Every finding on record at Vermillion Convalescent Center

Based on observation, interview, and record review, the facility failed to ensure the resident was assessed and a physician order was obtained prior to utilizing an audible bed and chair alarm for 1 of 2 residents reviewed for falls (Resident B). Findings include:On 6/17/26 at 12:35 p.m. during an initial observation and interview, Resident B sat in the main dining room with her husband. She was alert with some confusion noted during the interview. The resident indicated she had some falls but had not been hurt any of the times she fell. The resident was sitting in her wheelchair on a black air filled cushion and an incontinent pad. No anti-skid material was observed in the wheelchair. Observed anti-tip bars to the lower bottom of the wheelchair. The bars were upside down. No alarm observed on the chair. The husband indicated there was an alarm on the bed and usually there was a chair alarm and indicated the staff must have forgotten to put the chair alarm back on when they had gotten her up earlier. On 6/17 26 at 1:35 p.m., during an interview, the Occupational Therapist indicated Resident B did not have anti-skid material in the wheelchair seat because she no longer required it. She indicated the anti-tip bars were on the wheelchair incorrectly, but they had been fixed since she was made aware. She did not know who had placed them on incorrectly. On 8/18/26 at 10:00 a.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but was not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), muscle weakness, and difficulty walking. Review of the nurses progress notes indicated the resident had fallen three times. On 2/11/26 the resident slid out of a wheelchair. On 3/21/26 the resident fell walking to the bathroom. On 4/8/26 the resident slid out of wheelchair in the bathroom. No injuries were noted during any of the falls. A care plan, dated 8/5/26, indicated falls. The resident had multiple risk factors for falls. Interventions included, on 4/8/26 Dycem (anti-skid material) to wheelchair, check for placement every shift; on 3/31/26 Non-skid socks when in bed; on 1/19/26 remind resident and husband to call for assistance with transfers; on11/17/2025 anti-rollbacks to wheelchair; on 8/15/25 hang orange reminder sign in room to call for assistance; on 8/7/25 non-skid strips at bedside. The record lacked documentation of bed or chair alarm as an intervention and lacked documentation of anti-tip bars to wheelchair as an intervention. A quarterly Minimum Data Set Assessment (MDS) assessment, dated 5/7/26, indicated the resident had mild cognitive impairment and required assistance with daily care needs. On 6/18/26 at 11:55 a.m., during a phone interview, the resident's representative indicated she was concerned about the falls and indicated the resident was to have both a chair alarm and bed alarm, but when she had visited the alarm was not on or it had been turned off. At 12:20 p.m., during an interview Licensed Practical Nurse (LPN) 4 indicated the resident did have a chair alarm and a bed alarm. She indicated the reason for the alarm was because the resident would get up on her own or the husband would help her and not ask staff for assistance. The LPN indicated the facility required a physician order for an alarm and acknowledged the record lacked a physician order for either a chair or bed alarm. On 6/18/26 at 12:30 p.m., during an observation of the resident's bed. A bed alarm was on the bed but not attached to the alarm box. The resident was not in the facility at the time of the observation. The resident's husband indicated the alarm was placed on her chair before she left for dialysis and the staff had disconnected the bed alarm when they made the bed. On 6/18/26 at 1:46 p.m., during an interview, the Regional Nurse Consultant indicated the alarms were placed at one time as a nursing measure and should have been removed. She indicated since the resident had not had a fall for a while she no longer needed the alarm. On 6/18/26 at 2:00 p.m., the Regional Nurse Consultant provided a document titled Alarm position change, dated 9/17 and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: While position change alarms nay be implemented to monitor a resident's movements, for some residents, the use of position change alarms that are audible to the resident(s) may have the unintended consequence of inhibiting freedom of movement.Procedure.2. Should a position change alarm be deemed appropriate intervention by the team, a physician's order shall be obtained. This citation relates to Intake 3024588. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(w)410 IAC (Indiana Administrative Code) 16.2-3.1-26(a)410 IAC (Indiana Administrative Code) 16.2-3.1-26(b)

A. Based on observation, record review, and interview, the facility failed to ensure hand hygiene was performed during the medication pass and appropriate infection control techniques were utilized for 5 of 5 residents medication passes observed (Residents 33, 36, 48, 28, and 62). B. Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions (EBP) (use of gowns and gloves during high-contact resident care activities) were followed for 2 of 5 residents' medication passes observed (Residents 33 and 10). Findings include:A. On 8/15/25 at 8:06 a.m., Registered Nurse (RN) 22 was observed preparing medication for Resident 33. During the preparation, one of the pills fell onto the medication cart. RN 22 picked up the pill bare-handed and placed it into the medication cup. RN 22 entered Resident 33's room, put on gloves, and completed the resident's accu-check (finger stick to check blood sugar). The resident's blood sugar was 69 milligrams (mg)/deciliter (dl). RN 22 did not perform hand hygiene before or after the accu-check. At the same time, RN 22 indicated, based on the resident's accu-check results she would wait until later to administer the resident's medication and insulin. On 8/15/25 at 8:16 a.m., RN 22 prepared Resident 36's medication. RN 22 took a pair of gloves into Resident 36's room and placed them on the bedside table. RN 22 placed a pulse oximeter (used to estimate the oxygen saturation of a patient's blood and their pulse rate) on the resident's finger and indicated the resident's heart rate was 59 beats per minute (bpm). RN 22 did not clean the pulse oximeter before or after use or perform hand hygiene before or after administering medication to Resident 36. RN 22 took the gloves she had previously placed on the resident's bedside table with her when she left the resident's room. On 8/15/25 at 8:19 a.m., RN 22 checked Resident 48's blood pressure with a wrist cuff. RN 22 did not clean the wrist cuff before or after use or perform hand hygiene before or after the blood pressure check. RN 22 then prepared medication for Resident 48 and administered it to him. No hand hygiene was observed. On 8/15/25 at 8:25 a.m., RN 22 prepared Resident 28's routine insulin, checked her blood sugar, and indicated the resident did not require sliding scale insulin. RN 22 wore the same gloves that had been removed from Resident 36's bedside table to complete Resident 28's accu-check. RN 22 placed a pulse oximeter on the resident's finger and indicated the resident's heart rate was 70 bpm. RN 22 administered the resident's medication and insulin. RN 22 did not clean the pulse oximeter before or after use or perform hand hygiene before or after administering medication to Resident 28. On 8/15/25 at 8:42 a.m., RN 22 put on gloves and re-checked Resident 33's accu-check. The result was 137 mg/dl. RN 22 administered Resident 33's medication and insulin but did not perform hand hygiene before or after the administration. On 8/15/25 at 8:58 a.m., RN 22 checked Resident 62's blood pressure with the wrist cuff but did not clean the wrist cuff before or after its use. During an interview, on 8/15/25 at 8:59 a.m., RN 22 indicated she sometimes washed her hands when administering insulin, and she should have used hand sanitizer between resident medication administrations. She did not normally clean vital sign equipment between uses. She normally used bleach wipes to clean everything at the beginning of her shift, but she had not done it this morning. During an interview, on 8/15/25 at 9:20 a.m., the Director of Nursing (DON) indicated hand hygiene should have been performed before and after each residents' medication administration. The hand hygiene could have been hand sanitizer. Staff should have washed their hands at least every third resident during medication pass. The vital sign equipment should have been cleaned after each use. During an interview, on 8/15/25 at 10:45 a.m., the DON indicated gloves placed on a resident's bedside table should not have been used on a different resident, and pills should not have been touched bare handed. On 8/15/25 at 10:01 a.m., the Regional Nurse Consultant provided a document titled, Medication Administration, last revised in April 2017, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To safely administer medications as per physicians' orders. Policy: Licensed or qualified personnel shall be responsible to follow accepted practices of medication administration as per physicians' orders. Infection Control: 1. Wash hands with soap and water. Prior to beginning med pass, after direct contact with resident if hands become visibly soiled. Before and after administering.injections.2. Use alcohol gel or foam before between each resident unless using soap and water. 3. Never touch medications with hands. B. On 8/15/25 at 8:42 a.m., Registered Nurse (RN) 22 entered Resident 33's room to administer medications. Certified Nurse Aide (CNA) 23 was giving the resident a bed bath, using a shower cap to wash her hair. CNA 23 was wearing gloves but no gown. A sign on the resident's bathroom door indicated the resident required EBP. Resident 33's record was reviewed on 8/15/25 at 10:12 a.m. Diagnoses on the resident's profile included, but were not limited to, hidradenitis suppurativa (a chronic, inflammatory skin condition characterized by painful, boil-like lumps that typically appear in areas where skin rubs together, such as the armpits, groin, and buttocks) and a history of Proteus mirabilis (bacteria often associated with urinary tract infections). A physician's order, dated 5/1/24, indicated the resident required EBP. During an interview, on 8/15/25 at 8:59 a.m., RN 22 indicated Resident 33 required EBP, but she was not sure why. CNA 23 should have worn EBP when giving the resident a bed bath, but she was not sure about when she was washing the resident's hair. On 8/15/25 at 12:05 p.m., Licensed Practical Nurse (LPN) 20 was observed administering Resident 10's medication via a gastrostomy tube (g-tube) (tube inserted into the stomach for feeding and medication administration). LPN 20 wore gloves but no gown. A sign on the resident's bathroom door indicated the resident required EBP. Resident 10's record was reviewed on 8/15/25 at 2:11 p.m. A physician's order, dated 4/1/24, indicated the resident required EBP. During an interview, on 8/15/25 at 12:10 p.m., LPN 20 indicated Resident 10 required EBP, but she was not sure why. It depended on what type of care was being provided if a gown and gloves were required, but a gown was not required for g-tube medication administration. During an interview, on 8/18/25 at 11:28 a.m., the Director of Nursing (DON) indicated staff should have worn a gown and gloves during bed baths and g-tube medication administration for residents who required EBP. On 8/18/25 at 11:30 a.m., the DON provided a document titled, Enhanced Barrier Precautions., dated October 2019, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Enhanced Barrier Precautions (EBP) expand the use of PPE [personal protective equipment] beyond situations in which exposure to blood and body fluids is anticipated. These precautions entail the use of gown and gloves during 'high-contact' resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands and clothing to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time.and result in the silent spread of MDROs. Policy: This facility shall implement Enhanced Barrier Precautions.for those residents with an infection or colonization with a CDC [Centers for Disease Control]-targeted MDRO when Contact Precautions do not otherwise apply.Examples of 'high-contact' resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, bathing/showering.providing hygiene.device care or use.feeding tube. 3.1-18(l)

Based on record review and interview, the facility failed to ensure informed consent documents for psychotropic medications had been obtained, for 2 of 5 residents reviewed for unnecessary medications (Residents 73 and 1). Findings include: 1.Resident 73's record was reviewed on 8/14/25 at 11:43 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia, severe, with agitation (dementia that severely impacts daily life and functioning with agitation), Alzheimer's disease (a progressive brain disorder that gradually impairs memory, thinking, and reasoning skills, eventually affecting the ability to perform simple tasks), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that interferes with daily life), and irritability and anger. A significant change Minimum Data Set (MDS) assessment, dated 7/15/25, indicated the resident had severe cognitive deficit, physical behavioral symptoms directed towards others, and received an antipsychotic medication (drugs used to treat psychosis, a condition where a person experiences a disconnect from reality, often involving hallucinations and delusions). A physician's order, dated 8/8/25, indicated to administer one 25 milligram (mg) tablet of quetiapine (antipsychotic medication) by mouth at bedtime. The record lacked documentation of an informed consent form to administer the quetiapine 25 mg at bedtime. A physician's order, dated 8/14/25, indicated to administer one 5 mg tablet of melatonin (a dietary supplement containing a synthetic form of melatonin, a hormone naturally produced by the brain to help regulate the sleep-wake cycle) at bedtime. An informed consent form, dated 8/14/25, was observed to be signed by the resident's representative for consent to administer the melatonin. The form lacked documentation of consent to administer the quetiapine. During an interview, on 8/14/25 at 1:50 p.m., the south unit manager, Licensed Practical Nurse (LPN) 3, indicated the resident had returned from a recent hospital stay on the quetiapine. An informed consent document should have been completed at that time. She was unsure why the the quetiapine was not included on the informed consent document for the melatonin. During an interview, on 8/14/25 at 2:04 p.m., the Director of Nursing (DON) indicated the consent for the quetiapine should have been completed when the resident returned from the hospital on the medication or, at least, been included on the consent for the melatonin completed on 8/14/25. 2. On 8/18/25 at 9:47 a.m., the medical record of Resident 1 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), chronic respiratory failure (a long-term condition where the lungs can't adequately exchange oxygen and carbon dioxide), and metabolic encephalopathy (a brain disorder caused by chemical imbalances in the body, often due to issues with organs like the liver or kidneys). A physician order, dated 5/27/25, indicated to administer Ativan (lorazepam) tablet; 0.5 mg (milligram) 1 tablet; oral. Give 1 tablet under the tongue every 4 hours as needed for a 6 month exacerbation of anxiety/agitation due to end-of-life circumstance/hospice as needed. A physician order, dated 5/30/25, indicated to administer (Zyprexa) Olanzapine tablet; 5 mg oral once a day. An annual Minimum Data Set (MDS) assessment indicated the resident required maximum assistance from staff for all daily care needs and indicated he was not cognitively intact. The record indicated the resident was administered two psychotropic medications for anxiety and agitation. The record lacked notification to the family of psychotropic medication administration. On 8/14/25 at 2:00 p.m., during interview the Director of Nursing (DON) indicated the hospice agency notified the family of the initiation of the medications. On 8/14/25 at 2:30 p.m., the Director of Nursing (DON) presented a nurses note from the hospice agency indicating medications had been reviewed however, the documentation lacked evidence of notification and consent of the family regarding administration of psychotropic medication. The DON acknowledged it was the responsibility of the facility to inform the responsible party and obtain consent for use of psychotropic medications. On 8/14/2025 at 3:07 p.m., the DON provided a document titled, Psychotropic Medication Consent use and gradual dose reduction, dated 4/2025, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.16. Residents receiving an order for a new psychotropic medication , or dose increase to existing orders, shall have consent obtained from the resident or their resident representative. The consent (either signed or documented as verbal consent obtained) shall demonstrate a. having been informed of the risks, benefits, and alternatives to use of the medication.c. having been informed of their right to refuse the medication. 3.1-3(n)(2) 3.1-3(n)(3)

Based on observation interview and record review, the facility failed to ensure the call light was within the reach of the residents for 2 of 24 residents reviewed for call light placement (Residents 25 and 23).Findings include:1. On 8/14/2025 at 1:32 p.m., during initial routine observation, observed Resident 25 sleeping in bed. Call light was not within reach of the resident. Unable to locate the call light. On 8/15/2025 at 1:34 p.m., observed Resident 25 sitting in a recliner in her room. The call light was attached to the middle of the curtain within the folds of the curtain residents bed at the foot of the bed. The resident was unable to answer any interview questions. On 8/18/25 at 10:40 a.m., during an interview Certified Nurse Aide (CNA) 6 indicated she makes sure the call light was within reach of residents even if the resident did not use the call light. On 8/18/25 at 11:50 a.m., during an interview Certified Nurse Aide (CNA) 8 indicated she would make sure the call light was within reach of the resident even if the resident did not use the call light. On 8/18/25 at 1:39 p.m., the medical record of Resident 25 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A care plan, dated 8/6/2025, indicated the resident had cognitive loss and dementia the resident had the progressive cognitive and communicative deficits associated with a dementia diagnosis. Interventions included but were not limited to speak in a clear, low, calm tone of voice at a volume that is easily heard by the resident. The care plan lacked evidence of call light use or the residents ability to use a call light. 2. On 8/13/25 at 11:13 a.m., Resident 23 was observed up in his wheelchair, in his room. The call light was observed lying on the resident's bed, out of his reach. At the same time, the resident indicated if he needed assistance he was supposed to press the call light, but it had disappeared somewhere. When asked if he knew how to use the call light the resident indicated, Yeah, you just press it. On 8/15/25 at 1:49 p.m., Resident 23 was observed lying in bed. The call light was observed in the resident's recliner with linens piled on top of it. The recliner was approximately three feet from the resident's bed and out of the resident's reach. At the same time, the resident indicated he was supposed to have the call light, but he had no idea where it was. He would have used the call light for assistance if he needed it, if he was able to reach it. Resident 23's record was reviewed on 8/18/25 at 9:26 a.m. Diagnoses on the resident's profile included, but were not limited to, cerebral infarction (brain tissue death due to lack of blood supply) unspecified and hemiplegia (paralysis or severe weakness on one side of the body) affecting left side. A quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident had a moderate cognitive impairment, functional limitation in range of motion, and required assistance with ADLs. A care plan, initiated on 8/6/25, indicated the resident required assistance to transfer from the bed and was able to use the call light to ask for assistance. During an interview, on 8/18/25 at 11:25 am., Certified Nurse Aide (CNA) 18 indicated Resident 23 was able to use the call light to ask for assistance, and it should have been kept within his reach. On 8/18/25 at 11:12 a.m., the Administrator provided a document titled, Call Light, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. Policy: Resident's call light is to be within reach and answered promptly by facility personnel.Procedure.8. Call lights must remain functional and within reach of each resident. 3.1-3(a)

Based on interview and record review, the facility failed to ensure a resident was provided showers as preferred for 1 of 1 residents reviewed for choices (Resident 51). Findings include: During an interview, on 8/13/25 at 3:28 p.m., Resident 51 indicated she thought that the staff often forgot about her, and she did not receive her showers as scheduled. She was unable to recall when her last shower was. Resident 51's record was reviewed on 8/15/25 at 10:10 a.m. A significant change Minimum Data Set (MDS) assessment, dated 8/6/25, indicated the resident was cognitively intact and required moderate assistance with showers and toileting. A care plan, dated 5/15/25, indicated the resident requires assistance from 1-2 staff in preforming activities of daily living (ADL's) related to shortness of breath, pain, and incontinence. Interventions included, but were not limited to, offer bathing choices, showers/baths per schedule and more frequently if requested and as needed, and nail care as needed. Review of shower schedule indicated Resident 51 was to receive her showers on Tuesday and Saturday evening shift. Review of shower sheets, dated June 2025, indicated Resident 51 received a shower on 6/10/25, 6/17/25, and 6/29/25. The record lacked documentation of any other showers provided for the month of June. Review of shower sheets, dated July 2025, indicated Resident 51 received a shower on 7/28/25 and 7/29/25. The record lacked documentation of any other showers provided for the month of July. Review of shower sheets, dated August 2025, lacked documentation that the resident had received a shower up to the date of August 15. During an interview, on 8/15/25 at 10:41 a.m., Licensed Practical Nurse (LPN) 10 indicated Resident 51 doesn't usually refuse her showers, she would normally take showers when offered. During an interview, on 8/15/25 at 2:47 p.m., Regional Nurse Consultant (RNC) was unable to provide documentation that Resident 51 had received two showers a week as requested for the last 3 months. During an interview, on 8/15/24 at 2:30 p.m., Director of Nursing (DON) indicated staff should be documenting when they provide showers. On 8/15/25 at 2:47 p.m., the RNC provided a document with a revised date of 9/17, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: This facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility shall protect and promote the rights of the resident.3.1-3(u)(3)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse for 1 of 2 residents reviewed for abuse (Resident 1).Findings include:On 8/18/25 at 9:36 a.m., an allegation of abuse was reported by the Regional Nurse Consultant (RNC). Review of facility reported incident indicated an allegation of abuse was reported to IDOH on 8/16/25 at 8:40 a.m., by the facility Administrator. The report indicated Certified Nursing Aides (CNAs) 8 and 12 were caring for Resident 1's roommate in the first bed. Both CNAs saw CNA 11 at the bedside of Resident 1 in the same room, pulling Resident 1's hand off of the side rail, pushing the resident's arm into his stomach, speaking abruptly to the resident, and using profanity. The CNAs 8 and 12 immediately intervened and prevented further interaction between CNA 11 and the resident. A skin tear was noted to Resident 1's right arm. The CNA 11 responded that it was there last night and she didn't do it. However, one of the other CNAs had cared for Resident 1 the evening before and indicated there was no skin tear observed at that time. The other CNAs contacted the nurse and CNA 11 was sent home. Resident 1's Brief Interview for Mental Status (BIMS) score of 99 indicated the resident was rarely able to communicate verbally. On 8/18/25 at 9:47 a.m., the medical record of Resident 1 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to Alzheimer's disease, chronic respiratory failure (a long-term condition where the lungs can't adequately exchange oxygen and carbon dioxide), and metabolic encephalopathy (a brain disorder caused by chemical imbalances in the body, often due to issues with organs like the liver or kidneys). A physician order, dated 8/16/25, indicated to cleanse area and apply steri strips (thin, adhesive bandages used to close and protect minor cuts and wounds) to the right upper arm times 1 application, leave open to air, and monitor the site every shift. An annual Minimum Data Set (MDS) assessment indicated the resident required maximum assistance from staff for all daily care needs and indicated he had limited cognition. A care plan, dated 6/5/25, indicated the resident required one to two staff to assist in performing ADL's (activities of daily living) due to highly impaired vision, decreased communication, and severely impaired cognitive skills. Interventions included, but were not limited to, provide assist with ADL's as resident requires, and encourage the resident to participate in ADLs as much as possible. A nursing progress note, dated 8/16/25 at 7:45 p.m., indicated the CNA (Certified Nurse Aide) alerted the nurse to a new skin tear on the right upper arm. The area was cleansed and steri strips applied per doctor order. The Director of Nursing (DON) and resident's family member were also notified. A wound report indicated a skin tear was reported on 8/16/25 at 8:40 a.m. Measurements were length - head to toe direction 3 centimeters (cm), width - hip to hip direction 0.25 cm. The color of alteration in skin was red, there was a small amount of exudate (drainage) present which was bright red thin and bloody. The wound tissues were very moist, drainage was on less than 25% of the dressing, and there was no odor present. Skin tear type was a partial flap (skin) loss and the flap cannot be repositioned to cover the wound. The area was cleansed and 6 steri strips applied. On 8/18/25 at 10:45 a.m., during an interview Licensed Practical Nurse (LPN) 7 indicated she had not observed any issues with the resident being combative with the staff. On 8/18/25 at 10:40 a.m., during interview Certified Nurse Aide (CNA) 6 indicated at times the resident had become a little combative but not very often and she had not had any issues providing care to the resident. On 8/18/25 at 1:17 p.m., during an interview the Regional Nurse Consultant (RNC) indicated she spoke with CNA 11. The CNA advised her she was trying to roll the resident over and tried to remove his arm from the rail. The CNA indicated she may have pulled too hard but did not cause the skin tear. The CNA informed her she was going to quit, and the CNA was no longer employed at the facility. On 8/18/25 at 1:43 p.m., during an interview CNA 8 indicated she was at the end of the bed of Resident 1's roommate. She heard a bump sound and turned around to look at Resident 1. She saw CNA 11 rip Resident 1's arm off the side rail and slam his arm into his abdomen. She indicated CNA 11 was yelling and cussing at the resident. She heard the resident yelling out ouch that hurts, my arm, my arm. She indicated CNA 11 said Resident 1 had a skin tear and said she did not do that. CNA 8 went over to CNA 11, intervened, and advised her she would help her care for the resident. She then reported the incident to the nurse. She indicated the resident did resist care at times, but she did not observe him resisting care at that time. On 8/18/25 at 2:04 p.m., CNA 12 indicated she was in the room helping CNA 8 with Resident 1's roommate. She indicated she went to the bathroom in the residents' room. She came out and saw CNA 11 rip Resident 1's hand off the rail. CNA 11 started cussing and saying mean things to the resident. Resident 1 was saying ouch, ouch my arm, my arm. She indicated that CNA 8 intervened. CNA12 left the room to obtain a lift pad. CNA 8 then left the room to report the incident to the nurse. Resident 1 was not acting aggressive at the time. Resident 1 was blind, and they had to calmly talk to him. She indicated he was not aggressive with them. She thought he was afraid at the time because he did not usually talk much. On 8/15/2025 at 2:47 p.m., the (RNC) provided a document titled, Residents Rights, dated, and indicated it was the policy currently being used by the facility. The policy indicated, Policy. This facility shall treat each resident with respect and dignity and care for each resident in an environment that promotes maintenance of enhancement of his or her quality of life, recognizing each resident individuality. The facility shall protect and promote the rights of the resident. On 8/15/2025 at 2:47 p.m., the (RNC) provided a document titled, Abuse Prohibition, Reporting and Investigation, dated 9/2017, and indicated it was the policy currently being used by the facility.Physical abuse -includes hitting, slapping, pinching.Verbal abuse, oral.language that willfully includes disparaging and or derogatory terms to residents. 3.1-27(a)3.1-27(b)

Based on interview and record review the facility failed to ensure the administrator was notified immediately of an allegation of abuse of 1 of 2 residents reviewed for abuse (Resident 1). Findings include:On 8/18/25 at 9:36 a.m., an allegation of abuse was reported by the Regional Nurse Consultant (RNC). Review of facility reported incident indicated an allegation of abuse was reported to IDOH on 8/16/25 at 8:40 a.m., by the facility Administrator. The report indicated Certified Nursing Aides (CNAs) 8 and 12 were caring for Resident 1's roommate in the first bed. Both CNAs saw CNA 11 at the bedside of Resident 1 in the same room, pulling Resident 1's hand off of the side rail, pushing the resident's arm into his stomach, speaking abruptly to the resident, and using profanity. The CNAs 8 and 12 immediately intervened and prevented further interaction between CNA 11 and the resident. A skin tear was noted to Resident 1's right arm. The CNA 11 responded that it was there last night and she didn't do it. However, one of the other CNAs had cared for Resident 1 the evening before and indicated there was no skin tear observed at that time. The other CNAs contacted the nurse and CNA 11 was sent home. Resident 1's Brief Interview for Mental Status (BIMS) score of 99 indicated the resident was rarely able to communicate verbally. On 8/18/25 at 9:47 a.m., the medical record of Resident 1 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to Alzheimer's disease, chronic respiratory failure (a long-term condition where the lungs can't adequately exchange oxygen and carbon dioxide), and metabolic encephalopathy (a brain disorder caused by chemical imbalances in the body, often due to issues with organs like the liver or kidneys). A nursing progress note, dated 8/16/25 at 7:45 p.m., indicated the CNA (Certified Nurse Aide) alerted the nurse to a new skin tear on the right upper arm. The area was cleansed and steri strips applied per doctor order. The Director of Nursing (DON) and resident's family member were also notified. On 8/18/25 at 1:43 p.m., during an interview CNA 8 indicated she was at the end of the bed of Resident 1's roommate. She heard a bump sound and turned around to look at Resident 1. She saw CNA11 rip Resident 1's arm off the side rail and slam his arm into his abdomen. She indicated CNA 11 was yelling and cussing at the resident. She heard the resident yelling out ouch that hurts, my arm, my arm. She indicated CNA 11 said Resident 1 had a skin tear and said she did not do that. CNA 8 went over to CNA 11, intervened, and advised her she would help her care for the resident. She then reported the incident to the nurse. She indicated the resident did resist care at times, but she did not observe him resisting care at that time. On 8/18/2025 at 2:58 p.m., during an interview the Administrator indicated CNA 11 was sent home around 8 a.m. She indicated the incident happened around 7 a.m. CNA 11 was probably at the nurse's station playing on her phone between the time of the incident and being sent home. On 8/18/25 at 3:10 p.m., during an interview the Administrator indicated the facility called her at 8:45 a.m. She indicated CNA 11 was in the building for one and a half hours after the incident. However, she did not provide care to residents during that time. She indicated the nurse notified the nurse on call who then contacted the Social Services Director (SSD), and the SSD then called the Administrator. The Administrator indicated she was not immediately notified of the allegation of abuse. On 8/19/25 at 10:00 a.m., during an interview the SSD indicated she was notified at 8:45 a.m., by a CNA who witnessed the alleged abuse. She then notified the Administrator. She indicated she was unsure if the Administrator should be notified first. On 8/15/2025 at 2:47 p.m., the (RNC) provided a document titled, Abuse Prohibition, Reporting and Investigation, dated 9/2017, and indicated it was the policy currently being used by the facility.Physical abuse -includes hitting, slapping, pinching.Verbal abuse, oral.language that willfully includes disparaging and or derogatory terms to residents.If resident abuse, or suspicion of abuse is reported.2. The individual who witnessed the incident or who was informed of the allegation shall immediately notify a charge nurse assigned to the unit on which the resident resides.3. The charge nurse is responsible to notify the facility administrator and Director of Nursing immediately.4. Any facility personnel implicated in the alleged abuse shall be removed from resident care. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure fingernail care was provided for 1 of 24 residents reviewed for activities of daily living (ADLs) (Resident 23). Findings include: On 8/13/25 at 11:13 a.m., Resident 23's fingernails on the right hand were observed to be long and jagged with dark debris underneath them. On 8/14/25 at 10:12 a.m., Resident 23 was observed up in his wheelchair. The resident's fingernails on the right hand remained long and jagged with dark debris underneath them. On 8/15/25 at 1:49 p.m., Resident 23 was observed lying in bed. The resident's fingernails on the right hand remained long and jagged with dark debris underneath them. On 8/18/25 at 9:12 a.m., Resident 23 was observed up in his wheelchair. The resident's fingernails on the right hand remained long and jagged with dark debris underneath them. Resident 23's record was reviewed on 8/18/25 at 9:26 a.m. Diagnoses on the resident's profile included, but were not limited to, cerebral infarction (brain tissue death due to lack of blood supply) unspecified and hemiplegia (paralysis or severe weakness on one side of the body) affecting left side. A quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident had a moderate cognitive impairment, functional limitation in range of motion, and required partial/moderate assistance for personal hygiene. The assessment did not indicate the resident refused care. Progress notes, dated 7/19/25 to 8/18/25, lacked documentation the fingernail care was offered, provided, or refused. Shower sheets indicated the resident received a shower on 7/2/25, 7/6/25, 7/10/25, 7/23/25, 7/27/25, 7/30/25, 8/3/25, 8/6/25, 8/10/25, 8/13/25, and 8/17/25. The shower sheets lacked documentation fingernail care was offered, provided, or refused. A care plan, initiated on 7/22/25, indicated the resident required assistance of one or two staff members with ADLs. Interventions included, but were not limited to, nail care as needed. During an interview, on 8/18/25 at 11:23 a.m., Certified Nurse Aide (CNA) 16 indicated fingernail care should have been done as needed, and activity staff completed fingernail care at times as well. At the same time, CNA 17 indicated fingernail care should have been done with showers. If the resident refused care, it should have been documented on the shower sheets. During an interview, on 8/18/25 at 11:49 a.m., the Director of Nursing (DON) indicated she was not sure how often fingernail care should have been done, but she would check the policy. On 8/18/25 at 1:03 p.m., the DON provided a document titled, Fingernail Care, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Cleanliness and good grooming contribute to the dignity and self-esteem of resident. Policy: Nails should be kept short, clean, and free of rough or jagged edges. Fingernail care is provided when assigned, if fingernails appear soiled or have jagged edges, and as indicated. 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to ensure they communicated effectively with the wound specialist nurse practitioner (NP) when a resident developed a new pressure ulcer and failed to ensure appropriate infection control techniques were utilized during a dressing change for 1 of 2 residents reviewed for pressure ulcers (Resident 3). Findings include:On 8/15/25 at 2:39 p.m., Licensed Practical Nurse (LPN) 10 and the Director of Nursing (DON) were observed completing Resident 3's dressing changes to the coccyx (tailbone) and right hip. LPN 10 washed her hands, donned gloves, and removed the dressings from the resident's coccyx and right hip while wearing the same gloves. LPN 10 removed her gloves and donned a new pair of gloves but did not perform hand hygiene during the glove change. LPN 10 cleansed the wound to the resident's coccyx, removed her gloves, and donned a new pair but did not perform hand hygiene during the glove change. LPN 10 applied skin prep (protective skin barrier) around the wound on the resident's coccyx, packed the wound with calcium alginate (a type of dressing that manages drainage), and covered it with a dry dressing. LPN 10 removed her gloves and retrieved a dressing from the resident's dresser bare handed for the next treatment. LPN 10 donned new gloves after retrieving the dressing but did not perform hand hygiene prior to donning the gloves. LPN 10 cleansed the wound on the resident's hip, patted it dry, and applied Medihoney (promotes wound healing by creating a moist wound environment) to the wound with a cotton swab. LPN 10 applied skin prep around the wound to the resident's right hip and covered it with a dry dressing. There was a foul odor noted during the dressing change. Resident 3's record was reviewed on 8/14/25 at 11:46 a.m. Census information indicated the resident was admitted on [DATE] and was hospitalized from [DATE] to 2/20/25. Diagnoses on the resident's profile included, but were not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region and stage four (the most severe stage of a pressure injury, characterized by full-thickness skin and tissue loss extending into muscle, tendon, or bone) pressure ulcer of the sacral region. A significant change Minimum Data Set (MDS) assessment, dated 5/6/25, indicated the resident had a severe cognitive impairment, was dependent for activities of daily living (ADLs), and received pressure ulcer care. A nursing progress note, dated 7/3/24, indicated the resident was admitted to the facility with a stage two (partial thickness tissue loss, shallow open ulcer) pressure ulcer to the coccyx. A care plan, initiated on 7/3/24, indicated the resident had a stage two pressure ulcer to the coccyx. Interventions included, but were not limited to, treatment as ordered. A care plan, initiated 7/15/24, indicated the resident was at risk for pressure ulcer development. A nursing progress note, dated 7/17/24 indicated the stage two pressure ulcer to the resident's coccyx was healed. A Braden scale (assessment to determine pressure ulcer risk), dated 11/19/24, indicated the resident was at moderate risk for pressure ulcer development. A nursing progress note, dated 1/23/25, indicated the resident had a deep tissue injury (DTI) (damage to underlying soft tissues due to prolonged pressure and shearing) to the inner coccyx. The physician was notified, and a treatment was ordered. The note lacked documentation the contracted wound company was notified of the new wound. A wound management detail report, dated 1/23/25, indicated the resident had an unstageable DTI to the coccyx which measured 3 centimeters (cm) in length, 3.5 cm in width, and no depth. A care plan, initiated 1/23/25, indicated the resident had a pressure ulcer to the coccyx. Interventions included, but were not limited to, the resident was to be treated by the contracted wound management company. A nursing progress note, dated 1/24/25, indicated there was redness radiating down the resident's right buttock from the wound base. The area was tender to touch. The physician was notified, and an antibiotic was ordered. The noted lacked documentation the contracted wound company was notified of the wound changes and the antibiotic orders. A physician's order, dated 1/24/25, indicated ceftriaxone (antibiotic) one gram (gm) injected one time only for a localized skin and tissue infection. A physician's order, dated 1/24/25, indicated cephalexin (antibiotic) 250 milligrams (mg), 1 capsule by mouth 4 times daily for 7 days for a localized skin and tissue infection. An NP progress note from the contracted wound company, dated 1/29/25, indicated the facility requested the resident be evaluated for a new wound on the coccyx. The staff reported the resident had increased weakness and was ill which resulted in decreased mobility. The Director of Nursing (DON) reported the Medical Director was aware of the resident's decline. The NP noted an unstageable wound to the coccyx with surrounding redness, which measured 3.5 cm in length, 7 cm in width, and 0.1 cm in depth. The resident stated the area was painful. The NP discussed concerns regarding possible cellulitis (skin infection)/infection/osteomyelitis and the resident's high risk for sepsis (infection moving into bloodstream). The NP recommended an x-ray and wound culture and if any increased redness to the buttocks, fever, or chills were noted the medical director should have been notified and a transfer to the hospital for evaluation considered. The note lacked documentation the contracted wound company's NP was notified the resident's physician ordered antibiotics on 1/23/25. X-ray reports, dated 1/30/25, indicated x-rays of the lumbar (lower) spine, bilateral hips, and pelvis were completed due to pain and a DTI to the sacral region. The reports indicated osteoarthritic and degenerative disc changes. An NP progress note from the contracted wound company, dated 2/5/25, indicated the resident was followed for the unstageable wound on the coccyx. The redness on the right buttock was almost resolved. The wound was cleaner, had continued adhered sloughing (non-viable tissue to the wound bed), and remained unstageable. No odor was noted. The wound measured 3.5 cm in length, 4.5 cm in width, 0.1 cm in depth. The resident had increased pain and was unable to tolerate much debridement of the wound. The note lacked documentation the NP was notified the resident's physician ordered antibiotics on 1/23/25, the results of the ordered x-rays, or any information regarding the recommended wound culture. An NP progress note from the contracted wound company, dated 2/12/25, indicated the resident was followed for the unstageable wound to the coccyx. The Assistant Director of Nursing (ADON) reported the resident's wound was not improved. The resident complained of increased pain and yelled out when the wound was evaluated. There was a large amount of malodourous (foul smelling) purulent (thick, opaque drainage usually indicative of an infection) brown drainage from the wound. The wound bed was covered with thick, green/yellow sloughing. Induration (hardening of tissue) was noted to the right inner buttock. The NP recommended the resident be transferred to the Emergency Department (ED) for evaluation, intravenous (IV) antibiotics, wound culture, possible surgical debridement, and wound vac (a medical device which provided negative pressure promoting wound healing) placement. The wound measured 3.5 cm in length, 4.5 cm in width, and 1.3 cm in depth. The note lacked documentation the NP was notified the resident had already received antibiotics or any information regarding the previously recommended wound culture. The resident's record lacked documentation the wound culture was completed or a rationale for declining the wound culture after it was recommended by the wound NP, on 1/29/25, prior to the resident's hospital transfer on 2/12/25. Hospital documentation, dated 2/20/25, indicated the resident had a large unstageable pressure ulcer, covered with necrotic (dead) tissue, and foul smelling, to the sacral region. After debridement (medical/surgical procedure to remove dead tissue from a wound bed), the wound required wound vac therapy. The resident's discharge diagnosis was sacral wound with osteomyelitis. A nursing progress note, dated 2/20/25, indicated the resident returned from the hospital, after surgery to debride the wound and open up wound tunneling (tracts that extend from the main wound surface into deeper layers of tissue, creating passageways beneath the skin). Wound vac therapy was to be initiated once it arrived, and the resident had a peripherally inserted central catheter (PICC) line (used to give long-term IV medications) to the right upper chest. A nursing progress note, dated 2/24/25, indicated the resident continued on IV antibiotics. During an interview, on 8/13/25 at 3:26 p.m., the resident's family member indicated the resident developed a pressure ulcer that required surgical debridement. The surgical debridement left a very large open area. The wound developed at the facility. During an interview, on 8/15/25 at 12:23 p.m., the contracted wound company NP indicated if she was suspicious of osteomyelitis and an x-ray came back negative, then she would have probably recommended magnetic resonance imaging (MRI) (a non-invasive medical imaging technique that uses strong magnetic fields and radio waves to create detailed images of the body's internal structures). She was not able to see a lot of the chart if the records were on paper. If she really needed to see something, she would have had to request it. She checked her notes to see if she was aware of the x-ray results or if the wound culture was completed but was unable to find documentation. The NP indicated if she was notified of test results or an issue with obtaining a recommended test, then she would have noted it in her assessment notes. If it was not included in her notes, then she was not notified. If she had received a wound culture report, she likely would have recommended an oral antibiotic. The residents experienced a progressive decline, but the wound stabilized overall. During an interview, on 8/15/25 at 2:33 p.m., the Regional Nurse Consultant indicated she was not able to find any documentation the recommended wound culture was completed, but the resident was on an antibiotic around that time. During an interview, on 8/15/25 at 3:03 p.m., the DON indicated hand hygiene should have been completed between each glove change during the resident's dressing change. She was not sure if LPN 10 had hand sanitizer with her for the dressing change. She was not sure if the dressings could be removed from both wounds without changing gloves and completing hand hygiene. During an interview, on 8/15/25 at 3:11 p.m., the Regional Nurse Consultant indicated the resident's physician may not have wanted the wound culture at that time because the resident received antibiotics. She was unable to find documentation to support this. On 8/15/25 at 3:15 p.m., the Regional Nurse Consultant provided a document titled, Dressing-Clean Technique, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: A clean dressing technique is used to provide an appropriate environment conducive to wound healing. Policy: All dressings are performed by licensed personnel per physician's order using clean technique unless another technique is specified by the physician.Procedure.2. Remove soiled dressing and discard into designated waste receptacle. 3. Remove gloves, wash hands, and put on a pair of clean gloves. 4. Cleanse wound with solution as specified by physician. 5. Apply dressing as specified by physician, touching only outer part of dressing. Remove gloves. On 8/18/25 at 1:03 p.m., the DON provided a document titled, Pressure Ulcers, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To assure that residents with pressure ulcers will receive necessary care and treatment to promote healing, prevent new ulcers from developing and prevent infection. Policy: Pressure ulcers will be assessed and treated according to the Skin Management Program. Pressure Ulcer Definitions.Stage IV-Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. 3.1-40(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a indwelling urinary catheter (catheter; a tube inserted into the bladder through the urethra to drain urine) was kept from touching the floor, for 1 of 2 residents reviewed for urinary catheters (Resident 73).Findings include: During a random observation, on 8/13/25 at 3:22 p.m., the resident was observed sitting in his wheelchair in the activity room. His catheter bag (bag where urine was collected) was covered with a cloth covering and was in contact with the floor. During a random observation, on 8/15/25 at 11:03 a.m., the resident was observed sitting in his wheelchair at the activity room table. The catheter bag was covered with a cloth covering and the tubing was in contact with the floor. Resident 73's record was reviewed on 8/14/25 at 11:43 a.m. The profile indicated the resident's diagnoses included, but were not limited to, infection and inflammatory reaction due to indwelling urethral catheter (germs have entered the urinary tract through the catheter, causing an infection), urinary tract infection (a common infection that occurs when bacteria enters and multiplies within the urinary tract), and neuromuscular dysfunction of bladder, unspecified (also called neurogenic bladder; when the bladder and the nerves that control it aren't communicating properly).A significant change Minimum Data Set (MDS) assessment, dated 7/15/25, indicated the resident had severe cognitive deficit and required an indwelling urinary catheter.A care plan, dated 7/28/25, indicated the resident required a Foley (brand name) catheter due to neurogenic bladder and was at risk for infection. Interventions included, but were not limited to, position catheter tubing and catheter bag in such a way to avoid contact with the floor. During an interview, on 8/15/25 at 11:03 a.m., Certified Nursing Assistant (CNA) 4 indicated a catheter bag and/or the tubing should never be allowed to touch the floor as it was an infection risk. During an interview, on 8/15/25 at 2:30 p.m., the Director of Nursing (DON) indicated catheter bags, or the tubing should be kept from contact with the floor. On 8/15/25 at 2:30 p.m., the DON provided a document, with a revision date of 1/2020, titled, Urinary Drainage Bag Maintenance, and indicated it was the policy currently being used by the facility. The policy indicated, .Rule: .Urinary drainage bag should not be allowed to touch the floor .Use the Following Procedure to Secure the Drainage Bag: .2 .Do not allow the urinary drainage bag or tubing to touch the floor 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure Aplisol (solution used to test for previous exposure to tuberculosis) solution was disposed of once past the use by date during 1 of 2 medication room observations. Findings include:On 8/15/25 at 2:00 p.m., the south medication room was observed with Licensed Practical Nurse (LPN) 7. An opened vial of Aplisol was in the refrigerator with an opened date of 6/30/25. At the same time LPN 7 indicated she was not sure how long Aplisol could be used after being opened. During an interview, on 8/15/25 at 3:11 p.m., the Regional Nurse Consultant indicated Aplisol could be used for 30 days after opening and then it should have been disposed of. On 8/15/25 at 3:15 p.m., the Regional Nurse Consultant provided a document titled, Aplisol, last revised in November 2013, and indicated it was the policy currently being used by the facility. The policy indicated, .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 3.1-25(o)

Based on record review and interview, the facility failed to follow antibiotic stewardship protocol program for 1 of 24 residents reviewed for antibiotic use (Resident 26). Findings include:During an interview, on 8/13/25 at 2:39 p.m., Resident 26 indicated she had been on a prophylactic for a while due to her getting urinary tract infections in the past. Resident 26's record was reviewed on 8/18/25 at 9:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, urinary tract infection (UTI- an infection in any part of the urinary system), acute kidney failure (sudden and rapid decline in kidney function), and dysuria (painful or uncomfortable urination). A significant change Minimum Data Set (MDS) assessment, dated 7/9/25, indicated Resident 26 was cognitively intact and had received an antibiotic medication. A physician order, dated 4/1/25 with no stop date, indicated to administer Macrobid (antibiotic) 100mg (milligram) one capsule by mouth at bedtime for UTI maintenance dose prophylactic. A care plan, dated 7/21/25, indicated the resident had urinary incontinence. Interventions, included but were not limited to, encourage adequate fluid intake and monitor for signs and symptoms of infection. The record lacked documentation of a care plan for prophylactic antibiotic use. Review of history and physical documentation, dated 4/29/25, indicated Resident 26 was to continue Macrobid for UTI prophylaxis. The record lacked any recent urinalysis lab work ordered. The medical record indicated the resident had been on the prophylactic antibiotic since her admission date of 4/1/25. The record lacked documentation that the physician had assessed the resident to determine the need for prophylactic long-term use of an antibiotic and lacked evidence that the physician had educated the resident and or responsible party regarding the long-term use of antibiotics. During an interview, on 8/18/25 at 12:00 p.m., the Director of Nursing (DON) indicated Resident 26 sees a urologist and had been on the prophylactic antibiotic since before her admission to the facility. She was aware that prophylactic antibiotic use long term can cause antibiotic resistance. During an interview, on 8/18/25 at 3:17 p.m., the Infection Prevention (IP) nurse 3 indicated the facility utilized Mcgreers criteria a surveillance tools for infections in the long-term care facility. During an interview, on 8/19/25 at 9:10 a.m., the DON indicated Resident 26 was placed on the prophylactic antibiotic due to chronic urinary tract infections. She further indicated the facility had not performed a urinalysis (a laboratory test that examines a urine sample for various physical, chemical, and microscopic characteristics) since the resident was admitted to the facility on [DATE]. On 8/18/25 at 10:30 a.m., the Regional Nurse Consultant (RNC) provided a document with a revised date of 6/18, titled, Antibiotic Stewardship Program (ASP), and indicated it was the policy currently being used by the facility. The policy indicated, .According to the CDC (Center for Disease Control), improving the use of antibiotics in healthcare to protect patients and reduce threat of antibiotic resistance is a national priority.It is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. The policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety.

Based on observation, interview and record review, the facility failed to aid a resident in a manner that maintained or enhanced their dignity for 1 of 1 residents randomly observed for resident rights. (Resident 72). Findings include: On 7/18/24 at 10:00 a.m., observed Student Nurse Aide (4) transporting Resident 72 from the shower room to the resident's room while sitting in an open shower chair (a wheeled chair which provides support and stability to individuals who require assistance with bathing or using the restroom). The resident was wearing a blue long sleeve shirt and covered in the front with a light blanket. The back of the shower chair was uncovered, and the resident's buttocks was exposed. On 7/18/24 at 10:05 a.m., during an interview with Licensed Practical Nurse (LPN) 4 she indicated the resident should be completely covered before transporting in a shower chair. On 7/18/24 at 10:20 a.m., during an interview with Student Nurse Aide 4, she indicated the resident should have been covered prior to transporting the resident in a shower chair. On 7/18/24 at 1:30 p.m., the medical record of Resident 72 was reviewed. The resident was admitted with diagnosis including but not limited to, encephalopathy (damage or disease that affects the brain), altered mental status and cognitive communication deficit (trouble expressing needs using basic words and gestures). A care plan, dated 9/7/21, indicated the resident required assistance of one person for activities of daily living (ADL) care and transportation. An admission Minimum Data Set (MDS) assessment, dated 5/28/24, indicated the resident was not cognitively intact and she required maximum assistance of two persons for care needs. On 7/18/24 at 2:00 p.m., the Regional Nurse Consultant provided a document, titled, Resident Rights, dated 11/28/2016, and indicated it was the policy currently being used by the facility. The policy indicated, .Respect and Dignity. The resident has the right to be treated with respect and dignity 3.1-3(a)

Based on interview and record review, the facility failed to ensure documentation of a resident's transfer included information that the physician and family representative were notified of a resident being transferred to the hospital for 1 of 2 reviewed for hospitalization (Resident 17). Finding includes: During an interview, on 7/16/24 at 11:30 a.m., Resident 17 indicated she had recently been sent out to the hospital for a seizure and stayed overnight. Resident 17's record was reviewed on 7/22/24 at 10:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Epilepsy (group of non-communicable neurological disorders characterized by recurrent epileptic seizures [uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain]). A quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated the resident was cognitively intact. Review of the Situation, Background, Assessment, and Recommendation (SBAR) form, dated 6/18/24, indicated Resident 17 was being transported to the emergency room . The form was not completed in its entirety and lacked documentation of physician notification and family representative notification. Reivew of a nurse's note, dated 6/18/24 at 11:15 p.m., the note indicated Resident 17 had complained to a certified nurse's assistant (CNA) that she was not feeling well. The CNA reported to the nurse the resident was unresponsive to verbal stimulation. The resident did regain consciousness, but her color was pale with flushed face. The resident had nausea and vomiting times 2. Emergency Medical Services (EMS) was called to assist with transport to the hospital. The resident was alert at the time of transport. The nurse's note lacked documentation of a physician or family representative being notified of the transfer to the hospital for Resident 17. During an interview, on 7/22/24 at 10:19 a.m., Licensed Practical Nurse (LPN) 13 indicated the nursing staff should complete a SBAR form when sending out residents to the hospital. The form was then placed in a binder at the nurse's station when completed. During an interview, on 7/22/24 at 11:13 a.m., the Regional Nurse Consultant indicated she was unable to find any documentation of where the physician or family representative was notified of Resident 17's transfer to the hospital. The nurse, who had completed the SBAR, was no longer employed with the facility. On 7/22/24 at 11:00 a.m., the Regional Nurse Consultant provided a document with a revised date of 11/15, titled, SBAR Communication Form, .2. The licensed nurse will ensure relevant aspects of pages one through three are completed prior to calling the physician or other Healthcare Professional On 7/22/24 at 11:12 a.m., the Regional Nurse Consultant provided a document with a revised date of 11/16, titled, Change in Resident Condition/Emergency Transfer to Acute Care Hospital, and indicated it was the policy currently being used by the facility. The policy indicated, .In the event a resident's condition changes warranting medical attention, the licensed nurse shall complete the SBAR communication form and contact the physician .The family/resident representative shall be notified of the change in condition and corresponding physician orders 3.1-12(a)(5)(A) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(vii) 3.1-12(a)(6)(B)

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (catheter-a tube which is inserted into the bladder to drain urine) bag and tubing were kept from making contact with the floor for 1 of 1 residents reviewed for urinary catheters (Resident 36). Findings include: During the initial observation, on 7/16/24 at 2:03 p.m., Resident 36 was in his room sitting in a recliner. His catheter was attached to the lower portion of the recliner. The catheter urinary drainage bag (a bag attached to a indwelling urinary catheter to catch the urine) was in contact with the floor. During a random observation, on 7/17/24 at 1:16 p.m., the resident was in his room sitting in his wheelchair. The catheter tubing was observed in contact with the floor. During a random observation, on 7/18/24 at 2:13 p.m., the resident was sitting in his room in the recliner. His catheter was attached to the lower portion of his wheelchair next to the recliner. The catheter bag was observed in contact with the floor. During a random observation with the Assistant Director of Nursing (ADON), on 7/18/24 at 2:31 p.m., the resident was observed sitting in the recliner. The catheter bag was attached to the lower portion of his wheelchair sitting next to the recliner. The catheter bag was observed in contact with the floor. During a random observation, on 7/22/24 at 10:39 a.m., the resident was observed sitting on the side of his bed. The bed was in a very low position. A tub barrier, used to hold the catheter bag while the bed was in a low position, was flipped upside down and the catheter tubing was observed in contact with the floor. Resident 36's record was reviewed on 7/18/24 at 9:58 a.m. The profile indicated the resident's diagnoses included, but were not limited to, obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), unspecified hydronephrosis (a condition where one or both kidneys become stretched and swollen as the result of a build-up of urine inside them), retention of urine, and urinary tract infection (UTI). An admission Minimum Data Set (MDS) assessment, dated 6/21/24, indicated the resident had no cognitive deficit, required extensive assistance of two plus with transfers and toileting, and had an indwelling urinary catheter. A care plan, dated 6/25/24, and revised 7/5/24, indicated the resident had obstructive uropathy and had a catheter. Intervention included, but were not limited to, observed for signs and symptoms of infection. A physician's order, dated 7/9/24, with a stop date of 7/12 24, indicated to administer one amoxicillin-potassium clavulanate (a drug used to treat bacterial infections), 875-125 milligrams (mg) tablet, every 12 hours for urinary tract infection (UTI). During an interview, on 7/18/24 at 10:55 a.m., the resident indicated he was aware that he had been taking an antibiotic for a UTI. They had given him a new catheter, a week or so ago, because he had a UTI. He had only taken the antibiotic for 3 days or so and it ended about a week ago. During an interview, on 7/18/24 at 2:31 p.m., the ADON indicated catheter bags and the tubing should never be in contact with the floor. On 7/18/24 at 9:40 a.m., the Regional Nurse Consultant provided a document, with a revision date of 1/2020, titled Urinary Drainage Bag Maintenance, and indicated it was the policy currently being used by the facility. The policy indicated, .Rule: .Urinary drainage bag should not be allowed to touch the floor. Use the following procedure to secure the drainage bag: .2. Explain to the resident the following: .Do not allow the urinary drainage bag or tubing to touch the floor 3.1-41(a)(2)

Based on observations and interview, the facility failed to ensure medication were labeled and stored properly for 2 of 2 medication carts and 1 of 2 medication treatment carts reviewed for medication storage (Residents 72, 63 and 5). Findings include: On 7/18/24 at 11:00 a.m., during a medication cart observation. Lantus insulin pen (an injection device that you can use to deliver preloaded insulin into your subcutaneous tissue, the innermost layer of skin in your body) with the name of Resident 72 written on the side of the pen was observed. A pharmacy prescription label was not on the pen and there was no indication of when the insulin pen had been opened. Resident 72's Lantus insulin vial (a small glass bottle, used to store medication in the form of liquids) prescription label did not indicate the date it was opened. Resident 63's Lantus insulin pen pharmacy prescription label indicated the dispense date was 5/30/24. The label did not indicate the date it was opened. Resident 5's Novolog insulin pen prescription label indicated the dispense date was 5/1/24. The prescription label did not indicate the date it was opened. Resident 5's Aspart insulin pen prescription label indicated it was dispensed on 2/4/24. The label did not indicate the date it was opened. On 7/18/24 at 11:05 a.m., during an interview with Licensed Practical Nurse (LPN) 4, the nurse indicated every insulin vial and insulin pen should be dated when opened and be discarded after 16 to 30 days. On 7/19/14 at 9:35 a.m., during initial observation of north back hall treatment medication cart. Numerous prescribed ointments and topical medications were loose in the drawer, no medications were bagged, and several medications had no prescription labels. On 7/19/24 at 11:00 a.m., during an interview with the Assistant Director of Nursing, she indicated the treatment medications should be separated in individual bags in the treatment carts. On 7/18/2024 at 2:20 p.m., the Regional Nurse Consultant provided a document, titled Medication storage, Storing Drugs, dated 12/2017, and indicated it was the policy currently being used by the facility. The policy indicated, Procedures . 1.Each drug must be kept and stored in the labeled dispensing container .12. All drug storage areas must be clean, well lit, and free of clutter at all times On 7/18/2024 at 2:00 p.m., the Regional Nurse Consultant provided a document, titled, Medication Expiration, dated 9/2017, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .1 . d. Multiple dose injections, such as insulin will expire 28 days after opening unless otherwise noted by manufacturer .2. Facility staff shall date the label of any multiuse vial when the vial is first accessed . 3.1-25(j)

Based on record review and interview, the facility failed to ensure medications administered to a resident had been documented for 1 of 5 residents reviewed for unnecessary medication (Resident 39). Findings include: Resident 39's record was reviewed on 7/17/24 at 2:32 p.m. The profile indicated the resident's diagnoses included, but were not limited to, overactive bladder (causes sudden urges to urinate that may be hard to control), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and hyperlipidemia (elevated fats in the blood). A physician's order, dated 11/1/23, indicated to administer 1 tablet of oxybutynin chloride (used to treat symptoms of overactive bladder) 5 milligrams (mg) twice daily. The July 2024 Medication Administration Record (MAR) lacked documentation of the medication being administered on the evening shift of 7/3/24. A physician's order, dated 12/28/23, indicated to administer 1 tablet of galantamine (used to treat the symptoms of Alzheimer's disease [a type of dementia]), 4 mg two times daily. The July 2024 MAR lacked documentation of the medication being administered on the evening shift of 7/3/24. A physician's order, dated 1/24/24, indicated to administer 1 tablet of lorazepam (used to treat anxiety) 0.5 mg one time daily. The July 2024 MAR lacked documentation of the medication being administered on the evening shift of 7/3/24. A physician order, dated 2/29/24, indicated to administer 1 tablet of atorvastatin (drug to lower the amount of fats in the blood) 20 mg once daily. The July 2024 MAR lacked documentation of the medication being administered on the evening shift of 7/3/24. A physician's order, dated 6/26/24, indicated to administer 1 tablet of memantine (used to treat dementia) 10 mg two times daily. The July 2024 MAR lacked documentation of the medication being administered on the evening shift of 7/3/24. During an interview, on 7/18/24 at 1:45 p.m., the Regional Clinical Nurse indicated the expectation was that nurses would document the administered of a medication when the drug was administered. On 7/18/24 at 2:00 p.m., the Regional Nurse Consultant provided a document, with a revision date of 4/2017, titled, Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Guidelines for Medication Administration .21. Always record the dose of the medication on the MAR after the resident consumption 3.1-48(c)(2)

Based on record review, observation, and interview, the facility failed to ensure residents' self-releasing seat belts (used to keep a resident positioned properly in their wheelchair) were secured in a manner which allowed the residents to freely release the belts for 2 of 4 residents reviewed for physical restraint (Residents B and C). The deficient practice was corrected on 10/24/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An Indiana Department of Health (IDOH) reportable incident document, dated 10/24/23 at 11:15 a.m., indicated it had been reported that Certified Nursing Aide (CNA) 8 had used tape to secure the self-releasing seat belts of Resident B and Resident C, which removed the ability of the residents to self-release the seat belts. The facility's internal investigation was initiated. The CNA was immediately re-educated by the Assistant Director of Nursing (ADON) and was suspended from work, pending the results of the investigation. During an initial observation of the Expressions (memory care) unit, on 11/6/23 at 10:05 a.m., Residents B and D were observed sitting in the activity lounge participating in a morning activity. Both residents were observed with self-releasing seat belts in place. At the same time, Resident D was able to release her belt when requested. Resident B refused to release her belt and shook her head no. On 11/6/23 at 10:10 a.m., Resident C was observed in his room asleep in his wheelchair, with his seatbelt in place and intact. During an interview, on 11/6/23 at 10:18 a.m., Activities Assistant 3 indicated she worked on the unit specifically and had heard from other staff about someone putting tape on the seat belts of Residents B and C. She was not working when the incident happened. During an interview, on 11/6/23 at 10:25 a.m., CNA 4 indicated she had been told about the tape being placed on the seat belts of Resident B and C. She had never witnessed anything like this before. All of the residents who had the self-releasing belts were able to remove them when asked to. During an interview, on 11/6/23 at 10:36 a.m., Qualified Medication Aide (QMA) 5 indicated she was working on the unit and south hall on the day the incident had allegedly occurred but had only heard about it from other staff. She had not ever seen any issues with the self-releasing belts when she worked on the unit. During an interview, on 11/6/23 at 10:45 a.m., CNA 6 indicated she was working on a different unit of the facility on the date the incident supposedly happened. She did not see it firsthand but was told about it by other staff. She had never seen any tape on the self-releasing belts in the past. During an interview, on 11/6/23 at 10:51 a.m., the former Director of Nursing (DON) indicated on the date of the incident one of the high school Helping Hands (student from the local high school who observe CNAs and assist with non-hands on activities), who was in the facility working alongside CNA 8, had seen the tape on the seat belts. The student reported it to the charge nurse, Register Nurse (RN) 13. On 11/6/23 at 10:58 a.m., the Administrator (ADM) provided the facility's internal investigation documentation for review. At the same time, she indicated they had completed a full investigation of the allegations and sent the incident in as a reportable to IDOH. The CNA had been terminated following the investigation. There had not been any further incidents since this had been resolved. During an interview, on 11/6/23 at 11:37 a.m., Laundry Aide 11 indicated she had observed the tape on Resident C's seatbelt and had told CNA 8 that she could not do that because they were not allowed to restrain the residents. There was also a volunteer helper with the CNA at the time. She indicated CNA 8 acknowledged that she knew it was not allowed, but never made any attempt to remove the tape. The Laundry Aide indicated she told the QMA who was on duty on that hallway about what she had seen and what the CNA had said. She was unsure what happened after that. She gave the DON and the ADM her statement when they were investigating. Review of the facility's investigation documentation, included, but were not limited to the following: a. A statement from the former Director of Nursing (DON), dated 10/24/23, indicated the incident had been noticed by a high school student in the Helping Hands program and brought it to the attention of the nurse. A second statement indicated the facility had notified Resident B's family of the incident. b. An undated investigative interview statement, signed by the Administrator indicated CNA 9 had worked the day shift on 10/22/23. She noted that CNA 8 was on duty but had not provided toileting assistance to her residents. CNA 9 indicated she had gone into assist Resident C to the bathroom and noticed there was tape on his self-releasing seat belt. c. An undated handwritten statement, signed by Laundry Aide 11, indicated CNA 8 had told her that she had taped Resident C's seat belt because he would not stay in his wheelchair. The Laundry Aide observed the tape on the resident's seat belt. She then explained to CNA 8 that what she had done would get her into trouble. At that time, she indicated the Helping Hands student asked why it would get CNA 8 into trouble, and CNA 8 told the student that it was considered abuse to the resident, and they were not allowed to do that. d. An interview statement from Resident B, dated 10/24/23, indicated she did not know of anyone who had harmed her. She did not feel afraid or unsafe and felt everyone treated her very nice. e. A document titled, Possible or Potential Mental Anguish Assessment, dated 10/24/23, indicated Resident B had no signs or symptoms of potential mental anguish. f. A PHQ-9 (a depression assessment module, which scores each of the 9 depression diagnostic criteria as 0 [not at all] to 3 [nearly every day]) document, dated 10/24/23, indicated Resident B scored a 6 (mild depression). g. An interview statement for Resident C, dated 10/24/23, indicated the resident was not able to remember any incidence when anyone had mistreated or harmed him. He told the interviewer he felt fine, and he did not have any fear or feel unsafe. h. A document titled, Possible or Potential Mental Anguish Assessment, dated 10/24/23, indicated Resident C had no signs or symptoms of potential mental anguish. i. A PHQ-9 (a depression assessment module, which scores each of the 9 depression diagnostic criteria as 0 [not at all] to 3 [nearly every day]) document, dated 10/24/23, indicated Resident C scored a 11 (moderate depression). j. Nursing in-service sign-in sheets, dated 10/24/23, indicated education titled, Restraints, Self-release belt alarm, was provided as part of the investigation documentation. The DON had provided the education which covered the policy titled, Alarm, Position Change. k. Nursing in-service sign-in sheets, dated 10/24/23, for education titled, Mood/Behavior Management and CNA/Helping Hand Job Description, was provided as part of the investigation documentation. The DON had provided the education which covered the policies on Mood and Behavior and Abuse Prohibition. Signed copies of documents, titled, Abuse Prohibition/Know Your Role, had been signed by each staff person in attendance. l. A facility investigation document, dated 10/27/23, and signed by the ADM, indicated she had called CNA 8, into the facility, to discuss the incident. The CNA told her that she knew better than to put tape on the seat belt, but the resident just kept getting up from his chair, and she had done it to keep him safe. The Abuse policy was reviewed with the CNA. The CNA was terminated due to corporal punishment, involuntary seclusion, and unreasonable confinement. The CNA had never been back into the facility after her suspension, except to sign her termination paperwork. 1. Resident B's record was reviewed on 11/6/23 at 1:51 p.m. The resident diagnoses included, but were not limited to, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and mood disorder (a mental health condition that primarily affects a person's emotional state). An admission Minimum Data Set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 9/15/23, indicated the resident had severe cognitive deficit. A care plan, dated 9/19/23 and revised 10/22/23, indicated the resident had multiple risk factors for falls. Interventions included, but were not limited to, seat belt alarm. A physician's order, dated 10/9/23, indicated resident may use self-release belt to promote safety awareness. Utilization of self-release belt does not inhibit voluntary movement. An initial physical restraint assessment, dated 10/9/23, indicated the resident had a self-release seat belt and was able to release the belt upon command. 2, Resident C's record was reviewed on 11/6/23 at 2:41 p.m. The resident's diagnoses included, but were not limited to, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and frontotemporal dementia (a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost). A comprehensive Minimum Data Set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 10/27/23, indicated the resident had severe cognitive deficit. A care plan, dated 7/21/23 and updated on 11/3/23, indicated the resident had multiple risk factors for falls. Interventions included, but were not limited to, seat belt alarm to wheelchair. A physician's order, dated 10/6/23, indicated resident may use self-release belt to promote safety awareness. Utilization of self-release belt does not inhibit voluntary movement. An initial physical restraint assessment, dated 10/2/23, indicated the resident was able to release the belt upon command. On 11/6/23 at 2:14 p.m., the Nurse Consultant provided a document, with a revised date of 6/2023, titled, Abuse Prohibition, Reporting and Investigation, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: The facility shall prohibit and prevent abuse .This includes but is not limited to .any physical or chemical restraint .Physical abuse .Includes .controlling behavior through corporal punishment .which is physical punishment, is used to correct or control behavior The deficient practice was corrected by 10/24/23, after the facility implemented a systemic plan that included the following actions: provided a complete investigation of the incident; assessment of the physical, mental and emotional status of the residents involved; provided re-education to all nursing staff of restraints and the use of self-releasing seat belts along with mood and behavior management and abuse prohibition, reporting, and investigation policies and procedures; and termination of the staff responsible. The deficient practice was corrected on 10/24/23, prior to the start of the survey, and was therefore past noncompliance. This citation relates to complaint IN00420470. 3.1-3(w)

Based on record review, and interview, the facility failed to ensure the Code Status/Advanced Directive document matched the physician's order for code status for 1 of 24 residents reviewed for advanced directives (Resident 1). Finding includes: Resident 1's record was reviewed on [DATE] at 9:00 a.m. The physician's order, dated [DATE], indicated the resident was a full code (preferred to have CPR [cardio-pulmonary resuscitation] performed, if needed as a life-saving measure). The Indiana Physician Orders for Scope of Treatment (Post), document, signed [DATE], indicated the resident preferred to be a no code (did not prefer to have CPR performed as a life-saving measure). A document posted on the door of the chart rack at the nurse's station, indicated the resident was a full code. A care plan, dated [DATE], and reviewed on [DATE], indicated the resident's code status had been designated as a no code. During an interview, on [DATE] at 9:26 a.m., Licensed Practical Nurse (LPN) 10 indicated there was a listing of the residents' code status on the door of the chart rack at the nurse's station. The staff could also see the information in the residents' chart or in the computer system by their name. During an interview, on [DATE] at 9:29 a.m., Director of Nursing (DON) indicated she had never seen the document posted on the rack of the nurse's station and was not an approved document by her. She indicated the staff should have used the computer or chart to check residents' code status. During an interview, on [DATE] at 9:55 a.m., DON indicated a unit manager had created the code status document at the nurse's station to try to be helpful so that staff could find the information more readily. The DON indicated the code status on the computer and on the document at the nurse's station do not match the post form in Resident 1's chart. On [DATE] at 9:57 a.m., the DON provided a document, dated ,d+[DATE], titled. Code Status, and indicated it was the policy currently being used by the facility. The policy indicated, . The facility requires all physicians to address code status for each resident to delineate if resuscitative measures should be initiated. This enables nursing personnel to readily and clearly ascertain how to treat the resident in the event of an emergency 3XXX,d+[DATE](1)(4)

Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served for 1 of 1 test tray reviewed for temperature and palatability and 2 of 26 residents reviewed for food palatability (Residents 30 and 14). Findings include: During an interview, on 6/12/23 at 9:40 a.m., Resident 30 indicated she ate meals in her room and the food was often cold when she got it. The food cart sat on the hallway. It was not passed out in a timely manner from the staff and the food got cold before she received her food tray. During an interview, on 6/12/23 at 11:52 a.m., Resident 14 indicated she ate meals in her room and the food was cold when she got the food tray. During an interview, on 6/15/23 at 11:23 a.m., the Dietary Manager (DM) indicated food temperatures should be taken when food came out of the oven, after being placed onto the steam table, and prior to being plated. The hall food trays would be placed into the hall carts with the food plate covered with a plastic lid and plastic base. During a kitchen observation, on 6/15/23 at 11:23 a.m., the lunch meal food temperatures were taken after placement onto the steam table by Cook 16. The cube steak measured at 191 degrees Fahrenheit (F), the broccoli measured at 162 F, the brown gravy measured at 165 F, the mashed potatoes measured at 165 F. On 6/15/23 at 12:28 p.m., test tray food temperatures were measured by the Dietary Manager (DM). The cubed steak temperature measured at 136 F, the mashed potatoes temperature measured at 135 F, and the cooked broccoli temperature measured at 100 F. The DM indicated all cooked food should have been at least 135 F and the broccoli was not warm enough. On 6/15/23 at 12:50 p.m., DM provided and identified a document as a current facility policy, titled, Food Temperature on Service Line, dated 05/2018. The policy indicated, .Policy: Foods will be served at proper temperature to ensure food safety .Procedure: .4. Acceptable service temperatures are: .Meat, Entrees, Eggs > or = (greater than or equal to) 135 degrees Fahrenheit (F) .Potatoes, pasta > or = 135 F .Vegetables > or = 135 F 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to follow Centers for Disease Control and Prevention (CDC) guidance during a pandemic and ensure infection control practices for COVID-19 were implemented to prevent the potential for spread of COVID-19 by failing to place symptomatic residents into isolation for 4 residents who resided on a dementia green unit (a unit that houses residents with low risk of infection/who have not been exposed) (Residents F, B, C, and G), 3 of whom subsequently tested positive for COVID-19 (Residents F, B, and G). Another resident was asymptomatic but tested positive for COVID-19 (Resident E). The staff were not monitoring for all symptoms of COVID-19, not recognizing potential symptoms of COVID-19 and were not ensuring residents were kept socially distanced, as the symptomatic residents were observed in common areas of the unit and eating lunch at the same table. This resulted in potential exposure of the 6 other residents on the unit to COVID-19. The facility also failed to ensure proper personal protective equipment was worn into a yellow zone (a unit that houses residents who are symptomatic for or have been exposed to COVID-19) room (Residents M and L). This affected 6 of 11 residents reviewed for infection control, with potential for [MEDICAL CONDITION] to spread to the other 6 residents who resided on the dementia unit. The Immediate Jeopardy began on 12/10/20, when two days after two residents on the dementia unit tested positive for COVID-19, other residents with COVID-19 symptoms residing on the dementia unit were not placed on isolation precautions. Residents B, C, and F had elevated temperatures, and were not placed in isolation. Resident G was incontinent of loose stools in the hallway and was not placed in isolation. Residents B, E, and F ate lunch in the dining room without social distancing or masks. Residents B and F had elevated temperatures at lunch, and both later tested positive for COVID-19. Resident E was asymptomatic, but later tested positive for COVID-19. Staff were taking temperatures without proper hand hygiene or cleaning the equipment and were not monitoring for other symptoms of COVID-19. The Regional Director and Regional Nurse were notified of the Immediate Jeopardy at 4:52 p.m., on 12/10/20. The immediate jeopardy was removed on 12/11/20, but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During a continuous observation of the dementia locked unit on 12/10/20 from 11:44 a.m. to 11:47 a.m., the following was observed: Certified Nursing Assistant (CNA) 7 took Resident D's temperature in the activity/dining room with a thermometer that made contact with the resident's forehead. There was no barrier on the thermometer. CNA 7 then touched Resident D's arm, bare handed, and assisted her to another table. CNA 7 then took Resident F's temperature with the same thermometer in the activity/dining room. CNA 7 proceeded down the hall to Resident C's room and took his temperature with the same thermometer. The thermometer was not cleaned between uses, gloves were not worn, and no hand hygiene was completed. During a dining observation on the dementia locked unit on 12/10/20 at 11:56 a.m., Resident B, F and E were observed eating at the same dining room table. They were not wearing masks because they were eating, and they were not socially distanced. Staff was not observed to redirect residents to different tables or ask them to socially distance. On 12/10/20 at 11:58 a.m., Resident G was observed to have a loose bowel movement (BM) on the floor in the hallway. The resident was not isolated. On 12/10/20 at 12:22 p.m., Resident G was observed wandering the dementia locked unit, without a mask on. Resident G was not isolated, and there was no isolation signage on his room door. Resident F and E were observed sitting at a table together in the activity/dining room. Resident F and E were not socially distanced. Resident F had a mask in place over her mouth only, and it did not cover her nose. Resident E was not wearing a mask. Resident B stood near the table, not wearing a mask. Resident G was observed wandering in the same area, near the other residents, within six feet of them. On 12/10/20 at 1:40 p.m., Resident B, C, and G's rooms were observed with no signage to indicate the residents were isolated. There were no Personal Protective Equipment (PPE) carts outside the doors. On 12/10/20 at 1:41 p.m., Resident G was observed wandering in the common area of the dementia locked unit with no mask on, and he was not socially distanced from Resident D and B. Resident B was also observed wandering in the same area with a mask pulled down below her nose, not socially distanced. The residents were not isolated. During an interview, on 12/10/20 at 1:50 p.m., the Regional Nurse and Infection Preventionist (IP) indicated there were no COVID-19 positive residents in the building until 12/8/20. On 12/8/20, they tested all residents in the building, and two residents on the dementia locked unit were found to be positive for COVID-19. Those two residents were moved to the red zone (an area for COVID-19 positive residents). All the remaining residents were negative for COVID-19 on 12/8/20. On 12/10/20 at 4:00 p.m., the Regional Nurse and IP provided a facility floor plan and indicated it was the map currently being used by the facility. The color coded map indicated the dementia locked unit was a green zone (an area of the building where there were no cases of COVID-19 and the risk was low). a. Resident F's record was reviewed on 12/10/20 at 12:53 p.m. An admission Minimum Data Set (MDS) assessment, dated 11/27/20, indicated the resident had a moderate cognitive impairment. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. A temperature and symptom monitoring log, dated 12/8/20, indicated to monitor for a temperature of greater than 100.0 degrees F (Fahrenheit), cough, shortness of breath, respiratory rate, oxygen saturation percentage, malaise or fatigue, sore throat, nausea or vomiting, diarrhea, and muscle aches. The evening shift log indicated Resident F's temperature was 98.4 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/8/20, night shift, indicated the resident's temperature was 97.8 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/9/20, day shift, indicated the resident's temperature was 97.6 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/9/20, night shift, indicated the resident's temperature was 97.7 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A Bed Board, dated 12/9/20, indicated Resident F resided on the dementia locked unit with nine other residents. A temperature and symptom monitoring log, dated 12/10/20, day shift, indicated the resident's temperature was 99.2 degrees F at 8:00 a.m. and 99.6 at 11:45 a.m. The log lacked documentation of a respiratory rate, oxygen saturation, documentation of any other symptoms, placing the resident in isolation, and physician notification of the elevated temperature. Nurse's notes, dated December 2020, lacked documentation of assessment for symptoms of COVID-19, placing the resident in isolation, and physician notification of the elevated temperatures. An undated list of COVID-19 positive residents indicated Resident F was positive for COVID-19 on 12/10/20. During an interview, on 12/10/20 at 12:03 p.m., Certified Nursing Assistant (CNA) 7 indicated she took Resident F's temperature at 8:00 a.m., and 11:45 a.m. She notified Qualified Medication Aide (QMA) 4 and the Director of Nursing (DON) of the elevated temperatures. She was not told if the resident required isolation precautions. During an interview, on 12/10/20 at 5:00 p.m., the Regional Nurse and Infection Preventionist (IP) indicated Resident F had a point of care (POC) COVID-19 test related to elevated temperatures on 12/10/20, and she was positive for COVID-19. b. Resident B's record was reviewed on 12/10/20 at 12:32 p.m. A significant change Minimum Data Set (MDS) assessment, dated 10/7/20, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. A temperature and symptom monitoring log, dated 12/8/20, indicated to monitor for a temperature of greater than 100.0 degrees F, cough, shortness of breath, respiratory rate, oxygen saturation percentage, malaise or fatigue, sore throat, nausea or vomiting, diarrhea, and muscle aches. The evening shift log indicated Resident B's temperature was 98.1 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/8/20, night shift, indicated the resident's temperature was 96.9 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/9/20, day shift, indicated the resident's temperature was 98.6 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/9/20, night shift, lacked documentation the resident's temperature was checked, a respiratory rate, oxygen saturation, and no symptoms were documented. A Bed Board, dated 12/9/20, indicated Resident B resided on the dementia locked unit with nine other residents. A temperature and symptom monitoring log, dated 12/10/20, day shift, indicated the resident's temperature was 100.2 degrees F at 8:00 a.m., 100.6 degrees F at 11:45 a.m., and 101.5 degrees F at 12:30 p.m. The log lacked documentation of a respiratory rate, oxygen saturation, documentation of any other symptoms, placing the resident in isolation, and physician notification of the elevated temperature. Nurse's notes, dated December 2020, lacked documentation of assessment for symptoms of COVID-19, placing the resident in isolation, and physician notification of the elevated temperatures. An undated list of COVID-19 positive residents indicated Resident B was positive for COVID-19 on 12/11/20. During an interview, on 12/10/20 at 12:03 p.m., Certified Nursing Assistant (CNA) 7 indicated she took Resident B's temperature at 8:00 a.m., and 11:45 a.m. She notified Qualified Medication Aide (QMA) 4 and the Director of Nursing (DON) of the elevated temperatures. She was not told if the resident required isolation precautions. On 12/10/20 at 12:05 p.m., Qualified Medication Aide (QMA) 4 indicated she was aware Resident B had an elevated temperature and had administered Tylenol (a fever reducing medication). She was not sure if the physician had been notified of the temperature or if the resident required isolation. During an interview, on 12/10/20 at 12:35 p.m., QMA 4 indicated she checked the charting and was unable to find Resident B's temperature was checked on the night shift of 12/9/20. c. Resident C's record was reviewed on 12/10/20 at 1:21 p.m. A significant change Minimum Data Set (MDS) assessment, dated 9/2/20, indicated the resident had a moderate cognitive impairment. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. A temperature and symptom monitoring log, dated 12/8/20, indicated to monitor for a temperature of greater than 100.0 degrees F, cough, shortness of breath, respiratory rate, oxygen saturation percentage, malaise or fatigue, sore throat, nausea or vomiting, diarrhea, and muscle aches. The evening shift log indicated Resident C's temperature was 97.7 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/8/20, night shift, indicated the resident's temperature was 98.2 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and symptom monitoring log, dated 12/9/20, day shift, indicated the resident's temperature was 98.7 degrees F. The log lacked documentation of a respiratory rate or oxygen saturation, and no symptoms were documented. A temperature and monitoring log, dated 12/9/20, night shift, indicated the resident's temperature was 99.3 degrees F. The log lacked documentation of a respiratory rate, oxygen saturation, documentation of any other symptoms, placing the resident in isolation, and physician notification of the elevated temperature. A Bed Board, dated 12/9/20, indicated Resident C resided on the dementia locked unit with nine other residents. A temperature and symptom monitoring log, dated 12/10/20, day shift, indicated the resident's temperature was 99.3 degrees F at 8:00 a.m., and 99.6 degrees F at 11:45 a.m. The log lacked documentation of a respiratory rate, oxygen saturation, documentation of any other symptoms, placing the resident in isolation, and physician notification of the elevated temperature. Nurse's notes, dated December 2020, lacked documentation of assessment for symptoms of COVID-19, placing the resident in isolation, and physician notification of the elevated temperatures. During an interview, on 12/10/20 at 12:03 p.m., CNA 7 indicated she took Resident C's temperature at 8:00 a.m., and 11:45 a.m. She notified Qualified Medication Aide (QMA) 4 and the Director of Nursing (DON) of the elevated temperatures. She was not told if the resident required isolation precautions. During an interview, on 12/10/20 at 1:33 p.m., the Regional Nurse and Infection Preventionist (IP) indicated she was not sure why Resident C was not isolated because he had three temperatures over 99.0 degrees F. He should have been placed in isolation precautions. During an interview, on 12/11/20 at 12:17 p.m., the Regional Director indicated Resident C refused COVID-19 testing. He was placed on isolation precautions in a private room. d. Resident G's record was reviewed on 12/10/20 at 12:59 p.m. An admission Minimum Data Set (MDS) assessment, dated 11/26/20, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. A Bed Board, dated 12/9/20, indicated Resident G resided on the dementia locked unit with nine other residents. A temperature and symptom monitoring log, dated 12/10/20, indicated to monitor for a temperature of greater than 100.0 degrees F, cough, shortness of breath, respiratory rate, oxygen saturation percentage, malaise or fatigue, sore throat, nausea or vomiting, diarrhea, and muscle aches. The day shift log indicated Resident G's temperature was 98.7 degrees F. The log lacked documentation of a respiratory rate, oxygen saturation, documentation of any other symptoms, placing the resident in isolation, and physician notification of loose stools which the resident had on 12/10/20. Nurse's notes, dated December 2020, lacked documentation of assessment for symptoms of COVID-19, placing the resident in isolation, and physician notification of the loose stools. On 12/10/20 at 11:58 a.m., CNA 7 indicated Resident G had loose stools in the hallway twice today, and she was not sure if it was normal for the resident. She had reported it to Qualified Medication Aide (QMA) 4 and the Director of Nursing (DON). She was not told if the resident required isolation precautions. An undated list of COVID-19 positive residents indicated Resident G was positive for COVID-19 on 12/10/20. During an interview, on 12/10/20 at 12:05 p.m., QMA 4 indicated Resident G had loose stools on the floor in the hallway twice today. She was not sure if this was normal for him, and it probably should have been considered as a possible symptom of COVID-19. She had reported it to the DON but was not sure if the resident required isolation. He was not compliant with staying in his room or wearing a mask. She was not sure if the physician had been notified of the loose stools. During an interview, on 12/10/20 at 1:00 p.m., QMA 4 indicated there was a new physician's orders [REDACTED]. The DON instructed her to try to keep Resident G in isolation, but she did not think he would stay in his room. During an interview, on 12/10/20 at 1:33 p.m., the Regional Nurse and Infection Preventionist (IP) indicated she was not sure why Resident G's loose stools were not documented on the temperature and symptom monitoring log. It should have been documented. e. Resident D's record was reviewed on 12/10/20 at 1:17 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 9/30/20, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. A Bed Board, dated 12/9/20, indicated Resident D resided on the dementia locked unit with nine other residents. A temperature and symptom monitoring log, dated 12/10/20, indicated to monitor for a temperature of greater than 100.0 degrees F, cough, shortness of breath, respiratory rate, oxygen saturation percentage, malaise or fatigue, sore throat, nausea or vomiting, diarrhea, and muscle aches. The day shift log indicated Resident D's temperature was 99.2 degrees F at 8:00 a.m., and 98.9 degrees F at 11:45 degrees F. Nurse's notes, dated December 2020, lacked documentation of assessment for symptoms of COVID-19. During an interview, on 12/10/20 at 12:03 p.m., Certified Nursing Assistant (CNA) 7 indicated she took Resident D's temperature at 8:00 a.m., and 11:45 a.m. She notified Qualified Medication Aide (QMA) 4 and the Director of Nursing (DON) of the elevated temperature at 8:00 a.m. She was not told if the resident required isolation precautions. During an interview, on 12/14/20 at 3:45 p.m., the Regional Director indicated Resident D was positive for COVID-19 on 12/13/20. f. Resident E's record was reviewed on 12/10/20 at 1:12 p.m. An admission Minimum Data Set (MDS) assessment, dated 9/5/20, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. A Bed Board, dated 12/9/20, indicated Resident E resided on the dementia locked unit with nine other residents. A temperature and symptom monitoring log, dated 12/10/20, indicated to monitor for a temperature of greater than 100.0 degrees F, cough, shortness of breath, respiratory rate, oxygen saturation percentage, malaise or fatigue, sore throat, nausea or vomiting, diarrhea, and muscle aches. The day shift log indicated Resident E's temperature was 98.2 degrees F. The log lacked documentation of a respiratory rate, oxygen saturation, and documentation of any other symptoms. Nurse's notes, dated December 2020, lacked documentation of assessment for symptoms of COVID-19. An undated list of COVID-19 positive residents indicated Resident E was positive for COVID-19 on 12/10/20. During an interview, on 12/10/20 at 12:35 p.m., QMA 4 indicated there was no place she was aware of that told them what symptoms to monitor for COVID-19. This made it difficult for her to know what symptoms needed to be reported, and when residents needed to be isolated. They charted in the nurse's notes, only if a symptom was observed. She spoke with the DON and was instructed to place Residents B, C, D, and F in isolation, and they were to be tested for COVID-19. She was not sure if Resident G required isolation related to the loose stools, and she had forgotten to ask about him. During an interview, on 12/10/20 at 1:00 p.m., QMA 4 indicated a temperature of 99.0 degrees F to 100.0 degrees F was not considered a fever and would not have required isolation. She was told to report any temperatures over 100.0 degrees F. During an interview, on 12/10/20 at 1:33 p.m., the Regional Nurse and Infection Preventionist (IP) indicated the symptoms that should have been monitored for were on the temperature log. The staff should have been aware of this, but the copy on the dementia unit had been copied a lot of times and was very hard to read. The staff should have been aware to monitor for two or more temperatures of greater than 99.0 degrees F. She was not sure why the temperature and symptom log indicated to monitor for a temperature of greater than 100.0 degrees F. Residents with elevated temperatures or other symptoms of COVID-19 should not have been in the activity/dining room, and residents should have been socially distanced. On 12/10/20 at 1:45 p.m., the Regional Nurse and IP provided a temperature and symptom monitoring log, and indicated it was the one the dementia locked unit had been using. The log indicated, If Temperature is greater than or equal to 100.0 F consider factors such as excessive blankets, heat on high, etc., and recheck within 30 minutes and document recheck below. Check any symptoms exhibited. Nursing Administration and Physician must be notified if Temp verified to be greater than or equal to 100.0 degrees F and/or if symptoms present .monitor for cough, shortness of breath, respiratory rate, oxygen saturation, malaise and fatigue, sore throat, nausea and vomiting, diarrhea, muscle aches and pain .If ANY of the aforementioned symptoms are present, list time resident placed in contact/droplet precautions On 12/10/20 at 2:56 p.m., the Regional Nurse and IP provided a document titled, PANDEMIC COVID-19 EMERGENCY PREPAREDNESS PLAN, and indicated it was the policy currently being used by the facility. The policy indicated, The following plan will address infection control practices and procedures to be implemented by the facility COVID-19 Response Team in the event of outbreak of pandemic COVID-19 SURVEILLANCE/MONITORING: This facility shall screen .each resident (at least daily) .The facility shall maintain a system to monitor for, and internally review, development of COVID-19 among residents .Information from this monitoring system is used to implement prevention interventions .SUPPLIES AND RESOURCES: .Signs shall be posted immediately outside of resident rooms indicating appropriate Transmission-Based Precautions (isolation), as applicable and required personal protective equipment (PPE) .Necessary PPE shall be available in resident rooms and in other areas where resident care is provided .IDENTIFICATION AND MANAGEMENT OF ILL RESIDENTS: The facility has a process to identify/screen and manage residents with symptoms of respiratory infection .daily during their stay in the facility, which includes implementation of Transmission-Based Precautions, when indicated .RESIDENTS AND FACE COVERINGS: Residents will be encouraged to wear a mask or a face covering when outside of his/her room to prevent potential exposure. The facility shall supply a mask as needed. Should a resident refuse to wear a mask or have a condition causing difficulty when wearing a mask, facility staff shall encourage the resident to cover their mouth and nose with a tissue and remind or assist the resident to perform hand hygiene. The resident will be encouraged to social distance when outside of his/her room .EDUCATION AND TRAINING: The facility shall provide education and training to personnel .to help them understand the implications of, and basic prevention and control measures for, COVID-19 .Administrative staff of the facility shall be responsible to monitor staff for adherence with infection control practices (e.g., appropriate use of PPE, hand hygiene, adherence with TBP's, etc.) .RESIDENT-CARE EQUIPMENT: Follow standard precautions for handling and reprocessing used resident-care equipment, including medical devices: Wear gloves when handling and transporting used resident-care equipment .Wipe external surfaces of portable equipment .with an EPA-approved disinfectant upon removal from the resident's room On 12/10/20 at 4:35 p.m., the Regional Nurse and IP provided an updated temperature and symptom monitoring log and indicated it was the policy the facility should have been using. The log indicated, If Temperature is greater than or equal to 100.0 F consider factors such as excessive blankets, heat on high, etc., and recheck within 30 minutes and document below. Check any symptom(s) exhibited and nurse shall assess resident if symptom(s) present. Nursing Administration and Physician must be notified if Temp verified to be greater than or equal to 100.0 degrees F, repeated oral temps greater than 99.0 degrees F are observed, and/or symptom(s) currently exhibited .monitor for cough, shortness of breath, respiratory rate, oxygen saturation, malaise and fatigue, sore throat, nausea and vomiting, diarrhea, muscle aches and pain .If ANY of the aforementioned symptoms are present, list time resident placed in contact/droplet precautions The ISDH Guidance for out-of-hospital facilities, dated 3/29/20, indicated, The following is guidance for out of hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles: 1. Placement of patient /resident in contact-droplet precautions with proper PPE, including gown, glove, mask with face shield or eye protection. 2. Proper donning and doffing of personal protection equipment when in contact with COVID-19 residents Reduce the movement of staff between patients with and without COVID-19 precautions with proper PPE- gown, glove, mask with face shield or eye protection .Patients/residents with known or suspected COVID-19 should be cared for in a single-person (private) room with the door closed. Airborne infection isolation rooms (AIIR) are not required. Patients/residents with known or suspected COVID-19 should not share bathrooms with other patients/residents. All patients/residents returning from the hospital with suspected or confirmed COVID-19 should be cared for in a private room, or Cohorted with other patients of the same status in the same unit, wing, hallway, or building. Patients with close contact with a confirmed COVID-19 patient (e.g., roommate or infected staff without wearing PPE) should be isolated and follow 14 day self-monitoring guidelines. If they develop symptoms, and are confirmed or suspected to have COVID-19, they should remain isolation until at least 7 days after symptom onset and 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms (e.g., cough), whichever is longer . The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, indicated, If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario. Public health authorities can assist with decisions about resident placement .If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected [DIAGNOSES REDACTED].g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident 2. On 12/10/20 at 11:16 a.m., Certified Nursing Assistant (CNA) 6 was observed exiting Resident M and L's room on the skilled nursing unit. A sign was on the door which indicated isolation precautions. CNA 6 wore a surgical mask. The mask was double looped around her ears, creating a gap on each side. At the same time, CNA 6 indicated she wore an N95 (a respirator that protects against germs in droplets in the air) mask, sometimes, but had not picked one up today. Resident M's record was reviewed on 12/10/20 at 3:08 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/20, indicated the resident had a moderate cognitive impairment. [DIAGNOSES REDACTED]. A nurse's note, dated 12/1/20, indicated the resident had shortness of breath, increased cough, and wheezing throughout his lungs. The physician was notified. A physician's orders [REDACTED]. 3. Resident L's record was reviewed on 12/10/20 at 3:11 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 9/26/20, indicated the resident had a severe cognitive impairment for daily decision making. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During an interview, on 12/14/20 at 3:45 p.m., the Regional Director indicated Resident L was positive for COVID-19 on 12/14/20. On 12/10/20 at 2:56 p.m., the Regional Nurse and Infection Preventionist (IP) provided an untitled document, and indicated it was the policy currently being used by the facility. The policy indicated, .General Population PPE: Staff continue to wear procedure masks at all times .If a resident in the general population is in Contact/Droplet Precautions, the following must be followed: Precautions Cart .Mask (the caregiver should already be wearing a procedure mask), an N95 mask must be worn by the caregiver IF performing an aerosol generating procedure .should a caregiver prefer to(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure pressure relief interventions were implemented for 2 of 5 residents (Resident 4, Resident 60) and failed to ensure pressure ulcer care plans were followed for 2 of 5 residents (Resident 19, Resident 18) reviewed for pressure ulcers. This deficient practice resulted in Resident 4 experiencing an unstageable pressure injury to the left heel. Findings include: 1.During a random observation, on 8/12/19 at 9:03 a.m. Resident 4 was observed to have a protective heel boot to his left foot, the boot was turned sideways and not positioned correctly to the residents left heel. During an observation of Resident 4, on 8/12/19 at 9:07 a.m., with Licensed Practical Nurse (LPN) 8, she indicated the heel boot was upside down and backwards and had not been properly placed. The heel boot should have been properly placed. She was unsure when the dressing to the left heel had been last changed because it lacked initials and was not dated, it should have been initialed by the nurse who completed it and dated. During an observation, on 8/12/19 at 1:30 p.m. Resident 4 was observed to have a protective heel boot around his left ankle and turned backwards, the resident's heel was not in the heel protective boot. Resident 4's record was reviewed on 8/12/19 at 1:37 p.m. [DIAGNOSES REDACTED]. A Braden Scale (an assessment used to predict the risk of pressure ulcer development), dated 5/7/19, indicated the resident had a moderate risk for pressure ulcer development. A Braden Scale (an assessment used to predict the risk of pressure ulcer development), dated 7/24/19, indicated the resident had a mild risk for pressure ulcer development. A significant change Minimum Data Set (MDS), dated [DATE], indicated the resident had a stage 2 pressure ulcer. The resident had a moderately impaired cognition. A review of physician's orders [REDACTED]. A nursing re-admission assessment, dated 7/18/19, indicated the resident had a stage one pressure ulcer to the coccyx (area above the spine), measured 1.5 centimeters (cm) length by 1 cm width, with no depth documented. An initial pressure ulcer assessment, dated 7/19/19, indicated the resident's stage one pressure ulcer to the coccyx measured 1.5 centimeters (cm) length by 1cm width by less than 0.1 cm in depth. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated (MONTH) 2019, lacked documentation of a treatment order for the stage one pressure to the coccyx from 7/18/19 to 7/23/19. A 24 hour nurse's report, dated 7/20/19 through 7/23/19, indicated a coccyx pad had been applied to the resident's area on the coccyx. A mood and behavior communication memo, dated 7/21/19 at 9:00 p.m., indicated the resident been turned on his side and feet floated, but upon returning to the room he was on his back and had moved the pillow from under his feet. Even after educating of the effects he continued to do it. Interventions included, changed position and allowed resident to vent feelings. The interventions attempted indicated they were unsuccessful. The resident's record lacked documentation of other interventions attempted, or notification to the physician of refusal. A mood and behavior communication memo, dated 7/21/19 at 11:00 p.m., indicated the resident was checked during routine bed check and had continued to roll himself onto his back, kicking the pillow out from under his feet. The resident was non-compliant with instructions given to him about floating his heels and staying on his side. The interventions attempted included, toileting and changed position. The interventions indicated they were unsuccessful. The resident's record lacked documentation of other interventions attempted, or notification to the physician of refusal. A physician's progress note, dated 7/24/19, indicated the resident had no pressure ulcers. A physician's orders [REDACTED]. A MAR, dated (MONTH) 2019 and start dated 7/25/19, indicated to cleanse area on buttocks with wound cleaner, apply Purocol (collagen wound dressing) and cover with occlusive dressing every day. The MAR lacked documentation this had been completed on the following dates: 7/30/19, and 7/31/19. A mood and behavior communication memo, dated 7/25/19 at 11:00 p.m., indicated the resident was assisted to bed at 8:00 p.m. and placed on his left side. During the 2 hour bed check the resident had his heels on the bed and the pillows from under his bottom on the floor. The interventions attempted included toileting, changed position, provided fluids, provided 1:1 with resident, and allowed resident to vent feelings. The interventions indicated they were unsuccessful. The resident's record lacked documentation of other interventions attempted, or notification to the physician of refusal. A pressure ulcer assessment, dated 7/26/19, indicated the resident's stage one to the coccyx was now a stage 2 and measured 1.5 centimeters (cm) length by 0.5 cm width by less than 0.1 cm in depth. A MAR, dated (MONTH) 2019 and start dated 7/26/19, indicated active liquid protein, give 30 milliliters (ml) by mouth twice daily for wound healing. The MAR lacked documentation this had been completed on the following dates: at 8:00 a.m. on 7/26/19, 7/27/19, 7/29/19, and 7/30/19, and at 8:00 p.m. on 7/26/19. A MAR, dated (MONTH) 2019 and start dated 7/26/19, indicated low air loss mattress, check every shift for function. The MAR lacked documentation this had been completed for day and evening shift on 7/26/19, and evening and night shift on 7/31/19. An initial pressure ulcer assessment, dated 7/29/19, indicated the resident's unstageable pressure ulcer to the bottom of the left heel measured six cm in length by four cm in width, with no depth documented. The wound bed was black, and wound edges were smooth and black. A MAR, dated (MONTH) 2019 and start dated 7/30/19, indicated to apply marathon to the bottom of left heel, cover with Opitfoam (foam dressing) every shift and as needed. The MAR lacked documentation this had been completed for evening and night shift on 7/31/19. A pressure ulcer assessment, dated 8/2/19, indicated the resident's unstageable pressure ulcer to the bottom of the left heel measured six cm in length by four cm in width, with no depth documented. The wound bed was black, and wound edges were smooth and black. A pressure ulcer assessment, dated 8/9/19, indicated the resident's unstageable pressure ulcer to the bottom of the left heel measured six cm in length by four cm in width, with no depth documented. The wound bed was black, and wound edges were smooth and black. A care plan, initiated 11/22/16 and updated 5/29/19, indicated the resident was non-compliant with care/treatment recommendations of floating of heels. Interventions included, explain to resident why you were there, provide simple instructions, allow resident to vent feelings and provide reassurance, redirect any inappropriate behaviors, approach resident in a calm manner using a calm voice, provide praise when resident complies with care, monitor for changes in mood or behavior, and ensure resident's safety at all times. A care plan, initiated 7/25/19, indicated there resident was non-adherent with floating heels. Interventions included, but were not limited to, notify nurse of problems for further evaluation and possible physician and resident representative notification. A care plan, initiated 2/13/19 and updated 5/15/19, indicated the resident was at risk for pressure ulcers. Interventions included, but were not limited to, encourage nutrition/hydration, encourage and assist resident with turning and repositioning at least every two hours, and float heels in bed as tolerated. A care plan, initiated on 7/19/19, indicated the resident had a stage 2 pressure ulcer to the coccyx. Interventions included, but were not limited, dressing/treatment as ordered, encourage nutrition, hydration, and nutritional supplements to promote healing. During an interview, on 8/12/19 at 1:20 p.m., the Assistant Director of Nursing (ADON) indicated the resident had a pressure reducing mattress, was turned and repositioned every 2 hours, and toileted every 2 hours by staff after he readmitted with the stage one pressure ulcer to his coccyx on 7/18/19, these interventions were still in place currently. On 7/24/19 an order was received to apply [MEDICATION NAME] to the coccyx, and on 7/26/19 it was found the stage one had increased to a stage 2, at this time an air-loss mattress was ordered and delivered and put in place the same day. The unstageable to the left heel was found on 7/29/19, and had developed quickly. The resident had refused care, such as turning, repositioning, and toileting and was care planned for his refusals. During an interview, on 8/14/19 at 3:03 p.m., the Director of Nursing (DON) indicated physician's orders [REDACTED]. 2. Resident 60's record was reviewed on 8/13/19 at 11:27 a.m. An admission Minimum Data Set (MDS) assessment, dated 7/18/19, indicated the resident was cognitively intact and had a stage 2 pressure ulcer (skin is broken open to form an ulcer related to prolonged pressure to the area) which was present on admission. The resident's face sheet indicated the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A Braden Scale (an assessment used to predict the risk of pressure ulcer development), dated 7/14/19, indicated the resident had a moderate risk for pressure ulcer development. A nursing admission assessment, dated 7/14/19, indicated the resident had a stage 2 pressure ulcer to the coccyx (the area at the base of the spine), measured one centimeter (cm) in length by one cm in width. The comments area included, but was not limited to, apply house cream (barrier cream) and apply coccyx pad, change daily. An initial pressure ulcer assessment, dated 7/14/19, indicated the resident's stage 2 pressure ulcer to the coccyx measured one cm in length by one cm in width by less than 0.1 cm in depth. A physician's orders [REDACTED]. physician's orders [REDACTED]. A Medication Administration Record MAR, dated (MONTH) 2019, lacked documentation the resident received any treatment to the pressure ulcer on the coccyx on 7/14/19, 7/15/19, or 7/16/19. The house barrier cream and cover with coccyx pad treatment was initiated on 7/17/19. A pressure ulcer assessment, dated 7/23/19, indicated the resident's stage 2 pressure ulcer to the coccyx measured one cm in length by 3 cm in width by less than 0.1 cm in depth. A physician's orders [REDACTED]. Start Puracol (a type of absorbent dressing) to open area on buttocks and cover with coccyx pad and opsite (a transparent adhesive film) daily and as needed. A pressure ulcer assessment, dated 7/28/19, indicated the resident's stage 2 pressure ulcer to the coccyx measured 2.5 cm in length by one cm in width by less than 0.1 cm in depth. A care plan, last revised on 7/31/19, indicated the resident had a stage 2 pressures ulcer to the coccyx. A pressure ulcer assessment, dated 8/3/19, indicated the resident's stage 2 pressure ulcer to the coccyx measured 2.5 cm in length by one cm in width by less than 0.1 cm in depth. An initial pressure ulcer assessment, dated 8/3/19, indicated the resident had a stage 2 pressure ulcer to the left side of the coccyx, measured 0.5 cm in length by 0.5 cm in width by less than 0.1 cm in depth. A physician's orders [REDACTED]. The physician's orders [REDACTED]. A MAR, dated (MONTH) 2019, lacked documentation of any new treatment orders when the new pressure ulcer developed to the left side of the resident's coccyx on 8/3/19. A treatment was initiated to the area on 8/7/19. A care plan, last revised 8/8/19, indicated the resident had a stage 2 pressure ulcer to the left side of the coccyx. A pressure ulcer assessment, dated 8/10/19, indicated the resident's stage 2 pressure ulcer to the coccyx measured 2.5 cm in length by one cm in width by less than 0.1 cm in depth. A pressure ulcer assessment, dated 8/10/19, indicated the resident's stage 2 pressure ulcer to the left side of the coccyx measured 0.5 cm in length by 0.5 cm in width by less than 0.1 cm in depth. During an interview, on 8/13/19 at 2:07 p.m., the Registered Nurse (RN) Corporate Consultant indicated when a resident admitted with a pressure ulcer a treatment order should have been obtained upon admission. During an interview, on 8/13/19 at 2:17 p.m., the Director of Nursing (DON) reviewed the MAR from (MONTH) 2019, and was unable to find any documentation a treatment had been provided to the resident's pressure ulcer to the coccyx on 7/14/19, 7/15/19, or 7/16/19. The house barrier cream treatment was not documented as provided until 7/17/19. She reviewed the pressure ulcer assessment and indicated the pressure ulcer increased in size in the first week of the resident's stay in the facility. During an interview, on 8/13/19 at 2:29 p.m., Licensed Practical Nurse (LPN) 5 indicated she was unable to find any documentation a treatment was provided to the resident's pressure ulcer on the coccyx on 7/14/19, 7/15/19, or 7/16/19. The resident developed a new stage 2 pressure ulcer to the left side of the coccyx on 8/3/19. The order was not clarified to include both wounds until 8/7/19. Treatment orders should have been obtained when a new pressure ulcer was found. 3. Resident 19's record was reviewed on 8/13/19 at 11:22 a.m. A significant change in status assessment Minimum Data Set (MDS) assessment, dated 5/30/19, indicated the resident was moderately cognitively impaired and had developed a stage 2 pressure ulcer (skin was broken open to form an ulcer related to prolonged pressure to the area), while he resided in the facility. [DIAGNOSES REDACTED]. A nurse's note, dated 6/27/19, indicated hospice had notified the nurse of an area on the resident's buttocks. A Root Cause Analysis, dated 6/27/19, with the concern of Resident 19's development of a pressure ulcer to the buttocks stage 2, completed by the Assistant Director of Nursing/Wound Nurse (ADON) and the Director of Nursing (DON). The analysis indicated the resident had a Braden score of 16, which put the resident at risk for pressure areas and MASD (moisture-associated skin damage) due to the resident's right sided [MEDICAL CONDITION], incontinent of bladder, and bed/chair fast. A physician's orders [REDACTED]. Apply Medi honey and cover with dressing daily. A physician's orders [REDACTED]. Start Puracol and [MEDICATION NAME] dressing daily and as needed. A pressure ulcer care plan, dated 6/27/19, with interventions, included but not limited to, dressing treatment as ordered and Medi honey, cover with occlusive dressing daily. The care plan, did not include the updated 8/2/19 physician order. On 8/13/19 at 10:39 a.m., during an observation of Resident 19's right buttock pressure ulcer dressing change, ADON washed her hands and donned gloves, then cleaned scissors with an alcohol pad. With the same gloves on, ADON pushed the controls on the resident's bed to raise the bed, opened a package of Puracol collagen wound dressing and a package of [MEDICATION NAME] bandage, and applied the bandages to Resident 19's left buttock pressure ulcer, then pushed the bed controls to lower the bed, while she wore the same gloves, during the entire procedure. On 8/13/19 at 10:53 a.m., ADON indicated, during the dressing change, she should have washed her hands and donned new gloves after cleaning the scissors with the alcohol pad and after touching the bed controls. On 8/13/19 at 1:41 p.m., ADON indicated the pressure ulcer care plan should have been updated, when the doctor wrote a new treatment order for the pressure ulcer, on 8/2/19, discontinued the Medi honey treatment and started Puracol and the physician's orders [REDACTED]. On 8/13/19 at 2:00 p.m., the ADON provided and identified a currently facility policy, titled Handwashing/Hand Hygiene, dated 10/2014. The policy indicated, .Purpose: Hand hygiene is the single most important measure for preventing the spread of infection .Policy: The facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated .Situations that require hand hygiene include, but are not limited to: .Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .After handing soiled equipment or utensils 4. Resident's 18's record was reviewed on 8/12/19 at 1:47 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 5/28/19, indicated the resident was cognitively intact, required extensive assistance of one staff person for bed mobility, transfers, walking, dressing, and eating, and was at risk for development pressure ulcers. A nurse's note, dated 8/8/19 at 5:00 p.m., indicated Resident 18 received a shower and staff noticed area on the resident's left foot. Pressure area noted from resident's tennis shoe, also a small scabbed scratch noted to left great toe. The physician was notified and an order was given to nurse. Resident's daughter was visiting and made aware. A physician's orders [REDACTED]. Keep shoes off while the resident is resting in chair until healed. A pressure ulcer care plan had been initiated, on 8/8/19, interventions included, but were not limited to, apply [MEDICATION NAME] as directed and keep shoes off while resting in chair until healed. A Medication Administration Record (MAR), dated (MONTH) 2019 and start date 8/8/19, indicated keep shoes off while resident resting in chair until healed, lacked documentation the order had been completed daily and was blank. A root cause analysis, dated 8/8/19, with the concern Resident 18 had a stage one 1 (superficial redness or discoloration of intact skin which did not blanch when pressure was applied) to the top of the left foot and a scab to the top of the left great toe, with the root cause determined to be, the resident was tying her shoes too tight. During a random observation, on 8/12/19 at 2:42 p.m. Resident 18 was assisted to her room and seated in her recliner by Certified Nursing Assistant (CNA) 13. CNA 13 did not remove Resident 18's shoes prior to leaving the resident's room. On 8/12/19 at 2:47 p.m., Resident 18 was observed seated in her recliner with her shoes on her feet and she indicated her left foot hurt and she removed her left tennis shoe and thick, footie sock, which revealed two areas, one on the top of the left foot and a quarter size scab on the top of the left great toe. No Bandaid was observed on the resident's foot at that time. On 8/14/19 at 9:45 a.m., Resident 18 was observed seated in her chair with her feet propped up and eyes closed, wearing shoes and thick, footie socks. On 08/15/19 at 1:10 p.m., the Assistant Director of Nursing (ADON) indicated Resident 18's pressure ulcer was due to her shoes, because she tied the shoes too tight. Staff should have taken off the resident's shoes, when they placed the resident in her chair. Resident 18's daughter brought in Velcro shoes yesterday, which cannot be tied too tight. On 8/13/19 at 2:00 p.m., the Registered Nurse (RN) Nurse Consultant provided and identified as a current facility policy, dated 10/2014, titled Pressure Ulcer Prevention. The policy indicated, .Purpose: To prevent pressure ulcers and promote healing .Policy: Personnel will identify those residents most likely to experience skin breakdown, and take precautions necessary to prevent breakdown .Equipment: .Pressure relieving mattress .Pressure relieving seat cushion On 8/13/19 at 2:03 p.m., the Registered Nurse (RN) Nurse Consultant provided and identified as a current facility policy, dated 10/2014, titled Pressure Ulcers. The policy indicated, .Purpose: To assure that residents with pressure ulcers will receive necessary care and treatment to promote healing, prevent new ulcers from developing and prevent infection .Policy: .Pressure ulcers will be assessed and treated according to Skin Management Program .Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: .Skin temperature (warmth or coolness) .Tissue consistency (firm or boggy) .Sensation (pain, itching) .A defined area of persistent redness in lightly pigmented skin .Stage II - Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater .Procedures: .Treatment orders will be obtained. Orders will be reviewed periodically (approximately every 2-4 weeks) for efficacy .Presence and/or risk for development of, pressure ulcers shall be included on the resident's care plan 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident had documented evidence of signs and symptoms to justify the use of an indwelling urinary catheter (drainage tube that is inserted into the urinary bladder), and to provide urinary catheter care and treatments resulting in the resident being hospitalized with a urinary tract infection (UTI, an infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra) for 1 of 2 residents reviewed for UTI (Resident 4). Findings include: During a random observation, on 8/11/19 at 11:29 a.m., Resident 4's Foley catheter tubing was observed on the floor. At 11:48 a.m., an anonymous visitor of the resident indicated they had observed the Foley tubing on the floor a lot. During a random observation, on 8/12/19 at 9:01 a.m., Resident 4's Foley tubing was observed on the floor. During an observation, on 8/12/19 at 9:07 a.m., Resident 4 was observed with Licensed Practical Nurse (LPN) 8. The resident's Foley tubing was observed on the floor. LPN 8 indicated the Foley was on the floor at this time and should not have been. Resident 4's record was reviewed on 8/12/19 at 1:37 p.m. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS), dated [DATE], indicated the resident had an indwelling catheter and a urinary tract infection [MEDICAL CONDITION] within the last 30 days. The resident had a moderately impaired cognition. A progress note, dated 7/5/19, indicated a 16 French (Fr) (size) 10 cubic centimeters (cc) Foley was anchored. The physician's orders [REDACTED]. A review of the resident's record lacked documentation of signs and symptoms of [MEDICAL CONDITION] bladder. A mood and behavior communication memo, dated 7/8/19 at 9:00 a.m., indicated the resident continued to tug and pull at his catheter. Interventions included, changed position and provided 1:1 with resident. The outcome of the interventions indicated unchanged, the resident continued to play with catheter tubing. The resident's record lacked documentation the physician had been notified. A progress note, dated 7/14/19 at 6:00 p.m., indicated the resident had a temperature of 99.6 degrees Fahrenheit (F). A review of the resident's medical record lacked documentation the physician had been notified. A progress note, dated 7/15/19 at 12:30 p.m., indicated the resident was sent to the hospital for evaluation and treatment. The resident was shaking, sweating, pale skin color, fever of 100.5 degrees Fahrenheit (F), lethargic (state of weariness that involved diminished energy, mental capacity, and motivation), and urine was dark colored. A strong odor, and blood clots were noted in the urine. At 4:15 p.m., the hospital had called the facility and indicated the resident was admitted for UTI, altered mental status, and fever. A progress note, dated 7/18/19 at 5:00 p.m., indicated the resident was readmitted to the facility. A Medication Administration Record [REDACTED]. A MAR, dated (MONTH) 2019, lacked documentation the Foley had been changed as ordered on [DATE]. A MAR, dated (MONTH) 2019, lacked documentation Foley output had been recorded every shift as ordered on the MAR for the following dates: night shift on 8/5/19, day shift on 8/6/19, evening shift on 8/9/19. A physician's progress note, dated 8/3/19, indicated the resident had a Foley catheter, and [DIAGNOSES REDACTED]. A care plan, start dated 7/18/19, indicated the resident had a urinary tract infection. A care plan, updated 8/6/19, indicated the resident required the use of a Foley catheter due to [MEDICAL CONDITION] bladder. Interventions included, but were not limited to, monitor output, and monitor for signs and symptoms of infection such as; elevated temperature, pain, foul smelling urine, cloudy urine. During an interview, on 8/15/19 at 1:48 p.m., the Assistant Director of Nursing (ADON) indicated the resident's Foley tubing should not be on the floor, and the Foley should have been changed on 8/5/19 as ordered by the physician. She was unsure if it was lack of documentation by the nurse that it had been done, or if it just had not been completed. During an interview, on 8/15/19 at 2:49 p.m., the Registered Nurse (RN) Consultant, indicated she could not find any documentation the resident had any signs and symptoms of [MEDICAL CONDITION] bladder leading up to the insertion of the Foley and [DIAGNOSES REDACTED]. On 8/13/19 at 2:03 p.m., the Registered Nurse (RN) Consultant provided a document, dated 10/2014, titled, Catheter Insertion, Indwelling, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: Insertion of an indwelling urinary catheter will maintain continuous urinary drainage, facilitate frequent bladder irrigation and allow for instillation of medication into the bladder. Policy: Change catheter/tubing/bag monthly and as needed (PRN) unless otherwise indicated 3.1-41(a)(1) 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity and number of deficiencies cited and to ensure quality assurance procedures were followed and plans of action implemented to prevent deficiencies from re-occurring. This affected 4 residents reviewed for pressure ulcers 1 of 2 residents reviewed for Urinary Tract Infections, and 1 of 5 residents reviewed for unnecessary medications. Findings include: On 8/11/19 at 11:00 a.m., the Regional Director provided a document titled, QUALITY ASSESSMENT AND ASSURANCE/PERFORMANCE IMPROVEMENT, and indicated it was the policy currently being used by the facility. The policy indicated, PURPOSE: The Quality Assessment and Assurance Committee shall identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to action plans During this recertification and complaint survey, 8/11/19 to 8/15/19, two deficiencies were cited at harm level - F686 G, F690 G. F758 was cited at scope and severity of D. The facility's Quality Assurance Committee did not identify, develop, and implement appropriate measures to prevent deficiencies as follows: 1. Pressure ulcers: One resident developed an avoidable stage I pressure ulcer, which worsened to a stage 2 pressure ulcer, and developed an avoidable unstageable pressure ulcer. A second resident admitted with a stage 2 pressure ulcer, which increased in size, after the facility failed to ensure a treatment was initiated to the area. There was no evidence the facility had identified, developed, or implemented an action plan with measures to prevent the occurrence and worsening of pressure ulcers. Cross reference F686. 2. medications: [REDACTED] One resident was not administered anti-anxiety and anti-psychotic medications as ordered, had increased behaviors resulting in more psych medications being administered, and a resident to resident altercation which resulted in an injury of another resident. There was no evidence the facility had identified, developed, or implemented an action plan to ensure medications were administered appropriately, manage behaviors, prevent unnecessary [MEDICAL CONDITION] medications from being administered, and prevent resident to resident altercations. Cross reference F758. 3. One resident received an indwelling urinary catheter without documented signs and symptoms to justify its use, had indwelling urinary catheter tubing on the floor, lacked documentation the indwelling urinary catheter was changed per the physician's orders [REDACTED]. There was no evidence the facility had identified, developed, or implemented an action plan with measures to justify use of indwelling urinary catheters, prevent tubing from touching the floor, ensure indwelling urinary catheters were changed per physician's orders [REDACTED]. A review of deficiencies cited from the Recertification and State Licensure survey, dated 10/15/18, indicated the facility had failed to ensure indwelling urinary catheter tubing had not touched the floor. Cross reference F690. During an interview, on 8/15/19 at 1:59 p.m., the Administrator indicated the indwelling urinary catheter tubing being on the floor had been an issue during the previous annual recertification survey as well. She was not sure why it was still an issue. The Assistant Director of Nursing handled the pressure ulcer program. She thought the facility had not had much of an issue with pressure ulcers for the most part. The Quality Assurance Committee had not identified, developed, or implemented plans of action related to pressure ulcers, behaviors, medication administration, indwelling urinary catheters, and urinary tract infection prevention. 3.1-52(b)(2)