Every finding on record at Poplar Care Strategies

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 3 newly admitted residents reviewed. A basline care plan assessment was not completed and plan of care was not in place specific to the individualized resident needs. (Resident B)Finding includes:During record review on 4/28/26 at 11:00 A.M., Resident B's diagnoses included, but was not limited to heart failure and anxiety. Resident B was admitted to the facility on [DATE].Resident B had no baseline care plan in place pertaining to the resident's care needs.Resident B's Interim Care plan assessment, dated 4/21/26, was initiated but was not completed. During an interview on 4/29/26 at 12:15 P.M., the Director of Nursing (DON) indicated the admitting nurse usually completed the Interim Care plan assessment and that would initiate an individualized interim care plan. On 4/29/26 at 12:51 P.M., the Facility Administrator supplied a facility policy titled, Care Plans - Baseline, dated 2026. The policy included, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.This citation relates to Intakes 29994502, 2738801, and 2989481. 410 IAC (Indiana Administrative Code) 16.2-3.1-30(a)

Based on observation, interview, and record review, the facility failed to prevent accident hazards for 2 of 3 residents reviewed for accidents. A resident with supplemental oxygen was placed in a room with another resident with a documented history of non-compliance with the facility's non-smoking policy, which included the possecion of a vape pen in the resident room. The resident was alleged to be smoking in the resident's shared restroom and smoke was observed coming from the restroom while an oxygen concentrator was running in the resident's room. (Resident B, Resident C)Findings include:1. During an observation on 4/28/26 at 10:30 A.M., Resident B and Resident C were observed in the same room. Resident B was wearing supplemental oxygen received from an oxygen concentrator in the room. A sign outside the room door indicate no smoking was allowed due to the oxygen in use. During record review on 4/28/26 at 11:00 A.M., Resident B's diagnoses included, but was not limited to heart failure and anxiety. Resident B's vital signs included but were not limited to, on 4/25/26 during day shift at 9:00 A.M., and during the night shift at 9:05 P.M., the resident received supplemental oxygen via nasal cannula.Resident B's nurses notes included but were not limited to the following:4/22/26 at 2:02 A.M. - Resident is a new admission. The resident is alert and oriented but does lose track of time. The resident received two liters (L) of supplemental oxygen via nasal cannula. 4/25/26 at 12:30 A.M. - Call received from resident's spouse to report that the resident stated his roommate was smoking in the bathroom causing him to experience difficulty breathing. During an interview on 4/28/26 at 9:45 P.M., LPN 4 indicated she was the nurse on duty the night of 4/25/26 and was notified that Resident B's roommate was smoking in their bathroom. When she checked on the resident, it was obvious that the resident had been smoking, however, the resident denied smoking and staff was unable to search his belongings to remove any smoking devices. LPN 4 indicated the resident smoking in the facility had been an ongoing problem and that the facility had a no-smoking policy. During an interview on 4/29/26 at 10:30 A.M., Resident B indicated his roommate was smoking in the restroom one time. The roommate wheeled out of the restroom with a cloud of smoke behind him. Resident B indicated he could not handle the cigarette smoke and that he wears supplemental oxygen routinely. During an interview on 4/29/26 at 11:30 A.M., the Facility Administrator indicated Resident B should have been offered a room change following the smoking allegation/incident on 4/25/26. 2. During record review on 4/28/26 at 11:30 A.M., Resident C's diagnoses included, but was not limited to cannabis use, hallucinations, and delusional disorder. Resident C's most recent quarterly Minimum Data Set (MDS) assessment, dated 2/20/26, indicated the resident was cognitively intact. Resident C's care plan included, but was not limited to: Resident has brought marijuana and marijuana vape pens into the facility unwarranted. Resident C's routine psychiatry progress visit note, dated 12/30/25, included the resident had received marijuana as a Christmas gift while visiting family during the holiday and brought it back to the facility. Resident C's nurse's progress notes included but were not limited to the following:1/4/26 at 9:44 A.M. - Staff reported to this nurse that the resident's room and hall by room had the smell of marijuana vape.1/10/26 at 2:01 P.M. - This nurse was notified by CNAs that resident room smelled like marijuana again. This nurse reported complaint to the Director of Nursing (DON). 1/17/26 at 10:08 P.M. - This nurse was notified by a visitor that resident was up in the lobby area smoking marijuana. Resident was confronted by staff that he needed to quit smoking the marijuana in facility. Resident is suspected to have a marijuana vape pen. Front lobby does smell like marijuana. 4/24/26 at 12:50 A.M. - Resident was assessed following a complaint phone call from roommate's wife, reporting smoking in the bathroom. Upon assessment, the resident was found by their bedside. Initially, the resident denied the activity but later admitted to disposing of the illegal substance. The nurse reinforced safety, particularly given the roommate's oxygen therapy. During an interview on 4/29/26 at 11:50 A.M., CNA 9 indicated she had found a vape device in Resident C's room, out in the open. She notified her charge nurse, DON, and the Facility Administrator. CNA 9 indicated the police came to the facility and it was confiscated.Resident C's facility admission agreement included a Tobacco/Smoking Policy, signed by the resident on 11/17/25. The policy included, [Facility Name] has been established as a smoke free/tobacco free facility .On 4/29/26 at 12:51 P.M., the Facility Administrator supplied a facility policy titled Accidents and Incidents - Investigating and Reporting, dated 2026. The policy included, .Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.This citation relates to Intakes 2994502 and 2989481. 410 IAC (Indiana Administrative Code) 16.2.3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident receiving oxygen therapy had physician orders and a plan of care for the oxygen for 1 of 3 residents reviewed for oxygen therapy. A resident who routinely received supplemental oxygen had no physician's order to clarify the continuous need for oxygen therapy or for the amount of oxygen the resident required. (Resident B)Finding incudes:During an observation on 4/28/26 at 10:30 A.M., Resident B and Resident C were observed in the same room. Resident B was wearing supplemental oxygen received from an oxygen concentrator in the room and delivered via nasal cannula. During record review on 4/28/26 at 11:00 A.M., Resident B's diagnoses included, but was not limited to heart failure and anxiety. Resident B's vital signs included but were not limited to, resident received oxygen via nasal cannula daily, every shift, from the admission dated 4/21/26 through the review date 4/28/26. Resident B's physician orders did not included an order for routine supplemental oxygen and no clarification for routine supplemental oxygen levels. Resident B's physician orders did include an order to monitor temperature and oxygen levels every shift (started 4/21/26). Resident B had no plan of care that included the use of routine supplemental oxygen. During an observation and interview on 4/29/26 at 10:45 A.M., Resident B was wearing a nasal cannula and receiving oxygen from an oxygen concentrator set just above 2 liters (L). Resident B indicated he received oxygen at all times. During an interview on 4/29/26 at 10:55 A.M., LPN 7 indicated Resident B did receive routine supplemental oxygen and should have a physician's order for routine oxygen use. On 4/29/26 at 12:51 P.M., the Facility Administrator supplied a facility policy titled, Oxygen Administration, dated 2026. The policy included, Preparation . 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration .This citation relates to Intakes 29994502, 2738801, and 2989481. 410 IAC (Indiana Administrative Code) 16.2.3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the Activity Director was certified for 1 of 1 Activity Director reviewed. (Activity Director)Finding includes: During an interview on 1/5/26 at 1:30 P.M, the Administrator indicated the Activities Director had recently resigned, and the Activities Assistant was currently overseeing the activities.During an interview on 1/5/26 at 2:00 P.M., the Activities Assistant indicated she was not certified, and the facility currently lacked an Activities Director.During an interview on 1/7/26 at 10:03 A.M., the Administrator indicated 12/12/25 was the previous Activity's Director last day she worked. The facility had not utilized a consultant after she resigned.On 1/8/26 at 10:53 A.M., employee records were reviewed and lacked a current Activity Director.On 1/8/26 at 11:53 A.M., the Administrator provided a current, undated Nursing Home Activities: Resident Rights and the Role of Activities Staff policy that indicated, .The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who - i. Is licensed or registered, if applicable, by the state in which practicing; and ii. Is: a. Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or b. Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program; or c. Is a qualified occupational therapist or occupational therapy assistant; or d. Has completed a training course approved by the state.3.1-33 (e)

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and a homelike environment for residents, staff, and visitors for 6 of 10 rooms observed. (Room A1, Room A4, Room B2, Room B3, Room B6, Room F2)Findings include:1. On 1/5/26 at 10:19 A.M., Room A1 (shared by 3 residents) was observed with a strong odor of urine, brown substance smeared on raised toilet seat with handles at 2, 7, and 9 o' clock, and down the front of the toilet, 2 unlabeled bottles of moisturizing shampoo and body wash, an open tube of over the counter lotion and another unlabeled rash ointment on the back of the toilet, dust caked on the exhaust fan, the call light string was brown, and there were blue splatters on the wall to left of toilet and down the front of the toilet, and the tiles around the base of the toilet were brown. On 1/6/25 at 3:09 P.M., Room A1 was observed with a strong odor of urine, dust caked on the exhaust fan, the call light string was brown, and the tiles around the base of the toilet were brown. 2. On 1/5/26 at 1:49 P.M., Room A4 (private) was observed with a strong urine odor, dust caked on the exhaust fan, the call light string was brown, and the tiles around the base of the toilet were brown. On 1/8/26 at 9:17 A.M., the same was observed. urine odor. 3. During an observation on 1/5/26 at 10:03 A.M., the faucet handles and base in Room F2 were green. On 1/8/26 at 9:08 A.M., the same was observed in Room F2. 4. On 1/5/26 at 10:29 A.M., Room B2 was observed with a rolled up towel on the floor in front of the air conditioning unit. The bathroom was observed with a toilet seat riser with chipped paint on the legs where the resident's legs would sit. On 1/7/26 at 9:35 A.M., the same was observed. At that time, the Maintenance Assistant picked up the towel in front of the air conditioning unit, checked the unit, indicated he did not see any problems with the unit, and did not know why the towel was there. The towel was observed to have a yellowed stain on it. During an observation with the Maintenance Supervisor on 1/8/26 from 9:20 A.M. until 9:40 A.M., the same was observed on the toilet seat riser. The Maintenance Supervisor indicated he was unaware of the issue and would need to replace it. 5. On 1/5/26 at 10:49 A.M., the bathroom in Room B6 was observed with 1 of 2 lights on and working. On 1/8/26 at 9:06 A.M., the same was observed. During an observation with the Maintenance Supervisor on 1/8/26 from 9:20 A.M. until 9:40 A.M., the same was observed. He indicated he was unaware that the light was out. 6. On 1/5/26 at 10:53 A.M., the bathroom in Room B3 was observed with 1 of 2 lights on and working. On 1/8/26 at 9:05 A.M., the same was observed. During an observation with the Maintenance Supervisor on 1/8/26 from 9:20 A.M. until 9:40 A.M., the same was observed. He indicated he was unaware that the light was out. On 1/8/26 at 9:40 A.M., the Maintenance Supervisor indicated he had scheduled monthly maintenance checks on certain issues around the facility, but most had to do with life safety. He indicated any other issues, he was dependent on staff to let him know. He indicated there were forms at the two nurses stations that staff could fill out and submit to him. They could either put in a box by his office, or clip to the door. He indicated he was unsure of any policy related to preventative maintenance, but did follow the scheduled maintenance as a sort of policy. A preventative maintenance policy was requested and not provided. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure an infection control program to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents observed for incontinence care, and 1 of 2 residents observed for a wound dressing change. Staff did not sanitize hands between glove changes, did not wear required Personal Protective Equipment (PPE), and placed a resident's open wound on bed linen. (Resident 25, Resident 3, Resident 21, Resident 27)Findings include:1. On 1/5/26 at 10:19 A.M., Certified Nurse Aide (CNA) 25 was observed to assist Resident 3 out of bed and to the toilet. The room was observed with EBP signs just outside the doorway, and a cart with PPE. CNA 25 did not wear a gown during care. Resident 3 was assisted to the bathroom and onto the toilet. CNA 25 removed a soiled brief while the resident was sat on the toilet. While putting on the clean brief, CNA 25 scraped the inside and outside of the clean brief on the floor prior to placing it over the resident's feet. The clean brief was then pulled up onto the resident. On 1/6/26 at 9:35 A.M., Registered Nurse (RN) 21 and RN 5 were observed to change a dressing on Resident 3's heel. The soiled dressing was removed from the right foot, and the heel wound was placed on the bedding. A drape was then placed under the foot and the wound cleaned. RN 21 then removed the drape, and placed the heel wound back on the bedding. RN 5 placed a clean drape under the foot and finished the wound dressing. On 1/6/26 at 3:53 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, viral hepatitis, dementia, and seizure disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 10/2/25, indicated no cognitive impairment, and dependent on staff for toileting. Current physician orders included, but were not limited to: Enhanced Barrier Precautions (EBP) every shift for Wounds, dated 9/26/25. 2. On 1/5/26 at 10:00 A.M., Certified Nurse Aide (CNA) 25, CNA 9, and Licensed Practical Nurse (LPN) 15 were observed to assist Resident 21 with incontinence and colostomy care. The room was observed with EBP signs just outside the doorway, and a cart with PPE. CNA 25, CNA 9, and LPN 15 did not wear a gown during care. Prior to care, CNA 9 washed hands for 12 seconds. LPN 15 emptied the resident's colostomy bag, removed her gloves, and washed hands with a 6 second lather. After assisting the resident with care and into a wheelchair, CNA 9 washed hands for 14 seconds. On 1/6/26 at 6:00 A.M., Resident 21's clinical record was reviewed. Diagnoses included, but was not limited to, sacral pressure ulcer. The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated a sacral pressure ulcer, and dependent on staff for toileting. Current physician orders included, but were not limited to: Enhanced Barrier Precautions every shift for wounds to coccyx and colostomy, dated 3/6/25. 3. On 1/6/26 at 10:38 A.M., Certified Nurse Aide (CNA) 25 was observed to assist Resident 25 with toileting. CNA 25 put gloves on, locked the brakes on the wheelchair, and pulled the resident's pants down. Without changing gloves, CNA 25 cleaned the resident after a bowel movement. CNA 25 then removed the gloves, and put on another pair of gloves without sanitizing hands between glove changes. 4. During an observation on 1/6/26 at 3:19 A.M., Licensed Practical Nurse (LPN) 17 and Certified Nurse Aide (CNA) 18 performed incontinence care on Resident 21. CNA 18 completed a 4 second hand lather prior to donning gloves. LPN 17 and CNA 18 removed the soiled brief and failed to perform hand hygiene after they removed their soiled gloves. LPN 17 and CNA 18 donned gloves, fastened the new brief, and then pulled up Resident 21's covers with the same gloves. LPN 17 removed gloves and performed a 12 second hand lather. 5. On 1/6/26 at 3:09 P.M., CNA 25 and Qualified Medication Aide (QMA) 32 were observed toileting Resident 27. When QMA 32 was putting a clean pull up incontinence pad back on Resident 27 who was seated on the toilet, she brushed the inside of the pull up against the resident's soiled socks. During an interview on 1/6/26 at 10:07 A.M., the Infection Preventionist (IP) indicated hand hygiene should be performed between dirty and clean tasks, and hands should be lathered for at least 20 seconds. A resident's pull up incontinence pad should not touch the floor, socks, or shoes when putting it on the resident. During an interview on 1/7/26 at 9:52 A.M., CNA 25 indicated staff should wash hands with a 20 second lather. She also indicated if gloves were soiled or the resident had a bowel movement, staff should sanitize between glove changes. She indicated when a resident was on EBP, staff should wear a gown for direct contact. On 1/8/26 at 11:47 A.M., the Administrator provided a current Enhanced Barrier Precautions policy, dated 4/2024, that indicated If resident is on enhanced barrier precautions or contact precautions, wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient On 1/8/26 at 11:47 A.M., the Administrator provided a current non-dated Hand Hygiene policy that indicated Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of20 [sic] seconds (or longer) . 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure resident privacy for 4 of 4 random observations. Staff did not knock on doors prior to entering, and doors and curtains were not closed during a wound dressing change. (Resident 21, Resident 3, Resident 9, Resident 10)Findings include:1. On 1/6/26 at 3:19 A.M., Licensed Practical Nurse (LPN) 17 and Certified Nurse Aide (CNA) 18 were observed to enter Resident 21's room without knocking. Resident 21 was in the room at that time. 2. On 1/5/26 at 10:09 A.M., Certified Nurse Aide (CNA) 25 was observed to enter Resident 21's room without knocking. Resident 21 was in the room at the time. On 1/7/26 at 9:23 A.M., Registered Nurse (RN) 21 was observed to enter Resident 21's room without knocking. Resident 21 was in the room at the time. On 1/7/26 at 9:35 A.M., the Maintenance Assistant was observed to enter Resident 21's room without knocking. Resident 21 was in the room at the time. 3. On 1/6/26 at 3:18 A.M., Licensed Practical Nurse (LPN) 7 was observed to enter Resident 10's room without knocking. Resident 10 was in the room at the time. 4. On 1/7/26 at 9:45 A.M., RN 21 was observed to enter Resident 9's room without knocking. Resident 9 was in the room at the time. 5. On 1/5/26 at 10:09 A.M., CNA 25 and CNA 9 were observed to enter Resident 3's room without knocking to assist her out of bed. On 1/6/26 at 9:35 A.M., RN 21 and RN 5 were observed during a dressing change for Resident 3. The door nor the curtain were closed. During the dressing change, two staff members were observed to walk past the room, one stopping to speak with RN 5. On 1/7/26 at 9:52 A.M., CNA 25 indicated staff should provide resident privacy by knocking on doors prior to entering their room, pulling curtains, and shutting blinds prior to providing care. On 1/7/26 at 2:30 P.M., the Administrator provided a current Resident Care and Dignity policy, last revised 1/2024, that indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . privacy and confidentiality 3.1-3(o)

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity when being spoken to. During 1 of 1 random interview, a resident indicated staff spoke harshly to residents during care, were short with residents, and cursed. These actions led the resident to feel angry. (Resident B)Findings include:On 1/7/26 at 10:13 A.M., Resident B indicated concern that a few un-named staff members had spoken harshly with residents. She indicated she had not directly observed the treatment, but had heard it from her room and from the hallway. She indicated Certified Nurse Aides (CNAs) had been overheard telling residents to shut your mouth and forcing residents to go to bed when they did not want to. She indicated the CNAs could be heard being hateful and speaking bad to other residents, often cursing and being short with them. She indicated the behavior had been going on for several months, and although grievances had been filed regarding the situation, as well as being brought up in resident council meetings, the behavior had continued. She indicated the behavior angered her as she was worried about the other residents it was happening to. On 1/7/26 at 10:45 A.M., the Activities Assistant indicated she attended resident council meetings with the residents. She indicated during the meetings, residents had indicated that staff were cursing, griping, and had been snippy with residents at times. She indicated when the allegations were made, she filled out grievance forms and gave them to the Administrator. At that time, she indicated she could remember filling out at least two grievances related to staff behavior. On 1/7/26 at 11:03 A.M., the Administrator indicated she was aware of the complaints about staff behavior and acknowledged the grievances. She indicated education had been done to address the situation with in-services related to resident rights, professionalism, phone use, and watching tone. She indicated she had been made aware of the situation through reviewing resident council minutes and following through on the grievances. At that time, she indicated there was not a current plan in place to monitor staff behavior or ensure appropriate resident treatment, but that her door was always open for residents to speak with her, as well as the Director of Nursing (DON) and Social Services Director (SSD). She indicated negative behavior by staff was not encouraged and had written up staff, in-serviced staff, and counselled staff in regards to foul language and professionalism. On 1/8/26 at 1:30 P.M., resident council minutes were reviewed and indicated, but were not limited to, the following:8/5/25 New business: wants help to be nicer - they are mean, say they are tired, the way they talk, the F Word, being on phones, need more patience. Concern with CNAs being nicer.10/6/25 Concern with a CNA being abrasive.11/3/25 Concern with nursing: [nurse name] is a smart---. Staff getting snippy.1/5/26 Concern with gripey nursing staff.On 1/8/26 at 1:40 P.M., grievances were reviewed and indicated, but were not limited to, the following:10/6/25 Grievance came from resident council that a CNA was abrasive and tone was short. The CNA was educated to be mindful of tone.10/9/25 A resident indicated staff had been short with him. The CNA was educated on customer service.1/5/26 Grievance came from resident council that a CNA was gripey. The resident and CNA were spoken to.On 1/8/25 at 2:00 P.M., the Administrator provided in-services and counselling forms that included the following:April 2025 in-services on conduct behavior and telephone usage were given.10/21/25 in-services on conduct behavior and telephone usage were given.An undated in-service was given on resident privacy and respectful communication.A counselling form, dated 8/18/25, indicated a CNA was given verbal counselling on conduct, customer service, and cell phone use after resident complaints about the CNA being in a rush and being short and rude to them. The CNA was getting the residents up in the morning before they wanted to, and language was unprofessional. The form was signed by the CNA and DON.Another counselling form, dated 8/18/25, indicated a different CNA was given verbal counselling on conduct, customer service, and cell phone use for the same reasons. The form was signed by the CNA and DON.On 1/7/26 at 2:30 P.M., the Administrator provided a current Resident Care and Dignity policy, last revised 1/2024, that indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . be treated with respect, kindness, and dignityThis citation relates to Intake 2686980.3.1-3(a)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 2 residents reviewed for respiratory care. (Resident 32)Findings include: On 1/5/26 at 10:10 A.M., Resident 32 was observed sitting in his wheelchair with oxygen on via nasal cannula. At that time, a nasal spray (fluticasone propionate 50 micrograms (mcg) per spray) was observed on the bedside table. Resident 32 indicated he used the nasal spray whenever he needed to.On 1/6/26 at 8:08 A.M., Resident 32's clinical record was reviewed. Diagnosis included, but was not limited to, asthma.The most recent admission Minimum Data Set (MDS) assessment, dated 11/26/25, indicated Resident 32 was cognitively intact.Resident 32's clinical record lacked a current order for fluticasone propionate.Resident 32's clinical record lacked a care plan related to self-administering medications.Resident 32's clinical record lacked a self-administration assessment.During an interview on 1/8/26 at 9:15 A.M., Registered Nurse (RN) 3 indicated Resident 32 used the nasal spray in his room, and the clinical record lacked a current order to keep the nasal spray at bedside.On 1/8/26 at 11:47 A.M., the Administrator provided a current, undated Medication Administration policy that indicated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe.3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure a resident that was dependent on staff for Activities of Daily Living (ADLs) received necessary care to maintain their personal hygiene for 1 of 1 resident reviewed for ADL care. A dependent resident with Moisture Associated Skin Damage (MASD) was not offered or toileted every two hours as ordered. (Resident 27)Finding includes: On 1/7/26 at 9:09 A.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, osteoarthritis and dementia without behaviors.The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/26/25, indicated Resident 27's cognition was severely impaired, she was substantial/maximum assistance of staff (staff performs over half of the effort) for toileting, transfers, always incontinent of bowel and bladder, no behaviors of rejecting care, and had MASD skin conditions.Current physician's orders included, but were not limited to, the following:Offer to assist resident with toileting needs every two hours and as needed every day and night shift, ordered 12/8/22Mary's Magic Butt Cream as needed for redness every day and night shift for preventative measure, ordered 6/3/24Nystatin Powder 100,000 Unit/Gram Apply to groin topically every day and night shift for yeast, ordered 7/5/24Cleanse perineal (peri) area and between bilateral buttocks with gentle soap and water, rinse, and pat dry. Apply Mary's Magic Butt Cream to red and opened areas every day and night, ordered 12/23/25A current Skin Impairment Care Plan, last revised 12/12/25, indicated the resident had impairment to skin integrity related to weakness, impaired mobility, yeast to groin area, incontinence, chronic excoriation to buttocks, and included, but was not limited to, the following interventions:Follow facility protocols for treatment of injury, initiated 12/23/21Medications and treatments as ordered, initiated 12/23/21Progress notes from 8/1/25 to present were reviewed and indicated:On 8/6/25 Skin Issues Note: 1. Location: Intergluteal cleft (vertical groove seperating buttocks). Issue type: MASD. Skin issue Wound acquired in-house. 2. Location: Medial coccyx (tailbone). Issue type: Excoriated MASD. Wound acquired in-house. 3. Location: Buttocks - generalized. Issue type: MASD. Wound acquired in-house.On 8/11/25, a skin/wound note indicated Inner buttocks and labia were red and excoriated.On 8/13/25, a nurse's note indicated the resident had increased redness to vaginal area and was complaining of itching and burning in the vaginal area. Nurse Practitioner (NP) ordered Diflucan 150 milligram (mg), give one by mouth daily for three consecutive days for fungal infection.On 8/15/25, a nurse's note indicated the resident continued to complain of itching (in vaginal area). On 8/21/25, a skin issues note indicated areas on bottom and peri area were improving.On 8/27/25, a skin issues note indicated the resident presented with erythema (redness) and some skin breakdown on the buttocks.On 9/17/25, a skin issue note indicated MASD of intergluteal cleft, coccyx, and buttocks. Stable: previously deteriorating wound characteristics plateaued.On 12/23/25, a skin/wound note indicated the resident had scratched open areas on her pubic bone, all around the labia and in the perineum.The clinical record lacked documentation of the resident being encouraged and toileted every 2 hours as ordered.On 1/6/25 at 3:09 P.M., Certified Nurse Aide (CNA) 25 and Qualified Medication Aide (QMA) 32 were observed toileting Resident 27. CNA 25 and QMA 32 assisted the resident onto the toilet. QMA 32 removed a saturated incontinence pad and saturated pants from the resident. The resident was noted to have redness to her buttocks.During a continuous observation on 1/7/25 from 10:20 A.M. to 1:49 P.M., Resident 27 was observed in the dining room until 12:15 P.M. when the resident left the dining room propelling self in wheelchair to the hallway by the entrance to the facility. At 12:38 P.M., two CNAs walked past the resident but did not address the resident and returned with other residents from the dining room. At 1:49 P.M., the Activities Assistant asked the resident if she wanted to go to the activity and she was pushed in her wheelchair to the activity area.During an interview on 1/8/26 at 11:00 A.M., Licensed Practical Nurse (LPN) 16 indicated Resident 27 needed staff assistance to be toileted and have thorough personal hygiene care. She was constantly wet and should be encouraged to do toileting every 2 hours at least because if not, her bottom would get galled and excoriated quickly. She indicated they don't document the specific times that they offer the resident or toilet the resident because it didn't automatically pop up as a task every two hours to do. It's up to each CNA to keep track. They will usually do it upon arrival for shift, before breakfast, around 10:00 A.M., after lunch, and thereafter. The resident did not usually refuse care.During an interview on 1/8/26 at 12:26 P.M., the DON indicated she expected the resident to be offered and toileted every two hours as ordered. She expected the nurses checking off the task in the clinical record to make certain that it was being done. She was not aware that the order was not being followed.On 1/8/26 at 2:11 P.M., a current ADL policy was requested but not provided during the survey period.On 1/8/26 at 4:16 P.M., a current Comprehensive Care Plan Policy, dated 1/1/22, was provided by the Administrator and indicated, . It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care . The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality . 3.1-38(a)(2)(C)3.1-38(a)(3)(A)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 1 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls, a fall assessment was not completed after a fall, and an interdisciplinary note was not completed after a fall. (Resident 23)Findings include:During an observation on 1/05/2026 10:07 AM Resident 23 was observed in the common area with a staff member. She had fall socks on and a fall alarm attached to her wheelchair.On 1/5/26 at 3:21 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limit to, fracture of the right pubis, dementia, abnormalities of gait and mobility, and unsteadiness on feet.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, indicated Resident 23 had severe cognitive impairment and was dependent on staff for transfers and toileting.Resident 23's Physician's Orders included, but was not limited to, resident should not be left in the wheelchair unsupervised while in her room or in the lounge for safety, dated 10/14/25.Resident 23's care plan included, but was not limited to, The resident is at an increased risk for falls r/t [related to] having Confusion , Gait/balance problems, bowel and bladder incontinence, Psychoactive drug use , being unaware of her safety needs and having a history of recurrent falls, dated 9/29/25. Current interventions included, but were not limited to, resident should not be left in the lounge unsupervised while in her wheelchair, dated 10/22/25.On 11/13/25 at 3:56 P.M., a nurses note written by Registered Nurse (RN) 3 indicated the following, Heard pressure alarm sounding in TV [television] lounge at 1515 [3:15 P.M.]. Resident found laying flat on her back on the floor in front of TV [television].Resident 23's clinical record lacked a fall assessment after the fall on 11/13/25.Resident 23's clinical record lacked an interdisciplinary team (IDT) note after the fall on 11/13/25.During an interview on 1/6/26 at 7:33 A.M., RN 3 indicated that Resident 23 was in the lounge by herself when she fell on [DATE].During an interview on 1/6/26 at 7:41 A.M., the Director of Nursing (DON) indicated that Resident 23 was supposed to be supervised at all times when she was in the lounge. At that time, she further indicated she did not see a fall assessment or IDT note after the 11/13/25 fall, but she would expect a fall assessment and IDT note to be completed after every fall.On 1/8/26 at 11:47 A.M., the Administrator provided a current Falls-Clinical Protocol policy, revised March 2018 that indicated, .the staff and physician will identify pertinent interventions to try and prevent subsequent falls.3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent and treat a facility acquired pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Skin assessments were not completed and a resident's plan of care was not followed and revised to monitor and assess the resident's right ankle pressure ulcer. (Resident 7)Finding includes:On 1/6/26 at 9:53 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, polyneuropathy, and Stage II (Partial thickness loss of skin, which may present as a blister or shallow open sore) pressure ulcer. The stage of pressure listed was an inaccurate diagnosis. The resident had a Stage III (full-thickness loss of skin occurs, potentially exposing fat tissue. The ulcer may appear as a deep crater) pressure ulcer/injury.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated the resident was cognitively intact, dependent on staff assistance for showering, transfers, toileting, at risk for pressure ulcers, had one Stage III pressure ulcer, no pressure reducing device for chair or bed, no turning/repositioning program, on nutrition interventions to manage skin problems, receiving pressure ulcer care and had behavior of rejecting care one to three days out of the seven day look back period.Current physician's orders included, but were not limited to, the following:Regular diet, regular texture, thin consistency, give double portions of protein with meals, initiated 1/21/25 Protein powder, mix one scoop of protein powder in liquid of choice by mouth twice daily with meals, ordered 10/6/25 Enhanced Barrier Precautions (EBP-infection control measure requiring gown and gloves to be worn for high-contact care) every day and night shift related to Stage II pressure ulcer of right ankle, ordered 11/12/25 Magic Cup (nutrition supplement) with meals for weight loss and to promote wound healing. Staff to document the amount consumed, ordered 12/3/25 Cleanse the right ankle wound with wound cleanser and gently pat dry. Apply Calmoseptine (ointment used as a moisture barrier form a protective layer, keeping skin dry while its active ingredients promote healing by preventing moisture and irritants from further damaging the skin) to irritated skin around the outside of the wound. Hydrofera blue (foam wound dressings containing the antibacterial pigments methylene blue and gentian violet, designed to manage bacteria, control exudate, maintain moisture, and promote healing for various complex wounds) to wound bed only (cut to fit size), apply abdominal pad (ABD-a highly absorbent, thick dressing used to manage fluid, protect the wound, and promote healing by wicking moisture away from the skin.) and wrap with bulky kerlix gauze for additional protection every day shift Monday, Wednesday and Friday and as needed (PRN) if soiled or dislodged related to Stage II pressure ulcer on right ankle, ordered 12/10/25Appt on 1/14/26 with (name of wound care clinic), facility to transport one time related to Stage II pressure ulcer of right ankle, ordered 12/30/25Gently cleanse the wound and surrounding skin and pat dry. Apply a thick layer of LMX-4 (topical cream used to numb the skin for pain relief for minor procedures) and wrap loosely with a dressing and allow to set for 30 to 60 minutes prior to wound care of the right ankle. Cleanse numbing agent off of skin prior to completing treatment, every Monday, Wednesday, and Friday related to Stage II pressure ulcer of right ankle, ordered 1/7/26 A current Stage III pressure ulcer care plan, last revised on 9/10/25, included, but was not limited to, the following interventions:If the resident refuses treatment, confer with the resident, Interdisciplinary Team (IDT), and family to determine why and try alternative methods to gain compliance, initiated 3/19/25 Assess/record/monitor wound healing weekly and PRN. Measure length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report improvements and declines to the Medical Doctor (MD), initiated 3/19/25Follow facility policies/protocols for the prevention/treatment of skin breakdown, initiated 3/19/25Follow up with the wound clinic as per orders, initiated 7/2/25Monitor nutritional status. Serve diet as ordered, monitor intake, and record. Initiated 3/19/25Braden Scale skin risk assessments (a standardized tool used in healthcare to assess a patient's risk of developing pressure injuries/ ulcers based on various risk factors), dated 10/11/24 and 3/19/25, indicated the resident was at mild risk. The clinical record lacked documentation of quarterly skin assessments between them.Skin and wound assessments, progress notes, wound clinic care notes, and medication and treatment administration records (MAR/TAR) from 3/19/25 to present were reviewed and indicated the following:On 3/19/25 at 6:08 P.M., the resident complained of right ankle pain, and upon examination, an area of 0.1 centimeters (cm) length x 0.1 cm width on the outer right ankle was present. The area was red and warm to the touch, skin intact. Progress notes and skin/wound assessments indicated the wound was progressively worsening from a Stage I (skin is intact but shows a localized area of non-blanching redness that didn't fade after pressure was removed) pressure ulcer to a Stage III pressure ulcer. The resident started an antibiotic for an infection of the wound on 5/6/25, 5/18/25, and 6/17/25. The Nurse Practitioner (NP) ordered a referral to a wound care clinic for evaluation on 6/27/25 and started an antibiotic and probiotic for the infection of the right lateral ankle pressure ulcer. The resident's pain was controlled with Tylenol 650 milligrams (mg) every six hours as needed, and then Tramadol 50 mg twice daily was added eventually for better pain control. An appointment with the wound clinic was scheduled for 7/21/25.The initial wound clinic evaluation note, dated 7/21/25, indicated the Stage III pressure injury measured 1.6 cm (length) x 1.6 cm (width) x 0.1 cm (depth). The wound was open with 15% granulation tissue (the new, pinkish-red, moist connective tissue with new blood vessels formed on the surface of a healing wound, acting as a foundation to fill it in, protect against infection, and support the growth of new skin (epithelialization). A crucial sign a wound was progressing from inflammation to the proliferative (rebuilding stage) and 85% slough (a layer of yellowish, soft, stringy, or cheesy dead tissue that would build up on the wound bed, acting as a barrier to healing and a breeding ground for bacteria. It was a sign that a wound was stuck in the inflammatory healing stage and must typically be removed or debrided for healthy tissue to grow and for the wound to close properly, noted in the wound bed. Small amount of serosanguinous drainage (thin, pinkish-red or light red fluid from a wound, common in early healing). Peri wound clean, moist, and blanchable erythema (redness). Wound edges attached and well defined. Treatment plan: Cleanse with normal saline, cover with Iodoflex (a dressing that released iodine to fight a broad spectrum of microbes, managed exudate, the fluid that seeps from a wound, and absorbed slough to promote healing and reduce infection risk) and an ABD pad, secured with cast padding and kerlix gauze daily and prn.A wound clinic note, dated 7/29/25, indicated the wound was debrided (the medical removal of dead, damaged, or infected tissue). Measurements prior to debridement were 1.2 cm x 1 cm x 0.1 cm. Post-debridement measurements were the same. Treatment plan: Cleanse wound with normal saline, Collagenase Santyl ointment (used for enzymatic debridement) to be applied nickel thickness to the wound base only, avoiding healthy tissue surrounding the wound. Cover with ABD pad and kerlix gauze. Change dressing daily. Follow-up appointment on 8/12/25.A wound clinic note, dated 8/12/25, indicated the wound was debrided again. Pre debridement measurements were 1.3 cm x 0.8 cm with scant serous drainage (a thin, watery, clear to pale yellow fluid that helped clean the wound and keep it moist for cell repair) and 100 % wound bed eschar (a thick, black or brown, leathery layer of dead, dry tissue that formed over a severe wound, hindering healing and creating a breeding ground for infection). Wound looks really good at this point. All the pressure has been relieved, and there is no erythema and no bogginess to the eschar. At this point, I think just keeping the pressure off is going to allow this to epithelialized. Treatment plan: Cleanse wound with normal saline and cover wound with ABD pad and kerlix gauze daily and PRN if soiled or dislodged. Follow-up appointment on 9/9/25.A wound clinic note, dated 9/9/25, indicated the resident arrived without any protective dressing in place on the right ankle pressure wound. The fat layer was exposed, and ulceration showed signs of regression with mild clinical signs of secondary infection of erythema, edema (swelling), and purulent drainage (a thick, often milky or yellowish fluid draining from a wound indicating a bacterial infection). Measurements of the wound were 1.3 cm x 1.3 cm x 0.1 cm. The wound bed had 60% granulation and 40% slough with attached well-defined edges. Treatment plan: Antibiotic ordered for wound cellulitis. Patient to keep the heel lift boots on at all times when in a wheelchair or in bed. Cleanse the right ankle wound with normal saline, cover ulcer with adaptic calcium alginate dressing (a petrolatum-coated, non-adhering, highly absorbent dressing) and ABD pad. Secure with kerlix gauze daily and PRN if soiled or dislodged. Follow up appointment on 9/18/25.A wound Care note, dated 9/18/25, indicated the fat layer exposed ulceration was stable with minimal improvement. No signs of secondary infection. Further discussion was held about the patient not leaving the offloading protective boot in place due to her dementia. Change to adhered felt with offloading dressing and dress the wound Monday, Wednesday, and Fridays. Follow-up appointment scheduled.A wound clinic note, dated 10/2/25, indicated the fat layer exposed ulceration was stable with no signs of infection. The wound subcutaneous tissue was debrided of biofilm (a slimy, protective layer of microorganisms, like bacteria, fungi, algae, that stick to the surface in a moist environment). Post debridement measurements were 1 cm x 1 cm x 0.1 cm. Noted that the potential to heal was poor. Follow-up appointment scheduled. No new orders. Follow-up appointment scheduled 10/9/25.The wound clinic note from 10/9/25 was not available from the clinical record.A nursing note, dated 10/9/25, indicated facility and family were not happy with the care provided when the resident returned from her wound clinic visit on 10/9/25. The family requested a referral to a different wound clinic. An appointment was made for 10/15/25 at a different clinic.A wound clinic note, dated 10/15/25, indicated it was the initial visit for wound care to a Stage III pressure injury to the right ankle. Measurements of the wound were 2 cm x 2 cm x 0.1 cm. Fat layer exposed. A small amount of serosanguineous drainage was noted. Wound bed had no granulation, eschar, or epithelization, but did have slough. Edges of the wound were attached. Peri wound skin was erythematous, but temperature was normal, and no signs of infection. Local pulse was felt. Potential to heal was fair. Treatment plan: Apply Prisma dressing (collagen-based wound dressing that helped heal chronic wounds by turning into a gel, absorbing excess fluid, protecting against infection with silver, and creating a moist environment for new tissue growth ), dampened with normal saline. Cover with a border foam. Change dressing on Mondays and Fridays. Off load ankle area with a pillow or an offloading boot. See back 10/22/25.A wound clinic note, dated 10/22/25, indicated measurements of the wound were 2.2 cm x 2.5 cm x 0.1 cm. A small amount of serosanguineous drainage was observed, and it had bright red, pink, firm granulation and slough, but no eschar or epithelialization. The patient might benefit from debridement, but the patient would not tolerate it. Continue current treatment, but change dressing changes to Monday, Wednesday, and Friday. Return in 2 weeks.A wound clinic note, dated 11/5/25, indicated measurements of the wound were 2 cm x 2 cm x 0.1 cm. Redness present. A small amount of serosanguineous, creamy yellow drainage present. Drainage sent for culture and sensitivity. Wound bed was bright red, pink, firm, with granulation and slough present but no eschar or epithelization. Treatment plan: Keflex 500 mg, give one by mouth three times a day for seven days for the infection of the right lateral ankle pressure ulcer. Change dressing to Aquacel Ag dressing (antimicrobial wound dressing). Next visit 11/12/25.A wound clinic note, dated 11/12/25, indicated measurements of the wound were 2 cm x 2.5 cm x 0.1 cm. A small amount of creamy, yellow serosanguineous drainage present. Wound bed with slough, granulation, firm, bright red, and pink. No eschar or epithelization. Treatment Plan: Apply Calmoseptine ointment to irritated skin around the outside of the wound. Prisma dressing to wound bed. Cover with an absorbent dressing. Change the outer dressing on Mondays, Wednesdays, and Fridays. Due to the patient's pain with wound dressing changes, apply dry Prisma applied in layers. Should leave primary dressing of Prisma in place as long as possible (weekly) to prevent irritation from dressing changes on the wound. Hopefully, Prisma will keep the wound covered almost like a scab and keep the wound from getting infected, as well as prevent irritation. Reviewed drainage cultures growing protease and Methicillin-Resistant Staphylococcus Aureus (MRSA, a type of staph infection caused by bacteria resistant to many common antibiotics). Keflex 500 mg, give one by mouth three times a day, continued for five more days. Follow up on 12/3/25.A Nurse's note, dated 12/3/25, indicated the NP was in the facility to see the resident and ordered a right ankle x-ray to rule out osteomyelitis and ordered Clindamycin 300 mg, give one by mouth three times a day for ten days, and a probiotic for 20 days. The facility received a call from the wound care clinic to reschedule a missed appointment. Appointment rescheduled to 12/8/25.A Nurse's note, dated 12/7/25, indicated dressing to the right outer ankle was changed at that time. Very painful. 80% slough covered. Notified NP to request stronger pain medication and the need to add Medi-honey or Santyl for enzymatic debridement r/t slough. Norco 5/325 mg tablet (pain medication), give one tablet three times daily for pain management ordered.A wound clinic note, dated 12/8/25, indicated the patient complained of severe pain with any movement of the right ankle. Measurements of the wound were 3 cm x 3.2 cm x 0.2 cm. There was a moderate amount of serosanguineous drainage noted. Wound margin attached and wound bed has bright red, pink, firm granulation and slough. No epithelialization. The peri-wound skin exhibited maceration. Peri wound skin presented with signs/symptoms of infection. Treatment plan: Change dressings to Calmoseptine to the irritated skin around the outside of the wound. Apply Hydrofera dressing, cut to wound size, cover with ABD pad (folded in half for extra padding), wrap with kerlix gauze, and secure with tape on Mondays, Wednesdays, and Fridays. Try to avoid infection. Do not allow dressing to get wet when bathing. Offload ankle area with a pillow or an offloading boot at all times resident would allow. Follow up on 12/30/25.A Nurse's note, dated 12/30/25, indicated the wound care clinic called and the 12/30/25 appointment needed to be rescheduled to 1/14/26.The MAR/TAR from 3/19/25 to present were reviewed and indicated the treatments and medications were being given, but lacked documentation on the wound.It was documented throughout the clinical record the resident refused to float heels while in bed, to wear heel boots, and was resistant and combative to staff during wound care at times during the afternoon and evening hours.Skin assessments on other skin issues were completed weekly, but measurements of the wound and documentation of the wound characteristics were not documented weekly.The clinical record lacked documentation that the interventions of the plan of care were discussed and re-evaluated and new interventions tried to provide treatment of the pressure ulcer.Wound in-services were given by the DON on the following dates to nurses on staff:2/27/25-Topic: Prevention of pressure injuries, wound care, care plans8/3/25-Topic: Wound/skin issuesOn 1/7/26 at 9:09 A.M., Resident 7's bed was observed with a pressure-reducing mattress. On 1/7/26 from 10:20 A.M. to 12:00 P.M., Resident 7 was observed sitting in her wheelchair in the main dining room for a continuous observation. Her lunch was served without a double portion of protein, a magic cup was not offered, and the protein powder was not visible in the resident's tea, which was the only liquid she was served at that time. The resident, sitting in her wheelchair, propelled herself out of the dining room with her feet after she completed her meal to the front hallway by the entrance of the building.On 1/7/26 at 1:13 P.M., Licensed Practical Nurse (LPN) 16 was observed to ask Resident 7 if she would lie down to have the dressing to right ankle changed. The resident was resistive. LPN 16 indicated She does much better early morning when she is in bed already. The resident agreed to go to her room for wound care.On 1/7/26 at 1:20 P.M., staff was observed pushing the resident down the hallway into her room. Several staff members were present in the room. The resident refused observation of wound care at that time. On 1/8/26 at 9:20 A.M., Resident 7 was observed in her wheelchair, propelling herself in the hallway with both feet, and the resident was sitting on a pressure-reducing cushion.On 1/8/26 at 9:30 A.M., the MDS Coordinator indicated there was not an order for a pressure-reducing mattress or cushion to the wheelchair so the MDS assessment reflected that. If it's not an order that was signed off, she would have no way to capture that.During an interview on 1/8/26 at 10:15 A.M., LPN 16 indicated the resident was resistant to care at times and could be combative as well. She used to come in and do Resident 7's wound care first thing before shift started because the resident was usually waking around 5:00 A.M. and was more cooperative in the morning when she was still in bed. The treatment was ordered for day shift (7:00 A.M.-7:00 P.M.) because night shift would not always get to complete treatments before shift change. She was unsure how often the resident went to wound clinic but thought weekly on Wednesdays. She indicated there was not an order and the care plan did not indicate how often. At that time, she indicated skin assessments were to be done weekly and the nurse should get measurements at that time or with wound dressing changes. She would not document measurements, wound characteristics, or about the wound care when provided in the clinical record; she would just mark that it was completed on the MAR/TAR. She indicated the kitchen would put the protein powder in the resident's tea at meals. She was unaware why the order indicated it was to be provided twice daily with meals, because the MAR/TAR indicated it to be given at three meals and that was how it was documented it was given. The nursing staff should be checking the resident's meals because they were the ones documenting how much of the magic cup, protein powder, and meal was consumed. If the resident had been refusing the magic cup, protein powder, or double portions, then the dietary staff should bring that to the attention of the nurse and/or DON so they can notify the MD and try something else. The orders should be followed as written.During an interview on 1/8/25 at 11:24 A.M., the Dietary Manager indicated Resident 7 was on a regular diet, protein powder was put in food, and got double meat at breakfast and lunch. The resident was not receiving the magic cup ordered on 12/3/25. She got the protein powder in her food because she would not consume the magic cups. During an interview on 1/8/26 at 11:57 A.M., the DON indicated that, depending on how the wound looked, the resident was seeing wound care 1-2 times a week. She indicated the facility was not allowed to take pictures of the wound, so staff relied on skin assessments to compare progress. She was aware that the skin assessments of the facility as a whole were not consistently being completed, and signs and symptoms of infection and wound characteristics were not being documented. The resident's last wound assessment in-house was done on 12/8/25. She indicated they definitely need to follow up on measurements and documentation needed to be better so wounds could be better tracked. There was no other documentation with wound care provided other than marking it completed in the MAR/TAR. The weekly skin assessments were where they should do that, but depending on the nurse, they may document that and may not. She indicated she was not aware that the resident was more cooperative in the early morning for wound care, and that would be something they would check into changing. She indicated the kitchen would be giving the resident the magic cup, putting protein powder in liquid, and giving double portions of protein. She was not aware that the resident was not getting these, and there was confusion from staff about them. The protein powder should be taken at all meals, she indicated the order for twice daily (BID) was put in erroneously. She indicated the orders should be followed as written, and if the resident was non-compliant, it should be brought to the attention of her and the MD. She indicated the MDS coordinator would be the one to revise the care plan for the resident, and it should be resident-specific.On 1/8/26 at 2:05 P.M., a current Pressure Ulcer Prevention Policy, last revised April 2020, was provided by the administrator and indicated, . Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. evaluate, report, and document potential changes in the skin . Review the interventions and strategies for effectiveness on an ongoing basis . On 1/8/26 at 4:16 P.M., a current Skin Assessment and Documentation Policy, dated 12/1/21, was provided by the administrator and indicated, Braden scale for predicting pressure sore risk assessment is to be completed . quarterly . To complete the care plan correctly, it must include the interventions to prevent skin breakdown and interventions to treat actual breakdown when indicated . the care plan should be updated . as the resident's needs or condition changes . when completing a head to toe skin assessment you need to initiate appropriate skin grids, for each skin impairment identified, and document all of this on the skin assessment located in [electronic health recording system] . a weekly skin assessment must be completed by the nurse . weekly wound report for each pressure area. Once a new pressure area is identified, take the following steps: Measure each area once a week and PRN for any changes in the wound. Record the measurements and description on the wound report for the appropriate wound . Any changes in skin conditions should be reported to the nurse and physician for follow-up . a facility wound report: to be completed each week by a designated nurse in the facility, the director of nursing is responsible to see that this report is completed and accurate. Gather information and measurements from the resident skin assessments that are completed each week. Collect this data at a time that provides the most recent measurements to the Risk Management Team. This data will be used to review wound healing and evaluate the treatment plan for each resident with skin problems . On 1/8/26 at 4:16 P.M., a current Wound Care Policy, revised October 2010, was provided by the administrator and indicated, . The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data . notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice . On 1/8/26 at 4:16 P.M., a current Food and Nutrition Services Policy, revised October 2017, was provided by the Administrator and indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs . meals and/or nutritional supplements will be provided . Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . 3.1-40(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's plan of care for nutrition was followed for 1 of 1 residents reviewed for nutrition. A resident with weight loss was not receiving the diet and supplements ordered, the resident was not being weighed weekly as ordered, and the care plan was not revised. (Resident 7)Finding includes:On 1/6/26 at 9:53 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, polyneuropathy, and pressure ulcer.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated the resident was cognitively intact, supervision of staff for eating, dependent on staff assistance for showering, transfers, toileting, 137 pounds (lbs), 64 inches tall, had weight loss (not on prescribed regimen), no swallowing disorder, and not on a therapeutic diet.Current physician's orders included, but were not limited to, the following:Regular diet, regular texture, thin consistency, give double portions of protein with meals, initiated 1/21/25 Protein powder, mix one scoop of protein powder in liquid of choice by mouth twice daily with meals, ordered 10/6/25 Magic Cup (nutrition supplement) with meals for weight loss and to promote wound healing. Staff to document amount consumed, ordered 12/3/25 The clinical record lacked an order for weekly weights on Resident 7.A current Nutrition Care Plan, last revised 10/17/24, included, but was not limited to, the following interventions:Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors, initiated 10/17/24Provide and serve supplements as ordered, initiated 10/17/24Provide and serve diet as ordered. Monitor intake and record every meal, initiated 10/17/24Regular diet/regular texture/thin consistency, initiated 10/17/24Resident 7's documented weights since 11/1/25 to present included the following:On 11/1/25 at 9:55 A.M., 148.0 lbs (Mechanical Lift)On 12/2/25 at 8:27 A.M., 136.5 lbs (Wheelchair)On 1/5/26 at 7:43 A.M., 146.0 lbs (Wheelchair)The resident had a weight loss from 11/1/25 to 12/2/25 of -7.77%.Progress notes included, but were not limited to, the following:A weight change note, dated 12/3/25 at 3:13 P.M., indicated Interdisciplinary Team (IDT) reviewed significant weight loss. Resident's current weight is 136.5#. This is a 11.5 lbs (7.8%) loss in 30 days. She is on a regular diet and consumes all meals in the main dining room with set up assistance only. Appetite varied. On average she consumed 25-50% of all meals served. She was noted to snack throughout the day with items her family provides. She is currently getting a magic cup PO with her supper meal daily, protein powder by mouth, one scoop with meals to promote wound healing and a multi-vitamin with minerals by mouth daily. She has a chronic wound on her right ankle and is seen at Good Samaritan Wound Clinic weekly for this. She can be non-compliant at times with MD orders. Weight loss discussed with Nurse Practitioner (NP). New order given to increase current Magic Cup order from once daily with supper to with each meal. New order also given for weekly weights. Resident and POA aware.A nutrition/dietary note, dated 12/27/25 at 7:43 P.M., indicated Registered Dietitian (RD) Reviewed the clinical record due to weight loss of 7.8% in 30 days. BMI: 23.4. Diet: Regular diet w/ double protein portions. Supplements: magic cup w/ meals. One scoop protein powder with each meal. Intake: 25-75% of meals, accepts approximately 50% of magic cups. Magic cup at meals added on 12/3 due to weight loss. Recommendation: Continue current plan of care. RD to monitor weight and trends and follow up in January 2026.The Medication Administration Record/Treatment Administration Record (MAR/TAR) and indicated the resident was receiving the supplements and diet as ordered.On 1/7/26 from 10:20 A.M. to 12:00 P.M., Resident 7 was observed sitting in her wheelchair in the main dining room for a continuous observation. Her lunch was served without double portion of protein, a magic cup was not offered, and the protein powder was not visible in the resident's tea, which was the only liquid she was served at that time. The resident, sitting in her wheelchair, propelled herself out of the dining room with her feet after she completed her meal to the front hallway by the entrance of the building.During an interview on 1/7/26 at 9:35 A.M., Certified Nurse Aide (CNA) 25 indicated there should be an order for weights on residents that comes up on the CNA tasks to do. They weigh the resident and write it down for the nurse and they put it into the resident's clinical record. If a resident refuses, the nurse was notified and they would document that because the CNAs do not have access to charting on the residents. During an interview on 1/8/25 at 10:51 A.M., Licensed Practical Nurse (LPN) 16 indicated Resident 7 was on monthly weights, so there would not be a separate order for her because that's the standard. In regards to the weight entered on 12/2/25, if she would have entered that weight and noticed that much of a discrepancy, she would have had the resident reweighed and documented that. She was unsure why that was not done and why the order for the weekly weight from 12/3/25 was not entered. She indicated the resident was not likely to refuse being weighed because they can either do it by the mechanical lift or while she sat in the wheelchair. She indicated the kitchen would put the protein powder in the resident's tea at meals. She was unaware why the order indicated it was to be provided twice daily with meals because the MAR/TAR indicated it to be given at three meals and that was how it was documented it was given. The nursing staff should be checking the resident's meals because they were the ones documenting how much of the magic cup, protein powder, and meal were consumed. If the resident had been refusing the magic cup, protein powder, or double portions then the dietary staff should bring that to the attention of the nurse and/or Director of Nursing (DON) so they can notify the Medical Doctor (MD) and try something else. The orders should be followed as written.During an interview on 1/8/25 at 11:24 A.M., the Dietary Manager indicated Resident 7 was on a regular diet, protein powder was put in food, and got double meat at breakfast and lunch. Resident was not on a magic cup. She got the protein powder in her food because she would not drink the magic cups. During an interview on 1/8/26 at 11:57 A.M., the DON indicated she would have expected a reweight to be done before going to the Nurse Practitioner (NP) to see if it was true weight loss, but since it was not done, and the NP gave new orders, she had to expect it was a true weight loss on the resident. She indicated the kitchen would be giving the resident the magic cup, putting protein powder in liquid, and giving double portions of protein. She was not aware that the resident was not getting these and there was confusion from staff about them. The protein powder should be at all meals, she indicated the order for twice daily (BID) was put in erroneously. She indicated the orders should be followed as written and if the resident was non compliant, it should be brought to the attention of her and the MD. She indicated the MDS coordinator would be the one to revise the care plan for the resident and they should be resident specific.On 1/8/26 at 4:16 P.M., a current Food and Nutrition Services Policy, revised October 2017, was provided by the Administrator and indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs . meals and/or nutritional supplements will be provided . Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . On 1/8/26 at 4:16 P.M., a current Comprehensive Care Plan Policy, dated 1/1/22, was provided by the Administrator and indicated, . It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident . On 1/8/26 at 4:16 P.M., a current Weight and Measurement Policy, revised March 2011, was provided by the Administrator and indicated, . The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident . 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the safe, secure, and orderly storage of medications in 1 of 3 medication carts observed and 1 of 2 medication storage rooms observed. (East Hall medication storage room, [NAME] Hall medication cart)Findings include:1. During an observation on 10/9/25 at 11:20 A.M., the Hall 1 medication cart contained the medications Alka-[NAME], melatonin, and Dulcolax. The medications were contained in an original box with Resident D's name handwritten on the box. No labeling containing ordered dosage, route, frequency of administration, or prescriber name were on the medication. During an interview on 10/9/25 at 11:25 A.M., QMA 4 indicated Resident D's family had brought the unlabeled medications into the facility for the resident and that the resident did not have a physician's order to receive the medications. During record review on 10/9/25 at 12:00 P.M., Resident D's physician orders did not include orders for the resident to receive Alka-Seltzer, melatonin, or Dulcolax. Resident D's nurses progress notes included no documentation of when Resident D's family had brought the medications to the facility or that the physician was notified of a request to receive the medications Alka-Seltzer, melatonin, or Dulcolax.2. During an observation on 10/9/25 at 11:30 A.M., the Hall 2 medication storage room was observed. A medication storage refrigerator that contained resident beverages and resident medications had a temperature log sheet taped to the outside of the refrigerator door. The temperature log sheet included instructions Temperature Log - Must Be Completed Each Shift. The Log sheet for October 2025 had two columns, one for the 7:00 A.M. - 7:00 P.M. shift and another for the 7:00 P.M. - 7:00 A.M. shift. No documented temperature checks were recorded on the log on 10/3/25 (second shift), 10/4/25 (first shift), 10/5/25 (first shift), 10/6/25 (second shift), 10/7/25 (first and second shift), and 10/8/25 (second shift).During an interview on 10/9/25 at 11:35 A.M., LPN 7 indicated nursing staff should check and document the medication storage refrigerator temperature each shift at the beginning of their shift. LPN 7 indicated if a resident's family brings medications from home for a resident, nursing staff should notify the physician to obtain an order for the medications. If a medication is prescribed for a resident, a pharmacy label with all pertinent prescribing information should be included on the medication. If a pharmacy label is not on a medication, nursing staff should fill out a facility label. On 10/9/25 at 11:50 A.M., the Facility Administrator supplied a facility policy dated 07/2012, titled Storage of Medications and Biologicals. The policy included, .10. Medications requiring 'refrigeration' .are kept in a refrigerator with a thermometer to allow temperature monitoring.On 10/9/25 at 12:15 P.M., the Facility Administrator supplied a facility policy dated 07/2012, titled Medications Brought to the Facility by Resident or Family. The policy included, Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified by the nurse, and if the packaging meets the state, federal and facility's guidelines. Other unauthorized medications are not accepted by the facility . 1. Use of medication brought to the facility by a resident or family member is allowed only when the following conditions are met: a. The medication name, dosage form, and strength has been verified. b. The medication was ordered by the resident's physician and entered in the resident's medical record. c. The medication container is clearly labeled in accordance with the facility procedures for medication labeling and packaged in a manner consistent with facility guidelines for medications . This citation relates to intake 2617151. 3.1-25(j)3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 1 of 2 observations of care. Staff failed to complete hand hygiene after removal (doffing) of used gloves and prior to putting on (donning) new gloves and staff failed to complete hand hygiene immediately after doffing used gloves and prior to opening a resident's desk drawer and handing the resident a hair comb. (Resident B)Findings include:During an observation on 8/28/25 at 10:40 A.M., CNA 4 and CNA 5 were assisting Resident B to use the commode in the resident's bedroom bathroom. Resident B was assisted from a wheelchair to stand in front of the commode. CNA 4 and CNA 5 lowered resident's pants and brief and assisted Resident B to sit on the commode. CNA 4 and CNA 5 then assisted Resident B to stand, and CNA 5 provided perineal care. CNA 5 then encouraged Resident B to keep standing while CNA 5 doffed the gloves used prior and donned new gloves. No hand hygiene was completed between glove changes. CNA 5 then and CNA 4 then assisted Resident B by pulling the resident's pants up and lowering her into a wheelchair. Resident B was assisted to her bedroom. CNA 5 doffed the gloves, opened the resident's bedside table drawer, pulled a hair comb from the drawer and handed it to Resident B. CNA 5 indicated the resident that she needed to wash her hands. During an interview on 8/28/25 at 11:05 A.M., the Infection Preventionist (IP) indicated staff should change gloves when going from a dirty to clean task, perform hand hygiene between glove uses, should perform hand hygiene immediately after doffing gloves.On 8/28/25 at 12:10 P.M., the Facility Administrator supplied a facility policy titled, Handwashing/ Hand Hygiene, dated 2001. The policy included, This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol: or soap . and water for the following situations: .f. Before donning sterile gloves . m. After removing gloves . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .This citation relates to intake 2596781. 3.1-18(b)3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure adequate care was provided to prevent and treat new pressure wounds for 2 of 3 residents reviewed for pressure wounds. Initial observations of deteriorating skin areas were not documented or communicated, initial wound care was not documented following the development of pressure wounds, and ordered treatments were not completed for pressure wounds. (Resident D, Resident F) Findings include: 1. During an interview on 2/18/25 at 10:30 A.M., QMA 4 indicated that Resident D had multiple wounds. During an observation and interview on 2/18/25 at 3:30 P.M., Resident D was lying in bed with heel protector boots on each foot. Resident D indicated there were wounds on her feet and coccyx. Resident D's record review indicated the resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis, type II diabetes, need for assistance with personal care, obesity, and neurofunctional disorder of bladder. Resident D's most recent admission Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident was cognitively intact, no functional abilities were assessed, had no unhealed pressure wounds, was at risk for pressure wounds, had an indwelling catheter, and was frequently incontinent of bowel. Resident D's initial Braden Scale assessment, dated 12/13/24, indicated the resident was at risk for developing pressure injuries. Resident D's nurse's progress notes included, but were not limited to: 1/5/25 at 2:39 P.M. - Resident had 1 cm (centimeter) (length) x 1 cm (width) round open area on left gluteal fold of buttocks. A new treatment order was received. 1/12/25 at 12:30 P.M. - During resident's shower, some dry dressings on resident's left foot were observed and removed. A 3 cm x 2 cm deep tissue area on left heel. A left lateral foot deep tissue area that measured 1 cm x 1 cm and a left ankle deep tissue injury that measured 1 cm by 1 cm was observed. The Director of Nursing (DON) was notified. (A deep tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) 2/9/25 at 12:07 P.M. - Open area noted to resident's coccyx area that measured 1 cm x 0.5 cm. The DON was notified. Resident D's care plan included, but was not limited to; resident has deep tissue area to left heel, left lateral foot, and left ankle due to immobility and diabetes (initiated 1/12/25), resident has actual impairment to skin integrity caused by friction to left gluteal fold (initiated 1/15/25), and resident has an activity of daily living (ADL) self-care performance deficit due to activity intolerance, hemiplegia and limited mobility (initiated 1/15/25). An intervention included, administer treatments as ordered (initiated 1/15/25). No care plan to prevent the development of pressure wounds following the Braden Scale assessment on 12/13/24 was in place. No care plan for the treatment of the wound first observed on 1/5/25 to the gluteal fold was initiated prior to 1/15/25. Resident D's physician orders included, but were not limited to; peri-care twice daily and as needed during day and night shift (started 12/22/24), cleanse open area to left distal buttock with normal saline, apply MediHoney and cover with protective foam dressing every night and as needed (started 1/5/25), Betadine applied to deep tissue areas on left heel, left lateral foot and left ankle twice a day (started 1/12/25), and apply MediHoney to wound on left outer ankle twice a day and cover with non-adherent pad and secure with Kerlix (gauze bandage roll) (initiated 1/17/25). Resident D's Treatment Administration record during January 2025 indicated that treatment orders; cleanse open area to left distal buttock with normal saline, apply MediHoney and cover with protective foam dressing every night and as needed (started 1/5/25). The treatment was not completed on 1/18/25 and 1/23/25 due to the resident was asleep. The treatment order Betadine applied to deep tissue areas on left heel, left lateral foot and left ankle twice a day (started 1/12/25) was not completed 1/19/25, 1/23/25, and 1/24/25 due to the resident was asleep. The treatment order apply MediHoney to wound on left outer ankle twice a day and cover with non-adherent pad and secure with Kerlix (initiated 1/17/25). The treatment was not completed 1/18/25 and 1/23/25 due to the resident was asleep. Resident D's documented weekly wound assessments included: 1/5/25 - in house acquired, open lesion to left distal gluteal fold measured 1 cm x 1 cm 1/12/25 - in house acquired, open lesion to left distal gluteal fold measured 1 cm x 1 cm, in house acquired, left heel unstageable pressure ulcer measured 3 cm x 2 cm, in house acquired, left lateral foot unstageable pressure ulcer measured 1 cm x 1 cm, and in house acquired, left ankle unstageable pressure ulcer measured 1 cm x 11 cm. (Unstageable Pressure wound is a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore stage, cannot be determined.) 1/17/25 - in house acquired, open lesion to left distal gluteal fold measured 1 cm x 1 cm, in house acquired, left heel unstageable pressure ulcer measured 3 cm x 2 cm, in house acquired, left lateral foot unstageable pressure ulcer measured 1 cm x 1 cm, and in house acquired, left ankle unstageable pressure ulcer measured 3 cm x 3 cm. 1/24/25 - in house acquired, open lesion to left distal gluteal fold measured 1 cm x 1 cm, in house acquired, left heel unstageable pressure ulcer measured 3 cm x 2 cm, in house acquired, left lateral foot unstageable pressure ulcer measured 1 cm x 1 cm, and in house acquired, left ankle unstageable pressure ulcer measured 3 cm x 3 cm. 1/31/25 - in house acquired, open lesion to left distal gluteal fold measured 0.5 cm x 0.5 cm, in house acquired, left heel unstageable pressure ulcer measured 2 cm x 2 cm, in house acquired, left lateral foot unstageable pressure ulcer measured 1 cm x 1 cm, and in house acquired, left ankle unstageable pressure ulcer measured 2 cm x 2 cm. 2/6/25 - in house acquired, open lesion to left distal gluteal fold measured 0.5 cm x 0.5 cm, in house acquired, left heel unstageable pressure ulcer measured 2 cm x 2 cm, in house acquired, left lateral foot unstageable pressure ulcer measured 1 cm x 1 cm, and in house acquired, left ankle unstageable pressure ulcer measured 2 cm x 2 cm. 2/13/25 - in house acquired, open lesion to left distal gluteal fold measured 4.5 cm x 3 cm x 0.1 cm, in house acquired, left heel unstageable pressure ulcer measured 2 cm x 2 cm, in house acquired, left lateral foot unstageable pressure ulcer measured 1.5 cm x 1.5 cm, in house acquired, left ankle unstageable pressure ulcer measured 1 cm x 1.1 cm x 0.1 (depth), and in house acquired shearing injury to the right gluteus measured 4 cm x 3.5 cm x 0.1 cm. During an interview on 2/19/25 at 10:30 A.M., LPN 4 indicated on 1/12/25, a skin check was being completed on Resident D when border foam dressings were observed on the resident's left ankle. LPN 4 indicated that a CNA was instructed to remove the dressings as Resident D did not have wound orders for the left ankle. Three wounds were then observed by LPN 4. LPN 4 indicated being unaware of the wounds prior to observing them on 1/12/24. LPN 4 then completed a wound assessment and notified the DON. During an interview on 2/19/25 at 12:50 P.M., LPN 4 indicated a resident being asleep would not be an appropriate reason to not complete a routine ordered wound treatment and further indicated that staff should complete routine checks and incontinent care at night which would be a good time to complete a wound treatment. During an interview on 2/19/25 at 1:15 P.M., the DON indicated routine wound treatments should be completed as ordered and charting that a resident was asleep during the shift is not an appropriate reason for not completing wound care treatments. 2. Resident F's record review indicated the resident's diagnoses included, but were not limited to, neurocognative disorder, protein-calorie malnutrition, and anemia. Resident F's most recent admission Minimum Data Set (MDS) assessment, dated 12/18/24, indicated the resident was cognitively intact, was frequently incontinent of urine and occasionally incontinent of bowel. The resident required substantial assistance/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for rolling right to left while lying in bed and for lying to sitting on the side of the bed. Resident did not have a pressure ulcer/injury, had no unhealed pressure wounds, and was at risk for pressure wounds. Resident F's initial Braden Scale assessment, dated 12/11/24, indicated the resident was at risk for developing pressure injuries. A skin check, dated 12/11/24, indicated Resident F had a slightly pink area the coccyx that was present on admission. Resident F's care plan included, but was not limited to; at risk for impairment to skin integrity due to fracture of right femur/hip/sacrum/vertebra, Parkinson's disease, Lewy body dementia, hypothyroid, pulmonary embolism, protein malnutrition, anemia, depression, bilateral hearing loss, and history of cerebral infarction (initiated 12/13/24). Interventions included, follow facility protocols for treatment of injury and monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to the physician. Resident F's nurse's progress notes included, but were not limited to, a note by LPN 4 on 12/26/24 at 1:27 P.M., that indicated a border foam dressing was noticed on the coccyx area and removed. A 4 cm x 2 cm open area was observed. The area was cleansed with normal saline, protective dressing applied, and the DON was notified. Resident F's physician orders included, but were not limited to; cleanse wound on coccyx with normal saline, skin prep peri-wound, apply ColActive (collagen-based wound dressing that helps heal wounds) to wound, cover with border foam for protection daily (started 12/31/24). Resident F's Treatment Administration record during December 20424 contained no documentation that a wound treatment was ordered or administered to the resident's coccyx prior to 12/31/24. Resident F's documented weekly wound assessments included: 12/27/24 - Coccyx wound present on admission at a Stage I pressure wound. Area worsened to a Stage II pressure wound with the wound bed covered by 50 percent (%) granulation tissue and 50 % slough tissue with a moderate amount of serosanguinous drainage present and measured 4 cm x 2 cm x 1 cm. (A Stage I pressure wound is intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure wound is partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. A Stage III pressure wound is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.) 1/4/25 - Coccyx stage II pressure wound worsening with the wound bed covered by 25% granulation tissue and 75% slough tissue with serosanguinous drainage present and measured 3 cm x 3 cm x 1 cm. Peri-wound skin appeared more red and irritated. During an interview on 2/19/25 at 10:25 A.M., LPN 4 indicated completing Resident F's initial admission skin assessment and noted that a pink area to the resident's coccyx was blanchable and for that reason was not a staged wound and the area was not initially measured. On 12/26/24, LPN 4 was notified by CNA 8 that Resident F had a border foam dressing the coccyx. LPN 4 was not aware that the resident had a treatment order to the coccyx and removed the bordered dressing to observe an open area to the coccyx. LPN 4 indicated after asking about the wound, it was said that a CNA had observed Resident F's coccyx to have had a reddened area and was told to put a dressing on it. LPN 4 indicated no communication had been made to alert nursing or CNA 8 that Resident F had a reddened area and there had been no documentation in the resident's record of a worsening area to the coccyx. LPN 4 indicated nursing staff should document any changes in skin condition and notify the DON. On 2/19/25 at 1:30 P.M., the DON supplied two facility policies titled, Prevention of Pressure Injuries dated 4/2020, and Wound Care dated, 10/2010. The Prevention of Pressure Injuries policy indicated, .Monitoring 1. Evaluate, report and document potential changes in the skin. The Wound Care policy indicated, Documentation . The following information should be documented in the resident's medical record: 1. The type of wound care given 2. The date and time of the wound care was given . This citation relates to complaint IN00453477. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist working at least part-time at that facility. Finding includes: On 10/28/24 9:45 A.M., the Director of Nursing (DON) indicated she was the facility's appointed Infection Preventionist (IP) and full time DON. On 4/5/24 at 10:08 A.M., the DON indicated she it varied from week to week on how many hours were spent for IP duties, but she does not spend as much time on IP duties as she would like to. At that time, she indicated she did not have any documentation of hours worked as an IP. On 11/1/24 at 10:23 A.M., the DON provided a current, undated Infection Preventionist job description that indicated, An Infection Preventionist is an individual responsible for the Infection Prevention and Control Program, developed to control the spread of infections and/or outbreaks .

Based on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents observed for incontinence care. Staff did not use hand hygiene between glove changes during care and did not change gloves after touching multiple items before starting incontinence care. (Resident 13, Resident 27, Resident 15). Findings include: 1. On 10/30/24 at 9:20 A.M., CNA (Certified Nurse Aide) 5 and CNA 7 were observed doing incontinence care for Resident 13. Both CNAs cleaned their hands with sanitizer as they entered Resident 13's room. Both CNAs put on gloves. CNA 7 pulled the curtain around the resident, pushed the bed away from the wall, went behind the bed and pulled the covers down. CNA 5 used the remote to put the head of the bed down and raise the bed. They did not change gloves before starting care. CNA 7 unfastened the brief, pushed it down between her legs and assisted Resident 13 to turn to the right side. CNA 5 removed the brief, took a wipe and cleaned the resident from front to back, removed gloves, threw them in the trash can and put clean gloves on. CNA 5 did not sanitize her hands before putting the clean gloves on. CNA 5 placed a clean brief under the resident, assisted the resident to turn to the left side. CNA 7 pulled the brief through, assisted the resident to turn to her back, and fastened the brief. Both CNAs used the lift pad to pull the resident up in bed. CNA 5 removed her gloves, put them in the trash bag, removed the trash bag from the trash can and tied it shut, put a clean trash bag in the trash can, went to the bathroom and washed her hands. CNA 7 pulled the covers up on the resident, put the call light within reach, pushed the bed against the wall, removed gloves, went to the bathroom and washed her hands. 45933 2. On 10/30/24 at 9:56 A.M., CNA 5 and CNA 7 assisted Resident 27 to the bathroom. A brown substance was observed in the toilet before Resident 27 sat down. CNA 7 used toilet paper to wipe Resident 27's buttocks, changed gloves, and failed to perform hand hygiene between glove changes. After Resident 27 was finished using the bathroom, CNA 5 and CNA 7 failed to offer Resident 27 to wash her hands. 46416 3. On 10/30/24 at 10:44 A.M., Certified Nurse Aides (CNA) 5 and CNA 7 were observed while toileting Resident 15. Both CNAs failed to perform hand hygiene prior to putting on gloves. CNA 5 wiped the resident after a bowel movement. CNA 5 removed gloves and put on new gloves without hand hygiene between. CNA 5 and CNA 7 put a new incontinence pad and shorts on Resident 15, pulled them up, assisted the resident to stand and transfer to wheelchair, and pulled down his shirt. During an interview on 11/1/24 at 10:07 A.M., the Infection Preventionist indicated she would expect staff to sanitize hands before putting on gloves to do resident toileting and in between dirty and clean tasks. She would expect hand sanitizer to be used between dirty and clean tasks unless gloves were soiled, then she would expect staff to wash (lather) hands for 15 seconds or say the ABCs twice. Residents should be given the opportunity to wash their hands. On 10/31/24 at 1:00 P.M., a current Handwashing/Hand Hygiene Policy, revised August 2019, was provided by the Administrator and indicated . This facility considers hand hygiene the primary means to prevent the spread of infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Wash hands with soap [antimicrobial or non-antimicrobial] and water for the following situations: when hands are visibly soiled . use an alcohol-based hand rub . before and after direct contact with residents . before moving from a contaminated body site to a clean body site during resident care . after removing gloves . the use of gloves does not replace hand washing/hand hygiene . 3.1-18(l)

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchens observed. Hairnets did not cover hair, food temperature log was not completed for all meals, measuring devices/scoops were stored inside containers of ice, oats, sugar, thickener, and bread was touched with bare hands. (Kitchen) Findings include: 1. During an observation of the kitchen on 10/28/24 at 9:43 A.M., two dietary staff members had hair outside of their hairnets at their temples and nape of the neck. During an observation of the kitchen on 10/31/24 at 11:05 A.M., two dietary staff members had hair outside of their hairnets at their temples and nape of the neck. 2. On 10/28/24 at 9:53 A.M., the food temperature log was reviewed from October 1 through October 27, 2024 and lacked food temperatures for the following meals: 10/21/24 lunch 10/22/24 dinner 10/23/24 breakfast and lunch 10/24/24 breakfast and dinner 10/25/24 breakfast, lunch, and dinner 10/26/24 breakfast, lunch, and dinner 10/27/24 breakfast, lunch, and dinner 3. During an observation of the kitchen on 10/28/24 at 10:00 A.M., the following was observed: large container of oats had a cup placed inside large container of sugar had a cup placed inside ice cooler in dry storage had the ice scoop placed inside During an observation on 10/31/24 at 10:59 A.M., cups were still in the oats and sugar containers. 4. On 10/31/24 at 11:02 A.M., during an observation of staff preparing pureed broccoli, staff used the measuring spoon that was stored in the thickener container to measure thickener. It was touched with bare hands and then put back into the thickener container and placed back on the shelf. 5. On 10/31/24 at 11:42 A.M., kitchen staff grabbed 4 slices of bread from the bread bag with bare hands to make peanut butter and jelly and grilled cheese sandwiches. The staff member held the bread with her bare hands to prepare them. During an interview on 10/28/24 at 9:54 A.M., the Dietary Manager indicated temperatures of food should be taken before serving each meal and written on this page of the log. If the temperatures were not documented, then it was understood that they were not taken. During an interview on 11/1/24 at 10:07 A.M., the Infection Preventionist indicated kitchen staff should not touch food with their bare hands, gloves should be worn. All hair should be contained in hairnets. Scoops and measuring devices should not be stored inside the container. They should be stored in a plastic bag and cleaned every night. 38770 6. On 10/28/24 at 11:55 A.M., Certified Nurse Aide (CNA) 51 was observed to obtain a resident's lunch tray from the hall cart parked on the E Hall. A cup of orange juice was observed on the tray not covered. CNA 51 walked the tray 33 steps to Room A2, passing the front offices, conference room, and restrooms. On 10/28/24 at 11:57 A.M., CNA 51 was observed to obtain a resident's lunch tray from the hall cart parked on the E Hall. A drink and a bowl with a piece of cake was observed on the tray not covered. CNA 51 walked the same distance to Room A1. On 10/28/24 at 11:58 A.M., CNA 5 was observed to obtain a resident's lunch tray from the hall cart parked by Room A8. A drink and a bowl with a piece of cake was observed on the tray not covered. CNA 5 walked the tray to the B Hall, past the nurses station and common area, to Room B1. On 10/29/24 at 11:46 A.M., Dietary Aide 47 was observed to obtain a resident's lunch tray from the hall cart on E Hall. A bowl of pudding was observed uncovered on the tray. Dietary Aide 47 walked the tray 83 steps to Room B1. On 10/31/24 at 11:27 A.M., the Dietary Manager indicated all cups and desserts should be covered when administering hall trays to residents. On 11/1/24 at 10:16 A.M., the Administrator indicated while there was no written policy, it was the policy of the facility to cover food in the halls, not to have scoops in food items, hair should be be completely covered with a hairnet, and gloves should be used when touching food. On 11/1/24 at 11:30 A.M., the Administrator provided a current Food Preparation and Service Policy, revised April 2019, which indicated . Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness . The temperatures of foods held in steam tables are monitored . bare hand contact with food is prohibited . food and nutrition services staff wear hair restraints [hair net, hat, beard restraint, etc.] so that hair does not contact food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure residents who did not have a gradual dose reduction for psychotropic medications had a clinical contraindication documented for 1 of 5 residents reviewed for unnecessary medications. (Resident 12) Finding includes: On 10/29/24 at 10:38 A.M., Resident 12's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/5/24, indicated no cognitive impairment, and use of an antianxiety medication. No gradual dose reduction (GDR) information was listed. Current physician orders included, but were not limited to: Alprazolam 0.5mg (milligram) twice a day, dated 4/8/23. A nurse's note, dated 1/29/24, indicated a GDR recommendation was received to decrease alprazolam 0.5mg to 0.25mg. The GDR request was denied due to attempting this would not be in the best interest for this resident. On 10/30/24 at 1:17 P.M., the Director of Nursing (DON) indicated no other contraindication for GDR was located in Resident 12's clinical record. On 10/31/24 at 1:00 P.M., a current non-dated Medication Monitoring policy was provided and indicated In skilled nursing facilities, within 1st year after admission or after initiation, a gradual dose reduction (GDR) is attempted in 2 separate quarters, with at least one month between attempts. After 1st year, a GDR is attempted annually . GDR is clinically contraindicated if . MD has documented clinical rationale 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and a secured environment was in place to prevent a resident with dementia from exiting the facility and leaving the property. On 9/3/24, after being last seen by facility staff around 2:20 P.M., a resident exited the facility and was not realized to be missing until 3:15 P.M. when a search for the resident began. The resident was located by the Activity Director approximately 200 yards off facility property along a gravel road. (Resident C) This Immediate Jeopardy began on 9/3/24 when the facility failed to ensure Resident C did not exit the facility through an unsecured door toward the back of the building, located near the facility kitchen, and either walked behind or wheeled herself off the property and approximately 200 yards along a gravel road. The Activity Director located Resident C in a wheelchair alongside the gravel road while searching in a vehicle. Resident C was returned to the facility without incident or injury. The facility Administrator was notified of the Immediate Jeopardy on 9/10/24 at 4:45 P.M. The Immediate Jeopardy was removed on 9/11/24, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: A review of facility reported incidents on 9/10/24 at 11:15 A.M., included an IDOH (Indiana Department of Health) Reportable Incident form completed by the Facility Administrator, with an incident date of 9/3/24 at 3:15 P.M., indicated that staff noticed Resident C was not in the facility and initiated missing person procedure. The resident was located and returned to the facility without injury. A follow up to the reported incident, added 9/5/24, indicated Resident C had exited through a back door of the facility and the door alarm did not sound. On 9/10/24 at 11:20 A.M., the Facility Administrator indicated that Resident C had been outside in a courtyard with other residents and Activities staff on 9/3/24 and had been assisted back into the facility and left in a common area with other residents around 2:20 P.M. At approximately 3:15 P.M., RN 6 began a search for Resident C after she realized the resident had not been seen for a while. The Activity Director took a van to search off the facility property and found Resident C along a gravel road that passed along the facility property. It was believed the resident had exited out a back door near the facility kitchen. After the resident returned to facility, it was found that the back door near the kitchen was not alarming when opened. An observation of the back door and facility property on 9/10/24 at 11:25 A.M. included that the back door was not locked, but had a key pad that required a code to disable the alarm system. After exiting the door onto a concrete pad and parking area, the facility property ended along Elm Street, which turned from pavement to gravel just passed the facility's property. A horse pasture and barn were observed approximately 200 yards from the end of the facility property. The Facility Administrator indicated Resident C was found in a wheelchair along the facility side of the gravel road across from the barn and was returned to the facility at approximately 3:25 P.M. on 9/3/24. An observation of an electronic security control panel behind the nurse's station on Hall 2 on 9/10/24 at 11:30 A.M., included a light and a push button for each facility door. The Facility Administrator indicated staff were able to see when a door had been opened and if the key code had not been used prior to opening the door, an alarm would sound and affiliated light would flash. Staff then would be able to see which door was alarming and could silence the alarm by pushing the affiliated button. After silencing the alarm, staff would have to push a reset button that would then secure the door alarm. It was found on 9/3/24 that the back door Resident C was able to exit from had been silenced for an unknown reason, and had not been reset. A record review on 9/10/24 at 11:45 A.M., indicated Resident C's diagnoses included, but were not limited to, Alzheimer's disease, vascular dementia, type II diabetes, and chronic obstructive pulmonary disease. Resident C's most recent Quarterly Minimum Data Set (MDS) assessment, dated 6/19/24, indicated the resident had severe cognitive impairment, had no functional impairments to extremities, used a walker and/or wheelchair for ambulation, could walk 10 feet with supervision of one staff and could ambulate 50 feet in a wheelchair with partial to moderate assistance of one staff. Resident C's comprehensive care plan included, but was not limited to: A focus of resident had impaired cognitive function/dementia or impaired thought process due to Alzheimer's disease (initiated 6/18/24) with interventions that included, but were not limited to, cue, reorient and supervise resident as needed (initiated 6/18/24). A focus of resident had a successful elopement attempt from the facility (initiated 7/1/24) with interventions that included, but were not limited to, redirect resident from doors if exit seeking (initiated 7/3/24). A focus of resident is at risk for elopement (initiated 8/15/24) with interventions that included, but were not limited to, allow resident to roam through out facility freely (initiated 8/15/24) and check function of WanderGaurd every shift (initiated 8/15/24). Resident C's elopement risk evaluation, dated 6/22/24, indicated Resident C had a history of elopement or an attempted elopement while at home, had a history of elopement or attempted leaving the facility without informing staff, had verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered, and that the resident was at risk for elopement. Resident C's physician orders included, but were not limited to, WanderGaurd bracelet (a device that triggers door alarms and locks monitored doors to prevent the resident from leaving unattended) with an order date of 6/24/24. Resident C's nurse's progress notes included, but were not limited to the following: On 6/26/24 at 3:25 P.M. - Resident confused to where she is. Has been wandering throughout facility. Has WanderGaurd in place. Was looking out window on South Hall and pushed the door open. The alarm sounded and resident did not get out of the doorway. On 6/28/24 at 8:30 A.M. - Resident wandering the halls. Resident pushed on door at the end of the hall, setting off door alarm. Staff redirected resident and reset the alarm. On 6/29/24 at 11:20 A.M. - The door alarm was sounding and staff immediately went to door to find resident sitting in her wheelchair in the back parking lot. Resident had been in the parking lot for approximately 30 seconds before staff assisted resident back into facility. Resident wearing WanderGaurd bracelet and bracelet was functioning, however there is not a Wandergaurd security system set up at the back door. On 7/2/24 at 2:11 P.M. (Social Service Care Conference Note) - Spoke to residents family about the resident's future in the facility. If resident's condition improved and elopement was possible, would her needs be safely met in a facility that was designed more for wandering. Recommended another facility and family in agreement with recommendation. A transfer notice was presented at that time. On 7/8/24 at 6:27 P.M. - Resident pushed door open on rehab hall and set off the alarm. On 8/3/24 at 6:45 P.M. - Resident had been exhibiting exit seeking behaviors. Resident attempted to exit therapy door by shower room which was not an outside exit. Resident stated she wanted to go home. On 8/19/24 at 11:25 P.M. - Resident became agitated, confused, and combative with staff. Resident was exit-seeking and placed on one-to-one supervision. On 9/3/24 at 1:15 P.M. (back dated to incorrect time) - Resident exited back door of facility and was found sitting in her wheelchair. Staff brought resident back to facility. Resident voiced needing to check on her lawn [NAME]. Resident has severe cognitive deficits related to dementia. WanderGaurd in place to left ankle and functioning properly. However, the back door that resident exited through was not equipped with the WanderGaurd system. During an interview on 9/10/24 at 2:30 P.M., the Facility Administrator indicated that Resident C was not discharged following the elopement on 6/29/24 and after the notice of transfer was given and agreed to on 7/2/24 due to the resident being hospitalized and had a decline shortly thereafter. Resident C knew other residents at the facility and it was decided to let her stay at the facility. During an interview on 9/10/24 at 3:35 P.M., the Director of Nursing (DON) indicated that the back door alarm system should not have been silenced at the time Resident C was able to exit the facility on 9/3/24. During an interview on 9/12/24 at 10:15 A.M., the MDS nurse indicated that a plan of care should have been created as soon as possible following the elopement risk assessment completed on 6/22/24 that indicated the resident was at risk for elopement. On 9/10/24 at 4:00 P.M., the Facility Administrator supplied a facility policy titled, Elopement Risk/Unsafe Wandering, dated 10/5/11. The policy indicated, .Residents Identified At Risk For Elopement . Residents whose assessment identified unsafe wandering behavior shall also be considered at risk for elopement. If a resident is identified at risk for elopement the following steps may be taken: An alarm bracelet may be placed on the resident to audibly alert staff of attempts by the resident to exit. The care plan shall address behavior using resident specific goals and approaches as assessed by the Interdisciplinary Team . Facility staff will ensure that all exit alarms are responded to immediately . Resident with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement. These residents will have the following precautionary measures implemented to prevent repeat incidents of elopement. Resident will wear an alarm bracelet to alert staff if he or she is trying to leave facility . When a door alarm sounds, the facility will: Check alarm panel to determine which door has been opened . Reset the door alarm after it is determined by visual check that no residents have exited the building inappropriately, or is returned to the facility . Any employee deactivating an alarm may face disciplinary action . The Immediate Jeopardy, that began on 9/3/24, was removed on 9/11/24 when the facility in-serviced staff on elopement prevention and ensured the exit doors were secured with alarms that remained on, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the systemic plan of correction that had been developed and implemented to prevent recurrence. This citation relates to Complaint IN00442476. 3.1-45(a)(2)