Every finding on record at Waters of Rockport Skilled Nursing Facility, The

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with food safety standards to maintain a sanitary environment and prevent foodborne illness during 2 of 2 kitchen observations. Food preparation areas contained a build up of dust and debris, the walk in freezer contained food containers that were open to air, food containers were stored on the floor of the walk in refrigerator and dry food storage room, and resident refrigerators were not monitored routinely for 2 of 3 resident rooms observed. (Resident B, room [ROOM NUMBER], room [ROOM NUMBER])Findings includes: 1. Kitchen observation on 8/20/26 at 7:40 A.M., the walk in refrigerator contained a cardboard box of oranges sitting directly on the floor. The walk in freezer contained a box of mixed vegetables, a bag of cookie dough, and a box of hamburger patties that were open to air. The dry food storage room contained a box of yellow cake mix, a can of cheddar cheese sauce, a box of assorted jelly, a bag of one-minute oats, a bag of flour, a box of tomato juice, and flat of canned sauerkraut that were sitting directly on the floor. The dishwasher in the main food preparation area had a build up of dust and debris on top. The floor contained crumbs, dust, and debris under the three-compartment sink, the stove, oven and in the corners of kitchen. An overhead duct vent contained a build up of dust on and around the ceiling vent with a build of condensation drips above the plate warmer. An email correspondence from the Facility Administrator on 8/20/26 at 10:23 A.M., indicated the facility's last food truck delivery was on Tuesday 8/18/26. Kitchen observation on 8/20/26 at 11:20 A.M., the walk in freezer contained a box of mixed vegetables, a bag of cookie dough, and a box of hamburger patties that were open to air. The dishwasher in the main food preparation area had a build up of dust and debris on top. The floor contained crumbs, dust, and debris under the three-compartment sink, the stove, oven and in the corners of kitchen. An overhead duct vent contained a build up of dust on and around the ceiling vent with a build of condensation drips above the plate warmer. An interview on 8/20/26 at 11:45 A.M., the Regional Dietary Manager indicated the kitchen had been short on staff with the previous dietary manager working as the main cook and they had fallen behind with getting inventory up off the floor. The Regional Dietary Manager indicated the food should not be stored on the floor and food containers should be sealed in the refrigerator. On 8/20/26 at 12:35 P.M., the Facility Administrator supplied an undated facility policy titled, Sanitation Of Dietary Department. The policy included, The dietary staff shall maintain the sanitation of the dietary department through compliance with a written, comprehensive cleaning schedule. On 8/20/26 at 12:41 P.M., the Facility Administrator supplied a daily dietary cleaning schedule. The cleaning schedule included, .Mopping/sweeping the floor . Dish Area . Clean/sanitize outside of dish machine/handle (use delimer for buildup) .2. Observation of room [ROOM NUMBER] on 8/20/26 at 9:15 A.M., resident refrigerator contained yogurt cups, soft drinks, fruit cups and two cans of beer. The refrigerator contained no thermometer and no temperature check sheet was observed in the resident room. Observation of room [ROOM NUMBER] on 8/20/26 at 10:30 A.M., resident refrigerator contained a jar of pickles and condiments. No documentation of routine temperature checks was observed around the refrigerator. Resident B indicated staff checked the refrigerator about once a month. An interview on 8/20/26 at 11:45 A.M., the Housekeeping Manager indicated night shift CNA's should check resident room refrigerator temperature checks and complete routine cleaning. On 8/20/26 at 12:28 P.M. the Facility Administrator indicated no documentation of routine resident refrigerator temperature checks were found and supplied a facility policy titled, Guidelines For Unit (Resident Room) Refrigerators, dated 6/10/23. The policy included, Policy: It is the policy of the facility to assure that perishable food requiring refrigeration is stored at the proper temperature . 2) Each refrigerator will be provided with a thermometer to ensure that the refrigerator is maintained between 35 degrees and 40 degrees Fahrenheit. 3) The resident's refrigerator will be cleaned by the housekeeping department every seven days to check and see that all foods/drinks stored in the refrigerator are palatable and not beyond their expiration dates. 4) Refrigerator temps will be checked and documented daily . This citation relates to intake 3120192. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure residents were free from misappropriation for 1 of 1 residents reviewed for misappropriation. Three checks were taken from a resident's checkbook by a QMA. The QMA then used two checks in an attempt to transfer money from the resident's bank account to the QMA's account. (Resident D)Finding includes:During a review of facility reported incidents on 3/9/26 at 11:15 A.M., an incident dated 12/2/25, indicated Resident D notified staff that he received a phone call from his bank regarding suspicious activity on his account. QMA 13 was terminated from employment and arrested. Resident D's account was recovered, and proper paperwork was completed to restore funds. A review of the facility's investigation into the incident on 3/9/26 at 1:30 P.M., indicated Resident D's bank notified the resident of suspicious activity on his account on 12/1/25 at 3:30 P.M. On 12/2/25 at 2:00 P.M., Resident D notified staff. Facility staff, along with the resident, contacted the bank and were informed QMA 13 had attempted to cash a check (#1700) from the resident for $1,200.00. A review of the resident's check book showed that other check numbers 1695, 1698, and 1699 were missing and unaccounted for. It was determined that check number 1698 had been cashed for $700.00 on 11/30/25. Police were notified.During an interview on 3/10/26 at 11:25 A.M., the Facility Administrator indicated QMA 13 had stolen multiple checks from Resident D's checkbook and successfully cashed a check for $700.00. QMA 13 attempted to cash a second check for a larger amount and when asked for identification, QMA 13 fled the bank, leaving behind her driver's license. A bank employee then contacted the resident, and the facility was notified and confirmed QMA 13's information matched the driver's license. Police were notified and QMA 13 was arrested and terminated from employment after arriving for her next scheduled shift. On 3/10/26 at 12:18 P.M., the Facility Administrator supplied a facility policy titled, Abuse Prevention Program, dated 10/22/22. The policy included, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property . Exploitation/Misappropriation of resident property: is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the cognitively intact resident's consent .This citation relates to intake 2683467.410 IAC (Indiana Administrative Code) 16.2-3.1-28(a)

Based on interview and record review, the facility failed to ensure services were provided for treatment of an existing pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Following admission and then readmission from a hospital, a resident's pressure ulcer was not routinely assessed, and wound care orders were not immediately obtained for treatment. (Resident B)Finding includes:During record review on 3/9/26 at 10:15 A.M., Resident B's diagnoses included, but were not limited to muscle wasting and atrophy, protein-calorie malnutrition, anemia, and influenza. Resident B's most recent admission Minimum Data Set (MDS) assessment, dated 12/26/26, indicated the resident admitted to the facility with no unhealed pressure ulcers, was at risk for developing pressure ulcers, and was dependent for mobility, including rolling in side to side in bed. A Braden scale assessment (tool used to predict the risk for developing pressure ulcers), completed 1/10/26, indicated Resident B was at low risk for developing pressure ulcers. Resident B's physician orders included, but were not limited to, cleanse coccyx with wound cleanser, pat dry, cover with foam dressing (started 1/16/26 and discontinued 1/20/26), cleanse area to coccyx with wound cleanser, pat dry and apply border foam dressing (started 2/9/26 and discontinued 2/19/26).Resident B's care plan included, but was not limited to, resident has alteration in skin integrity: unstageable pressure injury (initiated 1/10/26). Interventions included but were not limited to; evaluate and change treatment as needed, observe and report any new concerns for evaluation and/or treatment changes or interventions, and observe skin per facility policy and with routine care.Resident B's weekly wound evaluation, dated 1/10/26 (Admission), included an initial wound assessment for Resident B's coccyx: Stage 1 pressure ulcerMeasurement: 7 centimeters (cm) length (L) x 4 cm width (W) x 0 cm depth (D)No drainage or exudateCurrent treatment: Not available (N/A)Date treatment ordered: N/AWound status/ Additional comments: Resident has redness on coccyx with a small open wound more toward the right buttocks. Wound nurse should look at it and give ideas to help with healing.Resident B's nurse's progress notes included, but were not limited to:1/10/26 at 8:33 A.M. - Post Admission/ readmission - skin condition: small open lesion on coccyx with surrounding redness and irritation. 1/12/26 at 1:03 A.M. - Post Admission/ readmission - skin condition: open lesion. Summary note: Resident is resting in room. Resident seemed very tired. Resident indicated she needs to sleep on her side because she has a bedsore. Resident B was admitted to the hospital on [DATE]. Resident B discharged from the hospital on 1/21/26 and returned to the facility.Resident B's hospital wound / ostomy evaluation dated 1/17/26 at 2:01 P.M., indicated the reason for consult was, Wound to buttocks on arrival. Was on last admission also (last admission was prior to facility admission on [DATE])Wound: unstageable pressure injury (present on arrival)Dimensions: 1.7 cm (L) x 0.4 cm (W) x 0.1 cm (D)Wound bed: 100% sloughPeri-wound skin: small pinpoint open area with pink moist tissue distal to larger area, presenting as stage 2 pressure injury (present on arrival).Drainage: scant serosanguinousNo signs or symptoms of infection. A facility admission / readmission assessment dated [DATE] at 4:36 P.M., included:Pressure ulcer to sacrumMeasurements: 1 cm (L) x 0.3 cm (W) x 0.1 cm (D)A nurse's progress note dated 2/6/26 at 3:20 A.M., indicated during a skin check, a wound on the coccyx was found by the nurse. A risk assessment was being submitted due to the wound. A wound assessment report, dated 2/18/26 included:Location: CoccyxMeasurements: 1 cm (L) x 0.5 cm (W) x 0.2 cm (D)Etiology: Pressure Ulcer / InjuryStage / Severity: UnstageableDate acquired: 1/21/26 (present on admission)% Granulation: 20% granulation% Slough: 80% sloughExudate amount: ModerateExudate description: Serosanguineous A wound assessment report, dated 2/25/26 included:Location: CoccyxMeasurements: 1 cm (L) x 0.5 cm (W) x 0.2 cm (D)Etiology: Pressure Ulcer / InjuryStage / Severity: UnstageableDate acquired: 1/21/26 (present on admission)% Granulation: 30% granulation% Slough: 70% sloughExudate amount: ModerateExudate description: Serosanguineous A wound assessment report, dated 3/4/26 included:Location: CoccyxMeasurements: 1.1 cm (L) x 0.7 cm (W) x 0.2 cm (D)Etiology: Pressure Ulcer / InjuryStage / Severity: UnstageableDate acquired: 1/21/26 (present on admission)% Granulation: 20% granulation% Slough: 80% sloughExudate amount: ModerateExudate description: Serosanguineous Resident B's Medication Administration Record (MAR) / Treatment Administration Record (TAR) from the admission date of 1/10/26 through February, 2026 indicated the resident did not receive routine wound treatment or have an order for routine wound treatment to the coccyx from 1/10/26 to 1/14/26 (discharged to hospital). Upon readmission on [DATE], Resident B did not receive routine wound treatment or have an order for routine wound treatment to the coccyx from 1/21/26 through 2/8/26.During an interview on 3/10/26 at 12:05 P.M., LPN 4 indicated initial admission or readmission wound assessments should trigger the nurse to obtain a wound treatment order. The wound care nurse would then complete weekly wound assessments. During an interview on 3/10/26 at 12:10 P.M., RN 6 indicated Resident B's coccyx wound assessments were not documented following the resident's readmission from the hospital on 1/21/26 until 2/18/26. On 3/10/26 at 12:20 P.M., the DON supplied a facility policy titled, Guidelines for Prevention/Treatment of Pressure Injuries, dated 10/9/23. The policy included, .Objectives: In accordance with Federal Regulations-and based on resident assessment, the facility will ensure: .2) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.This citation relates to intake 2785193. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a baseline care plan was developed for a newly admitted resident within 48 hours of admission for 1 of 2 newly admitted residents with pressure ulcers. A resident admitted on a Thursday and had no baseline care plan in place until the following Monday. (Resident C)Finding includes:During record review on 3/9/26 at 1:45 P.M., Resident C's diagnoses included but were not limited to, aphasia following other nontraumatic intracranial hemorrhage.Resident C's admission date was 3/5/26. Resident C's physician orders included but were not limited to, coccyx and right buttock: cleanse with wound cleanser, pat dry, apply calcium alginate with Medihoney, and cover with border foam dressing (started 3/5/26). Resident C's record contained no care plan or baseline care plan. During a review on 3/10/26 at 9:30 A.M., Resident C's record contained a baseline care plan for admission, dated 3/9/26 at 4:36 P.M.During an interview on 3/10/26 at 11:30 A.M., the Assistant Director of Nursing (ADON) indicated a resident baseline care plan should be put into place within one to two days after admission. On 3/10/26 at 12:18 P.M., the Facility Administrator supplied a facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated 3/23/21. The policy included, It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of admission . 1. Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan Assessment will be completed within 48 hours of admission and will address areas of imminent concern. At a minimum, it will address initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations. Observations, interview(s) with the resident and/or their representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment. a) The IDT Team will assist in the completion and implementation of the Baseline Care Plan to ensure compliance of completion within 48 hours per the regulation .This citation relates to intake 2785193. 410 IAC (Indiana Administrative Code) 16.2-3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure the resident received adequate supervision to prevent falls for 1 of 2 residents reviewed for accidents. The plan of care was not updated, and interventions were not implemented and reviewed for effectiveness for a high risk to fall resident with severely impaired cognition. This deficient practice resulted in multiple falls, one with major injury, where the resident sustained an acute fracture to right hip/pelvis and subacute left hip fracture. (Resident 28) Findings include: On 5/19/25 at 8:51 A.M., Resident 28 was observed sitting in a Broda chair (specialized seating system) in the east lobby in front of the television, hands empty, and trying to pull on his blanket. On 5/20/25 at 9:51 A.M., Resident 28 was observed sitting in a Broda chair in the east lobby in front of the television, hands empty, and trying to pull on his blanket. On 5/20/25 at 10:00 A.M. an Indiana Department of Health (IDOH) incident report, dated 2/9/25, was reviewed. It indicated Resident 28 fell forward out of his wheelchair while attempting to pick something up off the floor, was transferred to the hospital, and the hospital nurse reported to the facility Resident 28 had bilateral hip fractures. On 5/21/25 at 2:15 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with agitation, unsteadiness on feet, and generalized muscle weakness. Resident 28 was admitted to the facility on [DATE]. The most recent Quarterly MDS (Minimum Data Set) assessment prior to the fall, dated 12/9/24, indicated Resident 28's cognition was severely impaired, had no impairment of his upper or lower extremities, no pain presence, had two or more falls since admission, used a walker and wheelchair, partial to moderate assist (staff performs less than half the effort) for bed mobility and eating, substantial to maximum assist (staff performs more than half the effort) for transfers and showering, and totally dependent on staff for showering. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident 28's cognition was severely impaired, had two or more falls, one with major injury, since the last Quarterly MDS assessment, dated 12/9/24, was partial to moderate assist (staff performs less than half the effort) for bed mobility and eating, substantial to maximum assist (staff performs more than half the effort) for transfers and showering, and totally dependent on staff for showering, on hospice, and receiving an antianxiety and antidepressant medication. A plan of care for falls, initiated on 10/2/24 and last revised 5/20/25, indicated the resident was at risk to fall because of the following risk factors and included the following interventions: confusion/forgetfulness (intermittent or constant), frequently forgot to use assistive device for walking, history of fall(s) in the past 30 days, impaired balance with transfers with or without assistive device, incontinence, pain, required staff physical support to transfer, slow small shuffling gait, unsteady gait with or without assistive device, used assistive device for mobility, and weakness fall on 10/13/24, no injury, initiated 10/13/24 anti rollback device to wheelchair, initiated 2/21/25 and resolved on 5/20/25 bed in low position with safety mat beside bed, initiated 2/26/25 bed wheels must be locked at all times, initiated 10/2/24 brake extenders with bright colored tape in place on wheelchair, initiated 2/10/25 and resolved 2/24/25 call light in reach. Explain use of it upon admission and reinforce as needed, initiated 10/2/24 check oxygen saturation frequently - utilize prn oxygen as needed, initiated 2/24/25 encourage resident to eat meals in the dining room, initiated 2/20/25 fall 2/19/25 intervention: eat all meals in dining room, initiated 2/19/25 fall 2/8/25 immediate intervention: scoop mattress on bed, initiated 2/10/25 fall 2/9/25 immediate intervention sent to Emergency Department (ED) for evaluation, initiated 2/10/25 monitor for changes in gait/positioning, initiated 10/2/24 notify Medical Doctor (MD) of changes in condition, imitated 10/2/24 notify therapy of changes in condition, initiated 10/2/24 Offer to transfer resident from wheelchair to recliner after meals, initiated 1/29/25 rear anti-tippers to wheelchair, initiated 2/21/25 remind to use walker and keep in reach, initiated 10/2/24 and resolved 2/4/25 safety mat to floor beside bed, initiated 2/4/25 and resolved 2/6/25 use overnight briefs to reduce wake times, initiated 10/2/24 Resident was observed in a Broda Chair during all days of the survey which was not included in the plan of care. The most recent Other Fall Risk Assessment prior to the fall, dated 2/8/25, indicated Resident 28 was a high risk to fall. An Occupational Therapy Evaluation and Plan of Treatment Note, for certification period 11/22/24 through 12/19/24, indicated resident goals were to improve transfers/ambulation and help patient be less restless. Patient demonstrates good rehab potential as evidenced by prior level of functioning (PLOF), stable medical status, able to follow one step instructions, strong caregiver/family support, and positive results from previous physical therapy treatment, signed 11/23/24. Progress Notes from admission to present indicated the resident was admitted walking with a walker. The resident was restless, repeatedly getting up on his own to transfer from wheelchair and required 1:1 supervision of staff at times despite staff education on safety, redirection, and antianxiety medications used as needed. On 10/10/24 at 11:08 A.M., a Care Plan Meeting Note indicated there was a meeting with staff and resident's wife. The note lacked discussion about the resident's behaviors of increased confusion, restlessness, and anxiety. No new interventions or recommendations were given. Fall 1 On 10/12/24 at 4:45 P.M., the resident had a witnessed fall getting up from chair in front of nurse's station. The Interdisciplinary Team (IDT) note, dated 10/14/24, indicated immediate intervention implemented after the fall was to have the resident in recliner when in the lobby by the nurse's station, unless family or friends were visiting. The Fall Care Plan was not updated with that intervention. Fall 2 On 10/16/24 at 6:59 A.M., the nurse was called to the resident's room by Certified Nurse Aide (CNA) for fall of resident from his bed onto his buttocks on the floor, near the foot of the bed. Immediate intervention for fall was to place cushion mat on the floor next to his bed. The clinical record lacked IDT notes following the fall. Fall 3 On 10/17/24 at 8:30 A.M., Nursing Note indicated resident was anxious sitting in wheelchair in lobby and had been up and down numerous times. Attention span was nil and would return to what he was doing almost instantly. The nurse was in the hallway passing medications, looked up, and saw the resident standing in front of the wheelchair. The nurse tried to get the resident to sit as she walked over but when the resident tried to sit in his wheelchair, the chair rolled. The resident was able to sit on the edge of the seat. He was not falling, but slid very slowly, controlling how fast he was sliding by using his feet to slow down, finally resting on his buttocks. He then turned and was going to move the chair, but the chair turned over. The clinical record lacked IDT notes following the fall. The Fall Care Plan was not updated with a new intervention put into place at that time. Fall 4 On 10/28/24 at 12:07 P.M., witnessed fall when the resident attempted to get up from the wheelchair in the lobby without assistance. He immediately sat down on the floor on buttocks. He was assisted to the wheelchair with two persons and the resident continued to attempt to stand up from the wheelchair repeatedly. The clinical record lacked IDT notes following the fall. The Fall Care Plan was not updated with a new intervention put into place at that time. Fall 5 On 12/12/24 at 5:23 P.M., unwitnessed fall while resident was sitting in wheelchair in lobby, set up to eat dinner, and tried to stand up unassisted. He slipped and fell on his left side. Neurological checks were initiated, according to the Neurological Checks Form given, every 15 minutes for the first hour, every 30 minutes for two hours, every two hours for 12 hours, every four hours for 12 hours, every eight hours for three days, then daily for four days. These were completed for the first hour after the fall. They were not completed again until 12/13/24 at 7:50 A.M (12 hours between). They continued according to protocol until 12/17/24 but lacked the last 3 days of monitoring. The clinical record lacked IDT notes following the fall. The Fall Care Plan was not updated with a new intervention put into place at that time. Fall 6 On 1/28/25 at 11:00 A.M., resident sitting in wheelchair at nurse's station, leaned forward, and had witnessed fall to the floor hitting left elbow on the edge of the desk causing 5 centimeter (cm) c shaped skin tear. IDT Note, dated 1/29/24, indicated the immediate intervention was to put the resident in the recliner. IDT recommended staff transfer resident out of wheelchair following meals and assist into recliner. The plan of care was updated to Offer to transfer resident from wheelchair to recliner after meals on 1/29/25. Fall 7 On 2/8/25 at 10:30 P.M., the resident had an unwitnessed fall out of his bed in his room. CNAs found the resident on the floor, halfway on the mat and halfway off, laying on his right side, with his head on the floor. The resident had a skin tear to the right elbow. The IDT Note, dated 2/11/25, indicated a new intervention was to put raised perimeter mattress to bed and the care plan was updated. Fall 8 On 2/9/25 at 5:40 P.M., the resident had a witnessed fall, leaned over in wheelchair in the lobby to pick something up off the ground, fell onto the floor striking his head on the floor and laying on his left hip. A Skin Tear was noted to the right hand and pain noted during assessment. Received orders from the physician to send to the Emergency Department (ED) for evaluation. The resident was diagnosed with an acute fracture to right hip/pelvis and subacute left hip fracture. The resident's wife and doctor agreed resident would not have surgery due to age and would come back to the facility with pain medication. The IDT Note, dated 2/11/25, indicated a new intervention was to put brake extenders with bright colored tape to wheelchair until anti-roll back device can be obtained. Fall 9 On 2/19/25 at 5:30 P.M., a nursing note indicated the resident had an unwitnessed fall from the wheelchair in the lobby. He was found sitting on his buttocks in front of the door beside the chair. The table with half eaten food was pushed away from chair. IDT note, dated 2/20/25, indicated a new intervention was to encourage the resident to eat all meals in the dining room. Fall 10 On 2/21/25 at 12:31 P.M., the nursing note indicated the resident was found on the floor in the lobby to the left side of his wheelchair. IDT note, dated 2/24/25, indicated that the resident was found to have low oxygen saturation when assessed by the nurse after the unwitnessed fall. Anti-roll back device was delivered in the afternoon of 2/21/24 and was immediately placed on wheelchair along with anti-tippers. IDT recommends staff check oxygen saturation every four hours and utilize PRN oxygen. No further recommendations at that time. Out of the 10 falls, 8 of them occurred when the resident was sitting in his wheelchair in the lobby. The intervention after the fall 1 was to have the resident sit in the recliner when in the lobby by the nurse's station, unless family or friends were visiting. That intervention was not implemented, and the resident fell seven more times from his wheelchair in the lobby, one of them causing an acute fracture to his right hip/pelvis and a subacute left hip fracture. IDT meetings to discuss the fall and plan of care were not held after all falls, root cause analysis was not found after all falls, new interventions were not implemented after all falls, and the plan of care for Resident 28 was not revised after the falls as indicated by the facility's policy. On 2/21/25, a Nurse Practitioner's Note indicated she saw the resident for routine visit. Staff reported no new concerns. Plan: continue current care for dementia and anxiety. On 2/22/25 at 10:58 P.M., a nursing note indicated the resident was sitting in the recliner in the lobby trying to lean over to pick up things that weren't on the floor. The resident was admitted to the hospice services. On 2/23/25 at 9:56 P.M., the nursing note indicated the resident was brought back from the dining room because he wouldn't stay seated and wouldn't eat while in the dining room. The resident was sitting beside the nurse at the nurse's station. On 2/26/25 at 10:28 A.M., an IDT Note indicated the resident was reviewed for falls. Care plan interventions were in place and no new recommendations were given at that time. During an interview on 5/21/25 at 12:00 P.M., the Director of Nursing (DON) indicated after a fall, the IDT should meet the next business day to discuss the plan of care and update the care plan interventions the same day as the meeting. On 5/22/25 at 10:45 A.M., Resident 28 was asleep sitting in a Broda chair in the east lobby. During an interview on 5/23/25 at 9:25 A.M., the Therapy Services Program Manager indicated Resident 28 was on their caseload initially as a rehab to home resident but after repeatedly falling and increased confusion, he had remained at the facility. During an interview on 5/23/25 at 10:02 A.M., the resident's wife indicated the resident had been in a Broda chair for the last 2-3 weeks and it has worked better for him. Before that, he would see something on the floor and thought he needed to pick it up or he would stand and fall. On 5/23/25 at 10:50 A.M., a current non dated Incidents/Accidents/Falls Policy was provided by the DON and indicated, . residents who have an unwitnessed fall must have neuro checks started and continued per policy . 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. Note: each fall needs a new intervention rolled out . 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 goals with appropriate interventions in place . On 5/23/25 at 10:50 A.M., a current non dated Neuro (Neurological) Checks Policy was provided by the DON and indicated, . always do neuro checks if the fall was unwitnessed by a staff member . vital signs and neurological signs are taken and recorded as follows: BP [blood pressure], pulse, and pupil checks q [every] 15 minutes x [for] 2 hours, BP, pulse, and pupil checks q 30 minutes x 2 hours, BP, pulse, and pupil checks q 60 minutes x 4 hours, complete vital signs and neurological checks q 8 hours x 16 hours, then continue vital signs and neurological checks q 8 hours until 72 hours have lapsed and resident is stable . On 5/23/25 at 10:50 A.M., a current Baseline Care Plan Assessment/Comprehensive Care Plans Policy, last revised 3/23/21, was provided by the DON and indicated, . The comprehensive Care Plan will further expand on the resident's risks, goals, and interventions using the 'Person-Centered' Plan of care approach . the Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . staff will attend the morning meetings where in-depth review of the 24 hour report since the prior morning meeting are reviewed and discussed as well as new or changed orders, new admissions, readmissions, falls and other pertinent circumstances regarding the residents. They will then see that the care plans for these residents are revised and updated as necessary . 3.1-45(a)

Based on interview and record review, the facility failed to provide at least 80 square feet (sq. ft) per resident in double occupancy rooms and 100 sq. ft. in single occupancy rooms. This was evidenced in 14 of 43 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: During an interview on 5/22/25 10:13 A.M., the Administrator indicated the facility had room size waivers. A list of rooms and sizes was provided and were as follows: 1. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 2. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 3. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 4. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 5. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 6. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 7. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 8. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 9. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 10. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 11. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 12. room [ROOM NUMBER]: 2 beds with 154.65 total sq. ft. SNF/NF and 77.32 sq. ft. per resident. 13. room [ROOM NUMBER]: 1 bed with 90.52 sq. ft. per resident, SNF/NF. 14. room [ROOM NUMBER]: 1 bed with 90.52 sq. ft. per resident, SNF/NF. 3.1-19(l)(2)

2. On 5/19/25 at 6:36 A.M., Resident 19's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, depression, and gastroesophageal reflux disease (GERD). The most recent Quarterly Minimum Data Set (MDS) assessment, dated 3/18/25, indicated a moderate cognitive impairment. Current physician orders included, but were not limited to: Gas-X extra strength 125mg (milligrams) twice a day, dated 4/1/25. Pantoprazole Sodium 40mg once daily for GERD, dated 4/22/24. Famotidine 40mg once daily for GERD, dated 4/22/24. Levothyroxine Sodium 25mcg (micrograms) once daily for low thyroid hormone, dated 4/22/24. Sodium Chloride 1gm (gram) three times a day for supplement, dated 4/7/25. Guaifenesin ER (extended release) 600mg twice a day for congestion, dated 4/22/25. Wellbutrin 100mg twice a day for depression, dated 4/22/25. The following doses of medication were marked blank on the April 2025 and May 2025 Medication Administration Record (MAR): Gas-X 125mg P.M. dose on 4/12/25. Pantaprozole Sodium 40mg on 4/12/25, 4/13/25, 4/26/25, 5/3/25, 5/5/25, and 5/9/25. Famotidine 40mg on 4/12/25, 4/13/25, 4/26/25, 5/3/25, 5/5/25, and 5/9/25. Levothyroxine Sodium 25mcg on 4/12/25, 4/13/25, 4/26/25, 5/3/25, 5/5/25, and 5/9/25. Sodium Chloride 1gm P.M. dose on 5/2/25. Guaifenesin ER 600mg P.M. dose on 5/2/25. Wellbutrin 100mg P.M. dose on 5/2/25. 3. On 5/21/25 at 1:07 P.M., Resident 30's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and diabetes mellitus. The most recent Quarterly MDS assessment, dated 4/11/25, indicated a severe cognitive impairment. Current physician orders included, but were not limited to: Metformin 500mg twice daily for diabetes mellitus, dated 12/3/24. Cipro 500mg twice daily for urinary tract infection, dated 5/1/25. The following doses of medication were marked blank on the April 2025 and May 2025 MAR: Metformin 500mg P.M. dose on 4/7/25 and 4/12/25. Cipro 500mg P.M. dose on 5/2/25. 4. On 5/20/25 at 12:57 P.M., Resident 9's clinical record was reviewed. Diagnosis included, but were not limited to, atrial fibrillation, osteoporosis, congestive hear failure, and depression. The most recent Quarterly MDS assessment, dated 5/13/25, indicated a severe cognitive impairment. Current physician orders included, but were not limited to: Amoxicillin-Pot Clavulanate 875-125mg twice daily for upper respiratory infection for 10 days, dated 1/17/25 through 1/27/25. The following doses of Amoxicillin were marked blank on the January 2025 MAR: 1/23/25 and 1/24/25 A.M. doses. On 5/22/25 at 10:31 A.M., Registered Nurse (RN) 3 indicated she was unsure what the blanks meant in the MAR. She indicated if a medication was not administered, there were codes to enter for the appropriate circumstance such as medication refused, progress note, in the hospital, etc. On 5/22/25 at 11:43 A.M., the Director of Nursing (DON) indicated she was unsure why the resident MARs were not marked as being administered. She indicated sometimes the computer did not save the entries in the MAR, and sometimes did not recognize the morning entries due to shift change. She indicated any number of things could have happened, but there's was no way to tell. On 5/22/25 at 1:35 P.M., the Regional Director of Operations provided a current Medication Administration policy, last revised 5/17/21, that indicated The resident's MAR is initialed by the person administering a medication 3.1-50(a)(1) 3.1-50(a)(2) Based on interview and record review, the facility failed to ensure accurate documentation for 4 of 11 residents reviewed for clinical record accuracy. Residents medications and treatments were left blank on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). (Resident 136, Resident 19, Resident 30, Resident 9) Findings include: 1. On 5/10/15 at 11:56 A.M., Resident 136's clinical record was reviewed. Diagnoses included, but was not limited to, encephalopathy and acute respiratory failure. The most recent Discharge Minimum Data Set (MDS) assessment, dated 5/8/25 indicated Resident 136's cognitive status was unable to be assessed and she had a tracheostomy. Current Physician's Orders included, but was not limited to: Trach: change inner cannula daily, start date 4/9/25 Trach care every shift, start date 4/9/25 The following doses of medication were marked blank on the April 2025 Treatment Administration Record (TAR): Inner cannula changed on dayshift on 4/16, 4/22, and 4/23 Trach care on nightshift on 4/15 and on dayshift on 4/16, 4/22, and 4/23 During an interview on 5/22/25 at 8:26 A.M., Registered Nurse (RN) 3 indicated the inner cannula and trach care should be performed every shift and documented on the TAR.

Based on interview and record review, the facility failed to ensure employment of kitchen staff with appropriate competencies and skills. The kitchen manager was not certified. (Kitchen Manager) Finding includes: On 5/19/25 at 5:50 A.M., the Kitchen Manager indicated she did not have a certification in food service. On 5/22/25 at 10:24 A.M., the Regional Dietary Manager indicated she was certified withy Servsafe, but no one else in the kitchen was yet. She indicated all kitchen staff had been registered to take the certification class on 6/20/25. On 5/22/25 at 1:35 P.M., the Regional Director of Operations provided a current non-dated Dietary Manager Orientation policy that indicated The Dietary Manager shall receive appropriate orientation and training 3.1-20(e)

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 of 2 residents reviewed for dementia care. A resident with dementia that was a high risk to fall was not kept active resulting in increased restlessness and multiple falls. (Resident 28) Finding includes: On 5/19/25 at 8:51 A.M., Resident 28 was observed sitting in a Broda chair (specialized seating system) in the East Hall lobby in front of the television, hands empty, and trying to pull on his blanket. On 5/20/25 at 9:51 A.M., Resident 28 was observed sitting in a Broda chair in the East Hall lobby in front of the television, hands empty, and trying to pull on his blanket. On 5/22/25 at 10:45 A.M., Resident 28 was observed asleep sitting in a Broda chair in the East Hall lobby. On 5/22/25 at 11:16 A.M., Activities staff was observed notifying residents by room of activity but walked past resident seated in lobby without asking if he wanted to join. On 5/21/25 at 2:15 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with agitation, anxiety, depression, unsteadiness on feet, and generalized muscle weakness. Resident 28 was admitted to the facility on [DATE]. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident 28's cognition was severely impaired, had two or more falls, one with major injury, since the last Quarterly MDS assessment, dated 12/9/24, was partial to moderate assist (staff performs less than half the effort) for bed mobility and eating, substantial to maximum assist (staff performs more then half the effort) for transfers and showering, and totally dependent on staff for showering, on hospice, and receiving an antianxiety and antidepressant medication. The Activity assessment of the MDS identified his likes included music, animals, current events/news, group activities, go outside, religious services, and that doing his favorite activities was important to him. A current Dementia Care Plan, last revised 10/2/24, indicated the resident should be observed for signs and symptoms of increased confusion and complications related to dementia. A current Activities Care Plan, last revised 3/4/25, indicated the resident may be used to a different daily routine. He has a lot of interests like pet visits, exercise, playing games, keeping up with the news, watching TV and going outside. Interventions, all initiated 10/17/24, included: review the monthly calendar with the resident and ask where he/she would like it placed in their room so they may refer to it at their convenience introduce the resident to peers seated near them during activities and meals. Promote discussion and interaction by asking open-ended questions about interests, significant times in history, the old neighborhood, school days, holidays, etc assist during adjustment try to meet needs in timely manner allow to passively observe to familiarize self with activity program The most recent Quarterly Activity Progress Note, dated 4/4/25, indicated Resident 28 had been very active and he really used to enjoy activities but he doesn't come much anymore. He would love going outside and he enjoyed other things. Progress Notes from admission to 5/20/25 indicated Resident 28 mostly sat in the lobby (common area) of East Hall by the nurse's station, was very spontaneous with getting out of chair without assistance, very confused, and unable to redirect despite use of PRN (as needed) antianxiety medication, requiring 1:1 staff supervision at times. He attempted to pick up things that weren't there on the floor, staff was unable to understand speech as it was garbled most of time, and the resident needed constant reminders but seemed unable to comprehend what was being said to him in regards to his safety and included, but were not limited to the following notes: On 11/18/24 at 2:45 P.M., Nursing Note indicated resident's wife was requesting physical therapy for the resident so that he can go on walks because it would wear him out. She thought that would prevent him from having to take Ativan as often as he was. Resident 28 experienced 10 falls from 10/12/2024 through 2/21/25, eight of them taking place in the lobby area on the East Hall by the nurse's station, and one resulting in resident going to the Emergency Department (ED) for evaluation. After the fall the resident was diagnosed with acute fracture to right hip/pelvis and subacute left hip fracture. A Physical Therapy Evaluation Note, dated 11/22/24, indicated Per EMR [Electronic Medical Record]review . He has been more unsteady on his feet and due to his attempts to stand/amb [ambulate] on his own nsg [nursing] has administered Ativan, 1-2 times a day . Today, during eval [evaluation], pt [patient] appeared sedated [with Ativan given last night], but he was able to follow one step instructions . requested PT eval [physical therapy evaluation] to increase patient's activity to reduce his episodes of restlessness . pt presents with recent functional decline, coinciding w/recent and significant wt [weight] loss and the increased administration of Ativan, with adverse side effects . during the eval today, pt was drowsy/sedated. He tired quickly w/assessment. He was unable to tolerate gait/balance testing in standing. Significant atrophy was noted at trunk and extremities consist with inactivity . During an interview on 5/23/25 at 9:23 A.M., the Activities Director indicated Resident 28 participated in the ball and parachute games and liked the move and groove activity. She indicated she had been employed at the facility for approximately three weeks so she was unsure of what he did prior to that. She would like to implement more activities to engage dementia residents such as fidget blankets and sensory activities. During an interview on 5/23/25 at 9:23 A.M., the Director of Nursing (DON) indicated they were not doing anything special for dementia residents that she's aware of. During an interview on 5/23/25 at 10:00 A.M., any psychological consultations the resident had were requested from the Director of Nursing (DON). She indicated if he had any, she would bring them. These were not provided during the duration of the survey. She indicated she was unsure if the resident was able to voice that he refused activities, but he should be offered to go and/or provided with some that interested him. During an interview on 5/23/25 at 10:02 A.M., the resident's wife indicated the resident had been in a Broda chair for the last 2-3 weeks and it has worked better for him. Before that, he would see something on the floor and thought he needed to pick it up or he would stand and fall. During an interview on 5/23/25 at 10:25 A.M., the Therapy Services Program Manager indicated Resident 28 was on their caseload from 10/3/24 through 10/14/24 and was admitted as rehab to home so originally was on physical therapy and occupational therapy (PT/OT) caseload with end goal of going home. He was put on caseload again 11/22/24 through 12/19/24, PT only, due to a fall. At that time, he was more confused and trying to get up a lot. She did work with him personally, and indicated prior to coming to the facility, he had been a construction worker and was always busy. At the facility now, he was fidgeting around and trying to get up due to what she believed was boredom, not anxiousness because if you were talking with him or doing an activity with him 1:1, he was content. He got bored just sitting there. On 5/23/25 at 10:50 A.M., a current Guidelines for Caring for Residents with Alzheimer's and/or Dementia Policy, dated 11/20/24, was provided by the DON and indicated, . This need for assistance is often upsetting and frustrating to these people/residents. It is important to properly address these concerns early on . Plan activities that the person/resident enjoys and try to these activities at approximately the same time each day . Allow the person/resident to keep as much control of their life as possible as far as self participation in their care and making choices and having their preferences honored . speak with them, not at them . Finding ways to keep these people/residents active can become more challenging . Try to do group activities. Add music to activities. videos of various activities can be entertaining . Sitting in a room alone can be conducive to loneliness, isolation, and depression. These people/residents should be evaluated for 1:1 activities as indicated and this should be care planned . The care plan for those with Alzheimer's or dementia must be person-centered and must address concerns associated with any diagnoses, cognitive and/or physical deficits, medication, nutrition/diet/hydration, activities, any related special programming, any psych services to include and behavioral issues or any sleep issues, ADLs [Activities of Daily Living], safety [to include fall risk], skin issues, advanced directives, and any other concerns which are discovered . it is recommended that the care plan includes activities that help the patient/resident stay in touch with their pre-dementia lives . 3.1-37(a)

Based on interview and record review, the facility failed to ensure an accurate assessment of resident status for 3 of 11 residents reviewed for MDS (Minimum Data Set) assessment accuracy. Preadmission screening, antibiotic use, and UTI (urinary tract infection) diagnoses were incorrectly coded. (Resident 6, Resident 4, Resident 9) Findings include: 1. On 5/20/25 at 9:05 A.M., Resident 6's clinical record was reviewed. The most recent Annual Minimum Data Set (MDS) assessment, dated 1/31/25, indicated a level 2 PASRR (Preadmission Screening and Resident Review) had not been completed for the resident. A level 2 PASRR was completed on 3/7/24. 2. During an interview on 5/19/25 at 10:55 A.M., Resident 9's family member indicated Resident 9 has had several urinary tract infections (UTI's) since she had been in the facility. On 5/20/25 at 11:57 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but was not limited to, osteoporosis and and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 5/13/25, indicated Resident 9 was cognitively impaired and did not have a UTI in the last 30 days. Physicians Orders included, but was not limited to, Macrobid 100 milligrams (mg), give 1 capsule two times a day by mouth for a UTI, completed 5/8/25. 3. On 5/21/25 at 8:11 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but was not limited to, hypertension and hyperlipidemia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 4/18/25, indicated Resident 4 was cognitively intact and received an antibiotic during the 7 day look back period. Resident 4's Physician's Orders for the 7 day look back period lacked an order for an antibiotic. During an interview on 5/22/25 at 12:46 P.M., the MDS Coordinator indicated the order was for a UTI, but she did not code UTI on the MDS for Resident 9, the PASRR level 2 should have been indicated on the MDS for Resident 6, and the antibiotic was coded in error for Resident 4. During an interview on 5/22/25 at 12:51 P.M., the MDS Coordinator indicated she used the Resident Assessment Instrument (RAI) manual as the facility's policy.

Based on observation, interview, and record review, the facility failed to ensure a resident's medication regimen was free from chemical restraints for 1 of 5 residents reviewed for unnecessary medications. A resident's confusion increased after initiating Zoloft (antidepressant also used to control anxiety) and Ativan (antianxiety). Staff documented administering Ativan was ineffective for controlling the resident's restlessness and anxiety, the resident was given additional doses. (Resident 28) Findings include: On 5/19/25 at 8:51 A.M., Resident 28 was observed sitting in a Broda chair (specialized seating system) in the East Hall lobby in front of the television, hands empty, and trying to pull on his blanket. On 5/20/25 at 9:51 A.M., Resident 28 was observed sitting in a Broda chair in the East Hall lobby in front of the television, hands empty, and trying to pull on his blanket. On 5/22/25 at 10:45 A.M., Resident 28 was observed asleep sitting in a Broda chair in the East Hall lobby. On 5/21/25 at 2:15 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with agitation, anxiety, depression, unsteadiness on feet, and generalized muscle weakness. Resident 28 was admitted to the facility on [DATE]. The admission Minimum Data Sheet (MDS) assessment, dated 10/7/24, indicated Resident 28's cognition was severely impaired, had not had any falls in 6 months prior, was partial to moderate assist (staff performs less than half the effort) for bed mobility and eating, substantial to maximum assist (staff performs more than half the effort) for transfers and showering, and totally dependent on staff for showering, and receiving an antianxiety and antidepressant medication. The most recent Significant Change MDS assessment, dated 3/6/25, indicated Resident 28's cognition was severely impaired, had two or more falls, one with major injury, since the last Quarterly MDS assessment, dated 12/9/24, was partial to moderate assist (staff performs less than half the effort) for bed mobility and eating, substantial to maximum assist (staff performs more than half the effort) for transfers and showering, and totally dependent on staff for showering, on hospice, and receiving an antianxiety and antidepressant medication. Physician's Orders included, but were not limited to, the following: 10/2/24 May receive counseling/medication management services as needed 10/2/24 May receive services of psychiatrist and any other specialist as deemed necessary 10/5/24 Zoloft 25 milligram (mg), give one tablet by mouth in the evening for depression 2/2/25 Behavior monitoring every shift for resisting care/medications, sleep difficulties, anxiety, depressive symptoms 10/5/24 Ativan 0.5 mg, give one tablet by mouth every 12 hours PRN (as needed) for anxiety for 14 days and discontinued 10/19/24 10/23/24 Ativan 0.5 mg, give one tablet by mouth BID (twice daily) PRN for behaviors and discontinued 3/31/25 10/24/24 Ativan 0.5 mg, give one tablet by mouth daily at 1:00 P.M. for behaviors and discontinued 3/31/25 2/22/25 Ativan 0.5 mg, give one tablet every 30 minutes as needed for anxiety or restlessness and discontinued 3/31/25 4/1/25 Ativan 0.5 mg, give one tablet by mouth every 12 hours for behaviors and discontinued 4/11/25 4/11/25 Ativan 0.5 mg, give one tablet by mouth every six hours for behaviors and discontinued 5/9/25 5/9/25 Ativan 0.5 mg, give one tablet by mouth two times a day for behaviors 5/19/25 Ativan 0.5 mg, give one tablet by mouth every 30 minutes PRN for increased anxiety or terminal restlessness for 14 days A current Anxiety Care Plan, initiated and last revised 2/4/25, included, but was not limited to, the following interventions: give antianxiety medications ordered by physician, observe for side effects, refer concerns/changes to Medical Doctor (MD) PRN, and refer to psych services PRN. The resident is taking antianxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. The Anxiety Care Plan did not include resident specific interventions to try for anxiety, restlessness, shortness of breath, or unspecified behaviors before oral medication was administered. The clinical record lacked documentation of Resident 28 having a thorough assessment with a mental health professional. The Medication Administration Record (MAR) from 10/2/24 through 10/31/24 indicated Resident 28 received 14 PRN doses of Ativan 0.5 mg. Of those 14 doses, six doses were documented as ineffective for controlling the resident's anxiety. The MAR from 11/1/24 through 11/30/24 indicated Resident 28 received 29 doses of PRN Ativan 0.5 mg. Of those, one dose was documented as ineffective for controlling behaviors (unspecified) The MAR from 12/1/24 through 12/31/24 indicated Resident 28 received 25 doses of PRN Ativan 0.5 mg. Of those, six doses were documented as ineffective for controlling his behaviors (unspecified). The MAR from 1/1/25 through 1/31/25 indicated Resident 28 received 18 doses of PRN Ativan 0.5 mg. Of those, four doses were documented as ineffective for controlling his behaviors (unspecified). The MAR from 10/24/24 through 3/31/25 for routine Ativan 0.5 mg dose daily at 1:00 P.M. was not routinely assessed for effectiveness of the medication to control behaviors (unspecified). The MAR from 10/5/24 through the survey date Zoloft 25 mg daily at bedtime was not routinely assessed for effectiveness of the medication to control depression. Progress notes as follows: On 10/4/24 at 12:15 P.M. Physician/Practitioner Progress Note indicated the resident was sitting in the common area. Staff reported increased episodes of agitation with exit seeking behavior at times. Reviewed Veteran's Affairs (VA) Note dated August 2024. He was screened for depression, was positive, but medication was not started. Plan: Dementia with behavior/agitation: start Zoloft 25 mg at bedtime, Ativan 0.5 mg BID PRN x 14 days. On 10/8/24 at 5:24 P.M, a Medication Administration Note indicated Ativan 0.5 MG Give 1 tablet by mouth every 12 hours as needed for anxiety was ordered. The Resident is pacing halls. Won't sit still. On 10/10/24 at 11:08 A.M., Care Plan Meeting Note: A meeting was held with staff and resident's wife. The note lacked discussion on new medications ordered and about the resident's behaviors. No new interventions or recommendations were given. On 10/11/24 at 3:13 P.M., the Nursing Progress Note indicated the resident's wife had voiced concern that resident was more tired and not having coherent conversations. On 10/30/24 at 10:16 A.M. the Nurse Practitioner Visit Note indicated the resident had been up out of chair walking without assistance or walker and redirected multiple times by staff. Due to resident's difficulty to control impulse to get out of chair and anxiety, Ativan 0.5 mg daily at 1:00 P.M. was added to the PRN Ativan and Zoloft was continued. On 11/1/24 at 6:55 P.M., a Nursing Progress Note indicated resident had been up and down and had received PRN and routine Ativan. The resident was with activities 1:1 until the activities employee got off work and then seated in the lobby where staff had to attend to resident standing every few seconds. The Ativan administered was ineffective. Progress Notes from admission to 5/20/25 indicated Resident 28 mostly sat in the lobby (common area) of East Hall by the nurse's station, was very spontaneous with getting out of chair without assistance, very confused, and unable to redirect despite use of PRN antianxiety medication, requiring 1:1 staff supervision at times. He attempted to pick up things that weren't there on the floor. Unable to understand speech as it was garbled most of time. Needed constant reminders but seemed unable to comprehend what was being said to him in regard to his safety. A Physical Therapy note, dated 11/22/24 (no time recorded), indicated Resident had been more unsteady on his feet and due to attempts to stand/ambulate on his own nursing had administered Ativan, 1-2 times a day. The note indicated the resident was drowsy, sedated, and presented with a recent functional decline related to adverse effects from increased administration of Ativan. During an interview on 5/23/25 at 10:25 A.M., the Therapy Services Program Manager indicated Resident 28 was on their caseload from 11/22/24 through 12/19/24, due to a fall. At that time, he was more confused and tried to get up a lot. She indicated the resident was fidgeting around and trying to get up due to what she believed was boredom, not anxiousness. On 5/23/25 at 10:00 A.M., the Director of Nursing indicated she would request any psychological consultations for the resident. She was unable to provide any requests or service notes during the duration of the survey. On 5/23/25 at 11:27 A.M., the DON indicated the Resident 28's Zoloft dosage was not adjusted due to the Ativan being adjusted instead related to the behaviors. At that time, she indicated Side effect/behavior monitoring should have been documented every shift on the Medication or Treatment Administration Record (MAR/TAR). Behavior monitoring had not been consistently completed prior to the order starting date on 2/2/25. On 5/23/25 at 10:50 A.M., a current Guidelines for Psychotropic Medication Policy, dated 6/5/23, was provided by the DON and indicated, . Residents will not receive psychotropic medications unless other types of interventions have been attempted to meet the resident's targeted behavioral goals and have failed. These include Behavioral Programming, by a trained Behavioral Therapist . The objective is to ensure that the drug regimen of the residents is monitored and managed to promote and then to maintain each resident's highest practicable mental, physical and psycho-social well-being . Psychotropic medications may be used to treat an enduring condition . Not due to environmental stressors alone [e.g., alteration in the resident's customary location or daily routine, unfamiliar care provider] . Not due to psychological stressors alone [e.g., loneliness], anxiety or fear stemming from misunderstanding related to his/her cognitive impairment . 3.1-3(w) 3.1-48(a)

Based on observation, interview, and record review, the facility failed to ensure staffing sheets were posted for the correct day for 5 of 5 days during the survey. Findings include: During an observation on 5/19/25 at 5:40 A.M., the posted nurse staffing sheet by the front door was dated 5/16/25. At that time, the posted nurse staffing sheet, dated 5/18/25, was viewed on the back hallway that did not have resident's on the hall. During an observation on 5/19/25 at 7:02 A.M., the posted nurse staffing sheet by the front door was dated 5/16/25. During an observation on 5/20/25 at 8:57 A.M., the posted nurse staffing sheet by the front door was dated 5/19/25. During an observation on 5/21/25 at 8:00 A.M., the posted nurse staffing sheet by the front door was dated 5/20/25. During an observation on 5/22/25 at 8:09 A.M., the posted nurse staffing sheet by the front door was dated 5/21/25. During an observation on 5/23/25 at 8:01 A.M., the posted nurse staffing sheet was dated 5/22/25. During an interview on 5/19/25 at 7:03 A.M., the Director of Nursing (DON) indicated the first shift started at 6:00 A.M. During an interview on 5/23/25 at 8:19 A.M., the Scheduler Coordinator indicated posted nurse staffing is posted at 8:00 A.M. every morning at the front door and the back door. The current day should be posted. At that time, she further indicated staff does not post the posted nurse staffing sheets on the weekends. On 5/23/25 at 9:00 A.M., the DON provided a current Guidelines for Benefits Improvement Protection Act (BIPA) Staffing Posting Requirement, dated 7/24/24 that indicated, It is the policy of the facility .to comply with the requirement of daily posting of nursing staff in the facility .must post daily, at the beginning of each shift .

Based on interview and record review, the facility failed to ensure services were provided to prevent the development of pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. A resident's plan of care was not developed with interventions to prevent new pressure from developing after the resident was assessed to be at risk for pressure, and no documentation in the resident's record indicated the resident was turned or repositioned in accordance with physician orders. (Resident D) Findings include: During record review on 2/3/25 at 10:30 A.M., Resident D's diagnoses included, but were not limited to weakness, Parkinson's disease, unspecified abnormalities of gait and mobility, type 2 diabetes, dementia, and urge incontinence. Hospice started when? admitted ? discharge date ? Resident D's most recent admission Minimum Data Set (MDS) assessment, dated 11/27/24, indicated the resident was admitted to the facility with one unhealed Stage I pressure ulcer. (According to the National Pressure Injury Advisory Panel [NPIAP], a Stage I pressure ulcer is defined as: The skin is intact with nonblanchable erythema.) Resident D had moderate cognitive impairment, utilized a wheelchair for mobility, was dependent on two staff for transfers, and required partial assistance to roll from right to left in bed. A Braden scale assessment (tool used to predict the risk for developing pressure ulcers), completed 11/22/24, indicated Resident D was at low risk for developing pressure ulcers. Resident D's physician orders included, but were not limited to, turn and reposition every two hours and as needed (started 11/23/24). A Braden scale assessment, completed 11/30/24, indicated Resident D was at moderate risk for developing pressure injuries. A weekly wound assessment note, dated 12/13/24, indicated Resident D had no skin impairment and no wounds. Resident D's care plan included, but was not limited to, Skin integrity impairment (initiated 1/22/25) due to right heel and coccyx ulcer (revised 1/27/25). Resident D's care plan did not include a focus on the resident's risk for developing pressure ulcers following the Braden scale assessment on 11/30/24, nor did it include interventions to prevent the development of pressure ulcers prior to 1/22/25. Resident D's initial wound note dated 1/22/25 indicated Resident D had a new Stage II wound to the right heel that measured 5 cm x 4 cm x 0.1 cm. Resident D's progress notes included, but were not limited to: 1/23/25 at 1:17 P.M. - New pressure area noted to right heel on 1/22/25 by licensed nurse, during care. 1/25/25 at 12:49 P.M. - Resident has an area to the coccyx. A right-side blister measured 4.2 centimeters (cm)(length) x 6 cm (width). A left-side discolored area measured 4.9 cm x 4.3 cm. 1/28/25 at 3:31 P.M. - (Skin and wound note) - Resident was evaluated for a stage II pressure ulcer to right heel and an unstageable pressure ulcer to bilateral buttock. Education on the importance of frequent turns while in bed and frequent repositioning while in chair was provided. (According to the NPIAP a Stage II pressure ulcer is defined as: partial-thickness skin loss involving the epidermis and dermis. An unstageable pressure ulcer is obscured by slough or eschar which makes depth and extent of tissue damage unable to be determined.) Resident D's wound assessment report, dated 1/28/25, indicated the following: An unstageable pressure ulcer to the bilateral buttock measured 11 cm x 9.5 cm x 0.1 cm (depth). The wound bed was covered by 80% epithelial tissue and 20% slough. Peri wound was intact, fragile, macerated with edema and erythema (redness and swelling). A moderate amount of serosanguineous exudate was present. A stage II pressure ulcer to the right heel measured 4.5 cm x 6 cm x 0.1 cm. The wound bed was covered by 100% epithelial tissue. Peri wound was intact, fragile, and dry. No drainage was present. A review of Point of Care (POC) CNA charting for the month of January 2025 included documentation that Resident D had been turned and repositioned every two hours starting 1/27/25. No documentation of routine turning and repositioning was found in Resident D's record during the month of January 2025 prior to 1/27/25. During an interview on 2/3/25 at 11:15 A.M., LPN 4 indicated she was working as an aide and that the CNA's should document routine turning and repositioning. During an interview on 2/3/25 at 11:25 A.M., the Director of Nursing (DON) indicated that a change from low risk to moderate risk for developing pressure ulcers would typically trigger an update to the resident's care plan that would include interventions to prevent the development of pressure ulcers. On 2/3/25 at 2:40 P.M., the DON supplied a facility policy titled, International Guideline (Prevention and Treatment Pressure Ulcers/Injuries: Clinical Practice Guidelines), dated 10/9/23. The policy included, .Risk Assessment - A risk Assessment is considered the starting point for prevention of pressure injury . an 'at risk' resident can develop a pressure injury within hours of the onset of pressure. For this reason, the 'at risk' resident must be identified, and have specific interventions put promptly in place and care planned in an effort to prevent formation of pressure injury . Positioning and Mobilization . Turn and reposition resident who are 'at risk' for pressure injury often unless contraindicated. At least every 2 (two) hours is recommended . This citation relates to complaint IN00452313. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received food at safe and appetizing temperatures for 1 of 1 meal trays tested for taste and temperature of food. Finding includes: During an observation on 1/23/25 at 7:19 A.M., staff was pushing the enclosed meal tray cart from the kitchen to the [NAME] Hall. During an observation on 1/23/25 at 7:31 A.M., staff was passing the last meal tray for the hall. At that time, a meal tray was obtained to test for the taste and temperatures of the food. The scrambled eggs tested 89.0 degrees Fahrenheit and felt cold. The bacon tested at 76.3 degrees Fahrenheit and felt cold. During an interview on 1/23/25 at 8:06 A.M., Resident H indicated the temperature and variety of food was an ongoing problem. During an interview on 1/23/25 at 8:12 A.M., Resident F indicated the breakfast served to them this morning was barely warm. During an interview on 1/23/25 at 8:19 A.M., Resident J indicated the food was going downhill from when they were first admitted . Meals were either cold, overdone, or raw in the middle. Resident grievances from November 1, 2024 to present were reviewed and indicated the following: On 11/4/24, two residents were upset about lunch served. Chicken was not cooked all the way. During an interview on 1/23/25 at 10:36 A.M., the Administrator indicated she would expect all meals to be served at correct temperatures. On 1/23/25 at 11:40 A.M., a non dated current Food Temperature Policy was provided by the Administrator and indicated, Hot Food: . Hold at 135 degrees Fahrenheit or greater throughout the service process . This citation relates to complaint IN00451740. 3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 4 of 4 residents reviewed for pharmacy services. After the facility's contracted pharmacy failed to deliver routine medications, residents missed multiple prescribed daily medications. (Resident B, Resident C, Resident D, Resident F) Findings include: 1. During an interview on 1/9/25 at 10:45 A.M., Resident B indicated that he typically receives his ordered medications, but that there was an issue with some of the medications during a recent winter storm. During an interview on 1/9/25 at 11:00 A.M., Registered Nurse (RN) 6 indicated that there was an issue with the facility's contracted pharmacy delivery some of the resident's routine medications a few days prior and that resident went about a day without some of their medications. During record review on 1/9/25 at 11:20 A.M., Resident B's diagnoses included but were not limited to, acquired absence of leg above knee, hypertension, and congestive heart failure. Resident B's physician orders included, but were not limited to, furosemide 20 milligrams (mg) one time a day (started 12/28/24), potassium chloride extended release (ER) 10 milliequivants (mEq) one time a day (started 12/28/24), pravastatin sodium 80 mg one time a day (started 12/28/24), rivaroxaban 10 mg one time a day (started 12/28/24), and carvedilol 6.25 mg two times a day (started 12/27/24). Resident B's Medication Administration Record (MAR) for January 2025 indicated the resident did not receive the prescribed medications; furosemide 20 mg, potassium chloride ER 10 mEq, pravastatin sodium 80 mg, rivaroxaban 10 mg, and one dose of carvedilol 6.25 mg on 1/7/25. Resident B's nurse's progress notes indicated the following on 1/6/25 at 7:21 A.M.: (Blanket note affecting facility) Pharmacy notified nurse around midnight last night that they had canceled the run of medications due to the plane that delivers from their facility being canceled due to weather. This nurse asked what that meant for the medication rolls that were suppose to come during the night for medications on 1/6/25. At this time residents do not have any rolls of routine medication. Pharmacy indicated best they could do is try to get a driver to volunteer to make the drive but since they are under a state of emergency they don't have to work. Facility asked for an arrival time for medications as residents had no medication at all. All medications that can be, will be pulled from emergency kit in facility but not all medications are available and quantities are limited. 2. During record review on 1/9/25 at 11:30 A.M., Resident C's diagnoses included, but were not limited to, hypertension, hyperlipidemia, hypercholesterolemia, and heart disease. Resident C's physician orders included, but were not limited to, aspirin 81 mg one time daily (started 12/12/24), atorvastatin calcium 40 mg once daily (started 12/12/24), and losartan potassium 100 mg one time daily (started 8/29/24). Resident C's MAR for January 2025 indicated the resident did not receive the prescribed medications; aspirin 81 mg, atorvastatin calcium 40 mg, and losartan potassium 100 mg on 1/7/25. 3. During record review on 1/9/25 at 11:40 A.M., Resident D's diagnoses included, but were not limited to, muscle weakness, arthritis, low back pain, major depressive disorder, hypertension, urge incontinence, and chronic pain. Resident D's physician orders included, but were not limited to, ascorbic acid 500 mg one time daily (started 8/13/24), aspirin 81 mg one time a day (started 8/13/24), cetirizine hydrogen chloride (HCl) 10 mg one time daily (started 8/13/24), dilitiazem HCl ER 300 mg one time a day (started 8/13/24), duloxetine HCl delayed release particles 30 mg one time a day (started 8/13/24), duloxetine HCl delayed release particles 60 mg one time a day (started 8/13/24), fexofenandine HCl 180 mg one time a day (started 8/13/24), fluticasone propionate suspension 50 micrograms (mcg) 1 spray in each nostril one time a day (started 8/13/24), montelukast sodium 10 mg one time a day (started 8/12/24), omeprazole delayed release 20 mg (started 8/13/24), tamsulosin HCl 0.4 mg one time a day (started 8/10/24), tizanidine HCl 2 mg one time a day (started 8/26/24), and guaifenesin ER 1200 mg two times a day (started 8/12/24). Resident D's MAR for January 2025 indicated the resident did not receive the prescribed medications; ascorbic acid 500 mg on 1/7/25, aspirin 81 mg on 1/6/25 and 1/7/25, cetirizine HCl 10 mg on 1/6/25 and 1/7/25, dilitiazem HCl ER 300 mg on 1/6/25, duloxetine HCl delayed release particles 30 mg on 1/6/25, duloxetine HCl delayed release particles 60 mg on 1/6/25 and 1/7/25, fexofenandine HCl 180 mg on 1/6/25, fluticasone propionate suspension 50 mcg 1 spray in each nostril on 1/6/25, montelukast sodium 10 mg on 1/6/25, omeprazole delayed release 20 mg on 1/7/25, tamsulosin HCl 0.4 mg on 1/7/25, tizanidine HCl 2 mg on 1/6/25, and one dose of guaifenesin ER 1200 mg on 1/6/25. 4. During record review on 1/9/25 at 11:55 A.M., Resident F's diagnoses included but were not limited to, anxiety, atrial fibrillation, depression, hypertension, hypothyroidism, muscle weakness, Parkinson's disease, and gastro-esophageal reflux disease. Resident F's physician orders included but were not limited to, amiodarone HCl 200 mg one time a day (started 11/23/24), aspirin 81 mg one time a day (started 11/23/24), duloxetine HCl delayed release 30 mg one time a day (started 11/23/24), levothyroxine 50 mcg one time a day (started 11/23/24), magnesium oxide 400 mg one time a day (started 11/23/24), sennosides-docusate sodium 8.6-50 mg one time a day (started 11/23/24), rivastigmine tartrate 3 mg two times a day (started 11/23/24), buspirone HCl 5 mg three times a day (started 12/10/24), hydralazine HCl 25 mg three times a day (started 11/22/24), and carbidopa-levodopa 25-100 mg four times a day (started 11/22/24). Resident F's MAR for January 2025 indicated the resident did not receive the prescribed medications; amiodarone HCl 200 mg on 1/7/25, aspirin 81 mg on 1/6/25 and 1/7/25, duloxetine HCl delayed release 30 mg on 1/6/25 and 1/7/25, levothyroxine 50 mcg on 1/6/25 and 1/7/25, magnesium oxide 400 mg on 1/6/25 and 1/7/25, sennosides-docusate sodium 8.6-50 mg on 1/7/25, rivastigmine tartrate 3 mg two doses on 1/6/25 and one dose on 1/7/25, buspirone HCl 5 mg three doses on 1/6/25 and one dose on 1/7/25, hydralazine HCl 25 mg three doses on 1/6/25 and one dose on 1/7/25, and carbidopa-levodopa 25-100 mg one dose on 1/7/25. On 1/9/25 at 12:30 P.M., the facility's Facility Assessment, dated 1/1/24, indicated, .Resident support/care needs 2.1 List the types of care that your resident population requires and that you provide for your resident population . Medications . On 1/9/25 at 12:35 P.M., the facility emergency preparedness binder was reviewed. An undated document titled, Services Facility Can Provide in an Emergency Event, Continuity of Operations to Collaborators included, .Medications . Awareness of any limitations of administering medications . Administration of medications that residents need . On 1/9/25 at 1:15 P.M., the Facility Administrator supplied a facility policy titled, [Pharmacy Name] Policy and Procedure Manual 2023. A policy titled, 1.5 Pharmacy Services, dated 03/2023 indicated, An agreement is executed between authorized representatives of the facility and [Pharmacy] . [Pharmacy] agrees to perform the following pharmaceutical services, in addition to others that may be stipulated in the agreement: .providing medications packaged in accordance with the facility's needs and equipment requirements . Providing routine and timely pharmacy service 7 days per week and emergency pharmacy service 24 hour per day, seven days per week . This citation relates to complaint IN00450691. 3.1-25(a)

Based on interview and record review, the facility failed to employ a qualified Infection Preventionist. The full time Director of Nursing was also completing the Infection Preventionist duties. Finding includes: On 4/3/24 at 1:19 P.M., the Director of Nursing (DON) indicated she was the facility's appointed Infection Preventionist (IP). On 4/5/24 at 10:08 A.M., the DON indicated although she was a full time DON, about 8 hours had been spent earlier in the week on IP duties. At that time, she indicated the amount of hours dedicated to IP duties fluctuated depending on the amount of infections in the facility, and sometimes would stay over her usual hours. Hours spent on DON and IP specific duties were not documented. On 4/1/24 at 2:40 P.M., a current non-dated Infection Prevention and Control policy was provided and indicated There will be an appointed person to spearhead the Infection Prevention and Control Program. This person will be a licensed nurse, usually the DON or ADON [Assistant Director of Nursing] On 4/5/24 at 11:48 A.M., a current non-dated Infection Control job description was provided and indicated the Infection Preventionist reported to the DON.

Based on interview and record review, the facility failed to ensure the food service department was directed by a supervisor competent in food service management and knowledgeable in sanitation standards and food handling for 1 of 1 dietary managers reviewed. The dietary manager was not certified. (Dietary Manager) Finding includes: On 4/1/24 at 8:53 A.M., the Dietary Manager's certification and/or qualifications were requested. Employee records were provided and indicated the Dietary Manager's start date was January of 2023. During an interview on 4/4/24 at 8:00 A.M., the Administrator indicated the Dietary Manager was not certified but was enrolled in a class that started in November of 2023 and a goal completion date of November of 2024. On 4/5/24 at 10:43 A.M., the Administrator indicated there was not a policy for the Dietary Manager position requirements, but provided a current Dietary Director Job Description, dated 1/29/24, as a policy which indicated . education/experience: . be a graduate of an accredited course in dietetic training, approved by the American Dietetic Association . must be registered as a Food Service Director in this state . 3.1-20(h)

Based on interview and record review, the facility failed to ensure staff were completed with the CNA (Certified Nursing Aide) training program and evaluation within 4 months of their hire date for 5 of 5 staff that completed the CNA training program at the facility. The facility lacked information and supplies related to the CNA training program. Findings include: 1. A list of staff that had completed the CNA training program at the facility was provided by the Administrator on 4/2/24 at 11:30 A.M., and indicated the following: On 4/3/24 at 9:47 A.M., employee records were reviewed. Nurse Aide 41 had a start date of 3/23/23 and was not certified. Nurse Aide 43 had a start date of 6/21/23 and was not certified. Nurse Aide 45 had a start date of 8/14/21 and was not certified. Nurse Aide 51 had a start date 9/6/23 and was not certified. Nurse Aide 63 had a start date 6/21/23 and was not certified During an interview on 4/4/24 at 10:45 A.M., Nurse Aide (NA) 45 indicated she performed all CNA duties by herself, but did not take the test to be certified after the CNA class. During an interview on 4/4/24 1:01 P.M., the Administrator indicated that the 5 aides are technically still in training since they were unable to take the test and they should be certified before they worked on the unit by themselves. During an interview on 4/5/24 1:32 P.M., the Administrator indicated the most recent CNA class those students were in started on 7/5/23 and ended on 7/12/23. 46882 2. On 4/5/24 at 9:30 A.M., review of CNA Training Class information indicated the facility was no longer having CNA Training Classes due to the director of the program, the previous ADON (Assistant Director of Nursing) and the delegated instructor no longer worked at the facility. The facility lacked an individual file for each of the five students who took the last CNA Training Class in July of 2023. The files lacked documentation of the actual time frames of the classroom portion of the course, documentation of any and all assessment tools (including tests and quizzes) utilized during the course, documentation of PPD (purified protein derivative) testing and physical exams, criminal background checks, documentation of actual time frames and activities during the clinical experience, completed RCP (Resident Care Procedures) assessment tool, copy of testing information, letter or certificate that was issued to the student. During an interview on 4/5/24 at 9:30 A.M., the DON (Director of Nursing) did not know where the supplies for the class were at that time. She indicated she knew they had a blood pressure cuff, pulse oximeter and thermometer. She indicated the room where classes were held was turned into a chapel so there were not any supplies in there. During an interview on 4/5/24 at 10:30 A.M., the Administrator indicated she knew there was a practice mannequin and a synthetic penis that was used for classes. She was not sure what or where the other supplies were located. On 4/4/24 at 1:50 P.M., the Administrator provided a CNA job description, revised April 1, 2023 that indicated, .Must have and maintain an active searchable Certified Nursing Assistant [sic] certification in accordance with the state . 3.1-14(b)

Based on interview and record review, the facility failed to ensure adequate monitoring and supervision was done to keep a resident's drug regimen free from unnecessary drugs for 1 of 5 residents reviewed for unnecessary medications. A resident was getting narcotic pain medications from an outside physician. (Resident 29) Finding includes: On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The most recent Quarterly MDS Assessment, dated 1/2/24, indicated Resident 29's cognition was moderately impaired, a limited assist of 1 staff for bed mobility, transfers, toileting, and taking an opiod. Physician's Orders included, but were not limited to, the following: oxycodone-acetaminophen (Percocet-pain medication) 10-325 mg (milligram), give 1 tablet by mouth every hours as needed for pain, ordered 12/29/23 by the facility Nurse Practitioner (NP) The MARs (Medication Administration Record) were reviewed from September 2023 through March 2024 and indicated the resident did not take any Percocet in November 2023 or March 2024. Progress Notes included, but were not limited to, the following: On 12/17/23 at 2:55 P.M., Nursing Progress Note: . Res [resident] states he does not have any pain pills in his room and that he should have a whole drawer of them but we took them. Res said that we are taking his pills and giving them to other residents . On 12/17/23 at 4:15 P.M., Nursing Progress Note: . the resident has pain pills that were found earlier this week, in his room, prescribed by [name of nurse practitioner] . the facility does not have a written order for those pain pills . The resident becomes agitated . states he is withdrawing, will soon begin to puke, is having pain and exertion SOB . On 12/17/23 at 5:21 P.M., Nursing Progress Note: . resident is presenting with s/s [signs/symptoms] of detoxing and is to be sent to the ER . On 12/17/23 at 7:00 P.M., Nursing Progress Note: . Spoke with resident regarding keeping medications at his bedside. Pt [patient] had provided 3 bottles of Prestiq [an antidepressant] earlier in the day to the nurse. Resent [sic] stated he had forgotten he had received the medication and had not taken any. Resident stated was unsure if he needed it. Resident denied having any other medications or pain pills at his bedside. Educated resident that any medication provided by [Doctor Name] needs to be given to nurse upon his return and resident voiced understanding . On 12/17/23 at 10:15 P.M., Nursing Progress Note: . questioned where the bottle of pain meds [medications] found came from. Notified of the ARNP [Advanced Registered Nurse Practitioner] who was listed on bottle and that there was 67 [pills left] . On 3/22/24 at 3:49 P.M., Nursing Progress Note: . Res [resident] had 45 QTY [quantity of pills] bottle of Haldol [antipyschotic] 5 mg in his room . During an interview on 4/4/24 at 1:58 P.M., the Director of Nursing (DON) indicated the facility NP saw him there and wrote orders for medications, etc and then he went to his Primary Care Provider (PCP) and the PCP had also prescribed him medications they didn't know about. At that point, the Facility NP wouldn't order him more of the pain pills because the PCP was also ordering them. She was unaware that he was still getting narcotic pain pills from the PCP. The DON indicated they talked to Resident 29 about only seeing one doctor and he couldn't decide if he was going to stay with the PCP or Facility Nurse Practitioner and went back and forth. The DON indicated she tried to get records from the PCP but she had not been successful. She indicated the resident still saw both providers. The PCP also ordered Haldol (an antipyschotic) for his nerves and he was also getting an injection in his stomach at his office for weight loss. At that time, she indicated neither of these were on his medication list so the pharmacist reviewing his medications was probably not aware he had 2 physicians or some of the medications he was getting. During an interview on 4/5/24 at 10:55 A.M., Registered Nurse (RN) 3 indicated she was not sure who prescribed the pain medication in the medication cart. The physician's order in the electronic health record (EHR) indicated Facility NP but she was not certain because there was only room in the EHR to identify a couple providers and if a medication was ordered by a different provider, they would usually put additional directions under that prescription that would indicate who prescribed it, but there wasn't anything saying that. During an interview on 4/5/24 at 10:05 A.M., the Facility NP indicated after Resident 29 was caught with the pain pills in his room that were not prescribed by her, she had the DON try to contact that prescriber and figure out what medications were being prescribed so they would have an accurate medication list, but the DON was unsuccessful. The Facility NP indicated that she spoke with Resident 29 and educated him on only having one provider and she was under the impression he wasn't going to see the other provider anymore. She was unaware that he was still getting narcotic pain pills from the PCP. On 4/5/24 at 9:45 A.M., the Administrator indicated it would be their policy residents would not receive unnecessary medications. 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 8 of 9 residents reviewed for hospitalization s. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization . (Resident 17, Resident 30, Resident 29, Resident 8, Resident 19, Resident 21, Resident 10, Resident 7) Findings include: 1. On 4/2/24 at 8:44 A.M., Resident 7's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 1/14/24 and returned back to the facility from the hospital on 1/17/24. Resident 7's records lacked a bed hold policy. 2. On 4/2/24 at 11:55 A.M., Resident 17's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 11/12/24 and returned back to the facility from the hospital on 11/14/24. Resident 17's records lacked a bed hold policy. 46416 3. On 4/4/24 at 1:36 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and atrial fibrillation. The resident's clinical record indicated she was transferred to the hospital on 7/12/23 and 11/30/23. The clinical record lacked documentation that a bed hold policy was provided to the resident or resident representative. 4. On 4/4/24 at 11:04 A.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and pneumonia. The resident's clinical record indicated she was transferred to the hospital on 1/26/24. The clinical record lacked documentation that a bed hold policy was provided to the resident or resident representative. 5. On 4/2/24 at 12:31 P.M., Resident 21's clinical record was reviewed. Diagnoses included, but were not limited to chronic obstructive pulmonary disease and anxiety. The resident's clinical record indicated she was transferred to the hospital 2/2/24 and 2/11/24. The clinical record lacked documentation that a bed hold policy was provided to the resident or resident representative. 6. On 4/3/24 at 8:50 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and congestive heart disease. The resident's clinical record indicated he was transferred to the hospital on 12/17/23 and 12/23/24. The clinical record lacked documentation that a bed hold policy was provided to the resident or resident representative. 7. On 4/5/24 at 8:21 A.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and renal failure. The resident's clinical record indicated he was transferred to the hospital on 12/26/23. The clinical record lacked documentation that a bed hold policy was provided to the resident or resident representative. 46882 8. On 4/2/24 at 1:26 P.M., Resident 10's clinical records were reviewed. Diagnosis included, but was not limited to, pathological fracture of right ankle, hypertensive encephalopathy, asthma, chronic obstructive pulmonary disease, pneumonia, seizures, and multiple myeloma. The most current Quarterly, State Optional MDS (Minimum Data Set) Assessment, dated 1/15/24, indicated Resident 10 was cognitively intact, required limited assistance of one with bed mobility and transfers, extensive assistance of 2 for toilet use and supervision for eating. Resident 10 was hospitalized from 10/26/23 thru 10/2723 for sepsis, and 12/5/23 thru 12/8/23 for aspiration pneumonia. The clinical records lacked bed hold paperwork or documentation that bed hold paperwork was given to Resident 10 when transferred to the hospital. During an interview on 4/4/24 at 2:40 P.M., ADON (Assistant Director of Nursing) indicated when a resident was transferred to the hospital, they were sent with bed hold policy, a transfer discharge record and copy of medication and MAR (Medication Administration Record) of medications given for the day, immunizations, allergies, diagnosis and pertinent lab and x-ray information if needed for the hospitalization , and always send DNR (Do Not Resuscitate) paperwork. This should be sent every time a resident was sent to the hospital. On 4/4/24 at 11:54 A.M., an undated Bed Hold Policy was provided by the Business Office Manager which indicated, It is the policy of the facility to provide the Resident, Resident's family member and /or the Resident's legal representative, if applicable, in written form and/or by a telephone conservation prior to transfer to a hospital or prior to a Resident beginning therapeutic leave, for a duration of 24 hours or longer; certain information regarding the Resident's facility bed status and how the bed will be held. A copy of the Bed Hold policy given to the Resident, Resident's family member and/or the Resident's legal representative will be placed in the resident's record. This will be documented in the resident's record. 3.1-12(a)(25)(26)

Based on interview and record review, the facility failed to develop and implement interventions to manage a resident's falls, and failed to provide supervision for a resident resulting in a fall with a back fracture; and failed to utilize a mechanical lift per the plan of care, resulting in a fall with a right arm fracture, for 2 of 3 residents reviewed for falls, in a sample of 5. (Residents C and D) Findings include: 1. On 12/17/18 at 9:10 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident C had a history of [REDACTED]. Resident C was observed at that time sitting in a recliner in the resident lounge, asleep. The clinical record of Resident C was reviewed on 12/17/18 at 1:30 P.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 9/4/18, indicated Resident C had a severe memory deficit, and required extensive assist of two + persons for bed mobility, transfer, and walking. A test for balance indicated the resident was Not steady, only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer. An Occurrence Initial Assessment indicated: Date and time of occurrence, 09/06/2018, 23:15 (11:15 P.M.), Location of occurrence: residents (sic) room (number), Fall with injury. This nurse and CNA heard loud crash from residents room upon entering room resident was laying on right side in floor between recliner and bedside table noted to be in socks without shoes and when resident asked what happened she states 'I don't know I think I slipped' upon assessment noted small knot to back of left side of head with icepack applied to head .Type of injury: Bruise/hematoma (raised bruise) .Focus: Fall Risk: I am at risk for falls due to my condition and risk factors. Intervention: Initiate 15 minute checks x 72 hours until IDT (interdisciplinary team) can evaluate. A Post Occurrence Assessment, dated 9/7/18 at 2:12 P.M., indicated, Root cause: Resident currently has UTI (urinary tract infection) with weakness and increased confusion. IDT recommendations: Non skid socks. Fall Risk Assess: Confusion/forgetfulness (intermittent or constant), Weakness, Uses assistive device for mobility, Frequently forgets to use assistive device for walking. Unsafe or improper footwear. An Occurrence Initial Assessment indicated: Date and time of occurrence, 09/12/2018, 06:30 (A.M.), Location of occurrence: Resident's room .Resident found in floor near bathroom, sitting up with legs out in front of her. She stated 'I fell on my butt.' Resident denies hitting head, does c/o (complain of) pain in lower back and hips (this is chronic, and hard to say if this is new pain). No visible signs of injury noted upon assessment .Indicate level of pain: Hurts a Little More .2nd fall in a week. Resident continues to be weak . Intervention: Initiate 15 minute checks x 72 hours until IDT can evaluate. A Change in Condition Evaluation, dated 9/12/18 at 10:31 A.M., indicated: Abnormal vital signs, Falls, Food and/or fluid intake, Functional decline .This started on: 9/4/2018 .General weakness, Decreased mobility, Fall .HR (heart rate) elevated / BP (blood pressure) decreased from baseline .Does the resident have pain? Yes .Bilateral hips and lower back .Recommendation of Primary Clinician(s): Send to ER for Eval (evaluation) and Treat. The resident was transferred to the hospital on [DATE] at 10:39 A.M. A hospital note, dated 9/12/18 at 11:37 P.M., indicated, .presents with back pain after multiple falls at the nursing home. She was found to have an acute compression fracture .Patient has progressive dementia, likely Alzheimer's type. Her daughter reports that she has fallen may times in the last few months. Yesterday she was found on the floor near the bathroom .Assessment and Plan: Closed compression fracture of L1 lumbar vertebra (back) .Fall from ground level A Post Occurrence Assessment, dated 9/13/18 at 2:51 P.M., indicated, .no injuries noted at time of assessment upon further examination L1 fracture noted. Root cause: Confused resident not able to determine safety risk. IDT recommendations: Resident will be put on toileting program and will not be left alone in bathroom. Fall Risk Assess: History of fall(s) in past 30 days. Recurrent falls - 2 or more in past 30 days, Confusion/forgetfulness, Parkinson (sic) disease, Uses assistive device for mobility, Unsteady gait with or without assistive device, Slow small shuffling gait, Requires staff physical support to transfer. The resident returned from the hospital on [DATE]. An Occurrence Initial Assessment indicated: Date and time of occurrence, 09/22/2018, 20:00 (8:00 P.M.), Location of occurrence: Residents (sic) room. Fall with injury. Resident was yelling 'help me.' Upon entering residents room, resident was lying on the floor, toward the foot of the bed, on her back. This nurse did note blood drops on the floor beside her head. Resident stated that she was getting back in bed. Resident did have gripper socks on .Type of injury, Back of head, 1.3 cm (centimeter) skin tear .Fall Risk: I am at risk for falls due to my condition and risk factors. Intervention: Initiate 15 minute checks x 72 hours until IDT can evaluate. A Post Occurrence Assessment, dated 9/24/18 at 12:43 P.M., indicated, .Type of injury: abrasion to back of head. Root cause: transferring self unassisted. IDT recommendations: safety strips on floor in front of bed .Fall Risk Assess: Recurrent falls, Confusion/forgetfulness, Parkinson disease, Weakness, Poor vision or [MEDICAL CONDITION], Uses assistive device for mobility, Unsteady gait with or without assistive device, Slow small shuffling gait. Nurses Notes included the following notations: 11/22/18 at 3:02 P.M.: Up w/c (wheelchair) with assist .Alert with confusion 11/25/18 at 1:47 P.M.: .Alert with confusion .Cont (continue) to refuse brace daily An Occurrence Initial Assessment indicated: Date and time of occurrence, 12/05/2018, 05:30 (A.M.), Location of occurrence: Resident's room. CNA's entered room. Resident found lying on mat beside lowered bed on right shoulder lying on side. Resident voiced no urgent pain. After sitting upright stated that her right shoulder was a bit sore .right shoulder has 3 cm x 2 cm slightly reddened area .will obtain X-ray of right shoulder today. Spoke with Resident regarding importance of using call light to utilize staff assistance for transfers or needs to prevent further occurrences Fall Risk: I am at risk for falls due to my condition and risk factors. Intervention: Initiate 15 minute checks x 72 hours until IDT can evaluate. Nurses Notes indicated the x-rays were negative for fractures. A Post Occurrence Assessment, dated 12/5/18 at 9:12 A.M., indicated, .Type of injury: 3 cm x 2 cm reddened area to right shoulder - monitor until healed or no longer reddened. Root cause: (Left blank) IDT recommendations: Environmental check - findings that bed is in lowest position will be adjusting bed to appropriate height level to prevent further incident .Fall Risk Assess: (Left blank). An Occurrence Initial Assessment indicated: Date and time of occurrence, 12/17/2018, 01:45 (A.M.), Location of occurrence: Resident's room. CNA (name) entered the room for a routine bed-check and found resident on the floor in front of her chair lying on her R (right) side. Denies pain. States she didn't hit her head .Resident was not wearing non-skid socks. Encouraged to use call light if she needs assistance. Call light is in reach Fall Risk: I am at risk for falls due to my condition and risk factors. Intervention: Initiate 15 minute checks x 72 hours until IDT can evaluate. On 12/18/18 at 8:35 A.M., the DON was interviewed regarding Resident C's falls. She indicated Resident C had multiple interventions in place. She indicated the resident had fallen again during the night. The DON indicated she informed her staff that they may have to do hourly checks on her instead of 2 hours. She indicated the staff does 15 minute checks until they come up with interventions. The clinical record of Resident C was again reviewed on 12/18/18 at 9:10 A.M. An Occurrence Initial Assessment indicated: Date and time of occurrence, 12/18/2018, 02:40 (A.M.), Location of occurrence: Resident's room. Upon entering room, CNA's (sic) found Resident beside bed on top of blankets on knees sitting. Denied hitting head .Staff assisted resident to sitting position on bed .slight redness noted to bilat. (bilateral, or both) knees .States she wasn't sure why she was trying to get out of bed. Advised resident importance of use of call light to alert staff to help resident transfer or assist to restroom for safety reasons. Resident voiced understanding .Fall Risk: I am at risk for falls due to my condition and risk factors. Intervention: Initiate 15 minute checks x 72 hours until IDT can evaluate. A Resident Care Plan, initially dated 6/11/18 and updated 12/17/18, indicated, Fall Risk: I am at risk for falls due to my condition and risk factors. History of falls. Confusion/forgetfulness. Weakness, Incontinence. Uses assistive device for mobility. Unsteady fait (sic) with or without assistive device. Frequently forgets to use assistive device for walking. Impaired balance with transfers with or without assistive device. Requires staff physical support to transfer at times. The Interventions included: 12/17/18 Safety strips in front of recliner. 9/12/18 Do not leave alone in the bathroom. Call light in reach. Explain use of it upon admission and reinforce as needed. 2. The closed clinical record of Resident D was reviewed on 12/17/18 at 10:35 A.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly MDS assessment, dated 9/25/18, indicated Resident D had a severe memory impairment, and required extensive assist of two+ staff for bed mobility and toilet use. The resident was totally dependent on two+ staff for transfer, and did not walk. A test for balance indicated the resident was Not steady, only able to stabilize with staff assistance for surface-to-surface transfer. A Care Plan, initially dated 11/13/17 and updated for a target date of 2/25/19, indicated: Late loss ADL (activities of daily living): Transfers I need extensive assist with transfers due to Dx (diagnosis): flacid (sic) [MEDICAL CONDITION], weakness .Use of assistive device for mobility, Mechanical Lift. The Interventions included: Mechanical lift. An Occurrence Initial Assessment indicated: Date and time of occurrence, 11/24/2018, 2000 (8:00 P.M.), Location of occurrence: Resident's room (number). 2 Aids (sic) we're (sic) getting resident up from chair to put in bed. Resident became combative and Aids sat her on floor. There is no obvious injury. Resident is complaining of right arm pain but frequently complains of right arm pain. No deformities noted to right arm .Further comments: Educate staff on appropriate lifting techniques Nurses Notes included the following notations: 11/25/18 at 1:40 A.M.: .at 12:15 while being checked on resident had a purple bruise on her right arm around her shoulder into her under arm, and some swelling in bruised area, (name of hospice) notified .hospice called back and said for her to get x-rayed in the morning. 11/25/18 at 11:05 A.M.: Xray results received via fax, resulting, a displaced fracture through the surgical neck of humerus (upper arm) A Post Occurrence Assessment, dated 11/26/18 at 10:20 A.M., indicated, .Type of injury: no injury was noted at time of incident report, but on follow up assessments right arm became warm and swollen and resident appeared to be experiencing pain .x-ray was completed .Root Cause: improper transfer of resident causing injury .IDT recommendations: suspension of all staff present during transfer, education of all CNA's on Gait belt transfers, mechanical lift skills check off, reading and understanding assignment sheets On 12/17/18 at 1:15 P.M., the DON was interviewed. She indicated 1 CNA and 2 NAs (non-certified assistants) were with Resident D on 11/25/18. She indicated a CNA and NA were holding her up, while they were trying to clean her. She indicated she heard the resident became combative, and so they lowered her to the floor. The DON indicated the resident was supposed to require a mechanical lift for any transfers, and that information was on the CNA assignment sheets. She indicated none of the CNAs or NAs had their assignment sheets on them. The DON indicated the staff were suspended, and she inserviced all staff on mechanical lifts and assignment sheets. On 12/18/18 at 9:40 A.M., the Administrator provided the current facility policy, Fall Management Procedure, dated 4/13/16. The policy included: Purpose: To assess all residents for risk factors that may contribute to falling and to provide planned interventions identified by the team as appropriate for resident use in maintaining or returning to the highest level of physical, social, and psychosocial functioning as possible .The interdisciplinary health care plan team will determine which interventions are most appropriate for reducing the risk of falls, and/or injuries related to falls This Federal tag relates to Complaint IN 332. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure, residents at risk to experience falls were provided with adequate supervision and effective interventions to prevent falls for 3 of 3 residents who met the criteria for review of accidents. This deficient practice resulted in Resident M experiencing a nasal and spinal fracture and Resident F experiencing acute closed head injury and laceration to the face requiring 8 sutures. (Resident M, Resident F, Resident G) Findings include: 1. Resident M was observed on 10/27/15 at 9:06 A.M., sitting on a sofa in the East 1 nursing lounge. Resident M was observed to have a pad alarm and faded bruising under his/her eyes. The Unit Manager #2 indicated the bruising was from a recent fall. The clinical record for Resident M was reviewed on 10/27/15 at 1:45 P.M., the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, for Resident M dated 6/7/15 indicated Resident M had a Brief Interview for Mental Status (BIMS) score of 5. Indicating he/she was severely cognitively impaired. The care plan prior to 7/1/15 included, but was not limited to, a care plan for falls initiated 5/10/15. The interventions in place included, but were not limited to, Evaluate effectiveness and side effects of psychoactive medications (5/10/15), call light in reach 5/10/15, toilet every 2 hours while awake, offer toilet every 1 hour at bedtime (5/19/15) and, hip protectors at all times (6/9/15). The Nursing-Occurrence Initial Assessment forms for Resident M were reviewed and included: Fall #1 Resident M experienced an unwitnessed fall in the East 1 nursing lobby on 7/1/15 at 4:30 P.M. The report indicated resident M was found on the floor and complained of pain to right elbow. Resident M experience a skin tear to his/her elbow. No documentation of an immediate intervention was in place. The IDT (Interdisciplinary team) note dated 7/2/15 at 11:24 P.M., indicated the root cause of the fall was a lack of safety awareness related to decreased cognition and recommended resident M be monitored closely and redirected as needed. Fall #2 Resident M experienced an unwitnessed fall on 7/10/15 at 1:15 A.M. The document indicated Resident M was found on the floor in the bathroom of his/her room. Resident M experienced no injuries. No immediate intervention was documented on this sheet. The IDT note dated 7/10/15 at 1:00 P.M., indicated the root cause of this fall was decreased safety awareness, and recommended Resident M be checked every 2 hours. Fall #3 Resident M experienced an unwitnessed fall on 7/12/15 at 5:05 A.M. The document indicated Resident M was found on the floor in a sitting position in the floor in his/her room. Resident M had no injuries as a result of this fall. No documentation of an immediate intervention was observed. The IDT note dated 7/13/15 at 12:46 P.M., indicated the root cause of this fall was decreased safety awareness related to a [DIAGNOSES REDACTED]. Fall #4 Resident M experienced an unwitnessed fall on 7/13/15 at 6:30 A.M. The document indicated Resident M was found lying in bed with blood on the sheets. Resident M was observed to have a skin tear on his/her left elbow and indicated he/she had fallen. No other injuries noted. Nero checks started. No documentation of an immediate intervention was observed. No IDT note addressing this incident was observed. Fall #5 Resident M experienced a witnessed fall on 8/20/15 at 11:00 A.M. The document indicated a housekeeper heard noise coming from the room of Resident M. The document continued and included, Resident fell before staff could get to her. Resident was lying in floor in front of bed with head against bed frame. The immediate intervention put into place was to send Resident M to the emergency room (ER) for evaluation and treatment. Resident M experienced no injuries as a result of the fall. The IDT note dated 8/20/15 at 1:47 P.M indicated the root cause for Resident Ms' falls continued to be decreased safety awareness related to a [DIAGNOSES REDACTED]. Fall #6 Resident M experienced unwitnessed fall on 9/12/15 at 2:30 P.M. The document indicated a Certified Nursing Assistant had observed Resident M lying on the floor at his/her bedside. The document included Resident M experienced pain and was sent to the local hospital for evaluation and treatment. Resident M experienced no injuries as a result of the fall. No IDT notes addressing this incident was observed. Fall #7 Resident M experienced an unwitnesssed fall on 10/18/15 at 6:00 P.M., The document indicated Resident M was found on the floor in the bathroom floor of his/her room with active bleeding noted from the nose, mouth and head. The immediate intervention was to send Resident M to the emergency room for evaluation and treatment. Resident M was admitted to the hospital for observation and experienced a nasal fracture and a fracture of his/her cervical 5 vertebrate (spinal fracture). The IDT note dated 10/19/15 at 9:33 A.M., indicated the root cause of the fall was toileting self, with no evidence of incontinence. The recommendations were to encourage and assist with wearing non skid footwear at all times. During an interview with the Director of Nursing (DON) on 10/28/15 at 12:00 P.M., she indicated Resident M had experienced several falls with the last resulting in a nasal and spinal fracture. The falls were reviewed with the DON and she indicated: Fall #1 Resident M was found lying on the floor in the lobby of the East 1 nursing lobby at 4:30 P.M. She indicated the fall was unwitnessed and Resident M experienced a skin tear to his/her right elbow. She further indicated the immediate intervention was to encourage resident to stay on the sofa in the nursing lounge. Fall #2 Resident M was found lying in the floor on 7/10/15 at 1:15 A.M., in his/her bathroom. She indicated, the fall was unwitnessed, Resident M experienced no injuries and the facility revised Resident Ms toileting schedule to include toileting every 2 hours at night time. Fall #3 Resident M was found lying in the floor near the his/her bedside. She indicated Resident M experienced no injuries and the immediate intervention was to ensure Resident M was wearing proper footwear at all times, offer divisional activities and hourly rounding for a week. Fall #4 Resident M was found lying in bed with a skin tear. She indicated Resident M indicated she had fallen so it was treated as an unwitnessed fall and nero (nerological) checks were initiated. She indicated no documentation of IDT note could be provided and the intervention put into place included, but was not limited to getting Resident M out of bed when he/she was unable to sleep. Fall #5 Resident M was observed to fall while attempting to ambulate in his/her room. She indicated Resident M was sent to the emergency room for evaluation of treatment and the interventions put into place included, monitor closely and toilet per schedule. Fall #6 Resident was found lying on the floor in floor in room on 9/12/15 at 2:30 P.M., Resident M was sent to local hospital for evaluation and treatment. She indicated no IDT note could be provided but the intervention added was to place Resident M to be in the lobby rather then in bed in the evenings. She indicated the intervention was not a new one. Fall #7 Resident M was found in a sitting position in the bathroom of his/her bathroom on 10/18/15 at 6:00 P.M. She indicated Resident M was observed to have active bleeding from her nose and head and was sent to the local hospital and admitted for observation. She indicated Resident M experienced a nasal fracture as well as a spinal fracture located at the cervical 5 vertebrate. The IDT note dated 10/19/15 at 9:33 A.M., indicated the root cause of the fall was toileting self and the immediate intervention put into place was to encourage resident to wear non skid footwear at all times, 15 minute checks indefinably, and to place a chair alarm on Resident M. The DON indicated at this time that the previous interventions and supervision put into place for Resident M were ineffective. 2. On 10/27/15 Resident F was observed from 10:10 A.M. through 1:10 P.M. Resident F was observed sitting on the couch in the East hall 2 lounge/restorative dining room from 10:10 A.M. until 11:25 A.M., at which time Resident F was transferred to a wheelchair and positioned at the restorative dining table until 1:10 P.M. Resident F was observed to be unsupervised in the lounge/restorative dining room with no staff between 10:10 A.M. and 10:15 A.M. When RN #2 was working at the nurses' station on East hall 2, residents who were seated in the lounge/restorative dining room were not within her view for supervision. The clinical record of Resident F was reviewed on 10/27/15 at 2:00 P.M. The record indicated Resident F was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] and 9/19/15 indicated Resident F experienced severe cognitive impairment, required the assistance of 2 staff with transfers, was always incontinent and required the assistance of 2 staff for toileting. A Care Plan for falls dated 03/14/14 read as follows: .Interventions/Tasks .Reinforce need to call for assistance. Date initiated: 3/25/15 . Place on couch immediately following all meals .date initiated 2/12/15 .Resolved (discontinued) 10/27/15 . 8/3/15 res (resident) is not to be left up in w/c (wheelchair) unattended .Date initiated 8/5/2015. The undated Nurse to CNA Report Sheet provided by RN #2 on 10/27/15 at 10:15 A.M. read as follows for Resident F: Sit on couch in lobby immediately after meals .is not to be left up in w/c unattended. HIGH FALL RISK . The Nursing-Occurrence Initial assessment and the Facility-Post Occurrence IDT and Fall Risk Assessment . was provided by the Administrator in Training (AIT) on 10/27/15 at 4:30 P.M., and it indicated Resident F fell on the following days: Fall #1 occurred on 3/24/15 at 00:20 (12:20 A.M.). .Called to room by resident's roommate .Resident sitting on floor with back against bed and beside table smiling. Denies injury. Denies hitting head .12 inch long red, bruised abrasion left back with a smaller 6 inch abrasion right beside it .Placed in w/c and moved to lobby . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 3/31/15 at 9:59 A.M., read as follows: .Resident go (sic) out of bed unassisted and slid to floor .Resident needing to toilet .Mat placed at bedside, Metal bar on side of bed covered with padding .Leave bathroom light on at night with door partially open to provide some lighting in room. Fall #2 occurred on 5/14/15 at 17:20 (5:20 P.M.). .resident was sitting in w/c at table in main dining room. another resident stated resident sttod (sic) and fell . no injuries noted . No Facility-Post Occurrence IDT and fall risk Assessment was provided. Fall #3 occurred on 6/8/15 at 19:30 (7:20 P.M.) .res (resident) was sitting in w/c at dining room table facing nurses desk. this nurse was standing at med cart and heard res yelp, as this nurse turned around I witnessed res slide out of chair landing on butt sitting on floor . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 6/9/15 at 9:46 A.M., read as follows: .Resident attempted to transfer self from w/c to couch in auxiliary dining room et (and) fell .Root cause: Resident attempted to transfer self from w/c to couch .IDT recommendation: Re-educate staff r/t (related to) placing resident on couch after all meals. Th (sic) nurse is to assist the CNA with the transfer of the Resident from the wheelchair to the couch immediately following every meal. Fall #4 occurred on 8/3/15 at 7:40 (7:40 A.M.). this nurse was called to the dining room by cna (name of CNA). Res noted to be lying on her right side on the floor in front of wheelchair. Res wheelchair was not near the dining room table and res had not yet been served her meal. When this nurse asked res what happened to cause her fall she stated I don't know. Res was assessed and found to have no visible injuries . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 8/3/15 at 10:17 A.M., read as follows: .Resident found by CNA on right side on floor in dining room in front of her w/c, w/c was rolled back away from her Root cause: w/c was not properly positioned where it would not roll away from table .IDT recommendations: when resident up in w/c for meals and positioned at table be sure wheels are locked so w/c will not roll back causing resident to slide out of chair . Fall #5 occurred on 9/28/15 at 14:10 (2:10 P.M.). .Fall with injury .4 .Incident was unobserved. Staff member in nearby office heard small thud and went into dining area and found resident lying face down, mostly on the right side. When this RN asked what happened, resident stated, I don't know, I just hurt. Resident had been toileted less than 20 minutes prior to being placed onto the couch by this RN and CNA . A Nursing-Transfer to hospital . dated 9/28/15 at 14:19 (2:19P.M.) read as follows: .h. Injury from occurrence . Resdent (sic) fell from couch to floor, landing on forehead, causing laceration. Laceration on right hand. C/O 'complains of' pain in head and right arm. 5. USUAL PHYSICAL FUNCTIONING AND RISK ALERTS-PRIOR TO TRANSFER .a. Transfer ability .Extensive Assist .b. Bed Mobility .Extensive assist .g. Walking ability .Does not walk uses wheelchair .RISK ALERTS .Risk for falls . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 9/29/15 at 12:09P.M., read as follows: 4 .unaware of safety risk due to dementia .5. IDT recommendations: resident to be in w/c 'wheel chair' in common area when up . Resident F was observed to be sitting on the couch on 10/27/15, 10/28/15 and 10/29/15. The ED (Emergency Department) Report dated 9/28/15 was provided by (Hospital Name) on 10/29/15 and read as follows: .8 sutures placed .FINAL IMPRESSION 1. Acute closed head injury with laceration of face, status [REDACTED]. During an interview with the DON on 10/29/15 at 11:20 A.M., the DON indicated Resident F was admitted on [DATE] with a right hip fracture due to a fall and therefore Resident F was automatically assessed to be at a high risk to fall and needed close supervision to prevent falls. The DON further indicated the Regional Vice President had discussed removing the wall between the nurses' stations and the lounge/restortive dining areas to increase the ability of the nurses to communicate with and supervise the residents while they were at their desks. 3. During an observation on 10/27/15 at 12:45 P.M., CNA #14 took Resident G from the dining room to the resident's room. Upon entering Resident G's room, Resident G was observed in the bathroom sitting on the commode without a gait belt. CNA #14 walked with Resident G to the bed without the assistance of a walker and resident G was assisted to lie down. The clinical record of Resident G was reviewed on 10/28/15 at 10:30 P.M. The record indicated Resident G was admitted on [DATE] with [DIAGNOSES REDACTED]. The undated Nurse to CNA Report Sheet provided by RN #2 on 10/27/15 at 10:15 A.M., read as follows for Resident G: .Staff to get .up at 5am, toilet .and place .in lobby .Always amb (ambulate) with RW (rolling walker & (and) gait belt . A History and Physical Exam form dated 1/22/15 was provided by the director of Nursing on 10/29/15 at 11:15 A.M., and it read as follows: Diagnosis: [REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident G experienced severe cognitive impairment, required the assistance of 1 staff with transfers, was always incontinent and required the assistance of 1 staff for toileting. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident F experienced severe cognitive impairment for decision making and required the assistance of 2 staff for transfers and toileting. A Care Plan for falls dated 1/26/15 read as follows: Fall Risk .Hx of fall, confusion/forgetfulness, weakness .requires staff physical support for transfers, unsteady gait .History of fracture of vertebrae . .Interventions/Tasks .Toilet before and after all meals .Date initiated 3/10/15 . Get resident up @ (at) 5 a (A.M.) and place in lobby for closer supervision .Date initiated 4/12/15 .Resolved 6/4/15 . Offer toileting assistance at 5 am. Check resident and offer toilet assistance every 2 hours on odd hours .Date initiated 6/1/15 . 7-22-15 always ambulate with a rolling walker and gait belt . The Nursing-Occurrence Initial assessment and the Facility-Post Occurrence IDT and fall risk Assessment . was provided by MDS coordinator on 10/28/15 at 11:45 A.M., indicated Resident G fell on the following days: Fall #1 occurred on 3/10/15 at 13:30 (1:30 P.M.). .summoned to hall 2 dining room per CNA's. upon entering dining room observed resident lying on floor on right side .resident rubbing the back of head, stated she hit her head on the floor. resident unable to specify exactly where she was going or what she was planning on doing at the time of the fall .noted resident incontinent of b&b (bowel and bladder) . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 3/12/15 at 8:21 A.M., read as follows: .Resident lying on floor in Hall 2 dining room on right side .unwitnessed fall .Resident has dx (diagnosis) of dementia and is unaware that she cannot be up by herself unassisted. resident was incontinent at time of fall . IDT recommendations: Resident to be toileted bere (sic) and/or after meals to prevent resident wanting to get up per self and toilet . Fall #2 occurred on 3/14/15 at 12:00 (12:00 noon). .Summoned to (room of resident F), upon entering observed resident on floor lying on right side .resident stated need to void . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 3/16/15 at 8:51 A.M., read as follows: .Root cause: Resident needing to toilet .Urine dip stick done since needing to toilet soon after being toilted . Fall #3 occurred on 4/12/15 at 5:30 (5:30 A.M.) Bed alarm went off and CNA and this RN went to room to find resident lying in floor on left side between bathroom and closet .Small hematoma left outer brow. 6 inch abrasion left back . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 4/14/15 at 8:29 A.M., read as follows: .Resident has dementia and is not cognitively aware that she cannot get up on her own for transfer/ambulation .IDT recommendation: Resident to be gotten up at 5A and placed in lobby for close supervision . Fall #4 occurred on 5/31/15 at 05:20 (5:20 A.M.). .Resident's bed alarm sounding alerting this nurse to room. Upon entering doorway a bang was heard by this nurse. Resident found in sitting position with back against the wall between bed and bedside cabinet. Resident was asked if she was in pain, resident stated, I don't know, I think so, maybe.Resident toileted, changed and monitored. A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 6/4/15 at 2:19 P.M., read as follows: .Resident on floor between bed and nightstand in room. Resident noted to be incontinent at time .Root cause: resident had to go to the bathroom .IDT recommendations: Toileting plan changed to toilet every 2 hours while in bed on odd hours . Fall #5 occurred on 7/22/15 at 20:30 (8:30 P.M.). .Fall with injury .being escorted to bathroom with assistance of one. On entering bathroom resident tripped on feet and hit doorframe with left side of head. Small laceration bleeding, hematoma. Pressure applied with washrag. Left elbow with skin tear. 4 cm skin tear left elbow and 2 cm laceration left outer brow .Resident was sent to the ER for evaluation . A Facility-Post Occurrence IDT and fall risk Assessment (DON or designee only) . dated 7/23/15 at 9:30 A.M., read as follows: .Resident was being assisted per one staff member to bathroom .fell .hitting left side of head and left elbow .Root cause: unsteady gait .IDT recommendation: therapy to screen . During an interview on 10/29/15 at 11:20 A.M., the Director of Nursing (DON) indicated Resident G was sent to the emergency room and steri strips were applied to laceration above left eyebrow. The DON further indicated Resident G had a history of [REDACTED]. This Federal tag relates to Complaint IN 360. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care was provided, in that, two dependent residents admitted to the facility without areas of pressure developed pressure areas for 2 of 3 resident who met the criteria for review of pressure. (Resident #15, Resident #16) This deficient practice resulted in Resident #15 experiencing three deep tissue injuries to the right posterior calf. Findings include: 1. During an interview on 2/18/15 at 11:49 A.M., indicated Resident #15 had experienced pressure wounds related to the use of an immobilizer after admission to the facility. During an observation on 2/19/15 at 11:50 A.M., Resident #15 was sitting in a wheelchair wearing an immobilizer splint which extended from the right thigh to the bottom of the right calf. The wheelchair's right leg rest was elevated and Resident #15's right, immobilized leg was rested on the leg rest in an upward position. There were no additional pressure relieving cushions on the leg rest at that time. On 2/19/15 at 11:50 A.M., Resident #15 was observed sitting in a wheel chair with an immobilizer right leg resting on the leg rest of the wheelchair. The immobilized right leg was observed, at that time, in direct contact with the leg rest with no pressure relief. During an interview, at that time, Resident #15 indicated the immobilized right lower leg did not experience pressure relief in the bed or the chair. The clinical record of Resident #15 was reviewed on 2/23/15 at 9:30 A.M. The clinical record indicated Resident #15 was admitted to the facility on [DATE] without skin impairment and [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #15 was at risk for developing a pressure ulcer, experienced moderate cognitive impairment and needed the extensive assistance of 2 staff for bed mobility and transfers. A physician's orders [REDACTED]. The Nursing Admission assessment dated [DATE] indicated Resident #15 had no skin impairments upon admission and had a leg immobilizer on her right leg for a fractured right femur. A Care Plan "...area to back of right leg; fluid filled blister..." dated 2/3/15 indicated, "...Remove immobilizer daily and prn to inspect skin...sheep skin in immobilizer...no skin to skin contact..." The care plan lacked any documentation related to providing pressure relief to the immobilized right calf. Wound #1 A "Nursing-New skin alteration assessment dated [DATE] at 6:12 P.M., indicated, Resident #15 experienced a blister on the right lower calf. The assessment lacked any documentation pressure relief was provided to the immobilized right leg. A Pressure Ulcer assessment dated [DATE] at 2:21 P.M., lacked any documentation pressure relief was provided to the immobilized right leg. The assessment indicated, "...C. Definitions...STAGE 2: ...May also present as an intact or open/ruptured serum (clear liquid-filled blister..." A Pressure Ulcer assessment dated [DATE] at 4:25 P.M., lacked any documentation pressure relief was provided to the immobilized right leg. A Pressure Ulcer assessment dated [DATE] at 4:50 P.M., lacked any documentation pressure relief was provided to the immobilized right leg. During an interview on 2/20/15 at 12:15 P.M., the Wound Care Nurse indicated Wound #1 was caused by the metal support in the leg immobilizer. The Wound Care Nurse then indicated Resident #15 experienced a second wound (Wound #2) located lateral to Wound #1 on 2/16/15. Wound #2 A Pressure Ulcer assessment dated [DATE] at 4:15 P.M. indicated Resident #15 experience a purple Stage 2 blister below the bend of the right knee. The assessment lacked any documentation pressure relief was provided to the immobilized right leg. The assessment indicated, "...6. 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/or shear..." A Care Plan for "Stage 2 fluid filled blister below bend..."dated 2/16/15 lacked any documentation pressure relief was provided to the immobilized right leg. During an observation on 2/23/15 at 2:16 P.M., the immobilized right leg of Resident #15 was observed in direct contact with the surface of a foot stool. During an interview, at that time, LPN #14 indicated she was going to remove the right leg immobilizer and perform a dressing change. The right leg of Resident #15 was observed, at that time, to have multiple circular indentations of various sizes. During an interview, at that time, LPN #14 indicated the indentations were caused by the sheep skin insert. LPN #14 was then observed to remove the dressing from Wound #1 and indicated, at that time, the wound had re-opened when the dressing was removed. During an interview, at that time, LPN #14 indicated a third wound was observed on the right leg located distal to Wound #2. Wound #3 A "Nursing-New skin alteration assessment dated [DATE] at 8:56 P.M. indicated, Resident #15 experienced a "new dark purple area" below the bend of the right knee. The assessment lacked any documentation pressure relief was provided to the immobilized right leg. A Care Plan "...Stage 2 fluid filled blister below bend and to right of right knee..." dated 2/23/15 lacked any documentation pressure relief was provided to the immobilized right leg. During an interview with the DON (Director of Nursing) on 2/23/15 at 9:42 A.M., the DON indicated the facility did not have a policy and procedure for assessing splints and braces. The DON further indicated, at that time, pressure relief should have been provided. A Policy and Procedure provided by the MD'S nurse on 2/24/15 at 12:35 P.M., read as follows: "...1. PURPOSE...reduce risk factors that may contribute to the development of pressure ulcers..." 2. The clinical record of Resident #16 was reviewed on 2/23/15 at 9:10 A.M. The record indicated Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing Assessment indicated Resident #16 experienced severe cognitive impairment, required the extensive assist of one staff, was at risk to develop pressure areas and/or experienced no areas of pressure. The Re-admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #16 experienced severe cognitive impairment, required the extensive assistance of two staff for bed mobility, was at risk to develop pressure areas and/or experienced no areas of pressure. The Nursing Admission/Return assessment dated [DATE] indicated Resident #16 was admitted to the facility with no pressure related skin impairment. A Braden Scale risk assessment dated [DATE] at 9:00 P.M., indicated Resident #16 was at risk to develop pressure related skin impairment. A Nursing note dated 9/25/14 at 10:50 A.M. indicated, Resident #16 experienced a [MEDICAL CONDITION]. The concurrent Nursing notes from 9/28/14 at 10:41 A.M. through 9/30/14 at 10:41 A.M. were reviewed and the following was noted: A Nursing note dated 9/28/14 at 10:41 A.M. indicated, "...Res (resident) currently sitting in w/c (wheel chair) at nurse station talking to self..." A Nursing note dated 9/28/14 at 1:37 P.M. indicated, "...resting in bed with eyes closed..." A Nursing note dated 9/29/14 at 9:38 A.M. indicated, "... remains in bed asleep..." A Nursing note dated 9/24/14 at 11:16 A.M. indicated, "...is still in bed asleep. Res noted to (sic) resting..." A Nursing note dated 9/30/14 at 10:35 A.M. indicated, "...remains in bed unresponsive...repositioned...has been unresponsive X (times) 2 days..." The Nursing notes from 9/28/14 at 10:41 A.M. through 9/30/14 at 10:35 A.M. lacked any documentation Resident #16 was repositioned and/or provided pressure relief to the heels, calves, and/or buttocks. A Care Plan for "Skin risk" dated 9/19/14 included the following interventions: "encourage meal/fluid intake, monitor labs as available, monitor skin daily during care, notify physician and family of any change in skin integrity, provide pressure reducing device to bed, serve diet as ordered, skin assessment at least weekly by nurse, skin assessment upon admission and then every shift for the first 3 days." The plan lacked any documentation to indicate the repositioning and/or pressure relief interventions had been implemented after Resident #16 experienced a significant change in condition. A Nursing note dated 9/30/14 at 10:41 A.M. indicated, "...Noted a stage (sic) 2 pressure area measuring 5 cm (centimeters) X 4 cm to right heel et pressure area to left heel measuring 7.5 cm X 6 cm, both are fluid filled. Stage 2 pressure area to back of right calf measuring 1 cm X 1 cm, looks like a popped blister, surrounding tissue is red et blanchable. Stage 2 pressure area to right inner buttock measuring 4 cm X 4 cm, surrounding tissue is red et blanchable..." During an interview on 2/23/15 at 3:30 P.M., the DON (Director of Nursing) indicated no documentation could be provided to indicate care had been provided to Resident #16 after a significant change in condition was experienced to prevent the development of pressure areas. The DON further indicated, at that time, repositioning and pressure relief should have been provided after Resident #17 experienced a significant change in condition. The Policy and Procedure for Wound Assessment provided by the HFA (Health Facilities Administrator) on 2/24/15 at 12:00 P.M. indicated Definitions of Wounds: ...II. Stage II pressure ulcer...May also present as an intact ...ruptured ...blister..." 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for pressure ulcers did not develop a pressure area to her right outer ankle, not found until it was 100% necrotic; failed to implement wound care with established standards of practice, by applying [MEDICATION NAME] and leaving a pressure area open to air; and failed to assess wounds correctly, in that wounds were staged incorrectly, for 2 of 3 residents sampled with pressure sores, in a sample of 4. Resident A, Resident B Findings include: 1. On 2/9/12 at 9:30 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident A had pressure areas on her left outer ankle and her bottom. The DON indicated both areas were acquired at the facility. On 2/9/12 at 10:15 A.M., a skin assessment on Resident A was requested. The Unit Manager indicated the resident was admitted with "the area on her bottom." An open area was observed above the resident's buttocks. The wound bed was difficult to assess, due to a white ointment covering the area. The Unit Manager indicated the wound was a Stage II. The resident's left foot had a cloth heel protector on. The heel protector was observed to be soiled with dried blood. An open area was observed on the resident's left outer ankle. The pressure area's wound bed appeared yellow and brown, with depth, and was surrounded with redness. The pressure area was uncovered. The Unit Manager indicated the pressure area was being treated with [MEDICATION NAME] and "left open to air to help it dry." The Unit Manager indicated the pressure area was a Stage II. The Director of Nursing, also present during the assessment, indicated the pressure area would now be unstageable. The DON indicated the Unit Managers perform the wound management in the facility, and measure wounds weekly. A request to assess the pressure areas after they were cleansed was made to the DON. On 2/9/12 at 10:20 A.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. An admission assessment, dated 1/2/12 at 12:00 P.M., indicated, "...Has immobilizer on and dressing in place...very difficult to assess at this time...Does have areas to sacrum (buttocks area), also blisters noted to posterior thighs...." A Braden Scale for Predicting Pressure Sore Risk, dated 1/2/12 at 1:53 P.M., indicated, "Ability to respond meaningfully to pressure-related discomfort, Completely Limited...Degrees to which skin is exposed to moisture, Occasionally Moist...Degree of physical activity, Chairfast, Ability to change and control body position, Completely immobile, Nutrition, Probably Inadequate, Friction & Shear, Potential Problem...." A Progress Note, dated 1/3/12 at 11:57 A.M., indicated, "...Assessed sacrum, black area measuring 3 cm (centimeters) x 2 cm present, unstageable, the skin around black area measures 5 cm x 10 cm...Received orders for Silver sulfa cream to sacrum BID (twice daily) et (and) PRN (as needed)......" A Wound Assessment, dated 1/5/12, indicated, "Type of Wound: Pressure Unstageable, Location of wound:...coccyx, Measurement of wound in centimeters (cm): Length 3 cm, Width 2 cm...100 % eschar (hard black tissue), Surrounding skin: red, macerated, Exudate (drainage): serosanguinous (slightly bloody), Odor: foul odor...Current treatment: [MEDICATION NAME] cream to coccyx BID et PRN, covered with foam et secured...Decreased mobility, decreased cognition. Res (resident) on low air loss mattress, cushion in w/c (wheel chair). Res placed on sides, et turned q (every) 2 hours. Res admitted [DATE] from hospital with pressure area...." An admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had a short-term and long-term memory problem, was severely impaired in cognitive skills for daily decision-making, required extensive assistance of two+ staff for bed mobility, transfer, and toilet use. The MDS assessment indicated the resident had 1 unstageable pressure ulcer. A Wound Assessment, dated 1/10/12 at 3:03 P.M., indicated, "...Pressure-Stage II, Location, coccyx...Length 3 cm, Width 2 cm...wound bed moist, 100% pink, surrounding skin: red, macerated, no [MEDICATION NAME] cream to coccyx BID et PRN...." A Nursing Progress Note, dated 1/11/12 at 5:13 P.M., indicated, "D/C (discontinue) Immobilizer to L (left) leg. Monitor L leg q shift x 5 days for (signs and symptoms) of infection where removed...." A Care Plan, initially dated 1/5/12 and revised 1/13/12, indicated: "Focus, Skin Risk: Potential for skin breakdown related to: requires assist with bed mobility, weakness, recent acute care hospital stay." The Interventions included: "Monitor skin daily during care. Notify physician and family of any change in skin integrity. Low air mattress in place...Skin assessment al least weekly by nurse." A Nursing Assessment, dated 1/16/12 at 10:27 A.M., indicated, "...Current skin alteration being monitored or treated with dressings or ointments? No...." A "New Skin Alteration Assessment," dated 1/16/12 at 3:35 P.M., indicated, "...New wound description: (suspected pressure...) 2 cm (centimeters) x 1.8 cm pressure area to L (left) outer ankle. 100% necrotic, no odor, no drainage, surrounding skin is red. Res (resident) unable to state if pain is present...MD and daughter notified. Treatment orders received." A Nursing Progress Note, dated 1/16/12 at 3:43 P.M., indicated, "...Assessed Decub (decubitus ulcer) to L outer ankle. Area measures 2 cm x 1.8 cm, 100 % necrotic. Res unable to state if pain is present. Res has low air loss mattress, heelz (sic) up when in bed, bootie to L foot at all times. Res is on turn schedule...Tx (treatment) is Santyl to area, covered with foam et secured q day x 2 seeks, then wound nurse to reassess. Daughter notified." A Wound Assessment, dated 1/25/12, indicated, "...Type of Wound: Pressure-Unstageable...L outer ankle...Length 0.6, Width 0.6...Wound Bed: unable to determine...50% slough, 50% pink surrounding tissue, Surrounding Skin: red...." A Wound Assessment, dated 1/31/12, indicated, "Pressure - Unstageable...L outer ankle...Length 2, Width 1, Depth 1...50% slough, 50% dark red, Surrounding Skin: red, Exudate: brownish drainage...Pain assessment...Res unable to state, but moans during care. Treatment...Santyl to L outer ankle, covered with foam, et secure q day...." A Nursing Progress Note, dated 1/31/12 at 11:36 A.M., indicated, "Assessed sacrum, stage 2 area measuring 3 cm x 2 cm x 0.2 depth. 100 % pink, et macerated...." A Wound Assessment, dated 2/7/12, indicated, "Pressure- Stage II, Location of wound: coccyx, Measurement...Length 2, Width 2, Depth 0...50% slough et 50% dark pink tissue. Surrounding skin: pink et [MEDICATION NAME] cream to coccyx BID et PRN; covered with foam et secured...." A Wound Assessment, dated 2/7/12, indicated, "Pressure - Unstageable, Location- L outer ankle...Length 1, Width 0.5, Depth 0...75% slough, 25% dark red, Surrounding Skin: red, Exudate: brownish drainage...Treatment & [MEDICATION NAME] to ankle BID (twice daily) et PRN...." A Care Plan, initially dated 1/2/12 and revised 2/9/12, indicated: "Focus, Wound 1/2/12 Pressure stage II to coccyx. 2/9/12 Stage 2 to left outer ankle." The Interventions included: "2/9/12 Low air loss mattress in place. 2/9/12 Float heels off bed. DC'd foot bootie due to (Resident A) constantly sliding it off." A Care Plan regarding the left ankle wound from 1/16/12 until 2/9/12 was not located in the clinical record. On 2/9/12 at 11:15 A.M., Resident A's left outer ankle pressure area was re-assessed. The pressure area was covered with a dressing. The dressing was removed by the DON, and the wound bed appeared to be yellow and brown, with surrounding redness. The DON indicated the nurse had just called the physician, and obtained a different treatment for [REDACTED]. On 2/9/12 at 11:30 A.M., during interview with the DON, he indicated he was unsure how the pressure area on the left ankle was discovered. The DON indicated he had already signed his unit managers up for an upcoming wound class on February 16. On 2/9/12 at 11:35 A.M., the clinical record of Resident A was again reviewed. A Progress Note, dated 2/9/12 at 11:07 A.M., indicted, "10:25 am New order received to d/c (discontinue) [MEDICATION NAME] to outer left heel. Cleanse L outer heel with wound cleaner, pack with [MEDICATION NAME], cover with foam and secure q other day x 10 days then reasses (sic). Check placement of dressing q shift." An additional Nursing Progress Note,dated 2/9/12 at 11:31 A.M., indicated, "Assessed decub to L outer ankle. Ankle appears dry with dark center, et redness surrounding. Measures 1.2 cm x 0.7 cm x 0.2 cm in depth. MD notified of wound deterioration, et new orders received. Cleansed wound et wound appeared moist with beefy red tissue in wound bed...." On 2/9/12 at 1:10 P.M., during interview with the Unit Manager and the DON, the Unit Manager indicated she was notified by nursing staff on 1/16/12 that Resident A had an open area on her left ankle. The Unit Manager indicated she was unsure how it developed, but that the resident had had an immobilizer on. Both the Unit Manager and the DON indicated they were unsure how the area was discovered, and why it wasn't discovered prior to being necrotic. The DON indicated the resident liked to lay on her left side. The Unit Manager indicated she usually recommends the wound treatment to the physician, who then orders it. The Unit Manager indicated she had a wound care book that she refers to, and also consults "the old wound care nurse," who comes in periodically. The Unit Manager indicated she did not know the date of her wound care book. The Unit Manger indicated she obtained an order to discontinue the heel protectors, as the resident frequently kicked them off. On 2/10/12 at 11:35 A.M., the resident's pressure area on her buttocks was reassessed. The wound bed appeared pink with a small amount of yellow, and surrounding redness. On 2/13/12 at 8:45 A.M., during interview with the DON, he indicated he and other administrative staff had just completed pressure ulcer inservicing on 2/11/12 and 2/12/12. The DON also indicated the resident's bed was moved away from the wall to provide easier access to the resident. The DON indicated the resident's left ankle was reassessed, and provided the most recent wound note. The DON indicated he would now have staff document the measurements of the surrounding redness. The DON indicated the left ankle wound was now considered unstageable due to 100 % slough in the wound bed. A Wound Assessment, dated 2/13/12 at 8:16 A.M., indicated, "Pressure-Unstageable, Location: L outer ankle, Length 1.2, Width 1, Depth 0.1...100 % slough, Surrounding skin: Light red measuring 3 cm x 2.5 cm...." On 2/13/12 at 11:30 A.M., the DON provided a document which indicated the Unit Manager had last received inservicing of "Pressure Ulcer Prevention and Management" on 12/2/11. On 2/13/12 at 1:00 P.M., during interview with the MDS Coordinator, she indicated she did not know why she revised the care plan entry for the left ankle pressure area on 2/9/12, and did not know why there was not a previous care plan regarding the left ankle wound. 2. On 2/9/12 at 9:30 A.M., during the initial tour, the DON indicated Resident B had an "open area on his bottom." The DON indicated Resident B was admitted to the facility with the area. On 2/9/12 at 11:10 A.M., a skin assessment was requested. A small open area was observed on the resident's coccyx. The wound bed appeared pink, and was surrounded by darker fragile skin. The DON indicated at that time that the pressure area was a Stage II. The clinical record of Resident B was reviewed on 2/9/12 at 2:30 P.M. [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 12/28/11 at 1:38 P.M., indicated, "Wound on coccyx center beefy red measuring 3 cm x 2.1, et surrounding skin very red, warm to touch measuring 7 cm x 6 cm. When area is lightly touched res flinches, et moans with pain. Res encouraged to lay on sides, to keep pressure off of coccyx; however res declines as he states 'I'm not comfortable.'...." A Braden Scale for Predicting Pressure Sore Risk, dated 12/28/11 at 10:06 P.M., indicated: "Sensory Perception, Very Limited, Moisture, Occasionally Moist, Bedfast, Mobility Slightly Limited, Nutrition Very Poor, Friction & Shear Problem. The Braden Scale indicated the resident was "High Risk" for pressure sores. A Wound Assessment, dated 1/5/12 at 2:13 P.M., indicated: "Pressure-Unstageable, Location, Large Unstageable pressure area to coccyx, Length 2 cm, Width 2.8...Total area measures 5 cm x 5 cm center of wound opening measuring 2 cm x 2.8 cm...Wound bed beefy red, 0 necrosis, Surrounding skin red...Butt paste to coccyx covered with mediplex et secured, Dressing changed q 3 days et PRN...." An Admission Minimum Data Set (MDS) assessment, dated 1/6/12, indicated the resident had no long-term or short-term memory problems, and required extensive assistance of two+ staff for bed mobility, transfer, and toilet use. The MDS assessment indicated Resident B had 1 unstageable pressure ulcer. A Nursing Progress Note, dated 2/7/12 at 12:00 P.M., indicated, "Assessed decub to coccyx. Area closed, skin dry et intact. Area healed out; however for preventitive (sic)/precaution measures, orders remain for Magic Butt Paste q shift et PRN will remain in place...." The clinical record of Resident B was reviewed again on 2/10/12 at 10:00 A.M. A Nursing Progress Note, dated 2/9/12 at 3:14 P.M., indicated, "Area to coccyx has reopened since (2-7-12) measuring 0.2 cm x 0.2 cm x 0.1 cm. treatment of [REDACTED]." A Care Plan, initially dated 12/28/11 and revised 2/9/12, indicated: "Focus, Skin Risk, Potential for skin breakdown related to: decreased mobility, poor nutritional status." Interventions included: "Date Initiated: 2/9/12 Application of butt paste ointment to coccyx q shift et prn for prevention/protection." An additional Care Plan, initially dated 12/28/11 and revised 2/9/12, indicated: "Wound: Actual skin breakdown due to...unstageable wound on coccyx. Non-compliant with pressure reducing positioning." An additional revision, dated 2/10/12, indicated, "Actual skin breakdown due to pressure: wound to coccyx..." On 2/13/12 at 8:45 A.M., during interview with the DON, he indicated he had seen the resident's pressure ulcer when he was first admitted , and the wound appeared black with surrounding redness, which did make it unstageable. The DON indicated he did not know why the documentation did not reflect that assessment. The DON indicated the resident was to have magic butt paste applied to the coccyx every shift from 2/7/12. The DON indicated the resident's open area was reassessed, and a new physician's orders [REDACTED]. 3. On 2/10/12 at 1:00 P.M., the Administrator provided the current facility policy on "Skin Management Program," dated 3/8/10. The policy included: "...I. A comprehensive head to toe skin assessment (inspection) will be completed by a licensed nurse upon admission/return, and at least weekly thereafter. II. Residents who receive assistance with bathing and/or peri-care will be observed daily by nursing staff and any notation of red areas, open areas...will be reported to the licensed nurse for further assessment...Education: I. Routine education will be provided to the wound nurse(s) of each facility at least twice yearly to review ulcers staging, assessment, measurement, treatment options, dressing options and documentation...Quality Assurance Review: I. Pressure ulcers...will be assessed and monitored by the designated wound nurse(s) of the facility. Wound nurse(s) will monitor/assess for progression or regression of healing and treatments will be re-evaluated to ensure appropriateness...." 4. "Stages of Pressure Ulcers," AMDA-2008, included: Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence... Note: This area may be painful, firm, soft, warmer or cooler compared to adjacent skin. 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. Note: The depth of a Stage III or IV varies by anatomical location. The bridge of the nose, ear, occipitals and malleolus do not have subcutaneous tissue and these ulcers can be shallow. 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. "Pressure Ulcers in the Long-Term Care Setting," AMDA-2008, included: "...The physical examination should include identification of suspected deep tissue injury and staging of the ulcer or ulcers...The use of cytotoxic antiseptic solutions (e.g., [MEDICATION NAME] iodine ([MEDICATION NAME])...) should be discouraged because these agents may retard ulcer healing and increase resistance to subsequent antibiotic treatments...Cover and protect the ulcer and surrounding skin. The goals of dressing an ulcer are to: Keep the ulcer bed moist and the surrounding skin dry, Protect the ulcer from contamination, and Promote healing...." This federal tag relates to Complaint IN 039. 3.1-40(a)(1) 3.1-40(a)(2)