Every finding on record at University Place Health Center and Assisted Living

Based on interview and record review, the facility failed to ensure a resident was kept safe during a transfer by a staff member for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a minimally displaced oblique fracture of the mid tibial diaphysis (a stable, angled break in the middle shaft of the shinbone) and a minimally displaced spiral fracture of the proximal fibular diaphysis (a stable, low-energy injury near the knee). The deficient practice was corrected on 3/27/26, prior to the start of the survey, and therefore was past noncompliance.Findings include: During an interview, on 3/30/26 at 1:10 p.m., the Director of Nursing (DON) indicated Resident B was found to have bruising to her right leg on 3/20/26 and pain in her right hip. She was sent to the emergency room for evaluation. She received notification Resident B had a fractured right leg and an investigation was started. Resident B did not have a fall, was not mobile, and required a mechanical lift for all transfers. During the investigation, CNA 2 indicated she had completed a mechanical lift transfer (a device used to transfer residents with limited mobility) without assistance. The cause of the fracture was not determined. CNA 2 was terminated for not following procedure for the mechanical lift which could have caused the fracture of Resident B's right leg.The clinical record for Resident B was reviewed on 3/30/26 at 3:40 p.m. The diagnoses included, but were not limited to, abnormalities of gait and mobility, lack of coordination, and dementia.A physician's order, dated 11/20/24, indicated Resident B was a mechanical lift for all transfers.A care plan, dated 5/7/25, indicated Resident B had an impaired transfer ability. Interventions included, but were not limited to, a mechanical lift for transfers and a minimum of two staff members for all mechanical lift transfers.A nursing progress note, dated 3/21/26, indicated while being changed Resident B was found to have a bruise to her right shin and severe pain to her right hip. Resident B was assessed and staff could not find a pedal pulse to her right foot. Resident B was sent to the emergency room for evaluation.A nursing progress note, dated 3/21/26, indicated the emergency room reported the resident had a significant fracture to her right tibia and a spiral fracture to her right fibula.An emergency room report, dated 3/21/26, indicated the resident had a minimally displaced oblique fracture of mid tibial diaphysis and a minimally displaced spiral fracture of the proximal fibular diaphysis.A nursing progress note, dated 3/24/26, indicated Resident B returned to the facility, was non-weight bearing on her right leg, and was admitted to hospice care.A facility statement, dated 3/21/26, indicated CNA 2 and CNA 3 got Resident B up for dinner utilizing the mechanical lift and the resident had no complaint of pain. CNA 2 prepared the resident for bed after dinner and admitted she transferred the resident utilizing the mechanical lift without assistance. She denied any occurrence which could have led to the resident being injured.A facility statement, dated 3/21/26, indicated CNA 3 had assisted CNA 2 with the mechanical transfer of Resident B prior to dinner, and the resident did not have any pain. She did not assist CNA 2 with the transfer of Resident B after dinner.A facility statement, dated 3/21/26, RN 4 indicated Resident B did not exhibit any signs or symptoms of pain during the dinner meal or when she dispensed the evening medications at 7:30 p.m. RN 4 indicated she observed the mechanical lift in Resident B's room and CNA 2 was with the resident at the time. RN 4 indicated the resident's injury could have been caused during a mechanical transfer.A facility statement, dated 3/21/26, LPN 5 indicated the accident could have happened with a mechanical lift transfer or if the resident hit her leg on the metal portion of the bed frame. The bed frame was completely covered by the mattress except on the lateral surface.The facility investigation document indicated CNA 2 admitted she transferred Resident B after dinner, on 3/20/26, by herself utilizing a mechanical lift. CNA 2 indicated she had no issues with the transfer.During an interview, on 3/30/26 at 1:50 p.m., the Manager of Resident Services indicated all mechanical lift transfers were to have 2 people for safety and proper utilization of the lift machine. If one staff member utilized the machine, an accident could likely occur. After the investigation of Resident B's incident, all staff received an in-service and demonstrations on the proper mechanical lift procedure. Audits were ongoing and CNA 2 was terminated. During an interview, on 3/30/26 at 2:22 p.m., CNA 3 indicated the mechanical lift was utilized for resident transfers and 2 people must assist with the process. She did not assist CNA 2 with the transfer of Resident B after dinner. She did assist with the transfer prior to dinner and indicated Resident B needed 2 people to assist because she had difficulty at times with the transfer.A mechanical lift general guideline indicated at least 2 nursing assistants were needed to safely move a resident with a mechanical lift.A current facility policy and procedure, titled system competency subject: mechanical lift, not dated and provided by the Director of Nursing (DON) on 3/30/26 at 4:05 p.m., indicated .At least two nursing assistants are needed to safely move a resident with a mechanical lift.This deficient practice was corrected by 3/27/26 after the facility implemented a systemic plan that included the following actions: An in-service was conducted for all staff who utilize the mechanical lift, observations and audits of the utilization of the mechanical lift were conducted and are ongoing, CNA 2 was terminated.This citation relates to Intake 2962388.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a daily weight was obtained as ordered by the physician for 1 of 1 resident reviewed for edema. (Resident 6) Findings include:The clinical record for Resident 6 was reviewed on 11/24/25 at 12:31 p.m. The diagnoses included, but were not limited to, chronic congestive heart failure, atrial fibrillation, and hypertension. A physician's order, dated 11/8/25, indicated to obtain daily weights. The clinical record indicated a daily weight was missing on 11/14/25.The clinical record indicated, on 11/19/25, Resident 6 had a weight gain of 4.4 pounds in one day. A care plan, dated as revised on 11/18/25, indicated the resident had altered cardiovascular status. The interventions included, but were not limited to, monitor, document and report as needed any signs and symptoms of congestive heart failure, and any weight gain unrelated to intake. The progress notes, dated 11/8/25 through 11/25/26, did not indicate Resident 6 refused the daily weight on 11/14/25, or the physician was notified of the 4.4-pound weight gain in one day on 11/19/25. During an interview, on 11/25/25 at 9:41 a.m., the Director of Nursing (DON) indicated the facility did not have a congestive heart failure protocol. They discussed each resident in the Interdisciplinary Team (IDT) meeting and determined what to do with a congestive heart failure resident who gained weight. They would reweigh the resident to make sure the weight was accurate and then would determine if the physician needed to be notified. The dietitian looked at the weights daily and since Resident 6 did not trigger for a significant gain or loss the physician was not notified.During an interview, on 11/25/25 at 10:16 a.m., CNA 9 indicated she did not know the resident was a daily weight. When a resident had an order for a daily weight, the resident needed weighed and the weight documented. During an interview, on 11/25/25 at 10:58 a.m., the Dietician indicated she looked at the daily weights every day but weekends. She followed the 3-pound weight gain for one day, 5 pounds gain in one week, and then notified the physician. She did not notify the physician on 11/19/25. She did not assess for fluid gain and would notify the nurse if assessment was needed. During an interview, on 11/25/25 at 11:10 a.m., LPN 8 indicated if the resident had a greater than 3-pound weight gain in one day or greater than 5 pounds in one week the physician would need to be notified. The physician would be notified to see if a change to an order or an additional diuretic was needed. The facility did not have a weight policy for congestive heart failure.3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident received assistance with personal hygiene for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident 29)Findings include:During an interview, on 11/24/25 at 10:24 a.m., Resident 29's representative voiced concerns about Resident 29's showers. She indicated she had called the facility and asked if the resident received her shower. The staff indicated Resident 29 received one regularly. When the family visited the resident, the resident often had greasy hair and appeared dirty. When family questioned staff about the resident's appearance, staff indicated the resident had behaviors and they could not give her a shower. During an observation, on 11/20/25 at 1:42 p.m., Resident 29's hair was uncombed and greasy.During an observation, on 11/21/25 at 10:38 a.m., Resident 29's hair was greasy.During an observation, on 11/24/25 at 11:57 a.m., Resident 29's hair remained greasy. During an observation, on 11/25/25 at 10:32 a.m., Resident 29's hair was extremely greasy. The clinical record for Resident 29 was reviewed on 11/24/25 at 11:15 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, cognitive communication deficit, hypertension, glaucoma, pressure ulcer right buttock, and dementia.A care plan, dated 6/4/23, indicated Resident 29 required assistance with activities of daily living care. The interventions included, but were not limited to, personal hygiene and bathing assistance.A facility document, titled Care Giver Body Check Worksheet, indicated the resident received six (6) showers or bed baths from October 1 through October 31, 2025. There was no documentation to indicate the resident's hair was washed.A facility document, titled A Care Giver Body Check Worksheet, indicated the resident received five (5) showers or bed baths from November 1 through November 23, 2025. There was no documentation to indicate the resident's hair was washed.During an interview, on 11/25/25 at 9:52 a.m., the Director of Nursing (DON) indicated Resident 29 had some pain and behaviors. She did not know when the resident last had a shower. The CNAs completed a form, and the nurse signed the form. Resident 29 required a mechanical lift, and it was harder to get the resident in the shower with her behavior. They did have shower caps which helped the CNAs wash the residents' hair. During an interview, on 11/25/25 at 9:55 a.m., the Administrator indicated she kept close tabs on the shower caps. The CNA could use one to wash the resident's hair. She was unaware of the last time the resident had her hair washed with a shower cap. During an interview, on 11/25/25 at 10:15 a.m., CNA 9 indicated she did not normally work on Resident 29's unit. The facility had CNA care sheets which would tell when the residents' showers were scheduled. Resident 29's showers were scheduled for Monday and Thursdays. A CNA job description, dated 1/21/25 and received from the Administrator on 11/26/25 at 11:41 a.m., indicated .This role involves assisting residents with activities of daily living, medication reminders, and social and spiritual pursuits. This position will render personal care to residents and monitor their physical and cognitive wellbeing .Assist residents with activities of daily living including but not limited to; bathing, dressing, grooming, toileting, and medication reminders in accordance with care plans and established community policies and procedures A current facility policy, titled Activities of Daily Living (ADLs), dated 12/1/23 and received from the Administrator on 11/26/25 at 11:12 a.m., indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate A current facility policy, titled Resident Rights, dated 4/1/23 and received from the Administrator on 11/26/25 at 11:13 a.m., indicated .Residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Community .Residents have the right to be treated as individuals with consideration and respect for their privacy. Privacy shall be afforded for at least the following: a. Bathing. b. Personal care 3.1-38(a)(2)(A)3.1-38(a)(3)(B)3.1-38(b)(2)3.1-38(b)(3)3.1-38(f)

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Record Review (PASARR) screenings were accurate when completed and updated when new mental health diagnoses and medications were initiated for 2 of 2 residents reviewed for PASARR. (Resident 3 and 19)Findings include: 1. The clinical record for Resident 3 was reviewed on 11/24/25 at 11:24 a.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, anxiety, depression, and a psychotic disorder not due to a substance or known physiological condition. A notice of PASARR level I screen outcome, dated 2/10/25, did not include Resident 3's medication clozapine (an atypical antipsychotic).A physician's order, dated 10/3/25, indicated the resident was to receive clozapine 37.5 milligrams once a dayDuring an interview, on 11/25/25 at 10:05 a.m., the admission Coordinator indicated Resident 3 was on clozapine on admission. The medication should have been on her level 1 PASARR.2. The clinical record for Resident 19 was reviewed on 11/24/25 at 2:21 p.m. The diagnoses included, but were not limited to, dementia, anxiety, depression, and hypothyroidism. A notice of PASARR level I screen outcome, dated 11/7/23, indicated Resident 19 had a diagnosis of anxiety and was taking the medication Buspar.Resident 19's diagnosis list included depression with the start date of 8/29/24.A physician's order, with a start date of 8/30/24, indicated Resident 19 was on sertraline 25 milligrams once a day for depression.The notice of PASARR level I screen outcome did not include the diagnosis of depression. During an interview, on 11/25/25 at 10:05 a.m., the admission Coordinator indicated the PASARR for Resident 19 was not updated timely when a new mental health medication and diagnosis was added. The depression diagnosis was not included on the most recent PASARR and should be on the PASARR. A current facility policy, titled PASRR, Preadmission, screening and resident review - SNF, dated 6/1/23 and received from the Administrator on 11/25/25 at 12:52 p.m., indicated .The community will ensure that all new admissions are appropriately screened prior to admission to determine that the individual requires nursing community level of care and to identify any specialized services that may be necessary .Any resident of the community who has a condition of MI/ID/DD/Related Conditions who experiences a significant change in condition requiring reassessment, this must also be reviewed by the state specific agency 3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure assessments were completed and consent was obtained prior to the use of side rails for 1 of 2 residents reviewed for accident hazards. (Resident 21) Finding includes: During multiple observations, on 11/21/24 at 10:14 a.m., 11/22/24 at 9:13 a.m., and 11/25/24 at 10:47 a.m., a 1/4 side rail was raised and in use on Resident 21's bed. The clinical record for Resident 21 was reviewed on 11/22/24 at 12:36 p.m. The diagnoses included, but were not limited to, unspecified fracture of sacrum, low back pain, radiculopathy lumbar region, spinal stenosis, muscle weakness, diastolic congestive heart failure, cerebral infarction, and chronic pulmonary hypertension. A side rail assessment, completed on 11/1/24 at 4:17 p.m., indicated side rails were not indicated. The electronic record did not have documentation showing the risks and benefits of side rails were explained to Resident 21 or a consent was obtained prior to the use of side rails. During an interview, on 11/22/24 at 2:37 p.m., the Administrator indicated there was not a physician's order for side rails. A physician's order, dated 11/25/24 at 4:41 a.m., indicated to utilize 1/4 side rails to increase independence in bed mobility and in transfers. The physician's order was obtained after the side rails were on the resident's bed. During an interview, on 11/25/24 at 12:07 p.m., the Director of Nursing indicated the resident did not have a side rail assessment or consent completed until 11/25/24. The consent and assessment should have been completed when the side rails were applied. A current facility policy, titled Bed Safety and Bed Rails, last revised August 2022 and received from the Administrator on 11/22/24 at 3:10 p.m., indicated .The use of bed rails or side rails .is prohibited unless the criteria for use of bed rails have been met .including .resident assessment and informed consent .Before using bed rails for any reason, the staff shall inform the resident or representative about .the benefits and potential hazards associated with bed rails and obtain informed consent 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure staff obtained a follow-up weight and notified the physician of a weight gain for 1 of 1 resident reviewed for weight changes. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 11/22/24 at 12:16 p.m. The diagnoses included, but were not limited to, dementia without behavioral disturbances, cognitive communication deficit, major depressive disorder, and anxiety disorder. A physician's order, dated 6/21/24, indicated the resident was to receive Ensure (a dietary supplemental drink) three times a day. A care plan, revised on 8/28/24, indicated the resident had increased nutrient needs related to a wound to the coccyx. The interventions included, but were not limited to, diet as prescribed, monitor weight monthly, monitor oral intake of food and fluid, and to give a dietary supplement three times a day. The resident had the following weights: 1. On 11/4/24, the weight was 124.5 pounds. 2. On 11/11/24, the weight was 134.8 pounds. The resident had an 8.27% weight gain in 7 days. There was no documentation to indicate a new weight was obtained to verify the weight gain. There was no documentation of the physician being notified of the weight gain. During an interview, on 11/25/24 at 4:01 p.m., the Director of Nursing (DON) indicated when a resident had a weight loss or gain, she would discuss the weight with the dietitian. The residents with a weight loss or gain should be reweighed. During an interview, on 11/25/24 at 4:10 p.m., the Registered Dietician indicated she was in the building three days a week. The facility policy indicated when a resident had a weight gain or loss the resident should be weighed within 72 hours of the first weight. A current policy, titled Change of Condition, dated 12/1/23 and received from the Director of Nursing (DON) on 11/25/24 at 4:09 p.m., indicated .The Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition .Unless otherwise instructed by the resident, the Nurse will notify the resident's family or representative when .There is a significant change in the resident's physical, mental, or psychosocial status A current policy, titled Weight Management in Health Care Center, dated 9/1/22 and received from the Director of Nursing (DON) on 11/25/24 at 4:09 p.m., indicated .The staff nurse will validate that the weight is within acceptable limits. If a resident has a gain or loss of 5 pounds from their previous weight, a new weight must be obtained within 48 hours .The Registered Dietician is responsible for monitoring all weight changes and documenting significant weight loss/gain 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure medication carts were free from expired medications, medical supplies, and loose pills, and medications were properly labeled after opening for 1 of 2 medication carts reviewed for medication storage and labeling. (Hall 1) Findings include: During a medication storage observation, on 11/22/24 at 10:14 a.m., the following was observed: 1. Drawer 1 of the medication cart had: a. One (1) Erythromycin Ophthalmic Ointment (an antibiotic ointment for the eye) 5 mg (milligram) opened and not dated. b. Six (6) SwabCaps (a disinfecting cap for peripherally inserted central catheter) were in the cart and passed the expiration date of 11/1/24. During an interview, on 11/22/24 at 10:25 a.m., LPN 4 indicated the SwabCaps were expired and should not have been in the medication cart. 2. Drawer 2 of the medication cart had: a. Famotidine (an acid reducing medication) 10 mg tablets with an expiration date of 11/22/24. b. Acetaminophen (a fever reducer/pain reliever) 325 mg tablets with an expiration date of 9/3/24. c. Loperamide (an anti-diarrheal medication) 2 mg tablets with an expiration date of 10/24. d. Acetaminophen 325 mg tablets with an expiration date 11/18/24. e. Docusate Sodium (a stool softener) 100 mg capsules with an expiration date of 10/2/24. f. Guaifenesin (a medication to relieve chest congestion) Extended Release 600 mg tablets with an expiration date of 11/14/24. g. Blood glucose test strips with an open date of 11/4/24 and an expiration date of 10/31/24, six test strips remained in the bottle. During an interview, on 11/22/24 at 10:31 a.m., QMA 4 indicated the Famotidine had been discontinued and should not have been in the medication cart. 3. Drawer 3 of the medication cart had: a. Acetaminophen 325 mg tablets with an expiration date of 11/18/24. b. One (1) loose pill, peach in color. 4. Drawer 4 of the medication cart had: a. Colace (a stool softener) 100 mg tablets opened with no open date. 5. Drawer 5 of the medication cart had: a. One (1) loose pill, yellow in color. During an interview, on 11/22/24 at 10:31 a.m., QMA 3 indicated the nurses with access to the medication carts were responsible for checking expiration dates and loose pills. Pharmacy performed audits on the medication carts and checked for expiration dates as well. When a medication was opened, the nurse was responsible for writing the date on the medication bottle. A current facility policy, titled MEDICATION STORAGE IN THE FACILITY, last revised January 2018 and received from the Administrator on 11/22/24 at 1:53 p.m., indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory .and reordered from the pharmacy .Certain medications or package types such as .blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date .The nurse will check the expiration date of each medication before administering it .No expired medication will be administered to a resident .All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining 3.1-25(j) 3.1-25(k)(6) 3.1-25(o)

Based on interview and record review, the facility failed to ensure the policy and procedure for conducting an Abnormal Involuntary Movement Scale (AIMS) assessment upon admission and quarterly was followed for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 16) Finding includes: The clinical record for Resident 16 was reviewed on 11/22/24 at 12:37 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, unspecified dementia with psychotic disturbance, metabolic encephalopathy, chronic kidney disease, and unspecified convulsions. A physician's order, dated 11/27/23, indicated to give Seroquel (an antipsychotic) 50 milligrams two times a day for dementia with aggression. A care plan, revised on 5/14/24, indicated the resident used psychotropic medications related to dementia with aggression. An intervention indicated staff were to monitor and document any adverse reactions such as tardive dyskinesia. An AIMS assessment (a scale used to assess for tardive dyskinesia and its severity when prescribed antipsychotic medications) was completed on 10/16/24 at 6:03 p.m. During an interview, on 11/25/24 at 2:53 p.m., the Director of Nursing (DON) indicated an AIMS assessment was not completed for the resident until 10/16/24. This was the only AIMS assessment conducted for the resident. A current facility policy, titled Anti-psychotic Drug Use, dated 8/21/23 and provided by the DON on 11/25/24 at 4:06 p.m., indicated .The AIM's test should be completed upon beginning a new order for an anti-psychotic, and quarterly noting the appearance of any extra-pyramidal symptoms which previously were not present 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure a medication was held per the physician's order for 1 of 1 resident reviewed for quality of care. (Resident 131) Finding includes: The clinical record for Resident 131 was reviewed on 11/22/24 at 9:17 a.m. The diagnoses included, but were not limited to, essential hypertension, unspecified atrial fibrillation (a-fib), and transient cerebral ischemic attack (stroke). A physician's order, with a start date of 11/15/24, indicated Carvedilol (a medication to treat high blood pressure) oral tablet 6.25 milligrams. Give twice per day. Hold if the systolic blood pressure (SBP) was under 120. A review of the November Medication Administration Record (MAR) indicated: On 11/17/24, the systolic blood pressure was 117. Carvedilol was administered on the AM shift. On 11/17/24, the systolic blood pressure was 113. Carvedilol was administered on the PM shift. During an interview, on 11/25/24 at 9:41 a.m., RN 2 indicated the medication was not held and was given. The medication should have been held and a progress note should have been made. There was no progress note in the chart. During an interview, on 11/25/24 at 11:33 a.m., the Director of Nursing (DON) indicated the medication was administered on those shifts. A current facility policy, titled PREPERATION AND GENERAL GUIDELINES, dated as reviewed March 2021 and received from the Executive Director on 11/25/24 at 2:12 p.m., indicated .Medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so .Medications are administered in accordance with written orders of the prescriber 3.1-37(a)

Based on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) Level I was submitted after a new mental health diagnoses was added and an antidepressant medication was prescribed for 1 of 1 resident reviewed for PASARR. (Resident 1) Finding includes: The clinical record for Resident 1 was reviewed on 11/22/24 at 12:16 p.m. The diagnoses included, but were not limited to, dementia without behavioral disturbances, cognitive communication deficit, major depressive disorder, and anxiety disorder. A PASARR level I, dated 5/28/24, indicated the resident had no mental health diagnosis, dementia or neurocognitive disorder and no mental health medication. A physician's order, dated 8/31/24, indicated to give sertraline (an antidepressant medication) 100 milligram (mg) daily. There was no PASARR level I completed when the resident was ordered sertraline. During an interview, on 11/25/24 at 3:37 p.m., the Social Service Director (SSD) indicated a new level I PASARR was not completed. The admission staff would be in charge of implementing the PASARR and missed completing a new level I when a new antidepressant medication was ordered. The new diagnosis for this medication was not added. A current facility policy, titled Preadmission Screening and Annual Resident Review [PASAR], Preadmission, Screening & Resident Review - SNF, dated 6/1/23 and received from the Director of Nursing (DON) on 11/25/24 at 4:09 p.m., indicated .PASRR requires that all people entering Medicaid-certified nursing communities are evaluated for: Serious Mental Illness (SMI); Intellectual Disability (ID); Developmental Disabilities (DD); are placed in the most appropriate setting, and receive assessments to identify their service needs regardless of (the individual's) method of payment .The community will ensure that all new admissions are appropriately screened prior to admission to determine that the individual requires nursing community level of care and to identify any specialized services that may be necessary .Any resident of the community who has a condition of MI/ID/DD/Related Conditions who experiences a significant change in condition requiring reassessment, this must also be reviewed by the state specific agency 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a resident who needed assistance with eating was assisted timely for 1 of 11 residents observed in the dining room. (Resident 10) Finding includes: During a continuous dining observation in the main dining room, on 11/21/24 from 11:34 a.m. to 12:41 p.m., the following was observed: At 11:40 a.m., the first food tray was delivered to a resident in the dining room. Resident 10 was at her table waiting for her tray. At 12:14 p.m., a resident was helped to the dining room by therapy. She was then served her food at 12:31 p.m. Resident 10 was still waiting for her food. At 12:20 p.m., the kitchen staff were picking up food trays for multiple residents who had received their meals and were done eating. The staff was returning the trays to the kitchen. Resident 10 was still waiting for her tray. At 12:32 p.m., CNA 7 indicated Resident 10 was a feed and needed help eating. They usually waited until a CNA was available to serve a resident who needed help eating. CNA 7 was not observed passing trays and could have helped the resident eat. Resident 10 was still waiting on her food tray. At 12:38 p.m., a male resident came to the dining room from his room. He originally had a room tray but then came to the main dining room to eat. He sat down and was delivered his tray. Resident 10 was still waiting for her food. At 12:39 p.m., the kitchen staff were picking up more food trays from several residents who were done eating. Resident 10 was still waiting on her tray. At 12:41 p.m., Resident 10 was finally served her tray. It was over an hour from the first tray being passed to when Resident 10 received her food tray. Resident 10 watched several residents come to the dining room after her and receive their trays before she did. The clinical record for Resident 10 was reviewed on 11/25/24 at 12:00 p.m. The diagnoses included, but were not limited to, unspecified dementia, dysphagia (difficulty swallowing), depression, and basal cell carcinoma. A care plan, initiated on 8/12/24 and last revised on 11/5/24, indicated Resident 10 had increased nutrient needs. Interventions included, but were not limited to, provide food and fluids and provide dining assistance as necessary. A physician's order, with a start date of 8/5/24, indicated general diet, puree texture, and thin liquid consistency. During an interview, on 11/22/24 at 2:50 p.m., the Executive Director (ED) indicated they usually served residents as they came to the dining room. They would serve independent residents first, then pass room trays, and then pass trays to the residents who needed fed so a CNA could be available. Residents should not have to wait an hour for their trays to be served. A current policy, titled DINING AND FOOD SERVICES EXPERIENCE, last reviewed on 5/18/21 and received from the ED on 11/25/24 at 2:12 p.m., indicated .A resident's quality of life may be enhanced through their dining and/or food experience. The dining and/or food service is provided to ensure that nourishing, palatable and attractive meals based on individual resident needs are served, and that both food service and facility staff assist and support residents during the dining and/or food experience .Residents shall be promptly assisted with eating and provide necessary cueing 3.1-3(t)

Based on observation, interview and record review, the facility failed to notify the physician of significant weight changes for 4 of 6 residents reviewed for nutrition. (Residents 24, 10, 14, and 18) Findings include: 1. The record for Resident 24 was reviewed on 11/29/23 at 2:08 p.m. Diagnoses included, but were not limited to, type 2 diabetes, cellulitis, morbid obesity, and chronic kidney disease stage 3. A weight log indicated the following: On 10/2/23, the resident weighed 317 pounds. On 10/9/23, the resident weighed 319.2 pounds. On 11/1/23, the resident weighed 329.4 pounds. On 11/22/23, the resident weighed 343.6 pound. There was a significant weight gain of 8.3%, from 10/2/23 to 11/22/23, in 51 days. There was no notification to the physician noted in the record about the significant weight gain. 2. The record for Resident 10 was reviewed on 11/29/23 at 4:09 p.m. Diagnoses included, but were not limited to, type 2 diabetes, cellulitis of left lower limb, obesity, and osteomyelitis. A weight log indicated the following: On 11/1/2022, the resident weighed 301.4 pounds. On 11/17/2022, the resident weighed 301.4 pounds. On 12/4/2022, the resident weighed 318.4 pounds. On 1/5/2023, the resident weighed 284.2 pounds. On 2/4/2023, the resident weighed 315.2 pounds. On 2/15/20, the resident weighed 315.2 pounds. The resident had a significant weight gain of 5.64% from 11/17/22 to 12/4/22, and a significant weight loss of 10.74% from 12/4/22 to 1/5/23. There was no notification to the physician noted in the record about the significant weight changes. 3. The record for Resident 14 was reviewed on 11/30/23 at 10:37 a.m. Diagnoses included, but were not limited to, fluid overload, type 2 diabetes, morbid obesity, and chronic kidney disease. A physician's order, with a start date of 10/3/23 and an end date of 10/31/23, indicated to weigh the resident one time a day for 4 weeks. A weight log indicated the following: On 10/9/2023, the resident weighed 262.4 pounds. On 10/19/2023, the resident weighed 310.6 pounds. On 10/20/2023, the resident weighed 310.9 pounds. On 10/22/2023, the resident weighed 229.0 pounds. There was an 18.37% weight gain from 10/9/23 to 10/19/23, and a 26.34% weight loss from 10/20/23 to 10/22/23. There was no notification to the physician noted in the record about the significant weight changes. During an interview, on 12/1/23 at 4:53 p.m., the DON (Director of Nursing) indicated the facility should report significant weight changes to the provider. 44598 4. The record for Resident 18 was reviewed on 12/1/23 at 10:46 a.m. Diagnoses included, but were not limited to, gastrostomy (an artificial external opening into the stomach for nutritional support), dysphagia (difficulty swallowing), and cognitive communication deficit. A physician's order, dated 11/2/23, indicated weights on Monday for four weeks. A care plan, dated as revised 11/13/23, indicated the resident was at risk for nutrition and hydration risk related to dysphagia. Interventions included, but were not limited to, monitor oral intake of food and fluids, monitor weights weekly, diet as prescribed, and supplement at meals. The resident had the following weights: a. On 11/2/23, the resident's weight was 159 pounds. The weight was listed as confirmed. b. On 11/27/23, the resident's weight was 140 pounds. The weight was listed as confirmed which was a 11.95% (significant) weight loss in 25 days. During an interview, on 11/30/23 at 2:58 p.m., the DON indicated there was no documentation for notifying the physician or family of the 11.95% decrease in 25 days, from 11/2/23 to 11/27/23, and both should have been made aware. The Dietitian focused mainly on malnutrition and not significant weight loss. They follow the facility policy, and it stated both the physician and the family needed to be notified of a significant weight loss. A current policy, titled Weight Assessment and Intervention, dated 3/22 and received from the DON on 11/30/23 at 4:10 p.m., indicated .Resident weights are monitored for undesirable or unintended weight loss or gain .Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe A current policy, titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated 9/2017 and received from the DON on 11/30/23 at 4:10 p.m., indicated .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time .The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake .The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure supplements were secured in a resident's room for 1 of 1 resident reviewed for medication storage. (Resident 3) Finding includes: During an interview, on 11/27/23 at 12:33 p.m., Resident 3 had supplements all throughout his room, unsecured and in plain view. The resident indicated the facility did a self-administration assessment and allowed him to keep the supplements in his room. The record for Resident 3 was reviewed on 11/29/23 at 12:37 p.m. Diagnoses included, but were not limited to, type 2 diabetes, chronic kidney disease stage 3, and aneurysm (dilation of the wall of an artery) of an artery of the lower extremity. A physician's order, dated 8/8/22, indicated the resident could keep supplements and vitamins at bedside. During an observation, on 11/27/23 at 2:50 p.m., the resident was not in his room and his door was open with the supplements in view. During an observation, on 11/28/23 at 10:13 a.m., the resident was not in his room and his door was open with the supplements in view. During an observation, on 11/28/23 at 10:33 a.m., the resident was not in his room and his door was open with the supplements in view. During an observation, on 11/29/23 at 10:21 a.m., the resident was not in his room and his door was open with the supplements in view. During an interview, on 11/29/23 at 12:44 p.m., the DON (Director of Nursing) indicated their policy did not state supplements had to be locked up and secured. Some of the supplements the resident had, if ingested by other residents, could be dangerous. During an interview, on 12/2/23 at 4:55 p.m., the DON indicated the facility did not have a policy on medication storage which included storing supplements. 3.1-25(m)

Based on record review and interview, the facility failed to ensure symptom monitoring was in place for the use of an anticoagulant and a diuretic medication prescribed for 2 of 5 residents reviewed for unnecessary medications. (Resident 4 and 230) Findings include: 1. The record for Resident 4 was reviewed on 11/30/23 at 2:41 p.m. Diagnoses included, but were not limited to, retention of urine, atrial fibrillation, dementia, anxiety disorder, and cognitive communication deficit. A physician's order, dated 4/28/23, indicated Eliquis (an anticoagulant) 2.5 milligram (mg) tablet by mouth two times a day. A physician's order, dated 4/28/23, indicated Furosemide (a diuretic) 20 mg tablet by mouth two times a day. There was no documentation, physician's order, or care plan for monitoring side effects for the use of an anticoagulant or a diuretic medication. During an interview, on 12/1/23 at 9:00 a.m., the Director of Nursing (DON) indicated there should be care plans for both the anticoagulant and diuretic medication. The care plans sometimes would get deleted. The anticoagulant and diuretic medications should be monitored for side effects. 48525 2. The record for Resident 230 was reviewed on 11/29/23 at 12:05 p.m. Diagnoses included, but were not limited to, encephalopathy (disease which caused confusion), history of stroke, heart failure, and cognitive communication deficit. A physician's order, dated 11/17/23, indicated the resident was taking Eliquis 5 mg tablet twice per day. There was no physician's order or care plan to monitor for bleeding in the resident's record. During an interview, on 11/30/23 at 2:49 p.m., the DON (Director of Nursing) indicated if a resident was on an anticoagulant medication, then there should be monitoring for the risk of bleeding. A current policy, titled Anticoagulation - Clinical Protocol. dated as revised November 2018 and received from the DON on 11/20/23 at 4:00 p.m., indicated .Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications .If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next schedule dose of anticoagulation 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to keep a catheter bag from touching the ground for 1 of 2 residents reviewed for urinary catheter. (Resident 230) Finding includes: During an observation, on 11/27/23 at 2:53 p.m., Resident 230's catheter bag was touching the ground while he was lying in bed. During an observation, on 11/28/23 at 10:15 a.m., Resident 230's catheter bag was touching the ground while he was lying in bed. During an interview, on 11/28/23 at 11:10 a.m., RN 9 indicated the catheter bag should not be touching the ground. The record for Resident 230 was reviewed on 11/29/23 at 12:05 p.m. Diagnoses included, but were not limited to, encephalopathy (disease which caused confusion), cognitive communication deficit, benign prostatic hyperplasia (enlarged prostate glands), edema, history of a stroke, and type 2 diabetes. A physician's order, dated 11/27/23, indicated the resident had an indwelling 16 French size foley catheter. During an interview, on 11/28/23 at 3:25 p.m., the DON (Director of Nursing) indicated the catheter bag should not be touching the ground. A current policy, titled FOLEY CATHETER MANAGEMENT, dated as effective 9/1/23 and received from the DON on 11/30/23 at 4:10 p.m., indicated .Be sure the catheter tubing and drainage bag are kept off the floor 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to provide incontinence care for 1 of 3 residents reviewed for Activity of Daily Living (ADL). (Resident B) Finding includes: The record for Resident B was reviewed on 11/30/22 at 10:46 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbances, Parkinson's disease, and bowel and bladder incontinence. A care plan, dated as revised 8/2/23, indicated the resident was dependent on staff for most ADLs. Interventions included, but were not limited to, toileting, bowel and bladder incontinent, frequently check brief for soiling, personal hygiene, grooming and bathing the resident was dependent on staff assistance, utilize appropriate staff to assist the resident with ADLs. He was a maximum assist for most ADLs. During an observation, on 11/30/23 at 3:17 p.m., the hallway outside Resident B's room had a very strong odor. The resident was laying on his bed with a blanket covering his lower body. There was a soiled brief which contained urine and bowel movement along with a pair of pants pushed down toward the end of the bed and was dangling off the end of the mattress. During an interview, on 11/30/23 at 3:20 p.m., the Administrator entered the room and noticed the resident's pants and dirty brief. The Administrator told the resident she would get someone to assist him. During an observation, on 12/01/23 at 9:55 a.m., Resident B was sitting in the common area in front of the fireplace listening to Christmas music with a white sheet over his legs. During an observation, on 12/01/23 at 10:57 a.m., Resident B was being taken to his room by two CNAs for a shower. During an interview, on 12/01/23 at 10:57 a.m., CNA 4 indicated the last time the resident's brief was changed was at 7:00 a.m., when she got the resident up. During an interview, on 12/1/23 at 10:58 a.m., CNA 2 indicated she changed residents every two hours. Resident B had not been changed for almost four hours due to being busy with other residents. She had residents who required Hoyer lifts and a staff member called off today. Both CNA 4 and 2 indicated it was hard to get all their stuff done. The CNAs were observed to transfer the resident to the shower chair and pull down his brief and pants. His brief was wet, and his buttocks was red and pink in color. A current policy, titled Activities of Daily Living (ALDs), Supporting, dated 3/2018 and received by the Director of Nursing (DON) on 12/1/23 at 2:00 p.m., indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care) .elimination (toileting) This Federal Tag relates to Complaint IN00406166. 3.1-38(a)(2)(C)

Based on interview and record review, the facility failed to update care plans for an anticoagulant and a diuretic medication for 1 of 1 resident reviewed for care plans. (Resident 4) Finding includes: 1. The record for Resident 4 was reviewed on 11/30/23 at 2:41 p.m. Diagnoses included, but were not limited to, retention of urine, atrial fibrillation, dementia, anxiety disorder, and cognitive communication deficit. A physician's order, dated 4/28/23, indicated Eliquis (an anticoagulant) 2.5 milligram (mg) tablet by mouth two times a day. A physician's order, dated 4/28/23, indicated Furosemide (a diuretic) 20 mg tablet by mouth two times a day. A care plan for the anticoagulant or diuretic medication was not located. During an interview, on 12/1/23 at 9:00 a.m., the Director of Nursing (DON) indicated there should be care plans for the anticoagulant and diuretic medication. The care plans sometimes would get deleted and the anticoagulant and diuretic medication should be monitored. A current policy, titled Resident Comprehensive Career Plans - Skilled Nursing Facility (SNF), dated 5/23/23 and received from the DON on 12/1/23 at 2:00 p.m., indicated .Review and revise the care plan after each assessment. After each assessment means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS) as required, except discharge assessments .The baseline care plan must be based on the admission orders, information about the resident available from transferring provider, and discussion with the resident and resident representatives' participation in the care planning process 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure call lights were in reach and a bed was not in a high position for 1 of 1 resident reviewed for accommodation of needs. (Resident 23) Finding includes: During an observation, on 11/30/23 at 12:17 p.m., the call light was laying on the left side of the resident. The resident was unable to use her left hand to push the call light button for assistance. The resident's bed was raised in the highest position. The record for Resident 23 was reviewed on 11/30/23 at 11:48 a.m. Diagnoses included, but were not limited to, cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (paralysis which could affect the arms, legs and facial muscles) following cerebral infarction affecting left non-dominant side, and muscle weakness. A care plan, dated 5/26/23, indicated the resident had a history of cerebral vascular accident (CVA) with left side hemiparesis. Interventions included, but were not limited to, monitor and document the resident's ability for activity of daily living (ADL) and assist resident as needed. A care plan, dated 11/10/22, indicated the resident was a high risk for falls. Interventions included, but were not limited to, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. During an interview, on 11/30/23 at 12:50 p.m., CNA 2 indicated the facility had college students providing care to the resident. The students were the last ones in the resident's room. CNA 2 did not know when the students left or how long the bed was up in the highest position. The resident could not use her left arm and the call light should be on the right side where she could reach it. During an interview, on 11/30/23 at 12:57 p.m., CNA 2 indicated she was assigned to the resident and the bed should not be left up high and the call light should be placed on the resident's right side. During an interview, on 11/30/23 at 1:09 p.m., LPN 4 indicated the bed in the resident's room should never be left up high for safety reasons. The resident was not able to use her left arm to put her call light on and the resident needed the call light. A current policy, titled Answering the Call Light, dated 9/22 and received from the DON on 12/1/23 at 2:00 p.m., indicated .The purpose of this procedure is to ensure timely responses to the resident's request and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor 3.1-3(v)(1)

Based on interview and record review, the facility failed to submit a revised Preadmission Screen and Resident Review (PASARR) Level I after a new mental health diagnoses and the resident was prescribed an antipsychotic and antianxiety medication for 1 of 1 resident reviewed for PASARR. (Resident B) Finding includes: The record for Resident B was reviewed on 11/30/22 at 10:46 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbances, Parkinson's disease, and bowel and bladder incontinence. A PASARR Level I, dated 7/24/23, indicated the resident had no mental health diagnoses, dementia, or neurocognitive disorder. The resident did not have an antianxiety or antipsychotic medications ordered. If changes occur or new information refutes these findings, a new screen must be submitted. A physician's order, dated 11/28/23, indicated lorazepam (an antianxiety medication) 0.5 milligram (mg) tablet by mouth three times a day. A physician's order, dated 11/28/23, indicated lorazepam (an antianxiety) 0.5 mg tablet by mouth every 6 hours when needed. A physician's order, dated 11/27/23, indicated Seroquel (an antipsychotic) 25 mg tablet by mouth three times a day. There was no PASARR Level I completed when the resident was ordered lorazepam and Seroquel. No diagnoses of anxiety or behaviors were added. During an interview, on 12/1/23 at 9:00 a.m., the Director of Nursing (DON) indicated a new Level I PASARR was not completed. The Social Services Director (SSD) would oversee implementing the PASARR. The SSD missed completing a new Level I PASARR when a new antipsychotic and antianxiety medication was ordered. The new diagnoses for these medications were not added to the resident's diagnoses list. A current policy, titled Preadmission Screening and Annual Resident Review [PASAR], Preadmission, Screening & Resident Review - SNF, dated 5/23/23 and received from the DON on 12/1/23 at 2:00 p.m., indicated .PASRR requires that all people entering Medicaid-certified nursing communities are evaluated for: Serious Mental Illness (SMI); Intellectual Disability (ID); Developmental Disabilities (DD); are placed in the most appropriate setting, and receive assessments to identify their service needs regardless of (the individual's) method of payment .The community will ensure that all new admissions are appropriately screened prior to admission to determine that the individual requires nursing community level of care and to identify any specialized services that may be necessary .Any resident of the community who has a condition of MI/ID/DD/Related Conditions who experiences a significant change in condition requiring reassessment, this must also be reviewed by the state specific agency 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to have nurse staffing posted and, in a location, where it could easily be viewed for 4 of the 5 days during the survey. (November 27, 28, 29 and 30) Finding includes: During an observation, on 11/28/23 at 10:00 a.m., the surveyors could not locate the posted nurse staffing. During an interview, on 11/30/23 at 10:28 a.m., the Director of Nursing (DON) indicated the nurse staffing was not posted. The nurse staff posting needed to be written out and she did not have time to post the staffing. She knew the daily staffing needed to be displayed where everyone could see it. A current policy, titled, Posting Direct Care Daily Staffing Numbers, revised on 8/2022 and received from the Director of Nursing (DON) on 12/1/23 at 2:00 p.m., indicated, .Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents .Within two (2) hours of the beginning of each shift, the number of licensed nurses (RN's, LPN's, and LVN's and the number of unlicensed nursing personnel (CNAs and NA's) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .Records of staffing information for each shift are kept for a minimum of eighteen (18) months or as required by state law (whichever is greater) 3.1-17(b)

Based on observation, interview and record review, the facility failed to ensure a pressure wounds did worsen from a stage 2 to the resident requiring hospitalization for osteomylits and gangrene of 4th and 5th toe for 1 of 2 residents reviewed for pressure ulcers (Resident 24). Findings include: During an observation, on 8/16/19 at 1:27 p.m., Resident 24 was sitting up in a salon chair in the facility beauty shop. The resident was wearing a soft blue splint on her right lower leg and RN 1 indicated the resident had pressure areas on her heel and toes and wore the splint due to the pressure areas. The record for Resident 24 was reviewed on 8/16/19 at 1:27 p.m. [DIAGNOSES REDACTED]. A care plan, not dated, indicated the resident wore a brace or boot to the right leg to help with foot drop. The interventions included, but were not limited to, observe the skin under the brace or boot every shift for changes. A care plan, not dated, indicated the resident had a history of [REDACTED]. A physician's order, dated 7/21/19 and discontinued on 8/2/19, indicated a short leg brace was to be worn and removed after the resident was in bed, to observe for changes to the skin and remove the brace every shift and observe for changes in the skin. A wound assessment, dated 7/21/19, indicated the resident had an abrasion on her right 4th outer toe, length 0.5 cm, width 0.5 cm and depth 0.1 cm. The treatment was topical antibiotic ointment and a bandage. A wound assessment, dated 7/26/19, indicated the wound was worsening and infected. The length was 2 cm, depth 1.5 cm and depth 0.1 cm. There was increased warmth to the right foot, redness extending down the foot and the redness was marked to observe for further spreading. The physician was notified and Keflex (an antibiotic was ordered). A physician's order, dated 7/26/19, indicated Keflex (an antibiotic) 500 milligram (mg) four times daily for seven days. A wound assessment, dated 8/2/19, indicated the resident had an abrasion on her right 5th inner toe, length 0.8 centimeter (cm), width 0.5 cm, depth 0.1 cm with scant serous (yellow tinged and clear) drainage. The treatment was [MEDICATION NAME] (a wound and burn dressing) and a foam dressing daily. The resident indicated the wounds to her toes occurred due to her foot/leg brace holding in moisture between her toes and the resident was no longer wearing the brace. A wound assessment, dated 8/2/19, indicated the wound was healing. The length was 2 cm, width 1.3 cm and depth 0.1 cm. There was no redness, warmth or odor noted. The treatment was [MEDICATION NAME] and foam dressing daily. A wound clinic note, dated 8/7/19, indicated to start a new daily dressing to the resident's right 4th toe ulcer. Gently cleanse wound with normal saline, to pat dry, apply 1/8 inch santyl (an enzyme used to help the healing [MEDICAL CONDITION] skin ulcers) ointment to the open wound on toe, apply [MEDICATION NAME] (a foam based dressing to help avoid infection of open wounds) blue dressing to cover toe wound, moisten lightly with saline and squeeze out excess saline, cover and separate the 4th and 5th toe with foam dressing, secure foam and to avoid a shoe on right foot for now. A physician's order, dated 8/8/19, indicated to gently cleanse the wound one time daily with normal saline, to pat dry, apply 1/8 inch santyl ointment to open wound on toe, apply [MEDICATION NAME] blue dressing to cover the wound, moisten lightly with saline and squeeze out the excess, to cover and separate the 4th and 5th toe with foam dressing and secure the foam and to avoid a shoe on the right foot. The physician's order did not indicate which toe the dressing change was to be completed. A wound assessment, dated 8/9/19, indicated the wound status of the right 5th inner toe was worsening. The treatment was santyl, [MEDICATION NAME] blue with foam dressing daily. The measurements of the wound had increased to length 1.2 cm, width 0.6 cm and depth the same at 0.1 cm. There was 50% slough (dead tissue) and 50% granulation (healthy tissue). A wound assessment, dated 8/9/19 indicated the wound was worsening. The length was 2.5 cm, the width was 1.5 cm and the dept was 0.1 cm. The treatment was santyl and [MEDICATION NAME] blue with foam dressing daily. The wound was 25% slough and 75% granulation tissue. A Clinical Notes Report, dated 8/14/19 at 8:19 a.m., indicated the right 4th and 5th toe dressing was changed. The resident's caregiver was concerned because the top of the resident's right foot was slightly pink and warm. No other signs of infection were noted and the nurse indicated the site would continue to be observed. The Clinical Notes Report, dated 8/14/19 at 8:19 a.m., did not indicate the physician was notified of the pinkness and warm area of the top of the right foot. No measurements of the pink and warm area were documented. The resident was confused and disoriented. A Physician's Progress note, dated 8/15/19 and not timed, translated by the DON, indicated the right lateral toe wound was a stage 2 pressure ulcer, the right medial toe had a purulent (foul smelling) odor but no purulence (infection). The questionable mental status of the previous day had been resolved. The lab results were pending. The toe wound was clean and the resident received wound care from an outside wound clinic. The plan was to continue the same care. There was no documentation by the nursing staff of the condition of the top of the right foot the remainder of 8/14/19, no documentation on 8/15/19 and no documentation on 8/16/19 until 10:34 p.m. A Clinical Note, dated 8/16/19 at 9:30 p.m., indicated the wound to the right 4th and 5th toes had a huge change in appearance and both toes were a deep hue of purple and blue with peeling skin noted on the top of the toes. The physician was notified, an order for [REDACTED]. An emergency room report, dated 8/16/19 at 10:06 p.m., indicated the resident had right 4th and 5th toe wounds. The [DIAGNOSES REDACTED]. A hospital note, dated 8/17/19, indicated the resident had a right foot ulcer with [MEDICAL CONDITION], likely caused by her brace being worn too tightly, pretty extensively involving the foot and it could result in a limb threatening infection. An MRI (magnetic resonance imaging) scan, dated 8/17/19, indicated the impression of the fourth and fifth toes indicated possible osteo[DIAGNOSES REDACTED] (an infection of the bone). A hospital physician note, dated 8/19/19, indicated the resident had [MEDICAL CONDITION] to her right foot, well demarcated (distinguished) gangrene to 4th and 5th toes with exposed bone and positive for osteo[DIAGNOSES REDACTED] on MRI. The toes do not appear salvageable, but amendable (corrected) by amputation distally. Reviewed with the patient and the patient requested amputation. During an interview, on 8/20/19 at 1:38 p.m., the Medical Records/Wound Care/Clinical Educator nurse indicated she documented the 4th and 5th toes were worsening and did communicate the worsening to the physician, however she could not find documentation of notifying the physician of the worsening of the toes on 8/14/19. During an interview, on 8/21/19 at 5:03 p.m., the DON (Director of Nursing) indicated the staff nurses would have only documented on the condition of the resident's right foot if the condition had changed. She indicated there were no progress notes other than the note documented on 8/14/19 and 8/16/19 of the condition of the resident's right foot. A current policy, titled Skin Integrity Policy, dated 10/1/12 and received from the DON on 8/21/19 at 4:01 p.m., indicated, .It is the policy of the community to assess residents for skin integrity upon admission, weekly, and as needed thereafter .Purpose .to ensure skin integrity A current policy, titled Physician Notification of Resident Change of Condition, dated 10/1/2012, indicated, It is the policy of the community that the resident's physician will be notified of any change in the resident's condition .Purpose .To ensure that all residents receive prompt medical treatment to maintain optimal health and function .The nurse should not hesitate to contact the physician at any time for a resident problem which, in their best judgement, requires immediate medical attention .Outcome Evaluation .Monitor and re-evaluate the resident's status and responses to interventions .Documentation .All attempts to contact the physician .Physician's response 3.1-37(a)

Based on record review and interview ,the facility failed to notify the physician when the resident's pressure ulcer advanced in stage and size. This deficiency affected 1 of 3 residents reviewed for pressure ulcers.(Resident#2) Resident # 2's pressure ulcer increased from a Stage 3 to a Stage 4 ulcer and increased in size by greater 2 centimeters (cm) in length and and 3 cm width over a six week time frame without physician notification or intervention. Findings include: During the record review for Resident #2 on 7/22/15 at 1:30 p.m., a Wound /Skin Healing Record indicated a blister on the left ischium was noted and staged at Stage 2. It measured 0.6 centimeters (cm) length, 0.8 cm width, 0.1 cm depth. Physician notified on 4/20/15. Treatment was silver alginate daily with [MEDICATION NAME] dressing. 4/28/15: The wound measurement was 2.0 cm length, 2.0 cm width, 0.5 cm in depth. Dietary was notified on 4/28/15. Physician was notified on 4/28/15. Pressure Ulcer was staged at Stage 3. No change in treatment was noted. 5/5/15: The wound measurement was 2.0 cm length, 2.0 cm width, 0.5 cm depth. Stage 3, no change in treatment was noted. 5/12/15: The wound measurement was 2.0 cm length, 2.5 cm width, 0.3 cm depth, Stage 3, no change in treatment noted. 5/18/15: the wound measurement was 3.0 cm length, 3.2 cm width, 0.3 cm depth, Stage 3, no change in treatment noted. The Resident was seen in the wound care clinic. The treatment was changed to collagen powder with silver alginate with dressing. 5/25/15: The wound measurement was 3.5 cm length, 3.0 cm width, 0.2 cm depth, Stage 2 , no change in treatment noted. 6/2/15: The wound measurement was 3.4 cm length, 3.2 cm width, 0.3 cm depth, Stage 2, no change in treatment noted. 6/9/15: The wound measurement was 4.5 cm length, 5.0 cm width, 0.4 cm depth, Stage 3, no change in treatment noted. 6/16/15: The wound measurement was 5.0 cm length, 5.0 cm width, 0.4 cm depth, Stage 3, no change in treatment noted. 6/23/15: The wound measurement was 5.6 cm length, 5.5 cm width, 0.5 cm depth, Stage 4, no change in treatment noted. 6/30/15: The wound measurement was 5.6 cm length, 5.8 cm width, 0.4 cm depth, Stage 4, no change in treatment noted. 7/7/15: The wound measurement was 5.8 cm length, 5.6 cm width, 0.4 cm depth, Stage 4, no change in treatment noted. 7/14/15:The wound measurement was 5.9 cm length, 6.0 cm width, 0.3 cm depth, Stage 4, no treatment change noted. During an interview with the Interim Director of Nursing (DON) and the MDS (Minimum Data Set) Coordinator on 7/23/15 at 3:30 p.m., the MDS Coordinator indicated the wound care clinic managed the care for the resident. Physician on staff did not make changes to the treatment of [REDACTED]. A review of the policy titled Pressure Ulcer and Wound Management, not dated, indicated . treatment guidelines .record in progress notes at least weekly when skin problems are identified and reported to the physician . Weekly Skin Assessment Protocol .9. The nurse who identified the new or change in the skin condition is responsible for notifying the resident, physician and family/sponsor This Federal tag relates to complaint IN 503. 3.1-5(2)

Based on observation, record review and interview, the facility failed to provide provide pressure ulcer treatment, and failed to notify the physician when Resident # 2's pressure ulcer increased from a Stage 3 to a Stage 4 ulcer and increased in size by greater 2 centimeters (cm) in length and and 3 cm width over a six week time frame without physician notification or intervention for 1 of 3 residents reviewed for pressure ulcers. (Resident #2) Findings include: During the record review for Resident #2 on 7/22/15 at 1:30 p.m., a Wound /Skin Healing Record indicated a blister on the left ischium was noted and staged at Stage 2. It measured 0.6 centimeters (cm) length, 0.8 cm width, 0.1 cm depth. Physician notified on 4/20/15. Treatment was silver alginate daily with [MEDICATION NAME] dressing. 4/28/15: The wound measurement was 2.0 cm length, 2.0 cm width, 0.5 cm in depth. Dietary was notified on 4/28/15. Physician was notified on 4/28/15. Pressure Ulcer was staged at Stage 3. No change in treatment was noted. 5/5/15: The wound measurement was 2.0 cm length, 2.0 cm width, 0.5 cm depth. Stage 3, no change in treatment was noted. 5/12/15: The wound measurement was 2.0 cm length, 2.5 cm width, 0.3 cm depth, Stage 3, no change in treatment noted. 5/18/15: the wound measurement was 3.0 cm length, 3.2 cm width, 0.3 cm depth, Stage 3, no change in treatment noted. The Resident was seen in wound care clinic. The treatment was changed to collagen powder with silver alginate with dressing. 5/25/15: The wound measurement was 3.5 cm length, 3.0 cm width, 0.2 cm depth, Stage 2 , no change in treatment noted. 6/2/15: The wound measurement was 3.4 cm length, 3.2 cm width, 0.3 cm depth, Stage 2, no change in treatment noted. 6/9/15: The wound measurement was 4.5 cm length, 5.0 cm width, 0.4 cm depth, Stage 3, no change in treatment noted. 6/16/15: The wound measurement was 5.0 cm length, 5.0 cm width, 0.4 cm depth, Stage 3, no change in treatment noted. 6/23/15: The wound measurement was 5.6 cm length, 5.5 cm width, 0.5 cm depth, Stage 4, no change in treatment noted. 6/30/15: The wound measurement was 5.6 cm length, 5.8 cm width, 0.4 cm depth, Stage 4, no change in treatment noted. 7/7/15: The wound measurement was 5.8 cm length, 5.6 cm width, 0.4 cm depth, Stage 4, no change in treatment noted. 7/14/15:The wound measurement was 5.9 cm length, 6.0 cm width, 0.3 cm depth, Stage 4, no treatment change noted. 7/18/15: The wound measurement was 5.9 cm length, 6.0 cm width, 0.5 cm depth, Stage 4, Physician notified per telephone. A review of Wound Care Clinic progress note dated 7/1/15 , indicated Resident #2 had a left heel ulcer that continued to improve and decrease in size. During an interview with the Interim Director of Nursing (DON) and the MDS (Minimum Data Set) Coordinator on 7/23/15 at 3:30 p.m., the MDS Coordinator indicated the wound care clinic managed the care for the resident and the physician on staff did not make changes to the treatment of [REDACTED]. A review of the policy titled Pressure Ulcer and Wound Management, not dated, indicated . treatment guidelines .record in progress notes at least weekly when skin problems are identified and reported to the physician . Weekly Skin Assessment Protocol .9. The nurse who identified the new or change in the skin condition is responsible for notifying the resident, physician and family/sponsor This Federal tag relates to complaint IN 503. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to provide prevention interventions and timely treatment of [REDACTED]. This resulted in the residents redeveloping pressure ulcers after healing. (Residents #2, 12, and 17) Findings include: 1. The clinical record for Resident #2 was reviewed on 7/19/11 at 2:15 P.M. [DIAGNOSES REDACTED]. During observation of Resident #2 on 7/20/11 at 9:30 A.M., the resident was sitting in a wheelchair in the dining room. CNA #4 offered to take the resident to his room and he declined. CNA #4 did not reposition or offload the resident at this time. At 12:00 P.M. until 1:40 P.M., Resident #2 was in the dining room eating his lunch, the resident was not repositioned or offloaded during this time. Observation of Resident #2 on 7/21/11 at 9:53 A.M., the resident was sitting in the dining room finishing his breakfast with a Roho cushion in his wheelchair. CNA #4 helped to assist the resident into the recliner and placed the Roho cushion in the recliner seat at 10:30 A.M. Resident #2 asked if it was too early for bed and CNA #4 indicated she needed to keep him up because she will need to get him back up for lunch. Observation was made of Resident #2's wounds on 7/20/11 at 2:15 P.M. LPN #2 measured the left area on coccyx as 0.4 x 0.4 cm and did not measure the right buttock wound area. The area was pin point and scabbed over in appearance. The surrounding skin tissue was pink in color. A Minimum Data Set (MDS) yearly assessment, dated 7/1/11, indicated the resident was moderately cognitively impaired, required 2 person assist with transferring, bathing and hygiene, had no pressure ulcers, and had pressure reducing device for chair, bed and applications of ointments/medications. A resident care plan, dated 5/20/11, indicated "...Stage II pressure ulcer L with circle around it (left) buttock...1. [MEDICATION NAME] to coccyx, cover c with line over it (with) gauze, secure with tape BID (two times a day) per order see TAR (treatment administration record)...4. Assist to turn/reposition Q(every)2 hours when in bed..." A document titled 'Non-Pressure Skin Condition Report' on 5/18/11 indicated "...on R buttock an excoriated open area measuring 1 x .4 cm with s (without) indicated superficial depth. 5/20/11 New order For [MEDICATION NAME] c Polymem drsg, change q 3 days PRN initiated. 5/25/11 area measured 0.7 x 0.4 -6/1/11 area was healed...." Nurses notes indicated: 5/3/11 "...buttocks sl (slightly) reddened..." 5/19/11 "...skin impairment has "more depth"..." 5/24/11 "[MEDICATION NAME] with dressing applied to bil. (both sides) of coccyx..." No other nurses entries were noted regarding these areas during month of May. A document titled. 'Wound/Skin Healing Record' indicated: 5/20/11: "...AL side buttock,Stage II 0.5 x 0.5 cm superficial, pink,indicated notified dietician, physician and family 5/25/11: "...L side buttock, Stage II .5 x .5 cm superficial , pink, indicated notified dietary Physicians orders indicated: 5/20/11 "...Apply [MEDICATION NAME] to open area on coccyx, covered c with line over it (with) polymem drsg (dressing) change q 3 days and PRN (as needed) soilage..." 5/23/11 "...DC [MEDICATION NAME] et (and) Polymem to coccyx. triangle (change) to [MEDICATION NAME] to coccyx skin impairments cover with gauze et secure with tape..." A resident care plan, dated 6/3/11 and updated 6/20/11, indicated "...stage II open areas on buttocks and that the areas healed 6/27/11..." A document titled. 'Wound/Skin Healing Record' indicated: 6/1/11 : L side buttock healed..." 6/14/11: R side buttock, Stage II, .15 x .1, pink, currently applying Calmo BID requested new order, notified family 6/14/11: L side buttock, Stage II, .25x .25, currently requesting new order, receives Calmo BID, notified family 6/22/11: L side buttock, not staged .8 x .3, applying solosite c drsg, notified family 6/22/11: R side buttock, Stage II, .5 depth .2 , pink, applying Solo-Site c drsg 6/27/11: R side buttock healed 6/27/11: L side buttock healed Nurses notes indicated on 6/1/11 "...Red raised area 1.75cm x .6 cm present on R (right) outler (sic) buttock, hard to touch, notr (sic) to MD, [MEDICATION NAME] applied. There were no other nursing entries regarding the pressure ulcer or physician notification until 6/14/11. 6/14/11 "...Small open area noted on right and left coccyx,.physician notified and treatment requested..." 6/26/11 "...Open areas on buttocks improved; no drng (draining) or s/s (signs or symptoms) infection..." No other nursing entries were noted regarding open areas in month of June. Physicians orders noted; 6/21/11 "...Apply woundgel/Solosite to open areas on bil buttocks and cover with gauze BID and PRN soilage, until healed..." 6/23/11 "...D/C (discontinue) wound gel solosite to open area on bil buttocks healed..." There were no physician progress notes [REDACTED]. A current resident care plan, dated 7/1/11 and updated 7/19/11, indicated "...pressure ulcer risk related to poor mobility, incontinence...hx of skin breakdown in past...check for incontinence; clean and dry skin if wet or soiled. Perform complete skin assessment and record. Perform nutritional screening and providing Vitamin Therapy and Med pass (nutrition supplement) to help promote healing. Adjust diet/supplements as indicated to reduce the risk of skin breakdown. Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Use waffle overlay and Roho cushion on wheelchair to reduce pressure. Showers 3 x (times) per week to prevent excoriation...." Nurses notes indicated on 7/14/11 "...Res (resident) has 1.0 x 0.8 cm reddened open area on L coccyx. MD, spouse et Dietary notified. N.O. (new order) rec'd (received) to apply solosite to L coccyx open area BID x (times) 14 days then re-evaluate...." A document titled. 'Wound/Skin Healing Record' indicated: 7/13/11 "...Solosite to L coccyx open area BID x 14 days then re evaluate..." 7/13/11: L buttock 1.0 x 0.8, Stage II, notified dietary, physician and family, faxed MD for tx (treatment) 7/19/11 "...Solosite to R (right) coccyx open area BID x 14 days then re-eval..." 7/19/11: Rt (right) buttock, Stage II, 0.5 x 0.5, notified dietary and physician Nutrition Notes indicated: Meal intake records from 5/1/11 through 7/18/11 showed the resident ate more than 76 % of meal on average. A Nutrition Progress assessment, dated 3/9/11, indicated " Med pass-continuing supplement because resident likes the taste. Resident now has open area and will benefit from extra calories. No new diet/supplemental suggestions mentioned. Nutrition Assessment document, dated 6/2/11, indicated wound area healed and no new interventions suggested. Clinical Notes report for dietician, dated 6/16/11, indicated, "...Note open area to bottom. PO(by mouth) Intakes adequate to meet increased needs...7/7/11...Resident does have reoccurring open areas to coccyx, currently healed and receives MVI and vitamin C...." The resident's MAR (Medication Administration record) for April, May, June and July indicated Med Pass 3 oz (ounces) TID (three times a day), MVI (multivitamin) and Vitamin C were given during these three months. No changes in diet or vitamin supplements were documented. A policy provided by Director of Nursing (DON) on 7/21/11 at 10 A.M., titled "Prevention Protocol for Skin Care" and dated 7/1/2000, indicated "...Inspection of skin by trained personnel daily (may be best accomplished during bathing or a.m. care). Report any impairment or non-blanching [DIAGNOSES REDACTED] to the nurse in charge...if chair bound, utilize pressure relieving devices and reposition at least every 2 hours... if assessed for high risk for impairment of skin integrity ...if chair bound, reposition every 1-2 hours..." At the daily conference on 7/21/11 at 3: 40 P.M., a policy regarding pressure ulcer treatment was requested. A policy provided by DON on 7/22/11 at 1:30 P.M. was titled 'Pressure Ulcer/Wound Assessment and Documentation did not indicate what they would do to treat wound, the policy indicated how to assess wounds and staging of wounds. In an interview with the DON on 7/22/11 at 1:30 P.M., she indicated they had a new nurse doing wounds who had taken their long time wound nurse's place. She indicated she is "fairly new on the skilled side and has not been trained thoroughly on skin assessments." The DON indicated from the healing state to re-open area they are "missing the prevention piece" and they are aware of issues going on and that they need to be worked on. She also indicated it was "not good" that the open areas for Resident #2 discovered on 6/14/11 had not gotten any wound orders until 6/21/11. She indicated that 8 to 24 hours would be what she would expect for getting orders. She indicated the area documented on 5/18/11 should not have been documented as excoriation; rather it should have been documented as a pressure area. The DON indicated when transferring a resident from their wheelchair to their recliner they need to have their Roho cushion transferred with them if they have one. She indicated it would be nice to have dietary follow up and recommendations on unhealed areas. In an interview with the Dietician on 7/25/11 at 8:50 A.M., she indicated that in terms of the nutritional screening they discuss this is IDT (Interdisciplinary Disciplines Team) meetings. If someone has an open area, she looks to see if the areas are healing or not. If the resident is noted to be excoriated she looks to see if they are eating. The Dietician indicated that she has "fallen short on documentation of following residents" in regards to wounds. 2. Record review for Resident #12 was done 7/20/11 at 12:58 P.M. [DIAGNOSES REDACTED]. The record indicated the resident had been hospitalized [DATE] until 3/31/11. Observation on 7/21/11 at 10 A.M., of the settings on Resident #12 low air loss/ mattress setting was 5 and static. Resident was sitting in living room area by nurses station in a recliner. The resident had a disposable protective pad noted in the recliner. The resident had a Roho cushion on his wheelchair, which was sitting nearby in the living room area. During observation of the resident on 7/21/11 at 1:45 P.M., CNA #4 put the resident into bed and placed him on his side and did not touch any of the settings for the low air loss mattress. After CNA #4 prepared to leave room, she did not touch the settings. The control panel of the bed was set at '5' and static. There was a sticker taped underneath the static setting which said, "DO NOT TOUCH." In an interview immediately following the observation, CNA #4 indicated that she did not touch the low air loss bed settings and indicated that she did not know what they were supposed to be. There was a sticker on the control unit of the bed, but it was faded and difficult to read. During observation of Resident #12 on 7/25/11 at 9:45 A.M., he was lying on his left side with cushions behind his back when the DON and LPN #7 arrived in the room. LPN #7 looked at the area which she described as a healing stage II pressure. LPN# 7 provided treatment to the area. She indicated it was a fluid filled blister when the resident initially got it. The DON and LPN #7 were not sure how the resident got the area. In an interview with the DON on 7/21/11 at 2 P.M., she indicated she did not know what the setting of the mattress was to be and the CNA worksheet should indicate the settings. The CNA sheet provided by DON 7/21/11 at 2:15 P.M., indicated "...Alternating air mattress on bed-setting at 5 (change to firm with transfers-return to alternating when back to bed)..." The DON indicated the faded sticker on control panel read "Alternating every 5 minutes." The DON observed and indicated the bed was set on 5 and static and the "DO NOT TOUCH" sticker should be on the number setting side as the CNA's are not to touch these settings. The DON indicated the CNA's should hit the auto firm button to assist in transferring the resident out of bed and that they are to hit it again, which will reset the settings to the alternating every 5 minutes mode. She indicated that this was not done at this time. A resident care plan, dated 4/21/11, indicated ".. Stage II pressure ulcer to left lateral heel, at risk for delayed healing due to [MEDICAL CONDITION] [DIAGNOSES REDACTED]. plan did not address the open areas on coccyx/buttocks. The care plan, dated 5/19/11, had no new interventions listed and did not indicate settings for the low air loss mattress. The 7/8/11 care plan did not indicate the settings for the low air loss mattress. Physicians orders indicated the following wound orders for open areas: 2/17/11: [MEDICATION NAME] buttocks TID 3/4/11: R buttock Solosite TID x 10 days Xeroform R buttock fragile 3/14/11: buttocks solosite TID xeroform HS (bedtime) x 10 days 3/31/11: Secure antifungal to buttocks BID till healed 4/27/11: [MEDICATION NAME] TID to buttock Nurses notes indicated: 3/4/11: "N.O. for solosite and xeneform to R bottock (sic) fragile site, applied per order. fragile site 2.0 x 2.4 cm.- not open at this time..." 3/5/11: "...Red area R buttock with fragile skin remains intact; tx (treatment) done..." 3/6/11: "...Tx cont (continued) to red area R buttock; looks a little less red and fragile today..." 3/7/11: "...Trts (treatments) to buttock per order, decrease redness noted to R buttock..." 3/13/11: "...Xeroform tx to buttocks conts (continues) at hs et solosite during day. Res conts c routine immediate through conts c frequent loose stools..." Nutrition notes indicated on 4/7/11 that resident was [MEDICATION NAME] BID, Med pass QID (four times a day) and vitamin C. A nutrition assessment, dated 4/21/11, indicated that the resident had lost weight after a hospitalization in March for [MEDICAL CONDITION]. The document indicated that there would be monitoring of intake of food, consumption of off and weights, and wound healing. There was no indication of any changes in supplements or diet. Nurses notes indicated the following regarding the coccyx area: 5/13/11: "...Buttocks and groin reddened, [MEDICATION NAME] applied to buttocks..." 5/14/11: "...tx to buttocks cont: excoriation present..." 5/22/11: "...calmo to coccyx area which is reddened..." 5/23/11: "...coccys (sic) with superficial open areas to both sides of coccyx. calmo applied to coccyx area..." 5/27/11: "...Treatment to coccyx completed, area unchanged (sic)..." 6/4/11: "...Open areas on buttocks with no drng; tx done..." 6/17/11: "...tx completed to buttocks, L buttock pink, superficial open, R buttock pink et intact..." Physicians Orders for areas during same time frame indicated: 5/22/11: D/C (discontinue) [MEDICATION NAME] to buttock healed 5/24/11: Apply solosite buttocks BID xeroform HS 6/8/11: Silver alginate dressing to peri anal area ...Solosite BID to buttocks 6/9/11: Med Pass 3 oz (ounces) TID (supplement) 6/11/11: Assist to recliner after meals 6/29/11 Add Calmo ([MEDICATION NAME]) to buttocks PRN In an interview with DON on 7/22/11 at 9:45 A.M., she indicated the recliner that Resident #12 sat in was to her understanding pressure reducing. The DON was requested to provide the manufacturer's information regarding the recliner and pressure reduction. As of exit conference on 7/25/11 at 10:15 A.M., no further information was provided. She indicated she had provided everything she had at this time. The DON had indicated in an interview on 7/22/11 at 1:30 P.M., that in transferring a resident from their wheelchair to their recliner they need to have their Roho cushion transferred with them if they have one. 3. Record review for Resident #17 was done on 7/21/11 at 10:45 A.M., [DIAGNOSES REDACTED]. A Minimum Data Set assessment for admission done on 7/11/11 indicated that resident had severe cognitive impairment, requires assistance of 2 for dressing, toileting, hygiene and bathing, that the resident had been admitted to the facility with one Stage I, and two Stage II ulcers and that she was receiving ulcer care and applications of ointments/medications other than to feet. During observation on 7/22/11 at 8:45 A.M., the resident was in her recliner with a Chux pad (disposable pad) underneath her and no pressure relieving device. CNA #7 indicated that this was the only item in the chair and the resident had a cushion on her chair but they usually just put the pad on the recliner. RN #6 indicated the resident currently has an open area. During an observation of Resident #17 on 7/22/11 at 9:10 A.M., RN #6 did a dressing change and indicated she did the weekly measurements on 7/21/11. Observation of Resident #17 buttocks showed one pencil eraser sized open area on left mid buttock. On the right buttock she had 5 open areas. The right buttock had a penny sized area with four small areas in succession down the buttock. These areas were pin point in size and open. The surrounding area on buttocks was dark red in appearance. RN #6 indicated that they "look better today than they did yesterday." [MEDICATION NAME] treatment was put on the area and the resident was positioned on right side with pillow a against her back. A Resident care plan, dated 6/27/11, indicated "...Stage II areas on buttocks, present upon admission, at risk for further skin breakdown related to impaired mobility, episodes of incontinence and Diabetes diagnosis...interventions: Assess and record the size (LxWxD) of skin discoloration, [MEDICAL CONDITION], and pain status at least weekly. Check for incontinence; clean and dry skin if wet or soiled, perform complete skin assessment and record. Perform nutritional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown. Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/reposition. Treatment per MD order-see TAR..." The 7/5/11 care plan, had no new interventions listed. The 7/13/11 which is the current care plan had "...Vicair adjuster cushion on w/c (wheelchair) et recliner (arrow down) decrease pressure..." This was the only new intervention indicated. A Braden Scale, dated 6/27/11, indicated that resident was low risk for pressure. physician's orders [REDACTED]. 6/27/11: [MEDICATION NAME] to bil open areas on buttocks TID x 10 days [MEDICATION NAME] to excoriated areas on buttocks/groin TID x 10 days 7/12/11: [MEDICATION NAME] to coccyx TID x 14 days 7//21/11: D/C [MEDICATION NAME] drsg to open areas on buttocks, change QOD. Air alternating overlay to mattress. Wound/Skin Healing Record indicated: 6/25/11: R buttock Stage I, 4 cm x 8.5 cm <0.1 depth, pink, dietary, family and physician notified. 6/29/11: R buttock healed. 6/25/11: lower right buttock, Stage II, 1 cm x 0.3 cm < 0.1 cm depth, pink, dietary, family, and physician notified. 6/29/11: lower right buttock healed. 6/25/11: upper right buttock, Stage II, 0.3 cm x 0.5 cm <0.1 depth, pink, dietary, physician and family notified. 6/29/11: upper right buttock healed 6/25/11: R medial buttock, Stage II, 2 cm x 0.1 cm <0.1 cm depth, pink, dietary, physician and family notified. 6/29/11: R medial buttock, 1.7 x 0.1 <0.1 cm depth, pink. 7/6/11 : R medial buttock, 1.6 x 0.1 <0.1 cm depth, pink, 7/13/11: R medial buttock, 1.0 x 0.2 with 5.4 excoriated surrounding <0.1 cm depth. 7/21/11: R medial buttock healed 6/25/11: L buttock 3 cm x 7.2 cm <0.1 cm depth,pink wound bed, dietary notified, family notified. 6/29/11 L buttock healed 7/21/11: R of coccyx, Stage II, 6 x 2 not continuous pink with red surrounding color. 7/21/11: L of coccyx, 3 x 2.5 not continuous 0.1 pink wound bed with bright red peri wound area. A Nutrition assessment, dated 7/6/11, indicated "... open area to bilateral buttocks and intervention: encourage po (by mouth) intakes, especially protein, continue multivitamin. Resident should be able to meet increased needs to heal area..." Dietary progress note dated 7/14/11 indicated "...Continues to have open are (sic) to right medial buttock which is still open but healing well. (Resident name) makes own menu selections after choices are read to her. Continue nutrition problem: 1. Increased energy expenditure r/t (related to) wound healing-Continue intervention of:encourage po intakes of protein foods and multivitamin. Monitoring: 1. wound healing records and weights...." In an interview with Dietician on 7/25/11 at 8:50 A.M., information was requested about the procedure used to determine if a resident needs increased protein due to wound areas. She indicated that she uses the menu choices from residents and then picks higher protein foods. She indicated that she does not track how she does this nor the percentage of protein foods that are consumed. 3.1-40(a)(2)