Nursing) indicated since the COVID-19 shut down, and isolation on the red unit, the resident deteriorated very quickly with her dementia. She used to do the activities and walked all over the facility visiting other residents, but with the COVID-19 she guessed the resident reached her breaking point and couldn't cope. Occasionally staff would get a response from her, but not very often. Her mental status was stable up to June 2021. Her cognitive status in September 2021 had dropped to a 3 and at this time she was sure it would be lower. She indicated the resident probably didn't need the psychiatric medications she was on at this time. She has had no behaviors. She had not had any excessive scratching or picking since September 2021. The [CONDITION(S)] Management Policy, dated 9/17, provided on 3/1/22 at 1:00 p.m., by the Social Service Director, included, but was not limited to, .It is the policy of American Senior Communities to ensure that a resident's [CONDITION(S)] medications regimen helps promote the resident's highest practicable mental, and psychosocial well-being with person centered intervention and assessment. These medications are managed in collaboration with the attending physician, pharmacist, and facility staff to include non pharmacological interventions, assessment and reduction as applicable . 3.1-48(a)(6)

Based on observation, and interview, the facility failed to ensure foods were served at palatable temperatures for 2 of 3 observations of meal service. (Residents 18, 24, and 23) Findings include: During an observation, on 2/28/22 at 12:24 p.m., after the serving of hall trays on the North hall was completed, the Dietary Manager (DM) checked the temperature of foods on a test tray. The cheese burger patty was measured at 82.4 degrees Fahrenheit (F) and the mashed potatoes were measured at 110.9 degrees F. The DM indicated at this time, staff probably should not have put the cold dressings of lettuce, tomatoes, and onions on top of the cheeseburger patty. Upon tasting the test tray, the mashed potatoes and cheeseburger patty were cold to taste. The cheese on the burger had melted, but had re-hardened. During an observation, on 3/1/22 at 11:46 a.m., as the test tray was prepared by kitchen staff, a very strong, steady stream of cold air was blowing from the air vent above the steam table. The air conditioner was set to 64 degrees F, and the temperature in the room was displayed on the thermostat as 64 degrees F. During an observation, on 3/1/22 at 11:59 a.m., the Registered Dietician checked the temperature of foods on the test tray. The chili cheese dog was measured at 77.6 degrees F and the green beans were measured at 92 degrees F. The chili dog and chili sauce were cool to taste, The green beans felt room temperature to taste. The clinical record for Resident 18 was reviewed on 3/1/22 at 9:58 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], chronic [CONDITION(S)] ulcer with perforation, mixed [CONDITION(S)], and diabetes mellitus type 2. The Admission MDS (Minimum Data Set) assessment, dated 12/6/21, indicated the resident was cognitively intact. The physician's order, dated 12/10/21, indicated the resident received a regular diet, mechanical soft, with ground meats. During an interview, on 2/24/22 at 11:02 a.m., Resident 18 indicated her food was cold when she got it and it was not very tasty. During an interview, on 2/28/22 at 3:22 p.m., Resident 18 indicated her French fries and cheeseburger had been cold. The clinical record for Resident 24 was reviewed on 3/1/22 at 10:00 a.m. Diagnoses included, but were not limited to, gastro-[CONDITION(S)] reflux disease with esophagitis, [CONDITION(S)], type 2 diabetes mellitus, anxiety, and major depressive disorder. The Significant Change MDS (Minimum Data Set) assessment, dated 12/17/21, indicated the resident was cognitively intact. The physician's order, dated 10/19/21, indicated the resident received a regular diet. During an interview, on 2/28/22 at 12:53 p.m., Resident 24 indicated her cheeseburger and French fries had been cold, and most of the food half of the time she got it was cold. The clinical record for Resident 23 was reviewed on 3/1/22 at 9:55 a.m. Diagnoses included, but were not limited to, gastro-[CONDITION(S)] reflux disease with esophagitis, irritable bowel disorder, generalized anxiety, and major depressive disorder. The Quarterly MDS (Minimum Data Set) assessment, dated 12/14/21, indicated the resident was cognitively intact. The physician's order, dated 4/9/21, indicated the resident received a regular diet. During an interview, on 2/28/22 at 12:54 p.m., Resident 23 indicated her lunch that day had been okay, but it had not been hot. During an interview, on 3/1/22 at 12:00 p.m. the Registered Dietician indicated if trays came out of the kitchen at the right temperatures and everything was covered, he might expect a 10 degree change in temperature. Hot foods should be at 135 degrees F when serving. The Food Temperatures policy, last revised 11/17, provided on 3/1/22 at 8:55 a.m., included, but was not limited to, 1. Hot foods that are potentially hazardous will leave the kitchen (or steam table) at or above 135 F . 2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food . 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were followed during the COVID-19 pandemic related to proper use of Personal Protective Equipment and hand hygiene for 4 of 11 staff observed ( Maintenance Director, CNA 4, CNA 5, and IP) and temperature monitoring for 1 of 5 residents reviewed for infection control (Resident 2). Findings include: 1. During the initial tour, on 9/9/21 between 9:15 a.m. and 9:30 a.m., the following concerns were observed on the Annex Halls, which were currently under Yellow Zone Precautions: a. The Maintenance Director walked onto the yellow zone, wearing only a surgical mask. He was not wearing eye protection. He went down to Resident 2's room, donned a gown, but did not sanitize his hands, put on eye protection, or don an N95 mask, and entered the resident's room. There was a sign on the resident's room door, which indicated the resident was on Droplet Plus precautions and gloves, gown, mask and face protection were required prior to entry to the room. He began working on the resident's bed, then left the room and went to the linen closet on the hall. He grabbed a sheet and went back to the resident's room. He donned a gown, but did not don an N95 mask or lower his goggles before going back into the room and working on the bed. He was within 1 to 3 feet of the resident, and at times, was touching and moving the resident in his wheelchair. He did not sanitize his hands at any point. b. CNA (Certified Nursing Aide) 4 was observed in Resident 3's room. The resident's room had a sign on the door, which indicated the resident was in Droplet Plus precautions and gloves, gown, mask and face protection were required prior to entry into the room, and removed prior to exiting the room. CNA 4 was observed removing her gown and gloves within 3 feet of the resident's bed, placing them in a trash can directly next to the resident's bed. There was no trash can by the exit door for the CNA to utilize. During a second tour of the Annex halls, on 9/9/21 at 11:00 a.m., the following concerns were observed: c. CNA 5 entered Resident 4's room after donning the appropriate PPE. She was observed to touch the resident, covering him with a blanket and assisting him with a snack. The resident was sitting directly in the doorway of the room. CNA 5 went into the resident's room and removed her gown and gloves inside the room, placing them in a trash can by the resident's dresser. There was not a trash can by the exit door. She then walked past the resident, coming within less than 1 foot of the resident as she exited the room. CNA 5 donned PPE and entered Resident 5's room to deliver her meal tray. She then removed her PPE directly in front of the resident and placed her gown and gloves in a trash can within 3 feet of the resident before exiting the room. There was not a trash can by the room door for her to utilize. d. The Infection Preventionist was standing in the hallway by the medication cart, speaking to LPN 6 and was within 1 foot of the other staff member. Her surgical mask was pulled down below her nose. During an interview, on 9/9/21 at 9:30 a.m., Unit Manager 6 indicated staff were supposed to wear both an N95 and goggles or eye protection at all times when on the yellow zone. Then when entering resident rooms they should wear a gown, goggles or eye protection, a mask, and gloves. During an interview, on 9/9/21 at 12:00 p.m., the Infection Preventionist (IP) indicated all residents on the Annex Halls were in droplet isolation precautions at the time, due to possible exposure to a positive staff member. During a secondary interview, on 9/9/21 at 12:48 p.m., the IP indicated staff should be removing their PPE inside of the resident rooms, close to the resident doors. There should be a trash can by the door, or fairly close to it. 2. The clinical record review for Resident 2 was completed on 9/9/21 at 10:06 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation of any orders to monitor the resident's temperature daily between 8/9/21 and 9/7/21. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing note, dated 9/6/21, indicated the resident was in droplet plus isolation for possible COVID-19 exposure. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the temperature log indicated the resident's temperature was not obtained on the following days over the last month: August 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 23, 24, 28, 30, 31, September 1, 2, 3, 4, and 6, 2021. The resident's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 9/9/21 at 10:42 a.m., the DON indicated all residents were required to have temperatures taken at least once daily. They would have an order in place to monitor and document the temperature on the EMAR. During an interview, on 9/9/21 at 12:49 p.m., the IP indicated the order to monitor the resident's temperature may have been associated with a stop point at some time in the past and may have not been resumed as a daily order. The COVID-19 Resident Policy, last revised 8/13/21, provided on 9/9/21 at 12:45 p.m., included, but was not limited to, . Procedure . 2. Current Resident . a. All current residents will have at least daily temperature and COVID-19 symptom monitoring . The Standard and Transmission-Based Precautions (Isolation) Policy, last revised March 2021, provided on 9/9/21 at 12:45 p.m. by the IP, included, but was not limited to, Standard Precautions . Use of Personal Protective Equipment . Perform hand hygiene prior to entering the room and before leaving room . PPE should be discarded prior to leaving the room and hand hygiene performed . Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room . Droplet Plus Precautions . Use of Personal Protective Equipment . HCP [healthcare professionals] should wear an N95 . eye protection . gloves, and gown when caring for these residents . PPE must be appropriately doffed and discarded in trash prior to leaving the room . 3.1-18(b)

Based on observation, interview and record review, the facility failed to ensure resident rooms were at a comfortable temperature for 9 of 11 residents reviewed for comfortable environment. (Residents D, E, F, G, H, K, L, M, N) Findings include: On 7/26/21 at 2:20 p.m., while touring on the North Hall, the hall to the right of the nurses' station was observed to feel warm. Towards the center of the hall, on the left, was the hall thermometer which indicated a temperature of 79 degrees. The air in the hallway, at that point, was very warm and humid. With the passing of each room, the temperature was observed to become warmer with a noticeable difference at the last two rooms on each side of the hallway. 1. The clinical record for Resident D was reviewed on 7/27/21 at 1:21 p.m. Diagnosis included, but was not limited to, [CONDITION(S)]. On 7/26/21 at 3:57 p.m., the resident was observed in his bed with a fan blowing towards him. His legs were out from underneath the sheet. The past couple of days his room had been very hot and he kept his legs uncovered due to it being so hot. It has been this way since the summer started and he doesn't bother to say anything because they won't do anything about it. He did not sleep much throughout the night last night due to the heat and it was much hotter today than yesterday. Minimal (very small amount) cool air was observed blowing out from the air vent on the floor. 2. The clinical record for Resident E was reviewed on 7/27/21 at 12:45 p.m. Diagnoses included, but were not limited to, heart failure and [CONDITION(S)]. On 7/26/21 at 2:22 p.m., the resident was observed sitting up on the side of his bed with oxygen in place and a fan blowing towards him from across the room. He indicated anytime it was hot outside, and the humidity was high, his room was unbearably hot and he just sat and sweated. When you say something to the staff, all they do was to walk over, put their hand down by the air conditioning vent on the floor, and tell me there was cool air coming out. He indicated the past couple of days had been sweltering in the room which made it hard to sleep. He would sleep an hour, then wake up sweating. He was up all night last night because he was unable to sleep due to heat and finally fell asleep from exhaustion. He had been getting frequent headaches. Minimal cool air was observed blowing out from the air vent on the floor. 3. The clinical record for Resident F was reviewed on 7/27/21 at 12:50 p.m. Diagnoses included, but were not limited to, heart failure and respiratory failure. On 7/26/21 at 2:25 p.m., the resident was observed lying in bed covered with a sheet from the hips to his knees with oxygen in place. He indicated it had been very warm over the past couple of days and the heat in his room had been an ongoing issue over the past month. He had to have his pillowcase changed last night due to sweating so bad. Sometimes he can sleep and sometimes he cannot due to the temperature in the room. Minimal cool air was observed blowing out from the air vent on the floor. 4. The clinical record for Resident G was reviewed on 7/27/21 at 1:26 p.m. Diagnosis included, but was not limited to, [CONDITION(S)]. On 7/26/21 at 3:53 p.m., the resident was observed lying in bed with his eyes open and a fan blowing directly on his face. He indicated he was comfortable right now but would not be without his fan. Minimal cool air was observed blowing out from the air vent on the floor. 5. The clinical record for Resident H was reviewed on 7/27/21 at 1:30 p.m. Diagnoses included, but were not limited to, hypertension and [CONDITION(S)]. During an interview on 7/26/21 at 4:00 p.m., the resident indicated he needed some air conditioning in his room as it was too warm to sleep at night. Minimal cool air was observed blowing out from the air vent on the floor. 6. The clinical record for Resident K was reviewed on 7/27/21 at 1:37 p.m. Diagnosis included, but was not limited to, [CONDITION(S)]. During an interview on 7/26/21 at 4:02 p.m., the resident indicated it was so hot in his room that he asked the staff if he could sleep in the dining room so he could be cool. If he did not have a fan in his room, it would be hot as hell'. When he woke this morning, his pillow case was wet as well as his hair. Minimal cool air was observed blowing out from the air vent on the floor. 7. The clinical record for Resident L was reviewed on 7/27/21 at 1:46 p.m. Diagnosis included, but was not limited to, hypertension. During an interview on 7/26/21 at 4:04 p.m., the resident indicated it could stand to be a few degrees cooler in here. It was so hot yesterday evening that he was sweating. Minimal cool air was observed blowing out from the air vent on the floor. 8. The clinical record for Resident M was reviewed on 7/27/21 at 1:54 p.m. Diagnosis included, but was not limited to, [CONDITION(S)]. During an interview on 7/26/21 at 4:09 p.m., the resident indicated the heat in the building had been an ongoing issue since it started warming up outside. It had been so warm that it was hard to sleep even with a fan blowing directly on you. He has had to wet his head with cool water 2 to 3 times during the day due to sweating. Minimal cool air was observed blowing out from the air vent on the floor. 9. The clinical record for Resident N was reviewed on 7/27/21 at 2:01 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], heart failure and [CONDITION(S)]. During an interview on 7/26/21 at 6:00 p.m., the resident indicated his room was extremely warm. He used a sleep apnea machine and his roommate had an oxygen concentrator, both of which put off heat and makes the room even hotter. During a confidential interview, from 7/26/21 to 7/27/21, a staff member indicated the last couple of days had been very warm in the building and the residents were complaining of being hot. During a confidential interview, from 7/26/21 to 7/27/21, a family member indicated the heat in the building yesterday was just as bad as it was three weeks ago. When she assisted her loved one to change into her nightgown yesterday evening, her loved ones sheets, clothing and back were damp with sweat. During a confidential interview, from 7/26/21 to 7/27/21, a staff member indicated the last time it had gotten hot, cold wash rags were placed on the heads of the residents' because their faces were flushed and they were uncomfortable, especially the ones with oxygen. During an interview on 7/26/21 at 4:50 p.m., the Executive Director indicated the duct work that carried the cool air to the north hall had come apart but had now been taped back together. He was unsure as to how long it had been that way. He had been checking the residents' room temperatures and never had a reading above 81 degrees Fahrenheit. At 5:15 p.m., the Executive Director indicated it would take about 2 to 3 hours for the rooms to cool down. They had multiple window units over in storage from some years back and he instructed one of his maintenance staff to go to the storage unit to retrieve some of them to place in the room windows. On 7/27/21 at 12:34 p.m., the Executive Director provided a current copy of the document titled Resident Rights dated 1/2020. It included, but was not limited to, Quality of Life and Safe Environment .A resident has a right to care in an environment that promotes maintenance or enhancement of each resident's quality of life .The resident has the right to a safe .comfortable .homelike environment 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure appropriate interventions were in place for a resident (Resident D) who was at risk for developing pressure ulcers, which resulted in the development of an in house unstageable pressure ulcer to the left heel and one stage three pressure ulcer to the sacrum for 1 of 3 residents reviewed for pressure ulcers. Findings include: The clinical record for Resident D was reviewed on 8/31/20 at 11:10 a.m. The resident's [DIAGNOSES REDACTED]. The 5 day admission MDS (Minimum Data Set) assessment, dated 5/28/20, indicated the resident required two physical staff assistance with bed mobility. The significant change MDS assessment, dates 6/11/20, indicated the resident had no rejection of care. The admission observation, dated 5/22/20, indicated there were no alterations in the resident's skin. The Braden Scale for Predicting Pressure Sore Risk assessment, dated 5/22/20, indicated the resident was at risk for pressure ulcers due to occasionally moist skin, severely limited ability to walk, and required moderate to maximum assistance with moving. The care plan, dated 5/25/20, indicated the resident was at risk for skin break down due to occasionally moist skin, ability to walk severely limited and slightly limited ability to change position independently. Interventions included to assess skin weekly, encourage the resident to turn and reposition at least every 2 hours, and to provide assistance as needed. The weekly summary, dated 6/2/20 at 2:09 a.m., indicated there were no alterations in the resident's skin. The wound management detail report, dated 6/2/20 at 11:51 a.m., indicated the resident had a stage 3 pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue) to the sacrum which measured 6 cm (centimeters) in length, 4.5 cm in width, with a depth of 1 cm. The wound management detail report, dated 6/4/20 at 2:29 p.m., indicated the resident had an unstageable deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin caused by damage to the underlying soft tissue) to the left heel which measured 8 cm in length with a width of 7 cm. The wound management detail report, dated 6/12/20 at 11:56 a.m., indicated the resident had a stage 3 PU to the sacrum which measured 10 cm in length, 12 cm in width, with a depth of 0.3 cm. The resident's left heal had an unstageable deep tissue injury which measured 8 cm in length and 7 cm in width with no depth. The wound management detail report, dated 6/18/20 at 2:07 p.m., indicated the resident had an unstagable PU to the sacrum which measured 10 cm in length, 12 cm in width, with no depth. The resident's left heal had an unstageable deep tissue injury which measured 8 cm in length and 7 cm in width with no depth. The wound healing was declining. The resident was discharge from the facility on 6/23/20 to an acute hospital. During an interview on 8/31/20 at 12:52 p.m., the Director of Nursing indicated the resident acquired the pressure ulcers because of non-compliance with turning/repositioning and the resident just wanted to lay in bed. The clinical record lacked documentation of staff turning and repositioning, floating heels, and a non-compliance plan of care prior to the resident acquiring the pressure ulcers. On 8/31/20 at 2:28 p.m., the Administrator provided a current copy of the document titled Skin Management Program dated July 2020. It included, but was not limited to, Policy .It is the policy .to ensure that each resident receives care, consistent with professional standards, to prevent pressure ulcers and does not develop pressure ulcers This Federal tag relates to Complaint IN 200 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure the physician was notified, in a timely manner, when a resident (Resident B) presented with an acute change which resulted in an above the knee amputation of the left lower extremity for 1 of 5 residents reviewed for change in condition. Findings include: The clinical record for Resident B was reviewed on 10/25/17 at 11:38 a.m. [DIAGNOSES REDACTED]. The 9/19/17 quarterly MDS (Minimum Data Set) assessment indicated the resident had a BIMS (Brief Interview of Mental Status) score of 7 which signified severely impaired cognition. The ineffective tissue perfusion care plan, dated 6/5/15, indicated to notify the physician for signs of cyanosis (appearance of a blue or purple coloration of the skin). The nurse's note, dated 10/19/17 at 12:00 a.m., indicated redness to the left foot which extended up to the middle of the top and bottom of the foot, non-[MEDICAL CONDITION], cool to touch, and the tips of the 2nd, 3rd, and 4th toes were dark blue in color. The nurse's note, dated 10/19/17 at 6:27 a.m., indicated the resident's left foot continued with redness, non-[MEDICAL CONDITION], and the toes remained dark blue in color and cool to touch. The nurse's note, dated 10/19/17 at 7:25 a.m., indicated the nurse practitioner was called due to the resident's left foot being purple and all 5 toe tips black in color and a new order was received to send the resident to the emergency room . The resident transfer sheet, dated 10/19/17 at 7:24 a.m., indicated the resident was transferred to the hospital at 8:00 a.m. The emergency triage report, dated 10/19/17 at 8:45 a.m., indicated the resident's foot was purple, cold and toes were almost black and was reported the foot was last seen on Friday (10/13/17) and it was ok. The emergency room evaluation, dated 10/19/17 at 8:58 a.m., indicated the resident had contractures involving both lower extremities and the left foot was cold, a blue black discoloration from the midfoot to the toes, and most likely will need amputation of the left foot. The surgical consult note, dated 10/19/17 at 12:48 p.m., indicated the resident was admitted to the emergency room with a non-viable (not able to survive) left foot, cool to touch, purple in color, pulseless, and the tips of the left toes are all necrotic/mummified. The assessment and plan indicated the resident would eventually need a left leg amputation. The operation report, dated 10/23/17, indicated the following: Preoperative Diagnosis: [REDACTED].Procedure Performed: Left above-knee amputation . During an interview on 10/26/17 at 12:08 p.m., LPN (Licensed Practical Nurse) 3 indicated she was the resident's nurse on 10/19/17 and did not notify the physician of the residents change in condition. On 10/26/17 at 11:13 a.m., the Administrator provided a current copy of the document titled Resident Change of Condition, dated January 2015. It included, but was not limited to, the following: .Policy .It is the policy of this facility that all changes in resident condition will be communicated to the physician .and that appropriate, timely, and effective intervention takes place .Procedure .2. Acute Medical Change .a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . This Federal tag relates to Complaint IN 102 3.1-5(a)(2)(3)

Based on interview and record review, the facility failed to follow up on a resident's (Resident B) abnormal lab results (elevated white blood cell count of 13.7) which resulted in the need for intravenous antibiotics, after hospitalization , for a severe urinary tract infection for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident B was reviewed on 10/25/17 at 11:38 a.m. [DIAGNOSES REDACTED]. The 9/19/17 quarterly MDS (Minimum Data Set) assessment indicated the resident was incontinent of bladder. The hematology report, dated 7/1/17 at 9:55 a.m., indicated the resident had a white blood count (WBC) of 9.3 (normal range is 4.5 - 10.8). The physician progress notes [REDACTED]. The hematology (complete blood count) report, dated 9/28/17, indicated the resident's white blood cell count was elevated at 13.7. The nurse's note, dated 9/28/17 at 12:30 p.m., indicated the lab results were back with multiple abnormalities. The nurse practitioner was notified with new orders to obtain a [MEDICAL CONDITION] panel and basic metabolic panel in the morning. There were no new orders to address the elevated white blood cell count. The emergency department hematology report, dated 10/19/17 at 9:20 a.m., indicated the resident's white blood cell count was 19.7. The emergency department urinalysis, dated 10/19/17 at 9:25 a.m., indicated 3+ bacteria (normal range is negative) and white blood cells in the urine was 86 (normal range is 0-5) with a [DIAGNOSES REDACTED]. The emergency department evaluation, dated 10/19/17 at 11:23 a.m., indicated the resident was bolused with fluids and also give a dose of antibiotics and would need continued treatment for [REDACTED]. The hospital assessment plan, dated 10/20/17 at 8:49 a.m., indicated toxic metabolic [MEDICAL CONDITION] secondary to UTI (urinary tract infection). During an interview on 10/26/17 at 12:20 p.m., NP (Nurse Practitioner) 5 indicated the resident was suppose to follow up with [MEDICATION NAME] due to elevated enzymes as well as the elevated white blood cells. During an interview on 10/26/17 at 1:00 p.m., the Director of Nursing indicated there were no appointments scheduled for the resident to see a [MEDICATION NAME]. The clinical record lacked documentation of any orders or documentation related to sending the resident to [MEDICATION NAME] related to the abnormal labs. The Federal tag relates to Complaint IN 102 3.1-37(a)

Based on interview, observation and record review, the facility failed to ensure a resident had a physician's order for use, was supervised during use of a hot pack and was free from sustaining injury in that the resident developed a Second-degree burn while using a hot pack. This deficient practice affected 1 of 3 residents reviewed for accidents with injury. (Resident #B) Finding includes: Review of the clinical record for Resident #B on 5/12/16 at 10:00 a.m., indicated the resident was admitted to the facility from the hospital on [DATE]. [DIAGNOSES REDACTED]. During an interview with Resident #B on 5/12/16 at 10:35 a.m., the resident indicated he was unable to feel anything from his pelvic area down but for some reason whenever he was bothered with a possible kidney infection, he would have severe muscle spasms on the right side from his lower back to his right thigh area. The resident indicated he recently asked the nurse to fix him a moist hot pack by heating a towel in the microwave as he used to do at home and what staff had done in the past as he was having severe muscle spasms running from his low back down his right leg. He indicated this had always helped him in the past. Resident #B indicated when the nurse initially brought him the hot pack, he did not think it was warm enough, so he asked her to warm it up more in the microwave. When she brought it back, he then placed it on his upper right thigh. The resident indicated he had it on his thigh for quite a while and moved it around turning the pack in order to gain more heat. When asked if the nurse checked on him while he had the hot pack on his leg, he indicated the nurse did come in occasionally to ask if the pack was helping his spasms. He further indicated the nurse did not check on his skin nor remove the pack at any time while he used it. The resident indicated that since he had no feeling in his legs, he did not realize he had sustained a burn until the next day when he felt something wet while moving around and noticed the burn had a blister which popped. Documentation was lacking in the nursing notes of the nurse having assessed the resident's pain prior to giving the resident the hot pack and of the nurse checking the resident while the hot pack was in use. Interviews with 5 LPNs (Licensed Practical Nurses) on 5/12/16 between 11:50 a.m. and Noon, indicated the following: - LPN #1 - Have only been here a short time, but warming towels has never been allowed as you cannot regulate the temperature. Only allowed to use approved hot packs from the facility. - LPN #2 - Only allowed to use the hot packs facility has approved. As far as I know, we have never been allowed to use warmed towels in the microwave. - LPN #3 - We first need a physician's order; then only use the facility provided hot packs placed in a protective barrier like a towel or pillow case so its not directly against the skin. You only leave the pack on 20 minutes - no longer, and then off 20 minutes. Use of a heated towel is never allowed. - LPN #4 and #5 were also present during LPN #3's interview and agreed with what she had said. A 4/20/16 Incident Report presented by the Administrator at 1:00 p.m., indicated the area was an open blister which measured 3.4 by 3.0 centimeters; but had no pain associated with it due to the resident's [DIAGNOSES REDACTED]. A written statement by the nurse involved indicated Resident asked for a warm compress for L (left) leg due to muscle cramp. Heated moistened towels placed in bag & (and) applied to leg with towel over compress. Resident requested to have compress reheated because wasn't warm enough. The Administrator also presented a copy of the hot pack packaging the facility used titled Accu-Therm Hot Pack. The instructions included, but were not limited to: #3 Wrap in cloth. Among the warnings also listed on the package included, but not limited to: .Consult a Physician before using on sensory impaired individuals, check patient and pack regularly during product use .The unattended use of a hot compress by children, elderly or incapacitated person is dangerous . This Federal tag is related to Complaint IN 638. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure residents were assessed following a significant change in condition resulting in hospitalization for two residents. This deficient practice affected 2 of 6 residents reviewed for change of conditions. (Resident A and D). Findings include: 1. The clinical record for Resident A was reviewed on [DATE] at 11:00a.m. Resident A was admitted to the facility on [DATE]. He had diagnoses, including but not limited, to [MEDICAL CONDITION], high blood pressure, anxiety, and [MEDICAL CONDITION]. Resident A was admitted to the facility for rehabilitation following a bowel resection surgery. The physical therapy note dated [DATE] and untimed stated, "....The writer then requested the patient ambulate one more time before ending tx(treatment) session. Pt (patient) stated he didn't (think) he could. Then immediately, pt closed his eyes and stated, "is there a doctor here?" This writer reported, "not right now but there is a nurse. Is something wrong ?" Pt (patient) responded with eyes closed, and reached for this writers arm, "I'm passing out." Pt (patient) continued to state while rubbing this writers arm, "I need a doctor, I am passing out." This writer then assessed patients vital signs. BP(blood pressure) was ,[DATE], HR (heart rate) was 79, and O2 (oxygen) saturation was 97%. Reported to patient his vital signs looked good , but that we would go back to his room and alert the nurse. Pt was agreeable, and continued to report, " I need a doctor, I am passing out." No changes in posture or alarming signs of a problem had occurred. Pt continued to be alert, awake, and able to participate in putting legs on leg rests. Once to the bed, this writer requested the CNA assist with lying patient down. Pt was MinA (minimal assist) for transfers before treatment session. Transfers back to bed was Mod A of 2 (moderate assist of 2 people) to complete. Pt did participate in pushing up from chair, and pivoting feet. Once in supine position, CNA alerted nurse. Nurse came to the room to assess patient as well. Pt appeared to fall asleep with no signs of distress or labored breathing. Pt consistently complains that he is cold. This writer applied blankets, opened bathroom door where there is a ceiling heater, and turned on heather. Pt and roommate will often keep room door closed to trap heat. Closed door. Roommate reported he would alert nursing if any changes were made. This writer was attempting to get next resident on caseload when roommate came out and said, "he is doing something weird with is hand." This writer alerted nursing, who again, assessed patient...." The nurses notes for Resident A included the following: [DATE] at 1:30a.m.-Rd (resident) rec (received) dly (daily) skilled care for colon resection. Is A &O X3 (alert and oriented times 3). Incont (incontinent) of B &B (bowel and bladder). assist of one for transfers. call light within reach can and does make needs known. -9:15p.m.-Res (resident) resting in bed with eyes closed. BP (blood pressure) ,[DATE] P(pulse) 61 R (respirations) T (temperature 97.6 -3:00p.m.-late entry Res (resident in bed, stating he does not feel well and that he feels like he is going to pass out. Res (resident) denies pain or any specific needs. Just states he wants to rest. ,[DATE] 74 18 97 97%. No acute signs of distress noted. Res (resident) A &Ox3 (alert and oriented times 3). able to answer questions appropriately. will continue to monitor. -3:15p.m.(late entry)Res (resident) abed resting with eyes closed. Res responds when spoke to. No signs or symptoms of distress noted. Resident noted to be grimacing at times but continues to state he does not have any pain or want anything for comfort. Resident says he still does not feel well but is unable to specify any needs. ,[DATE] 72 16 97.2 96% accucheck 170 -3:30p.m.(late entry) Res abed, staff at bedside. Resident denies pain but continues to grimace and unable to state why. PERRLA (a normal assessment of the eyes indicating pupils equal, round, and reactive to light and accommodation), hand grasps firm and equal, moves all extremities without difficulty. ,[DATE], 18, 97.1, 95% -4:30p.m. (late entry) Res abed no sign or symptoms of distress noted. Res denies pain or any needs at this time. Res states he is not hungry and does not want any supper. Res says he is still uncomfortable but does not want anything for pain, to get OOB (out of bed), or be repositioned at this time. Neuro checks remain within normal limits ,[DATE] 76 97.1 96% -5:30p.m. (late entry)Res abed, appears to be sleeping, arouses easily when spoken to answers all questions easily when spoken to. answers all questions appropriately. resident did not eat any supper and states he does not want anything when offered by staff. 6:15p.m.-(late entry)Res abed with eyes closed. Easily awaken. Res denies any needs at this time. Vital signs stable. will continue to monitor. A document titled, "SBAR Communication Form" indicated on [DATE] at 6:25a.m. the physician was notified due to Resident A "unresponsive to verbal command or painful stimuli" The form also indicated Resident A's family was notified of his change in condition. Resident A was transferred to the hospital on [DATE] at 7:00a.m. and expired on [DATE] in the hospital. The radiology report from the hospital dated [DATE] at 1:26p.m. indicated Resident A had "...Multiple areas of recent infarction involving the right posterior cerebral artery distribution, both thalami, the mesencephalon, and both cerebellar hemispheres. The discharge summary dated [DATE] indicated Resident A had an acute stroke with coma. Resident A also had a possible leak from his bowel resection surgery. Resident A expired in the hospital on [DATE]. On [DATE] at 9:30a.m., RN#1 indicated a resident's assessment with acute changes would prompt further monitoring. RN#1 also indicated he provided care for Resident A a few times but nothing "stood out about him medically." On [DATE] at 10:40a.m., Resident A's family member was interviewed. She indicated she inquired with both the day and night shift nurse on [DATE] if the resident was having a stroke. She stated both nurses indicated the resident was resting. She indicated neither nurse would come to the residents room to assess him. She felt that "they were just blowing me off." On [DATE] at 2:33p.m., the Director of Nursing indicated, "if the nurses use the SBAR it is the same as their nurses notes. If a resident is requesting to see the doctor, I would expect the nurses to assess what's going on with them, and depending on the circumstances I would follow notify the physician and follow his orders. If a family requests to see the physician, we would honor that." On [DATE] at 3:00p.m., this writer attempted to contact the nurse providing care for Resident A on [DATE]. She was unavailable for interview. On [DATE] at 3:05p.m.,the Physical Therapist (PT #1) was interviewed. PT#1 provided care for Resident A on [DATE]. PT#1 reiterated her progress note, adding, "He was here for just a short time but be did really well. He was cooperative and compliant. I know that day I saw him after lunch, because he participated in all three (speech, occupational, and physical therapy). " PT#1 was unable to indicate the exact time of the therapy session. There was no documentation to indicate Resident A had a more thorough assessment being completed or the physician being notified until 9 hours after the resident requested to be seen by a physician. 2. Review of the clinical record for Resident #D on [DATE] at 12:50 p.m., indicated the resident had [DIAGNOSES REDACTED]. On [DATE], the resident was transferred to the hospital emergency room to have her suprapubic catheter changed. The Transfer Form indicated the reason to be "Catheter changed multiple times - needs suprapubic placement, not able to anchor catheter, increased urine retention". A [DATE] SBAR Communication Form (report form used to document change in condition in order to contact physician) completed at 3:20 p.m. indicated "It was reported to this nurse by 3rd shift nurse that cath (catheter) has been leaking around tubing all noc (night) (and) has been changed multiple x's (times). When this writer came onto unit, I assisted in changing cath. Urine noted to drain around cath but not thru tubing. Message left (with) (name of urologist) r/t (related to) any N/Os (new orders). MD returned call and stated to send res (resident) to ER to have cath replaced. N/O send to (name of hospital) ER. Resident was experiencing some nausea, distended abdomen, abdominal pain and tenderness also." The re-admitting [DIAGNOSES REDACTED]. During an interview with LPN #1 on [DATE] at 1:30 p.m., she indicated "I had just come on duty and had not even made rounds on my residents before the 3rd shift nurse got me and told me she had changed the resident's catheter multiple times during the night but that it was still leaking around. I watched her change it again but it was still leaking. We changed it again and was able to get it anchored, so I decided to monitor it for awhile before calling the MD. Around 9:30 a.m., I called her urologist because it kept leaking around the site and no urine was going into the bag. Did not get a call back after a while, so I called again and left a message. I called again around 3:,[DATE]:15 p.m. and his nurse said she would tell him right now and a few minutes later I got a call back with an order to send her out to the hospital ER. She was admitted with urosepsis. I also learned from the urologist that within 12 minutes, her stoma could close up, causing all that leaking." During this interview with LPN #1, LPN #2 also joined the interview indicating they would not have waited until the next shift came on to call the MD. They indicated that although they might not have contacted the urologist, they would have made the call to the resident's primary physician to update him on the resident's condition and get new orders. Review of the nursing notes indicated there was no documentation from the 3rd shift nurse and the first shift nurse of any assessment of the resident's overall condition, the need to change the catheter multiple times, and of the phone calls to the urologist until the SBAR Communication Form was completed at 3:20 p.m. on [DATE].. During an interview with the Director of Nursing on [DATE] at 2:30 p.m., she indicated if the nurse has to change the catheter at least 2 times and continued to have issues with it, there should be some type of documentation in the nursing notes. If having to change it multiple times, then reasonable expectations would be to call the primary physician even during the night, to inform him of the problems and obtain new orders if necessary. On [DATE] at 3:05 p.m., the Director of Nursing presented a copy of the "Signs and Symptoms - Immediate vs. Non-Immediate Notification to the Physician". Review of this book indicated "Urinary hesitancy or retention - Immediate - Abrupt decrease in urinary output, with lower abdominal distension, discomfort over bladder,..." A copy of the policy titled "Interact Care Path" was provided by the Director of Nursing on [DATE] at 3:02p.m. This documented indicated when family or patient have a medical complaint "demand to speak to a physician or have a medical assessment without delay." A copy of the policy titled, "Episodic Documentation" was provided by Medical Records on [DATE] at 12:50p.m. This policy effective [DATE], indicated, ..."will document significant resident care issues each shift until stabilized or the situation is otherwise resolved. 1. Enter the date and time of occurrence. 2. Document the facts regarding the care issue or incident as applicable, including but not limited to:vital signs, physical assessment, resident response, resident level of consciousness, symptoms. 3. notify physician and document the following: a. date and time physician notified b. orders obtained 4. notify responsible party and document the following:date and time responsible party notified. b. name of responsible party member. 3XXX,[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision and assistance when transported in a wheelchair, resulting in a fall with a laceration to the head requiring sutures, for 1 of 3 residents reviewed for falls, in a sample of 3. Resident A Findings include: 1. On 5/1/12 at 1:45 P.M., during the initial tour, LPN # 1 indicated Resident A had fallen recently and received sutures to her head. LPN # 1 indicated Resident A was not interviewable. On 5/1/12 at 2:30 P.M., Resident A was observed propelling herself up and down the hallways. Resident A was observed to be sitting near the edge of her wheelchair seat. A sensor alarm was attached to her wheelchair. On 5/1/12 at 2:40 P.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. A care plan, dated 1/18/12, indicated: "Fall/Injury Risk related to: Musculoskeletal, back pain, osteoporosis, Cognitive Impairment Factors, Dementia, Sensory Impairment Factors, visual...." The Interventions included: "Ambulation: 2A (two assist), Transfer: 2A...Chair alarm, Bed alarm...." A Minimum Data Set (MDS) assessment, dated 4/13/12, indicated Resident A had a short-term and long-term memory problem and was moderately impaired in cognitive skills for daily decision making. The MDS assessment indicated the resident required extensive assist of two+ staff for transfer, walking in room, and locomotion on the unit. A test for balance during transitions and walking indicated, "Not steady, only able to stabilize with staff assistance." An "Accident/Incident Report," dated 4/27/12 at 6:30 P.M., indicated, "...CNA (name of CNA # 1) was assisting res. (resident). CNA pulled w/c (wheelchair) back to (illegible) and res noted to come out of chair. Res hit back of head on bottom part of w/c...Pain Yes, back of head...Confused...Laceration 3.5 x .4 x .1 cm (centimeters)...Res sent out for tx (treatment) eval (evaluation) to ER (emergency room )...." A Progress Note, dated 4/27/12 at 8:00 P.M., indicated, "Res back from ER, res received 4 stitches...stitches intact to back of head...." A Progress Note, dated 4/30/12 at 10:35 A.M., indicated, "IDT (interdisciplinary team) met to review fall on 4/27. CNA was assisting resident in w/c, pulled w/c back to move resident out of hallway, resident slid out of w/c. Resident hit back of head on w/c causing laceration to back of head...returned (with) 4 stitches to head. CNA inserviced on making sure resident is sitting completely back in w/c before assisting to move resident...." A Multi-Disciplinary Therapy Screening Tool, dated 4/30/12, indicated, "...Fall from w/c on 4/27/12...Pt (patient) cushion (and) w/c appropriate for safe positioning." On 5/2/12 at 10:00 A.M., during interview with the Director of Nursing (DON), she indicated she was not present during the resident's fall on 4/27/12, but from what she understood, the CNA was trying to pull the resident out of the hallway, and pulled the wheelchair back, then the resident fell and hit her head on the wheelchair frame. The DON indicated that Resident A is "squirmy anyway," and she inserviced CNA # 1 that she should have told Resident A what she was doing prior to moving her. 2. On 5/2/12 at 12:40 P.M., the DON provided the current facility policy on "Transferring, Turning, Positioning, and Seating Safety Process," dated March 2007. The policy included: "...Residents will be transferred, turned, positioned and seated according to their co-morbidities and individual abilities. (Name of corporation) strives to reduce the risk of injury to residents with the use of transferring, turning, positioning and seating techniques and wheelchair safety checks...Observe the following when assessing wheelchair positioning:...Upright posture without excessively leaning to the right or left, Shoulders level when placed on arm rests, Head in neutral upright position....Reposition resident as indicated to maintain proper wheelchair position...." This federal tag relates to Complaint IN 305. 3.1-45(a)(2)