Every finding on record at Thornton Terrace Health Campus

Based on observation, record review, and interview, the facility failed to ensure the kitchen equipment was clean, sanitary and the removal of expired food items during 3 of 3 kitchen observations. This deficient practice had the potential to affect 45 of 45 residents who received meals in the facility.Findings include:1. During an observation of the kitchen, on 9/03/25 at 9:25 a.m., the following concerns were identified:-On the floor between the fryer and stove were food debris and a bug trap. There was a yellowish-brown greasy substance running down the right side of the stove. -There were three brown colored burnt areas on the back panel behind each burner of the stove top.-The drip pan under the stove top had a foil liner that was 100% covered with a tan substance and food debris.-The grill top to the left of the stove had a black build-up on the griddle irons.-The drip pan under the grill had a torn foil liner with a half inch of a brown liquid substance with a heavy coverage of food debris.-Dried food debris was observed on a large, slotted spoon hanging from the overhead rack, over the steam table. 2. During a return observation to the kitchen, on 9/4/25 at 9:26 a.m., the Dietary Manager indicated the char burner grill was used yesterday, so it was cleaned and the drip pan was cleaned. The foil was new. She indicated the stove top burners were cleaned every other day. The following concerns were still identified:-The drip pan under the stove top was the same with grease and food debris present. -The grease down the side of the stove was still visible.-The food debris and grease was still present on the floor between the stove and the fryer. -The burnt areas to the back panel of the stove top burners was still present. 3. During an observation, on 9/3/25 at 11:07 a.m., of the salads being assembled there were concerns. The open bag of shredded lettuce had an expiration date of 9/1/25 printed on the bag. [NAME] 13 opened the bag and started to place it on the plates. When asked what the expiration date on the lettuce was, she had trouble finding it. Once found, she indicated it was two days past the expiration date. She entered the walk-in refrigerator and obtained another bag of lettuce with an expiration date of 9/9/25. The four bags of salad greens next to the shredded lettuce was brown in color and had an expiration date of 8/28/25. During an interview, on 9/3/25 at 9:30 a.m., the Dietary Manager indicated the food company delivered on Tuesdays and Fridays. She only had issues with running out of produce sometimes. She could obtain the produce from a local store just down the highway, if she needed to, though.During an interview, on 9/3/25 at 11:13 a.m., the Dietary Manager indicated all staff should be monitoring the expiration dates of the foods. She will take photos of the dates on the salad mix and send them back to the food company for a refund, since it was delivered on Tuesday.The kitchen cleaning schedule, indicated the following:-The PM [NAME] Daily Cleaning List included: Wipe all tables and equipment down, Skim and wipe down the fryer, and Empty grease trap.-The AM [NAME] Daily Cleaning List included: Clean work area after each task. The Cleaning Schedules lacked documentation of emptying and cleaning the drip pans under the stove or grill; and cleaning the sides of the stove or the back panel.The Food Labeling and Dating Policy, dated 4/26/22, included, but was not limited to, . Any food item must have a received-on label/received on date, and or a label that indicates the production date and the use by date for the product. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident had an order to self administer medications related to medications left at the bedside for 1 of 4 residents reviewed for self-administration of medication. (Resident 31)Findings include:An observation, on 9/3/25 at 10:01 a.m., indicated Resident 31 had multiple medications in a medicine cup sitting on the resident's bedside table. No staff members were present or near the resident's room. The medications were due between 8:00 a.m. and 10:00 a.m. There was an open inhaler sitting next to the medicine cup on the bedside table. The resident was asleep and did not observe the medications sitting next to her breakfast bowls. During an interview, on 9/3/25 at 10:03 a.m., Licensed Practical Nurse (LPN) 9 looked at the orders and indicated there was no order for the resident for self-administration. She indicated the following medications were in the medication cup on the resident's bedside table: Tart cherry supplement; Potassium; metoprolol; Hair, Skin, and Nails vitamins; Lysine; Allopurinol; Norvasc; Bumetanide (Bumex); Fenofibrate; Iron; Omeprazole; Sertraline; Tramadol; Vitamin D3; and Wellbutrin, Inhaler. The record for Resident 31 was reviewed on 9/5/25 at 12:28 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, chronic diastolic congestive heart failure, type 2 diabetes mellitus with hyperglycemia, severe morbid obesity due to excess calories, obstructive sleep apnea, restless leg syndrome, hypothyroidism, depression, deficiency of the B group vitamins, cardiac murmur, carpal tunnel syndrome of the bilateral upper limbs, dry eye syndrome of bilateral lacrimal glands, muscle weakness, age-related osteoporosis, a lack of coordination, difficulty in walking, long term use of insulin, dependence on enabling machines and devices, a history of falling, dysphagia, metabolic encephalopathy, anemia, cognitive communication deficit, and abnormal posture. The care plan, dated 2/26/24 and revised 7/25/25, indicated the resident had an impairment in functional status. The interventions, dated 2/26/24, indicated staff were to encourage the resident to be as independent as safely possible, administer medications per physician's order, provide assistance as needed with self-care and mobility functional tasks. The physician's order, dated 2/26/24, indicated staff were to administer the Resident's 5 milligrams (mg) of amlodipine (Norvasc) daily between 6:00 a.m. and 10:00 a.m., for hypertension. The physician's order, dated 2/26/24, indicated staff were to administer the resident's 40 mg of omeprazole delayed release daily between 6:00 a.m. and 10:00 a.m. for GERD. The Quarterly Minimum Data Set (MDS) assessment, dated 3/5/24, indicated the resident was cognitively intact. The physician's order, dated 3/7/24, indicated staff were to administer the resident's 186 mg of Hair, Skin and Nails Advanced Multivitamin daily between 6:00 a.m. and 10:00 a.m. for hair and nail growth. The physician's order, dated 3/21/24, indicated staff were to administer the resident's 2 mg of bumetanide twice daily between 6:00 a.m. and 10:00 a.m. Then between 6:00 p.m. and 10:00 p.m., for congestive heart failure (CHF). The care plan, dated 5/23/24 and revised 7/25/25, indicated the resident had a diagnosis of attention deficit disorder. The interventions, dated 5/23/24, indicated staff were to administer medication as ordered. The care plan, dated 5/29/24 and revised 7/25/25, indicated the resident demonstrated a slight hearing loss. The interventions, dated 5/29/24, indicated staff were to communicate with the resident in a clear, concise manner, and increase the volume to ensure the resident received the message. The physician's order, dated 5/31/24, indicated staff were to administer the resident's 50 mg of tramadol three times daily between 6:00 a.m. and 10:00 a.m., then between 11:00 a.m. and 1:30 p.m., then between 6:00 p.m. and 10:00 p.m., for moderate pain. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 300 mg of allopurinol daily between 6:00 a.m. and 10 a.m., for gout. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 200 mg of sertraline daily between 6:00 p.m. and 10:00 p.m., for depression. The physician's order, dated 8/14/24, indicated staff were to administer the resident one puff of 100-25 mcg of Breo Ellipta (fluticasone furoate-vilanterol) blister with device; daily between 6:00 a.m. and 10:00 a.m., for chronic obstructive pulmonary disease (COPD). Please have the resident rinse their mouth out after each use to prevent thrush. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 1,000 mg of lysine daily between 6:00 a.m. and 10:00 a.m. for a supplement. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 50 mg of metoprolol twice daily between 6:00 a.m. and 10:00 a.m., then 6:00 p.m. and 10:00 p.m., for hypertension. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 10 milliequivalents (meq) of potassium extended release three times daily between 6:00 a.m. and 10:00 a.m., then between 11:00 a.m. and 1:30 p.m., then between 6:00 p.m. and 10:00 p.m., for hypokalemia. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 8.6 mg of senna [OTC] daily between 6:00 a.m. and 10:00 a.m., for bowel mobility. The physician's order, dated 8/14/24, indicated staff were to administer the resident's 30-250-75-75-20 mg of Tart Cherry (vitamin C-sweet cherry-celery-grape) twice daily between 6:00 a.m., then between 6:00 p.m. and 10:00 p.m., for gout. The physician's order, dated 8/22/24, indicated staff were to administer the resident's 325 mg of ferrous sulfate (iron) daily between 6:00 a.m. and 10:00 a.m., for a supplement. The physician's order, dated 9/7/24, indicated staff were to administer the resident's 25 mcg of Vitamin D3 (cholecalciferol-vitamin D3) daily between 6:00 a.m. and 10:00 a.m. The physician's order, dated 11/21/24, indicated staff were to administer the resident's 54 mg of fenofibrate daily between 6:00 a.m. and 10:00 a.m., for hypertriglyceridemia. The physician's order, dated 2/20/25, indicated staff were to administer the resident's 4 mg of ropinirole twice daily between 6:00 a.m. and 10:00 a.m., then between 6:00 p.m. and 10:00 p.m., for RLS. The physician's order, dated 3/6/25, indicated staff were to administer the resident's 150 mg of Wellbutrin extended release daily between 6:00 a.m. and 10:00 a.m. for depression. The Social Service note, dated 3/18/25 at 5:30 p.m., indicated a family member called, expressing concerns about phone conversations with the resident indicating the resident returned a phone call to him and the call was not going well. She was combative in conversation and had constant negative comments. The resident was getting upset with multiple family members often, and the family was concerned whether the new antidepressant was a good match or not. The Social Service note, dated 4/1/25 at 11:26 a.m., indicated Social Service and the Psychiatric Nurse Practitioner (NP) met for a behavioral management meeting. The resident was last seen by the psychiatric provider on 4/1/25. The resident was prescribed Sertraline, Trazadone, and Wellbutrin, per order. The mood behavior episodes were consistent with depression episodes. The resident was recently started on a new Wellbutrin dose on 3/6/25, and resident's family member indicated an improvement in the resident's overall mood this week. The recommendation was to hold on course on the current medication regimen. The physician's order, dated 8/21/25 indicated the resident should take the medications one at a time in a pureed carrier, three times daily between 6:00 a.m. and 2:00 p.m., then between 2:00 p.m. and 10:00 p.m., and between 10:00 p.m. and 6:00 a.m. The physician's order, dated 5/6/25, indicated the resident had episodes of the following swallowing issues: Dysphagia example of coughing or choking during meals or medication pass, loss of liquids or solids from the mouth when eating or drinking, holding food in their mouth or cheeks or residual food kept in their mouth after meals, complaints of difficulty swallowing, continuous throat clearing, et cetera (etc). Observe for new or worsening swallowing issues and notify the physician. Refer to speech therapy services as appropriate. Serve the diet as ordered with follow-up to the registered dietician as needed, three times a day between 10:00 p.m. and 6:00 a.m., then between 6:00 a.m. and 2:00 p.m., then between 2:00 p.m. and 10:00 p.m. The physician's order, dated 9/3/25 10:30 a.m., indicated the staff may leave the resident's medications at bedside for the resident to self-administer. The physician's order was acquired after notification to managed related to resident's medication being left at bedside. The resident's clinical record lacked a physician's order or current self administration assessment prior to the start of the survey. The record lacked documentation of a self-medication evaluation since the resident transferred for assisted living. During an interview, on 9/3/25 at 10:03 a.m., LPN 9 indicated she usually set the resident's medications on her bedside table. The resident was previously at the Assisted Living Hall, when the LPN worked there. The resident had an order for self-administration of medications when she was there, and she thought the resident still had the order. The resident had been on the current hall for quite a while since then. The Guidelines for Self-Administration of Medications policy, revised 5/22/18, included, but was not limited to, . Procedure 1. Residents requesting to self-medicate or has self medication as part of their plan of care shall be assessed using the observation [corporate name]- Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication. 6. A Self Medication plan of care will be initiated and updated as indicated. 7. The assessment will be reviewed quarterly, and PRN with change of condition.3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure the accuracy of skin assessments (Residents 2 and 23) and failed to ensure accurate coding of the Minimum Data Set assessments (Resident 11) for 3 of 6 residents reviewed for assessments. Findings include:1.The record for Resident 2 was reviewed on 9/7/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation The care plan, dated 11/2/21 and revised 7/9/25, indicated the resident was at risk for skin breakdown related to impaired mobility, type II diabetes, nutritional status, hand contractures, noncompliance with wearing a stump shrinking device. The interventions included, but were not limited to, floating the heels as needed, pressure reducing cushion to his chair, using moisture barrier to the perineal area as needed, a pressure reducing mattress to the bed, avoid shearing skin during positioning, turning, and transferring, encourage and provide assistance to turn and reposition for comfort as needed, conduct a weekly skin assessment, keep the linens clean and dry, keep the resident as clean and dry as possible and minimize skin exposure to moisture. The Register Dietary note, dated 9/16/25 at 8:39 a.m., indicated the resident had a diabetic ulcer to the right side of his foot. There was no edema observed to the resident's right foot. The resident was prescribed Prostat (supplement) 30 milligram (ML) twice a day for wound healing. The nurse's note, dated 9/20/24 at 10:54 a.m., indicated the resident had a wound to the right heel and right pinky toe. The right heel measured 3 centimeters (cm) by 3 cm and there was a calloused area to the resident's right pinky toe 2.7 cm by 2 cm. The nurse's note, dated 9/27/24 at 1:57 p.m., indicated the resident had a wound to the right heel and right pinky toe. The right heel measured 3 cm by 3 cm and the calloused area to the right pinky toe measured 2.6 cm by 2 cm. The nurse's note, dated 10/18/24 at 3:14 p.m., indicated the resident's dressing to the right heel was changed. The resident's heels were soft, a protective boot was in place, and a foam dressing was applied. The physician's note, dated 11/9/24 at 4:02 p.m., indicated the wound to the resident's right foot was dry and intact. The resident had a blister to the top of his right foot. He was taking doxycycline for the right foot wound. The nurse's note, dated 11/18/24 at 9:46 a.m., indicated Resident 2 had a dressing change to his right foot wound. A scant amount of sanguineous drainage was observed on the old dressing. The blister site to the top of his right foot was cleansed; and skin prep was applied to the blister and right heel. The nurse's note, dated 12/3/24, at 10:43 a.m., indicated the resident's right foot wound care was provided per physician's order. The wound had some red bloody drainage. Resident 2 was going to the wound care physician. The Nurse Practitioner (NP) note, dated 11/28/24 at 6:24 a.m., indicated the resident was hospitalized for cellulitis of the right foot. He underwent an amputation of the right fifth toe approximately two weeks ago due to a prior admission diagnosis of osteomyelitis. The wound was healing initially, but the resident observed increased erythema on the dorsum of the right foot. The wound nurse evaluated the resident and recommended hospital admission. The patient underwent a debridement and was discharged on an antibiotic. The nurse's note, dated 12/13/24 at 8:17 a.m., indicated the nurse had completed the treatment to the resident's right foot and a bone could be felt on the back end of the wound. The nurse's note, dated 12/21/24 at 3:00 p.m., indicated the resident's dressing to the right foot was completed. The wound was observed to be darker red than a few days ago. The nurse's note, dated 1/3/25 at 5:20 p.m., indicated the resident's dressing was completed. The wound bed was beefy red, and no signs and symptoms of infection were observed. The physician's note, dated 1/30/25 at 5:25 p.m., indicated Resident 2's wound continued to the right foot. Overall, the right foot was dark red, slightly edematous, and of normal temperature. The wound from removal of the pinky toe was epithelialized on all borders. The center was observed to be healthy granulation tissue. The wound posterior to original surgical wound had a punched out round appearance. The wound bed was less than 10 percent loosely adherent slough and the remainder was beefy red granulation tissue. The area to top of foot was observed with red granulation tissue to the wound bed with a very small point of firmly adherent slough in the center. The nurse's note, dated 4/9/25 at 7:23 p.m., indicated the resident was observed to have increased redness when the dressing was changed. The redness went from the top of ankle to the top of the toes. The nurse's note, dated 4/29/25 at 3:20 p.m., indicated the resident returned from an appointment with the physician. The right foot wound had a bone debridement scheduled for 5/7/25. The nurse's note, dated 6/7/25 at 6:08 p.m., indicated the resident was observed to have light yellow drainage from his wound and redness to the top of his right foot and around wound bed. The NP was contacted, and the resident was started on doxycycline 100 milligrams (mg) twice a day for 7 days. The nurse's note, dated 6/12/25 at 10:05 a.m., indicated the treatment was completed to the right foot wound. No edema was observed. Slight redness was observed to the peri wound and a scant amount of green drainage was on the old bandage. Resident 2 was scheduled for a debridement and xenograft on 6/19. The antibiotic and change the treatment to Anasept wound gel. The Clinically at Risk (CAR) note, dated 6/27/25 at 11:21 a.m., indicated the wound had showed improvement. The nurse's note, dated 8/5/25 at 5:07 p.m., indicated the resident returned from a doctor's appointment. The treatment included Prisma to the wound and changing the dressing every 3 days and as needed. The review of the facility skin assessments lacked documentation indicating the resident has a wound to the right foot. The resident's weekly skin assessment documentation indicated the following: -On 9/16/24, the resident's skin assessment had 0 marked to indicated the resident had no skin impairments. -On 9/23/24, the resident's skin assessment had 0 marked to indicated the resident had no skin impairments. -On 9/30/24, the resident's skin assessment had 0 marked to indicated the resident had no skin impairments. -On 10/24/25, the resident's skin assessment had 0 marked to indicated the resident had no skin impairments. had no skin impairment. --On 11/11/24, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 11/18/24, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 12/2/24, the resident's skin assessment, lacked documentation indicating a wound or skin issues were present. -On 12/9/24, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 12/16/24, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 12/23/24, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 12/30/24, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 1/6/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 1/13/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 1/20/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 2/3/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 2/10/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 2/17/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 2/24/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 3/3/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 3/10/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 3/17/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 3/24/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 3/31/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 4/7/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 5/5/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 5/12/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 5/19/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 5/26/26, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 6/2/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 6/16/25, the residents skin assessment lacked documentation indicating a wound or skin issues were present. -On 6/23/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 6/30/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 7/7/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 7/14/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 7/21/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 7/28/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 8/4/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 8/11/25, the resident' s skin assessment lacked documentation indicating a wound or skin issues were present. -On 8/18/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. -On 8/25/25, the resident's skin assessment lacked documentation indicating a wound or skin issues were present. During an interview, on 9/5/25 at 11:30 a.m., the DON indicated she had observed recently there was an issue with the skin assessments. During an interview, on 9/8/25 at 11:20 a.m., Licensed Practical Nurse (LPN) 12 indicated the facility skin assessments were done weekly every Monday. If the resident had no skin impairment issues the nurse would document a 0. If during the weekly skin assessment, the nurse found a new wound or skin issue they would document 1 indicating a new skin area. If the resident already had a wound and with no new wounds the nurse would document a 2. She indicated she would document a number each time she did a skin assessment. During an interview, on 9/8/25 at 11:30 a.m., Wound Care Nurse 3 indicated if a new wound was found after the Monday skin assessment the wound would be documented on the next skin assessment as an old wound. If the new wound was found on the day the skin assessments were done it would be classified as a new wound with a number 1. There should always be a number for the skin assessments in the clinical record. If a number was missing, then the assessment wasn't done or the nurse forgot to add the number to the skin assessment documentation. 2. During an observation, on 9/3/25 at 9:46 a.m., Resident 23 was lying on his left side in bed. Pillows were between his knees and under his knees. There was a pillow behind the resident. His caregiver was at his bedside. During an observation of Resident 23, on 9/8/25 at 8:50 a.m., Wound Care Nurse 3 gathered treatment supplies and brought them into the resident's room. CNAs 7 and 8 were using a full body mechanical lift to transfer the resident from his recliner to his bed. The resident was lying on his left back side asleep with a blanket covering him. The resident's caregiver was sitting next to the resident. There was a cushion on the seat of the recliner. Once the resident was transferred into bed, the resident's brief was pulled down and he was in the middle of a bowel movement. The wound dressing was getting soiled. Once the resident was cleaned and the brief was removed, the began to conduct the wound treatment change. The resident started to have another bowel movement. The resident's left hip had a reddened 5-inch diameter circular area. The CNAs applied barrier cream to the left hip. The Wound Care Nurse 3 performed hand hygiene and applied gloves. The staff did not apply gowns. The soiled dressing didn't have a date on it. The resident's coccyx had multiple areas of scarring from old wounds. The new wound had white colored granulation tissue on the quarter sized wound. The lower edge of the wound had a scant area of blood or drainage on it. The Wound Care Nurse 3 indicated the wound looked worse than it did last week. There were four quarter sized wounds around the new wound. The Wound Care Nurse 3 applied two small calcium alginate treatments to the wounds. She then applied the foam dressing over the alginate. Three cup sized red areas were observed on the resident's left buttock. The resident was placed on his left side. One pillow was placed behind the resident's back and hip area. One pillow was placed between his knees. One pillow was placed under his knees. Boots were placed on the resident's feet. During an observation of the resident, on 9/8/25 at 1:21 p.m., the resident was sitting on his left hip in his recliner. The resident was asleep. The record for Resident 23 was reviewed on 9/4/25 at 11:54 a.m. The resident's diagnoses included, but were not limited to dyskinesia, chronic ischemic heart disease, atherosclerotic heart disease of the coronary artery, abdominal aortic aneurysm, paraplegic immobility syndrome, disorders of the lung, bronchiectasis, hypothyroidism, hyperlipidemia, depression, anxiety disorder, anemia, hypertension, weakness, difficulty in walking, lack of coordination, repeated falls, personal history of malignant neoplasm of the prostate, and pneumonia. The care plan, dated 4/3/24 and revised 9/3/25, indicated the resident was at risk for skin breakdown related to impaired mobility, incontinence, bilateral knee contractures, and a history of skin breakdown. The interventions, dated 4/3/24, included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessments, pay particular attention to the bony prominences, encourage and assist to turn and reposition for comfort and as needed, float the heels as needed and tolerated, keep linens clean and dry, keep the resident as clean and dry as possible, minimize skin exposure to moisture, observe the feet during care for redness, swelling. or changes in condition; notify the physician as needed, pressure reducing cushion to the chair, pressure reducing mattress to the bed, treatments and preventative treatments as or when ordered, use a lifting device as needed for bed mobility, and use a moisture barrier product to the perineal area as needed. The care plan, dated 5/2/24 and revised 9/3/25, indicated the resident had MASD. The interventions, dated 5/2/24, included, but were not limited to, keep the resident's skin clean and dry, observe for pain, itching, or discomfort and treat as ordered, please observe MASD for a decline or signs and symptoms of infection, notifying the physician as needed, and treatment as ordered. The physician's order, dated 3/23/24, indicated staff were to conduct weekly skin assessment for the resident. The weekly skin assessment were documented with the following scale: 0=no impairment, 1=new impairment, 2=old impairment. The weekly skin assessments were completed once a day on Mondays between 6:00 a.m. and 2:00 p.m. The Skin Assessments lacked documentation of skin issues on the following dates: -On 9/16/24, the resident had no skin impairment. -On 9/23/24, the resident had no skin impairment. -On 10/14/24, the resident had no skin impairment. -On 10/28/24, the resident had no skin impairment. -On 11/4/24, the resident had no skin impairment. -On 11/11/24, the resident had no skin impairment. -On 11/18/24, the resident had no skin impairment. -On 11/25/24, the resident had no skin impairment. -On 12/2/24, the resident had no skin impairment. -On 12/9/24, the resident had no skin impairment. -On 12/16/24, the resident had no skin impairment. -On 12/23/24, the resident had no skin impairment. -On 12/30/24, the resident had no skin impairment. -On 1/6/25, the resident had no skin impairment. -On 1/13/25, the resident had no skin impairment. -On 1/20/25, the resident had no skin impairment. -On 1/27/25, the resident had no skin impairment. -On 2/17/25, the resident had no skin impairment. -On 3/10/25, the resident had no skin impairment. -On 3/17/25, the resident had no skin impairment. -On 3/24/25, the resident had no skin impairment. -On 3/31/25, the resident had no skin impairment. -On 5/26/25, the resident had no skin impairment. -On 6/2/25, the resident had no skin impairment. -On 8/4/25, the resident had no skin impairment. -On 8/11/25, the resident had no skin impairment. The record lacked documentation of accurate weekly skin assessments. The nurse's note, dated 8/4/24 at 4:28 p.m., indicated the nurse was called to resident's room by a CNA stating the resident had an open area to his buttocks. The area on the resident's buttock was cleansed and measured. The wound measured 6 cm long by 2.5 cm wide by less than 0.1 cm deep to the right buttock. The resident's left buttock area was purple in color with pinpoint open areas. The left buttock measured 4 cm long by 3 cm wide with no open areas. Both areas were cleansed and a foam dressing was applied. The care plan, dated 9/3/25, indicated the resident had a skin/wound infection of the moisture associated skin damage (MASD) area to the coccyx. The interventions, dated 9/3/25, included, but were not limited to, administer medications and treatments as ordered, evaluate, report, and record effectiveness, and or signs or symptoms of adverse side effects, assess pain and observe the wound and surrounding skin condition, report emergence of skin excoriation, assist with frequent turning and repositioning of the wound as appropriate, diet as ordered and encourage fluids unless contraindicated, consult with the dietitian as needed, observe for and report new or worsening signs or symptoms of skin/wound infection, observe for and report signs of sepsis, obtain laboratory work and diagnostic tests as ordered, report findings to the physician, obtain vital signs as ordered and indicated, record the amount, type, and odor of drainage from the wound or skin infection site, record the color, consistency, and location of the exudate, use proper infection control contact precautions as indicated and per policy when providing care. The nurse's note, dated 9/17/24 at 2:48 a.m., indicated CNAs were changing the resident, and notified the nurse of open areas to the resident's buttock. The resident had three discovered dime sized open areas on the buttock/coccyx area. The resident's wounds were cleansed and a foam dressing applied. The nutritional note, dated 9/23/24 at 9:26 a.m., indicated the resident's open areas were on the buttock/coccyx area and treatment was in place. The nurse's note, dated 9/26/24 at 1:40 p.m., indicated treatment to the resident's buttock was completed and the MASD appeared to be healing with no worsening. The nurse's note, dated 1/31/25 at 2:47 p.m., indicated the resident's toes were still discolored but appeared to be getting better. There was no pain or discomfort to the resident's toes. A skin prep was applied. The new area to the side of the left foot had appeared. The wound was red and blanchable. A skin prep was applied to it and an a faom dressing was placed for a barrier. The resident's legs were propped up with a pillow. The hospice RN was in to see the area as well, with no concerns per the RN. The nurse's note, dated 7/16/25 at 10:40 p.m., indicated the resident had three Stage 2 pressure ulcers to the left and right buttocks with 2 areas on the right buttock. The wounds were covered with a foam dressing. The nurse's note, dated 7/17/25 at 2:53 p.m., indicated the areas to the resident's buttocks were present as moisture associated skin damage and treatment was in place. The Quarterly MDS assessment, dated 8/29/25, indicated the resident was severely cognitively impaired. He was always incontinent of bowel and bladder and at risk for pressure ulcers or injuries. The nurse's note, dated 9/2/25 at 1:37 p.m., indicated the resident was observed to have an open area on the bottom. A foul smell was present when the dressing was removed. The area was cleansed with normal saline and covered with Mepilex. Hospice was in to see the resident and a new order to start 100 mg of doxycycline twice daily for 5 days was placed. The Interdisciplinary note, dated 9/5/25 at 10:05 a.m., indicated the wound care RN assessed the wound. A new treatment plan was in place, and an antibiotic was started. The nurse's note, dated 9/8/25 at 1:33 p.m., indicated the resident had healed areas to the bottom surrounding the wound. The wound area was red and purple in color. The area was blanchable. The treatment orders changed to a Calazyme paste and apply a foam dressing to be applied every 3 days. The resident and family were made aware. 3. The record for Resident 11 was reviewed on 9/8/25 at 1:26 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, without mention of fluctuations; dementia in other diseases classified elsewhere, unspecified severity; without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Takotsubo syndrome; hypertensive heart disease with heart failure; chronic combined systolic (congestive) and diastolic (congestive) heart failure, and essential hypertension. The Quarterly MDS assessment, dated 7/16/25, indicated the resident was in a High-Risk Drug Classes The resident's medication in the last 7 days or since admission was the following medication: E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin). Review of the current and discontinued physician's orders, from 1/1/25 through 9/8/25, indicated the resident was not prescribed or taking an anti-coagulant. The Signature of the RN Assessment Coordinator verified that the assessment was completed on 7/22/25 and all information was correct. During an interview, on 9/8/25 at 2:15 p.m., the MDS Coordinator indicated the anticoagulant box should have not been checked. It was a mistake in coding, It should have been checked for the antibiotic right below the anti-coagulant box. Resident 11 was not on an anti-coagulant or had not received an anti-coagulant during the assessment time line. The review of the Resident Assessment MDS manual, included, but was not limited to, .Coding instructions: all staff who complete any part of the MDS must enter their signatures, titles, sections or portion(s) they completed, and the date completed.Read the Attestation Statement carefully. You are certifying that the information you entered on the MDS to the best of your knowledge, most accurately reflect the resident's status. The Guidelines for Weekly Skin Observation policy, revised 5/14/25, included, but was not limited to, . The purpose of this policy is to: To monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated. Procedure 1. A full body observation shall be completed weekly by the licensed nurse. Cross Reference F684 and F741 3.1-31(d)(3)

Based on observation, record review and interview, the facility failed to ensure care plans were revised and implemented with interventions for 2 of 12 residents review for care plan revision. (Residents 2 and 23)Findings include:1.The record for Resident 2 was reviewed on 9/7/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation. The care plan, dated 11/2/21 and revised 7/9/25, indicated the resident was at risk for skin breakdown related to impaired mobility, type II diabetes, nutritional status, hand contractures, noncompliance with wearing a stump shrinking device. The interventions included, but were not limited to, floating the heels as needed, pressure reducing cushion to his chair, using moisture barrier to the perineal area as needed, a pressure reducing mattress to the bed, avoid shearing skin during positioning, turning, and transferring, encourage and provide assistance to turn and reposition for comfort as needed, conduct a weekly skin assessment, keep the linens clean and dry, keep the resident as clean and dry as possible and minimize skin exposure to moisture. The clinical record lacked documentation indicating the wound care nurse seen the resident before 12/2/24, revised care plan with new interventions and initiated a new care plan with interventions for wounds. The nurse's note, dated 9/6/24 at 11:35 a.m., indicated the resident had a right heel and right pinky toe wound. The right heel wound measured 3.5 cm in length by 2.7 cm in width and the resident's right pinky toe measured 2.0 cm in length by 1.5 cm in width. The Discipline Progress Note and the Observations Events, dated 9/10/25 at 12:02 p.m., indicated the resident's area to the bottom of his heel appeared purplish brown in color. The skin was intact and the resident voiced no complaints of pain or discomfort to area. Treatment orders were in place for the resident's wound. The resident had a history of diabetic ulcerations and had an ulcer to his left foot that had osteomyelitis, and the resident's left leg had been amputated below the knee. The resident had a callus area to the right side of his foot beneath the pinky toe. The treatment was in place as preventative for this area, the resident did not put pressure on the bottom of his foot, he would lay his right foot on its side. The resident had been non-compliant with wearing a pressure reducing boot while in bed, a brace while up, and wearing a shoe. Prior to the development of the wound, the resident had the following pressure reduction modalities in place: offload pressure to the right heel, float heel while in bed, moisture barrier cream, turning and repositioning, a pressure reducing mattress, a pressure reduction cushion to the wheelchair, weekly skin measurements, and the resident was now being followed on Clinical at risk (CAR) by the campus Wound Care Consultant (WCC). The recommendations included, but were not limited to, continue with prostat AWC 30 milliliters (ml) by mouth twice a day; laboratory test including a C-reactive protein (CRP); and a Sedimentation Rate (ESR) to determine a chronic inflammatory process, that could establish a poor healing diagnosis, albumin, pre albumin, lipid profile to determine potential decrease in circulation; and an Ankle-Brachial Index (ABI) to assess blood flow to the lower limbs. Recommended therapies to treat and evaluate as indicated. The resident continued with weekly skin assessments and the resident was to be followed CAR for wounds. The CAR note, dated 10/10/24 at 2:21 p.m., indicated the resident's right heel measured 3.6 cm in length and 2.5 cm in width. The resident had a calloused area to the right pinky toe and measured 3.4 cm in length by 2.5 cm in width. The pinky side wound had eschar tissue loosely attached, and the heel wound remained intact. A scant amount of purulent drainage was observed. The preventive measures included preservision, Neuriva, followed by the wound nurse and Registered Dietician (RD), and an air mattress. The CAR note, dated 12/13/14 at 12:05 p.m., indicated the resident's right pinky toe removal measured 8 cm in length by 4 cm in width, and the top of the foot measurements were 2.5 cm in length by 2 cm in width. The surgical wound to the top of the right foot remained stable and the surgical wound to the pinky toe removal was red with beefy granulation tissue. Preventive measures were preservision, Neuriva, followed by the wound care nurse and RD, air mattress on bed and pain medication. During an interview, on 9/5/25 at 11:00 a.m., [NAME] Director of Clinical Operation indicated the resident's wound documentation was not accurate and consistent. The wound should be determined what type of wound it was and be consistent with those diagnoses. If a wound was debrided it was still a pressure or vascular wound not a surgical wound. She indicated she had documented a prevention and treatment plan for the resident's wounds on 9/10/24 and staff did not follow the wound plan. During an interview, on 9/5/25 at 11:30 a.m., the Director of Nursing (DON) indicated there should have been a care plan specifically for the resident's right lateral wound. During an interview, on 9/9/25 at 10:25 a.m., MDS Coordinator indicated the facility had a care plan meeting every morning. Staff review any changes in orders, new orders, new skin issues, or anything that has changed with the resident. If a resident had a wound, IV (Intravenous) antibiotics, or an infection of the wound, the resident would have a short-term care plan. There should be a care plan for the wound and antibiotics. When an issue was identified a care plan would be added within twenty-four hours unless it was identified over a weekend then the issue would be added the following Monday. 2. The record for Resident 23 was reviewed on 9/4/25 at 11:54 a.m. The resident's diagnoses included, but were not limited to dyskinesia, chronic ischemic heart disease, atherosclerotic heart disease of the coronary artery, abdominal aortic aneurysm, paraplegic immobility syndrome, disorders of the lung, bronchiectasis, hypothyroidism, hyperlipidemia, depression, anxiety disorder, anemia, hypertension, weakness, difficulty in walking, lack of coordination, repeated falls, personal history of malignant neoplasm of the prostate, and pneumonia. The Quarterly MDS assessment, dated 8/29/25, indicated the resident was severely cognitively impaired. He was always incontinent of bowel and bladder and at risk for pressure ulcers or injuries. The required a mechanical full body lift for mobility. The care plan, dated 4/3/24 and revised 9/3/25, indicated the resident was at risk for skin breakdown related to impaired mobility, incontinence, bilateral knee contractures, and a history of skin breakdown. The interventions, dated 4/3/24, included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessments, pay particular attention to the bony prominences, encourage and assist to turn and reposition for comfort and as needed, float the heels as needed and tolerated, keep linens clean and dry, keep the resident as clean and dry as possible, minimize skin exposure to moisture, observe the feet during care for redness, swelling. or changes in condition; notify the physician as needed, pressure reducing cushion to the chair, pressure reducing mattress to the bed, treatments and preventative treatments as or when ordered, use a lifting device as needed for bed mobility, and use a moisture barrier product to the perineal area as needed. The care plan, dated 5/2/24 and revised 9/3/25, indicated the resident had MASD. The interventions, dated 5/2/24, included, but were not limited to, keep the resident's skin clean and dry, observe for pain, itching, or discomfort and treat as ordered, please observe MASD for a decline or signs and symptoms of infection, notifying the physician as needed, and treatment as ordered. The nurse's note, dated 8/4/24 at 4:28 p.m., indicated the nurse was called to resident's room by a CNA stating the resident had an open area to his buttocks. The area on the resident's buttock was cleansed and measured. The wound measured 6 cm long by 2.5 cm wide by less than 0.1 cm deep to the right buttock. The resident's left buttock area was purple in color with pinpoint open areas. The left buttock measured 4 cm long by 3 cm wide with no open areas. Both areas were cleansed and a foam dressing was applied. The care plan, dated 9/3/25, indicated the resident had a skin/wound infection of the moisture associated skin damage (MASD) area to the coccyx. The interventions, dated 9/3/25, included, but were not limited to, administer medications and treatments as ordered, evaluate, report, and record effectiveness, and or signs or symptoms of adverse side effects, assess pain and observe the wound and surrounding skin condition, report emergence of skin excoriation, assist with frequent turning and repositioning of the wound as appropriate, diet as ordered and encourage fluids unless contraindicated, consult with the dietitian as needed, observe for and report new or worsening signs or symptoms of skin/wound infection, observe for and report signs of sepsis, obtain laboratory work and diagnostic tests as ordered, report findings to the physician, obtain vital signs as ordered and indicated, record the amount, type, and odor of drainage from the wound or skin infection site, record the color, consistency, and location of the exudate, use proper infection control contact precautions as indicated and per policy when providing care. The nurse's note, dated 9/17/24 at 2:48 a.m., indicated CNAs were changing the resident, and notified the nurse of open areas to the resident's buttock. The resident had three discovered dime sized open areas on the buttock/coccyx area. The resident's wounds were cleansed and a foam dressing applied. The nutritional note, dated 9/23/24 at 9:26 a.m., indicated the resident's open areas were on the buttock/coccyx area and treatment was in place. The nurse's note, dated 9/26/24 at 1:40 p.m., indicated treatment to the resident's buttock was completed and the MASD appeared to be healing with no worsening. The nurse's note, dated 1/31/25 at 2:47 p.m., indicated the resident's toes were still discolored but appeared to be getting better. There was no pain or discomfort to the resident's toes. A skin prep was applied. The new area to the side of the left foot had appeared. The wound was red and blanchable. A skin prep was applied to it and an a foam dressing was placed for a barrier. The resident's legs were propped up with a pillow. The hospice RN was in to see the area as well, with no concerns per the RN. The nurse's note, dated 7/16/25 at 10:40 p.m., indicated the resident had three Stage 2 pressure ulcers to the left and right buttocks with 2 areas on the right buttock. The wounds were covered with a foam dressing. The nurse's note, dated 7/17/25 at 2:53 p.m., indicated the areas to the resident's buttocks were present as moisture associated skin damage and treatment was in place. The nurse's note, dated 9/2/25 at 1:37 p.m., indicated the resident was observed to have an open area on the bottom. A foul smell was present when the dressing was removed. The area was cleansed with normal saline and covered with Mepilex. Hospice was in to see the resident and a new order to start 100 mg of doxycycline twice daily for 5 days was placed. The Interdisciplinary note, dated 9/5/25 at 10:05 a.m., indicated the wound care RN assessed the wound. A new treatment plan was in place, and an antibiotic was started. The nurse's note, dated 9/8/25 at 1:33 p.m., indicated the resident had healed areas to the bottom surrounding the wound. The wound area was red and purple in color. The area was blanchable. The treatment orders changed to a Calazyme paste and apply a foam dressing to be applied every 3 days. The resident and family were made aware. During an observation of Resident 23, on 9/8/25 at 8:50 a.m., Wound Care Nurse 3 gathered treatment supplies and brought them into the resident's room. CNAs 7 and 8 were using a full body mechanical lift to transfer the resident from his recliner to his bed. The resident was lying on his left back side asleep with a blanket covering him. The resident's caregiver was sitting next to the resident. There was a cushion on the seat of the recliner. Once the resident was transferred into bed, the resident's brief was pulled down and he was in the middle of a bowel movement. The wound dressing was getting soiled. Once the resident was cleaned and the brief was removed, the began to conduct the wound treatment change. The resident started to have another bowel movement. The resident's left hip had a reddened 5-inch diameter circular area. The CNAs applied barrier cream to the left hip. The Wound Care Nurse 3 performed hand hygiene and applied gloves. The staff did not apply gowns. The soiled dressing didn't have a date on it. The resident's coccyx had multiple areas of scarring from old wounds. The new wound had white colored granulation tissue on the quarter sized wound. The lower edge of the wound had a scant area of blood or drainage on it. The Wound Care Nurse 3 indicated the wound looked worse than it did last week. There were four quarter sized wounds around the new wound. The Wound Care Nurse 3 applied two small calcium alginate treatments to the wounds. She then applied the foam dressing over the alginate. Three cup sized red areas were observed on the resident's left buttock. The resident was placed on his left side. One pillow was placed behind the resident's back and hip area. One pillow was placed between his knees. One pillow was placed under his knees. Boots were placed on the resident's feet. The record lacked updated care plan interventions related to wounds after 5/2/24 through 9/2/25, even through the resident continued to have skin impairment issues. The Comprehensive Care Plan Guideline policy, revised 5/22/18, included, but was not limited to, . Procedure 1. c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan. 3. The comprehensive care plan should be reviewed no less than quarterly and revised to reflect changes in the resident's condition as they occur . Cross Reference F684 and F741. 3.1-35 (d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure resident's wounds had accurate documentation for size, staging, and treatment for 2 of 2 residents reviewed for non pressure wounds.Findings include:1.During an observation of the resident on 9/8/25 at 1:21 p.m., the resident was sitting on his left hip in his recliner. The resident was asleep. The Infection Control Infection Tracker Event Report, dated 9/2/25, indicated Resident 23 had Cellulitis/Soft Tissue/Wound to the buttocks with light green drainage. This was a healthcare-associated infection. The signs and symptoms of the cellulitis/soft tissue/wound infection was redness, tenderness, and purulent drainage. The interventions were to give medications as prescribed for the infection, encourage fluids, monitor for effectiveness of the antibiotic, and monitor for signs and symptoms of the infection. The care plan, dated 5/2/24 and reviewed 9/3/25, indicated Resident 23 had moister associated skin damage (MASD. The interventions, dated 5/2/24, included, but were not limited to, keep the resident's skin clean and dry, observe for pain, itching, or discomfort and treat as ordered, please observe MASD for a decline or signs and symptoms of infection, notifying the physician as needed, and treatment as ordered. The nurse's note, dated 8/4/24 at 4:28 p.m., indicated the nurse was called to the resident's room by a CNA indicating the resident had an open area to his buttocks. The areas to the right buttock, were cleansed and measured 6 cm long by 2.5 cm wide by less than 0.1 cm deep. The area of the resident's buttocks was purple in color with pinpoint open areas throughout. The resident's left buttock measured 4 cm long by 3 cm wide with no open areas to the left buttock. Both areas were cleansed and a foam dressing was applied. Staff were educated to attempt to offload the resident's hips while up in the recliner. The Interdisciplinary note, dated 8/5/24 at 9:22 a.m., indicated the resident had moisture associated skin damage to the buttocks. The treatment and monitoring were in place at this time. The Wound Management assessment, dated 8/9/24 at 9:31 a.m., indicated the resident had dermatitis to the right buttock. The area was MASD not a true dermatitis. The nurse's note, dated 9/17/24 at 2:48 a.m., indicated CNAs were changing the resident and notified the nurse of open areas to the buttock. The resident had 3 dime sized open areas on the buttock/coccyx area. The area was cleansed and a foam dressing was applied. The Wound Management assessment, dated 9/26/24, indicated the resident's right buttock wound was 1 cm long by 1 cm wide. The resident continued with incontinence associated dermatitis with small open areas of skin damage from moisture. The follow-up wound note lacked documentation of measurements or treatment. The nurse's note, dated 7/16/25 at 10:40 p.m., indicated the resident had three Stage 2 pressure ulcers to the left and right buttocks with 2 areas on the right buttock. The wounds were covered with a foam dressing. The physician's order, dated 7/16/25, indicated staff were to apply magic butt cream cream; Nystatin 100,000 unit per gram (u/gram) ointment, bacitracin zinc 500 u/gram ointment, Hydrocortisone 1% ointment, zinc oxide 20%. See the package; topically four times a day and PRN. The Wound Management assessment, dated 7/16/25, indicated the first observation of the two open areas to the right buttock measured 0.5 cm long by 0.5 cm wide. The wound was documented as an unspecified ulcer. The nurse's note, dated 7/17/25 at 2:53 p.m., indicated the area to the resident's buttocks presented as moisture associated skin damage. The physician's order, dated 7/17/25, indicated staff were to observe the resident's dressing to the residents open area(s) of the buttocks every shift for drainage on the dressing and dislodgement. The physician's order, dated 7/17/25, indicated to cleanse the resident's wound to the buttocks PRN with wound cleanser or normal saline, pat dry, apply skin prep to peri-wound, and cover with foam dressing if dislodged or soiled. The Wound Management assessment, dated 7/17/25, indicated the open areas to the resident's right buttock were documented as MASD and were discontinued from Wound Management. The physician's order, dated 7/17/25, indicated to cleanse MASD wound to the buttocks with wound cleanser or normal saline, pat dry, apply skin prep to peri-wound, and cover with foam dressing every 5 days between 7:00 a.m. and 3:00 p.m. The physician's order, dated 8/20/25, indicated the resident was admitted under hospice services related to a terminal diagnosis of a neurocognitive disorder with Lewy Bodies. If the disease ran a normal course, the life expectancy was 6 months or less. The Quarterly MDS assessment, dated 8/29/25, indicated the resident was severely cognitively impaired. He was always incontinent of bowel and bladder and was at risk for pressure ulcers or injuries. The nurse's note, dated 9/2/25 at 1:37 p.m., indicated the resident was observed to have an open area on the bottom. A foul smell was present when the dressing was removed. The area was cleansed with normal saline and covered with Mepilex. Hospice was in to see the resident and a new order to start 100 mg of doxycycline twice daily for 5 days for the infection was placed. The care plan, dated 9/3/25, indicated the resident had a skin/wound infection of the MASD area to the coccyx. The interventions, dated 9/3/25, included, but was not limited to, administer medications and treatments as ordered, evaluate, report, and record effectiveness, and or signs or symptoms of adverse side effects, assess pain and observe the wound and surrounding skin condition, report emergence of skin excoriation, assist with frequent turning and repositioning of the wound as appropriate, diet as ordered and encourage fluids unless contraindicated, consult with the dietitian as needed, observe for and report new or worsening signs or symptoms of skin/wound infection, observe for and report signs of sepsis, obtain laboratory work and diagnostic tests as ordered, report findings to the physician, obtain vital signs as ordered and indicated, record the amount, type, and odor of drainage from the wound or skin infection site, record the color, consistency, and location of the exudate, use proper infection control contact precautions as indicated and per policy when providing care. The Interdisciplinary note, dated 9/5/25 at 10:05 a.m., indicated Wound Care Nurse 3 assessed the resident's wound. A new treatment plan was in place, and an antibiotic was started. During an interview on 9/5/25 at 10:28 a.m., the Regional Director of Clinical Operations (RDCO) indicated she had not looked at the wounds in the facility for at least three weeks. The wound nurse just quit last week. She did not always agree with the previous wound nurse's assessment and had educated the Former Wound RN 6 many times. The wound was something and it should be staged. The new Wound Care Nurse 3 was in training as the wound nurse. During an interview, on 9/5/25 at 11:50 a.m., the RDCO indicated not every wound would be included in the Wound Management. On 12/25/24, all types of skin areas were to be documented in Wound Management. The wound on 7/16/25 should have been documented in Wound Management. Even though the resident was having MASD, No physician would look at the wounds, unless they were very severe. Hospice would assess the wound and place orders for the most recent wound on 9/2/25. They did not order a wound culture. The documentation did not show what the wound was at times and the classification of the wound was confusing. The nurse's note, dated 9/8/25 at 1:33 p.m., indicated the resident had healed areas to the bottom surrounding the new wound. The wound area was red and purple in color. The area was blanchable. The treatment orders were changed to Calazyme paste and apply a foam dressing to be applied every 3 days. The physician's orders, dated 9/8/25, indicated to cleanse the resident's wound to the MASD buttocks with wound cleanser or normal saline, pat dry, apply skin prep to the peri-wound, apply Calazyme ointment to the wound bed and cover with a foam dressing every 3 days. 2. The record for Resident 2 was reviewed on 9/7/25 at 9:48 a.m. The diagnoses included, but were not limited to, osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation. The care plan, dated 11/2/21 and revised 7/9/25, indicated the resident was at risk for skin breakdown related to impaired mobility, type II diabetes, nutritional status, hand contractures, noncompliance with wearing a stump shrinking device. The interventions included, but were not limited to, floating the heels as needed, pressure reducing cushion to his chair, using moisture barrier to the perineal area as needed, a pressure reducing mattress to the bed, avoid shearing skin during positioning, turning, and transferring, encourage and provide assistance to turn and reposition for comfort as needed, conduct a weekly skin assessment, keep the linens clean and dry, keep the resident as clean and dry as possible and minimize skin exposure to moisture. The nurse's note, dated 8/29/24 at 3:01 p.m., indicated the resident was observed to have a deep tissue injury to the right lateral distal foot joint measuring 1.5 cm in length by 0.5 cm in width. The resident's foot turned out placing pressure on the area when sitting with his foot down. The nurse's note, dated 9/5/24, the resident had a blistered tissue that was intact. The tissue had 25 percent dark purple tissue and 75 percent flesh colored. The nurse's note, dated 9/6/24 at 11:35 a.m., indicated Resident 2 had a right heel and right pinky toe wound. The measurements for the right heel measured 3.5 cm in length by 2.7 cm in width. The toe measured 2.0 cm in length by 1.5 cm in width. The preventive measures included Preservision, Neuriva, and followed by the wound nurse. The Discipline Progress Note and the Observations Events, dated 9/10/25 at 12:02 p.m., indicated the resident's area to bottom of heel appears purplish brown in color, the skin was intact and voiced no complaints of pain or discomfort to area. Treatment orders were in place. Resident 2 had a history of diabetic ulcerations and had an ulcer to his left foot that had osteomyelitis, and the left leg had been amputated below the knee. The resident had a callus area to the right side of foot beneath the pinky toe. The treatment was in place as preventative for this area, as the resident was not noted to put pressure on the bottom of his foot, rather, he lays the right foot on its side. The resident had been non-compliant with wearing pressure reducing boot while in bed and bracing while up and wearing a shoe. Prior to the development of the wound, the resident had the following pressure reduction modalities in place: offload pressure to the right heel, float heel while in bed, moisture barrier cream, turning and repositioning, a pressure reducing mattress, a pressure reduction cushion to the wheelchair, weekly skin measurements, and the resident was now being followed on Clinical at Risk (CAR) by the campus WCC. The recommendations included continue with prostat AWC 30 milliliters (ml) by mouth twice a day, laboratory test including a C-reactive protein (CRP) and a Sedimentation Rate (ESR) to determine a chronic inflammatory process, that could establish a poor healing diagnosis, albumin, pre albumin, lipid profile to determine potential decrease in circulation, and an Ankle-Brachial Index (ABI) to assess blood flow to the lower limbs. Recommended therapies to treat and evaluate as indicated. Continue with weekly skin assessments and continue to follow in CAR for wounds. The nurse's note, dated 9/12/24 at 10:59 a.m., indicated the wound to the resident's right foot was without improvement. The NP was notified and indicated she would order a doppler to evaluate the arterial blood flow and investigate the possibility of getting a boot for offloading pressure. The nurse's note, dated 9/26/24, indicated the resident had a diabetic wound with dark brownish red intact tissue. The nurse's note, dated 10/3/24 at 2:03 p.m., indicated the resident's wound to the right lateral foot wound bed had turned dark purple in color. The foot was red, warm, and edematous. The resident was sent to the hospital. The CAR note, dated 10/10/24 at 2:21 p.m., indicated the resident's right heel measured 3.6 cm in length and 2.5 cm in width. The resident had a calloused area to the pinky toe that measured 3.4 cm in length by 2.5 cm in width. The pinky side wound had eschar tissue loosely attached, and the heel wound remained intact. A scant amount of purulent drainage was observed. The preventive measures included preservision, Neuriva, followed by the wound nurse and Registered Dietician (RD), and an air mattress. On 10/17/24, the resident had a diabetic wound to the right bottom of the foot on the posterior planter's aspect. The epidermis had dried up and came off. The underlying tissue was pink and appeared fragile. A foam dressing applied. The nurse note, dated 10/17/24, indicated the resident had a diabetic wound to the right bottom of the foot on the posterior planter's aspect. The epidermis had dried and came off. The underlying tissue was pink and appeared fragile. A foam dressing applied. The nurse's note, dated 11/1/24 at 7:22 a.m., indicated Resident 2 had increased confusion. The resident's temperature was 103.1 Fahrenheit. Staff were concerned the resident may be septic from his foot wound. The nurse's note, dated 11/14/24 at 10:09 a.m., indicated the resident's dressing was changed to the resident's right foot. Eschar spots remained intact. Red beefy meat continued to the top of the right foot with bleeding observed. A blister to the top of the food was still intact. The nurse's note, dated 11/21/24 at 4:02 p.m., indicated the resident's treatment to the right foot was completed. The wound had 75 percent granulating tissue and 25 percent firmly adherent necrotic tissue. The entire top of the right foot and bottom base of the toes were reddened and edematous. The resident was sent to the hospital. The nurse's note, dated 11/27/24 at 3:49 a.m., indicated the resident returned from the hospital. The resident's right foot wound was debrided while in the hospital. The resident was to continue to take antibiotics. The nurse's note, dated 12/01/24 at 1:53 p.m., indicated the resident's right side of his foot wound measured 8 cm in length by 4 cm in width by 1.5 cm in depth. The wound on the top of the resident's foot measured 1.5 cm in length by 3 cm in width by 0.3 cm in depth. The wound note, dated 12/2/24, indicated the resident's surgical incision had an open area. The surrounding tissue was warm to touch with serous drainage. The Physician Assistant (PA) note, dated 12/3/24 at 10:43 a.m., indicated the resident had a history of osteomyelitis and recent right foot toe amputation. The resident was seen for a follow-up of cellulitis of the right foot. He was previously hospitalized for cellulitis of the right foot and had a right foot toe amputation due to osteomyelitis, followed by debridement. He was discharged on Levaquin, which he completed. At the last visit, he was prescribed doxycycline 100 mg BID for 7 days, which he tolerated well. He reported reduced warmth of the foot and no fever or other signs of infection. The wound was healing as expected, with minimal drainage. He had an appointment with the wound physician on 12/3/24 and would continue doxycycline for three more weeks. The wound note, dated 12/5/24 at 12:53 p.m., indicated the resident's surgical incision had an open area. The wound was red with sanguineous drainage present. The wound measured 2.7 cm in length and 1.5 cm in width. The nurse's note, dated 12/12/24 at 2:00 p.m., indicated the nurse completed the treatment of the resident's right foot and observed a bone could be felt in the back end of the wound. The wound care physician was notified. The CAR note, dated 12/13/14 at 12:05 p.m., indicated the pinky toe removal measured 8 cm in length by 4 cm in width, and the top of the foot measurements were 2.5 cm in length by 2 cm in width. The surgical wound to the top of the right foot remained stable and the surgical wound to the pinky toe removal was red with beefy granulation tissue. Preventive measures were preservision, Neuriva, followed by the wound care nurse and RD, air mattress on bed and pain medication. The wound note, dated 1/30/25 at 5:36 p.m., indicated the surgical incision had an open area. The open area was red and had separated from the original incision and healing separately. The measurements included 1.6 cm in length and 1.6 cm in width. The wound note, dated 2/23/25 at 2:27 p.m., indicated the resident's incision with the open area was normal in color with sanguineous drainage. The measurements included 3 cm in length and 2 cm in width. The wound note, dated 3/27/25, indicated the resident had a surgical incision. The resident had a wound to the top of his right foot distal to the ankle. The nurse's note, dated 4/9/25 at 7:23 p.m., indicated the resident was observed to have increased redness during the dressing change. The redness ran from the top of the ankle to the top of the toes. The physician was notified, and a wound culture was ordered. If the resident's condition worsened at midnight the change contact the physician again with pictures of the area. The nurse's note, dated 4/10/25 at 12:14 p.m., indicated the treatment was completed to the wounds on the resident's right foot. The right foot was red in color and warm to touch. The wound bed was pale pink. The peri-wound was macerated with darkening of the tissue. The Physician Assistant (PA) was notified, and antibiotics were started. The nurse's note, dated 4/10/25 at 9:19 p.m., indicated the resident was observed with increased confusion, making unrealistic comments, and difficulty finding the proper words. The resident was aware he was confused and concerned about an infection to his foot. The resident was sent to the hospital. The nurse's note, dated 4/17/25 at 7:58 p.m., indicated the resident returned to the hospital. The right foot wound measured 5 cm in length by 3 cm in width. The resident was in contact isolation related to Methicillin Resistant Staphylococcus Aureus (MRSA). The PA notes, dated 4/24/25, indicated the resident was hospitalized for osteomyelitis which developed from a diabetic foot ulcer. A bone scan confirmed the osteomyelitis. The cultures indicated MRSA and started on antibiotics. He would follow up with surgery after completing the antibiotic course. It is unclear if debridement was performed during the hospitalization. The wound note, dated 4/25/25 at 2:26 p.m., indicated the resident's surgical wound edges were well approximated. Two surgical wounds had emerged. The surgical wound measured 3.5 cm in length by 2 cm in width. The nurse's note, dated 5/7/25 at 11:49 a.m., indicated the resident returned from the wound physician from wound debridement. The wound note, dated 5/29/25 at 2:32 p.m., indicated the resident's surgical incision was normal in color with serous drainage. The measurements included 3.5 cm in length by 2.4 cm in width. The wound note, dated 6/12/25 at 10:09 a.m., indicated the resident's surgical incision with the open area was red with purulent drainage. The tissue was 100 percent red non-granulating tissue. The peri wound was reddened, and a scant amount of green drainage was observed. The nurse's notes, dated 6/19/25 at 2:57 p.m., indicated the resident was admitted to the hospital for Xenograft procedure. The PA notes, dated 6/20/25 at 8:35 a.m., indicated the resident underwent an outpatient procedure at the hospital to obtain a skin graft for the foot, but was informed that the graft was not effective and would result in further amputation. The wound note, dated 7/17/25 at 12:09 p.m., indicated the resident's foot had an open area. The resident's skin was normal in color with sanguineous drainage. The tissue was 100 percent granulating tissue with patches of dark thickened tissue. The wound measured 2 cm in length by 1.5 cm in width. During an interview, on 9/5/25 at 11:00 a.m., the [NAME] Director of Clinical Operations indicated the resident's wound documentation was not accurate and consistent. The wound should be determined what type of wound it was and be consistent with those diagnoses. If a wound was debrided it was still a pressure or vascular wound not a surgical wound. She indicated she documented a prevention and treatment plan for the resident's wounds on 9/10/24 and staff did not follow the plan. The clinical record lacked documentation indicating the residents wounds were stage appropriate and implementation of the recommended treatments as documented. The Comprehensive Care Plan Guideline policy, revised 5/22/18, included, but was not limited to, . Procedure 1. c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan. 3. The comprehensive care plan should be reviewed no less than quarterly and revised to reflect changes in the resident's condition as they occur . Cross Reference F657 and F741. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident received medications as ordered for 1 of 5 residents reviewed for pharmacy services. (Resident 34) Findings include: The record for Resident 34 was reviewed on 8/16/24 at 9:32 a.m. The resident's diagnoses included, but were not limited to, anxiety disorder and depression. The care plan, dated 7/4/24, indicated the resident had a diagnosis of anxiety and demonstrated anxiousness, restlessness, agitation, and aggressive behaviors. The interventions included, but were not limited to, encourage the resident to voice the cause for his anxiety and problem solve ways to resolve stressors, identify and avoid triggers whenever possible, provide consistency and routine, monitor for increased signs and symptoms and resolve the concerns when possible. The Quarterly MDS (Minimum Data Set) assessment, dated 6/24/24, indicated the resident was moderately cognitively intact. The resident had physical behavioral symptoms directed toward others. The nurse's notes, dated 6/5/24 at 12:02 a.m., indicated the CNA (Certified Nursing Aide) was changing the resident. The resident punched the CNA in her face, pulled her hair out of her head, and choked her. The resident had punched another CNA in her face the night before. The resident did not have a PRN (as needed) medication to give. The nurse's note, dated 6/5/24 at 10:36 a.m., indicated the physician was made aware of the resident's increased behavior and combativeness. A new order was received for Ativan 1 mg every 8 hours PRN. The NP (Nurse Practitioner) note, dated 6/13/24 at 9:32 a.m., indicated the resident had advanced dementia and had increased combativeness during personal care. On 6/5/24, the physician wrote an order for Ativan 1 mg every 8 hours PRN for agitation. The prescription was never sent to pharmacy. The staff requested a prescription today. The resident was taking Depakote 250 mg oral at bedtime. During an interview on 8/19/24 at 10:00 a.m., LPN (Licensed Practical Nurse) 4 indicated when the nursing staff took a physician's order they would put the order in the computer system. When the physician ordered a medication like Ativan, the physician was responsible to send the prescription to the pharmacy via the computer. If the order was not filled within a couple of hours, staff should do a follow up and call the pharmacy or the physician to see if the prescription was sent. He would not wait any longer than 2 hours. The current Guidelines for Medications Orders policy included, but was not limited to, . b. Telephone or verbal orders shall be recorded in Matrix when received by the nurse receiving the order. 3.1-25(b)(1)(c)

Based on observation and interview, the facility failed to ensure influenza vaccinations were monitored for expiration dates and disposal of the expired medication for 1 of 4 observations of medication storage. (Medication Room refrigerator) Findings include: During an observation on 8/16/24 at 1:01 p.m., of the 200 Hall medication storage room with RN 5, four boxes of Fluzone influenza vaccination, plus an open box with one vial of Fluzone influenza vaccination had an expiration date of June 2024. She indicated the influenza vaccinations were dated June 2024, and she would check to make sure the boxes and vial were expired. There were 10 vials of the influenza vaccine in each box for a total of 41 vials. During an interview on 8/16/24 at 2:10 p.m., the ED (Executive Director) indicated the influenza vaccinations were expired. She indicated they had not been administered since the influenza season ended. During an interview on 8/20/24 at 8:43 a.m., LPN (Licensed Practical Nurse) 4 indicated if an influenza vaccination was expired, it would go to the DON (Director of Nursing) for disposal. The influenza vaccination period would begin in September or October. During an interview on 8/20/24 at 9:47 a.m., LPN 3 indicated the ADON (Assistant Director of Nursing) would monitor the vaccinations for expiration dates. Influenza vaccinations began in September or October each year. During an interview on 8/20/24 at 9:57 a.m., the DON indicated the vaccination's expiration dates were monitored by herself, the ADON, and the evening shift supervisor. It was just an oversight that they missed the vaccinations were expired. The Medication Storage In The Facility policy, revised January 2018, included, but was not limited to, . G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner . 3.1-25(o)

Based on record review and interview, the facility failed to ensure resident rights related to dignity for 1 of 3 residents reviewed for resident rights. (Resident B) Findings include: The record for resident B was reviewed on 1/10/23 at 11 33 AM. The diagnoses included, but were not limited to, incomplete lesion at C5 level of cervical spinal cord, quadriplegia C5 through 37 incomplete, attention deficit hyperactivity disorder, major depressive disorder, anxiety, paraplegia, reduce mobility, lack of coordination, muscle weakness, and difficulty in walking. The quarterly MDS (Minimum Data Set) assessment, Dated 12/27/23, indicated the resident was cognitively intact. The care plan initiated on 12/26/23 and last revised on 1/3/24 indicated the resident had a history of verbal behaviors directed towards staff such as threatening their jobs, accusing them of abuse, retaliatory behaviors, inappropriate attachment to staff, and recording conversations. The interventions included but were not limited to avoiding power struggles with resident conveying attitude of acceptance to resident, do not engage resident in sensitive topics, maintain a common environment, and approach to the resident in sensitive topics, maintain calm approach, provide care with two assistants, set expectations and limits for resident when a patient becomes verbally abusive stop, assure resident safety and reapproach at a later time. The State reportable incident, dated 12/21/23 at 12:01 p.m., indicated the resident reported a staff member called him a baby bird. The resident provided a recording of himself asking for a pop tart to be torn up into pieces. The CNA (Certified Nurse Aide) asked the resident if he needed her to baby bird it. The typed statement of the ED (Executive Director) indicated, on 12/21/23 at noon, Resident B wanted to talk to her regarding an allegation of that night shift had hurt his feelings. He had a recording which the ED listened to. The resident was upset. The ED's note, dated 12/22/23, indicated the resident had psychosocial monitoring in place. He was visibly upset. The ED offered support which was declined. The resident declined to have anyone called or have counseling services. During an interview, on 1/10/24 at 12:09 p.m., CNA 5 indicated she recalled the incident vaguely. She remembered she was opening a pop tart for him and she was joking around and asked him if he wanted her to baby bird it to him. She described what she meant by stating, It's just when you chew up someone's food and you feed it to them like a mommy bird. But I would never do that, absolutely. I would never do that. She confirmed she did state to the resident Do you need me to baby bird it? During an interview on 1/11/24 at 11:02 a.m., the ED indicated the resident had asked to speak with her and told her the incident had hurt his feelings. He initially told her CNA 5 told him she would chew his food up and spit it back into his mouth. She listened to the video immediately. The video showed Resident C had asked CNA 5 to tear up his poptart for him. CNA 5 responded, asking if the resident wanted her to baby bird it for him. The CNA was educated on professional language and approach. The facility's most current Resident Rights policy, included, but was not limited to, . Resident Rights . The resident has a right to a dignified existence . (e) Respect and dignity. The resident has a right to be treated with respect and dignity . This citation relates to Complaint IN0424598. 3.1-3(a)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions and response for dementia related behaviors for 1 of 3 residents reviewed for dementia care. (Resident C) Findings include: During an observation on 1/10/24 at 10:35 a.m., Resident C was in his bed. He was pleasantly confused and very hard of hearing. When asked his name he indicated a name which was not his. He was not able to be interviewed. He appeared pleasantly confused and in no distress. He had no visible bruising at this time. The record for Resident C was reviewed on 1/10/24 at 11:16 a.m. The diagnoses included, but were not limited to, unspecified psychosis, hallucinations, altered mental status, visual disturbance, unsteadiness on feet, and muscle weakness. The Quarterly MDS (Minimum Data Set) assessment, dated 11/24/23, indicated the resident was rarely or never understood and was not assessed for cognitive status. The nurses note, dated 9/26/23 at 12:49 a.m., indicated the resident was being verbally and physically aggressive that night. He refused his medications and began swinging and cussing at the nurse. The CNA (Certified Nurse Aide) was trying to check and change him that morning and the resident began swinging, pinching, cursing and yelling. The record lacked documentation of any interventions or their effectiveness for this incident. The nurse's note, dated 10/10/23 at 12:17 a.m., indicated the CNA was trying to change the resident and he became angry. He swung and hit her in the side. The resident calmed back down when left alone. The physician's note, dated 10/12/23 at 8:15 a.m., indicated the resident was seen for a follow-up to his conditions which included, but were not limited to, dementia. The resident was on medication for anxiety. He had no behavioral concerns and was eating and sleeping well. He was tolerating all medications. All chronic problems were stable. The nurse's note, dated 10/21/23 at 4:00 a.m., indicated while staff were changing the resident he began swinging and punched a CNA in the face three times. The Social Services note, dated 10/23/23 at 4:17 p.m., indicated the resident had an episode of being combative with care at 4:00 a.m., when attempting to change the resident. He had significantly impaired hearing and cognition. His care plan was updated to recommend staff approach him slowly and calmly when performing care as to do their best to not startle or agitate the resident who may be confused about what care was being performed and why. The care plan, initiated 10/23/23, indicated the resident demonstrated combative and resistive behaviors with staff during hands on care related to dementia. Goal was for the resident to not result in injury to self or others. The interventions included, but were not limited to, approach the resident in a calm and unhurried manner to deliver care and provide services, explain care process prior to delivery of care as needed, observe for signs of over stimulation, and encourage to move to less stimulating environments as needed. The care plan indicated the resident's showers were on Thursday and Sunday on third shift with a the the assistance of two staff members for transfers. The nurse's note, dated 11/1/23 at 5:48 a.m., indicated the resident became very agitated with staff when routine bed checks were completed that morning. He began swinging and stating I don't want to stand up. Staff reassured him he did not have to stand up, she just needed him to roll to the side. The resident rolled over and called the staff member a b***h and would not let go of the rail to roll back. When staff convinced the resident to roll back so they could finish changing his brief, he began to swing at staff. They were eventually able to complete the change and the resident calmed down. Staff were able to avoid being struck by the resident. The physician's note, dated 11/7/23 at 8:28 a.m., indicated the patient was seen for conditions including, but was not limited to, dementia. The resident was still on buspar 10 mg (milligrams) twice daily for anxiety. He had no new or acute complaints. He had no behavioral concerns and his chronic problems were otherwise stable. The physician's note, dated 12/12/23 at 8:28 a.m., indicated the resident was seen for a follow-up for health conditions which included, but were not limited to dementia. The resident's dementia was slowly declining, he was clinically comfortable, continue treatment. He had anxiety and Parkinson features which were controlled. The nurse's note dated 12/16/23 at 5:25 a.m.,,. indicated the resident had not slept for the past two nights. He had been yelling in the room and trying to get out of bed. He was brought to the living room to be more closely monitored. His roommate was angry about being woken up. The skin tear event, dated 12/17/23, indicated the resident had a skin tear to the left upper interior arm measuring 2 cm (centimeters) in L (length) by 2.5 cm in W (width), which was shallow, had a small amount of blood, irregular edges, and no pain. The activity during the occurrence was bathing and transferring. The area was cleansed with soap and water and first aid was given. The bruise event, dated 12/17/23, indicated the resident four areas of bruising. Bruise number 1 to his left upper arm was red, blue. Bruise number 2 to his forearm was red, blue. Bruise number 3 to his right forearm was red-blue and measured 1.5 cm in length by 4 cm in width. Bruise number 4 to his right outer upper arm was 2.5 cm in L by 2 cm in W and was red, blue. The bruises were obtained during bathing and transfer. The IDT note, dated 12/18/23 at 9:17 a.m., indicated the resident had a new skin tear and bruise noted. The skin areas occurred while care was being provided. Treatments and monitoring were in place. There was no further documentation with regards to how the resident obtained the bruising and skin tear during his bathing and transfer. The handwritten statement of LPN 4 dated 12/17/23 at 11:15 AM indicated at approximately 11:10 a.m., LPN (Licensed Practical Nurse) 4 was contacted by CNA 7 and it was reported that resident C was presenting with new bruising and a skin tear. Assessment of the resident was conducted, and the left arm showed new bruising and skin tears. The resident had no memory of how it happened. During report it was mentioned that the resident hit staff during showering. The typed statement of CNA 7, dated 12/17/23 at 7:19 PM, indicated on 12/17/23 during report, CNA 5 and CNA 6 stated Resident C was being combative so they two-person body lifted him out of the shower chair into bed. At 8:15 a.m., herself and another staff member went in to check on the resident and set him up for breakfast. He was dry so they sat the head of the bed up so he could eat. Family arrived at 10:00 a.m. and he had a few people in there, so they waited until family left to go back and check on him again. At 11:00 a.m. herself and another staff member went in to change him because he was wet and rolled him over and saw blood on the Chuck and draw sheet. As they were looking at the arm to see where the bleeding was coming from, they noticed he had several new bruises on both his left and right arms and open skin on both arms around the elbows. The other staff member stayed with the resident while CNA 7 went to grab LPN 4 to come take a look. He examined the resident and immediately went to call the ED and DON. The typed statement of CNA 5, dated 12/16/23, indicated the aid went into the room to check on the resident and see if the other aid needed help after the resident had his shower. The other aide stated the resident had struck her in the face multiple times during the shower and she couldn't get him hooked back up to the full body lift lift due to him being combative. They body lifted him back into bed and proceeded to try and check and change the resident she was at his hips trying to hold him over while the other aide was at the top holding him over while trying to wipe the resident clean of his bowel movement. The resident kept forcefully pushing back against the wall. CNA 5 told the other aide to just put a brief on him and come back later when the resident had calmed down. They didn't put a top on him at the time, they covered him up and made sure he was warm and safe. They gave him his call light, put up the side rail, and then put the bed at the lowest position. The resident was re-approached later by the other aid and care was provided. The typed statement of CNA 6, dated 12/17/23, indicated on 12/16/23 CNA 6 entered the resident's room to give the resident a shower. She turned on the light and spoke loud enough so the resident would understand and let him know that it was his shower day. She offered him his shower and he seemed understanding and willing to participate although he was a little agitated from being woken up. She rolled the resident over and placed the full body lift pad underneath him with the help of another aide. The resident seemed to be getting more agitated from being rolled, but generally liked showers. She thought once he saw the shower and maybe understood what was going on more that he would deescalate. As the other aide and she were trying to help the resident into the shower chair using the full body lift the resident was flailing his arms around and trying to hit and bite both of them. The other aide asked if she would be OK to give him his shower by him herself and she said yes that he should calm down once he was in the shower as he usually did. This time however the resident did not deescalate and was still very agitated as she was trying to shower him. The resident was still flailing around his arms and trying to hit and bite. The resident hit her in the face and arms as she was trying to bathe him. Her goal at this point was to get the resident clean and out of the shower as quickly as possible while also keeping himself and herself safe. Once she got him out of the shower, he was still very agitated and combative, so she called in another aide to assist her in putting him to bed. The resident was too escalated to safely use the full body lift, so the other aide and she had to underarm him into the bed. As they were trying to reposition and change the resident, he was still very escalated and was using his arms to push up against the wall as they were putting his brief on him. The other aide suggested that they leave his shirt off for now due to how he was being combative. They made sure he was clean safe and comfortable as best as they could at the time and then checked on him later and were able to provide care for him as he had deescalated. During an interview on 1/10/23 at 12:33 p.m., LPN 4 indicated he was familiar with Resident C and recalled opening new skin events on him. He was not the first person to identify the skin impairments. Two of his CNAs (Certified Nurse Aides) had brought it to his attention. They told him that they wanted me to make sure he saw them because it was new events of bruising and skin tears on his bilateral elbows. They did not tell him how they obtained them. They didn't move him and there was nothing that would have caused them. He'd had a shower the shift prior. CNA 5 and CNA 6 had been talking about giving him a shower. CNA 6 indicated he'd hit her and become combative in the shower which was not out of the ordinary for the resident. His typical response would be to switch it to a bed bath and make it as comfortable as possible and if still agitated then he would separate and give the resident to calm down. There was no sense in agitating the resident. During an interview on 1/10/24 at 12:46 p.m., CNA 7 indicated she and another staff member had gone in to care for Resident C and had pulled back the sheet and were getting ready to change him. They saw blood on his bed pad and saw a skin tear under his elbow. They looked even further and there was new bruising on his arms and skin tears under both elbows. They finished changing him and had LPN 4 come in to look at him. She told the nurse she wasn't sure what had gone on, but it didn't look too hot. He had little circle red dots on his back all over the top part of his back, and he had bruising on his hands. When they looked at him, they didn't know how he got that many bruises. He had them all over his arms and hands. It was very concerning to them. It was concerning because there was a ton of bruising and the skin tear looked like a nail had dug under it, his skin was fragile any ways. She was told that he was given a shower on third shift the night before, they did not say anything, they said he was fine. It was later in the day they said he was being combative and that he was yelling out no he didn't want to get it, but they continued and put him in the shower. They said he was punching CNA 6 in the face. The other aide involved was CNA 5. CNA 9 had told her this. She said she had been in the room when Resident C was punching CNA 6 in the face. She had been in there when they were transferring him and putting him in the shower, and he was refusing. During a confidential interview, between 1/10/24 and 1/11/24, Staff E indicated she had seen blood on Resident C's draw sheet and clear fluid. They got to looking and he had a skin tear on both elbows, and they observed bruising. They immediately told LPN 4. He also had what looked like purple petechia on his back. She was very concerned. They were told he was being combative, and the aides proceeded to shower him anyway. The shower sheet had indicated CNA 6 had given the resident his shower. CNA 9 had told her and CNA 7 the resident had been combative, and she held his hands down. CNA 5 and 6 had put him in the shower chair with the full body lift but because he was being so combative and was hitting CNA 6 in the face, they transferred him back without a lift. During an interview on 1/10/24 at 1:57 p.m., CNA 9 indicated the night of the incident the resident was due for a shower. He was normally a bed bath. CNA 6 was in there and she was trying to put the full body lift pad underneath of him. He was trying to hit her, and she was grabbing his arms for him to not hit her. The call button went off and she went in there and helped her. CNA 6 was kind of rough. She did think she should have re-approached and came back later. That was what they did when a resident was resistive to care, they came back later. She helped her put him in the shower chair and then once she got him in the shower, she left the room. She did not assist in holding down his hands. CNA 6 was holding his arms down a little so she could turn him. She did try to encourage her to stop the care. She told CNA 6 since he was combative and not wanting to do anything maybe they should come back later, but third shift was very persistent about getting showers done. CNA 6 didn't really say anything and continued with care. CNA 5 was in there after the shower and the call light went off again. They were trying to get the pad out from underneath him. He was being aggressive with them. They two-armed him from the chair to the bed. They didn't put a shirt on him, they just covered him up. was in there with her after the shower and the call light went off again, they were trying to get the pad out from underneath him, he was being aggressive with them. She didn't think CNA 6 meant anything by it, but she should have stopped what she was doing and came back later. During an interview on 1/10/24 at 2:05 p.m., the DON indicated she had been contacted by the ED, who said LPN 4 had contacted her with a concern about some areas on Resident C's skin. He did have some bruises, but nothing appeared to be malicious. He had little dots on his back from the shower chair, he was bruising very easily. CNA 6 had been the one in the room and she said she had gotten him up for the shower just fine but once he got in the chair, he got combative and resistive. CNA 6 indicated he would do that but then once he was in the shower, he would calm down, so she proceeded. However, while he was in the shower, he did strike her. She finished the shower and had CNA 5 come back in and help put him back to bed. They felt he was being too combative to get back in the full body lift and his orders were for a two person assist so they did stand him up. She would have recommended an alternate caregiver and if that didn't help give him space and time to calm down and re-approach. He had dementia and had resistive behaviors to care and things like that, but he was more resistive in the nights and evenings. One of the very first interventions were to switch him to a day shift shower. With dementia approach was very important. During an interview on 1/11/23 at 11:33 a.m., the ED indicated they had not done specific interventions when the resident had combative behaviors in September, or on 10/22/23. They were more worried about his refusal from a weight loss perspective and that's what they had focused on. They had failed to implement specific interventions to address his behaviors. The facility's most current education, titled Solving Difficult situations the Best Friends Way, included, but was not limited to, . Step 1: Be a Detective Stop, Look, and Listen for Triggers . Stop . Ask the person what's wrong . Sit with him or her for a bit . Show concern or affection . Remember to walk a mile in his or her shoes - be empathetic . The facility's most current Communication and Dementia policy, included, but was not limited to, . Communication is at the heart of our relationships with our loved ones . 8. Do not argue, confront, or correct. If conflict arises, treat it with a warm, tender attitude, and give gentle cues to your lobed one if they're making a mistake . 9. Do not give orders or make demands. Your loved one may take this as a sign of aggression and respond negatively . The facility's most current Comprehensive Care Plan Guideline policy, included, but was not limited to, . Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan .6. Comprehensive care plans need to remain accurate and current. a. New interventions will be added and updated during or directly following the CCM [Care coordination meeting] . This citation relates to Complaint IN00424277. 3-1.37(a)

Based on observation, record review, and interview, the facility failed to ensure medications were appropriately labeled and discarded within appropriate time frames in 3 of 3 medication carts observed for medication storage. (200 Front Hall cart, 200 Back Hall cart, and the Memory Care unit cart) Findings include: 1. During an observation on 6/30/23 at 8:49 a.m. ,of the 200 Hall Medication Cart with LPN (Licensed Practical Nurse) 9, the following concerns were observed: a. Resident 197's albuterol pro-air HFA (hydrofluoroalkane inhaler) was stored lying down in its side in the box. The side label of the medication indicated to store with the mouthpiece down. The clinical record for Resident 197 was reviewed on 6/30/23 at 1:00 p.m. The diagnoses included, but were not limited to COPD (chronic obstructive pulmonary disease) with acute exacerbation, acute respiratory failure with hypercapnia, and acute bronchitis. The physician's order, dated 6/9/23, indicated the resident received albuterol sulfate HFA aerosol inhaler 90 mcg/act (micrograms per actuation) 2 inhalations every 6 hours as needed. b. Resident 198's albuterol HFA inhaler was lying in its side in the top drawer of the medication cart. The clinical record for Resident 198 was reviewed on 6/30/23 at 1:05 p.m. The diagnoses included, but were not limited to, obstructive sleep apnea, dependence on supplemental oxygen, and congestive heart failure. The physician's order, dated 6/21/23, indicated the resident received albuterol sulfate HFA aerosol inhaler 90 mcg/act (micrograms per actuation) 2 inhalations every 6 hours as needed. During an interview on 6/30/23 at 8:51 a.m., LPN 9 indicated she was not aware of the inhaler needing to be stored mouthpiece down. 2. During an observation on 6/30/23 at 9:08 a.m., of the 200 Hall Front Medication Cart with QMA (Qualified Medication Aide) 10, the following concerns were observed: There was a opened foil package of Xiidra eye drop vials, containing 2 vials of the medication in the top drawer of the medication cart. There was no pharmacy labeling or resident information on the packet and it was not with the original container. QMA 10 indicated the eye drops belonged to Resident 31. It had a label she thought, but she could not locate it. There was an opened vial of lidocaine injection 1% solution in the top drawer of the cart belonging to Resident 31. The rubber stopper of the medication had several puncture marks in it. The vial indicated to discard the medication after being opened for 28 days. QMA 10 indicated the medication was supposed to be taken out when the order was completed, and it was completed on 6/26/23. The physician's order, dated 3/28/23, indicated the resident received Xiidra 5% 1 drop to each eye twice daily for glaucoma. The physician's order, dated 6/16/23 and ending on 6/26/23, indicated the resident received ertapenem 1 gram solution to be reconstituted with 1% lidocaine and injected intramuscularly once daily. 3. During an observation on 6/30/23 at 9:33 a.m., of the Memory Care Unit medication cart with LPN 8, Resident 8's Levemir flex pen was located in the top drawer of the medication cart. The medication cap indicated it was opened on 5/21/23 and was to be discarded on 6/18/23. During an interview on 6/30/23 at 9:35 a.m., LPN 8 indicated she did not have another insulin pen in the cart. The resident's last dose was on 6/29/23. The clinical record for Resident 8 was reviewed on 6/30/23 at 1:15 p.m. The diagnosis included, but was not limited to, diabetes mellitus type 2. The physician's order, dated 5/11/23, indicated the resident received Levemir flex pen 100 unit/mL (units per milliliter) 5 units once daily. During an interview on 7/3/23 at 10:09 a.m., the DON (Director of Nursing) indicated staff were usually pretty good about putting the inhalers upright. The nurse had them in plastic cups to keep them sitting upright and she didn't know what happened. She thought the nurse opened the new insulin pen, got sidetracked or distracted, and put the cap from the old insulin on the new insulin. They usually would mark the eye drops with the date opened, and normally they still had them with their bag with the labeling. Normally the foil package would be marked with the date opened and they would be kept in the box with the labeling on them. The Medication Ordering and Receiving from Pharmacy policy, last revised 11/18, provided on 6/30/23 at 11:13 a.m. by the Clinical Nurse, included, but was not limited to, . Procedures A. Labels are permanently affixed to the outside of the prescription container . If a label does not fit directly onto the product, e.g., eye drops, the label may be affixed to an outside container or carton, but the resident's name, at least, must be maintained directly on the actual product container . B. Each prescription medication label includes: 1) Resident's name. 2. Specific directions for use, including route of administration. 3) Medication Name . 4. Strength of medication . 5) Prescriber's name. 6.) Date dispensed. 7) Quantity of medication. 8) Beyond use (or expiration) date of medication. 9) Name, address, and telephone number of dispensing pharmacy . 11) Prescription number. 12. Accessory labels indicating storage requirements and special procedures . The Medication Storage in the Facility policy, last revised 11/18, provided on 6/30/23 at 11:13 a.m. by the Clinical Nurse, included, but was not limited to, . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Procedures . C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label . H. Outdated, contaminated, or deteriorated medications . are immediately removed from inventory, disposed of according to procedures for medication disposal . 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(4) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7) 3.1-25(o)

Based on record review and interview, the facility failed to ensure the physician was notified of residents change in condition for 2 of 16 residents reviewed for physician notification. (Residents 32 and 35) Findings include: 1. The record for Resident 32 was reviewed on 6/27/23 at 9:26 a.m. The diagnoses included, but were not limited to, essential hypertension and hyperlipidemia. The Quarterly MDS (Minimum Data Set) assessment, dated 5/28/23, indicated the resident was cognitively intact. The care plan, initiated on 2/23/23 and last revised on 6/5/23, indicated the resident had a potential for cardiovascular distress related to a diagnosis of hypertension. The interventions included, but were not limited to, provide medications as ordered, observe for and report side effects as needed, observe for signs/ symptoms of cardiovascular distress and report as needed, and obtain vital signs as ordered and needed. The nurse's note, dated 5/2/23 at 5:00 p.m., indicated the resident was sitting up in the dining room and stated, Can you check my blood pressure, I feel dizzy. His blood pressure at the time was 77/47 mmHg (millimeters of mercury) and his pulse was 80 bpm (beats per minute). At 5:12 p.m., he continued sitting up in the dining room, his blood pressure was 99/59 mmHg and his pulse was 76 mmHg. At 5:14 p.m., the resident was assisted back to his room by a nursing assistant, and he was sitting in his recliner. The clinical record lacked documentation of any notification to the physician of the resident having an episode of low blood pressure with dizziness on 5/2/23. The nurse's note, dated 5/4/23 at 11:21 a.m., indicated new orders for the resident's blood pressure parameters were received from the NP (Nurse Practitioner). The physician's orders, dated 5/4/23, indicated parameters were added to the resident's atenolol 50 mg (milligrams) once daily and his lisinopril 5 mg once daily to hold the medications for a systolic blood pressure (the top number of a blood pressure/heart at work) of less than 100, or a pulse of less than 60. The parameters did not indicate any diastolic (bottom number/heart at rest) parameters. The nurse's note, dated 5/11/23 at 8:06 p.m., indicated the resident complained of blurry vision after his evening meal. Staff checked his blood pressure at 5:20 p.m. and it was 83/44 mmHg. They offered him a full glass of water and he drank it. They advised him to stay seated until they rechecked his blood pressure. His blood pressure was rechecked at 5:45 p.m. and was 95/58 mmHg. The resident was assisted to his room and sat in his recliner. He was offered another large glass of water, and was up walking in his room at the time. The clinical record lacked documentation of any notification to the physician of the resident having an episode of low blood pressure with blurry vision on 5/11/23. The nurse's note, dated 6/17/23 at 7:17 p.m., indicated the resident reported feeling queasy after his evening meal. His blood pressure was checked an was 69/41 mmHg at 5:05 p.m. One glass of water was offered, which the resident drank. Staff monitored the resident. At 5:30 p.m., the resident was assisted back to his room. His blood pressure was rechecked and was 89/53 mmHg. The resident stated he felt a little bit better and was offered another large glass of water, which he consumed. His recheck at 7:15 p.m. was 101/61mmHg. The resident indicated he felt fine, and was just sleepy. Staff would continue to monitor. The clinical record lacked documentation of any notification to the physician of the resident having an episode of low blood pressure with complaints of feeling queasy on 6/17/23. The nurse's note, dated 6/19/23 at 1:43 p.m., indicated the physician was notified of the resident's hypotensive event. There were no new orders at the time. During an interview on 6/30/23 at 11:14 a.m., LPN (Licensed Practical Nurse) 9 indicated she would notify the physician of any blood pressures below 100 for systolic or 60 for diastolic. If the resident had symptoms like dizziness or feeling lightheaded she would notify the physician. She would notify the physician as soon as the resident presented with symptoms after she assessed the resident. During an interview on 6/30/23 at 1:40 p.m., LPN 8 indicated in the evening time, usually around supper was when the resident would say he was not feeling very good, and staff would check his blood pressure and it would be low. The physician should be notified anytime it was that low. She would notify any time the resident's blood pressure was below the parameters to where staff needed to hold the medication. He did not have parameters to notify for diastolic pressure, but she would notify the physician of a diastolic pressure of less than 50. She would notify any time the resident had a change in the symptoms, such as feeling queasy or dizzy with low blood pressures. The physician should have been contacted on the resident's blood pressure on 5/2/23 and 5/11/23, but she could not locate any documentation of notification to the physician on either of the incidents. They had not done any laboratory testing. The notes sounded like they were giving fluids because they thought he could be dehydrated. Low blood pressure could occur if a resident was dehydrated. There was an order to check his blood pressure in the evenings. Staff were supposed to notify the physician of any out of range results. During an interview on 7/3/23 at 9:56 a.m., the DON (Director of Nursing) indicated she would have expected the physician to be notified on 6/17/23 when the resident had the low blood pressure and queasiness. She would expect the doctor to be notified of anything below 90 and symptomatic, depending on their parameters. The review of all documentation from clinical record provided by the facility, on 7/3/23 at 10:50 a.m., lacked documentation of any parameters for diastolic pressure, any parameters for physician notification, any notification to the physician of the resident's blood pressures and change of conditions on 5/2/23 (until the following day), on 5/11/23, and on 6/17/23 (until two days later by LPN 8 on 6/19/23). During an interview on 7/3/23 at 11:24 a.m., Resident 32's physician indicated he expected to be notified of any clinical change or any blood pressure associated with symptoms or a change. If the concern was somewhat pressing staff were free to text and they texted him all the time. He would expect to be notified pretty promptly. He could not locate any documentation of being notified. During an interview on 7/3/23 at 11:35 a.m., the Executive Director (ED) indicated nurses were to make the documentation of physician notification. 2. The clinical record for Resident 8 was reviewed on 6/27/23 at 12:45 p.m. The diagnoses included, but were not limited to, type 2 Diabetes Mellitus with hypoglycemia without coma, hypocalcemia and hypokalemia. The care plan, initiated on 9/2/20 and last revised on 6/1/23, indicated the resident was at risk for hypoglycemia and hyperglycemia related to Diabetes Mellitus. The interventions included, but were not limited to, laboratory testing per physician's order and observe the resident for symptoms of hypoglycemia such as sweating, cold, clammy skin, numbness of the fingers, toes, mouth, rapid heartbeat, tremors, and dizziness. The nurse's note, dated 4/18/23 at 2:54 p.m., indicated the CNA (Certified Nurse Aide) called the nurse to the resident's room. The resident was convulsing. Her skin was red, cool, and clammy. The resident was alert and attempting to communicate with staff. Her blood sugar was 60 mg/dl (milligrams per deciliter). The resident stopped convulsing and was able to drink orange juice. After a few moments the resident able to communicate with this nurse and told her she felt awful. Her blood sugar was obtained again and was 66 mm/dl. The resident was taken to the common area and given snack and fluids. Her blood sugar was obtained again at 99 mg/dl. The physician was notified and gave new orders to discontinue the resident basaglar insulin and to check her hgb (hemoglobin) A1C. The nurse's note, dated 5/9/23 at 3:16 p.m., indicated the resident was presenting with seizure like activity. Her face was flushed, and she was very diaphoretic. Her blood sugar was 76 mg/dl. The incident lasted about 2 to 3 minutes. The record lacked documentation of the physician being notified at the time of the occurrence on 5/9/23. During an interview on 6/30/23 at 11:05 a.m., LPN 9 indicated on 5/9/23 the resident had jerking movements, she wasn't responding, she was twitching and jerking. Her whole body was twitching and jerking. It lasted 2 to 3 minutes from the time she was notified. She checked her sugar and they laid her down because she was in her wheelchair at the time. By the time they got her laid down the jerking had subsided. They always make the doctor aware of anything that was different. She would have typed it up in the system and she would have called the office or made him aware when he came in to the facility, but this was an incident and she would have made a call to the physician. If he gave orders she would have charted it. She could not recall any conversation with the physician. The physician notification should be located in the progress notes. The notification on the event was for the initial event on 4/18/23. During an interview on 6/30/23 at 1:33 p.m., LPN 8 indicated on 4/18/23 the resident had been convulsing, like with a seizure, but she was still alert. They were able to get her to come back around and get some juice and snack into her, and then when they notified the doctor they did change her insulin. If she had another incident of convulsions, she would notify the doctor. She reviewed the record and indicated she did not see any notification to the physician of the incident on 5/9/23. It would be in the progress notes. It was something the physician should have been notified of. During an interview on 7/3/23 at 9:50 a.m., the DON indicated the resident had some low blood sugars with seizure like activity. They were working on getting staff to put the documentation of physician notification in the nurse's notes. The physician should have been notified at the time of the occurrence. If the resident was having seizure like activity, she would expect the physician to be notified as soon as the resident was stabilized. The review of all documentation from the clinical record provided by the facility, on 7/3/23 at 10:47 a.m., lacked documentation of any notification to the physician of the resident having seizure-like activity with low blood sugar levels on 5/9/23. The Provider Notification Guidelines policy and procedure, last reviewed 12/31/22, provided on 6/29/23 at 2:10 p.m. by the Clinical Nurse, included but was not limited to, . Procedures 1. Resident assessments for change in condition . should be completed in a timely manner . 2. The provider should be notified of critical lab results or an immediate need by phone as soon as the results are known with a response received before the call is completed when possible. If the provider must be paged a call back is expected within 15 minutes to one hour depending on severity of the concern. If unable to reach the primary provider, the campus Medical Director will be notified . 6. During non-office hour times the nurse should notify the physician/provider by phone or abnormal lab results or the need for physician/provider intervention . 11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record . 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, record review, and interview, the facility failed to ensure residents received the appropriate perineal care related to infection control guide lines to prevent urinary tract infections for 3 of 6 residents reviewed for bowel and bladder. (Residents 3, 18, and 29) Findings include: 1. During an observation of incontinence and catheter care for Resident 3 on 6/29/23 at 9:45 a.m., CNAs (Certified Nurse Aides) 5 and 6 had the washcloths and towels set up on the bedside table. They performed hand hygiene and applied gloves. The labial area and catheter tubing were cleaned by CNA 5 and the resident was rolled onto her left side. The catheter bag was lifted above the level of the bladder and held there as CNA 5 was able to take it and place it on the left side of the bed. CNA 6 performed hand hygiene and applied gloves. CNA 6 used a folded washcloth, using a four-corner method with no rinse soap applied to each corner. CNA 6 cleaned the left buttock with 13 swipes of the same area of the washcloth corner. She folded the corner over and with 31 swipes of the same area of the washcloth, she cleaned the right buttock. She folded down the corner of the washcloth and cleaned the rectal area. The last corner was used to clean the rectal area, using a front to back swipe. A clean washcloth was obtained and with 14 swipes of the same area of the washcloth, she cleaned the left buttock. She folded the corner down and with 14 swipes of the same area of the washcloth, she cleaned the right buttock. She folded the washcloth and with 10 swipes of the same area of the washcloth, she cleaned the anal area. She folded the washcloth and with 8 swipes of the same area of the washcloth she cleaned the anal area again. The resident was dried and rolled onto her back. The catheter bag was lifted above the bladder and was held above the resident until CNA 6 could place it back onto the right side of the bed. Urine was observed backflowing toward the urethra. During an interview on 6/29/23 at 10:55 a.m., CNA 6 indicated she used the four-corner method to perform incontinence care. She would clean from front to back and would not use the same area of the washcloth to clean an area. The record for Resident 3 was reviewed on 6/29/23 at 1:50 p.m. The diagnoses included, but were not limited to, acute kidney failure, type 2 Diabetes Mellitus with diabetic chronic kidney disease, and neurogenic bladder. The Annual MDS (Minimum Data Set) assessment, dated 4/6/23, indicated the resident was cognitively intact. She required extensive assistance of 2 staff for toileting. The care plan, dated 8/23/19 and last revised on 4/7/23, indicated the resident used a Foley catheter for the diagnoses of urinary retention, neurogenic bladder, and obstruction. The interventions, dated 8/23/19, included, but were not limited to, observe for any signs of complication such as UTI (urinary tract infection), urethral trauma, strictures, bladder calculi or silent hydronephrosis and to notify the doctor, observe the tubing and avoid any obstructions, provide assist with catheter care, and change the Foley catheter per physician orders. The nurse's note, dated 1/18/23 at 8:53 a.m., indicated new orders for Doxycycline 100 mg for 7 days for a UTI. 2. During an observation on 6/29/23 at 12:47 p.m., CNAs 1 and 2 performed incontinence care for Resident 18. They performed hand hygiene and applied gloves and used wipes to clean the resident. The labial area was cleaned per policy. The resident was rolled onto her right side and CNA 2 obtained a wipe and using a circular motion she cleaned the right buttock toward the vaginal area with two passes with the same area of the wipe. She obtained another wipe and using a circular motion she cleaned toward the vaginal area with two more passes of the same area of the wipe. She dried the resident with a dry washcloth in the same manner. During an interview on 6/29/23 at 1:03 p.m., CNA 2 indicated when performing incontinence care she would clean the resident with wipes, folding between swipes or use it once, front to back. The record for Resident 18 was reviewed on 6/29/23 at 2:15 p.m. The diagnoses included, but were not limited to, dementia, immobility syndrome (paraplegic), muscle weakness (generalized), and unsteadiness on feet. The Quarterly MDS assessment, dated 4/2/23, indicated the resident was moderately cognitively impaired. She required extensive assistance of two staff for toileting. The physician's order, dated 8/25/22, indicated may dip urine with signs or symptoms of a UTI, then may send for culture and sensitivity if positive for leukocytes. The care plan, dated 9/13/22, indicated the resident experiences episodes of incontinence related to impaired cognition, impaired mobility, medications, and IBS (irritable bowel syndrome). The interventions, dated 9/13/22, included, but were not limited to, observe for signs and symptoms of a UTI and notify the physician as needed, provide incontinence care as needed 3. During an observation on 6/30/23 at 9:56 a.m., Resident 29 received incontinence care by CNAs 3 and 4. They performed hand hygiene and applied gloves. CNA 3 lowered the bed with her gloved hands, then performed incontinence care of the labial area, front to back. CNA 4 swiped 3 times the left and right creases in a back to front direction. No drying was observed. The resident was rolled onto her left side. CNA 3 obtained a wipe and swiped 2 times from back to front to the vaginal area from the left buttock. She obtained a new wipe and again swiped back to front from the left buttock. She obtained another wipe and swiped the anal area 5 times with the same area of the wipe from back to front. She obtained a wipe and swiped the coccyx area two times with the same area of the wipe. No drying was observed. Cream was applied to the coccyx and the brief was fastened. During an interview on 6/30/23 at 10:05 a.m., CNA 3 indicated she should wipe the creases and between, using different wipes or a different side to the wipe. She was unsure if the area should be dried, but indicated they would be given time to air dry. They would pat dry the area if they used a washcloth during care. She would swipe from front to back during care. The record for Resident 29 was reviewed on 6/30/23. The diagnoses included, but were not limited to, dementia with behavioral disturbance, falls, contractures of the left hand and forearm, contractures of the right hand and forearm, difficulty in walking, and hospice care. The physician's order, dated 4/15/21, indicated may dip urine for signs or symptoms of a UTI, then may send the urine for a culture and sensitivity if positive for leukocytes. The Admission MDS assessment, dated 4/22/21, indicated the resident was severely cognitively impaired. The resident required extensive assistance of 2 staff with toileting. The care plan, dated 4/29/21 and last revised on 4/25/23, indicated the resident experienced episodes of incontinence related to dementia, medication, and weakness. The interventions, dated 4/29/21, included, but were not limited to, observe for signs and symptoms of a UTI, and provide incontinence care as needed. The physician's order, dated 2/6/23, indicated to administer Macrobid 100 mg twice daily for 7 days for a UTI. The urinalysis, dated 2/15/23, indicated the urine was dark yellow and turbid. There was a trace of leukocytes and two plus bacteria. The nurse's note, dated 2/16/23 at 11:14 a.m., indicated the urine culture was pending. The physician was aware of the final UA results. A new order for Bactrim DS 800/160 mg twice a day for 5 days unless the culture results indicated this ABT would not be effective. The nurse's note, dated 2/17/23 at 8:43 a.m., indicated the ABT was administered per order with no ASE. The final urine culture was received and indicated <10,000 CFU/ML mixed flora isolated. The physician was notified with orders to continue the current ABT treatment. The nurse's note, dated 2/22/23 at 9:49 a.m., indicated the ABT was complete. Urine was to be obtained and sent to lab for follow up on 2/24/23. During an interview on 6/30/23 at 12:37 p.m., the DON (Director of Nursing) indicated her expectations were for staff to provide incontinence care using a front to back method. They could use either a wipe or a washcloth with the four-corner method. They could obtain a wipe for each swipe, instead of folding. During an interview on 7/3/23 at 9:48 a.m., the DON indicated staff shouldn't hold the catheter bag above the bladder. Instead they should set it on the bed to prevent urine backflow. The Perineal Care for Incontinence policy, last revised on 11/9/17, was provided by the Clinical Nurse on 6/30/23 at 12:43 p.m. The policy included, but was not limited to, . 7. Pay particular attention to infection prevention and control techniques when performing pericare, to prevent introduction of contamination that may lead to a urinary tract infection . The Urinary Catheter Care policy, last revised on 5/11/16, was provided by the Clinical Nurse on 6/30/23 at 12:43 p.m. The policy included, but was not limited to, . 4. The urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 20 . g. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly . l . Use one area of the wipe or washcloth for each downward, cleansing stroke. Change the position of the wipe or washcloth with each downward stroke. Next, change the wipe or washcloth to drag on the resident's skin or bed linen . 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) physician's order to hold medication were transcribed and held correctly for 1 of 3 residents reviewed for pharmaceutical services. Findings include: The incident report, dated 4/29/23 at 3:41 p.m., indicated Resident B was sent to the emergency department for abnormal labs. The resident returned from the emergency department with orders to hold spironolactone, metformin and meloxicam. The admitting nurse, LPN (Licensed Practical Nurse) 2 did not enter the medications to be held. A readmission audit was completed per policy and the error was found and corrected. The record for Resident B was reviewed on 5/15/23 at 3:11 p.m. The diagnoses included, but were not limited to, hypertensive heart disease and atrial fibrillation. The admission orders, dated 4/26/23, indicated the resident was to receive the following medications: - Spironolactone (diuretic) 25 mg (milligrams) in the morning between 6:00 a.m. and 10:00 a.m. - Metformin (anti-diabetic medication) 500 mg twice a day, in the morning between 6:00 a.m. and 10:00 a.m., and in the evening between 6:00 p.m. and 10:00 p.m. - Meloxicam (anti-inflammatory) 7.5 mg in the morning between 6:00 a.m. and 10:00 a.m. The progress note, dated 4/27/23 at 11:21 a.m., indicated a comprehensive metabolic panel was obtained per admission orders. The lab report, dated 4/28/23., indicated the resident had an elevated potassium level of 5.5 (normal range, 3.5 to 5.1) and a BUN (blood urea nitrogen) level of 51 (normal range, 6 to 21). The progress note, dated 4/28/23 at 1:45 p.m., indicated the physician was notified with a new order to send the resident to the emergency room for evaluation for the elevated potassium and BUN levels. The hospital discharge summary, dated 4/29/23 at 10:42 a.m., indicated to hold the resident's meloxicam, metformin and spironolactone. The clinical record lacked documentation of an order to hold the meloxicam, metformin and spironolactone. During an interview on 5/15/23 at 3:40 p.m., the Executive Director indicated, upon admission, the resident had admission orders for labs to be drawn. The resident had a high potassium level and was sent to the emergency department. The resident returned from the hospital with orders to hold the metformin, meloxicam and spironolactone. The orders were missed by LPN (Licensed Practical Nurse) 2 and the transcription error was found during the chart audit. On 5/15/23 at 5:43 p.m., the Executive Director provided a current copy of the document titled Medication Orders dated 11/18. It included, but was not limited to, The nurse on duty at the time the order is received enters it on the physician order sheet, telephone order sheet, or electronic medical record if not written there by the prescriber, and notes the order The deficient practice was corrected by 5/4/23, prior to the start of the survey, and was therefore past noncompliance. The facility identified, educated staff, monitored the pharmaceutical services, and audited the physician orders. This Federal tag relates to Complaint IN00407890 3.1-25(b)

Based on observation, record review, and interview, the facility failed to ensure interventions and assessments were implemented to prevent the development or worsening of new pressure ulcers for 2 of 5 residents reviewed for pressure ulcers, which resulted in the development of two stage III pressure ulcers. (Residents 18 and 20) Findings include: 1. The clinical record for Resident 18 was reviewed on 6/16/22 at 10:15 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 4/22/22, indicated the resident was cognitively intact. The resident was dependent on staff for ADL (Activities of Daily Living) care. The care plan, dated 3/5/21 and last revised on 5/5/22, indicated the resident had the potential for alterations in skin integrity related to immobility and incontinence. The interventions, dated 3/5/21, indicated to administer treatment as ordered, float heels as needed, observe skin during routine care giving for acute changes, pressure reducing cushion to chair, pressure reducing mattress and provide a weekly skin assessment by a licensed nurse. The care plan, dated 3/17/21 and last revised on 5/5/22, indicated the resident was at risk for skin breakdown related to multiple braces, immobility, current skin breakdown. The interventions, dated 3/17/21, indicated to avoid shearing of the skin during positioning, turning, and transferring, conduct weekly skin assessment, encourage and assist to turn and reposition for comfort, float heels as needed and pressure reducing cushion to chair and bed. The care plan, dated 4/20/22 and last revised on 5/5/22, indicated the resident had a pressure ulcer to the right side of the torso. The interventions, dated 4/20/22, indicated to assess and record the condition of the skin surrounding the pressure ulcer, pressure reducing cushion to the chair and bed, weekly skin assessment, measurement, and observation of the pressure ulcer and record. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT note, dated 3/7/22 at 9:46 a.m., indicated the resident had a recent surgery to the left arm. The incision cannot be visualized, and no treatment was to be done. The cast was adjustable and monitored for circulation, pain, and [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check for circulation. Three times a day 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m. The wound management note, dated 4/20/22 at 10:00 a.m., indicated the stage 3 pressure ulcer to the right upper quadrant of the abdomen was first observed. The wound measured 2 cm long by 1.5 cm wide by 0.2 cm deep. There was moderate serosanguineous exudate. 90% (percent) granulation tissue was present with light, yellow scattered slough throughout with moderate drainage with a macerated periwound. The IDT note, dated 4/20/22 at 12:40 p.m., indicated an assessment was completed and no further new skin issues were noted. The resident denied pain or discomfort to the area or elsewhere. Positionally; the resident was noted to have his torso leaning slightly to the right, most likely related to having his left arm elevated some since surgical intervention. Therapies had been contacted related to modification to the wheelchair for comfort and positioning. The nurse's note, dated 4/21/22 at 12:32 p.m., indicated the resident was followed for a new wound. The interventions and preventative were in place. A specialty chair provider was contacted for modification of his chair. The wound management note, dated 4/27/22 at 3:22 a.m., indicated the stage 3 pressure ulcer to the right upper quadrant of the abdomen measured 2 cm long by 1.5 cm wide by 0.2 cm deep. The wound had moderate serosanguineous exudate with 100% granulation and was improving. The wound management note, dated 5/4/22 at 11:42 a.m., indicated the stage 3 pressure ulcer to the right upper quadrant of the abdomen measured 1.6 cm long by 2 cm wide. The wound had moderate serosanguineous exudate and was improving. The nurse's wound note, dated 5/26/22 at 11:10 a.m., indicated the resident was followed for a wound to the side of the abdomen. The wound was resolving well. It now measured 0.5 cm long by 0.5 cm wide with no depth. The wound management note, dated 6/1/22 at 3:28 p.m., indicated the stage 3 pressure ulcer to the right upper quadrant of the abdomen measured 0.4 cm long by 0.4 cm wide. The wound had scabbed. During an interview on 6/15/22 at 10:30 a.m., the DON (Director of Nursing) indicated the only pressure ulcer the resident had was after having surgery and he was positioned in his chair on the right side. The chair caused pressure against the right rib area and since then it was being treated and was healing well. The nurse's note, dated 1/28/22 at 5:57 a.m., indicated the resident had a fluid filled blister to the right heel 4 cm (centimeters) long by 5 cm wide. Sure prep was applied at this time, will encourage resident to float his heels. Will notify the wound nurse. The nurse's note, dated 1/28/22 at 1:36 p.m., indicated the resident had a large fluid filled blister to plantar foot immediately distal to left heel. Area measures 5 cm long by 4 cm wide. Resident frequently with muscle spasms of lower extremities causing friction to the bottom of his feet and causing feet to lose proper position of foot pedals. The IDT (Interdisciplinary Team) note, dated 1/31/22 at 5:26 a.m., indicated the root cause to be muscle spasms in tennis shoes and dislodging feet from proper positioning. The resident was provided with soft heeled shoes until healed. The treatment was in place. The resident was to alert staff when he had continuing muscle spasms. The nurse's note, dated 2/17/22 at 12:10 p.m., indicated the resident was followed for a wound to the heel caused by friction. The wound presented as a stage 2 with a closed surface. The clinical record lacked documentation of the assessments and identification of skin breakdown prior to the development of the stage 3 pressure ulcer. During an interview on 6/17/22 at 11:48 a.m., the Wound Care Nurse indicated the resident had cushions to the seat of his wheelchair. He had muscle spasms since his injury. The resident could indicate what he needed. The resident developed the stage 3 wound from his wheelchair. She didn't know why it was found at a stage 3. It may have just come on suddenly. The resident ate only once daily. His protein and fluid intake were not what they should be. The blister to the heel was from muscle spasms. They tried to keep an eye on his positioning. Nothing could help prevent this. The foot pedals had no cushions. Therapy could look at him and his wheelchair. 2. The clinical record for Resident 20 was reviewed on 6/16/22 at 11:46 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment, dated 5/3/22, indicated the resident was moderately cognitively impaired. The resident required extensive one to two staff assistance with all of her activities of daily living. The care plan, dated 6/9/22, indicated the resident had a pressure ulcer to the coccyx. The interventions indicated for staff to observe for and report signs of pain related to pressure ulcer, pressure reducing mattress and chair, and weekly skin assessments. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin prep to the periwound and apply a [MEDICATION(S)] dressing every 5 days. The nurse's note, dated 6/9/22 at 8:21 a.m.,indicated the resident had a new wound area to coccyx. The wound care notes, dated 6/8/22, indicated the resident's coccyx was first identified on 6/8/22. The wound was not present on admission. The measurements indicated the wound length was 0.9 cm, width 0.3 cm, and the depth was 0.1 cm. Light serous drainage at a stage 3. The tissue type was granulation tissue with well defined edges. The skin surrounding the wound was pink in color. The clinical record lacked documentation indicating signs and symptoms of skin breakdown were identified before the pressure wound was first observed at a stage 3. The progress note, dated 6/15/22, indicated the Clinical Nurse assessed the resident's wound. She was admitted for long term care with a dressing to the coccyx for preventive with a history of previous shin breakdown. The resident had confusion at times. She requires moderate to maximum assistance with verbal ques. She was incontinent of her bladder and bowels. She was underweight with a BMI (body mass index) of 17.76 and had a history significant weight loss. The resident had an unstageable pressure ulcer to the right heel. The Treatment Administration History record, dated 5/25/22 to 6/15/22, indicated the resident had a weekly skin assessment on 6/6/22. The documentation indicated the resident had an old wound related to the resident's right heel. On 6/8/22 the clinical record documentation indicated the resident had a stage 3 pressure wound to the coccyx. During an interview on 6/15/22 at 2:00 p.m., the Wound Care Nurse indicated the resident's pressure wound was identified as a stage 3 when first observed. The resident had decreased mobility, and nutrition. There should have been some signs and symptoms indicating something was going on before the wound was found at a stage 3. She doesn't know how fast the wound opened up. Staff should assess the skin for blanchable, nutrition, low air mattress and chair cushion, float heels and turn and reposition. During an interview on 6/15/22 at 2:25 p.m., the DON indicated the wound care nurse staged the resident's wound at a stage 3 when the wound was found. She did not believe it was a stage 3 when found, but she had to accept what was documented. She failed to review the documentation and that was her fault. The resident went out to the doctor for 4 hours and if the wound was there she felt that made the coccyx wound worse. She did have a DTI (deep tissue injury) on her right heel that was not open. It would fluctuate some. The color had returned to normal and decreased in size. The resident did not like to float her heels for too long. The resident had [CONDITION(S)] and that contributed to her health. The air mattress was not on the resident's bed before 5/17/22. The air mattress was put on the bed 5/20/22. The weekly skin assessments are only documented one time per week with any skin issues. If a pressure wound was observed before or after the weekly assessment date an event would be filled out. The weekly skin would indicate the wound as old on the next time the weekly assess was done. During an interview on 6/17/22 at 1:00 p.m., the Memory Care Coordinator indicated interventions included to float heels, pressure reducing cushion in their wheelchair, low air mattress, turn and reposition, padding bony areas and skin prep for the fragile tissue. A pressure wound should be found before it's a stage 3. The resident's skin should be observed for signs and symptoms like blanching of the skin, [CONDITION(S)], redness, and any open areas. The weekly skin assessment came up on the electronic orders one time per week, but the resident's skin should be assessed during toileting, bathing, repositioning and peri care. There would be no reason a pressure wound would be first observed at a stage 3. 3.1-40(a)

Based on record review and interview, the facility failed to ensure physician notification for abnormal blood pressure values for 1 of 18 residents reviewed for physician notification. (Resident 38) Findings include: The clinical record for Resident 38 was reviewed on 6/16/22 at 9:18 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 12/13/21, indicated the resident had a potential for cardiovascular distress related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation of any parameters to notify the physician for abnormal blood pressure values. The review of the vitals report, indicated the following out of acceptable range blood pressure values as indicated in the clinical record by being flagged in red on the following dates: - On 12/26/21 at 2:57 p.m., the resident's blood pressure value was documented as 203 (systolic)/99 (diastolic) mmHg (millimeters of mercury). There was no documented notification to the physician. - On 12/29/21 at 3:18 p.m., the resident's blood pressure value was documented as 175/107 mmHg. There was no documented notification to the physician. - On 1/02/22 at 2:58 p.m., the resident's blood pressure value was documented as 225/115 mmHg. There was no documented notification to the physician. - On 2/7/22 at 3:13 p.m., the resident's blood pressure value was documented as 176/126 mmHg. There was no documented notification to the physician. - On 2/13/22 at 3:01 p.m., the resident's blood pressure value was documented as 192/70 mmHg. There was no documented notification to the physician. - On 2/16/22 at 2:39 p.m., the resident's blood pressure value was documented as 183/102 mmHg. There was no documented notification to the physician. The nurse's note, dated 2/16/22 at 2:39 p.m., indicated the resident was very anxious and tearful with an observed increase in her blood pressure and heart rate. Staff reported she got anxious and tearful every day around this time. There was no documentation of notification to the physician. - On 3/3/22 at 2:54 p.m., the resident's blood pressure value was documented as 190/103 mmHg. There was no documented notification to the physician. The nurse's note, dated 3/3/22 at 10:46 p.m., indicated the resident's blood pressure read 190/103 mmHg and the resident was in a state of crying, agitation, and shaking. There was no documentation of notification to the physician. - On 3/7/22 at 2:34 p.m., the resident's blood pressure value was documented as 179/101 mmHg. There was no documented notification to the physician. - On 3/18/22 at 7:56 a.m., the resident's blood pressure value was documented as 192/80 mmHg. There was no documented notification to the physician. The nurse's note, dated 3/21/22 at 5:12 p.m., indicated the resident had some [CONDITION(S)] activity, and was shaking. Her pulse was 113 and her blood pressure was 231/98 mmHg. The physician was notified, however at this time there was no documentation of any new orders. - On 4/7/22 at 2:46 p.m., the resident's blood pressure value was documented as 168/104 mmHg. There was no documented notification to the physician. - On 4/11/22 at 5:36 p.m., the resident's blood pressure value was documented as 178/103 mmHg. There was no documented notification to the physician. - On 5/2/22 at 5:26 p.m., the resident's blood pressure value was documented as 69/46 mmHg. There was no documented notification to the physician. - On 5/4/22 at 5:30 p.m., the resident's blood pressure value was documented as 66/42 mmHg. There was no documented notification to the physician. - On 5/19/22 at 6:52 p.m., the resident's blood pressure value was documented as 193/97 mmHg. There was no documented notification to the physician. - On 6/5/22 at 3:00 p.m., the resident's blood pressure value was documented as 197/85 mmHg. There was no documented notification to the physician. During an interview on 6/16/22 at 9:50 a.m., the DON (Director of Nursing) indicated each resident had parameters set and it should be inside their vitals. If the value was highlighted in red it was out of range for the physician. Documentation of physician notification for out of range values should be under the nurse's notes. The resident's blood pressures ran low, but there shouldn't be any exceptions. She would expect for the physician to be notified of any out of range blood pressure values. During an interview on 6/20/22 at 9:14 a.m., the Memory Care Coordinator indicated the resident's blood pressure depended on her activity. If she was up running around and moving around it would be up a little bit, and at times it dropped low. They would contact the physician for any blood pressures below 120/60. She was not sure if the physician had been notified of any high blood pressure values, but she would notify the physician of any systolic values over 180 to 190 and any diastolic over 100. The Physician- Provider Notification Guidelines Policy, last reviewed 12/1/21, provided on 6/17/22 at 11:13 a.m., included, but was not limited to, . To ensure the resident's physician or practitioner . is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care . 2. The provider should be notified of critical lab results or an immediate need by phone as soon as the results are known with a response received before the call is completed when possible. If the provider must be paged a call back is expected within 15 minutes to one hour depending on severity of the concern. If unable to reach the primary provider, the campus Medical Director will be notified . 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were applied and maintained for 2 of 6 residents reviewed for respiratory care. (Residents 24, and 27) Findings include: 1. During an observation of Resident 24's oxygen concentrator on 6/14/22 at 11:08 a.m., a filter could not be located. There was a moderate amount of a white dust gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. During an observation of Resident 24's oxygen concentrator on 6/15/22 at 2:07 p.m., a filter could not be located. There was a moderate amount of a white dust gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. During an observation of Resident 24's oxygen concentrator on 6/16/22 at 2:29 p.m., a filter could not be located. There was a moderate amount of a white dust gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. During an observation of Resident 24's oxygen concentrator on 6/17/22 at 8:20 a.m., a filter could not be located. There was a moderate amount of a white dust gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. The DON (Director of Nursing) was present and observed the resident's oxygen concentrator without a filter. The clinical record for Resident 24 was reviewed on 6/14/22 at 2:08 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 4/27/22, indicated the resident was cognitively intact. The care plan, dated 10/27/22 and last revised on 5/16/22, indicated the resident had the potential for complications, functional, and cognitive status decline related to respiratory disease. The interventions, dated 10/27/21, indicated staff were to administer oxygen per orders. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Change oxygen tubing monthly with special instructions: Date once a day on the 1st of the month 6:00 a.m. to 2:00 p.m., starting 1/19/22. - Clean the external concentrator filter every two weeks, once a day on Sundays every 2 weeks 11:00 p.m. to 6:00 a.m., starting 1/19/22. - Oxygen at 2 liters per nasal cannula three times a day 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m., starting 1/25/22. 2. During an observation of Resident 27's oxygen concentrator on 6/14/22 at 9:37 a.m., a filter could not be located. There was a slight amount of a white dust had gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. During an observation of Resident 27's oxygen concentrator on 6/15/22 at 2:07 p.m., a filter could not be located. There was a slight amount of a white dust had gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. During an observation of Resident 27's oxygen concentrator on 6/16/22 at 2:25 p.m., a filter could not be located. There was a slight amount of a white dust had gathered on the grill of the concentrator and a light was visible inside of the oxygen tank. During an observation of Resident 27's oxygen concentrator on 6/17/22 at 8:25 a.m., a slight build-up of a white dust was on the grill of the oxygen concentrator. The DON was present and observed the resident's oxygen concentrator without a filter. The clinical record for Resident 27 was reviewed on 6/16/22 at 2:24 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 6/9/22, indicated the resident was cognitively intact. The care plan, dated 2/24/22 and last revised on 5/30/22, indicated a potential for shortness of breath while lying flat related to chronic lung disease. The interventions dated 2/24/22 indicated to administer the oxygen per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The care plan dated 2/24/22 and last revised on 5/30/22 indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory disease. The interventions, dated 2/24/22, indicated staff were to administer the oxygen per physician orders. The nurse's note, dated 5/21/22 at 8:16 p.m., indicated during a routine medication administration, the resident had a deep cough for a couple of days. Upon assessment the resident indicated her voice was very soft and froggy sounding. The resident's cough was moist and the resident was unable to clear any [MEDICATION(S)]. The oxygen saturation was at 84% on room air. The oxygen was administered at 2 liters per minute by nasal cannula and the oxygen saturation was brought up to 95%. The physician was notified, and a STAT (immediate) chest x-ray was ordered. The IDT (Interdisciplinary Team) note, dated 5/22/22 at 10:34 p.m., indicated the resident had developed a cough. A chest x-ray was completed and indicated a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Antibiotics and treatments were in place. During an interview on 6/17/22 at 8:25 a.m., the DON indicated the filters should have been in place in the openings of the oxygen concentrators. The oxygen company came to the facility weekly, and they checked the oxygen tanks and cleaned the filters. During a follow up interview on 6/17/22 at 10:53 a.m. the DON indicated there was no oxygen policy. The facility counted on the manufacturer to clean the filter or make sure it was done. There was just a breakdown. 3.1-47(a)(6)

Based on record review and interview, the facility failed to conduct GDRs (Gradual Dose Reductions) of [CONDITION(S)] medications as required for 1 of 5 residents reviewed for unnecessary [CONDITION(S)] medications. (Resident 19) Findings include: The clinical record for Resident 19 was reviewed on 6/15/22 at 1:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, major depressive disorder, and cognitive communication deficit. The care plan, last revised 5/5/22, indicated the resident was at risk for adverse consequences related to receiving antipsychotic medication for major depressive disorder. The interventions included, but were not limited to; attempt GDR in two separate quarters with at least one month between the attempts during the first year the resident received an antipsychotic medication, then yearly, unless clinically contraindicated; attempt to give the lowest dose possible; GDR at least twice a year unless clinically contraindicated; pharmacy consultant review as needed; and review for continued need at least quarterly. The physician's orders, dated 4/15/21 and discontinued on 12/1/21, indicated the resident received the following medications for dementia with mood disorder: [MEDICATION(S)] 1 mg (milligrams) and 0.5 mg once daily and [MEDICATION(S)] 50 mg once daily. The pharmacy recommendation, dated 11/30/21, indicated the resident was due for a gradual dose reduction evaluation of her [MEDICATION(S)] 1 mg twice daily and 0.5 mg in the afternoon, and [MEDICATION(S)] 50 mg daily. The evaluation indicated the recommendation was accepted. The physician's orders, dated 12/1/21, indicated the resident was started on [MEDICATION(S)] 0.5 mg three times daily for dementia with mood disorder and [MEDICATION(S)] 25 mg daily for depression. The Social Services Note, dated 12/1/21 at 2:23 p.m., indicated the resident had a recent GDR of her [MEDICATION(S)] and [MEDICATION(S)] with no adverse reactions thus far. The clinical record lacked documentation of any further efforts to GDR. During an interview on 6/17/22 at 1:49 p.m., the Campus Support Clinical indicated the resident had two medications GDR'd in December but no others since her admission. The SSD (Social Services Director) had started in August and they realized it was an issue. During an interview, on 6/20/22 at 12:12 p.m., the SSD indicated he started in July 2021. The resident was on his list to be reviewed in July of this year for her second review. She had admitted in April of 2021. He could only start reviewing every six months since he started. Unfortunately it had overlapped where she admitted before he started. The [CONDITION(S)] Medication Usage and Gradual Dose Reductions Policy, last revised 10/9/17, provided on 6/17/22 by the Campus Support Clinical, included, but was not limited to, . Purpose . to ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation, and monitoring by the interdisciplinary team . 3. Efforts to reduce dosage or discontinue [CONDITION(S)] medications will be ongoing as appropriate . 4. A gradual dose reduction (GDR) will be attempted for two separate quarters (with at least one month between attempts) per physician's recommendation. Gradual dose reduction must be attempted annually thereafter, unless medically contraindicated . 3.1-48(a)(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) inventory list was completed, upon admission, for 1 of 3 residents reviewed for medical records. Findings include: The clinical record for Resident B was reviewed on 6/7/21 at 12:37 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility admission check list indicated an inventory sheet (a listing or a resident's personal belongings) was to be completed upon admission. The clinical record lacked documentation of an inventory sheet. During an interview on 6/8/21 at 12:20 p.m., the Executive Director indicated the inventory sheet was part of the admission check list and should have been completed upon admission. This Federal tag relates to Complaint IN 698 3.1-50(a)(1)

Based on observation and interview, the facility failed to mitigate the potential spread of COVID-19 during a pandemic related to inappropriate use of Personal Protective Equipment for 1 of 4 staff observed related to Infection Control. Findings include: During the 200 hall lunch tray pass on 12/21/20 at 11:35 a.m., the dietary aide brought both food carts to the unit and waited for the staff on the unit to open the doors to acquire their carts. Housekeeper 1 was observed to come from the main dining room and opened the 200 unit doors. She indicated to the dietary aide that she would take the carts to the aides on the unit. Housekeeper 1 was not wearing any personal protective equipment, including a mask or face shield In an interview with the DHS on 12/21/20 at 12:40 p.m., she indicated the housekeeper had probably went to her car for something when she left the unit, and instead of coming back in through the 100 hall doors which was the zone she was working on, she came in through the front door. Using Personal Protective Equipment (PPE) (August 2020) from the Centers of Disease Control (CDC) website. Healthcare personnel should adhere to Standard and Transmission-based Precautions when caring for patients with [DIAGNOSES REDACTED]-CoV-2 infection. Recommended PPE is described in the Infection Control Guidance. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Facilities should develop policies and procedures to ensure recommendations are appropriately applied in their setting. 3.1-18(j)

Based on interview, observation, and record review, the facility failed to ensure appropriate perineal care was provided for residents with a history of Urinary Tract Infections (UTIs) and/or indwelling catheter use for 2 of 3 residents reviewed for bowel / bladder incontinence and UTI care. (Residents B and C) Findings include: 1. During an observation on 9-8-20 at 10:45 a.m., Resident B received toileting perineal care (cleaning of the private areas), after a bowel movement, from RCA (Resident Care Aide) 1 and CRCA (Certified Resident Care Aide) 2. RCA 1 used a wet washcloth to clean the labial area, swiping 3 times with the same area of the washcloth. She folded the washcloth and swiped 3 more times using the same area of the cloth. The resident's indwelling urinary catheter was then emptied into the toilet. The brief was pulled up and the resident was transferred via hoyer lift. The clinical record for Resident B was reviewed on 9-8-20 at 1:46 p.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 8-23-19, indicated the resident was at risk for incontinence related to a history of needing assistance and incontinence. The Approach was for staff to provide assistance to toilet as needed. The care plan, dated 8-23-19, indicated the resident used a indwelling urinary catheter with a [DIAGNOSES REDACTED]. The resident was to be observed for any signs of UTI (urinary tract infection), urethral trauma, strictures, bladder [MEDICATION NAME] or silent hydro[DIAGNOSES REDACTED]. The physician was to be notified of any signs.Please record resident urinary output . The Event Report, dated 7-15-20, indicated the resident developed ESBL (extended spectrum beta-lactamase) of the urine. A urine culture was obtained on 7-13-20. She was placed in contact isolation. A foul odor to the urine was observed. an order for [REDACTED]. The Event Report, dated 7-29-20, indicated the resident had ESBL of the urine starting 7-27-20. A urine culture was obtained and a foul odor was observed. On 7-29-20 the resident was started on IV (intravenous) Imipenem 400 mg (milligrams) every 6 hours for 7 days. The resident was encourage to take fluids and the antibiotic use was monitored. During an interview with RCA 1, on 9/8/20 at 10:50 a.m., she indicated she cleaned the perineal area from front to back. She used one area of the wipe one time, then would either fold or discard. 2. During an observation on 9/8/20 at 11:16 a.m., Resident C received toileting perineal care from RCA 1 and CRCA 2. RCA 1 cleaned the resident from the labia to the rectum, using a front to back motion, with a wet wipe. She swiped with the same area of the wipe 2 times and folded the wipe. With the folded wipe she swiped 2 times with the same area of the wipe. The brief was pulled up and the resident was transferred into her wheelchair. The clinical record for Resident C was reviewed on 9-8-20 at 1:46 p.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 7-28-20, indicated the resident was at risk for skin breakdown related to immobility and incontinence. The staff were to keep the resident clean and dry and use a moisture barrier as needed. During an interview on 9-8-20 at 1:24 p.m., the DHS (Director of Health Services) indicated the washcloth or wipe used for perineal care could be folded and only a clean surface would be used for each individual swipe. The review of the Perineal Care for the Incontinent Guideline Policy and Procedure revised on 11/9/17 included, but was not limited to, .7. Pay particular attention to infection prevention and control techniques when performing PERINEAL care, to prevent introduction of contamination that may lead to a urinary tract infection . This Federal tag is related to Complaint IN 508. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure interventions were in place for residents (Resident D and Resident C) who were at an increased risk for developing pressure ulcers which resulted in a stage 3 pressure ulcer (Resident D) to the right heel and unstageable pressure ulcers to both heels (Resident C) for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident D was reviewed on 6/23/17 at 9:40 a.m. [DIAGNOSES REDACTED]. The 14 day MDS (Minimum Data Set) assessment, dated 3/30/17, indicated the resident was an extensive assist of 2 staff with bed mobility, at risk for developing pressure ulcers, and her skin was intact. The admission observation report, dated 3/16/17 at 8:16 p.m., indicated the resident was readmitted from the hospital with no skin impairment. The initial Plan of Care, dated 3/16/17, indicated to turn and reposition for comfort. The physician order, dated 3/17/17, indicated to float heels while abed. The skin integrity skin event report, dated 4/9/17 at 1:56 p.m., indicated the resident had a stage 3 (full thickness of skin is lost, exposing the subcutaneous tissues and presents as a deep crater) pressure ulcer to the right heel 5 cm (centimeters) long and 4.5 cm wide with a depth of 1 cm. The event report also indicated the new intervention was to float heels. The progress note, dated 4/9/17 at 2:16 p.m., indicated the resident had a stage 3 pressure area to the right heel. The 30 day MDS assessment, dated 4/13/17, indicated the resident had a stage 3 pressure ulcer that measured 5 cm long and 4.5 cm wide with a depth of 1 cm. The Care Plan, dated 4/10/17, indicated the resident had a pressure ulcer to the right heel. The interventions were to float the resident's heels while in bed, dated 4/21/17 and the resident was to have an air mattress to bed at all times, dated 4/14/17. The progress note, dated 4/9/17 at 3:15 a.m., indicated the resident was turned and repositioned. The clinical record lacked any other documentation that the resident was turned and repositioned from 3/16/17 through 4/9/17. There was no documentation of the resident's refusal to float heels on a pillow or a Care Plan for interventions related to the resident's refusal of care. During an interview on 6/23/17 at 10:26 a.m., the Director of Nursing indicated staff had some difficulties since the resident would move her legs off of the pillows and its probably how the area started. The policy titled Guidelines for Pressure Prevention, dated 8/2/16, included, but was not limited to, the following: .Purpose .to maintain good skin integrity and avoid development of pressure ulcers .float heels as needed .elevate heels of the bed . 2. The clinical record for Resident C was reviewed on 6/22/17 at 12:30 p.m. [DIAGNOSES REDACTED]. The admission (five day) MDS assessment, dated 4/19/17, indicated the resident was an extensive assist of 2 staff for bed mobility and at risk for developing pressure ulcers. The admission observation assessment, dated 4/12/17 at 7:30 p.m., indicated the resident's skin was intact, to elevate heels, and to turn and reposition for comfort with care. The skin integrity event, dated 4/14/17 at 10:58 a.m., indicated the resident had an unstageable area to the left heel, which measured 1 cm long and 1 cm wide. The progress note, dated 4/14/17 at 11:15 a.m., indicated therapy was working with the resident and noticed an area on the back of the heel. The progress note, dated 4/18/17 at 11:09 p.m., indicated the right heel was noted to be soft with black under skin. The skin integrity event, dated 4/18/17 at 11:04 p.m., indicated the resident had an unstageable area to the right heel, which measured 3 cm long and 2.5 cm wide. The immediate interventions included turn with care, float heels, and provide staff training to improve skin status. On 4/19/17, the area was re-assessed and measured 3 cm long and 5 cm wide. The Care Plan, dated 4/17/17, indicated the resident had a pressure ulcer to the left heel. The interventions were to float heels while in bed and the resident was to have an air mattress, dated 4/21/17. The Care Plan, dated 4/20/17, indicated the resident had a pressure ulcer to the right heel and to float heels while abed with an intervention date of 4/24/17 and an air mattress with an intervention date of 4/20/17 On 6/22/17 at 1:50 p.m. and 3:54 p.m., the resident was observed resting in bed with a blue wedge under her legs and her heels resting on the bed. During an interview on 6/23/17 at 10:26 a.m., the Director of Nursing indicated the resident was admitted with the areas to her heels, and unfortunately, they were not captured (record or express accurately) on admission. This Federal tag relates to Complaint IN 282 3.1-40(a)(1)

Based on observation, record review and interview, the facility failed to prevent an avoidable fall and to identify and treat the resulting fractured femur (thigh bone) in a timely manner (Resident B). This deficient practice resulted in Resident B experiencing pain, which limited the resident's activities. Findings include: Resident B was observed on 4/20/2015 at 1:20 p.m. in her wheelchair with her right leg immobilized and elevated. The resident indicated she broke her leg, but could not recall the incident. LPN (Licensed Practical Nurse) #2 was interviewed on 4/20/2015 at 2:05 p.m. LPN #2 indicated Resident B fell while being transported by a (college) student nurse on 4/2/2015. She indicated a mobile tib-fib (lower leg) x-ray was done. LPN #2 indicated the resident had more swelling and a right knee x-ray was obtained on 4/8/2015, which indicated a femur (thigh bone) fracture. Resident B's clinical record was reviewed on 4/20/2015 at 2:35 p.m. [DIAGNOSES REDACTED]. Resident B's quarterly Minimum Data Set (MDS) assessment, dated 3/24/2015, indicated a Brief Interview for Mental Status (BIMS) score of 12 of 15; indicating she was cognitively intact. Resident B's functional status indicated that she required 2+ person physical assist for all activities of daily living (ADLs), including bed mobility, transfers, toilet use, and personal hygiene. The resident was dependent on staff for all locomotion, via wheelchair, in her room and throughout the facility. Resident B's care plan, updated 6/23/2014, indicated, I am at risk for falls r/t (related to) decreased mobility and impaired cognition related to ALZ (Alzheimer's) DEMENTIA. Please transfer me with a MEC (mechanical) LIFT because I have arthritis to my knees and I can no longer safely bare (sic) my own weight. I require 2 (person) assist for bed mobility, max (maximum) for transfers, max for ambulating, 2 for bathing.and 2 for toileting. Resident B's care plan, updated 4/3/2015, indicated, I was with a nursing student and she was getting me up and I was too close to the edge of the bed. I c/o (complained of) pain in my right leg. Resident B's most recent quarterly Resident Lift Assessment Profile, completed 3/24/2015, indicated she required a standing (Sara) lift for all transfers. A Change in Condition form, dated 4/2/2015 at 9:30 a.m., indicated .Signature/title of nurse: (LPN #2). Condition change that prompted request for physician order: (blank). Describe signs and symptoms of condition change: Resident getting up slid to floor.c/o (complaint of) right knee & (down arrow) leg pain. Can we get an x-ray. Resident being transferred with (school nursing) student (without) lift. Physician order/response to communication: Radiology: x-ray right knee & (down arrow) leg. Follow up Date/time: 4/2/15 2 (p.m.) - 10 (p.m.) c/o (complaint of) knee pain. X-ray negative. Refuses to get up. Follow up Date/time: 4/3/15 1st (first shift) PRN (as needed) pain meds given. 4/3/2015 2 (p.m.) - 10 (p.m.) Continues to c/o knee & leg pain. physician's orders [REDACTED]. Indication - Dx (diagnosis): (up arrow) pain. T/O (telephone order) Dr. (name) / (LPN #2 signature). Mobile x-ray Radiology Report, dated 4/2/2015, indicated a right tibia/fibula AP & LAT was done with no fracture or dislocation observed. Fall Circumstance, Assessment and Intervention form, dated 4/2/2015, indicated, Time of fall: 09 (no minutes noted). Injury location: Right knee & (down arrow) leg. C/O pain (1-10): 9 (severe pain).Location: Right knee & (down arrow) leg. Care Plan: I had a recent fall because: (blank). My goal is to: not fall (check mark). Please help me do this by using/doing the following things: Other: Make sure Resident positioned in center of bed when getting up. IDT (Interdisciplinary Team) Review Date: 4/2/15. Root cause: too close to edge of bed, students involved. Intervention update appropriate: (blank). Change to: Educate student nurses re: following res (resident) transfer CP (care plan). Other comments: Students attempting to get res up (without) lift. physician's orders [REDACTED]. Indication - Dx (diagnosis): edema. T/O (telephone order) Dr. (name) / (LPN #2 signature). Mobile X-ray Radiology Report, dated 4/8/2015, indicated, Examination: KNEE.Right. Conclusion: Right distal femur (thigh) comminuted (splintered, crushed, or broken into pieces) fracture (broken bone). physician's orders [REDACTED]. Indication - Dx (diagnosis): Fx (fracture) to femur. Hospital Medical Imaging Report, dated 4/9/2015, indicated, Study: femur 2 views. Clinical history: pain. Description: There is a severely comminuted displaced fracture through the supracondylar femur. Impression: Severely comminuted distal femur fracture. emergency room Report, dated 4/9/2015 at 11:32 a.m., indicated, .Patient apparently has been having some pain over the past week. Patient tells me she is not ambulatory at baseline. She's not sure how her fever (sic) was broken. Physical Exam: .Musculoskeletal: There is swelling and tenderness over the right distal femur. emergency room Progress Notes, dated 4/9/2015 at 12:30 p.m., indicated, .the patient (Resident B) is non-weight bearing even prior to this fracture. Pain Circumstance, Assessment, Data Collection and Intervention, dated 4/9/2015 at 7:00 p.m. indicated, Location of pain: Rt (right) knee. R/T (related to): Rt (right) femur fracture. Type: Acute (check mark).Continuous (check mark).Intensity of the worst pain over the last 5 days?: Moderate pain (4-5) (checked). How much of the time has the resident experienced pain or hurting over the last 5 days? Almost constantly (circled). During the last 5 days, has the resident: Been on a scheduled pain regimen: No (circled). Received PRN (as needed) pain medication? Yes (circled). Have activities been limited because of pain: Yes (circled). [DIAGNOSES REDACTED]. There was no evidence in Resident B's clinical record that a physician saw Resident B after the fall on 4/2/2015 or prior to being sent to the Emergency Department on 4/9/2015. There was no evidence that staff contacted the physician regarding Resident B's condition after the negative x-ray on 4/2/2015 and prior to obtaining the right knee x-ray order on 4/8/2015. Resident B's Orthopedic Physician's Progress Notes, dated 4/15/015, indicated, (Resident B) stood up and fell in spite of the fact that she is non-ambulatory and she fell (illegible) a comminuted supracondylar (right) femur fracture. Was put in knee immobilizer which does not help. Pt (patient) complains of pain. On 4/20/2015 at 3:40 p.m., the Director of Health Services (DHS), indicated Resident B fell on [DATE] when a student nurse went into Resident B's room without prior knowledge of Resident B's care requirements attempted to assist the resident to a standing position from bed. On 4/22/2015 at 10:29 a.m., LPN #2 indicated she faxed the Change in Condition form to the physician and the physician called with orders to obtain an x-ray of Resident B's tibia-fibia (shin bones). The current Change in Condition Form Guidelines Policy and Procedure, was provided by the DHS on 4/22/2015 at 10:27 p.m. The procedure included, but was not limited to, 2. The nursing assessment will be entered onto the first section of the Condition Change Form labeled 'Change That Prompted Physician Request for Order.' Information should be completed in it's entirety. Physician Telephone Orders Section: .2. The nurse who receives the physician order [REDACTED].' section of the form that shall include the order, date and time the order is received from the attending physician. Care Plan Update Section: 1. The care plan update section will be completed in it's entirety. 2. If the problem area is a new area include measurable and time-specific goal(s), and realistic, individualized approaches, and the disciplines who will be involved in the care of the resident. The current Falls Management Program Guidelines Policy and Procedure was provided by the DHS on 4/20/2015 at 4:45 p.m. The procedure included, but was not limited to, .3. Should the resident experience a fall the attending nurse shall complete the 'Fall Circumstance and Reassessment Form.' The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by IDT to evaluate thoroughness of the investigation and appropriateness of the interventions. 4. An 'Accident and Incident Report' should be completed at the time of the incident. On 4/21/2015 at 2:43 p.m., the DHS provided a typed document which indicated, (Resident Name) 4/20/2015 Summary of investigation. On 4/2/15 (CNA (Certified Nurse Aide) #1) was approached by an (college) student asking her to come into (Resident B's) room. (CNA #1) stated she saw (Resident B) on her buttocks in front of her bed with her right leg out slightly bent at the knee. The student stated to her 'she told me she could stand' and the student began hysterically crying. The student stated that she was helping her stand and (Resident B's) knees gave out. LPN #2 stated she then went to retrieve the instructor who was off of the floor and found in the private dining room. The DHS, Corporate Clinical RN, and Executive Director were interviewed on 4/21/2015 at 4:10 p.m. The DHS indicated it was the responsibility of the college's clinical instructor to ensure that student nurses were made aware of resident conditions and care needs and that instructors were expected to be present for all direct resident care. The DHS indicated that facility staff was available for student nurses to utilize as a resource. The Corporate Clinical RN indicated student nurses have access to resident functional status and/or transfer requirements via care plans located in a binder at the nurses' station or in resident charts. The DHS indicated the Accident and Incident Report referred to in the Falls Management Program Guidelines was an internal document and the facility declined to provide the document. This Federal tag relates to the Investigation of Complaint IN 552. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide interventions to prevent the development of pressure ulcers in a resident admitted to the facility without pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. The resident developed an unstageable pressure ulcer within three weeks of being admitted to the facility. (Resident A) Findings include: The clinical record for Resident A was reviewed on 5/8/14 at 9:15 a.m. and indicated the resident had [DIAGNOSES REDACTED]. The resident was admitted to the facility in November 2013. The initial Minimum Data Set (MDS) assessment, dated 11/12/13, indicated the resident had no pressure ulcers, but was at risk for developing pressure ulcers. The MDS assessment indicated the resident needed the extensive assistance of two persons for bed mobility, transfer, dressing and toileting. The resident had a foley catheter and was occasionally incontinent of bowel. There was no plan of care developed to address the resident's risk of developing pressure ulcers. The quarterly MDS assessment, dated 1/17/14, indicated the resident had an unstageable pressure ulcer (slough/eschar; suspected deep tissue injury in evolution) measuring 5 centimeters (cm) long, 3.5 cm wide and 0.3 cm deep. The Treatment Administration Record indicated the resident's skin was assessed weekly and on 11/26/13, the nurse signed that the assessment was completed and a "0" was written on the record to indicate there were no skin issues. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 11/27/13, indicated the resident had an unstageable pressure ulcer on the right hip, measuring 3 cm long by 2.5 cm wide and less than 0.1 cm deep. The assessment indicated the physician and family were notified and treatment was initiated. The "Skin Impairment Circumstance, Assessment, and Intervention form, completed on 11/27/13, indicated the "res (resident) scoots around in bed & lays predominately on R (right) side. The prevention update was listed as "encourage resident to T & R (turn and reposition) q 2 (every 2 hours)." There was a "Pressure Ulcer Letter of Unavoidability," dated 12/1/13, with two marks indicating the "clinical conditions this resident exhibits that make the likelihood of this pressure ulcer unavoidable include, but are not limited to, resident immobility and: Pale skin and Noncompliance with care interventions, Turning and positioning." "Res only likes to lay on R (right) side." The resident's laboratory results, dated 11/3/13 indicated: [MEDICATION NAME] 3.8 (3.7 - 4.8) Total Protein 6.6 (6.7 - 8.9) There was no plan of care to address the resident's desire to lay on his left side, nor that he was noncompliant with turning from admission until the wound was identified on 11/27/13. The DON (Director of Nursing) was unable to provide a policy and procedure regarding interventions for a resident identified as being at high risk for pressure ulcers when requested on 5/8/14 at 11:14 a.m. Interview with the DON on 5/8/14 at 2:21 p.m., indicated the resident was big in size and he liked to stay up in the wheel chair and not lie down. She was unable to explain why the resident was assessed on 11/26/13 as having no skin concerns and on 11/27/13 was found with an unstageable pressure ulcer. She was unable to find a plan of care to address the resident's high risk for developing pressure ulcers. There was no plan to educate the resident on the risks associated with not following a turning schedule. The resident developed a second pressure ulcer on the left hip. It was first noted on 12/31/13 as a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough.), measuring 7 cm long, 8 cm wide and 0.2 cm deep. The resident continued to have the wounds when discharged from the facility in March 2014. The right hip wound was a Stage 4 (full thickness of skin and subcutaneous tissue is lost exposing the muscle and/or bone) and measured 2 cm long, 2.4 cm wide and 1 cm deep. The left hip wound was assessed as a Stage 2, measuring 1 cm long, 1 cm wide and 1.5 cm deep. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure appropriate treatment to prevent a further decrease in range of motion for 1 of 1 resident reviewed for range of motion (Resident #40). This deficient practice resulted in harm in that Resident #40, who's upper extremities were without impairment when she was admitted to the facility, developed bilateral hand contractures and is unable to complete activities of daily living (ADLs) as a result. Findings include: During staff interview with LPN #4 on 4/30/2014 at 10:16 a.m., she indicated that Resident #40 has contracture (defined as a condition of fixed high resistance to passive stretch of a muscle) of both hands and does not receive range of motion services nor does she have a splint device in place. Resident #40's clinical record was reviewed on 05/05/2014 9:43 a.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #40 was a one person physical assist for Bed Mobility, Transfers and Toilet use. For eating, Resident #40 required set up assistance. The annual Minimum Data Set assessment dated [DATE], indicated Resident #40 was required two or more people to physical assist for Bed Mobility, Transfers and Toilet use. For eating, Resident #40 required one person to physically assist. The most recent Minimum Data Set assessment, completed on 3/25/2014, indicated that Resident #40 did not receive active (when a person moves a body part on his own without any help or support from the therapist) range of motion. This assessment also indicated that Resident #40 did not receive passive (when the body part is moved by the therapist without any help from the patient) range of motion. The MDS, indicated that on 12/31/2013, and 3/35/2014, Resident #40's upper extremities were without impairment. The Resident #40's Brief Interview for Mental Status (BIMS) score was 13 of 15, indicating that she was cognitively intact. A Nursing Admission Assessment & Data Collection, dated 9/6/2013, indicated Resident #40 had bilateral hand contractures. The Monthly Nursing Assessments, dated 2/16/14, 3/19/14 and 4/13/2014, indicated Resident #40 had bilateral hand contractures and was unable to do ADLs (activities of daily living) due to both hands being contracted. A 12/21/2013 physician progress notes [REDACTED]. Resident #40's hands has (sic) multiple contractures, rendering both hands to clubs. Plan is for occupational therapy (OT) to work with pt. (patient) toward goal of flatter hands, and return of useful grasp/grip." The Occupational Therapist was interviewed on 5/5/2014 at 10:32 a.m., She indicated that Resident #40 was referred to therapy on 1/2/2014, due to a decrease function of hands. She indicated that "Therapy ordered therapeutic carrots for her to try, she was experiencing pain with any kind of stretching of her hands, the pt (patient) was educated on the therapeutic carrots." Resident #40 was discharged from therapy on 1/14/2014 due to progress had ceased. Nursing was informed that the pt. was discharged from PT (Physical Therapy) and OT (Occupational Therapy) on 1/14/2014, and to continue ROM (range of motion) and maintain schedule for therapy carrots. Resident #40 was interview on 5/5/2014 at 11:27 a.m. She indicated my hands started gradually to turn in, not sure when. If I try to open my fingers I have pain. For a short time I worked with physical therapy. They gave me therapy carrots to place in my hands, I have not used them lately." I don't know why I am not using them." When Resident #40 was ask, if she was able to open her hands, Resident #40 was observed to open right hand slightly and unable to open left hand. There were no care plans related to contractures, range of motion, or therapeutic carrots identified. Neither the Medication Administration Record [REDACTED]. 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to provide proper treatment and care for 3 residents receiving ostomy care for 3 of 3 residents reviewed for special services related to ostomy care (Residents B,C, and D). This deficient practice resulted in harm in that 1 resident's (Resident B) skin became impaired as a result of improper treatment and care of his [MEDICAL CONDITION] site. Findings include: 1. Resident B's closed clinical record was reviewed on 5/8/2014 at 10:29 a.m. and indicated that Resident B was admitted to the facility on [DATE] following an exploratory laparotomy, small bowel obstruction, and [MEDICAL CONDITION] (surgical construction of an artificial excretory opening through the abdominal wall) placement for post-surgical rehabilitation and education. [DIAGNOSES REDACTED]. Resident B was discharged from the facility on 3/19/14. A 3/13/2014 Nurse's Note indicated, "Had recent surgery for [REDACTED]. Incision with drsg (dressing). Proxy. (approximately) 7'' (inch) length incision with sutures present. To see Dr. (name) on 3/19/2014 for suture removal." physician's orders [REDACTED]. Ostomy care prn (as needed) enc (encourage) resident to do." Plan of Care, dated 3/13/2014, indicated, "Problem: ABD (abdominal) Incision. Goal: To have no s/s (signs/symptoms) infection. Intervention: Change drsg (dressing) daily per order. Observe for s/s infection. Empty, (change symbol) [MEDICAL CONDITION] bag as needed. There were no additional care plans related to [MEDICAL CONDITION] care or resident education. A review of the Medication Administration Records for 3/13/2013-3/31/2013, indicated, "Ostomy care prn (as needed). Enc (encourage) Resident to do." There was no documentation that this was done at any time. The 3/13/2014 Nursing Admission Assessment and Data Collection indicated "[MEDICAL CONDITION]" under the section entitled, "Elimination." There was nothing related to Resident B's [MEDICAL CONDITION] indicated under the section entitled, "Elimination Plan of Care." Skilled Nursing Assessment and Data Collection Forms, dated 3/15/2014 through 3/18/2014, indicated only "surgical wound" under the section entitled, "Skin". No additional Nurse's Notes, physician progress notes [REDACTED]. During an interview with LPN #4 on 5/2/2014 at 10:45 a.m., she indicated that staff does not document who provided [MEDICAL CONDITION] care, when it was provided, a description of the stoma/site, or what type/size of wafer,bag, or supplies were used. During a phone interview with Resident B's daughter on 5/8/2014 at 11:23 a.m., she indicated that her father was left to lay in his [MEDICAL CONDITION] leakage for several hours at a time and had "pretty bad burns" on the skin surrounding his [MEDICAL CONDITION] stoma. She further indicated that when the resident was seen for a follow-up appointment on 3/19/2014, the physician and nurse indicated to her that [MEDICAL CONDITION] caused by leakage (of gastro-intestinal contents) around the site as a result of staff "cutting the hole too big". She further indicated, "They were having a hard time getting the bags to stay on because of the burns. They were supposed to be good for 3 days or so, but they were having to change them twice a day or so. They did finally order a special powder...'stoma powder' I think....It took several weeks to recover with the home health nurse." Resident B's daughter also indicated that Resident B was not independent with his [MEDICAL CONDITION] care and was dependent on staff to change and empty the bag. She indicated that when he was discharged to home with home health services on 3/19/2014, he did not know how to care for his [MEDICAL CONDITION] site. During an interview with the Home Health Nurse who cared for Resident B following his discharge from the facility on 3/19/2014, she indicated that the resident had an "excoriated" area surrounding his stoma site, which took approximately one week to heal following his discharge. She further indicated that the resident did not receive adequate education and that the resident was not discharged with any [MEDICAL CONDITION] supplies, which is common practice. During an interview with the Director of Nursing (DoN) on 5/8/2014 at 2:47 p.m., she indicated that they do provide resident teaching related to self-care of [MEDICAL CONDITION]/[MEDICAL CONDITION] sites and that it is normally included in the care plan. She indicated, "I don't recall any excoriation around the stoma...rings being cut wrong...or leakage. The nurses would normally report something like that to me and then there would be a skin sheet." She further indicated, "We would send home 72 hours worth of supplies with instructions on how they can get supplies." She indicated that she could not find any documentation in Resident B's record that supplies were sent home with him when he was discharged on [DATE]. Additionally, she indicated that she could not find any Nurse's Notes, physician progress notes [REDACTED]. 2. Resident D's clinical record was reviewed on 5/2/2014 at 10:10 a.m. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 3/19/2014, indicated that Resident D had a Brief Interview for Mental Status (BIMS) score of 13; which indicated that she was cognitively intact. Resident D was interviewed on 5/2/2014 at 10:28 a.m. regarding her [MEDICAL CONDITION] care. She indicated, "Yes, they (staff) have problems. I don't know how to answer it cuz (sic)...we have some trouble sometimes...my, my, my...do they have all the supplies they need? Not always." Recapitulated physician's orders [REDACTED]." Nurses Notes dated 4/15/2014 indicated, "Req (requires) assist with ADLs (activities of daily living). Does have periods of confusion. Res (resident) does own [MEDICAL CONDITION] care...." The 4/17/2014 Monthly Nursing Assessment & Data Collection indicated, "Requires assist with all ADLs due to weakness and being unsteady when up. Res is non-ambulatory....Res has [MEDICAL CONDITION] and does own care." During an interview with LPN #4 on 5/2/2014 at 10:35 a.m., she was queried regarding orders and/or policy and procedure for Resident D's [MEDICAL CONDITION] care. She indicated, "There's no real order. She's pretty independent with it. She lets us know when it needs to be changed." Resident D's call light sounded on 5/2/2014 at 10:37 a.m., and LPN #4 responded. She indicated, "It ([MEDICAL CONDITION] bag) came undone...maybe when she turned or something." A large amount of brown liquid was observed to have leaked around the stoma site. LPN #4 was observed to gather supplies, don gloves, and pull the soiled wafer/bag from Resident D's skin. She cleaned the site with water and attempted to place the new, clean wafer over the stoma. The opening was noted to be several centimeters too small. She indicated, "Let me get my scissors." She then removed her gloves and washed her hands for 9 seconds before donning new gloves. LPN #4 removed scissors from her uniform and cut a jagged, uneven hole slightly larger than the original opening. She was observed to place the wafer on the stoma, with 1/3 of the wafer sitting on top of the stoma and not flush with the skin around the stoma. She then attached the [MEDICAL CONDITION] bag. She removed her gloves and washed her hands for 5 seconds before exiting the room. During an interview with LPN #4 on 5/2/2014 at 10:45 a.m., she indicated that staff does not document when they change the bag or wafer or provide [MEDICAL CONDITION] care. She indicated, "It's just included in the '[MEDICAL CONDITION] care Q shift. Independent with care.' order on the MAR." When asked how she would know when the bag was changed last, she indicated, "I could put it on the report sheet. I probably will put it on the report sheet, but I can't say everyone does." Regarding documentation that Resident D is "independent with [MEDICAL CONDITION] care", LPN #4 indicated, "At times she is....sometimes she'll empty her own bag into the toilet." She further indicated that Resident D does not change her own bag or wafer or provide stoma care. During an interview with the Director of Nursing (DoN) on 5/2/14 at 2:16 p.m., she indicated, "The doctor wanted the order written that way because it's the one thing she has to hang on to...for her independence." She further indicated that staff do not receive additional training related to [MEDICAL CONDITION]/[MEDICAL CONDITION] care. On 5/2/2014 at 2:27 p.m., the DoN was asked to observe Resident D's [MEDICAL CONDITION] site subsequent to the [MEDICAL CONDITION] care provided at 10:37 a.m. Upon entering the room, Resident D was found sitting in her wheelchair with a brown substance on her shirt and a large amount of brown liquid which had leaked through her adult brief and was leaking out around the wafer adhesive. The DoN donned gloves prior to assessing the resident's [MEDICAL CONDITION] site. She then removed the gloves and was observed to wash her hands for 3 seconds before donning clean gloves. She and RN #3 assisted Resident D to the bathroom via wheelchair and the DoN was observed to wipe a large amount of brown liquid from the seat of Resident D's wheelchair up towards the front of Resident D's peri-area. RN #3 cut a new wafer with scissors, donned gloves, placed the new wafer and bag onto Resident D's stoma, removed her gloves, and left the room. She did not wash her hands at any time. 3. The clinical record for Resident C was reviewed on 5/2/2014 at 9:30 a.m. [DIAGNOSES REDACTED]. Physician order [REDACTED]. On 5/2/2014 at 9:45 a.m., Resident C was observed sitting in her wheelchair sleeping in the lounge area close to the nurses desk. CNA #6 woke Resident C and asked her if she wanted to lay down. Resident C indicated she would "just sit out here." CNA #6 placed foot peddles on the wheelchair and elevated Resident C's legs as requested by LPN #4. On 5/2/2014 at 10:00 a.m., CNA #6 was observed taking Resident C to her room to have her [MEDICAL CONDITION] bag emptied. On 5/2/2014 at 10:05 a.m., CNA #6 was observed calling for LPN #4 to assist her. On 5/2/2014 at 10:07 a.m., LPN #4 was observed coming out of Resident C's room carrying a box of [MEDICAL CONDITION] supplies. LPN #4 went to the supply room came out and went down another residential hall then came back to Resident C's room. LPN #4 went to change the [MEDICAL CONDITION] bag and indicated she didn't have the supplies she needed. The supply drawer in Resident C's room was observed to contain multiple different [MEDICAL CONDITION] bag supplies, including different types of [MEDICAL CONDITION] bags. LPN #4 indicated that she did not have the supplies she needed, stating, "It may be a while before I can change this." LPN #4 then indicated she would change [MEDICAL CONDITION] bag using a bag without a wafer. On 5/2/2014 at 10:20 a.m., LPN #4 was observed in Resident C's room. LPN #4 washed her hands and placed [MEDICAL CONDITION] supplies on the bed side table. The opening on the [MEDICAL CONDITION] bag was cut larger than the stoma; glue was placed on the back side of the bag around the opening. LPN #4 donned gloves. The old [MEDICAL CONDITION] bag was removed. The skin around the ostomy was cleaned with a wet washcloth and dried with a dry washcloth. The dirty linens were placed in a plastic bag. The dirty gloves were removed and placed in trash bag. LPN #4 put a new pair of gloves on. The skin around ostomy had raised areas red in color and raw in appearance. The stoma itself was clean and pink in color. Stoma powder was sprinkled on the skin where the adhesive was to be placed. The [MEDICAL CONDITION] bag was placed with opening over the stoma. LPN #4 informed Resident C pressure needed to be applied to get the [MEDICAL CONDITION] bag to stick to her skin. Resident C grimaced and LPN #4 asked if it was tender and Resident C indicated it was. The supplies were placed back in Resident C's drawer. During an interview on 05/08/2014 at 1:45 p.m., LPN #4 indicated that when a resident is admitted to the facility, the physician does not send specific orders as to type, brand, or size of [MEDICAL CONDITION] supplies and that the facility nursing staff figures out what they have and what is needed to be used and ordered. The policy and procedure entitled, "Guidelines for [MEDICAL CONDITIONS]" was provided by the DoN on 5/2/2014 at 3:45 p.m. and reviewed at that time. The procedure included, but was not limited to, the following: "...Wash and dry hands thoroughly....Put on gloves....Cleanse skin with appropriate skin cleansing preparation....Remove and discard gloves into designated container. Wash and dry hands thoroughly....The following information should be recorded in the resident's medical record: a. The date and time the [MEDICAL CONDITION]/[MEDICAL CONDITION] care was provided. b. The name and title of the individual(s) who provided the [MEDICAL CONDITION]/[MEDICAL CONDITION] care. c. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of the skin. d. How the resident tolerated the procedure....f. The signature and title of the person recording the data. During an interview with the DoN on 5/8/2014 at 2:40 p.m., she indicated that Residents B, C, and D did not have adequate care plans and that staff had not been following the policy and procedure for [MEDICAL CONDITION] care. This Federal tag relates to Complaint # IN 512. 3.1-47(a)(3)

Based on record review and interview, the facility failed to provide interventions to prevent the development of pressure ulcers in a resident admitted to the facility without pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. The resident developed an unstageable pressure ulcer within three weeks of being admitted to the facility. (Resident A) Findings include: The clinical record for Resident A was reviewed on 5/8/14 at 9:15 a.m. and indicated the resident had [DIAGNOSES REDACTED]. The resident was admitted to the facility in November 2013. The initial Minimum Data Set (MDS) assessment, dated 11/12/13, indicated the resident had no pressure ulcers, but was at risk for developing pressure ulcers. The MDS assessment indicated the resident needed the extensive assistance of two persons for bed mobility, transfer, dressing and toileting. The resident had a foley catheter and was occasionally incontinent of bowel. There was no plan of care developed to address the resident's risk of developing pressure ulcers. The quarterly MDS assessment, dated 1/17/14, indicated the resident had an unstageable pressure ulcer (slough/eschar; suspected deep tissue injury in evolution) measuring 5 centimeters (cm) long, 3.5 cm wide and 0.3 cm deep. The Treatment Administration Record indicated the resident's skin was assessed weekly and on 11/26/13, the nurse signed that the assessment was completed and a "0" was written on the record to indicate there were no skin issues. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 11/27/13, indicated the resident had an unstageable pressure ulcer on the right hip, measuring 3 cm long by 2.5 cm wide and less than 0.1 cm deep. The assessment indicated the physician and family were notified and treatment was initiated. The "Skin Impairment Circumstance, Assessment, and Intervention form, completed on 11/27/13, indicated the "res (resident) scoots around in bed & lays predominately on R (right) side. The prevention update was listed as "encourage resident to T & R (turn and reposition) q 2 (every 2 hours)." There was a "Pressure Ulcer Letter of Unavoidability", dated 12/1/13, with two marks indicating the "clinical conditions this resident exhibits that make the likelihood of this pressure ulcer unavoidable include, but are not limited to, resident immobility and: Pale skin and Noncompliance with care interventions, Turning and positioning." "Res only likes to lay on R (right) side." The resident's laboratory results, dated 11/3/13 indicated: [MEDICATION NAME] 3.8 (3.7 - 4.8) Total Protein 6.6 (6.7 - 8.9) There was no plan of care to address the resident's desire to lay on his left side, nor that he was noncompliant with turning from admission until the wound was identified on 11/27/13. The DON (Director of Nursing) was unable to provide a policy and procedure regarding interventions for a resident identified as being at high risk for pressure ulcers when requested on 5/8/14 at 11:14 a.m. During an interview on 5/8/14 at 2:21 p.m., the DON indicated the resident was big in size and he liked to stay up in the wheel chair and not lie down. She was unable to explain why the resident was assessed on 11/26/13 as having no skin concerns and on 11/27/13 was found with an unstageable pressure ulcer. She was unable to find a plan of care to address the resident's high risk for developing pressure ulcers. There was no plan to educate the resident on the risks associated with not following a turning schedule. The resident developed a second pressure ulcer on the left hip. It was first noted on 12/31/13 as a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough.), measuring 7 cm long, 8 cm wide and 0.2 cm deep. The resident continued to have the wounds when discharged from the facility in March 2014. The right hip wound was a Stage 4 (full thickness of skin and subcutaneous tissue is lost exposing the muscle and/or bone) and measured 2 cm long, 2.4 cm wide and 1 cm deep. The left hip wound was assessed as a Stage 2, measuring 1 cm long, 1 cm wide and 1.5 cm deep. This Federal tag relates to Complaint #IN 397. 3.1-40(a)(1)