Every finding on record at Waters of Princeton, The

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment for residents who resided in the facility for 3 of 3 units observed. Baseboards, walls, door trim were marred, with holes, or chipped paint, floors had debris built up, missing lights fixtures, dust build up on fixtures, and dirt on window sills. ( Memory Springs unit, [NAME] Hall, East Hall, Resident D) Findings include: On 7/6/26 at 8:47 a.m., the following was observed on the Memory Springs unit: Urine odor between rooms 122- 125Baseboards on the hallways observed marredBaseboards in dining room, tops had dirt build up Window sills in dining room had dirt build up Wall to the right of the double doors leading to a patio, had multiple screw/nail holesTrim around double doors was marredHeat/air unit under window by double sink in dining room, had dirt build up on topDoor trim around resident rooms were marredChair with maroon seat covering across from nurse station, had stained fabricFloor was coming up by double sink in dining roomCabinet surfaces below double sink in dining room, marred exposing bare woodroom [ROOM NUMBER] walls were marred, bathroom walls marred, drywall was coming off, loose baseboard, caulking/floor around toilet was soiled brown substance, and stainedroom [ROOM NUMBER]- walls were marred, had dirt build up top of baseboards, and dirt build up on window sillsroom [ROOM NUMBER]- marred walls, dirt build up top of baseboards, blinds dustyroom [ROOM NUMBER]- walls were marredroom [ROOM NUMBER] & 123 shared bathroom- walls were marred, dust on light fixtures, floors were stickyroom [ROOM NUMBER]- walls were marred, drywall was coming off, window sill had dirt build up/dead bugsroom [ROOM NUMBER] & 125 shared bathroom- stains in toilet, dirt build up around walls, walls were marred, drywall coming off, dusty light fixturesroom [ROOM NUMBER]- walls were marred, holes in wall, drywall coming offroom [ROOM NUMBER] - walls were marred, baseboard was missing by chest of drawers/wall clock, dirt build up around walls, 2 holes in wall by head of bed, chest of drawers facing marred126 and 127 shared bathroom- walls marred/drywall coming off above baseboards, stains inside toilet and dirt build up around wallsroom [ROOM NUMBER] walls were marred, debris build up in vents in heat/air unit, baseboard coming off under television. Bathroom stains in toilet, drywall coming off above baseboards, missing baseboards, dirt build up around trim in doorway, dusty light fixtures, ceiling light cover dirt inside The following was observed on the East hall on 7/6/26: 10:21 a.m., the drywall was observed coming off the wall by room [ROOM NUMBER], room [ROOM NUMBER] was observed to have the chair rail on the wall broken/missing, walls marred, bathroom had stained toilet, stained sink, dirt build up around baseboards, the bathroom was shared with room [ROOM NUMBER]. Resident D who resided in room [ROOM NUMBER] said the missing/broken chair rail on the wall had been that way for months. 10:30 a.m., in room [ROOM NUMBER], the trim around the closet chipped, marred, bathroom had toilet stains, dirt build up in ceiling light cover, dirt around baseboards, floor sticky. The bathroom was shared with room [ROOM NUMBER]. 10:49 a.m., the bathroom in room [ROOM NUMBER] was observed to to have stains in the toilet, missing cover on the ceiling light, dirt build up around the baseboards. walls marred. The bathroom was shared with room [ROOM NUMBER]. 10:53 a.m., the bathroom in room [ROOM NUMBER] was observed to have dirt build up around baseboards, stains in toilet, dirt build up in ceiling light cover. The bathroom was shared with room [ROOM NUMBER] which was empty. 11:30 a.m., room [ROOM NUMBER] the bathroom was observed to have stains in the toilet, dirt in the cover on the ceiling light, baseboard coming off. The bathroom was shared with room [ROOM NUMBER]. The following was observed on the [NAME] hall: 10:57 a.m., room [ROOM NUMBER] large area on wall beside bed had peeling paint, the bathroom had toilet stains, dusty light fixtures, peeling paint, dirt build up around baseboards. The bathroom was shared with room [ROOM NUMBER]. 11:01 a.m., the bathroom in room [ROOM NUMBER] had toilet stains, drywall coming off, dirt build up in the light cover. The bathroom was shared with room [ROOM NUMBER]. During the survey on 7/6/26 and 7/7/26 the service hallway was observed to have marred trim around doorways, dirt build up around baseboards. On 7/7/26 at 12:42 p.m., the Administrator and Regional Consultant both indicated they had a bid for a contractor to do repairs to 5 rooms on the Memory Springs unit, no date was given for the start of the project. The Administrator indicated the rooms to be repaired were 123, 124, 125, 126, 127. On 7/7/26 at 12:51 p.m., the Maintenance Director indicated housekeeping does the facility cleaning, he usually gets work orders for things that need fixed, he checks rooms for needed repairs, nursing staff let him know if they observe something that needs repaired in resident rooms. On 7/7/26 at 2:56 p.m., the Housekeeping Director indicated rooms had not all been getting cleaned daily due to staffing shortage, multiple cleaners had been tried on the toilet stains, deep cleaning of rooms were to be done when a resident moved out of a room, monthly deep cleaning of rooms is on a schedule. On 7/7/26 at 10:30 a.m. the following was observed: Ceiling light in hallway by room [ROOM NUMBER], bugs/dirt build up inside cover Ceiling vent by room [ROOM NUMBER] dusty Black wheelchair sitting by room [ROOM NUMBER], back of seat torn, foam showingWheelchair sitting by room marked electrical panel, vinyl torn on front of seat, back of chair Wheelchair sitting by room [ROOM NUMBER], vinyl torn on left armrest Linen closet- soiled towel under bottoms half, gloves laying on floor, cove base missing around walls, drywall loose around sprinkler, debris/dirt on floorroom [ROOM NUMBER] bathroom- toilet stains, walls marred, sink stained, missing light fixture globes, 1 of 3 light bulbs not functioning, caulking around toilet base stained brown substance On 7/7/26 at 10:53 a.m., - Observed a spray can of glass cleaner with a soiled cloth on the nightstand in room [ROOM NUMBER]. On 7/7/26 at 3:20 p.m., the Administrator provided the current policy for guidelines for homelike environment, dated 6/20/23. The policy included but was not limited: It is the policy of the facility to ensure that the environment provided by the facility is safe, sanitary, functional and comfortable. The surroundings for the residents must also be homelike de-emphasizing the institutional character of the setting to be the greatest extent possible .Procedure: 1) As part of the daily Guardian Angel rounds as well as whenever it is noticed, institutional odors will be addressed and eliminated .7) Resident rooms as far as furniture/drapes/bedspreads should be agreeable with the resident as far as style and color/pattern as much as possible .9) Residents should be provided adequate, comfortable lighting .19) Furnishings should be safe, clean, and comfortable .23) All room contents to include clothes, furniture, devices, linens, bedspreads, privacy curtains, window coverings, wall hangings, wall paper and floors should be clean and in good repair. On 7/7/26 at 3:20 p.m., the Administrator provided the current undated housekeeping assignment list. It included but was not limited to: .Resident bathroom, clean mirrors, clean light fixtures, clean sinks including sides and bottom, clean toilet including the base, floor, walls, sweep and mop the floor. This citation relates to Intake 3042041. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(a)(4) 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 3 of 4 medication carts observed. (west hall medication cart and east halls medication carts) Findings include: 1. During an observation on 1/13/26 at 9:06 A.M., the following items were observed in the East back hall cart:Symbicort inhaler (no label) dated 9/28/25Humalog vial (no label or open date)loose medications:pink round tablet, imprint CL75white round tablet, imprint EP136white round tablet, imprint 1 (opposite side) 2white round tablet, imprint RE23orange round tablet, imprint 40 (opposite side) Hyellow oval tablet, imprint 18 (opposite side) Awhite oval tablet, imprint MA (opposite side) 3pink round tablet imprint RA 06orange round tablet imprint 128 (opposite side) Rorange round tablet imprint PH 034yellow round tablet imprint 7 98white round tablet imprint 50white oval tablet imprint 91 (opposite side) F 2. During an observation on 1/13/26 at 9:18 A.M., the following medications were observed in the East front hall cart:antacid liquid bottle (no label and no open date)box of sumatriptan 25 mg tablets (no label no open date) expired on 6/2025loose medications:white round tablet, no imprintyellow round tablet, imprint 81oval orange tablet imprint 20 (opposite side) 1010oval white tablet 3. During an observation on 1/13/26 at 9:30 A.M., the following medications were observed in the [NAME] Hall cart:Insulin Lantus vial - opened, no opened dateInsulin Basaglar pen not opened and not refrigerated (label states refrigerate until open) Two open insulin Basaglar pens (no open date)Insulin Degludec pen, dated open 12/4/25 expired 1/4/26Anora inhaler dated 11/11/25 no patient name or pharmacy labelAnora inhaler dated 1/8/25 no patient name or pharmacy labelAlbuterol sulfate inhaler no date, patient name, or pharmacy labelAlbuterol sulfate inhaler dated 12/18, no pharmacy label 4 packets of polyethylene glycol no patient name or pharmacy labelsloose medications:white round tablet imprint 209white round tablet PH 020white round tablet RE 23white round tablet no imprintin narcotic box: cup labeled [resident 39] oxy yellow round tablet with imprint 230 During an interview on 1/13/26 at 9:40 A.M., RN 5 indicated she was not sure where the loose narcotic medication came from, did not place pill in drawer and could not find where it was signed out of the narcotic medication administration book. On 1/16/26 at 1:46 P.M., the Administrator provided a policy titled Medication Storage in the Facility, dated 2/17, that indicated Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. On 1/16/26 at 1:46 P.M., the Administrator provided a policy titled Prescription Labels, dated 2/17, that indicated Each prescription medication label includes: Resident's first and last name, Drug name, Strength of medication dispensed, Directions for use, including route of administration. Please refer to Medication Administration Record (MAR) for any and all lengthy directions that cannot be completely transcribed onto the direction portion of the pharmacy label, Injectable medications will include strength per milliliter (mL) and the amount to be given in mL equivalent on label, Liquid medications will include strength per mL and the amount to be given in mL equivalent on label, Physician's name, Date medication dispensed, Quantity being dispensed, Expiration date of prescription, Name, address, and telephone number of provider pharmacy, Prescription number. 3.1-25(j) 3.1-25(m) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (200-hall)Finding includes:1. During an interview on 1/12/26 at 10:31 A.M., Resident 5 indicated that she ate in her room and the food was cold by the time it got to her.During an interview on 1/12/26 at 10:55 A.M., Resident 11 indicated that the food was lukewarm when served.During an interview on 1/12/26 at 10:56 A.M., Resident 14 indicated that the food was always cold.During an interview on 1/12/26 at 1:35 P.M., Resident 35 indicated that the food was cold.During an interview on 1/12/26 at 1:45 P.M., Resident 40 indicated that the food was cold.During an interview on 1/13/26 at 8:37 A.M., Resident 8 indicated that the food was always cold. 2. During the Resident Council meeting on 1/13/26 at 1:37 P.M., 10 out of 10 residents indicated that the food was not hot when served. 3. On 1/14/26 at 11:11 A.M., [NAME] 14 was observed taking the temperature of the lunch food on the steam table. Temperatures included, but were not limited to:pork roast - 179 Fahrenheit (F)mixed vegetables - 190 Frice - 200 [NAME] 1/14/26 at 11:43 A.M., a test tray was obtained from the long 200-hall. The food tasted cool. Temperatures were:rice - 128.8 Fvegetables - 136.6 Fpork roast - 118.6 F During an interview on 1/15/26 at 10:10 A.M., the Kitchen Manager indicated that food should only be three to four degrees cooler when served than what it was on the steam table. He indicated a heating element went out on the heating plates and he was waiting for a replacement. On 1/16/26 at 2:21 P.M. the Administrator provided a current Presentation of the Meal policy, dated 3/25/12, that indicated Meals are served attractively, accurately, efficiently, and at the appropriate temperature. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure documentation was complete and accurate for 1 of 1 residents reviewed for weight loss, 3 of 3 residents reviewed for insulin administration, and 1 of 3 residents reviewed for wounds. (Resident 9, Resident 28, Resident 5, Resident 14, and Resident 36) Findings include:1. On 1/14/26 at 2:16 P.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and major depressive disorder. The most current Annual Minimum Data Set (MDS) Assessment, dated 12/8/25, indicated Resident 9 was cognitively intact, required setup assistance for eating, weighed 175 pounds (lbs), and had a weight loss of 5 Percent (%) or more in the last month or 10% or more in last 6 months. A care conference was completed on 10/9/25 with the resident in attendance. Care conference notes indicated that the plan of care would continue without change. A current nutritional status care plan, dated 12/29/25, included, but was not limited to, the intervention to weigh the resident monthly or per facility protocol. A current potential for weight loss care plan, dated 1/12/26, included, but was not limited to, the intervention to obtain the resident's weight every month and as needed per policy. Physician orders included, but were not limited to:Monthly weight, dated 2/11/25. A weight summary indicated the following weights had been obtained since 1/14/25:4/18/25 - 231 lbs5/2/25 - 231 lbs6/11/25 - 231.5 lbs11/13/25 - 175 lbs (a 24.41% weight loss) The clinical record lacked documentation to indicate a follow up weight had been obtained, the physician and registered dietician had been notified of the weight loss, or interventions had been started. During an interview on 1/15/26 at 9:25 A.M., the Director of Nursing (DON) indicated that the weight obtained on 11/13/25 was probably not accurate. Resident 9 refused getting weighed a lot. On 1/15/26 at 9:55 A.M., Resident 9 was observed being weighed. Resident 9 weighed 263.5 lbs. During an interview on 1/15/26 at 10:03 A.M., the Administrator indicated that the previous DON entered Resident 9's weight wrong. 2. During an interview on 1/12/26 at 2:11 P.M., Resident 28 indicated that nursing staff sometimes checked his blood sugar and gave his insulin late. On 1/13/26 at 11:08 A.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/31/25, indicated Resident 28 was cognitively intact, required supervision for most Activities of Daily Living (ADLs), and received insulin 7 out of 7 days during the lookback period. A care conference was completed on 12/15/25 with the resident in attendance. Care conference notes indicated the plan of care would continue without change. A current diabetes with risk for hypoglycemia and/or hyperglycemia, dated 7/12/25, included, but were not limited to, the following interventions:Check blood sugars per order.Antidiabetic meds per order. Physician orders included, but were not limited to:insulin regular (a short-acting insulin) injection solution pen-injector 100 units per milliliter (units/mL) - Inject as per sliding scale: if 150 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 450 = 14 units; 451 - 500 = 16 units; 501 - 999 = 20 units, subcutaneously before meals for diabetes mellitus, dated 7/11/2. Lantus Solostar (a long-acting insulin) subcutaneous solution pen-injector 100 units/mL - Inject 10 units subcutaneously two times a day for diabetes mellitus, dated 7/11/25. The electronic Medication Administration Record (eMAR) for January 2026 was reviewed and indicated that insulin regular 100 units/mL was given outside of administration time parameters on the following days:1/1/26 - 12:00 P.M. dose was given at 2:09 P.M.1/2/26 - 7:00 A.M. dose was given at 9:42 A.M. and the blood glucose was taken at 5:54 A.M.1/3/26 - 12:00 P.M. dose was given at 1:50 P.M. and the blood glucose was taken at 12:14 P.M.1/3/26 - 5:00 P.M. dose was given at 11:21 P.M.1/4/26 - 7:00 A.M. dose was given at 11:17 A.M.1/5/26 - 7:00 A.M. dose was given at 8:26 A.M. and the blood glucose was taken at 6:02 A.M.1/5/26 - 12:00 P.M. dose was given at 1:22 P.M.1/7/26 - 7:00 A.M. dose was given at 10:04 A.M. and the blood glucose was taken at 5:03 A.M.1/7/26 - 12:00 P.M. dose was given at 1:43 P.M. and the blood glucose was taken at 11:48 A.M.1/8/26 - 5:00 P.M. dose was held due to a blood sugar of 145 that was taken at 10:05 P.M.1/9/26 - 7:00 A.M. dose was given at 8:20 A.M. and the blood glucose was taken at 5:32 A.M.1/9/26 - 5:00 P.M. dose was held due to a blood sugar of 89 that was taken at 9:28 P.M.1/10/26 - 7:00 A.M. dose was given at 8:09 A.M. and the blood glucose was taken at 5:03 A.M.1/10/26 - 12:00 P.M. dose was given at 1:13 P.M.1/11/26 - 7:00 A.M. dose was given at 8:07 A.M. and the blood glucose was taken at 5:17 A.M.1/11/26 - 12:00 P.M. dose was given at 3:07 P.M.The eMAR for January 2026 was reviewed and indicated that Lantus Solostar 100 units/mL was given outside of administration time parameters on the following days:1/2/26 - 7:00 A.M. dose was given at 9:42 A.M.1/2/26 - 7:00 P.M. dose was given at 9:26 P.M.1/3/26 - 7:00 A.M. dose was given at 9:42 A.M.1/3/26 - 7:00 P.M. dose was given at 11:22 P.M.1/4/26 - 7:00 A.M. dose was given at 11:18 A.M.1/4/26 - 7:00 P.M. dose was given at 9:55 P.M.1/5/26 - 7:00 A.M. dose was given at 8:27 A.M.1/5/26 - 7:00 P.M. dose was given at 8:18 P.M.1/6/26 - 7:00 P.M. dose was given on 1/7/26 at 1:20 A.M.1/7/26 - 7:00 A.M. dose was given at 10:04 A.M.1/7/26 - 7:00 P.M. dose was given at 10:50 P.M.1/8/26 - 7:00 P.M. dose was given at 10:05 P.M.1/9/26 - 7:00 A.M. dose was given at 8:20 A.M.1/10/26 - 7:00 A.M. dose was given at 8:09 A.M.1/11/26 - 7:00 A.M. dose was given at 8:07 A.M.1/11/26 - 7:00 P.M. dose was given at 8:20 P.M.1/12/26 - 7:00 P.M. dose was given at 8:50 P.M. 3. On 1/14/26 at 9:25 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/22/25, indicated Resident 5 was cognitively intact, was dependent on staff (staff does all the effort) for most Activities of Daily Living (ADLs), and received insulin 7 out of 7 days during the lookback period. A care conference was completed on 10/2/25 with the resident in attendance. Care conference notes indicated that the plan of care would continue without change. A current diabetes with risk for hypoglycemia and/or hyperglycemia, dated 1/7/26, included, but were not limited to, the following interventions:I will have Accu-Cheks (a blood glucometer reading) done per doctors' orders and results will be reported to doctor in a timely fashion if the reading is outside of the parameters provided by the doctor's order.Provide medications as ordered, Accu-Cheks as ordered, assure lab tests are done as ordered, etc. Notify doctor of any complications and abnormalities. Physician orders included, but were not limited to:Lantus Solostar (a long-acting insulin) subcutaneous solution pen-injector 100 units per milliliter (units/mL) - Inject 28 units subcutaneously in the morning for diabetes mellitus, dated 5/9/24. Lantus Solostar subcutaneous solution pen-injector 100 units/mL - Inject 15 units subcutaneously at bedtime for diabetes mellitus, dated 8/1/25.Novolog (a rapid-acting insulin) subcutaneous solution cartridge 100 units/mL - Inject 7 units subcutaneously before meals for diabetes mellitus - hold if blood Accu-chek is less than 80, dated 7/1/2.Check blood sugar before meals and at bedtime before meals and at bedtime for diabetes, dated 1/29/24. The electronic Medication Administration Record (eMAR) for January 2026 was reviewed and indicated that Lantus Solostar 28 units was scheduled for 7:00 A.M. daily and given outside of administration time parameters on the following days:1/2/26 - given at 9:34 A.M.1/3/26 - given at 10:37 A.M.1/5/26 - given at 8:13 A.M.1/7/26 - given at 9:16 A.M.1/14/26 - not marked as completed. The eMAR for January 2026 was reviewed and indicated that Lantus Solostar 15 units was scheduled for 8:00 P.M. daily and given outside of administration time parameters on the following days:1/1/26 - given at 9:25 P.M.1/3/26 - given at 10:31 P.M.1/7/26 - given at 10:55 P.M.1/8/26 - given at 10:09 P.M.1/9/26 - given at 11:08 P.M.1/12/26 - given at 10:08 P.M.1/13/26 - given at 11:19 P.M. The eMAR for January 2026 was reviewed and indicated that Novolog 7 units was given outside of administration time parameters on the following days:1/1/26 - 12:00 P.M. dose was given at 2:04 P.M.1/1/26 - 5:00 P.M. dose was given at 6:27 P.M.1/2/26 - 7:00 A.M. dose was given at 9:33 A.M. and the blood glucose was taken at 5:53 A.M.1/3/26 - 7:00 A.M. dose was given at 10:37 A.M. and the blood glucose was taken at 6:03 A.M.1/3/26 - 12:00 P.M. dose was given at 2:14 P.M. and the blood glucose was taken at 12:14 P.M.1/3/26 - 5:00 P.M. dose was given at 11:27 P.M. and the blood glucose was documented at that time as 136 and 2201/4/26 - 5:00 P.M. dose was given at 6:22 P.M.1/5/26 - 7:00 A.M. dose was given at 8:13 A.M. and the blood glucose was taken at 6:04 A.M.1/5/26 - 12:00 P.M. dose was given at 1:26 P.M.1/7/26 - 7:00 A.M. dose was given at 9:15 A.M. and the blood glucose was taken at 5:06 A.M.1/7/26 - 12:00 P.M. dose was given at 2:00 P.M. and the blood glucose was taken at 11:48 A.M.1/7/26 - 5:00 P.M. dose was given at 10:54 P.M. and the blood glucose was taken at 6:29 P.M.1/8/26 - 5:00 P.M. dose was given at 10:08 P.M. and the blood glucose was documented at 10:08 P.M. as 164 and at 10:09 P.M. as 224.1/9/26 - 12:00 P.M. dose was given at 8:31 P.M. and the blood glucose was taken at 11:30 A.M.1/9/26 - 5:00 P.M. dose was given at 5:37 P.M. and the blood glucose was taken at 9:36 P.M.1/13/25 - 12:00 P.M. dose was given at 2:15 P.M. and the blood glucose was taken at 11:02 A.M.1/14/26 - 7:00 A.M. dose not marked as complete. During an interview on 1/15/26 at 1:50 P.M., the Director of Nursing (DON) indicated that insulin could be administered anytime between one hour before and one hour after it was ordered. Blood glucose checks should also fall within those parameters. During an interview on 1/16/26 at 8:50 A.M., the DON indicated that the internet in the building was horrible and did not reach down all the hallways. Nursing staff sometimes had to administer medications and then document them later. Nursing staff should be documenting insulin administration in real time or if necessary, they should back chart to reflect the accurate administration time. 4. On 1/13/26 at 1:22 P.M., Resident 36's clinical record was reviewed. Resident 36 was admitted on [DATE]. Diagnoses included, but were not limited to Hidradenitis Suppurativa. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/14/25, indicated Resident 36 was cognitively intact, required supervision from staff for toileting and transfers, and had open skin lesions. Current physician orders included, but were not limited to: Cleanse right inguinal wound with normal saline and apply silver alginate and ABD pad twice a day and as needed every day and evening shift for hidradenitis suppurativa and as needed for hidradenitis suppurativa Start date 12/5/2. Cleanse left axillae lower with Vashe (normal saline if not available) apply silvadene 1% cream and silver alginate then ABD pad and rolled gauze twice a day and as needed, Nystatin powder to peri wound every day and evening shift for hidradenitis suppurativa AND as needed for hidradenitis suppurativa Start date 10/16/25. Cleanse right axillae with Vashe (or normal saline if not available)and apply silvadene 1% cream, silver alginate, and border gauze twice a day and as needed every day and evening shift for hidradenitis suppurativa and as needed for hidradenitis suppurativa Start date 10/16/25. The electronic Treatment Administration Record (eTAR) for November and December 2025 and January 2026 was reviewed and indicated that the following dates and times the resident was in the building, the wound dressings were not marked as administered or refused in the TAR or progress notes: 11/3/25 day shift. 11/11/25 day shift. 11/12/25 night shift. 11/25/25 day shift. 12/2/25 night shift. 12/3/25 night shift. 12/22/25 night shift. 12/31/25 day shif.t Current care plan included, but was not limited to: Has chronic Hidradenitis Suppurativa with lesions scattered on body with risk of pain. Date Initiated: 5/15/25. A physician progress note, dated 1/14/26 at 5:36 P. M., indicated Resident has a long history of Hidradenitis Suppurativa. No additional signs of infection. During an interview on 1/16/26 at 11:40 A.M., the Director of Nursing indicated wound dressings were changed, they were just not documented. 5. On 1/13/26 at 11:06 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease (COPD), and unspecified dementia. The Current Quarterly Minimum Data Set (MDS) Assessment date 12/29/25 indicated that Resident 14 was cognitively intact. Resident 14 needed supervision for eating, toileting, transferrring, and dressing, and was on insulin. Current physician orders included, but were not limited to: Insulin Lispro Injection Solution (Insulin Lispro)Inject as per sliding scale:if 0 - 149 = 0;150 - 190 = 3;191 - 230 = 6;231 - 270 = 9;271 - 310 = 12;311 - 350 = 15;351+ Notify MD if above 350,subcutaneously with meals for Diabetes Mellitus start date 6/18/25 and discontinue date of 11/25/26. Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale:if 200 - 250 = 3;251 - 300 = 5;301 - 350 = 7, Notify MD blood glucose if above 350; Hold if Blood glucose is below 200 subcutaneously at bedtime for Diabetes Mellitus. start dated 6/18/25 and d/c on 11/25/25. Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously two times a day for Diabetes Mellitus start date 7/30/25. Placed on hold 11/25/25. Glucose Oral Gel 40 % (Dextrose)(Diabetic Use)Give 20 gram by mouth every 1 hours as needed for Hypo/Hyperglycemia dated 7/28/25. The most recent care plan the resident had attended was 11/20/25 care plan was reviewed. The current care plan for diabetes mellitus and had potential for complications date 1/6/26. Interventions included, but was not limited to: I will have accuchecks done per doctors' orders and results with be reported to doctor in a timely fashion if the reading is outside of the parameters provided by the [NAME]. Observe for s/sx of hypoglycemia: sweating, cold clammy skin, numbness of fingers/toes/mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headache, lightheadedness, slurred speech, confusion, lack of coordination, etc. On 1/13/26 at 11:50 A.m., a grievance form filed on 11/22/25 by a familiy member of Resident 14 was reviewed. The form indicated the family member was concerned why the resident received the 11/20/25 8:00 P.M. scheduled insulins late resulting in the resident having a hypoglycemic episode. The November Medication Administration/Treatment Administration Record (MAR/TAR) indicated Resident 14 had a blood glucose of 217 at 8:00 P.M. Treatment for this blood sugar was to receive 3 Units of Lispro (Short Acting Insulin) for a sliding scale and a scheduled dose of 10 Units of Lantus(Long Acting Insulin) at 8:00 P.M. According to the MAR/TAR the resident did not receive the Lispro and Lantus until 00:15 A.M. on 11/21/25. The Nurses Progress notes lacked documentation of why the medications were given late and if the resident experienced a hypoglycemic episode at any time. During an interview on 1/16/26 at 1:00 P.M., the Adminstrator and Director of Nursing (DON) indicated the insulins were probably given and not documented well. Even when the blood sugar was low there was no documentation that it was low and how the incident was treated. On 1/16/26 at 1:46 P.M., the Administrator provided a current Guidelines for Nursing Documentation policy, dated 5/17/23, that indicated Document regular or baseline observations. Without knowing what is normal for each individual it is impossible to recognize problems and address them in a timely manner . Be timely in your documentation. It is easy to forget details in the bustle of business. Late notes happen. Should you need to document something out of time do it properly and in an orderly manner by first documenting when you are making the late note, then detailing the actual time the event occurred. Never be deceptive and back-date or fake that you are writing at an earlier time . Flow Charts need filled. Every organization has flow charts, do not leave them blank. Also, whenever an unusual event occurs remember to also go to the chart to document your findings. 3.1-50(a)(1)3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents who desired to self-administer their medications were evaluated for capability to self-administer medications for 1 of 1 residents observed with medications in their room. (Resident 11)Finding includes:On 1/12/26 at 10:59 A.M., Resident 11 was observed in his recliner with a bottle of nasal spray, a tube a Neosporin, a tub of Balmex, and a tub of Burt's Beeswax on the bedside table.On 1/14/26 at 11:08 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, cellulitis of buttock and chronic obstructive pulmonary disease (COPD).The most recent admission Minimum Data Set (MDS) Assessment, dated 11/3/25, indicated Resident 11 was cognitively intact, required setup assistance from staff for eating and required supervision of staff for transferring, and had one stage two and one stage three pressure ulcer.A care conference was completed on 1/5/26 with the resident in attendance. Care plans were reviewed.The clinical record lacked a self-administration of medication care plan.The clinical record lacked physician orders for nasal spray, Neosporin, Balmex, and Burt's Beeswax.The clinical record lacked a self-administration of medication evaluation.During an interview on 1/15/26 at 9:42 A.M., Resident 11 indicated that staff told him to hide his nasal spray, Neosporin, Balmex, and Burt's Beeswax in a drawer so State wouldn't see it because he was not supposed to have it. He would buy over the counter medications and have them delivered to the facility, and then the staff would take them away. He indicated he had never been offered an evaluation so that he could self-administer his medication and keep them at bedside.During an interview on 1/15/26 at 1:50 P.M., the Director of Nursing (DON) indicated that Resident 11 did not self-administer any medications. He kept buying things and staff kept confiscating them. She had not thought to evaluate Resident 11 for his capability to self-administer medication and could not think of a reason why he shouldn't be evaluated.On 1/16/26 at 9:20 A.M., the Social Service Director provided an admission consent for treatment, dated 10/29/25, that indicated Resident 11 did not want to self-administer his own medications.During an interview on 1/16/26 at 10:04 A.M., the Administrator indicated Resident 11 had not been assessed to self-administer medications nor had he been asked if he wanted to be assessed to self-administer his medications since 10/29/25.On 1/16/26 at 1:46 P.M., the Administrator provided a current undated Self-Administration of Medications By Residents policy that indicated Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facility interdisciplinary team . If the resident desires to self-administer medications, an assessment is conducted by an interdisciplinary team . residents may be reeducated and reevaluated for self- medication as determined by resident need or assessment by an interdisciplinary team.3.1-11(a)

Based on record review and interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs, that were ordered beyond 14 days, included an evaluation of need for the medication after 14 days and indicated a specific duration of use for 1 of 1 residents reviewed for non-pressure related wounds. (Resident 36) Finding includes:On 1/13/26 at 1:22 P.M., Resident 36's clinical record was reviewed. Resident 36 was admitted on [DATE]. Diagnoses included, but were not limited to, Hidradenitis Suppurativa and generalized anxiety. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/14/25, indicated Resident 36 was cognitively intact, required supervision from staff for toileting and transfers, and received antianxiety medication in the seven-day lookback period. Current physician orders included, but were not limited to: Clonazepam (an antianxiety medication) oral tablet 0.5 MG (milligrams). Give one tablet by mouth every 12 hours as needed for anxiety; Start date 5/15/25. The clinical record lacked an evaluation of need for the medication after 14 days and a specific duration of use. During an interview on 1/15/25 at 1:41 P.M., the Director of Nursing indicated Resident 36 did not have an assessment for PRN antianxiety medication, had not used clonazepam since admission, and should have been discontinued. On 1/16/26 at 1:46 P.M. the Administrator provided a policy titled Guidelines for Psychotropic Medication, dated 6/23, that indicated PRN orders for psychotropic drugs will be limited to 14 days, unless the physician identifies and documents rationale to extend the medication beyond 14 days. PRN antipsychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. 3.1-48(a)(2)

Based on record review and interview, the facility failed to ensure accuracy of assessments for 2 of 5 residents reviewed for unnecessary medications. (Resident 53 and Resident 12) Findings include: 1. On 1/13/26 at 2:16 P.M., Resident 53's clinical record was reviewed. Resident 53 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and anxiety.The most recent Quarterly Minimum Data Set (MDS) assessment dated , 11/19/25, indicated Resident 53 was severely cognitively impaired, required substantial supervision (staff do more than half of the work) for toileting and bathing, and received antipsychotic, antidepressant, and antiplatelet medication during the seven day lookback period.Current physician orders included, but were not limited to: Buspirone HCl Oral Tablet 5 MG (an antianxiety medication). Give 5 mg by mouth two times a day for anxiety, start date 9/29/25. The electronic medication administration record (eMAR) indicated Resident 53 received buspirone 5 MG on all seven days of the lookback period.The MDS assessment did not indicate Resident 53 took an antianxiety medication during the seven-day lookback period. The current care plan included but was not limited to: I am at risk for increased anxiousness with need for anxiolytic related to: Anxiety disorder; Observe/document/report PRN any adverse reactions to anti-anxiety therapy Date Initiated: 12/13/25.2. On 1/13/26 at 2:49 P.M., Resident 12's clinical record was reviewed. Resident 12 was admitted on [DATE]. Diagnosis included, but was not limited to, dementia.The most recent Quarterly MDS, dated [DATE], indicated Resident 12 was severely cognitively impaired, required partial assistance from staff for toileting and bathing, and received antipsychotic, antiplatelet, and anticonvulsant medication during the seven day look back period. Current physician orders included, but were not limited to: Tramadol HCl Tablet (an opioid pain medication) 50 MG (milligrams) Give one tablet by mouth every four hours as needed for moderate to severe pain start date 4/16/24. The electronic medication administration record (eMAR) indicated Resident 12 received Tramadol 50 MG on the following dates:11/13/25 at 1800.12/5/25 at 1813. The MDS assessment did not indicate Resident 12 took opioid medication during the seven-day lookback period. Current care plan included, but was not limited to: I am at increased risk for alteration in pain/discomfort or has current pain related to chronic pain. Date Initiated: 12/9/25. During an interview on 1/15/25 at 2:03 P.M., the MDS Coordinator indicated Resident 53's buspirone should have been coded for antianxiety during the seven-day lookback period, and Resident 12's tramadol taken in the 7-day lookback period should have been coded for opioid. During an interview on 1/16/26 at 11:35 A.M., the Regional Support Nurse indicated the facility did not have a policy for MDS Assessments, the facility should follow the RAI (Resident Assessment Instrument).

Based on observation, interview, and record review, the facility failed to ensure oxygen services were provided according to physician orders for 2 of 2 residents reviewed for respiratory care. Oxygen tubing not date. (Resident 11, Resident 14) Findings include:1. During a random observation on 1/12/26 at 11:08 A.M., Resident 14 was observed sitting in recliner with a nasal cannula had oxygen (O2) at 2.5 liter in his nose. The O2 and nebulizer tubing had no dated label, and the water bottle hooked onto the O2 concentrator had the date of 1/5/26. On 1/13/26 at 11:08 A.M., Resident 14's clinical record was reviewed. Diagnoses included but were not limited to, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, and Dementia. The Current Quarterly Minimum Data Set (MDS) Assessment date 12/29/25 indicated Resident 14 was cognitively intact. Resident 14 needed supervision for eating, toileting, transferrring, and dressing, also required oxygen. Current physician orders included, but were not limited to: Change and date nebulizer tubing once a week on Sunday night shift dated 11/22/25. Change O2 tubing weekly on Sunday night shift one time a day every Sunday. Change & date O2 & Hand Held Nebulizer (HHN) tubing weekly on Sunday night shift dated 6/19/25. The current care oxygen care plan indicated Resident 14 required the use of supplemental O2 related to COPD and Lung Cancer dated 1/6/26. Interventions included but were not limited to, Administered O2 as per MD order. dated 1/6/26. Monitor concentrator and/or E tank for correct setting of liters dated 1/6/26. During an interview on 1/16/26 at 2:00 P.M., Registered Nurse (RN) 5 indicated oxygen and nebulizer tubing is usually changed on Sundays by the night shift nurses. 2. On 1/12/26 at 10:59 A.M., Resident 11 was observed sitting in his recliner receiving two liters (L) of oxygen via nasal cannula. The oxygen tubing was not dated. At that time, Resident 11 indicated that staff had not changed his oxygen tubing since he was admitted to the facility. On 1/14/26 at 11:08 A.M., Resident 11's clinical record was reviewed. Resident 11 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). The most recent admission Minimum Data Set (MDS) Assessment, dated 11/3/25, indicated that Resident 11 was cognitively intact, required supervision for transfers, and was not receiving oxygen. An admission Assessment, dated 10/28/25, indicated Resident 11 was not receiving oxygen. A care conference was completed on 1/5/26 with the resident in attendance. Care plans were reviewed. A current risk for cardiac and respiratory distress care plan, dated 12/2/25, included, but was not limited to the following intervention:Use oxygen as ordered. The clinical record lacked a physician order for oxygen. A nursing progress note, dated 10/28/25 at 3:31 P.M., indicated Resident 11 arrived at the facility and was breathing room air. A provider note, dated 10/30/25 at 9:12 A.M., indicated that Resident 11 was breathing two L of oxygen via nasal cannula. A nursing progress note, dated 12/26/25 at 1:00 A.M., indicated Resident 11 complained of shortness of breath. Oxygen was set up and resident was placed on two L of oxygen via nasal cannula. On 1/15/26 at 9:42 A.M., Resident 11 was observed sitting in his recliner receiving two L of oxygen via nasal cannula. The oxygen tubing was not dated. During an interview on 1/16/26 at 8:50 A.M., the Director of Nursing (DON) indicated she was unable to find an oxygen order for Resident 11. On 1/16/26 at 1:46 P.M., the Administrator provided a current undated Oxygen Therapy policy that indicated Oxygen therapy is administered by licensed staff only as ordered by a physician or as an emergency measure until an order can be obtained. The physician's order will specify the rate of flow of oxygen . Discard disposable masks, cannulas, and tubing after use or when they become soiled. On 1/16/26 at 1:46 P.M., the Administrator provided a current undated Physician Orders - (Following Physician Orders) policy that indicated It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and professional standard for 3 of 7 residents observed during medication pass. Three medication errors were observed during 39 opportunities for error in medication administration. This resulted in a 10.34% error rate. (Resident 66, Resident 57, and Resident 5) Findings include:1. During a medication administration observation on 1/14/26 at 7:27 A.M., QMA 9 allowed Resident 66 to administer her own Budesonide-Formoterol Fumarate Inhalation; Resident 66 took one puff of the inhaler. On 1/14/26 at 8:23 A.M., Resident 66's clinical record was reviewed. Physician orders included, but were not limited to:Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (micrograms/actuation) two puffs twice a dayThe clinical record lacked a physician orders for Resident 66 to self administer her medication.Resident 66 was not administered the correct dose of the inhaler and QMA 9 did not offer Resident 66 to rinse her mouth out after the inhaler was used. 2. During a medication administration observation on 01/14/26 at 11:29 A.M., RN 5 administered 10 units of insulin glargine (long acting insulin) to Resident 57. On 1/14/26 at 11:52 A.M., Resident 57's clinical record was reviewed. Physician orders included, but were not limited to:Basaglar (Insulin glargine) KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (units/milliliters) Inject 50 units subcutaneously at bedtime for Diabetes Mellitus Start date 9/29/25Novolog (Insulin Aspart) Injection Solution 100 UNIT/ML (short acting insulin) Inject 10 units subcutaneously three times a day for diabetes 5/15/2025RN 5 did not prime the pen needle before the insulin was administer. RN 5 administered the wrong insulin to Resident 57. 3. During a medication administration observation on 01/14/26 at 11:39 A.M. RN 7 administered seven units of insulin lispro (Admelog) to Resident 5. On 1/14/26 at 12:03 P.M. Resident 5's clinical record was reviewed. Physician orders included, but were not limited to:Novolog PenFill Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Aspart) Inject 7 unit subcutaneously before meals for Hold if Blood Accucheck is less than 80 May substitute Fiasp or Admelog per pharmacy; Start date 7/1/24 RN 7 did not prime the pen needle before the insulin was administered. During an interview on 1/14/26 at 12:07 P.M., the Director of Nursing indicated insulin pen needle should be primed after the needle is attached to the insulin pen. On 1/16/26 at 12:35 P.M., the Administrator provided a policy titled Insulin Pen Injection Administration, dated 2/17, that indicated Check label to verify correct insulin product and patient. Remove pen cap and wipe rubber stopper with alcohol swab. Always use a new needle for each injection. Remove protective tab from needle and screw it into the pen device. To prime: turn the dose selector to 2 units. Hold pen with the needle pointing up and tap the cartridge gently to move air bubbles to the top. Press the button all the way in. A drop of insulin should appear at the tip of the needle. On 1/16/26 at 1:46 P.M., the Administrator provided a policy titled Medication Administration, dated 2/17, that indicated Before the medication pass Review the resident's Medication Administration Record (MAR) Read each order entirely. Remove medication from drawer. If there is any discrepancy between the MAR and the label, check physician orders before administering medication. 3.1-48(c)(1)

Based on observation, record review and interview, the facility failed to ensure a resident was free from significant medication errors for 1 of 2 residents observed for insulin administration (Resident 57). Resident 57 received the wrong insulin. Finding includes: During a medication administration observation on 01/14/26 at 11:29 A.M., Resident 57's blood sugar was 308; RN 5 administered 10 units of insulin glargine (long acting insulin) to Resident 57. On 1/14/26 at 11:52 A.M., Resident 57's clinical record was reviewed. Physician orders included, but were not limited to:Basaglar (Insulin glargine) KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (units/milliliters) Inject 50 units subcutaneously at bedtime for Diabetes Mellitus Start date 9/29/25Novolog (Insulin Aspart) Injection Solution 100 UNIT/ML (short acting insulin) Inject 10 units subcutaneously three times a day for diabetes 5/15/2025RN 5 administered the wrong insulin to Resident 57. During an interview on 1/14/25 at 12:07 P.M., the facility was notified of the medication error; the Regional Support Nurse indicated Resident 57 would be monitored and an investigation was started. A nursing progress note, dated 1/14/26 1:03 P.M., indicated the physician was notified and recommendations were to continue to monitor resident, check blood sugar every four hours two times and report back if blood sugar is less than 70, continue with medication list ordered. The medication administration record (MAR) indicated Resident 57's blood sugars following the wrong insulin administration were:325 on 1/14/26 at 4 P.M.484 on 1/14/26 at 8 P.M.266 on 1/15/26 at 8 A.M.254 on 1/15/26 at 11 A.M. On 1/16/26 at 1:46 P.M., the Administrator provided an undated policy titled Medication Administration Errors that indicated Upon identification of a medication error the facility will: Complete medication error report form. Notify the physician and family of the medication error. Conduct an investigation regarding how the error occurred. Institute interventions to prevent further recurrence of medication error. 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to implement proper use of Enhanced Barrier Precautions (EBP) and use of gloves for a random observation of wound care. (Resident 39) Findings include: On 1/15/26 at 1:40 P.M., during an observation of wound care, Registered Nurse (RN) 5 was observed performing the following steps during a dressing change for Resident 39:Donned gloves but did not apply gown for Personal Protective Equipment (PPE) due to the resident being on EBP.Removed old dressing on the resident's right leg. Placed some of the dressing material on the floor using the same gloves.Placed a clean towel under the right leg without changing gloves.Touched the Resident's left leg and removed old dressing with the same gloves.Removed gloves Washed hands with soap and water for 30 seconds and applied new gloves. Placed new gloves and irrigated the underside of the right leg with normal saline x2.Patted the wound with a 2x2 gauze.Used the same gloved hand to apply alginate dressing to right outer right leg wound.Had the same gloves on when irrigated the outer wound with normal saline Then used another 2x2 gauze pad to pat dry the irrigated area.Did not change gloves when grabbed dressing to get new gauze for dressing for legs.Held leg with same gloves and that did not change the gloves.Dropped gauze wrap on the floor and said she would cut above the dressing that was on the floor.Applied elastic wrap dressing with the same gloves.Removed gloves after placing elastive wrap dressing. Did not sanitize before placing new gloves.Placed dressing on left foot and with an adhesive dressing.Removed gloves did not sanitize.On 1/14 26 at 10:39 A.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, Diabetes Mellitus Type 2, venous insufficiency, and acquired absence of left leg below knee.The Current admission Minimum Data (MDS) assessment dated [DATE] indicated Resident 39 was cognitively intact, needed set up assistance for eating, and supervision for transferring, substantial-maximum assistance for hygiene, and partial to moderate assistance for dressing.Current Physician orders included, but were not limited to:Transmission Based-Droplet Isolation every shift dated 12/31/25.Cleanse Left Below Knee Amputation L BKA) with normal saline, and apply collagen with silver, calcium alginate with silver and border foam bid (two times a day) and prn (as needed) every day and evening shift dated 10/30/25.Wound care one time a day for wound dated 10/9/25The current care plan for wounds or skin openings that require a dressing dated 1/12/26 included interventions that included, but were not limited to:Follow Enhanced Precaution Guidelines when providing care and coming in direct contact with potentially infected material or devices. Direct Care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting and incontinence care. Device use, Catheter, Trach/Vent, central lines, feeding tube, wounds care or any skin opening requiring a dressing.Reinforce proper handwashing, follow personal equipment protocols and educate me and visitors on protocols as needed.During an interview on 1/15/26 at 2:25 P.M., RN 5 indicated she forgot to apply a gown before starting wound care on the resident.During an interview on 1/15/26 at 2:30 P.M., Regional Support Nurse 2 indicated that there should be gloves that should have been changed at least 2 times during the dressing changes.On 1/15/26 at 2:15 P.M., the Administrator provided a current, non-dated policy Enhanced Barrier Precautions. The policy indicated .Enhanced Barrier Precautions (EBP): Enhanced Barrier Precautions are defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of Multidrug-Resistant Organisms (MDROs) in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver .Proper hand hygiene is a critical requirement in all aspects of resident care to include any precautions such as universal/standard/contact/droplet/air borne as well as enhanced (EBP).3.1-18(b)3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure there was not an emergency call light in 6 of 6 public restrooms that could be utiized by residents in 2 of 2 observations. (Back Hallway, East Hallway) Findings Include: On 1/14/26 at 2:30 P.M., the woman's public restroom in the back hallway was observed to have no key or emergency call system. On 1/15/26 at 8:3 A.M., the public restrooms on back hall and east hall public were observed to have no key or emergency call bell systems. During an interview on 1/16/26 at 10:38 A.M., the administrator was not aware of the need to have an emergency call light or key for a public bathroom if could be accessed. She had been told different things. On 1/16/26 at 1:45 P.M., a policy for the call system was asked for and not received. 3.1-19(u)(2)

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and an account of all drugs were maintained for 2 of 2 nursing units reviewed. The narcotic drug count was not accurate. (East Unit, [NAME] Unit) Finding includes: On 8/27/25 at 10:51 a.m., RN 2 was observed to do a narcotic drug count on the East unit medication cart. The following was observed:hydrocodone- acetaminophen oral tablet 5-325 mg (milligram) -the narcotic count log indicated 23 available, RN 2 indicated 22 were in the drug pack.hydrocodone- acetaminophen Tablet 5-325 mg- the narcotic count log indicated 30 available, RN 2 indicated 29 were in the drug pack. RN 2 indicated she must have been in a hurry and forgot to sign the medications out after giving them, she typically signs the narcotic log as she gives them. On 8/27/25 at 11:04 a.m., QMA 2 was observed to do a narcotic drug count on the [NAME] unit medication cart. The following was observed:clonazepam oral tablet 0.5 mg - the narcotic count log indicated 17 available, QMA 2 indicated 16 were in the drug pack.Ativan tablet 1 mg- the narcotic count log indicated 8 available, QMA 2 indicated 7 were in the drug pack. QMA 2 indicated she was passing medications on 2 halls, was just behind and normally signs the medication out as she gives it. On 8/28/25 at 11:52 a.m., the DON provided the current policy for controlled substance medications with a date of 7/22/23. The policy included but was not limited to : .2) record each dose at the time of administration, 3) confirm that the amount of the controlled drug supply is correct prior to, as well as after, assembling the required dose that is being given-verifying the following: date, time, dosage, signature of nurse administering dosse, number of doses/quantity remaining .This citation relates to Intake 2580774.3.1-25(b)(3)

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed for wounds. Wound treatments were not signed as completed on the Electronic Medical Administration Record (EMAR). Resident B Finding includes: On 6/9/25 8:47 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral infarction due to thrombosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes mellitus, dysphagia, aphasia following cerebral infarction, altered mental status, acquired absence of other right toe, unspecified protein-calorie malnutrition, hyperlipidemia, hypertension, peripheral vascular disease, occlusion and stenosis of carotid artery. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was severely impaired, impairment one side upper and lower, toileting partial/moderate assist,( helper does less than half the effort) roll left to right partial/moderate assist, height 66 inches, weight 126. Resident B admitted to the facility on [DATE]. Care plans were reviewed and included but were to limited to: Wound is present- Abscess, Right 3rd toe, date initiated 3/23/25. Interventions included but were not limited to: Skin assessments weekly and prn (as needed), TX (treatment) as ordered, pressure reducing mattress/cushion in chair, initiated 3/23/25, resolved 5/7/25. Wound is present -Abscess, Right 2nd toe, initiated 3/23/25. Interventions included but were not limited to: Skin assessments weekly and prn, Tx as ordered, pressure reducing mattress/cushion in chair, initiated 3/23/25 resolved 5/7/25. Wound is present- Arterial ulcer, right lateral foot, initiated 4/24/25. Interventions included but were not limited to: Enc (encourage) resident to leave dressings on, F/U with surgeon/MD as needed, Pillow boot as ordered, pressure reducing mattress/cushion in chair, Tx as ordered, skin assessments weekly and prn, initiated 4/24/25. Wound is present- Left second toe, arterial ulcer, initiated 5/7/25. Interventions included but were not limited to: Skin assessments weekly and prn, Encourage to keep dressings on, pillow boot as ordered, pressure reducing mattress/cushion in chair, update MD as needed, initiated 5/7/25. Removes dressings and boot from foot, initiated 5/20/25. Interventions included but were not limited to: enc to keep boot on, Enc to keep dressings on, pillow boot as ordered, Tx as ordered, initiated 5/20/25. Surgical wound -Right foot Amputation of 2nd and 3rd toes, initiated 4/24/25. Wound is present- Abscess, right great toe, initiated 3/23/25, resolved. Potential for alterations in skin integrity due to PVD (peripheral vascular disease), initiated 3/3/25. At risk for skin break down due to decreased mobility, initiated 3/3/25. The resident displays behavioral symptoms related to: restlessness, agitation. This is evidenced by resistive to care, flailing limbs over the side of the bed; hitting feet on the air conditioner wall unit, on foot board of bed. His resistive care is also evidenced by refusing to wear heel boots and/or kicking them off after being put on, initiated 4/25/25. Interventions included but were not limited to: Give psycho-active medications as ordered. Record behavioral symptoms (e.g; verbal/physical aggression, inappropriate behavior), side effects (e.g; tardive dyskinesia, anticholinergic effects, initiated 4/25/25. Physicians orders and the Electronic Medication Administration Record (EMAR) were reviewed for March- June 2025 and included, but were not limited to: Place gauze in between big toe and 2nd digit, and 2nd digit and third digit of rt foot then paint areas with Betadine daily,one time a day for treatment, order date 3/23/25, d/c date 4/3/25. The Electronic Medication Administration Record (EMAR) was not signed as done on 3/26/25. Clean abscess to 3rd toe with wound cleanser apply medihoney secure with rolled gauze change daily every day shift for abscess, order date 3/28/25, d/c on 4/4/25. The EMAR was not signed as done on 4/4/25. Clean 2nd toe with wound cleanser apply medihoney secure with rolled gauze change daily day shift foot treatment, order date 3/28/25, d/c date 4/4/25. The EMAR was not signed as done on 4/4/25. Clean R great toe with wound cleanser apply medihoney secure with rolled gauze change daily every day shift for abscess, order date 3/28/25, d/c date 4/4/25. The EMAR was not signed as done on 4/4/25. Left foot: Betadine to area on 2nd toe. Place layered gauze between toes for padding. Pillow boot at all times every day shift for treatment, order date 5/6/25, d/c date 6/6/25. The EMAR was not signed as done on 5/10, 5/11, 5/24, 5/25, 5/30. Right foot: Apply Betadine to lateral foot wound. Cover lightly with Kerlix. No compression. Pillow boot on at all times. No dressing required to amputation site, every day shift for treatment, order date 5/6/25, d/c 5/30/25. The EMAR was not signed as done on 5/10, 5/11, 5/24, 5/25,5/30. Left foot: Betadine to area on 2nd toe daily. Place layered gauze between toes for padding and secure with rolled gauze. Pillow boot at all times every day shift for treatment, order date 6/6/25. The EMAR was not signed as done on 6/7. Left foot: Betadine to area on 2nd toe. Place layered gauze between toes for padding. Pillow boot at all times, order date 5/6/25, d/c 6/6. The EMAR was not signed as done on 6/4. Right lateral foot: Apply Betadine to lateral foot wound daily and leave open to air. Pillow boot on at all times. No dressing required to amputation site, every day shift for treatment, order date 5/30/25. The EMAR was not signed as done on 6/2, 6/6, 6/7. On 6/10/25 at 3:05 p.m., The DON provided the current policy for guidelines for physician orders with a date of 6/18/23. The policy included, but was not limited to: It is the policy of the facility to follow the orders of the physician 4) All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received. This citation relates to Complaint IN00460996. 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to notify the physician and resident representative of a change in condition for 1 of 3 residents reviewed for skin/wounds. A treatment order was not obtained for a pressure injury, a resident representative was not notified of a pressure wound or facial bruising. (Resident B) Findings include: On 1/10/25 at 8:56 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, personality disorder, diabetes mellitus, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, muscle weakness, unsteadiness on feet. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was severely impaired. Care plans included, but were not limited to: Wound is present - L (left) buttock, stage 2, date initiated 1/10/25. Interventions included, but were not limited to: Tx (treatment) as ordered, date initiate 1/10/25. January 2025 physician orders were reviewed and included but were not limited to: Lt. (left) buttock open area: cleanse with wound cleanser, apply skin prep, cover with hydrocolloid every t-t-sa (Tuesday, Thursday, Saturday), order date 1/10/25. Progress notes were reviewed and included, but were not limited to: 12/23/24 at 7:24 a.m., Resident has an open area Right side middle starting to red and starting to open, skin prepped and reported to ADON (Assistant Director Of Nursing). 12/23/24 9:31 a.m., Resident spot on the bottom 1x1 in size it is on the left middle of his(sic) buttocks. 12/24/24 2:56 a.m., continues on zpack for cough, no cough or adventitious lung sounds noted this shift, resident c/o (complained of) pain to coccyx, prn (as needed) Tylenol given, resident refused to roll onto side to alleviate pressure from coccyx, will continue to attempt pressure offloading and monitor resident status 1/1/25 at 10:34 p.m., Noted to have bruises around eyes from unknown cause/origin. Appeared to have caused by her eyeglasses. Resident denies pain to areas. 1/2/25 at 2:52 p.m., Res observed to have bruising to bilateral eyes from glasses. Res was picking something up and hit her bedside table and glasses were on and hit her nose bridge. [name of physician] gave order for X-ray to face. X-ray ordered. 1/3/25 at 2:38 p.m., X-ray results sent to NP Niece aware. On 1/10/25 at 10:00 a.m., Resident B was observed sitting in the dining room. Resident B was observed to have bruising around the eye area. On 1/10/25 at 10:36 a.m., the Assistant Director Of Nursing (ADON) indicated she was not aware of an open area to Resident B's buttock, she did not remember a nurse telling her about it, but may have been notified of area, she was going to investigate it. On 1/13/25 at 9:00 a.m., a progress noted dated 1/10/25 at 1:09 p.m. was reviewed: .8 x .8x(sic) .1, superficial area on It buttock with thin brown scab covering area. Denies and (sic) pain or tenderness to area and said , I'm alright. No drainage or odor present. Area cleansed with wound cleanser, area skin prepped and hydrocolloid applied and to be changed q t-t-sa. [name of physician] and niece (sic) [name] notified. Niece (sic) gave her care yesterday and said she did not see anything open at this time. A wound summary note dated 1/10/25 was reviewed and indicated the wound was identified on 1/10/25, left gluteal, stage 2, length .8, width .8, depth .1. On 1/13/25 at 9:10 a.m., the ADON indicated Resident B did have a pressure stage 2 to her left buttock, she had observed it on 1/10/25, the nurse did report it to her on 12/23/24, it just left her mind and she did not follow up on it. On 1/13/25 at 1:14 p.m., the Director Of Nursing (DON) indicated she could not find in the clinical record that Resident B's representative was notified of the bruising to the eyes when it was found on 1/1/25,the representative was at the facility on 1/2/25, she thought in the afternoon, and came and asked staff about the bruising she observed to Resident B. On 1/13/25 at 12:00 p.m., the DON provided the current policy on guidelines for notification of change in resident's condition/status/treatment, with a date of 6/29/24. The policy included, but was not limited to: Intent: It is the intent of the facility to ensure that the resident, their attending physician, and the resident's Responsible Party/POA are notified of changes in the resident's condition, status, or treatment. This notification will be done promptly in order to obtain any orders needed for appropriate treatment and/or monitoring related to the change- as well as to promote the resident right related to the right to make choices about treatment and care preferences .Nurses and other care staff are educated to identify changes in a resident's condition that require notification to the resident, their attending physician, and the resident's Responsible Party/POA .Examples of situations/circumstances when the physician must be immediately notified (after the physician is notified and the resident is stabilized, the resident's Responsible Party/POA will be notified .any incident/accident that results in injury to include injury of unknown origin .discovery of a pressure injury or skin alteration . This citation relates to Complaint IN00450688. 3.1-5(a)(1) 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and professional standard for 4 of 4 residents observed during medication pass. (Resident 10, Resident 39, Resident 42, Resident 30) Five medication errors were observed during 31 opportunities for error in medication administration. This resulted in a 16.13 error rate. Findings include: 1. During a medication administration on 10/18/24 at 8:02 A.M., RN 6 prepared the following medications for Resident 10: one tablet of certirizine 10 mg, one tablet of desvenlafaxine 100 mg, one tablet of famotidine 10 mg, one tablet of furosemide 40 mg, one tablet of meloxicam 7.5 mg, one tablet of Nuedexta 20-10mg, one tablet of vitamin D3 5000 units, one tablet of asenapine 5mg, and mixed a packet of polyethylene glycol in 8oz of water. RN 6 took the medications to Resident 10; Resident 10 took all of the medications orally and drank the polyethylene gylcol mixed in water. RN 6 then went to the EDK and removed a tablet of metoprolol 25mg, placed the pill in a medication cup, and gave the medication to Resident 10. On 10/18/24 at 9:45 A.M., Resident 10's clinical record was reviewed. Physician orders included, but were not limited to: asenapine 5mg take medication sublingually. During the medication administration, asenapine 5mg was not given to Resident 10 sublingually. 2. During the medication administration on 10/18/24 at 8:22 A.M., RN 6 prepared the following medications for Resident 39: one tablet of metformin 500mg, one soft gel of docusate sodium 100mg, one tablet of escitalopram 10 mg, one tablet of Farxiga 5 mg, one tablet of levetiracetam 1000mg, one tablet of metoprolol 25 mg, two tablets of quetiapine 25mg, attached a needle to the Admelog insulin pen and turned the dial to 10 units. RN 6 entered Resident 39's room and handed Resident 39 the cup of medications, then administered 10 units of Admelog insulin in Resident 39's right lower abdomen. During the medication administration, RN 6 did not prime the insulin pen needle prior to administration. Resident 39's clinical record was reviewed on 10/18/24 at 10:00 A.M. 3. During the medication administration on 10/18/24 at 8:40 A.M., RN 7 prepared the following insulin for Resident 42: Lantus insulin pen 70 units and lispro insulin pen 50 units. RN 7 primed each insulin pen with two units with the cap on, then set the dial to 70 units for Lantus insulin pen and 50 units to insulin lispro pen. RN 7 then administered 70 units of Lantus insulin in the resident's left lower abdomen and 50 units insulin lispro in the resident's left upper abdomen. During the medication administration, RN 7 did not prime the insulin pen needle properly prior to administration. Resident 42's clinical record was reviewed on 10/18/24 at 2:27 P.M. 4. During the medication administration on 10/18/24 at 8:52 A.M., RN 7 prepared the following medications for Resident 30: one tablet of Eliquis 5 mg, two tablets of Tylenol 235 mg, one tablet of folic acid 1mg, one tablet of lansoprazole 15mg, one tablet of vitamin D3 5000 units, one tablet of levothyroxine 50mcg, one tablet of lisinopril 20 mg, one tablet of loratadine 10 mg, a multivitamin tablet, and one tablet of olanzapine 5 mg. RN 7 took the cup of medications to Resident 30 and Resident 30 took the medications orally. On 10/18/24 at 9:55 A.M., Resident 30's clinical record was reviewed. Current physician orders included, but were not limited to: olanzapine 2.5mg give 2.5mg by mouth one time a day, Start date 10/1/24. During an interview on 10/18/24 at 10:07 A.M., RN 7 opened the medication cart and pulled the medication card for olanzapine and confirmed the instructions on the card indicated give 5mg twice a day. RN 7 indicated there were not 2.5 mg tablets available and Resident 30 had been given the incorrect dose during the medication pass. On 10/22/24 at 11:01 A.M., the Director of Nursing provided a policy titled Medication Administration, dated 2/2017, that indicated Review the resident's Medication Administration Record (MAR). Read each order entirely. Remove the medication from the drawer. If there is any discrepancy between the MAR and the label, check physician orders before administering medication. On 10/22/24 at 11:01 A.M., the Director of Nursing provided an insulin injection instruction leaflet that stated Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, removing air bubbles. A. Select a dose of 2 units by turning the dosage selector. B. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle. You may have to perform the safety test several times before insulin is seen. 3.1-48(c)(1)

Based on observation, interview and record review, the facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 2 of 2 medication carts observed. (100 hall west medication cart and 200 hall east medication cart) Findings include: 1. During an observation on 10/16/24 at 9:03 A.M., the 200 hall east medication cart contained the following items: Humalog insulin pen - opened; lacked opened on or expiration date Lantus insulin pen- opened; lacked opened on or expiration date, pen needle attached and not capped Latanoprost eye drops- expiration date 10/13/24 Lantus insulin pen - expiration date 9/23/24 Humalog insulin pen- lacked identification tag or resident name - expiration date 10/14/24 insulin aspart pen- name rubbed off of identification tag two insulin lispro pens - seal is unopened, tag on insulin states refrigerate until opening opened bottle of Pro-Stat (liquid protein)- lacked label or opened date 2. During an observation on 10/16/24 at 9:25 A.M., the 100 hall west medication cart contained the following items: Humalog insulin pen- expiration date 9/11/24 insulin lispro pen- expiration 9/11/24 Basaglar insulin pen- opened; lacked opened on or expiration date two novolog insulin pens - opened; lacked opened on or expiration date Lantus insulin pen- opened; lacked opened on or expiration date Two novolog insulin pens - seal is unopened, tag on insulin states refrigerate until opening Ozempic (antidiabetic medication) injection- unopened, tag on injection box states refrigerate until opening two Basaglar insulin pens - opened; lacked opened on or expiration date Bottle of opened Pro-Stat (liquid protein)- lacked label or opened date During an interview on 10/22/24 at 11:46 A.M., the Director of Nursing stated the facility was aware of the injections in the medication carts not being refrigerated properly due to pharmacy delivering the injections without ice packs. On 10/21/24 at 3:31 P.M., the Director of Nursing provided a policy titled Medication Storage in the Facility, dated 6/2012, that stated Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. Medications requiring refrigeration or temperature between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled, or without secure closures will be immediately withdrawn from stock. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists. 3.1-25(j) 3.1-25(m) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (200-hall) Finding includes: On 10/16/24 at 10:13 A.M., Resident 52 indicated the food was cold. On 10/16/24 at 10:38 A.M., Resident 31 indicated the food was cold. On 10/16/24 at 12:14 P.M., Resident 15 indicated the food tasted bad and was cold. On 10/17/24 at 10:45 A.M., Resident 42 indicated the food tasted bad and was cold. On 10/21/24 at 12:22 P.M., a test tray was obtained. Food temperatures for that meal were: BBQ chicken 102.9 F (Fahrenheit) Roasted potatoes 109.7 F Yellow squash 107.9 F At that time, the food tasted cold. On 10/21/24 at 12:31 P.M., the Dietary Manager expected food to be about 148 F when served. He indicated he was aware cold food was an issue and hoped to get new insulated holders and carts to help. On 10/22/24 at 10:05 A.M., the Dietary Manager provided an undated current Food Temperatures policy that indicated Best efforts will be made to present hot foods hot and cold foods cold at point of service . 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was correctly prepared for 4 of 4 residents who received puree altered diets. Finding includes: On [DATE] at 10:01 A.M., [NAME] 5 was observed preparing 4 servings of pureed beef and cheddar sandwiches. [NAME] 5 added the following ingredients to the blender and blended in between each item: 8 slices of pre-cooked roast beef 1-ounce (oz) scoop of mayonnaise 1-oz scoop of mayonnaise 1-oz scoop of mayonnaise 4 hamburger buns torn up 2 1-oz scoops of mayonnaise 2 1-oz scoops of mayonnaise 4 slices of cheese torn up 2 1-oz scoops of mayonnaise At that time, [NAME] 5 indicated the food did not look right and it would probably taste like straight mayonnaise. She indicated she usually would add broth to help with the consistency, but the recipe did not call for it. That was a new recipe and she had never made it before. Cook 5 added 4 more 1-oz scoops of mayonnaise. (Total mayonnaise added was 13-oz.) Cook 5 went to the reach-in refrigerator and obtained milk. The best by date on the milk was [DATE]. She added a quarter cup of milk to the blender and blended to pudding consistency. On [DATE] at 9:37 A.M., the Dietary Manager provided the recipe for the Beef and Cheddar Sandwich that was prepared by [NAME] 5 on [DATE]. The ingredients for one serving included: 2-oz shaved roast beef 1 slice cheese 1 bun The puree preparation instructions indicated to place in food processor and process to a smooth pudding like consistency. Add mayo, a little at a time, as needed to achieve smooth consistency. No serving size was identified per serving. On [DATE] at 2:32 P.M., the Dietary Manager indicated the menu and recipes were new to the facility. He indicated 13 oz of mayonnaise was a lot of mayonnaise and he would have advised [NAME] 5 to use milk to help achieve the appropriate consistency. At that time, he indicated expired food was thrown out daily and he didn't realize the milk in the refrigerator was expired. On [DATE] at 11:00 A.M., the Dietary Manager provided an undated current Characteristics and Procedures for Consistency Modified Foods policy that indicated Properly prepared pureed food has the following characteristics .it is soft (pudding like consistency) . Successfully pureeing food depends on using the right process as well as the right equipment. If you cannot puree an item to meet the above characteristics with the processing equipment that you have, contact your manager or dietician to determine an appropriate substitute. On [DATE] at 11:00 A.M., the Dietary Manager provided a current Pureed Food Preparation policy, dated [DATE], that indicated Milk, broth, soup, gravy, juice, and margarine will be used to thin the pureed food . The flavor of pureed foods will be checked as these items must have the same flavor as original regular menu item. On [DATE] at 11:21 A.M., the Director of Nursing (DON) provided a current First In First Out (FIFO) policy, dated ,d+[DATE], that indicated Stock must be used before the expiration date. Items not used by the expiration date will be discarded. 3XXX,d+[DATE](a)(3)

Based on observation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions during 3 of 3 kitchen observations and 1 of 1 dining observations. Staff did not wear hairnets, and gloves were not changed before touching food items. (Dietary Manager, [NAME] 5, [NAME] 14, Activities Department Staff) Findings include: 1. During a lunchtime dining observation on 10/16/24 at 12:00 P.M., Activities Department staff were observed assembling and serving hot dogs for lunch in the dining room. Residents placed orders and staff assembled buns, hot dogs, condiments, and chili in the dining room. Staff did not change gloves in between touching the hot dog buns and touching condiment bottles. Staff were not wearing hairnets while assembling food. 2. On 10/16/24 at 9:12 A.M., the Dietary Manager was observed in the kitchen without a beard net. [NAME] 5 and [NAME] 14 were observed in the kitchen wearing a hairnet that did not cover all of their hair. 3. On 10/17/24 at 10:01 A.M., the Dietary Manager was observed in the kitchen without a beard net. [NAME] 5 was observed in the kitchen wearing a hairnet that did not cover all of her hair. 4. On 10/21/24 at 11:30 A.M., [NAME] 5 was observed taking temperatures of lunch foods on the steam table. [NAME] 5 was wearing gloves. She touched her face, the refrigerator, a cart, the hot plate heater, the oven, a cooking tray, and a hot pad. Without changing gloves, [NAME] 5 reached in a bread bag and retrieved a bun, opened the bun, and prepared a chicken sandwich. [NAME] 5 was observed wearing a hairnet that did not cover all of her hair. At that time, the Dietary Manager was observed in the kitchen without a beard net. On 10/21/24 at 2:32 P.M., the Dietary Manager indicated hairnets were worn when handling food. All hair should be covered while wearing a hairnet including facial hair. At that time, he indicated gloves should be changed after touching nonfood items and before touching food, and [NAME] 5 should have changed gloves before touching the bun. On 10/22/24 at 10:05 A.M., the Dietary Manager provided an undated Glove Use policy that indicated Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled or when interruptions occur in the operation . Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: . During food preparation, as often as necessary .to prevent cross contamination when changing tasks. On 10/22/24 at 10:05 A.M., the Dietary Manager provided an undated current Hair Restraints/Jewelry/Nail Polish policy that indicated Hairnet, hat or hair restraint will be worn at all times in the kitchen. On 10/22/24 at 12:56 P.M., the Administrator provided a current Employee Health and Personal Hygiene policy, dated 9/17/23, that indicated Hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview, observation, and record review, the facility failed to ensure safety or supervision of a resident for 1 of 1 residents reviewed for falls resulting in major injury. This deficient practice resulted in a fall with a fractures requiring hospitalization . (Resident 43) Findings include: Resident 43's clinical record was reviewed on 8/23/23 at 2:21 P.M. Diagnoses included, but were not limited to, displaced fracture of second cervical vertebra. Resident 43's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 7/31/23, indicated the resident was severely cognitively impaired and required extensive assistance of two people for mobility, transfers, and toileting. Resident 43's care plan dated 10/27/22 included, but was not limited to, Resident is at risk of falls due to history or recent fall, staff to assist with transfers, and staff to assist with toileting. A nursing progress note dated 8/8/23 at 20:22 (8:22 P.M.) indicated Resident 43 Depends upon staff for ADL care. All transfers by staff assist. Taken to BR (bathroom) prn (as needed) by staff. A Nursing progress note dated 8/9/23 at 6:32 A.M. indicated resident was being toileted when they stood up and fell . Resident had a laceration on their forehead that was bleeding. Resident was transported to the hospital for evaluation. A nursing note dated 8/9/34 at 9:19 A.M. indicated the hospital had called the facility to report Resident 43 had sustained an acute fracture of the cervical spine, and was being transferred to another hospital. An IDT (integrated disciplinary team) note dated 8/9/23 at 12:15 P.M. indicated a CNA (certified nurse aide) was assisting Resident 43, left the Resident alone in the bathroom to go find the Resident's clothes, and the resident fell to the floor. The intervention noted was for a medication review to be completed. A progress note dated 8/11/23 at 10:42 A.M. indicated Resident 43 was unable to ambulate, having difficulty moving extremities, and a request for an increase in pain medication was made. A physician's order dated 8/11/23 indicated a C collar (cervical support brace) was to be worn as needed for comfort. During an observation on 8/21/23 at 12:06 P.M., Resident 43 was observed sitting at the dining table with bruising to the face, appeared agitated, and was yelling out. Staff attempted to console Resident 43 by moving away from the table to look out the glass doors in the dining room. Resident 43 was not wearing a C collar during the observation. During an interview on 8/24/23 at 8:52 A.M., the Director of Nursing (DON) indicated Resident 43 had been transferred and toileted by one CNA during the fall that occurred on 8/9/23 due to the resident being impulsive at times. The DON agreed that the IDT note stating the Resident had been transferred then left alone was accurate. The DON indicated the MDS information regarding how many staff is recommended for assistance should be reflected on the CNA assignment record provided at the beginning of each day to the CNA's, and the assignment records are reviewed, before being released to staff, during morning meetings with the Administrator, Director of Nursing, and Assistant Director of Nursing. A document titled CNA Assignment Sheet was provided on 8/24/23 at 11:02 A.M. by LPN (licensed practical nurse) 19. Resident 43 was listed as assist of 1. An undated policy titled incidents/accidents/falls was provided by the Administrator on 8/25/23 at 1:09 P.M. and indicated information collected will be used to implement corrective actions to include any needed training and the CNA information sheet will be updated as indicated to reflect the plan of care. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse for 1 of 3 residents reviewed for abuse. A resident with dementia was forcibly thrown to the ground by a nurse. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/1/22 at 9:36 P.M. (time according to video), when the facility failed to prevent physical abuse and psychological abuse for the reasonable person. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 3/29/22 at 10:20 A.M. The Immediate Jeopardy was removed on 3/30/22 at 2:25 P.M., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On 3/28/22 at 11:00 A.M., the Administrator indicated on the night of 3/1/22 around midnight, the DON (Director of Nursing) notified her of an incident at the facility involving Resident B and RN 13. The Administrator indicated no specifics about the incident were given at that time. She indicated video tapes were reviewed the following morning (3/2/22), which showed RN 13 grabbing Resident B by the arm, and Resident B fell to the floor. On 3/28/22 at 10:00 A.M., an incident report, dated 3/2/22, was reviewed and indicated on 3/1/22 at 9:36 P.M., [Resident B] entered nurses station. In attempt to redirect Nurse tool [sic] ahold of her arm's [sic] resident went down to ground On 3/28/22 at 11:26 A.M., Resident B was observed sitting in the common area of the locked dementia unit in a chair. Resident B was observed being assisted by staff to a standing position. Resident B did not complain of pain, and was not observed with a sling, brace, or any other device on her arms or shoulders. The resident was not interviewable. On 3/28/22 at 11:40 A.M., Resident B's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent annual MDS (Minimal Data Set), dated 2/10/22, was reviewed, and indicated a severe cognitive impairment. Resident B required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for transfers and toileting, and supervision of 1 staff for walking in corridor and eating. Resident B's current orders included, but were not limited to, up ad lib (1/26/21). Resident B's current care plans included, but were not limited to elopement risk/wanderer. Interventions included, but were not limited to, distract resident from wandering by offering pleasant diversions such as activities, food, conversation, and television. A potential for falls care plan, dated 1/28/21, included, but was not limited to intervention to not rush to resident when she stands up, and to approach resident in a calm slow manner. Progress notes included the following related to the incident on 3/1/22: 3/2/22 at 8:15 A.M. Resident sitting at dinning [sic] room table after breakfast with her eyes closed and head down. Resident alert to touch and voice. Resident pleasant. Right arm resting on arm rest of chair and her left resting in her lap. When touching arm resident did not grimace. She continued to sit there with her eyes closed and would respond from time to time with opening her eyes, or with a sigh. no swelling, warmth, skin intact, no crepitus noted upon palpation. when moving arm in front of her she still had her eyes closed. no facial grimace noted. when abducting her right arm from her side she did grimace as if she had discomfort with her eyes still closed. rom was stopped. Left arm full rom. no discomfort, no warmth, no crepitus, no redness, skin intact, no swelling with either extremity. Resident not able to follow ques to grasp this nurse hands to assess bilateral upper extremity strength. resident sat in dinning in the same position when this nurse left with nursing staff there to assist. 3/2/22 at 11:03 A.M. Resident allowed assistance with shower this am. Resident c/o [complains of] tenderness/soreness to bilat. [bilateral] upper arms. No bruising or swelling noted. Resident has difficulty lifting arms, esp. R [right] arm. 3/5/22 at 1:24 P.M. (Medical Practitioner note via telehealth visit) The patient is being seen today for recent fall who was reportedly related to a potential mal-handling [sic] of one on the nurses, patient was Xray'd with right humeral problem present. The patient was sent to Ortho Urgent Care who suggested PT [physical therapy] and OT [occupational therapy] services. On exam the patient appears to be comfortable and participating in therapy services. I will continue to re-evaluate the patient periodically. An x-ray report, dated 3/2/22, indicated the following impression/result: High riding humeral head concerning for rotator cuff injury On 3/28/22 at 1:10 P.M., Resident B's OT (Occupational Therapy) notes were provided. At that time, COTA (Certified Occupational Therapy Assistant) 7 indicated Resident B was on OT from 3/4/22 until 3/17/22. She indicated they were working with ROM (range of motion) with the resident, and at first, Resident B indicated the right shoulder was sore, but in a very short time, she was not complaining and back to her baseline with shoulder ROM. During an interview on 3/28/22 at 2:28 P.M., CNA 5 indicated on the night of 3/1/22, she was in the bathroom with a resident a couple doors down from the nurses station, when she heard RN 13 screaming for help. She indicated she left the room, and heard RN 13 say I will get you from behind here. CNA 5 indicated when she reached the nurses station, RN 13 was holding onto Resident B either under her arms, or on top of the arms, she couldn't remember, and Resident B was standing and crying. She indicated Resident B looked scared, and the best way she could describe it was if someone was holding a newborn baby, then screamed at them, Resident B appeared the way the baby would. She indicated her eyes were wide open, and just looked scared. She indicated she did not speak to RN 13, and indicated to Resident B to come with her to her room, as she took ahold of her hands and led her away from the nurses station. She indicated when Resident B was brought to her room, she complained about her right shoulder being sore. CNA 5 indicated she had a feeling something had happened to Resident B before she approached the nurses station, and about 3 hours later, notified the DON by phone about what had happened, and informed her she may want to review the tapes the following day. CNA 5 indicated prior to the incident, RN 13 had always spoke to residents and staff with an aggravated, bossy, and rude tone. During an interview on 3/28/22 at 12:55 P.M., LPN 9 indicated RN 13 had always seemed to be an impatient person with everyone, and had a gruff personality. During an interview on 3/28/22 at 10:29 A.M., CNA 8 indicated RN 13 was impatient with residents and staff. During an interview on 3/28/22 12:57 P.M., the SSD (Social Services Director) indicated she was aware of the incident that occurred with Resident B, and had followed up with the resident to observe any adverse effects as a result of the incident. The SSD indicated Resident B had no recollection of the incident, and exhibited no changes. During an interview on 3/28/22 at 10:40 A.M., the DON indicated she had been notified of an incident involving Resident B at around midnight the night of 3/1/22 when she was called about another resident falling. She indicated CNA 5 had asked the nurse that called her to inform her she may want to review the tapes on the dementia unit when she came in the following day. She indicated on the morning of 3/2/22, after the tapes were reviewed, the Administrator notified the state agency, APS, law enforcement, and the resident's family and doctor. The DON indicated she had first assumed that because RN 13 had just had back surgery, she thought she may have grabbed Resident 13 for stability, but figured out from the video that Resident B was pulled. She indicated prior to the incident, RN 13 was not too friendly. During an interview on 3/28/22 at 1:30 P.M., the Administrator indicated that after reviewing the tapes involving the incident with Resident B, she was shocked that the resident did not have any bruising, or any other marks on her from the incident. She indicated the tape was devastating to watch. During an interview on 3/28/22 at 12:18 P.M., Resident B's POA (Power of Attorney) indicated he believed the incident involving Resident B was abuse, and blamed RN 13. He indicated the police were pursuing a class 6 felony against RN 13. He indicated he was told by the facility there was an injury to the right rotator cuff following the incident, but was unsure if Resident B had that injury prior to the incident. On 3/28/22 at 10:00 A.M., an incident/investigation report from the local police department, dated 3/3/22, was provided and indicated that on 3/3/22, an officer took a report of battery from the facility against RN 13. The report indicated a video was reviewed that showed RN 13 pulling on Resident B in a violent manner, and jerked so hard Resident B fell to the ground, injuring her shoulder. On 3/28/22 at 2:55 P.M., the video tape of the incident involving Resident B (timestamped 3/1/22 at 9:36 A.M.) was reviewed with the following observations: Resident B was beside the nurses station shuffling toward the medication storage room, which was behind the nurses station. RN 13 was sitting behind the nurses station, looking ahead. Resident B turned her head to the left to face RN 13, and RN 13 continued to look straight ahead, as the resident continued to walk toward the medication storage room. When the resident was in the doorway of the medication storage room, RN 13 turned her head in the resident's direction, scooted her chair to the doorway, then stood up, flipping the chair she was sitting in backward. RN 13 grabbed Resident B's right arm toward the top just under the shoulder, and yanked it down across her own body until Resident B was on the floor sitting on her buttocks with her legs stretched out and her feet out in front of her. RN 13 then went behind the resident, grabbed the upper part of her arms from the outside, pulled her up off of her feet, and pivoted to left, facing the doorway, then lowered the resident to her feet. RN 13 changed her arm position to hold the resident under her arms around the ribs as the resident was not standing on her own, and slumping forward with her arms down in front of her. RN 13 raised her right arm to lean and brace herself in the doorway, then did not move positions for 10 seconds. RN 13 then reached down with her right arm, and tossed the chair that had flipped out of her way and to the other side of the nurses station. When the chair was moved, a jacket that was on the back of the chair fell to the ground. RN 13 then stepped on the jacket, and Resident B's right foot also was on top of the jacket. RN 13, holding Resident B from behind with her left arm wrapped around the resident's ribs, directed them out the hallway in a shuffling fashion, dragging the jacket on the floor with them. During the move from the doorway to the hallway, Resident B's arms were outstretched as though she was trying to locate a surface to hold on to. Another staff member appears from the opposite end of the hall and walked toward RN 13 and Resident B. That staff member took Resident B by the hands, and led her down the hall. RN 13 grabbed the jacket off the floor, and went back behind the nurses station. On 3/28/22 at 2:21 P.M., a current non-dated Abuse Prevention Program policy was proved that indicated It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property . This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals The Immediate Jeopardy, that began on 3/1/22, was removed on 3/30/22 when the facility audited facility staff on abuse identification, reporting, and behaviors, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 283. 3.1-27(a)(1)

Based on record review, observation, and interview, the facility failed to ensure residents, who admitted with no pressure ulcers, did not develop a pressure related skin injury for 2 of 2 residents reviewed for pressure. This deficient practice resulted in Resident 33 developing a Suspected Deep Tissue Injury (SDTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of under-lying soft tissue from pressure and/or shear) to his right lateral foot, Stage II (partial thickness loss of dermis) areas to the buttocks, and Resident 5 developing a Stage III (full thickness tissue loss) to his right heel and Stage II to his buttocks. (Resident 33, Resident 5) Findings include: 1. On 9/7/21 at 9:03 a.m., Resident 5 indicated he had a sore on his foot and one on his butt from just lying in bed. He has had them for a couple weeks. On 9/8/21 at 2:39 p.m., Resident 5 was observed sitting in his wheelchair. CNA 3 and CNA 4 were observed to apply gloves, transfer Resident 5 from his wheelchair per Hoyer lift to bed. Resident 5 was assisted to roll and the Hoyer sling was removed from under him. He indicated he was going to get back up at 4:30 p.m. CNA 3 removed Resident 5's shoes and applied a pressure relieving boot to his right foot. CNA 3 and CNA 5 assisted Resident 5 to move over in bed and tilted to side with a pillow to back and under calves to position. CNA 3 and CNA 5 removed their gloves and performed hand hygiene. On 9/8/21 at 1:36 p.m., Resident 5 was observed outside sitting in his wheelchair with tennis shoes on both feet, smoking On 9/8/21 at 2:59 p.m., the clinical record for Resident 5 was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant change MDS assessment, dated 12/14/20, indicated no unhealed pressure ulcers. The Quarterly MDS assessment, dated 3/16/21, indicated 1 Stage II (2) and 1 Deep Tissue Injury in evolution, and was not coded for pressure reducing device in chair. No Cognitive impairment. The Quarterly MDS assessment, dated 6/10/21, indicated 1 Stage II (2) pressure ulcer, and was not coded for pressure reducing device in chair. No cognitive impairment. Extensive assist of 2 staff for transfer, bed mobility, and toileting. Care plan res has wounds stage 3 to R heel, stage, wounds will heal TNR (till next review), diet and supplements as ordered, 2 to coccyx, date initiated 12/17/20. Interventions included, but were not limited to, notify family and md of any changes, dated 12/17/20. Pressure relieving mattress, dated 12/17/20. Pressure relieving to boots to bilateral heels, dated 2/12/21. Tx (treatment) as ordered, dated 12/17/20. Physicians active orders as of 9/9/21: Heel protectors at all times every shift dated 2/24/21. Cleanse area on left buttock apply collagen powder, silicone foam boarder dressing change QD (every day) and PRN (as needed) every day shift for wound healing, start date 8/8/21. A nursing progress note, dated 9/3/21 at 5:13 a.m., there is a 2 cm x 2 cm pressure wound on the coccyx, repositioning to try to relieve pressure off the sight [sic]. No complaint from resident. 8/16/21 at 9:06 p.m., .has been up in a w/c by Hoyer lift and 2 assist for supper and later for smoke break .prn pain medication given for c/o (complaint of) back and leg pain. 8/16/21 at 12:40 p.m., Res requested to lay down to void in his brief. Res was offered to be toileted by sit to stand or be laid down in bed and changed and got right back up for smoke break, which is at 1:30 p.m. Res refused both options and agreed to stay in bed and relinquish his smoke break at this time. Dietary progress note dated 8/5/21 at 1:19 p.m., .wt. (weight) indicating a significant wt. loss of -6.6% (percent) x 30/90D (days), wt. stable x 180D. Resident continues with Stage II (two) PI (pressure injury) on Right heel with minimal decrease in size per wound care. PI on R buttock healed (7/28). Receiving general, regular, thin diet with double protein at breakfast .intake 90% of meals .appears adequate for needs . SWAT (Skin and Weight Assessment Team) meeting, dated 9/1/21, indicated, but was not limited to, Potential Contributors of Indicator: DM (diabetes mellitus) non -compliant, decreased mobility, smoker, daily consumption of alcohol/regular sodas .skin impairment Left buttock .Interventions/Treatments: collagen and silicone foam border dressing. Swat recommendations: continue POC (plan of care) as currently written. Weekly Wound Evaluation, dated 9/3/21, indicated right heel, pressure injury (In-house Acquired) Stage III (three), length: 2 cm (centimeters), width: 2 cm, depth: blank. When was wound identified 9/3/21, .additional descriptions: 2 cm x 2 cm pressure wound on coccyx. Exudate: serous (clear), scant, with no odor. Tissue types: granulation (regenerating tissue) 50% (percent), slough (dead tissue) 50% .current preventative interventions: positioning devices. Weekly Wound Evaluation, dated 8/31/21, indicated left buttock, pressure injury (In-house Acquired), Stage II (two), length: 5, width: 3, depth: 0.4. Wound identified on 8/3/21. Skin 100%, wound color pink. Current treatment: S/S collagen powder silicone boarder foam dressing, date treatment ordered 8/7/21. Current preventative interventions: pressure redistribution mattress, wheelchair cushion, nutritional supplements, and heel boots. On 9/9/21 at 10:07 a.m., LPN 1 donned gloves, TNA 1 assisted Resident 5 to turn on his right side to expose open area to left buttock. TNA 1 and LPN 1 indicated Resident 5 liked to lay on his back all the time, and Resident 5 responded not anymore. LPN 1 applied collagen square, Dermafilm dressing applied, and then removed gloves and laid them on the bed side table. LPN 1 applied new gloves with no hand hygiene, removed the protective boot and sock from Resident 5's right foot. LPN 1 removed scissors from her pocket and cut the Kerlix wrapping the heel and noted the inner dressing was adhered to the wound. Resident 5 denied having sensation to the heel area. LPN 1 returned to the treatment cart wearing her gloves, rummaged in the cart drawers, and returned with supplies. LPN 1 wet the inner dressing with sterile saline to remove from the wound bed, and placed the dressing with the Kerlix on the bedside table. LPN 1 applied Dermafilm to the right heel and wrapped the area in Kerlix. LPN 1 removed tape from her pocket to secure the Kerlix and put the tape back in her pocket. LPN 1 put Resident 5's sock and protective boot back on. LPN 1 then removed her gloves and wadded the gloves and the dressings from the bed side table in her left hand to the front of her uniform top, held the small empty saline bottle in the crook of her arm, then walked to the treatment cart trash bin to discard. LPN 1 then performed hand hygiene. On 9/13/21 at 3:33 p.m., the MDS Coordinator provided copies of the Treatment Administration Record, dated 9/1/13-9/30/21. The record indicated order for Apply Magic Butt paste or equivalent barrier to right buttock BID (two times a day) for wound healing, dated 2/5/21, coded with check mark and nurses initials. Heel protectors at all times every shift, dated 2/24/21, and coded with a check mark every shift and nurses initials. Skin prep bilateral heels Q (every) shift for wound healing, dated 8/7/21, and coded with check mark and nurses initials. Cleanse area on left buttock apply Collagen powder, silicone foam boarder dressing QD (every day) and PRN (as needed) for wound healing dated 8/8/21, not coded as being completed during September. 2. On 9/7/21 at 10:40 a.m., Resident 33 was observed on lying on his back on a low air loss pressure relieving mattress, non-responsive to verbal stimuli, head of the bed elevated, and covered with a sheet. On 9/7/21 at 11:19 a.m., the CNA 2 indicated they had reported a couple of small spots on Resident 33's bottom to the nurse that morning. CNA 2 removed Resident 33's right sock to visualize dark pink area right lateral distal foot on bony prominence below small toe. He was sitting up in a high back wheelchair with a pommel cushion noted in the seat of the wheelchair, dressed in street clothing. On 9/8/21 at 2:35 p.m., Resident 33 was observed sitting in a high back wheelchair beside the bed in his room. He was fully dressed, arms crossed over his chest with fingers curled to palm, with gray shorts observed to have a wet line across the thighs from urinary incontinence. On 9/9/21 at 8:52 a.m., the clinical record for Resident 33 was reviewed. admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment dated [DATE], indicated at risk for pressure ulcers and no unhealed pressure ulcers The Quarterly MDS assessment dated [DATE], indicated Resident 33 had 1 unstageable-deep tissue: suspected deep tissue injury in evolution. Resident 33 required extensive assist of 2 or more staff for bed mobility, dependent for transfer with assist of 2 or more staff, and was always incontinent of bowel and bladder. The care plan, at risk for skin breakdown due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . pressure relieving mattress per facility policy, dated 3/23/21. The care plan, wound is present deep tissue pressure sore R foot, dated 7/10/21. Interventions included, but were not limited to, diet as ordered, dated 7/10/21. Pressure reducing mattress/cushion in chair, dated 7/10/21. Treatment as ordered, dated 7/10/21. Physicians order included, but were not limited to, up in chair daily, dated 5/21/21. Up with assistance of Hoyer and 2 staff in w/c, dated 8/11/21. Float heels every shift & T&R (turn and reposition), every 2 hours, dated 3/18/21. Apply skin prep to area on right foot BID two times a day for wound healing. Float heels every shift T&R (turn and reposition) every 2 hours, dated 3/18/21. Weekly Wound Evaluation dated 8/3/21 indicated, but was not limited to, right lateral foot (pinky toe), pressure injury (in house acquired), suspected deep tissue injury, length 0.2, width 0.2, .identified .7/1/21. Wound color: black. Current treatment: skin prep, .ordered 7/1/21. Current Preventative Interventions: pressure redistribution mattress, wheelchair cushion. Weekly Wound Evaluation dated 8/17/21, .Current Preventative Interventions: Pressure Redistribution Mattress, Wheelchair Cushion, Heel Boots. Weekly Wound Evaluation dated 9/7/21, Right buttock, pressure injury (In-house Acquired), Stage II (two), length: 1, width: 0.7, depth <(less than) 0.1, .wound identified 9/7/21 .current treatment: house barrier cream, ordered 9/7/21 .Current Preventative Interventions: Pressure Redistribution Mattress, Wheelchair Cushion, Heel Boots. Weekly Wound Evaluation dated 9/7/21, Left buttock, pressure injury (In-house Acquired), Stage II (two), length: 0.5, width: 0.5, depth <0.1, wound identified 9/7/21 .current treatment: house barrier cream, ordered 9/7/21 .Current Preventative Interventions: Pressure Redistribution Mattress, Wheelchair Cushion, Heel Boots. Nursing progress note dated 9/7/21 at 12:52 p.m., indicted while getting care from CNA it was noted resident has 2 areas open on buttocks. One on each side. Rt (right) measures 1 cm x 3/4 cm and left 1/2 cm x 1/2 cm. Applied skin prep . Nursing progress note dated 9/13/21 at 12:56 p.m., indicated, while receiving care from CNA, they noted another area on his left buttocks. Applied [MEDICATION(S)] cream to buttocks. Instructed CNA to turn side to side q (every) 2 hours and keep dry . Dr (Doctor) has been called. The Registered Dietician note dated 9/8/21 at 9:29 p.m., indicated .wt. (weight) loss of -9.7% (percent) times 180 days, wt. stable x 30/90 days. Res (resident) continues with PI (pressure injury) to R (right) lateral foot with no change in size per wound care. Stage II (two) PI on both R and L (left) buttock .intake appears adequate to meet needs . On 9/9/21 at 9:28 a.m., TNA 1 and CNA 1 were observed to provide incontinence care for Resident 33. An open area was observed on the left mid inner buttock, pale pink and irregularly shaped. Open area was observed on the right mid inner buttock beside the area on the left buttock with the appearance of a Stage II. Resident was observed to be incontinent of bowel and bladder. At completion of care, TNA 1 elevated the the head of the bed with Resident 33 positioned on his back, covered with a sheet, and left the room. No heel boot was visualized on Resident 33. On 9/9/21 at 9:55 a.m., LPN 1 was observed to do treatments for Resident 33's [CONDITION(S)], then turned Resident 33 on his side, loosened the incontinence brief, and applied [MEDICATION(S)] oxide to the open areas on Resident 33's buttocks. LPN 1 indicated he developed the areas from lying flat on his bottom and she preferred side to side. LPN 1 was then observed to cleanse the gastrostomy insertion site, and left the room with Resident 33 lying on his back with the head of the bed elevated. On 9/9/21 at 2:30 p.m., LPN 1 indicated I try to look at the treatment list to see what is needed, if I don't have what is needed, I try to substitute it with something that I think will work. On 9/9/21 at 2:39 p.m., the Director of Nursing indicated she does the wound measurements, or a nurse does and opens the Wound Eval (Evaluation Assessment). She usually had to go behind and lock the assessment. On 9/13/21 at 3:30 p.m., the Administrator provided the current facility policy, Preventive Skin Care, revised date 10/14/15. The Policy indicated, but was not limited to, .provide preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well-groomed and free from pressure sores . Residents identified as being at high risk for potential breakdown shall be turned and repositioned frequently to prevent redness that does not fade or blanche .positioning pillows or specialty devices may be used between two skin surfaces or to slightly elevate bony prominences/pressure areas off the mattress. Heels Up or specialty ordered therapeutic boots may be used to protect heels on those residents identified to be high risk. Pillows may be used to float heels to prevent potential pressure sores on those residents identified to be high risk. Ensure proper fit of wheelchairs, braces, shoes, and prosthetics devices .Maintain residents proper body alignment when repositioning and lifting residents .keep incontinent residents clean and dry . 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to provide adequate supervision to prevent repeated falls, resulting in a scalp laceration requiring sutures, for 1 of 3 residents reviewed for falls (Resident B). Findings include: The closed clinical record of Resident B was reviewed on 11/13/19 at 10:40 [NAME]M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurses Note, dated 9/12/19 at 4:45 P.M., indicated, .Alert and oriented x 3 (person, place, time) with occasional confusion A Physical Therapy (PT) Evaluation & Plan of Treatment, dated 9/13/19, indicated, Reason for referral .due to recent fall at home 9/6/19, weakness, decreased balance, inceased (sic) difficulty walking - bed mobility, transfers - standing activity, SOB (shortness of breath) on light exertion, decreased activity tolerance . The evaluation indicated Resident B was at a high risk of falls with injury. An Occupational Therapy Evaluation, dated 9/13/19, indicated Resident B was at risk for falls due to his impaired standing balance. An admission Minimum Data Set (MDS) assessment, dated 9/20/19, indicated the resident was severely impaired with cognition, and required extensive assistance of one person for bed mobility, transfer, and walking in the room and corridor. A test for balance during transitions and walking indicated the resident was not steady, only able to stabilize with staff assistance. Resident B had fallen in the previous 1 month prior to admission. Nurses Notes continued: 9/28/19 at 10:50 [NAME]M.: Resident A/O (alert and oriented) x 3 .is extensive assist x 1 for bathing and dressing .walks independently to the bathroom but will often urinate on the floor .this nurse educated resident on the importance of calling for help before using restroom A Speech Therapy Evaluation, dated 10/1/19, indicated, .exacerbation of cognitive impairment, decreased safety awareness and increased need for assistance from others . Nurses Notes continued: 10/2/19 at 2:29 [NAME]M.: Resident turned on call light, CNA went to room and found resident lying on his back next to his bed. No injury noted at this time. Resident states he was getting up to go the restroom and slipped off the bed onto the floor 10/2/19 at 11:40 [NAME]M.: IDT (interdisciplinary team) met to discuss recent fall where he slid off of bed. No evidence of injury. Care plan reviewed and is acceptable. Room change being considered at this time 10/2/19 at 9:29 P.M.: .needs assist with transfers but frequently tries to ambulate himself. He has fallen on 1 occasion without injury and had to be gotten off of floor by staff An incident report, dated 10/2/19 at 9:48 P.M., indicated, I was just entering this residents (sic) room when he came out of the bathroom. His sweat pants were down around and he tripped and fell to floor. This was witnessed by nurse and he did not hit his head .Alert with periods of forgetfulness .Decreased safety awareness . An incident report, dated 10/3/19 at 12:27 [NAME]M., indicated, .Res stated that he was walking to the bathroom and tripped over his feet and fell .Predisposing Physiological Factors: Confused, Incontinent, Gait Imbalance, Impaired Memory, Not Using Walker Nurses Notes continued: 10/3/19 at 12:40 [NAME]M.: At approx. 2205 (10:05 P.M.) this nurse was called to res (resident) room with other staff, and found res in a side lying position in his bathroom. Res was able to voice that he had no pain r/t (related to) the fall .ambulation back to his bed was done with staff assist x 2 .was then assisted back to his bed, gait unsteady and staff x 2 assist to get to his bed. Res was educated on using his call light for further assistance for transferring or ambulating .Will continue to monitor. 10/3/19 at 2:45 [NAME]M.: Upon observation during assistance with toileting, blood was on res sheet .Res has skin tear 2 cm (centimeters) on rt (right) elbow, and a 3 cm skin tear on right elbow, and a small abrasion to left hip. Res c/o (complains of) neck pain 10/3/19 at 9:09 [NAME]M.: Called to resident's room at 0630 (6:30 [NAME]M.). Staff was transferring resident to the bathroom, resident was using w/w (wheeled walker), lost balance and fell to floor. No new injuries noted .Up working with therapy this morning .Will continue to monitor. 10/3/19 at 3:53 P.M.: (Resident B) was fed lunch today. He could not eat on his own, even with verbal prompting .It is unclear at this time if this difficulty is d/t (due to) his dementia, if there is something wrong medically, or both. The resident was transferred to the facility's dementia unit on 10/3/19 at 3:55 P.M. Nurses Notes continued: 10/3/19 at 6:45 P.M.: It was reported to this nurse that approximately 6:30 PM resident was found on the floor besides (sic) his bed. Residents (sic) roommate was present & said that his room mate did not hit his head, but just rolled onto the floor 10/3/19 at 6:46 P.M.: .Asked resident what he was suppose (sic) to do if he wanted up. He said 'Push the red button for help!' Asked him if he pushed it, he said no. Asked him why, he said 'I don't know!' .Keeping resident in dining room for now for closer observation. The resident was transferred to the emergency roiagnom on [DATE] at 8:20 P.M. He returned to the facility on [DATE] at 3:10 P.M., diagnosed with [REDACTED]. An incident report, revised on 10/12/19 at 4:11 [NAME]M., indicated, .He was trying to get up to go to the bathroom, forgetting that his legs are weak et (and) sometimes they give out before he gets where he is going .Skin Tear Left lower leg (front) .Confused, Decreased safety awareness, Decreased Strength/Endurance, Toileting needs Nurses Notes continued: 10/12/19 at 5:14 [NAME]M.: Resident was wanting to use the bathroom, didn't want to wait for a urinal so tried to get up on his own, resulting in an unwitnessed fall, found one possible skin tear .call light attached to robe for easy use. 10/14/19 at 12:12 P.M.: IDT met to discuss recent fall while staff was retrieving urinal. No evidence of any injury. Therapy to eval (evaluate) for weakness of knees A Social Services note, dated 10/15/19 at 1:58 P.M., indicated, .Summary of Cognitive Status and plan of action if impaired: 7 indicating severe impairment . Nurses Notes continued: 10/18/19 at 12:43 [NAME]M.: This nurse was called to res room where res was found in a sitting position on the floor outside of the bathroom .Res was weak and has very unsteady gait with no assistance .res was educated on using his call light. Res assured staff he would not get back up on his own, but res was forgetful at times, so unaware if res will use call light An incident report, dated 10/18/19 at 12:42 [NAME]M., indicated, Res stated he was walking to the bathroom and sat down. Res forgetful at times, res stated he did not hit his head .Confused, Gait Imbalance, Decreased Strength/Endurance, Toileting Needs, Not Using Walker An incident report for an additional fall, dated 10/18/19 at 7:29 P.M., indicated, Called to residents (sic) room found resident on floor of bathroom .States he was just taking himself to the bathroom .Skin Tear Left elbow .Impaired Memory .Decreased safety awareness A Fall Risk Review, dated 10/18/19 at 12:59 [NAME]M., indicated, Does the resident have a history of falls within the last 3 months? Yes. Is resident receiving a medication that affects awareness, judgement or safety? Yes .Ambulation With assist .Gait/Balance: Balance problem while standing/walking, Requires use of assistive devices, Does the resident have any health condition that predisposes them to be at risk for falls? 1-2 Health Conditions .A score of 10 or ABOVE represents HIGH RISK .Total Score: 13. A Daily Skilled Nursing Note, dated 10/21/19 at 1:07 [NAME]M., included: Mental Status: Alert Person .Unsteady Balance/Gait, Weakness .he is incont (incontinent) B&B (bowel and bladder) A Daily Skilled Nursing Note, dated 10/21/19 at 9:23 P.M., included: Mental Status: Alert Person .Incontinence, Unsteady Balance/Gait Nurses Notes continued: 10/22/19 at 7:00 [NAME]M.: Res alarm sounded. This nurse and cna got to res room and res lying in floor between his bed and bathroom. Res lying on right side - Noted laceration to right side of forehead, 2 skin tears on right arm .Notified (name of physician) and new order received to send res to (name of hospital) for eval and tx (treatment) A hospital emergency room note, dated 10/22/19 at 10:56 [NAME]M., included: Chief Complaint: Patient presents with Fall .presents with a full thickness laceration to his scalp frontal region, with pressure dressing. Patient has a baseline of dementia. He has been falling out of bed several times this week .Number of sutures: 5 .Measuring 3.5 cm in length A facility Care Plan, dated 9/13/19, indicated: (Resident B) has a dx (diagnosis): Dementia with no behavioral disturbance with ST (short term) and LT (long term) memory problems and scored in the severe impairment on his first BIMS (brief interview for memory status). The Interventions included: Anticipate needs when able/prn (as needed). An additional facility Care Plan, initially dated 9/13/19, indicated: Potential for falls R/T (related to) poor safety awareness. The Interventions included: 10/21/2019 Add pull alarm. Call light in reach. 10/4/2019 Educate nursing staff to offer res to lay down. Educate staff to assist res with walking. 10/3/2019 Educate staff to offer toileting at beginning and end of each shift. Educate staff to offer toileting frequently. Encourage to ask for assist with transfer or ambulation prn On 11/14/19 at 1:50 P.M., the Administrator indicated the facility had identified concerns with falls, and had started an improvement plan on the first of October. On 11/14/19 at 2:00 P.M., the Administrator provided the current facility policy, Incidents/Accidents/Falls, undated. The policy included: .All falls will have a site investigation by appropriate staff in an effort to define the 'root cause' of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence .Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goal with appropriate interventions in place This Federal tag relates to Complaint IN 554. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to develop appropriate individualized interventions to prevent falls in a resident at high risk for falls, resulting in a fall with a right leg fracture, for 1 of 3 residents sampled with falls, in a sample of 8. Resident C Findings include: 1. On 9/30/14 at 9:00 A.M., during the initial tour, Resident C was observed lying in bed, on her back, wearing a hospital gown. The clinical record of Resident C was reviewed on 9/30/14 at 11:45 A.M. [DIAGNOSES REDACTED]. Progress notes included the following notations: 5/29/14 at 4:15 P.M.: "New admit...Entered facility by w/c (wheelchair). Son says she is a little weak to walk...." A Fall Risk Assessment, dated 5/29/14, indicated, "Intermittent Confusion, Ambulatory/Continent, 1-2 falls in past 3 months, Balance problem while standing, Balance problem while walking, Requires use of assistive devices..." A total number of the risk factors was not documented. A Physical Therapy Evaluation & Plan of Treatment, dated 5/30/14, included: "Reason for Referral:...falling twice at home same day and several falls at home in the past...The EMS (emergency medical system) staff came to her home x 2 day of admission asssting (sic) her off the floor after a fall...Impressions:...poor plus static and dynamic standing balance with recent history of several falls, inability to get up off the floor after falling...Risk factors:...high fall risk, osteoporosis...Hx (history)...CVA with recovery...." Progress notes continued: 6/3/14 at 6:31 P.M.: "...All transfers by staff assist...." An admission Minimum Data Set (MDS) assessment, dated 6/6/14, indicated the resident scored a 8 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance of one staff for transfer, walking, dressing, and personal hygiene. The MDS assessment indicated the resident was "Not steady, only able to stabilize with staff assistance" during a test for balance during transitions and walking. The resident had fallen in the month prior to admission to the facility, and had fallen since admission. Progress notes continued: 6/6/14 at 7:00 A.M.: "Called to res (resident) room by cna. Res lying on back in floor between closet and bed. Chair sitting next to res. Posterior head bleeding with large hematoma. Laceration 0.4 cm long. No sutures needed. Res states she was getting in closet and tripped over chair...." 6/9/14 at 6:11 A.M.: "Res removing pull alarm x 2 since 5 am taking self to bathroom enc (encourage) res to ring call light for assistance...." 6/9/14 at 1:54 P.M.: "Res alarm and working. Res has attempted to transfer unassisted sev (several) times this shift. Provided cues for safety...." 6/10/14 at 1:55 P.M.: "Res got up unassisted and lost balance falling onto left knee. 2 cm laceration noted. Small amount of bleeding. Skin approximated. Bleeding stopped. Steri strips applied...." 6/11/14 at 9:35 P.M.: "Summoned to residents (sic) room by residents roommate. Entered room to find resident lying on back by BR (bathroom) door, legs crossed, with Rt (right) leg over Lt (left) leg. Resident able to move Rt leg upon command, but thought her Lt leg was straight. This nurse had felt Lt knee and resident c/o (complained of) terrible pain to knee...." The resident was transferred to the hospital by ambulance on 6/11/14 at 10:14 P.M. A physician note, dated 6/26/14, indicated, "...Initially admitted ...for weakness...for rehab. However, very shortly (after) she came, she tried to get up herself (and) fell suffering a spiral fx (fracture) of Rt (right) tibia (leg)...." A resident care plan, dated 7/3/14, indicated, "Resident is at risk for falls D/T (due to) history of recent fall...Interventions, Keep call light in reach, Therapy screen...." A resident care plan regarding the resident's fall risk prior to 7/3/14 was not located at that time. On 10/2/14 at 10:00 A.M., the Director of Nursing (DON) provided a care plan, dated 5/29/14 and revised 6/6/14, which indicated, "Potential for falls R/T (related to) new surroundings and weakness. Interventions, Call light in reach. Encourage to ask for assist with transfer or ambulation prn (as needed). Keep paths free of clutter. Therapy screen quarterly and prn. 6-6-14 note in view to ask for assist use call light on bright paper." The DON indicated at that time that the care plan may have been under the therapy section, instead of the nursing section, regarding care plans. The DON indicated that after the resident first fell on [DATE], she added the bright reminder note. She indicated the resident also had alarms placed, but did not know why they were not documented on the care plan. She indicated the resident did not really fall on 6/10/14, but that she lost her balance and fell on to her wheelchair, causing the laceration. 2. On 10/2/14 at 2:15 P.M., the Director of Nursing provided the current facility policy on a "Fall Risk Assessment," undated. The policy included: "It is the intent of the facility that all resident (sic) will have a Risk Assessment for Falls performed on admission/readmission...For residents who score a 10 or above, develop a preventative care plan for falls...." The DON indicated she was unable to locate a facility Fall Prevention Policy. This Federal tag relates to Complaint IN 633. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident dependent for care received adequate pressure ulcer treatment, in that the facility failed to notify the physician and obtain treatment for [REDACTED]. Resident C Findings include: 1. On 4/4/13 at 10:00 A.M., the closed clinical record of Resident C was reviewed. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." On 4/5/13 at 12:00 P.M., Medical Records staff # 1 provided a Nursing Summary and Braden Scale for Predicting Pressure Sore Risk, dated 2/22/13. The Summary included: "...confused @ times, Does not walk...total assist (with) ADLs (activities of daily living), dressing, bathing, toileting..." The Braden Scale included: Sensory Perception Slightly Limited, Skin Constantly Moist, Activity Chairfast, Mobility Very Limited, Nutrition Probably Inadequate, and Friction and Shear Potential Problem. The Total Score was 12 ("High Risk: Total Score (equal or below) 12)." A Resident Care Plan, dated 6/5/12 and updated 2/28/13, indicated, "Potential for skin breakdown." The Nursing interventions included: "1. Enc. (encourage) turn, reposition...Skin check wkly (weekly) (and) PRN (as needed. 6. Notify Dr. of changes." An additional Resident Care Plan, dated 12/12 and updated 2/28/13, indicated, "Blister to Lt (left) heel vascular Stage 2." The Nursing interventions included: "Tx (treatment) as ordered...Skin check (with) care (and) wkly...Notify Dr. as needed." A Minimum Data Set (MDS) assessment, dated 3/5/13, indicated Resident C scored a 8 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident was totally dependent on one staff for bed mobility and dressing, and totally dependent on two + staff for transfer. The resident did not ambulate. The MDS assessment incorrectly indicated the resident had no pressure areas, no foot [MEDICAL CONDITION], and no arterial or venous ulcers. Skin assessment sheets included the following: "3/4/13, Wound type: blister, Location: (Left) heel, Length, Width, Depth: 2.1 x 2.2 cm (centimeters), Color: red, Drainage: serosang (thin bloody), Odor (none). Current treatment: Clean, cover (with)[MEDICATION NAME](cushioned dressing) (and) kerlix, skin prep." "3/11/13, Wound Type: blister, Location: (Left) heel, Length, Width, Depth 2.8 x 3.8, Color: black soft center, Drainage: small amts...Current Treatment, Clean, cover (with)[MEDICATION NAME](and) kerlix, skin prep." "3/18/13, Wound Type: blister, Location: (Left) heel, Length, Width, Depth 2.8 x 5 cm, Color: black (with) soft surrounding tissue, Drainage: minute...Current Treatment, Clean, cover (with) skin prep,[MEDICATION NAME](and) kerlix." An additional skin assessment sheet, dated 3/18/13, indicated, "Wound Type: blister open, Location: (Right) heel, Length, Width Depth: 4 x 5.2, Color: red (and) black...Current Treatment: (left blank)." Documentation that the physician was notified of the right heel area, or treatment received for the area, was not observed in the clinical record. An additional skin assessment, dated 3/23/13, indicated, "Location, coccyx, Length width depth: 2.5 x 1.2, Color, red, Tissue Type Code: 2, Tx Progress (left blank)." Nurse's Notes, dated 3/23/13 at 1:30 P.M., indicated: "...Res (resident)...unable to swallow food @ this time. Yellowish discharge noted from penis foreskin. Dr. notified and ordered to send Res. to hospital for eval and treat." The resident was transferred to the hospital on [DATE] at 2:30 P.M. A facility transfer form, dated 3/23/13, indicated: "Presence of Decubitus: Yes, coccyx...." A hospital emergency room record, dated 3/23/13 at 2:50 P.M., indicated, "Chief Complaint:...Pt. (patient) has decub (pressure ulcer) on Lt. (left) hip and coccyx, decub on scrotom (sic) and decub on heels...Pt. has decub on Rt. (right) heel that is approx. (approximately) 5 cm (centimeters) x 4 cm and is black and draining brown liquid...Lt heel has decub that is approx 7 cm x 4.5 cm and is black with some yellow tissue above it and draining brown liquid...Left hip has area that is red with small abrasions. Scrotum is red, swollen and has an open place that is draining yellow fluid...Coccyx has wound that is not draining, red...6:30 P.M. Decub to both heels have strong foul odor...." On 4/4/13 at 1:45 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was the nurse who had performed the weekly skin assessments, and had sent the resident out to the hospital on [DATE]. Regarding the skin assessment sheets, LPN # 1 at first indicated both of the resident's heels had open areas. LPN # 1 then indicated she must have written "right heel" by mistake, and had meant the left heel. LPN # 1 indicated the resident's coccyx had been red, and that she had informed the Director of Nursing about that. LPN # 1 indicated the resident's coccyx "opened up" the morning of 3/23/13, and she had not informed the physician prior to the resident being transferred to the hospital. On 4/5/13 at 10:25 A.M., facility inservices for the year were reviewed. There were no inservices regarding skin care or wound care for the years 2012 or 2013. An inservice, dated 2/11/13, indicated, "Resident Care." CNA assignment sheets were attached to the inservice. Resident C's entry indicated, "...Special Instructions, confused, brush teeth, total assist." The assignment sheet did not address skin prevention care measures. On 4/5/13 at 10:40 A.M., the Administrator and Director of Nursing (DON) were interviewed. The Administrator indicated she had been at the facility approximately 2 weeks. The DON indicated nursing staff are to check and measure residents' wounds weekly. The DON indicated Resident C had wounds to both heels, and she was unsure why there was no treatment order for the right heel. The DON indicated they had found the resident's open area on his coccyx the morning of 3/23/13. The DON indicated she was unaware of additional open areas. 2. Stages of Pressure Ulcers, AMDA - 2008, includes the following information: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissues. Stage I : Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the ulcer bed. Note: Until enough slough or eschar is removed to expose the base of the ulcer, the true depth and therefore stage, cannot be determined. 3. On 4/5/13 at 9:00 A.M., the Director of Nursing provided the current facility policy on "Pressure Ulcer Assessment and Staging," dated 7/1/11. The policy included, "Guideline: When a pressure area is identified, an accurate assessment will be completed; a treatment program will be initiated and monitored...Procedure: 1. When the Charge Nurse is aware of skin breakdown, whether in-house or upon a resident's admission, area is assessed and initial treatment started per physician orders...Initiate a treatment sheet and complete the Pressure Sore Report. Document site, stage, size, depth, drainage, color, odor, prevention and treatment response. 4. The physician's orders [REDACTED]...6. The physician is to be notified when a pressure sore develops and skin conditions do not show improvement within 2 weeks...Skin Condition Monitoring...1) When the Charge Nurse is aware of [MEDICAL CONDITION], wound, venous ulcers, or other skin abnormalities, the area is to be assessed and documented...3) Initiate treatment per physician's orders [REDACTED]...1) Observations of a resident's skin are made upon each time the resident is provided person care (sic) by the CNA's and licensed nurses...." This federal tag relates to Complaint IN 491. 3.1-40(a)(1) 3.1-40(a)(2)