Every finding on record at Northwest Manor Health Care Center

Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when a resident was transferred with only one staff and without a lift which resulted in actual harm of a tibia fracture for 1 of 6 residents reviewed for accidents (Resident 64), and the facility failed to prevent potential for accidents when a resident's medications were left at bedside without a self-administration assessment for 1 of 28 residents observed for environments (Resident 45).Findings include:Findings include: 1. On 5/12/26 at 9:20 a.m., Resident 64 was observed reclined in her bed, her right leg uncovered by the bed sheet so that her knee was observed. The knee was significantly swollen. Resident 64 was unable to indicate what happened. On 5/12/26 at 9:30 a.m., Physical Therapist (PT) 7 entered Resident 64's room and indicated, she needed to put a brace on the resident's knee before she left for an Orthopedic appointment later that day for a fracture she had sustained over the weekend. During an interview on 5/12/26 at 10:41 a.m., the Administrator (ADM) indicated the investigation was still ongoing into how Resident 64 acquired a tibia fracture. He indicated he had interviewed nursing staff and discovered, Resident 64 had been seen up in her wheelchair but without the Hoyer lift (a mechanical device that helps caregivers safely transfer individuals with limited mobility between beds, wheelchairs, or the toilet) pad underneath her per her usual. When the ADM questioned CNA 7, she admitted that she transferred Resident 64 into bed without the Hoyer lift. On 5/12/26 at 11:46 a.m., Resident 64 who had been brought to the front assistive dining room was heard as she called out, OW! Resident 64's right leg was extended outward and rested on a foot pedal. An unidentified Certified Nursing Aide (CNA) indicated as she was positioning Resident 64 to the table her extended leg must have bumped into something. During an interview on 5/12/26 at 12:53 p.m., CNA 8 indicated she worked with Resident 64 on a regular basis. CNA 8 confirmed the resident required a Hoyer lift for all transfers but indicated she had performed transfers of Resident 64 without the Hoyer lift to put her to bed on 5/8/26. During an interview on 5/12/26 at 1:08 p.m. CNA 9 indicated CNA 8 worked a double shift on 5/8/26 and put Resident 64 to bed. CNA 9 indicated she did not witness the transfer, but also confirmed, Resident 64 required a Hoyer lift for all transfers. On 5/12/26 at 9:34 a.m., Resident 64's record was reviewed. She was a long-term care resident who had diagnoses which included, but were not limited to, speech and language deficits following an unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), vascular dementia (damaged or blocked blood vessels that reduce blood flow and oxygen to the brain causing impaired judgment, difficulty planning, slower thinking, and memory loss), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden surges of electrical activity in the brain), and Pseudobulbar affect (a neurological condition characterized by sudden, uncontrollable, and inappropriate outbursts of laughing or crying). Resident 64 had a current physician's order, ordered 6/17/25, to use a Hoyer lift for all transfers. She had a comprehensive care plan, dated 2/27/26, which indicated she was dependent on staff for all activities of daily living (ADLs) which included, but were not limited to, bed mobility and transfers. An intervention for her transfer status was initiated 2/27/26 and specified the use of a Hoyer lift for all transfers. Her most recent comprehensive assessment was a quarterly Minimum Data Set (MDS) assessment, dated 3/17/26. The MDS indicated she was severely cognitively impaired and had exhibited no behaviors in the lookback window. A physician note, dated 3/18/26, indicated Resident 64 had .experienced suspected seizure activity on February 19 with tremors, no verbal response, and fixed gaze lasting a few minutes, and similar activity on January 17 with fixed gaze to the left, generalized spastic jerking, rapid respirations, and drooling.Patient has mixed type Alzheimer's and vascular dementia in severe stages with behavioral disturbance and limited verbal communication abilities following CVA [Cerebrovascular Accident, occurs when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients]. She remains dependent for all ADLs, wheelchair dependent with Hoyer lift for transfers. Nurses' notes, dated 4/15/26 at 11:19 am and 9:42 pm, indicated Resident 64 had seizure activity at 11:10 a.m. and 5 p.m. A nurse's note, dated 4/28/26 at 2:13 p.m., indicated Resident 64 was screaming and cursing at staff, hitting herself with closed fists, and holding on to the Hoyer lift during transfer shaking the lift. A nurse's note, dated 5/1/26 at 10:38 a.m., indicated the resident continued to scream out and was resistive to care, and would often grab the transfer sling and Hoyer during transfers. A Physiatry progress note, dated 5/5/26, indicated Resident 64's chief complaints were mobility and activities of daily living (ADL) deficits due to muscle atrophy (wasting or loss of muscle tissue), debility (a state of physical weakness), poor endurance (ability to sustain prolonged physical effort against fatigue), fall risk, and a history of CVA. The resident was picked up by therapy for rehabilitation due to generalized weakness, debility, poor endurance, and fall risk. The resident was pleasantly confused and only oriented to person. The note indicated, .Current functional status as of 5/1/26: The patient requires max assistance with bed mobility, max assistance with sit-to-stand transfers, and total assistance with chair to bed and bed to chair transfers using a Hoyer lift. She is unable to ambulate. A nursing progress note, dated 5/9/26 at 11:18 a.m., indicated Resident 64 had new and severe swelling and pain in her right knee with limited range of motion. The Nurse Practitioner (NP) was notified and a new order for Tylenol twice a day as needed was given. A nursing progress note, dated 5/9/26 at 4:09 p.m., indicated Resident 64 continued to have swelling with severe pain to her right knee with movement. Resident screaming during bed mobility specifically when right knee is touched. The Tylenol had been administered but was not effective. The NP was notified and a new order for an x-ray was given. A nursing progress note, dated 5/9/26 at 6:29 p.m., indicated Resident 64's x-ray results were received and showed an acute appearing proximal tibia fracture. Her family declined sending her to the emergency room, so an orthopedic (ortho) appointment was scheduled for 5/12/26. A nursing progress note, dated 5/10/26 at 6:01 a.m., indicated Resident 64 continued to have pain and yelled out with movement of her leg. Tylenol was given. A nursing progress note, dated 5/10/26 at10:37 a.m., indicated nursing staff contacted the on-call NP with concerns about exceeding the recommended dose of Tylenol and requested a repeat x-ray of Resident 64's knee. The NP declined the second x-ray, discontinued the Tylenol orders and gave new orders to give Tramadol every 8 hours as needed for knee pain. A NP progress note dated 5/11/26 at 12:00 a.m. indicated Resident 64 was seen for a follow up to the acute knee pain and swelling. Nursing reported noticing swelling to the patient's right knee on May 9 with pain noted with mobility. The on-call provider was notified, and orders were received for Tylenol 1000 mg twice daily as needed. Later that afternoon, nursing reported that pain to the right knee had worsened with movement, mobility, or touch. Imaging was ordered and completed, showing an acute proximal tibia fracture. The patient's family declined sending the patient to the ER for further evaluation and treatment. The patient was referred to Ortho with orders to elevate the right lower extremity and ice the knee as needed. The patient was made non-weight bearing to the right lower extremity. The patient is non-ambulatory at baseline and requires a Hoyer lift for transfers. Nursing notified the on-call provider again related to pain management, and tramadol 50 mg every 8 hours as needed was ordered. The patient did have seizure activity reported on May 7 while in bed. Staff was present during the seizure activity and did not observe any injury during the seizure activity. The patient has not had any recent falls and is dependent for mobility and transfers. A nursing progress note, dated 5/11/26 at 6:04 a.m., indicated Resident 64 continued to have pain with movement of her leg. Tylenol and ice packs were given. On 5/12/26 at 12:58 p.m., the Administrator provided a copy of current, but undated facility policy titled, Safe Lifting and Movement of Residents. The policy indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents in accordance with resident assessments, manufacturer instructions, and applicable federal and state regulations. Manual lifting of residents shall be eliminated when feasible and replaced with appropriate mechanical or assistive devices. Mechanical lifting devices shall be used for heavy lifting and for lifting and moving residents when manual lifting would place the resident or staff at risk. Failure to follow staffing requirements may result in corrective action. Safe lifting is incorporated into the facility's employee health and safety program, including injury prevention, training, and evaluation. On 5/12/26 at 11:05 a.m., the Administrator provided a copy of current, but undated facility policy titled, Fall Assessment. The policy indicated, Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 2. On 5/7/26 at 10:00 a.m., Resident 45 was observed with a cup of medications on his bedside table in his room. There were approximately 11 pills in the medication cup with a glass of water sitting next to the cup of pills. On 5/11/26 at 11:50 a.m., a record review was completed for Resident 45. He had the following diagnoses which included, but were not limited to, dementia (decline in memory and thinking skills severe enough to impair daily life) and cataracts (a clouding of the eye's natural lens that prevents light from clearly reaching the retina, leading to blurry, faded vision, and sensitivity to glare). A self-medication administration assessment was completed on 2/3/26. It indicated that resident was not to administer his medications on his own. On 5/11/26 at 12:05 p.m., during an interview with LPN 6, she indicated Resident 45 could not administer his own medications. A policy titled, Medication Administration, with no date was provided by the Executive Director on 5/12/26 at 1:02 p.m. It indicated, .Medication cannot, under any circumstance, be left at the patient bedside. Licensed staff must witness the ingestion of the prescribed medication by the resident. 410 Indiana Administrative Code (IAC) 16.2-3.1-45.

Based on observation, interview, and record review, the facility failed to ensure vital sign equipment was cleaned between residents (Residents 28 and 83), appropriate infection control techniques were used during blood glucose (sugar) checks, glucometers (measures blood sugar) were cleaned between residents (Residents 125 and 31), and enhanced barrier precautions (EBP) (infection control measures requiring staff to wear gowns and gloves during high-contact resident care to prevent the spread of multidrug-resistant organisms) were followed (Resident 93) during 5 of 35 medication observations. Findings include:1. During an observation, on 5/12/26 at 8:12 a.m., Licensed Practical Nurse (LPN) 5 used a portable vital signs machine to check Resident 28's blood pressure and oxygen saturation with the attached pulse oximeter. LPN 5 did not clean the blood pressure cuff or the pulse oximeter before or after using it. During an observation, on 5/12/26 at 8:23 a.m., LPN 5 used the same portable vital signs machine to check Resident 83's blood pressure and oxygen saturation. LPN 5 did not clean the blood pressure cuff or the pulse oximeter before or after using it. During an interview, on 5/12/26 at 9:58 a.m., the Director of Nursing (DON) indicated vital sign equipment should have been cleaned between each resident. On 5/12/26 at 11:04 a.m., the Administrator provided an undated document titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items.General Guidelines.c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include.blood pressure cuffs.d. Reusable items are cleaned and disinfected or sterilized between residents. 2. During an observation, on 5/12/26 at 11:13 a.m., LPN 6 checked Resident 125's blood glucose. LPN 6 removed a basket containing lancets, a container of glucometer strips, and the glucometer, and took it to Resident 125's room. LPN 6 sat the basket directly on the resident's bedside table with no barrier. With gloved hands, LPN 6 cleaned Resident 125's finger with an alcohol swab, reached into the communal container of glucometer strips, and placed one in the glucometer. LPN 6 completed the blood glucose check, put the container of glucometer strips and the glucometer back in the basket, and returned it to the medication cart. LPN 6 did not clean the glucometer before or after using it. During an observation, on 5/12/26 at 11:18 a.m., LPN 6 checked Resident 31's blood glucose. LPN 6 took the same basket, containing the lancets, a container of glucometer strips, and the glucometer, and entered the resident's room. LPN 6 placed the basket directly on the resident's bedside table and the glucometer on the resident's bed. No barriers were used. With gloved hands, LPN 6 cleaned Resident 31's finger with an alcohol swab, reached into the communal container of glucometer strips, and placed one in the glucometer. LPN 6 completed the blood glucose check, put the container of glucometer strips and the glucometer back in the basket, and returned it to the medication cart. LPN 6 did not clean the glucometer before or after using it. During an interview, on 5/12/26 at 11:20 a.m., LPN 6 indicated she thought the glucometer needed to be cleaned every third resident. On 5/12/26 at 12:56 p.m., the DON provided a list of residents who required blood glucose checks. The document indicated none of the residents had a blood-borne pathogen. During an interview, on 5/12/26 at 2:19 p.m., the DON indicated the glucometer should have been cleaned between each resident. She was not sure if a barrier should have been put down between the surface and the equipment or if it was acceptable for the nurse to use the same gloved hand that touched the resident to obtain the glucometer strip from the communal container of glucometer strips. On 5/12/26 at 3:28 p.m., the Administrator provided an undated document titled, Blood Glucose Monitoring, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.The licensed nurse performs the blood glucose test safely.4. Clean & Disinfect.c. Wash hands and apply gloves before cleaning the monitor. D. Thoroughly clean the meter. 3. During an observation, on 5/12/26 at 2:15 p.m., LPN 7 administered medication via gastrostomy tube (g-tube) (a tube inserted into the stomach through the abdomen for the administration of supplemental nutrition and medications) to Resident 93. A sign outside Resident 93's room indicated Enhanced Barrier Precautions (EBP) were required during high-contact care. LPN 7 did not wear a gown during the g-tube medication administration. During an interview, on 5/12/26 at 2:15 p.m., LPN 7 indicated she did not think Resident 93 required EBP. During an interview, on 5/12/26 at 2:19 p.m., the DON indicated EBP should have been used with the administration of medications via g-tube. Resident 93's record was reviewed on 5/12/26 at 2:50 p.m. A physician's order, dated 10/21/25, indicated enhanced barrier precautions related to the g-tube. On 5/12/26 at 3:28 p.m., the Administrator provided an undated document titled, Enhanced Barrier Precautions, and indicated it was the policy currently being used by the facility. The policy indicated, .Enhanced barrier precautions.are utilized to prevent the spread of multi-drug resistant organisms.to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity [as opposed to before entering the room].3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.g. device care or use.feeding tube. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on record review and interview, the facility failed to ensure documentation of a resident's chosen advanced directive was consistent across his medical record for 1 of 32 residents reviewed for accurate advanced directive documentation. (Resident 59)Findings include:On 12/8/26 at 12:29 p.m. Resident 59's medical record was reviewed. He was a rehab resident whose diagnoses included, but were not limited to, cerebral infarction (stroke) and hemiplegia (paralysis of one side of the body, often due to a stroke). Resident 59 was admitted to the facility on [DATE].Resident 59 had an Out of Hospital (OOH) Do Not Resuscitate (DNR) declaration, dated and signed on 2/20/26, uploaded into his medical record.A banner on Resident 59's medical record home page indicated he had elected to be a full code.Resident 59 had an active order for full code status dated 4/19/26.Resident 59 had an active care plan that indicated he was a DNR with a signed OOH DNR form on file, dated 2/23/26.During an interview on 5/13/26 at 11:10 a.m. the Director of Nursing (DON) indicated she was unaware there were discrepancies related to Resident 59's advanced directive status in his medical record. She indicated she would investigate it and correct any discrepancies immediately.On 5/13/26 at 12:37 p.m. a copy of a current facility policy titled Advanced Directives, dated September 2022 was provided. That policy indicated, .If the Resident Has an Advance Directive.2. The Director of Nursing Services (DNS) or designee notifies the attending physician of advanced directives.so that appropriate orders can be documented in the residents' medical record.3. The residents' wishes are communicated to the residents' direct care staff and physician by placing the advanced directive documents in a prominent, accessible location in the medical record.410 IAC (Indiana Administrative Code) 16.2-3.1-4(f)(4)(A)(ii).410 IAC (Indiana Administrative Code) 16.2-3.1-4(f)(5).

Based on record review and interview, the facility failed to ensure a Resident's Pre-admission Screening and Resident Review (PASRR) (a federal Medicaid requirement ensuring individuals with serious mental illness or intellectual disabilities are not inappropriately placed in nursing homes) was re-evaluated when there were inaccuracies on the assessment and when a psychiatric diagnosis was added for 2 of 3 residents reviewed for PASRR (Resident 8 and 76).Findings include:1. On 5/12/26 at 1:29 p.m. Resident 8's medical record was reviewed.She was a long-term care resident whose diagnoses included, but were not limited to, unspecified mood disorder, paranoid personality disorder (intense, irrational, and persistent feelings that others intend to harm, deceive, or exploit you), and depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and affects how you feel, think, and behave). Resident 8 had a diagnosis of schizophrenia (a chronic and severe brain disorder that affects how a person interprets reality causing a combination of hallucinations (such as hearing voices), delusions (false beliefs), disorganized thinking, and impaired daily functioning) that was added on 1/12/26 and deleted on 2/10/26, and a diagnosis of bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels) that was added on 1/12/16 and resolved on 3/24/26.Resident 8 had a PASRR assessment, dated 3/27/26, uploaded into her medical record. That assessment indicated Resident 8 currently had the following mental health diagnoses, schizophrenia, major depression (serious mood disorder characterized by a persistently low or sad mood, and a severe loss of interest in activities), bipolar disorder, and paranoid disorder.Resident 8's medical record lacked documentation of an active diagnosis of schizophrenia, major depression, or bipolar disorder on the date of the PASRR assessment.During an interview on 5/13/26 at 11:21 a.m. the Executive Director (ED) indicated the Director of Nursing (DON) was initiating a new PASRR assessment for Resident 8 to correct the inaccuracies. He indicated based on number 4 in their policy they should have done a new level 1 due to inaccuracies in the assessment.2. On 5/11/26 at 12:35 p.m. Resident 76's medical record was reviewed.He was a long-term care resident whose diagnoses included, but were not limited to, other specified mental disorders due to known physiological condition added on 3/16/26 and hallucinations (a false sensory perception that feels entirely real but occurs without any external physical stimulus) added on 4/27/26.Resident 76 had a PASRR assessment, dated 2/13/26, uploaded into his medical record. That assessment indicated he did not have any current mental health diagnoses.The record lacked documentation of a new PASRR assessment being completed when new mental health diagnoses were added on 3/16/26 and 4/27/26.During an interview on 5/13/26 at 11:35 a.m. the ED indicated they did not do a new PASRR when the new mental health diagnoses were added. He indicated the DON was initiating a new assessment immediately.On 5/13/26 at 12:37 p.m. a copy of a current, undated facility policy titled, Preadmission Screening and Resident Review (PASRR), was provided. That policy indicated, .4. Changes in Resident Condition: - A Resident Review is required if there is a significant change in status indicating the presence of or change in SMI [Serious Mental Illness], ID [Intellectual Disability], or RC [Related Conditions]. - The facility must notify the state PASRR authority and request a new evaluation if warranted.410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)

Based on record review and interview, the facility failed to provide a bed hold notification to residents or resident representatives for 2 of 4 residents reviewed for appropriate discharge process (Residents 114 and 82).Findings include:1. On 5/11/26 at 2:05 p.m., a record review was completed for Resident 114. She had the following diagnoses which included, but were not limited to, congestive heart failure (CHF, a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), diabetes mellitus type 2 (a chronic metabolic disorder where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels), and hypertension (high blood pressure). On 4/23/26 at 1:07 a.m., a progress note indicated Resident 114 complained of abdominal pain throughout the shift, rating it an 8 out of 10 on a pain scale. Her abdomen was distended. The physician was notified and an order was noted to send resident to the hospital for further evaluation. The resident's medical record lacked documentation of a bed hold. On 5/12/26 at 1:42 p.m., during an interview with the Director of Nursing (DON), she indicated she could not find any information related to the discharge on [DATE]. 2. On 5/11/26 at 9:23 a.m. Resident 82's medical record was reviewed. She was a long-term care Resident whose diagnoses included but were not limited to type 2 diabetes and chronic kidney disease (long-term, progressive loss of kidney function). A progress note, dated 2/24/26, indicated the facility sent Resident 82 to the hospital due to a critically low blood potassium level. The medical record lacked documentation that a bed hold notification was provided to Resident 82 or a Resident representative. During an interview on 5/13/26 at 10:27 a.m. the Director of Nursing (DON) indicated she was unable to find documentation of a signed bed hold notification for Resident 82's hospitalization on 2/24/26. On 5/13/26 at 12:37 p.m. a copy of a current, undated facility policy titled Bed-Holds and Returns was provided. That policy indicated, .Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Residents, regardless of payer source, are provided written notice about these policies at least twice:.b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) .

Based on observation, interview, and record review, the facility failed to ensure a resident who sustained a fall and complained of neck pain with swelling was assessed prior to being moved and was moved before emergency medical staff arrived for 1 of 3 residents reviewed for falls, (Resident 7), and failed to follow physician's orders related to congestive heart failure (CHF) (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to build up in the lungs and body) for 1 of 10 residents reviewed for quality of care (Resident 114).Findings include: 1. On 5/11/26 at 11:30 a.m., Resident 7's record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, chronic kidney disease (a progressive condition where damaged kidneys slowly lose their ability to filter waste and excess fluid from the blood) and hypertension (high blood pressure). A nursing progress note, dated 1/29/26 at 5:36 a.m., indicated, at appropriately 5:06 a.m., the Certified Nursing Aide (CNA) notified the writer that Resident 7 was found sitting on the floor beside his bed. Writer immediately assessed the resident. Resident 7 was found sitting on the floor, with his two hands on the bed, and one leg folded. The resident stated, I rolled out of bed. On assessment Resident 7 complained of pain at the back of his head. There was slight swelling noted to neck. All extremities were movable without pain or discomfort. No bruising or bleeding was observed at the time. With assistance of two CNAs, the resident was safely transferred back in bed. The resident was hypotensive [low blood pressure] with blood pressure of 73/42 and complained of dizziness. Speech was clear, but resident was dizzy. He responded to name, pain, and environment. While vital signs were being taken, resident experienced a seizure lasting approximately 1 minute. After the seizure activity stopped, the resident returned to baseline. Resident was positioned on side to prevent aspiration. The on call Nurse Practitioner (NP) was notified and a verbal order was received to send the resident to the emergency room (ER). Prior to the arrival of the Emergency Medical Services (EMS), Resident 7 had an additional seizure lasting 15 seconds. 911 was called at 5:15 a.m. EMS arrived at 5:20 a.m. Resident was transported to ER via EMS. An interdisciplinary team (IDT) progress note, dated 1/29/26 at 8:36 p.m., indicated, Resident had an unwitnessed fall on 1/29/26 at 5:06 a.m. CNA notified nurse that resident was sitting on the floor. Upon entering the room, the nurse noted that the resident was sitting on the floor with two hands on the bed and a leg folded. Resident stated to the nurse that he rolled out of bed. Nurse assessed resident; at time of assessment, resident [complained of] pain to the back of head. Nurse noted slight swelling to the neck. Resident [blood pressure] - 73/42, but able to move all extremities, AROM [active range of motion] without pain. Nursing staff assisted resident back into bed. On call ordered to send resident to ER for eval and tx d[due to] possible seizure activity. The resident's record lacked documentation of if the resident was moved prior to seizure activity, vital signs, and assessment were completed or after their completion. During an interview on 5/12/26 at 10:31 a.m., Licensed Practical Nurse (LPN) 10 indicated if a resident sustained a fall and complained of neck pain and/or if the assessment revealed neck swelling, the resident should absolutely not be moved. The nurse should try to keep the resident as still as possible until 911 arrived. During an interview on 5/12/26 at 10:33 a.m., Qualified Medication Aide (QMA) 11 indicated she could not assess a resident, but if she found a resident on the floor she would call for the nurse to immediately assess and try to keep the resident as still as possible. During an interview on 5/12/26 at 1:00 p.m., the Director of Nursing indicated if a resident sustained a fall witnessed or not, and complained of neck pain with noted neck swelling, the nurse should not move that resident until emergency medical professional arrived. The DON indicated it was unclear if the resident was moved before or after the assessment and seizure activity. On 5/12/26 at 11:05 a.m., the Administrator provided a copy of current, but undated facility policy titled, Fall Assessment. The policy indicated, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. On 5/11/26 at 2:05 p.m., a record review was completed for Resident 114. She had the following diagnoses which included but were not limited to, congestive heart failure (CHF) (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to build up in the lungs and body), and hypertension (high blood pressure). She had an order, dated 3/9/26, to weigh her daily related to CHF, special instructions: notify provider when resident weight is greater than 2 pounds per day or 5 pounds in one week. Resident 114 had a care plan dated 4/9/26. It indicated that resident was at risk for cardiac complications related to hypertension, coronary artery disease (CAD), and CHF. An intervention dated 3/9/26 indicated to weight resident daily. Resident 114's Medication Administration Record (MAR) was reviewed. On 4/16/26 her weight was 132.0 pounds and on 4/17/26 her weight was 137.0 pounds. That was a 5-pound weight gain. The record lacked documentation of notification of the physician. On 4/19/26 her weight was 133.2 and on 4/20/26 her weight was 136.6. That was a 3.4-pound weight gain. The record lacked documentation of notification of the physician. On 5/12/26 at 1:32 p.m., during an interview, the Director of Nursing indicated she could not find the notification of physician and resident was assigned to an outside provider. An undated policy titled, Reporting Weight Changes was provided by the Executive Director (ED) on 5/12/26 at 12:58 p.m. It indicated .Report significant weight loss/weight gain to the nurse supervisor and physician. 410 Indiana Administrative Code (IAC) 16.2-3.1-37.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 23 residents' MDS assessments reviewed (Resident 6). Findings include: Resident 6's record was reviewed on 5/11/26 at 11:50 a.m. Census information indicated the resident was admitted to the facility on [DATE]. An annual MDS assessment, dated 2/6/26, indicated the resident was cognitively intact and had one fall with a major injury. The resident's electronic record lacked documentation the resident had a fall with major injury. During an interview, on 5/11/26 at 1:00 p.m., the Director of Nursing (DON) indicated the annual MDS assessment, dated 2/6/26, was not accurate. The resident had not had a fall with major injury. The facility utilized the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual as their policy for MDS assessment accuracy. The CMS MDS RAI Manual Version 3.0, dated October 2025, indicated, .Coding Instructions for J1900.Code 1, one: if the resident had one non-injurious fall since admission/entry or reentry or prior assessment. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(b)(1)

Based on observation, interview, and record review, the facility failed to ensure care plan interventions were personalized and updated to include changes in shower preferences for 2 of 3 residents reviewed for bathing preferences (Residents B, and H). Findings include:1. During an interview on 7/21/25 at 10:15 a.m., Resident Representative 1 indicated Resident B had not received a shower for the past year, until after the family had complained and met with administrative staff. A Resident/Family Concern Form, dated 6/22/25 at 11:30 a.m., indicated Resident Representative 1 verbalized to the weekend supervisor she had a concern regarding Resident B not getting showers. The resolution, dated 6/23/25, indicated the resident got a shower and staff were educated on the use of a shower bed.On 7/21/25 at 11:00 a.m., Certified Nursing Assistant (CNA) 6 and an unidentified female staff member were observed using a mechanical lift to transfer Resident B out of bed into a specialized tilt and recline wheelchair. Resident B was observed to be wearing a green dress, black cap over her braided hair, a beaded bracelet, and gray socks. CNA 6 indicated he had not recently cared for the resident, but he was filling in for staffing today and had Resident B on his assignment list to give a bath.Resident B's clinical record was reviewed on 7/21/25 at 2:00 p.m. Resident B was admitted on [DATE] with diagnoses to include vascular dementia, hemiplegia and hemiparesis (paralysis on one side of the body) following a cerebral infarction affecting the left non-dominant side, morbid obesity, and dysphasia (neurological disorder that affects the ability to understand, produce, or use language). A Preferences for Customary Routine and Activities assessment, dated 6/24/25, indicated it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The assessment lacked documentation of Resident B's preferences. A care plan, dated 6/22/24, indicated the resident liked to choose bathing options, what to wear, listening to religious music, watching tv/comedies, and usually to be up by 10:00 a.m., and in bed by 3:00 a.m. Resident B's goal was to have her preferences met daily, and the approach was to be offered bathing options and what to wear. The care plan lacked documentation of chosen bathing options. A Care Plan Attendance Form with dates of 4/29/25 and 6/30/25 was signed as the plan of care meeting expectations and issues addressed. There was no documentation to describe what the issues might have been, how the issues were resolved, and no care plan update. Observation of CNA Assignment Sheets indicated Resident B was scheduled for showers on Wednesday and Saturday day shift.During an interview on 7/21/25 at 2:43 p.m., Licensed Practical Nurse (LPN) 5 indicated, Resident B had some confusion and did not always make her own decisions. Shower preferences were documented during care plan conferences between the resident/resident representative, Unit Manager (UM), and Social Service Director (SSD). If a resident could not make their own decisions, then the staff would follow family preference decisions to provide care. If a resident was combative and refused care or showers, that behavior would be documented, the refusals discussed with family, and care plan decisions documented. During an interview on 7/21/25 at 3:12 p.m., UM 1 indicated she shared duties with another nurse on a rotating schedule. Both nurses were responsible for attending care plan conferences for Wings 1 and 2, dependent on who was working. UM 1 indicated, Resident B's resident preference form had been completed, but it was vague. Resident bathing preferences should have been on the care plan and then linked to the CNA profile. A resident preference could also be set up to be clicked off/documented as completed on POC. All department heads or department representatives had the capability to add resident specific wishes on the care plan. If a confused resident was refusing care the family had specified, then a conversation would be had with the family to try and resolve, and the conversation and outcome would be documented in the resident record.2. On 7/21/25 at 10:55 a.m., Resident H was observed lying in a bariatric bed watching television. The resident indicated she liked getting a shower and thought she'd had one last week.On 7/22/25 at 9:24 a.m., Resident H was observed lying in the bed listening to a portable boom box. The resident indicated that she liked getting a shower and her hair washed, and she was supposed to be getting a shower that day. The resident indicated she was unable to stand to transfer, and the staff had to Hoyer her to the shower chair.Resident H's clinical record was reviewed on 7/21/25 at 2:59 p.m. Diagnoses on the resident's profile included, encephalopathy (a group of conditions that cause brain dysfunction) and obesity.A Preferences for Customary Routine and Activities assessment, dated 5/23/25, indicated it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The assessment lacked documentation of Resident H's preferences.A care plan, dated 6/20/23, indicated the resident liked to choose bathing options, word searches, bingo, listening to music R & B, watching tv/soap operas, religious activities, and checkers. Resident H's goal was to have her preferences met daily, and the approach was to be offered bathing options. The care plan lacked documentation of resident's refusal for showers.A Point of Care History report indicated the resident was totally dependent on staff for bathing and showers. The report indicated there was no documentation for showers or refusal of showers between 1/1/25 and 7/14/25. On 7/22/25 at 10:00 a.m., observation of Resident H's clinical record with the Assistant Director of Nursing (ADON). The resident record lacked documentation, in POC or on the paper shower/skin monitoring sheets, that the resident had received or refused a shower in 2025,During an interview on 7/22/25 at 10:16 a.m., the DON, ADON, and UM 1 indicated Resident H was known to change her mind about care. If she had refused to have a shower, an alternative shower method would have been given, and the refusal documented. The DON indicated, Resident H had not come forward and indicated she wanted or was not getting a shower.On 7/22/25 at 12:47 p.m., the ADM provided a Care Plans, Comprehensive Person-Centered policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, A comprehensive, person-centered care than that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.1. The interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.11. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' condition change. 12. The interdisciplinary team reviews and updates the care plan.This citation relates to Complaint 1627127. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide or document showers for 2 of 3 residents reviewed for bathing preferences (Residents B, and H).Findings include:1. During an interview on 7/21/25 at 10:15 a.m., Resident Representative 1 indicated Resident B had not received a shower for the past year, until after the family had complained and met with administrative staff. A Resident/Family Concern Form, dated 6/22/25 at 11:30 a.m., indicated Resident Representative 1 verbalized to the Weekend Supervisor she had a concern regarding Resident B not getting showers. The resolution, dated 6/23/25, indicated the resident got a shower and staff were educated on the use of a shower bed.On 7/21/25 at 11:00 a.m., Certified Nursing Assistant (CNA) 6 and an unidentified female staff member were observed using a mechanical lift to transfer Resident B out of bed into a specialized tilt and recline wheelchair. Resident B was observed to be wearing a green dress, black cap over her braided hair, a beaded bracelet, and gray socks. CNA 6 indicated he had not recently cared for the resident, but he was filling in and Resident B was on his assignment list to give a bath.On 7/22/25 at 9:15 a.m., Resident B was observed lying flat on her back in bed, eyes opened and covers to her chest. The resident was wearing a bright yellow tunic/dress and a beaded bracelet on her right wrist. The resident's braided hair was observed to be flattened and frizzy, it did not look as if it had been recently braided. The resident indicated she liked getting showers but did not remember if she'd had one recently.Resident B's clinical record was reviewed on 7/21/25 at 2:00 p.m. Resident B was admitted on [DATE] with diagnoses to include vascular dementia, hemiplegia and hemiparesis (paralysis on one side of the body) following a cerebral infarction affecting the left non-dominant side, morbid obesity, and dysphasia (neurological disorder that affects the ability to understand, produce, or use language). The annual MDS (Minimum Data Set) assessment, completed on 6/27/25, assessed Resident B as having severe cognitive impairment, and she B was dependent on staff for bathing, showers, and toileting. The resident utilized a mechanical lift for transfers and was propelled by staff in a manual wheelchair. It was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. A Preferences for Customary Routine and Activities assessment, dated 6/24/25, indicated it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The assessment lacked documentation of Resident B's preference(s). A care plan, dated 6/22/24, indicated the resident liked to choose bathing options, what to wear, listening to religious music, watching tv/comedies, and usually to be up by 10:00 a.m., and in bed by 3:00 a.m. Resident B's goal was to have her preferences met daily, and the approach was to be offered bathing options and what to wear.A Care Plan Attendance Forms with dates of 4/29/25 and 6/30/25 were signed as the plan of care meeting expectations and issues addressed. There was no documentation to describe what the issues might have been, how the issues were resolved, and no care plan update. CNA Assignment Sheets indicated Resident B was scheduled for showers on Wednesday and Saturday day shift.A typed note, dated 6/30/25, indicated in-service for all staff and Resident B specifically, included, Make sure the resident is getting her showers on Wednesday and Saturday day shift .Use the soap/hygiene products in her room .Use a Hoyer pad and shower bed .When the shower is done and the resident returns to her room, place 3-4 towels on the bed before lying the resident on the mattress .Once the resident is in bed, remove the towels and continue care .On shower days, the night CNA should not dress the resident, leave her in a gown since a shower will be done .The family prefers regular clothes instead of gowns Point of Care (POC - electronic documentation system) History report, indicated the resident was totally dependent on staff for bathing, showers, toilet use, and personal hygiene. The report indicated there was no documentation for showers or refusal of showers from 6/20/24 to 6/25/25. During an interview on 7/21/25 at 2:39 p.m., CNAs 10 and 11 indicated Resident B's shower day was documented in the shower book and on the daily CNA assignment sheet.During an interview on 7/21/25 at 2:43 p.m., Licensed Practical Nurse (LPN) 5 indicated Resident B had some confusion and did not always make her own decisions. Shower preferences were documented during care plan conferences between the resident/resident representative, Unit Manager (UM), and Social Service Director (SSD). If a resident could not make their own decisions, then the staff would follow family preference decisions to provide care. If a resident was combative and refused care or showers, that behavior would be documented, the refusals discussed with family, and care plan decisions documented. During an interview on 7/21/25 at 3:12 p.m., UM 1 indicated she shared duties with another nurse on a rotating schedule. Both nurses were responsible for attending care plan conferences for Wings 1 and 2, dependent on who was working. UM 1 indicated Resident B's resident preference form had been completed, but it was vague. Resident bathing preferences should have been on the care plan and then linked to the CNA profile. A resident preference could also be set up to be clicked off/documented as completed on POC. All department heads or department representatives had the capability to add resident specific wishes on the care plan. If a confused resident was refusing care the family had specified, then a conversation would be had with the family to try and resolve, and the conversation and outcome would be documented in the resident record.During an interview on 7/22/25 at 9:47 a.m., CNA 12 indicated she had helped give Resident B a shower the prior Saturday, and that documentation could be found in POC. During an interview on 7/22/25 at 8:56 a.m., Resident Representative 2 indicated Resident B had dementia, but had always been a very clean person, and was not known for refusing care or a shower. Resident Representative 2 indicated she knew the standard procedure for nursing home residents was to be offered showers on a weekly basis, and the family had no reason to believe their mother was not being given showers. On 6/21/25, Resident Representative 1 gave Resident B a bath and observed her to be dirty in hard-to-reach places. On 6/21/25, when she questioned staff, she received different responses about when the resident's shower day was, and the last time she'd been given a shower, and finally was told the resident had never been given a shower as the facility did not have the equipment to give her a shower. She also observed the residents' few toiletries were not opened, and Resident Representative 2 went that day to the store and purchased more toiletries to include shampoo and bath gel. Before leaving that evening, staff were asked to give the resident a shower. On 6/22/25 Resident Representative 2 visited again, and when staff were asked if Resident B had gotten a shower, she was told the resident was not given a shower as the staff thought she was clean enough. Resident Representative 1 then made a formal complaint, and Resident B did not receive a shower until Wednesday 6/25/25.On 7/22/25 at 9:51 a.m., observation of Resident B's record with LPN 5, who indicated she was the charge nurse in Resident B's hallway. The resident record lacked documentation of the resident having received a shower before 6/25/25.During an interview on 7/22/25 at 10:19 a.m., the Director of Nursing (DON) indicated on Saturday 6/21/25, Resident B's family was in the facility and asked about showers, and the resident was given a shower that day. On Monday 6/30/25, there was a care plan meeting with the family who were alleging the resident was not getting showers. The DON indicated she thought the resident had been getting showers, if not consistently, before the concern was brought forth by family. Aides should notify the charge nurse any time a resident refused a bath or shower, then the nurse could make sure the bath or shower was offered again at a later time. If the resident still refused to be bathed, the incident should be documented in the clinical record.2. On 7/21/25 at 10:55 a.m., Resident H was observed lying in a bariatric bed watching television. The resident indicated she liked getting a shower and thought she'd had one last week. On 7/22/25 at 9:24 a.m., Resident H was observed lying in the bed listening to a portable boom box. The resident indicated that she liked getting a shower and her hair washed, and she was supposed to be getting a shower that day. The resident indicated she was unable to stand to transfer, and the staff had to mechanically lift her to a shower chair.Resident H's clinical record was reviewed on 7/21/25 at 2:59 p.m. Diagnoses on the resident's profile included encephalopathy (a group of conditions that cause brain dysfunction) and obesity. A quarterly MDS assessment, completed on 6/7/25, assessed the resident as being cognitively intact, and she had no refusals of care. The resident required assistance for transfers, bathing, dressing, and toileting. A Preferences for Customary Routine and Activities assessment, dated 5/23/25, indicated it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The assessment lacked documentation of Resident H's bathing preference(s).A care plan, dated 6/20/23, indicated the resident liked to choose bathing options, word searches, bingo, listening to music R & B, watching tv/soap operas, religious activities, and checkers. Resident H's goal was to have her preferences met daily, and the approach was to be offered bathing options.A Point of Care History report indicated the resident was totally dependent on staff for bathing and showers. The report indicated there was no documentation for showers or refusal of showers between 1/1/25 and 7/14/25. On 7/22/25 at 10:00 a.m., observation of Resident H's clinical record with the Assistant Director of Nursing (ADON). The resident record lacked documentation, in POC or on paper shower/skin monitoring sheets, that the resident had received or refused a shower in 2025.During an interview on 7/22/25 at 10:16 a.m., the DON, ADON, and UM 1 indicated Resident H was known to change her mind about care. If she had refused to have a shower, an alternative shower method would have been given, and the refusal documented. The DON indicated Resident H had not come forward and indicated she wanted or was not getting a shower.During an interview on 7/22/25 at 10:42 a.m., UM 1 and LPN 5 indicated Resident H had been given a shower the prior week, but there was no documentation of the shower. UM 1 indicated CNA 7 had been told before she needed to document care. The ADON indicated when pulling the report for the prior week, Resident H was documented as having bed baths.On 7/22/25 at 11:01 a.m., the DON indicated Resident H had refused her shower that day, and that did not surprise her as the resident often changed her mind about the care she wanted. The CNA had been instructed to document the refusal.On 7/22/25 at 12:47 p.m., the Administrator (ADM) provided comprehensive shower sheets, dated 6/28/25 and 7/9/25, with a handwritten note that said shower. Shower sheets dated 3/8/25 and 6/25/25 had no documentation to indicate a shower had been given. On 7/22/25 at 11:01 a.m., the ADM provided a Resident Bathing/Showering policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, the purpose of the policy was to ensure that each resident was afforded the right to personal hygiene and dignity through routine and individualized bathing/showering. It was the policy of the facility to provide residents with bathing or showering services in accordance with their comprehensive care plan. 1. Each resident will be assessed upon admission and quarterly [or with significant changes] to determine bathing preferences.Residents' specific bathing preferences may be identified on the resident care plan or facility shower schedule.2. Residents shall be offered a bath or shower at least twice per week or more often as desired by the resident.Changes in frequency based on resident refusal or medical need must be documented ad addressed in care planning.All refusals and re-approach attempts must be documented.Daily documentation must include: Type of bath provided. Time and staff involved. Resident tolerance and any refusals.Changes in bathing routine, refusals, and clinical concerns ae to be reported to the charge nurse and IDT [Interdisciplinary Team].This citation relates to Complaint 1627127. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place as outlined in the residents' plan of care for 3 of 4 residents reviewed for falls (Residents 88, 96, and 85). Findings include: 1. On 6/5/25 at 2:22 p.m., Resident 88 was observed in the main dining room during a group activity. She was seated in a wheelchair and although she had a personal storage pouch, it was attached to the back of her wheelchair out of reach. She was not observed to have a reacher. On 6/9/25 at 8:35 a.m., Resident 88 was observed. She was seated in her wheelchair in the main dining room, in front of the nurses' station. Her eyes were closed and there was a stack of papers and a word search booklet which rested on her lap. Upon approach and calling her name, she raised her head and opened her eyes as the stack of papers began to slide from her lap. Resident 88 did not have a reacher. The personal storage pouch was attached to the back of her chair. Resident 88 indicated she must have nodded off asleep while she waited for the housekeepers to finish sweeping in the dining room. She indicated she was tired and wouldn't mind a nap. Resident 88 indicated she had a couple falls from out of her wheelchair because she would attempt to lean forward and reach for things that fell. She indicated she had a reacher before but did not know where it was and that it had been missing for a while. She indicated she did have a personal storage pouch but it was on the back of her wheelchair, and she could not reach it, when asked if staff would assist her to get things or put things away, she indicated, I ask, but you know how that goes. They are so busy, I don't bother them with the small stuff. A plastic chair alarm was observed underneath her pressure reducing cushion and when asked if that caused her cushion to slide, she demonstrated he ability to slough down and slide forward in the seat. She was able to reposition herself back up to an upright position and indicated, I try not to do that because I've learned the hard way. During a continuous observation from 6/9/25 at 8:40 a.m., until 9:00 a.m., Resident 88 was left unsupervised by nursing staff in the main dining room as two housekeepers swept, mopped, and wiped down tables. On 6/9/25 at 8:10 a.m., Resident 88's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, repeated falls, fracture of first and third lumbar vertebra and fracture of mandible (jaw). A nursing progress note, dated 9/19/24 at 6:28 p.m., indicated Resident 88 had been in the dining room with a peer when a loud noise was heard. Resident 88 was found on the floor with her face down. She was assisted back into her wheelchair with help from staff and taken back to her room where she was assessed and found to have sustained a skin tear to the middle of her nose and a hematoma to her forehead. Her vital signs and neuro checks were within normal limits, and the doctor was notified. An Interdisciplinary team (IDT) progress note, dated 9/20/24 at 12:35 p.m., indicated Resident 88 had an unwitnessed fall in the dining room after she attempted to reach something on the floor. A new intervention was put in place to ensure she was not left unattended in the dining room. Her care plan was updated. A nursing progress note, dated 1/11/25 at 7:29 p.m., indicated Resident 88 was found on the floor after she attempted to transfer from her wheelchair into her bed. An IDT progress note, dated 1/13/25 at 7:08 p.m., indicated a new intervention for fall prevention was to ensure Resident 88 was laid down after meals. Her care plan was updated. A nursing progress note, dated 5/11/25 at 6:51 p.m., indicated Resident 88 fell form her wheelchair while she was sitting in the dining room and she attempted to pick up an item that had fallen onto the floor. She sustained a laceration to the right eyebrow and was bleeding. She was transported to a local trauma hospital. A nursing progress note, dated 5/12/25 at 8:33 a.m., indicated Resident 88 returned form the hospital after she sustained right sided mandible fracture and thoracic spine fractures. An IDT progress note, dated 5/12/25 at 12:28 p.m., indicated Resident 88 sustained a fall on 5/11/25 after she was witnessed to attempt to pick up personal items from the dining room floor. Active bleeding was noted at the time of the fall, first aide was provided and after the resident complained of a headache she was sent to the emergency room for further evaluation and treatment. She was diagnosed with a right-side mandible fracture and fracture of the first and third thoracic spine. The IDT determined new interventions to be put in place were: a wheelchair side storage bag for personal items, a reacher to keep with and utilize while in her wheelchair and she was referred to therapy for wheelchair positioning. Her care plan was updated. Resident 88's comprehensive care plan was reviewed. She had a care plan, dated 4/1/24, which indicated she was at risk for falls related to her diagnoses. Interventions for this plan of care included, but were not limited to: therapy to procure reacher for resident's use created on 7/1/24 and reacher for resident to keep with wheelchair and utilize while in wheelchair created 5/12/25. An intervention in all caps, DO NOT LEAVE UNATTENDED IN DINING ROOM, created on 9/20/24 and PLEASE LAY RESIDENT DOWN AFTER MEALS, created 9/20/24. Resident 88's fall care plan also included interventions created on 9/11/24 for wheelchair and bed alarms to be placed. The record lacked documentation of a comprehensive fall risk assessment before the wheelchair and bed alarms were installed. The record lacked documentation that the resident and/or representatives were educated on the use of and/or alternatives before installing the alarms. The record lacked documentation that the resident and/or representative gave informed consent for the use of alarms before installation. 2. On 6/5/25 at 10:25 a.m. Resident 96 was observed as he laid in bed watching TV. There was a fall mat on floor next to the resident's bed, his call light was within reach, and there was a regular mattress on his bedframe. On 6/9/25 at 9:35 a.m. Resident 96's medical record was reviewed. He was a long-term care resident whose diagnoses included but were not limited to, dementia and unspecified psychosis. A progress note, dated 4/14/25 at 7:15 a.m., indicated the resident was found on the floor by his bed. No pain was noted, and the resident only indicated he was ready to get up. An Interdisciplinary Team (IDT) note, dated 4/15/25 at 9:10 p.m., indicated the new fall intervention for Resident 96's fall on 4/14/25 was to put a perimeter mattress (a mattress that features raised foam bolsters along its sides to help prevent Residents from rolling out of bed or accidentally falling) on his bedframe. On 6/9/25 at 1:05 p.m. Resident 96 was observed as he laid in bed with the bed in the lowest position and the floor mat was next to his bed. It was found that there was a regular mattress on his bedframe, no bolsters or perimeter mattress were present. 3. On 6/10/25 at 1:56 p.m. Resident 85's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to, type 2 diabetes, weakness, and repeated falls. A progress note, dated 9/8/24 at 12:13 a.m., indicated Resident 85 was found sitting on the floor next to her bed and wheelchair. An IDT note, dated 9/9/24 at 12:59 p.m., indicated the new fall intervention for Resident 85's fall on 9/8/25 was to educate her on the importance of call light use and not attempting to toilet herself. A progress note, dated 3/4/25 at 12:54 p.m., indicated the writer of the note was going to check Resident 85's blood sugar when they found the resident lying on the floor next to her bed. An IDT note, dated 3/5/25 at 5:28 p.m., indicated the new fall intervention for Resident 85's fall on 3/4/25 was to utilize a bed alarm. On 6/10/25 at 3:40 p.m. Resident 85 was observed as she laid in bed resting with her eyes closed. The door was closed upon entering the room. The resident's call light was found on the floor next to the bed. Licensed Practical Nurse (LPN) 10 who usually worked with Resident 85 came to observe the room. LPN 10 indicated they normally kept her door cracked because the resident liked the door closed, but they never closed it all the way. LPN 10 indicated the resident's call light should have been in bed with the resident within reach. When asked about Resident 85's bed alarm LPN 10 indicated it was a pad that goes on the bed that they could also use on the wheelchair. Upon observation of the bed alarm pad, it was found that the pad was not plugged into the alarm box. LPN plugged the bed pad into the alarm box and indicated it should always be plugged in to work properly. On 6/9/25 at 11:45 a.m., the Administrator provided a copy of current but undated facility policy titled, Assessing Falls and Their Causes. The policy indicated, .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors . When a resident falls, the following information should be recorded in the resident's medical record . interventions and appropriate interventions taken to prevent future falls On 6/9/25 at 11:45 a.m., the Administrator provided a copy of current but undated facility policy titled, Use of Chair [and Bed] Alarms. The policy indicated, .conduct a comprehensive fall risk assessment before initiating [an alarm] . consider alternatives to alarm use before implementation . discuss proposed alarm use with the resident and/or representative to obtain informed consent 3.1-45(a)(1) 3.1-45(a)(2)

On 6/9/25 at 9:24 a.m., a record review was completed for Resident 25. She had the following diagnoses which included but were not limited to chronic kidney disease, heart failure, high cholesterol, hypertension and overactive bladder. Her most recent Minimum Data Set (MDS) quarterly assessment indicated she had a fall with major injury. Resident 25's record lacked documentation of a fall with major injury. On 6/9/25 at 1:20 p.m., during an interview, the Director of Nursing (DON) indicated Resident 25 only had one fall on 4/25/25 and it did not result in an injury. On 6/9/25 at 2:00 p.m., during an interview, the MDS Coordinator indicated it must have been an entry error, and she would correct it. On 6/10/25 at 10:40 a.m. the Executive Director provided a copy of a current facility policy titled, MDS Error Correction undated. This policy only discussed what staff was to do if an error was discovered by a facility staff member, and how to correct the error. Based on observation, interview, and record review, the facility failed to accurately code a resident's fall status for 1 of 21 residents reviewed for assessment accuracy (Resident 25). Findings include:

Based on observation, interview, and record review, the facility failed to conduct a thorough skin assessment upon admission to identify and put a pressure ulcer treatment in place for 1 of 6 residents reviewed for pressure ulcers (Resident 100). Findings include: During an interview on 6/5/25 at 12:17 p.m., Resident 100's family member indicated several days after the resident admitted to the facility, they got a call from the facility to inform them there was a large wound on the back of the resident's head. From what the facility told them, the resident's hair was badly matted at the back of her head and when the staff went to wash her hair they noticed this wound. The family member indicated the resident had been in the hospital for nearly a month after her stroke, was unable to move at all, and kept on her back, so the wound started at the hospital. On 6/5/25 at 2:00 p.m., Resident 100 was observed. She was seated in a broda chair in the therapy gym. She was alert to her surroundings, but unable to hold a conversation. She was able to shake her head yes or no to answer questions and smiled at jokes. On 6/5/25 at 2:30 p.m., Resident 100's medical record was reviewed. She admitted to the facility on [DATE] with diagnoses which included, but were not limited to cerebral infarction (stroke) which resulted in full body hemiparesis/hemiplegia (muscle weakness/paralysis) and total dependence for all activities of daily living (ADLs). An admission nursing assessment, dated 4/22/25 at 1:03 a.m., indicated Resident 100 did not have any pressure ulcers upon her admission on [DATE]. An admission full body assessment, dated 4/22/25 at 12:30 a.m., indicated Resident 100 did not have any pressure ulcers upon her admission on [DATE]. An admission nursing progress note, dated 4/22/25 at 2:05 a.m., indicated Resident 100 was noted to have excoriation on her right thigh, bruises to her abdomen and the left thigh, a small laceration on the right inner elbow, and additional bruises on both her upper extremities. She required tube feeding for nutrition and was bedbound. A nursing progress note, dated 4/22/25 at 4:10 a.m., indicated Resident 100 was unable to move and had to be turned every two hours. A Physician Services progress note was documented late on 4/29/25 at 9:57 a.m., made effective for 4/24/25 at 9:57 a.m. The Physician visit was for an acute concern related to a wound on the back of the resident's head. Acute visit for wound. Therapies expressed concern over new wound after attempting to brush out matted area to back of head. Upon further inspection, found 5.5 x [by] 4.3 cm [centimeters] necrotic area with slough noted underneath . A nursing progress note, dated 4/24/25 at 4:00 p.m., indicated Resident 100 admitted to the facility on [DATE] with several skin impairments which included, but was not limited to, .area that appears to be related to pressure to back of head The wound team was notified and treatments were put in place. A new skin event titled, Skin Integrity Events - Pressure Sore/Statis Ulcer was opened on 4/24/25 at 3:19 p.m. and indicated Resident 100 had a new unstageable pressure ulcer (a pressure ulcer where the base of the wound is obscured by slough [yellow, tan, grey, green, or brown tissue] and/or eschar [tan, brown, or black tissue] which prevents a healthcare professional from accurately assessing the depth and true stage of the ulcer), to the back of her head which measured 5.5 cm long by 4.3 cm wide. A new treatment order was put in place to cleanse posterior occiput (back of head) with NS (normal saline), apply Santyl to necrotic area and cover with non-adherent dressing, secure with kerlix. Treatment was to do done every day and as needed (PRN) if soilage or dislodgement. A Wound Doctor and Interdisciplinary Team (IDT) progress note, dated 4/29/25 at 8:38 a.m., indicated Resident 100 was seen on wound rounds on 4/28/25 for an initial assessment. The wound doctor classified the wound as an unstageable pressure ulcer and proceeded to debried the wound. After the debridement procedure, the wound was reclassified as a stage IV pressure ulcer (full-thickness tissue loss with exposure of muscle, tendon, or bone) with a goal to heal. The Wound Doctor updated the treatments orders to, cleanse wound to posterior head with wound cleanser, pat dry and apply honey, then pack lightly with fluffed gauze as needed, cover with bordered gauze. Change daily and as needed. During an interview on 6/9/25 at 11:32 a.m., the Wound Doctor indicated he could not confirm the wound was acquired at the hospital because it was not identified or documented on any of her hospital records. At the time of his initial assessment, judging by the condition of the wound, it was most likely acquired at the hospital and was just missed on the facility's nursing admission assessments. After the wound was identified, she received routine treatments and was healed out during his visit that morning (6/9/25). On 6/9/25 at 11:45 a.m., the Administrator provided a copy of current but undated facility policy titled, Resident Skin Assessment Upon Admission. The policy indicated, Purpose: to ensure a thorough skin assessment is performed on each resident upon admission to identify existing conditions, prevent pressure injuries . The facility shall perform a comprehensive skin assessment on each resident within 24 hours of admission . The goal is early identification of ant existing wounds or skin integrity issues and prompt implementation of preventative and therapeutic interventions . conduct a full head-to-toe visual skin inspection 3.1-40(a)(2)

The facility failed to date medications for 1 of 3 medication carts observed. (100 hall Cart 1 and 2). Findings include: 1. Medication cart 1 on 100-hall was observed. Resident 92 had a bottle of latanoprost (used to treat glaucoma) in the medication cart that should be stored in the refrigerator until it was opened. She had a bottle of ofloxacin eye drops 0.3% (used for eye infections) with no date on it to indicate when it was opened. Resident 79 had a bottle of fluticasone nasal spray (used to treat allergies) 50 mcg in the medication cart with no date on it to indicate when it was opened. 2. Medication cart 2 on 100-hall was observed. Resident 40 had a bottle of Systane balance (used to treat dry eyes) in the medication cart with no date to indicate when it was opened. On 6/11/25 during a conversation with the Director of Nursing (DON), she indicated it was very difficult to keep up with dating of medications. A policy titled, Storage of Medications and Biologicals was provided by the Executive Director (ED) on 6/10/25 at 10:30 a.m. It indicated, .In accordance with State and Federal laws, manufacturer recommendations or supplier recommendations, the facility must store all medications and biological in locked compartments or storage rooms under proper temperature controls, and permit only authorized personnel to have access to the keys 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure puree food items were properly prepared and mixed according to the recipe and the equipment was thoroughly washed and sanitized. This deficient practice had the potential to affect 8 of 8 residents who received pureed food from the kitchen. Findings include: On 4/4/24 at 9:24 a.m., Cook 13 was observed as he prepared pureed lunch for the afternoon meal service. Cook 13 was not observed to conduct hand hygiene. He indicated he had already measured out the vegetables and added water and a blender was observed full of mixed vegetables submerged in water. Cook 13 turned on the blender and after several minutes, indicated the vegetables were done. He did not add any additional ingredients. When he poured the mixture into a pan, it was observed to be very thin and watery. When asked what texture the puree should be, Cook 13 indicated, just like this. When asked if he was going to add anything to the mixture, he indicated no, it was done, and he would put it on the stove to bring it to temperature and hold until lunch. When he finished with the vegetables, Cook 13 took the blender container and top to a 2-compartment sink. He turned on the tap water, rinsed the food particles from the blender, squeezed some down detergent into the container and used his bare, unwashed hands to swipe out the suds and remaining food particles. He did not allow for drying time and placed the dripping wet blender container back onto the base. When asked where/how he usually washed his equipment, Cook 13 indicated, sometimes he would take it across the hall to the dish room, but if he was in a hurry, he would just rinse it out there in the kitchen sink. Next, Cook 13 dumped pre-measured ground beef into the blender. He poured a large, unmeasured quantity of tap water in until the meat was covered and turned the blender on. After several minutes, he indicated it was done, and as he poured the pureed meat into a pan, it was observed to be very thin and watery. When asked about the texture, Cook 13 indicated, most of the water would steam out before lunch to create a thicker texture. During an interview on 4/4/24 at 9:35 a.m., the Dietary Manager (DM) was notified of the puree observations. The DM indicated that all dishes, utensils, and equipment should be run through the dish washing machine to ensure proper cleaning and sanitization. The DM indicated, pureed texture foods should not be too thin like a liquid, but more of the consistency of applesauce or pudding. At this time, copies of the vegetables and ground meat were requested. During a second observation on 4/4/24 at 10:04 a.m., Cook 13 was provided the recipes for the vegetables and ground meat, however he failed to properly measure out the ingredients and added an unknown quantity of bread with an unmeasured amount of gravy into the blender. He pureed the bread and gravy, then added it to the ground meat on the stove. The meat was still thin, so Cook 13 added an unmeasured amount of thickener into the pan and stirred until it reached an appropriate texture. Next, he added an unmeasured amount of thickener into the pan of mixed vegetables and stirred until it reached an appropriate texture. On 4/4/24 at 9:50 a.m., the DM provided copies of the recipes for mixed vegetables and cooked roast beef which provided specific and detailed instructions and measurements of ingredients, per serving size, that had not been followed during the observation. On 4/4/24 at 1:47 p.m., the Executive Director (ED) provided a copy of the current, but undated facility policy. The policy indicated, .Those residents who need pureed food shall receive a diet containing the same nutrient value as a regular diet. The pureed food will be seasoned as a regular diet and served at appropriate temperature and as attractively as possible. There is a menu written specifically for pureed diets. The recipe book details the method for preparation and serving size of pureed foods 3.1-21(a)

Based on observation, interview, and record review, the facility failed to ensure expired medications were discarded and a resident's supplements were labeled for 2 of 2 medication storage areas reviewed for medication storage (Resident 72). Findings include: During a medication storage observation on 4/4/24 at 11:05 a.m., the Wing 1 medication room was observed. Inside the refrigerator was a bottle of tuberculin serum (used to test for tuberculosis (TB)). The bottle was undated and was a multidose vial. The Wing 2 Medication cart was observed. A bottle of pro-stat (a supplement used to aid in wound healing) which belonged to Resident 72 was not labeled with the required minimum information. During an interview on 4/4/24 at 11:01 a.m., the Director of Nursing (DON) indicated, all medications for residents should be properly labeled, and the TB serum should have been discarded. On 4/4/24 at 12:58 p.m., the DON provided a copy of current facility policy titled, Storage of Medications, dated 9/18. The policy indicated, .Drugs dispensed in the manufacturer's original container will carry the manufacturer's original expiration date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached and unless the medication is: 1. In a multi-dose vial, 2 an ophthalmic medication, 3. An item for which the manufacturer has specified an unstable duration after opening 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, record review, and interview, the facility failed to accurately stage a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers (Resident 71). Findings include: On 4/3/24 at 11:20 a.m., a record review was completed for Resident 71. She had the following diagnoses which included, but were not limited to, anemia (a condition in which the body does not have enough healthy red blood cells), hypertension (HTN), hyperlipidemia (HLD), type 2 diabetes, hypothyroidism, history of stroke (CVA), difficulty speaking, and depression. On 7/1/22, her pressure ulcer to her sacrum was referred to as an unstageable (full thickness tissue loss where the depth of the wound is completely obscured by eschar or dead tissue in the wound bed) pressure ulcer. On 7/3/23, a Wound Assessment Report indicated the resident had a stage IV (full thickness tissue loss that extends through the fascia and may expose the muscle, bone, tendon, or joint) pressure ulcer to her sacrum. A Minimum Data Set (MDS) assessment, dated 7/8/23, was coded as resident having a stage IV pressure ulcer. On 7/28/22, her pressure ulcer to her sacrum was referenced as a stage IV. Resident 71 had a care plan dated 8/30/23. It indicated she had a pressure ulcer stage III to her sacrum. The goal indicated the wound would resolve with treatment. An intervention included to treat wound as ordered and weekly skin assessment. On 10/5/23, a Wound Assessment Report indicated resident had a stage III pressure ulcer to her sacrum. A MDS, dated [DATE], was coded as resident having a stage II (partial thickness loss of dermis that presents as a shallow open ulcer with a red or pink wound bed or an intact or ruptured blister) pressure ulcer. A MDS, dated [DATE], was coded as resident having a stage IV pressure ulcer. On 1/9/24, a Wound Assessment Report indicated resident had a stage III pressure ulcer to her sacrum. Resident's 1/7/24 MDS was coded as resident having a stage IV pressure ulcer. On 1/30/24, a Wound Assessment Report indicated resident had a stage III pressure ulcer to her sacrum. On 2/6/24, a physician's progress note indicated resident had a stage III pressure ulcer to her sacrum that measured 1.4 centimeters (cm) in length by (x) 1.0cm in width x 0.5cm in depth. Resident's 2/9/24 MDS was coded as resident having a stage IV pressure ulcer. On 2/27/24, a Wound Assessment Report revealed a sacrum wound, stage III (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle was not exposed). On 3/19/24, a Wound Assessment Report revealed a sacrum wound, stage III. She had a current physician's note, dated 4/1/24, which indicated Resident 71 had a stage III pressure ulcer to her sacrum. The wound was named number 3. The treatment was changed to collagen powder to promote extracellular matrix formation [an intricate network composed of an array of multidomain macromolecules organized in a cell/tissue specific manner] and autolytic debridement [a natural process by which endogenous phagocytic cells and proteolytic enzymes break down necrotic tissue] as no odor remains and, as such, no indication for Dakin's solution remains. During an interview with the Director of Nursing on 4/4/24 at 1:00 p.m., the DON indicated the MDS did not down stage pressure ulcers for the purpose of the MDS. They down staged according to current assessment of pressure ulcers. The RAI manual was referenced for accurate coding. A policy titled, Pressure Ulcer Prevention and Managing Skin Integrity, was provided by the DON on 4/4/24 at 12:58 p.m. It lacked documentation surrounding reverse staging or back staging. The NPUAP Position Statement on Staging, 2017 Clarifications January 24, 2017, indicated, .The NPUAP has long maintained this position and issued a position statement recommending against 'down staging' as early as the year 2006. One of the unintended consequences of identifying numerical stages of pressure injuries is that it invites the misinterpretation that 'stage' implies a progression (forward or backward). NPUAP's system implies no progression in any direction According to CMS RAI version 3.0 manual, dated October 2023, .M0300, Step 1: determine the deepest anatomical stage. Pressure ulcers do not heal in reverse sequence, that is the body does replace the types and layers of tissue that were lost during pressure ulcer development before they re-epithelize. Clinical standards do not support reverse staging or back staging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure comprhensive care plans were initiated and implement for 6 of 19 residents reviewed for comprehensive care planning (Residents 1, 46, 45, 198, 202, and 5). Findings include: 1. Resident 1's medical record was reviewed on 1/9/23 at 2:49 p.m. She was admitted on [DATE]. Her diagnoses included, but were not limited to fracture of right femur, chronic kidney disease, major depressive disorder, chronic heart failure, hypothyroidism, and protein-calorie malnutrition. Resident 1's Minimum Data Set (MDS), dated , 10/2/22 indicated she received extensive assistance with bed mobility. Her side rail assessment, dated 9/21/22, indicated she used her side rails as an enabler (the rail is used to promote independence with bed mobility). During an observation on 1/18/23 at 10:25 a.m., Resident 1 was observed lying on her right side in bed with her eyes closed. She had a half side rail on both sides of her bed. During an observation on 1/19/23 at 9:10 a.m., Resident 1 was observed lying on her right side with her eyes closed. She had a half side on both sides of her bed. Resident 1's care plan lacked a problem, goal, and interventions to address the use of side rails. 2. Resident 46's medical record was reviewed on 1/19/23 at 11:59 a.m. She was admitted on [DATE]. Her diagnoses included, but were not limited to epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), pneumonia (an infection of the lungs), acute embolism of deep veins of the lower extremities, anorexia (an eating disorder), autistic disorder (a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and non-verbal communication), contracture of muscle, multiple sites (permanent tightening of the muscles, tendon, skin and nearby tissues that causes the joints to shorten and become very stiff) and pressure ulcer of sacral region. Resident 46's MDS, dated [DATE], indicated she was dependent on two persons with bed mobility. Her side rail assessment, dated 12/13/22, indicated she used her side rails as an enabler. During an observation on 1/16/23 at 9:30 a.m., Resident 46 was observed lying in bed, facing her window. She was holding a stuffed animal. She has a low air loss mattress. She had her eyes opened, but she was non-verbal. She had one half side rails on both sides of her bed. During an observation on 1/19/23 at 10:16 a.m., Resident 46 was non-verbal. She was observed lying on her left side, holding a small stuffed animal in her right hand. She was able to make eye contact. She had one half side rails on both sides of her bed. Resident 46's care plan lacked a problem, goal, and interventions to address the use of side rails. 3. Resident 45's medical record was reviewed on 1/19/23 at 10:04 a.m. He was admitted on [DATE]. His diagnoses included, but were not limited to cerebral infarction (stroke), protein-calorie malnutrition, major depressive disorder, heart disease, vascular dementia, spinal stenosis (this happens when the space inside the backbone is too small, placing pressure on the spinal cord and nerves) and flexion deformity of the left hip. His MDS dated [DATE] indicated he was dependent on two persons for bed mobility. His side rail assessment, dated 11/15/22, indicated he was able to use the grab bars as an enabler. Resident 45 was observed on 1/17/23 at 9:38 a.m., lying in bed with his head pushing against a pad attached to his grab bar on the right side of his bed. He had an unpadded grab bar on the left side of the bed. He was unable to reposition himself in bed. Resident 45 was observed on 1/19/23 at 2:15 p.m. He was sitting up in his reclining chair. His head was leaning into the padded frame of the chair. He was unable to reposition in the chair. Resident 45's care plan lacked a problem, goal, and interventions to address the use of grab bars. During an interview on 1/20/23 at 9:40 a.m., with the Owner, Administrator and Director of Nursing, the DON indicated that Residents 1, 45 and 46 could use their rails as an enabler. The DON indicated the resident's medical record lacked a care plan to address the side rails on resident's bed. During an interview on 1/20/23 at 11:05 a.m., the DON indicated she would have Resident 46's one half rails changed to a grab bar. The DON demonstrated that Resident 46 could hold onto her bed rail. The DON demonstrated that Resident 45 could hold a blanket and shake her hand to indicate he could hold his grab bars, because he was able to grasp with his hand 37982 4. On 1/17/23 at 11:03 a.m., Resident 198 was observed and interviewed as she rested in bed watching television. On 1/18/23 at 9:54 a.m., Resident 198's medical record was reviewed. The diagnoses included, but were not limited to chronic kidney disease, hypertension (high blood pressure) and hyperlipidemia (high cholesterol). A physician's order, dated 12/29/22, indicated DNR, do not resuscitate. Resident 198 did not have an advanced directive care plan. On 1/19/23 the Executive Director provided an out of hospital do not resuscitate order and declaration form for Resident 198. The form was dated 1/19/23. 5. On 1/17/23 at 11:29 a.m., Resident 202 was observed and interviewed as he was seated in a wheel chair in his room watching television. The resident was somewhat confused. He did not know how long he had been at the facility and kept asking what he was suppose to do next. On 1/17/23 at 1:55 p.m., Resident 202's medical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection, sepsis (infection in the blood stream), encephalopathy (deterioration of the brain), kidney failure and malignant neoplasm of the prostate (cancer). Resident 202 had a out of hospital do not resuscitate declaration order, dated 1/5/23. Resident 202 did not have an advanced directive care plan. On 1/20/23 at 10:16 a.m., during an interview, the Director of Nursing (DON) indicated Residents 198 and 202 should have had all DNR documents and care plans in the medical record. 37981 6. On 1/19/23 at 2:16 p.m., Resident 5's record was reviewed. She was admitted on [DATE]. Her diagnoses included, but were not limited to, chronic respiratory failure (failure of the lungs to bring in enough oxygen and eliminate carbon dioxide), and cerebral infarction (stroke). Her physician's orders included, but were not limited to, administer 4 L oxygen via NC every shift, dated 7/22/22 and change oxygen tubing weekly, dated 7/24/22. Resident 5 did not have an oxygen care plan. On 1/19/23, the facility provided one, it indicated to administer oxygen, change the oxygen tubing per protocol and provide humidification. During an interview, on 1/20/23 at 1:52 p.m., the Director of Nursing (DON) indicated when a physician's order comes through, she reviewed it and it was mentioned in clinical morning meeting. The orders were distributed, reviewed, and an assessment would be completed. Recently, the facility added more assistance with physician orders with the DON writing further notes on the orders as PRN (as needed) reminders. All management staff wrote care plans. It was human error that Resident 5's oxygen care plan was missed.

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were revised and/or updated for 4 of 19 residents reviewed for comprehensive care planning (Residents 23, 45, 59 and 83). Finding include: 1. Resident 23's medical record was reviewed on 1/19/23 at 2:10 p.m. Her diagnoses included, but were not limited to, hyperlipidemia (high cholesterol), hypothyroidism (abnormally low activity of the thyroid gland), osteoarthritis, anxiety, anemia, depression, and acute embolism of the deep veins of the upper extremity. Resident 23 had a care plan, dated 5/21/21, addressing an acute UTI (Urinary Tract Infection). Her medical record lacked evidence of a UTI. Her care plan, dated 5/21/21, indicated she received two diuretics. Her physician orders lack orders for diuretic medications. Her Minimum Data Set (MDS), dated [DATE], indicated she did not receive any diuretics during the assessment period. Her care plan, dated 5/21/21, indicated she had difficulty with sleep due to insomnia. An intervention included to monitor the effectiveness of medication therapy. Her medication orders lacked an order for a medication to treat insomnia. Her MDS dated [DATE] did not indicate she received medication to treat insomnia during the assessment period. Her care plan, dated 5/21/21, indicated she received an anticoagulant medication. Her physician's orders lacked an order for an anticoagulant medication. Her MDS dated [DATE] did not indicate she received an anticoagulant during the assessment period. 2. Resident 45's medical record was reviewed on 1/19/23 at 10:04 a.m. His diagnoses included but were not limited to cerebral infarction (stroke), protein-calorie malnutrition, major depressive disorder, heart disease, vascular dementia, spinal stenosis (this happens when the space inside the backbone is too small, placing pressure on the spinal cord and nerves), and flexion deformity of the left hip (the hip cannot be straightened actively or passively). His care plan, dated 4/22/21, indicated he had a pressure ulcer to his sacrum. The medical record lacked orders or documentation to treat or address a pressure ulcer. His MDS, dated [DATE], indicated he does not have a pressure ulcer. His care plan, dated 4/22/21, indicated he used an antidepressant medication. His current physician orders lacked an antidepressant medication. His MDS, dated [DATE], did not indicate he received an antidepressant during the assessment period. 3. Resident 59's medical record was reviewed on 1/19/23 at 8:00 a.m. His diagnoses included, but were not limited to retention of urine, urinary tract infection, cerebral infarction (stroke), vision deficit, and sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissue). Resident 59's indwelling catheter was discontinued on 1/9/23. His care plan indicated he had a urinary catheter, indwelling, related to urinary retention. During an interview with the Owner, Administrator and Director of Nursing (DON) on 1/20/23 at 9:20 a.m., the DON indicated the UM (Unit Managers) are responsible for initiating and revising residents care plans with changes. The DON indicated herself and the Transitional Care Nurse will revise care plans also. The DON indicated they do a great job at initiating care plans, but need to do better at updating them. 38768 4. On 1/17/23 at 9:56 a.m., Resident 83 was initially observed. He laid in bed on his back, his eyes were open, and he answered questions appropriately. He was observed to be covered with three layers, a sheet, a fleece blanket, and a third top blanket. He indicated he was often cold and liked the weight of the blankets. He had pressure reliving boots to both of his feet but wore no socks so that his toes were in direct contact with the weight of the blankets. On 1/18/23 at 2:06 p.m., Resident 83 was observed. He remained in bed, covered with layers of blankets. His toes remained in contact with the weight of the blankets as they stuck out past his pressure reliving boots. He indicated his feet did not hurt, but sometimes his toes tingled. On 1/19/23 at 9:14 a.m., Resident 83 was observed. He remained in bed, covered with layers of blankets that laid across the top of his toes. On 1/19/23 at 11:42 a.m., CNA 15 entered Resident 83's room. She indicated Resident 83 liked to keep a lot of blankets over him because he got cold and when she removed his blankets so that his feet were uncovered, the following was observed: a. redness at the corner of his left big toe, approximately the size of dime. b. a red blister-like area to the knuckle of his left big toe, approximately the size of a pencil eraser. c. a smaller, red blister area to the knuckle of his right big toe. During an interview on 1/19/23 at 12:03 p.m., the Wound Nurse (WN) indicated Resident 83 was at a greater risk for pressure ulcers since he had a history of wounds and was on hospice. She reviewed his comprehensive care plans at that time and indicated the care plan for an open area on his coccyx should not still be active as that wound had been healed months ago. She indicated there did not appear to be any revisions in place to address the Resident's preference for additional blankets and how to prevent new areas from developing as a result of the blankets. During an interview on 1/19/23 at 12:30 p.m., the WN indicated she was not aware of any new areas to Resident 83's toes and was available to go observe them at this time. When she pulled his blankets back, the WN indicated it appeared there were three new areas, two to his left big toe, and one on his right big toe. Upon her initial assessment, she indicated all three areas were blanchable so they were not pressure ulcers at that time, but if left untreated could turn into pressure ulcers. It appeared the areas had developed from the weight of the sheets and from the sheets being tucked in, under his feet which pulled and put pressure to the areas. The WN indicated she would get new orders for skin prep to the areas, possibly order new pressure boots that would go higher over his toes to prevent the sheets from touching, and she would educate the aids not to tuck the sheets too tight. On 1/18/23 at 2:25 p.m., Resident 83's medical record was reviewed. He was a long-term care resident who received hospice care and diagnoses which included, but not limited to, Parkinson's disease. His comprehensive care plans were reviewed. He had a care plan which was initiated 7/31/22 for an open area to his coccyx which had not been revised to indicate the area was healed. He had a care plan which was initiated on 3/18/22 for being at risk of developing pressure ulcers related to incontinence, impaired mobility and medications, but had not been revised to address the Resident's preferences for his use of additional blankets. On 1/20/23 at 9:15 a.m., the ADM provided a copy of current, but undated facility policy titled, Updating Care Plans. The policy indicated, .actual or potential problems may be addressed . care plans will be continually reviewed and revised as needed 3.1-35(c)(2)

Based on observation, interview, and record review, the facility failed to provide range of motion for 4 of 4 residents reviewed for limitations in range of motion of joints (Residents 23, 1, 45, and 46). Findings include 1. Resident 23's medical record was reviewed on 1/19/23 at 2:10 p.m. Her diagnoses included, but were not limited to, hyperlipidemia (high cholesterol), hypothyroidism (abnormally low activity of the thyroid gland), osteoarthritis, anxiety, anemia, depression, and acute embolism (blood clot) of the deep veins of the upper extremity. Resident 23's Minimum Data Set (MDS) assessment, dated 10/19/22, indicated she required extensive assistance of 1 person to complete her personal hygiene (combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). The MDS indicated that she was not receiving restorative nursing services. Resident 23's care plan indicated she required assistance with all activities of daily living (ADLs) due to weakness and debility. An active goal indicated to refer the resident to occupational therapy to work on ADL retraining, dated 5/21/21. On 1/17/23 at 2:25 p.m., Resident 23 was observed in her room sitting in a chair. She indicated she just finished brushing her hair. She had arthritis in upper arms and shoulders making it difficult for her to brush her hair, but she pushed through and brushed her hair independently. Resident 23 indicated she had therapy, but since they stopped seeing her she had not had anyone help her with range of motion of her upper arms and shoulders. 2. Resident 46's medical record was reviewed on 1/19/23 at 11:59 a.m. Her diagnoses included, but were not limited to epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), pneumonia (an infection of the lungs), acute embolism (blood clot) of deep veins of the lower extremities, anorexia (an eating disorder), autistic disorder (a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and non-verbal communication), contracture of muscle, multiple sites (permanent tightening of the muscles, tendon, skin and nearby tissues that causes the joints to shorten and become very stiff), and pressure ulcer (bed sore) of sacral region. Her medication orders were reviewed. Resident 46's MDS, dated [DATE], indicated that she was totally dependent on staff to provide ADLs for her. The MDS indicated that she was not receiving restorative nursing and she was not receiving therapy services. Resident 46's care plan, dated 3/21/22, indicated she had an alteration in comfort/pain related to contractures. She had a care plan indicating she required assistance for all ADL's (bed mobility, transfers, toileting, and eating) related to intellectually disabled, contractures and dependent for all care. During an observation on 1/16/23 at 9:30 a.m., Resident 46 was observed lying in bed, facing her window. She was holding a stuffed animal. She had a low air loss mattress. She had her eyes opened, but she was non-verbal. During an observation on 1/19/23 at 10:16 a.m., Resident 46 was non-verbal. She was observed lying on her left side, holding a small stuffed animal in her right hand. She was able to make eye contact. 3. Resident 1's medical record was reviewed on 1/9/23 at 2:49 p.m. Her diagnoses included, but were not limited to fracture of right femur, chronic kidney disease, major depressive disorder, chronic heart failure, hypothyroidism, and protein-calorie malnutrition. Resident 1's MDS, dated , 10/2/22, indicated she received extensive assistance with her ADLs. Her MDS indicated she was not receiving a restorative nursing program. Her care plan, dated 9/22/22, indicated she required assistance for all ADLs bed mobility, transfers, toileting, and eating related to visual impairment and chronic pain. During an observation on 1/18/23 at 10:25 a.m., Resident 1 was observed lying on her right side in bed with her eyes closed. During an observation on 1/19/23 at 9:10 a.m., Resident 1 was observed lying on her right side with her eyes closed. 4. Resident 45's medical record was reviewed on 1/19/23 at 10:04 a.m. His diagnoses included but were not limited to cerebral infarction (stroke), protein-calorie malnutrition, major depressive disorder, heart disease, vascular dementia, spinal stenosis (this happens when the space inside the backbone is too small, placing pressure on the spinal cord and nerves), and flexion deformity of the left hip. His MDS, dated [DATE], indicated he was dependent of staff to complete his ADLs. The MDS indicated he was not receiving a restorative nursing program. His care plan dated 10/19/20 indicated he required assistance with all ADLs, bed mobility, transfers, toileting and eating related to dementia, CVA (cerebral vascular accident (stroke) with left sided weakness and impaired mobility. Resident 45 was observed on 1/17/23 at 9:38 a.m., lying in bed with his head pushing against a pad attached to his grab bar. He was unable to reposition himself in bed. Resident 45 was observed on 1/19/23 at 2:15 p.m. He was sitting up in his reclining chair. His head was leaning into the padded frame of the chair. He was unable to reposition in the chair. During an interview with the Owner, Administrator (ADM), Director of Nursing (DON) on 1/20/23 at 9:20 a.m., the DON indicated that range of motion was supposed be done during resident's ADL care. The staff did this to prevent further limitations and contractures for their residents. The DON indicated she could not provide any documentation indicating range of motion was completed. The Owner indicated the staff were to document range of motion on the electronic medical record. On 1/20/23 at 9:1454 a.m., the ADM provided a copy of current, but undated facility policy titled, Increase/Prevent Decrease in ROM/Mobility. The policy indicated, It is the policy of the facility to ensure it identifies and proves needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each residents physical, mental and psychosocial needs 3.1-47(a)(1)

Based on observation, interview, and record review, the facility failed to ensure resident respiratory durable medical equipment (DME) was stored according to policy, oxygen tubing was dated correctly, and oxygen was humidified according to facility policy for 4 of 4 residents reviewed for respiratory equipment use (Resident 5, 60, 26 and 29). Findings include: 1. On 1/17/23 at 11:38 a.m., Resident 5 was observed in bed with a nasal cannula (NC), eyes closed. Her oxygen was set at 4 liters (L), it was not humidified. Her oxygen tubing was dated 12/29/22. On 1/18/23 at 9:27 a.m., Resident 5 was observed in bed with a NC, eyes closed. Her oxygen was set at 4 liters (L), it was not humidified. Her oxygen tubing was dated 12/29/22. On 1/18/23 at 2:20 p.m., Resident 5 was observed in bed with a NC, eyes closed. Her oxygen was set at 4 liters (L), it was not humidified. Her oxygen tubing was dated 12/29/22. On 1/19/23 at 2:16 p.m., Resident 5's record was reviewed. She was admitted on 5/5/22. Her diagnoses included, but were not limited to, chronic respiratory failure (failure of the lungs to bring in enough oxygen and eliminate carbon dioxide), and cerebral infarction (stroke). Her physician's orders included, but were not limited to, administer 4 L oxygen via NC every shift, dated 7/22/22, and change oxygen tubing weekly, dated 7/24/22. Resident 5 did not have an oxygen care plan. On 1/19/23, the facility provided one, it indicated to change oxygen tubing per protocol and provide humidification. 2. On 1/17/23 at 11:21 a.m., Resident 60's unbagged NC was observed rolled up and laid on top of his oxygen concentrator. He was in his room utilizing a portable canister for oxygen. On 1/18/23 at 2:16 p.m., Resident 60's unbagged NC was observed rolled up and laid on top of his oxygen concentrator. He was in his room utilizing a portable canister for oxygen. On 1/19/23 at 12:07 p.m., his record was reviewed. His diagnoses included, but were not limited to, chronic respiratory failure and chronic cough, His physician orders included, but were not limited to, oxygen 2 L via nasal cannula, dated 12/23/22, and change oxygen tubing and humidifier weekly, dated 12/26/22. His oxygen care plan, dated 12/25/22, indicated he was at risk for respiratory complications and administer oxygen therapy as ordered. 3. In 1/18/23 at 2:30 p.m., Resident 26's NC was observed unbagged and undated. hanging on the oxygen concentrator. On 1/19/23 at 11:02 a.m., Resident 26's record was reviewed. Her diagnoses included, but were not limited to, chronic respiratory failure and diabetes mellitus. Her physician orders included, but were not limited to, administer 2 L oxygen via NC, dated 12/28/20, and change oxygen tubing weekly, dated 6/23/22. Her oxygen care plan, dated 2/5/21, indicated she received oxygen therapy due to respiratory failure and to administer oxygen therapy as ordered and change tubing per protocol. During an interview, on 1/18/23 at 2:33 p.m., Unit Manager (UM) 9 indicated NC and oxygen tubing should have been changed weekly and dated, NC when not in use should have been bagged, and if a resident was over 2 L of oxygen, then it should have been humidified. On 1/18/23 at 2:41 p.m., UM 9 was observed preparing and dating bags for Residents 26 and 60 oxygen tubing/NC. Licensed Practical Nurse (LPN) 4 was observed dating tubing for Resident's 26, 60, and 5, and dating a humidifier bottle for Resident 5. On 1/18/23 at 2:57 p.m., LPN 4 was observed to change the oxygen concentrator for one that would humidify the oxygen for Resident 5. On 1/18/23 at 1:48 p.m., the Director of Nurses (DON) indicated the nurses should have checked the oxygen tubing and changed and dated it as needed. The nurse should have been aware, if a resident was on 4 L of oxygen, the oxygen should have been humidified. 37982 4. On 1/18/23 at 10:45 a.m., during an observation and interview, Resident 29 was in his room wearing oxygen per nasal cannula (tube). The tubing and humidifier bottle, which was on the oxygen concentrator, were not dated. On 1/18/23 at 2:22 p.m., Resident 29 was observed as he sat on the side of his bed. He wore oxygen per nasal cannula, connected to a concentrator with humidification. He indicated sometimes they put a date on them but the last time they changed it it had not been marked. On 1/18/23 at 2:29 p.m., the medical record for Resident 29 was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure, COPD (chronic obstructive pulmonary disease, diabetes and obstructive sleep apnea. A physician order, dated 6/23/22, indicated 5 liters of oxygen per nasal cannula. change oxygen tubing and humidifier weekly. On 1/19/23 at 12:15 p.m., during an interview, Licensed Practical Nurse (LPN) 9, Unit Manager, indicated oxygen tubing and humidifier bottles should have had a date marked on them when they were changed. She did not know when Resident 29's tubing or humidifier bottle was changed. On 1/19/23 at 12:05 p.m., the Executive Director (ED) provided a current, undated policy, titled Departmental (Respiratory Therapy)- Prevention of Infection. This policy indicated The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Distilled water used in respiratory therapy must be dated and initialed when opened, and discarded after 14 days or as needed .Mark bottle with date and initials upon opening and discard after 14 days, or as needed .Change the oxygen cannulae and tubing every seven (7) days, or as needed .Keep oxygen cannulae and tubing used PRN [as needed] in a plastic bag when not in use 3.1-47(a)(6)

Based on interview and record review, the facility failed to assess, document, and monitor a resident's change in condition related to slurred speech, which resulted in the resident's admission to the Intensive Care Unit [MEDICAL CONDITION], for 1 of 4 residents reviewed for hospitalization . (Resident 50) Findings include: On 02/19/19 at 03:04 p.m., the medical record for Resident 50 was reviewed. The [DIAGNOSES REDACTED]. On 12/14/18 at 1:15 p.m., a Therapy note, signed by Physical Therapist 22, indicated Resident 50 was lethargic and slow to respond to commands. She required maximum assistance to scoot back in the chair. The Therapist attempted to have the resident work on sitting balance with reaching and she required constant verbal cues. The resident required maximum assistance of two staff members from sitting to stand with constant verbal cues. A quarterly MDS (Minimum Data Set) assessment, dated 09/21/18, indicated Resident 50 was cognitively alert and oriented. On 12/14/18 at 3:01 p.m., a Nurse's Progress Note, signed by Licensed Practical Nurse (LPN) 21, indicated Resident 50 had gone out to a Mental Health appointment in the A.M. The mental health physician (Physician 23) had called the facility and indicated she was unable to understand what the resident said, due to slurred speech. The LPN had noted an increase in slurred speech over the last couple days but still could understand most of what the resident said. Physician 23 had requested an in house (facility) MD to evaluate the resident for the possible cause of slurred speech. The supervisor and MD were notified. They were awaiting consult with MD and possible new orders. On 12/14/18 at 10:08 p.m., a Nurse's Progress Note, signed by LPN 20, indicated Resident 50 was evaluated by Physician 16 due to acute onset of [MEDICAL CONDITION], slurred speech, and confusion. Order was received to send resident to the emergency room for evaluation. Name of ambulance service transported resident via stretcher. Resident 50's skin assessment revealed no open areas, skin was intact upon leaving facility. All proper paperwork, including bed hold policy, was sent with resident to hospital. A report was called ahead to the emergency room . A physician's orders [REDACTED]. OK to send to (Name of Hospital) emergency room for evaluation of new onset slurred speech confusion and [MEDICAL CONDITION]. The hospital record, dated 12/15/18 at 1:01 a.m., indicated Resident 50 presented to the emergency department with a new onset of slurred speech. On arrival her temperature was 90.5 degrees Fahrenheit (oral) and 90.1 (rectal). The patient was admitted to the Intensive Care Unit due to hypothermia (low body temperature). The patient was sluggish to respond to questions. When asked patient about hypothermia she didn't know, but indicated it must have been from eating ice chips. Physician contacted the facility to get additional information. The facility reported the last vital signs recorded at facility was a blood pressure of 126/64, on 12/13/18. There were no recent temperatures or other vital signs. The facility nurse indicated the resident had slurred speech for two or three days. It was unclear if any other acute issues were occurring at the facility. The primary hospital diagnoses, for the admitted d 12/15/19, was listed as hypothermia, and [MEDICAL CONDITION], acute [MEDICAL CONDITION] (affecting the brain) related to infection, with dysarthria (difficult speech), left lower lobe pneumonia, complicated urinary tract infection, and [MEDICAL CONDITION] with [MEDICAL CONDITION] ([MEDICAL CONDITION], a blood clot) of the left lower extremity. On 02/21/19 at 9:04 a.m., the Director of Nurses provided copies of all nursing and physician documentation related to Resident 50's hospitalization . The only vital signs recorded from 12/09/18 to the hospital admission on 12/14/19 was a blood pressure dated 12/13/18 at 11:00 p.m. with results of 126/64. During an interview, on 02/21/19 at 11:04 a.m., the Director of Nurse indicated we use SBAR (situation, background, assessment, and recommendation) assessment here, and that was not documented. We have done one on one education with the nurse. He claimed he assessed the patient, and did everything, but there was no documentation. It was identified as a problem, and education was done. We looked at notes every day it was identified when it happened. Physician 16 is usually good about documenting notes, and she didn't make a note that day. The evening shift nurse sent her out to the hospital and documented at the end of her shift. Assessments, and vital signs should have been documented. The facility used a Quality Improvement Tool for review of Acute Care Transfers. Problems were identified when the tool was completed after the resident's hospital admission. During an interview, on 02/22/19 at 11:29 a.m., Physician 16 indicated the day Resident 50 went out to the hospital, she had seen her in the dining room as she (the physician) was headed out for the day. The resident had just returned from her mental health appointment with Physician 23. The resident had slurred speech and was delusional. She asked the nurse about vital signs and was told they were normal. She decided to send Resident 50 to the emergency room for evaluation and gave the order. She should have made a note, about the event, but she was headed out and did not document the assessment. On 02/22/19 at 12:08 p.m., the Director of Nurses provided a current, undated policy titled, Interact 4.0. This policy indicated, Purpose: To provide guidelines to formulate an assessment and properly communicate changes in condition to the physician .The licensed nurse will complete the SBAR tool for any acute change in condition .The SBAR tool is a framework to aid the licensed nurse to perform their assessment and formulate documentation for the resident's legal record .The Quality Improvement Tool for acute care transfers will be reviewed periodically to review all discharges to the hospital . 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident was properly repositioned in a broda chair (chair used for seating and positioning) resulting in extensive bruising across the mid chest area for 1 of 3 residents reviewed for accidents (Resident#28). Finding includes: Resident #28's record was reviewed on 1/27/14 at 12:18 P.M. Resident #28 had [DIAGNOSES REDACTED]. An annual Minimum Data Assessment Tool ((MDS) dated [DATE], indicated Resident #28 was cognitively impaired with a BIMS (Brief Mini Mental Status) score of 4 out of 10 and was totally dependant on staff for all activities of daily living. A nurse's note dated 10/15/2013 at 9:03 P.M., indicated, "...this writer to residents room, upon arrival and assessing resident this writer noted that res. (resident) mid chest and both lower parts of both breast had bruising present. Mid chest is purple in areas with yellowing present near the upper area of the bruised tissue, and both breast have purple colored bruising present toward the lower aspect of each breast. Resident states there is 0 pain based on the pain scale. Resident unable to convey how bruising occurred. Reported to Unit Manager and DON (Director of Nursing)...." A document titled "Wounds" and dated 10/16/2013, indicated, "...injury wound dimensions L (length) 10.0 cm (centimeters) and W (width) 32.0 cm... purple, yellow bruising...." A signed statement from the wound nurse dated 10/16/2013, indicated, "Observed an area of discoloration under resident's breasts. Measurements were documented. Appears to be an injury resulting from repositioning resident in her Broda chair by lifting Resident up under arms." During an interview on 1/27/2014 at 1:03 P.M., the DON indicated Resident #28's injury was "extensive across her chest." The DON indicated Resident #28 was on anticoagulant medication which made her bruise easily. During an interview with the DON and the Administrator on 1/27/2014 at 3:07 P.M., the DON indicated they were informed of the "bruising" on 10/15/13. The DON stated, "...We immediately involved the wound nurse.... It was determined at some point she was repositioned incorrectly in the broda chair... It was obvious someone went behind the broda and lifted her under her arms from behind. I would have expected them to have more than one person... This was one person going behind the broda and just lifting... it (bruised area) contained the whole area under the breast...." The DON was queried regarding facility policies for transferring and positioning. The facility was unable to provide a specific policy regarding positioning techniques. A document titled "Northwest Healthcare Topic: Education Related to Transferring Residents" provided by the DON on 1/29/2014 at 1:55 P.M., indicated, "...Education to include the possible complications resulting from an improper transfer technique, such as falls, strain/sprain/twisting/bruising..." At this time the DON indicated she expected staff not to pull or lift under resident's arms to reposition them. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure pressure prevention devices were properly used to prevent a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers, in a sample of 3 residents who met the criteria for stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) or stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers (Resident #50). Findings include: During observations on 11/28/2012 at 9:18 A.M., CNA #35 transferred Resident #50 from the wheelchair to the toilet. The resident was transferred back to her wheelchair and sat on a deflated waffle cushion (pressure prevention cushion) that had a ? inch cloth covered pad placed on top of the cushion. During observations on 11/28/12 at 9:57 A.M., Resident #50 rolled her wheelchair into hallway. The waffle cushion she sat on was deflated. During observation on 11/28/12 at 10:43 A.M., CNA #35 and RN #36 assisted Resident #50 with a transfer from the wheelchair to the toilet. The resident was transferred back to her wheelchair and sat on a deflated waffle cushion. During an observation on 11/28/2012 at 10:56 A.M., the Activities Director assisted Resident #50 to the dining table for a cup of tea. Resident #50 was seated in her wheelchair on a deflated waffle cushion. During an interview on 11/28/2012 at 12:58 P.M., CNA #35 indicated the waffle cushion should be checked frequently to be sure it is inflated. She indicated she was not aware the cushion was deflated when she transferred Resident #50 to the commode and returned her to the wheelchair at 10:43 A.M. During an interview on 11/28/2012 at 1:09 P.M., CNA #33 stated "(Resident #50's) waffle seat cushion may need to be pumped up." He indicated the level of inflation was determined by the resident's position or complaints of discomfort. During an interview on 11/28/2012 at 1:20 P.M., LPN #38 stated Resident #50 had a cushion in her chair and her position was supposed to be "shifted in the chair every couple of hours," when asked if there were specific interventions in regard to the pressure reducing cushion. During an interview on 11/28/2012 at 1:25 P.M., RN #39 indicated Resident #50's pressure reducing interventions were, "to keep the resident clean and dry and toileting." During observations on 11/28/2012 at 1:57 P.M., RN #37 provided wound care to Resident #50's right posterior thigh. The wound center was red and had a medium amount of serous drainage wiped from the wound. The wound bed was granulating and red. The skin surrounding the wound bed was pink, dry and scaling. RN #37 did not measure the wound but stated, "The wound has depth." A wound measurement documented on 11/26/2012 indicated, "...1.5 cm (length) X (by) 1.0 cm (width) X 0.2 cm (depth)...." During an interview on 11/28/2012 at 1:57 P.M., RN #37 stated the wound on Resident #50's right posterior thigh "was a result of sitting on the Roho (a wheelchair cushion used to relieve pressure) cushion valve." She indicated the resident had not used a Roho cushion since the wound occurred. RN #37 indicated the resident used a waffle or gel cushion for pressure relief after the open wound was discovered. The RN stated she "did not recall" who notified her of the resident's open wound on her right thigh. The RN stated, "the cushion was deflated and all balled up and under (Resident #50)," when she assessed Resident #50's right posterior thigh wound on 10/03/2012. During an interview on 11/28/2012 at 2 25 P.M., the Unit Manager indicated a Roho cushion had not been placed in Resident #50's wheelchair since discovering the open wound to the right posterior thigh. She stated, "The cushion valve caused the injury." The Unit Manager stated, "The cushion shifted in the chair, creating an opportunity for the valve to push against the resident's skin." During an interview on 11/28/2012 at 3 32 P.M., OT (Occupational Therapist) #40, indicated Resident #50's Roho cushion had been discontinued per nursing. OT #40 indicated the Roho cushion valve should have gone out the back of the resident's chair and should have been positioned so the valve pointed downward to prevent the resident from sitting on the valve. During an interview on 11/28/2012 at 3:54 P.M., the DoN indicated there was not a specific method for applying a Roho cushion in a wheelchair. She stated, "You just lay the (Roho) cushions on the chair." During an interview on 11/30/12 at 8:45 A.M., the DoN indicated Resident #50 should not have been sitting on a deflated cushion. Resident #50's record was reviewed on 11/28/2012 at 9:48 A.M. [DIAGNOSES REDACTED]. A pressure ulcer risk assessment, dated 5/25/12, indicated a score of 19, indicating Resident #50 had a high risk for pressure wounds. The MARs (Medications Administration Records), dated September 2012 and October 2012, indicated, "...WEEKLY HEAD TO TOE SKIN ASSESSMENT...." The MARs indicated skin assessments were completed on the 7th, 14th, 21st, and 28th of each month. The 10/07/2012 documentation indicated, "...open area to back of (R) (right) thigh...." The record did not indicate an open area to the right thigh prior to 10/07/2012. During an interview on 11/28/12 at 2:55 P.M., the DoN (Director of Nursing) indicated the nurses make the rounds for weekly skin assessments and only document if there is a problem. A "wound" record, dated 10/03/2012, indicated a NS (non-stageable (Unstageable - Pressure ulcer is known but not stageable due to non-removable dressing/device or due to the coverage of the wound bed by slough or eschar)) wound measuring 6.0 cm (centimeters) in length by 5.0 cm in width and NS depth with medium amount of serous (pale yellow and transparent) drainage. The record indicated the wound bed was red with necrosis (dead) and slough (shedding of skin) and the color was 10% (percent) black, 20% yellow-green and 70 % red. A physician's telephone order, dated 10/3/12, indicated, "...Clean area on R (right) upper thigh (inferior) with N/S (normal saline). Apply skin prep to wound perimeter. Santyl (therapy that removes necrotic tissue from wounds) Oint (ointment) to wound bed, cover (with) calcium alginate (wound dressing). Apply protective dressing qd (every day)...." An "Acute Care Plan," dated 10/3/12, indicated "Open area inner rt (right) thigh...." Interventions indicated, "...Check w/c (wheelchair) cushion freq (frequently) for inflation/position...." A "Geriatric Subsequent Visit Form," dated 10/4/12, indicated, "(R) post thigh (with) ulcer (with) min slough surrounding nonblan (non blanch) erythemia (redness)... (1) Pressure Ulcer thigh; due to w/c. Cushion replaced. Encouraging pt to get into bed QHS (every bedtime) (has always refused but did get in bed last nt (night)). Santyl & local wound care...." A Care plan, dated 10/05/2012, indicated, "...a potential for skin breakdown r/t (related to) decreased mobility, incontinence, DM (diabetes mellitus), Obesity...Pressure reducing surface to chair/bed...Check w/c cushion frequently for proper inflation & position...." The annual MDS (Minimum Data Set) assessment, dated 10/02/2012, indicated a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively alert. An undated policy/procedure, titled "PRESSURE ULCER RISK ASSESSMENT," indicated, "...IDENTIFY RESIDENTS AT RISK FOR PRESSURE ULCER DEVELOPMENT AND IMPLEMENT APPROPRIATED INTERVENTIONS, PRESSURE ULCER RISK TO BE COMPLETED OR ADMISSION, QUARTERLY AND WITH SIGNIFICANT CHANGE...." An undated policy, titled, "SKIN PREVENTION INTERVENTIONS," indicated, '...PRESSURE ULCER RISK IDENTIFIED, CARE PLAN WITH INTERVENTIONS BASED ON ASSESSMENT, WEEKLY SKIN ASSESSMENTS...." 3.1-40(a)(1)