Every finding on record at Terrace at Solarbron the

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 6 of 6 residents reviewed for as needed (PRN) antianxiety medications. Residents' PRN antianxiety medication orders did not indicate a specific duration of use. (Resident 7, Resident G, Resident 2, Resident 81, Resident 6, and Resident B)Finding includes:1.On 2/26/26 at 11:16 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/23/25, indicated Resident 7 was cognitively intact and received an antianxiety medication during the 7-day lookback period. A current anxiety disorder care plan, dated 11/13/25, indicated Resident 7 required the use of an antianxiety medication. Physician orders included, but were not limited to:lorazepam (an antianxiety medication) 0.5 milligrams (mg) - Give one tablet by mouth twice a day as needed for anxiety, dated 6/10/25. The order was listed as open ended and did not include a stop date. The December 2025, January 2026, and February 2026 electronic Medication Administration Record (eMAR) was reviewed. Resident 7 received PRN lorazepam 0.5 mg on the following days:12/8/25 at 2:49 P.M.1/5/26 at 2:12 P.M.2/2/26 at 1:44 P.M. 2. On 2/25/26 at 11:32 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/2/25, indicated Resident G had severe cognitive impairment and received an antianxiety medication during the 7-day lookback period. A current depression and anxiety diagnoses care plan, dated 2/25/26, indicated that Resident G required the use of an antianxiety medication. Current physician orders included, but were not limited to:hydroxyzine (an antianxiety medication) 25 milligrams (mg) - Give one tablet by mouth every eight hours as needed for anxiety, dated 2/4/26. The order was listed as open ended and did not include a stop date. The February 2026 electronic Medication Administration Record (eMAR) was reviewed. Resident G had not received the PRN hydroxyzine 25 mg. 3. On 2/25/26 at 11:04 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/25, indicated Resident 2 had severe cognitive impairment and received an antianxiety medication during the 7-day lookback period. A current anxiety care plan, dated 3/11/25 and revised 11/7/25, indicated Resident 2 received antipsychotic medication. Current physician orders included, but were not limited to:lorazepam (an antianxiety medication) 0.5 milligrams (mg) - Give one tablet by mouth every six hours as needed for anxiety, shortness of breath, and restlessness, dated 11/7/25. The order was listed as open ended and did not include a stop date. The February 2026 electronic Medication Administration Record (eMAR) was reviewed. Resident 2 received PRN lorazepam 0.5 mg on the following days:2/23/26 at 1:13 P.M.2/24/26 at 3:26 P.M. 4. On 2/25/26 at 1:54 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/3/25, indicated Resident B was severely cognitively impaired, required set-up assistance from staff for eating, toileting, and transfers, required supervision assistance from staff for bathing, and and had received antianxiety medication in the 7-day lookback period. The care plan included, but was not limited to: (Resident) has an anxiety disorder diagnosis. Restlessness is her most common symptoms. Requires the use of antianxiety medications; Start date 12/2/24 Physician orders included, but were not limited to: Xanax (antianxiety medication) tablet 0.25 mg (milligrams) one tablet three times a day as needed; Start date 2/23/26. The order did not include a stop date. The February and March 2026 (eMAR) was reviewed. Resident B received PRN Xanax 0.5 mg on the following days: 2/25/26 at 1:08 P.M. 2/26/26 at 12:49 A.M. 2/27/26 at 12:16 A.M. 2/27/26 at 1:18 P.M. 3/2/26 at 5:32 P.M. 5. On 2/24/26 at 10:42 A.M., Resident 81's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of female breast. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 1/22/26, indicated Resident 81 was mildly cognitively impaired, required maximal assistance (staff does most of the work) for toileting and transfers, and had not received antianxiety medication in the 7-day lookback period. Resident 81's lacked a care plan related to antianxiety medication use. Physician orders included, but were not limited to:lorazepam (antianxiety medication) tablet; 0.5 mg (milligrams) Give one tablet (0.5mg) every 30 minutes PRN for anxiety, agitation and dyspnea; Start date 1/21/26. The order did not include a stop date. The electronic Medication Administration Record (eMAR) indicated Resident 81 had not received lorazepam in February or March 2026. 6. On 2/26/26 at 10:08 A.M., Resident 6's clinical record was reviewed. The most recent Quarterly MDS Assessment, dated 12/8/25, indicated Resident 6 was cognitively intact, required partial assistance for bathing and transfers, maximal assistance from staff for toileting, and had received antianxiety medication in the 7-day lookback period. Diagnoses included, but were not limited to, generalized anxiety disorder. (Resident) has an anxiety, borderline personality disorder and post traumatic stress disorder (PTSD) that requires the use of antianxiety medication; Start date 2/28/25 Physician orders included, but were not limited to: clonazepam (antianxiety medication) tablet 0.5 mg (milligrams) take once a day as needed; Start date 10/20/25. The order did not include a stop date. The February and March 2026 electronic Medication Administration Record (eMAR) was reviewed. Resident B received PRN clonazepam 0.5 mg on the following days: 2/5/26 at 1:33 P.M. 3/2/26 at 11:18 A.M. During an interview on 3/3/26 at 11:28 A.M., the Director of Nursing (DON) indicated that the facility did not have a policy specific to PRN antianxiety medications and their duration of use, and the facility used the federal regulation. 410 IAC 16.2-3.1-48(a)(2)

Based on observation, interview, and record review, the facility failed to develop and implement care plans for 3 of 6 residents reviewed for falls and 3 of 6 residents reviewed for medication administration. A care plan was not developed for residents' who received anticonvulsants, antidepressants and antianxiety medications, and care plan interventions were not implemented to prevent falls. (Resident 9, Resident 30, Resident B, Resident 40, and Resident 81)Findings include: 1. On 2/24/26 at 11:30 A.M., Resident 9 was observed lying in bed without a call don't fall sign in the room. On 2/25/26 at 1:29 P.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, depression, dysphagia, and chronic respiratory failure with hypoxia. The current Quarterly Minimum Data Set (MDS) Assessment, dated 1/20/26, indicated Resident 9 was cognitively intact. Resident 9 took an antidepressant and anticonvulsant during the 7-day lookback period and had no history of falls until 1/9/26. Current physician orders included but were not limited to:Gabapentin (anticonvulsant) 100 milligrams (mg) - Give two capsules; orally, twice a day, dated 12/20/25 Duloxetine (antidepressant) capsule, delayed release (DR/EC) 30 mg - Give one capsule by mouth once daily, dated 12/31/25 The clinical record lacked a care plan related to the anticonvulsant and antidepressant medications. The current risk for falls care plan, revised 2/23/26, included, but were not limited to, the following interventions:Place a call don't fall sign in her room as a reminder to ask for staff assist with task completion, dated 9/15/25 On 2/26/26 at 2:50 P.M., Resident 9 was observed lying in bed without a call don't fall sign noted in the room. During an interview on 2/26/26 at 3:00 P.M., Certified Nurse Aide (CNA) 10 indicated that she did not know if there was a call don't fall sign in the resident's room. 2. On 2/24/26 at 10:30 A.M., Resident 30 was observed sitting in recliner with no bedside commode (BSC) nearby. On 2/24/26 at 2:36 P.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease with dyskinesia, without mention of fluctuations, Dysphagia following other cerebrovascular disease, and Depression, unspecified. The current admission Minimum Data Set (MDS) Assessment, dated 1/19/26, indicated Resident 30 was cognitively intact and had a history of falls. The current risk for falls care plan, revised 2/17/26, included, but were not limited to, the following interventions:Keep BSC within reach, empty frequently, dated 2/3/26. On 2/26/26 at 1:00 P.M., Resident 30 was observed sitting in recliner with no bedside commode nearby. During an interview on 3/2/26 at 9:33 A.M., Registered Nurse (RN) 12 indicated care plan interventions should be implemented if they were on the care plan. She was not aware of the resident's intervention for a bedside commode. 3. On 2/25/26 at 1:54 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/3/25, indicated Resident B was severely cognitively impaired, required set-up assistance from staff for eating, toileting, and transfers, and required supervision assistance from staff for bathing. Physician orders included, but were not limited to: hydrocodone-acetaminophen (a narcotic pain medication) tablet 5-325 mg (milligrams) one tablet every six hours as needed for pain; Start date 2/23/26 The care plan included, but was not limited to: (Resident) has a left femur fracture that requires monitoring and treatment as indicated; Start date 2/24/26 Resident at risk for falling and fall related injuries; Start Date 7/31/24Interventions:2/25/26 - Assist and encourage her to lie down or to sit in easy chair after visits with family2/1/26 - Offer and assist to toilet: upon rising, before and after meals, and prior to laying down An interdisciplinary team (IDT) note, dated 2/26/26 at 9:29 A.M., indicated IDT review of falls on 2/1/26 and 2/25/26. Care plan was reviewed and updated with intervention to offer and assist toilet upon rising, before and after meals, and before lying down, and assist and encourage her to lie down or to sit in easy chair after visits with family. During an observation on 3/2/26 at 1:21 P.M., Resident B returned from lunch in the dining room and was laid in bed. It was indicated that Resident B had not been offered to be toileted since prior to therapy at 10:00 A.M. At 1:34 P.M., family pushed Resident B's call light to ask staff for Resident B's brief to be changed. At 1:43 P.M., staff entered Resident B's room, removed her saturated brief, and put a dry brief on. Staff did not offer Resident B to attempt to use the toilet. During a continuous observation on 3/3/26 at 11:40 A.M., Resident B was laying in bed. At 12:07 P.M., staff brought Resident B's lunch tray into the room and sat it on the bedside table. Staff did not offer Resident B to attempt to use the toilet or change her brief before her meal. During an interview on 3/3/26 at 11:45 A.M., family indicated when they arrived at the facility, they could hear Resident B yelling for help from the nurse's station area, where four staff members were present. When the family member entered Resident B's room, Resident B was laying on the floor with a saturated brief. 4. On 2/25/26 at 9:37 A.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/17/25, indicated Resident 40 had severe cognitive impairment and did not receive an anticonvulsant during the 7-day lookback period (11/11/25 - 11/17/25). Physician orders included, but were not limited to:oxcarbazepine (an anticonvulsant medication) 150 milligrams (mg) - Give 150 mg tablet with 600 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 12/8/25oxcarbazepine 600 mg - Give 600 mg tablet with 150 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 12/8/25 A care conference was completed on 1/19/26 with Resident 40's family members in attendance. The care plans were reviewed. A current bipolar disorder diagnosis care plan, revised 2/16/26, indicated Resident 40 required the use of antipsychotic medications. The clinical record lacked a care plan related to Resident 40's use of an anticonvulsant medication. During an interview on 3/2/26 at 11:37 A.M., the MDS Coordinator indicated Resident 40 did not have a care plan specific to the anticonvulsant medication. 5. On 2/24/26 at 10:42 A.M., Resident 81's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of female breast. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 1/22/26, indicated Resident 81 was mildly cognitively impaired, required maximal assistance (staff does most of the work) for toileting and transfers, and had not received antianxiety medication in the 7-day lookback period. Physician orders included, but were not limited to:lorazepam (antianxiety medication) tablet; 0.5 mg (milligrams) Give one tablet (0.5mg) every 30 minutes PRN for anxiety, agitation and dyspnea; Start date 1/21/26. The order did not include a stop date. Resident 81's lacked a care plan related to antianxiety medication use. On 3/3/26 at 2:21 P.M., the Administrator provided a current Comprehensive Person-Centered Care Plan policy, revised December 2016, that indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The comprehensive, person-centered care plan will: .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .Incorporate identified problem areas; .Incorporate risk factors associated with identified problems; .Aid in preventing or reducing decline in the resident's functional status and/or functional levels; .Reflect currently recognized standards of practice for problem areas and conditions. 410 IAC 16.2-3.1-35(a)410 IAC 16.2-3.1-35(b)(1)

Based on observation, interview and record review, the facility failed to ensure medications were stored properly for 3 of 3 medication carts observed and 1 of 2 medication storage rooms observed. Medication carts contained loose medications, and a medication storage room refrigerator door was not closed. (100 Hall, 300 Hall, Memory Care Unit)Findings include:1. During an observation of the 300 Hall medication cart on 3/3/26 at 11:50 A.M., the third drawer down contained one loose tablet, the fourth drawer down contained one loose tablet, and the sixth drawer down contained one loose capsule. During an interview on 3/3/26 at 11:55 A.M., Licensed Practical Nurse (LPN) 6 indicated being uncertain what the tablet from the third drawer was. The tablet from fourth drawer appeared to be allopurinol 100 milligrams (mg), and capsule from the sixth drawer appeared to be carbamazepine 200 mg. LPN 6 indicated it was the responsibility of the nurse on the cart to ensure the cart remained organized and that the night shift nurse typically cleaned the cart.2. During an observation of the Memory Care Unit medication cart on 3/3/26 at 12:05 P.M., the third drawer down contained a loose tablet that was unable to be identified. 3. During an observation of the Memory Care Unit mediation storage room on 3/3/26 at 12:05 P.M., the refrigerator contained extra resident insulin pens. The refrigerator door was found to be open and a thermometer towards the front of the refrigerator indicated a temperature of 60 degrees Fahrenheit. During an interview on 3/3/26 at 12:10 P.M., Qualified Mediation Aide (QMA) 15 indicated the medication room refrigerator door should remain closed. 4. During an observation of the 100 Hall medication cart on 3/3/26 at 12:15 P.M., the eighth drawer down contained one unidentified tablet and the bottom drawer contained one loose capsule. During an interview on 3/3/26 at 12:20 P.M., Licensed Practical Nurse (LPN) 3 indicated the loose capsule found in the bottom drawer was a gabapentin capsule. On 3/3/26 at 3:21 P.M., the facility supplied an undated facility policy titled, drug storage. The policy included, Medications are dispensed in containers that meet or exceed official standards. These containers will be stored orderly in a secured area accessible to pharmacy personnel and to licensed nursing personnel designated by the facility per resident care policies. Medications will be stored at the facility in a manner consistent with manufacturers guidelines, such as proper temperature . Refrigerator Storage 1. Make sure the refrigerator is kept clean and organized. 2. Monitor refrigerator temperature daily. Maintain between 36-46 degrees .410 IAC 16.2-3.1-25(m)

Based on interview and record review the facility failed to ensure code status was clearly indicated for 2 of 2 residents reviewed for advanced directives. (Resident 30, Resident 46) Findings include: 1. On [DATE] at 1:30 P.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, vomiting, unspecified, lack of coordination, and abnormalities of gait and mobility.The current 5-day scheduled Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident 46 was cognitively intact and required setup assistance for eating and partial to moderate assistance of staff (staff does less than half the effort) for transferring. The code status on the resident profile dashboard listed Resident 46 as a full code. Current physician orders included, but were not limited to:Code Status: Do Not Resituate (DNR), dated [DATE]. The clinical record lacked a signed Advance Directive document for DNR.The current preferences care plan indicated that the resident had requested a DNR code status, dated [DATE]. Interventions included, but were not limited to:If there is no pulse noted, do not attempt CPR (cardiopulmonary resuscitation), dated [DATE].Implement comfort measures as indicated, dated [DATE]Provide resident and family ongoing opportunities to discuss advanced directive options, dated [DATE].During an interview on [DATE] at 11:10 A.M., Certified Nurse Aide (CNA) 4 indicated the resident was listed as a full code on the CNA assignment forms.During an interview on [DATE] at 11:15 A.M., Licensed Practical Nurse (LPN) 3 indicated that Resident 46 was a full code and there was not supposed to be an order for DNR. She indicated someone placed the order in the electronic health record (EHR) before the resident signed the paperwork. 2. On [DATE] at 2:36 P.M., Resident 30's clinical record was reviewed. Diagnoses included but were not limited to: Parkinson's disease with dyskinesia, without mention of fluctuations, Dysphagia following other cerebrovascular disease, and Depression, unspecified. The current admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident 30 was cognitively intact and required setup assistance for eating and partial to moderate assistance of staff (staff does less than half the effort) for toileting. Current physician orders included, but were not limited to:Code status is DNR (do not resuscitate) once a day, dated [DATE].Full code once a day, dated [DATE]. The current preferences care plan, dated [DATE], indicated the resident wished to have a DNR code status. Interventions included, but were not limited to:Code status will be honored through next review, dated [DATE].Staff will not administer CPR (cardiopulmonary resuscitation) and review code status as appropriate, dated [DATE]. During an interview on [DATE] at 11:45 A.M., Licensed Practical Nurse (LPN) 5 indicated that an order for a Full Code status should not have been there. Advance Directive documents indicated the resident was a DNR.On [DATE] at 2:31 P.M., the Administrator provided a current, non-dated policy Advance Directives. The policy indicated .Upon admission or with any change in advance directives, the nurse receiving the documents signed by the resident or legally appointed representative will update the resident's face sheet to reflect the resident's wishes and obtain and document a doctor's order for the resident's advance directives .The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive .410 IAC 16.2-3.1-4(f)(5)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for 1 of 5 residents reviewed for unnecessary medications. An anticonvulsant medication was not marked as received. (Resident 40)Finding includes: On 2/25/26 at 9:37 A.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disease.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/17/25, indicated Resident 40 had severe cognitive impairment and did not receive an anticonvulsant during the 7-day lookback period (11/11/25 - 11/17/25).Physician orders included, but were not limited to:oxcarbazepine (an anticonvulsant medication) 150 milligrams (mg) - Give 150 mg tablet with 600 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 12/8/25oxcarbazepine 600 mg - Give 600 mg tablet with 150 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 12/8/25Discontinued physician orders included, but were not limited to:oxcarbazepine 150 mg - Give 150 mg tablet with 600 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 3/15/24 and discontinued on 12/8/25oxcarbazepine 600 mg - Give 600 mg tablet with 150 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 3/15/24 and discontinued on 12/8/25The November 2025 electronic Medication Administration Record (eMAR) was reviewed. Resident 40 received oxcarbazepine 750 mg seven out of seven days during the 7-day lookback period. During an interview on 3/2/26 at 11:27 A.M., the MDS Coordinator indicated that Resident 40 received an anticonvulsant medication, but it was not coded on the 11/17/25 MDS Assessment.During an interview on 3/3/26 at 2:35 P.M., the Regional Support Nurse indicated the facility did not have a policy specific to MDS coding, and the facility used the Resident Assessment Instrument (RAI) user manual.

Based on interview and record review, the facility failed to ensure care plans were revised following changes in residents' conditions for 1 of 3 residents reviewed for wounds, 1 of 1 residents reviewed for behaviors, and 1 of 6 residents reviewed for falls. Care plans were not revised following deterioration of a wound, physically aggressive behavior events, and falls. (Resident C, Resident G, and Resident B)Findings include: 1. A record review on 2/24/26 at 10:30 A.M., indicated Resident C's diagnoses included, but were not limited to paraplegia, unspecified protein-calorie malnutrition, and unspecified dementia. Resident C's most recent admission Minimum Data Set (MDS) Assessment, dated 7/24/25, indicated the resident was admitted to the facility with one unhealed Stage II pressure ulcer, was at risk for developing pressure ulcers, had moderate cognitive impairment, and was dependent on staff for mobility, including rolling right to left in bed. Resident C's physician orders included, but were not limited to Elevate/Offload heels while in bed as tolerated (started 7/21/25), Turn and reposition per plan of care (started 7/21/25), Weekly head toe skin inspection to be completed per licensed nurse - if any areas are noted please complete a Skin Integrity Event (started 7/21/25), Coccyx: Place foam dressing as preventative to area - change daily (started 8/8/25 and discontinued 8/25/25), Coccyx: cleanse area with soap and water, pat dry, apply Santyl to wound bed ONLY, cover with bordered foam dressing daily (started 8/25/25). Resident C's care plan included but was not limited to resident at risk for skin breakdown due to impaired mobility, anemia, and paraplegia (created 7/22/25). Resident has a pressure ulcer to coccyx (created 8/11/25). Interventions included but were not limited to notify physician if area worsens, increase in pain or shows signs or symptoms of infection. (No interventions or updates regarding the coccyx wound were added following the creation on 8/11/25) Resident C's coccyx wound assessments included the initial assessment dated [DATE] at 2:10 P.M. Resident C's coccyx wound assessments on 8/11/25 and 8/18/25 indicated the wound was worsening. The clinical record lacked documentation to indicate that the care plan was revised following the deterioration of the wound on 8/11/25 and 8/18/25. 2. On 2/25/26 at 11:32 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behavioral disturbance. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/2/25, indicated Resident G had severe cognitive impairment, required setup assistance for Activities of Daily Living (ADLs), and had no behaviors during the lookback period. A care conference was completed on 1/7/26 with a family member in attendance. The care plans were reviewed. A current care plan addressing Resident G's physically aggressive behaviors, dated 7/9/25, indicated her most recent incident occurred on 12/2/25. Interventions included:New order for stat labs for complete metabolic profile (CMP) and complete blood count (CBC) and urinalysis (UA) with culture if indicated, dated 12/3/25Administer medication as needed, dated 8/14/25Behavioral health documentation, dated 8/14/25Encourage resident to participate in group activities, dated 8/14/25Monitor resident frequently for aggressive behaviors, dated 8/14/25Offer resident snack/beverage, dated 8/14/25Staff offer to speak to resident one on one and provide comfort and reassurance, dated 8/14/25Staff to ensure that both residents are safe, dated 8/14/25 A nursing progress note, dated 7/6/25 at 6:20 P.M., indicated that Resident G became physically aggressive with another resident. A Post Behavioral/Emotional Interdisciplinary Team (IDT) Form, dated 7/7/25, indicated that Resident G was attempting to assist another resident and got upset when staff tried to redirect her. One-to-one supervision was initiated. A care plan addressing Resident G's physically aggressive behavior was added to the clinical record on 7/9/25. A nursing progress note, dated 7/25/25 at 9:00 A.M., indicated that Resident G got into an altercation with another resident. The Nurse Practitioner (NP) was notified, and an order was received to send her to the emergency room (ER) for evaluation and treatment of increased behaviors. A nursing progress note, dated 7/25/25 at 1:23 P.M., indicated Resident G returned to the facility with no new orders. The clinical record lacked documentation to indicate the care plan was updated with a new intervention following the resident-to-resident altercation on 7/25/25. A Post Behavioral/Emotional IDT Form, dated 8/29/25, indicated that Resident G blocked a Certified Nurse Aide (CNA) from leaving her room after providing care to her roommate. Staff to announce their presence upon entering and explain to resident they are there to help was identified as the new intervention added to prevent recurrence. Staff to announce their presence upon entering and explain to resident they are there to help was not added to the care plan and the care plan was not revised with a new intervention following the resident-to-staff altercation on 8/29/25. A nursing progress note, dated 10/9/25 at 6:40 P.M., indicated Resident G was walking up the hallway with another resident. The other resident wanted to turn around and go the opposite way. Resident G continued to hold onto the resident until a staff member asked her to let the resident go. The clinical record lacked documentation to indicate the care plan was updated with a new intervention following the resident-to-resident altercation on 10/9/25. A nursing progress note, dated 12/2/25 at 5:12 P.M., indicated that Resident G initiated a physical altercation with another resident. New order for stat labs for complete metabolic profile (CMP) and complete blood count (CBC) and urinalysis (UA) with culture if indicated was added to the care plan on 12/3/25. A nursing progress note, dated 1/2/26 at 1:15 P.M., indicated Resident G had a physical altercation with another resident. A Post Behavioral/Emotional IDT Form, dated 1/2/26, indicated that 15-minute checks were initiated because redirection was not working. The clinical record lacked documentation to indicate the care plan was updated with a new intervention following the resident-to-resident altercation on 1/2/26. A nursing progress note, dated 1/3/26 at 12:55 P.M., indicated Resident G smacked another resident on the back of the head. When staff attempted to intervene, Resident G smacked a Qualified Medication Aide (QMA) on the back. A Social Services note, dated 1/3/26 at 1:31 P.M., indicated the Social Services Director (SSD) followed up with Resident G regarding the altercations. Resident G was unable to recall the altercations due to a diagnosis of dementia with history of disruptive behaviors. The NP was notified and an order was received to transfer Resident G to the ER for further evaluation. The note indicated that the IDT would continue to follow up on the behaviors once Resident G returned to the facility. A nursing progress note, dated 1/3/26 at 5:05 P.M., indicated Resident G returned to the facility. The clinical record lacked documentation to indicate the care plan was updated with a new intervention following the resident-to-resident and resident-to-staff altercations on 1/3/26. A nursing progress note, dated 1/5/26 at 9:00 A.M., indicated an order was received to transfer Resident G to a geriatric psychiatric hospital for evaluation and treatment. A nursing progress note, dated 1/7/26 at 2:24 P.M., indicated Resident G was transferred to a geriatric psychiatric hospital. A Behavioral Meeting Observation, dated 1/13/26, indicated Resident G had increased aggressive behaviors, was increasingly difficult to redirect, and was admitted to a psychiatric behavioral hospital. A nursing progress note, dated 2/4/26 at 11:30 A.M., indicated Resident G returned to the facility from the geriatric psychiatric hospital. The clinical record lacked documentation to indicate the care plan was revised to include new interventions upon the resident's return to the facility. A provider note, dated 2/5/26 at 1:28 P.M., indicated that during the readmission assessment, staff reported that since Resident G had been back, there had only been one issue in which the resident threated to assault a staff member's family. A nursing progress note, dated 2/6/26 at 12:36 P.M., indicated that Resident G swatted at a QMA who attempted to help her. The clinical record lacked documentation to indicate the care plan was updated with a new intervention following the resident-to-staff altercation on 2/6/26. A Behavior Event, dated 2/9/26 at 12:15 P.M., indicated that Resident G put her fingers on another resident's chest. The clinical record lacked documentation to indicate the care plan was updated with a new intervention following the resident-to-resident altercation on 2/9/26. A Behavioral Meeting Observation, dated 2/10/26, indicated Resident G returned from the psychiatric hospital with new medications/adjustments. Continue with the current plan of care was marked. The clinical record lacked documentation to indicate the care plan was revised to reflect the new medications and adjustments. During an interview on 3/2/26 at 10:23 A.M., QMA 15 indicated that Resident G had a history of behaviors and routinely received an antianxiety medication. He would also offer a snack to deescalate aggressive situations or another staff member would provide one on one supervision with her. He indicated he had gotten to know her and could see when her behavior was starting to escalate. He indicated that she used to be a CNA at another facility and believed she was still there sometimes. During an interview on 3/2/26 at 10:30 A.M., the Dementia Care Director indicated that Resident G was discussed daily in morning meeting. She indicated the resident used to be a CNA at another facility and thought she was staff sometimes. She indicated if staff tried to help her do something it would often trigger behavior. Staff were encouraged to be cognizant about what head space Resident G might be in and provide trauma-informed care. She indicated Resident G liked snacks, ginger ale, and playing cards and could often be redirected that way. On 3/2/26 at 10:52 A.M., the Director of Nursing (DON) indicated that care plans did not always get updated with new interventions after behavior events. It would depend on the resident. She was aware of Resident G's physically aggressive behavior events. On 3/3/26 at 10:10 A.M., the SSD indicated that behavior care plans were updated quarterly or as needed. Behavior Events were reviewed in the daily morning meeting. He indicated that the Dementia Care Director was responsible for updating the care plans for residents in the Memory Care Unit. During an interview on 3/3/26 at 10:22 A.M., the Dementia Care Director indicated that behavior care plans were updated quarterly and as needed. She reviewed behavior reports daily. She indicated care plans were reviewed when a resident returned to the facility from a hospital stay. Resident G's care plan related to physical aggression indicated that the last incident occurred on 12/2/25, but she had exhibited physically aggressive behavior since then and the care plan should have been updated. During an interview on 3/3/26 at 3:18 P.M., the Administrator indicated that the care plan was not always updated after each aggressive episode. 3. On 2/25/26 at 1:54 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/3/25, indicated Resident B was severely cognitively impaired, required set-up assistance from staff for eating, toileting, and transfers, and required supervision assistance from staff for bathing. Physician orders included, but were not limited to: hydrocodone-acetaminophen (a narcotic pain medication) tablet 5-325 mg (milligrams) one tablet every six hours as needed for pain; Start date 2/23/26 The care plan included, but was not limited to: (Resident) has a left femur fracture that requires monitoring and treatment as indicated; Start date 2/24/26 Resident at risk for falling and fall related injuries; Start Date 7/31/24 Interventions: 2/25/26 - Assist and encourage her to lie down or to sit in easy chair after visits with family 2/1/26 - Offer and assist to toilet: upon rising, before and after meals, and prior to laying down 1/5/26 - Environmental assessment completed with no abnormalities noted, unit director to contact family regarding replacement of walker 11/27/25 - Unit manager to contact family to educate them to encourage and ensure that resident is using her walker when out of facility with them 12/16/24 - Non skids next to bed, grab bar for transfers and mobility, per her request non skid strips in front of toilet An interdisciplinary team (IDT) note, dated 2/2/26 at 10:21 A.M., indicated IDT review of multiple falls over the weekend. Resident is currently at the hospital for evaluation and treatment of L femur fracture. IDT to review care plan and update interventions as indicated upon return. An interdisciplinary team (IDT) note, dated 2/26/26 at 9:29 A.M., indicated IDT review of falls on 2/1/26 and 2/25/26. Care plan was reviewed and updated with intervention to offer and assist toilet upon rising, before and after meals, and before lying down, and assist and encourage her to lie down or to sit in easy chair after visits with family. The clinical record lacked a review following the fall on 1/31/26. The care plan lacked an intervention implemented related to the fall that occurred on 1/31/26. During an interview on 3/2/26 at 10:52 A.M., the Director of Nursing (DON) indicated after a fall occurred the IDT had a meeting and developed a new intervention for each fall. The DON indicated Resident B's care plan was updated with one intervention since the falls occurred on the same weekend. On 3/2/26 at 10:20 A.M., the Administrator provided a facility policy titled, Wound Management Policy, dated 2/1/19. The policy included, .Wound Rounds: The Wound Team meets each week, preferably the same day and time to benefit the resident(s) being assessed. Each wound will be observed by the wound team to provide oversight of the care plan interventions and ensure that each resident ' s condition is accurately assessed in a timely manner. The skin conditions that the Wound Team should evaluate include, but are not limited to, the following: .New wounds or open areas . IDT: The interdisciplinary team (IDT) will document the wound assessment weekly in the medical record. Additional documentation can be inserted into the medical record using the progress notes. Each week a skin condition will be documented as: (1) Improved; (2) Unchanged; or (3) Worsened . Skin condition worsened: Notify MD, family and staff. Review the care plan/MD order(s)/Nurse aide sheet. Review skin inspection tool to ensure one is completed weekly. Review any changes made to the care plan/MD order(s)/nurse aide sheet. Review any new diagnostic information, laboratory work, x-ray, Doppler, etc. Review any assessment information provided by other disciplines outside of nursing such as; MD/NP/Specialist/Dietary. Assess resident ' s pain or review assessments of resident ' s pain. Determine if the physician ordered treatment has been evaluated for effectiveness, modified, or changed as appropriate and/or needed. Re-evaluate dietary interventions. If a pressure wound, discuss any additional interventions that could be added to further reduce pressure to the affected site. Confirm that a Root Cause Analysis has been completed On 3/3/26 at 2:21 P.M., the Administrator provided a policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, that indicated Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. This citation relates to intake 2721562. 410 IAC 16.2-3.1-35(a)401 IAC 16.2-3.1-35(b)(1)

Based on record review, observation, and interview, the facility failed to provide care to prevent a urinary tract infection and follow physician orders to treat a urinary tract infection (UTI) for 1 of 1 residents reviewed for active urinary tract infections. Staff did not perform proper hand hygiene while providing incontinence care to a resident with a current UTI and staff did not administer antibiotics as ordered for the active UTI. (Resident B) Finding includes: On 2/25/26 at 1:54 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/3/25, indicated Resident B was severely cognitively impaired, required set-up assistance from staff for eating, toileting, and transfers, and required supervision assistance from staff for bathing. Physician orders included, but were not limited to: Macrobid (an antibiotic medication) capsule 100 mg (milligrams) one capsule twice a day for five days; Start date 2/27/26 The care plan included, but was not limited to: (Resident) has history of reoccurring abnormal urinalysis that require antibiotic treatment; Edited: 2/25/26Intervention: Administer antibiotics as ordered During an observation of care on 3/2/26 at 1:43 P.M., Certified Nurse Aide (CNA) 7 and CNA 8 entered Resident B's room. CNA 7 and CNA 8 put gloves on. CNA 7 raised the bed and laid the bed flat with the bed remote with her gloved hand. CNA 7 looked in the closet for a brief. CNA 7 and CNA 8 rolled Resident B to her right side and pulled off the saturated brief beneath her. CNA 7 used wipes to clean Resident B's buttocks and put a new brief under her. CNA 7 applied cream with her right hand to the resident's buttocks, removed her right glove and put a new glove on her right hand. CNA 7 and CNA 8 rolled Resident B from her right side to her back, CNA 8 wiped the front of Resident B's perineal area from top to bottom. CNA 7 searched through items on Resident B's bedside table for a bottle of cream and then applied cream directly to the resident's vulvar area. CNA 8 fastened the residents brief and pulled her pants up. CNA 7 removed her gloves, collected the trash, and CNA 8 covered the resident with a blanket. CNA 8 lowered the bed and removed her gloves. Hand hygiene was not performed during care. During an observation on 3/3/26 at 8:25 A.M., Licensed Practical Nurse (LPN) 6 indicated she was unable to find Resident B's antibiotic medication in the medication cart or the medication storage room. During an interview on 3/3/26 at 8:52 A.M., the [pharmacy name] pharmacy technician indicated the pharmacy had two systems, one for receiving orders and one for sending out medications, and the systems had not aligned; Resident B's antibiotic, Macrobid 100 mg ordered on 2/26/26, was never sent to the facility and the facility had been using medication from the emergency drug kit (EDK). On 3/3/26 at 8:25 A.M., Resident B's electronic medication administration record was compared to the medications removed from the EDK. The following dates indicated Resident B did not receive Macrobid 100 mg:2/27/26 P.M. 2/28/26 P.M. The following dates indicated staff documented in the medical record that Resident B did receive the medication, but no medication was removed from the EDK to administer to Resident B:2/27/26 A.M.2/28/26 A.M. 3/2/26 A.M. During an interview on 3/3/26 at 10:59 A.M, the Director of Nursing (DON) indicated it was determined Resident B had missed four of nine doses of antibiotics from 2/27/26 to 3/3/26. During an interview on 3/3/26 at 1:40 P.M., the Infection Prevention Nurse indicated staff should perform hand hygiene and donn gloves before incontinence care, should change gloves between dirty and clean tasks, and should perform hand hygiene after care. On 3/3/26 at 2:35 P.M., the Regional Support Nurse indicated the facility did not have a policy related to the prevention or treatment of urinary tract infections, and that it was expected of staff to prevent and treat UTIs and follow physician orders in regards to antibiotics administration. On 3/3/26 at 2:21 P.M., the Administrator provided a policy titled Hand Washing/Hand Hygiene policy, dated 3/2016, that indicated Employees must wash their hands for at least twenty (40-60) seconds using anti-microbial or non-antimicrobial soap and water under the following conditions: When hands are visibly soiled before and after direct resident contact before and after assisting a resident with personal care upon and after coming in contact with a resident's intact skin 410 IAC 16.2-3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident's Nasal Jejunal (NJ) feeding tubing was monitored for correct placement for 1 of 1 residents reviewed for a feeding tube. (Resident 96)Finding includes:On 2/26/26 at 8:15 A.M., Resident 96 was observed lying on her right side with the NJ tube noted lying flat alongside the resident with the pink marker of the tube hanging out of left nares one inch. The nasal [NAME] endings were knotted underneath the distal part of the marker. On 2/25/26 at 2:28 P.M., Resident 96's clinical record was reviewed. Diagnoses included, but were not limited to, dysphagia following other cerebrovascular disease, Gastro-esophageal reflux disease without esophagitis, and borderline personality disorder. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) Assessment was still being processed. Current physician orders included, but were not limited to:Glucerna 1.5 Pump Rate: 50 milliliters per hour (mL / hr) continuous with water flushes 150 mL every six hours, dated 2/25/25 Physician orders lacked an order to check placement. The Medication Administration Record (MAR) for February 2026 lacked documentation to indicate placement of the NJ tube was checked or the distance where the marker was for NJ feeding tube. The current Nasogastric Tube Care plan related to dysphagia, dated 2/25/26, included interventions that were not limited to the following:Check placement and patency of feeding tube before each feeding or medication administration, dated 2/25/26.Provide enteral feedings and flushes per M.D. (medical doctor) orders, dated 2/25/26. During an interview on 2/26/26 at 8:30 A.M., Registered Nurse (RN) 9 indicated that the resident had to go to the hospital two days in a row for replacement of the NJ feeding tube. The resident sneezed it out the first time and the tube clogged the second time. She also indicated that the resident had an x-ray that indicated the feeding tube was curled upon itself in her abdomen and had to be reinserted at the hospital.During an interview on 2/26/26 at 9:30 A.M., RN 9 indicated the pink tab was the marker for the tube placement and the marker should be monitored daily. Staff should be documenting the placement of the marker on the feeding tube. She also placed a tab on the resident's face to keep the tube in place.During an interview on 2/26/26 at 9:45 A.M., Licensed Practical Nurse (LPN) 3 indicated that staff should have been documenting the measurement of the marker and they hadn't been.On 3/3/26 at 2:21 P.M., the Administrator provided a current, non-dated Licensed Nurse Nasogastric Care and Small-Bore Feedings Skill Validation. The validation form indicated .Mark tubing with adhesive tape or note striped markings already on the tube . 410 IAC 16.2-3.1-44(a)(1)

Based on interview and record review, the facility failed to ensure an attempt for management of pain was provided for 1 of 3 residents reviewed for falls resulting in fracture. (Resident B) Finding includes: On 2/25/26 at 1:54 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, urinary tract infection and fracture of left femur. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/3/25, indicated Resident B was severely cognitively impaired, required set-up assistance from staff for eating, toileting, and transfers, and required supervision assistance from staff for bathing. Physician orders included, but were not limited to: hydrocodone-acetaminophen (a narcotic pain medication) tablet 5-325 mg (milligrams) one tablet every six hours as needed for pain; Start date 2/23/26 acetaminophen (pain medication) capsule 325 mg two tablets by mouth every four hours as needed; Start date 2/23/26 Resident pain observation reveals: M=Pain level is manageable this shift, P=Pain level is not manageable this shift. pain rating per resident: use pain observation key code to document signs and symptoms of pain. If pain is not manageable document intervention(s) using the pain observation key code; Start date 2/23/26 buprenorphine (pain patch) five micrograms (mcg)/hour administer one patch weekly; Start date 2/27/26 The care plan included, but was not limited to: (Resident) has a left femur fracture that requires monitoring and treatment as indicated; Start date 2/24/26 (Resident) has a laceration to the left forehead/orbital area that requires monitoring and treatment as ordered; Start date 2/26/26Intervention: Monitor for any signs and symptoms of increased pain and treat as ordered. Follow up with physician as needed. On 2/27/26 during night shift, the electronic Medication Administration Record (eMAR) indicated Resident B experienced a pain of five on a scale of zero to ten. The eMAR lacked administration of non-pharmacological pain interventions or pain medication administered from 2/27/26 at 1:20 P.M. to 2/28/26 at 8 A.M. On 3/1/26 during day shift, the eMAR indicated Resident B experienced a pain of five on a scale of zero to ten, and on night shift experienced a pain of two on a scale of zero to ten. The eMAR lacked administration of pain medication from 2/28/26 at 8:27 P.M. to 3/2/26 at 8:23 A.M. A progress note, dated 3/2/26 at 10:18 A.M., indicated Resident B had only eaten three shrimps and a pudding all weekend. During an interview on 3/2/26 at 1:21 P.M., it was indicated Resident B had increased agitation, refusal of eating, and increased behaviors over the last few days. Family was able to talk to the resident on the phone and indicated the resident was in an immense amount of pain. Pain medication was then provided for Resident B. On 3/3/26 at 2:21 P.M., the Administrator provided a policy titled Pain policy, dated 5/2015, that indicated the goal for managing pain should be to achieve a consistent level of comfort while maintaining as much function as possible. Pain cannot be managed with analgesics alone, the underlying cause of the pain must be addressed whenever possible. 410 IAC 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure staff monitored for side effects of high-risk medications for 2 of 5 residents reviewed for unnecessary medications. Anticonvulsant and antidepressant medication side effects were not monitored. (Resident 40 and Resident 9)Findings include: 1. On 2/25/26 at 9:37 A.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/17/25, indicated Resident 40 had severe cognitive impairment and did not receive an anticonvulsant during the 7-day lookback period (11/11/25 - 11/17/25). Physician orders included, but were not limited to:oxcarbazepine (an anticonvulsant medication) 150 milligrams (mg) - Give 150 mg tablet with 600 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 12/8/25 oxcarbazepine 600 mg - Give 600 mg tablet with 150 mg tablet to equal 750 mg twice a day upon rising and before bedtime for bipolar disorder, dated 12/8/25 The clinical record lacked a care plan related to Resident 40's use of an anticonvulsant medication. The clinical record lacked an order to monitor for side effects related to anticonvulsant medication use. During an interview on 3/3/26 at 11:28 A.M., the Director of Nursing (DON) indicated that staff would monitor for the indication of a medication but not necessarily the side effects. During an interview on 3/3/26 at 12:22 P.M., the DON indicated that staff monitored for side effects of psychotropic medications that Resident 40 received such as olanzapine. Those side effects were similar to anticonvulsant side effects. During an interview on 3/3/26 at 12:30 P.M., Registered Nurse (RN) 9 indicated that the facility used the website drugs.com as a reference for medication. The article, Oxcarbazepine, dated 4/24/25, was retrieved on 3/3/26 from the drugs.com website at https://www.drugs.com/mtm/oxcarbazepine.html. The guidance included: Common side effects of oxcarbazepine may include: dizziness, drowsiness, tiredness; balance or coordination problems; nausea, vomiting; tremors or shaking; double vision; or rash. The article, Olanzapine, dated 7/24/24, was retrieved on 3/3/26 from the drugs.com website at https://www.drugs.com/mtm/olanzapine.html. The guidance included: Common side effects of olanzapine that affect 5% or more people who take it include postural hypotension (a drop in blood pressure when going from a lying or sitting position to standing), Constipation, Weight gain and increased appetite, Dizziness, Personality disorder, Restlessness, Sedation, Headache, Abdominal pain, Pain in the extremities, Tiredness or lack of energy, Dry mouth, and Tremor. 2. On 2/25/26 at 1:29 P.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, depression, dysphagia, and chronic respiratory failure with hypoxia. The current Quarterly Minimum Data Set (MDS) Assessment, dated 1/20/26, indicated Resident 9 was cognitively intact. Resident 9 received antidepressant and anticonvulsant medications during the 7-day look back period. Current physician orders included but were not limited to:gabapentin (anticonvulsant) 100 milligrams (mg) - Give two capsules orally twice a day, dated 12/20/25duloxetine (antidepressant) capsule, delayed release (DR/EC) 30 mg - Give one capsule orally once a day, dated 12/31/25 The clinical record lacked orders for monitoring side effects of anticonvulsants and antidepressants medications. During an interview on 3/3/26 at 2:35 P.M., the Regional Support Nurse indicated the facility did not have a policy specific to monitoring of high-risk medications, and the facility expected staff to monitor for side effects of medications. 10 IAC 16.2-3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure accurate and timely documentation in resident's medical records for 1 of 3 residents reviewed for pressure ulcers and 1 of 3 residents reviewed for unnecessary medications. A resident's record contained no documentation that bedtime snacks were provided according to the dietician's nutritional assessment, weekly wound assessments were not entered into the record timely, notes documented continuing therapy services after therapy services ended, and narcotic and antibiotic medication administration documentation did match narcotic sign out sheets, pharmacy delivery records, or the emergency drug kit (EDK) sign out sheets. (Resident B, Resident C) Findings include: 1. A record review on 2/24/26 at 10:30 A.M., indicated Resident C's diagnoses included, but were not limited to paraplegia, unspecified protein-calorie malnutrition, and unspecified dementia. Resident C's physician orders included, but were not limited to Weekly head toe skin inspection to be completed per licensed nurse - if any areas are noted please complete a Skin Integrity Event (started 7/21/25), Coccyx: Place foam dressing as preventative to area - change daily (started 8/8/25 and discontinued 8/25/25), Coccyx: cleanse area with soap and water, pat dry, apply Santyl to wound bed ONLY, cover with bordered foam dressing daily (started 8/25/25). Resident C's Nutritional assessment dated [DATE] indicated the resident was to or had been receiving a supplement / snack of bedtime snack. Resident C's coccyx wound assessments included: Date/Time Observed Pressure Ulcer: 8/4/25 at 2:10 P.M.Length - head to toe direction (centimeters) 4.5Width - side to side direction (centimeters) 1Stage: Unstageable - Deep Tissue InjuryTissue Type: Epithelial TissueComments: Husband present during assessment, informed of measurements and need to turn and reposition to relieve pressure to restore blood flow, also granddaughter present and asked if she could buy a body pillow to help with positioning.Created 8/8/25 at 8:13 P.M. Date/Time Observed Pressure Ulcer: 8/11/25 at 10:51 P.M.Length - head to toe direction (centimeters): 4.6Width - side to side direction (centimeters): 1Wound odor present? NoStage: Unstageable - Slough and/or EscharTissue Type: SloughPercent of wound covered by epithelialization tissue: 45Percent of wound covered by slough tissue: 55Wound healing status: DecliningCreated 8/25/25 at 8:56 P.M. Date/Time Observed Pressure Ulcer: 08/18/25 9:03 P.M.Length - head to toe direction (centimeters) 4.8Width - side to side direction (centimeters) 2.6Stage: Unstageable - Slough and/or EscharTissue Type: SloughPercent of wound covered by epithelialization tissue: 4Percent of wound covered by slough tissue: 96Wound healing status: DecliningCreated 8/25/25 at 9:06 P.M. Resident C's record contained no other documentation of the coccyx wound first assessed on 8/4/25 but not recorded into the resident's record until 8/8/25. Resident C did not receive a coccyx wound treatment order for the wound discovered on 8/4/25 until the wound was added to the record on 8/8/25. The following weekly assessments which indicated the worsening of the wound on 8/11/25 and 8/18/25 were not recorded into the resident's record until 8/25/25. The resident did not receive updated wound care orders for the worsening wound until the assessments were added to the record on 8/25/25. Resident C's record contained no physician orders to receive a bedtime snack and there was no documentation in the record that the resident ever received a bedtime snack. Resident C's progress notes dated 8/8/25 at 4:58 P.M., indicated the resident's last covered day (LCD) of 8/12/25 established by the intradisciplinary team (IDT) secondary to plateauing with skilled therapy services and no longer requiring skilled nursing services essential for achieving maximal potential. Resident C's progress notes dated 8/15/25, 8/19/25, 8/23/25, and 8/25/25 all indicated the resident's treatment included physical therapy and occupational therapy. During an interview on 3/2/26 at 10:47 A.M., Licensed Practical Nurse (LPN) 14 indicated that if a new wound was discovered, the nurse should open a wound event that would trigger an initial assessment that would be included in the resident record. After a wound event was created, a wound management/assessment would be triggered for the facility wound care nurse to complete routinely. If a resident received a recommendation for a bedtime snack, the nurse would obtain an order from the physician to be included in the resident's record and would be documented nightly if the resident received the bedtime snack. During an interview on 3/2/26 at 2:15 P.M., the Director of Nursing (DON) indicated the nutritional assessment completed for Resident C on 8/4/25 did not include a new recommendation for a bedtime snack but rather indicated the resident was already receiving a bedtime snack at the time of the assessment. The DON indicated the resident's initial wound assessment on 8/4/25 was entered into the wound management wound assessment and that a wound event was not created for the coccyx wound. 2. On 2/25/26 at 1:54 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, urinary tract infection, fracture of left femur, and anxiety. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/3/25, indicated Resident B was severely cognitively impaired, required set-up assistance from staff for eating, toileting, and transfers, and required supervision assistance from staff for bathing. Physician orders included, but were not limited to: Macrobid (an antibiotic medication) capsule 100 mg (milligrams) one capsule twice a day for five days; Start date 2/27/26 hydrocodone-acetaminophen (a narcotic pain medication) tablet 5-325 mg (milligrams) one tablet every six hours as needed for pain; Start date 2/23/26 Xanax (antianxiety medication) tablet 0.25 mg (milligrams) one tablet three times a day as needed; Start date 2/23/26 The care plan included, but was not limited to: (Resident) has history of reoccurring abnormal urinalysis that require antibiotic treatment; Edited: 2/25/26 Intervention: Administer antibiotics as ordered (Resident) has a left femur fracture that requires monitoring and treatment as indicated; Start date 2/24/26 (Resident) has an anxiety disorder diagnosis. Restlessness is her most common symptoms. Requires the use of antianxiety medications; Start date 12/2/24 During an interview on 3/3/26 at 8:52 A.M., the [pharmacy name] pharmacy technician indicated the pharmacy had two systems, one for receiving orders and one for sending out medications, and the systems had not aligned; Resident B's antibiotic, Macrobid 100 mg ordered on 2/26/26, was never sent to the facility and the facility had been using medication from the emergency drug kit (EDK). On 3/3/26 at 8:25 A.M., Resident B's electronic medication administration record was reviewed. The following dates staff had documented in the medical record that Resident B did receive an antibiotic, but no antibiotic was removed from the EDK to administer to Resident B:2/27/26 A.M.2/28/26 A.M. 3/2/26 A.M. On 3/3/26 at 10:59 A.M., the Director of Nursing (DON) provided a copy of the Controlled Drug Record for hydrocodone for Resident B. The following dates and times indicate a staff member signed hydrocodone out of the locked narcotic box, but the electronic medication administration record did not record a pain assessment or administration of hydrocodone to Resident B: 2/24/26 7:30 P.M. 2/25/26 6:00 P.M. 2/26/26 7:51 A.M. 2/27/26 7:00 A.M. 2/28/26 6:00 A.M. 2/28/26 2:30 P.M. 3/1/26 3:00 A.M. 3/1/26 10:00 A.M. 3/1/26 8:00 P.M. The following dates and times indicate a staff member signed Xanax out of the locked narcotic box, but the electronic medication administration record did not indicate evaluation of anxiety or administration of Xanax to Resident B: 2/26/26 7:51 A.M. 2/27/26 7:00 A.M. 2/27/26 10:00 P.M. 2/28/26 6:30 A.M. 2/28/26 2:30 P.M. 2/28/26 6:36 P.M. 3/1/26 3:00 A.M. 3/1/26 10:00 A.M. During an interview on 3/3/26 at 12:21 P.M., the DON indicated she was aware documentation of medication administration was an issue within the building. During an interview on 3/3/26 at 2:35 P.M., the Regional Nurse Coordinator indicated there was no specific facility policy regarding documentation, but that staff were expected to document timely and accurately. On 3/3/26 at 2:21 P.M., the Administrator provided am undated policy titled PRN (as needed) Medications, that indicated Upon the resident's complaint or observed symptom, the nurse will review the resident's medication profile to determine if a PRN order is available to address the situation. Medications given PRN (as needed) shall be recorded in the designated location on the front and reason for administration will be noted on the back of the Medication Administration Record (MAR). This record shall include the following: a. The resident's subjective symptoms or complaint OR the nurse's observation b. The dose, route, time, and, if appropriate, site c. The results of the medication given. This citation relates to intake 2721562. 410 IAC 16.2-3.1-50(a)(1) 410 IAC 16.2-3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed during incontinence care for 1 of 1 residents reviewed with a current urinary tract infection. (Resident B) Finding includes: During an observation of care on 3/2/26 at 1:43 P.M., Certified Nurse Aide (CNA) 7 and CNA 8 entered Resident B's room. CNA 7 and CNA 8 put gloves on. CNA 7 raised the bed and laid the bed flat with the bed remote with her gloved hand. CNA 7 looked in the closet for a brief. CNA 7 and CNA 8 rolled Resident B to her right side and pulled off the saturated brief beneath her. CNA 7 used wipes to clean Resident B's buttocks and put a new brief under her. CNA 7 applied cream with her right hand to the resident's buttocks, removed her right glove and put a new glove on her right hand. CNA 7 and CNA 8 rolled Resident B from her right side to her back, CNA 8 wiped the front of Resident B's perineal area from top to bottom. CNA 7 searched through items on Resident B's bedside table for a bottle of cream and then applied cream directly to the resident's vulvar area. CNA 8 fastened the residents brief and pulled her pants up. CNA 7 removed her gloves, collected the trash, and CNA 8 covered the resident with a blanket. CNA 8 lowered the bed and removed her gloves. Hand hygiene was not performed during care. During an interview on 3/3/26 at 1:40 P.M., the Infection Prevention Nurse indicated staff should perform hand hygiene and donn gloves before incontinence care, should change gloves between dirty and clean tasks, and should perform hand hygiene after care. On 3/3/26 at 2:21 P.M., the Administrator provided a policy titled Hand Washing/Hand Hygiene policy, dated 3/2016, that indicated Employees must wash their hands for at least twenty (40-60) seconds using anti-microbial or non-antimicrobial soap and water under the following conditions: When hands are visibly soiled before and after direct resident contact before and after assisting a resident with personal care upon and after coming in contact with a resident's intact skin 410 IAC 16.2-3.1-18(l)

Based on observation, interview, and record review, the facility failed to provide a sanitary environment for 1 of 5 units reviewed for environment. (Memory Care Unit) A blood spill remained on the carpet after a resident's fall. Finding includes:During an interview on 2/26/26 at 10:48 A.M., family indicated Resident B had a fall resulting in a head laceration. Family was visibly upset that when they entered the building, blood from Resident B's fall was still on the floor. During an observation on 2/26/26 at 11:15 A.M., there was approximately a 12 inch stain of what appeared to be dried blood, on the floor next to the nurses station in the Memory Care Unit. During an observation on 3/2/26 at 10:18 A.M., the stain was still prevalent on the floor next to the Memory Care Unit nurses station. During an interview on 3/3/26 at 8:37 A.M., Housekeeper 11 indicated that if a blood spill occurred, staff would clean the spill up immediately and would notify housekeeping to come and disinfect the area. They were unaware of the blood stain next to the nurses station on the Memory Care Unit. On 3/3/26 at 2:21 P.M., the Administrator provided a policy titled Cleaning of Spills or Splashes of Blood or Body Fluids, dated 6/2019, that indicated Spills or splashes of blood of body fluids must be cleaned, and the spill or splash area decontaminated as soon as practicable. Whoever spills or splashes blood or body fluids, or witnesses splattered or spilled blood anywhere in the community shall immediately contain the spill or splash as best as possible and notify environmental services that a spill or splash of blood or body fluids has occurred. 410 IAC 16.2-3.1-19(f)

Based on interview and record review, the facility failed to ensure notification was given to a resident's representative of a worsening pressure ulcer for 1 of 3 resident's reviewed for wounds. (Resident B)Finding includes:On 9/8/25 at 9:41 a.m., Resident B's clinical record was reviewed. Diagnoses included but were not limited to epidural hemorrhage without loss of consciousness, subsequent encounter, pressure ulcer of unspecified site, stage 2, protein-calorie malnutrition, paraplegia, unspecified, essential hypertension, hyperlipidemia, age-related osteoporosis, other fracture of T5-T6 vertebra, anemia, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and unspecified dementia. An admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident B's cognition was moderately impaired, dependent on bed mobility, and toileting. Resident B was admitted to the facility on [DATE] and discharged on 8/27/25. Care plans were reviewed and included, but were not limited to: Resident is at risk for skin breakdown r/t (related to) impaired mobility, anemia, paraplegia, initiated 7/22/25. Interventions included but were not limited to: assist with bed mobility as indicated, elevate heels as the resident will allow, monitor skin for signs of skin breakdown, pressure reduction cushion in wheelchair, pressure reduction mattress, RD (registered dietician) to evaluate as indicated, turn and reposition (bed mobility), per the resident's individual needs, initiated 7/22/25.The resident had unavoidable skin breakdown with continued expected unavoidable deterioration r/t terminal illness and life sustaining measures have been discouraged, continuous urinary incontinence, peripheral vascular disease, paraplegia, chronic bowel incontinence, initiated 8/4/25. Interventions included but were not limited to: assist with bed mobility as indicated, elevate heels as the resident will allow, monitor skin for signs of skin breakdown, pressure reduction cushion in wheelchair, pressure reduction mattress, turn and reposition (bed mobility) per resident's individual needs, weekly skin assessment, initiated 8/4/25. The resident has a pressure ulcer on the left ankle, initiated 8/11/25.Interventions included but were not limited to: administer treatment as ordered, assist the resident with turning and repositioning, bed mobility, initiated 8/11/25.The resident has a pressure ulcer on the left heel, initiated 8/11/25. Interventions included but were not limited to: administer treatment as ordered, assist the resident with turning and repositioning, bed mobility, initiated 8/11/25. The resident has a pressure ulcer to the coccyx, initiated 8/11/25. Interventions include but are not limited to: administer supplements/vitamins as ordered to promote wound healing, admisniter treatment as ordered, encourage 75-100 % of meal and encourage fluids per pan of care, notify MD if area worsens, increase in pain or shows signs or symptoms of infection, pressure reducing cushion in wheelchair, pressure reducing mattress on bed, provide incontinence care after each incontinent episode, report labs, initiated 8/11/25. Orders for August 2025 were reviewed and included, but were not limited to:Coccyx place foam dressing as a preventative to area. Change every (indicate days) once a day, 6:00 a.m. - 6:00 p.m., start date 8/8/25, discontinued 8/25/25, (left ankle, left heel) Apply skin prep as a preventative daily. Remove old treatment prior to applying new, start date 8/8/25, discontinue 8/25/25.Coccyx cleanse area with soap and water, pat dry, apply Santyl to wound bed only, cover with bordered foam dressing daily, once a day 6:00 a.m.- 6:00 p.m. start date 8/25/25, discontinue 8/27/25.left heel, apply skin prep as a preventative daily. Remove old treatment prior to applying new, once daily 6:00 a.m.- 6:00 p.m., start date 8/25/25, discontinue 8/27/25.left outer ankle apply betadine BID (twice a day) and leave open to air once daily 6:00 a.m.- 6:00 p.m, start date 6:00 a.m., discontinue 8/27/25. Wound notes were reviewed and included, but were not limited to:Pressure ulcer - coccyx, date identified 8/4/25 2:10 p.m.Unstageable -deep tissue L (length) 4.5 cm (centimeters) W (width) 1 cm Comments: husband present during assessment, informed of measurements and need to turn and reposition to relieve pressure to restore blood flow, also granddaughter present and asked if she could buy a body pillow to help with positioning. Pressure ulcer - coccyx- date observed 8/11/25 10:51 a.m.Unstageable- deep tissueL- 4.6 cm W 1 cm Wound healing status- decliningPressure ulcer -coccyx - date observed 8/18/25 9:03 a.m.Unstageable- slough and/or escharL- 4.8 cmW 2.6 cmWound healing status- decliningPressure ulcer- date observed 8/25/25 at 11:06 a.m.Unstageable -slough and/or escharL 5 cm W 5 cm Unstageable - slough and/or escharTissue type: necrotic tissue Wound odor- yes Wound healing status- decliningComments: recently noted cognitive decline, decline in mobility, and positive for COVID. Also, a decline in appetite. Pressure ulcer left ankle date identified 8/6/25 at 6:00 amUnstageable -deep tissue L 1 cm W 1 cm Comments: husband present during assessment and informed of measurements and need for repositioning and pressure relief. Pressure ulcer left heel date identified 8/6/25 at 6:00 a.m.Unstageable - deep tissueL 4 cmW 2.2 cmComments: husband present during assessment and informed of measurements and need for repositioning and pressure relief. A wound note dated 8/25/25 at 9:18 a.m. for the left ankle unstageable deep tissue wound indicated a scab was formed over are. Podus boots on bilateral feet, air mattress in place. TX (treatment) changed to betadine BID to the area and leave open to air. Physician and spouse notified.The clinical record contained no information that Resident B's POA's (power of attorney ) representatives were notified of the resident's decline in the coccyx wound, nor were they informed of the development of the wounds to the left ankle or heel. The clinical record indicated that Resident B's POAs were her grandson and granddaughter, and the first contact for financial and health. Resident B's husband's contact information was not listed on the face sheet. On 9/9/25 at 9:17 a.m., the Administrator indicated Resident B's POA was not notified of the decline of the coccyx wound; on 8/25/25, the physician and spouse were notified. On 9/10/25 at 12:38 p.m., the Administrator indicated the facility did not have a policy related to notifying a resident's representative of a change in a resident's condition. This citation relates to Intake 2606700.3.1-5(a)(2)

Based on the interview and record review, the facility failed to ensure that Activities of Daily Living (ADLs) were provided daily to residents. Bathing/showers were not documented as done. (Resident B, Resident C)Finding includes: On 9/8/25 at 9:41 a.m., the clinical record was reviewed, for resident B, diagnoses included but were not limited to, epidural hemorrhage without loss of consciousness, subsequent encounter, pressure ulcer of unspecified site, stage 2, protein-calorie malnutrition, paraplegia, unspecified, essential hypertension, hyperlipidemia, age-related osteoporosis, other fracture of T5-T6 vertebra, anemia, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and unspecified dementia. Resident B's clinical record included, but was not limited to, an admission MDS (Minimum Data Set) assessment, dated 7/24/25, indicated Resident B's shower/bathing dependent (the ability to bathe self, including washing, rinsing, and drying self). Resident B was admitted to the facility on [DATE] and discharged on 8/27/25. Care plans were reviewed and included, but were not limited to: ADL's functional status/rehabilitation potential, resident is unable to independently perform late loss ADL's r/t generalized weakness and debility, impaired gait and mobility, A-Fib, recurrent DVT ( deep vein thrombosis), osteoporosis, dementia, anemia, thoracic spinal epidural hematoma, paraplegia, chronic T5 FX (fracture), andb requires assistance/encouragement for bed mobility, transfers, toileting and eating, start date 7/22/5. Interventions included but were not limited to: assist/encourage resident in proper transfer/bed mobility, toileting/hygiene, and eating, start date 7/22/5Point of care history for bathing was reviewed for July and August 2025 and included the following:July 7/29- PBB (partial bed bath) 7/24- shower 7/23- PBB7/23- shower August 8/25 - PBB8/20 - PBB8/19 - PBB8/18 - PBB8/17 - PBB8/16 - PBB8/14 - PBB8/13 - PBB8/11 - CBB (complete bed bath)8/8 - PBB8/7 -PBB8/6 - PBB8/5 - PBB8/2 - PBBNo documentation of refusal was observed in the clinical record. On 9/9/25 at 2:19 p.m., Resident C's clinical record was reviewed. An admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident C's cognition was severely impaired, shower/bathe dependent ( the ability to bathe self, including washing, rinsing, and drying self). Resident C was admitted to the facility on [DATE].Care plans were reviewed and included, but were not limited to:Category: CNA Assignment Sheet: Resident has specific needs related to theircare, start date 7/17/25. Interventions included but were not limited to: Resident prefers a shower/bath on Tuesday and Friday and the day shift, start date 8/1/25. Point of care history for bathing was reviewed for July, August, and September 2025 and included the following:July7/29 - PBB7/22 - PBB7/21 - CBB7/20 - CBB August8/29 - PBB8/28 - PBB8/26 - CBB8/25 - PBB8/22 - CBB8/20 - PBB 8/19 - PBB8/17 - PBB8/16 - PBB8/14 - PBB 8/13 - PBB8/11 - CBB8/8 - PBB8/7 - PBB8/6 - PBB8/5 - PBB8/2 - PBB8/1 - CBBSeptember 9/8 - PBB9/3 - PBB9/2 - showerOn 9/10/25 at 11:24 a.m., CNA 2 indicated there is a shower sheet where bathing and resident refusals are documented. If a resident refuses, you have to ask them three different times and let the nurse know. Daily bathing is also supposed to be documented on the computer, including the type receivedOn 9/10/25 at 12:24 p.m., the Administrator provided the current policy on ADLs with a revised date of March 2018. The policy included but was not limited to: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .This citation relates to Intake 2606700.3.1-38(a)(1)

Based on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for the care of a colostomy for 1 of 1 residents reviewed for ostomies. (Resident D) Finding included: On 2/17/25 at 9:45 a.m., Resident D indicated he had a colostomy bag, the nurses took care of it, the Certified Nursing Aides (CNA) generally run from it if he needs care to it. On 2/18/25 at 10:13 a.m., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, colostomy status, age -related physical debility. An admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact, he had an ostomy. Resident D admitted to the facility on [DATE]. Care plans were reviewed and included, but were not limited to: Resident requires care and assistance related to ostomy; potential for complications, created date 1/17/25. Approaches included, but were not limited to: change wafer and ostomy as ordered, provided ostomy care as ordered and as needed (PRN), approach start date 1/17/25. January and February physician orders were reviewed and contained no orders for the care of Resident D's colostomy. On 2/20/25 at 2:37 p.m., Licensed Practical Nurse ( LPN) 2 indicated a resident who was admitted with a colostomy would need orders for the care of it. Depending on the resident, the colostomy would be changed every 2 to 3 days, the order goes in pretty quickly after the resident is admitted to the facility. No policy was provided for admitting physician orders. This citation relates to Complaint IN00453438, IN00453757, IN00453495. 3.1-30(a)

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were performed during 1 of 1 wound care and 2 of 2 random observation for cleaning equipment in between residents. (Resident 33, Resident 11, Resident 16, Resident 13) Findings include: 1. On 12/6/24 at 10:17 A.M., RN (Registered Nurse) 2 and LPN (Licensed Practical Nurse)10 were observed performing wound care on Resident 33. RN 2 and LPN 10 both sanitized hands and donned plastic gowns and gloves. RN 3 cleaned the bedside table with cleaning cloth, opened a plastic trash bag, and set up clean dressing supplies with the same gloves on. RN 3 did not change gloves before she began to open supplies for dressing change. LPN 19 placed a drape on the floor to catch debris from the leg wounds. RN 3 began to remove the old dressings from Resident 33's legs with the same gloves that were used to clean the table with. Both RN 3 and LPN 2 removed gloves, sanitized, and then donned new gloves. LPN 10 removed the dressings from the right lower leg, removed gloves, and did not sanitize hands before new gloves placed. RN 3 applied wound cleanser to legs and both preceded to clean legs with gauze. RN 3 did not change gloves or sanitize before new dressing was applied. LPN 10 did not change gloves when starting to place new dressing and wrapping with ace wraps. After leg wrapping was completed, both RN 3 and LPN 10 doffed gowns, gloves, and then sanitized. On 12/4/24 at 11:07 A.M., Resident 33's clinical record was reviewed. Diagnoses included, were not limited to, non-pressure chronic ulcer of left calf with fat layer exposed, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, cellulitis of right lower limb, and cellulitis of left lower limb. The recent Quarterly MDS (Minimum Data Set) Assessment indicated Resident 33 was cognitively intact, needed substantial help dressing and hygiene, but was independent with transfer. The resident had 3 venous ulcers on legs. Current Physician Orders included, but were not limited to: Betadine (povidone-iodine) solution; 10 %; amount: apply to buttocks/thigh; topical Special Instructions: apply to blood blisters to buttocks/thigh, Twice A Day Upon Rising 07:00 AM - 11:00 AM and Before Bedtime 06:00 PM - 10:00 PM dated 11/28/2024. The current care plan dated 10/7/24 indicated Resident 33 is at risk for complication related to bilateral lower leg venous ulcers and needed monitoring and treatment. Interventions included, but were not limited to, refer to inpatient rounding wound MD and nurse for monitoring and treatment and provide treatments to BLE (Bilateral Lower Extremities) as ordered. See MAR (Medication Administration Record) for current recommendations. During an interview 12/06/24 at 10:35 A.M., LPN 10 indicated the gloves should have been changed after the table was cleaned and before the supplies were opened. RN 3 indicate it was not done. During an interview on 12/10/24 at 9:10 A.M., the DON (Director of Nursing) indicated the gloves should be changed when going from dirty to clean and sanitized before new gloves applied. On 12/10/24 at 9:05 A.M., the DON provided a current policy Hand Washing/Hand Hygiene dated 3/24/2016. The policy indicated . hand hygiene with alcohol-based hand gel is the preferred if hands are not visibly soiled .use of hand gel is to be used in the following situations: before handling clean or soiled dressings, after handling used dressing, after removing gloves . 48147 2. During a continuous observation on 12/6/24 from 7:58 A.M. to 8:19 A.M., LPN 9 was observed wearing a blood pressure monitor around her wrist. She entered Resident 13's room, removed the monitor from her wrist, placed it on Resident 13's wrist, and took the resident's blood pressure. The blood pressure monitor was not sanitized after use. LPN 9 placed the blood pressure monitor into a small bag on the medication cart while preparing medication for Resident 16. 3. At 8:19 A.M., LPN 9 retrieved the blood pressure monitor from the small bag, placed it around her wrist, and entered Resident 16's room. LPN 9 removed the monitor from her wrist, placed it on Resident 16's wrist, and took the resident's blood pressure. The blood pressure monitor was not sanitized prior to use. On 12/9/24 at 8:45 A.M., the DON indicated that blood pressure equipment should be cleaned between residents. On 12/9/24 at 10:32 A.M., the DON provided a current Cleaning and Disinfection of Equipment policy, effective 6/6/2019, that indicated Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. 3.1-18(b)(1) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during 5 random observations. Odor was present in the facility and a resident wall was soiled with paint chipped out of the wall. (Memory Care Unit, East Hall Nurse Station, Front Lobby, room [ROOM NUMBER]) Findings include: 1. On 12/6/24 at 7:17 A.M., the Memory Care unit was noted to have an odor consistent with marijuana. 2. On 12/6/24 at 8:36 A.M., the East Hall Nurses Station was noted to have an odor consistent with marijuana. 3. On 12/9/24 at 8:45 A.M., the front lobby was noted to smell like sewer gas. During an anonymous interview, it was indicated that there was a strong odor upon entering the facility During an anonymous interview, it was indicated that there were pervasive odors in the facility especially on the East Hall. On 12/9/24 at 8:45 A.M., the Director of Nursing (DON) indicated staff and residents should not use marijuana while in the facility. She indicated the lobby sometimes smelled like sewer gas due to a backed-up trap, especially when it rained. At 12/9/24 at 10:32 A.M., the DON indicated there was not a specific policy for controlling odors and that housekeeping and maintenance took care of those issues. On 12/9/24 at 10:48 A.M., Housekeeper 5 indicated that if an odor was noticed, it would be treated accordingly with the most appropriate option. At that time, Housekeeper 5 provided an undated Daily Cleaning Inspection Form that indicated Closet looks and smells clean . Bathroom smells clean, no odors noted. 48057 4. During an observation on 12/4/24 at 10:44 A.M., dried deep red smears, missing chips of paint, and scuff marks were observed along the walls of room [ROOM NUMBER]. During an interview on 12/9/24 at 10:50 A.M., housekeeper 5 indicated each resident room is inspected each day, is deep cleaned once a week, and staff should clean anything out of the ordinary any time it is observed. A daily cleaning inspection form, dated 12/6/24, indicated a full deep clean was performed on 412. During an observation on 12/10/24 at 8:25 A.M., dried deep red smears, missing chips of paint, and scuff marks were observed along the walls of room [ROOM NUMBER]. On 12/9/24 at 1:11 P.M., the Director of Nursing provided a policy titled Quality of Life Homelike Environment, revised 8/09, indicated The facility staff and management shall maximize the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Cleanliness and order. The facility staff and management shall minimize the characteristics of the facility that reflect a depersonalized, institutional setting. Theses characteristics include: Institutional odors. This citation relates to Complaint IN00448045. 3.1-19(f)

Based on interview and record review, the facility failed to ensure a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form and Notice of Medicare Non-Coverage (NOMNC) was provided following the end of Medicare skilled services for 1 of 1 resident who discharged from Medicare services and continued to reside in the skilled nursing facility. (Resident 33) Findings included: On 12/6/2024 at 10:15 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form was blank in response to whether Resident 33 received the SNF-ABN form as well as the Notice of Medicare Non-Coverage (NOMNC) Form. The BPN review form provided to the facility indicated Resident 33's Medicare coverage would end on 8/3/2024. Regional Support 7 indicated they did not have the required documents (CMS 10055 AND NOMNC 10123) signed by the resident or representative for beneficiary notification. On 12/10/2024 at 11:05 A.M. the Director of Nursing indicated they do not have a policy in relation to advanced beneficiary notice of non-coverage but follow the instructions form found on the Center for Medicare and Medicaid Services website. 3.1-4(f)(2)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled properly for 2 of 2 medication carts observed. (West Hall, East Hall, Resident 16) Findings include: 1. On 12/4/24 at 9:33 A.M., the [NAME] Hall medication cart was reviewed. The following medications were observed without a label: Vial of ceftriaxone injection Vial of lidocaine, with an open date of 11/27/24 written on it with black marker Bottle of [NAME] aspirin, with an open date of 11/1/24 written on it with black marker At that time, Qualified Medication Aide (QMA) 8 indicated that the ceftriaxone and lidocaine were removed from the Emergency Drug Kit (EDK) and should have had the residents name written on it with black marker. The aspirin was brought in by a family member and should have had the resident's name written on it in black marker. 2. On 12/4/24 at 10:39 A.M., the East Hall medication cart was reviewed. The following medications were observed without a label: Lantus Solostar insulin pen, with an open date of 11/28/24 written on it in marker Humalog Kwikpen insulin pen, with an open date of 11/23/24 written on it in marker At that time, Licensed Practical Nurse (LPN) 9 indicated the insulin pens belonged to Resident 16 and should be labeled with his name. On 12/9/24 at 10:32 A.M., the Director of Nursing (DON) provided a current undated Medication Labeling policy that indicated All drugs dispensed for use by the residents in a facility .shall be labeled as follows: . a. Identification of the pharmacy; b. Resident's name; c. Date of Dispensing; d. Non-proprietary and/or proprietary name of the drug; e. Strength expressed in the metric system whenever possible . Over the counter medications used for a specific resident must identify that resident and have an appropriate pharmacy label applied. 3.1-25(j) 3.1-25(k) 3.1-25(l)

Based on observation, interview, and record review, the facility failed to ensure a sit to stand lift was used according to facility policy for 1 of 6 residents reviewed for falls. This deficient practice led to a fall with a fracture requiring hospitalization and surgical repair. (Resident M) Finding includes: During a confidential interview on 10/24/23 at 11:13 A.M., it was indicated that a CNA (Certified Nurse Aide) dropped Resident M while using a sit to stand lift resulting in a broken ankle. On 10/25/23 at 10:19 A.M., Resident M's clinical record was reviewed. Diagnosis included, but was not limited to, unspecified fracture of shaft of right femur. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 9/25/23, indicated Resident M had moderate cognitive impairment, had no falls since the prior assessment, and required assistance of 2 staff for bed mobility, transfers, toileting, and bathing. The quarterly MDS Assessment completed prior to the resident's fall, dated 1/17/23, indicated the resident had moderate cognitive impairment, had no falls since the prior assessment, and required extensive assistance of 2 staff for bed mobility, transfers, toileting, and bathing. A current falls care plan, dated 3/4/23, indicated the resident was at risk for falls with injury due to her impaired mobility, weakness, poor activity tolerance, and repair of right femur fracture. A previous falls care plan, dated 1/27/23, indicated the resident was at risk for falling and fall related injuries related to weakness, infection, and incontinence. A current behavioral care plan, dated 3/4/23, indicated the resident was noncompliant with care - selective as to which staff she would allow to work with; did not want to use sit to stand lift, but needed 2 staff minimum for safe transfers. A previous behavioral care plan, dated 1/27/23, indicated the resident was noncompliant with care - selective as to which staff she would allow to work with; did not want to use sit to stand lift, but needed 2 staff minimum for safe transfers. A Post Fall Assessment indicated Resident M sustained a witnessed fall on 2/28/23 at 5:15 P.M. while being transferred using a sit to stand lift. Progress notes related to the fall included, but were not limited to: 2/28/2023 6:18 P.M. Resident was on the sit to stand lift, weight became unbearable for staff. Staff lowered Resident to the floor, obtained the Hoyer lift administered pad and lifted resident to her recliner. No injury had occurred during transfers. Resident stated This was not bad. Refer for PT (physical therapy) to eval (evaluate) and treat. 3/01/2023 9:49 A.M. Resident c/o (complained of) pain 10/10 (10 on a pain scale of 1 to 10) to RLE (right lower extremity). Resident has bruise to right outer ankle. Notified [name of provider]. Order received for STAT (immediate) x-ray to bruised area RLE. 3/01/2023 3:02 P.M. Said nurse (writer) received Order for resident to be sent to [name of hospital] to eval and treat. Report giving [sic] to [name of nurse], called [name of emergency contact] to make aware. Management notified. 3/04/2023 1:00 P.M. Resident arrived via [name of company] transport van. She is on a Hoyer sling and in her wheelchair. She has an immbolizer [sic] on her right leg. She was transferred via Hoyer lift with assist of two staff from her chair to her bed. Sling was then removed and resident was positioned in her bed and pericare [sic] performed. She is now clean and dry. Skin assessment completed. Mild redness on buttocks from moisture contact. She has a [name of company] pain pump in her right leg set on 8. To disgard [sic] when empty. Resident M underwent surgery on 3/2/23 where a retrograde intramedullary nailing to the right femur was performed. 3/08/2023 8:39 A.M. IDT (Interdisciplinary Team) Note: Resident had incident on 2/28/23 where she was lowered to the floor due to weakness and unable to bear weight while being transferred in the sit to stand lift. Resident had increased pain to RLE the next morning, x-rays obtained and resident transferred to hospital for eval and tx (treatment). Resident returned to facility on 3/4/23. Care plan reviewed and updated upon return. Resident care profile updated to include Hoyer lift for transfers. A Post Fall Event Assessment, dated 3/2/23, indicated the fall on 2/28/23 was witnessed by [name of CNA 23] while being transferred from one surface to another using a sit and stand lift. The assessment indicated the resident said That girl swung me around and I told her to stop she was hurting my leg was hurting. Physical assessment showed new swelling, redness, and pain with active/passive ROM (range of motion). During an interview on 10/26/23 at 9:30 A.M., CCS (Corporate Clinical Support) 4 indicated two staff were needed to operate the sit to stand lift. At that time, she indicated she was unable to confirm details of the event including how many staff were operating the sit to stand lift because the staff involved no longer worked at the facility. During an interview on 10/27/23 at 1:30 P.M., CCS 4 indicated a representative from [name of company] came to the facility annually and provided an in-service on the sit to stand equipment. Following the in-service, staff completed a skills validation. At that time, she indicated after Resident M's fall, staff were provided additional education on the operation of the lift. A Transferring a Resident with a Hoyer/Mechanical Lift Skills Validation checklist was provided on 10/27/23 at 3:30 P.M. and indicated Two staff members are required for a mechanical lift. On 10/25/23 at 9:22 A.M. during a random observation, CNA 11 was observed transferring a resident from her wheelchair to the toilet and back to her wheelchair using a sit to stand lift by herself. On 10/27/23 at 2:48 P.M., CNA 11's Job Specific Orientation report was provided and indicated CNA 11 had received training on operating a lift on 9/19/23. On 10/26/23 at 11:05 A.M., a Transferring a Resident with a Stand Up Lift Skills Validations policy, undated, was provided and indicated Two staff members are required for a mechanical lift. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent falls for 1 of 3 resident reviewed for falls. The resident received two fractures in less than one month which resulted in multiple fractures to right arm. (Resident B) Finding includes: On 6/23/22 at 9:45 a.m., Resident B's record was reviewed. Diagnoses included, but not limited to, [CONDITION(S)], unspecified affecting right dominant side, [CONDITION(S)] following cerebral infarction, muscle weakness (generalized), age related physical debility, other abnormalities of gait and mobility, personal history of [CONDITION(S)] (TIA) and cerebral infarction without residual deficits. A quarterly MDS (Minimum Data Set) assessment, dated 5/10/22 indicated Resident B's cognition was severally impaired, the transfer, bed mobility, and toileting was extensive with 2 assist. Care plans were reviewed and included, not limited to, Resident is at risk for falling and fall related injuries related to impaired mobility, weakness, hx (history) of falls, right hemi r/t [CONDITION(S)]. Interventions included, not limited to, assist with ADL's (Activities of Daily Living), as needed to meet needs, assist with transfers as needed. Start date 6/29/21. ADL/Functional/Rehabilitation potential: resident is unable to independently perform late loss ADL's r/t impaired mobility, weakness, hx of falls, right arm hemi r/t [CONDITION(S)] and requires assistance/encouragement for bed mobility, transfers, toileting, and eating. Interventions included, not limited to provided assistance for transfers as indicated, start date 6/29/21. Orders for June 2022 were reviewed and included, not limited to: Activity level: Patient to transfer with assist x 2 with RW (rolling walker) with gait belt in place, start date 5/9/22. Progress notes were reviewed and included, not limited to: 5/4/22 at 1:02 p.m., Resident is requiring increased transfer and toileting assistance since re-admission .Staff is providing 2-3 for toileting, she is using BSC. 5/5/22 at 6:58 p.m., IDT note: .Her hospital stay has left her weaker and she has required assistance of 2 since returning from hospital . 5/18/22 at 7:30 p.m., resident was ambulating to bathroom with cna assist and cane, res lost balance and bumped arm on dining table in room causing skin tear to left elbow 4.5 cm area x 2.0 cm area, area cleansed with soap and h20 and steri-strips applied, will monitor for s+s [signs and symptoms] infection, md faxed. 5/18/22 at 10:08 p.m., res c/o left elbow hurting upon rom, noted swelling above left elbow. triage informed, awaiting reply . 5/19/22 at 10:21 a.m., New order per triage: Obtain stat xray of right elbow and shoulder. 5/19/22 at 5:15 p.m., NHT called concerning xray results, v/s and pain level. Xrays faxed to them . 5/19/22 at 5:24 p.m., NHT called, after talking to (name of physician), he said to speak with the family and see if they would like her sent out this evening or sent in the morning .Family states want resident sent to (name of hospital) this evening. 5/19/22 at 9:30 p.m., Resident returned from ER visit r/t right arm fracture . 5/20/22 at 3:30 p.m., .up with 2 assist WITH SHOES . Additional notes: Date/Time: 06/03/2022 10:30 AM Given in report this am that resident had been requesting pain medication. Stated resident was given a [MEDICATION(S)] earlier but was requesting another before it was time to have another one. This nurse ask if anything had happened to resident and night shift CNA and QMA stated no. When this nurse entered residents room this am resident was noted to be grimacing and diaphoretic. When ask what was wrong resident stated 'Arm hurt' this nurse called for the unit supervisor who was with resident next door. When ask where it hurt resident state 'here' and ran her left hand all the way up and down her arm. Sling was in place propped on a pillow. Supervisor talked with resident more while this nurse went to see if resident could have more pain medication and came back and administered [MEDICATION(S)]. Resident safety maintained, resident assessed from head to toe. DON notified, NHT notified with orders for STAT x-ray's, family notified. X-ray here and took x-ray with supervisor and DON in room. Orders received to send resident to ER for eval and tx. Family notified. AMR called at 9:45 arrived at 9:55 and left facility at 10:00. Created Date:06/03/2022 05:08 PM 6/03/2022 7:41 p.m., res returned from hospital per ambulance on stretcher with orders recd [received], splint right arm till seen by ortho, see [physician at name of clinic] within 7 days call for appt. ice packs for comfort, continue [MEDICATION(S)] for pain, resume orders. [MEDICATION(S)] 7.5mg q 6 hours routine. bp 129/74, pulse 74, resp 18, temp 98.2 , 02 sat 94% on r/a. no c/o pain or discomfort at this time. 6/08/2022 8:43 p.m. IDT Note: Resident reviewed for falls and injury during transfer that happened night of 6/2/22. Resident followed up with [name of clinic] today and is to be in sling at all times. Resident is receiving [MEDICATION(S)] 7.5mg routinely. Resident reports she feels much better and pain management is effective. On 6/23/22 at 12:20 p.m., Hospital provider notes were reviewed for 5/19/22 and included not limited to: .presenting today from a nursing facility after a fall with right arm injury. Reportedly found have a distal humerus fracture of her outpatient imaging . CLINICAL IMPRESSION 1. Distal right comminuted humeral fracture. 2. Possible nondisplaced distal radial fracture. The clinical records of the Hospital provider were reviewed at that time for the 6/3/22 incident and included not limited to: This patient comes emergency department for evaluation of right arm pain. She fell and broke her arm on the 19th and multiple fractures including distal humerus and radial head . XR HUMERUS RIGHT MIN 2 VIEWS Final Result by (name of physician) (06/03 1201) FINDINGS: Angulated right humeral neck fracture with comminuted fracture of the distal humeral metaphysis. The distal humeral metaphyseal fracture is similar to 5/19/2022. The humeral neck fracture is new. 1. Closed displaced fracture of surgical neck of right humerus, unspecified fracture morphology, initial encounter 2. Closed fracture of right wrist, initial encounter On 6/23/22 at 1:15 p.m., two state reported incidents were reviewed for Resident B and included not limited to: Report one: Incident date: 5/19/22 6:01 p.m. staff involved : CNA 1, CNA 2, CNA 3. Brief description of incident: 5/19/2022 around 7:30 p.m., resident was returning from bathroom with CNA 1. Resident was unable to keep her balance and bumped into table resulting in a skin tear. Resident reported she fell at 10:30 p.m., when being assisted from bathroom by CNA 2. Resident reported CNA 3 pulled on her arms. Type of injury: 5/19/22 resident has skin tear. Xrays were performed. Results: Recent transverse fracture distal humerus .Fracture distal humerus. Appears recent . Report two: Incident date: 6/3/22 8:01 a.m. staff involved: none listed Brief description of incident: 6/3/22 resident fell being transferred to bed. Type of injury: 6/3/22 humeral neck fracture. On 6/23/22 at 1:50 p.m., the DON was interviewed regarding Resident B's falls with fractures. The DON indicated that CNA 1 was assisting Resident B on both dates, was by herself assisting Resident B to transfer, was not using a gait belt on the fall on 5/18/22 and was supposed to have another staff member help her transfer, as Resident B is a 2 assist. The DON indicated she gave CNA 1 a verbal warning after the first fall, she is no longer employed at the facility because the CNA was assisting Resident B alone on the second fall. The DON indicated CNA 2 denied assisting Resident B, CNA 3, denied pulling on Resident B's arms, quit after she was suspended while the investigation was done of the fall. On 6/24/22 at 11:13 a.m., the DON indicated the progress notes dated 5/18/22 at 7:30 p.m., and 10:08 p.m., should have listed the right elbow instead of the left, the nurse mistakenly listed left instead of right. On 6/24/22 at 8:15 a.m., the DON provided the fall prevention policy dated May 2016. The policy included, not limited to . the following are guidelines for Community associates, interns, volunteers, and anyone else within [NAME], who interact with residents who may be a fall risk or have fallen .the components of this fall program include: 1. fall risk assessment, 2. fall event assessment, 3. Strategies of prevention, 4. Strategies of intervention, 5. Interdisciplinary guidance, 6. Care planning, and 7. Staff education .Strategies of prevention: Strategies for interventions to prevent falls will be individual for each patient. each section of fall risk assessment tool should be considered and staff should receive education pertaining to these risk factors to reduce falls . This Federal tag relates to Complaint IN 723. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent falls for 1 of 2 residents reviewed for accidents, which resulted in a fractured femur. (Resident 60) Finding includes: On 3/18/22 at 1:37 P.M., Resident 60 was observed sitting in a wheelchair in the dining room, slightly leaning head to the left side. On 3/21/22 at 8:36 A.M., Resident 60 was observed sitting in a wheelchair in the dining room, slouched forward and slightly leaning head to the left side. On 3/18/22 at 9:29 A.M., Resident 60's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's, dementia, anxiety, depression, and unsteadiness on feet. The most recent quarterly MDS (Minimal Data Set) assessment, dated 1/18/22, indicated Resident 60 was severely cognitively impaired. Resident 60 required extensive assistance of 1 staff with bed mobility, limited assistance of 1 staff with transfers, locomotion on the unit, eating, and toileting, and physical help of 1 staff with part of bathing, and the resident experienced 2 falls since their prior assessment. A risk for falls care plan, dated 12/25/21, included, but was not limited to, the following interventions: labs and urine checked to rule out infection (2/10/22), encourage bedtime toileting before bed (2/7/22), assist with ambulation as needed related to unsteady gait (10/25/21), escort resident to meals (8/30/21), assist with ADLs [activities of daily living] as needed (12/25/18), attempt to keep call light within her sight and reach to cue her to use for assistance as needed (1/20/22). The clinical record lacked falls risk assessments. Resident 60's falls included: Fall 1 2/5/22 8:17 A.M. Unwitnessed fall. Resident found in room lying on the floor on the right side. No injuries. The care plan was updated 2/7/22 to include encouraging resident to use the bathroom before bed. Fall 2 2/9/22 7:27 A.M. Unwitnessed fall. Resident was found by therapy staff lying on her bathroom floor on her back under the sink. At that time, a 3.5cm (centimeter) in diameter knot was observed above the right temple, purplish in color. The care plan was updated 2/10/22 to include labs and urine checked to rule out infection. Urine results indicated normal flora and unremarkable for infection. No other interventions were initiated on the plan of care after results were received. Fall 3 3/6/22 7:23 A.M. Witnessed fall. Resident in dining room ambulating toward a table. CNA witnessed resident getting unsteady, side stepped toward the left and fell before CNA was able to get to her. Resident complained of left hip pain. An x-ray of the left hip indicated a fracture involving proximal femur with no displacement. An IDT (Interdisciplinary Team) note, dated 3/7/22, indicated Residents results from x-ray, hairline fracture of left hip. Resident is out at [hospital] at this time. Intervention and Care plan will be updated when resident comes back to the facility. Resident 60 returned to he facility from the hospital on 3/9/22. The care plan lacked an updated intervention after the fall on 3/6/22. Implementation of the care plan could not be implemented as evidenced by observation on 3/16/22 at 11:30 A.M. Resident 60's call light by the bed had a pull string, as well as a cord with a push button. Neither the string nor the push button worked in the hall, and neither alerted at the nurses station. The call light in the bathroom was observed with a string wrapped around the handrail several times and unable to be pulled. On 3/22/22 at 9:33 A.M., the call light in Resident 60's bathroom was observed again with the string wrapped around the handrail several times and unable to be pulled. On 3/21/22 at 1:00 P.M., LPN 21 indicated Resident 60 used to be able to bring herself to the dining room, but after the most recent fall is unable to do so. She indicated her ambulation has declined since the hip fracture. On 3/22/22 at 10:27 A.M., the Regional Nurse Consultant indicated care plans should be updated with any significant change in resident status. At that time, the ADON (Assistant Director of Nursing) indicated orders and plan of care should be followed for all residents. On 3/22/22 at 10:26 A.M., a current change in a resident's condition or status policy, revised 10/10, indicated A significant change of condition is a decline or improvement in the resident's status that: Requires interdisciplinary review and/or revision to the care plan On 3/22/22 at 9:54 A.M., a current fall prevention policy, dated 5/16, was provided and indicated The fall risk assessment will be completed on each new admission, each readmission, with a change in resident condition, and quarterly with the minimum data set (MDS) schedule . A member/designee of the IDT will assist the team and update the care plan and the nurse aide assignment sheets to ensure accuracy of fall preventions . Fall risk care plans will be kept current by the IDT and other associates within each community 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure supervision was provided to prevent falls, resulting in a fall that caused hospitalization and bleeding in the brain for 1 resident (Resident P); and failed to implement interventions to prevent falls, for 3 of 4 residents reviewed for falls (Residents P, D, and B). Findings include: 1. On 1/4/22 at 9:30 A.M., during the initial tour of the Memory Care unit, the Director of Nursing (DON) indicated Resident P was currently in the hospital. He had recently fallen at the facility. The clinical record of Resident P was reviewed on 1/5/22 at 3:15 P.M. Diagnoses included, but were not limited to, [CONDITION(S)] and dementia. A care plan, dated 12/26/18 and updated 12/21/21, indicated: PROBLEM: Resident at risk for falling and fall related injuries related to hx [history] of falls, weakness, anxiety, the need for assist with transfers and toileting at times, possible medication side effects, and urinary incontinence along with dementia , psych dx [diagnosis] / psych meds. The Approaches included: Start Date: 12/21/2021 bolster to mattress; 11/15/2021 while in bed, ensure bed is in lowest position; 06/22/2020 Remind patient to ask for assist prior to transferring with walker; 12/26/2018 Assist with ADL's [activities of daily living] as needed to meet needs; 12/26/2018 Cue/remind Resident to utilize call light/pendant to seek assist as needed. A quarterly Minimum Data Set (MDS) assessment, dated 9/2/21, indicated Resident P had moderately impaired cognition, and required extensive assistance of 2 or more staff for bed mobility. The resident required total dependence of 2 or more staff for transfer, and did not ambulate. A test for balance during surface-to-surface transfer indicated, Not steady, only able to stabilize with staff assistance. Nurses notes included the following notations: 11/13/21 at 7:11 A.M.: CNA entered resident room to check on residents needs r/t [related to] call pendant. Resident noted laying on floor. This nurse entered room resident noted to be laying on right side with head on his pillow and covered from neck to feet with his blanket. CNA had been in the room 15 minutes prior . Resident stated 'I was trying to get my remote to lower my head and rolled out of bed' . Residents bed remote is out of residents reach r/t resident using it to raise the bed up to [sic]high. Re- Educated resident why the remote was not within which [sic]. 11/15/2021 at 9:23 A.M.: IDT [interdisciplinary team] met to review fall . Resident was noted to be on the floor with pillow under his head and covered with blanket. Resident stated he was reaching for his remote and rolled out of bed. No injuries noted upon assessment. MD and family notified of fall. Care plan reviewed and updated. Ensure bed in lowest position at all times while in bed. A Therapy Screen, dated 11/15/21 at 9:37 A.M., indicated, Fall screen - Resident declined therapy. Resident is a total assist. Was reaching for the remote and fell out of bed. Ensure items are within reach and bed is in lowest position. The therapy screen indicated Resident P was impaired in ADL's, transfers, ambulation, safety awareness, and cognition. The therapy recommendation indicated, No recommendations. Re-screen as needed. A quarterly MDS assessment, dated 12/3/21, indicated the resident had moderately impaired cognition, and required extensive assistance of one staff for bed mobility and transfer. A test for balance indicated he was not steady, and only able to balance with staff assistance. The resident had fallen twice since the last assessment. Nurses notes continued: 12/20/2021 at 5:00 P.M.: Called to resident's room by CNA who had entered room to get him up out of bed for supper and found him laying on the floor at the side of bed. No significant injuries noted but once up found that he'd hit the back of his head on the right side and it was about 3 cm [centimeters] in circumference and only raised slightly with some swelling. Denies any acute c/o's [complaints]. Vital signs and neuro checks initiated and all within normal limits for this resident. Ongoing monitoring. 12/21/2021 at 9:12 A.M.: IDT review of fall: patient on floor next to bed, noted raised are [sic] on head. no further injuries. patient alert oriented responds questions. intervention in place bolster to mattress. care plan updated, family and doctor aware. A Therapy Screen, dated 12/21/21 at 10:06 A.M., indicated, Fall screen - resident rolled from bed. Intervention is to recommend bolster to define bed boundaries. The therapy screen indicated the resident was impaired in self-care, transfers, ambulation - non ambulatory, safety awareness, and cognition. 12/23/2021 at 9:00 P.M.: [Recorded as Late Entry on 12/24/2021 01:16 AM] Called to residents room and resident on the floor on his right side. There is a large hematoma [raised bruise] on the right eye. No other injuries observed. Vital signs and neuro checks within normal limits. Called and notified daughter and called Dr . A Fall Event, dated 12/24/21 at 1:17 A.M., indicated the resident had been sitting in his wheelchair prior to the fall on 12/23/21 at 9:00 P.M., and was found on the floor next to the bed. The immediate intervention was to place the call light within reach, and do vital signs and neuro checks. Nurses notes continued: 12/24/2021 at 8:19 A.M.: F/u [follow up] fall. Report received that resident had a fall last night. Resident unable to give verbal responses at this time . Face has flat affect. Resident unable to follow commands. Weakness in BLE [legs] and BUE [arms]. Hematoma noted to right brow .Order obtained to send resident to ER An emergency room physician's note, dated 12/24/21 at 12:41 P.M., indicated, .Apparently, he fell and was on the floor around 1:00 this morning .the attendants felt that he was somehow altered mentally, and brought him to the hospital. His baseline is one of severe dementia, advanced [CONDITION(S)] .He has a periorbital [around the eye] contusion around the right eye .Today, he has a new subdural .his big issue is a traumatic brain injury .Assessment: 1. Fall with new traumatic brain injury An emergency room Trauma history and physical, dated 12/24/21, indicated, . brought to ED [emergency department] via [ambulance] today after an unwitnessed fall. Pt [patient] is aphasic [cannot speak] .Reportedly the pt lost consciousness after the fall. Pt has tremors in BUEs [arms]. Right periorbital ecchymosis [bruising around eye] noted. ASA [aspirin] 81 mg and [MEDICATION(S)] [blood thinner] noted on med list .Impression: . unwitnessed fall with large SDH [subdural hematoma, or brain bleed], small acute on chronic SDH bilaterally .hx of [CONDITION(S)] and severe dementia. On 1/6/22 at 10:15 A.M., the DON indicated Resident P was alert at times, but did have some confusion. The DON did not have additional information to add regarding Resident P's falls. 2. On 1/4/22 at 9:20 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident D had recently fallen. Resident D was observed sitting in a wheelchair in his room at that time. The clinical record of Resident D was reviewed on 1/5/22 at 10:30 A.M. Diagnoses included, but were not limited to, cerebral infarction (stroke) and abnormalities of gait and mobility. A care plan, initially dated 4/19/21 and updated 1/3/22, indicated, PROBLEM: History of falls and fall related injuries related to CEREBELLAR HEMORRHAGE and SEIZURES and HISTORY OF FALLS. The Approaches included: 01/03/2022 place sign in room to remind patient to call for assistance for transfer. 12/23/2021 non skid strips in front of recliner, bed, and toilet. 12/16/2021 Maintenance to repair/replace toilet seat. 07/07/2021 Ensure that dycem [a sticky-type material] is under the cushion on wheelchair seat. To prevent cushion from sliding. 07/05/2021 Dycem to recliner to assist with slipping. 04/19/2021 Cur/remind Resident to utilize call light to seek assist as needed. 05/10/2021 Offer/assist with non-skid socks frequently, as resident refuses to wear at all times. A quarterly MDS assessment, dated 11/12/21, indicated Resident D had severely impaired cognition. The resident required supervision of one person for transfer, and supervision of set up assistance for walking in room. A test for balance during transitions and walking was not completed. The resident had 2 or more falls since the last assessment. Nurses notes included the following notations: 10/22/2021 7:35 A.M.: [Recorded as Late Entry on 10/23/2021 07:23 AM] Notified by CNA that patient was lying on the floor in his bathroom. Upon entry noted pt sitting upright on his buttocks with bilateral legs extended in front of him. The pt was facing the toilet and voiced 'he slid down while going pee.' .Noted patient had no foot wear in place, non-skid socks put on patient and educated him that he has to wear some type of foot wear when he is up moving around, pt was argumentative with this writer. Educated staff to ensure patient has proper footwear on. Pt was assisted up from floor into w/c [wheelchair]with use of gait belt and 5 staff 10/25/2021 9:25 A.M.: IDT met to review fall. Resident fell while in bathroom. States he slid down while going to bathroom. Resident did not have non-skid footwear on at time of fall. Non-skid socks applied. Non skid strips to be placed in bathroom to reduce risk of fall. Care plan updated. Will continue to monitor. 10/26/2021 7:28 A.M.: patient found sittin [sic] up on bottom next to bed. stted [sic] he slid of side of bed. noted bed pads were under patient. patient currently using a mattress with bolsters. noted bed appeared to be slightly elevated for patient height . assist of 3 to stand 11/02/2021 7:53 A.M.: patient up in w/c in bathroom getting self ready for shower. staff in other room at end of hall heard resident call out. patient stated he was trying to get in shower without help. patient wa [sic] wearing brief only, shower was running. patient stated the w/c slipped out from under him while he was transferring. encouraged patient to call for assist, not to transfer self. 11/03/2021 1:08 P.M.: [Recorded as Late Entry on 11/23/2021 01:10 P.M.] IDT review fall on 11/2. Resident was in bathroom attempting to take shower. He slid in bathroom. No injury noted. IDT feel that non skid strips in BR would be beneficial. Plan of care updated. 12/15/2021 10:20 P.M.: Called to residents [sic] room per CNA due to fall in bathroom. Resident laying on left side next to toilet. No apparent injuries' observed. Denies any pain or discomfort. Resident helped to wheelchair .Will continue to monitor. 12/16/2021 9:34 A.M.: IDT met to review fall from 12/15/21 at 1020 P.M. Resident was noted to be lying beside toilet on L [left] side. No injuries noted upon assessment. Toilet seat noted to be loose. Intervention put into place: maintenance to replace/repair toilet seat. MD and family notified of fall. Care plan reviewed and updated at this time. 12/22/2021 5:31 P.M.: res [resident] witnessed by cna sliding out of recliner. full rom [range of motion] to ext x 4. no injuries noted. res did not hit head 12/31/2021 3:56 A.M.: Resident noted to be sitting on buttocks beside bed. Resident stated he was trying to get to his recliner. No injuries noted upon assessment. Resident did not have non-skid footwear on at time of fall. Vitals within normal range. Resident states he did not hit head. MD and family notified of fall. Will continue to monitor. 1/03/2022 10:50 A.M.: IDT review fo [sic] fall 12/31/21. patient reported he was transfering [sic] self from bed to get in recliner. no injuries noted, no c/o pain voiced. intervention in place place sign in room to remind patient to call for assist with transfer call so you don't fall. careplan updated, family and dr aware. On 1/5/22 at 11:30 A.M., Resident D was observed sleeping sitting in his recliner in his room. His recliner was by a window, and a dresser was between the bed and the recliner. The call light was lying by the bed, out of reach for the resident. The wheelchair was beside the resident. Dycem was not observed either under or on top of the wheelchair cushion. At that time, QMA 1 and LPN 1 were at the nurses station, and were questioned whether Resident D was supposed to have dycem in his chair. Both QMA 1 and LPN 1 indicated they did not know, but would check the resident's physician orders. They both checked the physician's orders, and indicated there was no order for the dycem. QMA 1 indicated she could ask physical therapy, because they were the ones responsible for providing the dycem for residents. On 1/6/22 at 10:15 A.M., the DON indicated Resident D was alert at times, but had confusion at times also, and so it was difficult to manage his falls. 3. On 1/4/22 at 3:35 P.M., the clinical record of Resident C was reviewed. Diagnoses included, but were not limited to, vascular dementia. An admission MDS assessment, dated 9/29/21, indicated Resident C had severely impaired cognition, and required extensive assistance of 2 or more staff for bed mobility and transfer. The resident had not ambulated during the previous 7 days. A test for balance during surface-to-surface transfers indicated, Not steady, only able to stabilize with human assistance. A care plan, initially dated 9/28/21 and updated 11/30/21, indicated, PROBLEM: History of falls and fall related injuries related to weakness, dementia. The Approaches included: 11/30/2021 handles/hand rails to toilet to assist with transfer and positioning on toilet. 11/16/2021 Therapy to eval for wheelchair positioning. 9/28/2021 Assist with ADL's as needed to meet needs. 9/28/2021 assist with transfers as needed. 9/28/2021 Cue/remind Resident to utilize call light to seek assist as needed. Nurses notes included the following notations: 11/15/2021 3:32 P.M.: Alerted by staff that resident was yelling for help. Upon entering room resident was laying on her right side with right arm behind her. Right hand was stuck in the leg rest knob on wheelchair. Resident ripped hand off wheelchair and began to get up. Assessment completed as best as it would, no apparent broken bones. Resident assisted into bed. Moderate amount of blood coming from right puncture wound to hand measuring approx. 4cm. Pressure applied, bleeding ceased and dressing applied. 911 notified, daughter notified, and appropriate paperwork prepared. 11/15/2021 4:12 P.M.: Social services inquired about where the wheelchair came from that resident injured her hand on as it was not the wheelchair therapy had issued to her. Informed social services that wheelchair was brought in a couple weeks ago for resident because her daughter [name], felt it was better suited for her mother as it was significantly smaller in size. Social services also inquired about how long resident could have been in the floor. This nurse had just been down that hall in [room number] checking vitals. A staff member stopped this nurse to let someone know that resident had just been taken to the bathroom. This nurse proceeded to go to [room number], take vitals, and then head back to nurse's station. Upon entering nurse's station this writer heard a scream from down the hall. Staff member yelled for this nurse to come to [room number]. Staff informed this nurse that after she helped toilet resident around 3PM, she went to get [another resident] her mail from the front desk and upon returning at 3:15 she heard resident say help. Upon entering room she noticed resident's right hand/arm was behind her so she was going to move the wheelchair. Staff reports she looked closer before touching the wheelchair and saw residents hand was stuck. Staff member immediately notified this nurse. A hospital discharge summary, dated 11/16/21, indicated, [Resident C] .with history of dementia and multiple falls .presents after fall from wheelchair in her nursing facility. She reportedly landed on her back and got her right hand caught in the wheelchair .Hospital Course: .Patient presents with right hand laceration that was repair in ED [emergency department] .consulted for L4 fx [back fracture] .Final diagnoses: S/P [status post] fall from wheelchair, L4 compression fx, Right hand laceration. 11/16/2021 9:14 A.M.: IDT met to review fall from 11/15/21 at 315 PM. Resident was sitting in wheelchair in room and was noted to be calling for help. Staff noted resident to be lying on R [right] side with R arm behind her. R hand noted to be stuck on peg for leg rest. Area cleaned by nurse and bandage applied. Resident sent to ER for further eval and treatment . Intervention put in place: therapy to eval for wheelchair positioning A Therapy Screen, dated 11/16/21 at 9:20 A.M., indicated, Resident with fall from w/c .Once returned from ER therapy will evaluate. The therapy screen indicated Resident D was impaired in ADL's, transfers, ambulation - non ambulatory, safety awareness and cognition. 11/16/2021 6:00 P.M.: Resident readmitted at this time, transported by ambulance. Transferred to bed from stretcher by emergency staff. Dressing in place to right hand laceration, hospital reported 8 stitches in place. Fingers to right hand swollen/red/warm to touch The resident was transferred to the Memory Care unit on 11/20/21 at 9:20 A.M. Nurses notes continued: 11/20/2021 2:27 P.M.: Witnessed fall in hallway by Memory Care nurses station. As resident was self propelling down towards the end of the hall holding onto the handrail with her left hand she attempted to stand. She was unable to straighten her knees. This caused her buttocks to slide off the wheelchair seat onto the ground. She was found sitting on her buttocks on the floor leaning up against the wall in at the end of the hallway yelling for help. No injuries 11/22/2021 9:42 A.M.: IDT met to review fall from 11/20/21 at 230 PM. Resident was attempting to stand in hallway using handrail. Resident slid out of chair onto floor. No injuries noted upon assessment. MD and family notified of fall. Care plan reviewed and updated at this time. Intervention put in place: therapy to eval for wheelchair positioning. 11/24/2021 8:18 P.M.: At approximately 6:42pm [Resident D's] room mate called out for help. When the CNA and myself arrived to her room [Resident D] was sitting on the floor in the entryway to the room. She stated she made it to the chair (from her bed), slid out of her chair to the floor and crawled to the entryway where we then found her . Upon assessment I saw a small red line over her middle spine about 1 inch long. The skin was not open. No other bruising seen A Therapy Screen, dated 11/26/21 at 12:16 P.M., indicated: Resident transferred herself from bed to w/c and then slid from w/c where she was found in doorway. Unsure if resident was in w/c that therapy had positioned her in. Resident should be in a reclining back w/c with posterior tilt and dycem in seat 11/29/2021 12:49 P.M.: Resident was being toileted by a therapist when resident reached for the toilet paper 'to help out' and fell between the wall and the toilet. Therapist witnessed the fall but was unable to get to resident in time due to the falls location. No injuries noted. Work order placed for maintenance to replace to toilet paper roll holder which was broken off when prior to residents fall [sic]. 11/30/2021 9:37 A.M.: IDT met to review fall from 11/29/21 at 1140 AM. Resident was being toileted by therapy and was reaching for toilet paper and fell off toilet. Therapist witnessed fall, no injuries noted upon assessment. Therapist unable to reach resident in time to prevent fall. Intervention to be put in place: Toilet seat with side handles for toilet positioning to be put in place On 1/5/22 at 3:15 P.M., the Administrator provided the current facility policy, Fall Prevention Policy and Procedure, dated May 2016. The policy included: A Fall Prevention Program is essential to the provision of care to our residents. Falls are among the most frequent critical health problems for older adults living in long-term care facilities .As such, the Community must take reasonable steps to ensure it implements best practices and evidence-based approaches to prevent falls and protect residents who are at risk for falling .Every resident will be considered a high risk for falls during their stay and individualized interventions will be introduced as needed for these residents. Other patients may be identified as very high risk for falls and additional interdisciplinary strategies to prevent falls and reduce fall risks will be implemented for this population .If a fall occurs, the interdisciplinary team (IDT) will meet collectively and examine the fall .Individualized interventions on the fall care plan will be duplicated onto care sheets to ensure care plan strategies are integrated into the health system On 1/6/22 at 10:15 A.M., the DON indicated he had no further information to provide regarding resident's falls. This Federal tag relates to Complaints IN 983 and IN 130. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to adequately supervise and implement specific interventions for 2 of 3 residents who were reviewed for falls. (Resident C and J) Resident C had multiple falls with two falls resulting in injuries. One resulted in a fracture of the right trochanter, and another a hematoma. A [NAME] monitor (portable electrocardiogram), used as an intervention, was misplaced and not replaced timely to monitor for [CONDITION(S)] symptoms. Findings include: 1. During the initial tour of the Memory Care unit, on 8/9/21 at 9:20 a.m., the Director of Nursing did not indicate Resident C had any falls or injuries with falls. During an observation on 8/9/21 at 12:30 p.m., Resident C was observed sitting in a recliner in her room. She was fully dressed. During an observation on 8/10/21 at 8:08 a.m., Resident C was observed sitting in a recliner in her room. Resident C was dressed in street clothes. Her bedside table was next to her. During a review of Resident C's clinical record on 8/10/21 at 10:24 a.m., the record indicated Resident C was severely cognitively impaired. Resident C's diagnoses included, but were not limited to, Alzheimer's disease, hypertension, Type II Diabetes, dementia. Resident C's Quarterly MDS, dated [DATE], indicated Resident C required supervision with ADLs, extensive assistance of one with hygiene, and physical help in part of bathing. Resident C required supervision and setup help for ambulating in her room. No falls were noted. Resident C's care plans included, but were not limited to, Resident is unable to perform late loss ADLs related to cognitive impairment secondary to dementia, and requires varying levels of assist with bed mobility, transfers, eating and toileting. Interventions included, but were not limited to, assist/set up for oral care at least twice daily, instruct resident in proper transfer, bed mobility, toileting/hygiene and feeding techniques, resident prefers to be assisted up in the morning at approximately 7-7:30 a.m. and to go to bed for the night at approximately 7:30-8 p.m., assist with daily household activities, provide incontinence care after toileting as needed. Start date 12/25/18, last revised 8/3/21. Resident is at risk for falling and fall related injuries related to pain, cognitive impairment secondary to dementia and incontinence. Interventions included, but were not limited to, appointment scheduled for cardiac overview on 8/2/21, lab values as follow up from fall, request heart/[NAME] monitor to check for [CONDITION(S)], staff to ensure patient has shoes on the correct feet, request visit from physician, schedule health drive appointment to see eye doctor on next visit, non-skid socks on at bedtime as tolerated, scoop/concave mattress, assist with ADLs as needed, keep personal items and frequently used items within reach, observe and report functional changes, place call light within sight and reach to cue her to use for assistance. Start date 12/25/18, revised 8/3/21. Orders included, but were not limited to, Concave mattress for safety. Start date 9/13/18. Heart Monitor x 14 days (remove monitor on the 16th and mail back on day shift), may shower but do not submerge [NAME] in water, push button on front of monitor if feeling dizzy or anything different. Start date 8/2/21, end 8/16/21. Resident C's assessments included, but were not limited to, 7/2/21 Fall risk assessment Assessment does not indicated if resident was high, moderate, or low risk for falls. Indicated a history of falls. 4/28/21 Fall risk assessment Assessment does not indicated if resident was high, moderate, or low risk for falls. Indicated a history of falls. A review of radiology reports indicated the following, 7/22/21- CT head without contrast. Impression: no evidence of acute intracranial process. Stable chronic changes. Interval development of an area of remote infarct in the right thalamus. 7/24/21- Right hip X-ray. Results: Avulsion greater trochanter. Appears recent. Osteopenia. [CONDITION(S)] change. Soft tissues unremarkable. Conclusion: Findings as above. If indicated clinically CT recommended. Resident C's progress notes indicated, but were not limited to, 6/16/21 at 3:53 p.m.-Resident ambulates without assistance. Gait unsteady at times, no recent falls. 6/21/21 at 3:09 a.m.- Resident reports she was turning over in bed and fell out of bed. Following fall from bed, resident independently got up from floor and came to nurses (sic) station to report that she had fallen. Has large goose-egg with ecchymosis and 5 cm (centimeters) skin tear to left forehead-cleansed with water. Alert and oriented to self, answering questions appropriately per baseline. Neuro checks initiated per protocol. No change in neuro status from baseline. Moving all extremities appropriately without evidence of fracture or dislocation. Reports mild discomfort to head where [CONDITION(S)] is present but denies other pain at this time. VSS (vital signs), see neuro flow sheet for vitals. [Name of physician] notified via fax. DON (Director of Nursing) notified via text message. Family to be called in morning before change of shift per QMA. 6/22/21 at 10:13 a.m.- IDT PROGRESS NOTE: On 6/21/21 at 3 a.m. resident was found on the floor beside her bed. Resident stated she rolled over in the bed and rolled out on to the floor. Resident with skin tear and hematoma to left side of forehead. Concave mattress to be placed on bed. 7/2/21 at 7:11 PM- Resident sitting in dining area visiting with peers. Alert and oriented to self as per baseline. Ambulatory independently, uses walker occasionally to steady gait. Can complete ADLs with assist of 1 and set up. Feeds self independently following set up. Denies pain or discomfort this PM. Continent of bowel and bladder. Hematoma to left face continues to heal appropriately. Unable to utilize call light appropriately due to dementia so needs are anticipated by staff. Able to voice needs appropriately . 7/20/21 at 4:27 p.m.- CNA alerted this nurse that resident was in the dining room sitting on her bottom. Upon assessment, resident was in the middle of the dining room on buttocks with hands behind her propping her in an upright position. Resident denies any injury or hitting head, stated, I lost my balance, my bottom is a little sore but that's it. Vitals obtained and WNL (within normal limits, no abnormalities noted to gait. Neuros WNL. Assisted resident to a dining room chair. Family/physician notified. Will obtain vitals every shift for 72 hours and neuros as directed. 7/21/21 at 12:10 a.m.- Resident sitting on floor near nursing desk. Sitting on buttocks with hands out beside her. Resident said she just sat down. Range of motion to arms and legs without difficulty. Denied pain or discomfort at this time. Ambulated back to room with 2 assist as resident somewhat unsteady. Assisted back to bed. Physician notified with no new orders, son notified and DON notified. Resident was fully dressed and barefoot. Vital signs and neuro checks initiated. 7/21/21 at 3:01 p.m.- Resident's granddaughter visiting with resident and felt she was not herself. Resident was seeing things not there. Granddaughter indicated this was how she used to be with a UTI (urinary tract infection). Faxed physician regarding resident's recent falls and not acting like her usual self, seeing things that are not there. 7/22/21 at 7:55 a.m.- Requested doctor to see for an acute visit for falls and hallucinations. 7/22/21 at 8:15 a.m.- Resident found on floor by Therapy just inside door way, lying on right side, signs and symptoms of pain to left hip. Resident was walking out to the dining room for breakfast. No injury noted to head. Resident was not responding as normal for resident. Physician and son notified. Resident was sent to hospital for evaluation and treatment. 7/22/21 at 12:03 p.m.- Recorded as late entry on 7/23/21 at 12:04 p.m Returned from emergency room . No new orders. 7/23/21 at 09:36 a.m.- IDT met to review falls. Resident fell and went to the emergency room for evaluation and treatment. Head CT was done without findings. Resident had a diagnosis of Vitamin B deficiency, will request a Vitamin B level. No UTI was found. Will request heart monitor related to recent repeated falls. Resident had fall with shoes on wrong feet. Will update CNA sheet to spot check her shoes to make sure they are on the correct feet. 7/23/21 at 6:03 p.m.- Recorded as Late Entry on 7/24/21 at 6:15 p.m. IDT review for behavior. Resident experiencing visual hallucinations of a child on the floor. Felt she needed to help the child get up. Resident exhibiting increased agitation when staff attempts to assist her and expresses, is stuck in a concert and can't get out. Stating staff, pushed her down is why she fell and was sitting on the floor .Experiencing severe cognitive deficit, processing difficulties, increased confusion, and resistiveness to staff assistance. New behaviors, hallucinations are new. Granddaughter reported resident acted like this previously when she had UTI. Resident has a history of Covid-19 in the last 6 months. Physician and family notified, labs drawn. No UTI noted. The CT scan indicated she had experienced a brain bleed historically. Staff to continue to reassure resident she is in the right place and safe. Will encourage family to visit for additional support and involvement. Will encourage resident to sleep in the living room area of the unit for additional secure feeling, will follow further recommendations from physician. Resident to wear heart monitor related to medical status complication. 7/23/21 at 9:03 a.m.- Resident resting quietly in bed with eyes closed, respirations are even and unlabored at rest. Resident has remained alert, oriented to self as per baseline, but this week has had increase in new confusion and was sent to the emergency room for work up related to falls and confusion. Resident has required assist of 2 during ambulation with possible [CONDITION(S)] sensation with position changes. Utilizing wheelchair for self- propelling and mobility at this time. Remains continent of bowel and bladder and able to feed self with set up by staff. Completes ADLs with extensive assist of 1. Pain from falls treated with PRN (as needed) Tylenol (analgesic). 7/24/21 at 11:12 a.m.- Resident continued to complain of right hip pain. Non-weight bearing right leg. Physician in this a.m. Discussed pain, guarding, and non- weight bearing. Received orders for right hip x-ray, if displaced fracture indicated, send to emergency room . Family notified. 7/24/21 at 4:11 p.m.- Received x-ray results which indicate: Avulsion of the right greater trochanter. Notified physician. Received orders to send to emergency room for evaluation and treatment. Notified son. Notified DON. 7/24/21 at 8:45 p.m.- Resident returned from hospital via ambulance. Vital signs as follows: BP 162/99, HR 64, R 16, 96% RA, T 98.2 orally. Resident complains of pain to right hip and leg, rubbing and grasping at right hip with position changes, hesitant to bear weight to right side with standing or transferring. Resident requires a total assist of 1 for transfers at this time. Orders from the emergency room are: weight bearing with walker flat foot. Resident to follow up with orthopaedic this week. Ambulate with assistance. Resume prior orders. Granddaughter updated regarding return of resident and orders received. Tylenol administered per PRN order for complaints of pain and discomfort. Reminded resident not to attempt to get out of bed without assistance, but she is more confused than baseline and is only oriented to self. Resident could not remember having a granddaughter told granddaughter had been updated that she had returned and updated on her condition. Extremely high risk for falls. Gripping socks in place and bed in lowest position and locked. Call light within reach, but resident unable to use appropriately. Denied further needs at present time. No other changes in condition or assessment at this time. Fax sent to physician regarding return of resident with no new orders, and with request from granddaughter to question about starting [MEDICATION(S)] (controlled pain medication) for increased pain related to trochanter displacement. 7/26/21 at 10:41 a.m. Two further interventions: 1. Follow-up with physician regarding a Heart Monitor Device. 2. Staff to provide more frequent checks on resident to promote her comfort and to reassure her with any personal care or other needs/wants. 7/26/21 at 4:15 p.m.- Resident appointment scheduled for 8/2/21 with orthopedics'. 7/28/21 at 3:36 p.m.- Physician's office called with appointment for heart monitor on 8/2/21. 7/30/21 at 9:02 a.m.- Resident has required assist of 2 during ambulation with possible [CONDITION(S)] sensation with position changes. Social worker arranging for cardiac monitor to assess for cardiac changes related to new falls. Utilizing wheelchair for self-propelling and mobility at this time. Remains continent of bowel and bladder and able to feed self with set up by staff. Completes ADLs with extensive assist of 1. Pain managed with scheduled Tylenol and [MEDICATION(S)] (analgesic) as ordered by physician. Orthopedic follow-up as scheduled for trochanter displacement. 8/7/21 at 8:15 p.m.- . Resident resting quietly in bed with eyes closed, resp (respirations) even and unlabored at rest. Alert, oriented to self, as is baseline. Ambulation mildly improved but gait remains unsteady and slow; requires assist of 1 for safety. Utilizing wheelchair for self -propelling and mobility as needed. Remains continent of bowel and bladder and able to feed self with set up by staff. Completes ADLs with extensive assist of 1. Pain managed with scheduled Tylenol and [MEDICATION(S)] as ordered by MD. Cardiac monitor in place. To continue therapy as directed by MD. 8/8/21 at 3:15 p.m.- [NAME] monitor is not in place and resident is unable to report where she put it. Notified physician and family is present and aware. During an interview with the Director of Nursing on 8/11/21 at 2:50 p.m., she indicated Resident C's [NAME] monitor had not been replaced yet. She was unsure where the original [NAME] monitor was, and how long it had been missing. She further indicated it was thought that Resident C's falls were cardiac related. 2. On 8/9/21 at 9:20 A.M., during the initial tour of the Memory Care unit, the Director of Nursing (DON) indicated Resident J had recently fallen. Resident J was observed at that time laying in bed, with upper and lower side rails up on the right side of her bed. The left side of her bed was against the wall. On 8/10/21 at 10:05 A.M., Resident J was observed sitting in a broda chair (a reclining-type wheelchair) in the lounge area with other residents. Staff were not observed in the lounge area. The clinical record of Resident J was reviewed on 8/10/21 at 10:55 A.M. Diagnoses included, but were not limited to, dementia. A Care Plan, dated 6/17/21 and edited 8/3/21, indicated: Problem: Resident at risk for falling and fall related injuries related to weakness/debility, impaired mobility, Dementia . The Approaches included: 3/21 Dycem [sticky material to prevent sliding] to seat of broada [sic] chair. 7/15/21 Therapy to evaluate for positioning in BROADA [sic] chair. 7/5/21 Provide activities when family done with visiting. 6/22/21 Hospice to bring patient BROADA [sic] chair to assist with positioning. 6/17/21 Assist with ADL's [activities of daily living] as needed to meet needs. 6/17/21 Assist with transfers as needed. 6/17/21 Cue/remind Resident to utilize call light to seek assist as needed. Resident Progress Notes included the following notations: 6/16/21 at 2:35 P.M.: Transported by wheelchair van to [name of facility]. Ambulated to [Memory Care unit] via broda chair with family. Daughter reports resident needs total assistance with ADL's [sic] and is unable to feed herself 6/16/21 at 9:25 P.M.: Resident was sitting in a chair in the TV room, BLE [bilateral lower extremities] were dsngling [sic] off the side and she was trying to get herself up. Resident was quickly put back in her chair properly. Resident shows significant s/sx [signs/symptoms] confusion .Nursing will continue to monitor. 6/18/21 at 3:38 P.M.: Resident found on floor in room, no injuries. Resident frequently leans out of chair An admission Minimum Data Set (MDS) assessment, dated 6/19/21, indicated the resident had a memory problem, required extensive assistance of two or more staff to transfer, and did not ambulate. The resident had fallen in the month prior to admission, and since admission. Resident Progress Notes continued: 6/22/21 at 10:41 A.M.: IDT [interdisciplinary team] Progress Note: On 6-18-21 at 3:21 pm patient was found on floor of her room. patient had been sitting in her W/C [wheelchair]. Patient with no injuries noted. Patient is on hospice caseload. Hospice notified to bring patient a BROADA [sic] chair to help with positioning. 7/3/21 at 5:40 P.M.: Called to TV lounge room noted broda chair tipped forward resting on foot rest and [NAME] [sic] wheels were up off floor. Patient layin [sic] in front of chair on her right side .staff noted blood on blouse on right elbow, small skin tear pprox [sic] 2 cm [centimeters] associated with bruising. Area cleaned 7/5/21 at 9:34 A.M.: IDT met to review fall. Resident leaned broada [sic] chair forward. Resident became anxious after family left. Intervention is to provide an activity after visits. 7/14/21 at 4:02 P.M.: Nurse called to [Memory Care unit]. Resident sitting in the w/c & slid out onto the floor. Re-opened skin tear to right elbow .Resident restless per usual, was in day room 7/15/21 at 9:24 A.M.: IDT met to review fall. Resident sitting up in Broda chair and slid out. Therapy to eval positioning in the Broda chair. Will continue to monitor. 8/2/21 at 1:35 P.M.: Resident had unwitnessed fall at this time, was sitting in Broda chair with legs elevated, in lounge, somehow able to lower legs and slide out of chair onto floor, no noted injury 8/3/21 at 9:43 A.M.: IDT met to review fall. Resident slid out of Broda chair while in the lounge area. Dycem will be placed in broda chair. Will continue to monitor. On 8/11/21 at 8:10 A.M., Resident J was observed lying in bed, with upper and lower side rails up on the right side of her bed. On 8/11/21 at 11:30 A.M., QMA 2 indicated Resident J required side rails on her bed for fall prevention. During an interview with QMA 1 on 8/10/21 at 8:15 A.M., she indicated it was difficult to see residents on the unit because of being on the medication cart passing medications, and the nurses' station being stationed where it was. CNAs try to supervise residents the best they can, but it is impossible to see all of them all the time since there are just two of them. During an interview with the Scheduler on 8/11/21 at 10:36 a.m., she indicated the Memory Care unit did not have a nurse on the unit. They were usually staffed with a QMA and two CNAs. She further indicated at night she had difficulty scheduling more than one CNA, and sometimes had to just schedule a second CNA for half the shift. On 8/11/21 at 3:30 P.M., the Assistant Director of Nursing (ADON) provided the current facility Fall Prevention Policy and Procedure, dated May 2016. The policy included: .the Community must take reasonable steps to ensure it implements, best practices and evidence-based approaches to prevent falls and protect residents who are at risk for falling. Due to the risks associated with falls for older adults living in long-term care facilities, compliance with this policy is essential .Each fall risk assessment will be individualized for every resident assessed .Each fall risk factor is unique for every resident. The community will discuss and analyze fall risk factors and utilize existing resources and create new educational plans to reduce falls .Strategies for interventions to prevent falls will be individual for each patient This Federal tag relates to Complaints IN 691 and IN 824. 3.1-45(a)(2) .

Based on interview and record review, the facility failed to provide treatment to an existing pressure wound, and failed to prevent the development of an additional pressure wound for 1 of 3 residents reviewed for pressure wounds. Resident B was admitted with stage 2 pressure wound that was not treated until 14 days after admission, the wound was then classified as a stage 3 which needed surgical debridement; the additional wound was observed on 4/4/21 and not treated until on 4/7/21 when identified as a necrotic unstagable to the mid back.(Resident B) Findings include: On 6/7/21 at 10:45 am Resident B's record was reviewed. Resident B had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated 3/23/21 indicated resident B's cognition was moderately impaired, bed mobility extensive assist with 2 assist, transfers extensive assist with 2 assist, tilting extensive 2 assist, urine always continent, bowel occasionally incontinent, pain level of 7, short of breath. The MDS was marked for no pressure areas to skin, pressure reducing device in bed and chair, and yes for pressure risk. Care plans were reviewed and included, but were not limited to: Resident is at risk for pressure ulcers/injuries r/t cancer, DM, CHF, [CONDITION(S)], and anxiety. Start date 3/22/21. Long term goal: resident will not develop pressure ulcers/injuries. Interventions included: assist resident with turning and repositioning, bed mobility, encourage 75-100% of meal and fluid consumption, pressure reducing cushion in wheelchair, pressure reducing mattress on bed, provide incontinence care after each incontinent episode, refer to RD as needed. Resident is at risk for falling and fall related injuries related to cancer, pressure ulcer, DM, CHF, [CONDITION(S)], anxiety. Start date 3/22/21. Resident is unable to independently perform late loss ADL's related to [CONDITION(S)], DM, pressure ulcer, CHF, Gerd, [CONDITION(S)], [CONDITION(S)], anxiety. Start date 3/22/21. An admission nursing care plan dated 3/21/21 included, but was not limited to, pressure reduction mattress in place, provide treatment per physicians orders for compromised skin, staff assistance provided to routinely turn, reposition, or offload pressure related areas, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan in regards to the admission pressure wound, and the new pressure wound, was not developed. A nursing admission observation skin assessment dated [DATE] at 12:00 p.m., indicated skin as warm, dry, normal color, normal skin turgor, no petechiae present, yes- to skin injury, pressure ulcer to coccyx, 2.0 x 0.5, depth can't be measured, stage 2 marked partial thickness: loss of epidermis & into but not through dermis, granulation : pink or beefy red with shiny moist, granular appearance, 100 % of wound covered by granulation tissue. Edges attached to bases, skin surrounding wound pink/normal, no exudate no odor. Marked as existing. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Santyl ([MEDICATION(S)] [CONDITION(S)] histo.), ointment; 250 unit/gram; amount: sm (small), topical, special instructions: after cleaning wound to coccyx with soap and water apply small amount of Santyl, cover with alginate then a dry dressing. Change daily, once a day upon rising 7:00 am- 2:00 p.m. Start date 4/2/21, DC date 4/7/21. Santyl ( [MEDICATION(S)] [CONDITION(S)] histo.), ointment; 250 unit/gram; amount sm, topical. Special instructions: coccyx cleanse wound with soap and water, pat dry, skin prep surrounding tissues, apply nickel thick amount of Santyl to wound bed, cover with Calcium Alginate, then dry dressing. Change daily and PRN ( as needed), for soiled or dislodgement, once a day upon rising 7:00 a.m.- 2:00 p.m. Start 4/7/21, DC date 4/8/21. Change dressing to coccyx PRN dislodgement r heavy soiling PRN. Start 4/2/21, DC 4/2/21. Coccyx wound dressing, every shift to check placement, if off or soiled, replace. Start date 4/7/21, DC 4/7/21. Coccyx wound dressing, every shift to check placement, if off or soiled, replace. Special instructions, coccyx cleanse wound with soap and water, pat dry, skin prep, surrounding tissues, apply nickel thick amount of Santyl to wound bed, cover with Calcium Alginate then dry dressing. Change daily and PRN for dislodgement. Start 4/7/21, DC 4/8/21. Mid spine, cleanse with WC, pat dry, skin prep area, apply Calcium Alginate over wound bed, cover with dry dressing, change daily and PRN for soiled or dislodgement. Start 4/7/21, DC 4/8/21. Turn and reposition per plan of care , special instructions, intervention code, I= independent, A= assist. Start 3/20/21, DC 4/8/21. Weekly head to toe skin inspection to be completed per licensed nurse. If any new areas are noted please complete the change of condition event. Start 3/20/21, DC 4/8/21. [MEDICATION(S)] Men (mv, ca, min-iron, fa-lycopene), tablet, 8 mg (milligram), iron-200 mcg( microgram), 600 mcg, 1 daily. Start 3/20/21, DC 3/21/21. Thera multivitamin with [MEDICATION(S)], 400 mcg (microgram), 1 tab oral once a day. Start 3/21/21, DC 4/8/21. Activity level, patient to be up with one assist x 1 with RW (rolling walker). Start 3/22/21, DC 4/8/21. Activity level, up as tolerated. Start 3/20/21, DC 3/22/21. Chemo infusion to be discontinued today 3/31/21. Port to be flushed with 10 cc NS and 5 cc 100 unit [MEDICATION(S)]. All of this information and bio bag for the disposal of the chemo material has been given to .DON. Start 3/31/21, DC 3/31/21. There were no admitting orders for treatment to the coccyx wound. The EMAR ( electronic medication administration record) was reviewed for March & April 2021. It was documented by nursing staff that Resident B refused his weekly skin assessments on 3/24/21, 3/31/21, 4/7/21. Turning and repositioning was documented as done on the EMAR. CNA daily charting for incontinent care for bowel and bladder were reviewed for March and April 2021, Resident B's charting indicated Resident B was both incontinent and continent. Progress notes were reviewed and included, but were not limited to the following: 3/20/21 at 11:52 a.m., .explained to .the admission process and that once orders processed and medications available for pain control, this nurse would finish up with questions, assessment and skin check. 3/24/21 at 10:09 a.m., .DX (diagnosis) of metastatic [CONDITION(S)], diet is CCD/NAS, but therapeutic diet restrictions are not indicated with inadequate PO intakes, pressure ulcer to coccyx, inadequate calorie/protein intake for healing. 3/30/21 at 12:46 p.m., .resident has excoriation noted to the buttock area, also chemo pump/ball present and remains in place at his time slowly administering chemo .Resident states that he is unable to stand and uses bedpan or urinal, he remains continent . 3/31/21 at 9:53 a.m., .continent of bowel and bladder .resident has excoriation noted to buttock area and also has chemo pump/ball present that remains in place at this time slowly administering chemo . 4/2/21 at 11:13 a.m., resident allowed staff to turn him on his side to get his bottom cleaned and change the chux and brief as they were soaking wet. Area that he came in with on his coccyx is now 1.5 cm x 1.3 cm and 100% necrotic. Notified triage with tx request of Santyl, Alginate and dry dressing daily and PRN soiling and dislodgement. Dressing placed as requested. Notified DON and Administrator. Educated resident on the fact that he needs to turn side to side at least a couple times day even though he is on an air mattress . 4/3/21 at 6:46 p.m., .dressing changed to wound on coccyx. Resident having increased episodes of incontinence . 4/4/21 at 7:28 a.m., ( recorded as late entry on 4/5/21 8:01 a.m.) .total care for ADL's and repositioning .refuses to turn side to side .continues with wound to coccyx which now demonstrates 100% slough to the wound bed, with less than 1 mm of noted granulation to the wound bed. Also has a new area to the mid back on his spine measuring 6.8 cm x 1 cm x 0.1 cm superficial. Placed foam dressing to area for pressure relief after cleansing and applying skin prep. Continues on air mattress. As he is having increased episodes of incontinence and d/t the wounds on his back side . The record lacked documentation of the primary physician being notified and/or the resident representative of the new area on mid back. Wound management notes were reviewed and included two sets of measurements and information for the wound to coccyx: (First Wound) Observation history (by wound management): date/time observed 4/7/21 1:45 p.m. Wound type- pressure ulcer, Wound location: coccyx, date/ time identified: 4/7/21 10:15 a.m., present on admission/re-entry : no Length- 3 cm (centimeters) Width- 2 cm Depth can't be measured, moderate amount of exudate, exudate color and consistency -serous ( clear, amber, thin, and watery), no odor present. Stage- Unstageable- slough and/or eschar, no undermining, no [MEDICATION(S)] tract/tunneling present. Tissue type- necrotic, wound margins well defined , skin surrounding wound pink/normal. No wound vac present Wound healing status- stable, 100% of wound covered by eschar tissue Comments- new date/time observed 4/7/21 10:15 a.m. Length -1.5 cm Width- 1.3 cm depth can't be measured, light exudate, exudate color and consistency- serous, no wound odor Stage- Unstageable -slough and/or eschar no undermining, no [MEDICATION(S)] tract/tunneling present. Tissue type- slough 100% of wound covered by slough tissue edges/margins attached to base, macerated/soft, well defined wound edges, skin surrounding wound pink/normal No wound vac present Wound healing status: stable (Second Wound) Wound management notes reviewed for pressure ulcer to mid-upper back and contained two sets of measurements and information for the pressure ulcer to the back. date/time observed on 4/7/21 1:46 p.m. Wound type- pressure ulcer Wound location- mid-upper back Additional location details- spine date/time identified 4/7/21 10:17 a.m. present on admission/reentry- no Length - 4 cm Width - 0.5 cm Depth- 0.1 cm Exudate- moderate, exudate color and consistency serous, no wound odor Stage- 3, no undermining, [MEDICATION(S)] tract/tunneling Tissue type- granulation, 100% of wound covered by granulation tissue Wound edges/margins attached to base, well defined, surrounding skin pink/normal, no wound vac Wound healing status- stable Comments- new Length- 6.8 cm Width- 1 cm Depth - 0.1 Exudate- none, no wound odor Stage- 3 Tissue type- granulation, 100% of wound covered by granulation tissue Wound edges/margins- attached to base, well defined, surrounding skin pink/normal, no wound vac Wound healing stage- stable Specialty physician wound evaluation & management summary notes dated 4/7/21, for the treatment done at the facility by the wound physician, were reviewed and included : History- chief complaint- the patient has multiple wounds History of present illness - at the request of the referring provider, name of physician, a thorough wound care assessment and evaluation was performed today .has a stage 3 pressure wound of the left upper back for at least 7 days duration. There is moderate serous exudate. There is no indication of pain associated with this condition Medications affecting wound healing, no medications found to be affecting wound healing in clinical context. Patients chart reviewed on 4/7/21. Review of systems: Appetite- good Supplements -MVI Support surfaces- bed group 2, chair pressure reduction, feet, pillow Appearance- no acute distress Orientation- oriented to person, place, time and situation Mood and affect- calm and cooperative Skin- neck normal, back, wound present, see focused wound exam below, abdomen, normal, groin/buttock, wound present, see focused exam bellow. Left lower extremity, normal, left upper extremity, normal,, right lower extremity, normal, right upper extremity, normal. (First Wound) Focused exam (site 3) -Unstageable (due to necrosis) coccyx Etiology (quality)- pressure MDS 3.0 stage- unstageable necrosis Duration- > 7 days Objective- healing Wound size ( L x W x D) 3 x 2 x 0.1 cm Surface area - 6.00 cm Exudate- Moderate serous Thick adherent devitalized necrotic tissue- 100 % Site 3: surgical excisional debridement procedure: Indication for procedure- remove necrotic tissue and establish margins of visible tissue Procedure note- this wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, 15 blade was used to surgically excise 6 cm of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied. (Second Wound) Focused wound exam ( site 4) pressure wound of the left upper back Etiology ( quality)- pressure MDS 3,0 stage- 3 Duration- > 7 days Objective- healing Wound size- (L x W x D) 4 x 0.5 x 0.1 cm Surface area- 2.00 cm Exudate- moderate serous Granulation tissue- 100% Dressing treatment plan- primary dressing(s)- alginate calcium apply once daily for 30 days Secondary dressing(s)- gauze island (w/bdr) apply once daily for 30 days Coordination of care- data and history pertinent to this patients care were obtained via patient, nursing staff. This patients care was discussed with another health care provider nursing staff member during this visit. The clinical documentation for this consult was made available to the referring physician . this documentation is also available to skilled nursing facility at any time and for placement in the skilled nursing facility record. Follow up- evaluation by wound care specialist within 7 days with further interventions as indicated. On 6/8/21 at 2:20 p.m., the Wound Nurse indicated she saw in Resident B's record that he was admitted with a pressure ulcer to his coccyx, but did not see orders for it until April of 2021. She further indicated she was not employed at the facility at the time the resident was admitted . On 6/8/21 at 2:26 p.m., the DON indicated she could not find a treatment order for the wound to Resident B's coccyx that he admitted with on 3/20/21, until 4/2/21, and that she did not know how it happened, but it was missed. She further indicated the IDT (interdisplinary team), reviews the new admissions, but did not review Resident B's admission until 3 days after he was admitted , but Resident B was on an air mattress since he was admitted , and care plans were done by IDT or the MDS (minimum data set) Coordinator. On 6/8/21 at 2:26 p.m., the Administrator indicated not having a treatment to Resident B's pressure wound was missed. On 6/8/21 at 2:48 p.m., the MDS Coordinator indicated she did not do the admission MDS for Resident B, it was done by a traveling MDS Coordinator, she was not sure why pressure wasn't coded. She further indicated when she does an admission MDS she asks the unit supervisor, admitting nurse, or wound nurse details about the resident's skin condition, and looks at admitting skin assessments. On 6/9/21 at 8:35 a.m., LPN 2 indicated she is not the official wound nurse, but she will do assessments if the admitting nurse who does the initial skin assessment asks her to so an order can be done for treatment, and she notifies triage. She does a dressing to the area, sends what it is to triage to see if the physician wants to keep it or change it. She further indicated the Wound physician comes every Wednesday, and has done so for maybe the last 6 months. She did not remember charting a progress note on 3/24/21 that indicated the resident had a pressure ulcer to the coccyx, a nurse informed her of the resident's pressure ulcer to his coccyx, and she observed it, she believes that is when she put in the order for Santyl and turned it over to the Wound physician. She could not remember a specific date that she assessed the wound. On 6/9/21 at 9:03 a.m., LPN 1 indicated she thinks Resident B came in with excoriation to his buttocks and she may have noted it as excoriation not pressure, in the 3/31/21 progress note due to the resident was a very large man and it was hard to assess. She further indicated when she does an initial skin assessment there may be existing orders for a skin treatment, and if an area is found on the skin assessment she opens an event and notifies the physician. Event documentation was reviewed in Resident B's record and no event for the pressure wound to the coccyx that was there on admit, was found. On 6/9/21 at 1:30 p.m., the DON provided the current skin assessment policy dated 2/1/19. The policy indicated the following: Policy statement- (name of company) is committed to providing quality care to our residents which includes ensuring the completion of through skin assessments on admission and throughout the resident's stay. Procedure- Residents within a (name of company) will have head- to- toe skin assessment completed by a licensed nurse upon admission and weekly thereafter. The head-to-toe skin assessment will be charted as completed by the licensed nurse. The nurse doing the assessment will document any abnormal findings affecting the skin. If a new skin condition is identified by a licensed nurse while completing a skin assessment, the nurse will open the appropriate skin integrity event in Matrix and complete all required sections. The licensed nurse that discovers a new open area will perform the following actions: 1. Notify the MD, obtain and enter a treatment order 2. Apply initial treatment 3. Notify the family 4. Inform other caregivers to ensure preventative interventions actions are put in place to promote healing and inhibit development of additional areas. 5. Document these items in the medical record. This Federal tag relates to Complaint IN 819. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers from developing and failed to ensure pressure ulcers were identified at an early stage, resulting in pressure ulcers found at the advanced stages of an unstageable wound and deep tissue injury (Resident B); wounds found at a Stage 3 (Resident D); and a wound found as a deep tissue injury (Resident C), for 3 of 3 residents reviewed with pressure ulcers. (Residents B, C, and D) Findings include: 1. On 8/26/19 at 11:10 [NAME]M., during the initial tour, the DON indicated Resident B had pressure ulcers on both of his heels, and had acquired them at the facility. On 8/26/19 at 1:20 P.M., the DON was observed changing the dressing on Resident B's right ankle pressure ulcer. The ulcer was on the resident's right ankle bone and had a mainly pink wound bed with a scant amount of yellow tissue. The ulcer was surrounded by redness. There was no drainage on previous dressing. The DON indicated she had already changed the resident's left heel dressing. The clinical record of Resident B was reviewed on 8/27/19 at 5:55 [NAME]M. [DIAGNOSES REDACTED]. An admission MDS assessment, dated 5/20/19, indicated Resident B was moderately impaired with his cognition, and required extensive assistance of two or more staff for bed mobility, transfer, and personal hygiene. The resident had no pressure ulcers. Resident Progress Notes included the following notations: 5/23/19 at 9:45 P.M.: Admit DX (diagnosis): Physical debility. Alert and confused 6/2/19 at 11:04 [NAME]M.: .Alert to self et (and) family with confusion to time and place .Extensive 1-2 (assist) for adl's. No c/o (complaints of) pain .1-2+ (mild to moderate) [MEDICAL CONDITION] noted to BLE (bilateral legs) 6/11/19 at 2:26 P.M.: Noted flat blood filled and dark yellow skin noted on lt (left) heel. Protective padded boot applied after painted with [MEDICATION NAME] et wrapped with dry clean dressing. Has had no c/o pain with foot until now. Did not like feet elevated on pillows at all 6/17/19 at 7:55 P.M.: DTI (deep tissue injury) to left heel shows progress in healing .He often c/o neuropathic discomfort and will move his foot in the bed, as well as c/o knee pain that creates a restless leg syndrome at times, which contributed to the wound .He will keep the boot in place most of the time 6/25/19 at 5:10 P.M.: DTI to right (sic) heel presents as an unstageable wound with hard intact black eschar that has pooled then dried from original blister .Resident wears a multipodus padded heel protector at all times to relieve pressure to heel 7/27/19 at 10:27 [NAME]M.: Call to Triage and requested new tx order for area to left heel which has changed .Area is 2.5 x 2.5 cm with then (sic) entire eschar detached from periwound leaving a 0.2 cm width and depth around the entire wound. Moderate amount of purulent (pus) foul smelling drainage .Resident does c/o pain to the heel and leg .To right lateral ankle there is a 0.5 cm x 0.5 cm x 0.1 cm depth with 0.2 cm of yellow slough to the very center .Periwound intact with slight increase in pink .Ongoing monitoring. Wound Management documentation included the following: Wound Type: Pressure Ulcer. Wound Location: Left heel. Date/Time Identified: 06/11/2019, 04:14 PM. Present on Admission/Re-entry? No. Length (centimeters): 3.5. Width (centimeters): 6.7. Can depth be measured: No. Stage: Unstageable - Deep Tissue. Comments: deep purple blister with surrounding purple discoloration at heel. The most recent wound assessment, dated 8/26/19 at 10:46 [NAME]M., included: Left Heel-Length: 2, Width: 1.7. Can depth be measured: Yes. Depth: 0.2. Stage: Stage III Wound Type: Pressure Ulcer. Wound Location: Right ankle. Date/Time Identified: 07/27/2019. 06:58 PM. Present on Admission/Re-entry: No .Length: 0.5 (centimeters). Width (centimeters): 0.5. Can depth be measured? No. Stage: Unstageable - Slough and/or Eschar. Percent of wound covered by slough tissue: 100 The most recent wound assessment, dated 8/26/19 at 4:12 P.M., included: Right Ankle-Length: 0.4, Width 0.4. Can depth be measured? Yes. Depth: 0.1. Stage: Stage III A Care Plan, initially dated 5/20/19 and edited 8/26/19, included: Resident is at risk for skin breakdown related to decreased mobility, incontinence at times and needing assistance with his ADLs, dry skin to BLE and self-scratching. The Approaches included: Assist to turn and reposition approximately every 2 hours as appropriate. Promptly request treatment orders for any identified areas of concern from wound nurse and/or MD. On 8/27/19 at 10:05 [NAME]M., the left heel wound was observed with DON. Resident B was observed sitting in a wheelchair in the doorway of his room, wearing non-skid socks. The DON indicated the resident must have kicked off his boots. The boots were observed lying in a chair in the resident's room. After the resident was assisted to bed, the DON removed the dressing on the left heel. A pressure ulcer was observed on the left heel. The wound bed was mainly pink, and had some depth. No surrounding redness was observed. The DON indicated she had received a treatment change order the previous day, since most of the slough was gone. When questioned how the resident obtained the pressure ulcers, the DON indicated the resident would not lay on his side. She was unsure of how he obtained the ulcer on his ankle. On 8/27/19 at 12:35 P.M., the DON indicated the resident had had a Doppler test performed prior to being admitted to the facility, which revealed some arterial disease. She classified the pressure ulcer on the right ankle since it was right on the bone, but was unsure of the ulcer on the left heel. 2. On 8/26/19 at 11:00 [NAME]M., during the initial tour, the Director of Nursing (DON) indicated Resident D had pressure ulcers and vascular wounds, and went to the wound care clinic. The clinical record of Resident D was reviewed on 8/27/19 at 6:30 [NAME]M. [DIAGNOSES REDACTED]. Resident Progress Notes included the following notations: A Skin Risk Assessment, dated 4/23/19 at 9:00 P.M., included: Does the resident need assistance to reposition? Yes. Does the resident move in a way that could cause friction or shearing? No, Does the resident sit up for more than 2 hour periods of time? No. Does the resident refuse care? No. Is the resident's skin exposed to moisture .Yes. Does the resident have a history of pressure ulcers or other skin condition? Yes. The resident was transferred to the hospital on [DATE] for shortness of breath, and returned to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 5/6/19, indicated Resident D required extensive assistance of two or more staff for bed mobility, was totally dependent on two or more staff for transfer, and required extensive assistance of one staff for personal hygiene. The resident had no pressure ulcers. Resident Progress Notes continued: 5/7/19 at 4:44 P.M.: .Patient displaying lethargy (weakness) this shift. Will respond to voice and touch .Max (maximum) assist x 2 (with 2 staff)/transferred with Hoyer (mechanical lift)/ADLs (activities of daily living) . 5/13/19 at 9:38 P.M.: .LLE, foot/ankle presents with +3 [MEDICAL CONDITION] (swelling), BLE elevated. Faint pedal pulses noted 5/16/19 at 6:03 [NAME]M.: Fax received from Wound Clinic for resident's wound being treated dated from TX (treatment) 5/8/19 .(new pressure) wound to left plantar heel 5 x 5 x 1 (measurements in mm) with eschar (dead tissue) Documentation of a facility assessment of the left heel pressure ulcer was not observed at that time. Resident Progress Notes continued: 5/20/19 at 8:08 P.M.: Wounds assessed today .The left heel has a peeling intact scab with surrounding deep purple coloration 2.8 x 2.8 (centimeters). The area is tender with assessment 5/28/19 at 12:22 P.M.: Resident went to wound clinic today and they were asked to look at both feet/heels, per wound clinic .left and right heel have stage 3 pressure areas Wound Care Management included the following: Wound Type: Pressure Ulcer. Wound Location: Left heel. Date/Time Identified: 05/20/19 08:03 PM .Length (centimeters): 1.2. Width (centimeters): 1.2. Can depth be measured? No .Stage: Unstageable - Slough and/or Eschar. Tissue Type: Necrotic (dead) Tissue, Percent of wound covered by eschar tissue: 100. Skin surrounding wound: Dark purple or rusting discoloration; Scaling The most recent facility wound assessment of the left heel pressure ulcer, dated 8/26/19 at 9:22 [NAME]M., included: Length: 1.1, Width: 1.2, Can depth be measured? No. Stage: Unstageable - Slough and/or Eschar. Tissue Type: Necrotic Tissue. Percent of wound covered by eschar tissue: 100. Wound Type: Pressure Ulcer. Wound Location: Right heel. Date/Time Identified: 05/27/2019 10:02 PM. Present on Admission/Re-entry? No .Length (centimeters): 3, Width (centimeters): 3.5. Can depth be measured: No. Stage: Unstageable - Deep Tissue .Comments: deep purple blister with surrounding deep purple tissue. The most recent facility wound assessment of the right heel pressure ulcer, dated 8/26/19 at 9:15 [NAME]M., included: Length: 2. Width: 3.2. Can depth be measured? No. Stage: Unstageable - Slough and/or Eschar. Tissue Type: Necrotic Tissue. Percent of wound covered by eschar tissue: 100 A Care Plan, initially dated 4/24/19 and updated 8/22/19, indicated: Resident is at risk for skin breakdown r/t (related to) age related skin changes, impaired mobility, dementia, and incontinence. The Approaches included: Assist to turn and reposition approximately every 2 hours as appropriate. Attempt to position resident with wrinkle free linen and clothing while in bed. Promptly request treatment orders for any identified areas of concern from wound nurse and/or MD. On 8/27/19 at 9:30 [NAME]M., the left heel wound was observed. The RN Staff Development Coordinator (SDC) removed the dressing off the of the resident's left heel. A scant amount of drainage was observed on the old dressing. A small pressure ulcer, with a mainly pink wound bed and a small amount of yellow, was observed on the left heel. The RN SDC indicated she was unsure how the resident obtained the pressure ulcer. The RN SDC added she was unsure if the resident had a pressure ulcer on the right heel. RN SDC indicated she completes dressing changes at times to remain current with resident needs. On 8/27/19 at 9:50 [NAME]M., the Unit Manager (UM) was interviewed regarding Resident D's wounds. The UM indicated she was the wound care nurse and that Resident D went to the wound care clinic. The resident did have a pressure ulcer on the right heel, but she was going to call the wound care clinic to see if she could change the dressing times from daily to changing the dressings with wound vac dressing changes on Mondays, Wednesdays, and Fridays, due to the resident complaining of pain. On 8/27/19 at 12:00 P.M., the UM indicated the wound care clinic requested that the dressing changes on the right heel pressure ulcer be completed daily, so that the area does not get worse. At that time, LPN 2 assisted the resident with positioning. A pressure ulcer was observed on the resident's right heel. The ulcer was completely hard, black tissue. On 8/27/19 at 12:35 P.M., the DON provided physician statements which indicated the areas on her legs would not heal due to her severe [MEDICAL CONDITION]. The DON did not respond when questioned why the ulcers were found at an advanced stage. 3. On 8/26/19 at 4:15 P.M., the closed clinical record of Resident C was reviewed. [DIAGNOSES REDACTED]. A Skin Risk Assessment, dated 7/16/19 at 8:15 P.M., included: Does the resident need assistance to reposition? Yes. Does the resident move in a way that could cause friction or shearing? Yes, Does the resident sit up for more than 2 hour periods of time? No. Does the resident refuse care? No. Is the resident's skin exposed to moisture .No. Is the resident underweight, obese or lost weight in the last 3 months? Yes. Does the resident have a history of pressure ulcers or other skin condition? No. Does the resident have poor fitting footwear? No Does the resident use splints, have a cast, brace or a contracture? Yes. An admission MDS assessment, dated 7/19/19, indicated Resident C had a mild memory impairment, required extensive assistance of two or more staff for bed mobility, and was totally dependent on two or more staff for personal hygiene and bathing. The resident had no pressure ulcers. Resident Progress Notes included the following notations: 8/2/19 at 1:41 [NAME]M.: Res. admitted with dx. of pathological fracture of left ankle .res. assist of 2 staff, transfers surfaces with a slide board, is NWB (no weight bearing) to LLE (left lower extremity), does have metal appliance secured to LLE r/t fracture, res. does go to [MEDICAL TREATMENT] routinely. 8/7/19 at 4:06 [NAME]M.: .Needs extensive assist due to strict NWB to LLE. No c/o pain or discomfort this shift 8/8/19 at 2:13 P.M.: .also has a new DTI noted to left heel measuring 3.5 x 4.2 with some fluid buildup and blackened area mid wound .heels are floated when in bed, but with [DEVICE] in place, she will often roll her leg to the side so it rests on the fixator, which puts her heel on the bed. She has a leg positioner to raise legs off bed, but with fixator present, the screw portions protrude into the cushion and it does not provide sufficient height. Will monitor for proper positioning to maintain pressure relief Wound Management documentation included the following: Wound Type: Pressure Ulcer. Wound Location: Left heel. Date/Time Identified: 08/08/2019. 03:48 PM. Present on Admission/Re-entry? No. Length (centimeters): 3.5. Width (centimeters): 4.2. Can depth be measured? No. Stage: Unstageable - Deep Tissue. Tissue Type: Necrotic Tissue. Percent of wound covered by eschar tissue: 100 A Care Plan, initially dated 7/17/19 and edited 8/9/19, indicated, Resident is at risk for skin breakdown related to having decreased mobility and requiring assistance . The Approaches included: Assist to turn and reposition approximately every 2 hours as appropriate. Promptly request treatment orders for any identified areas of concern from wound nurse and/or MD. On 8/27/19 at 10:30 [NAME]M., during an interview with the DON, she indicated the facility attempted to keep Resident C's leg off the bed, but that the family would move it sometimes. According to the National Pressure Ulcer Advisory Panel, the following include different stages of pressure ulcers: Stage 3 Pressure Injury: Full-thickness skin loss. Full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer, meets the definition of a Stage 3 pressure injury. Granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this becomes an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss occurs with exposed or directly palpable fascia, muscle tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. The depth of the injury varies by anatomical location. If slough or eschar obscures the extent of tissue loss, an injury such as this would be described as an Unstageable Pressure Injury. Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon or purple discoloration. This type of injury may involve either intact or non-intact skin, presenting with a localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. This type of injury involves full-thickness skin and tissue loss. The extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If the slough or eschar is removed from the wound, a stage 3 or 4 pressure injury will be revealed. On 8/27/19 at 12:20 P.M., the SDC provided the current facility policy, Skin Risk Policy, effective 2/1/19. The policy included, Residents who are admitted to a (name of corporation) community will have a skin risk assessment .If any of the skin risk assessment questions are answered 'yes,' then the resident: (1) is at risk for developing a wound .Each skin risk assessment question that is answered 'yes' will be addressed by the staff through the care plan process. An intervention or interventions will be added to the individual resident's care plan to ensure care is provided to: 1. Prevent the development of a new wound/open area This Federal tag relates to Complaint IN 838. 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident at risk for falls was supervised while on the commode, resulting in a fall and emergency room treatment, for 1 of 1 residents reviewed for falls, in a sample of 3. Resident A Findings include: The closed clinical record of Resident A was reviewed on 7/10/12 at 10:45 A.M. [DIAGNOSES REDACTED]. An Interdisciplinary Care Plan, dated 2/28/12, indicated a problem of "At risk for fall related injury as evidenced by: Fall Risk factors present as determined by Fall Risk Screen Related to:...HTN (hypertension) Confusion (secondary to) CVA, hemiparesis (one-sided weakness) - CVA, gait disturb (sic)...." An admission Minimum Data Set (MDS) assessment, dated 3/15/12, indicated the resident required extensive assistance of two+ staff for transfer and toilet use, and did not ambulate. A test for balance indicated, "Not steady, only able to stabilize with human assistance" while moving on and off toilet. The MDS assessment indicated the resident had fallen in the month prior to admission, and had fallen since admission to the facility. A physician's orders [REDACTED]." A Fall Risk Assessment, dated 5/13/12, indicated the resident had intermittent confusion, had a history of [REDACTED]. Nurses Notes included the following notations: 5/22/12 at 4:50 A.M.: "Called to (room number) by CNA to check area where Res (resident) had an old skin tear. CNA exiting Rm (room) as I entered. CNA stated 'She is on the toilet.' I approached the residents (sic) bathroom (and) observed resident on the floor beside toilet. Head to toe assessment revealed depressed area between raised area on (left) shoulder (and) raised area below left shoulder. Denied pain to that area...Blood noted on left parential (sic) area...Moderate amt (amount) of bleeding noted left paritial (sic) area. Pressure held until bleeding stopped. Other areas include a small laceration noted on left knee (and) small abrasion noted on left forearm...911 notified. (Name of physician) and POA notified (and) will meet res @ (hospital)." 5/22/12 at 9:00 A.M.: "Res returned from ER. Only new order may rinse hair now; no shampoo X 48 (hours). Res has head abrasion to (left) upper forehead 3 x 1.8 cm (centimeters) - monitor q (every shift. Also rec (received) skin tear to (left) elbow 1.6 x 0.3 cm...." During interview with the Administrator on 7/10/12 at 1:50 P.M., she indicated the CNA should not have left Resident A alone in the bathroom. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident with change in condition was assessed for distention of the bladder and signs and symptoms of dehydration. The deficient practice affected 1 of 4 residents sampled for dehydration and incontinence in a sample of 4. (Resident A) Resident A was transferred to the hospital emergency room and was admitted to the hospital. In the emergency room 2000 ml of urine was drained from the resident's bladder. [DIAGNOSES REDACTED]. Findings include: On 1/30/12 at 3:30 P.M., the clinical record of Resident A was reviewed. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurses Notes included the following notations: 11/9/11 at 5:30 P.M.: "admitted to (room number)...Occ (occasionally) forgetful...Incont (incontinent) of bladder uses briefs, dribbles...needs assist for set up of oral care, meals. Assist (two) transfer...." A "Hydration Status Assessment," dated 11/9/11, indicated the resident had decreased food & fluid intake, dry skin & mucous membranes, and functional impairments. The assessment indicated the resident was not on a diuretic, had no renal impairment or [MEDICAL CONDITION], was not lethargic, had no abnormal lab results of electrolyte imbalance, and had no increased fluid needs. The resident's total score on the assessment was 3 ("If 8 or above, MD to be notified & hydration management interventions followed"). An Interdisciplinary Care Plan, dated 11/9/11, indicated, "Resident diagnosed with [REDACTED]." Approaches included: "Offer and encourage intake of fluids...." An additional Interdisciplinary Care Plan, dated 11/9/11, indicated, "Resident has potential for complications related to urinary elimination due to urinary incontinence, overactive bladder." Approaches included: "Monitor for complications or c/o (complaints of) dysuria (difficulty urinating), frequency...reduced urine output...Encourage adequate fluid intake...." Nurses Notes continued: 11/10/11 at 2:00 P.M.: "...Res (resident) will respond weakly to questions, takes sips H2O(water) (with) assist. Required to be fed for meals, takes few bites...Incontinent of urine x 4...." 11/11/11 at 6:30 A.M.: "...Incontinent of bladder, denies pain or burning upon urination. Cont (continues) on ATB (antibiotic) for UTI (urinary tract infection)...Res does c/o (complain of) frequency...." 11/11/11 at 1:00 P.M.: "Call out to (name of physician) office r/t (related to) pain medication...Pt (patient) noted to be lethargic when taking...(No) NO's (new orders) @ this time." 11/11/11 at 1:05 P.M.: "...Remains on ATB for UTI...Taking fluids well (with) encouragement et (and) staff queing (sic) pt while eating. Continues to c/o lethargy et weakness...." 11/11/11 at 5:00 P.M.: "Pt c/o nausea earlier...." 11/12/11 at 2:00 P.M.: "...Remains on ATB for UTI...Complains of urinary frequency, no pain or burning with urination...." 11/12/11 at 6:30 P.M.: "...Taking fluids (without) problems. Encouraged to eat when offered. Pt takes bites only." 11/13/11 at 5:00 A.M.: "...ATB for UTI...fluids encouraged (and) well taken...." 11/14/11 at 2:00 P.M.: "...N.O. received for [MEDICATION NAME] (antibiotic) et [MEDICATION NAME] (diuretic)...Res c/o some nausea...." 11/14/11 at 9:15 P.M.: "Offered water at this time, drank well with encouragement. Denied need to use bathroom...." An Interdisciplinary Care Plan, dated 11/14/11, indicated, "Resident at risk for fluid volume deficit R/T (related to) Diuretic Use." Approaches included: "Monitor and report to physician signs and symptoms of dehydration...Physical signs & symptoms of dehydration. Discuss with resident any concerns about fluid intake. Encourage fluid intake with and between meals. Observe for S/S (signs and symptoms) of dehydration & report to nurse:...Cracked lips, Dry mucous membranes, Dry skin/poor skin turgor, Dark urine, Poor fluid intake/thirst...Increased confusion...." A Nutrition Risk Assessment, dated 11/15/11, indicated, "...Diet order, Mech (mechanical) soft (with) gr (ground) meat...Eating ability: Needs Tray Setup, Partial Assist/Cueing...Average fluid intake fair...Nutritional Needs Estimation...Fluid Needs (mL): 1590 mL...." An additional Interdisciplinary Care Plan, dated 11/15/11, indicated, "...Potential for alteration in nutrition r/t Diagnosis: [REDACTED]." Approaches included: "Monitor food/fluid intake." Nurses Notes continued: 11/15/11 at 4:30 A.M.: "...Refused to get up to the bathroom (and) used bedpan x 2...Continues on ATB for UTI...." 11/16/11 at 4:15 A.M.: "...Has been Inc x 1 this shift. Refused to get up (and) go to Bathroom. Has not used bedpan...Has drank plenty of fluids...." A Physical Therapy progress note, dated 11/17/11 and untimed, indicated, "Pt very lethargic today. Pt unable to eat breakfast per daughter. Pt had to be woken from a 3 hour nap...Pt could hardly keep head up in wc (wheelchair)...Pt tol (tolerance) very poor today. RN notified." A note faxed to the physician, dated 11/17/11 and untimed, indicated, "Pt has an order for [REDACTED].@ night et (and) is unable to sleep. Could we maybe try Requip?" An additional note faxed to the physician, dated 11/17/11 and untimed, indicated, "(Resident A) is currently on ATB for a poss (possible) dx (diagnosis) of pneumonia. She has an occ (occasional) weak cough, productive @ x's (times), do you think a PRN (as needed) [MEDICATION NAME] (nebulizer) tx (treatment) would help her...." A dietician note faxed to the physician, dated 11/17/11 and untimed, indicated, "Resident was seen by dietician (and) made the following recommendations...Residents (sic) wt. this week is 109 lbs (wt loss of 7 lbs x 1 wk). PO (by mouth) intake is poor to fair. Would like to add 90 cc Med Pass TID (three times daily) as supplement." Nurses Notes continued: 11/17/11 at 1:30 P.M.: "...Taking fluids well (with) encouragement...." 11/18/11 at 4:00 P.M.: "...Pt remains weak. Not taking much nutrition. Encouraging med pass and magic cup when does not eat...Incont of Bowel (and) bladder. Wears briefs...." 11/18/11 at 7:30 P.M.: "Called to pt room. Had large incontinent stool...Abd (abdomen) distended, hard knot noted @ umbilicus area. Nontender to palpation, done very gently. Abd mass firm to touch...New order need to transport to (name of hospital) ER (emergency room ) for evaluation if family wishes." The resident was transferred to the hospital on [DATE] at 7:50 P.M. A hospital emergency room note, dated 11/18/11 at 10:59 P.M., indicated, "...The patient was evaluated shortly after arrival...She was noted to have a large lower abdominal pelvic mass which appeared to be bladder distention initially on evaluation. She is very weak and dehydrated in appearance with dry oropharynx findings...She had a Foley catheter placed and drained almost over 2000 mL of urine...She does have a panic values sodium level of 118. She was started on some IV fluids...Final Impression, Abdominal pain, acute [MEDICAL CONDITION], Altered mental status, [MEDICAL CONDITION] (low sodium), hypokalemia (low potassium)...." A facility Food Intake Record, dated November 2011, indicated the resident consumed the following amounts of fluid: 11/10: 520 cc, 11/11: 530 cc, 11/12: 380 cc, 11/13: 480 cc, 11/14: 660 cc, 11/15: 720 cc, 11/16: 720 cc, 11/17: 580 cc, 11/18: 180 cc. A facility Resident Care Record, dated November 2011, indicated the resident was incontinent of bladder 7 times on 11/16, 6 times on 11/17, and 8 times on 11/18. The record did not specify the amount of the urine. On 1/31/12 at 9:20 A.M., during interview with RN # 1, she indicated she was the nurse who was working on 11/18/11 and transferred Resident A to the hospital. RN # 1 indicated she did not think the abdominal mass felt like a distended bladder. She indicated she felt like "something else must have been going on." RN # 1 indicated she knew the resident had been having wet briefs, and was on an antibiotic for a UTI. RN # 1 indicated she thought the resident had a previous history of "bladder problems." On 1/31/12 at 10:30 A.M., during interview with the Administrator and MDS Coordinator, they indicated the family of Resident A stayed with the resident frequently, and frequently would not let staff wake the resident to feed her or give her fluids. The Administrator indicated the nurse who transferred the resident to the hospital was not a new nurse, but an older more experienced nurse. This federal tag relates to Complaint IN 912. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident received sufficient fluid intake to prevent dehydration, resulting in hospitalization for dehydration, for 1 of 4 residents sampled for hydration, in a sample of 4. Resident A Findings include: On 1/30/12 at 1:25 P.M., during the initial tour with the MDS (Minimum Data Set) Coordinator, water pitchers or bottles were not observed at the bedside of dependent residents. On 1/30/12 at 3:30 P.M., the clinical record of Resident A was reviewed. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurses Notes included the following notations: 11/9/11 at 5:30 P.M.: "admitted to (room number)...Occ (occasionally) forgetful...Incont (incontinent) of bladder uses briefs, dribbles...needs assist for set up of oral care, meals. Assist (two) transfer...." A "Hydration Status Assessment," dated 11/9/11, indicated the resident had decreased food & fluid intake, dry skin & mucous membranes, and functional impairments. The assessment indicated the resident was not on a diuretic, had no renal impairment or [MEDICAL CONDITION], was not lethargic, had no abnormal lab results of electrolyte imbalance, and had no increased fluid needs. The resident's total score on the assessment was 3 ("If 8 or above, MD to be notified & hydration management interventions followed"). An Interdisciplinary Care Plan, dated 11/9/11, indicated, "Resident diagnosed with [REDACTED]." Approaches included: "Offer and encourage intake of fluids...." Nurses Notes continued: 11/10/11 at 2:00 P.M.: "...Res (resident) will respond weakly to questions, takes sips H2O (water) (with) assist. Required to be fed for meals, takes few bites...Incontinent of urine x 4...." 11/11/11 at 6:30 A.M.: "...Incontinent of bladder, denies pain or burning upon urination. Cont (continues) on ATB (antibiotic) for UTI (urinary tract infection)...Res does c/o (complain of) frequency...." 11/11/11 at 1:00 P.M.: "Call out to (name of physician) office r/t (related to) pain medication...Pt (patient) noted to be lethargic when taking...(No) NO's (new orders) @ this time." 11/11/11 at 1:05 P.M.: "...Remains on ATB for UTI...Taking fluids well (with) encouragement et (and) staff queing (sic) pt while eating. Continues to c/o lethargy et weakness...." 11/11/11 at 5:00 P.M.: "Pt c/o nausea earlier...." 11/12/11 at 2:00 P.M.: "...Remains on ATB for UTI...Complains of urinary frequency, no pain or burning with urination...." 11/12/11 at 6:30 P.M.: "...Taking fluids (without) problems. Encouraged to eat when offered. Pt takes bites only." 11/13/11 at 5:00 A.M.: "...ATB for UTI...fluids encouraged (and) well taken...." 11/14/11 at 2:00 P.M.: "...N.O. received for [MEDICATION NAME] (antibiotic) et [MEDICATION NAME] (diuretic)...Res c/o some nausea...." 11/14/11 at 9:15 P.M.: "Offered water at this time, drank well with encouragement. Denied need to use bathroom...." An Interdisciplinary Care Plan, dated 11/14/11, indicated, "Resident at risk for fluid volume deficit R/T (related to) Diuretic Use." Approaches included: "Monitor and report to physician signs and symptoms of dehydration...Physical signs & symptoms of dehydration. Discuss with resident any concerns about fluid intake. Encourage fluid intake with and between meals. Observe for S/S (signs and symptoms) of dehydration & report to nurse:...Cracked lips, Dry mucous membranes, Dry skin/poor skin turgor, Dark urine, Poor fluid intake/thirst...Increased confusion...." A Nutrition Risk Assessment, dated 11/15/11, indicated, "...Diet order, Mech (mechanical) soft (with) gr (ground) meat...Eating ability: Needs Tray Setup, Partial Assist/Cueing...Average fluid intake fair...Nutritional Needs Estimation...Fluid Needs (mL): 1590 mL...." An additional Interdisciplinary Care Plan, dated 11/15/11, indicated, "...Potential for alteration in nutrition r/t Diagnosis: [REDACTED]." Approaches included: "Monitor food/fluid intake." Nurses Notes continued: 11/15/11 at 4:30 A.M.: "...Refused to get up to the bathroom (and) used bedpan x 2...Continues on ATB for UTI...." 11/16/11 at 4:15 A.M.: "...Has been Inc x 1 this shift. Refused to get up (and) go to Bathroom. Has not used bedpan...Has drank plenty of fluids...." 11/17/11 at 1:30 P.M.: "...Taking fluids well (with) encouragement...." A Nutritional Progress Note, dated 11/17/11 at 9:00 A.M., indicated, "Residents (sic) wt (weight) 11/16/11 was 109 lbs, (down) 7 lbs x 1 wk (week). Wt loss likely d/t (due to) both poor intake (and) some fluid loss d/t [MEDICAL CONDITION] getting better from fx (and) repair...Intakes seem to be improving slightly...." Nurses Notes continued: 11/18/11 at 4:00 P.M.: "...Pt remains weak. Not taking much nutrition. Encouraging med pass and magic cup when does not eat...Incont of Bowel (and) bladder. Wears briefs...." 11/18/11 at 7:30 P.M.: "Called to pt room. Had large incontinent stool...Abd (abdomen) distended, hard knot noted...New order need to transport to (name of hospital) ER (emergency room ) for evaluation if family wishes." The resident was transferred to the hospital on [DATE] at 7:50 P.M. A hospital emergency room note, dated 11/18/11 at 10:59 P.M., indicated, "...The patient was evaluated shortly after arrival...She is very weak and dehydrated in appearance with dry oropharynx findings...She does have a panic values sodium level of 118. She was started on some IV fluids...Final Impression, Abdominal pain, acute [MEDICAL CONDITION], Altered mental status, [MEDICAL CONDITION] (low sodium), hypokalemia (low potassium)...." A facility Food Intake Record, dated November 2011, indicated the resident consumed the following amounts of fluid: 11/10: 520 cc, 11/11: 530 cc, 11/12: 380 cc, 11/13: 480 cc, 11/14: 660 cc, 11/15: 720 cc, 11/16: 720 cc, 11/17: 580 cc, 11/18: 180 cc. At 1/30/12 at 4:40 P.M., during a confidential family interview, the family member indicated she was unsure if water or ice was passed routinely to residents. At 1/30/12 at 5:40 P.M., during interview with CNA # 1, she indicated staff does not pass fresh ice water, but that water bottles are kept in the residents' refrigerators or next to them. CNA # 1 indicated the residents "have sinks in their rooms too" to obtain water if needed. On 1/31/12 at 8:55 A.M., during interview with LPN # 1, she indicated, "Everybody has bottles of water in their refrigerators. Dietary staff pass them every morning." LPN # 1 indicated the facility does not pass ice to residents. LPN # 1 indicated she was unaware of how many bottles of water are passed per day, or how often. On 1/31/12 at 10:30 A.M., during interview with the Registered Dietician (RD), she indicated dietary staff makes sure there are 3-4 water bottles in each resident's refrigerator every morning. The RD indicated staff does not track how many water bottles are replaced for each resident. The RD indicated the meal consumption logs probably do not indicate all of the fluids a resident receives during a day. On 1/31/12 at 10:30 A.M., during interview with the Administrator, she indicated the family of Resident A stayed with the resident frequently, and frequently would not let staff wake the resident to feed her or give her fluids. The Administrator indicated the staff should have documented that fact more thoroughly in the chart. On 1/31/12 at 9:25 A.M., the MDS Coordinator provided the current facility policy on "Hydration of Residents," undated. The policy included: "Purpose: To ensure that all residents are assessed for dehydration risk and encouraged to consume enough fluids to ensure adequate hydration...Hydration will be maintained by provision of fluids through meal service, juice and/or water given with administration of medication, replenishing water bottles, and offering juice or water throughout the day. Residents who may be at risk for dehydration are: Residents with weight loss of 3 pounds or more in one month. Residents with dry skin and mucous membranes. Residents on diuretics...Residents with electrolyte imbalance...Residents with lethargy. Residents with fluid loss and increased fluid needs (e.g...infection). Residents with functional impairments (e.g. decreased mobility, ambulate with 2 assist, bed bound). Residents with swallowing problems...Licensed personnel are responsible for monitoring residents for signs and symptoms of dehydration and for notifying the physician if symptoms occur...Place water bottles at bedside...and encourage residents to drink frequently...Nursing staff will monitor all residents for signs of dehydration (ex: dry mouth, nausea, confusion), implement hydration interventions and notify the physician as needed...Interventions...Identify and offer resident likes for fluids...Provide extra fluids with UTI (urinary tract infection)/fever...Beverage easy access." This federal tag relates to Complaint IN 912. 3.1-46(b)

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE A COMPREHENSIVE ASSESSMENT WAS DONE COMPLETELY FOR 1 OF 3 RESIDENTS WITH PRESSURE SORES IN A SAMPLE OF 6, WHEN A FULL BODY ASSESSMENT WAS NOT COMPLETED AND THE RESIDENT A DEVELOPED AN UNSTAGEABLE ESCHAR PRESSURE AREA ON THE RIGHT HEEL. RESIDENT #A FINDINGS INCLUDES: 1. THE FACILITY'S POLICY AND PROCEDURE TITLED, "PRESSURE ULCER PREVENTION" DATED 2003, INCLUDED, BUT WAS NOT LIMITED TO, "INSPECT BONY PROMINENCES AND DEPENDENT AREAS WITH EACH POSITION CHANGE. EACH RESIDENT WILL RECEIVE TOTAL BODY SKIN CHECK WEEKLY TO ASSESS FOR ANY CHANGES IN SKIN CONDITION". 2. RESIDENT A'S CLINICAL RECORD WAS REVIEWED ON 9/15/10 AT 9:00 A.M. [DIAGNOSES REDACTED]. THE ASSESSMENT INDICATED THE RESIDENT HAD LIMITED RANGE OF MOTION OF HER ARMS, FEET AND LEGS, WITH PARTIAL LOSS OF VOLUNTARY MOVEMENT. PROBLEM CONDITIONS INDICATED [MEDICAL CONDITION]. THE ASSESSMENT INDICATED THE RESIDENT HAD NO PRESSURE ULCERS AND/OR SKIN ISSUES. THE physician's orders [REDACTED]. 10/17/08, "WEEKLY SKIN INTEGRITY CHECK ON WED (Wednesday)." 11/04/08, "CLEANSE BILATERAL LOWER LEGS WITH SOAP & WATER, APPLY [MEDICATION NAME] LIGHT COMPRESSION BANDAGE. CHANGE TWICE WEEKLY AND AS NEEDED (Tuesday & Friday)." THE TREATMENT RECORDS FOR July 2010 AND AUGUST 2010 UP TO 8/3/10, DID NOT INDICATE ANY NEW SKIN ISSUES. REVIEW OF THE RESIDENT'S BATHING RECORD INDICATED THE RESIDENT RECEIVED A COMPLETE BED BATH ON AUGUST 2, 2010. NO SKIN ISSUES WAS REPORTED AT THAT TIME. THE "WOUND/SKIN HEALING RECORD" DATED 8/4/10, INDICATED THE FOLLOWING: DATE OF ONSET: 8/4/10 SITE: RIGHT HEEL SIZE IN CM: 3 CM X 4 CM DEPTH: ESCHAR WOUND BED: BLACK/BROWN SURROUNDING SKIN COLOR: WHITE/GRAY PALLOR SURROUNDING TISSUE/WOUND EDGES: PERIPHERAL TISSUE [MEDICAL CONDITION] THE NURSES NOTES INCLUDED, BUT WERE NOT LIMITED TO THE FOLLOWING: 8/3/10 AT 10:50 A.M. "DR (NAME) NOTIFIED OF REDDENED AREA (5 CM X 7 CM) (CENTIMETER) ON TOP OF (R) (RIGHT) FOOT (WITH) 1 CM BLEEDING OPEN AREA & 0.7 CM OPEN, NOT BLEEDING." 8/4/10 AT 10:30 A.M. "NOTED RED AREA WHICH MEASURES 4 CM X 3 CM BROWN/BLACK ESCHAR TISSUE (R) HEEL. UNABLE TO PALATE PEDAL PULSE EITHER FOOT. ABLE TO HEAR FAINT DORSALIS PEDIS PULSE (R) FOOT (WITH) DOPPLER, BUT UNABLE TO HEAR PEDAL PULSE (R) FOOT. ABLE TO HEAR FAINT PEDAL PULSE (L) (LEFT) FOOT. DR. (NAME) NOTIFIED." DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 9/15/10 AT 9:45 A.M. SHE INDICATED ON 8/3/10, RN #1 HAD REQUESTED HER TO LOOK AT THE TOP OF RESIDENT #A'S RIGHT FOOT. THE DON INDICATED SHE OBSERVED THE TOP OF RESIDENT'S RIGHT FOOT, BUT DID NOT OBSERVED THE RESIDENT'S RIGHT HEEL AT THAT TIME. SHE INDICATED SHE WAS NOT AWARE OF THE AREA ON THE RESIDENT'S RIGHT HEEL. SHE INDICATED SHE WAS NOT AWARE OF THE AREA ON THE RESIDENT'S RIGHT HEEL UNTIL 8/4/10. SHE INDICATED SHE WAS VERY UPSET THAT THE AREA HAD NOT BEEN IDENTIFIED SOONER. DURING AN INTERVIEW WITH RN #1 ON 9/15/10 AT 10:15 A.M. SHE INDICATED ON 8/3/10, SHE HAD REMOVED THE WRAP FROM RESIDENT A'S RIGHT LEG AND FOOT. SHE INDICATED AT THAT TIME SHE OBSERVED AN AREA ON TOP OF THE RESIDENT'S FOOT. SHE INDICATED SHE HAD REQUEST THAT THE DON OBSERVE THE AREA ON TOP OF RESIDENT A'S RIGHT FOOT. SHE INDICATED SHE DID NOT SEE THE AREA ON THE RESIDENT'S RIGHT HEEL AT THAT TIME. DURING AN INTERVIEW WITH RN #2 ON 9/16/10 AT 9:20 A.M. SHE INDICATED ON 8/4/10, A SKIN SWEEP OF THE BUILDING WAS CONDUCTED. SHE INDICATED AT THAT TIME A HALF DOLLAR SIZE, DARK BLOODY RED, BROWNISH AREA WAS OBSERVED ON THE RESIDENT'S RIGHT HEEL. SHE INDICATED THAT WAS SOMETHING YOU DID NOT WANT TO FIND ON A SKIN SWEEP AND COULD NOT UNDERSTAND WHY THE AREA HAD NOT BEEN IDENTIFIED SOONER. THE AREA ON THE RESIDENT'S RIGHT HEEL WAS OBSERVED ON 9/15/10 AT 1:20 P.M. THE AREA WAS APPROXIMATED BY SIGHT TO BE 1.5 CM X 2.8 CM, THE CENTER OF THE AREA HAD BLACK ESCHAR TISSUE. THE OUTER EDGE OF THE WOUND WAS PINK WITH NO DRAINAGE OR ODOR. THE RESIDENT'S CARE PLAN TITLED, "RESIDENT AT RISK FOR DEVELOPING A PRESSURE ULCER DUE TO INCONTINENCE, [MEDICAL CONDITIONS]", DATED 6/01/10, INCLUDED, BUT WAS NOT LIMITED TO "GOAL: RESIDENT WILL HAVE INTACT SKIN, FREE OF REDNESS OR BLISTERS OVER A BONY-PROMINENCE THROUGH NEXT REVIEW DATE 9/1/10". APPROACHES INCLUDED, BUT WERE NOT LIMITED TO, "WEEKLY SKIN ASSESSMENT. REPORT ANY RED OR OPEN AREAS TO NURSE". THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 235. 3.1-31(a)

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE 1 OF 3 RESIDENT WITH PRESSURE SORES (#A) IN A SAMPLE OF 6 WHO ENTERED THE FACILITY WITHOUT A PRESSURE SORE DID NOT DEVELOP A PRESSURE SORE AND FAILED TO ASSESS THE AREA. THIS RESULTED IN THE DEVELOPMENT OF A UNSTAGEABLE BLACK ESCHAR PRESSURE AREA ON THE RESIDENT'S RIGHT HEEL. RESIDENT #A FINDINGS INCLUDE: 1. 1. THE FACILITY'S POLICY AND PROCEDURE TITLED, "PRESSURE ULCER PREVENTION" DATED 2003, INCLUDED, BUT WAS NOT LIMITED TO, "PURPOSE: TO PREVENT TISSUE TRAUMA BY INCREASING CIRCULATION AND/OR PREVENT PRESSURE ON SUSCEPTIBLE AREAS. TO INITIATE NURSING INTERVENTIONS ALONG WITH MEDICAL ORDERS FOR PREVENTION OF TISSUE TRAUMA. POLICY: IT IS THE POLICY OF THIS FACILITY THAT A RESIDENT WHO ENTERS THE FACILITY WITHOUT PRESSURE SORES DOES NOT DEVELOP PRESSURE SORES UNLESS THE INDIVIDUAL'S CLINICAL CONDITION DEMONSTRATES THAT THEY WERE AVOIDABLE". 2. RESIDENT A'S CLINICAL RECORD WAS REVIEWED ON 9/15/10 AT 9:00 A.M. [DIAGNOSES REDACTED]. THE ASSESSMENT INDICATED THE RESIDENT HAD LIMITED RANGE OF MOTION OF HER ARMS, FEET AND LEGS, WITH PARTIAL LOSS OF VOLUNTARY MOVEMENT. PROBLEM CONDITIONS INDICATED [MEDICAL CONDITION]. THE ASSESSMENT INDICATED THE RESIDENT HAD NO PRESSURE ULCERS AND/OR SKIN ISSUES. THE physician's orders [REDACTED]. 10/17/08, "WEEKLY SKIN INTEGRITY CHECK ON WED (Wednesday)." 11/04/08, "CLEANSE BILATERAL LOWER LEGS WITH SOAP & WATER, APPLY [MEDICATION NAME] LIGHT COMPRESSION BANDAGE. CHANGE TWICE WEEKLY AND AS NEEDED (Tuesday & Friday)." THE TREATMENT RECORDS FOR July 2010 AND AUGUST 2010 UP TO 8/3/10, DID NOT INDICATE ANY NEW SKIN ISSUES. REVIEW OF THE RESIDENT'S BATHING RECORD INDICATED THE RESIDENT RECEIVED A COMPLETE BED BATH ON AUGUST 2, 2010. NO SKIN ISSUES WAS REPORTED AT THAT TIME. THE "WOUND/SKIN HEALING RECORD" DATED 8/4/10, INDICATED THE FOLLOWING: DATE OF ONSET: 8/4/10 SITE: RIGHT HEEL SIZE IN CM: 3 CM X 4 CM DEPTH: ESCHAR WOUND BED: BLACK/BROWN SURROUNDING SKIN COLOR: WHITE/GRAY PALLOR SURROUNDING TISSUE/WOUND EDGES: PERIPHERAL TISSUE [MEDICAL CONDITION] THE NURSES NOTES INCLUDED, BUT WERE NOT LIMITED TO THE FOLLOWING: 8/3/10 AT 10:50 A.M. "DR (NAME) NOTIFIED OF REDDENED AREA (5 CM X 7 CM) (CENTIMETER) ON TOP OF (R) (RIGHT) FOOT (WITH) 1 CM BLEEDING OPEN AREA & 0.7 CM OPEN, NOT BLEEDING." 8/4/10 AT 10:30 A.M. "NOTED RED AREA WHICH MEASURES 4 CM X 3 CM BROWN/BLACK ESCHAR TISSUE (R) HEEL. UNABLE TO PALATE PEDAL PULSE EITHER FOOT. ABLE TO HEAR FAINT DORSALIS PEDIS PULSE (R) FOOT (WITH) DOPPLER, BUT UNABLE TO HEAR PEDAL PULSE (R) FOOT. ABLE TO HEAR FAINT PEDAL PULSE (L) (LEFT) FOOT. DR. (NAME) NOTIFIED." DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 9/15/10 AT 9:45 A.M. SHE INDICATED ON 8/3/10, RN #1 HAD REQUESTED HER TO LOOK AT THE TOP OF RESIDENT #A'S RIGHT FOOT. THE DON INDICATED SHE OBSERVED THE TOP OF RESIDENT'S RIGHT FOOT, BUT DID NOT OBSERVED THE RESIDENT'S RIGHT HEEL AT THAT TIME. SHE INDICATED SHE WAS NOT AWARE OF THE AREA ON THE RESIDENT'S RIGHT HEEL. SHE INDICATED SHE WAS NOT AWARE OF THE AREA ON THE RESIDENT'S RIGHT HEEL UNTIL 8/4/10. SHE INDICATED SHE WAS VERY UPSET THAT THE AREA HAD NOT BEEN IDENTIFIED SOONER. DURING AN INTERVIEW WITH RN #1 ON 9/15/10 AT 10:15 A.M. SHE INDICATED ON 8/3/10, SHE HAD REMOVED THE WRAP FROM RESIDENT A'S RIGHT LEG AND FOOT. SHE INDICATED AT THAT TIME SHE OBSERVED AN AREA ON TOP OF THE RESIDENT'S FOOT. SHE INDICATED SHE HAD REQUEST THAT THE DON OBSERVE THE AREA ON TOP OF RESIDENT A'S RIGHT FOOT. SHE INDICATED SHE DID NOT SEE THE AREA ON THE RESIDENT'S RIGHT HEEL AT THAT TIME. DURING AN INTERVIEW WITH RN #2 ON 9/16/10 AT 9:20 A.M. SHE INDICATED ON 8/4/10, A SKIN SWEEP OF THE BUILDING WAS CONDUCTED. SHE INDICATED AT THAT TIME A HALF DOLLAR SIZE, DARK BLOODY RED, BROWNISH AREA WAS OBSERVED ON THE RESIDENT'S RIGHT HEEL. SHE INDICATED THAT WAS SOMETHING YOU DID NOT WANT TO FIND ON A SKIN SWEEP AND COULD NOT UNDERSTAND WHY THE AREA HAD NOT BEEN IDENTIFIED SOONER. THE AREA ON THE RESIDENT'S RIGHT HEEL WAS OBSERVED ON 9/15/10 AT 1:20 P.M. THE AREA WAS APPROXIMATED BY SIGHT TO BE 1.5 CM X 2.8 CM, THE CENTER OF THE AREA HAD BLACK ESCHAR TISSUE. THE OUTER EDGE OF THE WOUND WAS PINK WITH NO DRAINAGE OR ODOR. THE RESIDENT'S CARE PLAN TITLED, "RESIDENT AT RISK FOR DEVELOPING A PRESSURE ULCER DUE TO INCONTINENCE, [MEDICAL CONDITIONS]", DATED 6/01/10, INCLUDED, BUT WAS NOT LIMITED TO "GOAL: RESIDENT WILL HAVE INTACT SKIN, FREE OF REDNESS OR BLISTERS OVER A BONY-PROMINENCE THROUGH NEXT REVIEW DATE 9/1/10". APPROACHES INCLUDED, BUT WERE NOT LIMITED TO, "WEEKLY SKIN ASSESSMENT. REPORT ANY RED OR OPEN AREAS TO NURSE". THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 235. 3.1-40(a)(1) 3.1-40(a)(2)