Every finding on record at Twin City Health Care

Based on interview and record review, the facility failed to ensure residents or their representatives were provided with bed hold policies prior to hospitalization for 3 of 4 residents reviewed for hospitalization. (Residents 11, 19, and 25) Finding includes:1.Resident 11's clinical record was reviewed on 8/12/25 at 8:31 a.m. Diagnoses included unspecified dementia, schizophrenia, and delusional disorder.A quarterly, Minimum Data Set (MDS) assessment, dated 5/1/25, indicated the resident interview was unable to be completed.The clinical record lacked information regarding who received the bed hold policy when the resident was transferred to the hospital on 6/22/25.2.Resident 19's clinical record was reviewed on 8/12/25 at 8:39 a.m.Diagnoses included type two diabetes, chronic kidney disease stage three, and depression.An admission MDS assessment, dated 7/2/25, indicated the resident was cognitively intact.A progress note, dated 8/5/25 at 3:45 p.m., indicated the resident was transferred to the hospital for increased confusion. The clinical record lacked information regarding who received the bed hold policy.3.Resident 25's record was reviewed on 8/12/25 at 8:43 a.m. Diagnoses included congestive heart failure, essential hypertension, and chronic pain syndrome.A significant change MDS dated [DATE] indicated the resident was severely cognitively impaired. A progress note, dated 4/29/25 at 9:09 a.m. indicated the resident was transferred to the hospital for wheezing. The clinical record lacked information regarding who received the bed hold policy.During an interview with LPN 5 on 8/14/25 at 9:08 a.m., she indicated when a resident was transferred, the resident was sent out with forms containing code status, basic resident information, and a bed hold policy. The information was charted in a progress note.During an interview with the DON on 8/14/25 at 11:37 a.m., she indicated the residents' records lacked information about who the bed hold policy was given to for each of the three residents. Normally, the staff charted in the clinical record what information was given to the residents when they were discharged or transferred or who the paperwork was given to.During an interview, with the Administrator on 8/14/25 at 11:38 a.m., she indicated resident representatives were called when the resident required transfer and were informed when the resident returned. There was no place on the bed hold policy for a signature, and the facility did not have measures in place to document who received the bed hold policy. This information was to be in the paper chart or electronic health record.A current facility policy titled BEDHOLD, provided by the DON on 8/14/25 at 12:08 p.m., indicated the following: .Purpose: At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident or resident representative written notice which specifies the duration of the bed-hold policy.3.1-12(a)(6)(A)(i)

Based on observation and interview, the facility failed to appropriately date opened insulin pens for 2 of 4 medication carts observed for medication storage. (A Unit cart and C Unit cart) This had the potential to affect 6 of 6 residents who received insulin from A Unit and C Unit carts.Findings include:During a medication storage observation of the A Unit cart, accompanied by QMA 3, on [DATE] at 3:48 p.m., the following was observed: one Basaglar (insulin) 3 milliliters (ml) Kwikpen 100 units per ml, with the seal broken and the pen undated, with approximately 150 units used and one Basaglar 3 ml KwikPen 100 units per ml, with the seal broken and the pen undated, with approximately 75 units used.During a medication storage observation of the C Unit cart, accompanied by QMA 3, on [DATE] at 4:06 p.m., the following was observed: one Lantus (insulin) 3 milliliters (ml) KwikPen 100 units per ml, with the seal broken and then pen undated, with approximately 200 units used.During an interview on [DATE] at 4:11 p.m., QMA 3 indicated these insulin pens were not dated when they were opened. There was not a way to know when the insulin pens expired since they were not dated when they were opened. On [DATE] at 4:19 p.m., LPN 4 indicated Basaglar insulin pens expired 28 days from the date the insulin was opened. Different insulins expired in a manufacturer specified number of days from the date the insulin was opened. On [DATE] at 5:03 p.m., the DON indicated all insulin pens were required to have an opened date. Undated insulin pens could not be utilized and must be discarded. Insulin pens expired based on the manufacturer instructions for each insulin.Review of the Basaglar manufacturer instructions, revised 7/2021, indicated Basaglar KwikPens, opened and stored at room temperature, expired in 28 days even if they still contained Basaglar. Review of the Lantus manufacturer instructions, revised 05/2025, indicated Lantus prefilled pens, opened and stored at room temperature, expired in 28 days. A facility policy, dated 9/2017, titled MEDICATION EXPIRATION, provided by the Administrator on [DATE] at 5:20 p.m., indicated the following: POLICY: All medications dispensed by the pharmacy will have an expiration or information on calculating the expiration date once the medication is mixed/opened. PROCEDURE: 1. All medication dispensed from pharmacy shall contain an expiration date. d. Multiple dose injections, such as insulin will expire 28 days after opening unless otherwise noted by manufacturer.3.1-25 (j)3.1-25 (k)

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by not wearing appropriate personal protective equipment (PPE) in areas requiring transmission-based precautions (TBP) during random observations on the 100 and 200 halls. Findings include: During a random observation, on 9/11/24 at 11:29 a.m., Housekeeper 3 was seen entering and exiting room [ROOM NUMBER] while wearing gloves and a surgical mask. Signage on the door indicated the residents were in TBP and a gown, gloves, face shield and mask were required before entering the residents' room. During an interview, at the time of observation, Housekeeper 3 indicated she didn't need to wear a face shield, as she wore glasses. She only needed to wear gloves and a surgical mask. During a random observation, on 9/12/24 at 2:08 p.m., Housekeeper 3 entered a positive COVID-19 resident's room while wearing a gown and gloves. Signage on the door indicated the resident was on TBP and everyone must wear a gown, gloves, mask and face shield upon entering the room. During an interview, on 9/13/24 at 10:19 a.m., LPN 4 indicated she just needed to wear a gown, gloves, surgical mask, and a face shield when entering. She didn't need to wear an N95 (respirator) mask. During a random observation, on 9/13/24 at 11:28 a.m., CNA 5 entered Resident 31's room wearing a gown, gloves, surgical mask, and a face shield. During an interview, at the time of observation, CNA 5 indicated they could wear surgical masks upon entering a TBP resident's room. During an interview, on 9/13/24 at 1:31 p.m., the DON indicated signage for any resident on contact or droplet isolation was taped to the door. Staff should be wearing N95 masks if they entered an isolation room. The facility had plenty of PPE available. The facility had just had an in-service regarding infection control when the first resident tested positive for COVID-19. There were teachable moments completed as she walked through the facility. The facility was aware that they were having a problem with infection control. Housekeeper 3 completed a return demonstration for donning and doffing of PPE. Review of Resident 31's clinical record was completed on 9/16/24 at 10:38 a.m. Review of a progress note indicated he was positive for COVID-19 with symptoms of cough and nasal congestion. Current orders included strict droplet, single room isolation maintained, all services in the room due to positive COVID-19. A facility policy, dated 10/2015, provided by the Administrator on 9/17/24 at 3:13 p.m., titled Isolation (Transmission- Based Precautions) Guidelines, indicated the following: .5. All personnel must follow transmission- based precautions, as indicated 3.1-18(a)(2)

Based on observation, interview, and record review, the facility failed to ensure medications given by gastrostomy tube (G-tube) were administered according to physician's orders and facility policy for 1 of 7 residents observed for medication administration, resulting in an 8.89 % medication error rate. (Resident 31) Finding includes: During an observation, on 9/13/24 at 10:19 a.m., LPN 4 removed the stopper from Resident 31's G-tube, flushed the G-tube with 30 ml (milliliters) of water, and administered multiple medications one at a time via G-tube. The medications included escitalopram (antidepressant) 20 mg tablet crushed mixed with 20 ml water, multivitamin crushed mixed with 20 ml water, linezolid (antibiotic) 600 mg crushed and mixed with 20 ml water, and docusate sodium (50 mg/5 ml) 10 ml. Auscultation of an air bolus and a check for residual stomach contents was not performed prior to the medication administration. During an interview, immediately following the medication administration, LPN 4 indicated the resident took all medications via G-tube. Placement for the G-tube should have been checked prior to the administration of medications, which included an air bolus and a check for residual stomach contents. She had not completed a placement check. Resident 31's record was reviewed on 9/13/24 at 10:38 a.m. Diagnoses included dysphagia, nausea, and vomiting. Physician's orders included docusate sodium (stool softener) liquid 50 mg/5 ml - 10 ml orally twice a day (7/11/24), escitalopram (antidepressant) 20 mg orally daily (7/24/24), multivitamin orally daily (8/15/24), linezolid (antibiotic) 600 mg orally twice a day (8/30/24), Administer 10 ml air bolus via G-tube prior to administration of medications or feeding, and auscultate abdomen to confirm air movement and appropriate placement of feeding tube every shift. (2/9/24), Assess bowel sounds in all quadrants before and after medication administration, and hold if absent and notify medical provider for further instructions every shift. (2/9/24), and Check residual (stomach contents) before medication administration, including enteral nutrition. If less than 120 ml obtained, re-instill residual via feeding tube. If greater than 120 ml obtained, do not proceed and notify medical provider for further instructions every shift (2/9/24). During an interview, on 9/16/24 at 4:20 p.m., RN 6 indicated Resident 31 received all of his medications per G-tube. Resident 31 had attempted to take medications orally for about two days, but he did not like taking medications orally, and the medications were again administered per G-tube. To administer medications per G-tube, she listened to bowel sounds before and after medication administration. During an interview, on 9/17/24 at 2:00 p.m., the DON indicated prior to medication administration per G-tube, placement should be checked per facility policy. Resident 31 was to receive his medications per G-tube. He had wanted to take his medications orally and get rid of his G-tube. His medications had gone back and forth between oral and G-tube routes with some medicines taken orally and others taken via G-tube. An interdisciplinary care plan meeting with the resident representative was held on 9/13/24. The resident's medication administration was discussed and it was decided that G-tube medication administration was preferred. After the medical provider's consent, the DON had updated the medication orders on 9/17/24 to administer all medications via G-tube as some had been listed per oral route. A current facility policy, revised 4/2017 and provided by the Administrator on 9/17/24 at 3:17 p.m., titled Medication Administration, indicated .Licensed or qualified personnel shall be responsible to follow accepted practices of medication administration as per physicians' orders . Medications are administered to residents only as prescribed . Always observe the six rights of giving each medication . right route A current facility policy, dated 10/2014, provided by the Administrator on 9/17/24 at 3:17 p.m., titled Tube Feedings (Naso-gastric or Gastrostomy Tubes) indicated .Medication Administration via Gastrostomy Tube: .Check placement by auscultating the resident's abdomen about 3 inches below the sternum with the stethoscope, gently insert 10 cc [cubic centimeters] of air into the tube. You should hear the bubble entering the stomach. If you hear this sound, gently draw back on the piston of the syringe. The appearance of gastric content implies that the tube is patent and in the stomach. If no gastric content appears, the tube may be against the lining of the stomach or the tube may be obstructed. If you meet resistance as you aspirate for stomach content, stop the procedure. After you establish the tube is patent and in the correct position . Administer each medication 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure a medication (insulin) was administered according to professional standards for 5 of 41 residents (Residents 8, 9, 22, 11, and 19), resulting in a medication administration error rate of 12.2%. Findings include: On 9/22/23 at 6:45 am, during a medication administration observation with the DON, she administered 2 units of insulin aspart to Resident 8. She did not prime the pen needle before administration, and held the pen in the resident's left upper arm for less than 3 seconds before withdrawing the needle. During an interview, on 9/22/23 at 6:50 a.m., the DON indicated it was her practice to hold the needle in the injection site for 2 to 3 seconds. On 9/22/23 at 6:53 a.m., the DON administered 30 units of insulin detemir to Resident 9. She did not prime the needle before administration, and held the needle in place for less than 2 seconds. On 9/22/23 at 7:00 a.m., the DON administered 14 units of insulin lispro to Resident 22. She did not prime the needle before administration, and immediately removed the needle from resident's right upper abdomen. On 9/22/23 at 7:07 a.m., the DON administered 15 units of insulin detemir to Resident 11. She did not prime the needle before administration, and held the needle in place for less than 2 seconds. On 9/22/23 at 7:15 a.m., the DON administered 19 units of insulin glargine to Resident 19. She did not prime the needle before administration, and immediately removed the needle from the resident's right upper abdomen. Resident 8's clinical record was reviewed on 9/22/23 at 8:13 a.m. They had a current diagnosis of type 2 diabetes mellitus and a physician's order for Novolog FlexPen U-100 Insulin (insulin aspart u-100) per sliding scale to be administered twice a day with breakfast and dinner. Resident 9's clinical record was reviewed on 9/22/23 at 8:30 a.m. They had a current diagnosis of type 2 diabetes mellitus and a physician's order for Levemir 30 units (insulin detemir u-100) every morning. Resident 22's clinical record was reviewed on 9/22/23 at 8:48 a.m. They had a current diagnosis of type 2 diabetes mellitus and a physician's order for Humalog KwikPen Insulin (insulin lispro) 12 units twice a day and sliding scale for coverage. Resident 11's clinical record was reviewed on 9/22/23 at 9:00 a.m. They had a current diagnosis of type 2 diabetes mellitus and a physician's order for Levemir FlexPen (insulin detemir u-100) 15 units twice a day. Resident 19's clinical record was reviewed on 9/22/23 at 9:22 a.m. They had a current diagnosis of type 2 diabetes mellitus and a physician's order for Basaglar KwikPen U-100 Insulin (insulin glargine) twice a day. A current facility policy, titled Insulin Injections, provided by the Infection Prevention Nurse on 9/25/23 at 11:35 a.m. indicated the following: Administering Insulin .6) Inject the insulin: Let go of the skin pinch before you inject the insulin. Push the plunger with your thumb at a moderate, steady pace until the insulin is fully injected. If using a syringe, keep the needle in the skin for 5 seconds. If using a pen, keep the needle in the skin for 10 seconds Review of a 2018 document titled Insulin Pen Injections, retrieved from https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections, on 9/26/23 at 11:45 a.m., indicated the following: .Prime the insulin pen. Priming means removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears . Insert the needle with a quick motion into the skin at a 90-degree angle. Slowly push the knob of the pen all the way in to deliver your full dose. Remember to hold the pen at the site for 6-10 seconds, and then pull the needle out 3.1-48(c)(1)

Based on interview and record review, the facility failed to ensure a resident's code status was correctly listed and readily available in the resident's electronic medical record (EMR) for 1 of 16 residents reviewed for advance directives (Resident 83). Finding includes: Resident 83's record was reviewed on [DATE] at 3:49 p.m. Diagnoses included left and right femur fractures, chronic obstructive pulmonary disease, abnormal electrocardiogram, acute respiratory failure with hypoxia, and chronic atrial fibrillation. Her physician's orders included code status DNR (do not resuscitate) initiated on [DATE]. A Code Status/Advance Directives form indicated the resident did not want to have CPR (cardiopulmonary resuscitation) performed as a life-saving measure. The form, signed by the resident on [DATE], was in the paper chart. The face sheet in the EMR lacked her code status. The Continuity of Care record in the EMR indicated, under the Advance Directives section, No Advance Directives are on file for this resident. During an interview, on [DATE] at 1:24 p.m., RN 4 indicated if the resident's code status was a DNR, then it would be listed on the resident's face sheet in the EMR. During an interview, on [DATE] at 12:52 p.m., LPN 5 indicated to find a resident's code status she would get the resident's paper chart as that was the fastest method for her. The code status should also be listed on the face sheet in the EMR. During an interview, on [DATE] at 2:18 p.m., the DON indicated the EMR face sheet should have the code status of a resident as the staff might utilize this record to determine code status. If a resident did not have advance directives, then CPR would be performed. She was uncertain why the Resident 83's code status was missing from the face sheet or why the Continuity of Care record indicated she did not have advance directives. During the interview, she checked recently admitted residents and determined a few others were missing the listing of code status on their face sheets. She was uncertain, but believed the previous office manager had entered the code status for the new residents. The new office manager was probably not aware of that duty. A current facility policy, dated ,d+[DATE], provided by the Administrator on [DATE] at 3:17 p.m., titled Advance Directives, indicated .Nursing personnel shall be notified of the presence of an Advance Directive on the clinical record and shall be instructed about the procedures to be followed to assure the resident's expressed wishes are honored 3XXX,d+[DATE](f)(5)

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 resident-to-resident altercations reviewed for abuse (Resident 9 and 26). Finding includes: During an interview, on 9/20/23 at 9:35 a.m., Resident 9 indicated another resident had hit her several months ago. She no longer went near the other resident because of the altercation. Resident 9's clinical record was reviewed on 9/20/23 at 3:40 p.m. Her diagnoses included paranoid schizophrenia, bipolar disease, major depressive disorder, recurrent, anxiety disorder, and pseudobulbar affect. An 8/8/23 quarterly Minimum Data Set (MDS) assessment indicated she was cognitively intact and had exhibited no behaviors during the assessment period. She utilized a walker and a wheelchair for mobility and was independent with locomotion off and on the nursing unit. A care plan for false allegations against staff, initiated 11/15/22 and last revised on 8/23/23, indicated the resident had a history of making false allegations against staff regarding care or lack of care, abuse, and neglect. On 5/3/23, false allegations against other residents was added. The goal was for the resident to voice concerns to staff, and staff will investigate as indicated per policy through next review. Interventions included to encourage resident to notify staff of concerns, to interview resident regarding concerns to gain detailed knowledge of neglect/abuse, and to follow the facility abuse policy and procedure. During an interview, on 9/21/23 at 10:28 a.m., the Administrator provided an investigation into an allegation of abuse by Resident 9, and indicated she had not reported the allegation to the State Agency because the allegation was false. The investigation of the resident altercation on 5/3/23 was reviewed on 9/21/23 at 10:34 a.m. The resident had alleged that Resident 26 had hit her because she (Resident 9) had stopped in front of her (Resident 26). The area Resident 26 hit (her arm) was sore. Resident 26 indicated she had asked Resident 9 to move, she did not so she tapped Resident 9 on the arm to get her attention and talked louder. Another resident witnessed the event and corroborated Resident 26's version. Review of the camera footage of the event by the Social Service Director and the Administrator corroborated Resident 26's statement. They concluded there was no abuse, and the allegation was false. Resident 26's clinical record was reviewed on 9/21/23 at 2:31 p.m. Her diagnoses included unspecified intellectual disabilities, psychotic disorder with delusions due to known physiological condition, unspecified psychosis not due to a substance or known physiological condition, vascular dementia, anxiety disorder, major depressive disorder, recurrent, mood disorder due to known physiological condition, visual hallucinations, violent behavior, and delusional disorders. A 4/21/23 annual MDS assessment indicated the resident was cognitively intact and had not exhibited behaviors during the assessment period. She utilized a walker and a wheelchair for mobility and was independent with locomotion off and on the nursing unit. During an interview, on 9/25/23 at 2:26 p.m., the Director of Nursing (DON) indicated all allegations of abuse were investigated. The allegations were reported to the Administrator. The Administrator determined whether they were to be reported to the State Agency. During an interview, on 9/25/23 at 2:38 p.m., the Administrator indicated she had investigated the incident within a few minutes of the allegation. She had statements from Resident 26 and another resident who indicated Resident 9 was lightly tapped on the arm to get her attention. She viewed the camera recording and confirmed their statements. Since the allegation was a false allegation, she did not report the incident. A current facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated 1/2015, and provided during the entrance conference on 9/19/23 by the Administrator, indicated .If resident abuse or suspicion of abuse, is reported .The Administrator, Director of Nursing, or designee, is responsible to notify the following agencies as applicable: State Department of Health .The Administrator is responsible to coordinate the investigation, assure an accurate and complete written record of the incident and investigation, and to file a follow-up report with the State Department of Health. Said reporting of alleged violations shall be conducted immediately but not later than two (2) hours if the alleged violation involves abuse or results in serious bodily injury; and not later than twenty-four (24) hours if the alleged violation involved neglect exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury 3.1-28(e)

Based on observation, interview, and record review, the facility failed to ensure the results report from the last annual Indiana Department of Health (IDOH) survey were posted at an accessible height and in a readily accessible location for 2 of 2 residents interviewed in a group setting (Residents 4 and 5). This deficient practice had the potential to impact 34 of 34 residents/or representatives for those residents who resided in the facility. Findings include: During an observation on 9/20/23 at 9:28 a.m., a sign was posted in the lobby which indicated the last annual IDOH survey report was posted in the activity room. During an observation on 9/20/23 at 9:29 a.m., a sign identifying the activity room could not be located. Following directions received, the activity area was located on the B Hall. During an observation on 9/20/23 at 9:33 a.m., the last annual IDOH survey report was observed in a wall mounted box hanging approximately 5 feet from the ground, inside the activity room. The box had no labeling to indicate the binder was the survey report. By standing upright, and looking down on the spine of the binder, the label could be read. During a resident group interview on 9/21/23 at 3:04 p.m., 2 of 2 awake residents (Residents 4 & 5) indicated they would not be able to obtain and review the last annual IDOH survey results without assistance because they could not reach the report where it was posted. During an observation on 9/25/23 at 9:19 a.m., a direction sign, located at the end of the hall leading to the dining room and therapy area, indicated the activity room was located on this hall. There was no activity area located on this hallway, as the activity room was observed in the B Hall. During on interview on 9/25/23 at 9:21 a.m., the Administrator indicated the directions signs located at the end of each hallway had not been changed since her arrival in 2020. During an observation and interview in the activity room on 9/25/23 at 10:30 a.m., the Activity Director and Administrator indicated an individual would need to stand to reach the annual IDOH survey report binder. Review of a current, undated, facility policy titled, Resident Rights, provided by the Administrator during the 9/19/23 entrance conference and located in a survey preparedness binder, indicated the following: .The resident has the right to .Examine the results of the most recent survey of the facility conducted by Federal or State survey on and any plan of correction in effect with respect to the facility; and the facility must-- Post in a place readily accessible to residents, and family members .the results if the most recent survey of the facility .Post notice of availability of such report in areas of the facility that are prominent and accessible to the public 3.1-3(b)(1)

Based on record review and interview, the facility failed to report misappropriation of a resident's property related to missing morphine to law enforcement and to the Indiana Department of Health (IDOH) for 1 of 3 residents reviewed for misappropriation of property (Resident B). Findings include: During an interview with the Administrator, on 8/14/23 at 1:03 p.m., she indicated she received a call, not an allegation, from QMA 4 about Resident B's bottle of morphine, there was thought to be two bottles of morphine but only one was in the narcotic drawer. It was investigated, they looked for the bottle and couldn't see where he had two bottles. Education was provided to the staff and she came up with a form to count cards and bottles. During an interview with QMA 4, on 8/14/23 at 2:09 p.m., she thought there were two bottles of morphine but she wasn't 100% sure, she reported it to management. She did a narcotic count in the morning with RN 8, there was only one bottle but thought there had been two bottles, when she counted with LPN 15, in the evening, LPN 15 also thought there had been two bottles. QMA 4 remembered there was 18.75 mls left in his bottle because she was the last one that gave him morphine. During an interview with LPN 15, on 8/15/23 at 10:13 a.m., she indicated the last day she worked was 7/20/23 and there were two bottles of morphine for Resident B. During shift change, on 7/24/23 at 6:00 p.m., she did a narcotic count with QMA 4 and there was only one bottle of morphine in the drawer. QMA 4 indicated to her that there was only one bottle during narcotic count that morning. They were unable to find the narcotic count sheet or a disposition sheet so they called the DON. She was drug tested and in-serviced. During a follow up interview with QMA 4 on 8/15/23 10:31 a.m., with the ADON present, she indicated the last day she had worked was 7/21/23 and thought there had been two bottles. The DON had them look in all medication carts and the medication room. She distinctly remembered there was 18.75 ml that was left in the one bottle of morphine, because that was the count for quite some time. During an interview with the Administrator on 8/15/23 at 10:49 a.m., with the ADON present, she indicated they reviewed the camera footage, checked the shred box, the trash and the whole facility. They did drug screening, counted all the narcotics and took statements. They thought, maybe, there were not two bottles. They called the pharmacy to find out who requested the morphine to be filled on 7/11/23 but they couldn't tell her. They couldn't find the narcotic sheet for the missing morphine. She did not complete a police report or report to IDOH. They could not prove there was a missing bottle or conclude there was a second bottle. A current facility policy, dated 10/2014, titled DRUG DIVERSION, and provided by the Administrator on 8/15/23 at 8:43 a.m., indicated the following: POLICY: Should the facility note missing medication(s) indicative of possible drug diversion, the following steps shall be take and notifications made to applicable regulatory agency. PROCEDURE .2. Contact local law enforcement .3. Prepare an initial Reportable Incident to be forwarded to the State Department of Health (SDH) Cross reference F602. This Federal tag relates to complaint IN00414782. 3.1-28(c)

Based on interview and record review, the facility failed to ensure narcotic medication was free from diversion for 1 of 3 residents reviewed for misappropriation of resident property (Resident B). Findings include: Resident B's clinical record was reviewed on 8/14/23 at 2:47 p.m. Diagnoses included encounter for palliative care, anxiety disorder, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and chronic pulmonary edema. His current medications included morphine concentrate 0.25 ml (milliliter) every two hours as needed for shortness of breath or pain. Review of a Consolidated Delivery Sheet indicated, on 9/23/22 at 11:15 p.m., the pharmacy delivered a 30 ml bottle of morphine sulfate 100 mg/5 ml and it was signed for by a nurse at the facility. Review of the resident's MARs (Medication Administration Records) indicated the following: In September 2022, he was not administered morphine for the entire month. In October 2022, he was administered morphine 0.25 ml on 10/31/22. In November 2022, he was not administered morphine for the entire month. In December 2022, he was administered 0.25 mls of morphine, on 12/3/22 at 11:43 p.m., 12/8/22 at 4:21 p.m., 12/11/22 at 2:29 a.m., 12/13/22 at 2:30 p.m., and 12/21/22 at 7:22 p.m. In January 2023, he was not administered morphine for the entire month. In February 2023, he was not administered morphine for the entire month. In March 2023, he was administered 0.25 mls of morphine, on 3/1/23 at 7:38 p.m., 3/15/23 at 3:35 p.m., and 3/23/23 at 12:11 p.m. In April 2023, he was administered 0.25 mls of morphine, on 4/11/23 at 7:48 a.m. and at 9:53 p.m. In May 2023, he was administered 0.25 mls of morphine on 5/1/23 at 10:15 a.m. In June 2023, he was administered 0.25 mls of morphine on 6/14/23 at 9:45 a.m. In July 2023, he was administered 0.25 mls of morphine on 7/12/23 at 5:36 p.m. Review of a Consolidated Delivery Sheet indicated, on 7/11/23 at 10:35 p.m., the pharmacy delivered a 30 ml bottle of morphine sulfate 100 mg/5 ml and it was signed for by a nurse at the facility. During a narcotic count of the D hall medication cart with LPN 12, on 8/14/23 at 11:42 a.m., Resident B had one unopened and sealed 30 ml bottle of morphine. Review of the facility's investigation of a suspicion of diversion of Resident B's morphine was provided by the Administrator on 8/15/23 at 10:49 a.m., and indicated the following: A handwritten statement by LPN 15 indicated she remembered, on 7/20/23, there were two bottles of Roxanol (morphine) for Resident B. When she came to work, on Monday 7/24/23, during the narcotic count, she noticed there was only one bottle of Roxanol. She immediately called the DON. A handwritten statement by QMA 18 indicated on 7/21/23 at 2:00 p.m., when she counted with QMA 4, there were two boxes each containing a bottle of morphine, one opened and one unopened. At 6:00 p.m. the count was normal. There were still two bottles/boxes of morphine. A handwritten statement by QMA 4 indicated on Monday 7/24/23, when she counted with RN 8, she realized Resident B had one box of morphine missing. She was going to mention something to the DON about it not being in there, she just was going to make sure it wasn't discontinued, but she got busy and spaced it. At 6:00 p.m., when she was giving LPN 15 report and counted narcotics, LPN 15 also mentioned something about Resident B having two boxes of the morphine. She told LPN 15 she knew it and she was meaning to talk to the DON about it, but got busy and spaced it. LPN 15 also found it very odd, so she called the DON and the DON had them look in the medication room and a couple offices. They didn't find any trace of the morphine or the narcotic count sheet document. During an interview with the Administrator, on 8/14/23 at 1:03 p.m., she indicated she received a call, not an allegation, from QMA 4 about Resident B's bottle of morphine. There was thought to be two bottles of morphine but only one was in the narcotic drawer. It was investigated, they looked for the bottle, and couldn't find where he ever had two bottles. Education was provided to the staff and she came up with a form to count both cards and bottles. During an interview with QMA 4, on 8/14/23 at 2:09 p.m., she thought there were two bottles of morphine but she wasn't 100% sure. She reported it to management. When she did a narcotic count in the morning with RN 8, there was only one bottle but thought there had been two bottles. When she counted with LPN 15 in the evening, LPN 15 also thought there had been two bottles. QMA 4 remembered there was 18.75 mls left in his bottle because she was the last one that gave him morphine. During an interview with LPN 15, on 8/15/23 at 10:13 a.m., she indicated the last day she worked was 7/20/23 and there were two bottles of morphine for Resident B. During shift change, on 7/24/23 at 6:00 p.m., she did a narcotic count with QMA 4 and there was only one bottle of morphine in the drawer. QMA 4 indicated to her that there was only one bottle during narcotic count that morning. They were unable to find the narcotic count sheet or a disposition sheet so they called the DON. During a follow up interview with QMA 4 on 8/15/23 10:31 a.m., with the ADON present, she indicated the last day she had worked was 7/21/23 and thought there had been two bottles. The DON had them look in all medication carts and in the medication room. She distinctly remembered there were 18.75 ml left in the one bottle of morphine, because that was the count for quite some time. During an interview with the Administrator on 8/15/23 at 10:49 a.m., with the ADON present, she indicated they reviewed camera footage, checked the shred box, the trash, and the whole facility. They did drug screening, counted all the narcotics and took statements. They thought maybe, there were not two bottles. They called the pharmacy to find out who requested the morphine to be filled on 7/11/23 but they couldn't tell her. They couldn't find the narcotic sheet for the missing morphine. She did not complete a police report or report it to the Indiana Department of Health. They could not prove there was a missing bottle, or conclude there was a second bottle. A 1/2015, current facility policy, titled ABUSE PROHIBITION, REPORTING AND INVESTIGATION, provided by the Administrator on 8/15/23 at 8:43 a.m., indicated the following: POLICY: This facility shall prohibit and prevent .misappropriation of resident property .Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .2. The facility shall ensure that all alleged violations, including .misappropriation of resident property .are reported immediately to the administrator of the facility This Federal tag relates to complaint IN00414782. 3.1-28(a) 3.1-28(c)

Based on observation, record review and interview, the facility failed to revise a resident's care plan after a significant change in status with the placement of a new gastrostomy tube (g-tube) for 1 of 8 residents' care plans reviewed. (Resident 20) Finding includes: On 9/27/22 at 1:58 p.m., Resident 20 was in bed with her eyes closed. The head of the bed was elevated. A pump was hooked to the resident's feeding tube infusing Vital AF (liquid therapeutic nutrition) at 54 milliliters (mL) per hour. The resident's clinical record was reviewed on 9/27/22 at 2:29 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS) assessment, completed on 9/5/22, indicated the resident had a feeding tube. An eating care plan, initiated 5/3/22 with last revision date of 9/9/22, indicated the resident required staff assistance with meal consumption. The goal indicated the resident would receive necessary assistance, cueing, and supervision necessary to consume 75-100% of meals through next review. The interventions included, but were not limited to, the staff would set up meals, assist resident, and encourage resident at each meal and staff would ensure resident was seated in environment which would provide staff assistance and encourage meal consumption. The resident's clinical record lacked a care plan for a feeding tube. A Nurse's Note, dated 8/10/22 at 12 a.m., indicated the resident was NPO after midnight due to g-tube placement scheduled in the morning A Nurse's Note, dated 8/10/22 at 1:45 p.m., indicated the resident returned to the facility with a g-tube A Nurse's Note, dated 8/11/22 at 12:30 a.m., indicated the resident was sent to the hospital for signs and symptoms of severe abdominal pain. A Nurse's Note, dated 8/27/22 at 10:00 p.m., indicated the resident returned to the facility from the hospital with a g-tube. A Nurse's Note, dated 9/7/22 at 10:45 p.m., indicated the resident received all medications and feeding per g-tube. During an interview, on 9/28/22 at 11:56 a.m., the Director of Nursing (DON) indicated the resident's care plan for the feeding tube had been in the MDS nurse's office. A feeding tube care plan was provided with an initial date of 9/2/22 and revision date of 9/9/22. She indicated the resident's eating care plan which indicated the resident required staff assistance for meal consumption was discontinued today. She indicated it should have been discontinued when resident came back from the hospital on 8/27/22. She indicated Speech Therapy was currently evaluating the resident to see if the resident could safely consume pleasure foods. During an interview, on 9/29/22 at 1:24 p.m., Certified Nurse Aide (CNA) 2 indicated she used a CNA sheet to know what care a resident required. During an interview, on 9/29/22 at 1:25 p.m., CNA 3 indicated she used a CNA sheet for reference on what care or interventions a resident needed. She pulled the CNA sheet out of her pocket. Review of a facility record, titled Certified Nursing Assistant Assignment Sheet, dated 9/26/22 and provided by the Assistant Director of Nursing on 9/29/22 at 1:30 p.m., indicated the resident received thickened liquids and lacked diet instructions. During an interview, on 9/29/22 at 3:35 p.m. the DON indicated the staff should not be feeding the resident by mouth since return from the hospital on 8/27/22. She would expect the resident to have the speech therapy evaluation and recommendation prior to giving the resident anything by mouth. A current policy, titled Care Plan Development and Review and provided by the Administrator on 9/29/22 at 3:38 p.m., indicated .The comprehensive care plan shall be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to serve appetizing and palatable meals to residents. Findings include: During a Resident Council interview, on 6/29/21 at 1:35 p.m., the council attendees indicated the facility food was overcooked, mushy and unappetizing. They had to eat a lot of peanut butter and jelly sandwiches, chicken noodle soup, and lunchmeat and cheese sandwiches instead of the meals due to the poor quality of the food. They served a lot of mashed potatoes. They felt supper was the worst, and they frequently ordered out, which got to be expensive and not everyone could afford to. If they did ask for seconds of a food item, they were frequently told they had run out of food. During observation of a sample tray, on 7/1/21 at 11:11 a.m., the meal contained a small amount of shredded lettuce, a very small amount of shredded cheese, two tomato wedges, and a small amount of ground up cooked chicken. The salad serving covered less than half of the plate. There was a small packet of ranch dressing on the tray and a cup of chocolate pudding with whipped topping. The chicken lacked seasoning when tasted and the tomato wedges were hard and light in color. The pureed entree was a chicken and bread mixture, covered in brown gravy, and a scoop of mashed potatoes, covered in brown gravy. A cup of pudding and whipped topping was included on the meal tray. There was no vegetable offering. The chicken entree was very salty when tasted. During a meal observation, on 7/1/21 at 11:34 a.m., the meals served in the dining room had a small amount of shredded lettuce, a very small amount of shredded cheese, and a small amount of ground up cooked chicken with two tomato wedges. The pureed diet meals were a serving of the chicken entree with gravy, potatoes with gravy, and pudding. There was no vegetable offering with the meals. During an interview, on 7/1/21 at 11:51 a.m., Resident 23 indicated her lunch felt like diet food. She did not receive salad dressing with her meal. During an interview, on 7/2/21 at 9:08 a.m., the Dietary Manager indicated the residents had complained previously to him of the food not being as tasty as it could be. They have been re-training staff on preparation of the food served. The residents receiving pureed meals with the salad the day before were supposed to get tomato juice, but they didn't have any. During an interview, on 7/2/21 at 9:34 a.m., with the Administrator and Dietary Manager, the Administrator indicated the facility had experienced some food complaints, but a lot of the residents chose to have the chicken noodle soup or ham sandwiches instead of the planned meal. 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, interview, and record review, 44 opportunities of medication administration were observed and 4 of the 44 medications were not administered in accordance with physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During a medication administration observation on 7/1/21 at 8:02 a.m., the following was observed: QMA 24 prepared polyethylene [MEDICATION(S)] (laxative) powder for Resident 19 by measuring approximately 30 mL of powder in a medication cup. She poured the powder into a cup of liquid and mixed it. She indicated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/1/21 at 8:11 a.m., LPN 33 prepared a [MEDICATION(S)] (long acting insulin) pen for Resident 12 to inject 15 units. She did not prime the pen prior to dialing to 15 units. She then drew up three units of Novolog (rapid acting insulin) into a syringe after confirming his blood sugar with QMA 24. She administered the insulins to the resident in his lower abdomen. She did not sign off on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 7/1/21 at 8:55 a.m., LPN 33 indicated she should have primed the [MEDICATION(S)] pen with 2 units and should have signed the MAR, but she did not have a pen with her. On 7/1/21 at 8:20 a.m., QMA 24 prepared Resident 5's oral medications. After administration of the medications, she returned to the MAR. She had failed to administer the resident's [MEDICATION(S)] (antibiotic), went past the order as she signed off the medications administered, and did not note the omission until asked. She indicated she had missed the medication on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 12's medication orders were reviewed on 7/1/21 at 10:03 a.m. He had a current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . His next scheduled blood glucose check and Novolog insulin administration was scheduled for 11:00 a.m. Resident 5's medication orders were reviewed on 7/1/21 at 10:25 a.m. She had a current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/1/21 at 10:30 a.m., the DON indicated the insulins should have been administered as ordered. On 7/1/21 at 10:37 a.m., the ADON was observed to enter Resident 5's room to administer her insulin. During an interview, on 7/1/21 at 10:39 a.m., LPN 33 indicated she had administered an additional 20 units of Novolog to Resident 12 at around 9:45 a.m., after she had noted the omission when she signed off his MAR. Review of a current facility policy titled MEDICATION ADMINISTRATION, dated 4/2017 and provided by the DON on 7/1/21 at 3:39 p.m., indicated the following: .Always record the dose of medication on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a [MEDICATION(S)] informational document, provided by the Nurse Consultant on 7/1/21 at 3:40 p.m., indicated the following: .For [MEDICATION(S)] Flex Touch pen, prime the needle before each injection with 2 units of insulin

Based on observation, interview, and record review, the facility failed to ensure the dish machine was operated with the correct amount of sanitizer during a random observation of dish washing. Findings include: During the intial tour of the facility kitchen, on 6/28/21 at 8:59 a.m., Dietary Aide 35 was washing dishes in the dish machine. She indicated the machine used chlorine to sanitize the dishes. When she tested the chemical composition of the machine, she placed a litmus paper in the machine during the water rinse cycle. When the paper did not turn color, she attempted again while the machine was in the wash cycle. The Dietary Manager indicated the paper did not show the correct parts per million (ppm). The Dietary Manager and the Dietary Aide both confirmed they were not aware of when in the dish machine cycle to test for the correct amount of sanitizer. Review of a current facility policy titled Testing Sanitizer Concentration in Low Temperature Dish Machines, dated 5/2018 and provided by the Dietary Manager on 7/2/21 at 9:48 a.m., indicated the following: .Dip strip into un-agitated rinse water 3.1-21(l)(3)

Based on observation, interview, and record review, the facility failed to ensure pressure injuries were staged according to professional standards to ensure adequate treatment and failed to develop individualized interventions to promote healing for 2 of 4 residents reviewed for pressure injuries (Residents 31 and 38). Findings include: 1. On 6/30/21 at 8:09 a.m., Resident 31 was seated in her wheelchair in the family room with an orthopedic boot on her left foot. Review of Resident 31's clinical record was completed on 6/28/21 at 10:20 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had current, 5/1/21, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 7/1/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/8/21, quarterly, Minimum Data Set (MDS) assessment indicated she was moderately cognitively impaired and required extensive assistance with her ADLs and locomotion. She had one stage 2 pressure injury (partial thickness skin loss with a superficial ulcer presenting as an abrasion, blister or shallow crater) and two suspected deep tissue injuries (DTI) (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister) which were present upon admission to the facility. She had an active infection to one of her feet. She had a current, 3/3/21 care plan problem of a DTI to her left heel and left lateral foot. Interventions included, but were not limited to, treatment as ordered, monitor for progress in healing, and pressure relieving devices in place. The care plan lacked interventions addressing her feet, specifically. She had a current, 5/20/21, care plan problem of a pressure reducing or low air loss mattress. She had a current, 5/19/21, care plan problem of risk for pressure injury. The care plan did not address interventions specific to her feet. Review of a 3/3/21 hospital discharge note indicated she had a wound present to her left heel. Review of a facility Pressure Ulcer Assessment document indicated, but was not limited to, the following: On 3/3/21, she was admitted to the facility with a 5 centimeter (cm) long (L) x 3 cm wide (W) deep tissue injury to her left lateral foot, which was dark purple in color. On 3/30/21, the DTI was 5 cm L x 3 cm W, and was dark purple with a hard callous present. On 4/6/21, it remained a DTI, measuring 2 cm L x 1.5 cm W and was dark purple and hard, with irregular wound edges. On 4/13/21, it remained a DTI, measuring 4 cm L x 3 cm W and was dark purple with hard, yellow, calloused edges and irregular wound edges. On 5/11/21, it remained a DTI, measuring 2.5 cm L x 2 cm W x less than 0.1 cm depth. The wound bed was dark purple and hard, with irregular wound edges. On 5/25/21, it remained a DTI, measuring 2.2 cm L x 2.2 cm W x less than 0.1 cm depth with a dark purple wound bed and irregular, pink wound edges. On 6/1/21, it remained a DTI, measuring 2 cm L x 2.1 cm W, with a dark, hard callous and irregular wound edges. On 6/22/21, it remained a DTI, measuring 2 cm L x 1.5 cm W with no depth, but had a white/pink wound bed. On 6/29/21, it remained a DTI, measuring 2 cm L x 1.5 cm W x 0.2 cm depth and a white/red wound bed. Review of a facility Pressure Ulcer Assessment document indicated, but was not limited to, the following: On 3/3/21, she was admitted to the facility with a 3 cm L x 3 cm W DTI to her left heel, which was dark purple in color. On 3/30/21, it remained a DTI, measuring 3.8 cm L x 2.1 cm W, with a dark, hard callous present and a dark purple wound bed. On 4/6/21, it remained a DTI, measuring 4.7 cm L x 3.2 cm W, with a dark purple, hard wound bed and irregular wound edges. On 4/13/21, it remained a DTI, measuring 5.5 cm L x 4.5 cm W, with a hard, dark purple wound bed and yellow calloused wound edges. On 5/4/21, it remained a DTI, measuring 4.5 cm L x 5 cm W x less than 0.1 cm depth, with a dark purple wound bed. On 6/1/21, it remained a DTI, measuring 3.3 cm L x 3.6 cm W and a dark callous present to the wound bed. On 6/15/21, it remained a DTI, measuring 3 cm L x 3.7 cm W, with a dark red callous present to the wound bed. On 6/29/21, it remained a DTI, measuring 3 cm L x 3 cm W x less than 0.1 cm depth and a dark callous present to the wound bed. Review of a 4/29/21 Nurse Practitioner note indicated a small necrotic area to her left foot wound, with increased pain. An oral antibiotic was ordered and she was to start wearing pressure relieving boots. Review of a 6/9/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a wound care observation, on 7/1/21 at 2:11 p.m., accompanied by LPN 8, Resident 31's left lateral foot wound was open and approximately the size of a nickel, with a pink wound bed at the edges, and a small amount of thick, white tissue in the center. The wound to her left heel was open with a small amount of thick, white tissue in the center, approximately the diameter of a golf ball. In the center of the wound, a hard, dark piece of tissue was approximately the size of a quarter. During an interview, on 7/2/21 at 10:05 a.m., the DON indicated she was not aware Resident 31's wounds were open; they had previously been covered with dark scabs. She would have expected the medical provider to be contacted to change the treatment when the wound opened. During an interview, on 7/2/21 at 12:54 p.m., the Nurse Consultant indicated the facility had notified the Nurse Practitioner on 7/1/21 to clarify the wound care order to add using the dressings. 2. On 7/2/21 at 8:20 a.m., Resident 38 was seated in his wheelchair with socks on. Resident 38's clinical record was reviewed on 6/29/21 at 10:03 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/20/21, quarterly, MDS assessment indicated he was severely cognitively impaired and required extensive assistance with locomotion and did not walk. He had no skin issues and no foot problems. He had a current, 5/29/21, care plan problem of open [CONDITION(S)]/scab to his left pinky toe, tip of right big toe, and right pinky toe. Interventions included to treat as ordered and to monitor the areas. There were no interventions specific to his feet or not wearing shoes. He had a current, 6/3/21, care plan problem of risk for pressure ulcers. A 2/25/21 Nurse Practitioner note indicated he had been discharged from hospice services. A 5/10/21 Nurse Practitioner note indicated he had a stage 2 (a partial-thickness loss of skin with exposed dermis) pressure injury. Review of a non-pressure skin condition document indicated a 5/9/21 right great toe abrasion, measuring 1.4 L x 1.5 W x less than 0.1 cm depth, with a dry, pink wound bed. On 6/12/21, it measured 0.6 cm L x 0.5 cm W x less than 0.1 cm depth, and had a moist, pink wound bed. On 6/26/21, it measured 0.5 cm L x 0.5 cm W x less than 0.1 cm cm depth and had a calloused pink wound bed. Review of a non-pressure skin condition document indicated a 5/29/21 right pinky toe scab, measuring 0.5 cm L x 0.3 cm W x less than 0.1 cm depth and a dark purple wound bed. On 6/26/21, it measured 0.5 cm L x 0.2 cm W x less than 0.1 cm depth, with a dark purple wound bed. Review of a non-pressure skin condition document indicated a 5/29/21 left pinky toe scab, measuring 0.4 cm L x 0.5 cm W x less than 0.1 cm depth and a dark purple wound bed. On 6/26/21, it measured 0.4 cm L x 0.3 cm W x less than 0.1 cm depth, with a dark purple wound bed. During a wound observation, on 7/2/21 at 8:35 a.m., with the ADON, Resident 38's left 5th toe had a scab present to the top of his knuckle, approximately the size of a pencil-top eraser. His left great toe was absent. His right great toe had a scab to top of the toe, approximately the size of a flat thumbtack; his right 5th digit had a scab to the top of his knuckle, approximately the size of a pencil-top eraser. The ADON indicated, at the time of the observation, the wounds had been caused by his shoes, which he no longer wore. During an interview, on 7/2/21 at 10:05 a.m., the DON indicated the facility had not considered his wounds to be pressure injuries, as they had been caused by his shoes being too large, which rubbed his toes, not from the shoes being too tight. Review of a current facility policy, titled PRESSURE ULCERS, dated 10/2014 and provided by the DON on 7/2/21 at 10:25 a.m., indicated the following: .PURPOSE: To assure that residents with pressure ulcers will receive necessary care and treatment to promote healing, prevent new ulcers from developing and prevent infection .Treatment orders will be reviewed periodically (approximately every 2-4 weeks) for efficacy .Interventions to prevent further pressure ulcer formation shall be initiated Review of a 2016 document titled NPIAP [National Pressure Injury Advisory Panel] Pressure Injury Stages, retrieved from npiap.com, indicated the following: .Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4) 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to monitor fluid intake amounts for 1 of 3 residents reviewed on a physician-prescribed fluid restriction (Resident 33). Findings include: On 6/29/21 at 2:25 p.m., Resident 33 was near the nurses station, requesting ice water from a staff member who was passing ice water. The staff member indicated she had just put some water in his room. She gave him another cup of ice water to drink while he was seated near the nurses station. On 6/30/21 at 8:04 a.m., he was in bed. His partially eaten breakfast tray had been placed on the meal cart, with milk and juice in regular cups, both full , with the lids still on. On 6/30/21 at 11:27 a.m., the resident was seated in his wheelchair in his room with his meal tray in front of him. He had a foam, pre-packaged cup of ice cream and a large Kennedy cup each of milk and a colored liquid. Both cups were filled to just below the top. On 7/1/21 at 11:25 a.m., his breakfast tray remained in his room, with two large, empty Kennedy cups on the tray. Review of Resident 33's clinical record was completed on 6/29/21 at 9:39 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/14/21, significant change, Minimum Data Set (MDS) assessment indicated he was moderately cognitively impaired. He had an undated Fluid Distribution Sheet in his care plan folder, which indicated a total of 1500 mL daily. He was to receive 240 mL of fluid at each meal and 60 mL at 2:00 p.m. and at bedtime from the dietary department, for a total of 840 mL. He was to receive 220 mL from the nursing department on each shift, for a total of 660 mL. Review of meal intake documentation for June 2021 indicated he exceeded 840 mL from dietary for meals 16 of 30 days. Review of the June 2021 medication and treatment records did not indicate amounts of fluids taken by the resident with his ordered medications and supplements. There was no indication of a review of total daily fluid intakes. During an interview, on 7/1/21 at 1:38 p.m., CNA 43 indicated she was not aware of Resident 33 being on a fluid restriction. During an interview, on 7/1/21 at 1:39 p.m., QMA 18 indicated she was not aware of Resident 33 being on a fluid restriction and was not aware of any documentation required for intake regarding medications and treatments. During an interview, on 7/1/21 at 1:41 p.m., the DON indicated fluids were documented on the resident's meal and fluid consumption record. Medication documentation did not include amounts consumed with medications. During an observation of the facility's resident snack pantry, on 7/1/21 at 3:19 p.m., the nutritional ice cream was supplied in a six-ounce container and the health shakes in a four-ounce container. Review of a current facility policy, titled FLUID RESTRICTION, dated 10/2014 and provided by the DON on 7/2/21 at 10:25 a.m., indicated the following: .Restriction of fluid is often necessary when excessive fluid intake could jeopardize resident condition .Intake will be monitored in an effort to evaluate resident compliance .Fluids are substances which are liquid at room temperature .These include .ice cream .Should a resident choose to exercise his/her right, relative to medical treatment, and not comply with fluid restriction, the physician should be notified and the same documented in the clinical record 3.1-37(a)

A. Based on observation, interview, and record review, the facility failed to ensure supervision of residents to prevent the use of regular liquids for a resident with physician orders for thickened liquids during a random observation (Resident 12). B. Based on observation, interview, and record review, the facility failed to ensure a resident injury was assessed, monitored, reported to the appropriate parties, and to develop interventions to promote healing and prevent reoccurrence for 1 of 1 random observations of a large skin tear (Resident 37). Findings include: A. On 6/28/21 at 2:19 p.m., Resident 12 was observed to approach a medication cart at the nurses station, where a cup of water was sitting on top of it. He picked up the cup of water and drank all of the contents. There was no staff in the vicinity of the nurses station. When the observation was reported to LPN 16, she indicated he was to receive thickened liquids; he would guzzle drinks, which was why he was on thickened liquids. At the time of the observation, the resident continued to ambulate throughout the facility, and LPN 16 continued passing medications. On 6/29/21 at 9:39 a.m., Resident 12 was walking in the hallway, asking staff for a drink of water. Resident 12's clinical record was reviewed on 6/28/21 at 2:30 p.m. Diagnoses included, but were not limited to, [CONDITION(S)] depression, moderate mental [CONDITION(S)], diabetes type 1, and [CONDITION(S)] He had current physician orders for, but not limited to, pureed diet with nectar thickened liquids; may have mechanical soft for special occasion only with direct supervision. A 4/3/21, quarterly, Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired. He had a current, 4/21/21 nutrition care plan, which indicated he received a pureed diet with nectar thick liquids. He would eat too fast and had a swallowing disorder. Review of a nurses note, dated 6/28/21 at 12:00 p.m., indicated the resident chugged a glass of water at the nurses station, which was a thin liquid. A full respiratory assessment had been completed. Review of a current facility policy titled THICKENED LIQUIDS, dated 10/2014 and provided by the DON on 7/2/21 at 10:25 a.m., indicated the following: .PURPOSE: To ensure thickened liquids are provided as ordered for those residents who have been deemed unsafe to consume thin liquids .Should thickened liquids be appropriate, facility personnel shall ensure that resident receives liquids at the consistency ordered by physician B. During a random observation, on 6/28/21 at 10:21 a.m., Resident 37 was seated in her high backed wheelchair, with a large skin tear to her right forearm with skin closure strips present and dark purple discoloration surrounding the skin tear from her elbow to her wrist. Review of Resident 37's clinical record was completed on 6/28/21 at 2:10 p.m. Diagnoses included, but were not limited to, dementia and [CONDITION(S)]. A 5/19/21, quarterly, MDS assessment indicated she was severely cognitively impaired. Review of the resident's clinical record lacked information on the cause of her skin tear, treatment orders, nor goals for healing of the skin tear. The clinical record lacked notification of the medical provider and the resident's representative. During an interview, on 6/30/21 at 1:35 p.m., the DON indicated she was not aware of the skin tear. During an interview, on 6/30/21 at 2:03 p.m., the DON indicated she had not been notified of the resident sustaining a skin tear. The facility had determined it had occurred the prior Sunday (6/27/21) morning at shift change, when she had become combative during ADL cares. She had cut her arm with her own fingernail. The staff involved should have immediately reported it to the nurse on duty, who would have then reported it to the DON, the medical provider, and the resident's representative. At the time of the interview, she had not able to reach the nurses involved and was not aware of who had place the skin closure strips. Review of a 6/30/21 nurses note indicated the skin tear measured 5 centimeters (cm) long x 2.5 cm wide. Review of a current facility policy, titled ACCIDENT AND INCIDENT REPORTING, dated 10/2014 and provided by the Nurse Consultant on 6/30/21 at 2:12 p.m., indicated the following: .A written description of circumstances surrounding the incident is to be completed and submitted to the nursing supervisor as soon as possible during the tour of duty in which the incident occurred .after appropriate assessment and necessary emergency intervention is completed . 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review the facility failed to prevent a resident (Resident 40) from hitting another resident (Resident 19) in the face for 1 of 2 residents reviewed for abuse (Resident 19). Findings include: 1. [NAME] During an interview, on 11/12/19 at 10:53 a.m., Resident 19 indicated he had an altercation with Resident 40. Resident 40 was coming into his room and they were both at the entrance door to his room and he was starting to push on Resident 40's wheelchair to get him out of his room and Resident 40 hit him with a closed fist on the right side of his mouth and his mouth bled. The manager was told, it happened on a weekend, he talked to the police because he wanted charges filed on Resident 40, the police told him he didn't have a leg to stand on. The Administrator was aware and asked him if he wanted to move rooms and he did not want to move so they moved Resident 40 to the other hall. Resident 19's clinical record was reviewed on 11/13/19 at 11:18 a.m. [DIAGNOSES REDACTED]. His current medications included, but were not limited to, [MEDICATION NAME] (treat [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]) 500 mg (milligram) every morning, [MEDICATION NAME] 750 milligram (mg) every evening, [MEDICATION NAME] (anti-anxiety) 0.5 mg every morning, [MEDICATION NAME] 0.25 mg every evening, [MEDICATION NAME] HCL ([MEDICATION NAME]) (anti-depressant) 20 mg everyday and [MEDICATION NAME] (treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 1 mg twice daily and [MEDICATION NAME] (anti-anxiety) 5 mg twice daily. An annual, Minimum Data Set (MDS) assessment, dated 9/13/19, indicated the resident was cognitively intact. He required limited assistance of one staff member for transfers and walking in his room. He was independent with locomotion on and off the unit and he used a cane or wheelchair. He had an impairment to both sides of his lower extremities. He did not exhibit verbal or physical behaviors directed towards others. A Fear and Anxiety focused care plan, revised on 10/3/19, indicated the resident had a potential for fear and anxiety due to an incident on 9/7/19. Interventions included, but were not limited to, observe for signs and symptoms of anxiety or depressive symptoms such as crying, change in eating or sleeping patterns, isolation, etc., provide one to ones as needed, encourage the resident to voice all problems and concerns, provide reassurance as needed. A review of a facility reported incident, occurring 9/7/19 at 10:01 a.m. indicated a Respiratory Nurse was preparing to administer an aerosol treatment down the hall, when she heard Resident 19 yelling get out of here, you cant be in here. She immediately went to Resident 19's room where she found Resident 40 sitting in his wheelchair in the doorway of Resident 19's room. Resident 19 stated Resident 40 had opened his door. Resident 19 then shouted for him to leave, and tried to back his wheelchair up and Resident 40 swung his arms and hit Resident 19 in the face. Both residents were immediately assessed by a licensed nurse. No injuries were noted to Resident 40, and Resident 19 sustained a 1 cm (centimeter) x 0.1 cm laceration to his right inner lip. Both residents were immediately separated and placed on one to one with staff. Administrator, DON, MD (Medical Doctor), and POA's (Power of Attorney's) notified for both residents. A Nurses Note, dated 9/7/19 at 1015 a.m., indicated another resident went to Resideny 19's room and punched the resident in mouth. B. On 11/13/19 at 11:08 a.m., Resident 40 was propelling himself in his wheelchair from his room towards the dining room. On 11/14/19 at 9:52 a.m., the resident was up in his wheelchair, drinking a cup of coffee with one hand, spitting to his right side, and holding an empty cup in his left hand. On 11/15/19 at 4:32 p.m., the resident was in bed in his room. Resident 40's clinical record was reviewed on 11/13/19 at 12:57 p.m. [DIAGNOSES REDACTED]. His current medication included, but were not limited to, [MEDICATION NAME] 5 mg at bedtime, [MEDICATION NAME] (treat impulse control) 37.5 mg every morning and [MEDICATION NAME] (appetite stimulant) 7.5 mg at bedtime. A quarterly MDS assessment, dated 10/15/19, indicated the resident was severely cognitively impaired. He required extensive assistance of one staff member for transfers and walking in his room and in the corridor. He was independent with locomotion on the unit and required limited assistance with locomotion off the unit and he used a wheelchair. He had an impairment or one side of his upper extremities. He did not exhibit verbal or physical behaviors directed towards others. A nurses note, dated 9/7/19 at 10:15 a.m., indicated the resident went into another resident's room, a confrontation abrupted, an incident report was filled out. An interview with the Administrator, on 11/12/19 at 11:45 a.m., she indicated she reported the resident to resident altercation to the state agency, the residents were separated immediately and they moved Resident 40 to a different hall, they were both on 15 minute checks. Resident 40 does not normally come out of his room, only for meals and smoke breaks. An interview with CNA 53, on 11/15/19 at 1:48 p.m., she indicated they try to keep Resident 40 and Resident 19 separated try not to take them out to smoke at the same time. An interview with the Administrator with the DON and SSD (Social Service Director) present, on 11/15/19 at 4:55 p.m. she indicated Resident 40 is unable to see very good and she felt Resident 40 accidentally hit Resident 19 in the face when Resident 19 pushed Resident 40's wheelchair. Resident 40 had not had other incidents like this before. Resident 19 was not focused on Resident 40 until the incident in his room. They smoke together and eat in the dining room together and they don't have problems. They put him back on [MEDICATION NAME] (anti-anxiety), on Monday and could already see a difference in him, by the end of the week. A current facility policy, titled ABUSE PROHIBITION, REPORTING AND INVESTIGATION, revised 9/17 and provided by the Administrator on 11/15/19 at 4:35 p.m., indicated the following: Policy .Physical abuse - Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment .1. This facility shall not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies serving the resident, family members, resident representatives, legal guardians, sponsors, friends or other individuals 3.1-27(a)

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous items were securely stored in 1 of 2 shower rooms (A Hall). Findings include: During an initial tour of the facility, on 11/12/19 at 8:57 a.m., the following was observed in the A Hall shower room: a. The shower room door was propped open; the door was equipped with an electronic keypad lock. b. Four boxes of denture tablets on the bottom shelf of a floor shelving unit. c. Five loose safety razors and three opened bags of safety razors were on a middle shelf of the unit. d. An open set of nail clippers, and an unsecured sharps container were on the sink counter. During an interview, on 11/12/19 at 9:04 a.m., the DON and CNA 33 indicated the razors and denture tablets should have been stored securely, and the bathroom door should be closed. The DON indicated the sharps container should have been secured. During an interview, on 11/18/19 at 10:15 a.m., the Administrator indicated 12 of the facility's residents were cognitively impaired. Review of a current facility policy, titled PERSONAL CARE ITEMS/MEDICATIONS MAINTAINED BY THE RESIDENT, dated 10/2014 and provided by the Administrator on 11/18/19 at 9:19 a.m., indicated the following: .The facility shall attempt to balance the need to accommodate resident's personal preferences and maintain a home-like and dignified environment with the need to protect residents in the facility from potential harm .4. Facility assistance shall be offered to maintain personal care items/medications in a manner respectful of resident's rights and in a manner to ensure the health and safety of confused residents of the facility who could have potential access to those items 3.1-18(a)

Based in observation, interview and record review the facility failed to ensure resident behavioral symptoms were managed for 1 of 6 residents reviewed for behaviors (Resident 19). Findings include: On 11/13/19 at 11:16 a.m., Resident 19 was observed in the dining room waiting for lunch to be served. On 11/14/19 at 12:55 p.m., he was sitting near the nurses station in his wheelchair. On 11/15/19 at 4:23 p.m., he was outside smoking while sitting in his wheelchair. Resident 19's clinical record was reviewed on 11/13/19 at 11:18 a.m. [DIAGNOSES REDACTED]. His current medications included, but were not limited to, [MEDICATION NAME] (treat biopolar disorder and [MEDICAL CONDITION]) 500 mg (milligram) every morning, [MEDICATION NAME] 750 milligram (mg) every evening, [MEDICATION NAME] (anit-anxiety) 0.5 mg every morning, [MEDICATION NAME] 0.25 mg every evening, [MEDICATION NAME] HCL (hydorcloride) (anti-depressant) 20 mg everyday and [MEDICATION NAME] (treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 1 mg twice daily and [MEDICATION NAME] (anti-anxiety) 5 mg twice daily. An annual, Minimum Data Set (MDS) assessment, dated 9/13/19, indicated the resident was cognitively intact. He required limited assistance of one staff member for transfers and walking in his room. He was independent with locomotion on and off the unit and he used a cane or wheelchair. He had an impairment to both sides of his lower extremities. He did not exhibit verbal or physical behaviors directed towards others. A focused Mood and Behavior care plan, revised on 10/30/19, indicated the resident had a primary [DIAGNOSES REDACTED]. Interventions included, but were not limited to, encourage the resident to vent their feelings and provide reassurance, encourage activities of interest such as: music, visit with his sister, watching television, smoking and activity outings, redirect any inappropriate behavior and comments and assist resident in problem solving. A Verbal Behavioral Symptoms Directed Towards Others focused care plan, revised on 10/30/19, indicated the resident exhibited verbal behavioral symptoms directed towards others such as: screaming at others and cursing at others. Interventions included, but were not limited to, attempt to identify the immediate causal factor or event that precipitateed the behavior, remove the resident or others from the area as appropriate or necessary, provide a calm, quiet environment until the resident has calmed, approach the resident in a calm manner and explain procedures prior to providing care, attempt to use diversion, distraction, and reorientation to calm the resident such as: music, smoking, visit with sister and television. A Resident to Resident Altercation focused care plan, revised 10/6/19, indicated the resident had a resident to resident altercation on 9/7/19 and 10/6/19. Interventions included, but were not limited to, approach the resident from the front and in a firm, but calm voice: instruct the resident to stop, separate the residents's if applicable, encourage the resident to go to a quiet area until calm, notify the physician and resident representative as needed, notify the Administrator or designee as needed, administer medications as ordered, provide mental health services as ordered, place resident on 15 minute checks to ensure safety or one to ones as needed, as directed by immediate supervisor on duty, clear the area, if applicable, allow the resident to vent his feelings, if applicable, provide activity of choice and interest to direct attention such as: reading, watch television and sitting outside with sister. A review of the mood and behavior communication memo's indicated the following on 7/22/19 at 9:00 a.m., Resident 19 was smoking and asked another resident where all her money was, another resident indicated it was none of his business. He told her to shut up and not tell him what to say. A review of a facility reported incident, occurring 9/7/19 at 10:01 a.m. indicated a Respiratory Nurse was preparing to administer an aerosol treatment down the hall, when she heard Resident 19 yelling get out of here, you cant be in here. She immediately went to Resident 19's room where she found another resident sitting in his wheelchair in the doorway of Resident 19's room. Resident 19 stated that the other resident had opened his door. Resident 19 then shouted for him to leave, and tried to back his wheelchair up and the resident swung his arms and hit Resident 19 in the face. Both residents were immediately assessed by a licensed nurse. Resident 19 sustained a 1 cm (centimeter) x 0.1 cm laceration to his right inner lip. Both residents were immediately separated and placed on one to one with staff. Administrator, DON, MD (Medical Doctor), and POA's (Power of Attorney's) notified for both residents. Both residents were placed on 15 minute checks as a preventative measure. The other resident was moved to a new room on a different hall. Health care representative was notified and was in agreement. On 9/8/19 at 6:30 a.m., the resident was physically aggressive and socially inappropriate. The resident was seen following a resident he had previously had an altercation with. Yelling was heard. Resident 19 was sitting in front of the other resident with a fist clenched. Resident 19 was angry the other resident was near him. Resident 19 was allowed to vent feelings. Outcome improved after residents were separated. A telephone order, dated 9/16/19, indicated to discontinue the resident's [MEDICATION NAME] for an attempted GDR (Gradual Dose Reduction). On 10/6/19 at 9:00 a.m., the resident had agitation, restlessness and was verbally aggressive. The resident went down to smoking door. Another resident was already sitting by smoking door. A housekeeper was in the dining room mopping the floor and heard some yelling outside the door. Upon investigation Resident 19 was yelling go ahead and hit me repeatedly. The resident were separated and the nurses were notified. A quiet environment and one on one attention was provided. The resident was allowed to vent and time to calm and re-approach. Outcome improved. A review of a Facility Reported Incident, occurring on 10/6/19 at 9:01 a.m. , indicated the Housekeeping Supervisor was in the dining room moping the floors when she overheard commotion in the hallway. She stepped outside of the dining room to find Resident 19 yelling at another resident. Resident 19 stated they were sitting in the hallway waiting for smoke time, when that resident spit on himself. Resident 19 stated he told him to use a cup to spit in, and it made him mad and they began yelling at one another. The residents were immediately separated by staff, both residents were assessed by a licensed nurse with no injuries. On 10/20/19 at 7:45 a.m., the resident was making negative statements and was verbally aggressive. The resident was coming from breakfast and started yelling at a male resident because the resident was going too slow. The nurse tried to calm him however, he just kept rambling down to his room. One on one was provided, the outcome was unchanged. On 10/29/19 the resident was upset about two female resident roaming the halls outside his door and he was tired of the disrespect and he stated bible verses. A nurses note, dated 10/30/19 at 8:50 p.m., indicated the resident had two behaviors of forcefully shoving other residents by their wheelchair handles to move them out of his way. The resident was educated on asking staff to assist him, the resident lied by saying the residents had asked for his help in moving. The behaviors was witnessed for both residents. The POA/psychiatric nurse was notified, a behavior memo was turned in. A new order was received to give [MEDICATION NAME] 0.25 mg, one time for increased anxiety/agitation. A telephone order, dated 11/11/19, indicated to start [MEDICATION NAME] 5 mg p.o. (by mouth) BID (twice daily) for failed GDR for anxiety. On 11/14/19 at 1:06 p.m., the Social Service Director indicated interventions for Resident 19, were to keep the resident separate from other residents, check to see if he is in pain and if so let the nurse know, talk with him and find out what is bothering him, call his sister and she would come in to visit with him. On 11/14/19 at 1:38 p.m. the DON indicated Resident 19 didn't like another male resident in the facility. She wished they didnt have to do the GDR's. An interview with CNA 53, on 11/15/19 at 1:48 p.m., she indicated they keep Resident 19 separated from the resident he did not like and tried not to take them out to smoke at the same time. An interview with the Administrator, on 11/15/19 at 4:55 p.m. she indicated Resident 19 was not focused on the other male resident until the incident in his room. They smoke together and eat in the dining room together and they dont have problems. They put him back on [MEDICATION NAME] (anti-anxiety), on Monday and could already see a difference in him, by the end of the week. No further information was provided prior to exit from the facility. 3.1-43(a)(1)

Based on interview and record review, the facility failed to develop a behavior management program to address the residents refusal of care for 1 of 3 residents reviewed for resistive behaviors. This deficient practice resulted the resident requiring hospitalization and surgery. Findings include: The clinical record for Resident B was reviewed on 12/17/18 at 10:42 a.m. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, dated 10/24/18, indicated the resident was cognitively intact. He was independent with ambulation. A current health care plan, dated 1/25/18 and revised 10/23/18, indicated the resident sometimes rejected care that was necessary to achieve health and well-being. Interventions included, but were not limited to, explain the purpose of the visit, reapproach as needed and attempt to determine the cause for rejection. Another health care plan, dated 11/6/18, indicated the resident was at risk for the development of pressure ulcers. Interventions included, but were not limited to, head to toe skin assessment weekly, pressure reducing device to wheelchair and bed and to observe skin condition while providing care. A mood and behavior communication memo, dated 10/13/18, indicated the resident stated he had rabbit, snake and frog bites all over him and was waiting for his medicine to come in for them. Review of the monthly behavior flow record for (MONTH) (YEAR), no documentation was noted for hallucinations or false beliefs on 10/13/18. On 10/13/18, the resident fell in his room. He was sent to the emergency room and was found to have a non-displaced [MEDICAL CONDITION] patella. The resident elected to have non-surgical interventions and returned to the facility. A Nurse Practitioner (NP) progress note, dated 10/17/18, indicated the resident was seen for an an acute visit related to a fractured right patella. The note indicated No nursing or resident issues or concerns, at this time. A social service note, dated 10/26/18, indicated the residents legal guardian voiced some concerns related to the resident not taking his medications or showering. The guardian indicated to let her know if the resident was not showering and should would call him and talk to him. A mood and behavior communication memo, dated 10/29/18, indicated the resident was observed during a conversation with a staff member to have another conversation with two additional people that were not present. He then asked the other two people who were not in the room, if he should sign the paper and they told him to go ahead and sign it. Review of the monthly behavior flow record for (MONTH) (YEAR), no documentation was noted for hallucinations on 10/29/18. The resident had one documented episode of false belief and one episode of undefined [MEDICAL CONDITION]. Interventions attempted were effective on 10/29/18, 11/17/18 and 11/24/18. Review of the monthly behavior flow record for (MONTH) (YEAR), indicated the resident had one episode of rejection of care on 10/13/18 and two days of continuous rejection of care on 10/25/18 and 10/29/18. A new order was received on 11/1/18 to discontinue the current dose of [MEDICATION NAME] (antipsychotic medication) from 10 mg in the morning and 15 mg at night, to 15 mg twice daily related to a [DIAGNOSES REDACTED]. A social service note, dated 11/1/18, indicated [MEDICATION NAME] was increased to 15 mg twice daily related to rejection of care. Review of the monthly behavior flow record for (MONTH) (YEAR), indicated the resident had one episode of rejection of care on 11/26/18. The Medication Administration Record [REDACTED]. A social service note, dated 11/6/18, indicated the Social Service Director (SSD) had been checking psychiatric facilities that would admit the resident for treatment. A behavioral medicine evaluation note, dated 11/6/18, indicated the staff reported the resident was doing fair and always refused showers. The resident also reported hallucinations that snakes and animals were biting him. The note indicated the NP received a call from the Director of Nursing (DON) on 11/1/18, indicating the resident had been having hallucinations and could be seen talking to good and bad friends. A progress note, dated 11/14/18, indicated the resident was seen for an acute visit related to him not ambulating and being confined to his wheelchair. No nursing or resident issues or concerns were noted. A behavioral medicine evaluation note, dated 11/20/18, indicated staff reported the resident was doing fair. He had been refusing to sleep in his room and slept in his wheelchair in the lounge. Stated reported the resident was refusing more care than usual. A progress note, dated 11/20/18, indicated the resident was seen for an acute visit related to staff reporting the residents skin tone does not look right. The report indicated he had right knee and ankle swelling with peripheral pulses intact. He had a dusky appearance to his face. The NP ordered laboratory tests. A social service note, dated 11/26/18, indicated the SSD had not yet found a psychiatric facility for admission. Review of the monthly behavior flow record for (MONTH) (YEAR), the resident had 5 documented rejection of care behaviors and one day of continuous rejection of care behavior. A progress note, dated 12/7/18, indicated the resident was seen for an acute visit related to the resident reporting a bug bite to his buttocks. The resident agreed to an assessment of his buttocks and was found to have a stage 2 pressure ulcer. The report indicated he had no swelling on his extremities and peripheral pulses were intact. An initial pressure ulcer assessment report, dated 12/7/18, indicated the resident developed a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis) that measured 2.0 cm x 3.0 cm x 0.2 cm on his coccyx. A behavioral medicine evaluation note, dated 12/10/18, indicated staff reported the resident was doing poorly. The resident was refusing to wear his brace or follow physician orders. The NP indicated the resident was non-compliant and his health would deteriorate more without intervention. The NP recommended an admission to a psychiatric hospital for medication adjustment. A social service note, dated 12/11/18, indicated the SSD contacted a hospital for psychiatric evaluation and admission. The receiving hospital indicated the resident would need to come through the emergency room department for admission. A hospital admission note, dated 12/11/18, indicated the resident was brought by ambulance to the hospital for a psychiatric admission. On assessment, he was found to have an open wound to the right foot/ankle area with concern for deep tissue infection and possible bone involvement. The area was noted to have a foul odor. An x-ray (radiograph) was completed on 12/11/18, which suggested osteo[DIAGNOSES REDACTED] (infection in a bone). A Computed Tomography (CT) scan of the lower extremity was completed on 12/11/18. The CT suggested infectious tendinitis and osteo[DIAGNOSES REDACTED] of the posterior calcaneus (heel bone). A podiatry consult was obtained on 12/12/18. The assessment indicated there was a large posterior heel wound with exposure of a necrotic Achilles tendon and exposed bone on the heel. The wound had swelling, drainage and malodor. The resident was explained the risks, benefits and alternatives to surgery and decided to proceed with surgery. A post-operative report, dated 12/12/18, indicated the resident had debridement of the wound and resection of the Achilles tendon with partial calcanectomy. A wound consult was obtained on 12/13/18 for negative-pressure wound therapy. A hospital progress note, dated 12/13/18, indicated the resident had surgery on 12/12/18 with mild discomfort in the right foot. He was currently receiving Intravenous (IV) antibiotics and had a [DEVICE] in place. An infectious disease consult was obtained on 12/14/18 for a right heel infectious teno[DIAGNOSES REDACTED] ([DIAGNOSES REDACTED] sheath surrounding the tendon) with calcaneal bone osteo[DIAGNOSES REDACTED]. The consult indicated the resident underwent [REDACTED]. During an interview on 12/19/18 at 10:45 a.m., the SSD indicated Resident B had an increase in refusing Activities of Daily Living (ADL) care after he broke his knee. She did not hear about the bug and animal bites until the day before she sent him to the hospital around 12/10/18. He did not have any new or worsening behavior form. On 12/20/18 at 9:29 a.m., the SSD indicated the most recent Interdisciplinary Care Plan meeting was 10/25/18. The resident had been refusing showers and the staff were to inform the DON of the refusals and she would call his guardian. The guardian indicated she would call him and encourage him to take a shower. During an interview on 12/20/18 at 9:34 a.m., the DON indicated the guardian wanted to be called but did not want to make the resident mad. She would sometimes come in the side door of the facility so he did not know she had visited. No documentation was provided related to attempted calls to the guardian. Review of a current facility policy titled, MOOD AND BEHAVIOR PROGRAM, revised 11/2013 and provided by the Corporate Nurse on 12/18/18 at 2:29 p.m., indicated the following: .5. Should a mood/behavior be identified a new or worsening for the resident, an Evaluation of New or Worsening Mood or Behavior assessment will be initiated by social service or nursing and completed by the interdisciplinary team, in an attempt to identify any [MEDICATION NAME] or extrinsic factors which may be cause or precipitating the new or worsening mood(s) or behavior(s). This Federal tag relates to Complaint IN 714. 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent a fall for 1 of 3 residents reviewed for accidents (Resident B) and ensure fall interventions were in place for 2 of 3 residents reviewed for accidents (Resident C and D) This deficient practice resulted in Resident B sustaining a fracture of her left hip and laceration to the head requiring sutures. Findings include: 1. The clinical record for Resident B was reviewed on 4/30/18 at 10:29 a.m. [DIAGNOSES REDACTED]. On 4/27/18 at 5:30 a.m., the resident was asleep in her bed. On 4/30/18 at 2:20 p.m., the resident was asleep in her bed. A 3/10/18 significant change Minimum Data Set (MDS) assessment, indicated she was severely cognitively impaired. The resident required two person assistance with bed mobility and transfers. An order, dated 2/18/18, indicated to place a mat on each side of the bed due to fall risk. A health care plan, initiated 3/23/18 and revised 4/26/18, indicated the resident had multiple risk factors for falls related to unsteady gait, medication use and impaired balance. Interventions included, but were not limited to, monitor the resident frequently, utilize foot wear and ensure the resident is using assist device. On 2/4/18, a bed alarm was added as an intervention. On 2/18/18, floor mats on both sides of the bed were added as an intervention. On 2/9/18, a bed alarm and chair alarm were added as an intervention. A fall risk assessment, dated 2/1/18, indicated the resident was at a high risk for falls. On 2/4/18,the resident was found on the floor, in her room. No injuries were noted. A bed alarm was placed as an immediate intervention. On 2/18/18, staff responded to an alarm in the resident's room and the resident was found on the floor. The immediate intervention included to place floor mats on both sides of the bed. A nursing note, dated 4/8/18 at 7:55 p.m., indicated the resident was found on the floor, beside her bed. She had a large amount of blood pooled beside her head. The resident was assisted to her wheelchair and a dressing was applied to her wound. She had no change in her range of motion or cognition. She was sent to the hospital for evaluation and treatment. A Situation Background Assessment Recommendation (SBAR), dated 4/8/18, indicated a 2.0 cm x 2.0 cm laceration to the left side of her head. The resident was grimacing and shouting when touched. She had no change in her mental status. On 4/8/18 at 8:30 p.m., the resident was transported to the hospital. A progress note, dated 4/8/18 at 8:35 p.m., indicated the son was contacted and he reported the resident's bedside mat was on the floor beside the bed while the resident was laying in bed prior to the fall. The report indicated the staff found the mat folded up and tucked against the wall, next to the foot of the bed. The post fall investigation, dated 4/8/18, indicated the resident was a one or two person assist and her son had visited prior to the fall and had assisted her back to bed. The report indicated the alarm was not on at the time of the fall. On 4/8/18, a diagnostic radiology test was completed on her bilateral hips and pelvis. The radiology report indicated a mildly impacted subcapital right femur fracture. The resident received nine staples to close her laceration. On 4/11/18, the resident received surgical repair for the [MEDICAL CONDITION]. During the surgery, she required three units of packed red blood cells for acute blood loss. She was re-admitted to the facility on [DATE]. A re-admit order, dated 4/16/18, indicated to keep the bed in the lowest position, mats on floor and bed alarm in place. During the exit conference with the Administrator, Nurse Consultant (NC), Director of Nursing and Regional Director of Operations on 4/30/18 at 3:50 p.m., the NC indicated the mat was not on the floor by Resident B, but was folded up in the corner of her room. The alarm was on the bed, but did not sound. 2. The clinical record for Resident C was reviewed on 4/27/18 at 10:27 a.m. [DIAGNOSES REDACTED]. During the initial tour with CNA 3 on 4/27/18 at 6:40 a.m., Resident C was seated in her wheelchair in the main dining room. Resident C did not have an alarm on her wheelchair. A current physician's orders [REDACTED]. A current health care plan, dated 6/23/17 and revised 3/14/18, indicated Resident C had multiple risk factors for falls related to poor safety awareness, impaired balance and [MEDICAL CONDITION]. Interventions included, but were not limited to, wheel chair alarm, alarm in bed and low bed. A post fall investigation, dated 2/9/18, indicated Resident C fell out of bed at 1:10 p.m. The report indicated the alarm was in place and functioning. A post fall investigation, dated 2/9/18 at 7:50 p.m., indicated Resident C got out of bed because she thought she could walk. The report indicated the alarm was in place and functioning. A post fall investigation, dated 2/10/18 at 3:50 p.m., indicated Resident C was found next to her bed on the floor. The report indicated the alarm was in place and functioning. A Certified Nursing Assignment sheet indicated Resident C was to have both a bed and chair alarm. The assignment was last updated 4/2/18. 3. The clinical record for Resident D was reviewed on 4/27/18 at 12:14 p.m. [DIAGNOSES REDACTED]. During a tour with ADON on 4/27/18 at 8:19 a.m., Resident D did not have an alarm on her bed. On 4/27/18 at 8:49 a.m., the ADON indicated she had checked with staff to see if they were using her wheelchair alarm also on her bed. She indicated the staff stated they were not using the alarm on her bed. A current physician's orders [REDACTED]. A current health care plan, dated 8/24/17 and revised 3/15/18, indicated Resident D had multiple risk factors for falls related to impaired balance, difficulty standing and [MEDICATION NAME] degeneration. Interventions included, but were not limited to, bed alarm and chair alarm. A Certified Nursing Assignment sheet did not indicated Resident D had a personal alarm. The assignment sheet was last updated 4/13/18. A current facility policy, dated 10/14, titled ALARMED DEVICES, which was provided by the Administrator on 4/27/18 at 11:50 a.m., indicated the following: PURPOSE: Alarmed devices may be used to alert staff of unassisted resident movement. .1. A physician's orders [REDACTED]. 3. Facility personnel will routinely check the device for proper placement and function each shift. This Federal tag relates to Complaint IN 507. 3.1-(b)(1)

A. Based on observation, interview, and record review, the facility failed to provide adequate supervision and interventions to prevent falls for 2 of 4 residents reviewed for accidents (Residents 32 and 41). This deficient practice resulted in Resident 32 sustaining a fracture to her right arm with know history of recent falls. B. Based on observation, interview, and record review, the facility failed to ensure areas containing chemicals and potential hazards were secured for 2 of 2 shower rooms and 1 of 1 maintenance closets. This practice had the potential to affect 4 cognitively impaired residents with wandering behaviors of 59 residents in the facility. Findings include: A.1. On 2/14/18 9:00 a.m., Resident 32 was propelling herself in her wheelchair to the smoking patio. On 2/16/18 at 8:30 a.m., she was propelling herself in her wheelchair with her feet. Review of the clinical was completed on 2/14/18 at 8:44 a.m. She had been admitted to the facility from an assisted living facility. [DIAGNOSES REDACTED]. Medications included, but were not limited to, [MEDICATION NAME] (antidepressant) 7.5 mg daily, [MEDICATION NAME] (antidepressant) 100 mg daily, and [MEDICATION NAME] (antianxiety) 10 mg three times daily. A 10/30/17, admission, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. She required limited assistance with ADLs and was unsteady during transfers and ambulation. She had a current 2/12/18 care plan problem of risk for falls. Interventions included, but were not limited to, monitor frequently when call lights not available, keep items within reach, ensure wheelchair use, and educated to ask for assistance (10/21/17), and refer to therapy (10/23/17). A 2/12/18 care plan indicated she required assistance of up to one person with ADLs due to falls, poor safety awareness, and cognitive impairment. Interventions included, but were not limited to, assist with ADLs. She had a 2/12/18 care plan problem of needing the assistance of one person for transfers due to the potential for falls and significant injury when she lacked staff assistance. Interventions included, but were not limited to, staff will utilize any devices (CIRCLE) GAIT BELT, WALKER, CANE and interventions (for example, appropriate footwear necessary to safely transfer the resident). The care plan did not indicate which specific interventions would be utilized. A 10/20/17 Admission Assessment indicated she ambulated and transferred independently. A 10/20/17 Fall Risk Assessment indicated she was at risk for falls. Review of Nurses Notes and Fall Investigation documents, provided by the DON on 2/16/18 at 11:05 a.m., indicated the following: On 10/21/17, she was receiving 1:1 supervision due to continued exit seeking. At 1:25 p.m., she lost her balance and fell down onto her right arm while on the smoking patio. Her gait was noted to be unsteady at times and she was encouraged to seek assistance from staff as needed. Review of a 10/21/17 Post Fall Investigation document indicated the fall had occurred while she was walking and had lost her balance. It was noted as being her first fall in the facility, so interventions were not in place at the time of the fall. The document indicated she had an unsteady gait and was encouraged to seek assistance as needed. On 10/23/17, she was noted to have an unsteady gait, decreased cognition, decreased (unsteady) transfer ability, and loss of balance in ambulation. She continued to ambulate independently and had fallen on the back patio while smoking. A 10/23/17 Post Fall Investigation document indicated she had lost her balance and fell on the back patio while coming back inside from smoking. The document indicated she required a walker or wheelchair for ambulation, but had not received a wheelchair yet. Immediate interventions were to assess her vital signs and give her some Tylenol. On 10/24/17 at 12:25 p.m., she had fallen at the nurses station, and complained of right shoulder and arm pain. Orders were received at 2:00 p.m. for an X-ray of her shoulder. At 10:10 p.m., she was found sitting on the floor in her room, and was complaining of pain from her previous shoulder injury. A 10/24/17 Post Fall Investigation document indicated she had been at the nurses station and had .tried to move over and fell . The document indicated she used a walker, which she had at the time of the fall. The document indicated she had an alarm in place to her bed and the immediate intervention was to give her the walker back. A subsequent 10/24/17 Post Fall Investigation doucment indicated she had fallen in her room, but she was not able to verbalize what had happened. She required the use of an undefined assistive device. She was place in bed in the lowest possible position with a mat on the floor and her call light in reach. On 10/25/17 at 8 a.m., the Nurse Practitioner was notified of the X-ray results and she was sent to the emergency room for evaluation, where she was diagnosed with [REDACTED]. During an interview, on 2/16/18 at 8:47 a.m., CNA 30 indicated the resident used to walk, but had been in a wheelchair since she had fallen right after she admitted to the facility. During an interview, on 2/16/18 at 1:10 p.m., LPN 31 indicated the resident had been able to walk on her own when she admitted to the facility, but she was very unsteady. She indicated she had needed to use a wheelchair when she admitted to the facility, but they had to wait a few days to get one for her. During an interview, on 2/16/18 at 1:19 p.m., the DON indicated the resident was pretty anxious when she arrived to the facility and had been used to being able to go out and smoke and drink coffee whenever she had wanted to. She thought she had been rushed and fell , since she was adjusting to the facility. The assisted living facility had informed them she had fallen in the past and had no concept of safety. The facility did not want to place her in a wheelchair immediately, due to her having dementia, and was being assessed for walker use versus wheelchair use; she would just get out of the wheelchair and walk, so they gave her a walker to use for ambulation, as they felt it was safer. She already had the walker when she fell at the nurses station, and the immediate intervention was to send her out to have her arm fixed and then have her use a wheelchair. She had been found on the floor next to her bed on 10/24/17 after she had been assisted to bed for the night, so the immediate intervention put in place was to assist her back to bed. A. 2. The clinical record for Resident 41 was reviewed on 2/16/2018 at 8:41 a.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment, dated 1/13/18, indicated the resident was cognitively intact, required extensive assistance for transfers, extensive assistance of two people for toilet use, was unsteady while walking and had impairment to the right and left sides in both the upper and lower extremities. She had a current care plan, updated 1/26/18, titled FALLS which indicated the resident had a history of [REDACTED]. Interventions included, but were not limited to: provide adequate lighting, utilize foot wear with non skid soles, complete fall risk assessments, ensure resident is using a wheel chair. Re-educated of the use of call lights for staff assistance added 1/20/17. She had a current care plan, updated 1/26/18 titled, ADL ASSIS REQUIRED, which indicated the resident was a fall risk. Interventions included, but were not limited to, provide assistance with ADL's as much as possible. The current plan of care did not indicate she needed 2 person assist for toileting as the MDS indicated. Review of the POS [REDACTED] On 2/8/18 the resident fell in her room/bathroom while transferring. The resident was not independent with transfers and required two people. The form indicated there was two staff members present and only one staff member as a witness. There was increased confusion noted before the fall. The resident was unable to answer questions and confused and lethargic. The resident was sent to the emergency room . During an interview with LPN 65 on 2/16/18 at 10:48 a.m., she indicated the resident was trying to go the bathroom and fell . CNA 66 was with her and when she fell , then he came and got her. The resident transferred to bathroom, bed and wheelchair normally by herself. The resident did not fall a lot, does not think there were fall precautions. After the fall the resident was very confused, did not respond to questions and had elevated blood pressure so she called the doctor. During an interview with CNA 66 on 2/16/18 at 11:15 a.m., he indicated he was with the resident when she fell and he assisted her to the floor. She was moving slower than normal and began urinating on the floor and then fell backward. He would need to find another CNA and ask how residents transferred because there were no CNA sheets for them to get information off of. He knew a resident was a fall risk if they had a low bed or if they had mats at bedside. During an interview with the DON on 2/16/18 at 1:19 p.m., she indicated the resident was very active and independent even though she was a very sick lady. The resident was always up and about in her electric wheelchair. She had [MEDICAL CONDITION], cardiac failure, [MEDICAL CONDITION]. At times she was at risk for falling, she was stable at times and her abilities fluctuated up and down. Normally the DON would implement fall interventions after one fall. The staff tried explaining to the resident to use her call light. On (MONTH) 8th, the CNA was able to lower her to the floor even though the resident was morbidly obese and she was sent to emergency room . She had not felt good that morning. She indicated the facility did not do a root cause analysis when residents fell . They usually could figure out a potential cause. The resident required intermittent assistance when she came home from the hospital then they would build her back up and she would be more independent. Review of a current policy, titled FALL PREVENTION PROGRAM, dated 10/2014 and provided by the DON on 2/16/18 at 2:52 p.m., indicated the facility would identify residents at risk for falls and subsequently implement appropriate, individualized fall prevention interventions. A Fall Risk Assessment shall be completed upon admission and recommendations made for immediate interventions accordingly. Those interventions will be addressed on the CNA assignment sheet (or applicable communication device in use) and the resident's care plan. B. During an initial tour of the facility, beginning on 2/12/18 at 8:32 a.m., the following was observed: Three large, wet bath blankets were laying on the floor outside of the housekeeping closet on the E Hall. A treatment cart was against the wall near the entrance to the E Hall with, but not limited to, the following medications sitting on top of the cart: a large tub of [MEDICATION NAME] (steroid) 1% cream, two bottles of [MEDICATION NAME] (antifungal) powder, and a bottle of Hysept (diluted bleach solution) 0.25% liquid. At 8:40 a.m., the Maintenance room was observed to be unlocked. The room contained, but was not limited to, electronics servers, a bottle of wood finish, three take-out coffee cups with lids containing varying amounts of liquid, a spray bottle of hornet killer, cans of paint, a spray bottle of roach spray, a bottle of Blaster rust spray, three tubes of DAP sealant, a tub of dry wall mud, and a can of spray paint. The ADON indicated at the time of the observation all shower room doors and the maintenance room should be kept locked at all times. At 8:45 a.m., the D Hall shower room was observed to be unlocked. A cabinet above the toilet was unlocked and open. The cabinet contained, but was not limited to, reusable household rubber gloves, disinfectant cleaner, and shaving razors. During an interview, at 8:55 a.m., the Administrator indicated the bath blankets were on the floor due to a leak in the housekeeping closet; the mop sink had cycles of leaking between 3 a.m. and 4 a.m. daily. During a random observation, on 2/13/18 at 10:08 a.m., the E Hall shower room door was observed to be open and unattended. An unsecured sink vanity contained, but was not limited to, a spray bottle of Virex healthcare disinfectant cleaner, an open and partially filled sharps container, and shaving razors. During a random observation, on 2/13/18 at 10:10 a.m., the B Hall shower room door handle was observed to be locked, but the door was not latched closed. During a random observation, on 2/16/18 at 10:04 a.m., the E Hall shower room door was observed to be standing open and unattended. An unsecured sink vanity contained, but was not limited to, a spray bottle of Virex healthcare disinfectant cleaner, an open and partially filled sharps container, and shaving razors. At 10:10 a.m., CNA 38 indicated the shower door should be kept closed and locked at all times. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to identify causative factors in the development of a pressure ulcer and to prevent the development of a subsequent pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #60). Findings include: On 2/1/17 at 9:41 a.m., Resident #60 was sitting on a couch in the common room, with a pair of Velcro shoes athletic shoes on. On 2/1/17 at 10:09 a.m., he was up in his wheelchair, wearing the same shoes. The ADON indicated to him she was going to perform the wound care for his feet. He removed each shoe with the toes of the opposite foot, leaving a sock on each foot. The ADON then removed the sock from his right foot, revealing a large pea-sized dark scabbed area to his 2nd toe, just above the knuckle. The surrounding skin to his feet was smooth with no swelling or discoloration. The ADON indicated the area measured 0.9 centimeters long (cm) x 1.0 cm wide. The ADON removed the sock from his left foot, and indicated the area was healed. On 2/2/17 at 8:05 a.m., he was up in his wheelchair in his room, wearing the same Velcro shoes. Review of the clinical record began on 1/30/17 at 10:54 a.m. [DIAGNOSES REDACTED]. An 11/18/16, significant change, Minimum Data Set (MDS) Assessment, indicated he was significantly cognitively impaired, and required extensive assistance with ADLs. Review of an INITIAL PRESSURE ULCER ASSESSMENT, indicated the following: 11/18/16 unstageable pressure area (presents as ulcer in which depth of tissue damage is not able to be determined due to presence of non-viable tissue) to the right second toe- 0.6 L (long) x 0.6 W (wide) cm, area scabbed. 11/23/16 unstageable pressure area to the right second toe- 0.5 L x 0.5 cm W, area scabbed. 12/1/16- no change from the previous assessment. 12/8/16 unstageable pressure area to the right second toe- 0.7 cm L x 0.8 cm W, the area remained scabbed. 12/15/16 unstageable pressure area to the right second toe- 0.8 cm L x 1.0 cm W, with a large brown scab remaining. 12/22/16 no change from the previous assessment. 12/29/16 no change from the previous assessment. 1/5/17 no change from the previous assessment. 1/12/17 unstageable pressure area to the right second toe- 1.1 cm L x 0.9 cm W, with a scab remaining and wound-associated pain present. 1/20/17 unstageable pressure area to the right second toe- 1.0 cm L x 0.8 cm W, with a scab remaining and wound-associated pain present. 1/26/17 unstageable pressure area to the right second toe- 0.5 cm L x 0.7 cm W, with a scab remaining and wound-associated pain present. Review of an INITIAL PRESSURE ULCER ASSESSMENT, indicated the following: On 1/5/17, an unstageable pressure ulcer had developed to the tip of his left great toe, measuring 1.0 cm L x 1.2 cm W, presenting with a black scab covering the wound. 1/12/17 unstageable pressure area to the left great toe- 1.0 cm L x 0.5 cm W, presenting with a black and purple wound bed and wound-associated pain present. 1/20/17 unstageable pressure area to the left great toe- 0.7 cm L x 0.4 cm W, presenting with a purple wound bed and wound-associated pain present. 1/26/17 unstageable pressure area to the left great toe- 0.7 cm L x 0.4 cm W, presenting with a black and purple wound bed and wound-associated pain present. The resident had a current careplan for risk for pressure ulcer due to, but not limited to, decreased mobility, incontinence, and dementia. Interventions included, but were not limited to, pressure reducing cushions to bed and chair, and to encourage and assist with turning and repositioning every two hours. There were no interventions specific to relieving pressure to his feet or toes. The resident had current careplan problems of a pressure ulcer to both the right 2nd toe and left great toe. Interventions included, but were not limited to, treatment as ordered, monitor for infection, monitor for progress in healing, pressure relieving devices in place, and turn and reposition every two hours. There were no interventions specific to relieving pressure to his feet or toes. On 2/1/17 at 2:51 p.m., the ADON indicated the resident's shoes had caused each of the pressure ulcers, but he really liked wearing his shoes, although he had other pairs in his room. She confirmed there were no interventions included in his care plan regarding his feet. She indicated he was to follow up with a podiatrist, but was not aware of when this had been scheduled, due to a change in podiatry providers at the facility. Review of policy titled, Skin Management Program, dated 12/2013, and provided by the ADON on 2/1/17 at 3:43 p.m., indicated the following: .POLICY: This facility will assess/identify the presence of risk factors that may contribute to the development of pressure ulcers .in an effort to prevent skin breakdown and/or further deterioration .CARE PLAN IMPLEMENTATION: Interventions will be implemented according to the individual resident's risk factors in an effort to reduce the risk of development of pressure ulcers and/or promote the most effective healing of existing areas 3.1-40 (a)