Every finding on record at Miller's Merry Manor

Based on record review, staff interview, and facility policy review, the facility failed to ensure the Activities Program was directed by a qualified professional who met required training and certification standards prior to assuming the role of Activities Director. This failure had the potential to affect 69 of 69 residents who relied on the activities program to meet their psychosocial, emotional, and social needs. Findings include:During a review of employee records on 12/31/25 at 8:40 a.m., records indicated the Activities Director (AD) lacked the required training and/or certification for the position. The records lacked evidence of completion of an approved activities training course or documentation demonstrating qualifications consistent with regulatory requirements at the time the individual was hired into the position.During an interview with the AD on 1/6/25 at 9:52 a.m., she indicated she had been in the position since 12/1/25. Prior to becoming the AD, she was the assistant to the AD. There was no training required to be the assistant. After being hired as the AD, she signed up for online training. At the time of the interview, she was awaiting notification of a start date from the online program. During that waiting period, she continued to schedule activities like those of the previous AD.During an interview with the Administrator on 12/31/25 at 3:00 p.m., she indicated the AD's start date was 12/1/25. Both she and the AD were awaiting notification from the training program about a start date for the training. A current facility policy, titled Activity Director or Director of Life, provided by the administrator on 1/6/26 at 9:00 a.m., indicated the following: .Requirements/Qualifications: Therapeutic recreation specialist who is: 1. Licensed or registered, if applicable, by the State in which practicing. 2. Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized, accrediting body. 3. Has two (2) years' experience in a social or recreational program within the last five (5) years, one of which was full-time in a patient activities program in a health care setting. 4. Is a qualified occupational therapist or occupational therapy assistant.

A. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies for draining venous wounds to mitigate risk of contamination to the wounds and the risk of exposure to bodily fluids for others for 1 of 4 residents reviewed for pressure injuries. (Resident 64) B. Based on observation, interview and record review, the facility failed to maintain foley catheter tubing and drainage bags in a sanitary manner for 2 of 2 residents reviewed for foley catheters. (Residents 68 and 82) Findings include:A. During an observation, on 12/29/25 at 11:09 a.m., Resident 64 shuffled out of her room, using a two-wheel walker and wearing nonskid socks. Resident 64's clinical record was reviewed on 12/31/25 at 9:21 a.m. Diagnoses included old myocardial infarction (heart attack), generalized edema, atherosclerotic heart disease of the native coronary artery without angina pectoris, chronic obstructive pulmonary disease, altered mental status, dementia, lymphedema, and peripheral vascular disease. Current orders included the following: Wash both lower legs with normal saline or wound cleanser, pat dry, apply Xeroform (non-adhering wound treatment dressing), cover with alginate (wound treatment), wrap with gauze wrap or bordered silicone dressing daily and as needed for wound care (12/31/25) and cleanse left foot with normal saline or wound cleanser to the third toe area, pat dry, apply xeroform, cover with alginate, wrap with gauze wrap daily and as needed for soilage/dislodgement until healed (1/2/26). A quarterly Minimum Data Set (MDS) assessment, dated 10/10/25, indicated the resident was severely cognitively impaired. She had no behaviors during the assessment period. She required supervision/touching staff assistance for ambulation. She required set up and cueing for upper and lower body dressing. She was dependent on staff assistance for putting on/taking off footwear. A current care plan, initiated on 5/12/25, for wounds indicated that the resident was admitted with wounds that were potentially related to peripheral vascular disease with recurring areas to both lower extremities. Open areas to both lower extremities were nonhealing. Resident 64 frequently removed treatments after they were applied, declined lower extremity elevation, and family declined intervention for vascular insufficiency and chose to opt for comfort care. Interventions included administer treatment as ordered (5/12/25). A current care plan was initiated on 12/30/25 for a denuded (top layer of skin is gone) blister to left foot second toe. Interventions included treatment as ordered (12/30/25). A current care plan for edema, initiated on 1/23/25, indicated the resident had edema to her lower extremities with a potential for weight fluctuations. Both her lower extremities had breaks in the skin and were seeping. She removed the treatments from her lower extremities due to her preference for comfort. Interventions included administer treatment to right shin as ordered and encourage resident to leave dressing on. Staff had noted she removed the dressings (6/14/25). A current care plan for falls, initiated 1/23/25, indicated the resident was at risk for falls due to her condition and risk factors of unsteadiness, impaired mobility, diagnosis of dementia, chronic pain in both lower extremities, fluctuations in shuffling gait. Resident refused to apply nonslip socks and slippers at times. Interventions included encourage and assist with wearing non-skid footwear (3/31/25) and encourage the use of slippers (9/17/25). During an observation, on 12/31/25 at 11:23 a.m., Resident 64 shuffled, using a two-wheel walker, down the hall, then sat in a chair. Her legs and feet were swollen. She wore nonskid socks. During an observation, on 1/2/26 at 9:38 a.m., CNA 3 walked by Resident 64 as the resident shuffled, barefoot, using a two-wheel walker, down the hall on the unit. Her left pant leg was pulled up to her left knee. Three wounds with a small amount of serosanguineous (watery, bloody) drainage were open to air. The top wound had a line of serosanguineous drainage trailing down her leg about length of the diameter of a soup can. She had an open area to her left third toe near the foot. The end of the left foot third toe around toenail was swollen with a greenish tinge. The area had a wet appearance. During an observation, on 1/2/26 at 9:53 a.m., QMA 4 walked by Resident 64 as Resident 64 shuffled, barefoot, using a two-wheel walker, down the hall on the unit. Resident 64 entered Resident 70's room. She shuffled around the room and came back out. Her left pant leg remained pulled up, with draining wounds on her left leg and left foot third toe exposed. During an observation, on 1/2/26 at 10:15 a.m., the Wound Nurse assisted the resident to sit on the edge of the bed. The wounds continued to be visible, open, and draining a small amount of serosanguineous fluid with a line trailing from the top open area down her leg. During a wound care observation, on 1/2/26 at 10:19 a.m., the three wounds to the resident's left leg were cleansed and Xeroform, calcium alginate, and a bordered silicone dressing was applied by the Wound Nurse. She indicated, at the same time, the wounds were draining. The soles of the resident's feet were dirty and darkly soiled. The Wound Nurse put a nonskid sock on the resident's dirty right foot. She cleaned the resident's left foot, then cleansed the left third toe. The area to the left third toe had a darkened brown/black area at base of the toe. The area surrounding the nailbed and down the toe, about length of the diameter of a triple A battery, was swollen with a greenish color. The back of the toe had a darkened center with pale skin surrounding it. The area was draining a scant amount of yellowish drainage. The Wound Nurse applied Xeroform, calcium alginate, and a bordered silicone dressing to the toe. She put a clean nonskid sock on the resident's left foot. She indicated, at the same time, she should have washed the resident's left foot prior to putting on the nonskid sock. The resident often removed her wound dressings. The resident should not walk around the unit with the wounds draining without the wounds being covered. During an interview, on 1/2/25 at 3:36 p.m., QMA 4 indicated if a resident was walking around barefoot, she would make sure the resident was assisted to put on nonskid footwear. When a resident had open, draining wounds on legs and feet, she would make sure their legs and feet were wrapped or covered. During an observation, on 1/2/25 at 3:45 p.m., Resident 64 was lying on Resident 70's bed with nonskid socks on her feet. During an interview, on 1/2/25 at 3:54 p.m., QMA 5 indicated residents should wear proper footwear, and she would assist them as needed to put on their footwear. If a resident was walking around with draining wounds, she would notify the nurse immediately for proper treatment. The Nurses Notes in the resident's clinical record lacked documentation of the resident removing her dressings to her legs or her footwear on 1/2/25. During an interview, on 1/5/25 at 9:45 a.m., the DON indicated the ultimate goal would be for Resident 64 to have a dressing on her wounds, but the resident did at times remove them. If the dressings were removed, then the staff should redirect the resident away from other residents, and some sort of barrier should be attempted to be placed on the draining wounds. According to the Centers for Disease Control and Prevention (CDC) website, accessed on 1/6/25 at https://www.cdc.gov/infection-control/hcp/isolation-precautions/precautions.html#cdc_generic_section_2-iii-a-standard-precautions, .Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. A current facility policy, dated 6/11/25, titled Standard Precautions, provided by the Administrator on 1/5/25 at 10:19 a.m., indicated the following: .Standard Precautions are work practices that provide a basic level of infection control for the care of all patients in health care facilities regardless of their diagnosis or presumed infection status. 1. Standard Precautions (Minimum Precautions) apply to: a. Blood b. All body fluids, secretions and excretions except sweat regardless whether they contain visible blood c. Non-intact skin d. Mucous membranes 2. Standard Precautions are designed to reduce the risk of transmission of micro-organisms from both recognized and un-recognized sources of infection. They include: . b. Use of protective barriers, which may include gloves, gowns, plastic aprons, masks, eye shields or goggles. B1. During an observation, on 12/29/25 at 10:42 a.m., Resident 82 was observed sitting in her wheelchair. Her foley catheter tubing was lying on the floor beneath her wheelchair. During an observation, on 12/31/25 at 10:52 a.m., Resident 82 was observed participating in physical therapy. She sat in her wheelchair with her foley catheter bag underneath her wheelchair in a privacy bag. Half of the privacy bag touched the floor. A therapy staff member started propelling Resident 82 out of the therapy room and down the hallway toward Resident 82's room. The foley catheter bag was still attached to the underside of the resident's wheelchair. The privacy bag was dragging on the floor as Resident 82 was propelled down the hallway. During an observation, on 12/31/25 at 11:17 a.m., Resident 82 sat in her recliner with her legs elevated. Her foley catheter bag was lying on the floor to the right side of her recliner. During an interview, on 12/31/25 at 11:18 a.m., LPN 7 indicated foley catheter bags or tubing should not touch the ground. LPN 7 proceeded to attach Resident 82's foley catheter bag to the resident's walker, which was beside her recliner. On 12/31/25 at 11:23 a.m., CNA 8 indicated she had assisted Resident 82 into her wheelchair. CNA 8 was unable to attach the foley catheter bag to Resident 82's recliner, so she placed the foley catheter bag between the recliner and leg rest. Resident 82's clinical record was reviewed on 12/31/25 at 2:16 p.m. Diagnoses included right femur fracture and history of falls. Current orders included catheter care every shift and ensure catheter drainage bag is below the waist and covered, change as needed for leakage or dislodgement, change catheter drainage bag at the time of catheter change and enhanced barrier precautions during high contact resident care. A current care plan, initiated 12/24/25, indicated Resident 82's catheter would be maintained per plan of care daily and she would remain free from catheter related complications daily such as leakage or infection. Interventions included catheter care every shift and provide measures to prevent excessive pulling/ tension on the catheter tubing. During an interview, on 1/5/26 at 9:43 a.m., the DON indicated the foley catheter bag should be hanging below the resident's bladder. The foley catheter bag, tubing, and privacy bag should not touch the floor. B2. During an observation, on 1/6/26 at 1:01 p.m., Resident 68 was in her room sitting in her wheelchair. Her foley catheter was attached under her wheelchair with the foley catheter tubing lying on the floor. During an interview, on 1/6/26 at 1:03 p.m., RN 10 indicated Resident 68's foley catheter tubing should not touch the floor. RN 10 put on gloves before picking up Resident 68's foley catheter tubing and securing it inside the foley catheter privacy bag that was attached on the underneath side of Resident 68's wheelchair. Resident 68's clinical record was reviewed on 1/6/26 at 1:38 p.m. Diagnoses included urinary tract infections. Current orders included catheter care every shift and ensure catheter drainage bag is below the waist and covered, change as needed for leakage or dislodgement, change catheter drainage bag at the time of catheter change and cefpodoxime proxetil (antibiotic) 200 milligrams twice daily for urinary tract infection. A current care plan, initiated 1/2/26, indicated Resident 68's catheter would be maintained per plan of care daily and she would remain free from catheter related complications daily such as leakage or infection. Interventions included catheter care every shift and provide measures to prevent excessive pulling/ tension on the catheter tubing. A current facility policy, dated 8/30/07, titled Foley Catheter Care and Maintenance, provided by the Administrator, on 1/6/26 at 9:12 a.m., indicated the following: .E. Placement of Catheter Tubing Procedure. C. Ensure bag or tubing is not touching the floor 3.1-18(a)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident to prevent repeated falls for 1 of 3 residents reviewed for accidents. This deficiency resulted in Resident D sustaining multiple fractures to the vertebrae, ribs, and pelvis. Finding includes: During an observation, on 6/2/25 at 9:49 a.m., Resident D lay on his back in his low bed with his eyes closed in his darkened room. A visitor sat in a chair in his room. Resident D's clinical record was reviewed on 6/2/25 at 10:54 a.m. Diagnoses included mild cognitive impairment of uncertain or unknown etiology, unspecified dementia, urinary tract infection, site not specified, bacteriuria, retention of urine, unspecified, and benign prostatic hyperplasia (enlarged prostate) (BPH). Current orders included low bed with floor mat, keep bed in lowest position when in bed every shift (3/22/25), donepezil (for dementia) 5 milligrams (mg) daily at bedtime(3/19/25), sertraline (antidepressant) 25 mg two times a day (4/2/25), tamsulosin (for urinary retention) 0.4 mg two times a day (3/31/25), and oxycodone 5 mg every 6 hours for pain (5/30/25). An admission Minimum Data Set (MDS) assessment, dated 3/25/25, indicated the resident was severely cognitively impaired. He required setup/clean up assistance with eating. He required supervision/touching staff assistance with oral hygiene. He required partial/moderate staff assistance with personal hygiene, rolling left and right in bed, transfers, and ambulation for 10 feet. He required substantial/maximal staff assistance with toileting hygiene, showering/bathing, and upper/lower body dressing. He had an indwelling catheter and was occasionally incontinent of bowels. He had two falls with no injury since admission. A Nursing-Occurrence Initial Assessment, dated 3/18/25 at 10:50 p.m., indicated the resident fell in his bathroom. The staff observed the resident attempting to get out of bed unassisted, attempted to intervene, and had to lower the resident to the floor. The new immediate intervention was to remind the resident to use the call light. A Facility- Post Occurrence IDT (interdisciplinary team) & fall risk assessment, dated 3/20/25 at 1:01 p.m., indicated the root cause for the fall on 3/18/25 was the new environment, confusion with his BPH and urinary retention. He had recently received intravenous antibiotic for bacteriuria that was discontinued prior to admission to the facility. The IDT recommendations included the physician increased the tamsulosin and ordered labs. A care plan intervention initiated on 3/19/25 indicated labs were ordered. A Nursing-Occurrence Initial Assessment, on 3/22/25 at 6:15 a.m. indicated the resident fell in his room. He was found laying on his back on the floor next to the recliner. The resident indicated he did not know how to get a hold of anybody for help. The immediate new intervention was non-skid socks and initiation of 15-minute checks. A Facility-Post Occurrence IDT & fall risk assessment, on 3/24/25 at 8:37 a.m., for the 3/22/25 fall indicated the nursing staff found the resident on the floor on his back next to the recliner. He attempted to self-transfer and fell. The root cause for the fall was the resident's dementia/cognitive impairment. He was being treated for urinary tract infection and had increased confusion. The IDT recommendations included non-skid socks on at bedtime and bed to be in the lowest position with a low-profile mat at bedside. Care plan interventions initiated on 3/22/25 included bed in the lowest position and low profile mat on the floor next to the bed. A Nursing-Occurrence Initial Assessment, on 4/5/25 at 6:15 a.m., indicated the resident was found on the floor in his room sitting on his fall mat with a urinal in his hand. He indicated he wanted to move to the bathroom on his own. The immediate new intervention was initiation of 15-minute checks. A Facility- Post Occurrence IDT & fall risk assessment, on 4/7/25 at 9:58 a.m., for the fall on 4/5/25 at 6:15 a.m., indicated the resident was found on the mat beside his bed, and it was unclear if he fell or sat down on the mat. The root cause was determined to be he had his urinary catheter discontinued on 4/3/25. He continued to have urinary urges. The IDT recommendations included tamsulosin was decreased on 3/31/25 and staff was to toilet resident and assist him to the sit in the recliner in the morning with his urinal within reach. A care plan intervention initiated on 4/7/25 and resolved on 5/29/25 included staff to toilet and sit resident in recliner in the morning as he allowed. A Nursing-Occurrence Initial Assessment, on 4/12/25 at 7:40 a.m., indicated the resident had a fall with injury. He was found on the floor of his room. He indicated he was trying to go to the bathroom. He did not hit his head, but fell on his back and hand. He had two abrasions to his fight finger and bruising to his mid back area. The immediate new intervention was initiation of 15-minute checks. A Facility- Post Occurrence IDT & fall risk assessment, on 4/14/25 at 2:35 p.m., for the fall on 4/12/25 at 7:40 a.m., indicated the resident fell and received two abrasions to his right finger and bruising to his mid-back. The root cause of the fall was the resident attempted to self-transfer to go to the bathroom. The IDT recommendations included staff to assist resident with toileting every two hours while he was awake. A care plan intervention initiated on 4/12/25 indicated assist with toileting every two hours. A Nursing-Occurrence Initial Assessment, on 4/18/25 at 2:15 a.m., indicated the resident was found lying on his right side on the floor in the entrance of his bathroom. He indicated his legs became weak and gave out. The resident's call light was not working at that time. The call light was unplugged, then plugged back in and worked. The immediate new intervention was initiation of 15-minute checks. A Facility- Post Occurrence IDT & fall risk assessment, on 4/18/25 at 10:37 a.m., for the fall on 4/18/25 at 2:15 a.m., indicated the resident attempted to ambulate per self to the bathroom and fell. The root cause of the fall was the resident appeared to have lost his balance and lacked safety awareness to call the staff for assistance. The IDT recommendations included an occupational therapy assessment to determine if the resident needed services to continue due to his decrease in balance and safety with continue falls. The call light was assessed by maintenance. A care plan intervention initiated on 4/18/25 and resolved on 5/29/25 indicated therapy was to determine the need for continued services. A Nursing-Occurrence Initial Assessment, on 4/21/25 at 8:00 p.m., indicated the resident attempted to take himself off the toilet and was found lying on his left side with his head and shoulder against the bathroom door frame. The immediate new intervention was initiation of 15-minute checks. A Facility- Post Occurrence IDT & fall risk assessment, on 4/22/25 at 8:26 a.m., for the fall on 4/21/25 at 8:00 p.m., indicated the resident attempted to self-transfer off the toilet and fell. The root cause of the fall was the resident had dementia/cognitive impairment and poor safety awareness. The IDT recommendations included the staff to assist the resident to the bathroom and not leave him unattended while using the bathroom. A care plan intervention initiated on 4/22/25 indicated staff was to stay with the resident when toileted. A Nursing-Occurrence Initial Assessment, on 5/3/25 at 8:15 p.m., the resident was found laying on mat beside bed with his head toward the dresser. His feet were extended outwards toward the wall. He indicated he was trying to go to bed and forgot he needed help. The immediate new intervention was initiation of 15-minute checks. A Facility- Post Occurrence IDT & fall risk assessment, on 5/5/25 at 8:41 a.m., for the fall on 5/3/25 at 8:15 p.m., indicated the resident fell when he attempted to go to bed without staff assistance. He forgot to ask for help. The root cause was the resident had dementia/cognitive impairment, poor safety awareness, and attempted to transfer without staff assistance. The IDT recommendations included the staff were to offer to help the resident to lay down after dinner. A care plan intervention initiated on 5/5/25 indicated the resident was to follow up with the in-house ophthalmologist. A Nursing-Occurrence Initial Assessment, on 5/9/25 at 10:30 p.m., indicated the resident had fallen and had no injury. He was found on the floor on his left side. An eINTERACT Change in Condition Evaluation, on 5/10/25 at 6:44 a.m., indicated the resident had a change in condition that started during the night on 5/9/25. He had increased confusion, abrupt change and was unable to perform usual activities, needed more assistance with activities of daily living, general weakness, decline in ambulation/mobility abilities, and a decline in his transferring ability. He had pain in his left hip and symptoms worsened. Movement made the pain worse. Nothing made the pain better. The onset of the pain was new. A Progress Note, dated 5/10/25 at 7:35 a.m., indicated the resident was sent to the hospital due to left hip pain. A Nursing-Transfer to Hospital assessment, dated 5/10/25 at 7:43 a.m., indicate the resident was transferred to the hospital on 5/10/25 at 7:00 a.m. The reason for transfer was the resident fell at 10:30 p.m. on 5/9/25. He was complaining of severed pain to his left hip and could not move. A Progress Note, dated 5/10/25 at 12:41 p.m., indicated the resident was admitted to the hospital. The results of a Computed Tomography (CT) scan of the abdomen and pelvis, on 5/10/25 at 10:04 p.m., included the following: acute fractures of the number 9 and 10 thoracic vertebrae, acute fracture of the number 4 lumbar vertebra, acute displaced fractures of the left posterior number 10 and 11 ribs, acute mildly displaced fractures of the left upper and lower pubic rami (pelvis), and a small amount of hemorrhage in the pelvis. A hospital Discharge summary, dated [DATE], indicated the resident had been admitted on [DATE] for multiple fractures. The discharge diagnoses included acute pain, debility, decreased strength, endurance, and mobility, hemothorax on left, multiple fractures of the pelvis with stable disruption of the pelvic ring, and rib fracture. A Nursing-MDS supporting documentation assessment, dated 5/21/25 at 10:56 a.m., indicated the resident required partial/moderate staff assistance with eating and oral hygiene. He required substantial/maximal assistance for upper body dressing and rolling left and right in bed. He was dependent on the staff for toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off footwear. Transfers and ambulation were not attempted due to the resident's medical condition. During an observation, on 6/2/25 at 12:45 p.m., Resident D sat in a recliner with his feet elevated and shaved himself while his resident representative held a mirror. He had a mechanical lift net under him. At the same time, his resident's representative indicated Resident D had been up walking prior to his fall. Since his readmission to the facility, he had been in bed until the last few days. He had experienced increased pain since his fall, but the pain was beginning to lessen. During an observation, on 6/2/25 at 3:18 p.m., the resident rested in a low bed with his eyes closed. His room was darkened. During an interview, on 6/3/25 at 9:35 a.m., CNA 3 indicated the resident was a busy body and all over the place before he fell and went to the hospital. She checked on him often. He did not get out of bed anymore since he had returned from the hospital. The CNA did not know where to find what interventions were utilized to prevent the residents from falling, and she needed to ask her nurse. During an interview, on 6/3/25 at 9:40 a.m., LPN 4 indicated she was not on the nursing unit anytime the resident had fallen. He was very confused when he was first admitted to the facility. He was up and down and wandering everywhere. The staff reminded him constantly to call for assistance. He was confused since he returned from the hospital. She was uncertain if he had gotten up or not since his return from the hospital. During an interview, on 6/3/25 at 9:44 a.m., CNA 5 indicated the resident used gripper socks to prevent falls. He had changed rooms so he could more easily see the bathroom and get to it easier. The facility had a list that told the residents' limitations, but she did not know if it included the residents' fall interventions. She knew what the residents' regular behaviors were and would use interventions based on those. During an interview, on 6/3/25 at 9:47 a.m., the ADON indicated the residents' fall interventions were listed in the electronic medical record and could be accessed by the CNAs and the nurses. The CNA sheets were updated when new interventions were added. The new interventions were communicated verbally as well. The resident had a few falls prior to his fall which resulted in fractures and a hospital stay. During an interview, on 6/3/25 at 11:34 a.m., CNA 7 indicated she had worked at the facility for quite some time and knew what the residents needed. She communicated those needs to new staff that came on the unit. She was uncertain if the fall interventions were listed on the CNA sheet. Safety check lists with 15-minute checks, provided by the DON on 6/3/25 at 11:01 a.m., were reviewed. One safety checklist began on 3/18/25 at 10:45 p.m. and ended on 3/20/25 at 2:00 p.m. (a total of 39.25 hours). Another safety checklist began on 4/18/25 at 2:15 a.m. and ended on 4/19/25 at 6:45 a.m. (a total of 28.5 hours). One more safety checklist began on 4/21/25 at 8:00 p.m. and ended on 4/23/25 at 7:00 p.m. (a total of 47 hours). During an interview, on 6/3/25 at 12:17 p.m., RN 8 indicated the 15-minute checks done after a fall were done for 9 shifts like the neurological checks were done. During an interview, on 6/3/25 at 12:24 p.m., LPN 9 indicated the 15-minute checks done after a fall were done for 72 hours. During an interview, on 6/3/25 at 12:51 p.m., the DON indicated the resident fell a lot. His catheter had been removed, and he still seemed to have some urinary retention. He continued to try to get up and go to the bathroom. Since he came back from the hospital, he no longer tried to get up. She thought he had multiple falls prior to coming to the facility but was uncertain. When residents who had a history of falling were toileted, she did not expect the staff to leave them in the bathroom unattended. She worked the night shift after the resident fell. He had slept through the night when he woke up he was in severe pain and was unable to move. A current facility policy, provided by the Administrator on 6/3/25 at 1:13 p.m., titled Fall Management Procedure, indicated the following: .To assess all resident for risk factors that may contribute to falling and to provide planned interventions to help prevent falls as identified by the team and based upon root cause analysis to prevent reoccurrence This citation relates to Complaint IN00459383. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was served under sanitary methods regarding food handling, hand washing, and glove use. This deficient practice had the potential to impact 73 of 73 residents who received meals in the facility. Findings include: 1. A completed Roster Matrix form, provided by the facility on 10/30/24 following the entrance conference, indicated the facility had no residents who received nutrition by any alternate means other than oral eating. During a lunch meal service observation on 11/4/23 from 11:40 a.m. to 12:03 p.m., the following concerns regarding sanitary food preparation and distribution were made: Cook 5 wore gloves. She touched the outside of meal trays, thermal plate bases, heated tray pallets, bread bags, bread rolls, and cheese with her gloved hands. She did not change her gloved hands as she touched the various items. She used her solid gloved hands to open the bread rolls and placed cheese slices inside the roll. Using the same gloved hands, she handed the prepped roll to [NAME] 4, who took the roll with her gloved hands. [NAME] 5 did not change her gloves during this process. Cook 4 received prepared bread rolls and cheese with her gloved hands. She used her gloved hands and touched meal tickets, trays, plates, thermal bases. thermal lids, heated pallets, countertops, bread bags, bread rolls, and cheese. At no time during the meal service did she change her soiled gloves. Cook 5 left the kitchen wearing her soiled gloves. As she returned to the kitchen, she touched the door and the door knob. She was no longer wearing gloves. She took gloves from the glove box and placed said gloves on her hands. She did not wash her hands prior to applying the gloves. 2. During a dining observation of the memory care unit, on 11/4/24 at 12:00 p.m., residents were being served Philly cheese steak sandwiches on buns. At approximately 12:11 p.m., CNA 4 was observed taking trays from the food cart and delivering them to residents already seated at dining tables. The CNA delivered three trays to various residents. For each of the three residents, the CNA was observed to uncover their plates, offer ketchup to each, then proceeded to open the ketchup packets and squeeze the contents onto each resident's sandwich. The next resident to be served asked the CNA to cut the sandwich. The CNA proceeded to place her bare left hand on the bun, gripped it to secure it, and then used the resident's knife to cut the sandwich into halves. The CNA did not complete hand hygiene during the observation. During an interview on 11/4/24 at 12:03 p.m., the Dietary Manager indicated food should not be touched with gloved hands and hands should be washed before gloves were applied. A current, 10/6/15, policy titled Dietary Manual: Subject: Hand Washing, provided by the Administrator on 11/7/24 at 10:50 a.m., indicated the following .It is policy that all dietary employees know and understand when hand washing is required and how to properly wash their hands .F) After handling soiled surfaces, equipment or utensils .G) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks A current 9/9/15, facility policy titled, Dietary Manual: Subject: Glove Policy, provided by the Administrator on 11/7/24 at 10:50 a.m., indicated the following: .It is the policy that gloves use will be limited use glove and will be used for only one task. Hands will be properly washed before and after glove use .Procedure: 1) a. Whenever possible use utensils such as tongs, spoons and spatula instead of gloves to avoid getting the false sense of security with the gloves and over using gloves 4) d. If using gloves, hands must be properly washed before and after glove use .When making bread and butter and a new loaf needs to be opened, gloves must be removed, hands properly washed. Open new loaf of bread, then properly wash hands and don a new pair of gloves. 3.1-21(i)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter was handled in a manner to support the resident's dignity when the drainage bag was left in the view of sight of others within the facility. (Resident 68) Findings include: During an observation on 11/1/24 at 10:11 a.m., Resident 68's was in bed, with the catheter bag hanging on the right side of the bed frame. The bag was exposed and urine could be seen in the bag. During an observation on 11/6/24 at 9:47 a.m., the resident was in bed, with the urinary catheter bag hanging on the right side of the bed frame. The bag was exposed and urine could be seen in the bag. Resident 68's clinical record was reviewed on 11/6/24 at 10:50 a.m. Physician orders, dated 5/15/24, indicated catheter care should be performed every shift. The catheter drainage bag was to be below the waist and covered every shift. During a catheter care observation on 11/7/24 at 10:16 a.m., RN 3 indicated there was a device on the left side of the resident's bed, on the railing, which contained the catheter bag and served as a covering for the bag. The left side of the bed was against the wall. The RN was not sure why a similar device was not in place on the right side of the bed. The right side of the bed was visible to the rest of the room and from the hallway. A current facility policy, titled Foley Catheter Care & Maintenance, provided by the Administrator on 11/7/24 at 10:40 a.m., indicated the following: Placement of Catheter Tubing Procedure: 1) When in bed or wheel chair .b)Place in a catheter cover bag underneath wheelchair or on side of bed During an interview with the Infection Preventionist on 11/7/24 at 11:18 a.m., they indicated all catheter bags should be placed in dignity bags when residents are both in or out of their room(s). 3.1-3(a)

Based on observation, interview, and record review, the facility failed to serve a therapeutic pureed diet as ordered by a physician for 2 of 2 residents reviewed who received pureed diets ( Residents 42 and 43). Findings include: During a lunch meal observation on 11/4/24 from 11:20 a.m. to 11:47 a.m., a regular gelatin dessert with whipped topping was served to Residents 42 and 43. The gelatin was cubed in shape and topped with whipped cream. The cubes were solid pieces of gelatin. Both Residents 42 and 43 consumed a portion of the regular gelatin. During an observation on 11/4/24 at 11:50 a.m., Resident 43's meal ticket indicated gravy to meat and potatoes. Resident 43's meat and potatoes contained no gravy, nor was there gravy provided for a staff member to use for topping the food. A current facility lunch meal, portion size and texture serving guide (also known as a spread sheet), dated 11/4/24 and provided by the Administrator on 11/7/24 at 10:50 a.m., indicated residents who had pureed diet orders were menued to receive a 1/2 (#8 scoop) of pureed gelatin topped with whipped topping. The current facility recipe for pureed diet gelatin, dated 11/4/24 and provided by the Dietary Manager on 11/4/24 at 12:03 p.m., indicated cubed gelatin was to be placed in a blender or food processor and blended until smooth, then topped with whipped topping. The recipe for gelatin contained a standard package of gelatin and hot water. During an interview on 1/4/24 at 11:51 a.m., QMA 6 indicated she was not aware of Resident 43's menu card directing the use of gravy on meat and potatoes. During an interview, 11/04/24 at 12:06 p.m., QMA 6 indicated the dietary department never provided gravy. During the meal, the resident had eaten both items without gravy. During an interview on 11/4/24 at 12:04 p.m., the Dietary Manager indicated she had not realized the gelatin was menued to be pureed prior to service. 1. Resident 42's clinical record was reviewed on 11/04/24 at 2:18 p.m. Current diagnoses included vascular dementia, anxiety, and dysphasia- oropharyngeal phase. The resident had a current order for a pureed diet, dated 7/9/24. The resident had a current care plan problem/need regarding, nutritional risk due to related to a therapeutic diet, mechanically altered diet, a diagnosis of dysphasia, and a history of weight loss. This care plan problem originated 1/19/24. An approach to this problem was to serve a diet as ordered, dated 1/31/20. The resident's most recent speech therapy note for services from the period of 7/3/24 to 7/15/24 indicated the resident required a pureed diet due to a diagnosis of dysphasia. 2. Resident 43's clinical record was reviewed on 11/04/24 at 3:20 p.m. Current diagnoses included dementia, depression, and anxiety. The resident had a current order for a pureed diet served with extra butter, sauce, gravy for potatoes and meats, dated 1/15/24. The resident had a current care plan problem/need regarding, nutritional risk related to: mechanically altered diet, end stage illness/condition, and on hospice care, dated 2019. An approach to this problem/need was diet is served as ordered. The resident's most recent speech therapy note for services from the period of 1/15/24 to 1/29/24 indicated the resident required a pureed diet due to a diagnosis of dysphasia. The resident received treatment due to pneumonia related to inhalation of food and vomiting. A current, 11/23/2011, policy titled, Dietary Manual- Subject -Food Production Services, provided by the Administrator on 11/7/24 at 10:50 a.m., indicated the following: 2. Food is chopped, cut, ground and pureed to meet individual resident needs. Procedures to alter food texture are listed on the recipes .4. Food is served by following the therapeutic diet spreadsheets and is portioned by weighing and by using the correct serving utensils . A current, undated, facility policy titled, Diets Available In This Facility,provided by the Administrator on 11/7/24 at 10:50 a.m., indicated the following: Pureed, Regular diet with food pureed to a smooth pudding-like consistency. For those who have considerable problems chewing or swallowing . 3.1-21(b)

A. Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed according to facility policy and physician orders during wound care for 1 of 1 residents reviewed for wounds. (Resident 23) B. Based on observation and interview, the facility failed to ensure staff administered medications in a sanitary manner for 1 of 2 residents observed for medication administration. (Resident 20) Findings include: A. Resident 23's clinical record was reviewed on 11/6/24 at 3:02 p.m. Diagnoses included acute diastolic (congestive) heart failure, (other) abnormalities of gait and mobility, Type 2 diabetes mellitus with diabetic neuropathy, morbid (severe) obesity due to excess calories, unspecified fracture of left femur, and difficulty in walking. Current physician orders included (9/9/24) apply povidone iodine to left heel every shift for wound care, (6/7/24) skin protectant to right heel for skin protection, and (6/4/24) EBP during high-contact resident care. A current care plan, dated 6/4/24, indicated the resident required EBP during high-contact care due to antibiotic resistant bacteria in their urine and current wounds. Personal protective equipment (PPE) was to be accessible for use. A sign was to be placed on the door of the resident's room to communicate EBP to staff and visitors. During a review of progress notes on 11/7/24 at 9:36 a.m., a note from 11/4/24 at 11:01 am. indicated the pressure injury had a length of 1.0 centimeter (cm) and a width of 1.5 cm. During an observation on 11/7/24 at 10:05 a.m., RN 3 performed wound care to the left heel for Resident 23. Supplies were brought into the room and the nurse performed hand hygiene, donned gloves, and cleaned the pressure area with soap and water, dried the area, and applied povidone iodine (a topical antiseptic to prevent infections) to the left heel wound. The wound was approximately the size of a quarter and dark red in appearance. The nurse replaced the resident's sheet and blanket and disposed of used supplies at that time. During an interview with RN 3 on 11/7/24 at 10:35 a.m., she indicated a gown was not required for wound care. She was aware of the EBP ordered for the resident. Gowns were required only when performing peri-care (care of the genital area). A current facility policy, dated 4/6/24, titled Enhanced Precautions for Novel and Targeted MDRO's (multidrug resistant organisms) and provided by the Infection Preventionist on 11/7/24 at 10:10 a.m., indicated the following: Policy - To prevent the spread of multidrug resistant organisms (MDRO's) from one resident to another resident via health care workers hands and clothing and to protect vulnerable residents. The use of EBP is intended to interrupt the spread of novel or targeted MDRO's . EBP is targeted use of gown and glove use during high contact resident care activities for residents with wounds and indwelling devices .Procedure - Residents with wounds or indwelling devices and residents infected or colonized with an MDRO will be cared for by staff using a gown and gloves during high contact resident care .Examples of high contact resident care include, but are not limited to .8) performing wound care (caring for an opening in the skin .that is long lasting or chronic in nature such as pressure ulcers, diabetic wounds, non-healing surgical wounds, and chronic vascular ulcers During an interview with the Infection Preventionist on 11/7/24 at 11:28 a.m., the IP indicated wound care required PPE including gloves and gowns for wound care. In the case of Resident 23, the staff should gown and glove during wound care on the left heel. B. During a medication administration observation, on 11/6/24 at 9:22 a.m., Qualified Medication Aide (QMA) 7 prepared and administered oral medications for Resident 20. She then administered lubricant eye drops in each eye by using her bare left hand to lift each eye lid. The QMA did not perform hand hygiene, nor don gloves, before administering the eye drops. During an interview, on 11/6/24 at 9:42 a.m., QMA 7 indicated it was not her practice to don gloves prior to administering eye drops and was unsure if there was a facility policy pertaining to eye drop administration. A current facility policy, titled Eye Drops and Eye Ointment Procedure, provided by the Administrator on 11/6/24 at 11:16 a.m., indicated 16) Perform hand hygiene and put on gloves During an interview at the same time the policy was provided, the Administrator indicated it was the expectation of the facility that QMA 7 should be aware of this policy. 3.1-18(l)

Based on record review and interview, the facility failed to ensure pneumococcal vaccination (to protect against the bacterium Streptococcus pneumoniae) was offered or administered for 3 of 5 residents reviewed for immunizations. (Residents 32, 53, and 14) Findings include: 1. Resident 32's clinical record was reviewed on 11/4/24 at 11:40 a.m. Diagnoses included left-side non-dominant hemiplegia and hemiparesis following cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus. The resident admitted in 2020. Resident 32's immunization record indicated an undated refusal for the pneumococcal 13-valent conjugate vaccine (PCV 13) and pneumococcal polysaccharide vaccine (PPSV 23). A Pneumococcal/Prevnar 13 Vaccine Consent form, provided by the Infection Preventionist on 11/7/24 at 11:09 a.m., indicated the resident had refused the above vaccines on 2/28/20. During an interview, on 11/7/24 at 11:09 a.m., the Infection Preventionist indicated she discussed the importance of vaccines during care plan meetings, but was not able to provide additional documentation for consent or refusal following 2020, including in 2024. 2. Resident 53's clinical record was reviewed on 11/4/24 at 2:17 p.m. Diagnoses included orthopedic aftercare following surgical amputation, heart failure, and diabetes mellitus due to the underlying condition of hyperglycemia. The admitted was 4/19/24. Resident 53's immunization record indicated an undated refusal for the Pneumococcal 20-valent conjugate vaccine (Prevnar 20) and a entry marked as pending for the Prevnar 20 vaccination. A Pneumococcal Vaccine Consent form, provided by the Infection Preventionist on 11/7/24 at 11:09 a.m., indicated the resident wished to receive the recommended pneumococcal vaccine based upon vaccination history. During an interview, on 11/7/24 at 11:09 a.m., the Infection Preventionist indicated she was not able to explain the marked refusal or confirm if the resident had received the appropriate vaccination. 3. Resident 14's clinical record was reviewed on 11/6/24 at 11:47 a.m. Diagnoses included Alzheimer's Disease, COPD, and generalized anxiety disorder. The resident admitted in 2019. Resident 14's immunization record indicated an undated refusal for the PCV 13 vaccination. A Pneumococcal/Prevnar 13 Vaccine Consent form, provided by the Infection Preventionist on 11/7/24 at 11:09 a.m., indicated the resident had refused the PCV 13 on 3/25/19. During an interview, on 11/7/24 at 11:09 a.m., the Infection Preventionist indicated she discussed the importance of vaccines during care plan meetings, but was not able to provide additional documentation for consents or refusals in the years following 2019, including 2024. During a follow-up interview, on 11/7/24 at 12:10 p.m., the Infection Preventionist indicated she contacted residents and families yearly, starting in August, to discuss the current flu vaccinations and pneumococcal vaccines for each resident. She verified the residents' vaccinations in the clinical record and on the Children and [NAME] Immunization Registry Program (CHIRP). The pharmacy and physician determined the appropriate vaccination for each resident. The IP utilized the consent form, which had an option to decline the vaccine. The consent forms were uploaded to the medical record as soon as possible. A current facility policy, dated 7/6/15, titled Influenza and Pneumococcal Immunization Program, and provided by the Administrator on 10/30/24 following the entrance conference, indicated the following: .It is the policy of Miller's Health Systems to administer annual Influenza and Pneumococcal vaccines, as recommended by APIC and the CDC, to all residents residing in the facility . The facility will administer immunizations in accordance with recommendations established by the Centers of Disease Control and Prevention in effect at the time the immunizations are administered . A current facility policy, dated 10/11/22, titled Pneumococcal Disease Immunization Procedure, and provided by the Infection Preventionist on 11/7/24 at 2:17 p.m., indicated the following: .Pneumococcal vaccines PPSV 23 (Pneumococcal Polysaccharide vaccine) and PCV 15 and PCV 20 (Pneumococcal conjugate vaccines) will be offered, encouraged, and provided to all residents residing in the facility. The vaccine will be administered according to the Center for Disease Control and Prevention recommendations . 3.1-13(a)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner regarding dating and labeling foods, and failed to ensure the kitchen and equipment was maintained in a sanitary manner. This deficient practice had the potential to impact 66 residents who received meals prepared in the kitchen of 67 in the facility. Findings include: During a kitchen tour, accompanied by Dietary Aide 8, on 5/9/24 at 8:56 a.m., the following was observed: a. The walk-in refrigerator had undated and unlabeled foods as follows: a piece of meat in a tin pan, identified by the Dietary Aide as Salisbury steak, eight dessert cups contained honey dew melon, a dessert cup with a sliced tomato and sliced onion, a clear container with a green lid that contained a tan colored liquid identified by the Dietary Aide as chicken noodle soup, three foam cups contained sliced onion, sliced pickle and sliced tomato in each cup, four dessert cups contained mixed fruit, one dessert cup contained a brown and white substance identified by the Dietary Aide as chocolate pudding with whipped cream, a large tin pan contained bacon, three carafes of a red liquid identified by the Dietary Aide as cranberry juice, three pitchers of another red liquid identified by the Dietary Aide as fruit punch, three pitchers of yellow liquid identified by the Dietary Aide as lemonade, and three pitchers of a dark purple liquid identified by the Dietary Aide as grape juice. b. Near the stove, a serving tray on the bottom shelf of a wheeled cart contained 25 upside-down sugar condiment holders splattered with a brown and orange substance and with dark and light brown food crumbs. Dietary Aide 8 indicated the carts were for clean dishes, pans, and mixing bowls. [NAME] 5 approached the cart and indicated the dishes were dirty and removed them. The shelving unit to the left contained mixing bowls right-side up, with a dried brown liquid inside of them, a right-side up muffin pan with crumbs in it, two face-down medium sized steam table lids, and two face-up small steam table lids with brown food crumbs on them. c. The top of trash can lid, located under a non-operating sink, was labeled Coffee grounds only! When the lid was lifted, multiple small flies flew from inside of the trash can. Dietary Aide 8 indicated there were a lot of flies that had flown from the trash can and it needed to be emptied. d. Against the front of the cart warmer, a trash container with clean plates inside had a black substance across the entire lid. A gray substance had dripped down both sides of the trash can. A red/orange substance the size of a quarter was splattered on the left side of the trash can. In the grooves of the foot pedal to the trash can was brown debris and food crumbs. e. Under the prep table, was a large bin of bulk oatmeal. The container was not labeled or dated. Dietary Aide 8 indicated if the food was not in the original package, it should be labeled and dated. f. The back splash to the gas stove had black/brown substance splattered on it. Four of the six burners had a thick black burnt residue, and two of the six burners had brown food debris and brown food crumbs around them. The foil tray located under the burners had thick brown/ black burnt food residue with dark brown and light brown food crumbs scattered over the foil. Some of the food crumbs were identified by Dietary Aide 8 as potato pearls. [NAME] 5 approached the stove and removed the old foil. The tray under the foil had brown/black build up with light brown and dark brown potato pearls and crumbs scattered across the entire foil tray. [NAME] 5 indicated they were supposed to clean the foil tray every two to three days. g. The trash can under the prep table had a brown substance on it. Dietary Aide 8 indicated it was sticky and greasy. h. The nozzles to the coffee machine (where the coffee basket attached to the coffee maker) was splattered with a black substance. Dietary Aide 8 ran a finger across the nozzle, resulting in a thick black substance being removed. She indicated she was not sure when they were cleaned last. The following was observed in the dry storage room: a. An unlabeled and undated clear container contained a brown substance, identified by Dietary Aide 8 as brown sugar. b. A clear container, labeled with a use-by date of 11/30/22, contained a white substance identified by Dietary Aide 8 as white sugar. c. A white container with a clear lid contained a white powered substance identified by Dietary Aide 8 as powdered sugar had three black/gray specks in it. Dietary Aide 8 indicated the powdered sugar had not been used in a long time. She wasn't sure what the three black specks were. d. Located second from the top shelf were clear containers with powdered drinks packaged in aluminum type foil with no expiration dates on them. On the container with four grape drink packages was a sticker with the prepared date of 10/19/23, a container with 12 orange drink packages was a sticker with the prepared date crossed out and the use by date was 2/8/24, a container with six lemonade drink packages the prepared date was crossed out and the use by date was 4/5/24. a container with four prune drink packages, the prepared date was crossed out and the use by date was 1/6/24. Dietary Aide 8 indicated the packages did not have an expiration date on them. Staff refilled the containers and that was not the true use by date. e. There was scattered brown, black, and white debris on the entire floor of the kitchen from the dry storage room, between the prep area and stove, to the steam tables. There was a thick black grime built up under the wheels of the carts near the stove. Dietary Aide 8 provided two schedules for the month of May 2024 and the following areas were to be cleaned on a daily basis and included the following: label and date, garbage can lids, stove, sweep and mop. One of the schedules indicated the last time the items were cleaned was 5/5/24. The following was observed in the service area, between the kitchen and the dining room: a. A white substance was splattered across three of the four doors of the cabinets, from the countertop ice bath cooler, across the cereal cabinet doors to the cabinet door where linens were stored. In the cereal cabinet there were bran flakes, corn flakes, and cheerios scattered across the bottom of the cabinet. Dietary Aide 8 scratched the white substance with her fingernail and indicated she was not sure what the substance was. b. A clear container with a white powder, half covered with plastic wrap, identified by Dietary Aide 8 as thickener for liquids was not labeled or dated. c. A clear container with a brown powder identified by Dietary Aide 8 as hot chocolate was not labeled or dated. d. Under the freeze bar, there was an open concept cabinet containing a clear bag with a brown substance covering the entire bag and the bottom of the cabinet. As Dietary Aide 8 removed the bag from the bottom of the cabinet, it stuck. When it was removed, the Dietary Aide indicated there was a cleaning sponge inside the bag. e. An open concept rack built into the cabinet contained clean glasses in the racks. On the bottom of the cabinet was the top of a rodent trap turned on its side and exposed two metal flip rodent traps. There was brown debris scattered on the bottom of the cabinet and a broken piece of glass the size of a golf ball. During a tour of the kitchenette on the memory care unit, accompanied by Dietary Aide 8, on 5/9/24 at 10:16 a.m., the following was observed: a. Dietary Aide 8 opened the refrigerator door, and at the bottom of the door the seal to the door was in two pieces and both hung from the bottom of the door. Below the condiment shelf on the door a red substance was splashed and had dripped down the door. On the back wall of the inside of the refrigerator, a red substance was splashed and had dripped down the wall. On shelf just above the drawers at the bottom of the refrigerator was a red substance and at the bottom of refrigerator and on the floor near the left corner of the refrigerator was red liquid above the bottom drawers, on the shelf and red substance had ran down from the bottom of the door shelf. During an interview with the Dietary Manager, on 5/9/24 at 12:13 p.m., she indicated she was previously the Activity Director and was now the Dietary Manager, but was still doing a little bit of both jobs. She also had concerns about the cleanliness of the kitchen. Generally, when the food came off the truck it was automatically labeled and dated. Staffing had been a little rocky and they had hired a couple of people. They were working on retraining staff. There was a cleaning schedule for the dish room and as far as the kitchen went, the staff were to clean as they went. Sweeping and mopping were completed twice daily after lunch and after supper. The stove should be cleaned daily. During a follow-up visit to the kitchen, on 5/9/24 at 3:33 p.m., [NAME] 9 was visible from the serving window and did not have a hair net on. [NAME] 9 was standing between the prep table and the steam table. There was a pan of green beans on the stove. [NAME] 3 indicated [NAME] 9 had been at a meeting all day and was just dropping something off and normally wore a hair net in the kitchen. [NAME] 3 had her hair in a messy bun and no hair net was observed on her head. [NAME] 3 indicated her hair net was probably tangled up in her bun. She was the cook for the night, and there were only two dietary aides. It was difficult with two aides. They did not give second shift a dishwasher aide, and between the two of them, they had to cook, serve, clean, and do dishes after supper. [NAME] 3 tried to mop, take out trash, wipe the counters and make sure items were labeled and dated. During an interview with the former DON, Dietary Manager, and Administrator, on 5/9/24 at 4:30 p.m., the former DON indicated there was one resident who did not eat from the kitchen out of the 67 residents who were in the facility. During an interview with [NAME] 9, on 5/9/24 at 4:15 p.m., she indicated the kitchen was a mess. The facility tried to educate staff and they didn't listen. There had been a big turnover in the kitchen, and they had hired new staff. A current facility policy, titled Food Protection and Storage, provided by the Administrator on 5/9/24 at 10:48 a.m., indicated the following: .It is the policy of Miller's Health Systems, Inc. that all food shall be stored and protected under safe and sanitary conditions .Procedure .A. The Dietary Manager will check the food storage for: I. Clean floors and walls .IV. Clean and rust-free shelves with items organized .VII. Open boxes, containers of food are securely enclosed, labeled and dated .X. Food not in original containers are clearly labeled for contents, dated, and stored in food rated containers with tight fitting lids A current facility policy, titled Dietary Sanitation, provided by the Administrator, on 5/9/24 at 10:48 a.m., indicated the following: .Procedure: The Dietary Manager will modify cleaning procedures to meet cleaning methods and routines This citation relates to Complaint IN00433993. 3.1-21(i)(3)

Based on observation, interview, and record review the facility failed to implement individualized interventions to prevent the worsening of a pressure injury. (Resident 63) Finding includes: During an observation, on 1/25/24 at 9:15 a.m., Resident 63 was sitting on the edge of his bed looking at items on his bedside table. During an observation, on 1/26/24 at 10:24 a.m., the resident was lying on his back in bed with his eyes closed. During an observation, on 1/26/23 at 4:08 p.m., the resident was sitting in his wheelchair in his room. During an observation, on 1/29/24 at 11:30 a.m., the resident was sitting on the edge of his bed feeding himself lunch. Resident 63's clinical record was reviewed on 1/26/24 at 3:36 p.m. His diagnoses included depression, generalized anxiety disorder, metabolic encephalopathy, combined systolic and diastolic congestive heart failure, end stage renal disease, dependence on renal dialysis, fracture of the neck of the left femur, and polyneuropathy. His current physician orders included protein supplement two times a day (dated 1/16/24) and wash left buttock, pat dry, apply liquid barrier film and collagen to wound bed, cover with a silver containing foam dressing, change every three days and as needed for soilage or dislodgement one time a day for wound care (dated 1/17/24). The order recapitulation lacked orders for treatment to the wound on the left buttock prior to 1/17/24. The admission Minimum Data Set (MDS) assessment, dated 1/15/23, indicated the resident was severely cognitively impaired. He required substantial/maximal assistance with lower body dressing and with moving from a sitting to a standing position. He required partial/moderate assistance to move from lying on the bed to sitting on the edge of the bed and to move from sitting on the edge of the bed to lying on the bed. He was frequently incontinent of bladder and occasionally incontinent of bowels. He was at risk for developing a pressure injury. He had a stage 2 pressure injury on admission to the facility. He did not receive pressure injury care. He did not receive applications of ointments/medications other than to feet. A current wound care plan, initiated 1/9/24, indicated he was admitted with a wound that was potentially related to pressure, a pressure injury to left buttock. Risk factors included: debility, admitted with area, end stage renal disease requiring hemodialysis, congestive heart failure, history of smoking, coronary artery disease and low albumin. Interventions included administer protein supplement twice a day (1/25/24), administer treatment as ordered (1/9/24), assist with turning and repositioning as needed every two hours for pressure relief, and pressure relieving mattress. A current skin risk care plan, initiated 1/9/24, indicated the resident was at risk for skin breakdown. He had impaired mobility, frequent urine incontinence of small amounts, occasional bowel incontinence, history of smoking, end stage renal disease requiring hemodialysis, coronary artery disease, hypertension, and congestive heart failure. His interventions included assist to toilet &/or change frequently (1/25/24), monitor skin daily during care (1/9/24), provide a pressure reducing device to chair (1/25/24), provide a pressure reducing device to bed (1/9/24), and skin assessment at least weekly by the nurse (1/9/24). The nursing admission assessment, dated 1/8/24 at 11:37 p.m., indicated the resident admitted with a wound potentially related to pressure, described as two areas of excoriation to his left buttock. The measurement of the first area was 2 centimeters (cm) length (L) by 1 cm width (W). The measurement of the second area was 1 cm (L) by 0.3 cm (W). The assessment lacked a depth measurement of each area. A nursing assessment, dated 1/11/24 at 1:17 a.m., indicated the resident had a pressure related wound. A barrier cream was applied to the excoriation to the left buttock. A wound assessment, dated 1/17/24 at 1:54 p.m., indicated the resident had a pressure injury he was admitted with on his left buttock. The area was a stage 2 pressure injury with no change in status. The measurements of the pressure injury were 6.0 cm L by 2.5 cm W by greater than 0.1 cm depth. A progress note, dated 1/19/24 at 2:02 p.m., indicated an addendum to the admission assessment on 1/8/24. The report from the hospital indicated the resident had an abrasion to the left buttock. The facility admitting nurse evaluated the area as excoriation to the left buttock. The wound nurse evaluated the area to the left buttock as a stage 2 pressure injury. A wound assessment, dated 1/23/24 at 3:03 p.m., indicated the resident had a pressure injury he was admitted with on his left buttock. The area was a stage 2 pressure injury and was healing. The measurements of the pressure injury were 4.0 cm L by 2.5 cm W, with no depth. During wound observation, on 1/29/24 at 10:55 a.m., the resident's pressure injury on the left buttock/sacral area was the size of a quarter with less than 0.1 cm depth. At the same time, the Wound Nurse indicated the area had improved significantly. During an interview, on 1/29/24 at 11:45 a.m., the Wound Nurse indicated the resident was admitted with a wound to his buttocks. She was unable to locate orders for treatment to the pressure injury prior to 1/17/24 and indicated she would look into his record further. During an interview on 1/29/24 at 12:23 p.m., the Wound Nurse indicated the resident had received barrier cream to the pressure injury prior to 1/17/24, according to the several of the nursing assessments. Barrier cream did not require an order because it was a standard bedside cream. No treatment orders were initiated prior to 1/17/24. During an interview, on 1/30/24 at 2:45 p.m., CNA 6 indicated the resident could move around some on his own, but he had a lot of limitation because of his weakness. He rolled around in bed and often smeared bowel movement all over himself and the linens. Sometimes he had to be completely changed multiple times a shift because of his incontinence. At times, he would not permit the CNAs to change him. She applied barrier cream to his bottom like she did for all of her residents who were incontinent. During an interview, on 1/30/24 at 3:47 p.m., the ADON indicated the resident had a recent fracture and needed assistance with incontinence care and bed mobility. During an interview, on 1/30/24 at 3:51 p.m., CNA 7 indicated the resident was frequently incontinent. He required assistance to the bathroom and incontinence care. She put pillows on each side of him and assisted him to maneuver himself because his hip and bottom hurt. A current facility policy, dated 8/14/14, provided by the DON on 1/30/24 at 4:26 p.m., titled Skin Management Program, indicated .It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers .Interventions will be implemented according to the individual resident's risk factors that will best reduce the risk of development of pressure, diabetic ulcers, arterial or venous ulcers and/or promote the most effective healing of existing areas 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure biologicals requiring refrigeration for Residents 55 and 122 were monitored per CDC guidelines for 2 of 2 refrigerators reviewed for medication/biological storage. Findings include: During an observation of the North 2 nursing unit medication storage room on 1/30/24 at 9:43 a.m., the medication refrigerator was locked. At the same time, the ADON indicated the medication room refrigerator temperature was checked daily and contained medications and vaccines. She did not have a key to the refrigerator. During an observation of the Boulevard nursing unit medication storage room on 1/30/24 at 9:53 a.m., the refrigerator contained a COVID 19 vaccine for Resident 55. At the same time, QMA 4 indicated she did not know what was usually kept in the refrigerator, as she did not pass insulin or typically have refrigerated medications she administered on the unit. The refrigerator temperature was checked daily by night shift. Review of a facility document, titled Med Room Refrigerator Temperature Settings, provided by QMA 4 on 1/30/24 at 9:53 a.m., indicated the Boulevard Hall refrigerator had been checked daily. The log lacked a second temperature check for each day. During an observation of the North 2 nursing unit medication storage room on 1/30/24 at 1/30/24 at 10:41 a.m., the refrigerator contained an influenza vaccine and a pneumococcal 20-valent conjugate vaccine for Resident 122. At the same time, the Wound Nurse indicated the refrigerator temperature was checked daily. Review of a facility document, titled Med Room Refrigerator Temperature Settings, provided by the ADON on 1/30/24 at 10:42 a.m., indicated the North 2 Hall refrigerator had been checked daily. The log lacked a second temperature check for each day. During an interview on 1/30/24 at 12:50 p.m., the DON indicted the medication room refrigerator temperatures were checked daily, and vaccines were stored in them. During an interview on 1/30/24 at 4:41 p.m., the DON indicated the facility did not have a policy on the storage of vaccines. The article Vaccine Storage and Handling Toolkit - January 2023, was retrieved on 1/31/24 from the Centers of Disease Control and Prevention website at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. The guidance indicated if the temperature monitoring device did not read maximum/minimum temperatures then the temperature must be checked and recorded a minimum of two times a day as a minimal action to protect the vaccine supply. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure staff followed physician orders for enhanced barrier precautions during an aerosol-generating procedure for 1 of 1 residents reviewed for respiratory care. (Resident 15) Finding includes: Resident 15's medical record was reviewed on 1/26/24 at 10:22 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia (an insufficient amount of oxygen), and generalized anxiety disorder. Her physician's orders included droplet isolation precautions during tracheostomy care, suctioning, and aerosol treatments (dated 4/20/22) and enhanced barrier precautions (EBP) during high contact resident care for her tracheostomy (dated 5/26/23). During an observation, on 1/25/24 at 3:15 p.m., a sign on the resident's door indicated enhanced barrier precautions were to be performed by anyone performing high-contact resident care activities. Instructions included performing hand hygiene and wearing gloves and a gown, when caring for or accessing the resident's tracheostomy. During the same observation, another sign indicated personal protective equipment (PPE) was required when an aerosol-generating procedure was in progress. The PPE required to enter the room included hand hygiene, an N95 mask, gown, gloves, and eyewear. During an observation, on 1/29/24 at 3:15 p.m., LPN 8 administered an aerosol treatment to the resident via her tracheostomy. The nurse did not perform hand hygiene or don PPE. During an interview, on 1/30/24 at 12:16 p.m., LPN 8 indicated she was unsure whether or not PPE was to be worn during the aerosol-generating procedure. She would have to ask if it was appropriate to perform the procedure without gloves and a gown. A current facility policy, titled Aerosol Generating Procedures, dated 8/29/23, and provided by the Director of Nursing, on 1/30/24 at 4:54 p.m., indicated the following: .perform nebulizer treatments with standard precautions (gloves, mask, and gown if performing the procedure). If setting up and assessing only, mask and gloves 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure the facility and the hospice provider had communication documented between the LTC facility and the hospice for 1 of 2 residents reviewed for hospice services. (Residents 58) Findings include: Resident 58's clinical record was reviewed on 1/11/23 at 10:36 a.m. Current diagnoses included, but were not limited to, Alzheimer's disease, depression, anxiety, and chronic kidney disease. The resident had a current, 12/5/22 physician's order for hospice services. A current, 12/6/22, care plan problem/need indicated the resident had selected hospice services. An approach to this need was Hospice will provide services as listed in their individual hospice plan of care. An 1/3/23, Hospice IDG (unknown acronym) Comprehensive Assessment and Plan of Care Report indicated the following: a. The resident had received hospice services at home prior to moving to a SNF memory care unit. b. The recommendation was to continue skilled nursing visits once a week and home health aide visits two times a week. A 1/13/23 review of the hospice binder/notebook found only one entry for the approximately 6 weeks of hospice services (12/5/22 to 1/13/22) provided for the resident as she resided in the facility. The one entry was a signature from a hospice nurse who had been in the facility on 1/13/23. There was no documentation related to the visit. The binder lacked documentation related to when the Hospice Aides had visited and provided showers and other related services During an interview, on 1/13/23 at 11:08 a.m., the Dementia Unit Manager indicated she had no additional information from hospice other than what was located in the hospice binder/notebook. The Hospice Aides visited two times a week and provided showers. The Hospice Nurse visited once a week. She did see the individuals while they were in the facility. During a 1/13/23, 3:10 p.m. interview, the Administrator indicated the hospice provider failed to provided documents for each visit prior to 1/13/23 when contacted by the facility. The breakdown appeared to be caused when the resident changed from home based hospice to long term care hospice. A facility hospice contract titled, Protocol and Agreement for the Provision of Hospice (Routine and Respite) Medicare and Medicaid Benefit Services, dated 12/20/22 and provided by the Administrator on 1/17/23 at 11:32 a.m., indicated the following: .The Hospice shall: 1. Designate a Hospice Interdisciplinary team RN case manager to: (a) provide overall coordination of the hospice care of the resident with representatives of the Home; (b) communicate with representatives of the Home and other other health care providers participating in the provision of care for terminal illness related conditions and other conditions to ensure quality of care for the resident and family

Based on observation, record review, and interview, the facility failed to ensure toilet risers were maintained in a clean and sanitary manner for 1 of 5 resident rooms observed (room [ROOM NUMBER]). Findings include: During a random observation of room [ROOM NUMBER]'s bathroom, on 12/29/22 at 11:34 a.m., the front of the toilet riser had a dried brown substance, approximately the diameter of a softball. During an interview, on 12/29/22 at 11:39 a.m., the Director of Nursing (DON) indicated she did not like seeing the substance on the toilet riser. During an interview, on 12/29/22 at 11:42 a.m., Licensed Practical Nurse (LPN) 2 indicated the residents in room [ROOM NUMBER] required assistance to the bathroom and were unable to independently get into or out of the bathroom. The toilet riser should have been cleaned immediately after it was soiled. During an interview, on 12/30/22 at 11:05 a.m., the Housekeeping Supervisor indicated the housekeepers were responsible for cleaning the toilet risers while on duty. She indicated the housekeeper should have been notified when the toilet riser needed cleaned. When the housekeepers were not on duty the nursing staff was responsible for cleaning the toilet risers if they became soiled. Review of a current facility policy, titled General Instruction for Cleaning Supplies/Equipment, provided by the Administrator on 12/30/22 at 12:00 p.m., indicated the following: .Toilet risers are for multiple use and are cleaned by the housekeeping daily per scheduled cleaning This Federal tag relates to Complaints IN00395030. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 4 residents reviewed for falls (Resident 34). This deficient practice resulted in multiple falls hitting her head and the resident sustaining a left wrist fracture. Findings include: On 1/4/22 at 9:58 a.m. Resident 34 was propelling herself in her wheelchair, her left arm was wrapped in an ace bandage and in a shoulder sling. On 1/5/22 at 1:25 p.m., she was propelling herself in her wheelchair near the nurses station, her left arm was in a black cast and she was not wearing a sling. On 1/6/22 at 10:13 a.m., she was in the hall near the dining room, she grabbed the handrail and stood up, her alarm sounded, the Activity Assistant walked up and assisted her, RN 61 asked for someone to grab a gait belt to assist resident if she wanted to walk. She assisted her back into her wheelchair pushed her to the nurses station. LPN 47 walked the resident down the hall with a gait belt and RN 61 pushed the wheelchair behind the resident. On 1/7/22 at 12:51 p.m., she was in her wheelchair in the dining room. On 1/10/22 at 9:37 a.m., she was in her wheelchair near the nurses station. Resident 34's clinical record was reviewed on 1/6/22 at 11:20 a.m. Diagnoses included, but were not limited to, [CONDITION(S)] and collapse, essential hypertension, diabetes mellitus with diabetic [CONDITION(S)], [CONDITION(S)], unspecified dementia with behavioral disturbance, disorder of bone density and structure, unspecified fracture of the lower end of left radius and subsequent encounter for closed fracture with routine healing. Her medications included, but were not limited to, [MEDICATION(S)] (antibiotic) 300 mg (milligram) twice daily for [CONDITION(S)] (Urinary Tract Infection) for five days, insulin [MEDICATION(S)] solution (insulin) 100 unit/ml (milliliter) inject subcutaneously per sliding scale, [MEDICATION(S)] solution (insulin) inject 14 units subcutaneously daily, [MEDICATION(S)] (mood stabilizer) delayed release 250 mg three times daily, [MEDICATION(S)] 5 mg at bedtime, [MEDICATION(S)] (treat high blood pressure)10 mg daily, [MEDICATION(S)] extended release (treat high blood pressure) 25 mg twice daily and [MEDICATION(S)] ([CONDITION(S)]) 100 mg twice daily. Her physician orders included, but were not limited to, monitor bruising to left hand every shift for seven days from fall, cast care: elevate left wrist (as resident will allow) and wiggle fingers/toes each shift, check circulation of casted extremity every shift (pale nailbeds, tightness, pain, numbness, cold or tingling sensation) notify MD (medical doctor) if noted. Non-weight bearing to left upper extremity until follow up appointment, keep cast clean and dry until cast removed, sling as needed to left arm. Chair and bed alarm, check placement and function every shift, bed alarm on when in bed or sitting in chair or wheelchair and hipsters on for frequent fall, chart refusals. An admission MDS (Minimum Data Set) dated 11/23/21, indicated she was severely cognitively impaired. She required supervision of one staff member for assistance with bed mobility and transfers. She required limited assistance of one staff member to walk in her room, toilet use and personal hygiene. She required extensive assistance with one staff member to walk in the corridor, locomotion on/off the unit and dressing. She had an impairment to both sides of her upper extremities. She used a walker and wheelchair. She was frequently incontinent of urine and always continent of bowel. She had a fall with no injury and a fall with injury since admission or prior assessment which ever was most recent. Her current problem careplans included, but were not limited to, the following: She was at risk for complications related to healing from the fracture of her left wrist. X-rays note bones were osteopenic. Her goal was to have no complications related to fracture healing. Interventions were to assist her to therapy as ordered, monitor for pain and give pain medications as ordered, non-weight bearing to her left upper extremity until follow up appointment. She was at risk for falls due to her condition and risk factors. Risk factors included: history of [CONDITION(S)], very hard of hearing, frequently paced the hallways, unsafe use of walker that resulted in a fall, going in/out of others rooms (different environments), behaviors included kicking, unsteady gait, shuffled when ambulated, poor vision and hard of hearing to follow directions, frequently intentionally sat on the floor (announced that she was sitting on the floor), (ambulatory prior to admission to the facility)due to multiple falls, wheelchair offered as resident would allow, osteopenia, declined to wear hip protectors, recent fall(s) with left wrist fracture with cast. Her goal was her fall risk factors would be reduced in an attempt to avoid significant injury related to fall. Her interventions were call light in reach, explain use of it upon admission and reinforce as needed, monitor for changes in gait/positioning initiated on 11/16/21. Resident purposefully sat self on the floor without incident. She would voice that she was going to sit on floor initiated on 11/29/21. Keep MD updated in behaviors change that may affect fall risks, offer hand/hand assist with ambulation in hall if she would allow and didn't cause distress initiated on 12/3/21. Per therapy discharge - due to safety reasons, the patient required verbal cues for transfers and ambulation initiated on 12/9/21. Remove items in hands/arms when up walking around to prevent throwing resident off balance initiated on 12/10/21. Offer and encourage to wear helmet initiated on 12/17/21. Non-skid socks on at night and while in bed initiated on 12/21/21. Medication review per NP (Nurse Practitioner) initiated on 12/24/21. Every 15 minutes checks initiated on 12/31/21. Toilet/lay down after meals when resident allowed, bed/chair alarms initiated on 1/1/22. Urine analysis obtained initiated on 1/2/22, helmet ordered initiated on 1/3/22. Nursing-Occurrence Initial Assessment and Facility-Post Occurrence IDT (Interdisplinary Team) and fall risk assessment indicated, but not limited to, the following: On 11/20/21 at 3:45 p.m., she was sitting on the floor in doorway of room 174. No injuries were noted. She was unable to explain what happened. Interventions were she was placed in wheelchair due to she walked with her stomach sticking out, looking like she might fall backwards. She was encouraged to stand up straight but would not do it. IDT indicated the root cause was unsteady gait refused to use walker. Recommendations were encourage to use of walker. On 11/21/21 at 5:20 p.m., she was in the hallway next to the nurses station, walking with her walker and hit walker on the station and fell hitting her head. She had a 3 cm (centimeter) X 3 cm hematoma to the back the right side of her head. She complained of pain to the back of her head. Interventions were that she was placed in a wheelchair and her walker was removed due to resident walked too fast and erratically, moving walker from side to side. IDT indicated the root cause was walking erratically and moving walker side to side. Recommendation was remove walker and replace with wheelchair. On 11/27/21 at 2:10 p.m., it was reported to the nurse that she attempted to get into another residents room. The other resident pushed her out of his room; whereas, she fell back and hit her head on the floor. Interventions was she was assisted to her wheelchair. Due to resident going into multiple other residents' rooms she required one on one constant watching and assistance. IDT indicated she stood in male peers doorway and would not leave, contusion to back of head. Root cause she was a new resident and was adjusting to memory care. Recommendations were 15 minute checks for 72 hours. On 11/29/21 at 12:50 p.m. at the north end of hall, she sat on her buttocks against exit door. She had been exit seeking and tried to open end doors. She was not able to explain what had happened, just kept saying I want out of here. She had shoes on at time. No injuries were noted. Interventions was staff walked one on one with resident and attempt to lay down after meals. IDT indicated the root cause was she was new to the memory care unit was still adjusting to placement. Recommendations were offer and encourage to lay down after meals On 12/10/21 at 1:20 p.m., she laid on floor on the right side in main hallway outside of her bedroom door. She was assisted up with two staff members and sat in her recliner. She had a hematoma to back side of her head. Her shoes were on at time of the fall. Interventions were when up walking around, make sure resident doesn't have anything in hands/arms to throw off her balance. IDT indicated root cause was she was holding stuffed animal in arms which threw her off balance (has a small shuffled gait and sways body). Recommendations were encourage to not hold things when she ambulated. On 12/16/21 at 6:45 p.m., she stood by the coat rack in the hallway and attempted to take a hat off of the rack, lost her balance and fell straight back and hit her head. She had medium sized goose egg to her posterior head. Interventions was to have staff assist resident when she ambulated throughout the unit. IDT indicated the root cause was she lost her balance. Recommendations were to offer and encourage helmet. On 12/21/21 at 7:50 a.m., she yelled for help from her room. She laid on her back on floor beside the bed. She stated she was getting up from bed to go to the bathroom and slipped. She had socks on at time of fall and no shoes. No injuries were noted. Interventions was for her to have nonskid socks on at night while in bed. IDT indicated root cause was she did not have non skid socks on. Recommendations was non skid socks. On 12/31/21 at 9:15 a.m., she walked down the hallway in front of room 177 when staff noted her sitting on her bottom and fell back and hit her head on the floor. No pain voiced at time. She did have nonskid socks on at time of fall. Interventions was toilet and lay resident down after meals when she allowed. IDT indicated the root cause was repeated falls, she fell backwards when sitting on floor. Recommendations was to toilet and lay down after meals as resident allowed. On 12/31/21 at 2:15 p.m., she walked down the hallway in front of room 170, bumped in to wall and lost her balance and fell to the floor. No injuries were noted at time of fall. She complained of discomfort to her left wrist/arm, no swelling or bruising was noted at that time. Interventions were to continue 15 minute and neurological checks. IDT indicated the root cause was she had bumped into the wall and lost her balance. Recommendations were 15 minute checks and may x-ray left hand/wrist if needed. On 1/1/22 at 2:00 a.m., she was in her room and had been checked on approximately 30 minutes prior to fall, she was in the spare bed and was lying with her head to the bottom of the bed resting. CNA heard noise and went to her room, where she was noted lying on her back on the floor. No injuries, range of motion unchanged to bilateral legs and right arm. When helping resident up from floor, she complained of left arm/hand pain when her arm/hand was touched. Left hand thumb area and back of hand bruised with swelling noted to hand and wrist. Resident could not grip with her left hand and could not bend her hand at wrist. Resident had fallen three times in less than 24 hours. DON was made aware with new order for bed alarm on when in bed or sitting in chair or wheelchair. Bruising and swelling to left hand/wrist was from previous fall on 12/31/21 due to CNA made comment of hand and wrist looking swollen/bruised before last fall. Resident said she didn't hurt unless her arm was touched. Interventions were 15 minute checks, bed and chair alarm. IDT indicated root cause was the fall was unwitnessed and she was found on floor of her room. Recommendations were 15 minute checks, added bed and chair alarm, order for x-ray of left hand and wrist. Review of the x-ray results for the resident's left wrist, dated 1/1/22, indicated bones were osteopenic and severely comminuted, impacted distal left radius fracture with intra-articular extension to the radiocarpal joint, slightly displaced ulnar styloid fracture was also identified. On 1/2/22 at 3:31 p.m., she propelled herself with her feet in wheelchair down the hallway when she tried to stand, fell and hit her head. No injuries were noted. Interventions were hipsters started, helmet ordered and 15 minute safety checks re-started. One on one care started at that time. Pass on for a.m. shift to have psychiatry review her medications. IDT indicated root cause was she stood from wheelchair without locking the brakes. IDT recommendations were hipsters started, helmet ordered and 15 minute safety checks re-started. One on one care started at this time. Pass on for a.m. shift to have psychiatry to review her medications. A nurses note, dated 1/4/22 at 8:56 a.m., indicated she chose not to wear her hipsters at that time. A nurses note, dated 1/10/22 at 10:57 a.m., indicated she continued to make unassisted transfers with the alarm alerting staff throughout the shift. The CNA assignment sheet, dated 1/4/22, indicated her mobility and transfers was per self with supervision. Her general information included, but was not limited to, bed/chair alarm, hipsters, helmet ordered, one on one, toilet/lay down after meals, x-ray left hand, redirect from others rooms when possible and non-skid socks on at night in bed. During an interview with LPN 47, on 1/7/22 at 9:42 a.m., she indicated Resident 34 would exit seek, she would go to the door and say she was falling and slide herself to the floor purposefully. She had fallen while holding stuffed animals, family indicated she would attention seek by saying she was going to fall if they didn't help her. The last couple falls, she lost her balance. The helmet was ordered but hasn't came in yet. They have done 15 minutes checks, one on ones, bed/chair alarm, they tried to keep her in staff view when she is up. She was currently on antibiotic for a [CONDITION(S)] due to having to urinate more frequently. Review of the 1/1/22 fall investigation with the Administrator, on 1/7/22 at 10:52 a.m., he indicated on 1/1/22 she had a fall about 2:00 a.m., she was found her in room, x-ray of her wrist indicated her bones were osteopenic. He had spoken with the family about her falls when she had a orthopedic follow up appointment, family had indicated she had fallen at home and it was almost like a temper tantrum as she placed herself on the floor. She refused the hip protectors and the helmet was ordered. She was blind and had ran into the walls. During an interview with Agency QMA 45, on 1/10/22 at 3:17 p.m., she indicated this was her first time working on the dementia unit and was unfamiliar with Resident 34 and normally worked a different hall in the facility. Interventions for her falls would be making sure her path was clear, keep her busy so she would not be at risk for falling and look at her behaviors and take action as needed. She was not sure where to find interventions for falls but they were usually on the TAR (Treatment Administration Record) or MAR (Medication Administration Record). During an interview with CNA 56, on 1/10/22 at 3:50 p.m., she indicated they did one on ones with the resident and when she needed to care for another resident LPN 47 would watch Resident 34 and when Resident 34's family was in the facility they would sit with her. A current facility policy, titled Fall Management Procedure, provided by the Administrator, on 1/7/22 at 3:00 p.m., indicated the following: 1. Purpose A. To assess all residents for risk factors that may contribute to falling and to provide planned interventions identified by the team as appropriate for resident to use in maintaining or returning to the highest level or physical, social and psychosocial functioning as possible . 3. Post Fall Investigation A. If a fall occurs or is reported by a resident, visitor or staff member, the Post Fall Investigation will be completed to: .III. Determine what new or revised interventions will be implemented to reduce the risk of further and/or injuries from falls 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure cognitively impaired residents were provided with individualized activities programming for 4 of 5 residents reviewed for activities (Residents 2, 11, 39, and 60). Findings include: 1. On 1/4/22 at 1:09 p.m., Resident 2 was in her room, seated in her wheelchair, talking to someone not present. On 1/5/22 at 10:05 p.m., she was seated in her wheelchair in her room, looking at the wall. On 1/5/22 at 11:15 a.m., she was in her room, seated in her wheelchair. On 1/5/22 at 1:26 p.m., she was in her wheelchair in her room, alone, holding a copy of the facility daily newsletter; it was crumpled in her hand and she was speaking non-sensically. On 1/5/22 at 1:50 p.m., she remained alone in her room, holding the crumpled copy of the newsletter and speaking non-sensically. On 1/6/22 at 1:51 p.m., she was in bed, awake, with her room darkened. On 1/7/22 at 10:09 a.m., she was being assisted to lay down in her room. Her T.V. was on, playing Golden Girls. On 1/7/22 at 11:06 a.m., she remained in bed, awake. Review of Resident 2's clinical record was completed on 1/5/22 at 11:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 9/24/21, quarterly, Minimum Data Set (MDS) assessment indicated she was sometimes understood and sometimes understood others. She was dependent for mobility. She had a current, 2/6/20 care plan problem of being cognitively impaired and would benefit from activities adapted her cognitive abilities and was able to self initiate some activity. She continued to enjoy attendance in group activities as exhibited by responsiveness/smiles, eye contact, etc. From interviews with her representative, she was a social person, enjoyed keeping busy, and would enjoy involvement in activities. She received hospice services and would be placed on 1:1 list for room visits. She had a current, 3/27/19, care plan goal of will attend sensory activities. She had a current, 6/26/19, care plan goal of through past history and/or family interview, it had been determined she had always enjoyed music such as Elvis [NAME], Old Country and Gospel. She had a current, 6/29/21, care plan goal of through past history and/or family interview it had been determined her favorite activities were musical events, facility parties, visiting with family, snacking, pet visits, watching T.V., and time outdoors. She had a current, 3/27/19, care plan goal of through past history and/or family interview it had been determined religious beliefs and activities were important to her. She also enjoyed expressive arts activities. Review of a 6/30/21 FYI in her clinical record indicated she enjoyed group activities such as music and musical programs, time outdoors, cornhole games, facility parties, refreshments, dog visits, religious services and readings. She also had a busy box in her room. A 9/22/21 quarterly activity assessment indicated she enjoyed Bible study with a facility pastor, time outdoors in courtyard, dog visits, Resident Council, cornhole, exercises, and refreshments. She was mostly a passive attendee, but did watch the goings-on during these activities, and responded verbally and smiled during these activities. She watched T.V., napped, would look at magazines on occasion as long as they were mostly pictures, and had 1:1 visits with activity staff. She did not perform therapeutic work and had no busy box. She was visited by activity staff routinely, who talked with her, read to her, and played music for her. Although she was receptive to these visits, she was unable to talk like she once did when these visits started. She did make and keep eye contact, and continued to laugh. A 12/31/21 annual activity assessment indicated she enjoyed music sometimes, and was unable to tell what kind she liked. She did not enjoy animals or current events, it was not really important for her to attend group activities, but she would benefit from group activities. She watched T.V. and stayed in bed. She didn't enjoy going outside, but may benefit from it. Her T.V. was on during the time of the interview. Review of the resident's activities participation from 12/9/21 through 1/10/22 indicated she attended a special event on 12/14/21, 12/15/21, and 12/24/21 and reminisce on 12/26/21. She had been provided with 24 1:1 visits, for 1-5 minutes each, since 12/9/21. Resident 2 was not observed attending any group activities during the survey time period. 2. On 1/5/22 at 1:30 p.m., Resident 11 was in her room, seated in her wheelchair, chin to chest. Her roommate's T.V. was on, and the resident's side of the room was darkened. On 1/6/22 at 10:14 a.m., she was asleep in bed, with the room darkened. On 1/6/21 at 1:51 p.m., she was in bed, with her eyes open. Her room was darkened and the T.V. was off. On 1/7/22 at 9:01 a.m., she was assisted to her room by a CNA, from the lounge area, where the T.V. was showing the news on low volume. On 1/7/22 at 10:09 a.m., she was in bed. On 1/7/22 at 1:22 p.m., she was asleep in her wheelchair in her room. On 1/10/21 at 8:55 a.m., she was being assisted back to her room. Review of Resident 11's clinical record was completed on 1/4/22 at 11:09 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 10/7/21, annual, MDS assessment indicated she was moderately cognitively impaired and was dependent for locomotion off the unit. She had a current, 1/19/21 care plan problem of enjoying the increased socialization/ stimulation received through involvement in group activities. Some encouragement was needed at times, but once there, the activities were enjoyed. She enjoyed listening to music such as Gospel and easy listening. It was important for her to do things with groups of people such as music programs, facility parties, tossing games, religious services, Bible study, devotions, trivia games, and exercises. She required assistance to/from activities. Review of a 12/31/21 quarterly activity assessment indicated she enjoyed dog visits, baking, cooking, listening to music, Bible study with the facility pastor, and musical programs. She was both an active and passive participant. She enjoyed these activities once she got there because she communicated she did. She did need to be coaxed and begged because she would state she was tired or sick and needed to stay in bed. She also enjoyed church activities, time outdoors, music and musical programs, refreshments, napping, T.V., reading her Bible, time with her family and time with her pastor. Review of the resident's activities participation from 12/9/21 through 1/10/22 indicated she attended a special event on 12/14/21, 12/15/21, and 12/ 24/21. She had been provided with 23 1:1 visits, for 1-5 minutes each, since 12/9/21. 3. On 1/6/22 at 8:16 a.m., Resident 39 was in her room in her recliner chair, leaning to the right side, asleep. Her T.V. was on. On 1/6/21 at 1:51 p.m., she was in bed. On 1/7/22 at 10:09 a.m., she was asleep in her recliner chair. On 1/7/22 at 1:16 p.m., she was in bed. Review of Resident 39's clinical record was completed on 1/6/21 at 8:18 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 11/24/21, quarterly, MDS assessment indicated she was moderately cognitively impaired and required extensive assistance with mobility. She had a current, 8/31/21, care plan problem of enjoying the benefits of increased socialization/stimulation through activity involvement. She was social and accepted invitations to activities of her choosing. She had a current, 4/10/16 care plan goal of listening to music was important to her. She enjoyed country western, gospel, classical, and rock n' roll, except for hard rock. She needed to be reminded and have attendance encouraged in musical programs. It was very important for her to keep up with the news and she was to be invited to all current events and educational activities. She had a current, 8/30/21 care plan goal of the importance to her to do things with groups of people. She enjoyed arts and crafts, games, baking, musical programs, bingo, games, time outdoors, dog visits, religious programs and facility parties. She stated it was important for her to do her favorite activities such as time outdoors, visiting with family and friends, church and church functions, watching T.V., music and music programs, baking activities, tossing games,bingo, trivia games, crafts, movies, and facility parties/special events. Review of an 11/22/21, quarterly, activity assessment indicated she enjoyed bingo, Bible study, time outdoors, ring around the soda, Resident Council, dog visits, exercises, trivia games, crafts, refreshments, and crafts. She is active at times with these activities and states she enjoys them. She was part of resident council, however she liked to sleep more. Review of a 1/5/22 Nurse Practitioner note indicated overall she was declining both mentally and physically. Review of the resident's activities participation from 12/9/21 through 1/10/22 indicated she attended a special event on 12/14/21, 12/15/21, 12/ 24/21 and one group activity on 12/30/22. She had been provided with 23 1:1 visits, for 1-5 minutes each, since 12/9/21. 4. On 1/7/22 at 10:09 a.m., Resident 60 was in bed, awake. Her room was darkened and quiet. On 1/7/22 at 11:06 a.m., she remained in bed. On 1/10/22 at 10:00 a.m., she was in bed, with the room light off. Her roommate was watching T.V. On 1/10/22 at 11:25 a.m., she was seated in her wheelchair in the hallway near the laundry room. Review of Resident 60's clinical record was completed on 1/6/22 at 10:15 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/18/21, quarterly, MDS assessment indicated she rarely/never understood others and was rarely/never understood by others. She was dependent for mobility. She had a current, 9/21/21 care plan problem of being cognitively impaired and would benefit from activities that were adapted to her cognitive abilities. She was not able to self initiate activity. She had always been a people watcher, enjoyed being around others, and just watching what was going on. She continued to enjoy attendance in group activities as exhibited by responsiveness/smiles, eye contact, etc. She was added to the room visit list to be seen by activity staff throughout the week. Review of her activity participation for January 2022 indicated she attended one sensory group on 1/1/22 and seven 1:1 visits, each [MEDICATION(S)] 1-5 minutes, from 1/1/22 through 1/10/22. During an interview, on 1/10/22 at 9:40 a.m., Agency CNA 71 indicated staff could review the posted activity calendar and assist residents to the activity as needed. She would normally just ask someone if they wanted to go. Resident 2 mostly observed things, but still went sometimes. Resident 11 didn't like to leave her room too often. On 1/10/22 at 9:40 a.m., Activity Assistant 73 was inviting select residents to bingo at 10:30 a.m. During an interview, on 1/10/22 at 11:25 a.m., Activity Assistant 73 indicated she did 1:1 visits with Residents 2, 11, 39, and 60. She usually just talked or spent time with them. If Resident 11 was already in bed, she didn't like to come to group activities. Resident 39 didn't like leaving her room at all anymore. Residents 2 and 60 would sometimes enjoy just watching the people attending the activities. Resident 60 liked church services. During an interview, on 1/10/22 at 1:40 p.m., the Activity Director indicated Resident 11 received 1:1 visits in the mornings, as did pretty much all of the residents. She had gone to the facility Christmas party, and a few other activities, but not a whole lot. Resident 60 received 1:1 visits and attended sensory group. The Activity Director had not been doing sensory group, since she had only been employed for a few months. She would do sensory activities during 1:1 visits at times. Sensory activities basically involved feel and touch, so it could be done during the 1:1 visits. Resident 2 had come to activities in the past, but since she was on hospice services, she didn't attend group activities. Resident 39 really only came to parties. The residents also had T.V.s in their rooms. The Activity Director had been updating activity assessments and care plans, and making changes as necessary, over the past few months. If a resident no longer enjoyed attending group activities, they would then be changed to longer 1:1 visits two to three times a week. Review of the January 2022 Activity calendar indicated, but was not limited to, the following activities schedule for the survey time period: On 1/4/22, bean bag toss, sensory, and cooking club. On 1/5/22, bean bag toss, sensory, and cooking club. On 1/6/22, games, sensory, and Wheel of Fortune. On 1/7/22, The songs you like, sensory, and rock n' roll trivia; it was National Rock N' Roll day. On 1/10/22, bingo, sensory, and Bible study/worship service. Review of a current facility policy, titled Activity Care Plan ., dated 10/3/13 and provided by the Activity Director on 1/10/22 at 2:37 p.m., indicated the following: .identify the resident's needs and preferences with care, and to evaluate progress towards established goals through routine documentation. Activity care plan goals will be developed to aid the resident in pursuing meaningful leisure activities and enhancing functional, mental, and spiritual well-being .Care plans should also be initiated as activity needs change 3.1-33(a)

Based on observation, interview and record review the facility failed to ensure residents' weights who were nutritionally at risk were monitored as ordered by a physician for 2 of 6 residents sampled. (Resident 49 and 51) Findings: 1. During an observation, on 1/04/22 at 10:05 a.m., Resident 49 was resting in bed with his eyes closed. Greater than 50% of the breakfast meal remained on the breakfast tray setting on the bedside table beside the resident. During an observation, on 1/05/22 at 1:50 p.m., Resident 49 was resting in bed with his eyes closed. Greater than 50% of the lunch meal remained on the lunch tray setting on the bedside table beside resident. During an observation, on 1/07/22 at 12:58 p.m., Resident 49 pulled covers over himself and shut eyes. Greater than 50% of the lunch meal remained on the lunch tray setting on the bedside table beside resident. Resident 49's clinical record was reviewed, on 1/07/22 at 10:56 a.m., diagnoses, included but were not limited to, diabetes mellitus with [CONDITION(S)] and dysphagia, pharyngoesophageal phase. Resident admitted to the facility on [DATE]. Orders included, but were not limited to, mechanical soft carbohydrate-controlled diet and weekly weight. There were no weights for 1 of 4 weeks in October, 3 of 4 weeks in November, 4 of 5 weeks in December. A care plan initiated on 10/11/21 identified the resident was at nutritional risk with an intervention to monitor weights and intakes. Review of a progress note, dated 12/08/21 at 14:10 p.m., for a wound and weight meeting held on 12/08/21, indicated resident's weights were .[DATE]-no weight, [DATE]-170.6, [DATE]-176.8, [DATE]-no weight, [DATE]-no weight . Review of a progress note, dated 11/28/21 at 12:43 p.m., for a wound and weight meeting held on 11/26/21, indicated resident's weights were .[DATE]-no weight, [DATE]-170.6, [DATE]-176.8, [DATE]-no weight . During an interview, on 1/10/22 at 10:44 a.m., QMA 51 indicated weights to be taken are on a clipboard. A sheet is printed daily for any weights due that day. She indicated as a QMA she could also access the electronic medical record (EMR) and look at the medication and treatment administration record to check on any weights that were due. During an interview, on 1/10/22 at 10:59 a.m., LPN 52 indicated weekly and daily weights show up in the medication and treatment administration record and in the care plan. She indicated she directs the CNAs to get any weights due. During an interview, on 1/10/22 at 11:15 a.m., the ADON indicated each unit gets a paper with the resident weights due listed for the week. She indicated the unit manager hands out the list and follows up on missing weights. During an interview, on 1/10/22 at 11:41 a.m., the Unit Manager indicated she tracks the resident weights. She indicated she follows up on missing weights with the nurses and CNAs. 2. During an interview with an observation, on 1/05/21 at 8:47 a.m., Resident 51 was sitting in her wheelchair with a breakfast tray in front of her. She had eaten less than 25% of meal. She indicated she was not hungry and not going to eat any more. During an interview with an observation, on 1/07/22 at 12:59 p.m., Resident 51 was sitting in her wheelchair with her bedside table positioned approximately five feet away. A lunch tray setting on the bedside table contained 100% of her lunch. She indicated she was not hungry, sometimes her stomach hurts if she eats very much, and was not going to eat anything. Resident 51's clinical record was reviewed, on 1/07/22 at 1:55 p.m., diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders included, but were not limited to, [MEDICATION(S)] 20 mg daily, [MEDICATION(S)] delayed release 40 mg daily, mechanical soft diet, and weekly weight (every 7 days). There were no weights for 3 of 4 weeks in October, 1 of 4 weeks in November and 2 of 5 weeks in December A care plan initiated on 10/26/21 identified the resident was nutritionally at risk with an intervention to monitor weights and intakes. Review of a progress note, dated 12/23/21 at 12:48 p.m., for a wound and weight meeting held on 12/22/21, indicated the resident's weights were .[DATE]-168.2, [DATE]-168.4, [DATE]-168.4, [DATE]-no weight, [DATE]- 173.6, [DATE]-156.8 . During an interview, on 1/10/22 at 10:44 a.m., QMA 51 indicated weights to be taken were on a clipboard. A sheet was printed daily for any weights due that day. She indicated as a QMA she could also access the electronic medical record (EMR) and look at the medication and treatment administration record to check on any weights that were due. During an interview, on 1/10/22 at 10:59 a.m., LPN 52 indicated weekly and daily weights show up in the medication and treatment administration record and in care plan. She indicated she directs the nursing assistants to get any weights due. During an interview, on 1/10/22 at 11:15 a.m., the ADON indicated each unit gets a paper with the resident weights due listed for the week. She indicated the unit manager hands out the list and follows up on missing weights. During an interview, on 1/10/22 at 11:41 a.m., the Unit Manager indicated she tracks the resident weights. She indicated she follows up on missing weights with the nurses and CNAs. Review of a current facility policy, titled Weight Management Program provided by the DON on 1/10/21 at 2:58 p.m., indicated .all new admissions' height and weight will be measured within 24 hours of admission and recorded in the electronic medical record under the vital sign tab .Residents with continual weight change (loss or gain) of 5% of more in 30 days will remain on weekly weights until their weight has stabilized . 3.1-46(a)(1)

Based on interview and record review, the facility failed ensure a care plan was in place related to anticoagulant use for 1 of 3 residents reviewed for anticoagulant use (Resident 118). Findings include: Resident 118's clinical record was reviewed on 1/07/22 at 10:01 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan did not include anticoagulant use. During an interview, on 1/10/22 at 2:03 p.m., the DON indicated if a resident was using an anticoagulant, it should be on the care plan. Review of a current policy, titled Care Plan Development & Review provided by the DON on 1/10/21 at 3:46 p.m., indicated .The comprehensive care plan is designed to: . Identify and incorporate risk factors associated with identified focuses . 3.1-35(d)(1)

Based on observation, interview and record review, the facility failed to provide treatment and services as ordered to promote pressure wound healing for 3 of 4 residents reviewed for pressure ulcers. This deficient practice resulted in Resident D developing a wound with the bone exposed and Resident E developing Stage 3 wounds on his heels. Findings include: 1. During wound care for Resident D with on 7/19/21 at 10:45 a.m., LPN 3 removed an undated dressing to the left sacral area. The wound appeared to be full-thickness tissue loss with epibole (rolled edges). The wound base had slough and possible bone exposure. While reviewing the current treatment orders, no order was noted for the left sacral wound. The DON was asked to come and look at the wound. LPN 3 indicated the way the orders were written, it was difficult to understand because it all ran together. On 7/19/21 at 10:55 a.m., the DON indicated undermining appeared to be present with possible bone. She indicated she missed that wound, but took notes from the wound clinic, which he goes to every 2 weeks. The resident had multiple wound at the base of his back and buttocks. During an interview on 7/19/21 at 11:51 a.m., the DON indicated the former wound nurse took another position and she has been doing wound care. The wounds were measured on Wednesdays and she has been trying to keep up with it. The clinical record for Resident D was reviewed on a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission Minimum Data Set (MDS) assessment, dated 7/14/21, indicated the resident was cognitively intact. He was admitted with multiple wounds. A health care plan, dated 7/8/21, indicated the resident was admitted with pressure injury to the right buttocks, coccyx, left lower extremity, and right lower extremity. Interventions included, but were not limited to, administer treatment as ordered. A pressure injury report indicated the following wounds were noted on 7/16/21: a. Deep tissue injury, right plantar foot, 6.0 cm x 5.0 cm. b. Deep tissue injury, right little toe, 3.0 cm x 2.0 cm x 0.5 cm. c. Unstageable, right outer heel, 7.0 cm x 4.0 cm. d. Unstageable, right lower leg, 29.0 cm x 2.0 cm. e. Unstageable, right upper leg, 2.5 cm x 2.0 cm. f. Unstageable right outer heel, 7.0 cm x 4.0 cm. g. Deep tissue injury, right plantar outer foot, 2.0 cm x 0.5 cm. h. Unstageable, behind left leg, 4.5 cm x 2.0 cm. i. Unstageable, top of left knee, 2.0 cm x 1.0 cm. j. Unstageable, right buttocks, 6.5 cm x 3.0 cm. k. Unstageable, coccyx, 6.5 cm x 3.0 cm. l. Unstageable, left buttock, 5.0 cm x 3.5 cm. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] to eschar left sacrum, wet to dry on sacrum & ischium using dakins, 4 x 4's ABD pad & tape, [MEDICATION(S)] to rt [right] foot/toes, leg, ABD pad to rt foot, paint all areas of leg w/eschar w/[MEDICATION(S)], wrap in kerlix, [MEDICATION(S)] to lft [left] leg wound/eschar wrap in kerlix, tape every day shift for wound care. Review of the July TAR, on 7/9/21, indicated the treatment was signed off by a QMA. No treatment was completed on 7/10/21 or 7/14/21. A Braden scale, dated 7/6/21, indicated a score of 17, mild risk for developing a pressure ulcer. 2. During the initial tour with the DON on 7/16/21 at 1:12 p.m., Resident E was in bed and the DON indicated the resident had a pressure ulcer on his right foot medial ball of foot. A gauze dressing was applied around the foot and behind the heel. During wound care with the DON on 7/16/21 at 3:42 p.m., the undated gauze dressing was removed and no dressing was noted on the medial ball of the foot and gauze dressing was adhered to the heel. The DON then applied wound wash to soften the gauze. The gauze was removed and a wound was noted to the back of the heel, which the DON then stated it was an existing wound. During an observation on 7/19/21 at 8:05 a.m., Resident E observed seated at the side of his bed eating breakfast. The QMA pulled down his sock and the dressing was not dated and ball of the foot wound was not covered with any type of dressing. The clinical record for Resident E was reviewed on a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/28/21, indicated the resident had moderate cognitive impairment. He required two-person assistance for bed mobility. He was at risk for the development of pressure ulcers and had 2 unstageable wounds that developed after admission. The facility implemented a pressure reducing bed and chair, as well as, application of a non-surgical dressing. A health care plan, dated 2/4/21, indicated the resident had developed a pressure injury to the right heel and right inner ball of foot. Interventions included, but were not limited to, administer treatment as ordered. A Braden scale, dated 7/16/21, indicated a score of 16, mild risk for developing a pressure ulcer. A pressure injury report from 5/19/21 through 7/19/21 indicated the following: 1. Right outer heel, stage 3 a. 5/19/21, 4.0 cm x 3.0 cm. b. 5/26/21, 4.0 cm x 2.0 cm x <.1 cm. c. 6/2/21, 2.0 cm x 2.0 cm x <.1 cm. d. 6/9/21, 2.0 cm x 1.0 cm x <.1 cm. e. 6/16/21, 1.0 cm x 1.5 cm x <.1 cm. f. 6/23/21, 1.0 cm x 1.0 cm x <.1 cm. g. 6/30/21, 1.0 cm x 1.0 cm x <.1 cm. h. 7/7/21, 1.0 cm x 1.0 cm x <.1 cm. i. 7/16/21, 2.5 cm x 3.0 cm. 2. Right inner ball of foot, stage 3 a. 5/19/21, 4.0 cm x 3.0 cm. b. 5/26/21, 2.8 cm x 2.0 cm x <.1 cm. c. 6/2/21, 2.5 cm x 2.0 cm x <.1 cm. d. 6/9/21, 2.0 cm x 2.0 cm x <.1 cm. e. 6/16/21, 1.5 cm x 1.5 cm x <.1 cm. f. 6/23/21, 1.5 cm x 1.5 cm x <.1 cm. g. 6/30/21, 1.5 cm x 1.5 cm x <.1 cm. h. 7/7/21, 2.0 cm x 2.5 cm x <.1 cm. i. 7/16/21, 2.0 cm x 2.0 cm x <.1 cm. A NP note, dated 5/21/21, indicated the resident was seen for the evaluation of the right heel ulcer and right medial 1st metatarsal head pressure ulcer. The assessment and plan indicated to apply gauze moistened with Dakin's 1/4 strength applied to wound bed and covered with an Abdominal (ABD) dressings and change daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A NP note on 7/8/21, indicated the resident had skin breakdown on his left heel. The assessment and plan indicated to continue Lac-Hydrin Cream (ammonium [MEDICATION(S)] cream) to bilateral lower extremities related to issues with the right heel. The right heel also had a Deep Tissue Injury (DTI) and to continue Dakin's solution dressing changes. Review of the July TAR, the treatment was completed once on 7/17/21 and it was not completed on 7/16/21. The treatment was documented as having been done by a Qualified Medication Aide (QMA) on 7 occasions. 3. The clinical record for Resident B was reviewed on 7/16/21 at 1:55 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/24/21, indicated the resident was severely cognitively impaired. She required one-person assistance for bed mobility, transfer, eating and toileting. She was at risk for the development of pressure ulcers, but admitted with no pressure ulcers. She had 3 venous and/or arterial ulcers. The facility implemented a pressure reducing bed and chair, as well as, application of a non-surgical dressing. The most recent 5-day change MDS assessment, dated 6/20/21, indicated the resident was cognitively intact. She had a pressure ulcer over a bony prominence. She had 1 stage 2, 2 stage 3 pressure ulcers and 1 unstageable wound. The facility implemented a pressure reducing bed and chair, as well as, pressure injury care. The resident required two-person assistance for bed mobility. A health care plan, dated 5/7/21, indicated the resident was admitted with a wound that was potentially related to pressure on the right buttocks and left heel. Interventions included, but were not limited to, administer treatments as ordered. A Braden scale, dated 7/16/21, indicated a score of 16, mild risk for developing a pressure ulcer. A pressure injury report from 5/19/21 through 7/19/21 indicated the following: 1. Left heel, unstageable a. 5/19/21, 4.0 cm x 4.0 cm. b. 6/25/21, 3.0 cm x 2.5 cm. c. On 6/30/21, the heel wound was documented as Stage 3. The measurement indicated 3.0 cm x 2.0 cm. d. stage 3, 7/7/21, 2.0 cm x 2.0 cm. e. stage 3, 7/16/21, 2.0 cm x 1.0 cm x <.1 cm. An order, dated 6/27/21, indicated to apply skin prep to the peri wound, apply collagen to the wound bed and cover with foam dressing and change every other day. An NP note, dated 7/7/21, indicated the assessment and plan included treatment to the left heel pressure ulcer, stage 3. Review of the July TAR, indicated no treatment was completed 7/3/21 or 7/9/21. On 7/16/21 at 4:08 p.m., the DON indicated they currently were using a lot of agency staff. It was the QMAs responsibility to let the nurse know she had a dressing change to be done. During an interview on 7/16/21 at 4:20 p.m., QMA 2 indicated she would call the nurse to come and do the treatments when the were scheduled. She indicated the nurse had to come and do blood sugars so she would tell them at that time. The TAR was provided to QMA 2 which noted she had already signed for 7/16 that she had completed the treatment. She did not call the nurse to come and do the dressing change. She stated when she first started, the person who trained her wanted to make sure she knew how to sign off on an order, but that staff person was no longer here. She was aware she was unable to do any pressure wound care. During an interview on 7/19/21 at 11:51 a.m., the DON indicated there had been a treatment order for the ball of the foot back on 5/24/21, but the order must have dropped off. Review of a current facility policy, dated 5/17/17, titled Wound (Pressure Injury) & Non-wound Assessment & Documentation, which was provided by the DON on 7/20/21 at 3:17 p.m. indicated the following: 1. WOUNDS A. All wounds, as defined below, will be managed wound assessment will be completed to include: location, stage, current status, measurements, description, pain associatedd, PUSH scorre and current treatment. B. Even if the wound is being treated by .wound specialist, the facility will monitor the wound using the EMR to track This Federal tag relates to Complaints IN 134, IN 289 and IN 306. 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to provide treatment and services as ordered to promote wound healing for 1 of 4 residents reviewed for skin issues. Findings include: During the initial tour with the Director of Nursing (DON) on 7/16/21 at 1:05 p.m., she indicated Resident B had a vascular wound. The resident was seated in her recliner with gauze wrap to the left lower leg. On 7/16/21 at 1:32 p.m., LPN 1 indicated Resident B was being sent to the hospital for evaluation per family request. Prior to being sent, LPN 1 removed the gauze to the left lower leg and approximately 4 of the tendon was exposed. The resident stated her leg hurt when the nurse moved her leg. LPN 1 indicated she had been off for a while and there was nothing documented in the progress notes or wound notes relate to the exposed tendon. When she came back to work, the tendon was exposed. The clinical record for Resident B was reviewed on 7/16/21 at 1:55 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/24/21, indicated the resident was severely cognitively impaired. She required one-person assistance for bed mobility, transfer, eating and toileting. She was at risk for the development of pressure ulcers, but admitted with none. She had 3 venous and/or arterial ulcers on admission. The facility implemented a pressure reducing bed and chair, as well as, application of a non-surgical dressing. A health care plan, dated 10/28/20, indicated the resident had a chronic venous stasis ulcer on the top of lower left leg and left outer ankle with exposed hardware. Interventions included, but were not limited to, treatment to left outer ankle and top of right foot as ordered and treatment as ordered to bilateral lower extremities. A non-pressure wound report fro 5/19/21 through 7/19/21 indicated the following: A non-pressure wound report from 5/19/21 through 7/19/21 indicated the following measurements: Wound 1- a. On 5/19/21 at 1:27 p.m., indicated a healing venous stasis ulcer on the front lower leg that measured 1.5 cm x 1.5 cm x <.1 cm. b. 6/2/21 at 12:10 p.m., indicated an arterial ischemic ulcer on the front lower leg that measured 5.0 cm x 6.0 cm x 0.1 cm. c. 6/2/21 at 12:12 p.m., indicated an arterial ischemic ulcer on the front lower leg that measured 1.5 cm x 1.0 cm x 0.1 cm. d. 6/9/21 at 12:45 p.m., indicated a healing arterial ischemic ulcer on the front lower leg that measured 3.0 cm x 2.0 x 0.1 cm. e. 6/9/21 at 12:45 p.m., indicated a new arterial ischemic ulcer on the front lower leg that measured 3.0 cm x 2.0 x 0.1 cm. f. 6/16/21 at 12:16 p.m., indicated a healing arterial ischemic ulcer on the front lower leg that measured 1.0 cm x 1.5 x 0.1 cm. g. 6/16/21 at 12:19 p.m., indicated a healing arterial ischemic ulcer on the front lower leg that measured 1.0 cm x 1.0 x 0.1 cm. h. 6/25/21 at 3:34 p.m., indicated a healing arterial ischemic ulcer on the front lower leg that measured 0 cm x 0 cm x 0 cm. i. 6/25/21 at 3:39 p.m., indicated a resurfaced arterial ischemic ulcer on the front lower leg that measured 0 cm x 0 cm x 0 cm. Wound 2 - a. 6/25/21 at 4:06 p.m., indicated a new arterial ischemic ulcer on the left front of calf that measured 3.0 cm x 3.0 cm x <.1 cm. b. 6/25/21 at 4:07 p.m., indicated a new arterial ischemic ulcer on the left front of calf that measured 2.0 cm x 3.0 cm x <.1 cm. c. 6/30/21 at 1:53 p.m., indicated a closed arterial ischemic ulcer on the left front of calf that measured 0 cm x 0 cm x 0 cm. d. 7/7/21 at 3:56 p.m., indicated a arterial ischemic ulcer, no change, but stable on the left front of calf that measured 3.0 cm x 3.0 cm x <.1 cm. e. 7/15/21 at 1:28 p.m., indicated a non-healing arterial ischemic ulcer on the left front of calf that measured 8.0 cm x 5.0 cm x <.1 cm. The assessment failed to mention an exposed tendon. A Nurse Practitioner (NP) note, dated 7/6/2021 at 1:12 p.m., indicated the resident was found in her wheelchair and had bandages to both of her lower extremities. The bandages were removed for further evaluation as staff had requested evaluation of her lower extremities for possible infection. The resident had exposed hardware on the left lateral malleolus and now had exposed tendon on the left anterior lower leg poor wound healing potential. The plan included to apply skin prep to the left lateral malleolus and left lower leg periwound, apply Dakin's (broad-spectrum antimicrobial cleanser) 1/4 strength to moistened gauze to wound bed and cover with absorptive wrap with Kerlix ( bandage rolls provide fast-wicking action) and change daily and as needed. The plan also stated Chronic venous insufficiency with [CONDITION(S)]-recommend to wash bilateral legs with soap and water, apply [MEDICATION(S)] (topical cream) bid [twice daily] to bilateral legs, ACE wraps with light compression - elevate bilateral LE [left extremity] 3 times per day for 1.5-2 hours. Review of the July Treatment Administration Record (TAR), an order, dated 7/9/21 at 4:15 p.m., indicated to wash the open area to leg with wound cleanser pack with gent dakins soaked gauze cover with kerlix x 2 times daily two times a day. The July TAR indicated the treatment was not completed on 7/9/21, it was completed once on 7/10/21, 7/13/21, 7/14/21 and 7/15/21. A second order, dated 7/9/21 at 4:15 p.m., indicated Wash R LLE with soap and water cover open area with non adherent gauze .kerlix Left leg wash with soap and water, apply moist gauze (dakins) and cover with gauze over exposed hardware .change twice daily two times a day for wound care. The July TAR indicated the treatment was not completed on 7/9/21, it was completed once on 7/10/21, 7/13/21, 7/14/21 and 7/15/21. A Nurse Practitioner (NP) note, dated 7/12/2021 at 2:17 p.m. The order continued to same as on 7/9/21; Dakin's 1/4 strength daily and as needed. A progress note, dated 7/13/21 at 10:03 a.m., indicated the Inter-Disciplinary Team (IDT) met with therapy related to pain and discomfort in the resident's leg. The resident did not want to stand or walk much. Therapy planned to discontinue service and nursing reported the NP looked at the wound and was uncertain if the area would heal. On 7/15/21 at 1:24 p.m., the NP was notified of the worsening wound. A progress note, dated 7/16/21 at 12:17 p.m., indicated the resident's daughter requested to see the wound to her left lower leg. The daughter then requested the resident be sent to the hospital. A hospital progress note, dated 7/19/21, indicated the resident was seen by wound care related to a leg ulcer and exposed tendon. During an interview on 7/19/21 at 11:51 a.m., the DON indicated the former wound nurse took another position and she has been doing wound care. The wounds were measured on Wednesdays and she has been trying to keep up with it. On 7/16/21 at 4:08 p.m., the DON indicated they currently were using a lot of agency staff. It was the QMAs responsibility to let the nurse know she had a dressing change to be done. Review of a current facility policy, dated 5/17/17, titled Wound (Pressure Injury) & Non-wound Assessment & Documentation, which was provided by the DON on 7/20/21 at 3:17 p.m. indicated the following: 1. WOUNDS A. All wounds, as defined below, will be managed wound assessment will be completed to include: location, stage, current status, measurements, description, pain associatedd, PUSH scorre and current treatment. B. Even if the wound is being treated by .wound specialist, the facility will monitor the wound using the EMR to track This Federal tag relates to Complaints IN 134, IN 289 and IN 306. 3.1-40(a)(2)

A. Based on record review and interview, the facility failed to ensure adequate supervision of a resident with a known risk for falls for 1 of 2 residents reviewed for falls with major injury. This deficient practice resulted in the resident sustaining a wrist fracture and [MEDICAL CONDITION] during a subsequent fall (Resident 131). B. Based on observation, interview, and record review, the facility failed to ensure potentially hazardous items were securely stored on the dementia unit on 1 of 5 days of the survey period. Findings include: A. Review of Resident 131's closed clinical record was completed on 4/30/18 at 8:29 a.m. [DIAGNOSES REDACTED]. A 3/24/18 Admission Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. She required extensive assistance for ADLs, walking. and mobility. Her balance was unsteady and she needed staff assistance to stabilize herself. She used both a walker and a wheelchair. She had a 3/17/18 care plan for risk for falls. Interventions included, but were not limited to, her bed in lowest position with mat on floor (began on 3/21/18), monitor, offer assistance to the bathroom every two to three hours to establish a routine, rearrange furniture/trashcan to to allow for clear floor around head of bed (began on 3/21/18), and bed and chair alarms and every 15 minute checks (began on 3/22/18). She had a 3/22/18 care plan problem of a right wrist fracture. Review of a Nurses Assessment, dated 3/17/18, indicated she had fallen at her home, which resulted in a small subdural hematoma. She was alert and oriented to herself and situation, with a chronic confused state. She required standby assistance with her rolling walker in and out of her room, and assistance with toileting, and bed mobility. She had some lag to her left leg when walking and had a large purple hematoma to her left forehead related to a fall on 3/14/18 and a raccoon brown-red bruise to her left eye resulting from the same fall. A 3/17/18 Fall Risk Assessment indicated she had a history of [REDACTED]. Review of Progress Notes and Assessments indicated the following: On 3/20/18 at 2 a.m., she was found on the floor, sitting on her bottom. She had no obvious injury and an intervention for 15 minute checks were initiated as well a neurological checks. She was diagnosed with [REDACTED]. On 3/21/18 at 6:30 p.m., she was found on the floor in the Boulevard lounge, across from the nurses station. She had been in there eating her supper with her room-mate and her room-mate's visitor. Her roommate and visitor had left the lounge and Resident 131 had apparently tried to get out of her wheelchair and fell . She was found in a pool of blood, face down on the floor. An unnamed CNA held pressure to a large bruised area above her left eye that was open and bleeding profusely. She was transferred to the emergency department (ED) for treatment. A 3/21/18 ED triage report indicated she was diagnosed with [REDACTED]. A 3/22/18 Interdisciplinary Team (IDT) review indicated she had sustained a fall with a laceration above her left eye. The root cause was identified as unassisted transfers out of her wheelchair and the resident was forgetful and convinced she was able to walk and transfer independently like she used to. IDT recommendations were for a chair and bed alarms and 15 minute checks. A 3/26/18 physician visit note indicated she had a fall the previous week, and had developed a decreased ability to communicate. Her husband was inquiring about hospice, which the practitioner felt was indicated at that time. During an interview, on 5/1/18 at 10:25 a.m., LPN 33 indicated Resident 131 had primarily used a wheelchair for mobility, but used a walker in physical therapy. The facility staff kept her walker at her bedside and she would come out of her room at times unassisted. Staff propelled her wheelchair, and she was very unsteady when she walked with the walker. During an interview, on 5/1/18 at 10:30 a.m., with the DON and ADON, the ADON indicated that at the time of the 3/21/18 fall, the resident had been left alone in the lounge for only a few minutes. She was not aware of her trying to get out of wheelchair prior to this time, but she would ambulate in her room and used a wheelchair longer distances. During an interview, on 5/1/18 at 3:26 p.m., CNA 34 indicated the resident had walked with assistance for meals with a walker and standby assistance. She recalled that she could be unsteady at times, and had to be moved to a wheelchair. At the time of the resident's 3/21/18 fall, CNA 34 had been in the main dining room (MDR) on the Boulevard and the nurse on duty was at the nurses station across from the lounge, to monitor Resident 131. The nurse went to the MDR to let them know she was going to go on her rest break. As they walked back to the nurses station, the resident was found facedown on the floor in the lounge with her wheelchair behind her and her feet underneath the wheelchair. The wheelchair was facing the courtyard door. The resident was alone in the room. There was a large amount of blood under her head and she had a bleeding wound to her forehead. The nurse called 911 and transferred the resident to the hospital. Review of a current 4/13/16 facility policy, titled Fall Management Procedure, and provided by the DON on 5/1/18 at 11:15 a.m., indicated to assess all residents for risk factors that may contribute to falling and to provide planned interventions identified by the team as appropriate for resident use in maintaining or returning to the highest level of physical, social, and psychosocial functioning as possible. B. On 4/26/18 at 9:06 a.m., during an initial tour of the facility, the Boulevard shower room was observed to be unlocked and unattended. An unlocked and partially open wall cabinet in the shower room was observed to contain, but was not limited to, the following: A bottle of [MEDICATION NAME] 2% (antifungal) shampoo with a resident prescription label on it, a tube of partially used dermafungal cream with no resident identifier on it, nine disposable razors, and a partially-filled sharps container sat unsecured on the shelf. An open padlock and a key was on top of the soap dispenser. CNA 35 entered the shower room on 4/26/18 at 9:10 a.m. and indicated the room and cabinet should be kept locked. During an interview, on 5/2/18 at 2:29 p.m., the DON indicated there were 18 residents on the Boulevard able to either ambulate independently or were independently mobile. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to prevent the development of and to promote the healing of pressure ulcers for a resident identified as being at risk for 1 of 3 residents reviewed for pressure ulcers (Resident 31). Findings include: On 7/7/17 at 1:47 p.m., Resident 31 was in bed. Her mattress was set on static. On 7/7/17 at 1:55 p.m., she was in bed, requesting Tylenol for pain from LPN 33 prior to changing the dressing on her pressure wound to her buttock. On 7/7/17 at 2:30 p.m., she was in bed, with the mattress set on static. On 7/10/17 at 2:01 p.m., she was in bed, with the mattress set on static. Review of the clinical record began on 7/5/17 at 11:37 a.m. [DIAGNOSES REDACTED]. A quarterly, 5/10/17, Minimum Data Set (MDS) assessment indicated she required extensive assistance for bed mobility and was totally dependant on others for locomotion. The assessment indicated she was at risk for developing pressure ulcers. The clinical record indicated she had an unstageable pressure ulcer to her left buttock, which had developed in the facility on 5/30/17. She had a current 7/4/17 physician's orders [REDACTED]. A 5/26/16 physician's orders [REDACTED]. A 9/26/16 physician's orders [REDACTED]. A 5/23/17 physician exam note indicated she appeared lethargic, and was eating less and sleeping more. The note indicated she had a low-grade fever of 99.6 and appeared ill. A 5/30/17 physician exam note indicated she continued to appear ill, was being treated for [REDACTED]. A 6/5/17 physician exam note indicated she was out of bed and smiling, and was talking some. She had a current care plan problem of a urinary catheter due to an unstageable area to her left buttock. She had a current care plan problem of actual skin breakdown to her left buttocks. Interventions included, but were not limited to, low air loss mattress setting on 5. Review of a New Skin Alteration Assessment document, dated 5/30/17, indicated the following: .left buttock (outer) 1.3 cm (centimeters)/2cm blanchable (loses redness when touched, indicating blood flow)abrasion left buttock (inner) 2cm/2cm blanchable abrasion Right buttock 1.3/1/5 blanchable abrasion The note indicated the resident .gets [MEDICATION NAME] (sic) applied to areas at this time The assessment indicated the area was a skin alteration that would not need further assessment by the wound nurse. A Pressure Injury Assessment, dated 6/5/17, indicated a Deep Tissue Pressure Injury (DTPI) was present to Resident 31's left mid buttock, measuring 4 cm long (L) x 3.5 cm wide (W) x < 0.1 cm deep (D), with deep purple tissue present. The assessment indicated the wound originated as an abrasion, then the skin turned purple. Interventions included the following: pressure redistributing mattress and cushion, float heels, slider sheet while turning, care plan, and monitoring every shift. The assessment document described a DTPI as intact or non-intact skin with areas of persistent non-blanchable deep red, maroon, purple discoloration revealing a dark wound bed, with the injury resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface. A Pressure Injury Assessment, dated 6/5/17, indicated an Unstageable pressure ulcer was present to the resident's left inner buttock, measuring 1 cm L x 1 cm W x 0.1 cm D. The assessment indicated it had originated on 5/30/17. The assessment document described an Unstageable pressure ulcer as full-thickness skin and tissue loss in with the extent of tissue damage with the ulcer cannot be confirmed because it is obscured by slough (a yellow [MEDICATION NAME] tissue that consists of [MEDICATION NAME], pus, and protein material) or eschar (dark, dead skin tissue). The description indicated if slough or eschar is removed, a stage 3 or 4 pressure injury would be revealed. A Pressure Injury Assessment, dated 6/12/17, indicated the two pressure ulcers had combined into one Unstageable pressure ulcer to her left mid-buttock, measuring 4 cm L x 3.3 cm W with no depth due to a 2 cm L x 2.2 cm W black cap. A Pressure Injury Assessment, dated 7/3/17, indicated a non-healing 2.6 cm L x 2.6 cm W (no depth) with a black eschar cap measuring 2 cm L x 2.2 cm W. A Wound Clinic Note, dated 7/3/17, indicated the pressure ulcer measured 3 cm L x 2.8 cm W x 1.5 cm deep and was Unstageable due to necrosis. The note indicated the wound was debrided of a moderate amount of necrotic tissue during the visit. A Pressure Injury Assessment, dated 7/10/17, indicated the pressure ulcer measured 2.6 cm L x 2.6 cm W with no depth. The note indicated the black eschar cap was removed at the wound clinic on 7/3/17. During an observation of the completion of Resident 31's wound treatment by LPN 33 and LPN 31, on 7/7/17 at 2:30 p.m., an irregular-shaped wound, approximately the size of a large pink eraser, was observed to her left upper buttock. The wound bed was dark in color with a depth approximately the size of a pencil-top eraser. The edge of the wound rolled in at the 3 o'clock area. During an interview, on 7/10/17 at 1:17 p.m., CNA 34 indicated Resident 31 had been sick a few months ago, but her need for assistance with care hadn't changed. She indicated she had needed extensive assistance for care for a long time. On 7/10/17 at 1:56 p.m., LPN 35 indicated she did not know what setting the resident's mattress was to be set on. She indicated she was not able to locate it in the clinical record, but would find out. On 7/10/17 at 2:00 p.m., CNA 36 indicated she did not know what setting her mattress was to be set on. She indicated it was not on the CNA assignment sheet. During an interview, on 7/10/17 at 2:04 p.m., the ADON indicated the floor nurses were asked not to assign a stage to wounds, as the Wound Nurse (also the ADON), would assess the area and determine the stage. She indicated the 5/20/17 assessment could have been any break in the skin, not necessarily from pressure. The DON indicated the abrasion noted on the 5/20/17 assessment could have been a gaulded area noted during a change of the [MEDICATION NAME] dressing. She indicated she could not note any additional interventions implemented when the resident had taken ill acutely in late May 2017, although the facility was aware she was at risk for skin breakdown to her buttocks. They indicated the resident was a heavy wetter and her skin was continuously moist. They indicated she had been very ill in May, which had attributed to her developing the pressure ulcer. On 7/10/17 at 2:13 p.m., when asked why the 7/10/17 assessment indicated no depth to the wound, the ADON indicated the depth of the pressure ulcer was 0.3 cm that morning, she just hadn't finished documenting her assessment. She indicated she had completed the assessment between 5:30 and 6:00 a.m. that morning. On 7/10/17 at 2:14 p.m., LPN 35 indicated the mattress should be set at 5 and the information had been found in the care plan. The DON indicated at the time of the interview the information may not have been previously visible on the careplan, due to it being reviewed. Review of a policy, titled Wound (Pressure Injury) & Non-wound Assessment & Documentation, dated 5/17/17 and provided by the DON on 7/10/17 at 2:51 p.m., indicated all wounds would be managed by the facility wound nurse. The document defined an abrasion as .Skin has been rubbed or abraded away by friction such as a skinned knee 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure a resident was properly assessed, monitored and treated for [REDACTED].#95). Findings include: During an interview with Resident #95 on 7/7/16 at 10:46 A.M., she indicated she had wounds to her bottom and they hurt so bad that she cried every morning and every night when the staff changed her clothes and assisted her to bed. She further indicated when she sat in her wheelchair she did not have much, if any, pain. Resident #95 also indicated staff was supposed to check her brief every one to two hours to make sure she was dry, but it did not help with the pain. Furthermore, she indicated she asked staff the previous day to be sent to the wound clinic, but the staff was waiting on paperwork. During an observation of peri-care on 7/7/16 at 1:13 P.M., the following observations were made: Certified Nursing Assistant (CNA) #1, CNA #2 and Unit Manager #3 entered Resident #95's room. CNA #1 carried five washcloths and CNA #2 carried one towel. CNA #1 washed her hands and donned gloves. CNA #2 washed her hands and donned gloves. CNA #1 then used a paper towel to turn on the faucet and wet one washcloth. She then turned the faucet off with a paper towel. CNA #1 uncovered Resident #95 and undid her brief. CNA #1 removed her gloves and left the bedside, then returned. CNA #2 took the wet washcloth and sprayed perineal cleansing soap on it. She then began to wipe Resident #95's abdominal folds. She then folded the wet cloth and wiped the front of Resident #95's perineal area. Resident #95 began to moan and cry out as she was wiped. CNA #1 stated, take a deep breath to Resident #95 as CNA #2 continued to wipe. Multiple, circular, pinpoint to quarter size reddened and opened areas were visible on Resident #95's left thigh. Resident #95 used her right hand to grasp the bed rail and turned on her left side. CNA #2 used a new cloth to wipe the back of Resident #95's perineal area. Resident #95 continued to moan and cry out it hurts, it hurts repetitively. CNA #1 continued to state to Resident #95 to take deep breaths. CNA #1 also indicated that Resident #95 normally cried and moaned during perineal care. During an interview with Unit Manager #3 during the perineal care observation on 7/7/16 at 1:13 P.M., she indicated she had given Resident #95 [MEDICATION NAME] (a pain medication) thirty minutes ago. She further indicated Resident #95 received [MEDICATION NAME] three times a day. Furthermore, Unit Manager #3 indicated it did not appear the [MEDICATION NAME] was effective during perineal care. An observation of Resident #95's wounds were made on 7/8/16 at 11:27 A.M. The Director of Nursing (DON) was present and indicated the following observations: a. A quarter sized area to Resident #95's upper inner left thigh that was dark pink and cream colored. b. A nickel sized area to Resident #95's upper inner left thigh that was dark pink and cream colored. c. Two pencil eraser sized areas to Resident #95's upper inner left thigh that were dark pink and cream colored. d. A pinhead sized area to Resident #95's upper inner left thigh, towards the back, that was pink with a yellow-cream colored center. e. An area slightly larger than a quarter to Resident #95's upper inner left thigh, towards the back, that was scattered pink and cream colored. f. A pencil eraser sized area to Resident #95's upper inner left thigh, towards the back, that was scattered pink and cream colored. g. An area slightly smaller than a dime to Resident #95's right buttock that was pink and cream colored. h. An area to Resident #95's left center buttock that was cream colored with a pink center. i. An area to Resident #95's left outer buttock that was mostly cream colored with scattered pink throughout. An interview with the DON during the wounds observation indicated all of the areas noted had a break in skin integrity. She further indicated there were no formal measurements of the areas. During an interview with Resident #95 on 7/8/16 at 11:44 A.M., she indicated she would be more than happy to move and let people look at the wounds if it would get something to help. She also indicated it hurt to scoot or turn. Furthermore, she indicated that her bottom had hurt for 2 weeks. Resident #95 also indicated she loved to lay on her side but did not think she was allowed to because of her heels. The DON indicated Resident #95 previously had wounds on her heels, but they were healed now and she could lay on her side. During an interview with Resident #95 on 7/8/16 at 3:11 P.M., she indicated she let staff know when she was in pain, but did not ask for anything extra because she was on a routine pain pill. She further indicated that staff sometimes offered Tylenol, but she did not feel that it was effective. Resident #95 also indicated she would scream out when she urinated and was not changed right away. During an interview with RN #5 on 7/8/16 at 3:17 P.M., she indicated Resident #95 had the same skin condition to her buttocks and thighs for a long time. She further indicated the skin condition has never fully healed but it will get a little better at times. Furthermore, she indicated that she has heard Resident #95 cry out and believed it was probably the burning and stinging from the urine that caused her to be in pain. Resident #95's clinical record review began on 7/7/16 at 11:00 A.M. Resident #95's current [DIAGNOSES REDACTED]. Resident #95 had a current, 6/23/16, quarterly, Minimum Data Set (MDS) assessment that indicated she was cognitively intact and required extensive assistance with two or more people for bed mobility, transfers and toilet use. It also indicated she was frequently incontinent of bladder and had moisture associated skin damage. Resident #95 had a current, 6/17/16, care plan problem regarding occasional incontinence of bowel and frequent incontinence of bladder with potential for skin breakdown. Interventions for this problem included, but were not limited to, assist to toilet or check and change every two hours for bowel elimination, turn and reposition every 2-3 hours and as needed and weekly skin assessments. Resident #95 had a current care plan problem regarding chronic incontinent [MEDICAL CONDITION] with erosions to both inner thighs, inner buttocks and rectum. Interventions for this problem included, but were not limited to, monitor for signs and symptoms of infection and notify the physician as needed and monitor for complaints of pain or discomfort. Resident #95 had a current care plan problem regarding the potential for pain or discomfort related to history of wounds. Interventions for this problem included, but were not limited to, assess pain using the 0-10 scale, monitor the effectiveness of pain medications, notify physician as needed, administer pain medication per physician's orders [REDACTED]. Review of a document titled, Wound: Non-pressure wound assessment (facility wound nurse only), dated 6/13/16 at 1:03 P.M., and provided by the DON on 7/7/16 at 4:00 P.M., included the following: .1. Date originally noted: 05/20/2016 2. Type of wound . Incontinence associated [MEDICAL CONDITION] . 3. Current status . Closed over/resurfaced . 4. Describe the location of the wound more specifically . bilateral inner thighs, several erosions of chronic . Measurement of wound in centimeters: 5. Length 0 6. Width 0 7. Depth 0 8. Shape of wound . Irregular Wound Description: 9. WOUND . areas of erosions are open 10. WOUND EDGES . unattached 11. WOUND BED . red and irritated/inflamed . Pain assessment: 17. Pain Associated with wound assessment/treatment . Hurts a Little More . Treatment & Notification: 18. Current treatment . [MEDICATION NAME] (an antibiotic used to treat fungal infections) cream & powder Q (every) shift and PRN pillow case between thighs, check and change as needed sensicare (a protective barrier cream) Q shift PRN . duoderm (a [MEDICATION NAME] dressing) to erosions; left inner thigh, left back thigh and right inner/back thigh, change every 3 days . Wound progression (non-healing): 19 . areas are chronic from skin to skin contact. Obesity, non-ambulatory. Foley cath (catheter) to aide (sic) in wound healing incontinence [MEDICAL CONDITION] with erosion (sic). No progress noted . will DC (discontinue) cath. Erosions are chronic and become irritated and painful . Review of Resident #95's Nursing-Weekly Assessment(non-medicare), dated 6/11/16 - 7/7/16, provided by the DON on 7/7/16 at 4:00 P.M., indicated there were assessments completed on 6/11/16 and 7/2/16. The weekly nursing assessments included a skin assessment. During an interview with the DON on 7/7/16 at 4:00 P.M., she indicated there were no weekly nursing assessments during the weeks of 6/18 or 6/25. She further indicated weekly skin assessments would be included with the weekly nursing assessments and would not be located elsewhere. Furthermore, she indicated there were no other assessments done by the wound nurse other than the one on 6/13/16. Review of Resident #95's Progress Notes, dated 6/13/16 - 7/8/16, and provided by the DON on 7/8/16 at 11:18 A.M., included the following: .6/14/16 . She did complain of pain and discomfort to area on leg, but stated that the pillow cases and cream helps some. She reported that the NP is going to try a new cream and she wants to see how that goes. When she is incontinent, she holds the urine between her thighs, and [MEDICAL CONDITION] skin and causes sores. Cued her to try and spread legs to allow the urine to seep down so that it does not just sit on her skin. Author: (Name of Facility Social Worker) . 6/14/16 . Physician order [REDACTED]. Apply to inner thighs and buttocks topically two times a day for redness for 3 Weeks . Start Date: 6/14/16 End date: 7/5/16 . DC duoderm, dc [MEDICATION NAME] . 6/14/16 . PRN medication note . [MEDICATION NAME] Cream . Med not available at this time . 6/15/16 . PRN medication note . [MEDICATION NAME] Cream . Medication not available at this time . 6/16/16 . General Note . IDT (Interdisciplinary Team) . She has sore areas to legs . 6/16/16 . [MEDICATION NAME] Cream . Medication not available at this time . 6/17/16 . Received new orders per (Facility Physician Name): DC cream . start [MEDICATION NAME] (an antifungal) 1% cream every shift for incontinent [MEDICAL CONDITION] . start [MEDICATION NAME] (a steroid) 0.05% cream every shift for incontinence (sic) [MEDICAL CONDITION] . 7/7/16 . General Note . On 7/6/16 resident voiced to nursing staff she would like to see wound clinic with (Name of Hospital). Nurse spoke with NP (nurse practitioner) and NP agreed. Nurse obtained referral form from (Name of Hospital) wound clinic and filled it out. Wound referral is being faxed to (Name of Facility Physician) for signature at this time Review of a facility policy titled, Wound & Non-wound Assessment & Documentation, dated 4/13/16, provided by the DON on 7/8/16 at 11:18 A.M., included the following: .1. WOUNDS A. All wounds, as defined below, will be managed by the facility wound nurse(s) . Each week or more often if needed, the wound assessment will be completed to include: location, stage, current status, measurement, description, pain associated, PUSH score and current treatment . C. Definitions of wounds . XIV. Incontinent Associated [MEDICAL CONDITION] Inflammation and [DIAGNOSES REDACTED] (redness or inflammation of the skin) (with or without erosions and denudement) of skin that occurs when urine or stool comes into contact with perineal or perigenital skin 3.1-37(a)