Every finding on record at Ridgewood Health Campus

Based on interview, observation, and record review, the facility failed to update or revise a resident's care plan related to fall interventions for 1 of 17 residents reviewed for care plan revisions. (Resident 10)Findings include:During an interview, on 07/29/2026 at 1:08 P.M., Resident 10's family member indicated the resident had some complex diagnoses, both physical and psychological. He didn't participate in some of the activities he used to, although staff continued to encourage him. He had a sound machine in his room that he liked, but staff forgot to turn it on a lot. She was thinking of leaving a note for staff to remind them. The resident was observed in his room on 07/31/2026 at 9:15 A.M. The resident was sitting in his wheelchair, near his bed. A sound machine was observed on a small table on the right near the door. During an interview, on 08/04/2026 at 9:50 A.M., The Social Services Director (SSD) indicated she was very familiar with the resident and met with him often. The resident saw a neurologist outside of the facility and regularly saw a Psychiatric-Mental Health Nurse Practitioner (Psych NP) that came into the facility. The resident did experience delusions and hallucinations and he suffered from insomnia. They got him the sound machine several months ago, around Thanksgiving or Christmas last year. If the resident couldn't sleep, he would get antsy, the sound machine had helped a lot with that.The resident's clinical record was reviewed on 08/04/2026 at 11:52 A.M. A Quarterly Minimum Data Set assessment, dated 05/06/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease (a disorder of the nervous system that affects movement and gets worse over time), Non-Alzheimer's dementia (an umbrella medical term for brain disorders causing a severe loss of thinking and memory skills that interfere with daily life), psychotic disorder (a severe mental illness marked by a loss of contact with reality, core symptoms including delusions, hallucinations, and disorganized thinking), and insomnia (trouble falling asleep, staying asleep, or waking up too early). The resident experienced delusions and hallucinations during the assessment review period.During an interview, on 08/04/2026 at 11:00 A.M., the Director of Nursing (DON) indicated they considered the resident to have a Parkinson's type of dementia, and he did experience hallucinations and delusions. They recognized that the resident was falling more frequently at night. If he couldn't sleep, he was up and out of bed more at night, and that's when he was falling. They used a sound machine at night that had helped tremendously. The resident's complete and current care plan was reviewed on 08/04/2026 at 12:00 P.M. The record lacked documentation of a sound machine as an intervention related to the resident's risk for falls, his diagnosis of insomnia, or any of the other problems addressed in the resident's plan of care.During an interview, on 08/04/2026 at 12:02 P.M., the DON indicated when the sound machine was implemented there were some progress notes that stated staff were to monitor for the effectiveness of the sound machine, but there was no care plan that specified the sound machine was a current intervention.The current facility policy, titled Comprehensive Care Plan Guideline, dated 05/22/2018, was provided by the DON on 08/04/2026 at 10:43 A.M. The policy indicated, .Purpose Statement.To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines.Comprehensive care plans need to remain accurate and current.New interventions will be added and updated during or directly following CCM meeting.410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to follow MD orders related to skin treatments for 1 of 17 residents reviewed for quality of care. (Resident 6) Findings include:Resident 6 was observed sitting up in bed in her room on 07/29/2026 at 10:51 A.M. Bandages were wrapped around both of her legs up to just below her knees. The resident indicated nursing staff wrapped her legs weekly due to swelling. The resident's clinical record was reviewed on 07/31/2026 at 10:13 A.M. A Quarterly Minimum Data Set assessment, dated 06/10/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure and lymphedema (swelling in the soft tissues-most often in the arms or legs-caused by a buildup of protein-rich lymph fluid when the lymphatic system was blocked or damaged).The resident's current physician's orders included, but were not limited to, and open-ended order, with a start date of 07/02/2026, indicated once a week on Fridays nursing staff were to cleanse the resident's bilateral lower extremities with soap and water and apply unna boots (a medicated gauze bandage wrapped around the lower legs to reduce swelling) and Tubi grip (an elasticated tubular support bandage used to provide even, continuous pressure and firm support for swelling without the need for pins or tape). The dressing was to be changed every seven days.On Monday, 08/03/2026 at 9:41 A.M., the resident was observed in bed eating breakfast. The resident's legs were not wrapped and were pinkish purple in color and appeared to be swollen. The resident indicated the Facility Wound Nurse (FWN) usually wrapped her legs after her shower. She had a shower on Friday, and they didn't wrap her legs. Her legs hadn't been wrapped all weekend. On 08/03/2026 at 11:30 A.M. , the resident was observed sitting in her wheelchair next to her bed. The resident was wearing dark pink non-skid socks. The resident's legs were not wrapped and appeared swollen. On 08/03/26 at 1:03 P.M., the resident was observed sitting in her wheelchair next to her bed. The resident's overbed table was in front of her and she was eating lunch. The resident's legs were not wrapped and appeared swollen. During an interview, on 08/03/2026 at 1:04 P.M., Licensed Practical Nurse (LPN) 5 indicated nursing staff were to document the administration of medications and treatments in the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR). If a resident refused a treatment, or if a treatment was not administered for any reason, the record should reflect that. There would be a parenthesis around the nurse's initials and a note that indicated why the treatment wasn't administered. If a resident repeatedly refused a treatment, she would type a progress note and let the Nurse Practitioner (NP) know. There was also a binder at the nurses' station where they could leave a note for the NP to review. The LPN did not normally work on that hall, and she was not very familiar with the resident. She reviewed the resident's EMAR/ETAR and did not see an order to apply unna boots to the resident's legs, but if it was a treatment that was only administered once a week it wouldn't show up as something she needed to do. After looking further at the resident's record, she could see there was an order to apply unna boots on Fridays, but it was not a treatment on the ETAR she was required to administer that day (Monday). The resident's July 2026 ETAR was reviewed, and the resident's leg wraps were signed off as completed by a Qualified Medication Aide (QMA) on Friday, 07/31/2026.A Progress Note, dated 08/01/2026 at 9:25 P.M., by Registered Nurse 6 (RN) indicated the nurse offered to place the resident's unna boots on that evening and she refused. The resident stated she would put them on tomorrow. During an interview, on 08/03/2026 at 1:18 P.M., LPN 5 indicated the resident was not wearing the unna boots. The treatment did not show on the ETAR as something she needed to do. She thought the QMA signed off on the treatment in error, QMAs were not allowed to administer that type of treatment. The ETAR should reflect that the treatment was not administered. She had not known the treatment still needed to be administered. The current facility policy, titled SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, revised on 11/18, was provided by the Director of Nursing on 08/04/2026 at 10:43 A.M. The policy indicated, .If a resident refuses medication, document refusal on MAR or TAR 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to ensure medications were available for 1 of 19 residents reviewed for pharmacy services. (Resident 14) Findings include:The clinical record for Resident 14 was reviewed on 07/31/2026 at 1:16 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/04/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, obstructive and reflux uropathy (two distinct urinary tract conditions that both cause backward pressure and potential kidney damage, involving kidney stones, enlarged prostates, and abnormal urine backflow), rheumatoid arthritis (a chronic autoimmune disease where the immune system mistakenly attacks the lining of the joints), and hypertension (occurs when blood pushes too hard against your artery walls, high blood pressure). A current open-ended physician's order, with a start date of 09/01/2022, indicated the resident was to receive Tamsulosin 0.4 milligrams (mg) once a day, for a diagnosis of obstructive and reflux uropathy. The June and July 2026 Electronic Medication Administration Record (EMAR) indicated the medication had not been administered due to the item not being available on the following dates: 06/17/2026, 06/18/2026, 06/19/2026, 07/10/2026, 07/11/2026, 07/12/2026, and 07/15/2026.A current open-ended physician's order, with a start date of 12/16/2025, indicated the resident was to receive Leflunomide 10 mg once a day, for a diagnosis of rheumatoid arthritis. The June 2026 EMAR indicated the medication had not been administered due to the item not being available on the following dates: 06/17/2026, 06/18/2026, and 06/19/2026.A current open-ended physician's order, with a start date of 02/10/2026, indicated the resident was to receive Losartan 100 mg, once a day, for a diagnosis of hypertension. The July 2026 EMAR indicated the medication had not been administered due to the item not being available on the following dates: 07/07/2026, 07/10/2026, 07/11/2026, 07/12/2026, 07/14/2026, 07/15/2026, 07/16/2026, 07/18/2026, 07/19/2026, and 07/20/2026.The Progress Notes indicated the pharmacy was notified on the following dates:-On 06/13/2026, related to a refill on the Losartan,-On 06/15/2026, related to refills on Leflunomide and Tamsulosin,-On 06/19/2026, related to refills on Leflunomide and Tamsulosin, and-On 07/18/2026, related to refills on Losartan.The clinical record lacked documentation the pharmacy was notified consistently when medications were not available for the resident. During an interview, on 08/03/2026 at 3:26 P.M., RN 4 indicated they were dependent on the family to get the resident's medications from a local pharmacy. She had called the local pharmacy and the family several times. The resident had a few different medications that had not been available. Every time the staff do not have a medication to administer, they were supposed to follow-up by calling the pharmacy. If staff list the medication as not available, they were supposed to call the pharmacy and see why the medication was not here. If she knew a medication was getting low, she tried to get a hold of the resident's provider. The current ADMINISTRATION PROCEDURES FOR ALL MEDICATIONS policy, with a revised date of January 2018, was provided by the DON on 08/04/2026 10:43 A.M. The policy indicated, .administer medications in a safe and effective manner .The current Notification of Change in Condition policy, with a reviewed date of 12/08/2025, was provided by the DON on 08/04/2026 10:43 A.M. The policy indicated, .Purpose .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when .A need to alter treatment significantly .Documentation of notification or notification attempts should be recorded in the resident electronic health record .410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)410 IAC (Indiana Administrative Code) 16.2-3.1-25(g)(3)

Based on record review and interview, the facility failed to document resident meal consumptions for 1 of 18 resident records reviewed. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 08/03/2026 at 10:49 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 05/05/2026, indicated the resident was cognitively intact. The resident's diagnosis included but was not limited to, malnutrition (your body gets too few, too many, or the wrong balance of nutrients and calories to stay healthy). A Registered Dietician Note, dated 05/18/2026, indicated the resident had a significant change assessment completed due to the admission to hospice care. The resident had fortified foods; his intake was 51 to 75 % (percent) with some missed meals. The resident's meal consumptions were reviewed and indicated the following meals were not documented:- On 05/04/2026 at breakfast and lunch,- On 05/05/2026 at breakfast and lunch,- On 05/06/2026 at breakfast and lunch, - On 05/18/2026 at dinner,- On 05/20/2026 at breakfast and lunch,- On 05/31/2026 at breakfast and lunch, - On 06/01/2026 at dinner,- On 07/06/2026 at breakfast and lunch, and - On 07/31/2026 at lunch. During an interview, on 08/04/2026 at 1:50 P.M., Certified Nurse Aide (CNA) 2 indicated after a resident finished a meal the staff were required to document the amount of food they had eaten in the resident's clinical record. If she was running behind on her work, then she would leave the amounts for the next shift to input them into the electronic health record. The staff were required to document amounts eaten after each meal. The current facility policy titled Guidelines for Meal Service, with a review date of 12/31/2023, was provided by the Director of Nursing on 08/04/2026 at 2:11 P.M. The policy indicated, .Meal intake should be recorded in the electronic health record.410 IAC (Indiana Administrative Code) 16.2-31.-46(a)(1)

Based on record review, observation, and interview, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 1 of 2 observations of high-contact resident care activities related to infection control. (Resident 22)Findings include:Resident 22's clinical record was reviewed on 07/29/2026 at 1:00 P.M. A Quarterly Minimum Data Set assessment, dated 06/17/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes (a chronic condition where your body either cannot produce enough insulin or cannot effectively use the insulin it makes) and stroke. The resident had a diabetic foot ulcer. The resident's current MD orders, included an open-ended order, with a start date of 08/03/2026, that indicated staff were to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. During an observation, on 08/04/2026 at 12:17 P.M., a sign on the resident's door indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Everyone must wear gloves and a gown when providing care, including wound care. Licensed Practical Nurse (LPN) 3 entered the resident's room to change the dressing on the wound on the resident's left foot. LPN 3 washed her hands and donned gloves. She removed the resident's shoe and compression stocking and placed the resident's foot on the raised foot pedal of her wheelchair. She removed a pillow from the resident's bed and placed it under her foot. She removed the dressing from the bottom of the resident's foot and cleansed the wound. She changed her gloves and applied a new dressing to the wound. The LPN did not wear a gown during the wound care procedure.During an interview, on 08/04/2026 at 10:53 A.M., LPN 3 indicated the resident was in EBP, she should have worn a gown when she provided wound care. The current facility policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, with a revision date of 04/02/2024, was provided by the Director of Nursing on 08/04/2026 at 11:21 A.M. The policy indicated, .Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions.All Residents with chronic wounds, including but not limited to.diabetic foot ulcers.At minimum, staff shall wear gloves and gowns during high-contact care activities.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation and interview, the facility failed to maintain resident snack refrigerators appropriately related to proper labeling for 2 of 2 snack refrigerators observed. (Resident snack refrigerator in the Main Building and the Resident snack refrigerator in the Legacy Building) Findings include: 1. The residents' snack refrigerator for the Main Building was observed on 06/30/25 at 2:33 P.M., with the Assistant Director of Nursing (ADON), and contained the following: - A clear plastic bag in a bottom drawer containing a large soft taco with no resident name or date. - A brown plastic bag with to-go containers. The bag was labeled with a resident's first name and dated 06/21/25. The ADON indicated they kept resident food in the refrigerator for 30 days; it depended on what it was. The bag contained a cup cake, coleslaw, and a fried chicken dinner. The ADON indicated it was probably not good anymore. - A white bag, dated 6/25/25, with no resident name. The bag contained salad dressing, hot sauce packets, and crackers. - A plastic container with a salad, dated 06/25/25, with no resident name. The residents' snack freezer contained the following: - A bag labeled Aunt ****, dated 5/7. - A plastic container with Resident 74's name but no date. - A carton of chocolate ice cream with a resident's last name but no date. - A carton of vanilla ice cream with a resident's name but no date. - A strawberry cheesecake with no date or resident name. - A carton of pineapple sherbet with a resident's name and date. The ADON indicated the resident had passed away a month ago. - A box of popsicles with two resident names on it with no date. - A gray plastic bag with two small vanilla ice cream cups with no name or date. - A frozen Cajun style chicken and shrimp dinner with no name or date. - A cup with a frozen drink with no name or date. - A carton of strawberry ice cream with no date, labeled with 207 and a resident's initials. The ADON indicated the resident did not live in that room anymore. During an interview on 06/30/25 at 2:45 P.M., the ADON indicated items in the refrigerator should have a resident's name and a date. 2. The residents' snack refrigerator for the Legacy Building was observed on 06/30/25 at 2:56 P.M., with Licensed Practical Nurse (LPN) 6 and contained the following: - A bottle of clear soda, 1/2 full, with no name or date, and an expiration date of 06/02/25 on the bottle. - A can of an energy drink with no name or date. - A pink can of an energy drink with no name or date. - A half full carton of diabetic nutritional drink with no name or date. - A large vegetable tray, opened with a plastic seal that would not adhere to the tray edge with no name or date. - A bottle of dark soda, 2/3 full, with a resident's name but no date. The LPN indicated the resident had passed away. - A large pitcher of pink liquid dated 6/25. - A can of soda with no name or date and an expiration date of 04/17/23, - A bottle of dark soda, unopened, with no name or date. The sides of the bottle were compressed. - A bag of white grapes with a resident's name but no date. The residents' snack freezer contained the following: - A frozen drink in a cup with a resident's name but no date. During an interview, on 06/30/25 at 3:12 P.M., LPN 6 indicated the staff were to label items with a resident's name and a date when placing them in the refrigerator. During an interview, on 07/02/25 at 11:25 A.M., the Dietary Manager indicated leftovers from the kitchen were kept and served for three days. The current Food Brought Into Facility policy, with an approved date of January 2024, was provided during the Entrance Conference. The policy indicated, .PURPOSE .Storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption .Food or Beverage items are to be properly Labeled and Date marked, stored and discarded, in conjunction with the facilities Date [NAME] and labeling P&P . The current Food Labeling and Dating Policy, with a review date of 01/2025, was provided by the Director of Nursing on 06/30/25 at 3:23 P.M. The policy indicated, .Any food product removed from its original container, has a broken seal, has been processed in any way must have a label that contains the following .Item Name .Date and Time the food was labeled .Use by date .Initials of the person labeling the item .Securely cover the food item . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview, observation, and record review, the facility failed to provided Activities of Daily Living (ADL) care related to toileting a dependent resident in a timely manner for 4 of 24 residents reviewed. (Residents 8, 30, 25, and 23) Findings include: 1. During an interview, on 06/25/25 at 10:53 A.M., Resident 8, who resided on the 200 Hall, indicated she could not get help down here. It took two staff members to help her with toileting. She had been here in the facility for five years and did not have any trouble until this year. The clinical record for Resident 8 was reviewed on 06/26/25 at 11:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, fibula fracture, stroke, and Chronic Obstructive Pulmonary Disease (COPD). The resident required substantial/maximal assistance from staff for toileting. 2. During an interview, on 06/26/25 at 10:20 A.M., Resident 30, who resided on the 200 Hall, indicated call lights were usually answered within 15 minutes or less, but one day he had to wait, and he didn't make it. It was embarrassing. It was harder to get to the bathroom during mealtimes and he almost had an accident today. He had waited 20 minutes today for help to go to the bathroom, maybe even longer. The clinical record for Resident 30 was reviewed on 07/01/25 at 2:07 P.M. A 5-day Scheduled MDS assessment, dated 05/02/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, orthopedic after care following a surgical amputation, chronic kidney disease and diverticulosis. The resident Needed some help from staff with toileting. 3. During an interview and observation, on 06/25/25 at 1:11 P.M., Resident 25 indicated both Certified Nurse Aides (CNAs) from the 200 Hall went to the dining room during mealtimes. The resident indicated they would try to go to the bathroom before the CNAs left the hall. If they did not go before the CNAs' left then the resident had to wait until the CNAs' got back. The resident was in her room finishing her lunch. The clinical record for Resident 25 was reviewed on 07/01/25 at 1:59 P.M. An annual MDS assessment, dated 05/22/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, hypertension, arthritis, and depression. The resident was dependent upon staff for assistance for toileting. The resident was diagnosed with a UTI on 03/27/25. 4. During an observation and interview, on 06/25/25 at 1:09 P.M., Resident 23, who resided on the 200 Hall, was sitting in her wheelchair in her room. The resident's clothing appeared wet and was darker in color from her lap and up the front of her pants and stomach on down to her legs onto her thighs. The resident indicated she usually used a bed pan for toileting. On 06/25/25 at 2:11 P.M., the resident was in a common area getting ready for bingo. The resident's pants had been changed and the new pants showed no signs of wetness. The clinical record for Resident 23 was reviewed on 07/01/25 at 12:16 P.M. An admission MDS assessment, dated 04/16/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, and ulcerative colitis. The resident had been treated for Urinary Tract Infections from 06/08/25 to 06/13/25, and from 06/23/25 to 06/29/25. During an interview and observation, on 07/01/25 at 11:44 A.M., Resident 23 indicated she had to urinate and the staff member on the hall had told her they didn't have any help down there right now. The resident was sitting in her wheelchair next to her bed. No linens were observed on her bed. During an interview, on 07/01/25 at 11:45 A.M., Licensed Practical Nurse (LPN) 3 indicated she would call someone down from the dining room to help her toilet Resident 23. During an interview, on 07/01/25 at 12:05 P.M., the resident indicated no staff members had come to help her use the bathroom yet. On 07/01/25 at 12:14 P.M., two staff members, in dark black/blue polo shirts, walked down the 200 Hall pushing residents in wheelchairs. The nurse did not tell them Resident 23 needed to use the bathroom and the two staff members left the 200 Hall after returning the residents. (without assisting Resident 23) On 07/01/25 at 12:17 P.M., a staff member, in a dark black/blue polo shirt, brought another resident in a wheelchair back to the 200 Hall, parked the resident's wheelchair near the nurses' station, and left the 200 Hall. On 07/01/25 at 12:18 P.M., a staff member, in a dark black/blue polo shirt, brought another resident in a wheelchair back to the 200 Hall. On 07/01/25 at 12:18 P.M., a staff member, in a dark black/blue polo shirt, went into room [ROOM NUMBER] and dropped off a covered plate. On 07/01/25 at 12:23 P.M., a staff member, in a dark black/blue polo shirt, brought a resident back to the 200 Hall. On 07/01/25 at 12:24 P.M., two staff members in dark black/blue polo shirts came on the 200 Hall, one carrying food, and one pushing a resident in her wheelchair. One staff member was collecting used meal trays on the unit. During an interview and observation, on 07/01/25 at 12:27 P.M., Resident 23 indicated she knew the CNAs worked in the cafeteria during mealtimes. No one had come to help her yet. They usually had to wait a long time if they needed to use the bathroom around lunch time. The resident pushed her call light. During an observation and interview, on 07/01/25 at 12:31 P.M., LPN 3 and CNA 4 entered the resident's room. CNA 4 indicated the residents didn't usually have to wait 45 minutes to use the bathroom, but she had been in the dining room. LPN 3 indicated she had notified her manager that she needed help. During an interview, on 07/02/25 at 10:29 A.M., the Corporate Clinical Support nurse indicated Resident 23 had been toileted before lunch on the day in question and one of the signs and symptoms of a UTI was urgency. The Director of Nursing (DON) indicated the resident had recently been treated for a UTI. The nursing schedule for the duration of the survey time period indicated the CNAs scheduled to work on the 100, 200, and 300 Hallways were also noted to have (lunch) written by each name. During an interview, on 07/01/25 at 2:23 P.M., the Nursing Staff Scheduler indicated the notation (lunch) by the CNA's names on the schedule signified they were to go to the Dining Room to assist residents with their meals. If she did not put it on the schedule, the CNAs would not go to the Dining Room to help. The Scheduler indicated all the CNAs on the 100, 200, and 300 Halls went to the Dining Room to help with residents. A lot more of the residents on the 200 Hall stayed in their rooms for meals than in the 100 and 300 Halls. Usually, the nurses did not go down to help with lunch. All the CNAs did go down to help with lunch. The 200 Hall had more residents in general. The staff had phones. The nurse could call and get help, most of them called her, she was there Monday through Saturday. Roughly two or three residents that stayed on the 200 Hall for meals need two staff members for assistance. The nurse stayed on the hall during mealtimes. The current Resident Rights Know Your Rights under Federal Nursing Home Regulations policy, dated 03/15/17, was provided by the DON on 07/02/25 at 12:09 P.M. The policy indicated, .You have a right to a dignified existence, self-determination, and communication with and access to the persons and services inside .the facility . 3.1-38(a)(2)(C)

Based on observation, interview, and record review, the facility failed to ensure proper positioning of a resident's indwelling urinary catheter drainage bag related to a resident who had a history of Urinary Tract Infections (UTIs) for 1 of 4 residents reviewed for urinary catheters / UTIs. (Resident 48) Findings include: During an observation, on 06/30/25 at 11:59 A.M., Resident 48 was in the Assisted Dining Room in her wheelchair. Her indwelling urinary catheter bag was hanging under her wheelchair and touching the floor. There was a bend in the bag with a quarter inch by approximately four inches of the bag touching the floor. During an observation, on 06/30/25 at 1:12 P.M., the resident was sitting in her wheelchair in the common area across from the nurses' station on the 200 Hall. One of her soft protective boots was kicked off and on the floor in front of the resident. Her indwelling urinary catheter bag was hanging under her wheelchair and touching the floor. There was a bend in the bag with a quarter inch by approximately four inches of the bag touching the floor. On 06/30/25 at 1:27 P.M., RN 5 donned gloves, bent down in front of the resident, and assisted the resident with putting her soft boot back on her foot. The indwelling urinary catheter bag was hanging under her wheelchair and still touching the floor. During an interview and observation, on 06/30/25 at 1:32 P.M., Licensed Practical Nurse (LPN) 3 indicated the resident required the use of a mechanical lift for transfers. The catheter bag was observed with the LPN. The nurse donned gloves, verified the bag was touching the floor, indicated it should not be touching the floor, and adjusted the bag. During an interview, on 06/30/25 at 1:46 P.M., the Director of Nursing (DON) indicated the resident had recently been sent out to the hospital. She was in the hospital at the end of May and came back on 06/10/25. She had gall bladder problems but also had a UTI. She was being treated for a UTI prior to discharge to the hospital and the hospital continued with treatment for the UTI. The resident got UTIs fairly frequently and did not usually show symptoms for a UTI until it was really bad and she needed intravenous (IV) antibiotics. The Infection Tracking record was provided by the DON on 07/01/25 at 11:13 A.M. The record indicated the resident had been treated for a UTI on 05/27/25, and on 06/10/25. The clinical record for Resident 48 was reviewed on 06/26/25 at 11:22 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 06/16/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, neurogenic bladder, dementia, anxiety, depression, and stroke. The resident had an indwelling catheter and was always incontinent of bowel. The current Urinary Catheter Care policy, with a revised date of 12/16/24, was provided by the DON on 06/30/25 at 1:46 P.M. The policy indicated, .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure a resident's medications were accurately administered for 1 of 5 residents reviewed for pharmacy services. (Resident 20) Findings include: Resident 20's clinical record was reviewed on 06/30/25 at 10:21 A.M. A Significant Change Minimum Data Set assessment, dated 05/27/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, anemia, anxiety, and depression. The resident received antianxiety medications during the assessment review period. The resident's current physician's order included, but was not limited to, an open-ended order, with a start date of 05/20/25, for lorazepam (a medication for anxiety), 0.5 milligram (mg) tablet. Give 1/2 of a tablet three times a day. A Progress Note, dated 05/23/25 at 8:50 P.M., indicated the resident received an incorrect dose of routine lorazepam. The physician's order was for lorazepam 0.5 tablets, administer half of a 0.5 mg tablet, for a dose of 0.25 mg. The pharmacy sent whole tablets instead of half tablets. The resident received two doses of 0.5 mg of the anxiety medication. During an interview, on 07/01/25 at 3:19 P.M., Licensed Practical Nurse 7 indicated before administering medications, nurses were to ensure they had the right resident, the right medication, the right dose, the right time, and the right route. Some residents' medication dosage orders changed frequently, so she would always make sure the dose available from the pharmacy matched the physician's order in the computer before administering the medication. During an interview, on 07/01/25 at 3:35 P.M., the Director of Nursing (DON) indicated the first time the lorazepam was sent from the pharmacy it was a 0.5 mg tab. The medication was given twice. After that, the 0.5 mg tab was halved to make a 0.25 mg dose that was administered as ordered. The current facility policy, titled PREPARATION AND GENERAL GUIDELINES, dated 11/2018, was provided by the DON on 07/02/25 at 10:29 A.M. The policy indicated, .Medications are administered as prescribed .FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered .A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away . 3.1-48(a)(1)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheter care for 1 of 18 residents reviewed for infection control. (Resident 3) Findings include: On 06/27/25 at 10:47 A.M., Resident 3 was observed in a wheelchair in the beauty shop. Her indwelling urinary catheter bag was touching the floor. The Beautician proceeded to push the resident down the hallway and back to her room. A half an inch of her catheter bag was dragging on the floor. On 06/27/25 at 11:22 A.M., the resident was observed sitting in her wheelchair in her room talking with her roommate and a visitor. Her indwelling urinary catheter bag was hanging under her wheelchair with two inches of it touching the floor. On 06/27/25 at 12:27 P.M., the resident was observed in her wheelchair in her room eating lunch. Her indwelling urinary catheter bag was hanging under her wheelchair with two inches of it touching the floor. On 06/30/25 at 10:58 A.M., the resident was observed sitting in her wheelchair in her room. Her indwelling urinary catheter bag was hanging under her wheelchair with two inches of it touching the floor. There was also three inches of the catheter tubing touching the floor. On 06/30/25 at 1:33 P.M., the Resident was observed with Certified Nurse Aide (CNA) 2 sitting in her wheelchair in her room. There was two inches of her indwelling urinary catheter bag and three inches of catheter tubing touching the floor. CNA 2 indicated the urinary collection bag and tubing should not be touching the floor. The CNA donned gloves and a gown and repositioned the urinary catheter bag and tubing so there was none touching the floor. The resident's clinical record was reviewed on 06/27/25 at 11:11 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/10/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, heart failure, and renal insufficiency. The resident had an indwelling urinary catheter. The current Urinary Catheter Care policy with a reviewed date of 12/16/24, was provided by the Director of Nursing on 06/30/25 at 1:46 P.M. The policy indicated .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-18(b)

Based on observation and interview, the facility failed to provide a sanitary homelike environment related to odors for 1 of 3 resident room hallways observed. (200 Hall) Findings include: On 06/25/25 at 10:50 A.M., the 200 Hall smelled strongly of urine. During an interview and observation, on 06/25/25 at 10:53 A.M., Resident 8, who resided on the 200 Hall, indicated it smelled bad in the facility, and she had her family members bring her air freshener spray. The resident had a can of air freshener. The clinical record for Resident 8 was reviewed on 06/26/25 at 11:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, indicated the resident was moderately cognitively impaired. On 06/25/25 at 1:06 P.M., the 200 Hall smelled strongly of urine with the odor increasing around rooms [ROOM NUMBERS]. On 06/26/25 at 9:45 A.M., the 200 Hall smelled strongly of urine from Rooms 210 to 215. On 06/26/25 at 3:37 P.M., the 200 Hall smelled strongly of urine. On 06/30/25 at 1:29 P.M., the 200 Hall smelled strongly of urine. On 07/02/25 at 11:03 A.M., the 200 Hall smelled strongly of urine from Rooms 210 to 215. During an interview and observation on 07/02/25 at 11:13 A.M., the Corporate Clinical Support nurse indicated she could smell the strong urine odor while walking down the 200 Hall. The current Resident Rights policy, dated 03/15/17, was provided by the Director of Nursing (DON) on 07/02/25 at 12:09 P.M. The policy indicated, .You have the right to a safe, clean, comfortable and homelike environment . 3.1-19(f)(5)

Based on record review and interview, the facility failed to ensure the staff had the required six hours of dementia training within six months of hire and three hours annually thereafter for 2 of 10 employee records reviewed. (Qualified Medication Aid [QMA]8 Certified Nurse Aide [CNA] 9) Findings include: The employee records were provided by the Employee Experience Manager on 06/27/25. The following staff members failed to have the required number of hours of dementia training: - Qualified Medication Aide (QMA) 8 was hired on 10/05/21 and failed to have any current dementia training in her file. - Certified Nurse Aide (CNA) 9 was hired on 07/18/24 and had 3 hours of dementia training. On 06/30/25 at 10:00 A.M., the Administrator provided three hours of dementia training for QMA 8. The training was completed on 06/27/25. She had no additional dementia training for CNA 9. During an interview, on 06/30/25 at 3:47 P.M., the Administrator indicated the Employee Experience Manager had noticed some staff had missed their date for mandatory training. The Employee Experience Manager had advised them to have it completed as soon as possible. During an interview, on 06/30/25 at 3:50 P.M., Corporate Clinical Support Nurse indicated the facility did not have a policy related to dementia training they would follow state and federal regulations. 3.1-14(u)

Based on interview and record review, the facility failed to provide the scheduled Activities of Daily Living care related to bathing for 1 of 3 residents reviewed. (Resident 64) Findings include: During an interview on 07/22/24 at 2:13 P.M., Resident 64 indicated she was lucky to get a shower once a week. At home she showered every other day. The resident's clinical record was reviewed on 07/24/24 at 10:02 A.M. An admission MDS (Minimum Data Set) assessment, dated 06/29/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, a right hip fracture, Clostridioides difficile (C-diff, a bacteria that causes watery Diarrhea), and urinary tract infection. The resident tested positive for C-diff Toxins on 07/03/24. The Electronic Health Record History and the Shower Sheets indicated the resident had the following showers or complete bed baths from admission to the facility from 06/26/24 to 07/26/24: - On 07/04/24 the resident refused a shower. - On 07/08/24 the resident received a complete bed bath. - On 07/15/24 the resident received a shower. - On 07/18/24 the resident refused a shower. - On 07/22/24 the resident received a complete bed bath. The resident had only five documented showers, complete bed baths, or refusals since admission. The resident should have had 11 documented showers in the time frame reviewed. During an interview on 07/25/24 at 1:34 P.M., QMA (Qualified Medication Aide) 4 indicated residents were to be offered showers at least twice a week but could be more if requested. Bathing was to be documented in the electronic record and on a shower sheet. If there was a refusal, they would need to fill out a refusal form with the nurse. During an interview on 07/26/24 at 10:01 A.M., RN (Registered Nurse) 6 indicated the resident's scheduled shower days were Monday and Thursday evenings. If a resident refused to take a shower two different CNA's (Certified Nurse Aide) would attempt to offer the resident a shower and then the nurse would try. If they continued to refuse, then family was notified, and a refusal form was filled out and signed. The current facility policy, titled Guidelines for Bathing Preference with a review date of 12/31/22, was provided by the DON on 07/26/24 at 2:28 P.M. The policy indicated, .Bathing shall occur at least twice a week unless resident preference states otherwise . 3.1-38(a)(2)(A)

Based on observation, record review, and interview, the facility failed to follow appropriate infection control guidelines while providing indwelling urinary catheter care for residents with a history of UTIs (Urinary Tract Infections) for 2 of 3 residents reviewed for UTIs. (Residents 62 and 26) Findings include: 1. Indwelling urinary catheter care was observed for Resident 62 on 07/25/24 at 2:15 P.M., with CNA (Certified Nurse Aide) 2 and CNA 3. The staff donned gowns from the cart that was just inside the resident's room door due to the resident being in Enhanced Barrier Precautions and placed a plastic bag containing clean linens on the foot of the resident's bed. The staff donned gloves. CNA 2 prepared water in a basin in the bathroom for the procedure. CNA 3, wearing her gloves, proceeded to shut the window blind, turned on the light over the bed, and adjusted the resident's bed using the bed controls. CNA 2 brought the pan of water out and placed it on the over the bed table. The two staff members pulled the resident's pants down and rolled the resident side to side, placing a towel under their buttocks. CNA 3 put a clean towel in the tub of water then cleaned around the entry point of the catheter tubing at the head of the penis, turning the towel, pulling away from the body with each wipe, and detached and reattached the tubing from the anchor on the resident's left upper thigh. She cleaned the skin folds and leg creases turning the towel. The CNAs took the resident's boots off, sat them on the bed, took off the resident's pants, put on a new brief, put the resident's pants and shoes back on, and removed the towel from underneath the resident wearing the same gloves the entire time. The CNAs bagged the dirty linens, removed gowns and gloves, and washed their hands with soap and water. The clinical record for Resident 62 was reviewed on 07/24/24 at 10:10 A.M. A Scheduled 5-day MDS (Minimum Data Set) assessment, dated 07/02/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, UTI, sepsis, stroke, dementia, diverticulosis, partial intestinal obstruction, hemiplegia, and cirrhosis of the liver. The resident had an indwelling urinary catheter and was frequently incontinent of bowel An Infection Tracking Surveillance Log was provided by the Corporate Clinical Support on 07/29/24 at 10:45 A.M. The record indicated the resident was treated for a UTI from 07/12/24 to 07/18/24 with the antibiotic Macrobid. 38239 2. On 07/25/24 at 3:17 P.M., CNA 3 was observed as she provided suprapubic urinary catheter (an indwelling catheter placed through the skin, just above the pubic bone and into the bladder) care for Resident 26. CNA 3 washed her hands and donned gloves. With her gloved hands she moved papers and a remote control from the resident's overbed table. Supplies were placed on the overbed table and at the foot of the bed. She turned on the light, adjusted the window blinds, and repositioned the overbed table. She grabbed the bed controller and adjusted the position of the bed. She pulled the resident's blankets down. She took the basin with water over to the resident and let her feel the water to check the water temperature. She placed the basin back on the table, placed a washcloth in the basin, grabbed the roll of trash bags, opened a bag, and placed it at the foot of the bed. She exposed the resident's skin and the catheter insertion site, took the washcloth from the basin, applied a cleanser to it, and began cleaning the resident's urinary catheter. During an interview on 07/25/24 at 3:33 P.M., CNA 3 indicated after she adjusted the blinds and moved the resident's items around, she normally would have washed her hands and put on new gloves before performing the actual catheter care. The resident's clinical record was reviewed on 07/26/24 at 10:04 A.M. A Quarterly MDS assessment, dated 05/20/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, multiple sclerosis, cancer, stroke, neurogenic bladder, chronic myeloid leukemia, dementia, and depression. An Infection Tracking Surveillance Log was provided by the Corporate Clinical Support on 07/29/24 at 10:45 A.M. The record indicated the resident was treated for a UTI from 06/15/24 to 06/24/24 with the antibiotic Bactrim. The current facility policy, titled Urinary Catheter Care, reviewed on 12/31/23, was provided by the DON (Director of Nursing) on 07/29/24 at 11:30 A.M. The policy indicated, .Prior to the beginning of the procedure .close drapes/lower shades/close blinds .place the clean equipment on the bedside stand or overbed table .Arrange supplies .Wash and dry hands thoroughly .put on gloves .wash the resident's genitalia and perineum thoroughly .remove gloves .wash and dry your hands .put on clean gloves .cleanse and rinse the catheter from insertion site .Remove gloves .Wash and dry hands thoroughly .Reposition the bed covers .Make the resident comfortable .Wash and dry hands thoroughly . 3.1-41(a)(2)

Based on interview and record review, the facility failed to accurately complete comprehensive MDS (Minimum Data Set) assessments for 3 of 18 resident records reviewed for accuracy of assessments. (Residents 70, 37, and 31) Findings include: 1. The clinical record for Resident 70 was reviewed on 06/16/23 at 1:43 P.M. An Admission MDS assessment, dated 03/21/23, indicated the resident was admitted to the facility from an acute hospital. The diagnoses included, but were not limited to, stroke, coronary artery disease, and diabetes. A Discharge MDS assessment, dated 05/03/23, indicated the resident discharged from the facility and returned to an acute hospital. A Progress Note, dated 05/03/2023 at 10:09 A.M., indicated the resident discharged from the facility and was moving to the Assisted Living facility. The family helped move the resident's belongings, and the facility nurse gave report and resident paperwork to the Assisted Living nurse. During an interview on 06/21/23 at 11:21 A.M., the MDS Coordinator indicated the resident did not discharge to a hospital from the facility on 05/03/23. The resident discharged from the facility and went to the Assisted Living facility. The MDS assessment was incorrect. 34232 2. During an interview on 06/21/23 at 9:37 A.M., while reviewing the psychotropic medications for Resident 37 with the SSD (Social Services Director), it was discovered that the resident was not receiving an antianxiety medication. The clinical record was reviewed on 06/21/23 at 9:20 A.M. A 5-day scheduled MDS assessment, dated 05/30/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, anxiety, and depression. Section N, medications, indicated the resident had received an antianxiety medication for five of the five days of the review period. During an interview on 06/21/23 at 9:55 A.M., the SSD indicated the resident had not received an antianxiety medication during the review period. The 5-day scheduled MDS assessment, dated 05/30/23, was incorrect. The EMAR (Electronic Medication Administration Record) for May 2023, was provided by the Corporate MDS Support on 06/21/23 at 10:13 A.M. The record lacked a physician's order for an antianxiety medication. During an interview on 06/21/23 at 9:59 A.M., the MDS Coordinator indicated they did not have a policy for completing the MDS assessments, they followed the RAI (Resident Assessment Instrument) manual. 38769 3. During an interview on 06/15/23 at 12:58 P.M., Resident 31 indicated he had pain in both of his arms all the time. The clinical record for Resident 31 was reviewed on 06/21/23 at 11:12 A.M. An Admission MDS assessment, dated 04/28/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia and hypertension. Section N lacked documentation that opioids were administered in the seven day look back period. The April 2023 EMAR indicated the resident had received hydrocodone-acetaminophen 5-325 mg from 04/24/23 through 04/28/23. During an interview on 06/21/23 at 11:41 A.M., the MDS Coordinator indicated she would obtain resident information for medications usage from the EMAR. The medication usage was a seven day look back and the resident had received the opioid and the MDS should have reflected it. 3.1-31(c)(13) 3.1-31(d)

Based on interview, observation, and record review, the facility failed to prevent the development of an unstageable (obscured full-thickness skin and tissue loss, full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough, moist dead tissue, or eschar, dry dead tissue) pressure ulcer (Resident 57), and failed to implement Care Plan interventions to prevent the development of pressure ulcers (Resident 2) for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. During an interview on 06/15/23 at 1:09 P.M., Resident 57 indicated she had skin conditions the facility was treating. They put ointment on her bottom. There was just one tiny place on her bottom now. They put a little patch on it just as a precaution. The resident's sacral/coccyx area was observed with RN 14 on 06/20/23 at 1:57 P.M. There was a pencil eraser sized, light cream-colored scab at the top of the gluteal cleft, and a dime-sized red area on the right buttock. The clinical record was reviewed on 06/21/23 02:13 PM. A Scheduled 5-day MDS (Minimum Data Set) assessment, dated 05/29/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Enterocolitis due to Clostridium difficile (C-diff, a bacterium that causes an infection of the large intestine, colon), heart failure, and malnutrition. The resident was at risk for pressure ulcers and had three stage three pressure ulcers (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar, may be visible but does not obscure the depth of tissue loss), that were present on admission, and three unstageable pressure ulcers that were present on admission. A Discharge MDS assessment, dated 04/18/23, indicated the resident had no unhealed pressure ulcers. The resident returned on 04/20/23 from an acute hospital stay. A Discharge MDS assessment, dated 5/20/23, indicated the resident had one stage 3 pressure ulcer that was present on readmission/reentry, and two unstageable pressure ulcers, one of which was present on admission/reentry. A Wound Event Report, dated 05/06/23, was provided by the ADON (Assistant Director of Nursing)/Wound Nurse on 06/20/23 at 4:01 P.M. The report indicated the resident had acquired an open area on her coccyx that measured 0.75 cm (centimeters) x (by) 0.75 cm, that was not present on admission. The treatment was to apply wound gel to the open area and cover with a foam wound dressing, daily, until healed. The Wound Management Detail Report record was provided by the ADON/Wound Nurse on 06/20/23 at 4:01 P.M., and contained the following observations: - 05/09/23, the wound measured 1 cm x 0.5 cm x 0.1 cm deep, had a light amount of serous (clear, amber, thin and watery) drainage, was unstageable, and the wound bed was 25% covered with granulation (new) tissue, and 75% covered in slough. The record indicated the wound healed on 05/22/23. The Treatments Administration History record was provided by the ADON/Wound Nurse on 06/20/23 at 4:01 P.M. Prior to the development of the pressure ulcer on the resident's coccyx, the following treatment order, with a start date of 04/27/23 and a discontinued date of 05/07/23, was in place for a wound on the resident's sacrum that had been present on readmission: - Sacrum: cleanse wound with wound cleanser or normal saline, apply skin prep (a toughening agent) to peri-wound intact skin, apply Adaptic (a non-adherent dressing) to wound bed and cover with foam dressing, change once a day every five days. - Sacrum: cleanse wound with wound cleanser or normal saline, apply skin prep to peri-wound intact skin, apply Adaptic to wound bed and cover with foam dressing, change once a day every five days PRN (as needed). The record indicated the resident's dressing was applied on 05/02/23, and was discontinued on 05/07/23, after the development of the unstageable pressure ulcer to the resident's coccyx. No treatments were documented from 05/02/23 to 05/06/23, the day the wound was first observed. The Vitals Report record was provided by Corporate MDS Support on 06/21/23 at 11:40 A.M. The record indicated the resident had been incontinent of bowel with a large loose stool on 05/03/23 at 5:53 A.M., had a large liquid bowel movement with a foul odor on 05/04/23 at 10:21 A.M., and had been incontinent of bowel with a large loose stool on 05/06/23 at 2:08 P.M. During an interview on 06/20/23 at 2:38 P.M., the ADON/Wound Nurse indicated the coccyx wound was at the top of the gluteal cleft and that was the new wound identified on 05/06/23. The sacral wound was identified on 04/20/23. The sacral wound was above the coccyx wound. The coccyx wound was closed at this time. Prior to having the unstageable wound on her coccyx, the resident was getting skin prep applied to the area, along with a sacral dressing treatment order that was changed, starting on 04/27/23. She had a dressing on her sacrum. The sacral dressing covered the sacrum and the coccyx. She had a foam dressing in place as a preventative on 04/07/23. Preventative dressings were usually changed every five days but could stay on for seven days. On 04/27/23, the treatment was changed to adding Adaptic to add moisture to the area and to prevent the other dressing from sticking. The foam dressing was continued as well. The current Guidelines for Weekly Measurements policy, with a reviewed date of 12/31/22, was provided by Corporate Clinical Support on 06/21/23 at 2:24 P.M. The policy indicated, .PURPOSE .To monitor the effectiveness of interventions for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures . 38769 2. During an observation on 06/15/23 at 1:01 P.M., Resident 2 was lying in bed. Her eyes were closed. A pressure relieving boot was lying in the wheelchair and another one was lying in the recliner. The resident's enteral nutrition supplment (a form of nutrition delivered into the digestive system) was connected to a pump and running through tubing connected to their g-tube (gastrostomy tube) site. During an observation on 06/16/23 at 11:29 A.M., Resident 2 was lying in bed. Her heels were resting on the bed with a pillow under her calves. The pillow appeared flat. A pressure relieving boot was lying in the wheelchair and another one was lying in the recliner. The resident's supplemental nutrition was connected and running. The clinical record for Resident 2 was reviewed on 06/19/23 at 10:50 A.M. A Quarterly MDS assessment, dated 05/09/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, seizure disorder, anxiety, depression, and bipolar disorder. The resident was at risk for pressure ulcers. The Complete Care Plan was provided by the Cooperate Nurse on 06/20/23 at 3:47 P.M. A Care Plan titled, Skin Integrity was developed on 06/01/21, included an intervention to wear offloading boots to the bilateral feet at all times with a start date of 06/01/23. An open-ended physician's order, with a start date of 05/30/23, the staff were to apply offloading boots to the resident's bilateral feet at all times. The staff were to check the placement every shift. During an interview on 06/20/23 at 12:59 P.M., CNA 15 indicated the resident required total assistance of two staff with care. She was comatose and started on hospice the past weekend. She had been sent out to the hospital when she was unresponsive in the facility. During an interview on 06/20/23 at 1:12 P.M., LPN 12 indicated the resident was to wear offloading boots at all times, but she would kick them off. The staff would have to go back in and reapply them. During an interview on 06/20/23 at 3:01 P.M., the ADON indicated the resident was to have the boots on at all times but she would kick them off. If the resident wasn't wearing the boots it should be documented. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care planned interventions were in place for 1 of 3 residents reviewed for accident hazards. (Resident 3) Findings include: Resident 3's bathroom was observed on 06/16/23 at 11:23 A.M. The resident's call light had several pieces of bright pink colored tap on the pull string. Toilet safety rails were observed in place on each side of the toilet. The rails were gray in color. The resident's clinical record was reviewed on 06/20/23 at 1:55 P.M., A Quarterly MDS (Minimum Data Set) assessment, dated 02/24/23, indicated the resident was severely cognitively impaired. The resident required the extensive assistance of two staff members for transferring, toileting, and personal hygiene. The diagnoses included, but were not limited to, stroke, hemiplegia and hemiparesis, and diabetes. The resident's vision was severely impaired. The resident's upper and lower extremities were impaired on one side. The resident experienced two or more falls without injury since the last assessment. A progress note, dated 04/10/2023 at 9:39 P.M., indicated the resident was found on the floor in her bathroom. The resident stated she was attempting to transfer herself onto the toilet and missed, landing on her buttock. The resident complained of low back pain but was assessed and found to be without injury. A progress note, dated 04/11/2023 at 9:28 A.M., indicated an interdisciplinary team review determined the root cause of the fall was that the resident missed the toilet when she sat down, likely due to her visual impairment. An intervention to place handles on the toilet and mark them with bright colored tape to improve visibility was implemented. The resident's Category: Falls care plan was provided by Corporate Clinical Support on 06/20/23 at 1:48 P.M. Interventions included, but were not limited to, a current intervention, with a start date of 04/11/23, for handles on the toilet marked with bright colored tape to improve visibility. The resident's bathroom was observed with RN 13 on 06/20/23 at 11:33 A.M. There was no brightly colored tape on the safety rails on either side of the resident's toilet. RN 13 indicated she reviewed the resident's care plan, and it did indicate that there should be bright colored tape on the safety rails. The resident's vision was significantly impaired, and she liked the bright pink tape they used. The current facility policy, titled Falls Management Program Guidelines, with a review date of 03/16/22, was provided by the Corporate MDS Coordinator on 06/20/23 at 2:43 P.M. The policy indicated, .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures . 3.1-45(a)(2)

Based on observation and interview, the facility failed to post nurse staffing daily for 2 of 7 days during the survey period. Findings include: During an observation on 06/15/23 at 10:10 A.M., the nurse staffing was posted by the main entrance and dated for 06/09/23. During an observation on 06/15/23 at 2:48 P.M., the nurse staffing was posted by the main entrance and dated for 06/09/23. During an observation on 06/16/23 at 8:55 A.M., the nurse staffing was posted by the main entrance and dated for 06/09/23. During an interview on 06/21/23 at 1:15 P.M., the Scheduling Coordinator indicated she was responsible for ensuring staffing information was posted each day. She had been on vacation since 06/12/23 and today was her first day back at the facility. Staffing should be posted everyday. During an interview on 06/21/23 at 1:22 P.M., the Administrator indicated the Scheduling Coordinator handled staff posting. When she was on vacation, several staff members stepped in to update staff posting. The current facility policy, titled Guidelines for Staff Posting, with a review date on 12/31/22, was provided by Corporate Clinical Support on 06/21/23 at 2:05 P.M. The policy indicated, .At the beginning of each day the number and amount of hours of licensed nurses .and the number and hours of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted .

Based on record review and interview, that facility failed to provide medications for 1 of 18 residents reviewed for pharmacy services. (Resident 46) Findings include: 1a. The clinical record for Resident 46 was reviewed on 06/16/23 at 2:21 P.M. Am Admission MDS (Minimum Data Set) assessment, dated 05/05/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, malnutrition, and depression. A Progress Note, dated 06/08/23 at 4:24 P.M., indicated the resident's doxepin (an antidepressant medication) was reduced to 5 mg (milligrams) daily for seven days and then discontinue. A Progress Note, dated 06/13/23 at 1:40 P.M., indicated the pharmacy called and they were unable to split the doxepin capsule. The medication only came in 3 mg and 6 mg forms. The NP (Nurse Practitioner) was notified and a new order was obtained to start doxepin 3 mg everyday and continue with the original discontinue date. A physician's order, dated 05/02/23 through 06/08/23, indicated the resident was to receive doxepin 10 mg, once a day. A physician's order, dated 06/08/23 through 06/13/23, indicated the resident was to receive doxepin 5 mg, once a day. A physician's order, dated 06/13/23 through 06/14/23, indicated the resident was to receive doxepin 3 mg, once a day. The June 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident received the following doxepin medications: - On 06/08/23, 06/11/23, 06/12/23, the resident was administered 5 mg, and - On 06/14/23, the resident was administered 3 mg. The resident was not administered medications on 06/09/23, 06/10/23, and 06/13/23 due to the medication being unavailable. A New Prescription Summary, indicated the medication was a capsule and couldn't be split. The medication was only available in 6 mg and 3 mg. The facility was notified the following dates and times: - On 06/09/23 at 9:15 A.M., a staff member indicated she would clarify the medication with the NP next week, - On 06/10/23 at 3:03 P.M., the facility was faxed, - On 06/12/23 at 5:07 P.M., a staff member indicated she would clarify with the MD, and - On 06/13/23 at 12:55 P.M., a staff member indicated they were still working on clarification. During an interview on 06/21/23 at 10:28 A.M., the pharmacist indicated the doxepin medication was only available in 3 mg and 6 mg. The 10 mg medication was a capsule so the facility would not have been able to cut the previous medication in half. The pharmacy would have alerted the facility the same day the order was inputted that the medication was unavailable in the 5 mg form. The facility had been contacted on the 06/08/23 and 06/09/23. The medication was filled on 06/13/23 as a 3 mg tab. During an interview on 06/21/23 at 1:28 P.M., the Infection Preventionist indicated when a resident had a new medication order it would be transcribed into the computer and the pharmacy would get the medication order. The facility staff would call to make sure they got the order. The resident medications would be delivered the same day or the next day. If the medication was not available from the pharmacy the staff should call the physician and document in the progress note. The NP should have been notified sooner that the doxepin medication was unavailable in the 5 mg form. 1b. An open-ended physician's order with a start date of 05/01/23, indicated the resident was to be administered alendronate 70 mg, once a day on Monday, for bone health. The June 2023 EMAR/ETAR indicated the resident had not received the medication on 06/05/23 and 06/19/23 due to the medication being unavailable. During an interview on 06/20/23 at 1:07 P.M., LPN 15 indicated when a resident had a new medication order she would see if it was available in their medication bank and if not the she would call the pharmacy to see if she could get it from a back-up pharmacy (local pharmacy). If it came from the back-up it would get to the facility within one hour and a half and two hours. If the medication came from their pharmacy it would take them about four hours. The pharmacy delivered medications every night. The cutoff time to order medications and get them the same night was 12:00 P.M. If the medication was not available the pharmacy would notify the nurse with recommendations and she would call the NP. The NP should be notified the same day or within 24 hours of a medication not being available. During an interview on 06/21/23 at 10:28 A.M., the pharmacist indicated the alendronate was ordered from the pharmacy on 05/01/23 and 06/05/23. The medication was sent as a monthly supply with four tablets. During an interview on 06/21/23 at 1:28 P.M., the Infection Preventionist indicated the alendronate medication should have been reordered when the lat dose was given in May. The current facility policy titled, Unavailable Medications with a revised date of 11/2018, was provided by the Infection Preventionist on 06/21/23 at 2:38 P.M. The policy indicated, ' .The facility must make every effort to ensure that medications are available to meet the needs of each resident . 3.1-25(a)

Based on record review and interview, the facility failed to follow the physician's orders related to hold parameters for hypertension medications for 2 of 7 residents reviewed for unnecessary medications. (Residents 36 and 49) Findings include: 1. The clinical record for Resident 36 was reviewed on 06/20/23 at 3:27 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/12/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, chronic obstructive pulmonary disease, and stroke. The current Care Plan for Cardiovascular distress related to the diagnoses of hypertension and hyperlipidemia, with a reviewed date of 04/26/23, was provided by Corporate MDS Support on 06/20/23 at 4:08 P.M. Interventions included, but were not limited to, Medications as ordered, and obtain vital signs as ordered and needed. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for February 2023 was provided by Corporate MDS Support on 06/20/23 at 4:08 P.M. The record included, but was not limited to, the following physician's order: - An open-ended order for metoprolol succinate tablet extended release (a blood pressure medication), 50 mg, once a day, for hypertension. Special Instructions: Hold for Pulse < (less than) 60 or SBP (Systolic Blood Pressure), the top number, < 110, with a start date of 01/19/23, and a discontinued date of 03/17/23. The record indicated the medication had been administered outside of the ordered parameters, when the resident's pulse was less than 60 beats per minute, on the following dates: - On 02/02/23, the pulse was 52, - On 02/03/23, the pulse was 53, - On 02/09/23, the pulse was 56, - On 02/17/23, the pulse was 56, - On 02/19/23, the pulse was 53, - On 02/21/23, the pulse was 53, and - On 02/24/23, the pulse was 53. During an interview on 06/20/23 at 1:47 P.M., RN 14 indicated when a resident had hold parameters on a medication, for like a blood pressure medication, it was usually in the EMAR/ETAR. Staff could see it in the order. Staff should document the required values and notify the NP (Nurse Practitioner) that they were holding the medications. If there were no hold parameters, she would clarify the order with the NP and add parameters if needed. Staff should follow the physician's orders. She had not been inserviced on hold parameters recently. It was a nursing measure. The current Comprehensive Care Plan Guideline policy, with a revised date of 05/22/18, was provided by Corporate MDS Support on 06/20/23 at 2:43 P.M. The policy indicated, .PURPOSE .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions . The current ADMINISTRATION PROCEDURES FOR ALL MEDICATIONS policy, with a revised date of 11/18, was provided by Corporate Clinical Support on 06/21/23 at 9:05 A.M. The policy indicated, .To administer medications in a safe and effective manner .Check for vital signs, other tests to be done during/prior to medication administration . 38769 2. The clinical record for Resident 49 was reviewed on 06/19/23 at 10:30 A.M. A Quarterly MDS assessment, dated 05/30/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, anemia, hypertension, and renal insufficiency. An open-ended physician's order, with a start date of 05/10/23, indicated the staff were to administer metoprolol succinate, 25 mg once a day. The staff were to hold the medication if the resident's systolic blood pressure was less than 120 or the heart rate was less than 60. The May 2023 EMAR indicated the resident had received the medication when the systolic blood pressure was less than 120 on the following date and times: - On 05/10/23, the blood pressure was 106/68, - On 05/12/23, the blood pressure was 112/71, - On 05/19/23, the blood pressure was 111/76, - On 05/20/23, the blood pressure was 114/68, and - On 05/29/23, the blood pressure was 94/61. During an interview on 06/20/23 at 1:07 P.M., LPN 12 indicated if a resident's blood pressure medication had hold parameters, she would check the blood pressure and heart rate prior to giving the medication. She would not administer the medication if it was outside the parameters. The current ADMINISTRATION PROCEDURES FOR ALL MEDICATIONS policy, with a revised date of 11/18, was provided by Corporate Clinical Support on 06/21/23 at 9:05 A.M. The policy indicated, .To administer medications in a safe and effective manner .Check for vital signs, other tests to be done during/prior to medication administration . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure appropriate treatments were in place and implement interventions for a resident identified with an Unstageable (presents as ulcer in which depth of tissue damage is not able to be determined due to presence of nonviable tissue) pressure ulcer that developed into a Stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. (Resident 22) Findings include: Resident 22's coccyx wound was observed with the FWN (Facility Wound Nurse) 8 and Clinical Support Nurse 7 on 05/24/22 at 1:26 P.M. The resident was in bed and the wound dressing had already been removed. The resident was assisted as he rolled to one side to expose the wound. The wound measured 4.3 cm (centimeters) x (by) 3 cm, with a measured depth of 2.5 cm. There was 2.1 cm of undermining (erosion underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface). The wound bed was red, with a nickel sized area of yellow tissue visible within the wound. The wound was clean and there was no drainage or odor. The skin around the wound was intact, and there were no signs of infection. FWN 8 indicated the resident's wound was a Stage IV pressure ulcer. The resident went to the local wound clinic recently. During an interview on 05/24/22 at 1:56 P.M., FWN 8 indicated the resident had been declining, he was hospitalized in January, had some infections, and wasn't eating well. They started with a foam dressing, but it kept coming off because of the resident sliding down in his chair since he couldn't bend his knee. In March, the tiny areas around the wound became covered in slough (dead skin cells) so they just included the whole area in the wound measurement-that was why the wound measurements got larger. They have tried different treatments, they had increased and decreased the frequency of the treatments. The resident's health was improving, and the wound was improving as well. The resident's clinical record was reviewed on 05/25/22 at 10:46 A.M. The progress notes indicated the resident was hospitalized in January of 2022 and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with septic shock in the hospital. A progress note, dated 01/26/22 at 6:57 P.M., indicated the resident returned to the facility by ambulance. The resident had bruises on both arms from IV insertions. There was a small amount of shearing of the resident's skin on his buttocks. There was shearing of the skin on the resident's left thigh that was healing well. A 5 Day MDS (Minimum Data Set) assessment, dated 01/31/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an indwelling urinary catheter and was frequently incontinent of bowel. The resident was at risk for pressure ulcers but had no unhealed pressure ulcers during the assessment review period. The resident utilized pressure reducing devices for the bed and chair. A progress note, dated 02/05/22 at 2:09 P.M., indicated the resident had new open areas to the buttocks and coccyx. The area on the right buttock was not open, but shearing was present. A Skin Integrity Event, dated 02/05/22, indicated the resident had an area to the right buttock. The observation indicated the wound was 1 cm x 0.5 cm. The wound was not present on admission. The evaluation note indicated the wound was found to be an abrasion to newly healed skin. A Change in Condition Event, dated 02/05/22, indicated the resident had shearing to the right buttock. The evaluation note indicated the wound was found to be an abrasion and was already healed. A Skin Integrity Event, dated 02/05/22, indicated the resident had an open area to the left buttock. The observation indicated the wound was 1 cm x 0.5 cm. The wound was not present on admission. The evaluation note indicated the wound was found to be an abrasion and was already healed. A Skin Integrity Event, dated 02/05/22, indicated there was an open area to the resident's buttocks and coccyx. The observation indicated the wound located on the coccyx was 2 cm x 1.5 cm. The wound was not present on admission. The evaluation note indicated to see wound review. Wound Management documentation indicated the wound on the resident's coccyx was observed on 02/05/22 at 3:42 P.M. The wound measured 0.9 cm x 0.5 cm. The depth could not be measured. There was a moderate amount of serosanguineous (pale red to pink, thin and watery) drainage. The wound was Unstageable due to the slough present in the wound. During an interview on 05/24/22 at 3:00 P.M., the FWN 8 indicated the coccyx wound was identified by nursing staff on 2/05/22. The only treatment orders that were in place at the time the wound was identified was to cleanse the resident's skin with a personal cleanser and apply protective ointment or cream as needed after each incontinent episode. When she assessed the wound on 02/05/22, she would have given the floor nurse treatment orders. The floor nurse should have entered the orders into the computer. She would have likely told them to put a boarder dressing on the wound and to monitor the wound. There were no treatment orders for the wound on the resident's coccyx in the resident's clinical record until 02/15/22. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for February 2022 was reviewed and included the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply a basic foam dressing to the wound bed and then a [MEDICATION(S)] foam dressing. The dressing was to be changed every 3 days and as needed if soiled. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound Management documentation indicated the wound on the resident's coccyx was observed on 02/15/22 at 3:44 P.M. The wound measured 0.9 cm x 0.5 cm. The depth could not be measured. There was a moderate amount of drainage. The wound was Unstageable due to the slough. Wound Management documentation indicated the wound on the resident's coccyx was observed on 03/01/22 at 1:22 P.M. The wound measured 4.3 cm x 3.9 cm. The depth could not be measured. There was a moderate amount of drainage. The wound was Unstageable due to the slough. Comments indicated the reddened area around the wound had small scattered open areas with slough. The resident had decreased mobility related to a wrist fracture and respiratory infection. A progress note, dated 03/10/22 at 3:08 P.M., indicated the resident has had additional areas open to the coccyx in the peri-wound area of original wound, however they were improving. Wound Management documentation indicated the wound on the resident's coccyx was observed on 03/29/22 at 8:38 P.M. The wound measured 4.6 cm x 4.2 cm. The depth could not be measured. There was a moderate amount of drainage. The wound was Unstageable due to the slough. A progress note, dated 04/10/22 at 12:26 A.M., indicated the resident's coccyx wound dressing was changed as ordered. The peri-wound skin was intact with normal color. There was yellow slough in the wound bed. Wound Management documentation indicated the wound on the resident's coccyx was observed on 04/12/22 at 4:54 P.M. The wound measured 4.7 cm x 4.2 cm. The depth could not be measured. There was a heavy amount of drainage. The wound was Unstageable due to the slough. The EMAR/ETAR for March and April 2022 was reviewed and included the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow with a wet to dry dressing and cover with a [MEDICATION(S)] foam dressing. The dressing was to be changed daily and as needed if soiled. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Dakin's (an antimicrobial cleaner) solution to a gauze pad, ring out the gauze and apply it to the wound bed. Cover with a [MEDICATION(S)] foam dressing. The dressing was to be changed twice daily and as needed if soiled. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Dakin's solution to a gauze pad, ring out the gauze and apply it to the wound bed. Cover with a [MEDICATION(S)] foam dressing. The dressing was to be changed twice daily and as needed if soiled. Wound Management documentation indicated the wound on the resident's coccyx was observed on 05/03/22 at 6:45 P.M. The wound measured 3.9 cm x 4.0 cm. There was a moderate amount of clear/amber colored drainage. There was no wound staging documented. Wound Clinic visit documentation indicated the resident's wound was assessed at the clinic on 05/05/22. The wound was a Stage IV pressure ulcer with full thickness exposed support structure. Before debridement, the wound measured 2.5 cm x 4 cm, with depth of 3.5 cm. There was 4.5 cm of undermining. There was a moderate amount of slough. The character of the wound was deteriorated and necrotic with the fat layer exposed. Discharge instructions from the wound clinic indicated the resident was to return to the wound clinic for a follow up appointment on 05/19/22 at 9:15 A.M. During an interview on 05/25/22 at 9:58 A.M., the Wound Clinic Nurse indicated the resident was seen in the clinic on 05/05/22. The resident had a follow up appointment scheduled on 05/19/22, but he was a no show in their system. She was not sure why, no one canceled the appointment. The Wound Clinic Nurse indicated she saw the resident when he was inpatient in the hospital in January 2022. Hospital documentation indicated on 01/19/22 the resident had a Stage III pressure ulcer on his coccyx on admission to the hospital, and a Stage II pressure ulcer on his right buttock. Hospital documentation on 01/26/22 indicated the wound on the right buttock was healed. On 01/26/22 the wound on the coccyx measured 1 cm x 0.8 cm. She reviewed a photograph of the wound and indicated it was pencil eraser sized with healthy red tissue in the wound bed. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Dakin's solution to a gauze pad, ring out the gauze and apply it to the wound bed. Cover with a foam dressing, no [MEDICATION(S)] foam dressing. The dressing was to be changed twice daily and as needed if soiled. Wound Management documentation indicated the wound on the resident's coccyx was observed on 05/10/22 at 2:58 P.M. The wound measured 4.0 cm x 4.0 cm. There was a moderate amount of drainage. There was granulation tissue present. There was no wound staging documented. Review of the resident's clinical record indicated documentation from the resident's appointment at the wound clinic on 05/05/22 was attached to the clinical record on 05/16/22. The documentation indicated the resident was due for a follow up appointment at the wound clinic on 05/19/22 at 9:15 A.M. During an interview on 05/25/22 at 10:25 A.M., the DON (Director of Nursing) indicated she was not sure why the resident did not make it to the follow up appointment on 05/19/22. The facility did not have any documentation related to scheduling transportation to the appointment on 05/19/22. Normally, when a resident returned from an appointment, and a follow up appointment was indicated, the nurse would schedule transportation for the upcoming appointment. A progress note, dated 05/19/22 at 4:13 P.M., indicated a wound clinic appointment was made for 05/26/22 at 9:30 A.M. A request for transportation was submitted. The current facility policy titled Guidelines for Pressure Prevention, with a revision date of 12/01/21, was provided by the DON on 05/25/22 at 8:48 A.M. the policy indicated, .To maintain good skin integrity and avoid development of pressure ulcers .Care plan interventions shall be implemented . 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review, interview, and observations, the facility failed to prevent a resident who was at risk for skin breakdown from developing a Stage III pressure ulcer and to ensure interventions were in place for a resident who was admitted with pressure ulcers. This deficient practice effected 2 of 2 residents reviewed for pressure ulcers. (Resident 6 and 33) Findings include: 1. The clinical record for Resident 6 was reviewed on 07/12/19 at 12:02 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/19/19, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. Resident 6 was admitted to the facility on [DATE]. A Care Plan with a start date of 12/07/18, indicated Resident 6 was at risk for skin breakdown related to the need for assistance with bed mobility, hx (history) of [MEDICAL CONDITION], etc. The interventions, with a start date of 12/07/18, included, indicated to Encourage and assist to turn and reposition for comfort and as needed .Conduct weekly skin assessment . A physician's orders [REDACTED]. An open ended physician's orders [REDACTED]. A progress note, dated 03/02/19, indicated Resident noted to have open lesion to fore skin on penis. Area measures 3 cm (centimeters) long x 1.5 cm at widest. Area cleaned, F/C (catheter) anchored to leg to prevent further irritation, rubbing. Will continue to monitor area. A Wound Management documentation for Resident 6 was provided by the DON (Director of Nursing) on 07/17/19 at 10:51 A.M. The document indicated the wound had the following measurements and was classified as a pressure ulcer: Penile foreskin - 03/06/19, 0.5 cm by 2 cm. Stage II pressure ulcer. - 03/12/19, 0.3 cm by 0.3 cm by 0.4 cm. Stage IIl pressure ulcer. - 03/19/19, 1 cm by 1.2 cm by 0.2 cm. Stage lll pressure ulcer. - 03/26/19, 1 cm by 1.2 cm. Stage lll pressure ulcer. - 04/02/19, 1 cm by 1.2 cm. Stage lll pressure ulcer. - 04/09/19, 0.5 cm by 0.2 cm. Stage lll pressure ulcer. - 04/15/19, 0.8 cm by 0.8 cm. Stage lll pressure ulcer. - 04/22/19, 0.5 cm by 0.5 cm. Stage lll pressure ulcer. - 04/29/19, wound healed. During an interview on 07/15/19 at 2:40 P.M., the DON indicated the Certified Nurses Aide found the penile tear during evening catheter care and reported it to the nurse. An anchor strap was being used and did not seem to hold the tubing well. The current Guidelines for Pressure Prevention policy, with a revision date of 05/10/2017, was provided by the DON on 07/17/19 at 3:39 P.M. The policy indicated, .To maintain good skin integrity and avoid development of pressure ulcers . 2. The clinical record for Resident 33 was reviewed on 07/11/19 at 11:18 A.M. A Significant Change MDS assessment, dated 06/26/19, indicated the resident was severely cognitively impaired. The resident's [DIAGNOSES REDACTED]. During an observation on 07/09/19 at 12:24 P.M., Resident 33 was propelled into the restorative dining room with purple socks on her feet and a bandage to the right foot. The resident did not have any pressure reducing boots in place. During observations on 07/11/19 at 10:01 A.M. and 11:33 A.M., Resident 33 was laying in her bed. Her pressure reducing boots were laying in her wheelchair. During an observation on 07/11/19 at 2:37 P.M., Resident 33 was laying in her bed. She had a pillow under her legs with her heels touching the mattress and no pressure reducing boots in place. During an observation on 07/12/19 at 10:05 A.M., RN 2 and RN 3 were preparing Resident 33 to change her dressing to her right foot. The blankets were removed and the residents feet were on a pillow with her heels touching the bed. Her pressure reducing boots were in her wheelchair. a. A Wound Management form, dated 06/03/19, indicated Resident 33 had an Unstageable (full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcer to the right heel. The resident was readmitted to the facility with the pressure ulcer to the right heel on 06/03/19. The pressure ulcer measurements were as followed: -06/03/19 was 4 cm by 4 cm and unstageable pressure ulcer -06/10/19 was 4.7 cm by 4.7 cm and unstageable pressure ulcer -06/17/19 5.2 cm by 4.5 cm and unstageable pressure ulcer -06/24/19 5.2 cm by 5 cm and unstageable pressure ulcer -07/01/19 5.2 cm by 5 cm and unstageable pressure ulcer -07/08/19 5 cm by 5 cm and unstageable pressure ulcer b. A Wound Management form, dated 06/03/19, indicated Resident 33 had an Unstageable pressure ulcer to the distal medial (right top of the foot) of the right foot. The resident was readmitted to the facility with the pressure ulcer to the distal medial on 06/03/19. The pressure ulcer measurements were as followed: -06/03/19 was 2 cm by 1.9 cm and unstageable pressure ulcer -06/10/19 was 2.7 cm by 2.2 cm and unstageable pressure ulcer -06/17/19 was 2.6 cm by 1.9 cm and unstageable pressure ulcer -06/24/19 was 1.2 cm by 0.8 cm and unstageable pressure ulcer -07/01/19 was 1.1 cm by 0.8 and unstageable pressure ulcer -07/08/19 was 1.1 cm by 0.8 and unstageable pressure ulcer A Care Guide form, dated 07/11/19, indicated Resident 33 was to wear pressure reducing boots. A physician's orders [REDACTED]. During an interview on 07/15/19 at 2:46 P.M., the DON and ADON indicated Resident 33 went to the hospital and had returned to the facility with multiple pressure ulcers. She went out to the hospital again and returned to the facility with the pressure ulcers being worse. The resident had interventions such as, pressure reducing boots at all times; especially the right one because that was where the pressure ulcers were at, dressing changes, and a low loss air mattress. The resident started wearing the boots as soon as she came back from the hospital. It was added to the CNA (Certified Nurse Aides) Care Guide Sheets. The resident should have had an order for [REDACTED]. The current facility policy titled Guidelines for Pressure Prevention with a revision date of 05/10/17, was provided by the DON on 07/17/19 at 3:39 P.M. The policy indicated .Position body with pillows and other devices .float heels as needed .Elevate heels off the bed . The current facility policy titled Guidelines for General Wound and Skin Care with a revision date of 05/10/17 was provided by the DON on 07/17/19 at 3:39 P.M. The policy indicated, .To provide measures that will promote and maintain good skin integrity . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure that nursing staff immediately reported and investigated suspected physical abuse for one resident who reported an allegation of physical abuse in a sample of six residents. (Resident E). This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/20/2015 between 8:30 a.m. and 10:00 a.m. when a staff nurse was notified by Resident E's spouse of an alleged incident of physical abuse. The Executive Director and Regional Nurse Consultant were notified of the Immediate Jeopardy on 11/24/2015 at 5:45 p.m. The Immediate Jeopardy was removed on 11/25/2015 at 4:37 p.m., but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: Resident E's clinical record was reviewed on 11/19/2015 at 1:20 p.m. [DIAGNOSES REDACTED]. He was admitted to the facility for rehabilitation following left total hip arthroplasty , or hip replacement, on 11/6/2015. Occupational Therapy (OT) Plan of Care, dated 11/13/2015, indicated, Reason for referral: This [AGE] year old male underwent L (left) THA replacement on 11/6 (2015) following a fall on 11/3 (2015). The patient reports complaints of weakness and decreased functional abilities of ADLs (activities of daily living) and functional mobility Prior Residence and Living Arrangements: .Independent with ADLs and ambulation .Discharge Plans: Discharge home and independent Initial Assessment: Functional Deficits: Cognition: Prior Level: Independent (no problems). Current Level: Indendent (no problems) .Underlying impairments: Cognition, Orientation: (oriented to) person, facility, nursing/family, and time (x4) The document indicated Resident E required maximum assistance (76-99%) for ADL self care, upper and lower body dressing. The resident required moderate assistance (26-75%) for ADL self care, bathing and toileting. The resident required minimal assistance (1-25%) for functional transfers. Nursing Admission Assessment and Data Collection, dated 11/12/2015, indicated Resident E was alert and oriented. The resident required the assist of one for transfers and ADLs (activities of daily living). Social Service Progress Notes, dated 11/15/2015, indicated, Res (resident) is .A&O (alert and oriented) Resident E was interviewed on 11/20/2015 at 11:31 a.m. He was alert and oriented to person, place and time. The resident complained of pain and nausea. Nurse's Notes, dated 11/21/2015 at 10:50 p.m., indicated, (Ambulance service) arrived to transport resident to (Emergency Department) .for eval (evaluation) + (and) tx (treatment) per family request. Resident E's Hospital Neurosurgery History and Physical Notes, dated 11/22/2015 at 8:06 p.m. indicated, History of Present Illness: .He was noted to have altered mental status and was brought to (hospital) .MRI performed .showed SDH (subdural hematoma) Per patient, he was discussing his blood pressure/insulin regimen with staff .and then 'saw a bright green light' and woke up with a headache. Per family, his altered mental status is very uncharacteristic of him as he is usually fully oriented with exception of immediate post-op period following hip replacement. On 11/23/2015 at 12:15 p.m., Resident E's room was observed to be empty. LPN # 3 indicated the resident was discharged from the facility and admitted to the hospital. The Director of Health Services (DHS) was interviewed on 11/23/2015 at 12:45 p.m. She indicated Resident E was discharged from the facility and admitted to the hospital with [REDACTED]. The DHS indicated the family notified her earlier that morning that the resident had a subdural hematoma. The DHS did not report any allegations of abuse related to Resident E. Resident E's daughter was interviewed on 11/23/2015 at 2:36 p.m. She indicated she visited the resident at the facility on the evening on 11/21/2015. She indicated, He was admitted (to the hospital) with a subdural hematoma .(Resident E) said (in the hospital), 'A nurse came in (at the facility) and was going to give me a cup full of medicine .she had something green in her hand and hit me in the head. I remember the pain being so bad I seen (sic) a light. I think she wants to do me in .He (Resident E) was worried they were mad after my mom (Resident B's wife) had talked to (State Surveyor the day before).' He said it (staff who struck him) was the heavy set one with blonde hair .He couldn't give specifics on time Resident E's daughter indicated she notified the Director of Health Services (DHS) of the allegations earlier that morning. On 11/23/2015 at 3:30 p.m., the Executive Director (ED) and Regional Nurse Consultant (RNC) indicated the daughter of Resident E was at the facility earlier in the day and reported that Resident E alleged that a staff member hit him over the head. The ED indicated she then reported the incident to the State agency and they were in the process of investigating the allegation. The ED indicated there were three staff members who fit the description Resident E provided in the allegation. RN # 5 was interviewed on 11/23/2015 at 3:42 p.m. She indicated she worked on 11/22/2015 from 2:00 p.m. to 10:00 p.m. RN # 5 indicated the resident complained of a headache and was nauseated .restless .talking out of his head .not acting right. RN # 5 indicated Resident E was transferred to the Emergency Department for evaluation and treatment at the family's request. On 11/23/2015 at 5:05 p.m., the ED and RNC indicated they had not suspended any staff members pending completion of the investigation, but were collecting statements from all staff who worked on or around the date of the alleged incident prior to them returning to work. On 11/24/2015 at 2:02 p.m. the ED indicated she interviewed LPN # 3 earlier in the day, who indicated Resident E's wife reported to (LPN # 3) on 11/20/2015 that Resident B reported a staff member hit him in the head. The ED indicated LPN # 3 reported to her that she checked him over and he was fine .She didn't think anyone would do that. The ED further indicated she interviewed Certified Nursing Assistant (CNA) # 6, who worked the night shift on 11/21/2015, earlier in the day. The ED indicated CNA # 6 reported to her that Resident B's wife came in to the facility at approximately 3:00 a.m. (11/22/2015) following Resident B's discharge (the evening of 11/21/2015) to remove his personal items from his room and reported to CNA # 6 that her husband reported to her that someone or something green hit him in the head. The CNA indicated to the ED that the only green object in the resident's room was a green water pitcher. The ED and RNC indicated no staff had been suspended and the investigation was in progress. A typed statement, dated 11/23/2015, was provided by the ED on 11/24/2015 at 2:02 p.m. The document indicated, 11/23/15. At approximately 9:00 a.m. (Resident E's wife and daughter) came in to talk to (DHS). Family stated that (Resident E) had a subdural hematoma Daughter stated that (Resident E) has made the same accusation two times at the hospital about something green hitting him in the head after he received his medicine. Daughter stated the description of the staff member was a Short Blond Stalky (sic) girl on nights (shift) A typed statement, dated 11/24/2015, was provided by the ED on 11/24/2015 at 2:02 p.m. The document indicated, .12:50 p.m. Writer (ED) spoke with (CNA # 6) on phone, whom (sic) worked Friday (11/20/2015) and Saturday (11/21/2015) .(CNA # 6) stated that when the wife came back in around 3 a.m. and told (CNA # 6) that (Resident E) stated at the hospital that someone or something hit him in the head that was green. (CNA # 6) went into the room and the only thing that was green was his water picture (sic) that he had been drinking out of. It was still full of water. A typed statement, dated 11/24/2015, was provided by the Executive Director (ED) on 11/24/2015 at 2:02 p.m. The document indicated, Writer (ED) interviewed (LPN # 2) at 1:15 p.m. regarding working last Friday (11/20/2015) with (Resident E) (LPN # 2/Unit Manager) stated the wife (of Resident E) stated that (Resident E) was making a comment about a man hitting him in the head with something green. (LPN # 2) questioned wife if (Resident E) was confused and wife told her he did not seem to be. Wife asked (LPN # 2) if she thought anyone would hit him. (LPN #2) stated no to the wife and stated that nothing had been reported A typed statement, dated 11/24/2015, was provided by the ED on 11/24/2015 at 4:35 p.m. The document indicated, 11/24/15 - SW (Social Work) called (LPN # 3) into the office (LPN # 3) recounted an interaction between a res (Resident E's) wife and her. (LPN # 3) stated she spoke to wife last week poss (possibly) Friday. Wife approached her and said 'he (res) said he remembers someone hitting him last night in the head w/ (with) something green.' Res wife asked, 'Do you think someone would do that?' (LPN # 3) replied No, of course not LPN # 3 was interviewed on 11/24/2015 at 5:07 p.m. She indicated she was the charge nurse on Tanner (200) hall. She indicated, I'm pretty sure it (wife reporting incident to her) was Friday (11/20/2015) .I don't know exactly. It was definitely between eight thirty and ten a.m. I was in the middle of med (medication) pass. (Resident E's wife) approached me and said somebody hit him over the head with something green .a green object .something like that .he mentioned sometime in the night .he could have been dreaming .some man may have hit him with a green object. LPN # 3 indicated she asked Resident E's wife if he was hurt and his wife indicated, He doesn't have any marks on him. LPN # 3 indicated, I went back to my med pass and forgot it .I didn't (assess him). I know I should have. CNA # 8 was interviewed on 11/24/2015 at 9:55 p.m. The CNA indicated, I don't know (regarding time frame for reporting abuse). I know they (named ED and DHS) usually leave after dinner, so probably before dinner. CNA # 6 was interviewed on 11/24/2015 at 9:59 p.m. The CNA indicated she worked night shift on 11/21/2015. Resident E's wife came back after he was discharged to collect his belongings. The CNA indicated, That was the time she kept saying something hit his head No I didn't (report) because he was already sent out and he was kind of not making sense. CNA # 6 indicated Resident E's change in mental status was sudden and he was normally with it. The current Abuse and Neglect Procedural Guidelines Policy and Procedure was provided by the Executive Director on 11/20/2015 at 2:00 p.m. The procedure indicated, .3. Definitions: .c. Physical Abuse - includes hitting, slapping, pinching, spitting, holding or handling roughly, etc .ii. Staff to resident abuse with or without injury .e. Protection: .i. Upon identification of suspected abuse or neglect, immediately provide for the safety of the resident .iv. Suspend suspected employee(s) pending outcome of investigation The current Accident and Incident Reporting Guidelines Policy and Procedure, provided by the ED on 11/24/2015 at 2:02 p.m., indicated, Procedure: 1. All .allegations of abuse .shall be reported to the department supervisor as soon as it is discovered or when information of occurrence is learned .3. The assigned nurse or nursing supervisor shall complete an assessment and provide medical interventions as warranted. 4. Reporting of .abuse to state and federal agencies shall be in compliance in accordance with agency guidelines .6. The assigned nurse or nursing supervisor shall: a. Examine all accident, incident or abused victims. b. Notify the attending physician or medical director of the occurrence .7. Investigative action shall be initiated by the attending nurse and/or nursing supervisor The Immediate Jeopardy that began on November 20, 2015 was removed on November 25, 2015 when through observation, interview and record review, the facility began inservicing staff and completing head-to-toe assessments on all non-interviewable residents in the facility. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of on-going monitoring and assessment, and because not all staff had been inserviced. This Federal tag relates to complaint IN 417. 3.1-28(c) 3.1-28(d)

Based on observation, interview and record review, the facility failed to ensure written policies and procedures prohibiting the mistreatment, neglect and abuse of residents were implemented after an alleged incident of physical abuse was reported to staff for 1 of 6 residents reviewed for abuse. (Resident E) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/20/2015 between 8:30 a.m. and 10:00 a.m. when a staff nurse was notified by Resident E's spouse of an alleged incident of physical abuse. The Executive Director and Regional Nurse Consultant were notified of the Immediate Jeopardy on 11/24/2015 at 5:45 p.m. The Immediate Jeopardy was removed on 11/25/2015 at 4:37 p.m., but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: Resident E's daughter was interviewed on 11/23/2015 at 2:36 p.m. She indicated she visited the resident in the evening on 11/21/2015. She indicated, He was admitted (to the hospital) with a subdural hematoma .(Resident E) said (in the hospital), 'A nurse came in (at the facility) and was going to give me a cup full of medicine .she had something green in her hand and hit me in the head. I remember the pain being so bad I seen (sic) a light. I think she wants to do me in .He (Resident E) was worried they were mad after my mom (Resident E's wife) had talked to (State Surveyor the day before).' He said it (staff who struck him) was the heavy set one with blonde hair .He couldn't give specifics on time Resident E's daughter indicated she notified the Director of Health Services (DHS) of the allegations earlier in that morning. On 11/23/2015 at 3:30 p.m., the Executive Director (ED) and Regional Nurse Consultant (RNC) indicated the daughter of Resident E was at the facility earlier in the day and reported that Resident E alleged that a staff member hit him over the head. The ED indicated at that time, she reported the incident to the State agency and they were in the process of investigating the allegation. The ED indicated there were three staff members who fit the description Resident E provided in the allegation. RN # 5 was interviewed on 11/23/2015 at 3:42 p.m. She indicated she worked on 11/22/2015 from 2:00 p.m. to 10:00 p.m. RN # 5 indicated the resident complained of a headache and was nauseated .restless .talking out of his head .not acting right. RN # 5 indicated Resident E was transferred to the Emergency Department for evaluation and treatment at the family's request. On 11/23/2015 at 5:05 p.m., the ED and RNC indicated they had not suspended any staff members pending completion of the investigation, but were collecting statements from all staff who worked on or around the date of the alleged incident prior to them returning to work. On 11/24/2015 at 2:02 p.m. the ED indicated she interviewed LPN # 3 earlier in the day, who indicated Resident E's wife reported to (LPN # 3) on 11/20/2015 that Resident E reported a staff member hit him in the head. The ED indicated LPN # 3 reported to her that she checked him over and he was fine .She didn't think anyone would do that. The ED further indicated she interviewed Certified Nursing Assistant (CNA) # 6, who worked the night shift on 11/21/2015, earlier in the day. The ED indicated CNA # 6 reported to her that Resident E's wife came in to the facility at approximately 3:00 a.m. (11/22/2015) following Resident E's discharge (the evening of 11/21/2015) to remove his personal items from his room and reported to CNA # 6 that her husband reported to her that someone or something green hit him in the head. The CNA indicated to the ED that the only green object in the resident's room was a green water pitcher. The ED and RNC indicated no staff had been suspended and the investigation was in progress. A typed statement, dated 11/23/2015, was provided by the ED on 11/24/2015 at 2:02 p.m. The document indicated, 11/23/15. At approximately 9:00 a.m. (Resident E's wife and daughter) came in to talk to (DHS). Family stated that (Resident E) had a subdural hematoma Daughter stated that (Resident E) has made the same accusation two times at the hospital about something green hitting him in the head after he received his medicine. Daughter stated the description of the staff member was a Short Blond Stalky (sic) girl on nights (shift) A typed statement, dated 11/24/2015, was provided by the ED on 11/24/2015 at 2:02 p.m. The document indicated, .12:50 p.m. Writer (ED) spoke with (CNA # 6) on phone, whom (sic) worked Friday (11/20/2015) and Saturday (11/21/2015) .(CNA # 6) stated that when the wife came back in around 3 a.m. and told (CNA # 6) that (Resident E) stated at the hospital that someone or something hit him in the head that was green. (CNA # 6) went into the room and the only thing that was green was his water picture (sic) that he had been drinking out of. It was still full of water. A typed statement, dated 11/24/2015, was provided by the Executive Director (ED) on 11/24/2015 at 2:02 p.m. The document indicated, Writer (ED) interviewed (LPN # 2) at 1:15 p.m. regarding working last Friday (11/20/2015) with (Resident E) (LPN # 2/Unit Manager) stated the wife (of Resident E) stated that (Resident E) was making a comment about a man hitting him in the head with something green. (LPN # 2) questioned wife if (Resident E) was confused and wife told her he did not seem to be. Wife asked (LPN # 2) if she thought anyone would hit him. (LPN #2) stated no to the wife and stated that nothing had been reported A typed statement, dated 11/24/2015, was provided by the ED on 11/24/2015 at 4:35 p.m. The document indicated, 11/24/15 - SW (Social Work) called (LPN # 3) into the office (LPN # 3) recounted an interaction between a res (Resident E's) wife and her. (LPN # 3) stated she spoke to wife last week (poss (possibly) Friday. Wife approached her and said 'he (res) said he remembers someone hitting him last night in the head w/ (with) something green.' Res wife asked 'Do you think someone would do that?' (LPN # 3) replied No, of course not LPN # 3 was interviewed on 11/24/2015 at 5:07 p.m. She indicated she was the charge nurse on Tanner (200) hall. She indicated, I'm pretty sure it (wife reporting incident to her) was Friday (11/20/2015) .I don't know exactly. It was definitely between eight thirty and ten a.m I was in the middle of med (medication) pass. (Resident E's wife) approached me and said somebody hit him over the head with something green .a green object .something like that .he mentioned sometime in the night .he could have been dreaming .some man may have hit him with a green object. LPN # 3 indicated she asked Resident B's wife if he was hurt and his wife indicated, He doesn't have any marks on him. LPN # 3 indicated, I went back to my med pass and forgot it .I didn't (assess him). I know I should have. CNA # 8 was interviewed on 11/24/2015 at 9:55 p.m. The CNA indicated, I don't know (regarding time frame for reporting abuse). I know they (named ED and DHS) usually leave after dinner, so probably before dinner. CNA # 6 was interviewed on 11/24/2015 at 9:59 p.m. The CNA indicated she worked night shift on 11/21/2015. Resident E's wife came back after he was discharged to collect his belongings. The CNA indicated, That was the time she kept saying something hit his head No I didn't (report) because he was already sent out and he was kind of not making sense. CNA # 6 indicated Resident E's change in mental status was sudden and he was normally with it. The current Abuse and Neglect Procedural Guidelines Policy and Procedure was provided by the Executive Director on 11/20/2015 at 2:00 p.m. The procedure indicated, .3. Definitions: .c. Physical Abuse - includes hitting, slapping, pinching, spitting, holding or handling roughly, etc .ii. Staff to resident abuse with or without injury .e. Protection: .i. Upon identification of suspected abuse or neglect, immediately provide for the safety of the resident .iv. Suspend suspected employee(s) pending outcome of investigation The current Accident and Incident Reporting Guidelines Policy and Procedure, provided by the ED on 11/24/2015 at 2:02 p.m., indicated, Procedure: 1. All .allegations of abuse .shall be reported to the department supervisor as soon as it is discovered or when information of occurrence is learned .3. The assigned nurse or nursing supervisor shall complete an assessment and provide medical interventions as warranted. 4. Reporting of .abuse to state and federal agencies shall be in compliance in accordance with agency guidelines .6. The assigned nurse or nursing supervisor shall: a. Examine all accident, incident or abused victims. b. Notify the attending physician or medical director of the occurrence .7. Investigative action shall be initiated by the attending nurse and/or nursing supervisor The Immediate Jeopardy that began on November 20, 2015 was removed on November 25, 2015 when through observation, interview and record review, the facility began inservicing staff and completing head-to-toe assessments on all non-interviewable residents in the facility. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of on-going monitoring and assessment, and because not all staff had been inserviced. This Federal tag relates to complaint IN 417. 3.1-28(a)