Every finding on record at Sellersburg Healthcare Center

Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident C) Findings include:The clinical record for Resident C was reviewed on 7/27/26 at 11:19 a.m. The resident's diagnosis included, but was not limited to, chronic pain syndrome (a condition where body pain lasts longer than three to six months, causing extra problems such as severe tiredness, sad moods, and trouble sleeping).The incident report, dated 6/19/26, indicated one card of Oxycodone (narcotic pain medication) was delivered from pharmacy on 6/16/26 and found to be unaccounted for.The pharmacy packaging slip, dated 6/16/26, indicated 30 tablets of Oxycodone 15 mg (milligram), were delivered to the facility for Resident C and signed for by Licensed Practical Nurse (LPN) 7. LPN 7 no longer worked at the facility.The written interview statement, dated 6/19/26, indicated LPN 7 reported that she received medications from the pharmacy carrier on 6/19/26, opened the bag, signed the manifest and delivered the medication to LPN 5, who was in a room with a resident. LPN 5 told LPN 7 to sit the medications on the dresser. LPN 7 placed the medications on the dresser and informed LPN 5 that there were 6 different prescriptions for resident's. LPN 7 then went to the nurse's cart and signed (the controlled substance inventory tracker) that she had given the medications to LPN 5. The June 2026 controlled substance inventory tracker lacked documentation of Resident C's Oxycodone that was delivered on 6/16/26.During an interview, on 7/27/26 at 10:26 a.m., the Director of Nursing indicated on Friday, 6/19/26, LPN 8 had called the pharmacy to reorder the resident's Oxycodone because had only 8 tablets left. The pharmacy informed LPN 8 that 30 tablets of the Oxycodone had been delivered to the facility on 6/16/26. LPN 8 then reported the information and an investigation was started. The facility could not account for the missing medication.On 7/28/26 at 1:14 p.m., the Executive Director provided a current, undated copy of the document titled INDIANA Abuse & Neglect & Misappropriation of Property. It included, but was not limited to, Policy .It is policy of this facility to provide resident centered care .It is the intent of this facility to prevent .the misappropriation of their property This deficient practice was corrected on 6/21/26, prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan which included the following: All staff were educated on narcotic chain of custody resident abuse with an emphasis on misappropriation of property (6/19/26); medication cart audits were completed with no new findings (6/19/26); All alert and oriented residents were interviewed with no negative responses (6/19/26); Skin sweeps and pain assessments were completed on all residents with no negative findings (6/19/26); Staff interviews were completed with no negative findings (6/20/26); a 30 day look back was completed on all pharmacy receipts with no new findings (6/21/26). 410 IAC (Indiana Authorization Code 16.2-3.1-28(a)

Based on interview and record review, the facility failed to ensure a resident's admission evaluation assessment accurately reflected wounds present on admission (Resident C); failed to ensure documentation of wound care was completed (Resident C); and failed to ensure the administration of a resident's (Resident C) narcotic pain medication was documented on the medication administration record for 1 of 4 residents reviewed for medical records. Findings include:1.a. The clinical record for Resident C was reviewed on 4/16/26 at 10:03 a.m. The resident's diagnoses included, but were not limited to, morbid obesity, anxiety and depression.The hospital discharge records indicated Resident C had an area to the coccyx, left buttock and excoriation to the abdominal folds.The facility admission evaluation assessment, dated 2/17/26 at 11:40 p.m., indicated Resident C had no skin areas noted. The assessment was completed and signed by Registered Nurse (RN) 5.The progress note, dated 2/18/26 at 11:54 a.m., indicated the Interdisciplinary Team (IDR) skin assessment indicated the resident had non-blanchable areas to the sacrum, left buttock and excoriation to the abdominal folds.During an interview, on 4/17/26 at 10:17 a.m., RN 5 indicated when residents were admitted , the admitting nurse conducted a brief skin assessment. RN 5 could not recall the resident or if wounds were present on admission.On 4/20/26 at 3:20 p.m., the Director of Nursing provided a current, undated copy of the document titled admission Evaluation. It included, but was not limited to, Policy.It is the policy of this facility to provide resident centered care.A systemic evaluation is completed by a licensed nurse upon admission/readmission to assist in determining the most effective and appropriate care needs of each resident.1(b) The clinical record for Resident C was reviewed on 4/16/26 at 10:03 a.m. The resident's diagnoses included, but were not limited to, anxiety and depression.The progress note, dated 2/18/26 at 11:54 a.m., indicated the IDT skin assessment indicated the resident had a non-blanchable areas to the sacrum, left buttock and excoriation to the abdominal folds.The physician's order, dated 2/19/26, indicated staff were to apply Calmoseptine (a multipurpose, moisture barrier ointment designed to protect and heal skin irritation) to the deep tissue injury on the left buttock three times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m.The February 2026 treatment administration record lacked documentation of the treatment completion on 2/21/26 at 2:00 p.m. and on 2/27/26 at 10:00 p.m.The physician's order, dated 2/19/26, indicated staff were to cleanse the resident's sacral wound with wound cleanser/normal saline, apply medical grade honey to the base of the wound and cover with a silicone bordered gauze three times a day a6 6:00 a.m., 2:00 p.m. and 10:00 p.m.The February 2026 treatment record lacked documentation of treatment completion on 2/21/26 at 2:00 p.m.The physician's order, dated 2/19/26, indicated the resident was to receive Oxycodone-Acetaminophen (narcotic pain medication) 10-325 mg (milligrams) every 4 hours as needed for pain.Review of the February 2026 and March 2026 controlled substance administration record indicated the resident received the medication on the following dates and times: 2/21/26 at 6:30 p.m.; 2/22/26 at 8:45 a.m.; 2/23/26 at 8:00 a.m., 12:00 p.m. and 4:00 p.m.; 2/24/26 at 2:00 a.m., 8:00 a.m. and 4:00 p.m.; 2/25/26 at 12:00 p.m. and 4:00 p.m.; 2/26/26 at 4:30 p.m. and 9:00 p.m.; 2/27/26 at 9:00 p.m.; 2/28/26 at 9:00 a.m.; 3/01/26 at 9:00 p.m.; 3/04/26 at 8:00 a.m., 4:00 p.m. and 8:00 p.m.; 3/05/26 at 12:00 a.m., 4:00 a.m., 12:00 p.m. and 4:00 p.m.; 3/06/26 at 8:00 p.m.; 3/07/26 at 5:00 a.m., 1:00 p.m. and 8:00 p.m.; 3/08/26 at 12:00 a.m., 4:00 a.m. and 8:00 p.m.; 3/09/26 at 12:00 a.m. and 4:00 a.m.; and 3/13/26 at 3:00 p.m.The February 2026 and March 2026 lacked documentation of the administration of the resident's narcotic pain medication listed above.During an interview, on 4/20/26 at 1:58 p.m., LPN 8 indicated when treatments were completed, the nurse that completed the treatment would initial the treatment administration record. When as needed (PRN) narcotic pain medication was administered, the medication would be signed out on the controlled substance administration record and on the medication administration record.On 4/20/26 at 3:20 p.m., the Director of Nursing provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Definitions.Medication Administration Record - the legal documentation for medication administration.Policy.It is the policy of this facility to provide resident centered care.Procedure.Medications will be charted when given.PRN medications will have a reason documented for giving and the effectiveness of the drug.Documentation will be current for medication administration. This Citation relates to Intakes 2972337 and 2977221 410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure medication carts were locked, while unattended, for 2 of 6 medication carts. Findings include:During an observation, on 4/17/26 between 1:14 p.m. and 1:18 p.m., the medication cart for the 100 Hall was observed to be unlocked and unattended. During an observation, on 4/17/26 at 1:20 p.m., the medication cart on the 300 Hall was observed to be unlocked and unattended. During an interview, on 4/17/26 at 1:22 p.m., Licensed Practical Nurse (LPN) 4 indicated the medication carts should be locked while unattended. On 4/17/26 at 2:07 p.m., the Director of Nursing provided a current copy of the document titled Storage of Medications dated 9/2025. It included, but was not limited to, Policy.Medications.are stored safely, securely, and properly.Medication.carts.are locked when not attended. 410 IAC (Indiana Authorization Code) 16.2-3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure insulin flexpens were monitored for expiration dates for 4 of 33 insulin pens reviewed. (Residents 21, 24, 112, and 94), failed to ensure the pharmacy label and open date were on eye drops for 1 of 1 resident reviewed. (Resident 56) and failed to ensure documentation on the Controlled Substance Administration Record of administered narcotics for 2 of 33 residents reviewed for medication storage. (Residents 9 and 96) Findings include:1. During an observation on 12/10/25 at 1:32 p.m., Resident 21's Glargine flexpen had an open date of 11/4/25. The handwritten expiration date indicated 12/3/25. The record for Resident 21 was reviewed on 12/10/25 at 2:15 p.m. The resident's diagnoses included, but was not limited to, type 2 diabetes mellitus and dementia. The care plan, dated 8/15/23 and revised 7/16/25, indicated the resident had diabetes. The interventions, dated 8/15/23, included, but were not limited to, administer insulin injections per orders and rotate injection sites. The physician's order, dated 7/31/25, indicated staff were to administer the resident 15 units of Glargine subcutaneously at bedtime for type 2 diabetes mellitus. The resident's blood sugar readings indicated the following: On 12/4/25 at 9:20 p.m., the resident's blood sugar reading was of 159 milligrams per deciliter (mg/dL). On 12/5/25 at 10:28 p.m., the resident's blood sugar reading was 300 mg/dL. On 12/6/25 at 4:23 p.m., the resident's blood sugar reading was 123 mg/dL. On 12/7/25 at 8:31 p.m., the resident's blood sugar reading was 175 mg/dL. On 12/8/25 at 8:45 p.m., the resident's blood sugar reading was 145 mg/dL. On 12/9/25 at 5:58 p.m., the resident's blood sugar reading was 137 mg/dL. The December 2025 Medication Administration Record (MAR) indicated the resident received Glargine daily at bedtime from 12/4/25 to 12/9/25. The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. The resident received insulin in the last 7 days before the assessment. 2. During an observation on 12/10/25 at 1:34 p.m., Resident 24's Humalog (fast acting insulin) flexpen was opened on 11/5/25. The handwritten expiration date indicated 11/21/25. The record for Resident 24 was reviewed on 12/10/25 at 2:25 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus and mild cognitive impairment. The physician's order, dated 6/20/25, indicated to administer Lispro (Humalog) insulin per sliding scale: if 151 to 200 mg/dL give 2 units; 201 to 250 mg/dL give 4 units; 251 to 300 mg/dL give 6 units; 301 to 350 mg/dL give 8 units; 351 to 400 mg/dL give 10 units. Call the physician if the blood sugar was less than 70 or greater than 400 mg/dL, subcutaneously before meals and at bedtime for diabetes. The insulin was discontinued on 12/10/25. The care plan, dated 7/3/24 and revised 12/11/25, indicated the resident had diabetes. The interventions, dated 7/3/24, included, but was not limited to, administer insulin injections per orders, and rotate the injection sites, obtain blood sugars per orders, report abnormal findings to medical provider, resident or resident representative. The November 2025 MAR indicated the resident received Humalog daily per sliding scale from 11/22/25 to 11/30/25. The December 2025 MAR indicated the resident received Humalog daily per sliding scale from 12/1/25 to 12/9/25. The Quarterly MDS assessment, dated 12/8/25, indicated the resident was severely cognitively impaired. The resident received insulin in the last 7 days before the assessment. The blood sugar readings indicated the following: On 11/22/25 at 5:02 p.m., the resident's blood sugar reading was 83 mg/dL. On 11/23/25 at 9:02 p.m., the resident's blood sugar reading was 132 mg/dL. On 11/24/25 at 11:55 p.m., the resident's blood sugar reading was 183 mg/dL. On 11/25/25 at 8:09 p.m., the resident's blood sugar reading was 165 mg/dL. On 11/26/25 at 9:11 p.m., the resident's blood sugar reading was 107 mg/dL. On 11/27/25 at 4:24 p.m., the resident's blood sugar reading was 118 mg/dL. On 11/28/25 at 8:44 p.m., the resident's blood sugar reading was 87 mg/dL. On 11/29/25 at 11:45 p.m., the resident's blood sugar reading was 82 mg/dL. On 11/30/25 at 9:22 p.m., the resident's blood sugar reading was 126 mg/dL. On 12/1/25 at 9:04 p.m., the resident's blood sugar reading was 112 mg/dL. On 12/2/25 at 9:51 p.m., the resident's blood sugar reading was 129 mg/dL. On 12/3/25 at 8:23 p.m., the resident's blood sugar reading was 97 mg/dL. On 12/4/25 at 9:19 p.m., the resident's blood sugar reading was 126 mg/dL. On 12/5/25 at 10:31 p.m., the resident's blood sugar reading was 172 mg/dL. On 12/6/25 at 3:17 p.m., the resident's blood sugar reading was 180 mg/dL. On 12/7/25 at 8:37 p.m., the resident's blood sugar reading was 115 mg/dL. On 12/8/25 at 9:15 p.m., the resident's blood sugar reading was 232 mg/dL. On 12/9/25 at 4:47 p.m., the resident's blood sugar reading was 107 mg/dL. 3. During an observation on 12/10/25 at 1:34 p.m., Resident 112's Glargine flexpen was opened on 11/5/25. The handwritten expiration date indicated 11/21/25. The record for Resident 24 was reviewed on 12/10/25 at 2:25 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus and mild cognitive impairment. The care plan, dated 10/7/25, indicated the resident had diabetes. The interventions, dated 7/3/24, included, but were not limited to, administer insulin injections per orders, and rotate the injection sites, obtain blood sugars per orders, report abnormal findings to medical provider, resident or resident representative. The physician's order, dated 11/6/25 and revised to 11/5/25, indicated staff were to administer the resident's 12 units subcutaneously of Glargine every morning for diabetes mellitus. The admission MDS Assessment, dated 11/12/25, indicated the resident was severely cognitively impaired. The resident received insulin in the last 7 days before the assessment. The physician's order, dated 12/1/25, indicated to administer 8 units subcutaneously of Glargine in the evening for diabetes mellitus. The November 2025 MAR indicated the resident received Glargine daily at bedtime from 11/22/25 to 11/30/25. The December 2025 MAR indicated the resident received Glargine daily in the evening from 12/1/25 to 12/9/25. The resident's blood sugar readings indicated the following: On 11/22/25 at 5:02 p.m., the resident's blood sugar reading was 83 mg/dL. On 11/23/25 at 9:02 p.m., the resident's blood sugar reading was 132 mg/dL. On 11/24/25 at 11:55 p.m., the resident's blood sugar reading was 183 mg/dL. On 11/25/25 at 8:09 p.m., the resident's blood sugar reading was 165 mg/dL. On 11/26/25 at 9:11 p.m., the resident's blood sugar reading was 107 mg/dL. On 11/27/25 at 4:24 p.m., the resident's blood sugar reading was 118 mg/dL. On 11/28/25 at 8:44 p.m., the resident's blood sugar reading was 87 mg/dL. On 11/29/25 at 11:45 p.m., the resident's blood sugar reading was 82 mg/dL. On 11/30/25 at 9:22 p.m., the resident's blood sugar reading was 126 mg/dL. On 12/1/25 at 9:04 p.m., the resident's blood sugar reading was 112 mg/dL. On 12/2/25 at 9:51 p.m., the resident's blood sugar reading was 129 mg/dL. On 12/3/25 at 8:23 p.m., the resident's blood sugar reading was 97 mg/dL. On 12/4/25 at 9:19 p.m., the resident's blood sugar reading was 126 mg/dL. On 12/5/25 at 10:31 p.m., the resident's blood sugar reading was 172 mg/dL. On 12/6/25 at 3:17 p.m., the resident's blood sugar reading was 180 mg/dL. On 12/7/25 at 8:37 p.m., the resident's blood sugar reading was 115 mg/dL. On 12/8/25 at 9:15 p.m., the resident's blood sugar reading was 232 mg/dL. On 12/9/25 at 4:47 p.m., the resident's blood sugar reading was 107 mg/dL. 4. During an observation on 12/10/25 at 1:36 p.m., Resident 94's Glargine flexpen was opened on 11/9/25. The handwritten expiration date indicated 12/9/25. The record for Resident 94 was reviewed on 12/15/25 at 10:26 a.m., The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy and end stage renal disease. The care plan, dated 4/21/25 and revised 7/28/25, indicated the resident had diabetes with retinopathy and neuropathy. The interventions, dated 4/21/25 and revised 7/28/25, included, but were not limited to, administer insulin injections per orders. Rotate the injection sites. observe for signs and symptoms of hyperglycemia, observe for signs and symptoms of hypoglycemia. Obtain and monitor lab work and diagnostic studies, as ordered. Report abnormal findings to the medical provider, resident or resident representative. The nurse's note, dated 9/8/25 at 10:11 p.m., indicated a new physician's order was received to discontinue the 12 units subcutaneously of Glargine and start 8 units subcutaneously of Glargine two times daily for diabetes mellitus. The Quarterly MDS assessment, dated 11/5/25, indicated the resident was cognitively intact. The resident received insulin in the last 7 days before the assessment. The physician's order, dated 12/3/25, indicated to administer 8 units of Glargine subcutaneously two times daily for diabetes. The December 2025 MAR indicated the resident received 12/10/25. The resident's blood sugar on 12/10/25 at indicated the blood sugar reading was as followed: On 10/31/25 at 5:23 p.m., the resident's blood sugar reading was 116 mg/dL. On 11/2/25 at 9:51 a.m., the resident's blood sugar reading was 148 mg/dL. On 11/2/25 at 4:53 p.m., the resident's blood sugar reading was 131 mg/dL. On 11/3/25 at 5:13 p.m., the resident's blood sugar reading was 142 mg/dL. On 11/4/25 at 9:53 a.m., the resident's blood sugar reading was 93 mg/dL. On 11/4/25 at 4:28 p.m., the resident's blood sugar reading was 117 mg/dL. On 11/12/25 at 8:28 p.m., the resident's blood sugar reading was 179 mg/dL. On 11/13/25 at 9:45 a.m., the resident's blood sugar reading was 131 mg/dL. On 11/13/25 at 8:34 p.m., the resident's blood sugar reading was 151 mg/dL. On 11/14/25 at 10:37 a.m., the resident's blood sugar reading was 115 mg/dL. On 11/15/25 at 9:30 a.m., the resident's blood sugar reading was 162 mg/dL. On 11/16/25 at 10:34 a.m., the resident's blood sugar reading was 155 mg/dL. On 11/16/25 at 9:13 p.m., the resident's blood sugar reading was 141 mg/dL. On 11/17/25 at 8:51 a.m., the resident's blood sugar reading was 188 mg/dL. On 11/17/25 at 8:11 p.m., the resident's blood sugar reading was 181 mg/dL. On 11/18/25 at 10:51 a.m., the resident's blood sugar reading was 120 mg/dL. On 11/19/25 at 11:08 a.m., the resident's blood sugar reading was 121 mg/dL. On 11/19/25 at 8:50 p.m., the resident's blood sugar reading was 199 mg/dL. On 11/20/25 at 10:43 a.m., the resident's blood sugar reading was 122 mg/dL. On 11/20/25 at 8:14 p.m., the resident's blood sugar reading was 192 mg/dL. On 11/22/25 at 11:07 a.m., the resident's blood sugar reading was 192 mg/dL. On 11/23/25 at 10:36 a.m., the resident's blood sugar reading was 103 mg/dL. On 11/23/25 at 9:04 p.m., the resident's blood sugar reading was 164 mg/dL On 11/24/25 at 7:51 a.m., the resident's blood sugar reading was 130 mg/dL. On 11/25/25 at 8:35 p.m., the resident's blood sugar reading was 223 mg/dL. On 11/27/25 at 11:00 a.m., the resident's blood sugar reading was 179 mg/dL. On 11/30/25 at 9:24 p.m., the resident's blood sugar reading was 265 mg/dL. On 12/1/25 at 8:07 a.m., the resident's blood sugar reading was 167 mg/dL. On 12/2/25 at 9:31 p.m., the resident's blood sugar reading was 132 mg/dL. 5. During an observation on 12/10/25 at 1:37 p.m., Resident 56's Latanoprost eye drops had no label with the physician's order, pharmacy information, or open date on the bottle. There was no box available for the eye drops. The eye drops can be used for 42 days after opening. During an interview on 12/10/25 at 1:56 p.m., RN 9 indicated she should verify the order for the eye drops, note the expiration date, check the resident information, and check the Medication Administration Record. She indicated she just threw away the eye drop bottle due to not having the physician's order with the eye drop bottle. The record for Resident 56 was reviewed on 12/15/25 at 8:35 a.m. The resident's diagnoses included, but were not limited to, seasonal allergic rhinitis and hypertension. The physician's order, dated 3/5/24, indicated staff were to administer the resident 1 drop of Latanoprost in both eyes at bedtime for dry eyes. The care plan, dated 3/17/24 and revised 3/27/25, indicated the resident had hypertension and hyperlipidemia. The interventions, dated 3/17/24, included, but were not limited to, Administer medications per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, the resident and resident representative. Observe for signs or symptoms of elevated blood pressure. Report any abnormal findings to the medical provider, the resident or resident representative. Obtain and monitor lab work and diagnostic studies, as ordered. Report abnormal findings to the medical provider, the resident or resident representative. The November 2025 MAR indicated the resident received Latanoprost eye drops between 11/1/25 and 11/30/25. The Quarterly MDS assessment, dated 11/5/25, indicated the resident was moderately cognitively impaired. The December 2025 MAR indicated the resident received Latanoprost eye drops 12/1/25 and 12/9/25 During an interview on 12/10/25 at 1:37 p.m., RN 10 indicated she should check the expiration dates on medication before administering it. She never signed out medications until she administered them. 6. The record for Resident 9 was reviewed on 12/10/25 at 12:30 p.m., the resident's diagnoses included but were not limited to, surgical aftercare following surgery on the digestive system, and diverticulitis of the intestine with perforation abscess. The physician's order, dated 12/3/25 at 2:00 p.m., indicated the resident was to receive oxycodone HCl (hydrochloride) oral tablet 5 mg. Give 1 tablet every 4 hours for chronic pain. The care plan, dated 8/19/25, indicated the resident had complaints of acute and chronic pain. The interventions included, but were not limited to, administer non-pharmacological interventions and evaluate the effectiveness of the interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery), complete a pain assessment on admission / re-admission, quarterly, significant change, and as needed, (PRN) follow the physician orders for complaint of pain, and notify the medical provider, and the resident representative if interventions are unsuccessful. The admission MDS assessment, dated, 9/17/25 indicated the resident was cognitively intact. During an observation on the 100 unit, on 12/10/25 at 11:30 a.m., Licensed Practical Nurse 11 (LPN) was observed bringing a pain pill into Resident 9. She indicated here is your pain pill I forgot to give it to you. The resident was to receive a Hydrocodone 5 milligram (mg) every 4 hours for chronic pain at 10:00 a.m. During the Narcotic count on 12/10/25 at 12:30 p.m., the nurse had signed out the oxycodone HCI 5 mg at 10:00 a.m. as given. 7. The record for Resident 96 was reviewed on 12/10/25 at 1:00 p.m. The diagnoses included but were not limited to, anoxic brain damage, acute respiratory failure with hypoxia, dependence of a ventilator, tracheostomy, and anxiety. The physician order, dated 11/26/25, indicated diazepam 10 mg, give 2 tablets via her gastrostomy tube 2 times a day for anxiety. The care plan, dated 6/2/25 and revised on 10/14/25, indicated the resident was on anti-anxiety medication related to anxiety. The interventions included, but were not limited to, maintain a consistent daily routine, when possible, observe for side effects of the medication, and provide anti-anxiety medication per medical provider's orders. The review of the Quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired. During a narcotic count, on 12/10/25 at 1:30 p.m., on the 400 unit the count indicated for Resident 96 had 16 Diazepam 10 mg left on the card. The narcotic sign out sheet indicated the resident had 14 Diazepam 10 mg left. LPN 12 had signed out 2 Diazepam 10 mg as given to the resident at 8:00 a.m. The LPN indicated she signed out the medication on the narcotic sign out record and she forgot to give the medication. During an interview, on 12/16/25 at 8:37 a.m., the Regional Director of Clinical Operations (RDCO) indicated the narcotics should be signed out when the nurse pulled the narcotic out of the lock box and ready to give the medication. During an interview, on 12/16/25 at 9:00 a.m., LPN 13 indicated when giving a narcotic medication she would sign out the narcotic when she pulled the medication from the narcotic box. A narcotic should not be signed out until the medication was removed and time given. The current Medication Administration policy included, but was not limited to, .z. Do not administer medication of the label is not legible or missing aa. For medications that expire, label the date opened on the label (insulin, irrigation solutions etc.) ee. Narcotics will be signed out when given ff. Medications will be administered within the time frame of one hour before up to one hour after time ordered . 3.1-25(b)(1)(c) 3.1-25(n) 3.1-25(0)

Based on record review and interview, the facility failed to ensure residents received a minimum of a shower or bed bath twice weekly. This deficient practice affected 2 of 99 residents reviewed for Activities of Daily Living (ADLs). (Residents 2 and 14).Findings include During the Resident Council meeting, on 12/11/25 at 2:30 p.m.,. with 8 residents, which the Activities Director indicated were alert and oriented, several residents indicated they were not getting their showers twice weekly according to the shower schedules. No explanations were given by the Certified Nurse Aides (CNAs) or they were told the residents the next shift or the next day, a shower would be given. The residents indicated this was not happening.1.The record for Resident 2 was reviewed on 12/11/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), paranoid schizophrenia, major depressive disorder, anxiety disorder, drug induced subacute dyskinesia, chronic pain, and mild neurocognitive disorder due to known physiological condition without behavioral disturbance.The Quarterly Minimum Data Set (MDS) assessment, dated 12/1/25, indicated the resident had moderate cognitive impairment with long and short term memory issues, had no behavioral issues, and required partial to moderate assistance with showering.A care plan, dated 1/20/23 with a revision date of 12/3/25, indicated the resident had a problem with a decline in her ADLs due to COPD with schizophrenia and dyskinesia. The goal was for the resident to be without a decline in Range of Motion (ROM). The approaches included, but were not limited to, required partial to moderate assistance with showering or bathing self; and required partial to moderate assistance with tub or shower transfers.A review of the shower sheets, from 9/15/25 through 12/8/25, indicated the following days had no check off as to whether the resident received a shower or not: 9/15/25, 9/22/25, 9/29/25, 10/9/25, 10/13/25, 10/16/25, 10/20/25, 10/23/25, 10/30/25, 11/3/25, 11/10/25, 11/17/25, 11/20/25, 11/24/25, 12/1/25, 12/4/25, and 12/18/25.During an interview with the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO), on 12/15/25 at 8:15 a.m., the DON indicated that if the CNAs signed their name to the section on skin checks, then the resident received a shower. Even if they did not check off on the sheet whether the resident received a shower, it was assumed a shower was given. The CNAs were required to let the nurses know if a resident refused a shower as the nurse would need to evaluate the resident as to why he/she refused a shower. The nurse would then sign the shower sheet, which indicated she reviewed the resident and documented the refusal in the clinical record. Review of the resident's record, from 9/1/25 through 12/10/25, indicated the documentation was lacking as to whether the resident refused a shower or bed bath.During an interview with Resident 2, on 12/11/25 at 10:28 a.m., she indicated she was not always getting her showers as scheduled. She did not know why they frequently skipped her.2. During the Resident Council meeting on 12/11/25 at 2:30 p.m., Resident 14 indicated she frequently had to ask the CNAs if she was going to get her shower or not. Shower days were Sunday and Thursday. She indicated the CNA gave her a bed bath today instead.The record for Resident 14 was reviewed on 12/15/25 at 11:40 a.m. The resident's diagnoses included, but were not limited to, end stage renal disease (ESRD), bipolar disorder, and dependence on renal dialysis.The admission MDS assessment, dated 9/25/25, indicated the resident was alert and oriented but required cues to answer questions appropriately at times; had no mood or behavior issues; required substantial to maximum assistance for showers; required substantial to maximum assistance for bathing herself and showering; and required partial to moderate assistance for personal hygiene.A care plan, dated 9/18/25 with a revision date of 10/7/25, indicated the resident had an ADL self performance deficit due to impaired mobility, The goal was for the resident to improve her current level of function. The approaches included, but were not limited to, substantial to maximal assistance to bath and shower self, and required partial to moderate assistance for personal hygiene. The review of the shower sheets, from 9/21/25 through 12/7/25, indicated the following days had no check off as to whether the resident received a shower or not: 9/21/25, 9/28/25, 10/5/25, 10/9/25, 10/12/25, 10/16/25, 10/19/25, 10/23/25, 10/26/25, 10/30/25, 11/2/25, 11/4/25, 11/9/25, 11/13/25, 11/16/25, 11/20/25, 11/23/25, 11/27/25, 11/30/25, 12/4/25, and 12/7/25. Review of the record's progress notes, from 9/18/25 through 12/14/25 indicated there was no documentation of the resident having refused a bed bath or shower. During an interview, on 12/15/25 at 11:10 a.m., CNA 4 indicated the shower sheets were filled out checking Accept or Refusal whenever a resident received their showers. If the form was not marked as having a shower, then one would have to the resident and ask them. The shower days for the residents were hanging in the clean linen room. During an interview, on 12/15/25 at 11:15 a.m., CNA 5 indicated the shower sheets were marked as to whether the resident had a shower or refused. If they were not marked, then one would have to talk to the CNA who was caring for the resident or the resident themselves.During an interview, on 12/15/25 at 11:25 a.m., CNA 6 indicated the shower sheets were completed as Accept or Refusal and there was a shower list that was followed twice weekly for each resident. If it was not marked, then one would have to ask the resident if they received a shower that day.On 12/15/25 at 10:15 am, the RDCO presented a copy of the facility's current policy on Routine Resident Care. The policy included, but was not limited to, Procedure: 2. Provide routine care by a certified nursing assistant with specialized training in rehabilitation/restorative care under the supervision of a licensed nurse including but not limited to: .g. Assisting and teaching activities of daily living 3. Unlicensed staff: a. Provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse. b. Routine care by a nursing assistant includes but is not limited to the following: 3.1-38(a)(2)(A)3.1-38(b)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident with a history of Urinary Tract Infection (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 2 of 4 residents reviewed for bowel and bladder. (Residents 106 and 7)Findings include:1. During an observation, on 12/9/25 at 9:15 a.m., Resident 106 was lying in her bed. Resident 106's urinary catheter bag was 2/3 full of urine which was sitting on the floor. The tubing was also lying on the floor with yellow urine and sediment in the tubing. There was no barrier between the catheter and the floor.During an observation, 12/15/25 at 12:52 p.m., Resident 106 was lying in her bed on her back. The urinary catheter drainage system was sitting on the floor with 1/3 full of dark yellow urine. The tubing was also lying on the floor with dark yellow urine. The resident's bed had been lowered down as far as it could go. There was no barrier between the catheter and the floor.During an observation of incontinence care, on 12/11/25 at 11:18 a.m., for Resident 106 by Certified Nurse Aides (CNAs) 7 and 8. Both CNAs performed hand hygiene and PPE (personal protective equipment) was applied. The catheter bag was placed at the foot of the bed. The resident's brief was unfastened. CNA 8 used wipes and swiped the perineum front to back. She obtained a clean wipe and with 2 swipes down the tubing, she cleaned the tubing. The resident was turned onto her right side, and the rectal area was cleaned. CNA 8 indicated that they typically do not place briefs on the resident, however they were told by nursing to use the brief due to the catheter leaking a small amount. CNA 8 removed her gloves and used hand sanitizer. She applied fresh gloves. CNA 8 lifted the catheter bag to CNA 7 by lifting it above the resident's bladder and placed it on the left side of the bed. Urine was observed flowing up the tubing, toward the resident while it was lifted. The CNAs removed their PPE and performed hand hygiene.The record for Resident 106 was reviewed on 12/9/25 at 10:25 a.m. The resident's diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder, cerebral infarction, carrier of carbapenem-resistant acinetobacter baumannii, a need for assistance with personal care.The care plan, dated 6/10/24 and revised 8/4/25, indicated the resident had an indwelling catheter for neurogenic bladder. The interventions, dated 6/10/24, included, but were not limited to, provide catheter care every shift and as needed (PRN), monitor for pain, fever, chills, purulent drainage or other signs and symptoms of a urinary tract infection (UTI), change drainage bag, and ensure securement device in place.The care plan lacked documentation of any interventions related to placing a barrier between the catheter collection bag and the floor.A physician's order, dated 11/27/25, indicated the resident was to have an indwelling catheter #16 french with a 10 milliliter (ml) [NAME] for continuous drain due to the diagnosis of neurogenic bladder.A physician's order, dated 11/27/25, indicated the resident was to have indwelling catheter tubing using an anchoring device to prevent movement and urethral traction.A physician's order, dated 11/27/25, indicated the resident was to have indwelling urinary Catheters output to be measured and recorded every shift.A physician's order, dated 11/27/25, indicated the resident was to have indwelling urinary catheter care every shift and PRN with soap and water.A physician's order, dated 11/27/25, indicated the resident was to have the indwelling urinary catheter changed as needed once per day.A physician's order, dated 11/28/25, indicated the resident was prescribed Daptomycin 500 milligram (MG) (antibiotic) intravenously one time a day for UTI for a duration of 6 weeks.A physician's order, dated 11/28/25, indicated the resident was prescribed Ceftolozane-Tazobactam 1.5 (1-0.5) grams (antibiotic) intravenously every 8 hours for UTI for a duration of 6 weeks.An alert charting progress note, dated 11/28/25 at 9:32 a.m., indicated the resident was on intravenous (IV) antibiotics due to having a UTI.A physician's order, dated 12/5/25, indicated the resident was to be in enhanced barrier precautions due to medical devices and the resident' s history of carbapenem-resistant acinetobacter baumannii (CRAB) bacteria, Carbapenem-resistant Pseudomonas aeruginosa (CRPA) and Candida auris (C. auris).During an interview, on 12/16/25 at 8:34 a.m., the Regional Director of Clinical Operations indicated that there should be a barrier between a catheter collection bag and the floor.During an interview, on 12/16/25 at 9:30 a.m., the Infection Preventionist (IP) indicated that there was no reason that a catheter collection bag should be on the floor. The IP indicated that she had repeatedly told nursing staff to put a wash basin under the catheter collection bag if it was on the floor.2. During an observation, on 12/9/25 at 9:30 a.m., Resident 7 was lying in bed on her left side. The urinary catheter drainage system was sitting on the floor with the collection bag 1/2 full of urine. There was no barrier between the catheter and the floor. During an observation, on 12/9/25 at 1:55 p.m., Resident 7 was lying in bed on her right side. The urinary catheter drainage system was sitting on the floor with a minimal amount of urine in the collection bag. There was no barrier between the catheter and the floorThe record for Resident 7 was reviewed on 12/12/2025 at 10:42 a.m. The resident's diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, brain stem stroke syndrome, need for assistance with personal care, and locked-in state.The care plan, dated 2/27/25 and no revision, indicated the resident had an indwelling catheter due to having neurogenic bladder. The interventions, dated 2/27/25, included, but were not limited to, provide catheter care every shift and PRN, position catheter bag and tubing below the level of the bladder and provide privacy bag, secure catheter to the leg with security device, observe, record, report to the doctor signs of UTI, enhanced barrier precautions when providing care to urinary catheter, change catheter per physician order and PRN, and change drainage bag per physician order and PRN.The care plan lacked documentation of any interventions related to placing a barrier between the catheter collection bag and the floor.The Discharge Minimum Data Set (MDS) assessment, dated 11/14/25, indicated the resident was severely cognitively impaired. The resident has an indwelling foley catheterA physician's order, dated 12/5/25, indicated the resident was to have indwelling urinary catheter care every shift and PRN with soap and water. Secure straps to securement device and document output of urine every shift.A physician's order, dated 12/5/25, indicated the resident was to have an indwelling catheter #16 french with a 10 ml balloon for continuous drain due to the diagnosis of neurogenic bladder. The order also was written for the indwelling urinary catheter to be in a privacy bag.A physician's order, dated 12/5/25, indicated the resident was to have the indwelling urinary catheter changed as needed once per day.The urinalysis results, dated 12/8/25 and reported 12/9/25, indicated the urine had 2 plus blood, 3 plus leukocytes, 2.0-3.0 Urobilinogen, 1 plus protein, and 2 plus bacteria. The culture results indicated no growth. A physician's order, dated 12/9/25, indicated the resident was to be in enhanced barrier precautions due to medical devices and the resident's history of CRPA.A nurse's note, dated 12/9/25 at 1:58 p.m., indicated that an order by the facility nurse practitioner (NP) was for Rocephin 1 gm by intramuscular injection for three days (antibiotic), secure a peripheral intravenous placement and start normal saline IV fluids to run at 100 millimeters (ML) for 1 liter of fluids related to leukocytosis and fever. A nurse's note, dated 12/9/25 at 2:12 p.m., indicated that a 22 gauge (G) IV catheter was placed in the resident's hand. The IV Fluids were started at 100 ml/hr.A nurse's note, dated 12/9/25 at 5:24 p.m., indicated that the facility NP gave an order to contact the hospice company to evaluate and treat the resident.A nurse's note, dated 12/11/25 at 8:35 p.m., indicated that the resident was found without a pulse and was non-responsive. The resident was followed by hospice and was a do not resuscitate (DNR). The resident's status was verified by 2 nurses and the respiratory therapist. The Catheter Drainage Bag and Tube Maintenance policy was provided by the Regional Director of Clinical operations on 12/16/25 at 9:00 a.m. It included: It is the policy of this facility to provide resident care that meets the psychosocial, physical, and emotional needs and concerns of the residents.Procedure: Catheter Bags and tubing. I. Drainage bags will not be placed on the floor.3.1-41 (a) (1)

Based on interview and record review, the facility failed to ensure a blood pressure medication was held for a resident (Resident E) with blood pressure readings in the physician's ordered hold parameters for 1 of 4 residents reviewed for quality of care. Findings include: The clinical record for Resident E was reviewed on 6/24/25 at 2:40 p.m. The resident's diagnosis included, but was not limited to, hypotension. The physician's order, dated 5/27/25, indicated the resident was to receive Midodrine HCl (hydrochloride) 15 mg (milligrams) three times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. for hypotension. The medication was to be held if the resident's systolic blood pressure (SBP) was greater than 120. The June 2025 medication administration record indicated the resident's medication was administered when the resident's SBP was greater than 120 on the following dates and times: - On 6/24/25 at 2:00 p.m., the resident's Midodrine was administered with a SBP of 139. - On 6/15/25 at 2:00 p.m., the resident's Midodrine was administered with a SBP of 132. - On 6/20/25 at 2:00 p.m., the resident's Midodrine was administered with a SBP of 141. - On 6/20/25 at 10:00 p.m., the resident's Midodrine was administered with a SBP of 125. - On 6/21/25 at 10:00 p.m., the resident's Midodrine was administered with a SBP of 126. - On 6/22/25 at 2:00 p.m., the resident's Midodrine was administered with a SBP of 132. - On 6/22/25 at 10:00 p.m., the resident's Midodrine was administered with a SBP of 136. During an interview, on 6/24/25 at 2:58 p.m., Qualified Medication Aide 5 indicated if a resident's blood pressure was out of the physician's ordered hold parameters, then the medication should have been held. On 6/24/25 at 3:13 p.m., the Director of Nursing provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Policy .It is the policy of this facility to provided resident centered care .Procedure .Administer medication only as prescribed by the provider This Citation relates to Complaint IN00460759 3.1-37

Based on record review and interview, the facility failed to ensure insulin was administered as ordered by the physician on multiple days for 3 of 7 residents reviewed for pharmacy services. (Residents 207, 83, and 204) Findings include: 1. The record for Resident 207 was reviewed on 10/15/24 at 8:27 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy and foot ulcer, sepsis, and elevated white blood cell count. The physician's order, dated 9/20/24, indicated staff were to administer Humalog per sliding scale subcutaneously per before meals. Give 4 units for blood sugar readings of 151 - 200 mg/dL (milligrams per deciliter), 6 units for blood sugar readings of 201 - 250 mg/dL, 8 units for blood sugar readings of 251 - 300 mg/dL, 10 units for blood sugar readings of 301 - 350 mg/dL, and give 12 units for blood sugar readings greater than 350 mg/dL and call the physician or nurse practitioner. The physician's order, dated 9/20/24, indicated staff were to administer the resident's 35 units of Lantus SoloStar pen-injector, subcutaneously, two times a day for diabetes mellitus. The physicians' order, dated 9/20/24, indicated staff were to administer the resident's 20 units of Humalog subcutaneously with meals for diabetes mellitus. The care plan, dated 9/24/24, indicated the resident had diabetes with neuropathy and a diabetic ulcer. The interventions, dated 9/24/24, included, but were not limited to, administer insulin injections per orders and to rotate the injection sites. The resident's blood sugar readings ranged from 111 mg/dL on 9/25/24 to 399 mg/dL on 10/8/24. The September 2024 MAR (Medication Administration Record) indicated the following concerns for the twice daily, 35 units of Lantus SoloStar pen-injector: - The resident's Lantus was scheduled (due) on 9/21/24 at 8:00 p.m. The Lantus was administered on 9/21/24 at 10:55 p.m., by RN 13. - Due on 9/24/24 at 8:00 a.m., the Lantus was administered on 9/24/24 at 9:45 a.m., by RN 15. - Due on 9/25/24 at 8:00 p.m., the Lantus was administered on 9/26/24 at 12:13 a.m., by RN 16. - Due on 9/26/24 at 8:00 a.m., the Lantus was administered on 9/26/24 at 9:53 a.m., by LPN (Licensed Practical Nurse) 17. - Due on 9/26/24 at 8:00 p.m., the Lantus was administered on 9/26/24 at 9:34 p.m., by LPN 18. - Due on 9/27/24 at 8:00 a.m., the Lantus was administered on 9/27/24 at 12:37 p.m., by RN 19. - Due on 9/27/24 at 8:00 p.m., the Lantus was administered on 9/28/24 at 2:58 a.m., by LPN 20. - Due on 9/28/24 at 8:00 p.m., the Lantus was administered on 9/28/24 at 11:33 p.m., by LPN 20. - Due on 9/29/24 at 8:00 p.m., the Lantus was administered on 9/29/24 at 11:32 p.m., by RN 13. - Due on 9/30/24 at 8:00 a.m., the Lantus was administered on 9/30/24 at 9:31 a.m., by RN 14. - Due on 9/30/24 at 8:00 p.m., the Lantus was administered on 9/30/24 at 11:40 p.m., by LPN 20. The September 2024 MAR (Medication Administration Record) indicated the following concerns for the Humalog injection per sliding scale before meals: - The resident's Humalog was due on 9/21/24 at 7:00 a.m. The Humalog was administered on 9/21/24 at 8:24 a.m., by RN 21. - Due on 9/22/24 at 7:00 a.m., the Humalog was administered on 9/22/24 at 8:16 a.m. by RN 21. - Due on 9/24/24 at 7:00 a.m., the Humalog was administered on 9/24/24 at 9:43 a.m., by RN 15. - Due on 9/25/24 at 7:00 a.m., the Humalog was administered on 9/25/24 at 9:10 a.m., by RN 36. - Due on 9/26/24 at 7:00 a.m., the Humalog was administered on 9/26/24 at 9:53 a.m., by LPN 17. - Due on 9/27/24 at 7:00 a.m., the Humalog was administered on 9/27/24 at 8:40 a.m., by RN 19. - Due on 9/27/24 at 11:00 a.m., the Humalog was administered on 9/27/24 at 12:37 p.m., by RN 19. - Due on 9/27/24 at 4:00 p.m., the Humalog was administered on 9/27/24 at 5:39 p.m., by RN 19. - Due on 9/28/24 at 7:00 a.m., the Humalog was administered on 9/28/24 at 8:32 a.m., by RN 19. - Due on 9/28/24 at 4:00 p.m., the Humalog was administered on 9/28/24 at 5:47 p.m., by RN 19. - Due on 9/29/24 at 7:00 a.m., the Humalog was administered on 9/29/24 at 8:17 a.m., by RN 19. - Due on 9/29/24 at 4:00 p.m., the Humalog was administered on 9/29/24 at 5:56 p.m., by RN 19. - Due on 9/30/24 at 4:00 p.m., the Humalog was administered on 9/30/24 at 5:49 p.m., by RN 19. The September 2024 MAR (Medication Administration Record) indicated the following concerns for the Humalog Injection 20 units with meals: - The resident's Humalog was due on 9/24/24 at 7:30 a.m. The Humalog was administered on 9/24/24 at 9:45 a.m., by RN 15. - Due on 9/24/24 at 11:30 a.m., the Humalog was administered on 9/24/24 at 4:12 p.m., by RN 15. - Due on 9/24/24 at 4:30 p.m., the Humalog was administered on 9/24/24 at 4:12 p.m., by RN 15. - Due on 9/25/24 at 7:30 a.m., the Humalog was administered on 9/25/24 at 9:11 a.m., by RN 36. - Due on 9/26/24 at 7:30 a.m., the Humalog was administered on 9/26/24 at 9:53 a.m., by LPN 17. - Due on 9/26/24 at 11:30 a.m., the Humalog was administered on 9/26/24 at 1:26 p.m., by LPN 17. - Due on 9/27/24 at 7:30 a.m., the Humalog was administered on 9/27/24 at 12:27 p.m., by RN 19. - Due on 9/27/24 at 11:30 a.m., the Humalog was administered on 9/27/24 at 4:44 p.m., by RN 19. - Due on 9/27/24 at 4:30 p.m., the Humalog was administered on 9/27/24 at 5:57 p.m., by RN 19. - Due on 9/28/24 at 4:30 p.m., the Humalog was administered on 9/28/24 at 5:47 p.m., by RN 19. - Due on 9/29/24 at 11:30 a.m., the Humalog was administered on 9/29/24 at 3:22 p.m., by RN 19. The RN then administered the 4:30 p.m., dose at 5:56 p.m. - Due on 9/30/24 at 4:30 p.m., the Humalog was administered on 9/30/24 at 5:49 p.m., by RN 14. 2. The record for Resident 83 was reviewed on 10/10/24 at 1:14 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, polyneuropathy, morbid obesity due to excess calories, and dependence on renal dialysis. The care plan, dated 9/5/24, indicated the resident had diabetes. The interventions, dated 9/5/24, included, but were not limited to, administer medications per the medical provider's orders, obtain blood sugars per orders, and report abnormal findings to the medical provider, the resident and the resident representative. The physician's order, dated 9/4/24, indicated for staff were to administer the resident's 10 units of insulin glargine pen injector subcutaneously at bedtime for diabetes mellitus. The physician's order, dated 9/4/24, indicated for staff were to administer the resident's 5 units of Humalog subcutaneously, before meals for diabetes mellitus. The review of the resident's blood sugar reading between 9/4/24 and 10/11/24 indicated a range from 123 on admission to 351 mg/dL recently. The September 2024 MAR indicated the following concerns for 10 units of insulin glargine before meals: - The resident's insulin glargine was due on 9/6/24 at 9:00 p.m. The glargine was administered on 9/6/24 at 11:29 p.m., by LPN 20. - Due on 9/7/24 at 9:00 p.m., the glargine was administered on 9/7/24 at 10:45 p.m., by LPN 20. - Due on 9/8/24 at 9:00 p.m., the glargine was administered on 9/9/24 at 12:26 a.m., by RN 16. - Due on 9/9/24 at 9:00 p.m., the glargine was administered on 9/10/24 at 12:09 a.m., by RN 16. - Due on 9/10/24 at 9:00 p.m., the glargine was administered on 9/10/24 at 11:22 p.m., by RN 16. - Due on 9/11/24 at 9:00 p.m., the glargine was administered on 9/12/24 at 2:17 a.m., by RN 16. - Due on 9/12/24 at 9:00 p.m., the glargine was administered on 9/13/24 at 12:51 a.m., by LPN 20. - Due on 9/14/24 at 9:00 p.m., the glargine was administered on 9/14/24 at 11:23 p.m., by LPN 20. - Due on 9/15/24 at 9:00 p.m., the glargine was administered on 9/16/24 at 5:38 a.m., by RN 16. - Due on 9/16/24 at 9:00 p.m., the glargine was administered on 9/17/24 at 12:25 a.m., by RN 16. - Due on 9/17/24 at 9:00 p.m., the glargine was administered on 09/17/24 at 11:55 p.m., by RN 16. - Due on 9/18/24 at 9:00 p.m., the glargine was administered on 9/19/24 at 3:09 a.m., by RN 16. - Due on 9/22/24 at 9:00 p.m., the glargine was administered on 9/22/24 at 11:10 p.m., by RN 25. - Due on 9/23/24 at 9:00 p.m., the glargine was administered on 9/24/24 at 3:40 a.m., by RN 16. - Due on 9/24/24 at 9:00 p.m., the glargine was administered on 9/25/24 at 1:58 a.m., by RN 16. - Due on 9/25/24 at 9:00 p.m., the glargine was administered on 9/26/24 at 3:06 a.m., by RN 16. - Due on 9/27/24 at 9:00 p.m., the glargine was administered on 9/28/24 at 3:36 a.m., by LPN 20. - Due on 9/28/24 at 9:00 p.m., the glargine was administered on 9/28/24 at 10:45 p.m., by LPN 20. - Due on 9/29/24 at 9:00 p.m., the glargine was administered on 9/30/24 at 2:45 a.m., by QMA (Qualified Medication Aide) 22. - Due on 9/30/24 at 9:00 p.m., the glargine was administered on 10/1/24 at 12:29 a.m., by LPN 20. The September 2024 MAR indicated the following concerns 5 units Humalog injection before meals: - The resident's Humalog was due on 9/5/24 at 7:00 a.m. The Humalog was administered on 9/5/24 at 8:50 a.m., by RN 23. - Due on 9/5/24 11:00 a.m., the Humalog was administered on 9/5/24 at 11:55 a.m., by RN 23. - Due on 9/6/24 at 11:00 a.m., the Humalog was administered on 9/6/24 at 12:20 p.m., by RN 14. - Due on 9/8/24 at 7:00 a.m., the Humalog was administered on 9/8/24 at 9:11 a.m., by LPN 17. - Due on 9/9/24 at 7:00 a.m., the Humalog was administered on 9/9/24 at 10:24 a.m., by LPN 17. - Due on 9/10/24 at 7:00 a.m., the Humalog was administered on 9/10/24 at 8:44 a.m., by RN 19. - Due on 9/11/24 at 11:00 a.m., the Humalog was administered on 9/11/24 at 2:05 p.m. by QMA 24. - Due on 9/12/24 at 7:00 a.m., the Humalog was administered on 9/12/24 at 9:38 a.m., by LPN, 17. - Due on 9/14/24 at 7:00 a.m., the Humalog was administered on 9/14/24 at 8:22 a.m., by RN 19. - Due on 9/15/24 at 7:00 a.m., the Humalog was administered on 9/15/24 at 10:06 a.m., by QMA 24. - Due on 9/15/24 at 11:00 a.m., the Humalog was administered on 9/15/24 at 12:13 p.m., by RN 19. - Due on 9/16/24 at 11:00 a.m., the Humalog was administered on 9/16/24 at 1:11 p.m., by LPN 17. - Due on 9/17/24 at 11:00 a.m., the Humalog was administered on 9/17/24 at 12:12 p.m., by RN 19. - Due on 9/17/24 at 4:00 p.m., the Humalog was administered on 9/17/24 at 5:26 p.m., by RN 19. - Due on 9/18/24 at 7:00 a.m., the Humalog was administered on 9/18/24 at 10:23 a.m., by RN 19. - Due on 9/18/24 at 4:00 p.m., the Humalog was administered on 9/18/24 at 5:24 p.m., by RN 19. - Due on 9/19/24 at 7:00 a.m., the Humalog was administered on 9/19/24 at 8:20 a.m., by RN 19. - Due on 9/19/24 at 11:00 a.m., the Humalog was administered on 9/19/24 at 12:25 p.m., by RN 15. - Due on 9/20/24 at 7:00 a.m., the Humalog was administered on 9/20/24 at 9:05 a.m., by RN 37. - Due on 9/20/24 at 4:00 p.m., the Humalog was administered on 9/20/24 at 5:20 p.m., by RN 37. - Due on 9/21/24 at 7:00 a.m., the Humalog was administered on 9/21/24 at 9:29 a.m., by LPN 18. - Due on 9/21/24 at 11:00 a.m., the Humalog was administered on 9/21/24 at 12:55 p.m., by LPN 18. - Due on 9/22/24 at 7:00 a.m., the Humalog was administered on 9/22/24 at 11:25 a.m., by QMA 24. - Due on 9/25/24 at 7:00 a.m., the Humalog was administered on 9/25/24 at 9:33 a.m., by RN 38. - Due on 9/27/24 at 7:00 a.m., the Humalog was administered on 9/27/24 at 9:25 a.m., by RN 19. - Due on 9/28/24 at 7:00 a.m., the Humalog was administered on 9/28/24 at 10:20 a.m., by RN 14. - Due on 9/29/24 at 7:00 a.m., the Humalog was administered on 9/29/24 at 9:18 a.m., by LPN 18. - Due on 9/30/24 at 7:00 a.m., the Humalog was administered on 9/30/24 at 11:57 a.m., by QMA 24. - Due on 9/30/24 at 11:00 a.m., the Humalog was administered on 9/30/24 at 1:29 p.m., by RN 14. - Due on 9/30/24 at 4:00 p.m., the Humalog was administered on 9/30/24 at 5:42 p.m., by QMA 24. The October 2024 MAR indicated the following concerns for 10 units of insulin glargine before meals: - The resident's insulin glargine was due on 10/1/24 at 9:00 p.m. The glargine was administered on 10/1/24 at 11:08 p.m., by LPN 20. - Due on 10/2/24 at 9:00 p.m., the glargine was administered on 10/2/24 at 11:38 p.m., by LPN 20. - Due on 10/4/24 at 9:00 p.m., the glargine was administered on 10/5/24 at 3:30 a.m., by RN 25. - Due on 10/5/24 at 9:00 p.m., the glargine was administered on 10/5/24 at 10:46 p.m., LPN 26. - Due on 10/6/24 at 9:00 p.m., the glargine was administered on 10/7/24 at 1:16 a.m., by RN 16. - Due on 10/7/24 at 9:00 p.m., the glargine was administered on 10/8/24 at 2:59 a.m., by RN 16. - Due on 10/8/24 at 9:00 p.m., the glargine was administered on 10/9/24 at 2:32 a.m., by RN 16. - Due on 10/9/24 at 9:00 p.m., the glargine was administered on 10/10/24 at 2:43 a.m., by RN 16. - Due on 10/10/24 at 9:00 p.m., the glargine was administered on 10/10/24 at 11:03 p.m., by LPN 20. The October 2024 MAR indicated the following concerns 5 units Humalog injection before meals: - The resident's Humalog was due on 10/2/24 at 7:00 a.m. The Humalog was administered on 10/2/24 at 8:52 a.m., by RN 19. - Due on 10/4/24 at 7:00 a.m., the Humalog was administered on 10/4/24 at 10:31 a.m., by RN 14. - Due on 10/7/24 at 7:00 a.m., the Humalog was administered on 10/7/24 at 10:15 a.m., by QMA 24. - Due on 10/7/24 at 11:00 a.m., the Humalog was administered on 10/7/24 at 1:43 p.m., by QMA 24. - Due on 10/7/24 at 4:00 p.m., the Humalog was administered on 10/7/24 at 6:12 p.m., by RN 14. - Due on 10/8/24 at 7:00 a.m., the Humalog was administered on 10/8/24 at 9:13 a.m., by RN 19. - Due on 10/9/24 at 7:00 a.m., the Humalog was administered on 10/9/24 at 8:17 a.m., by RN 19. - Due on 10/9/24 at 11:00 a.m., the Humalog was administered on 10/9/24 at 1:03 p.m., by RN 19. - Due on 10/9/24 at 4:00 p.m., the Humalog was administered on 10/9/24 at 5:16 p.m., by RN 19. - Due on 10/10/24 at 7:00 a.m., the Humalog was administered on 10/10/24 at 8:36 a.m., by RN 14. - Due on 10/10/24 at 11:00 a.m., the Humalog was administered on 10/10/24 at 12:43 p.m., by RN 14. 3. The record for Resident 204 was reviewed on 10/10/24 at 8:29 a.m. The resident's diagnoses included, but were not limited to, acquired absence of the left leg below the knee, type 2 diabetes mellitus with neuropathy, morbid obesity due to excess calories, diabetic ulcers of the right toes and foot. The care plan, dated 10/5/24, indicated the resident had a left below the knee amputation, diabetic foot ulcer to the right heel and great toe. The intervention, dated 10/5/24, included, but was not limited to, administer medications as ordered. The physician's order, dated 10/5/24, indicated staff were to administer the resident's 4 units of Humalog KwikPen subcutaneously before meals for diabetes mellitus. The physician's order, dated 10/5/24 indicated staff were to administer the resident's Humalog per sliding scale subcutaneously if the blood sugar was greater than 400, notify the physician and inject as per sliding scale with 2 units for a blood sugar of 151 - 200 mg/dL, 4 units for a blood sugar of 201 - 250 mg/dL, 4 units for a blood sugar of 251 - 300 mg/dL, 5 units for a blood sugar of 301 - 350 mg/dL, 6 units for a blood sugar of 351 - 400 mg/dL before meals and at bedtime. If the blood sugar was less than 60, notify the physician. The physician's order, dated 10/5/24, indicated staff were to administer the resident's 25 units of Lantus subcutaneously daily for diabetes mellitus. The resident's blood sugar readings indicated the resident ranged between 203 mg/dL to 394 mg/dL. The October 2024 MAR (Medication Administration Record) indicated the following concerns for the twice daily, 25 units of Lantus SoloStar pen-injector: - The resident's Lantus was due on 10/05/24 ordered at 7:00 p.m. The lantus was received on 10/05/24 at 10:56 p.m., by LPN 26. - Due on 10/06/24 at 7:00 p.m., the Lantus was administered on 10/06/24 at 8:49 p.m., by RN 16. - Due on 10/07/24 at 7:00 p.m., the Lantus was administered on 10/07/24 at 8:50 p.m., by RN 16. - Due on 10/08/24 at 7:00 p.m., the Lantus was administered on 10/09/24 at 12:06 a.m., by RN 16. - Due on 10/09/24 at 7:00 p.m., the Lantus was administered on 10/09/24 at 9:30 p.m., by RN 16. The October 2024 MAR indicated the following concerns for the 4 units Humalog Kwikpen injection before meals and per sliding scale before meals and at bedtime if the blood sugar was greater than 400 mg/dL: - The resident's Humalog was due on 10/5/24 at 7:00 a.m. The Humalog was administered on 10/5/24 at 10:46 a.m., by LPN 27. - Due on 10/05/24 at 7:00 a.m., the Humalog was administered on 10/5/24 at 10:45 a.m., by LPN 27. - Due on 10/5/24 at 9:00 p.m., the Humalog was administered on 10/5/24 at 10:56 p.m., by LPN 26. - Due on 10/6/24 at 7:00 a.m., the Humalog was administered on 10/6/24 at 8:46 a.m., by LPN 27. - Due on 10/6/24 at 7:00 a.m., the Humalog was administered on 10/6/24 at 8:47 a.m., by LPN 27. - Due on 10/6/24 at 4:00 p.m., the Humalog was administered on 10/6/24 at 3:46 p.m., by LPN 27. - Due on 10/7/24 at 7:00 a.m., the Humalog was administered on 10/7/24 at 9:21 a.m., by RN 14. - Due on 10/7/24 at 7:00 a.m., the Humalog was administered on 10/7/24 at 9:21 a.m., by RN 14. - Due on 10/7/24 at 11:00 a.m., the Humalog was administered on 10/7/24 at 12:32 p.m., by RN 14. - Due on 10/7/24 at 11:00 a.m., the Humalog was administered on 10/7/24 at 12:33 p.m., by RN 14. - Due on 10/8/24 at 11:00 a.m., the Humalog was administered on 10/8/24 at 12:16 p.m., by RN 19. - Due on 10/8/24 at 11:00 a.m., the Humalog was administered on 10/8/24 at 12:17 p.m., by RN 19. - Due on 10/8/24 at 4:00 a.m., the Humalog was administered on 10/8/24 at 5:21 p.m., by RN 19. - Due on 10/8/24 at 4:00 p.m., the Humalog was administered on 10/8/24 at 5:22 p.m., by RN 19. - Due on 10/8/24 at 9:00 p.m., the Humalog was administered on 10/9/24 at 12:06 a.m., by RN 16. - Due on 10/9/24 at 7:00 a.m., the Humalog was administered on 10/9/24 at 11:20 a.m., then the 11:00 a.m. dose was administered at 11:30 a.m., by RN 19. - Due on 10/9/24 at 9:00 p.m., the Humalog was administered on 10/10/24 at 12:46 a.m., by RN 16. The review of the October MAR on 10/9/24 at 10:15 a.m., the resident had not received his Humalog injection on time. An observation of the resident at this time indicated that breakfast had already been served and removed from the resident's room. During an interview on 10/8/24 at 9:44 a.m., Resident 204 indicated his blood sugars were running high at the facility. During an interview on 10/9/24 at 11:28 a.m., Resident 204 indicated he wasn't sure if he got his insulin this morning or if he got his accu check. He wasn't sure when he got his insulin after he went to sleep the previous night. During an interview on 10/10/24 at 8:35 a.m., Resident 204 indicated he had not received a finger stick, or insulin this morning. The nurse was observed at the beginning of the hall with the medication cart, preparing medications to administer. Breakfast had already been served and removed. The review of the October MAR on 10/10/24 at 8:46 a.m., indicated Resident 204 had still not received his Humalog injection this morning. Breakfast had already been served and removed from the residents' room. During an interview on 10/11/24 at 8:30 a.m., Resident 204 indicated he had just received his insulin. He had already eaten his breakfast when he received his insulin. The nurse performed his accu check just prior to his injection of insulin. The empty breakfast tray was sitting on his bedside table and the nurse was observed preparing to administer medications, two doors down the hall, past the resident's room. During a confidential interview between 10/7/24 and 10/15/24, Staff C indicated it was difficult to complete medication administration due to the number of residents. On occasion there were issues with keeping up with both the accu checks and insulin administration. Those were performed together. There were times that the residents received insulin after the meals were served. If an insulin was administered late, the resident could have hyperglycemia when they ate, or they could have had a low blood sugar and would have needed orange juice or something to raise their blood sugar. During a confidential interview between 10/7/24 and 10/15/24, Staff D indicated it could be hard to get medications completed on the days that were busy. During a confidential interview between 10/7/24 and 10/15/24, Staff E indicated they had no issues with providing medications. They had administered insulin only a few times late but couldn't remember the dates. During a confidential interview between 10/7/24 and 10/15/24, Staff F indicated the blood sugars were obtained and the insulin would be given at the same time. They were late at times if something was going on in the facility. The insulin administration should be documented when they were administered. If an insulin was late, there was the chance of the blood sugar running high. The current Medication Administration policy, included, but was not limited to, . Procedure: I. General Procedures: a. Administer medication only as prescribed by the provider . ff. Medications will be administered within the time frame of one hour before up to one hour after time ordered. i. For medication to be taken around meals: 1. Before Meals: provide medications thirty (30) minutes before meal time . IV. Documentation a. Documentation of medication will be current for medication administration. b. Documentation of medications will follow accepted standards of nursing practice. 3.1-48(a)(6)

Based on observation, record review and interview, the facility failed to make a reasonable effort to meet the preferences of the residents' meal choices in that scheduled menu items were being substituted due to unavailability with the same food items being served almost daily during 4 of 4 observations. This deficient practice affected 83 of 100 residents who received meals from the kitchen. Findings include: During confidential interviews with residents, between 10/7/24 and 10/15/24, the following concerns were voiced: - Resident D indicated hamburgers were served 4 days in a row and the wanted the ravioli instead. The broccoli was not completely cooked; the same food was served multiple times a week; and the hot foods were not hot and the cold foods were not cold. - Resident E indicated voiced multiple concerns of never getting the correct meal and the same food was served multiple times per week. -Resident F indicated the food was just not good. - Resident G indicated ice cream was not on the lunch tray; the broccoli was not completely cooked; there was no sauce or butter on the ravioli and it was very dry. The ravioli was dried up on the edges and curled up. - Resident H indicated the food was not good today and that the same food was served multiple times per week. - Resident J indicated there was barely any food on the plate, and small portions were served at times. They often did not follow the menus, the food was cold at times, the potatoes were frequently not done or hard, especially the baked potatoes and hash browns. - Resident K indicated although being a dialysis patient and tomatoes and potatoes were frequently served which were against the renal diet. They indicated that it felt like they were not getting enough to eat due to not eating the potatoes and tomatoes. They were served beef stew the other day which had potatoes and tomatoes in it and were not able eat it. The broccoli served yesterday was too hard to eat; and the plain ravioli was dry and hard around the edges. They could not eat half of it. The review of the menu for 10/7/24, indicated the lunch meal was to be the following: - Bruschetta Chicken - Seasoned [NAME] Beans - Garlic Roasted Red Potatoes During an observation of the lunch meal serviced on 10/7/24 at 11:35 a.m., the items listed on the menu were being served. During a second observation of the lunch meal being served on 10/7/24 at 12:15 p.m., the following was observed: - The Dietary Manager and [NAME] 32 were observed serving teriyaki chicken, stewed tomatoes and mashed potatoes instead of the menu items. [NAME] 32 indicated he had ran out of everything that was supposed to be served and was using whatever he had on hand. He indicated he followed the recipes and the count sheet when preparing all the items and did not know why he ran out. The residents were not informed they were not getting the menu items, nor were they asked if they wanted the teriyaki chicken, stewed tomatoes and mashed potatoes or something else. During an interview with the Regional Dietary Manager on 10/9/24 at 10:45 a.m., she indicated she was not aware that the cook ran out of chicken, green beans and red potatoes as she was only told that they were short two pieces of chicken. Nor was she aware of the items being substituted because they were handy. The review of the menu for 10/9/24, indicated the lunch meal was to be the following: - Cheese Ravioli with marinara sauce - Caesar salad - Garlic bread sticks - Mandarin oranges During the lunch food temperature observation on 10/9/24 at 11:34 a.m., a random temperature check of a bowl of Caesar salad on one of the residents' trays indicated the temperature was 64 degrees Fahrenheit. The Regional Dietary Manager instructed the staff to remove every bowl that was already on the lunch trays which had been set up earlier and to dispose of it. The Dietary Manager was observed to place all the bowls of salad back into the walk in refrigerator. He indicated he thought that he could still use salads if he got them cold again. A decision was made to substitute broccoli as the vegetable instead of the Caesar salad. The review of the evening (supper) menu for 10/14/24, indicated Au Gratin potatoes were scheduled to be served. The review of the scheduled lunch menu for 10/15/24, the following was to be served: - Marinated chicken thighs - Spinach - Oven browned potatoes The review of the posted menu for lunch on 10/15/24, indicated a change had been made from oven roasted potatoes to Au Gratin potatoes which also had been served the night before. During an interview with [NAME] 35 on 10/15/24 at 1:15 p.m., she indicated they had run out of potatoes therefore the oven browned potatoes were substituted with the Au Gratin potatoes. The review of the facility's current policy on Food: Quality and Palatability revised on 2/2023, included, but were not limited to, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature .Procedures: 1. The Dining Serviced Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code .4. The Cook(s) prepare food in accordance with the recipes and season for region and/or ethic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention . The review of the facility's current policy on Menus revised on 10/2022, included, but was not limited to, Policy Statement: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an appropriate planning guide. Procedures: 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas . Cross Reference F804 3.1-21(a)(1) 3.1-21(a)(2) 3.1-21(a)(4)

Based on observation and interview, the facility failed to ensure meals were at appropriate temperatures and palatable for residents during 2 of 2 temperature checks and 1 of 1 meal test trays. This had the potential to affect 83 of 100 residents who ate meals at the facility. Findings include: 1. During confidential interviews with residents while on the initial tour of the facility on 10/7/24 between 9:45 a.m. and 11:00 a.m., the following concerns were voiced: - Resident A indicated the food was cold when it reached them, it looked unappealing, and the taste was worse. If they asked for a substitute, it could be worse than the main meal. Their family member told them it looked like the food they got in prison. They were a diabetic and were not getting enough to eat. - Resident B indicated the food was often cold due to it sitting on the halls when brought from the kitchen. They indicated it was not worth it to ask the staff to heat it up. 2. During the lunch food temperature observation on 10/7/24 at 11:30 a.m., with [NAME] 32, the following food temperatures were obtained by [NAME] 32. The temperatures did not meet the required serving temperatures: - Puree chicken was 150 degrees Fahrenheit - the item was removed and placed back into the steamer; at 11:40 a.m. The item was now 171 degrees Fahrenheit. - Puree green beans were 132 degrees Fahrenheit - the item was removed and placed back into the steamer; at 11:41 a.m., the item was now 163 degrees Fahrenheit. - Potato soup was 133 degrees Fahrenheit - it was decided to not serve the soup. 3. During the lunch food temperature observation on 10/9/24 at 11:34 a.m., the following food temperatures were obtained which did not meet the required serving temperatures: - Caesar salad was 64 degrees Fahrenheit - the Regional Dietary Manager instructed the staff to remove every bowl that was already on the lunch trays which had been set up earlier and dispose of it. The Dietary Manager was observed to place all the bowls of salad back into the walk in refrigerator. He indicated he thought that he could still use salads if he got them cold again. - Mixed vegetable salad was 69 degrees Fahrenheit - Potato salad was 82 degrees Fahrenheit Both items were immediately removed by the cook and the Dietary Manager was informed. At 11:45 a.m., the Dietary Manager put a pan of steamed broccoli into the steam table to be served instead of the Caesar salad. At 11:55 a.m., he indicated the temperature was 171 degrees Fahrenheit when he took it out of the steamer and was now 142 degrees Fahrenheit On 10/9/24 at 12:02 p.m., test tray was placed on the 300 unit meal cart to determine the temperature of the food. A check of the temperature of the food items by the Regional Dietary Director at 12:32 p.m., after the last tray was served, indicated the following temperatures: - Broccoli was 114 degrees Fahrenheit - Ravioli with sauce was 125.8 degrees Fahrenheit - Mandarin oranges were 55 The Regional Dietary Manager indicated at this time, that the food items were not at a temperature that was considered appetizing. A taste of the food items at 12:39 p.m., indicated the ravioli needed more sauce, was sticky as the ravioli was clumped together, and was dry tasting. The broccoli was very undercooked and difficult to chew. The bread stick was soft and easy to chew and the mandarin oranges were cold and sweet. During confidential interviews with residents, between 10/7/24 and 10/15/24, the following concerns were voiced: - Resident D indicated hamburgers were served 4 days in a row and the wanted the ravioli instead. The broccoli was not completely cooked; the same food was served multiple times a week; and the hot foods were not hot and the cold foods were not cold. - Resident E indicated voiced multiple concerns of never getting the correct meal and the same food was served multiple times per week. -Resident F indicated the food was just not good. - Resident G indicated ice cream was not on the lunch tray; the broccoli was not completely cooked; there was no sauce or butter on the ravioli and it was very dry. The ravioli was dried up on the edges and curled up. - Resident H indicated the food was not good today and that the same food was served multiple times per week. - Resident J indicated there was barely any food on the plate, and small portions were served at times. They often did not follow the menus, the food was cold at times, the potatoes were frequently not done or hard, especially the baked potatoes and hash browns. - Resident K indicated although being a dialysis patient and tomatoes and potatoes were frequently served which were against the renal diet. They indicated that it felt like they were not getting enough to eat due to not eating the potatoes and tomatoes. They were served beef stew the other day which had potatoes and tomatoes in it and were not able eat it. The broccoli served yesterday was too hard to eat; and the plain ravioli was dry and hard around the edges. They could not eat half of it. The review of the facility's current policy on Food: Quality and Palatability included, but were not limited to, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature .Procedures: 1. The Dining Serviced Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code .4. The Cook(s) prepare food in accordance with the recipes and season for region and/or ethic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention . Cross Reference F803 3.1-21(a)(2)

Based on observation and interview, the facility failed to ensure food was served and stored under sanitary conditions during 3 of 3 kitchen observations. This deficiency had the potential to affect 83 of 100 residents currently receiving meals from the kitchen. Findings include: 1. During the initial tour of the kitchen while accompanied by the Dietary Manager and the Regional Dietary Manager on 10/07/24 at 9:15 a.m. , the following concerns were observed: - The Dry storage room in the corner next to a shelving unit and the canned goods rack, was a white drain. The inside of this drain, the tiles surrounding the drain, the pipe above the drain, and the wall from the door to the pipe had greenish/gray in color substance. - The floor behind and under the steamer had a heavy accumulation of yellow food particles and a heavy buildup of dirt and food particles brownish/black in color. - The steamer had multiple white streaks which ran down all sides of the unit. The drain tray in front of the steamer had brown and tan food particles and pieces of foil in it. - A blue floor plate, which held the stove wheel in place, as identified by [NAME] 32 and the tiles surrounding the plate had brown and tan food particles on them. - The oven doors had multiple white streaks that ran down the doors. There were areas of black burnt on substances in the bottom of both ovens. - The top of the trash can by the steamer and hand wash sink had heavy soil and food particles on the lid. - The left side of the ice maker had a moderate coating of white/gray substance on the vent. - The stove top had yellow/tan food particles on the top and the burners. There also areas of black burnt on debris. - Four of six tray carts had dark brown liquid, a straw and clear liquid spills inside on the bottoms. [NAME] streaks ran down the length of the carts. - The entire floor edges and corners of the kitchen, dry storage room, wheels of the stove, steamer, preparation tables and convection oven had a build-up of black particles/grime. 2. During an observation of the kitchen while accompanied by the Dietary Manager on 10/7/24 at 11:30 a.m., the following concerns were observed: - The same issues identified at 9:15 a.m. remained an issue. The wall in the dry storage room behind the shelving unit from the door to the pipe was now cleaned with no observed greenish/gray in color substance on the wall. 3. During an observation of the kitchen on 10/9/24 at 10:05 a.m., the following concerns were observed: - The same issues identified on 10/7/24 at 9:15 a.m. and 11:30 a.m. remained a concern. - The outside of the thickener, sugar, flour, and brown sugar canisters were sticky to the touch with crumbs on top. - The double preparation sink was greasy inside to the touch, which was able to be wiped away with a paper towel. - The outside of six of six food carts had brown and white streaks down the length of the carts. A review of the as completed Weekly Cleaning Schedule for 10/6/24 to 10/12/24, indicated the following tasks were signed off as having been completed: Cooks: - Tuesday (10/8/24) Day - Clean Convection Oven - Wednesday (10/9/24) Day - Clean Grill Top. - Thursday (10/10/24) Night - Under Cooks Station - Saturday (10/12/24) Day - Conventional Oven; Nights - Stove Drip Pan AM Aides: - Monday (10/7/24) Day - Underneath Aide Station - Friday (10/11/24) - Clean Trash Can and clean handwashing sinks PM Aides: - Thursday (10/10/24) - Clean Underneath Station - Saturday (10/12/24) - Trash Cans The cleaning schedule failed to address cleaning the Dry Storage Room, the food carts which held the trays, the double preparation sink, the stove, and the floor underneath the equipment. A review of the facility's current policy on Environment last revised on 9/2027 included, but was not limited to : Policy Statement: All food preparation areas, food service areas, .will be maintained in a clean and sanitary condition. Procedure: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including, floors, walls, .2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing all food service equipment and surfaces .4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure appropriate infection control measures were followed during high contact care for 8 of 11 staff observations of infection control. (CNA 39, CNA 40, CNA 9, CNA 8, CNA 7, CNA 29, CNA 30 and CNA 4) Findings include, 1. During the initial tour of the facility on 10/7/24 at 9:15 a.m., observation of the 400 Unit indicated 11 of 15 residents were in enhanced barrier precautions (an infection control techniques to reduce the spread of multidrug resistant organisms) and 1 of 15 residents was in droplet precautions (set of infection control measures to prevent the spread of pathogens that are transmitted through respiratory droplets). During an observation on 10/7/24 between 10:00 a.m. and 10:15 a.m., CNA (Certified Nurse Aide) 39 was walking exited a resident's room with a bag of soiled linen in her right hand. She walked down the 400 Hallway towards the soiled linen room and the bag was transferred to her left hand. The CNA then as a staff member was walking out of the soiled linen room the CNA walked in the doorway and discarded the bag of soiled linens. She then immediately turned around and walked out of the doorway and down the 400 Hall towards another resident's room. No hand washing or hand sanitizing was observed. During an observation of the 400 Hallway on 10/7/24 between 10:15 a.m. and 10:30 a.m., CNA 40 was observed to be holding a bag of soiled linen in her left hand as she walked out of a resident's room. The CNA walked past two residents' rooms and then used hand sanitizer rubbing both hands together while holding the bag in left fingertips. She then walked to the soiled line room and disposed of the bag. After disposing of the bag she turned and walked down the hallway with another CNA towards the residents' rooms. No other hand washing, or hand sanitizing was observed. During an observation of the 400 Hallway on 10/8/24 at 12:00 p.m., two CNA's were observed exiting a resident room with bags of trash and resident care items. CNA 7 carried the bags to the soiled linen room and disposed of the bags. The CNA did not perform hand washing or sanitize her hands. CNA 7 entered another resident's room and CNA 8 went to the nurse's station where she picked up papers and then laid them back on the desk. During an observation on 10/8/24 at 2:00 p.m., CNA 9 was observed exiting a resident's room with a bag of trash. She then proceeded to use the hand sanitizer while holding the bag of trash. a. The record for Resident 91 was reviewed on 10/8/24 at 8:26 a.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, the need for personal assistance with personal care, and tracheotomy care. The Quarterly MDS (Minimum Data Set) assessment, dated 9/24/24, indicated the resident was rarely or never understood as she was unresponsive. She was totally dependent for all her ADLs (Activities of Daily Living) and was unable to assist with these activities. The physician's order, dated 9/23/24, indicated to use enhanced barrier precautions related to open wounds and indwelling medical devices: Gastrointestinal-tube and tracheotomy. When dressing, bathing, showering, transferring in room, therapy, personal hygiene, changing linen, providing hygiene, changing briefs and assisting with toileting every shift. The physician's order, dated Amoxicillin-POT Clavulanate tablet 875-125 mg (milligrams) via G-tube (gastrostomy tube) was to be given every 12 hours times 7 days for pneumonia and UTI (Urinary Tract Infection). The start date was 10/2/24. The nurse's note dated 8/14/24 at 1:00 a.m., Vancomycin HCl (Hydrocloride) intravenous solution reconstituted 1 gm intravenously in the morning for leukocytosis until 08/16/24 at 5:59 a.m., in 100 ml (milliliters) of normal saline over 60 minutes for leukocytosis, from 8/14/24 to 8/16/24. During an interview on 10/8/24 at 9:00 a.m., the RDCO (Regional Director of Clinical Operations) indicated she had observed CNA 9 on 10/7/24 working the ventilation unit and she had used hand sanitizer with the dirty trash bag in her hands. She indicated she had educated the CNAs on 10/6/24 on hand hygiene after she was made aware there was an issue with respiratory and UTI infections on the ventilation/tracheostomy unit. b. The record for Resident 250 was reviewed on 8/6/22 at 11:22 a.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, the need for assistance with personal care, tracheostomy, cerebral infarction, other sites of candidiasis, and a carrier of CRAB (Carbapenem-Resistant Acinetobacter Baumannii). The Admission MDS assessment, dated 9/3/24, indicated the resident was rarely or never understood as she was nonresponsive. The resident was totally dependent on staff for her ADLs. The physician's order, dated 8/27/24, indicated to provide oral and tracheal suction every shift and every two hours as needed and perform oral care every shift and as needed. Enhanced barrier precautions related to a history of Candida Auris, CRAB, colostomy, tracheotomy, gastrointestinal tube, open wounds, a midline and when dressing, or bathing, showering, transferring, therapy, personal hygiene, changing linen, providing hygiene, and changing briefs or assisting with toileting every shift. The physician's order, dated 10/15/24, indicated to administer Ceftazidime intravenous solution reconstituted 1 gm intravenously every 8 hours for Acinetobacter Baumannii Crab in sputum for 7 days. Droplet precautions related to CRAB in sputum. The start date was 10/15/24. During an interview on 10/9/24 at 10:00 a.m., the RT (Respiratory Therapist) indicated hand hygiene was the most important procedure to prevent the spread of infection especially when care for tracheotomy residents. They tried not to break the Heat Moisture Exchange any more than they must. The tracheotomies were moist and warm, and bacteria thrive in that environment. tracheostomy care was provided every 12 hours and as needed. Nurses were allowed to provide trach care and to suction when needed. He indicated 95 percent of the time an RT was in the facility. The infection CRAB was easily transmitted, and the ventilation residents were more susceptible to infections. c. The record for Resident 36 was reviewed on 10/8/24 at 11:21 a.m. The resident's diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, and resistance to other specified Beta Lactam antibiotics, candidiasis, a carrier of carbapenem-resistant Enterobacter [NAME], acute infections, streptococcus group B, other bacterial agents, pseudomonas, and a tracheostomy. The physician's order, dated 10/2/24, indicated Doxycycline Monohydrate Oral Capsule 100 mg give 1 capsule via G-Tube two times a day for pneumonia for 7 days. The physician's order, indicated dated 10/6/24, indicated enhanced barrier precautions related to a history of CRE (Carbapenem-Resistant Enterobacterales), CRAB, CRPA (Carbapenem Resistant Pseudomonas Aeruginosa), Candidas Auris, tracheotomy, g-tube, a right chest IJ (Internal Jugular) dressing, bathing, showering, transferring, therapy, personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting every shift. The physician's order, dated 10/6/14, indicated to administer Amoxcillin-Potassium Clavulanate oral tablet 875-125 mg and give 1 tablet via g-Tube every morning and at bedtime for hydronephrosis for 10 administrations. d. The record for Resident 92 was reviewed on 10/8/24 at 8:50 a.m. The resident's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, methicillin resistant staphylococcus aureus infection, pseudomonas, and Osteomyelitis of the vertebra, sacral and sacrococcygeal region on admission. The Quarterly MDS assessment, dated 9/6/24, indicated the resident was rarely or never understood. The resident required complete dependence on staff for her ADL's. The physician's orders, with a start date of 7/8/24 and dated 10/9/24, indicated enhanced barrier precautions related to a history of Candidas auris and pseudomonas aeruginosa MDRO (Multi Drug Resistant Organisms), indwelling medical device- tracheotomy, gastrointestinal tube, a right chest port, a midline, (IV site) and open wounds. If Vancocin Pulvules (Vancomycin) was ordered orally, change the order to vancomycin slurry. The review of the respiratory surveillance form, dated 10/11/24 at 8:30 a.m., indicated eleven out of fifteen residents residing on the ventilation unit (400 Unit) had been or are currently on antibiotics for an infection. During an interview on 10/11/24 at 9:40 a.m., the IP ( Infection Control Nurse) indicated the 400 Unit was the vent unit and they were very sick residents. Most of the residents had a history of MDRO. When a culture was done it seemed like the MDROs always came up. She would review the cultures and make sure the resident was on the right antibiotic. The IP indicated she did not agree with the observations of the staff not washing their hands. The staff had been educated that they could have one clean and one dirty hand. The ventilation resident do not get showers. They get bed baths with hibiclens and the hibiclens were not rinsed off. The staff had been educated on PPEs and the disposal of the PPEs. The IP indicated currently the residents on the 400 Unit have been treated for their infections and were not currently on antibiotics. During an interview on 10/15/24 at 11:30 a.m., the Respiratory Therapy Director indicated the main way to prevent the spread of infections was handwashing and proper PPEs. He indicated when he saw someone not following infection control procedures he would educate the staff member. He indicated the ventilation unit did have a high number of infections on the unit. He indicated when RT checked the resident's oxygen with a pulse oximeter, they were to clean the pulse oximeter with a bleach wipe before using it on another resident. He indicated he believed handing washing was the most important aspect of preventing the spread of infection. 15251 2. During observation of the 300 Hallway of staff hand hygiene on 10/10/24 between 10:00 a.m. and 10:30 a.m., the following was observed: - CNA 29 was observed coming out of room [ROOM NUMBER] after providing incontinence care. She was carrying a plastic bag of soiled brief and wipes. She was observed to sanitize one hand while holding the soiled bag with the other hand and then transferred the soiled bag to her clean hand while she sanitized the other hand. She then double bagged the soiled items and proceeded to throw it away in the soiled utility room. No hand washing or sanitizing was observed to have occurred either in the soiled utility room nor from the sanitizer unit on the wall outside the soiled utility room. - CNA 30 was observed to enter the soiled utility room carrying a bag of soiled incontinent items to dispose of. No hand washing or sanitizing was observed to have occurred either in the soiled utility room or from the sanitizer unit on the wall outside the soiled utility room. During an interview with the Infection Preventionist on 10/11/24 at 9:40 a.m., she indicated she kept a binder which contained her random observations of staff performing hand sanitizing or washing prior to entrance to a resident's room and upon leaving the room. If she saw staff were doing it wrong, she indicated she would provide education on the spot to them. 34309 3. During an observation on 10/10/24 at 1:42 p.m., CNA 4 performed perineal care on the resident. She performed handwashing and applied gloves. Using wipes, the CNA cleaned the groin, then swiped down the right crease with the same area of the wipe. She did not dry the resident. She then had the resident roll onto her left side and with 4 swipes with the same area of the wipe, cleaned the buttocks. The resident rolled onto her back and the brief was fastened. The resident was not dried, and the brief was fastened. The CNA removed her gloves and performed handwashing. During an interview on 10/11/24 at 10:48 a.m., CNA 4 indicated she would clean the resident from front to back. She normally used wipes for perineal care. She didn't dry the resident when using a wipe. If she cleaned the resident with a washcloth, she would dry the resident. When using a wipe, she would use one wipe for each swipe. The record for Resident 60 was reviewed on 10/11/24 at 10:00 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with complications, hypertension, need for assistance with personal care, and herpes viral infection. The current care plan, with a start date of 4/14/23, indicated the resident was incontinent of urine. The interventions, dated 4/14/23, included, but was not limited to, wash, rinse and dry the perineum, and apply barrier creams as needed. The Quarterly MDS assessment, dated 5/30/24, indicated the resident was cognitively intact. The resident required partial to moderate assistance for toileting hygiene. The Infection Control policy, dated 3/9/2000, and last revised on 2/4/22, indicated . The goals of the facility infection prevention program are to: a. Reduce the spread of infectious disease within the facility through implementation of the Stand and Transmission-based Precautions b. Improve antibiotic stewardship as part of the ICIP plan c. Comply with federal, state and local community disease reporting requirements d. Monitor occurrences of infection and implement appropriate control measures e. Investigate outbreaks and report to the QAPI committee f. Identify and correct problems relating to infection prevention practices g. Maintain compliance with state and federal regulations relating to infection prevention . b. Surveillance of Infections ii. Prevention of spread of infections is accomplished by education and implementation for the use of hand hygiene, standard precautions, and transmission-based precautions as appropriate, with treatment and follow-up and employee work restrictions for illness . The current Perineal Care Male and Female policy, included, but was not limited to, . Equipment and Supplies: If using disposable perineum wipes: a) Disposable wipes b) Towel c) Personal Protective Equipment (e.g. gown, gloves, mask, eye protection, etc., as needed) . Female Residents: . 2-Wash perineal area, wiping from front to back. a) Separate labia and wash area downward from front to back . d) Gently dry the perineum . 5- Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. 6- Rinse and dry thoroughly . Cross Reference F690

Based on observation, record review and interview, the facility failed to ensure that care was provided related to mobility and mouth care for 2 of 11 residents reviewed for Activities of Daily Living. (Residents 46 and 250) Findings include, 1. During an observation on 10/8/24 at 11:30 a.m., Resident 46 was observed in the bed. He had a below the knee amputation on the left leg. The resident indicated he did not get up out of the bed and he would like to get up. He wasn't sure why no one got him up. The record for Resident 46 was reviewed on 10/9/24 at 8:25 a.m. The resident's diagnoses included, but were not limited to, orthopedic aftercare following a surgical amputation, acquired absence of the left leg below the knee, and muscle weakness. The Annual Minimum Data Set (MDS) assessment, dated 9/6/24, indicated the resident was moderately cognitively intact. The resident required complete dependence of staff for transfers. The resident required a wheelchair for mobility. The physician's order, dated 5/30/24, indicated to encourage the resident to get out of bed daily, one time a day for mobility. The resident needed to be supervised while he was up in his wheelchair. The care plan, with a start date of 9/3/22 and a revision date of 9/30/24, indicated the resident required assistance's with ADLs. The interventions included, but were not limited to, the resident required staff assistance of two for putting on and taking off footwear, transfers, required the use of a mechanical lift with the assistance of two staff members, and mobility. The Social Service note, dated 9/6/24 at 4:25 p.m., indicated the resident communicated well with staff and used his call light appropriately when needing assistance. The resident indicated that his sleep routine had improved since the last assessment. He added that he does feel tired and experiences some sadness about his mobility limitations. During an interview on 10/10/24 at 2:15 p.m., Certified Nursing Aide (CNA) 4 indicated the resident loved it when he got up. He did refuse if he wasn't feeling good. He was not safe in his wheelchair and needed supervision. She indicated he enjoyed going to the dining room to eat dinner. When dinner was over, she would take him back to the hall lobby and let him watch the big television while she was charting. She indicated she thought physical therapy was going to evaluate the resident for a deeper chair. During an interview on 10/11/24 at 9:15 a.m., the Physical Therapy Director indicated last summer OT (Occupational Therapy) and PT (Physical Therapy) worked several months with the resident. He was evaluated for a different chair and received one that was bigger and deeper. He had to have a leg rest with his left prosthesis leg on for stability. If his feet were on the footrest, he did good. His prosthetic leg was on for sitting in the chair and not for walking. The staff had been educated on getting the resident up in his chair with a Hoyer lift. The resident forgot his left leg had been amputated. He tried to get up and that was why he needed supervision while up in the chair. She indicated OT had educated and monitored the resident and staff from July to November of 2023. She was not sure why the resident wasn't getting up because there was no reason he couldn't get up. Any time the resident needed re-evaluated, they would do that. The resident did tend to refuse getting up out of bed. He had short term memory loss and forgot he agreed to get up then he would refuse. 2. During an observation on 10/10/24 at 11:00 a.m., Resident 250's hair looked greasy and tangled. Her hair had not been combed. The resident's mouth and lips were dry in appearance. Her mouth was dry and had dried mucous around her lips, tongue and the roof of her mouth. During an observation on 10/11/24 at 1:10 p.m., the resident's mouth and lips were dry. The resident's mouth had dried flaky mucous on her teeth. The record for Resident 250 was reviewed on 8/6/22 at 11:22 a.m. The resident's diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, the need for assistance with personal care, tracheotomy, cerebral infarction, other sites of candidiasis, and a carrier of Carbapenem-Resistant Acinetobacter Baumannii (CRAB). The Admission MDS assessment, dated 9/3/24, indicated the resident was rarely or never understood. The resident was totally dependent on staff for her ADLs. The physician's order, dated 8/28/24 at 6:00 a.m., indicated staff were to provide mouth care every shift. During an interview on 10/11/24 at 1:15 p.m., RN 6 indicated oral care should be done every two hours and as needed. When Respiratory Therapy did tracheotomy care they would provide oral care. The current Routine Resident Care policy, indicated . i. Assisting or provides for personal care 1. bathing 2. dressing 3. eating and hydration 4. toileting . f. Assisting in techniques of ambulation and in providing exercises as directed by the physical therapist, speech therapist, or occupational therapist between visits . i. Assisting with special devices such as prosthesis, eating devices, other . 3.1-38 (a)(3)

Based on observation, record review, and interview, the facility failed to ensure the prevention of Urinary Tract Infections and proper perineal care for 2 of 6 residents reviewed for bowel and bladder. (Residents 4 and 36) Findings include: 1. The record for Resident 4 was reviewed on 10/10/24 at 2:50 p.m. The resident's diagnoses included, but were not limited to, cerebral palsy, neuromuscular dysfunction of the bladder, muscle weakness, need for assistance with personal care, anemia, and candidiasis. The current care plan, start date 6/28/23, indicated the resident had an indwelling urinary catheter related to a neurogenic bladder. The interventions, dated 6/29/23, indicated to place the resident in Enhanced Barrier Precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting, and peri-care, providing care to the urinary catheter, and to provide catheter care every shift and PRN (as needed), and to notify the medical provider if the urine was abnormal in color, consistency, or odor. The current physician's order, dated 8/2/23, indicated staff were to provide indwelling catheter care every shift and PRN with soap and water. Secure the straps, if applicable, and document the output every shift. The Quarterly Minimum Data Set (MDS) assessment, dated 4/17/24, indicated the resident was severely cognitively impaired and was dependent on staff for toileting hygiene. The urinalysis results, dated 9/21/24, indicated the resident had one plus bacteria of the urine, three plus leukocyte esterase, and trace amounts of blood and protein. The physician's orders, dated 9/21/24, indicated to administer 1 gram of ceftriaxone (antibiotic) intravenously, every 24 hours for 5 days for leukocytosis (high white blood cell count). The culture and sensitivity, dated 9/26/24, indicated the urine had resulted in greater than 100,000 CFU/mL (colony forming units per milliliter) of providencia stuartii (gram negative bacteria most commonly caused by contact with contaminated persons or objects) with possible extended spectrum beta lactamases (ESBL), which were enzymes indicating resistance to most beta-lactam antibiotics. The physician's order, dated 9/29/24, indicated to administer 300 mg of cefdinir (antibiotic) by way of g-tube, every morning and at bedtime, for 10 days for a UTI (urinary tract infection). During an observation of incontinence care on 10/10/24 at 10:18 a.m., for Resident 4 by CNAs (Certified Nurse Aides) 7 and 8. Both CNAs performed hand hygiene and PPE (personal protective equipment) was applied. The catheter bag was placed at the foot of the bed. The resident's brief was unfastened. CNA 7 used wipes and swiped the left crease 5 times with the same area of the wipe. She obtained a wipe and with 11 swipes with the same area of the wipe, she cleaned the scrotum. She obtained a clean wipe and with 3 swipes of the same area of the wipe, she cleaned the scrotum. She folded the wipe and with 8 swipes with the same area of the wipe, she cleaned the scrotum again. She obtained a clean wipe and swiped down the penis, toward the tip of the penis. She obtained a clean wipe and with 2 pulls down the tubing, she cleaned the tubing. The penis was not cleaned. She sprayed the scrotum and with 13 swipes of the same area of the wipe, she cleaned the scrotum. She obtained another clean wipe and with 6 swipes of the same area of the wipe, she cleaned the scrotum. She obtained a clean wipe, and with 15 swipes with the same area of the wipe, she cleaned the scrotum. The resident was turned onto his left side and the rectal area was cleaned. The CNA applied barrier cream to the rectal area. No redness was observed to the bottom or groin. CNA 7 removed her gloves and used hand sanitizer. She applied fresh gloves. CNA 7 lifted the catheter bag to CNA 8 by lifting it above the resident's bladder and placed it on the left side of the bed. Urine was observed flowing up the tubing, toward the resident. The PPE was removed and hand sanitizer was applied by the CNAs. The trash was removed to the soiled utility room. The trash cans were overflowing onto the floor in the soiled utility room. Both CNAs performed handwashing. During an interview on 10/10/24 at 10:39 a.m., CNA 7 indicated she would clean the creases, then wipe the area under the rectum, on the scrotum. She would then clean the top of the penis and wipe the area around the catheter, by holding the catheter tubing and pulling out away from the tip of the penis. She would then apply cream on the resident. She would turn the resident onto their side and clean their bottom. She would then use hand sanitizer and place clean gloves on. She would finish dressing the resident. When using wipes she would use the wipe once for each swipe, then fold and use. Then a new wipe would be obtained. She felt that during the care on the resident, she didn't change her gloves after the care to apply the cream. 2. The record for Resident 36 was reviewed on 10/11/24 at 11:44 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, severe morbid obesity due to excessive calories, schizophrenia, muscle wasting and atrophy, muscle weakness, metabolic encephalopathy, resistance to beta lactam antibiotics, candidiasis, streptococcus group B, pseudomonas (aeruginosa, pseudo mallei), and anemia. The current care plan, start date of 3/11/21, indicated the resident was incontinent of urine related to impaired mobility. The interventions, dated 5/10/23, included, but were not limited to, apply barrier creams as needed, check the resident for incontinence. Wash, rinse and dry the perineum, and change their clothing PRN after incontinent episodes, observe for signs and symptoms of UTI, and observe and report to the medical provider if one was identified. The Annual MDS assessment from a previous admission, dated 3/1/24, indicated the resident was cognitively intact. The resident required substantial to maximal assistance for toileting hygiene. The urinalysis, dated 5/3/24, indicated the resident's results had a small one plus blood and large three plus leukocyte esterase. The culture and sensitivity, dated 5/3/24, indicated Klebsiella pneumoniae ESBL with a growth of greater than 100,000 CFU/mL. The nurse's note, dated 8/19/24 at 12:15 p.m., indicated the resident arrived to the facility by ambulance with two attendants. The resident would open her eyes occasionally when spoken to and was aroused with physical stimuli. The record indicated, dated 8/19/24, the resident had an infection and was receiving an intravenous antibiotic for a UTI with ESBL. On 8/19/24, an order was received for an intravenous antibiotic for a UTI with ESBL. The physician's note, dated 8/22/24 at 1:00 a.m., indicated the resident's laboratory results resulted in a high blood urea nitrogen (BUN) level of 58 mg/dL (milligrams per deciliter) and a high creatinine level of 1.3 mg/dL. The record indicated on 8/25/24, the resident had an infection and received an intravenous antibiotic for a UTI with ESBL. The Admission MDS assessment, dated 8/26/24, lacked documentation of a cognitive status. The physician's note, dated 8/29/24 at 1:00 a.m., indicated the resident was followed by a nephrologist for elevated serum creatinine levels on 8/22/24. The urinalysis culture and sensitivity indicated the urine had resulted in greater than 100,000 CFU/mL of Klebsiella pneumoniae ESBL. The resident had resistance to third generation cephalosporins, monobactams, and cephamycins. The physician's order, dated 10/6/24, indicated the nursing staff were to administer 875-125 mg of Amoxicillin-Potassium Clavulanate by gastrostomy tube every morning and at bedtime for hydronephrosis for 10 days. The current Perineal Care Male and Female policy, included, but was not limited to, . Equipment and Supplies: If using disposable perineum wipes: a) Disposable wipes b) Towel c) Personal Protective Equipment (e.g. gown, gloves, mask, eye protection, etc., as needed) . b) Continue to wash perineum moving from inside outward to the thighs . Male Residents: . 2- Wash perineal area starting with urethra and working outward. 3- If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area . 5- Wash and rinse urethral area using a circular motion. 6- Continue to wash the perineal area including the penis, scrotum and inner thighs . 9- Gently dry perineum following same sequence . 13- Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. 14- Dry area thoroughly . The current Catheter Care policy, included, but was not limited to, . The risk of bacteremia in residents with indwelling catheters is 3-36 times more likely than residents without an indwelling catheter. Biofilm is the most important cause of bacteriuria in residents with catheters. Reducing the biofilm by performing daily care may help prevent symptomatic infections and incorporate antibiotic stewardship recommendations to reduce unnecessary drugs and antibiotics to reduce resistant strains of infections, as well as maintain the dignity of hygiene of the resident . Cross Reference F880 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure an increase in free water flushes was implemented (Resident B) and failed to ensure staff followed parameters for blood pressure medication administration (Resident D) for 2 of 3 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident B was reviewed on 9/24/24 at 10:08 a.m. The resident's diagnosis included, but was not limited to, gastrostomy status. The physician's order, dated 7/9/24, indicated to flush the resident's feeding tube with 30 ml (milliliters) of free water every hour. The resident's laboratory report, dated 7/15/24, indicated the resident's BUN (blood urea nitrogen) test result was elevated at 31 mg/dl (normal 10 mg/dl to 20mg/dl). A higher than 20 mg/dl suggest that the kidneys may not be functioning at optimal capacity. The nurse practitioner note, dated 7/16/24, indicated to increase the resident's free water flushes to 40 cc's (cubic centimeters) every hour. The clinical record lacked documentation of an order to increase the resident's free water dosage or an increase of the free water flushes to 40 ml. During an interview on 9/26/24 at 1:55 p.m., the Director of Nursing indicated the nurse practitioner was responsible for putting the order in. The order should have been put in the system and the nurse practitioner did not enter them into the system. 2. The clinical record for Resident D was reviewed on 9/25/24 at 10:01 a.m. The diagnosis included, but was not limited to, orthostatic hypotension. The physician's order, dated 7/16/24, indicated the resident was to receive Midodrine HCl (hydrochloride) 10 mg (milligrams) three times a day at 8:00 a.m., 12:00 p.m. and 5:00 p.m. for low blood pressure. The medication was to be held for a systolic blood pressure (SBP) greater than 120. Review of the August 2024 medication administration record indicated the resident received the medication as follows: -8/03/24 at 5:00 p.m. with a SBP of 121 -8/06/24 at 12 p.m. with a SBP of 121 -8/07/24 at 12 p.m. with a SBP of 122 and at 5:00 p.m. with a SBP of 124 -8/08/24 at 8:00 a.m. with a SBP of 126; 12 p.m. with SBP of 123 and 5:00 p.m. with a SBP of 128 -8/11/24 at 12 p.m. with a SBP of 121 and at 5:00 p.m. with a SBP of 129 -8/14/24 at 8:00 a.m. with a SBP of 121 -8/17/24 at 12 p.m. with a SBP of 127 and at 5:00 p.m. with a SBP of 121 -8/21/24 at 8:00 a.m. with a SBP of 121 and at 12 p.m. with a SBP of 129 -8/23/24 at 8:00 a.m. with a SBP of 129 -8/28/24 at 8:00 a.m. with a SBP of 121 -8/29/24 at 5:00 p.m. with a SBP of 121 Review of the the September 2024 medication administration record indicated the resident received the medication as follows: -9/01/24 at 5:00 p.m. with a SBP of 121 -9/02/24 at 12 p.m. with a SBP of 132 -9/06/24 at 8:00 a.m. with a SBP of 122 -9/09/24 at 5:00 p.m. with a SBP of 121 -9/12/24 at 8:00 a.m. with a SBP of 125 -9/14/24 at 12 p.m. with a SBP of 121 and 5:00 p.m. with a SBP of 122 -9/17/24 at 12 p.m. with a SBP of 122 -9/18/24 at 12 p.m. with a SBP of 122 -9/20/24 at 8:00 a.m. with a SBP of 122; 12 p.m. with a SBP of 128; 5:00 p.m. with a SBP of 125 During an interview on 9/26/24 at 2:34 p.m., RN (Registered Nurse) 7 indicated medication parameters should always be followed. On 9/26/24 at 2:45 p.m., the Director of Nursing provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Procedure .Administer medication only as prescribed by the provider This Citation relates to Complaint IN00442515 3.1-37

Based on interview and record review, the facility failed to implement Indwelling catheter care for a resident (Resident B), upon readmission, for 1 of 3 residents reviewed for Indwelling catheters. Findings include: The clinical record for Resident B was reviewed on 9/24/24 at 10:08 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction, bacterial meningitis, gastrostomy status and urinary retention. The care plan, dated 7/5/24, indicated the resident had an indwelling catheter and staff were to provide catheter care every shift. The progress noted, dated 8/16/24 at 7:30 p.m., indicated Resident B was sent to the emergency room for evaluation. Resident B was readmitted to the facility on [DATE] at 5:00 p.m. The hospital history and physical, dated 8/16/24, indicated Resident B had chronic urinary retention, an indwelling catheter was in place which was changed. The resident's indwelling catheter was replaced during the resident's hospital stay. The clinical record lacked documentation of the resident's indwelling catheter care on 8/25/24 and 8/26/24, after the resident's readmission to the facility. During an interview on 9/26/24 at 3:00 p.m., RN (Registered Nurse) 5 indicated a resident's indwelling catheter care should be implemented upon admission. The current, undated policy titled Catheter Care included, but was not limited to, Policy .It is the policy of this facility to provide resident care that meets the .physical .needs .of the resident .Catheter care is performed at least twice daily on residents that have indwelling catheters This Citation relates to Complaint IN00442515 3.1-41(a)

Based on interview and record review, the facility failed to implement a laboratory order for a resident (Resident B) for 1 of 3 residents reviewed for laboratory services. Findings include: The clinical record for Resident B was reviewed on 9/24/24 at 10:08 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction, respiratory failure and hypercalcemia. The nurse practitioner note, dated 7/16/24 at 8:00 a.m., indicated to obtain a BMP (basic metabolic panel) on 7/19/24 due to elevated calcium level of 10.9 (normal range was 8.5 to 10.2). The nurse practitioner note, dated 7/19/24 at 8:15 a.m., indicated the BMP needed to be obtained. The clinical record lacked documentation of the BMP requested by the nurse practitioner. During an interview on 9/26/24 at 1:55 p.m., the Director of Nursing indicated the nurse practitioner was responsible for putting the lab order in. The order should have been put in the system and the nurse practitioner did not enter them into the system. On 9/26/24 at 2:45 p.m., the Director of Nursing provided a current, undated copy of the document titled Laboratory and Radiological Services and Results Reporting. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care that meets the .physical .needs .of the residents .The facility will secure laboratory .services that meet the needs of the resident This Citation relates to Complaint IN00442515 3.1-49(a)

Based on observation, interview, and record review, the facility failed to ensure the treatment for a resident's venous wound was completed, as ordered by the physician, for 1 of 3 residents reviewed for wound care. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/20/23 at 10:49 a.m. The diagnosis included, but was not limited to, vascular wounds to the bilateral lower extremities. On 11/20/23 at 12:00 p.m., Resident B was observed sitting up in his wheelchair in his room with an unna boot (special bandage used for the treatment of venous wounds/ulcers) in place to his bilateral lower extremities. The care plan, dated 12/20/21, indicated the resident had impaired skin integrity and to complete treatments as ordered by the medical provider. The November 2023 Treatment Administration Record (TAR) indicated staff were to cleanse the resident's wounds to the right lower extremity with normal saline or wound cleanser, pat dry, apply hydrofera blue to the open areas and cover with an unna boot every day shift on Tuesday and Friday. The November 2023 TAR lacked documentation of the completion of the treatment on 11/10/23. During an interview on 11/21/23 at 12:05 p.m., RN (Registered Nurse) 4 indicated once a treatment was completed, it should be signed off on the TAR. On 11/21/23 at 12:40 p.m., the Director of Nursing provided a current, undated copy of the document titled Skin Care and Wound Management. It included, but was not limited to, Policy .Residents/patients admitted with .skin integrity issues will receive treatment as indicated This Citation relates to Complaint IN00419997 3.1-37

Based on interview and record review, the facility failed to ensure laboratory services were obtained, as ordered by the physician, for 1 of 3 residents reviewed for laboratory services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/20/23 at 10:49 a.m. The diagnoses included, but were not limited to, chronic osteomylitis, diabetes and end stage renal disease. The physician's order, dated 10/25/23, indicated to obtain Resident B's weekly creatine level, in the evening, for six weeks. The creatine level was to be drawn once a week on Fridays for six weeks. Review of the November 2023 Treatment Administration Record indicated the resident's creatine level was not obtained on Friday, 11/10/23, as ordered by the physician. During an interview on 11/21/23, the Director of Nursing indicated the lab was not obtained on 11/10/23. On 11/21/23 at 12:40 p.m., the Director of Nursing provided a current, undated copy of the document titled Laboratory and Radiological Services and Results Reporting. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .The facility is responsible for the quality and timeliness of services .The facility will request laboratory .services .when ordered by a physician This Citation relates to Complaint IN00419997 3.1-49(a)

Based on observation, record review, and interview, the facility failed to ensure appropriate oversight of medication administration during 5 of 6 random observations. (Residents 32, 37, 11, and 38) Findings include: 1. During an observation of Resident 32 on 8/13/23 at 9:03 a.m., there was a medication cup sitting on the resident's bedside table with two round, white tablets, in the cup. The resident indicated she did not know what the tablets were. During an interview on 8/13/23 at 10:11 a.m., RN 9 indicated she had given Resident 32 her medications with water a while ago. She told the resident they were on her left side. She had not stayed to observe the resident taking the medication. The clinical record for Resident 32 was reviewed on 8/13/23 at 10:00 a.m. The resident's diagnoses included, but were not limited to, blindness of the right eye and weakness. The Annual MDS (Minimum Data Set) Assessment, dated 7/4/23, indicated the resident was cognitively intact. The physician's order, dated 6/29/22, indicated the resident received Tylenol 325 mg (milligrams) every 6 hours as needed for pain. The MAR (Medication Administration Record) lacked documentation of any administration of Tylenol to the resident on the morning of 8/13/23. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications, or any orders for the resident's medications to be left at her bedside. 2. During an observation of Resident 37 on 8/13/23 at 10:01 a.m., the resident was lying in bed. There was a medication cup with two white tablets with an imprint of 54/27 and one unmarked white capsule inside of it. The resident indicated she could not reach the tablets to take them. During an interview on 8/13/23 at 10:07 a.m., Resident 37's roommate, Resident 70, indicated they had not yet received their morning medications so the medications on Resident 37's table had to be her medications from the night prior. The Quarterly MDS Assessment for Resident 70, dated 7/3/23, indicated the resident was cognitively intact. During an interview on 8/13/23 at 10:09 a.m., RN 9 indicated she had not taken any medications to Resident 37 yet that morning and they appeared to be her evening medications. She thought they were her Tylenol and another medication she could not identify. There were some residents who wanted staff to leave their medications at the bedside, but she was aware they should stay with the residents until they took their medications. The clinical record for Resident 37 was reviewed on 8/13/23 at 11:30 a.m. The diagnoses included, but were not limited to, unspecified dementia, wedge compression fracture of lumbar vertebra, and need for assistance with personal care. The Annual MDS Assessment, dated 7/4/23, indicated the resident was cognitively intact. The physician's order, dated 5/23/23, indicated the resident received 2 tablets of Tylenol 325 mg every 6 hours as needed for pain. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications, or any orders for the resident's medications to be left at her bedside. 3. During an observation of Resident 11 on 8/16/23 at 8:37 a.m., the resident was resting in bed. There was a medication cup on her bedside table containing several medications. The medications included a small, white, round tablet with an imprint of ZC41 (identified on a pill identifier website as Coreg 12.5 mg); a blue oblong tablet, stamped A on one side and 17 on the other side (identified on a pill identification website as Zoloft 50 mg); one white round tablet with no imprint; one red gel capsule; and 1 white round tablet with scoring down the middle and no imprint. The resident indicated she thought the medications included her pain reliever, a muscle relaxer, a stool softener, and her anti-anxiety medication, but was not certain what they all were. Staff ordinarily stayed with her until she took them. The clinical record for Resident 11 was reviewed on 8/16/23 at 9:00 a.m. The diagnoses included, but were not limited to, rheumatoid arthritis, constipation, hypertension, and depression. The Annual MDS Assessment, dated 6/23/23, indicated the resident was cognitively intact. The physician's orders included, but were not limited to, Coreg 12.5 mg twice daily, Colace 100 mg twice daily, Flexeril 5 mg every 8 hours as needed for pain, and sertraline 50 mg 3 tablets every morning. The MAR indicated the resident's morning medications for 8/16/23 had been marked as administered. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications, or any orders for the resident's medications to be left at her bedside. 34309 4. a. During an observation on 8/13/23 at 11:25 a.m., Resident 38 was taking two pills on her bedside table. The nurse was not near the room. One pill was white and oblong with a score line. The other pill was round and white. The resident indicated they were pain pills and one was a Norco. During and interview on 8/13/23 at 12:24 p.m., RN 9 indicated she had left the medication for Resident 38 and she could take the Norco on her own. She would later check on the resident to make sure she had taken it after leaving the medication. b. During an observation of Resident 38 on 8/16/23 at 8:34 a.m., she had 11 medications in the medication cup, 2 pills were on the bed, and 2 others were under her forearm on her bed. The nurse was not on the hall. The resident indicated she fell asleep. The resident had a blue color substance on the left corner of her mouth. The record for Resident 38 was reviewed on 8/13/23 at 8:18 a.m. The diagnoses included, but were not limited to, chronic pain, neuropathy, GERD (gastro-esophageal reflux disease), RLS (restless leg syndrome), COPD (chronic obstructive pulmonary disease), diabetes mellitus, hyperlipidemia, and atrial fibrillation. The Quarterly MDS (Minimum Data Set) assessment, dated 5/15/23, indicated the resident was cognitively intact. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications, or any orders for the resident's medications to be left at her bedside. The care plan, dated 10/6/20, indicated the resident had chronic pain related to headaches and was at further risk due to GERD, RLS, and neuropathy. The interventions included, but were not limited to, administer medication per physician's orders and observe for side effects of pain medication. During an interview on 8/16/23 at 8:25 a.m., the DON (Director of Nursing) indicated LPN (Licensed Practical Nurse) 14 had administered the medications to her residents and left the building to take her family member to an appointment. She would be back later in the day. During an interview on 8/16/23 at 8:51 a.m., the DON indicated they should stay with the residents while taking their pills. The DON brought the medications to the medication cart where LPN 9 had returned to the nurse's station. The LPN identified the following medications she had provided to Resident 38: -metformin HCL ER 500 mg give 2 tablets in the morning for diabetes. -Colace capsule, 100 mg give 2 capsules in the morning. -Cyclobenzaprine HCL 5 mg give 1 tablet three times daily for muscle spasms. -Meclizine 12.5 mg give 1 tablet two times daily for dizziness. -Carafate 1 gram give 1 tablet before meals for GERD -Gabapentin 600 mg give 1 tablet three times daily for neuropathy. -Fenofibrate 48 mg give 1 tablet in the morning for hyperlipidemia. -Glimepiride 1 mg give 1 tablet in the morning for diabetes. -Reglan 5 mg give 1 tablet before meals and at bedtime for GERD. -Phenergan 12.5 mg every 24 hours as needed for nausea. -Lasix 40 mg 1 tablet daily for edema. -Metoprolol tartrate 25 mg give 1 tablet in the morning for atrial fibrillation. -Norco 5-325 mg give 1 tablet every 4 hours for increased abdominal pain. -Modafinil 200 mg give 1 tablet in the morning for COPD. During an interview on 8/16/23 at 8:52 a.m., LPN 9 indicated she sat with the resident while she took her medication. She guessed she didn't pay attention to her when she gave the resident her the pills. The blue medication was her Keppra. At noon she would have had more than one pill, she did get a pain pill. The procedure was to sit with the resident while they took their medications. The current Medication Administration policy included, but was not limited to, . I. General Procedures . i. Safety and avoiding adverse effects is considered a high priority for medication administration and may preclude some preferences . bb. Do not leave medication at bedside . 3.1-11(a)

Based on observation, interview and record review, the facility failed to ensure a resident (Resident B) was free from staff to resident abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/8/23 when Resident B alleged the Social Services Director (SSD) kissed him. The SSD was banned from the resident's room on 7/8/23. Resident B had new negative behaviors of acting out, thrashing, and hitting his head on his bed mattress on 7/11/23. The SSD had sent the resident explicit photos of herself to an IPAD the resident had in his possession on 7/14/23 and 7/17/23. On 7/18/23, the resident had an increase in behaviors of cursing and yelling at staff with unsuccessful redirection. The Executive Director, Director of Nursing and Regional Director of Clinical Operations were notified of the Immediate Jeopardy on 7/27/23. The Immediate Jeopardy was removed on 7/28/23, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record for Resident B was reviewed on 7/25/23 at 12:39 p.m. The resident's diagnoses included, but were not limited to, traumatic subdural hemorrhage with loss of consciousness, ventilator dependent, acute and chronic respiratory failure with hypoxia, and fractures of the skull base, right sided zygomatic, right side lateral orbital wall, left tibia, right forearm and cervical. The quarterly MDS (Minimum Data Set) assessment, dated 7/13/23, indicated the resident's cognition was intact. The follow up incident report, dated 7/10/23, indicated during an investigation of an abuse allegation, Resident B alleged a new concern to Staff Member 7 that the SSD would come to his room and kiss him. The progress note, dated 7/11/23 at 2:13 p.m., indicated the resident had continued to display previously observed behaviors such as aggressiveness, yelling, and using profanity towards staff at numerous times throughout the day. (There were no other behavior notes prior to 7/11/23.) The care plan, dated 7/12/23, indicated Resident B had a behavior problem of acting out, thrashing and hitting his head on the mattress when he does not get what he wants; expects staff to spend extended amounts of time with him after care had been provided; attempts to manipulate staff to stay in his room longer; and had made allegations of sexual inappropriateness by staff yet denied the allegations. The interventions included, but were not limited to, approach/speak in a calm manner, consult behavioral health as needed, communicate with resident regarding behaviors, encourage family/girlfriend to visit more often and spend more time with resident to decrease behaviors, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, encourage to express feelings, and notify physician of increased episodes of behaviors. The progress note, dated 7/18/23 at 7:48 a.m., indicated the resident had increased behaviors, cussed and yelled at the clinical staff. Re-direction of the resident was attempted but was unsuccessful. During an interview of 7/25/23 at 1:55 p.m., Resident B indicated no one had ever abused or mistreated him in any way. He denied any kind of relationship with the SSD. They were rumors and he was not sure why the rumors started. The SSD was better than all the other aides. The resident denied any texting, touching, or intimacy of any kind. The SSD was banned (on 7/8/23) from his room. He was sick of the aides as he had to wait on them. The rumors had upset him. He just felt like people were not listening to him. During a confidential interview on 7/25/23 at 3:58 p.m., the complainant indicated that the SSD and Resident B were having a relationship. It was reported to the complainant that a staff member witnessed Resident B and the SSD kiss. The SSD was in the resident's room a lot, and there was a lot of texting between the two. The SSD texted the resident's ex-girlfriend and the family called and had the SSD banned from his room. The resident received texts from the SSD that stated, I love you and Resident B responded with you make my d*** hard. During an interview on 7/25/23 at 4:10 p.m., Staff Member 7 indicated she had witnessed the text messages between Resident B and the SSD. The resident would ask Staff Member 7 to send texts for him because of the limited use of his hands. She recognized the number as a number she had in her phone, which was the number of the SSD. The resident saved the SSD's number under a different name to hide the communication. Before she realized she had been sending texts to the SSD for the resident, she was told by the resident that it was his wife. The resident texted on the IPAD and the texts are very big and several texts could be seen. There were texts that said I love you back and forth. There was a text with the word masturbating in it. She also saw a text to the resident from the SSD number that said when the SSD was rubbing lotion on his arms and legs, she did not know how she had the self-control to stop. The two were still texting. The resident made it clear to her that they were still in communication. The SSD used to never come down and help feed the residents on the 400 Hall. After Resident B admitted , the SSD would feed the resident at just about every single meal with the door closed. On this hall, the doors are not allowed to be closed due to the tracheotomies. Staff Member 7 had entered the resident's room one day when the door was closed to check on him. The SSD was in there feeding the resident and gave her a hateful look. The staff member did not understand why the SSD would look at her that way. During an interview on 7/25/23 at 4:22 p.m., Staff Member 8 indicated she did observe a number on Resident B's phone and recognized the number as the SSD, because all the staff had that number. She had not ever texted for the resident. During an interview on 7/25/23 at 4:25 p.m., Staff Member 10 indicated she could not say for sure whether there was a relationship between the SSD and Resident B. Resident B had told Staff Member 10 that he and the SSD were still in communication when there was not supposed to be any communication between them. During an interview on 7/25/23 at 4:29 p.m., Staff Member 11 indicated she had spoken with the SSD and asked why she was at the facility late every night. The SSD told her that she was told she had to. She had not seen any texts between Resident B or the SSD. Staff Member 11 told the SSD that if she was doing what she heard, she needed to stop. The staff had an obligation to the residents and that line cannot be crossed. During an interview on 7/26/23 at 11:28 a.m., Staff Member 12 indicated she reported the texting on 7/6/23. Prior to Resident B admitting to the facility the SSD was never on the hall. After Resident B came to the facility the SSD was on the hall and fed the resident breakfast, lunch and dinner. The resident would have Staff Member 12 and Staff Member 15 text for him. He asked Staff Member 15 to text someone for him. When both staff members asked the resident who the someone was, the resident just laughed. Resident B told both staff members that the SSD was not allowed in his room anymore. Staff Member 12 exited the room at that time and asked the DON (Director of Nursing) about the SSD not being allowed in the resident's room and about the texts. The DON asked her to look at the number next time. She did and she and the Unit Manager confirmed the number belonged to the SSD and reported it. Resident B asked Staff Member 12 and Staff Member 15 who they thought the person was the resident was having them text. Staff Member 12 responded with the SSD's name and Resident B stated yes. Resident B had Staff Member 12 send a text to the number that said, stick with the plan and are you coming down for lunch. Staff Member 12 could see previous texts due to the size of the IPAD screen. One text said, I love you and another good night, all from the number of the SSD. There was a message that Resident B had sent to the SSD number which said, you make my d*** so hard. This past Friday (7/21/23), there was a text sent from Resident B to the SSD number that said, you take such good care of daddy and then the response from the SSD number was I love you so much. Not long after that, food was delivered to the resident. Staff Member 12 was not sure if it was a coincidence or not but thought it strange that food was delivered to the resident not long after the text messages. During a telephone interview on 7/26/23 at 1:02 p.m., Staff Member 14 indicated the SSD had purchased clothes for Resident B. A delivery came with the SSD name on the box. Staff Member 14 asked who the clothes were for and was told Resident B. She was not sure whether the SSD had purchased the IPAD for Resident B. During an interview on 7/26/23 at 1:31 p.m., Staff Member 15 indicated that Resident B had called both she and Staff Member 12 to his room. Resident B told them both that he and the SSD had been texting and he had the SSD number saved as another woman. The only name Staff Member 15 had seen was the other woman with a heart emoji next to the name. During an interview on 7/27/23 at 9:45 a.m., the ED (Executive Director) indicated she had the SSD come in for an interview. The SSD let her look at her phone. There were no inappropriate messages that she could see. The SSD told her the IPAD was hers and she had purchased it during COVID for facetime visits with families. The SSD was letting Resident B use the IPAD until he got his cell phone and was better able to work the phone since he only had the use of one hand. Since the IPAD did not belong to the resident, they were going to ask to see the IPAD and give him the chance to delete his personal information in order not to violate his rights. The progress note, dated 7/27/23 at 10:14 a.m., indicated the DON and ED discussed with resident that the IPAD was loaned to him for short term use and that facility needed to retrieve the IPAD related to the ongoing investigation. The resident got upset and stated, No you cannot have it, I have personal stuff in there I do not want anyone to see. It was explained to the resident that he would have adequate time to remove anything personal that he did not want anyone to see. The resident agreed to 1 hour of time to remove his personal information. During an observation of the IPAD on 7/27/23 at 1:35 p.m., with the DON present, the IPAD showed no text messages between the resident and the SSD. Review of the history on the IPAD, under photos, there were 5 explicit photos sent to the resident on 7/14/23 and 7/17/23. The DON identified the person in the photos as the facilities SSD. One of the photos sent to the IPAD by the SSD while the resident had the IPAD in his possession was of the SSD without clothing. On 7/25/23 at 12:15 p.m., the Director of Nursing provided a current, undated copy of the document titled INDIANA Abuse & Neglect & Misappropriation of Properly. It included, but was not limited to, Mistreatment .In Indiana is defined as staff .exploiting a resident .Examples .romantic and/or inappropriate relationship between staff and resident that does not involve physical intimacy .texting romantic notes to a resident .Policy .It is the policy of this facility to provide resident centered care that meets the psychosocial .and emotional needs .of the residents .It is the intent of this facility to prevent abuse, mistreatment .of residents The Immediate Jeopardy, that began on 7/8/23, was removed on 7/28/23, when the facility conducted the following: The DON/Designee completed a full house audit of all interviewable residents for any concerns of abuse (dated 7/27/23); skin assessments were completed on all residents unable to complete interviews and assessed for signs and symptoms of decline in psychosocial well-being (dated 7/27/23); all facility communication devices were reviewed and audited for any inappropriate communication between staff and residents (dated 7/27/23); all staff were educated on abuse with focus on types of abuse, inappropriate communications via in person or electronic communication devices, proper boundaries between staff and resident (dated 7/27/23); resident rights (dated 7/28/23); standard of conduct and cell phone policy (dated 7/27/23); change of condition with focus on behavior notification and follow up with the appropriate psychosocial evaluation and monitoring (dated 7/27/23). This Federal tag relates to Complaints IN00412690 and IN00413727. 3.1-27(a)(1)

Based on observation, record review, and interview, the facility failed to implement interventions to prevent the development and worsening of multiple facility acquired pressure ulcers resulting in three unstageable wounds, two Stage 3 pressure ulcers (PU) and a reopened Stage 2 PU. Two of the pressure ulcers worsened to a Stage 4; two of the pressure ulcers developed infections; and one Stage 4 PU worsened with [CONDITION(S)] requiring IV antibiotics for 5 of 10 residents reviewed for Presure Ulcers. (Residents E, D, B, C, and F) The Immediate Jeopardy began on 1/13/22 when the facility failed to identify, prevent, and implement interventions to prevent and worsening of pressure ulcers. The Executive Director, Director of Nursing, and Clinical Director of Clinical Operations were notified of the Immediate Jeopardy on 8/12/22 at 3:30 p.m. The Immediate Jeopardy was removed on 8/16/22, but noncompliance remained at the lower scope and severity level of H. Findings include: 1. The clinical record for Resident E was reviewed on 8/9/22 at 11:08 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) assessment, dated 6/3/22, indicated the resident was cognitively intact, did not exhibit any refusal of care behaviors, required extensive assistance of two staff with bed mobility and personal hygiene, was completely dependent with toileting, was always incontinent of stool, was at risk for developing pressure ulcers, had a stage 3 pressure ulcer which was present on admission, a stage 4 pressure ulcer which was not present on admission, had a pressure reducing device for her bed, but did not have a turning or repositioning program, and received pressure ulcer care. The resident had impairments in functional range of motion to the bilateral upper and lower extremities. The care plan, dated 6/7/21, indicated the resident was at risk for altered skin integrity due to disease process, immobility, incontinence, [CONDITION(S)], and g-tube (feeding tube) status. The interventions included, but were not limited to, administer treatments as ordered, apply appropriate pressure reducing appliances to bed and wheelchair, apply barrier creams post incontinent episodes, apply protective garments as ordered, avoid pressure from drainage tubes, orthotics, braces, and footwear, complete skin at risk assessment upon admission, readmission, quarterly and as needed, complete weekly skin checks, ensure residents are turned and repositioned, evaluate existing wound daily for changes, notify resident or representative and medical provider of any decline in wound healing, nutritional consult on admission, quarterly, and as needed, podiatry consult as ordered, provide appropriate off-loading cushion to chair, provide appropriate off-loading mattress, provide diet as ordered, and PT/OT to evaluate and treat as needed for positioning and wound care. The wound analysis, dated 5/18/21, indicated the resident had an area of MASD (Moisture-Associated Skin Damage) to the sacrum, acquired in house. No measurements were documented. The wound had scant sanguineous drainage, was debrided, and a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound had been active since 4/27/21, and the clinical record indicated the wound later developed into two stage 3 pressure ulcers to the left ishium and coccyx on 1/13/22. The wound analysis, dated 1/13/22, indicated the resident had a stage 3 pressure ulcer to the coccyx, measuring 3.37 cm in length by 4.07 cm in width by 0.10 cm in depth which was worsening. It had 90% granulation and 10% epithelialization, the peri wound was fragile, there was scant serous drainage. Treatment included to cleanse with wound cleanser three times weekly and dress with medi-honey and bordered foam and ensure compliance with turning and repositioning. The wound analysis, dated 1/13/22, indicated the resident had a new unstageable pressure ulcer to the left ischium, measuring 2.63 cm on length, 2.28 cm in width by 0.1 cm in depth. The wound had 2.71 cm of red tissue, 0.32 cm of pink tissue, and 0.45 cm of black tissue. There was scant serosanguinous drainage. The wound was 100% slough or eschar (dead tissue). The treatment indicated to cleanse with normal saline, apply [MEDICATION(S)], and a bordered foam dressing three times weekly. The clinical record indicated this wound healed on 2/8/22. The wound note, dated 1/13/22 at 9:14 p.m., indicated the resident was seen for a comprehensive skin and wound evaluation for a left ischium ulcer and coccyx pressure ulcer. The resident had a stage 3 pressure ulcer to the left ischium which was new, and a stage 3 pressure ulcer to the coccyx, which was previously MASD. Recommendations included pressure reduction and discussion with staff at the time of the visit of recommendations to include heel protection and pressure reduction to bony prominences, recommendations to provide frequent incontinent care. Due to the patient's comorbidities and risk factors for wound decompensation the patient required turning and repositioning every 1 hour and may consider avoiding sitting or lying directly flat at all times when possible. The care plan lacked documentation of any updates with interventions to turn and reposition the resident every hour. The wound analysis, dated 1/18/22, indicated the resident had a wound to the right ischium, which was first observed on 1/13/22. The wound was classified as an unstageable pressure ulcer. The wound measured 1.40 cm in length, 1.28 cm in width, and 0 cm in depth. The wound was 100% covered with slough or eschar. Treatment indicated to cleanse with normal saline and apply [MEDICATION(S)] and a bordered foam dressing every 3 days. The wound analysis, dated 1/18/22, indicated the coccyx wound measured 7.43 cm in length, with a width of 9.69 cm and a depth of 0 cm. The wound was worsening, and had 70% granulation, 30% slough, moderate serosanguinous drainage with no odor, and the treatment was unchanged. Pressure reduction included mattress overlay, specialty bed, ensure compliance with turning protocol, and wedge/foam cushion for offloading. The wound note, dated 1/18/22 at 4:01 p.m., indicated the resident was seen for a comprehensive wound evaluation for left and right ischium ulcers and a pressure ulcer to her coccyx and her right back. The wounds were described as a stage 3 pressure ulcer to her left ischium and a stage 3 pressure ulcer to her coccyx with major overall worsening, which was previously MASD. She had a new area to the right upper back which was classified as a deep tissue injury. The resident had experienced an oral intake decline and often refused meals. The resident was severely contracted in almost every joint. Staff indicated the resident refused to turn many times to relieve pressure. The physician discussed pressure reduction and turning precautions with staff at the time of the visit, including heel protection and pressure reduction to bony prominences. The resident had extensive wound decline, culture and lab results were pending with a potential for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required turning and repositioning every hour and may consider avoiding sitting or lying directly flat at all times when possible. The wound analysis, dated 1/18/22, indicated the resident had a new suspected DTI to the right back, measuring 12.56 cm in length, 6.08 cm in width, and 0 cm in depth. Treatment included skin prep twice daily. The clinical record indicated this wound was healed on 3/15/22. The lab report, dated 1/19/22, indicated the resident had a basic metabolic panel (BMP) and a complete blood count (CBC). The resident's white blood cell count was high at 13.0 k/cmm with a normal value range of 4.5 to 10.8K/cmm. The resident's absolute neuts were high at 9.90 K/uL with a normal value range of 1.50 to 7.60 K/uL. The resident's monocytes were high at 1.20 K/uL with a normal value range of 0.15 to 1/10 K/uL. The resident's EOS were high at 0.10 K/uL with a normal value range of 0.20 to 0.80 K/uL. The nurse's note, dated 1/19/22 at 2:47 p.m., indicated the NP reviewed the resident's lab results and ordered [MEDICATION(S)] 100 mg every morning and at bedtime for a wound infection for 10 days. The wound note, dated 1/26/22 at 8:23 p.m., indicated the resident had multiple scattered pressure ulcers with observed deep tissue injuries. She had increased moisture at the wound site. Staff were encouraged to keep the site always covered and avoid contamination with feces. She required turning and repositioning every hour. The wound analysis, dated 2/22/22, indicated the wound measured 9.13 cm in L x 8.69 cm in width x 0.02 cm in D (depth), improving, 60% granulation, 40% slough. Treatment unchanged. The wound was debrided. The wound note, dated 2/22/22 at 6:29 p.m., indicated the surgical debridement was performed to the resident's ulcer. Devitalized epidermis, dermis and subcutaneous tissue (tissue that impedes healing and acts as an origin for wound infection) including but not limited to biofilm were removed to keep the wound in an active state of healing. Nursing staff were given detailed ulcer care instructions and asked to monitor for any signs of prolonged bleeding or debridement intolerance. The wound note, dated 3/15/22 at 2:30 p.m., indicated the resident's wounds were now joining together. The re-admission skin grid pressure assessment, dated 4/1/22, indicated the resident had a stage 3 pressure ulcer to the sacrum measuring 6.5 cm in L x 6 cm in W x 0 cm in D. The treatment order, dated 4/1/22, indicated to apply [MEDICATION(S)]-zinc oxide lotion to sacrum twice daily for skin irritation. The wound analysis, dated 4/5/22, indicated the sacrum wound measured 6.48 cm in L, 7.33 cm in W, 0.02 cm in D. The wound was worsening and was now classified as a stage 4 with exposed bone. There was 60% granulation and 40% slough. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound analysis, dated 4/5/22, indicated the resident had an unstageable pressure ulcer to the left upper sacrum which was previously grouped with the sacrum and had separated and made as it's own wound. The wound measured 2.62 cm in length, 1.57 cm in width, and 0 cm in depth. The wound was covered with 100% slough or eschar. The wound note, dated 4/5/22 at 9:40 p.m., indicated the resident had a comprehensive skin and wound evaluation for readmission to the facility. She had a stage 4 pressure ulcer to the sacrum which was previously a stage 3 and a stage 3 to the upper sacrum which was previously clustered with the sacrum. She had a right hip unstageable pressure ulcer. The physician recommended to keep the wound dry, to turn and reposition every 1 hour, and a nutrition consult. The nurse's note, dated 5/4/22 at 8:50 p.m., indicated the resident returned to the facility and was refusing all skin assessments, however had a wound to her sacrum. The wound analysis, dated 5/6/22, indicated the wound measured 4.27 cm in L x 5.58 cm in W x 0.01 cm in depth, improving, 90% granulation 10% slough, treatment unchanged. During an observation on 8/10/22 at 10:11 a.m., Resident E was resting abed. Her lower extremities were completely contracted and were positioned on a pillow, with her right foot and heel directly touching the pillow and were not offloaded. Her left heel was floating off the edge of the pillow. The resident did not have any pressure relief boots in place. The Respiratory Therapy Director removed the blanket and observed the resident, however, did not reposition the resident or place any pressure relief boots on her. During an observation on 8/10/22 at 11:47 a.m., LPN 7 and the Wound Nurse entered the resident's room to perform wound care. The blankets were removed and both of the resident's heels were observed to be lying directly on a pillow and were not properly offloaded. There were no pressure relief boots in place. A large portion of the resident's bottom was covered in scar tissue. The wound nurse indicated she believed the resident had a stage 3 pressure ulcer and the facility had a lot of pressure ulcers. Two open areas were observed to the coccyx which appeared to be fully granulating with less than 5% yellow tissue. The wound was cleansed, collagen with silver was applied to the wound bed with a foam border secondary dressing applied. The resident was repositioned with her heels again lying directly on the pillow and not floated. Staff indicated the care was completed and left the room. On 8/11/22, Resident E was observed to be lying turned to her right side in her bed. The resident's heels were resting directly on a pillow, with both heels touching and resting on the surface of the pillow. At 8:33 a.m., a nurse entered the room but did not reposition the resident. At 8:50 a.m., the Wounds Care nurse entered the room but did not reposition the resident. Staff did not reposition the resident until 10:42 a.m., when CNA 5 and CNA 6 entered the room and turned her to the left side. They replaced the pillow under the resident's feet, resting her heels directly on the pillow without allowing them to float. The resident did not appear to be resistive to turning or repositioning and did not refuse to allow staff to turn her. During an interview on 8/11/22 at 10:33 a.m., CNA 5 and CNA 6 indicated they had not turned the resident since before breakfast, which would have been prior to 8:00 that morning. During an interview on 8/11/22 at 10:42 a.m., CNA 5 and CNA 6 indicated they tried to turn the residents every 2 hours but, . we may be a little off . They were not aware of the resident requiring any more frequent turning schedules. They were unaware of the resident every wearing heel protector boots, and they had never seen any in her room. During an interview, on 8/12/22 at 8:42 a.m., the Wound NP indicated when she took over care for the resident, she had a lot of sacral and hip wounds. She at one point had an upper back wound, and now was dealing with a stage 4 wound to her sacrum. She was very contracted and underweight. If she were to put pressure on the pillows, there would be a concern for developing a pressure wound. If the resident had boots, she had not seen them on her. She recommended they off load and float the resident's heels, and she would have recommended heel protectors in the past. 2. The clinical record for Resident D was reviewed on 8/9/22 at 1:13 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission skin assessment, dated 5/4/22, indicated the resident had a stage 4 pressure ulcer to the coccyx which measured 10 cm in length, by 7 cm in width, by 0.5 cm in depth. The resident's sensory perception was completely limited, his skin was constantly moist, he was bedfast, he was completely immobile, his nutrition was very poor, and he had an identified problem with friction and shear. His Braden scale scoring was 6, which was classified as a very high risk for developing pressure ulcers. The care plan, dated 5/5/22, Indicated the resident had impaired skin integrity, including pressure ulcers to his coccyx, a stage 3 to his sacrum, a stage 2 pressure ulcer to his left heel, related to immobility. An intervention to elevate the resident's legs as he would allow was initiated on 8/3/22. The care plan indicated to ensure the resident was turned and repositioned but did not specify a schedule or instructions to turn every hour. The wound analysis, dated 5/6/22, indicated the resident had an unstageable pressure ulcer to the sacrum, which was present on admission, which measured 8.39 cm in L x 4.99 cm in W x 0 cm in depth. The treatment indicated to cleanse with normal saline, and dress with medi-honey and bordered foam every 3 days and as needed for soilage. The wound note, dated 5/11/22 at 4:05 p.m., indicated the resident had multiple wounds including an unstageable pressure ulcer to the sacrum, an unstageable pressure ulcer to the left heel and a deep tissue injury to the right heel. Recommendations included, but were not limited to, heel protection and pressure reduction to bony prominences, turning every 1 hours due to the patient's comorbidities and risk factors for wound decompensation and new wound development, avoid sitting or lying flat at all times when possible. A nutrition consult was recommended to optimize wound healing. The Wound Analysis, dated 6/3/22, indicated the resident's wound was worsening. The measurements were 7.63 cm in L x 9.1 cm in W x 0 cm in D. The resident's treatment was unchanged. The Admission MDS assessment, dated 6/8/22, indicated the resident was severely cognitively impaired, was totally dependent on staff for bed mobility, toileting, and personal hygiene, did not exhibit any behaviors of rejection of care, was at risk for developing pressure ulcers. The resident had a pressure reducing device for the chair and bed and pressure ulcer care but did not indicate a turning and repositioning program. The wound analysis, dated 6/14/22, indicated the wound was reclassified as a stage 3 pressure ulcer. The wound analysis, dated 7/12/22, indicated the wound measured 6.88 cm in L x 8.51 cm in W x 2.5 cm in D, stable. The measurements were post debridement, treatment unchanged. The wound analysis, dated 7/22/22, indicated the resident developed a new unstageable pressure ulcer to the right elbow, measuring 1.38 cm in length by 1.02 cm in W by 0 cm in D. It was a suspected DTI. Treatment indicated to apply skin prep and leave open to air three times daily. Preventative measures included offloading the elbow on a pillow. The wound analysis, dated 8/5/22, indicated the resident developed a new stage 2 pressure ulcer to the right posterior leg measuring 6.45 cm in L x 4.2 cm in W x 0 cm in depth which was described as having intact epithelium which was serous filled (a blister). Treatment indicated to apply skin prep and leave open to air twice daily. During an observation on 8/10/22 at 11:13 a.m., the wound nurse and LPN 7 provided wound care for Resident D. The wound to the resident's coccyx appeared to be a large open wound with approximately 30% of the wound bed covered with yellow stringy tissue. The wound to the resident's right elbow was scabbed over and indicated as healed by the wound nurse. The wound to the resident's left heel was a superficial pink, healing wound with scant serosanguineous drainage. The wound to the right posterior leg was observed to be healing, with no drainage, there was a dry area of reddish discoloration. A new wound to the resident's right ankle bone was observed at this time which the Wound Nurse estimated was approximately 2 cm in length by 1 cm in width, with 25% of the wound presenting as a red open area, and 75% of the wound with a moist, darkened black-purple area. There was a scant amount of serosanguinous drainage as described by the Wound Nurse to the edge of the wound. The wound nurse indicated the resident often got blisters on his lower extremities. The Skin Grid Pressure note, dated 8/10/22 at 1:00 p.m., indicated the resident had a new area to the right outer ankle, which was classified as a stage one. The measurements of the wound were 2 cm in length by 1 cm in width, by 0.2 cm in depth. The IDT follow up note, dated 8/10/22 at 1:23 p.m., indicated the resident had developed a new stage 1 pressure ulcer to his right outer ankle, the root cause was pressure to the right outer ankle. The intervention put into place was heel lift boots, dietary consult on 8/10/22, and prostat twice daily. Observations of Resident D were conducted on 8/11/22. At 8:20 a.m., the resident was observed to be lying on his right side, with a purple wedge pillow under his right elbow, heel protector boots in place, and a pillow under his left side. At 8:56 a.m., the nurse entered the room and provided medications to the resident. She exited the room at 9:05 a.m., but did not reposition the resident during the time she was in the room. At 9:05 a.m., the Wound Nurse entered the room and administered the resident's tube feeding and replaced his water flush bag but did not turn or reposition the resident. She exited the room at 9:20 a.m. Staff did not enter the resident's room again until 10:20 a.m., when CNA 5 and CNA 6 entered the room to provide care and reposition the resident. They both indicated the last time they repositioned the resident was before 8:00 that same morning. The area to the resident's right ankle was observed to be about nickel sized, with a dark, black hardened tissue covering the wound bed. The surrounding skin was reddened. The wound appeared larger than the day before. The CNA's removed the pillows from the resident's left side, and moved it to his right side, and removed the wedge from the resident's right side and moved it to his left side. The resident was not turned and remained positioned on his right side. The CNAs did not attempt to reposition the resident onto his back or his right side. The resident did not make any independent movement or attempts to reject or resist care. During an interview on 8/11/22 at 9:20 a.m., CNA 5 and CNA 6 both indicated they tried to turn the resident every 2 hours, from his right side to his back, or his left side, however the resident preferred his right side and usually ended up going back there so they moved the pillows and wedges to the opposite side of whatever side they were on. They were not aware of the resident needing to be turned any more frequently than every 2 hours. During an interview on 8/11/22 at 11:24 a.m., the DON indicated usually a stage 1 pressure ulcer was not open. It was a non-blanchable reddened or discolored area. If it were open, it would be a stage 2, 3, or 4. If the wound was moist and dark, it sounded like it would be a DTI. She was informed of the resident developing a new pressure wound on 8/10/22 by the Wound Nurse, who informed her it a stage 1 pressure ulcer and it wasn't opened. She had described it to her as discolored and it was a stage 1. With the resident's comorbidities, things could happen very quickly for him. His skin assessment was due either 8/10/22 or 8/11/22. It had been several days since he'd had a true skin assessment. The Wound Nurse told her it looked like a scab, but she wasn't sure if it was scab. She told the wound nurse if it was opened it was a stage 2, 3, or 4. The Wound NP may change the staging. During an interview on 8/12/22 at 8:40 a.m., the Wound NP indicated she saw the resident on 8/12/22 for a new wound to his ankle. She was not able to stage it and classified it as an unstageable pressure ulcer. The perimeter of the wound had opened. The facility told her they thought it was a DTI, but because the skin had broken open and she could not see the wound bed it was unstageable. The resident had admitted with a wound to his sacrum. He had developed a lot of DTIs since admission to the facility. He was very overweight, and very hard to move in bed. It was hard to get him in a decent position. He liked to cross his legs and ankles so she could see how he got the ankle wound. Staff should be turning him every 2 hours, but if they could do more that would be great. Their system automatically recommended turning every 1 hour, but that was not very feasible. She recommended they turn at least every 2 hours. It was hard for her to say the wounds to either Resident D or Resident E were unavoidable. They were both at a very high risk for developing new wounds. She would have to see both residents daily to know if they were unavoidable. The Wound Analysis, dated 8/12/22, indicated the resident was seen by the Wound NP. He had a new unstageable pressure ulcer to the right lateral ankle. The wound measured 1.68 cm in length, by 1.58 cm in width, by 0.01 cm in depth. There was 1.14 squared cm of black tissue to the wound bed and scant serous drainage. The recommended treatment was to cleanse with normal saline, apply [MEDICATION(S)], and a bordered foam daily. The pressure reduction interventions included to float the resident's heels and apply soft offloading boots. 3.The clinical record for Resident B was reviewed on 8/10/22 at 1:32 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 10/23/21, indicated the resident had impairments to the bilateral lower extremities. The annual MDS assessment, dated 7/29/22, indicated the resident was cognitively intact, did not exhibit any refusal of care behaviors, required extensive assistance of two staff with bed mobility and personal hygiene, was completely dependent with toileting, was always incontinent of stool, was at risk for developing pressure ulcers, had a stage 4 pressure ulcer which was not present on admission, had a pressure reducing boot for his right heel, but did not have a turning or repositioning program, and received pressure ulcer care. The resident had impairments to the bilateral lower extremities. The care plan, dated 11/24/21 and revised on 6/22/22, indicated the resident had the potential and actual impairment to skin integrity related to impaired mobility with [CONDITION(S)]. The right heel pressure ulcer was unstageable on 11/23/21 and resolved on 5/18/22. On 6/22/22 the pressure wound reopened at a stage 4. The bottom of the right foot deep tissue injury on 12/14/21 and resolved on 1/4/22. The interventions included, but were not limited to, educate the resident, family and caregivers of causative factors and measures to prevent skin injury, elevate legs and float heels as resident will allow, encourage good nutrition and hydration in order to promote healthier skin, encourage resident to turn and reposition every 1 to 2 hours as resident will allow, followed by wound consult, and identify and document potential causative factors and eliminate or resolve where possible, keep the skin clean and dry. Staff were to monitor and document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to the physician, use pressure relieving and reducing cushion to protect the skin while the resident was up in the chair. Treatments as ordered. The wound analysis, dated 11/23/21, indicated the resident had a suspected deep tissue injury the right heel. The measurements included length 4.45 cm (centimeters), width 4.35 cm, and depth 0. The pressure wound was acquired in house. The periwound was macerated (when the skin was in contact with moisture for too long). Treatment included [MEDICATION(S)] dressing with a secondary kling or kerlix dressing. The dressing was to be changed 2 times a day and elevate the resident legs to level of his heart or above for 30 minutes one time a day. Pressure reduction and offloading, elevate legs regularly using a wedge or foam for offloading. The wound analysis, dated 1/25/22, indicated the resident's right heel was a stage 4 with exposed tendons. The measurements included length 4.58 cm, width 4.62 cm, and depth 1.00 cm. The wound had a heavy amount of serosanguinous drainage and had a malodorous odor. The peri wound was [CONDITION(S)]. Treatments included cleanse the wound with normal saline, Dakin's moist to dry dressing, and cover with a border dressing. The wound analysis, dated 3/01/22, indicated the right heel wound was a stage 4. The measurements included length 3.84 cm, width 4.07 cm, and depth 0. The wound had 60 % (percent) granulation tissue and 40% slough or eschar. There was a moderate amount of serosanguinous drainage with no odor. The peri wound had [CONDITION(S)]. The treatments included cleanse the wound with normal saline and apply a collagen dressing 1 time per day and cover with a boarder dressing. The wound analysis, dated 2/8/22, indicated the resident's right heel was a stage 4 and the wound bed had exposed tendons. Measurements included length 4.84 cm, width 5.88 cm, and depth 0.30 cm. The wound has 90% granulation tissue and 10% slough or eschar. There was a moderate amount of serosanguinous drainage with no odor. The Peri wound had [CONDITION(S)]. Treatments included cleanse the wound with normal saline, apply a Santyl dressing and cover with a bordered dressing 1 time a day. The wound analysis, dated 3/8/22, indicated the resident's right heel wound measurements included length 3.98 cm, width 4.26 cm, and depth 0.01 cm. The wound had 80% granulation tissue and 20% slough or eschar. Moderate amount of serous drainage with no odor. The peri wound had [CONDITION(S)]. Treatments included a collagen dressing and covered with a secondary bordered gauze 1 time per day. The wound analysis, dated 5/24/22, indicated the residents right heel had heeled. The wound analysis, dated 6/24/22, indicated the right heel pressure wound reopened at a stage 4. Measurements included length 3.25 cm, width 4.35 cm, and depth 0.30 cm. The wound had 20% granulation tissue and 80% slough or eschar. Moderate amount of serosanguinous drainage with no odor. The peri wound was intact. Treatments included cleanse the wound with normal saline and apply a hydrogel dressing covered with a bordered gauze dressing. The NP progress note, dated 7/5/22, indicated she recommend continuation of elevation of legs while in bed as well as floating bilateral heels. Wound culture was ordered by medical nurse practitioner and still awaiting results. The X-ray obtained showed [CONDITION(S)], but medical provider was awaiting culture for specified antibiotic orders. The labs were reviewed, and the white blood cell count is within normal limits. Additional Recommendations included, the resident had a pressure injury, pressure reduction and turning precautions discussed with staff at time of visit, including heel protection and pressure reduction to bony prominences. The resident was at a moderate to severe risk of significant complications, morbidity and/or mortality due to comorbidities and wound. The culture and lab results are pending with a potential for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP progress note, dated 7/13/22, indicated a follow up to the resident's right heel pressure wound [CONDITION(S)]. The right heel x-ray showed possible [CONDITION(S)] on 7/1/22 and the wound culture results. The resident was started on IV (Intravenous) antibiotics for 10 days and a prevalon boot to the right foot. The resident's right heel wound had reopened with drainage and swelling. The resident was paraplegic and could not feel his bilateral lower extremities. During an observation on 8/11/22 at 1:00 p.m., the wound care nurse donned gloves and removed the resident's prevalon boot and old dressing. She cleaned the wound with NS (Normal Saline). She removed her gloves and donned a clean pair of gloves and applied the collagen with silver [MEDICATION(S)] dressing. A boarded foam dressing was applied over the collagen dressing. The wound had a scabbed area approximately three and a half inch long. The wound had a small dark area in the middle of the scab. No drainage or foul odor. During an interview on 8/10/22 at 1:32 p.m., Resident B indicated he was paralyzed fr

Based on observation, interview and record review, the facility failed to ensure residents (Residents B and C) were provided adequate supervision and assistance of two staff members in accordance with their assessments and comprehensive care plans when a resident (Resident B) was transferred with a mechanical lift, by one staff member, which resulted in a T3 (thoracic vertebrae)and T4 fracture after a fall from the lift and when a staff member provided care to a resident (Resident C) which resulted in a fall from the bed and medical intervention of 13 sutures for 2 of 3 residents reviewed for accident hazards. Findings include: 1. The clinical record for Resident B was reviewed on 5/24/22 at 11:10 a.m. The diagnosis included, but was not limited to, [CONDITION(S)]. The quarterly MDS (Minimum Data Set) assessment, dated 4/20/22, indicated the resident had intact cognition and required the physical assistance of two staff members for transfers. The care plan, dated 1/28/21, indicated the resident had a self-care deficit and required a two person (staff) support with the mechanical lift transfers. The incident report, dated 5/17/22 at 10:50 a.m., indicated Resident B had a witnessed fall during a transfer which resulted in a T3 and T4 fracture. The IDT (Interdisciplinary) follow up note, dated 5/18/22 at 11:00 a.m., indicated the resident fell from the lift and complained of neck and back pain. The resident was sent to the emergency department for evaluation. The resident was transferred with the use of a mechanical lift from the wheelchair to the bed by one staff member. The resident was care planned for the assistance of two staff with transfers The emergency department note, dated 5/18/22, indicated the resident had fallen from a mechanical lift during a transfer, landed on her head, and complained of neck and upper back pain. The hospital radiology report, dated 5/18/22, indicated the resident had a compression fracture of the T3 and an impaction fracture of the T4. During an interview on 5/24/22 at 10:16 a.m., Resident B indicated PCA (Personal Care Assistant) 4 was transferring her alone. She was 4 to 5 feet in the air when one of the straps came undone. She slid out of the back of the lift pad and landed on her head and back. During an interview on 5/24/22 at 10:46 a.m., the Director of Nursing indicated she felt the lift pad strap was not secured and PCA 4 was no longer at the facility. 2. The clinical record for Resident C was reviewed on 5/24/22 at 11:34 a.m. The diagnoses included, but were not limited to, acute/chronic [CONDITION(S)] and ventilator dependent. The admission MDS assessment, dated 4/28/22, indicated the resident had intact cognition and required the physical assistance of two staff members for bed mobility. On 5/24/22 at 5:15 p.m., the resident's left lower extremity was observed with 13 sutures and 5 steri strips (adhesive bandages) in place. The care plan, dated 4/13/22, indicated the resident had a self-care deficit and required staff assistance of two with bed mobility. The progress note, dated 5/11/22 at 8:10 a.m., indicated the resident had a fall with a laceration to the lower extremity and pressure was applied. CNA (Certified Nursing Assistant) 3 was providing care and the resident normally holds on to the enabler bar. The resident lost her grip and CNA 3's attempt to prevent the fall was not successful. The resident was sent to the emergency department for evaluation. The skin grid non-pressure sheet, dated 5/11/22 at 9:00 a.m., indicated the laceration measured 18 cm (centimeters) in length and 3 cm in width. During an interview on 5/24/22 at 11:34 a.m., the resident was observed resting in bed. The left lower shin was covered with a large bandage. Resident C indicated CNA 3 was the only aide providing care at the time of the incident. CNA 3 pulled her lift sheet towards the left and rolled her on her right side, at which time her legs were at the edge of the bed. CNA 3 again, pulled the lift sheet towards the left and her legs went off the edge of the bed. She had 13 stitches to her shin. During an interview on 5/24/22 at 4:59 p.m., LPN (Licensed Practical Nurse) 6 indicated the residents' care plan should always be followed. On 5/24/22 at 5:42 p.m., the Executive Director provided a current copy of the document titled Plan of Care Overview dated 7/26/18. It included, but was not limited to, Definitions .PoC: for the purpose of this policy the Plan of Care, also Care Plan is written treatment provided for a resident that is resident-focused and provides for optimal personalized care .It is the policy of the facility to provide resident centered care .Safety is a primary concerns for our residents This Federal tag relates to Complaint IN 637 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and to sufficiently monitor residents with a history of drug abuse, and to prevent behaviors of drug abuse, for 3 of 3 residents reviewed. Resulting in one resident becoming unresponsive, one resident admitting to purchasing and doing drugs, and one resident with slurred speech. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE], the facility failed to ensure staff did not give access of illicit drugs to residents inside the facility. On [DATE] a staff member solicited to sell Residents C and B, heroin and [MEDICATION(S)] (meth) and provided the drugs on [DATE]. Resident C was found unresponsive and had [MEDICATION(S)] administered. A substance identified as heroin by the police department was found on [DATE] in Resident C's drawer. During an interview on [DATE] at 2:36 p.m., Resident B admitted to purchasing meth from a staff member. On [DATE] Resident D's speech was slurred, and her pupils were dilated. Resident D was unable to state her name and was unable to follow simple commands. The Health Facility Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE] 12:12 p.m. Findings include: 1. The clinical record for Resident C was review on [DATE] at 10:49 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact, had adequate hearing, adequate vision with corrective lenses, clear speech, was understood, and understands others. She required one staff member extensive assistance for mobility, transfer, and ADLs (Activities of Daily Living). She was occasionally incontinent of bladder and bowel. A Progress Note dated [DATE] at 4:35 p.m., indicated the nurse was notified by a Certified Nursing Assistant (CNA) that Resident C was unresponsive. Upon entering the room, Resident C was noted to be on her back, and was a dusky color, had a thready pulse, and no respirations. Resident C was non-responsive to painful stimulation via a sternal rub. The NP (Nurse Practitioner) order was received for [MEDICATION(S)] which was administered in right deltoid without difficulty. A Progress Note dated [DATE] at 3:05 p.m., indicated there was a NP ordered received for a one-time dose of [MEDICATION(S)] to be administered. Staff were to inject 1 ml (milliliter) subcutaneously one time only for over sedation. A Progress Note dated [DATE] at 3:51 p.m., indicated Resident C was unresponsive at 3:05 p.m. Resident C was unresponsive to stimuli and breathing was shallow and labored. Resident C was ventilated with an AMBU bag. Resident's C pupils were pinpoint and fixed. EMS arrived and transported Resident C at 3:17 p.m. On [DATE] at 2:53 p.m., the DON provided a Police Report dated [DATE] at 4:35 p.m. The report indicated employee (Staff 2) stated she had found what appeared to be heroin in a patient's room. The suspected substance was tested , and it showed positive for heroin. Resident C stated that an employee (Staff 3) had sold it to her. She advised she had purchased the heroin from a cleaning lady that works there. On [DATE] at 11:49 a.m., the Regional Clinical Support Nurse (RCSN) provided documents for Residents C. She indicated she was aware there was no documentation from the Social Service Director (SSD) on [DATE], to indicate a drug program or other services. The RCSN indicated she was aware there were no care plans for drug abuse for the resident, prior to the incidents. On [DATE] at 1:23 p.m. the RCSN provided a Psychiatry Initial Consult document dated [DATE]. The report indicated Resident C reported to the NP that she used to use some drugs. During a telephone interview on [DATE] at 1:57 p.m., Resident C's counselor indicated he had worked with her on urges, sobriety, and she had been clean since [DATE]. Relapse prevention was not a part of her treatment later in 2020. Emotional stability was the focus at that point. He did not think drug abuse was a concern as it was not anticipated while she was in the facility. During an interview on [DATE] at 2:14 p.m., the NP indicated Resident C had been clean and the NP had no knowledge of her drug abuse until the recent event, and she then included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP indicated drug addiction was not curable but resident could be in remission. Monitoring for drug abuse was not done due to being in the facility and was shocked when it happened. During an interview on [DATE] at 2:06 p.m. LPN 8 indicated he was the nurse that had found Resident C unresponsive. The Resident had received [MEDICATION(S)] and was sent out to the hospital. 2. The clinical record for Resident B was review on [DATE] at 9:49 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated [DATE], indicated Resident B was cognitively intact. She had adequate hearing and vision, clear speech, was understood, and understands others. She required one physical staff member's extensive assistance for mobility, transfer, and ADLs. A Psychotherapy Note, dated [DATE], indicated part of the session focused on Resident B's substance abuse and how it had affected her life and things she could do differently instead of using drugs, including talking with family, focusing on things happening in the long-term care center, and asking for help. A Psychiatry Progress Note, dated [DATE], indicated Resident B had recently used meth while in the facility and wasn't taking responsibility for her actions, stating she was just following her roommate's lead. On [DATE] at 2:53 p.m., the DON provided a Police Report dated [DATE] at 4:35 p.m. The report indicated the officer was dispatched to the facility in reference to a drug investigation. When the officer spoke with Resident B, she advised she did in fact purchase meth from the same cleaning lady. She gave the employee $15.00 on [DATE] and received the meth on [DATE]. Staff 2 advised there was no meth left to recover. During an interview on [DATE] at 2:36 p.m., Resident B indicated she had been in another room, and was Resident C's roommate. A housekeeper came in and was talking about how she had relapsed. This was how the whole thing got started, another resident (Resident C) had asked if they could buy meth or heroin, and they gave the housekeeper money, and four days later she came back and brought the drugs. Resident B indicated Resident C did the heroin and then she turned purple. Resident C was sent to the hospital. The police came and they found heroin in Resident C's drawer. Resident B indicated she had not done any heroin, but she did do the meth. On [DATE] at 11:49 a.m., the Regional Clinical Support Nurse (RCSN) provided documents for Residents B. She indicated she was aware there was no documentation from the Social Service Director (SSD) on [DATE], to indicate the offer of a drug program or other services. The RCSN indicated she was aware there were no care plans for drug abuse for these residents, prior to the incidents. During an interview on [DATE] at 1:23 p.m., the Administrator, RCSN, and DON indicated Residents B had no care plan for drug abuse prior to the event on [DATE]. During an interview on [DATE] at 2:14 p.m., the NP indicated Resident B had been given cessation education due to the recent event. When Resident B was admitted she was on a vent and drug abuse education was not appropriate. Resident B had stop dates for all pain medications given due to bad teeth, even though she did argue she needed them. Resident B had a drug abuse history documented on admission. During an interview on [DATE] at 11:05 a.m., Resident B indicated prior to her admission to the facility she had gone to AA meetings and gotten clean on her own. She had not received any support services like AA or NA while a resident in the facility. 3. The clinical record for Resident D was reviewed on [DATE] at 1:09 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS assessment, dated [DATE], indicated Resident D was cognitively intact, had adequate hearing and vision, clear speech, was understood, and understands others. She required two physical staff extensive assistance for mobility, total dependent for transfer and ADLs. A Progress Note dated [DATE] at 3:57 p.m., indicated the nurse entered Resident D's room to give her routine scheduled medicine. Resident D was asleep and difficult to arouse. Once the nurse was able to wake the resident up with a stern sternal rub, the resident was unable to keep her eyes open for a long period of time. Resident D's speech was slurred, and her pupils were dilated. The Resident then began to tell the CNA and nurse, that her visitor from last night, who fixed her wheelchair battery, had brought her a gram of meth and she smoked it in a chicken bowl or bone. Resident D was unable to state her name and was unable to follow simple commands. A Progress Note, dated [DATE] at 4:16 p.m., indicated the resident was slurring her words and not acting like her baseline. A Progress Note, dated [DATE] at 4:45 p.m., indicated EMS was contacted. The hospital was contacted and a report was given, EMS arrived to transport the resident. Resident D refused to go. Resident D was placed on 15-minute checks. Scheduled narcotics were held for the remainder of the shift due to sedation and lethargy. A Progress Note, dated [DATE] at 4:00 p.m., indicated Resident D was asleep, respirations were even and labored, with use of accessory muscles observed. X-ray results show new right parahilar and left basilar infiltrates. NP was notified, an order was received to send the resident to hospital for evaluation and treatment related to respiratory distress. A SS Note dated [DATE] at 4:39 p.m., indicated SS followed up with Resident D after a recent ER visit due to altered mental status. Resident D was reeducated and reviewed illicit drug policy for the facility. A Care Plan, with an initial date of [DATE], indicated Resident D had suicidal ideation's and would verbalize intentions to abuse drugs in order to inflict self-harm. The interventions included, but were not limited to, Behavioral Health consults as needed, consult with pastoral care, psych services, and/or support groups. A Psychotherapy Note, dated [DATE], indicated Resident D had a long history of drug abuse treatment. She had also been in treatment several times for [MEDICATION(S)] addition. Her addiction resulted in several medical issues and her [CONDITION(S)]. A Psychotherapy Note, dated [DATE], indicated Resident D had recently become a paraplegic after [CONDITION(S)] due to IV drug use. A Psychotherapy Note, dated [DATE], indicated Resident D had reported that the primary care physician had lowered pain and anxiety medication due to increased lethargy reported by the nurse. A Psychotherapy Note, dated [DATE], indicated Resident D was upset that her pain medications and anxiety medications had been decreased, and was somewhat medication seeking. A Psychotherapy Note, dated [DATE], indicated Resident D had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated the resident had disorganized thoughts. A Psychotherapy Note, dated [DATE], indicated staff had a recent concern that Resident D had used illicit drugs. A Psychotherapy Note, dated [DATE], indicated there was a concern Resident D may have been doing illegal drugs but refused to take a drug screen. The report indicated Resident D did not seem concerned about consequences of her actions despite the things that her drug use had caused her. During an interview on [DATE] at 1:23 p.m., the Administrator, RCSN, and DON indicated Residents D had no care plan for drug abuse prior to the event on [DATE]. During an interview on [DATE] at 2:14 p.m., the NP indicated Resident D had a drug abuse history documented on admission. The NP indicated Resident D had a recent incident of talking out of her head, was lethargic, but had refused a drug screen. She did later agree to one, but it was past the point of detection so it was not completed. During an interview on [DATE] at 10:07 a.m., the Psychotherapist indicated he did see Resident D in the facility. He indicated he did not treat her for drug addiction. They had talked about her past addiction and her alleged use of illicit drugs in the facility, and she became angry. She had underlying issues and he allowed the resident to direct their focus and they were working on her self-esteem. During an interview on [DATE] at 12:10 p.m., Resident D indicated she had gone to a seven-day rehab in 2018. She had gone into a more intense rehab program in 2019 and had received [MEDICATION(S)]. In [DATE] she had almost died and was paralyzed from the neck down. She had been clean for about two and a half years. During an interview and record review on [DATE] at 2:53 p.m., the DON provided text messages between staff. The text message indicated Staff 3 was ask if she had ever gone to the building when she wasn't scheduled to work and she replied yes and said there are days she will work a full shift and not realize she wasn't on the schedule until the end of day. The current facility policy Policy for Resident Substance Abuse in Facility was provided by the DON on [DATE] at 2:53 p.m. The Policy indicated, Definitions: Abused substances: .is meant to imply drugs consumed by any route that have no medical use or drugs that are prescribed .may also include alcohol .Drug Paraphernalia: .any equipment, product, or material that is used .for making, using or concealing drugs, typically for recreation purposes .Illicit drug: .a drug that is potentially dangerous, has a high potential for abuse and has no currently accepted medical use .Policy: .to provide guidance to the staff when substance abuse is confirmed or suspected in a resident .Procedure: .I. a. inform resident .of this substance abuse policy upon admission .II. Management of Acute Episodes .iv. For suspected illicit or illegal drug use, administer [MEDICATION(S)] per instructions on the label .IV. b. Care plan and education .i. provide options for treatment available to resident including but not limited to: 1. Psychological evaluation and/or counseling .2. Medical evaluation and/or counseling .ii. Care plan resident specific triggers for abusing drugs . The Past noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: The facility reviewed all residents with a history of substance abuse for specific treatment/counseling options ([DATE]); All staff were interviewed to identify any other concerns with staff or resident solicitation, use of alcohol, or illegal substances ([DATE]); All staff were educated on Resident Substance Abuse policy and Abuse, Neglect and Misappropriation of Resident Property ([DATE]); and implementation of a screening process, upon admission, for residents with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal tag relates to Complaint IN 354 3.,d+[DATE]

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to identify and prevent the development and worsening of pressure ulcers for 7 of 9 residents reviewed for pressure ulcers, which resulted in the development of four in house pressure ulcers, and the worsening of four pressure ulcers. (Resident 60, 36, 9, 33, 81, 67, and 19) Findings include: 1. During an observation, on 6/22/21 at 11:08 a.m., the wound care nurse indicated Resident 60's left buttock wound was a Stage 4 with exposed muscle. The nurse removed the old dressing and a moderate amount brownish drainage was noted on the dressing. The wound was cleaned with NS (Normal Saline) and the peri wound was intact. The nurse packed the wound with calcium alginate and applied a foam dressing. No odor was noted. The wound was about the size of a silver dollar. The wound bed was red and no drainage was noted draining from the wound. The nurse's admission assessment, dated 10/17/19, indicated the resident did not have any pressure injuries or skin impairments to the left buttock on admission. The clinical record for Resident 60 was reviewed, on 6/24/21 at 8:42 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS (Minimum Data Set) assessment, dated 8/12/20 indicated the resident was severely cognitively impaired. The resident required total dependence of two physical staff for ADL's (activities of daily living). The resident was a risk for developing pressure ulcers and the resident currently had no pressure ulcers. The resident currently had pressure reducing cushions on chair and bed. The Skin Grid Pressure assessment, dated 2/23/21, indicated the resident had a new Stage III pressure injury to the left buttock, measuring 3 cm (centimeters) in length, by 3.5 cm in width by 0.1 cm in depth with serous drainage, epithelialization tissue and slough present. The wound was facility acquired. Treatment included for staff to cleanse wound with normal sailine, pat dry, apply Medi honey to the wound bed, and cover with dressing until resolved every 12 hours and as needed with a start date 2/24/21. The wound treatment, dated 2/27/21, indicated to cleanse left buttock ulcer with NS, pat dry, apply skin prep to periwound bed, apply Santyl and the calcium alginate to wound bed only, cover with boarder foam. The current care plan, dated 6/23/21, indicated the resident had a Stage III pressure ulcer to the left buttock. Interventions included, but not limited to, air mattress in place, educated resident's representative about proper skin care to prevent skin breakdown, encourage resident to frequently shift weight, evaluate skin for area of blanching or redness, evaluate ulcer characteristics, keep skin clean and well lubricated, limit sitting to 60 minutes; off load wound, reposition per facility protocol: turn side to side and front to back, while in bed every 1 to 2 hours as resident tolerated. Revision, dated 3/12/21, indicated to monitor ulcer for signs of progression or decline, notify family of new onset findings, notify provider if no sign of improvement on current wound regimen, provide wound care per treatment order. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound prevention indicated staff were to cleanse coccyx with soap and water, pat dry, apply skin prep to coccyx and cover with 4 x (by) 4 bordered foam. Complete daily wound assessments, document abnormalities in progress notes, and document level of pain at wound site every night shift for wound management of the left buttock. The Skin Grid Pressure assessment, dated 3/4/21, indicated the left buttock wound had deteriorated. The measurements were length 4.5 cm, width 3.5 cm, depth 0.1 cm. The wound was classified as unstageable. The wound care orders, dated 3/4/21, included, but were not limited to, Santyl Ointment 250 units/gm (grams), apply to left buttock topically every day shift for wound care. The order was discontinued 3/5/21. The night shift treatment orders included, cleanse left buttock ulcer with NS, pat dry, apply skin prep to peri wound only, apply Santyl and then calcium alginate to wound bed only, and cover with a foam border. The discontinued date was 4/23/21. The Skin Grid Pressure assessment, dated 3/11/21, indicated the stage III pressure wound to left buttock had deteriorated. The measurements were 5 cm in length, by 5 cm in width, by 0.1 in depth with granulation tissue, eschar and slough were present. The wound bed was reddened, necrotic and white tissue with serous drainage. No tunneling was noted. The wound was not improving with current treatment. Treatment recommendations were to continue current treatment orders. The Wound Evaluation form, dated 3/11/21, indicated A new pressure wound to the coccyx, measuring 1 cm in length, by 0.5 cm in width, 0.1 cm in depth, unstageable, eschar present, necrotic wound bed, and serous drainage. Treatment included a border foam and skin prep every three days. The Wound Evaluation form, dated 3/18/21, indicated the resident has a stage III pressure wound to the coccyx , measuring 0.9 in length, by 0.6 in width, by 0.1 in depth, wound bed pink and reddened, medium amount serous drainage, surface 0.54 cm exudate: moderate serous granulation tissue 100%. Treatment included a border foam and skin prep every three days. The Skin Grid Pressure assessment, dated 3/25/21, indicated the wound had improved, measuring 5.5 cm in length, by 5.5 cm in width, by 3 cm in depth, granulation tissue, slough present, wound bed reddened and yellow, with serous drainage. Surface area 30.25 cm 2, 40% slough, 60% granulation. The wound was in an [CONDITION(S)] stage and was unable to progress to a healing phase because of biofilm. Bedside excisional debridement was completed by the wound doctor. Tunneling was present. Treatment included skin prep to peri-wound, santyl and calcium alginate to wound bed and cover with bordered foam. The Skin Grid Pressure assessment, dated 4/8/21, indicated the had wound improved, measuring 6 cm in length, by 4 cm in width, by 2.5 cm in depth, granulation tissue and slough present, serous drainage. Surface area 24.00 cm 2 (square centimeters) 30% slough 70%. Surface area 24.00 cm 2 30% slough 70% granulation tissue. The wound was in an [CONDITION(S)] stage and was unable to progress to the healing phase due to biofilm. Excisional debridement completed at bedside by the wound care doctor. Treatment continues with Santyl. Calcium alginate and foam dressing. The Wound Evaluation form, dated 4/8/21, indicated the stage II pressure wound to the coccyx was healed. The Skin Grid Pressure assessment, dated 4/22/21, indicated the left buttock pressure wound was a stage IV, measuring 6 cm in length, by 4 cm in width, by 3 cm in depth, granulation tissue and slough present, reddened and yellow wound bed, serous drainage. The surface area 24.00 cm 2, 10% slough, 90% granulation. The wound was an [CONDITION(S)] stage, and unable to progress to healing phase due to biofilm. Excisional debridement completed at bedside by the wound care doctor. Treatment continues with Santyl, calcium alginate and a foam dressing. The Wound Evaluation form, dated 4/27/21, indicated the first assessment of existing wound by new care provider. Stage IV pressure ulcer acquired in house. Moderate amount serosanguinous drainage, tunneling at 12:00, measuring 3.20 cm in depth, exposed muscle and exposed bone, attached edges. Treatment includes calcium alginate and border foam. Ensure compliance with turning protocol and speciality bed. The Wound Evaluation form, dated 5/5/21, indicated left buttock pressure wound was a stage IV, tunneling at 12:00, 80% granulation 20% slough, depth 2.50 cm, pack iodaform in tunnel, friable, exposed muscle, and exposed bone, moderate serosanguinous drainage, cleanse with normal saline, calcium alginate border foam. Ensure compliance with turning protocol, wedge/foam cushion for offloading, and speciality bed. The Wound Evaluation form, dated 6/1/21, indicated left buttock pressure ulcer was a stage IV measuring length 2.75 cm, width 1.60 cm, and depth 2.50 cm. Tunneling at 12:00 and packed tunnel with iodaform. The wound had exposed muscle and improving. There was a moderate amount of serosanguinous drainage and no odor. Treatment included cleanse wound with NS, calcium alginate and a border foam dressing. Ensure compliance with turning protocol, wedge/foam cushion for off loading and speciality bed. During an interview, on 06/22/21 at 11:03 a.m., the resident's family member indicated he was the resident's essential caregiver. He assisted with the resident's care, but could not turn her due to his health condition. He was the one that found the pressure wound on the resident's left buttock. He indicated the wound was black and about the size of a soda can. He asked the CNA (Certified Nurses Aide) what it was and she left the room and got the resident's nurse, and when the nurse saw the wound she stated, Oh my God. During an interview, on 6/22/21 at 11:08 a.m., the wound care nurse from a wound care agency indicated the resident's stage III wound was facility acquired. The resident's wound was a Stage 4 with 100% granulation with exposed muscle. The measurements included depth 3 cm and tunneling, width 1.56 cm and length 1.07 cm. There was no foul odor and a moderate amount serosanguinous drainage. The wound nurse indicated the wound was healing and the peri wound was intact. During an interview, on 6/30/21 at 9:50 a.m., RN 17 indicated the residents with pressure ulcer should have a special mattress, cushion in wheelchair, use Braden Scale to identify potential for skin breakdown, weekly skin assessments, and CNA reporting any skin issues to the nurse. The facility had a wound care nurse. The skin assessment on [DATE] indicated the resident did not have any skin issues. The stage III pressure ulcer was found on February 23, 2021 with the next skin assessment. If the resident had a skin issue present before the wound became a stage III it should have been found. 2. The clinical record for Resident 36 was reviewed on 06/23/21 at 2:09 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 4/28/21, indicated the resident was alert and oriented. The resident required the assistance of one physical staff member for mobility and ALS's. The resident was at risk for pressure ulcers and currently had one unstagable pressure ulcer. The care plan, dated 2/1/21, indicated the resident was at risk for impaired skin integrity. The interventions included, but were not limited to, approach: Educate Resident / Representative about proper skin care to prevent skin breakdown, causes of pressure ulcers, encourage the resident to frequently shift her weight, offload her heels, turn every 2 hours. Position the resident to reduce causes of friction or shear, provide skin care per facility guidelines, utilize pillows or foam wedges to avoid direct contact with bony prominences and utilize pressure relieving devices on appropriate surfaces. The Weekly Skin Checks lacked documentation on 2/5/21, 2/12/21, 2/19/21, 2/26/21, 3/12/21, 3/19/21, 3/26/21, 4/2/21, 4/9/21, 4/16/21, and 5/4/21 of any new skin conditions. The Skin Grid Pressure evaluation, dated 4/20/21, indicated the resident had a new pressure area to the left heel. The suspected deep tissue injury measured 4.5 cm long by 2.5 cm wide. The Wound Evaluation, dated 4/27/21, indicated the resident's pressure ulcer to the left posterior heel measured 1.46 cm long, by 1.73 cm wide, by 0.10 cm deep. The wound had 100 % granulation and was a Stage 3 pressure ulcer. The wound bed was friable with hyper-granulation, moderate serosanguinous drainage. The dressing change frequency was three times per week, cleanse the wound with normal saline, pressure reduction with offloading, ensure compliance with turning protocol, specialty bed, dressings of [MEDICATION(S)], with a secondary dressing of bordered foam. The Wound Evaluation, dated 5/25/21, indicated the wound to the left posterior heel measured 0.66 cm long by 0.70 cm wide by 0.20 cm deep. There was 70% granulation, 30% slough/eschar and was friable. The treatment orders continued with a specialty bed. The Wound Evaluation, dated 6/1/21, indicated the wound to the left posterior heel measured 0.95 cm long by 0.69 cm wide by 0.10 cm deep. There was 100% granulation and the wound bed was friable. The treatment orders were to cleanse wound with normal saline, pressure reduction/offloading, ensure compliance with turning protocol, specialty bed, dressings of skin prep. The wound was improving. The Wound Evaluation, dated 6/15/21, indicated the wound to the left posterior heel measured 0.77 cm long by 0.83 cm wide by 0.20 cm deep. There was 95% granulation and 5 % slough/eschar and the wound bed was friable (easily crumbled or pulverized) and the wound was worsening. The periwound was macerated. The dressing change frequency twice daily, cleanse the wound with wound cleanser, pressure reduction/offloading, ensure compliance with turning protocol, wedge/ foam cushion for offloading, specialty bed, dressings of skin prep. The secondary dressings were for a bordered gauze. The Wound Evaluation, dated 6/22/21, indicated the wound to the left posterior heel measured 0.19 cm long by 0.08 cm wide, by 0.20 cm deep. There was scant serosanguinous drainage, the odor was malodorous. The dressing was to be changed every other day, cleanse the wound with normal saline, ensure compliance with turning protocol. The dressings were for [MEDICATION(S)] with a secondary bordered gauze setting. The Treatment Administration Records indicated for April 2021, the following missed documentation: - Pressure reducing mattress every night shift for prevention. No documentation on 4/9/21. - Daily Wound assessment not documented as completed on 4/28/21. - Heel lift boots at all times every shift for wound management. Not documented as completed on 4/28/21. The Treatment Administration Records indicated for May 2021, the following missed documentation: - Daily Wound assessment not documented as completed on 5/22/21, 5/26/21 and 5/27/21 on the day shift and 5/7/21 and 5/21/21 on the night shift. - Wound care; left heel-cleanse with normal saline, pat dry, apply [MEDICATION(S)] to wound bed and cover with bordered foam every shift every Monday, Wednesday, Friday for wound care. Not documented on 5/7/21 and 5/21/21 on the night shift. The Treatment Administration Records indicated for June 2021, the following missed documentation: - Daily Wound assessment not documented as completed on 6/3/21, 6/11/21, 6/8/21, 6/11/21, and 6/14/21 on the day shift. 3. The clinical record for Resident 9 was reviewed on 6/23/21 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment, dated 6/24/21, indicated the resident was alert and oriented. The resident required the extensive physical assistance of two staff members for bed mobility. The resident was at risk for pressure ulcers and currently had three unstagable pressure ulcers. The care plan, dated 3/17/21, indicated the resident was at risk for altered skin integrity related to immobility. The interventions were to administer treatments as ordered by the medical provider; apply appropriate pressure reducing appliances to bed and to wheelchair; complete the skin at risk assessment upon admission, readmission, quarterly, and as needed and complete Weekly Skin checks. The care plan, dated 3/17/21, indicated the resident was at risk for impaired skin integrity. The interventions were to evaluate the skin for areas of blanching or redness, monitor for moisture, and apply barrier product as needed; position the resident to reduce causes of friction or shear; provide skin care per facility guidelines and as needed; and utilize pressure relieving devices on appropriate surfaces. The nurse's note, dated 3/16/21 at 3:06 p.m., indicated the resident's skin was wet, dry, and intact with a small area or excoriation noted to the mid spine and left mid back. The Skin Admission Assessment, dated 3/16/21, indicated the resident had no skin issues. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Weekly Skin Assessment, dated 3/23/21, indicated the resident had no skin issues. The Skin Grid Non-Pressure assessment, dated 3/26/21, indicated the right iliac crest had a friction or shear measuring 2 cm long, by 2 cm wide, by 0 depth. The abrasion was pale red or pink with bloody exudate with small drainage. The treatment was to cleanse the area with normal saline, pat dry, and apply a border foam dressing. The Grid Non-Pressure assessment, dated 3/26/21, indicated the upper mid vertebrae had a friction or shear measuring 2 cm long, by 2 cm wide, by 0 deep. The abrasion was pale red or pink with bloody exudate and a small amount of drainage. The treatment was to cleanse the area with normal saline pat dry, and apply border foam. The Skin Grid Non-Pressure assessment, dated 3/26/21, indicated an all over skin moisture associated breakdown of the coccyx. The wound was pale red or pink. The treatment was to cleanse the wound with normal saline, pat dry, and apply prescription butt cream to the affected area, turn and reposition every two hours. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Grid Non-Pressure assessment, dated 4/2/21, indicated the upper mid vertebrae had a friction or shear, measuring 2 cm by 2 cm by 0 deep. The abrasion was yellow tan with serous exudate. This shearing wound bed had slough in it. A consult with the medical doctor was initiated. The current orders of the foam dressing were continued. The Skin Grid Non-Pressure assessment, dated 4/2/21, indicated the area to the coccyx measured 0.5 cm long by 1.2 cm wide. The area was red, moist, and grainy, with optimal granulation, and serous exudate. The shearing wound extended to the right buttock. The wound was not focused on the coccyx. The medical doctor was consulted for management due to the location. The current order of the foam dressing was continued. The Skin Grid Non-Pressure assessment, dated 4/2/21, indicated the right iliac crest friction or shearing was resolved. The Skin Grid Pressure assessment, dated 4/8/21, indicated the area to the coccyx measured 0.5 cm long, by 0.5 cm wide, by 0.1 cm deep and was a Stage II. Granulation tissue was present, with a reddened wound bed, serous exudate, and medium drainage. This wound was classified as a shearing wound and extended to right buttock. Wound was now focused in coccyx. The medical doctor was consulted to ensure improvement and resolution of wound. The medical doctor re-classified wound as a stage II pressure injury. The Skin Grid Pressure assessment, dated 4/8/21, indicated the upper mid vertebrae measuring 1 cm long, by 1 cm wide, by 0.1 cm deep and was a stage II. There was redness with granulation tissue present with serous exudate and medium drainage. The wound was classified as a shearing wound. The medical doctor was consulted to ensure improvement and resolution. The doctor reclassified the wound as a stage II pressure injury. The Skin Grid Pressure assessment, dated 4/15/21, indicated the wound to the coccyx measured 0.5 cm long, by 0.3 cm wide, by 0.1 cm deep and was a stage II. Granulation tissue was present with a reddened wound bed, blood tinged exudate, and medium drainage. The Skin Grid Pressure assessment, dated 4/22/21, indicated the area to the upper mid vertebrae measured 0.5 cm long by 0.5 cm wide by 0.1 cm deep and was a stage II. The area was reddened with granulation tissue present and a serous exudate with medium drainage. The treatment ordered was to apply a foam dressing. The Weekly Skin Checks, dated 5/5/21 and 5/12/21, indicated the treatment was continued to the buttocks as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse must complete the skin observation tool. Document any new areas on the form and complete a change in condition every day shift every Wednesday. The Weekly Skin Check, dated 5/15/21, indicated the MASD (Moisture Associated Skin Damage) to the sacrum was a new non-pressure skin condition. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Daily wound assessment. Document abnormalities in progress notes. Document level of pain at wound site every shift for wound management to the left heel. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin/Wound Notes, dated 6/8/21 and 6/15/21, indicated a comprehensive skin and wound evaluation for MASD to the sacrum, left heel DTI (deep tissue injury) and mid upper back. The wounds to the right mid back (previously identified as right upper and lower back) stage 2 pressure ulcer reopened, left heel DTI, MASD sacrum, DTI to right lateral ankle. The nurse's note, dated 6/15/21 at 5:45 p.m., indicated a new order per the medical doctor and verified per the nurse practitioner for a pharmacy butt cream. Apply to buttocks topically every day and night shift 15 grams, [MEDICATION(S)] 10% Ointment 15 grams, [MEDICATION(S)] Ointment 15 grams, [MEDICATION(S)] 1% Ointment 15 grams, [MEDICATION(S)] Ointment and apply to the bilateral buttock topically every 8 hours as needed. The Treatment Administration Records for April 2021 indicated the following missed documentation: - Resident to be on Low Air Loss Mattress every shift for skin breakdown prevention. Not documented as completed on 4/15/21 and 4/29/21 on the day shift and on 4/27/21 on the night shift. - Turn and reposition every two hours every shift for preventative. Not documented and completed on 4/15/21 and 4/29/21 on the day shift and on 4/27/21 on the night shift. - Apply House barrier cream to the bilateral buttocks every shift for prevention. Not documented as completed on 4/15/21 and 4/29/21 on the day shift and on 4/27/21 on the night shift. - Float heels every shift for preventative. Not documented as completed on 4/15/21 and 4/29/21 on the day shift and on 4/27/21 on the night shift. - Provide wound care to the coccyx of cleansing with normal saline, pat dry, apply skin prep to peri-wound and cover with bordered foam every shift for wound care. Not documented as completed on 4/15/21. - Provide wound care for the right mid-upper back by cleansing with normal saline, pat dry, apply skin prep to peri-wound and cover with 4 x 4 bordered gauze every day shift for wound care. Not documented as completed on 4/15/21. - The weekly head to toe skin assessments by the nurse completed on the skin observation tool. Document any new areas on the form and complete a change in condition every night shift. Not documented as completed from 4/1/21 to 4/28/21. The order was discontinued on 4/29/21. - Daily Wound assessments for the coccyx were not documented as completed on 4/15/21. The order was discontinued on 4/23/21. - Daily Wound assessments for the right mid-upper back were not documented as completed on 4/15/21 and 4/29/21. The order was discontinued on 5/25/21. The Treatment Administration Records for May 2021 indicated the following missed documentation: - Daily Wound assessment of the sacrum not documented as completed on 5/24/21, 5/25/21, 5/28/21, and 5/31/21. The order was discontinued on 6/15/21. - Cleanse wound to Sacrum with normal saline; pat dry, apply skin prep to peri-wound, apply [MEDICATION(S)] to wound bed, cover with border foam gauze every shift for wound management. Not documented as completed on 5/31/21. The order was discontinued on 6/1/21. - Daily Wound assessment of the right mid-upper back was not documented as completed on 5/10/21, 5/14/21, 5/17/21, 5/18/21, and 5/24/21. The order was discontinued on 5/25/21. The Treatment Administration Records for June 2021 indicated the following missed documentation: - The Resident was to be on a Low Air Loss Mattress every shift for skin breakdown prevention. Not documented as completed on 6/11/21 and 6/13/21 on the day shift and 6/12/21 on the night shift. - Daily Wound assessment for the left heal was not documented as completed on 6/7/21, 6/8/21, 6/11/21, 6/13/21, 6/14/21, 6/15/21, and 6/21/21 on the day shift and on 6/12/21 on the night shift. - Staff were to encourage the resident to turn and reposition every two hours every shift for preventative. Not documented as completed on 6/11/21 and 6/13/21 on the day shift and on 6/12/21 on the night shift. - Float the resident's heels every shift for preventative. Not documented as completed on 6/11/21 and 6/13/21 on the day shift and on 6/12/21 on the night shift. - Daily Wound assessment of the sacrum was not documented as completed on 6/1/21, 6/7/21, 6/8/21, 6/11/21, 6/13/21, 6/14/21, and 6/15/21 on the day shift and on 6/12/21 on the night shift. - Provide wound Care for the mid back of cleansing the area with wound cleanser, pat dry, and apply skin prep to peri-wound and cover with foam every day shift for wound care. Not documented as completed on 6/11/21 and 6/13/21. - Staff were to apply protective boots to bilateral heel related to prevention every shift for prevention. Not documented as completed on 6/11/21 and 6/13/21 on the day shift and on 6/12/21 on the night shift. - Staff were to apply skin prep to bilateral heels every shift for wound care. Not documented on 6/11/21 and 6/13/21 on the day shift and on 6/12/21 on the night shift. - Daily Wound assessment for the right mid-upper back were not documented as completed on 6/7/21, 6/8/21, 6/11/21, 6/13/21, 6/14/21, 6/15/21, and 6/21/21. During a confidential interview, between 6/22/21 and 6/24/21, Staff F indicated the pillow had not been placed correctly under Resident 9, to relieve the pressure under the resident's back. He felt there had been an increase of pressure ulcers since the wound nurse was no longer working at the facility. The pressure ulcer increase was due to a staffing issue. The nurses were used to the CNAs turning and repositioning the residents and the wound nurse caring for them. The staff weren't using the wedges correctly. 4. The clinical record for Resident 33 was reviewed, on 6/24/21 at 9:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 1/18/21, indicated the resident was at risk for impaired skin integrity. The interventions included, but were not limited to, education to prevent skin tears and abrasions, education on use of lift device, and utilizing pressure reducing devices. The care plan, dated 4/27/21, indicated the resident had impaired skin integrity or was at risk for altered skin integrity. The interventions indicated to administer treatments as ordered by medical provider; apply appropriate pressure reducing appliances to bed and to wheelchair; complete skin at risk assessment upon admission, readmission, quarterly, and as needed; complete weekly skin checks; and evaluate existing wound daily, for changes such as redness, [CONDITION(S)], drainage, pain, foul odor. The Clinical Admission Evaluation, dated 1/15/21, indicated the resident had a Stage IV pressure ulcer to the coccyx and unstageable area to the left Ischium. The Skin Grid Pressure assessment, dated 1/21/21, indicated the Stage IV pressure ulcer to the sacrum was first observed on 1/15/21 and measured 4.5 cm long, by 7.5 cm wide, by 3.0 cm deep and was obtained prior to admission. The wound bed was red or pink with moderate blood tinged exudate and medium drainage. The surface area had 100 % granulation. The Skin/Wound note, dated 2/4/21, indicated new orders were given per the medical doctor to discontinue the wound vac. Cleanse the sacral ulcer with normal saline, pat dry, apply skin prep to the peri wound bed, apply calcium alginate, and cover with border foam. The Skin Grid Pressure assessment, dated 2/11/21, indicated the stage IV wound to the sacrum had deteriorated. The wound measure 6 cm long by 8 cm wide by 3 cm deep. The Skin Grid Pressure assessment, dated 2/18/21, indicated the stage IV wound was still deteriorating and measured 6.0 cm long by 8.5 cm wide by 3.0 cm deep. The exudate was serous with medium drainage. New orders were given per the medical doctor to cleanse the sacral ulcer with [MEDICATION(S)] spray, pat dry, apply skin prep to the peri wound bed, apply calcium alginate with silver to the wound bed only, and cover with border foam every shift for wound care. The physician's note, 2/21/21, indicated the resident not had a fever of 102.3 degrees and a heart rate of 124. The sacral ulcer had a foul smelling odor. The plan was to obtain an ulcer wound culture. Start intravenous fluids with [MEDICATION(S)] and [MEDICATION(S)]. The resident had [CONDITION(S)], septic shock, and was transferred to the emergency room . The Skin Grid Pressure assessment, dated 3/2/21, indicated a new suspected deep tissue injury to the left heel which was acquired at the hospital. It measured 3.0 cm long, by 3.0 cm wide, by 0 depth. There was also a new SDTI to the right heel which measured 3.0 cm long, by 4.0 cm wide, by 0 depth. The Skin Grid Pressure assessment, dated 3/4/21, indicated the stage IV pressure ulcer to the sacrum measured 8.0 cm long, by 14 cm wide, by 3.0 cm deep. Documented as improved. New treatment orders were recommended. The right heel was now a stage II and measured 2.5 cm long, by 3.5 cm wide, by 0 depth. The Skin Grid Pressure assessment, dated 3/11/21, indicated the left heel SDTI measured 1.0 cm long, by 1.5 cm, wide by 0 depth. The Skin Grid Pressure assessment, dated 3/18/21, indicated the stage IV had deteriorated and measured 8.7 cm long, 11.5 cm wide, and 3.0 cm deep. The Skin Grid Pressure assessment, dated 3/4/21, indicated the right heel SDTI measured 3.5 cm long by 2.5 cm wide by 0 and had deteriorated. The Skin Wound note, dated 3/25/21, indicated a late entry from the Interdisciplinary Team wound note: Resident continued to be followed by the medical doctor for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to ensure pain medication was administered timely and provided effective pain control for a resident (Resident C) with complaints of pain after a fall which resulted in a right femur fracture for 1 of 3 residents reviewed for pain management. Findings include: The clinical record for Resident C was reviewed on 11/12/19 at 2:28 p.m. The resident's [DIAGNOSES REDACTED]. The progress note, dated 10/25/19 at 2:55 a.m., indicated the resident was found lying on the floor, on the left side, next to the bed. The resident's pain level was 10 out of 10 from the right hip/thigh area. Vital signs were taken and the resident was assisted back to bed. There was no acute distress except for the pain level from the right hip area. The witness statement, dated 10/25/19 at 3:10 a.m., indicated the resident received PRN Tylenol for her pain. The pain observation assessment, dated 10/25/19 at 3:54 a.m., indicated the resident's pain level was a verbal pain scale .9 The resident described the pain as sharp, throbbing, and sore. The resident did not receive a scheduled pain medication. The resident received a PRN (as needed) pain medication of Tylenol. PRN pain medication in use .Tylenol .effective .no . The PRN Tylenol was not documented on the resident's MAR. The effectiveness of the PRN medication was not documented on the resident's MAR. The MAR (Medication Administration Record) lacked documentation of any pain medication administered to the resident from 10/01/19 through 10/31/19. After the resident's pain assessment on 10/25/19 at 3:54 a.m., the clinical record lacked any documentation that the resident's pain was re-assessed or the physician was notified of the ineffectiveness of pain relief (9 out of 10) for over 4 hours. The radiology report, dated 10/25/19 at 8:16 a.m., indicated the resident had an acute [MEDICAL CONDITION] femur region. The incident report, dated 10/25/19 at 9:01 a.m., indicated the resident was found on the floor at 2:45 a.m., on the left side of the bed, and complained of mild pain to the right lower extremity. During an interview on 11/13/19 at 12:55 p.m., LPN (Licensed Practical Nurse) 3 indicated when a PRN medication was administered, the medication was signed by the nurse on the MAR and then followed up on to ensure the effectiveness of the medication. On 11/14/19 at 11:38 a.m., the Director of Nursing provided a current copy of the document titled Medication Administration dated 5/29/19. It included, but was not limited to, Definition .Medication Administration Record - the legal documentation for medication administration .Procedure .Medications will be charted when given .PRN medications will have a reason documented for giving and the effectiveness of the drug This Federal tag relates to Complaint IN 600 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for pressure ulcers and admitted with no skin breakdown received assessments and care to prevent pressure ulcers, resulting in stage 4 pressure ulcers to the heels (Resident C) for 1 of 4 residents reviewed for pressure ulcers in the sample of 10, and a Stage 3 ulcer to the back (Resident M) for 1 of 1 resident reviewed for pressure ulcers in the supplemental sample of 3. In addition to the residents in immediate jeopardy, the facility failed to provide assessment and care to prevent the development of Stage 2 pressure ulcers for 2 of 4 residents reviewed for pressure ulcers in the sample of 10. (Resident A, H) The immediate jeopardy began on 12/26/11 when nursing found a Stage IV pressure ulcer after the resident complained of pain to his heels and the family requested nursing look at his heels. The Administrator and Director of Corporate Operations acting as Interim Director of Nursing Services were notified on 1/09/12 at 11:25 a.m. The immediate jeopardy was removed on 1/10/12 at 9 a.m., but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident C was reviewed on 01/05/2011 at 1:10 p.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from a hospital. The Transfer Form accompanying the resident upon admission, under the section for wounds and pressure ulcer was blank. The Minimum Data Set (MDS) assessment, completed on 12/13/11, indicated the resident was at risk for developing pressure ulcers. Section V of "Care Area Assessment (CAA) Summary #16 Pressure Ulcer" indicated the "Location and Date of CAA Information" was the H & P (history and physical), TAR (treatment administration record) and ADL (activities of daily living) tracker. The Late Loss ADL Flow Sheet for the month of December 2011 indicated the resident required total assistance of one person physical assist in bed mobility, transfers and toilet use. The history and physical from the hospital indicated, "Extremities: The patient has difficulty in moving his legs, which has been present for some time but worse since fall..." The Patient Nursing Evaluation completed on 12/4/2011, indicated the resident had "yellow bruising across chest, right groin, purple bruising--skin tear right elbow approximately 4 (centimeters) ...buttocks intact." No issues with skin impairment of the heels was noted. admission orders [REDACTED]. The Medication Record used to document treatments was initialed as this treatment being completed on all dates in December with the exception of the 18th, 20th, 21st, and 26th. A care plan dated 12/13/11, indicated the following: "Skin/tissue Integrity Impaired: Potential" Goal: "Will have skin intact" Approach: "Turn & reposition every 2 hours while in bed" "Use positioning and pressure relieving device bed and w/c (wheel chair)" "Report any red or open areas" "Skin checklist per facility policy" Additional problem on 12/26/11 "Stage IV (four) to Lt & Rt (left and right) heels. Approach: 12/16/11 "[MEDICATION NAME] every shift, elevate heels off bed" 12/29/11 "Float heels, no shoes, slipper socks to ambulate." Resident Progress Notes dated 12/26/11 at 15:30 (3:30 p.m.) indicated "Assessment of bilateral feet per family request secondary res. c/o (complaints of) hurting areas found on bilateral heels R (right) 4 x 3.3 centimeters L (left) 1 x 1 centimeters necrotic, soft. Supervisor (name) notified of findings recommend for (name of wound doctor) to eval.(evaluate) on Thursday, N.O. (new order) written for [MEDICATION NAME] to bil (bilateral) heels." Resident Progress Notes dated 12/27/11 at 07:00 a.m. indicated "This nurse assessed res. bil (bilateral) heels this am. Lt (left) heel measure 1 x 1 x 0.70. Appears to have firm black eschar on outer aspects of heel. No redness to surrounding skin. Heel is soft. Rt. (right) heel measures 4 x 4.5 x 0.70. Surrounding skin immediate edges reddened, blanches to touch. Small amount of drainage noted to rt. heel, no odor. Heels up on pills (pillows). Upon assessment res had quick facial grimace during palpation. In quired (sic) if res would take prn (as needed) pain med, res stated he did not feel it was necessary. Assessment reported to floor nurse to monitor pain. Order for (name of doctor) to eval. and tx (evaluate and treat), will continue with [MEDICATION NAME] to heels. (up arrow) to indicated heels off mattress, while abed. Careplan updated to reflect areas et current interventions with skin and pain." On 12/29/11, the resident was seen by a wound care service, with the following documented on the evaluation sheet: "...s/p (status [REDACTED]. Pt. with increased confusion, decreased mobility. Non stageable/developed B (bilateral) heel decubs." "Pain my feet hurt" Plan: "Pressure relief, no shoes, [MEDICATION NAME] daily to ea. (each) wound and cover with dry drsg (dressing). Heels up." During observation with LPN #2, on 01/06/12 at 5:52 a.m., the resident was observed to have slipper socks on in bed and the HeelZup elevating cushion was touching the bed foot board. The resident's heels were touching the mattress without benefit of a pressure relief device. On 01/06/12, the instruction sheet for the HeelZup cushion was provided by the facility at 10:10 a.m. The instruction sheet indicated to "Gently raise both legs of the patient and place the HeelZup cushion under the legs with both heels fully suspended." "For more leg elevation or to enhance patient comfort you may place a pillow on top of the HeelZup cushion. The raised borders will hold the pillow in place, preventing lateral movement. Always inspect for skin integrity every two hours." On 01/05/12 the wound care physician documented "Plan: Continue pressure relief and daily [MEDICATION NAME]. Will likely debride R (right) heel soon." On 01/09/12 at 8:57 a.m., during observation of the treatment provided to the resident's heels, the left heel had a dark area approximately 0.5 centimeters in the center of the heel. The resident indicated the area was tender. The left heel had a black area approximately 2.8 centimeters in circumference with the black area loosening on the inner aspect. 2. The clinical record for Resident M was reviewed on 1/9/12 at 11:40 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The admission assessment Minimum Data Set ((MDS) dated [DATE], included, but was not limited to: The resident was cognitively intact, required extensive assistance from two people for bed mobility, and under skin condition - was at risk of developing pressure ulcers, "...has one or more unhealed pressure ulcer(s) at Stage 1 or higher; 1 Stage 3 pressure ulcer... most severe tissue type for any pressure ulcer slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous." The resident's Interim Plan of Care, which was not dated, included, but was not limited to: "5. Skin Integrity Pressure Ulcer (left blank)." The Nutritional Needs Care Plan, dated 12/29/11, included, but was not limited to: "Increased demands for nutrients due to wounds to abdomen x 2 and back Stage III monitor wound status." The most recent Comprehensive Care Plan Report dated 1/5/2012, included, but was not limited to: "Problem #8 Skin/tissue integrity impaired; Potential risk r/t (related to) mobility and Stage 3 on back; Goal; Will have no new skin breakdown with healing of pressure wound on back and healing of abdominal surgical sites x 90 days; Approach 1. Turn & reposition Q 2 hrs and prn. 2. 1/5/2012 Pressure reduction mattress on bed and cushion in w/c; 3. 1/5/2012 Report any red or open areas; 4. 1/5/2012 Skin checks per facility policy; 5. 1/5/2012 Treatments as ordered 6. 1/5/2012 Wound care to follow (named doctor)." The resident's Weekly Skin Check Sheet included, but was not limited to: "12/23/11 2+ [MEDICAL CONDITION]" and "12/30/11 No new skin impairments noted." The resident's Weekly Pressure Ulcer BWAT (Bates-Jensen Wound Assessment Tool) Report dated 12/29/11, indicated the resident had a Stage III Pressure Ulcer. The December 2011 Treatment Record included, but was not limited to: Pressure Reduction mattress every day, Pressure Reduction cushion every day, both ordered 12/23/11. A Wound Care Initial Evaluation dated 12/29/11, included, but was not limited to: Wound #2 Back Stage III 2.9 x 3.0 x 0.1 sm. (small) serous exudate; No granulation; Yellow Necrosis; Diagnosis: [REDACTED]." On 1/9/12 at 1:40 p.m., on entrance to resident M's room, there was no answer to the knock on the door. The resident was not in the room at this time. The Medical Records Director was walking down the hall. She was queried as to what type of mattress was on the bed. She indicated it was a regular low air flow mattress. At 1:45 p.m., the resident was observed in the physical therapy department. When queried, the resident indicated there was a cushion in her wheelchair, in which she was seated, and she was taking therapy as she was wanting to go home. On 1/9/12 at 1:45 p.m., the Medical Records Director provided a copy of the current CNA (Certified Nursing Assistant) Assignment Sheet for 1/9/2012 which lacked any reference to the pressure ulcer and need for a cushion in the resident's wheelchair. On 1/9/12 at 4 p.m., the IDON provided a Wound Consult Note dated 1/9/12, which indicated, " Resident (named) has a large post-op abdominal wound and a smaller gluteal decub secondary to pressure from her wound vac tubing. She is mobile and able to perform pressure relief without assistance. The vac tubing has been repositioned so that it is no longer a concern and her wound should heal without complication with local wound care and a pressure relief mattress. An air mattress is not needed with a wound of this type on a patient with adequate mobility." This consult was faxed to the facility on [DATE] at 3:42 p.m. During interview on 1/9/12 at 4 p.m., the IDON indicated Resident M did not require any additional pressure relieving devices. During observation on 1/10/2012 at 10:30 a.m., wound care for Resident M was done by LPN # 8 under clean technique. The wound was on the coccyx and approximately 3.5 x 3.5 inch circular and 0.5 inch deep and was beefy red with yellow slough, and a 0.5 inch area of eschar (black). Area surrounding the wound was reddened. The Immediate Jeopardy that began on 12/26/11 was removed on 1/10/12 when the facility began assessing all residents for pressure ulcers and began inservicing all nursing staff, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because assessment of residents and inservicing continues and monitoring is to be done. 3. The clinical record for Resident A was reviewed on 1/5/12 at 10:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The admission assessment Minimum Data Set ((MDS) dated [DATE], included, but was not limited to: Cognitively intact, Skin Condition: Resident at risk for developing pressure ulcer. No current pressure ulcers were coded. For bed mobility, resident required extensive assistance of two person assist and personal hygiene with extensive assist of one person. The Resident Weekly Skin Check Sheet indicated no pressure ulcers on 10/20/11, 10/27/11, 11/3/11, 11/10/11 "No new skin impairments noted," and 11/17/11 "No skin impairment noted." Resident Progress Notes included, but were not limited to, the following: 10/27/11 "Change BLE (bilateral lower extremity) una boots PRN (as needed) only if they become displaced. Have therapy assess RLE (right lower extremity) for [MEDICAL CONDITION], massage when wrap is taken down." Documentation was lacking of the heels being assessed prior to 11/1/11. On 11/1/11 "New area found - to R foot 1.5 x 1.0 cm (centimeters) - non - stagable (sic) - NO (New order) received for skin prep q. (every) shift." The Weekly Pressure Ulcer BWAT Report dated 11/1/11, indicated an Unstageable/Deep Tissue Injury was found. The Interim Plan of Care, which was not dated, included, but was not limited to: "Skin Integrity Wound Care R hip incision on admission; Problem: Risk for Skin Impairment; Goal: Pt will experience no breakdown x 40 days; Approach: 1. Weekly skin assessments; 2. Preventative Care; 3. Notify MD of any changes." A Comprehensive Care Plan Report dated 10/27/11, indicated: Problem: Skin/tissue integrity impaired potential, with a hand written note on 11/1 "NS (Non Stageable) R heel;" Goal 1. 10/27/11 incision heal w/o (without) s/s (signs/symptoms) infection, skin remain free of breakdown; Est (estimated) Date 1/24/12; Approach: 1. 10/27/11 Pressure reduction bed and w/c (wheelchair); staff assist to T/P (turn/position) Q (every) 2 hours in bed; txs (treatments) as MD orders; Monitor skin for changes; Weekly skin assessments; Monitor incision for s/s infection thru healing 11/4 Dr. (name) wound specialist to eval (evaluate) and tx (treat)." A Physician Telephone Order dated 11/10/11 1510 (3:10 p.m.), indicated 1. D/C (discontinue) skin prep to R heel 2. Acquaphor to R heel/foot BID (twice a day) 3. Elevate R heel off of bed 4. Shoe to R foot only with PT (Physical Therapy) (ok to wear splint at all time). Documentation was lacking of the care plan being updated on 11/10/11 to include the skin treatment ordered by the MD. On 11/10/11 a Wound Care Initial Evaluation was in the clinical record which included, but was not limited to: [DIAGNOSES REDACTED]." Documentation was lacking to indicate the treatment change was updated to the care plan. Follow - up visit on 11/17/11: "Wound 1 R heel, Stage II 1.7 x 0.7 x 1.0. No exudate, no granulation, no necrosis. Diagnosis: [REDACTED]. Documentation was lacking the treatment was updated to the care plan. On 1/6/12 at 9:55 a.m., in interview with the Physical Therapist, he indicated he did not see anything on the resident's heel prior to 11/11/11 when he got doctor's orders. 4. On 1/9/2012 at 10:40 a.m., review of the clinical record for Resident H indicated [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 12/2/2011, indicated the resident did not have any pressure areas. On 12/18/2011 at 1:00 p.m., resident progress notes indicated a change of condition form indicating "area on coccyx now open 2 cm oblong area." On 12/18/2011, a physician order [REDACTED]." Review of the weekly pressure ulcer BWAT (Bates-Jensen Wound Assessment Tool) dated 12/18/2011, 12/25/2011, 1/2/2012, indicated a stage 2 pressure sore. Review of the indicators of pressure ulcer(s), under extrinsic risk factors, indicated, but was not limited to; resident confined to a chair all or most of the time and is in need of a seat cushion to reduce or relieve pressure and pressure reduction bed, and to turn and reposition every 2 hours and as needed. The resident was identified as "at high risk for skin breakdown." On 1/9/2012 at 12:20 p.m., resident H was observed sitting in the north activity room in a high back wheel chair with a pressure reducing cushion in place. Review of the comprehensive care plan report dated 12/6/2011, indicated, but was not limited to, the following: Problem-at risk for skin breakdown, Goal-will be free of skin breakdown, Approach-monitor skin changes. Problem-physical mobility, Goal-will not develop further complications of immobility e.g. (for example) pressure sores, contractures, pneumonitis, Approach-turn and reposition every 2 hours. Problem-skin/tissue integrity impaired, Goal-will have skin intact for the next 90 days, Approach-turn and reposition every 2 hours and as needed. A comprehensive care plan report updated on 12/18/2011, indicated: Problem-stage 2 coccyx, Goal - resolve without further complication or infection, Approach-#1 assist with turn and reposition every 2 hours as needed, # 2 encourage change position while in wheel chair every 2 hours and as needed per staff, # 3 treatment per order, # 4 monitor signs and symptoms of infection. On 1/9/2012 at 12:20 p.m., in an interview with Licensed Practical Nurse (LPN) # 7, she indicated the resident's wound is almost healed, but treatment is still on going. On 1/9/12 at 1:00 p.m.,the facility policy and procedure for Pressure Ulcer Prevention was reviewed and included, but was not limited to: ...9. "....Implement interventions to attempt to stabilize, reduce or remove underlying risk factors. (TL 6102) Risk Analysis Guide. 10. Monitor the impact of the interventions, and modify the interventions as appropriate. 11. Use positioning techniques to keep the resident's heels off the bed. A care plan approach may be raising the foot of a hospital-type bed to elevate the legs at intervals can take pressure off the heels and aid circulation. 12. Evaluate and individualize use of various devices to reduce or relieve pressure and/or reduce skin injuries that may result in pressure ulcers (i.e. heel protectors, heel splints, rectal pouches). a. Increase mobility, activity. b. Reposition every 1-2 hours. For example, residents at higher risk for pressure ulcers may need repositioning more than every hour when sitting in a chair (especially if they show evidence of stage 1 pressure ulcers with less frequent repositioning). 13. Implement interventions to decrease the magnitude of pressure, friction, and shear on the pressure ulcer and to prevent further pressure ulcers. a. Minimize shear and friction (proper positioning, transferring and turning techniques). b. Maintain HOB at lowest elevation possible. c. Use lifting devices (e.g., trapeze/bed linen). 14. Place residents identified at risk on a pressure-reducing mattress. Avoid standard hospital mattresses. Matching a device's potential therapeutic benefit with the resident's specific situation should choose appropriate support surfaces or devices. For example multiple ulcers, limited turning surfaces, ability to maintain position. (PRO ) Specialty Bed/Products (FRM -01) Mattress/bed and/or Products's Request Form 15. Develop care plan on the degree and areas of risk and update as necessary. 16. Educate and document staff and family member/responsible party on interventions to reduce or prevent pressure ulcers. 17. Assess resident from head to toe for skin effectiveness of care plan interventions and document in the resident's medical record: a. Upon admission within 6 hours. b. At least weekly c. Upon transfer and/or discharge (FRM -09) Resident Weekly Skin Check Sheet. (FRM ) Treatment Administration Record (TAR) " The Policy for Positioning a Resident with Pressure Ulcers was reviewed on 01/09/2012 at 1:00 p.m. The policy included but was not limited to: Procedure: 1. "...Repositioning a. Reposition resident at lease every two hours whether the resident is in bed or in a chair. b. Some residents may require repositioning more frequently depending on location of the ulcer and nutritional and hydration status. c. The repositioning schedule should be incorporated into the resident's care plan. 2. Heel Pressure Ulcer a. Place pillow under calf of legs (e.g., off loading ramp off loading boots) to maintain alignment and prevent/contact with bed unless contraindicate (i.e. ,[MEDICAL CONDITION]) (deep vein thrombus). b. Assess resident to ensure that pressure is not being redistributed to the calf. c. Assess for new areas of pressure that my be caused by a pressure-relieving device. ..." Documentation Guidelines: 1. " Update resident's care plan with the appropriate positioning intervention." 2. "Communicate with nursing staff positioning intervention." 3. "Document the effectiveness of repositioning the resident in the medical record." 4. "Document in the resident's medical record on the designated form resident weekly." skin check and need for a specialty/bed/product. 5. "Update the care plan, as the resident's needs change." 6. "Notification of physician and family member/responsible party as necessary." 7. " Signature and Title. " This federal tag relates to complaint IN 837. 3.1-40(a)(1) 3.1-40(a)(2)

A. Based on record review and interview, the facility to contact a resident's physician and/or the Medical Director, when a resident complained of headache and vomited following a fall with head injury, for 1 of 1 resident reviewed with a head injury from a fall who subsequently died , in a sample of 10. (Resident B) B. Based on record review and interview, the facility failed to notify the physician when blood glucose readings fell below or above physician-set parameters, for 2 of 2 residents reviewed for blood glucose monitoring in a sample of 10 residents. (Residents E and I) Findings include: A.1. The clinical record for Resident B was reviewed on [DATE] at 12:55 p.m. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was cognitively intact and had a fall since admission. Resident Progress Notes included, but were not limited to: [DATE] at 9:30 a.m. "This nurse called to pt (patient) room by CNA (certified nursing assistant) pt found sitting on bathroom (sic). Pt A &O (alert & oriented) x 3. No c/o (complaints of) pain or discomfort voiced. When asked what happened pt stating she was standing to transfer to bathroom and was trying to move raised toilet seat over to toilet when she lost her balance & fell . Denies hitting head. Skin intact. V/S (vital/signs) stable. Neuro checks initiated. Pt educated to ask for assist when transferring voiced understanding. will cont. (continue) to monitor." [DATE] at 11:30 p.m. "CNA answered call light, pt's roommate (sic) was helping pt. by alerting staff that res. rolled out of bed onto floor. Pt laying on L (left) side on floor, pt was seen to be calm, not in any distress skin normal tones, dry, warm to touch. VS (Vital Signs): ,[DATE] (blood pressure), 76 (pulse), 91% on RA (oxygen saturation on room air), 24 bpm (breaths per minute). No visible injuries, pt able to perform AROM (active range of motion) to all extremities, pat able to move to sitting position unassisted. Nurse & CNA assisted pt to standing position without difficulty no c/o pain. Sitting VS on edge of bed: ,[DATE], 72, 98.0, 24, 90 %. Notified DNS (Director of Nursing Service), MD & family, no adverse reactions." [DATE] at 2:50 a.m. "Pt c/o headache, pt has a small "goose egg" to L (left) side of head, palpated hard to touch, pt states does not hurt when nurse touches, pt emesis 20 ml (milliliters) of clear brown liquid. Gave pt po (by mouth) Tylenol 650 mg PRN (as needed) d/t (due to) [MEDICATION NAME] ,[DATE] not available, pharmacy sending. Gave pt PRN [MEDICATION NAME] for nausea, have a call out to MD. Notified DNS to changes. Will continue to monitor." Documentation was lacking the physician was called again and/or the Medical Director notified. [DATE] at 4:10 a.m. "This writer went into check on pt, pt unresponsive, pupils fixed, called in another RN, ox sat 94% on 2 L (liters), ,[DATE], 79, 30 bpm, called 911 and sent pt to (named hospital) ER (emergency room ) for evaluation & treatment, notified DNS & family of transfer. RN stayed with pt until EMS (emergency medical service) arrived." [DATE] at 4:30 a.m. "EMS arrived and transported pt to hospital via stretcher...." [DATE] at 6:20 p.m. "Res. son, (named) came to facility to pick up Res. belongings and spoke with DNS stating his mother had expired at (different named hospital) ER today." On [DATE] at 2:32 p.m., the interim DNS (Director of Nursing Services) indicated RN #1 assessed Resident B at 2:50 a.m., noted the hematoma, and called the MD and DNS. The DNS indicated the RN should have sent her out or called the Medical Director. The DNS indicated the doctor did not call back, the DNS directed RN #1 to monitor the resident. B.1. Review of the clinical record for Resident #E on [DATE] at 1:45 p.m., indicated the resident had [DIAGNOSES REDACTED]. On [DATE], the physician gave an order for [REDACTED]. Review of the [DATE] Diabetic Monitoring Flow Sheet indicated the resident had blood glucose readings which fell outside the set parameters which required physician notification: - ,[DATE] = 1100 (11:00 a.m.) - critical high - ,[DATE] = 2000 (8:00 p.m.) - 49 - ,[DATE] = 1600 (4:00 p.m.) - high - ,[DATE] = 1115 (11:15 a.m.) - high - ,[DATE] = 1100 - 42 - ,[DATE] = 2000 - high - ,[DATE] = 1600 - high -,[DATE] = 2000 - high - ,[DATE] = 0600 (6:00 a.m.) - 58 - ,[DATE] = 1100 - 58 - ,[DATE] = 0600 - 59 Review of the [DATE] Diabetic Monitoring Flow Sheet indicated the resident had blood glucose readings which fell outside the set parameters which required physician notification: - ,[DATE] = 0600 - 27 - ,[DATE] = 1600 - high - ,[DATE] = 1100 - 48 Review of the nursing notes between ,[DATE] and [DATE] lacked documentation of the physician having been notified when the blood glucose levels fell outside the physician set parameters. B.2. Review of the clinical record for Resident #I on [DATE] at 11:50 a.m., indicated the resident had [DIAGNOSES REDACTED]. On [DATE], the physician gave an order for [REDACTED]. Review of the [DATE] Diabetic Monitoring Flow Record indicated the resident had blood glucose readings which fell outside the set parameters which required physician notification: - ,[DATE] = 2000 - high - ,[DATE] = 1600 - 58 - ,[DATE] = 1100 - 48 Review of the [DATE] Diabetic Monitoring Flow Record indicated the resident had blood glucose readings which fell outside the set parameters which required physician notification: - ,[DATE] = 2000 - high - ,[DATE] = 1130 - high - ,[DATE] = 1600 - high - ,[DATE] = 0945 (9:45 a.m.) - high - ,[DATE] = 1100 - 58 - ,[DATE] = 1100 - high - ,[DATE] = 0600 (6:00 a.m.) - 40 - ,[DATE] = 0600 - high " = 2000 - high - ,[DATE] = 1100 - high " = 1900 (7:00 p.m.) - high Review of the nursing notes between ,[DATE] and [DATE] lacked documentation of the physician having been notified when the blood glucose levels fell outside the physician set parameters. When queried about what to do if blood glucose readings fell outside set parameters, interviews with LPNs (licensed practical nurse) #3, 4 and 5 on [DATE] between 4:35 p.m. and 4:45 p.m., indicated the following: - LPN #5 - "Would call physician is the blood sugars were below 60 or above 500. - LPN #4 - "Would call the doctor if the blood sugars were above 500 after I re-checked it." - LPN #3 - "If blood sugar was low, I would give orange juice and then re-check it in ,[DATE] minutes. If it was very high, call the physician." On [DATE] at 4:50 p.m., the District Director of Clinical Operations presented a copy of the facility's current policy and procedure on "Condition Change of a Resident." Review of this policy at this time indicated: "...Definition: IMMEDIATE NOTIFICATION - the physician should be informed at the time the event occurs either directly or by pager...The nurse should not hesitate to contact the physician at any time for a problem that in their judgement requires immediate medical attention...Procedure:...5. Notify the physician of the clinical problems. If the attending is not available, notify the alternate physician on call then Medical Director...11. Monitor and reassess resident's condition and response to the interventions until stable or until emergency personnel arrives and takes over care for transfer to acute care..." This Federal tag is related to Complaint IN 837. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)

Based on record review and interview, the facility failed to ensure a safe transfer for 1 of 2 residents reviewed utilizing the Hoyer Lift in a sample of 7 which resulted in the resident being treated for [REDACTED]. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/8/10 at 3:05 p.m. The resident [DIAGNOSES REDACTED]. Resident Progress Notes included, but were not limited to: "12/5/09 1520 (3:20 p.m.) Called to RM (room) per CNA (Certified Nursing Assistant) Res (Resident) found laying on floor with lift pad still attached to lift. Res c/o (complains of) neck pain - assessed Res and call placed to (named) NP (Nurse Practitioner). N.O. (New order) to send to (named hospital) ER (emergency room ) for eval (evaluation)...Small abrasion noted to L (Left) ear..." Review of the Resident Transfer Form, dated 12/05/09, included, but was not limited to: "Additional Pertinent Information: Res was being transferred by lift and was about 5'-6' feet in air and fell out of sling and hit neck. C/O (complains of) neck pain. Res keep (sic) on floor still." The resident was sent to the emergency room . On 9/9/10 at 1:15 p.m., review of the emergency room , notes dated 12/05/09, indicated Resident C was treated for [REDACTED]. Review of the Post Fall Evaluation, dated 12/5/09 and timed 1520 (3:20 p.m.) indicated "Injury Res was being transfered (sic) per Hoyer lift to W/C (wheel chair) and slipped and fell out of left onto floor...CNA transferring Res to W/C." Review of the Comprehensive Care Plan, dated 10/12/2009, included, but was not limited to: "Problem (12) Resident is at risk for falls R/T (related to) Psychotropic medication, [DIAGNOSES REDACTED]; Goal: Will be free from injury; Approach: (07) Hoyer Lift for all transfers with 2 staff." On 09/09/10 at 3:15 p.m., the Director of Nursing provided the Policy and Procedure for the Mechanical Lift (Sling Lift) with a revision date of 10/31/08. The procedure included, but was not limited to: "4. Obtain assistance from another staff member for transfer as necessary. Two people are required when using the Mechanical Lift: a. one to spot. b. One to maneuver the lift." In interview with the Director of Nursing on 09/09/10 at 1:20 p.m., she indicated CNA #1 had a 1:1 inservice and provided her Orientation Checklist which included, but was not limited to Saf-Lit Program dated 7/22/09. In interview with the Staff Development Coordinator on 09/09/10 at 4 p.m., she indicated the "Saf-Lift" included the Mechanical Lift (Sling Lift) which was the same as the above P/P. This federal tag relates to Complaint Number IN 937. 3.1-45(a)(2)