Every finding on record at St Andrews Health Campus

Based on observation and interview, the facility failed to store food items for residents appropriately related to expired foods for 1 of 2 kitchen observations. This deficient practice had the potential to affect 57 of 57 resident that reside in the facility. Findings include:During the initial kitchen tour and interview with the Dietary Manager (DM), on 01/08/2026 at 10:30 A.M., the following was observed: -Two plastic packages of sliced turkey deli meat with an expiration date of November 2025, were laying on the top shelf of a wheeled cart. The DM indicated it had been frozen and was recently thawed. They were going to use it for lunch. There was no date on the packages as to when the packages of turkey were thawed. The DM threw both packages in the garbage can, -The top white plate in the plate warmer had a large splatter of off-white colored debris with green specks on the surface of the plate, the DM placed it in the dirty dish area. The dry storage room contained the following: -One square plastic tub of quinoa labeled with a use by date of 03/18/2025,-One square plastic tub of rice labeled with a use by date of 06/08/2025,-One square plastic tub of dry pasta labeled with a use by date of 09/26/2025,-One square plastic tub of dry beans labeled with a use by date of 06/09/2025,-One square plastic tub of split peas labeled with a use by date of 06/08/2025,-A one gallon jug of [NAME] wine for cooking labeled with a use by date of 10/29/2024,-A one gallon jug of [NAME] wine for cooking labeled with a use by date of 02/22/2025, that had the Corporate Dining Support Services name on it, who used to be the DM in the facility up until two months ago. The current DM indicated inventory was assessed two times a week. The items in the dry storage room had not been used recently. During an interview, on 01/15/2026 at 11:55 A.M., the DM indicated food items were labeled and disposed of when they reached the date on the label. During an interview, on 01/15/2026 12:20 PM., the Assistant Director of Nursing (ADON) indicated all the residents in the facility received foods from the facility kitchen. The current Storage Procedures policy for Culinary Services, with a revised date of 07/10/2025, was provided by the Director of Nursing on 01/14/2026 at 1:05 P.M. The policy indicated, .Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance.Open packages are labeled, dated, and stored in closed containers.Stock is dated and rotated so that the oldest items are used first. 3.1-21(i)(3)

Based on record review, interview, and observation, the facility failed to follow physician's orders related to hold parameters for medications and identify skin impairments in a timely manner for 3 of 17 residents reviewed for Quality of Care. (Residents 8, 52, and 43)Findings include:1.The clinical record for Resident 8 was reviewed on 01/09/2026 at 1:15 P.M. An Annual Minimum Data Set (MDS) assessment, dated 10/10/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, hypertension, dementia, anxiety, and depression. The Electronic Medication Administration Record (EMAR) for November and December 2025, were provided by the Director of Nursing (DON) on 01/14/2026 at 1:05 P.M. The record indicated the resident had the following current physician's order: -Losartan, a cardiovascular medication, 25 milligrams (mg) once a day, between 6:00 A.M. and 10:00 A.M. The special instructions for the medication indicated the medication was to be held, not given, if the resident's systolic (top number) blood pressure (b/p) was 120 or less, per hospice. The medication was given, not held, on the following dates: -On 11/02/2025, the resident's b/p was 116/69. -On 11/05/2025, the resident's b/p was 111/68. -On 11/06/2025, the resident's b/p was 115/72. -On 11/07/2025, the resident's b/p was 110/64. -On 11/10/2025, the resident's b/p was 118/66. -On 11/11/2025, the resident's b/p was 116/65. -On 11/12/2025, the resident's b/p was 110/69. -On 11/16/2025, the resident's b/p was 118/69. -On 11/19/2025, the resident's b/p was 118/74. -On 11/23/2025, the resident's b/p was 95/55. -On 12/01/2025, the resident's b/p was 107/59. -On 12/30/2025, the resident's b/p was 118/68. -On 12/31/2025, the resident's b/p was 118/69. The Progress Notes for November and December 2025 were reviewed on 01/09/2026 at 1:36 P.M. The record lacked documentation the physician was notified of the medication being outside of the hold parameters or a reason the medication was given. The resident's Care Plan for Potential for cardiovascular distress related to diagnoses of hypotension and hypertension was provided by the DON on 01/14/2026 at 1:05 P.M. An Approach, with a start date of 07/28/2023, indicated staff were to, .Obtain vital signs as ordered and needed . 2. The clinical record for Resident 52 was reviewed on 01/12/2026 at 11:45 AM. An admission MDS assessment, dated 11/14/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension and Parkinson's disease. An open-ended physician's order, with a start date of 11/10/2025, indicated the staff were to administer amlodipine 10 mg, once a day. The staff were to hold the medication if the resident's blood pressure was less than or equal to 110/60 or the pulse was less than or equal to 60. The November and December 2025, and January 2026, EMAR indicated the resident had received the medication when the pulse was less than or equal to 60 on the following dates and times: -On 11/11/2025 when the resident's pulse was 57. -On 11/12/2025 when the resident's pulse was 58. -On 11/18/2025 when the resident's pulse was 53.-On 11/23/2025 when the resident's pulse was 59.-On 11/24/2025 when the resident's pulse was 54.-On 11/29/2025 when the resident's pulse was 52.-On 11/30/2025 when the resident's pulse was 59.-On 12/02/2025 when the resident's pulse was 60. -On 12/03/2025 when the resident's pulse was 56.-On 12/04/2025 when the resident's pulse was 56. -On 12/10/2025 when the resident's pulse was 60. -On 12/13/2025 when the resident's pulse was 59.-On 12/20/2025 when the resident's pulse was 60.-On 12/23/2025 when the resident's pulse was 60. -On 12/24/2025 when the resident's pulse was 60.-On 01/09/2025 when the resident's pulse was 60. -On 01/10/2025 when the resident's pulse was 59. During an interview, on 01/13/2025 at 10:54 A.M., RN 5 indicated if a resident's medication had hold parameters, then she would obtain the vital signs before giving the medication. If the vital sign values were not within the parameters to give the medication, she would hold (not give) the medication. She would document in the EMAR that the medication was not administered due to the resident's condition. The current MEDICATION ADMINISTRATION GENERAL GUIDELINES policy, with a revised date of 11/2018, was provided by the Director of Nursing (DON) on 01/14/2026 at 1:05 P.M The policy indicated, .Medications are administered in accordance with written orders of the prescriber . 3. During an observation and interview, on 01/08/2026 at 12:50 P.M., Resident 43 was sitting in her room. She had on a pair of capri style pants. On her right lower leg there was a dime size, dark scab. The resident indicated she was unsure what had happened. During an observation, on 01/12/2026 at 1:39 P.M., Resident 43 was sitting in the doorway to her room. She had on capri style pants. On her right lower leg there was a dime size, dark scab. The clinical record for Resident 43 was reviewed on 01/13/2026 1:14 P.M. A Quarterly MDS assessment, dated 10/09/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, senile degeneration of the brain, heart failure, hypertension, diabetes, non-Alzheimer's dementia, anxiety, and depression. During an interview, on 01/13/2026 at 10:50 A.M., RN 5 indicated the resident mostly cared for herself but needed assistance at times. If a resident had new skin impairments, the nurse would assess the area and open a skin event in the electronic clinical record. The resident had told her about the scab on her leg the day before. She had not opened a skin event and was just keeping an eye on it to make sure it didn't bust open. During an interview, on 01/13/2026 at 1:56 P.M., the ADON indicated if a Nurse or Certified Nurse Aide (CNA) found a new skin impairment then it should be documented in the clinical record. The nurses document in a progress note and the CNA's document in their CNA charting. The nurse would also need to notify the physician and get new orders. During an interview, on 01/13/2025 at 2:06 P.M., the ADON indicated she was unaware of the scab to the resident's leg. The resident did like to pick at her skin but that wasn't an excuse, and the staff should have documented that the resident had an area to her leg. The resident's clinical record lacked any documentation related to the skin impairment to the right lower leg until the afternoon of 01/13/2025. The current facility policy titled, Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, with a review date of 11/19/2025, was provided by the DON on 01/14/2025 at 9:24 A.M. The policy indicated, .Utilize to describe and monitor.If skin alterations occur post admission.Complete Skin Tear/Laceration Incident in EHR [Electronic Health Record].IDT [Interdisciplinary Team] should review this timely and wound nurse or designee complete an assessment in wound management or Wound Zoom . Continue to monitor weekly in wound management. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheters for a resident with a Urinary Tract Infection (UTI) for 1 of 2 residents reviewed for urinary catheters / UTIs. (Resident 38)Findings include: On 01/13/2026 at 8:59 A.M., Resident 38 was observed in his room sitting in his recliner. The resident's indwelling urinary catheter tubing and drainage bag were hanging on the side of a waste basket next to the resident's chair. During an interview, on 01/13/2026 at 1:42 P.M., RN 12 indicated the resident currently had a UTI and would begin taking an antibiotic that day. On 01/13/2026 at 1:47 P.M., the resident was observed in his room sitting in his recliner. The resident's catheter tubing and drainage bag were laying on the floor near the resident's feet. On 01/13/2026 at 3:31 P.M., the resident was observed in his room sitting in his recliner. The resident's catheter tubing and drainage bag were laying on the floor near the resident's feet. On 01/13/2026 at 3:50 P.M., Certified Nurse Aide (CNA) 4 entered the resident's room and observed the resident's catheter bag and tubing laying on the floor. The CNA picked up the catheter bag and hung it on the side of the waste basket near the resident's chair. The CNA indicated it was normal to hang the bag on the waste basket. He probably should have hung the bag on the other side of the resident's chair and not on the waste basket. It might have been an infection control issue. The resident's record was reviewed on 01/12/2026 at 11:02 A.M. A Quarterly Minimum Data Set assessment, dated 11/17/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, renal insufficiency, and neurogenic bladder. The resident had an indwelling urinary catheter.The resident's current Care Plans were reviewed, and included, but were not limited to, a Care Plan, with a start date of 01/13/2026, that indicated the resident had an active diagnosis of a urinary tract infection. Interventions included, but were not limited to, an intervention to use proper infection control precautions as indicated and per policy when providing toileting, incontinence care, or catheter care.The resident's current physician's orders included, but were not limited to an order, with a start date of 01/13/2026 for Macrobid (an antibiotic) 100 milligrams twice a day until 01/20/2026 for a UTI.The current facility policy, titled Urinary Catheter Care, with a reviewed-on date of 12/16/2024, was provided by the Director of Nursing on 01/14/2026 at 2:50 P.M. The policy indicated, .To prevent infection of the resident's urinary tract.Be sure catheter tubing and drainage bag are kept off the floor.3.1-41(a)(2)

Based on record review and interview, the facility failed to have medications available for a resident for 1 of 17 residents reviewed for pharmacy services. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 01/09/2026 at 2:42 P.M. An admission Minimum Data Set (MDS) assessment, dated 12/12/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, pressure ulcer, heart failure, hypertension, wound infection, diabetes, non-Alzheimer's dementia, malnutrition, and vascular dementia.A physician's order, dated 12/09/2025 through 12/10/2025, indicated the resident was to receive Lovenox (enoxaparin), 30 mg subcutaneously (an injection administered just under the skin), every 12 hours. The resident's December 2025 Electronic Medication Administration Record (EMAR) indicated the resident did not receive the medication on 12/09/2025, between 6:00 A.M. and 10:00 A.M., due to the medication being unavailable. A physician's order, dated 12/10/2025 through 12/25/2025, indicated the resident was to received enoxaparin, 90 mg subcutaneously (an injection administered just under the skin), every 12 hours. The resident's December 2025 EMAR indicated the resident did not receive the medication on 12/22/2025, between 6:00 A.M. and 10:00 A.M., and on 12/22/2025, between 6:00 P.M. and 10:00 P.M., due to the medication not being available. The clinical record lacked indication the physician was notified the medication was unavailable. During an interview, on 01/13/2025 at 1:50 P.M., the Assistant Director of Nursing (ADON) indicated when a resident was due for more medications the nurse would just hit the resupply button on the EMAR. If it was a recurrent order, the resident's medications came every Thursday for a week's worth of medications. If it was a new order, then the medication would come the next day. If they needed a medication sooner, they would call the pharmacy, and the medication would arrive at the facility in about four hours. If a resident was missing a medication, the physician should be notified, and it should be documented in the EMAR or a progress note. For syringe medications, like the resident's Lovenox, it should be reordered when there were only five doses left. The current facility policy titled Medication Orders, with a revised date of 11/2018, was provided by the Director of Nursing (DON) on 01/14/2025 at 9:24 A.M. The policy indicated, .The prescriber is contacted by facility personnel for direction when delivery of a medication will be delayed or the medication is not or will not be available.3.1-25(a)

Based on record review and interview, the facility failed to prevent a significant medication error related to an anticoagulant (blood thinner) medication for 1 of 7 residents reviewed for unnecessary medications. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 01/09/2026 at 2:42 P.M. An admission Minimum Data Set (MDS) assessment, dated 12/12/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, pressure ulcer, heart failure, hypertension, wound infection, diabetes, non-Alzheimer's dementia, malnutrition, and vascular dementia. A Hospital Discharge summary, dated [DATE], indicated the resident was to receive Lovenox (enoxaparin), 90 milligrams (mg), subcutaneously (an injection administered just under the skin), every 12 hours. A physician's order, dated 12/09/2025 through 12/10/2025, indicated the resident was to receive enoxaparin, 30 mg every 12 hours.A Progress Note, dated 12/10/2025 at 7:37 A.M., indicated there was a transcription error noted. The resident's Lovenox order was updated to include the correct dosing. The physician and Power of Attorney were updated of the medication transcription error. The resident had no adverse side effects at that time. Staff education was provided and monitoring would continue. There were no new orders at that time. The resident's December 2025 Electronic Medication Administration Record (EMAR) indicated the resident had received the Lovenox medication, 30 mg, twice, once on 12/09/2025 between 6:00 P.M. and 10:00 P.M., and once on 12/10/2025, between 6:00 A.M. and 10:00 A.M. During an interview, on 01/13/2025 at 10:54 A.M., RN 5 indicated when a resident admitted to the facility from the hospital the nurse would transcribe the physician's orders into the resident's electronic clinical record and a second nurse would verify the orders were correct before the resident's medications could be administered.During an interview, on 01/13/2025 at 1:50 P.M., the Assistant Director of Nursing (ADON) indicated when the resident readmitted from the hospital in December (2025) there was a medication transcription error. The resident's Lovenox was transcribed for 30 mg and should have been 90 mg. At that time, she educated the nurse that made the error and the nurse that verified the medications. The current facility policy titled Medication Orders, with a revised date of 11/2018, was provided by the Director of Nursing (DON) on 01/14/2025 at 9:24 A.M. The policy indicated, .Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.To facilitate effective communication, documentation, and aid in prevention of medication errors, medication orders should be clear and concise.The current facility policy titled, Guidelines for Medication Error Reporting, with a review date of 12/12/2025, was provided by the DON on 01/14/2025 at 9:24 A.M. The policy indicated, .To identify medications given in error and expedite correction actions.3.1-48(c)(2)

Based on record review, observation, and interview, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 2 of 3 observations of high-contact resident care activities. (Residents 58 and 2) Findings include:1. Resident 58's clinical record was reviewed on 01/12/2026 at 11:00 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/05/2025, indicated the resident was severely cognitively impaired. The resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, Alzheimer's dementia, diabetes, and stroke. The resident was at risk for pressure ulcers and had a Stage 3 (Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue was often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure ulcer that was present on admission/re-entry. The resident's current physician's orders included an open-ended order, with a start date of 12/08/2025, indicated staff were to apply Santyl (an enzymatic ointment) to the resident's sacral wound once a day. During an observation, on 01/12/2026 at 1:35 P.M., RN 12 entered the resident's room to provide wound care. There was no sign on the door that indicated the resident was in EBP. RN 12 washed her hands, donned gloves, and approached the resident's bedside. The bed was in a low position. The RN got down on her knees on the floor next to the bed and proceeded to change the dressing on the resident's sacral wound. The RN leaned on the side of the bed and rested her right arm/elbow on the mattress multiple times during the procedure. The RN did not wear a gown when she administered the wound treatment. During an interview, on 01/12/2026 at 3:34 P.M., RN 3 indicated residents with open wounds, feeding tubes, and catheters were in EBP. If staff were administering wound treatments or dealing with any tubing, staff were to wear gowns and gloves. During an interview, on 01/14/2026 at 9:51 A.M., The Assistant Director of Nursing (ADON) indicated the resident's current pressure ulcer on her sacrum was first identified in November 2025. The current facility sign for EBP was provided by the Director of Nursing on 01/14/2026 at 2:50 P.M. The sign indicated staff were to STOP and the resident was in ENHANCED BARRIER PRECAUTIONS. Providers and staff were to wear gloves and a gown for High-Contact Resident Care Activities, including, but not limited to, wound care (any skin opening requiring a dressing) and device care or use (central line, urinary catheter, feeding tube, and tracheostomy). 2. During an observation, on 01/12/2026 at 2:54 P.M., RN 12 prepared a medication, Warfarin two milligrams, for Resident 2 to be administered via the resident's gastrointestinal tube (G-tube). The G-tube was to be flushed with 30 cubic centimeters (cc's) of water before and after the medication was administered. The RN crushed the medication and dissolved it in 10 cc's of water in a small medication cup while standing at the medication cart in the hallway. The resident's room door had a sign posted on the outside indicating the resident was in Enhanced Barrier Precautions (EBP). The RN entered the resident's room with her supplies and the medication. She sat the items down, entered the bathroom, and washed her hands. The RN donned gloves, checked the placement of the G-tube using her stethoscope, placing it on the resident's abdomen, flushed the G-tube with water, administered the medication, and flushed the G-tube with water again. The RN failed to don a gown prior to managing the administration of the medication via the resident's G-tube. The clinical record for Resident 2 was reviewed on 01/13/2026 at 3:24 P.M. An Annual MDS assessment, dated 10/16/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke and heart failure. The resident had a feeding tube and was on a mechanically altered diet. The physician's orders included, but were not limited to, the following: -Warfarin two milligrams, once a day via gastric tube, and -Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. The resident's Care Plan included, but was not limited to, Resident requires enhanced barrier precautions (EBP) during high-contact care related to presence of: feeding tube. An Approach, with a start date of 04/01/2024, indicated staff were to utilize a gown and gloves per EBP policy during indwelling device care .feeding tube . The current Enhanced Barrier Precautions (EBP) Standard Operating Procedure policy, with an Approved date of 04/01/2024, was provided by the DON on 01/14/2026 at 1:05 P.M. The policy indicated, .EBP .will be in place during high contact care activities for residents with the following conditions .All residents with .pressure ulcers .All residents with indwelling medical devices .feeding tubes . 3.1-18(b)(2)

Based on record review and interview, the facility failed to ensure staff met the requirement of completing three hours of annual dementia training for 1 of 10 Nurse Aide/employee records reviewed. (Qualified Medication Aide/CNA 6)Findings include:The employee records were provided by the Employee Experience Manager (EXM) on 01/15/2026. The following staff member failed to have the required number of hours of annual dementia training:- QMA 6 was hired on 11/12/2021 and failed to have any current annual dementia training in her file for 2025. During an interview, on 01/15/2026 at 11:23 A.M., the Director of Nursing indicated the corporation recently changed training management systems. The facility could provide no documentation that indicated QMA 6 completed the annual dementia training in 2025.The current, undated facility policy, titled Training (Required/Personal Development) was provided by the EXM on 01/15/2026 at 11:12 A.M. The policy indicated, .Mandatory trainings are assigned annually to employees based on their role in the organization in order to comply with State and Federal regulations for senior care.3.1-14(u)

Based on record review and interview, the facility failed to provide prescribed medications for 1 of 6 residents reviewed for pharmacy services. (Resident 40) Findings include: The clinical record for Resident 40 was reviewed on 12/11/24 at 11:24 A.M. An Admission Minimum Data Set (MDS) assessment, dated 10/02/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, anxiety, and macular degeneration. The physician's orders were reviewed on 12/11/24 at 11:29 A.M., and included, but were not limited to, the following current order: - Brimonidine eye drops (used to lower fluid pressure in the eyes), one drop in the left eye three times a day at 7:30 A.M., 2:00 P.M., and 10:00 P.M., with a start date of 09/29/24. The November Electronic Medication Administration Record (EMAR) indicated the medication was not given and documented as unavailable on the following dates and times: - 11/24/24 at 10:00 P.M., - 11/25/24 at 7:30 A.M. and 2:00 P.M., - 11/26/24 at 7:30 A.M., 2:00 P.M., and 10:00 P.M., - 11/27/24 at 10:00 P.M., - 11/28/24 at 7:30 A.M., 2:00 P.M., and 10:00 P.M., and - 11/29/24 at 7:30 A.M. and 2:00 P.M. During an interview on 12/11/24 at 1:56 P.M., Qualified Medication Aide (QMA) 3 indicated staff could peel a sticker off of the eye drop bottles and inhalers and fax the order to the pharmacy or they could press the reorder button on the EMAR. During an interview on 12/11/24 at 1:57 P.M., the Assistant Director of Nursing (ADON) indicated when pressing the reorder button on the EMAR before 7:00 P.M. on weekdays, or 3:00 P.M. on weekends, the medication should be delivered to the facility in less than 24 hours. Medications usually came in after midnight of the day they were ordered. During an interview on 12/13/24 at 10:18 A.M., RN 4 indicated they had called the pharmacy, and the pharmacy indicated they had sent the eye drops. When medications came in, the nurse on duty would sign the list saying they were received. They had checked the other medication carts and could not find the eye drops. When staff ordered medications, they usually would arrive at the facility that same night. During an interview on 12/13/24 at 2:39 P.M., the ADON indicated they could use any of the local pharmacies if they needed a medication they were having difficulty getting from the primary pharmacy. The current UNAVAILABLE MEDICATIONS policy, with a revised date of 11/18, was provided by the ADON on 12/13/24 at 3:02 P.M. The policy indicated, .The facility must make every effort to ensure that medications are available to meet the needs of each resident . 3.1-25(g)(3) 3.1-37(a)

Based on observation and interview, the facility failed to maintain residents' snack refrigerator related to unlabeled items for 1 of 1 resident snack refrigerators reviewed. (Health Center snack refrigerator) Findings include: The nourishment area in the Health Center was observed with Qualified Medication Aide (QMA) 2 on 12/16/24 at 9:17 A.M. The snack refrigerator contained the following: - Three lidded bowls that contained what looked like oats and milk that were labeled as belonging to a current resident in the facility. There were instructions for reheating the contents of the bowls. The bowls were not dated and QMA 2 was not sure when the items were brought into the facility. - A bag from a fast-food restaurant with a container of dried out french fries and a wrapped sandwich. The bottom of the bag was discolored from grease. A resident's nickname was written on the bag, but the bag was not labeled with a received-on date. - A white plastic bag from a fast-food restaurant with a half-eaten burrito bowl inside. The bag was not labeled in any way. - A Styrofoam cup of milk with a lid labeled with a resident's first name. The cup was dated 12/07/24. QMA 2 removed the cup and poured the milk out. During an interview on 12/16/24 at 9:20 A.M., QMA 2 indicated food items brought in by family should be labeled with the resident's name and the date it was received. The current facility policy, titled Food Brought Into Facility, dated 01/2023, was provided by the Assistant Director of Nursing (ADON) on 12/16/24 at 1:57 P.M. The policy indicated, .Food or Beverage items are to be properly Labeled and Date marked, stored and discarded, in conjunction with the facilities Date [NAME] and labeling [Policy and Procedure] P&P . The current facility policy, titled Food Labeling and Dating Policy, dated 01/2024, was provided by the ADON on 12/16/24 at 1:57 P.M. The policy indicated, .Any food product .must have a label that contains the following .Date and Time the food was labeled .Use by date . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to store medications appropriately related labeling medication and having unsecured loose tablets in the medication carts for 2 of 3 medication carts reviewed. (The 100 Hall Medication Cart and the 200 Hall Medication Cart) Findings include: 1. The 100 Hall Medication Cart was observed on 11/06/23 at 10:15 A.M., with RN 3. The Cart contained the following loose pills laying in the bottom of the drawers: - two small yellow oval tablets, and - one small white oval tablet, During an interview on 11/06/23 at 10:16 A.M., RN 3 indicated there should not be any loose pills in the medication cart. 2. The 200 Hall Medication Cart was observed on 11/06/23 at 9:58 A.M., with LPN (Licensed Practical Nurse) 4. The Cart contained the following: - a bottle of Refresh eye drops with no resident name and no opened date. During an interview on 11/06/23 at 9:59 A.M., LPN 4 indicated all medication in the medication cart should be labeled with the resident's name and have an opened date. The current facility policy titled, MEDICATION STORAGE IN THE FACILITY with a revised date of 11/2018 was provided by the Director of Nursing on 11/06/23 at 10:54 A.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . 3.1-25(m)

Based on record review and interview, the facility failed to notify the physician for a change in a resident's condition related to weights for 1 of 5 residents reviewed for unnecessary medications. (Resident 15) Findings include: The clinical record for Resident 15 was reviewed on 11/01/23 at 10:49 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 10/01/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, and peripheral vascular disease. The resident had taken medications that included, but was not limited to, a diuretic (water pill). The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for October and September 2023 related to the resident's weights were provided by the Scheduler on 11/03/23 at 11:38 A.M. The record indicated the resident was to be weighed weekly. The MD/NP (Nurse Practitioner) were to be notified if the resident gained three pounds or more in a week. The record included, but was not limited to, the following: - On 10/23/23, the resident gained 3.5 pounds, the record lacked the MD/NP notification. - On 10/09/23, the resident gained 4.8 pounds, the record lacked the MD/NP notification. - On 10/02/23, the resident's weight was not obtained, no reason was documented, and the MD/NP was not notified. - On 09/18/23, the resident's weight was not obtained, no reason was documented, and the MD/NP was not notified. Vitals records for weights for September and October 2023, were provided by the Scheduler on 11/03/23 at 11:38 A.M. The record lacked documentation that the resident had been weighed on 10/02/23 or 09/18/23. A Care Plan for Nutrition was provided by the Scheduler on 11/03/23 at 11:38 A.M. The Care Plan included, but was not limited to, an intervention to, Obtain weight as ordered/needed, with a start date of 01/04/21. Progress Notes for September and October 2023, were provided by the Scheduler on 11/03/23 at 11:38 A.M. The record lacked documentation that the MD/NP had been notified on 10/23/23 or 10/09/23, or that the resident had been weighed on 10/02/23 or 09/18/23. During an interview on 11/03/23 at 10:47 A.M., LPN (Licensed Practical Nurse) 5 indicated CNAs (Certified Nurse Aides) and nursing staff obtained residents' weights. If there was an order for a daily or weekly weight it would come up on the EMAR. Whoever was passing medications on the medication cart would document the weights in the EMAR. If the physician was to be notified it would be documented on the EMAR and staff would have to put a Progress Note in the EHR (Electronic Health Record) stating what the MD recommended. During an interview on 11/03/23 at 11:09 A.M., the DON (Director of Nursing) indicated the physician should have been notified of the resident's weight changes. The current Guidelines for Weight Tracking policy, with a reviewed date of 12/31/22, was provided by the Scheduler on 11/03/23 at 11:38 A.M. The policy indicated, .Purpose .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .The weight should be recorded in the individual resident medical record . The current Physician-Provider Notification Guidelines policy, with a reviewed date of 12/31/22, was provided by the Scheduler on 11/03/23 at 11:38 A.M. The policy indicated, .Purpose .The ensure the resident's physician or practitioner .is aware of .change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care .Attempts to notify the physician/provider and their response should be documented in the resident electronic health record . 3.1-5(a)(2)

Based on record review, interview, and observation, the facility failed to implement neurological checks (neurological assessments) following a fall and failed to follow appropriate guidelines for insulin pen usage for 2 of 17 residents reviewed for Quality of Care. (Residents 10 and 31) Findings include: 1. The clinical record for Resident 10 was reviewed on 11/03/23 at 2:47 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/10/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, Parkinson's disease and stroke. The resident had two or more falls with no injury and two or more falls with injuries that were not major since the previous assessment, dated 06/26/23. The Progress Notes were provided by the DON (Director of Nursing) on 11/06/23 at 10:54 A.M., and included, but were not limited to, the following: - A note, dated 10/19/23 at 9:41 P.M., indicated the resident was observed on the floor in his room, lying on his left side. - An IDT (Interdisciplinary Team) note dated 10/23/23 at 8:24 A.M., indicated the resident had an unwitnessed fall in his room on 10/19/23. A Fall Event report, dated 10/19/23 at 3:45 P.M., was provided by the DON on 11/06/23 at 10:54 A.M. The report indicated the resident had an unwitnessed fall in their room and staff were to initiate the Neuro check order set. The event contained the initial set of vital signs and neuro (neurological) checks only. During an interview on 11/06/23 at 10:07 A.M., RN 3 indicated when a resident had an unwitnessed fall, the staff obtained vital signs, assessed the resident for injury, assisted them to get up, and started neuro checks every 15 minutes x (times) 4, every 30 minutes x 4, every hour x 4, every 4 hours x 5; and they monitored vital signs and pain for 72 hours. During an interview on 11/06/23 at 10:11 A.M., the DON indicated neuro checks would be documented in the EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) and they would also be in the vitals record as well. Neuro checks should have been completed for the fall on 10/19/23. The EMAR/ETAR for October 2023 was reviewed on 11/06/23 at 10:30 A.M. The record lacked documentation the neuro checks had been initiated for the fall on 10/19/23. The Vital Signs record for October 2023 was provided by the DON on 11/06/23 at 10:54 A.M. The record included one set (temperature, pulse, respirations, blood pressure, and oxygen saturation) of vital signs on 10/19/23 at 3:45 P.M., and one blood pressure value documented at 8:19 P.M. No other vital signs were documented until 10/20/23 at 7:20 P.M. The current Guidelines for Neurological Checks policy, with a reviewed date of 12/31/22, was provided by the DON on 11/06/23 at 10:54 A.M. The policy indicated, .Residents having a fall should be evaluated for injury .Neuro-checks for 24 hours should be completed within the Fall Event Form . 2. Medication administration was observed on 11/01/23 at 11:49 A.M., with LPN (Licensed Practical Nurse) 2. The nurse checked Resident 31's blood sugar level and indicated the resident was to receive three units of Humalog insulin plus sliding scale insulin before meals. The resident's blood sugar level was 132 and, therefore, would only get the scheduled three units of Humalog insulin. The nurse checked the resident's order, unlocked the medication cart, retrieved the insulin pen from the cart, checked the label, cleaned the hub of the pen, applied the needle, primed the pen with two units with the white needle cap still on the pen, and holding the pen upright. The cap was not transparent. During an interview on 11/01/23 at 11:56 A.M., LPN 2 indicated the purpose of priming the insulin pen was to make sure the bubbles were out of the pen. You had to hold the pen upright. You should be able to see insulin come out of the tip of the needle, and she could not see that with the needle cap still in place. The physician's order for Humalog was provided by the DON on 11/03/23 at 2:54 P.M., and indicated the resident was to receive three units of insulin, subcutaneously, before meals. The undated pharmacy guidelines for Preparing an Insulin Pen for Use policy was provided by the DON on 11/03/23 at 2:54 P.M. The policy indicated, .Remove pen cap .Wipe the rubber septum with an alcohol swab .Remove the seal from the new needle .Line the needle up straight with the pen and screw the needle on .Remove the outer needle cover and do not throw away .Dial a 2-unit prime/test dose .Hold the pen upright, lightly tap the pen reservoir so any air bubbles will rise to the top .Press the injection button all the way in to make sure insulin comes out the end of the needle . 3.1-5(a)(2)

Based on interview, observation, and record review, the facility failed to follow the physician's orders for a dressing change to a pressure ulcer for 1 of 3 residents reviewed for wound care. (Resident 43) Findings include: During an interview on 11/02/23 at 10:47 A.M., LPN (Licensed Practical Nurse) 2 reviewed Resident 43's wound dressing change order and indicated they were to cleanse the left inner ankle area, pat dry, apply Santyl ointment (a prescription medication that removes dead tissue) to the wound bed, and cover with a foam dressing. The dressing was to be changed daily. Wound care for Resident 43 was observed on 11/02/23 at 10:58 A.M., with LPN 2. The nurse prepared the dressing change supplies and followed appropriate infection control guidelines. The nurse removed the soft foam boot that was protecting the resident's left ankle, removed their sock, and removed the old dressing that was dated 10/31. There was a small amount of drainage on the old dressing. The wound, located on the left inner ankle bony prominence, was the size of a pencil eraser. The nurse proceeded with the dressing change and dated the dressing when finished. The nurse indicated staff were to date and initial the dressings. The resident's dressing was to be changed daily and as needed. The dressing should have been changed yesterday (11/01/23). During an interview on 11/02/23 at 11:19 A.M., the DON (Director of Nursing) indicated the resident was admitted with the wound on her inner ankle. They had a wound nurse who evaluated wounds weekly and it would be documented under Wound Management. The clinical record was reviewed on 11/02/23 at 11:37 A.M. An Admission MDS (Minimum Data Set) assessment, dated 10/04/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. The resident was at risk for pressure ulcers and had one unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [non-viable yellow, tan, gray, green or brown tissue; usually moist] or eschar [dead, black, brown, or dead tissue]), that was present on admission. The Wound Management records for the resident's ankle wound were provided by the DON on 11/03/23 at 2:52 P.M., and included, but were not limited to, the following assessments: - On 09/29/23, the wound measured 1 cm (centimeter) x (by) 0.7 cm, was unstageable, and the wound bed was covered with slough, and - On 10/30/23, the wound measured 0.4 cm x 0.3 cm, and the wound bed was covered with granulation (new connective) tissue. The Progress Notes were provided by the DON on 11/03/23 at 2:52 P.M. There were no notes indicating the dressing change had been completed on 11/01/23. The ETAR (Electronic Treatment Administration Record) was provided by the DON on 11/03/23 at 2:52 P.M., and included, but was not limited to, the following current physician's order: - Wound Care, left inner ankle, cleanse area and pat dry. Apply Santyl to wound bed. Cover with a foam dressing and change daily and as needed if soiled/dislodged. The ETAR was documented that the dressing change had been completed on 11/01/23. The current Dressing Changes policy, with a reviewed date of 12/31/22, was provided by the DON on 11/03/23 at 2:52 P.M. The policy indicated, .To ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize / control contamination . This citation relates to Complaint IN00419961. 3.1-40(a)(2)

Based on record review and interview, the facility failed to follow a physician's order for daily weights related to edema for 1 of 2 residents reviewed for hydration. (Resident 52) Findings include: The clinical record for Resident 52 was reviewed on 11/01/23 at 10:46 A.M. An Admission MDS (Minimum Data Set) assessment, dated 10/20/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, metabolic encephalopathy, lymphedema, cardiomegaly, anxiety, and depression. An NP (Nurse Practitioner) Progress Note, dated 10/23/23, indicated the resident was being seen for post seven-day admission follow-up. The assessment and plan included but was not limited to, .Edema: Start HCTZ (Hydrochlorothiazide) 25 mg (milligrams) daily x (times) 3 days and daily weight . The clinical record lacked indication the resident was weighed daily from 10/24/23 through 11/03/23. During an interview on 11/03/23 at 10:47 A.M., LPN (Licensed Practical Nurse) 5 indicated CNAs (Certified Nurse Aides) and nursing staff obtained residents' weights. If there was an order for a daily or weekly weight it would come up on the EMAR. Whoever was passing medications on the medication cart would document the weights in the EMAR. If the physician was to be notified it would be documented on the EMAR and staff would have to put a Progress Note in the EHR (Electronic Health Record) stating what the MD recommended. During an interview on 11/03/23 at 9:51 A.M., the ADON (Assistant Director of Nursing) indicated the residents daily weight order from 10/23/23 was missed and should have been started on 10/24/23. The nurses would have transcribed the NP's orders the day she was in the building, but the management team should have caught the missed order the next day during their morning meeting. The current facility policy titled, Guidelines for Weight Tracking, with a review date of 12/31/22, was provided by the DON (Director of Nursing) on 11/03/23 at 2:52 P.M. The policy indicated, .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .The weight should be recorded in the individual resident medical record . 3.1-46(a)(1)

Based on record review and interview, the facility failed to follow a physician's order related to a gradual dose reduction of an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 11/01/23 at 9:56 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/06/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, non-Alzheimer dementia, Parkinson's disease, anxiety, and psychotic disorder. A Behavior Management Team Gradual Dosage Reduction Recommendation, dated 03/28/23, indicated the resident was currently taking Seroquel (an antipsychotic medication) 12.5 mg (milligrams) every day. The consideration was given to gradual dose reduction to discontinue the Seroquel at that time. The form was signed by the Nurse Practitioner the same day. A facility Gradual Dose Reduction (GDR) Circumstance was started on 03/29/23 indication the resident Seroquel 12.5 mg every day was GDR' d. The form indicated the resident's representative was notified on 04/03/23. A Progress Note, dated 03/29/23 at 10:02 A.M., indicated the Behavior management team met on 03/28/23 for a monthly behavior meeting. The residents Seroquel 12.5 mg once a day was up for review. The Psychologist and NP decided to discontinue at the time. A Progress Note, dated 03/29/23 at 10:05 A.M., indicated the resident Seroquel was discontinued for GDR per the MD and the POA (Power of Attorney) was aware. A Progress Note, dated 03/30/23 at 12:18 A.M., indicated the resident was without concerns related to the discontinuing of Seroquel. A Progress Note, dated 03/31/23 at 12:52 A.M., indicated the resident continued a GDR of Seroquel with no adverse side effects. A Progress Note, dated 04/01/23 at 1:03 A.M., indicated the resident had no adverse effects related to the GDR of Seroquel. A Progress Note, dated 04/01/23 at 5:55 P.M., indicated the resident had no adverse side effects related to the GDR of Seroquel. A Progress Note, dated 04/03/23 at 7:43 A.M., indicated the IDT (Interdisciplinary Team) reviewed the GDR event and agreed with monitoring the resident for signs and symptoms of changes in mood/behavior related to discontinuation of Seroquel. The POA was notified. The resident was without issues at the time. The resident's family was without concerns. A physician's order, dated 01/23/23 through 04/25/23, indicated the resident was to receive Seroquel 12.5 mg, every day for psychotic disorder. The March and April 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received the medication daily from 03/28/23 through 04/24/23. During an interview on 11/01/23 at 3:09 P.M., the Social Service Director indicated behavior meetings were completed monthly and they would review the resident's charts that were up for review. If a GDR was needed, then they would discuss if it needed to be decreased or stayed the same. If the medication was going to be GDR' d, then the NP would usually agree or disagree in the meeting. A progress note would be inputted, and the order would be changed if the medication changed. During an interview on 11/01/23 at 3:23 P.M., the ADON (Assistant Director of Nursing) indicated she could not see where the resident's Seroquel had been discontinued. The medication should have changed or there should have been a progress note indicating the family refused to discontinue the medication. The current facility policy titled, Psychotropic Medication Usage and Gradual Dose Reduction with a review date of 12/31/22 was provided by the DON (Director of Nursing) on 11/03/23 at 2:52 P.M. The policy indicated, .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Efforts to reduce dosage or discontinue psychotropic medications will be ongoing, as appropriate .Gradual dose reductions will be documented on the appropriate event in the EHR [Electronic Health Record] . 3.1-48(a)(2)

Based on interview and record review, the facility failed to transfer a resident appropriately resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/20/23 at 2:38 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was severely cognitively impaired. The resident required extensive assistance of two or more staff for mobility, transfer, and ADLs (Activities of Daily Living). She was always incontinent of bladder and frequently incontinent of bowel. The diagnoses included, but were not limited to, dementia, bone density and structure disorder, and abnormal posture. A Progress Note, dated 2/8/23 at 7:27 a.m., indicated Resident B's left shoulder was noted to be edematous, extending down to the elbow. The resident's bicep area had bruising, and she stated, it hurts. A Progress Note, dated 2/8/23 at 11:00 a.m., indicated an X-ray preliminary result showed a noticeable fracture. A Progress Note, dated 2/8/23 a t 2:21 p.m., indicated the ER (emergency room ) called to report Resident B had a comminuted transverse oblique fracture of the proximal humeral shaft. During a record review and interview on 2/21/23 at 1:30 p.m., the DON (Director of Nursing) indicated the date of the incident was 2/6/23 when staff heard a popping noise during a transfer. It was determined that Resident B was transferred by one staff member's assistance and not two staff member per her care plan. An Event Report, dated 2/8/23, indicated Resident B had a left arm fracture. During an interview on 2/21/23 at 11:47 a.m., QMA (Qualified Medication Assistant) 2 indicated if a resident required two person assist for transfers, it would require two staff members using a gait belt, and then the two staff would assist the resident to transfer. The CNAs (Certified Nursing Aides) have care sheets and it would indicate the number of staff needed and/or type of equipment needed to assist a resident during a transfer. During an interview on 2/21/23 at 11:58 a.m., CNA 3 indicated she was working on Resident B's Hall with another aide; that aide was going to put Resident B to bed. QMA 4 called her to help with Resident B, who was on the foot of the bed. The only way to lift her up was by to arm and leg her up. QMA 4 told her, she had heard a pop when she transferred Resident B to the bed earlier. Resident B required two staff members' assistance and did not have on a gait belt when she went into the room to assist. During an interview on 2/21/23 at 1:37 p.m., QMA 4 indicated it was a very busy night on 2/6/23, it was right after dinner, and there were multiple call lights going off. Her CNA partner went to lay someone else down, and she went to lay Resident B down by herself. When she went to lay the resident down, she heard the resident's shoulder pop. She was not being as careful about the transfer as she usually was, due to the multiple call lights going off. She did have a CNA pocket sheet and it stated Resident B required two-person assistance. During a record review and interview on 2/21/23 at 2:09 p.m., a Care Plan, dated 3/25/22, was provided by the ADON (Assistant Director of Nursing). The profile care guide indicated the staff were to use a sit to stand lift for transfers. The ADON indicated, prior to 2/8/23 Resident B required two-person extensive assistance or staff could use the sit to stand lift. A Physical Therapy Plan of Care, dated 2/10/22, was provided on 2/21/23 at 2:45 p.m. The initial Assessment Current Level of Functional Deficits indicated a mechanical lift was used. The ability to transfer was dependent, that the helper does all the effort, and the Resident does none of the effort to complete the activity with the assistance of two or more helpers. A Point of Care Report was provided by the ADON (Assistant Director of Nursing) on 2/22/23 at 11:48 a.m. The report indicated on 2/4/23 Resident B required extensive assistance for transfer. On 2/5/23 the resident required total dependence for transfer. On 2/6/23 the resident required extensive assistance for transfer. The current facility policy, Resident Transfers, and dated 3/21/22, was provided by the DON on 2/21/23 at 11:38 a.m. The Policy indicated, .To ensure the safety of residents .when performing mobility/transfer tasks .SOP Details 1. Determine the type of .amount of assistance required to assist with safe mobility . This Federal tag relates to Complaint IN00401389. 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify the physician and family of a cognitively impaired resident's change in condition, in a timely manner, for 1 of 3 residents reviewed for physician notification. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/20/23 at 2:38 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was severely cognitively impaired. The resident required extensive assistance of two staff members for mobility, transfer, and ADLs (Activities of Daily Living). The diagnoses included, but were not limited to, dementia, bone density and structure disorder, and abnormal posture. A Progress Note, dated 2/8/23 a t 2:21 p.m., indicated the ER (emergency room ) called to report Resident B had a comminuted transverse oblique fracture of the proximal humeral shaft. During an interview on 2/21/23 at 11:38, the Nurse Practitioner (NP) indicated she was notified of Resident B having edema and bruising on 2/8/23 and ordered an x-ray and then had her sent out to the ER. During an interview on 2/21/23 at 1:37 p.m., QMA 4 indicated it was a very busy night, it was right after dinner, and there were multiple call lights going off. Her CNA (Certified Nurse Aide) partner went to lay someone else down, and she went to lay Resident B down by herself. When she went to lay the resident down, she heard the resident's shoulder pop. She was not being as careful about the transfer as she usually was, due to the multiple call lights going off. She did have a CNA pocket sheet and it stated Resident B required two staff members' assistance. During a record review and interview on 2/21/23 at 1:30 p.m., the DON (Director of Nursing) indicated the date of the incident was on 2/6/23. The QMA indicated she heard a popping noise during transfer. During an internal investigation it was determined that Resident B was transferred by one staff member's assistance and not two staff members' assistance per her care plan. An Event Report, dated 2/8/23, indicated Resident B had a left arm fracture. During an interview on 2/22/23 at 11:39 a.m., the DON indicated there was no documentation of an assessment being completed on 2/6/23 or 2/7/23. The clinical record lacked the physician's or family notification of the popping noise during a transfer. The current facility policy, Physician-Provider Notification Guidelines, and with a revision date of 9/12/17 , was provided by the DON on 2/23/23 at 1:06 p.m. The Policy indicated, .Purpose: To ensure the resident's physician .is aware of all .change in condition, suspected injury .should be completed in a timely manner . This Federal tag relates to Complaint IN00401389. 3.1-5(a)(1)

Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage (Resident 41); and follow physician's orders, ensure treatments were in place, and initiate monitoring of a wound (Residents 19, 28, and 48). for 4 of 17 residents reviewed for quality of care Findings include: 1. During a medication administration observation on 12/13/22 at 11:02 A.M., LPN (Licensed Practical Nurse) 10 prepared to administer Resident 41's routine and sliding scale insulin. LPN 10 removed the Novolog insulin pen from the medication cart and attached a capped needle to the pen. She held the pen sideways and indicated she was going to prime the pen. She dialed up 1 unit of insulin and pressed the button to expel the insulin. She then dialed up the ordered amount of insulin and administered the medication to the resident. During an interview on 12/13/22 at 11:07 A.M., LPN 10 indicated she should have cleansed the insulin pen with alcohol before she attached the needle, and she should have held the pen upright to prime it instead of sideways. The current Novolog package insert, with a revised date of 11/2019, was provided by the Corporate Nurse Consultant on 12/13/22 at 4:13 P.M. The insert indicated, .Before each injection .Pull off the pen cap .wipe the rubber stopper with an alcohol swab .To avoid injecting air and to ensure proper dosing .Turn the dose selector to select 2 units. Hold your insulin .Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the bottom all the way in .A drop of insulin should appear at the needle tip . 2. On 12/06/22 at 1:02 P.M., Resident 19 was observed in her room laying on her bed. The resident was wearing blue jeans and green non-skid socks. The resident was not wearing TED hose (Thrombo-Embolic Deterrent stockings) The resident's legs were swollen, and she indicated her feet hurt. On 12/07/22 at 9:00 A.M., the resident was observed in her wheelchair in the hall near her room. The resident was wearing blue jeans and green non-skid socks. The resident was not wearing TED hose. On 12/08/22 at 9:53 A.M., the resident was observed in her room laying on her bed. The resident was wearing black slacks and green non-skid socks. The resident's legs were swollen, and she was not wearing TED hose. On 12/12/22 at 8:35 A.M., the resident was observed heading to her room in her wheelchair. The resident was not wearing TED hose. The resident's clinical record was reviewed on 12/12/22 at 9:30 A.M. An Annual MDS (Minimum Data Set) assessment, dated 08/24/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, atrial fibrillation, coronary artery disease, hypertension, and dementia. The resident required extensive staff assistance with dressing. The resident's December 2022 ETAR (Electronic Treatment Administration Record) was provided by the Corporate Nurse Consultant on 12/13/22 at 4:13 P.M. The current physician's orders included an opened ended treatment order, with a start date of 08/17/21, that indicated staff were to apply TED hose in the morning and remove them at night. The treatments were checked off as administered every day as ordered. The clinical record lacked documentation of the resident's refusal to wear TED hose prior to 12/12/22. During an interview on 12/12/22 at 11:00 A.M., CNA/QMA (Certified Nurse Aide/Qualified Medication Aide) 12 indicated the resident didn't like to wear the TED hose, and they just put non-skid socks on her. The aides were supposed to notify the nurse if a resident refused treatments. During an interview on 12/13/22 at 10:48 A.M., LPN 10 indicated the aides generally applied the hose, but the nurses check the residents to ensure the hose are on. If a resident refused, it would be documented in the ETAR. If a resident consistently refused a treatment, they would notify the MD. During an interview on 12/14/22 at 2:01 P.M., the Corporate Nurse Consultant indicated they could not provide a policy for following MD orders, it was just standard professional practice to follow MD orders. 3. During an interview on 12/07/22 at 11:13 A.M., Resident 28's family member indicated the resident wore compression stockings. She thought staff applied the stockings when he would get up for the day. On 12/12/22 at 11:00 A.M., the resident was observed in the common area in his wheelchair. The resident was wearing blue compression stockings with zippers. CNA/QMA 12 indicated the resident's family member brought them. On 12/13/22 at 10:44 A.M., the resident was observed in the common area in his wheelchair. The resident was wearing blue compression stockings. The resident's clinical record was reviewed on 12/12/22 at 12:55 P.M. A Quarterly MDS assessment, dated 09/23/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, hypertension, aphasia, and hemiplegia/hemiparesis. The resident's current physician's orders were reviewed. There was no indication the resident had a physician's order for the compression stockings. During an interview on 12/13/22 at 10:48 A.M., LPN 10 indicated nurses could apply compression stockings as a nursing measure, but they would have to get physician's order for the treatment. During an interview on 12/13/22 at 3:37 P.M., the DON (Director of Nursing) indicated the resident should have a physician's order for the compression stockings. 38769 4. During an observation on 12/06/22 at 2:27 P.M., Resident 48 was sitting in her room in a wheelchair. She had a white 4 (inch) x (by) 4 adhesive dressing to the right outer upper leg dated 11/30. During an observation and interview on 12/08/22 at 9:54 A.M., Resident 48 was sitting in her room in a wheelchair. The resident indicated she had a dressing on her right outer leg that had been there for a while. She wasn't sure what she had done. The resident pulled up her right pant leg and there were two white adhesive dressings covering the right outer leg. The dressing was dated 11/30. During an observation on 12/08/22 at 2:22 P.M., LPN 10 had gone into Resident 48's room and asked if she could observe her right leg. The resident pulled up her pant leg. The nurse donned gloves and removed the white adhesive dressings that were dated 11/30. The resident had 4 small scattered scabs. The clinical record for Resident 48 was reviewed on 12/08/22 at 10:08 A.M. A Quarterly MDS assessment, dated 08/25/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension and diabetes. The Point of Care Skin Problem form indicated the resident's skin was clear from 11/30/22 through 12/08/22. The residents clinical record lacked any documentation related to the areas to the right outer leg. During an interview on 12/08/22 at 2:13 P.M., LPN 10 indicated the residents' skins were assessed daily. The Certified Nurse Aides would look at the residents' skin daily and report findings to the nurse. If the resident had any new skin concerns the nurse would initiate a new skin event in the clinical record. The event would include the type of skin concern, such as pressure, skin tears, and bruises, and include a measurement. She was unaware of Resident 48 having any skin issues at that time and looked in the resident's record. The resident's clinical record lacked any documented skin concerns. During an interview on 12/08/22 at 2:27 P.M., LPN 10 indicated the resident's clinical record should have had an event completed for the skin areas on the right leg. The current facility policy titled, Guidelines for General Wound and Skin Care, with an approval date of 12/01/2021, was provided by the Corporate Nurse Consultant on 12/08/22 at 12:10 P.M. The policy indicated, .to provide measures that will promote and maintain good skin integrity .Document the type of wound, location, stage [if applicable], length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet . The current facility policy titled, Guidelines for Weekly Skin Observation, with a review date of 03/16/22 was provided by the Corporate Nurse Consultant on 12/08/22 at 12:10 P.M. The policy indicated, .to monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated .Initiate applicable Wound Event if a new area of impairment is identified .In addition to the Weekly Observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified . 3.1-37(a) 3.1-47(a)(1)

Based on interview and record review, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to anticoagulant medications for 5 of 18 residents reviewed for accuracy of assessments. (Residents 48, 39, 36, 37, and 34) Findings include: 1. The clinical record for Resident 48 was reviewed on 12/13/22 at 3:16 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/25/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, inflammatory liver disease, hypertension, and diabetes. The resident had received an anticoagulant for seven of seven days during the review period. The physician's medication order for November, 2022, indicated the resident was prescribed Aspirin (antiplatelet) 81 mg (milligram) once a day. The November 2022 EMAR (Electronic Medication Administration Record) lacked documentation that the resident had received any anticoagulant during the review period. 2. The clinical record for Resident 39 was reviewed on 12/13/22 at 3:16 P.M. A Quarterly MDS assessment, dated 11/09/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, coronary artery disease, heart failure, hypertension, and diabetes. The resident had received an anticoagulant for seven of seven days during the review period. The physician's medication order for November, 2022, indicated the resident was prescribed Clopidogrel (antiplatelet) 75 mg once a day. The November 2022 EMAR lacked documentation that the resident had received an anticoagulant during the review period. During an interview on 12/13/22 at 3:22 P.M., the MDS Coordinator indicated to obtain resident information for the MDS assessments she would go through the the residents history and physicals, physician charting, progress notes, electronic mediation administration records, electronic treatment administration records, and events. For the resident medications she would not document Plavix as an anticoagulant but would document aspirin, warfarin, and Eliquis. 38239 3. The clinical record for Resident 36 was reviewed on 12/13/22 at 10:27 A.M. A Scheduled 5-day MDS assessment, dated 11/28/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, hypertension, and CVA (Cerebral Vascular Accident). The assessment indicated the resident received an anticoagulant medication on seven of the seven days of the review period. The physician's medication order for November, 2022, indicated the resident was prescribed Aspirin 81 mg once a day. The EMAR for November 2022 was provided by LPN 11 on 12/13/22 at 4:16 P.M. The record lacked documentation that the resident had received an anticoagulant during the review period. 33613 4. The clinical record for Resident 37 was reviewed on 12/12/22 at 10:32 A.M. An Annual MDS assessment, dated 10/13/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension and Chronic Obstructive Pulmonary Disease. The resident received an anticoagulant for seven of the seven days during the review period. The physician's medication order for October, 2022, indicated the resident was prescribed Aspirin 81 mg once a day. The EMAR for October 2022 was provided by LPN 11 on 12/13/22 at 4:16 P.M. The record lacked documentation that the resident had received an anticoagulant during the review period. 34232 5. The clinical record for Resident 34 was reviewed on 12/07/22 at 11:17 A.M. A Quarterly MDS assessment, dated 09/26/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension and muscle weakness. The resident received an anticoagulant for seven of the seven days during the review period. The physician's medication order for September, 2022, indicated the resident was prescribed Aspirin 81 mg once a day. The EMAR for September 2022 was provided by LPN 11 on 12/13/22 at 4:16 P.M. The record lacked documentation that the resident had received an anticoagulant during the review period. During an interview on 12/13/22 at 3:37 P.M., the MDS Coordinator indicated aspirin or plavix (Clopidogrel) was coded in error and should have not been coded as an anticoagulant on the MDS assessments. The RAI (Resident Assessment Instrument) medication coding guidelines were provided by the MDS Coordinator on 12/13/22 at 3:38 P.M. The guidelines indicated, .Anticoagulant .Do not code antiplatelet medications such as aspirin . 3.1-31(c)(13)

Based on interview, observation, and record review, the facility failed to prevent and correctly identify a pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. (Resident 45) Findings include: During an interview and observation on 12/06/22 at 2:28 P.M., Resident 45 indicated she had a place on her right heel that she had been receiving treatments and had been to the doctor to have it looked at. She had a pressure relieving boot in place. During an observation on 12/13/22 at 10:17 A.M., Resident 45 was sitting in her wheelchair in her room. The resident had a pressure relieving boot in place. She gave permission for the DON (Director of Nursing) to observe her right heel. The resident's heel was free from open areas and was clean, there was no redness observed. The clinical record for Resident 45 was reviewed on 12/08/22 at 10:43 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/16/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, multiple sclerosis, hypertension, diabetes, non-Alzheimer's dementia, anxiety, and depression. The resident had a diabetic ulcer. A Point of Care History for skin problems records indicated the resident's skin was clear from 08/01/22 through 08/31/22. A Facility Wound Management Detail Report, dated 08/15/22 at 1:30 P.M., indicated the resident had a diabetic ulcer to the right heel. The wound measured 1.5 cm (centimeters) x (by) 2.5 cm x 0.1 cm. There was a light amount of serosanguineous (pale red to pink, thin and watery) drainage. There was partial thickness loss (loss of the epidermis and into but not through the dermis). The wound edges were irregular and macerated/soft. A treatment was initiated. A Facility Wound Management Detail Report, dated 08/25/22 at 8:32 A.M., indicated the resident had a diabetic ulcer to the right heel. The wound measured 1.8 cm x 3.2 cm x 0.1 cm. There was a moderate amount of serosanguineous drainage. The wound was covered in 100% slough (white/yellow, dead tissue). A Facility Wound Management Detain Report, dated 09/01/22 at 8:59 A.M., indicated the resident had a diabetic ulcer to the right heel. The wound measured 1.5 cm x 1.5 cm x 0.1 cm. There was a light amount of serosanguineous drainage. The wound had full thickness loss (through the dermis and down to the subcutaneous tissue, muscle), and was covered in 60% slough. There were treatments in place per the wound clinic. A Local Wound Clinic Note, dated 09/01/22, indicated the resident was seen for an initial visit. She presented with a wound to the right heel. The wound was a Stage 3 (full thickness tissue loss, subcutaneous fat may be visible, slough may be present but does not obscure the depth of tissue loss) pressure ulcer with ulceration of fat/eschar (black/dry tissue). There was a small amount of serosanguineous drainage. The wound measured 1.5 cm x 1.5 cm x 0.1 cm. A Facility Wound Management Detail Report, dated 10/06/22 at 10:50 A.M., indicated the resident had a diabetic ulcer to the right heel. The wound measured 1.2 cm x 1.4 cm x 0.1 cm. There was a moderate amount of serosanguineous drainage. The wound had full thickness loss and was covered in 30% slough. A Facility Wound Management Detail Report, dated 11/17/22 at 1:20 P.M., indicated the wound had healed. The clinical record lacked any documentation related to the right heel until it was an open ulcer. During an interview on 12/08/22 at 2:05 P.M., the local wound clinic indicated the resident had been seen for wound management for a wound to her right heel. Her initial visit was 09/01/22 and the first impression of the wound presented as a Stage 3 pressure ulcer. They had debrided the wound and it remained a Stage 3 following the debridement. After the debridement of the wound, it measured 1.5 cm x 1.5 cm x 0.1 cm. The wound had healed on 11/15/22. During an interview on 12/08/22 at 2:13 P.M., LPN (Licensed Practical Nurse) 10 indicated the residents' skins were assessed daily. The Certified Nurse Aides would look at the resident skin daily and report findings to the nurse. The nurses had an assessment order that would be documented on in the treatment record for a weekly skin assessment. If the resident had any new skin concerns the nurse would initiate a new skin event in the clinical record. The event would include the type of skin concern, such as pressure, skin tears, and bruises, and include a measurement. She was unaware of Resident 48 having any skin issues at that time, looked in the resident record, and the record had lacked any documented skin concerns. During an interview on 12/12/22 at 2:28 P.M., QMA/CNA (Qualified Medication Aide/Certified Nurse Aide) 13 indicated the resident didn't have any open wounds at that time but had a wound in the past that was on her right heel. It had started out as a small area. The CNAs would monitor the resident skins daily. If the resident had any new skin concerns of open areas, bruises, or any other concerns she would document it in the Point of Care History for skin and let the nurse know. During an interview on 12/12/22 at 2:45 P.M., LPN 11, the Wound Nurse, indicated the resident had gone out to the wound clinic for her right heel and the wound had since healed. The wound had started as a diabetic ulcer. The wound had needed some debridement. The resident skin was to be monitored by the CNAs with showers and they reported any new findings to the nurse. The nurse would also observer the residents' skin on their shower days. If the residents had any new skin concerns the CNAs could document in the Point of Care and the nurse would open a new skin event or wound management assessment? if it was an ulcer. When the resident had went out to the wound clinic and they classified the wound as a Stage 3 pressure ulcer, the facility did not classify it as a pressure ulcer because they believed it was a diabetic ulcer. The facility would not usually reclassify the wounds due to knowing the resident's history better. The resident had a history of diabetes. The staff should have noted reddened or boggy skin to the heel prior to it being open. There was no documentation related to the heel until the ulcer was open. The current facility policy titled, Guidelines for General Wound and Skin Care, with an approval date of 12/01/2021, was provided by the Corporate Nurse Consultant on 12/08/22 at 12:10 P.M. The policy indicated, .to provide measures that will promote and maintain good skin integrity .Document the type of wound, location, stage [if applicable], length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet . The current facility policy titled, Guidelines for Weekly Skin Observation, with a review date of 03/16/22 was provided by the Corporate Nurse Consultant on 12/08/22 at 12:10 P.M. The policy indicated, .to monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated .Initiate applicable Wound Event if a new area of impairment is identified .In addition to the Weekly Observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified . The current Pressure/Stasis/Arterial/Diabetic Wound Guidelines policy, with a revised date of 12/01/21, was provided by the Corporate Nurse Consultant on 12/12/22 at 3:59 P.M. The policy indicated, PURPOSE .To provide weekly documentation of wound measurements and condition . The current facility policy titled, Guidelines for Pressure Prevention, with a revision date of 12/01/21, was provided by the Corporate Nurse Consultant on 12/12/22 at 3:59 P.M. The policy indicated, .To maintain good skin integrity and avoid development of pressure ulcers . 3.1-40(a)