Every finding on record at St Charles Health Campus

Based on interview and record review, the facility failed to ensure services were provided to prevent the development of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. The facility failed to obtain adequate physician orders or instructions following the removal of a non-removable brace, which resulted in the development of an unstageable pressure ulcer to the left heel (Wound 2). Following an assessment by a wound care clinic that indicated a newly developed unstageable pressure ulcer to the top of the left foot (Wound 3), the facility failed to assess the wound routinely or create a plan of care to address the wound. (According to the National Pressure Injury Advisory Panel [NPIAP], an unstageable pressure ulcer is defined as: wound is obscured by slough or eschar which makes depth and extent of tissue damage unable to be determined.) This deficient practice resulted in the facility failing to prevent and assess developed pressure wounds and failing to update the residents' plan of care for pressure wounds. (Resident D) Findings include: During record review on 2/3/25 at 10:30 A.M., Resident D's diagnoses included, but were not limited to fracture of left tibia, Alzheimer's disease, dementia and anxiety. Resident D's most recent admission Minimum Data Set (MDS) assessment, dated 8/15/24, indicated the resident was admitted to the facility with one unhealed unstageable pressure ulcer (Wound 1), was at risk for developing pressure ulcers, and had severe cognitive impairment. A Braden scale assessment (tool used to predict the risk for developing pressure ulcers), completed 8/12/24, indicated Resident D was at moderate risk for developing pressure ulcers. Resident D's physician orders included, but were not limited to, non-weight bearing to left lower extremity (started 8/12/24), apply foam dressing to deep tissue injury to left great toe (Wound 1) (started 8/1/2/25), observe non-removable dressing to left lower extremity for drainage on dressing and for dislodgement, leave splint in place, do not remove, call orthopedic physician if the brace gets wet (started 8/12/25), cleanse left heel wound (Wound 2), cover with heel foam dressing, cast padding from toes to just below knee, ace wrap from toes to knee, apply heel lift boot (started 8/27/25), cover wound on heel (Wound 2), left great toe (Wound 1), and top of left foot (Wound 3) with bordered foam-wrap, change dressing every other day and assess wounds (started 9/5/25). Resident D's care plan included, but was not limited to, resident has a pressure ulcer to the left great toe (Wound 1) upon admission (initiated 8/14/24) and left heel (Wound 2) (revised 8/29/25). Resident demonstrates non-compliance with plan of care as evidenced by removing dressing and splint (initiated 8/15/25 and revised 9/10/25.) Resident at risk for skin breakdown (initiated and last revised 8/29/25). Resident D's care plan did not include a focus specific to the pressure ulcer to the top of the left foot (Wound 3). Resident D's progress notes included, but were not limited to: 8/12/24 at 12:35 P.M. - Resident arrived at facility with splint/wrap in place to left lower extremity. The family discussed deep tissue injury to the top of the left great toe (Wound 1) that measured 1.5 centimeters (cm) (length) x 1 cm (width) potentially caused by the previous hard splint. 8/13/24 at 2:37 A.M. - Resident had a fracture to the left lower extremity with a non-removable splint in place. 08/15/24 at 2:55 A.M. - Resident continued to remove dressing and splint to left lower extremity. Resident removed dressing two times this shift. 8/16/24 at 3:34 A.M. - Resident continued to be non-compliant with non-weightbearing orders and non-compliant with orders for non-removable dressing and splint to the left lower extremity. The surgical incision site was red and warm to the touch with serosanguineous drainage noted. Orthopedic physician's office notified and awaiting response. Resident complained of pain to the lower left extremity earlier in the shift and treated with pain medication. 8/26/24 at 6:48 P.M. - Resident returned from appointment at orthopedic physician's office with Physician Assistant (PA) 4 with new orders for: 1. Strict non-weight bearing. 2. Daily skin checks. 3. Wound care to the left heel pressure ulcer (Wound 2). 4. Pad heel. 5. Elevate but no direct heel pressure. 08/27/24 at 3:08 P.M. - Staff spoke with resident's family member regarding concern of left heel skin impairment. Also spoke with PA 4 at orthopedic physician's office to update that family was planning to follow up with the wound care clinic. Treatment orders updated and wound management initiated. 08/28/24 at 8:47 A.M. - Resident admitted with deep tissue injury to let great toe (Wound 1). At an orthopedic appointment, the splint was removed with noted pressure to left heel (Wound 2). Resident admitted with non-removable splint to left lower extremity, however the resident removed frequently. Orthopedic physician office updated regarding removal of splint. 09/04/24 at 8:27 A.M. - Upon entering the resident room for assessment and treatment, the left lower extremity dressing and boot had been removed by the resident. 09/11/24 at 8:00 A.M. - Resident continued to remove dressing and boot frequently. Noted two scabs to top of left foot on this date, foam dressing in place. Distal area is 3 cm x 0.5 cm, and proximal area is 2 cm x 0.3 cm. 10/08/24 at 3:50 P.M. -Resident returned from wound care clinic with a football dressing to left foot. This dressing to only be changed weekly per wound care clinic. 10/09/24 at 6:54 A.M. Resident removed football dressing to left foot. Called family to update. Resident D's left heel wound (Wound 2) assessments included but were not limited to the initial wound assessment dated [DATE] at 8:45 A.M., 3.2 cm x 3.6 cm, unable to determine depth, no drainage, no odors, unstageable deep tissue injury. Weekly left heel wound assessments were completed. No weekly assessments were completed for Resident D's left top of foot unstageable pressure ulcer (Wound 3). Resident D's orthopedic physician's office visit notes included, but were not limited to: 8/26/24 - Patient's visit note - Resident D returned for follow up status post Open Reduction Internal Fixation (ORIF) procedure of tibial fracture performed 8/9/24. Family stated resident had some compliance issues and was walking on the postoperative splint. The facility took down the splint and has reportedly replaced it several times. Physical Findings (left foot exam) Resident has a new heel pressure ulcer (Wound 2) that is about the size of a silver dollar. There is concern for potential necrotic tissue. 9/12/24 - Patient's visit note - Resident D returned for follow up status post ORIF procedure of tibial fracture performed 8/9/24. She has a heel ulcer (Wound 2) from a misapplied splint. Resident D's wound clinic visit notes included, but were not limited to: 9/3/24 - Wound visit notes did not include an assessment of Resident D's wounds but did include new treatment order comments of; cover wounds on heel (Wound 2), left great toe (Wound 1), and top of left foot (Wound 3) with bordered foam dressing and remove every other day to assess the site for breakdown and replace the foam boarder. 9/17/24 - Wound care orders included wound location of left heel (Wound 2), left dorsal (upper side or top) foot (Wound 3), and left first toe (Wound 1). 10/8/24 - Wound assessments for the left dorsal (top) foot wound first assessed on 9/3/24 included the wound measurements of 0.5 cm x 0.3 cm x 0.1 cm (depth). (Wound 3) 10/22/24 - Wound care orders included associated diagnoses an unstageable pressure ulcer of dorsum of left foot (Wound 3) and unstageable pressure ulcer of left heel (Wound 2). During an interview on 4/25/25 at 9:30 A.M., PA 4 indicated having observed Resident D on 8/26/24 during a two week post operative appointment. PA 4 indicated a non-removable splint was applied in the orthopedic physician's office following the Resident's surgical procedure. PA 4 indicated the resident's left foot was wrapped with a padded dressing and a hard splint was applied over the padding. When Resident D arrived for the appointment on 8/26/24, the splint had been applied incorrectly with the padded dressing wrapped around the outside of the hard splint and had resulted in a pressure area to the left heel (Wound 2). PA 4 indicated he was unaware of any notification from the facility regarding Resident D removing the splint and dressing prior to her appointment on 8/26/24. During an interview on 4/25/25 at 10:05 A.M., the Director of Nursing (DON) indicated the wound on top of Resident D's left foot (Wound 3) was assessed on 9/11/24 at the facility as a scabbed area and not a pressure ulcer, therefore the wound was not entered into a wound management program that would have initiated routine wound assessments. During an interview on 4/25/25 at 11:00 A.M., the DON indicated that the orthopedic physician's office did not respond to the notification attempt documented on 8/16/24, and the facility staff replaced the non-removable splint themselves (prior to the development of the unstageable pressure ulcer to Resident D's left heel (Wound 2). The facility did not reassess the area on top of Resident D's left foot (Wound 3) following the diagnosis of an unstageable pressure ulcer to the area during a wound care clinic visit on 10/22/24. No weekly assessments of that wound were documented. During an interview on 4/25/25 at 12:10 P.M., LPN 8 indicated nursing staff should document when a physician's office is notified and if awaiting reply. Nursing staff should continue to contact the physician's office if a reply is not received and should document all attempts of notification. On 4/25/25 at 1:30 P.M., the DON supplied a facility policy titled, Guidelines for Pressure Prevention, dated 12/17/24. The policy included, Care plan interventions shall be implemented based on risk factors identified in the nursing assessment Inspect the skin daily during care of signs of breakdown or changes to the skin . Utilize padding for casts and splints. Monitor skin closely when these devices are present . This citation relates to complaint IN00457254. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 3 residents reviewed for falls. New interventions were not placed following falls to prevent further falls for a cognitively impaired resident. (Resident G) Finding includes: On 12/11/24 at 1:57 P.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, left tibia shaft fracture, osteoporosis, and Alzheimer's disease. Resident G was admitted to the facility on [DATE] and discharged [DATE]. The most recent Admission MDS (Minimum Data Set) Assessment, dated 8/15/24, indicated a severe cognitive impairment and no behaviors. Resident G was dependent on staff for toileting, bed mobility, transfers, and from sitting to standing. Resident G had experienced a fall with fracture that required surgical repair prior to admission. Physician orders included, but were not limited to: Activity: Two staff assist - Strict NWB (non-weight bearing) to left leg, dated 9/3/24. Sounding alarms to bed and chair at all times, and to check the function each shift three times a day, dated 9/9/24. Nurse to verify that bed and chair alarms functioning properly each shift, three times a day, dated 10/21/24. A falls care plan, dated 8/29/24, included the following interventions: Nurse to verify that alarm is functioning, dated 10/21/24. Not to be left in room in wheelchair unattended, dated 9/30/24. Sounding alarm to bed and chair, dated 9/10/24. Mat beside bed, dated 9/10/24. Toileting schedule, dated 9/9/24. Encourage resident to assume standing position slowly, dated 8/29/24. Ensure the floor is free of liquids and foreign objects, dated 8/29/24. Keep call light in reach, dated 8/29/24. Keep personal and frequently used items within reach, dated 8/29/24. Provided non-skid footwear, dated 8/29/24. Staff to assist resident with transfers as needed, dated 8/29/24. Therapy evaluate and treat as needed, dated 8/29/24. An ADL (activities of daily living) care plan, dated 8/29/24, indicated Resident G required staff assistance to complete mobility functional tasks completely and safely. A hospital post-operative note, dated 8/9/24, indicated Resident G was admitted for surgical repair of a closed displaced comminuted fracture of shaft of left tibia From 9/8/24 through 10/19/24, Resident G experienced the following falls: Fall 1 A progress note, dated 9/8/24 at 4:30 P.M. indicated Resident G fell in her room at 4:00 P.M. after restlessly wheeling around hallway. The resident was observed on the floor in the entryway of the bathroom after attempting to transfer self to toilet. The note indicated the new intervention was to routinely toilet the resident. The falls care plan was updated on 9/9/24 to include an intervention of toileting schedule. The clinical record lacked documentation that the toileting schedule had been followed or implemented. On 12/12/24 at 10:53 A.M., the Director of Nursing (DON) indicated Resident G's toileting schedule had been started on 9/9/24, and the Certified Nurse Aides (CNA) would have followed their assignment sheet at that time for the toileting schedule, but would not necessarily document it. On 9/8/24, an x-ray was ordered for the left leg. A progress note dated 9/8/24 at 9:36 P.M. indicated a left fibular neck fracture. Results were communicated with the physician, who indicated he would like for the resident to be monitored overnight and for the orthopedic to be notified the following morning on how to proceed. Resident G's clinical record lacked documentation of the communication with the orthopedic physician on 9/9/24. On 12/12/24 at 10:53 A.M., DON indicated she was unable to find any documentation of the communication with the orthopedic physician. She indicated there were no new orders related to the x-ray findings, because it had shown an existing fracture that the resident was admitted with. At that time, she was unaware that the x-ray result had indicated a new fracture of the fibula. A progress note dated 9/11/24 indicated Resident G's fall on 9/8/24 was reviewed. Resident was non-weight bearing to the left lower extremity and transferred self from the wheelchair and fell to the floor. The note indicated an x-ray was completed with no new fractures. Per daughter's request, Resident G was to have sounding alarms to the wheelchair and bed at all times. An order for sounding alarms was initiated 9/9/24. A progress note, documented by Registered Nurse (RN) 3 on 9/13/24, indicated Resident G had been making several attempts to wheel herself to her room. RN 3 informed the resident that she could not stay in her room by herself because she would attempt to get up by herself and was strict non-weight bearing to the left lower extremity. Fall 2 A progress note dated 9/28/24 at 8:18 P.M. indicated the nurse was notified by the CNA of the resident attempting to self transfer to the toilet. The fall was not witnessed and the resident was found on the bathroom floor. An Interdisciplinary Team (IDT) note, dated 9/30/24, indicated the resident was toileted and assisted to bed after being found on the bathroom floor on 9/28/24. The note indicated a new intervention to not be left in the room in wheelchair unattended. The falls care plan was updated on 9/30/24 to include not to be left in room in wheelchair unattended. On 12/12/24 at 10:30 A.M., RN 3 indicated is was known by all staff that Resident G was not to get up by herself due to being non-weight bearing on her left leg, and would try to constantly. She indicated the resident had the behaviors of trying to get up on her own from the time she was admitted to the facility. She indicated all staff were actively supervising Resident G and trying to prevent her from getting up on her own well before an intervention was placed to do so. Fall 3 A progress note on 10/19/24 at 4:45 P.M. indicated Resident G was found by the door in her room. Fall was unwitnessed. The resident indicated she crawled to the door. At the time of the fall, the alarm did not sound. An IDT note dated 10/21/24 indicated following the fall on 10/19/24, the new intervention would be for the nurse to verify that alarm was functioning properly each shift. The falls care plan was updated on 10/21/24 to include an intervention for the nurse to verify that the alarm is functioning properly each shift. The order for alarms dated 9/9/24 indicated to check for functionality each shift. On 12/12/24 at 10:39 A.M., CNA 25 indicated all residents that were at risk of falling were toileting frequently. She indicated CNA assignment sheets were updated daily with mobility assistance indicated for each resident. On 12/12/24 at 10:57 A.M., Qualified Medication Aide (QMA) 21 indicated Resident G required a lot of supervision due to her wanting to get up and go home. She indicated the resident needed pretty much a 1:1 supervision, and at times staff would call her daughter to sit with her because they could not supervise her as she required. She indicated Resident G was very confused and believed she could get up on her own, and staff was aware from the time she was admitted that she needed constant supervision. On 12/12/24 at 10:30 A.M., RN 3 indicated Resident G was confused and attempted to get up on her own from day one. She indicated staff would try and keep her in the common area or by the nurses station as she had strict NWB orders to the left leg. On 12/12/24 at 11:34 A.M., the DON indicated she was unsure why the alarm was not sounding when Resident G fell on [DATE]. She indicated the facility did not typically use sounding alarms, but the resident's daughter was insistent on using them, so the facility complied. She indicated care plans should be revised and updated following each fall, and depending on the circumstances, a new intervention put into place. On 12/12/24 at 1:08 P.M., a current Fall Management policy, dated 12/31/23, was provided and indicated Any orders received from the physician should be noted and carried out . The resident care plan should be updated to reflect any new or change in interventions This citation relates to Complaint IN00447969 and Complaint IN00447994. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for the capability to self administer medications for 1 of 15 residents observed during medication administration and 1 of 1 random observation with medications in their room. (Resident 39, Resident 12) Findings include: 1. On 6/17/24 at 11:03 A.M., while Registered Nurse (RN) 14 administered Azo Bladder Control 300 mg, 2 capsules, the following medications were observed sitting on the bedside table in Resident 39's room: - Albuterol sulfate (a medication used to treat Asthma and Chronic Obstructive Pulmonary Disease) inhaler- 1 puff by mouth every 2 hours as needed on the label - Fluticasone (a nose spray for allergies) -label faded and unreadable - Asmanex (an inhaled medication used to treat asthma) 220 mcg-no label At that time, RN 14 did not acknowledge the medications sitting on the bedside table. On 6/17/24 at 11:55 A.M., Resident 39's clinical records were reviewed. The diagnoses included, but were not limited to, asthma and COPD (Chronic Obstructive Pulmonary Disease). The most recent Quarterly MDS (Minimum Data Set) assessment, dated 5/28/24, indicated Resident 39 was cognitively intact. The Physician Orders included, but were not limited to the following: - Fluticasone propionate over the counter spray, 50 mcg (micrograms), 1 spray nasally, once a day, start date 6/27/23. - Ventolin HFA (Hydrofluoroalkane) (albuterol sulfate) HFA aerosol inhaler, 90 mcg, one puff, every two hours, as needed, start date 11/16/22. Asmanex Twisthaler (mometasone) aerosol powder breath activated, 220 mcg, one puff. May Keep At Bedside, discontinue when supply depleted, then start Pulmicort, twice a day, as needed, start date 8/10/23 and discontinued date 8/30/23 The clinical records lacked a care plan for self administration of medications. During an interview on 6/17/24 at 11:27 A.M., RN 14 indicated as needed medications should be in the medication cart. Resident 39 did not have Self Administration of Medication Assessments completed. She was unsure how often residents were reassessed for self administration. At that time, she left the medications at the bedside. On 6/17/24 at 11:47 A.M., RN 14 provided a Self Administration of Medication Assessment, dated 7/27/23 for Asmanex inhaler, which was discontinued on 8/30/23. No other Self Administration of Medication Assessments were provided. During an interview on 6/18/24 at 10:03 A.M., Resident 39 indicated she used the inhalers she had in her room. 46416 2. On 6/13/24 at 10:04 A.M., one albuterol sulfate and one Ventolin hand held inhaler, one Flonase nasal spray bottle, and one bottle of Tums were observed lying on Resident 12's bedside table. On 6/17/24 at 10:58 A.M., one albuterol sulfate inhaler and one bottle of Flonase nasal spray was observed lying on Resident 12's bedside table. On 6/14/24 at 2:12 P.M., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, pulmonary fibrosis, allergies, and gastroesophageal reflux disease (GERD) without esophagitis. The most recent Quarterly MDS assessment, dated 4/7/24 indicated Resident 12 was cognitively intact. Current Physician's Orders included, but were not limited to, the following: Flonase Allergy Relief (fluticasone) 50 micrograms (mcg), 2 sprays to both nostrils once daily, ordered 11/10/16 Ventolin (albuterol sulfate) HFA aerosol inhaler; 90 mcg, 2 puffs as needed for cough/wheeze every 4 hours, ordered 4/19/23 The current Physician's Orders lacked an order for Tums and the self administration of medications. A current Pulmonary Fibrosis Care Plan, revised 5/9/24, included, but was not limited to the following intervention: Medications per MD (Medical Doctor) order, initiated 5/27/22 A current Use of Nasal Spray Steroids Care Plan, revised 5/9/24, included, but was not limited to, the following interventions: Administer medication per MD order, initiated 2/20/20 Notify MD of any adverse effects noted, initiated 2/20/20 Observe and record effectiveness of drug treatment, initiated 2/20/20 A current GERD Care Plan, revised 5/9/24, included, but was not limited to the following intervention: Administer medication as ordered by physician, initiated 12/28/17. Resident 12's clinical record lacked a care plan for self administration of medications and which medications were to be self administrated. A Self Administration of Medication form, dated 1/1/23, indicated the resident could not properly dispense eye drops, inhalers, nebulizers, nasal sprays, etc, that the self administered medications should be stored in the nursing medication cart, and did not indicate which medications the resident could self administer. During an interview on 6/14/24 at 12:51 P.M., Resident 12 indicated she used the inhalers, nasal spray, and Tums on her bedside table when she needed them. The inhalers were used every 4 hours or so and she did not get help from staff and did not tell staff when she used them. During an interview on 6/17/24 at 11:03 A.M., Licensed Practical Nurse (LPN) 12 indicated she thought Resident 12 self administered eye drops and nasal spray. She indicated that the Social Services Director (SSD) did assessments on residents every 90 days and the Brief Interview for Mental Status (BIMS) had to be high, like 15 or above and if the BIMS changed she was to let the nurses know. At that time, she indicated Resident 12's last assessment was done in January of 2023 for self administering medications. At that time, she indicated there should be care plan for self administration of medications in the resident's clinical record but she was not sure if there had to be a specific order to self administer medications. During an interview on 6/17/24 at 3:04 P.M., the Director of Nursing (DON) indicated the Self Administration Assessment was done by nursing staff initially if the resident wanted to self administer medications, when their cognition status changed, and/or as needed. When the SSD did her quarterly BIMS Assessment, she was to let the nurses, Assistant Director of Nursing (ADON), or DON know if something had changed so they could reassess the resident for self administering medications. If the resident's cognition was intact and the medications were PRN (as needed), staff did not keep track of resident's medication use. On 6/18/24 at 8:45 A.M., a current Self Administration of Medications Policy, revised 5/22/18, was provided by the DON and indicated . ensure the safe administration of medication for residents who request to self medicate or when self medication is a part of their plan of care . Residents requesting to self medicate or has self medication as a part of their plan of care shall be assessed using the [name of company] Self Administration of Medication . results of the assessment will be presented to the physician for evaluation and an order for self medication . the order should include the type of medication[s] the resident is able to self medicate . The medication will be kept in a locked drawer in the residents' room. The resident will maintain the key, as well as, a key will be maintained by the licensed nurse and or QMA [Qualified Medication Aide] . periodic verification of administration compliance will be observed by nursing staff. A self medication plan of care will be initiated and updated as indicated. The assessment will be reviewed quarterly, and PRN with change of condition . 3.1-11(a)

Based on interview and record review, the facility failed to provide necessary documentation to ensure a resident or responsible party was issued a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) before the proposed end of services for 1 of 3 beneficiary notices reviewed. (Resident 46) Findings include: On 6/13/24 at 2:25 P.M., during review of the Medicare Part A discharge notices, Resident 46's notice stated the last day covered for Part A was 5/10/24 and indicated, Other .Facility initiated and family agreed duet [sic] to lack of progress/participation in therapy related to overall decline in condition. At that time the Social Service Director (SSD) indicated a SNFABN form and NOMNC was not provided due to the resident declining and the family was considering hospice services. On 6/13/24 at 2:30 P.M., Resident 46's clinical record was reviewed and indicated a hospice evaluation was ordered on 5/17/24. On 6/18/24 at 8:45 A.M., the Director of Nursing (DON) provided a NOMNC Completion policy, revised 10/24/22, that indicated, .For residents being notified of discontinuation of their Medicare coverage, the NOMNC is required to be issued 2 calendar days prior to the actual discharge from Medicare . and a SNFABN should be issued, when the resident intends to continue services and the campus believes services may not be covered under Medicare . 3.1-4(f)(3)

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for 1 of 1 shower rooms and 2 of 13 bathrooms observed for environment. Tiles were broken, grout was soiled, build up was around the toilet base, doorknobs were loose, handrails were wrapped with frayed duct tape, paint was missing, and odors were present. (room [ROOM NUMBER], room [ROOM NUMBER], Shower Room on 200 Hall) Findings includes: 1. During an observation on 6/13/24 at 10:13 A.M., a strong odor of bowel movement and missing paint by the toilet paper holder was observed in the bathroom of room [ROOM NUMBER]. On 6/17/24 at 10:55 A.M., the same was observed. 2. During an observation on 6/13/24 at 10:04 A.M., in the bathroom of room [ROOM NUMBER], the handrail on the wall by the toilet had a red Dycem (non-slip pad) and a blue Dycem duct taped to the hand rail. There was also duct tape at the back of the rail. The duct tape was frayed. On 6/17/24 at 10:58 A.M., the same was observed. 3. During an observation on 6/18/24 at 10:50 A.M., in the 200 Hall shower room, the door to enter the shower room was black on the bottom. Inside, to the left where the first shower stall wall met the floor, there were cracked and missing pieces of tile. Between the first and second shower stalls, there was a cracked tile with the piece missing. Inside the second shower stall by the drain on the floor, there were cracked floor tiles. In both showers, along the wall where it met the floor there was a dark brown substance along the quarter round and the grout halfway up all shower walls and the floors was soiled. The wall by the bathroom had a cracked and missing tile. The doorknob to the bathroom was loose and there was a brown substance around the base of the toilet. There was no string on the call light in the bathroom. On 6/19/24 at 8:58 A.M., the same was observed. During an anonymous interview on 6/13/24 at 8:40 A.M., they indicated there were odors of urine and bowel movement in the facility. During an interview on 6/18/24 at 10:41 A.M., the Director of Nursing (DON) indicated the duct tape and Dycems that were taped to the handrail in the bathroom of room [ROOM NUMBER] was from a previous resident in that room and was used to keep hands from slipping on the rail. Neither resident currently in the room indicated they used it. The most recent admission in that room was 4/1/24. At that time, she indicated she was not aware it was there and she had taken them off and cleaned the rail. During an interview on 6/19/24 at 9:11 A.M., the Maintenance Director indicated they had been working on painting throughout the facility. Their process was to go through the rooms and bathrooms and apply plaster if needed, let the plaster dry, and paint the areas in the next couple days. At that time, he indicated he was aware of the cracked and missing tiles in the shower room and they were getting replacement tiles. Their staff should pressure wash the shower rooms, especially the dirty grout every 3 months. He was not aware the door knob was loose but those were to be checked monthly and retightened as needed. He indicated staff would either tell him verbally and/or place a work order in the maintenance electronic work order system (TELS) to let him and his assistant know if something needed their attention. They did rounds everyday and the work orders were checked right away in the morning, at lunch, and possibly in the afternoons too. They worked very closely with housekeeping when things need repaired or replaced. During an interview on 6/19/24 at 9:12 A.M., Housekeeper 3 indicated every room gets cleaned everyday and they always looked to see if something needed picked up, pull trash and put plenty of trash bags in the trash can, put cleaning spray on and in the toilet and sink in the bathroom, refill paper towels and soap if needed, wipe everything down, and do the floors. She indicated there was a housekeeping sheet that they were responsible for filling out with the room number and what they did in the room. On 6/19/24 at 9:54 A.M., a current non dated Room Cleaning Policy, was provided by Administrator 2 and indicated Health Center resident rooms are cleaned daily and deep cleaned monthly . If there are any maintenance issues generate a work order in TELS . On 6/19/24 at 9:54 A.M., a current Floor Care Policy, revised 2/5/18, was provided by Administrator 2 and indicated It is the goal of the ES [Environmental Services] Department to maintain the floor and achieve a long useful life and great appearance . On 6/19/24 at 9:54 A.M., a current Preventative Maintenance Policy, dated 2/6/24, was provided by Administrator 2 and indicated Preventative maintenance is an integral part of the Director of Plant Operations duties . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure the plan of care was implemented and interventions were in place for 1 of 3 residents reviewed for accidents. A resident's fall intervention was not in place during 1 of 1 observations of the resident in bed. (Resident C) Finding includes: During record review on 10/4/23 at 10:30 A.M., Resident C's diagnoses included, but were not limited to dementia with behavioral disturbance, altered mental status, unsteadiness on feet and disorientation. Resident C's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/8/23, indicated the resident had severe cognitive impairment. Resident C's physician orders included but were not limited to; lay resident down after lunch and dinner, and Low bed with extended bed surface when in bed (started 6/11/22). Resident C's care plan included but was not limited to; Resident is at risk for falls due to history of falls, medication use, incontinence, and Parkinson's Disease. Interventions included but were not limited to; extended bed surface (started 6/13/22). During an observation and interview on 10/4/23 at 2:00 P.M., CNA 3 and CNA 5 assisted Resident C to bed. Resident C's bed was put into low position and fall mats (approximately 2 inches thick) were placed on the floor aside the bed. CNA 3 indicated the mats were to prevent injury from the resident rolling or crawling out of bed. CNA 3 indicated she often sees the resident on the mats when she starts her shift in the morning. During an interview on 10/4/23 at 2:40 P.M., QMA 4 indicated that Resident C had changed rooms from another hall recently and that he used to have a mattress that bumped up level to his bed mattress, but fall mats are being used in his current room. QMA 4 did not know why the bed extender mattress was not being used. During an interview on 10/4/23 at 2:30 P.M., PT 7 (Physical Therapist) indicated that an extended bed surface should be an extension of the mattress surface and would be placed at an even height next to the original mattress to allow a resident to roll onto the extended bed surface, preventing a fall. If a resident rolls off a mattress to a lower surface, that would be a change of plain and should be considered a fall. On 10/4/23 at 3:15 P.M., the facility administrator supplied a facility policy titled, Comprehensive Care Plan Guideline, and dated 12/31/22. The policy includes, Purpose .To ensure appropriateness of services and communication that will meet the resident's needs . 4. Pertinent care plan approaches are communicated to the nursing staff . 6. Comprehensive care plans need to remain accurate and current. This Federal tag relates to complaint IN00418639. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 3 of 4 observations of resident care. Handwashing was not completed between dirty to clean tasks. Gloves were not changed between dirty and clean tasks. Glucometers were not properly cleaned. (Resident F, Resident C) Findings include: 1. On 6/15/23 at 10:59 A.M., Resident F was observed for incontinence care. CNA 20 and CNA 28 put gloves on when they entered the room with the lift. CNA 20 pulled the privacy curtain. Resident F was sitting up in a wheelchair. CNA 20 and CNA 28 attached the lift straps to the lift. CNA 20 used the controls and raised Resident F out of wheelchair, moved her over the bed while CNA 28 guided the lift seat and centered her over the bed. CNA 20 lowered the resident, removed the lift straps and pushed the lift to the other side of the room. CNA 20 pulled Resident F's pants down, unfastened the soiled incontinence pad, pushed the incontinence pad down, used wipes to peri care of the resident. CNA 20 threw the wipes in the trash bag, and rolled Resident F to right side touching her right arm and right leg. CNA 28 held Resident F over while CNA 20 cleaned Resident F's backside with wipes, removed the soiled incontinence pad from under the resident, put it in trash bag, placed a clean incontinence pad under Resident F, applied barrier protectant cream, and rolled her to her left side. CNA 20 removed her gloves and went to the bathroom to wash her hands and put on clean gloves. CNA 28 pulled up the clean incontinence pad, rolled Resident F to her back and fastened the incontinence pad. Resident F's pants were soiled so CNA 28 removed the pants and went to the closet to get clean pants. CNA 20 and CNA 28 put the pants on Resident F. CNA 28 turned Resident F to the left side to pull pants up and turned her to her right side to pull the pants up the rest of the way. CNA 28 then removed her gloves, sanitized, and put on clean gloves. CNA 20 pushed the lift to the bed and attached lift to straps on the lift pad, and lifted Resident F off the bed. CNA 28 helped guide the lift seat and centered her over the wheelchair. CNA 20 lowered resident to the wheelchair. CNA 20 and CNA 28 removed the lift straps from the lift. CNA 20 brushed Resident F's hair, placed a blanket over her legs, pushed her to the beside of her bed, and put the call light in her lap. CNA 28 made the resident's bed. CNA 20 removed the trash bag from the trash can and tied it shut. CNA 20 and CNA 28 failed to change gloves and perform hand hygiene between dirty and clean tasks. 45933 2. During an observation on 6/15/23 at 9:13 A.M., CNA (Certified Nurse Aide) 16 and CNA 20 transferred Resident C from a wheelchair to the bed with a mechanical lift and performed incontinence care. CNA 16 put on gloves, attached the lift pad to the lift, touched the resident to help position them in the bed, pulled the privacy curtain shut, and removed Resident C's soiled incontinence pad. CNA 16 performed perineal (peri) care, placed a clean incontinence pad under the resident, assisted Resident C to turn and touched the residents left leg and left arm, fastened the incontinence pad, and pulled up Resident C's pants. CNA 16 then attached the lift pad to the lift, removed the trash bag with the soiled incontinence pad from the trash can, helped position the resident into the wheelchair and removed the lift pad. CNA 16 then opened the door and pushed the lift out into the hallway. CNA 16 failed to change gloves and perform hand hygiene between dirty and clean tasks. During an interview on 6/15/23 at 11:29 A.M., the ADON (Assistant Director of Nursing) indicated if multiple surfaces are touched, gloves should be changed before performing peri care, and gloves should be changed between dirty and clean tasks even if they are not visibly soiled because there could still be residue on them. 3. During an observation on 6/15/23 at 11:18 A.M., LPN (Licensed Practical Nurse) 8 used a glucometer to obtain Resident F's blood glucose level. LPN 8 used an alcohol swab to clean the machine when she was finished and immediately placed the glucometer into a clear bag. LPN 8 then removed gloves and washed hands for 10 seconds. During an interview on 6/14/23 at 1:39 P.M., CNA 26 indicated that hands should be lathered with soap for 40 seconds. During an interview on 6/15/23 at 11:30 A.M., RN (Registered Nurse) 12 indicated glucometers should be cleaned after every use with sani wipes and left out to dry for 2 minutes. A current Guideline for Handwashing/Hand Hygiene policy, revised 2/9/17, was provided by the DON on 6/15/23 at 12:11 P.M., and indicated Health Care Workers (HCW) shall use hand hygiene at times such as: . d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc. The DON indicated there was not a separate policy on glove use, and glove use was mentioned in the Hand Hygiene policy. A current Glucometer Cleaning and Control Test Guidelines policy, dated 12/31/22, was provided by the DON (Director of Nursing) on 6/15/23 at 12:11 P.M., and indicated .Clean glucometer surface .by wiping with a cloth dampened with soap and water or isopropyl alcohol . At that time, the DON indicated that she was unaware that the policy differed from the instructions in the (name of glucometer) user manual. A current (name of glucometer) User Instruction Manual was provided by the DON on 6/15/23 at 12:11 P.M., and indicated .The meter should be cleaned and disinfected after use on each patient . It listed 4 different cleaning agents and Isopropyl alcohol was not listed as an appropriate cleaning agent for the glucometer. This Federal tag relates to complaint IN00410128. 3.1-18(l) 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment was maintained in 3 of 3 resident halls, 1 of 1 laundry rooms, and 1 of 1 common shower rooms. Resident room floors were sticky and debris was on the floor, resident items were uncovered and unlabeled in shared bathrooms, there was a strong urine odor in the bathroom, and vent covers were soiled in the shower room and laundry room. (100 Hall, 200 Hall, 300 Hall, Hall 200 Shower Room, Laundry room) Findings include: 1. During an interview on 2/27/23 at 11:29 A.M., room [ROOM NUMBER]'s family indicated the roommate was urinating on the bathroom floor and toilet seat. The family member also indicated that staff was asked to clean the bathroom floor and spray the room because it smelled like a litter box. This was a shared room with two residents. On 2/28/23 at 3:43 P.M., the (shared) bathroom in room [ROOM NUMBER] was observed with dark yellow urine and toilet paper in the toilet. The non-slip strips in front of the toilet were covered with black lines. On 3/3/23 at 8:54 A.M., room [ROOM NUMBER] was observed with dark yellow urine in the toilet and there was a clear liquid on the floor in front of the toilet. The bathroom had a strong urine odor. room [ROOM NUMBER] had a strong odor of urine. 38770 2. On 2/28/23 at 8:48 A.M., room [ROOM NUMBER] (private room) was observed with paint chip debris on the floor just outside of the bathroom door by the doorframe. The call light that was wrapped around the resident's bed did not work, and the bathroom was observed with 2 (two) uncovered graduated cylinders sitting on the back of the toilet with a yellow film in the bottom of them, a washbasin and bedpan on the floor under the sink uncovered, the floor was sticky, and the sink was slow to drain (40 seconds to drain the sink when it was 1/3 full). On 3/2/23 at 8:30 A.M., room [ROOM NUMBER] was observed with paint chip debris still on the floor, the call light was still not working, but was coiled and sitting on the recliner, the 2 uncovered graduated cylinders were still on the back of the toilet, and the sink was still slow to drain. 3. On 2/28/23 at 2:13 P.M., room [ROOM NUMBER] (private room) was observed with a broken outlet cover with exposed jagged edges by the bed, white debris between the bed and the wall, the floor was covered with food crumb debris, the bathroom floor was sticky, a glove was in the sink, 2 (two) spoons were behind the faucet on the sink, a wipes pack was sitting on the back of the toilet uncovered with a wipe exposed, a used wash cloth was observed on the floor behind the toilet wadded up, and the base of the toilet was observed with discolored caulk that was broken up and coming up from the floor. On 3/2/23 at 8:25 A.M., the same was observed in room [ROOM NUMBER]. 4. On 2/27/23 at 2:21 P.M., room [ROOM NUMBER] (private room) was observed with a tissue under the AC (air condition) unit, food crumb debris on the floor, and the call light did not work. An uncovered washbasin was observed on the bathroom floor under the sink, debris in all corners of the bathroom, the toilet tank was leaning back resting on the wall, and the vent in the bathroom ceiling did not have a cover. On 3/2/23 at 9:50 A.M., room [ROOM NUMBER] was observed with food crumb debris on the floor, debris in the corners of the bathroom, the toilet tank was still tilted and resting on the wall, and the vent was still not covered in the bathroom ceiling. 5. On 2/27/23 at 10:45 A.M., Resident 40 was observed sitting in a wheelchair in the common area during an activity. The front left corner of the chair cushion was ripped open with the foam inside of it exposed. On 3/2/23 at 9:55 A.M., Resident 40 was observed sitting in a wheelchair in the common area. The front left corner of the chair cushion was still ripped open with exposed foam. At that time, Hospice CNA (Certified Nurse Aide) 15 indicated Resident 40's cushion was most likely provided by hospice, and that typically the hospice staff would change them as needed. Hospice CNA 15 indicated she had visited Resident 40 that morning, but did not notice the ripped cushion. 46416 6. On 2/27/23 at 1:36 P.M., an empty denture cup and an uncovered toothbrush were observed laying on the sink, unlabeled in the shared bathroom of room [ROOM NUMBER] with 2 (two) residents. On 3/3/23 at 8:40 A.M., the denture cup was still on the sink unlabeled. 7. On 2/27/23 at 11:28 A.M., a tube of toothpaste and an uncovered toothbrush, were observed unlabeled and laying on the sink in the shared bathroom of room [ROOM NUMBER] with 2 (two) residents. 8. On 2/27/23 at 10:59 A.M., in the shared bathroom of room [ROOM NUMBER] with 2 (two) residents, 1 (one) empty, pink denture cup, a razor, and a tube of toothpaste, without the lid closing it, were observed unlabeled on the sink. An uncovered incontinence pad and an unlabeled tube of denture adhesive were observed laying on the back of the toilet . There were 3 (three) open bags of resident incontinence pads observed on the bathroom floor, with 2 (two) loose incontinent pads laying on top of a bag. Another unlabeled, empty, pink denture cup was observed sitting on top of the paper towel holder. 4 (four) uncovered, pink wash basins were observed on the floor under the sink. An uncovered toothbrush, 1 (one) purple denture cup, 1 (one) yellow denture cup, and a tube of toothpaste were observed laying on the storage container against the wall unlabeled. On 3/3/23 at 8:38 A.M., the same was observed. 9. On 2/28/23 at 9:54 A.M., in the shared bathroom of room [ROOM NUMBER] with 2 (two) residents, an open bag of resident incontinence pads was observed on the floor. A brown substance was observed smeared on front of the toilet bowl, on the toilet seat, and 2 (two) brown smears the size of a quarter on the floor by the sink. On 3/3/23 8:41 A.M., the plastic on the right handlebar of toilet seat was cracked and the front quarter of the plastic is missing. During an interview on 3/3/23 at 10:51 A.M., CNA 32 indicated the handlebar should not be like that and Resident 21 used that bathroom. She indicated she would put in a work order for maintenance to fix it. During an interview on 3/3/23 at 11:00 A.M., Housekeeper 7 indicated they were unsure how long the handlebar looked like that. At that time, they indicated maintenance should be aware of it because it isn't safe for the resident and it shouldn't be like that. During an interview on 3/3/23 at 10:53 A.M., CNA 9 indicated that resident items in the bathroom should be labeled and covered if needed. They further indicated bags of resident incontinence pads were usually kept in the closet and there shouldn't be uncovered incontinence pads laying out. 46819 10. During observation of the laundry area on 3/1/2023, at 10:46 A.M., the vent covers on the ceiling above the washing machines were visibly soiled, rusty, and covered with a mold-like substance. The ceiling had large tan spots which laundry staff indicated had been a water or condensation leak that maintenance had repaired but not re-painted. There was a palm-sized patch of drywall falling off the ceiling above the washer on the right. Laundry staff indicated there was a leak behind the first washing machine that squirts water out into the gutter behind the machine. The gutter behind the washing machines had a black mold-like substance growing above the gutter, in the middle of the wall. There were two hooks on the wall above the washer on the left that were holding dusty old belts and hoses hanging above the washers. Staff indicated they're so old they probably wouldn't work on the machines they have. Staff indicated that housekeeping never does a thorough cleaning in the laundry and the laundry staff just do whatever they can. The laundry staff indicated some of their equipment was in very poor condition. For example, they indicated the middle washer was down for about a year and a half and they just got it going again. The containers used to sort the clothes are frames made of plastic pipe that have metal frames inside to hold the bags of soiled laundry. The metal frames are bent out of shape and fall out of the plastic pipe onto the floor when they are full of soiled laundry. Staff have informed management about it but did not get a commitment to replace or repair them The laundry staff indicated the equipment with casters (laundry carts, trash containers, etc.) needs new casters. They added that some of them are so dirty you can't get them clean anymore, described them as so gunked up they don't roll anymore, with accumulated debris over the years, like a bad grocery cart. It's back breaking. You have to shove them. Observed rusty wheels on three of three laundry carts, the rubber on the wheels is old and cracked. Staff sprayed cleaner on one of them and ran it across paper towels, and the wheel left black streaks on the paper. Staff also indicated a need for more space to expand the laundry. We are crammed to the [NAME] in here and need space to organize. 11. On 2/27/23 at 10:00 A.M., Resident 19 complained the shower room being cold when they take showers. Resident indicated It gets so dirty a dog wouldn't take a shower in there. On 2/27/23 at 10:07 A.M., Resident 24 complained the shower room was cold all the time and the water was lukewarm. On 3/7/23 at 9:59 A.M., the common shower room was observed to be soiled. Specifically, the trash can next to the toilet was overflowing with paper towels, there was paper debris on the floor around the toilet. In the shower anteroom, there were wet tissues, used latex gloves, and washcloths on the floor, and a trash can overflowing with used briefs and other trash. There were 3 shower stalls. Two of them had plastic bottles, used bandages, and wet wash cloths on the floor. There were used latex gloves on the floor next to the bathtub. The shower room floor was soiled and sticky to walk on. The vent on the ceiling just inside the main entry door and the area around it was covered with a black/gray mold-like substance; the wall above the door is covered with black/gray mold-like substance. The shower room felt very cool, but there was no thermostat in the room to assess the temperature. There was a small heater on the ceiling in the middle of the room. When turned on, the heater put out a very small amount of heat. During an interview on 3/3/23 at 8:47 A.M., Housekeeper 7 indicated all resident rooms and bathrooms should have been cleaned daily by housekeeping, and floors vacuumed daily as well. At that time, she indicated anything that the residents used daily should be cleaned. During an interview on 3/3/23 at 10:40 A.M., the Maintenance Supervisor indicated he has been aware of most room concerns for several days, but had not gotten around to fixing them. He indicated he would need a plumber to fix room [ROOM NUMBER]'s toilet, and had not scheduled one yet. He also indicated he was made aware of the broken outlet cover in room [ROOM NUMBER] earlier in the week. He indicated he was not aware of the handrail plastic being cracked and missing in the bathroom of room [ROOM NUMBER]. He is unsure how long it had been in that condition. At that time, he indicated there was no specific policy related to maintenance, but he had a monthly schedule of possible concerns to look over in resident rooms, and at all other times, he relied on work orders to be filled out by other staff. He indicated if staff observed a maintenance concern, they needed to fill out a work order, which were reviewed daily every morning and again in the afternoon. On 3/3/23 at 1:58 P.M., a current Room Cleaning policy, revised 6/15/22, was provided and indicated Health Center resident rooms are cleaned daily and deep cleaned monthly . If there are any maintenance issues generate a work order in TELS [maintenance communication system] On 3/5/23 at 9:35 A.M., the DON (Director of Nursing) indicated there was not a policy but it was the facility's policy to label and cover resident items This Federal tag relates to Complaint IN00399595. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure care plan interventions and physician orders were followed for 2 of 4 residents reviewed for accidents, and 1 of 2 residents reviewed for nutrition. Interventions for resident's plan of care, including wearing non-skid socks, not sitting in the wheelchair in resident's room, having a Call, don't fall sign in resident's room, and use of a pummel cushion on resident's wheelchair, were not followed. (Resident 34, Resident 26, Resident 38) Findings include: 1. On 2/27/23 at 10:45 A.M., Resident 34 was observed sitting in a wheelchair in the common area during an activity. Resident 34 was wearing socks that were not non-skid. On 2/28/23 at 9:49 A.M., Resident 34 was observed sitting in a wheelchair in the common area. Resident 34 was wearing socks that were not non-skid. On 2/27/23 at 1:56 P.M., Resident 34's clinical record was reviewed. The most recent quarterly MDS (minimum data set) Assessment, dated 1/4/23, indicated resident's cognition status could not be assessed, and Resident 34 required extensive assistance of 2 (two) staff with dressing. A risk for falls care plan, dated 4/8/22, included, but was not limited to, the following intervention: Provide non-skid footwear, dated 4/8/22. On 3/3/23 at 8:11 A.M., Resident 34 was observed sitting in a wheelchair in the common area. Resident 34 was wearing socks that were not non-skid. At that time, CNA (Certified Nurse Aide) 9 indicated she had assisted Resident 34 getting dressed that morning, and was not offered any other choices for clothing, that what he was currently wearing was the only thing that was offered to him to wear. During an interview on 3/3/23 at 10:35 A.M., the DON (Director of Nursing) indicated she was unaware that providing non-skid footwear was an intervention in Resident 34's risk for falls care plan. 46416 2. On 3/2/23 at 10:39 A.M., Resident 26 was observed sitting in their wheelchair, in their room, without staff present. At that time, no signs were observed in resident's room to alert resident and the call light was on their left recliner armrest not in reach of the resident. On 2/28/23 at 3:10 P.M., Resident 26's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness (generalized), unsteadiness on feet, difficulty in walking, and long term use of anticoagulants. The most recent annual MDS Assessment, dated 1/21/23, indicated Resident 26's was severely cognitively impaired, was an extensive assist of 1 (one) staff for bed mobility and transferring, and an extensive assist of 2 (two) staff for toileting. Current physician's orders included, but were not limited to: Check for placement of Call, don't fall sign in room three times a day, started 12/22/22 Do not leave sitting up in w/c (wheelchair) in room - transfer to recliner or bed, started 12/22/22 A current risk for falls care plan, dated 3/26/21, included, but was not limited to, the following interventions: Call, don't fall visual cues placed in room, initiated 8/31/21 Resident to only be in w/c for transfers/transports. While in room, encourage resident to sit in recliner or lie in bed, initiated 4/1/21 A current care plan, dated 3/31/22, included, but was not limited to the following intervention: Do not leave resident in w/c in room, transfer to bed or recliner, started 3/31/22. During an interview on 3/2/23 at 10:48 A.M., RN (Registered Nurse) 24 indicated Resident 26 should not be left sitting in their wheelchair in their room. During an interview on 3/3/23 at 10:57 A.M., CNA (Certified Nurse Aide) 32 observed there was not a Call, don't fall sign in Resident 26's room to alert the resident. At that time, they indicated they were unsure if that was an intervention that should be in place for the resident. 46819 3. On 2/28/23 at 8:46 A.M., during interview with Resident 38, the room was observed to have debris such as used Kleenex and snack wrappers on the floor between the resident's bed and the bathroom. In the shared bathroom, the wastebasket was overflowing with paper towels and other waste onto the floor. On 3/3/23 at 1:15 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, Dementia in other diseases classified elsewhere, Type 2 diabetes mellitus with diabetic polyneuropathy, depression, anxiety, and Unspecified sequelae of cerebral infarction. The most recent quarterly MDS Assessment, dated 1/27/23, indicated resident was cognitively intact and required extensive assistance of 1 (one) staff for bed mobility, transfers, toileting, and eating, and required physical assistance with bathing. A current fall risk care plan, dated 7/11/22, included, but was not limited to, the following interventions: Pommel cushion placed in chair, dated 9/8/22 Ensure the floor is free of liquids and foreign objects, dated 7/11/22 On 3/1/23 at 8:32 A.M., Resident's room was observed to still have debris on the floor. On 3/1/23 at 9:24 A.M., Resident 38 was observed sitting on her bed. The area between the resident's bed and the bathroom was still cluttered with used Kleenex and other debris. On 3/3/23 at 10:03 A.M., Observed Resident 38 in bed. The wheelchair by her bed had a flat cushion rather than a pommel cushion on it. There was also clutter on the floor, such as used Kleenex, snack wrappers, and a lipstick tube. On 3/6/23 at 8:53 A.M., Observed Resident 38 up in wheelchair moving herself down the hall towards her room. Cushion in wheelchair was a flat cushion. A pummel cushion was not observed. Observed resident's room with used towels on the floor, as well as used Kleenex, and other debris. On 3/7/23 at 9:45 A.M., Resident 38 was out of room. The shared bathroom (shared by 2 residents) still had paper towels and debris on the floor. The wastebasket nearest the door in the room was overflowing with trash to the floor. On 3/3/23 at 1:58 P.M., a current Comprehensive Care Plan Guideline policy, dated 5/22/18, was provided and indicated the purpose of the policy was To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines . Comprehensive care plan need to remain accurate and current. At that time, the DON indicated staff should follow the resident's plan of care. 3.1-35(a) 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice in 2 of 4 residents reviewed for respiratory care. The oxygen concentrator filter was visibly soiled, oxygen tubing and humidifier bottles were not dated, and the incorrect oxygen flow rate was set on the concentrator. (Resident 42, Resident 9) Findings include: 1. During the initial interview with Resident 42 on 2/27/23 at 11:05 A.M., the resident indicated she used her oxygen as needed. Tubing on the concentrator was observed to have a date of 1/7 (no year indicated) and the filter had grayish lint all around the edges and dust flew off the filter when it was removed and put back. On 3/6/2023 at 10:25 A.M., Resident 42's records were reviewed. Diagnoses included, but were not limited to, chronic kidney disease, unspecified dementia with behavioral disturbance, emphysema, shortness of breath, and difficulty walking. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 1/30/23, indicated resident was severely cognitively impaired and required extensive assistance of 2 (two) staff for bed mobility, transfers, and toileting. Current physician orders included, but were not limited to, Change oxygen tubing monthly, dated 4/14/22 Clean external concentrator filter every two weeks on Sundays, dated 4/14/22 A current Potential for Shortness of Breath Care plan included, but was not limited to: Administer oxygen per MD order and as needed, dated 1/1/22 On 2/28/23 at 1:08 P.M., Resident 42 was observed at rest in her reclining wheelchair in her room. Oxygen concentrator filter was still soiled with dust. On 3/1/23 at 9:14 A.M., Resident 42 was observed in room in reclining wheelchair, oxygen concentrator filter was still soiled with dust. During an interview on 2/28/23 at 1:10 P.M., RN (Registered Nurse) 25 indicated Resident 42's respiratory status stayed fairly stable. 46416 2. On 2/27/23 at 11:23 A.M., Resident 9 was observed laying in bed with oxygen being administered with nasal cannula. The tubing was dated 2/2 (year was not indicated), the humidifier bottle was empty and undated, and the flow rate was set at 4 LPM (liters per minute). On 3/1/23 at 10:41 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and polyosteoarthritis, unspecified. The most recent quarterly MDS Assessment, dated 2/4/23, indicated Resident 9 was moderately cognitively impaired, on oxygen, and they were an extensive assist of 2 (two) staff for bed mobility and transfers. Current physician's orders included, but were not limited to, the following: Oxygen at 2 LPM per nasal cannula continuous, started 10/20/2022 and discontinued 2/27/2023 at 12:04 P.M. Oxygen at 4 LPM per nasal cannula continuous, started 2/27/23 at 12:04 P.M. Change oxygen tubing monthly on the 1st day of the month, started 10/20/2022 A current potential for complications related to COPD care plan, revised 2/17/23, included, but was not limited to, the following intervention: Administer oxygen as ordered, initiated 10/21/22 On 2/28/23 at 9:36 A.M., Resident 9 was observed laying in bed with their nasal cannula on and oxygen flow rate at 4 LPM, but the machine was not turned on. At that time, the humidifier bottle was empty and not dated. The tubing was dated 2/2 (no year indicated). On 3/1/23 at 8:47 A.M., the oxygen tubing for Resident 9 was observed to be dated 2/27 (no year indicated) and the humidifier bottle was full but not dated. On 3/1/23 at 9:05 A.M., Resident 9 was observed sitting in her room, in her wheelchair, wearing oxygen per n/c (nasal cannula) from portable concentrator with tubing that was not dated. On 3/1/23 at 12:31 P.M., Resident 9 was observed laying in bed wearing her nasal cannula with the oxygen flow rate set on 3.5 LPM and the tubing and humidifier bottle undated. On 3/2/23 at 8:31 A.M., Resident 9 was observed in the dining room eating breakfast, sitting in wheelchair with n/c and portable oxygen concentrator. The tubing was not dated. On 3/2/23 at 10:44 A.M., Resident 9 was observed laying in bed wearing n/c and oxygen flow rate set on 3.5 LPM. The tubing and humidifier bottle were not dated. During an interview on 3/2/23 at 11:04 A.M., RN 24 indicated that the resident would not adjust the oxygen flow rate on the machine and the oxygen flow rate and machine should be checked by nursing every shift. At that time, they also indicated that the tubing is changed weekly on night shift and should be dated. If the humidifier bottle was low, it should be changed and dated. During an interview on 3/2/23 at 11:08 A.M., RN 24 observed that there was no date on Resident 9's oxygen tubing or humidifier bottle. At that time, RN 24 observed the oxygen flow rate was a little under 4 LPM, like 3.5-3.75 LPM, and then adjusted oxygen flow rate to 4 LPM. On the way out of the resident's room, they observed the portable oxygen concentrator hanging on the resident's wheelchair and indicated the tubing was not dated and should be. During an interview on 3/5/23 at 9:35 A.M., the DON (Director of Nursing) indicated the nurses should check the oxygen concentrator, humidifier bottle, and flow rate every shift. On 3/6/23 at 10:30 A.M., a current Administration of Oxygen policy, revised 5/2018, was provided by the DON and indicated 1. Verify physician's order . 14. Date the tubing for the date it was initiated. a. tubing should be changed monthly and PRN (as needed) . 17. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered . A humidifier should be used for resident receiving oxygen at 4 LPM or above . 21. Observe the resident upon setup and periodically thereafter . 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 3 of 7 residents reviewed for unnecessary medications. Resident's had PRN (as needed) anti-anxiety medications that were ordered for greater than 14 days without a rationale included in their clinical record. (Resident 50, Resident 25, Resident 30) Findings include: 1. On 3/1/23 at 9:46 A.M., Resident 50's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and depression. Resident 50 was admitted [DATE]. The most recent admission MDS (Minimum Data Set) Assessment, dated 11/22/22, indicated Resident 50 was moderately cognitively impaired, they received an anti-anxiety medication 0 of 7 days, and had no behaviors during the assessment look back period. Current physician orders included, but were not limited to: alprazolam (an anti-anxiety medication) tablet 0.25 mg (milligram) orally for anxiety three times a day PRN, started 11/16/22 with no indicated stop date. The current MAR (medication administration record) from 2/1/23 through 3/1/23 was reviewed and indicated Resident 50 was assessed 3 (three) times daily for behaviors of excessive worry, restlessness, and agitation. There were no behaviors documented. It also indicated Resident 50 was administered the ordered PRN alprazolam on the following dates: 2/3/23 at 12:01 A.M. 2/8/23 at 9:16 A.M. 2/11/23 at 8:58 A.M. 2/28/23 at 3:35 P.M. 3/1/23 at 6:40 P.M. Resident 50's clinical record lacked any physician notes with a rationale to continue alprazolam PRN after the 14 day evaluations. 38770 2. On 2/28/23 at 10:06 A.M., Resident 25's clinical record was reviewed. Diagnoses included, but were not limited to, seizures and anxiety. The most recent admission MDS Assessment, dated 1/23/23, indicated Resident 25 was cognitively intact, and received antianxiety medications 7 of 7 days during the look back period. Current orders included, but were not limited to: lorazepam (an anti-anxiety medication) solution 2 mg/mL (milligrams per milliliter) injection, IM (intramuscular) for seizures every 2 (two) hours PRN, ordered 1/17/23 with no indicated stop date. The MAR (medication administration record) from January 2023 through March 2023 indicated Resident 25 received lorazepam 2 mg/mL IM on 1/18/23. Progress notes included, but were not limited to the following: 1/17/23 at 2:01 P.M. Spoke with [doctor's name] of orders received from hospital . ordered Lorazepam 2 mg IM every 2hrs PRN seizure activity . 1/31/23 at 4:21 P.M. Lorazepam 2 mg Q2hrs [every 2 hours] for seizures . The clinical record lacked other documentation of a rationale as to why Resident 25 was taking a PRN anti-anxiety medication beyond 14 days or the need for a second anti-anxiety medication. During an interview on 3/2/23 at 8:12 A.M., LPN (Licensed Practical Nurse) 5 indicated if Resident 25 were to have seizure activity, she would administer lorazepam 2mg IM injection, as there was a current order for every 2 hours as needed. 46882 3. On 2/28/23 at 2:03 P.M., Resident 30's clinical record was reviewed. Resident 30 was admitted on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, personal history of traumatic brain injury, altered mental status, unspecified dementia, unspecified severity, with other behavioral disturbance, and major depressive disorder, recurrent, moderate. The most recent quarterly MDS Assessment, dated 2/2/23, indicated Resident 30 was moderately cognitively impaired and an anti-anxiety medication was administered for 7 of 7 days during the look back period. Current physician orders included, but were not limited to the following: Ativan (lorazepam) 0.5 mg twice a day for anxiety, dated 9/14/22-2/9/23 Ativan (lorazepam) 0.5 mg tablet every 6 hours PRN for agitation, dated 11/29/2022 with no end date Re-evaluate PRN Ativan every two weeks, dated 9/29/22 Anti-Anxiety Medication Use-Observe resident closely for significant side effects: sedation, drowsiness, ataxia(drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash, dated 9/14/22 Resident 30's clinical records indicated pharmacy reviews were done monthly from 9/27/22 through 2/10/23. A GDR (gradual dose reduction) completed on 2/10/23 indicated the pharmacist recommended assessing the psychotropic PRN medication, lorazepam 0.5 mg po (by mouth) every six hours PRN for agitation which had been active since 11/29/22. The physician's evaluation lacked a rationale to continue the medication. Resident 30's clinical records lacked any physician notes with a rationale to continue lorazepam PRN after the 14 day evaluations. During an interview on 3/2/23 at 9:55 A.M., LPN 5 indicated Resident 30 hadn't needed the PRN Ativan for a long time. Once he was put on Haldol, he has been very pleasant. She has not had any reports of any behaviors in the last two weeks. During an interview on 3/2/23 at 11:15 A.M., the DON (Director of Nursing) indicated the PRN anti-anxiety medications were reviewed every two weeks by the prescriber to see if they need to continue as PRN or become a routine medication. If they need to stay PRN, the prescriber will put the reason within their physician note in the resident's clinical record. On 3/3/23 at 1:58 P.M., a current Psychotropic Medication Usage policy, revised 10/9/17, was provided by the DON and indicated . 1. Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process . 8. PRN order for psychotropic drugs are limited to 14 days. Except as provided if the attending physician or prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order . 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure that medications which had been discontinued were given to a resident, for 1 of 1 residents reviewed for a medication errors, and not following the plan of care. (Resident G) Findings include: On 10/7/20 at 2:40 P.M., the clinical record of Resident G was reviewed. A hospital Discharge Information document, dated 2/15/20, included medications to be given at the facility. The [MEDICATION NAME](an antibiotic), Tamsulosin (a medication used for prostate difficulties), and [MEDICATION NAME] (a medication given for enlarged prostates) were not documented as medications to be given. Nurses Notes included the following notations: 2/15/20 at 3:05 P.M.: Resident readmitted 2/16/20 at 1:44 P.M.: Resident notified of medication errors from this am's med pass. Resident assessed and negative for any ADRs (adverse drug reactions). MD notified and aware of med error. This nurse went over current meds with resident and all questions answered at this time. Will continue to monitor. On 10/8/20 at 10:15 A.M., the Director of Nursing (DON) indicated Resident G had been readmitted to the facility on [DATE]. The nurse mistakenly did not discontinue 3 medications that the resident had been on previously, but had been discontinued in the hospital. The resident received the 3 medications in error. The week-end supervisor had educated the nurse responsible for the error. The DON provided a document at that time which included: Medication Error Event, 2/16/20, Description: Medication Error .What is the Correct Order? No Cipro, Tamsulosin, or [MEDICATION NAME] to be given. Old d/c'd (discontinued) orders. Type of Error: Incorrect Medication .Resident notified and assessed for any adverse reactions. MD notified. Orders d/c'd and medication orders audited by WE (week-end) supervisor On 10/8/20 at 12:20 P.M., the DON provided the current facility policy, Guidelines for Admission Nursing Observation and Data Collection, dated 5/22/18. The policy included: Notations shall be made regarding verification of physician orders [REDACTED]. 3.1-35(c)(2)(A)

Based on interview and record review, the facility failed to notify a resident's representative of a new medication, for 1 of 3 residents reviewed for notification of a change in condition. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 5/29/20 at 11:00 A.M. The resident's face sheet indicated Family Member C was the resident's responsible party. Family Member C's spouse was also listed as an emergency contact. An admission Minimum Data Set (MDS) assessment, dated 3/26/20, indicated Resident B had a mild memory impairment. A Speech Therapy note, dated 4/1/20, indicated, Patient at a moderate level of cognitive impairment. Patient had previously been at a mild level. Resident Progress Notes, dated 4/3/20 at 12:55 P.M., indicated, N/O (new order) received for [MEDICATION NAME] 0.1 % gtts (drops). 2 gtts sl (sublingual, or under the tongue) tid (three times daily) r/t (related to) increased salivation. Documentation that the resident or the responsible party was notified of the new medication was not found in the clinical record. On 5/29/20 at 12:05 P.M., Family Member C was interviewed. Family Member C indicated neither he nor his wife was informed of the resident's order for [MEDICATION NAME] on 4/3/20. He indicated if he would have been notified, he would have informed the facility that the resident was unable to receive [MEDICATION NAME]. The family member indicated he was unaware of the new order until a staff member informed him on 4/5/20 that Resident B had fallen, and that the [MEDICATION NAME] was to be discontinued. On 5/29/20 at 2:20 P.M., during an interview with the Administrator, Director of Nursing (DON), and the Corporate Nurse, the DON indicated she had spoken with the nurse who had taken the [MEDICATION NAME] order. The reason the family had not been notified was that the resident was cognitively intact, and so there was no reason to call the family. On 5/29/20 at 2:50 P.M., the DON provided the current facility policy, Notification of Change in Condition, dated 5/23/18. The policy included, Purpose: To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when .2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly .Procedures: .2. The responsible party should be notified of change in condition or diagnostic testing results in a timely manner. 3. If the responsible party is unable to be reached a message may be left if this person has given their permission to do so .Documentation of notification or notification attempts should be recorded in the resident electronic record. This Federal tag relates to Complaint IN 832. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure the prevention of pressure injuries for 1 of 2 residents reviewed for pressure. A resident developed a stage III pressure injury to the left ankle and three stage II pressure injuries to posterior left thigh. (Resident 5) Findings include: During record review on 1/31/18 at 9:00 A.M., Resident 5's [DIAGNOSES REDACTED]. The most recent MDS (Minimal Data Set) (Significant change in status 1/23/18) indicated Resident 5 had 3 Stage II pressure injuries (the National Pressure Ulcer Advisory Panel defines a Stage II pressure injury as a Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) and 1 Stage III pressure injury (the National Pressure Ulcer Advisory Panel defines a Stage III pressure injury as a Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible). The MDS indicated the pressure injuries were not present upon admission/entry or reentry. The MDS also indicated Resident 5's cognition was moderately impaired and the resident required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. A Braden scale assessment completed on 9/21/17 indicated the resident was at risk for skin integrity. During review of Resident 5's care plans, a care plan dated 9/26/17 indicated the resident was at risk for skin breakdown due to incontinence, decreased mobility, and diagnosis. The care plan goal indicated the resident's skin will remain intact. A progress note dated 10/23/17 indicated that staff noted a black area with redness around it to Resident 5's left outer ankle while giving a shower that morning. The black blister area measured 2 cm (centimeters) long x 1.8 cm wide. Redness surrounding the blister was measured to be 8 cm x 5 cm. New order was received. A care plan dated 10/24/17 indicated Resident 5 had a pressure ulcer to the left ankle due to new diabetic shoes. Wound assessments - Left ankle measurements: 10/24/17 - 2 cm (centimeters) long x 1.8 cm wide (unstageable) 10/31/17 - 2 cm x 1.4 cm (unstageable) - wound noted with yellow slough, surrounding skin pink in color 11/07/17 - 1.4 cm x 1 cm (unstageable) 11/14/17 - 1.3 cm x 1 cm (unstageable) - slough or eschar present 11/21/17 - 1 cm x 1.3 cm x 0.3 cm in depth (unstageable) - slough or eschar present 11/29/17 - 1.4 cm x 1 cm x 0.3 cm (stage III) area clearing 12/05/17 - 1.4 cm x 1 cm x 0.4 cm (stage III) 12/13/17 - 1.4 cm x 1 cm x 0.4 cm (stage III) 12/19/17 - 1.4 cm x 1 cm x 0.1 cm (stage III) area dry, no drainage or odor 12/26/17 - 1.4 cm x 1.2 cm x 0.3 cm (stage III) 01/02/18 - 1.4 cm x 1.1 cm x 0.3 cm (stage III) 01/09/18 - 1.4 cm x 1.3 cm x 0.5 cm (stage III) 1/17/18 - 1.5 cm x 1.1 cm x 0.4 cm (stage III) 1/23/18 - 1.3 cm x 1 cm x 0.5 cm (stage III) 1/30/18 -1.8 cm x 1 cm x 0.3 cm (stage III) A progress note dated 1/15/18 indicated 3 Stage II pressure areas were found to Resident 5's posterior left middle thigh. Left thigh measurements #1: 1/15/18 - 1 cm x 1.4 cm x 0.1 cm (stage II) 1/17/18 - 1 cm x 1.4 cm x 01 cm (stage II) 1/23/18 - 1.8 cm x 2 cm x 01 cm (stage II) 1/30/18 - 1.5 cm x 1.6 cm x 01 cm (stage II) Left thigh measurements #2: 1/15/18 - 1.6 cm x 2 cm x 0.1 cm (stage II) 1/17/18 - 1.6 cm x 2 cm x 0.1 cm (stage II) 1/23/18 - 1.5 cm x 1.5 cm x 0.1 cm (stage II) 1/30/18 - 1.2 cm x 1.2 cm x 0.1 cm (stage II) Left thigh measurements #3: 1/15/18 - 2 cm x 2 cm x 0.1 cm (stage II) 1/17/18 - 2 cm x 2 cm (stage II) 1/23/18 - 2 cm x 2.3 x 0.1 cm (stage II) 1/30/18 - 1.5 cm x 2.2 cm x 0.1 cm (stage II) During review of physicians orders the following orders were included, but were not limited to: 10/31/17 - Prostat (protein supplement) for wound healing 11/1/17 - (MONTH) change dressing to left ankle as needed for soiling or dislodgment 11/7/17 - Cleanse wound to left ankle with [MEDICATION NAME] spray (antimicrobial wound cleanser) and 4 x 4 gauze . 11/15/17 - Physical therapy 5 days a week, EStim (electrical stimulation) for wound care 12/19/17 - Therapy to perform Anodyne (infrared light therapy) to left ankle as ordered 5 times weekly to improve healing of wound 1/9/18 - Physical therapy 5 days per week - Anodyne and EStim to left lateral malleolus wound 1/16/18 - Cleanse posterior left thigh areas, skin prep to area around wound 1/16/18 - Cleanse wound to left ankle with [MEDICATION NAME] spray and 4 x 4 gauze, . 1/22/18 - Anchor size 18 French Foley catheter for 7 days then reevaluate due to wound to left thigh and redness around perineal area, moisture delaying healing During review of nursing progress notes, the following notes indicated the progress of Resident 5's developed pressure areas: 11/3/17 - resident has DTI (deep tissue injury) to left ankle that was caused by new diabetic shoes, area noted with yellow slough in center . 11/9/17 - resident continues with area to left ankle, area presents as unstageable with necrotic tissue and slough, area has decreased in size . 11/15/17 - dressing changed to left outer ankle , slough present to wound bed, peri-wound red, tender to the touch . 11/16/17 - area to left outer ankle that is classified as unstageable wound, covered with yellow slough 11/22/17 - continues with wound to left ankle, slough less to wound bed . 12/1/17 - resident has stage III wound to left ankle with some yellow slough 12/7/17 - resident continues with wound left lateral ankle, clean pink moist wound bed 12/15/17 - continues with wound to left ankle, clean and pink , no drainage, 12/25/17 - resident incontinent of BM (bowel movement), while cleaning resident, stasis area noted above bend of resident's left knee . 12/25/17 - dressing to left posterior upper leg, resident turned in bed to offload pressure 12/27/17 - all areas reclassified to abrasions. These areas are not stasis, to continue treatment as ordered and monitor for changes 12/28/17 - review of all skin areas , areas are abrasion not stasis 12/29/17 - resident continues with wound to left ankle, clean with pink tissue 1/5/18 - resident continues with wound to left ankle, area clean, no redness 1/9/18 - labs reviewed by NP (Nurse practitioner), although cognition and labs continue to decline, tests do not reflect acute abnormalities 1/15/18 - found (3) Stage II areas to posterior left mid-thigh. Areas measures and treatment in place . 1/19/18 - resident wound to outer right (sic) continues to show slow progress, therapy to treat . 1/22/18 - new order for Foley Catheter for 7 days due to wound to left thigh and redness to peri-area, moisture from incontinence delaying wound healing process 1/26/18 - informed NP of drainage on dressing from left ankle, yellow/green in color with redness surrounding wound area, foul odor noted from wound, ordered ATB (antibiotic) for left ankle [MEDICAL CONDITION] 1/26/18 - Stage III to left outer ankle, and 3 stage II to thigh, areas are healing well 1/30/18 - note for wounds, nutrition status fair with good intakes On 1/31/18 at 2:00 P.M., during an observation, the ADON (Assistant Director of Nursing) entered Resident 5's room, removed a 4 x 4 bandage covering three Stage II pressure ulcers on the mid to lower posterior left thigh. Resident 5 was lying in bed with both feet raised on two pillows. Three Stage II areas were observed in close proximity to one another. The areas were well defined and the surrounding tissue was pink in color with little to no drainage present. The ADON indicated treatments were being done every three days to the areas. The ADON cleaned the area and applied a new 4 x 4 bandage. The ADON unwrapped the Coban to the Stage III area on Resident 5's left ankle. A 4 x 4 bandage was removed to expose the pressure area. The bandage was soiled from yellow slough, the pressure ulcer was half covered by yellow slough, and the tissue surrounding the area was pink in color. The ADON indicated the slough was not present during the dressing change the previous day and that the resident is currently receiving an antibiotic for the left ankle. After the area was cleansed and covered by the ADON, PT 4 (Physical Therapist) entered the resident's room to apply an electrotherapy treatment for [REDACTED]. PT 4 indicated the areas used to be red and tender and could not say exactly how the areas formed, but could of been from the resident using the wheelchair. During an interview with Resident 5 on 1/31/18 at 10:50 A.M., the resident indicated being unsure of how the pressure injuries developed. Resident 5 indicated there was a sore on the left ankle and then the area opened up. The resident indicated that the pressure injuries are doing okay. The resident also indicated that while laying down in bed, staff tries to keep both feet propped on pillows. During the interview, Resident 5 was in their room, sitting in a wheel chair with a pressure reducing cushion, was wearing non slip gripper socks, and did not have foot pedals attached to the wheel chair. During an interview on 2/1/18 at 8:10 A.M., LPN 9 indicated Resident 5's diabetic shoe rubbed against the left ankle and caused the pressure area to the left ankle, and the three pressure areas to the posterior left thigh may have come from the resident propelling self in the wheelchair. LPN 9 indicated interventions were to leave the shoes off, use foot pedals while in the wheelchair, and keep feet elevated while in bed. LPN 9 also indicated the urinary catheter was placed to promote healing of the 3 Stage II pressure areas on the resident's posterior left thigh. LPN 9 indicated the resident was incontinent and would flush, then becoming completely saturated with urine. LPN 9 indicated the resident was on a check and change program to be checked and changed every two hours. During an interview with the ADON on 01/31/18 at 10:37 A.M., the ADON indicated Resident 5 may have acquired pressure areas while using the wheelchair for locomotion and indicated the wounds are improving. During an interview with PT 4 on 1/31/18 at 11:10 A.M., PT 4 indicated using EStim (electric stimulation) and Anodyne therapies for Resident 5's Stage III pressure ulcer to the left ankle 5 days a week. PT 4 indicated therapy has been wrapping Coban around the left ankle daily and the treatments and therapies appear to be helping to improve the healing of the area. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents' privacy and dignity was maintained for 2 of 2 residents reviewed for dignity and during 4 random observations throughout the survey. Staff were unable to meet the resident needs in a timely manner and staff failed to knock on residents' doors before entering their rooms. (Resident 95, Resident 245, Resident 33, Resident 19) Findings include: 1. During an interview on 1/25/18 at 2:15 P.M., Resident 95 indicated she had to use the bathroom around 8:00 A.M., so she pushed her call light. Resident 95 indicated it took 25 minutes for the CNA to come into her room and assist her to the bathroom. Resident 95 indicated when the CNA entered the room Resident 95 said, It's too late. I have already wet my pants. Resident 95 indicated the CNA cleaned her up and the CNA said, Sorry, I had someone else to take care of. Resident 95 said, I know they try. During an observation on 1/30/18 at 9:53 A.M., CNA 6 took Resident 95 to the bathroom. CNA 6 indicated Resident 95 experienced incontinence, mainly at night, when she was asleep, but not during the day, adding that, once in a while, she would have an accident and would call for assistance. CNA 6 indicated that most of the time Resident 95 knew when she had to go to the bathroom. The clinical record for Resident 95 was reviewed on 1/29/18 at 9:30 A.M. The record indicated Resident 95's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 95 experienced no cognitive impairment. The assessment further indicated Resident 95 required the extensive assistance of two staff for toileting and transfers, and was occasionally incontinent. A Care Plan for Bowel and Bladder dated 1/16/18 included, but was not limited to, the following interventions: .01/16/2018 .Offer and assist with toileting upon rising, before and after meals, at bed time, and as needed . The Residents' Rights were provided by the Director of Nursing on 1/3/18 at 10:14 A.M., and read as follows: .The resident has the right to a dignified existence . 2. On 1/26/18 at 9:05 A.M., while conducting a confidential interview with resident 245 in the resident's room with the door closed, CNA 4 (Certified Nurses Aide) entered the room without knocking. Then, without speaking to the resident, CNA 4 went into the resident's bathroom, emptied the trash can, and exited the room. During the same interview at 9:25 A.M., CNA 4 opened the door again without knocking, entered the room, then knocked on the open door before asking if Resident 245 would like the breakfast plate removed. 3. On 1/26/18 at 11:05 A.M., while conducting a confidential interview with Resident 19's family member with the resident's door closed, CNA 4 opened the door and entered the room without knocking and asked the family member if Resident 19 needed to use the restroom. 4. During an interview on 1/26/18 at 10:19 A.M, Resident 33 indicated that certain CNA's have been trained to always knock on the door before entering, but not all staff knock before coming into the room. During an observation on 1/26/18 at 10:41 A.M., HA 5 (Hospitality Aid) entered Resident 33's room without knocking. On 1/30/18 at 9:37 A.M., CNA 16 indicated in order to provide dignity and privacy to the residents, staff should always close the door when providing care, pull the curtain if resident's are in a shared room, and knock on the door before entering the room. On 2/1/18 at 8:45 A.M., the DON (Director of Nursing) provided a facility policy with a revision date of 8/11/16 that indicated Our residents have a right to be treated with dignity and respect and Our residents have a right to privacy. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure residents who were at risk to fall were transferred safely, had functioning equipment, and that adequate supervision was provided for 4 of 5 residents who met the criteria for review of accidents. (Resident 95, Resident 14, Resident 4, Resident 36) Findings include: 1. During an observation on 1/30/18 at 9:53 A.M., CNA 6 took Resident 95 to the bathroom. CNA 6 transferred Resident 95 from the wheelchair to the commode without using a gait belt. Upon transferring Resident 95 from the commode to the wheelchair CNA 6 used a gait belt, indicating at that time Resident 95 does not like to use the gait belt when being transferred to the commode. CNA 6 indicated Resident 95 experiences incontinence mainly at night when she is asleep, but not during the day, but further adding that once in a while Resident 95 will have an accident. CNA 6 indicated that most of the time Resident 95 knows when she has to go to the bathroom. The clinical record for Resident 95 was reviewed on 1/29/18 at 9:30 A.M. The record indicated Resident 95's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicate Resident 95 experienced no cognitive impairment. The assessment further indicated Resident 95 required the extensive assistance of two staff for toileting and transfers, experienced unsteadiness transfers, was only able to stabilize balance with staff assistance, and had a history of [REDACTED]. A Care Plan for Falls dated 1/9/18 included, but was not limited to the following interventions: 01/11/2018 .Educate staff regarding transfers from wheelchair . A Physician order [REDACTED].ACTIVITY-Up with assist x (times) 1 . A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/10/2018 09:26 P.M .Location of Fall .Resident Bathroom .Attempting to transfer to w/c (wheelchair) with staff .W/C - Wheels not locked . A progress note dated 1/10/18 at 9:33 P.M., read as follows: .CRCA (CNA) came to nurse stating resident had fallen. Resident in restroom on floor in front of toilet holding on to grab bar . CRCA states she was attempting to transfer resident from toilet to w/c et (and) w/c wheels had not been locked et slipped out from under resident causing her to slide to the floor. Staff educated at this time on ensuring w/c brakes are on during resident transfers . During an interview on 2/1/18 at 2:03 P.M., the Director of Nursing indicated it was the facility policy to always lock the brakes on a wheelchair before transferring a resident. A policy for Guidelines for Gait Belt Use was provided on 1/31/18 at 9:30 A.M., and read as follows: .To ensure safety for the resident and staff during transfers and mobility activities .1. Gait belts should be used according to the plan of care for the individual resident . 2. During an observation and interview on 1/30/18 at 8:32 A.M., Resident 14 was sitting in her wheelchair with her call light wrapped around the wheelchair arm. Resident 14 indicated the staff requested she use the call light and ask for assistance when she needed to use the bathroom. The clinical record for Resident 14 was reviewed on 1/29/18 at 9:30 A.M. The record indicated Resident 14's [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicate Resident 14 experienced no cognitive impairment. The assessment further indicated Resident 14 required the extensive assistance of two staff for transfers, experienced unsteadiness transfers, was only able to stabilize balance with staff assistance, and had a history of [REDACTED]. A Care Plan for Falls dated 10/11/17 included, but was not limited to the following interventions: Re-educate to utilize call light for assistance .10/11/17 .12/21/17 Call light clipped to resident at all times when in room . A Physician order [REDACTED].ACTIVITY-Up with assist x (times) 1 . Fall 1 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 11/4/2017 09:34 P.M .Location of Fall .Resident Room .Transferring self .Resident weak, needs assistance with transfers .Witnessed .No .Alarm not clipped to back . A progress note dated 11/4/17 at 9:33 P.M., read as follows: .This nurse was approached by CRCA at approximately 2130 (9:30 P.M.) stating resident was on knees in room. Res (resident) fell to knees when trying to transfer self to bed without help. Clip alarm not clipped to resident at this time. Res reminded to call for help and staff reminded to check alarm placements . A progress note dated 11/6/17 at 3:42 P.M., read as follows: .IDT review fall event .Resident transferring self from w/c to bed per self. Alarm not sounding. Clip alarm not attached to clothing .Upon further investigation, resident states she removed clip from clothing .Staff to check placement of clip alarm every 2 hours . Fall 2 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 12/21/2017 03:21 A.M .Location of Fall .Resident Room .Transferring self .couldn't find call light .Witnessed .No . A progress note dated 12/21/17 at 3:26 A.M., read as follows: .Found resident kneeling on floor next to bed. Resident states she couldn't find call light and tried to take self to bathroom .Resident assist up and to restroom . Call light clipped to clothing within resident reach . During an interview on 2/1/18 at 2:03 P.M., the Director of Nursing indicated it was the facility policy to always lock the brakes on a wheelchair before transferring a resident. A policy for Guidelines for Gait Belt Use was provided on 1/31/18 at 9:30 A.M., and read as follows: .To ensure safety for the resident and staff during transfers and mobility activities .1. Gait belts should be used according to the plan of care for the individual resident . 3. During an observation and interview on 1/29/18 at 1:58 P.M., Resident 4 was sitting in her wheelchair in her room with the door closed. Resident 4 was placing papers in a plastic bag and indicated she was packing. The clinical record for Resident 4 was reviewed on 1/30/18 at 2:30 P.M. The record indicated Resident 14's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicate Resident 4 experienced mild cognitive impairment. The assessment further indicated Resident 4 required the extensive assistance of two staff for transfers, toileting, was only able to stabilize and balance with staff assistance, and had a history of [REDACTED]. A Care Plan for Falls dated 10/4/17 included, but was not limited to the following interventions: 01/05/2018 Staff educated to assure alarms to chair are in place and working A Physicians orders dated 1/5/18 read as follows: .Change batteries in alarms monthly . A Physician order [REDACTED].ACTIVITY: Up with assist x 1 . Fall 1 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 10/28/2017 12:50 P.M .Location of Fall .Resident Bathroom .Transferring self .Alarms not sounding .Witnessed .No . A progress note dated 10/28/17 at 1:05 P.M., read as follows: .This nurse was standing at med cart et (and) heard resident yell from residents restroom. this nurse responded to yell et found resident sitting in the middle of her restroom floor on her bottom .CRCAs assisted resident back to her W/C et toileted resident .Intervention for resident to be toileted before and after meals. All alarms in place et fx (functioning) . Fall 2 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/12/2018 3:23 A.M .Location of Fall .Resident Room .Reaching for object .Witnessed .No . A progress note dated 1/12/18 at 3:34 A.M., read as follows: .resident in room hollering for daughter found sitting in floor by w/c states slid out of w/c states im not hurt .resident to br (bathroom) then to bed . Fall 3 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/15/2018 10:19 A.M .Location of Fall .Resident Room .Reaching for object .Witnessed .No . A progress note dated 1/15/18 at 10:24 A.M., read as follows: .Hospice nurse here to visit resident and heard resident yelling in room. This nurse and hospice nurse went into residents room resident was found kneeling in room at foot of bed .This nurse found seat belt alarm to not be functioning battery is bad this nurse replaced battery and alarm is functioning at this time .Battery in alarm to be changed monthly . Fall 4 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/25/2018 1:30 P.M .Location of Fall .Resident Room .Ambulation .Witnessed .Yes . A progress note dated 1/25/18 at 1:00 P.M., read as follows: .Alarm sounding when CRCA entered resident room and noted resident up and walking in room unassisted. Resident lost balance and fell to floor. CRCA attempted to get to resident but couldn't reach resident in time . During an interview on 2/1/18 at 2:03 P.M., the Director of Nursing indicated it was the facility's policy to prevent falls by ensuring all interventions were in place and functioning. 4. On 1/31/18 at 1:32 P.M., Resident 36 was observed sitting in his wheelchair in his room. On 1/31/18 at 1:13 P.M., Resident 36's clinical record was reviewed. Resident 36 was admitted [DATE]. Resident 23's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 12/18/17, indicated Resident 36 required extensive assistance of two persons for transfers and toileting. The MDS further indicated Resident 36 had one fall without injury since the prior assessment. The MDS lacked an assessment for Resident 36's cognitive status. The Care Plans included, but were not limited to; Resident is at risk for falling, initiated on 10/25/17. The interventions included, but were not limited to: Therapy evaluation and treat as needed (10/25/17), Staff to assist resident with transfers as needed, assist of one (10/25/17), keep personal items and frequently used items within reach (10/25/17), keep call light within reach (10/25/17), ensure the floor is free of liquids and foreign objects (10/25/17), encourage resident to assume standing position slowly (10/25/17), dycem to recliner to prevent resident from unintentionally sliding out of chair (10/26/17), bed in lowest position (10/26/17), educate resident to ask for assistance repositioning in chair (10/29/17), resident is non-compliant with asking for assistance at times with transfers, transfer pole between bed and recliner to aid in self transfers if so chooses (11/2/17), wheelchair seat tilted back (11/16/17), therapy to work with positioning (11/22/17), provide non-skid footwear, gripper socks while in bed (11/22/17), front/rear anti-tippers to wheelchair to prevent wheelchair from unintentionally flipping forward (11/28/17), alarms discontinued (12/7/17), place walker in clean utility room out of way (1/4/18), dysem to wheelchair to prevent resident from unintentionally sliding out of chair (1/22/17), perimeter mattress to bed at all times (1/27/18). FALL 1 An Event Report, dated 10/29/17, indicated Resident 36 had a fall on that date (10/29/17). The Event Report indicated Resident 36 was pushing self back in recliner and lost footing. The safety equipment in place was a pressure alarm and was functioning at the time of the incident. The new intervention indicated the resident was educated. The Progress Notes attached to the Event Report included, but were not limited to: 10/29/17 at 9:35 P.M.: At 2120 (9:20 P.M.),staff went past room and observed Res (resident) kneeling in front of recliner. Per Res, he had been attempting to scoot self back in recliner and lost his footing, causing him to fall to his knees. Res denies c/o (complaints) pain or discomfort. ROM (range of motion) WNL (within normal limits) x 4 (times four) ext (extremities). No visible injuries noted. VSS (vital signs stable). Res denies hitting head. After assessment, Res assisted up and into bed per request . Res educated to call for staff assist when repositioning self in chair. FALL 2 An Event Report, dated 11/2/17, indicated Resident 36 had a fall on that date (11/2/17). The Event Report indicated Resident 36 was transferring self. The safety equipment in place was a call light and alarm and was functioning at the time of the incident. The new intervention indicated the resident was educated. The Progress Notes attached to the Event Report included, but were not limited to: 11/2/17 at 10:53 A.M.: Resident was lounging in his bed reading a book. Call light was in reach. Alarm began to sound, CNA immediately answered alarm and called for this nurse. As this nurse entered the resident room resident was in the process of standing up. Resident was kneeling at the side of the bed. Resident states he was getting up and can't get up from the side of the bed unless he has something to grab onto (sic). Resident states he get on his knees in the floor so that he can pull up using the bed rail and arm of his recliner. Resident educated on asking for assistance and not transferring without help . 11/2/17 at 1:51 P.M.: .Transfer pole to be placed in room to aid in transferring from bed or chairs. Alarms to be discontinued. Therapy aware and will work with pole transfers as well . FALL 3 An Event Report, dated 11/7/17, indicated Resident 36 had a fall on that date (11/7/17). The Event Report indicated Resident 36 was transferring self. The call light was out of reach. The safety equipment in place was an alarm and was functioning at the time of the incident. The new interventions indicated to toilet the resident, evaluate continence, bed in lowest position, and gripper socks. The Progress Notes attached to the Event Report included, but were not limited to: 11/7/17 at 10:45 P.M.: This nurse had just looked into residents room to assure he was in bed. Came out of report and personal alarm was sounding in residents room. When I approached room staff had already got to resident. He was sitting beside bed. He said he was trying to use the bathroom . On inspection residents call light was not in reach. Staff educated on assuring call lights are within reach and residents are toileted properly before assisting to bed. Gripper sock were also applied et (and) to be wore (sic) while abed (sic). FALL 4 An Event Report, dated 11/16/17, indicated Resident 36 had a fall on that date (11/16/17). The Event Report indicated Resident 36 was leaning forward. The safety equipment in place was alarms and dycem and was functioning at the time of the incident. The new intervention indicated therapy to evaluate for positioning. The Progress Notes attached to the Event Report included, but were not limited to: 11/16/17 at 10:47 A.M.: This nurse was walking down the hall, this nurse heard an alarm sounding. This nurse was at the beginning of the 200 Hall, immediately wen to room [ROOM NUMBER] where the sound was coming from and found this resident on the floor. Resident was upset with himself 11/17/18 at 11:27 A.M.: IDT (Interdisciplinary Team) reviewed fall event from 11/16/17. Found resident sitting on floor after leaning forward in w/c (wheelchair) and sliding out to the floor . Fall 5 An Event Report, dated 11/28/17, indicated Resident 36 had a fall on that date (11/28/17). The Event Report indicated Resident 36 thought there was trash on the floor. The safety equipment in place was an alarm and dycem and were functioning at the time of the incident. The Fall Risk Re-Assessment, indicated Resident 36 had a cognitive or memory impairment that effects safety and judgment. The new intervention indicated front anti tippers were to be placed on the wheelchair. The Progress Notes, attached to to the Event Report included, but were not limited to: 11/28/17 at 1:38 P.M.: Resident was leaning forward in his wheelchair. Resident stated he thought he seen trash in the floor and was trying to pick it up. Resident leaned forward, tucked his feet under his wheelchair, resident hit his head on the dresser and the wheelchair landed on top of this resident . New order to have front anti-tippers . Fall 6 An Event Report, dated 12/10/17, indicated Resident 36 had a fall on that date (12/10/17). The Event Report indicated Resident 36 was reaching for an object. The safety equipment in place was anti tippers to front and back of wheelchair and chair adjustments which were functioning at the time of the incident. The Fall Risk Re-Assessment indicated the resident has a cognitive or memory impairment that effects safety and judgment. The Progress Notes attached to the Event Report included, but were not limited to: 12/10/17 at 10:45 A.M.: Resident was toileted at 1030 (sic) by CRCA (CNA). Prior to CRCA leaving resident room. (sic) CRCA clipped call light to his bed, in reach. CRCA asked 'Is there anything else I can do for you?' This resident stated, 'No.' CRCA stated, 'Use your call light if you want or need anything.' Resident then nodded his head down then up Resident then go into his closet, got out his cotton hat and tossed it towards his recliner. Walker was placed in front of the recliner because this resident had been using the other side of the room. Resident forgot his walker was placed there before tossing his hat. Resident stated, 'I thought that I could just stand up and reach over and get it without bothering someone over this silly matter.' .Resident educated to utilize call light for any want or need . 12/11/17 at 11:35 A.M.: IDT reviewed fall event from 12/10/17. Resident had a fall while picking up hat off floor .Intervention: Educated resident to utilize the use of call light . Fall 7 An Event Report, dated 1/3/18, indicated Resident 36 had a fall on that date (1/3/18). The Event Report indicated the resident had been sitting in the wheelchair and frequently used objects were out of reach. The Event Report further indicated no safety equipment was ordered at the time of the incident. The new intervention was to keep the walker in the clean utility room when not in use. The Progress Notes attached to the Event Report, included, but was not limited to: 1/3/18 at 12:13 P.M.: Resident scooted forward in w/c to try to move walker out from in front of recliner so he could straighten up blankets in recliner and slid out of w/c .Walker to be kept in clean utility room when not in use . Fall 8 An Event Report, dated 1/26/18, indicated Resident 36 had a fall on that date (1/26/18). The Event Report indicated the resident was turning and repositioning in bed and rolled out. The safety equipment in place was the bed in the lowest position and was functioning at the time of the incident. The new intervention was a perimeter mattress. The Progress Notes attached to the Event Report included, but was not limited to: 1/26/17 at 4:45 A.M.: CRCA alerted this nurse of resident being on the floor trying to climb back into bed. Resident reported he was trying to turn in bed and rolled out onto the floor . Fall 9 An Event Report, dated 1/27/17, indicated Resident 36 had a fall on that date (1/27/18). The Event Report indicated the resident was attempting to use the restroom without assistance. The Event Report further indicated no safety equipment was ordered at the time of the incident. The new intervention indicated to assist the resident back from lunch and toilet. The Progress Notes attached to the Event Report included, but was not limited to: 1/27/17 at 2:17 P.M.: Resident noted lying on floor in bathroom . Resident stated he was going to the bathroom. This nurse reminded resident to utilize call light for assistance to the restroom . N.O. (new order) Resident to be assisted back to room from lunch et. (and) toileted . On 2/1/18 at 9:38 A.M., the DON was interviewed. The DON indicated on Fall 1, a dycem was in the recliner because the Event Report did not indicate the intervention was not in place. The DON during Fall 3 Resident 36's call light was out of reach. The DON indicated during Fall 7, she assumed the dycem was in the wheelchair because the Event Report id not indicate it was not present. The DON indicated the dycem to the wheelchair was initiated on 10/26/17. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staffing was adequate to prevent falls for 4 of 5 residents who met the criteria for review of accidents, to prevent pressure injuries for 1 of 2 residents who met the criteria for review of pressure ulcers, and were unable to meet the needs of the residents for 4 of 13 confidential resident interviews, on 3 of 3 nursing units, in a facility census of 49. (Resident 36, Resident 95, Resident 14, Resident 4, Resident 5) Findings include: 1. During the survey period of 1/25/18 through 2/1/18, the following comments were made while random confidential interviews were conducted: a. A resident indicated it took 25 minutes for a CNA (Certified Nursing Assistant) to come and assist to the bathroom, and by the time the CNA came in, the resident indicated It's too late. I have already wet my pants. The resident indicated the CNA said Sorry, I had someone else to take care of. b. I have had accidents waiting on them to come assist me. I have waited 30-45 minutes. c. I have had to wait 30 minutes before for staff. d. They are short on staff and could use more help. On 1/29/18, at 11:00 A.M., CNA assignment sheets were provided. The assignment sheets indicated 22 residents were on 100 Hall, 16 residents were on 200 Hall, and 11 residents were on 300 Hall. On 1/31/18 at 9:14 A.M., the following interviews took place: LPN 3 indicated there was 1 nurse, 1 CNA, 2 residents that required a full body lift for transfers, 1 resident that required a stand aid lift, 1 resident with a foley catheter, 1 resident with a feeding tube, and 5 residents that required 2 person assist on the 100 Hall. The ADON (Assistant Director of Nursing) indicated there were 2 nurses, 2 CNA's, 2 residents that required a full body lift for transfers, 3 residents that required a stand aid lift, and 5 residents that required a 2 person assist on the 200 Hall. RN 5 indicated there was 1 nurse, 1 CNA, 1 resident that required a full body lift for transfers, and 6 residents that required a 2 person assist on the 300 Hall. On 1/31/18 at 11:15 A.M., the Staffing Coordinator indicated the facility was staffed according to the following: Days and Evenings: 100 Hall - 1 Nurse and 2 CNA's 200 Hall - 1 Nurse and 1 CNA 300 Hall - 1 Nurse and 1 CNA 1 RCA (Resident Care Associate) Nights: 1 Nurse to cover 200 Hall and half of 100 Hall 1 Nurse to cover 300 Hall and half of 100 Hall 2 CNA's to cover 100, 200, and 300 Halls At this time, the Staffing Coordinator indicated on 1/31/18, the census total was 49 residents. On 1/31/18 at 11:41 A.M., the nursing staffing schedule was provided. The Staffing Coordinator indicated the schedule was as worked for 1/10/18 through 1/23/18. The staffing schedule indicated the following (entire Health Campus, no specific Hall assignment): 1/12/18 Night - 1 Nurse, no other nursing staff 1/13/18 Evening - 1 Nurse (6p - 10p), 4 CNA's Night - 3 Nurses, no other nursing staff 1/15/18 Night - 1 Nurse, 2 CNA's 1/16/18 Night - 1 Nurse, 1 CNA 1/17/18 Evening - 1 Nurse, 3 CNA's Night - 1 CNA (10p - 5a), no other nursing staff until 6a on 1/18/18 1/18/18 Evening - 1 Nurse, 4 CNA's 1/19/18 Evening - 1 Nurse (2p - 6p), 1 CNA (2:30p - 10p), 1 CNA (4p - 9p), 1 CNA (2p - 6p), 1 CNA Float (4:15p - 6p), 1 RCA (4p - 9p) 1/20/18 Night - 2 Nurses, no other nursing staff 1/21/18 Night - 1 Nurse (10p - 6a), 1 Nurse (10p - 2a), no other nursing staff 1/22/18 Night - 3 Nurses, no other nursing staff During an interview on 2/1/18 at 8:09 A.M., CNA 6 indicated unless the residents request otherwise, morning care, showers, and any other care had to be performed in the morning by day shift because there was not time for the night shift to complete care for everyone. 2. Insufficient staffing was indicated by the development of an avoidable pressure ulcer for Resident 5. On 1/31/18 at 9:00 A.M., Resident 5's clinical record was reviewed. The record indicated a care plan, dated 10/24/17, that Resident 5 had a pressure ulcer to the left ankle due to new diabetic shoes. A progress note dated 1/15/18 indicated 3 Stage II pressure areas were found to Resident 5's posterior left middle thigh. The most recent MDS (Minimal Data Set) (Significant change in status 1/23/18) indicated Resident 5 had 3 Stage II pressure ulcers and 1 Stage III pressure ulcer that were not present upon admission/entry or reentry. During an interview at 8:10 A.M., LPN 9 indicated Resident 5's diabetic shoe rubbed against the left ankle and caused the pressure area to the left ankle, and the three pressure areas to the posterior left thigh may have come from the resident propelling self in the wheelchair. During an interview with the ADON on 01/31/18 at 10:37 A.M., the ADON indicated Resident 5 may have acquired pressure areas while using w/c for locomotion and indicated the wounds are improving. 3. Insufficient staffing was indicated by 4 residents experiencing multiple falls. a. Resident 36's clinical record was reviewed on (MONTH) 31, (YEAR) at 1: 13 p.m. and contained the following information: FALL 1 An Event Report, dated 10/29/17, indicated Resident 36 had a fall on that date (10/29/17). The Event Report indicated Resident 36 was pushing self back in recliner and lost footing. The safety equipment in place was a pressure alarm and was functioning at the time of the incident. The new intervention indicated the resident was educated. The Progress Notes attached to the Event Report included, but were not limited to: 10/29/17 at 9:35 P.M.: At 2120 (9:20 P.M.),staff went past room and observed Res (resident) kneeling in front of recliner. Per Res, he had been attempting to scoot self back in recliner and lost his footing, causing him to fall to his knees. Res denies c/o (complaints) pain or discomfort. ROM (range of motion) WNL (within normal limits) x 4 (times four) ext (extremities). No visible injuries noted. VSS (vital signs stable). Res denies hitting head. After assessment, Res assisted up and into bed per request Res educated to call for staff assist when repositioning self in chair. FALL 2 An Event Report, dated 11/2/17, indicated Resident 36 had a fall on that date (11/2/17). The Event Report indicated Resident 36 was transferring self. The safety equipment in place was a call light and alarm and was functioning at the time of the incident. The new intervention indicated the resident was educated. The Progress Notes attached to the Event Report included, but were not limited to: 11/2/17 at 10:53 A.M.: Resident was lounging in his bed reading a book. Call light was in reach. Alarm began to sound, CNA immediately answered alarm and called for this nurse. As this nurse entered the resident room resident was in the process of standing up. Resident was kneeling at the side of the bed. Resident states he was getting up and can't get up from the side of the bed unless he has something to grab onto (sic). Resident states he get on his knees in the floor so that he can pull up using the bed rail and arm of his recliner. Resident educated on asking for assistance and not transferring without help . FALL 3 An Event Report, dated 11/7/17, indicated Resident 36 had a fall on that date (11/7/17). The Event Report indicated Resident 36 was transferring self. The call light was out of reach. The safety equipment in place was an alarm and was functioning at the time of the incident. The new interventions indicated to toilet the resident, evaluate continence, bed in lowest position, and gripper socks. The Progress Notes attached to the Event Report included, but were not limited to: 11/7/17 at 10:45 P.M.: This nurse had just looked into residents room to assure he was in bed. Came out of report and personal alarm was sounding in residents room. When I approached room staff had already got to resident. He was sitting beside bed. He said he was trying to use the bathroom On inspection residents call light was not in reach. Staff educated on assuring call lights are within reach and residents are toileted properly before assisting to bed. Gripper sock were also applied et (and) to be wore (sic) while abed (sic). FALL 4 An Event Report, dated 11/16/17, indicated Resident 36 had a fall on that date (11/16/17). The Event Report indicated Resident 36 was leaning forward. The safety equipment in place was alarms and dycem and was functioning at the time of the incident. The new intervention indicated therapy to evaluate for positioning. The Progress Notes attached to the Event Report included, but were not limited to: 11/16/17 at 10:47 A.M.: This nurse was walking down the hall, this nurse heard an alarm sounding. This nurse was at the beginning of the 200 Hall, immediately wen to room [ROOM NUMBER] where the sound was coming from and found this resident on the floor. Resident was upset with himself 11/17/18 at 11:27 A.M.: IDT (Interdisciplinary Team) reviewed fall event from 11/16/17. Found resident sitting on floor after leaning forward in w/c (wheelchair) and sliding out to the floor . Fall 5 An Event Report, dated 11/28/17, indicated Resident 36 had a fall on that date (11/28/17). The Event Report indicated Resident 36 thought there was trash on the floor. The safety equipment in place was an alarm and dycem and were functioning at the time of the incident. The Fall Risk Re-Assessment, indicated Resident 36 had a cognitive or memory impairment that effects safety and judgment. The new intervention indicated front anti tippers were to be placed on the wheelchair. The Progress Notes, attached to to the Event Report included, but were not limited to: 11/28/17 at 1:38 P.M.: Resident was leaning forward in his wheelchair. Resident stated he thought he seen trash in the floor and was trying to pick it up. Resident leaned forward, tucked his feet under his wheelchair, resident hit his head on the dresser and the wheelchair landed on top of this resident . New order to have front anti-tippers Fall 6 An Event Report, dated 12/10/17, indicated Resident 36 had a fall on that date (12/10/17). The Event Report indicated Resident 36 was reaching for an object. The safety equipment in place was anti tippers to front and back of wheelchair and chair adjustments which were functioning at the time of the incident. The Fall Risk Re-Assessment indicated the resident has a cognitive or memory impairment that effects safety and judgment. The Progress Notes attached to the Event Report included, but were not limited to: 12/10/17 at 10:45 A.M.: Resident was toileted at 1030 (sic) by CRCA (CNA). Prior to CRCA leaving resident room. (sic) CRCA clipped call light to his bed, in reach. CRCA asked 'Is there anything else I can do for you?' This resident stated, 'No.' CRCA stated, 'Use your call light if you want or need anything.' Resident then nodded his head down then up Resident then go into his closet, got out his cotton hat and tossed it towards his recliner. Walker was placed in front of the recliner because this resident had been using the other side of the room. Resident forgot his walker was placed there before tossing his hat. Resident stated, 'I thought that I could just stand up and reach over and get it without bothering someone over this silly matter.' .Resident educated to utilize call light for any want or need . Fall 7 An Event Report, dated 1/3/18, indicated Resident 36 had a fall on that date (1/3/18). The Event Report indicated the resident had been sitting in the wheelchair and frequently used objects were out of reach. The Event Report further indicated no safety equipment was ordered at the time of the incident. The new intervention was to keep the walker in the clean utility room when not in use. The Progress Notes attached to the Event Report, included, but was not limited to: 1/3/18 at 12:13 P.M.: Resident scooted forward in w/c to try to move walker out from in front of recliner so he could straighten up blankets in recliner and slid out of w/c . Walker to be kept in clean utility room when not in use Fall 8 An Event Report, dated 1/26/18, indicated Resident 36 had a fall on that date (1/26/18). The Event Report indicated the resident was turning and repositioning in bed and rolled out. The safety equipment in place was the bed in the lowest position and was functioning at the time of the incident. The new intervention was a perimeter mattress. The Progress Notes attached to the Event Report included, but was not limited to: 1/26/17 at 4:45 A.M.: CRCA alerted this nurse of resident being on the floor trying to climb back into bed. Resident reported he was trying to turn in bed and rolled out onto the floor Fall 9 An Event Report, dated 1/27/17, indicated Resident 36 had a fall on that date (1/27/18). The Event Report indicated the resident was attempting to use the restroom without assistance. The Event Report further indicated no safety equipment was ordered at the time of the incident. The new intervention indicated to assist the resident back from lunch and toilet. The Progress Notes attached to the Event Report included, but was not limited to: 1/27/17 at 2:17 P.M.: Resident noted lying on floor in bathroom . Resident stated he was going to the bathroom. This nurse reminded resident to utilize call light for assistance to the restroom . N.O. (new order) Resident to be assisted back to room from lunch et. (and) toileted . b. The clinical record for Resident 95 was reviewed on 1/29/18 at 9:30 A.M. A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/10/2018 09:26 P.M .Location of Fall .Resident Bathroom .Attempting to transfer without w/c (wheelchair) with staff .W/C - Wheels not locked . A progress note dated 1/10/18 at 9:33 P.M., read as follows: .CRCA came to nurse stating resident had fallen. Resident in restroom on floor in front of toilet holding on to grab bar . CRCA states she was attempting to transfer resident from toilet to w/c et (and) w/c wheels had not been locked et slipped out from under resident causing her to slide to the floor. Staff educated at this time on ensuring w/c brakes are on during resident transfers . c. Clinical record of Resident 14 was reviewed on (MONTH) 29, (YEAR) at 9:30 A.M., the record contained the following information: Fall 1 The clinical record for Resident 14 was reviewed on 1/29/18 at 9:30 A.M. A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 11/4/2017 09:34 P.M .Location of Fall .Resident Room .Transferring self .Resident weak, needs assistance with transfers .Witnessed .No .Alarm not clipped to back . A progress note dated 11/4/17 at 9:33 P.M., read as follows: .This nurse was approached by CRCA at approximately 2130 (9:30 P.M.) stating resident was on knees in room. Res (resident) fell to knees when trying to transfer self to bed without help. Clip alarm not clipped to resident at this time. Res reminded to call for help and staff reminded to check alarm placements . Fall 2 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 12/21/2017 03:21 A.M .Location of Fall .Resident Room .Transferring self .couldn't find call light .Witnessed .No . A progress note dated 12/21/17 at 3:26 A.M., read as follows: .Found resident kneeling on floor next to bed. Resident states she couldn't find call light and tried to take self to bathroom .Resident assist up and to restroom . Call light clipped to clothing within resident reach . d. The Clinical record of Resident 14 was reviewed on (MONTH) 29, (YEAR) at 1: 58 P.M., the following was contained in the record: Fall 1 The clinical record for Resident 4 was reviewed on 1/30/18 at 2:30 P.M. A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 10/28/2017 12:50 P.M .Location of Fall .Resident Bathroom .Transferring self .Alarms not sounding .Witnessed .No . A progress note dated 10/28/17 at 1:05 P.M., read as follows: .This nurse was standing at med cart et (and) heard resident yell from residents restroom. this nurse responded to yell et found resident sitting in the middle of her restroom floor on her bottom .CRCAs assisted resident back to her W/C et toileted resident .Intervention for resident to be toileted before and after meals. All alarms in place et fx (functioning) . Fall 2 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/12/2018 3:23 A.M .Location of Fall .Resident Room .Reaching for object .Witnessed .No . A progress note dated 1/12/18 at 3:34 A.M., read as follows: .resident in room hollering for daughter found sitting in floor by w/c states slid out of w/c states im not hurt .resident to br (bathroom) then to bed . Fall 3 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/15/2018 10:19 A.M .Location of Fall .Resident Room .Reaching for object .Witnessed .No . A progress note dated 1/15/18 at 10:24 A.M., read as follows: .Hospice nurse here to visit resident and heard resident yelling in room. This nurse and hospice nurse went into residents room resident was found kneeling in room at foot of bed . This nurse found seat belt alarm to not be functioning battery is bad this nurse replaced battery and alarm is functioning at this time . Battery in alarm to be changed monthly . Fall 4 A Safety Event --Trilogy -Fall Event form read as follows: .Event Date: 01/25/2018 1:30 P.M .Location of Fall .Resident Room .Ambulation .Witnessed .Yes . A progress note dated 1/25/18 at 1:00 P.M., read as follows: .Alarm sounding when CRCA entered resident room and noted resident up and walking in room unassisted. Resident lost balance and fell to floor. CRCA attempted to get to resident but couldn't reach resident in time . During an interview on 2/1/18 at 8:45 A.M., the DON indicated there was not a specific staffing policy, but it was the facility policy to staff based on resident needs. 3.1-17(b)

Based on observation, interview, and record review, the facility failed to ensure food was served at an appetizing temperature for 4 of 8 residents reviewed for food temperatures. (Resident 95, Resident 25, Resident 15, Resident 18) Findings include: During an interview on 1/25/18 at 10:53 A.M., Resident 15 indicated he ate in the dining room. Resident 15 said, Everything is cold that is supposed to be hot. During an interview on 1/25/18 at 10:53 A.M., Resident 25's Family Member FM (1) indicated Resident 25 ate most of his meals in the dining room. FM 1 indicated sometimes she came in and assisted Resident 25 with his meals and Resident 25's food would be cold. During an interview on 1/25/18 at 2:19 P.M., Resident 95 indicated the food would be cold sometimes. Resident 95 further indicated food was especially cold during breakfast. During an interview on 1/30/18 at 8:55 A.M., Resident 95 indicated the eggs were overcooked this morning. The Resident Council minutes were provided by the Activities Director on 1/31/18 at 9:50 A.M., and the notes read as follows: .Resident 15 voiced that his food is sometimes served cold . 10/26/17 . Resident 18 .voiced his concern for the food not always served warm enough to his liking . 6/26/17 . Resident 100 .voiced concern of the Brunch Meal being cold, esp (especially) the potatoes (sic) .5/22/27 . During an observation on 1/30/18 at 11:30 A.M., the Dietary Manager (DM) took temperatures of the foods on the salad bar with a thermometer, but did not document the temperatures in a temperature log. During an interview with the DM at that time, she indicated that she documented temperatures in another log. The DM asked the Regional Dining Manager (RDM) if she had the log for the salad bar and the RDM indicated that she did not. The DM then asked the RDM if she should be recording the temperatures of the salad bar daily. The Regional Dining Manager confirmed to the DM that she should be documenting the temperatures of the salad bar daily. The DM said, Oh, I didn't know I was supposed to do that. I'll start right away. During an interview with the Dietary Assistant 1 (DA 1) on 1/30/18 at 11:35 A.M., DA 1 indicated that she would be serving food from the steam table in the dining room at lunch that day. DA 1 indicated she would take the temperatures of the food right before she started serving. When asked whether she documented food temperatures in a daily log, DA 1 indicated she did not document the temperature of the food in a daily log. DA 1 said, I don't document it anywhere. I just temp it. On 1/30/17 at 12:08 P.M., DA 1 was observed taking the temperatures of the Salisbury steaks that were located on the steam table in the dining room. DA 1 placed a thermometer into a Salisbury steak located on the right side of the pan which was lined with steaks on left and right sides. DA 1 indicated the temperature of the steak located on the right side was 129.8 F. DA 1 then moved the thermometer to the steaks on the left side of the pan and checked the temperature. The thermometer read 150.0 F degrees according to the Assistant Dietary Manager. The DA 1 proceeded to prepare plates to serve residents. At that time, the ADM was questioned whether it was appropriate to serve steaks that were tested at 129.8 F degrees. The ADM responded by saying, I think it would be OK. The ADM then asked, Should I have taken it back and warmed it? After 2 plates of food had been plated and served, the ADM asked DA 1 to remove the steak that had tested low. DA 1 removed one Salisbury steak from the left side of the pan (which had tested at 150 F degrees), placed it on a plate and handed it to the ADM. During an interview with the Dietary Manager (DM) on 1/30/17 at 12:15 P.M., the DM indicated the temperature of the food on the steam table should be 135 degrees. During an interview on 1/31/18 at 10:00 A.M., the Regional Dining Manager indicated it was ridiculous to think that different pieces of meat in the same pan could vary that much in temperature. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure meals were served, prepared and distributed in accordance with professional standards for food service safety. Temperatures for food on a steam table and salad bar were not documented in a log for 1 of 2 observations of the kitchen and the facility failed to ensure sanitary preparation and distribution of food. A hairnet was not worn, food was placed against an apron, and food was touched with a contaminated glove in 1 of 2 dining rooms observed. An ice scoop was placed on a contaminated surface on 1 of 1 hall carts observed. Findings include: 1. During an observation on 1/30/18 at 11:30 A.M., the Dietary Manager (DM) took temperatures of the foods on the salad bar with a thermometer, but did not document the temperatures in a temperature log. During an interview with the DM at that time, she indicated that she documented temperatures in another log. The DM asked the Regional Dining Manager (RDM) if she had the log for the salad bar and the RDM indicated that she did not. The DM then asked the RDM if she should be recording the temperatures of the salad bar daily. The Regional Dining Manager confirmed to the DM that she should be documenting the temperatures of the salad bar daily. The DM said, Oh, I didn't know I was supposed to do that. I'll start right away. During an interview with the Dietary Assistant 1 (DA 1) on 1/30/18 at 11:35 A.M., DA 1 indicated that she would be serving food from the steam table in the dining room at lunch that day. DA 1 indicated she would take the temperatures of the food right before she started serving. When asked whether she documented food temperatures in a daily log, DA 1 indicated she did not document the temperature of the food in a daily log. DA 1 said, I don't document it anywhere. I just temp it. On 1/30/18 at 12:01 P.M., DA 1 was observed preparing to check the temperatures of the food on the steam table which was located in the dining room. DA 1 took an unsheathed thermometer from the pocket of her white coat and, before sanitizing the thermometer, placed it inside the baked apples. During an interview with the DM at that time, the DM said, name (DA 1's) pocket is clean, but it probably needed to be sanitized first. On 1/30/17 at 12:08 P.M., DA 1 was observed taking the temeratures of the Salisbury steaks that were located on the steam table in the dining room. DA 1 placed a thermometer into a Salisbury steak located on the right side of the pan which was lined with steaks on left and right sides. DA 1 indicated the temperature of the steak located on the right side was 129.8 F. DA 1 then moved the thermometer to the steaks on the left side of the pan and checked the temperature. The thermometer read 150.0 F degrees according to the Assistant Dietary Manager. The DA 1 proceeded to prepare plates to serve residents. At that time, the ADM was questioned whether it was appropriate to serve steaks that were tested at 129.8 F degrees. The ADM responded by saying, I think it would be OK. The ADM then asked, Should I have taken it back and warmed it? After 2 plates of food had been plated and served, the ADM asked DA 1 to remove the steak that had tested low. DA 1 removed one Salisbury steak from the left side of the pan (which had tested at 150 F degrees), placed it on a plate and handed it to the ADM. During an interview with the DM on 1/30/17 at 12:15 P.M., the DM indicated the temperature of the food on the steam table should be 135 degrees. During an interview on 1/31/18 at 10:00 A.M., the Regional Dining Manager indicated it was ridiculous to think that different pieces of meat in the same pan could be vary that much in temperature. The policy and procedure for Food Temp-Serving Line was provided by the Regional Dietary Manager on 1/30/17 at 1:35 P.M., and it read as follows: .The temperatures of all foods on the service line will be measured and recorded at every meal .1. Hot foods in the steam table are maintained at greater than 135 degrees F (Fahrenheit) Temperatures are taken prior to service . 2. On 1/25/18 at 12:10 P.M., Volunteer 1 was observed in the main dining room plating food behind the steam table without a hairnet on. 3. On 1/25/18 at 12:16 P.M., Volunteer 1 was observed to take a clear wrap off of a plate of vegetables while pressing the plate against apron, touching the food against the apron. 4. On 1/25/18 at 12:18 P.M., Volunteer 1 was observed to handle a stack of meal cards, put right hand flat on a serving tray, touched apron, then grabbed a plate with thumb on the inside of the plate touching the food on the plate. Volunteer 1 was wearing gloves. 5. On 1/25/18 at 12:37 P.M., Cook 1 was observed to prepare drinks from a meal cart in the 300 Hall. Cook 1 took the ice scoop from a container, scooped ice into a cup, and placed the scoop onto a piece of paper on the cart. Cook 1 took the ice scoop from the paper, scooped ice into a cup, and placed the scoop on a debris-covered mat on the cart. Cook 1 took the ice scoop from the mat and placed it in the ice scoop container, then used the ice scoop to fill a cup with ice. All cups filled with ice were taken to residents in the 300 Hall. During an interview on 1/25/18 at 12:42 P.M., Cook 1 indicated the ice scoop should be put in the container specified for the scoop and not placed on a mat or any other surface. During an interview on 2/1/18 at 11:35 A.M., while discussing the 1/25/18 dining service, the DM (Dietary Manager) indicated I don't believe you. I told the kitchen staff on that day that State was here and they needed to wear their hairnets. On 1/31/18 at 10:44 A.M., a Hair Restraint policy was provided. The policy indicated All Dining Service employees will be required will be required to wear hair restraints as required by the 209 Federal Food Code . On 1/31/18 at 11:01 A.M., a Food Production Guidelines-Sanitation and Safety policy was provided. The policy indicated .Suitable utensils, such as forks, knives, tongs, or scoops shall be provided to minimize handling of food . Plates, silverware, glasses, etc. are handled so hands do not touch the areas where the food or mouth will be placed . During an interview on 2/1/18 at 7:40 A.M., the DON (Director of Nursing) indicated the facility's policy is to keep the ice scoop in a separate container and not to lay on any other surface. 3.1-20(a) 3.1-21(a)(2) 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to accommodate a resident's preference for side rails on the bed for 1 of 4 residents reviewed for side rails. (Resident 25) Findings include: 1. During an interview on 1/26/18 at 9:27 A.M., Family Member (FM 1) indicated the facility staff informed her Resident 25's bed rails had to be removed due to the Indiana State Department of Health's rule that residents could no longer have side rails on their bed if the resident could not move to use them on their own. FM 1 indicated she would have preferred Resident 25 have side rails. FM 1 indicated Resident 25 would grab the side rail if instructed to do so. FM 1 indicated the CNA's would assist him to turn and reposition and he would assist with turning. The clinical record of Resident 25 was reviewed on 1/29/18 at 9:50 A.M. The record indicated the [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 25 experienced severe cognitive impairment. The assessment further indicated Resident 25 required the extensive assistance of two staff for bed mobility and transfers. A Care Plan for ADL's (activities of daily living) dated 9/12/17 included the following intervention: .Encourage resident to do as much as safely possible for self . During an interview on 1/29/18 at 1:27 P.M., the Director of Nursing (DON) indicated all residents who were residing in the facility had a side rail evaluation form completed. The DON indicated that, whenever a resident did not meet the criteria for side rails, the side rails were subsequently removed from their bed. The DON further indicated that, if a family member wanted a resident to have side rails, the family member had the option to sign a self-determination of care form and the rails would subsequently be replaced on the bed. During an interview on 1/29/18 at 2:19 P.M., the DON indicated Resident 25's side bed rail evaluation was missed and was not completed, but should have had the evaluation completed to determine whether he was eligible for side rails on his bed. The DON indicated she had spoken to Resident 25's family member and that a side rail had been placed on Resident 25's bed. A policy for Guidelines for the Use of Bed Rails was provided by the DON on 1/29/18 at 1:19 P.M., and it read as follows: .the resident is assessed to the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident's representative . 3.1-3(v)(1)

Based on interview and record review, the facility failed to notify the physician and family of a resident's condition change, resulting in the resident being transferred to the hospital and hospitalized , for 1 of 3 residents reviewed for notification, in a sample of 3. Resident C Findings include: The closed clinical record of Resident C was reviewed on 8/31/16 at 11:00 A.M. [DIAGNOSES REDACTED]. An admission assessment, dated 8/4/16 at 5:32 P.M., indicated Resident C required a 2 person staff assistance with transfer, was alert and oriented x 3, speech was clear, responded to commands, and had full weight bearing. Nurses Notes included the following notations: 8/5/16 at 5:47 A.M.: Resident was given PRN (as needed) pain meds for pain to LLE (left lower extremity). Medication was effective. Resident very cooperative and in pleasant mood. Staff assisted resident into wheelchair to go to appointment .Resident is sitting at nurses station conversing with other residents. A Social Services Progress Note, dated 8/5/16 at 3:20 P.M., indicated, .Resident is alert with some confusion and forgetfulness .Will continue to observe. Nurses Notes continued: 8/8/16 at 5:45 A.M.: Rsd (resident) restless this noc (night). PRN pain medication given .effective for the pain. Rsd rang call light multiple times this noc and was not sure what he rang for. This nurse stayed and spoke with Rsd just general conversation. Snack offered and eaten, water offered throughout the noc, urinal used a few times 8/13/16 at 8:30 A.M.: Resident resting in bed quietly with eyes closed at this time. This nurse asked resident if he was having any pain. Resident responded, 'No, not right now.' This nurse asked resident if he would like to get out of bed et (and) go to breakfast. Resident stated 'No, I don't feel too good. I'll get up tomorrow.' Resident repositioned for comfort, et encouraged to get up for meals. Will continue to monitor. 8/14/16 at 10:24 A.M.: Resident resting quietly in bed at this time. Resident replies 'No' when asked if he is in pain Resident refusing to get out of bed et eats meals in room. Will continue to monitor. 8/14/16 at 1:11 P.M.: Resident refusing to leave brief or blankets on. When asked if he is uncomfortable, resident does not respond. Resident requiring total dependance (sic) with all ADL (activities of daily living) tasks including use of urinal, eating, et drinking. Resident denies pain at this time .Will continue to monitor. Documentation of further assessment of the resident, including a neurological assessment and vital signs, was not found after 8/14/16 at 1:11 P.M. until 8/15/16 at 12:27 P.M. Nurses Notes continued: 8/15/16 at 12:27 P.M.: N.O. (new order) to send resident to (name of hospital) for eval (evaluation) and treat. 1220 (12:20 P.M.) EMS (emergency medical services) was called. An Ambulance Service note, dated 8/15/16 at 12:35 P.M., indicated, .Upon arrival the pt (patient) was found was alert but would only respond with moan (sic) and groans. The nurse in the room stated that last night the nurse who was taking care reported that he was only moaning and groaning for them and they could not get a response out of him either. The current nurse that we were speaking too (sic) stated that the last time she seen him was this past Friday and his mental status was normal then. The Pt. was alert but would only respond with moans and groans .The Pt. could not open his eyes upon command. I then opened them and found that the pt's right pupil was constricted .and the pt's left pupil was dilated Emergency Department (ED) Nurse Documentation, dated 8/15/16 at 1:05 P.M., indicated, History, Arrived by EMS. Historian: EMS and nursing home nurse. This started yesterday. (Patient was known to be in state of altered mental status since yesterday. EMS was called from (name of facility) after brother of patient requested transportation to hospital for evaluation of condition, 'because his brother is not normally like this.' Patient arrives to ER, moaning with head turned to the left. Pupils are different in appearance and size .Patient will open his eyes in response to voice, does not give appropriate answers but only moans .After pt arrived, called (name of facility) for a report, Spoke with (LPN # 1) , she stated he was acting differently and could barely answer yes or no questions and was moaning continuously, was unsure what was wrong, but they got him into a wheelchair and took him to breakfast, then because he would not eat put him back to bed.' Pt brother states 'I called the dr office and told them that he needed to be seen, and he had them call the ambulance.' Upon arrival pt is moaning will answer no at times. Pt mouth and eyes are matted shut ED Physician Documentation, dated 8/15/16 at 1:21 P.M., indicated, Chief Complaint: Decreased Mental Status. The patient was found unresponsive. This started yesterday and is still present .Appearance: Lethargic. Patient in severe distress .Disoriented to place and time. Eyes open to pain .Clinical Impression, Acute mental status change with lethargy and confusion A hospital History and Physical, dated 8/15/16 at 5:59 P.M., indicated, .Patient is poorly responsive .history of, for the past 2 days, having mental status changes where previously he spoke to this brother on the phone at least once a day, sometimes twice a day, was able to interact and have conversation. The last 2 days, the brother has been unable to get him on the phone at the nursing home. The brother went to the nursing home today to check on him, found that the patient could not speak, had some drooping on the right side of his face. They became concerned and then brought him into the emergency room at that time .Patient opens his eyes. Patient moans with any movement. Patient is unable to answer questions at this time A hospital Discharge Summary, dated 8/22/16, indicated, Discharge Diagnoses: [REDACTED]. 2. Septic emboli (blood clots) and acute embolic stroke .3. (MRSA) [MEDICAL CONDITION], secondary to bilateral extremity [MEDICAL CONDITION] and deep wounds. 4. Bilateral extremity [MEDICAL CONDITION] and venous stasis changes .Brain MRI showed septic emboli in multiple areas of brain . A facility Nurses Note indicated, Recorded as Late Entry on 08/16/2016 02:01 PM) Around lunch on Monday, 8/15/16, resident's brother (name) came to see resident. He tried to talk to resident, but resident did not respond much to brother. Brother asked nurse about resident and nurse stated that resident seemed to be like this most of the day and when asked about pain or discomfort, resident denied any. Brother mentioned that he may contact (name of physician) and see what he thought. Nurse took resident down to restorative to feed him lunch. He took a few bites and then started to pocket and spit out the food During lunch, nurse was called out of dining room for a phone call from (name of physician's) office .Nurse told (name of physician) office that resident was just moaning but said that he didn't need anything and wasn't in any pain. (Name of physician) office said that maybe it would be a good idea to send him to the ER for Eval and Treat. Nurse got paperwork together and called EMS for transport. EMS arrived and transported resident to (hospital) to eval and treat. On 9/1/16 at 9:45 A.M., during an interview with LPN # 2, she indicated she worked on the resident's hall on 8/13/16 and 8/14/16. She indicated she could not really remember details regarding Resident C, and then reviewed her notes. She indicated the resident denied pain when she asked him. She indicated the resident did not want to get out of bed, but that was not unusual for him. She indicated the resident was not really unresponsive, but just didn't want to talk. She indicated she never thought to call the physician; she felt like the resident was just giving up. On 9/1/16 at 10:05 A.M., LPN # 1 was interviewed. LPN # 1 indicated she was working on 8/15/16. She indicated Resident C kept moaning, like he didn't feel well. She indicated he sounded like he was hurting, but that he denied pain. She indicated he did not want to get up, but the staff got him up for lunch. She indicated the resident's brother came to visit, and indicated, Maybe I'll call the doctor. LPN # 1 indicated she told the brother to let her know what the doctor said. She indicated the resident started pocketing food, and wasn't acting right. She indicated the physician's office called her back, and she informed them that the resident kept moaning, but denied everything, and his vital signs were good. She indicated the office nurse told her to send him to the emergency room . She indicated she could not remember if the night nurse told her that the resident had not been acting right, nor could remember if she told the ambulance driver or the hospital that the resident had not been acting right for a couple of days. On 9/1/16 at 11:30 A.M., during an interview with the Administrator and the Director of Nursing (DON), the DON indicated the resident frequently moaned out. She indicated she saw the resident the morning of 8/15/16, and did not feel that there was a condition change. The Administrator and DON indicated the resident did require total care at times, so that was not a condition change either. The DON indicated she did not know why the ambulance and hospital reports indicated LPN # 1 informed them that the resident had been like that for the day previous. The Administrator indicated perhaps LPN # 1 did not know the resident very well. On 9/1/16 at 3:45 P.M., RN # 1 was interviewed. RN # 1 indicated he was helping out on Sunday 8/14/16 until approximately 8:00 P.M. RN # 1 indicated he had not worked much with Resident C. He indicated when he came in, Resident C was asleep, and did not appear in any distress. He indicated he did start moaning at approximately 7:30 P.M., and so he gave him a pain pill. He indicated the resident did not get up for supper. He indicated he thought the resident did respond to him, but just acted more tired than usual. On 9/1/16 at 12:35 P.M., the DON provided the current facility policy on Guidelines for Change in Resident Condition, undated. The policy included: Policy, To identify resident changes in condition. The clinical team is committed to the resident's assessment and care planning eschar (sic) to address changes in needs of each resident served .Notification of the resident physician and responsible party will be documented in EHR (electronic health record) reflecting date and time of notification. This Federal tag relates to Complaint IN 041. 3.1-5(a)(2)

Based on interview and record review, the facility failed to completely assess a resident with a mental status change, and failed to recognize and document areas of skin impairment, resulting in the hospitalization for [MEDICAL CONDITION] a wound infection which spread to the heart, for 1 of 3 residents reviewed with skin impairments and assessments, in a finding of 3. Resident C Findings include: The closed clinical record of Resident C was reviewed on 8/31/16 at 11:00 A.M. [DIAGNOSES REDACTED]. An admission assessment, dated 8/4/16 at 5:32 P.M., indicated Resident C required a 2 person staff assistance with transfer, was alert and oriented x 3, speech was clear, responded to commands, and had full weight bearing. Nurses Notes included the following notations: 8/5/16 at 5:47 A.M.: Resident was given PRN (as needed) pain meds for pain to LLE (left lower extremity). Medication was effective. Resident very cooperative and in pleasant mood. Staff assisted resident into wheelchair to go to appointment .Resident is sitting at nurses station conversing with other residents. A Social Services Progress Note, dated 8/5/16 at 3:20 P.M., indicated, .Resident is alert with some confusion and forgetfulness .Will continue to observe. Nurses Notes continued: 8/8/16 at 5:45 A.M.: Rsd (resident) restless this noc (night). PRN pain medication given .effective for the pain. Rsd rang call light multiple times this noc and was not sure what he rang for. This nurse stayed and spoke with Rsd just general conversation. Snack offered and eaten, water offered throughout the noc, urinal used a few times A Skin Integrity Event, dated 8/10/16 at 1:29 P.M., indicated: Stasis to Left Inner Foot. Stasis wound present on admission? Yes .Length: 3.5 (centimeters) Width: 1.6, Depth: <0.1, Partial thickness, Granulation Tissue - beefy deep red and irregular surface .No Exudate (drainage) .No pain .Treatment Orders: [MEDICATION NAME] AG every 3 days and PRN (as needed) soiling. A Skin Integrity Event, dated 8/10/16 at 3:33 P.M., indicated: Deep Tissue Injury to Right Great Toe Tip. Length: 1.5, Width: 1.0, Depth: <0.1, Present on Admission? No, Unable to Stage, Eschar - firm dry desiccated (no moisture) black to brown appearance .Skin Prep as Ordered. A Skin Integrity Event, dated 8/11/16 at 1:58 P.M., indicated: Unstageable Left Heel. Length: 2.5 (centimeters) Width: 3.0, Depth: <0.1, Present on admission? Yes. Unable to stage - Unable to visualize wound bed, suspected deep tissue injury. [MEDICATION NAME] tissue - new skin growing in superficial wound deep pink, pearly pink, Granulation Tissue - beefy deep red and irregular surface. Eschar No Exudate .No pain .Treatment Orders: Skin Prep and Apply [MEDICATION NAME] every 3 days and PRN. Nurses Notes continued: 8/13/16 at 8:30 A.M.: Resident resting in bed quietly with eyes closed at this time. This nurse asked resident if he was having any pain. Resident responded, 'No, not right now.' This nurse asked resident if he would like to get out of bed et (and) go to breakfast. Resident stated 'No, I don't feel too good. I'll get up tomorrow.' Resident repositioned for comfort, et encouraged to get up for meals. Will continue to monitor. 8/14/16 at 10:24 A.M.: Resident resting quietly in bed at this time. Resident replies 'No' when asked if he is in pain Resident refusing to get out of bed et eats meals in room. Will continue to monitor. 8/14/16 at 1:11 P.M.: Resident refusing to leave brief or blankets on. When asked if he is uncomfortable, resident does not respond. Resident requiring total dependance (sic) with all ADL (activities of daily living) tasks including use of urinal, eating, et drinking. Resident denies pain at this time .Will continue to monitor. Documentation of further assessment of the resident, including a neurological assessment and vital signs, was not found after 8/14/16 at 1:11 P.M. until 8/15/16 at 12:27 P.M. Nurses Notes continued: 8/15/16 at 12:27 P.M.: N.O. (new order) to send resident to (name of hospital) for eval (evaluation) and treat. 1220 (12:20 P.M.) EMS (emergency medical services) was called. An Ambulance Service note, dated 8/15/16 at 12:35 P.M., indicated, .Upon arrival the pt (patient) was found was alert but would only respond with moan (sic) and groans. The nurse in the room stated that last night the nurse who was taking care reported that he was only moaning and groaning for them and they could not get a response out of him either. The current nurse that we were speaking too (sic) stated that the last time she seen him was this past Friday and his mental status was normal then. The Pt. was alert but would only respond with moans and groans .The Pt. could not open his eyes upon command. I then opened them and found that the pt's right pupil was constricted .and the pt's left pupil was dilated Emergency Department (ED) Nurse Documentation, dated 8/15/16 at 1:05 P.M., indicated, History, Arrived by EMS. Historian: EMS and nursing home nurse. This started yesterday. (Patient was known to be in state of altered mental status since yesterday. EMS was called from (name of facility) after brother of patient requested transportation to hospital for evaluation of condition, 'because his brother is not normally like this.' Patient arrives to ER, moaning with head turned to the left. Pupils are different in appearance and size. T-shirt that patient is wearing is spotted with emesis. Patient will open his eyes in response to voice, does not give appropriate answers but only moans. Multiple decubitus are found on bilateral feet in various sizes. Lower extremities are dark in colour (sic) and dry After pt arrived, called (name of facility) for a report, Spoke with (LPN # 1) , she stated he was acting differently and could barely answer yes or no questions and was moaning continuously, was unsure what was wrong, but they got him into a wheelchair and took him to breakfast, then because he would not eat put him back to bed.' Pt brother states 'I called the dr office and told them that he needed to be seen, and he had them call the ambulance.' Upon arrival pt is moaning will answer no at times. Pt mouth and eyes are matted shut. Pt noted to have 3 decub (decubitus ulcers) on the rt (right) foot and 2 on the left foot .Oral care provided, scrambled eggs and green leafy roughage removed from mouth, pt had copious amounts secretions, lips were crusted over. Pt face washed and the crusts removed from bilateral eyes . ED Physician Documentation, dated 8/15/16 at 1:21 P.M., indicated, Chief Complaint: Decreased Mental Status. The patient was found unresponsive. This started yesterday and is still present .Appearance: Lethargic. Patient in severe distress .lower extremity [MEDICAL CONDITION] with multiple decubitus ulcers .Disoriented to place and time. Eyes open to pain .Clinical Impression, Acute mental status change with lethargy and confusion A hospital History and Physical, dated 8/15/16 at 5:59 P.M., indicated, .Patient is poorly responsive .history of, for the past 2 days, having mental status changes where previously he spoke to this brother on the phone at least once a day, sometimes twice a day, was able to interact and have conversation. The last 2 days, the brother has been unable to get him on the phone at the nursing home. The brother went to the nursing home today to check on him, found that the patient could not speak, had some drooping on the right side of his face. They became concerned and then brought him into the emergency room at that time .Patient opens his eyes. Patient moans with any movement. Patient is unable to answer questions at this time .He has noticeable swelling of the left lower extremity .does seem to have tenderness with palpation of the leg .He has some open pressure ulcer-type areas and arterial ulcerations of his lower extremities We will obtain wound cultures. We will also get a wound consult A hospital Skin Care Assessment, dated 8/16/16, included the following: 1. Upper Right Coccyx Pressure Ulcer, Stage 1, 2. Right Lower Coccyx Pressure Ulcer, Stage 1, 3. Right Heel Pressure Ulcer, Suspected Deep Tissue Injury, Length 2.5 cm, Width 2.2 cm. 4. Right great toe, Suspected deep tissue injury, Length 1.0, Width 1.0. 5. Lower Middle Back Pressure Ulcer, Unstageable, Drainage amount Scant, Drainage Amount Serosanguineous, General Appearance Red, Black (Eschar), Brown (Eschar), Draining, Length 0.9 cm, Width, 1.0 cm, Depth Obscure .SDTI (suspected deep tissue injury) .opening as measured above surrounding purple/red SDTI measures total 2.8 cm x 1.6 cm. 6. Left Upper Lateral Calf Suspected Venous/Arterial, Red/Purple Intact, Length 4.5 cm, Width 2.5 cm. 7. Left middle back pressure ulcer, Stage 1. 8. Left medial foot suspected venous/arterial Wound, Drainage amount scant, Drainage Description Serosanguineous, Red, White Slough, Black (Eschar), Length, 2.5 cm, Width 2.9 cm, 10% Red, 10% Yellow, 80% Black. 9. Left Lower Calf Suspected Venous/Arterial, Red/Purple Intact, Length 1.0 cm, Width 2.6 cm. 9. Left Lower Back Pressure Ulcer, Stage 1. 10. Left lateral foot Suspected Venous/Arterial, Fluid Filled Blister, Length 1.1 cm, Width 0.5 cm. 11. Left heel Pressure Ulcer, Unstageable, Black, Length 1.6 cm, Width 1.2 cm, 100% Black. 12. Left great toe, Skin split between toes. A hospital Discharge Summary, dated 8/22/16, indicated, Discharge Diagnoses: [REDACTED]. 2. Septic emboli (blood clots) and acute embolic stroke .3. (MRSA) [MEDICAL CONDITION], secondary to bilateral extremity [MEDICAL CONDITION] and deep wounds. 4. Bilateral extremity [MEDICAL CONDITION] and venous stasis changes .Brain MRI showed septic emboli in multiple areas of brain . A facility Nurses Note indicated, Recorded as Late Entry on 08/16/2016 02:01 PM) Around lunch on Monday, 8/15/16, resident's brother (name) came to see resident. He tried to talk to resident, but resident did not respond much to brother. Brother asked nurse about resident and nurse stated that resident seemed to be like this most of the day and when asked about pain or discomfort, resident denied any. Brother mentioned that he may contact (name of physician) and see what he thought. Nurse took resident down to restorative to feed him lunch. He took a few bites and then started to pocket and spit out the food During lunch, nurse was called out of dining room for a phone call from (name of physician's) office .Nurse told (name of physician) office that resident was just moaning but said that he didn't need anything and wasn't in any pain. (Name of physician) office said that maybe it would be a good idea to send him to the ER for Eval and Treat. Nurse got paperwork together and called EMS for transport. EMS arrived and transported resident to (hospital) to eval and treat. On 9/1/16 at 9:45 A.M., during an interview with LPN # 2, she indicated she worked on the resident's hall on 8/13/16 and 8/14/16. She indicated she could not really remember details regarding Resident C, and then reviewed her notes. She indicated the resident denied pain when she asked him. She indicated the resident did not want to get out of bed, but that was not unusual for him. She indicated the resident was not really unresponsive, but just didn't want to talk. She indicated she never thought to call the physician; she felt like the resident was just giving up. On 9/1/16 at 10:05 A.M., LPN # 1 was interviewed. LPN # 1 indicated she was working on 8/15/16. She indicated Resident C kept moaning, like he didn't feel well. She indicated he sounded like he was hurting, but that he denied pain. She indicated he did not want to get up, but the staff got him up for lunch. She indicated the resident's brother came to visit, and indicated, Maybe I'll call the doctor. LPN # 1 indicated she told the brother to let her know what the doctor said. She indicated the resident started pocketing food, and wasn't acting right. She indicated the physician's office called her back, and she informed them that the resident kept moaning, but denied everything, and his vital signs were good. She indicated the office nurse told her to send him to the emergency room . She indicated she could not remember if the night nurse told her that the resident had not been acting right, nor could remember if she told the ambulance driver or the hospital that the resident had not been acting right for a couple of days. She indicated she did not remember if she performed wound care that morning. On 9/1/16 at 11:30 A.M., during an interview with the Administrator and the Director of Nursing (DON), the DON indicated the resident frequently moaned out. She indicated she saw the resident the morning of 8/15/16, and did not feel that there was a condition change. The Administrator and DON indicated the resident did require total care at times, so that was not a condition change either. The DON indicated she did not know why the ambulance and hospital reports indicated LPN # 1 informed them that the resident had been like that for the day previous. The Administrator indicated perhaps LPN # 1 did not know the resident very well. The DON indicated the resident did not have skin impairments on the right side. The Administrator indicated perhaps the resident laid on a cot in the ER for an extended time, and obtained the areas there. On 9/1/16 at 3:30 P.M., the DON indicated she had spoken to RN # 1, who worked 8/14/16, and had performed the resident's dressing changes. She indicated RN # 1 did not observe any new skin areas on the resident. The DON indicated the CNAs who were working with the resident did not notice new skin areas. On 9/1/16 at 3:45 P.M., RN # 1 was interviewed. RN # 1 indicated he was helping out on Sunday 8/14/16 until approximately 8:00 P.M. RN # 1 indicated he had not worked much with Resident C. He indicated when he came in, Resident C was asleep, and did not appear in any distress. He indicated he did start moaning at approximately 7:30 P.M., and so he gave him a pain pill. He indicated the resident did not get up for supper. He indicated he thought the resident did respond to him, but just acted more tired than usual. RN # 1 indicated he did not notice any new skin areas other than those on his back and his left foot. On 9/1/16 at 3:10 P.M., the Assistant Director of Nursing (ADON) provided the current facility policy on Weekly Skin Assessment, revised 5/10/16. The policy included: Purpose: To monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development state and implement other preventative and/or treatment measures as indicated .Initiate applicable Wound Event if a new area of impairment is identified (Pressure/Stasis/Arterial/Diabetic/Surgical or Other). Please initiate an event for each area identified This Federal tag relates to Complaint IN 041. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure weekly skin assessments were completed to ensure pressure sores were identified promptly for 1 of 1 resident reviewed with an unstageable pressure sore. This resulted in a pressure sore of the heel identified as an unstageable pressure sore when identified on 3/16/12. (Resident #19) Findings include: On 8/8/12 at 3:50 P.M., Resident #19's clinical record was reviewed. [DIAGNOSES REDACTED]. Her nursing admission nursing assessment dated [DATE], indicated she was admitted to this facility on 1/3/12, with a cast due to a left ankle fracture. This assessment indicated, "Res (resident) has cast placed at ER (emergency room ) for fx (fracture). Non- removable, unable to assess." Her treatment orders inititated 1/3/12 included, but were not limited to: weekly skin checks, float heels while abed, and check for pedal pulse et circulation in left lower extremity every shift. On 8/9/12 at 8:36 A.M., during interview with the Assistant Director of Nursing (ADON), she indicated, Resident #19 was admitted on [DATE] with a soft cast and her toes were visible on the left foot. A transfer sheet from the hospital dated 1/15/12, indicated the resident was returning to the facility after surgical repair of a left ankle fracture on 1/10/12. This transfer sheet diagram indicated a soft cast was on the left foot from below the knee and included the foot with the toes exposed out of the cast. Treatment orders dated 1/15/12, after return to the facility included, but were not limited to: ice pack to left ankle prn pain or [MEDICAL CONDITION], off load heel at all times, keep left leg cast clean and dry, and weekly skin assessments. Weekly skin assessments were documented on 1/15/12 1/22/12, and 1/29/12 after return to the facility after surgery. On 8/9/12 at 8:36 A.M., during interview with the ADON, she indicated the resident returned to the physician on 2/16/12, and her cast was removed on 2/16/12. At that time the physician ordered a walker boot to be worn at all times except bathing. The ADON indicated the resident was non weight bearing with the walker boot. The ADON indicated the walker boot was a velcro boot and could be taken off during bathing. She indicated there was no dressing to change with the walker boot. She indicated weekly skin assessment included all skin areas of the body. Review of the February 2012 treatment record indicated weekly skin assessments were completed on 2/5/12, 2/12/12, 2/19/12, and 2/26/12. This documentation included but was not limited to: keep left leg cast clean and dry, off load heels at all times, ice to left ankle for pain and [MEDICAL CONDITION], aggressive elevation of left lower extremity, and turn and reposition every 2 hours. On 8/7/12 at 1:52 P.M., a pressure ulcer assessment for Resident #19 was reviewed. This assessment dated [DATE], indicated an "E (un-stageable--non removable dressing, slough/eschar, suspected deep tissue injury in evolution)" of the left heel. The assessment indicated, "not able to assess had nonremovable boot on." The area was black with unapproximaataed wound edges. Measurements were 5 cm (length) x 4 cm (width) and depth "E." Review of the March 2012 treatment record of Resident #19, indicated a weekly skin assessment had been completed on 3/4/12, 3/16/12, 3/18/12, and 3/25/12. Documentation was lacking for a skin assessment on the date of 3/11/12. Documentation was lacking between 3/4/12 and 3/16/12, a period of 11 days. On 8/9/12 at 8:36 A.M., during interview with the ADON, she indicated a nurse had been "written up" (displinary action) due to lack of documentation in regard to a skin check on 3/11/12. She indicated the nurse indicated she had done the skin assessment on 3/11/12 and saw the area on the left heel. She indicated the nurse had thought there was already a treatment being done for this area. She indicated CNA # 1 who was routinely scheduled for continutity of resident care on Resident #19's unit thought the nurses were aware of the left heel area. The ADON also indicated at this time, Resident #19's daughter had accompanied Resident #19 to her appointment for the removal of the cast on 2/16/12. The daughter, when notified by the facility on 3/16/12 about the heel pressure area, indicated she had seen the area when the cast had been removed on 2/16/12. On 8/9/12 at 9:45 A.M., the left heel pressure area was observed during a dressing change. The heel was observed as an open area, approximately 4 cm x 3 cm, with no drainage, slough, or odor noted. On 8/9/12 at 9:57 A.M., CNA #1 who had consistently provided care for Resident #19 (since admission) was interviewed regarding care when the resident had a cast and a walking boot to the left foot. She indicated when the resident had a cast or the walking boot applied, she had not taken the boot or cast off to wash the foot. She indicated the CNAs had not provided care for the left foot, just the nurses had cared for the left foot. She indicated she had been instructed not to do anything to the left foot. On 8/9/12 at 10:11 A.M., the wound nurse who had completed the dressing change on 8/9/12 at 9:45 A.M., was interviewed. She indicated the left heel wound at present appeared as a stage 4, but she had continued to document it as the stage first observed, unstageable. The facility Weekly Skin Assessment Guideline policy (revised 4/08) was reviewed on 8/10/12 at 12:05 P.M. This policy indicated, "Purpose: 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. Procedure: 1. A full body assessment shall be completed weekly by the licensed nurse. 2. Upon admission the admitting nurse shall include as parat of the admission orders [REDACTED]. 0= no areas of skin impairment, 1 = new areas of skin impairment (see wound sheet), 2= existing area of impairment (see wound sheet)... ...6. In addition to the Weekly Assessment 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." 3.1-40(a)(1)